Understanding Intraoperative Transfusion Decision-Making Variability: A Qualitative Study.

There is evidence of significant intraoperative red blood cell (RBC) transfusion variability that cannot be explained by case-mix, and may reflect unwarranted transfusions. The objective was to explore the source of intraoperative RBC transfusion variability by eliciting the beliefs of anesthesiologists and surgeons that underlie transfusion decisions. Interviews based on the Theoretical Domains Framework were conducted to identify beliefs about intraoperative transfusion. Content analysis was performed to group statements into domains. Relevant domains were selected based on frequency of beliefs, perceived influence on transfusion, and the presence of conflicting beliefs within domains. Of the 28 transfusion experts recruited internationally (16 anesthesiologists, 12 surgeons), 24 (86%) were Canadian or American and 11 (39%) identified as female. Eight relevant domains were identified: (1) Knowledge (insufficient evidence to guide intraoperative transfusion), (2) Social/professional role and identity (surgeons/anesthesiologists share responsibility for transfusions), (3) Beliefs about consequences (concerns about morbidity of transfusion/anemia), (4) Environmental context/resources (transfusions influenced by type of surgery, local blood supply, cost of transfusion), (5) Social influences (institutional culture, judgment by peers, surgeon-anesthesiologist relationship, patient preference influencing transfusion decisions), (6) Behavioral regulation (need for intraoperative transfusion guidelines, usefulness of audits and educational sessions to guide transfusion), (7) Nature of the behaviors (overtransfusion remains commonplace, transfusion practice becoming more restrictive over time), and (8) Memory, attention, and decision processes (various patient and operative characteristics are incorporated into transfusion decisions). This study identified a range of factors underlying intraoperative transfusion decision-making and partly explain the variability in transfusion behavior. Targeted theory-informed behavior-change interventions derived from this work could help reduce intraoperative transfusion variability.

Extended-duration thromboprophylaxis for abdominopelvic surgery: Development and evaluation of a risk-stratified patient decision aid to facilitate shared decision making.

Background: Extended-duration thromboprophylaxis is used to decrease risk of venous thromboembolism (VTE) after surgery but may increase the risk of bleeding. The decision to complete a course of extended-duration thromboprophylaxis can be challenging. Objective: The objective of this study was to develop an acceptable patient decision aid (PtDA) to facilitate shared decision making for the use of extended-duration thromboprophylaxis following major abdominal surgery. Methods: An evidence-based, risk-stratified PtDA was created. The evidence on benefits and harms of a 28-day postoperative course of low-molecular-weight heparin (LMWH) versus in-hospital prophylaxis only were synthesized. Outcomes included minor bleeding, major bleeding, clinically significant VTE, and fatal VTE. Risks were calculated and reported by Caprini score. Alpha testing of the PtDA draft with various stakeholders was performed using a 10-question survey to assess acceptability of the PtDA with patients, thrombosis experts, and surgeons. The primary outcome was the acceptability of the PtDA. Results: Acceptability testing was performed with 11 patients, 11 thrombosis experts, and 11 surgeons. Most responders felt the language on the PtDA was easy to follow (28/33, 85%), and that the information was well balanced between management options (9/11 [82%] patients; 17/21 [80%] clinicians). Most patients (9/11, 82%) and clinicians (18/22, 82%) believed it would be a useful clinical tool, and were satisfied with the overall quality of the PtDA (27/33, 82%). Conclusions: A risk-stratified, evidence-based PtDA was created to facilitate shared decision making for the use of extended-duration LMWH following major abdominal surgery. This clinical tool was acceptable with patients and physicians and is available at https://decisionaid.ohri.ca/decaids.html.

A pre-clerkship simulation-based procedural skills curriculum: decreasing anxiety and improving confidence of procedural skill performance.

INTRODUCTION: Pre-clerkship procedural skills training is not yet a standard across Canadian medical school curricula, resulting in limited exposure to procedures upon entering clerkship. While simulated skills training has been documented in the literature to improve performance in technical ability, anxiety and confidence have yet to be investigated despite their documented impact on performance and learning. This study therefore aims to evaluate the effect of pre-clerkship procedural skills training on medical student anxiety and confidence. METHODS: A procedural skills training program was designed based on an evidence-based near-peer, flipped classroom model of education. Ninety-two second-year medical students volunteered for the study. Fifty-six were randomized to the training group, and 36 were randomized to the control group. Students in the training group attended seven procedural skills tutorials over seven months. The control group represented the average medical school student without standardized procedural training. Student anxiety and confidence were assessed at the beginning and end of the program using the State Trait Anxiety Inventory and Confidence Questionnaires. RESULTS: Students who participated in the procedural skills program demonstrated greater reductions in their state anxiety and greater improvements in confidence compared to the control group. CONCLUSION: Longitudinal procedural skills training in the simulation setting has demonstrated improvements in anxiety and confidence among pre-clerkship medical students. These added benefits to training have the potential to ease medical students' transition into clerkship, while also contributing to a safer and more effective clinical experience. Therefore, future integration of standardized pre-clerkship procedural skills training within medical school curricula should be considered.

INTRODUCTION: Les cursus de pré-externat des facultés de médecine canadiennes ne prévoient pas systématiquement de formation sur les habiletés techniques avant, si bien qu'à leur arrivée à l'externat, les étudiants ont une exposition limitée aux gestes techniques. Tandis que l'amélioration des aptitudes techniques par la simulation est bien documentée, il n'y a aucune étude sur l'effet de ces simulations sur l'anxiété et la confiance malgré leur impact avéré sur la performance et l'apprentissage. Cette étude vise donc à évaluer l'effet d'une formation sur les habiletés techniques au pré-externat sur l'anxiété et la confiance des étudiants en médecine. MÉTHODES: Une formation sur les habiletés techniques a été conçue sur la base d'un modèle d'enseignement fondé sur les données probantes, par les quasi-pairs suivant une approche de classe inversée. Quatre-vingt-douze étudiants en deuxième année de médecine ont participé à l'étude sur une base volontaire. Cinquante-six d'entre eux ont été répartis au hasard dans le groupe qui devait recevoir la formation, et 36 dans le groupe contrôle. Les étudiants du groupe qui a reçu la formation ont assisté à sept tutoriels étalés sur une période de sept mois. Le groupe témoin représentait l'étudiant en médecine moyen sans formation normalisée axée sur les habiletés techniques. L'anxiété et la confiance des étudiants ont été évaluées au début et à la fin du programme à l'aide du questionnaire State Trait Anxiety Inventory (questionnaire sur l'anxiété chronique et réactionnelle) et d'un questionnaire sur la confiance. RÉSULTATS: Chez les étudiants qui ont participé au programme de formation sur les habiletés techniques, la baisse de l'anxiété et l'amélioration de la confiance en soi ont été plus importantes que chez les étudiants du groupe contrôle. CONCLUSION: La formation longitudinale axée sur les habiletés techniques en contexte de simulation a eu des effets positifs en ce qui concerne l'anxiété et la confiance chez les étudiants en médecine au pré-externat. La formation offre l'avantage supplémentaire de faciliter la transition des étudiants en médecine vers l'externat, tout en contribuant à rendre l'expérience clinique plus sûre et plus efficace. Il serait donc intéressant pour les facultés de médecine d'intégrer dans le cursus une formation normalisée axée sur les habiletés techniques au pré-externat.

The impact of measuring split kidney function on post-donation kidney function: A retrospective cohort study.

BACKGROUND: Studies have reported agreement between computed tomography (CT) and renography for the determination of split kidney function. However, their correlation with post-donation kidney function remains unclear. We compared CT measurements with renography in assessment of split kidney function (SKF) and their correlations with post-donation kidney function. METHODS: A single-centre, retrospective cohort study of 248 donors from January 1, 2009-July 31, 2019 were assessed. Pearson correlations were used to assess post-donation kidney function with renography and CT-based measurements. Furthermore, we examined high risk groups with SKF difference greater than 10% on renography and donors with post-donation eGFR less than 60 mL/min/1.73m2. RESULTS: 62% of donors were women with a mean (standard deviation) pre-donation eGFR 99 (20) and post-donation eGFR 67 (22) mL/min/1.73m2 at 31 months of follow-up. Post-donation kidney function was poorly correlated with both CT-based measurements and renography, including the subgroup of donors with post-donation eGFR less than 60 mL/min/1.73m2 (r less than 0.4 for all). There was agreement between CT-based measurements and renography for SKF determination (Bland-Altman agreement [bias, 95% limits of agreement] for renography vs: CT volume, 0.76%, -7.60-9.15%; modified ellipsoid,1.01%, -8.38-10.42%; CC dimension, 0.44%, -7.06-7.94); however, CT missed SKF greater than 10% found by renography in 20 out 26 (77%) of donors. CONCLUSIONS: In a single centre study of 248 living donors, we found no correlation between CT or renography and post-donation eGFR. Further research is needed to determine optimal ways to predict remaining kidney function after donation.

Extended thromboprophylaxis following major abdominal/pelvic cancer-related surgery: A systematic review and meta-analysis of the literature.

BACKGROUND: Postoperative venous thromboembolism (VTE) is a significant source of morbidity and mortality in cancer patients undergoing major abdominopelvic surgery. Many guidelines recommend the use of extended duration postoperative low molecular weight heparin (LMWH) thromboprophylaxis, although the evidence for its overall safety and efficacy is unclear. AIMS: We sought to assess the 30-day postoperative rates of VTE and bleeding complications following major abdominopelvic cancer surgery and to explore the potential risks and benefits of extended duration thromboprophylaxis with LMWH in such setting. METHODS: A systematic search of the literature was conducted. Observational studies and RCTs of adult patients that underwent abdominopelvic cancer surgery were included. Pooled proportions for the outcome measures and pooled relative risks for the extended duration thromboprophylaxis analyses were generated. RESULTS: A total of 68 studies (1,631,118 patients) were included in the analysis. The 30-day postoperative rate of VTE was 1.7% (95%CI: 1.5 to 1.9, I2 = 98%). The postoperative rate of clinically-relevant bleeding complications was 3.5% (95%CI: 1.6 to 6.1, I2 = 99%). Extended duration thromboprophylaxis was associated with a significant reduction in the incidence of clinical VTE (1.0% vs 2.1%; Risk ratio (RR) 0.48, 95%CI: 0.31 to 0.74; I2 = 0), without a significant increase in clinically-relevant bleeding (4.0% vs. 4.9%; RR 1.0, 95%CI: 0.66 to 1.5, I2 = 0). CONCLUSIONS: The overall risk of symptomatic VTE within 30 days of surgery was relatively low. Extended LMWH thromboprophylaxis following major abdominopelvic cancer surgery was associated with a reduced incidence of clinical VTE without an increase in clinically-relevant bleeding.

Exercise training differentially alters axial and appendicular marrow cellularity in old mice.

Aging gradually renders bone marrow hematopoietically inactive. Endurance exercise reverses this phenotype in young mice. Here, we determine the effects in aged mice. Twenty-two month old mice (n = 6) underwent a progressive exercise training protocol. In appendicular bones, marrow cellularity increased by 51% (p < 0.05) and marrow CFU, CFU-GM, and CAFC increased by 12%, 71%, and 86%, respectively (p < 0.05). Vertebral cellularity remained unchanged. The mechanical forces associated with treadmill exercise training may be responsible for these observations.

Skeletal muscle satellite cells are located at a closer proximity to capillaries in healthy young compared with older men.

BACKGROUND: Skeletal muscle satellite cells (SC) are instrumental in maintenance of muscle fibres, the adaptive responses to exercise, and there is an age-related decline in SC. A spatial relationship exists between SC and muscle fibre capillaries. In the present study, we aimed to investigate whether chronologic age has an impact on the spatial relationship between SC and muscle fibre capillaries. Secondly, we determined whether this spatial relationship changes in response to a single session of resistance exercise. METHODS: Muscle biopsies were obtained from the vastus lateralis of previously untrained young men (YM, 24 ± 3 years; n = 23) and older men (OM, 67 ± 4 years; n = 22) at rest. A subset of YM (n = 9) performed a single bout of resistance exercise, where additional muscle biopsies taken at 24 and 72 h post-exercise recovery. Skeletal muscle fibre capillarization, SC content, and activation status were assessed using immunofluorescent microscopy of muscle cross sections. RESULTS: Type II muscle fibre SC and capillary content was significantly lower in the YM compared with OM (P < 0.05). Furthermore, type II muscle fibre SC were located at a greater distance from the nearest capillary in OM compared with YM (21.6 ± 1.3 vs. 17.0 ± 0.8 µm, respectively; P < 0.05). In response to a single bout of exercise, we observed a significant increase in SC number and activation status (P < 0.05). In addition, activated vs. quiescent SC were situated closer (P < 0.05) to capillaries. CONCLUSIONS: We demonstrate that there is a greater distance between capillaries and type II fibre-associated SC in OM as compared with YM. Furthermore, quiescent SC are located significantly further away from capillaries than active SC after single bout of exercise. Our data have implications for how muscle adapts to exercise and how aging may affect such adaptations.