Residency Application Selection Committee Discriminatory Ability in Identifying Artificial Intelligence-Generated Personal Statements.

OBJECTIVE: Advances in artificial intelligence (AI) have given rise to sophisticated algorithms capable of generating human-like text. The goal of this study was to evaluate the ability of human reviewers to reliably differentiate personal statements (PS) written by human authors from those generated by AI software. SETTING: Four personal statements from the archives of two surgical program directors were de-identified and used as the human samples. Two AI platforms were used to generate nine additional PS. PARTICIPANTS: Four surgeons from the residency selection committees of two surgical residency programs of a large multihospital system served as blinded reviewers. AI was also asked to evaluate each PS sample for authorship. DESIGN: Sensitivity, specificity and accuracy of the reviewers in identifying the PS author were calculated. Kappa statistic for correlation between the hypothesized author and the true author were calculated. Inter-rater reliability was calculated using the kappa statistic with Light's modification given more than two reviewers in a fully-crossed design. Logistic regression was performed with to model the impact of perceived creativity, writing quality, and authorship or the likelihood of offering an interview. RESULTS: Human reviewer sensitivity for identifying an AI-generated PS was 0.87 with specificity of 0.37 and overall accuracy of 0.55. The level of agreement by kappa statistic of the reviewer estimate of authorship and the true authorship was 0.19 (slight agreement). The reviewers themselves had an inter-rater reliability of 0.067 (poor), with only complete agreement (four out of four reviewers) on two PS, both authored by humans. The odds ratio of offering an interview (compared to a composite of "backup" status or no interview) to a perceived human author was 7 times that of a perceived AI author (95% confidence interval 1.5276 to 32.0758, p=0.0144). AI hypothesized human authorship for twelve of the PS, with the last one "unsure." CONCLUSIONS: The increasing pervasiveness of AI will have far-reaching effects including on the resident application and recruitment process. Identifying AI-generated personal statements is exceedingly difficult. With the decreasing availability of objective data to assess applicants, a review and potential restructuring of the approach to resident recruitment may be warranted.

Analysis of Operating Room Personnel Perspectives to Enhance Medical Student Readiness for Surgery.

OBJECTIVE: We sought to better define surgical etiquette and elucidate operating room (OR) personnel expectations of medical students to determine areas for medical education improvement. DESIGN: A questionnaire probing medical student performance regarding elements of OR etiquette was developed. Questions were designed to obtain structured feedback through Likert scales and open-ended responses. Descriptive and thematic analysis was conducted on Likert scale and free-text responses, respectively. SETTING: Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ. Tertiary academic center. PARTICIPANTS: A questionnaire was distributed to nurses, surgical and anesthesia faculty and residents. The survey was distributed via email amongst various hospitals, predominantly our home institution. RESULTS: We received 126 complete responses. About half of respondents (46.3%) self-identified as female. Most respondents were part of the surgical team (74.7%), with most (57.8%) from attending physicians. A majority of respondents agreed that medical students responded well to feedback. Roughly half of respondents agreed that medical students understand their role, maintain sterility, and assist in delivery of effective patient care. More than half of respondents did not believe that medical students understand traffic patterns. The majority of respondents indicated that medical students are not appropriately prepared with basic surgical skills prior to entering the OR. Two-thirds of respondents did not feel that medical students contribute towards maintaining safety in the OR. We identified 4 themes from free text responses: students should assume an active role in the OR, utilize situational awareness, understand sterility and OR workflow, and have knowledge of basic operative technique and anatomy. CONCLUSIONS: Medical students are not meeting OR personnel expectations and may benefit from early educational interventions to optimize the OR as a learning environment.

Understanding How Experts Do It: A Conceptual Framework for the Open Transversus Abdominis Release Procedure.

BACKGROUND: The safe and effective performance of a posterior component separation via a transversus abdominis release (TAR) requires intraoperative judgement and decision-making skills that are difficult to define, standardize, and teach. We herein present the first qualitative study which builds a framework upon which training and objective evaluation of a TAR can be based. METHODS: Hierarchical and cognitive task analyses for a TAR procedure were performed using semistructured interviews of hernia experts to describe the thoughts and behaviors that exemplify optimal performance. Verbal data was recorded, transcribed, coded, and thematically analyzed. RESULTS: A conceptual framework was synthesized based on literary sources (4 book chapters, 4 peer-reviewed articles, 3 online videos), 2 field observations, and interviews of 4 hernia experts [median 66 minutes (44-78)]. Subject matter experts practiced a median of 6.5 years (1.5-16) and have completed a median of 300 (60-500) TARs. After 5 rounds of inductive analysis, 80 subtasks, 86 potential errors, 36 cognitive behaviors, and 17 decision points were identified and categorized into 10 procedural steps (midline laparotomy, adhesiolysis, retrorectus dissection, etc.) and 9 fundamental principles: patient physiology and disease burden; tactical modification; tissue reconstruction and wound healing; task completion; choice of technique and instruments; safe planes and danger zones; exposure, ergonomics, environmental limitations; anticipation and forward planning; and tissue trauma and handling. CONCLUSION: This is the first study to define the key tasks, decisions, and cognitive behaviors that are essential to a successful TAR procedure.

Macrophage subtype predicts lymph node metastasis in oesophageal adenocarcinoma and promotes cancer cell invasion in vitro.

BACKGROUND: Currently, there is a lack of ideal biomarkers for predicting nodal status in preoperative stage of oesophageal adenocarcinoma (EAC) to aid optimising therapeutic options. We studied the potential of applying subtype macrophages to predict lymph node metastasis and prognosis in EAC. MATERIAL AND METHODS: Fifty-three EAC resection specimens were immunostained with CD68, CD40 (M1), and CD163 (M2). Lymphatic vessel density (LVD) was estimated with the staining of D2-40. Subsequently, we tested if M2d macrophage could promote EAC cell migration and invasion. RESULTS: In EAC without neoadjuvant treatment, an increase in M2-like macrophage was associated with poor patient survival, independent of the locations of macrophages in tumour. The M2/M1 ratio that represented the balance between M2- and M1-like macrophages was significantly higher in nodal-positive EACs than that in nodal-negative EACs, and inversely correlated with patient overall survival. The M2/M1 ratio was not related to LVD. EAC cell polarised THP1 cell into M2d-like macrophage, which promoted EAC cell migration and invasion. Neoadjuvant therapy appeared to diminish the correlation between the M2/M1 ratio and survival. CONCLUSIONS: The ratio of M2/M1 macrophage may serve as a sensitive marker to predict lymph node metastasis and poor prognosis in EAC without neoadjuvant therapy. M2d macrophage may have important roles in EAC metastasis.

Neoadjuvant treatment response in negative nodes is an important prognosticator after esophagectomy.

BACKGROUND: The current American Joint Committee on Cancer Seventh Edition (AJCC7) pathologic staging for esophageal adenocarcinoma (EAC) is derived from data assessing the outcomes of patients having undergone esophagectomy without neoadjuvant treatment and has unclear significance in patients who have received multimodality therapy. Lymph nodes with evidence of neoadjuvant treatment effect without residual cancer cells may be observed and are not traditionally considered in pathologic reports, but may have prognostic significance. METHODS: All patients who underwent esophagectomy after completing neoadjuvant therapy for EAC at our institution between 2006 and 2012 were reviewed. Slides of pathologic specimens were reexamined for locoregional treatment-response nodes lacking viable cancer cells but with evidence of acellular mucin pools, central fibrosis, necrosis, or calcifications suggesting prior tumor involvement. Kaplan-Meier survival functions were estimated, and Cox proportional hazards regression models were used to compare staging models. RESULTS: Ninety patients (82 men) underwent esophagectomy after neoadjuvant therapy for EAC (mean age, 61.8 ± 8.9 years). All patients received preoperative chemotherapy, and 50 patients also underwent preoperative radiotherapy. Median Kaplan-Meier survival was 55.6 months, and 5-year survival was 35% (95% confidence interval, 19% to 62%). A total of 100 treatment-response nodes were found in 38 patients. For patients with limited nodal disease (62 ypN0-N1), the presence of treatment-response nodes was associated with significantly worse survival (p = 0.03) compared with patients lacking such nodes. Adjusting for patient age and AJCC7 pathologic stage showed the presence of treatment-response nodes significantly increased the risk of death (hazard ratio, 2.7; 95% confidence interval, 1.1 to 6.9; p = 0.04). When stage-adjusted survival was modeled, counting treatment-response nodes as positive nodes offered a better model fit than ignoring them. CONCLUSIONS: Treatment-response lymph nodes detected from esophagectomy specimens in patients having undergone neoadjuvant chemotherapy or combined chemoradiation for EAC provide valuable prognostic information, particularly in patients with limited nodal disease. The current practice of considering lymph nodes lacking viable cancer cells, but with evidence of tumor necrosis, as pathologically negative likely results in understaging. Future efforts at revising the staging system for EAC should consider incorporating treatment-response lymph nodes in the analysis.

24-h multichannel intraluminal impedance-pH monitoring may be an inadequate test for detecting gastroesophageal reflux in patients with mixed typical and atypical symptoms.

BACKGROUND: The detection of gastroesophageal reflux (GERD) via pH testing is the key component of the evaluation of patients considered for antireflux surgery. Two common pH testing systems exist, a multichannel, intraluminal impedance-pH monitoring (MII-pH) catheter, and wireless (Bravo(®)) capsule; however, discrepancies between the two systems exist. In patients with atypical symptoms, MII-pH catheter is often used preferentially. We aimed to elucidate the magnitude of this discrepancy and to assess the diagnostic value of MII-pH and the Bravo wireless capsule in a population of patients with mixed respiratory and typical symptoms. METHODS: The study population consisted of 66 patients tested with MII-pH and Bravo pH testing within 90 days between July 2009 and 2013. All patients presented with laryngo-pharyngo-respiratory (LPR) symptoms. Patient demographics, symptomatology, manometric and endoscopic findings, and pH monitoring parameters were analyzed. Patients were divided into four comparison groups: both pH tests positive, MII-pH negative/Bravo positive, MII-pH positive/Bravo negative, and both pH tests negative. RESULTS: Nearly half of the patients (44%) had discordant pH test results. Of these, 90% (26/29) had a negative MII-pH but positive Bravo study. In this group, the difference in the DeMeester score was large, a median of 29.3. These patients had a higher BMI (28.5 vs. 26.1, p = 0.0357), were more likely to complain of heartburn (50 vs. 23%, p = 0.0110), to have a hiatal hernia, (85 vs. 53%, p = 0.0075) and a structurally defective lower esophageal sphincter (LES, 85 vs. 58%, p = 0.0208). CONCLUSIONS: In patients with LPR symptoms, we found a high prevalence of discordant esophageal pH results, most commonly a negative MII-pH catheter and positive Bravo. As these patients exhibited characteristics consistent with GERD (heartburn, defective LES, hiatal hernia), the Bravo results are likely true. A 24-h MII-pH catheter study may be inadequate to diagnose GERD in this patient population.

Eliminating a need for esophagectomy: endoscopic treatment of Barrett esophagus with early esophageal neoplasia.

Over the past several years, endoscopic ablation and resection have become a new standard of care in the management of Barrett esophagus (BE) with high-grade dysplasia (HGD) or intramucosal adenocarcinoma (IMC). Risk factors for failure of endoscopic therapy and the need for subsequent esophagectomy have not been well elucidated. The aims of this study were to determine the efficacy of radiofrequency ablation (RFA) with or without endoscopic mucosal resection (EMR) in the management of BE with HGD or IMC, to discern factors predictive of endoscopic treatment failure, and to assess the effect of endoscopic therapies on esophagectomy volume at our institution. Data were obtained retrospectively for all patients who underwent endoscopic therapies or esophagectomy for a diagnosis of BE with HGD or IMC in our department between January 1, 2004, and December 31, 2012. Complete remission (CR) of BE or HGD or IMC was defined as 2 consecutive biopsy sessions without BE or HGD or IMC and no subsequent recurrence. Recurrence was defined by the return of BE or HGD or IMC after initial remission. Progression was defined as worsening of HGD to IMC or worsening of IMC to submucosal neoplasia or beyond. Overall, 57 patients underwent RFA with or without EMR for BE with HGD (n = 45) or IMC (n = 12) between 2007 and 2012, with a median follow-up duration of 35.4 months (range: 18.5-52.0 months). The 57 patients underwent 181 ablation sessions and more than half (61%) of patients underwent EMR as a component of treatment. There were no major procedural complications or deaths, with only 2 minor complications including 1 symptomatic stricture requiring dilation. Multifocal HGD or IMC was present in 43% (25/57) of patients. CR of IMC was achieved in 100% (12/12) at a median of 6.1 months, CR of dysplasia was achieved in 79% (45/57) at a median of 11.5 months, and CR of BE was achieved in 49% (28/57) at a median of 18.4 months. Following initial remission, 28% of patients (16/57) had recurrence of dysplasia (n = 12) or BE (n = 4). Progression to IMC occurred in 7% (4/57). All patients without CR continue endoscopic treatment. No patient required esophagectomy or developed metastatic disease. Overall, 6 patients died during the follow-up interval, none from esophageal cancer. Factors associated with failure to achieve CR of BE included increasing length of BE (6.0 ± 0.6 vs 4.0 ± 0.6cm, P = 0.03) and shorter duration of follow-up (28.5 ± 3.8 months vs 49.0 ± 5.8 months, P = 0.004). Shorter surveillance duration (17.8 ± 7.6 months vs 63.9 ± 14.4 months, P = 0.009) and shorter follow-up (21.1 ± 6.1 months vs 43.2 ± 4.1 months) were the only significant factors associated with failure to eradicate dysplasia. Our use of esophagectomy as primary therapy for BE with HGD or IMC has diminished since we began using endoscopic therapies in 2007. From a maximum of 16 esophagectomies per year for early Barrett neoplasia in 2006, we performed only 3 esophageal resections for such early disease in 2012, all for IMC, and we have not performed an esophagectomy for HGD since 2008. Although recurrence of BE or dysplasia/IMC was not uncommon, RFA with or without EMR ultimately resulted in CR of IMC in all patients, CR of HGD in the majority (79%), and CR of BE in nearly half (49%). No patient treated endoscopically for HGD or IMC subsequently required esophagectomy. In patients with BE with HGD or IMC, RFA and EMR are safe and highly effective. The use of endoscopic therapies appears justified as the new standard of care in most cases of BE with early esophageal neoplasia.

Gastroesophageal reflux disease, proton-pump inhibitor use and Barrett's esophagus in esophageal adenocarcinoma: Trends revisited.

PURPOSE: Screening for esophageal adenocarcinoma (EAC) has not become policy in part over concerns in identifying the high-risk group. It is often claimed that a significant proportion of patients developing EAC do not report preexisting reflux symptoms or prior treatment for gastroesophageal reflux disease (GERD). As such, our aim was to assess the prevalence of GERD symptoms, proton pump inhibitor (PPI) use and Barrett's esophagus (BE) and their impact on survival in patients undergoing esophagectomy for EAC. METHODS: The study population consisted of 345 consecutive patients who underwent esophagectomy for EAC between 2000 and 2011 at a university-based medical center. Patients with a diagnosis of esophageal squamous cell carcinoma and those who underwent esophagectomy for benign disease were excluded. The prevalence of preoperative GERD symptoms, defined as presence of heartburn, regurgitation or epigastric pain, PPI use (>6 months) and BE, defined by the phrases "Barrett's esophagus," "intestinal epithelium," "specialized epithelium," or "goblet cell metaplasia" in the patients' preoperative clinical notes were retrospectively collected. Overall long-term and stage-specific survival was compared in patients with and without the presence of preoperative GERD symptoms, PPI use, or BE. RESULTS: The majority of patients (64%; 221/345) had preoperative GERD symptoms and a history of PPI use (52%; 179/345). A preoperative diagnosis of BE was present in 34% (118/345) of patients. Kaplan-Meier survival analysis revealed a marked survival advantage in patients undergoing esophagectomy who had preoperative GERD symptoms, PPI use or BE diagnosis (P ≤ .001). The survival advantage remained when stratified for American Joint Committee on Cancer stage in patients with preoperative PPI use (P = .015) but was less pronounced in patients with GERD symptoms or BE (P = .136 and P = .225, respectively). CONCLUSION: These data show that the oft-quoted statistic that the majority of patients with EAC do not report preexisting GERD or PPI use is false. Furthermore, a diagnosis of BE is present in a surprisingly high proportion of patients (34%). There is a distinct survival advantage in patients with preoperative GERD symptoms, PPI use, and BE diagnosis, which may not be simply owing to earlier stage at diagnosis. Screening may affect survival outcomes in more patients with EAC than previously anticipated.

Treatment strategies for esophageal cancer.

The treatment of esophageal cancer has evolved considerably in the past decade and depends largely on the extent of disease at the time of presentation. For disease confined to the esophageal mucosa, endoscopic therapy is replacing esophagectomy as the standard of care. For locoregional disease, neoadjuvant chemoradiation followed by esophagectomy is the best strategy for optimizing long-term survival. In the minority of patents who present with metastatic disease, the prognosis is poor. Palliative therapies available for these patients include chemotherapy, radiation, endoscopic therapies to ameliorate obstruction or bleeding, and surgical intervention to optimize nutritional status or to relieve obstruction.

Perceiving a discontinuity in motion.

Studies have shown that the position of a target stimulus is misperceived owing to ongoing motion. Although static forces (fixation, landmarks) affect perceived position, motion remains the overwhelming force driving estimates of position. Motion endpoint estimates biased in the direction of motion are perceptual signatures of motion's dominant role in localization. We sought conditions in which static forces exert the predominant influence over perceived position: stimulus displays for which target position is perceived backward relative to motion. We used a target that moved diagonally with constant speed, abruptly turned 90° and continued at constant speed; observers localized the discontinuity. This yielded a previously undescribed effect, "turn-point shift," the tendency of observers to estimate the position of orthogonal direction change backward relative to subsequent motion direction. Display and mislocalization direction differ from past studies. Static forces (foveal attraction, repulsion by subsequently occupied spatial positions) were found to be responsible. Delayed turn-point estimates, reconstructed from probing the entire trajectory, shifted the horizontal coordinate forward in the direction of motion. This implies more than one percept of turn-point position. As various estimates of turn-point position arise at different times, under different task demands, the perceptual system does not necessarily resolve conflicts between them.

Cyclopean flash-lag illusion.

Possible physiological mechanisms to explain the flash-lag effect, in which subjects perceive a flashed item that is co-localized with a moving item as trailing behind the moving item, have been found within the retina of lower species, and in the motor pathways of humans. Here, we demonstrate flash-lag employing "second-order" moving and flashed stimuli, defined solely by their binocular-disparity, to circumvent any possible "early" contributions to the effect. A significant flash-lag effect was measured with cyclopean stimuli composed entirely of correlated random dot patterns. When the disparity-defined moving stimulus was replaced with a luminance-defined one, potentially engaging retinal mechanisms, the magnitude of the measured effect showed no significant change. Thus, in primates, though retinal mechanisms may contribute, flash-lag must be explained through cortical processes.

Gaze direction modulates visual aftereffects in depth and color.

Prior physiological studies indicate that gaze direction modulates the gain of neural responses to visual stimuli. Here, we test gaze modulation in the perceptual domain using color and depth aftereffects. After confirming retinotopy of the effects, we employed a balanced alternating adaptation paradigm (adaptation alternates between opponent stimuli) to demonstrate that opposite color and depth aftereffects can co-develop at the same retinal location for different gaze directions. The results provide strong evidence for (a) gaze modulation of aftereffects, (b) generality of gaze modulation across two visual attributes, and (c) perceptual correlates of the modulation of neural activity by gaze direction.