Implication Statement Is your resident call schedule fairly distributed between your residents? We thought so for Family Medicine in Saskatchewan, but an analysis of two years of schedule data indicated otherwise. Over the two-year program, the average per-resident call burden ranged from 0.44 to 1.2 shifts per week. Using the ratio of total shifts to total weeks to consistently quantify resident call burden across sites, we highlight the value of longer-term metrics and demonstrate how other institutions may also develop more equitable call schedules.

Background and Objectives: Intrauterine device (IUD) placement is common in primary care and is a required training objective of family medicine postgraduate programs. Ultrasound guidance is available to assist medical trainees with determining the correct uterine position and proper IUD placement, providing immediate confirmation for both the clinician and the patient. In the present study, we sought to determine whether ultrasound-guided versus nonultrasound-guided IUD placement within a family medicine training environment improves resident confidence, as well as patient pain scores and procedural time. Methods: We conducted a prospective, randomized controlled trial of IUD placement by ultrasound guidance versus no ultrasound at the family medicine resident training clinic in Saskatoon, Saskatchewan, Canada. We compared resident confidence pre- and postprocedure, patient-reported pain scores at three time points, and total procedure time between the ultrasound-guided and control groups using marginal models. Confidence levels and pain scores were reported using 0- to 10-point box scales. Results: A total of 49 patients and 30 residents were enrolled. The average increase in resident-reported confidence was greater in the ultrasound-guided group (mean difference = 1.2 points, P=.01). Patient pain scores were similar between the ultrasound and control groups at all time points (mean difference=–0.2 points, P=.45). Procedural time in the ultrasound-guided group was longer (mean difference = 10.9 minutes, P=.03). Conclusions: Ultrasound-guided IUD placement results in improved family medicine resident-reported confidence without compromising patient comfort.

INTRODUCTION:Family medicine residents at the University of Saskatchewan's La Ronge Family Medicine Residency Training Programme provide resident-led clinics, based on community-identified needs, to serve patients who might experience barriers to care. Learners are challenged to advance their independent clinical decision-making while gaining experience providing culturally informed and sensitive care. This study aimed to determine how the La Ronge resident-led clinics could be further optimised for both resident training and healthcare delivery. METHODS:We interviewed La Ronge Residency Training Programme graduates over the past 6 years (2018-2023). Interviews were conversational, with a semi-structured guide. Questions inquired about the impact the clinics had on participants, benefits, drawbacks and suggestions for change. Following the interviews, an inductive, reflective, thematic analysis was undertaken. RESULTS:Response rate was 100% (n = 15). Six themes emerged: building skills for practice with distant supervision; overcoming barriers and resource limitations; awareness of inequities; building culturally respectful relationships; optimising clinic utilisation; and ways of implementing change. Participants felt resident-led clinics encouraged their growth like no other opportunity in the Residency Training Programme. The level of independence in resident-led clinics came with a trade-off in supervision, as there was a desire to balance these aspects. CONCLUSIONS:Resident-led clinics promoted professional and personal development. Additional community collaboration, along with optimising clinic utilisation, such as improved translational and booking services, could benefit patients, communities and residents. INTRODUCTION:Les résidents en médecine familiale du programme de résidence en médecine familiale de La Ronge, de l'Université de la Saskatchewan, offrent des cliniques dirigées par des résidents, en fonction des besoins identifiés par la communauté, afin de servir les patients qui pourraient rencontrer des obstacles à l'accès aux soins. Les apprenants sont appelés à développer leur autonomie dans la prise de décisions cliniques tout en acquérant de l'expérience dans la prestation de soins culturellement adaptés et sensibles. Cette étude avait pour objectif de déterminer comment les cliniques dirigées par les résidents de La Ronge pourraient être encore mieux optimisées, tant pour la formation des résidents que pour l'amélioration de l'offre de soins. MTHODES:Nous avons interviewé les diplômés du programme de résidence en médecine familiale de La Ronge au cours des six dernières années (2018-2023). Les entretiens se sont déroulés sous forme de conversations guidées de manière semi-structurée. Les questions portaient sur l'impact des cliniques dirigées par les résidents, les avantages et les inconvénients perçus, ainsi que sur les suggestions d'amélioration. À la suite des entretiens, une analyse thématique inductive et réflexive a été réalisée. RSULTATS:Le taux de réponse a été de 100% (n = 15). Six thèmes se sont dégagés: le développement des compétences cliniques avec une supervision à distance; le dépassement des obstacles et des limites en ressources; la prise de conscience des inégalités; l'établissement de relations respectueuses sur le plan culturel; l'optimisation de l'utilisation des cliniques; et les façons de mettre en œuvre des changements. Les participants ont estimé que les cliniques dirigées par les résidents avaient favorisé leur croissance professionnelle d'une manière unique dans le cadre du programme de résidence. Le degré d'indépendance associé à ces cliniques s'accompagnait toutefois d'un compromis au niveau de la supervision, certains exprimant le besoin de trouver un meilleur équilibre entre ces deux dimensions. CONCLUSIONS:Les cliniques dirigées par les résidents ont contribué à leur développement professionnel et personnel. Un renforcement de la collaboration communautaire, jumelé à une optimisation de l'utilisation des cliniques - par exemple, grâce à de meilleurs services de traduction et de prise de rendez-vous - pourrait profiter aux patients, aux communautés et aux résidents.

BACKGROUND: Physicians encounter stressors with potential long-term psychological consequences. However, a comprehensive picture of post-traumatic stress disorder (PTSD) prevalence and symptomatic work-related event occurrence across practice stages is lacking. OBJECTIVE: To evaluate PTSD prevalence and the occurrence of work-related symptomatic events among physicians and medical learners. METHODS: In 2017, we surveyed 3,036 physicians, residents, and students within the province of Saskatchewan, Canada. Participants completed the Life Events Checklist (LEC) for DSM 4 and the PTSD Checklist for DSM 4-Civilian version (PCL-C). They also reported work-related events that triggered PTSD-like symptoms. The prevalence of a positive PTSD screen (PCL-C ≥ 36) and the proportion identifying a symptomatic work event were determined. The t-test, Chi-square test, and multiple regression were used to evaluate associations between respondent characteristics and these outcomes. RESULTS: Among 565 respondents, 21.2% screened positively, with similarity across career stages. Thirty-nine percent reported a symptom-inducing work event, with many training-related. Although independent PTSD predictors were not identified, partnered residents and surgical residents were more likely to identify a work-related event. Internationally trained practicing physicians were less likely to identify an event. CONCLUSION: Both symptom-inducing work events and PTSD are frequent, broadly based concerns requiring better preventive strategies across career stages.

Increased family physician workloads have strained primary care. The objective of this study was to describe the frequency and types of quality concerns identified among Saskatchewan's family physicians, changes in these concerns over time, associated physician characteristics, and recommendations made for improvement. In this repeated cross-sectional study (1997-2020), we examined family physician assessment reports from the Saskatchewan Practice Enhancement Program, a mandatory practice review strategy, for quality concerns on three outcomes: care, medical record, and facility. We recorded demographic and practice characteristics, the presence or absence of quality concerns, and the type of recommendations made. Concern incidence was calculated both overall and across subperiods, and three outcome-specific multiple logistic regression models were developed. Recommendations made were quantified, and their nature was evaluated using thematic analysis. Among 824 assessments, 20.8% identified concerns, with a statistically significant increase in 2015-20 over earlier years (14.2% versus 43.4%, P < .001). Corresponding proportions also significantly increased within each quality outcome (6.0%-37.1%, P < .001 for care concerns; 12.7%-19.6%, P = .03 for medical record concerns; 3.9%-21.0%, P < .001 for facility concerns). We found statistically significant adjusted associations between care concerns and both urban location [odds ratio (OR): 2.2; 95% confidence interval (CI): 1.30, 3.8] and international medical training (OR: 2.4; 95% CI: 1.34, 4.2); facility concerns and solo practice (OR: 2.5 95% CI: 1.10, 5.7); and medical record concerns and male gender (OR: 1.88; 95% CI: 1.09, 3.3), solo practice (OR: 1.67; 95% CI: 1.01, 2.7), and increased age. Reflecting a statistically significant interaction found between age as a continuous covariate and time period, older physicians were more likely to have a medical record concern in later years (OR: 1.072; 95% CI: 1.026, 1.120) compared to earlier ones (OR: 1.021; 95% CI: 1.001, 1.043). Among physicians where a concern was identified, recommendations most frequently pertained to documentation (91.2%), chronic disease management (78.2%), cumulative patient profiles (62.9%), laboratory investigations (53.5%), medications (51.8%), and emergency preparedness (51.2%). A concerning and increasing proportion of family physicians have quality gaps, with identifiable factors and recurring recommendations. These findings provide direction for strategic support development.

PURPOSE:Quantify resident caseload during call and determine if there are consistent differences in call volumes for individuals or resident subgroups.METHODS:Accession codes for after-hours computed tomography (CT) cases dictated by residents between July 1, 2012 and January 9, 2017 were reviewed. Case volumes by patient visits and body regions scanned were determined and categorized according to time period, year, and individual resident. Mean shift Relative Value Units (RVUs) were calculated by year. Descriptive statistics, linear mixed modeling, and linear regression determined mean values, differences between residents, associations between independent variables and outcomes, and changes over time. Consistent differences between residents were assessed as a measure of good or bad luck / karma on call.RESULTS:During this time there were 23,032 patients and 30,766 anatomic regions scanned during 1,652 call shifts among 32 residents. Over the whole period, there were on average 10.6 patients and 14.3 body regions scanned on weekday shifts and 22.3 patients and 29.4 body regions scanned during weekend shifts. Annually, the mean number of patients, body regions, and RVUs scanned per shift increased by an average of 0.2 (1%), 0.4 (2%), and 1.2 (5%) (all p < 0.05) respectively in regression models. There was variability in call experiences, but only 1 resident had a disproportionate number of higher volume calls and fewer lower volume shifts than expected.CONCLUSIONS:Annual increases in scan volumes were modest. Although residents' experiences varied, little of this was attributable to consistent personal differences, including luck or call karma.

Background:Long-term care (LTC) facilities require urgent, evidence-based care renewal. During 2020 three medical student-driven research projects aiming to study care satisfaction, patient care team dynamics, and advance care directive effectiveness in a local LTC facility required a marked shift in approach due to COVID-19 regulations.Methods:All three projects were re-invented as rapid reviews from their initial designs intended to provide a baseline for quality improvement projects. English-limited PubMed searches for publications within the past 10 years were undertaken. Review articles were prioritized and supplemented by individual studies. Students reviewed the initial abstracts, reviewed them with a supervisor/mentor, assessed the articles for quality, and synthesized major themes.Results:A total of 52 publications were evaluated for the final synthesis of all three projects. Relevant information was retrieved for all three areas, suitable for local evaluation/intervention at micro, meso, and macro policy levels.Conclusions:Rapid reviews of issue-specific, long-term care literature are low resource avenues towards coordinated care improvement. They may also serve as rapid means for regular policy updates while providing next-generation care providers with improved LTC perspectives.

Evidence suggests that phenobarbital can be used to treat alcohol withdrawal syndrome as monotherapy; however, the therapeutic cornerstone remains benzodiazepines. To date, studies comparing the two treatment modalities in the emergency department (ED) are few. We sought to determine whether phenobarbital versus benzodiazepine monotherapy impacts ED length of stay and need for admission among adult presentations at a single regional hospital. In June 2019, a treatment algorithm offering both phenobarbital and diazepam pathways was introduced at the Battlefords Union Hospital ED, an 11-bed unit treating 27 000 patients annually in North Battleford, Saskatchewan, Canada. A subsequent retrospective observational study evaluated all adult alcohol withdrawal syndrome presentations between June 2019 and January 2021. Medical records were reviewed for visit date, age, sex, comorbidities, psychosocial factors, Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scores, secondary diagnoses, time of day, protocol adherence, attending physician, length of stay, disposition, and ED return. Descriptive statistics, log-rank testing, simple regression, and multiple regression were used in analysis. Of the 184 presentations, 30.4% were treated with phenobarbital. Median length of stay for phenobarbital versus benzodiazepine therapy was 4.4 h and 4.4 h, respectively (p = 0.21). Of the phenobarbital presentations, 9.4% were hospitalized versus 17.1% of the benzodiazepine presentations (p = 0.20). When adjusted for confounders, phenobarbital-treated presentations were 71.3% less likely to be admitted (p = 0.03). This research suggests that phenobarbital performs similarly to benzodiazepines regarding alcohol withdrawal ED length of stay and may result in reduced hospitalizations.

Responding to a provincial government decision to develop two Urgent Care Centres (UCCs) in Saskatchewan, we undertook a rapid review of published literature with the objective of determining best practices for their creation and functioning. Two English-limited PubMed database searches combining “after-hours care,” “ambulatory care,” “emergency medicine,” “urgent care,” “minor emergency,” “walk-in,” and “Canada” over the past 10 years were the sources of articles for our review. Articles were independently reviewed by two authors and synthesized collaboratively. From 833 articles, 44 were utilized in the review. Six considerations in the following areas were subsequently outlined: expected impact, preferred location, healthcare services collaboration, available services, staffing priorities, and community partnerships. These principles were considered against the backdrop of currently successful Canadian UCCs. This review indicates that general principles for the successful development of UCCs exist; these may guide the establishment and functioning of UCCs both in Saskatchewan and elsewhere.

Background Painful experiences are common among hospitalized children. Long-term negative biopsychosocial consequences of undertreated pain are recognized. Aims The study benchmarks pain prevalence, assessment, and treatment as first steps to improve pain care in a Canadian tertiary hospital. Methods Single-day audits were undertaken on the pediatric ward (PW), pediatric emergency department (ED), and maternal services (MS). Participants (child or caregiver proxy) reported hospital pain experiences in the preceding 24 h; medical records were reviewed for assessment and treatment. Results Among 84 participants, pain prevalence ranged from 75% to 88%; mean pain intensity ranged from 5.7 to 6.5/10. Prevalence of moderate to severe pain was 78% on PW, 65% in ED, and 55% on MS; needle pokes were the most frequent cause of worst pain. Documentation of pain assessment varied by setting (PW, 93%; ED, 13%; MS, 0%). Documented maximum pain scores were significantly lower compared to participant report (mean difference 4.5/10, SD 3.1, P < 0.0001). A total 29% (6/21) of infants with heel lance or injection received breastfeeding or sucrose, and 29% (7/24) of participants receiving other needle procedures had documented or reported topical lidocaine use. All participants on MS underwent needle procedures. Conclusions Pain is experienced commonly by infants and children in PW, ED, and MS. Pain assessment documentation is not routine and underestimates participant report. Evidence-based pain management strategies are underutilized. An institution-wide quality improvement approach is required to address pain care. Pain assessment and needle pain prevention and treatment should be prioritized in these pediatric acute care and newborn care settings.

Background Resuscitation guidelines recommend that chest compressions be performed over the lower sternum. Current computed tomography and magnetic resonance imaging studies suggest that the current area of compression does not target the left ventricle (LV). Using transthoracic ultrasound, we sought to identify potential anatomic landmarks that would result in compressions over the LV in the majority of our study participants. Methodology We recruited 64 healthy men and women (over the age of 40) from the Simulated Patient Program at the University of Saskatchewan. Using ultrasound, we identified the LV and the associated surface anatomy in terms of intercostal space (ICS) and parasternal or mid-clavicular lines. We also collected biometric data including body mass index, chest circumference, and the corresponding inter-nipple line ICS. Results The LV was located along the left sternal border in 62 (96.9%) participants. The most frequent LV location was along the left sternal border at the sixth ICS in 26 (40.6%) participants, with 13 (20.3%) at the fifth and 10 (15.6%) participants at the seventh ICS. In two (3.1%) participants, the LV was found along the midclavicular zone at the fifth ICS. The area from the fifth to seventh ICS on the left sternal border, typically covered by an adult palm centered at the sixth ICS, overlaid 49 of 64 (76.6%, 95% confidence interval [CI]: 64.3-86.2%) identified LV locations. By comparison, centering the heel of the palm over the inter-nipple line at the left sternal border would cover the LV in 46 (71.9%, 95% CI: 59.2-82.4%) participants. Conclusions A novel area of compression over the left sternal border at the inter-nipple line would result in compressions over the LV in nearly three-quarters of our study participants. Future research should investigate whether this proposed area of compression is applicable to a broader population including those with cardiac and thoracic disease.

BACKGROUND:The utility of magnetic resonance imaging (MRI) in the primary care setting is uncertain, with a perception that there is less likelihood for surgery after MRI ordered by general practitioners (GPs) when compared with orthopaedic surgeons and sports medicine physicians. Additionally, the influence of patient age and sex on subsequent surgical intervention is currently unknown. PURPOSE/HYPOTHESIS:The purpose of this study was to compare surgical incidence after MRI referrals by orthopaedic surgeons, GPs, and sports medicine physicians, including a subset analysis for GP patients based on type of approval given by the radiologist. The authors also wanted to explore the association of age and sex on subsequent surgical intervention. They hypothesized that surgical incidence after MRI ordered by orthopaedic surgeons and sports medicine physicians would be higher than after MRI ordered by GPs. STUDY DESIGN:Cohort study; Level of evidence, 3. METHODS:Knee MRI referrals by the 3 physician cohorts during May to December 2017 were assessed. For GP patients, the types of approval or recommendation from a radiologist were categorized. Subsequent surgical intervention status was then compared among referral groups up to 2 years after MRI. Associations of age and sex with surgical occurrence were also assessed. Chi-square test, analysis of variance, and univariate/multivariable logistic regression were used for statistical analysis. RESULTS:Overall, 407 referrals were evaluated (GP, n = 173; orthopaedic, n = 176; sports medicine, n = 58). Surgical incidence was not significantly higher for orthopaedic and sports medicine than GP referrals at 3 months (10%, 3%, and 6%, respectively; P = .23), 6 months (20%, 17%, and 15%; P = .49), and 2 years (30%, 35%, and 24%; P = .25). Surgical incidence for GP patients was higher after discussion with a radiologist or when evaluating specific pathology on prior imaging versus less defined reasons (30.4% vs 15.7%, respectively; P = .03). Surgical incidence was lower for older patients (11% vs 31% for >60 years vs all other age groups combined; P = .002), and women were less likely to undergo surgery than men (22% vs 35%, respectively; P = .008). CONCLUSION:Surgical incidence after MRI was likely appropriately lower for older patients. Lower incidence for female patients is of uncertain cause and warrants further study.

Background and objective Emergency departments (EDs) often find the number of arriving patients exceeding their capacity and find it difficult to triage them in a timely manner. The potential risk to the safety of patients awaiting assessment by a triage professional has led some hospitals to consider implementing patient self-triage, such as using kiosks. Published studies about patient self-triage are scarce and information about patients’ ability to accurately assess the acuity of their condition or predict their need to be hospitalized is limited. In this study, we aimed to compare computer-assisted patient self-triage scores versus the scores assigned by the dedicated ED triage nurse (TN). Methods This pilot study enrolled patients presenting to a tertiary care hospital ED without ambulance transport. They were asked a short series of simple questions based on an algorithm, which then generated a triage score. Patients were asked whether they were likely to be admitted to the hospital. Patients then entered the usual ED system of triage. The algorithm-generated triage score was then compared with the Canadian Triage and Acuity Scale (CTAS) score assigned by the TN. Whether the patients actually required hospital admission was determined by checking their medical records. Results Among the 492 patients enrolled, agreement of triage scores was observed in 27%. Acuity was overestimated by 65% of patients. Underestimation of acuity occurred in 8%. Among patients predicting hospitalization, 17% were admitted, but the odds ratio (OR) for admission was 3.4. Half of the patients with cardiorespiratory complaints were correct in predicting the need for hospitalization. Conclusion The use of a short questionnaire by patients to self-triage showed limited accuracy, but sensitivity was high for some serious medical conditions. The prediction of hospitalization was more accurate with regard to cardiorespiratory complaints.

Background Despite automated defibrillation and compression-first resuscitation, out-of-hospital cardiac arrest (OHCA) survival remains low. Resuscitation guidelines recommend that chest compressions should be done over the lower half of the sternum, but evidence indicates that this is often associated with outflow obstruction. Emerging studies suggest that compression directly over the left ventricle (LV) may improve survival and outcomes, but rapid and reliable localization of the LV is a major obstacle for those first responding to OHCA. This study aimed to determine if a simplified, easy-to-use ultrasound device (bladder scanner) can reliably locate the heart when applied over the intercostal spaces of the anterior thorax in supine patients. Furthermore, we sought to describe the association between largest scan volumes and underlying cardiac anatomy with particular attention to the long axis of the LV. Methodology We recruited healthy male and female volunteers over 40 years of age. Using a bladder scanner to evaluate the left sternal border and mid-clavicular lines, we determined the maximal scan volumes at 10 intercostal spaces for each participant. Cardiac ultrasound was then used to evaluate the corresponding underlying cardiac anatomy and determine the area overlying the long-axis view of the LV. Descriptive statistics (means with standard deviations [SD], medians with interquartile ranges, and frequencies with proportions) were used to quantify demographic information, typical scan volumes across the chest, the frequencies of the best long-axis LV view location. This was then repeated for left sternal border assessments only. Kappa was determined when evaluating agreement between the largest left sternal border scan volume and the best long-axis LV view location. Results The long-axis LV was the predominant structure underlying the largest scan volume in 39/51 (76.5%) patients. When limited to left sternal border volumes only, the long axis of the LV was underlying the maximum volume intercostal space in 46/51 (90.2%; 95% confidence interval [CI]: 78.6%, 96.7%). The largest left sternal border scan volumes were located over the best long-axis LV view in 39/51 (76.5%, 95% CI: 62.5%, 87.2%) of the study participants with a Kappa statistic of 0.68 (95% CI: 0.52, 0.84; p < 0.0001). Conclusions In this cross-sectional study of healthy volunteers, an easy-to-use ultrasound device (bladder scanner) was able to reliably localize the heart. Largest scan volumes over the left sternal border showed substantial agreement with the intercostal space overlying the long axis of the LV. Further investigations are warranted to determine if such localization is reliable in cardiac arrest patients.

Background: In the prehospital setting, pit-crew models of cardiopulmonary resuscitation (CPR) have shown improvements in survival after out-of-hospital cardiac arrest (OHCA). Certain districts in North America have adopted this model, including Saskatoon, Saskatchewan, Canada. Objectives: Our objectives were to determine whether pit-crew CPR has an impact on survival to discharge after OHCA in Saskatoon, Canada. Methods: This was a retrospective pre- and postintervention study. All adult patients who had an OHCA between January 1, 2011 and December 31, 2017 of presumed cardiac origin, in which the resuscitation attempt included CPR by trained prehospital responders, were considered for analysis. Our primary outcome was survival to discharge. Survival to admission and return of spontaneous circulation were secondary outcomes. Results: There were 860 OHCAs considered for our study. After 46 exclusions there were 442 in the non-pit-crew group (average age 63.7 years; 64.5% male) and 372 in the pit-crew group (average age 63.5 years; 67.5% male). Survival to discharge after an OHCA was 10.4% (95% confidence interval 7.7-13.6%) in the non-pit-crew group and 12.4% (95% CI 9.2-16.2%) in the pitcrew group, which did not meet statistical significance. Return of spontaneous circulation and survival to admission were 48.4% and 31.3%, respectively, in the non-pit-crew group and 46.7% and 32.3%, respectively, in the pit-crew group. Conclusions: In our study, implementation of a pitcrew CPR model was not associated with an improvement in survival to discharge after OHCA. (C) 2020 Elsevier Inc. All rights reserved.

Background. Guidelines recommend modified ultrafiltration (MUF) and cell washing for blood conservation after cardiopulmonary bypass (CPB), although information on outcomes is lacking. This research compared online MUF (ultrafiltration of the patient's entire circulating volume) with off-line MUF (ultrafiltration of the residual CPB volume) and centrifugation (cell washing of the residual CPB volume). Methods. This prospective cohort study enrolled 99 consecutive patients, grouped by method (group I, online MUF, n = 35; group II, off-line MUF, n = 30; group III, centrifugation, n = 34). Primary outcome was transfusion by 18 hours. Secondary outcomes were 18-hour hemoglobin levels, fluid balance (weight change), and biomarker levels indicating coagulation and organ function. Results. By 18 hours, 22.9%, 6.7%, and 14.7% of group I, II, and III patients, respectively, had undergone transfusion (P = .19). Percentage weight gain differed by group (group I, 5.7%; group II, 1.3%; group III, 4.5%; P <.0001). Baseline to 18-hour hemoglobin change also differed by group, with the group I increase significantly exceeding that of group II (P = .002) but not differing from group III (P = .36). After adjustment for European System for Cardiac Operative Risk Evaluation II (EuroSCORE), weight gain, and transfusion, only the group II to III difference remained significant (P = .002). Conclusions. Online MUF does not appear to offer a reduction in blood transfusion over other methods. Although patients undergoing online MUF had greater improvement in baseline to 18-hour hemoglobin compared with patients undergoing off-line MUF, this benefit appeared attributable to fluid shifting. Off-line MUF was associated with the least frequent transfusions. Although online MUF does not appear to reduce blood transfusion, larger prospective randomized controlled studies are required for confirmation. (C) 2020 by The Society of Thoracic Surgeons

Background Careful design of preprinted order sets is needed to prevent medical overuse. Recent work suggests that removing a single checkbox from an order set changes physicians’ clinical decision-making. Local problem During a 2-month period, our coronary care unit (CCU) ordered almost eight times as many serum thyroid-stimulating hormone (TSH) tests as our neighbouring intensive care unit, many without a reasonable clinical basis. We postulated that we could reduce inappropriate testing and improve clinical laboratory stewardship by removing the TSH checkbox from the CCU admission order set. Methods After we retrospectively evaluated CCU TSH ordering before intervention, the checkbox was removed from the CCU admission order set. Twelve weeks later, we commenced a prospective 2-month assessment of TSH testing and clinical sequelae of thyroid disease among all CCU admissions. If clinical indications were absent or testing had occurred within 6 weeks, TSH requests were labelled as ‘inappropriate’. Results Physician ordering and, specifically, inappropriate ordering decreased substantially after the intervention. In 2016 among physician-ordered TSH tests, 60.6% (66/109) were inappropriate; in 2017 this decreased to 20% (2/10, p=0.01). Overall, the net effect of checkbox removal saw the decrease in TSH testing without clinical indication outweigh an increase in missed testing where indications appear to exist. Conclusions Provision of an optional checkbox for a laboratory test in an admission order set can promote overuse of laboratory resources. Simple removal of a checkbox may dramatically change test ordering patterns and promote clinical laboratory stewardship. Given our reliance on order sets, particularly by trainees, changes to order sets must be cautious to assure guideline-directed care is maintained.

Highlights Larger, arm port polyurethane catheters have more potential for: ○ Venous thrombosis ○ Multivessel venous thrombosis ○ Access vein occlusive thrombosis Arm port venous thrombosis is more frequent than suspected and is asymptomatic

INTRODUCTION:This study aimed to develop a risk stratification model to differentiate benign and malignant MRI-imaged musculoskeletal soft-tissue tumours, informing decisions surrounding biopsy and follow-up imaging. METHODS:Imaging of patients who underwent MRI and subsequent biopsy to evaluate a soft-tissue mass was retrospectively reviewed. Features analysed included patient age; tumour size; shape; margins; enhancement pattern; signal intensity pattern; deep fascia, neurovascular bundle, bone and joint involvement; and the presence of necrosis, haemorrhage, oedema and intralesional fat. Univariate comparisons, by final histopathological status, employed t-tests and chi-square tests, followed by simple and multiple logistic regressions. Variables included in the final multiple regression model were used to define a three-level risk stratification strategy. RESULTS:One-hundred and ten patients were included in the analysis. Univariate relationships were identified between malignancy and age, tumour size, deep fascia involvement, neurovascular involvement, necrosis, haemorrhage, oedema and heterogeneous enhancement (all P < 0.01). Final multiple regression modelling included size, enhancement and oedema. Thirty of 40 (75%) tumours >5 cm with surrounding oedema ('high risk') were malignant, 13 of 47 (28%) tumours with one or more of tumour size >5 cm, surrounding oedema or heterogeneous enhancement ('moderate risk') were malignant, and none of the 16 tumours ≤5 cm with the absence of surrounding oedema and heterogeneous enhancement ('low risk') were malignant. CONCLUSIONS:A model including tumour size, enhancement and oedema has potential to stratify soft-tissue tumours into high-, intermediate- and low-risk categories; this may inform decisions surrounding biopsy and follow-up imaging.