Addressing Professionalism, Social, and Communication Competencies in Surgical Residency Via Integrated Humanities Workshops: A Pilot Curriculum

OBJECTIVE

We aimed to conduct professionalism and social competencies (PSC) training by integrating humanities into structured workshops, and to assess reception of this curriculum by first-year surgical residents.

DESIGN

An IRB-approved, pilot curriculum consisting of 4 interactive workshops for surgical interns was developed. The workshops were scheduled quarterly, often in small group format, and supplemental readings were assigned. Humanities media utilized to illustrate PSC included survival scenarios, reflective writing, television portrayals, and social media. Emphasis was placed on recognizing personal values and experiences that influence judgment and decision-making, using social media responsibly, identifying and overcoming communication barriers related to generational changes in training (especially technology and work-life balance), and tackling stereotypes of surgeons. Anonymous and voluntary pre- and postcurriculum surveys were administered. Univariate analysis of responses was performed with JMP Pro v12 using Fisher's exact, χ², and Students' t-tests for categorical and continuous variables.

SETTING

The study took place at the Cleveland Clinic in Cleveland, OH, within the general surgery program.

PARTICIPANTS

Surgical interns at the Cleveland Clinic were included in the study. A total of 16 surgical interns completed the curriculum.

RESULTS

Sixteen surgical interns participated in the curriculum: 69% were domestic medical school graduates (DG) and 31% were international medical school graduates (IMG). Overall, the majority (81%) of residents had received PSC courses during medical school: 100% of DG compared to 40% of IMG (p = 0.02). Before beginning the curriculum, 86% responded that additional PSC training would be useful during residency, which increased to 94% upon completion (p = 0.58). Mean number of responses supporting the usefulness of PSC training increased from 1.5 ± 0.2 before the curriculum to 1.75 ± 0.2 upon completion (p = 0.4). When describing public and medical student perceptions of surgeons, 60% and 83% of adjectives used were negative, respectively. When describing perceptions of female surgeons, 88% of adjectives used were negative.

CONCLUSIONS

Most interns received prior PSC coursework; however, the majority still desired additional training during residency. After completion, a greater percentage of interns responded that PSC training was important and choose more reasons in favor of the curriculum. Formalized didactics should be strongly considered, especially in programs with IMG. Future areas of investigation include expanding the cohort to additional years of residency; potentially identifying unique PSC needs for each postgraduate year.

Under-vaccinated groups in Europe and their beliefs, attitudes and reasons for non-vaccination; two systematic reviews

BACKGROUND

Despite effective national immunisation programmes in Europe, some groups remain incompletely or un-vaccinated ('under-vaccinated'), with underserved minorities and certain religious/ideological groups repeatedly being involved in outbreaks of vaccine preventable diseases (VPD). Gaining insight into factors regarding acceptance of vaccination of 'under-vaccinated groups' (UVGs) might give opportunities to communicate with them in a trusty and reliable manner that respects their belief system and that, maybe, increase vaccination uptake. We aimed to identify and describe UVGs in Europe and to describe beliefs, attitudes and reasons for non-vaccination in the identified UVGs.

METHODS

We defined a UVG as a group of persons who share the same beliefs and/or live in socially close-knit communities in Europe and who have/had historically low vaccination coverage and/or experienced outbreaks of VPDs since 1950. We searched MEDLINE, EMBASE and PsycINFO databases using specific search term combinations. For the first systematic review, studies that described a group in Europe with an outbreak or low vaccination coverage for a VPD were selected and for the second systematic review, studies that described possible factors that are associated with non-vaccination in these groups were selected.

RESULTS

We selected 48 articles out of 606 and 13 articles out of 406 from the first and second search, respectively. Five UVGs were identified in the literature: Orthodox Protestant communities, Anthroposophists, Roma, Irish Travellers, and Orthodox Jewish communities. The main reported factors regarding vaccination were perceived non-severity of traditional "childhood" diseases, fear of vaccine side-effects, and need for more information about for example risk of vaccination.

CONCLUSIONS

Within each UVG identified, there are a variety of health beliefs and objections to vaccination. In addition, similar factors are shared by several of these groups. Communication strategies regarding these similar factors such as educating people about the risks associated with being vaccinated versus not being vaccinated, addressing their concerns, and countering vaccination myths present among members of a specific UVG through a trusted source, can establish a reliable relationship with these groups and increase their vaccination uptake. Furthermore, other interventions such as improving access to health care could certainly increase vaccination uptake in Roma and Irish travellers.

International validation of the European Organisation for Research and Treatment of Cancer QLQ-BRECON23 quality-of-life questionnaire for women undergoing breast reconstruction

Background

The aim was to carry out phase 4 international field-testing of the European Organisation for Research and Treatment of Cancer (EORTC) breast reconstruction (BRECON) module. The primary objective was finalization of its scale structure. Secondary objectives were evaluation of its reliability, validity, responsiveness, acceptability and interpretability in patients with breast cancer undergoing mastectomy and reconstruction.

Methods

The EORTC module development guidelines were followed. Patients were recruited from 28 centres in seven countries. A prospective cohort completed the QLQ-BRECON15 before mastectomy and the QLQ-BRECON24 at 4–8 months after reconstruction. The cross-sectional cohort completed the QLQ-BRECON24 at 1–5 years after reconstruction, and repeated this 2–8 weeks later (test–retest reliability). All participants completed debriefing questionnaires.

Results

A total of 438 patients were recruited, 234 in the prospective cohort and 204 in the cross-sectional cohort. A total of 414 reconstructions were immediate, with a comparable number of implants (176) and donor-site flaps (166). Control groups comprised patients who underwent two-stage implant procedures (72, 75 per cent) or delayed reconstruction (24, 25 per cent). Psychometric scale validity was supported by moderate to high item-own scale and item-total correlations (over 0·5). Questionnaire validity was confirmed by good scale-to-sample targeting, and computable scale scores exceeding 50 per cent, except nipple cosmesis (over 40 per cent). In known-group comparisons, QLQ-BRECON24 scales and items differentiated between patient groups defined by clinical criteria, such as type and timing of reconstruction, postmastectomy radiotherapy and surgical complications, with moderate effect sizes. Prospectively, sexuality and surgical side-effects scales showed significant responsiveness over time (P < 0·001). Scale reliability was supported by high Cronbach's α coefficients (over 0·7) and test–retest (intraclass correlation more than 0·8). One item (finding a well fitting bra) was excluded based on high floor/ceiling effects, poor test–retest and weak correlations in factor analysis (below 0·3), thus generating the QLQ-BRECON23 questionnaire.

Conclusion

The QLQ-BRECON23 is an internationally validated tool to be used alongside the EORTC QLQ-C30 (cancer) and QLQ-BR23 (breast cancer) questionnaires for evaluating quality of life and satisfaction after breast reconstruction.

Abstract P4-21-26: Population pharmacokinetics (PK) and exposure-response (E-R) analysis of trastuzumab emtansine (T-DM1) in patients with HER2+ metastatic breast cancer (MBC) who have received at least two prior regimens of HER2-directed therapy

Background:

TH3RESA was a Phase III randomized study to evaluate the efficacy and safety of trastuzumab emtansine (T-DM1) compared to treatment of physician's choice (TPC) in patients with HER2+ MBC who have progression after at least two regimens of HER2-directed therapy. Population pharmacokinetic (PK) and exposure-response (E-R) analyses were performed to characterize T-DM1 PK as well as E-R relationship for key efficacy and safety endpoints in the population.

Methods:

Post-hoc analysis based on historical T-DM1 population PK models was performed to assess whether PK is consistent with historical data. E-R analyses with OS and PFS were conducted using Cox proportional hazard (CPH) models with exposure metrics (model-predicted Cycle 1 Cmin and AUCss) included in the model. Logistic regression models were used for binary endpoints of overall response rate (ORR) and key safety endpoints with exposure metrics included as continuous variable only. To supplement the E-R analysis for OS and PFS, case matching analyses were conducted to compare OS and PFS in the lowest exposure quartile (Q1) vs. higher exposure quartiles (Q2-4) to their corresponding matched control.

Results:

Historical T-DM1 population PK model well described T-DM1 PK in TH3RESA study. In CPH analyses with OS and PFS, hazard ratios (HR) of both efficacy endpoints consistently decreased with increasing T-DM1 exposure. The E-R relationship is supported by case matching analyses, where T-DM1 treated patients were stratified by model-predicted Cycle 1 Cmin. HRs of OS and PFS for patients at Q2−4 versus their matched TPC patients (HR (95%CI): 0.58 (0.44, 0.78) for OS; 0.47 (0.36, 0.62) for PFS) were numerically smaller than that of T-DM1 treated patients at Q1 versus their corresponding matched TPC patients (HR (95%CI): 0.96 (0.63, 1.47) for OS; 0.92 (0.64, 1.32) for PFS). For ORR, an E-R trend was also noted. On the other hand, no E-R relationship was identified with key safety endpoints.

HR for Quartile of Cmin Before and After Adjusting for Risk Factors QuartileUnadjusted HR (95% CI)Adjusted HR (95% CI)OSQ11.14 (0.832, 1.55)0.886 (0.64, 1.23) Q20.828 (0.6, 1.14)0.685 (0.493, 0.952) Q30.532 (0.374, 0.757)0.559 (0.391, 0.798) Q40.352 (0.238, 0.521)0.405 (0.272, 0.603)PFSQ10.852 (0.63, 1.15)0.831 (0.614, 1.12) Q20.635 (0.463, 0.872)0.619 (0.451, 0.85) Q30.428 (0.3, 0.609)0.442 (0.31, 0.632) Q40.237 (0.158, 0.357)0.258 (0.171, 0.389)

HR for Quartile of AUCss Before and After Adjusting for Risk Factors QuartileUnadjusted HR (95% CI)Adjusted HR (95% CI)OSQ11.07 (0.782, 1.47)0.774 (0.555, 1.08) Q20.651 (0.464, 0.912)0.567 (0.402, 0.801) Q30.662 (0.472, 0.929)0.736 (0.523, 1.04) Q40.406 (0.280, 0.588)0.458 (0.315, 0.667)PFSQ10.69 (0.505, 0.941)0.657 (0.481, 0.897) Q20.66 (0.479, 0.908)0.681 (0.494, 0.940) Q30.524 (0.377, 0.730)0.545 (0.390, 0.760) Q40.235 (0.155, 0.355)0.253 (0.167, 0.383)

Conclusion:

T-DM1 PK in TH3RESA patient population is similar to historical data. Although an E-R relationship was observed for efficacy, the results need to be interpreted with caution given the potential confounding association between risk factor and PK. No E-R relationship was observed for the safety endpoints examined.

Citation Format: Chen S-C, Polhamus D, Riggs M, French J, Wang X, Smitt M, Hoersch S, Strasak A, Chernyukhin N, Quartino A, Jin J, Girish S, Li C. Population pharmacokinetics (PK) and exposure-response (E-R) analysis of trastuzumab emtansine (T-DM1) in patients with HER2+ metastatic breast cancer (MBC) who have received at least two prior regimens of HER2-directed therapy [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-21-26.

Animal-to-Human Dose Translation of Obiltoxaximab for Treatment of Inhalational Anthrax Under the US FDA Animal Rule

Obiltoxaximab, a monoclonal antibody against protective antigen (PA), is approved for treatment of inhalational anthrax under the US Food and Drug Administration's (FDA) Animal Rule. The human dose was selected and justified by comparing observed obiltoxaximab exposures in healthy and infected New Zealand White rabbits and cynomolgus macaques to observed exposures in healthy humans, to simulated exposures in healthy and infected humans, and to serum PA levels in infected animals. In humans, at 16 mg/kg intravenous, obiltoxaximab AUC was >2 times that in animals, while maximum serum concentrations were comparable to those in animals and were maintained in excess of the concentration required for PA neutralization in infected animals for 2-3 weeks. Obiltoxaximab 16 mg/kg in humans provided exposure beyond that of 16 mg/kg in animals, ensuring a sufficient duration of PA neutralization to allow for adaptive immunity development. Our approach to dose translation may be applicable to other agents being developed under the Animal Rule.

Expert opinion on advanced techniques for hemostasis in liver surgery

BACKGROUND

Reduction of perioperative blood loss and intraoperative transfusion are two major factors associated with improving outcomes in liver surgery. There is currently no consensus as to the best technique to achieve this.

METHODS

An international Panel of Experts (EP), made up of hepatobiliary surgeons from well-known high-volume centres was assembled to share their experience with regard to the management of blood loss during liver resection surgery. The process included: a review of the current literature by the panel, a face-to-face meeting and an on-line survey completed by the EP prior to and following the face-to-face meeting, based on predetermined case scenarios. During the meeting the most frequently researched surgical techniques were appraised by the EP in terms of intraoperative blood loss.

RESULTS

All EP members agreed that high quality research on the subject was lacking. Following an agreed risk stratification algorithm, the EP concurred with the existing research that a haemostatic device should always be used along with any user preferred surgical instrumentation in both open and laparoscopic liver resection procedures, independently from stratification of bleeding risk. The combined use of Ultrasonic Dissector (UD) and saline-coupled bipolar sealing device (Aquamantys(®)) was the EP preferred technique for both open and laparoscopic surgery.

CONCLUSIONS

This EP propose the use of a bipolar sealer and UD for the best resection technique and essential equipment to minimise blood loss during liver surgery, stratified according to transfusion risk, in both open and laparoscopic liver resection.

Patient preferences for timing and access to radiation therapy

PURPOSE

Patient preferences for radiation therapy (rt) access were investigated.

METHODS

Patients completing a course of rt at 6 centres received a 17-item survey that rated preferences for time of day; day of week; actual, ideal, and reasonable travel times for rt; and actual, ideal, and reasonable times between referral and first oncologic consultation. Patients receiving single-fraction rt or brachytherapy alone were excluded.

RESULTS

Of the respondents who returned surveys (n = 1053), 54% were women, and 74% had received more than 15 rt fractions. With respect to appointment times, 88% agreed or strongly agreed that rt between 08h00 and 16h30 was preferred; 14%-15% preferred 07h30-08h00 or 16h30-17h00; 10% preferred 17h00-18h00; and 6% or fewer preferred times before 07h30 or after 18h00. A preference not to receive rt before 07h30 or after 18h00 was expressed by 30% or more of the respondents. When days of the week were considered, 18% and 11% would have preferred to receive rt on a Saturday or Sunday respectively; 52% and 55% would have preferred not to receive rt on those days. A travel time of 1 hour or less for rt was reported by 82%, but 61% felt that a travel time of 1 hour or more was reasonable. A first consultation within 2 weeks of referral was felt to be ideal or reasonable by 88% and 73% of patients respectively.

CONCLUSIONS

An rt service designed to meet patient preferences would make most capacity available between 08h00 and 16h30 on weekdays and provide 10%-20% of rt capacity on weekends and during 07h30-08h00 and 16h30-18h00 on weekdays. Approximately 80%, but not all, of the responding patients preferred a 2-week or shorter interval between referral and first oncologic consultation.

Brain activation during neurocognitive testing using functional near-infrared spectroscopy in patients following concussion compared to healthy controls

There is no accepted clinical imaging modality for concussion, and current imaging modalities including fMRI, DTI, and PET are expensive and inaccessible to most clinics/patients. Functional near-infrared spectroscopy (fNIRS) is a non-invasive, portable, and low-cost imaging modality that can measure brain activity. The purpose of this study was to compare brain activity as measured by fNIRS in concussed and age-matched controls during the performance of cognitive tasks from a computerized neurocognitive test battery. Participants included nine currently symptomatic patients aged 18-45 years with a recent (15-45 days) sport-related concussion and five age-matched healthy controls. The participants completed a computerized neurocognitive test battery while wearing the fNIRS unit. Our results demonstrated reduced brain activation in the concussed subject group during word memory, (spatial) design memory, digit-symbol substitution (symbol match), and working memory (X's and O's) tasks. Behavioral performance (percent-correct and reaction time respectively) was lower for concussed participants on the word memory, design memory, and symbol match tasks than controls. The results of this preliminary study suggest that fNIRS could be a useful, portable assessment tool to assess reduced brain activation and augment current approaches to assessment and management of patients following concussion.

A case of severe necrotising pancreatitis following ampullary biopsy

We present a case of necrotising pancreatitis following ampullary biopsy in a patient with Barrett's oesophagus. The patient needed multiple necrosectomies and several admissions to the intensive care unit. This report is only the third and most severe case of pancreatitis following ampullary biopsy, highlighting its importance as a complication.

Comparison of Faxitron™ versus MicroCT imaging of the skeleton of the suckling rat

Currently, in pre and postnatal development studies or in juvenile rat studies, bone growth is assessed "for cause" by simple measurements of long bone length in vivo and at termination. This manuscript compares two radiographic methods for in vivo assessment of long bones in suckling rats; 2D imaging using a Faxitron™ and 3D imaging using μCT. This paper illustrates that it is possible to image the unanaesthetised postnatal day 1 rat by Faxitron™ using a simple Micropore™ tape restraint method. With isoflurane anaesthesia, it was possible to obtain high quality μCT images of pups from day of birth. No pups were rejected by their mothers following either technique. The Faxitron™ was straightforward and fast, however the μCT 3D images were of greater overall utility. Either method could be used for longitudinal investigation of long bone observations made previously in embryofetal development studies, or for other mechanistic work.