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An injured child’s chance of surviving improves when treated at a trauma center prepared to care for children

Key Takeaways  Credit: American College of Surgeons Key Takeaways  Trauma centers with the highest pediatric readiness scores (93 or greater) on a national…

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Key Takeaways 

Credit: American College of Surgeons

Key Takeaways 

  • Trauma centers with the highest pediatric readiness scores (93 or greater) on a national assessment have much lower death rates than centers scoring lower. 

  • All trauma centers should address gaps in pediatric emergency care — most importantly, the lack of having a pediatric-specific quality improvement plan. 

BOSTON (October 20, 2023): Children initially treated at trauma centers with the highest level of preparedness to care for children, called pediatric readiness, are significantly less likely to die than those initially treated at trauma facilities with lower pediatric readiness levels, new research shows. The findings are being presented at the American College of Surgeons (ACS) Clinical Congress 2023. 

“What happens in that first hour after injury really impacts whether you survive, so rapid access to trauma center care for kids is important,” said principal investigator Aaron Jensen, MD, FACS, trauma medical director at the University of California, San Francisco (UCSF) Benioff Children’s Hospital Oakland.  

“But most children in the United States receive initial trauma care at non-pediatric centers because they are more readily available,” Dr. Jensen said. 

Trauma centers that specialize in treating children have the comprehensive infrastructure and resources needed to care for injured children, Dr. Jensen said. Emergency departments (EDs) in centers without comprehensive pediatric capabilities must be ready to resuscitate and stabilize severely injured children and quickly transfer them to pediatric trauma centers, he noted.  

Study details 

In this study, the investigators aimed to identify a minimum threshold of pediatric readiness among trauma centers that represents the lowest chance of patient death. To do so, they used data from the 2021 national assessment administered by the National Pediatric Readiness Project (NPRP).*  

The NPRP works to ensure that all EDs in the U.S. are prepared to provide high-quality emergency care for children. It uses a voluntary survey for EDs to self-assess pediatric readiness across six domains: administration and care coordination, personnel, quality improvement, patient safety, policies and procedures, and equipment and supplies. Survey responses are used to create a weighted pediatric readiness score that ranges from zero to 100. 

The new study included 790 U.S. trauma centers, 630 of which completed the NPRP’s 2021 national assessment, contributed data to the ACS National Trauma Data Bank® (NTDB), and treated at least some children from newborns through age 15 years. Most centers were not pediatric trauma centers, Dr. Jensen said. 

The research team used ACS Pediatric Trauma Quality Improvement Program risk-adjusted models to estimate the adjusted odds of dying in each trauma center. Center-level adjusted mortality estimates were then compared across quartiles of ED pediatric readiness at the initial treating trauma center. 

Centers that reported pediatric readiness in the top 25th percentile (a score of 93 or higher) had the lowest adjusted odds of death, the investigators reported. This high-readiness quartile had 17 to 27 percent lower adjusted odds of death than any other quartile. 

Gaps in care 

Among the lower-scoring quartiles, Dr. Jensen said, “the most common deficiencies are lack of a pediatric emergency care coordinator, pediatric-specific quality improvement plan, and pediatric disaster preparedness plan.” 

The researchers found that having a pediatric-specific quality improvement plan was independently associated with significantly lower odds of death.  

Dr. Jensen stressed that the goal of pediatric readiness is not to transform every ED into a pediatric trauma center providing the full spectrum of emergency care for children. Rather, the goal is to help EDs optimize the initial care for pediatric trauma patients. Ways that EDs can improve their pediatric readiness are easy and usually inexpensive, he stated. 

“Access for kids to high-quality pediatric trauma care is an achievable goal and has a real impact on kids,” Dr. Jensen said. 

NPRP pediatric readiness scores are not publicly available. However, according to Dr. Jensen, almost every ACS-verified Level I pediatric trauma center in the study had pediatric readiness scores in the top quartile. ACS-verified trauma centers are searchable on the ACS website. 

Caroline Melhado, MD, a study coauthor and UCSF general surgery resident, presented this research at the conference. 

Other study coauthors: Katherine Remick, MD; Amy Miskovic, MS; Bhavin Patel, MPH; Hilary Hewes, MD; Avery B. Nathens, MD, PhD, FACS; Craig Newgard, MD, MPH; Brian Yorkgitis, DO, FACS; and Michael Dingeldein, MD, FACS. 

The study authors have no disclosures. 

Funding: This research was supported by the Health Resources and Services Administration (HRSA, #U07MC37471­01­00) of the U.S. Department of Health and Human Services (HHS) as part of the Emergency Medical Services for Children Innovation and Improvement Center. The contents are those of the authors and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. government. 

This research has been accepted for publication in Annals of Surgery. 

Citation: Melhado C, et al. The Association Between Pediatric Readiness Scores and Mortality for Injured Children Treated at US Trauma Centers, Scientific Forum, American College of Surgeons (ACS) Clinical Congress 2023. 

________________________ 

* The NPRP is led by the U.S. government’s Emergency Medical Services for Children Program in partnership with the American Academy of Pediatrics, American College of Emergency Physicians, and Emergency Nurses Association. 

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About the American College of Surgeons 

The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for all surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has approximately 90,000 members and is the largest organization of surgeons in the world. “FACS” designates that a surgeon is a Fellow of the American College of Surgeons.

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A cancer survival calculator is being developed using artificial intelligence

Key Takeaways  Credit: American College of Surgeons Key Takeaways  A cancer survival calculator prototype developed with machine learning showed that…

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October 20, 2023

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Key Takeaways 

Credit: American College of Surgeons

Key Takeaways 

  • A cancer survival calculator prototype developed with machine learning showed that for each of three cancer types tested, more factors than cancer stage significantly influenced patients’ survival. 
  • Preliminary research on the calculator found high accuracy of this individualized survival estimator. 

BOSTON (October 20, 2023): Researchers have developed an artificial intelligence (AI)–based tool for estimating a newly diagnosed cancer patient’s chances for surviving long term, according to a study presented at the American College of Surgeons (ACS) Clinical Congress 2023. 

Currently, estimating survival rates for patients with cancer primarily depends on their cancer stage, said lead study author Lauren Janczewski, MD, a clinical scholar with ACS Cancer Programs and a general surgical resident at Northwestern University McGaw Medical Center, Chicago.  

“There is a multitude of other factors that may influence a patient’s survival beyond just their staging criteria,” Dr. Janczewski said. “We sought to develop this Cancer Survival Calculator to provide a more personalized estimate of what patients can expect regarding their cancer prognosis.” 

Using a type of AI known as machine learning, the multicenter research team created a prototype tool called the Cancer Survival Calculator and tested it on a nationwide cancer dataset. Initial tests estimated five-year survival for patients with cancers of the breast, thyroid, and pancreas. 

Study details 

According to Dr. Janczewski, this study aimed to identify the patient, tumor, and treatment characteristics that most greatly influence patient survival for each cancer type. 

After cancer experts recommended characteristics to study, the researchers collected relevant information from patients diagnosed in 2015 and 2017 with breast, thyroid, and pancreatic cancers. The patients’ records were part of the National Cancer Database (NCDB), which contains records of 72 percent of newly diagnosed cancer cases in the United States.* 

Three-fourths of the collected data were used to train the machine learning algorithms to recognize patterns between characteristics at diagnosis and patients’ survival at five years, and then to rank the factors with the greatest influence on survival. With the remaining data, the researchers used statistical methods to test the prototype’s accuracy in estimating survival. 

Key findings 

The team included data from 259,485 breast cancer patients, 76,624 thyroid cancer patients, and 84,514 pancreatic cancer patients. The researchers found multiple characteristics specific to patients, tumors, and treatments for all three cancer sites significantly influenced survival.  

The top four factors influencing whether patients were alive five years after diagnosis were as follows, by cancer site: 

  • Breast cancer: (1) whether the patient had cancer surgery, (2) the patient’s age at diagnosis, (3) tumor size, and (4) time from diagnosis to treatment. 
  • Thyroid cancer: (1) age at diagnosis, (2) tumor size, (3) time to treatment, and (4) lymph node involvement. 
  • Pancreatic cancer: (1) cancer surgery; (2) histology, or microscopic analysis of the cancer, (3) tumor size, and (4) age at diagnosis. 

Also found to be important for survival from breast cancer were hormone receptor status, which is part of breast cancer staging, and the presence of Ki-67, a biomarker in breast cancer. 

Although some of the predictive factors, such as tumor size, are part of cancer staging, Dr. Janczewski said their results showed that many more factors influence survival for cancer patients beyond their disease stage. 

Furthermore, their validation testing showed that the calculator was “highly accurate” for all three cancer sites at estimating cancer survival rates – within nine to 10 months of actual survival, Dr. Janczewski reported. 

Advantages of the new calculator 

The Cancer Survival Calculator differs in several ways from cancer survival estimators already in use, according to Dr. Janczewski: 

  1. The novel calculator includes specific tumor biomarkers and treatment variables that are known to affect a patient’s estimated prognosis, which Dr. Janczewski said many prior survival calculators lack.  
  2. The dataset used to develop the new calculator, the NCDB, is more comprehensive than other calculators’ datasets, according to Dr. Janczewski.
  3. The Cancer Survival Calculator uses new data modeling, such as machine learning, which speeds up processing. The models’ risk predictions also demonstrated improved accuracy compared with predictions generated by older calculators, she said.  

Future steps 

The next steps that Dr. Janczewski identified are to finalize a user interface that will allow the use of the Cancer Survival Calculator in clinical practice, followed by pilot testing the calculator at selected cancer centers.  

Eventually, the researchers hope to broaden the calculator by adding all other cancer sites included in the NCDB. Initially, the calculator included breast, thyroid, and pancreatic cancers because these cancers have diverse patient populations and differing frequencies and average survival rates, she said. 

The research team plans to make the finalized informational tool available to healthcare practitioners. 

Study coauthors are Joseph Cotler, PhD; Bryan Palis, MA; Tanya Hoskin, MA; Courtney Day, MS; Ryan Merkow, MD, MS, FACS; Heidi Nelson, MD, FACS; Tracy Wang, MD, FACS; and Judy Boughey, MBBCh, FACS. Mayo Clinic and the Medical College of Wisconsin were study centers with Northwestern University. 

The study authors have no disclosures. 

Citation: Janczewski L, et al. Development of a National Cancer Survival Calculator Prototype Using Machine Learning, Scientific Forum, American College of Surgeons (ACS) Clinical Congress 2023. 

___________________ 

*The NCDB is a joint program of the ACS Commission on Cancer and the American Cancer Society. The database collects more than 1.5 million new cancer cases each year. 

# # # 

About the American College of Surgeons 

The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for all surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has approximately 90,000 members and is the largest organization of surgeons in the world. “FACS” designates that a surgeon is a Fellow of the American College of Surgeons.

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More than 7,500 daily steps prior to surgery is associated with lower risk of postoperative complications

Key takeaways  Credit: American College of Surgeons Key takeaways  Using Fitbit activity tracking data, researchers identified patients who might be…

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October 20, 2023

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Key takeaways 

Credit: American College of Surgeons

Key takeaways 

  • Using Fitbit activity tracking data, researchers identified patients who might be at higher risk of postoperative complications. Fewer daily steps were associated with a higher rate of complications postoperatively.  

  • The odds of complications within 90 days after hospital discharge were reduced by half if a patient took more than 7,500 steps a day before the operation, after adjusting for the complexity of the procedure, comorbidities, and other factors.  

CHICAGO (October 20, 2023): Patients who recorded more walking activity prior to surgery, regardless of complexity of the operation or their health status, showed 51% reduced odds for postoperative complications than less active patients, according to research findings being presented at the American College of Surgeons (ACS) Clinical Congress 2023. 

Postoperative complications typically occur in about 30% of patients,1 and about half of all complications occur after the patient leaves the hospital.2 

“Fitbits and other wearable devices could potentially be linked to Electronic Health Records (EHRs) and have that data be something that surgeons consider when planning perioperative care for their patients,” said lead study author Carson Gehl, a second-year medical student at the Medical College of Wisconsin in Milwaukee. “This could really come to fruition to improve postoperative outcomes.” 

Researchers analyzed health data for 475 people participating in the All of Us Research Program — a National Institutes of Health-sponsored program focusing on the relationship between lifestyle, biology, and environment in diverse populations — who used a Fitbit device, worn like a watch, that measured their daily steps. This is the only population-level study to explore the association between physical activity, as measured by a Fitbit, and 90-day postoperative complications, according to the study authors. 

“We used the combination of EHRs and Fitbit data to uncover how to potentially improve surgical outcomes. In our study, we looked at how many steps patients recorded on any given day, which is a proxy for physical activity,” Gehl said.  

“However, the fitness data wasn’t limited to the immediate preoperative period. The length of their activity record could be six months or several years before surgery. This is more reflective of chronic physical activity habits, versus the physical activity in the immediate preoperative period.” 

Participants underwent a wide range of operations, including general surgery, orthopedic surgery, and neurosurgery, and were an average age of 57 years old. Women comprised 74.7% of participants, and 85.2% of participants were White.  

Key findings 

  • About 12.6% of study participants experienced a complication within 90 days of surgery. 

  • The odds of experiencing a complication within 30 days after surgery were 45% less (odds ratio 0.55) if patients took more than 7,500 steps per day prior to surgery than if their Fitbit recorded fewer than 7,500 steps.  

  • After adjusting for comorbidities, BMI, sex, race, and complexity of the operation, the odds of experiencing a complication were 51% lower (odds ratio 0.49) if patients had Fitbit data showing they had walked more than 7,500 steps per day before surgery.  

“If we find people who are at high risk, using these Fitbit tools, we could monitor them more closely following their procedure because that allows us to catch problems before they progress beyond control,” Gehl said. “Another goal of our research is to modify physical activity in the preoperative period and improve postoperative outcomes. We need more studies and evidence to answer that question.” 

A limitation of the study was that available Fitbit data came from a less diverse group of patients. Fitbit is a device worn like a watch to self-track sleep, physical activity, and heart rate data. Study participants had to have their own Fitbit device, which limits the generalizability of the study results.  

Study co-authors are Nathaniel B. Verhagen; Tahseen Shaik; Xin Yang, PhD; Bradley W. Taylor; Ugwuji N. Maduekwe, MD, FACS; and Anai Kothari, MD, MS.   

The study was funded by the National Institutes of Health. 

Citation: Gehl CJ, et al. Wearable Device/Smart Watch Activity Trackers as a Tool for Surgical Risk Stratification, Scientific Forum, American College of Surgeons (ACS) Clinical Congress 2023. 

______________________  

1 Dharap SB, Barbaniya P, Navgale S. Incidence and Risk Factors of Postoperative Complications in General Surgery Patients. Cureus. 2022 Nov 1;14(11):e30975. 

2 Wick, Elizabeth C., et al. Readmission Rates and Cost Following Colorectal Surgery. Diseases of the Colon & Rectum. 54(12):1475-1479; Dec. 2011. 

# # #  

About the American College of Surgeons  

The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for all surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has approximately 90,000 members and is the largest organization of surgeons in the world. “FACS” designates that a surgeon is a Fellow of the American College of Surgeons.

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A Year-End Rally In Europe Seems Like Wishful Thinking

A Year-End Rally In Europe Seems Like Wishful Thinking

By Michael Msika, Bloomberg Markets Live reporter and strategist

Soaring bond yields,…

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October 20, 2023

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A Year-End Rally In Europe Seems Like Wishful Thinking

By Michael Msika, Bloomberg Markets Live reporter and strategist

Soaring bond yields, a conflict in the Middle East and a tricky earnings season to navigate have cemented market strategists’ view that a year-end rally in European stocks isn’t on the cards.

The Stoxx Europe 600 index is expected to end the year at 450 points, according to the average of 16 strategists in a Bloomberg survey — just 1% above Wednesday’s close. Britain’s FTSE 100 is forecast to end 2023 pretty much where it is now, while the Euro Stoxx 50 and Germany’s DAX are seen rising by less than 3%.

With the global economy expected to slow, and with so many moving parts in the market, the average target hasn’t changed much from predictions made a month ago. Among those surveyed, the two most bearish firms — Bank of America and TFS — raised their targets by as much as 5%, while four firms cut their forecasts by a similar magnitude.

"With the relative valuation of equities to bonds at levels not seen since the great financial crisis, and earnings momentum in negative territory, we expect European equities to remain under pressure from any further increase in bond yields,” says Societe Generale head of European equity strategy Roland Kaloyan. He reiterated his Stoxx 600 year-end target of 440 points, but expects further downside in the first half of 2024 as the economy weakens.

For many strategists, stocks will be in a holding pattern while bond yields remain high, and the earnings season just kicking off has the potential to disappoint.

“The European macro backdrop has been weakening for some time and the third quarter was no exception,” says UBS strategist Gerry Fowler. He says results may show company margins are starting to contract as the economy stalls. “More sectors are not only reporting very weak new orders but also more recently, weakening backlogs of work too. This is a sign of imminent profit warnings.”

At the same time, the recent spike in bond yields is unlikely to reverse quickly, implying valuations are now slightly expensive in Europe. “Valuations can’t bail out weaker earnings until we are closer to ECB/Fed rate cuts in the middle of 2024,” Fowler says.

This round of forecasts comes after almost three months of declines for European stocks. The market has been paring its year-to-date gain amid a steep bond selloff that sent US benchmark Treasury yields to the highest level since July 2007, causing cracks for equities. Economic data has also been a headwind, with contracting PMIs in Europe and disappointing numbers out of China.

The latest risk that strategists are considering is war in the Middle East. While it isn’t seen as a significant threat to markets by most, it is an additional risk in the event of a major escalation.

“The geopolitical risk premium is unlikely to go away quickly,” say Barclays strategists led by Emmanuel Cau. He recommended that investors look at hedges like increasing allocation to energy, and reiterated a 490 target for the Stoxx 600. That’s the highest in the survey and implies a 10% rally into year end.

On the buy-side, investors are still bearish in the near term. The Bank of America fund manager survey in October showed that 55% see downside for European equities over the next few months because of high interest rates and falling earnings in the region. Still, more than half expect some upside over the next year.

BofA strategists are also cautious on the trajectory of earnings in the region. They see nearly 15% downside for the Stoxx 600 12-month forward EPS by the third quarter of next year, with strategists led by Sebastian Raedler saying that weakening global growth momentum and fading inflation support are growing headwinds. Their 410 target for the Stoxx 600 implies about 8% downside.

Tyler Durden Fri, 10/20/2023 - 12:25

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