Positive surgical margins after breast-conserving surgery for ductal carcinoma in-situ: does histologic grade or estrogen receptor status matter?

PURPOSE: DCIS has been shown to have a higher rate of positive margins following breast-conserving surgery (BCS) than invasive breast cancer. We aim to analyze certain factors of DCIS, specifically histologic grade and estrogen receptor (ER) status, in patients with positive surgical margins following BCS to determine if there is an association. METHODS: A retrospective review of our institutional patient registry was performed to identify women with DCIS and microinvasive DCIS who underwent BCS by a single surgeon from 1999 to 2021. Demographics and clinicopathologic characteristics between patients with and without positive surgical margins were compared using chi-square or Student's t-test. We assessed factors associated with positive margins using univariate and multivariable logistic regression. RESULTS: Of the 615 patients evaluated, there was no significant difference in demographics between the patients with and without positive surgical margins. Increasing tumor size was an independent risk factor for margin positivity (P = < 0.001). On univariate analysis both high histologic grade (P = 0.009) and negative ER status (P = < 0.001) were significantly associated with positive surgical margins. However, when adjusted in multivariable analysis, only negative ER status remained significantly associated with margin positivity (OR = 0.39 [95% CI 0.20-0.77]; P = 0.006). CONCLUSION: The study confirms increased tumor size as a risk factor for positive surgical margins. We also demonstrated that ER negative DCIS was independently associated with a higher rate of positive margins after BCS. Given this information, we can modify our surgical approach to reduce rate of positive margins in patients with large-sized ER negative DCIS.

The use of a total bowel length measurement protocol may reduce reoperations and complications after single-anastomosis duodenal switch.

INTRODUCTION: Most surgeons who perform single-anastomosis duodeno-ileal switches (SADI-S) use a pre-determined common channel length without measuring total bowel length (TBL). However, TBL varies between patients, and a standardized common channel length could contribute to malabsorptive complications and reoperations following SADI-S. The purpose of this study was to determine whether using a TBL measurement protocol to individualize common channel length would be associated with reduced reoperations and complications. METHODS: A prospectively maintained data registry was retrospectively reviewed to identify all patients who underwent SADI-S between September 2017 and February 2022. In April 2021, we began using TBL measurements during SADI-S with 40% of the TBL used as the length for the common channel. Outcomes pre-TBL and post-TBL measurement protocol were compared. RESULTS: A total of 119 SADI-S recipients (59 pre-TBL; 60 post-TBL) were included. The pre-TBL group had a higher frequency of reoperations (23.7% vs 1.7%, p < 0.001) and late complications (29.3% vs 3.3%, p < 0.001). The mean time to reoperation was 13.7 months in the pre-TBL group and 6.7 months in the post-TBL group (p = 0.347). Patients in the post-TBL group had significantly higher serum albumin levels at 3 months (4.2 g/dL vs 3.5 g/dL, p < 0.001), 6 months (4.1 g/dL vs 3.6 g/dL, p < 0.001), and 12 months (4.2 g/dL vs 3.8 g/dL, p = 0.023) postoperatively when compared to the pre-TBL group. CONCLUSION: Using TBL measurements to individualize common channel length was associated with a significant reduction in reoperations and late complications following SADI-S.

Impact of Patient-Reported Penicillin Allergy on Antibiotic Prophylaxis and Surgical Site Infection Among Patients Undergoing Colorectal Surgery.

BACKGROUND: Surgical site infections are a major preventable source of morbidity, mortality, and increased health care expenditures after colorectal surgery. Patients with penicillin allergy may not receive the recommended preoperative antibiotics, putting them at increased risk for surgical site infections. OBJECTIVE: This study aimed to evaluate the impact of patient-reported penicillin allergy on preoperative antibiotic prophylaxis and surgical site infection rates among patients undergoing major colon and rectal procedures. DESIGN: This is a retrospective observational study. SETTING: This study was conducted at a tertiary teaching hospital in Dallas. PATIENTS: Adults undergoing colectomy or proctectomy between July 2012 and July 2019 were included. MAIN OUTCOME MEASURES: The primary outcomes measured were preoperative antibiotic choice and surgical site infection. RESULTS: Among 2198 patients included in the study, 12.26% (n = 307) reported a penicillin allergy. Patients with penicillin allergy were more likely to be white (82%) and female (54%; p < 0.01). The most common type of allergic reaction reported was rash (36.5%), whereas 7.2% of patients reported anaphylaxis. Patients with self-reported penicillin allergy were less likely to receive beta-lactam antibiotics than patients who did not report a penicillin allergy (79.8% vs 96.7%, p < 0.001). Overall, 143 (6.5%) patients had surgical site infections. On multivariable logistic regression, there was no difference in rates of surgical site infection between patients with penicillin allergy vs those without penicillin allergy (adjusted OR 1.14; 95% CI, 0.71-1.82). LIMITATIONS: A limitation of this study was its retrospective study design. CONCLUSIONS: Self-reported penicillin allergy among patients undergoing colorectal surgery is common; however, only a small number of these patients report any serious adverse reactions. Patients with self-reported penicillin allergy are less likely to receive beta-lactam antibiotics and more likely to receive non-beta-lactam antibiotics. However, this does not affect the rate of surgical site infection among these patients, and these patients can be safely prescribed non-beta-lactam antibiotics without negatively impacting surgical site infection rates. See Video Abstract at http://links.lww.com/DCR/B838 .IMPACTO DE LA ALERGIA A LA PENICILINA INFORMADA POR EL PACIENTE EN LA PROFILAXIS ANTIBIÓTICA Y LA INFECCIÓN DEL SITIO OPERATORIO ENTRE PACIENTES DE CIRUGÍA COLORECTAL. ANTECEDENTES: Las infecciones del sitio operatorio son una de las principales fuentes prevenibles de morbilidad, mortalidad y aumento del gasto sanitario después de cirugía colorrectal. Es posible que los pacientes con alergia a la penicilina no reciban los antibióticos preoperatorios recomendados, lo que los pone en mayor riesgo de infecciones en el sitio operatorio. OBJETIVO: Este estudio tuvo como objetivo evaluar el impacto de la alergia a la penicilina informada por el paciente sobre la profilaxis antibiótica preoperatoria y las tasas de infección del sitio operatorio entre pacientes sometidos a procedimientos mayores de colon y recto. DISEO: Estudio observacional retrospectivo. AJUSTE: Hospital universitario terciario en Dallas. PACIENTES: Adultos sometidos a colectomía o proctectomía entre julio de 2012 a julio de 2019. PRINCIPALES MEDIDAS DE DESENLACE: Elección de antibióticos preoperatorios e infección del sitio operatorio. RESULTADOS: Entre los 2198 pacientes incluidos en el estudio, el 12,26% (n = 307) informó alergia a la penicilina. Los pacientes con alergia a la penicilina tenían más probabilidades de ser blancos (82%) y mujeres (54%) ( p < 0,01). El tipo más común de reacción alérgica notificada fue erupción cutánea (36,5%), mientras que el 7,2% de los pacientes notificó anafilaxia. Los pacientes con alergia a la penicilina autoinformada tenían menos probabilidades de recibir antibióticos betalactámicos en comparación con los pacientes que no informaron alergia a la penicilina (79,8% frente a 96,7%, p < 0,001). En general, hubo 143 (6,5%) pacientes con infecciones del sitio operatorio. En la regresión logística multivariable no hubo diferencias en las tasas de infección del sitio operatorio entre los pacientes con alergia a la penicilina frente a los que no tenían alergia a la penicilina (razón de probabilidades ajustada 1,14; intervalo de confianza del 95%, 0,71-1,82). LIMITACIONES: Diseño de estudio retrospectivo. CONCLUSIONES: La alergia a la penicilina autoinformada entre los pacientes de cirugía colorrectal es común, sin embargo, solo un pequeño número de estos pacientes informan reacciones adversas graves. Los pacientes con alergia a la penicilina autoinformada tienen menos probabilidades de recibir antibióticos betalactámicos y más probabilidades de recibir antibióticos no betalactámicos. Sin embargo, esto no afecta la tasa de infección del sitio quirúrgico entre estos pacientes y se les puede recetar de forma segura con antibióticos no betalactámicos sin afectar negativamente las tasas de infección del sitio quirúrgico. Consulte Video Resumen en http://links.lww.com/DCR/B838 . (Traducción-Dr. Juan Carlos Reyes ).

Psychometric validity and reliability of the 10- and 2-item Connor-Davidson resilience scales among a national sample of Americans responding to the Covid-19 pandemic: an item response theory analysis.

PURPOSE: Psychometric validity/reliability of 10-item and 2-item abbreviations of the Connor-Davidson Resilience Scale (CD-RISC-10; CD-RISC-2) was investigated via item response theory and classic approaches. METHODS: We sampled 5023 adult American participants in a June/July 2020 survey on the COVID-19 pandemic's psychological effects. Our questionnaire incorporated the CD-RISC-10 with other validated measures. CD-RISC-10 items were ranked on item-to-scale correlations, loadings on a one-factor confirmatory factor analysis model, and item slope/threshold parameters plus information curves from a unidimensional graded response model. Concurrent validity of the highest ranked item pair was evaluated vis-à-vis the CD-RISC-10 and CD-RISC-2. Internal consistency, based on average variance extracted (AVE) and multiple reliability coefficients, was also compared. Convergent/divergent validity was tested by correlating anxiety, depression, fear of COVID-19, anxiety sensitivity, coping, and personality measures with both scales and the highest ranked item pair. Binary agreement/classification indexes assessed inter-rater reliability. RESULTS: Items 2 and 9 from CD-RISC-10 ranked the highest. Reliability coefficients were > 0.93, > 0.72, and > 0.82 for the CD-RISC-10, CD-RISC-2, vs summation of items 2 and 9. AVEs were 0.66, 0.67, and 0.77. CD-RISC abbreviations and the summation of items 2 and 9 correlated negatively with anxiety (> - 0.43), depression (> - 0.42), and fear of COVID-19 (> - 0.34); positively with emotional stability (> 0.53) and conscientiousness (> 0.40). Compared to the CD-RISC-2, summative scores of items 2 and 9 more efficiently classified/discriminated high resilience on the CD-RISC-10. CONCLUSION: We confirmed construct validity/reliability of copyrighted CD-RISC abbreviations. The CD-RISC-10's items 2 and 9 were psychometrically more salient than the CD-RISC-2.

Psychological differences in adults with and without a COVID-19 diagnosis.

BACKGROUND: Substantial evidence is emerging regarding the broad societal and psychological impacts of the COVID-19 pandemic, but little is known about whether infected individuals are differently affected. AIM: We evaluated psychological differences between individuals who do vs. do not report testing positive for COVID-19. METHODS: An online survey was offered to adults (≥18 years) who were diagnosed with COVID-19 by a provider within a large integrated-delivery healthcare system, enrolled in COVID-19-related clinical trials at the healthcare system, or responded to targeted local distribution. Measures assessed included the 8-item Patient Health Questionnaire depression scale, Generalized Anxiety Disorder 7-item Scale, and Posttraumatic Diagnostic Scale for DSM-5. RESULTS: Of 487 respondents, 43% reported testing positive for COVID-19, including 11% requiring hospitalization. Overall rates of general anxiety disorder and posttraumatic stress were 34% and 16%, respectively, with no significant differences between groups. Prevalence of depression was higher among respondents reporting a positive COVID-19 test (52% vs. 31%). This difference persisted after controlling for respondent characteristics (odds ratio = 3.7, p < 0.01). CONCLUSIONS: People who report testing positive for COVID-19, even those not requiring hospitalization, have increased risk for depression. Mental health care screening and services should be offered to individuals testing positive, facilitating early intervention.

The work-related stressors and coping strategies of group-employed rural health care practitioners: A qualitative study.

BACKGROUND: Escalating demands on practitioners, stagnating/dwindling resources, and diminishing autonomy have heightened patient-care work-related stress. Using qualitative content/thematic analysis of responses to open-ended survey questions, plus spontaneous comments, we sought to identify rural clinicians' subjective perceptions of their workplace stressors and typical adaptive/coping strategies. METHODS: Within a hybrid inductive-deductive approach, we framed empirical themes (derived by consensus, corroborated with text segments, and extant literature) into theory-based coding templates by which we analyzed the data. RESULTS: Of 308 (65.1% of) recipients completing questionnaires, 290 (94%) answered open-ended questions and/or provided comments. Categorizing stressors by socio-ecology, they cited four themes: Organizational, practitioner/staff-related, patient-related, and third party-induced stressors. Organizational stressors were referenced most conspicuously. How respondents described their coping fitted the Stress, Appraisal and Coping. [Lazarus and Folkman (1984): New York, NY: Springer Publishing Company, Inc] model. Emotion-focused were referenced more than problem-focused approaches. Themes scarcely differed by demographics, except for marital status. CONCLUSIONS: Findings highlight needs for resilience coaching, rekindling work meaningfulness, mentorship in work-home balance/limit-setting, supportive peer networks, and deeper teamwork.

Frequency of satisfaction and dissatisfaction with practice among rural-based, group-employed physicians and non-physician practitioners.

BACKGROUND: Widespread dissatisfaction among United States (U.S.) clinicians could endanger ongoing reforms. Practitioners in rural/underserved areas withstand stressors that are unique to or accentuated in those settings. Medical professionals employed by integrating delivery systems are often distressed by the cacophony of organizational change(s) that such consolidation portends. We investigated the factors associated with dis/satisfaction with rural practice among doctors/non-physician practitioners employed by an integrated healthcare delivery network serving 9 counties of upstate New York, during a time of organizational transition. METHODS: We linked administrative data about practice units with cross-sectional data from a self-administered multi-dimensional questionnaire that contained practitioner demographics plus valid scales assessing autonomy/relatedness needs, risk aversion, tolerance for uncertainty/ambiguity, meaningfulness of patient care, and workload. We targeted medical professionals on the institutional payroll for inclusion. We excluded those who retired, resigned or were fired during the study launch, plus members of the advisory board and research team. Fixed-effects beta regressions were performed to test univariate associations between each factor and the percent of time a provider was dis/satisfied. Factors that manifested significant fixed effects were entered into multivariate, inflated beta regression models of the proportion of time that practitioners were dis/satisfied, incorporating clustering by practice unit as a random effect. RESULTS: Of the 473 eligible participants. 308 (65.1 %) completed the questionnaire. 59.1 % of respondents were doctoral-level; 40.9 % mid-level practitioners. Practitioners with heavier workloads and/or greater uncertainty intolerance were less likely to enjoy top-quintile satisfaction; those deriving greater meaning from practice were more likely. Higher meaningfulness and gratified relational needs increased one's likelihood of being in the lowest quintile of dissatisfaction; heavier workload and greater intolerance of uncertainty reduced that likelihood. Practitioner demographics and most practice unit characteristics did not manifest any independent effect. CONCLUSIONS: Mutable factors, such as workload, work meaningfulness, relational needs, uncertainty/ambiguity tolerance, and risk-taking attitudes displayed the strongest association with practitioner satisfaction/dissatisfaction, independent of demographics and practice unit characteristics. Organizational efforts should be dedicated to a redesign of group-employment models, including more equitable division of clinical labor, building supportive peer networks, and uncertainty/risk tolerance coaching, to improve the quality of work life among rural practitioners.

Study protocol of a systematic review and metaanalysis of stress and burnout among general surgery residents.

Introduction: Chronic workplace stress and burnout are impediments to physicians' professional fulfillment, healthcare organizations' efficiency, and patient care quality/safety. General surgery residents are especially at risk due to the complexity of their training. We report the protocol of a metaanalysis of chronic stress and burnout among Accreditation Council for Graduate Medical Education (ACGME)-affiliated general surgery residents in the era after duty-hour reforms, plus downstream effects on their health and clinical performance. Methods: The proposed systematic review and metaanalysis (PROSPERO registration CRD42021277626) will synthesize/pool data from studies of chronic stress and burnout among general surgery residents at ACGME-affiliated programs. The timeframe under review is subdivided into three intervals: (a) after the 2003 duty-hour restrictions but before 2011 reforms, (b) after the 2011 reforms but before the coronavirus pandemic, and (c) the first 3 years after the pandemic's outbreak. Only studies reporting outcomes based on validated instruments will be included. Qualitative studies, commentaries/editorials, narrative reviews, and studies not published in English will be excluded. Multivariable analyses will adjust for sample characteristics and the methodological quality of included studies. Conclusions: The metaanalysis will yield evidence reflecting experiences of North American-based general surgery residents in the years after ACGME-mandated duty-hour restructuring.

The Mayo Leadership Impact Index Adapted for Matrix Leadership Structures: Initial Validity Evidence.

Importance: Physician burnout has reached crisis levels. Supportive leadership is one of the strongest drivers of physician well-being, and monitoring supervisor support is key to developing well-being focused leadership skills. Existing measures of leader support were designed within "direct report" supervision structures limiting their applicability to matrixed leadership reporting structures where direct reports are not the predominant norm. Antecedently, no measure of leadership support is validated specifically for implementation in matrixed leadership structures. Objective: Adapt and validate the Mayo Leadership Impact Index (MLII) for settings with matrixed leadership structures. Design: A psychometric validation study utilizing classical test theory and item response theory. Setting: A tripartite hospital system in the southwestern US. Participants: Physician-respondents to a 2023 cross-sectional survey. Main Outcomes and Measures: After pilot testing, the adapted MLII was examined using a unidimensional graded response model and confirmatory factor analyses. Convergent validity was investigated via correlations with professional fulfillment, perceived autonomy support, self-valuation, and peer connectedness/respect. Divergent validity was tested via correlations with burnout. Results: Of the three candidate revisions of the MLII, the 9-item adaptation was selected for its superior validity/reliability indices. Standardized Cronbach's and Ordinal alpha coefficients were 0.958 and 0.973, respectively. CFA loadings exceeded 0.70 (p < 0.001), and coefficients of variation (R2) exceeded 0.60 for all items. GRM slope parameters indicated "high" to "very high" item discrimination. Items 2, 5, and 8 were the most informative. Positive correlations of the adapted MLII with professional fulfillment, perceived autonomy support, and peer connectedness/respect were observed, supporting convergent validity. Negative correlation with overall burnout supports divergent validity. Conclusions and Relevance: The findings provide evidence of the adapted MLII's validity, reliability, and appropriateness for implementation within matrixed leadership settings. Prior to this study, no leadership support measure had been validated for use among the growing number of healthcare systems with matrixed leadership reporting structures.

Question: : What is the validity and reliability of a well-being centered leadership measure adapted for use in healthcare systems with matrixed, multiform reporting structures? Findings: : Classical test theory and item response theory analyses of cross-sectional survey data from 158 physician-respondents supported the adapted measure's construct validity. All reliability coefficients were strong. Leadership ratings positively correlated with professional fulfillment, autonomy support, self-valuation, and peer connectedness/respect, and negatively correlated with burnout. Meaning: : Findings support the adapted measure's validity and reliability. This study is the first to demonstrate a valid empirical measure of well-being centered leadership behaviors in settings with multiform, matrixed leadership structures.

Ketamine intolerance in patients on enhanced recovery after surgery protocols undergoing colorectal operations.

BACKGROUND: Ketamine is used in enhanced recovery after surgery (ERAS) protocols because of its beneficial antihyperalgesic and antitolerance effects. However, adverse effects such as hallucinations, sedation, and diplopia could limit ketamine's utility. The main objective of this study was to identify rates of ketamine side effects in postoperative patients after colorectal surgery and, secondarily, to compare short-term outcomes between patients receiving ketamine analgesia and controls. METHODS: This was a retrospective observational cohort study. Subjects were adults who underwent ERAS protocol-guided colorectal surgery at a large, integrated health system. Patients were grouped into ketamine-receiving and preketamine cohorts. Patients receiving ketamine were divided into tolerant and intolerant groups. Propensity score-adjusted models tested multivariate associations of ketamine tolerance/intolerance vs control group. RESULTS: A total of 732 patients underwent colorectal surgery within the ERAS program before ketamine's introduction (control). After ketamine's introduction, 467 patients received the medication. Intolerance was seen in 29% of ketamine recipients, and the most common side effect was diplopia. Demographics and surgical variables did not differ between cohorts. Multivariate models revealed no significant differences in hospital stays. Pain scores in the first 24 hours after surgery were slightly higher in patients receiving ketamine. Opiate consumption after surgery was lower for both ketamine tolerant and ketamine intolerant cohorts than for controls. CONCLUSION: Rates of ketamine intolerance are high, which can limit its use and potential effectiveness. Ketamine analgesia significantly reduced opiate consumption without increasing hospital stays after colorectal surgery, regardless of whether it was tolerated.

Longitudinal validation of the Fear of COVID-19 Scale in a nationwide United States sample: An item response theory model across three inflection points of the pandemic.

The COVID-19 pandemic's global emergence/spread caused widespread fear. Measurement/tracking of COVID-19 fear could facilitate remediation. Despite the Fear of COVID-19 Scale (FCV-19S)'s validation in multiple languages/countries, nationwide United States (U.S.) studies are scarce. Cross-sectional classical test theory-based validation studies predominate. Our longitudinal study sampled respondents to a 3-wave, nationwide, online survey. We calibrated the FCV-19S using a unidimensional graded response model. Item/scale monotonicity, discrimination, informativeness, goodness-of-fit, criterion validity, internal consistency, and test-retest reliability were assessed. Items 7, 6, and 3 consistently displayed very high discrimination. Other items had moderate-to-high discrimination. Items 3, 6, and 7 were most (items 1 and 5 the least) informative. [Correction added on 18 May 2023, after first online publication: In the preceding sentence, the term 'items one-fifth least' has been changed to 'items 1 and 5 the least'.] Item scalability was 0.62-0.69; full-scale scalability 0.65-0.67. Ordinal reliability coefficient was 0.94; test-retest intraclass correlation coefficient 0.84. Positive correlations with posttraumatic stress/anxiety/depression, and negative correlations with emotional stability/resilience supported convergent/divergent validity. The FCV-19S validly/reliably captures temporal variation in COVID-19 fear across the U.S.

National trends in distribution of underrepresented minorities within United States general surgery residency programs: A longitudinal panel study.

BACKGROUND: Cultural affinity with a provider improves satisfactoriness of healthcare. We examined 2005-2019 trends in racial/ethnic diversity/inclusion within general surgery residency programs. METHODS: We triangulated 2005-2019 race/ethnicity data from Association of American Medical Colleges surveys of 4th-year medical students, the Electronic Residency Application Service, and Accreditation Council for Graduate Medical Education-affiliated general surgery residencies. Temporal trends in minority representation were tested for significance. RESULTS: Underrepresented racial/ethnic minorities in medicine (URiMs) increased among graduating MDs from 7.6% in 2005 to 11.8% in 2019 (p < 0.0001), as did their proportion among surgery residency applicants during 2005-2019 (p < 0.0001). However, proportions of URiMs among general surgery residents (≈8.5%), and of programs without URiMs (≈18.8%), stagnated. CONCLUSIONS: Growing URiM proportions among medical school graduates and surgery residency applicants did not improve URiM representation among surgery trainees nor shrink the percentage of programs without URiMs. Deeper research into motivators underlying URiMs' residency program preferences is warranted.

Intentions to receive COVID-19 vaccines in the united states: Sociodemographic factors and personal experiences with COVID-19.

OBJECTIVES: Information regarding vaccination and the association with individuals' characteristics, experiences, and information sources is important for crafting public health campaigns to maximize uptake. Our objective was to investigate factors associated with intentions for COVID-19 vaccination among a sample of U.S. adults using a population-based cross-sectional survey. METHOD: Data were collected via an online questionnaire administered nationwide from January 4, to January 7, 2021 following the emergency use authorization for two SARS-CoV-2 mRNA-based vaccines. RESULTS: Of 936 U.S. adult respondents, 66% stated an intention to be vaccinated once a COVID-19 vaccine was available to them; 14.7% responded "maybe" and 19.6% "no." Unadjusted and multivariate associations revealed "no/maybe" vaccination intentions were associated with younger age, female, Black race, lower income, history of not receiving the influenza vaccine, lower fear of COVID-19, suffering moderate to severe reduction in access to food/nutrition, and lower trust in health care authorities, personal health care providers, and/or traditional news media as sources of COVID-19 information. Of respondents "maybe" intending to be vaccinated, 65% reported "a lot" of trust in personal health care providers as sources of COVID-19 information. Respondents stating "no" intention to be vaccinated were skeptical of all COVID-19 information sources considered. CONCLUSIONS: Our findings confirm observations predating COVID-19 vaccine availability regarding sociodemographic characteristics associated with vaccine hesitancy in the United States. We further identify personal health care providers as the most trusted information source among people who "maybe" intend to get vaccinated and demonstrate the challenge in reaching people not intending to be vaccinated. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Pain management after laparoscopic appendectomy: Comparative effectiveness of innovative pre-emptive analgesia using liposomal bupivacaine.

BACKGROUND: Laparoscopic appendectomy is standard of care for appendicitis in the US. Pain control that limits opioids is an important area of research given the opioid epidemic. This study examined post-appendectomy inpatient opioid use and pain scores following intraoperative use of liposomal bupivacaine (LB) versus non-liposomal bupivacaine. METHODS: This was a retrospective cohort study of 155 adults who underwent laparoscopic appendectomy for acute appendicitis. Patients were divided into four cohorts based on the analgesia administered: (i) bupivacaine hydrochloride (BH)± epinephrine; (ii) undiluted LB; (iii) LB diluted with normal saline; and (iv) LB diluted with BH. RESULTS: Baseline demographic/clinical attributes, intra-operative findings, and post-operative pain scores were equivalent across cohorts. Post-operative pre-discharge opioid use was higher in the BH vs. LB cohorts (mean 60.4 vs. 46.0, 35.5, and 30.4 morphine milligram equivalents, respectively; p < 0.001). CONCLUSIONS: Pre-emptive analgesia with LB during laparoscopic appendectomy can reduce inpatient opioid use without significantly increasing post-operative pain scores.

The relationship between stigma and mental health in a population of individuals with COVID-19.

PURPOSE: Illness stigma has been observed across previous outbreaks including Ebola, SARS, HIV/AIDS, and now COVID-19. Although both the stigma of having COVID-19 as well as mental health impacts of COVID-19 have been studied, limited research exists regarding the relationship of stigma and mental health in this population. Thus, the primary purpose of the present study was to examine the relationship between stigma and mental health in adults with COVID-19. METHOD: Adult respondents with a diagnosis of COVID-19 (N = 632) completed an online questionnaire distributed between April 17, 2020, and April 18, 2021. The study measures included the Patient Health Questionnaire 8 (PHQ-8), the Generalized Anxiety Disorder 7-item (GAD-7), and the 8-Item Stigma Scale for Chronic Illness (SSCI-8) tailored to measure perceived stigmatization from a COVID-19 diagnosis. RESULTS: Participants (mean age = 51) were mostly female (71%), White (73%), married (70%), obese (56%), and had a chronic health condition (56%). Female sex, education status, working from home or not working owing to COVID-19, previous mental health diagnosis, history of chronic illness, and being a current/former smoker were associated with higher stigma scores, whereas older age and Black race were associated with lower stigma scores. CONCLUSIONS: Greater stigma and psychological distress was observed in females with a previously diagnosed psychiatric illness and/or chronic health condition. Our findings suggest a disproportionate burden of mental health/psychiatric symptoms/sequelae, including stigma and PTSD, among COVID-19 survivors with a history of mental illness. Further studies are needed to fully characterize COVID-19 related stigma and subsequent mental health experiences. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Resilience, Well-being, and Empathy Among Private Practice Physicians and Advanced Practice Providers in Texas: A Structural Equation Model Study.

OBJECTIVE: To investigate structural relationships of latent constructs such as occupational wellbeing, resilience, work meaningfulness, and psychological empowerment with affective and cognitive clinical empathy among a community of physicians and advanced practice providers. METHODS: We conducted a cross-sectional observational study. We gathered data by an anonymous self-administered multidimensional questionnaire disseminated electronically between March and May 2016. Participants were physicians and advanced practice providers belonging to the Health Texas Provider Network, a group private practice affiliated with the Baylor Scott and White Health system. We excluded allied health care staff (eg, nurses) and trainees (eg, residents, medical students). We pursued a 3-step strategy: (1) confirmatory factor analysis of a theory-driven measurement model, (2) a modified structural equation model from which pathways with nonsignificant path coefficients were deleted, and (3) multigroup analyses of the modified model. RESULTS: Cognitive empathy was the strongest predictor of affective empathy. We observed modest positive associations of resilience with cognitive and affective empathy and of well-being and meaning with affective but not with cognitive empathy. Resilience, meaning, and psychological empowerment were surprisingly negatively associated with well-being, suggesting diminished self-care among practitioners. Effects of psychological empowerment on empathy and well-being were mediated by resilience and meaning. CONCLUSION: Cognitive empathy directly influenced affective empathy; well-being and meaningfulness exerted direct positive effects on affective but not on cognitive empathy, whereas resilience had direct positive associations with both empathy dimensions. Resilience and meaning manifested direct, negative associations with well-being, revealing clinicians' disproportionate focus on patient care at the expense of self-care.

A systematic review and meta-analysis of surgery delays and survival in breast, lung and colon cancers: Implication for surgical triage during the COVID-19 pandemic.

BACKGROUND: Thousands of cancer surgeries were delayed during the peak of the COVID-19 pandemic. This study examines if surgical delays impact survival for breast, lung and colon cancers. METHODS: PubMed/MEDLINE, EMBASE, Cochrane Library and Web of Science were searched. Articles evaluating the relationship between delays in surgery and overall survival (OS), disease-free survival (DFS) or cancer-specific survival (CSS) were included. RESULTS: Of the 14,422 articles screened, 25 were included in the review and 18 (totaling 2,533,355 patients) were pooled for meta-analyses. Delaying surgery for 12 weeks may decrease OS in breast (HR 1.46, 95%CI 1.28-1.65), lung (HR 1.04, 95%CI 1.02-1.06) and colon (HR 1.24, 95%CI 1.12-1.38) cancers. When breast cancers were analyzed by stage, OS was decreased in stages I (HR 1.27, 95%CI 1.16-1.40) and II (HR 1.13, 95%CI 1.02-1.24) but not in stage III (HR 1.20, 95%CI 0.94-1.53). CONCLUSION: Delaying breast, lung and colon cancer surgeries during the COVID-19 pandemic may decrease survival.

Psychological Characteristics of Recipients Pretransplantation in the Dallas UtErus Transplant Study (DUETS).

INTRODUCTION: Uterus transplantation is now a viable option for fertility treatment for women with absolute uterine factor infertility. Psychological assessment is recommended as a part of the perioperative evaluation process. RESEARCH OBJECTIVE: The purpose of this study was to examine the psychological characteristics and mental health history of the 20 women who participated in the Dallas UtErus Transplant Study (DUETS) trial. DESIGN: This retrospective observational descriptive study was part of a prospective clinical trial. Prior to transplant, 20 women completed a clinical psychological interview, 19 of whom also completed psychological assessment measures including the Hospital Anxiety and Depression Scale, Patient Health Questionnaire 9 item, Generalized Anxiety Disorder 7 item, PTSD Checklist for DSM-5, 36-Item Short Form, Connor-Davidson Resilience Scale 10 item, and Dyadic Adjustment Scale. RESULTS: Women who participated in the trial had high health-related quality of life and minimal psychological history, with most reporting psychological distress associated with their initial infertility diagnosis (N = 13). None of the participants endorsed psychological distress to meet clinical concerns on the psychological measures used. Satisfaction with relationship adjustment with their partners was also high. CONCLUSIONS: Women with absolute uterine factor infertility who underwent uterus transplant demonstrated low psychological distress on assessment measures, were resilient, had high health related quality of life, and strong satisfaction with the quality of relationships with their partners. Although some women reported either current or past psychological diagnosis, most reported psychological distress that occurred at the time of the infertility diagnosis and appeared to resolve over time.

Physicians' perceptions of autonomy support during transition to value-based reimbursement: A multi-center psychometric evaluation of six-item and three-item measures.

BACKGROUND: Successive health system reforms have steadily eroded physician autonomy. Escalating accountability demands placed on physicians concurrent with diminishing autonomy plus widespread "cost cutting" endanger clinical work-life quality and, in turn, threaten patient-care quality, safety, and continuity. This has engendered a renewed emphasis on bettering physician work-life to safeguard patient care. Research indicates that autonomy support could be an effective intervention point in this dynamic, and that improving healthcare practitioners' experience of autonomy can promote better patient outcomes. New measures of autonomy support towards physicians during systemic/organizational transformation are thus needed. OBJECTIVE: We investigated the validity and reliability of two versions of a brief measure of physicians' perceptions of autonomy support. DESIGN: Psychometric evaluation of practitioners' responses to a theory-based, pilot-tested, multi-center, cross-sectional survey-questionnaire. PARTICIPANTS: Physicians serving in California, Massachusetts, or upstate New York clinical practices implementing pay-for-performance incentives were eligible. We obtained responses from 1,534 (35.14%) of 4,365 physicians surveyed. ANALYSIS: We randomly partitioned the study sample equitably into derivation and validation subsamples. We conducted parallel analysis, inter-item/point-biserial correlations, and item-response-theory-based graded response modeling on six autonomy support items. Three items with the highest (a) point-biserial correlations, (b) item-level discrimination and (c) information capture were used to construct a short-form (3-item) version of the full (6-item) autonomy scale. We utilized exploratory structural equation modeling and confirmatory factor analysis to establish the factor structure and construct validity of the full-length and short-form scales before comparing their factor invariance, reliability and interrater agreement across physician subgroups. FINDINGS: All six autonomy support items loaded highly onto one factor accounting for the majority of variance and demonstrating good data fit. The three most discriminating and informative items loaded equally well onto a single factor with similar goodness-of-fit to the data. The three-item scale correlated highly with its six-item parent, showing equally high sensitivity and specificity in discriminating high autonomy support. Variability in scores nested predominantly at within- rather than between-subgroup levels. CONCLUSIONS AND IMPLICATIONS: Our data supported the factor structure, construct validity, internal consistency, and reliability of six- and three-item autonomy support scales. These brief tools are easily incorporated into multi-dimensional questionnaires at relatively low cost.

Predictors of cardiopulmonary hospitalization in chronic spinal cord injury.

OBJECTIVE: To investigate longitudinal risk factors of hospitalization for circulatory and pulmonary diseases among veterans with chronic spinal cord injury (SCI). Circulatory and respiratory system illnesses are leading causes of death in patients with chronic SCI, yet risk factors for related hospitalizations have not been characterized. DESIGN: Prospective cohort study. SETTING: Veterans Affairs (VA) Boston Healthcare System, Boston, Massachusetts. PARTICIPANTS/DATA SOURCES: Veterans (N=309) greater than or equal to 1 year post-SCI from the VA Boston Chronic SCI cohort who completed a health questionnaire and underwent spirometry at study entry. Baseline data were linked to 1996 through 2003 hospitalization records from the VA National Patient Care Database. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Cardiopulmonary hospital admissions, the predictors of which were assessed by multivariate Cox regression. RESULTS: Of 1478 admissions observed, 143 were a result of cardiopulmonary (77 circulatory and 66 respiratory) illnesses. Independent predictors were greater age (3% increase/y), hypertension, and the lowest body mass index quintile (<22.4 kg/m2). A greater percentage-predicted forced expiratory volume in 1 second was associated with reduced risk. SCI level and completeness of injury were not statistically significant after adjusting for these risk factors. CONCLUSIONS: Cardiopulmonary hospitalization risk in persons with chronic SCI is related to greater age and medical factors that, if recognized, may result in strategies for reducing future hospitalizations.