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OBJECTIVE Surgical site infection (SSI) is a leading cause of morbidity following posterior spine surgery. The optimal choice of skin closure technique depending on patient- and procedure-specific characteristics remains to be elucidated. METHODS The Neurosurgery Enterprise Registry (NER) at Mayo Clinic was queried for patients who underwent posterior spine surgery from 2017 to 2023. Propensity matching was performed to match patients on the basis of the development of SSI and baseline characteristics, including age, sex, race, and comorbidities. Perioperative outcomes were analyzed using data from the NER and medical records. RESULTS A total of 18,842 cases of posterior spine surgery were identified in the NER, and SSI was observed in 154 cases (0.8%). Of these patients, 308 patients were included in the 1:1 propensity score–matched cohort analysis, with 154 patients included in each group. Sutures were used in 224 patients (72.7%) and staples in 84 patients (27.3%) (p < 0.01). Female patients comprised 45.1% of the sutures group and 46.4% of the staples group (p = 0.8). The mean ± SD age was 59.8 ± 15.4 years in the sutures group and 60.8 ± 11.9 years in the staples group (p = 0.6). Fusion was performed in 27.2% of patients in the sutures group and 44% in the staples group (p < 0.01). Multilevel fusion comprised 68.9% of fusion cases in the sutures group and 67.6% in the staples group (p = 0.8). Comorbidities, such as diabetes (p = 0.6), hypertension (p = 0.1), and the use of disease-modifying antirheumatic drugs (DMARDs) (p = 0.5) and immunosuppressants (p = 0.2), did not differ between groups. Univariate analysis performed in the propensity score–matched cohort showed that SSI was observed in 53.6% of patients in the sutures group and 40.5% in the staples group (p = 0.04). No significant differences were noted regarding 30-day (p = 0.3), 90-day (p = 0.2), and 1-year (p = 0.3) readmissions and 30-day (p = 0.7), 90-day (p = 0.8), and 1-year (p = 0.8) reoperations. On multivariable logistic regression, SSI was not significantly associated with the choice of skin closure technique (p = 0.3). CONCLUSIONS After adjustment for spinal fusion, number of fused levels, the use of immunosuppressants, and other risk factors, SSI development was not significantly associated with the use of sutures versus staples following posterior spine surgery in our institution. Additionally, no significant differences were observed regarding baseline characteristics and other perioperative outcomes. The authors’ analysis shows that skin closure technique did not significantly affect SSI rates and other outcomes in these patients.

BACKGROUND: Familial hypercholesterolemia (FH) is an autosomal dominant genetic disorder that increases risk for premature coronary artery disease and has accessible and effective interventions. The Dutch lipid clinic network is currently the most used diagnostic criterion; however, genetic sequencing provides a definitive diagnosis of FH. The goals of this study were to determine whether germline genetic screening using exome sequencing could be used to efficiently identify individuals who were genotype positive for FH. METHODS: Participants were recruited from 3 geographically and racially diverse sites in the United States (Rochester, MN; Phoenix, AZ; and Jacksonville, FL). Participants underwent Exome+ sequencing (dba Helix, San Mateo, CA) and return of results for specific genetic findings in APOB , LDLR , or PCSK9 . A chart review was performed to collect demographics, personal, and family cardiovascular history. RESULTS: At the time of the study, 84 413 participants were enrolled in the Tapestry study. Annotation and interpretation of all variants in genes for FH resulted in the identification of 419 likely pathogenic and pathogenic variants (prevalence, 0.50%), which included 116 APOB , 298 LDLR , and 5 PCSK9 . Sixty-six percent were female, the mean body mass index was 27.3, with 12.3% reporting a history of diabetes. Hypertriglyceridemia (≥150 mg/dL) was present in 39.5% and reduced HDL (<50 mg/dL) was present in 56.7% of patients. 27.5% of patients were not on cholesterol-lowering medications, and only 10% of FH carriers were at goal low-density lipoprotein cholesterol levels. A history of coronary artery disease was reported in 22.4% of the cohort. Nearly 90% of these participants were newly diagnosed carriers of FH. Only 30.8% of confirmed genetic diagnoses of FH satisfied clinical (Dutch lipid clinic network) criteria for a diagnosis. CONCLUSIONS: Our results emphasize the need for wider utilization of germline genetic sequencing for enhanced screening and detection of individuals who have familial hypercholesterolemia. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT05212428.

PURPOSE Lack of race- and age-diversity in clinical trials adversely affects generalizability of trial results and equity of trial access. Research on barriers to representative accrual has focused on patient-level factors. We aimed to define site-level factors affecting the diversity of accrual to a multicenter clinical trial. METHODS Alliance 191901 (GETSET) is a national randomized controlled trial testing interventions to promote breast cancer endocrine therapy adherence, which oversamples Black women and those under age 50 years at 30% thresholds. A secondary study objective is to examine site-level factors associated with accrual of Black and younger participants. At 50% accrual to the parent study, we performed prespecified analyses of association between site characteristics (region, neighborhood racial composition, Alliance membership type, number of recent accruals to cooperative research group trials) and the proportion of Black patients and younger patients accrued. We also examined trajectories of accrual over time for race- and age-specified subgroups. RESULTS The analysis included 124 sites. Among 590 participants, 9.7% were Black, and 22.4% were age <50 years. Neither site type nor historical accrual volume was associated with Black participant recruitment. Southern sites recruited higher proportions of Black participants (19.0% v 7.3% for West, P < .001). Neighborhood racial composition was positively associated with recruitment of Black participants (16.2% at sites from highest Black composition v 1.4% in lowest, P < .01). Recruitment trajectories of Black participants were slower than target rates, whereas those among non-Black participants were faster. CONCLUSION Neighborhood composition and geographic region were predictors of proportions of Black participants accrued to A191901 sites, but site type and historical accrual volume were not. When trials must limit site selection, identifying sites based on neighborhood composition and geography may be an appropriate tool for increasing trial diversity.

BACKGROUND. We developed a prospective, multicenter “registry” to evaluate the effect of extracorporeal photopheresis for lung transplant recipients who develop chronic lung allograft dysfunction (CLAD) with the bronchiolitis obliterans syndrome (BOS) phenotype (CLAD/BOS) and who are refractory to conventional standard-of-care therapy. METHODS. Data from 258 lung transplant recipients enrolled in the Registry between April 2015 and April 2022 were included in this analysis. All recorded parameters (eg, demographics), including forced expiratory volume in 1 s (FEV1) measurements and indices (FEV1% baseline, FEV1 rate of decline) at several time periods, were included in multivariate linear/logistic and Kaplan-Meier analyses to evaluate potential associations with survival. RESULTS. Mortality at 6 and 12 mo after CLAD/BOS diagnosis was 5% and 14%, whereas mortality at 6 and 12 mo after enrollment was 15% and 26%, respectively. The primary cause of death in the cohort was respiratory failure or graft failure (74%). Rate of FEV1 decline (log) at enrollment was independently associated with survival (log days) from CLAD/BOS diagnosis and enrollment (r = 0.55 and r = 0.3, respectively). The rates of FEV1 decline among survivors were lower (–77 ± 89 mL/mo) compared with nonsurvivors (–148 ± 155 mL/mo) at 6 mo after enrollment (P = 0.0001). CONCLUSIONS. The rate of FEV1 decline quantified using at least 5 FEV1 measurements is a robust surrogate outcome. We plan to use these findings to revise our randomized controlled trial to facilitate risk adjustment using FEV1 rate of decline strata at enrollment and as a scientifically valid surrogate for outcome.

Abstract Introduction The deep inferior epigastric artery perforator (DIEP) flap is widely used for breast reconstruction, with donor site complications influenced by various factors. This study assessed the impact of incisional negative pressure wound therapy (iNPWT) on donor site healing compared to standard dressings (SD). Methods A retrospective review of DIEP flap reconstructions performed between 2017 and 2022 was conducted. Donor sites were managed with either SD or iNPWT (PREVENA PLUS™, 3M). Outcomes assessed included donor-site complications, drain duration, length of stay, and readmissions. Predictors of complications were analyzed using univariable and multivariable logistic regression. Results A total of 320 patients were included; iNPWT was applied in 165 (51.6%) and SD in 155 (48.4%). Baseline demographics and comorbidities were comparable between groups. Complication rates within 30 days were 23.0% for iNPWT and 27.1% for SD (p = 0.401); iNPWT use was associated with significantly earlier drain removal (median 13 vs. 17 days, p = 0.004). Multivariable analysis identified smoking as an independent predictor of donor-site complications (aOR 1.74, 95% CI 1.05–2.86, p = 0.030); iNPWT was not significantly associated with reduced complication rates (OR 1.00, 95% CI 0.64–1.58, p = 0.977). Conclusions Smoking was confirmed as a significant predictor of donor-site morbidity. While iNPWT did not lower overall complication rates, it modestly reduced drain duration. Further prospective studies are warranted to define its role in DIEP flap reconstruction. Level of Evidence Level III, therapeutic study

BACKGROUND: To reduce technical variation in cancer surgery, the Commission on Cancer (CoC) recently implemented 6 operative standards as part of its national cancer center accreditation process. CoC sites are evaluated for compliance with these standards through scheduled visits conducted by trained site reviewers. We characterized site reviewers’ perspectives on the implementation of the operative standards. STUDY DESIGN: Twenty interviews were conducted with CoC site reviewers using a semistructured interview guide based on the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework. Themes were identified using thematic analysis mapped to the updated Consolidated Framework for Implementation Research. RESULTS: Site reviewers viewed the operative standards as an effective starting point for improving technical quality and were optimistic the standards would lead to positive change. Compliance was associated with supportive site leadership, effective interdisciplinary communication, and the availability of adequate personnel and institutional resources. In contrast, resistance from surgeons was identified as a key barrier. CoC site reviewers interpret their role as extending beyond assessing compliance, viewing themselves as advocates, educators, and partners to the sites. CONCLUSIONS: Overall, CoC site reviewers perceive the operative standards favorably. To enhance implementation of the operative standards, efforts should focus on modifiable institutional and individual-level factors, such as leadership support and surgeon engagement. Additionally, the multifaceted role of the site reviewers presents a valuable opportunity to improve compliance by formalizing the supportive relationship between reviewers and sites.

Objective: To develop an artificial intelligence–based pipeline to assess and triage patient-submitted postoperative wound images. Background: The rise of outpatient surgeries, remote monitoring, and patient-submitted wound images via online portals has contributed to a growing administrative workload on clinicians. Early identification of surgical site infection (SSI) is essential for reducing postoperative morbidity. Methods: Patients ≥18 years old who underwent surgery at 9 affiliated Mayo Clinic hospitals (2019-2022) and were captured by the National Surgical Quality Improvement Program (NSQIP) were included. Eligibility required submission of one image via the patient portal within 30 days after surgery. Images were independently screened in duplicate to determine the presence of an incision. SSI outcomes were obtained from NSQIP. The developed model consisted of 2 stages: incision detection and SSI detection in images with incisions. Four pretrained architectures were evaluated using 10-fold cross-validation, with upsampling and data augmentation to mitigate class imbalance. An end-to-end pipeline, image quality assessment and sensitivity analysis stratified by race were also performed. Results: Among 6060 patients, the median age was 54 years (interquartile range: 40–65), 61.4% (n=3805) were female, and 92.5% (n=5731) identified as White. SSIs were confirmed in 6.2% (n=386) images. Vision Transformer outperformed all others, achieving an incision detection accuracy of 0.94 (area under the curve=0.98) and an SSI detection accuracy of 0.73 (area under the curve=0.81). In addition, it demonstrated strong performance in assessing image quality. Sensitivity analysis revealed comparable performance across racial subgroups. Conclusion: This artificial intelligence pipeline demonstrates promising performance in automating wound image assessment and SSI detection, reducing clinical workload and improving postoperative care.

Abstract Background Medical chaperones are authorized individuals present during physical examinations involving the genitals, breasts/chest, or anal areas. The use of medical chaperones may provide an opportunity to improve transgender and gender diverse (TGD) patients’ experiences with sensitive examinations. Aim To examine TGD adult patients’ preferences and comfort for having a medical chaperone and whether TGD-specific characteristics, social anxiety symptoms, and feelings of medical mistrust are associated with preference for having a medical chaperone present during a sensitive physical examination. Methods This study used a cross-sectional survey that randomly sampled adult patients from a gender clinic in the Midwest region of the U.S. A total of 420 surveys were mailed. Sixty-two surveys were returned undeliverable, 358 reached recipients; 151 were returned (42.1% response rate). The survey included items related to demographics, gender-related anatomical dysphoria, social anxiety symptoms, feelings of medical mistrust, and preference and comfort towards medical chaperones. Results Among 149 respondents, 74 (49.7%) reported comfort for the idea of having a medical chaperone present during a sensitive physical examination, 50 (33.6%) reported neutral comfort, and 25 (16.8%) reported discomfort. Among 147 respondents, 89 (60.5%) endorsed a preference for a female medical chaperone. We found no associations between gender-related anatomical dysphoria or social anxiety symptoms and comfort for having a medical chaperone, or the gender preference for a medical chaperone. Medical mistrust was associated with lower comfort with having a medical chaperone present during a sensitive physical examination. Clinical Implications Routinely offering medical chaperones, especially female chaperones, is like to be generally acceptable to most TGD patients. These findings may inform clinic policies on providing medical chaperones during sensitive examinations. Strengths and Limitations This study is the first to examine TGD preferences for medical chaperones. Findings are limited by a single site, homogeneous sample, cross-sectional design, and reliance on hypothetical rather than observed examinations. Conclusion TGD adults report comfort with the concept of having a medical chaperone during sensitive examinations and most would prefer the chaperone to be female. Preference for having a medical chaperone present during a sensitive physical exam is not likely influenced by gender dysphoria or social anxiety.

The exact physiological role of BACE2 in endothelial function of systemic arteries is unknown. Our study shows that thromboxane A2 and prostaglandin F2α are responsible for impairment of endothelium-dependent relaxations in endothelium-specific BACE2-deficient mice. The data support an important role of BACE2 in the control of endothelial arachidonic acid metabolism and vasomotor function.