House Staff

This study was not blinded. Medical wards in the control group received “usual care”, which we defined as having no active or passive KT strategies to improve thromboprophylaxis in place. Medical wards in the intervention group received a multicomponent intervention consisting of the following:
1. Education sessions: Distribution of posters; a pamphlet describing current VTE practice patterns and the need to optimize thromboprophylaxis; and bimonthly educational sessions for ward physicians (and house staff, if applicable), nurses, and pharmacists. Pamphlets were distributed in paper format and via electronic mail to individuals who could not attend the sessions.
2. Standardized VTE risk assessment algorithm and physicians’ orders: (see Figure 1) These paper-based forms, modeled after the 8^th edition of the ACCP Evidence-Based Clinical Practice Guidelines, were available on internal medicine wards during the study period [4 (link)]. Local principal investigators (PIs) were asked to ensure that clinical staff were aware of the forms and to encourage their completion for eligible patients.
3. Audit and feedback: Real-time chart audits of eligible patients were done to determine whether patients were appropriately managed for thromboprophylaxis within 24 hours of admission. The entire health record during the relevant admission was searched to corroborate thrombosis and bleeding risk factors. All audits were done by one of two data management assistants, and data entry was validated by the study coordinator (NL) and two research assistants. Performance-based feedback sessions were done at 4, 12, and 16 weeks to relay results to clinical staff. Aggregate feedback was provided verbally and in a written handout at the sessions. The handout was also distributed in paper format and via electronic mail to individuals who could not attend the sessions.

The bedside interpreter intervention has been previously described.^{8 (link),12 (link),20 (link)} It consisted of placing a dual-handset interpreter telephone at the bedside of every patient who preferred a non-English language for their health care starting in late December 2012 in one academic health center. A programmed button provides rapid 24-h access to professional medical interpreters for more than 100 languages.
The dual-handset allows the patient to speak into one handset, the clinician to speak into the second handset, and the professional interpreter (vendor-based or in-house staff) to facilitate the conversation from a remote location. Before the intervention, up to three dual-handset interpreter telephones were available on most units, located on mobile carts, and kept at the nursing station or in locked cabinets until needed.
In-person professional interpreters could be scheduled during weekdays (8 am to 5 pm) before and throughout the intervention period.

The study was part of research project IG 2020 ID 24501, supported by the Italian Association for Cancer Research (AIRC) and approved by the Ethical Committee of the Regional Health District “Area Vasta Emilia Nord” (AVEN, http://www.ausl.pc.it/comitato_etico/), protocol #2021/0081925. Fasting (12 h) blood specimens were collected before surgery in lavender-top blood tubes (K2-EDTA) at a quaternary skull base and neurotologic center (Gruppo Otologico Clinic, Piacenza, Italy), from 56 patients affected with HNPGL (59 samples, as 3 patients were sampled at two metachronous surgical stages), 10 patients with acoustic neuroma (AN), and 2 with cholesteatoma (CH). Fasting blood samples from 24 healthy age-matched controls (HCs) were donated by consenting in-house staff declaring no specific diseases and regularly controlled by institutional health check (Table S2). Informed consent was obtained from all recruited subjects. All the HNPGL plasma samples, except 4 from tympanic HNPGLs, derived from patients who had been embolized approximately 72 h before blood sampling. Blood samples were maintained at ambient temperature, plasma was prepared within 24 h by centrifugation (10 min at 1000 x g speed at room temperature), aliquoted in sterile 1.5 ml Eppendorf tubes and stored at -80 °C until testing. 21 HNPGL patients were tested on both plasma and whole dried venous blood (DVB) samples. The latter were obtained by spotting 50 μL (~1 drop) of fresh blood onto untouched Whatman 903 (W-903) filter paper discs. Spotted filters were dried for 2–3 h under hood at room temperature and saved in sterile envelopes at room temperature until testing. Twenty-four healthy volunteers were selected as controls. Nine (9) individual DVB specimens were obtained as described above from healthy controls. In parallel, samples of dried capillary blood (DCB) obtained by spotting few drops of capillary blood onto W-903 filter paper were donated from 16 healthy controls. Age and sex distribution of the healthy controls (HCs) and of the HNPGL and acoustic neuroma/cholesteatoma (AN/CH) patients are reported in Table S3; essential clinicopathologic and genetic characteristics of the HNPGL patients, including tumor localization, Shamblin class (used here for both carotid body and vagal PGLs according to Sanna M. et al.) [9 , 56 , 57 ], Sanna’s modified Fisch class (for tympanic/tympanojugular PGLs) [10 , 58 (link)] and SDHx germline mutation status, are listed in Table S4.

The data management system is comprised of data entry, cleaning, back-up, and the generation of regular reports. Built-in quality control mechanisms were developed to ensure data quality and confidentiality. Prescriptions were analysed using the mentioned WHO indicators. Information was collected about the prescriber also in terms of their hierarchical designation, e.g., general resident doctors, post-graduate residents, and senior doctors (Medical officer/Demonstrator/Clinical Tutor, Assistant Professor, Associate Professor and Professor).
A house staff is a junior resident who has completed undergraduate medical degree (MBBS) and internship but yet to join for a post graduate course. Faculty in clinical disciplines include Residential Medical Officer (RMO) cum Clinical Tutor, Assistant Professor, Associate Professor, and Professor. All have qualified with post-graduate medical degrees (MD).
All the above proportions were compared across age groups (pediatric and adult) and different categories of prescribers. The prescriptions were assessed using a “Consensus Committee approach”.