A Neurosurgical Readmissions Reduction Program in an Academic Hospital Leveraging Machine Learning, Workflow Analysis, and Simulation.

BACKGROUND: Predicting 30-day hospital readmissions is crucial for improving patient outcomes, optimizing resource allocation, and achieving financial savings. Existing studies reporting the development of machine learning (ML) models predictive of neurosurgical readmissions do not report factors related to clinical implementation. OBJECTIVES: Train individual predictive models with good performance (area under the receiver operating characteristic curve or AUROC > 0.8), identify potential interventions through semi-structured interviews, and demonstrate estimated clinical and financial impact of these models. METHODS: Electronic health records were utilized with five ML methodologies: gradient boosting, decision tree, random forest, ridge logistic regression, and linear support vector machine. Variables of interest were determined by domain experts and literature. The dataset was split divided 80% for training and validation and 20% for testing randomly. Clinical workflow analysis was conducted using semi-structured interviews to identify possible intervention points. Calibrated agent-based models (ABMs), based on a previous study with interventions, were applied to simulate reductions of the 30-day readmission rate and financial costs. RESULTS: The dataset covered 12,334 neurosurgical intensive care unit (NSICU) admissions (11,029 patients); 1,903 spine surgery admissions (1,641 patients), and 2,208 traumatic brain injury (TBI) admissions (2,185 patients), with readmission rate of 13.13, 13.93, and 23.73%, respectively. The random forest model for NSICU achieved best performance with an AUROC score of 0.89, capturing potential patients effectively. Six interventions were identified through 12 semi-structured interviews targeting preoperative, inpatient stay, discharge phases, and follow-up phases. Calibrated ABMs simulated median readmission reduction rates and resulted in 13.13 to 10.12% (NSICU), 13.90 to 10.98% (spine surgery), and 23.64 to 21.20% (TBI). Approximately $1,300,614.28 in saving resulted from potential interventions. CONCLUSION: This study reports the successful development and simulation of an ML-based approach for predicting and reducing 30-day hospital readmissions in neurosurgery. The intervention shows feasibility in improving patient outcomes and reducing financial losses.

Consistency of Faraday cup and ionization chamber dosimetry of proton fields and the role of nuclear interactions.

BACKGROUND: A Faraday cup (FC) facilitates a quite clean measurement of the proton fluence emerging from clinical spot-scanning nozzles with narrow pencil-beams. The utilization of FCs appears to be an attractive option for high dose rate delivery modes and the source models of Monte-Carlo (MC) dose engines. However, previous studies revealed discrepancies of 3%-6% between reference dosimetry with ionization chambers (ICs) and FC-based dosimetry. This has prevented the widespread use of FCs for dosimetry in proton therapy. PURPOSE: The current study aims at bridging the gap between FC dosimetry and IC dosimetry of proton fields delivered with spot-scanning treatment heads. Particularly, a novel method to evaluate FC measurements is introduced. METHODS: A consistency check is formulated, which makes use of the energy balance and the reciprocity theorem. The measurement data comprise central-axis depth distributions of the absorbed dose of quasi-monochromatic fields with a width of about 28.5 cm and FC measurements of the reciprocal fields with a single spot. These data are complemented by a look-up of energy-range tables, the average Q-value of transmutations, and the escape energy carried away by neutrons and photons. The latter data are computed by MC simulations, which in turn are validated with measurements of the distal dose tail and neutron out-of-field doses. For comparison, the conventional approach of FC evaluation is performed, which computes absorbed dose from the product of fluence and stopping power. The results from the FC measurements are compared with the standard dosimetry protocols and improved reference dosimetry methods. RESULTS: The deviation between the conventional FC-based dosimetry and the IC-based one according to standard dosimetry protocols was -4.7 ( ± $\pm$ 3.3)% for a 100 MeV field and -3.6 ( ± $\pm$ 3.5)% for 200 MeV, thereby agreeing within the reported uncertainties. The deviations could be reduced to -4.0 ( ± $\pm$ 2.9)% and -3.0 ( ± $\pm$ 3.1)% by adopting state-of-the-art reference dosimetry methods. The alternative approach using the energy balance gave deviations of only -1.9% (100 MeV) and -2.6% (200 MeV) using state-of-the-art dosimetry. The standard uncertainty of this novel approach was estimated to be about 2%. CONCLUSIONS: An alternative concept has been established to determine the absorbed dose of monoenergetic proton fields with an FC. It eliminates the strong dependence of the conventional FC-based approach on the MC simulation of the stopping-power and of the secondary ions, which according to the study at hand is the major contributor to the underestimation of the absorbed dose. Some contributions to the uncertainty of the novel approach could potentially be reduced in future studies. This would allow for accurate consistency tests of conventional dosimetry procedures.

Engaging patients and parents to improve mental health intervention for youth with rheumatological disease.

BACKGROUND: Mental health disorders are common in youth with rheumatological disease yet optimal intervention strategies are understudied in this population. We examined patient and parent perspectives on mental health intervention for youth with rheumatological disease. METHODS: We conducted a mixed methods cross-sectional study, via anonymous online survey, developed by researchers together with patient/parent partners, to quantitatively and qualitatively examine youth experiences with mental health services and resources in North America. Patients ages 14-24 years with juvenile idiopathic arthritis, juvenile dermatomyositis, or systemic lupus erythematous, and parents of patients ages 8-24 with these diseases were eligible (not required to participate in pairs). Participants self-reported mental health problems (categorized into clinician-diagnosed disorders vs self-diagnosed symptoms) and treatments (e.g. therapy, medications) received for the youth. Multivariate linear regression models compared patient and parent mean Likert ratings for level of: i) comfort with mental health providers, and ii) barriers to seeking mental health services, adjusting for potential confounders (patient age, gender, disease duration, and patient/parent visual analog score for disease-related health). Participants indicated usefulness of mental health resources; text responses describing these experiences were analyzed by qualitative description. RESULTS: Participants included 123 patients and 324 parents. Patients reported clinician-diagnosed anxiety (39%) and depression (35%); another 27 and 18% endorsed self-diagnosed symptoms of these disorders, respectively. 80% of patients with clinician-diagnosed disorders reported receiving treatment, while 11% of those with self-diagnosed symptoms reported any treatment. Patients were less comfortable than parents with all mental health providers. The top two barriers to treatment for patients and parents were concerns about mental health providers not understanding the rheumatological disease, and inadequate insurance coverage. Over 60% had used patient mental health resources, and over 60% of these participants found them to be helpful, although text responses identified a desire for resources tailored to patients with rheumatological disease. CONCLUSION: Self-reported mental health problems are prevalent for youth in this sample with rheumatological disease, and obstacles to mental health treatment include disease-related and logistic factors. Strategies are needed to improve acceptance and accessibility of mental health intervention, including routine mental health screening and availability of disease-specific mental health resources.

Author Correction: Evidence for a serpentinized plate interface favouring continental subduction.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Evidence for a serpentinized plate interface favouring continental subduction.

The dynamics of continental subduction is largely controlled by the rheological properties of rocks involved along the subduction channel. Serpentinites have low viscosity at geological strain rates. However, compelling geophysical evidence of a serpentinite channel during continental subduction is still lacking. Here we show that anomalously low shear-wave seismic velocities are found beneath the Western Alps, along the plate interface between the European slab and the overlying Adriatic mantle. We propose that these seismic velocities indicate the stacked remnants of a weak fossilised serpentinite channel, which includes both slivers of abyssal serpentinite formed at the ocean floor and mantle-wedge serpentinite formed by fluid release from the subducting slab. Our results suggest that this serpentinized plate interface may have favoured the subduction of continental crust into the upper mantle and the formation/exhumation of ultra-high pressure metamorphic rocks, providing new constraints to develop the conceptual and quantitative understanding of continental-subduction dynamics.

Identifying Research Priorities among Patients and Families of Children with Rheumatic Diseases Living in the United States.

OBJECTIVE: To improve the quality and participation in pediatric rheumatology research, patient-prioritized studies should be emphasized. We collaborated with United States-based pediatric rheumatology advocacy organizations to survey patients and caregivers of children with rheumatic diseases to identify what research topics were most important to them. METHODS: We conducted Web-based surveys and focus groups (FG) of patients and caregivers of children with juvenile myositis (JM), juvenile arthritis (JA), and childhood-onset systemic lupus erythematosus (cSLE). Surveys were emailed to listservs and posted to social media sites of JM, JA, and cSLE patient advocacy organizations. An initial survey asked open-ended questions about patient/caregiver research preferences. Responses were further characterized through FG. A final ranking survey asked respondents to rank from a list of research themes the 7 most important to them. RESULTS: There were 365 JM respondents, 44 JA respondents, and 32 cSLE respondents to the final ranking survey. The top research priority for JM was finding new treatments, and for JA and cSLE, the priority was understanding genetic/environmental etiology. The 3 prioritized research themes common across all disease groups were medication side effects, disease flare, and disease etiology. CONCLUSION: Patient-centered research prioritization is recognized as valuable in conducting high-quality research, yet there is a paucity of data describing patient/family preferences, especially in pediatrics. We used multimodal methodologies to assess current patient/caregiver research priorities to help frame the agenda for the pediatric rheumatology research community. Patients and caregivers from all surveyed disease groups prioritized the study of medication side effects, disease flares, and disease etiology.

The AlpArray Seismic Network: A Large-Scale European Experiment to Image the Alpine Orogen.

The AlpArray programme is a multinational, European consortium to advance our understanding of orogenesis and its relationship to mantle dynamics, plate reorganizations, surface processes and seismic hazard in the Alps-Apennines-Carpathians-Dinarides orogenic system. The AlpArray Seismic Network has been deployed with contributions from 36 institutions from 11 countries to map physical properties of the lithosphere and asthenosphere in 3D and thus to obtain new, high-resolution geophysical images of structures from the surface down to the base of the mantle transition zone. With over 600 broadband stations operated for 2 years, this seismic experiment is one of the largest simultaneously operated seismological networks in the academic domain, employing hexagonal coverage with station spacing at less than 52 km. This dense and regularly spaced experiment is made possible by the coordinated coeval deployment of temporary stations from numerous national pools, including ocean-bottom seismometers, which were funded by different national agencies. They combine with permanent networks, which also required the cooperation of many different operators. Together these stations ultimately fill coverage gaps. Following a short overview of previous large-scale seismological experiments in the Alpine region, we here present the goals, construction, deployment, characteristics and data management of the AlpArray Seismic Network, which will provide data that is expected to be unprecedented in quality to image the complex Alpine mountains at depth.

Nanostructured polymer brushes.

Nanopatterned polymer brushes with sub-50-nm resolution were prepared by a combination of electron-beam chemical lithography (EBCL) of self-assembled monolayers (SAMs) and surface-initiated photopolymerization (SIPP). As a further development of our previous work, selective EBCL was performed with a highly focused electron beam and not via a mask, to region-selectively convert a SAM of 4'-nitro-1,1'-biphenyl-4-thiol to defined areas of crosslinked 4'-amino-1,1'-biphenyl-4-thiol. These "written" structures were then used to prepare surface-bonded, asymmetric, azo initiator sites of 4'-azomethylmalonodinitrile-1,1'-biphenyl-4-thiol. In the presence of bulk styrene, SIPP amplified the primary structures of line widths from 500 to 10 nm to polystyrene structures of line widths 530 nm down to approximately 45 nm at a brush height of 10 or 7 nm, respectively, as measured by scanning electron microscopy and atomic force microscopy (AFM). The relative position of individual structures was within a tolerance of a few nanometers, as verified by AFM. At line-to-line spacings down to 50-70 nm, individual polymer brush structures are still observable. Below this threshold, neighboring structures merge due to chain overlap.

Long-range correlations in the diffuse seismic coda.

The late seismic coda may contain coherent information about the elastic response of Earth. We computed the correlations of the seismic codas of 101 distant earthquakes recorded at stations that were tens of kilometers apart. By stacking cross-correlation functions of codas, we found a low-frequency coherent part in the diffuse field. The extracted pulses have the polarization characteristics and group velocities expected for Rayleigh and Love waves. The set of cross-correlations has the symmetries of the surface-wave part of the Green tensor. This seismological example shows that diffuse waves produced by distant sources are sufficient to retrieve direct waves between two perfectly located points of observation. Because it relies on general properties of diffuse waves, this result has potential applications in other fields.