Effect of Surgical Team Communication on Adherence to Opioid Discharge Guidelines in Post-Operative Inpatients.

OBJECTIVE: Current opioid prescribing guidelines state that post-operative inpatients who do not receive opioids in the 24 hours preceding discharge do not require an opioid prescription on discharge. This study was designed to assess providers' understanding of opioid discharge guidelines and explore drivers of adherence. DESIGN: An electronic survey was released which assessed knowledge of opioid discharge guidelines and probed surgical team communication. Kruskal-Wallis tests were used to determine differences between provider types. Spearman's correlation evaluated relationships between estimated and observed adherence to guidelines. SETTING: Yale New-Haven Hospital, (tertiary, university-based) PARTICIPANTS: Surgical residents, advanced practice providers (APPs) and attendings who discharged inpatients with opioids between November 2017-August 2019 RESULTS: The response rate was 36% (90/253), including 36% (49/136) of residents, 23% (13/56) of APPs, and 46% (28/61) of attendings. Seventy eight percent of participants believed patients who met the guideline should "never" or "sometimes" receive opioids on discharge. There was a significant difference between attending preferences and what residents (H22 = 202.7, p = 0.0001) and APPs (H22 = 24.6, p = 0.003) believed were the attending's preferences. Eleven percent of attendings preferred their patients to "most of the time" or "always" receive opioids on discharge, while 45% of residents and 54% of APPs reported the same. Overall, 57% of attendings reported they "most of the time" or "always" communicated their discharge preferences while 12% of residents (H22 = -20.4, p = 0.0003) and 8% of APPs (H22 = -23.5, p = 0.003) reported the same. There was no correlation between all groups' estimated adherence to the guidelines and observed adherence (rs = 0.135, p = 0.206). CONCLUSIONS: This study demonstrates that surgical residents, APPs, and attendings are aware of the guideline but breakdowns in communication between the attending and the surgical team may contribute to deviation from this guideline. Improving communication may lead to improved adherence to post-operative opioid discharge prescribing guidelines.

Characterizing the social media footprint of general surgery residency programs.

BACKGROUND: The medical community has increasingly embraced social media for a variety of purposes, including trainee education, research dissemination, professional networking, and recruitment of trainees and faculty. Platform choice and usage patterns appear to vary by specialty and purpose, but few studies comprehensively assess programs' social media presence. Prior studies assessed general surgery departments' Twitter use but omitted additional social media platforms and residency-specific accounts. OBJECTIVE: This study sought to broadly characterize the social media footprint of U.S. general surgery residency programs. METHODS: Using a protocolized search of program websites, social media platforms (Twitter, Facebook, Instagram, LinkedIn), and internet search, cross-sectional data on social media usage in March 2020 were collected for programs, their affiliated departments, their program directors (PDs), and their assistant/associate PDs (APDs). RESULTS: 318 general surgery residency programs, 313 PDs, and 296 APDs were identified. 47.2% of programs had surgery-specific accounts on ≥1 platform. 40.2% of PDs and APDs had ≥1 account on Twitter and/or LinkedIn. Program type was associated with social media adoption and Twitter utilization, with lower usage among university-affiliated and independent programs (p<0.01). CONCLUSIONS: Most general surgery residencies, especially non-university-based programs, lacked any department or residency accounts across Twitter, Facebook, and Instagram by March 2020. These findings highlight opportunities for increased social media engagement and act as a pre-pandemic baseline for future investigations of how the shift to virtual trainee education, recruitment, conferences, and clinical care affect social media use.

Residency Program Use of Social Media in the COVID-19 Era: An Applicant's Perspective.

General surgery residency programs' use of social media has exploded since early spring 2020, as it became clear that the COVID-19 pandemic would prevent away rotations and in-person interviews. Faced with the prospect of ranking programs they cannot visit, applicants are becoming reliant on programs' use of social media to showcase program culture, now a key recruitment tool. However, proper etiquette for applicant engagement with programs' social media accounts is unclear. Who administers these accounts - residents, program directors, program coordinators, or marketing staff? The subjectivity of criteria for "potentially unprofessional" content may pose disproportionate risks to female applicants and applicants of color. From this applicant's perspective, programs' recent use of social media has been informative and humanizing. It is our hope that departments, programs, and residents continue to post on social media throughout the application cycle. However, we applicants would benefit from clear guidance and expectations as to how to engage with residency programs via social media.

Increased Virulence of Descending Thoracic and Thoracoabdominal Aortic Aneurysms in Women.

BACKGROUND: This study evaluates sex differences in the natural history of descending thoracic and thoracoabdominal aortic aneurysms (DTTAAs). METHODS: In all, 907 patients with descending thoracic and thoracoabdominal aortic sizes greater than 3 cm were retrospectively reviewed. Growth rate estimates were performed utilizing an instrumental variables approach. Yearly complication rates as a function of aortic size were computed. RESULTS: There were 615 men (67.8%) and 292 women (32.2%) treated between 1990 and 2018, with mean aortic diameters of 4.1 ± 1.4 cm and 4.8 ± 1.6 cm, respectively (P < .001). The mean growth rate of DTTAAs was 0.17 cm per year in men and 0.25 cm per year in women (P < .001), increasing with increasing aneurysm size. Dissection, rupture, or aortic death or the combination of the three occurred at double the rate for women compared with men (5.8% vs 2.3% per year for the combined endpoint). Diameter of DTTAA greater than 5 cm was associated with 26.3% (male) and 33.1% (female) average yearly rates of the composite endpoint of rupture, dissection, and death (P < .05). The probability of fatal complications (rupture and death) increased sharply at 5.75 cm in both sexes. Between 4.5 and 5.75 cm, there was another hinge-point of higher probability of fatal complications among women. CONCLUSIONS: Women diagnosed with DTTAA fare worse. Faster aneurysm growth and higher rates of dissection, rupture, and aortic death are apparent among women. Current guidelines recommend surgical intervention at 5.5 to 6 cm for DTTAAs without sex considerations. Our findings suggest that increased virulence of DTTAA in women may indicate surgery at a somewhat smaller diameter.

Thoracic aortic aneurysm gene dictionary.

Thoracic aortic aneurysm is typically clinically silent, with a natural history of progressive enlargement until a potentially lethal complication such as rupture or dissection occurs. Underlying genetic predisposition strongly influences the risk of thoracic aortic aneurysm and dissection. Familial cases are more virulent, have a higher rate of aneurysm growth, and occur earlier in life. To date, over 30 genes have been associated with syndromic and non-syndromic thoracic aortic aneurysm and dissection. The causative genes and their specific variants help to predict the disease phenotype, including age at presentation, risk of dissection at small aortic sizes, and risk of other cardiovascular and systemic manifestations. This genetic "dictionary" is already a clinical reality, allowing us to personalize care based on specific causative mutations for a substantial proportion of these patients. Widespread genetic sequencing of thoracic aortic aneurysm and dissection patients has been and continues to be crucial to the rapid expansion of this dictionary and ultimately, the delivery of truly personalized care to every patient.

Generic and Brand-Name Thyroid Hormone Drug Use Among Commercially Insured and Medicare Beneficiaries, 2007 Through 2016.

CONTEXT: Generic drugs account for 9 out of 10 prescriptions dispensed in the United States but for a lower proportion of commonly prescribed thyroid hormone replacement therapies. OBJECTIVE: Characterize temporal patterns of generic and brand-name thyroid hormone drug use, including patient and prescriber characteristics associated with brand-name use. DESIGN AND SETTING: Cross-sectional longitudinal analysis of national data from a large administrative claims database from January 2007 through December 2016. PATIENTS: Adults with insurance coverage through commercial, Medicare Advantage, and Medicare Part D health plans. MAIN OUTCOME MEASURES: Generic and brand-name thyroid hormone drug use. RESULTS: From 2007 to 2016, the annual number of thyroid hormone treatment pharmacy fills increased from 8,905,836 in 2007 to 11,613,923 in 2016, 73.6% of which were for generic levothyroxine, 23.4% for brand-name levothyroxine, and the remaining for other formulations. Dispensing of generic thyroid hormone drugs increased from 59.8% in 2007 to 84.9% in 2016 and was consistently higher among Medicare Advantage and Medicare Part D when compared with the commercial beneficiary population. For all three beneficiary populations, use of brand-name products was less common among older adults and more common among women and those receiving prescriptions from endocrinologists and was more common among those of white race and with greater household income for the Medicare Advantage and commercial beneficiary populations (P < 0.001). CONCLUSIONS: Brand-name thyroid hormone product use declined from 2007 to 2016 among three large, national insurer beneficiary populations. Although certain patient characteristics were associated with brand-name use, prescriber specialty was the strongest predictor.