Software-driven chronic disease management: Algorithm design and implementation in a community-based blood pressure control pilot.

Background: Optimal guideline-directed medical therapy is rarely attained in practice, resulting in inadequate control of diseases such as hypertension, with poorer results in under-resourced communities. Technology, including artificial intelligence-driven decision support and software-driven workflow transformation, can potentially improve disease outcomes at a reduced cost, although it must be integrated with a holistic approach. Methods: We describe the design of a software platform that enables rapid iterative remote management of >20 conditions across cardiac-kidney-metabolic disease. The platform distributes work across a care team of providers and care navigators, automates decision-making, ordering, and documentation, supports rapid incorporation of new evidence, and launches pragmatic trials. We describe software used in a 500-person community-based blood pressure control implemented as a single-arm quality improvement program. The primary endpoint was the proportion of patients meeting the Healthcare Effectiveness Data and Information Set quality measure blood pressure goal (<140/90) at 12 weeks. Results: A total of 1609 patients were screened, 945 (59%) were found to have uncontrolled hypertension, and 512 patients consented to join the program. The average age was 61 ± 11 years; 59% were female, and 99% self-identified as Black. Blood pressure distribution was: 10% Stage 1 (SBP 130-139 mmHg or DBP 80-89 mmHg), 69% Stage 2 (SBP 140-179 mmHg or DBP 90-119 mmHg), and 21% Stage 3 (SBP >180 mmHg or DBP >120 mmHg). Two hundred four patients (39%) proceeded to a provider encounter, and 160 of these (78%) completed the program. The Healthcare Effectiveness Data and Information Set blood pressure goal was achieved in <12 weeks of enrollment for 141 participants (69% of those enrolled, 88% of those who completed the program). Conclusion: Software-driven remote blood pressure is feasible, although strategies to improve patient enrollment will be needed to achieve maximum impact. Future work will be required to compare outcomes to usual care and evaluate concurrent management of multiple cardiac-kidney-metabolic conditions.

Prospective, multi-site evaluation of the Cepheid Xpert Xpress CoV-2 plus test on nasal and nasopharyngeal swabs.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) continues its largely aseasonal spread with millions of cases per year. Highly sensitive, point-of-care testing is critical for rapid detection of coronavirus disease 2019 (COVID-19) cases and initiation of antiviral therapy to avert adverse health outcomes and reduce onward transmission of the virus. While hundreds of COVID-19 diagnostics received emergency use authorization from the FDA during the pandemic, significantly fewer have navigated the course to FDA clearance or approval. Here, we determined the clinical performance of the Cepheid Xpert Xpress CoV-2 plus for detection of SARS-CoV-2 in 3,750 anterior nasal swab (NS) specimens and nasopharyngeal swab (NPS) from 32 sites in comparison to the FDA-authorized BioFire Respiratory Panel 2.1. Three-quarters of specimens collected were tested on the Xpert Xpress CoV-2 plus in the point-of-care setting. Overall positive percent agreement (PPA) was 98.1% (95% CI: 96.7%-98.9%) and negative percent agreement (NPA) was 98.3% (97.7%-98.7%). Performance of the Xpert Xpress CoV-2 plus was slightly improved in NS compared to NPS specimens, with PPA of 99.3% versus 97.0% (Fisher's exact test, P = 0.06) and NPA of 98.3% versus 98.2% (P = 0.89), respectively. Assay PPA was similar between untrained and trained users (98.7% vs 97.3%, P = 0.75), while NPA was slightly improved for untrained users (99.0% vs 97.6%, P = 0.0003). This study showed that Cepheid Xpert Xpress COV-2 plus is highly sensitive and specific/has high PPA and NPA for detection of SARS-CoV-2 from both NS and NPS specimens. IMPORTANCE: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) continues to cause millions of infections and tens of thousands of deaths per year in the United States. While the FDA authorized hundreds of SARS-CoV-2 tests during the public health emergency, significantly fewer have made the transition to being cleared or approved. There continues to be a need for FDA-authorized point-of-care SARS-CoV-2 testing that can be performed by untrained users. We conducted a large prospective study of the Cepheid Xpert Xpress CoV-2 plus test for detection of SARS-CoV-2 in both nasal and nasopharyngeal swabs by trained and untrained users. The assay demonstrated excellent clinical performance characteristics and, as a result of this study, was cleared by the FDA.

Trends in Medicare Utilization and Reimbursement of Tracheostomy From 2000 to 2022.

OBJECTIVE: To analyze the utilization and reimbursement for tracheostomy. STUDY DESIGN: Retrospective Cross-Sectional Study. SETTING: Centers for Medicare & Medicaid Services (CMS) Medicare Provider Utilization and Payment Data (2013 and 2021) and Part B Medicare Fee-For-Service National Summary Data (2000-2022). METHODS: Utilization, payment, and specialty breakdown were analyzed for planned tracheostomy (Current Procedural Terminology [CPT] codes 31600, 31601, 31610) and emergency tracheostomy (CPT codes 31603, 31605). RESULTS: From 2000 to 2022, there was a 48.9% decrease (40,754-20,812) in number of planned tracheostomies and a 75.3% decrease (3277-811) in number of emergency tracheostomies, leading to an overall decrease of 51%. Similarly, there was a 59.3% inflation-adjusted decrease ($13.4-$5.5 million) in total reimbursement for planned tracheostomies and an 82.1% inflation-adjusted decrease ($1.1 million-$205 thousand) in total reimbursement for emergency tracheostomies. There was a 20.3% inflation-adjusted decrease ($329-$262) in reimbursement per planned tracheostomy and a 27.7% inflation-adjusted decrease ($349-$252) in reimbursement per emergency tracheostomy. In our sample of 280 high-volume tracheostomy providers in 2021 (28.2% otolaryngology, 28.2% general surgery, 14.6% thoracic surgery, 14.3% pulmonary disease, 6.4% critical care), the average provider performed 15.8 tracheostomies and was reimbursed $5362. CONCLUSION: Despite significant declines in tracheostomy utilization and reimbursement, understanding trends for these lifesaving procedures are critical for otolaryngologists and other providers in delivering high-quality care, and can be used by surgeons, hospital systems, and policymakers to guide future health care legislation.

Trends in Soft Palate Surgery and Reimbursements for Obstructive Sleep Apnea Among the Medicare Population.

OBJECTIVES: This study aims to analyze trends in utilization and reimbursement of soft palate surgery for OSA using the Medicare national database. METHODS: A retrospective analysis of the 2000 to 2021 Part B National Summery datafiles using current Procedural Terminology (CPT) codes 42145 (uvulopalatopharyngoplasty [UPPP]), 42950 (pharyngoplasty [PP]), and 42140 (uvulectomy [UVU]) was performed. RESULTS: Between 2000 and 2021, the number of OSA surgeries fell 65.7% from 4208 to 1443. UPPP fell 87.6% from 3455 in 2000 to 428 in 2021 (P < .001). UVU also fell in popularity, from 568 to 376 (33.8%; P < .001). In contrast, the performance of PP rose 245.4% over time, from 185 to 639 (P < .001). When comparing 2000 to 2009, both PP and UVU rose in relative use (from 4.4% to 12.3% and from 13.5% to 20.4% of all soft palate OSA surgeries, respectively), while UPPP fell (82.1% to 67.3%; P < .001). Total Medicare payments for all 3 procedures fell 57.2% from $1 658 844 to $633 091 (P < .001). Adjusted total UPPP payments fell 88.7% (P < .001). Adjusted total PP payment rose 137.5% to $262 538 in 2021 (P < .001). CONCLUSION: Soft palate surgery for OSA has declined amongst the Medicare population over 21 years (2000-2021). The more individualized and tissue sparing PP has risen in popularity but did not overcome the large decline of the traditional UPPP. Accordingly, there was a 75.7% fall in inflation-adjusted reimbursements. Overall, our data indicates a decline in soft palate surgery in the management of geriatric OSA, with modest relative increase in pharyngoplasty procedures.

Acute Liver Failure Induced by Provitalize: A Menopause Supplement Concocted From Herbs & Probiotics.

Drug-induced liver injury is one of the most common causes of acute liver failure in the Western world. Despite discontinuation of the offending agent, it can still tax a grim prognosis. We describe a case of a menopausal woman taking a herbal supplement called "Provitalize" to relieve hot flashes and bloating. This is the first case report of liver injury from this supplement. She initially presented with mild jaundice and elevated transaminases. Unfortunately, she rapidly progressed to encephalopathy, experienced multiorgan failure, and then died.

Characterizing the Rise in Dupilumab Prescriptions and Costs: A Medicare Part D Study.

Dupilumab indications have expanded since 2017 Food and Drug Administration (FDA) approval, though evolving prescribing patterns remains to be explored. Annual 2017 to 2021 Medicare Part D claims data was queried. The number of prescribers rose from 142 in 2017 to 6244 in 2021 (r = 0.971; P = .006). Accordingly, the number of Medicare claims and costs both rose, from 2444 to 157,401 (r = 0.986; P = .002) and from $7.59 million to $540.5 million (r = 0.982; P = .003), respectively. While dermatologists made up the bulk of providers in 2017 (78.9%), they only made up 38.1% of providers in 2021. Otolaryngologists were the least represented specialty. In 2021, most providers (98.0%) had only 10 or fewer Medicare patients for whom they prescribed dupilumab. Dupilumab is becoming an increasingly prevalent treatment modality for a variety of indications in the Medicare population. This comes with an incredibly large financial burden on patients and Medicare. The profile of prescribers has changed, mirroring the FDA-approved indications.

Developing an automated algorithm for identification of children and adolescents with diabetes using electronic health records from the OneFlorida+ clinical research network.

AIM: To develop an automated computable phenotype (CP) algorithm for identifying diabetes cases in children and adolescents using electronic health records (EHRs) from the UF Health System. MATERIALS AND METHODS: The CP algorithm was iteratively derived based on structured data from EHRs (UF Health System 2012-2020). We randomly selected 536 presumed cases among individuals aged <18 years who had (1) glycated haemoglobin levels ≥ 6.5%; or (2) fasting glucose levels ≥126 mg/dL; or (3) random plasma glucose levels ≥200 mg/dL; or (4) a diabetes-related diagnosis code from an inpatient or outpatient encounter; or (5) prescribed, administered, or dispensed diabetes-related medication. Four reviewers independently reviewed the patient charts to determine diabetes status and type. RESULTS: Presumed cases without type 1 (T1D) or type 2 diabetes (T2D) diagnosis codes were categorized as non-diabetes/other types of diabetes. The rest were categorized as T1D if the most recent diagnosis was T1D, or otherwise categorized as T2D if the most recent diagnosis was T2D. Next, we applied a list of diagnoses and procedures that can determine diabetes type (e.g., steroid use suggests induced diabetes) to correct misclassifications from Step 1. Among the 536 reviewed cases, 159 and 64 had T1D and T2D, respectively. The sensitivity, specificity, and positive predictive values of the CP algorithm were 94%, 98% and 96%, respectively, for T1D and 95%, 95% and 73% for T2D. CONCLUSION: We developed a highly accurate EHR-based CP for diabetes in youth based on EHR data from UF Health. Consistent with prior studies, T2D was more difficult to identify using these methods.

Economic evaluation of extended panel analysis in cancer patients with historical NHS diagnostic germline genetic testing - A modeling study based on real-world data.

BACKGROUND: The South West Thames Centre for Genomics implemented a wider diagnostic Next Generation Sequencing (NGS) gene panel for eligible cancer patients undergoing diagnostic testing whilst restricting data analysis and reporting for BRCA1/BRCA2/PALB2/CHEK2 1100delC only as per contemporaneous guidelines. This study investigated the cost-utility of reanalyzing existing diagnostic grade extended panel data for truncating germline pathogenic variants (GPVs) in known moderate risk cancer susceptibility genes (CSGs) and performing follow-up genetic testing for first-degree relatives if patients have an identified CSG allele. METHODS: Reanalysis of existing NGS data was undertaken in 889 samples from cancer patients contemporaneously eligible through the NHS England National Genomic Test Directory (NGTD) codes R207 (ovarian) or R208 (breast) who had tested negative for BRCA1/BRCA2/PALB2 and CHEK2 1100delC founder variant. We modeled the cost and health outcomes for comparisons between: 1. Extending reanalysis to ATM truncating GPVs (partial extended testing) versus historical genetic testing, and 2. Extending analysis to ATM truncating GPV/BRIP1 truncating GPV/CHEK2 truncating GPV excluding CHEK2 1100delC/RAD51C truncating GPV/RAD51D truncating GPV (full extended testing) versus historical genetic testing. RESULTS: For partial extended testing, the ICER compared with historical genetic testing was UK£49,671/QALY. For full extended testing, the ICER compared with historical genetic testing of historical genetic testing was UK£5716/QALY. The full extended testing remained cost-effective with a 30% increase in genetic testing cost. CONCLUSION: Where existing NGS data for cancer susceptibility genes is stored to diagnostic standard in UK laboratories, this study suggests it is cost-effective to analyze, report and clinically manage patients and relatives by extended analysis to an 8-gene panel compared to the historical genetic testing.

3D-printed neck phantoms with detailed anatomy for ultrasound-guided procedure and device testing.

Objectives: With rapid advances in ultrasound-guided procedures, there is an unmet need for echogenic phantoms with sufficient anatomical details for artificial intelligence and ultrasound-guided device testing. We developed a method for creating neck phantoms for novel otolaryngology-related device testing. To achieve accurate representation of the anatomy, we utilized CT scans and 3D printing technology to create customized agar molds, thus providing high-fidelity yet cost-effective tools. Methods: Based on previous studies, the key components in our neck phantom include the cervical vertebrae, trachea, common carotid arteries, internal jugular veins, thyroid gland, and surrounding soft tissue. Open-source image analysis software were employed to process CT data to generate high fidelity 3D models of the target structures. Resin molds were 3D printed and filled with various agar mixtures to mimic anatomical echogenicity. Results: Following the method proposed, we successfully assembled the neck phantom which provided a detailed representation of the target structures. To evaluate the results, ultrasound data was collected on the phantom and living tissue and analyzed with ImageJ. We were able to demonstrate echogenicity comparable to that of living tissue. Conclusion: The proposed method for building neck phantoms with detailed anatomical features offers a valuable, detailed, low-cost tool for medical training and device testing in otolaryngology, particularly for novel devices that involve artificial intelligence (AI) guidance and robotic-based needle insertion. Additional anatomical refinements and validation studies could further enhance the consistency and accuracy, thus paving the way for future advancements in ultrasound training and research, and ultimately benefiting patient care and safety.

Development of PainFace software to simplify, standardize, and scale up mouse grimace analyses.

ABSTRACT: Facial grimacing is used to quantify spontaneous pain in mice and other mammals, but scoring relies on humans with different levels of proficiency. Here, we developed a cloud-based software platform called PainFace ( http://painface.net ) that uses machine learning to detect 4 facial action units of the mouse grimace scale (orbitals, nose, ears, whiskers) and score facial grimaces of black-coated C57BL/6 male and female mice on a 0 to 8 scale. Platform accuracy was validated in 2 different laboratories, with 3 conditions that evoke grimacing-laparotomy surgery, bilateral hindpaw injection of carrageenan, and intraplantar injection of formalin. PainFace can generate up to 1 grimace score per second from a standard 30 frames/s video, making it possible to quantify facial grimacing over time, and operates at a speed that scales with computing power. By analyzing the frequency distribution of grimace scores, we found that mice spent 7x more time in a "high grimace" state following laparotomy surgery relative to sham surgery controls. Our study shows that PainFace reproducibly quantifies facial grimaces indicative of nonevoked spontaneous pain and enables laboratories to standardize and scale-up facial grimace analyses.

Tracheal Anastomosis Leaks Across Suture Techniques and Tensions: A Biomechanical Ex Vivo Study.

BACKGROUND: Anastomotic leak after tracheal resection may occur while coughing in the early postoperative period. We investigated the varying effects of suturing technique, stretch, and tension on anastomotic leaks during simulated coughs. METHODS: End-to-end anastomoses were performed using continuous or interrupted sutures on excised porcine larynges. Tracheas were secured to a pressurized system simulating cough forces, submerged in a water bath, and stretched to 1, 2, and 3 cm above baseline. Peak pressure, incomplete cough generation, and observed leakages were recorded. Parameters were analyzed using Analysis of Variance (ANOVA), multiple linear regression, and logistic regression modeling. RESULTS: Peak tension (B = -0.660, p < 0.001) and stretch lengths (B = -0.329, p = 0.006) were associated with variance in peak pressure (R2 = 0.77, F(3,294) = 8.182, p < 0.001). Incomplete coughs increased with higher peak tension (odds ratio [OR] = 15.627, p < 0.001) and stretching to 3 cm above baseline (OR = 4.335, p < 0.007). Similarly, leak occurrences, primarily from the posterior tracheal wall, increased with higher peak tension (OR = 1.787, p < 0.001) and stretching to 3 cm (OR = 2.613, p = 0.017). No significance was identified with suturing technique. CONCLUSION: Interrupted and continuous suture techniques do not differ in anastomotic strength during simulated coughs. Increased peak tracheal tension is associated with a weaker anastomosis, and tracheal stretch to 3 cm was associated with a weaker anastomosis. Our study supports the commonly held clinical belief that, to create a stronger anastomosis, tension should be minimized, and particular attention should be placed at the posterior tracheal wall during closure. LEVEL OF EVIDENCE: N/A, Benchtop study Laryngoscope, 2024.

Determinants of pharmacists' confidence to participate in antimicrobial stewardship: A confirmatory factor analysis.

AIM: Pharmacists are essential members of hospital antimicrobial stewardship (AMS) teams. A lack of self-perceived confidence can limit pharmacists' involvement and contributions. Pharmacists working in AMS have reported a lack of confidence. There is currently a lack of validated measures to assess pharmacists' self-perceived confidence when working in AMS and contributors to this confidence. This study aimed to identify variables contributing to pharmacist self-perceived confidence and validate an AMS hospital pharmacist survey tool using confirmatory factor analysis (CFA). METHODS: Responses from a survey of Australian and French hospital pharmacists were used to undertake CFA and path analysis on factors related to pharmacists' self-perceived confidence. It was hypothesized that pharmacists' self-perceived confidence would be impacted by time working in AMS, perceived importance of AMS programmes, perceived barriers to participating in AMS and current participation. RESULTS: CFA demonstrated a good model fit between the factors. Items included in the model loaded well to their respective factors with acceptable reliability. Path analysis demonstrated that time working in AMS had a significant impact on pharmacists' self-perceived confidence, while perceived barriers had a negatively significant relationship. Pharmacy participation in AMS and perceived importance of AMS programmes had a non-significant impact. CONCLUSION: Findings demonstrated that the survey tool showed good validity and identified factors that can impact pharmacists' self-perceived confidence when working in hospital AMS programmes. Having a validated survey tool can identify factors that can reduce pharmacists' self-perceived confidence. Strategies can then be developed to address these factors and subsequently improve pharmacists' self-perceived confidence.

Comparative evaluation of alkaline ionized water and normal water on oral microbial flora: An in-vitro study.

Background: Various artificial chemical agents have been evaluated over many years with respect to their antimicrobial effect in oral cavity. The gold standard for removal of plaque is usage of chlorhexidine, but it can cause alteration in taste sensation and staining of teeth. Electrolytes and oxidizing water may be useful against microbes, but its clinical application has still not been evaluated. Hence this present study was conducted to evaluate the effectiveness of the alkaline ionized water on oral microbial flora. Materials and Methods: Ten non-carious, un-restored and intact freshly extracted human teeth were collected and sectioned using a round bur. Each tooth was sectioned longitudinally in two parts and stored in closed sterile containers which was filled with alkaline ionized water (Group 1) and normal water (Group 2), respectively for 15 days. The microbial growth was analyzed prior to dipping in the solutions, 3 days, 7 days and 15 days. The pH of alkaline ionized water and normal water was evaluated using pH meter before placing teeth in different solutions. Results were analyzed using t-test and the level of significance was set at ≤ 0.05. Results: No difference in bacterial colony was observed before test and after 3 days among Group 1 and Group 2, respectively. After 7 days and 15 days, statistically significant decrease in bacterial colony count was seen among Group 1 as compared to Group 2 (P ≤ 0.05). Conclusion: It was then concluded that alkaline ionized water can be effective in reduction of oral microbial flora.

Fabrication of a wearable and foldable photodetector based on a WSe2-MXene 2D-2D heterostructure using a scalable handprint technique.

Several studies on semiconductor material-based single-band, high-performance photosensitive, and chemically stable photodetectors are available; however, the lack of broad spectral response, device flexibility, and biodegradability prevents them from being used in wearable and flexible electronics. Apart from that, the selection of the device fabrication technique is a very crucial factor nowadays in terms of equipment utilization and environmental friendliness. This report presents a study demonstrating a straightforward solvent- and equipment-free handprint technique for the fabrication of WSe2-Ti3C2TX flexible, biodegradable, robust, and broadband (Vis-NIR) photodetectors. X-ray diffraction (XRD), field emission scanning electron microscopy (FESEM), energy dispersive X-ray spectroscopy (EDX), UV-visible spectroscopy, and X-ray photoelectron spectroscopy (XPS) confirm the formation of a WSe2-Ti3C2TX film. The WSe2-Ti3C2TX van der Waals heterostructure plays a key role in enhancing the optoelectrical properties. The as-prepared photodetector exhibits efficient broadband response with a photoresponsivity and a detectivity of 0.3 mA W-1 and 6.8 × 1010 Jones, respectively, under NIR (780 nm) irradiation (1.0 V bias). Under various pressure and temperature conditions, the device's flexibility and durability were tested. The biodegradable photodetector prepared through the solvent- and equipment-free handprint technique has the potential to attract significant interest in wearable and flexible electronics in the future.

Medicare volume and reimbursement trends in lingual and hyoid procedures for obstructive sleep apnea.

OBJECTIVES: This study aims to analyze utilization and reimbursement trends in lingual and hyoid surgery for obstructive sleep apnea (OSA). METHODS: Annual retrospective data on lingual and hyoid OSA surgeries was obtained from the 2000-2021 Medicare Part B National Summary Datafiles. Current Procedural Terminology (CPT) codes utilized included 21,685 (hyoid myotomy and suspension [HMS]), 41,512 (tongue base suspension [TBS]), 41,530 (radiofrequency ablation of the tongue [RFT]) and 42,870 (lingual tonsillectomy [LT]). RESULTS: The number of lingual and hyoid OSA surgeries rose 2777 % from 121 in 2000 to 3481 in 2015, before falling 82.9 % to 594 in 2021. Accordingly, Medicare payments rose 17,899 % from an inflation-adjusted $46,958 in 2000 to $8.45 million in 2015, before falling drastically to $341,011 in 2021. As the number of HMSs (2000: 91; 2015: 84; 2021: 165), TBS (2009: 48; 2015: 31; 2021: 16), and LTs (2000: 121; 2015: 261; 2021: 234) only experienced modest changes in utilization, this change was largely driven by RFT (2009: 340; 2015: 3105; 2021: 179). Average Medicare payments for RFT rose from $1110 in 2009 to $2994 in 2015, before falling drastically to $737 in 2021. CONCLUSION: Lingual and hyoid surgery for OSA has overall fallen in utilization among the Medicare population from 2000 to 2021. However, there was a brief spike in usage, peaking in 2015, driven by the adoption (and then quick dismissal) of RFT. The rise and fall in RFT use coincide with the rise and fall in reimbursement.

Effects of Surgeon-Preferred Staff and Staff Turnover on Operating Time and Complication Rates in Reverse and Anatomic Total Shoulder Arthroplasty.

BACKGROUND: This study focuses on investigating the risk factors of increased operating room time and patient complication rates after total shoulder arthroplasty cases (both reverse and anatomic). We hypothesize that the use of surgeon-preferred staff will improve operating room efficiency and reduce complication rates while increased staff turnover will decrease efficiency and increase complications. METHODS: This is a single-center, retrospective study focused on determining the effects of staffing on operating room time and efficiency in total shoulder arthroplasty. The study included patients who underwent total shoulder arthroplasty by a single fellowship-trained orthopaedic surgeon from 2018 to 2023. RESULTS: Four hundred twenty-three patients were included in the study from August 2018 to April 2023, 264 of which were reverse total shoulder arthroplasty (rTSA) and 159 were anatomic total shoulder arthroplasty (aTSA). In both rTSA and aTSA, the presence of surgeon-preferred staff markedly decreased operating room time. In rTSA, staff turnover increased risk of 90-day complications. CONCLUSION: Because the presence of surgeon-preferred staff affects operating room time and efficiency, orthopaedic surgeons should train multiple surgical teams so that efficiency is not affected by the loss of personnel during a case. To reduce 90-day complication rates in rTSA, staff breaks and turnover should be minimized as much as possible because this has a direct effect on patient outcomes. Effort from hospital administration and management should be put toward reducing turnover to improve patient outcomes.

How Variable are Patient Comorbidity Profiles Among Practicing Otolaryngologists?

OBJECTIVE: To determine whether certain groups of otolaryngologists (ORLs) are treating cohorts of patients with more comorbidities. STUDY DESIGN: Cross-sectional population-based analysis. SETTING: 2019 Medicare Provider Utilization and Payment Dataset. METHODS: Each ORL's average Medicare hierarchical condition category (HCC) risk score, a comorbidity index calculated from a patient's comorbidities, was collected. These were stratified and compared by various physician characteristics, including practice region and rurality, years in practice, gender, subspecialty, and setting (academic vs community). RESULTS: Among 8959 ORLs, the mean HCC risk score for Medicare patients was 1.35 ± 0.35. On univariate analysis, ORLs practicing in urban (compared to rural), ORLs in academic settings (compared to community), and early career ORLs all had a patient population with a higher HCC risk score (P < .001 for all). On multivariate analysis controlling for gender, rurality, graduation year, and region, rural setting was associated with decreased odds of having a high-risk patient population (odds ratio: 0.58 [95% confidence interval, CI: 0.48-0.71]; P < .001), while those more recently graduated has an increased risk (2000-2009: 1.41 [1.01-1.96], P = .046; 2010-2015: 2.30 [1.63-3.25], P < .001). In a separate subgroup analysis, subspecialty differences were seen and community setting was associated with decreased odds of having a high-risk patient population (0.36 [0.23-0.55]; P < .001). CONCLUSION: There is variability in patient comorbidity profiles among ORLs, with those in urban settings, those more recently graduated, and those in academic settings treating a group with more comorbidities. As the comorbidity burden may increase the cost of practice and complications, these findings may have important implications for health inequity.

An Endoscopic Ultrasound Diagnosis of a Rare Cause of Pancreatic Body Mass Demonstrating the Transformation to Large B-Cell Lymphoma.

The presence of lymphoma in the gastrointestinal tract is most frequently manifested in the stomach and intestines. Pancreatic lymphomas consist of only 0.5% of all pancreatic neoplasms. In this case, we present a patient afflicted by follicular lymphoma with pancreatic involvement. To monitor the progression of this patient's lymphoma, endoscopic ultrasound was used to observe its transformation to large B-cell lymphoma and guide therapy.

A Pilot Randomized Trial of Combined Cognitive-Behavioral Therapy and Exercise Training Versus Exercise Training Alone for the Management of Chronic Insomnia in Obstructive Sleep Apnea.

Insomnia treatment among individuals with comorbid insomnia and obstructive sleep apnea is suboptimal. In a pilot randomized controlled trial, 19 individuals with comorbid insomnia and obstructive sleep apnea were allocated to one of two arms: EX + EX, consisting of two 8-week phases of exercise training (EX), or RE + CBTiEX, encompassing 8 weeks of relaxation training (RE) followed by 8 weeks of combined cognitive-behavioral therapy and exercise (CBTiEX). Outcomes included Insomnia Severity Index (ISI), polysomnography, and cardiorespiratory fitness measures. A mixed-model analysis of variance revealed a Group × Time interaction on peak oxygen consumption change, F(1, 14) = 10.1, p = .007, and EX increased peak oxygen consumption (p = .03, g' = -0.41) and reduced ISI (p = .001, g' = 0.82) compared with RE (p = .49, g = 0.16) post-8 weeks. Post-16 weeks, there was a significant Group × Time interaction (p = .014) driven by RE + CBTiEX yielding a larger improvement in ISI (p = .023, g' = 1.48) than EX + EX (p = .88, g' < 0.1). Objective sleep was unchanged. This study showed promising effects of regular EX alone and combined with cognitive-behavioral therapy for insomnia on ISI in comorbid insomnia and obstructive sleep apnea.