Value of Adherence to Posttreatment Follow-Up Guidelines for Head and Neck Squamous Cell Carcinoma

OBJECTIVES

The utility of intensive posttreatment surveillance of head and neck squamous cell carcinoma (HNSCC) has been debated. The objective is to investigate adherence to the National Comprehensive Cancer Network (NCCN) posttreatment follow-up guidelines and assess the association with recurrence and survival.

METHODS

A total of 452 patients diagnosed with HNSCC at an academic medical center in a socioeconomically disadvantaged, urban setting were categorized by adherence to NCCN follow-up guidelines. Survival analyses were conducted to study the association between adherence and the 5-year overall survival and disease-specific survival in the entire cohort and subset of patients with documented recurrence.

RESULTS

We found that 23.5% of patients were adherent to NCCN follow-up guidelines in the first year after treatment, and 15.9% were adherent over 5 years. Adherence in the first year was significantly associated with 5-year overall survival (HR 0.634; 95% CI 0.443-0.906; p = 0.0124) and disease-specific survival (HR 0.556; 95% CI 0.312-0.992; p = 0.0470), but consistent adherence over 5 years did not show a significant association. Among the 21.7% of the cohort with recurrence, adherence was not associated with early-stage recurrence (AJCC stage I/II). In this subset, first year adherence was associated with improved disease-specific but not overall survival, and adherence over 5 years was not associated with survival.

CONCLUSION

Adherence to NCCN follow-up guidelines in the first year after treatment was associated with a better chance of 5-year overall and disease-specific survival, but this significant association was not observed among those who demonstrated consistent adherence over 5 years.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:708-716, 2024.

Evaluation of breast tumor morphologies from African American and Caucasian patients

The primary aim of this research was to investigate potential differences of breast tumor morphologies across African American and Caucasian racial groups by utilizing machine learning (ML) and artificial intelligence (AI) methods. While breast cancer disparities can partially be attributed to social determinants of health, tumor biology also contributes to survival outcomes. The rate of breast tumor growth is largely dependent on the extracellular matrix (ECM). Current research suggests the cellular components of the ECM may vary among racial and ethnic populations, and this may contribute to the incidence of cancer in African Americans. We utilized a supervised AI method to evaluate morphological differences between African American and Caucasian breast cancer tumors. Images used for analysis were downloaded from the Cancer Genome Atlas (TCGA) biorepository stored in the NIH Genomic Data Commons (GDC) data portal. We designed an ML classifier using the AlexNet model provided in PyTorch's torchvision package. The model was pre-trained and adapted via transfer learning resulting in a classification accuracy of 92.1% when using our breast cancer tumor image database split into 80% of training set and 20% of testing set. We interpreted the results of the AlexNet and ResNet50 models using LIME and saliency mapping as the explainers. Based on the images from our bi-racial testing set, this study confirmed significant variations of tumor and ECM regions in the different racial groups evaluated. Based on these findings, further analysis and characterization may provide new insight into disparities associated with the incidence of breast cancer.

Development and Interrater Agreement of a Novel Classification System Combining Medical and Surgical Adverse Event Reporting

Importance

Categorization systems for adverse events are not standardized across care settings and specialties and do not always include near miss events (events where there was potential for patient harm, but where no actual harm occurred), making it difficult to effectively assess patient safety for quality improvement.

Objective

To develop and assess interrater agreement on a classification system for adverse events reporting that incorporates events in both inpatient and outpatient settings across medical and surgical subspecialties including near miss events.

Design, Setting, and Participants

A cross-sectional study in a tertiary care center including 174 patient cases occurring from 2018 to 2020 was carried out. Data were abstracted from a Department of Otorhinolaryngology-Head and Neck Surgery Quality Assurance database. The cases were comprised of near miss and adverse events occurring in adult and pediatric patients in inpatient, outpatient, and emergency department settings. The ratings took place in March and April of 2022.

Exposures

Four raters (2 attending physicians and 2 senior resident physicians) were recruited to classify these cases according to 3 classification systems: the National Coordinating Council for Medication Error Reporting and Prevention (NCC-MERP), Clavien-Dindo, and our novel Quality Improvement Classification System (QICS).

Main Outcomes and Measures

The primary outcome was overall interrater agreements using Fleiss κ.

Results

Across all 4 raters grading 174 cases, the NCC-MERP, Clavien-Dindo, and QICS received a κ score. Fair-to-moderate interrater reliability was observed between the resident and attending physician groups across the 3 classification systems: NCC-MERP (κ = 0.33; 95% CI, 0.30-0.35), Clavien-Dindo (κ = 0.47; 95% CI, 0.43-0.50), and QICS (κ = 0.42; 95% CI, 0.39-0.44). Strong interrater concordance was observed for complications across all scenarios.

Conclusion and Relevance

This cross-sectional study found that the new QICS classification scheme was applicable to wide-ranging clinical scenarios with a focus on patient-centered outcomes including near miss events. In addition, QICS allowed for the comparison of patient outcome data in a multitude of settings.

Adaptations to water stress and pastoralism in the Turkana of northwest Kenya

The Turkana people inhabit arid regions of east Africa-where temperatures are high and water is scarce-and they practice subsistence pastoralism, such that their diet is primarily composed of animal products. Working with Turkana communities, we sequenced 367 genomes and identified 8 regions putatively involved in adaptation to water stress and pastoralism. One of these regions includes a putative enhancer for STC1-a kidney-expressed gene involved in the response to dehydration and the metabolism of purine-rich foods such as red meat. We show that STC1 is induced by antidiuretic hormone in humans, is associated with urea levels in the Turkana themselves, and is under strong selection in this population (s∼0.041). This work highlights that partnerships with subsistence-level groups can lead to new models of human physiology with biomedical relevance.

Elbow arthroplasty in trauma-current concepts review

Introduction

Despite advancements in modern locking plate technology, distal humerus fractures in the elderly remain difficult to treat. A subset of fractures in this osteoporotic bone includes multiple, shallow articular fragments that renders fixation unreliable, precluding early motion and acceptable functional outcomes. Arthroplasty, in the form of either Total Elbow Arthroplasty (TEA) or Distal Humeral Hemiarthroplasty (DHH) are alternative treatment options in this cohort and are being increasingly used.

Methods

This article reviews the use of TEA or DHH for acute distal humerus fracture, including patient selection, pre-operative planning, surgical approach, implant positioning, rehabilitation, outcomes and complications.

Results

Arthroplasties are being increasingly used for acute distal humerus fractures, however they introduce potential complications not seen with fixation. Due care must be employed to correct implant positioning which is a function of implant rotation, implant length and implant sizing. We describe a robust technique for epicondyle repair in DHH and unlinked TEA to avoid instability. Outcomes of DHH and TEA for acute distal humerus fracture are encouraging, however further long-term outcome and comparative data regarding arthroplasty is required.

Conclusions

Short to medium term outcomes demonstrate that both DHH and TEA are valuable options for selected patients, although attention to technique is required to minimise potential complications.

False lithium toxicity secondary to lithium heparin test tube: A case report and review

This case demonstrates a false elevation of serum lithium concentrations that can occur when blood samples are collected using lithium heparin (green-top) tubes. The patient was a 58-year-old female on chronic lithium therapy for bipolar disorder who presented to the emergency department following an overdose of 5 unidentified medications. The patient was overly sedated and exhibited paradoxical laughter, slurred speech, and mild abdominal pain. The recommended maintenance lithium concentration is 0.6 to 1.0 mmol/L, and she had previously been stable within this therapeutic range. The initial lithium concentration drawn upon admission was 2.05 mmol/L. No intervening treatment was made with the exception of intravenous fluids due to a lack of correlation between clinical presentation and the lithium concentration. Six hours later, a repeat lithium concentration of <0.10 mmol/L was obtained. Upon investigation, it was discovered that the initial blood sample was obtained in a lithium heparin green-top tube instead of the recommended plastic tubes with either sodium heparin or dipotassium ethylenediamine tetraacetic acid as the anticoagulant. As this case demonstrates, lithium heparin tubes have the potential to cause falsely elevated lithium concentrations. It is important for health care professionals to be aware of the false elevations that can occur when blood samples are taken in this type of tube.

Reliability, Validity, and Responsiveness of the Mini-Balance Evaluation Systems Test in Ambulatory Individuals with Multiple Sclerosis

Purpose: The purpose of this study was to determine the reliability, validity, and responsiveness of the Mini-Balance Evaluation Systems Test (MBT) in persons with multiple sclerosis (pwMS). Method: A total of 32 pwMS completed a questionnaire on disease severity, the Activities-specific Balance Confidence Scale (ABC), and the MBT. The MBT was re-administered 1 week later. Results: The interrater and test-retest reliability of the total MBT and subscales were excellent. The standard error of measurement for the total MBT, calculated from test-retest and interrater reliability, respectively, was 1.32 and 1.07. The minimal detectable change (MDC) for the total MBT was 3.74; the MDC for the subscales ranged from 0.98 (sensory) to 2.38 (gait). The correlations between individual subscale scores and the total MBT, among subscales, and between the total MBT and disease severity and ABC were excellent. Correlations between the total MBT and age, MS type, and fall and imbalance histories were moderate. Disease severity and ABC scores were the strongest predictors of MBT score. No floor effects were found. Ceiling effects were found for two subscales, but not for the total MBT. Conclusions: The MBT is reliable and valid in pwMS. MDC values will facilitate assessing the effectiveness of treatment. Because ceiling effects were found for two subscales, but not the total MBT, it is recommended that clinicians administer the MBT in its entirety.

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

Exaggeration of PFS by blinded, independent, central review (BICR)

BACKGROUND

Recent published studies have shown meaningful discrepancies between local investigator and blinded, independent, central review (BICR) assessed median progression-free survival (PFS). When the local review but not BICR shows progression, generally, no further assessments are carried out and patients are censored in the BICR analysis, leading to violation of the statistical assumptions of independence between censoring and outcome used in survival analysis methods.

METHODS

We carried out a simulation study to assess methodological reasons behind these discrepancies and corroborated our findings in a case study of three BRCA-mutated ovarian cancer trials. We briefly outline possible methodological solutions that may lead to improved estimation of the BICR medians.

RESULTS

The Kaplan-Meier (KM) curve for the BICR PFS can often be exaggerated. The degree of bias is largest when there is reasonably strong correlation between BICR and local PFS, especially when PFS is long compared with assessment frequency. This can result in an exaggeration of the medians and their difference; however, the hazard ratio (HR) is much less susceptible to bias. Our simulation shows that when the true BICR median PFS was 19 months, and patients assessed every 12 weeks, the estimated KM curves were materially biased whenever the correlation between BICR and local PFS was 0.4 or greater. This was corroborated by case studies where, in the active arm, the BICR median PFS was between 6 and 11 months greater than the local median PFS. Further research is required to find improved methods for estimating BICR survival curves.

CONCLUSIONS

In general, when there is a difference between local and BICR medians, the true BICR KM curve is likely to be exaggerated and its true median will probably lie somewhere between the observed local and BICR medians. Presentation of data should always include both BICR and local results whenever a BICR is carried out.

Studies on the behaviour and control of phlebotomine sandflies using experimental houses

Programmes for the control of phlebotomine sandflies (Diptera: Psychodidae), the vectors of leishmaniases, mainly target adults because larval breeding sites are generally unknown or inaccessible. To determine how blood-questing sandfly females enter homes and to develop means for their control, an experimental house (EH) was constructed in a village endemic for cutaneous leishmaniasis. Initially, carbon dioxide (CO₂ )-baited suction traps were installed inside the EH to attract and capture sandflies. For other experiments, the windows of the EH were fitted with CO₂ -baited window entrance traps (WETs) that allow each window to be considered as a separate unit. The majority of captures inside the EH and in WETs consisted of Phlebotomus sergenti, a species that enters inhabited houses relatively infrequently. Analyses of collections in WETs and in sticky traps on external walls showed that sandflies entered windows having landed previously on the wall below or either side of the window. Shelves constructed below windows significantly reduced the numbers of sandflies that entered both the EH and inhabited houses. The lining of internal walls with insecticide-impregnated fabric significantly increased mortality rates of sandflies captured inside the EH. To reduce the biting burden imposed by phlebotomine sandflies, several control measures must be integrated and sustained.

CRP polymorphisms and DNA methylation of the AIM2 gene influence associations between trauma exposure, PTSD, and C-reactive protein

BACKGROUND

Recent studies have implicated inflammatory processes in the pathophysiology of posttraumatic stress disorder (PTSD). C-reactive protein (CRP) is a widely-used measure of peripheral inflammation, but little is known about the genetic and epigenetic factors that influence blood levels of C-reactive protein (CRP) in individuals with PTSD.

METHODS

Participants were 286 U.S. military veterans of post-9/11 conflicts (57% with current PTSD). Analyses focused on single nucleotide polymorphisms (SNPs) in the CRP gene and DNA methylation at cg10636246 in AIM2-a locus recently linked to CRP levels through results from a large-scale epigenome-wide association study.

RESULTS

PTSD was positively correlated with serum CRP levels with PTSD cases more likely to have CRP levels in the clinically-elevated range compared to those without a PTSD diagnosis. Multivariate analyses that controlled for white blood cell proportions, genetic principal components, age and sex, showed this association to be mediated by methylation at the AIM2 locus. rs3091244, a functional SNP in the CRP promoter region, moderated the association between lifetime trauma exposure and current PTSD severity. Analyses also revealed that the top SNPs from the largest genome-wide association study of CRP conducted to date (rs1205 and rs2794520) significantly interacted with PTSD to influence CRP levels.

CONCLUSIONS

These findings provide new insights into genetic and epigenetic mechanisms of inflammatory processes in the pathophysiology of PTSD and point to new directions for biomarker identification and treatment development for patients with PTSD.

BDNF genotype is associated with hippocampal volume in mild traumatic brain injury

The negative long-term effects of mild traumatic brain injury (mTBI) have been a growing concern in recent years, with accumulating evidence suggesting that mTBI combined with additional vulnerability factors may induce neurodegenerative-type changes in the brain. However, the factors instantiating risk for neurodegenerative disease following mTBI are unknown. This study examined the link between mTBI and brain-derived neurotrophic factor (BDNF) genotype, which has previously been shown to regulate processes involved in neurodegeneration including synaptic plasticity and facilitation of neural survival through its expression. Specifically, we examined nine BDNF single-nucleotide polymorphisms (SNPs; rs908867, rs11030094, rs6265, rs10501087, rs1157659, rs1491850, rs11030107, rs7127507 and rs12273363) previously associated with brain atrophy or memory deficits in mTBI. Participants were 165 white, non-Hispanic Iraq and Afghanistan war veterans between the ages of 19 and 58, 110 of whom had at least one mTBI in their lifetime. Results showed that the BDNF SNP rs1157659 interacted with mTBI to predict hippocampal volume. Furthermore, exploratory analysis of functional resting state data showed that rs1157659 minor allele homozygotes with a history of mTBI had reduced functional connectivity in the default mode network compared to major allele homozygotes and heterozygotes. Apolipoprotein E (APOE) was not a significant predictor of hippocampal volume or functional connectivity. These results suggest that rs1157659 minor allele homozygotes may be at greater risk for neurodegeneration after exposure to mTBI and provide further evidence for a potential role for BDNF in regulating neural processes following mTBI.

Periodic health examinations and missed opportunities among patients likely needing mental health care

OBJECTIVES

Periodic health examinations (PHEs) are the most common reason adults see primary care providers. It is unknown if PHEs serve as a "safe portal" for patients with mental health needs to initiate care. We examined how physician communication styles impact mental health service delivery in PHEs.

STUDY DESIGN

Retrospective observational study using audio-recordings of 255 PHEs with patients likely to need mental health care.

METHODS

Mixed-methods examined the timing of a mental health discussion (MHD), its quality, and the relationship between MHD quality and physician practice styles. MHD quality was measured against evidence-based practices as a 3-level variable (evidence-based, perfunctory, or absent). Physician practice styles were measured by: visit length, verbal dominance, and elicitation of a patient's agenda. A generalized ordered logit model was used.

RESULTS

Many patients came with mental health concerns, as over 50% of the MHDs occurred in the first 5 minutes of the visit. One-third of the 255 patients had an evidence-based MHD, another third had a perfunctory MHD, and the remaining had no MHD. MHD quality was significantly associated with physician communication styles. Visits with physicians who tend to spend more time with patients, fully elicit patients' agendas, and let patients talk (instead of being verbally dominant) were more likely to deliver evidence-based MHD.

CONCLUSIONS

If done well, PHEs could be a safe portal for patients to seek mental health care, but most PHEs fell short. Improving PHE quality may require reimbursement for longer visits and coaching for physicians to more fully elicit patients' agendas and to listen more attentively.

Visual sign phonology: insights into human reading and language from a natural soundless phonology

Among the most prevailing assumptions in science and society about the human reading process is that sound and sound-based phonology are critical to young readers. The child's sound-to-letter decoding is viewed as universal and vital to deriving meaning from print. We offer a different view. The crucial link for early reading success is not between segmental sounds and print. Instead the human brain's capacity to segment, categorize, and discern linguistic patterning makes possible the capacity to segment all languages. This biological process includes the segmentation of languages on the hands in signed languages. Exposure to natural sign language in early life equally affords the child's discovery of silent segmental units in visual sign phonology (VSP) that can also facilitate segmental decoding of print. We consider powerful biological evidence about the brain, how it builds sound and sign phonology, and why sound and sign phonology are equally important in language learning and reading. We offer a testable theoretical account, reading model, and predictions about how VSP can facilitate segmentation and mapping between print and meaning. We explain how VSP can be a powerful facilitator of all children's reading success (deaf and hearing)-an account with profound transformative impact on learning to read in deaf children with different language backgrounds. The existence of VSP has important implications for understanding core properties of all human language and reading, challenges assumptions about language and reading as being tied to sound, and provides novel insight into a remarkable biological equivalence in signed and spoken languages. WIREs Cogn Sci 2016, 7:366-381. doi: 10.1002/wcs.1404 For further resources related to this article, please visit the WIREs website.

Effects of a dedicated regional psychiatric emergency service on boarding of psychiatric patients in area emergency departments

Introduction

Mental health patients boarding for long hours, even days, in United States emergency departments (EDs) awaiting transfer for psychiatric services has become a considerable and widespread problem. Past studies have shown average boarding times ranging from 6.8 hours to 34 hours. Most proposed solutions to this issue have focused solely on increasing available inpatient psychiatric hospital beds, rather than considering alternative emergency care designs that could provide prompt access to treatment and might reduce the need for many hospitalizations. One suggested option has been the “regional dedicated emergency psychiatric facility,” which serves to evaluate and treat all mental health patients for a given area, and can accept direct transfers from other EDs. This study sought to assess the effects of a regional dedicated emergency psychiatric facility design known at the “Alameda Model” on boarding times and hospitalization rates for psychiatric patients in area EDs.

Methods

Over a 30-day period beginning in January 2013, 5 community hospitals in Alameda County, California, tracked all ED patients on involuntary mental health holds to determine boarding time, defined as the difference between when they were deemed stable for psychiatric disposition and the time they were discharged from the ED for transfer to the regional psychiatric emergency service. Patients were also followed to determine the percentage admitted to inpatient psychiatric units after evaluation and treatment in the psychiatric emergency service.

Results

In a total sample of 144 patients, the average boarding time was approximately 1 hour and 48 minutes. Only 24.8% were admitted for inpatient psychiatric hospitalization from the psychiatric emergency service.

Conclusion

The results of this study indicate that the Alameda Model of transferring patients from general hospital EDs to a regional psychiatric emergency service reduced the length of boarding times for patients awaiting psychiatric care by over 80% versus comparable state ED averages. Additionally, the psychiatric emergency service can provide assessment and treatment that may stabilize over 75% of the crisis mental health population at this level of care, thus dramatically alleviating the demand for inpatient psychiatric beds. The improved, timely access to care, along with the savings from reduced boarding times and hospitalization costs, may well justify the costs of a regional psychiatric emergency service in appropriate systems.

Patients report better satisfaction with part-time primary care physicians, despite less continuity of care and access

BACKGROUND

The growing number of primary care physicians (PCPs) reducing their clinical work hours has raised concerns about meeting the future demand for services and fulfilling the continuity and access mandates for patient-centered care. However, the patient's experience of care with part-time physicians is relatively unknown, and may be mediated by continuity and access to care outcomes.

OBJECTIVE

We aimed to examine the relationships between a physicians' clinical full-time equivalent (FTE), continuity of care, access to care, and patient satisfaction with the physician.

DESIGN

We used a multi-level structural equation estimation, with continuity and access modeled as mediators, for a cross-section in 2010.

PARTICIPANTS

The study included family medicine (n = 104) and internal medicine (n = 101) physicians in a multi-specialty group practice, along with their patient satisfaction survey responses (n = 12,688).

MAIN MEASURES

Physician level FTE, continuity of care received by patients, continuity of care provided by physician, and a Press Ganey patient satisfaction with the physician score, on a 0-100 % scale, were measured. Access to care was measured as days to the third next-available appointment.

KEY RESULTS

Physician FTE was directly associated with better continuity of care received (0.172% per FTE, p < 0.001), better continuity of care provided (0.108% per FTE, p < 0.001), and better access to care (-0.033 days per FTE, p < 0.01), but worse patient satisfaction scores (-0.080% per FTE, p = 0.03). The continuity of care provided was a significant mediator (0.016% per FTE, p < 0.01) of the relationship between FTE and patient satisfaction; but overall, reduced clinical work hours were associated with better patient satisfaction (-0.053 % per FTE, p = 0.03).

CONCLUSIONS

These results suggest that PCPs who choose to work fewer clinical hours may have worse continuity and access, but they may provide a better patient experience. Physician workforce planning should consider these care attributes when considering the role of part-time PCPs in practice redesign efforts and initiatives to meet the demand for primary care services.

Leveraging electronic health records to develop measurements for processes of care

OBJECTIVES

To assess the reliability of data in electronic health records (EHRs) for measuring processes of care among primary care physicians (PCPs) and examine the relationship between these measures and clinical outcomes.

DATA SOURCES/STUDY SETTING

EHR data from 15,370 patients with diabetes, 49,561 with hypertension, in a group practice serving four Northern California counties.

STUDY DESIGN/METHODS

Exploratory factor analysis (EFA) and multilevel analyses of the relationships between processes of care variables and factor scales with control of hemoglobin A1c, blood pressure (BP), and low density lipoprotein (LDL) among patients with diabetes and BP among patients with hypertension.

PRINCIPAL FINDINGS

Volume of e-messages, number of days to the third-next-available appointment, and team communication emerged as reliable factors of PCP processes of care in EFA (Cronbach's alpha=0.73, 0.62, and 0.91). Volume of e-messages was associated with higher odds of LDL control (≤100) (OR=1.13, p<.05) among patients with diabetes. Frequent in-person visits were associated with better BP (OR=1.02, p<.01) and LDL control (OR=1.01, p<.01) among patients with diabetes, and better BP control (OR=1.04, p<.01) among patients with hypertension.

CONCLUSIONS

The EHR offers process of care measures which can augment patient-reported measures of patient-centeredness. Two of them are significantly associated with clinical outcomes. Future research should examine their association with additional outcomes.

Abstract P6-08-06: Use of an NIH PROMIS® instrument to identify predictors of fatigue in breast cancer patients receiving adjuvant chemotherapy

Background: Fatigue is one of the most common side effects of treatment for breast cancer (BC). This study used a daily diary approach to investigate the course of fatigue in BC patients receiving adjuvant chemotherapy. We examined clinical (BSA, menopausal status, stage, hemoglobin levels) and self-reported biopsychosocial factors (anxiety, depression, pain, physical and social functioning) as predictors of fatigue after chemotherapy infusion.

Methods: We enrolled 28 stage I (39%), II (50%), and III (11%) BC patients (mean age = 48.9 years, SD = 9.7) receiving standard adjuvant chemotherapy. Fatigue was assessed over 14 consecutive days (day −2 to +11) using a modified version of the NIH Patient-Reported Outcomes Measurement Information System (PROMIS®) fatigue short-form. Putative predictors of fatigue were assessed in the week prior to infusion. Anxiety and depression were measured with computerized adaptive testing. Pain, physical functioning, and social functioning were assessed using PROMIS global health items. Clinical variables were abstracted from patients' medical records. Analyses used individual growth curve modeling to examine overall levels of post-infusion fatigue and rates of change (amplitude) in daily fatigue over a 14-day period prior to the next infusion.

Results: Daily fatigue varied considerably over the 14 day study period, following a sinusoidal pattern. Fatigue T-scores increased from near-normal values (mean = 53) by about 1 SD (p &lt; .001) during the first 3 days post-infusion (mean = 62), peaked on days 3–6, and decreased to near-normal (mean = 53) by day 11. Higher baseline anxiety, depression, pain and problems with physical functioning independently predicted higher overall fatigue levels during the post-infusion period (p &lt; .001). In addition, baseline pain and physical functioning predicted distinct patterns of change in fatigue scores (p &lt; .05). Fatigue showed a steep rise and fall in patients with less pain and better physical functioning at baseline, rapidly returning to pre-infusion levels. Fatigue was more constant in patients with greater pain and worse physical functioning at baseline. These patients reported higher fatigue scores prior to infusion but experienced fewer dynamic changes in response to chemotherapy. Medical variables and social functioning were not associated with baseline fatigue levels or changes in fatigue.

Conclusions: This study demonstrates that BC patients with greater anxiety, depression, pain or poor physical functioning at baseline are at risk for prolonged and severe fatigue during treatment with chemotherapy. Patients with low pain and high physical functioning experience sharper changes in fatigue after infusion with quick return to baseline. The NIH PROMIS questionnaire provides a powerful quantitative method to identify predictors of chemotherapy-related fatigue. Identification of these predictors is critical for effective management of patient expectations and the development of targeted interventions to improve tolerance and functioning during adjuvant chemotherapy for breast cancer.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P6-08-06.

Impact of the mental healthcare delivery system on california emergency departments

Introduction

This is an observational study of emergency departments (ED) in California to identify factors related to the magnitude of ED utilization by patients with mental health needs.

Methods

In 2010, an online survey was administered to ED directors in California querying them about factors related to the evaluation, timeliness to appropriate psychiatric treatment, and disposition of patients presenting to EDs with psychiatric complaints.

Results

One hundred twenty-three ED directors from 42 of California's 58 counties responded to the survey. The mean number of hours it took for psychiatric evaluations to be completed in the ED, from the time referral was placed to completed evaluation, was 5.97 hours (95% confidence interval [CI], 4.82–7.13). The average wait time for adult patients with a primary psychiatric diagnosis in the ED, once the decision to admit was made until placement into an inpatient psychiatric bed or transfer to an appropriate level of care, was 10.05 hours (95% CI, 8.69–11.52). The average wait time for pediatric patients with a primary psychiatric diagnosis was 12.97 hours (95% CI, 11.16–14.77). The most common reason reported for extended ED stays for this patient population was lack of inpatient psychiatric beds.

Conclusion

The extraordinary wait times for patients with mental illness in the ED, as well as the lack of resources available to EDs for effectively treating and appropriately placing these patients, indicate the existence of a mental health system in California that prevents patients in acute need of psychiatric treatment from getting it at the right time, in the right place.

Drink a little; take a few drugs: do nurses have knowledge to identify and manage in-patients at risk of drugs and alcohol?

INTRODUCTION AND AIMS

The widespread use of alcohol and other drugs poses particular problems during hospitalisation. Although nurses have been identified as an appropriate group to screen patients and provide acute and ongoing management to people with drug and alcohol-related problems, rates of screening are low. The aims of this study were to identify current practices for screening by nurses working in medical and surgical wards, determine their knowledge relating to problems associated with substance use and identify their self-reported skills in managing patients with drug- and alcohol-related problems.

DESIGN AND METHODS

A chart audit of medical records was completed and a survey was distributed to nurses working in the study wards.

RESULTS

Screening for alcohol and drug use was documented on only 22/79 medical records, and detailed information about quantity and duration of use was recorded in only nine. Overall, the nurses reported that they had little knowledge about substance use problems, and felt that they lacked skills to care adequately for these patients.

DISCUSSION AND CONCLUSIONS

The results of this study suggest a need for a comprehensive training and education to ensure that nurses are familiar with policies and protocols for management of patients and to assist nurses to provide evidence-based care and make appropriate referrals to specialist services.

Search for flavor-changing-neutral-current d meson decays

We study the flavor-changing-neutral-current process c-->u micro(+) micro(-) using 1.3 fb(-1) of pp[over ] collisions at square root s = 1.96 TeV recorded by the D0 detector operating at the Fermilab Tevatron Collider. We see clear indications of the charged-current mediated D(s)(+) and D(+)-->phipi(+) --> micro(+)micro(-)pi(+) final states with significance greater than 4 standard deviations above background for the D(+) state. We search for the continuum neutral-current decay of D(+)-->pi(+) micro(+) micro(-) in the dimuon invariant mass spectrum away from the phi resonance. We see no evidence of signal above background and set a limit of B(D(+) --> pi(+) micro(+) micro(-))<3.9 x 10(-6) at the 90% C.L. This limit places the most stringent constraint on new phenomena in the c--> u micro(+) micro(-) transition.

Use of treatment records and lung lesion scoring to estimate the effect of respiratory disease on growth during early and late finishing periods in South African feedlot cattle

Growth, morbidity, and slaughter data from 2,036 calves in 2 South African feedlots were used to estimate the effect of bovine respiratory disease (BRD) and of lung lesion type and extent on growth during the early (processing to d 35) and late (d 35 to slaughter) finishing periods. Calves were weighed at processing (d 5 after arrival), on d 35, and at slaughter after a mean of 137 d on feed. All calves were monitored twice daily and were treated for BRD if rectal temperature was > 40 degrees C or if other specific signs of BRD were present. After slaughter, the occurrence and extent of parenchymal bronchopneumonic lesions and pleural adhesions were recorded. Subclinical BRD (never treated but with lung lesions at slaughter) occurred in 29.7% and clinical BRD in 22.6% of calves. Lung lesions were present in 43% of calves at slaughter; 8.6% had parenchymal lesions and 38.8% had pleural adhesions. Using a combined case definition (treated for BRD and/or lung lesions present at slaughter), the incidence of BRD was 52.5%. During the early finishing period, clinical BRD reduced ADG by 216 g (P < 0.001), subclinical BRD reduced ADG by 91 g (P < 0.001), and the combined effect of BRD was a 143 g reduction in ADG (P < 0.001). After d 35, animals treated for BRD tended to grow faster than those with subclinical BRD (P = 0.11), indicating that treatment was generally successful in reducing economic losses. The extent of bronchopneumonic lesions at slaughter was not associated with reduced growth during the early finishing period (P = 0.27), but extensive lesions reduced ADG by 88 g during the late period (P = 0.02). In contrast, the extent of pleural adhesions was not associated with reduced growth rate during the late finishing period (P = 0.37) but was strongly associated with reduced ADG before d 35; there was a 101 g reduction (P < 0.001) and a 220 g reduction (P = 0.01) for adhesions involving < 50% and > 50% of the pleural surfaces, respectively. Thus, although the presence of bronchopneumonic lesions and pleural adhesions at slaughter were both associated with reductions in overall ADG, they were indicative of production losses having occurred at different times during the finishing period. The overall effect of BRD was a 24 g reduction in ADG (P = 0.02) and a 5.1 d increase in days on feed (P < 0.001). The hidden cost of reduced growth rate due to BRD amounted to $3.41 per calf with clinical or subclinical BRD, or $1.79 per animal entering the feedlot.

Search for production of single top quarks via tcg and tug flavor-changing-neutral-current couplings

We search for the production of single top quarks via flavor-changing-neutral-current couplings of a gluon to the top quark and a charm (c) or up (u) quark. We analyze 230 pb{-1} of lepton+jets data from pp[over] collisions at a center of mass energy of 1.96 TeV collected by the D0 detector at the Fermilab Tevatron Collider. We observe no significant deviation from standard model predictions, and hence set upper limits on the anomalous coupling parameters kappa{g}{c}/Lambda and kappa{g}{u}/Lambda, where kappa{g} define the strength of tcg and tug couplings, and Lambda defines the scale of new physics. The limits at 95% C.L. are kappa{g}{c}/Lambda<0.15 TeV-1 and kappa{g}{u}/Lambda<0.037 TeV-1.

Measurement of the Lambdab0 lifetime using semileptonic decays

We report a measurement of the Lambda(b)(0) lifetime using a sample corresponding to 1.3 fb(-1) of data collected by the D0 experiment in 2002-2006 during run II of the Fermilab Tevatron collider. The Lambda(b)(0) baryon is reconstructed via the decay Lambda(b)(0)-->micronuLambda(c)(+)X. Using 4437+/-329 signal candidates, we measure the Lambda(b)(0) lifetime to be tau(Lambda(b)(0))=1.290(-0.110)(+0.119)(stat)(-0.091)(+0.087)(syst) ps, which is among the most precise measurements in semileptonic Lambda(b)(0) decays. This result is in good agreement with the world average value.

Properties of L=1 B(1) and B(2)* mesons

This Letter presents the first strong evidence for the resolution of the excited B mesons B(1) and B(2)* as two separate states in fully reconstructed decays to B(+)(*)pi(-). The mass of B(1) is measured to be 5720.6+/-2.4+/-1.4 MeV/c(2) and the mass difference DeltaM between B(2)* and B(1) is 26.2+/-3.1+/-0.9 MeV/c;{2}, giving the mass of the B(2)* as 5746.8+/-2.4+/-1.7 MeV/c(2). The production rate for B(1) and B(2)* mesons is determined to be a fraction (13.9+/-1.9+/-3.2)% of the production rate of the B+ meson.

Measurement of the Lambda b lifetime in the exclusive decay Lambda b --> J/psi Lambda

We have measured the Lambda b lifetime using the exclusive decay Lambda b --> J/psi Lambda, based on 1.2 fb(-1) of data collected with the D0 detector during 2002-2006. From 171 reconstructed Lambda b decays, where the J/psi and Lambda are identified via the decays J/psi --> mu+ mu- and Lambda --> ppi, we measured the Lambda b lifetime to be tau(Lambda b)=1.218 (+0.130)/(-0.115) (stat) +/- 0.042(syst) ps. We also measured the B0 lifetime in the decay B0 --> J/psi(mu+ mu-)K(0)/(S)(pi+ pi-) to be tau(B0)=1.501 (+0.078)/(-0.074) (stat) +/- 0.050(syst) ps, yielding a lifetime ratio of tau(Lambda b)/tau(B0)=0.811 (+0.096)/(-0.087) (stat) +/- 0.034(syst).

Search for stopped gluinos from pp collisions at square root s = 1.96 TeV

Long-lived, heavy particles are predicted in a number of models beyond the standard model of particle physics. We present the first direct search for such particles' decays, occurring up to 100 h after their production and not synchronized with an accelerator bunch crossing. We apply the analysis to the gluino (g), predicted in split supersymmetry, which after hadronization can become charged and lose enough momentum through ionization to come to rest in dense particle detectors. Approximately 410 pb(-1) of pp collisions at square root(s) = 1.96 TeV collected with the D0 detector during Run II of the Fermilab Tevatron collider are analyzed in search of such "stopped gluinos" decaying into a gluon and a neutralino (chi(1)(0)). Limits are placed on the (gluino cross section) x (probability to stop) x [BR(g --> g chi(1)(0))] as a function of the gluino and chi(1)(0) masses, for gluino lifetimes from 30 micros-100 h.

Search for third-generation scalar leptoquarks in pp at square root s=1.96 TeV

We report on a search for charge-1/3 third-generation leptoquarks (LQ) produced in pp collisions at square root s =1.96 TeV using the D0 detector at Fermilab. Third-generation leptoquarks are assumed to be produced in pairs and to decay to a tau neutrino and a b quark with branching fraction B. We place upper limits on sigma(pp --> LQLQ)B2 as a function of the leptoquark mass M(LQ). Assuming B=1, we exclude at the 95% confidence level third-generation scalar leptoquarks with M(LQ)<229 GeV.

Direct observation of the strange b baryon Xib-

We report the first direct observation of the strange b baryon Xi(b)- (Xi(b)+). We reconstruct the decay Xi(b)- -->J/psiXi-, with J/psi-->mu+mu-, and Xi--->Lambdapi--->ppi-pi- in pp collisions at square root of s =1.96 TeV. Using 1.3 fb(-1) of data collected by the D0 detector, we observe 15.2 +/- 4.4(stat)(-0.4)(+1.9)(syst) Xi(b)- candidates at a mass of 5.774 +/- 0.011(stat) +/- 0.015(syst) GeV. The significance of the observed signal is 5.5 sigma, equivalent to a probability of 3.3 x 10(-8) of it arising from a background fluctuation. Normalizing to the decay Lambda(b)-->J/psiLambda, we measure the relative rate sigma(Xi(b-) x B(Xi)b})- -->J/psiXi-)/sigma(Lambda(b)) x B(Lambda(b)-->J/psiLambda) = 0.28+/-0.09(stat)(-0.08)(+0.09)(syst).

Search for techniparticles in e+jets events at D0

We search for the technicolor process pp-->rhoT/omegaT-->WpiT in events containing one electron and two jets, in data corresponding to an integrated luminosity of 390 pb(-1), recorded by the D0 experiment at the Fermilab Tevatron. Technicolor predicts that technipions pi(T) decay dominantly into bb, bc, or bc, depending on their charge. In these events b and c quarks are identified by their secondary decay vertices within jets. Two analysis methods based on topological variables are presented. Since no excess above the standard model prediction was found, the result is presented as an exclusion in the pi(T) vs rho(T) mass plane for a given set of model parameters.