Palliative Approach Remains Lacking in Terminal Hospital Admissions for Chronic Disease Across Rural Settings: Multisite Retrospective Medical Record Audit.

INTRODUCTION/AIM: Despite clear benefit from palliative care in end-stage chronic diseases, access is often limited, and rural access largely undescribed. This study sought to determine if a palliative approach is provided to people with chronic disease in their terminal hospital admission. METHODS: Multisite, retrospective medical record audit, of decedents with a primary diagnosis of chronic lung, heart, or renal failure, or multimorbidity of these conditions over 2019. RESULTS: Of 241 decedents, across five clinical sites, 143 (59.3%) were men, with mean age 80.47 years (SD 11.509), and diagnoses of chronic lung (n = 56, 23.2%), heart (n = 56, 23.2%), renal (n = 24, 10.0%) or multimorbidity disease (n = 105, 43.6%), and had 2.88 (3.04SD) admissions within 12 months. Outpatient chronic disease care was evident (n = 171, 73.7%), however, contact with a private physician (n = 91, 37.8%), chronic disease program (n = 61, 25.3%), or specialist nurse (n = 17, 7.1%) were less apparent. "Not-for-resuscitation" orders were common (n = 139, 57.7%), however, advance care planning (n = 71, 29.5%), preferred place of death (n = 18, 7.9%), and spiritual support (n = 18, 7.5%) were rarely documented. Referral to and input from palliative services were low (n = 74, 30.7% and n = 49, 20.3%), as was review of nonessential medications or blood tests (n = 86, 35.7%, and n = 78, 32.4%). Opioids were prescribed in 45.2% (n = 109). Hospital site and diagnosis were significantly associated with outpatient care and palliative approach (P<0.001). CONCLUSIONS: End-of-life planning and specialist palliative care involvement occurred infrequently for people with chronic disease who died in rural hospitals. Targeted strategies are necessary to improve care for these prevalent and high needs rural populations.

Cortical resting motor threshold difference in asleep-awake craniotomy for motor eloquent gliomas: WHO grading influences motor pathway excitability.

Developing neurophysiological tools to predict WHO tumor grade can empower the treating teams for a better surgical decision-making process. A total of 38 patients with supratentorial diffuse gliomas underwent an asleep-awake-sedated craniotomies for tumor removal with intraoperative neuromonitoring. The resting motor threshold was calculated for different train stimulation paradigms during awake and asleep phases. Receiver operating characteristic analysis and Bayesian regression models were performed to analyze the prediction of tumor grading based on the resting motor threshold differences. Significant positive spearman correlations were observed between resting motor threshold excitability difference and WHO tumor grade for train stimulation paradigms of 5 (R = 0.54, P = 0.00063), 4 (R = 0.49, P = 0.002), 3 (R = 0.51, P = 0.001), and 2 pulses (R = 0.54, P = 0.0007). Kruskal-Wallis analysis of the median revealed a positive significant difference between the median of excitability difference and WHO tumor grade in all paradigms. Receiver operating characteristic analysis showed 3 mA difference as the best predictor of high-grade glioma across different patterns of motor pathway stimulation. Bayesian regression found that an excitability difference above 3 mA would indicate a 75.8% probability of a glioma being high grade. Our results suggest that cortical motor excitability difference between the asleep and awake phases in glioma surgery could correlate with tumor grade.

Screening and intervention for intimate partner violence at trauma centers and emergency departments: an evidence-based systematic review from the Eastern Association for the Surgery of Trauma.

Background: Intimate partner violence (IPV) is a serious public health issue with a substantial burden on society. Screening and intervention practices vary widely and there are no standard guidelines. Our objective was to review research on current practices for IPV prevention in emergency departments and trauma centers in the USA and provide evidenced-based recommendations. Methods: An evidence-based systematic review of the literature was conducted to address screening and intervention for IPV in adult trauma and emergency department patients. The Grading of Recommendations, Assessment, Development and Evaluations methodology was used to determine the quality of evidence. Studies were included if they addressed our prespecified population, intervention, control, and outcomes questions. Case reports, editorials, and abstracts were excluded from review. Results: Seven studies met inclusion criteria. All seven were centered around screening for IPV; none addressed interventions when abuse was identified. Screening instruments varied across studies. Although it is unclear if one tool is more accurate than others, significantly more victims were identified when screening protocols were implemented compared with non-standardized approaches to identifying IPV victims. Conclusion: Overall, there were very limited data addressing the topic of IPV screening and intervention in emergency medical settings, and the quality of the evidence was low. With likely low risk and a significant potential benefit, we conditionally recommend implementation of a screening protocol to identify victims of IPV in adults treated in the emergency department and trauma centers. Although the purpose of screening would ultimately be to provide resources for victims, no studies that assessed distinct interventions met our inclusion criteria. Therefore, we cannot make specific recommendations related to IPV interventions. PROSPERO registration number: CRD42020219517.

Surgical resection, radiotherapy and percutaneous thermal ablation for treatment of stage 1 non-small cell lung cancer: protocol for a systematic review and network meta-analysis.

INTRODUCTION: Non-small cell lung cancer (NSCLC) makes up the majority of lung cancer cases. Currently, surgical resection is the gold standard of treatment. However, as patients are becoming medically more complex presenting with advanced disease, minimally invasive image-guided percutaneous ablations are gaining popularity. Therefore, comparison of surgical, ablative and second-line external beam therapies will help clinicians, as management of NSCLC changes. We will conduct a meta-analysis, reviewing literature investigating these therapies in adult patients diagnosed with stage 1 NSCLC, with neither hilar nor mediastinal nodal involvement, confirmed either through cytology or histology regardless of type. METHODS AND ANALYSIS: We will search electronic databases (MEDLINE, Embase, Web of Science, Scopus, ClinicalTrials.gov, Cochrane) from their inception to January 2021 to identify randomised controlled trials (RCTs), cluster RCTs and cohort studies comparing survival and clinical outcomes between any two interventions (lobectomy, wedge resection, video-assisted thoracoscopic surgery/robot-assisted thoracoscopic surgery, radiofrequency ablation, microwave ablation, cryoablation and consolidated radiation therapies (external beam radiation therapy, stereotactic body radiation therapy, and 3D conformal radiation therapy). The primary outcomes will include cancer-specific survival, lung disease-free survival, locoregional recurrence, death, toxicity and non-target organ injury. We will also search published and unpublished studies in trial registries and will review references of included studies for possible inclusion. Risk of bias will be assessed using tools developed by the Cochrane collaboration. Two reviewers will independently assess the eligibility of studies and conduct the corresponding risk of bias assessments. For each outcome, given enough studies, we will conduct a network meta-analysis. Finally, we will use the Confidence in Network Meta-Analysis tool to assess quality of the evidence for each of the primary outcomes. ETHICS AND DISSEMINATION: We aim to share our findings through high-impact peer review. As interventional techniques become more popular, it will be important for providers in multidisciplinary teams caring for these patients to receive continuing medical education related to these interventions. Data will be made available to readers. PROSPERO REGISTRATION NUMBER: CRD42021276629.

Tissue engineered vascular grafts transform into autologous neovessels capable of native function and growth.

Background: Tissue-engineered vascular grafts (TEVGs) have the potential to advance the surgical management of infants and children requiring congenital heart surgery by creating functional vascular conduits with growth capacity. Methods: Herein, we used an integrative computational-experimental approach to elucidate the natural history of neovessel formation in a large animal preclinical model; combining an in vitro accelerated degradation study with mechanical testing, large animal implantation studies with in vivo imaging and histology, and data-informed computational growth and remodeling models. Results: Our findings demonstrate that the structural integrity of the polymeric scaffold is lost over the first 26 weeks in vivo, while polymeric fragments persist for up to 52 weeks. Our models predict that early neotissue accumulation is driven primarily by inflammatory processes in response to the implanted polymeric scaffold, but that turnover becomes progressively mechano-mediated as the scaffold degrades. Using a lamb model, we confirm that early neotissue formation results primarily from the foreign body reaction induced by the scaffold, resulting in an early period of dynamic remodeling characterized by transient TEVG narrowing. As the scaffold degrades, mechano-mediated neotissue remodeling becomes dominant around 26 weeks. After the scaffold degrades completely, the resulting neovessel undergoes growth and remodeling that mimicks native vessel behavior, including biological growth capacity, further supported by fluid-structure interaction simulations providing detailed hemodynamic and wall stress information. Conclusions: These findings provide insights into TEVG remodeling, and have important implications for clinical use and future development of TEVGs for children with congenital heart disease.

Methodology for eliciting the brainstem trigeminal-hypoglossal reflex in humans under general anesthesia.

OBJECTIVE: Brainstem trigeminal-hypoglossal reflexes (THRs), also known as the jaw-tongue reflexes, coordinate the position of the tongue in the mouth in relation to the jaw movement during oromotor behaviors such as mastication, swallowing, vocalization, and breathing. Their use in brainstem surgery however, has never been assessed in spite of its potential benefit possibly due to the lack of a methodology to elicit these reflexes under general anesthesia. METHODS: We proposed a technique to elicit the THRs during total intravenous anesthesia (TIVA) consisting on a V3 infrazygomatic train stimulation paradigm and recording from the Styloglossus (31 patients) and the Genioglossus (21 patients) muscles to elicit long latency responses. RESULTS: The THR was successfully recorded using the V3 stimulation point in 82.1% of patients, of which 96.9% presented a response on the Styloglossus muscle (Jaw-opening reflex) while 0.06% presented a response on the Genioglossus muscle instead (Jaw-closing reflex). CONCLUSIONS: The THRs can be successfully recorded in surgery under general anaesthesia with the predominant reflex seen being the jaw-opening reflex. SIGNIFICANCE: We provide a novel method to elicit the THRs during general anesthesia, which could be of aid in brainstem surgery.

Clinical Case-Conference Blogs: Integrating Clinical Librarians to Enhance Resident Education and Enforce ACGME Competencies.

Resident conferences are primary educational endeavors for trainees and faculty alike. We describe the development of collaborative clinician-librarian educational blogs within the Internal Medicine (2009), Pediatrics (2012), and General Surgery (2018) residency programs. Clinical librarians attended resident conferences and generated evidence-based blog posts based on learning topics and clinical questions encountered during the conferences. In the decade since introduction of the blogs, this partnership has resulted in over 2000 blog posts and generated over 1800 individual views per month. The development of a clinical librarian-managed blog serves as a relevant resource for promoting evidence-based practices within a case-based learning curriculum, engages interdisciplinary collaboration through existing resources, and is generalizable across various clinical practice disciplines and trainees.

Development of a Surgical Evidence Blog at Morbidity and Mortality Conferences: Integrating Clinical Librarians to Enhance Resident Education.

INTRODUCTION: Surgical morbidity and mortality (M&M) conference is a primary educational endeavor for trainees and faculty alike. Case presentations are enhanced by inclusion of clinical evidence; however, trainees are frequently limited in their ability to collect and share this type of material. METHODS: A surgical evidence web log ("blog") was created in partnership between the Clinical Librarian Service and the Department of Surgery. A clinical librarian attended weekly departmental M&M conferences and reviewed evidence in collaboration with a surgical resident. For each case presented, the clinical librarian created an evidence-based blog post based on specific learning topics encountered in the routine discussion of the M&M conference. The goal of this surgeon-librarian partnership was to enhance M&M's educational value by reinforcing learning topics, serving as a repository of case-based evidence, and involving trainees in evidence-based surgical practice. RESULTS: Blog posts included summaries of available evidence, critical reviews of seminal studies, and reviews of evidence-based guidelines framed in the context of the case. New blog posts were promoted via direct links in an existing weekly newsletter sent to all trainees and faculty in the department. Within the first year, surgical residents reported increased interaction with the literature, and 100% reported gaining knowledge that they would otherwise not receive through their standard readings, with 73% of residents using this to influence clinical practice and 87% applying knowledge in test preparation. This surgeon-librarian partnership enforces interdisciplinary collaboration through existing resources, and is highly generalizable to both surgical and medical training programs. CONCLUSIONS: In this study, the development of a surgical evidence blog represents an effective resource for promoting evidence-based practices within a case-based learning curriculum. This intervention is the first report in the literature to integrate the expertise and resources of a Clinical Librarian Service with an evidence-based resident educational curriculum in a surgical residency program.

Successful Percutaneous Recanalization of a Chronically Occluded Inferior Vena Cava in a Young Child.

Young children with congenital heart disease are undergoing an increasing number of catheter-based interventions. These procedures can lead to obstruction of large central veins, making future interventions more challenging or even impossible. We present a young child with a chronically occluded inferior vena cava (IVC) secondary to prior catheterization-based interventions for congenital heart disease. The IVC was recanalized with serial angioplasty and stent placement with continued patency for over two years. Despite the long duration of obstruction, the IVC was successfully recanalized, eliminating the potential consequences of long-term IVC obstruction and making it easier for future catheter-based interventions, if needed.