94.13 Development of Rating Criteria for Providing Peer Feedback on Surgical Technical Skill

Posted on January 18, 2018

S. Bharadwaj1, S. Meyerson1, R. Love1,2, A. Bharat1, M. DeCamp1, D. D. Odell1,2  1Feinberg School Of Medicine – Northwestern University,Surgery,Chicago, IL, USA 2Northwestern University Surgical Outcomes & Quality Improvement Center (SOQIC),Surgery,Chicago, IL, USA

Introduction: Surgeon technical skill has been shown to correlate with post-operative complication rates in a variety of surgical procedures. However, variation in technical skills has not been assessed in pulmonary surgery. The objective of this project is to pilot a platform through which thoracic surgeons can give and receive anonymous peer feedback on their technical skills in thoracoscopic lobectomy.

Methods: A review of technical literature was first performed to develop definitions for the key surgical steps involved in a thoracoscopic lobectomy – port placement; hilar exposure; isolation and division of the pulmonary artery, pulmonary vein, and bronchus respectively; and division of the interlobar fissure. The steps were further broken down into subtasks (i.e. establish exposure, mobilize the pulmonary artery) to allow for more detailed discrimination. A literature search was conducted to isolate common errors and difficulties encountered during each subtask (i.e. phrenic nerve injury during hilar exposure). Using these common errors and the well-established Objective Structured Assessment of Technical Skill (OSATS) criteria as a guideline, a scoring rubric was developed to assess surgical technical skill in each subtask using a 5-point Likert scale. This rubric was presented for feedback to a focus group of four experienced thoracic surgeons.

Results: Surgeons identified significant variability in the operative approach to resection of each anatomic lobe (i.e. right upper vs. left lower). Right upper lobectomy was identified as having as the most consistent anatomy and surgical approach. Five keys steps were identified by the expert panel as important, consistent components of the operation and were chosen for discrete measure development. These included isolation and division of the pulmonary vein, truncus anterior, posterior ascending artery, airway, and minor fissure. Port placement and hilar exposure were deemed highly variable in technique and nonessential for assessing technical skill. The panel favored development of a skill-centric scoring rubric without subtask and error stratification. Using the OSATS global 5-point rating scale, the panel identified the most significant outcome measures for evaluating technical skill as “Time and Motion,” “Establishing Exposure,” “Respect for Tissue,” and “Flow of Operation and Forward Planning.” Based on this feedback, new rating criteria were created including (1) a Global Scoring Criteria, developed using the above OSATS measures on a 5-point Likert scale, and (2) a free-text form to provide constructive, individualized feedback.

Conclusion: Development of a technical rating system specific for lobectomy will allow for the first ever assessments of technical skill in thoracic surgery. A multi-institution trial incorporating this rating system as a basis for anonymous peer feedback is currently underway.

 

94.10 Empowering Bystanders to Intervene: Chicago South Side Trauma First Responders Course

Posted on January 18, 2018

B. Wondimu1, S. Speedy1, T. Barnum1, F. Cosey-Gay2, S. Regan3, L. Stone3, M. Shapiro1, M. Swaroop1, L. C. Tatebe1  1Northwestern University,Chicago, IL, USA 2University Of Chicago,Chicago, IL, USA 3University Of Illinois At Chicago,Chicago, IL, USA

Introduction:
The city of Chicago has one of the highest rates of violence in the country, and this violence has been shown to disproportionately affect socioeconomically disadvantaged neighborhoods in the south side. The paucity of trauma centers in the south side of Chicago leads to prolonged transport times, increasing morbidity and mortality for those affected by penetrating traumas. A community based Trauma First Responders Course (TFRC) designed for bystanders could potentially mitigate this effect.  Bystanders are present at 60-97% of traumas and more likely to assist if given prior training. We seek to design and implement an evidence-based, community driven course designed for the general public to empower bystanders to intervene.

Methods:
A three-hour TFRC was designed using community based focus groups and qualitative analysis of the bystander effect. The course addressed basic first aid, trauma wound care, principles of bystander care, and the psychological impact of trauma. The course was taught in community centers, churches, and schools, to both minor and adult participants. Pre- and post-course questionnaires were offered. Eight evidence-based empowerment questions were assessed on a scale of 1 to 10. Ten knowledge-based questions were presented as single best of four multiple choice answers. The change in empowerment measures and knowledge scores were analyzed using chi-squared methods with p<0.05 considered significant.

Results:
Over the 7 courses offered thus far, 92 participants completed both the pre- and post-course assessments. The mean increase in empowerment was 2.42 out of 10 (0.41-4.66). The area with most improvement was ability to apply a tourniquet, followed by ability to render first aid. Improvement in 5 knowledge-based questions reached significance: tourniquet usage (p<0.01), management of impaled object (p=0.01), exposure to bodily fluids (p<0.01), initial trauma care (p<0.01), and scene safety (p<0.01). Over all 10 questions, participants had a 14% improvement (p=0.02).

Conclusion:
An evidence-based community TFRC is currently being offered throughout Chicago’s south side. The course has been shown to improve both bystander empowerment and knowledge of initial trauma care in the field, particularly trauma wound management and scene safety. Enrollment is ongoing and will improve the power of the study. In addition, 6-month follow-up assessments will be performed to assess knowledge retention and applicability.
 

91.11 Legislative Advocacy for Pre-Hospital Systems in Bolivia

Posted on January 18, 2018

S. D. South1, M. Boeck2, J. E. Foianini1, M. Swaroop1  1Northwestern University,Surgery,Chicago, IL, USA 2Cornell University,General Surgery,Ithaca, NY, USA

Introduction: Ninety percent of injury-associated deaths occur in low-and middle-income countries (LMICs), most in the pre-hospital setting. We sought to describe obstacles to, and propose novel solutions for, developing a pre-hospital system in Santa Cruz de la Sierra, Bolivia, which lacks a formal emergency medical response system.

Methods: From August to December 2016, needs-based assessments were performed with local stakeholders, including policy makers, physicians, and firefighters via interviews and focus groups. Questions focused on a review of available resources, previous attempts to establish pre-hospital system elements, and current medical-legal culture.

Results: In Santa Cruz de la Sierra there are two classes of ambulances: private and public. Private ambulance services respond to unique eight-digit telephone numbers. There is no emergency number for public ambulances or for communicating with authorities during a medical emergency. Law enforcement plays no formal role in providing or coordinating emergency medical care. Ambulances are not regulated and operate with varying levels of medical equipment and training. The Bolivian system of referencia y contrareferencia (the inter-hospital patient transfer system) is the sole user of public ambulances, and does not respond to public requests for emergency services. The call center for coordinating inter-hospital transfers is housed within the operational center that responds to large-scale disasters and possesses the necessary resources to serve as a potential dispatch center. There are no governmentally recognized or accredited pre-hospital personnel training standards, resulting in a paucity of medical care during transport. Policy makers consider the absence of trained personnel as the most cumbersome barrier to legislation supporting effective pre-hospital care. There is a large pool of unemployed and underemployed physicians in the region. Within this group there is a desire to work as public volunteers in exchange for additional training and field experience, which stakeholders recognize as an untapped resource.

Conclusion: Critical pre-hospital system deficits, and the recognition of underutilized resources, prompted our group to propose a strategy to merge unmet needs with untapped reserves in Santa Cruz de la Sierra. Specifically, this translated into a service-learning program that will provide didactic courses and field training to unemployed and under-employed physicians in exchange for ambulance staffing. In response to this proposal, the department of health invited our group to write legislation to support a pre-hospital system, including mandates that establish a single medical emergency response number, regulatory services for ambulance dispatch, and policy supporting pre-hospital training programs. This study demonstrates how collaborative assessment can be used to derive novel solutions to, and drive legislative policy support for, trauma systems in LMIC’s.

9.01 ALERT: Your patient refused VTE prophylaxis. Resident role in ensuring VTE chemoprophylaxis

Posted on January 18, 2018

M. Shyu1,2, L. Kreutzer2, K. Y. Bilimoria2,3, A. D. Yang2,3, J. K. Johnson2,3  1Feinberg School Of Medicine – Northwestern University,Chicago, IL, USA 2Feinberg School Of Medicine – Northwestern University,Surgical Outcomes And Quality Improvement Center (SOQIC), Department Of Surgery,Chicago, IL, USA 3Feinberg School Of Medicine – Northwestern University,Center For Healthcare Studies In The Institute For Public Health And Medicine,Chicago, IL, USA

Introduction: Venous Thromboembolism (VTE) is a serious medical condition that results in preventable morbidity and mortality. Optimal VTE prophylaxis in hospitalized patients includes ambulation, mechanical prophylaxis, and chemoprophylaxis; however, patients often refuse chemoprophylaxis which raises their VTE risk. Institutional data highlighted that surgical residents have high rates of unanswered electronic VTE prophylaxis alerts. Our objective was to better understand resident barriers to providing appropriate VTE prophylaxis and responding to alerts.

Methods:  Semi-structured interviews were conducted with 18 preliminary and categorical general surgery residents at one hospital who had received at least 10 alerts over 9 months. The interview shared resident-specific alert response and asked about their understanding of VTE prophylaxis components, barriers to patient communication, and reasons for alert nonresponse. Interviews were recorded and transcribed verbatim. Common themes were identified using a constant-comparative approach. The Theoretical Domains Framework (TDF) was used to study behavioral factors creating barriers to VTE prophylaxis.

Results: Five themes describe resident barriers to VTE chemoprophylaxis provision and alert response: knowledge, setting patient expectations, administration verification, communication of prophylaxis failures, and alert fatigue. These themes map to three TDF domains: knowledge, social/professional role and identity, and environmental context and resources (Table). Residents have misconceptions about the necessity of, and contraindications to, chemoprophylaxis (knowledge). Residents expected nurses to execute orders and notify them of patient refusals (social/professional role and identity). Residents said they educate patients on chemoprophylaxis only if the patient asks questions or refuses the shot and rarely set patient expectations preoperatively. Reasons for nonresponse to alerts included alert de-prioritization and fatigue (environmental context and resources). Residents mostly overestimate personal performance with regard to alert response rate and individual patient refusal rate.

Conclusion: Knowledge, social/professional role and identity, and environmental context and resources affect resident provision of appropriate VTE prophylaxis and alert response. Specific interventions to improve VTE prophylaxis rates and reduce patient refusals will need to address factors identified in our resident-focused study. Future initiatives will use similar methods to explore the perspectives of attending surgeons in VTE prophylaxis provision.

89.13 Carcinoma of the Ampulla of Vater: Biologic and Surgical Factors Predicting Recurrence and Survival

Posted on January 18, 2018

E. C. Poli1,2, S. J. Stocker2, C. Wang2, V. Parini4, R. Marsh3, R. Prinz2, C. R. Hall2, M. S. Talamonti2  1University Of Chicago,Department Of General Surgery,Chicago, IL, USA 2Northshore University Health System,Department Of Surgery,Evanston, IL, USA 3Northshore University Health System,Section Of Gastrointestinal Oncology,Evanston, IL, USA 4Northwestern University,Comprehensive Cancer Center,Chicago, IL, USA

Introduction: Carcinoma of the ampulla of Vater accounts for 6.8-20% of all periampullary tumors. The purpose of this study was to determine prognostic factors affecting disease-free and overall survival following pancreaticoduodenectomy for localized, non-metastatic disease.

Methods: This was an IRB approved retrospective review of a prospectively maintained database of patients operated on for ampullary carcinoma from 1997-2014 at Northwestern Memorial and NorthShore University HealthSystem hospitals.  Regression analyses were performed on clinical and pathologic data to determine significant predictors of recurrence and mortality.

Results: A total of 104 patients were included in the study: 52 (50%) were female; mean age of all patients was 64, and 90 (87%) were Caucasian. Eighty-one patients (78%) had a biliary stent placed prior to surgery. Tumor characteristics are as follows: T0/Tis 4 (4%), T1 10 (10%), T2 32 (31%), T3 39 (38%), T4 19 (18%); N0 51 (49%), N1 53 (51%).  Lymphovascular invasion was present in 49 (49%) and perineural invasion in 31 (57%) patients. There was a positive resection margin in 3 (3%) patients. The median number of positive nodes was 2 and the median LN ratio was 0.13. Eighteen patients (34%) had a LN ratio >20%. Pathologic data with IHC staining was gathered for 63 patients; 20 (32%) had intestinal type, 37 (59%) had biliary type, and 4 (6%) had mixed tumors. Median follow-up was 39 months and 57 (56%) patients died during follow-up. The 5-year disease-free survival rate was 42% and the 5-year overall survival rate was 50%. On univariate analysis, factors that were significant predictors of recurrence included elevated serum bilirubin level (p=0.005, HR=1.1), AJCC Stage 3 (p=0.007, HR=3.1), tumor size > 20mm (p=0.029, HR= 2.1), positive node status (p=0.048, HR=1.9), perineural invasion (p=0.05, HR=2.5), and positive resection margin (p=0.003, HR=5.4).  On multivariate analysis, elevated serum bilirubin and positive resection margin were significant for recurrence.  Factors that were significant predictors of mortality on univariate analysis included tumor size >20mm (p=0.005, HR=2.3), positive node status (p=0.034, HR=1.8), major vessel involvement (p=0.014, HR=3.5), and AJCC stage (p=0.13, HR= 2.4). When controlling for T category, tumor size, major vessel involvement, and positive resection margin were significant on multivariate analysis and positive node status approached significance.

Conclusion: In this cohort of patients with ampullary cancers treated by surgical resection, the predominant determinants of recurrence and overall-survival included biologic and pathologic factors that reflect the extent of local and regional disease. The effectiveness of surgical intervention was driven by the ability to achieve a complete margin-negative extirpation of localized disease. These findings may help guide treatment recommendations for patients with poor prognostic factors as delineated in this series.

 

87.14 Operative experience with pediatric adnexal pathology at stand-alone children’s hospitals

Posted on January 18, 2018

K. S. Corkum1,2, T. B. Lautz1,2, E. E. Rowell1,2  1Northwestern University Feinberg School Of Medicine,Department Of Surgery,Chicago, IL, USA 2Ann And Robert H. Lurie Children’s Hospital Of Chicago,Division Of Pediatric Surgery,Chicago, IL, USA

Introduction:  Multiple surgical sub-specialties are trained to perform adnexal cases involving the ovaries/gonads in pediatric and adolescent females, including pediatric general surgery, gynecology, and pediatric urology. There is limited published data on the overall distribution and volume of cases by surgical subspecialty. 

Methods:  The Pediatric Health Information System (PHIS) database, an administrative database representing stand-alone pediatric hospitals, was queried from 2013 to 2016 for all adnexal cases using ICD-9/ICD-10 procedure codes for ages ranging from 0 to 21 years of age. In addition to patient demographics, the principal procedure, principal diagnosis, and procedure physician sub-specialty were extracted for analysis. Two institutions were excluded from the study due to incomplete data. Surgeons were categorized into pediatric general surgeons, gynecologists, and urologists.

Results: A total of 47 institutions were included in the study with a total of 1,601 cases over the three-year study period. Median age was 14 years old [IQR 11-16]. The most common diagnosis across all procedures was an ovarian cyst (n=718, 44.8%). Laparoscopic unilateral oophorectomy (n=578, 36.1%) was the most common procedure performed. Pediatric surgeons performed 1035 (64.6%) overall cases, compared with 341 (21.3%) by gynecologists and 73 (4.6%) by urologists. Pediatric surgeons performed a significantly higher proportion of cases than the other surgical sub-specialties for children between 0 and 17 years old (p<0.001). No cases were performed by gynecologists for patients ages 0 to 1 years old or for neonatal pathology. There was no significant difference between the proportion of cases performed by pediatric surgeons and gynecologists for ages 18-21 years old. Pediatric surgeons performed significantly higher proportion of laparoscopic unilateral oophorectomy (61.9% vs 25.3%, p<0.001), open unilateral oophorectomy (76.8% vs 16.2%, p<0.001), and laparoscopic unilateral cystectomy (55.1% vs 19.5%, p<0.001) cases than gynecologist. Pediatric surgeons performed a significantly higher proportion of cases than gynecologist for most diagnoses including benign/malignant ovarian mass (69.8% vs 19.9%, p<0.001), ovarian torsion (65.8% vs 27.6%, p<0.001), and ovarian cyst (68.0% vs 22.4%, p<0.001). In patients with disorders of sex development, urologist performed a higher proportion of cases than both pediatric surgeons and gynecologists (69.7% vs 13.9% vs 13.9%, p<0.001). 

Conclusion: Pediatric surgeons perform the majority of adnexal operations at stand-alone pediatric hospitals, with the exceptions of children with a disorder of sex development, patients between 18 and 21 years old, and bilateral oophorectomy cases.  Pediatric surgeons should be included in adnexal cases involving a neonate, infant, or young child because of their operative experience and technical facility with advanced minimally invasive surgery in children. 

 

87.06 Testicular tissue cryopreservation for prepubertal males receiving fertility threatening medical therapy

Posted on January 18, 2018

K. S. Corkum1,3, T. B. Lautz1,3, B. A. Lockart3,5, E. K. Johnson2,4, E. E. Rowell1,3  1Northwestern University Feinberg School Of Medicine,Department Of Surgery,Chicago, IL, USA 2Northwestern University Feinberg School Of Medicine,Department Of Urology,Chicago, IL, USA 3Ann And Robert H. Lurie Children’s Hospital Of Chicago,Division Of Pediatric Surgery,Chicago, IL, USA 4Ann And Robert H. Lurie Children’s Hospital Of Chicago,Division Of Urology,Chicago, IL, USA 5Ann And Robert H. Lurie Children’s Hospital Of Chicago,Division Of Hematology, Oncology, And Stem Cell Transplant,Chicago, IL, USA

Introduction:  Children with a variety of oncologic, genetic, endocrine, and rheumatologic conditions may be candidates for fertility preservation (FP) as part of their comprehensive care. Post-pubertal males have the ability to sperm bank prior to receiving gonadotoxic therapy, but FP options for prepubertal males have been previously unavailable. Testicular tissue cryopreservation (TTC) provides an experimental option for FP for prepubertal males facing potential infertility due to their medical diagnosis or treatment. Limited published data exists regarding surgical technique and outcomes for children undergoing TTC. The aim of this study was to describe our Fertility and Hormone Preservation and Restoration Program’s experience with testicular wedge biopsy for TTC.

Methods:  A retrospective review of TTC cases between August 2015 to July 2017 was performed.  Patients qualified for the IRB approved experimental TTC protocol if they had a greater than 80% risk of long-term azoospermia from their planned medical therapy. High-risk treatments included total body radiation, testicular radiation, and/or high-dose alkylating chemotherapy. A trans-scrotal wedge biopsy was performed for each patient. A small portion of tissue was sent to pathology, and the remainder sent for TTC. 

Results: TTC was performed in 16 patients. Mean age was 9.5 years (range 5 months -18 years). Ninety-four percent were prepubertal. Thirty-seven percent had a musculoskeletal malignancy (Ewing sarcoma, osteosarcoma, rhabdomyosarcoma) and 31% had a primary neurologic malignancy (medulloblastoma, glioma, astrocytoma). Fifty percent of patients had received chemotherapy prior to TTC, with 31% of patients presenting with relapsed primary disease. TTC was performed in conjunction with another procedure, such as a central venous port insertion and/or bone marrow biopsy, in 56% of cases. Two patients underwent testicular sperm extraction at the time of testicular biopsy. Average estimated blood loss was three milliliters. One patient developed scrotal cellulitis after initiation of chemotherapy and required admission for intravenous antibiotics. All TTC cases were performed as same-day surgery or during an existing admission. Average time to the start of medical therapy was eight days with no reported delays. Pathologic analysis revealed normal testicular tissue in 13 patients. In three patients who had received chemotherapy prior to TTC, spermatogonia were present, but in low numbers. 

Conclusion: Unilateral testicular wedge biopsy for TTC can be performed safely and can be effectively paired with other necessary procedures under one general anesthetic. The majority of patients in our series had normal testicular tissue on pathology. TTC remains an experimental option for FP for prepubertal males as no spermatogenic recovery or pregnancies from cryopreserved testicular tissues have been reported to date.

 

86.11 Prolonged Extracorporeal Membrane Oxygenation Is Associated With Poor Neurologic Outcomes

Posted on January 18, 2018

G. J. Ares1,2, C. Buonpane2, I. Helenowski3, F. Hebal2, C. J. Hunter2  1University Of Illinois At Chicago,Department Of Surgery,Chicago, IL, USA 2Ann & Robert H. Lurie Children’s Hospital Of Chicago,Division Of Pediatric Surgery,Chicago, IL, USA 3Northwestern University,Department Of Surgery,Chicago, IL, USA

Introduction:
Extracorporeal membrane oxygenation (ECMO) has been used as a rescue intervention in neonates and infants in acute cardiopulmonary failure. However, these patients are at high risk for long term morbidity including neurologic dysfunction and mortality. While survival has been reported with ECMO courses >14 days, no studies have looked at meaningful survival and recovery after prolonged ECMO >21 days which has been cited as an arbitrary cut-off time in some centers. We hypothesized that patients with prolonged ECMO courses (>21 days) would have poor overall survival and quality of life.

Methods:
We performed a single institution, retrospective review of medical records for patients <18 years old receiving ECMO for >/= 21 days for any indication, between the years 2007 and 2017. The primary outcome was survival to hospital discharge. Secondary outcomes included neurologic dysfunction and other morbidities documented following the initial hospitalization. 

Results:
Fourteen patients met inclusion criteria. Survival to hospital discharge for this group was 36%, which is significantly lower than the reported 60% survival for children requiring ECMO <14 days. Patients who started ECMO after 100 days of age were more likely to survive (p=0.03). Patients requiring ECMO support for congenital cardiac or pulmonary conditions had decreased survival compared to those with acquired etiologies (2/2 patients with acquired cardiac failure, and 3/6 patients with acquired pulmonary indication for ECMO survived, compared to 0/6 survivors for congenital cardiac or pulmonary etiologies (p=0.03)). Patients who were progressively weaned from ECMO support were more likely to survive, compared to those who discontinued ECMO secondary to minimal progress or circuit complications (p=0.005). Only 1 of the 5 survivors made a full recovery without residual neurologic deficits. The other 4 had adverse neurologic outcomes, including ischemic/hemorrhagic stroke, behavioral and learning disabilities, extremity amputation or contractures impairing ambulation, epilepsy, cortical blindness, sensorineural hearing loss, and/or inability to achieve pulmonary independence. 

Conclusion:
Prolonged ECMO courses of >21 days are associated with decreased survival to hospital discharge. There are minimal data to support prolongation of ECMO for neonates with congenital cardiac or pulmonary failure. Furthermore, long term outcomes for prolonged ECMO survivors are characterized by neurologic impairments, learning disabilities, and impaired mobility. These need to be considered with families in the discussion to justify prolonged support.
 

80.17 Increased Claudin 2 is associated with a Human Enteroid Model of Necrotizing Enterocolitis

Posted on January 18, 2018

G. J. Ares1,3, C. Yuan3, D. Wood3, C. J. Hunter2,3  1University Of Illinois At Chicago,Department Of Surgery,Chicago, IL, USA 2Ann & Robert H. Lurie Children’s Hospital Of Chicago,Division Of Pediatric Surgery,Chicago, IL, USA 3Northwestern University,Department Of Pediatrics,Chicago, IL, USA

Introduction:
Necrotizing enterocolitis (NEC) is the most common gastrointestinal emergency in neonates, affecting 5-10% of patients in the neonatal intensive care unit. Despite decades of research, its pathophysiology remains poorly understood. Enteroids are 3-dimensional epithelial organoids derived from intestinal stem cells (ISC). These novel structures allow for the study of complex physiologic interactions, with closer resemblance to the gut microenvironment than single cell tissue culture. Tight junctions (TJ) are paracellular protein complexes essential in regulating intestinal barrier structure. Claudin 2 is a pore forming TJ protein that regulates permeability. We hypothesized that Claudin 2 will be overexpressed in human enteroids exposed to lipopolysaccharide (LPS)-induced experimental NEC.

Methods:
After IRB approval, human intestinal fragments were obtained from patients undergoing bowel resection for NEC vs other conditions (controls). ISC were harvested by isolation of intestinal crypts and incubation in Matrigel with human ISC culture media for 5 days. Enteroids were exposed to LPS for 24 hours in an in vitro model of experimental NEC and compared to untreated controls. Claudin 2 was analyzed by immunofluorescence mean fluorescent intensity (MFI) in human tissue samples as well as in enteroids. Data was analyzed with student’s T-test.  

Results:
Immunofluorescent microscopy (IF) demonstrated co-localization of Claudin 2 and actin in both control and +LPS enteroid groups at the expected, intercellular portion of the cell membrane. An increase of Claudin 2 expression was identified in +LPS enteroids vs controls (MFI=17677±1672 vs 7664±831 (p<0.0001), respectively). Likewise, there as increased Claudin 2 expression in humans with NEC vs controls (MFI=687±38 vs 1525±126 (p<0.0001)). In both humans and enteroids, IF revealed internalization of Claudin 2 from the cell membrane (controls) to that of a spiculated intracellular pattern in human and experimental NEC (+LPS) (Figure 1).

Conclusion:
In conclusion, human ISC-derived LPS-treated enteroids are a novel in vitro model of NEC. Both an increase in Claudin 2 expression and internalization are found in LPS-treated enteroids as well as in humans with NEC. The change in this pore-forming TJ protein may be responsible for the increased intestinal permeability seen in NEC. Further research in TJ proteins and enteroid models may delineate the pathophysiology of NEC that leads to the breakdown of barrier integrity and identify therapeutic targets.

77.02 Are Residents Really Burned Out? A Comprehensive Study of Surgical Resident Burnout and Well-Being

Posted on January 18, 2018

B. Hewitt1, J. W. Chung1, A. R. Dahlke1, A. D. Yang1, K. E. Engelhardt1, E. Blay1, J. T. Moskowitz2, E. O. Cheung2, F. R. Lewis3, K. Y. Bilimoria1  1Northwestern University,Surgical Outcomes And Quality Improvement Center,Chicago, IL, USA 2Northwestern University,Osher Center For Integrative Medicine,Chicago, ILLINOIS, USA 3American Board Of Surgery,Philadelphia, PENNSYLVANIA, USA

Introduction:  Despite great interest in resident wellness, little is known about actual rates of resident burnout as current data are limited by poor response rates, small sample sizes, or use of non-validated measures. Surgical residents are hypothesized to be at particular risk for burnout and poor well-being. We used novel national survey data with responses from nearly all U.S. general surgery residents to (1) examine burnout and poor well-being prevalence and (2) identify factors associated with burnout and well-being.

Methods:  All general surgery residents were surveyed (99% response rate) at the time of the January 2017 American Board of Surgery In-Training Examination (ABSITE) regarding wellness, duty hour violations, preparation for residency, and occupational safety. The main resident wellness outcomes were burnout (abbreviated Maslach Burnout Inventory – 6 items) and psychiatric well-being (General Health Questionnaire-12 which identifies those at risk for non-psychotic psychiatric illness). Hierarchical logistic regression analyses were performed to examine resident and program factors associated with burnout and well-being.

Results: Of 7,441 residents offered the survey, 7,387 residents (99.3%) in 260 surgical residency programs completed all items related to resident wellness. Overall, burnout was reported in 23.8% (n=1,756) of residents and poor psychiatric well-being in 44.3% (n=3,270). From the burnout assessment, 16.0% (n=1,184) of residents responded that they “do not really care what happens to some patients” at least a few times a month, and 18.1% (n=1,337) of residents responded that they daily “feel fatigued in the morning having to face another day on the job.” In multivariable models, burnout was more likely among male residents (OR 1.15 [95% CI 1.01-1.31]), those who felt unprepared for residency (OR 1.65 [95% CI 1.44-1.90]), and those who violated the 80 hour weekly average duty hour limit (violations in 1-4 of the past 6 months: OR 1.54 [95% CI 1.35-1.77]; violations in ≥5 months: OR 2.35 [95% CI 1.80-3.07]) compared to no violations. Burnout was not significantly associated with post graduate year (PGY). Poor psychiatric well-being was associated with similar factors with the exception of female residents (OR 1.25 [95% CI 1.12-1.38]) and PGY 1 residents (OR 1.19 [95% CI 1.04-1.35]) compared to PGY 4/5 residents who were more likely to report poor psychiatric well-being. There was no significant difference in burnout or psychiatric well-being between the Flexible and Standard arms of the FIRST Trial.

Conclusion: In this national survey including 99% of clinically active surgical residents in the U.S., burnout and poor psychiatric well-being were prevalent in surgical residents and more likely in residents who reported feeling unprepared for residency and those who violated duty hour limits. Solutions to improve resident wellness are needed and should address these associated factors.

76.04 Multi-institution Evaluation of Adherence to Comprehensive Postoperative VTE Chemoprophylaxis

Posted on January 18, 2018

B. Hewitt1, E. Blay1, L. J. Kreutzer1, K. Y. Bilimoria1, A. D. Yang1  1Northwestern University,Surgical Outcomes And Quality Improvement Center,Chicago, IL, USA

Introduction:  Venous thromboembolism (VTE) is the leading cause of preventable hospital mortality. Current quality measures for VTE prophylaxis are problematic due to surveillance bias, are not comprehensive, do not ensure appropriate administration, and cannot identify reasons why failures to provide chemoprophylaxis occur.

Methods:  We examined adherence to a novel process measure in patients who underwent elective or non-elective colectomy over an 18 month period at 36 hospitals in a statewide surgical collaborative. The process measure assessed comprehensive VTE chemoprophylaxis during a patient’s entire inpatient hospitalization, including reasons chemoprophylaxis was not given. Unadjusted and adjusted analyses were performed to identify reasons for failure to provide defect-free chemoprophylaxis and examine patient- and hospital-level factors associated with failure.

Results: Out of 4,086 total colectomies, the standard SCIP-VTE-2 prophylaxis measure publicly reported by CMS identified failure in care in only 1% of cases; however, the new measure unmasked failure to provide defect-free VTE chemoprophylaxis in 18% of cases. Reasons for failure included medication not ordered (29.6%), patient refusal (29.5%), incorrect dosage/frequency (7.9%), patient off unit (3.3%), and other (29.6%). Patients were more likely to fail the chemoprophylaxis process measure if treated at safety net hospitals (Odds Ratio [OR] 1.60, 95% Confidence Interval [CI] 1.06-2.41; p=0.03) or if they were ≤ 40 years old (OR 1.52, 95% CI 1.05-2.20; p=0.03 compared to age ≥ 75 years). Patients treated at Magnet nursing-accredited hospitals (OR 0.45, 95% CI 0.30-0.67; p<0.001) or undergoing elective colectomy (OR 0.77, 95% CI 0.62-0.96; p=0.02 compared to non-elective colectomy) were less likely to fail chemoprophylaxis. Patients ≤ 40 years old (OR 2.20, 95% CI 1.43-3.40; p<0.001), underweight patients (OR 2.19, 95% CI 1.28-3.77; p=0.004) or those that received treatment at safety net (OR 1.97, 95% CI 1.07-3.62; p=0.03 compared to non-safety net hospitals) or teaching hospitals (OR 2.82, 95% CI 1.37-5.84; p=0.005 compared to non-teaching hospitals) were more likely to refuse chemoprophylaxis.

Conclusion: This is the first multi-institution study examining failure patterns in providing comprehensive postoperative VTE chemoprophylaxis. In stark contrast to SCIP-VTE-2, our measure unmasked chemoprophylaxis failures in 18% of colectomies in a statewide surgical collaborative. Most chemoprophylaxis failures were due to patient refusals and ordering errors, occurring throughout the inpatient postoperative period. Thus, hospitals should focus improvement efforts on ensuring patients receive VTE prophylaxis throughout their entire hospitalization.

75.07 Utilizing Technology for Global Surgery: A Survey of the West African College of Surgeons

Posted on January 18, 2018

A. Ashok1, C. Stephens1, E. Ameh2, M. Swaroop3, E. Yang1, S. Krishnaswami1  3Northwestern University,Feinberg School Of Medicine,Chicago, IL, USA 1Oregon Health And Science University,Pediatric Surgery,Portland, OR, USA 2National Hospital,Abuja, FEDERAL CAPITAL TERRITORY, Nigeria

Introduction:

A previous AAS sponsored workshop demonstrated that high-income country (HIC) participants had strong interest in using Information and Communication Technology platforms (ICT) to facilitate global surgery collaborations. However, access, usage, and utility of ICT in Low-and Middle-Income Countries (LMIC) was unknown. We hypothesized that LMIC surgeons shared similiar interest in using ICT to facilitate international collaborations and education initiatives.

Methods:  

We conducted a survey of members of the West African College of Surgeons (WACS). Topics included computer and internet access/utilization, familiarity with ICT, such as social media (SM), virtual document sharing platforms (VDS), virtual meeting applications (VM), and learning management systems (LM), and interest in ICT adoption. English and French surveys were distributed through RedCap™ and in paper at the WACS and Pan African Pediatric Surgical Association conferences. Statistical analyses were done on STATA 14 using chi-squared tests, with Bonferroni corrections.

Results:

In total, 83 individuals began the survey, and 71% completed all sections. Respondents came from 9 countries (80% were faculty) and were equally split in years of practice (50% > 10 years). All respondents reported computer access, using laptops (91%), smartphones (82%) and tablets (62%). A significantly greater proportion (95%) of participants used SM compared to all other modalities (p<0.001). Commonly used SM platforms included Facebook, LinkedIn and WhatsApp, with 77% using them for professional reasons and 57% for education. VDS was used by 60% of participants, 73% of whom used it for education. The utilization of other ICTs was lower (VM 43%, LM 32%). Unreliable wifi hindered every ICT, less often SM (41%) and VDS (23%), and more commonly VM (64%) and LM (52%). Despite this, VM was typically used in international collaboration (79%), as compared to SM (42%, p=0.007), VDS (42%, p=0.007), or LM (32%, p=0.001, see figure). The vast majority of respondents (98%) expressed interest in using ICT to support local and international collaboration, with SM favored in medical education (85%) and VDS favored in collaborations (86%).

Conclusion:

ICT platforms have potential for supporting bidirectional education initiatives and international collaborations in resource limited areas, with surgeons in both HIC and LMIC expressing high levels of interest. Given the penetrance and reliability of SM and VDS, despite relative underusage and, at times, unreliable and limited wifi, there is significant potential for increased use of both platforms. Workshops providing instruction on ICT use are warranted to support the expansion of ICT use in global surgical collaborations. 

 

75.01 Utilizing Nurse-focused Simulation Sessions to Decrease Patient Refusal of VTE Chemoprophylaxis

Posted on January 18, 2018

L. J. Kreutzer3, A. D. Yang2,3, D. B. Hewitt3,4, K. Y. Bilimoria2,3, J. K. Johnson2,3  2Feinberg School Of Medicine – Northwestern University,Center For Healthcare Studies In The Institute For Public Health And Medicine,Chicago, IL, USA 3Feinberg School Of Medicine – Northwestern University,Surgical Outcomes And Quality Improvement Center,Chicago, IL, USA 4Thomas Jefferson University,Surgery,Philadelphia, PA, USA

Introduction: Venous thromboembolism (VTE) is the leading cause of preventable inpatient death. VTE prophylaxis for moderate to high risk patients includes chemoprophylaxis; however, patients who refuse prophylaxis increase their VTE risk. Studies suggest that nurses can influence patient compliance with VTE prophylaxis. We previously conducted nursing focus groups at one hospital and found that they felt ill-equipped to handle patient refusals of VTE chemoprophylaxis. Our objective was to assess the effectiveness of a structured simulation session designed to equip nurses with skills to handle conversations with patients refusing VTE chemoprophylaxis.

Methods: Based on the findings from our qualitative study, we developed a 20-minute interactive in-person patient VTE chemoprophylaxis refusal simulation (Figure) as part of a larger VTE Prophylaxis Improvement Bundle. The simulation session goals were to 1) discuss the perspective of inpatients who refuse VTE chemoprophylaxis, 2) equip nurses with strategies to address patient refusals, 3) provide opportunities for nurses to learn from each other, and 4) to practice the nurse-patient conversation around VTE chemoprophylaxis refusal. After a brief brainstorming session discussing reasons why patients refuse VTE prophylaxis, nurse participants role-played as both the nurse and patient in a scenario where a patient refuses VTE chemoprophylaxis. The facilitators then debriefed the entire group of nurses to discuss effective strategies to respond to patient concerns. Participants then switched roles and repeated the role-play. Nurses received a reference sheet on effective strategies to respond to patients who decline VTE prophylaxis. We evaluated nurses’ perceptions of the utility and effectiveness of the experience with a post-session survey.

Results:We conducted 17 patient refusal simulation sessions including a total of 122 nurses from 4 inpatient units. After the simulation session, 98.4% of nurses felt ‘Quite a Bit’ or ‘A Great Deal’ able to speak with patients refusing VTE chemoprophylaxis compared to 76.2% pre-intervention (P<0.001). Furthermore, 94% of nurses intended to change their practice as a result of the session. Attendees translated lessons learned as they returned to their units: “After the session, I saw a lot more confidence when nurses were explaining the benefits of the medication to help prevent VTE.” – Unit Nurse Manager

Conclusion:A brief, focused interactive simulation session met an educational need and improved nurses’ ability to discuss VTE prophylaxis with patients. Future efforts will focus on expanding the initiative across our hospital system by integrating the sessions into the nursing education curriculum.

 

6.16 SURGICAL STAGING SUPERIOR TO PET SCAN FOR ASSESSMENT OF DISEASE RESPONSE FOR MEDIASTINAL LYMPHOMA

Posted on January 18, 2018

L. Kane1, H. Savas1, M. DeCamp1, A. Bharat1  1Feinberg School Of Medicine – Northwestern University,Chicago, IL, USA

Introduction:

Mediastinal lymphoma affects young individuals, typically in the second through fourth decades of life, and constitutes over 7% of all lymphomas. The primary treatment modality remains systemic chemotherapy with or without radiation. Response to therapy is determined using PET scan. Unfortunately, in over 25% of patients, PET remains positive and it is unclear whether persistent PET avidity in the mediastinum represents residual disease or inflammatory changes resulting from therapy. Percutaneous image guided biopsy has typically resulted in poor accuracy due to the heterogeneity of the residual mass as well as the difficult nature of needle access. We hypothesized that minimally invasive thoracoscopic techniques would enable better sampling of the PET avid mediastinal lesion, allowing accurate assessment of residual disease following first-line treatment of mediastinal lymphomas.

Methods:
This is a retrospective analysis of a prospectively maintained database. Between January 2009 and December 2015, all patients (n=77) who underwent initial surgical incisional biopsy for diagnosis were included. The surgical biopsies were performed using minimally invasive techniques (video-thoracoscopy or robotic surgery) and required the surgeon to keep performing the biopsy until frozen section was positive or at least until the mass on the ipsilateral hemi-mediastinum was resected. Statistical analysis was performed by a biostatistician using SPSS software. 

Results:
Of the study cohort, 34 patients underwent surgical restaging for PET avid residual mass while 43 either had a complete response with no PET activity or were lost to follow up. The cohort of 34 patients included 76% Caucasians, 50% females, and had a median age of 28 years. The types of lymphoma were predominantly Hodgkins (32%) and Diffuse Large B cell Lymphoma (38%). In these 34 patients with residual PET activity, surgical biopsy revealed presence of lymphoma in 53% of patients. Patients detected to have persistent lymphoma revealed no significant difference in tumor volume reduction compared to those with no residual disease (51% versus 39%) and no significant difference in reduction in PET SUV (68% versus 60%). In all biopsies, significant adhesions between lung and mediastinum were noted, and the median length of the surgical procedure was 75 minutes. However, there were no surgical complications. The length of stay for all patients was less than 24 hours. All patients detected to have residual lymphoma underwent second-line therapy guided by the pathological analysis. 

Conclusion:
While the current standard for patients with mediastinal lymphoma presenting with residual PET activity after completion of first line therapy is surveillance alone, our data suggests that a large number of these patients have residual lymphoma which can be safely diagnosed using minimally invasive surgery. Detection of residual lymphoma has significant implications in further treatment of these patients. 

57.19 Global Health Preparation: Surgery and Anesthesia Simulation

Posted on January 18, 2018

D. M. Langston1, M. Eskendar1, F. M. Peralta1, A. Doobay-Persaud1, N. Issa1, S. Galvin1, M. Swaroop1  1Northwestern University,Chicago, IL, USA

Introduction:
Five billion people lack access to safe, quality, and timely surgical healthcare. Basic surgical and anesthesia care can and should be provided by general practitioners in low resource settings. Training of these providers through simulation, a validated tool in educational programs for resident training, is a viable platform to impart surgical and anesthesia skills. No research is available, however, on the impact of basic skills simulation on preparedness for clinical care in global health field experiences, specifically involving surgery and anesthesia care. In preparation for a global health rotation, a team based simulation session was designed for non-surgical and anesthesia residents to evaluate the ability of simulation based learning to optimize knowledge, skills, and confidence levels as these relate to surgery and anesthesia care.

Methods:
Didactic and experiential training stations were developed based on six common surgical and anesthesia conditions identified by surgery and anesthesia global health faculty. Participants completed a pre- and post- self-assessment test utilizing a 3-point Likert Scale. Results were compared to evaluate the effectiveness of training and improvement in self-reported confidence in skill performance. 

Results:
Thirteen non-surgery and anesthesia resident physicians from 5 specialty areas participated in the training. All resident physicians spent 30 minutes at each of the 6 stations while being mentored and then monitored by surgery and anesthesia attending and resident physicians.  The participants who completed the post-test (n=13) considered the training either useful (85%, n=11) and/or of excellent quality (69%, n=9).  At the completion of the session, most trainees felt very comfortable performing intravenous line placement (92%, n=12), bag mask ventilation (100%), and incision and drainage (100%). Trainees felt the least comfortable performing laryngoscopy (23%, n=3) and conscious sedation (46%, n=6).

Conclusion:
Simulation for non-surgery and anesthesia resident trainees anticipating a global health experience is feasible and easily implemented. There continues to be a paucity of basic surgery and anesthesia care in low resource settings. Simulation training is a validated method to train not only general practitioners in basic surgery and anesthesia care, but also non-physician providers.
 

5.10 The Effect of Obesity on Operating Room Utilization in Breast Surgery

Posted on January 18, 2018

N. Tata1, J. Dunderdale2, I. Helenowski3, B. Jovanovic3, R. Marcus4, S. Kulkarni2  1Feinberg School Of Medicine – Northwestern University,Chicago, IL, USA 2Feinberg School Of Medicine – Northwestern University,Department Of Surgery,Chicago, IL, USA 3Feinberg School Of Medicine – Northwestern University,Department Of Preventative Medicine,Chicago, IL, USA 4Feinberg School Of Medicine – Northwestern University,Department Of Anesthesia,Chicago, IL, USA

Introduction: The current obesity epidemic is associated with increased health care costs and comorbidities such as diabetes and heart disease.  However, the effect of obesity on OR utilization has not been completely evaluated.  The goal of our study was to examine how operative time (OPT) and total time in the operating room (TTOR) for common breast procedures are affected by patient BMI.  We hypothesized that operating room utilization would vary significantly with BMI, with the difference being greater for more extensive breast procedures compared to minimally invasive procedures. 

Methods:  For this study, the American College of Surgeons National Surgical Quality Improvement Project (NSQIP) databases for 2010-2012 were searched.  Patients undergoing the selected breast operations were filtered out by CPT code.  They were divided into groups based on their BMI and their weight.  Using the two-sample t-test, OPT and TTOR for the procedures were compared among the lowest and highest BMI categories, as well as the lowest and highest weight categories. To further characterize the effect of BMI on operative time, a linear regression t-test was used to demonstrate increase in OPT as a function of unit increase in BMI.

Results:  When the lowest and highest BMI groups were compared for all procedures, significant differences in OPT and TTOR were seen (p<0.0001).  Ultimately, our analysis included 47,557 patients for OPT data and 32, 455 for TTOR data.  Overall, there was a fourteen minute difference in OPT and an eighteen minute difference in TTOR.  Similarly, when the lowest and highest weight categories were compared for all procedures, a significant difference in OPT of thirteen minutes was seen, while the difference in TTOR was seventeen minutes.  In both BMI and weight analyses, though significant differences were noted for lumpectomy alone and lumpectomy plus SLNB, the effect of patient BMI on ALND and mastectomy is even more pronounced.

For every ten unit increase in BMI, there was a 9.6 minute increase in operative time for lumpectomy ALND and 14.3 minutes increase for mastectomy ALND procedures.  For simpler procedures like lumpectomy and lumpectomy SNLB, the increase in operative time with ten unit BMI increase was 2.4 and 5.2 minutes respectively.

Conclusion: Patient BMI and weight significantly affect OPT and TTOR for common breast procedures.  However, the difference is greater for ALND and mastectomy.  Therefore, when scheduling more extensive breast procedures, patient BMI should be taken into account to improve operating room scheduling and adjust physician compensation.  

5.06 Effect of Preoperative MRI on Rate of Local and Distant Recurrence of Breast Cancer

Posted on January 18, 2018

A. Roy1, Z. Zeng3, X. Li6, S. Espino4, Y. Luo3, H. Jiang5, S. Khan4  1Northwestern University,Feinberg School Of Medicine,Chicago, IL, USA 3Northwestern University,Department Of Preventative Medicine, Feinberg School Of Medicine,Chicago, IL, USA 4Northwestern University,Department Of Surgery, Feinberg School Of Medicine,Chicago, IL, USA 5Northwestern University,Department Of Statistics,Evanston, IL, USA 6Harvard School Of Public Health,Department Of Social & Behavioral Sciences,Boston, MA, USA

Introduction: The most sensitive imaging modality currently used to detect multifocal and metacentric breast cancer is magnetic resonance imaging (MRI), yet its role in preoperative evaluation of disease extent remains controversial. It was initially hoped that preoperative MRI use would allow more complete resection of disease and would improve outcomes, but a prospective study has shown that it does not reduce re-excisions and retrospective analyses do not support an improvement in cancer outcomes. However, the number of local recurrences and patients in these studies is small. In an attempt to clarify the potential benefit of pre-operative breast MRI for long-term breast cancer outcomes, we report a retrospective review of data on 3902 women diagnosed with primary breast cancer at the Lynn Sage Breast Center of Northwestern Medicine.  

Methods: The Enterprise Data Warehouse of Northwestern Medicine was searched for women diagnosed with ductal carcinoma in situ (DCIS) or invasive breast cancer who underwent breast conservation therapy (BCT) between 2000-2016. The use of preoperative MRI was extracted along with clinical and therapeutic details. The frequencies of local recurrence (LR) and distant recurrence (DR) were evaluated with Cox proportional hazards model, adjusting for age, race, tumor size, tumor grade, lymph node status, ER status, PR status, HER2 status, P53 status, Ki67 status, systemic therapy status, and radiation therapy status.  

Results: Among 3902 women with primary breast cancer, 1,303 had preoperative MRI and 2,599 did not. Compared to the women who did not have MRI, women with MRI were younger (55 vs 59 years, p<0.0001), had larger tumor size (1.64 cm vs 1.55 cm, p=0.03), and underwent systemic therapy more frequently (p<0.0001). Median follow-up time for the MRI group was 75 months, and for the non-MRI group was 125 months (p<.0001). Ipsilateral LR was experienced by 224 women (5.74%), and DR occurred in 227 women (5.82%). In univariable Cox regression models, the hazard ratio (HR) with use of MRI was 0.94 (95% CI 0.71 to 1.24; p=0.65) for LR; and 0.84 (95% CI 0.62 to 1.15; p=0.29) for DR. In multivariable Cox regression models, the HR with use of MRI was 0.88 (95% CI 0.65 to 1.17; p=0.37) for LR; and 0.77 (95% CI 0.56 to 1.06; p=0.11) for DR.   

Conclusion: Women who received preoperative MRI differed significantly from those who did not, but cancer outcomes for either local or distant recurrence following BCT were not significantly different by MRI use. However, this and other retrospective analyses are likely subject to bias given the factors that appear to drive the use of MRI.   

 

46.01 Quality of Life in Patients with MEN-2 Compared to US Normative and Chronic Disease Populations

Posted on January 18, 2018

M. N. Mongelli1, I. Helenowski1, S. Yount1, C. Sturgeon1  1Feinberg School Of Medicine – Northwestern University,Chicago, IL, USA

Introduction:  Patient-Reported Outcomes (PROs) are being measured in many chronic disease states to inform decisions about intervention and management of disease while minimizing patient suffering and side effects. There is a paucity of data on health-related quality of life (HRQOL) and PROs in patients with Multiple Endocrine Neoplasia Type-2 (MEN-2). We hypothesized that HRQOL in MEN-2 patients would be lower than that of the general United States (US) population, but similar to that of patients suffering from other chronic diseases.

Methods:  Adults ≥ 18 years were recruited from an online MEN support group and completed the PROMIS-29 questionnaire (n=46). Responses were converted into t-scores for each of the seven health domains. T-scores of PROMIS domains were compared to US normative data using a one-sample t-test. PROMIS scores for other conditions, including low back pain, cancer, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), major depressive disorder, rheumatoid arthritis (RA), neuroendocrine tumors (NET), primary hyperparathyroidism (PHPT), and MEN-1 were obtained through literature review. T-scores for health domains were compared to other conditions using a Wilcoxon signed-rank test.

Results: The mean age was 46.1 years and the average time since diagnosis was 14.1 years. Compared to the US normative population, MEN-2 patients reported statistically significantly more anxiety (56.1±11.2, p=.001), depression (54.6±11.2, p=.008), fatigue (61.0±10.4, p<.001), pain interference (55.2±11.1, p =.003), and sleep disturbance (57.0±3.7, p<.001), as well as significantly decreased physical functioning (44.6±9.5, p<.001) and ability to participate in social roles (45.8±9.7, p=.005). MEN-2 patients reported statistically significantly greater fatigue than patients with cancer (p<.0001), COPD (p=.01), RA (p=.0001), NET (p=.0007), and PHPT (p<.0001), greater pain interference than patients with PHPT (p<.0001), and improved physical functioning compared to patients with low back pain (p<.0001), CHF (p<.0001), and COPD (p=.0002).

Conclusion: PROs may be a valuable tool to inform the management of patients with MEN-2. Our study is the first to use the PROMIS-29 metric to directly compare PROs between MEN-2 and other chronic conditions. Individuals with MEN-2 reported worse HRQOL in all 7 domains compared to normative data. There is a pattern of increased fatigue among MEN-2 patients compared to many other chronic conditions, even though MEN-2 patients report greater physical functioning than other chronic diseases.  Prospective longitudinal evaluation of PROs in MEN-2 should be conducted in order to identify treatments associated with the highest HRQOL.

 

45.07 The Effect of Author Gender on Sex Bias in Surgical Research

Posted on January 18, 2018

N. Xiao1, N. Mansukhani1, D. Fregolente2, M. Kibbe1,3  1Northwestern University,Department Of Surgery,Chicago, IL, USA 2Northwestern University,Department Of Chemical And Biological Engineering,Chicago, IL, USA 3University Of North Carolina At Chapel Hill,Department Of Surgery,Chapel Hill, NC, USA

Introduction:
Previous studies have demonstrated that sex bias exists in surgical research. Females are underrepresented as research subjects and as investigators in surgical scientific research. We aimed to investigate the effect of author gender on sex-bias in surgical research, and to explore whether investigators benefit from performing sex-inclusion research. We hypothesized that author gender impacts sex-bias.

Methods:
Data were abstracted from 1,921 original, peer-reviewed articles published from 01/01/11-12/31/12 in 5 general-interest surgery journals. Excluded were articles that pertained to a sex-specific disease, did not report the number of subjects, or contained gender ambiguous author names. Abstracted data included gender of the first and last author, number of female and male subjects included in each study, surgical specialty, and number of citations received per article. Quantification of sex bias was performed by examining the inclusion of male and female subjects and sex-matching of included subjects. Further analysis of the presence of sex-based reporting of data, sex-based statistical analysis of data, and sex-based discussion of the data was included. 

Results:
Of the 1,802 articles included in this study, a total of 2,791 (77.4%) first and last authors were male. 70.3% of first authors and 84.6% of last authors were male. The prevalence of male authors was consistent across all five journals and among both clinical and basic science research (p=NS). Investigations in breast, endocrine, and surgical education were conducted by more female investigators compared to other specialties (p<0.05). Female authors recruited a higher median number of female subjects compared to their male counterparts (p=0.01), but sex-matched the inclusion of subjects less frequently. There were no differences between male and female authors in sex-based reporting, sex-based statistical analysis, and sex-based discussion of the data, nor the number of citations received. However, studies which performed sex-based reporting yielded 2.8 more citations (95% CI 1.2 – 4.4, P<0.01), studies which performed sex-based statistical analysis yielded 3.5 more citations (95% CI 1.8 – 5.1, P<0.01), and studies containing a sex-based discussion of the data yielded 2.6 (95% CI 0.7 – 4.5, P<0.01) more citations compared to studies which did not report, analyze, or discuss data by sex. Articles with higher percent sex matching of subjects also received more citations, with an increase of 1 citation per 4.8% (95% CI 2.0 – 7.7%, P<0.01) increase in percent of sex matching.

Conclusion:

Sex bias in surgical research is prevalent among both men and women authors. However, women authors include proportionally more female subjects in their studies compared to male authors. Lastly, studies which address sex bias received significantly more citations. 

 

45.06 Do Surgeon Demographics and Surgical Specialty Drive Patient Experience Scores?

Posted on January 18, 2018

K. E. Engelhardt1,2, R. S. Matulewicz1, J. O. DeLancey1, C. Quinn1, L. Kreutzer1, K. Y. Bilimoria1  1Northwestern University,Chicago, IL, USA 2Medical University Of South Carolina,Charleston, Sc, USA

Introduction:  Optimizing the patient experience has become a focus for hospitals, physicians, and other healthcare providers in recent years.  The Centers for Medicare and Medicaid Services publicly reports patient-reported “likelihood to recommend” (LTR) for group practices and may report LTR for individual surgeons in the future. However, it is hypothesized that surgeon-level factors (e.g. age, sex, training, and specialty) may influence LTR scores.  The objective of this study was to assess the relationship between surgeon factors and surgeon-specific LTR scores.

Methods:  Patient experience survey data were analyzed from a common, third party, nationally-available survey for all surgeons at a single adult academic medical center for fiscal years 2013-2016. All surgical subspecialties were included. This survey includes questions about the patient’s experience with the surgeon in the clinic setting. Hierarchical logistic regression modeling was used to identify factors associated with a top box response (i.e., best score) on the surgeon-specific LTR question.

Results: A total of 18,100 surveys were returned for 118 surgical faculty members representing an overall response rate of 19.2%; mean individual question response rate among those who returned surveys was 94.4% (range 80.0-97.2%). Surgeons in our cohort were predominately male (78.0%) and fellowship-trained (72.9%). Surgeon-specific top box LTR percentages ranged from 54.5% to 97.5%.  In adjusted analyses (Table), certain specialties had a significantly lower likelihood of top box LTR score when compared to general surgery (ophthalmology OR 0.60, 95%CI 0.42-0.85; ENT OR 0.64, 95%CI 0.41-1.00).  Surgeon age, gender, and medical training characteristics (e.g., fellowship trained, top-25 medical school graduate, etc.) were not significantly associated with top box LTR response.  In our data, no surgeon was rated significantly better or worse overall than the mean of all other surgeons studied (i.e. there was poor residual intraclass correlation: 0.059).

Conclusion: Surgeon demographics and medical training history were not significantly associated with LTR scores for individual surgeons.  However, certain surgical specialties were associated with LTR responses. Adjustment for surgical specialty may be necessary to reduce bias and accurately portray patient experience when comparing LTR scores across departments of surgery.  
 

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