Citations

Abstract Purpose The U.S. population is rapidly aging. The supply of surgeons needed to meet this demand should be evaluated. This study evaluated the trends in supply of Medicare surgeons by specialty and by U.S. state and region. Method All surgeons associated with a National Provider Identifier for cardiothoracic surgery, colorectal surgery, general surgery, gynecologic oncology, hand surgery, neurosurgery, obstetrics-gynecology, ophthalmology, oral and maxillofacial surgery, orthopedic surgery, otolaryngology, plastic and reconstructive surgery, surgical oncology, urology, and vascular surgery from 2013 to 2019 on the Centers for Medicare & Medicaid Services website were included. The absolute number of physicians was adjusted per 100,000 Medicare beneficiaries. Annual change was calculated by linear regression model, and the compound annual growth rate (CAGR) was calculated per specialty. Results The absolute number of physicians per 100,000 beneficiaries increased in 6 of 15 specialties during the study period. Vascular surgery had the largest annual increase (+0.23; CAGR, +2.75%), and obstetrics-gynecology had the largest annual decrease (−1.08; CAGR, −1.44%). Surgical oncology showed the largest positive CAGR (+4.20%). Oral and maxillofacial surgery had the largest negative CAGR (−2.86%). The Northeast was above the national average in supply for each specialty. The Midwest had the most specialties with positive CAGRs. The South did not meet the national average for physicians in any specialty. Conclusions This analysis of 15 surgical specialties provides important context to predicted physician shortages to the Medicare population. The study found geographic variation by region across specialty, which has important implications for health care planning from the level of undergraduate medical education to provision of hospital resources. Overall, the supply of surgeons across all specialties may not be sufficient to meet the demand of the rapidly aging U.S. population. Future study is needed to evaluate why surgeons are leaving the Medicare program.

Abstract Purpose: Early detection of neurofibromatosis type 1 (NF1)–associated peripheral nerve sheath tumors (PNST) informs clinical decision-making, enabling early definitive treatment and potentially averting deadly outcomes. In this study, we describe a cell-free DNA (cfDNA) fragmentomic approach that distinguishes nonmalignant, premalignant, and malignant forms of PNST in the cancer predisposition syndrome, NF1. Experimental Design: cfDNA was isolated from plasma samples of a novel cohort of 101 patients with NF1 and 21 healthy controls and underwent whole-genome sequencing. We investigated diagnosis-specific signatures of copy-number alterations with in silico size selection as well as fragment profiles. Fragmentomics were analyzed using complementary feature types: bin-wise fragment size ratios, end motifs, and fragment non-negative matrix factorization signatures. Results: The novel cohort of patients with NF1 validated that our previous cfDNA copy-number alteration–based approach identifies malignant PNST (MPNST) but cannot distinguish between benign and premalignant states. Fragmentomic methods were able to differentiate premalignant states including atypical neurofibromas (AN). Fragmentomics also adjudicated AN cases suspicious for MPNST, correctly diagnosing samples noninvasively, which could have informed clinical management. Conclusions: Novel cfDNA fragmentomic signatures distinguish AN from benign plexiform neurofibromas and MPNST, enabling more precise clinical diagnosis and management. This study pioneers the early detection of malignant and premalignant PNST in NF1 and provides a blueprint for decentralizing noninvasive cancer surveillance in hereditary cancer predisposition syndromes.

Background: The aim of this study was to examine the effect of applying synchronized music and appropriate music selection on motivation for exercise and achieving better results in individuals of different fitness levels. Methods: The study included a total of 20 female participants, who for certain analyses were divided into two groups with slightly different levels of aerobic fitness: students from the Faculty of Sport and Physical Education (n = 10, age 23.0 ± 2.8), and middle-aged adult women exercising recreationally (n = 10, age 38.3 ± 11.6). Cardiopulmonary exercise testing (CPET) was conducted using a treadmill and gas analysis equipment, and motivational music qualities were assessed using the BMRI-2 questionnaire. The procedure included an initial maximal CPET test, echocardiography, and spirometric tests, followed by an interview to select preferred music tracks. A second CPET test was then performed with the chosen motivational music. The Borg Rating of Perceived Exertion (RPE) scale was used in both tests. Results: The internal consistency of the questionnaire was confirmed with a Cronbach’s Alpha of 0.982. The synchronized motivational music significantly improved cardiopulmonary parameters such as peak oxygen consumption (peak VO2), oxygen consumption (VO2) at the second ventilatory threshold (VT2), peak heart rate (peak HR), test duration, and reduced perceived exertion (RPE) at the beginning of the test and at the intensity level corresponding to the VT2. Negligible differences were noted between students and recreational athletes, so it can be assumed that music had an equal impact on these two groups of subjects. Conclusions: The study concluded that synchronous motivational music significantly enhances cardiopulmonary performance and reduces perceived fatigue during physical exertion by serving as a key motivational element and facilitating more economical movement.

Antithrombotic treatment in patients with atrial fibrillation (AF) and acute coronary syndrome (ACS) poses a dilemma. We compared outcomes of dual antithrombotic therapy (DAT) (direct oral anticoagulants (DOACs)/warfarin + antiplatelets) vs triple antithrombotic therapy (TAT) (DOACs/warfarin, aspirin, and P2Y12 inhibitor) in this population. Multiple databases were searched from inception to December 17, 2023 to identify randomized controlled trials (RCTs) comparing DAT vs TAT in patients with AF and ACS. Outcomes included major adverse cardiac events (MACE), bleeding events, stroke, stent thrombosis, and myocardial infarction (MI). Relative risk and 95% confidence intervals were estimated with a random-effects model using the inverse-variance technique. We assigned I 2 > 50% as an indicator of statistical heterogeneity. p -Value <0.05 was considered significant. Ten RCTs comprising 6186 patients on TAT (female 26%, mean age 71 ± 9 years) and 6800 patients on DAT (female 27%, mean age 71 ± 9 years) were included. Patients receiving DAT experienced lower rates of bleeding events compared to those receiving TAT, with relative risks of 0.69 [0.55–0.87] ( p < 0.001), 0.65 [0.40–1.06] ( p = 0.09), and 0.62 [0.46–0.84] ( p < 0.001) for TAT durations of 3, 6, and 12 months, respectively. No difference was seen in the occurrence of MACE, MI, stroke, or stent thrombosis between DAT and TAT across all three durations of TAT. This is the largest pooled analysis comparing TAT to DAT stratified by the duration of antithrombotic therapy. Our results revealed that DAT was associated with reduced bleeding risk despite no difference in other outcomes.

Background and Objective Game-based learning has been used in medical education, but there are limited studies to date addressing the use of gamification in child abuse education. Child abuse is a content area that is undertaught in medical schools. This study aimed to explore the feasibility, acceptability, and perception among medical students of the online game-based platform Kahoot! for learning about child abuse. Materials and methods Kahoot! was utilized to deliver a 1-hour child abuse education session to 10 groups of medical students on their pediatric clerkship between 2021 and 2023. At each of the game-based sessions, medical students were asked whether they had used Kahoot! before, whether they preferred Kahoot! to a traditional lecture style, and whether they would like Kahoot! to be utilized for their education in other specialties. They were asked to describe this format of education in 20 characters or less and were given the opportunity to provide both quantitative and qualitative feedback through routine medical school course evaluations. A secondary outcome of this study sought to assess the enthusiasm of physicians in the field of child abuse for use of Kahoot! in medical education. We report descriptive statistics for the quantitative measures and a narrative summary supplemented by a visual representation of the qualitative feedback. Results A total of 346 students participated in the game-based education sessions. Ninety-three percent of participants preferred the game-based education compared to a traditional lecture format, and 90% wanted gamification to be utilized by other specialties. Qualitative feedback from the students described the format as engaging, fun, and interactive. Of 165 physicians in the field of child abuse who were surveyed about their interest in using Kahoot! , 159 (96%) responded affirmatively that they would consider incorporating it into their teaching regimen. Conclusion Our findings suggest the use of gamification was feasible and acceptable to medical students as well as physicians in the field of child abuse. Most medical students preferred the use of game-based education to traditional lectures and found the content to be fun, engaging, and interactive.

Abstract Background: For resectable gastric cancer, postoperative adjuvant chemotherapy remains the standard modality for preventing recurrence and improving survival. Although a previous study proposed a model for stratifying risk and determining the likelihood of chemotherapeutic benefit following surgery, this model requires molecular genomic analysis of tumour tissues and only uses unidimensional data. However, a recent study revealed that a multiomics approach reflects more compressive cancer characteristics, providing more precise prediction of treatment response. Recent advancements indicate that radiomics features are predictive biomarkers of treatment response. The present study investigated whether computed tomography (CT) image-based quantitative radiomics combined with genomics data can provide clinically actionable information for a more detailed stratification of cancer patients. Methods: This retrospective multicohort study included patients with advanced gastric cancer treated with surgery plus adjuvant chemotherapy or surgery alone. Two filters were used to extract 1,106 radiomics features from preoperative venous-phase CT images. Dimensional reduction was performed via Cox regression with the LASSO method, following which the coefficients were used to determine the Rad-score. The optimal cutoff point was determined via the Kaplan-Meier method and used to divide the cohort into high- and low-risk groups. The primary endpoints were the predictive and prognostic performance of the Rad-score and nomogram in terms of overall survival and the value of adding the Rad-score to genetic information. Findings: The optimal Rad-score (11·978379207) successfully stratified patients into low- and high risk groups. Improved survival was noted among patients defined to have a ‘poor prognosis’ with GZMB–, WARS–, and SFRP+ genetic test results and among high-risk patients based on the Rad-score when no adjuvant chemotherapy was provided. Interpretation: Our findings suggest that the Rad-score can be used to further stratify patients in the response group, preventing potentially ineffective treatment and unnecessary adverse events in those with advanced gastric cancer

Study Design Retrospective cohort study. Objective The impact of paraspinal sarcopenia following fusions that extend to the upper thoracic spine remain unknown. The purpose of the present study was to assess the impact of sarcopenia on the development of PJK and PJF following spine fusion surgery from the upper thoracic spine to the pelvis. Methods We performed a retrospective review of patients who underwent spine fusion surgery that extended caudally to the pelvis and terminated cranially between T1-6. The cohort was divided into 2 groups: (1) patients without PJK or PJF and (2) patients with PJK and/or PJF. Univariate and multivariate analyses were performed to determine risk factors for the development of proximal junctional complications. Results We identified 81 patients for inclusion in this study. Mean HU at the UIV was 186.1 ± 47.5 in the cohort of patients without PJK or PJF, which was substantially higher than values recorded in the PJK/PJF subgroup (142.4 ± 40.2) ( P < 0.001). Severe multifidus sarcopenia was identified at a higher rate in the subgroup of patients who developed proximal junction pathology (66.7%) than in the subgroup of patients who developed neither PJK nor PJF (7.4%; P < 0.001). Multivariate analysis demonstrated both low HU at the UIV and moderate-severe multifidus sarcopenia to be risk factors for the development of PJK and PJF. Conclusions Severe paraspinal sarcopenia and diminished bone density at the UIV impart an increased risk of developing PJK and PJF in following thoracolumbar fusions from the upper thoracic spine to the pelvis.

Abstract Introduction The risk of malignancy (ROM) remains an area of interest for further evaluation in reporting systems including in International System for reporting serous fluid cytopathology (TIS), which is a standardized system for reporting effusion cytology. Herein, we report our findings in further investigation of ROM in TIS by studying on paired pleural effusion specimens and corresponding pleural biopsies with emphasis on negative for malignancy, and atypia of undetermined significance categories. Materials and Methods The Johns Hopkins Hospital pathology database was retrospectively searched for patients with a pleural biopsy (PBX) and a paired pleural effusion (PF) cytology specimens over a 4‐year period. We employed the TIS categories. The following statistical parameters were evaluated: sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and ROM. Results A total of 223 patient cases were included. Effusions TIS reclassification and ROM were as follows: 1.8% non‐diagnostic (ROM 75%), 75.8% negative for malignancy (ROM 23%), 4.9% atypical cells of undetermined significance (ROM 45%), 2.2% suspicious for malignancy (ROM 80%), and 15.2% malignant (ROM 100%). Overall accuracy, sensitivity, specificity, PPV and NPV were calculated and were 79.4%, 45%, 97.7%, 91.2% and 77%, respectively. Among, discordant cases diagnosed negative for malignancy on PF and positive for malignancy on PBX, there were significant number of lymphomas, mesotheliomas, and sarcomas. Lung cancer was the most common carcinoma; however, rare types of carcinomas were noted. Cells blocks and immunohistochemistry (IHC) studies were utilized to confirm either malignant conditions or rule out malignancy in both cell blocks and histology biopsies. Conclusion This study demonstrates the high specificity and ROM for ‘malignant’ and ‘suspicious for malignancy’ categories in the TIS reporting system and highlights the modest negative predictive value for the ‘negative for malignancy’ category. Although Tissue biopsies are usually considered as ‘gold standard’, any definitive diagnosis of malignancy of body fluid should be considered positive for malignancy in further clinical decision‐making.

Introduction The treatment of cancer is associated with high risk for toxicity and high cost. Strategies to enhance the value, quality, and safety of cancer care are often managed independently of one another. Oncology stewardship is a potential framework to unify these efforts and enhance outcomes. This landscape survey establishes baseline information on oncology stewardship in the United States. Methods The Hematology/Oncology Pharmacy Association (HOPA) distributed a 38-item survey composed of demographic, institutional, clinical decision-making, support staff, metrics, and technology sections to 675 HOPA members between 9 September 2022 and 9 October 2022. Results Most organizations (78%) have adopted general pharmacy stewardship practices; however, only 31% reported having established a formalized oncology stewardship team. More than 70% of respondents reported implementation of biosimilars, formulary management, and dose rounding as oncology stewardship initiatives in both inpatient and outpatient settings. Frequently cited barriers to oncology stewardship included lack of clinical pharmacist availability (74%), lack of oncology stewardship training (62%), lack of physician/provider buy-in (32%), and lack of cost-saving metrics (33%). Only 6.6% of survey respondents reported their organization had defined “value in oncology.” Lack of a formalized stewardship program was most often cited (77%) as the rationale for not defining value. Conclusions Less than one-third of respondents have established oncology stewardship programs; however, most are providing oncology stewardship practices. This manuscript serves as a call to action for stakeholders to work together to formalize oncology stewardship programs that optimize value, quality, and safety for patients with cancer.