Long per-rectal endoscopic myotomy for a case of Hirchsprung's disease.

Video 1The colonoscopy showed a nondilated rectum, distal sigmoid, and a roomy, dilated proximal colon, with the transition zone at 23 cm from the squamo-columnar junction.

Paving the way for universal medical student training in serious illness communication: the Massachusetts Medical Schools' Collaborative.

BACKGROUND: Patients with serious illness look to their clinicians for discussion and guidance on high-stakes treatment decisions, which are complex, emotional and value-laden. However, required training in serious illness communication is rare in U.S. medical schools, with efforts at curricular reform stymied by competing institutional demands, lack of resources and accreditation requirements. We describe an approach to building and scaling medical student training in serious illness communication through the creation of a statewide collaborative of medical schools. METHODS: The Massachusetts Medical Schools' Collaborative is a first-of-its-kind group that promotes longitudinal, developmentally-based curricula in serious illness communication for all students. Convened externally by the Massachusetts Coalition for Serious Illness Care, the collaborative includes faculty, staff, and students from four medical schools. RESULTS: The collaborative started with listening to member's perspectives and collectively developed core competencies in serious illness communication for implementation at each school. We share early lessons on the opportunities, challenges and sustainability of our statewide collective action to influence curricular reform, which can be replicated in other topic areas. CONCLUSIONS: Our next steps include curriculum mapping, student focus groups and faculty development to guide successful and enduring implementation of the competencies to impact undergraduate medical education in Massachusetts and beyond.

Safety Attitude of Operating Room Personnel Associated With Accurate Completion of a Surgical Checklist: A Cross-sectional Observational Study.

OBJECTIVE: How the checklist is executed in routine practice may reflect the teamwork and safety climate in the operating room (OR). This cross-sectional study aimed to identify whether the presence of a fully completed checklist in medical records was associated with teams' safety attitudes. METHODS: Data from 29 French hospitals, including 5677 operated patients and 834 OR professionals, were prospectively collected. The degree of checklist compliance was categorized for each patient in 1 of 4 ways: full, incomplete, inaccurate, and no checklist completed. The members of OR teams were invited to complete a questionnaire including teamwork climate measurement (Safety Attitudes Questionnaire) and their opinion regarding checklist use, checklist audibly reading, and communication change with checklist. Multilevel modeling was performed to investigate the effect of variables related to hospitals and professionals on checklist compliance, after adjustment for patient characteristics. RESULTS: A checklist was present for 83% of patients, but only 35% demonstrated full completion. Compared with no checklist, full completion was associated with higher safety attitude (high teamwork climate [adjusted odds ratio for full completion, 4.14; 95% confidence interval, 1.75-9.76]; communication change [1.31, 1.04-1.66]; checklist aloud reading [1.16, 1.02-1.32]) and was reinforced by the designation of a checklist coordinator (2.43, 1.06-5.55). Incomplete completion was also associated with enhanced safety attitude contrary to inaccurate completion. CONCLUSIONS: Compliance with checklists is associated with safer OR team practice and can be considered as an indicator of the extent of safety in OR practice.

Increased Body Mass Index is Associated With Lower Risk of Hypocalcemia in Total Thyroidectomy Patients.

INTRODUCTION: Hypocalcemia following total thyroidectomy is common due to postoperative parathyroid dysfunction. We sought to identify the impact of obesity on postthyroidectomy hypocalcemia. METHODS: We performed a single-center retrospective study of all total thyroidectomies performed from 2016 to 2019 after implementation of an updated calcium supplementation protocol. Patient characteristics and outcomes were measured including body mass index (BMI), postoperative hypocalcemia (Ca <8.3), and hypocalcemic symptoms. RESULTS: Overall, 559 total thyroidectomies were performed. A total of 146 patients (26.2%) developed hypocalcemia requiring supplementation adjustment and 116 patients (20.8%) developed mild hypocalcemia symptoms. On multivariable analysis, younger patients, patients with lower preoperative calcium, and lower BMI were more likely to develop postoperative hypocalcemia (all P < 0.05). Similarly, younger patients and patients with BMI <25 were more likely to develop hypocalcemic symptoms (all P < 0.05). CONCLUSIONS: Younger age and lower BMI were associated with increased risk of hypocalcemia after total thyroidectomy. These patients may benefit from preoperative and/or increased postoperative supplementation.

Surgeons' Coaching Techniques in the Surgical Coaching for Operative Performance Enhancement (SCOPE) Program.

OBJECTIVE: To evaluate coaching techniques used by practicing surgeons who underwent dedicated coach training in a peer surgical coaching program. BACKGROUND: Surgical coaching is a developing strategy for improving surgeons' intraoperative performance. How to cultivate effective coaching skills among practicing surgeons is uncertain. METHODS: Through the Surgical Coaching for Operative Performance Enhancement (SCOPE) program, 46 surgeons within 4 US academic medical centers were assigned 1:1 into coach/coachee pairs. All attended a 3-hour Surgical Coaching Workshop-developed using evidence from the fields of surgery and education-then received weekly reminders. We analyzed workshop evaluations and audio transcripts of postoperative debriefs between coach/coachee pairs, co-coding themes based on established principles of effective coaching: (i) self-identified goals, (ii) collaborative analysis, (iii) constructive feedback, and (iv) action planning. Coaching principles were cross-referenced with intraoperative performance topics: technical, nontechnical, and teaching skills. RESULTS: For the 8 postoperative debriefs analyzed, mean duration was 24.4 min (range 7-47 minutes). Overall, 326 coaching examples were identified, demonstrating application of all 4 core principles of coaching. Constructive feedback (17.6 examples per debrief) and collaborative analysis (16.3) were utilized more frequently than goal-setting (3.9) and action planning (3.0). Debriefs focused more often on nontechnical skills (60%) than technical skills (32%) or teaching-specific skills (8%). Among surgeons who completed the workshop evaluation (82% completion rate), 90% rated the Surgical Coaching Workshop "good" or "excellent." CONCLUSIONS: Short-course coach trainings can help practicing surgeons use effective coaching techniques to guide their peers' performance improvement in a way that aligns with surgical culture.

Tribute to Dr. Takuo Aoyagi, inventor of pulse oximetry.

INTRODUCTION: Dr. Takuo Aoyagi invented pulse oximetry in 1974. Pulse oximeters are widely used worldwide, most recently making headlines during the COVID-19 pandemic. Dr. Aoyagi passed away on April 18, 2020, aware of the significance of his invention, but still actively searching for the theory that would take his invention to new heights. METHOD: Many people who knew Dr. Aoyagi, or knew of him and his invention, agreed to participate in this tribute to his work. The authors, from Japan and around the world, represent all aspects of the development of medical devices, including scientists and engineers, clinicians, academics, business people, and clinical practitioners. RESULTS: While the idea of pulse oximetry originated in Japan, device development lagged in Japan due to a lack of business, clinical, and academic interest. Awareness of the importance of anesthesia safety in the US, due to academic foresight and media attention, in combination with excellence in technological innovation, led to widespread use of pulse oximetry around the world. CONCLUSION: Dr. Aoyagi's final wish was to find a theory of pulse oximetry. We hope this tribute to him and his invention will inspire a new generation of scientists, clinicians, and related organizations to secure the foundation of the theory.

Implementation of SARS-CoV2 Screening in K-12 Schools Using In-School Pooled Molecular Testing and Deconvolution by Rapid Antigen Test.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) testing is one component of a multilayered mitigation strategy to enable safe in-person school attendance for the K-12 school population. However, costs, logistics, and uncertainty about effectiveness are potential barriers to implementation. We assessed early data from the Massachusetts K-12 public school pooled SARS-CoV2 testing program, which incorporates two novel design elements: in-school "pod pooling" for assembling pools of dry anterior nasal swabs from 5 to 10 individuals and positive pool deconvolution using the BinaxNOW antigen rapid diagnostic test (Ag RDT), to assess the operational and analytical feasibility of this approach. Over 3 months, 187,597 individual swabs were tested across 39,297 pools from 738 schools. The pool positivity rate was 0.8%; 98.2% of pools tested negative and 0.2% inconclusive, and 0.8% of pools submitted could not be tested. Of 310 positive pools, 70.6% had an N1 or N2 probe cycle threshold (CT) value of ≤30. In reflex testing (performed on specimens newly collected from members of the positive pool), 92.5% of fully deconvoluted pools with an N1 or N2 target CT of ≤30 identified a positive individual using the BinaxNOW test performed 1 to 3 days later. However, of 124 positive pools with full reflex testing data available for analysis, 32 (25.8%) of BinaxNOW pool deconvolution testing attempts did not identify a positive individual, requiring additional reflex testing. With sufficient staffing support and low pool positivity rates, pooled sample collection and reflex testing were feasible for schools. These early program findings confirm that screening for K-12 students and staff is achievable at scale with a scheme that incorporates in-school pooling, primary testing by reverse transcription-PCR (RT-PCR), and Ag RDT reflex/deconvolution testing.

Completion Thyroidectomy is Less Common Following Updated 2015 American Thyroid Association Guidelines.

BACKGROUND: The 2015 American Thyroid Association (ATA) guidelines recommended that low-risk, differentiated thyroid cancers (DTC) between 1 and 4 cm may be treated with thyroid lobectomy alone. We sought to determine the effect of these guideline changes on the rate of completion thyroidectomy (CT) for low-risk DTC and factors influencing surgical decision-making. METHODS: All patients from 2014 to 2018 who received an initial thyroid lobectomy at our institution with final pathology demonstrating DTC were included. Patients were divided into "pre" and "post" guideline cohorts (2014-2015 and 2016-2018, respectively). The rate of CT was compared between the two cohorts. Patient demographics and tumor characteristics were examined for association with CT. RESULTS: A total of 163 patients met study criteria: 63 patients in the 2014-2015 ("pre") and 100 in the 2016-2018 ("post") group. In the "pre" period, 41 (65.1%) patients received CT compared with 43 (43.0%) in the "post" period (p < 0.01)-a 34% decrease in the rate of completion surgery (p < 0.01). Of low-risk patients with DTC between 1 and 4 cm in size, 17 of 35 (48.6%) received CT in the "pre" period compared with 15 of 60 (25.0%) in the post period-a 48.6% decrease in the rate of completion surgery (p = 0.02). Greater tumor size, capsular invasion, and multifocality were associated with CT in low-risk "post" guideline patients (p < 0.05 for all). CONCLUSIONS: The rate of CT decreased significantly by 48.6% for low-risk patients with DTC between 1 and 4 cm, demonstrating recognition of the 2015 ATA guidelines. However, 25% of these patients underwent CT, suggesting additional factors influencing the decision for further treatment.

Does adherence to evidence-based practices during childbirth prevent perinatal mortality? A post-hoc analysis of 3,274 births in Uttar Pradesh, India.

BACKGROUND: Evidence-based practices that reduce childbirth-related morbidity and mortality are core processes to quality of care. In the BetterBirth trial, a matched-pair, cluster-randomised controlled trial of a coaching-based implementation of the WHO Safe Childbirth Checklist (SCC) in Uttar Pradesh, India, we observed a significant increase in adherence to practices, but no reduction in perinatal mortality. METHODS: Within the BetterBirth trial, we observed birth attendants in a subset of study sites providing care to labouring women to assess the adherence to individual and groups of practices. We observed care from admission to the facility until 1 hour post partum. We followed observed women/newborns for 7-day perinatal health outcomes. Using this observational data, we conducted a post-hoc, exploratory analysis to understand the relationship of birth attendants' practice adherence to perinatal mortality. FINDINGS: Across 30 primary health facilities, we observed 3274 deliveries and obtained 7-day health outcomes. Adherence to individual practices, containing supply preparation and direct provider care, varied widely (0·51 to 99·78%). We recorded 166 perinatal deaths (50·71 per 1000 births), including 56 (17·1 per 1000) stillbirths. Each additional practice performed was significantly associated with reduced odds of perinatal (OR: 0·82, 95% CI: 0·72, 0·93) and early neonatal mortality (OR: 0·78, 95% CI: 0·71, 0·85). Each additional practice as part of direct provider care was associated strongly with reduced odds of perinatal (OR: 0·73, 95% CI: 0·62, 0·86) and early neonatal mortality (OR: 0·67, 95% CI: 0·56, 0·80). No individual practice or single supply preparation was associated with perinatal mortality. INTERPRETATION: Adherence to practices on the WHO SCC is associated with reduced mortality, indicating that adherence is a valid indicator of higher quality of care. However, the causal relationships between practices and outcomes are complex. FUNDING: Bill & Melinda Gates Foundation. TRIAL REGISTRATION DETAILS: ClinicalTrials.gov: NCT02148952; Universal Trial Number: U1111-1131-5647.

Safely Practicing in a New Environment: A Qualitative Study to Inform Physician Onboarding Practices.

BACKGROUND: Physicians are frequently asked to practice in hospitals different from their home institution, often under contracts called professional service agreements (PSAs). With highly variable onboarding processes, traveling physicians are often left to "figure out" the available resources, processes of care, crucial relationships, and culture of the new institution. This research aimed to understand the current practices of onboarding for the purpose of informing future improvements in practice. METHODS: Two physicians conducted semistructured, in-depth interviews with physicians working at hospitals beyond their home institution. A thematic qualitative analysis was performed. RESULTS: The sample included 20 physicians from six specialties. Key findings include (1) the basic logistics of providing care in a new environment are often not incorporated into physician onboarding and can limit physicians' ability to provide care efficiently and effectively; (2) the strength of interpersonal relationships greatly influences the ability of physicians to get help when working in new environments; and (3) managing clinical emergencies in unfamiliar settings can result in significant perceived risk to patient safety due to delays in providing care. CONCLUSION: The onboarding process, for physicians working in new institutions, provides significant opportunity for improvement. In the future, more work is needed to ensure that the most notable differences between institutions are clarified, physicians have the necessary information and professional relationships to handle emergencies, and they know which patients they can safely care for in their new institution.

Earlier identification of seriously ill patients: an implementation case series.

OBJECTIVE: To describe the strategies used by a collection of healthcare systems to apply different methods of identifying seriously ill patients for a targeted palliative care intervention to improve communication around goals and values. METHODS: We present an implementation case series describing the experiences, challenges and best practices in applying patient selection strategies across multiple healthcare systems implementing the Serious Illness Care Program (SICP). RESULTS: Five sites across the USA and England described their individual experiences implementing patient selection as part of the SICP. They employed a combination of clinician screens (such as the 'Surprise Question'), disease-specific criteria, existing registries or algorithms as a starting point. Notably, each describes adaptation and evolution of their patient selection methodology over time, with several sites moving towards using more advanced machine learning-based analytical approaches. CONCLUSIONS: Involving clinical and programme staff to choose a simple initial method for patient identification is the ideal starting place for selecting patients for palliative care interventions. However, improving and refining methods over time is important and we need ongoing research into better patient selection methodologies that move beyond mortality prediction and instead focus on identifying seriously ill patients-those with poor quality of life, worsening functional status and medical care that is negatively impacting their families.

Using Smartphones to Capture Novel Recovery Metrics After Cancer Surgery.

Importance: Patient-generated health data captured from smartphone sensors have the potential to better quantify the physical outcomes of surgery. The ability of these data to discriminate between postoperative trends in physical activity remains unknown. Objective: To assess whether physical activity captured from smartphone accelerometer data can be used to describe postoperative recovery among patients undergoing cancer operations. Design, Setting, and Participants: This prospective observational cohort study was conducted from July 2017 to April 2019 in a single academic tertiary care hospital in the United States. Preoperatively, adults (age ≥18 years) who spoke English and were undergoing elective operations for skin, soft tissue, head, neck, and abdominal cancers were approached. Patients were excluded if they did not own a smartphone. Exposures: Study participants downloaded an application that collected smartphone accelerometer data continuously for 1 week preoperatively and 6 months postoperatively. Main Outcomes and Measures: The primary end points were trends in daily exertional activity and the ability to achieve at least 60 minutes of daily exertional activity after surgery among patients with vs without a clinically significant postoperative event. Postoperative events were defined as complications, emergency department presentations, readmissions, reoperations, and mortality. Results: A total of 139 individuals were approached. In the 62 enrolled patients, who were followed up for a median (interquartile range [IQR]) of 147 (77-179) days, there were no preprocedural differences between patients with vs without a postoperative event. Seventeen patients (27%) experienced a postoperative event. These patients had longer operations than those without a postoperative event (median [IQR], 225 [152-402] minutes vs 107 [68-174] minutes; P < .001), as well as greater blood loss (median [IQR], 200 [35-515] mL vs 25 [5-100] mL; P = .006) and more follow-up visits (median [IQR], 2 [2-4] visits vs 1 [1-2] visits; P = .002). Compared with mean baseline daily exertional activity, patients with a postoperative event had lower activity at week 1 (difference, -41.6 [95% CI, -75.1 to -8.0] minutes; P = .02), week 3 (difference, -40.0 [95% CI, -72.3 to -3.6] minutes; P = .03), week 5 (difference, -39.6 [95% CI, -69.1 to -10.1] minutes; P = .01), and week 6 (difference, -36.2 [95% CI, -64.5 to -7.8] minutes; P = .01) postoperatively. Fewer of these patients were able to achieve 60 minutes of daily exertional activity in the 6 weeks postoperatively (proportions: week 1, 0.40 [95% CI, 0.31-0.49]; P < .001; week 2, 0.49 [95% CI, 0.40-0.58]; P = .003; week 3, 0.39 [95% CI, 0.30-0.48]; P < .001; week 4, 0.47 [95% CI, 0.38-0.57]; P < .001; week 5, 0.51 [95% CI, 0.42-0.60]; P < .001; week 6, 0.73 [95% CI, 0.68-0.79] vs 0.43 [95% CI, 0.33-0.52]; P < .001). Conclusions and Relevance: Smartphone accelerometer data can describe differences in postoperative physical activity among patients with vs without a postoperative event. These data help objectively quantify patient-centered surgical recovery, which have the potential to improve and promote shared decision-making, recovery monitoring, and patient engagement.

Development and Feasibility Testing of a Device Briefing Tool and Training to Improve Patient Safety During Introduction of New Devices in Operating Rooms: Best Practices and Lessons Learned.

BACKGROUND: Introducing new surgical devices into the operating room (OR) can serve as a critical opportunity to address patient safety. The effectiveness of OR briefings to improve communication, teamwork, and safety has not been evaluated in this setting. METHODS: Ariadne Labs and Johnson and Johnson (J&J) collaborated to develop and assess an intervention including a Device Briefing Tool (DBT) and novel multidisciplinary team training for clinicians (surgeons and nurses) around the introduction of a new device in the OR. J&J sales representatives trained clinicians to use the DBT, a communication tool to improve patient safety when a new device is used for the first time. Surveys were administered to representatives (n = 10), surgeons (n = 15), and nurses (n = 30) at the baseline, after trainings, and after using the DBT in an operation at six different Thai hospitals. RESULTS: Familiarity with the Surgical Safety Checklist (SURGICAL SAFETY CHECKLIST) varied but increased post-training. Regarding trainings, 90% of representatives felt they very much or completely met all learning objectives but 50% felt only slightly prepared to train clinicians on using DBT. Post-training, clinician confidence in using a new device rose from 47 to 85%. Regarding the DBT, 90% of clinicians felt confident using it and reported they were very likely to use it in the future. Overall, over 90% of all clinicians and representatives felt safe having surgery in their hospitals. CONCLUSIONS: There is high acceptability and feasibility of the multidisciplinary trainings and the DBT among representatives and clinicians, albeit in a limited number of participants from a small number of institutions.

Unpacking the null: a post-hoc analysis of a cluster-randomised controlled trial of the WHO Safe Childbirth Checklist in Uttar Pradesh, India (BetterBirth).

BACKGROUND: A coaching-based implementation of the WHO Safe Childbirth Checklist in Uttar Pradesh, India, improved adherence to evidence-based practices, but did not reduce perinatal mortality, maternal morbidity, or maternal mortality. We examined facility-level correlates of the outcomes, which varied widely across the 120 study facilities. METHODS: We did a post-hoc analysis of the coaching-based implementation of the WHO Safe Childbirth Checklist in Uttar Pradesh. We used multivariable modelling to identify correlations between 30 facility-level characteristics and each health outcome (perinatal mortality, maternal morbidity, or maternal mortality). To identify contexts in which the intervention might have had an effect, we then ran the models on data restricted to the period of intensive coaching and among patients not referred out of the facilities. FINDINGS: In the multivariable context, perinatal mortality was associated with only 3 of the 30 variables: female literacy at the district level, geographical location, and previous neonatal mortality. Maternal morbidity was only associated with geographical location. No facility-level predictors were associated with maternal mortality. Among facilities in the lowest tertile of birth volume (<95 births per month), our models estimated perinatal mortality was 17 (95% CI 11·7-24·8) per 1000 births in the intervention group versus 38 (31·6-44·8) per 1000 in the control group (p<0·0001). INTERPRETATION: Mortality was not directly associated with measured facility-level indicators but was associated with general risk factors. The absence of correlation between expected predictors and patient outcomes and the association between improved outcomes and the intervention in smaller facilities suggest a need for additional measures of quality of care that take into account complexity. FUNDING: Bill & Melinda Gates Foundation.

A Cohort Analysis of Clinical and Ultrasound Variables Predicting Cancer Risk in 20,001 Consecutive Thyroid Nodules.

CONTEXT: Assessing thyroid nodules for malignancy is complex. The impact of patient and nodule factors on cancer evaluation is uncertain. OBJECTIVES: To determine precise estimates of cancer risk associated with clinical and sonographic variables obtained during thyroid nodule assessment. DESIGN: Analysis of consecutive adult patients evaluated with ultrasound-guided fine-needle aspiration for a thyroid nodule ≥1 cm between 1995 and 2017. Demographics, nodule sonographic appearance, and pathologic findings were collected. MAIN OUTCOME MEASURES: Estimated risk for thyroid nodule malignancy for patient and sonographic variables using mixed-effect logistic regression. RESULTS: In 9967 patients [84% women, median age 53 years (range 18 to 95)], thyroid cancer was confirmed in 1974 of 20,001 thyroid nodules (9.9%). Significant ORs for malignancy were demonstrated for patient age <52 years [OR: 1.82, 95% CI (1.63 to 2.05), P < 0.0001], male sex [OR: 1.68 (1.45 to 1.93), P < 0.0001], nodule size [OR: 1.30 (1.14 to 1.49) for 20 to 19 mm, OR: 1.59 (1.34 to 1.88) for 30 to 39 mm, and OR: 1.71 (1.43 to 2.04) for ≥40 mm compared with 10 to 19 mm, P < 0.0001 for all], cystic content [OR: 0.43 (0.37 to 0.50) for 25% to 75% cystic and OR: 0.21 (0.15 to 0.28) for >75% compared with predominantly solid, P < 0.0001 for both], and the presence of additional nodules ≥1 cm [OR: 0.69 (0.60 to 0.79) for two nodules, OR: 0.41 (0.34 to 0.49) for three nodules, and OR: 0.19 (0.16 to 0.22) for greater than or equal to four nodules compared with one nodule, P < 0.0001 for all]. A free online calculator was constructed to provide malignancy-risk estimates based on these variables. CONCLUSIONS: Patient and nodule characteristics enable more precise thyroid nodule risk assessment. These variables are obtained during routine initial thyroid nodule evaluation and provide new insights into individualized thyroid nodule care.