BACKGROUND: We aimed to study the impact of operative time on textbook outcome (TO), especially postoperative complications and length of postoperative stay in minimally invasive esophagectomy.
METHODS: Patients undergoing esophagectomy for curative intent within a prospectively maintained database from 2016 to 2022 were retrieved. Relationships between operative time and outcomes were quantified using multivariable mixed-effects models with medical teams random effects. A restricted cubic spline (RCS) plotting was used to characterize correlation between operative time and the odds for achieving TO.
RESULTS: Data of 2210 patients were examined. Median operative time was 270 mins (interquartile range, 233-313) for all cases. Overall, 902 patients (40.8%) achieved TO. Among non-TO patients, 226 patients (10.2%) had a major complication (grade ≥ III), 433 patients (19.6%) stayed postoperatively longer than 14 days. Multivariable analysis revealed operative time was associated with higher odds of major complications (odds ratio 1.005, P < 0.001) and prolonged postoperative stay (≥ 14 days) (odds ratio 1.003, P = 0.006). The relationship between operative time and TO exhibited an inverse-U shape, with 298 mins identified as the tipping point for the highest odds of achieving TO.
CONCLUSIONS: Longer operative time displayed an adverse influence on postoperative morbidity and increased lengths of postoperative stay. In the present study, the TO displayed an inverse U-shaped correlation with operative time, with a significant peak at 298 mins. Potential factors contributing to prolonged operative time may potentiate targets for quality metrics and risk-adjustment process.

OBJECTIVE: To evaluate the additional advantages of integrating contrast-enhanced ultrasound (CEUS) into the Ovarian-Adnexal Reporting and Data System (O-RADS) ultrasound (US) for the characterization of adnexal lesions with solid components.
METHODS: This prospective multicenter study recruited women suspected of having adnexal lesions with solid components between September 2021 and December 2022. All patients scheduled for surgery underwent preoperative CEUS and US examinations. The lesions were categorized according to the O-RADS US system, and quantitative CEUS indexes were recorded. Pathological results served as the reference standard. Univariable and multivariable analyses were performed to identify risk factors for malignancy in adnexal lesions with solid components. Receiver operating characteristic (ROC) curve analysis was employed to assess diagnostic performance.
RESULTS: A total of 180 lesions in 175 women were included in the study. Among these masses, 80 were malignant and 100 were benign. Multivariable analysis revealed that serum CA-125, the presence of acoustic shadowing, and peak intensity (PI) ratio (PImass/PIuterus) of solid components on CEUS were independently associated with adnexal malignancy. The modified CEUS risk stratification model demonstrated superior diagnostic value in assessing adnexal lesions with solid components compared to O-RADS US (AUC: 0.91 vs 0.78, p < 0.001) and exhibited comparable performance to the Assessment of Different NEoplasias in the adnexa (ADNEX) model (AUC 0.91 vs 0.86, p = 0.07).
CONCLUSIONS: Our findings underscore the potential value of CEUS as an adjunctive tool for enhancing the precision of diagnostic evaluations of O-RADS US.
CONCLUSIONS: The promising performance of the modified CEUS risk stratification model suggests its potential to mitigate unnecessary surgeries in the characterization of adnexal lesions with solid components.
CONCLUSIONS: • The additional value of CEUS to O-RADS US in distinguishing between benign and malignant adnexal lesions with solid components requires further evaluation. • The modified CEUS risk stratification model displayed superior diagnostic value and specificity in characterizing adnexal lesions with solid components when compared to O-RADS US. • The inclusion of CEUS demonstrated potential in reducing the need for unnecessary surgeries in the characterization of adnexal lesions with solid components.

OBJECTIVE: Intradialytic hypotension (IDH) is closely associated with adverse clinical outcomes in HD-patients. An IDH predictor model is important for IDH risk screening and clinical decision-making. In this study, we used Machine learning (ML) to develop IDH model for risk prediction in HD patients.
METHODS: 62,227 dialysis sessions were randomly partitioned into training data (70%), test data (20%), and validation data (10%). IDH-A model based on twenty-seven variables was constructed for risk prediction for the next HD treatment. IDH-B model based on ten variables from 64,870 dialysis sessions was developed for risk assessment before each HD treatment. Light Gradient Boosting Machine (LightGBM), Linear Discriminant Analysis, support vector machines, XGBoost, TabNet, and multilayer perceptron were used to develop the predictor model.
RESULTS: In IDH-A model, we identified the LightGBM method as the best-performing and interpretable model with C- statistics of 0.82 in Fall30Nadir90 definitions, which was higher than those obtained using the other models (P<0.01). In other IDH standards of Nadir90, Nadir100, Fall20, Fall30, and Fall20Nadir90, the LightGBM method had a performance with C- statistics ranged 0.77 to 0.89. As a complementary application, the LightGBM model in IDH-B model achieved C- statistics of 0.68 in Fall30Nadir90 definitions and 0.69 to 0.78 in the other five IDH standards, which were also higher than the other methods, respectively.
CONCLUSIONS: Use ML, we identified the LightGBM method as the good-performing and interpretable model. We identified the top variables as the high-risk factors for IDH incident in HD-patient. IDH-A and IDH-B model can usefully complement each other for risk prediction and further facilitate timely intervention through applied into different clinical setting.

OBJECTIVE: Significant variability in the quality of healthcare supplied by hospitals is drawing broad attention from the United States Centers for Medicare and Medicaid Services. The primary issue is to evaluate hospital performance based on patient outcomes. Generalized linear random-effects models are a promising analytical tool for evaluating hospital performance. However, hospital compare data often violate the classical assumptions of normality on random effects and linearity representation on transformed conditional mean structures in these models.
METHODS: In this article, we proposed and tested the performance of a class of hospital compare models that embraces nonparametric mean structures with semi-nonparametric hospital random effects. Such models were further improved and integrated into a zero-inflated model. [Formula: see text] programs to implement these newly proposed hospital compare models were thoroughly developed. The [Formula: see text] programs are freely available via a GitHub (https:\\\\www.GitHub.com) repository.
RESULTS: We demonstrate the robustness of the proposed hospital compare models by conducting intensive empirical studies. Flexible semi-nonparametric random effects and functional fixed-effects mean structure were used to analyze patient mortality in a large-scale intensive care unit data set. After applying the proposed models to assess standardized modality rates and address patient-mix variability across hospitals, we detected those underperforming hospitals with higher mortality rates.
CONCLUSIONS: Our research findings highlight how constructing advanced assessment tools for hospital performance could support better decision-making at the administrative and public levels. The proposed hospital compare models are comprehensive in their capacity to identify patterns of hospital random effects and to convey the variability in healthcare quality with powerful accuracy and interpretability.

BACKGROUND: The aim of the study was to identify case-mix adjusters for the Chinese version of the Child Hospital Consumer Assessment of Healthcare Providers and Systems (Child-HCAHPS) and assess the impact of case-mix adjustment on patient experience measures in China.
METHODS: This study analyzed data collected from six National Regional Center for Pediatric across China retrospectively. Participants were children aged ≤17 years and their guardians who completed the survey. The Chinese Child-HCAHPS was used to measure pediatric inpatient care experience. Candidate case-mix adjusters were assessed using a summary measure of explanatory power. Changes in scores and rankings of the six centers were quantified to assess the impact of adjustment.
RESULTS: A total of 2708 respondents completed the survey from January to March 2021, with a response rate of 7-15%. The child\'s global health status and the respondent being the child\'s mother were identified as case-mix adjusters, and case-mix adjustment models for 18 patient experience items were constructed. Kendall\'s τ correlation of hospital rankings before and after adjustment ranged from 0.73 to 1.00.
CONCLUSIONS: Although the impact of case-mix adjustment may appear modest in our sample, it demonstrated the feasibility, necessity, and methodology for further development of case-mix adjustment models in pediatric healthcare facilities in China.
CONCLUSIONS: Case-mix adjustment models adjust for factors that are unamendable by healthcare providers that may affect patient experience ratings, thereby improving the comparability of institutional-level ratings. Standardized case-mix adjustment protocols for quality measures need to be modified in different settings. This is the first study to identify adjustment variables and the possible impact of case-mix adjustment on pediatric inpatients\' experience measures in a Chinese population. This study provided evidence on the feasibility and necessity for further development of case-mix adjustment models for pediatric healthcare facilities in China.

The validity of risk-adjustment methods based on administrative data has been questioned because hospital referral regions with higher diagnosis frequencies report lower case-fatality rates, implying that diagnoses do not track the underlying health risk. The objective of this study is to test the hypothesis that regional variation of diagnostic frequency in inpatient records is not associated with different coding practices but a reflection of the underlying health risks.
We applied two stratification methods to Medicare Analysis and Provider Review data from 2009 through 2014: (1) the number of chronic conditions; and, (2) quartiles of Risk Stratification Index (RSI)-defined risk. After sorting hospital referral regions into quintiles of diagnostic frequency, we examined all-cause mortality.
Medicare Analysis and Provider Review administrative database.
18 126 301 hospitalised Medicare fee-for-service beneficiaries aged 65 or older who had at least one hospital-based procedure between 2009 and 2014.
Coding frequency and baseline regional population risk factors by hospital referral region.
One year all-cause mortality in patients having the same number of chronic conditions or within the same RSI score quartile across US health referral regions, grouped by diagnostic frequency.
No consistent relationship between diagnostic frequency and mortality in the risk stratum defined by number of chronic conditions was detected. In the strata defined by RSI quartile, there was no decrease in mortality as a function of diagnostic frequency. Instead, adjusted mortality was positively correlated with socioeconomic risk factors.
Using present-on-admission codes only, diagnostic frequency among inpatients with at least one hospital-based procedure appears to be consequent to differences in baseline population health status, rather than diagnostic coding practices. In this population, claims-based risk-adjustment using RSI appears to be useful for assessing hospital outcomes and performance.

Thromboembolic events are the most serious complication of atrial fibrillation (AF), and the left atrial appendage (LAA) is the most important site of thrombosis in patients with AF. During the period of COVID-19, a non-invasive left atrial appendage detection method is particularly important in order to reduce the exposure of the virus. This study used CT three-dimensional reconstruction methods to explore the relationship between LAA morphology, LAA orifice area and its mechanical function in patients with non-valvular atrial fibrillation (NVAF).
A total of 81 consecutive patients with NVAF (36 cases of paroxysmal atrial fibrillation and 45 cases of persistent atrial fibrillation) who were planned to undergo catheter radiofrequency ablation were enrolled. All patients were examined by transthoracic echocardiography (TTE), TEE, and computed tomography angiography (CTA) before surgery. The LAA orifice area was obtained according to the images of CTA. According to the left atrial appendage morphology, it was divided into chicken wing type and non-chicken wing type. At the same time, TEE was performed to determine left atrial appendage flow velocity (LAAFV), and the relationship between the left atrial appendage orifice area and LAAFV was analyzed.
The LAAFV in Non-chicken wing group was lower than that in Chicken wing group (36.2 ± 15.0 cm/s vs. 49.1 ± 22.0 cm/s, p-value < 0.05). In the subgroup analysis, the LAAFV in Non-chicken wing group was lower than that in Chicken wing group in the paroxysmal AF (44.0 ± 14.3 cm/s vs. 60.2 ± 22.8 cm/s, p-value < 0.05). In the persistent AF, similar results were observed (29.7 ± 12.4 cm/s vs. 40.8 ± 17.7 cm/s, p-value < 0.05). The LAAFV in persistent AF group was lower than that in paroxysmal AF group (34.6 ± 15.8 cm/s vs. 49.9 ± 20.0 cm/s, p-value < 0.001). The LAAFV was negatively correlated with left atrial dimension (R = - 0.451, p-value < 0.001), LAA orifice area (R= - 0.438, p-value < 0.001) and left ventricular mass index (LVMI) (R= - 0.624, p-value < 0.001), while it was positively correlated with LVEF (R = 0.271, p-value = 0.014). Multiple linear regression analysis showed that LAA morphology (β = - 0.335, p-value < 0.001), LAA orifice area (β = -  0.185, p-value = 0.033), AF type (β = - 0.167, p-value = 0.043) and LVMI (β = - 0.465, p-value < 0.001) were independent factors of LAAFV.
The LAA orifice area is closely related to the mechanical function of the LAA in patients with NVAF. The larger LAA orifice area and LVMI, Non-chicken wing LAA and persistent AF are independent predictors of decreased mechanical function of LAA, and these parameters might be helpful for better management of LA thrombosis.

The influenza surveillance has been received much attention in public health area. For the cases with excessive zeroes, the zero-inflated Poisson process is widely used. However, the traditional control charts based on zero-inflated Poisson model, ignore the association between influenza cases and risk factors, and thus may lead to unexpected mistakes when implementing monitoring charts.
In this paper, we proposed risk-adjusted zero-inflated Poisson cumulative sum control charts, in which the risk factors were put to adjust the risk of influenza and the adjustment was made by zero-inflated Poisson regression. We respectively proposed the control chart monitoring the parameters individually and simultaneously.
The performance of our proposed risk-adjusted zero-inflated Poisson cumulative sum control chart was evaluated and compared with the unadjusted standard cumulative sum control charts in simulation studies. The results show that for different distribution of impact factors and different coefficients, the risk-adjusted cumulative sum charts can generate much less false alarm than the standard ones. Finally, the influenza surveillance data from Hong Kong is used to illustrate the application of the proposed chart.
Our results suggest that the adjusted cumulative sum control chart we proposed is more accurate and credible than the unadjusted standard control charts because of the lower false alarm rate of the adjusted ones. Even the unadjusted control charts may signal a little faster than the adjusted ones, the alarm they raise may have low credibility since they also raise alarm frequently even the processes are in control. Thus we suggest using the risk-adjusted cumulative sum control charts to monitor the influenza surveillance data to alert accurately, credibly and relatively quickly.

UNASSIGNED: Subacromial impingement syndrome (SIS) after hook plate fixation for acromioclavicular joint (AC) dislocation was the most common complication. However, the researches on its\' influential factors were rare. The purpose of this study was to identify the risk factors by analyzing the influencing factors of postoperative SIS and minimize the incidence of SIS in clinical surgery.We retrospectively analyzed the prospectively collected data from 330 consecutive patients with AC joint dislocation between August 2014 and August 2017 at our institute. The SIS was presented as the dependent variable at the last follow-up when the internal fixation was removed. The independent variables included age, gender, body-mass index (BMI), smoking status, alcohol consumption, type of injury, Rockwood Classification, site of injury, operation time, injury-to-surgery, the distance between the hook body and the acromion (DBA), the depth of hook tip (DHT), the distance between the hook plate and the humeral head (DHH), the distance between the acromion and the humeral head (DAH), the hook plate angle (AHP) and acromial shape. Logistic regression analysis was performed to identify independent influential factors of SIS.A total of 312 cases were included and 18 cases were lost. The follow-up rate was 94.5%. In without SIS group, there were 225 cases (123 males and 102 females). In with SIS group, a total of 87 cases were included (56 males and 31 females). The incidence of SIS was 27.8%. DHT (OR = 9.385, 95% CI = 4.883 to 18.040, P < .001) and DBA (OR = 2.444, 95% CI = 1.591 to 3.755, P < .001) were the significant independent risk factor for SIS of AC dislocation treat with hook plate. DAH (OR = 0.597, 95% CI = 0.396 to 0.900, P = .014) and acromial shape with flat and straight (OR = 0.325, 95% CI = 0.135 to 0.785, P = .012) were also independent factors of SIS, but they were all protective.The SIS had a high incidence in fixation of clavicular hook plate for AC dislocation. DHT and DBA were two independent risk factors, DAH and acromial shape with flat and straight were two independent protective factors for SIS. In clinical surgery, we should avoid risk factors to reduce the incidence of SIS.

UNASSIGNED: The present study aimed to develop nomograms to predict survival in patients with chondroblastic osteosarcoma (COS).An analysis was conducted of 320 cases of COS collected from the surveillance, epidemiology, and end results (SEER) database between 2004 and 2015. Independent prognostic factors were screened using univariate and multivariate Cox analyses. Subsequently, nomograms were established to predict the patients\' cancer-specific survival (CSS) and overall survival (OS) rates. The prediction accuracy and discriminative ability of the nomograms were examined using calibration curves and the concordance index (C-index).As revealed in the univariate and multivariate Cox regression analysis, age, tumor size, the primary site, the presence of metastasis, a history of having undergone surgery, and a history of having received radiotherapy were found to be independent prognostic factors associated with survival in patients with COS (all P < .05). Furthermore, age >39 years, the presence of distant metastasis, no history of having undergone any surgery, and tumor size >103 mm were found to be associated with poor prognosis in patients, while the primary site of the mandible and no history of having undergone radiotherapy showed associations with a more favorable prognosis in patients. Next, nomograms were constructed to predict the OS and CSS in patients with COS.We constructed nomograms that can provide accurate survival predictions in patients with chondroblastic osteosarcoma. These nomograms can help surgeons customize the treatment strategies for patients with chondroblastic osteosarcoma.