Mortality index is more accurate than volume in predicting outcome and failure to rescue in Medicare beneficiaries undergoing robotic right upper lobectomy.

Background: Surgical volume is known to influence failure to rescue (FTR), defined as death following a complication. Robotic lung surgery continues to expand and there is variability in outcomes among hospitals. We sought to estimate the contribution of hospital-based factors on outcomes and FTR following robotic right upper lobectomy (RRUL). Methods: Using the Centers for Medicare and Medicaid Services inpatient claims database, we evaluated all patients age ≥65 years with a diagnosis of lung cancer who underwent RRUL between January 2018 and December 2020. We excluded patients who had undergone segmentectomy, sublobar, wedge, or bronchoplastic resection; had metastatic or nonmalignant disease; or had a history of neoadjuvant chemotherapy. Primary outcomes included FTR rate, length of stay (LOS), readmissions, conversion to open surgery, complications, and costs. We analyzed hospitals by tertiles of volume and Medicare Mortality Index (MMI). Defined as the institutional number of deaths per number of survivors, MMI is a marker of overall hospital performance and quality. Propensity score models were adjusted for confounding using goodness of fit. Results: Data for 4317 patients who underwent robotic right upper lobectomy were analyzed. Hospitals were categorized by volume of cases (low, <9; medium, 9-20; high, >20) and MMI (low, <0.04; medium, 0.04-0.13; high, >0.13). After propensity score balancing, patients from tertiles of lowest volume and highest MMI had higher costs ($34,222 vs $30,316; P = .006), as well as higher mortality (odds ratio, 7.46; 95% confidence interval, 2.67-28.2; P < .001). Compared to high-volume centers, low-volume centers had higher rates of conversion to open surgery, respiratory failure, hemorrhagic anemia, and death; longer LOS; and greater cost (P < .001 for all). The C-statistic for volume as a predictor of overall mortality was 0.6, and the FTR was 0.8. Hospitals in the highest tertile of MMI had the highest rates of conversion to open surgery (P = .01), pneumothorax (P = .02), and respiratory failure (P < .001). They also had the highest mortality and rate of readmission, longest LOS, and greatest costs (P < .001 for all) and the shortest survival (P < .001). The C-statistic for MMI as a predictor of overall mortality was 0.8, and FTR was 0.9. Conclusions: The MMI incorporates hospital-based factors in the adjudication of outcomes and is a more sensitive predictor of FTR rates than volume alone. Combining MMI and volume may provide a metric that can guide quality improvement and cost-effectiveness measures in hospitals seeking to implement robotic lung surgery programs.

Intersection of Race, Rurality, and Income in Defining Access to Minimally Invasive Lung Surgery.

BACKGROUND: Race is a potent influencer of healthcare access. Geography and income may exert equal or greater influence on patient outcomes. We sought to define the intersection of race, rurality, and income and their influence on access to minimally invasive lung surgery in Medicare beneficiaries. METHODS: Medicare and Medicaid Services data were used to evaluate patients with lung cancer who underwent right upper lobectomy, via open, robotic-assisted (RATS), or video-assisted thoracic surgery (VATS) between 2018 and 2020. International Classification of Diseases 10th edition was used to define diagnoses and procedures. We excluded sub-lobar, segmental, wedge, bronchoplastic, or reoperative patients with non-malignant or metastatic disease or a history of neoadjuvant chemotherapy. Risk adjustment was performed using inverse probability of treatment weighting (IPTW) propensity scores with generalized linear models and Cox Proportional Hazards models. RESULTS: The cohort comprised 13,404 patients, 4,291 (32.1%) open, 4,317 (32.2%) RATS, and 4,796 (35.8%) VATS. Black/Urban patients had significantly higher RATS and VATS rates (p<0.001), higher long-term survival (p=0.007), fewer open resections (p<0.001), and lower overall mortality (p=0.007). Low-income Black/Urban patients had higher RATS (p=0.002), VATS (p<0.001), higher long-term survival (p=0.005), fewer open resections (p<0.001), and lower overall mortality compared to rural white patients. (p=0.005). CONCLUSIONS: Rural white populations living close to the federal poverty line may suffer a burden of disparity traditionally observed among poor Black people. This suggests a need for health policies that extend services to impoverished, rural areas to mitigate social determinants of health.

Powered air-purifying respirator (PAPR) disinfection and risk of surface damage from hydrogen peroxide and quaternary ammonium chloride-based disinfectants.

Reusable Powered Air Purifying Respirators (PAPRs) have been increasingly used as an alternative to disposable masks or respirators for healthcare workers needing protection from respiratory droplets containing respiratory viruses, but little information is available concerning how well PAPRs resist damage from repeat disinfection over their lifetime. This study tested parts from four PAPRs against four commercially available hydrogen peroxide and quaternary ammonium chloride disinfectants by immersion for 28 days to simulate prolonged exposure. Risk of surface damage was assessed through color change, mass change, and visual observation of damage. Minimal risk of damage was found for three of the disinfectants tested and for the fourth disinfectant, a risk of surface damage to a small number of parts. Exposure to tap water caused similar damage in many cases. The study demonstrated that risk of surface damage varied by part and disinfectant, indicating that some disinfectants are more likely to be compatible against the wide range of materials and parts in a commercial PAPR and other disinfectants may show varying compatibility, with more risk to certain materials or parts.

The Critical Role of Stereopsis in Virtual and Mixed Reality Learning Environments.

Anatomy education has been revolutionized through digital media, resulting in major advances in realism, portability, scalability, and user satisfaction. However, while such approaches may well be more portable, realistic, or satisfying than traditional photographic presentations, it is less clear that they have any superiority in terms of student learning. In this study, it was hypothesized that virtual and mixed reality presentations of pelvic anatomy will have an advantage over two-dimensional (2D) presentations and perform approximately equal to physical models and that this advantage over 2D presentations will be reduced when stereopsis is decreased by covering the non-dominant eye. Groups of 20 undergraduate students learned pelvic anatomy under seven conditions: physical model with and without stereo vision, mixed reality with and without stereo vision, virtual reality with and without stereo vision, and key views on a computer monitor. All were tested with a cadaveric pelvis and a 15-item, short-answer recognition test. Compared to the key views, the physical model had a 70% increase in accuracy in structure identification; the virtual reality a 25% increase, and the mixed reality a non-significant 2.5% change. Blocking stereopsis reduced performance on the physical model by 15%, on virtual reality by 60%, but by only 2.5% on the mixed reality technology. The data show that virtual and mixed reality technologies tested are inferior to physical models and that true stereopsis is critical in learning anatomy.

Quantification of hexagonal boron nitride impurities in boron nitride nanotubes via FTIR spectroscopy.

Preparation of high-quality boron nitride nanotubes (BNNTs) from commercially available stock is critical for eventual industry adoption and to perform comprehensive experimental studies of BNNTs. Separation of hexagonal boron nitride (h-BN) and BNNTs is a significant challenge, and equally so, quantification of h-BN content in mixed samples is a major challenge due to their nearly identical properties. This work introduces a simple method of quantifying h-BN content in BNNTs based on FTIR analysis. Quantification is achieved by "spiking" a BNNT sample with pure nanoscale h-BN as an internal standard. To demonstrate the efficacy of the quantification technique two BNNT enrichment methods, surfactant wrapping and centrifugation, and a novel sonication-assisted isovolumetric filtration are introduced. FTIR spectra of enriched samples show clear trends throughout the processes. We propose and demonstrate that FTIR peak ratios of the transverse and buckling modes of mixed h-BN/BNNT samples can be used to calibrate and quantify h-BN content in any BNNT sample. Hopefully, this method enables as-received BNNTs to be quantifiably enriched from low purity commercial feedstocks, enabling future development and study of BNNTs and related technology.

Bis-phenylethynyl polyhedral oligomeric silsesquioxanes: new high-temperature, processable thermosetting materials.

Bis-phenylethynyl polyhedral oligomeric silsesquioxane (bis-PE-POSS) compounds were synthesized and thermally cured yielding crosslinked materials. After curing at 370 °C, thermal decomposition occurs near 600 °C under nitrogen. These materials were synthesized by condensation of a new phenylethynyl-functional dichlorosilane onto tetrasilanol phenyl POSS, yielding two geometric isomers.

Therapeutic efficacy of laparoscopic cholecystectomy in the treatment of biliary dyskinesia.

BACKGROUND: The outcome of laparoscopic cholecystectomy for patients who present with "classic" biliary colic without evidence of cholelithiasis or acute inflammation (biliary dyskinesia) is not well documented. This study evaluates whether a cholecystokinin dimethyl iminodiacetic acid (CCK-HIDA) scan can predict relief of symptoms in this group of patients. METHODS: Patients who underwent laparoscopic cholecystectomy after a normal ultrasound and with an abnormal dimethyl iminodiacetic acid scan were retrospectively reviewed. Symptomatic improvement was correlated with degree of dyskinesia, histologic findings, sex, and age. RESULTS: One hundred seventy-six patients were studied and 69% were available for followup at a mean interval of 16 months. One hundred fourteen patients (94%) had complete or partial relief of symptoms. No correlation was found between degree of relief and degree of impaired ejection (31% to 50% versus <30%), the histologic findings, sex, or age. CONCLUSIONS: Abnormal cholecystokinin dimethyl iminodiacetic acid scan effectively predicts relief of symptoms in patients undergoing laparoscopic cholecystectomy for biliary dyskinesia.

Clinical trials for pulmonary metastasectomy.

There remains great controversy as to the indications and true benefits for pulmonary metastasectomy. The number of metastatic lesions, length of disease-free interval, and unilaterality has shown to be important prognostic factors on overall survival. In this review, we evaluate a number of clinical trials and critically assess the rational to perform pulmonary metastasectomy, which is a local treatment for a systemic disease process.