Immigration Status and Breast Cancer Surgery Quality of Care Metrics: A Population-Level Analysis

INTRODUCTION

As immigrant women face challenges accessing health care, we hypothesized that immigration status would be associated with fewer women with breast cancer receiving surgery for curable disease, fewer undergoing breast conserving surgery (BCS), and longer wait time to surgery.

METHODS

A population-level retrospective cohort study, including women aged 18-70 years with Stage I-III breast cancer diagnosed between 2010 and 2016 in Ontario was conducted. Multivariable analysis was performed to assess odds of undergoing surgery, receiving BCS and wait time to surgery.

RESULTS

A total of 31,755 patients were included [26,253 (82.7%) Canadian-born and 5502 (17.3%) immigrant women]. Immigrant women were younger (mean age 51.6 vs. 56.1 years) and less often presented with Stage I/II disease (87.4% vs. 89.8%) (both p < .001). On multivariable analysis, there was no difference between immigrant women and Canadian-born women in odds of undergoing surgery [Stage I OR 0.93 (95% CI 0.79-1.11), Stage II 1.04 (0.89-1.22), Stage III 1.22 (0.94-1.57)], receiving BCS [Stage I 0.93 (0.82-1.05), Stage II 0.96 (0.86-1.07), Stage III 1.00 (0.83-1.22)], or wait time [Stage I 0.45 (-0.61-1.50), Stage II 0.33 (-0.86-1.52), Stage III 3.03 (-0.05-6.12)]. In exploratory analysis, new immigrants did not have surgery more than established immigrants (12.9% vs. 10.1%), and refugee women had longer wait time compared with economic-class immigrants (39.5 vs. 35.3 days).

CONCLUSIONS

We observed differences in measures of socioeconomic disadvantage and disease characteristics between immigrant and Canadian-born women with breast cancer. Upon adjusting for these factors, no differences emerged in rate of surgery, rate of BCS, and time to surgery. The lack of disparity suggests barriers to accessing basic components of breast cancer care may be mitigated by the universal healthcare system in Canada.

AI-Human Hybrid Workflow Enhances Teleophthalmology for the Detection of Diabetic Retinopathy

Objective

Detection of diabetic retinopathy (DR) outside of specialized eye care settings is an important means of access to vision-preserving health maintenance. Remote interpretation of fundus photographs acquired in a primary care or other nonophthalmic setting in a store-and-forward manner is a predominant paradigm of teleophthalmology screening programs. Artificial intelligence (AI)-based image interpretation offers an alternative means of DR detection. IDx-DR (Digital Diagnostics Inc) is a Food and Drug Administration-authorized autonomous testing device for DR. We evaluated the diagnostic performance of IDx-DR compared with human-based teleophthalmology over 2 and a half years. Additionally, we evaluated an AI-human hybrid workflow that combines AI-system evaluation with human expert-based assessment for referable cases.

Design

Prospective cohort study and retrospective analysis.

Participants

Diabetic patients ≥ 18 years old without a prior DR diagnosis or DR examination in the past year presenting for routine DR screening in a primary care clinic.

Methods

Macula-centered and optic nerve-centered fundus photographs were evaluated by an AI algorithm followed by consensus-based overreading by retina specialists at the Stanford Ophthalmic Reading Center. Detection of more-than-mild diabetic retinopathy (MTMDR) was compared with in-person examination by a retina specialist.

Main Outcome Measures

Sensitivity, specificity, accuracy, positive predictive value, and gradability achieved by the AI algorithm and retina specialists.

Results

The AI algorithm had higher sensitivity (95.5% sensitivity; 95% confidence interval [CI], 86.7%-100%) but lower specificity (60.3% specificity; 95% CI, 47.7%-72.9%) for detection of MTMDR compared with remote image interpretation by retina specialists (69.5% sensitivity; 95% CI, 50.7%-88.3%; 96.9% specificity; 95% CI, 93.5%-100%). Gradability of encounters was also lower for the AI algorithm (62.5%) compared with retina specialists (93.1%). A 2-step AI-human hybrid workflow in which the AI algorithm initially rendered an assessment followed by overread by a retina specialist of MTMDR-positive encounters resulted in a sensitivity of 95.5% (95% CI, 86.7%-100%) and a specificity of 98.2% (95% CI, 94.6%-100%). Similarly, a 2-step overread by retina specialists of AI-ungradable encounters improved gradability from 63.5% to 95.6% of encounters.

Conclusions

Implementation of an AI-human hybrid teleophthalmology workflow may both decrease reliance on human specialist effort and improve diagnostic accuracy.

Financial Disclosures

Proprietary or commercial disclosure may be found after the references.

Reconciliation in human adults: a video-assisted naturalistic observational study of post conflict conciliatory behaviour in interpersonal aggression

Reconciliation is an aspect of conflict resolution, with similar behavioural patterns documented in non-human primates, human children, and human adults of non-Western, non-industrialized cultures. Reconciliation amongst adults of industrialized societies has rarely been studied. We observed naturally occurring conflicts between adults, captured by public security cameras in England. Reconciliation was found in one-quarter of all conflicts and was more prevalent in milder conflicts. Reconciliation typically occurred spontaneously between opponents — and was found within friendship groups and across stranger groups. Reconciliation between opponents also appeared to be stimulated by peers, law enforcement, or shared objects. In some instances, reconciliation extended beyond the initial conflict dyad toward victimized third-party peacemakers. These findings add to growing cross-cultural and cross-species evidence demonstrating the presence and function of post-conflict reconciliation. We extend the repertoire of reconciliatory behaviour and introduce five common features of reconciliation that are central to the study of adult peacemaking.

Primary Care 2.0: A Prospective Evaluation of a Novel Model of Advanced Team Care With Expanded Medical Assistant Support

PURPOSE

Assess effectiveness of Primary Care 2.0: a team-based model that incorporates increased medical assistant (MA) to primary care physician (PCP) ratio, integration of advanced practice clinicians, expanded MA roles, and extended the interprofessional team.

METHODS

Prospective, quasi-experimental evaluation of staff/clinician team development and wellness survey data, comparing Primary Care 2.0 to conventional clinics within our academic health care system. We surveyed before the model launch and every 6-9 months up to 24 months post implementation. Secondary outcomes (cost, quality metrics, patient satisfaction) were assessed via routinely collected operational data.

RESULTS

Team development significantly increased in the Primary Care 2.0 clinic, sustained across all 3 post implementation time points (+12.2, +8.5, + 10.1 respectively, vs baseline, on the 100-point Team Development Measure) relative to the comparison clinics. Among wellness domains, only "control of work" approached significant gains (+0.5 on a 5-point Likert scale, P = .05), but was not sustained. Burnout did not have statistically significant relative changes; the Primary Care 2.0 site showed a temporal trend of improvement at 9 and 15 months. Reversal of this trend at 2 years corresponded to contextual changes, specifically, reduced MA to PCP staffing ratio. Adjusted models confirmed an inverse relationship between team development and burnout (P <.0001). Secondary outcomes generally remained stable between intervention and comparison clinics with suggestion of labor cost savings.

CONCLUSIONS

The Primary Care 2.0 model of enhanced team-based primary care demonstrates team development is a plausible key to protect against burnout, but is not sufficient alone. The results reinforce that transformation to team-based care cannot be a 1-time effort and institutional commitment is integral.

SnapShot: The Regulatory Genome

Enhancers switch genes on and off in response to a variety of intrinsic and external cellular signals. They are the cornerstone of gene regulation and the most pervasive constituents of the regulatory genome. Sequence polymorphisms in enhancer DNAs are a major source of population diversity and predilection to disease. To view this SnapShot, open or download the PDF.

A roadmap to build a phenotypic metric of ageing: insights from the Baltimore Longitudinal Study of Aging

Over the past three decades, considerable effort has been dedicated to quantifying the pace of ageing yet identifying the most essential metrics of ageing remains challenging due to lack of comprehensive measurements and heterogeneity of the ageing processes. Most of the previously proposed metrics of ageing have been emerged from cross-sectional associations with chronological age and predictive accuracy of mortality, thus lacking a conceptual model of functional or phenotypic domains. Further, such models may be biased by selective attrition and are unable to address underlying biological constructs contributing to functional markers of age-related decline. Using longitudinal data from the Baltimore Longitudinal Study of Aging (BLSA), we propose a conceptual framework to identify metrics of ageing that may capture the hierarchical and temporal relationships between functional ageing, phenotypic ageing and biological ageing based on four hypothesized domains: body composition, energy regulation, homeostatic mechanisms and neurodegeneration/neuroplasticity. We explored the longitudinal trajectories of key variables within these phenotypes using linear mixed-effects models and more than 10 years of data. Understanding the longitudinal trajectories across these domains in the BLSA provides a reference for researchers, informs future refinement of the phenotypic ageing framework and establishes a solid foundation for future models of biological ageing.

Abstract P3-05-01: Age-related methylation signals of breast cancer risk in blood

BACKGROUND: Age is the biggest risk factor for developing breast cancer, which suggests that the biological aging process is a direct driver of cancer etiology. In all normal tissues, DNA methylation status changes systematically with age and is believed to mediate the biological consequences of aging. DNA methylation patterns, commonly referred to as 'Epigenetic Clocks', can be used as measures of aging. However, the chronologic and epigenetic ages can have subtle differences in different individuals. We hypothesize that accelerated epigenetic aging (i.e. DNA methylation indicating an older age than the chronologic age of the individual) is a risk factor for breast cancer development.

METHODS: We used DNA methylation data from blood samples and clinical data from n=2,107 participants in the Women's Health Initiative (WHI) and tested the association between breast cancer risk and two of the most commonly used epigenetic clocks by Horvath (based on 353 CpGs) and Hannum et al. (based on 71 CpGs). DNA methylation in whole blood was measured using the Illumina HumanMethylation450 BeadChip. We used Cox proportional hazard models to assess the association between two epigenetic age predictors (calculated using the algorithms by Horvath and Hannum et al.) and subsequent risk of breast cancer. The model was adjusted for several breast cancer risk factors including: chronologic age at the time of blood sampling, observational vs. clinical trial, clinical trial arm, race/ethnicity, education, BMI, waist-hip ratio, smoking, alcohol, age at menopause, age at menarche, number of pregnancies, age at first birth, previous mastectomy, months breastfed, and cell count estimates. Family history data and BRCA mutation status was incomplete in the WHI and therefore could not be included in our analysis.

RESULTS: Increased epigenetic age determined by the Horvath clock relative to chronological age was associated with increased future incidence of invasive breast cancer, even after adjusting for known risk factors (HR=1.04, P=0.03). Utilizing the Hannum clock, we found no significant association between epigenetic age and breast cancer risk (HR=1.01, P=0.568). When we included both age predictors as independent variables in a single model, the strength of the association between the Horvath epigenetic age and breast cancer risk increased (Horvath HR=1.09, P=6.3e-5; Hannum HR=0.95, p=0.077), such that every one year increase in epigenetic age relative to chronological age was associated with a 9% increased risk of future breast cancer. These results suggest that the aging signal in the Horvath clock that is unique from that captured by Hannum is what drives the specific association with breast cancer.

CONCLUSIONS: Our results support the hypothesis that “accelerated” epigenetic aging measured in the blood increases breast cancer risk. We also demonstrate that the two epigenetic clocks capture different aspects of aging, only some of which have implications for breast cancer risk. Epigenetic clocks may assist in targeting breast cancer screening to higher risk populations in the future, and understanding the biological mechanisms that are altered by the epigenetic changes may lead to new risk reduction strategies.

Citation Format: Hofstatter EW, Levine M, Hatzis C, Pusztai L. Age-related methylation signals of breast cancer risk in blood [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-05-01.

The premarket assessment of the cost-effectiveness of a predictive technology "Straticyte™" for the early detection of oral cancer: a decision analytic model

INTRODUCTION

Approximately half of oral cancers are detected in advanced stages. The current gold standard is histopathological assessment of biopsied tissue, which is subjective and dependent on expertise. Straticyte™, a novel prognostic tool at the pre-market stage, that more accurately identifies patients at high risk for oral cancer than histopathology alone. This study conducts an early cost-effectiveness analysis (CEA) of Straticyte™ and histopathology versus histopathology alone for oral cancer diagnosis in adult patients.

METHODS

A decision-analytic model was constructed after narrowing the scope of Straticyte™, and defining application paths. Data was gathered using the belief elicitation method, and systematic review and meta-analysis. The early CEA was conducted from private-payer and patient perspectives, capturing both direct and indirect costs over a five-year time horizon. One-way and probabilistic sensitivity analyses were conducted to investigate uncertainty.

RESULTS

Compared to histopathology alone, histopathology with Straticyte™ was the dominant strategy, resulting in fewer cancer cases (31 versus 36 per 100 patients) and lower total costs per cancer case avoided (3,360 versus 3,553). This remained robust when Straticyte™ was applied to moderate and mild cases, but became slightly more expensive but still more effective than histopathology alone when Straticyte™ was applied to only mild cases. The probabilistic and one-way sensitivity analyses demonstrated that incorporating Straticyte™ to the current algorithm would be cost-effective over a wide range of parameters and willingness-to-pay values.

CONCLUSION

This study demonstrates high probability that Straticyte™ and histopathology will be cost-effective, which encourages continued investment in the product. The analysis is informed by limited clinical data on Straticyte™, however as more data becomes available, more precise estimates will be generated.

Abstract P4-19-02: Young women with early stage breast cancer and their supportive care needs: Results from a regional survey

Background

Approximately 18% of all newly diagnosed breast cancer cases in Canada occur in women less than 50 years of age. Young women with breast cancer (YWBC) may experience unique physical and psycho-social issues yet there is a lack of data outlining their specific needs and concerns across the trajectory of care. This study described the unmet supportive care needs of YWBC at a regional cancer centre in southern Ontario, Canada.

Objectives

1. To describe unmet supportive care needs of young women (&lt;45 years) with early stage breast cancer in a representative region by using the Supportive Cancer Needs Survey (SCNS-SF34).

2. To describe the level of satisfaction with information to support cancer treatment decision making and causes of distress among YWBC (&lt;45 years) in a representative region.

Study Design

This study used a prospective survey design that was administered to consenting YWBC. The Supportive Care Needs Survey (SCNS-SF34) was used to measure respondents' need for cancer support and care. This instrument captures needs through 34-items that cover five domains: psychological needs, health system and informational needs, physical and daily living needs, patient care support needs and sexuality needs. In addition, an original 26-item survey questionnaire was administered. Survey items were developed from the recurring themes of an earlier project that informed 4 levels of inquiry: demographics, decision making/ informational support, disease and treatment characteristics, and causes of distress.

Results

Fifty-one patients were approached by a member of their circle of care. Of these patients, 35 completed the survey resulting in a 69% response rate. The majority of respondents were between the ages of 33 and 40 (48.6%), were diagnosed within 6 to 12 months of study entry (60.0%); had a university degree (51.4%); were married (82.9%) and (65.7%) have young children.

The three most common Moderate to High Unmet Supportive Care needs (rated 4 or 5 on a 5-point Likert scale) were: “Worries of those close to you” (34.3%), “Fears about the cancer spreading” (34.3%), “Anxiety” (28.6%) all of which reside in the psychological domain. Overall respondents agreed or strongly agreed to statements regarding their level of satisfaction with information to support cancer treatment decision making provided by their oncology team. Respondents did score lower in satisfaction with the information their oncology team provided regarding fertility. In terms of psychosocial support, 40% percent of respondents reported they had met with a social worker and 17% reported attending a breast cancer support group.

Conclusion

The results highlight that the supportive care needs of many YWBC are unmet, particularly those related to psychological burden and fertility concerns. Early identification and appropriate referral to fertility specialists and/or supportive care social workers could improve current practice. Further research is needed to explore how barriers to fertility and supportive care needs of young adults with cancer may best be overcome.

Citation Format: Ratcliffe J, Hodgson N, Rana P, Forbes M, Levine M, Sussman J. Young women with early stage breast cancer and their supportive care needs: Results from a regional survey [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-19-02.

Dental Plaque Toxins are not Lymphotoxins

A major portion of the toxic activity of plaque extracts to cells in culture is due to macromolecules which might be lymphotoxins derived from antigen or mitogen-activated lymphocytes in the gingiva. Assays of sensitivity to aL929 and HeLa cells, and of the effect of neutralizing antibody, indicated that the plaque toxins did not have the properties of the lymphotoxins. The results are consistent with other findings and suggest that the toxins are microbial exotoxins.

Improving Organ Utilization to Help Overcome the Tragedies of the Opioid Epidemic

Death rates from drug overdoses have nearly doubled since 2003, with over 47 000 deaths in 2014. This is largely attributable to the opioid epidemic. If the unfortunate deaths of otherwise healthy people have yielded an increase in organ donors, then this might serve as perhaps the only comforting factor among this tragic and unnecessary loss of life. In this viewpoint, we present data from the Organ Procurement and Transplantation Network (OPTN) that show how the greatest relative increases in the mechanism of death among deceased donors from 2003 to 2014 were drug overdoses. Unfortunately, despite the absolute increase in the number of donors who died from a drug overdose, the mean organ yield was significantly lower than in other categories, in part due to concerns about disease transmission. In this paper, we present data on the changes in donation from donors with a drug overdose as a result of the opioid epidemic and discuss the need to educate transplant candidates and their physicians about the low risk of disease transmission compared to the greater risk of dying on a transplant waitlist.

Vitamin C: the known and the unknown and Goldilocks

Vitamin C (Ascorbic Acid), the antiscorbutic vitamin, cannot be synthesized by humans and other primates, and has to be obtained from diet. Ascorbic acid is an electron donor and acts as a cofactor for fifteen mammalian enzymes. Two sodium-dependent transporters are specific for ascorbic acid, and its oxidation product dehydroascorbic acid is transported by glucose transporters. Ascorbic acid is differentially accumulated by most tissues and body fluids. Plasma and tissue vitamin C concentrations are dependent on amount consumed, bioavailability, renal excretion, and utilization. To be biologically meaningful or to be clinically relevant, in vitro and in vivo studies of vitamin C actions have to take into account physiologic concentrations of the vitamin. In this paper, we review vitamin C physiology; the many phenomena involving vitamin C where new knowledge has accrued or where understanding remains limited; raise questions about the vitamin that remain to be answered; and explore lines of investigations that are likely to be fruitful.

Dose-associated pulmonary complication rates after fresh frozen plasma administration for warfarin reversal

ESSENTIALS: Fresh frozen plasma (FFP) may be associated with a dose-based risk of pulmonary complications. Patients received FFP for warfarin reversal at a large academic hospital over a 3-year period. Almost 20% developed pulmonary complications, and the risk was highest after > 3 units of FFP. The risk of pulmonary complications remained significant in multivariable analysis.

BACKGROUND

Fresh frozen plasma (FFP) is often administered to reverse warfarin anticoagulation. Administration has been associated with pulmonary complications, but it is unclear whether this risk is dose-related. Aims We sought to characterize the incidence and dose relationship of pulmonary complications, including transfusion-associated circulatory overload (TACO) and transfusion-related acute lung injury (TRALI), after FFP administration for warfarin reversal.

METHODS

We performed a structured retrospective review of patients who received FFP for warfarin reversal in the emergency department (ED) of an academic tertiary-care hospital over a 3-year period. Logistic regression was used to explore the relationship between FFP dose and risk of pulmonary events.

RESULTS

Two hundred and fifty-one patients met the inclusion criteria. Overall, 49 patients (20%) developed pulmonary complications, including 30 (12%) with TACO, two (1%) with TRALI, and 17 (7%) with pulmonary edema not meeting the criteria for TACO. Pulmonary complications were significantly more frequent in those who received > 3 units of FFP (34.0% versus 15.6%, 95% confidence interval for risk difference 7.9%-8.9%). After stratification by subtype of complication, only the risk of TACO was statistically significant (28.3% versus 7.6%, 95% confidence interval for risk difference 8.2%-16.6%). In multivariable analysis controlling for age, sex, initial systolic blood pressure, and intravenous fluids given in the ED, > 3 units of FFP remained a significant risk factor for pulmonary complications (odds ratio 2.49, 95% confidence interval 1.21-5.13).

CONCLUSIONS

Almost 20% of patients who received FFP for warfarin reversal developed pulmonary complications, primarily TACO, and this risk increased with > 3 units of FFP. Clinicians should be aware of and prepared to manage these complications.

Transmission of Hepatitis C Virus From Organ Donors Despite Nucleic Acid Test Screening

Nucleic acid testing (NAT) for hepatitis C virus (HCV) is recommended for screening of organ donors, yet not all donor infections may be detected. We describe three US clusters of HCV transmission from donors at increased risk for HCV infection. Donor's and recipients' medical records were reviewed. Newly infected recipients were interviewed. Donor-derived HCV infection was considered when infection was newly detected after transplantation in recipients of organs from increased risk donors. Stored donor sera and tissue samples were tested for HCV RNA with high-sensitivity quantitative PCR. Posttransplant and pretransplant recipient sera were tested for HCV RNA. Quasispecies analysis of hypervariable region-1 was used to establish genetic relatedness of recipient HCV variants. Each donor had evidence of injection drug use preceding death. Of 12 recipients, 8 were HCV-infected-6 were newly diagnosed posttransplant. HCV RNA was retrospectively detected in stored samples from donor immunologic tissue collected at organ procurement. Phylogenetic analysis showed two clusters of closely related HCV variants from recipients. These investigations identified the first known HCV transmissions from increased risk organ donors with negative NAT screening, indicating very recent donor infection. Recipient informed consent and posttransplant screening for blood-borne pathogens are essential when considering increased risk donors.

Regional and temporal variations of Leptospira seropositivity in dogs in the United States, 2000-2010

BACKGROUND

Previous studies have reported a seasonal increased risk for leptospirosis, but there is no consistent seasonality reported across regions in the United States.

OBJECTIVES

To evaluate and compare seasonal patterns in seropositivity for leptospirosis in dogs for 4 US regions (northeast [NE], midwest [MW], south-central [SC], and California-southern west coast [CS]).

ANIMALS

Forty four thousand nine hundred and sixteen canine serum samples submitted to a commercial laboratory for microscopic agglutination tests (MAT) from 2000 through 2010.

METHODS

In this retrospective study, positive cases were defined as MAT titers ≥1 : 3,200 for at least one of 7 tested serovars. Four geographic regions were defined, and MAT results were included in regional analyses based on hospital zipcode. A seasonal-trend decomposition method for times series was utilized for the analysis. Monthly variation in the seropositive rate was evaluated using a seasonal cycle subseries plot and logistic regression.

RESULTS

Two thousand and twelve of 44,916 (4.48%) samples were seropositive. Compared to seropositive rates for February, significantly higher monthly rates occurred during the 2nd half of the year in the MW (OR 3.92-6.35) and NE (OR 2.03-4.80) regions, and only in January (OR 2.34) and December (OR 1.74) in the SC region. Monthly seropositive rates indicative of seasonality were observed earlier in the calendar year for both CS and SC regions.

CONCLUSIONS AND CLINICAL IMPORTANCE

Seasonal patterns for seropositivity to leptospires differed by geographic region. Although risk of infection in dogs can occur year round, knowledge of seasonal trends can assist veterinarians in formulating differential diagnoses and evaluation of exposure risk.

Early rehospitalization after kidney transplantation: assessing preventability and prognosis

Early rehospitalization after kidney transplantation (KT) is common and may predict future adverse outcomes. Previous studies using claims data have been limited in identifying preventable rehospitalizations. We assembled a cohort of 753 adults at our institution undergoing KT from January 1, 2003 to December 31, 2007. Two physicians independently reviewed medical records of 237 patients (32%) with early rehospitalization and identified (1) primary reason for and (2) preventability of rehospitalization. Mortality and graft failure were ascertained through linkage to the Scientific Registry of Transplant Recipients. Leading reasons for rehospitalization included surgical complications (15%), rejection (14%), volume shifts (11%) and systemic and surgical wound infections (11% and 2.5%). Reviewer agreement on primary reason (85% of cases) was strong (kappa = 0.78). Only 19 rehospitalizations (8%) met preventability criteria. Using logistic regression, weekend discharge (odds ratio [OR] 1.59, p = 0.01), waitlist time (OR 1.10, p = 0.04) and longer initial length of stay (OR 1.42, p = 0.03) were associated with early rehospitalization. Using Cox regression, early rehospitalization was associated with mortality (hazard ratio [HR] 1.55; p = 0.03) but not graft loss (HR 1.33; p = 0.09). Early rehospitalization has diverse causes and presents challenges as a quality metric after KT. These results should be validated prospectively at multiple centers to identify vulnerable patients and modifiable processes-of-care.

Assessing the toxicity and associated costs among pediatric patients admitted with unintentional poisonings of attention-deficit/hyperactivity disorder drugs in the United States

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is widespread, with a national (United States) prevalence of nearly 10%. The 2011 changes in the diagnostic criteria will likely further increase the prevalence of this disorder. Little is known about the incidence of toxicity from unintentional poisonings of ADHD medications. This study attempted to determine the incidence of these ingestions and the corresponding financial impact in the United States.

METHODS

Four geographically different centers were chosen. Subjects with unintentional poisonings due to ADHD medications were included if the admission dates were between 2000 and 2002 (cohort A) or between 2009 and 2010 (cohort B). Using data from the participating hospitals and the number of monitored beds in each corresponding county, data were extrapolated on a national (United States) level.

RESULTS

Sixty-three subjects were admitted at four hospitals (18, cohort A and 45, cohort B). The crude incidence rate ratio increased in the later time frame as compared to that in the earlier time frame (incidence rate ratio, 3.13; 95% CI, 1.80-5.68; p < 0.0001). The median (IQR) charges per patient, adjusted for inflation, were $4780 ($3,895-$8,287) and $5912 ($3,432-$9,433) for cohorts A and B, respectively (p = 0.57). If the subjects in the participating counties were only admitted to the participating hospitals, the annual charges, extrapolated throughout the United States for the two periods, would be $2,419,016 and $8,129,538, respectively. If the subjects were evenly distributed across all pediatric monitored beds in a given county, the annual charges extrapolated throughout the United States for the two periods would be $5,694,232 and $24,126,640, respectively.

CONCLUSION

The incidence of unintentional poisonings from ADHD drugs is increasing and is associated with a significant cost.

[Uncertainty in the radiological evaluation of deformity in proximal humerus fractures]

INTRODUCTION

The accurate measurement of the deformity of proximal humerus fractures is essential for a proper treatment, particularly in the growing bone. Due to the local pain the correct projection in standard X-rays is difficult to achieve and, in contrast to other joints, cannot be verified in the X-ray. Even with the correct projections a mismeasurement can occur when the rotation is 45° to both planes. The aim of this study was to objectify the error sources and reveal starting points for an improvement.

MATERIAL AND METHODS

In a three-step study we initially developed a mathemathical formula in cooperation with the faculty of mathematics of the University of Duisburg-Essen. This formula was proved with X-ray imaging of a steel rod which was bent 120°, simulating a 60° deformity. X-ray images with different rotation and tilt were taken and compared with the values calculated with the above-mentioned formula. In the third step X-rays of a healthy shoulder in different rotation and tilt positions were presented to 2 orthopaedic and 3 radiological consultants. The aim was to determine the direction and amount of rotation and tilt.

RESULTS

The first theoretical step resulted in a mathematical formula which describes the optical deformation based on real deformation, tilt and rotation. The evaluation showed a mean difference of 0.5° (0-1.2°) between the calculated and the measured values. In the third step, evaluation of the X-rays of a shoulder showed that two in 50 (4 %) of the values were correct, in additional 28 cases (56 %) the tendency of the direction of the rotation was correct, the extent of the rotation was missed by 19.6° (0-60°). Ante- and retroversion were evaluated correctly in nine cases (18 %), the extent was missed by a mean of 23° (0-50°). In seven cases (18 %) the tendency for rotation and ante-/retroversion was correct, in 11 cases (22 %) one or both aspects could not be evaluated, in additional 8 cases (16 %) the extent could not be estimated.

DISCUSSION

Our results show that rotation and tilt of the proximal humerus cannot be estimated in shoulder X-rays and therefore a reliable measurement of the deformity of proximal humerus fractures is extremely unsafe. This problem is relevant for clinical practice because of the high likeliness of unaccurate projections in shoulder X-ray imaging after trauma. Especially for the growing bone the problem is evident, so that new ways of determining the deformity are mandatory.

Pharmacological ascorbate with gemcitabine for the control of metastatic and node-positive pancreatic cancer (PACMAN): results from a phase I clinical trial

BACKGROUND

Treatment for pancreatic cancer with pharmacological ascorbate (ascorbic acid, vitamin C) decreases tumor progression in preclinical models. A phase I clinical trial was performed to establish safety and tolerability of pharmacological ascorbate combined with gemcitabine in patients with biopsy-proven stage IV pancreatic adenocarcinoma.

DESIGN

Nine subjects received twice-weekly intravenous ascorbate (15-125 g) employing Simon's accelerated titration design to achieve a targeted post-infusion plasma level of ≥350 mg/dL (≥20 mM). Subjects received concurrent gemcitabine. Disease burden, weight, performance status, hematologic and metabolic laboratories, time to progression and overall survival were monitored.

RESULTS

Mean plasma ascorbate trough levels were significantly higher than baseline (1.46 ± 0.02 vs. 0.78 ± 0.09 mg/dL, i.e., 83 vs. 44 μM, p < 0.001). Adverse events attributable to the drug combination were rare and included diarrhea (n = 4) and dry mouth (n = 6). Dose-limiting criteria were not met for this study. Mean survival of subjects completing at least two cycles (8 weeks) of therapy was 13 ± 2 months.

CONCLUSIONS

Data suggest pharmacologic ascorbate administered concurrently with gemcitabine is well tolerated. Initial data from this small sampling suggest some efficacy. Further studies powered to determine efficacy should be conducted.

Risk of end-stage renal disease among liver transplant recipients with pretransplant renal dysfunction

Guidelines recommend restricting simultaneous liver-kidney (SLK) transplant to candidates with prolonged dialysis or estimated glomerular filtration rate (eGFR) <30 mL/min/1.73m(2) for 90 days. However, few studies exist to support the latter recommendation. Using Scientific Registry of Transplant Recipients and Medicare dialysis data, we assembled a cohort of 4997 liver transplant recipients from February 27, 2002-January 1, 2008. Serial eGFRs were calculated from serum creatinines submitted with MELD reports. We categorized recipients by eGFR patterns in the 90 days pretransplant: Group 1 (eGFR always >30), Group 2 (eGFR fluctuated), Group 3 (eGFR always <30) and Group 4 (short-term dialysis). For Group 2, we characterized fluctuations in renal function using time-weighted mean eGFR. Among liver-alone recipients in Group 3, the rate of end-stage renal disease (ESRD) by 3 years was 31%, versus <10% for other groups (p < 0.001). In multivariable Cox regression, eGFR Group, diabetes (HR 2.65, p < 0.001) and black race (HR 1.83, p = 0.02) were associated with ESRD. Among liver-alone recipients in Group 2, only diabetics with time-weighted mean eGFR <30 had a substantial ESRD risk (25.6%). In summary, among liver transplant candidates not on prolonged dialysis, SLK should be considered for those whose eGFR is always <30 and diabetic candidates whose weighted mean eGFR is <30 for 90 days.