Patients' perceptions of the post-pancreatectomy discharge process.

BACKGROUND: Complications after pancreatectomies contribute to poor outcomes. Patients are expected to identify signs/symptoms leading to these complications but may be poorly educated on how to identify them. We assessed the impact of an educational tool on patient perceptions of, and satisfaction with the discharge process, and its effect on readmission rates. METHODS: A prospective cohort study with retrospective chart review including patients who underwent pancreatic resection was undertaken. An interactive educational module (iBook) that provided information about the procedure, possible complications, and peri-discharge information was implemented. English-speaking patients were equally divided into the pre- and post-iBook cohorts. Primary outcome was patients' satisfaction with discharge; Secondary outcomes were 30- and 90-day readmission rates. RESULTS: 100 patients were included. Mean age was 65.5 ± 12.6, 46% were female, and 92.3% were white. Most patients underwent Whipple procedures (72%), and distal pancreatectomies (26%). In the post-implementation group, 92% were satisfied with the discharge process, and 89% reported it was a good tool. There were no statistical differences in 30- and 90-day readmission rates between cohorts. CONCLUSION: The iBook positively impacted patients' satisfaction and preparedness for discharge. Readmission rates were not statistically significantly impacted but could be investigated with further studies of greater sample sizes.

Delayed Presentation of First Rib Osteomyelitis Following Trauma.

Rib osteomyelitis can be caused by a contiguous infection after a traumatic fracture. Post traumatic osteomyelitis can present as chronic six or more weeks after bone infection. However, this patient developed first rib osteomyelitis 17 years after trauma, following the initiation of anticoagulation therapy. 17 years ago, a 55-year-old male patient was in a motor vehicle collision. He was diagnosed with a left first rib fracture and an internal carotid dissection. He subsequently underwent a left subclavian central venous catheter placement. His rib fracture was managed nonoperatively and the carotid dissection was treated with endovascular stent placement. He now presents with symptomatic carotid stent stenosis which is treated with anti-platelet and anticoagulation therapy. He then developed a hematoma over the old rib fracture, and subsequently developed acute osteomyelitis. As seen here, a remote history of traumatic first rib fracture remains a risk factor for osteomyelitis despite the passage of time.

Language Proficiency and Survival in Pancreatic Cancer: a Propensity Score-Matched Analysis.

BACKGROUND: Limited English proficiency has been shown to negatively affect health outcomes. However, as of now, little is known about survival rates of patients with limited English proficiency (LEP) and pancreatic ductal adenocarcinoma (PDAC) when compared to patients with English proficiency (EP) in an urban, non-safety net setting. We aimed to compare survival rates between patients with LEP and those with EP who had a diagnosis of PDAC. METHODS: A single-institution retrospective propensity-matched cohort study of patients with biopsy-proven PDAC was undertaken. Demographics, clinical characteristics, and language information were collected for all participants. Patients were classified as having LEP or EP based on their preferred speaking language at the time of admission and matched on baseline characteristics using propensity scores. Survival analysis methods were used to study survival rates in patients with PDAC based on their EP status. RESULTS: Of 739 included patients, 71 (9.48%) had LEP, mean age was 68.4 ± 10.9, and 51.8% were female. Both groups of patients were comparable for age, gender, marital status, and time to treatment. LEP status was associated with higher odds of death in both unmatched (HR 1.65, 95% CI 1.22-2.22) and matched (HR 1.60, 95% CI 1.03-2.47) analyses. Additionally, patients with LEP had significantly decreased odds of receiving cancer-directed treatment and increased odds of advanced stage cancer at presentation. CONCLUSIONS: In this cohort of patients with PDAC, LEP predicted worse survival. The results of this study suggest that, after accounting for interpreter use, other factors contribute to this disparity. Such factors, as yet unmeasured, may include health literacy and cultural expectations, for which further investigation is warranted to better understand and limit this survival disparity.

Time to surgery in thoracic cancers and prioritization during COVID-19: a systematic review.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has overwhelmed hospital resources worldwide, requiring widespread cancellation of non-emergency operations, including lung and esophageal cancer operations. In the United States, while hospitals begin to increase surgical volume and tackle the backlog of cases, the specter of a "second wave," with a potential vaccine months to years away, highlights the ongoing need to triage cases based upon the risk of surgical delay. We synthesize the available literature on time to surgery and its impact on outcomes along with a critical appraisal of the released triage guidelines in the United States. METHODS: We performed a systematic literature review using PubMed according to preferred reporting items for systematic reviews and meta-analyses guidelines evaluating relevant literature from the past 15 years. RESULTS: Out of 679 screened abstracts, 12 studies investigating time to surgery in lung cancer were included. In stage I-II lung cancer, delayed resection beyond 6 to 8 weeks is consistently associated with lower survival. No identified evidence justifies a 2 cm cutoff for immediate versus delayed surgery. For stage IIIa lung cancer, time to surgery greater than 6 weeks after neoadjuvant therapy is similarly associated with worse survival. For esophageal cancer, 254 abstracts were screened and 23 studies were included. Minimal literature addresses primary esophagectomy, but time to surgery over 8 weeks is associated with lower survival. In the neoadjuvant setting, longer time to surgery is associated with increased pathologic complete response, but also decreased survival. The optimal window for esophagectomy following neoadjuvant therapy is 6 to 8 weeks. CONCLUSIONS: In the setting of the COVID-19 pandemic, timely resection of lung and esophageal cancer should be prioritized whenever possible based upon local resources and disease-burden.

Gastrointestinal Malignancies and the COVID-19 Pandemic: Evidence-Based Triage to Surgery.

BACKGROUND: The COVID-19 pandemic has led to widespread cancelation of electively scheduled surgeries, including for colorectal, pancreatic, and gastric cancer. The American College of Surgeons and the Society of Surgical Oncology have released guidelines for triage of these procedures. We seek to synthesize available evidence on delayed resection and oncologic outcomes, while also providing a critical assessment of the released guidelines. METHODS: A systematic review was conducted to identify literature between 2005 and 2020 investigating the impact of time to surgery on oncologic outcomes in colorectal, pancreatic, and gastric cancer. RESULTS: For colorectal cancer, 1066 abstracts were screened and 43 papers were included. In primarily resected colon cancer, delay over 30 to 40 days is associated with lower survival. In rectal cancer, time to surgery over 7 to 8 weeks following neoadjuvant therapy is associated with decreased survival. Three hundred ninety-four abstracts were screened for pancreatic cancer and nine studies were included. Two studies demonstrate increased unexpected progression with delayed surgery over 30 days. Out of 633 abstracts screened for gastric cancer, six studies were included. No identified study demonstrated worse survival with increased time to surgery. CONCLUSION: Moderate evidence suggests that delayed resection of colorectal cancer worsens survival; the impact of time to surgery on gastric and pancreatic cancer outcomes is uncertain. Early resection of gastrointestinal malignancies provides the best chance for curative therapy. During the COVID-19 pandemic, prioritization of procedures should account for available evidence on time to surgery and oncologic outcomes.

The Learning Environment in Surgery Clerkship: What are Faculty Perceptions?

OBJECTIVE: Multiple efforts have sought to improve teaching effectiveness and the learning environment (LE), but prior research has not focused on attending physicians' perceptions of mistreatment or contribution to the LE. The purpose of this study was to assess the perception and role of surgical faculty in the medical student LE. DESIGN: A semistructured interview guide was developed using a comprehensive approach including extensive literature search and focus groups. Data were audio-recorded and transcribed verbatim. Content analysis was used to identify emergent themes. SETTING: Beth Israel Deaconess Medical Center, an academic tertiary care facility located in Boston, Massachusetts. PARTICIPANTS: Fifteen faculty in the Department of Surgery underwent detailed interviews. Participants were selected using purposive-stratified criterion-based sampling. RESULTS: Multiple themes emerged: (1) The competing demands on medical student's time are a negative factor in the LE; (2) Faculty expectations conflict with the existing curriculum; (3) Faculty are concerned with the possibility of being reported for providing negative feedback; (4) Faculty remain unfamiliar with policies regarding the LE/mistreatment; (5) A motivated medical student makes the educational interaction more productive independent of specialty of choice. CONCLUSIONS: Faculty identified that the most important factors contributing to a negative LE were a mismatch between expectations of medical students and faculty, and the conflict between the current curriculum and the faculty member's perceived ideal educational framework. Importantly, faculties were largely unfamiliar with LE/mistreatment policies and standards. These findings suggest a need for targeted curricula for faculty to raise awareness of components of a positive LE and tools to teach effectively within the contemporary medical school curriculum.

Braden scale for pressure ulcer risk predicts rehabilitation placement after pancreatic resection.

BACKGROUND: Patients undergoing pancreatic resection frequently require rehabilitation facilities after hospital discharge. We evaluated the predictive role of validated markers of frailty on rehabilitation facility placement to identify patients who may require this service. METHODS: Single-center retrospective cohort study of patients who underwent pancreatic resection from 2010 to 2015. 90-day morbidity and mortality were calculated. Postoperative validated markers of frailty (Activities of Daily Living scale, Braden scale [assesses pressure ulcer risk, lower scores = higher risk] and Morse fall scale) were evaluated via multivariate regression to identify predictors of discharge to rehabilitation facility. RESULTS: 470 patients with complete data were included. Mean age was 62 and 49.2% were male. Postoperative median length of stay (LOS) was 8 (IQR 7-10). 92 (19.66%) patients were discharged to rehabilitation facilities and 138 (29.49%) patients were readmitted within 90 days. On multivariate analysis, age, sex, LOS > 8 days, inpatient Comprehensive Complication Index (CCI) and initial Braden scale were predictive of rehabilitation placement. CONCLUSION: A marker of frailty routinely collected daily by nursing staff, the Braden scale, is available to help surgeons predict the need for postoperative rehabilitation placement after pancreatic resection. Engaging discharge planning services for at-risk patients may help prevent delayed hospital discharge and should be further evaluated.

Mistreatment and the Learning Environment: A Mixed Methods Approach to Assess Knowledge and Raise Awareness Amongst Residents.

OBJECTIVE: Trainee mistreatment, either intentional or unintentional, negatively affects the learning environment. This study was undertaken to evaluate the impact of an educational intervention about mistreatment and the learning environment on general surgery residents. DESIGN: Video-based modules were developed and added to the residency curriculum. Modules provided definitions and examples of active and passive mistreatment and components of positive and negative learning environments. A mixed-methods approach was used to assess the impact of this intervention. Residents completed a previously validated pre and post-test of related knowledge and attitudes (Abuse Sensitivity Questionnaire). Wilcoxon Signed Rank test was used to compare test results. During video-review sessions, discussion was prompted amongst residents using a semistructured interview guide. Immersion crystallization method was used to identify dominant themes. SETTING: Beth Israel Deaconess Medical Center, an academic tertiary care facility located in Boston, Massachusetts. PARTICIPANTS: All general surgery residents in our institution (n = 58) were invited to complete a survey at 3 time points. RESULTS: Fifty-eight residents (55% male) responded to the survey (100% response rate). Mean age was 30.2 year (SD 3.9). Perception of nicknames related to personal identifiers (p = 0.0065) and name-calling (p = 0.02) changed significantly postintervention (Table 1). Regarding standards of behavior, 42 (72.4%) residents considered yelling not to be abusive unless it occurred frequently or constantly; 15 (25.8%) residents considered swearing (not directed at a person) as "not abuse"; 6 (10.3%) considered constructive criticism to be abusive if it was frequent or constant; and 24 (41%) residents feel powerless to intervene in these scenarios. Multiple themes emerged regarding resident-student interactions: (1) resident perception that description of behavior as mistreatment depends on medical student sensitivity; (2) neglect of medical students avoids trouble (e.g., being labeled as active mistreatment); (3) failure to integrate students into the surgical team may occur due to perceived lack of student interest; and (4) communication with the medical student is key. Residents reported that discussion along with video review was more effective than video review alone. CONCLUSIONS: The video-based curriculum on mistreatment and the learning environment created awareness amongst residents about this important topic. Knowledge and attitudes about mistreatment changed in some areas postintervention. These findings suggest a need for development of complementary curricula to improve resident awareness and understanding of components of a positive learning environment and definition/examples of mistreatment.

Using Individual Clinical Evaluations to Assess Residents' Clinical Judgment; Feasibility and Residents' Perception.

OBJECTIVE: In surgical training, most assessment tools focus on advanced clinical decision-making or operative skill. Available tools often require significant investment of resources and time. A high stakes oral examination is also required to become board-certified in surgery. We developed Individual Clinical Evaluation (ICE) to evaluate intern-level clinical decision-making in a time- and cost-efficient manner, and to introduce the face-to-face evaluation setting. DESIGN: Intern-level ICE consists of 3 clinical scenarios commonly encountered by surgical trainees. Each scenario was developed to be presented in a step-by-step manner to an intern by an attending physician or chief resident. The interns had 17 minutes to complete the face-to-face evaluation and 3 minutes to receive feedback on their performance. The feedback was transcribed and sent to the interns along with incorrect answers. Eighty percent correct was set as a minimum to pass each scenario and continue with the next one. Interns who failed were retested until they passed. Frequency of incorrect response was tracked by question/content area. After passing the 3 scenarios, interns completed a survey about their experience with ICE. SETTING: Beth Israel Deaconess Medical Center, an academic tertiary care facility located in Boston, Massachusetts. PARTICIPANTS: All first-year surgery residents in our institution (n = 17) were invited to complete a survey. RESULTS: All 2016-2017 surgical interns (17) completed the ICEs. A total of $171 (US) was spent conducting the ICEs, and an average of 17 minutes was used to complete each evaluation. In total, 5 different residents failed 1 scenario, with the most common mistake being: failing to stabilize respiration before starting management. After completing the 3 clinical scenarios, more than 90% of respondents agreed or strongly agreed that the evaluations were appropriately challenging for training level, and that the evaluations helped to identify personal strengths and weaknesses in skill and knowledge. The majority believed their knowledge improved as a result of the ICE and felt better prepared to manage these scenarios (88% and 76%, respectively). CONCLUSIONS: The ICE is an inexpensive and time efficient way to introduce interns to board type examinations and assess their preparedness for perioperative patient care issues. Common errors were identified which were able to inform educational efforts. ICEs were well accepted by residents. Next steps include extension of the ICE to PGY2 and PGY3 residents.