22.10 Rapamycin Improves Adaptive Venous Remodeling and Decreases Arteriovenous Fistula Wall Thickening

Posted on January 31, 2019

A. Fereydooni1,2, X. Guo2,3, H. Hu2, T. Isaji2, N. Nassiri4, L. Zhang3, A. Dardik2,4  1Howard Hughes Medical Institute,Chevy Chase, MD, USA 2Vascular Biology And Therapeutics Program,Yale School Of Medicine,NEW HAVEN, CT, USA 3Renji Hospital, Shanghai Jiaotong University,Department Of Vascular Surgery,Shanghai, SHANGHAI, China 4Yale University School Of Medicine,Department Of Surgery, Section Of Vascular And Endovascular Surgery,New Haven, CT, USA

Introduction: Arteriovenous fistulae (AVF) continue to be the most common access created for hemodialysis, but up to 50% of AVFs fail to mature, suggesting a need to improve AVF maturation. In a mouse model, Akt1 expression increases during AVF maturation and reduced Akt1 expression in vivo reduces fistula wall thickness and diameter and improves long-term patency.  Mammalian target of rapamycin (mTOR) is a key regulatory protein that integrates signals from the Akt pathway to coordinate cell growth and proliferation. We hypothesized that inhibition of the Akt1-mTORC1 axis reduces pathologic venous remodeling that is associated with failure of AVF maturation.

Methods:  A C57BL6/J mouse aortocaval fistula model was used (male, 9–12 weeks). Mice were injected with 0 or 100 μg of rapamycin (intraperitoneal) daily.  The AVF (venous limb) of control- and rapamycin-injected mice were harvested at days 0, 3, 7 and 21 and for comparison analysis.  Post-operative vessel remodeling was assessed using serial ultrasound measurements of the AVF diameter and computer morphometry to measure vessel wall thickness.  AVF were compared for leukocyte, M1 and M2 macrophage surface markers and expression level of Akt1 signaling proteins using Western blot and immunofluorescence (IF) intensity.

Results: Rapamycin reduced AVF wall thickness (day 3, 4.4 μm vs 7.6 μm; day 7, 4.7 μm vs 17.8 μm; day 21, 6.2 μm vs 42.2 μm; p<0.01; n=4), without any change in AVF diameter (1-11% reduction in relative diameter; p>0.5 for day 21; n=6).  Rapamycin decreased PCNA expression (day 3 and 7, p< 0.05; n=3), but did not increase cleaved caspase-3 expression (day 3, 7, and 21 p>0.05; n=3) in AVF.  Deposition of collagen I, collagen III and fibronectin also decreased in AVF of rapamycin-treated mice, compared to control mice (41-63% reduction in IF intensity of all three markers at day 21, p< 0.05 for collagen I and III day 7 and 21; n=4; p< 0.01 for fibronectin day 3, 7 and 21; n=5).  Rapamycin treatment was associated with diminished phosphorylation of the mTORC1 pathway: Akt1, 4EBP1 and p70S6K (p<0.001; n=5-7), but not of the mTORC2 pathway: PKC-α  and SGK1 (p>0.4; n=4).  Both leukocyte CD45+ and macrophage CD68+ protein expression increased in AVF compared to sham-operated vein (days 3, 7 and 21; p<0.05).  Macrophage depletion with clodronate liposomes reduced AVF wall thickness compared to control veins (p< 0.01, day 21; n=3). Rapamycin also reduced macrophage CD68+ protein expression as well as both M1 and M2 macrophage activity in AVF (iNOS, TNF-α, IL-10 and CD206, day 7, p<0.04; n=4).

Conclusion: Rapamycin reduces inflammation and wall thickening during AVF maturation through the Akt1-mTORC1 signaling pathway.  Rapamycin may be a translational strategy to improve AVF patency.

 

22.09 Immunologic Profiling of Rejection Risk in HIV-Positive Solid Organ Transplant Recipients

Posted on January 31, 2019

S. N. Chu2, S. Wisel1, B. Shaw1, K. Lee1, M. Mintz1, C. Ward1, E. Chuu1, K. Melli1, K. Sugisaki1, P. Stock1, Q. Tang1  1University Of California – San Francisco,Department Of Surgery,San Francisco, CA, USA 2University Of California – San Francisco,School Of Medicine,San Francisco, CA, USA

Introduction:  HIV(+) solid­ organ transplant recipients are predisposed to a three times higher rate of rejection episodes when compared to HIV(­-) recipients, but immunological correlates of rejection in this population have not previously been identified. Here we describe our investigation of immunologic phenotype and gene expression profiling to identify functional differences between Rejectors (Rej) and Non­-Rejectors (NR).

Methods:  Donor and recipient peripheral blood mononuclear cells (PBMCs) were collected prior to transplant. Rej were selected based on biopsy­-proven acute cellular rejection. Kidney transplant recipients were stratified by Rej (n=28) versus NR (n=56), as compared to matched HIV(­-) kidney transplant recipients, HIV(+) non­transplant controls and HIV(­-), ESRD(­-) healthy control subjects (n=25 per group). These patients were profiled using flow cytometric panels to characterize cellular subsets, activation status, and Treg phenotype. Groups were compared for variance using the Kruskal­-Wallis test, with pairwise comparison performed between groups by Dunn’s post­-test. For gene expression analysis, pre­-transplant HIV(+) liver recipient PBMCs from Rej (n=6) and NR (n=6) were co­-cultured in mixed lymphocyte reaction (MLR) in vitro with either CD40L-­stimulated donor or 3rd party B cells. Donor B cells were removed by immunodepletion and recipient cells were analyzed using a custom NanoString panel. Raw counts were normalized and p­-values were adjusted using the Benjamini­-Hochberg procedure.

Results: HIV(+) Rej were found to have markers of increased pre­-transplant immune activation as compared to NR, with a bias toward activation of the innate immune system. They exhibited a significantly altered monocyte phenotype, including decreased HLA­-DR expression on CD14+CD16+ intermediate monocytes. Moreover, Rej have increased B cell activation by HLA­-DR expression and less activated Tregs by decreased percentage of CD39+ Tregs. The frequency of Tregs did not differ between the two groups. After alloantigen stimulation, Rej showed increased gene expression of T­-cell activation markers, CD28 and ICOS. Interestingly, NR displayed upregulation of regulatory ligands in the leukocyte immunoglobulin­like receptor (LILR) family, including LILRB1, LILRA1, LILRB4, as well as a higher proportion of PD1+ CD8+ T cells compared to Rej. Differential gene expression was preserved irrespective of stimulus by either donor or 3rd party.

Conclusion: Overall, our results suggest that increased rates of rejection in HIV(+) kidney and liver transplants correlate with pre­-transplant, recipient­-specific immune dysfunction. Concordance in gene expression profile following stimulation with donor or 3rd party suggests that differential gene expression is an intrinsic, recipient­-driven propensity to immune activation in Rej and immune regulation in NR.

22.08 Setting of Care in Colon Cancer: Which Patients Benefit the Most from Care at Academic Centers?

Posted on January 31, 2019

J. K. Ewing1, J. J. Cabo1, X. Shu2, X. O. Shu2, M. Tan1, K. Idrees1, C. E. Bailey1  1Vanderbilt University Medical Center,Department Of Surgery, Division Of Surgical Oncology And Endocrine Surgery,Nashville, TN, USA 2Vanderbilt University Medical Center,Division Of Epidemiology,Nashville, TN, USA

Introduction: Some studies show that care at an academic center (AC) improves survival for patients with advanced stage colon cancer (CC). However, it remains unclear which patients have the greatest survival benefit from treatment at AC. The primary aim of this study is to determine which patients have the most improvement in overall survival (OS) from treatment at AC, relative to other treatment facilities (TF).

Methods: A retrospective cohort study of adults with histologically confirmed CC was performed using the National Cancer Database (2004-2014). TF were classified as community cancer programs (CCP; 100-500 cases/year), comprehensive community cancer programs (CCCP; >500 cases/yr), academic centers (AC; >500 cases/yr with residency training program), or integrated network cancer programs (INCP; multi-center organizations). Demographic and clinical factors were compared according to TF. Kaplan-Meier curves and log-rank tests were used for univariate survival analysis. Cox proportional hazard models were used to assess the impact of TF on OS after adjusting for patient, tumor, and treatment characteristics.  Subgroup analyses were performed stratifying by stage, age, and race.

Results:The cohort included 433,997 patients with median age of 69(Interquartile range: 59-78). Most were white(83.8%), had Medicare(55.4%) or private insurance(34.8%), and were treated at CCCP(49.1%) or AC(26.5%). Median OS was greatest for patients treated at AC(107.1 months), compared to INCP(98.5 mo), CCCP(95.9 mo), and CCP(90.2 mo) (P<0.001). On multivariate analysis, there was no significant difference in OS between patients with stage IV CC treated at CCCP or INCP relative to those treated at CCP. However, an improvement in OS was observed for patients with stage IV CC treated at AC(Hazard ratio [HR] 0.85, 95% Confidence Interval [CI] 0.83-0.87, P<0.001) (Figure 1A). Similarly, among patients younger than 70, patients treated at CCCP or INCP had similar OS relative to those treated at CCP, whereas those treated at AC had improved OS relative to those treated at CCP(HR 0.86, 95% CI 0.84-0.88, P<0.001) (Fig. 1B). Finally, for African American (AA) patients, treatment at CCCP and INCP had similar OS compared to treatment at CCP, whereas improved OS was observed for AA patients treated at AC(HR 0.88, 95% CI 0.84-.91, P<0.001). A similar pattern was observed for non-white, non-AA patients (Fig. 1C).

Conclusion:Treatment at AC is especially beneficial for patients with stage IV CC, patients younger than 70, and non-white patients. For these patients, treatment at AC was independently associated with 12-15% reduced mortality relative to treatment at CCP. Further work is needed to examine why certain groups benefit more from care at AC.

22.07 Expansion Coverage and Preferential Utilization of Cancer Surgery Among Minorities and Low-Income Groups

Posted on January 31, 2019

A. B. Crocker1, A. Zeymo1,2, J. McDermott1, D. Xiao1, T. Watson4, T. DeLeire5, N. Shara2,3, K. S. Chan1,2, W. B. Al-Refaie1,4  1MedStar-Georgetown Surgical Outcomes Research Center,Washington, DC, USA 2MedStar Health Research Institute,Washington, DC, USA 3Georgetown-Howard Universities Center for Clinical and Translational Science,Washington, DC, USA 4Department of Surgery, MedStar-Georgetown University Hospital,,Washington, DC, USA 5Georgetown McCourt School of Public Policy,Washington, DC, USA

Introduction:
Pre-Affordable Care Act (ACA) Medicaid expansions have demonstrated inconsistent effects on cancer surgery utilization rates among racial minorities and low-income Americans. Currently, it remains unknown how Medicaid expansion coverage under the ACA will impact these vulnerable populations with long standing disparities in access and outcomes of surgical cancer care. Using a quasi-experimental design, this study seeks to examine whether Medicaid expansion differentially increased the utilization of surgical cancer care for low-income groups and racial minorities in states that expanded their Medicaid program relative to states that did not.

Methods:
A cohort of over 95,000 patients aged 18-64 years who underwent cancer surgery were examined in two Medicaid expansion states (Kentucky and Maryland) vs. two non-expansion states (Florida and North Carolina). This evaluation utilized merged data from the State Inpatient Database, American Hospital Association, and the Area Resource File from the Health Resources and Services Administration for the years 2012-2015. Poisson interrupted time series analysis (ITS) were performed to examine the impact of ACA Medicaid expansion on the utilization of surgical cancer care for the uninsured overall, low-income persons, and racial and ethnic minorities after adjusting for age, sex, Elixhauser comorbidity score, population- and provider-level characteristics.

Results:
Following Medicaid expansion, the share of Medicaid patients receiving surgical cancer care in expansion states increased by 56%, compared to an 11% decrease in non-expansion states (p <0.001). Simultaneously, the percentage of uninsured patients declined by 63.4% in expansion states relative to a 10% reduction in non-expansion states (p < 0.001).  For persons from low-income zip codes, Medicaid expansion was associated with an immediate 24% increase in utilization (p = 0.002), relative to no significant change in non-expansion states. However, there were no significant trends observed post ACA expansion for racial and ethnic minorities in expansion vs. non-expansion states (Figure). 

Conclusion:
In this quasi-experimental evaluation, Medicaid expansion was associated with greater utilization of cancer surgery by low-income Americans, but provided no preferential effects for racial minorities in expansion states. Beyond the availability of coverage, these early findings highlight the need for additional investigation to uncover other factors that contribute to racial disparities in surgical cancer care.
 

22.06 Post-thyroidectomy Neck Appearance and Impact on Quality of Life in Thyroid Cancer Survivors

Posted on January 31, 2019

S. Kurumety1, I. Helenowski1, S. Goswami1, B. Peipert1, S. Yount2, C. Sturgeon1  2Feinberg School Of Medicine – Northwestern University,Department Of Medical Social Sciences,Chicago, IL, USA 1Feinberg School Of Medicine – Northwestern University,Department Of Surgery,Chicago, IL, USA

Introduction:  There is a paucity of patient-reported data on thyroidectomy scar perception. The magnitude and duration of the impact of thyroidectomy scar on quality of life (QOL) is not known. We hypothesized that age, sex and race would predict scar perception, and that worse scar perception would correlate with lower?QOL. Furthermore, we hypothesized that over time, scar perception would improve.

Methods: Adults >18 years who had undergone thyroidectomy for cancer?(n=1743)?were recruited from a support group and surveyed online. Demographics, clinical characteristics, and treatment history were assessed. Scar perception was scored on a 5-point Likert scale.?QOL was evaluated via PROMIS-29. Respondents were grouped and compared based on their responses. The relationship between scar perception, patient characteristics, and QOL were?analyzed?with univariable and multivariable?models. Kruskal-Wallis, Fisher’s exact test, and cumulative logistic regression were used to compare?categorical variables. The relationship?between PROMIS domains and scar perception?were?analyzed using Spearman partial correlation coefficients?(r)?adjusted for age and years after surgery.?Holms-Bonferroni was used to correct for multiple comparisons.

Results: Increasing age?was associated with?better?scar perception (OR 0.975/year; 95% CI 0.967-0.983; p<0.001).?71% of respondents age >45?years?reported no concern over scar, compared to only 53% of respondents?<45;?p < 0.0001. Increased time since surgery?was?also associated with?improved?scar perception (OR 0.962/year; 95% CI 0.947-0.977; p<0.0001), but there was no statistically significant difference between current and baseline neck appearance >2 years after surgery. On multivariable analysis, age >45 years (OR 0.65; [0.52-0.81] p=0.0001), >2 years since surgery (OR 0.57; 95% CI 0.46-0.70; p<0.0001), and higher self-reported QOL (OR 0.77; 95% CI 0.67-0.89; p=0.0003) were independent predictors of better self-reported scar appearance. In patients <2 years after surgery (n=568), the PROMIS domains of anxiety (rs=0.19; p<0.0001), depression (rs=0.21; p<0.0001), social function (rs=-0.18; p<0.0001), and fatigue (rs=0.21; p<0.0001) had weak but statistically significant associations with worse scar appearance. Sex and race/ethnicity were not associated with scar perception.

Conclusions: This is the largest study conducted in the U.S to evaluate scar perception after thyroidectomy, and the first to use PROMIS measures.??Age >45, >2 years since surgery, and higher self-reported QOL were independent predictors of better scar perception.??There was no significant difference between perception of current and baseline neck appearance in the group of respondents >2 years after thyroidectomy. There was a weak correlation between scar perception?and?PROMIS domains in patients who had surgery within 2 years. The impact of thyroidectomy scar on QOL appears to be mild and transient and plateaus after 2 years.

22.05 The Human Antibody and Cellular Response to MHC Compatible Swine Cell

Posted on January 31, 2019

J. M. Ladowski1, G. Martens1, L. Reyes1, M. Tector1, A. J. Tector1  1University Of Alabama at Birmingham,Birmingham, Alabama, USA

Introduction:  Xenotransplantation is a solution to the growing need for life-saving transplantable organs. Recent advances in genetic engineering allow for rapid manipulation of the swine genome. We hypothesize that genetically engineered cells possessing recipient-matched class I major histocompatibility complex (MHC), on a swine MHC deficient background, would reduce both antibody- and cellular-mediated rejection.

Methods:  Two CRISPR gRNA plasmids were designed to remove the entire coding sequence of the swine class I MHC and co-transfected with a third plasmid containing a promoterless Hygromycin resistance gene surrounded by PhiC31 recombinase sequences, followed with a promoterless human class I MHC cDNA. The response of MHC-matched individuals to the human MHC expressing swine cell was evaluated in a flow cytometry crossmatch (FCXM), 24-hour IFN-y ELISPOT assay, and a mixed lymphocyte reaction (MLR) to measure an immediate, recall, and delayed response.  

Results: A cell line expressing human class I MHC was successfully generated using the described approach. Individuals with no preformed to the class I MHC chosen in this experimental model demonstrated significantly less IgG antibody binding to the human MHC positive swine cell compared to the MHC deficient parent line (one-way ANOVA, p < 0.0001). The ELISPOT revealed significantly more IFN-y release for both MHC-matched and non-MHC-matched individuals in response to the human MHC positive swine cell line (paired two-tailed Wilcoxon test, p = 0.0078 and 0.0156 respectively). A human MHC expressing swine cell elicited less, but not significant, proliferation in the MLR assay compared to the swine MHC expressing cell for MHC-matched but significantly less for non-MHC-matched individuals (Figure 1 unpaired, two-tailed Wilcoxon test p = 0.1250 and 0.0312 respectively).

Conclusion: The development of the CRISPR/Cas9 system allows for complex genetic engineering strategies to be achieved rapidly. This study demonstrates that expression of human MHC on a MHC devoid swine cell can reduce the humoral and cellular response for MHC-matched individuals, but may result in a higher recall response as measured by IFN-y production.

Figure 1:  Results of the proliferation in the CFSE-based MLR of HLA-A2 positive (Figure 1A) and HLA-A2 negative (Figure 1B) PBMC responders to the HLA-A2+ AEC (Lane 1) and SLA class I positive AEC (Lane 2). An unpaired, two-tailed Wilcoxon test for the four HLA-A2 positive responders found no statistical significance between the HLA-A2 positive AEC vs the SLA class I positive AEC (p = 0.1250). For the six HLA-A2 negative responders, statistical difference was found between the HLA-A2 positive AEC vs the SLA class I positive AEC (*, p = 0.0312).

22.04 Learning from England’s Best Practice Tariff: Process Measure Pay-for-Performance Can Improve Outcomes

Posted on January 31, 2019

C. K. Zogg1,2,3, D. Metcalfe3, A. Judge4, D. C. Perry3, M. L. Costa3, B. J. Gabbe5, A. H. Haider2  1Yale University School Of Medicine,New Haven, CT, USA 2Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA 3University of Oxford,Oxford, United Kingdom 4University of Bristol,Bristol, United Kingdom 5Monash University,Melbourne, Australia

Introduction: Since passage of the Patient Protection and Affordable Care Act in 2010, Medicare has renewed efforts to improve the quality of older adult health through the introduction of an expanding set of outcome-based readmission and mortality pay-for-performance (P4P) measures. Among trauma patients, potential P4P has met with mixed success given concerns about the heterogeneous nature of patients that trauma providers treat and resultant variations in outcome measures. A novel approach taken by the National Health Service in England could offer a viable alternative plan. The objective of this study was to assess the effectiveness of the 2007-2010 English provider consensus-driven, process measure-based P4P Hip Fracture Best Practice Tariff (BPT) on improving trauma outcomes.

Methods: Quasi-experimental interrupted time-series and difference-in-difference analysis of 2000-2014 death certificate-linked data from England (Hospital Episode Statistics), Scotland (Scottish Morbidity Records), and the United States (100% Medicare all-payer claims). The study compared before-and-after differences in English temporal trends relative to those of Scotland and the US. Outcomes included: 30/90/365-day mortality, readmission, index hospital length of stay, and time to surgery. The study also assessed projections for the number of lives saved and readmissions averted were the BPT to be implemented in Scotland and the US.

Results: A total of 878,860 English, 97,487 Scottish, and 2,994,748 US index fractures were included among adults ≥65y. Following BPT introduction in England, 30-day mortality decreased instantaneously by an absolute value of -2.6 (95%CI -3.5, -1.7) percentage-points and continued to drop by an average of -0.2 (-0.4, -0.1) percentage-points per year (DID-Scotland: -1.6; DID-US: -2.2). 90-day mortality decreased more precipitously, dropping by an absolute value of -5.6 (-7.1, -4.2) percentage-points and an annual average thereafter of -0.2 (-0.5, 0.0) percentage-points per year (DID-Scotland: -1.9; DID-US: -2.9). Similar improvements were observed in readmission (e.g. 30-day ITSA: -1.4 [-2.3, -0.5]), time to surgery, and length of stay. Projections suggest that were the BPT to be implemented in Scotland and the US (Figure), by 2030, as many as 1,377 Scottish and 11,434 US lives could be saved.

Conclusion: In contrast to outcome-based P4P, process measure P4P such as that implemented through the English Hip Fracture BPT could result in significant improvements in outcomes for US patients while remaining more applicable to heterogeneous trauma populations and acceptable to trauma providers. As efforts to improve older adult health continue to increase, there are important lessons to be learned from initiatives like the BPT

22.03 Targeted Checklist Compliance with Oral and Mechanical Prep Improves Surgical Site Infection Rates

Posted on January 31, 2019

C. L. Antonacci1, D. Armellino2, K. Cifu-Tursellino2, M. E. Schilling2, S. Dechario2, G. Husk2, M. Jarrett2, A. Antonacci2  1Tulane University School Of Medicine,New Orleans, LA, USA 2North Shore University And Long Island Jewish Medical Center,Manhasset, NY, USA

Introduction:

In addition to increased patient morbidity and mortality, National Surgical Quality Improvement Program data suggest that surgical site infection (SSI) accounts for a 9.2% increase in hospital costs above uncomplicated colectomy cases.  This project, which included 12 acute care facilities, was designed to reduce the incidence of post-colectomy SSI by implementing a system-wide standardized surgical bundle checklist, monthly communication of outcome data to practitioners and analysis of factors contributing to organ space infection, as defined by the National Healthcare Safety Network (NHSN). 

Methods:

A colectomy bundle checklist was utilized to gather information on clinical practice from 761 colectomy cases within our system from 1/1/2016 to 12/31/2017.  Data was entered into a relational database analyzing over 50 patient, procedure, SSI and bundle compliance elements at the system, hospital and surgeon level.   Documentation compliance with the checklist items was compared to surgeon specific NHSN infection rates (< 2.5% and > 2.5%) by paired Student’s t-test.

Results:

Compared to 2016, elective post-colectomy SSIs for our health system in 2017 were reduced by 33% with a 45.3% reduction in intrabdominal infections, a 71.4% reduction in deep space infections and a 6.1% reduction in superficial site infections.  Bundle checklist compliance was analyzed with respect to pre-operative use of oral antibiotics, mechanical bowel prep, and intra-operative re-dosing of IV antibiotics. Of 540 elective colectomy cases, 420 (77.78%) were in compliance with regard to oral antibiotics, 468 (86.67%) with mechanical bowel prep, and 441 (81.67%) with re-dosing IV antibiotics. Of 39 surgeons with checklist data and NHSN reported infections, 4 (10.26%) had infection rates less than 2.5%, while 35 (89.74%) had infection rates greater than 2.5%.  Statistically significant differences were observed in checklist compliance between surgeons with infection rates <2.5% and >2.5%, respectively, for: (1) oral antibiotics 186/217 (85.7%) v. 87/134 (64.9%), p < 0.002; and (2) mechanical bowel prep 194/217 (89.4%) v. 36/65 (55.5%), p<0.006.  The use of intra-operative re-dosing of IV antibiotics 171/217 (78.8%) v. 113/130 (86.9%) was not significantly different.

Conclusion:

These data suggest that implementing a system-wide standardized surgical bundle checklist  and  relational database system can significantly reduce the incidence of elective colectomy SSIs. Analysis of bundle checklist compliance between low infection rate surgeons (<2.5%) and high infection rate surgeons (>2.5%) demonstrates significantly lower utilization of pre-operative oral antibiotic and mechanical bowel preps in high infection rate surgeons. These data further suggest that target compliance rates may need to be set in the 85% to 90% range for these bundle items to achieve optimal reductions in elective colectomy SSIs. 

 

22.02 The Impact of Prehospital Whole Blood on Arrival Physiology, Shock, and Transfusion Requirements

Posted on January 31, 2019

N. Merutka1, J. Williams1, C. E. Wade1, B. A. Cotton1  1McGovern Medical School at UT Health,Acute Care Surgery,Houston, TEXAS, USA

Introduction: Several US trauma centers have begun incorporating uncrossmatched, group O whole blood into civilian trauma resuscitation. Our hospital has recently added this product to our aeromedical transport services. We hypothesized that patients receiving whole blood in the field would arrive to the emergency department with more improved vital signs, improved lactate and base deficit, and would receive less transfusions following arrival when compared to those patients receiving pre-hospital component transfusions. 

Methods: In Novemeber 2017, we added low-titer group O whole blood (WB) to each of our helicopters, alongside that of existing RBCs and plasma. We collected information on all trauma patients receiving prehospital uncrossed, emergency release blood products between 11/01/17 and 07/31/18. Patients were divided into those who received any prehospital WB and those who received only RBC and or plasma (COMP). Initial field vital signs, arrival vital signs, arrival lbaoratory values, and ED and post-ED blood products were captured. Statistical analysis was performed using STATA 12.1. Continuous data are presented as medians (25th-75th IQR) with comparisons performed using Wilcoxon ranksum. Categorical data are reported as proportions and tested for significance using Fisher’s exact test. Following univariate analyses, a multivariate model was created to evaluate post-arrival blood products, controlling injury severity score, field vital signs, and age. 

Results: 174 patients met criteria, with 98 receiving prehospital WB and 63 receiving COMP therapy. 116 WB units were transfused in the prehospital setting. Of those receiving WB prehospital, 84 (82%) received 1 U, 14 (12%) received 2U. There was no difference in age, sex, race, or injury severity scores between the two groups. While field pulse was similar (WB: median 117 vs. COMP: 114; p=0.649), WB patients had lower field systolic pressures (median 101 vs. 125; p=0.026) and were more likely to have positive field FAST exam (37% vs. 20%; p=0.053). On arrival, however, WB patients had lower pulse and higher systolic pressures than COMP patients (TABLE). There was no difference in arrival base excess and lactate values (TABLE). However, WB patients had less ED and post-ED blood transfusions than the COMP group. A multivariate linear regression model demonstrated that field WB was associated with a reduction in ED blood transfusions (corr. coef. -10.8, 95% C.I. -19.0 to -2.5; p=0.018).

Conclusion: Prehospital WB transfusion is associated with improved arrival physiology with similar degrees of shock compared to COMP treated pateints. More importantly, WB pateints received less transfusions after arrival than their COMP counterparts. 

22.01 Neural Input Modulates Aberrant Cell Fate After Extremity Trauma

Posted on January 31, 2019

C. Hwang1, C. A. Kubiak1, M. Sorkin1, C. A. Pagani1, T. Rehse1, M. A. Garada1, Z. N. Khatib1, P. Kotha1, J. Lisiecki1, D. M. Stepien1, N. D. Visser1, K. Vasquez1, A. W. James1, Y. S. Niknafs1, P. S. Cederna1, S. W. Kemp1, B. Levi1  1University Of Michigan,Surgery,Ann Arbor, MI, USA

Introduction: Heterotopic ossification (HO) is a painful, debilitating formation of ectopic bone, often found after severe polytrauma, burn and neural injury. Literature has implicated neurotrophic signals such as nerve growth factor (NGF) as crucial signals for normal bone development. Additionally,  secreted neural peptides including substance P (SP) have been demonstrated as capable of regulating osteoblast behavior, modulating osteogenic cues, and producing ectopic bone when exogenously introduced. Thus, we hypothesized that innervation is crucial to pathologic stem cell differentiation and resultant HO.

Methods: C57BL/6J male mice were stratified to burn/tenotomy (BT) or BT+neurectomy. The Achilles tendon was bisected and accompanied by 30% TBSA dorsal burn. Sciatic/sural nerves were transected at midthigh (proximal/distal to bifurcation, respectively). Hindlimbs were analyzed via µCT at 9 weeks (n=3-5/group). Sections (n=1) from the ankle were immunolabeled (IF) at 1 and 3 weeks. Myeloperoxidase (MPO) activity was measured via in vivo imaging system at the ankle at 4 days (n=4-5/group). From BT mice, mRNA was harvested from injured and uninjured tendon (n=3/group) and hybridized to Affymetrix microarray (1 week) or processed for whole transcriptome via RNAseq (3 weeks). Microarray data of human ligament cells from GEO dataset GSE5464 were analyzed using linear modeling with empirical Bayes method for differential expression.

Results: Sciatic neurectomy upon BT significantly reduced total HO (Fig A, 4.7 v. 1.57mm3, p=0.036). IF imaging of NGF and SP showed robust protein expression at 1 week with limited colocalization of F4/80 or Ly6G (Fig. B,C). Neurectomies did not cause changes in MPO levels (Fig. D). BT (Fig. E, right) induced upregulation of characteristic genes of inflammation (Il6, Ptgs2, Ptger1, Il1a, Tacr1) vs. ininjured tendon at 1 week (left). Similar upregulation was observed at 3 weeks (Fig. F). Notable neurotrophins, Ngf, Gdnf, and Brdf, were also upregulated.  GEO data exhibited parallel trends of Ngf and Brdf in human spinal ligament cells subjected to cyclic strain (Fig. G); a loading shown to be associated with ossification of connective tissues.

Conclusion: Interruption of innervation to an injury site inhibits post-traumatic ossification independent of myeloid cell infiltration (MPO) during the acute response. In mice, BT induces upregulation of neurotrophin genes in both acute and sub-acute timepoints, concordant with upregulation seen in strained human cells. BT exhibited robust labeling of NGF, spatially distinct from macrophages and PMNs, along with SP, a well characterized regulator of osteogenesis. This data suggests neural signals modulate aberrant wound healing as demonstrated by HO formation.

20.21 Prospects and challenges of research in pediatric surgery in Nigeria

Posted on January 31, 2019

P. M. Mshelbwala1, O. O. Osagie1  1University of Abuja-Teaching Hospital,Department Of Surgery,Gwagalada, FCT, Nigeria

Background: Pediatric surgery is a relatively young speciality in Nigeria which is still evolving. Trainees must develop a research topic and defend a thesis as part of their final examination aimed at stimulating them to incorporate research into their clinical practice.

Aim: To review the potentials and current challenges in research faced by pediatric surgeons in Nigeria.

Materials and Methods: A review of data from the two regional postgraduate surgical colleges regarding thesis presented by pediatric surgeons and abstracts presented at annual scientific meetings of the national pediatric surgical association over a 15-year period was done. An online survey of pediatric surgeons using a semi-structured questionnaire was also carried out.

Results: Twelve thesis have been successfully defended in 14 years at the National Postgraduate Medical College of Nigeria (NPMCN). While the West African College of Surgeons (WACS) received 32 in four years. The Association of Pediatric Surgeons of Nigeria(APSON) had 599 abstracts presented at its annual scientific meetings from 2003 to 2017; an average of 40 per year.

The survey was sent to 142 of the 185 registered pediatric surgeons in Nigeria, out of which 68 responded, with more than 76% practicing in tertiary teaching hospitals.

In the last three years, 46 surgeons were involved in one to four research studies, 82.3% of which were observational and none clinical trials. Seven had not participated in any research. Institutional support for research was available to about 70% of the surgeons which comprised secretarial support(57.44%), funding(21.3%), protected time(13.2%), research assistants(10.6%) and provision of research mentorship(8.5%).

Factors hindering research included incomplete patients’ records, difficulty in accessing funds, limited internet access, lack of interest, inability to develop research collaborations, difficulty in publishing findings. Others were limited research capacity, dearth of ideas and lack of protected time.
Recommendations ranged from additional training on research methodology & grant writing, the use of electronic medical records (EMS), increased collaboration among pediatric surgeons to improved access to funding and journals.

Conclusion: The volume and quality of research in pediatric surgery in Nigeria is relatively low and the inclusion of a thesis into residency training has not translated into increased research clinical practice. Relevant institutional support may enhance the output and impact of research amongst pediatric surgeons.
 

20.20 The Impact of Gender on Resident Operative Experience

Posted on January 31, 2019

L. Gade1,2, A. Watkins1, H. Yeo1  1Weill Cornell Medical College,Surgery,New York, NY, USA 2New York Hospital Queens,Surgery,Flushing, NY, USA

Introduction:  Studies assessing the practice patterns of attending surgeons have demonstrated gender based differences in subspecialty choice for surgeons who pursued fellowship and gender differences in the types of cases performed by general surgeons who did not pursue fellowship. It is possible that gender disparities in practice patterns at the attending level may be driven by exposure and experience at the resident level. However, gender differences in resident operative exposure have not been studied. In this study, we compare differences in case volume and case type based on resident gender.

 

Methods:  The cumulative 5 year ACGME resident case logs for all general surgery residents who completed training between 2015-2016 at two different surgery programs were obtained. 13 residents, 2 women and 11 men, were included. Cases were subdivided into 17 categories including 16 ACGME categories plus all cases labeled “Not for major credit” by assigning each current procedural terminology (CPT) code to one ACGME category using the ACGME’s “Tracked Codes Report”. CPT codes that fell under more than one category were assigned to one category. CPT codes from “Nonoperative Trauma” and “Critical Care” categories were removed. Total number of cases and cases performed in individual categories were stratified by gender. T-test and chi square were used where appropriate.

Results: Among the 13 residents, 16,414 cases were performed. There was no significant difference in the number of cases performed by men and women (1,285 +/- 188 vs 1,137 +/- 119, p=.156). Women performed significantly more breast (11.13% vs 7.31%, p<0.05) and endocrine (6.16% vs 2.70%, p<0.05) cases while men performed significantly more alimentary tract (10.32% vs 8.53%, p<.05), abdomen (14.9% vs 12.5%, p<.05), and vascular (8.39% vs 6.11%, p<.05) cases.

Conclusion:This pilot study demonstrates that while the volume of cases that male and female residents perform is similar, breast and endocrine cases comprise a significantly higher percent of female residents’ case volume while alimentary tract, abdomen, and vascular cases comprise a significantly higher percent of male residents’ case volume. Because their exposure is different than that of their male colleagues, this may affect female fellowship choice, confidence in underexposed subspecialties, and ultimately, career trajectory.  Poor representation of women attendings in multiple general surgery subspecialties may deferentially impact trainees’ access to role models and may perpetuate stereotypes and bias in general surgery. The gender difference in case distribution seen in this study may also be related to the underrepresentation of women attendings in multiple subspecialties. We are working to expand this pilot study on a larger scale to be more representative. Further research must be done on a national level to assess gender equity in surgical training.
 

20.19 Perioperative Educational Time Out: Building an Educational Framework

Posted on January 31, 2019

M. M. Esquivel1, I. Wapnir1, R. Yang1, M. L. Melcher1  1Stanford University,General Surgery,Palo Alto, CA, USA

Introduction:  

We previously introduced an Educational Time Out (ETO) tool to promote discussions between attendings and trainees about the patient presentation, indications for surgery and surgical plan immediately before an operation. Our goal was to build on the pre-operative ETO and to develop a post-operative ETO to encourage immediate feedback and promote discussions on post-operative considerations. The aim was to expand the perioperative educational framework. 

Methods:  

A working group of two attendings and two general surgery residents at our institution was formed. The group met with faculty and residents of several surgical specialties and asked open-ended questions regarding their opinions on important elements to be included in a Pre- and Post-Operative ETO. These interviews were completed from March to July 2018. The working group summarized and prioritized concepts from the interviews and developed a pre-operative ETO with specifics for several surgical specialties and cases, and a post-operative ETO to be used across all specialties.

Results: T

he pre-operative ETO that was developed is represented by the PREDICT mnemonic. PREDICT stands for Presentation, Risk factors, Examination findings, Diagnosis/Differential, Incision/Intraoperative steps, Concerns, and Treatment. The post-operative ETO developed is represented by the COPE mnemonic, which stands for Closure, Operation, Performance, and Extension of care. Specific PREDICT characteristics for three surgeries were defined, as well as a detailed description of COPE, and are presented here (Table 1).

Conclusion: 

We believe educational time outs, both pre- and post-operatively, should be a part of every surgical case. Education Time Outs not only promote communication between attendings and trainees, but they also foster resident education. Faculty can use PREDICT and COPE to provide a formal educational framework that reinforces key learning elements for trainees. These ETO models are simple and specific tools residents can use to organize their preparation for each surgical case. More research is needed to measure the impact of ETO use at our institution, with an implementation and control group.

 

20.18 Twitter as tool for Departments of Surgery: What is the role for Program Directors?

Posted on January 31, 2019

H. J. Logghe1, A. Salles2, K. A. Chojnacki1, C. J. Yeo1, R. Aggarwal1  1Thomas Jefferson University,Surgery,Philadelphia, PA, USA 2Washington University,Surgery,St. Louis, MO, USA

Introduction: Social media, Twitter (Twitter, Inc., San Francisco, CA) in particular, plays an increasingly influential role in academia and surgical education. Many surgical departments now have Twitter accounts, some with separate accounts for departmental divisions and residency programs. In this capacity, Twitter is used to develop departmental brands, celebrate departmental achievements, and disseminate science pioneered by faculty and residents. Currently few institutions measure social media activity for academic promotion and expectations of program directors to represent their programs on Twitter and other social media remain ambiguous.

Methods:  At Surgical Education Week 2018, an in-person workshop on Twitter use for surgery residency programs was held. Topics covered included 1) The importance of a strategic Twitter presence for program directors and residency programs, 2) Initial steps in establishing Twitter accounts as a program director and on behalf of the residency program, and 3) Strategies used to effectively develop a brand on social media for the purposes of enhancing program reputation and recruitment. At the close of the session, a survey was disseminated to all participants.

Results: Seventeen of 25 attendees completed the survey. Twelve of 17 respondents reported a personal Twitter account; 7/15 respondents reported a departmental Twitter account. Eight of ten respondents reported institutional social media guidelines. The majority of respondents strongly agreed residency programs should have a social media presence (1 = Strongly Disagree to 5 = Strongly Agree; mean 4.29, SD 0.81) and that program branding is part of the program director's role (mean 4.57, SD 0.59). Five of 15 respondents reported feeling well-equipped to fulfill that role. When asked “What are the three greatest challenges to successful residency program social media use?” responses fell into four categories: time (16); content, confidentiality and professionalism (14); institutional support (7); and inexperience (4). Key results are shown in the table.

Conclusion: The majority of program directors reported a personal Twitter account and just under half of their respective programs had departmental Twitter accounts. While the majority of respondents believed program branding is part of the program director's role, only one third felt equipped to fill that role. Respondents rated social media as a useful tool to increase dissemination of departmental research and to increase the number of program applicants. Future research should explore effective social media strategies to disseminate departmental research, promote positive branding, and reach potential users.

 

20.17 Incoming Residents’ Knot Tying and Suturing Skills: Are Medical School Boot Camps Sufficient?

Posted on January 31, 2019

R. McMillan1, P. Redlich1, R. Treat1, M. Goldblatt1, T. Carver1, C. M. Dodgion1, Z. Prewitt1, J. R. Peschman1, C. Davis1, J. Grushka2, T. Krausert1, L. Olson1, B. Lewis1, M. J. Malinowski1  1Medical College of Wisconsin,Surgery,Milwaukee, WI, USA 2McGill University Health Centre,Montreal, QUEBEC, Canada

Introduction:
Many medical schools offer M4 boot camps to improve student’s preparedness for residency. Significant faculty effort is expended in the design and teaching fundamental surgical skills in these courses. For three consecutive years, we studied the knot tying and suturing skills of incoming residents as part of a multi-day orientation program. We evaluated the impact of medical school boot camps on intern knot tying and suturing skills when measured at the start of residency.

Methods:
42 interns completed questionnaires over three-consecutive years regarding their M4 boot camp experiences.  In June of 2016-2018, interns were evaluated on suturing (18 one-point items), knot tying (16 one-point items), overall performance (1 five-point item, 5=high), and quality (1 five-point item) by three surgeons, blinded to the questionnaire results, using modified assessment forms published by the APDS/ACS for OSATS and global rating evaluation.  Descriptive statistics are reported with means (Mn) and standard deviation (s).  Scores were compared based on length of boot camp (≤ 10 days vs > 10 days), hours of supervised instruction (≤ 5 hours vs > 5 hours), and annual hours dedicated to practice of suturing and knot tying skills (≤ 10 hours vs > 10 hours).  The association of skills is reported with Spearman rho (SpR) correlations and inter-rater reliability determined by intraclass correlation coefficients (ICC). Analysis generated with IBM® SPSS® 24.0.

Results:

Over three years, 26 of 42 (62%) interns reported boot-camp training. In comparing groups with and without training, scores in suturing (9.6(4.6) vs 9.8(4.1), p<0.908), knot tying (9.1(3.6) vs 8.4(4.1), p<0.574), overall performance (2.0(0.6) vs 1.9(0.7), p<0.424), and quality (2.0(0.6) vs 1.9(0.7), p<0.665) demonstrated no statistical significance.  All six pairwise correlations of the four skill evaluations were significant (SpR range=0.75-0.95), p<0.001), and ratings were consistent (ICC(2,1)=0.23-0.63, p<.002).  There was no significant difference in any of the four assessment scores when split by completion of boot camp, length of boot camp, hours of supervised instruction, or hours dedicated to practice.

Conclusion:
Our study could not demonstrate a statistically significant benefit in knot tying and suturing skills of students who enroll in M4 boot camp courses as measured at the start of residency. However, suturing and knot tying ratings were strongly related to each other and overall quality and performance. This finding indicates that faculty are evaluating consistent levels of suturing and knot tying skills for each intern, and that the skills are strong indicators of overall performance.  Residency programs should be prepared to teach these skills to their entering residents. Further study is warranted to evaluate the benefit of boot camps on other technical skills of incoming residents.
 

20.16 The Cost of Integration of Robotic Surgery Training in the Curriculum of General Surgery Residency

Posted on January 31, 2019

M. Malekpour1, M. Fluck1, M. Alaparthi1, M. Shabahang1  1Geisinger Medical Center,Department Of General Surgery,Danville, PENNSYLVANIA, USA

Introduction:
Robotic-assisted surgery (RAS) is a newly-introduced technology with some General Surgery Residency programs recently integrating it into their curriculum. The cost-effectiveness of RAS training in general surgery residency is debated.

Methods:
All outpatient cholecystectomy cases from 2013 to 2017 were included in this study. Patients were divided into laparoscopic and robotic-assisted groups. We focused on comparison of the cost and length-of-stay (LOS) for cases based on the presence of residents.

Results:
During the 5-year study-period, 1774 cases were included. Residents were scrubbed in 70% of laparoscopic cases (1125 cases from a total of 1605 laparoscopic cholecystectomies) and 45% of robotic-assisted cases (75 cases from a total of 165 robotic-assisted cholecystectomies). Presence of residents were associated with significantly reduced costs in both laparoscopic and robotic-assisted cases (both p<0.0001). Although the presence of residents was associated with significantly longer LOSs in laparoscopic cases (12.6 vs 9.8 hours, p=0.0003), there was no association between the presence of residence and LOS in robotic-assisted cases (11.8 vs 9.6 hours, p=0.63).

Conclusion:
Presence of residence in outpatient robotic-assisted laparoscopic cholecystectomies was associated with less cost. General Surgery residency programs should consider integration of RAS in their curriculums.
 

20.14 The Readability of Surgical Consent Forms is Poor Across Three Countries

Posted on January 31, 2019

A. Chakrabarty1, E. Kaplan1, L. Wood1, I. Marques1, K. Kichler1, S. J. Baker1, J. W. Toh3, E. M. Muller2, G. D. Kennedy1, M. S. Morris1, J. S. Richman1, D. I. Chu1  1University Of Alabama at Birmingham,Birmingham, Alabama, USA 2University of Cape Town,General Surgery,Cape Town, WESTERN CAPE, South Africa 3University Of Sydney,Sydney, NSW, Australia

Introduction:
The American Medical Association (AMA) and the National Institutes of Health (NIH) recommend that education materials given to patients should not exceed a sixth-grade reading level. Consent forms are legal documents that patients are expected to read, understand and sign before any surgical procedure. It is unclear, however, how readable contemporary consent forms are and whether these levels vary internationally. We hypothesized that the readability of consent forms would be poor and exceed the recommended sixth grade reading level.

Methods:
Major surgery English-consent forms were collected from four tertiary-care referral-centers across three countries: USA, Australia, and South Africa. Consent forms were analyzed to assess readability using four instruments: Flesch-Kincaid Grade Level (FKGL) instrument, SMOG (Simple Measure of Gobbledygook), PEMAT (Patient Education Materials Assessment Tool), and PCR (Print Communication Rating). Three independent observers analyzed each form to assess readability. 

Results:
Seven consent forms were analyzed from three countries.  None of the materials were under sixth-grade reading level when analyzed with FKGL and SMOG with average grade-level scores of 12.0 ± 2.4 SD and 15.2 ± 2.0 SD, respectively. The range for FKGL was 9 to 15 while the range for SMOG was 13.5 to 17 where the higher scores indicate a higher reading level. While no significant differences existed between FKGL and SMOG scores by institutions, Australia had the best FKGL and SMOG scores, at 9 and 13.5 respectively. The average PEMAT scores were 70.8% ± 13.8 SD for understandability and 30.5% ± 25.8 SD for actionability, with scores closer to 100% being ideal. No significant differences in PEMAT scores were observed by institutions, but Australia had the highest PEMAT scores for both understandability and actionability, at 85.2% and 40%, respectively. The average PCR score was 40.1 ± 4.6 SD and all consent forms scored in the 24-47 score range, for which “augmented efforts to eliminate literacy-related barriers” are recommended. While no significant differences in PCR scores were observed by institution, Australia again had the highest score, at 43 ± 5.2 SD.

Conclusion:
The readability of major surgery consent forms from three countries varied but was overall poor and failed to meet the AMA/NIH recommended sixth-grade reading level. While consent forms are legal documents, considerations should be made to make consent forms more readable and understandable.
 

20.13 What Does the Average Person Know about Endocrine and Vascular Surgeons?

Posted on January 31, 2019

A. Aune1, A. Asban1, R. Mallick1, H. Chen1, B. Lindeman1  1University Of Alabama at Birmingham,Department Of Surgery,Birmingham, Alabama, USA

Introduction:
Surgical fields are becoming increasingly specialized. This can lead to misunderstanding or confusion about the scope of practice of different surgeons by the individual seeking specialized surgical care. To assess public understanding of sub-specialty surgeons, we sought to survey general knowledge of the specialty areas of Endocrine Surgery and Vascular Surgery. 

Methods:
A survey was conducted in three locations in Birmingham, Alabama: a local farmers market, a public park, and the University of Alabama at Birmingham Hospital (UAB). Fifty people were surveyed at random at each of the three locations, with hospital staff identified by wearing a hospital ID badges recruited at the UAB hospital location. Participants were asked to define both an endocrine surgeon and vascular surgeon, as well as identify aspects of their practice. Participant’s answers to the survey were recorded and coded by three evaluators (two MD, one PharmD candidate). Survey responses were assessed for correct definition of the specialty (Yes/No), recognition of being a surgeon (Yes/No), spectrum of practice (None, Partial or Complete), and presence of a common misconception (Yes/No). Inter-rater reliability (kappa) was calculated for each question. The Chi-square test was used to compare the difference in each answer between the two specialties. 

Results:
A total of 150 people participated in the study. The majority were female (58%) and approximately 50 years of age or less (65%). Inter-rater reliability from 0.32-0.84 was observed, and agreement from 40% to 98% between raters was achieved for all questions. Significantly more respondents recognized endocrine surgery as a surgical profession (21%) compared to vascular surgeons (18%) (p<0.001). However, significantly fewer could define what an endocrine surgeon does (14%) than could define what a vascular surgeon does (57%). Only 3% of respondents could identify the entire spectrum of practice of an endocrine surgeon, with 42% and 55% providing partially or completely incorrect responses, respectively. Significantly more respondents could identify all of a vascular surgeon’s spectrum of practice (11%), with 60% and 29% providing partial or completely incorrect responses, respectively (p<0.001). Endocrine surgeons were most often confused for endocrinologists (40%), while vascular surgeons were most often confused for cardiovascular surgeons (22%).  

Conclusion:
This study reveals an overall lack of understanding among the general public about what endocrine and vascular surgeons are and their spectrum of practice and shows that public understanding of the field of endocrine surgery is very low. More efforts need to be made to increase the visibility of these fields and communicate these surgeons’ specialized expertise. 

20.12 Improving Patient Education Material is Feasible at the VA

Posted on January 31, 2019

C. M. Rentas1, S. Baker1, E. Malone1, J. Richman1, G. Yang1, M. Morris1  1University Of Alabama at Birmingham,Birmingham, Alabama, USA

Introduction: Health literacy is a predictor of a patient’s health status. Despite variability of patient health literacy, patient education handouts remain the most widely used form of medical information. The American Medical Association (AMA) and National Institutes of Health (NIH) recommend that patient information be presented at 6th grade reading level or lower. Not only do patient education handouts need to be readable, the medical information presented should also be understandable to the general public. We hypothesized that patient education handouts at our local Veterans Affairs Medical Center general surgery clinic were written above a 6th grade reading level and contained information that was not understandable to the average patient.

Methods: Routine patient education materials were collected from the general surgery clinic. The Flesch-Kincaid Grade Level (FKGL) instrument was used to analyze the texts to generate a FKGL score without any correction of misspellings or grammatical errors. To assess understandability, we used the Patient Education Materials Assessment Tool (PEMAT) and recorded scores of “understandability” and “actionability” for each patient education handout. Then, patient education handouts were re-written using recommendations from the Centers for Disease Control and Prevention’s “Simply Put” guide for creating easy-to-understand materials and re-assessed using the FKGL and PEMAT tools.

Results: We collected 5 patient education handouts from the general surgery clinic covering various topics such as: colectomy, hernia repair, cholecystectomy. The overall average FKGL for the handouts was 7.94 (SD 0.49), exceeding the NIH/AMA standards sixth grade level by an average of 1.94 grade levels (95% CI=7.33-8.55; p <0.0002). The overall average PEMAT scores for both understandabilty and actionability were 40% (SD 6%). Handouts were then rewritten. The average time to rewrite a handout was 1 hour. Upon re-assessment the average FKGL for the rewritten handouts was 5.4 (SD 0.35, 95% CI=4.97-5.83) % below the grade level. The average PEMAT understandability and actionability scores for the rewritten material are 100% and 82%, respectively (SD 0, 2%), compared to 40% for both before.

Conclusion: The readability of patient education material in our VA general surgery clinic is poor and deviates significantly from AMA/NIH recommendations. With limited time and resources, the FKGL and PEMAT scores for the patient education handouts were improved using the “Simply Put” guidelines to ensure readability and understandability of medical information.

 

20.11 Medical Student Perceptions Following Participation in a Surgical Boot Camp – A Qualitative Analysis

Posted on January 31, 2019

E. Palmquist1, T. Feeney2, A. Chatterjee1, D. Nepomnayshy3, L. Chen1  1Tufts Medical Center,Department Of Surgery,Boston, MA, USA 2Boston University,Department Of Surgery,Boston, MA, USA 3Lahey Hospital & Medical Center,Department Of Surgery,Burlington, MA, USA

Introduction: There have been many changes to surgical education over the last few decades. With increased attention to patient safety, there is a push to better prepare our medical students prior to starting a surgical residency. We present our results from a pilot study of creating a senior medical student surgical boot camp including analysis of the learner’s perspectives of boot camps.

Methods: Graduating senior medical students entering a surgical residency underwent a voluntary three-day surgical boot camp. Pre-and post-surveys were used to evaluate confidence levels of common patient management issues as well as technical skills. Qualitative analysis of a focus group using a general inductive approach was used to develop themes surrounding students’ perceptions of boot camps.
 

 

Results: Ten medical students completed the boot camp. We found that most students were somewhat confident (3 on a 5-point Likert scale) in their abilities to manage common intern problems with increased variation among students for technical skills prior to the boot camp. Students all had improvements in confidence scores post boot camp for all measured tasks.

From our qualitative analysis we found that students prefer a voluntary, surgery specific boot camp at the end of medical school as oppose to the start of their residency. Being given the choice to partake in the intervention provided the participating students with more motivation during the boot camp, supporting adult learning theory. Some of the students’ major concerns include being the first point of contact for patient issues as well as being the first responder to patient emergencies. Students worry about their ability to multi-task and manage a large amount of information which differed from their experience as a medical student. In addition, students are realistic about their expectations from a preparatory boot camp and value it as an experience to help “jump start” their transition to residency.

 

Conclusion: Our pilot study suggests that surgical boot camps may successfully improve students’ confidence in patient management and technical skills prior to the start of their intern year. In addition, we found major themes surrounding students’ perceptions of boot camp which may assist with future development of these programs. Students prefer a voluntary boot camp and value the experience at a medical school level. In addition, they are realistic in that a preparatory course will not teach them all they need to know prior to residency but more as a tool to help their transition.  
 

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