Defining conditions for effective interdisciplinary care team communication in an open surgical intensive care unit: a qualitative study.

OBJECTIVE: Poor interdisciplinary care team communication has been associated with increased mortality. The study aimed to define conditions for effective interdisciplinary care team communication. DESIGN: An observational cross-sectional qualitative study. SETTING: A surgical intensive care unit in a large, urban, academic referral medical centre. PARTICIPANTS: A total 6 interviews and 10 focus groups from February to June 2021 (N=33) were performed. Interdisciplinary clinicians who cared for critically ill patients were interviewed. Participants included intensivist, transplant, colorectal, vascular, surgical oncology, trauma faculty surgeons (n=10); emergency medicine, surgery, gynaecology, radiology physicians-in-training (n=6), advanced practice providers (n=5), nurses (n=7), fellows (n=1) and subspecialist clinicians such as respiratory therapists, pharmacists and dieticians (n=4). Audiorecorded content of interviews and focus groups were deidentified and transcribed verbatim. The study team iteratively generated the codebook. All transcripts were independently coded by two team members. PRIMARY OUTCOME: Conditions for effective interdisciplinary care team communication. RESULTS: We identified five themes relating to conditions for effective interdisciplinary care team communication in our surgical intensive care unit setting: role definition, formal processes, informal communication pathways, hierarchical influences and psychological safety. Participants reported that clear role definition and standardised formal communication processes empowered clinicians to engage in discussions that mitigated hierarchy and facilitated psychological safety. CONCLUSIONS: Standardising communication and creating defined roles in formal processes can promote effective interdisciplinary care team communication by fostering psychological safety.

A qualitative study of how team characteristics and leadership are associated with information sharing in multidisciplinary intensive care units.

BACKGROUND: Better information sharing in intensive care units has been associated with lower risk-adjusted mortality. This study explored how team characteristics and leadership are associated with information sharing in 4 intensive care units in a single large urban, academic medical center. METHODS: A qualitative study was conducted to understand how team characteristics and leadership are associated with information sharing. Qualitative data were conducted through ethnographic observations. One postdoctoral research fellow and one PhD qualitative researcher conducted nonparticipant observations of a Medical, Surgical, Neurological, and Cardiothoracic intensive care unit morning and afternoon rounds, as well as nurse and resident handoffs from May to September 2021. Field notes of observations were thematically analyzed using deductive reasoning anchored to the Edmondson Team Learning Model. This study included nurses, physicians (ie, intensivists, surgeons, fellows, and residents), medical students, pharmacists, respiratory therapists, dieticians, physical therapists, physician assistants, and nurse practitioners. RESULTS: We conducted 50 person-hours of observations involving 148 providers. Three themes emerged from the qualitative analysis: (1) team leaders used variable leadership techniques to involve team members in discussions for information sharing related to patient care, (2) predefined tasks for team members allowed them to prepare for effective information sharing during intensive care unit rounds, and (3) a psychologically safe environment allowed team members to participate in discussions for information sharing related to patient care. CONCLUSION: Inclusive team leadership is foundational in creating a psychologically safe environment for effective information sharing.

Reviewing ACGME Plastic Surgery Fellowship Case Logs: Is Surgical Experience Increasing?

INTRODUCTION: Over the last decade, there has been a 32% decrease in independent plastic surgery fellowships. The growing prevalence of 6-year integrated plastic surgery residencies, duty hour restrictions, and new subspecialty training fellowships for general surgeons have changed the training experience of plastic surgery fellows. METHODS: A retrospective review of the Accreditation Council for Graduate Medical Education (ACGME) case logs for graduating fellows of independent plastic surgery fellowships in the United States was conducted from 2011 to 2019. A linear regression analysis was conducted for each case log code and category, and a 95% level of confidence was assumed (α = 0.05). RESULTS: In 2011, 141 residents from 69 programs graduated with an average of 1469.7 cases. In 2019, 84 residents from 47 programs graduated with an average of 1952 cases. Index procedures significantly increased overall during the 9 y (P < 0.001). Categorical cases increased in esthetics (P < 0.001), including facelift, browlift, blepharoplasty, and more. Categorical cases increased in reconstructive surgery (P < 0.001), including treatment of deformities of the skin, lower extremities, and trunk, nerve decompression, and hand reconstruction. In breast procedures, an increase was seen in the reduction of mammoplasty, reconstruction, and treatment of other breast deformities. In head and neck procedures, an increase was seen in resection of head and neck neoplasms and secondary cleft lip repair. Decreases in procedural numbers were seen in primary cleft lip repair and hand reconstruction by primary closure. CONCLUSIONS: Despite a 32% decline in the number of independent plastic surgery fellowships over the last 9 y, plastic surgery fellows are obtaining significantly more surgical experience, both in esthetic and reconstructive surgery.

Jaundice and Elevated Beta-Human Chorionic Gonadotropin in a Female: Duodenal Choriocarcinoma, Not Pregnancy.

A 29-year-old woman with developmental delay presented with 2.5 weeks of jaundice of the skin with accompanying microcytic anemia (hemoglobin 6.8 g/dL, mean corpuscular volume 70.5 fL), elevated liver enzymes (aspartate aminotransferase 77 U/L, alanine aminotransferase 95 U/L, alkaline phosphatase 362 U/L), total bilirubin (9.5 mg/dL; 4.4 mg/dL direct), lipase (325 U/L), and cancer antigen 19-9 (68 U/mL). The patient had no prior gastrointestinal or liver disease. CT of the chest/abdomen/pelvis found a large lobulated non-fully obstructing mass in the second and third part of the duodenum, with endoscopic biopsies yielding an invasive, well-differentiated adenocarcinoma positive for cytoplasmic-stained cells to antibody to beta-human chorionic gonadotropin (hCG) antigen, suggesting a duodenal choriocarcinoma. Treatment included biliary drainage with a percutaneous transhepatic catheter and folinic acid, fluorouracil, and oxaliplatin (FOLFOX) chemotherapy, but a repeat CT scan five months later revealed an increase in tumor size and invasion; the patient died shortly thereafter. Beta-hCG-secreting choriocarcinomas are rare, rapidly growing, highly invasive malignant tumors and are uncommonly present at extragonadal sites.

Iliopsoas Mass, Hydroureter, and Back Squats: Using Biomechanics and Diagnostic Persistence to Diagnose a Germ Cell Tumor.

Background: Lesions in the iliopsoas compartment carry a broad differential diagnosis, including infection, tumor, or hematoma, and less commonly, retroperitoneal fibrosis, atrophy secondary to paralysis or muscle disease, foreign body, calcifications secondary to trauma, or rhabdomyolysis. Iliopsoas lesions are oftentimes accompanied by nonspecific symptoms, resulting in a delayed diagnosis. Case Report: We present the case of a 43-year-old male with acute radiating groin pain who was found to have a traumatic iliopsoas hemorrhagic lesion causing ureteral compression and ureteral dilatation, all presumably originating from a new-onset weight-training program. The patient had a drain placed for fluid removal and decompression, with the initial pathologic specimen confirming muscle fibers and an inflammatory process. Further patient symptomology with combined imaging and pathologic persistence yielded a diagnosis of a germ cell tumor. Conclusion: The importance of a plausible differential diagnosis combined with clinical diagnostic persistence must be stressed to all clinicians. Our patient's unrelenting inguinal pain led to a justified repeat psoas mass biopsy, imaging, and laboratory workup that led to a diagnosis of psoas germ cell tumor and immediate chemotherapy plan.

Acute Dysphagia Caused by Sarcomatoid Squamous Cell Carcinoma of the Esophagus.

Sarcomatoid squamous cell carcinoma of the esophagus is a rare etiology of esophageal cancer. Due to its large polypoid character, patients suffering from this disease typically present with progressive dysphagia, weight loss, odynophagia, or chest pain. Risk factors for esophageal cancer include smoking, alcohol use, and chronic gastroesophageal reflux disease. We present a case of an elderly female who presented to our hospital with a one-week history of progressive dysphagia secondary to a large esophageal sarcomatoid squamous cell carcinoma.

Immunomodulator and Biologic Agent Effects on Sleep Quality in Patients With Inflammatory Bowel Disease.

BACKGROUND: Inflammatory bowel disease (IBD) can disrupt normal sleep physiology and amplify a negative perception about quality of life. Evidence suggests increased circulation of inflammatory cytokines, such as tumor necrosis factor-alpha and interleukin-1, may play a role. METHODS: A total of 56 patients completed the Pittsburgh Sleep Quality Index (PSQI) to measure 7 sleep domains: sleep quality, sleep latency, sleep duration, sleep efficacy, sleep disturbance, sleep medications, and daytime dysfunction. Domain scores were summed to determine the presence or absence of sleep impairment. We compared patients taking immunomodulators or biologic agents to patients not on immunomodulator or biologic agent therapy. Demographics and IBD-related clinical information were collected to adjust for potential confounders that may secondarily affect sleep, such as body mass index, depression/anxiety, and sleep-affecting medications. RESULTS: The majority of patients with IBD (46 [82%]) reported poor sleep quality; 22 (79%) of the patients taking immunomodulators or biologic agents and 24 (86%) of the patients not on these therapies had a global PSQI score ≥5, suggestive of poor sleep quality. However, we found no significant difference between the 2 groups. When we analyzed the 7 PSQI sleep domains individually, we found improved sleep duration in the group taking immunomodulators or biologic agents compared to the group not on therapy, although the difference was not statistically significant. CONCLUSION: The majority of patients with IBD experience some degree of sleep impairment, and treatment with immunomodulators and biologic agents does not appear to improve sleep quality. A multicenter study with a larger sample size is warranted to better assess the diverse population of patients with IBD and the factors that impact their sleep. Routine assessment of sleep quality during IBD clinical encounters is recommended.

Bowel Preparations Administered the Morning of Colonoscopy Provide Similar Efficacy to a Split Dose Regimen: A Meta Analysis.

BACKGROUND: Comparative efficacy of same-day bowel preparations for colonoscopy remains unclear. AIMS: A meta-analysis of randomized controlled trials comparing the efficacy of same-day versus split dose bowel preparations for colonoscopy. METHODS: A systematic search was conducted in MEDLINE, clinicaltrials.gov, Cochrane Registry, EMBASE, SCOPUS, Web of Science and CINAHL. Studies were gathered using keywords: "morning preparation", "morning bowel preparation", "same day bowel preparation", and "colonoscopy." Pooled estimates of bowel preparation quality were analyzed among studies with categorical and continuous outcomes according to relative risk (RR) or mean difference (MD). A random effects model was chosen a priori for all analyses. RESULTS: A total of 1216 studies were retrieved with 15 trials meeting inclusion criteria. The categorical outcome of high quality bowel preparation for any same-day bowel preparation versus any split preparation was no different with a RR 0.95 [0.90;1.00] (P=0.62). Adenoma detection rate (ADR) was not different between groups, RR 0.97 [0.79;1.20] (P=0.81). Willingness to repeat and tolerability did not differ (RR 1.14 [0.96,1.36] (P=0.14) and RR 1.00 [0.96;1.04] (P=0.98), respectively. Adverse events were similar except for bloating, which was less frequent among the same-day preparation group, RR 0.68 [0.40;0.94] (P=0.02). CONCLUSION: No clinically significant differences were noted among recipients of same day or split dose regimens. Adenoma detection rate, willingness to repeat and tolerability were similar, but bloating and interference with sleep favored the same-day preparations. Given lack of clinical differences, patient preference should dictate timing of colonoscopy preparation.

Sigmoid Colonic Polyp as Initial Presentation of Metastatic Papillary Renal Cell Carcinoma.

BACKGROUND: Upon initial presentation, 25%-30% of patients with renal cell carcinoma have metastatic disease. Metastasis to the gastrointestinal tract is rare, but when it occurs, the large bowel is the least common site. CASE REPORT: A 75-year-old white male presented with vague abdominal symptoms and worsening hemoglobin and hematocrit levels. Colonoscopy revealed a polyp in the distal portion of the sigmoid colon. Histologic and immunohistochemical analysis suggested metastatic papillary renal cell carcinoma. CONCLUSION: To the best of our knowledge, this patient had a rare case of metastatic papillary renal cell carcinoma that metastasized to the colon and presented as a colon polyp.

Meckel Diverticulum Harboring a Rare Gastrointestinal Stromal Tumor.

BACKGROUND: Tumors within a Meckel diverticulum are a rare complication observed in only 0.5%-3.2% of symptomatic cases. The majority of tumors are benign, but some malignant tumors, such as gastrointestinal stromal tumors (GISTs) can occur. CASE REPORT: We report the case of a 48-year-old female who presented with severe abdominal pain and nausea and was found to have a GIST arising from a Meckel diverticulum. CONCLUSION: The differential diagnosis of a pelvic mass in a middle-aged female presenting with gastrointestinal symptoms must remain broad. With an atypical presentation site, distinguishing benign tumors from malignant tumors such as GISTs is of paramount importance.

Successful Liver Transplantation for Hyperammonemic Fibrolamellar Hepatocellular Carcinoma.

Fibrolamellar hepatocellular carcinoma is a rare hepatocellular tumor usually arising in noninfected and noncirrhotic livers. Only 2 cases accompanied by hyperammonemia due to intrahepatic shunting have been reported. A 23-year-old white woman presented with a 2-week history of nausea, vomiting, generalized weakness, and intermittent right upper quadrant pain. Abdominal computerized tomography revealed a 13 x 9-cm hepatic mass. Core-needle biopsy revealed fibrolamellar hepatocellular carcinoma. She presented with coma due to hyperammonemia levels (peak at 437 mcg/dL) but without metastatic disease. She was urgently transplanted, started on daily sorafenib 8 weeks after transplantation, and was free of disease at 1 year after transplantation.

Choice of sedation and its impact on adenoma detection rate in screening colonoscopies.

BACKGROUND: Studies have demonstrated that the use of sedation (regardless of type) increases polyp detection rates during colonoscopy. Compared to conscious sedation (CS), propofol sedation (PS) has led to detection of more advanced polyps, yet no apparent difference was found in the overall adenoma detection rate (ADR) in patients undergoing colonoscopy for various reasons. We aimed to assess whether there was a significant difference in the ADR in patients specifically undergoing screening colonoscopies using PS versus CS. METHODS: This is a retrospective analysis of 699 consecutive patients who underwent inpatient screening colonoscopies at one academic inpatient center. The decision to perform endoscopy using PS versus CS was determined on an individual basis by each provider, taking into account various patient parameters. RESULTS: No significant difference was noted between ADR or location of detected adenomas between the CS and PS groups. When accounting for each variable, only total endoscopy time of less than 20 min resulted in a statistically significant ADR difference between the two sedation groups (CS: 15.6% vs PS: 21.3%, P = 0.038). CONCLUSION: ADR in screening colonoscopies is not increased by the use of PS compared to CS. While the use of propofol-based anesthesia is clearly associated with increased patient satisfaction and pain levels, the ADR is not enhanced, and its widespread use in screening colonoscopy sedation should still be investigated.