A Systematic Review of Metrics Utilized in the Selection and Prediction of Future Performance of Residents in the United States

Background Aligning resident and training program attributes is critical. Many programs screen and select residents using assessment tools not grounded in available evidence. This can introduce bias and inappropriate trainee recruitment. Prior reviews of this literature did not include the important lens of diversity, equity, and inclusion (DEI). Objective This study's objective is to summarize the evidence linking elements in the Electronic Residency Application Service (ERAS) application with selection and training outcomes, including DEI factors. Methods A systematic review was conducted on March 30, 2022, concordant with PRISMA guidelines, to identify the data supporting the use of elements contained in ERAS and interviews for residency training programs in the United States. Studies were coded into the topics of research, awards, United States Medical Licensing Examination (USMLE) scores, personal statement, letters of recommendation, medical school transcripts, work and volunteer experiences, medical school demographics, DEI, and presence of additional degrees, as well as the interview. Results The 2599 identified unique studies were reviewed by 2 authors with conflicts adjudicated by a third. Ultimately, 231 meeting inclusion criteria were included (kappa=0.53). Conclusions Based on the studies reviewed, low-quality research supports use of the interview, Medical Student Performance Evaluation, personal statement, research productivity, prior experience, and letters of recommendation in resident selection, while USMLE scores, grades, national ranking, attainment of additional degrees, and receipt of awards should have a limited role in this process.

Harmonization of criteria and terminology in fetal rat skeletal evaluations

BACKGROUND

A survey of laboratories in North American and Europe that routinely conduct fetal skeletal examinations was performed with the purpose of (1) understanding current terminology used for classifying skeletal findings in developmental toxicity (DT) studies and (2) understanding the criteria used to identify relatively common findings that sufficiently deviate from normal. The goal was to promote terminology harmonization and improve interlaboratory consistency in the criteria used to identify developmental anomalies.

METHODS

The survey, designed based on terminology for developmental anomalies recommended by an international collaboration (Makris et al., Congenital Anomalies, 2009;49(3):123-246), was conducted by a subgroup (authors of this publication) of the Royal Society of Biology's International Register of Fetal Morphologists (IRFM).

RESULTS

Individual and summarized anonymized responses are provided here. The authors, who are expert fetal morphologists with experience performing fetal examinations, reviewed the responses and generated recommendations on preferred terminology and criteria for determining when morphological variations deviate from normal and warrant recording of the findings for skeletal observations in Sprague Dawley (SD) fetal rats. The objective of these recommendations is to complement Makris et al. (Congenital Anomalies, 2009;49(3):123-246).

CONCLUSION

The broad application will improve interlaboratory harmonization of recording fetal skeleton findings in developmental toxicity studies intended for regulatory submissions, including SEND (Standard for Exchange of Nonclinical Data).

Work-related injuries and attendance at a Canadian regional emergency department

BACKGROUND

Monitoring trends in the burden of illness and injury attributable to work is key in assessing occupational health hazards; however, New Brunswick does not participate in the Canadian National Ambulatory Care Reporting System which itself does not collect details of occupation and industry.

AIMS

We set out to determine the proportion of emergency department attendances that were attributable to a work-related cause. We also wanted to evaluate the recording of occupation in the electronic health record system, and to describe the characteristics of patients with a work-related presentation.

METHODS

A retrospective observational study over a 1-year period was conducted using an administrative database obtained from Canadian Emergency Department Information System. Descriptive statistics are used to present the analysis of categorical and continuous data.

RESULTS

A total of 49 365 patients were included for analysis. Two per cent of patients presented with a self-reported work-related condition. Health care and social assistance, construction, retail trade and manufacturing were the most common industries reported by patients.

CONCLUSIONS

This study found the rate of work-related medical conditions to be substantially less than expected, and that occupation was not captured for any patients presenting to the emergency department with a work-related condition, despite a field being available in the electronic health record registration system. We were able to analyse the industry sectors for work-related presentations. The recording and coding of occupation and industry would significantly benefit occupational epidemiology in emergency medicine as well as potentially improving patient outcomes and health system efficiencies.

A-29 Consistency of Clinical Profiles Across Repeat Concussions

Purpose: To evaluate the association between concussion profiles within individual patients across repeat concussions. Methods: Retrospective chart review of 100 adolescents (57.3% male) aged 10–21 years presenting to a concussion clinic within 30 days of injury for two separate injuries between 2011 and 2021. Clinicians conducted multidomain assessments including vestibular/ocular motor screening, neurocognitive testing, symptoms and medical/injury history to adjudicate the following concussion clinical profiles: vestibular, ocular, post-traumatic migraine, cognitive fatigue, and anxiety/mood. Chi-square tests with odds ratios (OR) and 95% confidence intervals (CI) were conducted to examine the association of each profile from the first to the second concussion. Results: Chi-square analyses supported associations between the first and second concussions (time between injuries = 667.1 ± 529.2 days) for the vestibular (χ2 = 10.08, p < 0.01, OR = 3.75, 95% CI = 1.63–8.62), ocular (χ2 = 6.51, p < 0.05, OR = 3.51, 95% CI = 1.30–9.46), and migraine (χ2 = 11.056, p < 0.001, OR = 4.01, 95% CI = 1.73–9.29) profiles, such that having that profile at first concussion was associated with increased likelihood of having the same profile at second concussion. Chi-square analyses for cognitive fatigue and anxiety/mood were not significant. Conclusions: Vestibular, ocular, and migraine profiles at first injury predicted their presence at second injury, which may reflect consistent underlying risk factors (e.g., sex migraine history) for these profiles. Conversely, no association was supported for anxiety/mood and cognitive fatigue profiles across injuries. The present findings are the first to demonstrate that certain profiles are likely to recur after repeat concussion. This information can be used by clinicians to inform earlier, targeted treatment recommendations for associated profiles.

Intravascular lithotripsy during percutaneous coronary intervention for calcified coronary lesions: analysis of patient and procedural characteristics and clinical outcomes

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction

Coronary artery calcification is frequently encountered during percutaneous coronary intervention (PCI). It can reduce PCI success and increase intra-procedural and post-procedural complications, including stent embolization, under-expansion and mal-apposition. Intravascular lithotripsy (IVL) is a new tool developed to treat calcified coronary lesions.

Purpose

Retrospective analysis of all cases of intravascular lithotripsy performed within our local health district to examine patient and procedural characteristics and clinical outcomes.

Methods

All patients undergoing PCI with intravascular lithotripsy between September 2019-August 2021 within our local health district were analysed. Patient and procedural characteristics and clinical outcomes were recorded.

Results

67 patients (50 men) were included with mean age 71.4 ± 8.7years. Risk factors prevalence included smoking (34%), hypertension (82%), dyslipidaemia (69%) and diabetes (46%). Trans-radial artery access was used in 38 patients (57%). IVL was performed most commonly in the left anterior descending artery (52%),[Figure 1]. IVL was utilised in 9 chronic total occlusions and 12 bifurcation lesions. Intracoronary (IC) imaging was performed in 59 patients (88%), intravascular ultrasound in 41(61%) and optical coherence tomography in 18 (27%). 41 (69%) patients had imaging performed pre and post IVL and post PCI.  IC imaging identified 14 cases with 270º calcification arc and 45 cases with 360º arc. Nine cases (13.4%) required rotational atherectomy prior to IVL (most commonly 1.75mm burr). Mean reference vessel diameter was 3.2 ± 0.3mm. Mean lesion length was 36.3 ± 16.5mm. Mean pre-PCI stenosis was 85.5 ± 10.8%. Drug eluting stents were successfully deployed in 57 cases (85%), 10 had balloon angioplasty alone. Mean stent length was 39.2 ± 17.8mm. Mean post-PCI stenosis was 4.5 ± 13.3% (median 0%). Figure 2 shows a statistically significant increase in minimum lumen diameter and minimum lumen area post-IVL and minimal-stent-area (MSA) post-PCI. Mean stent expansion was 83%. Mean screening time 35.8 ± 17.8 minutes with mean contrast used 207.3 ± 78.7mL. No sustained arrhythmias or side-branch loss occurred. Vessel rupture was recorded in one patient necessitating urgent cardiac surgery (due to oversized balloon) and in 4 cases the IVL balloon could not cross the lesion.

Conclusion

Our experience shows that IVL is safe and effective and facilitates stent delivery and expansion. Intracoronary imaging is important to determine the need for calcium modification and evaluate its success prior to stent delivery and to confirm optimised stent expansion. Abstract Figure. Breakdown of PCI Artery  Abstract Figure. IC Dimensions Pre/Post IVL/Post PCI

Value of Standardized Testing in Surgical Training

Standardized testing remains a cornerstone of assessment in surgical education. Summative standardized tests make up a bulk of the certification requirements that encompasses demonstration of efficient, safe application of clinically relevant surgical knowledge and skills. Formative standardized tests serve similar role to guide teaching endeavors for the programs and comparison of individual trainees on a national level. Ongoing rigorous psychometric evaluations of the standardized tests ensure reliability and validity; however, standardized tests are not without their limitations and biases.

Efficacy of Virtual Case-Based General Surgery Clerkship Curriculum During COVID-19 Distancing

OBJECTIVE

The COVID-19 pandemic created a paradigm shift in medical education with a reliance upon alternative teaching methods to deliver meaningful surgery clerkship content. This study examines the efficacy of a novel, case-based virtual surgery clerkship curriculum to determine its impact on student experience during quarantine.

STUDY DESIGN

Sixteen third-year medical students enrolled in the General Surgery clerkship between April through June 2020 during COVID-19 distancing at a quaternary medical center (Cleveland Clinic, Cleveland, OH) participated in this study. Course surveys, including a 10-question curriculum-based multiple-choice assessment, were administered before and after the clerkship. Analyses include student self-perception of readiness to see a surgical consult independently, students' interest in pursuing a General Surgery residency, and improvement of surgical knowledge.

RESULTS AND CONCLUSION

On a 5-point Likert scale, students felt significantly more assured in their ability to independently assess a surgical consult by the end of the course. Five (31%) students reported an influence of the curriculum on their personal interest in a career in General Surgery. Mean scores on the curriculum-based knowledge assessment increased. These findings highlight that a virtual platform can be a reliable alternative adjunct that delivers surgical content and positively impacts student experience.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s40670-020-01126-5.

Impact of cardiac rehabilitation on 3 year outcomes amongst patients after acute coronary syndrome: (ACS) SNAPSHOT ACS follow-up study

Background

Cardiovascular disease is the leading cause of disease burden globally. With advancements in medical and surgical care more people are surviving initial acute coronary syndrome (ACS) and are in need of secondary prevention and cardiac rehabilitation (CR). Increasing availability of high quality individual-level data linkage provides robust estimates of outcomes long-term.

Purpose

To compare 3 year outcomes amongst ACS survivors who did and did not participate in Australian CR programs.

Methods

SNAPSHOT ACS follow-up study included 1806 patients admitted to 232 hospitals who were followed-up by data linkage (cross-jurisdictional morbidity, national death index, Pharmaceutical Benefit Schedule) at 6 and 36 months to compare those who did/not attend CR.

Results

In total, the cohort had a mean age of 65.8 (13.4) years, 60% were male, only 25% (461/1806) attended CR. During index admission, attendees were more likely to have had PCI (39% v 14%, p<0.001), CABG (11% v 2%, p<0.001) and a diagnosis of STEMI (21% v 5%, p<0.001) than those who did not attend. However, there was no significant difference between CR attendees/non-attendees for risk factors (LDL-cholesterol, smoking, obesity). Only 19% of eligible women attended CR compared to 30% of men (p<0.001). At 36 months, there were fewer deaths amongst CR attendees (19/461, 4.1%) than non-attendees (116/1345, 8.6%) (p=0.001). CR attendees were more likely to have repeat ACS, PCI, CABG at both 6 and 36 months (Table). At 36 months, CR attendees were more likely to have been prescribed antiplatelets (78% v 53%, p<0.001), statins (91% 73%, p<0.001), beta-blockers (11% v 13%, p=0.002) and ACEI/ARBs (72% v 61%, p<0.001) than non-attendees.

Conclusions

Amongst Australian ACS survivors, participation in CR was associated with less likelihood of death and increased prescription of pharmacotherapy. However, attendance at CR was associated with higher rates of repeat ACS and revascularisation.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): New South Wales Cardiovascular Research Network, National Heart Foundation

The impact of socioeconomic status on secondary prevention of the acute coronary syndrome

Background

Although socioeconomic status (SES) has been reported to be associated with health inequities, there are limited studies exploring the association between SES and secondary prevention of acute coronary syndrome (ACS) in countries with universal health cover.

Purpose

The aim is to examine whether SES has an impact on the secondary prevention of ACS in Australia.

Methods

Australian SNAPSHOT ACS data (2012) and its 18-month follow-up data were linked to admissions data from 6 jurisdictions covering all states and territories, national death index and Medicare Pharmaceutical Benefits Scheme data covering up to 3 years post-discharge. The five SES groups (lowest in Group 1 and highest in Group 5) were derived from the Australian Bureau of Statistics Socio-Economic Indexes for Areas (SEIFA) using the residential postcode at baseline. Outcomes were cardiac rehabilitation (CR) participation and smoking rate at 18 months post discharge as well as the use of ≥3 of the 4 indicated medications, all-cause death and cardiovascular disease (CVD) rates by 36 months of discharge. Outcomes were compared between the groups using the multilevel logistic regression with covariates of SES (5 groups), sex, GRACE risk score (4 groups), ACS diagnosis (STEMI/NSTEMI/UA) and the jurisdictions where the admissions data were linked.

Results

Of 1655 patients with ACS (mean age 68±13.5 yrs, 65% were male), who were discharged from hospital alive and had linked data available, 353 (21%) were in SES Group 1 (lowest SES), 369 (22%) in Group 2, 382 (23%) in Group 3, 296 (18%) in Group 4 and 255 (15%) in Group 5 (highest SES). Baseline clinical characteristics were comparable across the five SES groups. At 18-month after discharge, 1014 (61%) patients were followed-up with comparable loss to follow-up in each group. After adjustment, fewer patients in the lower SES groups (Groups 1 and 2) had participated in CR than those in the highest SES group (Group 5) (OR (95% CI): 0.60 (0.36, 0.99) and 0.56 (0.35, 0.91), respectively). Moreover, the odds of smoking was greater in Group 3 than Group 5 (2.60 (1.15, 5.89)) but no trend was found across the groups. By 36 months of discharge after adjustment, there was no difference in the odds of using ≥3 out of 4 medications between the SES groups. Despite this, patients in Groups 1 and 2 were significantly more likely to die than those in the highest SES group (1.96 (1.19, 3.21) and 1.91 (1.19, 3.07), respectively). The odds of CVD readmission did not differ across SES groups.

Conclusion

This study suggests that patients with low SES were less likely to participate in CR programs and more likely to die than those with high SES. Smoking rates varied between patients with intermediate and high SES but no trend was found across the groups. Despite the universal health cover available, inequity between the SES groups still exist. Future research is needed to further explore strategies to help close the evidence-practice gaps.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Australian National Heart Foundation Postdoctoral Fellowship

A-40 Predictors of Failed Effort Testing at Initial Clinic Visit for Concussion Rehabilitation and Outcomes

Objective

Neuropsychological evaluation of concussion typically includes performance validity testing to assess effort. The aim of this study was to explore the usefulness of effort testing as part of initial screening for concussion rehabilitation, including determining the factors that predict effort testing and evaluate outcomes between “good effort” and “failed effort” groups.

Method

Records of 76 patients aged 16–66 years old (M = 40.58 years, SD = 14.18) seen for rehabilitation of non-sport concussion from 2018–2019 were reviewed. Patients completed clinical interview, neurocognitive screening (ImPACT), effort testing (Word Memory Test), vestibular/oculomotor screening (VOMS), and the post-concussion symptom scale (PCSS). A logistic regression (LR) was conducted to predict effort, with predictors including mental health history, secondary gain, work injury, days post-injury, and PCSS. A series of one-way ANOVAs evaluated outcomes from concussion rehabilitation between the good and failed effort groups.

Results

Failed effort occurred in 42% of cases. The LR accurately classified 81.8% of individuals, with mental health history (p = .01) and PCSS (p = .02) as the only significant predictors of effort. There were no differences in recovery time (p = .56) between effort groups, but the failed effort group took longer to return to work (p = .03). Half of individuals who failed effort were seen until discharge, and 69% of them reported no symptoms/mild symptoms at discharge.

Conclusions

Failure of effort testing was predicted by a history of mental health and high symptom burden. Individuals who fail effort testing at initial visit for concussion rehabilitation take longer to return to functional activity but are capable of achieving recovery with compliance and appropriate rehabilitation.

Educational Targets to Reduce Medication Errors by General Surgery Residents

OBJECTIVE

Hospitalized patients are exposed to more than 1 medication error per day, but there are limited data concerning the factors associated with medication order errors made by general surgery residents. The objective of this study was to identify patterns in medication order errors amongst general surgery residents, which may provide educational targets to reduce medication errors by this population of providers.

DESIGN

This study used a retrospective cohort design to review inpatient medication orders placed via a computerized physician order entry system by general surgery residents at a single academic medical center from July 2011 to February 2018.

SETTING

A single large academic medical center located in the Midwest, United States.

PARTICIPANTS

General surgery residents completing residency between July 2011 and February 2018 and their respective inpatient medication orders.

RESULTS

Of 571,811 included medication orders placed by 169 unique general surgery residents, 4.2% (n = 24,177) triggered pharmacist intervention, and 11 (0.001%) resulted in significant near-miss events. Of orders requiring pharmacist intervention, most were either duplicate therapies (n = 8703, 36.1%) or errors in renal dosing (n = 7576, 31.3%). Error rates were higher within pharmaceutical classes ordered less frequently, with the notable exception of antimicrobials and anticoagulants, which accounted for 20.1% (n = 5280) and 13.5% (n = 3270) of all order errors, respectively. In a multivariable model, errors were more likely to occur in the intensive care unit versus other units (OR = 1.21, 95%CI = 1.14-1.29) and in August versus other months (OR = 1.09, 95%CI = 1.01-1.17), but were independent of other resident and order characteristics.

CONCLUSIONS

This study identified that resident medication order errors are common and are associated with specific therapeutic classes, the beginning of academic years, and intensive care unit patients. These findings represent potential targets for educational interventions and highlight the role of interdisciplinary teams in providing quality surgical care.

How We Do It: Creation of a Low-Cost Endoscopic Skills Model for Fundamentals of Endoscopic Surgery Training

OBJECTIVE

To design a low cost, high fidelity endoscopic skills model to help surgical trainees pass the Fundamentals of Endoscopic Surgery (FES) testing.

DESIGN

A homemade synthetic colon model was designed using liquid silicon and other commercially available products. The construction and design of the model is described here. The model was then successfully integrated into our simulation curriculum and endoscopic skills training modules.

SETTING

Cleveland Clinic Foundation, Cleveland, Ohio; large academic quaternary referral institution.

PARTICIPANTS

PGY 1-5 general surgery residents preparing for Fundamentals of Endoscopic Surgery testing.

RESULTS

A versatile, high fidelity model was designed for a total cost of approximately 25 dollars per unit. The model can be used with clinical endoscopic towers and easily integrated into an institution's simulation and endoscopic training curriculum. The flexibility of design allows trainees to practice all of the key motor skills necessary for FES examination success.

CONCLUSIONS

A homemade endoscopic colon model can be constructed at an affordable price point using commercially available materials. These models have significant versatility, low cost, and flexibility of design allowing for easy incorporation into a surgical residency simulation training program.

4938Left ventricular global longitudinal strain recovery predicts scar size reduction and systolic remodelling post ST-elevation myocardial infarction

Background

Left ventricular (LV) strain has prognostic utility following ST-elevation myocardial infarction (STEMI); however, serial changes in LV strain has not been evaluated post-infarct. We sought to determine the relationship between post-STEMI transthoracic echocardiographic (TTE) LV global longitudinal strain (GLS) and cardiac magnetic resonance (CMR) imaging derived scar size and LV systolic remodelling.

Methods

Following revascularisation, 172 first STEMI patients (85% male, 56.9±10.7 years) had paired TTE for GLS, and CMR to evaluate scar size and LV systolic function at baseline (2–7 days) and follow-up (8–10 weeks). Patients were divided into 3 groups according to absolute baseline GLS: group 1 (GLS ≥16%), group 2 (12%< GLS <16%), group 3 (GLS ≤12%). GLS recovery was defined as ≥10% increase in GLS at follow-up, excluding patients with normal baseline GLS. LV systolic adverse remodelling was defined as ≥15% increase in LVESV. LV systolic reverse remodelling was defined as ≥15% decrease in LVESV. Scar reduction was defined as ≥30% decrease in scar size.

Results

Group 1 and 2 had smaller follow-up scar size and higher LVEF compared to group 3 (p<0.0001 for both, see table). There was no difference in scar size reduction or systolic reverse remodeling among the baseline GLS groups (p>0.05 for both). Importantly, no patients from group 1 demonstrated systolic adverse remodelling. Relative change in GLS is significantly correlated with changes in LVEF (r=0.354, p<0.0001) and scar size (r=−0.262, p<0.0001), see figure. On multivariate binary logistic analysis, patients who demonstrated GLS recovery had greater reduction in scar size (OR=2.77 (1.09–7.01), p=0.032) and LV systolic reverse remodelling (OR=9.63 (1.21–76.41), p=0.032).

Follow-up parameters within GLS groups All patients (n=172) Group 1 (n=47) Group 2 (n=72) Group 3 (n=53) Follow-up GLS, % 16.02±3.44 19.38±1.90 16.36±2.09 12.57±2.69 GLS recovery, n 110 (64%) 19 (40%) 53 (74%) 38 (72%) Follow-up scar size, % 7.67±5.40 5.01±3.38 6.27±3.73 12.02±6.24 Follow-up LVEF, % 51.80±10.20 57.83±6.95 54.14±8.02 43.26±9.83 Data presented as mean ± SD or n (%).

Correlation graphs for change in GLS

Conclusion

Stratification of STEMI patients by baseline GLS was a determinant of CMR scar size as well as LV systolic function. However, the evaluation of GLS recovery could provide additional insights into reduction in scar size and LV systolic remodelling, both important prognostic markers. Thus, echocardiographic serial GLS evaluation may be a relevant non-invasive parameter, that is cheaper and more widely available for monitoring STEMI patients and guiding therapy.

P4343Reconciling acute coronary syndrome diagnoses between linked administrative data and hospital medical records in medical research

Background/Introduction

Administrative data incorporating the International Classification of Diseases 10th Revision (ICD-10) is commonly used in cardiac research. Using patient records, diagnoses are systematically coded by trained coders who have limited/no clinical experience. Therefore, it is important to understand how systematically coded cardiac diagnoses compare with clinically assessed diagnoses to better analyse and interpret studies that have used linked administrative data to adjudicate patient's diagnosis.

Purpose

To assess the agreement between the acute coronary syndrome (ACS) diagnoses according to linked data compared to those extracted from hospital medical records by clinicians participating in a national registry and determine the factors associated with diagnoses disagreement.

Methods

The rate of ST-elevation myocardial infarction (STEMI), non-STEMI (NSTEMI) and unstable angina (UA) obtained from the medical records, from admission to discharge, for the nationwide SNAPSHOT ACS audit in 2012 were compared to the corresponding ICD-10 Australian Modification (ICD-10-AM) codes using linked data from 6 jurisdictions covering all Australian states (6) and territories (2). The proportions of the overall agreement (OA), the positive agreement (PA) and the Cohen's weighted kappa and the 95% confidence interval (CI) were derived using both data sources for STEMI, NSTEMI and UA individually, where kappa≥0.8 confers strong agreement and 0.6≤kappa<0.8 moderate agreement. The factors associated with the diagnostic disagreement were explored using multilevel multivariable logistic regression model (backward selection method), accounting for the hospital clustering effect.

Results

Overall, 3130 patients had both medical records and linked data available for comparison. The degree of agreement was greatest for STEMI and lowest for UA (STEMI: OA=97%, PA=85%, kappa (95% CI)=0.84 (0.81, 0.87); NSTEMI: OA=91%, PA=81%, kappa (95% CI)=0.76 (0.73,0.79); UA: OA = 81%, PA=53%, kappa (95% CI)=0.41 (0.38, 0.45)). Further, the independent factors associated with the disagreement between the medical records and the linked data were the diagnosis of UA (UA vs. STEMI (odds ratio (95% CI)): 6.85 (4.12, 11.40)), not receiving revascularisation (2.27 (1.69, 3.03)), and the state where the ICD-10-AM was coded (p=0.007) (see Figure).

Figure 1

Conclusion

This study suggests that the agreement between the systematically coded diagnoses from linked administrative data and the diagnosis from the clinical assessment is greater in patients who received revascularisation and worse in those with UA. Also, the degree of agreement varies between states. As the linked data and the ICD codes are being used more often in research to support the evidence-based policies and practice, more attention is needed in testing and improving the accuracy of the ICD-10 codes as well as the ICD-11 codes that are soon to be introduced.

Acknowledgement/Funding

KH is funded by Heart Foundation Postdoctoral Fellowship. SNAPSHOT data linkage project was funded by the NSW Heart Foundation CVRN Project Grant

P2708Clopidogrel versus ticagrelor on coronary microvascular and peripheral endothelial function after non-ST elevation acute coronary syndrome: a randomised trial

Background

Ticagrelor has been shown to reduce microvascular injury and improve peripheral endothelial function compared to clopidogrel in ST-elevation myocardial infarction and stable patients. However, comparable data is lacking in non-ST elevation acute coronary syndromes (NSTE-ACS).

Purpose

To investigate the effects of clopidogrel versus ticagrelor on coronary microvascular function and peripheral endothelial function in NSTE-ACS patients.

Methods

Patients hospitalised for NSTE-ACS were prospectively randomised 1:1 to clopidogrel (300mg loading then 75mg daily) or ticagrelor (180mg loading then 90mg twice-daily). Coronary microvascular function was assessed with index of microcirculatory resistance (IMR) in the infarct related artery (IRA) and non-IRA before and after percutaneous coronary intervention (PCI) using a standard pressure-temperature coronary wire. Peripheral endothelial function was assessed with flow-mediated vasodilation (FMD) of the brachial artery, performed on admission prior to antiplatelet loading and again before discharge, using a pneumatic cuff and 10MHz linear ultrasound transducer.

Results

A total of 40 patients were included for analysis (Figure 1). Median age was 53.5 (IQR 49.0–61.5) years, 35 (87.5%) were male, 11 (27.5%) had diabetes, 19 (47.5%) were smokers. Median peak troponin T was 527 (175–1006.5) ng/L, median GRACE score 91.5 (78.3–103.3) and median SYNTAX score 13 (6–20). Baseline characteristics were similar between both groups. There was no significant difference in the median baseline IMR between the 2 groups in both the IRA (clopidogrel 14.4 [IQR 12.2–18.6] vs ticagrelor 20.8 [11.3–27.4], p=0.22) and non-IRA (14.0 [11.0–22.0] vs 14.0 [10.0–29.5] respectively, p=0.74). 28 patients underwent PCI to the IRA (12 clopidogrel, 16 ticagrelor). There was no significant difference in the median post-PCI IMR between the 2 groups (19.5 [14.5–24.5] vs 29.0 [19.0–35.6] respectively, p=0.11). However, there was significant worsening of post-PCI compared with pre-PCI IMR (19.5 vs 15.0, p=0.049) in the clopidogrel group but not in the ticagrelor group (29.0 vs 25.4, p=0.47). FMD was performed in 23 patients (9 clopidogrel, 14 ticagrelor). Admission median %FMD (change in post-stimulus diameter as a percentage of the baseline diameter) was similar between the 2 groups (13.2% [10.1–17.6] vs 12.2% [10.2–15.8] respectively, p=0.41). There was a trend towards higher median pre-discharge %FMD in the ticagrelor group (12.8% [12.2–18.0]) compared to the clopidogrel group (10.4% [9.5–11.2], p=0.09). There was a trend towards lower pre-discharge %FMD compared to admission in the clopidogrel group (10.4% vs 13.2%, p=0.05) but not the ticagrelor group (12.8% vs 12.2%, p=0.43).

Figure 1

Conclusions

In our NSTE-ACS patients undergoing PCI, ticagrelor resulted in less disruption of coronary microvascular function and may also have beneficial effects on peripheral endothelial function compared to clopidogrel.

Acknowledgement/Funding

Dr. James Xu is funded by a post-graduate scholarship from the Australian Government Research Training Program (RTP)

P1483Serial changes in peak left atrial strain predicts diastolic remodelling following percutaneous revascularisation for ST-segment elevation myocardial infarction

Background

Echocardiographic 2D speckle tracking peak left atrial (LA) strain reflects LA reservoir function. Limited studies have reported the relationship between peak LA strain and diastolic dysfunction. In addition, adverse diastolic remodeling (ADR) has been reported, to have better prognostic value than single diastolic function assessment following ST-elevation myocardial infarction (STEMI).

Purpose

We examined the relationship between serial changes in echocardiographic peak LA strain and diastolic function in STEMI patients.

Methods

186 percutaneously revascularized first presentation STEMI patients (87% male, 56.9±10.6 years) underwent serial TTE at baseline (2–7 days) and at follow-up (8–10 weeks) post-STEMI. Peak LA reservoir strain measurements were analysed from apical 2-, 3- and 4- chamber views. Diastolic function was graded as per 2016 guidelines: normal, grade 1, grade 2 and grade 3. ADR was defined as worsening of diastolic function grade (≥1) from baseline to follow-up, or persistent grade 3.

Results

Lower baseline peak LA strain was associated with grade 2 and grade 3 diastolic dysfunction compared to normal and grade 1 function at follow-up (p<0.05, see figure and table). Change in LA strain was less with worsening grades of diastolic function (see table). ADR was seen in 33 patients. Lower baseline peak LA strain predicted ADR (B=0.86 (0.80–0.92), p<0.0001). In addition, a reduction in peak LA strain at follow up was independently associated with ADR (B=0.91 (0.84–0.97), p=0.007) (see figure).

Diastolic function grades with LA strain Follow-up diastolic function Baseline peak LA strain (%) Follow-up peak LA strain (%) Change in peak LA strain (%) Normal (n=91) 35.70±6.38 40.97±8.10 5.26±6.07 Grade 1 (n=61) 30.70±6.97 34.54±8.77 3.84±6.32 Grade 2 (n=17) 23.95±6.11 25.49±5.93 1.54±4.70 Grade 3 (n=17) 23.66±8.07 23.49±10.64 −0.17±7.44 Data presented as mean ± SD.

Peak LA strain vs diastolic function

Conclusion

Peak LA strain is associated with diastolic function following STEMI and differentiates normal diastolic function from diastolic dysfunction. Serial changes in peak LA strain correlated with diastolic remodelling. Longer-term follow-up is required to determine the prognostic value of changes in peak LA strain, and diastolic remodelling.

Comparison of Clinical Outcomes Following Patients' First and Second Concussions

Purpose

The objective of this study was to examine differences in self-reported symptoms, neurocognitive performance, and vestibular-ocular insufficiencies between patients’ first and second concussions. A secondary purpose was to explore the role of risk factors on recovery.

Methods

We conducted a retrospective medical chart review of 73 (32-M/41-F) patients aged 15.69 (SD=1.67) years from a concussion specialty clinic with two separate concussions (84.9% of 1st and 79.5% of 2nd sport-related) that occurred between August 2010 and April 2018. Clinical outcomes included the PCSS, ImPACT, and the Vestibular/Ocular Motor Screening (VOMS). A series of paired samples t-tests were used to compare clinical outcomes along with chi-square analyses for risk factor associations.

Results

Verbal memory scores were higher following the second (M=80.67, SD=15.3) (M=76.32, SD=15.65) (t[73]=–2.18, p=.03) concussion. Visual motor processing speed was faster following the second concussion (M=35.04, SD= 7.90) (M=31.35, SD=7.63) (t[73]=–5.72, p<.001). There were no other significant differences observed. Recovery time was similar for the first (61.07, SD=58.41.5) and second (67.91 SD=70.10) respectively, t(70)=–.91, p=.37. There was no relationship between any risk factors, and recovery time for either injury with the exception a significant association between gender and recovery time (>21 days) with the 1st injury for females (χ2, N=73)=10.58, p=.001.

Conclusion

Findings suggest that a second concussion does not result in more pronounced symptoms, worse neurocognitive performance, or increased deficits on vestibular/ocular performance and/or longer recovery time. The only significant risk factor to a recovery over 21 days included gender.

Abstract P2-14-26: Withdrawn

This abstract was withdrawn by the authors.

Citation Format: Meybodi F, Sedaghat N, French J, Elder E. Withdrawn [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-14-26.

Utilization of Quality Improvement Methodology to Standardize Communication of Outside Hospital Transfers in a General Surgery Program

OBJECTIVE

There is no standardized method of communication regarding the arrival of outside hospital (OSH) transfers at our institution. We utilized quality improvement methodologies to enhance sign-out, benefiting both resident workflow and patient care.

DESIGN

A dynamic census log of pending OSH transfers was created. Total number of OSH transfers (with or without prior notification), time to admission orders, and resident self-reported preparedness in receiving/triaging OSH admissions were measured before and after implementation of the census log tool.

SETTING

Quaternary referral hospital in Cleveland, Ohio.

PARTICIPANTS

The census log was made available to General Surgery residents on receiving surgical teams. After the data collection period, it was made available to all residents in the program.

RESULTS

A total of 93 patients were transferred to receiving surgical teams during our 13-week study period. Resident notification of the OSH transfer prior to patient's arrival increased from 44.7% pre- to 70.3% postimplementation of the tool (p = 0.03). When residents received prior notification of pending transfers, time to place admission orders decreased from 81.2 ± 79.9 minutes to 40.4 ± 36.8 minutes (p = 0.0029). Junior residents' self-reported preparedness in admitting an OSH transfer did not significantly differ when they received prior notification versus when they did not. In contrast, senior residents' self-reported higher levels of preparedness in the instances where they received prior notification of a pending transfer.

CONCLUSIONS

In light of the recent Clinical Learning Environment Review program set forth by the Accreditation Council for Graduate Medical Education, trainees are expected to engage in improvement processes as it relates to patient safety and transitions of care. The development and implementation of our tool demonstrate that quality improvement methodologies can be effectively applied to resident workflow challenges, improving both trainee education and patient care.