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This summary of the proceedings of the 2023 ACR Intersociety Meeting discusses the seven most important challenges facing radiology today: declining reimbursement, corporatization and consolidation, inadequate labor force, imaging appropriateness, burnout, turf wars with nonphysicians, and workflow efficiency. Participants in the Intersociety Summer Conference-2023 focused their effort on identifying potential solutions given how critical these topics are to the sustainability of the profession., (Copyright © 2024 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Introduction: Myocardial infarction (MI) is one of the most life-threatening pathologies characterized by sudden cardiac death and is among the leading causes of mortality in the developed world., Aims: This study investigates the demographic, socio-economic, and healthcare access disparities in the US among patients with myocardial infarction (MI)., Methodology: This was a retrospective original research study conducted using the BRFSS (Behavioural risk factor surveillance system) database of CDC (Centers for disease control and prevention).Data was extracted from the BRFSS on 3rd January 2024 to identify patients with MI in the year 2021 and multivariate models were used to assess the relationship between factors such as age, gender, income levels, and education in patients with myocardial infarction., Results: Individuals in the age group of 65 years or older constituted the highest percentage of MI cases at 66.33 % (OR, 16.66; 95 % CI, 10.27-27.02; p-value <0.0001).Males showed a higher prevalence of MI, accounting for 61.19 % of cases, and females demonstrated lower susceptibility (OR, 0.46; 95 % CI, 0.43-0.50; p-value <0.0001).High school graduates (Grade 12 or GED) exhibited the highest incidence at 32.08 % (OR, 1.44; 95 % CI, 0.81-2.56; p-value 0.2084). Retirees accounted for the highest incidence at 56.06 %, with significantly increased odds compared to those employed for wages (OR, 1.93; 95 % CI, 1.71-2.19; p-value <0.0001).The analysis of income levels indicated the highest MI incidence in the $25,000 <= Income < $35,000 group (17.31 % of cases)., Conclusions: Additional research is necessary to further disentangle the interaction between MI and factors such as age, gender, education level, race, employment status, and income level, and as the findings of this study suggest, retired individuals and individuals from lower-income groups indicate a disparity in access to timely treatment regarding MI. Thus, the determination of such discrepancies needs to be addressed regarding how such factors affect access to timely healthcare, especially in matters of widely prevalent diseases such as MI., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier Inc. All rights reserved.)

The American Association of Nurse Anesthesiology (AANA) Practice Committee, in collaboration with AANA Professional Practice staff, advisory panels, and subject matter experts, annually applies a standardized evidence-based process to review, evaluate, and revise clinical resource documents found in the Professional Practice Manual for the CRNA (Certified Registered Nurse Anesthetist) and on the AANA website. This article highlights several revised and newly developed documents, which include topics such as diversity, equity, and inclusion, anesthesia and analgesia for obstetric patients, and safe injection guidelines., (Copyright © by the American Association of Nurse Anesthetists.)

Purpose/objectives: An increase in the use of remote therapeutic monitoring (RTM) has been spurred by nationwide factors including the COVID-19 pandemic, authorized reimbursement of RTM by the Centers for Medicare & Medicaid Services, and more frequent use of big data analytics in health care delivery. This article discusses the use of RTM by care teams at the point of care and explores the role of the case manager in RTM to address patients' unmet needs., Primary Practice Settings: Although RTM may be utilized across inpatient and outpatient levels of care, this article focuses on outpatient care such as community clinics, provider groups, and home health care., Findings/conclusions: When implemented along with care management interventions, RTM applications have the potential to improve patient adherence, enhance communication between patients and their providers, streamline resource allocation, and address social determinants of health impacting patient care and outcomes., Implications for Case Management Practice: RTM reimbursement models are rapidly evolving, utilizing real-world and patient-reported data to identify and initiate timely, individualized solutions that meet the holistic needs of each patient. Use of an RTM system allows the case manager to build rapport with the patient while quickly identifying care gaps and delivering appropriate interventions that can maximize patient outcomes. RTM can drive savings and bring revenue to the system or practice while providing salient documentation of social determinants of health that can be addressed with validation of proven care coordination interventions., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: We built Bayesian Network (BN) models to explain roles of different patient-specific factors affecting racial differences in breast cancer stage at diagnosis, and to identify healthcare related factors that can be intervened to reduce racial health disparities., Methods: We studied women age 67-74 with initial diagnosis of breast cancer during 2006-2014 in the National Cancer Institute's SEER-Medicare dataset. Our models included four measured variables (tumor grade, hormone receptor status, screening utilization and biopsy delay) expressed through two latent pathways-a tumor biology path, and health-care access/utilization path. We used various Bayesian model assessment tools to evaluate these two latent pathways as well as each of the four measured variables in explaining racial disparities in stage-at-diagnosis., Results: Among 3,010 Black non-Hispanic (NH) and 30,310 White NH breast cancer patients, respectively 70.2% vs 76.9% were initially diagnosed at local stage, 25.3% vs 20.3% with regional stage, and 4.56% vs 2.80% with distant stage-at-diagnosis. Overall, BN performed approximately 4.7 times better than Classification And Regression Tree (CART) (Breiman L, Friedman JH, Stone CJ, Olshen RA. Classification and regression trees. CRC press; 1984) in predicting stage-at-diagnosis. The utilization of screening mammography is the most prominent contributor to the accuracy of the BN model. Hormone receptor (HR) status and tumor grade are useful for explaining racial disparity in stage-at diagnosis, while log-delay in biopsy impeded good prediction., Conclusions: Mammography utilization had a significant effect on racial differences in breast cancer stage-at-diagnosis, while tumor biology factors had less impact. Biopsy delay also aided in predicting local and regional stages-at-diagnosis for Black NH women but not for white NH women., (© 2023. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Background: There is a paucity of data regarding epidemiology, temporal trends, and outcomes of patients with cardiogenic shock (CS) and end-stage renal disease (chronic kidney disease stage V on hemodialysis)., Methods: This is a retrospective cohort study using the United States Renal Data System database from January 1, 2006 to December 31, 2019. We analyzed trends of CS, percutaneous mechanical support (intraaortic balloon pump, percutaneous ventricular assist device [Impella and Tandemheart], and extracorporeal membrane oxygenation) utilization, index mortality, 30-day mortality, and 1-year all-cause mortality in end-stage renal disease patients., Results: A total of 43 825 end-stage renal disease patients were hospitalized with CS (median age, 67.8 years [IQR, 59.4-75.8] and 59.1% men). From 2006 to 2019, the incidence of CS increased from 275 to 578 per 100 000 patients ( P trend <0.001). The index mortality rate declined from 54.1% in 2006 to 40.8% in 2019 ( P trend =0.44), and the 1-year all-cause mortality decreased from 63% in 2006 to 61.8% in 2018 ( P trend =0.73), but neither trend was statistically significant. There was a significantly decreased utilization of intra-aortic balloon pumps from 17 832 to 7992 ( P trend <0.001), increased utilization of percutaneous ventricular assist device from 137 to 5201 ( P trend <0.001) and increase in extracorporeal membrane oxygenation use from 69 to 904 per 100 000 patients ( P trend <0.001). After adjusting for covariates, there was no significant difference in index mortality between CS patients requiring percutaneous mechanical support versus those not requiring percutaneous mechanical support (odds ratio, 0.97 [CI, 0.91-1.02]; P =0.22). On multivariable regression analysis, older age, peripheral vascular disease, diabetes, and time on dialysis were independent predictors of higher index mortality., Conclusions: The incidence of CS in end-stage renal disease patients has doubled without significant change in the trend of index mortality despite the use of percutaneous mechanical support., Competing Interests: Disclosures None.

The ACR Intersociety Committee meeting of 2022 (ISC-2022) was convened around the theme of "Recovering From The Great Resignation, Moral Injury and Other Stressors: Rebuilding Radiology for a Robust Future." Representatives from 29 radiology organizations, including all radiology subspecialties, radiation oncology, and medical physics, as well as academic and private practice radiologists, met for 3 days in early August in Park City, Utah, to search for solutions to the most pressing problems facing the specialty of radiology in 2022. Of these, the mismatch between the clinical workload and the available radiologist workforce was foremost-as many other identifiable problems flowed downstream from this, including high job turnover, lack of time for teaching and research, radiologist burnout, and moral injury., (Copyright © 2023 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Crucial to the fight against sex trafficking 1 is understanding the experiences of victims and survivors. Survivor surveys have illuminated key areas to address, but a clear gap in the research is in the reproductive, gynecological, and procreative health issues of victims and survivors. This article opens the door to research and dialogue by publishing the findings of a pilot survivor survey focused on survivors' sexual and reproductive health. The retrospective survey offers preliminary findings for a larger national study underway in 2023 that will enable healthcare providers, service providers and other first responders to identify and better meet the unique needs of victims and survivors of human trafficking in this area., (Copyright © 2023 by the National Legal Center for the Medically Dependent & Disabled, Inc.)

Abstract: In a sudden death investigation of a service member with sickle cell trait (SCT), evidence of sickle cell crisis further complicated by coexisting, undiagnosed diabetic ketoacidosis called into question the synergistic effects of diabetic ketoacidosis on red blood cell sickling. Sickle cell trait affects more than 4 million people in the United States (US) with the highest prevalence in non-Hispanic Blacks (7%-9%; Mil Med 2017;182(3):e1819-e1824). The heterozygous state of sickled hemoglobin was previously considered a benign condition causing sickling during hypoxic, high-stress conditions such as exercise and high altitude ( Am Assoc Clin Chem 2017). However, research within the last decade shows evidence of sudden death among SCT patients ( J Forensic Sci 2011;56(5):1352-1360). It has been shown that the presence of sickled hemoglobin artificially lowers levels of hemoglobin A1c making it a less effective biomarker for red blood cell glycosylation over time in sickle cell patients ( JAMA 2017;317(5):507-515). The limited scope of medical understanding of the effects of SCT in combination with other comorbidities requires further investigation and better diagnostic criteria. The uniqueness of the US Military and its screening program for sickle cell disease (SCD) and SCT allows for more detection. Since May 2006, newborn screening for SCD/SCT has been a national requirement; however, anyone older than 14 years may not know their SCD/SCT status ( Semin Perinatol 2010;34(2):134-44). The previous absence of such national screening makes it more challenging to identify SCT and SCD patients even within high-risk populations. Furthermore, patients may not know or understand the results of their SCD/SCT status testing. International standards for the autopsy of decedents with SCD and SCT exist ( R Coll Pathol 2017). Within the US, testing of vitreous electrolytes is a common practice in suspected natural death cases, but a review of the US literature did not demonstrate any autopsy standards or recommendations for persons with SCT or high-risk persons for sickling pathologies. The identification of a new diagnosis of type 2 diabetes mellitus, as the cause of death, is not uncommon; however, this case indicates that type 2 diabetes mellitus was not the sole contributing factor. It further illustrates that the US may be underestimating the impact of SCD and SCT as a cause of death, a contributing factor to death, and its synergistic effects with other pathologic processes. We propose a stringent literature review in conjunction with a review of international autopsy standards to develop national autopsy standards and possible SCT/SCD screening recommendations for high-risk persons at the time of autopsy., Competing Interests: The authors report no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Jacob Green was born in 1790 to a prominent New Jersey family of scholars and theologians. He taught at the College of New Jersey (now Princeton University) from 1818 to 1822 before co-founding Jefferson Medical College (now Thomas Jefferson University) in 1825, where he taught Chemistry until his death in 1841. Between 1818 and 1831, he published a series of nine papers on lizards, salamanders, and snakes, authoring the original description of several well-known species of salamanders from the eastern United States. Many of his names are ambiguous; some have been adjudicated by the ICZN, while others are currently treated as nomina dubia. Here, we review all of Green's publications, report on newly re-discovered or re-interpreted material from several major natural history collections, and resolve most if not all remaining issues through a series of taxonomic actions. In particular, we first designate a neotype for Salamandra nigra Green, 1818. We then place S. sinciput-albida Green, 1818 and S. frontalis Gray in Cuvier, 1831 in synonymy with S. scutata Temminck in Temminck Schlegel, 1838 and invoke Reversal of Precedence under Article 23.9 to designate them nomina oblita. We also designate a lectotype for S. bislineata Green, 1818. Finally, we resurrect the name S. fusca Green, 1818 as the valid name for the species Desmognathus fuscus, assuming priority over Triturus fuscus Rafinesque, 1820, designating S. fusca Laurenti, 1768 a nomen oblitum, and placing S. nigra Green, 1818 in synonymy. While Green's herpetological legacy is not as expansive as that of some of his successors such as Holbrook, he is nonetheless a foundational early worker in salamanders, having described some of the most-studied species in the world.

Predicting species presence and richness on islands is important for understanding the origins of communities and how likely it is that species will disperse and resist extinction. The equilibrium theory of island biogeography (ETIB) and, as a simple model of sampling abundances, the unified neutral theory of biodiversity (UNTB), predict that in situations where mainland to island migration is high, species-abundance relationships explain the presence of taxa on islands. Thus, more abundant mainland species should have a higher probability of occurring on adjacent islands. In contrast to UNTB, if certain groups have traits that permit them to disperse to islands better than other taxa, then phylogeny may be more predictive of which taxa will occur on islands. Taking surveys of 54 island snake communities in the Eastern Nearctic along with mainland communities that have abundance data for each species, we use phylogenetic assembly methods and UNTB estimates to predict island communities. Species richness is predicted by island area, whereas turnover from the mainland to island communities is random with respect to phylogeny. Community structure appears to be ecologically neutral and abundance on the mainland is the best predictor of presence on islands. With regard to young and proximate islands, where allopatric or cladogenetic speciation is not a factor, we find that simple neutral models following UNTB and ETIB predict the structure of island communities., (© 2015 The Author(s).)

Objective: To test the hypothesis that adolescent obesity would be associated with greater risks of adverse health in severely obese adults., Methods: Before weight loss surgery, adult participants in the Longitudinal Assessment of Bariatric Surgery-2 underwent detailed anthropometric and comorbidity assessment. Weight status at age 18 was retrospectively determined. Participants who were ≥80% certain of recalled height and weight at age 18 (1502 of 2308) were included. Log binomial regression was used to evaluate whether weight status at age 18 was independently associated with risk of comorbid conditions at time of surgery controlling for potential confounders., Results: Median age and adult body mass index (BMI) were 47 years and 46, respectively. At age 18, 42% of subjects were healthy weight, 29% overweight, 16% class 1 obese, and 13% class ≥2 obese. Compared with healthy weight at age 18, class ≥2 obesity at age 18 independently increased the risk of lower-extremity venous edema with skin manifestations by 435% (P < .0001), severe walking limitation by 321% (P < .0001), abnormal kidney function by 302% (P < .0001), polycystic ovary syndrome by 74% (P = .03), asthma by 48% (P = .01), diabetes by 42% (P < .01), obstructive sleep apnea by 25% (P < .01), and hypertension (by varying degrees based on age and gender). Conversely, the associated risk of hyperlipidemia was reduced by 61% (P < .01)., Conclusions: Severe obesity at age 18 was independently associated with increased risk of several comorbid conditions in adults undergoing bariatric surgery.

Introduction: Total colonic aganglionosis represents a significant challenge for pediatric surgeons. Long-term results are suboptimal and complications are very common. We analyzed our experience to formulate recommendations to achieve better results and avoid complications and sequelae., Methods: The medical records of patients with total colonic aganglionosis that were operated on by us primarily or secondarily were reviewed. We evaluated: number of operations performed, preventable complications, bowel control or presence of stomas, and clinical follow-up. Based on this experience we describe our current approach for this condition. IRB approval was obtained., Results: 27 patients were identified (19 males, 8 females). 12 patients had the primary pullthrough performed by us and 15 were operated on elsewhere before coming to us for reoperation. The average number of operations per patient was 6.8 (1-40). We identified several preventable complications: ileostomy prolapse or stricture (21), severe diaper rash (10), obstructive symptoms following a pouch or patch-type of pullthrough (9), infection, abscess, and fistula after the pullthrough (5); wrong histologic diagnosis leading to colostomy opening in aganglionic bowel (4) with consequent pullthrough of aganglionic intestine in two of them; anastomotic stricture/acquired atresia (3); and destroyed anal canal and permanent fecal incontinence (2). 15 patients have bowel control; 11 have an ileostomy: temporary (7) and permanent (4); and one is less than 3 years of age. Length of follow-up ranged from 1 to 17 years. Based on this experience, our approach for this condition consists of: colectomy with straight ileoanal anastomosis and ileostomy at presentation, followed by ileostomy closure only when the child is toilet trained for urine and is willing to tolerate rectal irrigations., Conclusion: Total colonic aganglionosis remains a serious surgical challenge. Patients suffering from the condition, have multiple complications, sequelae, and often require reoperations. We found that it is possible to prevent many of these by properly fixing the stoma, avoiding pouch or patch procedures, delaying ileostomy closure, having pathology expertise, and with meticulous surgical technique starting the dissection/anastomosis well above the dentate line.

Objective: To develop a preliminary taxonomy of primary care medical errors., Design: Qualitative analysis to identify categories of error reported during a randomized controlled trial of computer and paper reporting methods., Setting: The National Network for Family Practice and Primary Care Research., Participants: Family physicians., Main Outcome Measures: Medical error category, context, and consequence., Results: Forty two physicians made 344 reports: 284 (82.6%) arose from healthcare systems dysfunction; 46 (13.4%) were errors due to gaps in knowledge or skills; and 14 (4.1%) were reports of adverse events, not errors. The main subcategories were: administrative failure (102; 30.9% of errors), investigation failures (82; 24.8%), treatment delivery lapses (76; 23.0%), miscommunication (19; 5.8%), payment systems problems (4; 1.2%), error in the execution of a clinical task (19; 5.8%), wrong treatment decision (14; 4.2%), and wrong diagnosis (13; 3.9%). Most reports were of errors that were recognized and occurred in reporters' practices. Affected patients ranged in age from 8 months to 100 years, were of both sexes, and represented all major US ethnic groups. Almost half the reports were of events which had adverse consequences. Ten errors resulted in patients being admitted to hospital and one patient died., Conclusions: This medical error taxonomy, developed from self-reports of errors observed by family physicians during their routine clinical practice, emphasizes problems in healthcare processes and acknowledges medical errors arising from shortfalls in clinical knowledge and skills. Patient safety strategies with most effect in primary care settings need to be broader than the current focus on medication errors.