Education modalities for serious illness communication training: A scoping review on the impact on clinician behavior and patient outcomes.

BACKGROUND: Several clinician training interventions have been developed in the past decade to address serious illness communication. While numerous studies report on clinician attitudes and confidence, little is reported on individual education modalities and their impact on actual behavior change and patient outcomes. AIM: To examine what is known about the education modalities used in serious illness communication training and their impact on clinician behaviors and patient outcomes. DESIGN: A scoping review using the Joanna Briggs Methods Manual for Scoping Reviews was conducted to examine studies measuring clinician behaviors or patient outcomes. DATA SOURCES: Ovid MEDLINE and EMBASE databases were searched for English-language studies published between January 2011 and March 2023. RESULTS: The search identified 1317 articles: 76 met inclusion criteria describing 64 unique interventions. Common education modalities used were: single workshop (n = 29), multiple workshops (n = 11), single workshop with coaching (n = 7), and multiple workshops with coaching (n = 5); though they were inconsistently structured. Studies reporting improved clinician skills tended to be in simulation settings with neither clinical practice nor patient outcomes explored. While some studies reported behavior changes or improved patient outcomes, they did not necessarily confirm improvements in clinician skills. As multiple modalities were commonly used and often embedded within quality improvement initiatives, the impact of individual modalities could not be determined. CONCLUSION: This scoping review of serious illness communication interventions found heterogeneity among education modalities used and limited evidence supporting their effectiveness in impacting patient-centered outcomes and long-term clinician skill acquisition. Well-defined educational modalities and consistent measures of behavior change and standard patient-centered outcomes are needed.

A double-blinded, randomized trial comparing surgeon-administered transversus abdominis plane block with placebo after midline laparotomy in gynecologic oncology surgery.

BACKGROUND: Surgeon-administered transversus abdominis plane block is a contemporary approach to providing postoperative analgesia, and this approach is performed by transperitoneally administering local anesthetic in the plane between the internal oblique and transversus abdominis muscles to target the sensory nerves of the anterolateral abdominal wall. Although this technique is used in many centers, it has not been studied prospectively in patients undergoing a midline laparotomy. OBJECTIVE: This study aimed to evaluate whether surgeon-administered transversus abdominis plane block reduces postoperative opioid requirements and improves clinical outcomes. STUDY DESIGN: In this double-blind, randomized, placebo-controlled trial, patients with a suspected or proven gynecologic malignancy undergoing surgery through a midline laparotomy at 1 Canadian tertiary academic center were randomized to either the bupivacaine group (surgeon-administered transversus abdominis plane blocks with 40 mL of 0.25% bupivacaine) or the placebo group (surgeon-administered transversus abdominis plane blocks with 40 mL of normal saline solution) before fascial closure. The primary outcome was the total dose of opioids (in morphine milligram equivalents) received in the first 24 hours after surgery. The secondary outcomes included opioid doses between 24 and 48 hours, pain scores, postoperative nausea and vomiting, incidence of clinical ileus, time to flatus, and hospital length of stay. The exclusion criteria included contraindications to study medication, history of chronic opioid use, significant adhesions on the anterior abdominal wall preventing access to the injection site, concurrent nonabdominal surgical procedure, and the planned use of neuraxial anesthesia or analgesia. To detect a 20% decrease in opioid requirements with a 2-sided type 1 error of 5% and power of 80%, a sample size of 36 patients per group was calculated. RESULTS: From October 2020 to November 2021, 38 patients were randomized to the bupivacaine arm, and 41 patients were randomized to the placebo arm. The mean age was 60 years, and the mean body mass index was 29.3. A supraumbilical incision was used in 30 of 79 cases (38.0%), and bowel resection was performed in 10 of 79 cases (12.7%). Patient and surgical characteristics were evenly distributed. The patients in the bupivacaine group required 98.0±59.2 morphine milligram equivalents in the first 24 hours after surgery, whereas the patients in the placebo group required 100.8±44.0 morphine milligram equivalents (P=.85). The mean pain score at 4 hours after surgery was 3.1±2.4 (0-10 scale) in the intervention group vs 3.1±2.0 in the placebo group (P=.93). Clinically significant nausea or vomiting was reported in 1 of 38 patients (2.6%) in the intervention group vs 1 of 41 patients (2.4%) in the placebo group (P=.95). Time to first flatus, rates of clinical ileus, and length of stay were similar between groups. Subgroup analysis of patients with a body mass index of <25 and patients who received an infraumbilical incision showed similarly comparable outcomes. CONCLUSION: Surgeon-administered transversus abdominis plane block with bupivacaine was not found to be superior to the placebo intervention in reducing postoperative opioid requirements or improving other postoperative outcomes for patients undergoing a midline laparotomy. These results differed from previous reports evaluating the ultrasound-guided transversus abdominis plane block approach. Surgeon-administered transversus abdominis plane block should not be considered standard of care in postoperative multimodal analgesia.

Ondansetron in Pregnancy and the Risk of Congenital Malformations: A Systematic Review.

OBJECTIVE: Ondansetron, not approved for use in pregnancy, is increasingly being prescribed for nausea and vomiting in pregnancy and hyperemesis gravidarum. A number of recent lawsuits have highlighted the possibility that ondansetron may cause congenital malformations. The aim of this study was to systematically review epidemiological evidence on the potential association of prenatal exposure to ondansetron and congenital malformations. METHODS: Systematic searches in Medline and Embase were performed in June 2017 using controlled vocabulary and key words, and references of search results were reviewed. Full papers (RCTs, cohort, and case-control studies) were eligible for inclusion if they reported fetal outcomes of prenatal ondansetron exposure in humans. Excluded were: case reports, studies involving pre-medication with ondansetron prior to CS, animal studies, and foreign languages studies. RESULTS: Ten epidemiologic studies were included: five large retrospective cohort studies, two prospective observational studies, two population-based case-controls. and a retrospective case series. Sample sizes ranged from 17 to 1 501 434 infants exposed to ondansetron. A case-control study identified an association between prenatal exposure to ondansetron and cleft palate, and one cohort study found an increased risk of cardiovascular defects. These findings were not reproduced in the other studies. CONCLUSION: While further investigation of the literature is needed, our results highlight the paucity of evidence linking prenatal exposure to ondansetron to an increased risk of congenital malformations. There is a need for additional epidemiologic studies to confirm whether ondansetron represents a safe and effective alternative treatment for nausea and vomiting in pregnancy and hyperemesis gravidarum.

Effect of Uterine Cavity Sonographic Measurements on Medical Management Failure in Women With Early Pregnancy Loss.

OBJECTIVES: Medical management is commonly used among women with early pregnancy failure. The purpose of our study was to evaluate uterine content sonographic measurements for predicting medical management failure in early pregnancy loss. METHODS: We conducted a retrospective cohort study in a university-affiliated hospital center including all women discharged from the emergency department (ED) with a diagnosis of early pregnancy failure who had medical management with misoprostol between 2011 and 2013. Only women with sonograms available for review were included in our study. All images were reviewed and the following cavity measurements, excluding the endometrial lining, were measured: cavity anteroposterior distance, cavity longitudinal distance, cavity transverse distance, and cavity volume. Logistic regression analysis was used to identify measurements that were independently associated with a subsequent need for dilation and curettage (D&C) and an unplanned return to the ED. RESULTS: Among 823 women presenting to the ED with first-trimester bleeding, 227 met inclusion criteria. Of all measurements evaluated, the cavity anteroposterior distance was found to be independently associated with D&C and an unplanned return to the ED. When a cavity anteroposterior distance cutoff of 15 mm was used, women were more likely to require D&C (adjusted odds ratio, 2.65; 95% confidence interval, 1.31-5.36; P< .01) and to have an unplanned return to the ED (adjusted odds ratio, 2.59; 95% confidence interval, 1.41-4.79; P < .01). In women with a cavity anteroposterior distance of less than 15 mm, 87.1% had successful medical management of early pregnancy loss, and 80.0% did not require an unplanned return to the ED. CONCLUSIONS: Although there is a need for further validation, patients identified as having a cavity anteroposterior distance of less than 15 mm should be considered good candidates for successful medical management.

Effect of Planned Mode of Delivery in Women with Advanced Maternal Age.

OBJECTIVES: The purpose of this study was to determine the prognostic value of planned primary elective cesarean section versus planned vaginal delivery in women with advanced maternal age. METHODS: We conducted a population-based, retrospective cohort study using the United States' Health Care Cost and Utilization Project's Nationwide Inpatient Sample to evaluate maternal outcomes in women with advanced maternal age delivering from 2003 to 2012. Healthy women who underwent primary elective cesarean section constituted a surrogate for low-risk planned cesarean delivery. Logistic regression was used to compare outcomes between women with planned cesarean and planned vaginal delivery. RESULTS: Among seven million births, we identified 442,067 deliveries in healthy women with advanced maternal age. The planned cesarean group comprised 7.96 % of women in the cohort. When compared to healthy women in the planned vaginal group, women in the planned cesarean group had a significantly higher mortality ratio (2.56/10,000 vs. 0.44/10,000, p < 0.01). The planned cesarean group was also at higher odds of numerous complications, including peripartum hysterectomy OR 1.81 (1.36-2.40), p < 0.01, cardiac arrest OR 5.39 (4.54-6.38), p < 0.01, acute renal failure OR 3.39 (1.78-6.46), p < 0.01 and sepsis OR 2.27 (1.25-4.14), p < 0.01. CONCLUSIONS FOR PRACTICE: Planned cesarean section is a key factor significantly influencing maternal morbidity and mortality in healthy women with advanced maternal age. When possible, planned cesarean deliveries should be avoided in this population.

Effect of Menstrual Age on Failure of Medical Management in Women With Early Pregnancy Loss.

OBJECTIVE: Women with failure of an early pregnancy and a gestational age of <8 weeks are considered good candidates for medical management. The purpose of our study was to evaluate the effect of menstrual age on the outcome of medical management in women with loss of a pregnancy at an estimated gestational age<8 weeks by ultrasound (US). METHODS: We conducted a retrospective cohort study of all women discharged from the emergency department (ED) between 2011 and 2013 with a diagnosis of early pregnancy failure who were managed with misoprostol and who had a gestational age of <8 weeks on US. We used logistic regression to estimate the effect of menstrual age on failed medical management, defined as requiring dilatation and curettage (D and C) or having an unplanned return to the ED (URED). RESULTS: Among 823 pregnant women presenting to the ED with first trimester bleeding, 199 had pregnancy failure at <8 weeks by US and were discharged to use misoprostol. Increasing menstrual age was associated with an increased risk of D and C and URED. Specifically, the risk of D and C was 11.8% at <8 weeks, 18.5% at 8 to 9 weeks, 25.3% at 10 to 11 weeks, and 30.6% at ≥12 weeks (P<0.05). The risk of URED was 14.7% at <8 weeks, 27.8% at 8 to 9 weeks, 36.0% at 10 to 11 weeks, and 41.7% at ≥12 weeks (P<0.05). CONCLUSION: Increasing gestational age according to menstrual dates is associated with an increased rate of failed medical management in women with early pregnancy loss, independent of gestational age estimated by ultrasound. Gestational age by menstrual dates should be considered when discussing treatment options with women who have an early pregnancy failure.

Objectif : Les femmes qui connaissent une fausse couche précoce et qui présentent un âge gestationnel < 8 semaines sont considérées comme étant de bonnes candidates pour une prise en charge médicale. Notre étude avait pour objectif d'évaluer l'effet de l'âge menstruel sur l'issue de la prise en charge médicale des femmes qui connaissent une fausse couche à un âge gestationnel estimé à < 8 semaines par échographie. Méthodes : Nous avons mené une étude de cohorte rétrospective qui portait sur toutes les femmes qui ont, entre 2011 et 2013, obtenu leur congé du service des urgences en raison d'un diagnostic de fausse couche précoce, qui ont été traitées au moyen de misoprostol et chez qui l'échographie a déterminé que l'âge gestationnel était inférieur à huit semaines. Nous avons utilisé une régression logistique pour estimer l'effet de l'âge menstruel sur l'échec de la prise en charge médicale (lequel était défini par la nécessité de procéder à une dilatation-curetage [DC] ou d'effectuer un retour imprévu au service des urgences [RISU]). Résultats : Parmi 823 femmes enceintes s'étant présentées au service des urgences en raison de saignements au premier trimestre, 199 ont connu une fausse couche à < 8 semaines (âge gestationnel déterminé par échographie) et ont obtenu leur congé de l'hôpital à la suite de la mise en œuvre d'un traitement au misoprostol. Le risque de DC et de RISU était proportionnel à l'âge menstruel. Plus particulièrement, le risque de DC était de 11,8% à < 8 semaines, de 18,5 % à 8-9 semaines, de 25,3 % à 10-11 semaines et de 30,6 % à ≥ 12 semaines (P < 0,05). Le risque de RISU était de 14,7 % à < 8 semaines, de 27,8 % à 8-9 semaines, de 36,0 % à 10-11 semaines et de 41,7 % à ≥ 12 semaines (P < 0,05). Conclusion : La hausse de l'âge gestationnel (en fonction des dates menstruelles) est associée à une hausse du taux d'échec de la prise en charge médicale chez les femmes qui connaissent une fausse couche précoce, sans égard à l'âge gestationnel estimé par échographie. L'âge gestationnel déterminé en fonction des dates menstruelles devrait être pris en considération au moment de discuter des options de traitement avec les femmes qui connaissent une fausse couche précoce.

Intraoperative predictors of appendiceal abnormalities in patients with mucinous ovarian neoplasms.

OBJECTIVE: To evaluate intraoperative factors predicting appendiceal pathology during gynecologic oncology surgery for suspected mucinous ovarian neoplasms. METHODS: We conducted a retrospective study on 225 patients with mucinous ovarian neoplasms who underwent surgery for an adnexal mass with concurrent appendectomy between 2000 and 2018. Regression analyses were used to evaluate intraoperative factors, such as frozen section of the ovarian mass and surgeon's impression of the appendix in predicting appendiceal pathology. RESULTS: Most patients (77.8%) had a normal appendix on final pathology. Abnormal appendix cases (n = 26) included: metastasis from high-grade adenocarcinoma of the ovary (n = 1), neuroendocrine tumor of the appendix (n = 4), and low-grade appendiceal mucinous neoplasms (n = 26; 23 associated with a mucinous ovarian adenocarcinoma, 2 with a benign mucinous ovarian cystadenoma, and 1 with a borderline mucinous ovarian tumor). Combining normal intraoperative appearance of the appendix with benign or borderline frozen section yielded a negative predictive value of 85.1%, with 14.9% of patients being misclassified, and 6.0% having a neuroendocrine tumor or low-grade appendiceal neoplasm. CONCLUSION: Benign or borderline frozen section of an ovarian mucinous neoplasm and normal appearing appendix have limited predictive value for appendiceal pathology. Appendectomy with removal of the mesoappendix should be considered in all cases of mucinous ovarian neoplasm, regardless of intraoperative findings.

Sentinel lymph node biopsy in endometrial cancer: The new norm - A multicentre, international experience.

OBJECTIVES: The landscape of early-stage endometrial cancer treatment has changed dramatically over the last decade. The aim of this study is to provide a real-world view of the impact sentinel lymph node (SLN) biopsy has had on both clinical practice and patient outcomes. We describe detection and recurrence rates, as well as our experience in managing low volume lymph node disease. METHODS: We conducted an international, multicenter retrospective cohort study of 1012 patients with apparent early-stage endometrial cancer. Eligible patients underwent primary surgical staging and SLN biopsy in one of three large academic tertiary cancer centers in Canada or the Republic of Korea between 2015 and 2019. Demographic, surgical, clinicopathologic and recurrence data were collected through chart review. RESULTS: A total of 1012 patients were included. Overall SLN detection rate for all tracer types was 94.1% and recurrence rate was 5.3%. Higher FIGO stage (III vs. I/II) was associated with failed bilateral mapping (OR 2.27, 95%CI 1.14-4.52). We identified seven patients with micrometastases and 12 with isolated tumor cells, of which only one patient with micrometastases recurred at 17 months. Recurrence rates based on risk groups were 2.1%, 5.3%, 8.1%, and 9.9% for low, intermediate, high-intermediate, and high risk, respectively. CONCLUSION: SLN biopsy is safe and feasible. Detection rates are high, regardless of which tracer type is used and recurrence rates are low, especially in low and intermediate risk disease. Patients with low volume metastases appear to have low risk of recurrence, but replication of our findings by large prospective studies are needed to elucidate their clinical importance.

Cardiopulmonary resuscitation of pregnant women in the emergency department.

AIM: Little is known about outcomes of cardiopulmonary resuscitation (CPR) in pregnancy. The purpose of this study was to determine the prognostic value of pregnancy in women receiving CPR in the emergency department (ED). METHODS: We conducted a population-based, matched cohort study using the Nationwide Emergency Department Sample (NEDS) from 2006 to 2010. A cohort of pregnant women receiving CPR in the ED was compared to an age-matched cohort of non-pregnant women at a 1:10 ratio. Conditional logistic regression was used to calculate the odds ratio (OR) and corresponding 95% confidence intervals (95% CIs) for variables of interest and survival. RESULTS: Among 8162 women requiring CPR in the ED, we identified 157 pregnant women. Pregnancy was associated with better overall survival of 36.9% compared to 25.9% in non-pregnant women, OR 1.89 (1.32-2.70), p < 0.01. Traumatic injury was identified as a significant predictor of outcome in pregnancy. In non-trauma patients, pregnant women had significantly better odds of surviving CPR than non-pregnant women, OR 2.10 (1.41-3.13), p < 0.01. In cases of trauma, no significant difference was observed between groups. CONCLUSION: Although further studies are needed, CPR in pregnancy is associated with a better prognosis compared to non-pregnant women, with trauma status being a key factor predicting outcome in the pregnant patient.