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Preliminary development of an ultrabrief two-item bedside test for delirium

Wed, 05/04/2016 - 2:27pm

BACKGROUND: Delirium is common, morbid, and costly, yet is greatly under-recognized among hospitalized older adults.

OBJECTIVE: To identify the best single and pair of mental status test items that predict the presence of delirium.

DESIGN, SETTING: Diagnostic test evaluation study that enrolled medicine inpatients aged 75 years or older at an academic medical center.

METHODS: Patients underwent a clinical reference standard assessment involving a patient interview, medical record review, and interviews with family members and nurses to determine the presence or absence of Diagnostic and Statistical Manual of Mental Disorders, 4th Edition defined delirium. Participants also underwent the three-dimensional Confusion Assessment Method (3D-CAM), a brief, validated assessment for delirium. Individual items and pairs of items from the 3D-CAM were evaluated to determine sensitivity and specificity relative to the reference standard delirium diagnosis.

RESULTS: Of the 201 participants (mean age 84 years, 62% female), 42 (21%) had delirium based on the clinical reference standard. The single item with the best test characteristics was "months of the year backwards" with a sensitivity of 83% (95% confidence interval [CI]: 69%-93%) and specificity of 69% (95% CI: 61%-76%). The best 2-item screen was the combination of "months of the year backwards" and "what is the day of the week?" with a sensitivity of 93% (95% CI: 81%-99%) and specificity of 64% (95% CI: 56%-70%).

CONCLUSIONS: We identified a single item with > 80% and pair of items with > 90% sensitivity for delirium. If validated prospectively, these items will serve as an initial innovative screening step for delirium identification in hospitalized older adults.

Antecedents of the child behavior checklist-dysregulation profile in children born extremely preterm

Wed, 05/04/2016 - 2:26pm

OBJECTIVE: Extremely preterm newborns are at heightened risk for emotional and behavioral dysregulation later in childhood. Our goal was to systematically evaluate the antenatal and early postnatal antecedents that might mediate the association between extreme preterm birth and emotional and behavioral dysregulation at age 2 years (corrected age).

METHOD: In a multi-site prospective study, the parents of 826 infants born before 28 weeks gestation completed a Child Behavior Checklist (CBCL) when the child was 2 years corrected age. We compared the maternal, pregnancy, placenta, delivery, and newborn characteristics, as well as early postnatal characteristics and exposures of those who satisfied criteria for the CBCL-Dysregulation Profile (CBCL-DP) to those of their peers. We then used time-oriented logistic regression models, starting first with antenatal variables that distinguished children with the CBCL-DP profile from their peers, and then added the distinguishing postnatal variables.

RESULTS: Approximately 9% of the children had a CBCL-DP. In the time-oriented logistic regression model with antenatal variables only, low maternal education achievement, passive smoking, and recovery of Mycoplasma from the placenta were associated with increased risk, whereas histologic chorioamnionitis was associated with reduced risk. None of the postnatal variables added statistically significant discriminating information.

CONCLUSION: Very preterm newborns who later manifest the CBCL-DP at age 2 years differ in multiple ways from their preterm peers who do not develop the CBCL-DP, raising the possibility that potentially modifiable antenatal and early postnatal phenomena contribute to the risk of developing emotional and behavioral dysregulation.

The remote brief intervention and referral to treatment model: Development, functionality, acceptability, and feasibility

Wed, 05/04/2016 - 2:26pm

BACKGROUND: Screening, brief intervention, and referral to treatment (SBIRT) is effective for reducing risky alcohol use across a variety of medical settings. However, most programs have been unsustainable because of cost and time demands. Telehealth may alleviate on-site clinician burden. This exploratory study examines the feasibility of a new Remote Brief Intervention and Referral to Treatment (R-BIRT) model.

METHODS: Eligible emergency department (ED) patients were enrolled into one of five models. (1) Warm Handoff: clinician-facilitated phone call during ED visit. (2) Patient Direct: patient-initiated call during visit. (3) Electronic Referral: patient contacted by R-BIRT personnel post visit. (4) Patient Choice: choice of models 1-3. (5) Modified Patient Choice: choice of models 1-2, Electronic Referral offered if 1-2 were declined. Once connected, a health coach offered assessment, counseling, and referral to treatment. Follow up assessments were conducted at 1 and 3 months. Primary outcomes measured were acceptance, satisfaction, and completion rates.

RESULTS: Of 125 eligible patients, 50 were enrolled, for an acceptance rate of 40%. Feedback and satisfaction ratings were generally positive. Completion rates were 58% overall, with patients enrolled into a model wherein the consultation occurred during the ED visit, as opposed to after the visit, much more likely to complete a consultation, 90% vs. 10%, chi(2) (4, N=50)=34.8, p < 0.001.

CONCLUSIONS: The R-BIRT offers a feasible alternative to in-person alcohol SBIRT and should be studied further. The public health impact of having accessible, sustainable, evidence-based SBIRT for substance use across a range of medical settings could be considerable.

A Comparison of Training Experience, Training Satisfaction, and Job Search Experiences between Integrated Vascular Surgery Residency and Traditional Vascular Surgery Fellowship Graduates

Wed, 05/04/2016 - 2:26pm

BACKGROUND: The first 2 integrated vascular residents in the United States graduated in 2012, and in 2013, 11 more entered the job market. The purpose of this study was to compare the job search experiences of the first cohort of integrated 0 + 5 graduates to their counterparts completing traditional 5 + 2 fellowship programs.

METHODS: An anonymous, Web-based, 15-question survey was sent to all 11 graduating integrated residents in 2013 and to the 25 corresponding 5 + 2 graduating fellows within the same institution. Questions focused on the following domains: training experience, job search timelines and outcomes, and overall satisfaction with each training paradigm.

RESULTS: Survey response was nearly 81% for the 0 + 5 graduates and 64% for the 5 + 2 graduates. Overall, there was no significant difference between residents and fellows in the operative experience obtained as measured by the number of open and endovascular cases logged. Dedicated research time during the entire training period was similar between residents and fellows. Nearly all graduates were extremely satisfied with their training and had positive experiences during their job searches with respect to starting salaries, numbers of offers, and desired practice type. More 0 + 5 residents chose academic and mixed practices over private practices compared with 5 + 2 fellowship graduates.

CONCLUSIONS: Although longer term data are needed to understand the impact of the addition of 0 + 5 graduating residents to the vascular surgery work force, preliminary survey results suggest that both training paradigms (0 + 5 and 5 + 2) provide positive training experiences that result in excellent job search experiences. Based on the current and future need for vascular surgeons in the work force, the continued growth and expansion of integrated 0 + 5 vascular surgery residency positions as an alternative to traditional fellowship training is thus far justified.

Evaluating Use of Higher Dose Oxybutynin in Combination with Desmopressin for Refractory Nocturnal Enuresis

Tue, 05/03/2016 - 2:19pm

Background: Nocturnal enuresis is a common pediatric condition with limited treatment options. In older children, pharmacologic therapy is often the preferred treatment. Pharmacologic therapies including Desmopressin (DDAVP) or Imipramine are effective in 40-50% of children. However Imipramine has serious safety concerns. DDAVP in combination with a fixed dose anticholinergic has been shown to be useful in individuals who fail DDAVP monotherapy, but still fails to achieve success rates greater than 60%.

Objective: Our goal is to explore the efficacy and safety of using combination therapy DDAVP plus Oxybutynin with increasing dose ofOxybutynin in patients refractory to standard combination therapy.

Study Design: A single institution, IRB approved, retrospective chart review of 61 patients (ages 7-18) including those with monosymptomatic primary nocturnal enuresis and non-monosymptomatic enuresis with Controlled Daytime Voiding Symptoms (CDVS) treated initially with DDAVP. All patients who failed initial therapy with DDAVP were started on combination therapy DDAVP (0.6 mg) plus standard dose (5 mg) Oxybutynin. In patients who failed standard combination therapy, the dose of Oxybutynin was titrated upwards until response or maximum dose 10 mg was achieved. Demographic and medical history data were evaluated to determine predictive factors associated with response/failure to different therapy groups.

Results: The use of escalating doses of Oxybutynin in combination with DDAVP achieved an overall response rate of 96.7% defined as a two-week period without any enuretic events following initiation oftreatment. Low Dose Combination Therapy (LDCT) (0.6mg DDAVP + 5 mg Oxybutynin) had a response rate of 68%. Advanced Dose Combination Therapy (ADCT) (0.6 mg DDAVP + 7.5-10 mg Oxybutynin) had a response rate of75.0%. A statistically significant relationship was found correlating both ADD/ADHD and CDVS with failure on monotherapy. No patients in the study reported any adverse events or side effects from the medications.

Discussion: The overall success rate of 96.7% with titrated doses of Oxybutynin in combination with DDAVP is considerably higher than the response rates on fixed dose combination therapy quoted in the literature and supports the need for further evaluation in larger studies. Additionally, we found a statistically significant association between monotherapy failure and children with either ADD/ADHD or controlled daytime voiding symptoms. Our study is limited by small numbers and larger studies are needed to confirm these results.

Conclusion: Our results suggest that ADCT is a safe and effective treatment option for primary nocturnal enuresis refractory to standard and low dose combination therapy.

Multiple Imputation based Clustering Validation (MIV) for Big Longitudinal Trial Data with Missing Values in eHealth

Tue, 05/03/2016 - 1:52pm

Web-delivered trials are an important component in eHealth services. These trials, mostly behavior-based, generate big heterogeneous data that are longitudinal, high dimensional with missing values. Unsupervised learning methods have been widely applied in this area, however, validating the optimal number of clusters has been challenging. Built upon our multiple imputation (MI) based fuzzy clustering, MIfuzzy, we proposed a new multiple imputation based validation (MIV) framework and corresponding MIV algorithms for clustering big longitudinal eHealth data with missing values, more generally for fuzzy-logic based clustering methods. Specifically, we detect the optimal number of clusters by auto-searching and -synthesizing a suite of MI-based validation methods and indices, including conventional (bootstrap or cross-validation based) and emerging (modularity-based) validation indices for general clustering methods as well as the specific one (Xie and Beni) for fuzzy clustering. The MIV performance was demonstrated on a big longitudinal dataset from a real web-delivered trial and using simulation. The results indicate MI-based Xie and Beni index for fuzzy-clustering are more appropriate for detecting the optimal number of clusters for such complex data. The MIV concept and algorithms could be easily adapted to different types of clustering that could process big incomplete longitudinal trial data in eHealth services.

ESammon: A computationaly enhanced sammon mapping based on data density

Tue, 05/03/2016 - 1:52pm

Sammon mapping is a widely used visualization technique to display complex data from high-to low-dimensional space. However, its extensive computational cost may pose potential computational challenges to big data visualization. This paper proposes a computationally-enhanced Sammon mapping (ESammon) by leveraging the characteristics of spatial data density. Unlike the conventional Sammon, ESammon preserves critical pairwise distances between data points in the process of projection, instead of all distances. Specifically, we integrated the Directed-Acyclic-Graph (DAG) based data density characterization method to select the critical distances. The numerical results demonstrated that our ESammon can achieve comparable projection results as the conventional Sammon mapping while reducing the computational cost from O(N2) to O(N).

A tumor suppressor function of the Msr1 gene in leukemia stem cells of chronic myeloid leukemia

Sun, 05/01/2016 - 10:25pm

We have shown that Alox5 is a critical regulator of leukemia stem cells (LSCs) in a BCR-ABL-induced chronic myeloid leukemia (CML) mouse model, and we hypothesize that the Alox5 pathway represents a major molecular network that regulates LSC function. Therefore, we sought to dissect this pathway by comparing the gene expression profiles of wild type and Alox5(-/-) LSCs. DNA microarray analysis revealed a small group of candidate genes that exhibited changes in the levels of transcription in the absence of Alox5 expression. In particular, we noted that the expression of the Msr1 gene was upregulated in Alox5(-/-) LSCs, suggesting that Msr1 suppresses the proliferation of LSCs. Using CML mouse model, we show that Msr1 is downregulated by BCR-ABL and this down-regulation is partially restored by Alox5 deletion, and that Msr1 deletion causes acceleration of CML development. Moreover, Msr1 deletion markedly increases LSC function through its effects on cell cycle progression and apoptosis. We also show that Msr1 affects CML development by regulating the PI3K-AKT pathway and beta-Catenin. Together, these results demonstrate that Msr1 suppresses LSCs and CML development. The enhancement of the tumor suppressor function of Msr1 may be of significance in the development of novel therapeutic strategies for CML.

Arachidonate 15-lipoxygenase is required for chronic myeloid leukemia stem cell survival

Sun, 05/01/2016 - 10:25pm

Cancer stem cells (CSCs) are responsible for the initiation and maintenance of some types of cancer, suggesting that inhibition of these cells may limit disease progression and relapse. Unfortunately, few CSC-specific genes have been identified. Here, we determined that the gene encoding arachidonate 15-lipoxygenase (Alox15/15-LO) is essential for the survival of leukemia stem cells (LSCs) in a murine model of BCR-ABL-induced chronic myeloid leukemia (CML). In the absence of Alox15, BCR-ABL was unable to induce CML in mice. Furthermore, Alox15 deletion impaired LSC function by affecting cell division and apoptosis, leading to an eventual depletion of LSCs. Moreover, chemical inhibition of 15-LO function impaired LSC function and attenuated CML in mice. The defective CML phenotype in Alox15-deficient animals was rescued by depleting the gene encoding P-selectin, which is upregulated in Alox15-deficient animals. Both deletion and overexpression of P-selectin affected the survival of LSCs. In human CML cell lines and CD34+ cells, knockdown of Alox15 or inhibition of 15-LO dramatically reduced survival. Loss of Alox15 altered expression of PTEN, PI3K/AKT, and the transcription factor ICSBP, which are known mediators of cancer pathogenesis. These results suggest that ALOX15 has potential as a therapeutic target for eradicating LSCs in CML.

Durable Results with In Situ Graft Repair of Ruptured Salmonella Aneurysm in a Patient with Autoimmune Deficiency Syndrome

Fri, 04/29/2016 - 4:05pm

We describe a case of a 42-year-old male patient with advanced autoimmune deficiency syndrome (AIDS) (CD4 count of 16 cells/mm) found to have a ruptured infected infrarenal aortic aneurysm. Emergent in situ repair was performed with a Hemashield Dacron graft (Boston Scientific, Natick, MA). Aortic tissue cultures grew group DSalmonella. Patient was placed initially on intravenous ciprofloxacin followed by lifelong oral levofloxacin and trimethoprim. Over 2 years following repair, he remains asymptomatic, with repair intact and no recurrent infection. This case is the first reported successful long-term repair of a ruptured salmonella infected abdominal aortic aneurysm in the setting of advanced AIDS.

Association between First Trimester Pregnancy Associated Plasma Protein–A (PAPP-A) and Gestational Diabetes Mellitus Development

Fri, 04/29/2016 - 3:27pm

Background: Gestational diabetes (GDM) is a common pregnancy complication with significant cardiometabolic consequences for mothers and offspring. Previous research from our group suggests that adipose tissue IGFBP-5 and its unique metalloprotease PAPP-A (Pregnancy Associated Plasma Protein-A) may play mechanistic roles in GDM development by regulating functional IGF-1 levels and lipid storage and metabolism.

Aim: To examine the relationship between circulating PAPP-A levels and GDM development. We hypothesized that high first trimester PAPP-A levels would be associated with decreased GDM risk.

Methods: A retrospective cohort of women delivering singleton gestations at UMass Memorial Healthcare (2009, 2010, 2014, 2015) was assembled by abstracting electronic medical records. PAPP-A was measured in first trimester (11-14 weeks), and reported as quartiles of multiples of the mean (MoM) based on gestational age and adjusted for maternal weight and race/ethnicity. GDM diagnosis based on standard 2-step protocol (~24-28 weeks; failed 50g 1hr glucola screen then ≥2 abnormal values per Carpenter-Coustan criteria on 100g 3hr glucose tolerance test). Crude and multivariable-adjusted logistic regression models estimated the association between PAPP-A MoM quartiles and GDM.

Results: Women (N=1,251) were 29.7 (SD:5.7) years old and 12.5 (SD:0.6) weeks gestation at PAPP-A measurement. 7.6% (n=95) developed GDM. Median PAPP-A MoM were 0.7 (inter-quartile range [IQR]=0.5-1.0) among women with GDM and 0.9 (IQR=0.6-1.3) among controls; 39% versus 23% were in the 1st quartile, respectively. After adjusting for pre-pregnancy body mass index, nuchal translucency, crown rump length, smoking status, and parity, women with PAPP-A MoM in 2nd, 3rd, and 4th quartiles had 52% (OR=0.48, 95%CI=0.26-0.88), 45% (OR=0.55, 95%CI=0.30-0.99) and 73% (OR=0.27, 95%CI=0.13-0.53) lower odds of GDM compared to women in the 1st quartile.

Conclusion: Higher PAPP-A MoM levels were associated with lower GDM risk. Future studies will assess whether higher PAPP-A levels are associated with enhanced IGF-1 signaling and improved pregnancy metabolic homeostasis.

Treatment of bacterial skin infections in ED observation units: factors influencing prescribing practice

Fri, 04/29/2016 - 3:27pm

OBJECTIVE: The Infectious Disease Society of America (IDSA) publishes evidence-based guidelines for the treatment of skin and soft tissue infections. How closely physicians follow these guidelines is unknown, particularly in the emergency department observation unit (EDOU) where increasing numbers of patients are treatment for these infections. Our objectives were to describe (1) the antibiotic treatment patterns EDOU patients, (2) physicians' adherence to the IDSA guidelines, and (3) factors that influence physician's prescribing practices.

METHODS: This prospective cohort enrolled adult patients discharged from an EDOU at an academic medical center after treatment for a skin or soft tissue infection. Information was collected from chart review and patient interview pertaining to the patient's sociodemographic characteristics, presenting illness, and antibiotic treatment regimens. Treatment regimens were compared with national guidelines.

RESULTS: The study included 193 patients of which only 43% were treated according to IDSA guidelines, 42% were overtreated, and 15% were undertreated. Women were more likely to be undertreated (relative risk, 1.58; 95% confidence interval, 1.21-2.06), whereas patients 50 years and older were at risk for overtreatment (relative risk, 1.44; 95% confidence interval, 1.03-2.02). Women also received shorter courses of antibiotic therapy with an average of 9.6 days of treatment compared with 10.6 days for men.

CONCLUSIONS: Physician antibiotic prescribing practices demonstrated poor adherence to IDSA guidelines and were influenced by the patient's age and sex. Standardized antibiotic protocols for treatment of skin and soft tissue infections to IDSA guidelines in the EDOU would minimize physician bias.

Positive surgical margins in radical prostatectomy patients do not predict long-term oncological outcomes: results from the Shared Equal Access Regional Cancer Hospital (SEARCH) cohort

Fri, 04/29/2016 - 3:27pm

OBJECTIVE: To assess the impact of positive surgical margins (PSMs) on long-term outcomes after radical prostatectomy (RP), including metastasis, castrate-resistant prostate cancer (CRPC), and prostate cancer-specific mortality (PCSM).

PATIENTS AND METHODS: Retrospective study of 4 051 men in the Shared Equal Access Regional Cancer Hospital (SEARCH) cohort treated by RP from 1988 to 2013. Proportional hazard models were used to estimate hazard ratios (HRs) of PSMs in predicting biochemical recurrence (BCR), CRPC, metastases, and PCSM. To determine if PSMs were more predictive in certain patients, analyses were stratified by pathological Gleason score, stage, and preoperative prostate-specific antigen (PSA) level.

RESULTS: The median (interquartile range) follow-up was 6.6 (3.2-10.6) years and 1 127 patients had > 10 years of follow-up. During this time, 302 (32%) men had BCR, 112 (3%) developed CRPC, 144 (4%) developed metastases, and 83 (2%) died from prostate cancer. There were 1 600 (40%) men with PSMs. In unadjusted models, PSMs were significantly associated with all adverse outcomes: BCR, CRPC, metastases and PCSM (all P < /= 0.001). After adjusting for demographic and pathological characteristics, PSMs were associated with increased risk of only BCR (HR 1.98, P < 0.001), and not CRPC, metastases, or PCSM (HR < /=1.29, P > 0.18). Similar results were seen when stratified by pathological Gleason score, stage, or PSA level, and when patients who underwent adjuvant radiotherapy were excluded.

CONCLUSIONS: PSMs after RP are not an independent risk factor for CRPC, metastasis, or PCSM overall or within any subset. In the absence of other high-risk features, PSMs alone may not be an indication for adjuvant radiotherapy.

Continuing challenges in the diagnosis and management of obscure gastrointestinal bleeding

Fri, 04/29/2016 - 3:26pm

The diagnosis and management of obscure gastrointestinal bleeding (OGIB) have changed dramatically since the introduction of video capsule endoscopy (VCE) followed by deep enteroscopy and other imaging technologies in the last decade. Significant advances have been made, yet there remains room for improvement in our diagnostic yield and treatment capabilities for recurrent OGIB. In this review, we will summarize the latest technologies for the diagnosis of OGIB, limitations of VCE, technological enhancement in VCE, and different management options for OGIB.

CT in the Emergency Department: A Real-Time Study of Changes in Physician Decision Making

Fri, 04/29/2016 - 3:26pm

Purpose: To determine how physicians' diagnoses, diagnostic uncertainty, and management decisions are affected by the results of computed tomography (CT) in emergency department settings.

Materials and Methods: This study was approved by the institutional review board and compliant with HIPAA. Data were collected between July 12, 2012, and January 13, 2014. The requirement to obtain patient consent was waived. In this prospective, four-center study, patients presenting to the emergency department who were referred for CT with abdominal pain, chest pain and/or dyspnea, or headache were identified. Physicians were surveyed before and after CT to determine the leading diagnosis, diagnostic confidence (on a scale of 0% to 100%), alternative "rule out" diagnosis, and management decisions. Primary measures were the proportion of patients for whom the leading diagnosis or admission decision changed and median changes in diagnostic confidence. Secondary measures addressed alternative diagnoses and return-to-care visits (eg, to emergency department) at 1-month follow-up. Regression analysis was used to identify associations between primary measures and site and participant characteristics.

Results: Both surveys were completed for 1280 patients by 245 physicians. The leading diagnosis changed in 235 of 460 patients with abdominal pain (51%), 163 of 387 with chest pain and/or dyspnea (42%), and 103 of 433 with headache (24%). Pre-CT diagnostic confidence was inversely associated with the likelihood of a diagnostic change (P < .0001). Median changes in confidence were substantial (increases of 25%, 20%, and 13%, respectively, for patients with abdominal pain, chest pain and/or dyspnea, and headache; P < .0001); median post-CT confidence was high (95% for all three groups). CT helped confirm or exclude at least 95% of alternative diagnoses. Admission decisions changed in 116 of 457 patients with abdominal pain (25%), 72 of 387 with chest pain and/or dyspnea (19%), and 81 of 426 with headache (19%). During follow-up, 70 of 450 patients with abdominal pain (15%), 53 of 387 with chest pain and/or dyspnea (14%), and 49 of 433 with headache (11%) returned for the same indication. In general, changes in leading diagnosis, diagnostic confidence, and admission decisions were not well explained with site or participant characteristics.

Conclusion: Physicians' diagnoses and admission decisions changed frequently after CT, and diagnostic uncertainty was alleviated.

Projected Effects of Radiation-Induced Cancers on Life Expectancy in Patients Undergoing CT Surveillance for Limited-Stage Hodgkin Lymphoma: A Markov Model

Fri, 04/29/2016 - 3:25pm

OBJECTIVE: Patients with limited-stage Hodgkin lymphoma (HL) undergo frequent posttreatment surveillance CT examinations, raising concerns about the cumulative magnitude of radiation exposure. The purpose of this study was to project radiation-induced cancer risks relative to competing risks of HL and account for the differential timing of each.

MATERIALS AND METHODS: We adapted a previously developed Markov model to project lifetime mortality risks and life expectancy losses due to HL versus radiation-induced cancers in HL patients undergoing surveillance CT. In the base case, we modeled 35-year-old men and women undergoing seven CT examinations of the chest, abdomen, and pelvis over 5 years. Radiation-induced cancer risks and deaths for 17 organ systems were modeled using an organ-specific approach, accounting for specific anatomy exposed at CT. Cohorts of 20-, 50-, and 65-year-old men and women were evaluated in secondary analyses. Markov chain Monte Carlo methods were used to estimate the uncertainty of radiation risk projections.

RESULTS: For 35-year-old adults, we projected 3324/100,000 (men) and 3345/100,000 (women) deaths from recurrent lymphoma and 245/100,000 (men, 95% uncertainty interval [UI]: 121-369) and 317/100,000 (women, 95% UI: 202-432) radiation-induced cancer deaths. Discrepancies in life expectancy losses between HL (428 days in men, 482 days in women) and radiation-induced cancers (11.6 days in men, [95% UI: 5.7-17.5], 15.6 days in women [95% UI: 9.8-21.4]) were proportionately greater because of the delayed timing of radiation-induced cancers relative to recurrent HL. Deaths and life expectancy losses from radiation-induced cancers were highest in the youngest cohorts.

CONCLUSION: Given the low rate of radiation-induced cancer deaths associated with CT surveillance, modest CT benefits would justify its use in patients with limited-stage HL.

Radiation exposure from CT-guided ablation of renal masses: effects on life expectancy

Fri, 04/29/2016 - 3:25pm

OBJECTIVE. The purpose of this article is to project the effects of radiation exposure on life expectancy (LE) in patients who opt for CT-guided radiofrequency ablation (RFA) instead of surgery for renal cell carcinoma (RCC).

MATERIALS AND METHODS. We developed a decision-analytic Markov model to compare LE losses attributable to radiation exposure in hypothetical 65-year-old patients who undergo CT-guided RFA versus surgery for small ( < /= 4 cm) RCC. We incorporated mortality risks from RCC, radiation-induced cancers (for procedural and follow-up CT scans), and all other causes; institutional data informed the RFA procedural effective dose. Radiation-induced cancer risks were generated using an organ-specific approach. Effects of varying model parameters and of dose-reduction strategies were evaluated in sensitivity analysis.

RESULTS. Cumulative RFA exposures (up to 305.2 mSv for one session plus surveillance) exceeded those from surgery (up to 87.2 mSv). In 65-year-old men, excess LE loss from radiation-induced cancers, comparing RFA to surgery, was 11.7 days (14.6 days for RFA vs 2.9 days for surgery). Results varied with sex and age; this difference increased to 14.6 days in 65-year-old women and to 21.5 days in 55-year-old men. Dose-reduction strategies that addressed follow-up rather than procedural exposure had a greater impact. In 65-year-old men, this difference decreased to 3.8 days if post-RFA follow-up scans were restricted to a single phase; even elimination of RFA procedural exposure could not achieve equivalent benefits.

CONCLUSION. CT-guided RFA remains a safe alternative to surgery, but with decreasing age, the higher burden of radiation exposure merits explicit consideration. Dose-reduction strategies that target follow-up rather than procedural exposure will have a greater impact.

The relationship between coping styles in response to unfair treatment and understanding of diabetes self-care

Fri, 04/29/2016 - 3:25pm

PURPOSE: This study examined the relationship between coping style and understanding of diabetes self-care among African American and white elders in a southern Medicare-managed care plan.

METHODS: Participants were identified through a diabetes-related pharmacy claim or ICD-9 code and completed a computer-assisted telephone survey in 2006-2007. Understanding of diabetes self-care was assessed using the Diabetes Care Profile Understanding (DCP-U) scale. Coping styles were classified as active (talk about it/take action) or passive (keep it to yourself). Linear regression was used to estimate the associations between coping style with the DCP-U, adjusting for age, sex, education, and comorbidities. Based on the conceptual model, 4 separate categories were established for African American and white participants who displayed active and passive coping styles.

RESULTS: Of 1420 participants, the mean age was 73 years, 46% were African American, and 63% were female. Most respondents (77%) exhibited active coping in response to unfair treatment. For African American participants in the study, active coping was associated with higher adjusted mean DCP-U scores when compared to participants with a passive coping style. No difference in DCP-U score was noted among white participants on the basis of coping style.

CONCLUSIONS: Active coping was more strongly associated with understanding of diabetes self-care among older African Americans than whites. Future research on coping styles may give new insights into reducing diabetes disparities among racial/ethnic minorities.

Clostridium difficile infection after colorectal surgery: a rare but costly complication

Fri, 04/29/2016 - 3:25pm

BACKGROUND: The incidence and virulence of Clostridium difficile infection (CDI) are on the rise. The characteristics of patients who develop CDI following colorectal resection have been infrequently studied.

MATERIALS AND METHODS: We utilized the University HealthSystem Consortium database to identify adult patients undergoing colorectal surgery between 2008 and 2012. We examined the patient-related risk factors for CDI and 30-day outcomes related to its occurrence.

RESULTS: A total of 84,648 patients met our inclusion criteria, of which the average age was 60 years and 50% were female. CDI occurred in 1,266 (1.5%) patients during the years under study. The strongest predictors of CDI were emergent procedure, inflammatory bowel disease (IBD), and major/extreme APR-DRG severity of illness score. CDI was associated with a higher rate of complications, intensive care unit (ICU) admission, longer preoperative inpatient stay, 30-day readmission rate, and death within 30 days compared to non-CDI patients. Cost of the index stay was, on average, $14,130 higher for CDI patients compared with non-CDI patients.

CONCLUSION: Emergent procedures, higher severity of illness, and inflammatory bowel disease are significant risk factors for postoperative CDI in patients undergoing colorectal surgery. Once established, CDI is associated with worse outcomes and higher costs. The poor outcomes of these patients and increased costs highlight the importance of prevention strategies targeting high-risk patients.