Microsatellite instability (MSI) is a molecular marker of deficient DNA mismatch repair (dMMR) that is found in approximately 15% of colorectal cancer (CRC) patients. Testing all CRC patients for MSI/dMMR is recommended as screening for Lynch Syndrome and, more recently, to determine eligibility for immune checkpoint inhibitors in advanced disease. However, universal testing for MSI/dMMR has not been uniformly implemented because of cost and resource limitations. Artificial intelligence has been used to predict MSI/dMMR directly from hematoxylin and eosin (H&E) stained tissue slides. We review the emerging data regarding the utility of machine learning for MSI classification, focusing on CRC. We also provide the clinician with an introduction to image analysis with machine learning and convolutional neural networks. Machine learning can predict MSI/dMMR with high accuracy in high quality, curated datasets. Accuracy can be significantly decreased when applied to cohorts with different ethnic and/or clinical characteristics, or different tissue preparation protocols. Research is ongoing to determine the optimal machine learning methods for predicting MSI, which will need to be compared to current clinical practices, including next-generation sequencing. Predicting response to immunotherapy remains an unmet need.

Introduction: Understanding the trend of student authorship is crucial in determining its correlation to scholarly impact for corresponding authors. Our objective is to investigate student authorship rates over time in articles published in JAMA Internal Medicine (IM), as well as to examine potential effects student authors have on scholarly impact scores of corresponding authors via H-index measures. Methods: Authorship data including student authors (SA), first student authors, and corresponding authors (CA) from prior JAMA IM publications between 2010 and 2018 were collected, with a total of 701 studies. Analysis of variance (ANOVA) and independent sample t-tests were performed to assess for differences in the mean by publishing year and student authorship, respectively. Results: Of 4591 total authors, 683 (14.9%) were considered student authors. The percentage of student authorship increased from 46.3% to 58.0% between 2010 and 2018, respectively. No difference in average H-indices of CA between SA and non-SA groups (overall NSA H i mean: 30.2, vs SA H i mean: 32.1, p=0.371) was noted. Discussion: Student participation in research is not a disadvantage to scholarly impact for corresponding authors. Increased student authorship reflects a promising trend towards greater student participation in research within the field of medicine.

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Background Routine preoperative staging in pancreas cancer is controversial. We sought to evaluate the rates of diagnostic laparoscopy (DLAP) for pancreatic cancer. Methods We queried the National Surgical Quality Improvement Program for patients with pancreas cancer (2005)(2006)(2007)(2008)(2009)(2010)(2011)(2012)(2013) and compared groups who underwent DLAP, exploratory laparotomy (XLAP), pancreas resection (RSXN) or therapeutic bypass (THBP). We compared demographics, comorbidities, postoperative complications, 30-day mortality (Chi-square P \ 0.05) and trends over time (R 2 0-1). Results We identified 17,138 patients (RSXN 81.8%, XLAP 16.5%, THBP 8.2%, and DLAP 12.9%), with some having multiple CPT codes. Only 10.3% (n = 1432) of RSXN patients underwent DLAP prior to resection. XLAP occurred in 49.5% of non-RSXN patients, of whom 67.1% had no other operation. The percentage of patients undergoing RSXN increased 20.3% over time (R 2 0.81), while DLAP decreased 52.6% (R 2 0.92). XLAP patients without other operations decreased from 4.2 to 2.4%, although not linearly (R 2 0.31). Only 10.3% of XLAP had a diagnostic laparoscopy as well, leaving nearly 90% of these patients with an exploratory laparotomy without RSXN or THBP. Discussion Diagnostic laparoscopy for pancreas malignancy is becoming less common but could benefit a subset of patients who undergo open exploration without resection or therapeutic bypass.

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Background: Assessment of the effectiveness of tuberculosis control strategies requires the periodic measurement of M. tuberculosis transmission in populations, which is notoriously difficult. One well-established method is to measure the prevalence of infectious pulmonary tuberculosis in the population which is then repeated at a second time point after a period of ‘intervention’, such as scale up of the Search-Treat-Prevent strategy of the Zero TB Cities initiative, allowing for a ‘before and after’ comparison.  Protocol: The concurrent adult pulmonary tuberculosis prevalence survey (using digital radiography and Xpert MTB/RIF Ultra) and child M. tuberculosis infection survey (using QuantiFERON-TB® Gold Plus) will primarily provide a baseline measure of the burden of adult infectious tuberculosis in Karachi and assess whether a large-scale interferon gamma release assay survey in children aged 2 to 4 years is feasible. The target population for the prevalence survey is comprised of a stratified random sample of all adults aged 15 years and above and all children aged 2 to 4 years resident in four districts in Karachi. The survey procedures and analyses to estimate pulmonary tuberculosis prevalence are based on the World Health Organization methodology for tuberculosis prevalence surveys. Ethics and dissemination: The study protocol has been approved by the Interactive Research Development / The Indus Hospital Research Centre Research Ethics Committee in Karachi, Pakistan and the London School of Hygiene & Tropical Medicine Research Ethics Committee. Due to non-representative sampling in this setting, where a large proportion of the population are illiterate and are reluctant to provide fingerprints due to concerns about personal security, verbal informed consent will be obtained from each eligible participant or guardian. Results will be submitted to international peer-reviewed journals, presented at international conferences and shared with participating communities and with the Provincial and National TB programme.

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