Large variation in radiation dose for routine abdomen CT: reasons for excess and easy tips for reduction

OBJECTIVE

To characterize the use and impact of radiation dose reduction techniques in actual practice for routine abdomen CT.

METHODS

We retrospectively analyzed consecutive routine abdomen CT scans in adults from a large dose registry, contributed by 95 hospitals and imaging facilities. Grouping exams into deciles by, first, patient size, and second, size-adjusted dose length product (DLP), we summarized dose and technical parameters and estimated which parameters contributed most to between-protocols dose variation. Lastly, we modeled the total population dose if all protocols with mean size-adjusted DLP above 433 or 645 mGy-cm were reduced to these thresholds.

RESULTS

A total of 748,846 CTs were performed using 1033 unique protocols. When sorted by patient size, patients with larger abdominal diameters had increased dose and effective mAs (milliampere seconds), even after adjusting for patient size. When sorted by size-adjusted dose, patients in the highest versus the lowest decile in size-adjusted DLP received 6.4 times the average dose (1680 vs 265 mGy-cm) even though diameter was no different (312 vs 309 mm). Effective mAs was 2.1-fold higher, unadjusted CTDIvol 2.9-fold, and phase 2.5-fold for patients in the highest versus lowest size-adjusted DLP decile. There was virtually no change in kV (kilovolt). Automatic exposure control was widely used to modulate mAs, whereas kV modulation was rare. Phase was the strongest driver of between-protocols variation. Broad adoption of optimized protocols could result in total population dose reductions of 18.6-40%.

CONCLUSION

There are large variations in radiation doses for routine abdomen CT unrelated to patient size. Modification of kV and single-phase scanning could result in substantial dose reduction.

CLINICAL RELEVANCE

Radiation dose-optimization techniques for routine abdomen CT are routinely under-utilized leading to higher doses than needed. Greater modification of technical parameters and number of phases could result in substantial reduction in radiation exposure to patients.

KEY POINTS

• Based on an analysis of 748,846 routine abdomen CT scans in adults, radiation doses varied tremendously across patients of the same size and optimization techniques were routinely under-utilized. • The difference in observed dose was due to variation in technical parameters and phase count. Automatic exposure control was commonly used to modify effective mAs, whereas kV was rarely adjusted for patient size. Routine abdomen CT should be performed using a single phase, yet multi-phase was common. • kV modulation by patient size and restriction to a single phase for routine abdomen indications could result in substantial reduction in radiation doses using well-established dose optimization approaches.

Increasing Accrual of Racial and Ethnic Minorities in Breast Cancer Clinical Trials by Partnering with Community Hospitals

PURPOSE/OBJECTIVE(S)

Clinical trials provide the highest level of evidence in evaluating the safety and efficacy of new radiation approaches for breast cancer. However, there is a significant lack of racial and ethnic diversity among participants who are enrolled. This discrepancy in research inclusion leads to limitations in applying clinical data, therapeutic indices, technique safety, and toxicity to a diverse patient population. A community-based approach, such as the inclusion of community hospitals in trial enrollment, has been shown to boost participation within these underserved populations. The aim of this study was to evaluate the rate of enrollment of racial and ethnic minorities in breast cancer clinical trials with the inclusion of community hospitals within an NYC hospital system.

MATERIALS/METHODS

Trial enrollment of breast cancer patients at 3 hospitals was retrospectively assessed. Patient demographics, including age, race, and ethnicity, were compared by enrollment setting. Eligible trials included prospective, randomized clinical trials assessing breast cancer irradiation. Participating hospitals included an academic hospital in Manhattan (MH), and 2 community hospitals in Brooklyn (BH) and Queens (QH). Collectively, these hospitals have a catchment area of 6.2 million, of which 35.2% are White, 19.7% are Asian, 18.3% are Black/African American (B/AA), and 21.2% are Hispanic/Latino (H/L). There is a wide demographic variety within this catchment area. BH serves neighborhoods with a B/AA population as high as 85% and QH serves neighborhoods with an Asian population as high as 54%.

RESULTS

From January to December 2022, 146 patients were enrolled in 4 breast cancer trials opened at MH (59.6%, n = 87), BH (28.8%, n = 42), and QH (11.6%, n = 17). The average age was 63.3 (SD = 12.1). Of all patients enrolled, 52.7% identified as White, 23.2% as B/AA, 13% as Asian, and 8.9% as H/L. Of the patients enrolled at MH, 64.4% identified as White, 12.6% as B/AA, 8% as Asian, and 8% as H/L. At BH, 50% identified as B/AA, 38% as White, 4.7% as Asian, and 11.9% as H/L. At QH, 58.8% identified as Asian, 29.4% as White, and 11.8% as B/AA. B/AA (OR = 4.41, 95% CI, 1.94-10.03; p<.01) and Asian (OR = 2.92, 95% CI, 1.07-7.93; p<.05) patients were more likely to be enrolled at a community hospital when compared to an academic hospital. There was no difference in enrollment rates between campuses for H/L patients (OR = 1.29, 95% CI, 0.41-4.06; p = .66).

CONCLUSION

Enrollment of participants from underrepresented racial and ethnic populations in clinical trials is critical to ensuring health equity. These findings suggest partnerships with community hospitals located in underserved populations can be a strategy to improve diversity among clinical trial participants. As it is well-documented that community hospitals can deliver high quality research with similar trial metrics to larger, academic hospitals, partnerships with community hospitals are a feasible way to reduce disparities in breast cancer research.

Familial risk for endometriosis and its interaction with smoking, age at menarche and body mass index: a population-based cohort study among siblings

OBJECTIVE

To quantify familial risk of endometriosis among full siblings and examine interactions between family history and smoking, age at menarche or body mass index (BMI).

DESIGN, SETTING AND POPULATION

Population-based nationwide cohort study.

METHODS

Using data from the Korean National Health Insurance and Screening Programme databases on kinship, healthcare utilisation, lifestyle and anthropometrics, we identified 2 109 288 women with full siblings and their environmental risk factors from 2002 to 2018. Familial risks were estimated using Cox proportional-hazards models, represented as incidence risk ratios (IRR) with 95% CI. Interaction between family history and smoking, age at menarche or BMI were assessed on an additive scale.

MAIN OUTCOME MEASURES

IRR of endometriosis among women with and without affected siblings.

RESULTS

From 19 195 women with affected siblings, 1126 developed endometriosis with an incidence of 35.45/10 000 person-years. Familial risk of endometriosis with versus without affected siblings was increased to IRR 2.75 (95% CI 2.25-3.36), and the highest risk was with affected twins (IRR 6.98; 95% CI 4.19-11.62). Women with both a family history and either smoking, early menarche or low BMI had a significantly higher risk of endometriosis compared with the general population and can be regarded as a high-risk group, the IRRs were 4.28 (95% CI 2.43-7.55), 3.47 (95% CI 2.82-4.26) and 3.09 (95% CI 2.68-3.56), respectively. Substantial effect modification of the associations was noted by smoking and early menarche, as their combined risk with family history exceeded the sum of their individual risks, which was also statistically significant.

CONCLUSION

Genetic factors are the primary contributor to the familial aggregation of endometriosis. Significant gene-environment interaction exists between family history and smoking or early menarche.

Incidence, survival, and risk of cardiovascular events in adult inflammatory myopathies in South Korea: a nationwide population-based study

OBJECTIVE

Epidemiological studies on inflammatory myopathies (IMs) show widely variable results, and studies on Asians are lacking. Despite emerging interest in the cardiovascular disease (CVD) risk associated with IMs, the prevalence of CVD in IM patients and its impact on mortality remain unclear. We conducted a nationwide, population-based study on the incidence, mortality, and associated major CVD events of IMs in the Republic of Korea over 11 years.

METHOD

Using the nationwide, population-based National Health Insurance claims database and the Rare Intractable Disease registration programme, we estimated incidence, mortality, and CVD occurrence. Survival was examined using the Kaplan-Meier method. Mortality rate in IMs with CVD was analysed by Cox proportional hazards regression.

RESULTS

There were 3014 incident cases, 640 of whom died during the study period. The mean annual incidence was 7.16/10⁶. Dermatomyositis (DM) and polymyositis (PM) had 5 year survival rates of 76.8% and 79.3%, respectively. Cardiovascular events occurred in 155 patients and 40.6% of IM patients with CVD died. Acute myocardial infarction in men had the highest risk of any CVD event in both DM [standardized incidence ratio (SIR) 4.2, 95% confidence interval (95% CI) 2.4-7.2] and PM (SIR 3.5, 95% CI 1.8-7.0). Haemorrhagic stroke had the highest hazard ratio (HR) in both DM (HR 2.31, 95% CI 1.13-4.70) and PM patients (HR 2.10, 95% CI 1.03-4.27) compared with the general population with CVD.

CONCLUSION

We found persistently low incidence, poor survival, and high major CVD incidence in IMs, and increased mortality in IMs with CVD.

Changing home care aides: Differences between family and non-family care in California Medicaid home and community-based services

In California Medicaid home-and-community-based services (HCBS), recipients' family members receive payment as home care aides (HCAs). We analyzed data on first-time HCBS recipients to examine factors associated with the likelihood of switching HCAs within the first year of services. Those with family HCAs were less than half as likely to change than those with non-family HCAs and racial/ethnic minorities with non-family HCAs had the highest switching rates. Lower wages and local unemployment were associated with switching of non-family HCAs but not family HCAs. Policymakers can foster continuity of home care by paying family members for home care and raising worker wages.

Predictors of Nursing Facility Entry by Medicaid-Only Older Adults and Persons With Disabilities in California

Nearly one-third of adult Medicaid beneficiaries who receive long-term services and supports (LTSS) consist of older adults and persons with disabilities who are not eligible for Medicare. Beneficiaries, advocates, and policymakers have all sought to shift LTSS to home and community settings as an alternative to institutional care. We conducted a retrospective cohort study of Medicaid-only adults in California with new use of LTSS in 2006-2007 (N = 31 849) to identify unique predictors of entering nursing facilities versus receiving Medicaid home and community-based services (HCBS). Among new users, 18.3% entered into nursing facilities, whereas 81.7% initiated HCBS. In addition to chronic conditions, functional and cognitive limitations, substance abuse disorders (odds ratio [OR] 1.35; 95% confidence interval [CI]: 1.23, 1.48), and homelessness (OR: 4.35, 9% CI: 3.72, 5.08) were associated with higher odds of nursing facility entry. For older adults and persons with disabilities covered by Medicaid only, integration with housing and behavioral health services may be key to enabling beneficiaries to receive LTSS in noninstitutional settings.

Small-angle neutron scattering study of a dense microemulsion system formed with an ionic liquid

Mixtures of water, octane and 1-octanol with 1-tetradecyl-3-methylimidazolium chloride (C₁₄MIM·Cl), often referred to as a surface active ionic liquid (SAIL), form water-in-oil microemulsions that have potential application as extraction media for various metal ions. Here, we present a structural study by small-angle neutron scattering (SANS) of dense microemulsions formed by surfactant-rich mixtures of these four compounds to understand how the SAIL can be used to tune the structures and properties of the microemulsions. The SANS experiments revealed that the microemulsions formed are composed of two phases, a water-in-oil microemulsion and a bicontinuous microemulsion, which becomes the dominant phase at high surfactant concentration. In this concentration regime, the surfactant film becomes more rigid, having a higher bending modulus that results from the parallel stacking of the imidazolium ring of the SAIL. At lower surfactant concentrations, the molecular packing of the SAIL does not change with the water content of the microemulsion. The results presented here correlate well with previously observed changes in the interaction between the IL cation and metal ions (Y. Tong, L. Han and Y. Yang, Ind. Eng. Chem. Res., 2012, 51, 16438-16443), while the capacity of the microemulsion system for water remains high enough for using the system as an extraction medium.

Housing Changes and Moves into Supportive Housing Among Adults with Disabilities

About one fifth of the adult population with disabilities living in the community moved during a 12-to 24-month period between 1994 and 1996. This article examines the extent to which the ability to perform activities of daily living (ADL) and instrumental activities of daily living (IADL) was associated with these moves. Data are from the 1994-1995 National Health Interview Survey (NHIS), the 1994-1995 Supplement on Disability, and the Disability Followback Survey. Analyses controlled for gender, income, living alone, racelethnicity, health status, and selected mental conditions. Decreased IADL ability had little association with the likelihood of moving, whereas increased difficulty with the ADL tasks of bathing, dressing, eating, and toileting generally increased this likelihood. These effects were more evident among those age 65+ than among those ages 18 to 64, and more common among house than apartment residents. For older persons, increases in ADL difficulties were associated with moves into supportive housing.

Solar optics-based active panel for solar energy storage and disinfection of greywater

Smart city and innovative building strategies are becoming increasingly more necessary because advancing a sustainable building system is regarded as a promising solution to overcome the depleting water and energy. However, current sustainable building systems mainly focus on energy saving and miss a holistic integration of water regeneration and energy generation. Here, we present a theoretical study of a solar optics-based active panel (SOAP) that enables both solar energy storage and photothermal disinfection of greywater simultaneously. Solar collector efficiency of energy storage and disinfection rate of greywater have been investigated. Due to the light focusing by microlens, the solar collector efficiency is enhanced from 25% to 65%, compared to that without the microlens. The simulation of greywater sterilization shows that 100% disinfection can be accomplished by our SOAP for different types of bacteria including Escherichia coli. Numerical simulation reveals that our SOAP as a lab-on-a-wall system can resolve the water and energy problem in future sustainable building systems.

Health Care Use Before and After Entering Long-Term Services and Supports

Objective: We examined the health care utilization patterns of Medicare and Medicaid enrollees (MMEs) before and after initiating long-term care in the community or after admission to a nursing facility (NF). Method: We used administrative data to compare hospitalizations, emergency department (ED) visits, and post-acute care use of MMEs receiving long-term care in California in 2006-2007. Results: MMEs admitted to a NF for long-term care had much greater use of hospitalizations, ED visits, and post-acute care before initiating long-term care than those entering long-term care in the community. Post-entry, community service users had less than half the average monthly hospital and ED use compared with the NF cohort. Conclusion: Hospital and ED use prior to and following NF and personal care program entry suggest a need for reassessing the monitoring of these high-risk populations and the communication between health and community care providers.

Disparities in Service Use and Expenditures for People With Intellectual and Developmental Disabilities in California in 2005 and 2013

This study examined service use and expenditures for people with intellectual and developmental disabilities (IDD) living at home and in the community in California in 2005 and 2013. The number of people assessed for IDD services increased, along with the percentage of individuals who did not receive any services between 2005 and 2013. Controlling for client needs, children age 3-21 were less likely than other age groups to receive any services using logistic regressions. All racial and ethnic minority groups were less likely to receive any services than were white populations. Females, younger people, and all racial and ethnic minority groups who received services had significantly lower expenditures, with wide geographic variations. The disparities by age, gender, race/ethnicity, and geography have persisted over time in California.

Hidden Owners, Hidden Profits, and Poor Nursing Home Care: A Case Study

The study examined the ownership transparency, financial accountability, and quality indicators of a regional for-profit nursing home chain in California, using a case study methodology to analyze data on the chain's ownership and management structure, financial data, staffing levels, deficiencies and complaints, and litigation. Secondary data were obtained from regulatory and cost reports and litigation cases. Qualitative descriptions of ownership and management were presented and quantitative analyses were conducted by comparing financial and quality indicators with other California for-profit chains, for-profit non-chains, and nonprofit nursing home groups in 2011. The chain's complex, interlocking individual and corporate owners and property companies obscured its ownership structure and financial arrangements. Nursing and support services expenditures were lower than nonprofits and administrative costs were higher than for-profit non-chains. The chain's nurse staffing was lower than expected staffing levels; its deficiencies and citations were higher than in nonprofits; and a number of lawsuits resulted in bankruptcy. Profits were hidden in the chain's management fees, lease agreements, interest payments to owners, and purchases from related-party companies. Greater ownership transparency and financial accountability requirements are needed to ensure regulatory oversight and quality of care.

Payment rates for personal care assistants and the use of long-term services and supports among those dually eligible for Medicare and Medicaid

OBJECTIVE

To examine the association between payment rates for personal care assistants and use of long-term services and supports (LTSS) following hospital discharge among dual eligible Medicare and Medicaid beneficiaries.

DATA SOURCES

State hospital discharge, Medicaid and Medicare claims, and assessment data on California Medicaid LTSS users from 2006 to 2008.

STUDY DESIGN

Cross-sectional study. We used multinomial logistic regression to analyze county personal care assistant payment rates and postdischarge LTSS use, and estimate marginal probabilities of each outcome across the range of rates paid in California.

DATA EXTRACTION METHODS

We identified dual eligible Medicare and Medicaid adult beneficiaries discharged from an acute care hospital with no hospitalizations or LTSS use in the preceding 12 months.

PRINCIPAL FINDINGS

Personal care assistant payment rates were modestly associated with home and community-based services (HCBS) use versus nursing facility entry following hospital discharge (RRR 1.2, 95 percent CI: 1.0-1.4). For a rate of $6.75 per hour, the probability of HCBS use was 5.6 percent (95 percent CI: 4.2-7.1); at $11.75 per hour, 18.0 percent (95 percent CI: 12.5-23.4). Payment rate was not associated with the probability of nursing facility entry.

CONCLUSIONS

Higher payment rates for personal care assistants may increase utilization of HCBS, but with limited substitution for nursing facility care.

Coating NiTi archwires with diamond-like carbon films: reducing fluoride-induced corrosion and improving frictional properties

This study aims to coat diamond-like carbon (DLC) films onto nickel-titanium (NiTi) orthodontic archwires. The film protects against fluoride-induced corrosion and will improve orthodontic friction. 'Mirror-confinement-type electron cyclotron resonance plasma sputtering' was utilized to deposit DLC films onto NiTi archwires. The influence of a fluoride-containing environment on the surface topography and the friction force between the brackets and archwires were investigated. The results confirmed the superior nature of the DLC coating, with less surface roughness variation for DLC-coated archwires after immersion in a high fluoride ion environment. Friction tests also showed that applying a DLC coating significantly decreased the fretting wear and the coefficient of friction, both in ambient air and artificial saliva. Thus, DLC coatings are recommended to reduce fluoride-induced corrosion and improve orthodontic friction.

Personal service assistance: musculoskeletal disorders and injuries in consumer-directed home care

BACKGROUND

Like other types of care for disabled or elderly adults, consumer-directed personal assistance services may present multi-factorial risks for work-related musculoskeletal disorders (WRMSDs).

METHODS

Using survey data, we compared providers experiencing WRMSDs in the previous year to those who did not, seeking to identify functional, temporal, physical, and relationship risk factors for transient and chronic conditions.

RESULTS

Longer work experience with the recipient and more frequent bending increased the risk of being in the most chronic group (≥12 painful episodes), whereas predictable work hours with rest breaks and greater social support from the recipient appeared protective. For transient conditions (one to two episodes), longer work experience with the recipient and predictable hours with rest breaks appeared protective.

CONCLUSIONS

We offer recommendations to improve hazard assessment as well as training and information distribution related to home care programs. With the population aging, home care jobs require increasing oversight to prevent WRMSDs.

Interaction with Suv39H1 is critical for Snail-mediated E-cadherin repression in breast cancer

Expression of E-cadherin, a hallmark of epithelial-mesenchymal transition (EMT), is often lost due to promoter DNA methylation in basal-like breast cancer (BLBC), which contributes to the metastatic advantage of this disease; however, the underlying mechanism remains unclear. Here, we identified that Snail interacted with Suv39H1 (suppressor of variegation 3-9 homolog 1), a major methyltransferase responsible for H3K9me3 that intimately links to DNA methylation. We demonstrated that the SNAG domain of Snail and the SET domain of Suv39H1 were required for their mutual interactions. We found that H3K9me3 and DNA methylation on the E-cadherin promoter were higher in BLBC cell lines. We showed that Snail interacted with Suv39H1 and recruited it to the E-cadherin promoter for transcriptional repression. Knockdown of Suv39H1 restored E-cadherin expression by blocking H3K9me3 and DNA methylation and resulted in the inhibition of cell migration, invasion and metastasis of BLBC. Our study not only reveals a critical mechanism underlying the epigenetic regulation of EMT, but also paves a way for the development of new treatment strategies against this disease.

In-home supportive services for individuals with cerebral palsy in California

INTRODUCTION

Individuals with cerebral palsy (CP) may require personal assistance services for optimal functioning. The primary goal of this project is to determine if differences in health services exist between individuals with CP with family versus non-family member paid personal assistance providers. The secondary goal is to describe the population of children and non-elderly adults with CP receiving in-home supportive services (IHSS) and determine their health care costs compared to other IHSS recipients.

METHODS

Administrative data from the California Departments of Health and Human Services, Social Services and Developmental Services were linked and de-identified to provide information about individuals receiving IHSS in California in 2005. Recipients with CP were characterized and compared by age. Then to determine the factors associated with hospital use and emergency room (ER) use for IHSS recipients with CP adjusted odds were calculated. Monthly expenditures were calculated from claims data.

RESULTS

2.3% of all IHSS recipients in 2005 had CP of which 46% were children. 59% of recipients with CP have a parent as their paid provider. The presence of other medical diagnoses was the only factor associated with increased adjusted odds of hospital and ER use for both child-aged and non-elderly adult recipients with CP. Functional limitations and provider type were not associated with increased odds of health care utilization. Monthly health care expenditures for recipients with CP were ∼$1000 higher than for other IHSS recipients.

CONCLUSIONS

Having a parent as the IHSS provider was not associated with difference in health service utilization. This finding supports the policy of allowing parents to be paid providers.

A new vicious cycle involving glutamate excitotoxicity, oxidative stress and mitochondrial dynamics

Glutamate excitotoxicity leads to fragmented mitochondria in neurodegenerative diseases, mediated by nitric oxide and S-nitrosylation of dynamin-related protein 1, a mitochondrial outer membrane fission protein. Optic atrophy gene 1 (OPA1) is an inner membrane protein important for mitochondrial fusion. Autosomal dominant optic atrophy (ADOA), caused by mutations in OPA1, is a neurodegenerative disease affecting mainly retinal ganglion cells (RGCs). Here, we showed that OPA1 deficiency in an ADOA model influences N-methyl-D-aspartate (NMDA) receptor expression, which is involved in glutamate excitotoxicity and oxidative stress. Opa1(enu/+) mice show a slow progressive loss of RGCs, activation of astroglia and microglia, and pronounced mitochondrial fission in optic nerve heads as found by electron tomography. Expression of NMDA receptors (NR1, 2A, and 2B) in the retina of Opa1(enu/+) mice was significantly increased as determined by western blot and immunohistochemistry. Superoxide dismutase 2 (SOD2) expression was significantly decreased, the apoptotic pathway was activated as Bax was increased, and phosphorylated Bad and BcL-xL were decreased. Our results conclusively demonstrate that not only glutamate excitotoxicity and/or oxidative stress alters mitochondrial fission/fusion, but that an imbalance in mitochondrial fission/fusion in turn leads to NMDA receptor upregulation and oxidative stress. Therefore, we propose a new vicious cycle involved in neurodegeneration that includes glutamate excitotoxicity, oxidative stress, and mitochondrial dynamics.

Allowing spouses to be paid personal care providers: spouse availability and effects on Medicaid-funded service use and expenditures

PURPOSE OF THE STUDY

 Medicaid service use and expenditure and quality of care outcomes in California's personal care program known as In-Home Supportive Service (IHSS) are described. Analyses investigated Medicaid expenditures, hospital use, and nursing home stays, comparing recipients who have paid spouse caregivers with those having other relatives or unrelated individuals as their caregivers. 

DESIGN AND METHODS

 Medicaid claims and IHSS assessment data for calendar year 2005 were linked for IHSS recipients aged 18 years or older (n = 386,447) 

RESULTS

 The rates of ambulatory care-sensitive hospital admissions and Medicaid-covered nursing home placements were at least comparable among IHSS recipients' with spouse, parent, other relative, or nonrelative caregivers. Statistically significant differences reflected more desirable outcomes for those with relatives as paid caregivers. In no comparisons did those with spouse providers have worse outcomes than those with nonrelative providers. Average monthly Medicaid expenditures for all services were also lower for IHSS recipients with family provider. 

IMPLICATIONS

 There were no financial disadvantages and some advantages to Medicaid in terms of lower average Medicaid expenditures and fewer nursing home admissions when using spouses, parents, and other relatives as paid IHSS providers. This argues in favor of honoring the recipient's and family's preference for such providers.

Nurse staffing and deficiencies in the largest for-profit nursing home chains and chains owned by private equity companies

OBJECTIVE

To compare staffing levels and deficiencies of the 10 largest U.S. for-profit nursing home chains with five other ownership groups and chain staffing and deficiencies before and after purchase by four private equity (PE) companies.

DATA SOURCES

Facilities for the largest for-profit chains were identified through Internet searches and company reports and matched with federal secondary data for 2003-2008 for each ownership group.

STUDY DESIGN

Descriptive statistics and generalized estimation equation panel regression models examined staffing and deficiencies by ownership groups in the 2003-2008 period, controlling for facility characteristics, resident acuity, and market factors with state fixed effects.

PRINCIPAL FINDINGS

The top 10 for-profit chains had lower registered nurse and total nurse staffing hours than government facilities, controlling for other factors. The top 10 chains received 36 percent higher deficiencies and 41 percent higher serious deficiencies than government facilities. Other for-profit facilities also had lower staffing and higher deficiencies than government facilities. The chains purchased by PE companies showed little change in staffing levels, but the number of deficiencies and serious deficiencies increased in some postpurchase years compared with the prepurchase period.

CONCLUSIONS

There is a need for greater study of large for-profit chains as well as those chains purchased by PE companies.

Variation in types of service use and expenditures for individuals with developmental disabilities

BACKGROUND

this study examined the types of services and expenditures for 8 service categories provided by regional centers to 138,336 individuals with developmental disabilities living at home and in the community in California in 2004-2005.

METHODS

logistic regressions of secondary data were used to predict the types of services received, and ordinary least squares regressions were used to predict types of service expenditures.

RESULTS

higher client needs generally were associated with higher odds of receiving services and with expenditures, although the types of services varied by client need. Controlling for client needs and other factors, males were more likely to receive out-of-home services. Individuals aged 3-21 years were generally less likely to receive many services but were more likely to receive in-home and out-of-home respite services than were those over age 62. All racial and ethnic minority groups were less likely to receive support and out-of-home services than were whites and had lower expenditures, although these varied by the types of services. The supply of nursing homes, community care facilities, area population characteristics, and regional centers also predicted variations in service use and expenditure patterns.

CONCLUSION

studies of the underlying reasons for the variations are needed to ensure equity in access to all types of services and expenditures.

Long-range acoustic communication in deep water using a towed array

In September 2010 a long-range acoustic communication (LRAC10) experiment was carried out in deep water off the Southern California Coast. The experiment involved two mobile components: (1) a source towed slowly at a speed of 2-3 knots at ∼75-m depth and (2) a horizontal line array towed at 3.5 knots at a depth of ∼200 m. Phase-coherent communication sequences were transmitted in the frequency band of 200-300 Hz at various ranges (100-700 km). Initial analysis of the LRAC10 data demonstrates that an information rate of 50 bits/s can be achieved over ∼550-km range using quadrature-phase shift-keying (QPSK) modulation and error-correction coding combined with beamforming.

Direct projections from the caudal vestibular nuclei to the ventrolateral medulla in the rat

While the basic pathways mediating vestibulo-ocular, -spinal, and -collic reflexes have been described in detail, little is known about vestibular projections to central autonomic sites. Previous studies have primarily focused on projections from the caudal vestibular region to solitary, vagal and parabrachial nuclei, but have noted a sparse innervation of the ventrolateral medulla. Since a direct pathway from the vestibular nuclei to the rostral ventrolateral medulla would provide a morphological substrate for rapid modifications in blood pressure, heart rate and respiration with changes in posture and locomotion, the present study examined anatomical evidence for this pathway using anterograde and retrograde tract tracing and immunofluorescence detection in brainstem sections of the rat medulla. The results provide anatomical evidence for direct pathways from the caudal vestibular nuclear complex to the rostral and caudal ventrolateral medullary regions. The projections are conveyed by fine and highly varicose axons that ramify bilaterally, with greater terminal densities present ipsilateral to the injection site and more rostrally in the ventrolateral medulla. In the rostral ventrolateral medulla, these processes are highly branched and extremely varicose, primarily directed toward the somata and proximal dendrites of non-catecholaminergic neurons, with minor projections to the distal dendrites of catecholaminergic cells. In the caudal ventrolateral medulla, the axons of vestibular nucleus neurons are more modestly branched with fewer varicosities, and their endings are contiguous with both the perikarya and dendrites of catecholamine-containing neurons. These data suggest that vestibular neurons preferentially target the rostral ventrolateral medulla, and can thereby provide a morphological basis for a short latency vestibulo-sympathetic pathway.

hSSB1 binds and protects p21 from ubiquitin-mediated degradation and positively correlates with p21 in human hepatocellular carcinomas

Downregulation of hSSB1, a single-stranded DNA-binding protein, causes increased radiosensitivity, defective checkpoint activation and genomic instability. However, the mechanisms of hSSB1 function in these responses remain to be uncovered. Here, we present evidence that hSSB1 directly binds p21 and this interaction may prevent p21 from ubiquitin-mediated degradation. Furthermore, both promotion of the G1/S transition and abrogation of the G2/M checkpoints induced by hSSB1 knockdown are partially dependent on p21. Most importantly, hSSB1 and p21 levels are positively correlated in human hepatocellular carcinomas (HCC), as determined by immunostaining. Therefore, hSSB1 may positively modulate p21 to regulate cell cycle progression and DNA damage response, implicating hSSB1 as a novel, promising therapeutic target for cancers such as HCC.

Effect of feeding Mucuna pruriens on helminth parasite infestation in lambs

ETHNOPHARMACOLOGICAL RELEVANCE

Mucuna pruriens is a tropical legume anecdotally reputed to have anthelmintic properties. This study was conducted to examine the validity of such claims.

AIM OF THE STUDY

The aim of this study was to determine if ingestion of Mucuna seeds reduces helminth parasite infestation in lambs.

MATERIALS AND METHODS

Thirty-six Dorper x Katahdin ram lambs were assigned to three treatments, a cottonseed meal based control diet, a diet in which Mucuna replaced cottonseed meal and the control diet with levamisole (7.5mg/kg body weight) administration. All diets were isonitrogenous and isocaloric. The 12 lambs in each treatment were assigned randomly to 4 pens, each containing 3 lambs. Lambs were trickle infected three times per week by gavage with infectious Haemonchus contortus larvae (2000 larvae/lamb) for 3 weeks.

RESULTS

Levamisole treatment decreased fecal egg counts by 87% and abomasal worm counts by 83%. Mucuna intake did not statistically affect fecal egg counts or abomasal worm counts, though numerical (P>0.10) reductions of 7.4% and 18.1%, respectively were evident. Anemia indicators, feed intake, and lamb growth were unaffected by treatment.

CONCLUSIONS

Levamisole reduced the Haemonchus parasite burden in lambs significantly but feeding Mucuna reduced the burden by levels unlikely to eliminate the clinical effects of parasitism.

Factors associated with living in developmental centers in California

This study examined need, predisposing, market, and regional factors that predicted the likelihood of individuals with developmental disabilities living in state developmental centers (DCs) compared with living at home, in community care, or in intermediate care (ICFs) and other facilities. Secondary data analysis using logistic regression models was conducted for all individuals ages 21 years or older who had moderate, severe, or profound intellectual disability. Client needs were the most important factors associated with living arrangements, with those in DCs having more complex needs. Men had higher odds of living in DCs than in other settings, whereas older individuals had lower odds of living in DCs than in ICFs for persons with developmental disabilities and other facilities. Asians/Pacific Islanders, African Americans, and Hispanics were less likely to live in DCs than to live at home. The supply of residential care beds for the elderly reduced the likelihood of living in DCs, and the odds of living in a DC varied widely across regions. Controlling for need, many other factors predicted living arrangements. Policymakers need to ensure adequate resources and provider supply to reduce the need by individuals with intellectual disability to live in DCs and to transition individuals from DCs into other living arrangements.

Immediate breast reconstruction with contralateral pectoralis major myomammary flap for breast conserving surgery

Abstract #5157

Purpose: The breast reconstruction techniques are mandatory in case of the indication permits for there has been lots of data showing no less survival as far as surgery keeps the principle of cancer surgery. It could be selected by many factors but mainly by breast size, site of tumor. The latissimus dorsi musculocutaneous flap (LDMCF) is one of the most commonly used techniques in early breast cancer patient who has small breast. But, it has difficulties to supply enough tissues to the widely excised tumor site. And especially in case of ptosis patient, reduction mammoplasty only is not enough to get the symmetry of the breast. We suggest a pectoralis major myomammary flap(PMMF) as a useful technique for the patients with ptosis.&#x2028; Methods: Seventeen patients with ptosis were treated with breast conserving using PMMF surgery. A quadrantectomy rather than lumpectomy was performed through a planned skin incision, and axillary lymph node dissection was performed according to the sentinel lymph node result. PMMF is harvested carefully without perforating branch injury of internal thoracic artery. And reconstruction was done by the PMMF through the medial tunnel between both breasts.&#x2028; Results: Among those of seventeen patients, seroma occurred in two patients and no necrosis was occurred. The cosmetic result showed good in fifteen and excellent in two patients based on four-point scoring system of breast cosmetics.&#x2028; Conclusions: After enough quadrantectomy to keep the cancer surgery principles, PMMF was quite useful to supply proper tissues for breast reconstructions, especially for the ptosis patient.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5157.

Irinotecan and bevacizumab in progressive primary brain tumors: The Cleveland Clinic experience

2077

Background: High-grade gliomas are generally resistant to modern chemotherapy. In the case of glioblastoma multiforme, median overall survival has been less than 12 months and progression free survival of less than 4 months. For patients with recurrent GBMs, the 6 month progression free survival is 15–20%. The combination of irinotecan and bevacizumab is an active regimen in the treatment of this disease. Herein we report the experiences with this regimen at our institution with the objective of identifying a therapy with a better outcome than historical results. Methods: Single institutional, retrospective review of 27 patients with recurrent or progressive high grade gliomas treated at the Cleveland Clinic Brain Tumor Institute from 7/2005 through 10/2006. Patients had progressed on at least one prior chemotherapy. Patients with prior irinotecan or bevacizumab were excluded. Patients were analyzed on an intention-to-treat basis, and outcomes estimated by the Kaplan-Meier method. Results: The median age of the group was 46 years (range 5–69). The median number of prior therapies was 2 (range 1–10). Twenty of 27 patients have progressed (74%), and 11 of 27 patients have died (41%). Kaplan-Meier estimates for outcomes are summarized in the table . Progression-free survival at 6 months is 46 %, with median of 5.1 months. Overall survival at 6 months is 84%, with median of 12.6 months. In 7 patients, treatment was terminated early prior to progression. Significant toxicities include: one patient who developed hematuria, one patient with deep venous thrombosis and one patient who experienced intracranial hemorrhage. Conclusions: Our experience suggests that the combination of irinotecan and bevacizumab improves the 6-month progression-free survival when compared to historical figures. The rate of severe toxicities is consistent with prior reports and mandates careful selection of patients. Further randomized, phase 3 studies should be done to validate these results.

[Table: see text]

No significant financial relationships to disclose.

Outcomes in a nursing home transition case-management program targeting new admissions

PURPOSE

The Providing Assistance to Caregivers in Transition (PACT) program offers nursing home discharge planning and case management for individuals in the transitional period following a return to the community. The PACT program targeted individuals newly admitted to nursing homes and worked with a family caregiver to develop and implement a nursing home discharge plan.

DESIGN AND METHOD

Reported are the results of a randomized control design evaluating the program's effectiveness. Those individuals randomly assigned to the intervention group (n = 33) received PACT case management in addition to their usual medical and nursing home care. The individuals in the control group (n = 29) continued their usual care.

RESULT

There were no statistical differences in the discharge rate (84% treatment vs 76% controls) or in the median length of stay (42 days vs 55 days) between the two groups of individuals.

IMPLICATIONS

Replications or extensions of a PACT-type intervention might consider a broader mix of nursing homes, working directly with the nursing home's admission Minimum Data Set coordinator in patient selection, or working with Medicare or Medicaid HMO plans.

Functional heterogeneity of prostatic intra-epithelial neoplasia: Length of hormonal therapy influences response

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Background: Prostatic intraepithelial neoplasia (PIN) is a premalignant lesion of the prostate etiologically linked to prostate cancer. While androgen deprivation therapy (ADT) has been used to reduce prostate cancer, there are controversial data regarding the effect of ADT on PIN. We hypothesized that PIN is a heterogeneous entity with respect to hormone responsiveness, that this may explain aspects of the heterogeneity in the natural history of this disease, and have used the clinical model of ADT followed by radical prostatectomy as a test of this hypothesis. Methods: We performed a retrospective study on a cohort of patients who underwent prostatectomy with biopsy proven prostate cancer. Study patients were those who must have received at least 3 months of ADT at the discretion of their surgeons. Patients from the same cohort who did not undergo ADT were used as controls. Patients were randomly selected from the database and their pathology slides were reviewed by a blinded pathologist looking for presence of PIN with an independent observer. Fisher’s exact test was used to compare the proportions of subjects who had residual PIN in the study group and the control group. Exact logistic regression was used to evaluate the duration of ADT in PIN regression. Results: Eighteen patients initially diagnosed with PIN who did not receive hormonal therapy were identified; 28 patients with PIN who underwent hormonal therapy were also studied. All patients who did not receive hormonal therapy had residual PIN whereas 7 of 28 patients undergoing ADT had no residual PIN (p = 0.043). Evaluation of hormonal therapy between responders and non-responders showed statistically significant association between PIN regression and hormone therapy duration (p < 0.001). However PIN response to ADT was not uniform as 16% of patients with ADT longer than 6 months had residual PIN, suggesting variable sensitivity of PIN to ADT. Conclusions: Our results demonstrate that ADT does cause PIN regression, and that there is heterogeneity in this effect with respect to hormonal duration. We propose for future prospective, multi-centered, randomized trials in which ADT impact on PIN is characterized further.

No significant financial relationships to disclose.

Living quarters and unmet need for personal care assistance among adults with disabilities

OBJECTIVES

This study used a person-environment (P-E) framework to examine individual capabilities and social and physical environmental attributes for their association with unmet assistance needs in activities of daily living (ADLs). Analyses were replicated among five ADLs (bathing, dressing, transferring, toileting, eating) and test the relative risk of apartment dwellers compared to those living in houses.

METHODS

Data were obtained from the National Health Interview Survey, Supplement on Disability Followback Survey. Analyses consisted of a nationally representative sample of aged and nonaged adults with one or more ADL limitations.

RESULTS

Slightly less than 1 in 5 subjects with a specific ADL limitation had unmet needs for that ADL. This was true across all ADLs. The likelihood of unmet ADL assistance increased with the number of ADL limitations and other health status indicators. It was at least 50% higher among those living in apartments than in houses and higher among Hispanics. There were no differences by age or gender.

DISCUSSION

The P-E framework postulates that individuals seek settings matched to their capabilities, but findings suggest that many are at risk for adaptation at any one time. Specific risk factors are identified. Selection factors like preferences, expectations, and adaptation options available have not been directly measured.

Unmet Need for Personal Assistance Services: Estimating the Shortfall in Hours of Help and Adverse Consequences

OBJECTIVES

Perceived unmet need for personal assistance services (PAS) in activities of daily living (ADLs) and instrumental ADLs and its association with reduced hours of help received and with adverse consequences due to lack of help are examined for adults aged 18 and older using data from the 1994-1997 National Health Interview Survey on Disability.

METHODS

A two-part multivariate regression model of the probability of PAS use and hours of help received was developed to control for need level, living arrangements, and other characteristics that may differ between persons with met and unmet needs and to determine the shortfall in hours associated with unmet need.

RESULTS

Individuals with unmet need for personal assistance with two or more of the five basic ADLs have a shortfall of 16.6 hours of help per week compared with those whose needs are met. The relative shortfall is twice as great for persons who live alone as for those who live with others. People who live alone and have unmet needs fare worse than people with unmet needs who live with others, and both groups are more likely than those whose needs are met to experience adverse consequences, including discomfort, weight loss, dehydration, falls, burns, and dissatisfaction with the help received.

DISCUSSION

Overall, just 6.6% of needed hours are unmet among the 3.3 million people needing help in two or more ADLs. We estimate the annual cost of eliminating unmet need among persons with incomes under 300% of the Supplemental Security Income level between 1.2 and 2.7 billion dollars for those living alone and from 2.2 to 7.1 billion dollars for those living with others.

Estimating paid and unpaid hours of personal assistance services in activities of daily living provided to adults living at home

OBJECTIVE

To estimate the total hours of paid and unpaid personal assistance of daily living provided to adults living at home in the United States using nationally representative household survey data.

DATA SOURCES

The Disability Followback Survey of the National Health Interview Survey on Disability (NHIS-D) conducted from 1994 to 1997.

DATA COLLECTION/EXTRACTION METHODS

Data were obtained on persons receiving help with up to 5 ADLs and 10 IADLs, for up to 4 helpers, including the activities they helped with, whether the helper was paid or not, and the number of hours of help provided in the two weeks prior to the survey. The sample consists of 8,471 household-resident adults ages 18 and older receiving help with personal assistance. About 22 percent of the sample has missing data on hours, which we impute by multiple regression models using demographic, ADL, and IADL variables.

FINDINGS

We estimate that 13.2 million noninstitutionalized adults receive an average of 31.4 hours per week of personal assistance in ADLs and IADLs per week, with 3.2 million people receiving an average of 17.6 hours of paid help and 11.7 million receiving an average of 30.7 hours of unpaid help. More persons ages 18-64 received help than those ages 65 and older (6.9 versus 6.2 million), but working-age recipients had fewer hours (27.4 versus 35.9) per week, due in part to less severe levels of disability.

CONCLUSIONS

Personal assistance provided to adults with disabilities amounts to 21.5 billion hours of help per year, with an economic value in 1996 approaching $200 billion. Only 16 percent of this total is paid, representing $32 billion in home health services spent annually. This study, the first to estimate hours of assistance for both working-age and older adults, documents that older persons are more likely to receive paid personal assistance, while working-age people rely to a greater extent on unpaid help. This study begins to articulate the division of labor in the provision of personal assistance. Estimates of paid and unpaid hours of help by number of ADLs should inform policy concerning eligibility boundaries in long term care.