Short-acting opioid prescriptions and Workers' Compensation using the National Ambulatory Medical Care Survey

BACKGROUND

Short-acting opioids have been utilized for pain management with little known about their use in patients on Workers' Compensation (WC) insurance. Our goal was to investigate this association in the ambulatory care setting.

METHODS

Using the National Ambulatory Medical Care Survey, visits from patients aged 18-64 during the years 2010 until 2018 were evaluated (excluding 2017 due to data availability). Demographic and co-morbidity data from each visit was obtained along with the visit year. The first short-acting opioid medication prescribed in the database was considered. Survey-weighted frequencies were evaluated. Logistic regression estimated the crude and adjusted odds ratios (OR) with 95% confidence intervals for the use of short-acting opioid prescription.

RESULTS

There were 155,947 included visits with 62.5% for female patients. Most patients were White with 11.7% identifying as Black, and 6% identifying as another race. Over 13% of the sample was of Hispanic descent. WC was the identified insurance type in 1.6% of the sample population. Of these patients, 25.6% were prescribed a short-acting opioid, compared with 10.1% of those with another identified insurance. On multivariable regression, Black patients had increased odds of being prescribed a short-acting opioid compared to white patients (OR: 1.22, 95% CI: 1.11-1.34). Those on WC had 1.7-fold higher odds of being prescribed short-acting opioids (95% CI: 1.46-2.06).

CONCLUSION

Certain patient characteristics, including having WC insurance, increased the odds of a short-acting opioid prescription. Further work is needed to identify prescribing patterns in specific high-risk occupational groups, as well as to elicit potential associated health outcomes.

Postoperative CT surveillance in the evaluation of local recurrence after sub-lobar resection of neoplastic lesions of the lung

OBJECTIVE

As indications for sub-lobar resections increase, it will become more important to identify risk factors for postsurgical recurrence. We investigated retrospectively the association between local recurrence after sub-lobar resection of neoplastic lung lesions and pre- and post-operative CT imaging and pathologic features.

MATERIALS AND METHODS

We reviewed retrospectively neoplastic lung lesions with postoperative chest CT surveillance of sub-lobar resections in 2006-2016. We defined "suspicious" findings as nodularity ≥3 mm or soft tissue thickening ≥4 mm along the suture line and/or progression and explored their association with local recurrence. Primary lung cancer stage, tumoral invasion of lymphatics, visceral pleura or large vessels, bronchial and vascular margin distance were also assessed.

RESULTS

Our study group included 45 cases of sub-lobar resection took for either primary (n = 37) or metastatic (n = 8) lung tumors. Local recurrence was observed in 16 of those patients. New nodularity ≥3 mm or soft tissue thickening ≥4 mm along the suture line on surveillance CT was significantly associated with local recurrence (p = 0.037). Additionally, solid nodule (p = 0.005), age at surgery ≤60 years (p = 0.006), two or more sites of invasion (p < 0.0001) and poor histologic differentiation (p = 0.0001) were also significantly associated with local tumor recurrence. Of 16 patients with surveillance post-surgical PET-CT, 15 had elevated FDG uptake.

CONCLUSION

The postoperative changes along the suture line should follow a predictable time course demonstrating a pattern of stability, thinning or resolution on CT surveillance. New or increasing postoperative nodularity ≥3 mm or soft tissue thickening ≥4 mm along the suture line requires close diagnostic work-up. Surgical pathology characteristics added prognostic value on postoperative recurrence surveillance.

The diagnostic accuracy of perfusion-only scan in the diagnosis of pulmonary embolism in the era of COVID-19: A single-center study of 434 patients

INTRODUCTION

There is a paucity of data in the literature regarding the diagnostic accuracy of perfusion (Q)-only studies in the absence of ventilation images. This study aims to assess the diagnostic accuracy of Q-only imaging in the pandemic era.

METHODS

Patients who underwent Q-only imaging for pulmonary embolism between March 2020 and February 2021 were analyzed. Patients who underwent lung quantification analysis were excluded. Q-only test results were reported as per modified PIOPED II criteria and single positron emission tomography/computed tomography (SPECT/CT) imaging was performed as needed. Patients were considered concordant or discordant by correlating the Q-only results with CT angiogram (CTA) or clinical diagnosis made through chart review. The diagnostic accuracy was calculated after excluding intermediate probability and nondiagnostic studies.

RESULTS

Four hundred and thirty-four patients were identified. One hundred and twenty-eight patients (29.4%) underwent ultrasound Doppler, 37 patients (8.5%) underwent CTA, and 16 patients (3.6%) underwent both. After excluding patients with intermediate probability or nondiagnostic studies and who did not have follow-up (a total of 87 patients [20%]), 347 patients were enrolled in the final analysis. The combined planar and SPECT/CT sensitivity and specificity were 85.4% (72.2%-93.9% confidence interval [CI]) and 98.7% (96.9%-98.6% CI), respectively. The positive predictive value (PPV) of the Q-only imaging was 89.1% (77.3%-95.1% CI) and the negative predictive value (NPV) was 98.2% (96.4%-99% CI). The sensitivity with SPECT/CT reached 100% (CI: 71.5%-100%) with a specificity of 92.3% (CI: 64%-99.8%). The PPV was 85.7% (CI: 62.1%-95.6%) and the NPV was 100%.

CONCLUSION

Q-only imaging provides clinically acceptable results. The sensitivity of the Q-only scan is increased when coupled with SPECT/CT.

Assessment of HCC response to Yttrium-90 radioembolization with gadoxetate disodium MRI: correlation with histopathology

BACKGROUND AND AIMS

Transarterial ⁹⁰Y radioembolization (TARE) is increasingly being used for hepatocellular carcinoma (HCC) treatment. However, tumor response assessment after TARE may be challenging. We aimed to assess the diagnostic performance of gadoxetate disodium MRI for predicting complete pathologic necrosis (CPN) of HCC treated with TARE, using histopathology as the reference standard.

METHODS

This retrospective study included 48 patients (M/F: 36/12, mean age: 62 years) with HCC treated by TARE followed by surgery with gadoxetate disodium MRI within 90 days of surgery. Two radiologists evaluated tumor response using RECIST1.1, mRECIST, EASL, and LI-RADS-TR criteria and evaluated the percentage of necrosis on subtraction during late arterial, portal venous, and hepatobiliary phases (AP/PVP/HBP). Statistical analysis included inter-reader agreement, correlation between radiologic and pathologic percentage of necrosis, and prediction of CPN using logistic regression and ROC analyses.

RESULTS

Histopathology demonstrated 71 HCCs (2.8 ± 1.7 cm, range: 0.5-7.5 cm) including 42 with CPN, 22 with partial necrosis, and 7 without necrosis. EASL and percentage of tumor necrosis on subtraction at the AP/PVP were independent predictors of CPN (p = 0.02-0.03). Percentage of necrosis, mRECIST, EASL, and LI-RADS-TR had fair to good performance for diagnosing CPN (AUCs: 0.78 - 0.83), with a significant difference between subtraction and LI-RADS-TR for reader 2, and in specificity between subtraction and other criteria for both readers (p-range: 0.01-0.04). Radiologic percentage of necrosis was significantly correlated to histopathologic degree of tumor necrosis (r = 0.66 - 0.8, p < 0.001).

CONCLUSIONS

Percentage of tumor necrosis on subtraction and EASL criteria were significant independent predictors of CPN in HCC treated with TARE. Image subtraction should be considered for assessing HCC response to TARE when using MRI.

KEY POINTS

• Percentage of tumor necrosis on image subtraction and EASL criteria are significant independent predictors of complete pathologic necrosis in hepatocellular carcinoma treated with⁹⁰Y radioembolization. • Subtraction, mRECIST, EASL, and LI-RADS-TR have fair to good performance for diagnosing complete pathologic necrosis in hepatocellular carcinoma treated with⁹⁰Y radioembolization.

Nonoperative Management of Hallux Limitus Using a Novel Forefoot Orthosis

Hallux limitus is among the most common arthritides of the foot and ankle, with increasing incidence in the aging population. Despite its prevalence and disease burden, treatment of the condition remains poorly understood. Many patients will fail initial conservative management, whereas controversy exists surrounding indications for and outcomes of surgery. The present study sought to examine the impact of a novel forefoot orthosis on foot function, pain, and plantar pressure distributions in patients with symptomatic hallux limitus. Nineteen adult patients completed a questionnaire consisting of the 23-item Foot Function Index and a 10-point visual analogue scale measuring pain. Standing pedobarographic maps were generated using a foot scanning system. Participants were instructed to wear the orthosis in athletic shoes for 4 weeks. Eighteen participants (94.7%) experienced improvements in foot function and pain, with 12 (63.2%) reporting complete resolution of pain at the end of the 4-week trial. Mean Foot Function Index scores improved significantly from 43.0% at baseline to 11.0% with the orthosis (p < .001). Similarly, mean visual analogue scale pain scores decreased significantly from 4.87 to 1.18 (p < .001). Pedobarographic analysis while wearing the orthosis demonstrated increased ability of participants to bear weight on the arthritic hallux metatarsophalangeal joint and restoration of physiologic stance. Compared to existing products, the device was well tolerated and did not require footwear modifications or impede normal gait. Overall, the orthosis offers an appealing solution to patients dissatisfied with existing treatment options as well as those who may be averse to or ineligible for surgery.

Geriatric emergency department revisits after discharge with Potentially Inappropriate Medications: A retrospective cohort study

OBJECTIVE

To determine whether Potentially Inappropriate Medications (PIMs) prescribed in an academic emergency department (ED) are associated with increased ED revisits in older adults.

METHODS

A retrospective chart review of Medicare beneficiaries 65 years and older, discharged from an academic ED (January 2012 - November 2015) with any PIMs versus no PIMs. PIMs were defined using Category 1 of the 2015 Updated Beers criteria. Primary outcomes, obtained from a Medicare database linked to hospital ED subjects, were ED revisits 3 and 30 days from index ED discharge. Adjusted multiple logistic regression was used with entropy balance weighted covariates: Age in years, Gender, Race, Number of discharge medications, Charlson Comorbidity Index (CCI) score, Emergency Severity Index scores (ESI), Chief Complaint, Medicaid status, and prior 90 Day ED visits.

RESULTS

Over the study period, there were a total of 7,591 Medicare beneficiaries 65+ discharged from the ED with a prescription; 1,383 (18%) received one or more PIMs. ED revisits in 30 days were fewer for the PIMs cohort (12% PIMs vs 16% no PIMs, OR 0.79, 95% CI 0.65 - 0.95, P value <0.005). Hospital admissions in 30 days were fewer for the PIMs cohort (4 PIMs vs 7% no PIMs, OR 0.75, 95% CI 0.56 - 1.00, P value <0.005). In addition to PIMs, covariate risk factors associated with ED revisits in 30 days included comorbidity severity, history of prior ED revisits, chief complaint, and Medicaid status. Risk factors associated with hospitalization in 30 days included those plus age and emergency severity index, but not race nor ethnicity.

CONCLUSIONS

Patients discharged from the ED receiving potentially inappropriate medications as defined by Category 1 of the 2015 updated Beers criteria had lower odds of revisiting the ED within 30 days of index visit. Sociodemographic factors such as gender and race did not predict ED revisits or hospital admissions. Clinical characteristics predicted ED revisits and hospital admissions, the strongest risk being increasing Charlson Comorbidity Index score followed by triage acuity and chief complaint. Future studies are needed to delineate the implications of our findings.

The Prescription of Long-Acting Opioids for Working-Age Patients With Workers' Compensation or Chronic Illness Diagnoses in the United States: From the National Ambulatory Medical Care Survey (NAMCS), 2010 to 2016

OBJECTIVE

To examine associations of workers' compensation, chronic conditions, age, sex, and race/ethnicity with primary prescription of long-acting opioids (LAO) among working-age patients in ambulatory care.

METHODS

Using the National Ambulatory Medical Care Survey (2010 to 2016), we conducted descriptive, bivariate, and multivariate logistic regression analyses of patients aged 18 to 64 with an LAO as their primary medication.

RESULTS

Those prescribed an LAO were more likely to be men (adjusted odds ratio [aOR] = 1.48, 95% CI 1.13, 1.91), have workers' compensation (aOR = 2.00, 95% CI 1.12, 3.57), or have diagnoses of lower back pain (aOR = 4.70, 95% CI 3.51, 6.29), arthritis (aOR = 1.53, 95% CI 1.11, 2.09), or depression (aOR = 1.69; 95% CI 1.24, 2.31). Hispanic ethnicity/race had a lower likelihood of LAO use compared with non-Hispanic White (aOR = 0.58; 95% CI 0.37, 0.90).

CONCLUSIONS

Male sex, workers' compensation, and diagnoses of lower back pain, arthritis, or depression were independently associated with increased LAO prescription odds.

Efficacy of Intravenous Immunoglobulin for Preventing Infections in Patients with Multiple Myeloma

INTRODUCTION

Despite many recent advances in the treatment of multiple myeloma (MM), infection remains a major cause of morbidity and mortality. Prior studies have shown mixed results using intravenous immunoglobulin (IVIG) to prevent infections in MM and were conducted prior to most modern MM therapies.

PATIENTS AND METHODS

We retrospectively reviewed all patients with MM treated with IVIG at our institution from 2010 to 2017. The primary endpoint was the incidence rate ratio (IRR) of infectious events (IEs) per patient-year during IVIG versus observation.

RESULTS

A total of 68 patients were included; 151 IEs occurred during 918 months of IVIG treatment, whereas 446 IEs occurred during 2484 months of observation. Although the annual rate of IEs was substantially higher during periods of progressive disease (PD) compared with non-PD (4.9 vs. 1.8; P < .001), most IEs occurred during periods of non-PD (75% vs. 25% during PD). There was no overall difference in the annual rate of IEs per patient between IVIG and observation (1.97 vs. 2.16; IRR, 0.92; 95% confidence interval [CI], 0.76-1.10; P = .376). The subgroup of patients with hypogammaglobulinemia and whose myeloma was in a non-PD phase had a significant reduction in all-grade IEs (1.20 vs. 1.92; IRR, 0.63; 95% CI, 0.45-0.88; P = .009) and ≥ grade 3 IEs (0.25 vs. 0.56; IRR, 0.45; 95% CI, 0.22-0.94; P = .041) with IVIG compared with observation.

CONCLUSION

Although treatment with IVIG did not show benefit in the overall population, there may be subgroups of patients that derive significant benefit. Additional observational studies are needed to confirm these findings and further refine patient selection.

Outcomes and Prognosis Factors in Patients With Vena Cava Filters in a Quaternary Medical Center: A 5-Year Retrospective Analysis

BACKGROUND

Indications for inferior vena cava filter (IVCF) placement are controversial. This study assesses the proportion of different indications for IVCF placement and the associated 30-day event rates and predictors for all-cause mortality, deep vein thrombosis (DVT), pulmonary embolism, and bleeding after IVCF placement.

METHOD

In this 5-year retrospective cohort observational study in a quaternary care center, consecutive patients with IVCF placement were identified through cross-matching of 3 database sets and classified into 3 indication groups defined as "standard" in patients with venous thromboembolism (VTE) and contraindication to anticoagulants, "extended" in patients with VTE but no contraindication to anticoagulants, and "prophylactic" in patients without VTE.

RESULTS

We identified 1248 IVCF placements, that is, 238 (19.1%) IVCF placements for standard indications, 583 (46.7%) IVCF placements for extended indications, and 427 (34.2%) IVCF placements for prophylactic indications. Deep vein thrombosis rates [95% confidence interval] were higher in the extended (8.06% [5.98-10.58]) and prophylactic (7.73% [5.38-10.68]) groups than in the standard group (3.36% [1.46-6.52]). Mortality rates were higher in the standard group (12.18% [8.31-17.03]) than in the extended group (7.55% [5.54-9.99]) and the prophylactic (5.85% [3.82-8.52]) group. Bleeding rates were higher in the standard group (4.62% [2.33-8.12]) than in the prophylactic group (2.11% [0.97-3.96]). Best predictors for VTE were acute medical conditions; best predictors for mortality were age, acute medical conditions, cancer, and Medicare health insurance.

CONCLUSIONS

Prophylactic and extended indications account for the majority of IVCF placements. The standard indication is associated with the lowest VTE rate that may be explained by the competing risk of mortality higher in this group and related to the underlying medical conditions and bleeding risk. In the prophylactic group (no VTE at baseline), the exceedingly high DVT rate may be related to the IVCF placement.

Validation of Right Atrial Area as a Measure of Right Atrial Size and Normal Values of in Healthy Pediatric Population by Two-Dimensional Echocardiography

Right atrial (RA) size is a prognostic indicator for heart failure and cardiovascular death in adults. Data regarding use of RA area (RAA) by two-dimensional echocardiography as a surrogate for RA size and allometric modeling to define appropriate indexing of the RAA are lacking. Our objective was to validate RAA as a reliable measure of RA size and to define normal reference values by transthoracic echocardiography (TTE) in a large population of healthy children and develop Z-scores using a validated allometric model for indexing RAA independent of age, sex, and body size. Agreement between RAA and volume by 2D, 3D TTE, and MRI was assessed. RAA not volume by 2D TTE is an excellent surrogate for RA size. RAA/BSA¹ has an inverse correlation with BSA with a residual relationship to BSA (r = - 0.54, p < 0.0001). The allometric exponent (AE) derived for the entire cohort (0.85) also fails to eliminate the residual relationship. The entire cohort divided into two groups with a BSA cut-off of 1 m² to provide the best-fit allometric model (r = 0). The AE by least square regression analysis for each group is 0.95 and 0.88 for BSA < 1 m² and > 1 m², respectively, and was validated against an independent sample. The mean indexed RAA ± SD for BSA ≤ 1 m² and > 1 m² is 9.7 ± 1.3 cm² and 8.7 ± 1.3 cm², respectively, and was used to derive Z-scores. RAA by 2D TTE is superior to 2D or 3D echocardiography-derived RA volume as a measure of RA size using CMR as the reference standard. RAA when indexed to BSA¹, decreases as body size increases. The best-fit allometric modeling is used to create Z scores. RAA/BSA^0.95 for BSA < 1 m² and RAA/BSA^0.88 for those with BSA > 1 m² can be used to derive Z scores.

Active design in affordable housing: A public health nudge

This pilot study investigates the impact of active design (AD) strategies on physical activity (PA) among adults living in two Leadership in Energy and Environmental Design (LEED) certified affordable housing developments in the South Bronx, New York. One building incorporates LEED Innovation in Design (ID) Credit: Design for Health through Increased Physical Activity. Tenants in an affordable housing building (AH) incorporating active design strategies completed PA self-assessments at their lease signing and one year later in 2015. Trained research assistants obtained body measurements. Residents of neighboring non-AD affordable housing (MCV) served as a comparison. Thirty four adults were recruited from AH and 29 from MCV, retention was 56% (n = 19) and 52% (n = 15) respectively at one year. The two groups' body mass index (BMI) and high-risk waist-to-hip ratio (WHR) were not statistically significantly different when analyzed as continuous variables, although BMI category had a greater decline at AH than at MCV (p = 0.054). There was a 31.5% increase in AH participants meeting MPA requirements and a statistically significant improvement in females (p = 0.031); while there was no change in the MCV participants overall or when stratified by gender. AH participants were significantly more likely to have reported increased stair use and less likely to have reported no change or decreased stair use than participants from MCV participants (p = 0.033). Housing has a role in individual health outcomes and behavior change, broad adoption of active design strategies in affordable housing is warranted to improve physical activity measures.

Falls in Older Patients with Cancer Undergoing Surgery: Prevalence and Association with Geriatric Syndromes and Levels of Disability Assessed in Preoperative Evaluation

Falls are common among older adults. However, not much is known about the prevalence of falls among older patients with cancer. In 2015, older patients with cancer referred to Geriatrics service for preoperative evaluation were assessed for fall history, basic and instrumental activities of daily living (ADL and IADL), KPS, and use of assistive device. Of 806 patients, 215 (26.7%) patients reported fall. Incidence of last fall inside and outside home was 54.4% and 45.5%, respectively. Among patients with no falls, 33.6% had KPS ≤ 80 compared to 59.6% with one-time fall and 60.7% with multiple falls (p < 0.001). Among IADL, 8.5% of patients with no falls were unable to do shopping compared with 14.7% in one-time fall and 18.8% in multiple fallers (p < 0.001). In ADL items, the percentage of patients who were limited a lot in walking outside was 10.7% in no falls, 20.2% in one-time fall, and 27.1% in multiple fallers groups (p < 0.001). Only 17.8% of patients with no falls were using canes while 27.7% of patients with one-time fall and 38.8% with multiple falls were using canes (p < 0.001). Falls are prevalent among older patients with cancer. Fall history and number of falls are associated with functional status.

Characteristics of Vitamin B12 Deficiency in Patients With Plasma Cell Disorders

BACKGROUND

Although increased rates of vitamin B12 deficiency have been reported in patients with plasma cell dyscrasias (PCDs), no mechanism has been identified. Excess free light chains (FLCs) could disrupt the renal proximal tubule receptors where B12 is reabsorbed. We sought to characterize the relationship between B12 deficiency and PCDs. We hypothesized that rates of B12 deficiency would be highest in patients with PCDs with high FLC burdens.

METHODS

We reviewed the electronic medical records of 501 patients who met inclusion criteria (diagnosed PCD with documented serum B12 and FLC levels) to obtain clinical data recorded prior to patients' lowest B12 levels.

RESULTS

Overall, 20.0% of patients had low vitamin B12. There was an expected negative correlation between estimated glomular filtration rate and FLC (r_s = -0.317; P < .001). However, low B12 levels were more prevalent in patients with preserved renal function (P = .047). Low B12 was associated with lower mean corpuscular volume (P = .037).

CONCLUSION

Higher FLC burden was associated with poor kidney function but not with low B12. Low B12 was seen more commonly in patients with preserved kidney function. Mean corpuscular volume was statistically but not clinically different between patients with low and normal B12 and, therefore, may not be a reliable indicator of B12 deficiency in PCDs. Prospective studies should compare B12 metabolites with FLC levels. Detection of B12 deficiency among patients with PCDs remains important to reduce neurologic dysfunction and cytopenias, sequelae common to B12 deficiency and PCDs.

Dose escalation of definitive radiation is not associated with improved survival for cervical esophageal cancer: a National Cancer Data Base (NCDB) analysis

For cervical esophageal cancer (CEC), National Comprehensive Cancer Network guidelines support RT to 50-50.4 Gy with chemotherapy but acknowledge higher doses may be appropriate. This study uses the National Cancer Database (NCDB) to characterize RT practices and identify if a dose-response relationship exists for overall survival (OS) for definitive treatment of CEC. We queried the NCDB for patients diagnosed with Stage I-III CEC from 2004 to 2013, and selected patients receiving definitive RT with doses between 50 and 74 Gy. Using multivariate logistic regression, the database was analyzed to determine factors associated with use of RT > 50.4 Gy. Patients were then stratified into three dose categories. Predictors of OS were analyzed with univariate and multivariate methods using the Kaplan-Meier curves, the log-rank test, and the Cox proportional hazards analysis. We stratified 789 patients with CEC who were treated with definitive radiation ± chemotherapy: 50-50.4 Gy ('standard'), >50.4 and <66 Gy ('medium'), and 66-74 Gy ('high'). Of these patients, 215 (27%) received standard doses, 375 (48%) received medium doses, and 199 (25%) received high doses. Patients with Medicaid insurance and those with Stage II disease were less likely (P < 0.05) to receive >50.4 Gy. Sex, histology, distance to treatment facility, and academic/community facility type were not significantly associated with receipt of >50.4 Gy. There was no association between dose and OS for the medium or high groups when using univariate analysis or analysis adjusted for demographic, facility, and clinical attributes. Stage III disease and the Charlson-Deyo scores of 1 or 2 were associated with higher mortality (P < 0.05), while female sex and use of chemotherapy were associated with lower mortality (P < 0.01). Nearly three-fourths of CEC patients in the United States are treated with RT > 50.4 Gy. Higher radiation doses were not associated with increased OS in CEC patients in the NCDB.

Impact of changing indications and increased utilization of fetal echocardiography on prenatal detection of congenital heart disease

BACKGROUND

Antenatal diagnosis of congenital heart defects (CHD) can impact outcomes in neonates with severe CHD. Obstetric screening guidelines and the indications for fetal echocardiography (FE) have evolved in an attempt to improve the early prenatal detection of CHD. Analyzing yield for specific indications will help clinicians better stratify at-risk pregnancies.

METHODS

Retrospective cohort study of all FE performed between 2000 and 2010 at a single tertiary care academic medical center in New York City. A total of 9878 FE met inclusion criteria for our study. In cases of multiple gestations (MG), each fetus was counted as a separate study.

RESULTS

The number of new diagnosis of fetal CHD by FEs increased 200%. There was a statistically significant increase in those referred for suspected CHD, increased nuchal translucency (NT), MG, and suboptimal imaging (P < .001). The indication of "suboptimal imaging" (SO) not only accounted for 5.23% of all referrals from 2000 to 2002, compared to 22.26% of all referrals from 2008 to 2010 (P < .0001), but also had the lowest yield for diagnoses of CHD (P < .02).

CONCLUSIONS

Over the past decade, there has been an increase in utilization of FE with a proportional increase in prenatally diagnosed CHD. For indications such as suspected CHD, NT and MG increases in referrals have led to a proportionate increase in fetal diagnosis of CHD. SO as an indication has the lowest yield of fetal diagnosis of CHD. Antenatal detection of CHD may be improved by a change in obstetric imaging protocols to ensure appropriate referrals.

Obesity and Outcomes in Patients with Metastatic Urothelial Carcinoma

Background: Obesity has been associated with worse outcomes in patients with clinically localized urothelial cancer. However, this impact has not been evaluated in metastatic disease.

Objective: To assess the impact of obesity on outcomes of patients with metastatic urothelial cancer.

Methods: Data from 537 patients were aggregated from eight phase II and phase III clinical trials investigating first-line cisplatin-based combination therapy in metastatic urothelial cancer. Chemotherapy regimen, adverse events, treatment response, and survival outcomes were compared across body mass index (BMI) and body surface area (BSA) categories.

Results: BMI was classified according to WHO criteria (<18.5 underweight, 18.5–24.99 normal weight, 25–29.99 overweight, >30 obese). BSA was classified as either below or greater than or equal to (average for this cohort (1.87 m² for males and 1.66 m² for females). There was no significant difference in number of chemotherapy cycles, adverse events, and response rate or survival outcomes (overall and progression-free) across BMI and BSA categories. There was no significant difference in adverse events across BMI categories, but the incidences of embolic events and renal failure were higher in patients with an average or higher BSA than those with a lower than average BSA (6.6% vs. 3.1% for renal failure p = 0.06; 5.9% vs. 2.7% for renal failure, p = 0.07). There was no significant difference in response rate or survival outcomes (overall and progression-free) amongst BMI and BSA categories.

Conclusions: Obese patients with metastatic urothelial cancer on cisplatin-based therapies have similar response rates, survival outcomes, and tolerability of cisplatin-based therapy to non-obese patients.

Increased hepatic progenitor cell response and ductular reaction in patients with severe recurrent HCV post-liver transplantation

OBJECTIVES

Post-liver transplant (LT) hepatitis C virus (HCV) patients may develop allograft cirrhosis and rarely fibrosing cholestatic hepatitis (FCH), while others have a stable course. Hepatic progenitor cells (HPC) may be implicated in liver injury and fibrogenesis through ductular reaction (DR). We studied HPC response and DR in three distinct post-LT patterns of HCV: stable recurrence, allograft cirrhosis, and FCH.

METHODS

We identified 52 patients with untreated recurrent HCV and longitudinal liver biopsies (20 stable/23 cirrhosis/9 FCH) and eight healthy controls. Archived liver biopsy specimens for three time points (LT; initial recurrence; and clinical outcome) were stained for cytokeratin-7. Manual HPC counts and DR quantification using image analysis were performed.

RESULTS

HCV counts and DR at LT did not differ across groups. At initial recurrence, HPC expansion occurred only in patients who developed cirrhosis, while prominent DR was present in those who developed FCH vs. stable and controls (p < 0.05). At outcome biopsies, HPC response and DR were increased in cirrhosis and FCH vs. stable and controls (p < 0.05). HPC response and DR did not differ in stable vs.

CONCLUSIONS

These findings suggest that an altered HPC response assessed by cytokeratin-7 stain after LT may predict severity of HCV recurrence.

Impact of obesity in patients with metastatic urothelial carcinoma

346

Background: Obesity has been associated with worse outcomes in patients with clinically localized urothelial cancer. However, the impact of obesity on outcomes of patients with metastatic disease has not previously been evaluated. Methods: Data from 537 patients were aggregated from eight phase II and phase III clinical trials investigating first-line cisplatin-based combination therapy in metastatic urothelial cancer. Chemotherapy regimen, adverse events, treatment response, and survival outcomes were compared across body mass index (BMI) and body surface area (BSA) categories. Results: BMI was classified according to WHO criteria (<18.5 underweight (4.1 % of patients), 18.5-24.99 normal weight (42.8%), 25-29.99 overweight (41.0%), >30 obese (12.1%)). BSA was classified as either below (56.8% of patients) or greater than or equal to (43.2%) the European average (1.91 m2 for males and 1.71 m2 for females). There was no significant difference in number of chemotherapy cycles across BMI and BSA categories. Patients’ treatment regimens significantly differed across BMI (p=0.02) and BSA (p<0.01) categories, with patients with higher BMI category and average or above BSA more likely to receive gemcitabine-cisplatin-based therapy rather than MVAC (methotrexate, vinblastine, doxorubicin, and cisplatin)-based or other therapy regimens. There was no significant difference in adverse events across BMI categories, but the incidence of embolic events was significantly higher in patients with an average or higher BSA (6.6%) than those with a lower than average BSA (2.7%) (p=0.03). There was no significant difference in response rate or survival outcomes (overall and progression-free) amongst BMI and BSA categories. Conclusions: Obese patients with metastatic urothelial cancer on cisplatin-based therapies have similar response rates and survival outcomes to non-obese patients. Toleration of cisplatin-based therapy is similar across BMI and BSA categories, with the exception of a higher incidence of embolic events in patients with an above average BSA.

Ten-year experience of more than 35,000 orofacial clefts in Africa

BACKGROUND

Surgical correction of orofacial clefts greatly mitigates negative outcomes. However, access to reconstructive surgery is limited in developing countries. The present study reviews epidemiological data from a single charitable organization, Smile Train, with a database of surgical cases from 33 African countries from 2001-2011.

METHODS

Demographic and clinical patient data were collected from questionnaires completed by the participating surgeons. These data were recorded in Excel, analyzed using SPSS and compared with previously reported data.

RESULTS

Questionnaires were completed for 36,384 patients by 389 African surgeons. The distribution of clefts was: 34.44% clefts of the lip (CL), 58.87% clefts of the lip and palate (CLP), and 6.69% clefts of the palate only (CP). The male to female ratio was 1.46:1, and the unilateral: bilateral ratio 2.93:1, with left-sided predominance 1.69:1. Associated anomalies were found in 4.18% of patients. The most frequent surgeries included primary lip/nose repairs, unilateral (68.36%) and bilateral (11.84%). There was seasonal variation in the frequency of oral cleft births with the highest in January and lowest by December. The average age at surgery was 9.34 years and increased in countries with lower gross domestic products. The average hospital stay was 4.5 days. The reported complication rate was 1.92%.

CONCLUSIONS

With the exception of cleft palates, results follow trends of worldwide epidemiologic reports of 25% CL, 50% CLP, and 25% CP, 2:1 unilateral:bilateral and left:right ratios, and male predominance. Fewer than expected patients, especially females, presented with isolated cleft palates, suggesting that limitations in economic resources and cultural aesthetics of the obvious lip deformity may outweigh functional concerns and access to treatment for females. A fewer than expected associated anomalies suggests either true ethnic variation, or that more severely-affected patients are not presenting for treatment. The epidemiology of orofacial clefting in Africa has been difficult to assess due to the diversity of the continent and the considerable variation among study designs. The large sample size of the data collected provides a basis for further study of the epidemiology of orofacial clefting in Africa.

Clinical trial awareness: Changes over time and sociodemographic disparities

BACKGROUND OR AIMS

Lack of clinical trial awareness is a known obstacle to clinical trial enrollment. We sought to define the prevalence of clinical trial awareness in the US population, determine characteristics associated with increased trial awareness, and explore potential disparities in trial awareness.

METHODS

We utilized data from the Health Information National Trends Survey from 2008 and 2012. Logistic regression was utilized to assess predictors of clinical trial awareness, particularly sociodemographic variables and information-seeking preferences. Trial awareness and information-seeking preferences were compared in patient subgroups and between the two time periods.

RESULTS

Clinical trial awareness increased from 68% to 74% between 2008 and 2012. In the 2012 dataset, higher education level (odds ratio: 3.52, 95% confidence interval: 2.16-5.74), higher yearly income category (odds ratio: 1.84, 95% confidence interval: 1.17-2.89), and Internet use (odds ratio: 2.13, 95% confidence interval: 1.52-3.00) were significantly associated with clinical trial awareness. Hispanic ethnicity (odds ratio: 0.41, 95% confidence interval: 0.25-0.68) was significantly associated with decreased awareness. Clinical trial awareness increased in African-American/Blacks (Δ10.6%) and Hispanics (Δ10.7%) between 2008 and 2012, as did Internet use in both subgroups (Δ14.2%, Δ18.1%, respectively).

CONCLUSION

Overall clinical trial awareness has increased between 2008 and 2012, although a large subset of the population still lacks general awareness of clinical trials. Racial and ethnic disparities in trial awareness exist, although disparities may be decreasing among the Black population. These findings may help target educational efforts and inform approaches to increasing trial awareness.

Early detection of recurrent disease by FDG-PET/CT leads to management changes in patients with squamous cell cancer of the head and neck

OBJECTIVE

The objective of this study was to compare the efficacy of surveillance high-resolution computed tomography (HRCT) and physical examination/endoscopy (PE/E) with the efficacy of fluorodeoxyglucose (FDG)-positron emission tomography (PET)/HRCT for the detection of relapse in head and neck squamous cell carcinoma (HNSCC) after primary treatment.

METHODS

This is a retrospective analysis of contemporaneously performed FDG-PET/HRCT, neck HRCT, and PE/E in 99 curatively treated patients with HNSCC during post-therapy surveillance to compare performance test characteristics in the detection of early recurrence or second primary cancer.

RESULTS

Relapse occurred in 19 of 99 patients (20%) during a median follow-up of 21 months (range: 9-52 months). Median time to first PET/HRCT was 3.5 months. The median time to radiological recurrence was 6 months (range: 2.3-32 months). FDG-PET/HRCT detected more disease recurrences or second primary cancers and did so earlier than HRCT or PE/E. The sensitivity, specificity, and positive and negative predictive values for detecting locoregional and distant recurrence or second primary cancer were 100%, 87.3%, 56.5%, and 100%, respectively, for PET/HRCT versus 61.5%, 94.9%, 66.7%, and 93.8%, respectively, for HRCT versus 23.1%, 98.7%, 75%, and 88.6%, respectively, for PE/E. In 19 patients with true positive PET/HRCT findings, a significant change in the management of disease occurred, prompting either salvage or systemic therapy. Of the 14 curatively treated patients, 11 were alive with without disease at a median follow-up of 31.5 months.

CONCLUSION

FDG-PET/HRCT has a high sensitivity in the early detection of relapse or second primary cancer in patients with HNSCC, with significant management implications. Given improvements in therapy and changes in HNSCC biology, appropriate modifications in current post-therapy surveillance may be required to determine effective salvage or definitive therapies.

Interim FDG PET/CT to predict progression-free survival (PFS) better than clinical and baseline metabolic measurements in Hodgkin lymphoma (cHL)

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Background: Previous studies in cHL have demonstrated that conventional methods to risk stratify patients into various prognostic groups and predict PFS may not be sufficient to individualize therapy. Metabolic parameters using FDG-PET may be helpful for developing a prognostic algorithm and predict PFS. Objectives: To determine the best predictor of PFS among various variables of tm metabolic measurements at baseline and at interim PET/CT compared to conventional methods in cHL patients. Methods: Retrospective evaluation of prospectively acquired data in 58 cHL pts, all stages [IIB-IV:41%, >IPS-3:24%, unfavorable (UF):44%]. Eligibility: PET/CT prior to and after 1 cycle (PET1) ABVD therapy, imaging at 60min+15min, follow-up>24 mo. Baseline PET parameters including metabolic tumor volume (MTV), total lesion glycolysis (TLG), SUVmax, and SULpeak were determined using gradient method (PETVCAR2, GE Healthcare, WI). Data were also evaluated at PET1 for %ΔMTV, %ΔSUVmax, %ΔTLG, PERCIST criteria and visually with Deauville 5-PS. Variables were correlated with PFS. Results: Median follow-up: 32.2 mo. Of 58 pts 14 relapsed (median PFS:6.5 mo). Results for PFS are displayed in the Table. No baseline conventional (stage, IPS, UF vs F) or PET variable was associated with PFS. The best predictor of PFS was Deauville 5-PS at PET1. PERCIST and %ΔTLG using gradient method trended toward significance. Conclusions: Deauville 5-PS best predicts PFS at PET1 in cHL. Neither baseline PET nor conventional prognostic factors correlated with PFS in this group of cHL pts. Risk-stratification of cHL using tumor metabolic volumetry and PERCIST criteria may require a larger sample size and further assessment of various methodologies. [Table: see text]

Effect of early detection of recurrent disease by FDG PET/CT on management of patients with squamous cell cancer of the head and neck (HNSCC)

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Background: Despite the increasing cure rates a substantial fraction of HNSCC patients (pts) will present with locoregional and/or distant relapse within 3 years of definitive therapy. The prognosis of HNSCC pts after failure of first-line therapy has been poor but recent changes in the biology of HNSCC, advances in surgical techniques and radiotherapy; and new drugs may lead to improved salvage therapy. Notably, the success of these developments are implicitly dependent on early diagnosis disease. Our objective was to compare the efficacy of surveillance FDG-PET/CT to that of high resolution CT (HRCT) and physical exam (PE/E) for detection of early relapse in HNSCC after completion of primary treatment. Methods: A retrospective analysis of FDG-PET/CT, neck HRCT and PE/E was performed in 99 curatively treated HNSCC pts during post-therapy surveillance (PTS) to compare the performance characteristics of the tests in the detection of early recurrence or metachronous cancer. Results: A total of 19/99 (20%) pts had recurrence during a median follow-up of 21mo (range:9-52). Median time to first PET/CT was 3.5mo. The median time to radiological recurrence was 6 mo (range:2.3-32). PET/CT detected more disease recurrences or second primaries and did so earlier than HRCT and PE/E. Sensitivity, specificity, PPVand NPV for detecting locoregional and distant recurrence or metachronous cancer : 100%, 87.3%, 56.5% and 100% for PET/CT vs. 61.5%, 94.9%, 66.7% and 93.8% for HRCT vs. 23.1%, 98.7%, 75% and 88.6% for PE/E. In all 19 pts with a true positive PET/CT there was a significant management change prompting either salvage or definitive surgery or initiation of systemic therapy. Of the 14 recurrent pts treated with curative intent, 11 were alive with no evidence of disease at a median follow up of 31.5 mo. Conclusions: FDG-PET/CT has a high sensitivity in the early detection of relapse or second primary cancer in HNSCC, associated with significant management implications. Given improvements in therapy and changes in HNSSC biology, appropriate modifications in the current recommended algorithms of the NCCN for PTS may be required to engage effective salvage or definitive therapies.

Normal Values of Left Atrial Volume in Pediatric Age Group Using a Validated Allometric Model

Background—

Left atrial volume (LAV) increase is an indicator of diastolic dysfunction and a surrogate marker of significant left to right shunts. Normalization of LAV is currently performed by indexing to body surface area 1 (BSA 1 ). The indexed LAV thus derived does not account for the nonlinear relationship of physiologic variables to BSA and has not been tested for independence to body size. Our objective was to identify a valid allometric model for indexing LAV and use it to develop Z-scores in children.

Methods and Results—

LAV was measured in 300 normal subjects by echocardiography using the biplane area length method. LAV/BSA 1 had a residual relationship to BSA (r=0.52, P <0.0001). The allometric exponent (AE) derived for the entire cohort (1.27) using the least squares regression analysis also failed to eliminate the residual relationship to BSA (r=−0.15, P =0.01). Dividing the cohort in two groups with a BSA cut-off of 1 m 2 provided the best-fit allometric model. The AE for each group was 1.48 and 1.08 for BSA≤1 m 2 and >1 m 2 , respectively, and was validated against an independent sample. The mean indexed LAV±SD for BSA≤1 m 2 and >1 m 2 is 31.5±5.5 mL and 26.0±4.2 mL, respectively, and was used to derive Z-scores.

Conclusions—

This study demonstrates the fallacy of using “per-BSA 1 standards” for normalization of LAV in pediatrics. LAV/BSA 1.48 for children with BSA≤1 m 2 and LAV/BSA 1.08 for those with BSA>1 m 2 is accurate and can be used to derive Z-scores.

Measures of obesity associated with asthma diagnosis in ethnic minority children

Objective. The study objective was to examine relationships between different body size measurements and asthma in ethnic minority children. Methods. We used data from a community-based study of 505 children aged 6-to-8 years old to study the association of percent body fat, fat distribution, and BMI percentile with asthma diagnosis. Poisson regression models were used to compute prevalence ratios (PRs) for sex-specific quintiles of the body fat measures on the main outcome of asthma. Results. When comparing the highest quintile of each body fat measure to the combined lowest two quintiles, higher body mass index percentile, percent body fat, and waist circumference all were associated with a higher likelihood of physician-diagnosed asthma (PR = 1.63 (95% CI 1.12-2.39), 1.50 (95% CI 1.02-2.21), and 1.56 (95% CI 1.04-2.34), resp.). Conclusions. This study found a significant association between increased body size and asthma diagnosis, regardless of the measurement examined.

Development of and recovery from difficulty with activities of daily living: an analysis of national data

BACKGROUND

National-level data are needed on predictors of mild physical impairment among older adults to assist policy makers with resource allocation.

METHOD

We analyzed data on adults above age 64 from the Medicare Current Beneficiary Survey (MCBS) with no activity of daily living (ADL) difficulties at baseline ( n = 14,226). Five ADLs were measured annually and recovery was defined as regaining complete ADL function at follow-up.

RESULTS

The strongest correlates of ADL difficulty were use of antipsychotic medications (adjusted odds ratio [AOR] = 1.93, 95% confidence interval [CI] = 1.44 to 2.58), instrumental ADL difficulty (AOR = 1.90, 95% CI = 1.74 to 2.07), and fair-poor general health (AOR = 1.59, 95% CI = 1.42 to 1.78). Only the number of incident ADL difficulties was associated with recovery (AOR = 0.02, 95% CI = 0.01 to 0.02).

CONCLUSION

Identifying factors associated with development of mild physical impairment could help direct patients toward preventive care programs to preempt decline in physical function.

Remifentanil for endotracheal intubation in neonates: a randomised controlled trial

OBJECTIVE

To evaluate the efficacy and safety of remifentanil as a premedication in neonates undergoing elective endotracheal intubation.

DESIGN

A double-blind randomised controlled trial.

SETTING

Tertiary care neonatal intensive care unit.

PATIENTS

Haemodynamically stable term and preterm neonates requiring elective endotracheal intubation.

INTERVENTIONS

Infants in the intervention arm received remifentanil (3 microg/kg) and normal saline placebo. The control group received fentanyl (2 microg/kg) and succinylcholine (2 mg/kg). Both groups also received atropine (20 microg/kg) as part of the premedication regime.

MAIN OUTCOME MEASURES

The primary outcome was time to successful intubation. Secondary outcomes included time to return of spontaneous respirations, oxygen saturation, heart rate and blood pressure changes during the procedure, adverse events and a survey of intubation conditions.

RESULTS

A total of 15 infants were randomised to each group. Baseline characteristics were similar in both groups. The median time to successful intubation was not statistically different (247 s in the remifentanil group vs 156 s in the fentanyl group, p=0.88). The intubation conditions were rated more favourably with fentanyl by the intubators. Although not statistically significant, chest wall rigidity was observed more commonly with remifentanil.

CONCLUSIONS

Although remifentanil is comparable to fentanyl and succinylcholine in attenuating adverse physiologic responses during neonatal intubation, muscle rigidity is a concern at doses of 3 microg/kg. Further trials are required to evaluate ideal dosing regimens and combinations of agents for use with remifentanil in neonates.

Evaluation of a Telehealth Clinic as a Means to Facilitate Dermatologic Consultation: Pilot Project to Assess the Efficiency and Experience of Teledermatology Used in a Primary Care Network

Background:

Primary care offices spend considerable time coordinating the specialist referral process. Patients experience long wait times for consultation and intervention.

Objective:

To determine if telehealth combined with interdisciplinary team–based care can reduce wait times for dermatologic consultation while making the consultation process easier for physicians.

Methods:

Retrospective chart reviews as well as patient, referring physician, nonreferring physician, clinic physician, nurse, and teledermatologist interviews were used to evaluate the clinic. A comparative immersion approach generated themes from field notes. Wait times, appointment times, and encounter durations were measured.

Results:

Twenty-eight patients were seen (23 had previous specialist referral experience) within 1 week of referral compared to a wait period of 104 days for conventional referral. Patients requiring intervention were treated within 1 week of their initial appointment. Referring practitioners were concerned that they would lose control of patients' care. An easier referral process and faster intakes met physician expectations.

Conclusions:

Teledermatology improves the timeliness of appointments. Patients forgo face-to-face appointments if alternatives are available sooner. Physicians are concerned about their own liability if dermatologists do not assess the patient in person but will refer through teledermatology when patients are seen faster and they remain in control of the care process.

Primary care physicians' experiences with electronic medical records: implementation experience in community, urban, hospital, and academic family medicine

OBJECTIVE

To understand how remuneration and care setting affect the implementation of electronic medical records (EMRs).

DESIGN

Semistructured interviews were used to illicit descriptions from community-based family physicians (paid on a fee-for-service basis) and from urban, hospital, and academic family physicians (remunerated via alternative payment models or sessional pay for activities pertaining to EMR implementation).

SETTING

Small suburban community and large urban-, hospital-, and academic-based family medicine clinics in Alberta. All participants were supported by a jurisdictional EMR certification funding mechanism.

PARTICIPANTS

Physicians who practised in 1 or a combination of the above settings and had experience implementing and using EMRs.

METHODS

Purposive and maximum variation sampling was used to obtain descriptive data from key informants through individually conducted semistructured interviews. The interview guide, which was developed from key findings of our previous literature review, was used in a previous study of community-based family physicians on this same topic. Field notes were analyzed to generate themes through a comparative immersion approach.

MAIN FINDINGS

Physicians in urban, hospital, and academic settings leverage professional working relationships to investigate EMRs, a resource not available to community physicians. Physicians in urban, hospital, and academic settings work in larger interdisciplinary teams with a greater need for interdisciplinary care coordination, EMR training, and technical support. These practices were able to support the cost of project management or technical support resources. These physicians followed a planned system rollout approach compared with community physicians who installed their systems quickly and required users to transition to the new system immediately. Electronic medical records did not increase, or decrease, patient throughput. Physicians developed ways of including patients in the note-taking process.

CONCLUSION

We studied physicians' procurement approaches under various payment models. Our findings do not suggest that one remuneration approach supports EMR adoption any more than another. Rather, this study suggests that stronger physician professional networks used in information gathering, more complete training, and in-house technical support might be more influential than remuneration in facilitating the EMR adoption experience.

Primary Care Physicians' Experience with Electronic Medical Records: Barriers to Implementation in a Fee-for-Service Environment

Our aging population has exacerbated strong and divergent trends between health human resource supply and demand. One way to mitigate future inequities is through the adoption of health information technology (HIT). Our previous research showed a number of risks and mitigating factors which affected HIT implementation success. We confirmed these findings through semistructured interviews with nine Alberta clinics. Sociotechnical factors significantly affected physicians' implementation success. Physicians reported that the time constraints limited their willingness to investigate, procure, and implement an EMR. The combination of antiquated exam room design, complex HIT user interfaces, insufficient physician computer skills, and the urgency in patient encounters precipitated by a fee-for-service remuneration model and long waitlists compromised the quantity, if not the quality, of the information exchange. Alternative remuneration and access to services plans might be considered to drive prudent behavior during physician office system implementation.

Adopting electronic medical records in primary care: lessons learned from health information systems implementation experience in seven countries

The adoption of health information systems is seen world wide as one method to mitigate the widening health care demand and supply gap. The purpose of this review was to identify the current state of knowledge about health information systems adoption in primary care. The goal was to understand factors and influencers affecting implementation outcomes from previous health information systems implementations experiences. A comprehensive systematic literature review of peer reviewed and grey literature was undertaken to identify the current state of knowledge regarding the implementation of health information systems. A total of 6 databases, 27 journal websites, 20 websites from grey sources, 9 websites from medical colleges and professional associations as well as 22 government/commission websites were searched. The searches returned almost 3700 article titles. Eighty-six articles met our inclusion and exclusion criteria. Articles show that systems' graphical user interface design quality, feature functionality, project management, procurement and users' previous experience affect implementation outcomes. Implementers had concerns about factors such as privacy, patient safety, provider/patient relations, staff anxiety, time factors, quality of care, finances, efficiency, and liability. The review showed that implementers can insulate the project from such concerns by establishing strong leadership, using project management techniques, establishing standards and training their staff to ensure such risks do not compromise implementation success. The review revealed the concept of socio-technical factors, or "fit" factors, that complicate health information systems deployment. The socio-technical perspective considers how the technical features of a health information system interact with the social features of a health care work environment. The review showed that quality of care, patient safety and provider/patient relations were not, positively or negatively, affected by systems implementation. The fact that no articles were found reviewing the benefits or drawbacks of health information systems accruing to patients should be concern to adopters, payers and jurisdictions. No studies were found that compared how provider-patient interactions in interviews are effected when providers used electronic health information systems as opposed to the paper equivalent. Very little information was available about privacy and liability.

Subspecialty evaluation of chronically ill hospitalized patients with suspected immune defects

BACKGROUND

The diagnosis of primary immunodeficiency is suggested by recurrent or unusual infections and inflammatory and autoimmune conditions. Because the diversity of immune defects and clinical presentations poses a diagnostic challenge in hospital populations, a computer algorithm was devised to help identify patients.

OBJECTIVE

To assess use of pertinent subspecialty clinics by patients with clinical features of immunodeficiency.

METHODS

Using a validated algorithm based on International Classification of Diseases, Ninth Revision (ICD-9), codes applied to The Mount Sinai Hospital billing records, we investigated hospitalized patients, 60 years or younger, who had been diagnosed as having conditions associated with immunodeficiency, excluding those with confounding medical conditions. Immunodeficiency-related disease codes were given a weighted score based on relative severity and expressed as a sum for admissions between January 1, 1999, and December 31, 2003. Demographic features, subspecialty care, and clinic attendance were determined.

RESULTS

The 296 computer-identified patients with illnesses characteristic of immunodeficiency were 35.8% Hispanic, 27.0% African American, and 21.6% white; their median age was 13.3 years. Patients were hospitalized 1,261 times, or a median of 4.2 times each (range, 1-42 times), and had 5,700 diagnoses. Of the patients, 75.0% received primary care at The Mount Sinai Hospital. Although the most common diagnosis was pneumonia (n = 243), 45% of patients never received allergy/immunology or pulmonary subspecialty care.

CONCLUSION

Despite receiving primary medical care at the same hospital, many frequently hospitalized subjects with features of immunodeficiency do not receive medical care in appropriate subspecialty clinics.

Recognizing primary immune deficiency in clinical practice

Primary immunodeficiency results in recurrent infections, organ dysfunction, and autoimmunity. We studied 237 patients referred for suspicion of immunodeficiency, using a scoring system based on clinical information. The 113 patients with immunodeficiency had higher scores and more episodes of chronic illnesses and were more likely to have neutropenia, lymphopenia, or splenomegaly.

Identifying undiagnosed primary immunodeficiency diseases in minority subjects by using computer sorting of diagnosis codes

BACKGROUND

Primary immunodeficiency diseases occur in all populations, but these diagnoses are rarely made in minority subjects in the United States.

OBJECTIVE

We sought to develop and validate a method to identify patients without diagnoses but with immunodeficiency in an urban hospital with a substantial minority patient population.

METHODS

We developed a scoring algorithm on the basis of International Classification of Disease, Ninth Revision (ICD-9) codes to identify all hospitalized patients age 60 years or less who had been given a diagnosis of 2 or more of 174 ICD-9-coded complications associated with immunodeficiency. Codes were weighted for severity and expressed as a sum for all admissions between October 1, 1995, and December 31, 2002. Patients with, for example, cancer or HIV or those after transplantation or major surgery were excluded. Demographic features of subjects with aggregated ICD-9 codes suggestive of immunodeficiency were compared with those of other inpatients; 59 computer-selected subjects were then tested for immune defects.

RESULTS

The computer-identified group contained 533 patients (0.4% of all inpatients), who had been hospitalized 2683 times. The median age was 6.6 years. Sixty-five percent were African American or Hispanic, and 61% were insured by Medicaid, which is significantly more than other inpatients younger than 60 years of age (median age, 32.6 years; 37% minority, 27% insured by Medicaid; P<.0001). Primary immunodeficiency was found in 17 (29%) of the 59 subjects tested. Thirteen other patients had secondary immune defects, and 86% of immunodeficient subjects were Hispanic or African American.

CONCLUSIONS

An ICD-9-based scoring algorithm identifies patients demographically different from other hospitalized subjects who have multiple illnesses suggestive of immunodeficiency. This group contains undiagnosed minority patients with immunodeficiency.

Study of smoking behavior in asbestos workers

BACKGROUND

Asbestos exposure and concomitant cigarette smoking markedly increase the risk of lung cancer and contribute to the prevalence and severity of pulmonary interstitial fibrosis.

METHODS

A cross-sectional survey of 214 asbestos workers was initiated to determine the prevalence of smoking and their readiness to quit smoking using the stage of change theory.

RESULTS

The study was comprised of 61 never smokers (28.5%), 118 ex-smokers (55.1%), and 35 current smokers (16.4%). Reasons for smoking cessation in ex-smokers included perception of ill-health (51%) and knowledge of smoking-asbestos hazards (3.4%). Stage of change of current smokers revealed: precontemplation (26.5%), contemplation (35%), preparation (29%), and action (8.8%). Current smokers had the highest prevalence of small airway obstruction on spirometry.

CONCLUSIONS

A detailed smoking history during medical surveillance activities will enable the occupational physician to identify asbestos workers who have difficulty quitting and to develop a system in which such individuals can be referred to comprehensive smoking cessation programs.

Impact of a joint labor-management ergonomics program on upper extremity musculoskeletal symptoms among garment workers

This study evaluated the effect of an ergonomics intervention program on the prevalence and intensity of symptoms of upper extremity work-related musculoskeletal disorders among 36 garment workers performing an operation called spooling. Adjustable chairs were introduced and workers were trained in their use. Symptom surveys were administered prior to and 6 months after introduction of adjustable chairs. Quantitative pre- and post-intervention measurement of joint position was performed utilizing videotapes among a subgroup of nineteen. Eighty nine percent of the cohort reported pain in either the neck or at least one upper extremity anatomic site prior to the adjustable chair intervention. Among subjects reporting pain at baseline, there were significantly decreased pain levels in 10 of 11 anatomic sites after the intervention. Among all subjects, the proportion reporting pain decreased for each anatomic site following the intervention, with statistically significant decreases in 3 sites. However, there were only modest declines in awkward posture among the videotaped subgroup. This study suggests that introduction of an ergonomics program focused on education and introduction of an adjustable chair may diminish musculoskeletal symptomatology in apparel manufacturing workers.

A randomized, double masked, controlled trial of botulinum toxin type A in essential hand tremor

OBJECTIVE

To evaluate the safety and efficacy of botulinum toxin type A injection in essential tremor of the hand.

BACKGROUND

Botulinum toxin type A is an effective treatment for dystonia, spasticity, and other movement disorders and has been found to be useful in open-label studies and one double-masked study of essential hand tremor.

METHODS

One hundred thirty-three patients with essential tremor were randomized to low-dose (50 U) or high-dose (100 U) botulinum toxin type A (Botox) or vehicle placebo treatment. Injections were made into the wrist flexors and extensors. Patients were followed for 16 weeks. The effect of treatment was assessed by clinical rating scales, measures of motor tasks and functional disability, and global assessment of treatment. Hand strength was evaluated by clinical rating and by a dynamometer.

RESULTS

Both doses of botulinum toxin type A significantly reduced postural tremor on the clinical rating scales after 4 to 16 weeks. However, kinetic tremor was significantly reduced only at the 6-week examination. Measures of motor tasks and functional disability were not consistently improved with botulinum toxin type A treatment. Grip strength was reduced for the low- and high-dose botulinum toxin type A groups as compared with the placebo group. Adverse reactions consisted mainly of dose-dependent hand weakness.

CONCLUSION

Botulinum toxin type A injections for essential tremor of the hands resulted in significant improvement of postural, but not kinetic, hand tremors and resulted in limited functional efficacy. Hand weakness is a dose-dependent significant side effect of treatment at the doses used in this study.

Socioeconomic factors and asthma hospitalization rates in New York City

Asthma morbidity and mortality are not distributed homogeneously among populations. To assess the relationship between asthma hospitalization rates and socioeconomic factors, we conducted an ecologic analysis using small geographical areas defined by postal zip code in New York City. Asthma hospitalization rates correlated with low median family income, percentage of minorities in the population, and percentage of children under the age of 18. Lack of access to preventive health care, poor housing conditions, environmental exposures, and genetic susceptibility may contribute to high incidence of asthma in some neighborhoods. This report supports the role of socioeconomic factors in asthma and serves to provide data for regulatory and health agencies to concentrate their efforts on neighborhoods most in need.

Action research applied to a preceptorship program

In this article the authors describe the development of a framework designed to discuss expectations between preceptors, orientees, nursing unit managers and clinical nurse educators. Action research theory provided the framework for this process. Preceptors found the process of articulating expectations helpful, relevant, and meaningful to their practice.

Risk factors for serious injury during falls by older persons in the community

BACKGROUND

Serious fall injury represents a little studied, yet common and potentially preventable, cause of morbidity and mortality among older persons. We determined the frequency of, and risk factors for, experiencing serious fall injury events among older persons in the community.

SUBJECTS

A representative sample of 1103 community-living persons aged 72 years and older underwent comprehensive baseline and 1-year evaluations.

MAIN OUTCOME MEASURES

During a median 31 months of follow-up, fall data were obtained using fall calendars. Injury data were obtained from telephone interviews and from surveillance of emergency room and hospital records.

RESULTS

At least one fall was experienced by 546 (49%) participants. A total of 123 participants, representing 23% of fallers and 12% of the cohort, experienced 183 serious fall injury events. The factors independently associated with experiencing a serious injury during a fall included cognitive impairment (adjusted odds ratios 2.2; 95% confidence interval 1.5, 3.2); presence of at least two chronic conditions (2.0; 1.4, 2.9); balance and gait impairment (1.8; 1.3, 2.7); and low body mass index (1.8; 1.2, 2.5). In a separate analysis, including only subjects who fell, female gender (1.8; 1.1, 2.9) as well as most of the above factors were associated with experiencing a fall injury.

CONCLUSIONS

Several readily identifiable factors appeared to distinguish the subgroup of older fallers at risk for suffering a serious fall injury. These factors should help guide who and what to target in prevention efforts.