Tumor-infiltrating lymphocytes as a prognostic and predictive factor for Melanoma.

INTRODUCTION: Tumor-infiltrating lymphocytes (TILs) have been investigated as prognostic factors in melanoma. Recent advancements in assessing the tumor microenvironment in the setting of more widespread use of immune checkpoint blockade have reignited interest in identifying predictive biomarkers. This review examines the function and significance of TILs in cutaneous melanoma, evaluating their potential as prognostic and predictive markers. AREAS COVERED: A literature search was conducted on papers covering tumor infiltrating lymphocytes in cutaneous melanoma available online in PubMed and Web of Science from inception to 1 December 2023, supplemented by citation searching. This article encompasses the assessment of TILs, the role of TILs in the immune microenvironment, TILs as a prognostic factor, TILs as a predictive factor for immunotherapy response, and clinical applications of TILs in the treatment of cutaneous melanoma. EXPERT OPINION: Tumor-infiltrating lymphocytes play a heterogeneous role in cutaneous melanoma. While they have historically been associated with improved survival, their status as independent prognostic or predictive factors remains uncertain. Novel methods of TIL assessment, such as determination of TIL subtypes and molecular signaling, demonstrate potential for predicting therapeutic response. Further, while their clinical utility in risk-stratification in melanoma treatment shows promise, a lack of consensus data hinders standardized application.

High-risk Opioid Prescribing Associated with Postoperative New Persistent Opioid Use in Adolescents and Young Adults.

OBJECTIVE: In this study, we explored which postoperative opioid prescribing practices were associated with persistent opioid use among adolescents and young adults. BACKGROUND: Approximately 5% of adolescents and young adults develop postoperative new persistent opioid use. The impact of physician prescribing practices on persistent use among young patients is unknown. METHODS: We identified opioid-naïve patients aged 13 to 21 who underwent 1 of 13 procedures (2008-2016) and filled a perioperative opioid prescription using commercial insurance claims (Optum Deidentified Clinformatics Data Mart Database). Persistent use was defined as ≥ 1 opioid prescription fill 91 to 180 days after surgery. High-risk opioid prescribing included overlapping opioid prescriptions, co-prescribed benzodiazepines, high daily prescribed dosage, long-acting formulations, and multiple prescribers. Logistic regression modeled persistent use as a function of exposure to high-risk prescribing, adjusted for patient demographics, procedure, and comorbidities. RESULTS: High-risk opioid prescribing practices increased from 34.9% to 43.5% over the study period; the largest increase was in co-prescribed benzodiazepines (24.1%-33.4%). High-risk opioid prescribing was associated with persistent use (aOR 1.235 [1.12,1.36]). Receipt of prescriptions from multiple opioid prescribers was individually associated with persistent use (aOR 1.288 [1.16,1.44]). The majority of opioid prescriptions to patients with persistent use beyond the postoperative period were from nonsurgical prescribers (79.6%). CONCLUSIONS: High-risk opioid prescribing practices, particularly receiving prescriptions from multiple prescribers across specialties, were associated with a significant increase in adolescent and young adult patients' risk of persistent opioid use. Prescription drug monitoring programs may help identify young patients at risk of persistent opioid use.

The Road to Mastery: An Analysis of Goal Orientation in the Transition from Medical School to Surgical Residency.

PURPOSE: Goal orientation (GO) is a psychological construct which describes an individual's intrinsic motivation for learning in terms of mastery and performance goals. Mastery goals relate to the intrinsic drive to learn for the sake of learning, while performance goals are oriented toward validating one's own competence by seeking favorable judgments (Performance Approach; PAP) or avoiding negative judgments (Performance Avoid; PAV). Having a mastery GO has been shown to improve overall job satisfaction as well as optimize job performance. We therefore aimed to examine how GO changes during the transition to residency, which is a notoriously challenging period in medical education, and identify interventions that can increase mastery of GO. METHODS: The validated Goal Orientation in Surgical Trainees (GO-ST) instrument was administered to incoming surgical interns (n = 19) during orientation in a single, university-based program and again at 3 months into the internship. The perceived stress scale (PSS) was also administered at 3 months. Focus groups were used to assess resident perceptions and identify interventions at the end of the 3-month period. RESULTS: Eighteen interns (95%) completed a baseline GO-ST assessment and the 3-month follow-up, including the PSS. Mastery GO decreased from orientation to 3-month follow-up for the entire cohort, but this was not significant (3.89-3.63; p = 0.19). Preliminary interns showed a significant increase in PAV orientation after 3 months (3.28-3.67; p = 0.04) and had significantly lower mastery orientation scores at this time (4.07 vs 3.19; p = 0.02). PSS was significantly higher in preliminary interns at 3 months (18.56 vs 11.89; p = 0.04). Those who were predominantly mastery oriented had significantly lower perceived stress scores (11.64 vs 20.10; p = 0.002) compared with those that had performance goal orientations (PAP and PAV). Five interns (28%) participated in focus groups-identifying pertinent themes: 1) Perceptions of competence, 2) Training security; 3) Feedback approach, 4) Expectations of competence, and 5) Approaches to growth. CONCLUSION: Mastery GO declines during the transition to surgical residency. Maladaptive PAV orientation increases in preliminary interns due to different short-term priorities and assumptions of competence. Expectations and perceptions of intern competence by senior residents and attendings have a large impact on intern GO. Identifying interventions that optimize mastery goal orientation and minimize performance avoid orientation will potentially minimize intern stress, thereby improving both well-being and clinical performance.

Building an Equitable Surgical Training Pipeline: Leadership Exposure for the Advancement of Gender and Underrepresented Minority Equity in Surgery (LEAGUES).

OBJECTIVE: Underrepresented minority (URM) medical students face many educational challenges. Barriers include lack of equitable representation, scarce mentorship, and the effects of systemic racism. For students interested in diversity and health equity, perceptions of surgical culture may discourage pursuing surgical specialties. We describe a national pilot for a novel surgical pipeline program, Leadership Exposure for the Advancement of Gender and Underrepresented Minority Equity in Surgery (LEAGUES), which utilizes early exposure, mentorship, and community building to empower URM students in pursuit of academic surgical careers. DESIGN: A 4-week virtual program included pairing students with faculty research mentors, virtual skills sessions, and seminars on leadership, advocacy, and career development. Participants underwent semi-structured interviews before and after participation, assessing experiences with mentorship and research, interest in surgery, career aspirations, and perceived barriers to career goals. SETTING: Department of Surgery, Michigan Medicine, Ann Arbor, Michigan. PARTICIPANTS: Rising second-year medical students. RESULTS: All 3 participants were Latinx; 2 were first-generation college students. Participants had no surgical mentorship and limited research exposure, citing a desire to learn research methodology, connect with mentors, and build towards a career working with underserved communities as motivating factors for participation. Perceived barriers to a surgical career included surgical culture, burnout, and lack of research expertise or academic network necessary for success. At completion of the program, participants described several themes: (1) new positive perspective on academic surgical culture, (2) interest and confidence in research, (3) hope for improving health disparities, (4) networking and longitudinal mentorship connections contributing to a sense of surgical community, and (5) eagerness to share resources with colleagues at their home institutions. CONCLUSIONS: LEAGUES program participants acquired tools and motivation to pursue careers in surgery, and established valuable longitudinal network and mentor relationships. LEAGUES is a novel model for national surgical pipeline programs.

Association of caregiver-reported education with locked storage and disposal of prescription opioids after children's surgery.

PURPOSE: This study aimed to assess whether caregiver-reported storage and disposal education were associated with locked opioid storage and disposal of leftover opioids after children's surgery. METHODS: Caregivers of children <18 years who were prescribed an opioid were surveyed 7-21 days after surgery at an academic children's hospital (4/1/2018-3/31/2019) on opioid-related education and management practices (54% response rate). Multivariable logistic regression models were estimated for locked storage and disposal of leftover opioids as functions of storage and disposal education, adjusting for demographics, procedure, prescription characteristics, and postoperative day at time of survey. MAIN FINDINGS: Among 606 respondents, storage education was reported by 366 (60.4%) and locked storage by 111 caregivers (18.3%). Caregivers who reported verbal storage education (aOR 3.01 (95% CI 1.52-5.94); p = 0.001) or both written and verbal storage education (aOR 2.18 (95% CI 1.30-3.68); p = 0.003) were more likely to lock opioids in storage. Among 451 caregivers with leftover opioids, disposal education was reported by 226 (50.1%) and disposal by 111 caregivers (24.6%). There was no association between verbal and/or written disposal education with disposal. CONCLUSION: Caregivers infrequently reported education, locked storage, and disposal of leftover opioids after children's surgery. Education may improve locked opioid storage, but additional strategies are needed to increase disposal. TYPE OF STUDY: Treatment. LEVEL OF EVIDENCE: Level III.

Association of Opioid Quantity and Caregiver Education with Pain Control after Pediatric Tonsillectomy.

OBJECTIVE: To examine whether a service guideline reducing postoperative opioid prescription quantities and caregiver-reported education to use nonopioid analgesics first are associated with caregiver-reported pain control after pediatric tonsillectomy. STUDY DESIGN: Prospective cohort study (July 2018-April 2019). SETTING: Pediatric otolaryngology service at a tertiary academic children's hospital. SUBJECTS AND METHODS: Caregivers of patients aged 1 to 11 years undergoing tonsillectomy (N = 764) were surveyed 7 to 21 days after surgery regarding pain control, education to use nonopioid analgesics first, and opioid use. Respondents who were not prescribed opioids or had missing data were excluded. Logistic regression modeled caregiver-reported pain control as a function of service guideline implementation (December 2018) recommending 20 rather than 30 doses for postoperative opioid prescriptions and caregiver-reported analgesic education, adjusting for patient demographics. RESULTS: Among 430 respondents (56% response), 387 patients were included. The sample was 43% female with a mean age of 5.0 years (SD, 2.5). Pain control was reported as good (226 respondents, 58%) or adequate/poor (161 respondents, 42%). Mean opioid prescription quantity was 27 doses (SD, 7.9) before and 21 doses (SD, 6.1) after guideline implementation (P < .001). Education to use nonopioids first was reported by 308 respondents (80%). In regression, prescribing guideline implementation was not associated with pain control (adjusted odds ratio, 1.3; 95% CI, 0.9-2.0; P = .22), but caregiver-reported education to use nonopioids first was associated with a higher odds of good pain control (adjusted odds ratio, 1.9; 95% CI, 1.1-3.2; P = .02). CONCLUSION: Caregiver education to use nonopioid analgesics first may be a modifiable health care practice to improve pain control as postoperative opioid prescription quantities are reduced.