Perception of shared learning environment differs between vascular surgery and general surgery residents

BACKGROUND

An enriching learning environment is integral to resident wellness and education. Integrated vascular (VS) and general surgery (GS) residents share 18 months of core GS rotations during the postgraduate years 1-3 (PGY1-3); differences in their experiences may help identify practical levers for change.

METHODS

We used a convergent mixed-methods design. Cross-sectional surveys were administered after the 2020 American Board of Surgery In-Training Examination and Vascular Surgery In-Training Examination, assessing eight domains of the learning environment and resident wellness. Multivariable logistic regression models identified factors associated with thoughts of attrition between categorical PGY1-3 residents at 57 institutions with both GS and VS programs. Resident focus groups were conducted during the 2022 Vascular Annual Meeting to elicit more granular details about the experience of the learning environment. Transcripts were analyzed using inductive and deductive logics until thematic saturation was achieved.

RESULTS

Surveys were completed by 205 VS and 1198 GS PGY1-3 residents (response rates 76.8% for VS and 82.5% for GS). After adjusting for resident demographics, PGY level, and program type, GS residents were more likely than their VS peers to consider leaving their programs (odds ratio [OR]: 2.61, 95% confidence interval [CI]: 1.37-4.99). This finding did not persist after adjusting for differences in perceptions of the learning environment, specifically: GS residents had higher odds of mistreatment (OR: 1.99, 95% CI: 1.36-2.90), poorer work-life integration (OR: 2.88, 95% CI: 1.41-5.87), less resident camaraderie (OR: 3.51, 95% CI: 2.26-5.45), and decreased meaning in work (OR: 2.94, 95% CI: 1.80-4.83). Qualitative data provided insight into how the shared learning environment was perceived differently: (1) vascular trainees expressed that early specialization and a smaller, more invested faculty allow for an apprenticeship model with early operative exposure, hands-on guidance, frequent feedback, and thus early skill acquisition (meaning in work); (2) a smaller program is conducive to closer relationships with co-residents and faculty, increasing familiarity (camaraderie and work-life integration); and (3) due to increased familiarity with program leadership, vascular trainees feel more comfortable reporting mistreatment, allowing for prompt responses (mistreatment).

CONCLUSIONS

Despite sharing a learning environment, VS and GS residents experience training differently, contributing to differential thoughts of attrition. These differences may be attributable to intrinsic features of the integrated training paradigm that are not easily replicated by GS programs, such as smaller program size and higher faculty investment due to early specialization. Alternative strategies to compensate for these inherent differences should be considered (eg, structured operative entrustment programs and faculty incentivization).

Suicidal ideation, perception of personal safety, and career regret among emergency medicine residents during the COVID-19 pandemic

Objectives

The COVID-19 pandemic was disruptive for trainees and may have affected career decisions for some learners. This study examined the impact of the pandemic on emergency medicine (EM) resident perceptions of their mental health, perceptions of personal safety, and career choice regret.

Methods

This was a cross-sectional survey study administered following the 2021 American Board of Emergency Medicine In-Training Examination (ITE). Survey measures included suicidal ideation (SI), COVID concerns in terms of infection prevention and control (IPC) training, COVID risk to self and/or COVID risk to family, and COVID-related career regret. COVID concerns were compared by gender and race/ethnicity using Pearson's chi-square tests. Multivariable logistic regression models were used to test the association between SI and COVID concerns, resident characteristics, and program characteristics.

Results

A total of 6980 out of 8491 EM residents (82.2%) from 244 programs completed the survey. Only 1.1% of participants reported insufficient training in COVID IPC practices. Participants were concerned about COVID risk to themselves (40.3%) and to their families (63.3%) due to their job roles. These concerns were more common among women or nonbinary (vs. men); all other races/ethnicities (vs. non-Hispanic Whites); senior residents (vs. PGY-1, PGY-2 residents); and residents who were married or in relationships (vs. single or divorced). A total of 6.1% of participants reported that COVID made them reconsider choosing EM as their career. Career regret in this cohort was higher than that in the proportion (3.2%) expressing career regret in the 2020 ITE (p < 0.001). Career regret was more common among women or nonbinary (vs. men); all other races/ethnicities (vs. non-Hispanic Whites); and senior residents (vs. PGY-1, PGY-2 residents). The overall SI rate was 2.6%, which did not differ from that of the 2020 sample of EM residents (2.5%, p = 0.88).

Conclusions

Many EM residents reported concerns about COVID risks to themselves and their families. Although the rate of SI remained unchanged, more EM residents reported career regret during the COVID pandemic.

Institutional Validation Study Inferring 2% MGMT Methylation Positive Impact on Survival in Newly Diagnosed Glioblastoma (GBM) Patients

PURPOSE/OBJECTIVE(S)

O6-methylguanine DNA methyltransferase (MGMT) MATERIALS/METHODS: is a well-established prognostic factor in patients with newly diagnosed glioblastoma (GBM). However, there is no consensus on a standardized method of threshold for MGMT testing. Previous studies have reported levels of as little as 1-3% to confer better prognosis. This study reports a single institutional experience of determining methylation status via methylation-sensitive high-resolution melting (MS-HRM). Previous literature suggests 10% cutoff for MGMT methylation using MS-HRM. We hereby report clinical outcomes using a lower threshold of 2%.

MATERIALS/METHODS

GBM patients treated at our institution retrospectively reviewed between the years 2013 and 2022 were included in the study. Patients who received hypofractionated radiation (<60 Gy) were excluded. All patients had MS-HRM test for MGMT methylation status. A real-time PCR assay was used to amplify a 62 base-pair region of MGMT for both methylated and unmethylated alleles. PCR products underwent HRM analysis and the fraction of methylated DNA was determined by comparison with a standard curve. Clinical data were collected retrospectively. Kaplan-Meier and log-rank tests were performed to compare survival.

RESULTS

A total of 181 patients with newly diagnosed GBM were initially included in this study. 42 patients treated with hypofractionated radiation were excluded. All patients received concurrent and maintenance temozolomide. Median age was 61.5 years. A total of 84 patients had MGMT methylation levels <2%, and 55 patients had MGMT methylation level ≥ 2% with a median methylation level of 28.5% (Range 0.8%-100%). Patients with MGMT methylation level ≥ 2% had an improved median overall survival (25.1 vs 16.0 months; p = 0.006) and improved median progression free survival (11.3 vs 7.9 months; p = 0.017). In a multivariable mode that included age, use of tumor-treating fields, KPS, sex, and BMI, only age, KPS, and MGMT remained significant.

CONCLUSION

Our institutional review confirmed low level of MGMT hypermethylation (≥ 2%) predicts improved outcome in patients with newly diagnosed GBM. Further investigation on optimal cut off level for MGMT methylation is still warranted.

Body Mass Index (BMI) at Time of Diagnosis as a Prognostic Indicator in Patients with Newly Diagnosed Glioblastoma (GBM)

PURPOSE/OBJECTIVE(S)

Glioblastoma (GBM) is the most common primary brain cancer in adults with very poor prognosis. Metabolic drivers of tumorigenesis are highly relevant within the central nervous system, where glucose is the sole source of energy. The impact of obesity on survival outcomes in patients with GBM has not been well reported and some initial results are inconsistent. This study investigates the factor of body mass index (BMI) in patients diagnosed with GBM. This study evaluated the prognostic association of BMI with survival outcomes in patients with newly diagnosed GBM.

MATERIALS/METHODS

Patientswith newly diagnosed GBM at our institution from 2015-2022 were included in this study. All patients were >18 years of age and received 60 Gy of radiation therapy with concurrent and adjuvant temozolomide following maximal safe resection. Through retrospective chart review, patient BMI at the time of diagnosis and overall survival (OS) were recorded. Analysis was done between patient groups of underweight/normal weight (BMI <25) and overweight/obese (BMI ≥ 25.00). The subgroup of overweight patients was also divided into subgroups of overweight (BMI 25.00-29.99) and obese (BMI≥30.00). A difference in clinical outcomes of overall survival was evaluated between the groups using Gehan-Breslow-Wilcoxon and log-rank tests.

RESULTS

Atotal of 393 patients met inclusion criteria. Median age 57.3 years, range 18.8-92.7. 185 female and 208 were male. 120 patients had a BMI <25 and 273 had a BMI ≥ 25.00. Median survival in patients with BMI <25 was 24.90 months and in patients with BMI ≥ 25.00, 18.20 months (p = 0.0001; HR 0.6552, 95% CI 0.5299-0.8101). We further divided patients with BMI ≥ 25.00 to 25-29.99 (n = 152) and BMI≥30.00 (n = 121). Both groups' OS were significantly worse than patients with BMI < 25 (p = 0.006). There was no difference in survival outcomes between patients with a BMI 25.00-29.99 and BMI≥30.00, with median OS 19.0 months and 18.1 months, respectively.

CONCLUSION

Patient baseline BMI <25 appears to be a prognostic indicator and correlates to improves overall survival for patients with newly diagnosed GBM. This study adds to the existing literature supporting overweight/obesity is associated with worse survival for GBM patients. Additional studies are warranted for further analysis of BMI and survival outcomes in GBM patients across patient demographics.

Workplace Mistreatment, Career Choice Regret, and Burnout in Emergency Medicine Residency Training in the United States

STUDY OBJECTIVE

The influence of workplace mistreatment on the well-being and career satisfaction of emergency medicine residents is unknown. This study examined the relationships between burnout, career choice regret, and workplace mistreatment in a national sample of emergency medicine residents.

METHODS

This was a secondary analysis of a survey study on the prevalence of workplace mistreatment among emergency residents. Residents who reported emotional exhaustion or depersonalization at least once per week were considered to have burnout. Residents who reported dissatisfaction with their decision to become an emergency physician were considered to have career choice regret. Respondents also reported the type (discrimination, abuse, sexual harassment) and frequency of mistreatment over the academic year. Multivariable logistic regression, adjusting for program characteristics, was used to examine resident characteristics associated with burnout and career choice regret, with the frequency of mistreatment as a covariate.

RESULTS

Of the 8,162 eligible residents, 7,680 (94.1 %) participated. About a third of respondents reported burnout (2,188 of 6,902, 31.7%), whereas a minority (224 of 6,923, 3.2%) reported career choice regret. Of the 7,087 responses on mistreatment frequency, 2,117 (29.9%) reported "a few times per year," and 1,296 (18.3%) reported "a few times per month or more." Compared with residents who never experienced mistreatment, residents who reported increasing frequencies of mistreatment were associated with having burnout-from mistreatment a few times per year (OR [odds ratio],1.6; 99% CI [confidence interval], 1.3 to 1.9) to a few times per month or more (OR, 3.3; 99% CI, 2.7 to 4.1). Compared with residents without burnout, residents who reported burnout were associated with having career choice regret (OR, 11.3; 99% CI, 7.0 to 18.1). After adjusting for burnout, there were no significant relationships between the frequency of mistreatment and career choice regret.

CONCLUSIONS

Workplace mistreatment is associated with burnout, but not career choice regret, among emergency medicine residents. Efforts to address workplace mistreatment may improve emergency medicine residents' professional well-being.

Artificial Intelligence-Assisted Evaluation of the Spatial Relationship between Brain Arteriovenous Malformations and the Corticospinal Tract to Predict Postsurgical Motor Defects

BACKGROUND AND PURPOSE

Preoperative evaluation of brain AVMs is crucial for the selection of surgical candidates. Our goal was to use artificial intelligence to predict postsurgical motor defects in patients with brain AVMs involving motor-related areas.

MATERIALS AND METHODS

Eighty-three patients who underwent microsurgical resection of brain AVMs involving motor-related areas were retrospectively reviewed. Four artificial intelligence-based indicators were calculated with artificial intelligence on TOF-MRA and DTI, including FN5mm/50mm (the proportion of fiber numbers within 5-50mm from the lesion border), FN10mm/50mm (the same but within 10-50mm), FP5mm/50mm (the proportion of fiber voxel points within 5-50mm from the lesion border), and FP10mm/50mm (the same but within 10-50mm). The association between the variables and long-term postsurgical motor defects was analyzed using univariate and multivariate analyses. Least absolute shrinkage and selection operator regression with the Pearson correlation coefficient was used to select the optimal features to develop the machine learning model to predict postsurgical motor defects. The area under the curve was calculated to evaluate the predictive performance.

RESULTS

In patients with and without postsurgical motor defects, the mean FN5mm/50mm, FN10mm/50mm, FP5mm/50mm, and FP10mm/50mm were 0.24 (SD, 0.24) and 0.03 (SD, 0.06), 0.37 (SD, 0.27) and 0.06 (SD, 0.08), 0.06 (SD, 0.10) and 0.01 (SD, 0.02), and 0.10 (SD, 0.12) and 0.02 (SD, 0.05), respectively. Univariate and multivariate logistic analyses identified FN10mm/50mm as an independent risk factor for long-term postsurgical motor defects (P = .002). FN10mm/50mm achieved a mean area under the curve of 0.86 (SD, 0.08). The mean area under the curve of the machine learning model consisting of FN10mm/50mm, diffuseness, and the Spetzler-Martin score was 0.88 (SD, 0.07).

CONCLUSIONS

The artificial intelligence-based indicator, FN10mm/50mm, can reflect the lesion-fiber spatial relationship and act as a dominant predictor for postsurgical motor defects in patients with brain AVMs involving motor-related areas.

What They Are Not Telling Us: Analysis of Nonresponders on a National Survey of Resident Well-Being

To characterize nonrespondents to a national survey about trainee well-being, examine response patterns to questions of sensitive nature, and assess how nonresponse biases prevalence estimates of mistreatment and well-being.

Background

Surgical trainees are at risk for burnout and mistreatment, which are discernible only by self-report. Therefore, prevalence estimates may be biased by nonresponse.

Methods

A survey was administered with the 2018 and 2019 American Board of Surgery In-Training Examinations assessing demographics, dissatisfaction with education and career, mistreatment, burnout, thoughts of attrition, and suicidality. Responders in 2019 were characterized as survey "Completers," "Discontinuers" (quit before the end), and "Selective Responders" (selectively answered questions throughout). Multivariable logistic regression assessed associations of respondent type with mistreatment and well-being outcomes, adjusting for individual and program characteristics. Longitudinal survey identifiers linked survey responses for eligible trainees between 2018 and 2019 surveys to further inform nonresponse patterns.

Results

In 2019, 6956 (85.6%) of 8129 eligible trainees initiated the survey, with 66.5% Completers, 17.5% Discontinuers, and 16.0% Selective Responders. Items with the highest response rates included dissatisfaction with education and career (93.2%), burnout (86.3%), thoughts of attrition (90.8%), and suicidality (94.4%). Discontinuers and Selective Responders were more often junior residents and racially/ethnically minoritized than Completers. No differences were seen in burnout and suicidality rates between Discontinuers, Selective Responders, and Completers. Non-White or Hispanic residents were more likely to skip questions about racial/ethnic discrimination than non-Hispanic White residents (21.2% vs 15.8%; odds ratio [OR], 1.35; 95% confidence interval [CI], 1.19-1.53), particularly when asked to identify the source. Women were not more likely to omit questions regarding gender/gender identity/sexual orientation discrimination (OR, 0.91; 95% CI, 0.79-1.04) or its sources (OR, 1.02; 95% CI, 0.89-1.16). Both Discontinuers and Selective Responders more frequently reported physical abuse (2.5% vs 1.1%; P = 0.001) and racial discrimination (18.3% vs 13.6%; P < 0.001) on the previous survey (2018) than Completers.

Conclusions

Overall response rates are high for this survey. Prevalence estimates of burnout, suicidality, and gender discrimination are likely minimally impacted by nonresponse. Nonresponse to survey items about racial/ethnic discrimination by racially/ethnically minoritized residents likely results in underestimation of this type of mistreatment.

Association of preoperative smoking with complications following major gastrointestinal surgery

BACKGROUND

Understanding modifiable surgical risk factors is essential for preoperative optimization. We evaluated the association between smoking and complications following major gastrointestinal surgery.

METHODS

Patients who underwent elective colorectal, pancreatic, gastric, or hepatic procedures were identified in the 2017 ACS NSQIP dataset. The primary outcome was 30-day death or serious morbidity (DSM). Secondary outcomes included pulmonary complications, wound complications, and readmission. Multivariable logistic regression was used to evaluate the association between smoking and these outcomes.

RESULTS

A total of 46,921 patients were identified, of whom 7,671 (16.3%) were smokers. Smoking was associated with DSM (23.2% vs. 20.4%, OR 1.15 [1.08-1.23]), wound complications (13.0% vs. 10.4%, OR 1.24 [1.14-1.34]), pulmonary complications (4.9% vs 2.9%, OR 1.93 [1.70-2.20]), and unplanned readmission (12.6% vs. 11%, OR 1.14 [95% CI 1.06-1.23]).

CONCLUSIONS

Smoking is associated with complications following major gastrointestinal surgery. Patients who smoke should be counseled prior to surgery regarding risks.

Prevalence and risk factors for burnout in U.S. vascular surgery trainees

OBJECTIVE

Burnout and suicidality are known risks for vascular surgeons above other surgical subspecialties, with surgical trainees at risk for exposure to factors that increase burnout. This study aimed to inform initiatives to improve wellness by assessing the prevalence of hazards in vascular training (mistreatment, duty-hour violations) and the rates of wellness outcomes (burnout, thoughts of attrition/specialty change/suicide). We hypothesized that mistreatment and duty-hour violations would predispose trainees to increased burnout.

METHODS

We performed a cross-sectional study of residents and fellows enrolled in accredited United States vascular surgery training programs using a voluntary, confidential survey administered during the 2020 Vascular Surgery In-Training Examination. The primary outcome assessed was burnout symptoms reported on a weekly basis or more frequently. The rates of wellness outcomes were measured. The association of mistreatment and duty hours with the primary outcome was modeled with multivariable logistic regression.

RESULTS

A total of 475 residents and fellows who were enrolled in one of 120 vascular surgery training programs completed the survey (84.2% response rate). Of 408 trainees completing burnout survey items, 182 (44.6%) reported symptoms of burnout. Fewer trainees reported thoughts of attrition (n = 42 [10.0%], specialty change (n = 35 [8.4%]), or suicide (n = 22 [4.9%]). Mistreatment was reported by 191 vascular trainees (47.3%) and was more common in female trainees (n = 63 [48.5%] reporting monthly or more frequently) compared with male trainees (n = 51 [18.6%]; P < .001). Duty-hour violations were also more commonly reported by female trainees (n = 31 [21.4%] reporting 3+ months in violation) compared with male trainees (n = 50 [16.2%]; P = .002). After controlling for race/ethnicity, postgraduate year, program type, and geography, female trainees were less likely to report burnout (odds ratio [OR], 0.49; 95% confidence interval [CI], 0.28-0.86). Trainees experiencing mistreatment monthly or more were three times more likely to report burnout (OR, 3.09; 95% CI, 1.78-5.39). Frequency of duty-hour violations also increased the odds of reporting burnout (1-2 months in violation: OR, 2.09; 95% CI, 1.17-3.73; 3+ months in violation: OR, 3.95; 95% CI, 2.24-6.97).

CONCLUSIONS

Nearly one-half of vascular surgery trainees reported symptoms of burnout, which was associated with frequency of mistreatment and duty-hour violations. Interventions to improve well-being in vascular surgery must be tailored to the local training environment to address trainee experiences that contribute to burnout.

[Molluscicidal effect of immersion with 50% wettable powder of niclosamide ethanolamine salt against Oncomelania hupensis on the soil surface and inside the soil layer in winter]

OBJECTIVE

To evaluate the molluscicidal effect of 50% wettable powder of niclosamide ethanolamine salt (WPNES) against Oncomelania hupensis on the soil surface and inside the soil layer by immersion method in winter.

METHODS

O. hupensis snails were placed on the soil surface and 2, 5 cm and 10 cm under the soil layer outdoors in winter, and then immersed in 50% WPNES at concentrations of 1 mg/L and 2 mg/L for 1, 3 d and 7 d, while dechlorinated water served as controls. Snail mortality was observed following immersion with 50% WPNES on the soil surface and inside the soil layer.

RESULTS

Following immersion with 50% WPNES at concentrations of 2 mg/L and 1 mg/L outdoors in winter, the 3-day corrected snail mortality rates were 98.0% and 76.0% on the soil surface, and the 7-day corrected snail mortality rate was both 100.0%. Following immersion with 50% WPNES at concentrations of 2 mg/L and 1 mg/L outdoors in winter, the 7-day corrected snail mortality rates were 95.5% and 85.6% 2 cm below the soil layer, 66.0% and 6.4% 5 cm below the soil layer. However, the 7-day snail mortality rate swere comparable between the 50% WPNES treatment group (at 2 mg/L and 1 mg/L) and controls 10 cm below the soil layer (both P > 0.05).

CONCLUSIONS

Immersion of 50% WPNES at a concentration of 2 mg/L for 7 days presents a high molluscicidal efficacy against O. hupensis on the soil surface and 5 cm within the soil layers in winter.

Assessing cost-effectiveness of hepatitis C testing pathways in Georgia using the Hep C Testing Calculator

The cost of testing can be a substantial contributor to hepatitis C virus (HCV) elimination program costs in many low- and middle-income countries such as Georgia, resulting in the need for innovative and cost-effective strategies for testing. Our objective was to investigate the most cost-effective testing pathways for scaling-up HCV testing in Georgia. We developed a Markov-based model with a lifetime horizon that simulates the natural history of HCV, and the cost of detection and treatment of HCV. We then created an interactive online tool that uses results from the Markov-based model to evaluate the cost-effectiveness of different HCV testing pathways. We compared the current standard-of-care (SoC) testing pathway and four innovative testing pathways for Georgia. The SoC testing was cost-saving compared to no testing, but all four new HCV testing pathways further increased QALYs and decreased costs. The pathway with the highest patient follow-up, due to on-site testing, resulted in the highest discounted QALYs (124 QALY more than the SoC) and lowest costs ($127,052 less than the SoC) per 10,000 persons screened. The current testing algorithm in Georgia can be replaced with a new pathway that is more effective while being cost-saving.

Prevalence of Discrimination, Abuse, and Harassment in Emergency Medicine Residency Training in the US

IMPORTANCE

The prevalence of workplace mistreatment and its association with the well-being of emergency medicine (EM) residents is unclear. More information about the sources of mistreatment might encourage residency leadership to develop and implement more effective strategies to improve professional well-being not only during residency but also throughout the physician's career.

OBJECTIVE

To examine the prevalence, types, and sources of perceived workplace mistreatment during training among EM residents in the US and the association between mistreatment and suicidal ideation.

DESIGN, SETTING, AND PARTICIPANTS

In this survey study conducted from February 25 to 29, 2020, all residents enrolled in EM residencies accredited by the Accreditation Council for Graduate Medical Education (ACGME) who participated in the 2020 American Board of Emergency Medicine computer-based In-training Examination were invited to participate. A multiple-choice, 35-item survey was administered after the examination asking residents to self-report the frequency, sources, and types of mistreatment experienced during residency training and whether they had suicidal thoughts.

MAIN OUTCOMES AND MEASURES

The types and frequency of workplace mistreatment and the sources of the mistreatment were identified, and rates of self-reported suicidality were obtained. Multivariable logistic regression models were used to examine resident and program characteristics associated with suicidal thoughts.

RESULTS

Of 8162 eligible EM residents, 7680 (94.1%) responded to at least 1 question on the survey; 6503 (79.7%) completed the survey in its entirety. A total of 243 ACGME-accredited residency programs participated, and 1 did not. The study cohort included 4768 male residents (62.1%), 2698 female residents (35.1%), 4919 non-Hispanic White residents (64.0%), 2620 residents from other racial/ethnic groups (Alaska Native, American Indian, Asian or Pacific Islander, African American, Mexican American, Native Hawaiian, Puerto Rican, other Hispanic, or mixed or other race) (34.1%), 483 residents who identified as lesbian, gay, bisexual, transgender, queer, or other (LGBTQ+) (6.3%), and 5951 residents who were married or in a relationship (77.5%). Of the total participants, 3463 (45.1%) reported exposure to some type of workplace mistreatment (eg, discrimination, abuse, or harassment) during the most recent academic year. A frequent source of mistreatment was identified as patients and/or patients' families; 1234 respondents (58.7%) reported gender discrimination, 867 (67.5%) racial discrimination, 282 (85.2%) physical abuse, and 723 (69.1%) sexual harassment from patients and/or family members. Suicidal thoughts occurring during the past year were reported by 178 residents (2.5%), with similar prevalence by gender (108 men [2.4%]; 59 women [2.4%]) and race/ethnicity (113 non-Hispanic White residents [2.4%]; 65 residents from other racial/ethnic groups [2.7%]).

CONCLUSIONS AND RELEVANCE

In this survey study, EM residents reported that workplace mistreatment occurred frequently. The findings suggest common sources of mistreatment for which educational interventions may be developed to help ensure resident wellness and career satisfaction.

Patient Perspectives on the Extent of Surgery and Radioactive Iodine Treatment for Low-Risk Differentiated Thyroid Cancer

OBJECTIVE

To understand patient perspective regarding recommended changes in the 2015 American Thyroid Association (ATA) guidelines. Specifically, in regard to active surveillance (AS) of some small differentiated thyroid cancer (DTC), performance of less extensive surgery for low-risk DTC, and more selective administration of radioactive iodine (RAI).

METHODS

An online survey was disseminated to thyroid cancer patient advocacy organizations and members of the ATA to distribute to the patients. Data were collected on demographic and treatment information, and patient experience with DTC. Patients were asked "what if" scenarios on core topics, including AS, extent of surgery, and indications for RAI.

RESULTS

Survey responses were analyzed from 1546 patients with DTC: 1478 (96%) had a total thyroidectomy, and 1167 (76%) underwent RAI. If there was no change in the overall cancer outcome, 606 (39%) of respondents would have considered lobectomy over total thyroidectomy, 536 (35%) would have opted for AS, and 638 (41%) would have chosen to forego RAI. Moreover, (774/1217) 64% of respondents wanted more time with their clinicians when making decisions about the extent of surgery. A total of 621/1167 of patients experienced significant side effects with RAI, and 351/1167 of patients felt that the risks of treatment were not well explained. 1237/1546 (80%) of patients felt that AS would not be overly burdensome, and quality of life was the main reason cited for choosing AS.

CONCLUSION

Patient perspective regarding choice in the management of low-risk DTC varies widely, and a large proportion of DTC patients would change aspects of their care if oncologic outcomes were equivalent.

Efficacy of risankizumab in patients with moderate-to-severe plaque psoriasis by baseline demographics, disease characteristics and prior biologic therapy: an integrated analysis of the phase III UltIMMa-1 and UltIMMa-2 studies

BACKGROUND

Risankizumab is a humanized IgG monoclonal antibody that selectively inhibits interleukin-23 through binding the p19 subunit. In Phase 3 trials, risankizumab demonstrated superior efficacy compared with adalimumab and ustekinumab in patients with moderate-to-severe plaque psoriasis. Here, we evaluated the impact of baseline characteristics on efficacy of risankizumab compared with ustekinumab in patients with moderate-to-severe plaque psoriasis.

METHODS

This analysis included all patients initially randomized to risankizumab or ustekinumab from the replicate, double-blinded, randomized, placebo-controlled phase 3 trials, UltIMMa-1 (NCT02684370) and UltIMMa-2 (NCT02684357). Patients received either risankizumab (150 mg) or ustekinumab (weight-based; 45 or 90 mg per label) at weeks 0, 4, 16, 28 and 40. Efficacy was assessed as the proportion of patients achieving ≥90% improvement in Psoriasis Area and Severity Index (PASI 90) at weeks 16 and 52 by baseline patient demographics, disease characteristics and prior biologic exposure. Mean per cent improvement in PASI was calculated by body weight and body mass index at week 52. Missing efficacy data were imputed as non-responders for categorical variables and last observation carried forward for continuous variables. Logistic regression analyses assessed for interactions between treatment and five independent variables (age, sex, weight, baseline PASI score and presence of psoriatic arthritis) at both weeks 16 and 52.

RESULTS

Baseline patient demographics, disease characteristics and prior biologic exposure were similar between patients randomized to risankizumab (n = 598) and ustekinumab (n = 199). At weeks 16 and 52, risankizumab demonstrated superior efficacy compared with ustekinumab across these patient characteristics (P < 0.01). Logistic regression analyses demonstrated that risankizumab was superior to ustekinumab at weeks 16 and 52 in all models tested (P < 0.0001 for all).

CONCLUSIONS

Risankizumab demonstrated consistent and superior efficacy compared with ustekinumab regardless of patient demographics, disease characteristics or prior biologic exposure.

The cost-effectiveness of pharmacotherapy and lifestyle intervention in the treatment of obesity

BACKGROUND

The Food and Drug Administration has approved several pharmacotherapies for the treatment of obesity. This study assesses the cost-effectiveness of six pharmacotherapies and lifestyle intervention for people with mild obesity (body mass indices [BMIs] 30 to 35).

METHODS

A microsimulation model was constructed to compare seven weight loss strategies plus no treatment: intensive lifestyle intervention, orlistat, phentermine, phentermine/topiramate, lorcaserin, liraglutide, and semaglutide. Weight loss, quality-of-life scores, and costs were estimated using clinical trials and other published literature. Endpoints included costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs) with a willingness-to-pay (WTP) threshold of $100 000/QALY. Results were analysed at 1-, 3-, and 5-year time horizons.

RESULTS

At each of the three follow-up periods, phentermine was the cost-effective strategy, with ICERs of $46 258/QALY, $20 157/QALY, and $17 880/QALY after 1, 3, and 5 years, respectively. Semaglutide was the most effective strategy in the 3- and 5-year time horizons, with total QALYs of 2.224 and 3.711, respectively. However, the ICERs were prohibitively high at $1 437 340/QALY after 3 years and $576 931/QALY after 5 years. Deterministic and probabilistic sensitivity analyses indicated these results were robust.

CONCLUSIONS

Phentermine is the cost-effective pharmacologic weight-loss strategy. Although semaglutide is the most effective, it is not cost-effective because of its high price.

Integrated analysis of differentially expressed genes in esophageal squamous cell carcinoma using bioinformatics

Esophageal squamous cell carcinoma (ESCC) is a deadly disease. To identify key genes in esophageal squamous cell carcinoma, we followed a strategy utilizing the laiurger microarray dataset (GSE38129) as the training set and another independent microarray dataset (GSE20347) as the validation set. Following quality control, differentially expressed genes (DEGs) were obtained using R software. Functional enrichment analysis was performed using DAVID database and the DEG co-expression network was established with Weighted Gene Co-Expression Network Analysis (WGCNA) and visualized by Cytoscape. The prognosis-related hub genes were then identified by Kaplan-Meier analysis based on the TCGA database. A total of 188 DEGs were obtained; 88 up-regulated genes and 100 down-regulated. The up-regulated DEGs were significantly associated with extracellular matrix organization and disassembly while down-regulated DEGs were significantly related to keratinocyte differentiation. Blue and turquoise co-expression modules were established and 18 hub genes were identified. The blue module was associated with mitotic nuclear division, cell division and mitotic cytokinesis and the turquoise module was associated with collagen catabolic process, extracellular matrix organization and keratinocyte differentiation. We established that the TPX2, CDK1 and CEP55 blue module hub genes were associated with relapse-free survival, and our overall results not only identify key genes but also provide potential novel biomarkers for ESCC diagnosis and treatment.

Lorenz Curves and Gini Coefficient Analyses Indicate Inefficiencies in Esophageal Adenocarcinoma Screening

Rates of esophageal adenocarcinoma (EAC) have increased rapidly in the United States and much of western Europe, and 5-year survival continues to be poor.¹ Prevention and early detection efforts for EAC have focused on identifying persons with EAC precursor state, Barrett's esophagus, but the survival benefit has been disappointingly low.

Preventive use of carvedilol for anthracycline-induced cardiotoxicity: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Clinical or subclinical cardiotoxicity is a concern for cancer patients receiving anthracycline-based chemotherapy. Carvedilol is promising for preventing anthracycline-induced cardiotoxicity (AIC). This review appraised the preventive effects of carvedilol against AIC based on randomized controlled trials (RCTs).

METHODS

The Cochrane Collaboration Central Register of Controlled Trials, PubMed, and Embase databases were searched from inception to March 27, 2018. RCTs using carvedilol for the prevention of AIC were selected. Risk of bias and methodological quality were assessed. Meta-analysis was conducted, when applicable, for the trial endpoints; otherwise the data were analyzed descriptively.

RESULTS

Nine RCTs comprising 717 patients were selected. The risk of bias was unclear and the methodological quality differed substantially. Data pooling of five eligible studies indicated no decreased mortality in patients receiving carvedilol (risk difference = -0.02, 95% CI: -0.07-0.04, p = 0.57, I² = 44%). The impact on the incidence of left ventricular systolic dysfunction (LVSD) was inconsistently reported but meta-analysis was not applicable due to discordant LVSD definitions. Data pooling of eight studies and a subgroup analysis indicated a higher left ventricular ejection fraction (LVEF) with substantial heterogeneity in the carvedilol group (mean difference [MD] = 5.23, 95% CI: 2.20-8.27, p = 0.0007, I² = 95%, and MD = 4.65, 95% CI: 0.67-8.64, p = 0.02, I² = 90%, respectively). Further analysis of echocardiographic parameters and biomarkers showed weak evidence of improvement in diastolic function and troponin I level by carvedilol administration.

CONCLUSION

Preventive use of carvedilol in patients undergoing anthracycline-based chemotherapy may be associated with a reduced incidence of LVSD, higher LVEF value, better diastolic function, and lower troponin I level. RCTs with larger sample size and longer follow-up are needed to verify these findings.

Neoadjuvant FOLFIRINOX for Patients with Borderline Resectable or Locally Advanced Pancreatic Cancer: Results of a Decision Analysis

Decision‐analytic modeling can provide a methodologic platform that integrates the best available data to quantitatively explore clinical decisions by simulating a hypothetical clinical trial between competing strategies. This article analyzes a mathematical decision‐analytic model to estimate the long‐term clinical outcomes and cost‐effectiveness of neoadjuvant FOLFIRINOX compared with surgery followed by adjuvant gemcitabine monotherapy or gemcitabine/capecitabine for patients with potentially resectable pancreatic ductal adenocarcinoma.

Background.

The effectiveness and cost‐effectiveness of using neoadjuvant FOLFIRINOX (nFOLFIRINOX) for patients with borderline resectable or locally advanced pancreatic ductal adenocarcinoma (BR/LA PDAC) are unknown. Our objective was to determine whether nFOLFIRINOX is more effective or cost‐effective for patients with BR/LA PDAC compared with upfront resection surgery and adjuvant gemcitabine plus capecitabine (GEM/CAPE) or gemcitabine monotherapy (GEM).

Materials and Methods.

We performed a decision‐analysis to assess the value of nFOLFIRINOX versus GEM/CAPE or GEM using a mathematical simulation model. Model transition probabilities were estimated using published and institutional clinical data. Model outcomes included overall and disease‐free survival, quality‐adjusted life‐years (QALYs), cost in U.S. dollars, and cost‐effectiveness expressed as an incremental cost‐effectiveness ratio. Deterministic and probabilistic sensitivity analyses explored the uncertainty of model assumptions.

Results.

Model results found median overall survival (34.5/28.0/22.0 months) and disease‐free survival (15.0/14.0/13.0 months) were better for nFOLFIRINOX compared with GEM/CAPE and GEM. nFOLFIRINOX was the optimal strategy on an efficiency frontier, resulting in an additional 0.35 life‐years, or 0.30 QALYs, at a cost of $46,200/QALY gained compared with GEM/CAPE. Sensitivity analysis found that cancer recurrence and complete resection rates most affected model results, but were otherwise robust. Probabilistic sensitivity analyses found that nFOLFIRINOX was cost‐effective 92.4% of the time at a willingness‐to‐pay threshold of $100,000/QALY.

Conclusion.

Our modeling analysis suggests that nFOLFIRINOX is preferable to upfront surgery for patients with BR/LA PDAC from both an effectiveness and cost‐effectiveness standpoint. Additional clinical data that further define the long‐term effectiveness of nFOLFIRINOX are needed to confirm our results.

Implications for Practice.

Increasingly, neoadjuvant FOLFIRINOX has been used for borderline resectable and locally advanced pancreatic cancer with the goal of rendering them resectable and decreasing risk of recurrence. Despite many efforts to show the benefits of neoadjuvant over adjuvant therapies, clinical evidence to guide this decision is largely lacking. Decision‐analytic modeling can provide a methodologic platform that integrates the best available data to quantitatively explore clinical decisions by simulating a hypothetical clinical trial. This modeling analysis suggests that neoadjuvant FOLFIRINOX is preferable to upfront surgery and adjuvant therapies by various outcome metrics including quality‐adjusted life years, overall survival, and incremental cost‐effectiveness ratio.

[A preliminary study of Dao gao yao huang shi shu (Oath of Praying for the King of Medicine), a Chinese version of Hippocratic Oath]

Dao gao yao huang shi shu (Oath of Praying for the King of Medicine), also called Wang jia zan qi shi (Wang Jiazan's Seven Oaths), published in the Fifty-seventh Year of Qianlong Reign (1792) of the Qing Dynasty in the Wu yi hui jiang (Collected Discourses of Doctors from Wu Region), the earliest medical periodicals in China, was the earliest Doctor's Oath ever seen since doctors inherited the traditional medical ethics, that is, a Chinese version of Hippocratic Oath. Sun Simiao's Da yi jing cheng (Proficiency and Sincerity of Great Doctors) was a superb essay of medical ethics without using the style of oath, while Dao gao yao huang shi shu was a complete model of "Oath Statement" from its title to the contents. It inherited the contents from Da yi jing cheng and enriched its connotation of "forbearance to humiliation and enduring poverty" . What's more, its systematization and stylization of oath mark that China's medical ethics as a norm, a creed and a normative expression starts to sprout and germinate, and becomes one of the signs of the gradual maturity of profession of traditional Chinese medicine.

Widespread Chromosomal Losses and Mitochondrial DNA Alterations as Genetic Drivers in Hürthle Cell Carcinoma

Hürthle cell carcinoma of the thyroid (HCC) is a form of thyroid cancer recalcitrant to radioiodine therapy that exhibits an accumulation of mitochondria. We performed whole-exome sequencing on a cohort of primary, recurrent, and metastatic tumors, and identified recurrent mutations in DAXX, TP53, NRAS, NF1, CDKN1A, ARHGAP35, and the TERT promoter. Parallel analysis of mtDNA revealed recurrent homoplasmic mutations in subunits of complex I of the electron transport chain. Analysis of DNA copy-number alterations uncovered widespread loss of chromosomes culminating in near-haploid chromosomal content in a large fraction of HCC, which was maintained during metastatic spread. This work uncovers a distinct molecular origin of HCC compared with other thyroid malignancies.

Circulating BRAFV600E Levels Correlate with Treatment in Patients with Thyroid Carcinoma

BACKGROUND

BRAF^V600E is the most common mutation in papillary thyroid carcinoma (PTC) and can be associated with aggressive disease. Previously, a highly sensitive blood RNA-based BRAF^V600E assay was reported. The objective of this study was to assess the correlation of BRAF^V600E circulating tumor RNA levels with surgical and medical treatment.

METHODS

Circulating BRAF^V600E levels were assessed in (i) a murine model of undifferentiated (anaplastic) thyroid carcinoma with known BRAF^V600E mutation undergoing BRAF^V600E-inhibitor (BRAFi) treatment, and (ii) in 111 patients enrolled prior to thyroidectomy (n = 86) or treatment of advanced recurrent or metastatic PTC (n = 25). Blood samples were drawn for BRAF^V600E analysis before and after treatment. Testing characteristics were assessed and positivity criteria optimized. Changes in blood BRAF^V600E values were assessed and compared to clinical characteristics and response to therapy.

RESULTS

In a murine model of anaplastic thyroid carcinoma with BRAF^V600E mutation, blood BRAF^V600E RNA correlated with tumor volume in animals treated with BRAFi. In tissue BRAF^V600E-positive (n = 36) patients undergoing initial surgery for PTC, blood BRAF^V600E levels declined postoperatively (median 370.0-178.5 fg/ng; p = 0.002). In four patients with metastatic or poorly differentiated thyroid carcinoma receiving targeted therapies, blood BRAF^V600E declined following therapy and corresponded with radiographic evidence of partial response or stable disease.

CONCLUSIONS

This study shows the correlation of blood BRAF^V600E levels in response to treatment in both an established animal model of thyroid cancer and in patients with BRAF^V600E-positive tumors with all stages of disease. This assay represents an alternative biomarker in patients with positive thyroglobulin antibodies, and tumors, which do not express thyroglobulin.

Intrapartum obstetric care in the United States military: Comparison of military and civilian care systems within TRICARE

BACKGROUND

Expectant mothers who are beneficiaries of TRICARE (universal insurance to United States Armed Services members and their dependents) can choose to receive care within direct (salary-based) or purchased (fee-for-service) care systems. We sought to compare frequency of intrapartum obstetric procedures and outcomes such as severe acute maternal morbidity (SAMM) and common postpartum complications between direct and purchased care systems within TRICARE.

METHODS

TRICARE (2006-2010) claims data were used to identify deliveries. Patient demographics, frequency of types of delivery (noninstrumental vaginal, cesarean, and instrumental vaginal), comorbid conditions, SAMM, and common postpartum complications were compared between the two systems of care. Multivariable models adjusted for patient clinical/demographic factors determined the odds of common complications and SAMM complications in purchased care compared with direct care.

RESULTS

A total of 440 138 deliveries were identified. Compared with direct care, purchased care had higher frequency (30.9% vs 25.8%, P<.001) and higher adjusted odds (aOR 1.37 [CI 1.34-1.38]) of cesarean delivery. In stratified analysis by mode of delivery, purchased care had lower odds of common complications for all modes of delivery (aOR[CI]:noninstrumental vaginal: 0.72 [0.71-0.74], cesarean: 0.71 [0.68-0.75], instrumental vaginal: 0.64 [0.60-0.68]) than direct care. However, purchased care had higher odds of SAMM complications for cesarean delivery (aOR 1.31 [CI 1.19-1.44]) compared with direct care.

CONCLUSION

Direct care has a higher vaginal delivery rate but also a higher rate of common complications compared with purchased care. Study of direct and purchased care systems in TRICARE may have potential use as a surrogate for comparing obstetric care between salary-based systems and fee-for-service systems in the United States.

Neoadjuvant FOLFIRINOX for patients with borderline resectable or locally advanced pancreatic cancer: Results of a decision analysis

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Background: With the advent of more effective therapies for metastatic pancreatic ductal adenocarcinoma (PDAC), efforts to incorporate these agents, such as FOLFIRINOX, into the neoadjuvant setting are increasing. However, the efficacy and cost-effectiveness of using neoadjuvant FOLFIRINOX for patients with borderline resectable or locally advanced PDAC are unknown. We performed a decision analysis to assess the value of neoadjuvant FOLFIRINOX versus upfront surgery and adjuvant therapy. Methods: We developed a mathematical simulation model to evaluate the efficacy and cost-effectiveness of neoadjuvant FOLFIRINOX compared to upfront surgery and adjuvant therapy. We used published and institutional data as inputs to inform model development. Model outcomes included overall and disease-free survival, net benefits expressed as discounted quality-adjusted life-years (QALYs), costs in US dollars, and cost-effectiveness expressed as an incremental cost-effectiveness ratio. We used deterministic and probabilistic sensitivity analyses to explore the uncertainty of model assumptions. Results: Model estimated median overall survival (29 vs 23 months) and disease-free survival (14 vs 13 months) were better for neoadjuvant strategy compared with upfront surgery. Neoadjuvant strategy resulted in an additional 0.68 life-years gained, or 0.57 QALYs, at a cost of $59,000/QALY gained. Sensitivity analysis found that cancer recurrence rates affected model results the most. Our findings were otherwise robust with respect to changes in other model parameters, including chemotherapy toxicity, surgical complications and cancer mortality. Probabilistic sensitivity analyses showed that neoadjuvant strategy was cost-effective 80% of the time with a willingness-to-pay threshold of $100,000/QALY. Conclusions: Our model results demonstrate that neoadjuvant strategy is preferable to upfront surgery for patients with borderline resectable or locally advanced PDAC from both an efficacy and cost-effectiveness standpoint. Additional clinical data are needed to further define the long-term effectiveness of neoadjuvant FOLFIRINOX to confirm our results.

The thyroid cancer policy model: A mathematical simulation model of papillary thyroid carcinoma in The U.S. population

Background

Thyroid cancer affects over ½ million people in the U.S. and the incidence of thyroid cancer has increased worldwide at a rate higher than any other cancer, while survival has remained largely unchanged. The aim of this research was to develop, calibrate and verify a mathematical disease model to simulate the natural history of papillary thyroid cancer, which will serve as a platform to assess the effectiveness of clinical and cancer control interventions.

Methods

Herein, we modeled the natural pre-clinical course of both benign and malignant thyroid nodules with biologically relevant health states from normal to detected nodule. Using established calibration techniques, optimal parameter sets for tumor growth characteristics, development rate, and detection rate were used to fit Surveillance Epidemiology and End Results (SEER) incidence data and other calibration targets.

Results

Model outputs compared to calibration targets demonstrating sufficient calibration fit and model validation are presented including primary targets of SEER incidence data and size distribution at detection of malignancy. Additionally, we show the predicted underlying benign and malignant prevalence of nodules in the population, the probability of detection based on size of nodule, and estimates of growth over time in both benign and malignant nodules.

Conclusions

This comprehensive model provides a dynamic platform employable for future comparative effectiveness research. Future model analyses will test and assess various clinical management strategies to improve patient outcomes related to thyroid cancer and optimize resource utilization for patients with thyroid nodules.

Wnt signaling in cancer

Wnt signaling is one of the key cascades regulating development and stemness, and has also been tightly associated with cancer. The role of Wnt signaling in carcinogenesis has most prominently been described for colorectal cancer, but aberrant Wnt signaling is observed in many more cancer entities. Here, we review current insights into novel components of Wnt pathways and describe their impact on cancer development. Furthermore, we highlight expanding functions of Wnt signaling for both solid and liquid tumors. We also describe current findings how Wnt signaling affects maintenance of cancer stem cells, metastasis and immune control. Finally, we provide an overview of current strategies to antagonize Wnt signaling in cancer and challenges that are associated with such approaches.

MIM regulates the trafficking of bone marrow cells via modulating surface expression of CXCR4

Missing in metastasis (MIM) is abundantly expressed in hematopoietic cells. Here we characterized the impact of MIM deficiency on murine bone marrow (BM) cells. Although MIM^-/- cells proliferated similarly to wild type (WT), they exhibited stronger response to chemokine SDF-1, increase in surface expression of CXCR4, impaired CXCR4 internalization and constitutive activation of Rac, Cdc42 and p38. Transplantation of MIM^-/- BM cells into lethally irradiated mice showed enhanced homing to BM, which was abolished when mice were pretreated with a p38 antagonist. Interestingly, MIM^-/- BM cells, including hematopoietic stem and progenitor cells (HSPCs), showed 2 to 5-fold increase in mobilization into the peripheral blood upon treatment with AMD3100. In vitro, MIM^-/- leukocytes were susceptible to AMD3100 and maintained increased response to AMD3100 for mobilization even after transfer into wild type mice. MIM^-/- mice had also a higher level of SDF-1 in the circulation. Our data highlighted an unprecedented role of MIM in the homoeostasis of BM cells, including HSPCs, through modulation of the CXCR4/SDF-1 axis and interactions of BM leukocytes with their microenvironments.

Therapeutic effect of Pleurotus eryngii cellulose on experimental fatty liver in rats

The aim of this study was to explore the therapeutic effect of Pleurotus eryngii cellulose on experimental fatty liver in rats. Rats were fed high-fat fodder to establish a rat fatty liver model, and were then fed different concentrations of Pleurotus eryngii cellulose for six weeks. Lipitor was used as a positive control. Measured levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), total cholesterol (TC), and total triglyceride (TG); the activity of malondialdehyde (MDA), superoxide dismutase (SOD), hepatic lipase (HL), and lipoprotein lipase; and liver histopathological changes. Successfully established rat fatty liver model after feeding high-fat fodder for one week. A diet of P. eryngii cellulose for six weeks significantly reduced ALT, AST, TC, and TG levels in rat serum (P < 0.01); TC and AST levels in P. eryngii cellulose high-dose group and Lipitor group were not significantly different from those of the control (P > 0.05). SOD activity increased significantly, while MDA and HL activity decreased (P < 0.05); fatty degeneration and fat accumulation both decreased in hepatic tissue. Hepatic protection of P. eryngii cellulose showed dose-related effect. P. eryngii cellulose can affect lipid metabolism, having therapeutic effects on fatty liver in rats.

Thermal boundary resistance at Au/Ge/Ge and Au/Si/Ge interfaces

Amorphous Ge (a-Ge), crystalline Ge (c-Ge), and amorphous Si (a-Si) thin films were deposited on a Ge substrate at different temperatures by magnetron sputtering.