Search

Background Patient experience is often measured quantitatively, but that approach has limitations for understanding the entire experience. Qualitative methods can help to understand more complex issues most important to patients and their families. The purpose of the present work was to use a qualitative analysis examining the patient experience of ambulatory cancer care in Ontario to generate a deeper understanding of the patient experience and to lead to solutions for improvement. Methods Data from the Ambulatory Oncology Patient Satisfaction Survey (AOPSS) for 2013–2015 were used to conduct a qualitative content analysis. The aopss is a retrospective paper-based survey, mailed to patients who are currently receiving cancer treatment or who have received cancer treatment within the preceding 6 months, that is designed to capture their experiences. Patients who were surveyed were asked, “Is there anything else you would like to tell us about your cancer care services?” The National Research Corporation Canada’s patient-centred care framework was used to guide the analysis. Results From the 5391 patients who responded, 7328 coded responses were generated, of which 3658 (49.9%) were related to the patient-centred care framework. New subthemes were identified: diagnosis sensitivity; emotional support resources; care delivery with care, compassion, and comfort; continuity of care between departments and in the community; access to cancer centre personnel; patient–health care provider communication; confidence in the health care provider; wait times; health care provider and treatment coordination; and parking. Conclusions The results identify facilitators and barriers to the patient experience in the ambulatory cancer treatment setting from the patient perspective and identify opportunities to improve the patient experience. [ABSTRACT FROM AUTHOR]

A reduction in blood supply to any limb causes ischaemia, pain and morbidity. Critical limb ischaemia is the most serious presentation of peripheral vascular disease. One in five patients with critical limb ischaemia will die within six months of diagnosis and one in three will require amputation in this time. Improving blood flow to the limb, via the administration of angiogenic agents, could relieve pain and avoid amputation. Herein, chitosan is combined with β-glycerophosphate to form a thermoresponsive formulation (chitosan/β-GP) that will flow through a syringe and needle at room temperature but will form a gel at body temperature. The chitosan/β-GP hydrogel, with or without the angiogenic molecule desferrioxamine (DFO), was injected into the mouse hind limb, following vessel ligation, to test the ability of the formulations to induce angiogenesis. The effects of the formulations were measured using laser Doppler imaging to determine limb perfusion and CD31 staining to quantify the number of blood vessels. Twenty-eight days following induction of ischaemia, the chitosan/β-GP and chitosan/β-GP + 100 µM DFO formulations had significantly (p < 0.001 and p < 0.05, respectively) improved blood flow in the ischaemic limb compared with an untreated control. Chitosan/β-GP increased vessel number by 1.7-fold in the thigh of the ischaemic limb compared with an untreated control, while chitosan/β-GP + 100 µM DFO increased vessel number 1.8-fold. Chitosan/β-GP represents a potential minimally invasive treatment for critical limb ischaemia. [ABSTRACT FROM AUTHOR]

The resin-dentin interface formed by two dentin adhesives, Optibond (OPTI, Kerr) and Scotchbond Multi- Purpose (SBMP, 3M), was ultramorphologically examined by transmission electron microscopy (TEM). Ultrastructural information from nondemineralized and demineralized sections was correlated. It was hypothesized that the different chemical formulations of the two adhesives would result in a different morphological appearance of the hybrid layer. Ultrastructural TEM examination proved that each of the two dentin adhesive systems was able to establish a micromechanical bond between dentin and resin with the formation of a hybrid layer. However, the interfacial hybridization process that took place to produce this resin- dentin bond appeared to be specifically related to the chemical composition and application modes of both systems. OPTI consistently presented with a hybrid layer with a relatively uniform ultrastructure, electron density, and acid resistance. These three parameters were found to be more variable for the hybrid layer formed by SBMP. Characteristic of SBMP was the identification of an amorphous phase deposited at the outer surface of the hybrid layer. Although both adhesive systems investigated follow a total-etch concept, their specific chemical formulations result in different interfacial ultrastructures that are probably related to different underlying bonding mechanisms. The clinical significance of these morphological findings, however, is still unknown. [ABSTRACT FROM AUTHOR]

Owing to the frequency and severity of eating disorder psychopathology amongst female adolescents and young adults, research examining the development and prevention of disordered eating has focused predominantly on these populations. However dieting awareness and weight control behaviours are evident in children as young as seven, and are particularly apparent in girls. Psycho-educational and early intervention programs subsequently developed for preadolescent children have had limited success due to their theoretical grounding in adult and adolescent research and their focus on the 'pathological', rather than an understanding of what constitutes 'normal' versus 'non-normal' eating behaviours for children. In an attempt to redress this lack of understanding, the present study used semi-structured interviews to examine the eating and dieting related knowledge, attitudes and behaviours of nineteen girls (aged 6 to 13 years). Participant's primary caregiver (i.e., mothers) also completed a short open-ended questionnaire. The findings from the qualitative analysis indicated that young girls' eating and dieting related beliefs and behaviours are shaped via a complex interplay between developmental and socialisation processes and individual differences. The findings of this study will provide the basis for programs promoting positive health outcomes for young girls. [ABSTRACT FROM AUTHOR]

In nature, the number of genome or chromosome copies within cells (ploidy) can vary between species and environmental conditions, potentially influencing how organisms adapt to changing environments. Although ploidy levels cannot be easily determined by standard genome sequencing, understanding ploidy is crucial for the quantitative interpretation of molecular data. Cyanobacteria are known to contain haploid, oligoploid, and polyploid species. The smallest cyanobacteria, picocyanobacteria (less than 2 μm in diameter), have a widespread distribution ranging from marine to freshwater environments, contributing significantly to global primary production. In this study, we determined the ploidy level of genetically and physiologically diverse brackish picocyanobacteria isolated from the Baltic Sea using a qPCR assay targeting the rbcL gene. The strains contained one to four genome copies per cell. The ploidy level was not linked with phylogeny based on the identity of the 16S rRNA gene. The variation of ploidy among the brackish strains was lower compared to what has been reported for freshwater strains and was more similar to what has been reported for marine strains. The potential ecological advantage of polyploidy among picocyanobacteria has yet to be described. Our study highlights the importance of considering ploidy to interpret the abundance and adaptation of brackish picocyanobacteria., (© 2024 The Author(s). Environmental Microbiology Reports published by John Wiley & Sons Ltd.)

Objective: The objective of this study was to measure potential associations between surgeon sex and number of days alive and at home (DAH)., Background: Patients treated by female surgeons appear to have lower rates of mortality, complications, readmissions, and healthcare costs when compared with male surgeons. DAH is a validated measure, shown to better capture the patient experience of postoperative recovery., Methods: We conducted a retrospective study of adults (≥18 years of age) undergoing common surgeries between January 01, 2007 and December 31, 2019 in Ontario, Canada. The outcome measures were the number of DAH within 30-, 90-, and 365-days. The data was summarized using descriptive statistics and adjusted using multivariable generalized estimating equations., Results: During the study period, 1,165,711 individuals were included, of which 61.9% (N = 721,575) were female. Those managed by a female surgeon experienced a higher mean number of DAH when compared with male surgeons at 365 days (351.7 vs. 342.1 days; P < 0.001) and at each earlier time point. This remained consistent following adjustment for covariates, with patients of female surgeons experiencing a higher number of DAH at all time points, including at 365 days (343.2 [339.5-347.1] vs . 339.4 [335.9-343.0] days). Multivariable regression modeling revealed that patients of male surgeons had a significantly lower number of DAH versus female surgeons., Conclusions: Patients of female surgeons experienced a higher number of DAH when compared with those treated by male surgeons at all time points. More time spent at home after surgery may in turn lower costs of care, resource utilization, and potentially improve quality of life. Further studies are needed to examine these findings across other care contexts., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Importance: Prior research has shown differences in postoperative outcomes for patients treated by female and male surgeons. It is important to understand, from a health system and payer perspective, whether surgical health care costs differ according to the surgeon's sex., Objective: To examine the association between surgeon sex and health care costs among patients undergoing surgery., Design, Setting, and Participants: This population-based, retrospective cohort study included adult patients undergoing 1 of 25 common elective or emergent surgical procedures between January 1, 2007, and December 31, 2019, in Ontario, Canada. Analysis was performed from October 2022 to March 2023., Exposure: Surgeon sex., Main Outcome and Measure: The primary outcome was total health care costs assessed 1 year following surgery. Secondarily, total health care costs at 30 and 90 days, as well as specific cost categories, were assessed. Generalized estimating equations were used with procedure-level clustering to compare costs between patients undergoing equivalent surgeries performed by female and male surgeons, with further adjustment for patient-, surgeon-, anesthesiologist-, hospital-, and procedure-level covariates., Results: Among 1 165 711 included patients, 151 054 were treated by a female surgeon and 1 014 657 were treated by a male surgeon. Analyzed at the procedure-specific level and accounting for patient-, surgeon-, anesthesiologist-, and hospital-level covariates, 1-year total health care costs were higher for patients treated by male surgeons ($24 882; 95% CI, $20 780-$29 794) than female surgeons ($18 517; 95% CI, $16 080-$21 324) (adjusted absolute difference, $6365; 95% CI, $3491-9238; adjusted relative risk, 1.10; 95% CI, 1.05-1.14). Similar patterns were observed at 30 days (adjusted absolute difference, $3115; 95% CI, $1682-$4548) and 90 days (adjusted absolute difference, $4228; 95% CI, $2255-$6202)., Conclusions and Relevance: This analysis found lower 30-day, 90-day, and 1-year health care costs for patients treated by female surgeons compared with those treated by male surgeons. These data further underscore the importance of creating inclusive policies and environments supportive of women surgeons to improve recruitment and retention of a more diverse and representative workforce.

Importance: Sex- and gender-based differences in a surgeon's medical practice and communication may be factors in patients' perioperative outcomes. Patients treated by female surgeons have improved 30-day outcomes. However, whether these outcomes persist over longer follow-up has not been assessed., Objective: To examine whether surgeon sex is associated with 90-day and 1-year outcomes among patients undergoing common surgeries., Design, Setting, and Participants: A population-based retrospective cohort study was conducted in adults in Ontario, Canada, undergoing 1 of 25 common elective or emergent surgeries between January 1, 2007, and December 31, 2019. Analysis was performed between July 15 and October 20, 2022., Exposure: Surgeon sex., Main Outcomes and Measures: An adverse postoperative event, defined as the composite of death, readmission, or complication, was assessed at 90 days and 1 year following surgery. Secondarily, each of these outcomes was assessed individually. Outcomes were compared between patients treated by female and male surgeons using generalized estimating equations with clustering at the level of the surgical procedure, accounting for patient-, procedure-, surgeon-, anesthesiologist-, and facility-level covariates., Results: Among 1 165 711 included patients, 151 054 were treated by a female and 1 014 657 by a male surgeon. Overall, 14.3% of the patients had 1 or more adverse postoperative outcomes at 90 days and 25.0% had 1 or more adverse postoperative outcomes 1 year following surgery. Among these, 2.0% of patients died within 90 days and 4.3% died within 1 year. Multivariable-adjusted rates of the composite end point were higher among patients treated by male than female surgeons at both 90 days (13.9% vs 12.5%; adjusted odds ratio [AOR], 1.08; 95% CI, 1.03-1.13) and 1 year (25.0% vs 20.7%; AOR, 1.06; 95% CI, 1.01-1.12). Similar patterns were observed for mortality at 90 days (0.8% vs 0.5%; AOR 1.25; 95% CI, 1.12-1.39) and 1 year (2.4% vs 1.6%; AOR, 1.24; 95% CI, 1.13-1.36)., Conclusions and Relevance: After accounting for patient, procedure, surgeon, anesthesiologist, and hospital characteristics, the findings of this cohort study suggest that patients treated by female surgeons have lower rates of adverse postoperative outcomes including death at 90 days and 1 year after surgery compared with those treated by male surgeons. These findings further support differences in patient outcomes based on physician sex that warrant deeper study regarding underlying causes and potential solutions.

Cluster 5 picocyanobacteria significantly contribute to primary productivity in aquatic ecosystems. Estuarine populations are highly diverse and consist of many co-occurring strains, but their physiology remains largely understudied. In this study, we characterized 17 novel estuarine picocyanobacterial strains. Phylogenetic analysis of the 16S rRNA and pigment genes (cpcB and cpeBA) uncovered multiple estuarine and freshwater-related clusters and pigment types. Assays with five representative strains (three phycocyanin rich and two phycoerythrin rich) under temperature (10-30°C), light (10-190 μmol photons m -2  s -1 ), and salinity (2-14 PSU) gradients revealed distinct growth optima and tolerance, indicating that genetic variability was accompanied by physiological diversity. Adaptability to environmental conditions was associated with differential pigment content and photosynthetic performance. Amplicon sequence variants at a coastal and an offshore station linked population dynamics with phylogenetic clusters, supporting that strains isolated in this study represent key ecotypes within the Baltic Sea picocyanobacterial community. The functional diversity found within strains with the same pigment type suggests that understanding estuarine picocyanobacterial ecology requires analysis beyond the phycocyanin and phycoerythrin divide. This new knowledge of the environmental preferences in estuarine picocyanobacteria is important for understanding and evaluating productivity in current and future ecosystems., (© 2023 The Authors. Environmental Microbiology published by Applied Microbiology International and John Wiley & Sons Ltd.)

Purpose: Peers are uniquely able to draw on their lived experiences to support trauma survivors' recovery. By understanding the functions and outcomes of peer support and the factors that impact implementation, evidence can be mobilized to enhance its application and uptake into standard practice. As such, we aimed to review the literature on peer support for trauma survivors to: examine the role of peer support in recovery; describe the nature and extent of peer support; Examine the influence of peer support on health and well-being; and identify the barriers and facilitators to developing and implementing peer support., Methods: Scoping review methodology as outlined by Arksey and O'Malley., Results: Ninety-three articles were reviewed. Peer support was highlighted as an important component of care for trauma survivors and provided hope and guidance for the future post-injury. Most peer support programs were offered in the community and provided one-on-one support from peer mentors using various modalities. Interventions were successful when they involved knowledgeable peer mentors and maintained participant engagement. Prior negative experiences and stigma/privacy concerns deterred trauma survivors from participating., Conclusions: Peer support fulfills several functions throughout trauma survivors' recovery that may not otherwise be met within existing health care systems. Implications for rehabilitationBy understanding the functions and outcomes and the factors that impact implementation of peer support, evidence can be mobilized to enhance its application and uptake into standard practice.Peers provide trauma survivors with socioemotional support as well as assistance in daily management and life navigation post-injury.Peer support provided hope and guidance for the future after injury and improved self-efficacy amongst trauma survivors.Peer support programs are most likely to be successful when they involve knowledgeable peer mentors, are flexibly delivered, align with organizations' values and priorities, and have adequate resources and funding to support their implementation.

Early in the COVID-19 pandemic restricted family presence in hospitals was a widespread public health intervention to preserve critical resources and mitigate the virus's spread. In this study, we explore the experiences of surgical care providers and family members of hospitalized surgical patients during the period of highly restricted visiting (March 2020 to April 2021) in a large Canadian academic hospital. Thirty-four interviews were completed with hospital providers, family members and members of the hospital's visitor task force. To understand hospital providers' experiences, we highlight the ethical tensions produced by the biomedical and public health ethics frameworks that converged during COVID-19 in hospital providers' bedside practice. Providers grappled with mixed feelings in support of and against restricted visiting, while simultaneously experiencing gaps in resources and care and acting as patient gatekeepers. To understand family members' experiences of communication and care, we use the theory of institutional betrayal to interpret the negative impacts of episodic and systemic communication failures during restricted visiting. Family members of the most vulnerable patients (and patients) experienced short- and long-term effects including anxiety, fear, and refusal of further care. Our analysis draws attention to the complex ways that hospital care providers and families of hospitalized surgical patients sought to establish and reconfigure how trust and patient-centeredness could be achieved under these unprecedented conditions. Practical learnings from this study suggest that if family presence in hospitals must be limited in the future, dedicated personnel for communication and emotional support for patients, families and staff must be prioritized., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2022 Published by Elsevier Ltd.)

In October 2018, prior to the legalization of cannabis in Canada, a survey was completed by 1050 Memorial University of Newfoundland students. Both descriptive quantitative and thematic qualitative data analyzes were used. Approximately 16% of the sample reported ever using cannabis for medicinal purposes (n=175), with only 16.6% of medicinal users reporting authorization by a healthcare provider (HCP). The majority (80.2%) were aware of possible side effects of cannabis. Prior personal experience (65.3%) and peer influence (59.5%) informed participants' medicinal use. Approximately 40% reported having replaced/reduced prescribed medication. Roughly 60% of medicinal users had not disclosed their use to their HCP. Consistent with previous studies, medicinal cannabis use among postsecondary students appears to be largely motivated for mental health related conditions and is grounded in personal experience versus evidence-based guidelines. There is a need for increased communication between HCPs and patients to promote lower-risk use among medicinal cannabis users., (© 2021. National Council for Behavioral Health.)

Importance: Patient-reported symptom burden was recently found to be associated with emergency department use and unplanned hospitalization (ED/Hosp) in patients with head and neck cancer. It was hypothesized that symptom scores could be combined with administrative health data to accurately risk stratify patients., Objective: To develop and validate a machine learning approach to predict future ED/Hosp in patients with head and neck cancer., Design, Setting, and Participants: This was a population-based predictive modeling study of patients in Ontario, Canada, diagnosed with head and neck cancer from January 2007 through March 2018. All outpatient clinical encounters were identified. Edmonton Symptom Assessment System (ESAS) scores and clinical and demographic factors were abstracted. Training and test cohorts were randomly generated in a 4:1 ratio. Various machine learning algorithms were explored, including (1) logistic regression using a least absolute shrinkage and selection operator, (2) random forest, (3) gradient boosting machine, (4) k-nearest neighbors, and (5) an artificial neural network. Data analysis was performed from September 2021 to January 2022., Main Outcomes and Measures: The main outcome was any 14-day ED/Hosp event following symptom assessment. The performance of each model was assessed on the test cohort using the area under the receiver operator characteristic (AUROC) curve and calibration plots. Shapley values were used to identify the variables with greatest contribution to the model., Results: The training cohort consisted of 9409 patients (mean [SD] age, 63.3 [10.9] years) undergoing 59 089 symptom assessments (80%). The remaining 2352 patients (mean [SD] age, 63.3 [11] years) and 14 193 symptom assessments were set aside as the test cohort (20%). Several models had high predictive accuracy, particularly the gradient boosting machine (validation AUROC, 0.80 [95% CI, 0.78-0.81]). A Youden-based cutoff corresponded to a validation sensitivity of 0.77 and specificity of 0.66. Patient-reported symptom scores were consistently identified as being the most predictive features within models. A second model built only with symptom severity data had an AUROC of 0.72 (95% CI, 0.70-0.74)., Conclusions and Relevance: In this study, machine learning approaches predicted with a high degree of accuracy ED/Hosp in patients with head and neck cancer. These tools could be used to accurately risk stratify patients and may help direct targeted intervention.

Background: Despite decades-long involvement of trauma survivors in hospital-based program delivery, their roles and impact on trauma care have not been previously described. We aimed to characterize the literature on trauma survivor involvement in hospital-based injury prevention, violence intervention and peer support programs to map what is currently known and identify future research opportunities., Methods: A scoping review was conducted following the Joanna Briggs Institute (JBI) methodology. Articles were identified through electronic databases and gray literature. Included articles described hospital-based injury prevention programs, violence intervention programs and peer support programs that involved trauma survivors leveraging their injury experiences to counsel others. Studies were screened and data were abstracted in duplicate. Data were synthesized generally and by program type., Results: Thirty-six published articles and four program reports were included. Peer support programs were described in 21 articles, mainly involving trauma survivors as mentors or peer supporters. Peer support programs' most commonly reported outcome was participant satisfaction (n = 6), followed by participant self-efficacy (n = 5), depression (n = 4), and community integration (n = 3). Eleven injury prevention studies were included, all involving trauma survivors as speakers in youth targeted programs. Injury prevention studies commonly reported outcomes of participants' risk behaviors and awareness (n = 9). Violence intervention programs were included in four articles involving trauma survivors as intervention counsellors. Recidivism rate was the most commonly reported outcome (n = 3). Variability exists across and within program types when reporting on involved trauma survivors' gender, age, selection and training, duration of involvement and number of survivors involved. Outcomes related to trauma survivors' own experiences and the impacts to them of program involvement were under-studied., Conclusions: Significant opportunity exists to fill current knowledge gaps in trauma survivors' involvement in trauma program delivery. There is a need to describe more fully who involved trauma survivors are to inform the development of effective future interventions., Competing Interests: Declaration of Competing Interests None declared., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Introduction: Following a cancer diagnosis, patients and their caregivers face crucial decisions regarding goals of care and treatment, which have consequences that can persist throughout their cancer journey. To foster informed and value-driven treatment choices, evidence-based information on outcomes relevant to patients is needed. Traditionally, clinical studies have largely focused on a few concrete and easily measurable outcomes such as survival, disease progression and immediate treatment toxicities. These outcomes do not capture other important factors that patients consider when making treatment decisions. Patient-centred outcomes (PCOs) reflect the patients' individual values, preferences, needs and circumstances that are essential to directing meaningful and informed healthcare discussions. Often, however, these outcomes are not included in research protocols in a standardised and practical fashion. This scoping review will summarise the existing literature on PCOs in gastrointestinal (GI) cancer care as well as the tools used to assess these outcomes. A comprehensive list of these PCOs will be generated for future efforts to develop a core outcome set., Methods and Analysis: This scoping review will follow Arksey and O'Malley's expanded framework for scoping reviews. We will systematically search Medline, Embase, CINAHL, Cochrane Library and APA PsycINFO databases for studies examining PCOs in the context of GI cancer. We will include studies published in or after the year 2000 up to the date of the final searches, with no language restrictions. Studies involving adult patients with GI cancers and discussion of any PCOs will be included. Opinion pieces, protocols, case reports and abstracts will be excluded. Two authors will independently perform two rounds of screening to select studies for inclusion. The data from full texts will be extracted, charted and summarised both quantitatively and qualitatively., Ethics and Dissemination: No ethics approval is required for this scoping review. Results will be disseminated through scientific publication and presentation at relevant conferences., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Importance: Patients with head and neck cancer manage a variety of symptoms at home on an outpatient basis. Clinician review alone often leaves patient symptoms undetected and untreated. Standardized symptom assessment using patient-reported outcomes (PROs) has been shown in randomized clinical trials to improve symptom detection and overall survival, although translation into real-world settings remains a challenge., Objective: To better understand how patients with head and neck cancer cope with cancer-related symptoms and to examine their perspectives on standardized symptom assessment., Design, Participants, and Setting: This was a qualitative analysis using semistructured interviews of patients with head and neck cancer and their caregivers from November 2, 2020, to April 16, 2021, at a regional tertiary center in Canada. Purposive sampling was used to recruit a varied group of participants (cancer subsite, treatment received, sociodemographic factors). Drawing on the Supportive Care Framework, a thematic approach was used to analyze the data. Data analysis was performed from November 2, 2020, to August 2, 2021., Main Outcomes and Measures: Patient perception of ambulatory symptom management and standardized symptom assessment., Results: Among 20 participants (median [range] age, 59.5 [33-74] years; 9 [45%] female; 13 [65%] White individuals), 4 themes were identified: (1) timely physical symptom management, (2) information as a tool for symptom management, (3) barriers to psychosocial support, and (4) external factors magnifying symptom burden. Participants' perceptions of standardized symptom assessment varied. Some individuals described the symptom monitoring process as facilitating self-reflection and symptom detection. Others felt disempowered by the process, particularly when symptom scores were inconsistently reviewed or acted on., Conclusions and Relevance: This qualitative analysis provides a novel description of head and neck cancer symptom management from the patient perspective. The 4 identified themes and accompanying recommendations serve as guides for enhanced symptom monitoring.

Objective: People with HIV (PWH) and co-infected with hepatitis C virus (PWH + HCV) have increased risk of cardiovascular disease (CVD). Peri-coronary inflammation, measured by fat attenuation index (FAI) on coronary computed tomography angiography (CCTA), independently predicts cardiovascular risk in the general population but has not been studied in the PWH + HCV population. We tested whether peri-coronary inflammation is increased in PWH or PWH + HCV, and whether inflammation changes over time., Design: Cross-sectional analysis to determine FAI differences among groups. Longitudinal analysis in PWH to assess changes in inflammation over time., Methods: Age-matched and sex-matched seropositive groups (PWH and PWH + HCV) virologically suppressed on antiretroviral therapy, HCV viremic, and without prior CVD and matched controls underwent CCTA. Peri-coronary FAI was measured around the proximal right coronary artery (RCA) and left anterior descending artery (LAD). Follow-up CCTA was performed in 22 PWH after 20.6-27.4 months., Results: A total of 101 participants (48 women) were studied (60 PWH, 19 PWH + HCV and 22 controls). In adjusted analyses, peri-coronary FAI did not differ between seropositive groups and controls. Low attenuation coronary plaque was significantly less common in seropositive groups compared with controls (LAD, P = 0.035; and RCA, P = 0.017, respectively). Peri-coronary FAI values significantly progressed between baseline and follow-up in PWH (RCA: P = 0.001, LAD: P = <0.001)., Conclusion: PWH and PWH + HCV without history of CVD do not have significantly worse peri-coronary inflammation, assessed by FAI, compared with matched controls. However, peri-coronary inflammation in mono-infected PWH significantly increased over approximately 22 months. FAI measures may be an important imaging biomarker for tracking asymptomatic CVD progression in PWH., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Medical trainees' negative perceptions towards older adult care have been widely reported, catalyzing targeted curricula in geriatric medicine. Little is known about surgical residents' attitudes toward and perceptions of the educational value of caring for injured older adults. This information is needed to ensure the surgical workforce is adequately trained to care for this growing patient population. In this study, we assessed surgical trainees' attitudes towards geriatric trauma care to inform a curriculum in geriatric trauma., Methods: We surveyed North American general surgery trainees' beliefs and attitudes toward caring for older trauma patients, and the educational value they ascribed to learning about older trauma patient care. Descriptive statistics were used to report participant characteristics and responses., Results: Three hundred general surgery trainees from 94 post-graduate programs responded. Respondents reported too much time co-ordinating care (56%), managing non-operative patients (56%), and discharge planning (65%), all activities important to the care of older trauma patients. They recognized the importance of geriatric trauma care for their future careers (52%) but were least interested in reading about managing geriatric trauma patients (28%). When asked to rank clinical vignettes by educational value, respondents ranked the case of an older adult as least interesting (74%). As respondents progressed through their training, they reported less interest in geriatric trauma care., Conclusions: Our survey results demonstrate the generally negative attitudes and beliefs held by postgraduate surgical trainees towards the care of older adult trauma patients. Future work should focus on identifying specific changes to the postgraduate surgical curriculum which can effectively alter these attitudes and beliefs and improve the care for injured older adults., (© 2022. The Author(s).)

Competing Interests: The authors report no conflicts of interest.

Purpose: Transitions across care settings can be stressful for trauma patients, and when poorly executed, can lead to poor outcomes. Early physical medicine and rehabilitation (PM&R) consults in acute care settings can optimize the continuum of care for trauma patients, but there is a need for additional insight on its impact. This study aimed to better understand how early PM&R consults influence the continuum of care between acute and rehabilitation trauma settings., Methods: Four focus groups were conducted with 21 trauma acute care and rehabilitation staff, and data were analyzed via content analysis., Results: The main themes identified were: (1) patient-level considerations (i. readiness for rehab [mental health]; ii. patient education and expectations for rehab); (2) clinical-team considerations (i. physiatry role clarity and role limitations; ii. access and accuracy of information; iii. departmental silos); and (3) system-level considerations (i. occupancy and discharge pressures; ii. inter-facility coordination and patient flow)., Conclusions: Although both acute and rehabilitation care staff find early PM&R consults as being important to support the recovery of trauma patients, there is a need for greater role clarity of the physiatrist across settings and a more refined implementation approach to better meet the communication needs of clinical staff. Implications for RehabilitationEarly physical medicine and rehabilitation consults are seen by acute care and rehabilitation front-line staff as valuable for optimizing the continuum of trauma care.There is a lack of clarity on the role of physiatrists among acute care and rehabilitation clinical staff.The physiatrist plays an important role to help prepare trauma patients for rehabilitation. For patients with complex physical and/or mental health challenges, the physiatrist can also serve as an advocate for access to rehabilitation services.

Objective: To appraise the quality of reporting on guideline, protocol, and algorithm implementations in adult trauma settings according to the Revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0)., Background: At present we do not know if published reports of guideline implementations in trauma settings are of sufficient quality to facilitate replication by other centers wishing to implement the same or similar guidelines., Methods: A systematic review of the literature was conducted. Articles were identified through electronic databases and hand searching relevant trauma journals. Studies meeting inclusion criteria focused on a guideline, protocol, or algorithm that targeted adult trauma patients ≥18 years and/or trauma patient care providers, and evaluated the effectiveness of guideline, protocol, or algorithm implementation in terms of change in clinical practice or patient outcomes. Each included study was assessed in duplicate for adherence to the 18-item SQUIRE 2.0 criteria. The primary endpoint was the proportion of studies meeting at least 80% (score ≥15) of SQUIRE 2.0., Results: Of 7368 screened studies, 74 met inclusion criteria. Thirty-nine percent of studies scored ≥80% on SQUIRE 2.0. Criteria that were met most frequently were abstract (93%), problem description (93%), and specific aims (89%). The lowest scores appeared in the funding (28%), context (47%), and results (54%) criteria. No study indicated using SQUIRE 2.0 as a guideline to writing the report., Conclusions: Significant opportunity exists to improve the utility of guideline implementation reports in adult trauma settings, particularly in the domains of study context and the implications of context for study outcomes., Competing Interests: The authors report no conflicts of interest., (Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Rates of contralateral prophylactic mastectomy (CPM) have doubled over the last decade among women considered low risk for developing contralateral breast cancer. Despite the strong association between CPM and breast reconstruction, little is known about the clinical encounter between patients and plastic surgeons. A qualitative study was performed to understand how plastic surgeons describe their roles in the treatment decision-making process through their consultations with women who have unilateral early-stage breast cancer., Methods: Semi-structured interviews with Ontario plastic surgeons were conducted. An inductive and interpretive thematic approach was initially used to analyze the data. The four principles of biomedical ethics then served as the conceptual lens to interpret the findings., Results: The participants in this study were 18 plastic surgeons, and data saturation was reached. Four themes were identified: maintaining non-maleficence, supporting patient autonomy, delivering (un)equal health care, and providing care to enhance well-being. The ongoing push-pull between competing ethical principles was the overarching theme, specifically, striving to balance parallel responsibilities to do no harm while also respecting patients' rights to make their own healthcare decisions., Conclusions: In this patient-centric climate, it is important to acknowledge that patients may value outcomes such as achieving greater peace of mind above other clinical factors and are willing to incur additional risks to achieve these goals. Shared decision-making will help to reveal the rationale underlying each individual's treatment choice, which in turn will allow physicians to appropriately weigh patient requests with the best available medical evidence when counseling women on decision-making for breast cancer care.

Background: The American College of Surgeons' Trauma Quality Improvement Program (TQIP) provides trauma centres with performance reports on their processes and outcomes of care relative to their peers. This study explored how performance reports are used by trauma centre leaders to engage in performance improvement and perceived barriers to use., Study Design: Qualitative focus group study with trauma medical directors (TMDs) and trauma programme managers (TPMs) in US trauma centres. Consistent with qualitative descriptive analysis, data collection and interpretation were inductively and iteratively completed. Major themes were derived using a constant comparative technique., Results: Six focus groups were conducted involving 22 TMDs and 22 TPMs. Three major themes were captured: (1) technical uses of performance reports; (2) cultural uses of performance reports; (3) opportunities to enhance the role and value of TQIP. First, technical uses included using reports to assess data collection procedures, data quality and areas of poor performance relative to peers. In this domain, barriers to report use included not trusting others' data quality and challenges with report interpretation. Second, reports were used to influence practice change by fostering inter-specialty discussions, leveraging resources for quality improvement, community engagement and regional collaboratives. Perceived lack of specialist engagement was viewed as an impediment in this domain. Lastly, identified opportunities for TQIP to support report use involved clarifying the relationship between verification and performance reports, and increasing partnerships with nursing associations., Conclusion: Trauma centre improvement leaders indicated practical and social uses of performance reports that can affect intention and ability to change. Recommendations to optimise programme participation include a focus on data quality, adequate resource provision and enhanced support for regional collaboratives., Competing Interests: Competing interests: AN is Medical Director of the American College of Surgeons’ trauma quality programmes. CH is Manager of Data and Report Operations at American College of Surgeons. MN is Program Manager, Trauma Quality Improvement Program at American College of Surgeons., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Compassion fatigue (CF) is the profound sense of emotional exhaustion that care providers can experience as the result of helping others in distress. CF can contribute to burnout (BO), depression, and stress-related illness. While surgeons and surgical trainees may be at high risk for developing CF, it has not been adequately characterized or explored in this population. The objective of this study was to examine the prevalence and impact of CF in surgical trainees with a view to inform a management strategy., Study Design and Setting: A mixed method study was conducted using survey and interview methods. An email survey including the Professional Quality of Life Scale Version 5, an instrument to assess CF, was sent to all trainees in the Department of Surgery at the University of Toronto. Survey data were analyzed descriptively and using one-sample t tests. Semistructured interviews were conducted with volunteered trainees. Data collection and analysis occurred iteratively and inductively using the constant comparison method., Results: One hundred fifteen trainees completed the survey representing a 47% response rate. Ninety-nine respondents (40.7%) completed the Professional Quality of Life Scale tool. The mean score on the compassion satisfaction subscale was 36.9 (SD 6.7), on the BO subscale was 26.2 (SD 5.6), and on the secondary traumatic stress (STS) subscale was 21.2 (SD 6.3). The mean on the compassion satisfaction subscale was not statistically different from the population mean (p = 0.22). The means for the BO and STS scales were statistically higher in our study sample compared to the normative data (p < 0.0001 for each). Thematic qualitative findings indicated trainees experienced CF symptoms. Participants described systemic barriers to mitigating CF including workload and a cultural expectation to be unemotional at work., Conclusion: Surgical trainees report high levels of BO and STS and currently use informal coping strategies outside of their academic and hospital environments. Trainees are likely to welcome and benefit from an organized response to support their emotional health when facing difficult patient encounters., (Copyright © 2019 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Quality improvement (QI) training is an essential component of postgraduate surgical education and can occur through formal and informal education programs. Informal QI education requires that faculty take advantage of learning opportunities in the hospital setting. Trauma rotations appear ideal opportunities for informal QI learning given that performance improvement is a mandatory component of care at verified trauma centers. It is unclear, however, whether QI initiatives within trauma programs are well integrated into trainee education. This study explored the QI learning environment in a level 1 academic trauma center., Study Design: An ethnographic study using observation and interviews methods. The theoretical lens of hidden curriculum was used to interpret the data and generate hypotheses around faculty and trainee experiences., Setting: University of Toronto and Sunnybrook Health Sciences Center., Participants: Twenty-seven observations involving more than 50 faculty and trainees; seventeen interviews with faculty and surgical trainees., Results: All faculty and trainees endorsed QI and informal QI learning. Discrepant experiences were found regarding opportunities to learn and do QI in the clinical setting. Faculty viewed themselves as perpetually doing and teaching QI while trainees perceived little to no QI learning. Trainees identified Morbidity and Mortality rounds as the main opportunity for QI learning; however, traditional teaching style through "pimping" and a largely clinical focus acted as barriers to QI education. Furthermore, trainees chiefly viewed QI as service to the institution, rather than as a form of learning, which contributed to their disinterest in taking up informal QI lessons., Conclusion: Informal QI education is highly valued and desired in academic trauma centers but enduring teaching methods, inconsistencies in the cultural learning environment and a hidden curriculum devaluing QI learning are persistent barriers to change., (Copyright © 2018 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: General surgeons’ retirement plans have wide-ranging personal, professional and system-level effects. We explored the drivers of and barriers to surgeon retirement to identify opportunities to support career-long retirement planning., Methods: We conducted a qualitative study from May to October 2016 using semi-structured telephone interviews (mean duration 29 min) with general surgeons in Ontario. We used a purposive sampling strategy to recruit surgeons at 3 career stages (no plans to retire within next 5 yr, had slowed down practice or planned to slowdown within 5 yr, and no longer operating as primary surgeon). We analyzed the data using established techniques of thematic analysis., Results: We interviewed 22 general surgeons. Their retirement status ranged from fully retired to no plans to retire. Preservation of reputation and quality care, commitment and succession planning, and retirement planning were dominant themes. Mid-career and senior surgeons’ plans were made later in their careers and were driven by desires to preserve reputations and surgical identity. Younger surgeons’ (≤ 50 yr) early retirement was driven by lifestyle choices and work environment. Logistical barriers and financial insecurity led to retirement delay., Conclusion: Surgeons begin to plan for retirement both early and late in their careers. Most surgeons wish to establish retirement plans that allow for the gradual reduction of surgical patient care and the creation of job opportunities for younger colleagues balanced by a continued contribution to the profession. Opportunities to support surgeons at all career stages in their retirement planning require further exploration., Competing Interests: None declared.

Background: Studies in the intensive care unit (ICU) suggest that better communication between families of critically ill patients and healthcare providers is needed; however, most randomized trials targeting interventions to improve communication have failed to achieve family-centered outcomes. We aim to offer a novel analysis of the complexities involved in building positive family-provider relationships in the ICU through the consideration of not only communication but other important aspects of family-provider interactions, including family integration, collaboration, and empowerment. Our goal is to explore family members' perspectives on the enablers and challenges to establishing therapeutic alliance with ICU physicians and nurses., Methods: We used the concept of therapeutic alliance as an organizational and analytic tool to conduct an interview-based qualitative study in a 20-bed adult medical-surgical ICU in an academic hospital in Toronto, Canada. Nineteen family members of critically ill patients who acted as substitute decision-makers and/or regularly interacted with ICU providers were interviewed. Participants were sampled purposefully to ensure maximum variation along predetermined criteria. A hybrid inductive-deductive approach to analysis was used., Results: Participating family members highlighted the complementary roles and practices of ICU nurses and physicians in building therapeutic alliance. They reported how both provider groups had profession specific and shared contributions to foster family communication, integration, and collaboration, while physicians played a key role in family empowerment. Families' lack of familiarity with ICU personnel and processes, physicians' sporadic availability and use of medical jargon during rounds, however, reinforced long established power differences between lay families and expert physicians and challenged family integration. Family members also identified informal interactions as missed opportunities for relationship-building with physicians. While informal interactions with nurses at the bedside facilitated therapeutic alliance, inconsistent and ad-hoc interactions related to routine decision-making hindered family empowerment., Conclusions: Multiple opportunities exist to improve family-provider relationships in the ICU. The four dimensions of therapeutic alliance prove analytically useful to highlight those aspects that work well and need improvement, such as in the areas of family integration and empowerment.

Background: Miniature size in horses represents an extreme reduction of withers height that originated after domestication. In some breeds, it is a highly desired trait representing a breed- or subtype-specific feature. The genomic changes that emerged due to strong-targeted selection towards this distinct type remain unclear., Results: Comparisons of whole-genome sequencing data from two Miniature Shetland ponies and one standard-sized Shetland pony, performed to elucidate genetic determinants for miniature size, revealed four synergistic variants, limiting withers height to 34.25 in. (87 cm). Runs of homozygosity regions were detected spanning these four variants in both the Miniature Shetland ponies and the standard-sized Shetland pony. They were shown to be characteristic of the Shetland pony breed, resulting in a miniature type under specific genotypic combinations. These four genetic variants explained 72% of the size variation among Shetland ponies and related breeds. The length of the homozygous regions indicate that they arose over 1000 years ago. In addition, a copy number variant was identified in DIAPH3 harboring a loss exclusively in ponies and donkeys and thus representing a potential height-associated variant., Conclusion: This study reveals main drivers for miniature size in horses identified in whole genome data and thus provides relevant candidate genes for extremely short stature in mammals.

Introduction: Quality improvement (QI) is mandatory in trauma centres but there is no prescription for doing successful QI. Considerable variation in implementation strategies and inconsistent use of evidence-based protocols therefore exist across centres. The quality of reporting on these strategies may limit the transferability of successful initiatives across centres. This systematic review will assess the quality of reporting on guideline, protocol or algorithm implementation within a trauma centre in terms of the Revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0)., Methods and Analysis: We will search for English language articles published after 2010 in EMBASE, MEDLINE, CINAHL electronic databases and the Cochrane Central Register of Controlled Trials. The database search will be supplemented by searching trial registries and grey literature online. Included studies will evaluate the effectiveness of guideline implementation in terms of change in clinical practice or improvement in patient outcomes. The primary outcome will be a global score reporting the proportion of studies respecting at least 80% of the SQUIRE 2.0 criteria and will be obtained based on the 18-items identified in the SQUIRE 2.0 guidelines. Secondary outcome will be the risk of bias assessed with the Risk Of Bias In Non-randomised Studies- of Interventions tool for observational cohort studies and with the Cochrane Collaboration tool for randomised controlled trials. Meta-analyses will be conducted in randomised controlled trials to estimate the effectiveness of guideline implementation if studies are not heterogeneous. If meta-analyses are conducted, we will combine studies according to the risk of bias (low, moderate or high/unclear) in subgroup analyses. All study titles, abstracts and full-text screening will be completed independently and in duplicate by the review team members. Data extraction and risk of bias assessment will also be done independently and in duplicate., Ethics and Dissemination: Results will be disseminated through scientific publication and conferences., Prospero Registration Number: CRD42018084273., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)