Presentation and outcomes of paediatric craniopharyngioma in the west of Scotland: a 25 year experience.

PURPOSE: Craniopharyngiomas can be aggressive leading to significant complications and morbidity. It is not clear whether there are any predictive factors for incidence or outcomes. Our aim was therefore to record the incidence, presentation, characteristics and progression of paediatric craniopharyngiomas in the West of Scotland. METHOD: Retrospective case note review for children diagnosed with paediatric craniopharyngiomas at the Royal Hospital for Children Glasgow, from 1995 to 2021 was conducted. All analyses were conducted using GraphPad Prism 9.4.0. RESULTS: Of 21 patients diagnosed with craniopharyngiomas, the most common presenting symptoms were headaches (17/21, 81%); visual impairment (13/21, 62%); vomiting (9/21, 43%) and growth failure (7/21, 33%). Seventeen (81%) patients underwent hydrocephalus and/or resection surgery within 3 months of diagnosis, usually within the first 2 weeks (13/21, 62%). Subtotal resection surgeries were performed in 71% of patients, and median time between subsequent resection surgeries for tumour recurrence was 4 years (0,11). BMI SDS increased at 5 year follow-up (p = 0.021) with 43% being obese (BMI > + 2SD). More patients acquired hypopituitarism post-operatively (14/16, 88%) compared to pre-operatively (4/15, 27%). A greater incidence of craniopharyngiomas were reported in more affluent areas (10/21, 48%) (SIMD score 8-10) compared to more deprived areas (6/10, 29%) (SIMD score 1-3). Five patients (24%) died with a median time between diagnosis and death of 9 years (6,13). CONCLUSION: Over 25 years the management of craniopharyngioma has changed substantially. Co-morbidities such as obesity are difficult to manage post-operatively and mortality risk can be up to 25% according to our cohort.

Shoulder Pain Associated With Multiple Arteriovenous Malformations Successfully Treated With Embolization.

A 44-year-old male presented with left upper extremity and shoulder pain with worsening functional impairment after years of repetitive use, overtraining, and multiple injuries from weightlifting and mixed martial arts. Imaging showed no obvious injury or ligamentous deformity other than mild osteoarthritis (OA) of the left glenohumeral joint. Duplex ultrasonography (US) revealed four arteriovenous malformations (AVMs) surrounding the shoulder joint and left upper extremity. The vasculature was mapped via angiography through a transradial approach. Initial treatment included transarterial embolization of two AVMs off the axillary artery and branching anterior circumflex humeral artery. Secondary treatment included embolization of two lesions months later via direct puncture, one through a transvenous approach and the second through direct transmalformation cannulation, via the nidus, near the clavicle and posterior scapular lateral border. Treatment resulted in significant improvement in pain and range of motion. Follow-up assessments revealed improvement in overall symptoms, recovered function, and return to exercise and competitive mixed martial arts. This case highlights the value of duplex ultrasonography, embolization, and transarterial and transvenous approaches for the treatment of AVM-associated extremity or joint pain.

Embolization for the treatment of large, complex fibroids in an outpatient setting: A report of 2 cases.

Uterine leiomyomas are the most common benign pelvic tumors in premenopausal women, causing significant morbidity. Uterine fibroid embolization is a minimally invasive alternative to traditional open or laparoscopic surgeries for the management of symptomatic uterine leiomyoma. For large fibroids, hospitalization after treatment is often required. However, there are limited data on patients with large, complex uterine leiomyomas treated by embolization. This report of 2 cases describes 2 females with large, complex fibroids causing pain and decreased quality of life who were evaluated and treated with embolization in the outpatient setting. Each patient underwent transradial cannulation and uterine artery embolization under local anesthesia or conscious sedation and returned home without complication. For women wishing to preserve their uterus, uterine fibroid embolization is an effective nonsurgical alternative to hysterectomy and myomectomy in an outpatient setting. If standard protocols are followed, embolization by way of transradial artery catheterization is safe for the treatment of large, complex, symptomatic fibroids in the outpatient setting; however, additional studies with larger cohorts are warranted. Accessing the uterine arteries transradially reduces the risk of intra- and post-operative complications for patients, reduces their time spent in a hospital, and minimizes operating costs.

Posterior segmental fixation for thoraco-lumbar and lumbar fractures: a comparative outcome study between open and percutaneous techniques.

PURPOSE: Showing results of open and percutaneous surgical management of traumatic AO type A3, A4 and B2 thoracic and lumbar fractures. METHODS: Retrospective comparative analysis of traditional open fusion versus percutaneous navigated fixation of thoracic and lumbar spinal fractures. Minimum 24 months follow-up to collect ODI and VAS outcome scores for comparative analysis was required. RESULTS: Fifty-seven patients with a mean age of 39 years met the inclusion criteria. Twenty-six patients were in the open group (Group O) and 31 in the percutaneous group (Group P). The majority of fractures were either type A3 or A4; there were three type B chance fractures in Group O and one in Group P. VAS and ODI scores followed comparable trends in the two groups until the final follow-up. The main statistically significant result between the two groups was blood loss, which was lower in Group P (110 versus 270 ml in Group O on average), although this did not reflect into different clinical outcomes. Similar peri-operative measures of operating time and length of stay were found between the two groups. A significantly higher degree of loss of reduction was noted at follow-up in Group P (8° versus 5° in Group O on average). CONCLUSIONS: Open and percutaneous posterior fixation techniques of thoracic and lumbar fractures in this cohort were associated with different perioperative blood losses as well as radiological measurements, but not with clinically meaningful differences in patient reported outcome measures at 24 months' follow-up.

Clinical and Financial Implications of 2 Treatment Strategies for Donor-derived Hepatitis C Infections.

Transplanting hepatitis C viremic donor organs into hepatitis C virus (HCV)-negative recipients is becoming increasingly common; however, practices for posttransplant direct-acting antiviral (DAA) treatment vary widely. Protracted insurance authorization processes for DAA therapy often lead to treatment delays. METHODS: At our institution, 2 strategies for providing DAA therapy to HCV- recipients of HCV+ transplants have been used. For thoracic organ recipients, an institution-subsidized course of initial therapy was provided to ensure an early treatment initiation date. For abdominal organ recipients, insurance approval for DAA coverage was sought once viremia developed, and treatment was initiated only once the insurance-authorized supply of drug was received. To evaluate the clinical impact of these 2 strategies, we retrospectively collected data pertaining to the timing of DAA initiation, duration of recipient viremia, and monetary costs incurred by patients and the institution for patients managed under these 2 DAA coverage strategies. RESULTS: One hundred fifty-two transplants were performed using HCV viremic donor organs. Eighty-nine patients received DAA treatment without subsidy, and 62 received DAA treatment with subsidy. One patient who never developed viremia posttransplant received no treatment. Subsidizing the initial course enabled earlier treatment initiation (median, 4 d [interquartile range (IQR), 2-7] vs 10 [IQR, 8-13]; P < 0.001) and shorter duration of viremia (median, 16 d [IQR, 12-29] vs 36 [IQR, 30-47]; P < 0.001). Institutional costs averaged $9173 per subsidized patient and $168 per nonsubsidized patient. Three needlestick exposures occurred in caregivers of viremic patients. CONCLUSIONS: Recipients and their caregivers stand to benefit from earlier DAA treatment initiation; however, institutional costs to subsidize DAA therapy before insurance authorization are substantial. Insurance authorization processes for DAAs should be revised to accommodate this unique patient group.

Gender and racial disparities in the transplant surgery workforce.

PURPOSE OF REVIEW: This review explores trends in the United States (US) transplant surgery workforce with a focus on historical demographics, post-fellowship job market, and quality of life reported by transplant surgeons. Ongoing efforts to improve women and racial/ethnic minority representation in transplant surgery are highlighted. Future directions to create a transplant workforce that reflects the diversity of the US population are discussed. RECENT FINDINGS: Representation of women and racial and ethnic minorities among transplant surgeons is minimal. Although recent data shows an improvement in the number of Black transplant surgeons from 2% to 5.5% and an increase in women to 12%, the White to Non-White transplant workforce ratio has increased 35% from 2000 to 2013. Transplant surgeons report an average of 4.3 call nights per week and less than five leisure days a month. Transplant ranks 1st among surgical sub-specialties in the prevalence of three well-studied facets of burnout. Concerns about lifestyle may contribute to the decreasing demand for advanced training in abdominal transplantation by US graduates. SUMMARY: Minimal improvements have been made in transplant surgery workforce diversity. Sustained and intentional recruitment and promotion efforts are needed to improve the representation of women and minority physicians and advanced practice providers in the field.

Transplant Surgery Pipeline: A Report from the American Society of Transplant Surgeons Pipeline Taskforce.

BACKGROUND: Transplant surgery fellowship has evolved over the years and today there are 66 accredited training programs in the US and Canada. There is growing concern, however, about the number of US-trained general surgery residents pursuing transplant surgery. In this study, we examined the transplant surgery pipeline, comparing it with other surgical subspecialty fellowships, and characterized the resident transplantation experience. METHODS: Datasets were compiled and analyzed from surgical fellowship match data obtained from the National Resident Matching Program and ACGME reports and relative fellowship competitiveness was assessed. The surgical resident training experience in transplantation was evaluated. RESULTS: From 2006 to 2018, a total of 1,094 applicants have applied for 946 transplant surgery fellowship positions; 299 (27.3%) were US graduates. During this period, there was a 0.8% decrease per year in US-trained surgical residents matching into transplant surgery (p = 0.042). In addition, transplant surgery was one of the least competitive fellowships compared with other National Resident Matching Program surgical subspeciality fellowships, as measured by the number of US applicants per available fellowship position, average number of fellowship programs listed on each applicant's rank list, and proportion of unfilled fellowship positions (each, p < 0.05). Finally, from 2015 to 2017, there were 57 general surgery residency programs that produced 77 transplant surgery fellows, but nearly one-half of the fellows (n = 36 [46.8%]) came from 16 (28.1%) programs. CONCLUSIONS: Transplant surgery is one of the least competitive and sought after surgical fellowships for US-trained residents. These findings highlight the need for dedicated efforts to increase exposure, mentorship, and interest in transplantation to recruit strong US graduates.

Use of Direct Intracranial Pressure and Brain Tissue Oxygen Monitoring in Perioperative Management of Patients with Moyamoya Disease.

Intracranial pressure monitoring and brain tissue oxygen monitoring are commonly used in head injury for goal-directed therapies, but there may be more indications for its use. Moyamoya disease involves progressive stenosis of the arterial circulation and formation of collateral vessels that are at risk of hemorrhage. The risk of ischemic events during revascularization surgery and postoperatively is high. Impaired cerebral autoregulation may be one of the factors that are implicated. We present our experience with monitoring of cerebral oxygenation and autoregulation in the pathological hemisphere during the perioperative period in four patients with moyamoya disease.

Telemetric Intracranial Pressure: A Snapshot Does not Give the Full Story.

Telemetric intracranial pressure (ICP) monitors are useful tools in the management of complex hydrocephalus and idiopathic intracranial hypertension (IIH). Clinicians may use them as a "snapshot" screening tool to assess shunt function or ICP. We compared "snapshot" telemetric ICP recordings with extended, in-patient periods of monitoring to determine whether this practice is safe and useful for clinical decision making.

Extinguishing burnout: National analysis of predictors and effects of burnout in abdominal transplant surgery fellows.

Burnout among surgeons has been attributed to increased workload and decreased autonomy. Although prior studies have examined burnout among transplant surgeons, no studies have evaluated burnout in abdominal transplant surgery fellows. The objective of our study was to identify predictors of burnout and understand its impact on personal and patient care during fellowship. A survey was sent to all abdominal transplant surgery fellows in an American Society of Transplant Surgeons-accredited fellowship. The response rate was 59.2% (n = 77) and 22.7% (n = 17) of fellows met criteria for burnout. Fellows with lower grit scores were more likely to exhibit burnout compared with fellows with higher scores (3.6 vs 4.0, P = .026). Those with burnout were more likely to work >100 hours per week (58.8% vs 27.6%, P = .023), have severe work-related stress (58.8% vs 22.4%, P = .010), consider quitting fellowship (94.1% vs 20.7%, P < .001), or make a medical error (35.3% vs 5.2%, P = .003). This national analysis of abdominal transplant fellows found that burnout rates are relatively low, but few fellows engage in self-care. Personal and program-related factors attribute to burnout and it has unacceptable effects on patient care. Transplant societies and fellowship programs should develop interventions to give fellows tools to prevent and combat burnout.

Simultaneous Living Donor Kidney Transplant and Laparoscopic Native Nephrectomy: An Approach to Kidney Transplant Candidates with Suspected Renal-Cell Carcinoma.

Introduction: Kidney transplant candidates are occasionally found during the pre-transplant evaluation to have a suspicious mass in a native kidney. Further work-up and management of such a mass may delay transplantation for several months, which may create logistic barriers to transplant, particularly if there are timing constraints of the donor. In this study, we report our experience with simultaneous living donor kidney transplant and laparoscopic native nephrectomy, where the indication for nephrectomy was a suspicious lesion. Methods: We performed a retrospective review of patients who underwent simultaneous kidney transplant and native nephrectomy using prospectively collected data. We analyzed relevant patient characteristics, surgical details, pathologic results, and long-term follow-up. Results: We identified 16 patients who underwent simultaneous living donor kidney transplantation and laparoscopic native nephrectomy at our institution between 2013 and 2018. Ten (62.5%) patients were found to have renal-cell carcinoma (RCC) on the final pathology. No patients had recurrent RCC, at a median follow-up of 4 years. Conclusion: For patients who are planning to undergo a living donor kidney transplant and are found to have a small mass that is suspicious for RCC, a simultaneous living donor kidney transplant and laparoscopic native nephrectomy is a possible approach in selected patients.

General Surgery Residents' Perception of Feedback: We Can Do Better.

BACKGROUND: Feedback (FB) regarding perioperative care is essential in general surgery residents' (GSRs) training. We hypothesized that FB would be distributed unevenly across preoperative (PrO), intraoperative (IO), and postoperative (PO) continuum of the perioperative period. We aimed to compare results between university- and community-hospital settings planning to institute structured, formalized FB in a large health care system operating multiple surgery residency programs in departments that are linked strategically. METHODS: Quantitative, cross-sectional, Likert scale anonymous surveys were distributed to all GSRs (categorical and preliminary; university: community 1:2). Twenty-five questions considered frequency and perceived quality of FB in PrO, IO, and PO settings. Data were tabulated using REDCap and analyzed in Microsoft Excel using the Mann-Whitney U test, with α = 0.05. Comparisons were made between university- and community-hospital settings, between junior (Post-Graduate Year (PGY) 1-3) and senior (PGY 4-5) GSRs, and by gender. RESULTS: Among 115 GSRs surveyed, 83 (72%) responded. Whereas 93% reported receiving some FB within the past year, 46% reported receiving FB ≤ 20% of the time. A majority (58%) found FB to be helpful ≥ 80% of the time. Among GSRs, 77%, 24%, and 64% reported receiving PrO, IO, or PO FB ≤ 20% of the time, respectively, but 52% also believed that FB was lacking in all 3 areas. Most GSRs wanted designated time for PrO planning FB (82%) and PO FB (87%), respectively. Thirty-six percent of GSRs reported that senior/chief (i.e., PGY-4/PGY-5 GSRs) took them through cases ≥40% of the time; notably,78% reported that FB from senior/chief GSRs was equally or more valuable than FB from attending surgeons. A majority (78%) reported that attending surgeons stated explicitly when they were providing FB only ≤20% of the time. GSRs at the community hospital campuses reported receiving a higher likelihood of "any" FB, IO FB, and PO FB (p < 0.05). Most GSRs surveyed preferred a structured format and designated times for debriefing and evaluation of performance. Subanalyses of gender and GSR level of training showed no differences. CONCLUSIONS: FB during GSR training varies across the perioperative continuum of care. Community programs seem to do better than University Programs. More work need to be done to elucidate why differences exist between the frequency of FB at University and Community programs. Further, data show particularly low FB outside of the operating room. Ideally, according to respondents, FB would be provided in a structured format and at designated times for debriefing and evaluation of performance, which poses a challenge considering the temporal dynamism of general surgery services.

Entrustable Professional Activities: Do General Surgery Residents Trust Them?

BACKGROUND: The American Board of Surgery has initiated a pilot study to investigate the incorporation of Entrustable Professional Activities (EPAs) into the training of general surgery residents (GSR). Limited data exist on perception of EPAs by GSR. We aimed to assess the impact of EPAs on GSR for 2 included program topics: inguinal hernia and general surgery consultation. STUDY DESIGN: A 21-question, cross-sectional, Likert scale survey was distributed to 64 GSR at an urban university hospital to assess perceptions and apprehensions regarding EPA implementation. The Mann-Whitney U test was used to analyze differences in responses between junior residents (PGY 1-3) and senior residents (PGY 4-5), and by gender of respondent, α = 0.05. RESULTS: Forty-one (64%) GSR completed surveys. Approximately one-half of respondents had "faint to some" knowledge about EPAs. Fifty-seven percent of GSR were "moderately to highly concerned" about being assessed by attending surgeons with whom they did not have a prior relationship. Additionally, concerns were raised about being assessed by attending surgeons who may have observed their patient interaction only in part. Most GSR expressed "little to no concern" about impact of EPAs to potentially increase workload, the view of their program director as to their clinical competency, or American Board of Surgery plans to use collected data. Forty-two percent GSR in PGY 1 to 3 were "moderately to highly" concerned about impact on progression to the next year of residency, whereas senior GSR had "little to no concern." Most GSR (57%) expressed "moderate to high" concern about emergency medicine attending physicians evaluating them. Similar themes regarding EMA evaluation were identified in the comments section of the survey. CONCLUSIONS: EPAs are intended to be a major part of GSR's competency-based assessment and advancement. More work needs to be done to alleviate concerns as to who should provide assessments, as well as in defining how EPAs will be used to assess clinical competency.

Antibiotic prophylaxis for ureteral stent removal after kidney transplantation.

There are no guidelines for antibiotic prophylaxis for ureteral stent removal after kidney transplantation. We reviewed the charts of 277 adult kidney transplant recipients with ureteral stents transplanted at our center between September 2014 and December 2015 and investigated whether antibiotic prophylaxis for stent removal was associated with reduced incidence of urinary tract infections (UTI). We defined UTI as a urine culture ≥104  CFU/mL of bacterial isolates irrespective of symptoms. Primary outcome was the incidence of UTI within four weeks of stent removal. Among the 277 recipients, 199 (72%) were on sulfamethoxazole/trimethoprim (SMZ/TMP) as Pneumocystis jirovecii prophylaxis. At the time of ureteral stent removal, 56 recipients (20%) received additional antibiotic prophylaxis (ABX+) and 221 (80%) did not (ABX-). The difference in the incidence of UTI in the ABX(+) group (16%) and ABX(-) group (19%) was not statistically significant (P = 0.85). Variables independently associated with the development of UTI were recipient age (odds ratio [OR] 1.04, [95% confidence interval 1.01-1.07]) and UTI while stents were in situ (OR 3.9 [2.00-7.62]). Use of SMZ/TMP was protective (OR 0.35 [0.18-0.7]). Our study does not show a statistically significant benefit for additional antibiotic prophylaxis for ureteral stent removal. Antibiotic prophylaxis may be beneficial for recipients not on SMZ/TMP at the time of stent removal.

Parathyroidectomy versus Cinacalcet in the Management of Tertiary Hyperparathyroidism: Surgery Improves Renal Transplant Allograft Survival.

BACKGROUND: Renal transplant allograft function in patients with tertiary hyperparathyroidism who are treated with cinacalcet versus parathyroidectomy remains unclear. METHODS: This is a retrospective, single-center review of patients with tertiary hyperparathyroidism between 2000 and 2017. We compared clinical parameters and outcomes, including renal allograft failure in patients who had undergone parathyroidectomy versus treatment with cinacalcet therapy. RESULTS: A total of 133 patients were included (33 who received parathyroidectomy and 100 who received cinacalcet); median renal allograft survival was 5.9 years (interquartile range 4.0-9.0). There were no differences in age, sex, body mass index, comorbidities, duration of pretransplant dialysis, cadaveric donor utilization, or rates of delayed allograft function between cohorts. In the parathyroidectomy cohort, normalization of parathyroid hormone occurred more frequently (67% vs 15%, P < .001) and renal allograft failure rates were less (9% vs 33%, P = .007), with similar median posttransplant follow-up (7.0 years [interquartile range 4.5-10.0]). On multivariable analysis, parathyroidectomy was inversely associated with allograft failure (odds ratio 0.20, 95%-confidence interval 0.06-0.71, P = .013); there were no other associated factors. A greater median parathyroid hormone (pg/mL) 1 year posttransplant (348 [interquartile range 204-493] vs 195 [interquartile range 147-297], P = .025) was associated with allograft failure in the cinacalcet cohort. CONCLUSION: Parathyroidectomy for tertiary hyperparathyroidism is associated with lesser rates of renal allograft failure compared with cinacalcet management. Patients with inadequate parathyroid hormone control on cinacalcet at 1 year posttransplant should be considered for parathyroidectomy to prevent potential allograft failure.

Operating Room Attire Policy and Healthcare Cost: Favoring Evidence over Action for Prevention of Surgical Site Infections.

BACKGROUND: The Association of Perioperative Registered Nurses (AORN) released new guidelines for operating room attire in 2015 in an attempt to reduce surgical site infections (SSIs). These guidelines have been adopted by the Centers for Medicare and Medicaid Services. We aimed to assess the relationships among operating room attire, SSIs, and healthcare costs. STUDY DESIGN: In March 2016, our center introduced the AORN attire policy. National Health Safety Network data from our hospital were collected on general surgery, cardiac, neurosurgery, orthopaedic, and gynecology procedures from January 2014 to November 2017. The SSI rates and microbiological culture data for 30,493 procedures before and after policy implementation were compared using propensity score matching. The associated costs of the AORN policy were analyzed. RESULTS: After 1:1 propensity score matching, 12,585 matched pairs spanning the policy change were included (25,170 patients total); before policy change (BC group) and after policy change (AC group). The rate of SSIs did not differ between groups (1.0% AC group vs 1.1% BC group; p = 0.7). There was no difference in the incidence of Staphylococcal species cultured from wounds (19.3% AC group vs 16.8% BC group; p = 0.6). Multivariable analyses demonstrated that wound classification and emergent procedures were the strongest independent predictors of SSIs. The cost of attire for 1 person entering the operating room increased from $0.07 to $0.12 before policy change to $1.11 to $1.38 after policy change. Use of the mandated operating room long-sleeved jackets alone in our institution was associated with an added cost of $1,128,078 annually, which translates to an estimated $540 million per year for all US hospitals combined. CONCLUSIONS: Implementation of the AORN guidelines has not decreased SSIs and has increased healthcare costs.

Racial and ethnic disparities in promotion and retention of academic surgeons.

BACKGROUND: Racial/ethnic diversity remains poor in academic surgery. However, no study has quantified differences in the rates of retention and promotion of underrepresented minority (URM) academic surgeons. METHODS: The American Association of Medical Colleges Faculty Roster was used to track all first-time assistant and associate professors appointed between 1/1/2003 and 12/31/2006. Primary endpoints were percent promotion and retention at ten-year follow-up. RESULTS: Initially, the majority of assistant and associate professors of surgery were White (62%; 75%). Black assistant professors had lower 10-year promotion rates across all specialties (p < 0.01). There were no race/ethnicity-based differences in promotion for associate professors. Retention rates were higher for White assistant professors than Asian or Black/Hispanic/Other minority faculty (61.3% vs 52.8% vs. 50.8% respectively; p < 0.01). There was no difference in 10-year retention rates among associate professors based on race/ethnicity. CONCLUSIONS: Underrepresented minority surgeons are less likely to remain in academia and Black assistant professors have the lowest rates of promotion. These findings highlight the need to develop institutional programs to better support and develop minority faculty members in academic medicine.

Eye of the beholder: Risk calculators and barriers to adoption in surgical trainees.

BACKGROUND: Accurate risk assessment before surgery is complex and hampered by behavioral factors. Underutilized risk-based decision-support tools may counteract these barriers. The purpose of this study was to identify perceptions of and barriers to the use of surgical risk-assessment tools and assess the importance of data framing as a barrier to adoption in surgical trainees. METHODS: We distributed a survey and risk assessment activity to surgical trainees at four training institutions. The primary outcomes of this study were descriptive risk assessment practices currently performed by residents, identifiable influences and obstacles to adoption, and the variability of preference sets when comparing modified System Usability Scores of a current risk calculator to a purpose-built calculator revision. Risk calculator comparison responses were compared with simple and multivariable regression to identify predictors for preferentiality. RESULTS: We collected responses from 124 surgical residents (39% response rate). Participants endorsed familiarity with direct verbal communication (100%), sketch diagrams (87%), and brochures (59%). The most contemporary risk communication frameworks, such as best-worst case scenario framing (38%), case-specific risk calculators (43%), and all-procedure calculators (52%) were the least familiar. Usage favored traditional models of communication with only 26% of residents regularly using a strategy other than direct verbal discussion or anatomic sketch diagrams. Barriers limiting routine use included lack of electronic and clinical workflow integration. The mean modified System Usability Scores domain scores were widely dispersed for all domains, and no domain demonstrated one calculator's superiority over another. CONCLUSION: Risk assessment tools are underutilized by trainees. Of importance, preference sets of clinicians appear to be unpredictable and may benefit more from a customizable, bespoke approach.