American College of Lifestyle Medicine Expert Consensus Statement: Lifestyle Medicine for Optimal Outcomes in Primary Care.

OBJECTIVE: Identify areas of consensus on integrating lifestyle medicine (LM) into primary care to achieve optimal outcomes. METHODS: Experts in both LM and primary care followed an a priori protocol for developing consensus statements. Using an iterative, online process, panel members expressed levels of agreement with statements, resulting in classification as consensus, near consensus, or no consensus. RESULTS: The panel identified 124 candidate statements addressing: (1) Integration into Primary Care, (2) Delivery Models, (3) Provider Education, (4) Evidence-base for LM, (5) Vital Signs, (6) Treatment, (7) Resource Referral and Reimbursement, (8) Patient, Family, and Community Involvement; Shared Decision-Making, (9) Social Determinants of Health and Health Equity, and (10) Barriers to LM. After three iterations of an online Delphi survey, statement revisions, and removal of duplicative statements, 65 statements met criteria for consensus, 24 for near consensus, and 35 for no consensus. Consensus was reached on key topics that included LM being recognized as an essential component of primary care in patients of all ages, including LM as a foundational element of health professional education. CONCLUSION: The practice of LM in primary care can be strengthened by applying these statements to improve quality of care, inform policy, and identify areas for future research.

Sexual minority disparities in psychosocial functioning following substance use recovery among a representative sample of US adults.

Purpose: Sexual minority (SM; e.g., gay, lesbian, bisexual) individuals are disproportionately impacted by alcohol and other drug (AOD) use disorders and psychosocial factors that can exacerbate AOD use disorders and hinder recovery. This study examines SM sub-group differences (monosexual [gay/lesbian] versus bisexual) regarding adaptation to recovery measured by indices of psychosocial functioning. Identifying differential needs of gay/lesbian versus bisexual individuals could improve services to better meet the needs of SM individuals in recovery. Methods: Using data from the National Recovery Study, a nationally representative cross-sectional sample of US adults who reported resolving an AOD problem (N = 2,002), we compared heterosexual to monosexual and bisexual SM individuals on socio-demographic characteristics, AOD use and treatment, and psychosocial variables. Results: Bisexual individuals were significantly younger than heterosexual individuals (p = .002 and p ≤ 0.001 among men and women, respectively) and reported significantly fewer years since AOD problem resolution compared to heterosexual individuals (p = .004 and p = .003 among men and women, respectively). Most notably, bisexual individuals, but not gay/lesbian individuals, reported significantly lower quality of life (QOL), happiness, self-esteem, and significantly higher distress compared to heterosexual individuals. Conclusion: Bisexual, but not monosexual, SM individuals in recovery from an AOD use disorder, were younger and reported worse psychosocial functioning than heterosexual individuals. Findings highlight significant differences between monosexual versus bisexual identified individuals with a notable disadvantage experienced by bisexual individuals. More needs to be learned about the challenges faced by bisexual individuals in recovery to better address their needs and support long-term AOD recovery.

Evaluation of objective tools and artificial intelligence in robotic surgery technical skills assessment: a systematic review.

BACKGROUND: There is a need to standardize training in robotic surgery, including objective assessment for accreditation. This systematic review aimed to identify objective tools for technical skills assessment, providing evaluation statuses to guide research and inform implementation into training curricula. METHODS: A systematic literature search was conducted in accordance with the PRISMA guidelines. Ovid Embase/Medline, PubMed and Web of Science were searched. Inclusion criterion: robotic surgery technical skills tools. Exclusion criteria: non-technical, laparoscopy or open skills only. Manual tools and automated performance metrics (APMs) were analysed using Messick's concept of validity and the Oxford Centre of Evidence-Based Medicine (OCEBM) Levels of Evidence and Recommendation (LoR). A bespoke tool analysed artificial intelligence (AI) studies. The Modified Downs-Black checklist was used to assess risk of bias. RESULTS: Two hundred and forty-seven studies were analysed, identifying: 8 global rating scales, 26 procedure-/task-specific tools, 3 main error-based methods, 10 simulators, 28 studies analysing APMs and 53 AI studies. Global Evaluative Assessment of Robotic Skills and the da Vinci Skills Simulator were the most evaluated tools at LoR 1 (OCEBM). Three procedure-specific tools, 3 error-based methods and 1 non-simulator APMs reached LoR 2. AI models estimated outcomes (skill or clinical), demonstrating superior accuracy rates in the laboratory with 60 per cent of methods reporting accuracies over 90 per cent, compared to real surgery ranging from 67 to 100 per cent. CONCLUSIONS: Manual and automated assessment tools for robotic surgery are not well validated and require further evaluation before use in accreditation processes.PROSPERO: registration ID CRD42022304901.

BACKGROUND: Robotic surgery is increasingly used worldwide to treat many different diseases. The robot is controlled by a surgeon, which may give them greater precision and better outcomes for patients. However, surgeons' robotic skills should be assessed properly, to make sure patients are safe, to improve feedback and for exam assessments for certification to indicate competency. This should be done by experts, using assessment tools that have been agreed upon and proven to work. AIM: This review's aim was to find and explain which training and examination tools are best for assessing surgeons' robotic skills and to find out what gaps remain requiring future research. METHOD: This review searched for all available studies looking at assessment tools in robotic surgery and summarized their findings using several different methods. FINDINGS AND CONCLUSION: Two hundred and forty-seven studies were looked at, finding many assessment tools. Further research is needed for operation-specific and automatic assessment tools before they should be used in the clinical setting.

Understanding Financial Relationships Between Orthopedic Surgeons and Industry for Research.

OBJECTIVE: This study sought to understand trends in industry payments for research awarded to orthopedic surgeons. MATERIALS AND METHODS: The Centers for Medicare & Medicaid Services Open Payments database was queried for the years 2016 to 2021 for industry payments for research. Financial analyses were performed to understand temporal trends and differences by orthopedic subspecialty and principal investigator characteristics such as sex. The threshold for statistical significance was set at .05. RESULTS: A total of 2014 orthopedic surgeons were identified, among whom 542 adult reconstruction (27%) and 460 sports medicine (23%) surgeons were major beneficiaries. Seventy-one female orthopedic surgeons comprised the minority (4%). Total research payments awarded during the study period aggregated to $266,633,592, with adult reconstruction ($88,819,047; 33%) and sports medicine ($57,949,822; 22%) receiving the highest amounts. Total research payments awarded trended upward yearly except for a decline in 2020 that subsequently rebounded (P<.001). Median annual research payment per orthopedic surgeon was $13,375. Median total industry payments per orthopedic surgeon differed between specialties (P <.001), with the highest amounts for adult reconstruction ($44,063) and sports medicine ($34,567) and the lowest amounts for hand ($12,052) and foot and ankle ($19,233). Median total payments did not differ significantly when stratified by sex (P=.276) and region (P=.906). Specialties in which the respective top three companies offered the majority of the research funding were musculoskeletal oncology (90%), pediatric orthopedics (66%), and shoulder and elbow (64%). CONCLUSION: These results can be used as a primer for orthopedic surgeons seeking to leverage industry relationships to fund translational research. [Orthopedics. 2024;47(3):172-178.].

Cost-Effectiveness of Robot-Assisted Radical Cystectomy vs Open Radical Cystectomy for Patients With Bladder Cancer.

Importance: The value to payers of robot-assisted radical cystectomy with intracorporeal urinary diversion (iRARC) when compared with open radical cystectomy (ORC) for patients with bladder cancer is unclear. Objectives: To compare the cost-effectiveness of iRARC with that of ORC. Design, Setting, and Participants: This economic evaluation used individual patient data from a randomized clinical trial at 9 surgical centers in the United Kingdom. Patients with nonmetastatic bladder cancer were recruited from March 20, 2017, to January 29, 2020. The analysis used a health service perspective and a 90-day time horizon, with supplementary analyses exploring patient benefits up to 1 year. Deterministic and probabilistic sensitivity analyses were undertaken. Data were analyzed from January 13, 2022, to March 10, 2023. Interventions: Patients were randomized to receive either iRARC (n = 169) or ORC (n = 169). Main Outcomes and Measures: Costs of surgery were calculated using surgery timings and equipment costs, with other hospital data based on counts of activity. Quality-adjusted life-years were calculated from European Quality of Life 5-Dimension 5-Level instrument responses. Prespecified subgroup analyses were undertaken based on patient characteristics and type of diversion. Results: A total of 305 patients with available outcome data were included in the analysis, with a mean (SD) age of 68.3 (8.1) years, and of whom 241 (79.0%) were men. Robot-assisted radical cystectomy was associated with statistically significant reductions in admissions to intensive therapy (6.35% [95% CI, 0.42%-12.28%]), and readmissions to hospital (14.56% [95% CI, 5.00%-24.11%]), but increases in theater time (31.35 [95% CI, 13.67-49.02] minutes). The additional cost of iRARC per patient was £1124 (95% CI, -£576 to £2824 [US $1622 (95% CI, -$831 to $4075)]) with an associated gain in quality-adjusted life-years of 0.01124 (95% CI, 0.00391-0.01857). The incremental cost-effectiveness ratio was £100 008 (US $144 312) per quality-adjusted life-year gained. Robot-assisted radical cystectomy had a much higher probability of being cost-effective for subgroups defined by age, tumor stage, and performance status. Conclusions and Relevance: In this economic evaluation of surgery for patients with bladder cancer, iRARC reduced short-term morbidity and some associated costs. While the resulting cost-effectiveness ratio was in excess of thresholds used by many publicly funded health systems, patient subgroups were identified for which iRARC had a high probability of being cost-effective. Trial Registration: ClinicalTrials.gov Identifier: NCT03049410.

Study protocol for a randomised controlled trial to evaluate the use of melanoma surveillance photography to the Improve early detection of MelanomA in ultra-hiGh and high-risk patiEnts (the IMAGE trial).

INTRODUCTION: Melanoma surveillance photography (MSP) is a comprehensive surveillance method that comprises two- or three-dimensional total body photography with tagged digital dermoscopy, performed at prescribed intervals. It has the potential to reduce unnecessary biopsies and enhance early detection of melanoma, but it is not yet standard care for all high-risk patients in Australia. This protocol describes a randomised controlled trial (RCT) designed to evaluate the clinical impact and cost-effectiveness of using MSP for the surveillance of individuals at ultra-high or high risk of melanoma from a health system perspective. METHODS AND DESIGN: This is a registry-based, unblinded, multi-site, parallel-arm RCT that will be conducted over 3 years. We aim to recruit 580 participants from three Australian states: Victoria, New South Wales and Queensland, via state cancer registries or direct referral from clinicians. Eligible participants within 24 months of a primary cutaneous melanoma diagnosis will be randomised 1:1 to receive either MSP in addition to their routine clinical surveillance (intervention group) or routine clinical surveillance without MSP (control group). Most participants will continue surveillance with their usual care provider, and the frequency of follow-up visits in both groups will depend on the stage of their primary melanoma and risk factors. The primary outcome measure of the study is the number of unnecessary biopsies (i.e. false positives, being cases where a lesion is biopsied due to suspected melanoma on clinical examination, either with or without MSP, but the resulting histopathology finding is negative for melanoma). Secondary outcomes include the evaluation of health economic outcomes, quality of life and patient acceptability. Two sub-studies will explore the benefit of MSP in high-risk patients prior to a melanoma diagnosis and the diagnostic performance of MSP in the teledermatology setting compared to the en face clinical setting. DISCUSSION: This trial will determine the clinical efficacy, cost-effectiveness and affordability of MSP to facilitate policy decision-making at the national and local levels, across primary and specialist care. TRIAL REGISTRATION: ClinicalTrials.gov NCT04385732 . Registered on May 13, 2020.

Cost-analysis of robot-assisted radical cystectomy in Europe: A cross-country comparison.

BACKGROUND: Robotic-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) is surging worldwide. Aim of the study was to perform a multicentric cost-analysis of RARC by comparing the gross cost of the intervention across hospitals in four different European countries. METHODS: Patients who underwent RARC + ICUD were recruited from eleven European centers in four European countries (Belgium, France, Netherlands, and UK) between 2015 and 2020. Costs were divided into six parts: cost for hospital stay, cost for ICU stay, cost for surgical theater occupation, cost for transfusion, cost for robotic instruments, and cost for stapling instruments. These costs were individually assessed for each patient. RESULTS: A total of 490 patients were included. Median operative time was 300(270-360) minutes and median hospital length-of-stay was 11(8-15) days. The average total cost of RARC was 14.794€ (95%CI 14.300-15.200€). A significant difference was found for the total cost, as well as the various subcosts abovementioned, between the four included countries. Different sets and types of robotic instruments were used by each center, leading to a difference in cost of robotic instrumentation. Nearly 84% of costs of RARC were due to hospital stay (42%), ICU stay (3%) and operative time (39%), while 16% of costs were due to robotic (8%) and stapling (8%) instruments. CONCLUSION: Costs and subcosts of RARC + ICUD vary significantly across European countries and are mainly dependent of hospital length-of-stay and operative time rather than robotic instrumentation. Decreasing length-of-stay and reducing operative time could help to decrease the cost of RARC and make it more widely accessible.

Photodynamic versus white-light-guided resection of first-diagnosis non-muscle-invasive bladder cancer: PHOTO RCT.

BACKGROUND: Around 7500 people are diagnosed with non-muscle-invasive bladder cancer in the UK annually. Recurrence following transurethral resection of bladder tumour is common, and the intensive monitoring schedule required after initial treatment has associated costs for patients and the NHS. In photodynamic diagnosis, before transurethral resection of bladder tumour, a photosensitiser that is preferentially absorbed by tumour cells is instilled intravesically. Transurethral resection of bladder tumour is then conducted under blue light, causing the photosensitiser to fluoresce. Photodynamic diagnosis-guided transurethral resection of bladder tumour offers better diagnostic accuracy than standard white-light-guided transurethral resection of bladder tumour, potentially reducing the chance of subsequent recurrence. OBJECTIVE: The objective was to assess the clinical effectiveness and cost-effectiveness of photodynamic diagnosis-guided transurethral resection of bladder tumour. DESIGN: This was a multicentre, pragmatic, open-label, parallel-group, non-masked, superiority randomised controlled trial. Allocation was by remote web-based service, using a 1 : 1 ratio and a minimisation algorithm balanced by centre and sex. SETTING: The setting was 22 NHS hospitals. PARTICIPANTS: Patients aged ≥ 16 years with a suspected first diagnosis of high-risk non-muscle-invasive bladder cancer, no contraindications to photodynamic diagnosis and written informed consent were eligible. INTERVENTIONS: Photodynamic diagnosis-guided transurethral resection of bladder tumour and standard white-light cystoscopy transurethral resection of bladder tumour. MAIN OUTCOME MEASURES: The primary clinical outcome measure was the time to recurrence from the date of randomisation to the date of pathologically proven first recurrence (or intercurrent bladder cancer death). The primary health economic outcome was the incremental cost per quality-adjusted life-year gained at 3 years. RESULTS: We enrolled 538 participants from 22 UK hospitals between 11 November 2014 and 6 February 2018. Of these, 269 were allocated to photodynamic diagnosis and 269 were allocated to white light. A total of 112 participants were excluded from the analysis because of ineligibility (n = 5), lack of non-muscle-invasive bladder cancer diagnosis following transurethral resection of bladder tumour (n = 89) or early cystectomy (n = 18). In total, 209 photodynamic diagnosis and 217 white-light participants were included in the clinical end-point analysis population. All randomised participants were included in the cost-effectiveness analysis. Over a median follow-up period of 21 months for the photodynamic diagnosis group and 22 months for the white-light group, there were 86 recurrences (3-year recurrence-free survival rate 57.8%, 95% confidence interval 50.7% to 64.2%) in the photodynamic diagnosis group and 84 recurrences (3-year recurrence-free survival rate 61.6%, 95% confidence interval 54.7% to 67.8%) in the white-light group (hazard ratio 0.94, 95% confidence interval 0.69 to 1.28; p = 0.70). Adverse event frequency was low and similar in both groups [12 (5.7%) in the photodynamic diagnosis group vs. 12 (5.5%) in the white-light group]. At 3 years, the total cost was £12,881 for photodynamic diagnosis-guided transurethral resection of bladder tumour and £12,005 for white light. There was no evidence of differences in the use of health services or total cost at 3 years. At 3 years, the quality-adjusted life-years gain was 2.094 in the photodynamic diagnosis transurethral resection of bladder tumour group and 2.087 in the white light group. The probability that photodynamic diagnosis-guided transurethral resection of bladder tumour was cost-effective was never > 30% over the range of society's cost-effectiveness thresholds. LIMITATIONS: Fewer patients than anticipated were correctly diagnosed with intermediate- to high-risk non-muscle-invasive bladder cancer before transurethral resection of bladder tumour and the ratio of intermediate- to high-risk non-muscle-invasive bladder cancer was higher than expected, reducing the number of observed recurrences and the statistical power. CONCLUSIONS: Photodynamic diagnosis-guided transurethral resection of bladder tumour did not reduce recurrences, nor was it likely to be cost-effective compared with white light at 3 years. Photodynamic diagnosis-guided transurethral resection of bladder tumour is not supported in the management of primary intermediate- to high-risk non-muscle-invasive bladder cancer. FUTURE WORK: Further work should include the modelling of appropriate surveillance schedules and exploring predictive and prognostic biomarkers. TRIAL REGISTRATION: This trial is registered as ISRCTN84013636. FUNDING: This project was funded by the National Institute for Health and Care Research ( NIHR ) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 40. See the NIHR Journals Library website for further project information.

Around 7500 people are diagnosed with early-stage bladder cancer in the UK each year. Early bladder cancer is contained within the bladder and has not yet invaded the bladder's muscle wall or spread elsewhere in the body. The cancer will return (recur) in around half of people after initial treatment and they have to attend hospital for regular check-ups, with costs to both them and the NHS. The first step in treating early bladder cancer is surgery to remove the tumour. This surgery is normally performed under white light. Photodynamic diagnosis is a new technique in which a liquid is put into the patient's bladder before surgery and a blue light is used during the operation. This causes the bladder cancer to fluoresce so that it can be seen more easily by the surgeon. The Photodynamic versus white-light-guided resection of first diagnosis non-muscle-invasive bladder cancer ( PHOTO ) trial aimed to find out whether or not using photodynamic diagnosis at initial surgery would reduce how often the cancer recurred and whether or not this could reduce the cost of treating early bladder cancer. A total of 538 people with early bladder cancer who had a medium to high chance of their cancer returning after treatment were enrolled in the PHOTO trial. They were included in one of two treatment groups, at random: 269 had photodynamic surgery and 269 had standard white-light surgery. People in both groups were monitored regularly for any recurrences, with further treatment as appropriate. After 3 years, 4 out of 10 people in each group had a recurrence of their bladder cancer. We found no difference between the treatment groups in the number of people with recurrences. We found no evidence of a benefit to patients, and the total costs of photodynamic surgery were higher than those of standard white light. We therefore recommend that it is no longer used in the treatment of this group of patients.

Metabolic costs associated with seawater acclimation in a euryhaline teleost, the fourspine stickleback (Apeltes quadracus).

The cost of osmoregulation in teleosts has been debated for decades, with estimates ranging from one to 30 % of routine metabolic rate. The variation in the energy budget appears to be greater for euryhaline fish due to their ability to withstand dynamic salinity levels. In this study, a time course of metabolic and physiological responses of the euryhaline fourspine stickleback (Apeltes quadracus) acclimated to freshwater (FW) and then exposed to seawater (SW) was examined. There was 18% mortality in the first 3 days following exposure to SW, with no mortalities in the FW control group. Gill Na+/K+-ATPase (NKA) activity, an index of osmoregulatory capacity, increased 2.6-fold in SW fish peaking on days 7 and 14. Gill citrate synthase activity, an index of aerobic capacity, was 50-62% greater in SW than FW fish and peaked on day 7. Tissue water content was significantly lower in the SW fish on day 1 only, returning to FW levels by day 3. Routine metabolic rate was decreased within 24 h of SW exposure and was maintained slightly (8-22%) but significantly lower in SW compared to FW water controls throughout the 2-week experiment. These results indicate that elevated salinity resulted in increased SW osmoregulatory and aerobic capacity in the gill, but with a reduced whole animal metabolic rate to this euryhaline species.

Populational Perceptions Regarding Decision to Visit the Emergency Room with Chest Pain During COVID-19.

INTRODUCTION: A significant decrease in emergency presentations of acute cardiac conditions has been observed during the COVID-19 pandemic. We aimed to understand perceptions that influence people's decisions whether to present to the emergency department (ED) with symptoms related to acute cardiovascular events to inform necessary medical communication. METHODS: We recruited users of Amazon Mechanical Turk (Seattle, WA) to participate in a survey to elucidate perceptions of COVID-19 risk associated with a visit to the ED. A conjoint analysis was designed based on commonly reported factors associated with people's decisions to present to the ED during the pandemic to calculate preference utilities. RESULTS: After exclusions, 1003 participants completed the survey between 12/5/2020 and 12/6/2020. Participants ranked the perceived risk of contracting COVID-19 at the ED as one of the highest, only second to that at bars and restaurants. Only 68% (685/1003) were willing to present to the ED immediately with severe chest pain. Fear of further transmitting the virus to loved ones was the most frequently cited reason for not presenting. Conjoint analysis demonstrated severe chest pain to be the dominant factor in the decision to present to the ED. CONCLUSIONS: The risk of contracting COVID-19 while presenting to the ED for a life-threatening cardiovascular symptom is overestimated and is strongly affected by social factors.

Coronary Endarterectomy: Analysis of The Society of Thoracic Surgeons Adult Cardiac Surgery Database.

BACKGROUND: Coronary endarterectomy (CE) is an uncommon and often unplanned technique used to approach difficult targets during coronary artery bypass grafting (CABG). We evaluated the outcomes of CABG with CE (CE-CABG) using The Society of Thoracic Surgeons Adult Cardiac Surgery Database. METHODS: All isolated, first-time, elective or urgent CABG cases from July 2011 to September 2019 in the Adult Cardiac Surgery Database were retrospectively reviewed. Because of a higher risk profile in the patients undergoing CE-CABG, we performed propensity score matching. Primary outcomes included operative mortality and postoperative myocardial infarction. For patients ≥65 years, long-term mortality and rehospitalization were evaluated using linked data from Centers for Medicare and Medicaid Services. RESULTS: Of the total 1 111 792 patients included, 32 164 (2.9%) had CE-CABG and 1 079 628 (97.1%) underwent CABG alone. The majority of CE-CABG involved a single-vessel endarterectomy (86.9%; n = 27 945); the left anterior descending was most common (40.9%; n = 13 161). Compared with propensity score-matched CABG, CE-CABG had increased operative mortality (3.2% vs 1.7%; P < .0001; odds ratio, 1.81; 95% CI, 1.63-2.01) and postoperative myocardial infarction (6.8% vs 3.9%; P < .0001; odds ratio, 1.80; 95% CI, 1.68-1.93). CE-CABG had higher risk of mortality in the first year and rehospitalization for myocardial infarction in the first 3 years but was comparable to CABG alone thereafter. Subgroup analysis showed no difference between CE-CABG of the left anterior descending compared with CE-CABG of other coronary arteries. CONCLUSIONS: This analysis demonstrates that CE-CABG has acceptable long-term outcomes and serves as a benchmark for what can be expected when this rare procedure is used.

Recovery among sexual minorities in the united states population: Prevalence, characteristics, quality of life and functioning compared with heterosexual majority.

BACKGROUND: Lesbian, gay, and bisexual individuals ("sexual minorities" [SMs]) are overrepresented among individuals suffering from alcohol and other drug (AOD) problems. However, little is known regarding differences, particularly in functioning and well-being, between SMs and heterosexuals in recovery from AOD problems. METHOD: Cross-sectional, nationally representative sample of US adults who resolved an AOD problem (N = 2002; National Recovery Study [Kelly et al., 2017]). Univariate analyses tested for differences between SMs and heterosexuals on socio-demographic, AOD use/treatment and clinical/legal factors. Unadjusted regressions tested for group differences on indices of current functioning and well-being. Multivariable regressions investigated factors that differentiated groups to understand which might explain any observed group disparities in functioning and well-being. LOWESS analyses explored differences across time in recovery on functioning/well-being. RESULTS: Prevalence of SMs in the US recovery population was 11.7% (n = 220). Compared with heterosexuals (88.3%, n = 1666), SMs had shorter time in recovery (OR=0.97; 95% CI: 0.96, 0.99); were less likely to be employed (OR=0.64; 95% CI: 0.43, 0.96); and more likely to have a co-occurring psychiatric disorder (OR=2.24; 95% CI: 1.49, 3.37), an arrest history (OR=1.61; 95% CI: 1.08, 2.39), and report opioids as primary substance (OR=2.50; 95% CI: 1.18, 5.28). Unadjusted models showed, compared to heterosexuals, SMs had significantly worse levels on all functioning and well-being outcomes. Adjusted models explained most differences, except for psychological distress. CONCLUSION: SMs evince more problematic clinical/legal histories and face greater psychosocial challenges in recovery. Research is needed to understand the unique experiences of recovering SMs in order to better address observed functioning and well-being disparities.

Volume of frail patients predicts outcome in frail patients after cardiac surgery.

OBJECTIVE: Recent data from major noncardiac surgery suggest that outcomes in frail patients are better predicted by a hospital's volume of frail patients specifically, rather than overall surgical volume. We sought to evaluate this "frailty volume-frailty outcome relationship" in patients undergoing cardiac surgery. METHODS: We studied 72,818 frail patients undergoing coronary artery bypass grafting or valve replacement surgery from 2010 to 2014 using the Nationwide Readmissions Database. Frailty was defined using the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnoses indicator. Multilevel logistic regression was used to assess the independent effect of frailty volume by quartile on mortality, surgical complications, failure to rescue, nonhome discharge, 30-day readmissions, length of stay, and hospital costs in frail patients. RESULTS: In comparing the highest volume quartiles with the lowest, both overall cardiac surgical volume and volume for frail patients were significantly associated with shorter length of stay and reduced costs. However, frailty volume was also independently associated with significantly reduced in-hospital mortality (odds ratio, 0.79; 95% confidence interval, 0.67-0.94; P = .006) and failure to rescue (odds ratio, 0.83; 95% confidence interval, 0.70-0.98; P = .03), whereas no such association was seen between overall volume and either mortality (odds ratio, 0.94; 95% confidence interval, 0.74-1.10; P = .43) or failure to rescue (odds ratio, 0.98; 95% confidence interval, 0.83-1.17; P = .85). Neither frailty volume nor overall volume showed any significant relationship with the rate of 30-day readmissions. CONCLUSIONS: In frail patients undergoing cardiac surgery, surgical volume of frail patients was a significant independent of predictor of in-hospital mortality and failure to rescue, whereas overall surgical volume was not. Thus, the "frailty volume-outcome relationship" superseded the traditional "volume-outcome relationship" in frail patients with cardiac disease.

Digital Health Coaching for Type 2 Diabetes: Randomized Controlled Trial of Healthy at Home.

Digital health coaching is an intervention for type 2 diabetes mellitus (T2DM) that has potential to improve the quality of care for patients. Previous research has established the efficacy of digital interventions for behavior change. This pilot study addresses a research gap in finding effective and accessible behavioral interventions for under-resourced individuals with T2DM. We examined the impact of Healthy at Home, a 12-week phone and SMS-based (short message service) digital health coaching program, on insulin resistance which is an upstream marker for T2DM progression. We compared this intervention to usual diabetic care in a family medicine residency clinic in a randomized controlled trial. Digital health coaching significantly improved participants' calculated Homeostatic Model Assessment for Insulin Resistance (HOMA2-IR) by -0.9 ± 0.4 compared with the control group (p = 0.029). This significance remained after controlling for years diagnosed with T2DM, enrollment in Medicaid, access to food, baseline stage of change, and race (p = 0.027). Increasing access to digital health coaching may lead to more effective control of diabetes for under-resourced patients. This study demonstrates the potential to implement a personalized, scalable, and effective digital health intervention to treat and manage T2DM through a lifestyle and behavioral approach to improve clinical outcomes (http://clinicaltrials.gov, NCT04872647).

Feasibility of a Mobile Health App for Routine Outcome Monitoring and Feedback in SMART Recovery Mutual Support Groups: Stage 1 Mixed Methods Pilot Study.

BACKGROUND: Mutual support groups are an important source of long-term help for people impacted by addictive behaviors. Routine outcome monitoring (ROM) and feedback are yet to be implemented in these settings. SMART Recovery mutual support groups focus on self-empowerment and use evidence-based techniques (eg, motivational and behavioral strategies). Trained facilitators lead all SMART Recovery groups, providing an opportunity to implement ROM. OBJECTIVE: The aim of this stage 1 pilot study is to explore the feasibility, acceptability, and preliminary outcomes of a novel, purpose-built mobile health ROM and feedback app (SMART Track) in mutual support groups coordinated by SMART Recovery Australia (SRAU) over 8 weeks. METHODS: SMART Track was developed during phase 1 of this study using participatory design methods and an iterative development process. During phase 2, 72 SRAU group participants were recruited to a nonrandomized, prospective, single-arm trial of the SMART Track app. Four modes of data collection were used: ROM data directly entered by participants into the app; app data analytics captured by Amplitude Analytics (number of visits, number of unique users, visit duration, time of visit, and user retention); baseline, 2-, and 8-week follow-up assessments conducted through telephone; and qualitative telephone interviews with a convenience sample of study participants (20/72, 28%) and facilitators (n=8). RESULTS: Of the 72 study participants, 68 (94%) created a SMART Track account, 64 (88%) used SMART Track at least once, and 42 (58%) used the app for more than 5 weeks. During week 1, 83% (60/72) of participants entered ROM data for one or more outcomes, decreasing to 31% (22/72) by the end of 8 weeks. The two main screens designed to provide personal feedback data (Urges screen and Overall Progress screen) were the most frequently visited sections of the app. Qualitative feedback from participants and facilitators supported the acceptability of SMART Track and the need for improved integration into the SRAU groups. Participants reported significant reductions between the baseline and 8- week scores on the Severity of Dependence Scale (mean difference 1.93, SD 3.02; 95% CI 1.12-2.73) and the Kessler Psychological Distress Scale-10 (mean difference 3.96, SD 8.31; 95% CI 1.75-6.17), but no change on the Substance Use Recovery Evaluator (mean difference 0.11, SD 7.97; 95% CI -2.02 to 2.24) was reported. CONCLUSIONS: Findings support the feasibility, acceptability, and utility of SMART Track. Given that sustained engagement with mobile health apps is notoriously difficult to achieve, our findings are promising. SMART Track offers a potential solution for ROM and personal feedback, particularly for people with substance use disorders who attend mutual support groups. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12619000686101; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=377336. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/15113.

Reasons to be cheerful: Personal, civic, and economic achievements after resolving an alcohol or drug problem in the United States population.

OBJECTIVE: Alcohol and other drug (AOD) use disorders impose a prodigious personal and societal burden. While most remit, little is known about the achievements accrued as people accomplish and sustain addiction recovery. Greater knowledge regarding the nature and prevalence of such achievements, when such achievements occur, what factors influence accrual of achievements, and how such achievements relate to other indices of functioning would support treatment and policy planning, and may instill hope for individuals and families seeking AOD problem resolution. METHODS: Nationally representative, cross-sectional survey of United States (US) population of persons who have overcome an AOD problem (N = 2,002), assessing individual factors and achievements in 4 domains: self-improvement; family engagement; civic, and economic participation. Logistic and linear regression models tested theorized associations among variables. RESULTS: Most (80.1%) achieved at least one achievement associated with the 4 domains. A linear monotonic relationship was observed with greater achievements accruing with greater time in recovery. Accrual of achievements after AOD problem resolution was related to racial minority status, more education, earlier age of substance use initiation, illicit drugs as primary substance used, more years since resolving AOD problem, more psychiatric diagnoses, lower psychological distress, and regular 12-step program attendance. Multiple regression analyses found greater total achievements were independently associated with greater self-esteem, happiness, quality of life, and recovery capital. CONCLUSIONS: Most individuals achieve an increasing number of achievements with time since AOD problem resolution, and these are associated with gains in measures of well-being that may support ongoing AOD problem remission, and recovery. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Assessment of Patients' Ability to Review Electronic Health Record Information to Identify Potential Errors: Cross-sectional Web-Based Survey.

BACKGROUND: Sharing personal health information positively impacts quality of care across several domains, and particularly, safety and patient-centeredness. Patients may identify and flag up inconsistencies in their electronic health records (EHRs), leading to improved information quality and patient safety. However, in order to identify potential errors, patients need to be able to understand the information contained in their EHRs. OBJECTIVE: The aim of this study was to assess patients' perceptions of their ability to understand the information contained in their EHRs and to analyze the main barriers to their understanding. Additionally, the main types of patient-reported errors were characterized. METHODS: A cross-sectional web-based survey was undertaken between March 2017 and September 2017. A total of 682 registered users of the Care Information Exchange, a patient portal, with at least one access during the time of the study were invited to complete the survey containing both structured (multiple choice) and unstructured (free text) questions. The survey contained questions on patients' perceived ability to understand their EHR information and therefore, to identify errors. Free-text questions allowed respondents to expand on the reasoning for their structured responses and provide more detail about their perceptions of EHRs and identifying errors within them. Qualitative data were systematically reviewed by 2 independent researchers using the framework analysis method in order to identify emerging themes. RESULTS: A total of 210 responses were obtained. The majority of the responses (123/210, 58.6%) reported understanding of the information. The main barriers identified were information-related (medical terminology and knowledge and interpretation of test results) and technology-related (user-friendliness of the portal, information display). Inconsistencies relating to incomplete and incorrect information were reported in 12.4% (26/210) of the responses. CONCLUSIONS: While the majority of the responses affirmed the understanding of the information contained within the EHRs, both technology and information-based barriers persist. There is a potential to improve the system design to better support opportunities for patients to identify errors. This is with the aim of improving the accuracy, quality, and timeliness of the information held in the EHRs and a mechanism to further engage patients in their health care.

Management of patients who opt for radical prostatectomy during the coronavirus disease 2019 (COVID-19) pandemic: an international accelerated consensus statement.

OBJECTIVE: Coronavirus disease-19 (COVID-19) pandemic caused delays in definitive treatment of patients with prostate cancer. Beyond the immediate delay a backlog for future patients is expected. The objective of this work is to develop guidance on criteria for prioritisation of surgery and reconfiguring management pathways for patients with non-metastatic prostate cancer who opt for surgical treatment. A second aim was to identify the infection prevention and control (IPC) measures to achieve a low likelihood of coronavirus disease 2019 (COVID-19) hazard if radical prostatectomy (RP) was to be carried out during the outbreak and whilst the disease is endemic. METHODS: We conducted an accelerated consensus process and systematic review of the evidence on COVID-19 and reviewed international guidance on prostate cancer. These were presented to an international prostate cancer expert panel (n = 34) through an online meeting. The consensus process underwent three rounds of survey in total. Additions to the second- and third-round surveys were formulated based on the answers and comments from the previous rounds. The Consensus opinion was defined as ≥80% agreement and this was used to reconfigure the prostate cancer pathways. RESULTS: Evidence on the delayed management of patients with prostate cancer is scarce. There was 100% agreement that prostate cancer pathways should be reconfigured and measures developed to prevent nosocomial COVID-19 for patients treated surgically. Consensus was reached on prioritisation criteria of patients for surgery and management pathways for those who have delayed treatment. IPC measures to achieve a low likelihood of nosocomial COVID-19 were coined as 'COVID-19 cold' sites. CONCLUSION: Reconfiguring management pathways for patients with prostate cancer is recommended if significant delay (>3-6 months) in surgical management is unavoidable. The mapped pathways provide guidance for such patients. The IPC processes proposed provide a framework for providing RP within an environment with low COVID-19 risk during the outbreak or when the disease remains endemic. The broader concepts could be adapted to other indications beyond prostate cancer surgery.

Feasibility of a Mobile Health App for Routine Outcome Monitoring and Feedback in Mutual Support Groups Coordinated by SMART Recovery Australia: Protocol for a Pilot Study.

BACKGROUND: Despite the importance and popularity of mutual support groups, there have been no systematic attempts to implement and evaluate routine outcome monitoring (ROM) in these settings. Unlike other mutual support groups for addiction, trained facilitators lead all Self-Management and Recovery Training (SMART Recovery) groups, thereby providing an opportunity to implement ROM as a routine component of SMART Recovery groups. OBJECTIVE: This study protocol aims to describe a stage 1 pilot study designed to explore the feasibility and acceptability of a novel, purpose-built mobile health (mHealth) ROM and feedback app (Smart Track) in SMART Recovery groups coordinated by SMART Recovery Australia (SRAU) The secondary objectives are to describe Smart Track usage patterns, explore psychometric properties of the ROM items (ie, internal reliability and convergent and divergent validity), and provide preliminary evidence for participant reported outcomes (such as alcohol and other drug use, self-reported recovery, and mental health). METHODS: Participants (n=100) from the SMART Recovery groups across New South Wales, Australia, will be recruited to a nonrandomized, prospective, single-arm trial of the Smart Track app. There are 4 modes of data collection: (1) ROM data collected from group participants via the Smart Track app, (2) data analytics summarizing user interactions with Smart Track, (3) quantitative interview and survey data of group participants (baseline, 2-week follow-up, and 2-month follow-up), and (4) qualitative interviews with group participants (n=20) and facilitators (n=10). Feasibility and acceptability (primary objectives) will be analyzed using descriptive statistics, a cost analysis, and a qualitative evaluation. RESULTS: At the time of submission, 13 sites (25 groups per week) had agreed to be involved. Funding was awarded on August 14, 2017, and ethics approval was granted on April 26, 2018 (HREC/18/WGONG/34; 2018/099). Enrollment is due to commence in July 2019. Data collection is due to be finalized in October 2019. CONCLUSIONS: To the best of our knowledge, this study is the first to use ROM and tailored feedback within a mutual support group setting for addictive behaviors. Our study design will provide an opportunity to identify the acceptability of a novel mHealth ROM and feedback app within this setting and provide detailed information on what factors promote or hinder ROM usage within this context. This project aims to offer a new tool, should Smart Track prove feasible and acceptable, that service providers, policy makers, and researchers could use in the future to understand the impact of SMART Recovery groups. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12619000686101; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=377336. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/15113.