Predicting Mortality Prior to Interhospital Hospital for "Unseen" General Surgery Patients: Development, Validation and Feasibility Trial of a Mortality Risk Calculator.

OBJECTIVE: Develop and validate a mortality risk calculator that could be utilized at the time of transfer, leveraging routinely collected variables that could be obtained by trained non-clinical transfer personnel. SUMMARY BACKGROUND DATA: There are no objective tools to predict mortality at the time of inter-hospital transfer for Emergency General Surgery (EGS) patients that are "unseen" by the accepting system. METHODS: Patients transferred to general or colorectal surgery services from January 2016 through August 2022 were retrospectively identified and randomly divided into training and validation cohorts (3:1 ratio). The primary outcome was admission-related mortality, defined as death during the index admission or within 30 days post-discharge. Multiple predictive models were developed and validated. RESULTS: Among 4,664 transferred patients, 280 (6.0%) experienced mortality. Predictive models were generated utilizing 19 routinely collected variables; the penalized regression model was selected over other models due to excellent performance using only 12 variables. The model performance on the validating set resulted in an area under the receiver operating characteristic curve, sensitivity, specificity, and balanced accuracy of 0.851, 0.90, 0.67, and 0.79, respectively. After bias correction, Brier score was 0.04, indicating a strong association between the assigned risk and the observed frequency of mortality. CONCLUSION: A risk calculator using twelve variables has excellent predictive ability for mortality at the time of interhospital transfer among "unseen" EGS patients. Quantifying a patient's mortality risk at the time of transfer could improve patient triage, bed and resource allocation, and standardize care.

The effect of virtual interviews on the musculoskeletal radiology fellowship match.

OBJECTIVE: Resulting from the COVID-19 pandemic, a virtual interview format was adopted in lieu of in-person interviews for fellowship recruitment. The purpose of this study is to analyze the potential effect that virtual interviews have on musculoskeletal radiology fellowship match results and collect opinions of the process. MATERIALS AND METHODS: An anonymous survey was sent to 87 listed US-based musculoskeletal radiology fellowship directors, who were asked for their 2019-2020 and 2020-2021 match data: fellowship positions, interviewees, ranked interviewees, and matched ranks. They rated effectiveness of virtual interviews on a ten-point scale (1 poor-10 excellent) and provided an ideal percentage of future interviews to be conducted virtually. RESULTS: Thirty responses were received (34.4% response rate). Primary analysis found significant increase in the mean number of candidates ranked in 2020-2021, 14.6 to 17.5 (p = 0.047). The mean rank of matched applicants increased from 6.02 to 6.43, without significance (p = 0.821). Secondary analysis, which attempted to exclude internally matched programs, found significant increases in 2020-2021 in the mean number of applicants-28.7 to 32.4 (p = 0.017), interviews conducted-17.8 to 21.3 (p = 0.007), and candidates ranked by programs-16.3 to 19.8 (p = 0.015). The mean rank of matched applicants increased from 6.39 to 7.03, without significance (p = 0.713). CONCLUSION: With results showing an increase in applications, interviews conducted, and ranked applicants while lowering the average rank of matched candidates, musculoskeletal radiology fellowship directors should consider interviewing more applicants than they usually would in the prior in-person recruitment format.

Stage IV Non-breast Cancer Patients and Screening Mammography: It is Time to Stop.

BACKGROUND: Patients diagnosed with metastatic cancer have shortened life expectancy with questionable benefit of routine screening mammography (SM). The aim of this study was to evaluate the incidence and consequences of continued SM in the setting of reduced survival from stage IV non-breast cancer. METHODS: Women diagnosed with Stage IV non-breast cancer at a single institution from 2015 to 2019 were queried from the institutional tumor registry for demographics, stage IV cancer diagnosis, and survival. Incidence and timing of SM after stage IV diagnosis and further diagnostic workup were extracted from the medical record. RESULTS: 790 women with Stage IV non-breast cancer were identified, 109 (14%) had at least 1 SM, 23% required diagnostic mammography, 7% breast biopsy, and 1% breast surgery. No breast cancers were identified. SM was ordered most often in stage IV gynecological cancers (28%), with more common cancers still seeing a high percentage of patients screened (lung 10%, colorectal 15%). Study 3-year survival was 26% (95% confidence interval [CI] 23-30%), with 74% mortality during follow up and median time from Stage IV diagnosis to death of 1.2 years (CI 0.4-2.3 years). Of patients screened, 41/109 died within 2 years of undergoing SM. CONCLUSIONS: Despite low overall survival for patients diagnosed with metastatic non-breast cancer, 14% of women underwent SM which resulted in additional imaging, biopsies, and surgery with no new breast cancers identified. Continued SM in this population offers risk without benefit of reduced breast cancer mortality and should no longer continue in women with stage IV non-breast cancer.

Preoperative Calcium and Parathyroid Hormone Values Are Poor Predictors of Gland Volume and Multigland Disease in Primary Hyperparathyroidism: A Review of 2000 Consecutive Patients.

OBJECTIVE: Calcium and parathyroid hormone (PTH) values are believed to have a linear relationship in patients with primary hyperparathyroidism and correlate with parathyroid gland size, with higher values predicting single-gland disease. In this modern series, these preoperative values were correlated with operative findings to determine their utility in predicting the gland involvement at parathyroid exploration. METHODS: Two thousand consecutive patients who underwent initial surgery for sporadic primary hyperparathyroidism from 2000 to 2014 were reviewed. All patients underwent a 4-gland exploration. Relationships between preoperative calcium and PTH values with the total gland volume of each patient were examined and stratified using the number of involved glands: single adenoma (SA), double adenoma (DA), and hyperplasia (H). RESULTS: There were 1274 (64%) SA, 359 (18%) DA, and 367 (18%) H cases. There was a poor correlation between preoperative calcium and PTH values (R = 0.37) and both poorly correlated with the total gland volume (R < 0.40). Similarly, subgroup analysis using the number of involved glands showed poor correlation. The mean total gland volume was similar among all subgroups (SA = 1.28 cm3, DA = 1.43 cm3, and H = 1.27 cm3; P = .52), implying that individual glands were smaller in multigland disease. SA was found in 271 (53%) of patients with calcium levels of ≤10.5 mg/dL and 122 (78%) with levels of ≥12 mg/dL (P < .001). CONCLUSION: This is the largest series correlating preoperative calcium and PTH values with operative findings of gland size and number of diseased glands. Although a lower calcium value predicts somewhat more multigland disease, the overall poor correlation should make the parathyroid surgeon aware that gland size and multigland disease cannot be predicted by preoperative laboratory testing.

The Everted Acetabular Labrum: Patho-anatomy, Magnetic Resonance Imaging and Arthroscopic Findings of a Native Variant.

PURPOSE: The purpose of this study was to introduce a native labral variant, the everted acetabular labrum, and to describe the patho-anatomy, magnetic resonance imaging and magnetic resonance arthrogram (MRI/MRA) characteristics and the arthroscopic findings in this condition. METHODS: All primary hip arthroscopy procedures performed by the senior author between June 2013 and January 2020 were reviewed retrospectively. An everted acetabular labrum was identified as a segment of labrum that lacked apposition to the femoral head with the hip off traction. All everted labra were treated with labral advancement and repair with or without augmentation or reconstruction. The labrum-to-femoral head distance was measured in 3T MRI/MRA at the 1-2 o'clock position. A random selection of 38 hips without an everted labrum served as controls to compare radiographic parameters. RESULTS: A total of 68 hips were identified as having an everted labrum during the study period (mean age, 29.1 years), and 55 hips had advanced imaging available for review. MRI/MRA scans revealed the everted labrum to have a triangular shape in 17 hips (31%) and a blunted/round shape in 38 hips (69%), which differed significantly from controls (triangular 25/38 [66%], blunted 13/38 [34%], P < 0.001). The average labrum-to-femoral head distance was 1.4 mm for everted labra versus 0.0 mm for controls (P < 0.0001) and the mean labral lengths and widths were significantly shorter than those of controls (both P < 0.01). Of the hips, 8 underwent labral reconstruction or augmentation, and 61 underwent labral advancement/repair. CONCLUSION: The everted acetabular labrum is a native variant that is identifiable during hip arthroscopy by assessing the labral seal off traction. Preoperative MRI/MRA findings can be highly predictive of an everted labrum. Surgical treatment includes labral advancement and repair or reconstruction to restore contact between the labrum and the femoral head. LEVEL OF EVIDENCE: III, retrospective comparative study.

Spinal Injections.

Spinal pain is a common complaint and cause of disability in the United States, affecting most individuals at some point in their lives. The complex anatomy of the spine leads to multiple potential and coexisting etiologies for pain, and the differentiation of these sources can present a diagnostic challenge. Image-guided spinal injections can provide both diagnostic information identifying pain location as well as prolonged therapeutic relief as an alternative to medical management. Anesthetic and corticosteroid medications can be administered within the epidural space through transforaminal or interlaminar approaches, blocking various sensory nerves, or directly within the facet joints. Proceduralists must be aware of associated patient considerations, techniques, and potential complications to perform the procedures safely. We discuss image-guided spinal injection techniques, based on best practices and our experiences.

Drug Calculation Errors in Anesthesiology Residents and Faculty: An Analysis of Contributing Factors.

BACKGROUND: Limited data exist regarding computational drug error rates in anesthesia residents and faculty. We investigated the frequency and magnitude of computational errors in a sample of anesthesia residents and faculty. METHODS: With institutional review board approval from 7 academic institutions in the United States, a 15-question computational test was distributed during rounds. Error rates and the magnitude of the errors were analyzed according to resident versus faculty, years of practice (or residency training), duration of sleep, type of question, and institution. RESULTS: A total of 371 completed the test: 209 residents and 162 faculty. Both groups committed 2 errors (median value) per test, for a mean error rate of 17.0%. Twenty percent of residents and 25% of faculty scored 100% correct answers. The error rate for postgraduate year 2 residents was less than for postgraduate year 1 (P = .012). The error rate for faculty increased with years of experience, with a weak correlation (R = 0.22; P = .007). The error rates were independent of the number of hours of sleep. The error rate for percentage-type questions was greater than for rate, dose, and ratio questions (P = .001). The error rates varied with the number of operations needed to calculate the answer (P < .001). The frequency of large errors (100-fold greater or less than the correct answer) by residents was twice that of faculty. Error rates varied among institutions ranged from 12% to 22% (P = .021). CONCLUSIONS: Anesthesiology residents and faculty erred frequently on a computational test, with junior residents and faculty with more experience committing errors more frequently. Residents committed more serious errors twice as frequently as faculty.

Psoriasis Area Severity Index (PASI) and the Dermatology Life Quality Index (DLQI): the correlation between disease severity and psychological burden in patients treated with biological therapies.

BACKGROUND: Multiple metrics evaluate the efficacy of psoriasis treatment, but interestingly, the correlation between the mostly widely used clinical trial efficacy end point, the physician-rendered Psoriasis Area Severity Index PASI score and, the most widely used quality of life metric, the Dermatology Life Quality Index DLQI, is not always high. OBJECTIVE: To perform a systematic review to determine PASI to DLQI correlation. METHODS: RCTs of biological agents for the treatment of moderate-to-severe psoriasis were reviewed in accordance with PRISMA guidelines. The mean percentage PASI improvement and change in mean DLQI values were recorded and compared for treatment groups from baseline to 10-16 weeks of therapy. RESULTS: A search of the literature yielded 155 sources, of which 13 RCTs met inclusion and exclusion criteria. Percentage of PASI improvement from baseline correlates with DLQI changes with an r(2) value of 0.80 from baseline through weeks 10-16. When grouped by mean percentage reduction in PASI, agents demonstrating >75% mean reduction in PASI demonstrated a mean DLQI improvement over agents that achieved <75%-50% mean reduction in PASI or <50% mean reduction in PASI [minimal clinically important difference (MCID) 3.2]. In addition, a reduction in mean PASI of at least 75%, predicted a mean movement from DLQI band 3 to DLQI band 1, in all nine treatment arms demonstrating such efficacy. CONCLUSIONS: Mean PASI and DLQI correlate predictably in patients with chronic moderate-to-severe plaque psoriasis undergoing treatment with biological agents. A reduction in PASI of at least 75% can translate to significant quality-of-life improvement in patients treated with these therapies.

Disparities in Breast Cancer Care-How Factors Related to Prevention, Diagnosis, and Treatment Drive Inequity.

Breast cancer survival has increased significantly over the last few decades due to more effective strategies for prevention and risk modification, advancements in imaging detection, screening, and multimodal treatment algorithms. However, many have observed disparities in benefits derived from such improvements across populations and demographic groups. This review summarizes published works that contextualize modern disparities in breast cancer prevention, diagnosis, and treatment and presents potential strategies for reducing disparities. We conducted searches for studies that directly investigated and/or reported disparities in breast cancer prevention, detection, or treatment. Demographic factors, social determinants of health, and inequitable healthcare delivery may impede the ability of individuals and communities to employ risk-mitigating behaviors and prevention strategies. The disparate access to quality screening and timely diagnosis experienced by various groups poses significant hurdles to optimal care and survival. Finally, barriers to access and inequitable healthcare delivery patterns reinforce inequitable application of standards of care. Cumulatively, these disparities underlie notable differences in the incidence, severity, and survival of breast cancers. Efforts toward mitigation will require collaborative approaches and partnerships between communities, governments, and healthcare organizations, which must be considered equal stakeholders in the fight for equity in breast cancer care and outcomes.

The effect of gadolinium-based intravenous contrast in the initial characterization of musculoskeletal soft tissue tumors.

OBJECTIVE: To determine if gadolinium-based contrast agents increase the sensitivity, specificity or reader confidence of malignant potential in musculoskeletal soft tissue tumors. METHODS: Pre- and post-contrast MRI studies from 87 patients were read by three independent radiologists of different experience. Readers noted malignant potential and confidence in their diagnosis based on pre-contrast and post-contrast MRI studies. Statistical models assessed for agreement between MRI reader diagnosis and pathologic results as well as analyzing effects of contrast on reader confidence. Inter- and intra-observer variabilities of malignant potential were also calculated. RESULTS: 87 patients (48 benign and 39 malignant; mean [± SD] age 51 ± 17.9 and 57.1 ± 17.1, respectively) were evaluated. For all readers, pre-contrast and post-contrast sensitivities were 68.1 % and 70.6 % while pre-contrast and post-contrast specificities were 84.6 % and 83.8 %, respectively without significant change (p=0.88). There was not a significant association with the use of contrast and prediction of malignant potential with or without the resident reader (p=0.65 and p=0.82). Use of contrast was significantly associated with higher levels of reader confidence (p=0.02) for all readers. Inter- and intra-observer variabilities were in good agreement (W = 0.77 and 0.70). CONCLUSION: The addition of a post-contrast sequence increased reader confidence in their diagnosis without a corresponding significant increase in accurate prediction of malignant potential.

Gender representation in the Central Surgical Association: A call to action.

BACKGROUND: Organizations such as the Central Surgical Association are important for promulgating advances in general surgery, but diversity and inclusion profoundly affect what is presented and discussed. The objective of this study was to evaluate gender representation trends at the Central Surgical Association and its annual meetings over the past 13 years. METHODS: Publicly available Central Surgical Association meeting proceedings from 2010 to 2022 were reviewed for society leaders, new members, invited speakers and moderators, and contributors to scientific sessions (first authors, senior authors). Gender identity was assessed through professional online platforms. The 2017 and 2021 meetings were conjoined with the Midwest Surgical Association. Incomplete data were obtained from 2013 and 2020-2022. RESULTS: A total of 2,158 individuals were reviewed, 554 (25.7%) of which were women. The overall trend of the absolute proportion of women participation increased by 1.8% per year (R2 = 0.7, P < .01). For leadership roles, 42/205 (20%) were women, with a 2.4% per year increase (R2 = 0.45, P = .02). For speaker roles, 82/384 (21.4%) were women, with a 2.2% increase per year (R2 = 0.6, P < .01). For scientific contributions, 253 first (35.9%) and 136 (19.3%) senior authors of 704 were women, with 1.5% (R2 = 0.4, P = .02) and 1.3% (R2 = 0.4, P = .03) increase per year, respectively. CONCLUSION: There has been a positive trend in women's involvement at Central Surgical Association meetings for leaders, speakers, and scientific authors. Diversity allows variate experiences to contribute to surgical advancements; thus, measures by the Central Surgical Association to ensure adequate representation should continue.

Does selective intraoperative music reduce pain following abdominal wall reconstruction? A double-blind randomized controlled trial.

PURPOSE: Although intraoperative music is purported to mitigate postoperative pain after some procedures, its application has never been explored in abdominal wall reconstruction (AWR). We sought to determine whether intraoperative music would decrease early postoperative pain following AWR. METHODS: We conducted a placebo-controlled, patient-, surgeon-, and assessor-blinded, randomized controlled trial at a single center between June 2022 and July 2023 including 321 adult patients undergoing open AWR with retromuscular mesh. Patients received noise-canceling headphones and were randomized 1:1 to patient-selected music or silence after induction, stratified by preoperative chronic opioid use. All patients received multimodal pain control. The primary outcome was pain (NRS-11) at 24 ± 3 h. The primary outcome was analyzed by linear regression with pre-specified covariates (chronic opioid use, hernia width, operative time, myofascial release, anxiety disorder diagnosis, and preoperative STAI-6 score). RESULTS: 178 patients were randomized to music, 164 of which were analyzed. 177 were randomized to silence, 157 of which were analyzed. At 24 ± 3 h postoperatively, there was no difference in the primary outcome of NRS-11 scores (5.18 ± 2.62 vs 5.27 ± 2.46, p = 0.75). After adjusting for prespecified covariates, the difference of NRS-11 scores at 24 ± 3 h between the music and silence groups remained insignificant (p = 0.83). There was no difference in NRS-11 or STAI-6 scores at 48 ± 3 and 72 ± 3 h, intraoperative sedation, or postoperative narcotic usage. CONCLUSION: For patients undergoing AWR, there was no benefit of intraoperative music over routine multimodal pain control for early postoperative pain reduction. TRIAL REGISTRATION: ClinicalTrials.gov: NCT05374096.

Human monoclonal antibody MBL-HCV1 delays HCV viral rebound following liver transplantation: a randomized controlled study.

Rapid allograft infection complicates liver transplantation (LT) in patients with hepatitis C virus (HCV). Pegylated interferon-α and ribavirin therapy after LT has significant toxicity and limited efficacy. The effect of a human monoclonal antibody targeting the HCV E2 glycoprotein (MBL-HCV1) on viral clearance was examined in a randomized, double-blind, placebo-controlled pilot study in patients infected with HCV genotype 1a undergoing LT. Subjects received 11 infusions of 50 mg/kg MBL-HCV1 (n=6) or placebo (n=5) intravenously with three infusions on day of transplant, a single infusion on days 1 through 7 and one infusion on day 14 after LT. MBL-HCV1 was well-tolerated and reduced viral load for a period ranging from 7 to 28 days. Median change in viral load (log10 IU/mL) from baseline was significantly greater (p=0.02) for the antibody-treated group (range -3.07 to -3.34) compared to placebo group (range -0.331 to -1.01) on days 3 through 6 posttransplant. MBL-HCV1 treatment significantly delayed median time to viral rebound compared to placebo treatment (18.7 days vs. 2.4 days, p<0.001). As with other HCV monotherapies, antibody-treated subjects had resistance-associated variants at the time of viral rebound. A combination study of MBL-HCV1 with a direct-acting antiviral is underway.

Ultrasound elastography for fibrosis surveillance is cost effective in patients with chronic hepatitis C virus in the UK.

BACKGROUND: Chronic hepatitis C (HCV) is a significant risk factor for cirrhosis and subsequently hepatocellular carcinoma (HCC). HCV patients with cirrhosis are screened for HCC every 6 months. Surveillance for progression to cirrhosis and consequently access to HCC screening is not standardized. Liver biopsy, the usual test to determine cirrhosis, carries a significant risk of morbidity and associated mortality. Transient ultrasound elastography (fibroscan) is a non-invasive test for cirrhosis. PURPOSE: This study assesses the cost effectiveness of annual surveillance for cirrhosis in patients with chronic HCV and the effect of replacing biopsy with fibroscan to diagnose cirrhosis. METHOD: A Markov decision analytic model simulated a hypothetical cohort of 10,000 patients with chronic HCV initially without fibrosis over their lifetime. The cirrhosis surveillance strategies assessed were: no surveillance; current practice; fibroscan in current practice with biopsy to confirm cirrhosis; fibroscan completely replacing biopsy in current practice (definitive); annual biopsy; annual fibroscan with biopsy to confirm cirrhosis; annual definitive fibroscan. RESULTS: Our results demonstrate that annual definitive fibroscan is the optimal strategy to diagnose cirrhosis. In our study, it diagnosed 20 % more cirrhosis cases than the current strategy, with 549 extra patients per 10,000 accessing screening over a lifetime and, consequently, 76 additional HCC cases diagnosed. The lifetime cost is £98.78 extra per patient compared to the current strategy for 1.72 additional unadjusted life years. Annual fibroscan surveillance of 132 patients results in the diagnosis one additional HCC case over a lifetime. The incremental cost-effectiveness ratio for an annual definitive fibroscan is £6,557.06/quality-adjusted life years gained. CONCLUSION: Annual definitive fibroscan may be a cost-effective surveillance strategy to identify cirrhosis in patients with chronic HCV, thereby allowing access of these patients to HCC screening.

Corrigendum: Opportunities for human factors in machine learning.

[This corrects the article DOI: 10.3389/frai.2023.1130190.].

Opportunities for human factors in machine learning.

Introduction: The field of machine learning and its subfield of deep learning have grown rapidly in recent years. With the speed of advancement, it is nearly impossible for data scientists to maintain expert knowledge of cutting-edge techniques. This study applies human factors methods to the field of machine learning to address these difficulties. Methods: Using semi-structured interviews with data scientists at a National Laboratory, we sought to understand the process used when working with machine learning models, the challenges encountered, and the ways that human factors might contribute to addressing those challenges. Results: Results of the interviews were analyzed to create a generalization of the process of working with machine learning models. Issues encountered during each process step are described. Discussion: Recommendations and areas for collaboration between data scientists and human factors experts are provided, with the goal of creating better tools, knowledge, and guidance for machine learning scientists.

Asymptomatic Intracardiac Cement Embolism Following Kyphoplasty.

Cement extravasation can occur during vertebral body augmentation such as kyphoplasty and vertebroplasty with diverse presentation and resultant treatment. The cement can embolize through venous vasculature to the thorax where it poses a potential threat to the cardiovascular and pulmonary systems. A thorough risk-benefit analysis should be conducted to select the appropriate treatment course. We present an asymptomatic case of cement extravasation to the heart and lungs during kyphoplasty.