Gauging the Acceptance of Telemedicine in Postoperative Evaluation of Uncomplicated Laparoscopic Appendectomy and Cholecystectomy.

Background: Telemedicine is a rising field, with continuous expansion into different realms of health care delivery. However, minimal research has been done to analyze the utilization in surgical specialties. This study aims to assess satisfaction and acceptance of postoperative telehealth care after uncomplicated general surgery cases. Methods: Patients who had undergone uncomplicated laparoscopic cholecystectomy or uncomplicated laparoscopic appendectomy were eligible to be enrolled in this study. Patients with gangrenous gallbladder, malignancy, operative complications, or appendix perforation were excluded. The experimental group underwent postoperative follow-up within a web-based platform (http://bluejeans.com), whereas the control group had an in-person clinic visit. Survey results containing satisfaction, comfort, and time usage were obtained. Likert scale 1-5 was utilized to quantify responses. Results: Thirty patients were enrolled into this prospective single intervention trial (20 experimental, 10 control). Ninety percent (n = 18) of the experimental group stated satisfaction with their visit, and 75% (n = 15) would suggest telemedicine usage to other physicians. Postoperative visit satisfaction was not statistically different between the experimental and control groups (4.2 vs. 4.5, p = 0.124). A higher percentage of the control group took >3 h for the visit than the telemedicine group (30% vs. 15%), with two individuals in the control group dedicating their full day to the visit, compared with zero individuals in the experimental group. Comfort with technology used during the visit was not statistically different between the telemedicine and in-person groups (4.35 vs. 4.5, p = 0.641). Conclusions: Telemedicine for postoperative evaluation on selective general surgery cases is feasible and provides adequate patient satisfaction and improved time utilization.

Older Patients with Advanced Chronic Kidney Disease and Their Perspectives on Prognostic Information: a Qualitative Study.

BACKGROUND: Prognostic information is key to shared decision-making, particularly in life-limiting illness like advanced chronic kidney disease (CKD). OBJECTIVE: To understand the prognostic information preferences expressed by older patients with CKD. DESIGN AND PARTICIPANTS: Qualitative study of 28 consecutively enrolled patients over 65 years of age with non-dialysis dependent CKD stages 3b-5, receiving care in a multi-disciplinary CKD clinic. APPROACH: Semi-structured telephone or in-person interviews to explore patients' preference for and perceived value of individualized prognostic information. Interviews were analyzed using inductive content analysis. KEY RESULTS: We completed interviews with 28 patients (77.7 ± SD 6.8 years, 69% men). Patients varied in their preference for prognostic information and more were interested in their risk of progression to end-stage kidney disease (ESKD) than in life expectancy. Many conflated ESKD risk with risk of death, perceiving a binary choice between dialysis and quick decline and death. Patients expressed that prognostic information would allow them to plan, take care of important business, and think about their treatment options. Patients were accepting of prognostic uncertainty and imagined leveraging it to nurture hope or motivate them to better manage risk factors. They endorsed the desire to receive prognosis of life expectancy even though it may be hard to accept or difficult to talk about but worried it could create helplessness for other patients in their situation. CONCLUSION: Most, but not all, patients were interested in prognostic information and could see its value in motivating behavior change and allowing planning. Some patients expressed concern that information on life expectancy might cause depression and hopelessness. Therefore, prognostic information is most appropriate as part of a clinical conversation that fosters shared decision-making and helps patients consider treatment risks, benefits, and burdens in context of their lives.

Hierarchical Task Analysis Reimagined as a Planning Tool for Surgery During Exploration Space Flight.

Background: Preparation for exploration class space flight requires planning to support human life in many circumstances including healthcare emergencies such as the need for acute surgical care, a notable example of which is appendicitis. Although performing a laparoscopic appendectomy on Earth is routine for a trained general surgeon, it is far from routine for a non-surgeon working in microgravity where IVs do not drip, drains do not drain, and gaseous anesthetic is out of the question. Because the procedure for laparoscopic appendectomy is so well documented, it was the ideal procedure on which to base a study on how to deconstruct a surgical procedure to examine all actions, skills, equipment, and supplies needed for success by non-surgeons working in an extreme environment. Study Design: Our challenge was to develop a task analysis model robust enough to include 3 performers (in the roles of surgeon, assistant, and anesthesiologist) including each action and instrument or supply item needed in chronological order, while indicating which actions were completed independently and which were done in tandem. We also had to indicate where variations in the actions would be determined by the negative response of the patient (failure mode), and which actions and supply items needed further research to accommodate working in microgravity. We opted to begin with a hierarchical task analysis model (HTA) because the steps in the task are sequential; but we expanded the typical linear presentation of data to a multi-column spread sheet with active links to instructional video clips where needed. Content development was an iterative process beginning with a scoping review of literature to select a baseline task analysis of the procedure. The SAGES 2010 approach was selected as most comprehensive, but logically focused on the surgeon's performance with few references to the assistant or anesthesiologist. Those gaps were filled using content from training materials developed for surgical technicians and nurse anesthetists. The second step was an expert review of the spread sheet to identify gaps and inadequacies. The third step was a minute comparison of spread sheet content to actions and equipment as documented on 2 videotapes of the procedure performed by our team surgeon on otherwise healthy patients. The final review was accomplished by replicating the procedure on 360° video (with narration) using the spread sheet as a guide, then cross checking and correcting the spread sheet to correspond with the 360° video. This test procedure was performed on a lightly preserved, fresh cadaver since working at that very slow, deliberate pace would not be in the best interest of an actual patient. Results: In this study, simulation was actually used to test the expanded HTA rather than to evaluate a learner. The final spread sheet included 178 lines, 13 columns, 13 illustrations, and 4 active links to instructional video clips. Thirteen items or issues were identified as needing further research, 8 action sequences were identified as generalizable skills, and 27 supply or equipment items were identified as multipurpose. Excluding the pharmaceuticals necessary for IV general anesthesia (that research is on-going), we were able to replicate a laparoscopic appendectomy on a fresh cadaver using no more than 30 items. The procedure was done using 3 trocars with very few instrument exchanges through the trocars since the surgical assistant assumed the role of laparoscopic camera operator during the procedure. Conclusion: An expanded HTA of a surgical procedure can produce many useful outcomes including integrated training for all team members, review of instrumentation and supplies and, in our case, identifying areas for adapting to an extreme environment. Using an interdisciplinary team including instructional designers, subject matter experts from medicine and biomedical engineering, and media production enriched the process.

Impact of the Lack of Diversity Within Surgery Career Pathways and Mitigating Factors.

The lack of diversity in surgical career pathways impacts the cultural competence of the learning and working environment, the variety of leadership styles found within surgical leadership, and the ability of an organization to achieve equity in the workplace due to ongoing mistrust and untouched bias. Leading mitigating factors include developing pathways for greater numbers of diverse people at the high school and college level and implicit bias training. Though educators have had some success with these factors in the initial stages of diversifying early pathways, these factors are not yet correlated to entry into a surgical career. Future solutions to the lack of diversity in surgery will be predicated on surgeons collectively valuing justice, equity, diversity, and inclusion.

"Who Doesn't Like Receiving Good News?" Perspectives of Individuals Who Received Genomic Screening Results by Mail.

As genomic sequencing expands to screen larger numbers of individuals, offering genetic counseling to everyone may not be possible. One approach to managing this limitation is for a genetic counselor to communicate clinically actionable results in person or by telephone, but report other results by mail. We employed this approach in a large genomic implementation study. In this paper, we describe participants' experiences receiving genomic screening results by mail. We conducted 50 semi-structured telephone interviews with individuals who received neutral genomic screening results by mail. Most participants were satisfied receiving neutral results by mail. Participants generally had a good understanding of results; however, a few participants had misunderstandings about their genomic screening results, including mistaken beliefs about their disease risk and the comprehensiveness of the test. No one reported plans to alter health behaviors, defer medical evaluations, or take other actions that might be considered medically problematic. Reporting neutral results by mail is unlikely to cause recipients distress or generate misunderstandings that may result in reduced vigilance in following recommended preventive health strategies. Nonetheless, some individuals may benefit from additional genetic counseling support to help situate their results in the context of personal concerns and illness experiences.

Integrating Genomic Screening into Primary Care: Provider Experiences Caring for Latino Patients at a Community-Based Health Center.

INTRODUCTION: Minority communities have had limited access to advances in genomic medicine. Mayo Clinic and Mountain Park Health Center, a Federally Qualified Health Center in Phoenix, Arizona, partnered to assess the feasibility of offering genomic screening to Latino patients receiving care at a community-based health center. We examined primary care provider (PCP) experiences reporting genomic screening results and integrating those results into patient care. METHODS: We conducted open-ended, semi-structured interviews with PCPs and other members of the health care team charged with supporting patients who received positive genomic screening results. Interviews were recorded, transcribed, and analyzed thematically. RESULTS: Of the 500 patients who pursued genomic screening, 10 received results indicating a genetic variant that warranted clinical management. PCPs felt genomic screening was valuable to patients and their families, and that genomic research should strive to include underrepresented minorities. Providers identified multiple challenges integrating genomic sequencing into patient care, including difficulties maintaining patient contact over time; arranging follow-up medical care; and managing results in an environment with limited genetics expertise. Providers also reflected on the ethics of offering genomic sequencing to patients who may not be able to pursue diagnostic testing or follow-up care due to financial constraints. CONCLUSIONS: Our results highlight the potential benefits and challenges of bringing advances in precision medicine to community-based health centers serving under-resourced populations. By proactively considering patient support needs, and identifying financial assistance programs and patient-referral mechanisms to support patients who may need specialized medical care, PCPs and other health care providers can help to ensure that precision medicine lives up to its full potential as a tool for improving patient care.

Experiences of Latino Participants Receiving Neutral Genomic Screening Results: A Qualitative Study.

PURPOSE: The aim of the study was to characterize experiences of Latino participants receiving genomic screening results. METHODS: Participants were recruited at a federally qualified health center in the USA. In-person, semi-structured interviews were conducted in either Spanish or English by a bilingual, bicultural interviewer. Questions focused on motivations for pursuing genomic sequencing, concerns about receiving genomic screening results, and perceived benefits of receiving genomic information. Interviews were audio-recorded, transcribed, and translated. RESULTS: Fifty individuals completed an interview; 39 were conducted in Spanish. Participants described mixed motivations for pursuing genomic screening. Participants viewed the benefits of genomic screening in relation to not only their personal health but to the health of their families and their communities. Participants tended to have few concerns about genomic screening. Those concerns related to potential loss of privacy, misuses of genomic information, and the possibility of receiving distressing results. Some participants had misunderstandings about the scope of the test and the potential implications of their results. Most felt it was better to know about a genetic predisposition to disease than to remain uninformed. Participants felt that genomic screening was worthwhile. DISCUSSION: This is one of the first studies to examine the experiences of Latino individuals receiving genomic screening results. Our results suggest that many Latino patients in the US see value in genomic screening and have limited concerns about its potential to cause harm. These results inform ongoing efforts to increase the availability of genomic medicine to underrepresented populations and add to our understanding of sociocultural drivers in the adoption of precision medicine.

Increasing access to individualized medicine: a matched-cohort study examining Latino participant experiences of genomic screening.

PURPOSE: Multiple efforts are underway to increase the inclusion of racial minority participants in genomic research and new forms of individualized medicine. These efforts should include studies that characterize how individuals from minority communities experience genomic medicine in diverse health-care settings and how they integrate genetic knowledge into their understandings of health-care needs. METHODS: As part of a large, multisite genomic sequencing study, we surveyed individuals to assess their decision to pursue genomic risk evaluation. Participants included Latino patients recruited at Mountain Park Health Center, a Federally Qualified Health Center in Phoenix, Arizona, and non-Latino patients recruited at a large academic medical center (Mayo Clinic in Rochester, MN). Both groups agreed to receive individualized genomic risk assessments. RESULTS: Comparisons between cohorts showed that Latino respondents had lower levels of decisional conflict about pursuing genomic screening but generally scored lower on genetic knowledge. Latino respondents were also more likely to have concerns about the misuse of genomic information, despite both groups having similar views about the value of genomic risk evaluation. CONCLUSION: Our results highlight the importance of evaluating sociocultural factors that influence minority patient engagement with genomic medicine in diverse health-care settings.

"They're Not Going to Do Nothing for Me": Research Participants' Attitudes towards Elective Genetic Counseling.

As applications of genomic sequencing have expanded, offering genetic counseling support to all patients is arguably no longer practical. Additionally, whether individuals desire and value genetic counseling services for genomic screening is unclear. We offered elective genetic counseling to 5110 individuals prior to undergoing sequencing and 2310 participants who received neutral results to assess demand. A total of 0.2% of the study participants accessed genetic counseling services prior to sequencing, and 0.3% reached out after receiving neutral results. We later conducted 50 interviews with participants to understand why they did not access these services. Many interviewees did not recall the availability of genetic counseling and were unfamiliar with the profession. Interviewees described not needing counseling before sequencing because they understood the study and felt that they could cope with any result. Counseling was considered equally unnecessary after learning neutral results. Although the participants had questions about their results, they did not feel that speaking with a genetic counselor would be helpful. Genomic screening efforts that employ opt-in models of genetic counseling may need to clarify the potential value of genetic counseling support from the outset and feature genetic counseling services more prominently in program materials.

At a Moment's Notice: Community Advisory Board Perspectives on Biobank Communication to Supplement Broad Consent.

INTRODUCTION: To address ethical concerns about the of future research authorization, biobanks employing a broad model of consent can design ongoing communication with contributors. Notifying contributors at the time of sample distribution provides one form of communication to supplement broad consent. However, little is known about how community-informed governance might anticipate contributor responses and inform communication efforts. OBJECTIVE: We explored the attitudes of members of a three-site Community Advisory Board (CAB) network. CAB members responded to a hypothetical proposal for notifying biobank contributors at the time of sample distribution to researchers utilizing the biobank. METHODS: We used regularly scheduled CAB meetings to facilitate 3 large-group and 6 small-group discussions. Discussions were audio-recorded, transcribed, and analyzed for thematic content using descriptive thematic analysis. RESULTS: The results challenged our expectation of general support for the proposed communications. While CAB members identified some advantages, they were concerned about several potential harms to biobank contributors and the biobank. The CABs understood biobank communication in terms of an ongoing relationship with the biobank and a personal contribution to research. CONCLUSION: Our findings contribute to the emerging literature on community engagement in biobanking. Additional communication with biobank contributors can serve a variety of value-based objectives to supplement broad consent. Design of communication efforts by biobanks can be improved by CAB members' anticipation of the unintended consequences of additional contact with contributors. CAB members' holistic interpretation of communication efforts suggests that biobank leadership considers all communication options as part of a more comprehensive communications strategy.

An evaluation of dehydrated human amnion/chorion membrane allografts for pressure ulcer treatment: a case series.

OBJECTIVE: Pressure ulcers (PU; also known as pressure injuries) affect about three million adults in the US and cost an estimated $11 billion dollars annually to treat. Prevention is most desirable, however, once a patient develops a PU, the focus shifts to effective treatment and rapid closure to improve health outcomes. We sought to evaluate outcomes in 10 patients with category II and III PUs treated with dehydrated human amnion/chorion membrane (dHACM) allografts. METHOD: All patients were treated with weekly application of dHACM plus standard wound care (SoC) and followed for eight weeks. RESULTS: Of the PUs, two were category II and eight were category III. The average PU size at dHACM initiation was 3.42±1.76cm2. After the first application of dHACM 7/10 (70%) of PUs responded to treatment with a reduction in wound size. Within two weeks of dHACM initiation into the plan of care, 4/10 (40%) of PUs had reduced in size by >50%. By week four, 60% of PUs (6/10) had reduced in size by >50%. Overall, during the eight week evaluation period, 9/10 PUs reduced in size, three of which healed completely. CONCLUSION: dHACM allografts appear to be a viable treatment option for category II and III PUs.

Assessing optimism and pessimism about genomic medicine: Development of a genomic orientation scale.

Efforts to characterize stakeholder attitudes about the implementation of genomic medicine would benefit from a validated instrument for measuring public views of the potential benefits and harms of genomic technologies, which would facilitate comparison across populations and clinical settings. We sought to develop a scale to evaluate attitudes about the future of genomic medicine. We developed a 21-item scale that examined the likelihood of various outcomes of genomic medicine. The scale was administered to participants in a genomic sequencing study. Exploratory factor analysis was conducted and bivariate correlations were calculated. The genomic orientation (GO) scale was completed by 2895 participants. A two-factor structure was identified, corresponding to an optimism subscale (16 items, α = 0.89) and a pessimism subscale (5 items, α = 0.63). Genomic optimism was positively associated with a perceived value of genetic test results, higher health literacy, and decreased decisional conflict about participation in a genomic research study. Genomic pessimism was associated with concerns about genetic testing, lower health literacy, and increased decisional conflict about the decision to participate in the study. The GO scale is a promising tool for measuring both positive and negative views regarding the future of genomic medicine and deserves further validation.

Managing the Unimaginable: Biobank Participant Views on Reconsent for Whole Genome Sequencing of Stored Biospecimens.

Background: DNA biobanks frequently obtain broad permissions from sample donors, who agree to allow their biospecimens to be used for a variety of future purposes. A limitation of this approach is that it may not be possible to discuss or anticipate all potential uses of biospecimens at the time patient consent is obtained. We surveyed biobank participants to clarify their views regarding the need to be informed about research involving whole genome sequencing (WGS). Methods: We invited 1200 participants in the Mayo Clinic Biobank to complete a survey inquiring about their support for WGS; their interest in being recontacted before WGS of their biospecimens; whether they would consent to WGS if asked; and the acceptability of proceeding with WGS if sample donors could not be reached. Results: Six hundred eighty-seven biobank participants returned completed surveys (57% response). More than 96% of biobank participants were supportive of WGS and would give permission for WGS of their sample, if asked. Nonetheless, 61% of biobank participants felt they should be recontacted before WGS was done. Participants were divided regarding the permissibility of conducting WGS if efforts to recontact sample donors were unsuccessful. Discussion: Our findings highlight a potential discrepancy between the broad permissions granted by biobank participants at the time they donated biospecimens and their views about the application of WGS to their samples. Biobank participants appear to value the ability to confirm their commitment to genetic research when the studies in question involve WGS, a technological capacity they may not have anticipated at the time they donated their biospecimens. Efforts to reevaluate biobank participants' views about the acceptability of new technologies may help to ensure alignment of participants' current beliefs and research applications that would have been difficult to anticipate at the time biospecimens were collected.

Should pretest genetic counselling be required for patients pursuing genomic sequencing? Results from a survey of participants in a large genomic implementation study.

PURPOSE: We assessed the decision-making of individuals pursuing genomic sequencing without a requirement for pretest genetic counselling. We sought to describe the extent to which individuals who decline genetic counselling reported decisional conflict or struggled to make a decision to pursue genomic testing. METHODS: We administered a 100-item survey to 3037 individuals who consented to the Return of Actionable Variants Empirical study, a genomic medicine implementation study supported by the National Institutes of Health (USA) eMERGE consortium. The primary outcomes of interest were self-reported decisional conflict about the decision to participate in the study and time required to reach a decision. RESULTS: We received 2895 completed surveys (response rate=95.3%), and of these respondents 97.8% completed the decisional conflict scale in its entirety. A majority of individuals (63%) had minimal or no decisional conflict about the pursuit of genomic sequencing and were able to reach a decision quickly (78%). Multivariable logistic regression analyses identified several characteristics associated with decisional conflict, including lower education, lower health literacy, lower self-efficacy in coping, lack of prior experience with genetic testing, not discussing study participation with a family member or friend, and being male. CONCLUSION: As genomic sequencing is used more widely, genetic counselling resources may not be sufficient to meet demand. Our results challenge the notion that all individuals need genetic counselling in order to make an informed decision about genomic sequencing.

Utilizing Surgical Bootcamps to Teach Core Entrustable Professional Activities to Senior Medical Students.

To promote residency preparedness, the Association of American Medical Colleges defined 13 core entrustable professional activities for entering residency (CEPAERs), which represent tasks that students should be able to perform on day one of residency. At the authors' institution, a four-week surgery boot camp course is offered to senior medical students, which may provide an effective mechanism for teaching the CEPAERs. Nine senior students participating in a surgery boot camp course were subjected to pre- and post-course surveys. Student expectations were closely aligned with the CEPAERs. Competence was demonstrated in all CEPAERs; however, four students did require remediation with Advanced Cardiovascular Life Support before achieving competence. In the "death on the wards module," we found a significant increase in student confidence (19.78, SD 1.47, P > 0.05 vs 31.56, SD 1.49, P < 0.01) and knowledge (16.11, SD 1.32, P > 0.05 vs 31.33, SD 2.04, P < 0.01). In a one-year follow-up survey, all participants agreed that the boot camp course was useful and positively impacted their intern year. Surgical boot camp courses provide an effective and reproducible means for teaching the CEPAERs and was found useful in preparing medical students for residency.

Management Approaches for Enterocutaneous Fistulas.

There are very few clinical studies that highlight a definitive and comprehensive guideline for the management of enterocutaneous fistulas. Most accepted guidelines are found in textbooks and are taken from expert advice and case reports. The goal of this review is to highlight advancements relevant to the management of enterocutaneous fistulas from the recent two to three years. Although strong evidence-based guidelines are lacking, the consensus is that a multidisciplinary team working with a clear treatment plan targeting multiple aspects of management can maximize patient outcomes.

Usefulness of virtual reality in assessment of medical student laparoscopic skill.

BACKGROUND: This study evaluates if undergraduate medical trainees' laparoscopic skills acquisition could be assessed using a virtual reality (VR) simulator and how the resultant metrics correlate with performance of Fundamentals of Laparoscopic Surgery (FLS) tasks. Our hypothesis is that the VR simulator metrics will correlate with passing results in a competency-based curriculum (FLS). MATERIALS AND METHODS: Twenty-eight fourth-year medical students applying for surgical residency were recruited to participate in a VR training curriculum comprised of camera navigation, hand eye coordination, and FLS tasks: circle cutting (CC), ligating loop (LL), peg transfer (PT), and intracorporeal knot tying (IKT). Students were given 8 wk to achieve proficiency goals, after which they were observed performing FLS tasks. The ability of the VR simulator to detect penalties in each of the FLS tasks and correlations of time taken to complete tasks are reported. RESULTS: Twenty-five students trained in all components of the curriculum. All students were proficient in camera navigation and hand eye coordination tasks. Proficiency was achieved in CC, LL, PT, and IKT by 21, 19, 23, and one student, respectively. VR simulation showed high specificity for predicting zero penalties on the observed CC, LL, and PT tasks (80%, 75%, and 80%, respectively). CONCLUSIONS: VR can be used to assess medical student's acquisition of laparoscopic skills. The absence of penalties in the simulator reasonably predicts the absence of penalties in all FLS skills, except IKT. The skills acquired by trainees can be used in residency for further monitoring of progress toward proficiency.

A Tick Antivirulence Protein Potentiates Antibiotics against Staphylococcus aureus.

New strategies are needed to combat antibiotic resistance, especially against pathogens such as methicillin-resistant Staphylococcus aureus A tick antifreeze glycoprotein, IAFGP, possesses potent antibiofilm properties against a variety of clinical pathogens, including S. aureus Synergy between IAFGP, or a peptide (P1) representative of a repeat region of the protein, with different antibiotics was assessed in vitro Antibiotics that synergized with either IAFPG or P1 were further evaluated in vivo using vertebrate and invertebrate infection models. IAFGP readily enhanced the efficacy of antibiotics against S. aureus Synergy with daptomycin, an antibiotic used to treat methicillin-resistant S. aureus, was observed in vitro and in vivo using iafgp-transgenic mice and flies. Furthermore, synergy with ciprofloxacin or gentamicin, antibiotics not generally used to treat S. aureus, was also perceived. The combined effect of the antibiotic and IAFGP was associated with improved permeation of the antibiotic into the cell. Our results highlight that synergy of IAFGP with antibiotics traditionally used to treat this pathogen, and enhancement of the potency of antibiotics not commonly used against this microbe, can provide novel alternative therapeutic strategies to combat bacterial infections.