A systematic review of large language models and their implications in medical education.

INTRODUCTION: In the past year, the use of large language models (LLMs) has generated significant interest and excitement because of their potential to revolutionise various fields, including medical education for aspiring physicians. Although medical students undergo a demanding educational process to become competent health care professionals, the emergence of LLMs presents a promising solution to challenges like information overload, time constraints and pressure on clinical educators. However, integrating LLMs into medical education raises critical concerns and challenges for educators, professionals and students. This systematic review aims to explore LLM applications in medical education, specifically their impact on medical students' learning experiences. METHODS: A systematic search was performed in PubMed, Web of Science and Embase for articles discussing the applications of LLMs in medical education using selected keywords related to LLMs and medical education, from the time of ChatGPT's debut until February 2024. Only articles available in full text or English were reviewed. The credibility of each study was critically appraised by two independent reviewers. RESULTS: The systematic review identified 166 studies, of which 40 were found by review to be relevant to the study. Among the 40 relevant studies, key themes included LLM capabilities, benefits such as personalised learning and challenges regarding content accuracy. Importantly, 42.5% of these studies specifically evaluated LLMs in a novel way, including ChatGPT, in contexts such as medical exams and clinical/biomedical information, highlighting their potential in replicating human-level performance in medical knowledge. The remaining studies broadly discussed the prospective role of LLMs in medical education, reflecting a keen interest in their future potential despite current constraints. CONCLUSIONS: The responsible implementation of LLMs in medical education offers a promising opportunity to enhance learning experiences. However, ensuring information accuracy, emphasising skill-building and maintaining ethical safeguards are crucial. Continuous critical evaluation and interdisciplinary collaboration are essential for the appropriate integration of LLMs in medical education.

Use of telehealth simulation to teach the enhanced primary care RN role through community/public health-focused simulations.

America is facing a primary care provider shortage. Enhanced primary care RNs (EPC-RNs), registered nurses working at the top of their practice scope, can be an important part of community-based primary care provision. Typically, community health nursing education has not included primary care-based clinical experiences, and there is a clinical site shortage. Teaching students about EPC-RN roles can be an important domain of community/public health nursing education. Simulation is a creative pedagogical approach to learning about the EPC-RN role. The purpose of this manuscript is to 1) describe EPC-RN Telehealth Simulation development; and 2) describe student simulation feedback. Nursing faculty and simulation experts designed five simulations for community health students to teach about the EPC-RN role, incorporating recommendations from the Quad Council Coalition of Public Health Nursing Organizations community/public health nursing competencies and the National Competencies for Registered Nurses in Primary Care. Retrospective, descriptive quantitative, and qualitative student feedback data (n = 519) was collected through QuestionPro over multiple semesters. Student feedback data demonstrated support of the use of the simulations in community/public health nursing education. The EPC-RN Telehealth Simulations prepared pre-licensure nursing students to practice in community-based primary care settings. Innovative, sustainable experiences such as this can improve community/public health nursing education.

Creation of an Enhanced Primary Care Registered Nurse Preceptor Role: A Pilot Project.

Historically, community health nursing education has not encompassed clinical sites in primary care. Primary care can be an important domain of community health nursing education. However, student practicum opportunities are limited by the number of and underutilization of RNs practicing at the full scope of their licensure (including assessment, client education, care planning and evaluation of care interventions) who can serve as student preceptors, especially in rural areas. This article describes the creation and implementation of the Enhanced Primary Care Registered Nurse (EPCRN) role in rural primary care clinics, as well as evaluates student perceptions of the EPCRN-precepted clinical experience. One nursing school used a federal training award to create the role of Enhanced Primary Care Registered Nurses (EPCRNs) to practice in federally-designated Rural Health Clinics. The EPCRNs worked in the Rural Health Clinics performing patient care and also functioned as student preceptors. Student experiences were evaluated through quantitative and qualitative methods, namely the Clinical Learning Experience, Supervision, and Nurse Teacher (CLES+T) scale and focus groups. This pilot project demonstrated positive pre-licensure student experience feedback as well as role value and sustainability for the health system. This pilot served as an example of a process for EPCRN role design within a primary care clinic site. It also demonstrated the importance of innovative, sustainable academic-practice partnerships.

Evaluating the efficacy and mechanism of metformin targets on reducing Alzheimer's disease risk in the general population: a Mendelian randomisation study.

AIMS/HYPOTHESIS: Metformin use has been associated with reduced incidence of dementia in diabetic individuals in observational studies. However, the causality between the two in the general population is unclear. This study uses Mendelian randomisation (MR) to investigate the causal effect of metformin targets on Alzheimer's disease and potential causal mechanisms in the brain linking the two. METHODS: Genetic proxies for the effects of metformin drug targets were identified as variants in the gene for the corresponding target that associated with HbA1c level (N=344,182) and expression level of the corresponding gene (N≤31,684). The cognitive outcomes were derived from genome-wide association studies comprising 527,138 middle-aged Europeans, including 71,880 with Alzheimer's disease or Alzheimer's disease-by-proxy. MR estimates representing lifelong metformin use on Alzheimer's disease and cognitive function in the general population were generated. Effect of expression level of 22 metformin-related genes in brain cortex (N=6601 donors) on Alzheimer's disease was further estimated. RESULTS: Genetically proxied metformin use, equivalent to a 6.75 mmol/mol (1.09%) reduction on HbA1c, was associated with 4% lower odds of Alzheimer's disease (OR 0.96 [95% CI 0.95, 0.98], p=1.06×10-4) in non-diabetic individuals. One metformin target, mitochondrial complex 1 (MCI), showed a robust effect on Alzheimer's disease (OR 0.88, p=4.73×10-4) that was independent of AMP-activated protein kinase. MR of expression in brain cortex tissue showed that decreased MCI-related gene (NDUFA2) expression was associated with lower Alzheimer's disease risk (OR 0.95, p=4.64×10-4) and favourable cognitive function. CONCLUSIONS/INTERPRETATION: Metformin use may cause reduced Alzheimer's disease risk in the general population. Mitochondrial function and the NDUFA2 gene are plausible mechanisms of action in dementia protection.

Implementing Enhanced Primary Care Registered Nurse Reimbursement in Rural Health Clinics: A Policy Analysis.

Rural Health Clinics (RHCs) were created in 1977 to address the high health care needs, limited provider access, and poor health outcomes of rural Americans. Although innovative at their inception, the provider-centric model of RHC cost-based reimbursement structures has not evolved, leaving limited opportunities for change; many have failed. Comprehensive, proactive change is needed. Registered nurses (RNs) working at the top of their practice scope are a neglected clinical resource that can improve access, quality, value, and satisfaction for rural patient communities. RHC reimbursement policy must evolve to sustain and support this significant RN role. RNs have demonstrated value in care continuity and disease management, but there is little research on the utilization of RNs using their enhanced skill set in RHCs. Using the Bardach and Patashnik's eight steps of policy analysis, the authors will describe the background and regulations of RHCs, identify current barriers to improving the health of America's rural residents, and then provide evidence to support a new policy option according to the Quadruple Aim framework. The result is a sustainable policy recommendation designed to best serve rural communities.

Automating the Classification of Complexity of Medical Decision-Making in Patient-Provider Messaging in a Patient Portal.

BACKGROUND: Patient portals are consumer health applications that allow patients to view their health information. Portals facilitate the interactions between patients and their caregivers by offering secure messaging. Patients communicate different needs through portal messages. Medical needs contain requests for delivery of care (e.g. reporting new symptoms). Automating the classification of medical decision complexity in portal messages has not been investigated. MATERIALS AND METHODS: We trained two multiclass classifiers, multinomial Naïve Bayes and random forest on 500 message threads, to quantify and label the complexity of decision-making into four classes: no decision, straightforward, low, and moderate. We compared the performance of the models to using only the number of medical terms without training a machine learning model. RESULTS: Our analysis demonstrated that machine learning models have better performance than the model that did not use machine learning. Moreover, machine learning models could quantify the complexity of decision-making that the messages contained with 0.59, 0.45, and 0.58 for macro, micro, and weighted precision and 0.63,0.41, and 0.63 for macro, micro, and weighted recall. CONCLUSIONS: This study is one of the first to attempt to classify patient portal messages by whether they involve medical decision-making and the complexity of that decision-making. Machine learning classifiers trained on message content resulted in better message thread classification than classifiers that employed medical terms in the messages alone.

Association of Genetic Risk of Obesity with Postoperative Complications Using Mendelian Randomization.

BACKGROUND: The extent to which obesity and genetics determine postoperative complications is incompletely understood. METHODS: We performed a retrospective study using two population cohorts with electronic health record (EHR) data. The first included 736,726 adults with body mass index (BMI) recorded between 1990 and 2017 at Vanderbilt University Medical Center. The second cohort consisted of 65,174 individuals from 12 institutions contributing EHR and genome-wide genotyping data to the Electronic Medical Records and Genomics (eMERGE) Network. Pairwise logistic regression analyses were used to measure the association of BMI categories with postoperative complications derived from International Classification of Disease-9 codes, including postoperative infection, incisional hernia, and intestinal obstruction. A genetic risk score was constructed from 97 obesity-risk single-nucleotide polymorphisms for a Mendelian randomization study to determine the association of genetic risk of obesity on postoperative complications. Logistic regression analyses were adjusted for sex, age, site, and race/principal components. RESULTS: Individuals with overweight or obese BMI (≥25 kg/m2) had increased risk of incisional hernia (odds ratio [OR] 1.7-5.5, p < 3.1 × 10-20), and people with obesity (BMI ≥ 30 kg/m2) had increased risk of postoperative infection (OR 1.2-2.3, p < 2.5 × 10-5). In the eMERGE cohort, genetically predicted BMI was associated with incisional hernia (OR 2.1 [95% CI 1.8-2.5], p = 1.4 × 10-6) and postoperative infection (OR 1.6 [95% CI 1.4-1.9], p = 3.1 × 10-6). Association findings were similar after limitation of the cohorts to those who underwent abdominal procedures. CONCLUSIONS: Clinical and Mendelian randomization studies suggest that obesity, as measured by BMI, is associated with the development of postoperative incisional hernia and infection.

Association Between Genetically Proxied Inhibition of HMG-CoA Reductase and Epithelial Ovarian Cancer.

Importance: Preclinical and epidemiological studies indicate a potential chemopreventive role of statins in epithelial ovarian cancer risk. Objective: To evaluate the association of genetically proxied inhibition of 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase (ie, genetic variants related to lower function of HMG-CoA reductase, target of statins) with epithelial ovarian cancer among the general population and in BRCA1/2 mutation carriers. Design, Setting, and Participants: Single-nucleotide polymorphisms (SNPs) in HMGCR, NPC1L1, and PCSK9 associated with low-density lipoprotein (LDL) cholesterol in a genome-wide association study (GWAS) meta-analysis (N ≤196 475) were used to proxy therapeutic inhibition of HMG-CoA reductase, Niemann-Pick C1-Like 1 (NPC1L1) and proprotein convertase subtilisin/kexin type 9 (PCSK9), respectively. Summary statistics were obtained for these SNPs from a GWAS meta-analysis of case-control analyses of invasive epithelial ovarian cancer in the Ovarian Cancer Association Consortium (OCAC; N = 63 347) and from a GWAS meta-analysis of retrospective cohort analyses of epithelial ovarian cancer among BRCA1/2 mutation carriers in the Consortium of Investigators of Modifiers of BRCA1/2 (CIMBA; N = 31 448). Across the 2 consortia, participants were enrolled between 1973 and 2014 and followed up through 2015. OCAC participants came from 14 countries and CIMBA participants came from 25 countries. SNPs were combined into multi-allelic models and mendelian randomization estimates representing lifelong inhibition of targets were generated using inverse-variance weighted random-effects models. Exposures: Primary exposure was genetically proxied inhibition of HMG-CoA reductase and secondary exposures were genetically proxied inhibition of NPC1L1 and PCSK9 and genetically proxied circulating LDL cholesterol levels. Main Outcomes and Measures: Overall and histotype-specific invasive epithelial ovarian cancer (general population) and epithelial ovarian cancer (BRCA1/2 mutation carriers), measured as ovarian cancer odds (general population) and hazard ratio (BRCA1/2 mutation carriers). Results: The OCAC sample included 22 406 women with invasive epithelial ovarian cancer and 40 941 control individuals and the CIMBA sample included 3887 women with epithelial ovarian cancer and 27 561 control individuals. Median ages for the cohorts ranged from 41.5 to 59.0 years and all participants were of European ancestry. In the primary analysis, genetically proxied HMG-CoA reductase inhibition equivalent to a 1-mmol/L (38.7-mg/dL) reduction in LDL cholesterol was associated with lower odds of epithelial ovarian cancer (odds ratio [OR], 0.60 [95% CI, 0.43-0.83]; P = .002). In BRCA1/2 mutation carriers, genetically proxied HMG-CoA reductase inhibition was associated with lower ovarian cancer risk (hazard ratio, 0.69 [95% CI, 0.51-0.93]; P = .01). In secondary analyses, there were no significant associations of genetically proxied inhibition of NPC1L1 (OR, 0.97 [95% CI, 0.53-1.75]; P = .91), PCSK9 (OR, 0.98 [95% CI, 0.85-1.13]; P = .80), or circulating LDL cholesterol (OR, 0.98 [95% CI, 0.91-1.05]; P = .55) with epithelial ovarian cancer. Conclusions and Relevance: Genetically proxied inhibition of HMG-CoA reductase was significantly associated with lower odds of epithelial ovarian cancer. However, these findings do not indicate risk reduction from medications that inhibit HMG-CoA reductase; further research is needed to understand whether there is a similar association with such medications.

Care Delivered by Pediatric Surgical Specialties Through Patient Portal Messaging.

BACKGROUND: Patient portals are online applications that typically allow users to interact with providers using secure messaging. Portal messaging use and content have not been studied in pediatric surgical specialties. MATERIALS AND METHODS: We obtained all message threads initiated by pediatric patients/caregivers and sent to pediatric surgical providers through the Vanderbilt University Medical Center patient portal from June 1, 2014 to December 31, 2014. We collected patient demographics and providers' surgical specialties. We determined the number of message threads and individual messages sent by patients/caregivers and providers by specialty. Message content was analyzed by semantic types using a validated consumer health taxonomy. RESULTS: Most threads were about male (176, 60.3%), white (239, 81.8%), non-Hispanic (278, 95.2%) patients with a median age of 6 y (range: 0-21 y). A total of 292 message threads containing 1679 individual messages were sent with mean 5.8 (standard deviation [SD] 5.0) messages per thread. Messages were sent more frequently regarding younger patients (P = 0.001). Physicians directly contributed to 161 (55%) message threads. Otolaryngology received the most threads (123, 42.1%) and messages (790, 47.1%). Specialties exchanging the most messages per thread were cardiac surgery (mean 7.0, SD 11.7), and dermatology (7.0, SD 6.9). Most message threads (273, 93.5%) involved delivery of medical care with 123 (42.1%) involving appointments/scheduling; 99 (33.9%) medical problems; 81 (27.7%) treatments; 68 (23.3%) testing; and 29 (9.9%) referrals. CONCLUSIONS: Pediatric surgeons deliver substantial care within portal messages exchanged with pediatric patients and caregivers. Institutions adopting portals should consider effects on provider workload and potential disparities in access to care.

Enhancing Recovery After Kasai Portoenterostomy With Epidural Analgesia.

BACKGROUND: Biliary atresia (BA) is a rare obstructive cholangiopathy that presents in early infancy. The Kasai portoenterostomy (PE) improves survival with the native liver. Epidural analgesia is an appealing option to control pain in this fragile patient population, yet its safety, efficacy, and potential benefits remain unproven. METHODS: Patients undergoing PE for BA between 2001 and 2016 at a single institution were identified by ICD codes. Preoperative laboratories, procedure details, and recovery outcomes were reviewed retrospectively. Outcomes of interest were need for postoperative mechanical ventilation, pain scores, normalized opioid administration, return of bowel function, and length of hospital stay after PE. RESULTS: Of 47 infants undergoing PE for BA, 25 received epidural analgesia, and 22 did not. Infants with epidurals received less systemic opioids over the first 96 h postoperatively than those without (P < 0.001). Epidurals were associated with lower pain scores between 6 and 30 h postoperatively (P = 0.01 to 0.04), during which the highest median 6-h interval pain score was 0.2 (IQR 0-1.3) for patients with epidurals yet 2.1 (IQR 1.2-3.3) for patients without. Patients with epidurals (88%, n = 22) were more commonly extubated before leaving the operating room than those without (59%, n = 13; P = 0.02). No significant difference was observed in time to first bowel movement (P = 0.48) or first oral feed (P = 0.81). However, infants with epidurals had shorter hospital stays after PE than those without (6 d [IQR 5-7] versus 8 d [IQR 6.3-11], P = 0.01). No major complications were associated with epidural catheters. CONCLUSIONS: Epidural analgesia in patients undergoing PE for BA appears safe and effectively controls pain while minimizing the need for systemic opioids. Reduced need for mechanical ventilation postoperatively and shortened hospital stays serve as further evidence for using epidurals to enhance recovery after PE.

Impact of the Alphabet Strategy on Improving Diabetes Care at a Free Health Clinic.

The complexity and cost of diabetes care are barriers to a free health clinic attempting to provide quality care to uninsured patients. The alphabet strategy intervention was selected to increase the number of patients with diabetes receiving care according to the American Diabetes Association guidelines because it is simple and cost-effective. The project results revealed statistically significant increases in clinic uptake of diabetes education, blood pressure interventions, proteinuria, glucose control measurement and intervention, eye exams, and foot exams. The findings may be useful to other free health clinics attempting to provide quality care to their patients with diabetes.

Overview of literature on RMC and applications to Tanzania.

Respectful maternity care research in Tanzania continues to increase. This is an overview of the literature summarizing research based on the domains which comprise this quality of care indicator, ranging from exploratory and descriptive to quantitative measurements of birth perinatal outcomes when respectful interventions are made. The domains of respectful care are reflected in the seven Universal Rights of Childbearing Women but go further to implicate facility administrators and policy makers to provide supportive infrastructure to allay disrespect and abuse.The research methodologies continue to be problematic and several ethical cautions restrict how much control is possible. Similarly, the barriers to collecting accurate accounts in qualitative studies of disrespect require astute interviewing and observation techniques. The participatory community-based and the critical sociology and human rights frameworks appear to provide a good basis for both researcher and participants to identify problems and determine possible solutions to the multiple factors that contribute to disrespect and abuse. The work-life conditions of midwives in the Global South are plagued with poor infrastructure and significantly low resources which deters respectful care while decreasing retention of workers. Researchers and policy-makers have addressed disrespectful care by building human resource capacity, by strengthening professional organizations and by educating midwives in low-resource countries. Furthermore, researchers encourage midwives not only to acquire attitudinal change and to adopt respectful maternity care skills, but also to emerge as leaders and change agents.Safe methods for conducting care while addressing low resources, skilled management of conflict and creative innovations to engage the community are all interventions that are being considered for quality improvement research. Tanzania is poised to evaluate the outcomes of education workshops that address all seven domains of respectful care.

Measuring the Value of a Clinical Practice Guideline for Children With Perforated Appendicitis.

OBJECTIVE: To determine the incremental cost-effectiveness of a clinical practice guideline (CPG) compared with "usual care" for treatment of perforated appendicitis in children. Secondary objective was to compare cost analyses using hospital accounting system data versus data in the Pediatric Health Information System (PHIS). BACKGROUND: Value-based surgical care (outcomes relative to costs) is frequently touted, but outcomes and costs are rarely measured together. METHODS: During an 18-month period, 122 children with perforated appendicitis at a tertiary referral children's hospital were treated using an evidence-based CPG. Clinical outcomes and costs for the CPG cohort were compared with patients in the 30-month period before CPG implementation (n = 191 children). RESULTS: With CPG-directed care, intra-abdominal abscess rate decreased from 0.24 to 0.10 (adjusted risk ratio 0.44, 95% confidence interval [CI] 0.26-0.75). The rate of any adverse event decreased from 0.30 to 0.23 (adjusted risk ratio 0.82, 95% CI 0.58-1.17). Mean total hospital costs per patient (hospital accounting system) decreased from $16,466 to $10,528 (adjusted absolute difference-$5451, 95% CI -$7755 to -$3147), leading to estimated adjusted total savings of $665,022 during the study period. Costs obtained from the PHIS database also showed reduction with CPG-directed care (-$6669, 95% CI -$8949 to -$4389 per patient). In Bayesian cost-effectiveness analyses, likelihood that CPG was the dominant strategy was 91%. CONCLUSIONS: An evidence-based CPG increased the value of surgical care for children with perforated appendicitis by improving outcomes and lowering costs. Hospital cost accounting data and pre-existing cost data within the PHIS database provided similar results.

Complexity of medical decision-making in care provided by surgeons through patient portals.

BACKGROUND: Patient portals are online applications that allow patients to interact with healthcare organizations and view information. Portal messages exchanged between patients and providers contain diverse types of communications, including delivery of medical care. The types of communications and complexity of medical decision-making in portal messages sent to surgeons have not been studied. MATERIALS AND METHODS: We obtained all message threads initiated by patients and exchanged with surgical providers through the Vanderbilt University Medical Center patient portal from June 1 to December 31, 2014. Five hundred randomly selected messages were manually analyzed by two research team members to determine the types of communication (i.e., informational, medical, logistical, or social), whether medical care was delivered, and complexity of medical decision-making as defined for outpatient billing in each message thread. RESULTS: A total of 9408 message threads were sent to 401 surgical providers during the study period. In the 500 threads selected for detailed analysis, 1293 distinct issues were communicated, with an average of 2.6 issues per thread. Medical needs were communicated in 453 message threads (90.6%). Further, 339 message threads (67.8%) contained medical decision-making. Overall complexity of medical decision-making was straightforward in 210 messages (62%), low in 102 messages (30%), and moderate in 27 messages (8%). No highly complex decisions were made over portal messaging. CONCLUSIONS: Through patient portal messages, surgeons deliver substantial medical care with varied levels of medical complexity. Models for compensation of online care must be developed as consumer and surgeon adoption of these technologies increases.

Review of information technology for surgical patient care.

BACKGROUND: Electronic health records (EHRs), computerized provider order entry (CPOE), and patient portals have experienced increased adoption by health care systems. The objective of this study was to review evidence regarding the impact of such health information technologies (HIT) on surgical practice. MATERIALS AND METHODS: A search of Medline, EMBASE, CINAHL, and the Cochrane Library was performed to identify data-driven, nonsurvey studies about the effects of HIT on surgical care. Domain experts were queried for relevant articles. Two authors independently reviewed abstracts for inclusion criteria and analyzed full text of eligible articles. RESULTS: A total of 2890 citations were identified. Of them, 32 observational studies and two randomized controlled trials met eligibility criteria. EHR or CPOE improved appropriate antibiotic administration for surgical procedures in 13 comparative observational studies. Five comparative observational studies indicated that electronically generated operative notes had increased accuracy, completeness, and availability in the medical record. The Internet as an information resource about surgical procedures was generally inadequate. Surgical patients and providers demonstrated rapid adoption of patient portals, with increasing proportions of online versus inperson outpatient surgical encounters. CONCLUSIONS: The overall quality of evidence about the effects of HIT in surgical practice was low. Current data suggest an improvement in appropriate perioperative antibiotic administration and accuracy of operative reports from CPOE and EHR applications. Online consumer health educational resources and patient portals are popular among patients and families, but their impact has not been studied well in surgical populations. With increasing adoption of HIT, further research is needed to optimize the efficacy of such tools in surgical care.

Peri-operative risk factors for delayed gastric emptying after a pancreaticoduodenectomy.

BACKGROUND: Delayed gastric emptying (DGE) is a frequent cause of morbidity, prolonged hospital stay and readmission after a pancreaticoduodenectomy (PD). We sought to evaluate predictive peri-operative factors for DGE after a PD. METHODS: Four hundred and sixteen consecutive patients who underwent a PD at our tertiary referral centre were identified. Univariate and multivariate (MV) logistic regression models were used to assess peri-operative factors associated with the development of clinically significant DGE and a post-operative pancreatic fistula (POPF). RESULTS: DGE occurred in 24% of patients (n = 98) with Grades B and C occurring at 13.5% (n = 55) and 10.5% (n = 43), respectively. Using MV regression, a body mass index (BMI) ≥35 [odds ratio (OR) = 3.19], operating room (OR) length >5.5 h (OR = 2.72) and prophylactic octreotide use (OR = 2.04) were independently associated with an increased risk of DGE. DGE patients had a significantly longer median hospital stay (12 versus 7 days), higher 90-day readmission rates (32% versus 18%) and an increased incidence of a pancreatic fistula (59% versus 27%). When controlling for POPF, only OR length >5.5 h (OR 2.73) remained significantly associated with DGE. CONCLUSIONS: DGE remains a significant cause of morbidity, increased hospital stay and readmission after PD. Our findings suggest patients with a BMI ≥35 or longer OR times have a higher risk of DGE either independently or through the development of POPF. These patients should be considered for possible enteral feeding tube placement along with limited octreotide use to decrease the potential risk and consequences of DGE.

Value of intraoperative neck margin analysis during Whipple for pancreatic adenocarcinoma: a multicenter analysis of 1399 patients.

INTRODUCTION: During pancreaticoduodenectomy (PD) for ductal adenocarcinoma, a frozen section (FS) neck margin is typically assessed, and if positive, additional pancreas is removed to achieve an R0 margin. We analyzed the association of this practice with improved overall survival (OS). METHODS: Patients who underwent PD for pancreatic ductal adenocarcinoma from January 2000 to August 2012 at 8 academic centers were classified by neck margin status as negative (R0) or microscopically positive (R1) on the basis of FS and permanent section (PS). Impact on OS of converting an FS-R1-neck margin to a PS-R0-neck margin by additional resection was assessed. RESULTS: A total of 1399 patients had FS neck margins analyzed. Median OS was 19.7 months. On FS, 152 patients (10.9%) were R1, and an additional 51 patients (3.6%) had false-negative FS-R0 margins. PS-R0-neck was achieved in 1196 patients (85.5%), 131 patients (9.3%) remained PS-R1, and 72 patients (5.1%) were converted from FS-R1-to-PS-R0 by additional resection. Median OS for PS-R0-neck patients was 21.1 months versus 13.7 months for PS-R1-neck patients (P < 0.001) and 11.9 months for FS-R1-to-PS-R0 patients (P < 0.001). Both FS-R1-to-PS-R0 and PS-R1-neck patients had larger tumors (P = 0.001), more perineural invasion (P = 0.02), and more node positivity (P = 0.08) than PS-R0-neck patients. On multivariate analysis controlling for adverse pathologic factors, FS-R1-to-PS-R0 conversion remained associated with significantly worse OS compared with PS-R0-neck patients (hazard ratio: 1.55; P = 0.009). CONCLUSIONS: For patients who undergo pancreaticoduodenectomy for pancreatic ductal adenocarcinoma, additional resection to achieve a negative neck margin after positive frozen section is not associated with improved OS.

The effect of health insurance status on the treatment and outcomes of patients with colorectal cancer.

BACKGROUND AND OBJECTIVES: Uninsured and underinsured cancer patients often have delayed diagnosis and inferior outcomes. As healthcare reform proceeds in the US, this disparity may gain increasing importance. Our objective was to investigate the impact of health insurance status on the presentation, treatment, and survival among colorectal cancer (CRC) patients. METHODS: A total of 10,692 patients diagnosed with CRC between 2004 and 2008 identified from the Tennessee Cancer Registry were stratified into five groups: Private, Medicare, Military, Medicaid, and uninsured. Multivariable regression models were constructed to test the association of insurance with receipt of recommended adjuvant therapy and overall survival (OS). RESULTS: Uninsured and Medicaid patients were more often African American (AA) and presented with higher stage tumors (P < 0.001). Medicare patients were less likely to receive recommended adjuvant therapy (OR 0.54). Lack of insurance, Medicaid, and failure to receive recommended adjuvant therapy were independently associated with worse OS. CONCLUSIONS: Although uninsured and Medicaid patients receive recommended adjuvant therapy comparable to other patients, they present with later stage disease and have a worse OS. Future studies are needed to better explain these disparities especially in the light of changing healthcare climate in the US.

Replicating the Association of Variants in BSN and APBA1 with Obesity in Diverse Populations.

In a recent study by Zhao et al., rare protein-truncating variants (PTVs) in the BSN and APBA1 genes showed effects on obesity that exceeded those of well-known genes such as MC4R in a UK cohort. In this study, we leveraged the All of Us Research Program, to investigate the association of predicted LoF (pLoF) PTVs in BSN and APBA1 with body mass index (BMI) across a population of diverse ancestry. Our analysis revealed that the impact of pLoF variants in BSN and APBA1 on BMI was notably greater in this cohort, especially among individuals of European ancestry. Additionally, a phenome-wide association study (PheWAS) using the extensive phenotypic data available in the All of Us Research Program uncovered novel associations of BSN and APBA1 heterozygous pLoF carriers with various phenotypes. Specifically, BSN pLoF variants were associated with pulmonary hypertension, atrial fibrillation, and anticoagulant use, while APBA1 pLoF variants were linked to disorders of the temporomandibular joint. These findings underscore the potential of large-scale biobanks in advancing genetic discovery.