Interventions to Promote Safety Culture in Cancer Care: A Systematic Review.

OBJECTIVES: There is limited guidance on how to effectively promote safety culture in health care settings. We performed a systematic review to identify interventions to promote safety culture, specifically in oncology settings. METHODS: Medical Subject Headings and text words for "safety culture" and "cancer care" were combined to conduct structured searches of MEDLINE, EMBASE, CDSR, CINAHL, Cochrane CENTRAL, PsycINFO, Scopus, and Web of Science for peer-reviewed articles published from 1999 to 2021. To be included, articles had to evaluate a safety culture intervention in an oncology setting using a randomized or nonrandomized, pre-post (controlled or uncontrolled), interrupted time series, or repeated-measures study design. The review followed PRISMA guidelines; quality of included citations was assessed using the ROBINS-I risk of bias tool. RESULTS: Eighteen articles meeting the inclusion criteria were retained, reporting on interventions in radiation (14 of 18), medical (3 of 18), or general oncology (1 of 18) settings. Articles most commonly addressed incident learning systems (7 of 18), lean initiatives (4 of 18), or quality improvement programs (3 of 18). Although 72% of studies reported improvement in safety culture, there was substantial heterogeneity in the evaluation approach; rates of reporting of adverse events (9 of 18) or Agency for Healthcare Research and Quality Safety Culture survey results (9 of 18) were the most commonly used metrics. Most of the studies had moderate (28%) or severe (67%) risk of bias. CONCLUSIONS: Despite a growing evidence base describing interventions to promote safety culture in cancer care, definitive recommendations were difficult to make because of heterogeneity in study designs and outcomes. Implementation of incident learning systems seems to hold most promise.

Provably-secure quantum randomness expansion with uncharacterised homodyne detection.

Quantum random number generators (QRNGs) are able to generate numbers that are certifiably random, even to an agent who holds some side information. Such systems typically require that the elements being used are precisely calibrated and validly certified for a credible security analysis. However, this can be experimentally challenging and result in potential side-channels which could compromise the security of the QRNG. In this work, we propose, design and experimentally demonstrate a QRNG protocol that completely removes the calibration requirement for the measurement device. Moreover, our protocol is secure against quantum side information. We also take into account the finite-size effects and remove the independent and identically distributed requirement for the measurement side. More importantly, our QRNG scheme features a simple implementation which uses only standard optical components and are readily implementable on integrated-photonic platforms. To validate the feasibility and practicability of the protocol, we set up a fibre-optical experimental system with a home-made homodyne detector with an effective efficiency of 91.7% at 1550 nm. The system works at a rate of 2.5 MHz, and obtains a net randomness expansion rate of 4.98 kbits/s at 1010 rounds. Our results pave the way for an integrated QRNG with self-testing feature and provable security.

Experimental symmetric private information retrieval with measurement-device-independent quantum network.

Secure information retrieval is an essential task in today's highly digitised society. In some applications, it may be necessary that user query's privacy and database content's security are enforced. For these settings, symmetric private information retrieval (SPIR) could be employed, but its implementation is known to be demanding, requiring a private key-exchange network as the base layer. Here, we report for the first time a realisation of provably-secure SPIR supported by a quantum-secure key-exchange network. The SPIR scheme looks at biometric security, offering secure retrieval of 582-byte fingerprint files from a database with 800 entries. Our experimental results clearly demonstrate the feasibility of SPIR with quantum secure communications, thereby opening up new possibilities in secure distributed data storage and cloud computing over the future Quantum Internet.

A device-independent quantum key distribution system for distant users.

Device-independent quantum key distribution (DIQKD) enables the generation of secret keys over an untrusted channel using uncharacterized and potentially untrusted devices1-9. The proper and secure functioning of the devices can be certified by a statistical test using a Bell inequality10-12. This test originates from the foundations of quantum physics and also ensures robustness against implementation loopholes13, thereby leaving only the integrity of the users' locations to be guaranteed by other means. The realization of DIQKD, however, is extremely challenging-mainly because it is difficult to establish high-quality entangled states between two remote locations with high detection efficiency. Here we present an experimental system that enables for DIQKD between two distant users. The experiment is based on the generation and analysis of event-ready entanglement between two independently trapped single rubidium atoms located in buildings 400 metre apart14. By achieving an entanglement fidelity of [Formula: see text] and implementing a DIQKD protocol with random key basis15, we observe a significant violation of a Bell inequality of S = 2.578(75)-above the classical limit of 2-and a quantum bit error rate of only 0.078(9). For the protocol, this results in a secret key rate of 0.07 bits per entanglement generation event in the asymptotic limit, and thus demonstrates the system's capability to generate secret keys. Our results of secure key exchange with potentially untrusted devices pave the way to the ultimate form of quantum secure communications in future quantum networks.

Avoidance of Total Knee Replacement in a Population Health Setting: Introducing a Noninvasive Biomechanical Intervention for Patients with Knee Osteoarthritis.

The observed increase in osteoarthritis (OA) of the knee as a result of an aging population and the obesity epidemic has led to a concomitant increase in the rates of total knee replacement (TKR), placing an additional financial and social burden on the ability of health care systems to control medical costs. Our study shows how a home-based, noninvasive biomechanical intervention reduced the rate of progression to surgery for a cohort of 237 patients with knee OA deemed eligible for TKR based on pre-established clinical selection criteria. Over the 24-month study period, 204 patients (86%) avoided surgery, with only 33 patients (14%, 95% confidence interval 82%-91%) progressing to a TKR with an average length of time to TKR of 324 days (ranging from 31 to 671 days). The application of this intervention provides health plans and provider networks managing patient care under financial risk arrangements an opportunity to realize significant cost savings without compromising quality of care or clinical outcomes.

High-performance InGaAs/InAlAs single-photon avalanche diode with a triple-mesa structure for near-infrared photon detection.

We present a novel, to the best of our knowledge, InGaAs/InAlAs single-photon avalanche diode (SPAD) with a triple-mesa structure. Compared with the traditional mesa structures, the horizontal distribution of the electric field decreases dramatically, while the peaks of the electric field at the mesa edges are well eliminated in the triple-mesa structure, leading to an excellent suppression of the surface leakage current and premature breakdown. Furthermore, the temperature coefficient of the breakdown voltage was measured to be as small as 37.4 mV/K within a range from 150 to 270 K. Eventually, one of the highest single-photon detection efficiencies of 35% among all the InGaAs/InAlAs SPADs with a decent dark count rate of ${3.3} \times {{10}^7}\;{\rm Hz}$ was achieved at 240 K. Combined with the inherent ease of integration of the mesa structure, this high-performance triple-mesa InGaAs/InAlAs SPAD provides an effective solution for the fabrication of SPAD arrays and the on-chip integration of quantum systems.

Device-independent quantum key distribution with random key basis.

Device-independent quantum key distribution (DIQKD) is the art of using untrusted devices to distribute secret keys in an insecure network. It thus represents the ultimate form of cryptography, offering not only information-theoretic security against channel attacks, but also against attacks exploiting implementation loopholes. In recent years, much progress has been made towards realising the first DIQKD experiments, but current proposals are just out of reach of today's loophole-free Bell experiments. Here, we significantly narrow the gap between the theory and practice of DIQKD with a simple variant of the original protocol based on the celebrated Clauser-Horne-Shimony-Holt (CHSH) Bell inequality. By using two randomly chosen key generating bases instead of one, we show that our protocol significantly improves over the original DIQKD protocol, enabling positive keys in the high noise regime for the first time. We also compute the finite-key security of the protocol for general attacks, showing that approximately 108-1010 measurement rounds are needed to achieve positive rates using state-of-the-art experimental parameters. Our proposed DIQKD protocol thus represents a highly promising path towards the first realisation of DIQKD in practice.

Security Analysis of Quantum Key Distribution with Small Block Length and Its Application to Quantum Space Communications.

The security of real-world quantum key distribution (QKD) critically depends on the number of data points the system can collect in a finite time interval. To date, state-of-the-art finite-key security analyses require block lengths in the order of 10^{4} bits to obtain positive secret keys. This requirement, however, can be very difficult to achieve in practice, especially in the case of entanglement-based satellite QKD, where the overall channel loss can go up to 70 dB or more. Here, we provide an improved finite-key security analysis which reduces the block length requirement by 14% to 17% for standard channel and protocol settings. In practical terms, this reduction could save entanglement-based satellite QKD weeks of measurement time and resources, thereby bringing space-based QKD technology closer to reality. As an application, we use the improved analysis to show that the recently reported Micius QKD satellite is capable of generating positive secret keys with a 10^{-5} security level.

Chemoradiotherapy Using Carboplatin plus Paclitaxel versus Cisplatin plus Fluorouracil for Esophageal or Gastroesophageal Junction Cancer.

BACKGROUND: Trimodality therapy (TMT) with neoadjuvant chemoradiotherapy (nCRT) using concurrent carboplatin plus paclitaxel (CP) followed by surgery is the standard of care for locoregional esophageal or gastroesophageal junction (GEJ) cancers. Alternatively, nCRT with cisplatin plus fluorouracil (CF) can be used. Definitive chemoradiotherapy (dCRT) with CP or CF can be used if surgery is not planned. In the absence of comparative trials, we aimed to evaluate outcomes of CP and CF in the settings of TMT and dCRT. METHODS: A single-site, retrospective cohort study was conducted at the Princess Margaret Cancer Centre to identify all patients who received CRT for locoregional esophageal or GEJ cancer. Overall survival (OS) and disease-free survival (DFS) were assessed using the Kaplan-Meier method and multivariable Cox regression model. The inverse probability treatment weighting (IPTW) method was used for sensitivity analysis. RESULTS: Between 2011 and 2015, 93 patients with esophageal (49%) and GEJ (51%) cancers underwent nCRT (n = 67; 72%) or dCRT (n = 26; 28%). Median age was 62.3 years and 74% were male. Median follow-up was 23.9 months. Comparing CP to CF in the setting of TMT, the OS and DFS rates were similar. In the setting of dCRT, CP was associated with significantly inferior 3-year OS (36 vs. 63%; p = 0.001; HR 3.1; 95% CI: 1.2-7.7) and DFS (0 vs. 41%; p = 0.004; HR 3.6; 95% CI: 1.4-8.9) on multivariable and IPTW sensitivity analyses. CONCLUSIONS: TMT with CF and CP produced comparable outcomes. However, for dCRT, CF may be a superior regimen.

Bright-light detector control emulates the local bounds of Bell-type inequalities.

It is well-known that no local model-in theory-can simulate the outcome statistics of a Bell-type experiment as long as the detection efficiency is higher than a threshold value. For the Clauser-Horne-Shimony-Holt (CHSH) Bell inequality this theoretical threshold value is [Formula: see text]. On the other hand, Phys. Rev. Lett. 107, 170404 (2011) outlined an explicit practical model that can fake the CHSH inequality for a detection efficiency of up to 0.5. In this work, we close this gap. More specifically, we propose a method to emulate a Bell inequality at the threshold detection efficiency using existing optical detector control techniques. For a Clauser-Horne-Shimony-Holt inequality, it emulates the CHSH violation predicted by quantum mechanics up to [Formula: see text]. For the Garg-Mermin inequality-re-calibrated by incorporating non-detection events-our method emulates its exact local bound at any efficiency above the threshold. This confirms that attacks on secure quantum communication protocols based on Bell violation is a real threat if the detection efficiency loophole is not closed.

Impact of adjuvant therapy in patients with a microscopically positive margin after resection for gastric and esophageal cancers.

BACKGROUND: A microscopically positive (R1) resection margin following resection for gastric and esophageal cancers has been documented to be a poor prognostic factor. The optimal strategy and impact of different modalities of adjuvant treatment for an R1 resection margin remain unclear. METHODS: A retrospective analysis was performed for patients with gastric and esophageal adenocarcinoma treated at the Princess Margaret Cancer Centre (PMCC) from 2006-2016. Electronic medical records of all patients with an R1 resection margin were reviewed. Kaplan-Meier and Cox proportional hazards methods were used to analyze recurrence free survival (RFS) and overall survival (OS) with stage and neoadjuvant treatment as covariates in the multivariate analysis. RESULTS: We identified 69 gastric and esophageal adenocarcinoma patients with a R1 resection. Neoadjuvant chemoradiation was used in 13% of patients, neoadjuvant chemotherapy in 12%, surgery alone in 75%. Margins involved included proximal in 30%, distal in 14%, radial in 52% and multiple margins in 3% of patients. Pathological staging showed 3% with stage I disease, 20% stage II and 74% stage III. Adjuvant therapy was given in 52% of R1 pts (28% CRT, 20% chemotherapy alone, 3% radiation alone, 1% reoperation). Median RFS was 14.1 months [95% confidence interval (CI), 11.1-17.2]. The site of first recurrence was 72% distant, 12% mixed, 16% locoregional alone. Median OS was 34.5 months (95% CI, 23.3-57.9) for all patients. There was no significant difference in RFS (adjusted P=0.26) or OS (adjusted P=0.83) comparing modality of adjuvant therapy. CONCLUSIONS: Most patients with positive margins after resection for gastric and esophageal cancer had advanced pathologic stage and prognosis was poor. Our study did not find improved RFS or OS with adjuvant treatment and only one patient had reresection. The main failure pattern was distant recurrence, suggesting that patients being considered for adjuvant radiotherapy (RT) should be carefully selected. Further studies are required to determine factors to select patients with good prognosis despite a positive margin, or those who may benefit from adjuvant treatment.

Surveillance and outcomes after curative resection for gastroesophageal adenocarcinoma.

BACKGROUND: The goal of surveillance testing is to enable curative salvage therapy through early disease detection, however supporting evidence in gastroesophageal adenocarcinoma is limited. We evaluated frequency of successful salvage therapy and outcomes in patients who underwent surveillance. METHODS: A single-site, retrospective cohort study was conducted to identify all patients who received curative resection for gastroesophageal adenocarcinoma. Surveillance testing were those investigations not triggered by abnormal symptoms, physical examination, or blood tests. Successful salvage therapy was any potentially curative therapy for disease recurrence which resulted in postrecurrence disease-free survival ≥2 years. Time-to-event data were analyzed using the Kaplan-Meier method and log rank tests. RESULTS: Between 2011 and 2016, 210 consecutive patients were reviewed. Esophageal (14%), gastroesophageal junction (40%), and gastric adenocarcinomas (45%) were treated with surgery alone (29%) or multimodality therapy (71%). Adjuvant therapy was administered in 35%. At median follow-up of 38.3 months, 5-year overall survival (OS) rate was 56%. Among 97 recurrences, 53% were surveillance-detected, and 46% were symptomatic. None was detected by surveillance endoscopy. Median time-to-recurrence (TTR) was 14.8 months. Recurrences included locoregional only (4%), distant (86%), and both (10%). Salvage therapy was attempted in 15 patients, 4 were successful. Compared to symptomatic recurrences, patients with surveillance-detected recurrences had longer median OS (36.2 vs 23.7 months, P = .004) and postrecurrence survival (PRS, 16.5 vs 4.6 months, P < .001), but similar TTR (16.2 vs 13.3 months, P = .40) and duration of palliative chemotherapy (3.9 vs 3.3 months, P = .64). CONCLUSIONS: Among patients surveyed, 96% of recurrences were distant, and salvage therapy was successful in only 1.9% of patients. Longer OS in patients with surveillance-detected compared to symptomatic recurrences was not associated with significant earlier disease detection, and may be contributed by differences in disease biology. Further prospective data are warranted to establish the benefit of surveillance testing in gastroesophageal adenocarcinoma.

Advantage Distillation for Device-Independent Quantum Key Distribution.

Device-independent quantum key distribution (DIQKD) offers the prospect of distributing secret keys with only minimal security assumptions, by making use of a Bell violation. However, existing DIQKD security proofs have low noise tolerances, making a proof-of-principle demonstration currently infeasible. We investigate whether the noise tolerance can be improved by using advantage distillation, which refers to using two-way communication instead of the one-way error correction currently used in DIQKD security proofs. We derive an efficiently verifiable condition to certify that advantage distillation is secure against collective attacks in a variety of DIQKD scenarios, and use this to show that it can indeed allow higher noise tolerances, which could help to pave the way towards an experimental implementation of DIQKD.

Provably Secure Symmetric Private Information Retrieval with Quantum Cryptography.

Private information retrieval (PIR) is a database query protocol that provides user privacy in that the user can learn a particular entry of the database of his interest but his query would be hidden from the data centre. Symmetric private information retrieval (SPIR) takes PIR further by additionally offering database privacy, where the user cannot learn any additional entries of the database. Unconditionally secure SPIR solutions with multiple databases are known classically, but are unrealistic because they require long shared secret keys between the parties for secure communication and shared randomness in the protocol. Here, we propose using quantum key distribution (QKD) instead for a practical implementation, which can realise both the secure communication and shared randomness requirements. We prove that QKD maintains the security of the SPIR protocol and that it is also secure against any external eavesdropper. We also show how such a classical-quantum system could be implemented practically, using the example of a two-database SPIR protocol with keys generated by measurement device-independent QKD. Through key rate calculations, we show that such an implementation is feasible at the metropolitan level with current QKD technology.

Provably secure and high-rate quantum key distribution with time-bin qudits.

The security of conventional cryptography systems is threatened in the forthcoming era of quantum computers. Quantum key distribution (QKD) features fundamentally proven security and offers a promising option for quantum-proof cryptography solution. Although prototype QKD systems over optical fiber have been demonstrated over the years, the key generation rates remain several orders of magnitude lower than current classical communication systems. In an effort toward a commercially viable QKD system with improved key generation rates, we developed a discrete-variable QKD system based on time-bin quantum photonic states that can generate provably secure cryptographic keys at megabit-per-second rates over metropolitan distances. We use high-dimensional quantum states that transmit more than one secret bit per received photon, alleviating detector saturation effects in the superconducting nanowire single-photon detectors used in our system that feature very high detection efficiency (of more than 70%) and low timing jitter (of less than 40 ps). Our system is constructed using commercial off-the-shelf components, and the adopted protocol can be readily extended to free-space quantum channels. The security analysis adopted to distill the keys ensures that the demonstrated protocol is robust against coherent attacks, finite-size effects, and a broad class of experimental imperfections identified in our system.

Economic Considerations in the Use of Novel Targeted Therapies for Lung Cancer: Review of Current Literature.

Lung cancer remains the leading cause of cancer-related death and economic burden worldwide. Despite the heavy toll of lung cancer, multiple new advances have improved patient outcomes, largely through precision medicine and targeted therapy. The associated rising economic burden however may impact the uptake of novel therapeutic agents in lung cancer, thereby limiting patient access. This article identifies and reviews economic evaluations of targeted agents in lung cancer in the era of precision medicine. Articles evaluating biomarker-directed test-and-treat strategies are also reviewed to evaluate the cost impact of novel therapeutic agents at a population level. The Quality of Health Economic Studies instrument is applied to assess the quality of included studies. Forty-six studies are reviewed and encompass studies of epidermal growth factor receptor inhibitors and monoclonal antibodies, anaplastic lymphoma kinase inhibitors, vascular endothelial growth factor and vascular endothelial growth factor receptor inhibitors and immunotherapy (programmed death-1 inhibitors). Key factors influencing results of economic analyses include comparators chosen, perspective used, magnitude of clinical benefit, utility weighting of outcomes and drug acquisition costs. Biomarker-driven decision making should be integrated into cost evaluations given the important role of molecular testing for individualising treatment for non-small-cell lung cancer. We conclude that despite major clinical advances in lung cancer therapeutics, cost remains an important consideration in the adoption of novel therapies.

Patients with Advanced Non-Small Cell Lung Cancer: Are Research Biopsies a Barrier to Participation in Clinical Trials?

OBJECTIVES: Clinical trials of therapies for non-small cell lung cancer (NSCLC) are increasingly requiring mandatory tumor samples or research biopsies, both of which are potential barriers to trial participation. We assessed the impact of performance of research biopsies on the enrollment of patients with advanced NSCLC in clinical trials. METHODS: The cases of patients with advanced NSCLC who had been evaluated for clinical trials of systemic therapy at the Princess Margaret Cancer Centre from January 2007 to March 2015 were reviewed. RESULTS: Of the 55 clinical trials identified, 38 required tumor samples for enrollment. Six mandated repeat biopsies, whereas 32 permitted use of archival samples. Trial participation was offered to 636 patients at 940 unique study encounters, with some patients enrolling in multiple trials. Of the patients in 549 encounters during which participation in a therapeutic trial was offered, 60% received study treatment. More patients received study treatment (83% versus 55%, p < 0.0001) and study treatment was started earlier (after 9 days versus after 16, p = 0.002) when the trial did not have a mandatory tissue sample requirement. A similar trend was noted for trials permitting use of archival tissue versus mandatory repeat biopsies. The most common barriers to trial enrollment included absence of a required biomarker (34%), withdrawal of consent (20%), deterioration or death (17%), other exclusion criteria (15%), and insufficient biopsy tissue (10%). CONCLUSION: A growing number of NSCLC trials are requiring tumor tissue for treatment eligibility, which appears to be a significant barrier to trial enrollment. Potential solutions include use of available diagnostic samples (e.g., cytology samples), development of peripheral blood assays for molecular markers, faster central laboratory testing turnaround time, and more resources for rapid biopsy.

Self-testing quantum random number generator.

The generation of random numbers is a task of paramount importance in modern science. A central problem for both classical and quantum randomness generation is to estimate the entropy of the data generated by a given device. Here we present a protocol for self-testing quantum random number generation, in which the user can monitor the entropy in real time. Based on a few general assumptions, our protocol guarantees continuous generation of high quality randomness, without the need for a detailed characterization of the devices. Using a fully optical setup, we implement our protocol and illustrate its self-testing capacity. Our work thus provides a practical approach to quantum randomness generation in a scenario of trusted but error-prone devices.

Chlamydia pneumoniae infection of monocytes in vitro stimulates innate and adaptive immune responses relevant to those in Alzheimer's disease.

BACKGROUND: Alzheimer's disease (AD) is a progressive neurodegenerative disorder in which infection with Chlamydia pneumoniae (Cpn) has been associated. Cpn is an obligate intracellular respiratory pathogen that may enter the central nervous system (CNS) following infection and trafficking of monocytes through the blood-brain barrier. Following this entry, these cells may secrete pro-inflammatory cytokines and chemokines that have been identified in the AD brain, which have been thought to contribute to AD neurodegeneration. The objectives of this work were: (i) to determine if Cpn infection influences monocyte gene transcript expression at 48 hours post-infection and (ii) to analyze whether pro-inflammatory cytokines are produced and secreted from these cells over 24 to 120 hours post-infection. METHODS: Gene transcription was analyzed by RT-PCR using an innate and adaptive immunity microarray with 84 genes organized into 5 functional categories: inflammatory response, host defense against bacteria, antibacterial humoral response, septic shock, and cytokines, chemokines and their receptors. Statistical analysis of the results was performed using the Student's t-test. P-values ≤ 0.05 were considered to be significant. ELISA was performed on supernatants from uninfected and Cpn-infected THP1 monocytes followed by statistical analysis with ANOVA. RESULTS: When Cpn-infected THP1 human monocytes were compared to control uninfected monocytes at 48 hours post-infection, 17 genes were found to have a significant 4-fold or greater expression, and no gene expression was found to be down-regulated. Furthermore, cytokine secretion (IL-1ß, IL-6, IL-8) appears to be maintained for an extended period of infection. CONCLUSIONS: Utilizing RT-PCR and ELISA techniques, our data demonstrate that Cpn infection of THP1 human monocytes promotes an innate immune response and suggests a potential role in the initiation of inflammation in sporadic/late-onset Alzheimer's disease.

Quality improvement: an assessment of participation and attitudes of medical oncologists.

PURPOSE: Although quality improvement (QI) is an integral part of cancer care, there are few QI publications in the medical oncology literature. We examined the prevailing attitudes of medical oncologists toward QI and causes for the low QI publication rate in the medical oncology literature. METHODS: Using a modified Dillman method, we distributed a 13-question online survey to medical oncologists across Canada asking about their attitudes toward and involvement in QI and perceived barriers to publishing QI studies. RESULTS: We attained a 43% response rate (143 of 332). Of the responding oncologists, 97% (138) agreed that QI was an important aspect of their practice, although only 49% (70) had participated in QI in the past 5 years. Physicians with administrative responsibility were more likely than clinicians to be involved in QI (P = .008). Most QI participants focused on domains of safety (70%) and patient centeredness (67%). Among QI participants, 72% did not publish their findings, because of lack of time (34%), no identifiable journals (14%), and unfamiliarity with QI methodology (10%). Barriers for QI nonparticipants included uncertainty about how to get involved (45%), lack of time (18%), and limited institutional support or recognition (18%). QI participants had greater awareness of recent practice-changing QI publications compared with nonparticipants (P = .003). CONCLUSION: Canadian medical oncologists face limitations to participating in and publishing QI initiatives because of lack of knowledge about ongoing initiatives, lack of time, and lack of resources to aid publication. Improving networking opportunities and prioritizing QI at the institutional level can address this need.