Recent Publications by CFE Educators

BACKGROUND

Burnout among physicians is an increasing concern, and surgeons are not immune to this threat. The ongoing COVID-19 pandemic has caused dramatic changes to surgeon workflow, often leading to redeployment to other clinical areas, slowdown and shutdown of elective surgery practices, and an uncertain future of surgical practice in the post-pandemic setting. Paradoxically, for many surgeons who had to prepare for but not immediately care for a major surge, the crisis did allow for reflective opportunities and a resetting of priorities that could serve to mitigate chronic patterns contributory to Burnout.

METHODS

SAGES Reimagining the Practice of Surgery task force convened a webinar to discuss lessons learned from the COVID pandemic that may address burnout.

RESULTS

Burnout is multifactorial and may vary in cause among different generation/experience groups. Those that report burnout symptoms often complain of lacking purpose or meaning in their work. Although many mechanisms to address Burnout are from a defensive standpoint-including coping mechanisms, problem solving, and identification of a physician having wellness difficulties-offensive mechanisms such as pursuing purpose and meaning and finding joy in one's work can serve as reset points that promote thriving and fulfillment. Understanding what motivates physicians will help physician leaders to develop and sustain effective teams. Reinvigorating the surgical workforce around themes of meaning and joy in the service rendered via our surgical skills may diminish Burnout through generative and aspirational strategies, as opposed to merely reactive ones. Fostering an educational environment free of discriminatory or demeaning behavior may produce a new workforce conducive to enhanced and resilient wellbeing at the start of careers.

CONCLUSION

Surgeon wellness and self-care must be considered an important factor in the future of all healthcare delivery systems, a need reaffirmed by the COVID-19 pandemic.

OBJECTIVE

To systematically review the literature to determine the difference in complications between standard twill and Velcro ties following pediatric tracheostomy.

DATA SOURCES

MEDLINE, Embase, the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, Web of Science, and CINAHL Plus were searched up to August 2020.

REVIEW METHODS

Two authors independently screened articles for eligibility. Retrospective and prospective studies were included as long as there was a direct comparison between twill and Velcro ties. Quantitative and qualitative analysis was performed. The main outcomes were skin-related complications and accidental decannulation.

RESULTS

Three studies were included in the final analysis: 1 randomized prospective trial and 2 retrospective studies. There were 238 patients total (137 twill, 101 Velcro). Combined analysis showed skin-related complications in 23% of the Velcro group and 44% of the twill group. Meta-analysis for skin-related complications showed no significant difference when comparing Velcro with standard twill ties (risk ratio, 0.53 [95% CI, 0.24-1.17]; = .12, n = 238 participants from 3 studies, = 66%). Accidental decannulation rates were overall low and comparable between groups (1.0% of twill, 1.4% of Velcro).

CONCLUSION

Based on limited data, skin-related complications were not statistically different between Velcro and twill ties. Accidental decannulation is rare with Velcro and standard twill ties, and both are viable options following pediatric tracheostomy.

Mammographic density (MD) phenotypes are strongly associated with breast cancer risk and highly heritable. In this GWAS meta-analysis of 24,192 women, we identify 31 MD loci at P  5 × 10, tripling the number known to 46. Seventeen identified MD loci also are associated with breast cancer risk in an independent meta-analysis (P  0.05). Mendelian randomization analyses show that genetic estimates of dense area (DA), nondense area (NDA), and percent density (PD) are all significantly associated with breast cancer risk (P  0.05). Pathway analyses reveal distinct biological processes involving DA, NDA and PD loci. These findings provide additional insights into the genetic basis of MD phenotypes and their associations with breast cancer risk.

BACKGROUND

Generalized convulsive status epilepticus (GCSE) is a neurologic emergency demanding prehospital identification and treatment. Evaluating real-world practice requires accurately identifying the target population; however, it is unclear whether emergency medical services (EMS) documentation accurately identifies patients with GCSE.

OBJECTIVE

To evaluate the validity of EMS diagnostic impressions for GCSE.

METHODS

This was an analysis of electronic medical records of a California county EMS system from 2013 to 2018. We identified all cases with a primary diagnostic impression of "seizure-active," "seizure-post," or "seizure-not otherwise specified (NOS)" and within each diagnostic category, we randomly selected 75 adult and 25 pediatric records. Two authors reviewed the provider narrative of these 300 charts to determine a clinical seizure diagnosis according to prespecified definitions. We calculated a kappa for interrater reliability of the clinical diagnosis. We then calculated the positive predictive value (PPV), sensitivity, and specificity of an EMS diagnosis of "seizure-active" diagnosis for identifying GCSE. Sensitivity and specificity calculations were weighted according to the distribution of seizure cases in the overall population. We performed a descriptive analysis of records with an incorrect EMS diagnosis of GCSE or seizure.

RESULTS

Of 38,995 total records for seizure, there were 3401 (8.7%) seizure-active cases, 12,478 (32.0%) seizure-NOS cases, and 23,116 (59.4%) seizure-post cases. An EMS diagnosis of "seizure-active" had a PPV of 65.0% (95% CI 54.8-74.3), sensitivity of 54.6% (95% confidence interval [CI] 39.3-69.0), and specificity of 96.6% (95% CI 95.1-97.6) for capturing GCSE. Limiting the case definition to patients who received an EMS diagnosis of "seizure-active" and were treated with a benzodiazepine increased the PPV (80.2%; 95% CI 69.9-88.2) and specificity (99.3%; 95% CI 98.7-99.6) while the sensitivity decreased (25.1%; 95% CI 17.0-35.3). Across the 300 records reviewed, there were 19 (6.3%) patients who had a non-seizure related diagnosis including non-epileptic spells (7 records), altered mental status (8 records), tremors (2 records), anxiety (1 record), and stroke (1 record).

CONCLUSIONS

EMS diagnostic impressions have reasonable PPV and specificity but low sensitivity for GCSE. Improved coding algorithms and training will allow for improved benchmarking, quality improvement, and research about this neurologic emergency.

BACKGROUND

Adenoma detection rate (ADR) is the colonoscopy quality metric with the strongest association to interval or "missed" cancer. Accurate measurement of ADR can be laborious and costly.

AIMS

Our aim was to determine if administrative procedure codes for colonoscopy and text searches of pathology results for adenoma mentions could estimate ADR.

METHODS

We identified US Veterans with a colonoscopy using Current Procedure Terminology (CPT) codes between January 2013 and December 2016 at ten Veterans Affairs sites. We applied simple text searches using Microsoft SQL Server full-text searches to query all pathology notes for "adenoma(s)" or "adenomatous" text mentions to calculate ADRs. To validate our identification of colonoscopy procedures, endoscopists of record, and adenoma detection from the electronic health record, we manually reviewed a random sample of 2000 procedure and pathology notes from the 10 sites.

RESULTS

Structured data fields were accurate in identification of colonoscopies being performed (PPV = 0.99; 95% CI 0.99-1.00) and identifying the endoscopist of record (PPV of 0.95; 95% CI 0.94-0.96) for ADR measurement. Simple text searches of pathology notes for adenoma mentions had excellent performance statistics as follows: sensitivity 0.99 (95% CI 0.98-1.00), specificity 0.93 (95% CI 0.92-0.95), NPV 0.99 (95% CI 0.98-1.00), and PPV 0.93 (0.91-0.94) for measurement of ADR. There was no clinically significant difference in the estimates of overall ADR vs. screening ADR (p > 0.05).

CONCLUSIONS

Measuring ADR using administrative codes and text searches from pathology results is an efficient method to broadly survey colonoscopy quality.

OBJECTIVE

We sought to assess the extent to which both crowd and intraoperative attending ratings using objective structured assessment of technical skill (OSATS) or global objective assessment of laparoscopic skills (GOALS) would correlate with the system for improving procedural learning (SIMPL) Zwisch and Performance scales.

DESIGN

Comparison of directly observed versus crowd sourced review of operative video.

SETTING

Operative video captured at 2 institutions.

PARTICIPANTS

Six (6) core general surgery procedures, 3 open and 3 laparoscopic, were selected from the American Board of Surgery's Resident Assessments list. Thirty-two cases performed by General Surgery residents across all training levels at 2 institutions were filmed. Videos were condensed using a standardized protocol to include the critical portion of the procedure.  Condensed videos were then submitted to crowd-sourced assessment of technical skills (C-SATS), an online crowd source-driven assessment service, for assessment using the appropriate resident assessment form (GOALS or OSATS) as well as with the SIMPL Zwisch and Performance scales. Crowd workers watched an educational tutorial on how to use the Zwisch and SIMPL Performance rating scales prior to participating. Attendings scored residents using the same tools immediately after the shared operative experience. Statistical analysis was performed using Pearson's correlation coefficient.

RESULTS

Crowd raters evaluated 32 procedures using GOALS/OSATS, Zwisch and Performance (35-50 ratings per video). Attendings also evaluated all 32 procedures using GOALS/OSATS and 26 of the procedures using SIMPL Zwisch and Performance. Pearson correlation coefficients with 95% confidence intervals for crowd ratings were: GOALS and Zwisch -0.40 [-0.73 to 0.10], OSATS and Zwisch 0.11 [-0.41 to 0.57], GOALS and Performance -0.06 [-0.44 to 0.35], and OSATS and Performance 0.22 [-0.46 to 0.20]. Pearson correlation coefficients for attendings were: GOALS and Zwisch (0.77), OSATS and Zwisch (0.65), GOALS and Performance (0.93), and OSATS and Performance (0.59).

CONCLUSIONS

Overall, correlations between crowd-sourced ratings using GOALS/OSATS and SIMPL global operative performance ratings tools were weak, yet for attendings, they were strong. Direct attending assessment may be required for evaluation of global performance while crowd sourcing may be more suitable for technical assessment.  Further studies are needed to see if more extensive crowd training would result in improved ability for global performance evaluation.

BACKGROUND

Although rates of total skin-sparing (nipple-sparing) mastectomies are increasing, the oncologic safety of this procedure has not been evaluated in invasive lobular carcinoma (ILC). ILC is the second most common type of breast cancer, and its diffuse growth pattern and high positive margin rates potentially increase the risk of poor outcomes from less extensive surgical resection.

METHODS

We compared time to local recurrence and positive margin rates in a cohort of 300 patients with ILC undergoing either total skin-sparing mastectomy (TSSM), skin-sparing mastectomy, or simple mastectomy between the years 2000-2020. Data were obtained from a prospectively maintained institutional database and were analyzed by using univariate statistics, the log-rank test, and multivariate Cox proportional hazards models.

RESULTS

Of 300 cases, mastectomy type was TSSM in 119 (39.7%), skin-sparing mastectomy in 52 (17.3%), and simple mastectomy in 129 (43%). The rate of TSSM increased significantly with time (p  0.001) and was associated with younger age at diagnosis (p = 0.0007). There was no difference in time to local recurrence on univariate and multivariate analysis, nor difference in positive margin rates by mastectomy type. Factors significantly associated with shorter local recurrence-free survival were higher tumor stage and tumor grade.

CONCLUSIONS

TSSM can be safely offered to patients with ILC, despite the diffuse growth pattern seen in this tumor type.