Error Management Training and Adaptive Expertise in Learning Computed Tomography Interpretation: A Randomized Clinical Trial.

Importance: Adaptive expertise helps physicians apply their skills to novel clinical cases and reduce preventable errors. Error management training (EMT) has been shown to improve adaptive expertise with procedural skills; however, its application to cognitive skills in medical education is unclear. Objective: To evaluate whether EMT improves adaptive expertise when learning the cognitive skill of head computed tomography (CT) interpretation. Design, Setting, and Participants: This 3-arm randomized clinical trial was conducted from July 8, 2022, to March 30, 2023, in 7 geographically diverse emergency medicine residency programs. Participants were postgraduate year 1 through 4 emergency medicine residents masked to the hypothesis. Interventions: Participants were randomized 1:1:1 to a difficult EMT, easy EMT, or error avoidance training (EAT) control learning strategy for completing an online head CT curriculum. Both EMT cohorts received no didactic instruction before scrolling through head CT cases, whereas the EAT group did. The difficult EMT cohort answered difficult questions about the teaching cases, leading to errors, whereas the easy EMT cohort answered easy questions, leading to fewer errors. All 3 cohorts used the same cases. Main Outcomes and Measures: The primary outcome was a difference in adaptive expertise among the 3 cohorts, as measured using a head CT posttest. Secondary outcomes were (1) differences in routine expertise, (2) whether the quantity of errors during training mediated differences in adaptive expertise, and (3) the interaction between prior residency training and the learning strategies. Results: Among 212 randomized participants (mean [SD] age, 28.8 [2.0] years; 107 men [50.5%]), 70 were allocated to the difficult EMT, 71 to the easy EMT, and 71 to the EAT control cohorts; 150 participants (70.8%) completed the posttest. The difficult EMT cohort outperformed both the easy EMT and EAT cohorts on adaptive expertise cases (60.6% [95% CI, 56.1%-65.1%] vs 45.2% [95% CI, 39.9%-50.6%], vs 40.9% [95% CI, 36.0%-45.7%], respectively; P < .001), with a large effect size (η2 = 0.19). There was no significant difference in routine expertise. The difficult EMT cohort made more errors during training than the easy EMT cohort. Mediation analysis showed that the number of errors during training explained 87.2% of the difficult EMT learning strategy's effect on improving adaptive expertise (P = .01). The difficult EMT learning strategy was more effective in improving adaptive expertise for residents earlier in training, with a large effect size (η2 = 0.25; P = .002). Conclusions and Relevance: In this randomized clinical trial, the findings show that EMT is an effective method to develop physicians' adaptive expertise with cognitive skills. Trial Registration: ClinicalTrials.gov Identifier: NCT05284838.

Integral Dose or Mean Dose for Predicting Radiosurgery Response in Patients With Trigeminal Neuralgia: A Proposal to Target the Narrowest Part of the Nerve.

BACKGROUND AND OBJECTIVES: Stereotactic radiosurgery (SRS) is effective for patients with medically refractory trigeminal neuralgia with a 75%-90% response rate. Consideration of the integral dose (ID) to the target nerve within the 50% isodose line was reported to help select prescription doses to maximize effectiveness and minimize bothersome numbness. The objective of this study was to externally validate the ID as a predictor of outcomes after SRS. METHODS: We reviewed the outcomes and parameters of 94 consecutive patients of type 1 trigeminal neuralgia who had SRS for the first time where nerve ID was calculated. 70% of the prescription doses were 80 Gy, with 28% at 85 Gy, and 2% at 70 Gy. RESULTS: The median follow-up time was 14.4 months. A total of 85 (90%) patients reported significant pain relief (Barrow Neurological Institute I-III) after initial SRS. The median pain recurrence-free survival was 82 months (95% CI 41.1-NA), and estimates at 1, 3, and 5 years were 80.5%, 65.5%, and 55.9%, respectively. The ID was not significantly associated with initial pain relief, or affect the risk of pain recurrence or sensory dysfunction after SRS using the Cox proportional hazards model. A nerve mean dose ≥65 Gy was associated with a reduced risk of pain recurrence on multivariate analysis (hazard ratio 0.408, P = .039). Twenty (21%) patients experienced sensory dysfunction after SRS with 3 (3%) requiring further medications, which was not correlated with the prescription dose or brainstem maximum dose. CONCLUSION: The ID did not predict recurrence-free survival or sensory dysfunction. Our observations suggest improved nerve coverage by the most powerful area of the isocenter, for instance, by targeting a narrower segment if feasible, could result in more durable pain relief. Further studies to validate these findings are needed.

Radiation Therapy for Lung Cancer: Imaging Appearances and Pitfalls.

Radiation therapy is part of a multimodality treatment approach to lung cancer. The radiologist must be aware of both the expected and the unexpected imaging findings of the post-radiation therapy patient, including the time course for development of post- radiation therapy pneumonitis and fibrosis. In this review, a brief discussion of radiation therapy techniques and indications is presented, followed by an image-heavy differential diagnostic approach. The review focuses on computed tomography imaging examples to help distinguish normal postradiation pneumonitis and fibrosis from alternative complications, such as infection, local recurrence, or radiation-induced malignancy.

Harnessing the cGAS-STING pathway to potentiate radiation therapy: current approaches and future directions.

In this review, we cover the current understanding of how radiation therapy, which uses ionizing radiation to kill cancer cells, mediates an anti-tumor immune response through the cGAS-STING pathway, and how STING agonists might potentiate this. We examine how cGAS-STING signaling mediates the release of inflammatory cytokines in response to nuclear and mitochondrial DNA entering the cytoplasm. The significance of this in the context of cancer is explored, such as in response to cell-damaging therapies and genomic instability. The contribution of the immune and non-immune cells in the tumor microenvironment is considered. This review also discusses the burgeoning understanding of STING signaling that is independent of inflammatory cytokine release and the various mechanisms by which cancer cells can evade STING signaling. We review the available data on how ionizing radiation stimulates cGAS-STING signaling as well as how STING agonists may potentiate the anti-tumor immune response induced by ionizing radiation. There is also discussion of how novel radiation modalities may affect cGAS-STING signaling. We conclude with a discussion of ongoing and planned clinical trials combining radiation therapy with STING agonists, and provide insights to consider when planning future clinical trials combining these treatments.

Judicious use of corticosteroid injections prior to shoulder arthroplasty does not compromise outcomes at a minimum of 2 years following surgery.

BACKGROUND: The use of total shoulder arthroplasty is continuing to rise with its expanding indications. For patients with chronic conditions, such as glenohumeral arthritis and rotator cuff arthropathy, nonoperative treatment is typically done prior to arthroplasty and often includes corticosteroid injections (CSIs). Recent studies in the shoulder arthroplasty literature as well as applied from the hip and knee literature have focused on the risk of periprosthetic infection. Literature is lacking as to whether the judicious use of corticosteroids in the year prior to arthroplasty influences patient-reported outcomes (PROs). The purpose of this study was to determine if preoperative CSIs prior to shoulder arthroplasty affected 2-year PROs. METHODS: Retrospective review of anatomic and reverse total shoulder arthroplasty (RSA) patients (n = 230) was performed at a single institution including multiple surgeons. Patients were included if they had preoperative and a minimum of 2-year postoperative PROs, including: American Shoulder and Elbow Surgeons (ASES), visual analog scale, Single Assessment Numeric Evaluation, Veteran's RAND 12 Physical Component Score, and Veteran's RAND 12 Mental Component Score. Patients were included in the injection group if they had received an injection, either glenohumeral or subacromial, within 12 months prior to arthroplasty (inject = 134). Subgroup analysis included anatomic (total shoulder arthroplasty [TSA] = 92) and RSA (RSA = 138) as well as those with no injection within 12 months prior to surgery. An analysis of variance was used to compare outcomes between patients who received an injection and those who did not prior to TSA and RSA. RESULTS: There were 230 patients included with 134 patients in the injection group and 96 in the no injection group. Patients who received an injection in the year prior to arthroplasty displayed a significantly higher ASES (82 [16.23 standard deviation] vs. 76 [19.43 standard deviation], P < .01) and Single Assessment Numeric Evaluation (70 [24.49 standard deviation] vs. 63 [29.22 standard deviation], P < .01) scores vs. those who had not received injection. There was no difference when comparing preoperative injection vs. no injection in patients undergoing TSA. Those patients undergoing RSA displayed significantly higher ASES scores (P < .01). There were no significant differences in visual analog scale, Veteran's RAND 12 Physical Component Score, and Veteran's RAND 12 Mental Component Score among any analysis (P > .05), and the minimal clinically important difference in ASES was not different between groups (P.09). CONCLUSION: CSIs within 12 months prior to anatomic and RSA do not compromise PROs during a minimum of 2-year follow-up. Although more complications occurred in the injection group, it did not reach statistical significance and warrants further study in a larger population.

Predictive Factors Associated With Radiation Myelopathy in Pediatric Patients With Cancer: A PENTEC Comprehensive Review.

PURPOSE: Radiation myelitis (RM) is a rare complication of radiation therapy (RT). The Pediatric Normal Tissue Effects in the Clinic spinal cord task force aimed to identify RT dose effects and assess risk factors for RM in children. Through systematic review, we analyzed RT dose, fraction size, latency between completion of RT and toxicity, chemotherapy use, age when irradiated, and sex. METHODS AND MATERIALS: We conducted literature searches of peer-reviewed manuscripts published from 1964 to June 2017 evaluating RM among children. Normality of variables was assessed with Kolmogorov-Smirnov or Shapiro-Wilk tests. Spearman's rank correlation coefficients were used to test correlations between RT dose/fraction size and latency between RT and development of toxicity. RESULTS: Of 1329 identified and screened reports, 144 reports were fully reviewed and determined to have adequate data for analysis; 16 of these reports had a total of 33 cases of RM with a median age of 13 years (range, 0.2-18) at the time of RT. The most common primary tumor histologies were rhabdomyosarcoma (n = 9), medulloblastoma (n = 5), and Hodgkin lymphoma (n = 2); the most common chemotherapy agents given were vincristine (n = 15), intrathecal methotrexate (n = 12), and intrathecal cytarabine (n = 10). The median RT dose and fraction size were 40 Gy (range, 24-57.4 Gy) and 1.8 Gy (range, 1.3-2.6 Gy), respectively. RT dose resulting in RM in patients who also received chemotherapy was lower than in those not receiving chemotherapy (mean 39.6 vs 49.7 Gy; P = .04). There was no association of age with RT dose. The median latency period was 7 months (range, 1-29). Higher RT dose was correlated with longer latency periods (P = .03) to RM whereas sex, age, fraction size, and chemotherapy use were not. Two of 17 patients with adequate follow-up recovered from RM; unfortunately, it was fatal in 6 of 15 evaluable patients. Complication probability modeling was not possible because of the rarity of events. CONCLUSIONS: This report demonstrates a relatively short latency from RT (with or without chemotherapy) to RM and a wide range of doses (including fraction sizes) associated with RM. No apparent association with age at the time of RT could be discerned. Chemotherapy appears to reduce spinal cord tolerance. Recovery from RM is rare, and it is often fatal.

Long-Term Impact of COVID-19 Related Disruption of National Health Service Elective Services on Emergency Major Lower Limb Amputations.

BACKGROUND: The COVID-19 pandemic has affected the healthcare systems worldwide since the dawn of 2020. In March 2020, the United Kingdom government announced the first national lockdown which severely disturbed all National Health Service (NHS) healthcare elective services. Our aim is to assess the long-term impact of COVID-19 related disruption of NHS elective services on emergency major lower limb amputations (MLLAs). METHODS: Patients' data for emergency MLLA for critical limb-threatening ischemia and diabetic foot infections performed at Aberdeen Royal Infirmary was collected through Trakcare and divided into the control prepandemic group (April 2018-March 2020) and the pandemic group (April 2020-March 2022). The statistical analysis was conducted using the IBM SPSS software (v28.0.1.1 [14]). RESULTS: A total of 358 patients underwent MLLA and 206 (57.5%) of these had diabetes mellitus. There was a 17% increase in the number of urgent referrals and every 1 in 5 of these finally underwent an amputation. There was an increase in the absolute number of Above- and Below-Knee amputations. There was a statistically significant increase by 33% in emergency MLLAs during the pandemic period (P < 0.05). A total of 165 postoperative deaths up to December 2022 were recorded with 30-day mortality rate of 7.26% (n = 26). CONCLUSIONS: NHS vascular management groups should update themselves with evolving technologies to optimize the care provided during future unprecedented times. Furthermore, more effective measures should also be implemented to avoid delayed presentations, which can potentially lead to higher rates of major limb amputations.

Selective Personalized RadioImmunotherapy for Locally Advanced Non-Small-Cell Lung Cancer Trial (SPRINT).

PURPOSE: Standard therapy for locally advanced non-small-cell lung cancer (LA-NSCLC) is concurrent chemoradiotherapy followed by adjuvant durvalumab. For biomarker-selected patients with LA-NSCLC, we hypothesized that sequential pembrolizumab and risk-adapted radiotherapy, without chemotherapy, would be well-tolerated and effective. METHODS: Patients with stage III NSCLC or unresectable stage II NSCLC and an Eastern Cooperative Oncology Group performance status of 0-1 were eligible for this trial. Patients with a PD-L1 tumor proportion score (TPS) of ≥50% received three cycles of induction pembrolizumab (200 mg, once every 21 days), followed by a 20-fraction course of risk-adapted thoracic radiotherapy (55 Gy delivered to tumors or lymph nodes with metabolic volume exceeding 20 cc, 48 Gy delivered to smaller lesions), followed by consolidation pembrolizumab to complete a 1-year treatment course. The primary study end point was 1-year progression-free survival (PFS). Secondary end points included response rates after induction pembrolizumab, overall survival (OS), and adverse events. RESULTS: Twenty-five patients with a PD-L1 TPS of ≥50% were enrolled. The median age was 71, most patients (88%) had stage IIIA or IIIB disease, and the median PD-L1 TPS was 75%. Two patients developed disease progression during induction pembrolizumab, and two patients discontinued pembrolizumab after one infusion because of immune-related adverse events. Using RECIST criteria, 12 patients (48%) exhibited a partial or complete response after induction pembrolizumab. Twenty-four patients (96%) received definitive thoracic radiotherapy. The 1-year PFS rate is 76%, satisfying our efficacy objective. One- and 2-year OS rates are 92% and 76%, respectively. The most common grade 3 adverse events were colitis (n = 2, 8%) and esophagitis (n = 2, 8%), and no higher-grade treatment-related adverse events have occurred. CONCLUSION: Pembrolizumab and risk-adapted radiotherapy, without chemotherapy, are a promising treatment approach for patients with LA-NSCLC with a PD-L1 TPS of ≥50%.

Erythematous plaques on the bilateral dorsal hands.

Neutrophilic dermatosis of the dorsal hands is a rare cutaneous disorder characterized by the sudden onset of painful, haemorrhagic, and pustular bullae with violaceous rims on the dorsal aspects of the hands. Here we present a 61-year old male with a 1-week history of tender, haemorrhagic, and pustular bullae on both dorsal hands, evolving into ulcerative plaques with haemorrhagic crusting over 5 days. A 4 mm lesional punch biopsy revealed a diffuse dermal infiltrate of numerous neutrophils intermixed with lymphocytes and histiocytes, along with epidermal spongiosis and neutrophilic exocytosis. No leukocytoclastic vasculitis was identified. The provided images document the progression of this rare inflammatory process. Understanding such cases is crucial for accurate diagnosis and management.

B7-H3 Associates with IMPDH2 and Regulates Cancer Cell Survival.

Lung cancer is one of the most common cancers worldwide, and despite improvements in treatment regimens, patient prognosis remains poor. Lung adenocarcinomas develop from the lung epithelia and understanding how specific genetic and environmental factors lead to oncogenic transformation in these cells is of great importance to define the pathways that contribute to tumorigenesis. The recent rise in the use of immunotherapy to treat different cancers has prompted the exploration of immune modulators in tumour cells that may provide new targets to manipulate this process. Of these, the B7 family of cell surface receptors, which includes PD-1, is of particular interest due to its role in modulating immune cell responses within the tumour microenvironment. B7-H3 (CD276) is one family member that is upregulated in many cancer types and suggested to contribute to tumour-immune interactions. However, the function and ligand(s) for this receptor in normal lung epithelia and the mechanisms through which the overexpression of B7-H3 regulate cancer progression in the absence of immune cell interactions remain unclear. Here, we present evidence that B7-H3 is associated with one of the key rate-limiting metabolic enzymes IMPDH2, and the localisation of this complex is altered in human lung cancer cells that express high levels of B7-H3. Mechanistically, the IMPDH2:B7-H3 complex provides a protective role in cancer cells to escape oxidative stress triggered by chemotherapy, thus leading to cell survival. We further demonstrate that the loss of B7-H3 in cancer cells has no effect on growth or migration in 2D but promotes the expansion of 3D spheroids in an IMPDH2-dependent manner. These findings provide new insights into the B7-H3 function in the metabolic homeostasis of normal and transformed lung cancer cells, and whilst this molecule remains an interesting target for immunotherapy, these findings caution against the use of anti-B7-H3 therapies in certain clinical settings.

The Role of Radiation Therapy in Adult and Pediatric Keloid Management: A National Survey of Radiation Oncologists.

INTRODUCTION: Radiation therapy is a promising modality for treating keloids after surgical excision. However, it is currently not standard practice among physicians because of concern surrounding the risk of radiation-induced secondary cancers, especially among pediatric patients. There is minimal research assessing the complications for radiation therapy in keloid management. AIM: The goal of this study was to determine radiation oncologists' perspectives about the utility and appropriateness of radiation therapy for keloid management in both adult and pediatric patients. This study also aimed to characterize radiation modality, dose, fractionation, and secondary complications observed by providers. METHODS: An electronic survey was delivered to 3102 members of the American Society for Radiation Oncology. The survey subjects were radiation oncologists who are currently practicing in the United States. Rates of responses were analyzed. RESULTS: A total of 114 responses from practicing radiation oncologists were received. Of these, 113 providers (99.1%) supported radiation therapy for keloid management in adults, whereas only 54.9% supported radiation therapy for pediatric patients. Of 101 providers that treated adults in the past year, the majority used external beam: electrons (84.2%), applied 3 fraction regimens (54.4%), and delivered radiation within 24 hours postexcision (45.5%). In pediatric patients, only 42 providers reported treating at least 1 patient. The majority used electron beam radiation (76.2%), applied 3 faction regimens (65%), and delivered radiation on the same day of keloid excision (50.0%) The main concern when treating pediatric patients were risk of secondary malignancy (92.1%). CONCLUSION: Although radiation therapy appears to be a widely accepted adjuvant treatment option for adults with keloids, the use of radiation therapy for pediatric patients is less widely accepted because of concerns regarding secondary malignancy. The findings suggest additional studies need to be carried out to assess the risk of those complications.

Low-Dose Radiosurgery for Brain Metastases in the Era of Modern Systemic Therapy.

BACKGROUND AND OBJECTIVES: Dose selection for brain metastases stereotactic radiosurgery (SRS) classically has been based on tumor diameter with a reduction of dose in the settings of prior brain irradiation, larger tumor volumes, and critical brain location. However, retrospective series have shown local control rates to be suboptimal with reduced doses. We hypothesized that lower doses could be effective for specific tumor biologies with concomitant systemic therapies. This study aims to report the local control (LC) and toxicity when using low-dose SRS in the era of modern systemic therapy. METHODS: We reviewed 102 patients with 688 tumors managed between 2014 and 2021 who had low-margin dose radiosurgery, defined as ≤14 Gy. Tumor control was correlated with demographic, clinical, and dosimetric data. RESULTS: The main primary cancer types were lung in 48 (47.1%), breast in 31 (30.4%), melanoma in 8 (7.8%), and others in 15 patients (11.7%). The median tumor volume was 0.037cc (0.002-26.31 cm 3 ), and the median margin dose was 14 Gy (range 10-14). The local failure (LF) cumulative incidence at 1 and 2 years was 6% and 12%, respectively. On competing risk regression analysis, larger volume, melanoma histology, and margin dose were predictors of LF. The 1-year and 2-year cumulative incidence of adverse radiation effects (ARE: an adverse imaging-defined response includes increased enhancement and peritumoral edema) was 0.8% and 2%. CONCLUSION: It is feasible to achieve acceptable LC in BMs with low-dose SRS. Volume, melanoma histology, and margin dose seem to be predictors for LF. The value of a low-dose approach may be in the management of patients with higher numbers of small or adjacent tumors with a history of whole brain radio therapy or multiple SRS sessions and in tumors in critical locations with the aim of LC and preservation of neurological function.

Target Enrichment and Extensive Population Sampling Help Untangle the Recent, Rapid Radiation of Oenothera Sect. Calylophus.

Oenothera sect. Calylophus is a North American group of 13 recognized taxa in the evening primrose family (Onagraceae) with an evolutionary history that may include independent origins of bee pollination, edaphic endemism, and permanent translocation heterozygosity. Like other groups that radiated relatively recently and rapidly, taxon boundaries within Oenothera sect. Calylophus have remained challenging to circumscribe. In this study, we used target enrichment, flanking noncoding regions, gene tree/species tree methods, tests for gene flow modified for target-enrichment data, and morphometric analysis to reconstruct phylogenetic hypotheses, evaluate current taxon circumscriptions, and examine character evolution in Oenothera sect. Calylophus. Because sect. Calylophus comprises a clade with a relatively restricted geographic range, we were able to extensively sample across the range of geographic, edaphic, and morphological diversity in the group. We found that the combination of exons and flanking noncoding regions led to improved support for species relationships. We reconstructed potential hybrid origins of some accessions and note that if processes such as hybridization are not taken into account, the number of inferred evolutionary transitions may be artificially inflated. We recovered strong evidence for multiple evolutionary origins of bee pollination from ancestral hawkmoth pollination, edaphic specialization on gypsum, and permanent translocation heterozygosity. This study applies newly emerging techniques alongside dense infraspecific sampling and morphological analyses to effectively reconstruct the recalcitrant history of a rapid radiation. [Gypsum endemism; Oenothera sect. Calylophus; Onagraceae; phylogenomics; pollinator shift; recent radiation; target enrichment.].

Multi-institutional Validation of Improved Vesicoureteral Reflux Assessment With Simple and Machine Learning Approaches.

PURPOSE: Vesicoureteral reflux grading from voiding cystourethrograms is highly subjective with low reliability. We aimed to demonstrate improved reliability for vesicoureteral reflux grading with simple and machine learning approaches using ureteral tortuosity and dilatation on voiding cystourethrograms. MATERIALS AND METHODS: Voiding cystourethrograms were collected from our institution for training and 5 external data sets for validation. Each voiding cystourethrogram was graded by 5-7 raters to determine a consensus vesicoureteral reflux grade label and inter- and intra-rater reliability was assessed. Each voiding cystourethrogram was assessed for 4 features: ureteral tortuosity, proximal, distal, and maximum ureteral dilatation. The labels were then assigned to the combination of the 4 features. A machine learning-based model, qVUR, was trained to predict vesicoureteral reflux grade from these features and model performance was assessed by AUROC (area under the receiver-operator-characteristic). RESULTS: A total of 1,492 kidneys and ureters were collected from voiding cystourethrograms resulting in a total of 8,230 independent gradings. The internal inter-rater reliability for vesicoureteral reflux grading was 0.44 with a median percent agreement of 0.71 and low intra-rater reliability. Higher values for each feature were associated with higher vesicoureteral reflux grade. qVUR performed with an accuracy of 0.62 (AUROC=0.84) with stable performance across all external data sets. The model improved vesicoureteral reflux grade reliability by 3.6-fold compared to traditional grading (P < .001). CONCLUSIONS: In a large pediatric population from multiple institutions, we show that machine learning-based assessment for vesicoureteral reflux improves reliability compared to current grading methods. qVUR is generalizable and robust with similar accuracy to clinicians but the added prognostic value of quantitative measures warrants further study.

A Rare Occurrence of Phantom Tongue Pain.

This is a case of phantom tongue pain observed in a 65-year-old male with a history of adenoid cystic carcinoma with involvement of the base of the tongue and supraglottic laryngopharyngeal cancer who underwent a laryngopharyngectomy and glossectomy for treatment. The patient subsequently developed phantom tongue pain in acute rehabilitation. Post total glossectomy phantom pain is rare, and as this is a singular appendage, current techniques that rely on the presence of an intact limb, such as mirror therapy could not be applied to our patient. Therefore mental imagery techniques originally developed for extremity amputation required adaptation to the context of total glossectomy. Recommended anticonvulsant medications, desensitization, and mental imagery techniques for phantom limb pain were effective in relieving the patient's phantom tongue pain. Utilizing therapeutic desensitization techniques may allow for the direction of neuroplasticity in order to decrease pain.

The Impact of Perioperative and Operative Variables on Early Postoperative Complications Following Primary Hypospadias Repair.

OBJECTIVE: To evaluate possible risk factors for complications following primary hypospadias repair relative to factors associated with timing of hypospadias repair in terms of case order, morning or afternoon scheduling, perioperative delays, and surgeon's daily work schedule as well as individual operative techniques. METHODS: We retrospectively reviewed charts of 422 boys undergoing primary hypospadias repair with a sutured urethroplasty by 1 of 3 surgeons over a 10-year period and the surgeon's daily schedule. RESULTS: The median age and IQR of the patients at time of operation was 0.79 (0.57) years, and median follow-up was 259 (664) days. A significant increase in the rate of any complication was noted with morning vs afternoon cases for the group overall with morning cases having a hazard 2.3 times higher than afternoon cases (P =.012). Additionally, there was a significant increase in hazard of complication with increasing difference in time between actual procedure duration vs scheduled duration, with hazard of complication increasing 5% for each increase of 15 minutes of surgical time (P =.043). CONCLUSION: A variety of previously identified potential risk factors for hypospadias complications were identified. Our analysis also demonstrated variability in level of risk of different factors between surgeons, reinforcing the utility of surgeons monitoring their own results in response to changes in technique. Novel potential risk factors for some surgeons identified in our study included an increased risk of complications when the hypospadias was done in the morning rather than the afternoon and when the procedure lasted longer than scheduled.

Dynamic Management of Lung Cancer Care During Surging COVID-19.

Management of patients with lung cancer continues to be challenging during the COVID-19 pandemic, due to the increased risk of complications in this subset of patients. During the COVID-19 surge in New York City, New York University Langone Health adopted triage strategies to help with care for lung cancer patients, with good surgical outcomes and no transmission of COVID-19 to patients or healthcare workers. Here, we will review current recommendations regarding screening and management of lung cancer patients during both a non-surge phase and surge phase of COVID-19.

Improving health behaviors in patients with peripheral arterial disease - A pilot study of supported self-management.

PURPOSE OF THE RESEARCH: This pilot study reports the feasibility of a future randomized controlled trial (RCT) investigating the effect of supported self-management through low-intensity psychological intervention in patients with peripheral arterial disease (PAD) resulting in claudication. The study protocol, measurement instrument, data collection, and analysis were evaluated. Clinical outcome measures include depression and anxiety scores, smoking cessation, activity (step count), weight, and quality of life. Both Quantitative and Qualitative data were collected to evaluate participant experience and the clinical impact of a supported self-management intervention delivered in a routine clinical setting. METHODS: Participants received an initial one to one assessment with a health psychologist. Demographic data and baseline clinical outcome measures were recorded. These included Hospital Anxiety and Depression Scale score (HADS), health-related quality of life questionnaire (EQ-5D-3 L), number of cigarettes smoked daily, weight/BMI, and daily step count. Participants each received an activity tracker to record daily step count and were followed up weekly to provide psychological input, including goal setting, overcoming barriers, and preventing relapse. Quantitative data collection was scheduled at baseline, 3 and 6 months (final follow-up). At the final follow-up, participants provided qualitative feedback reflecting upon their experience of the intervention and its impact. Descriptive statistical analysis and simple paired samples t-test were employed in data evaluation. RESULTS: The sample size was small (n = 30). Twenty-three participants were followed up to 6 months. Depression scores improved with statistical significance from baseline to 6-month follow-up. Eight participants stopped smoking (47% reduction); a further 9 greatly reduced their intake. A borderline statistically significant increase of daily step count was achieved between baseline and 6-month follow-up. In addition, positive weight loss trends were observed in a predominantly obese or overweight cohort. The qualitative feedback highlighted participants understood and embraced the information delivered regarding the importance of health behavior change. Participants were able to link tailored action plans with what mattered to them with the help of the Health Psychologist. CONCLUSION: This study embraces the contemporary ideology of enabling self-management of long-term conditions to improve clinical outcomes. As a pilot study, we have shown that an expanded, randomized controlled trial is both safe and feasible. A positive trend in clinical outcomes suggests this patient group may benefit from supported self-management through low-intensity psychological intervention, where other forms of early intervention have historically faltered.