Cutting for Equity-Reconstructing the Culture of Surgery that is Still Toxic for Women Surgeons.

Women surgeons face sexism, hostile workplace environments, gender discrimination, sexual harassment and isolation in their training and practice settings, sometimes at significant personal cost. The stakes for telling these stories have been very high for female surgeons who fear exposure, lack of support, and retaliation. Times are changing and with more voices being raised, women are feeling more empowered to speak up. With the advent of #MeToo and #TimesUpHealthcare, communities are developing that create spaces for women to tell their stories. These narratives document the experiences of women surgeons and the resilience they demonstrate in overcoming the gender-related obstacles they face. While each experience is unique, there is considerable overlap in the themes revealed by these narratives. Despite the variations in their stories, these surgeons are in agreement that the culture of surgery needs to change and that the contributions that women can bring-empathy, collaboration, compassion, kindness, wisdom, empowerment, and zero tolerance for abusive behavior, to name a few-will enrich the culture of surgery and improve patient care.

Helping Her Heal: Randomized clinical trial to enhance dyadic outcomes in couples.

OBJECTIVE: The objective of this study was to test the short-term efficacy of a brief, fully manualized marital communication and interpersonal support intervention for couples facing recently diagnosed breast cancer. METHODS: A total of 322 women diagnosed within 6 months with stages 0 to III breast cancer and their 322 spouse caregivers were enrolled. Spouses in the experimental group received five 30- to 60-minute intervention sessions at 2-week intervals by master's-prepared patient educators; controls received the booklet, "What's Happening to the Woman I Love?" Outcomes were assessed at 3, 6, and 9 months using the linear mixed models within an intent-to-treat analysis. RESULTS: Compared with controls, at 3 months, spouse caregivers significantly improved on standardized measures of depressed mood, anxiety, cancer-related marital communication, interpersonal support, and self-care. All differences except depressed mood and anxiety were sustained at 9 months. Wives significantly improved at 3 months on marital communication and positive appraisal of spouses' interpersonal support; gains remained significant at 9 months. Compared with controls on chemotherapy, wives in the experimental group additionally improved on depressed mood and tended to improve on anxiety. CONCLUSIONS: A brief, fully manualized intervention delivered directly to spouse caregivers early in the course of their wives' medical treatment improves caregivers' self-care and behavioral-emotional adjustment and wives' positive view of their spouses' support and communication. The brevity and manualized structure of the intervention argue strongly for its scalability, use in cost-sensitive settings, and its potential dissemination through e-health channels.

The Johns Hopkins Fall Risk Assessment Tool: A Study of Reliability and Validity.

Patient falls and fall-related injury remain a safety concern. The Johns Hopkins Fall Risk Assessment Tool (JHFRAT) was developed to facilitate early detection of risk for anticipated physiologic falls in adult inpatients. Psychometric properties in acute care settings have not yet been fully established; this study sought to fill that gap. Results indicate that the JHFRAT is reliable, with high sensitivity and negative predictive validity. Specificity and positive predictive validity were lower than expected.

Accelerated Partial Breast Irradiation: Using the CyberKnife as the Radiation Delivery Platform in the Treatment of Early Breast Cancer.

We evaluate the CyberKnife (Accuray Incorporated, Sunnyvale, CA, USA) for non-invasive delivery of accelerated partial breast irradiation (APBI) in early breast cancer patients. Between 6/2009 and 5/2011, nine patients were treated with CyberKnife APBI. Normal tissue constraints were imposed as outlined in the National Surgical Adjuvant Breast and Bowel Project B-39/Radiation Therapy Oncology Group 0413 (NSABP/RTOG) Protocol (Vicini and White, 2007). Patients received a total dose of 30 Gy in five fractions (group 1, n = 2) or 34 Gy in 10 fractions (group 2, n = 7) delivered to the planning treatment volume (PTV) defined as the clinical target volume (CTV) +2 mm. The CTV was defined as either the lumpectomy cavity plus 10 mm (n = 2) or 15 mm (n = 7). The cavity was defined by a T2-weighted non-contrast breast MRI fused to a planning non-contrast thoracic CT. The CyberKnife Synchrony system tracked gold fiducials sutured into the cavity wall during lumpectomy. Treatments started 4-5 weeks after lumpectomy. The mean PTV was 100 cm(3) (range, 92-108 cm(3)) and 105 cm(3) (range, 49-241 cm(3)) and the mean PTV isodose prescription line was 70% for groups 1 and 2, respectively. The mean percent of whole breast reference volume receiving 100 and 50% of the dose (V(100) and V(50)) for group 1 was 11% (range, 8-13%) and 23% (range, 16-30%) and for group 2 was 11% (range, 7-14%) and 26% (range, 21-35.0%), respectively. At a median 7 months follow-up (range, 4-26 months), no acute toxicities were seen. Acute cosmetic outcomes were excellent or good in all patients; for those patients with more than 12 months follow-up the late cosmesis outcomes were excellent or good. In conclusion, the lack of observable acute side effects and current excellent/good cosmetic outcomes is promising. We believe this suggests the CyberKnife is a suitable non-invasive radiation platform for delivering APBI with achievable normal tissue constraints.

Within-subjects comparison of the HiRes and Fidelity120 speech processing strategies: speech perception and its relation to place-pitch sensitivity.

OBJECTIVES: Previous studies have confirmed that current steering can increase the number of discriminable pitches available to many cochlear implant (CI) users; however, the ability to perceive additional pitches has not been linked to improved speech perception. The primary goals of this study were to determine (1) whether adult CI users can achieve higher levels of spectral cue transmission with a speech processing strategy that implements current steering (Fidelity120) than with a predecessor strategy (HiRes) and, if so, (2) whether the magnitude of improvement can be predicted from individual differences in place-pitch sensitivity. A secondary goal was to determine whether Fidelity120 supports higher levels of speech recognition in noise than HiRes. DESIGN: A within-subjects repeated measures design evaluated speech perception performance with Fidelity120 relative to HiRes in 10 adult CI users. Subjects used the novel strategy (either HiRes or Fidelity120) for 8 wks during the main study; a subset of five subjects used Fidelity120 for three additional months after the main study. Speech perception was assessed for the spectral cues related to vowel F1 frequency, vowel F2 frequency, and consonant place of articulation; overall transmitted information for vowels and consonants; and sentence recognition in noise. Place-pitch sensitivity was measured for electrode pairs in the apical, middle, and basal regions of the implanted array using a psychophysical pitch-ranking task. RESULTS: With one exception, there was no effect of strategy (HiRes versus Fidelity120) on the speech measures tested, either during the main study (N = 10) or after extended use of Fidelity120 (N = 5). The exception was a small but significant advantage for HiRes over Fidelity120 for consonant perception during the main study. Examination of individual subjects' data revealed that 3 of 10 subjects demonstrated improved perception of one or more spectral cues with Fidelity120 relative to HiRes after 8 wks or longer experience with Fidelity120. Another three subjects exhibited initial decrements in spectral cue perception with Fidelity120 at the 8-wk time point; however, evidence from one subject suggested that such decrements may resolve with additional experience. Place-pitch thresholds were inversely related to improvements in vowel F2 frequency perception with Fidelity120 relative to HiRes. However, no relationship was observed between place-pitch thresholds and the other spectral measures (vowel F1 frequency or consonant place of articulation). CONCLUSIONS: Findings suggest that Fidelity120 supports small improvements in the perception of spectral speech cues in some Advanced Bionics CI users; however, many users show no clear benefit. Benefits are more likely to occur for vowel spectral cues (related to F1 and F2 frequency) than for consonant spectral cues (related to place of articulation). There was an inconsistent relationship between place-pitch sensitivity and improvements in spectral cue perception with Fidelity120 relative to HiRes. This may partly reflect the small number of sites at which place-pitch thresholds were measured. Contrary to some previous reports, there was no clear evidence that Fidelity120 supports improved sentence recognition in noise.

Use of the ABC care bundle to standardize guideline implementation in a cardiac surgical population: a pilot study.

A cardiac surgical progressive care unit implemented the ABC's of Cardiovascular Risk Reduction Care Bundle to determine whether the use of a packaged approach to medication prescription and lifestyle counseling would improve adherence to secondary risk-reduction guidelines in postcoronary artery bypass graft patients. A pilot study was carried out to assess changes in adherence to guideline recommendations post-Care Bundle implementation. Findings support using a systematic strategy to improve guideline adherence in this population.

Critical pathway effectiveness: assessing the impact of patient, hospital care, and pathway characteristics using qualitative comparative analysis.

OBJECTIVE: To qualitatively describe patient, hospital care, and critical pathway characteristics that may be associated with pathway effectiveness in reducing length of stay. DATA SOURCES/STUDY SETTING: Administrative data and review of pathway documentation and a sample of medical records for each of 26 surgical critical pathways in a tertiary care center's department of surgery, 1988-1998. STUDY DESIGN: Retrospective qualitative study. DATA COLLECTION/ABSTRACTION METHODS: Using information from a literature review and consultation with experts, we developed a list of characteristics that might impact critical pathway effectiveness. We used hypothesis-driven qualitative comparative analysis to describe key primary and secondary characteristics that might differentiate effective from ineffective critical pathways. PRINCIPAL FINDINGS: " All 7 of the 26 pathways associated with a reduced length of stay had at least one of the following characteristics: (1) no preexisting trend toward lower length of stay for the procedure (71 percent), and/or (2) it was the first pathway implemented in its surgical service (71 percent). In addition, pathways effective in reducing length of stay tended to be for procedures with lower patient severity of illness, as indicated by fewer intensive care days and lower mortality. Effective pathways tended to be used more frequently than ineffective pathways (77 versus 59 percent of medical records with pathway documents present), but high rates of documented pathway use were not necessary for pathway effectiveness. CONCLUSIONS: Critical pathway programs may have limited effectiveness, and may be effective only in certain situations. Because pathway utilization was not a strong predictor of pathway effectiveness, the mechanism by which critical pathways may reduce length of stay is unclear.

Lesbian health matters: a pap test education campaign nearly thwarted by discrimination.

The Pap test detects cell changes in the cervix that can be treated, preventing cancer from developing. Regular screening reduced cervical cancer deaths by 70% since 1950. Lesbians may not be adequately screened because of a misperception that they do not need Pap tests. The "Lesbian Health Matters" public and provider education campaign was implemented to address this problem. Paid advertisements were placed on two radio stations and in four newspapers. After 1 week, both radio stations cancelled the ads due to listener complaints about hearing the word "lesbian" on the radio. The community responded to this discriminatory action by demanding the campaign be completed, creating publicity that increased the campaign's reach to 34% of women in the region. A training program was implemented reaching 219 providers. Thirty-two hundred health providers were surveyed regarding lesbian-friendly practice. A database of 293 providers was created and 120 referrals made.

Pain experienced by laparoscopic donor nephrectomy patients in an academic medical setting.

CONTEXT: Since 1996, 414 laparoscopic live donor nephrectomy procedures have been completed at our institution. Although this procedure has gained acceptance within the past 5 years, little is known about its nursing implications. OBJECTIVE: The purpose of this performance improvement project was to identify pain management practices, satisfaction levels, and clinical outcomes among patients undergoing laparoscopic live donor nephrectomy. PATIENTS: Data were collected for a convenience sample of 70 patients for 18 months. INTERVENTION: Several pain management methods were used, including patient-controlled analgesia and intramuscular and oral medications. RESULTS: Pain ratings ranged from 3.2 to 3.8 for the first 36 hours postoperatively. The mean pain level did not differ significantly between pain regimes. At discharge, patients perceived a mean overall pain level of 5.0 but anticipated a pain level of 6.1. A significant negative correlation between satisfaction and pain rating also was noted. CONCLUSIONS: Opportunities exist to standardize current regimens of pain medications and address pain level and treatment 24 hours postoperatively.

Are critical pathways effective for reducing postoperative length of stay?

BACKGROUND: Many hospitals use critical pathways to attempt to reduce postoperative length of stay (PLOS) for diverse conditions and procedures. OBJECTIVE: To evaluate whether critical pathways were associated with reductions in postoperative PLOS after accounting for prepathway trends in PLOS. RESEARCH DESIGN: Retrospective cohort study, from 1988 to 1998. SETTING: Academic medical center department of surgery. SUBJECTS: A total of 10,960 admissions eligible for 1 of 26 critical pathways implemented from 1990 to 1996, from 2 years before to 2 years after each pathway implementation date. Coding definitions were developed and validated to identify admissions eligible for each pathway, and data were abstracted from the hospital's discharge database. MEASURE: A pathway was considered effective if, after its implementation, there was a statistically significant decrease in the prepathway trend for PLOS. RESULTS: Median number of annual eligible admissions per pathway was 59 (range, 18-706). Median PLOS for the prepathway periods was 8 days (interquartile range, 5-10 days). For 16 (62%) pathways, PLOS was already declining in the prepathway period. After adjusting for demographics, comorbidity, admission characteristics, and prepathway time trends in PLOS, 7 (27%) pathways were associated with a significant postimplementation decrease in the rate of change in PLOS (range among the 7 pathways, 5-45% decrease) and none with a significant increase from the prepathway trend for PLOS. CONCLUSION: Critical pathways may decrease postoperative stay for some, but not all, surgeries. Trends toward decreasing length of stay over time may reduce the impact of critical pathways on this outcome.

Vancomycin and gentamicin in neonates: hindsight, current controversies, and forethought.

The use of both vancomycin and gentamicin in the treatment of suspected or documented neonatal infections, while routine, is a challenge for bedside and advanced practice nurses caring for neonates in intensive care units. A review of the background information surrounding neonatal infections as well as the history, intended use, and the pharmacokinetic and pharmacodynamic properties of vancomycin and gentamicin is presented with the goal of aiding in proper treatment with these two medications. Specific attention is given to doses in special situations, means of drug monitoring, strategies for avoiding antibiotic resistance, alternative medication choices, and areas for future investigation.