Digital Health Platforms for Breast Cancer Care: A Scoping Review.

Breast cancer is a significant global health concern affecting millions of women each year. Digital health platforms are an easily accessible intervention that can improve patient care, though their efficacy in breast cancer care is unknown. This scoping review aims to provide an overview of existing research on the utilization of digital health platforms for breast cancer care and identify key trends and gaps in the literature. A comprehensive literature search was conducted across electronic databases, including Ovid MEDLINE, Elsevier EMBASE, and Elsevier Scopus databases. The search strategy incorporated keywords related to "digital health platforms", "breast cancer care", and associated terminologies. After screening for eligibility, a total of 25 articles were included in this scoping review. The identified studies comprised mobile applications and web-based interventions. These platforms demonstrated various functionalities, including patient education, symptom monitoring, treatment adherence, and psychosocial support. The findings indicate the potential of digital health platforms in improving breast cancer care and patients' overall experiences. The positive impact on patient outcomes, including improved quality of life and reduced psychological distress, underscores the importance of incorporating digital health solutions into breast cancer management. Additional research is necessary to validate the effectiveness of these platforms in diverse patient populations and assess their impact on healthcare-resource utilization.

Healthcare resource utilization for chronic low back pain among high-utilizers.

BACKGROUND: Chronic low back pain is a leading cause of morbidity and is among the largest cost drivers for the healthcare system. Research on healthcare resource utilization of patients with low back pain who are not surgical candidates is limited, and few studies follow individuals who generate high healthcare costs over time. PURPOSE: This claims study aimed to identify patients with high-impact mechanical, chronic low back pain (CLBP), quantify their low back pain-related health resource utilization, and explore associated patient characteristics. We hypothesize that patients in the top quartile of healthcare resource utilization in the second year after initial diagnosis will continue to generate considerable back pain-related costs in subsequent years. STUDY DESIGN/SETTING: IBM MarketScan Research Databases from 2009-2019 were retrospectively analyzed. PATIENT SAMPLE: Adults in the United States with an initial diagnosis of low back pain between 2010 and 2014 who did not have cancer, spine surgery, recent pregnancy, or inflammatory spine conditions, were identified using the International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) codes. To ensure patients had chronic low back pain, it was required that individuals had additional claims with a low back pain diagnosis 6 to 12 and 12 to 24 months after initial diagnosis. OUTCOME MEASURES: Cost and utilization of inpatient visits, outpatient visits, emergency room visits, pharmacologic and non-pharmacologic treatment options and imaging for chronic low back pain. METHODS: Annual back pain-related costs and the use of pharmacologic and nonpharmacologic treatments for 5 years were analyzed. Logistic regression was utilized to identify factors associated with persistent high spending. RESULTS: Of 16,917 individuals who met the criteria for chronic low back pain, 4,229 met the criteria for having high healthcare utilization, defined as being in the top quartile of back pain-related costs in the 12 to 24 months after their initial diagnosis. The mean and median back pain-related cost in the first year after an initial diagnosis was $7,112 (SD $9,670) and $4,405 (Q1 $2,147, Q3 $8,461). Mean and median back pain related costs in the second year were $11,989 (SD $20,316) and $5,935 (Q1 $3,892, Q3 $10,678). Costs continued to be incurred in years 3 to 5 at a reduced rate. The cumulative mean cost for back pain over the 5 years following the initial diagnosis was $31,459 (SD $39,545). The majority of costs were from outpatient services. Almost a quarter of the high utilizers remained in the top quartile of back pain-related costs during years 3 to 5 after the initial diagnosis, and another 19% remained in the top quartile for 2 of the 3 subsequent years. For these two groups combined (42%), the 5-year cumulative mean cost for back pain was $43,818 (SD $48,270). Patient characteristics associated with a higher likelihood of remaining as high utilizers were diabetes, having a greater number of outpatient visits and pharmacologic prescriptions, and lower utilization of imaging services. CONCLUSION: This is one of the first studies to use an administrative claims database to identify high healthcare resource utilizers among a population of United States individuals with nonsurgical, chronic low back pain and follow their utilization over time. There was a population of individuals who continued to experience high costs 5 years beyond their initial diagnosis, and the majority of individuals continued to seek outpatient services. Further longitudinal claims research that incorporates symptom severity is needed to understand the economic implications of this condition.

Quantifying the Opportunity Cost of Neurosurgical Resident Education.

BACKGROUND/OBJECTIVE: Education is at the core of neurosurgical residency, but little research in to the cost of neurosurgical education exists. This study aimed to quantify costs of resident education in an academic neurosurgery program using traditional teaching methods and the Surgical Autonomy Program (SAP), a structured training program. METHODS: SAP assesses autonomy by categorizing cases into zones of proximal development (opening, exposure, key section, and closing). All first-time, 1-level to 4-level anterior cervical discectomy and fusion (ACDF) cases between March 2014 and March 2022 from 1 attending surgeon were divided into 3 groups: independent cases, cases with traditional resident teaching, and cases with SAP teaching. Surgical times for all cases were collected and compared within levels of surgery between groups. RESULTS: The study found 2140 ACDF cases, with 1758 independent, 223 with traditional teaching, and 159 with SAP. For 1-level to 4-level ACDFs, teaching took longer than it did with independent cases, with SAP teaching adding additional time. A 1-level ACDF performed with a resident (100.1 ± 24.3 minutes) took about as long as a 3-level ACDF performed independently (97.1 ± 8.9 minutes). The average time for 2-level cases was 72.0 ± 18.2 minutes independently, 121.7 ± 33.7 minutes traditional, and 143.4 ± 34.9 minutes SAP, with significant differences among all groups. CONCLUSIONS: Teaching takes significant time compared with operating independently. There is also a financial cost to educating residents, because operating room time is expensive. Because attending neurosurgeons lose time to perform more surgeries when teaching residents, there is a need to acknowledge surgeons who devote time to training the next generation of neurosurgeons.

Best Practices for Writing Letters of Recommendation for Maternal-Fetal Medicine Fellowship: An Empty Scoping Review.

OBJECTIVES: Though letters of recommendation (LOR) for Maternal-Fetal Medicine (MFM) fellowship are a critical part of application process, little is known regarding best practices for writing them. This scoping review sought to identify published data outlining best practices in writing MFM fellowship LOR. STUDY DESIGN: Scoping review conducted using Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and JBI guidelines. MEDLINE, Embase, Web of Science, and ERIC were searched, by professional medical librarian using database-specific controlled vocabulary and keywords representing MFM, fellowship, as well as personnel selection, academic performance, examinations, or clinical competence in 4/22. Prior to execution, the search was peer reviewed by another professional medical librarian using the Peer Review Electronic Search Strategies (PRESS) checklist. Citations imported to Covidence, dual screened by authors with disagreements resolved by discussion, and extraction performed by one author and checked by the second. RESULTS: A total of 1,154 studies were identified, with 162 removed as duplicates. Of the 992 screened, 10 imported for full-text review. None of these met inclusion criteria; four were not about fellows and six did not report on best practices for writing LOR for MFM. CONCLUSION: No articles were identified that outlined best practices for writing LOR for MFM fellowship. The lack of guidance and published data guiding those writing LOR for MFM fellowship applicants is concerning given the importance of these as a tool used by fellowship directors in selecting applicants for interviews and ranking. KEY POINTS: · No published articles were identified addressing best practices for writing LOR for MFM fellowship.. · Fellowship directors rely on LOR for offering interviews and rank list.. · Future research is urgently needed to identify best practices..

A Nationwide Analysis of Aneurysmal Subarachnoid Hemorrhage Mortality, Complications, and Health Economics in the USA.

Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating neurological condition. Endovascular coiling or surgical clipping have equivocal success rates, but relatively little is known regarding the health economics and complications of these procedures at the population level. We aimed to analyze the complication profiles and healthcare resource utilization (HRCU) associated with the treatment of aSAH in the USA. We performed a retrospective analysis utilizing the IBM MarketScan database between 2008 and 2015. Primary outcomes included economic analysis stratified by post-operative complication; determination of the effect of several factors on total cost by multivariable regression; and analysis of the incidence, timing, and associated HCRU of aSAH-related post-operative complications. Of the 2374 patients meeting inclusion criteria for economic analysis, 1783 (75.1%) patients had at least one of the ten complications. The most common complications included hydrocephalus (43.8%), transient cerebral ischemia (including vasospasm) (30.6%), ischemic stroke (29.1%), syndrome of inappropriate antidiuretic hormone (SIADH)/hyposmolarity/hyponatremia (22.1%), and seizures (14.9%). Patients who experienced complications had higher median 90-day total costs [$161,127 (Q1 to Q3, $101,411 to $257,662)] than those who did not [$97,376 (Q1 to Q3, $55,692 to $147,447)]. Length of stay was longest for those with pulmonary embolism and pneumonia (27 days) and shortest for those with SIADH/hyposmolarity/hyponatremia (16 days). Brain compression/herniation had the highest mortality rate (19.5%). In total, 14.6% of all patients experienced a readmission within 30 days. In conclusion, patients with aSAH have high post-operative complication rates and costs. Development of novel interventions to reduce complications and improve outcomes is crucial.

Outcomes With a Mobile Digital Health Platform for Patients Undergoing Spine Surgery: Retrospective Analysis.

BACKGROUND: Digital health solutions have been shown to enhance outcomes for individuals with chronic medical illnesses, but few have been validated for surgical patients. The digital health platform ManageMySurgery (MMS) has been validated for spine surgery as a feasible method for patients along their surgical journey through in-app education and completion of patient-reported outcomes surveys. OBJECTIVE: The aim of this study is to determine the rates of 90-day emergency room (ER) visits, readmissions, and complications in patients undergoing spine surgery using MMS compared to patients using traditional perioperative care alone. METHODS: Patients undergoing spine surgery at a US-based academic hospital were invited to use MMS perioperatively between December 2017 and September 2021. All patients received standard perioperative care and were classified as MMS users if they logged into the app. Demographic information and 90-day outcomes were acquired via electronic health record review. The odds ratios of having 90-day ER visits, readmissions, mild complications, and severe complications between the MMS and non-MMS groups were estimated using logistic regression models. RESULTS: A total of 1015 patients were invited, with 679 using MMS. MMS users and nonusers had similar demographics: the average ages were 57.9 (SD 12.5) years and 61.5 (SD 12.7) years, 54.1% (367/679) and 47.3% (159/336) were male, and 90.1% (612/679) and 88.7% (298/336) had commercial or Medicare insurance, respectively. Cervical fusions (559/1015, 55.07%) and single-approach lumbar fusions (231/1015, 22.76%) were the most common procedures for all patients. MMS users had a lower 90-day readmission rate (55/679, 8.1%) than did nonusers (30/336, 8.9%). Mild complications (MMS: 56/679, 8.3%; non-MMS: 32/336, 9.5%) and severe complications (MMS: 66/679, 9.7%; non-MMS: 43/336, 12.8%) were also lower in MMS users. MMS users had a lower 90-day ER visit rate (MMS: 62/679, 9.1%; non-MMS: 45/336, 13.4%). After adjustments were made for age and sex, the odds of having 90-day ER visits for MMS users were 32% lower than those for nonusers, but this difference was not statistically significant (odds ratio 0.68, 95% CI 0.45-1.02; P=.06). CONCLUSIONS: This is one of the first studies to show differences in acute outcomes for people undergoing spine surgery who use a digital health app. This study found a correlation between MMS use and fewer postsurgical ER visits in a large group of spine surgery patients. A planned randomized controlled trial will provide additional evidence of whether this digital health tool can be used as an intervention to improve patient outcomes.

Construct validity of the Surgical Autonomy Program for the training of neurosurgical residents.

OBJECTIVE: There is no standard way in which physicians teach or evaluate surgical residents intraoperatively, and residents are proving to not be fully competent at core surgical procedures upon graduating. The Surgical Autonomy Program (SAP) is a novel educational model that combines a modified version of the Zwisch scale with Vygotsky's social learning theory. The objective of this study was to establish preliminary validity evidence that SAP is a reliable measure of autonomy and a useful tool for tracking competency over time. METHODS: The SAP breaks each surgical case into 4 parts, or zones of proximal development (ZPDs). Residents are evaluated on a 4-tier autonomy scale (TAGS scale) for each ZPD in every surgical case. Attendings were provided with a teaching session about SAP and identified appropriate ZPDs for surgical cases under their area of expertise. All neurosurgery residents at Duke University Hospital from July 2017 to July 2021 participated in this study. Chi-square tests and ordinal logistic regression were used for the analyses. RESULTS: Between 2017 and 2021, there were 4885 cases logged by 27 residents. There were 30 attendings who evaluated residents using SAP. Faculty completed evaluations on 91% of cases. The ZPD of focus directly correlated with year of residency (postgraduate year) (χ2 = 1221.1, df = 15, p < 0.001). The autonomy level increased with year of residency (χ2 = 3553.5, df = 15, p < 0.001). An ordinal regression analysis showed that for every year increase in postgraduate year, the odds of operating at a higher level of independence was 2.16 times greater (95% CI 2.11-2.21, p < 0.001). The odds of residents performing with greater autonomy was lowest for the most complex portion of the case (ZPD3) (OR 0.18, 95% CI 0.17-0.20, p < 0.001). Residents have less autonomy with increased case complexity (χ2 = 160.28, df = 6, p < 0.001). Compared with average cases, residents were more likely to operate with greater autonomy on easy cases (OR 1.44, 95% CI 1.29-1.61, p < 0.001) and less likely to do so on difficult cases (OR 0.72, 95% CI 0.67-0.77, p < 0.001). CONCLUSIONS: This study demonstrates preliminary evidence supporting the construct validity of the SAP. This tool successfully tracks resident autonomy and progress over time. The authors' smartphone application was widely used among surgical faculty and residents, supporting integration into the perioperative workflow. Wide implementation of SAP across multiple surgical centers will aid in the movement toward a competency-based residency education system.

Psychophysiological Markers of Performance and Learning during Simulated Marksmanship in Immersive Virtual Reality.

The fusion of immersive virtual reality, kinematic movement tracking, and EEG offers a powerful test bed for naturalistic neuroscience research. Here, we combined these elements to investigate the neuro-behavioral mechanisms underlying precision visual-motor control as 20 participants completed a three-visit, visual-motor, coincidence-anticipation task, modeled after Olympic Trap Shooting and performed in immersive and interactive virtual reality. Analyses of the kinematic metrics demonstrated learning of more efficient movements with significantly faster hand RTs, earlier trigger response times, and higher spatial precision, leading to an average of 13% improvement in shot scores across the visits. As revealed through spectral and time-locked analyses of the EEG beta band (13-30 Hz), power measured prior to target launch and visual-evoked potential amplitudes measured immediately after the target launch correlated with subsequent reactive kinematic performance in the shooting task. Moreover, both launch-locked and shot/feedback-locked visual-evoked potentials became earlier and more negative with practice, pointing to neural mechanisms that may contribute to the development of visual-motor proficiency. Collectively, these findings illustrate EEG and kinematic biomarkers of precision motor control and changes in the neurophysiological substrates that may underlie motor learning.

Genetic determinants of LDL cholesterol and risk of intracerebral haemorrhage.

PURPOSE OF REVIEW: The role of lipids in spontaneous, nontraumatic intracerebral haemorrhage (ICH) remains controversial, as some studies suggest that lower levels of total and LDL cholesterol could increase the risk of this disease. Because of their random assortment during meiosis, genetic variants known to associate with lipid levels can be used as instruments to evaluate this relationship from a causal perspective. The purpose of this review is to summarize the existing literature related to genetically determined LDL cholesterol levels and risk of ICH. RECENT FINDINGS: A number of studies have demonstrated that lower LDL levels are associated with a higher risk of ICH and a higher burden of neuroimaging markers of cerebral small vessel disease, such as microbleeds and white matter hyperintensity volume. As for genetically elevated lipid levels, several studies confirmed an inverse association between LDL levels and ICH. However, a number of observational studies and large meta-analyses of clinical trials of statins have failed to show such association. SUMMARY: Observational studies and clinical trials of statins have yielded inconsistent results regarding a possible link between LDL levels and the risk of ICH. Genetic studies focused on genetically elevated LDL levels and risk of ICH have, for the most, found an inverse association.

Genetic underpinnings of cerebral edema in acute brain injury: an opportunity for pathway discovery.

Cerebral edema constitutes an important contributor to secondary injury in acute brain injury. The quantification of cerebral edema in neuroimaging, a well-established biomarker of secondary brain injury, represents a useful intermediate phenotype to study edema formation. Population genetics provides powerful tools to identify novel susceptibility genes, biological pathways and therapeutic targets related to brain edema formation. Here, we provide an overview of the pathogenesis of cerebral edema, introduce relevant genetic methods to study this process, and discuss the ongoing research on the genetic underpinnings of edema formation in acute brain injury. The epsilon 2 and 4 variants within the Apolipoprotein E (APOE) gene are associated with worse outcome after traumatic brain injury and intracerebral hemorrhage, and recent studies link these polymorphisms to inflammatory processes that lead to blood-brain barrier disruption and vasogenic edema. For the Haptoglobin gene (HP), the Hp 2-2 genotype associates with worse outcome after acute brain injury, whereas the haptoglobin Hp 1-1 genotype correlates with increased edema in the early phases of intracerebral hemorrhage. Another important protein in cerebral edema is aquaporin 4, coded by the AQP4 gene. AQP4 mutations contribute to the formation of cytotoxic edema, and further genetic research is necessary to help elucidate the mediating mechanism. Findings supporting the target genes outlined above require replication in larger samples and evaluation in non-white populations. These next steps will be significantly facilitated by the rapid changes observed in the field of population genetics, including large international collaborations, open access to genetic data, and significant reductions in the cost of genotyping technologies.

Genetically Elevated LDL Associates with Lower Risk of Intracerebral Hemorrhage.

OBJECTIVE: Observational studies point to an inverse correlation between low-density lipoprotein (LDL) cholesterol levels and risk of intracerebral hemorrhage (ICH), but it remains unclear whether this association is causal. We tested the hypothesis that genetically elevated LDL is associated with reduced risk of ICH. METHODS: We constructed one polygenic risk score (PRS) per lipid trait (total cholesterol, LDL, high-density lipoprotein [HDL], and triglycerides) using independent genomewide significant single nucleotide polymorphisms (SNPs) for each trait. We used data from 316,428 individuals enrolled in the UK Biobank to estimate the effect of each PRS on its corresponding trait, and data from 1,286 ICH cases and 1,261 matched controls to estimate the effect of each PRS on ICH risk. We used these estimates to conduct Mendelian Randomization (MR) analyses. RESULTS: We identified 410, 339, 393, and 317 lipid-related SNPs for total cholesterol, LDL, HDL, and triglycerides, respectively. All four PRSs were strongly associated with their corresponding trait (all p < 1.00 × 10-100 ). While one SD increase in the PRSs for total cholesterol (odds ratio [OR] = 0.92; 95% confidence interval [CI] = 0.85-0.99; p = 0.03) and LDL cholesterol (OR = 0.88; 95% CI = 0.81-0.95; p = 0.002) were inversely associated with ICH risk, no significant associations were found for HDL and triglycerides (both p > 0.05). MR analyses indicated that 1mmol/L (38.67mg/dL) increase of genetically instrumented total and LDL cholesterol were associated with 23% (OR = 0.77; 95% CI = 0.65-0.98; p = 0.03) and 41% lower risks of ICH (OR = 0.59; 95% CI = 0.42-0.82; p = 0.002), respectively. INTERPRETATION: Genetically elevated LDL levels were associated with lower risk of ICH, providing support for a potential causal role of LDL cholesterol in ICH. ANN NEUROL 2020 ANN NEUROL 2020;88:56-66.

Deep Learning for Automated Measurement of Hemorrhage and Perihematomal Edema in Supratentorial Intracerebral Hemorrhage.

Background and Purpose- Volumes of hemorrhage and perihematomal edema (PHE) are well-established biomarkers of primary and secondary injury, respectively, in spontaneous intracerebral hemorrhage. An automated imaging pipeline capable of accurately and rapidly quantifying these biomarkers would facilitate large cohort studies evaluating underlying mechanisms of injury. Methods- Regions of hemorrhage and PHE were manually delineated on computed tomography scans of patients enrolled in 2 intracerebral hemorrhage studies. Manual ground-truth masks from the first cohort were used to train a fully convolutional neural network to segment images into hemorrhage and PHE. The primary outcome was automated-versus-human concordance in hemorrhage and PHE volumes. The secondary outcome was voxel-by-voxel overlap of segmentations, quantified by the Dice similarity coefficient (DSC). Algorithm performance was validated on 84 scans from the second study. Results- Two hundred twenty-four scans from 124 patients with supratentorial intracerebral hemorrhage were used for algorithm derivation. Median volumes were 18 mL (interquartile range, 8-43) for hemorrhage and 12 mL (interquartile range, 5-30) for PHE. Concordance was excellent (0.96) for automated quantification of hemorrhage and good (0.81) for PHE, with DSC of 0.90 (interquartile range, 0.85-0.93) and 0.54 (0.39-0.65), respectively. External validation confirmed algorithm accuracy for hemorrhage (concordance 0.98, DSC 0.90) and PHE (concordance 0.90, DSC 0.55). This was comparable with the consistency observed between 2 human raters (DSC 0.90 for hemorrhage, 0.57 for PHE). Conclusions- We have developed a deep learning-based imaging algorithm capable of accurately measuring hemorrhage and PHE volumes. Rapid and consistent automated biomarker quantification may accelerate powerful and precise studies of disease biology in large cohorts of intracerebral hemorrhage patients.