Comparison of Global Evaluative Assessment of Robotic Surgery with objective performance indicators for the assessment of skill during robotic-assisted thoracic surgery.

BACKGROUND: The Global Evaluative Assessment of Robotic Skills is a popular but ultimately subjective assessment tool in robotic-assisted surgery. An alternative approach is to record system or console events or calculate instrument kinematics to derive objective performance indicators. The aim of this study was to compare these 2 approaches and correlate the Global Evaluative Assessment of Robotic Skills with different types of objective performance indicators during robotic-assisted lobectomy. METHODS: Video, system event, and kinematic data were recorded from the robotic surgical system during left upper lobectomy on a standardized perfused and pulsatile ex vivo porcine heart-lung model. Videos were segmented into steps, and the superior vein dissection was graded independently by 2 blinded expert surgeons with Global Evaluative Assessment of Robotic Skills. Objective performance indicators representing categories for energy use, event data, movement, smoothness, time, and wrist articulation were calculated for the same task and compared to Global Evaluative Assessment of Robotic Skills scores. RESULTS: Video and data from 51 cases were analyzed (44 fellows, 7 attendings). Global Evaluative Assessment of Robotic Skills scores were significantly higher for attendings (P < .05), but there was a significant difference in raters' scores of 31.4% (defined as >20% difference in total score). The interclass correlation was 0.44 for 1 rater and 0.61 for 2 raters. Objective performance indicators correlated with Global Evaluative Assessment of Robotic Skills to varying degrees. The most highly correlated Global Evaluative Assessment of Robotic Skills domain was efficiency. Instrument movement and smoothness were highly correlated among objective performance indicator categories. Of individual objective performance indicators, right-hand median jerk, an objective performance indicator of change of acceleration, had the highest correlation coefficient (0.55). CONCLUSION: There was a relatively poor overall correlation between the Global Evaluative Assessment of Robotic Skills and objective performance indicators. However, both appear strongly correlated for certain metrics such as efficiency and smoothness. Objective performance indicators may be a potentially more quantitative and granular approach to assessing skill, given that they can be calculated mathematically and automatically without subjective interpretation.

Pre-existing conditions associated with post-acute sequelae of COVID-19.

Post-acute sequelae of COVID-19 (PASC) are conditions that occur or remain at least 28 days after SARS-CoV-2 infection. While some risk factors for PASC have been identified, little is known about pre-existing conditions that render one susceptible to developing PASC. Data from participants (n = 1224) in a longitudinal COVID-19 cohort study in Arizona were used to investigate comorbid conditions associated with PASC. After adjustment of the models for age, BMI, gender, race, and smoking, the following pre-existing conditions were statistically significantly associated with the development of PASC: asthma (OR = 1.54; 95% CI = 1.10-2.15); chronic constipation (OR = 4.29; 95% CI = 1.15-16.00); reflux (OR = 1.54; 95% CI = 1.01-2.34); rheumatoid arthritis (OR = 3.69; 95%CI = 1.15-11.82); seasonal allergies (OR = 1.56; 95% CI = 1.22-1.98); and depression/anxiety (OR = 1.72; 95% CI = 1.17-2.52). When grouping conditions together, statistically significant associations with PASC were observed for respiratory (OR = 1.47; 95% CI = 1.06-2.14); gastrointestinal (OR = 1.62; 95% CI = 1.16-2.26), and autoimmune conditions (OR = 4.38; 95% CI = 1.59-12.06). After adjustment for severity of acute SARS-CoV-2 infection and depression/anxiety, seasonal allergies (OR = 1.48; 95% CI 1.15-1.91) and autoimmune disease (OR = 3.78; 95% CI - 1.31-10.91) remained significantly associated with risk for PASC. These findings indicate that numerous pre-existing conditions may be associated with an increased risk for the development of PASC. Patients with these conditions should consider taking extra steps to avoid infection.

The Costs and Benefits of Environmental Memory for Reef-Building Corals Coping with Recurring Marine Heatwaves.

Marine heatwaves are occurring more frequently as climate change intensifies, resulting in global mass coral bleaching events several times per decade. Despite the time between marine heatwaves decreasing, there is evidence that reef-building corals can develop increased bleaching resistance across repetitive marine heatwaves. This phenomenon of acclimatization via environmental memory may be an important strategy to ensure coral persistence; however, we still understand very little about the apparent acclimatization or, conversely, sensitization (i.e., stress accumulation or weakening) of reef-building corals to consecutive heatwaves and its implications for the trajectory and resilience of coral reefs. Here, we highlight that not only will some corals become stress hardened via marine heatwaves, but many other individuals will suffer sensitization during repeat heatwaves that further exacerbates their stress response during repeat events and depresses fitness. Under current and predicted climate change, it is necessary to gain a better understanding of the acclimatization vs. sensitization trajectories of different species and individuals on the reef, as well as identify whether changes in bleaching susceptibility relates to physiological acclimatization, trade-offs with other biological processes, and ultimately coral persistence in the Anthropocene.

Association of Childhood Socioeconomic Status with Leukocyte Telomere Length Among African Americans and the Mediating Role of Behavioral and Psychosocial Factors: Results from the GENE-FORECAST Study.

PURPOSE: We examined if childhood socioeconomic status (SES) was related to adult leucocyte telomere length (TL) using the data of 361 African American (AA) participants from the GENE-FORECAST Study. We also assessed the mediating role of behavioral and psychosocial factors in the association between childhood SES and adult TL. METHODS: Childhood SES was assessed individually by using participant's mother's education and occupation, father's education and occupation, parental home ownership, and family structure. TL was assessed using the quantitative polymerase chain reaction method. Information on potential confounders and mediators were collected. The associations of childhood SES with TL were assessed using multivariable linear regression models. We used path analysis to quantify and test the share of these associations that was statistically explained by each of the mediators (participant's educational attainment, smoking status, physical activity, dietary habit, perceived stress, and depressive symptoms). RESULTS: Mother's education was associated with longer average TL (ß: 0.021; 95% CI: 0.001, 0.04, p=0.038) in confounder adjusted models. Once mediators were introduced in the model, the estimates were reduced and remained marginally significant (ß: 0.017; 95% CI: -0.003, 0.038, p=0.061). According to path model, approximately 19% of the effect of mother's education on TL (ß: 0.004; 95% CI: -0.001, 0.01, p < 0.10) was mediated through participant's own education level. No significant mediation effect was observed for any other mediators. CONCLUSIONS: These data provide evidence that participant's mother's education was positively linked to adult TL in AA population. Participant's own educational level partially explained this association.

Identification of Staphylococcus pseudintermedius Isolates from Wound Cultures by Matrix-Assisted Laser Desorption Ionization-Time of Flight Mass Spectrometry Improves Accuracy of Susceptibility Reporting at an Increase in Cost.

Staphylococcus pseudintermedius can easily be mistaken for Staphylococcus aureus using phenotypic and rapid biochemical methods. We began confirming the identification of all coagulase-positive staphylococci isolated from human wound cultures at our centralized laboratory, servicing both community and inpatients, with matrix-assisted laser desorption ionization-time of flight mass spectrometry instead of using phenotypic and rapid biochemical tests, and determined the prevalence of S. pseudintermedius since the change in identification procedure and at what cost. A retrospective review was performed on all wound swab cultures from which coagulase-positive staphylococci were isolated 7 months before and after the change in identification procedure. A total of 49 S. intermedius/pseudintermedius (SIP) isolates were identified, including 7 isolates from 14,401 wound cultures in the before period and 42 isolates from 14,147 wound cultures in the after period. The number of SIP isolates as a proportion of isolated coagulase-positive staphylococci increased significantly from the before, 7/6,351 (0.1%), to the after, 42/5,435 (0.7%), period (difference, 0.6% [95% confidence interval, 0.037 to 0.83%, P < 0.0001]). Antibiotic susceptibility testing was performed in 42 isolates; none had an oxacillin MIC of 1.0 to 2.0 µg/ml, the range in which, if the isolate was misidentified as S. aureus, a very major error in susceptibility interpretation would occur. The increase in cost of the change in identification procedure was Can$17,558 per year in our laboratory, performing microbiology testing for community and acute-care patients in a zone servicing nearly 1.7 million people. While we will only continue to learn more about this emerging pathogen if we make attempts to properly identify it in clinical cultures, the additional time and cost involved may be unacceptably high in some laboratories. .

An ecological study of the association between neighborhood racial and economic residential segregation with COVID-19 vulnerability in the United States' capital city.

PURPOSE: The COVID-19 pandemic has had a profound impact on American life. However, the burden of the pandemic has not been distributed equally. The purpose of this study was to investigate whether racial and economic residential segregation were associated with COVID-19 related factors in the nation's capital, Washington D.C., during the first year of the pandemic. METHODS: Racial, economic, and racialized economic segregation were assessed using the Index of Concentration at the Extremes measure and data from the 2014-2018 American Community Survey. COVID-19 related factors (i.e., incidence, testing rate, and percent positivity) were assessed using data from the Washington D.C. government. Spearman rank correlation was used to assess the relationship between each segregation measure and each COVID-19 related factor. RESULTS: Washington D.C. neighborhoods with a higher concentration of African Americans, lower income residents, and African Americans with low income had a higher incidence of COVID-19 and greater percent positivity, but lower testing rates compared to their counterparts. CONCLUSIONS: There is a geographic mismatch between neighborhoods most vulnerable to COVID-19 and the neighborhoods where the testing resources are being used. More resources should be allocated to the most vulnerable neighborhoods to address the COVID-19 pandemic in an equitable manner.

How to Bring Surgery to the Next Level: Interpretable Skills Assessment in Robotic-Assisted Surgery.

INTRODUCTION: A surgeon's technical skills are an important factor in delivering optimal patient care. Most existing methods to estimate technical skills remain subjective and resource intensive. Robotic-assisted surgery (RAS) provides a unique opportunity to develop objective metrics using key elements of intraoperative surgeon behavior which can be captured unobtrusively, such as instrument positions and button presses. Recent studies have shown that objective metrics based on these data (referred to as objective performance indicators [OPIs]) correlate to select clinical outcomes during robotic-assisted radical prostatectomy. However, the current OPIs remain difficult to interpret directly and, therefore, to use within structured feedback to improve surgical efficiencies. METHODS: We analyzed kinematic and event data from da Vinci surgical systems (Intuitive Surgical, Inc., Sunnyvale, CA, USA) to calculate values that can summarize the use of robotic instruments, referred to as OPIs. These indicators were mapped to broader technical skill categories of established training protocols. A data-driven approach was then applied to further sub-select OPIs that distinguish skill for each technical skill category within each training task. This subset of OPIs was used to build a set of logistic regression classifiers that predict the probability of expertise in that skill to identify targeted improvement and practice. The final, proposed feedback using OPIs was based on the coefficients of the logistic regression model to highlight specific actions that can be taken to improve. RESULTS: We determine that for the majority of skills, only a small subset of OPIs (2-10) are required to achieve the highest model accuracies (80-95%) for estimating technical skills within clinical-like tasks on a porcine model. The majority of the skill models have similar accuracy as models predicting overall expertise for a task (80-98%). Skill models can divide a prediction into interpretable categories for simpler, targeted feedback. CONCLUSION: We define and validate a methodology to create interpretable metrics for key technical skills during clinical-like tasks when performing RAS. Using this framework for evaluating technical skills, we believe that surgical trainees can better understand both what can be improved and how to improve.

Market Sensitivity of Solar-Fossil Hybrid Electricity Generation to Price, Efficiency, Policy, and Fuel Projections.

Ideally, new electricity generating units will have low capital costs, low fuel costs, minimal environmental impacts, and satisfy demand without concerns of intermittency. When expanding generating capacity, candidate technologies can be evaluated against criteria such as these. Alternatively, it may be possible to pair technologies in such a way that the combination addresses these criteria better than either technology individually. One such approach is to pair concentrated solar power and natural gas combined-cycle units. This paper analyzes how an integrated solar combined cycle (ISCC) facility could fare in the larger US electricity production market, although the results are generalizable to a wider range of technologies. Modeling results suggest that a critical consideration is the extent to which ISCC qualifies as being renewable under state-level renewable portfolio standards (RPSs). The technology would be utilized at a higher level if it fully satisfies an RPS; however, even if the technology does not satisfy an RPS, it would be market-competitive if optimistic goals for capital cost and avoided natural gas purchases are met. Furthermore, if used in parts of the country with strong solar resources, ISCC could produce as much as 14% of national electricity generation in 2050. Whether adoption of ISCC leads to reduced air pollutant and greenhouse gas emissions is dependent on the technologies it displaces. Under default assumptions, the new ISCC capacity primarily displaces renewable and natural gas facilities as opposed to facilities with higher air pollutant emissions. Thus, the air pollution benefits of ISCC may be limited.

Expression of socially sensitive genes: The multi-ethnic study of atherosclerosis.

BACKGROUND: Gene expression may be an important biological mediator in associations between social factors and health. However, previous studies were limited by small sample sizes and use of differing cell types with heterogeneous expression patterns. We use a large population-based cohort with gene expression measured solely in monocytes to investigate associations between seven social factors and expression of genes previously found to be sensitive to social factors. METHODS: We employ three methodological approaches: 1) omnibus test for the entire gene set (Global ANCOVA), 2) assessment of each association individually (linear regression), and 3) machine learning method that performs variable selection with correlated predictors (elastic net). RESULTS: In global analyses, significant associations with the a priori defined socially sensitive gene set were detected for major or lifetime discrimination and chronic burden (p = 0.019 and p = 0.047, respectively). Marginally significant associations were detected for loneliness and adult socioeconomic status (p = 0.066, p = 0.093, respectively). No associations were significant in linear regression analyses after accounting for multiple testing. However, a small percentage of gene expressions (up to 11%) were associated with at least one social factor using elastic net. CONCLUSION: The Global ANCOVA and elastic net findings suggest that a small percentage of genes may be "socially sensitive," (i.e. demonstrate differential expression by social factor), yet single gene approaches such as linear regression may be ill powered to capture this relationship. Future research should further investigate the biological mechanisms through which social factors act to influence gene expression and how systemic changes in gene expression affect overall health.

Is it time for the 4th P in nurse practitioner education? Physical assessment, pharmacology, pathophysiology, and procedures: A systematic review.

BACKGROUND AND PURPOSE: Nurse practitioners (NPs) perform diagnostic and clinical procedure skills in the acute, specialty, urgent, and primary care settings. Nurse practitioners surveyed on readiness for practice report a lack of confidence and education preparation for performing selected advanced diagnostic and skills. As NPs gain independent, full practice scope, it is imperative advanced diagnostic and procedure skills used in practice are taught in nurse practitioner curriculum. The purpose of this review is to document a systematic review of the literature, answering the following question: Among primary care NPs, does current program curriculum align with current procedures and skills in theclinical setting? METHODS: PubMed, Cochrane, Scopus, CINAHL, and Embase were searched between inception and 2018 using the search terms "advanced practice nursing, clinical competence, diagnostic techniques or procedures, and primary health care." Following the preferred reporting items for systematic reviews and meta-analysis guidelines, nine articles were included in the synthesis. CONCLUSION: There is scant research regarding NP educational preparation of skills and procedures. Study findings indicate that programs are not teaching all the procedures deemed important. Education should promote improved congruence between the skills and procedures taught in program curricula and those used in clinical practice. IMPLICATIONS FOR PRACTICE: It is critical to complete an education practice survey measuring skill and procedure preparation and competency at graduation. Survey results will determine whether skill and procedure guidelines are indicated for NP education. A recommendation may include minimal skills and procedure for all nurse practitioner curricula.

Evolution of the United States Energy System and Related Emissions under Varying Social and Technological Development Paradigms: Plausible Scenarios for Use in Robust Decision Making.

The energy system is the primary source of air pollution. Thus, evolution of the energy system into the future will affect society's ability to maintain air quality. Anticipating this evolution is difficult because of inherent uncertainty in predicting future energy demand, fuel use, and technology adoption. We apply scenario planning to address this uncertainty, developing four very different visions of the future. Stakeholder engagement suggested that technological progress and social attitudes toward the environment are critical and uncertain factors for determining future emissions. Combining transformative and static assumptions about these factors yields a matrix of four scenarios that encompass a wide range of outcomes. We implement these scenarios in the U.S. Environmental Protection Agency MARKet ALlocation (MARKAL) model. Results suggest that both shifting attitudes and technology transformation may lead to emission reductions relative to the present, even without additional policies. Emission caps, such as the Cross-State Air-Pollution Rule, are most effective at protecting against future emission increases. An important outcome of this work is the scenario-implementation approach, which uses technology-specific discount rates to encourage scenario-specific technology and fuel choices. End-use energy demands are modified to approximate societal changes. This implementation allows the model to respond to perturbations in manners consistent with each scenario.

Are fecal indicator bacteria appropriate measures of recreational water risks in the tropics: A cohort study of beach goers in Brazil?

Regulating recreational water exposure to pathogens within the tropics is a major public health and economic concern. Although numerous epidemiological studies estimating the risk to recreational marine water exposure have been conducted since the 1950s, few studies have been done in the tropics. Furthermore, many have suggested that the use of fecal indicator bacteria for monitoring recreational water quality in temperate regions is not appropriate in the tropics. We analyzed a large cohort study of five beaches in Sao Paulo, Brazil, conducted during consecutive weekends in the summer of 1999 that estimated risk to water, sand, and food exposures. Enterococci and Escherichia coli concentrations were measured each day of the study. Elevated risks were estimated for both swimming (OR = 1.36 95% CI: 1.05-1.58) and sand contact (OR = 1.29 95% CI 1.05-1.58). A 1 log increase in enterococci concentration was associated with an 11% increase in risk (OR = 1.11 95% CI: 1.04-1.19). For E. coli a 1-log increase in concentration was associated with 19% increase in risk (OR = 1.19 95% CI: 1.14-1.28). Most countries with beaches in the tropics are lower or middle income countries (LMIC) and rely on tourism as a major source of income. We present data that suggests fecal indicator bacteria such as enterococci are an appropriate indicator of risk in tropical urban settings where contamination is coming from predominantly human sources. Additional studies in tropical settings could help inform and refine guidelines for safe use of recreational waters.

Outcomes and costs associated with a history of vancomycin exposure in patients with MRSA-related complicated bacteremia and infective endocarditis.

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) is the primary cause of complicated bacteremia (CB) and infective endocarditis (IE). Studies have compared the costs of treatment with vancomycin to those of other agents, as well as the efficacy and tolerability of these treatments. However, a literature search found no published studies of the effects of vancomycin exposure on outcomes and hospital costs in patients with CB or IE due to MRSA. OBJECTIVE: The aim of this study was to determine whether there is a quantitative relationship between the duration of vancomycin treatment or cumulative vancomycin exposure and outcomes or costs in patient with CB or IE due to MRSA. METHODS: Electronic medical records of confirmed cases of MRSA-related CB or IE from July 1, 2006, to June 30, 2008, were retrospectively reviewed to identify patients with a history of vancomycin exposure or no vancomycin exposure. Those who received vancomycin were stratified by the amount of drug administered or the duration of treatment to determine the relationship between treatment and outcomes. Data collected included demographic information, treatment information, attributable mortality, MIC data, and hospital costs. Classification and regression tree analysis (CART) was used to determine whether a history of vancomycin exposure was associated with treatment failure, attributable mortality, or both. The Mann-Whitney U test and the Fisher exact test were used for univariate analyses, and logistic regression was used for multivariate modeling. RESULTS: Data from 50 patients were evaluated (CB, 32; IE, 18). Overall rates of failure and attributable mortality were 32% and 16%, respectively. No significant differences were observed between the variables and costs. The CART break points for failure were ≥18.75 g and ≥14 days of vancomycin treatment in the previous 3 years; for attributable mortality, the CART break points were ≥45 g and ≥31 days. In the final multivariate model for failure, ≥18.75 g and ≥14 days of vancomycin treatment in the previous 3 years were predictors of failure (both, P = 0.002). Acute Physiology and Chronic Health Evaluation (APACHE) II score (P = 0.04), ≥45 g (P = 0.002), and ≥31 days of treatment (P = 0.002) in the previous 3 years were predictors of attributable mortality after adjustment for all covariates. CONCLUSIONS: Using the present model, cumulative vancomycin amount and duration were associated with attributable mortality and clinical failure but not with costs.

The effect of policy changes on hepatitis A vaccine uptake in Arizona children, 1995-2008.

OBJECTIVE: In 1995, the first hepatitis A vaccines became available for use. At that time, Arizona had the highest hepatitis A incidence of all 50 states. During that same time period, the Arizona State Immunization Information System (ASIIS) was created to collect information on all immunizations given in the state. Four state-level hepatitis A vaccination policies were enacted according to Centers for Disease Control and Prevention recommendations and local initiatives from 1996 to 2005. Our primary objective was to assess the impact of these policies on vaccine uptake in children. METHODS: Immunization records from ASIIS were used to calculate yearly coverage of children with at least one reported hepatitis A vaccination between 1995 and 2008. Proportions vaccinated were calculated by age group (12-23 months, 24-59 months, 5-9 years, 10-14 years, and 15-19 years) for three regions: Maricopa County; Apache and Navajo counties; and the remaining 12 Arizona counties, which were grouped as one to reflect different target groups for the four policies examined. We calculated percent changes from before and after each policy implementation. RESULTS: Significantly different percent changes were detected among the three regions that related to the four policies implemented. Percent change in uptake was consistently higher in the regions that were targeted for that specific policy. CONCLUSIONS: Analysis of ASIIS data revealed a major effect of hepatitis A policy recommendations on vaccine uptake in Arizona. Targeting high-risk populations through vaccine recommendations and child care entry requirements was highly successful in achieving higher vaccination coverage.