Preparing Anesthesiology Residents for Operating Room Communication Challenges: A New Approach for Conflict Resolution Training.

BACKGROUND: The hierarchical culture in high-stake areas such as operating rooms (ORs) may create volatile communication challenges. This unfunded exploratory study sought to establish whether a conflict resolution course was effective in preparing anesthesiology residents to handle and deescalate disagreements that may arise in the clinical environment, especially when challenging a surgeon. METHODS: Thirty-seven anesthesiology residents were assessed for ability to deescalate conflict. Nineteen had completed a conflict resolution course, and 18 had not. The 2-hour course used 10 videotaped vignettes that showed attending anesthesiologists, patients, and surgeons challenging residents in a potentially confrontational situation. Guided review of the videos and discussions was focused on how the resident could optimally engage in conflict resolution. To determine efficacy of the conflict resolution course, we used simulation-based testing. The setting was a simulated OR with loud music playing (75-80 dB) under the control of the surgeon. The music was used as a tool to create a potential, realistic confrontation with the surgeon to test conflict resolution skills. The initial evaluation of the resident was whether they ignored the music, asked for the surgeon to turn it off, or attempted to turn it off themselves. The second evaluation was whether the resident attempted to deescalate (eg, calmly negotiate for the music to be turned off or down) when the surgeon was scripted to adamantly refuse. Two trained observers evaluated residents' responses to the surgeon's refusal. RESULTS: Of the residents who experienced the confrontational situation and had not yet taken the conflict resolution course, 1 of 5 (20.0%; 95% CI, 0.5-71.6) were judged to have deescalated the situation. In comparison, of those who had taken the course, 14 of 15 (93.3%; 95% CI, 68.1-99.8) were judged to have deescalated the situation (P = .002). Only 2 of 19 (10.5%; 95% CI, 1.3-33.1) of those who completed the course ignored the music on entering the OR versus 10 of 18 (55.6%; 95% CI, 30.8-78.5) who did not complete the course (P = .004). CONCLUSIONS: This study suggests that a conflict resolution course may improve the ability of anesthesiology residents to defuse clinical conflicts. It also demonstrated the effectiveness of a novel, simulation-based assessment of communication skills used to defuse OR confrontation.

Why Money Alone Can't (Always) "Nudge" Physicians: The Role of Behavioral Economics in the Design of Physician Incentives.

Behavioral economics seeks to define how humans respond to incentives, how to maximize desired behavioral change, and how to avoid perverse negative impacts on work effort. Relatively new in their application to physician behavior, behavioral economic principles have primarily been used to construct optimized financial incentives. This review introduces and evaluates the essential components of building successful financial incentive programs for physicians, adhering to the principles of behavioral economics. Referencing conceptual publications, observational studies, and the relatively sparse controlled studies, the authors offer physician leaders, healthcare administrators, and practicing anesthesiologists the issues to consider when designing physician incentive programs to maximize effectiveness and minimize unintended consequences.

Targeted Use of Alcohol-Based Hand Rub on Gloves During Task Dense Periods: One Step Closer to Pathogen Containment by Anesthesia Providers in the Operating Room.

BACKGROUND: Anesthesia providers' hand hygiene practices in the operating room may contribute to the transmission of bacteria. There is a debate, however, over the best approaches for pathogen containment during task dense periods (induction and extubation) of anesthesia care. A novel approach to reducing pathogen spread during these task dense periods is the use of alcohol-based hand rub on gloves when it may be difficult to either change gloves or clean hands. METHODS: To evaluate the impact of alcohol-based hand rub on gloves, we estimated perforation rates of 50 gloves that were worn as pairs by volunteers for 2 hours at a time applying alcohol-based hand rub every 15 minutes (total of 8 alcohol-based hand rub applications per pair of gloves). We also identified perforation rates of 50 new, unused gloves. To evaluate the ability to perform routine anesthesia functions, volunteers were asked to pick up a coin from a table top and document whether the gloves felt normal or sticky at each 15-minute period. RESULTS: Fifty new gloves (not exposed to alcohol-based hand rub) were tested for integrity using the Food and Drug Administration-approved process, and one was found to have a microperforation. Of the 50 gloves that had been applied with alcohol-based hand rub 8 times, no microperforations were identified. All volunteers demonstrated tactile competence by picking up a coin from a table top after 8 alcohol-based hand rub applications; in addition, as the number of alcohol-based hand rub applications progressed, the volunteers reported increased stickiness. CONCLUSIONS: This study suggests that the use of alcohol-based hand rub on commonly used nitrile examination gloves does not compromise glove integrity or hamper the ability to safely perform routine anesthesia functions.

Does Adherence to World Health Organization Hand Hygiene Protocols in the Operating Room Have the Potential to Produce Irritant Contact Dermatitis in Anesthesia Providers?

Anesthesia providers have the burden of constant hand hygiene during task dense periods. The requirement for hand hygiene often demands frequent application of alcohol-based hand rub. To assess whether frequent alcohol-based hand rub use leads to skin changes or irritant contact dermatitis, volunteers cleaned their hands with alcohol-based hand rub every 15 minutes for 8 hours for 5 sequential days. They were examined by a dermatologist before and after and asked about subjective skin changes. Results suggest an increase in irritant contact dermatitis scores and subjective complaints.

Noninvasive follicular thyroid neoplasm with papillary-like nuclear features: An interobserver study of key cytomorphological features from a large academic medical centre.

OBJECTIVE: Because of the indolent nature of noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) and potential requisite for a more conservative treatment, it is crucial to identify features of this entity preoperatively. Our group recently published findings that there are several cytomorphological features that may be used as clues to distinguish NIFTP, papillary thyroid carcinoma (PTC) and follicular adenoma (FA) on fine needle aspiration. Therefore, we aimed to determine the interobserver reproducibility of these findings. METHODS: Presurgical fine-needle aspiration slides from NIFTP (n = 30), classic PTC (n = 30) and FA (n = 30) collected from 1/2013-8/2016 were reviewed by seven cytopathologists blindly. Presence of selected cytomorphological features was recorded and compared to determine percent agreement and inter-rater reliability among study cytopathologists using Gwet's AC1 statistics. RESULTS: For all the cytomorphological features, the overall percent agreement amongst the pathologists ranged between 65.1% and 86.8% (Gwet's AC1 0.30-0.80). There was substantial or almost perfect agreement (Gwet's AC1 > 0.60) in seven cytomorphological features in the classic PTC group, in six features in the NIFTP group and in five features in the FA group. There were no features with poor agreement (Gwet's AC1 < 0.0). CONCLUSIONS: The current study supports the reproducibility of our previous findings. The high level of agreement amongst pathologists for these groups, and particularly the NIFTP group, supports the notion that when viewed in combination as a cytological profile, these cytomorphological features may assist the cytopathologist in raising the possibility of NIFTP preoperatively. This can potentially aid clinicians in deciding whether more conservative treatment may be appropriate.

Learning curve and competence for volumetric laser endomicroscopy in Barrett's esophagus using cumulative sum analysis.

BACKGROUND AND STUDY AIMS: Little is known about the learning curve for image interpretation in volumetric laser endomicroscopy (VLE) in Barrett's esophagus (BE). The goal of this study was to calculate the learning curve, competence of image interpretation, sensitivity, specificity, and accuracy of VLE among novice users. METHODS: 31 novice users viewed 96 VLE images electronically at three academic institutions after a brief training session. There were 24 images of each histologic type: normal gastric cardia, normal esophageal squamous epithelium, non-neoplastic BE, and neoplastic BE. The users were asked to identify the correct tissue type and level of confidence. The cumulative summation (CUSUM) technique was used to construct a learning curve. RESULTS: 22 (71 %) of the physicians achieved VLE interpretation competency during their 96-slide review. Half of the physicians achieved competency at 65 images (95 % confidence interval [CI] 45 - 85). There was a statistically significant association between confidence in diagnosis and selecting the correct histologic tissue type (P < 0.001). The median accuracy for esophageal squamous epithelium, normal gastric cardia, non-neoplastic BE, and neoplastic BE was 96 % (95 %CI 95 % - 96 %), 95 % (95 %CI 94 % - 96 %), 90 % (95 %CI 88 % - 91 %), 96 % (95 %CI 95 % - 96 %). The overall accuracy was 95 % (95 %CI 93 % - 95 %). CONCLUSION: The majority of novice users achieved competence in image interpretation of VLE for BE, using a pre-selected image set, with a favorable learning curve after a brief training session. An electronic review of VLE images, prior to real-time use of VLE, is encouraged.

Putting POP-Q to the test: does C - D = cervical length?

INTRODUCTION AND HYPOTHESIS: We investigated the correlation between calculated cervical length (CCL) and gross specimen cervical length (GCL) after total vaginal hysterectomy (TVH) at the time of surgery for pelvic organ prolapse (POP). METHODS: This was a retrospective chart review of patients who had undergone TVH with reconstructive surgery for POP between 2013 and 2015. Patients without an intact specimen or documented cervical length in the pathology report were excluded. CCL was defined as the absolute difference between Pelvic Organ Prolapse Quantification (POP-Q) points C and D. GCL was obtained from the pathology report as the distance from the external to the internal os. The Bland-Altman method was used to assess the accuracy of POP-Q measurements with a priori ranges. Symptom severity was evaluated using the PFDI-20 questionnaire. Analysis of variance was used to model both GCL and CCL as a function of prolapse stage and the leading compartment. RESULTS: The final analysis included 202 subjects. Of the CCL measurements, 56.93% were within ±2 cm of GCL, while 36.14% were within ±1 cm. POP stage was significantly associated with GCL (P < 0.0024). CCL was significantly longer in patients with stage 4 POP (3.57 cm, 95% CI 3.13-4.00) than in those with stage 2 POP (P < 0.0017; mean 2.68 cm, 95% CI 2.45-2.92) and stage 3 POP (P < 0.0300; mean 2.94 cm, 95% CI 2.73-3.15). There were no significant correlations between PFDI scores and CCL or GCL. CONCLUSIONS: The agreement between POP-Q CCL (|C - D|) and GCL decreases with increasing POP-Q stage. There was no correlation between POP symptom severity and GCL or CCL. GCL significantly increased with increasing POP stage.

Introductions During Time-outs: Do Surgical Team Members Know One Another's Names?

BACKGROUND: Introductions are the first item of the time-out in the World Health Organization Surgical Safety Checklist (SSC). It has yet to be established that surgical teams use colleagues' names or consider the use of names important. A study was conducted to determine if using the SSC has a measurable impact on name retention and to assess if operating room (OR) personnel believe it is important to know the names of their colleagues or for their colleagues to know theirs. METHODS: All OR personnel were individually interviewed at the end of 25 surgical cases in which the SSC was used. They were asked (1) to name each OR participant, and (2) if they believed it is important to know the names of their team members and (3) for their team members to know their name. RESULTS: Of the 150 OR personnel interviewed, 147 (98%) named the surgery attending correctly. The surgery attending named only 44% of other OR staff (p <0.001). Only 62% of the OR staff correctly named the anesthesiology attending. The anesthesiology resident was the least well known but was able to name 82% of the others. The anesthesiology attending named his or her resident 100% of the time; the surgery attending correctly named his or her resident only 68% of the time (p = 0.002). CONCLUSION: This study suggests that OR personnel may consider introductions to be another bureaucratic hurdle instead of the safety check they were designed to be. It appears that this first step of the time-out is often being performed perfunctorily.

Clinical Significance of Nonsustained Ventricular Tachycardia on Stored Electrograms in Permanent Pacemaker Patients.

BACKGROUND: Permanent pacemaker electrograms record a variety of arrhythmias, including nonsustained ventricular tachycardia (NSVT). Little has been reported regarding incidence and clinical significance of NSVT in pacemaker patients after long-term monitoring. METHODS: Records from all patients implanted with Medtronic pacemakers (Medtronic, Minneapolis, MN, USA) at a single institution from January 1, 2009 to February 27, 2012 were reviewed. Demographic characteristics, imaging studies, pacemaker interrogations, and the Social Security Death Index were examined in patients older than 18 years of age who had ≥ 2 follow-up device interrogations. RESULTS: A total of 262 patients with an ejection fraction (EF) >40% were included in the final analysis with a mean follow-up of 29.2 months. Of these patients, 83.2% (n = 218) had hypertension (HTN) and 45.4% (n = 119) had NSVT. Among patients with an EF ≥ 55%, hypertensive patients had a NSVT burden 2.46 times greater than normotensive patients (incidence rate ratio: 2.46, 95% confidence interval: 1.10-5.50; P < 0.028). NSVT was not associated with increased mortality (P < 0.1229). CONCLUSION: In this cohort of patients, there was a high prevalence of HTN and while hypertensive subjects had a significantly higher NSVT burden, NSVT was not associated with an increased mortality.

Nosocomial Bloodstream Infections in Patients Receiving Extracorporeal Life Support: Variability in Prevention Practices: A Survey of the Extracorporeal Life Support Organization Members.

Nosocomial blood stream infections (BSIs) increase both the morbidity and the mortality of patients receiving extracorporeal life support (ECLS). The aim of this study was to identify common practices for blood stream infection prevention among national Extracorporeal Membrane Oxygenation (ECMO) programs. An electronic survey that comprised of a 16-item questionnaire was sent out to all ECMO program directors and coordinators within the United States that are part of the Extracorporeal Life Support Organization (ELSO) registry. A total of 152 institutions in 40 states were surveyed, with 85 (55%) responses. One-quarter of the institutions responded that an ECMO infection-prevention bundle or checklist was used during the cannulation. Less than half responded that an ECMO infection-prevention bundle or checklist was used for cannula maintenance, although a majority (82.9%) of institutions responded that a "standard approach to cannula dressings" was used. Half of the respondents reported antimicrobial prophylaxis was routinely prescribed for patients on ECMO, although specific regimens varied widely. Of the institutions, 34.2% reported sending daily blood cultures as part of routine surveillance. Smaller programs were more likely to send daily surveillance blood cultures (58.8%, P < .01). We found no clear consensus on practices used to prevent BSI in patients receiving ECMO.

The influence of high fidelity simulation on first responders retention of CPR knowledge.

INTRODUCTION: The purpose of this study was to identify the impact of high-fidelity simulation on the retention of basic life support cardiopulmonary resuscitation (CPR) knowledge among a group of healthcare providers (HCPs). METHODS: A twenty-five question exam was completed by nurses and nurse technicians over a two-year period before and after mandatory CPR training with high-fidelity simulation. RESULTS: Most HCPs scored near 50% or below the passing score (80%) with a mean range of scores between 28% and 84%. HCPs missed questions on the exam that requested specific details related to technique or human physiology during CPR. CONCLUSION: The current teaching method for basic life support may be enhanced by using high-fidelity simulation, but this modality alone is not enough to support HCPs retention of CPR knowledge. Additional studies are needed to identify strategies that will help HCPs remember specific and detailed information in the CPR algorithm.

Effects of prostaglandin E2 on p53 mRNA transcription and p53 mutagenesis during T-cell-independent human B-cell clonal expansion.

Within T-cell-dependent germinal centers, p53 gene transcription is repressed by Bcl-6 and is thus less vulnerable to mutation. Malignant lymphomas within inflamed extranodal sites exhibit a relatively high incidence of p53 mutations. The latter might originate from normal B-cell clones manifesting activation-induced cytosine deaminase (AID) and up-regulated p53 following T-cell-independent (TI) stimulation. We here examine p53 gene transcription in such TI clones, with a focus on modulatory effects of prostaglandin E2 (PGE2), and evaluate progeny for p53 mutations. Resting IgM(+)IgD(+)CD27(-) B cells from human tonsils were labeled with CFSE and stimulated in vitro with complement-coated antigen surrogate, IL-4, and BAFF ± exogenous PGE2 (50 nM) or an analog specific for the EP2 PGE2 receptor. We use flow cytometry to measure p53 and AID protein within variably divided blasts, qRT-PCR of p53 mRNA from cultures with or without actinomycin D to monitor mRNA transcription/stability, and single-cell p53 RT-PCR/sequencing to assess progeny for p53 mutations. We report that EP2 signaling triggers increased p53 gene transcriptional activity in AID(+) cycling blasts (P<0.01). Progeny exhibit p53 mutations at a frequency (8.5 × 10(-4)) greater than the baseline error rate (<0.8 × 10(-4)). We conclude that, devoid of the repressive influences of Bcl-6, dividing B lymphoblasts in inflamed tissues should display heightened p53 transcription and increased risk of p53 mutagenesis.

A New Approach to Pathogen Containment in the Operating Room: Sheathing the Laryngoscope After Intubation.

BACKGROUND: Anesthesiologists may contribute to postoperative infections by means of the transmission of blood and pathogens to the patient and the environment in the operating room (OR). Our primary aims were to determine whether contamination of the IV hub, the anesthesia work area, and the patient could be reduced after induction of anesthesia by removing the risk associated with contaminants on the laryngoscope handle and blade. Therefore, we conducted a study in a simulated OR where some of the participants sheathed the laryngoscope handle and blade in a glove immediately after it was used to perform an endotracheal intubation. METHODS: Forty-five anesthesiology residents (postgraduate year 2-4) were enrolled in a study consisting of identical simulation sessions. On entry to the simulated OR, the residents were asked to perform an anesthetic, including induction and endotracheal intubation timed to approximately 6 minutes. Of the 45 simulation sessions, 15 were with a control group conducted with the intubating resident wearing single gloves, 15 with the intubating resident using double gloves with the outer pair removed and discarded after verified intubation, and 15 wearing double gloves and sheathing the laryngoscope in one of the outer gloves after intubation. Before the start of the scenario, the lips and inside of the mouth of the mannequin were coated with a fluorescent marking gel. After each of the 45 simulations, an observer examined the OR using an ultraviolet light to determine the presence of fluorescence on 25 sites: 7 on the patient and 18 in the anesthesia environment. RESULTS: Of the 7 sites on the patient, ultraviolet light detected contamination on an average of 5.7 (95% confidence interval, 4.4-7.2) sites under the single-glove condition, 2.1 (1.5-3.1) sites with double gloves, and 0.4 (0.2-1.0) sites with double gloves with sheathing. All 3 conditions were significantly different from one another at P < 0.001. Of the 18 environmental sites, ultraviolet light detected fluorescence on an average of 13.2 (95% confidence interval, 11.3-15.6) sites under the single-glove condition, 3.5 (2.6-4.7) with double gloves, and 0.5 (0.2-1.0) with double gloves with sheathing. Again, all 3 conditions were significantly different from one another at P < 0.001. CONCLUSIONS: The results of this study suggest that when an anesthesiologist in a simulated OR sheaths the laryngoscope immediately after endotracheal intubation, contamination of the IV hub, patient, and intraoperative environment is significantly reduced.

Double gloves: a randomized trial to evaluate a simple strategy to reduce contamination in the operating room.

BACKGROUND: Oral flora, blood-borne pathogens, and bacterial contamination pose a direct risk of infection to patients and health care workers. We conducted a study in a simulated operating room using a newly validated technology to determine whether the use of 2 sets of gloves, with the outer set removed immediately after endotracheal intubation, may reduce this risk. METHODS: Forty-one anesthesiology residents (PGY 2-4) were enrolled in a study consisting of individual or group simulation sessions. On entry to the simulated operating room, the residents were asked to perform an anesthetic induction and tracheal intubation timed to approximately 6 minutes; they were unaware of the study design. Of the 22 simulation sessions, 11 were conducted with the intubating resident wearing single gloves, and 11 with the intubating resident using double gloves with the outer pair removed after verified intubation. Before the start of the scenario, we coated the lips and inside of the mouth of the mannequin with a fluorescent marking gel as a surrogate pathogen. After the simulation, an observer examined 40 different sites using a handheld ultraviolet light in the operating room to determine the transfer of surrogate pathogens to the patient and the patient's environment. Residents who wore double gloves were instructed by a confederate nurse to remove the outer set immediately after completion of the intubation. Forty sites of potential intraoperative pathogen spread were identified and assigned a score. RESULTS: The difference in the rate of contamination between anesthesiology residents who wore single gloves versus those with double gloves was clinically and statistically significant. The number of sites that were contaminated in the operating room when the intubating resident wore single gloves was 20.3 ± 1.4 (mean ± SE); the number of contaminated sites when residents wore double gloves was 5.0 ± 0.7 (P < 0.001). CONCLUSIONS: The results of this study suggest that when an anesthesiologist wears 2 sets of gloves during laryngoscopy and intubation and then removes the outer set immediately after intubation, the contamination of the intraoperative environment is dramatically reduced.

The use of a novel technology to study dynamics of pathogen transmission in the operating room.

Pathogenic organisms have been found in the intraoperative environment, potentially posing a risk of infection that could cause morbidity and mortality. In an effort to understand how a patient's bacteria can be spread throughout the operating room with the anesthesia provider as a vector, we conducted a study using recently developed experimental technology in a simulated operating room environment with a high-fidelity human patient simulator.

Predicting anti-fat attitudes: individual differences based on actual and perceived body size, weight importance, entity mindset, and ethnicity.

The purpose of the current study was to examine the relative impact of actual and perceived weight, weight importance, entity mindset, and ethnicity on anti-fat attitudes as well as to examine whether certain variables play the role of mediator. Participants included a multiethnic U.S. sample of 923 female undergraduates who completed a series of measures online. Lower BMI, higher perceived weight, higher importance of weight, endorsement of an entity mindset, and identification as White as compared to Black, Hispanic, or Asian predicted higher overall anti-fat attitudes. Examination of the individual Antifat Attitudes Questionnaire subscales (i.e. dislike, fear of fat, and willpower) using Relative Weight Analysis suggested that weight importance is an important predictor of multiple aspects of anti-fat attitudes. In addition, weight importance mediated the relationship between perceived weight and fear of fat as well as the relationship between ethnicity and dislike. Implications of findings and future research directions are discussed.

Using simulation technology to identify gaps between education and practice among new graduate nurses.

Applied knowledge was observed among nurse groups from a medical-surgical residency program to measure clinical performance during simulation training. Twenty groups of new graduate nurses were observed during five simulated clinical scenarios, and their performances were scored on a 24-item checklist. Nurse groups showed significant improvement (p < 0.001) in applied knowledge in four clinical domains from week 1 to week 5, and the results provided valuable information of the groups' overall performances. In two of the five scenarios, poor decisions and prioritization of competing tasks were factors associated with lower performance group scores. Complex patient conditions may pose a challenge for new graduate nurses, and standardized training during the residency program may help instructors recognize specific factors to address during the transition from education to practice.

Increasing hip fractures in patients receiving hemodialysis and peritoneal dialysis.

BACKGROUND/AIMS: Dialysis patients are at increased risk for hip fractures. Because changes in treatment of metabolic bone disease in this population may have impacted bone fragility, this study aims to analyze the longitudinal risk for fractures in hemodialysis (HD) and peritoneal dialysis (PD) patients. METHODS: Using the United States Renal Data System database from 1992 to 2009, the temporal trend in hip fractures requiring hospitalization was analyzed using an overdispersed Poisson regression model. Generalized Estimating Equations were used to assess the adjusted effect of dialysis modality on hip fractures. RESULTS: 842,028 HD and 87,086 PD patients were included. There was a significant temporal increase in hip fractures in both HD and PD with stabilization of rates after 2005. With stratification, the increase in fractures occurred in patients who were white and over 65 years of age. In adjusted analyses, HD patients had 1.6 times greater odds of hip fracture than PD patients (OR 1.60 95% CI 1.52, 1.68, p < 0.001). CONCLUSIONS: In contrast to the declining hip fracture rates in the general population, we identified a temporal rise in incidence of hip fractures in HD and PD patients. HD patients were at a higher risk for hip fractures than PD patients after adjustment for recognized bone fragility risk factors. The increase in fracture rate over time was limited to older white patients in both HD and PD, the demographics being consistent with osteoporosis risk. Further research is indicated to better understand the longitudinal trend in hip fractures and the discordance between HD and PD.

Increased bone fractures among elderly United States hemodialysis patients.

BACKGROUND: Fractures are an important cause of morbidity in hemodialysis patients. Multiple advances in the treatment of mineral and bone disease in hemodialysis patients have occurred. The purpose of this study was to determine whether the rate of fractures in hemodialysis patients has changed over time. METHODS: We studied US Renal Data System (USRDS) datasets to determine the rates of hospitalized fractures among hemodialysis patients. The primary outcome was incidence of fractures requiring hospitalization. The fracture rate per 1000 person-years was calculated by year from 1992 to 2009. The first 90 days after initiating dialysis were excluded from analysis. RESULTS: The incidence of hip and vertebral fractures increased from 12.5 fractures per 1000 patient-years in 1992 to 25.3 per 1000 patient-years in 2004 (P < 0.0001). Arm and leg fractures increased from 3.2 per 1000 patient-years in 1992 to 7.7 per 1000 patient-years in 2009 (P < 0.0001). The greatest increase in hip and verterbral fracture rate was seen in white patients >65 years of age. After 2004, the incidence rate of these fractures stabilized and subtly declined, but did not decrease significantly. CONCLUSIONS: Fracture rates increased significantly in hemodialysis patients from 1992 to 2004, with most of the increase occurring in elderly white patients. Assessment of fracture risk and management in dialysis patients at greatest risk requires greater emphasis and further study.

Preferences for cancer support group topics and group satisfaction among patients and caregivers.

This study investigated patients living with cancer and caregivers of patients living with cancer with regard to cancer support group content and satisfaction with this model of support (N = 3,723). Using a cross-sectional survey design participants were recruited through registered users of the NexCura Cancer Profiler website. Demographic and clinical variables, including perceived social support, were compared between patients and caregivers. Topic importance questions, and the proportion of patients and caregivers who selected those topics identified as very important and important, was calculated and compared. Group satisfaction was elicited and compared between patients and caregivers. This research can be used to inform, guide, and support group work helping address patient and caregiver need improving their quality of life.