A Computer Vision Algorithm to Predict Superior Mesenteric Artery Margin Status for Patients with Pancreatic Ductal Adenocarcinoma.

OBJECTIVE: To evaluate the feasibility of developing a computer vision algorithm that uses preoperative computed tomography (CT) scans to predict superior mesenteric artery (SMA) margin status in patients undergoing Whipple for pancreatic ductal adenocarcinoma (PDAC), and to compare algorithm performance to that of expert abdominal radiologists and surgical oncologists. SUMMARY BACKGROUND DATA: Complete surgical resection is the only chance to achieve a cure for PDAC; however, current modalities to predict vascular invasion have limited accuracy. METHODS: Adult patients with PDAC who underwent Whipple and had preoperative contrast-enhanced CT scans were included (2010-2022). The SMA was manually annotated on the CT scans, and we trained a U-Net algorithm for SMA segmentation and a ResNet50 algorithm for predicting SMA margin status. Radiologists and surgeons reviewed the scans in a blinded fashion. SMA margin status per pathology reports was the reference. RESULTS: Two hundred patients were included. Forty patients (20%) had a positive SMA margin. For the segmentation task, the U-Net model achieved a Dice Similarity Coefficient of 0.90. For the classification task, all readers demonstrated limited sensitivity, although the algorithm had the highest sensitivity at 0.43 (versus 0.23 and 0.36 for the radiologists and surgeons, respectively). Specificity was universally excellent, with the radiologist and algorithm demonstrating the highest specificity at 0.94. Finally, the accuracy of the algorithm was 0.85 versus 0.80 and 0.76 for the radiologists and surgeons, respectively. CONCLUSIONS: We demonstrated the feasibility of developing a computer vision algorithm to predict SMA margin status using preoperative CT scans, highlighting its potential to augment the prediction of vascular involvement.

National practice patterns in the use of endoscopic ultrasound biopsy for resectable Pancreatic Neuroendocrine Tumors: Insights into the role of DOTATATE PET/CT in diagnosis.

INTRODUCTION: Pancreatic neuroendocrine tumors (PNETs) are typically diagnosed using endoscopic ultrasound-guided (EUS) biopsy, which can be associated with complications. Since 2016, DOTATATE PET/CT has emerged as an effective tool to localize and stage PNETs. METHODS: Patients with PNETs who underwent R0 resections were identified from the 2004-2019 National Cancer Database PUF. Joinpoint regression and multivariable logistic regression were used to analyze trends in the use of biopsy. RESULTS: Of 16,746 R0 resected PNET patients, 44 â€‹% underwent diagnostic biopsy. Joinpoint regression showed a significant increase in the use of biopsy from 2004 to 2019 (APC 1.80, p â€‹< â€‹0.001). A higher percentage of patients diagnosed after DOTATATE approval underwent biopsy compared to those diagnosed before (48 â€‹% vs. 42 â€‹%, p â€‹< â€‹0.001). Adjusted analysis showed diagnosis after 2016 was associated with increased odds of biopsy (OR â€‹= â€‹1.67, p â€‹< â€‹0.001). CONCLUSIONS: Despite technologic advancement with DOTATATE PET/CT, there has been a significant increase in the proportion of resectable PNETs undergoing preoperative biopsy.

"Doing well": Intraoperative entrustable professional activity assessments provided limited technical feedback.

Background: Entrustable Professional Activities (EPAs) allow for the assessment of specific, observable, essential tasks in medical education. Since being developed in non-surgical fields, EPA assessments have been implemented in surgery to explore intraoperative entrustment. However, assessment burden is a significant problem for faculty, and it is unknown whether EPA assessments enable formative technical feedback. EPAs' formative utility could inform how surgical programs facilitate technical feedback for trainees. We aimed to assess the extent to which narrative comments provided through the Fellowship Council (FC) EPA assessments contained technical feedback. Methods: The FC previously collected EPA assessments for subspecialty surgical fellows from September 2020 to October 2022. Two raters reviewed assessments' narrative comments for inclusion of each skill area that makes up part of the Objective Structured Assessment of Technical Skills (OSATS). A third rater reconciled discrepant ratings. Results: During the study period, there were 3302 completed EPA assessments, including 1191 fellow self-assessments, 1124 faculty assessments, and 987 assessments without an identified assessor role. We found that assessments' narrative comments related to a median of two of the seven OSATS areas (IQR:1-2). There were no comments relevant to any of the seven OSATS areas in 16.0 % of all assessments. Conclusions: In this review of narrative comments for EPA assessments from the FC, we found that limited technical feedback of the kind included in the OSATS was provided in many assessments. These results suggest benefit to adjusting the EPA form, enhancing faculty development, or continuing additional types of targeted technical assessment intraoperatively. Key message: This analysis of narrative comments from fellowship EPA assessments showed that many assessments included limited technical feedback. To allow for continued technical feedback for fellows, these results highlight the need for further refinements of the EPA assessment form, additional faculty development, or ongoing use of other types of technical assessment.

Using the Number of N95® Filtering Facepiece Respirator Models as an Indicator of Supply Chain Stability in a US Health-Care System.

OBJECTIVES: Personal protective equipment (PPE) supply chain disruptions force US health-care entities to adopt conservation strategies such as procurement from different respirator manufacturers. This research seeks to better understand how the number of respirator models on hand can serve as an indicator of N95 filtering facepiece respirator (FFR) supply chain stability or disruption. METHODS: Researchers looked at differences in the mean number of N95 FFR models, averaged weekly, from 10 hospitals in a health-care system over 15 wk from June 1 to September 10, 2020. Participating hospitals entered near-daily PPE inventory data by manufacturer and model number. RESULTS: A linear mixed effect model was run in SPSS v. 26 using a random intercept for hospitals, with week as a fixed predictor and mean number of respirator models (averaged weekly) on hand as the dependent variable. Each week showed a small but significant effect compared with the past week (P < 0.001), where the average weekly number of respirator models on hand decreased. CONCLUSIONS: The limited data may indicate a resolution of supply chain disruptions and warrant further investigation. Consequently, the number of respirator models may be applicable as an indicator of supply chain stability and be more easily ascertained and tracked by health-care entities.

A Machine Learning Approach to Predict Postoperative Pancreatic Fistula After Pancreaticoduodenectomy Using Only Preoperatively Known Data.

BACKGROUND: Clinically-relevant postoperative pancreatic fistula (CR-POPF) following pancreaticoduodenectomy (PD) is a major postoperative complication and the primary determinant of surgical outcomes. However, the majority of current risk calculators utilize intraoperative and postoperative variables, limiting their utility in the preoperative setting. Therefore, we aimed to develop a user-friendly risk calculator to predict CR-POPF following PD using state-of-the-art machine learning (ML) algorithms and only preoperatively known variables. METHODS: Adult patients undergoing elective PD for non-metastatic pancreatic cancer were identified from the ACS-NSQIP targeted pancreatectomy dataset (2014-2019). The primary endpoint was development of CR-POPF (grade B or C). Secondary endpoints included discharge to facility, 30-day mortality, and a composite of overall and significant complications. Four models (logistic regression, neural network, random forest, and XGBoost) were trained, validated and a user-friendly risk calculator was then developed. RESULTS: Of the 8666 patients who underwent elective PD, 13% (n = 1160) developed CR-POPF. XGBoost was the best performing model (AUC = 0.72), and the top five preoperative variables associated with CR-POPF were non-adenocarcinoma histology, lack of neoadjuvant chemotherapy, pancreatic duct size less than 3 mm, higher BMI, and higher preoperative serum creatinine. Model performance for 30-day mortality, discharge to a facility, and overall and significant complications ranged from AUC 0.62-0.78. CONCLUSIONS: In this study, we developed and validated an ML model using only preoperatively known variables to predict CR-POPF following PD. The risk calculator can be used in the preoperative setting to inform clinical decision-making and patient counseling.

Pneumoconiosis incidence and prevalence among US Medicare beneficiaries, 1999-2019.

BACKGROUND: Pneumoconiosis is a group of occupational lung diseases caused by dust and fiber exposure. This study analyzes Medicare claims to estimate the burden of pneumoconiosis among fee-for-service (FFS; Medicare Parts A and B) Medicare beneficiaries during 1999-2019 in the United States. METHODS: Claim and enrollment information from 81 million continuously enrolled FFS Medicare beneficiaries were analyzed. Beneficiaries with any pneumoconiosis and cause-specific pneumoconiosis (e.g., asbestosis, silicosis) were identified using three case definitions (broad, intermediate, and narrow) with varying diagnostic criteria based on claim International Classification of Diseases, Clinical Modification (ICD-CM) diagnosis codes and Healthcare Common Procedure Coding System codes. Results are presented as ranges of values for the three case definitions. RESULTS: The 21-year prevalence range for any pneumoconiosis was 345,383-677,361 (412-833 per 100,000 beneficiaries) using the three case definitions. The highest prevalence was among those ≥75 years of age, males, Whites, and North American Natives. Most claims (70.0%-72.5%) included an ICD-CM diagnosis code for asbestosis. The broad pneumoconiosis prevalence rate increased significantly (p < 0.001) during 2002-2009 by 3%-10% annually and declined significantly by 3%-5% annually starting in 2009. The average annual broad incidence rate declined significantly by 7% annually during 2009-2019. CONCLUSIONS: Despite the decline in rate for any pneumoconiosis among Medicare beneficiaries, which is primarily attributed to a decline in asbestosis, pneumoconiosis is prevalent among FFS Medicare beneficiaries.

National Practice Patterns in Malignant Peritoneal Mesothelioma: Updates in Management and Survival.

BACKGROUND: Malignant peritoneal mesothelioma (MPM) is a rare malignancy with a historically poor prognosis. Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) has emerged as an effective therapy for patients with peritoneal malignancies. A contemporary analysis of trends in management of and survival from MPM is warranted. METHODS: Patients with MPM were identified from the National Cancer Database (2004-2018). Patients were categorized by treatment (CRS-HIPEC, CRS-chemotherapy, CRS only, chemotherapy only, no treatment), and joinpoint regression was employed to compute the annual percent change (APC) in treatment over time. Multivariable Cox proportional hazards models were used to analyze factors associated with survival. RESULTS: Of 2683 patients with MPM, 19.1% underwent CRS-HIPEC, and 21.1% received no treatment. Joinpoint regression revealed a statistically significant increase in the proportion of patients undergoing CRS-HIPEC over time (APC 3.21, p = 0.01), and a concurrent decrease in the proportion of patients who underwent no treatment (APC - 2.21, p = 0.02). Median overall survival was 19.5 months. Factors independently associated with survival included CRS-HIPEC, CRS, histology, sex, age, race, Charlson Comorbidity Index, insurance, and hospital type. Although there was a strong association between year of diagnosis and survival on univariate analysis (2016-2018 HR 0.67, p < 0.001), this association was attenuated after adjustment for treatment. CONCLUSIONS: CRS-HIPEC is increasingly employed as a treatment for MPM. In parallel, there has been a decrease in patients receiving no treatment with an increase in overall survival. These findings suggest that patients with MPM may be receiving more appropriate therapy; however, a substantial proportion of patients may remain undertreated.

Sharps Injury Rates Reported Among US Workers: National Electronic Injury Surveillance System-Occupational Supplement 2006 to 2020.

OBJECTIVE: To examine sharps injury (SI) rates among US workers treated in hospital emergency departments. METHODS: A national probability-based sample of approximately 67 US hospital emergency departments from the National Electronic Injury Surveillance System-Occupational Supplement was used to examine annual national estimates of SI rates (number of injuries/10,000 full-time equivalents) for US workers from 2006 to 2020. RESULTS: Among the general US worker population, the 25- to 34-year age group experienced the highest annual SI rate. Health care industry workers experienced SI rates up to 16 times the rate of all US workers. CONCLUSION: Younger age (≤34 years) is associated with increased SI risk. Tailored prevention efforts should be developed to address the specific needs of these workers, especially among health care workers. Continual occupational surveillance will maximize the health and safety of US workers.

Recognizing the psychological impact of a glioma diagnosis on mental and behavioral health: a systematic review of what neurosurgeons need to know.

A cancer diagnosis is life altering and frequently associated with both acute and long-lasting psychosocial and behavioral distress for patients. The impact of a diffuse glioma diagnosis on mental health is an important aspect of the patient experience with their disease. This needs to be understood by neurosurgeons so these concerns can be appropriately addressed in a timely fashion and integrated into the multidisciplinary care of neuro-oncology patients. The relatively grave prognosis associated with diffuse gliomas, the morbidity associated with treatment, and the constant threat of developing a new neurological deficit all can negatively affect a patient's mental ability to cope and ultimately manifest in mental health disorders such as anxiety and depression. The objective of this systematic review was to describe the variety of behavioral health disorders patients may experience following a glioma diagnosis and discuss possible treatment options. The PubMed, Web of Science, Embase, and PsycINFO databases were searched through July 1, 2022, using broad search terms, which resulted in 5028 studies that were uploaded to Covidence systematic review software. Duplicates, non-English-language studies, and studies with irrelevant outcomes or incorrect design were removed (n = 3167). A total of 92 articles reporting behavioral health outcomes in brain tumor patients were categorized and extracted for associations with overall mental health, anxiety, depression, distress, stress, pharmacology, interventions, and mental health in caregivers. The authors identified numerous studies reporting the prevalence of mental health disorders and their negative influence in this population. However, there is a paucity of literature on therapeutic options for patients. Given the strong correlation between patient quality of life and mental well-being, there is a considerable need for early recognition and treatment of these behavioral health disorders to optimize everyday functioning for patients.

The role of emergency incident type in identifying first responders' health exposure risks.

Fire-based emergency management service (EMS) personnel are dispatched to various incidents daily, many of which have unique occupational risks. To fully understand the variability of incident types and how to best prepare and respond, an exploration of the U.S. coding system of incident types is necessary. This study uses potential exposure to SARS-CoV-2 as a case example to understand if and how coding categories for incident call types may be updated to improve data standardization and emergency response decision making. Researchers received emergency response incident data generated by three fire department computer-aided dispatch (CAD) systems between March and September 2020. Each incident was labeled EMS, Fire, or Other. Of the 162,766 incidents, approximately 8.1% (n = 13,144) noted potential SARS-CoV-2 exposure within their narrative descriptions of which 86.3% were coded as EMS, 9.9% as Fire, and 3.9% as Other. To assess coding variability across incident types, researchers used the original 3-incident type variable and a new 5-incident type variable reassigned by researchers into EMS, Fire, Other, Hazmat, and Motor Vehicle. Logit regressions compared differences in potential exposure using the 3- and 5-incident type variables. When evaluating the 3-incident type variable, those responding to a Fire versus an EMS incident were 84% less likely to be associated with potential exposure to SARS-CoV-2. For the 5-incident type variable, those responding to Fire incidents were 77% less likely to be associated with a potential exposure than those responding to EMS incidents. Changes in potential exposure between the 3- and 5-incident type models show the need to understand how incident types are assigned. This demonstrates the need for data standardization to accurately categorize incident types to improve emergency preparedness and response. Results have implications for incident type coding at fire department municipality and national levels.

Sarcopenia Diagnosed Using Masseter Muscle Diameter as a Survival Correlate in Elderly Patients with Glioblastoma.

BACKGROUND: Elderly patients with glioblastoma (GBM) have a worse prognosis than do younger patients. The present study aimed to identify the patient, treatment, and imaging features, including measures of sarcopenia, associated with worse survival and 90-day postoperative mortality for elderly patients with GBM. METHODS: A single-center retrospective study was conducted of patients aged ≥79 years at surgery who had undergone biopsy or resection of a World Health Organization grade IV GBM at the initial diagnosis. Imaging features of sarcopenia were collected, including the masseter and temporalis muscle diameters. Multivariate analyses were performed to identify factors associated with survival and 30-day complications. RESULTS: The cohort included 110 patients with a mean age of 82.8 years at surgery and a median preoperative Karnofsky performance scale score of 80. The majority of patients underwent a surgical resection (66.4%) while a minority underwent biopsy (33.6%). Adjuvant chemo- and/or radiation therapy were used in 72.5% of the cohort. On multivariate analysis, age (hazard ratio [HR], 7.97; 95% confidence interval [CI], 1.63-36.3), adjuvant therapy (RT or TMZ vs. none: HR, 0.12; 95% CI, 0.05-0.3; RT plus TMZ vs. none: HR, 0.05; 95% CI, 0.02-0.14), surgical resection (HR, 0.46; 95% CI, 0.24-0.9), multifocality (HR, 2.7; 95% CI, 1.14-6.4), and masseter diameter (HR, 0.12; 95% CI, 0.02-0.78) were associated with survival. Masseter diameter was the only factor associated with 90-day mortality after surgical resection (P = 0.044). CONCLUSIONS: GBM patients over the age of 79 have acceptable outcomes after resection, followed by adjuvant chemotherapy and RT. In addition to the treatment factors that predicted for survival, a decreased masseter diameter on preoperative imaging, a marker of sarcopenia, was associated with shorter overall survival and 90-day mortality after surgical resection.

Understanding Filtering Facepiece Respirators.

How to ensure adequate protection.

Lessons Learned from the Development and Demonstration of a PPE Inventory Monitoring System for US Hospitals.

An international system should be established to support personal protective equipment (PPE) inventory monitoring, particularly within the healthcare industry. In this article, the authors discuss the development and 15-week deployment of a proof-of-concept prototype that included the use of a Healthcare Trust Data Platform to secure and transmit PPE-related data. Seventy-eight hospitals participated, including 66 large hospital systems, 11 medium-sized hospital systems, and a single hospital. Hospitals reported near-daily inventory information for N95 respirators, surgical masks, and face shields, ultimately providing 159 different PPE model numbers. Researchers cross-checked the data to ensure the PPE could be accurately identified. In cases where the model number was inaccurately reported, researchers corrected the numbers whenever possible. Of the PPE model numbers reported, 74.2% were verified-60.5% of N95 respirators, 40.0% of face shields, and 84.0% of surgical masks. The authors discuss the need to standardize how PPE is reported, possible aspects of a PPE data standard, and standards groups who may assist with this effort. Having such PPE data standards would enable better communication across hospital systems and assist in emergency preparedness efforts during pandemics or natural disasters.

Applying the Social Vulnerability Index as a Leading Indicator to Protect Fire-Based Emergency Medical Service Responders' Health.

During emergencies, areas with higher social vulnerability experience an increased risk for negative health outcomes. However, research has not extrapolated this concept to understand how the workers who respond to these areas may be affected. Researchers from the National Institute for Occupational Safety and Health (NIOSH) merged approximately 160,000 emergency response calls received from three fire departments during the COVID-19 pandemic with the CDC's publicly available Social Vulnerability Index (SVI) to examine the utility of SVI as a leading indicator of occupational health and safety risks. Multiple regressions, binomial logit models, and relative weights analyses were used to answer the research questions. Researchers found that higher social vulnerability on household composition, minority/language, and housing/transportation increase the risk of first responders' exposure to SARS-CoV-2. Higher socioeconomic, household, and minority vulnerability were significantly associated with response calls that required emergency treatment and transport in comparison to fire-related or other calls that are also managed by fire departments. These results have implications for more strategic emergency response planning during the COVID-19 pandemic, as well as improving Total Worker Health® and future of work initiatives at the worker and workplace levels within the fire service industry.

Medical claims paid by workers' compensation insurance among US Medicare beneficiaries, 1999-2016.

BACKGROUND: Workers' compensation claims among Medicare beneficiaries have not been described previously. To examine the healthcare burden of work-related injury and illness among Medicare beneficiaries, we assessed the characteristics, healthcare utilization, and financial costs among Medicare beneficiaries with claims for which workers' compensation was the primary payer. METHODS: We extracted final action fee-for-service Medicare claims from 1999 to 2016 where workers' compensation had primary responsibility for claim payment and beneficiary, claim type, diagnoses, and cost information from these claims. RESULTS: During 1999-2016, workers' compensation was the primary payer for 2,010,200 claims among 330,491 Medicare beneficiaries, and 58.7% of these beneficiaries had more than one claim. Carrier claims submitted by noninstitutional providers constituted the majority (94.5%) of claims. Diagnosis codes indicated 19.4% of claims were related to diseases of the musculoskeletal system and connective tissue and 12.9% were related to disease of the circulatory system. Workers' compensation insurance paid $880.4 million for these claims while Medicare paid $269.7 million and beneficiaries paid $37.4 million. CONCLUSIONS: Workers' compensation paid 74% of the total amount to providers for these work-related medical claims among Medicare beneficiaries. Claim diagnoses were similar to those of all workers' compensation claims in the United States. Describing these work-related claims helps identify the healthcare burden due to occupational injury and illness among Medicare beneficiaries resulting from employment and identifies a need for more comprehensive collection and surveillance of work-related medical claims.

Baseline neuropsychological profiles in prion disease predict survival time.

OBJECTIVE: Few studies have captured the neuropsychological profile of sporadic Creutzfeldt-Jakob disease (sCJD) with neuropsychological testing, and little is known about cognitive predictors of survival. We characterized baseline neuropsychological performance in sCJD and investigated associations with survival. METHODS: sCJD participants who completed the MMSE (n = 118), 61 sCJD of whom also completed a neuropsychological battery at baseline, and 135 age-matched healthy controls, were included. Composite scores of global cognition, memory, executive functions, visuospatial, and language were derived. Cox proportional hazard models estimated survival time, controlling for age and education. Additional models adjusted for Barthel Index and PRNP codon 129 polymorphism. RESULTS: sCJD participants performed significantly worse than controls on all cognitive tasks and composites with most showing very large effect sizes. The three tests showing the largest group differences were delayed verbal recall (Hedges'g = 4.08, P < 0.0001), Stroop Inhibition (Hedges'g = 3.14, P < 0.0001), and Modified Trails (Hedges'g = 2.94, P < 0.0001). Memory (95%) and executive functioning (87%) composites were most commonly impaired. Poorer global (HR = 0.65, P < 0.0001), visuospatial (HR = 0.82, P < 0.0001), and memory (HR = 0.82, P = 0.01) composites predicted shorter survival. Visuospatial cognition remained a significant predictor even after adjusting for all other cognitive composites; each standard deviation decrease in visuospatial cognition was associated with an 18% higher chance of death (HR = 0.82, P < 0.003). Global (HR = 0.68, P = 0.03) and visuospatial (HR = 0.82, P = 0.001) composites remained significant predictors after controlling for Barthel Index and codon 129. INTERPRETATION: sCJD participants exhibit a broad range of cognitive impairments, with memory and executive functioning deficits in the vast majority. Neuropsychological assessment, particularly of visuospatial abilities, informs prognostication in sCJD.