The impact of the California state lockdown during the COVID-19 pandemic on management of patients with pancreatic ductal adenocarcinoma.

BACKGROUND AND OBJECTIVES: The SARS-COVID-19 pandemic significantly limited healthcare access. We sought to evaluate whether California's lockdown in March 2020 affected staging and time to treatment of pancreatic ductal adenocarcinoma (PDAC). We hypothesized that patients diagnosed after the lockdown would have longer time to treatment and higher stage at presentation. METHODS: We retrospectively identified and categorized 1294 patients presenting to five University of California healthcare systems with a new diagnosis of PDAC into "pre-lockdown" and "post-lockdown" groups based on timing of pathologic diagnosis. RESULTS: In the 12 months pre-lockdown, 835 patients were diagnosed with PDAC, and 459 patients in the 6 months post-lockdown. Demographics, staging, and treatment type were similar between eras. There was a decreased male:female ratio post- versus pre-lockdown (0.97 vs. 1.25; p = 0.03). Time from symptom onset to first treatment was significantly increased among females post-lockdown (p = 0.001). However, overall time from diagnosis to first treatment was shorter in the post-lockdown era (median 23 vs. 26 days, p < 0.001). CONCLUSIONS: The COVID-19 lockdown did not significantly delay initial presentation, diagnosis, or treatment of newly diagnosed PDAC patients. Time from diagnosis to first treatment was shorter post-lockdown. Reduced healthcare utilization for minor complaints and increased telehealth utilization may have contributed.

Adolescent Tobacco/Nicotine Use and the Potential Role of Contingency Management-based Interventions.

ABSTRACT: The high prevalence of tobacco/nicotine use among youth, including e-cigarettes, is a public health problem in the United States. Early exposure leads to an increased risk of dependence and health consequences in adulthood. We reviewed the literature on current treatment approaches for nicotine/tobacco use in adolescents/young adults and highlighted underexplored areas of treatment research. There are no current Food and Drug Administration-approved medications for treatment of nicotine/tobacco use disorders in adolescents. However, in research settings and on a case-to-case basis, clinical practice medications (including nicotine replacement therapy, bupropion, and varenicline) have been prescribed to this population with consideration of risk-benefit analysis when behavioral treatments are not sufficient to address dependence. Among the nonpharmacological interventions, there is evidence to support the potential for expanded use of contingency management in youth. Neural differences predisposing adolescents to substance use, along with higher attentiveness to value of options in decision making (flexible reward system) may enhance the effectiveness of reward-based approaches for treatment of substance use disorders in this population. The overall high rates of nonresponders across psychosocial and pharmacological treatments highlight the importance of considering novel strategies to improve existing interventions. We suggest that future research be done that considers unique characteristics of today's adolescents, such as high social activism and engagement with digital rewards to tailor contingency management for this age group and assess its effectiveness. Adolescents could potentially benefit from rewards administered through digital media (eg, video games, computer-based apps, and social media influencers).

A review of ophthalmology education in the era of generative artificial intelligence.

PURPOSE: To explore the integration of generative AI, specifically large language models (LLMs), in ophthalmology education and practice, addressing their applications, benefits, challenges, and future directions. DESIGN: A literature review and analysis of current AI applications and educational programs in ophthalmology. METHODS: Analysis of published studies, reviews, articles, websites, and institutional reports on AI use in ophthalmology. Examination of educational programs incorporating AI, including curriculum frameworks, training methodologies, and evaluations of AI performance on medical examinations and clinical case studies. RESULTS: Generative AI, particularly LLMs, shows potential to improve diagnostic accuracy and patient care in ophthalmology. Applications include aiding in patient, physician, and medical students' education. However, challenges such as AI hallucinations, biases, lack of interpretability, and outdated training data limit clinical deployment. Studies revealed varying levels of accuracy of LLMs on ophthalmology board exam questions, underscoring the need for more reliable AI integration. Several educational programs nationwide provide AI and data science training relevant to clinical medicine and ophthalmology. CONCLUSIONS: Generative AI and LLMs offer promising advancements in ophthalmology education and practice. Addressing challenges through comprehensive curricula that include fundamental AI principles, ethical guidelines, and updated, unbiased training data is crucial. Future directions include developing clinically relevant evaluation metrics, implementing hybrid models with human oversight, leveraging image-rich data, and benchmarking AI performance against ophthalmologists. Robust policies on data privacy, security, and transparency are essential for fostering a safe and ethical environment for AI applications in ophthalmology.

Medical, Environmental, and Social Determinants Associated With Periocular Cutaneous Malignancies in the United States Using the All of Us National Database.

OBJECTIVE: To identify common factors associated with periocular cutaneous malignancies using the National Institutes of Health (NIH) All of Us database. METHODOLOGY: In this case-control study, we extracted electronic health records and sociodemographic data for 385 cases of periocular cutaneous malignancies from the All of Us nationwide database. Controls (N = 1540) were matched to the demographic characteristics of the 2020 United States Census. Bivariate analyses and multivariable logistic regression determined variables significantly associated with increased odds of periocular cutaneous malignancies. We analyzed medical, environmental, and social determinants to evaluate which factors were associated with increased odds of periocular cutaneous malignancies. RESULTS: Among the cases, the mean (standard deviation) age was 66.8 (11.2) years at the time of diagnosis. The majority were male (207, 54%) and white (361, 94%). Periocular cutaneous malignancy was significantly more likely among individuals with high sun exposure (odds ratio [OR] 14.79, 95% confidence interval [CI] 3.35-85.73, P = 0.001), those identifying as white race (OR 3.88, 95% CI 1.06-25.33, P = 0.079), and those with higher socioeconomic status, including higher annual income (OR 1.35, 95% CI 1.25-1.46, P < 0.001). CONCLUSIONS: This study demonstrates similar risk factors for periocular cutaneous malignancies, echoing prior research that showed increased associations with lighter-pigmented skin and higher socioeconomic status. It also sheds light on the positive impact of physician surveillance and health utilization factors in the early detection and treatment of these malignancies, aspects less explored in prior analyses.

Geographic Patterns of Ocular Oncologist Supply and Patient Demand for Uveal Melanoma Treatment in the United States: A Supply and Demand Analysis.

Purpose: To study geographic patterns of supply and demand for uveal melanoma and other ocular oncology healthcare by ocular oncology physicians in the United States. Methods: Google search interest data was obtained through trends.google.com. The combined-state density of ocular oncology physicians was calculated by dividing the number of practicing ocular oncologists in each state and its surrounding states by the state population. Relative search volume (RSV) values were divided by ocular oncology physician density to calculate the Google relative demand index (gRDI) for each state. Medicare (mRDI) and IRIS® Registry (iRDI) relative demand indices were calculated using prevalence data obtained through the Vision and Eye Health Surveillance System (VEHSS). Data from the US Census Bureau and Centers for Disease Control (CDC) databases were also utilized to analyze associations with poverty rates, percent living in urban or rural areas, vision screening rates, and ocular neoplasm rates. Results: Alabama showed the highest RSV (100), while the lowest was reported in New Mexico (20). Vermont had the highest density of combined-state ocular oncology ophthalmologists (1.85 per 100,000 residents). New Mexico had the lowest RDI (0.013 gRDI, 0.015 mRDI, 0.018 iRDI) with 32 combined-state ocular oncologists and a population of 2,114,371. Ocular neoplasm prevalence rates ranged between 1.32% and 5.40% and significantly correlated with RSV. Single-state gRDI correlated with rural status and negatively correlated with urban areas (≥50,000 individuals). Single-state ophthalmologist density correlated positively with percent living in urban areas and vision screening rates, and negatively with rural status. Conclusion: This study uncovered significant heterogeneity in the geographical distribution of ocular oncology physicians and RDI throughout the United States, highlighting potential undersupply scenarios. This may guide efforts to increase ocular oncology physician and surgeon availability in areas of need.

Implementation Mapping of the Collaborative University of California Teleophthalmology Initiative (CUTI): A Qualitative Study Using the Exploration, Preparation, Implementation, and Sustainment (EPIS) Framework.

Background This study aimed to investigate the rationale, barriers, and facilitators of teleretinal camera implementation in primary care and endocrinology clinics for diabetic retinopathy (DR) screening across University of California (UC) health systems utilizing the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework. Methodology Institutional representatives from UC Los Angeles, San Diego, San Francisco, and Davis participated in a series of focus group meetings to elicit implementation facilitators and barriers for teleophthalmology programs within their campuses. Site representatives also completed a survey regarding their program's performance over the calendar year 2022 in the following areas: DR screening camera sites, payment sources and coding, screening workflows including clinical, information technology (IT), reading, results, pathologic findings, and follow-up, including patient outreach for abnormal results. Focus group and survey results were mapped to the EPIS framework to gain insights into the implementation process of these programs and identify areas for optimization. Results Four UC campuses with 20 active camera sites screened 7,450 patients in the calendar year 2022. The average DR screening rate across the four campuses was 55%. Variations between sources of payment, turn-around time, image-grading structure, image-report characteristics, IT infrastructure, and patient outreach strategies were identified between sites. Closing gaps in IT integration between data systems, ensuring the financial sustainability of the program, and optimizing patient outreach remain primary challenges across sites and serve as good opportunities for cross-institutional learning. Conclusions Despite the potential for long-term cost savings and improving access to care, numerous obstacles continue to hinder the widespread implementation of teleretinal DR screening. Implementation science approaches can identify strategies for addressing these challenges and optimizing implementation.

Tailored order set in the electronic health record decreases postoperative opioid prescriptions.

BACKGROUND: Adherence to opioid prescribing protocols after operations remains challenging despite published guidelines. Integration of these guidelines with the electronic health record could potentially improve their adoption. We hypothesize that implementing an electronic health record order set containing prepopulated tablet quantities tailored to surgical procedures based on published guidelines will decrease postoperative opioid prescription. METHODS: We conducted a 12-month prepost intervention study on adult patients who underwent appendectomy, cholecystectomy, inguinal or umbilical hernia repair, thyroidectomy, or parathyroidectomy at a single institution. An electronic health record order set was developed with prepopulated opioid tablet quantities reflecting the upper limit of published recommendations. The primary endpoint was change in morphine milligram equivalent prescribed postintervention and was analyzed using linear regression adjusting for age, race, procedure, and prescriber training level. Secondary endpoints were emergency department visits for pain-related issues and opioid refill rates. RESULTS: We identified 524 patients (mean age = 53, 51% male) in our baseline cohort and 433 patients (mean age = 52, 58% male) in our postintervention group. The mean morphine milligram equivalent prescribed was 62.6 and 50.4 for the preintervention and postintervention cohorts, respectively (P = .049). Thyroidectomies and parathyroidectomies achieved the largest decrease after intervention, which decreased to 42.6 morphine milligram equivalent from 79.7 morphine milligram equivalent preintervention (P < .001). Refill rate was 1.6% postintervention compared to 3.1% preintervention (P = .20), and emergency department visit for pain control rate was 0.2% post intervention and 2.5% preintervention (P = .005). CONCLUSION: An electronic health record tailored order set based on prescription guidelines is a safe, effective, and scalable intervention for decreasing opioid prescriptions after operations.