Patient Characteristics Impact Performance of AI Algorithm in Interpreting Negative Screening Digital Breast Tomosynthesis Studies.

Background Artificial intelligence (AI) is increasingly used to manage radiologists' workloads. The impact of patient characteristics on AI performance has not been well studied. Purpose To understand the impact of patient characteristics (race and ethnicity, age, and breast density) on the performance of an AI algorithm interpreting negative screening digital breast tomosynthesis (DBT) examinations. Materials and Methods This retrospective cohort study identified negative screening DBT examinations from an academic institution from January 1, 2016, to December 31, 2019. All examinations had 2 years of follow-up without a diagnosis of atypia or breast malignancy and were therefore considered true negatives. A subset of unique patients was randomly selected to provide a broad distribution of race and ethnicity. DBT studies in this final cohort were interpreted by a U.S. Food and Drug Administration-approved AI algorithm, which generated case scores (malignancy certainty) and risk scores (1-year subsequent malignancy risk) for each mammogram. Positive examinations were classified based on vendor-provided thresholds for both scores. Multivariable logistic regression was used to understand relationships between the scores and patient characteristics. Results A total of 4855 patients (median age, 54 years [IQR, 46-63 years]) were included: 27% (1316 of 4855) White, 26% (1261 of 4855) Black, 28% (1351 of 4855) Asian, and 19% (927 of 4855) Hispanic patients. False-positive case scores were significantly more likely in Black patients (odds ratio [OR] = 1.5 [95% CI: 1.2, 1.8]) and less likely in Asian patients (OR = 0.7 [95% CI: 0.5, 0.9]) compared with White patients, and more likely in older patients (71-80 years; OR = 1.9 [95% CI: 1.5, 2.5]) and less likely in younger patients (41-50 years; OR = 0.6 [95% CI: 0.5, 0.7]) compared with patients aged 51-60 years. False-positive risk scores were more likely in Black patients (OR = 1.5 [95% CI: 1.0, 2.0]), patients aged 61-70 years (OR = 3.5 [95% CI: 2.4, 5.1]), and patients with extremely dense breasts (OR = 2.8 [95% CI: 1.3, 5.8]) compared with White patients, patients aged 51-60 years, and patients with fatty density breasts, respectively. Conclusion Patient characteristics influenced the case and risk scores of a Food and Drug Administration-approved AI algorithm analyzing negative screening DBT examinations. © RSNA, 2024.

What Matters Most: The Documented Goals, Values and Motivators of Advanced Cancer Patients.

BACKGROUND: Goals of care conversations are essential to delivery of goal concordant care. Infrequent and inconsistent goals of care documentation potentially limit delivery of goal concordant care. METHODS: At Kaiser Permanente San Francisco Cancer Center, a standardized documentation template was designed and implemented to increase goals of care documentation by oncologists. The centralized, prompt-based template included value clarification of the goals and values of advanced cancer patients beyond treatment preferences. Documented conversations using the template during the initial pilot period were reviewed to characterization the clinical context in which conversations were recorded. Common goals and motivators were also identified. RESULTS: A total of 178 advanced cancer patients had at least 1 documented conversation by a medical oncologist using the goals of care template. Oncologists consistently documented within the template goals of therapy and motivating factors in decision making. The most frequently documented goals of care were "Avoiding Pain and Suffering," "Physical Independence," and "Living as Long as Possible." The least recorded goal was "Comfort Focused Treatment Only." CONCLUSIONS: Review of oncologist documented goals of care conversations using a prompt-based template allowed for characterization of the clinical context, therapy goals and motivators of advanced cancer patients. Communication of goals of care conversations by oncologists using a standardized prompt-based template within a centralized location has the potential to improve delivery of goal concordant care.

Current use of the National Surgical Quality Improvement Program surgical risk calculator in academic surgery: a mixed-methods study.

Background: This study aims to quantitatively assess use of the NSQIP surgical risk calculator (NSRC) in contemporary surgical practice and to identify barriers to use and potential interventions that might increase use. Materials and methods: We performed a cross-sectional study of surgeons at seven institutions. The primary outcomes were self-reported application of the calculator in general clinical practice and specific clinical scenarios as well as reported barriers to use. Results: In our sample of 99 surgeons (49.7% response rate), 73.7% reported use of the NSRC in the past month. Approximately half (51.9%) of respondents reported infrequent NSRC use (<20% of preoperative discussions), while 14.3% used it in ≥40% of preoperative assessments. Reported use was higher in nonelective cases (30.2% vs 11.1%) and in patients who were ≥65 years old (37.1% vs 13.0%), functionally dependent (41.2% vs 6.6%), or with surrogate consent (39.9% vs 20.4%). NSRC use was not associated with training status or years in practice. Respondents identified a lack of influence on the decision to pursue surgery as well as concerns regarding the calculator's accuracy as barriers to use. Surgeons suggested improving integration to workflow and better education as strategies to increase NSRC use. Conclusions: Many surgeons reported use of the NSRC, but few used it frequently. Surgeons reported more frequent use in nonelective cases and frail patients, suggesting the calculator is of greater utility for high-risk patients. Surgeons raised concerns about perceived accuracy and suggested additional education as well as integration of the calculator into the electronic health record.

Alcohol withdrawal syndrome in trauma patients: a study using the Trauma Quality Program Participant User File.

Objective: To identify the rates and possible predictors of alcohol withdrawal syndrome (AWS) among adult trauma patients. Methods: This is a retrospective review of all adult patients (18 years or older) included in the 2017 and 2018 American College of Surgeons Trauma Quality Program Participant User File (PUF). The main outcomes were rates and predictors of AWS. Results: 1 677 351 adult patients were included in the analysis. AWS was reported in 11 056 (0.7%). The rate increased to 0.9% in patients admitted for more than 2 days and 1.1% in those admitted for more than 3 days. Patients with AWS were more likely to be male (82.7% vs. 60.7%, p<0.001), have a history of alcohol use disorder (AUD) (70.3% vs. 5.6%, p<0.001) and have a positive blood alcohol concentration (BAC) on admission (68.2% vs. 28.6%, p<0.001). In a multivariable logistic regression, history of AUD (OR 12.9, 95% CI 12.1 to 13.7), cirrhosis (OR 2.1, 95% CI 1.9 to 2.3), positive toxicology screen for barbiturates (OR 2.1, 95% CI 1.6 to 2.7), tricyclic antidepressants (OR 2.2, 95% CI 1.5 to 3.1) or alcohol (OR 2.5, 95% CI 2.4 to 2.7), and Abbreviated Injury Scale head score of ≥3 (OR 1.7, 95% CI 1.6 to 1.8) were the strongest predictors for AWS. Conversely, only 2.7% of patients with a positive BAC on admission, 7.6% with a history of AUD and 4.9% with cirrhosis developed AWS. Conclusion: AWS after trauma was an uncommon occurrence in the patients in the PUF, even in higher-risk patient populations. Level of evidence: IV: retrospective study with more than one negative criterion.

Venous Thromboembolism and Thymic Hyperplasia in the Setting of Silent Graves' Disease.

Venous thromboembolism is a common, yet serious life-threatening condition that has many well-recognized associations which include but are not limited to pregnancy, polycythemia, trauma, immobility, and malignancy. The pathophysiology behind the pro-coagulant effects of hyperthyroidism has been well established; however, there are no current guidelines regarding deep venous thrombosis (DVT) surveillance in patients with hyperthyroidism. In this report, we discuss the case of a 36-year-old female with no significant past medical history (PMH) with the exception of a 15 pack-year smoking history, who presented to us with an extensive, rapidly-progressing lower extremity DVT. Despite aggressive treatment measures, she developed a pulmonary embolus in the hospital. During her stay, she was diagnosed with Graves' disease by hormone profile and thyroid-stimulating hormone receptor (TSH-R) antibody positivity. Additionally, an incidental thymic mass, likely thymic hyperplasia, was found on imaging and presumed to be associated with Graves' disease. This case study reports a difficult-to-treat venous thromboembolism in the setting of Graves' disease along with a review of current literature and pathophysiology on the subject.

Differential requirements for the Eps15 homology domain proteins EHD4 and EHD2 in the regulation of mammalian ciliogenesis.

The endocytic protein EHD1 controls primary ciliogenesis by facilitating fusion of the ciliary vesicle and by removal of CP110 from the mother centriole. EHD3, the closest EHD1 paralog, has a similar regulatory role, but initial evidence suggested that the other two more distal paralogs, EHD2 and EHD4 may be dispensable for ciliogenesis. Herein, we define a novel role for EHD4, but not EHD2, in regulating primary ciliogenesis. To better understand the mechanisms and differential functions of the EHD proteins in ciliogenesis, we first demonstrated a requirement for EHD1 ATP-binding to promote ciliogenesis. We then identified two sequence motifs that are entirely conserved between EH domains of EHD1, EHD3 and EHD4, but display key amino acid differences within the EHD2 EH domain. Substitution of either P446 or E470 in EHD1 with the aligning S451 or W475 residues from EHD2 was sufficient to prevent rescue of ciliogenesis in EHD1-depleted cells upon reintroduction of EHD1. Overall, our data enhance the current understanding of the EHD paralogs in ciliogenesis, demonstrate a need for ATP-binding and identify conserved sequences in the EH domains of EHD1, EHD3 and EHD4 that regulate EHD1 binding to proteins and its ability to rescue ciliogenesis in EHD1-depleted cells.

Case report of congenital intestinal malrotation in an adult discovered three months status-post appendectomy.

INTRODUCTION AND IMPORTANCE: Intestinal malrotation is a congenital anomaly primarily diagnosed in children, with limited cases reported in adults. Prompt recognition is necessary to prevent life-threatening complications including bowel ischemia and death. We present a rare case of adult intestinal malrotation highlighting difficulty in diagnosis and surgical management. CASE PRESENTATION: A 37-year-old Caucasian woman presented with a 3-day history of worsening diffuse abdominal pain, three months status-post laparoscopic appendectomy. CT scan with contrast of the abdomen and pelvis demonstrated small bowel mesenteric swirling and descending duodenal transition point. Differential diagnosis included intestinal malrotation versus small bowel obstruction. Pre-operatively, the patient expressed frustration with years of abdominal pain and lack of improvement. Treatment with open surgical small bowel detorsion and ligation of the Ladd's bands was performed, after initial laparoscopic intervention was complicated by enterotomy. The patient recovered well post-operatively with final diagnosis of intestinal malrotation with midgut volvulus. Discharge home was delayed due to polysubstance withdrawal. Post-operatively, the patient reported immediate relief of symptoms which persisted at 2-week and 2-month follow-ups. CLINICAL DISCUSSION: Few reports of congenital malrotation diagnosed in adulthood are reported. This highlights the importance of evaluating all patients for malrotation when the appendix is found outside of the normal positioning in the RLQ, as surgical correction of malrotation is of utmost importance in such patients. CONCLUSION: Clinicians should consider intestinal malrotation in adults with recurrent vague abdominal symptoms. To our knowledge, this is the first report of congenital malrotation discovered in an adult after prior appendectomy.

Understanding the Presentation of Terminal Ileitis.

Our patient is a 47-year-old African American female with a past medical history of recurrent episodes of small bowel obstruction. She presented to the emergency department with symptoms of nausea, vomiting, and abdominal pain. Upon further evaluation, imaging showed obstruction at the terminal ileum. Based on the holistic clinical presentation, we initially thought that this patient was experiencing symptoms of early onset Crohn's disease. Gastroenterology evaluated the patient and was uncertain of the formal diagnosis. Colonoscopy and biopsy were not pathognomonic for Crohn's disease, suggesting that there may be a component of terminal ileitis or another inflammatory bowel disease process. This case exemplifies the degree to which these inflammatory bowel disease processes frequently overlap.

Serotonin Toxicity Precipitated by Tramadol in the Setting of Polypharmacy: A Case of Serotonin Syndrome.

Serotonin syndrome (SS), a potentially life-threatening condition, typically occurs due to polypharmacy and interaction with multiple serotonergic agents. The case presented here is based on a serotonin syndrome (SS) diagnosis, precipitated by newly prescribed tramadol in conjunction with previously prescribed serotonergic medications. A 79-year-old woman receiving combined citalopram and trazodone for major depressive disorder alongside oxycodone for chronic pain developed generalized weakness, tremors, altered mentation, episodic auditory and visual hallucinations, fever, tachypnea, tachycardia, and diaphoresis a few days after tramadol was prescribed for pain. On clinical examination to medication reconciliation, and ruling out other causes of altered mental status, it became evident that the addition of tramadol had resulted in acute serotonin toxicity. SS is important to recognize because many healthcare providers encounter it during their careers. This diagnosis is essential to include in the differential diagnosis, especially when a medication not often associated with serotonin, like opiates, is the culprit.

The cubane paradigm in bioactive molecule discovery: further scope, limitations and the cyclooctatetraene complement.

The cubane phenyl ring bioisostere paradigm was further explored in an extensive study covering a wide range of pharmaceutical and agrochemical templates, which included antibiotics (cefaclor, penicillin G) and antihistamine (diphenhydramine), a smooth muscle relaxant (alverine), an anaesthetic (ketamine), an agrochemical instecticide (triflumuron), an antiparasitic (benznidazole) and an anticancer agent (tamibarotene). This investigation highlights the scope and limitations of incorporating cubane into bioactive molecule discovery, both in terms of synthetic compatibility and physical property matching. Cubane maintained bioisosterism in the case of the Chagas disease antiparasitic benznidazole, although it was less active in the case of the anticancer agent (tamibarotenne). Application of the cyclooctatetraene (COT) (bio)motif complement was found to optimize benznidazole relative to the benzene parent, and augmented anticancer activity relative to the cubane analogue in the case of tamibarotene. Like all bioisosteres, scaffolds and biomotifs, however, there are limitations (e.g. synthetic implementation), and these have been specifically highlighted herein using failed examples. A summary of all templates prepared to date by our group that were biologically evaluated strongly supports the concept that cubane is a valuable tool in bioactive molecule discovery and COT is a viable complement.

Trends and Outcomes of Synchronous Resection of Colorectal Metastasis in the Modern Era-Analysis of Targeted Hepatic NSQIP Database.

BACKGROUND: Previous studies using the NSQIP database to study hepatectomies lacked hepatic specific variables and outcomes. We used the targeted NSQIP hepatectomy database to examine the nationwide trend and the safety profile of synchronous liver and colorectal resection compared with hepatectomy alone for colorectal liver metastasis. METHODS: The targeted NSQIP hepatectomy database from 2014 was used to study patients who underwent hepatectomy for diagnosis of adenocarcinoma of the colon and rectum. RESULTS: Of the 3064 hepatic resections in the database, 1138 cases were performed for colorectal metastasis. Of these, 1040 were liver-alone surgery and 98 were synchronous liver and colorectal resection. Most (58.7%) patients received neoadjuvant therapy. The rate of neoadjuvant therapy, intraoperative ablation, biliary reconstruction, and the use of minimally invasive technique were similar between the two groups. The overall 30-d mortality in this cohort was low (1.1%). While the mortality rate in the synchronous group was similar to liver-only group (3.1% versus 0.9%, P = 0.077). The rate of liver failure (3.3% versus 4.1%, P = 0.722) and biliary leak (5.3% versus 9.6%, P = 0.084) were similar between the two groups. However, the rate of major complications was higher on multivariable analyses (25.5% versus 12.1%, OR 2.5, 95% CI 1.5-4.1, P < 0.001) for the synchronous group. CONCLUSIONS: Hepatic resection for colorectal metastasis in the modern era has low short-term mortality. While synchronous resection was associated with a higher incidence of major complications, liver-specific complications did not increase with synchronous resection.

Mechanisms of Regulated and Dysregulated CARD11 Signaling in Adaptive Immunity and Disease.

CARD11 functions as a key signaling scaffold that controls antigen-induced lymphocyte activation during the adaptive immune response. Somatic mutations in CARD11 are frequently found in Non-Hodgkin lymphoma, and at least three classes of germline CARD11 mutations have been described as the basis for primary immunodeficiency. In this review, we summarize our current understanding of how CARD11 signals, how its activity is regulated, and how mutations bypass normal regulation to cause disease.

Allele-defined genome of the autopolyploid sugarcane Saccharum spontaneum L.

Modern sugarcanes are polyploid interspecific hybrids, combining high sugar content from Saccharum officinarum with hardiness, disease resistance and ratooning of Saccharum spontaneum. Sequencing of a haploid S. spontaneum, AP85-441, facilitated the assembly of 32 pseudo-chromosomes comprising 8 homologous groups of 4 members each, bearing 35,525 genes with alleles defined. The reduction of basic chromosome number from 10 to 8 in S. spontaneum was caused by fissions of 2 ancestral chromosomes followed by translocations to 4 chromosomes. Surprisingly, 80% of nucleotide binding site-encoding genes associated with disease resistance are located in 4 rearranged chromosomes and 51% of those in rearranged regions. Resequencing of 64 S. spontaneum genomes identified balancing selection in rearranged regions, maintaining their diversity. Introgressed S. spontaneum chromosomes in modern sugarcanes are randomly distributed in AP85-441 genome, indicating random recombination among homologs in different S. spontaneum accessions. The allele-defined Saccharum genome offers new knowledge and resources to accelerate sugarcane improvement.

Incidence of Ventral Hernia Repair after Open Abdominal Aortic Aneurysm and Open Aortofemoral or Aortoiliac Bypass Surgery: An Analysis of 17,594 Patients in the State of New York.

The purpose of our study was to evaluate the rate of ventral hernia repair (VHR) after open abdominal aortic anneurysm in New York State compared with the rate of VHR after open abdominal aortic bypass procedures. The Statewide Planning and Research Cooperative System database was queried for all abdominal aortic aneurysm (AAA) and bypass procedures performed between 2000 and 2010. Social security death index was used to identify patients who died. The cause-specific Cox proportional hazard model was applied to compare the risk of having follow-up VHR between patients with AAA and bypass with death as a competing risk event. A multivariable model was used to explore independent relationship with the risk of having follow-up ventral hernia after adjusting for other factors. There were 9314 patients who underwent open AAA repair, 739 (7.93%) of which had subsequent VHR. Comparatively, 8280 patients underwent aortofemoral or aortoiliac bypass procedures, with 480 (5.8%) undergoing subsequent VHR. The observed one-year, five-year, and 10-year VHR rates for AAA versus bypass were 2.8 versus 1.8 per cent, 10.0 versus 8.0 per cent, 10.7 versus 9.38 per cent, respectively. After controlling for all other factors, patients undergoing AAA repair were more likely and elderly patients were less likely to undergo VHR (P < 0.0001). Patients with serious comorbid conditions such as valvular disease, diabetes mellitus, and neurologic disorders were less likely to undergo subsequent VHR controlling for other factors. VHR after AAA procedures is more common compared with bypass procedures for occlusive disease. Because this patient population has significant comorbidity, prophylactic mesh placement may play a role in preventing necessity for future procedures.

Implantable cardioverter defibrillators and permanent pacemakers: prevalence and patient outcomes after trauma.

BACKGROUND: The prevalence and outcomes of older trauma patients with implantable cardioverter defibrillators (ICDs) or permanent pacemakers (PPMs) is unknown. METHODS: The trauma registry at a regional trauma center was reviewed for blunt trauma patients, aged ≥ 60 years, admitted between 2007 and 2014. Medical records of cardiac devices patients were reviewed. RESULTS: Of 4,193 admissions, there were 146 ICD, 233 PPM, and 3,814 no device patients; median Injury Severity Score was 9. Most cardiac device patients had substantial underlying heart disease. Patients with ICDs (13.0%) and PPMs (8.6%) had higher mortality rates than no device patients (5.6%, P = .0002). Among cardiac device patients who died, the device was functioning properly in all that were interrogated; the most common cause of death was intracranial hemorrhage. On propensity score analysis, cardiac devices were not independent predictors of mortality but rather surrogate variables associated with other predictors of mortality. CONCLUSIONS: Approximately 9.0% of admitted older patients had cardiac devices. Their presence identified patients who had higher mortality rates, likely because of their underlying comorbidities, including cardiac dysfunction.

Transcortical screw fixation of the olecranon shows equivalent strength and improved stability compared with tension band fixation.

OBJECTIVES: Currently, the standard for 21-B3.1 olecranon fracture fixation is the tension band wire construct described by the AO foundation. Although this technique effectively repairs displaced olecranon fractures and osteotomies, it is associated with a high rate of secondary surgery for implant removal due to hardware "back out," prominence, and discomfort. The senior author of this study has used transcortical screw fixation for olecranon fractures and osteotomies to avoid hardware discomfort but has been unable to find literature documenting the strength of this method. Accordingly, we compared the strength and stability of transcortical screw fixation with tension band fixation of simple transverse olecranon fractures under cyclical loading. METHODS: Eighteen fourth-generation synthetic biomechanical testing ulnas underwent a transverse olecranon osteotomy and were repaired by tension banding or screw fixation. Two 4.0 mm partially threaded screws inserted across the fracture gap into the anterior cortex of the ulna achieved screw fixation. Ulnas were tested in 2 ways as follows: (1) cyclic loading that simulated pushing up from a chair; and (2) single cycle loading to failure. Fracture displacement was recorded using a transducer that was placed on the posterior surface of the ulna. RESULTS: Differences between screw fixation and tension banding in the peak displacement during cyclic loading and single cycle load to failure were not significant. Screw fixation did show significantly less "trough" displacement (resting position between cycles) during cyclic loading indicating less plastic deformation. CONCLUSIONS: In a synthetic bone model of simple transverse olecranon fractures, screw fixation provided equivalent strength and less plastic deformation as compared with tension banding.

Rapid on-site pathologic evaluation does not increase the efficacy of endobronchial ultrasonographic biopsy for mediastinal staging.

BACKGROUND: Endobronchial ultrasonography with transbronchial needle aspiration (EBUS-TBNA) has been shown to be equivalent to mediastinoscopy in lung cancer staging for mediastinal node involvement. Rapid on-site evaluation (ROSE) to determine the adequacy of nodal sampling has been claimed to be beneficial. METHODS: A retrospective evaluation was performed in 170 patients who underwent EBUS-TBNA from July 2008 to May 2011. The patients were classified as having either high or low pretest probability for mediastinal disease based on history and radiographic imaging. ROSE was compared with the final pathology reports based on slides and cell blocks. RESULTS: One hundred thirty-one (77%) patients were classified as being in the high pretest cohort based on clinical staging. Of these, 101 (77%) patients had adequate tissue sampling based on ROSE, with 70 (69%) patients having positive mediastinal disease. In the 30 (23%) patients who had inadequate tissue by ROSE, the final analysis of all the prepared slides and cell blocks allowed for a diagnosis in all but 8 patients. The sensitivity and specificity of ROSE in the high pretest probability cohort were 89.5% and 96.4%, respectively, whereas the overall sensitivity and specificity of EBUS-TBNA was 92.1% and 100%, respectively. Despite having inadequate tissue on ROSE in 30 of 131 patients, sufficient tissue was available on final analysis for diagnosis in 22 of 30 patients. CONCLUSIONS: ROSE does not impact clinical decision making if a thorough mediastinal staging using EBUS is performed. Despite inadequate tissue sampling assessment by ROSE, a final diagnosis was made in most patients, potentially avoiding an additional surgical procedure to prove mediastinal disease.

Evidence of resistance development by Staphylococcus aureus to an in vitro, multiple stage application of 405 nm light from a supraluminous diode array.

OBJECTIVE: The aim of this study was to determine whether Staphylococcus aureus could develop a resistance to 405 nm light. BACKGROUND DATA: Research indicates that certain wavelengths and treatment parameters of light promote growth of bacteria; however, our earlier work indicated that blue light effectively inactivates growth of S. aureus in vitro. METHODS: S. aureus was tested because of its frequent isolation from skin infections and wounds. The organism was treated with 405 nm light from supraluminous diodes at a dose of 9 J/cm(2). RESULTS: As anticipated, blue light produced a significant (p≤0.05) inactivation of S. aureus growth. Subsequent applications of blue light to subcultured generations of S. aureus were increasingly effective through four stages (generations). Beginning with stage five, a decrease in effectiveness (resistance) was observed. CONCLUSIONS: Appropriate doses of 405-nm blue light inhibit the growth of S. aureus in vitro. This research does suggest that S. aureus may be capable of developing resistance to blue light irradiation.