Demographics, diagnostics, treatment, and outcomes of patients presenting with acute groin hernia: 15-year multicentre retrospective cohort study

BACKGROUND

Groin hernias commonly present acutely in high-risk populations and can be challenging to manage. This retrospective, observational study aimed to report on patient demographics and outcomes, following acute admissions with a groin hernia, in relation to contemporary investigative and management practices.

METHODS

Adult (≥18 years old) patients who presented acutely with a groin hernia to nine National Health Service trusts in the north of England between 2002 and 2016 were included. Data were collected regarding patient demographics, radiological investigations, and operative intervention. The primary outcome of interest was 30-day inpatient mortality rate.

RESULTS

Overall, 6165 patients with acute groin hernia were included (4698 inguinal and 1467 femoral hernias). There was a male preponderance (72.5 per cent) with median age of 73 years (interquartile range (i.q.r.) 58-82). The burden of patient co-morbidity increased over the study period (P < 0.001). Operative repair was performed in 2258 (55.1 per cent) of patients with an inguinal and 1321 (90.1 per cent) of patients with a femoral hernia. Bowel resection was more commonly required for femoral hernias (14.7 per cent) than inguinal hernias (3.5 per cent, P < 0.001) and in obstructed (14.6 versus 0.2 per cent, P < 0.001) or strangulated (58.4 versus 4.5 per cent, P < 0.001) hernias. The 30-day mortality rate was 3.1 per cent for the overall cohort and 3.9 per cent for those who underwent surgery. Bowel resection was associated with increased duration of hospital stay (P < 0.001) and 30-day inpatient mortality rate (P < 0.001). Following adjustment for confounding variables, advanced age, co-morbidity, obstruction, and strangulation were all associated with an increased 30-day mortality rate (all P < 0.001).

CONCLUSION

Emergency hernia repair has high mortality rates. Advanced age and co-morbidity increase both duration of hospital stay and 30-day mortality rate.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

EP.FRI.704 Emergency colorectal surgery outcomes within a non-specialist split site service – a retrospective cohort study

Aims

Within this region, Upper GI and Colorectal subspecialties are located at separate hospitals. This study aims to determine outcomes of critically unwell patients undergoing emergency colorectal surgery off-site at the non-colorectal specialist centre.

Methods

An observational retrospective study of emergency colorectal laparotomies at a major acute teaching hospital (non-colorectal specialist centre) between January 2016 and August 2020 was performed. The primary outcome was 30-day mortality. Secondary outcomes included rate of primary anastomosis, complications and overall mortality. The NELA predicted mortality risk was obtained from notes or retrospectively calculated. Subgroup analysis of colorectal surgeon involvement was performed. 

Results

One hundred and eighteen patients were included (median age 64 years, 55% female).  The median NELA mortality score was 5.8% (IQR 1.9 – 14.7%). The 30-day mortality rate was 22% (26/118). The rate of primary anastomosis was 31%. Patients having an anastomosis had a lower median NELA score compared those patients who did not (1.6% vs. 7.85%). Forty five (38%) patients had Clavien-Dindo grade IV-V complication. Colorectal Surgeon involvement in the operation (23/118), was associated with a lower 30-day mortality (17.4% colorectal surgeon vs. 23.2% emergency general surgeon alone) albeit in patients with a lower median NELA score (4.5% vs. 6.7%) and a similar rate of primary anastomosis was achieved (31.6% vs. 30.9%).

Conclusions

The high mortality rate highlights a specific group of acutely unwell patients unfit for transfer to the subspecialist unit. Good outcomes were seen where a colorectal surgeon was involved, however a similar rate of primary anastomosis was demonstrated.

NELA.02Trends in management and outcomes for patients presenting acutely with inguinal hernia

Aims

Rates of emergency inguinal hernia presentations are increasing as ‘watch and wait’ management approaches become more popular. This study aimed to review current practice regarding clinical management of patients admitted acutely with an inguinal hernia in the North of England.

Methods

Patients ≥18 years admitted acutely with an inguinal hernia between 2002-2016 to North of England NHS trusts were identified. Data on demographics, investigations and operative interventions was collected. Outcomes analysed included rate of bowel resection, length of stay (LoS) and 30-day postoperative mortality.

Results

A total of 4698 patients presented acutely with an inguinal hernia, and 2588 patients (55.0%) underwent emergency surgery. Pre-operative CT scanning increased from 1.0% (2002-2006) to 12.1% (2012-2016) (p &lt; 0.001). Patients who had a pre-operative CT were less likely to undergo repair than those who did not (42.2% vs. 56.0%, p &lt; 0.001). Rates of bowel resection were higher in patients who had a CT (9.6% vs. 2.7%, p &lt; 0.001). Of those presenting with obstructive symptoms, only 5.7% required bowel resection, 85.7% of these being small bowel. Bowel resection was associated with increased LoS (p &lt; 0.001) and 30-day postoperative mortality (18.8% vs. 2.0%, p &lt; 0.001). Laparoscopic repair, used in 119 procedures (4.6%), was associated with shorter mean LoS compared with open repair (3.0 vs 4.4 days, p &lt; 0.001) but no difference in 30-day mortality (p = 0.169).

Conclusions

Emergency inguinal hernia repairs, requiring bowel resection, are associated with significantly increased LoS and a 9-fold increase in 30-day mortality. These findings raise important aspects to be discussed with patients during the consent process.

TP6.2.2 Multi-disciplinary interventions to increase utilisation of NELA scores and critical care involvement following emergency colorectal surgery

Aims

This audit aimed to assess pre-operative NELA risk score documentation and subsequent specialist peri-operative critical care involvement.

Methods

This complete audit cycle retrospectively reviewed notes (electronic patient records, anaesthetic charts and CEPOD booking forms) of all patients undergoing emergency laparotomy between March and May 2019. The NELA score was calculated retrospectively if not documented. Following the initial audit, the following multi-disciplinary interventions were instituted: alteration of the physical CEPOD booking form to include NELA score (Surgical); a sticker added to anaesthetic charts to prompt NELA calculation (Anaesthetic), formal recording of NELA score during theatre brief (Theatre staff); and by increasing awareness of NELA via departmental education (All). The audit cycle was completed by reassessment between October and November 2020.

Results

The initial cycle included 34 patients, with only 2 (6%) having a NELA documented. The repeat cycle included 35 patients, with 29 (83%) having a NELA documented. Regarding post-operative critical care admissions, both cycles found that 100% of patients with a NELA of ≥ 5%, were admitted to either surgical HDU or ICU (n = 17 in first cycle, n = 17 in second cycle). For those with a high-risk NELA of ≥ 10% (n = 11 in first cycle, n = 7 in second cycle), only 2 (18%) were admitted to ICU in the first cycle vs 7 (100%) in the second cycle.

Conclusions

This complete audit cycle demonstrates improved NELA score calculation following institution of several multidisciplinary interventions. The improved NELA score uptake was associated with increased critical care review and admission to ITU in high-risk cases.

SP3.2.15 Patient demographics and outcomes following emergency presentation with a groin hernia; a 15-year retrospective cohort study from the North of England

Aims

Over 70,000 groin hernia repairs are performed in the UK annually. While most are performed in day-case settings, emergency presentation remains common and has a high associated morbidity and mortality. This study aims to report on patient demographics and outcomes following emergency presentation with a groin hernia.

Methods

Data was collected for all patients &gt;18 years admitted acutely with an inguinal or femoral hernia to NHS trusts between 2002-2016 in the North of England. This included patient demographics and operative interventions. Outcomes of interest were thirty-day inpatient mortality and length of stay (LoS).

Results

Overall, 6165 patients presented as an emergency with a groin hernia (76.2% inguinal) over the 15-year study period. There was a male preponderance (n = 4469, 72.5%) with a median age of 73 years (IQR: 58,82). No changes in the distribution of age or gender were noted over the study period. Comorbidity, as measured by Charlson score, increased over time (p &lt; 0.001). Median LoS was 2 days (IQR: 1,5), increasing with age and comorbidity (both p &lt; 0.001). Emergency surgery was performed for 3904 patients (63.3%). The thirty-day mortality rate of 3.1% rose to 3.7% in the subgroup of patients undergoing operative repair and 5.6% in those with associated bowel obstruction. Greater comorbidity and advanced age were again associated with increased mortality (both p &lt; 0.001).

Conclusions

This study highlights changing patient demographics more comorbid patients presenting acutely with groin hernias. These patients must be counselled regarding their increased mortality risk as part of the shared decision-making process.

1609 Patient Demographics and Outcomes Following Acute Presentation with An Inguinal Hernia; A 15-Year Retrospective Cohort Study from The North of England

Aim

Although inguinal hernia repair is one of the most common elective procedures performed, emergency repair carries a far greater risk to patients. This study aimed to report on patient demographics and outcomes following emergency presentation with an inguinal hernia.

Method

Patients ≥18 years admitted acutely with an inguinal hernia across NHS trusts in the North of England between 2002-2016 were identified. Data were collected on demographics, investigations, and operative interventions. Outcomes including length of stay (LoS) and 30-day mortality were analysed.

Results

A total of 4698 patients presented over the 15-year study period. The cohort were predominantly male (n = 4133, 88.0%) with median age of 71 years (IQR: 56-81). Whilst no significant difference in age or gender were found across the study period, comorbidities, as measured by Charlson score, increased over time (p &lt; 0.001). In those who underwent operative intervention (n = 2580), median length of stay was 3 days (IQR: 2-5) and 30-day inpatient mortality rate was 2.5%. Advanced age and comorbidity were associated with higher overall 30-day mortality and post-operative 30-day mortality (both p &lt; 0.001).

Conclusions

This study highlights the frailty of patients presenting as emergency with complications secondary to inguinal hernia. Given the increased risk observed in this patient group, it is vital that perioperative care is optimised, and patients are counselled appropriately.

1601 Trends in Investigation, Management and Patient Outcomes Following Emergency Presentation with Groin Hernia

Aim

Groin hernias are associated with an increased morbidity and mortality following emergency presentations. This study aimed to review current practices regarding investigation and operative management of acute admissions of groin hernias in the North of England.

Method

Patients ≥18 years admitted as an emergency with femoral or inguinal hernias, between 2002-2016, across NHS trusts in the North of England were included. Data on demographics, investigations and operative interventions was collected. Outcomes of interest included rate of bowel resection, length of stay (LoS) and 30-day postoperative mortality.

Results

A total of 6165 patients were identified over 15 years: 4698 inguinal hernias and 1467 femoral hernias. 3904 (63.3%) underwent emergency surgery. Pre-operative CT scanning increased from 1.0% (2002-2006) to 12.3% (2012-2016) (p &lt; 0.001) and was associated with a reduced rate of surgical intervention (64.0% vs. 55.3%, p &lt; 0.001). Bowel resection was higher amongst patients who underwent CT (16.6% vs. 6.4%, p &lt; 0.001). Of those presenting with bowel obstruction, 11.7% required resection, 95.9% of these being small bowel. Bowel resection was associated with increased LoS (p &lt; 0.001) and 30-day postoperative mortality (16.4% vs. 2.8%, p &lt; 0.001). Laparoscopic repair, utilised in 177 procedures (4.5%), was associated with a shorter LoS compared to open repair (4.7 vs 5.5 days, p &lt; 0.001) but no difference in mortality.

Conclusions

Emergency hernia repair, particularly cases requiring bowel resection, have high mortality rates. Pre-operative CT scanning is associated with reduced rates of operative intervention. Further research is required to assess the impact these changes have on surgical decision-making, and subsequent patient outcomes.

Abstract P6-16-04: IL6ST, a biomarker of endocrine therapy response, has potential in identifying a subgroup of women with ER+ DCIS who are more likely to benefit from adjuvant endocrine therapy

Background: Ductal carcinoma in situ (DCIS) lesions are non-obligate precursors to invasive breast cancer (IBC). With the ultimate goal of preventing the development of invasive disease, DCIS is typically treated by breast-conserving surgery (BCS). Adjuvant radiotherapy (RT) is given for high-grade disease to reduce the risk of in-breast tumour recurrence (IBTR). The use of endocrine therapy (ET) for DCIS varies, as studies show a modest benefit but no survival improvement; in the UK, guidelines recommend ET for DCIS in some scenarios but only instead of, rather than in addition to, RT. This project sought to characterise the biology of ER+ DCIS and identify a group of women who are likely to gain the most benefit from the addition of adjuvant ET.

Patients: Cohort A - 77 women with ER+ (Allred 7/8) high-grade DCIS treated with BCS plus RT, 20 of whom developed IBTR.Cohort B - 70 women with ER+ (Allred 7/8) low/intermediate-grade DCIS treated with BCS alone, 12 of whom developed IBTR.Cohort C - 68 women with ER+ (Allred 7/8) DCIS treated with BCS plus ET.

All patients were treated locally between 2000 and 2016 and the median follow-up is 6 years.

Methods: We performed whole-genome transcriptomic QuantSeq sequencing of samples from cohort A. Sequencing of cohort B and C is currently underway. IL6ST levels were validated using immunohistochemistry and RNAScope.

Results: In cohort A, only a subset (34/77) of tumours had gene expression profiles consistent with active ER signalling. Levels of IL6ST, a biomarker for ET response, could differentiate these two subgroups and this was validated at protein level using immunohistochemistry. The low ER signalling subgroup were associated with higher levels of EGFR, HER2 and MAPK signalling. 20/77 high-grade DCIS cases recurred within 10 years. 50% of these recurred as IBC (rather than DCIS) and these were associated with higher levels of IL6ST, had active ER signalling and higher levels of proliferation-associated and estrogen receptor target genes, known to be decreased by ET, in the primary DCIS lesion.

Discussion: Our findings suggest that some high-grade ER+ DCIS patients have active ER signalling while in others ER signalling remains low despite highly expressing the ER protein. IL6ST, a biomarker of endocrine therapy response can be used to differentiate these two groups of ER+ DCIS. DCIS lesions which recurred as IBC had active ER signalling and also higher levels of proliferation genes known to be decreased by ET compared with DCIS which recurred as further DCIS. These findings suggest that IL6ST may have a role in identifying a subset of ER+ DCIS which are at a higher risk of developing advanced disease and are also more likely to benefit from the addition of adjuvant ET, with a better risk-to-benefit ratio than observed in previous studies that considered a less targeted use of this treatment strategy, thus potentially reducing the risk of IBC recurrence. These findings will be validated in a cohort of low/intermediate-grade DCIS who received no adjuvant RT (cohort B) and a cohort of patients who received adjuvant ET as part of their treatment (cohort C).

Citation Format: Carlos Martinez-Perez, Charlene Kay, Rebecca Swan, Gregory E Ekatah, Laura M Arthur, James Meehan, Mark Gray, Andrew H Sims, Olga Oikonomidou, Arran K Turnbull, J Michael Dixon. IL6ST, a biomarker of endocrine therapy response, has potential in identifying a subgroup of women with ER+ DCIS who are more likely to benefit from adjuvant endocrine therapy [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P6-16-04.

Abstract P2-11-06: Assessment of ESR1 genomic aberrations and their role in endocrine therapy resistance in breast cancer

Background: Endocrine therapy (ET) is an effective treatment of estrogen receptor positive (ER+) breast cancer (BC). However, not all ER+ cancers respond to ET and many eventually acquire resistance. Genomic aberrations in ESR1 have been reported to play a role in resistance to treatment. ESR1 mutations (ESRMs), reported in 10-50% of metastatic or recurrent BCs treated with aromatase inhibitors (AIs), can lead to constitutive activation and reduced sensitivity to ET. The incidence and clinical implications of ESR1 amplification (ESRA) is not well-established. A variety of structural rearrangements involving ESR1 have been reported in primary BCs, with some more strongly associated with tamoxifen and AI resistance. This study aimed to establish a rapid, reliable and cost-effective method to screen and monitor ESR1 genomic aberrations in clinical BC tissue samples and relate these to the 1st line and subsequent ETs patients received.

Patients:

• Cohort A - 20 post-menopausal women (PMW) with ER+ BC who had acquired resistance to AIs and received subsequent lines of ET. Previous NGS data were available for these patients.

• Cohort (B) - 425 ER+ BC patients, with paired matched tissue samples from the primary and progressive/recurrent cancer on 1st line ET; sites included local recurrence (25%), nodal recurrence (29%), distant recurrence (3%) and primary progression on neoadjuvant ET (44%). Median follow-up 10 years. All patients received 2nd line ET, 14% developed a further recurrence on 2nd line ET.

Methods: ESRMs were assessed by allele-specific real-time quantitative (rt-qPCR) and digital droplet PCR (ddPCR) assays, a novel fluorometric in situ mutation detection (ISMD) approaches and AmpliSeq targeted sequencing. ESRA and ESR1 fusions were detected by targeted sequencing and validated using FISH and custom ligation assays for commonly-reported fusion proteins (currently ESR1-e6&gt;YAP1 and ESR1-e6&gt;PCDH11X), respectively.

Results: Results from ddPCR and ISMD were consistent with NGS findings in cohort A. There was expansion of D538G mutant clones with acquired resistance in 5/20 patients (25%). ESR1 copy number gain was seen in 11/20 patients (55%) in resistant samples. Gene amplification was confirmed by FISH in 6, corresponding to those with the highest gain from the NGS data. In cohort B, recurrent/resistant samples (including 2nd recurrences) with matched primaries are currently being screened for ESR1 genomic aberrations using all methods allowing for a comprehensive comparison. This will allow full characterisation of mutations, copy number changes and gene fusions in the largest cohort of ET resistant cancers to date. Results will be interpreted in the context of 1st line ET (51% Tamoxifen, 34% non-steroidal AI, 8% exemestane, 7% other ET) and 2nd line ET in the 14% of patients who developed a 2nd recurrence. ESR1 genomic aberrations have been identified in 38% of samples to date, with specific aberrations associated with particular ETs.

Discussion:

• A reliable, robust and cost-effective methodology for the detection and quantitation of ESR1 aberrations in clinical BC samples has been developed and compared with NGS and targeted sequencing approaches.

• This method would allow rapid screening for key aberrations with the potential to inform selection of 2nd line therapy.

• Multiplexing of fluorometric assays may enable in situ clonality analysis that allows visualisation of multiple genomic driver aberrations simultaneously.

• In the largest cohort of patients with resistance to ET to date, there is a high incidence of ESR1 genomic aberrations. These are associated with specific ETs. Analysis between these changes and response, disease-free and overall breast cancer-specific survival on 2nd line ET is currently ongoing.

Citation Format: Carlos Martinez-Perez, Charlene Kay, James Meehan, Mark Gray, Rebecca Swan, Lorna Renshaw, Jane Keys, Andrew H Sims, Olga Oikonomidou, J Michael Dixon, Arran K Turnbull. Assessment of ESR1 genomic aberrations and their role in endocrine therapy resistance in breast cancer [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P2-11-06.

Development of an interprofessional clinical learning environment report card

Multiple factors in the learning environment can encourage or impede student learning. Unanswered questions regarding the shared learning environment for graduate nursing and medical education and the desire for an ongoing improvement process drove creation of an interprofessional collaborative and development of an Interprofessional Clinical Learning Environment Report Card (I-CLERC) at one U.S. academic medical center. The I-CLERC offers a process and a product for institutionalizing a shared assessment tool to inform improvement efforts, track progress and promote accountability. In addition, it enhances interprofessional collaboration, with students and faculty from both nursing and medicine working together to define excellence, monitor performance, and identify areas for improvement in the shared clinical learning environment. The purpose of this manuscript is to describe development and implementation of an interdisciplinary, institutional collaborative for ongoing evaluation of the shared clinical learning environment.

The differential expression of omega-3 and omega-6 fatty acid metabolising enzymes in colorectal cancer and its prognostic significance

Background:

Colorectal cancer is a common malignancy and one of the leading causes of cancer-related deaths. The metabolism of omega fatty acids has been implicated in tumour growth and metastasis.

Methods:

This study has characterised the expression of omega fatty acid metabolising enzymes CYP4A11, CYP4F11, CYP4V2 and CYP4Z1 using monoclonal antibodies we have developed. Immunohistochemistry was performed on a tissue microarray containing 650 primary colorectal cancers, 285 lymph node metastasis and 50 normal colonic mucosa.

Results:

The differential expression of CYP4A11 and CYP4F11 showed a strong association with survival in both the whole patient cohort (hazard ratio (HR)=1.203, 95% CI=1.092–1.324, χ²=14.968, P=0.001) and in mismatch repair-proficient tumours (HR=1.276, 95% CI=1.095–1.488, χ²=9.988, P=0.007). Multivariate analysis revealed that the differential expression of CYP4A11 and CYP4F11 was independently prognostic in both the whole patient cohort (P=0.019) and in mismatch repair proficient tumours (P=0.046).

Conclusions:

A significant and independent association has been identified between overall survival and the differential expression of CYP4A11 and CYP4F11 in the whole patient cohort and in mismatch repair-proficient tumours.

Formal training in vaccine safety to address parental concerns not routinely conducted in U.S. pediatric residency programs

OBJECTIVE

To determine if U.S. pediatric residency programs provide formal training in vaccine safety to address parental vaccine concerns.

METHODS

An electronic survey was mailed to all members of the Association of Pediatric Program Directors (APPD) to assess (1) if U.S. pediatric residency programs were providing formal vaccine safety training, (2) the content and format of the training if provided, and (3) interest in a training module for programs without training. Two follow-up surveys were mailed at 2 week intervals. Responses to the survey were collected at 4 weeks following the last mailing and analyzed. Logistic regression was used to assess the impact of program size on the likelihood of vaccine safety training. Pearson's chi square was used to compare programs with and without formal vaccine safety training in 5 U.S. regions.

RESULTS

The survey was sent to 199 APPD members; 92 completed the survey (response rate 46.2%). Thirty-eight respondents (41%) had formal training in vaccine safety for pediatric residents at their programs; 54 (59%) did not. Of those that did not, the majority (81.5%) were interested in formal vaccine safety training for their residents. Of all respondents, 78% agreed that training in vaccine safety was a high priority for resident education. Thirty-five percent of all respondents agreed that local parental attitudes about vaccines influenced the likelihood of formal vaccine safety training.

CONCLUSION

Most pediatric residency programs surveyed do not include formal training on vaccine safety; yet, such training is supported by pediatric residency program directors as a priority for pediatric residents.

Pediatric Palliative Care Instruction for Residents

A 1-day training event for pediatric residents with interdisciplinary staff was held, which was modeled after the Initiative for Pediatric Palliative Care (IPPC). Training included relational communication, cultural humility, pain–symptom management, family-centered care, team problem solving, and strategic planning using didactic, small group, and plenary platforms. Two bereaved parents were co-learners and trainers. Twenty-six interdisciplinary staff participated. A positive impact was measured in new knowledge gained, value in collaborative learning with health care professionals and families, and ability to work with professionals outside participants' own unit. Confidence to advocate for improved pediatric palliative care was also noted. The IPPC curriculum is easily adapted for resident education. Incorporating family members as co-learners and teachers is valuable. Advocacy for pediatric palliative care may follow this type of experience.

A simplified observation tool for residents in the outpatient clinic

BACKGROUND

The Accreditation Council for Graduate Medical Education promotes direct observation of residents as a key assessment tool for competency in patient care, professionalism, and communication skills. Although tools exist, validity and reliability have not been demonstrated for most, and many tools may have limited feasibility because of time constraints and other reasons. We conducted a study to measure feasibility of a simplified observation tool to evaluate these competencies and provide timely feedback.

METHODS

In the pediatric resident continuity clinic of a large children's hospital, we used a direct observation form with a 3-point scale for 16 items in the domains of patient care, professionalism, and communication skills. The form was divided by portion of visit, with specific items mapped to 1 or more of the competencies, and was used to provide direct oral feedback to the resident. Faculty and residents completed surveys rating the process (ease of use, satisfaction, and self-assessed usefulness) on a 5-point Likert scale.

RESULTS

The study encompassed 89 surveys completed by attending physicians; 98% (87 of 89) of the time the form was easy to use, 99% (88) of the time its use did not interfere with patient flow, and 93% (83) of the observations provided useful information for resident feedback. Residents completed 70 surveys, with the majority (69%, 48) reporting they were comfortable about being observed by an attending physician; 87% (61) thought that direct observation did not significantly affect their efficiency. Ninety-seven percent of the time (68) residents reported that direct observation provided useful feedback.

CONCLUSION

The data suggest the form was well-received by both faculty and residents, and enabled attending physicians to provide useful feedback.

Cutaneous papillomatosis and carcinomatosis in the Western barred bandicoot (Perameles bougainville)

A progressive wart-like syndrome in both captive and wild populations of the Western barred bandicoot (WBB) is hindering conservation efforts to prevent the extinction of this endangered marsupial. In this study, 42 WBBs exhibiting the papillomatosis and carcinomatosis syndrome were examined. The disease was characterized by multicentric proliferative lesions involving cutaneous and mucosal surfaces, which were seen clinically to increase in size with time. Grossly and histologically the smaller skin lesions resembled papillomas, whereas the larger lesions were most commonly observed to be squamous cell carcinomas. Large amphophilic intranuclear inclusion bodies were observed in hyperplastic conjunctival lesions of 8 WBBs under light microscopy. Conjunctival lesions from 2 WBBs examined using transmission electron microscopy contained a crystalline array of spherical electron-dense particles of 45-nm diameter, within the nucleus of conjunctival epithelial cells, consistent with a papillomavirus or polyomavirus. Conjunctival samples from 3 bandicoots that contained intranuclear inclusion bodies also demonstrated a positive immunohistochemical reaction after indirect immunohistochemistry for papillomavirus structural antigens. Ultrastructural and/or immunohistochemical evidence of an etiologic agent was not identified in the nonconjunctival lesions examined. Here we describe the gross, histopathologic, ultrastructural, and immunohistochemical findings of a papillomatosis and carcinomatosis syndrome recently identified in the WBB.

Child fatalities from religion-motivated medical neglect

OBJECTIVE

To evaluate deaths of children from families in which faith healing was practiced in lieu of medical care and to determine if such deaths were preventable.

DESIGN

Cases of child fatality in faith-healing sects were reviewed. Probability of survival for each was then estimated based on expected survival rates for children with similar disorders who receive medical care.

PARTICIPANTS

One hundred seventy-two children who died between 1975 and 1995 and were identified by referral or record search. Criteria for inclusion were evidence that parents withheld medical care because of reliance on religious rituals and documentation sufficient to determine the cause of death.

RESULTS

One hundred forty fatalities were from conditions for which survival rates with medical care would have exceeded 90%. Eighteen more had expected survival rates of >50%. All but 3 of the remainder would likely have had some benefit from clinical help.

CONCLUSIONS

When faith healing is used to the exclusion of medical treatment, the number of preventable child fatalities and the associated suffering are substantial and warrant public concern. Existing laws may be inadequate to protect children from this form of medical neglect.