Citations

Surgeons are at high risk of developing long-term Work-Related Musculoskeletal Disorders (WMSDs) due to awkward sustained postures. Passive spine-supporting exoskeletons are a potential intervention to improve posture and reduce fatigue. The NekSpine ® was evaluated by 21 surgeons (15 male) across two hospital sites within a quaternary academic hospital system. Each surgeon performed at least two comparable procedures, one with the exoskeleton and one without. Surgeons completed pre- and postoperative surveys assessing NASA-TLX workload, usability, body-part discomfort, overall fatigue, and workflow disruptions. Eighty-two cases were evaluated (43 exoskeleton cases). Compared with baseline cases, surgeons reported reduced neck and upper back discomfort and lower overall fatigue when using the exoskeleton. The NekSpine ® exoskeleton may reduce spinal discomfort and fatigue during surgery, supporting its potential as an ergonomic intervention for surgeons.

Background Surgeons face elevated risks of musculoskeletal disorders due to prolonged operating times, awkward postures, and repetitive tasks, which can impair performance and well-being. Microbreaks have emerged as a potential ergonomic intervention to reduce discomfort and fatigue during surgery. Objective The main goal of this study was to investigate and compare the intraoperative usability and effectiveness of two break scheduling strategies using the OR-Stretch TM Web-App. Furthermore, surgeons’ feedback on the primary barriers to implementation of the OR-Stretch Web-App was recorded. Methods This study used a randomized, within-subjects crossover design. Fourteen surgeons (eight females) performed three surgical procedures with the following microbreak schedules; (1) microbreaks every 30 min with an optional ten-minute snooze (Break-30), (2) microbreaks every 60 min with an optional ten-minute snooze (Break-60), or (3) no microbreaks (Baseline). Outcomes were measured using self-reported subjective surveys (e.g., discomfort, fatigue, workload, and usability). Results Surgeons found both Break-30 and Break-60 conditions aided physical performance, mental focus, body pain/discomfort, and level of fatigue (self-reported improvement between 28.6% and 78.6%). No significant differences were observed in surgeons’ subjective evaluations of the Break-30 and Break-60 conditions; however, the data suggest that Break-60 is preferable to the Break-30 condition. Conclusions This study provides evidence supporting the OR-Stretch Web-App as a potential surgical ergonomic intervention. However, enhancing the Web-App's user-friendliness and developing strategies to synchronize microbreaks with appropriate times during surgeries, to avoid disrupting the surgical workflow, are critical areas for future studies.

e16018 Background: Intrahepatic cholangiocarcinoma (iCCA) exhibits marked heterogeneity in outcomes that is incompletely explained by stage or treatment timing. Although treatment delay is frequently cited as a modifiable risk factor, its prognostic significance in real-world practice remains unclear. We applied machine learning (ML) to model iCCA as a dynamic disease process and to evaluate whether longitudinal disease trajectories better explain outcomes than treatment timing alone. Methods: We conducted a population-based retrospective analysis of adults diagnosed with iCCA using the Surveillance, Epidemiology, and End Results (SEER) database (2000–2022). Time from diagnosis to first cancer-directed therapy was categorized as ≤30 days, 31–60 days, or > 60 days. Associations between treatment delay, disease characteristics, and overall survival (OS) were assessed using multivariable logistic and Cox regression models. To capture real-world disease evolution, each patient’s clinical course was encoded as an ordered longitudinal sequence of diagnosis, treatment states (surgery, chemotherapy, radiation), and outcome. Unsupervised ML was used to identify latent disease-course trajectories. A supervised ML model using variables available at diagnosis was developed to predict membership in high-risk trajectories. Results: The cohort included 18,312 patients with iCCA. Treatment initiation beyond 30 days occurred in more than half of patients and was more common in localized than advanced disease. In adjusted survival analyses, shorter time to treatment was paradoxically associated with worse OS, consistent with confounding by disease severity rather than a protective effect of delay. Unsupervised ML identified four distinct and reproducible disease trajectories with markedly different outcomes. Median OS ranged from approximately 2 months in early-failure trajectories to approximately 15 months in favorable multimodality trajectories. Trajectory membership was not fully explained by stage or treatment timing. A supervised ML model predicted high-risk trajectory membership with good discrimination (AUC 0.82). Key predictors included tumor grade, age, tumor burden, and incomplete staging, whereas treatment timing had minimal influence. Conclusions: In iCCA, treatment delay reflects underlying disease biology and care prioritization rather than independently determining survival. ML-based trajectory modeling reveals clinically meaningful disease courses that better explain outcome heterogeneity than treatment timing or stage alone and enables early identification of patients at highest risk for unfavorable real-world outcomes.

9021 Background: An escape room is a team-based activity in which participants collaborate to solve puzzles within a fixed time limit and escape. Prior studies demonstrate high learner satisfaction and improved teamwork and communication with medical education escape rooms. To date, no published reports describe an escape room designed specifically for hematology/oncology (hem/onc) fellows. As part of Hem/Onc Curriculum, we designed and implemented a hem/onc-focused escape room and evaluated learner satisfaction and perceived learning impact. Methods: The escape room was designed using evidence-based learning science principles (Table 1). Teams worked to solve sequential puzzles, centered on a patient case, addressing key hem/onc concepts, including transfusion medicine, peripheral blood smears, lymphoma classification, and coagulation disorders. Each solved puzzle revealed additional patient laboratory and pathology data. Successful completion required teams to diagnose the patient and select appropriate treatment. Following the activity, teams participated in a facilitator-led debrief focused on team dynamics, communication, and problem solving. Teams observed each other and shared feedback. A larger group debrief co-led by chief fellows and faculty reviewed learning objectives and key takeaways. Learner outcomes were assessed using a post-activity survey evaluating satisfaction, engagement, and impact on learning. Results: Eighteen learners participated, including 14 hem/onc fellows, 1 APP hem/onc fellow, and 3 internal medicine residents. Three of four teams escaped within 1 hour (mean completion time, 52 minutes). All participants provided positive verbal feedback. Fifteen learners completed the post-activity survey, and all respondents reported satisfaction with the activity and would recommend it for future fellows. One-word descriptors included “engaging,” “fun,” and “challenging.” Most respondents (93.3%) agreed that the activity reinforced key hem/onc concepts and improved confidence in clinical problem-solving. All learners felt the activity supported learning, and 93.3% reported that collaboration enhanced the learning experience. Participants identified team-based problem solving, clinical application, and interactive puzzles as the most effective components. Conclusions: A hem/onc escape room resulted in high learner satisfaction and reinforced hem/onc knowledge and clinical problem-solving. This feasible, fun, and innovative activity complements traditional fellowship education by leveraging adult learning principles through gamified, team-based learning and should be incorporated into training programs’ curriculum. Learning science principles applied in a hem/onc escape room. Active Learning Belonging Contrasting Cases Debriefing Deliberate Practice Elaboration Generation Listening and Sharing Reward Worked Examples

Abstract Objectives: Community-acquired intra-abdominal infections (CA-IAIs) are a leading cause of US hospitalizations. Piperacillin-tazobactam is often used to empirically treat CA-IAIs, despite national guidelines recommending narrower-spectrum antibiotics for these infections. The overuse of broad-spectrum agents such as piperacillin-tazobactam contributes to antibiotic resistance, which poses serious public health challenges. This resident-led quality improvement initiative aimed to reduce unnecessary piperacillin-tazobactam use for treating CA-IAIs measured as DOT/1,000 patient-days by 10% without adversely affecting hospital length of stay (LOS). Methods: Using the DMAIC (define, measure, analyze, improve, control) framework, we identified barriers to appropriate antibiotic use and developed a treatment algorithm for CA-IAIs that included clear guidelines and exclusion criteria. This algorithm was disseminated to internal medicine residents and emergency department physicians along with educational sessions to highlight updated CA-IAI treatment recommendations, antibiotic resistance, and appropriate antibiotic ordering via the electronic health record. Antimicrobial stewardship pharmacists provided overnight support to assist with de-escalation. Data were collected over a 10-month period spanning 2 intervention phases. The primary outcome was piperacillin-tazobactam use, measured as days of therapy (DOT) per 1,000 patient-days and DOT per patient LOS. Mean LOS served as the balancing measure. Results: Piperacillin-tazobactam use was significantly reduced ( P < .001) after the interventions without increasing the mean LOS. Conclusion: This project raised awareness of antibiotic resistance and led to lasting improvements in reducing the inappropriate use of piperacillin-tazobactam to treat CA-IAIs, without affecting the mean LOS. This was attributed to the strong collaboration among a multidisciplinary team of infectious disease physicians, antimicrobial stewardship team members, residents, emergency department physicians, and faculty.

Introduction: The use of intravascular ultrasound (IVUS) to guide lower extremity deep venous stent placement is associated with improved identification of the degree of maximal vessel stenosis, vessel obstruction, and thrombus burden, compared to venography alone. As the US medical system moves towards value-based care, the financial impact of interventional tools requires close consideration. Currently, there are limited evaluations of the cost effectiveness of IVUS during venous procedures. Research Question: This study seeks to examine the cost-effectiveness of IVUS in lower extremity deep venous interventions. Methods: Medicare fee-for-service claims data from 2016 through 2021 for beneficiaries aged ≥ 65 years undergoing lower extremity venous interventions with stent placement, thrombolysis, and/or thrombectomy were analyzed. Cost ratios between IVUS-guided and non-IVUS-guided procedures were assessed using gamma regression, adjusting for demographic and clinical variables. Results: A total of 52,610 patients were included, with 42.6% undergoing IVUS-guided procedures. IVUS utilization varied by setting, with higher usage in hospital-based outpatient centers (75.3%) and ambulatory surgical centers/outpatient-based laboratories (ASC/OBL; 86.4%) compared to inpatient hospitalizations (10.4%). Among inpatient procedures, IVUS-guided venous intervention was associated with greater cost than non-IVUS procedures at 90 days, with an adjusted cost ratio of 1.04 (95% CI 1.01-1.07), yet was associated with an average 0.6-day shorter hospitalization (p < 0.001; Figure 1, Figure 2 ). There were marginal increased costs associated with use of IVUS in inpatient procedures persisting through one- and three-years follow-up, with adjusted cost ratios of 1.05 (95% CI 1.02-1.08) and 1.05 (95% CI 1.02-1.09), respectively. In contrast, IVUS use was associated with significant cost savings in outpatient settings, with adjusted cost ratios of 0.71 (95% CI 0.69-0.73) in hospital-based outpatient settings and 0.75 (95% CI 0.73-0.78) in ASC/OBL at 90 days. These cost savings persisted at one- and three-year follow-up. Conclusions: IVUS-guided venous intervention was associated with cost savings in outpatient and ASC/OBL settings, while maintaining near cost equivalence in inpatient settings. These findings suggest that in addition to the clinical benefit of IVUS for venous intervention, IVUS is a cost-effective strategy, particularly in the outpatient setting.

Objective: To evaluate the effectiveness of an intraoperative exoskeleton that supports surgeons’ heads, necks, and backs to reduce neck discomfort. Background: Surgeons are at a considerable risk of developing neck pain and related injuries. Passive exoskeletons are a potential intervention to support surgeons’ body parts and alleviate strain and discomfort. Methods: The NekSpine (a passive neck exoskeleton) was trialed on 12 surgeons (7 males and 5 females) across 6 specialties. Each surgeon performed 4 surgical procedures, 2 with the NekSpine (exoskeleton) and 2 without (baseline). Exoskeleton and baseline surgeries were paired primarily by surgical procedure and secondarily by duration. Surgeons completed surveys that included the NASA-TLX and usability questions before and after surgical procedures to evaluate body part discomfort, overall fatigue, workload, and potential disruptions to the surgical workflow. Surgeons also wore inertial measurement units to objectively record their upper arms, neck, and torso postures. Results: Use of the exoskeleton yielded significant decreases in discomfort in the neck, left shoulder, right shoulder, and left arm. Reductions in percent surgical duration in risk 4 (extreme risk postures) coupled with increases spent in risk 2 (moderate risk postures) for the neck and torso were noted. Surgeons reported overall favorable usability results with the exoskeleton not interfering with the surgical workflow, and most stated that they would use the exoskeleton again. Conclusions: The NekSpine is a promising intervention to alleviate surgeons’ neck discomfort and improve their neck and torso postures.

Inadequate light penetration in tissues restricts photodynamic therapy to treating only superficial tumors. To enable x-ray–excited photodynamic therapy (XPDT) that targets deep-seated tumors, we synthesized a nanoscintillator-photosensitizer complex containing 5% Eu-doped Y 2 O 3 fluorescing at 611 nanometers and decorated with SiO 2 containing the scintillation-coupled photosensitizer methylene blue and a polyethylene glycol coating [PEGylated Y 2 O 3 :Eu@SiO 2 -methylene blue (pYSM)]. When irradiated, pYSMs generate singlet oxygen species in vitro, causing cytotoxicity with hallmarks of immunogenic cell death (calreticulin translocation to the cell membrane). Intravenously administered pYSMs home passively to pancreatic tumor xenografts and, upon 10 gray irradiation, cause significant tumor regression ( P < 0.01). On combining XPDT with anti-PD1 immunotherapy, a distant nonirradiated tumor also regresses via an increase in intratumoral activated CD8 + cytotoxic T cells. Collectively, we advance a systemically delivered XPDT strategy that mediates an antitumor effect in both irradiated and nonirradiated (abscopal) tumors when coupled with immunotherapy, converting an immunologically “cold” tumor to an immunologically “hot” tumor.

Burnout is a challenging issue among surgeons. Many factors have been linked to burnout, such as an inadequate work-life balance, high stress levels, and the frequency of on-call, overnight shifts. There is a lack of research on factors in surgeons’ daily lives associated with burnout. This study observed trauma surgeons with daily surveys assessing stress and fatigue over 9 days (6 day shifts, three night shifts). This study analyzes surgeons’ stress and fatigue levels. The study population was compared to the population of US critical care surgeons to ensure representativeness based on age, sex, and rates of burnout. Overnight shifts showed high stress and fatigue levels relative to off days, day shifts, the 3 days before, and the 3 days after overnight shifts. Days performing surgery were also more stressful and fatiguing than non-surgery work days and off days. Fatigue and stress levels were minimized during off days.