Peter Allen

BACKGROUND: Resection remains the cornerstone of curative-intent treatment for biliary tract cancers (BTCs). However, recent randomized data also support a role for adjuvant chemotherapy (AC). This study aimed to characterize trends in the use of AC and subsequent outcomes in gallbladder cancer and cholangiocarcinoma (CCA). METHODS: The National Cancer Database (NCDB) was queried for patients with resected, localized BTC from 2010 to 2018. Trends in AC were compared among BTC subtypes and stages of disease. Multivariable logistic regression was used to identify factors associated with receipt of AC. Survival analysis was performed with Kaplan-Meier and multivariable Cox proportional hazards methods. RESULTS: The study identified 7039 patients: 4657 (66%) with gallbladder cancer, 1159 (17%) with intrahepatic CCA (iCCA), and 1223 (17%) with extrahepatic CCA (eCCA). Adjuvant chemotherapy was administered to 2172 (31%) patients, increasing from 23% in 2010 to 41% in 2018. Factors associated with AC included female sex, year of diagnosis, private insurance, care at an academic center, higher education, eCCA (vs iCCA), positive margins, and stage II or III disease (vs stage I). Alternatively, increasing age, higher comorbidity score, gallbladder cancer (vs iCCA), and farther travel distance for treatment were associated with reduced odds of AC. Overall, AC was not associated with a survival advantage. However, subgroup analysis showed that AC was associated with a significant reduction in mortality among patients with eCCA. CONCLUSIONS: Among the patients with resected BTC, those who received AC were in the minority. In the context of recent randomized data and evolving recommendations, emphasis on guideline concordance with a focus on at-risk populations may improve outcomes.

OBJECTIVE: Implement a machine learning model using only the restricted data available at case creation time to predict surgical case length for multiple services at different locations. BACKGROUND: The Operating Room (OR) is one of the most expensive resources in a health system, estimated to cost $22-133 per minute and generate about 40% of the hospital revenue. Accurate prediction of surgical case length is necessary for efficient scheduling and cost-effective utilization of the OR and other resources. METHODS: We introduced a similarity cascade to capture the complexity of cases and surgeon influence on the case length and incorporated that into a gradient boosting machine learning model. The model loss function was customized to improve the balance between over- and under-prediction of the case length. A production pipeline was created to seamlessly deploy and implement the model across our institution. RESULTS: The prospective analysis showed that the model output was gradually adopted by the schedulers and outperformed the scheduler-predicted case length in Aug-Dec 2022. In 33,815 surgical cases across outpatient and inpatient platforms, the operational implementation predicted 11.2% fewer under-predicted cases and 5.9% more cases within 20% of the actual case length compared with the schedulers and only over-predicted 5.3% more. The model assisted schedulers to predict 3.4% more cases within 20% of the actual case length and 4.3% fewer under-predicted cases. CONCLUSIONS: We created a unique framework that is being leveraged every day to predict surgical case length more accurately at case posting time and could be potentially utilized to deploy future machine learning models.

Patients with unresectable colorectal liver metastases are commonly treated with systemic chemotherapy to convert their disease to an operable state. Unfortunately, many patients remain unresectable after first-line chemotherapy and resort to second- and third-line regimens with poor results. Liver-directed strategies have historically been used in this setting. There has been a renewed interest in offering hepatic artery infusion chemotherapy combined with systemic chemotherapy to improve resectability or palliate disease. Prospective studies over the past 2 decades have produced encouraging data, even in chemorefractory patients. This therapy has expanded to multiple centers across North America and worldwide with similar results. This review addresses these data, specifically focusing on conversion to resection and palliation of colorectal liver metastases after patients have received multiple lines of systemic chemotherapy.

BACKGROUND: Golf is a moderate-intensity physical activity that provides positive physical and mental health benefits. However, the inclusiveness of the sport for individuals with disabilities globally is unknown. OBJECTIVE: To characterize the demographics and disability characteristics of individuals engaging in disability golf globally. It was hypothesized that the majority of participants would be middle-aged, male, and from countries with higher gross domestic product, similar to the nondisabled population. DESIGN: Descriptive, cross-sectional analysis using European Disability Golf Association (EDGA) database. SETTING: Various international golf tournaments. PARTICIPANTS: Golfers (n = 1734) with disability from 44 countries registered with the EDGA (2017-2021). INTERVENTIONS: Not applicable. MAIN OUTCOMES: Descriptive analyses of frequencies, distributions, and means differences of demographic characteristics (age, gender, type of disability, level of handicap, golf cart use, and country of origin) of golfers with disability were performed. Data provided analysis of the association between number of participants and a country's gross domestic product (GDP). RESULTS: Individuals had a mean age of 52.5 (±15.6) years: 1589 (91.6%) male and 145 (8.4%) female. Twenty-three countries had female participation. The most commonly reported primary disability diagnoses were neurologic (24.8%), orthopedic (21.4%), and amputation below the knee (14.4%). Neurologic impairments (24.7%) were most common in men and orthopedic impairments (29.7%) were most common in women. Individuals with neurological impairments (27.4%) most frequently required golf carts to play. The GDP of a country had a positive correlation (r = 0.68) with the number of registered golfers with disability. CONCLUSION: Golf is played by individuals with a variety of disabilities and provides numerous benefits. However, there is an underrepresentation of youth, women, and individuals with certain impairments and from lower-income countries. These are the potential areas of opportunity to improve engagement and inclusiveness of golf.