Diatoms in maggots; a potential tool for drowning diagnosis - A preliminary study

Advanced putrefaction causes extensive loss of soft tissue, rendering it difficult to use the diatom test as a reliable diagnostic tool for drowning investigations. A positive diatom test in carrion insect larvae may provide significant assistance in overcoming the challenge of decomposition. The studies determined the utility of diatom test in carrion larvae on severely decomposed bodies. A modified acid digestion method involving nitric acid, K2Cr2O7 and HCl, was used to digest the blowfly larvae feeding on piglet carrion previously drowned in freshwater and sea water, respectively. Extracted diatom frustules were analysed and characterised using light microscopy coupled to a digital camera. Diatoms recovered from maggots on sea-drowned piglets were similar to diatoms from sea water (drowning medium). Centric diatoms recovered in maggots were higher (200 ± 60 diatoms/ mL) than pennate diatoms (80 ± 20 diatoms/mL). Isolated diatoms common to both maggots and water samples included Coscinodiscus sp. and Navicular spp. Albeit, there were no diatoms recovered from maggots on freshwater-drowned piglets. The findings of this study suggest that the diatom test is still a reliable diagnostic tool to determine if drowning was involved in the death of a fully decomposed body. This is the first study that isolated diatoms from maggots feeding on drowned bodies. It serves as the basis for further research into the utility of maggots for drowning investigations.

Equity and Performance Improvement: A Novel Toolkit That Makes Using an Equity Lens the Default

Performance improvement methodologies do not currently include any structures that encourage analysis of how bias, inequity, or social determinants of health (SDOH) contribute to outcomes. The Montefiore Center for Performance Improvement developed a novel quality improvement (QI) toolkit that ingrains issues of diversity, equity, and inclusion (DEI) and SDOH into the Institute for Healthcare Improvement's tools. The toolkit prompts QI teams to evaluate DEI and SDOH at each step of the journey, including an updated charter and stratified baseline tool, a new fishbone diagram for the discovery phase with a tail to include DEI and SDOH, and additions in the Study and Act sessions of the Plan-Do-Study-Act worksheet to address these issues. After development and dissemination of this toolkit, the authors conducted a pre-post analysis of projects conducted by QI fellows in their institution. Prior to introducing the new toolkit, 22.9% of projects from 2016 to 2021 incorporated DEI/SDOH into any stage of the QI process. After implementing the amended tools, this increased to 88.9% in the 2022 fellowship. These results show that this simple approach can hardwire consideration of DEI and SDOH into improvement projects.

A systematic review of the measurement properties of aspects of psychological capacity in older adults

OBJECTIVE

to examine the measurement properties of instruments that have been used to measure aspects of psychological capacity in adults aged 60 years and over.

METHODS

the databases PsycINFO, MEDLINE, EMCARE and Scopus from 2010 were searched using search terms related to psychological capacity, older persons and measurement properties. Both data extraction and risk-of-bias assessment were conducted using the COSMIN (COnsensus-based Standards for the selection of health Measurement INstruments) criteria using Covidence software.

RESULTS

the full text of 326 articles were reviewed and a total of 30 studies were included, plus two further articles identified from reference lists (n = 32). No single instrument measuring psychological capacity was identified. Twenty (n = 20) instruments were identified that measure seven constructs of psychological capacity: Resilience; Sense of coherence; Hope; Mindfulness; Optimism; Attachment to life; Emotional regulation.

CONCLUSIONS

this systematic review identified potential measures of psychological capacity in older adults. The review will inform further work to develop a single comprehensive measure of psychological capacity in older adults.

Family Support, Perceived Physical Activeness and Chronic Non-Communicable Diseases as Determinants of Formal Healthcare Utilization Among Older Adults with Low Income and Health Insurance Subscription in Ghana

Evidence suggests that enrollment in a health insurance scheme is associated with higher levels of formal healthcare utilization among older adults, especially those with low income in sub-Saharan Africa (SSA), including Ghana. This study examines the prevalence of formal healthcare utilization and associated factors among older adults with low income and health insurance subscription enrolled in a social intervention program (known as the Livelihood Empowerment Against Poverty [LEAP] program) in Ghana. Cross-sectional data were obtained from an Aging, Health, Lifestyle and Health Services Survey conducted in 2018 among 200 older adults aged 65 years and above enrolled in the LEAP program. The results showed that almost 9 in 10 (87%) older adults utilized formal healthcare services for their health problems. Older adults who received family support, rated themselves to be physically active and had non-communicable diseases (NCDs) were more significantly likely to utilise formal health care services than their counter parts. We recommend that health policies and programs for older adults with low income and health insurance subscription under the LEAP program should consider the roles of family support, physical activeness and NCDs in influencing their use of formal healthcare services.

System, institutional, and client-level factors associated with formal healthcare utilisation among older adults with low income under a social protection scheme in Ghana

BACKGROUND

In sub-Saharan African context, effect of system, institutional and client-level factors on formal healthcare utilisation among older adults with low income, especially those under a social protection scheme (called Livelihood Empowerment against Poverty [LEAP] programme) is least explored in the literature. However, an adequate understanding of how these factors contribute to formal healthcare utilisation among older adults who are classified as poor (in terms of low income) is important to inform health policy decisions. The aim of this study, therefore, was to examine the contributions of system, institutional and client-level factors in formal healthcare utilisation among older adults with low income under the LEAP programme in Ghana.

METHODS

Data associated with this study were obtained from an Ageing, Health, Lifestyle and Health Services survey conducted between 1 and 20 June 2018 (N = 200) in the Atwima Nwabiagya Municipal and Atwima Nwabiagya North District of Ghana. Multivariable logistic regressions were used to determine system, institutional and client-level factors associated with formal healthcare utilisation among older adults with low income under the LEAP programme in Ghana. The significance of the test was set at a probability value of 0.05 or below.

RESULTS

The study revealed that participants who relied on the LEAP programme and/or health insurance subscription to cater for their healthcare expenses (AOR: 11.934, CI: 1.151-123.777), those whose family/caregivers decided on when and where to use formal healthcare (AOR:12.409; CI: 2.198-70.076) and those who did not encounter communication problem with healthcare providers (AOR: 1.358; CI: 1.074-3.737) were significantly more likely to utilise formal healthcare services compared with their counterparts. The study further found that participants who perceived the attitude of healthcare providers as poor (AOR: 0.889; CI: 0.24-0.931) and those who spent 20-40 minutes at the healthcare facility were significantly less likely to utilise formal healthcare services compared with their counterparts (AOR: 0.070; CI: 0.006-0.195).

CONCLUSION

Our findings suggest that reducing waiting time at healthcare facilities, improving social protection and/or health insurance schemes, improving patient-doctor communication and promoting attitudinal change programmes (such as orientations and supportive supervision) for healthcare providers may help to facilitate the use of needed formal healthcare services by older adults with low income in Ghana.

The Relationship between Chronic Non-Communicable Diseases of Fish Farm Household Members and Production Efficiency: The Case of Ghana

Prior studies explored the production and technical efficiency of fish farms and farmers from the perspectives of factors such as credit access and cooperative membership. We focused on the chronic non-communicable diseases (NCDs) of household members and their quantitative impacts on fish farm production efficiency, based on data of earthen pond fish farms from two regions (Bono East and Ashanti) in Ghana. A data envelopment analysis (DEA) and the IV Tobit technique were employed for the study's analysis. From the study's observations, we draw the following conclusions. We found that the NCDs of household members indeed reduce farm production efficiency, and the heterogeneous impact of the NCDs of female members on farm production efficiency was more prominent than that of male members. Insights from this study suggest that the national government should provide farmers with the necessary medical care through the provision of subsidized health insurance, which can facilitate access to healthcare services. Moreover, NGOs and governments should encourage health literacy, i.e., organizing programs aimed at educating farmers on NCDs and their impact on agriculture.

Understanding Unmet Care Needs of Rural Older Adults with Chronic Health Conditions: A Qualitative Study

BACKGROUND

Rural populations experience poorer access to the necessary health services for chronic health conditions. Although studies of rural healthcare access continue to expand, most are based on quantitative data, yet normative views and lived experiences of rural adults might offer a better understanding of healthcare access and their specific unmet needs. This qualitative study sought the views of both rural-centric older people and healthcare professionals to understand health needs, barriers, and enablers of accessing health services, with a focus on chronic health condition(s).

METHODS

Between April and July 2022, separate in-depth interviews were conducted with 20 older people (≥60 years) in a rural South Australian community. Additionally, focus group interviews were conducted with 15 healthcare professionals involved in providing health services to older adults. Transcripts were coded using the NVivo software and data were thematically analysed.

RESULTS

Participants described a range of unmet care needs including chronic disease management, specialist care, psychological distress, and the need for formal care services. Four barriers to meeting care needs were identified: Workforce shortages, a lack of continuity of care, self-transportation, and long waiting times for appointments. Self-efficacy, social support, and positive provider attitudes emerged as crucial enabling factors of service use among rural ageing populations.

DISCUSSION

Older adults confront four broad ranges of unmet needs: Chronic disease management care, specialist care, psychological care, and formal care. There are potential facilitators, such as self-efficacy, provider positive attitudes, and social support, that could be leveraged to improve healthcare services access for older adults.

An investigation on the role of electric vehicles in alleviating environmental pollution: evidence from five leading economies

The relationship between battery electric vehicles (BEV) and carbon dioxide emission (CO₂) has significant environmental outcomes. Notwithstanding, battery electric vehicles have not been extensively explored through econometric approach. For countries to meet their net zero targets, it is crucial to consider the role of battery electric vehicles, renewable energy consumption, and CO₂. As a result, it is critical to scrutinize a variety of variables that contribute to a sustainable future. This study therefore examines the dynamic correlation between BEV, gross domestic product (GDP), urbanization (URB), renewable energy consumption (REC), population (POP), and CO₂ in five leading countries (the United States of America (USA), China, France, Germany, and Norway) using panel data from 2010 to 2020. The study adopted the Westerlund cointegration method to ascertain the long-term nexus among the series. The cross-sectionally augmented autoregressive distributed lag CS-ARDL technique is adopted to evaluate the variables long-run elasticity. The study applied the common correlated effect mean group (CCEMG) and augmented mean group (AMG) approach to ascertain the robustness of the long-run relationships among the variables. Dumitrescu and Hurlin's panel causality analysis determines the extent of the significant causality linkage. The results demonstrate that increased economic growth, urbanization, and population growth accelerate carbon emissions and environmental depletion. However, BEVs were found to be more energy efficient and the adoption of renewable energy through the manufacturing and battery production process would reduce CO₂ emission especially in China and the USA. Finally, the research proposed several policy implications for policy and decision-makers in the five leading countries for combating climate change and increasing productivity in the electric vehicle market and renewable energy consumption.

The effects of simmelian ties on innovation of low-carbon technology: a study of top managers' environmental awareness and stakeholder pressure in China

Low-carbon technology innovation (LTI) engenders environmental protection and socioeconomic development. Hence, low-carbon innovation of enterprises becomes a crucial policy arena for national development and climate mitigation strategy. LTI is now associated with enhanced reputation and competitive edge of enterprises. We constructed a framework to empirically explore the impact of simmelian ties (ST) on LTI, testing the moderating effect of stakeholder pressure in this relationship. We used a sample of 385 employees from industrial enterprises in China through a structured questionnaire. The study results show that: first, when the enterprise is in a strong ST, the top managers' awareness of environmental benefits has a significant positive impact on LTI. Second, when the enterprise is in a weak ST, top managers' awareness of environmental risk has a significant positive impact on LTI. Third, pressure of key stakeholders and pressure of secondary stakeholders positively moderate the interaction between ST and top managers' environmental awareness (TMEA) on the impact of LTI. Fourth, the moderating effect of key stakeholders' pressure was observed to be stronger than that of secondary stakeholders' pressure. Theoretically, this paper contributes to literature by developing a framework to investigate interaction between ST, TMEA and LTI under different stakeholder pressures. Based on this framework, we provide a theoretical reference for enterprises to choose the appropriate and optimal TMEA for competitive edge.

Paternalistic leadership, employee creativity, and retention: The role of psychological empowerment

Drawing upon the cognitive evaluation theory, this study examined the relationship among the three dimensions of paternalistic leadership, namely, authoritarianism, benevolence, and morality on both employee creativity and intention to stay. Data from 344 subordinates and 132 leaders/supervisors were collected from 32 SMEs in the manufacturing industry of Ghana. The findings of the study revealed that while authoritarian leadership has a negative relationship with creativity, benevolent leadership impacts positively on both creativity and intention to stay. No significant relationship was recorded between moral leadership and creativity, as well as authoritarian leadership and intention to stay. Moreover, psychological empowerment was found to mediate the relationship among benevolent leadership, creativity, and intention to stay, as well as between moral leadership and intention to stay. The study provides a fresh practical and theoretical perspective on the underlying mechanism pertaining to the relationship among paternalistic leadership, creativity, and intention to stay.

The Prevalence of Chronic Physical and Mental Health Conditions in Older Adults Across South Australia and Their Independent Effects on General Practitioner Visits

Rural older adults (≥60), compared to their urban counterparts, are identified as higher users of general practitioner (GP) services. However, whether this pattern of health seeking is influenced more so by physical or mental conditions is unclear. We explore the independent effect of chronic physical and mental health conditions on GP use in Australia. Datasets on population health was available from the South Australia's Department of health in 2013-2017 (n = 20,522). We examined prevalence of common physical and mental conditions and GP use by the Modified Monash Model of remoteness. Physical and mental health burden was similar across South Australia. General practitioner visits with suicidal ideation for rural and remote locations were 4.7 (95% CI, 1.6-13.6) and 4.8 (95% CI, 1.9-11.7), respectively, compared to urban Adelaide 1.5 (95% CI, 1.0-2.3). While there is equal burden of mental health across South Australia, access to mental health resources for nonurban Australians remains a significant challenge.

A socio-geographic perspective of health and economic impacts of COVID-19 on poor households in ghana

COVID-19 outbreak has had multidimensional effects on human lives. The impacts are expected to be more severe on poor households, especially in resource-constraint economies such as Ghana. The Country has a higher poverty rate [24.2%] and this is likely to upsurge in the coming years due to this pandemic. We aimed to document the pandemic-related health and socioeconomic hazards in Ghana. A content analysis of relevant literature, and a qualitative survey using a socioecological lens were conducted. Based on the Ghana Living Standard Survey report (GLSS 7), twenty interviewees were recruited from 3 most poverty-stricken regions in the country to verify the findings of the content review. The findings indicate a significant health burden and a large-scale socioeconomic negative outcome among the Ghanaian poor households. The disproportionate health access by the poor and the rural inhabitants has and will continue to exacerbate. The social hazards are mainly circumscribed relating to poor economic conditions due to job losses, lack of access to income/savings, food insecurity, and lack of welfare support. At the national level, the economy is particularly vulnerable due to low levels of economic diversification. The ultimate manifestation of the pandemic impacts are higher risk of morbidity and mortality rates, and deteriorating wellbeing and livelihoods. These highlights are beneficial to policymakers, development partners, and human rights advocates to make collaborative efforts in helping the poor households during and the post-pandemic periods.

Outpatient healthcare utilization among incident cases of systemic sclerosis: results from a population-based US cohort (1988-2016)

OBJECTIVE

Systemic sclerosis (SSc) is a complex, heterogeneous connective tissue disease with multiorgan dysfunction. This study aimed to compare healthcare utilization among incident cases of SSc versus age- and gender-matched comparators.

METHOD

A population-based cohort of physician-diagnosed patients with SSc in Olmsted County, MN, USA, from 1 January 1988 to 31 December 2016 was assembled. A 2:1 cohort of age- and gender-matched non-SSc subjects was randomly selected for comparison. Patients were followed until death, migration from Olmsted County, or 31 December 2017. Outpatient utilization data were obtained beginning 12 months before the SSc incidence/index date and compared using negative binomial and multinomial models. Services were summarized as visit-days to avoid overestimation of services provided.

RESULTS

The study included 69 incident SSc cases and 138 non-SSc comparators (mean ± sd age 57 ± 16 years at diagnosis/index, 90% female). Patients with SSc had higher utilization of outpatient physician, laboratory, and combined radiology visit-days annually for the year before and for each of the first 5 years after diagnosis than comparators. Among patients with SSc, healthcare utilization was highest during the year of SSc diagnosis. Rate ratios comparing utilization in patients with and without SSc ranged from 1.8 to 3.0 for all comparisons.

CONCLUSION

Higher utilization of outpatient physician, laboratory, and radiology visit-days was observed among patients with SSc compared to non-SSc subjects throughout 5 years of disease duration, indicating high and continued care needs in this patient population. The highest utilization of services among SSc patients occurred during the year of SSc diagnosis.

Changes in Frequency of Surveillance Imaging of Survivors of Diffuse Large B-Cell Lymphoma After the American Society of Hematology Choosing Wisely Recommendations

In 2013, the American Society of Hematology (ASH) published recommendations with Choosing Wisely to limit surveillance imaging in aggressive lymphoma. We studied surveillance imaging practice patterns for diffuse large B-cell lymphoma (DLBCL) before and after the ASH Choosing Wisely campaign. We used OptumLabs Data Warehouse, a national insurance claims database, to retrospectively study imaging frequency in survivors of DLBCL from 2008 to 2016. Three time periods were defined: Period 1 (2008 to 2010), Period 2 (2011 to 2013), and Period 3 (2014 to 2016). One thousand four hundred seventy-two patients were included. Median follow up was approximately 2 years. During the first and second years of surveillance, imaging remained stable between Period 1 (years 1 and 2: 199 [91%] and 137 [83%], respectively) and Period 2 (years 1 and 2: 257 [88%] and 172 [77%], respectively; P = .38), but decreased in Period 3 (years 1 and 2: 315 [78%] and 83 [61%], respectively; P < .01). In a multivariable logistic regression, year after 2012 was a significant predictor of decreased overuse (more than two scans per year in the first year of surveillance; [odds ratio, 0.49 for 2013 v 2008; P = .02]). Our study demonstrated the rate of surveillance scans-both computed tomography and positron emission tomography imaging-in DLBCL decreased after the ASH Choosing Wisely campaign. Multiple factors, such as changes in recommendations, reimbursement, and provider knowledge base, may have all contributed and should be studied further.

What are the predictors of emergency department utilization and readmission following extremity bone sarcoma resection?

INTRODUCTION

Treatment for bone sarcomas are large undertakings. Emergency department (ED) visits and unplanned hospital readmissions are a potential target for cost containment. The purpose of this study was to evaluate the risk factors for ED visits and unplanned readmissions following extremity bone sarcoma surgery.

METHODS

Data from Optum Labs Data Warehouse, a national administrative claims database, was analyzed to identify patients with extremity bone sarcomas from 2006 to 2017. Multivariable logistic regression was used to identify factors associated with ED visits and readmissions.

RESULTS

Of 1390 (743 males, 647 female) adult patients, 137 (12%) visited the ED and 245 (18%) were readmitted within 30 days of discharge. The most common indication for ED visits (n = 63, 45.9%) and readmission (n = 119, 48.5%) were complications of surgery. Length of stay >10 days was associated with ED utilization (OR, 1.83; P = .01) and readmission (OR, 4.47; P < .001).

CONCLUSION

One in ten patients will use the ED, and one in five patients will be readmitted to the hospital within 30 days of discharge following extremity bone sarcoma surgery. Length of stay was associated with ED visits and readmission. These patients could be targeted with alternative management strategies in the outpatient setting with early clinical follow-up to minimize readmission.

Use of Imaging During Staging and Surveillance of Localized Colon Cancer in a Large Insured Population

BACKGROUND

Adherence to surveillance guidelines in resected colon cancer has significant implications for patient morbidity, cost of care, and healthcare utilization. This study measured the underuse and overuse of imaging for staging and surveillance in stage I-II colon cancer.

METHODS

The OptumLabs database was queried for administrative claims data on adult patients with stage I-II colon cancer who underwent surgery alone in 2008 through 2016. Use of PET and CT imaging was evaluated during both initial staging (n=6,921) and surveillance for patients with at least 1 year of follow-up (n=5,466). "High use" was defined as >2 CT abdominal/pelvic (CT A/P) or PET scans per year during surveillance.

RESULTS

Overall, 27% of patients with stage I-II colon cancer did not have a staging CT A/P or PET scan and 95% did not have a CT chest scan. However, rates of staging CT A/P and CT chest scans increased from 62.0% (2008) to 74.8% (2016) and from 2.3% (2008) to 7.1% (2016), respectively. Staging PET use was overall very low (5.2%). During surveillance, approximately 30% of patients received a CT A/P or PET and 5% received a CT chest scan within the first year after surgery. Of patients who had surveillance CT A/P or PET scans, the proportion receiving >2 scans within the first year (high use) declined from 32.4% (2008) to 9.6% (2016) (P = .01).

CONCLUSIONS

Although PET use remains appropriately low, many patients with stage I-II colon cancer do not receive appropriate staging and surveillance CT chest scans. Among those who do receive these scans during surveillance, high use has declined significantly over time.

Survival outcomes for patients with surgically induced end-stage renal disease

INTRODUCTION

While medically induced end-stage renal disease (m-ESRD) has been well-studied, outcomes in patients with surgically induced ESRD (s-ESRD) are unknown. We sought to quantitatively compare the non-oncological outcomes for s-ESRD and m-ESRD in a large, population-based cohort.

METHODS

Medicare patients >65 years old initiating hemodialysis were identified using the U.S. Renal Data System database (2000-2012). Metastatic cancer, prior transplant history, and nephrectomy for polycystic kidney disease were exclusion criteria. Patients were classified as having s-ESRD or m-ESRD based on hospital and physician claims for nephrectomy within a year preceding the onset of maintenance hemodialysis. Outcomes included non-cancer mortality (NCM), overall survival (OS), cardiovascular event (CVE), and renal transplantation. Time-to-event analyses were performed using Kaplan-Meier and cumulative incidence curves, and multivariable Cox and Fine-and-Grey regression models.

RESULTS

The cohort included 312 612 patients, of whom 1648 (0.53%) had s-ESRD. Compared to m-ESRD patients, s-ESRD patients had a significantly lower five-year cumulative incidence of NCM (68% vs. 80%; p<0.001) and CVE (62% vs. 68%; p<0.001), with a correspondingly higher probability of OS (22% vs. 17%; p<0.001) and rate of renal transplantation (3.6% vs. 2.0%; p<0.001). On multivariable analyses, s-ESRD remained associated with lower risks of NCM (p<0.001) and CVE (p<0.001), improved OS (p<0.001), and higher chance of renal transplantation (p<0.001).

CONCLUSIONS

While outcomes for s-ESRD appear more favorable than m-ESRD, s-ESRD is still associated with a substantial risk of NCM and CVE, and a low incidence of renal transplantation in Medicare patients >65 years old. These non-oncological outcomes are worth considering in patients potentially facing postoperative ESRD.

Association of Psoriasis With Comorbidity Development in Children With Psoriasis

Importance

Children with psoriasis are at increased risk for comorbidities. Many children with psoriasis are also overweight or obese; it is unknown whether the increased risk of comorbidities in these children is independent of obesity.

Objective

To determine the risk of elevated lipid levels (hyperlipidemia/hypertriglyceridemia), hypertension, metabolic syndrome, polycystic ovarian syndrome, diabetes, nonalcoholic liver disease, and elevated liver enzyme levels in children with and without psoriasis, after accounting for obesity.

Design, Setting, and Participants

This was a retrospective cohort study of claims data from Optum Laboratories Data Warehouse (includes 150 million privately insured and Medicare enrollees). A cohort of 29 957 children with psoriasis (affected children) and an age-, sex-, and race-matched comparator cohort of 29 957 children without psoriasis were identified and divided into 4 groups: (1) nonobese, without psoriasis (reference cohort); (2) nonobese, with psoriasis; (3) obese, without psoriasis; and (4) obese, with psoriasis.

Main Outcomes and Measures

Risk of developing comorbidities (Cox proportional hazards regression).

Results

The overall mean (SD) age of those included in the cohort was 12.0 (4.4) years, and 16 034 (53.5%) were girls. At baseline, more affected children were obese (862 [2.9%] vs 463 [1.5%]; P < .001 for all comparisons). Children with psoriasis were significantly more likely to develop each of the comorbidities than those without psoriasis (P < .01). Obesity was a strong risk factor for development of each comorbidity, even in those without psoriasis (hazard ratios [HRs] ranging from 2.26 to 18.11). The risk of comorbidities was 40% to 75% higher among nonobese children with vs without psoriasis: elevated lipid levels (HR, 1.42; 95% CI, 1.25-1.62), hypertension (HR, 1.64; 95% CI, 1.40-1.93), diabetes (HR, 1.58; 95% CI, 1.27-1.95), metabolic syndrome (HR, 1.62; 95% CI, 1.13-2.33), polycystic ovarian syndrome (HR, 1.49; 95% CI, 1.18-1.88), nonalcoholic liver disease (HR, 1.76; 95% CI, 1.16-2.65), and elevated liver enzyme levels (HR, 1.46; 95% CI, 1.27-1.67). Except for hypertension (P = .03), no significant interaction occurred between psoriasis and obesity on the risk of comorbidities.

Conclusions and Relevance

Children with psoriasis are at greater risk of developing obesity, hyperlipidemia, hypertension, diabetes, metabolic syndrome, polycystic ovarian syndrome, nonalcoholic liver disease, and elevated liver function enzyme levels than children without psoriasis. While psoriasis is a small independent risk factor for the development of these comorbidities, obesity is a much stronger contributor to comorbidity development in children with psoriasis.

Factors Associated with Emergency Department Utilization and Admission in Patients with Colorectal Cancer

PURPOSE

We assessed emergency department (ED) utilization in patients with colorectal cancer to identify factors associated with ED visits and subsequent admission, as well as identify a high-risk subset of patients that could be targeted to reduce ED visits.

METHODS

Data from Optum Labs Data Warehouse, a national administrative claims database, was retrospectively analyzed to identify patients with colorectal cancer from 2008 to 2014. Multivariable logistic regression was used to identify factors associated with ED visits and ED "super-users" (3+ visits). Repeated measures analysis was used to model ED visits resulting in hospitalization as a logistic regression based on treatments 30 days prior to ED visit.

RESULTS

Of 13,466 patients with colorectal cancer, 7440 (55.2%) had at least one ED visit within 12 months of diagnosis. Factors associated with having an ED visit included non-white race, advancing age, increased comorbidities, and receipt of chemotherapy or radiation. 69.2% of patients who visited the ED were admitted to the hospital. A group of 1834 "super-users" comprised 13.6% of our population yet accounted for 52.1% of the total number of ED visits and 32.3% of admissions.

CONCLUSIONS

Over half of privately insured patients undergoing treatment for colorectal cancer will visit the ED within 12 months of diagnosis. Within this group, we identify common factors for a high-risk subset of patients with three or more ED visits who account for over half of all ED visits and a third of all admissions. These patients could potentially be targeted with alternative management strategies in the outpatient setting.

Risk Factors for Early Hip or Knee Prosthetic Joint Infection (PJI): Analysis of a Nationwide American Insurance Claims Dataset

Background

While several studies have identified risk factors for PJI using insurance claims data, these data sets have been limited to a single regional insurance dataset or to the Medicare population. We sought to investigate risk factors for early PJI among patients undergoing total hip or knee arthroplasty (THKA).

Methods

All patients who underwent primary THKA between January 1, 2004 and July 31, 2014 with 12 months of continuous preceding medical and pharmacy insurance coverage were included in the study. The primary outcome of PJI required both a compatible procedure code and a diagnostic code during an inpatient stay from the time of THKA through 90 days after discharge. Comorbidities were based on ICD-9 codes in the preceding 12 months and patients with a prior diagnosis of PJI during that time period were excluded. Univariate and multivariate analysis was performed using logistic regression.

Results

A total of 147,053 patients underwent THKA during the study period, including 97,448 patients with TKA and 49,605 with THA. PJI occurred in 754 (0.5%) patients. Female gender was independently associated with lower odds of PJI (Figure). A number of biologically plausible factors were associated with increased risk, including chronic skin ulcer, obesity, substance use disorders, joint sarcoma, and malnutrition. The adjusted odds of PJI increased in a stepwise fashion with each increase in the Charlson comorbidity index (CCI), with those with a score of 4 or more having a nearly 2-fold adjusted odds of PJI compared with a score of 0 (OR 1.91; 95% CI 1.29 −2.82). Previously observed risk factors diabetes mellitus, rheumatoid arthritis, and chronic renal failure were associated with increased odds of PJI on univariate analysis, but not after adjustment.

Conclusion

These data identify several potentially modifiable risk factors for preoperative optimization, including obesity, malnutrition, chronic skin ulcers, and substance-use disorders. The level of comorbidity as assessed by the CCI provides a rough estimate of the increasing risk of PJI. The pathobiology of additional risk factors observed here deserves further study.

Disclosures

All authors: No reported disclosures.