Stanford University Medical Center Research Articles

The outcome of revision total hip arthroplasty for instability.

Instability is a common indication for revision total hip arthroplasty (THA). However, even after the initial revision, some patients continue to have recurrent dislocation. The aim of this study was to assess the risk for recurrent dislocation after revision THA for instability. Between 2009 and 2019, 163 patients underwent revision THA for instability at Stanford University Medical Center. Of these, 33 (20.2%) required re-revision due to recurrent dislocation. Cox proportional hazard models, with death and re-revision surgery for periprosthetic infection as competing events, were used to analyze the risk factors, including the size and alignment of the components. Paired t-tests or Wilcoxon signed-rank tests were used to assess the outcome using the Veterans RAND 12 (VR-12) physical and VR-12 mental scores, the Harris Hip Score (HHS) pain and function, and the Hip disability and Osteoarthritis Outcome score for Joint Replacement (HOOS, JR). The median follow-up was 3.1 years (interquartile range 2.0 to 5.1). The one-year cumulative incidence of recurrent dislocation after revision was 8.7%, which increased to 18.8% at five years and 31.9% at ten years postoperatively. In multivariable analysis, a high American Society of Anesthesiologists (ASA) grade (hazard ratio (HR) 2.72 (95% confidence interval (CI) 1.13 to 6.60)), BMI between 25 and 30 kg/m2 (HR 4.31 (95% CI 1.52 to 12.27)), the use of specialized liners (HR 5.39 (95% CI 1.97 to 14.79) to 10.55 (95% CI 2.27 to 49.15)), lumbopelvic stiffness (HR 6.03 (95% CI 1.80 to 20.23)), and postoperative abductor weakness (HR 7.48 (95% CI 2.34 to 23.91)) were significant risk factors for recurrent dislocation. Increasing the size of the acetabular component by > 1 mm significantly decreased the risk of dislocation (HR 0.89 (95% CI 0.82 to 0.96)). The VR-12 physical and HHS (pain and function) scores improved significantly at mid term. Patients requiring revision THA for instability are at risk of recurrent dislocation. Higher ASA grades, being overweight, a previous lumbopelvic fusion, the use of specialized liners, and postoperative abductor weakness are significant risk factors.

Simple models vs. deep learning in detecting low ejection fraction from the electrocardiogram

Abstract Aims Deep learning methods have recently gained success in detecting left ventricular systolic dysfunction (LVSD) from electrocardiogram (ECG) waveforms. Despite their high level of accuracy, they are difficult to interpret and deploy broadly in the clinical setting. In this study, we set out to determine whether simpler models based on standard ECG measurements could detect LVSD with similar accuracy to that of deep learning models. Methods and results Using an observational data set of 40 994 matched 12-lead ECGs and transthoracic echocardiograms, we trained a range of models with increasing complexity to detect LVSD based on ECG waveforms and derived measurements. The training data were acquired from the Stanford University Medical Center. External validation data were acquired from the Columbia Medical Center and the UK Biobank. The Stanford data set consisted of 40 994 matched ECGs and echocardiograms, of which 9.72% had LVSD. A random forest model using 555 discrete, automated measurements achieved an area under the receiver operator characteristic curve (AUC) of 0.92 (0.91–0.93), similar to a deep learning waveform model with an AUC of 0.94 (0.93–0.94). A logistic regression model based on five measurements achieved high performance [AUC of 0.86 (0.85–0.87)], close to a deep learning model and better than N-terminal prohormone brain natriuretic peptide (NT-proBNP). Finally, we found that simpler models were more portable across sites, with experiments at two independent, external sites. Conclusion Our study demonstrates the value of simple electrocardiographic models that perform nearly as well as deep learning models, while being much easier to implement and interpret.

Real world outcomes in patients with metastatic castration-resistant prostate cancer (mCRPC) treated with lutetium-177-PSMA-vipivotide tetraxetan (Lu177-PVT).

86 Background: Lu177-PVT is a novel radioligand, which was recently approved by the FDA to treat mCRPC. Real world data on its use and efficacy is limited. We aimed to build a new retrospective cohort of patients with mCRPC treated with 177Lu PSMA-617 in order to investigate clinical and pathological variables associated with treatment responses. Methods: We identified patients with a confirmed diagnosis of prostate cancer and were treated at Stanford University Medical Center with at least one dose of Lu177-PVT including trial patients. Data collection included demographic, clinicopathological and outcome variables. Statistical analysis was performed using Chi-squared and log-rank Kaplan-Meier analysis. Results: We identified 85 patients who met study criteria and were treated between March 2021 and June 2023, the median age was 66, 33% were non-white, median PSA at treatment initiation was 60, and 94% had osseous metastasis. Patients were pretreated with a median of six lines (range: 1-10) of prior therapy including local therapies; prostatectomy (28%), radiation (61%), brachytherapy (11%), taxane (78%), immunotherapy including checkpoint inhibitor and Sipuleucel-T (24%), PARP inhibitor (6%), and Radium-223 (15%). A majority of patients also received prior germline or somatic genetic testing (79%), with homologous recombination germline and somatic deficiencies present in 13% of patients. Of the identified cohort, 19 patients were still undergoing active treatment with Lu177-PVT at the time of data collection. Of the 66 patients not currently undergoing active Lu177-PVT treatment, 29 patients discontinued treatment due to progressive disease (44%) and 14 (21%) to toxicity related to 177Lu PSMA-617, completing a median of 4 cycles. 47 patients (71%) had an overall decline in their PSA from baseline, with 32 patients (49%) experiencing a decrease greater than fifty percent. Median overall survival of patients not actively receiving 177Lu PSMA-617 treatment was 366 days. Age, previous lines of therapy, and median time from diagnosis were not predictive of PSA treatment response (greater than fifty-percent reduction from baseline PSA). Conclusions: Lu177-PVT is a promising treatment for mCRPC in patients. Our results confirm ‘real-world’ activity of Lu177-PVT and align well with VISION study results, though real-world overall survival was comparatively shorter (12 months vs 15 months in VISION trial). Further investigation is warranted into predictors of response and toxicity.

Clinicopathological features and clinical outcomes in individuals with Krukenberg tumors of colorectal origin.

191 Background: Krukenberg tumors (KT) are metastases to the ovary generally originating from a gastrointestinal primary such as colorectal carcinoma. The prognosis is poor with KT, and clinicopathological features associated with clinical outcomes have not been extensively studied. The study aimed to investigate the associations of clinicopathological features with outcomes in patients with KT of colorectal carcinoma (CRC) origin. Methods: This retrospective study utilized medical records and patient registries to identify 160 patients with a confirmed histopathological diagnosis of KT at Stanford University Medical Center between 2000 and 2020. Data collection included demographics, historical, clinicopathological, treatment and outcome variables. The primary tumor type was (N, %): CRC (101, 63.1%); gastric (24, 15%), breast (13, 8.1%); small bowel (10, 6.2%), other (12, 7.5%). Statistical analysis was performed using Chi-squared, Mann-Whitney U, and log-rank Kaplan-Meier analysis. Results: Analysis of the CRC cohort subdivided by location of the primary, N: 45 vs. 56, right colon (R) vs. left colon (L) revealed no significant difference in median age at diagnosis of KT, race/ethnicity, oligometastatic disease, histopathological differentiation or ovarian tumor volume. Patients with R vs L sided CRC primaries had a higher proportion of synchronous presentation at the time of KT diagnosis (75.6% vs 41.1%, R vs L, p<0.001). Time to progression was not different, but overall survival (OS) was shorter in R CRC (767 vs. 1246 days, R vs. L, p <0.01). By Kaplan-Meier analysis, patients with R CRC had a shorter OS (log-rank p=0.016). In the subgroup with unilateral KT, R sided CRC primaries involved the R ovary (85%) whereas L-sided CRC primaries involved the L ovary (70%) ( χ2, p<0.002). Patient with bilateral (B) versus unilateral (U) had a larger ovarian tumor volume (2,073cm3 vs. 307 cm3, p<0.01) but no difference in oligometastatic disease, chronicity, time to progression or overall survival. There was no statistical difference (p=0.93) between the association of bilateral KT inter-ovarian tumor size and CRC Laterality within individual patients. Conclusions: In this study, KT tumors predominantly originate from CRC. The clinical features of R versus L CRC, such as chronicity and OS are conveyed prognostically in patients with KT. Individuals with L CRC exhibited a better overall prognosis compared to those with R CRC. In patients with unilateral KT metastasis to ipsilateral ovary is significantly associated with location of CRC and is suggestive of a retrograde lymphatic or transcoelomic route of metastatic spread. Further studies are needed to confirm these findings and to elucidate ovarian organ tropism mediators that facilitate development and growth in metastatic ovarian cancer.

Deep learning for transesophageal echocardiography view classification

Transesophageal echocardiography (TEE) imaging is a vital tool used in the evaluation of complex cardiac pathology and the management of cardiac surgery patients. A key limitation to the application of deep learning strategies to intraoperative and intraprocedural TEE data is the complexity and unstructured nature of these images. In the present study, we developed a deep learning-based, multi-category TEE view classification model that can be used to add structure to intraoperative and intraprocedural TEE imaging data. More specifically, we trained a convolutional neural network (CNN) to predict standardized TEE views using labeled intraoperative and intraprocedural TEE videos from Cedars-Sinai Medical Center (CSMC). We externally validated our model on intraoperative TEE videos from Stanford University Medical Center (SUMC). Accuracy of our model was high across all labeled views. The highest performance was achieved for the Trans-Gastric Left Ventricular Short Axis View (area under the receiver operating curve [AUC] = 0.971 at CSMC, 0.957 at SUMC), the Mid-Esophageal Long Axis View (AUC = 0.954 at CSMC, 0.905 at SUMC), the Mid-Esophageal Aortic Valve Short Axis View (AUC = 0.946 at CSMC, 0.898 at SUMC), and the Mid-Esophageal 4-Chamber View (AUC = 0.939 at CSMC, 0.902 at SUMC). Ultimately, we demonstrate that our deep learning model can accurately classify standardized TEE views, which will facilitate further downstream deep learning analyses for intraoperative and intraprocedural TEE imaging.

Differential Mortality Outcomes in Real-world Patients with Lean, Nonobese, and Obese Nonalcoholic Fatty Liver Disease.

Nonalcoholic fatty liver disease (NAFLD) is commonly associated with obesity but can develop in normal-weight people (lean NAFLD). We compared outcomes in lean, overweight, and obese NAFLD. This retrospective chart review included patients at Stanford University Medical Center with NAFLD confirmed by imaging between March 1995 and December 2021. Lean, overweight, and obese patients had body mass index of <25.0, >25.0 and <29.9, and ≥30.0 kg/m2 for non-Asian and >23.0 and ≥27.5 for overweight and obese Asian patients. A total of 9061 lean (10.2%), overweight (31.7%), and obese (58.1%) patients were included. Lean patients were 5 years older than obese patients (53±17.4 vs. 48.7±15.1 years), more were female (59.6% vs. 55.2%), white (49.1% vs. 46.5%), had NASH (29.2% vs. 22.5%), cirrhosis (25.3% vs.19.2%), or nonliver cancer (25.3% vs. 18.3%). Fewer had diabetes (21.7% vs. 35.8%) or metabolic comorbidities (all p<0.0001). Lean NAFLD patients had liver-related mortality similar to other groups but higher overall (p=0.01) and nonliver-related (p=0.02) mortality. After multivariable model adjustment for covariates, differences between lean and obese NAFLD in liver-related, nonliver-related, and overall mortality (adjusted hazard ratios of 1.34, 1.00, and 1.32; p=0.66, 0.99, and 0.20, respectively) were not significant. Lean NAFLD had fewer metabolic comorbidities but similar adverse or worse outcomes, suggesting that it is not benign. Healthcare providers should provide the same level of care and intervention as for overweight and obese NAFLD.

RADT-35. STEREOTACTIC RADIOSURGERY FOR RESIDUAL, RECURRENT, AND METASTATIC HEMANGIOPERICYTOMAS: A SINGLE INSTITUTION EXPERIENCE

Abstract INTRODUCTION Hemangiopericytomas are infrequent vascular tumors originating from Zimmermann pericytes. The conventional treatment approach involves gross total resection (GTR), followed by adjuvant radiotherapy. Nevertheless, due to their tendency to infiltrate dural sinuses, high degree of vascularity, and anatomic inaccessibility, radical resection may be challenging with substantial risk of recurrence. To address this challenge, stereotactic radiosurgery (SRS) has been proposed as a promising adjuvant therapy. Objectives Our study aims to evaluate the effectiveness and safety of SRS as a potential treatment modality in patients with residual, recurrent, and metastatic hemangiopericytomas. METHODS From 1998 to 2023, 27 patients with 101 tumors underwent CyberKnife SRS at Stanford University Medical Center. The median age was 51 years at the time of treatment. The median follow-up period from SRS was 103 months (range: 6-250). All patients underwent upfront surgical resection. The median tumor volume was 1.5 cc. The median single-fraction equivalent dose (SFED) was 19 Gy. The SRS was administered at the 76% of the median isodose line (range: 64-89). RESULTS Of the 101 treated tumors, 24 (23.8%) progressed with a median time to recurrence of 30 months. At 10 years, the rates of local tumor control (LTC), overall survival (OS), and progression-free survival (PFS) were 74.3%, 80.8%, and 67%, respectively. In patients with residual lesions, the LTC rates were significantly greater when compared to those with residual or metastatic tumors. There was no significant difference between patients with residual, recurrent, and metastatic hemangiopericytomas in OS and PFS. Notably, no cases of radiation-induced adverse events were detected. CONCLUSION Our study provides the largest single-institutional retrospective series with hemangiopericytomas treated with SRS. SRS leads to excellent LTC, PFS, and OS at 10 years with negligible risk for adverse events. Therefore, it is an effective and safe management modality for patients with residual, recurrent, and metastatic hemangiopericytomas.

A deep learning-based electrocardiogram risk score for long term cardiovascular death and disease

The electrocardiogram (ECG) is the most frequently performed cardiovascular diagnostic test, but it is unclear how much information resting ECGs contain about long term cardiovascular risk. Here we report that a deep convolutional neural network can accurately predict the long-term risk of cardiovascular mortality and disease based on a resting ECG alone. Using a large dataset of resting 12-lead ECGs collected at Stanford University Medical Center, we developed SEER, the Stanford Estimator of Electrocardiogram Risk. SEER predicts 5-year cardiovascular mortality with an area under the receiver operator characteristic curve (AUC) of 0.83 in a held-out test set at Stanford, and with AUCs of 0.78 and 0.83 respectively when independently evaluated at Cedars-Sinai Medical Center and Columbia University Irving Medical Center. SEER predicts 5-year atherosclerotic disease (ASCVD) with an AUC of 0.67, similar to the Pooled Cohort Equations for ASCVD Risk, while being only modestly correlated. When used in conjunction with the Pooled Cohort Equations, SEER accurately reclassified 16% of patients from low to moderate risk, uncovering a group with an actual average 9.9% 10-year ASCVD risk who would not have otherwise been indicated for statin therapy. SEER can also predict several other cardiovascular conditions such as heart failure and atrial fibrillation. Using only lead I of the ECG it predicts 5-year cardiovascular mortality with an AUC of 0.80. SEER, used alongside the Pooled Cohort Equations and other risk tools, can substantially improve cardiovascular risk stratification and aid in medical decision making.

Differences in liver and mortality outcomes of non-alcoholic fatty liver disease by race and ethnicity: A longitudinal real-world study.

Understanding of nonalcoholic fatty liver disease (NAFLD) continues to expand, but the relationship between race and ethnicity and NAFLD outside the use of cross-sectional data is lacking. Using longitudinal data, we investigated the role of race and ethnicity in adverse outcomes in NAFLD patients. Patients with NAFLD confirmed by imaging via manual chart review from any clinics at Stanford University Medical Center (1995-2021) were included. Primary study outcomes were incidence of liver events and mortality (overall and non-liver related). The study included 9,340 NAFLD patients: White (44.1%), Black (2.29%), Hispanic (27.9%), and Asian (25.7%) patients. For liver events, the cumulative 5-year incidence was highest among White (19.1%) patients, lowest among Black (7.9%) patients, and similar among Asian and Hispanic patients (~15%). The 5-year and 10-year cumulative overall mortality was highest for Black patients (9.2% and 15.0%, respectively, vs. 2.5-3.5% and 4.3-7.3% in other groups) as well as for non-liver mortality. On multivariable regression analysis, compared to White patients, only Asian group was associated with lower liver-related outcomes (aHR: 0.83, P=0.027), while Black patients were at more than two times higher risk of both non-liver related (aHR: 2.35, P=0.010) and overall mortality (aHR: 2.13, P=0.022) as well as Hispanic patients (overall mortality: aHR: 1.44, P=0.022). Compared to White patients, Black patients with NAFLD were at the highest risk for overall and non-liver-related mortality, followed by Hispanic patients with Asian patients at the lowest risk for all adverse outcomes. Culturally sensitive and appropriate programs may be needed for more successful interventions.

Multicenter evaluation of recurrence in endoscopic submucosal dissection and endoscopic mucosal resection in the colon: A Western perspective.

While colon endoscopic mucosal resection (EMR) is an effective technique, removal of larger polyps often requires piecemeal resection, which can increase recurrence rates. Endoscopic submucosal dissection (ESD) in the colon offers the ability for en bloc resection and is well-described in Asia, but there are limited studies comparing ESD vs EMR in the West. To evaluate different techniques in endoscopic resection of large polyps in the colon and to identify factors for recurrence. The study is a retrospective comparison of ESD, EMR and knife-assisted endoscopic resection performed at Stanford University Medical Center and Veterans Affairs Palo Alto Health Care System between 2016 and 2020. Knife-assisted endoscopic resection was defined as use of electrosurgical knife to facilitate snare resection, such as for circumferential incision. Patients ≥ 18 years of age undergoing colonoscopy with removal of polyp(s) ≥ 20 mm were included. The primary outcome was recurrence on follow-up. A total of 376 patients and 428 polyps were included. Mean polyp size was greatest in the ESD group (35.8 mm), followed by knife-assisted endoscopic resection (33.3 mm) and EMR (30.5 mm) (P < 0.001). ESD achieved highest en bloc resection (90.4%) followed by knife-assisted endoscopic resection (31.1%) and EMR (20.2%) (P < 0.001). A total of 287 polyps had follow-up (67.1%). On follow-up analysis, recurrence rate was lowest in knife-assisted endoscopic resection (0.0%) and ESD (1.3%) and highest in EMR (12.9%) (P = 0.0017). En bloc polyp resection had significantly lower rate of recurrence (1.9%) compared to non-en bloc (12.0%, P = 0.003). On multivariate analysis, ESD (in comparison to EMR) adjusted for polyp size was found to significantly reduce risk of recurrence [adjusted hazard ratio 0.06 (95%CI: 0.01-0.57, P = 0.014)]. In our study, EMR had significantly higher recurrence compared to ESD and knife-assisted endoscopic resection. We found factors including resection by ESD, en bloc removal, and use of circumferential incision were associated with significantly decreased recurrence. While further studies are needed, we have demonstrated the efficacy of ESD in a Western population.

Associations Between Subclinical Hypothyroidism and Renal Function

Clinical ThyroidologyVol. 35, No. 5 HypothyroidismAssociations Between Subclinical Hypothyroidism and Renal FunctionElizabeth A. McAninchElizabeth A. McAninchDivision of Endocrinology, Gerontology and Metabolism, Department of Medicine, Stanford University Medical Center, Stanford, California, U.S.A.Search for more papers by this authorPublished Online:12 May 2023https://doi.org/10.1089/ct.2023;35.178-179AboutSectionsView articleView Full TextPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail View article"Associations Between Subclinical Hypothyroidism and Renal Function." Clinical Thyroidology, 35(5), pp. 178–179FiguresReferencesRelatedDetails Volume 35Issue 5May 2023 Information© Copyright 2023, Mary Ann Liebert, Inc.To cite this article:Elizabeth A. McAninch.Associations Between Subclinical Hypothyroidism and Renal Function.Clinical Thyroidology.May 2023.178-179.http://doi.org/10.1089/ct.2023;35.178-179Published in Volume: 35 Issue 5: May 12, 2023PDF download

Genetic and Microenvironment Features Do Not Distinguish Follicular Lymphoma Patients Requiring Immediate or Deferred Treatment.

Genetic and Microenvironment Features Do Not Distinguish Follicular Lymphoma Patients Requiring Immediate or Deferred Treatment.

A deep-learning algorithm to classify skin lesions from mpox virus infection

Undetected infection and delayed isolation of infected individuals are key factors driving the monkeypox virus (now termed mpox virus or MPXV) outbreak. To enable earlier detection of MPXV infection, we developed an image-based deep convolutional neural network (named MPXV-CNN) for the identification of the characteristic skin lesions caused by MPXV. We assembled a dataset of 139,198 skin lesion images, split into training/validation and testing cohorts, comprising non-MPXV images (n = 138,522) from eight dermatological repositories and MPXV images (n = 676) from the scientific literature, news articles, social media and a prospective cohort of the Stanford University Medical Center (n = 63 images from 12 patients, all male). In the validation and testing cohorts, the sensitivity of the MPXV-CNN was 0.83 and 0.91, the specificity was 0.965 and 0.898 and the area under the curve was 0.967 and 0.966, respectively. In the prospective cohort, the sensitivity was 0.89. The classification performance of the MPXV-CNN was robust across various skin tones and body regions. To facilitate the usage of the algorithm, we developed a web-based app by which the MPXV-CNN can be accessed for patient guidance. The capability of the MPXV-CNN for identifying MPXV lesions has the potential to aid in MPXV outbreak mitigation.

Editorial introductions.

Editorial introductions.

How Should I Take My Levothyroxine?

How Should I Take My Levothyroxine?

The inflamed immune phenotype (IIP): A clinically actionable artificial intelligence (AI)-based biomarker predictive of immune checkpoint inhibitor (ICI) outcomes across &gt;16 primary tumor types.

2621 Background: The IIP, defined by enriched intratumoral tumor-infiltrating lymphocytes (TIL), is a potential tumor-agnostic biomarker of responsiveness to ICI therapy. Here, we validate the IIP, as assessed by Lunit SCOPE IO, an AI-powered spatial TIL analyzer that runs on routine H&amp;E-stained whole-slide images (WSI), for clinical outcome prediction in a large, multi-center international cohort of ICI-treated patients, demonstrating its utility as a practical biomarker to guide ICI treatment planning. Methods: Lunit SCOPE IO was developed using 17,849 H&amp;E WSI of multiple cancer types, annotated by 104 board-certified pathologists (13.5 x 109 µm2 area and 6.2 x 106 TIL). IIP+ tumors were defined as those with ≥ 20% of all 1 mm2 tumor tiles in a WSI classified as having a high intratumoral TIL density. We evaluated the correlation between IIP and ICI treatment outcomes (overall response rate (ORR) and progression-free survival (PFS), assessed by RECIST v1.1) in a real-world dataset of 1,806 patients ( &gt; 16 primary tumor types) retrospectively collected from Stanford University Medical Center, Samsung Medical Center, Chonnam National University Hospital, Seoul National University Bundang Hospital, and Northwestern University. IIP status was sub-analyzed by PD-L1 22C3 tumor proportion score (TPS, n = 798), microsatellite status, and tumor mutational burden (TMB, n = 130). Results: The IIP+ phenotype (35.2%, 636 of 1,806) was highly enriched in nasopharyngeal carcinoma (68.0%), melanoma (56.3%), renal cell carcinoma (52.9%), and non-small cell lung cancer (NSCLC, 33.7%). The IIP+ proportion by PD-L1 TPS ( &lt; 1% / ≥ 1%) was 21.6% and 40.7%, respectively. While 33.3% of microsatellite unstable (MSI-H) or TMB-high (≥ 10/Mb) tumors were IIP+, a substantial proportion (26.1%) of microsatellite stable (MSS), TMB-low tumors were IIP+. The ORR in IIP+ patients was significantly higher (26.0% vs. 15.8% in IIP-, p &lt; 0.001). Median PFS for IIP+ was 5.3 months (95% CI 4.6-6.9 m), significantly longer than that for IIP- (3.1 m, 95% CI 2.8-3.6 m), with a hazard ratio (HR) of 0.68 (95% CI 0.61-0.76, p &lt; 0.001). The association held after excluding NSCLC patients (n = 909) (HR 0.69, 95% CI 0.59-0.81, p &lt; 0.001). On subgroup analysis, IIP+ correlated significantly with prolonged PFS, regardless of ICI regimen (mono / combo therapy) or PD-L1 TPS ( &lt; 1% / ≥ 1%). Of note, IIP+ was predictive of favorable PFS only in the MSS, TMB-low group (n = 88, HR 0.56, 95% CI 0.33-0.96), but not in the MSI-H or TMB-high groups. Conclusions: The IIP, as evaluated by Lunit SCOPE IO, may represent a practical, clinically-actionable biomarker predictive of favorable ICI treatment outcomes across diverse cancer patient populations, including those with PD-L1 negative, MSS/TMB-low tumors, in whom predictive biomarkers are urgently needed.

Validation and algorithmic audit of a deep learning system for the detection of proximal femoral fractures in patients in the emergency department: a diagnostic accuracy study

Proximal femoral fractures are an important clinical and public health issue associated with substantial morbidity and early mortality. Artificial intelligence might offer improved diagnostic accuracy for these fractures, but typical approaches to testing of artificial intelligence models can underestimate the risks of artificial intelligence-based diagnostic systems. We present a preclinical evaluation of a deep learning model intended to detect proximal femoral fractures in frontal x-ray films in emergency department patients, trained on films from the Royal Adelaide Hospital (Adelaide, SA, Australia). This evaluation included a reader study comparing the performance of the model against five radiologists (three musculoskeletal specialists and two general radiologists) on a dataset of 200 fracture cases and 200 non-fractures (also from the Royal Adelaide Hospital), an external validation study using a dataset obtained from Stanford University Medical Center, CA, USA, and an algorithmic audit to detect any unusual or unexpected model behaviour. In the reader study, the area under the receiver operating characteristic curve (AUC) for the performance of the deep learning model was 0·994 (95% CI 0·988-0·999) compared with an AUC of 0·969 (0·960-0·978) for the five radiologists. This strong model performance was maintained on external validation, with an AUC of 0·980 (0·931-1·000). However, the preclinical evaluation identified barriers to safe deployment, including a substantial shift in the model operating point on external validation and an increased error rate on cases with abnormal bones (eg, Paget's disease). The model outperformed the radiologists tested and maintained performance on external validation, but showed several unexpected limitations during further testing. Thorough preclinical evaluation of artificial intelligence models, including algorithmic auditing, can reveal unexpected and potentially harmful behaviour even in high-performance artificial intelligence systems, which can inform future clinical testing and deployment decisions. None.

Reinforced Biologic Mesh Reduces Postoperative Complications Compared to Biologic Mesh after Ventral Hernia Repair.

Background:The use of biologic mesh to reinforce the abdominal wall in ventral hernia repair has been proposed as a viable alternative to synthetic mesh, particularly for high-risk patients and in contaminated settings. However, a comparison of clinical outcomes between the currently available biologic mesh types has yet to be performed.Methods:We performed a retrospective analysis of 141 patients who had undergone ventral hernia repair with biologic mesh, including noncross-linked porcine ADM (NC-PADM) (n = 51), cross-linked porcine ADM (C-PADM) (n = 17), reinforced biologic ovine rumen (RBOR) (n = 36), and bovine ADM (BADM) (n = 37) at the Stanford University Medical Center between 2002 and 2020. Postoperative donor site complications and rates of hernia recurrence were compared between patients with different biologic mesh types.Results:Abdominal complications occurred in 47.1% of patients with NC-PADM, 52.9% of patients with C-PADM, 16.7% of patients with RBOR, and 43.2% of patients with BADM (P = 0.015). Relative risk for overall complications was higher in patients who had received NC-PADM (RR = 2.64, P = 0.0182), C-PADM (RR = 3.19, P = 0.0127), and BADM (RR = 2.11, P = 0.0773) compared with those who had received RBOR. Furthermore, relative risk for hernia recurrence was also higher in all other mesh types compared with RBOR.Conclusion:Our data indicate that RBOR decreases abdominal complications and recurrence rates after ventral hernia repair compared with NC-PADM, C-PADM, and BADM.

Greetings From the Editor of Clinical Thyroidology

Clinical ThyroidologyVol. 34, No. 1 Greetings from the EditorFree AccessGreetings From the Editor of Clinical ThyroidologyAngela M. LeungAngela M. LeungSearch for more papers by this authorPublished Online:4 Jan 2022https://doi.org/10.1089/ct.2022;34.4-5AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail DEAR COLLEAGUES,Happy new year! We're pleased to ring in the new year with this first issue of 2022. I'm particularly thrilled to introduce the newest members of our editorial board, toward the mission of continually providing a diverse set of perspectives, areas of focus, and commentaries to the literature we review. Please join me in welcoming our newest experts to the Clinical Thyroidology editorial board: Dr. Sara Ahmadi, Brigham and Women's Hospital, U.S.A.Dr. Takashi Akamizu, Kuma Hospital, Japan.Dr. Lindsay Bischoff, Vanderbilt University, U.S.A.Dr. Kenneth Burman, Georgetown University, U.S.A.Dr. Mayumi Endo, University of Washington, U.S.A.Dr. Natalia Genere, Washington University, U.S.A.Dr. Giorgio Grani, Sapienza University of Rome, ItalyDr. Allen Ho, Cedars Sinai Medical Center, U.S.A.Dr. Joana Klubo-Gwiezdzinska, National Institutes of Health, U.S.A.Dr. Anupam Kotwal, University of Nebraska Medical Center, U.S.ADr. Elizabeth McAninch, Stanford University Medical Center, U.S.A.Dr. Alex Tessnow, University of Texas Southwestern Medical Center, U.S.A.In this issue, we begin with Dr. Gary Francis reviewing a study that examines the associations between thyroid disorders in adolescence and incident type 2 diabetes mellitus in adulthood. Is there good news for those waiting for a thyroid hormone treatment that can maintain sustained serum T3 concentrations? Dr. Elizabeth McAninch discusses a Phase 1 clinical trial of PZL, a new compound that shows promise to do just that. Addressing the topic of hyperthyroidism, Drs. Matthew Balcerek and Donald McLeod review a meta-analysis assessing the associations between radioactive iodine use and incident cancer risks, while Dr. Lilah Morris-Wiseman shares her perspective on a patient survey study surrounding quality of life and thyroid-specific symptoms before and after thyroidectomy for Graves’ disease.Dr. Natalia Genere summarizes a study assessing the very common clinical scenario of incidentally finding a thyroid nodule on FDG PET CT scanning — should these incidentalomas be standardly evaluated for a potential biopsy? On a similar topic, Dr. Giorgio Grani provides his perspectives on a recent meta-analysis assessing the appropriateness of thyroid ultrasonography use in routine clinical practice.Epidemiologic considerations of the rising incidence of thyroid cancer is assessed in a study discussed by Drs. Reem ElSheikh and Spyridoula Maraka. Drs. Omar El Kawkgi and Juan Brito discuss a survey study assessing the demographic characteristics of patients with thyroid cancer and their clinicians who advise their diagnostic and treatment recommendations. The mechanisms of resistance from lenvatinib combined with anti-PD-1 combination therapy are explored in a recent study covered by Dr. Benjamin Gigliotti. From a surgical perspective, Drs. Amanda Bastien and Allen Ho provide their insights on how anatomic variations of the recurrent laryngeal nerve may be an important consideration during thyroid surgery.Finally, we are thrilled to feature the top-scoring abstracts presented at the 2021 Annual Meeting of the American Thyroid Association throughout the journal this year. Our first abstract this year is authored by Drs. Malik Faheem, Yasaman Motlaghzadeh, Ivana Jankovic, and Chrysoula Dosiou, who describe a case series of 3 patients who all experienced silent thyroiditis following receipt of an mRNA vaccine for SARS-CoV-2. I urge you all to read their description of these interesting patients and proposed possible mechanisms for this entity.We invite our readers to join us through our social media channels. Through the following, we discuss content featured in each month's issue and other issues related to hot topics in the clinical thyroid literature:Twitter:https://twitter.com/clinicalthyroid(@clinicalthyroid)Facebook:https://www.facebook.com/ThyroidAssociationLinkedIn:https://www.linkedin.com/company/american-thyroid-associationYoutube:https://www.youtube.com/user/thyroidorgAlso, note that most of the material covered in Clinical Thyroidology is also translated into shorter lay summaries in our sister journal, Clinical Thyroidology for the Public [CTFP] (https://www.thyroid.org/patient-thyroid-information/ct-for-patients), that is edited by Dr. Alan Farwell and his team each month. The summaries in CTFP may be of use to patients and the public who are interested in reading more about recently published studies in the clinical thyroid literature.I hope that each issue provides helpful reviews, commentaries, editorials, and perspectives regarding how best to treat patients with thyroid disease. Guidelines for submitting Letters to the Editor and select Guest Editorials that cover timely and innovative aspects of clinical thyroid disease management may be found at https://home.liebertpub.com/publications/clinical-thyroidologyand174/623/for-authors.Thank you again for your interest in Clinical Thyroidology. Please feel free to send me any questions or comments at clinicalthyroidology@thyroid.org.Warmest regards,Angela M. Leung, MD, MScEditor-in-Chief, Clinical ThyroidologyFiguresReferencesRelatedDetails Volume 34Issue 1Jan 2022 InformationCopyright 2022 American Thyroid Association, Inc.To cite this article:Angela M. Leung.Greetings From the Editor of Clinical Thyroidology.Clinical Thyroidology.Jan 2022.4-5.http://doi.org/10.1089/ct.2022;34.4-5Published in Volume: 34 Issue 1: January 4, 2022PDF download

Decision-Making Experiences and Decisional Regret in Patients Receiving Implanted Cardioverter-Defibrillators

Background: Patient education before the placement of an implantable cardioverter-defibrillator (ICD) is strongly recommended to prevent or mitigate feelings of regret and frustration in ICD recipients. Medicare guidelines for ICDs require a shared decision-making approach that focuses on patients' health goals, values, and preferences before implantation. However, many patients are not fully informed of what to expect when recovering from ICD placement or living with an ICD long-term. Objectives: Our objective is to understand decision-making processes and decisional regret in patients requiring ICDs using in-depth interviews. Methods: Nineteen patients at Stanford University Medical Center were recruited to participate in individual interviews using closed-ended and open-ended questions to engage dialogue. Notes taken during interviews were assessed and used to identify major themes. Results: Participants described a lack of adequate education about ICD postoperative recovery and long-term, postimplantation considerations such as avoiding electromagnetic fields, false-positive ICD shocks, and the esthetic effect of ICD implantation. In addition, feelings of fear and anxiety were prevalent in participants' recollections of accepting an ICD. Conclusion: Further improvement in patient education before ICD placement is needed. The decision-making process can be simplified and patient regret and frustration minimized by providing reliable information that is accessible and interactive.