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1.
Menopause ; 29(6): 723-727, 2022 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-35674652

RESUMO

OBJECTIVE: Overactive bladder affects 17% of women, and adherence to treatment is notoriously low. The objective of this pilot study is to investigate the efficacy and feasibility of the use of asynchronous telehealth visits for the treatment of women with overactive bladder. METHODS: This is a pilot study of women who participated in the asynchronous telehealth program with a new diagnosis of overactive bladder presenting to the Massachusetts General Hospital from January of 2020 to March of 2021. Pre-post differences in Urogenital Distress Inventory score-6, and Incontinence Severity Index Scores were compared with paired t tests as coprimary endpoints. To assess potential mechanisms of association between asynchronous visits and patient-reported outcomes, total fluid intake, caffeinated beverage consumption, urinary frequency, episodes of urinary leakage were also compared as secondary endpoints. RESULTS: A total of 23 women participated, with 50 e-visits completed. The first asynchronous visit was completed after a median of 42days (IQR 36, 51.5) from the initial visit. There was a decrease in the Urogenital Distress Inventory-6 score between the first asynchronous visit and the last (29 points, IQR 16, 37 vs 12 points, IQR 12, 25), respectively (P = 0.014). Similar findings were seen with the Incontinence Severity Index questionnaire, from three (IQR 2, 4) to three (IQR 1, 3) after the asynchronous visit (P = 0.002). CONCLUSION: We demonstrate the feasibility of asynchronous visits for the treatment of overactive bladder. Although our results suggest efficacy, given the prepost change in overactive bladder-related questionnaire scores following asynchronous visits, the comparative effectiveness of asynchronous visits versus regular care needs to be confirmed in a randomized trial.


Video Summary:http://links.lww.com/MENO/A917.


Assuntos
Telemedicina , Bexiga Urinária Hiperativa , Incontinência Urinária , Feminino , Humanos , Projetos Piloto , Inquéritos e Questionários , Resultado do Tratamento , Bexiga Urinária Hiperativa/terapia , Incontinência Urinária/complicações
2.
J Med Syst ; 46(5): 26, 2022 Apr 08.
Artigo em Inglês | MEDLINE | ID: mdl-35396607

RESUMO

We investigated the impact of preoperative gabapentin on perioperative intravenous opioid requirements and post anesthesia care unit length of stay (PACU LOS) for patients undergoing laparoscopic and vaginal hysterectomies within an Enhanced Recovery After Surgery (ERAS) pathway. A multidisciplinary team retrospectively examined 2,015 patients who underwent laparoscopic or vaginal hysterectomies between October 2016 and January 2020 at a single academic institution. The average PACU LOS was 168 min among patients who did not receive gabapentin vs. 180 min both among patients who received ≤ 300 mg of gabapentin and patients who received > 300 mg of gabapentin. After adjusting for demographics and medical comorbidities, PACU LOS for patients given ≤ 300 mg gabapentin was 6% longer (rate ratio (RR) = 1.06, 95% CI = 1.01-1.11) than for patients who were not given gabapentin, and for patients who received > 300 mg of gabapentin was 7% longer (RR = 1.07, 95%CI = 1.01-1.13) than for those who did not receive gabapentin. Patients who received ≤ 300 mg gabapentin received 9% less perioperative intravenous hydromorphone than patients who did not receive gabapentin (RR = 0.91, 95% CI = 0.86 - 0.97); patients who received > 300 mg of gabapentin received 12% less perioperative intravenous hydromorphone than patients who did not receive gabapentin (RR = 0.88, 95% CI = 0.82 - 0.95). These findings represent an absolute difference of 0.09 mg intravenous hydromorphone. There were no statistically significant differences in total intravenous fentanyl received. Preoperative gabapentin given as part of an ERAS pathway is associated with statistically but not clinically significant increases in PACU LOS and decreases in total perioperative intravenous opioid use.


Assuntos
Analgésicos Opioides , Recuperação Pós-Cirúrgica Melhorada , Analgésicos Opioides/uso terapêutico , Feminino , Gabapentina , Humanos , Hidromorfona , Histerectomia , Tempo de Internação , Dor Pós-Operatória/tratamento farmacológico , Estudos Retrospectivos
3.
J Surg Res ; 274: 185-195, 2022 06.
Artigo em Inglês | MEDLINE | ID: mdl-35180495

RESUMO

INTRODUCTION: Intraoperative deaths (IODs) are rare but catastrophic. We systematically analyzed IODs to identify clinical and patient safety patterns. METHODS: IODs in a large academic center between 2015 and 2019 were included. Perioperative details were systematically reviewed, focusing on (1) identifying phenotypes of IOD, (2) describing emerging themes immediately preceding cardiac arrest, and (3) suggesting interventions to mitigate IOD in each phenotype. RESULTS: Forty-one patients were included. Three IOD phenotypes were identified: trauma (T), nontrauma emergency (NT), and elective (EL) surgery patients, each with 2 sub-phenotypes (e.g., ELm and ELv for elective surgery with medical arrests or vascular injury and bleeding, respectively). In phenotype T, cardiopulmonary resuscitation was initiated before incision in 42%, resuscitative thoracotomy was performed in 33%, and transient return of spontaneous circulation was achieved in 30% of patients. In phenotype NT, ruptured aortic aneurysms accounted for half the cases, and median blood product utilization was 2,694 mL. In phenotype ELm, preoperative evaluation did not include electrocardiogram in 12%, cardiac consultation in 62%, stress test in 87%, and chest x-ray in 37% of patients. In phenotype ELv, 83% had a single peripheral intravenous line, and vascular injury was almost always followed by escalation in monitoring (e.g., central/arterial line), alert to the blood bank, and call for surgical backup. CONCLUSIONS: We have created a framework for IOD that can help with intraoperative safety and quality analysis. Focusing on interventions that address appropriateness versus futility in care in phenotypes T and NT, and on prevention and mitigation of intraoperative vessel injury (e.g., intraoperative rescue team) or preoperative optimization in phenotype EL may help prevent IODs.


Assuntos
Reanimação Cardiopulmonar , Parada Cardíaca , Lesões do Sistema Vascular , Parada Cardíaca/etiologia , Parada Cardíaca/prevenção & controle , Hemorragia , Humanos , Toracotomia
4.
J Gen Intern Med ; 2022 Jan 28.
Artigo em Inglês | MEDLINE | ID: mdl-35091916

RESUMO

BACKGROUND: Understanding association between factors related to clinical work environment and well-being can inform strategies to improve physicians' work experience. OBJECTIVE: To model and quantify what drivers of work composition, team structure, and dynamics are associated with well-being. DESIGN: Utilizing social network modeling, this cohort study of physicians in an academic health center examined inbasket messaging data from 2018 to 2019 to identify work composition, team structure, and dynamics features. Indicators from a survey in 2019 were used as dependent variables to identify factors predictive of well-being. PARTICIPANTS: EHR data available for 188 physicians and their care teams from 18 primary care practices; survey data available for 163/188 physicians. MAIN MEASURES: Area under the receiver operating characteristic curve (AUC) of logistic regression models to predict well-being dependent variables was assessed out-of-sample. KEY RESULTS: The mean AUC of the model for the dependent variables of emotional exhaustion, vigor, and professional fulfillment was, respectively, 0.665 (SD 0.085), 0.700 (SD 0.082), and 0.669 (SD 0.082). Predictors associated with decreased well-being included physician centrality within support team (OR 3.90, 95% CI 1.28-11.97, P=0.01) and share of messages related to scheduling (OR 1.10, 95% CI 1.03-1.17, P=0.003). Predictors associated with increased well-being included higher number of medical assistants within close support team (OR 0.91, 95% CI 0.83-0.99, P=0.05), nurse-centered message writing practices (OR 0.89, 95% CI 0.83-0.95, P=0.001), and share of messages related to ambiguous diagnosis (OR 0.92, 95% CI 0.87-0.98, P=0.01). CONCLUSIONS: Through integration of EHR data with social network modeling, the analysis highlights new characteristics of care team structure and dynamics that are associated with physician well-being. This quantitative methodology can be utilized to assess in a refined data-driven way the impact of organizational changes to improve well-being through optimizing team dynamics and work composition.

5.
Ann Surg ; 275(3): 500-505, 2022 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-32657935

RESUMO

OBJECTIVE: To understand the surgeon's perceived value of PROMs in 5 different surgical subspecialties. SUMMARY OF BACKGROUND DATA: PROMs are validated questionnaires that assess the symptoms, function, and quality of life from the patient's perspective. Despite the increasing support for use of PROMs in the literature, there is limited uptake amongst surgeons. Furthermore, there is insufficient understanding of the surgeons' perceived value of PROMs. The aim of this study is to understand how surgeons perceive value in PROMs. METHODS: We conducted an exploratory qualitative study to understand the perceived value of PROMs from the perspective of surgeons in various subspecialties. Per convenience sampling, we conducted semi-structured interviews with 30 surgeons from 5 subspecialties across 3 academic medical centers. The surgical subspecialties included bariatric surgery, breast oncologic surgery, orthopedic surgery, plastic and reconstructive surgery, and rhinology. Interviews were transcribed, coded, and evaluated with thematic analysis. RESULTS: Surgeons endorsed that PROMs can be used to enhance clinical management, counsel patients in the preoperative and postoperative settings, and elicit sensitive information from patients that otherwise may go undetected. Obstacles to PROMs use include failure to generate actionable data, implementation obstacles, and inappropriate use of PROMs as a performance metric, with concerns regarding inadequate risk adjustment. CONCLUSIONS: Establishing an effective PROMs program requires an understanding of the surgeon's perspective of PROMs. Despite obstacles, different subspecialty surgeons find PROMs to be valuable in different settings, depending on the specialty and clinical context.


Assuntos
Atitude do Pessoal de Saúde , Medidas de Resultados Relatados pelo Paciente , Especialidades Cirúrgicas , Cirurgiões/psicologia , Humanos , Pesquisa Qualitativa
7.
Am J Manag Care ; 27(12): e420-e425, 2021 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-34889584

RESUMO

OBJECTIVES: Hospital at home (HAH) is a health care delivery model that substitutes hospital-level services in the home for inpatient hospitalizations. HAH has been shown to be safe and effective for medical patients but has not been investigated in surgical readmissions. We estimated the potential impact of an HAH program for patients readmitted within 60 days postoperatively and described the characteristics of eligible patients to aid in the design of future programs. STUDY DESIGN: This was a cross-sectional study of 60-day postoperative readmissions at a tertiary care center in 2018. METHODS: We identified the number of readmissions that may have been eligible for HAH, collected descriptive information, and estimated the financial margin that could have been generated had eligible readmissions been diverted to HAH. RESULTS: There were 2366 readmissions within 60 days of surgery in 2018. A total of 731 readmissions met inclusion criteria for HAH (30.1%), accounting for 4152 bed days. Of these readmissions, the most common diagnoses were infection, gastrointestinal complications, and cardiac complications. Patients' home addresses were within 16 miles of the hospital in 447 cases (61.1%). Avoidance of these readmissions and use of the beds for new admissions represented a potential backfill margin of $8.8 million, not incorporating the cost of HAH. CONCLUSIONS: Many 60-day postoperative readmissions may be amenable to HAH enrollment, representing a significant opportunity to improve patient experience and generate hospital revenue. This is of particular interest in the post-COVID-19 era. To maximize their impact, HAH programs should tailor clinical and operational services to this population.


Assuntos
COVID-19 , Readmissão do Paciente , Estudos Transversais , Hospitais , Humanos , SARS-CoV-2
8.
Obstet Gynecol ; 138(4): 565-573, 2021 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-34623068

RESUMO

OBJECTIVE: To evaluate outcomes of the first pregnancy after fertility-sparing surgery in patients with early-stage cervical cancer. METHODS: We performed a population-based study of women aged 18-45 years with a history of stage I cervical cancer reported to the 2000-2012 California Cancer Registry. Data were linked to the OSHPD (California Office of Statewide Health Planning and Development) birth and discharge data sets. We included patients with cervical cancer who conceived at least 3 months after a fertility-sparing surgery, which included cervical conization or loop electrosurgical excision procedure. Those undergoing trachelectomy were excluded. The primary outcome was preterm birth. Secondary outcomes included growth restriction, neonatal morbidity, stillbirth, cesarean delivery, and severe maternal morbidity. We used propensity scores to match similar women from two groups in a 1:2 ratio of case group participants to control group participants: population individuals without cancer and individuals with cervical cancer (women who delivered before their cervical cancer diagnosis). Wald statistics and logistic regressions were used to evaluate outcomes. RESULTS: Of 4,087 patients with cervical cancer, 118 (2.9%) conceived after fertility-sparing surgery, and 107 met inclusion criteria and were matched to control group participants. Squamous cell carcinoma was the most common histology (63.2%), followed by adenocarcinoma (30.8%). Patients in the case group had higher odds of preterm birth before 37 weeks of gestation compared with both control groups (21.5% vs 9.3%, odds ratio [OR] 2.7, 95% CI 1.4-5.1; 21.5% vs 12.7%, OR 1.9, 95% CI 1.0-3.6), but not preterm birth before 32 weeks. Neonatal morbidity was more common among the patients in the case group relative to those in the cervical cancer control group (15.9% vs 6.9%, OR 2.5, 95% CI 1.2-5.5). There were no differences in rates of growth restriction, stillbirth, cesarean delivery, and maternal morbidity. CONCLUSION: In a population-based cohort, patients who conceived after surgery for cervical cancer had higher odds of preterm delivery compared with control groups.


Assuntos
Colo do Útero/cirurgia , Conização/métodos , Preservação da Fertilidade/métodos , Resultado da Gravidez/epidemiologia , Neoplasias do Colo do Útero/cirurgia , Adolescente , Adulto , Carcinoma de Células Escamosas/patologia , Carcinoma de Células Escamosas/cirurgia , Colo do Útero/patologia , Cesárea/estatística & dados numéricos , Estudos de Coortes , Feminino , Retardo do Crescimento Fetal/epidemiologia , Número de Gestações , Humanos , Recém-Nascido , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Gravidez , Complicações Neoplásicas na Gravidez/cirurgia , Nascimento Prematuro/epidemiologia , Pontuação de Propensão , Natimorto/epidemiologia , Traquelectomia/métodos , Adulto Jovem
9.
Cancers (Basel) ; 13(17)2021 Aug 26.
Artigo em Inglês | MEDLINE | ID: mdl-34503128

RESUMO

Ascites refers to the abnormal accumulation of fluid in the peritoneum resulting from an underlying pathology, such as metastatic cancer. Among all cancers, advanced-stage epithelial ovarian cancer is most frequently associated with the production of malignant ascites and is the leading cause of death from gynecologic malignancies. Despite decades of evidence showing that the accumulation of peritoneal fluid portends the poorest outcomes for cancer patients, the role of malignant ascites in promoting metastasis and therapy resistance remains poorly understood. This review summarizes the current understanding of malignant ascites, with a focus on ovarian cancer. The first section provides an overview of heterogeneity in ovarian cancer and the pathophysiology of malignant ascites. Next, analytical methods used to characterize the cellular and acellular components of malignant ascites, as well the role of these components in modulating cell biology, are discussed. The review then provides a perspective on the pressures and forces that tumors are subjected to in the presence of malignant ascites and the impact of physical stress on therapy resistance. Treatment options for malignant ascites, including surgical, pharmacological and photochemical interventions are then discussed to highlight challenges and opportunities at the interface of drug discovery, device development and physical sciences in oncology.

11.
Gynecol Oncol ; 162(3): 613-618, 2021 09.
Artigo em Inglês | MEDLINE | ID: mdl-34247769

RESUMO

OBJECTIVE: The objective of this study was to determine the proportion of patients with a pre-invasive endometrial lesion who meet Mayo criteria for lymph node dissection on final pathology to determine if the use of sentinel lymph node biopsy in patients with pre-invasive lesions would be warranted. METHODS: All women who underwent hysterectomy for a pre-invasive endometrial lesion (atypical hyperplasia or endometrial intra-epithelial neoplasia) between 2009 and 2019 were included for analysis. Relevant statistical tests were utilized to test the associations between patient, operative, and pathologic characteristics. RESULTS: 141 patients met inclusion criteria. 51 patients (36%) had a final diagnosis of cancer, the majority (96%) of which were Stage IA grade 1 endometrioid carcinomas. Seven patients (5%) met Mayo criteria on final pathology (one grade 3, seven size >2 cm, one >50% myoinvasive). Three of these seven patients had lymph nodes assessed of which 0% had metastases. Six of these patients had frozen section performed, and 2 met (33%) Mayo criteria intraoperatively. Of the seven patients in the overall cohort that had lymph node sampling, six had a final diagnosis of cancer and none had positive lymph nodes. Of the 51 patients with cancer, only 10 had cancer diagnosed using frozen section, and only two met intra-operative Mayo criteria. Age > 55 was predictive of meeting Mayo criteria on final pathology (p = 0.007). No patients experienced a cancer recurrence across a median follow up of 24.3 months. CONCLUSIONS: Atypical hyperplasia and endometrial intra-epithelial neoplasia portend low risk disease and universal nodal assessment is of limited value.


Assuntos
Carcinoma Endometrioide/patologia , Neoplasias do Endométrio/patologia , Linfonodos/patologia , Lesões Pré-Cancerosas/patologia , Biópsia de Linfonodo Sentinela/métodos , Adulto , Idoso , Carcinoma in Situ/patologia , Carcinoma in Situ/cirurgia , Carcinoma Endometrioide/cirurgia , Hiperplasia Endometrial/patologia , Hiperplasia Endometrial/cirurgia , Neoplasias do Endométrio/cirurgia , Feminino , Humanos , Histerectomia , Excisão de Linfonodo , Linfonodos/cirurgia , Pessoa de Meia-Idade , Lesões Pré-Cancerosas/cirurgia
13.
JCO Glob Oncol ; 7: 1032-1066, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-34185571

RESUMO

PURPOSE: To provide expert guidance to clinicians and policymakers in three resource-constrained settings on diagnosis and staging of adult women with ovarian masses and treatment of patients with epithelial ovarian (including fallopian tube and primary peritoneal) cancer. METHODS: A multidisciplinary, multinational ASCO Expert Panel reviewed existing guidelines, conducted a modified ADAPTE process, and conducted a formal consensus process with additional experts. RESULTS: Existing sets of guidelines from eight guideline developers were found and reviewed for resource-constrained settings; adapted recommendations from nine guidelines form the evidence base, informing two rounds of formal consensus; and all recommendations received ≥ 75% agreement. RECOMMENDATIONS: Evaluation of adult symptomatic women in all settings includes symptom assessment, family history, and ultrasound and cancer antigen 125 serum tumor marker levels where feasible. In limited and enhanced settings, additional imaging may be requested. Diagnosis, staging, and/or treatment involves surgery. Presurgical workup of every suspected ovarian cancer requires a metastatic workup. Only trained clinicians with logistical support should perform surgical staging; treatment requires histologic confirmation; surgical goal is staging disease and performing complete cytoreduction to no gross residual disease. In first-line therapy, platinum-based chemotherapy is recommended; in advanced stages, patients may receive neoadjuvant chemotherapy. After neoadjuvant chemotherapy, all patients should be evaluated for interval debulking surgery. Targeted therapy is not recommended in basic or limited settings. Specialized interventions are resource-dependent, for example, laparoscopy, fertility-sparing surgery, genetic testing, and targeted therapy. Multidisciplinary cancer care and palliative care should be offered.Additional information can be found at www.asco.org/resource-stratified-guidelines. It is ASCO's view that health care providers and health care system decision makers should be guided by the recommendations for the highest stratum of resources available. The guideline is intended to complement but not replace local guidelines.


Assuntos
Neoplasias Ovarianas , Adulto , Antígeno Ca-125 , Carcinoma Epitelial do Ovário/diagnóstico , Carcinoma Epitelial do Ovário/terapia , Procedimentos Cirúrgicos de Citorredução , Feminino , Humanos , Terapia Neoadjuvante , Neoplasias Ovarianas/diagnóstico , Neoplasias Ovarianas/terapia
15.
Obstet Gynecol ; 137(6): 1109-1118, 2021 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-33957660

RESUMO

OBJECTIVE: To evaluate the outcomes of the first pregnancy after fertility-sparing surgery in patients treated for early-stage ovarian cancer. METHODS: We performed a retrospective study of women aged 18-45 years with a history of stage IA or IC ovarian cancer reported to the California Cancer Registry for the years 2000-2012. These data were linked to the 2000-2012 California Office of Statewide Health Planning and Development birth and discharge data sets to ascertain oncologic characteristics and obstetric outcomes. We included in the case group ovarian cancer patients who conceived at least 3 months after fertility-sparing surgery. The primary outcome was preterm birth, and only the first pregnancy after cancer diagnosis was considered. Secondary outcomes included small-for-gestational-age (SGA) neonates, neonatal morbidity (respiratory support within 72 hours after birth, hypoxic-ischemic encephalopathy, seizures, infection, meconium aspiration syndrome, birth trauma, and intracranial or subgaleal hemorrhage), and severe maternal morbidity as defined by the Centers for Disease Control and Prevention. Propensity scores were used to match women in a 1:2 ratio for the case group and the control group. Wald statistics and logistic regressions were used to evaluate outcomes. RESULTS: A total of 153 patients who conceived after fertility-sparing surgery were matched to 306 women in a control group. Histologic types included epithelial (55%), germ-cell (37%), and sex-cord stromal (7%). Treatment for ovarian cancer was not associated with preterm birth before 37 weeks of gestation (13.7% vs 11.4%; odds ratio [OR] 1.23, 95% CI 0.69-2.20), SGA neonates (birth weight less than the 10th percentile: 11.8% vs 12.7%; OR 0.91, 95% CI 0.50-1.66), severe maternal morbidity (2.6% vs 1.3%; OR 2.03, 95% CI 0.50-8.25), or neonatal morbidity (both 5.9% OR 1.00, 95% CI 0.44-2.28). CONCLUSION: Patients who conceived at least 3 months after surgery for early-stage ovarian cancer did not have an increased risk of adverse obstetric outcomes.


Assuntos
Preservação da Fertilidade , Neoplasias Ovarianas/cirurgia , Resultado da Gravidez/epidemiologia , Nascimento Prematuro/epidemiologia , Adolescente , Adulto , Traumatismos do Nascimento/epidemiologia , California/epidemiologia , Estudos de Casos e Controles , Feminino , Humanos , Hipóxia-Isquemia Encefálica/epidemiologia , Recém-Nascido , Recém-Nascido Pequeno para a Idade Gestacional , Hemorragias Intracranianas/epidemiologia , Síndrome de Aspiração de Mecônio/epidemiologia , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Neoplasias Ovarianas/patologia , Período Pós-Operatório , Gravidez , Complicações na Gravidez/epidemiologia , Pontuação de Propensão , Sistema de Registros , Respiração Artificial/estatística & dados numéricos , Estudos Retrospectivos , Adulto Jovem
16.
J Am Coll Radiol ; 18(5): 663-668, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-33958082

RESUMO

OBJECTIVE: To implement a multifaceted wellness program in an academic radiology department to prevent burnout and to assess initial outcomes with special focus on the challenges related to the coronavirus disease 2019 (COVID-19) pandemic. METHODS: A wellness program was established to address institutional and personal factors of burnout. The program focused on interventions to improve efficiency of practice, provide personal and career support, and create a culture of wellness. The components of the program were designed with input from radiology faculty, and the program was financially supported by the hospital's physician organization. A survey was performed 6 months after the initiation of the program to determine radiologist engagement and satisfaction. With the onset of the COVID-19 pandemic, a new survey was administered to identify needs of faculty and adjust initiatives. This study was exempt from institutional review board approval. RESULTS: The majority of radiologists (79%) agreed or strongly agreed that the wellness program provided opportunities to connect with coworkers. All radiologists agreed that the program was helpful and should be continued. During the COVID-19 pandemic, 49% of physicians requested initiatives focused on well-being, emotional health, and mindfulness to support them during the crisis. CONCLUSIONS: The implementation of a faculty wellness program in an academic radiology department addressed institutional and personal factors of burnout, allowed faculty to connect with coworkers, and was found to be helpful by all radiologists. The COVID-19 pandemic shifted needs to well-being and emotional health initiatives. Follow-up data are necessary to assess its effect on burnout reduction.


Assuntos
Esgotamento Profissional , COVID-19 , Radiologia , Esgotamento Profissional/epidemiologia , Esgotamento Profissional/prevenção & controle , Promoção da Saúde , Humanos , Pandemias , Radiologia/educação , SARS-CoV-2
17.
J Gen Intern Med ; 2021 Apr 26.
Artigo em Inglês | MEDLINE | ID: mdl-33904030

RESUMO

BACKGROUND: Physicians need to learn and work amidst a plethora of uncertainties, which may drive burnout. Understanding differences in tolerance of uncertainty is an important research area. OBJECTIVE: To examine factors associated with tolerance of uncertainty, including well-being metrics such as burnout. DESIGN: Online confidential survey. SETTING: The Massachusetts General Physicians Organization (MGPO). PARTICIPANTS: All 2172 clinically active faculty in the MGPO. MAIN MEASURES: We examined associations for tolerance of uncertainty with demographic information, personal and professional characteristics, and physician well-being metrics. KEY RESULTS: Two thousand twenty (93%) physicians responded. Multivariable analyses identified significant associations of lower tolerance of uncertainty with female gender (OR, 1.23; 95% CI, 1.03-1.48); primary care practice (OR, 1.56; 95% CI, 1.22-2.00); years since training (OR, 0.99; 95% CI, 0.98-0.995); and lacking a trusted advisor (OR, 1.25; 95% CI, 1.03-1.53). Adjusting for demographic and professional characteristics, physicians with low tolerance of uncertainty had higher likelihood of being burned-out (OR, 3.06; 95% CI, 2.41-3.88), were less likely to be satisfied with career (OR, 0.37; 95% CI, 0.26-0.52), and less likely to be engaged at work (RR, 0.87; 95% CI, 0.84-0.90). CONCLUSION: At a time when concern about physician well-being is high, with much speculation about causes of burnout, we found a strong relationship between tolerance of uncertainty and physician well-being, across specialties. Particular attention likely needs to be paid to those with less experience, those in specialties with high rates of undifferentiated illness and uncertainty, such as primary care, and ensuring all physicians have access to a trusted advisor. These results generate the potential hypothesis that efforts focused in understanding and embracing uncertainty could be potentially effective for reducing burnout. This concept should be tested in prospective trials.

18.
Ann Surg Oncol ; 28(11): 6705-6713, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-33683525

RESUMO

BACKGROUND: Ovarian cancer with miliary disease spread is an aggressive phenotype lacking targeted management strategies. We sought to determine whether adjuvant intravenous/intraperitoneal (IV/IP) chemotherapy is beneficial in this disease setting. METHODS: Patient/tumor characteristics and survival data of patients with stage IIIC epithelial ovarian cancer who underwent optimal primary debulking surgery from 01/2010 to 11/2014 were abstracted from records. Chi-square and Mann-Whitney U tests were used to compare categorical and continuous variables. The Kaplan-Meier method was used to estimate survival curves, and outcomes were compared using log-rank tests. Factors significant on univariate analysis were combined into multivariate logistic regression survival models. RESULTS: Among 90 patients with miliary disease spread, 41 (46%) received IV/IP chemotherapy and 49 (54%) received IV chemotherapy. IV/IP chemotherapy, compared with IV chemotherapy, resulted in improved progression-free survival (PFS; 23.0 versus 12.0 months; p = 0.0002) and overall survival (OS; 52 versus 36 months; p = 0.002) in patients with miliary disease. Among 78 patients with nonmiliary disease spread, 23 (29%) underwent IV/IP chemotherapy and 55 (71%) underwent IV chemotherapy. There was no PFS or OS benefit associated with IV/IP chemotherapy over IV chemotherapy in these patients. On multivariate analysis, IV/IP chemotherapy was associated with improved PFS (HR, 0.28; 95% CI 0.15-0.53) and OS (HR, 0.33; 95% CI 0.18-0.61) in patients with miliary disease compared with those with nonmiliary disease (PFS [HR, 1.53; 95% CI 0.74-3.19]; OS [HR, 1.47; 95% CI 0.70-3.09]). CONCLUSIONS: Adjuvant IV/IP chemotherapy was associated with oncologic benefit in miliary disease spread. This survival benefit was not observed in nonmiliary disease.


Assuntos
Protocolos de Quimioterapia Combinada Antineoplásica , Neoplasias Ovarianas , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Carcinoma Epitelial do Ovário/tratamento farmacológico , Carcinoma Epitelial do Ovário/patologia , Quimioterapia Adjuvante , Procedimentos Cirúrgicos de Citorredução , Intervalo Livre de Doença , Feminino , Humanos , Infusões Parenterais , Estadiamento de Neoplasias , Neoplasias Ovarianas/tratamento farmacológico , Neoplasias Ovarianas/patologia , Estudos Retrospectivos
19.
BMC Anesthesiol ; 21(1): 36, 2021 02 05.
Artigo em Inglês | MEDLINE | ID: mdl-33546602

RESUMO

BACKGROUND: The Massachusetts General Hospital is a large, quaternary care institution with 58 operating rooms, 164 anesthesiologists, 76 certified nurse anesthetists (CRNAs), an anesthesiology residency program that admits 25 residents annually, and 35 surgeons who perform laparoscopic, vaginal, and open hysterectomies. In March of 2018, our institution launched an Enhanced Recovery After Surgery (ERAS) pathway for patients undergoing hysterectomy. To implement the anesthesia bundle of this pathway, an intensive 14-month educational endeavor was created and put into effect. There were no subsequent additional educational interventions. METHODS: We retrospectively reviewed records of 2570 patients who underwent hysterectomy between October 2016 and March 2020 to determine adherence to the anesthesia bundle of the ERAS Hysterectomy pathway. RESULTS: Increased adherence to the four elements of the anesthesia bundle (p < 0.001) was achieved during the intervention period. Compliance with the pathway was sustained in the post-intervention period despite no additional actions. CONCLUSIONS: Implementing the anesthesia bundle of an ERAS pathway in a large anesthesia group with diverse providers successfully occurred using implementation science-based approach of intense interventions, and these results were maintained after the intervention ceased.


Assuntos
Serviço Hospitalar de Anestesia , Anestesiologia/métodos , Recuperação Pós-Cirúrgica Melhorada , Histerectomia , Feminino , Humanos , Massachusetts , Pessoa de Meia-Idade , Estudos Retrospectivos
20.
J Healthc Qual ; 43(3): 145-152, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-32168121

RESUMO

BACKGROUND: Unnecessary hospitalizations may pose the risk of iatrogenic complications, suboptimal patient experience, and increased cost. Administrative data lack granularity to understand the proportion and causes of hospitalizations preventable through optimizing care continuum (HPOCC). We aim to identify the incidence and causes of HPOCC through clinician-adjudicated chart review. METHODS: A retrospective review was performed for inpatient admissions from the emergency department (ED) over 1 week. Each admission was reviewed by a clinician to determine whether it is an HPOCC defined as not requiring inpatient care with the assumption of idealized outpatient care and social support. RESULTS: Of the 515 patients admitted from the ED, 31 (6.0%) patients were judged to have had an HPOCC. Causes of HPOCC include urgent diagnostics (9, 29.0%), unnecessary transfer from a long-term facility (7, 23.0%), needing IV therapy (5, 16.0%), benign incidental finding (5, 16.0%), diagnostic uncertainty in complex chronic illness (3, 10.0%), and lack of access to care for disposition (2, 6.0%). CONCLUSION: Hospitalizations preventable through optimizing care continuum account for about 1 in every 15 hospitalizations in an urban academic medical center. The need for urgent diagnostics accounts for a plurality of HPOCC and could be an important target for quality improvement.


Assuntos
Assistência Ambulatorial , Hospitalização , Continuidade da Assistência ao Paciente , Serviço Hospitalar de Emergência , Humanos , Estudos Retrospectivos
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