Culture

More than 27 percent of children living on Guam between the ages of 2 and 8 were found to be obese or overweight, according to a study from the University of Guam's Children's Healthy Living Program. The findings were published on Aug. 20 in the journal Nutrients.

Guam's statistic sits just above the national average, based on reports from the U.S. Centers for Disease Control and Prevention.

"The big -- and concerning -- take home message is the unhealthy habits and behavioral patterns we found likely contributing to this high rate: too much screen time, the processed and sugary foods and beverages, and, most surprisingly, poor sleeping habits," said co-author and program lead Rachael T. Leon Guerrero, a registered dietitian who holds a doctorate in human nutrition. "It's a dangerous territory to be in since childhood weight issues can lead to obesity in adulthood, which only increases their risk for health problems like cardiovascular disease and cancer among others."

The study helps fill a longstanding gap in health data collection in the United States and its territories, which has historically omitted Pacific Islanders from many national surveys and studies. Pacific Islanders remain one of the largest growing ethnic minorities in the United States, yet their needs are often unmet due to a dearth in data often used to inform prevention strategies and programs.

The study surveyed 860 children and their caregivers and found that 99 percent of children did not consume the recommended daily fruit and vegetable intake (1 to 1.5 cups per day), while 40 percent did not meet the recommended daily hours of sleep (between eight and 11 hours). Obese or overweight children are statistically more likely to suffer from sleep disturbances.

Nearly 85 percent of children exceeded the two-hour recommended screen time. The average was five hours per day, which is comparable to figures in the states. Among the group, 83 percent consumed sugary and sweet beverages. The recommended consumption is zero.

Those who considered themselves part of the Westernized lifestyle (80 percent) -- which contains processed, high fat, and sugary foods -- were twice as likely to be overweight or obese. More than half of the children (58 percent) also came from families living below the poverty line, and more than 80 percent were receiving some form of food assistance.

In Guam, the program -- officially known as the Children's Healthy Living Program for Remote Underserved Minority Populations in the Pacific Region -- is a partnership among the University of Guam, the government, and schools that tracks children's weight rates on Guam and throughout the region and implements interventions to help improve them.

Most recently, researchers collected data in March 2020 to analyze the effectiveness of those interventions. Those results are expected in 2021.

"We need to better understand these types of disparities so we can help our communities and their children maximize their health and well-being," Leon Guerrero said.

The study was supported with grants from U.S. Department of Agriculture's National Institute of Food and Agriculture. Researchers included Rachael T. Leon Guerrero, L. Robert Barber, Tanisha F. Aflague, Yvette C. Paulino, Margaret P. Hattori-Uchima, and Mark Acosta from the University of Guam, Lynne R. Wilkens from the University of Hawaii Cancer Center, and Rachel Novotny from the University of Hawaii at Manoa.

The complete research article can be read at https://www.mdpi.com/2072-6643/12/9/2527.

A new study published this week in the journal Philosophical Transactions of the Royal Society B demonstrates a first attempt at using the methods of ancient bacterial detection, pioneered in studies of past epidemics, to characterise the microbial diversity of ancient gut contents from two medieval latrines. The findings provide insights into the microbiomes of pre-industrial agricultural populations, which may provide much-needed context for interpreting the health of modern microbiomes.

Over the years, scientists have noted that those living in industrialised societies have a notably different microbiome compared to hunter-gatherer communities around the world. From this, a growing body of evidence has linked changes in our microbiome to many of the diseases of the modern industrialised world, such as inflammatory bowel disease, allergies, and obesity. The current study helps to characterize the change in gut microbiomes and highlights the value of ancient latrines as sources of bio-molecular information.

Piers Mitchell of Cambridge University specialises in the gut contents of past people through analysis of unusual substrates. By looking at the contents of archaeological latrines and desiccated faeces under the microscope, he and his team have learned volumes about the intestinal parasites that plagued our ancestors.

"Microscopic analysis can show the eggs of parasitic worms that lived in the intestines, but many microbes in the gut are simply too small to see," comments Mitchell. "If we are to determine what constitutes a healthy microbiome for modern people, we should start looking at the microbiomes of our ancestors who lived before antibiotic use, fast food, and the other trappings of industrialisation."

Kirsten Bos, a specialist in ancient bacterial DNA from the Max Planck Institute for the Science of Human History and co-leader the study, was first sceptical about the feasibility of investigating the contents of latrines that had long been out of order.

"At the outset we weren't sure if molecular signatures of gut contents would survive in the latrines over hundreds of years. Many of our successes in ancient bacterial retrieval thus far have come from calcified tissues like bones and dental calculus, which offer very different preservation conditions. Nevertheless," says Bos, "I was really hoping the data here would change my perspective."

The team analysed sediment from medieval latrines in Jerusalem and Riga, Latvia dating from the 14th-15th century CE. The first challenge was distinguishing bacteria that once formed the ancient gut from those that are normally found in the soil, an unavoidable consequence of working with archaeological material.

The researchers identified a wide range of bacteria, archaea, protozoa, parasitic worms, fungi and other organisms, including many taxa known to inhabit the intestines of modern humans. "It seems latrines are indeed valuable sources for both microscopic and molecular information," concludes Bos.

Susanna Sabin, a doctoral alumna of the MPI-SHH who co-led the study, compared the latrine DNA to those from other sources, including microbiomes from industrial and foraging populations, as well as waste water and soil.

"We found that the microbiome at Jerusalem and Riga had some common characteristics - they did show similarity to modern hunter gatherer microbiomes and modern industrial microbiomes, but were different enough that they formed their own unique group. We don't know of a modern source that harbours the microbial content we see here."

The use of latrines, where the faeces of many people are mixed together, allowed the researchers unprecedented insight into the microbiomes of entire communities.

"These latrines gave us much more representative information about the wider pre-industrial population of these regions than an individual faecal sample would have," explains Mitchell. "Combining evidence from light microscopy and ancient DNA analysis allows us to identify the amazing variety of organisms present in the intestines of our ancestors who lived centuries ago."

Despite the promise of this new approach for investigating the microbiome, challenges remain.

"We'll need many more studies at other archaeological sites and time periods to fully understand how the microbiome changed in human groups over time," says Bos. "However, we have taken a key step in showing that DNA recovery of ancient intestinal contents from past latrines can work."

A new study published this week demonstrates a first attempt at using the methods of ancient bacterial detection, pioneered in studies of past epidemics, to characterize the microbial diversity of ancient gut contents from two medieval latrines. The findings provide insights into the microbiomes of pre-industrial agricultural populations, which may provide much-needed context for interpreting the health of modern microbiomes.

Over the years, scientists have noted that those living in industrialized societies have a notably different microbiome compared to hunter-gatherer communities around the world. From this, a growing body of evidence has linked changes in our microbiome to many of the diseases of the modern industrialized world, such as inflammatory bowel disease, allergies, and obesity. The current study helps to characterize the change in gut microbiomes and highlights the value of ancient latrines as sources of bio-molecular information.

Ancient Gut Microbiomes: Exploring the Bowels of History

Piers Mitchell of Cambridge University specializes in the gut contents of past people through analysis of unusual substrates. By looking at the contents of archaeological latrines and desiccated faeces under the microscope, he and his team have learned volumes about the intestinal parasites that plagued our ancestors.

"Microscopic analysis can show the eggs of parasitic worms that lived in the intestines, but many microbes in the gut are simply too small to see," comments Mitchell. "If we are to determine what constitutes a healthy microbiome for modern people, we should start looking at the microbiomes of our ancestors who lived before antibiotic use, fast food, and the other trappings of industrialization."

Kirsten Bos, a specialist in ancient bacterial DNA from the Max Planck Institute for the Science of Human History and co-leader the study, was first skeptical about the feasibility of investigating the contents of latrines that had long been out of order.

"At the outset we weren't sure if molecular signatures of gut contents would survive in the latrines over hundreds of years. Many of our successes in ancient bacterial retrieval thus far have come from calcified tissues like bones and dental calculus, which offer very different preservation conditions. Nevertheless," says Bos, "I was really hoping the data here would change my perspective."

The team analyzed sediment from medieval latrines in Jerusalem and Riga, Latvia dating from the 14th-15th century CE. The first challenge was distinguishing bacteria that once formed the ancient gut from those that were introduced by the environment, an unavoidable consequence of working with archaeological material.

The researchers identified a wide range of bacteria, archaea, protozoa, parasitic worms, fungi and other organisms, including many taxa known to inhabit the intestines of modern humans.

"It seems latrines are indeed valuable sources for both microscopic and molecular information," concludes Bos.

No Modern Matches for Ancient Microbiomes

Susanna Sabin, a doctoral alumna of the MPI-SHH who co-led the study, compared the latrine DNA to those from other sources, including microbiomes from industrial and foraging populations, as well as waste water and soil.

"We found that the microbiome at Jerusalem and Riga had some common characteristics - they did show similarity to modern hunter gatherer microbiomes and modern industrial microbiomes, but were different enough that they formed their own unique group. We don't know of a modern source that harbors the microbial content we see here."

The use of latrines, where the faeces of many people are mixed together, allowed the researchers unprecedented insight into the microbiomes of entire communities.

"These latrines gave us much more representative information about the wider pre-industrial population of these regions than an individual faecal sample would have," explains Mitchell. "Combining evidence from light microscopy and ancient DNA analysis allows us to identify the amazing variety of organisms present in the intestines of our ancestors who lived centuries ago."

Despite the promise of this new approach for investigating the microbiome, challenges remain.

"We'll need many more studies at other archaeological sites and time periods to fully understand how the microbiome changed in human groups over time," says Bos. "However, we have taken a key step in showing that DNA recovery of ancient intestinal contents from past latrines can work."

Our brain responds differently if we talk to a person of a different socioeconomic background from our own compared to when we speak to someone whose background is similar, according to a new imaging study by UCL and Yale researchers.

In the study, published in the journal Social Cognitive and Affective Neuroscience, 39 pairs of participants had a conversation with each other while wearing headsets that tracked brain activity.

Researchers found that, among pairs of people who had very different socioeconomic backgrounds - calculated according to education level and family income - there was a higher level of activity in an area of the frontal lobe called the left dorsolateral prefrontal cortex. The area is associated with speech production and rule-based language as well as cognitive and attentional control.

The findings support previous research suggesting that frontal lobe systems play a role in detecting bias and helping us to regulate our behaviour to avoid bias expression. The increased activity in the left frontal lobe was observed in both participants and was more alike than the brain responses of participants talking to someone of a similar background.

In a questionnaire following their task, participants paired with people of different backgrounds reported a slightly higher level of anxiety and effort during their conversation than those in similar-background pairs.

Professor Joy Hirsch (UCL Medical Physics & Biomedical Engineering and Yale) said: "For the first time, we have identified the neural mechanisms involved in social interactions between people of different backgrounds.

"I believe our findings offer a hopeful message. We know that humans can have positive social encounters with others who are different. Now we have the neurobiological basis - our brains have apparently developed a frontal lobe system that helps us deal with diversity."

Participants' brain activity was tracked using a new technique called functional near-infrared spectroscopy (fNIRS), which monitors blood flow and blood oxygenation by measuring changes in near-infrared light and involves wearing only a light headset. Previous studies have involved using MRI scans, which require patients to lie down and keep still, making conversation difficult.

The conversation task lasted for 12 minutes and involved participants being randomly assigned four subjects on themes such as "What did you do last summer?" and "How do you bake a cake?"

After their conversation task, participants were asked about the level of education they had completed and their parents' annual income and given a score based on these details. Pairs of participants were classified as either "high-disparity" or "low-disparity" depending on how different their scores were.

The two groups - different-background pairs and similar-background pairs - were matched in terms of age, race and gender, minimising the impact of these variables on the results. The participants were recruited from Yale's home city of New Haven in Connecticut, both from within the campus and beyond. They ranged in age from 19 to 44 and had a wide variety of socioeconomic backgrounds.

Lead author Olivia Descorbeth, a Yale University graduate who came up with the research proposal while still at school, said: "We wanted to know if the brain responded differently when we talked to others of a different socioeconomic background. Now we know that it does and that humans have a neurobiology that helps us navigate social differences."

For many, getting older can unfortunately mean an increased risk of illness from cardiovascular disease to cancer. University of Michigan scientists are actively researching the biological underpinnings of aging with the aim of developing interventions that could potentially help people live longer, healthier lives.

A new paper in the journal Science Advances describes the discovery of several promising small molecules that appear to reduce cellular stress in mouse skin cells and could lengthen life.

"Cellular stress resistance appears to be a common feature of long-lived organisms, such as invertebrates and mice," says the paper's lead author David Lombard, M.D., Ph.D., associate professor of pathology. Lombard is part of a multidisciplinary group at U-M's Paul F. Glenn Center for Aging. Recent research from colleague and fellow study author Richard Miller, M.D., Ph.D., found several promising drugs, including rapamycin, a cancer drug, and acarbose, a diabetes drug, that extended life in mice.

The new study, which uses high throughput screening, a technique that allows for the examination of hundreds of compounds at once, gets around some of the limitations posed by mouse studies.

"Mice live on average three years, which makes using them for longevity studies time-consuming and expensive," Lombard explains. By using cells to examine how a cell responds to stress, they hope to develop a proxy system with which to look at aging.

For the study, mouse skin cells were exposed to three types of environmental stress: a toxic herbicide called paraquat, the heavy metal cadmium and methyl methansulfonate, which damages DNA. After treatment with more than 4500 compounds, the team identified hundreds of small molecules that conferred some degree of protection against one or more of the stressors. The team then focused on eight compounds for a closer examination of how they worked at the molecular level.

Lombard explains that two candidates, AEG 3482 and cardamonin (found in spices such as cardamom), appeared to activate the Nrf2/SKN-1 pathway. Previous research has shown that this pathway helps cells resist stress and is implicated in the life-lengthening effects of several other interventions in C. elegans, a worm frequently used for aging studies, and can even extend the lifespan of male mice.

Comparing their findings to a different study of longevity in C. elegans, they found some of the same compounds that protected worms from stress were of the same class as those that their team identified as effective in mouse cells.

The team notes that their method has limitations. For example, they found that rapamycin and acarbose, previously shown to extend life in mice, did not protect against the stressors they used. And, says Lombard, a lot more work needs to occur before the findings can be extrapolated to humans. "I think the bottom line is we're fairly different than worms and flies, and some of these drugs have similar effects in different organisms, but it's not a one to one relationship."

Lombard says the promise of the method is its ability to find interesting drugs for follow up, especially to study their mechanism of action. "I don't think any are ready for lifespan studies, but what we've identified is an interesting group of compounds that have some intriguing effects in cells and in invertebrates."

Paper cited: "High-throughput small-molecule screening reveals Nrf2-dependent and -independent pathways of cellular stress resistance," Science Advances, DOI: 10.1126/sciadv.aaz7628

CHICAGO - Researchers have identified genetic mutations that appear to protect women from severe bleeding after childbirth, a leading cause of maternal death. A preliminary study of the findings is being presented at the ANESTHESIOLOGY® 2020 annual meeting.

DNA, which carries genetic information in cells, contain biological instructions. A genetic mutation, which is a permanent change in the DNA, can be beneficial, decreasing a person's risk for a disease or condition, or harmful, increasing that risk.

Previous research has suggested genetics may play a role in the risk of bleeding after childbirth, called postpartum hemorrhage, but specific genes associated with the risk have not been identified. In this study, researchers identified several genetic mutations that appear to be associated with a reduced risk for postpartum hemorrhage.

"This research suggests there may be biological mechanisms that are protective," said Vesela Kovacheva, M.D., Ph.D., lead author of the study and an assistant professor of anesthesiology at Harvard Medical School, Boston. "After further research, we may be able to design drugs that target these pathways to prevent or help treat postpartum hemorrhage."

Drawing from the UK Biobank, an independent nonprofit initiative of more than 500,000 people, the researchers compared DNA in 1,424 women who had postpartum hemorrhage to 4,272 women who had an uncomplicated childbirth. They identified five genetic mutations that were associated with the risk for postpartum hemorrhage. The common theme in all of these mutations is that they are found near genes associated with the immune system.

The research adds to the growing evidence that the immune system plays a role in a normal pregnancy and delivery. Once the genes that have been identified in the study are verified, women could eventually be screened to determine their risk for postpartum hemorrhage, Dr. Kovacheva said.

"These newly identified mutations - or differences in the structure of the DNA - may decrease the risk for hemorrhage, but we do not know why," said Dr. Kovacheva. "We don't know if the exact genes identified are involved or if those mutations affect other genes. Our next step is to study them further to learn more about how they work."

CHICAGO - Almost 20 years into the opioid epidemic, there finally is evidence of significant and continual decreases in the abuse of these risky pain medications, according to an analysis of national data being presented at the ANESTHESIOLOGY® 2020 annual meeting.

The rate of prescription opioids fell 26% between 2007 and 2018, according to the researchers' analysis of the National Survey on Drug Use and Health, an annual survey of about 70,000 Americans age 12 and older asking about their use of tobacco, alcohol and drugs.

For the analysis, prescription opioid abuse was defined as use without the consent of a physician. While opioids can be beneficial for short-term relief, in most cases they should not be used long-term because of their significant side effects and risk for addiction.

"Prior research has shown slight reductions in abuse rates, but our analysis shows we're tracking statistically significant year-to-year declines in abuse, indicating that the decrease is not an anomaly and truly represents a trend in falling prescription drug abuse levels," said Mario Moric, M.S., lead author of the study and a biostatistician at Rush University Medical Center, Chicago. "We believe the message of the dangers of opioid use without supervision of a medical professional is finally getting through and changing people's mindset and behavior."

In 2007, 4.9% of the respondents said they had abused prescription pain medications the previous year. In 2018 (the most recent year for which data are available), 3.7% said they had done so. The difference represents a 26% decrease in abuse. The analysis showed significant declines from 2012 to 2018, with the exception of 2015, when higher numbers were reported due to a survey redesign introduced that year.

"Pain medications such as opioids are an important resource in the treatment and care of patients, but they are not a cure-all," said Asokumar Buvanendran, M.D., co-author of the study, chair of the American Society of Anesthesiologists Committee on Pain Medicine and executive vice chair of anesthesiology at Rush University Medical Center. "Since opioids have risks and can be highly addictive, they should be used only under the supervision of a physician who can consider their safety and how the medication will affect a patient over time. Prescribers and patients are now better armed with the information they need to make educated choices in pain management."

CHICAGO: Military surgical teams face unique demands on and off the battlefield. Combat trauma represents 0.5 percent of the 1 million annual military health system hospital admissions, presenting a challenge for military surgical teams to remain combat ready. Previous research has established the many benefits of military-civilian partnerships for training military surgeons prior to deployment and retaining critical skills during deployment.* However, there exists a lack of data about the readiness and case volumes of other members of Army Forward Resuscitative Surgical Teams (FRSTs). Researchers who studied clinical practice patterns in non-physician members of Army FRSTs, particularly comparing the experience of active duty and Army reservist team members, presented their findings during the virtual American College of Surgeons (ACS) Clinical Congress 2020.

"When we split up the groups into Army reservists and active duty members of FRSTs, we saw that the Army reservists were spending a lot more time in their civilian duties treating patients and gaining health care experience," said lead study author Matthew S. Sussman, MD, a resident in vascular surgery at the University of Miami/Jackson Memorial Hospital. "But if we can integrate the active duty members into civilian centers, it can provide more experience for these team members so that when they are deployed, they can provide the best and safest care to the wounded."

The driving idea behind military-civilian partnerships is that by integrating military surgical teams in civilian trauma centers, military surgeons will be able to keep their skills sharp while they're not deployed, and will also be able to share lessons learned from the battlefield to enhance civilian trauma care back home. This study, which looked at non-physician members of FRSTs at Ryder Trauma Center at Jackson Memorial Hospital in Miami - a facility with a longstanding military-civilian partnership - established that the benefits of military-civilian partnerships also extend to other members of the surgical team.

The research team surveyed 499 FRST members. Of the 483 responses received, 208 were Army reservists (AR) and 275 were active duty (AD). For the FRST members surveyed, combat experience was similar for AD vs. AR non-physician team members: 50 percent vs. 52 percent had at least one combat deployment, 52 percent vs. 60 percent of peri-deployment patient load was trauma-related, and 31 percent vs. 32 percent had at least 40 patient contacts during their most recent deployment. However, the medical experience differed between the two groups: 18 percent of AD vs. 29 percent of AR had more than 15 years of experience in practice, and 4 percent AD vs. 17 percent AR spent more than 50 percent of their time treating critically injured patients. The researchers noted that these differences persisted across all specialties, including CRNAs, critical care nurses, ER nurses, perioperative nurses, OR techs, LPNs, and combat medics.

"The deployed experience is very similar, regardless of whether you're active duty or a reservist. But it's the clinical practice at home that really makes a difference between these groups. The acuity of patient contacts, the focus on trauma, and the years of experience were significantly different in the reservists compared with active duty team members," said Lieutenant Colonel Mark D. Buzzelli, MD, FACS, Army Trauma Training Detachment, Ryder Trauma Center, Miami, Fla.

The researchers noted that to address these gaps and to enhance care provided while deployed, active duty FRST members should have plenty of clinical training opportunities prior to deployment. "To maintain readiness and provide optimal care for our injured warriors, trauma teams - not just individuals - must embed within civilian centers," the researchers concluded.

"The Army has been proactive in terms of establishing additional military-civilian partnerships, identifying the need to ensure our military providers who provide trauma care have those optimal opportunities for training," said Colonel Kirby R. Gross, MD, FACS, Army Trauma Training Detachment, Ryder Trauma Center, Miami, Fla. "These findings reinforce and validate the proactive decisions our leadership has been making."

CHICAGO: New applications of artificial intelligence (AI) in health care settings have shown early success in improving survival and outcomes in traffic accident victims transported by ambulance and in predicting survival after liver transplantation, according to two research studies presented at the virtual American College of Surgeons Clinical Congress 2020.

Both studies evaluated how AI can crunch massive amounts of data to support decision-making by surgeons and other care providers at the point of care.

In one study, researchers at the University of Minnesota applied a previously published AI approach known as natural language processing (NLP)1 to categorize treatment needs and medical interventions for 22,529 motor vehicle crash patients that emergency medical service (EMS) personnel transported to ACS-verified Level I trauma centers in Minnesota. According to a 2016 study by the National Academies of Sciences, Engineering, and Medicine, 20 percent of medical injury deaths are potentially preventable2 representing a quality gap the researchers sought to address.

Reviewing the performance of EMS teams to profile potentially preventable deaths can enable quality improvement efforts to reduce these deaths. "Currently this process for performance review is manual, time-consuming, and expensive," said senior author Christopher James Tignanelli, MD, FACS. "AI allows possible automation of this process." NLP is an AI protocol that extracts key data from spoken or written text that providers--EMS personnel in this study--enter into the electronic record as a key component of their report. Dr. Tignanelli is an assistant professor of surgery, division of acute care surgery, at the University of Minnesota Medical School, and affiliate faculty at the Institute for Health Informatics at the University of Minnesota.

In this study, two trauma surgeons independently and manually reviewed a random selection of 1 percent of patient records and determined treatment needs and medical interventions. To evaluate the accuracy of the AI system, the manual determinations were compared with the NLP determinations. "Overall the algorithm performed with very high accuracy," Dr. Tignanelli said.

Typically after EMS personnel enter their notes into the electronic health record, oversight personnel cull through them and determine whether the patient received appropriate care, usually a week or so afterward. "That's quite a labor-intensive process," said presenting author Jacob Swann, MD, a burn and trauma fellow at Regions Hospital in St. Paul, Minn. "The goal of this project and what it validated was to automate a lot of those notes."

The NLP approach ran those notes through an algorithm to separate the notes of consequential medical interventions from less consequential ones. "That can streamline the manual review process," Dr. Swann said. "It's not performed at the accuracy level that would allow you to take the physician out of it and say that AI can determine with complete accuracy if the standard of care was given or not, but it does perform well."

The AI pipeline Dr. Swann and colleagues studied determined that only about one quarter (242 of 936) patients who needed an airway intervention actually got one before they arrived at the hospital, and that about two-thirds (110 of 170) of those who did not have adequate intravenous access and needed access into the bone, known as intraosseous (IO) access, during advance cardiac life support did receive IO access.

"Being able to identify systemic errors allows you to improve the entire health system," Dr. Swann said. "Having the ability to look at large aggregate data and go through 330,000 charts over several minutes with an AI-reading algorithm, to identify specific areas for potential improvement--whether it's getting intravenous access in our patients or having problems with splinting long bone fractures--allows you separate the signal from the noise and then figure out where the problem lies."

The "holy grail," noted Dr. Swann, is to have an AI system that can listen and observe EMS personnel during en route care and assist with complex decision making by recommending care options in real time.

For the second AI study, researchers at Baylor College of Medicine, Houston, tested four different machine-learning models for predicting survival after liver transplantation. The two models that showed high accuracy for predicting survival are known as the Random Forest and AdaBoost models. Lead author Rowland Pettit, MD-PhD candidate at Baylor, explained that Random Forest (RF) is an ensemble learning method that combines the outputs of multiple decision trees and predicts an outcome by a "majority wins" approach.

The models took into account a total of 324 disease characteristics to determine survivability. The strongest factors were acuity of illness and the recipient's disease course, Mr. Pettit said.

The study selected all 109,742 adult patients who had one liver transplant from the United Network of Organ Sharing database since its inception in 1984. The RF model showed an accuracy, reported as area under the curve, of 80 percent for predicting survival at one month, 79 percent at three months, 75 percent at one year, and 73 percent at three and five years. None of the other models showed predictability exceeding 70 percent.

"The most readily accessible application of these models would be for regulation, providing immediate feedback to clinicians about their outcomes for the past year and how they and their centers performed compared to others," Mr. Pettit said. "Being able to accurately predict whether a patient should have survived or not is crucial to then accurately providing feedback."

This type of AI model also has the potential to integrate with electronic medical record systems and physician workflows to provide benchmarks, he added. "It would be very easy with an integrated model to run predictions for every patient on a liver transplant waiting list in real time and determine the probability of each patient living at one, three or five years," he said. "This step is not to make the decision for the clinician, but to add a further clinician-assistance decision-making tool to give them quantitative data for use in organ allocation decisions."

CHICAGO: Surgical patients who participate in virtual follow-up visits after their operations spend a similar amount of time with surgical team members as those who meet face-to-face. Moreover, these patients benefit by spending less time waiting at and traveling to the clinic for in-person appointments, according to research findings presented at the virtual American College of Surgeons Clinical Congress 2020.

"I think it's really valuable for patients to understand that, in the virtual space scenario, they are still going to get quality time with their surgical team," said lead study author Caroline Reinke, MD, FACS, associate professor of surgery at Atrium Health in Charlotte, N.C. "A virtual appointment does not shorten that time, and there is still an ability to answer questions, connect, and address ongoing medical care."

Due to the Coronavirus Disease 2019 (COVID-19) pandemic and the widespread adoption of technology, many surgical patients are being offered virtual appointments in place of traditional in-person visits. The researchers say this is one of the first studies to look at how patients spend their time in post-operative virtual visits compared with face-to-face consultations.

The study design was a non-inferiority, randomized controlled trial that involved more than 400 patients who underwent laparoscopic appendectomy or cholecystectomy at two hospitals in Charlotte, N.C. and were randomized 2:1 to a post-discharge virtual visit or to an in-person visit. The study began in August 2017 but was put on hold in March 2020 due to COVID-19.

"Other studies have looked at the total visit time, but they haven't been able to break down the specific amount of time the patient spends with the provider. And we wanted to know if that was the same or different between a virtual visit and an in-person visit," Dr. Reinke said. "We wanted to get down to the nitty gritty of how much face time was actually being spent between the surgical team member and the patient."

Researchers tracked total time the patients spent checking in, waiting in the waiting room and exam room, meeting with the surgical team member, and being discharged after the exam. For in-person visits, on-site waiting time and an estimated drive time was factored into the overall time commitment.

Just 64 percent of patients completed the follow-up visit. "Sometimes, patients are doing so well after minimally invasive surgery that about 30 percent of these patients don't show up for a post-operative visit," Dr. Reinke said.

Overall, results showed that the total clinic time was longer for in-person visits than virtual visits (58 minutes vs. 19 minutes). However, patients in both groups spent the same amount of face time with a member of their surgical team (8.3 minutes vs. 8.2 minutes) discussing their post-operative recovery.

"I was pleasantly surprised that the amount of time patients spent with the surgical team member was the same, because one of the main concerns with virtual visits is that patients feel disconnected and that there isn't as much value in it," Dr. Reinke said.

Importantly, patients placed a high value on convenience and flexibility. "We received overwhelmingly positive responses to this patient-centered care option." Dr. Reinke said. "Patients were able to do the post-operative visit at work or at home while caring for children, without having to disrupt their day in such a significant way."

The researchers also found that patients embraced the virtual scenario. The satisfaction rate between both groups of patients was similar (94 percent vs. 98 percent).

In addition, wait time was much less for patients who got virtual care. "Even for virtual visits, the amount of time the patients spent checking in and waiting was about 55 percent of total time. Because virtual visits have the same regulations as in-person visits, even if you take out the components of waiting room and patient flow within the clinic, patients are still spending about half of their time on the logistics of check in," Dr. Reinke. "Yet, with virtual visits, there is still much less time spent waiting, about 80 percent less time."

Still, some patients are not comfortable with the technology. The number of patients who couldn't or didn't want to do a virtual visit was higher than expected, according to the authors.

"I think there are some patients that would really just rather come in and shake someone's hand," Dr. Reinke said. "I think for surgery it's a little bit different, because with surgical care there are incisions to check on. However, we were able to check on incisions pretty easily, having patients show us their incisions virtually on the video screen."

CHICAGO: The STOP THE BLEED® course teaches a skill with lifesaving potential that is easy to learn and globally relevant. Two studies presented at the American College of Surgeons (ACS) Clinical Congress 2020 provide evidence that STOP THE BLEED® training is effective and has made a lifesaving difference around the world.

In one study, an hour-long STOP THE BLEED® course was taught to 121 nursing students at the Kabala Nursing School in rural Sierra Leone. After one year, a survey was administered to the participants to learn whether they encountered bleeding emergencies and whether they were able to administer bleeding control techniques. Seventy-six people responded to the survey, reporting a total of 190 encounters with life-threatening bleeding situations.

The most common injuries requiring a bleeding control intervention were motorcycle collisions (34 percent), knife wounds (19 percent), and car accidents (13 percent). Participants reported they most commonly used wound packing (41 percent), direct pressure (26 percent), and tourniquet application (20 percent). Because they were able to intervene, nearly all of the patients (94 percent) survived, with a majority (82 percent) reporting to the hospital for further medical care.

"People are getting basic medical knowledge, which is essential. With or without a medical background, they can apply this knowledge to save a life," said Samba Jalloh, MB, ChB, of the College of Medicine and Allied Health Sciences, Freetown, Sierra Leone.

In low-to-middle income countries (LMICs), access to health care can be sporadic and the burden of injury can be significant. The findings from this study provide evidence that STOP THE BLEED® training can be implemented in LMICs with sustained success in treating bleeding emergencies before a patient is able to be transported to a hospital.

"Here, there are a lot of risks. Transportation is not very safe, and hospitals can be far away from villages. Knowing how to stop the bleed is very important. People are using the skill to save lives," Dr. Jalloh said.

The researchers stressed that these findings demonstrate enormous lifesaving applicability of STOP THE BLEED® training in Sierra Leone. They noted that future studies should focus on the specifics of adapting bleeding control for use in other LMICs.

"With the efforts of Dr. Jalloh, the course became a mandatory component of house staff training in Freetown. Successful technique usage and course dissemination have encouraged us to think of ways to improve bleeding control training in the United States and abroad. These findings support further emphasis on lifesaving prehospital interventions and represent a great example of sustainable, bidirectional global surgical teamwork," said lead study author Vennila Padmanaban, MD, a surgical resident at Rutgers New Jersey Medical School, Newark.

In another study from researchers in Connecticut, STOP THE BLEED® course attendees demonstrated a strong proficiency of bleeding control knowledge after one year, and course participants, including previously untrained attendees, reported successfully applying hemorrhage control techniques to save lives.

"In our study, we had people as young as 14 and as old as 64 report that they used bleeding control skills. Eight of these people had not undergone any previous training in bleeding control and seven of the people who used the skills did not work as a first responder or in a health care setting," said lead study author Jeremy Fridling, a fourth-year medical student at the Frank H. Netter MD School of Medicine at Quinnipiac University, North Haven, Conn.

The researchers tracked 1,030 STOP THE BLEED® course attendees, administering surveys before and after the course, as well as six and twelve months later. Of the respondents, 31 participants (8.4 percent) applied bleeding control skills to live victims, with 29 (93.5 percent) reporting a successful outcome.

In the post-course surveys, the average response was between "agree" and "strongly agree" for confidence in knowledge and skills. Notably, the average response (on a 1-5 scale) significantly increased from pre (4.1) to post (4.6), six-month (4.4), and twelve-month (4.5) for willingness to treat a victim with serious bleeding.

"This study is a validation that regular, ordinary people--if you train them and give them a chance and empower them to do a public good and stop bleeding--can stop bleeding with a successful outcome," said study coauthor Lenworth Jacobs, MD, MPH, FACS, professor of surgery, University of Connecticut, and Medical Director, ACS STOP THE BLEED® program.

CHICAGO: People age 65 years and older account for 40 percent of inpatient operations and one-third of outpatient procedures,1,2 and these older patients are more vulnerable to longer hospital stays and other complications after surgery than younger patients. A beta test of a program for older adults who undergo major surgery has resulted in shorter hospital stays and lower rates of post-surgery delirium, among other improved outcomes, according to research presented at the virtual American College of Surgeons (ACS) Clinical Congress 2020.

The Aging Veterans Surgical Wellness (AVSW) program at the Rocky Mountain Regional Veterans Affairs Medical Center in Aurora, Colorado, served as a beta testing site for the American College of Surgeons Geriatric Surgery Verification program (ACS GSV). The study involved 186 patients, 158 of whom were matched according to age and type of operation to a comparative control group of 308 patients from the national Veterans Affairs Surgical Quality Improvement Program (VASQIP) database.

"When we looked at the matched cohort from the VASQIP data base, we found a decreased hospital length of stay of four days compared to five days, which is very significant," said Alexandra Kovar, MD, a general surgery resident at the University of Colorado School of Medicine and chief resident for quality and safety at the Rocky Mountain Regional VA Medical Center.

"When we compared our outcomes to those reported in previously published research, two important postoperative outcomes in our patient population showed significant improvement: development of postoperative delirium and functional health postoperatively."

The rate of post-surgery delirium in the AVSW population was 9.3 percent compared with 12.1 percent reported in the ACS National Surgical Quality Improvement Program Geriatric Surgery Pilot study.3 Likewise, only 19.1 percent of the AVSW patients reported functional cognitive decline after their operations compared with 42.9 percent in the pilot study. "These variables are specifically important to older adults because the development of postoperative delirium can affect their cognition long term," Dr. Kovar said. "Functional health is related to independence, mobility, and overall quality of life."

The ACS GSV program was introduced July 2019. It sets forth 32 different surgical standards that hospitals can use for a multidisciplinary team approach to optimize surgical care for older adults facing surgery. The standards address the preoperative work-up, postoperative management, care transition, data collection, quality improvement, professional and community outreach, and research.

Senior study author Thomas Nichols Robinson, MD, FACS, chief of surgery at Rocky Mountain Regional VA Medical Center and a member of the ACS GSV program panel, noted that the standards can be implemented at any hospital. "The majority of these standards are aimed at the clinical processes necessary to optimize the surgical care of older adults, but the standards also address the administrative support needed to improve the surgical care of older adults, and measurement outcomes necessary to improve the care of older adults in your hospital," he said.

Dr. Kovar noted two interventions were important to the success of the AVSW program. "The implementation of the preoperative multidisciplinary conference where we talk about the patients prior to having surgery," she said. "We discuss their needs in the three phases of care, for example, whether they're going to need physical therapy, occupational therapy, or a nutritional consult. We get them teed up for surgery so when they arrive they're ready to go. The second intervention is the daily inpatient rounding team, who assesses the patient on a daily basis."

In the next step for their research, Dr. Kovar and colleagues aim to enroll more patients and include more specific internal and external cohorts to evaluate more postoperative outcomes, including 30-day post-surgery death and complications. Future variables would include patient-reported outcomes and outcomes using telehealth, she said.

Added Dr. Robinson, "Surgeons intuitively recognize that the group at highest risk of poor outcomes are older adults; the frail older adult is at highest risk for longer hospital stays, complications, and needing to go to institutions after discharge. This program directly addresses those needs unique to frail older adults to try to prevent poor outcomes after surgery."

"The results of this beta pilot show how well the Geriatric Surgery Verification program works in a hospital that puts forth the institutional commitment to improve the care of older adults facing surgery. Identifying and addressing potential vulnerabilities specific to the geriatric surgical patient such as delirium, result in better patient outcomes. And a reduced hospital stay is not only a good outcome for patients, it also indicates a more efficient use of resources," said Clifford Y. Ko, MD, MSHS, FACS, principal investigator for the ACS Geriatric Surgery Verification program, who was not involved with the study.

CHICAGO: Pregnant women who underwent immediate surgery to treat a ruptured or abscessed appendix and their fetuses had significantly better outcomes than those whose condition was managed without an operation. Results from a nationwide study presented at the virtual American College of Surgeons Clinical Congress 2020 form the basis for the potential development of a consensus on optimal management of complicated appendicitis in pregnancy.

Currently, the management of appendicitis in the general population is somewhat controversial and is especially true for complicated appendicitis. Increasing numbers of surgeons prefer a trial of nonsurgical management; others recommend an immediate operation," explained Kazuhide Matsushima, MD, FACS, an assistant professor of clinical surgery, Keck School of Medicine, University of Southern California (USC), Los Angeles. "This study is a great first step toward a consensus regarding the optimal management of complicated appendicitis in pregnant patients. Randomized clinical trials are necessary to provide that consensus," he added.

"Based on the current evidence we have, which includes this study, our recommendation would be for surgeons to pursue immediate operation for pregnant patients with complicated appendicitis. Every day of delay to surgery means worse clinical outcomes for the patients as well as the fetus," said Vincent Cheng, MD, a general surgery resident and lead author of the study at USC.

Since the 19th Century, surgery has been the most widely accepted treatment for appendicitis; more than 300,000 appendectomies are performed annually in the US.1 Laparoscopic appendectomy is the most common surgical treatment.2,3 Despite this history, the management of acute appendicitis is still open to debate in terms of such questions as the timing of appendectomy, the safety of in-hospital delay, and the indications for performing appendectomy following a course of antibiotics.4, 5, 6, 7

Moreover, increasing numbers of patients in the U.S. are being treated for appendicitis non-operatively. The number has doubled in the last 20 years, according to results of a study presented at the American College of Surgeons Clinical Congress 2017.8

Appendicitis during pregnancy is relatively uncommon. While the raw number and incidence of appendicitis during pregnancy is low, it is actually the most common non-obstetric emergency during pregnancy. It is also the most common non-obstetric reason for surgery during pregnancy, Dr. Cheng said. About 0.1 percent of pregnant women have appendicitis; in one study, 25 percent of 713 pregnant patients with appendicitis had a perforated appendix.9,10,11 Nonetheless, the condition carries a high risk of serious complications, including loss of the fetus.9 Perforation of the appendix increases the risk of death of the mother.11

Because of the low incidence of complicated appendicitis in pregnancy, there are no specific recommendations or guidelines on management. A team of surgeons from USC therefore set out to evaluate current treatment of complicated appendicitis in pregnancy by comparing maternal and fetal complications after operative and non-operative management.

The researchers reviewed the National Inpatient Sample dataset from 2003-2015 to identify 8,087 cases of complicated appendicitis in pregnancy. Most (55 percent) had immediate non-invasive surgery. Forty-five percent began a course of non-operative management, which involved a course of antibiotics with or without percutaneous drainage of the inflamed organ. Of the 45 percent of patients who began non-operative management, 74 percent failed and later required an operation (either a laparoscopic procedure or an open appendectomy).

Preterm labor, delivery, and pregnancy termination were more common in the group of women who had non-operative management or delayed surgery than in those who had immediate surgery; the odds of developing these complications were one to three times higher for the non-operative group. Sepsis also was two to four times more common in these groups of patients. The rate of any complication was lowest among patients who had immediate surgery (30 percent) and overall length of stay was two days shorter for these patients.

While further study is needed to eventually arrive at a consensus for treating complicated appendicitis in pregnancy, findings from the study may help guide surgeons and patients. Dr. Matsushima stressed the importance of telling patients that the management of this condition is controversial and explaining the treatment options and risks.

Dr. Cheng pointed out that "every situation is different and every patient is different so the discussion about how to manage this disease process should be a joint process between the patient and the surgeon that presents the pros and cons of the treatment options."

CHICAGO: Transportation barriers, such as personal access to a vehicle or public transportation, disproportionally affect minority communities, according to results of a new study presented at the virtual American College of Surgeons (ACS) Clinical Congress 2020.

The study was performed by researchers at the University of Colorado at Aurora who used geographic information systems (GIS) to better understand traffic paths to hospitals offering elective and emergency surgical care throughout Denver. They tracked public transportation routes across census tracts and found areas with higher minority populations have nearly double the travel time burden to health care facilities when using public transportation.

Facilities with acute surgical capacity (emergency department, intensive care unit, and acute care surgery services) were identified within a 20-mile radius of the city center. Travel times were then estimated from the center of each census tract to the nearest facility by the shortest route. Using this method, the researchers determined travel times for individuals traveling by both car and public bus for a Monday morning appointment, weighted by percentage of the population in each census tract without vehicle access according to the American Community Survey.

For the 144 census tracts within Denver, the researchers found patients traveling by car were likely to spend approximately 12 minutes time driving to a health care facility as opposed to 33 minutes each way when traveling by public transportation. The overall drive times weighted by lack of vehicle access across the city are estimated to be 11 minutes by car and 28 minutes by bus. Additionally, census tracts with higher minority populations and higher populations without access to a personal vehicle saw approximately 3 minutes in increased travel time by bus for every 10 percent increase in the minority population.

Impact of Transportation Access on Medical Care

Barriers to health care access like race, income, and having insurance are well-documented, but structural barriers, like geography, can act in similar ways. In Denver specifically, freeway routes dividing the city and communities have shut residents off from resources to which they were previously able to walk. Prior work by the same group found that lack of health care coverage was not a significant barrier to surgical care where the majority of patients who presented emergently had some health care coverage, and many of the patients had sufficient coverage such that they had already been scheduled for elective surgical consultation, or even surgery itself.1

Regardless of type of health care coverage, patients who presented emergently tended to live in areas of higher social vulnerability and were overwhelmingly non-white.2 Qualitative data derived from narrative data in the charts revealed that a common factor leading to emergent presentation included difficulties arranging transportation. In fact, approximately 3.6 million people in the United States forgo medical care due to transportation issues, such as lack of vehicle access, inadequate infrastructure, long distances, and lengthy travel times to reach services.3 As a result, procedures that could be treated in an outpatient appointment can frequently run the risk of becoming emergency situations.

Transportation patterns in areas where people don't have access to a vehicle can add 30 or more minutes to travel to an appointment. "When you factor in that people have to take additional time off from their jobs to go to an appointment to get elective care, and add in the fact that a lot of people have jobs where they don't have a lot of paid time off or the ability to take off that much time in a day, you may be looking at them having to take an entire day off to be able to make it to an elective surgical appointment. So, you're adding barrier after barrier, and these things tend to compound themselves," said study coinvestigator Catherine Velopulos, MD, MHS, FACS, a health services researcher and associate professor of surgery at the University of Colorado School of Medicine.

The findings also suggest a double effect of transportation barriers. Not only are some patients facing a greater barrier in terms of the percent of the population that has access to a private vehicle, but those same populations also have longer public transportation times per mile to acute care surgical facilities.

Using GIS to improve health care access

Census data can be used with GIS mapping to collect information about the environment, allowing local governments to identify communities with disproportionate transportation burden to acute care surgical services. By identifying where increased burden exists, cities can make structural changes to accommodate these needs.

"Place truly matters. Where you're located and where you live affects your health care outcomes," said coinvestigator Heather Carmichael, MD, a surgical resident at the University of Colorado School of Medicine. "If you can identify where patients are coming from, that gives you a lot of information about the environment that they're in that can affect their health care outcomes. And location of residence may be easier to determine in a research setting than in individually collecting each of those sociodemographic variables for an individual patient."

Understanding this combined data helps communities focus on where best to place resources like outreach programs and other forms of health care navigation, like Colorado's Non-Emergent Medical Transportation services, as well as to reevaluate traditional bus routes and pick up locations to better suit the needs of the community.

"A lot of people's access to the health care system is through surgical disease," added Dr. Velopulos, "And it's important for us as surgeons to recognize that we have a duty to improve access to care all around because it makes our patients healthier and our surgical outcomes better, and it allows us to reach our patients at an earlier point in their disease."

A study conducted at 19 universities by IU researchers and their colleagues in the U.S. and Canada, found that a brief social belonging exercise, administered online before students arrive on campus, boosts the performance and persistence of students in STEM disciplines - science, technology, engineering and math - who speak English as a second language.

Published this week in the journal Science Advances, the study demonstrates that the exercise increases ESL students' perception that a sense of belonging on campus will grow over time. It also increases the number of STEM credits ESL students successfully completed, as well as their STEM GPAs.

As Jennifer LaCosse, an IU post-doctoral researcher and lead author on the study, explained, ESL students are greatly underrepresented in U.S. colleges, particularly within STEM fields, and their absence is a disadvantage both to the students themselves and the economy more broadly. Having a college degree, particularly in STEM fields, gives ESL students the opportunity to have higher paying jobs and more successful careers overall. It also creates a diverse and multilingual workforce that is needed to meet the needs of an increasingly globalized economy.

Results of the study suggest that one way to increase the representation and academic success of ESL students in STEM is to target their sense of belonging. "Students often ask themselves, 'Do I belong here?' and we know that this concern can undermine academic performance and persistence," said LaCosse.

Students who speak English as a second language often report concerns about not fitting in with native English-speaking students and a lack of social connections. In addition, many are required to pass language proficiency tests or enroll in special ESL courses during their first few years of college.

"These policies can metaphorically and literally separate ESL students from non-ESL students during the pivotal transition to college when feelings of belonging are critical," said LaCosse. "Finding ways of buttressing ESL students' feelings of belonging may be essential to their academic success--which is what we wanted to examine in our research."

The study utilized data collected at 19 universities from more than 12,000 STEM students by the College Transition Collaborative, a partnership co-founded by IU social psychologist and study co-author Mary Murphy. Students in the study who were randomly assigned to receive the social belonging treatment, read short stories attributed to juniors and seniors describing the challenges they faced in their transition to college. The students in the stories initially questioned the degree to which they belonged in college; and yet, with time they ultimately developed a greater sense of belonging. Study participants followed the readings with a writing exercise about their own experiences.

Results of the study revealed that both ESL and non-ESL students who received the social belonging exercise anticipated greater growth in their sense of belonging than students who received the control treatment. However, these psychological gains in belonging only bolstered the academic persistence and performance of ESL students. Specifically, STEM-interested ESL students who received the social-belonging exercise (vs. the control group, which did not) completed more of the STEM courses that they began in their first term in college--and this effect persisted through the first year. ESL students who completed the social belonging exercise also earned higher STEM GPAs in Term 1 than did their ESL peers who did not.

"People do not often think about ESL students as a disadvantaged group in the same way they do about other disadvantaged students, such as Black or women students," observed LaCosse. "The results of this study, however, provide rigorous empirical evidence that ESL students have similar psychological experiences to these other disadvantaged students."

As co-author Mary Murphy, IU professor of psychological and brain sciences noted, "Because of the large sample size across so many universities this is one of the first studies to quantitatively examine and mitigate this important psychological barrier for ESL students in STEM fields as they begin college."

"The findings are really exciting," said LaCosse, "because ESL students' psychological experiences in higher education have received far less attention than they deserve. Our research suggests that we need to rethink the policies and practices that are in place that create and maintain the underrepresentation of ESL students in higher education."