Jonathan C. Silverstein

Primary care physician PSA screening practices before and after the final U.S. Preventive Services Task Force recommendation

OBJECTIVES In May 2012, United States Preventive Services Task Force (USPSTF) finalized its recommendation against prostate-specific antigen (PSA) screening in all men. We aimed to assess trends in PSA screening frequency amongst primary care physicians (PCPs) surrounding the May 2012 USPSTF recommendation. METHODS AND MATERIALS The electronic data warehouse was used to identify men aged between 40 and 79 years with no history of prostate cancer or urology visit who were evaluated by an internal medicine or family practice physician between 2007 and 2012. Analyses were directed toward PSA testing within 6-month time period from June to November, with particular focus on the 2011 (pre-USPSTF recommendation) and 2012 (post-USPSTF recommendation) cohorts. The primary outcome measure was proportion of men with at least 1 PSA test during the 6-month pre- and post-USPSTF recommendation periods. RESULTS A total of 112,221 men met inclusion criteria. There was a significant decrease in screening frequency between the 2011 and 2012 cohorts (8.6% vs. 7.6%, P = 0.0001; adjusted odds ratio 0.89, 95% confidence interval 0.83-0.95). This decrease was most evident amongst patients aged 40 to 49 years (5.6% vs. 4.6%, P = 0.004) and 70 to 79 years (7.9% vs. 6.2%, P = 0.01). A significant decrease was also observed in patients with highest previous PSA value<1.0 (P<0.0001) and 1.0 to 2.49 ng/ml (P = 0.0074). CONCLUSIONS Since the USPSTF recommendation was finalized, there is evidence of continuing decreases in PSA testing by PCPs. PCPs may be shifting toward more selective screening practices, as decreases in screening are most pronounced in the youngest and oldest patients and in those with history of PSA values<2.5 ng/ml.

In-hospital Complications and Mortality After Elective Spinal Fusion Surgery in the United States: A Study of the Nationwide Inpatient Sample From 2001 to 2005

Spinal fusion surgery has increased dramatically and patients presenting for surgery are often more medically challenging. We hypothesized that advanced age and coexisting morbidities have increased in the population undergoing spinal fusion and are associated with greater risks for immediate complications and mortality. The Nationwide Inpatient Sample was retrospectively reviewed for discharges after a principal procedure code for elective spinal fusion. Total records meeting study inclusion criteria were 254,640. Coexisting morbidities were tabulated using Elixhauser comorbidities and the Charlson comorbidity index. Logistic regression identified risk factors associated with in-hospital mortality and early complications. The largest increase in spinal fusion surgery was in patients >65 years. Overall, those with at least 1 comorbidity increased (49% to 62%; P=0.002), as did mean Charlson index (0.146 to 0.202; P<0.001). In-hospital mortality was 0.13%, but 0.29%, and 0.64% for patients of 65 to 74, and those ≥75 years, respectively. Adjusted odds ratios for complications in 65-year to 74-year olds versus <65 years was 1.78 (95% confidence interval, 1.71-1.84; P<0.001), and for mortality 3.81 (95% confidence interval, 2.62-5.55; P<0.001); risks increased with the number of coexisting morbidities. Congestive heart failure, chronic pulmonary disease, coagulopathy, metastatic cancer, renal failure, and weight loss significantly correlated with in-hospital mortality, whereas hypertension or hypothyroidism had, unexpectedly, the opposite effect. Although it is known for some other forms of complex surgery, we showed that elderly and medically complex spinal fusion patients were at increased risk for in-hospital mortality and early complications. The majority of complications were operative, pulmonary, cardiovascular, or genito-urinary. Patient risk correlated with the number and nature of coexisting morbidities.

Synergies and Distinctions between Computational Disciplines in Biomedical Research: Perspective from the Clinical and Translational Science Award Programs

Clinical and translational research increasingly requires computation. Projects may involve multiple computationally oriented groups including information technology (IT) professionals, computer scientists, and biomedical informaticians. However, many biomedical researchers are not aware of the distinctions among these complementary groups, leading to confusion, delays, and suboptimal results. Although written from the perspective of Clinical and Translational Science Award (CTSA) programs within academic medical centers, this article addresses issues that extend beyond clinical and translational research. The authors describe the complementary but distinct roles of operational IT, research IT, computer science, and biomedical informatics using a clinical data warehouse as a running example. In general, IT professionals focus on technology. The authors distinguish between two types of IT groups within academic medical centers: central or administrative IT (supporting the administrative computing needs of large organizations) and research IT (supporting the computing needs of researchers). Computer scientists focus on general issues of computation such as designing faster computers or more efficient algorithms, rather than specific applications. In contrast, informaticians are concerned with data, information, and knowledge. Biomedical informaticians draw on a variety of tools, including but not limited to computers, to solve information problems in health care and biomedicine. The paper concludes with recommendations regarding administrative structures that can help to maximize the benefit of computation to biomedical research within academic health centers.

Virtual reality: new method of teaching anorectal and pelvic floor anatomy.

AbstractPURPOSE: A clear understanding of the intricate spatial relationships among the structures of the pelvic floor, rectum, and anal canal is essential for the treatment of numerous pathologic conditions. Virtual-reality technology allows improved visualization of three-dimensional structures over conventional media because it supports stereoscopic-vision, viewer-centered perspective, large angles of view, and interactivity. We describe a novel virtual reality-based model designed to teach anorectal and pelvic floor anatomy, pathology, and surgery. METHODS: A static physical model depicting the pelvic floor and anorectum was created and digitized at 1-mm intervals in a CT scanner. Multiple software programs were used along with endoscopic images to generate a realistic interactive computer model, which was designed to be viewed on a networked, interactive, virtual-reality display (CAVE® or ImmersaDesk®). A standard examination of ten basic anorectal and pelvic floor anatomy questions was administered to third-year (n = 6) and fourth-year (n = 7) surgical residents. A workshop using the Virtual Pelvic Floor Model was then given, and the standard examination was readministered so that it was possible to evaluate the effectiveness of the Digital Pelvic Floor Model as an educational instrument. RESULTS: Training on the Virtual Pelvic Floor Model produced substantial improvements in the overall average test scores for the two groups, with an overall increase of 41 percent (P = 0.001) and 21 percent (P = 0.0007) for third-year and fourth-year residents, respectively. Resident evaluations after the workshop also confirmed the effectiveness of understanding pelvic anatomy using the Virtual Pelvic Floor Model. CONCLUSION: This model provides an innovative interactive educational framework that allows educators to overcome some of the barriers to teaching surgical and endoscopic principles based on understanding highly complex three-dimensional anatomy. Using this collaborative, shared virtual-reality environment, teachers and students can interact from locations world-wide to manipulate the components of this model to achieve the educational goals of this project along with the potential for virtual surgery.

Translational integrity and continuity: Personalized biomedical data integration

Translational research data are generated in multiple research domains from the bedside to experimental laboratories. These data are typically stored in heterogeneous databases, held by segregated research domains, and described with inconsistent terminologies. Such inconsistency and fragmentation of data significantly impedes the efficiency of tracking and analyzing human-centered records. To address this problem, we have developed a data repository and management system named TraM (http://tram.uchicago.edu), based on a domain ontology integrated entity relationship model. The TraM system has the flexibility to recruit dynamically evolving domain concepts and the ability to support data integration for a broad range of translational research. The web-based application interfaces of TraM allow curators to improve data quality and provide robust and user-friendly cross-domain query functions. In its current stage, TraM relies on a semi-automated mechanism to standardize and restructure source data for data integration and thus does not support real-time data application.

CAPriCORN: Chicago Area Patient-Centered Outcomes Research Network

The Chicago Area Patient-Centered Outcomes Research Network (CAPriCORN) represents an unprecedented collaboration across diverse healthcare institutions including private, county, and state hospitals and health systems, a consortium of Federally Qualified Health Centers, and two Department of Veterans Affairs hospitals. CAPriCORN builds on the strengths of our institutions to develop a cross-cutting infrastructure for sustainable and patient-centered comparative effectiveness research in Chicago. Unique aspects include collaboration with the University HealthSystem Consortium to aggregate data across sites, a centralized communication center to integrate patient recruitment with the data infrastructure, and a centralized institutional review board to ensure a strong and efficient human subject protection program. With coordination by the Chicago Community Trust and the Illinois Medical District Commission, CAPriCORN will model how healthcare institutions can overcome barriers of data integration, marketplace competition, and care fragmentation to develop, test, and implement strategies to improve care for diverse populations and reduce health disparities.

Automatic perceptual color map generation for realistic volume visualization

Advances in computed tomography imaging technology and inexpensive high performance computer graphics hardware are making high-resolution, full color (24-bit) volume visualizations commonplace. However, many of the color maps used in volume rendering provide questionable value in knowledge representation and are non-perceptual thus biasing data analysis or even obscuring information. These drawbacks, coupled with our need for realistic anatomical volume rendering for teaching and surgical planning, has motivated us to explore the auto-generation of color maps that combine natural colorization with the perceptual discriminating capacity of grayscale. As evidenced by the examples shown that have been created by the algorithm described, the merging of perceptually accurate and realistically colorized virtual anatomy appears to insightfully interpret and impartially enhance volume rendered patient data.

Commentary: Unintended consequences of health information technology: A need for biomedical informatics

Professor and Chair Department of Biomedical Informatics, University of Pittsburgh School ofMedicine, Pittsburgh, PAIn all science, error precedes the truth, and it is better it should go first than last.-- Sir Hugh Walpole (English novelist, 1884–1941)Health information technology (HIT) can address important problems in clinical care andbiomedical research. These problems include lack of compliance with clinical practiceguidelines [1], insufficient use of preventative medicine services [2] and numerousimpediments to clinical/translational research [ 3]. However, front-line patient care informationsystems that can influence care may worsen outcomes as well as improve them. Increasingly,there is evidence of significant, unintended and deleterious effects of well-meaning HIT efforts[4]. In this paper we present examples of such deleterious effects and argue that: 1) HIT is atool that can influence health care and biomedicine (for good or ill) and 2) biomedicalinformatics efforts are needed to ensure that HIT fulfills its promise in biomedicine.

Comparison of tumor markers for predicting outcomes after resection of nonfunctioning pancreatic neuroendocrine tumors

BACKGROUND This study compares the predictability of 5 tumor markers for distant metastasis and mortality in pancreatic neuroendocrine tumors (PNETs). METHODS A total of 128 patients who underwent pancreatectomy for nonfunctioning PNETs between 1998 and 2011 were evaluated. Tumor specimens were stained via immunochemistry for cytoplasmic and nuclear survivin, cytokeratin 19 (CK19), c-KIT, and Ki67. Univariate and multivariate regression analyses and receiver operating characteristics curve were used to evaluate the predictive value of these markers. RESULTS A total of 116 tumors (91%) were positive for cytoplasmic survivin, 95 (74%) for nuclear survivin, 85 (66.4%) for CK19, 3 for c-KIT, and 41 (32%) for Ki67 >3%. Twelve (9%) tumors expressed none of the markers. Survivin, CK19, and c-KIT had no substantial effect on distant metastasis or mortality. Age >55 years, grade 3 histology, distant metastasis, and Ki67 >3% were associated with mortality (P < .05). A cut-off of Ki67 >3% was the best predictor (83%) of mortality with an area under the curve of 0.85. Ki67 >3% also predicted occurrence of distant metastases with odds ratio of 9.22 and 95% confidence interval of 1.55-54.55 (P < .015). CONCLUSION Of the 5 markers studied, only Ki67 >3% was greatly associated with distant metastasis and death. Survivin, CK19, and c-KIT had no prognostic value in nonfunctioning PNETs.

An optimized web-based approach for collaborative stereoscopic medical visualization

Objective Medical visualization tools have traditionally been constrained to tethered imaging workstations or proprietary client viewers, typically part of hospital radiology systems. To improve accessibility to real-time, remote, interactive, stereoscopic visualization and to enable collaboration among multiple viewing locations, we developed an open source approach requiring only a standard web browser with no added client-side software. Materials and Methods Our collaborative, web-based, stereoscopic, visualization system, CoWebViz, has been used successfully for the past 2 years at the University of Chicago to teach immersive virtual anatomy classes. It is a server application that streams server-side visualization applications to client front-ends, comprised solely of a standard web browser with no added software. Results We describe optimization considerations, usability, and performance results, which make CoWebViz practical for broad clinical use. We clarify technical advances including: enhanced threaded architecture, optimized visualization distribution algorithms, a wide range of supported stereoscopic presentation technologies, and the salient theoretical and empirical network parameters that affect our web-based visualization approach. Discussion The implementations demonstrate usability and performance benefits of a simple web-based approach for complex clinical visualization scenarios. Using this approach overcomes technical challenges that require third-party web browser plug-ins, resulting in the most lightweight client. Conclusions Compared to special software and hardware deployments, unmodified web browsers enhance remote user accessibility to interactive medical visualization. Whereas local hardware and software deployments may provide better interactivity than remote applications, our implementation demonstrates that a simplified, stable, client approach using standard web browsers is sufficient for high quality three-dimensional, stereoscopic, collaborative and interactive visualization.