NCI Cancer Research Data Commons: Resources to Share Key Cancer Data

Since 2014, the NCI has launched a series of data commons as part of the Cancer Research Data Commons (CRDC) ecosystem housing genomic, proteomic, imaging, and clinical data to support cancer research and promote data sharing of NCI-funded studies. This review describes each data commons (Genomic Data Commons, Proteomic Data Commons, Integrated Canine Data Commons, Cancer Data Service, Imaging Data Commons, and Clinical and Translational Data Commons), including their unique and shared features, accomplishments, and challenges. Also discussed is how the CRDC data commons implement Findable, Accessible, Interoperable, Reusable (FAIR) principles and promote data sharing in support of the new NIH Data Management and Sharing Policy. See related articles by Brady et al., p. 1384, Pot et al., p. 1396, and Kim et al., p. 1404.

Provider-to-provider telehealth for sepsis patients in a cohort of rural emergency departments

BACKGROUND

Telehealth has been proposed as one strategy to improve the quality of time-sensitive sepsis care in rural emergency departments (EDs). The purpose of this study was to measure the association between telehealth-supplemented ED (tele-ED) care, health care costs, and clinical outcomes among patients with sepsis in rural EDs.

METHODS

Cohort study using Medicare fee-for-service claims data for beneficiaries treated for sepsis in rural EDs between February 1, 2017, and September 30, 2019. Our primary hospital-level analysis used multivariable generalized estimating equations to measure the association between treatment in a tele-ED-capable hospital and 30-day total costs of care. In our supporting secondary analysis, we conducted a propensity-matched analysis of patients who used tele-ED with matched controls from non-tele-ED-capable hospitals. Our primary outcome was total health care payments among index hospitalized patients between the index ED visit and 30 days after hospital discharge, and our secondary outcomes included hospital mortality, hospital length of stay, 90-day mortality, 28-day hospital-free days, and 30-day inpatient readmissions.

RESULTS

In our primary analysis, sepsis patients in tele-ED-capable hospitals had 6.7% higher (95% confidence interval [CI] 2.1%-11.5%) total health care costs compared to those in non-tele-ED-capable hospitals. In our propensity-matched patient-level analysis, total health care costs were 23% higher (95% CI 16.5%-30.4%) in tele-ED cases than matched non-tele-ED controls. Clinical outcomes were similar.

CONCLUSIONS

Tele-ED capability in a mature rural tele-ED network was not associated with decreased health care costs or improved clinical outcomes. Future work is needed to reduce rural-urban sepsis care disparities and formalize systems of regionalized care.

Assessing evidence-based practice among Australian radiographers: A self-report survey

INTRODUCTION

Evidence-based practice (EBP) is essential for ensuring the delivery of effective and efficient healthcare. Despite this, EBP is not always well implemented in the clinical environment. Evidence suggests that the application of EBP is likely impacted by healthcare workers' attitudes, knowledge and skills. While there has been a recent proliferation of international research examining diagnostic radiographers' attitudes towards, knowledge of and skills in EBP, no such research exists in an Australian context.

METHODS

This study presents the results of a validated self-report survey, the evidence-based practice questionnaire (EBPQ), administered to Australian diagnostic radiographers. The data were described and aggregated means were calculated for each of the domains. Inferential statistical tests were computed, including Cronbach's alpha, Pearson's correlations and independent t-tests, and Kruskal-Wallis tests.

RESULTS

The aggregated mean for the practice domain was 5.02 (SD 1.104), for the attitudes domain it was 5.41 (SD 1.169), and for the knowledge and skills domain, it was 5.20 (SD 1.177) on a seven-point scale. Significant associations were identified among these domains, with individuals holding higher qualifications and occupying leadership positions more likely to score higher. Additionally, the modality in which an individual primarily practiced appeared to also have an impact on their score. However, no significant correlation was found between any domain and the number of years an individual had been practicing.

CONCLUSION

This research has established a baseline of Australian diagnostic radiographers' practices, knowledge skills and attitudes towards evidence-based practice.

IMPLICATIONS FOR PRACTICE

This baseline can inform the development of interventions aimed at enhancing the role of evidence-based practice in the sampled population.

How medical learners and educators decide what counts as mistreatment: A qualitative study

INTRODUCTION

The mistreatment or abuse (maltreatment) of medical learners by their peers and supervisors has been documented globally for decades, and there is significant research about the prevalence, sequelae and strategies for intervention. However, there is evidence that learners experience maltreatment as being less clear cut than do researchers, educators and administrators. This definitional ambiguity creates problems for understanding and addressing this issue. The objective of this study was to understand how medical learners and educators make sense of less-than-ideal interactions in the clinical learning environment, and to describe which factors influenced their perception that the encounter constituted maltreatment.

METHODS

Using constructivist grounded theory, we interviewed 16 medical students, 15 residents or fellows, and 18 educators associated with a single medical school (n = 49). Data collection began with the most junior learners, iterating with analysis as we progressed through the project. Constant comparative analysis was used to gather and compare stories of 'definitely', 'maybe' and 'definitely not' maltreatment across a variety of axes including experience level, clinical setting and type of interaction.

RESULTS

Our data show that learners and educators have difficulty classifying their experiences of negative interpersonal interaction, except in the most severe and concrete cases. While there was tremendous variation in the way they categorised similar experiences, there was consistency in the elements drawn upon to make sense of those experiences. Participants interpreted negative interpersonal interactions on an individual basis by considering factors related to the interaction, initiator and recipient.

CONCLUSIONS

Only the most negative behaviour is consistently understood as maltreatment; a complex process of individual sense-making is required to determine the acceptability of each interaction. The differences between how individuals judge these interactions highlight an opportunity for administrative, research and faculty development intervention.

Outcomes Associated With Rural Emergency Department Provider-to-Provider Telehealth for Sepsis Care: A Multicenter Cohort Study

STUDY OBJECTIVE

To test the hypothesis that provider-to-provider tele-emergency department care is associated with more 28-day hospital-free days and improved Surviving Sepsis Campaign (SSC) guideline adherence in rural emergency departments (EDs).

METHODS

Multicenter (n=23), propensity-matched, cohort study using medical records of patients with sepsis from rural hospitals in an established, on-demand, rural video tele-ED network in the upper Midwest between August 2016 and June 2019. The primary outcome was 28-day hospital-free days, with secondary outcomes of 28-day inhospital mortality and SSC guideline adherence.

RESULTS

A total of 1,191 patients were included in the analysis, with tele-ED used for 326 (27%). Tele-ED cases were more likely to be transferred to another hospital (88% versus 8%, difference 79%, 95% confidence interval [CI] 75% to 83%). After matching and regression adjustment, tele-ED cases did not have more 28-day hospital-free days (difference 0.07 days more for tele-ED, 95% CI -0.04 to 0.17) or 28-day inhospital mortality (adjusted odds ratio [aOR] 0.51, 95% CI 0.16 to 1.60). Adherence with both the SSC 3-hour bundle (aOR 0.59, 95% CI 0.28 to 1.22) and complete bundle (aOR 0.45, 95% CI 0.02 to 11.60) were similar. An a priori-defined subgroup of patients treated by advanced practice providers suggested that the mortality was lower in the cohort with tele-ED use (aOR 0.11, 95% CI 0.02 to 0.73) despite no significant difference in complete SSC bundle adherence (aOR 2.88, 95% CI 0.52 to 15.86).

CONCLUSION

Rural emergency department patients treated with provider-to-provider tele-ED care in a mature network appear to have similar clinical outcomes to those treated without.

Carriage of Staphylococcus pseudintermedius by clinically normal dogs in Canterbury, New Zealand

AIMS

To investigate the frequency of carriage of methicillin-susceptible and methicillin-resistant Staphylococcus pseudintermedius (MRSP) in a population of clinically normal dogs within the Christchurch and wider Canterbury region, an area in which MRSP has been detected.

METHODS

Buccal and perianal swabs were collected from 126 clinically normal dogs presenting at veterinary clinics in the Christchurch/Canterbury region for de-sexing or routine vaccination. S. pseudintermedius was isolated by selective culture. Isolates were tested for susceptibility to 12 antimicrobials by disc diffusion.

RESULTS

S. pseudintermedius was isolated from 92/126 (73.0 (95% CI = 64.4-80.5)%) dogs, with 38/126 (30.2 (95% CI = 22.3-39.0)%) positive dogs carrying S. pseudintermedius at both sampled sites. More animals (78/126; 61.9; (95% CI: 52.8-70.4)%) had positive mouth cultures than positive perianal region cultures (52/126; 41.3 (95% CI: 32.6-50.4)%). No MRSP was isolated from clinically normal dogs. However, resistance to penicillin (106/130 (85.1%) swabs) and tetracycline (33/130 (25.4%) swabs) was seen.

CONCLUSIONS

The majority of the dogs in this sample were carriers of S. pseudintermedius. However none of these isolates were MRSP.

CLINICAL RELEVANCE

While most clinically normal dogs in the studied region are likely to be carriers of S. pseudintermedius, only a small proportion, if any, are likely to be carriers of MRSP. Antibiotic stewardship practices may be important to maintain low-level circulation of drug-resistant bacterial lineages.

Modeling and integration of N-glycan biomarkers in a comprehensive biomarker data model

Molecular biomarkers measure discrete components of biological processes that can contribute to disorders when impaired. Great interest exists in discovering early cancer biomarkers to improve outcomes. Biomarkers represented in a standardized data model, integrated with multi-omics data, may improve understanding and use of novel biomarkers such as glycans and glycoconjugates. Among altered components in tumorigenesis, N-glycans exhibit substantial biomarker potential, when analyzed with their protein carriers. However, such data are distributed across publications and databases of diverse formats, which hampers their use in research and clinical application. Mass spectrometry measures of fifty N-glycans, on seven serum proteins in liver disease, were integrated (as a panel) into a cancer biomarker data model, providing a unique identifier, standard nomenclature, links to glycan resources, and accession and ontology annotations to standard protein, gene, disease, and biomarker information. Data provenance was documented with a standardized FDA-supported BioCompute Object. Using the biomarker data model allows capture of granular information, such as glycans with different levels of abundance in cirrhosis, hepatocellular carcinoma, and transplant groups. Such representation in a standardized data model harmonizes glycomics data in a unified framework, making glycan-protein biomarker data exploration more available to investigators and to other data resources. The biomarker data model we describe can be used by researchers to describe their novel glycan and glycoconjugate biomarkers, can integrate N-glycan biomarker data with multi-source biomedical data, and can foster discovery and insight within a unified data framework for glycan biomarker representation thereby making the data FAIR (Findable, Accessible, Interoperable, Reusable) (https://www.go-fair.org/fair-principles/).

Rewards and recognition for Canadian distributed medical education preceptors: a qualitative analysis

Background: Recognition of Distributed Medical Education (DME) preceptors by medical schools ensures that important community-based training opportunities remain available to learners. Yet the literature seldom explores what rewards are meaningful to this population of teachers. The goal of our national project was to provide guidance to medical schools about the financial remuneration and non-financial rewards that are most valued by DME preceptors.

Methods: In this qualitative study, we invited DME faculty members from all Canadian medical schools to participate in semi-structured interviews. Participants with a range of medical specialties, stages of career, and geographic locations were interviewed via Zoom videoconferencing. The sessions in English and French were audio-recorded and transcribed. We used line-by-line inductive coding and thematic analysis to examine participant talk about meaningful preceptor recognition.

Results: Fourteen participants from multiple provinces were interviewed. Results indicated that the DME faculty are a diverse group of people with diverse needs. Most of the interviewees appreciated the rewards and recognition provided by their medical schools but felt that there are areas for improvement. Recognition is not necessarily monetary and should be tailored to the needs and the values of the recipient. Other themes included: benefits and challenges of being a preceptor, current institutional structures and supports, and the impact of the pandemic on preceptors.

Conclusions: The interviews highlighted the importance placed by preceptors on personal rewards and a wide variety of forms of recognition. Based on the findings, we suggest specific steps that medical schools can take to support, engage, and recognize DME faculty.

A Brief History of Human Challenge Studies (1900-2021) Emphasising the Virology, Regulatory and Ethical Requirements, Raison D'etre, Ethnography, Selection of Volunteers and Unit Design

Venetian quarantine 400 years ago was an important public health measure. Since 1900 this has been refined to include "challenge" or deliberate infection with pathogens be they viruses, bacteria, or parasites. Our focus is virology and ranges from the early experiments in Cuba with Yellow Fever Virus to the most widespread pathogen of our current times, COVID-19. The latter has so far caused over four million deaths worldwide and 190 million cases of the disease. Quarantine and challenge were also used to investigate the Spanish Influenza of 1918 which caused over 100 million deaths. We consider here the merits of the approach, that is the speeding up of knowledge in a practical sense leading to the more rapid licensing of vaccines and antimicrobials. At the core of quarantine and challenge initiatives is the design of the unit to allow safe confinement of the pathogen and protection of the staff. Most important though is the safety of volunteers. We can see now, as in 1900, that members of our society are prepared and willing to engage in these experiments for the public good. Our ethnology study, where the investigator observed the experiment from within the quarantine, gave us the first indication of changing attitudes amongst volunteers whilst in quarantine. These quarantine experiments, referred to as challenge studies, human infection studies, or "controlled human infection models" involve thousands of clinical samples taken over two to three weeks and can provide a wealth of immunological and molecular data on the infection itself and could allow the discovery of new targets for vaccines and therapeutics. The Yellow Fever studies from 121 years ago gave the impetus for development of a successful vaccine still used today whilst also uncovering the nature of the Yellow Fever agent, namely that it was a virus. We outline how carefully these experiments are approached and the necessity to have high quality units with self-contained air-flow along with extensive personal protective equipment for nursing and medical staff. Most important is the employment of highly trained scientific, medical and nursing staff. We face a future of emerging pathogens driven by the increasing global population, deforestation, climate change, antibiotic resistance and increased global travel. These emerging pathogens may be pathogens we currently are not aware of or have not caused outbreaks historically but could also be mutated forms of known pathogens including viruses such as influenza (H7N9, H5N1 etc.) and coronaviruses. This calls for challenge studies to be part of future pandemic preparedness as an additional tool to assist with the rapid development of broad-spectrum antimicrobials, immunomodulators and new vaccines.

An economic and health outcome evaluation of telehealth in rural sepsis care: a comparative effectiveness study

Aim: Sepsis is a top contributor to in-hospital mortality and, healthcare expenditures and telehealth have been shown to improve short-term sepsis care in rural hospitals. This study will evaluate the effect of provider-to-provider video telehealth in rural emergency departments (EDs) on healthcare costs and long-term outcomes for sepsis patients. Materials & methods: We will use Medicare administrative claims to compare total healthcare expenditures, mortality, length-of-stay, readmissions, and category-specific costs between telehealth-subscribing and control hospitals. Results: The results of this work will demonstrate the extent to which telehealth use is associated with total healthcare expenditures for sepsis care. Conclusion: These findings will be important to inform future policy initiatives to improve sepsis care in rural EDs. Clinical Trial Registration: NCT05072145 (ClinicalTrials.gov).

Rewards and recognition for Canadian distributed medical education preceptors: a qualitative analysis

Background: Recognition of Distributed Medical Education (DME) preceptors by medical institutions ensures that important community-based training opportunities remain available to learners. Yet the literature seldom explores what rewards are meaningful to this population of teachers. The goal of our national project was to provide guidance to medical schools about the financial remuneration and non-financial rewards that are most valued by DME preceptors. Methods: In this qualitative study, we invited DME faculty members from all Canadian medical schools to participate in semi-structured interviews. Participants with a range of medical specialties, stages of career, and geographic locations were interviewed via Zoom videoconferencing. The sessions in English and French were audio-recorded and transcribed. We used line-by-line inductive coding and thematic analysis to examine participant talk about meaningful preceptor recognition. Results: Fourteen participants from multiple provinces were interviewed. Results indicated that the DME faculty are a diverse group of people with diverse needs. Most of the interviewees appreciated the rewards and recognition provided by their institutions but felt that there are areas for improvement. Recognition is not necessarily monetary and should be tailored to the needs and the values of the recipient. Other themes included: benefits and challenges of being a preceptor, current institutional structures and supports, and the impact of the pandemic on preceptors. Conclusions: The interviews highlighted the importance placed by preceptors on personal rewards and a wide variety of forms of recognition. Based on the findings, we suggest specific steps that medical institutions can take to support, engage, and recognize DME faculty.

Currencies of recognition: What rewards and recognition do Canadian distributed medical education preceptors value?

Background: Medical schools spend considerable time, effort, and money on recognition initiatives for rural and distributed medical education (DME) faculty. Previous literature has focused on intrinsic motivation to teach and there is little in the literature to guide institutional recognition efforts or to predict which items or types of recognition will be most appreciated.

Methods: To better understand how rural and DME faculty in Canada value different forms of recognition, we asked faculty members from all Canadian medical schools to complete a bilingual, national online survey evaluating their perceptions of currently offered rewards and recognition. The survey received a robust response in both English and French, across nine Canadian provinces and one territory.

Results: Our results indicated that there were three distinct ways that preceptors looked at recognition; these perspectives were consistent across geographic and demographic variables. These “clusters” or “currencies of recognition” included: i) Formal institutional recognition, ii) connections, growth and development, and iii) tokens of gratitude. Financial recognition was also found to be important but separate from the three clusters. Some preceptors did value support of intrinsic motivation most important, and for others extrinsic motivators, or a mix of both was most valued.

Conclusions: Study results will help medical schools make effective choices in efforts to find impactful ways to recognize rural and DME faculty.

Energizing scholarly activity in a regional medical campus

Medical education is increasingly delivered at distributed sites away from Academic Health Sciences Centres. The Council of Ontario Faculties of Medicine recommends schools develop resources and metrics to foster regional campus scholarly activity. Opportunities for distributed program trainees must support learning core skills in research and critical appraisal to comply with medical school accreditation standards and to develop their interests and skills in scholarly work for their future medical careers. We describe a scholarly activity program that is a template for distributed campuses or regional teaching sites seeking to increase learner and faculty engagement and research productivity.

28 Review of Operative and Non-Operative Time-Use During General Anaesthetic Cases in a Busy Surgical Oncology Service

Aim

To review theatre running times of all general anaesthetic cases performed in a single theatre during a set six-week period. We intend to assess the division of theatre time between operative and non-operative tasks and review areas of improvement in our department.

Method

The data was collected concurrently by a member of the surgical team (AB) at the time of surgery. Date, surgical procedure, and time elapsed from knife-to-skin (KTS) to skin closure were monitored between the hours 08:30–17:00. Results were reviewed and presented graphically using Microsoft Excel. Instances of theatre over-running were identified, and these outliers were reviewed in more detail.

Results

We identified two main time management issues in our department. The first occurs prior to the first procedure which highlighted significant delays with only one instance of KTS at 08:30 during the period of data collection. The second notable issue is the pattern of delays. There was a trend toward longer delays between cases as the day proceeds.

Conclusions

Upon review of our data, we were able to identify possible areas of improvement in the time management of our theatre group. These improvements will allow for accurate theatre planning which should be a priority for all stakeholders given the significant waiting lists created by the COVID19 pandemic. There are many peer-reviewed methods of improving the efficiency of departments such as ours. Further work is required to discuss targets for improvement with relevant stakeholders and to implement PDSA cycles to assess the impact of implemented changes in our theatre.

24 Mediastinal Ectopic Parathyroid Adenoma Causing Malignant Hypercalcaemia in a Young Female - a Case Report and Review of Literature

Ectopic parathyroid tissue can pose difficulties in diagnosis and management of patients with hyperparathyroidism. Due to the embryological origins of the inferior parathyroid glands from the 3rd pharyngeal arch where they develop with the thymus; they can have variable anatomical locations, including the anterior mediastinum. While the incidence of ectopic parathyroid glands varies in the literature mediastinal parathyroid tissue is extremely rare. This anatomical variation has important diagnostic and surgical ramifications for patients and is an important topic for trainees in medical endocrinology, endocrine surgery, and cardiothoracic surgery to be aware of.

We present the case of a 22-year-old woman who presented as an emergency with severe hypercalcaemia. Who was subsequently found to have an ectopic mediastinal parathyroid adenoma. She underwent surgery within days of her initial presentation providing her with an immediate cure and restoring her calcium homeostasis. Despite diagnostic and operative challenges, combined care from our endocrine and cardio-thoracic surgical teams ensured an uneventful post-operative recovery for this patient.

Thioether-Based Polymeric Micelles with Fine-Tuned Oxidation Sensitivities for Chemotherapeutic Drug Delivery

Oxidation-sensitive drug delivery systems (DDSs) have attracted attention due to the potential to improve efficacy and safety of chemotherapeutics. These systems are designed to release the payload in response to oxidative stress conditions, which are associated with many types of cancer. Despite extensive research on the development of oxidation-sensitive DDS, the lack of selectivity toward cancer cells over healthy cells remains a challenge. Here, we report the design and characterization of polymeric micelles containing thioether groups with varying oxidation sensitivities within the micellar core, which become hydrophilic upon thioether oxidation, leading to destabilization of the micellar structure. We first used the thioether model compounds, 3-methylthiopropylamide (TPAM), thiomorpholine amide (TMAM), and 4-(methylthio)benzylamide (TPhAM) to investigate the effect of the chemical structures of the thioethers on the oxidation by hydrogen peroxide (H₂O₂). TPAM shows the fastest oxidation, followed by TMAM and TPhAM, showing that the oxidation reaction of thioethers can be modulated by changing the substituent groups bound to the sulfur atom. We next prepared micelles containing these different thioether groups within the core (TP, TM, and TPh micelles). The micelles containing the thioether groups with a higher oxidation sensitivity were destabilized by H₂O₂ at a lower concentration. Micelle destabilization was also tested in human liver cancer (HepG2) cells and human umbilical vein endothelial cells (HUVECs). The TP micelles having the highest oxidation sensitivity were destabilized in both HepG2 cells and HUVECs, while the TPh micelles, which showed the lowest reactivity toward H₂O₂, were stable in these cell lines. The TM micelles possessing a moderate oxidation sensitivity were destabilized in HepG2 cells but were stable in HUVECs. Furthermore, the micelles were loaded with doxorubicin (Dox) to evaluate their potential in drug delivery applications. Among the micelles, the TM micelles loaded with Dox showed the enhanced relative toxicity in HepG2 cells over HUVECs. Therefore, our approach to fine-tune the oxidation sensitivity of the micelles has potential for improving therapeutic efficacy and safety of drugs in cancer treatment.

COVID-19 biomarkers and their overlap with comorbidities in a disease biomarker data model

In response to the COVID-19 outbreak, scientists and medical researchers are capturing a wide range of host responses, symptoms and lingering postrecovery problems within the human population. These variable clinical manifestations suggest differences in influential factors, such as innate and adaptive host immunity, existing or underlying health conditions, comorbidities, genetics and other factors—compounding the complexity of COVID-19 pathobiology and potential biomarkers associated with the disease, as they become available. The heterogeneous data pose challenges for efficient extrapolation of information into clinical applications. We have curated 145 COVID-19 biomarkers by developing a novel cross-cutting disease biomarker data model that allows integration and evaluation of biomarkers in patients with comorbidities. Most biomarkers are related to the immune (SAA, TNF-∝ and IP-10) or coagulation (D-dimer, antithrombin and VWF) cascades, suggesting complex vascular pathobiology of the disease. Furthermore, we observe commonality with established cancer biomarkers (ACE2, IL-6, IL-4 and IL-2) as well as biomarkers for metabolic syndrome and diabetes (CRP, NLR and LDL). We explore these trends as we put forth a COVID-19 biomarker resource (https://data.oncomx.org/covid19) that will help researchers and diagnosticians alike.

Why do few medical students report their experiences of mistreatment to administration?

INTRODUCTION

Over 50% of medical students worldwide report experiencing mistreatment and abuse during their clinical education, yet only a small proportion of students report these concerns to administration. It is unknown how medical students make sense of their experiences of mistreatment and come to decide whether to formally report these experiences. Improved understanding of this phenomenon will facilitate changes at the administrative and institutional levels to better support students.

METHODS

Using Constructivist Grounded Theory, we interviewed 19 current and former medical students from one institution about their experiences with mistreatment and reporting. Data were analysed in an iterative fashion, using focused and theoretical forms of coding.

RESULTS

The decision of whether to report mistreatment is only one phase in the process that students report experiencing when encountering mistreatment. This process can be understood as a journey consisting of five phases: Situating, Experiencing and Appraising, Reacting, Deciding and Moving Forward. Students move through these phases as they come to understand their position as medical learners and their ability to trust and be safe within this institution. Each experience of mistreatment causes students to react to what has happened to them, decide if they will share their experiences and reach out for support. They choose if they are going to report the mistreatment, at what cost and for what outcomes. Students continue through their training while incorporating their experiences into their understanding of the culture in which they are learning and continually resituating themselves within the institution.

DISCUSSION

Student perceptions of trust or mistrust in their educational institution are highly influential when it comes to reporting mistreatment. Interventions designed to support students and decrease exposure to mistreatment may be best focused on increasing organisational trust between students and the medical school.

TELEmedicine as an intervention for sepsis in emergency departments: a multicenter, comparative effectiveness study (TELEvISED Study)

Sepsis is a life-threatening infection that affects over 1.7 million Americans annually. Low-volume rural hospitals have worse sepsis outcomes, and emergency department (ED)-based telemedicine (tele-ED) has been one promising strategy for improving rural sepsis care. The objective of this study is to evaluate the impact of tele-ED consultation on sepsis care and outcomes in rural ED patients. The TELEvISED study is a multicenter (n = 25) retrospective propensity-matched comparative effectiveness study of tele-ED care for rural sepsis patients in a mature tele-ED network. Telemedicine-exposed patients will be matched with non telemedicine patients using a propensity score to predict tele-ED use. The primary outcome is 28-day hospital free days, and secondary outcomes include adherence with guidelines, mortality and organ failure. ClinicalTrials.gov: NCT04441944.

Use of an electronic medical record dashboard to identify gaps in osteoporosis care

Using an electronic medical record (EMR)-based dashboard, this study explored osteoporosis care gaps in primary care. Eighty-four physicians shared their practice activities related to bone mineral density testing, 10-year fracture risk calculation and treatment for those at high risk. Significant gaps in fracture risk calculation and osteoporosis management were identified.

PURPOSE

To identify care gaps in osteoporosis management focusing on Canadian clinical practice guidelines (CPG) related to bone mineral density (BMD) testing, 10-year fracture risk calculation and treatment for those at high risk.

METHODS

The ADVANTAGE OP EMR tool consists of an interactive algorithm to facilitate assessment and management of fracture risk using CPG. The FRAX® and Canadian Association of Radiologists and Osteoporosis Canada (CAROC) tools were embedded to facilitate 10-year fracture risk calculation. Physicians managed patients as clinically indicated but with EMR reminders of guideline recommendations; participants shared practice level data on management activities after 18-month use of the tool.

RESULTS

Eighty-four physicians (54%) of 154 who agreed to participate in this study shared their aggregate practice activities. Across all practices, there were 171,310 adult patients, 40 years of age and older, of whom 17,214 (10%) were at elevated risk for fracture. Sixty-two percent of patients potentially at elevated risk for fractures did not have BMD testing completed; most common reasons for this were intention to order BMD later (48%), physician belief that BMD was not required (15%) and patient refusal (20%). For patients with BMD completed, fracture risk was calculated in 29%; 19% were at high risk, of whom 37% were not treated with osteoporosis medications as recommended by CPG.

CONCLUSION

Despite access to CPG and fracture risk calculators through the ADVANTAGE OP EMR tool, significant gaps remain in fracture risk calculation and osteoporosis management. Additional strategies are needed to address this clinical inertia among family physicians.

OncoMX: A Knowledgebase for Exploring Cancer Biomarkers in the Context of Related Cancer and Healthy Data

PURPOSE

The purpose of OncoMX¹ knowledgebase development was to integrate cancer biomarker and relevant data types into a meta-portal, enabling the research of cancer biomarkers side by side with other pertinent multidimensional data types.

METHODS

Cancer mutation, cancer differential expression, cancer expression specificity, healthy gene expression from human and mouse, literature mining for cancer mutation and cancer expression, and biomarker data were integrated, unified by relevant biomedical ontologies, and subjected to rule-based automated quality control before ingestion into the database.

RESULTS

OncoMX provides integrated data encompassing more than 1,000 unique biomarker entries (939 from the Early Detection Research Network [EDRN] and 96 from the US Food and Drug Administration) mapped to 20,576 genes that have either mutation or differential expression in cancer. Sentences reporting mutation or differential expression in cancer were extracted from more than 40,000 publications, and healthy gene expression data with samples mapped to organs are available for both human genes and their mouse orthologs.

CONCLUSION

OncoMX has prioritized user feedback as a means of guiding development priorities. By mapping to and integrating data from several cancer genomics resources, it is hoped that OncoMX will foster a dynamic engagement between bioinformaticians and cancer biomarker researchers. This engagement should culminate in a community resource that substantially improves the ability and efficiency of exploring cancer biomarker data and related multidimensional data.

Absence of Low-Energy Shape Coexistence in ^{80}Ge: The Nonobservation of a Proposed Excited 0_{2}^{+} Level at 639 keV

The ^{80}Ge structure was investigated in a high-statistics β-decay experiment of ^{80}Ga using the GRIFFIN spectrometer at TRIUMF-ISAC through γ, β-e, e-γ, and γ-γ spectroscopy. No evidence was found for the recently reported 0_{2}^{+} 639-keV level suggested as evidence for low-energy shape coexistence in ^{80}Ge. Large-scale shell model calculations performed in ^{78,80,82}Ge place the 0_{2}^{+} level in ^{80}Ge at 2 MeV. The new experimental evidence combined with shell model predictions indicate that low-energy shape coexistence is not present in ^{80}Ge.

Use of Hologic LOCalizer radiofrequency identification (RFID) tags to localise impalpable breast lesions and axillary nodes: experience of the first 150 cases in a UK breast unit

AIM

To report the outcome of 150 patients using the Hologic LOCalizer RFID (radiofrequency identification) tag system, including the first reported use of RFID tags in the axilla.

MATERIALS AND METHODS

Data were collected prospectively from the first tag insertion (12 June 2019) until 150 consecutive patients had undergone surgery (excision date 9 January 2020).

RESULTS

A total of 177 tags were targeted to 177 malignant lesions in 150 women. Tags were inserted an average of 7.8 days before surgery (range 0-71 days). One hundred and twenty-six tags were targeted to a single lesion in one breast only; the remainder of tags were targeted to multiple lesions in one or both breasts, as well as to axillary lymph nodes. In addition, two cases involved the use of two tags to bracket microcalcification. All except three tags were satisfactorily deployed at their initial intended target. The majority of target lesions were masses (n=142, mean size 13.8 mm), with a range of other targets including post-vacuum-assisted biopsy cavities, marker clips post-neoadjuvant chemotherapy, architectural distortions, and clipped metastatic lymph nodes. All tags were successfully retrieved at surgical excision. Re-excision rate was 8.7%. There were no tag-specific surgical complications.

CONCLUSIONS

The RFID tag system demonstrates many advantages over guidewires, and is effective at targeting axillary lymph nodes and multiple sites within the same breast.

Building Novel Research Capacity in a Regional Medical Campus Emergency Medicine Program: 1.0 Origins and Partnerships

The Emergency Medicine Researchers of Niagara (EMRoN) program is an evolving research incubator with the Niagara Regional Campus (NRC) of McMaster University’s Michael G DeGroote School of Medicine and Niagara Health (NH) that is becoming a productive research organization aligned with the strategic priorities of its partner organizations (NRC and NH). EMRoN is committed to advancing local community health care standards and sharing best practices with provincial and national peers.  In its first two years of operation EMRoN has achieved success in new structures, processes and outcomes that position it well to be a fulsome research organization for years to come.

The relationship between regional medical campus enrollment and rates of matching to family medicine residency

BACKGROUND

The Michael G. DeGroote School of Medicine expanded its medical education across three campus sites (Hamilton, Niagara Regional and Waterloo Regional) in 2007. Ensuring the efficacy and equivalency of the quality of training are important accreditation considerations in distributed medical education. In addition, given the social accountability mission implicit to distributed medical education, the proportion of learners at each campus that match to family medicine residency programs upon graduation is of particular interest.

METHODS

By way of between campus comparisons of Canadian Residency Matching Service (CaRMS) match rates, this study investigates the family medicine match proportion of medical students from McMaster's three medical education campuses. These analyses are further supported by between campus comparisons of Personal Progress Index (PPI), Objective Structured Clinical Examination (OSCE), Medical Council of Canada Qualifying Examination-Part 1 (MCCQE1) performances that offer insight into the equivalency and efficacy of the educational outcomes at each campus.

RESULTS

The Niagara Regional Campus (NRC) demonstrated a significantly greater proportion of students matched to family medicine. With respect to education equivalency, the proportion of students' PPI scores that were more than two SD below the mean was comparable across campuses. OSCE analysis yielded less than 2% differences across campuses with no differences in the last year of training. The MCCQE1 pass rates were not statistically significant between campuses and there were no differences in CaRMS match rates. With respect to education efficacy, there were no differences among the three campuses' pass rates on the MCCQE1 and CaRMS match rates with the national rates.

CONCLUSIONS

Students in all campuses received equivalent educational experiences and were efficacious when compared to national metrics, while residency matches to family medicine were greater in the NRC. The reasons for this difference may be a factor of resident and leadership role-models as well as the local hospital and community environment.

Scholarly activity as a selection criterion in the Canadian Residency Matching Service (CaRMS): A review of published criteria by internal medicine, family medicine, and pediatrics programs

BACKGROUND

Undergraduate medical students seek as much information as possible as to how residency programs select candidates. The Canadian Residency Matching Service (CaRMS) website is one of their primary sources of information. Students may be more competitive in the match if they know whether scholarly activity is used in the selection process by their preferred programs, as described on the CaRMS website.

METHODS

For all 17 Canadian faculties of medicine, 2019 R1 entry internal medicine, family medicine and pediatrics program descriptions were reviewed on the CaRMS website looking for keywords related to scholarly activity.

RESULTS

Forty-one percent of family medicine, 65% of internal medicine and 71% of pediatric programs explicitly stated having interest in applicants with scholarly experience. In Western Canada, 80% of internal medicine and 60% of pediatrics programs included scholarly activity in their CaRMS description of criteria considered in ranking applications. Similarly, in Ontario, 66% of internal medicine and 83% of pediatrics programs mentioned scholarly activity as a valuable quality. In Quebec 100% of family medicine and 50% of pediatrics programs include scholarly activity in their descriptions. Pediatrics and family medicine programs (100%) in Atlantic Canada mentioned scholarly activities but neither of the two Atlantic Canada internal medicine programs mentioned scholarly activities.

CONCLUSION

Undergraduate medical students can use this project to prioritize extracurricular activities and scholarly work to be competitive for application to family medicine, internal medicine and pediatrics residency programs.

Robotic-assisted unicompartmental knee arthroplasty has a greater early functional outcome when compared to manual total knee arthroplasty for isolated medial compartment arthritis

Aims

The primary aim of the study was to compare the knee-specific functional outcome of robotic unicompartmental knee arthroplasty (rUKA) with manual total knee arthroplasty (mTKA) for the management of isolated medial compartment osteoarthritis. Secondary aims were to compare length of hospital stay, general health improvement, and satisfaction between rUKA and mTKA.

Methods

A powered (1:3 ratio) cohort study was performed. A total of 30 patients undergoing rUKA were propensity score matched to 90 patients undergoing mTKA for isolated medial compartment arthritis. Patients were matched for age, sex, body mass index (BMI), and preoperative function. The Oxford Knee Score (OKS) and EuroQol five-dimension questionnaire (EQ-5D) were collected preoperatively and six months postoperatively. The Forgotten Joint Score (FJS) and patient satisfaction were collected six months postoperatively. Length of hospital stay was also recorded.

Results

There were no significant differences in the preoperative demographics (p ⩾ 0.150) or function (p ⩾ 0.230) between the groups. The six-month OKS was significantly greater in the rUKA group when compared with the mTKA group (difference 7.7, p < 0.001). There was also a greater six-month postoperative EQ-5D (difference 0.148, p = 0.002) and FJS (difference 24.2, p < 0.001) for the rUKA when compared to the mTKA. No patient was dissatisfied in the rUKA group and five (6%) were dissatisfied in the mTKA, but this was not significant (p = 0.210). Length of stay was significantly (p < 0.001) shorter in the rUKA group (median two days, interquartile range (IQR) 1 to 3) compared to the mTKA (median four days, IQR 3 to 5).

Conclusion

Patients with isolated medial compartment arthritis had a greater knee-specific functional outcome and generic health with a shorter length of hospital stay after rUKA when compared to mTKA.

Cite this article: Bone Joint Res 2019;9(1):15–22.

Tele-emergency behavioural health in rural and underserved areas

INTRODUCTION

Challenges accessing behavioural health services in rural and underserved areas are compounded by severe shortages of behavioural health specialists, and difficulties placing patients. Tele-emergency (tele-ED) behavioural health is a promising solution for enhancing access to specialists and assisting in patient placement. This paper describes two tele-ED behavioural health models in the Midwest delivering mental- and substance use disorder services to rural and underserved adult populations.

METHODS

We performed an in-depth examination of two tele-ED behavioural health programmes and their consultation processes. We provide a retrospective case-control analysis of patient characteristics, patient diagnoses, and disposition status for each model. Data were collected from 19 spoke hospitals across the two programmes between November 2015 and December 2017.

RESULTS

Tele-ED was activated in 15% of the Avera Health sample and 58% of the Union Hospital sample. This is primarily a reflection of the sample selection process in each model and how each programme is operationalised. Suicide and/or poisoning by drugs were the most frequent diagnoses followed by mood disorders. Rate of transfer to another inpatient facility was much higher for tele-ED cases than controls in both models.

DISCUSSION

This paper describes how two distinct tele-ED behavioural health models operating in unique contexts address challenges in access and placement for patients in rural and underserved areas presenting to EDs with behavioural health conditions. The notable difference in disposition rates between cases and controls is indicative of the impact each model is having on care practices and processes.

One Health operations: a critical component in the International Health Regulations Monitoring and Evaluation Framework

Under the International Health Regulations (IHR, 2005), a legally binding document adopted by 196 States Parties, countries are required to develop their capacity to rapidly detect, assess, notify and respond to unusual health events of potential international concern. To support countries in monitoring and enhancing their capacities and complying with the IHR (2005), the World Health Organization (WHO) developed the IHR Monitoring and Evaluation Framework (IHR MEF). This framework comprises four complementary components: the State Party Annual Report, the Joint External Evaluation, after-action reviews and simulation exercises. The first two are used to review capacities and the second two to help to explore their functionality. The contribution of different disciplines, sectors, and areas of work, joining forces through a One Health approach, is essential for the implementation of the IHR (2005). Therefore, WHO, in partnership with the Food and Agriculture Organization of the United Nations (FAO), the World Organisation for Animal Health (OIE), and other international and national partners, has actively worked on facilitating the inclusion of the relevant sectors, in particular the animal health sector, in each of the four components of the IHR MEF. Other tools complement the IHR MEF, such as the WHO/OIE IHR-PVS [Performance of Veterinary Services] National Bridging Workshops, which facilitate the optimal use of the results of the IHR MEF and the OIE Performance of Veterinary Services Pathway and create an opportunity for stakeholders from animal health and human health services to work on the coordination of their efforts. The results of these various tools are used in countries' planning processes and are incorporated in their National Action Plan for Health Security to accelerate the implementation of IHR core capacities. The present article describes how One Health is incorporated in all components of the IHR MEF.

Single Portion Packaging and the Use of User Test Protocols to Determine Patient Accessibility

In 2015, the UK National Health Service (NHS) established a taskforce to review single portion food and beverage packaging, which has been identified as a potential challenge to users in hospitals. Hence, a study was undertaken to determine the suitability and accessibility of the current single portion packs. The packaging was assessed using ISO 17480 (Guidelines for Accessible Packaging), Annex D. The standard determines a pass or fail of packaging opening asking a panel 20 older adults to open a pack. A pack is recorded as a failure if within the 20 people cohort, there is an example of pack being unable to be opened within the time limit (defined as 1 minute) or the overall satisfaction score ranks below 3 on a 5-point Likert scale. Ten standard single portion packaging items were randomly selected for testing. The packs were chosen to reflect a broad range of food and beverage and packaging types. The results showed that the standard provided useful assessment data, identifying that 70% of the packs were so poorly designed that they failed to pass the standard, with 50% of the packs having examples that were unopenable by the participants, whilst a further 20% rated poorly for satisfaction.

Abstract 2463: Prototype open-access biomarker knowledgebase for genetic tests for breast cancer

Cancer biomarkers have become integral components of many clinical protocols and research studies. Nonetheless there still is an urgent need for more accurate, less invasive, and cost-effective biomarker tests to advance precision oncology. Despite considerable success in the preclinical setting, most candidate biomarker tests have yet to receive regulatory clearance or approval and gain market acceptance. To better understand the challenges facing modern biomarker research and facilitate access to biomarker-related information, this study aims to delineate the paths to approval of genetic tests for breast cancer. Public databases were searched to identify approved tests and respective biomarkers. A prototype format for unified biomarker information was developed iteratively due to the highly variable presentation of this data. A knowledgebase of FDA-approved genetic biomarkers for breast cancer was built as a pilot implementation of this format. This model is extensible to a larger database of biomarkers to be hosted in OncoMX (https://oncomx.org), which integrates cancer mutation, differential expression, literature mining, and pathway information. Fields in the prototype database were populated based on findings from the FDA website, PubMed, and other open-source databases. The resulting dataset is structured with the corresponding readme following the BioCompute Object (BCO) model. This BCO-compliant approach enables provenance capture and transparency of data processing, both of which are critical to large-scale data integration efforts. The adherence to BCO standards is expected to enhance the usability of the resulting data and to streamline the subsequent integration of multiple biomarker datasets. In the rapidly evolving field of oncologic biomarker research, this open-source biomarker knowledgebase offers clinicians and researchers a streamlined access to genetic tests information including corresponding genes, guides to evidence, clinical trial data, links to archival databases, and context for the behavior of the implicated gene in other disease and normal processes.

Citation Format: Dara Baker, Natalie Fedorova Abrams, Amanda Bell, Maureen Colbert, Hayley Dingerdissen, Evan Holmes, Samir Gupta, Robel Kahsay, Heather Kincaid, David Liu, A. S. M. Ashique Mahmood, Frédéric B. Bastian, Marc Robinson-Rechavi, Elena Schwartz, K. Vijay-Shanker, Daniel Crichton, Raja Mazumder. Prototype open-access biomarker knowledgebase for genetic tests for breast cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 2463.

Use Of Telemedicine For ED Physician Coverage In Critical Access Hospitals Increased After CMS Policy Clarification

There is a chronic shortage of physicians to cover emergency departments (EDs) in critical access hospitals. A 2013 memorandum from the Centers for Medicare and Medicaid Services clarified that a telemedicine physician could fulfill the regulatory requirements for physician backup when advanced practice providers were at telemedicine-equipped critical access hospital EDs but local physicians were not. In a sample of nineteen hospitals, coverage schedules in 2016 showed that seven had begun the use of tele-ED physician backup for advanced practice providers, decreasing local physician coverage in their EDs. These seven hospitals tended to have decreasing ED staffing costs, while the hospitals not applying this policy showed continually increasing staffing costs over time. Telemedicine also provided other benefits, such as improved physician recruitment and retention. In the future, more critical access hospitals will likely use telemedicine to provide physician backup for advanced practice providers staffing the ED.

The Association Between Telemedicine and Emergency Department (ED) Disposition: A Stepped Wedge Design of an ED-Based Telemedicine Program in Critical Access Hospitals

PURPOSE

To study the relationship between the availability and activation of emergency department-based telemedicine (teleED) and patient disposition in Critical Access Hospitals (CAHs).

METHODS

A non randomized stepped wedge design examined 133,396 ED visits in 15 CAHs that subscribe to a single teleED provider. Data were available for at least 12 months prior to teleED implementation and at least 12 months of post-implementation. Primary analyses were conducted using multinomial logistic regression models with teleED availability (indicator of post-teleED implementation period) and activation (indicator of utilization of teleED service) predicting discharge disposition adjusting for age, sex, and clinical diagnosis.

RESULTS

Patients for whom teleED was activated were more likely to be transferred [adjusted odds ratio (aOR) = 12.04; 95% confidence interval (CI), 10.97-13.21] and more likely to be admitted to the local hospital (aOR = 3.23; 95% CI, 2.84-3.67) than to be routinely discharged. This pattern was confirmed for patients presenting with chest pain, mental illness, and injury/poisoning. However, in the period following teleED implementation, patients presenting to EDs after telemedicine was available, but not necessarily utilized, were less likely to be admitted to the local hospital (aOR = 0.79; 95% CI, 0.76-0.82) than to be routinely discharged.

CONCLUSIONS

Telemedicine availability in CAH EDs is associated with a higher likelihood of routine discharges from the ED possibly due to changes in care associated with teleED implementation. The relationship between teleED use and disposition may be related to selection in activating teleED for cases more likely to require hospital inpatient care.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.