The Development and Pilot Testing of a Minority Stress Psychoeducation Tool for Transgender and Nonbinary People.

Purpose: In this study, we aimed to develop and test the acceptability of a minority stress psychoeducation tool for transgender and nonbinary (TNB) people. Methods: Patients in one treatment group who were enrolled in a larger randomized controlled trial received this study's minority stress psychoeducation pre-treatment. Data on the acceptability of the tool and minority stress experiences were collected post-treatment. Results: All (100%) patients reported that the psychoeducation tool was helpful and qualitative data suggested patients experienced an increased ability to externalize minority stress experiences. Conclusion: Results support the acceptability of this minority stress psychoeducation tool for TNB patients. Clinical trial number: NCT03369054.

Contribution of Basic Science Education to the Professional Identity Development of Medical Learners: A Critical Scoping Review.

PURPOSE: Professional identity development (PID) has become an important focus of medical education. To date, contributions of basic science education to physician PID have not been broadly explored. This review explores the literature surrounding the contribution of basic science education to the PID of medical learners and interprets findings critically in terms of the landscapes of practice (LoP) framework. METHOD: In this critical scoping review, the authors searched 12 different databases and professional organization websites from January 1988 to October 2022 for references relating to how, if at all, the basic science component of medical education contributes to the PID of medical learners. The LoP learning theory was chosen as a framework for critically interpreting the identified articles. RESULTS: Of the 6,674 identified references, 257 met the inclusion criteria. After data extraction, content analysis of recorded key findings was used to ensure all findings were incorporated into the synthesis. Findings aligned with and were critically interpreted in relation to the 3 LoP modes of identification: engagement (engaging in the work of a physician), imagination (imagining oneself becoming a "good doctor"), and alignment (aligning with the practices and expectations of a medical community or specialty). Within each mode of identification, it was possible to see how basic science may support, or catalyze, PID and how basic science may serve as a barrier, or an inhibitor, to PID or contribute to the development of negative aspects of identity development. CONCLUSIONS: The LoP learning theory suggests that the effect of basic science on physicians' PID is most effective if educators view themselves as guides through interfaces between their scientific disciplines and medicine. Learners need opportunities to be engaged, to imagine how their current learning activities and developing skills will be useful as future physicians, and to feel alignment with medical specialties.

The benefit of sentinel lymph node biopsy in elderly patients with melanoma: A retrospective analysis of SEER Medicare data (2010-2018).

BACKGROUND: Sentinel lymph node status is critical for melanoma staging and treatment. However, the factors influencing SLNB and its oncologic benefits in elderly patients are unclear. METHODS: We conducted a retrospective analysis of patients aged ≥65 with clinically node-negative melanoma and Breslow depth ≥1 â€‹mm, using Surveillance, Epidemiology, and End Results Medicare database (2010-2018). Multivariable logistic regression assessed SLNB likelihood by demographic and clinical factors, and Cox-proportional hazard models evaluated overall and melanoma-specific mortality (MSM) for SLNB recipients versus non-recipients. RESULTS: Of 13,160 melanoma patients, 62.29 â€‹% underwent SLNB. SLNB was linked to reduced all-cause mortality (HR: 0.65 [95%CI 0.61-0.70]) and MSM (HR: 0.76 [95%CI 0.67-0.85]). Older age, non-White race, male sex, and unmarried status was associated with decreased SLNB likelihood, while cardiopulmonary, neurologic, and secondary cancer comorbidities were associated with increased SLNB likelihood. CONCLUSIONS: Though less frequently performed, SLNB is associated with lower mortality in elderly melanoma patients. Advanced age alone should not contraindicate SLNB.

Use of telehealth to improve healthcare access and outcomes in surgical oncology.

The dimensions of healthcare access includes availability, accessibility, accommodation, affordability, and accessibility. Many patients face significant barriers to accessing oncologic care and subsequently, health outcomes are suboptimal. Telehealth offers an opportunity to mitigate many of these barriers to improve health access and outcomes. This review discusses how telehealth can be leveraged to improve healthcare access in surgical oncology while also highlighting important challenges to realizing the full potential of this mode of healthcare delivery.

People Place Larger Bets When Risky Choices Provide a Postbet Option to Cash Out.

After a risky choice, decision makers must frequently wait out a delay period before the outcome of their choice becomes known. In contemporary sports-betting apps, decision makers can "cash out" of their bet during this delay period by accepting a discounted immediate payout. An important open question is how availability of a postchoice cash-out option alters choice. We investigated this question using a novel gambling task that incorporated a cash-out option during the delay between bet and outcome. Across two experiments (N = 240 adults, recruited via Prolific), cash-out availability increased participants' bet amounts by up to 35%. Participants who were more likely to cash out when odds deteriorated were less likely to cash out when odds improved. Furthermore, the effect of cash-out availability on bet amounts was positively correlated with individual differences in cash-out propensity for bets with deteriorating odds only. These results suggest that cash-out availability may promote larger bets by allowing bettors to avoid losing their entire stake.

Case report: Tremor in the placebo condition of a blinded clinical trial of intermittent theta-burst stimulation for cocaine use disorder.

We report a case of a new-onset, persistent tremor that developed during a clinical trial (NCT02927236) of intermittent theta burst stimulation [iTBS, a form of repetitive magnetic transcranial magnetic stimulation (rTMS)] for cocaine use disorder. Although the participant exhibited an exceptionally strong clinical response, subsequent unblinding revealed that they received sham iTBS. This case highlights the potential for strong functional neurological placebo responses in rTMS trials, and functional disorders might be a marker of a placebo response. Additionally, we note the possibility that the weak e-fields produced by some sham rTMS systems may induce clinically relevant effects.

Risky effort.

Decision-making involves weighing up the outcome likelihood, potential rewards, and effort needed. Previous research has focused on the trade-offs between risk and reward or between effort and reward. Here we bridge this gap and examine how risk in effort levels influences choice. We focus on how two key properties of choice influence risk preferences for effort: changes in magnitude and probability. Two experiments assessed people's risk attitudes for effort, and an additional experiment provided a control condition using monetary gambles. The extent to which people valued effort was related to their pattern of risk preferences. Unlike with monetary outcomes, however, there was substantial heterogeneity in effort-based risk preferences: People who responded to effort as costly exhibited a "flipped" interaction pattern of risk preferences. The direction of the pattern depended on whether people treated effort as a loss of resources. Most, but not all, people treat effort as a loss and are more willing to take risks to avoid potentially high levels of effort.

Using a novel 'difference-in-differences' method and syndromic surveillance to estimate the change in local healthcare utilisation during periods of media reporting in the early stages of the COVID-19 pandemic in England.

OBJECTIVES: Syndromic surveillance supplements traditional laboratory reporting for infectious diseases monitoring. Prior to widespread COVID-19 community surveillance, syndromic surveillance was one of several systems providing real-time information on changes in healthcare-seeking behaviour. The study objective was to identify changes in healthcare utilisation during periods of high local media reporting in England using 'difference-in-differences' (DiD). STUDY DESIGN: A retrospective observational study was conducted using five media events in January-February 2020 in England on four routinely monitored syndromic surveillance indicators. METHODS: Dates 'exposed' to a media event were estimated using Google Trends internet search intensity data (terms = 'coronavirus' and local authority [LA]). We constructed a negative-binomial regression model for each indicator and event time period to estimate a direct effect. RESULTS: We estimated a four-fold increase in telehealth 'cough' calls and a 1.4-fold increase in emergency department (ED) attendances for acute respiratory illness in Brighton and Hove, when a so-called 'superspreading event' in this location was reported in local and national media. Significant decreases were observed in the Buxton (telehealth and ED attendance) and Wirral (ED attendance) areas during media reports of a returnee from an outbreak abroad and a quarantine site opening in the area respectively. CONCLUSIONS: We used a novel approach to directly estimate changes in syndromic surveillance reporting during the early phase of the COVID-19 pandemic in England, providing contextual information on the interpretation of changes in health indicators. With careful consideration of event timings, DiD is useful in producing real-time estimates on specific indicators for informing public health action.

The roles of phishing knowledge, cue utilization, and decision styles in phishing email detection.

This study investigated the roles of phishing knowledge, cue utilization, and decision styles in contributing to phishing email detection. Participants (N = 145) completed an online email sorting task, and measures of phishing knowledge, email decision styles, cue utilization, and email security awareness. Cue utilization was the only factor that uniquely predicted the capacity to discriminate phishing from genuine emails. Phishing knowledge was associated with greater phishing detection and a bias towards classifying all emails as phishing. A preference for intuitive decision making predicted lower detection of phishing emails, driven by a greater tendency to classify emails as genuine. These findings support the proposition that cue utilization is a distinct cognitive process that enables expert performance. The outcomes indicate that, in addition to increasing phishing knowledge and developing safe behavioral patterns, anti-phishing training needs to provide opportunities for trainees to develop meaningful cue associations.

Critical updates in neuroendocrine tumors: Version 9 American Joint Committee on Cancer staging system for gastroenteropancreatic neuroendocrine tumors.

The American Joint Committee on Cancer (AJCC) staging system for all cancer sites, including gastroenteropancreatic neuroendocrine tumors (GEP-NETs), is meant to be dynamic, requiring periodic updates to optimize AJCC staging definitions. This entails the collaboration of experts charged with evaluating new evidence that supports changes to each staging system. GEP-NETs are the second most prevalent neoplasm of gastrointestinal origin after colorectal cancer. Since publication of the AJCC eighth edition, the World Health Organization has updated the classification and separates grade 3 GEP-NETs from poorly differentiated neuroendocrine carcinoma. In addition, because of major advancements in diagnostic and therapeutic technologies for GEP-NETs, AJCC version 9 advocates against the use of serum chromogranin A for the diagnosis and monitoring of GEP-NETs. Furthermore, AJCC version 9 recognizes the increasing role of endoscopy and endoscopic resection in the diagnosis and management of NETs, particularly in the stomach, duodenum, and colorectum. Finally, T1NXM0 has been added to stage I in these disease sites as well as in the appendix.

Transmembrane domain-driven PD-1 dimers mediate T cell inhibition.

Programmed cell death-1 (PD-1) is a potent immune checkpoint receptor on T lymphocytes. Upon engagement by its ligands, PD-L1 or PD-L2, PD-1 inhibits T cell activation and can promote immune tolerance. Antagonism of PD-1 signaling has proven effective in cancer immunotherapy, and conversely, agonists of the receptor may have a role in treating autoimmune disease. Some immune receptors function as dimers, but PD-1 has been considered monomeric. Here, we show that PD-1 and its ligands form dimers as a consequence of transmembrane domain interactions and that propensity for dimerization correlates with the ability of PD-1 to inhibit immune responses, antitumor immunity, cytotoxic T cell function, and autoimmune tissue destruction. These observations contribute to our understanding of the PD-1 axis and how it can potentially be manipulated for improved treatment of cancer and autoimmune diseases.

Structural insights reveal interplay between LAG-3 homodimerization, ligand binding, and function.

Lymphocyte activation gene-3 (LAG-3) is an inhibitory receptor expressed on activated T cells and an emerging immunotherapy target. Domain 1 (D1) of LAG-3, which has been purported to directly interact with major histocompatibility complex class II (MHCII) and fibrinogen-like protein 1 (FGL1), has been the major focus for the development of therapeutic antibodies that inhibit LAG-3 receptor-ligand interactions and restore T cell function. Here, we present a high-resolution structure of glycosylated mouse LAG-3 ectodomain, identifying that cis-homodimerization, mediated through a network of hydrophobic residues within domain 2 (D2), is critically required for LAG-3 function. Additionally, we found a previously unidentified key protein-glycan interaction in the dimer interface that affects the spatial orientation of the neighboring D1 domain. Mutation of LAG-3 D2 residues reduced dimer formation, dramatically abolished LAG-3 binding to both MHCII and FGL1 ligands, and consequentially inhibited the role of LAG-3 in suppressing T cell responses. Intriguingly, we showed that antibodies directed against D1, D2, and D3 domains are all capable of blocking LAG-3 dimer formation and MHCII and FGL-1 ligand binding, suggesting a potential allosteric model of LAG-3 function tightly regulated by dimerization. Furthermore, our work reveals unique epitopes, in addition to D1, that can be targeted for immunotherapy of cancer and other human diseases.

BERT-Based Neural Network for Inpatient Fall Detection From Electronic Medical Records: Retrospective Cohort Study.

BACKGROUND: Inpatient falls are a substantial concern for health care providers and are associated with negative outcomes for patients. Automated detection of falls using machine learning (ML) algorithms may aid in improving patient safety and reducing the occurrence of falls. OBJECTIVE: This study aims to develop and evaluate an ML algorithm for inpatient fall detection using multidisciplinary progress record notes and a pretrained Bidirectional Encoder Representation from Transformers (BERT) language model. METHODS: A cohort of 4323 adult patients admitted to 3 acute care hospitals in Calgary, Alberta, Canada from 2016 to 2021 were randomly sampled. Trained reviewers determined falls from patient charts, which were linked to electronic medical records and administrative data. The BERT-based language model was pretrained on clinical notes, and a fall detection algorithm was developed based on a neural network binary classification architecture. RESULTS: To address various use scenarios, we developed 3 different Alberta hospital notes-specific BERT models: a high sensitivity model (sensitivity 97.7, IQR 87.7-99.9), a high positive predictive value model (positive predictive value 85.7, IQR 57.2-98.2), and the high F1-score model (F1=64.4). Our proposed method outperformed 3 classical ML algorithms and an International Classification of Diseases code-based algorithm for fall detection, showing its potential for improved performance in diverse clinical settings. CONCLUSIONS: The developed algorithm provides an automated and accurate method for inpatient fall detection using multidisciplinary progress record notes and a pretrained BERT language model. This method could be implemented in clinical practice to improve patient safety and reduce the occurrence of falls in hospitals.

Automated extraction of weight, height, and obesity in electronic medical records are highly valid.

Objective: Coding of obesity using the International Classification of Diseases (ICD) in healthcare administrative databases is under-reported and thus unreliable for measuring prevalence or incidence. This study aimed to develop and test a rule-based algorithm for automating the detection and severity of obesity using height and weight collected in several sections of the Electronic Medical Records (EMRs). Methods: In this cross-sectional study, 1904 inpatient charts randomly selected in three hospitals in Calgary, Canada between January and June 2015 were reviewed and linked with AllScripts Sunrise Clinical Manager EMRs. A rule-based algorithm was created which looks for patients' height and weight values recorded in EMRs. Clinical notes were split into sentences and searched for height and weight, and BMI was computed. Results: The study cohort consisted of 1904 patients with 50.8% females and 43.3% > 64 years of age. The final model to identify obesity within EMRs resulted in a sensitivity of 92.9%, specificity of 98.4%, positive predictive value of 96.7%, negative predictive value of 96.6%, and F1 score of 94.8%. Conclusions: This study developed a highly valid rule-based EMR algorithm that detects height and weight. This could allow large-scale analyses using obesity that were previously not possible.

Single-Photon Emission Computed Tomography/Computed Tomography Utilization for Extremity Melanomas at a High-Volume Center.

INTRODUCTION: Planar lymphoscintigraphy (PL) is commonly used in mapping before sentinel lymph node biopsy (SLNB) for invasive cutaneous melanoma. Recently, single-photon emission computed tomography (SPECT)/ computed tomography (CT) has been utilized, in addition to PL, for detailed anatomic information and detection of sentinel lymph nodes (SLNs) outside of the primary nodal basin in truncal and head and neck melanoma. Following a protocol change due to COVID-19, our institution began routinely obtaining both PL and SPECT-CT imaging for all melanoma SLN mapping. We hypothesized that SPECT-CT is associated with higher instances of SLNBs from "nontraditional" nodal basins (NTNB) for extremity melanomas. METHODS: Patients with extremity melanoma (2017-2022) who underwent SLNB were grouped into SPECT-CT with PL versus PL alone. Outcomes were total SLNs removed, + or-SLN status, total NTNB sampled, and postoperative complication rate. Poisson regression and logistic regression models were used to assess association of SPECT-CT with patient outcomes. RESULTS: Of 380 patients with extremity melanoma, 42.11% had SPECT-CT. There were no differences between the groups with regards to age at diagnosis or sex. From 2020 to 2022, all patients underwent SPECT-CT. SPECT-CT was associated with increased odds of SLNB from an NTNB, (odds ratio = 2.39 [95% confidence interval: 1.25-4.67]). There was no difference in odds of number of SLNs sampled, SLN positivity rate, or postoperative complication rate with SPECT-CT. CONCLUSIONS: Routine SPECT-CT was associated with higher incidence of SLNB in NTNB but did not increase number of SLNs removed or SLN positivity rate. The added value of routine SPECT-CT in cutaneous melanoma of the extremities remains to be defined.

The Future of Decisions From Experience: Connecting Real-World Decision Problems to Cognitive Processes.

In many important real-world decision domains, such as finance, the environment, and health, behavior is strongly influenced by experience. Renewed interest in studying this influence led to important advancements in the understanding of these decisions from experience (DfE) in the last 20 years. Building on this literature, we suggest ways the standard experimental design should be extended to better approach important real-world DfE. These extensions include, for example, introducing more complex choice situations, delaying feedback, and including social interactions. When acting upon experiences in these richer and more complicated environments, extensive cognitive processes go into making a decision. Therefore, we argue for integrating cognitive processes more explicitly into experimental research in DfE. These cognitive processes include attention to and perception of numeric and nonnumeric experiences, the influence of episodic and semantic memory, and the mental models involved in learning processes. Understanding these basic cognitive processes can advance the modeling, understanding and prediction of DfE in the laboratory and in the real world. We highlight the potential of experimental research in DfE for theory integration across the behavioral, decision, and cognitive sciences. Furthermore, this research could lead to new methodology that better informs decision-making and policy interventions.

Data-driven optimization of version 9 American Joint Committee on Cancer staging system for anal cancer.

INTRODUCTION: The American Joint Committee on Cancer (AJCC) staging system undergoes periodic revisions to maintain contemporary survival outcomes related to stage. Recently, the AJCC has developed a novel, systematic approach incorporating survival data to refine stage groupings. The objective of this study was to demonstrate data-driven optimization of the version 9 AJCC staging system for anal cancer assessed through a defined validation approach. METHODS: The National Cancer Database was queried for patients diagnosed with anal cancer in 2012 through 2017. Kaplan-Meier methods analyzed 5-year survival by individual clinical T category, N category, M category, and overall stage. Cox proportional hazards models validated overall survival of the revised TNM stage groupings. RESULTS: Overall, 24,328 cases of anal cancer were included. Evaluation of the 8th edition AJCC stage groups demonstrated a lack of hierarchical prognostic order. Survival at 5 years for stage I was 84.4%, 77.4% for stage IIA, and 63.7% for stage IIB; however, stage IIIA disease demonstrated a 73.0% survival, followed by 58.4% for stage IIIB, 59.9% for stage IIIC, and 22.5% for stage IV (p <.001). Thus, stage IIB was redefined as T1-2N1M0, whereas Stage IIIA was redefined as T3N0-1M0. Reevaluation of 5-year survival based on data-informed stage groupings now demonstrates hierarchical prognostic order and validated via Cox proportional hazards models. CONCLUSION: The 8th edition AJCC survival data demonstrated a lack of hierarchical prognostic order and informed revised stage groupings in the version 9 AJCC staging system for anal cancer. Thus, a validated data-driven optimization approach can be implemented for staging revisions across all disease sites moving forward.