The Efficacy of Real-time Computer-aided Detection of Colonic Neoplasia in Community Practice: A Pragmatic Randomized Controlled Trial.

BACKGROUND & AIMS: The use of computer-aided detection (CADe) has increased the adenoma detection rates (ADRs) during colorectal cancer (CRC) screening/surveillance in randomized controlled trials (RCTs) but has not shown benefit in real-world implementation studies. We performed a single-center pragmatic RCT to evaluate the impact of real-time CADe on ADRs in colonoscopy performed by community gastroenterologists. METHODS: We enrolled 1100 patients undergoing colonoscopy for CRC screening, surveillance, positive fecal-immunohistochemical tests, and diagnostic indications at one community-based center from September 2022 to March 2023. Patients were randomly assigned (1:1) to traditional colonoscopy or real-time CADe. Blinded pathologists analyzed histopathologic findings. The primary outcome was ADR (the percentage of patients with at least 1 histologically proven adenoma or carcinoma). Secondary outcomes were adenomas detected per colonoscopy (APC), sessile-serrated lesion detection rate, and non-neoplastic resection rate. RESULTS: The median age was 55.5 years (interquartile range, 50-62 years), 61% were female, 72.7% were of Hispanic ethnicity, and 9.1% had inadequate bowel preparation. The ADR for the CADe group was significantly higher than the traditional colonoscopy group (42.5% vs 34.4%; P = .005). The mean APC was significantly higher in the CADe group compared with the traditional colonoscopy group (0.89 ± 1.46 vs 0.60 ± 1.12; P < .001). The improvement in adenoma detection was driven by increased detection of <5 mm adenomas. CADe had a higher sessile-serrated lesion detection rate than traditional colonoscopy (4.7% vs 2.0%; P = .01). The improvement in ADR with CADe was significantly higher in the first half of the study (47.2% vs 33.7%; P = .002) compared with the second half (38.7% vs 34.9%; P = .33). CONCLUSIONS: In a single-center pragmatic RCT, real-time CADe modestly improved ADR and APC in average-detector community endoscopists. (ClinicalTrials.gov number, NCT05963724).

Rapid detection of the widely circulating B.1.617.2 (Delta) SARS-CoV-2 variant.

The emergence of the B.1.617.2 (Delta) variant of the severe acute syndrome coronavirus (SARS-CoV-2) that emerged in 2019 (COVID-19), resulted in a surge of cases in India and has expanded and been detected across the world, including in the United States. The B.1.617.2 (Delta) variant has been seen to be twice more transmissible coupled with potential increases in disease severity and immune escape. As a result, case numbers and hospitalisations are once again on the rise in the USA. On 16 July 2021, the Centers for Disease Control and Prevention (CDC) reported a 7-day average 69.3% increase in new cases and a 35% increase in hospitalisations. Although the gold standard for SARS-CoV-2 variants identification remains genomic sequencing, this approach is not accessible to many clinical laboratories. The main goal of this study was to validate and implement the detection of the B.1.617.2 (Delta) variant utilising an open reverse transcription polymerase chain reaction (RT-PCR) platform by explicitly detecting the S-gene target failure (SGTF) corresponding to the deletion of two amino acids (ΔE156/ΔF157) characteristic of B.1.617.2 (Delta) variant. This approach was conceived as a rapid screening of B.1.617.2 (Delta) variant in conjunction with CDC's recommended N1 (nucleocapsid gene), N2, and RP (human RNase P) genes, as a pre-screening tool prior to viral genomic sequencing. We assessed 4,937 samples from 5 July to 5 September 2021. We identified the B.1.617.2 (Delta) variant in 435 of 495 positive samples (87.8%); the additional positive samples (7 samples, 1.4%) were found to belong to the B.1.1.7 (Alpha, UK) lineage and the remaining 53 samples (10.7%) were reported as 'other' lineages. Whole genome sequencing of 46 randomly selected samples validated the strains identified as positive and negative for the B.1.617.2 (Delta) variant and confirmed the S gene deletion in addition to B.1.617.2 characteristic mutations including L452R, T478K, P681R and D950N located in the spike protein. This modality has been used as routine testing at the Riverside University System Health (RUHS) Medical Center as a method for detection of B.1.617.2 (Delta) to pre-screen samples before genome sequencing. The assay can be easily implemented in clinical laboratories, most notably those with limited economic resources and access to genomic platforms.

Rapid Integrated Healthcare Response for the First US Evacuees from Wuhan, China, During the COVID-19 Pandemic.

On January 29, 2020, a total of 195 US citizens were evacuated from the coronavirus disease 2019 (COVID-19) epidemic in Wuhan, China, to March Air Reserve Base in Riverside, California, and entered the first federally mandated quarantine in over 50 years. With less than 1-d notice, a multi-disciplinary team from Riverside County and Riverside University Health System in conjunction with local and federal agencies established on-site 24-h medical care and behavioral health support. This report details the coordinated efforts by multiple teams that took place to provide care for the passengers and to support the surrounding community.

European Society of Trauma and Emergency Surgery (ESTES) recommendations for trauma and emergency surgery preparation during times of COVID-19 infection.

A series of recommendations regarding hospital perioperative preparation for the COVID-19 pandemic were compiled to inform surgeons worldwide on how to provide emergency surgery and trauma care during enduring times.The recommendations are divided into eight domains: (1) General recommendation for surgical services; (2) Emergency Surgery for critically ill COVID-19 positive or suspected patients -Preoperative planning and case selection; (3) Operating Room setup; (4) patient transport to the OR; (5) Surgical staff preparation; (6) Anesthesia considerations; (7) Surgical approach; and (8) Case Completion.The European Society of Emergency Surgery board endorsed these recommendations.

Resuming elective surgical services in times of COVID-19 infection.

The consequences of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus have been devastating to the healthcare system. As the positive effects of social distancing, mandatory masking, and societal lockdown on the spread of the disease and its incidence in the community were documented, societal and financial pressures mounted worldwide, prompting efforts to "re-open" countries, states, communities, businesses, and schools. The same happened with hospital, which had to start developing strategies to resume elective surgery activities. This manuscript describes the pre-requisites as well as the strategies for resuming surgical activity, be it in the outpatient or inpatient setting.

Characteristics and Correlates of Word Use in Physician-Patient Communication.

BACKGROUND: Numerous studies have described and evaluated communication in healthcare contexts, but these studies have focused on broad content and complex units of behavior. Growing evidence reveals the predictive power and importance of precise linguistic characteristics of communication. PURPOSE: This study aims to document characteristics, predictors, and correlates of word use within specific linguistic categories by physicians and patients during a healthcare visit. METHODS: Conversations between patients (n = 145) and their physician (n = 6) were audio recorded, transcribed, and analyzed using Linguistic Inquiry Word Count software. Patients also completed questionnaires prior to and immediately following the visit and (for a subset of patients) at a follow-up visit, which assessed patients' demographics, how much they liked the physician, and self-reported adherence. Physicians completed a questionnaire following the initial visit that assessed the patient's health status, the physician's optimism regarding the upcoming treatment, and satisfaction with the productivity of the visit. RESULTS: Patients and physicians differed in the extent of their word use in key linguistic categories, while also maintaining significant linguistic synchrony. Demographic characteristics and health status predicted variability in patients' and physicians' word use, and word use predicted key visit outcomes. Most notably, patients liked their physician more when physicians used fewer negative emotion words and were less adherent when physicians used more singular first-person pronouns. CONCLUSIONS: These findings reveal patterns in the way physicians speak to patients who vary in their demographic characteristics and health status and point to potentially fruitful targets for linguistic interventions with both physicians and patients.

Patients' anxiety and hope: predictors and adherence intentions in an acute care context.

CONTEXT: Good patient-provider interactions promote satisfaction with health care, adherence to treatment recommendations and improved health. However, little research has examined patients' emotions and how they relate to patients' experiences with health care and their adherence intentions in acute care settings. OBJECTIVE: This study examined the predictors and consequences of two emotions pertinent to the uncertainty of acute health-care experiences: anxiety and hopefulness. DESIGN: Patients who arrived at a general surgery clinic for an initial consultation were interviewed before and after the consultation. Prior to the consultation with a physician, patients completed baseline measures of their emotional state. Following the consultation, patients completed measures of understanding of the information provided by the surgeon, perceived control over treatment decisions, adherence intentions and emotional state. RESULTS: Understanding and control predicted less anxiety and greater hopefulness, compared to baseline. Only hopefulness predicted adherence intentions. These relationships remained even after controlling for characteristics of the patients and interactions. DISCUSSION: These findings identify aspects of psychosocial care that are critical for promoting positive (and mitigating negative) emotional states in patients. Even in a brief consultation in a clinic setting, physicians may be able to improve patients' emotional state by promoting a sense of control and clarifying information they convey, and patients' positive emotional states may be critical for raising adherence intentions.

Expectations in the context of gallbladder and hernia surgery: a descriptive report.

OBJECTIVE: Patients' expectations predict important health outcomes. The goal of this study is to describe the types of expectations that hernia and gallbladder patients have for the outcomes of their surgery and to identify relationships between these expectations and both patient- and surgeon-reported variables. DESIGN: Patients (N = 143) at an out-patient surgery clinic completed self-report questionnaires before and after a pre-surgical consultation in which they learned they would be scheduled for surgery. After indicating their general expectations for their surgical outcomes (positive or negative), patients reported specific outcome expectations, which were coded into eight categories: functional improvement, symptom relief, quality-of-life improvement, emotional improvement, general health, no effect expected, no response (or unsure) and negative expectations. RESULTS: Functional improvement and symptom relief were the most common types of expectations mentioned by patients. A key finding was a significant difference in the pattern of expectations provided by Hispanic versus non-Hispanic patients, as well as between patients across the range of health literacy. CONCLUSIONS: Patients undergoing hernia and gallbladder surgery have a variety of expectations, and these expectations vary across demographic groups. Patients who are particularly vulnerable to poor physician communication have positive but diffuse expectations.

Who is satisfied with general surgery clinic visits?

BACKGROUND: Patient satisfaction is an important patient outcome because it informs researchers and practitioners about patients' experience and identifies potential problems with their care. Patient satisfaction is typically studied through physician-patient interactions in primary care settings, and little is known about satisfaction with surgical consultations. METHODS: Participants responded to questionnaires before and after a surgical consultation. The study was conducted in a diverse outpatient clinic within a county hospital in Southern California. Participants were patients who came to the surgery clinic for their first appointment after referral from a primary care provider for a surgical consultation. RESULTS: Patients' ethnicity, educational attainment, and insurance status predict their satisfaction, and patients reliably differed in their satisfaction with care providers and with the hospital where they received their care. CONCLUSIONS: These findings add to knowledge about patient care by highlighting associations between patients' demographic characteristics and patients' differential satisfaction with particular entities within the context of surgical care.

The relative importance of patients' decisional control preferences and experiences.

OBJECTIVE: Patients' role in treatment decision-making can influence psychosocial and health-related outcomes (i.e. satisfaction, felt respect, adherence). We examined decisional control in a surgical context, identifying correlates of patients' preferences and experiences. DESIGN: 380 patients and 7 surgeons were surveyed during initial surgical consultation visits in a low-income outpatient clinic. MEASURES: Patients reported preferences for (pre-consultation) and experiences of (post-consultation) decisional control, demographics, satisfaction with care, and adherence to treatment recommendations. Surgeons rated patients' health status. RESULTS: Preferences for and experiences of decisional control were unrelated, suggesting significant preference-experience misalignment. However, this misalignment did not appear to be consequential for patient outcomes. Rather, more decisional control, regardless of patients' preferences, predicted greater satisfaction with care and greater self-reported adherence as assessed at a post-surgical appointment. CONCLUSIONS: Decisional control predicts better outcomes for patients, regardless of their preferences for control over treatment decisions. These findings suggest that interventions should aim to increase patients' degree of decisional control when feasible and appropriate.

Operative experience of residents in US general surgery programs: a gap between expectation and experience.

OBJECTIVE: The purpose of the study was to identify a group of operations which general surgery residency program directors believed residents should be competent to perform by the end of 5 years of training and then ascertain actual resident experience with these procedures during their training. SUMMARY BACKGROUND DATA: There is concern about the adequacy of training of general surgeons in the United States. The American Board of Surgery and the Association of Program Directors in Surgery undertook a study to determine what operative procedures residency program directors consider to be essential to the practice of general surgery and then we measured the actual operative experience of graduating residents in those procedures, as reported to the Residency Review Committee for Surgery (RRC). METHODS: An electronic survey was sent to residency program directors at the 254 general surgery programs in the US accredited by the RRC as of spring 2006. The program directors were presented with a list of 300 types of operations. Program directors graded the 300 procedures "A," "B," or "C" using the following criteria: A--graduating general surgery residents should be competent to perform the procedure independently; B--graduating residents should be familiar with the procedure, but not necessarily competent to perform it; and C--graduating residents neither need to be familiar with nor competent to perform the procedure. After ballots were tallied, the actual resident operative experience reported to the RRC by all residents finishing general surgery training in June 2005 was reviewed. RESULTS: One hundred twenty-one of the 300 operations were considered A level procedures by a majority of program directors (PDs). Graduating 2005 US residents (n = 1022) performed only 18 of the 121 A procedures, an average of more than 10 times during residency; 83 of 121 procedures were performed on an average less than 5 times and 31 procedures less than once. For 63 of the 121 procedures, the mode (most commonly reported) experience was 0. In addition, there was significant variation between residents in operative experience for specific procedures. In virtually all cases, the mean reported experience exceeded the mode, suggesting that the mean is a poor measure of typical experience. CONCLUSIONS: These data pose important problems for surgical educators. Methods will have to be developed to allow surgeons to reach a basic level of competence in procedures which they are likely to experience only rarely during residency. Even for more commonly performed procedures, the numbers of repetitions are not very robust, stressing the need to determine objectively whether residents are actually achieving basic competency in these operations. Finally, the large variations in experience between individuals in our residency system need to be explored, understood, and remedied.

The 'Celtic cross' technique for immediate umbilical reconstruction post-laparotomy and surgical ablation of the umbilicus.

SUMMARY: We present a novel method for immediate umbilical reconstruction following surgical ablation of the umbilicus that is simple and reproducible with aesthetically satisfactory results.

Multi-institutional validation of a web-based core competency assessment system.

OBJECTIVE: The Association of Program Directors in Surgery and the Division of Education of the American College of Surgeons developed and implemented a web-based system for end-of-rotation faculty assessment of ACGME core competencies of residents. This study assesses its reliability and validity across multiple programs. METHODS: Each assessment included ratings (1-5 scale) on 23 items reflecting the 6 core competencies. A total of 4241 end-of-rotation assessments were completed for 332 general surgery residents (> or =5 evaluations each) at 5 sites during the 2004-2005 and 2005-2006 academic years. The mean rating for each resident on each item was computed for each academic year. The mean rating of items representing each competency was computed for each resident. Additional data included USMLE and ABSITE scores, PGY, and status in program (categorical, designated preliminary, and undesignated preliminary). RESULTS: Coefficient alpha was greater than 0.90 for each competency score. Mean ratings for each competency increased significantly (p < 0.01) as a function of PGY. Mean ratings for professionalism and interpersonal/communication skills (IPC) were significantly higher than all other competencies at all PGY levels. Competency ratings of PGY 1 residents correlated significantly with USMLE Step I, ranging from (r = 0.26, p < 0.01) for Professionalism to (r = 0.41, p < 0.001) for Systems-Based Practice. Ratings of Knowledge (r = 0.31, p < 0.01), Practice-Based Learning & Improvement (PBLI; r = 0.22, p < 0.05), and Systems-Based Practice (r = 0.20, p < 0.05) correlated significantly with 2005 ABSITE Total Percentile. Ratings of all competencies correlated significantly with the 2006 ABSITE Total Percentile Score (range: r = 0.20, p < 0.05 for professionalism to r = 0.35, p < 0.001 for knowledge). Categorical and designated preliminary residents received significantly higher ratings (p < 0.05) than nondesignated preliminaries for knowledge, patient care, PBLI, and systems-based practice only. CONCLUSIONS: Faculty ratings of core competencies are internally consistent. The pattern of statistically significant correlations between competency ratings and USMLE and ABSITE scores supports the postdictive and concurrent validity, respectively, of faculty perceptions of resident knowledge. The pattern of increased ratings as a function of PGY supports the construct validity of faculty ratings of resident core competencies.

An internet-based residency assessment application that fulfills the outcome project's requirements.

PURPOSE: The acquisition and organization of information about surgical resident performance, as well as the assessment of the educational value of different rotations, is cumbersome and time consuming. The additional requirement by the Accreditation Council of Graduate Medical Education (ACGME) to assess General Competencies in the Outcome Project has multiplied the paperwork and workload demanded from each program director and residency coordinator. The purpose of our study was to simplify the collection of information and to organize it in a way that would fulfill the requirements of the Outcome Project. METHODS: We developed an Internet-based application for maintaining a database of residents, faculty, rotations, and their evaluations. RESULTS: The modular design allows flexibility in the selection of different tools that can be added at the discretion of the program director. The use of this application has facilitated the assessment process. Evaluations are instantly available for review. CONCLUSIONS: The General Competencies of any resident can be easily demonstrated, compared, and presented in an organized fashion that allows quick reaction to problems and facilitates compliance with the Outcome Project with little additional work for the residency staff.