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Initiation of the ABCD3-I algorithm for expediated evaluation of transient ischemic attack patients in an emergency department.

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Initiation of the ABCD3-I algorithm for expediated evaluation of transient ischemic attack patients in an emergency department.

Am J Emerg Med. 2019 Jun 10;:

Authors: Dahlquist RT, Young JM, Reyner K, Farzad A, Moleno RB, Gandham G, Ho AF, Wang H

Abstract
BACKGROUND: The use of ABCD3-I score for Transient ischemic attack (TIA) evaluation has not been widely investigated in the ED. We aim to determine the performance and cost-effectiveness of an ABCD3-I based pathway for expedited evaluation of TIA patients in the ED.
METHODS: We conducted a single-center, pre- and post-intervention study among ED patients with possible TIA. Accrual occurred for seven months before (Oct. 2016-April 2017) and after (Oct. 2017-April 2018) implementing the ABCD3-I algorithm with a five-month wash-in period (May-Sept. 2017). Total ED length of stay (LOS), admissions to the hospital, healthcare cost, and 90-day ED returns with subsequent stroke were analyzed and compared.
RESULTS: Pre-implementation and post-implementation cohorts included 143 and 118 patients respectively. A total of 132 (92%) patients were admitted to the hospital in the pre-implementation cohort in comparison to 28 (24%) patients admitted in the post-implementation cohort (p < 0.001) with similar 90-day post-discharge stroke occurrence (2 in pre-implementation versus 1 in post-implementation groups, p > 0.05). The mean ABCD2 scores were 4.5 (1.4) in pre- and 4.1 (1.3) in post-implementation cohorts (p = 0.01). The mean ABCD3-I scores were 4.5 (1.8) in post-implementation cohorts. Total ED LOS was 310 min (201, 420) in pre- and 275 min (222, 342) in post-implementation cohorts (p > 0.05). Utilization of the ABCD3-I algorithm saved an average of over 40% of total healthcare cost per patient in the post-implementation cohort.
CONCLUSIONS: The initiation of an ABCD3-I based pathway for TIA evaluation in the ED significantly decreased hospital admissions and cost with similar 90-day neurological outcomes.

PMID: 31230922 [PubMed - as supplied by publisher]

Where Are the Opportunities for Reducing Health Care Spending Within Alternative Payment Models?

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Where Are the Opportunities for Reducing Health Care Spending Within Alternative Payment Models?

J Oncol Pract. 2018 06;14(6):e375-e383

Authors: Rocque GB, Williams CP, Kenzik KM, Jackson BE, Halilova KI, Sullivan MM, Rocconi RP, Azuero A, Kvale EA, Huh WK, Partridge EE, Pisu M

Abstract
PURPOSE: The Oncology Care Model (OCM) is a highly controversial specialty care model developed by the Centers for Medicare & Medicaid aimed to provide higher-quality care at lower cost. Because oncologists will be increasingly held accountable for spending as well as quality within new value-based health care models like the OCM, they need to understand the drivers of total spending for their patients.
METHODS: This retrospective cohort study included patients ≥ 65 years of age with primary fee-for-service Medicare insurance who received antineoplastic therapy at 12 cancer centers in the Southeast from 2012 to 2014. Medicare administrative claims data were used to identify health care spending during the prechemotherapy period (from cancer diagnosis to antineoplastic therapy initiation) and during the OCM episodes of care triggered by antineoplastic treatment. Total health care spending per episode includes all types of services received by a patient, including nononcology services. Spending was further characterized by type of service.
RESULTS: Average total health care spending in the three OCM episodes of care was $33,838 (n = 3,427), $23,811 (n = 1,207), and $19,241 (n = 678). Antineoplastic drugs accounted for 27%, 32%, and 36% of total health care spending in the first, second, and third episodes. Ten drugs, used by 31% of patients, contributed 61% to drug spending ($18.8 million) in the first episode. Inpatient spending also substantially contributed to total costs, representing 17% to 20% ($30.5 million) of total health care spending.
CONCLUSION: Health care spending was heavily driven by both antineoplastic drugs and hospital use. Oncologists' ability to affect these types of spending will determine their success under alternative payment models.

PMID: 28981388 [PubMed - indexed for MEDLINE]

Affordable Care Act and cancer stage at diagnosis in an underserved population.

Bassam Ghabach, MD - Thu, 06/20/2019 - 18:53
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Affordable Care Act and cancer stage at diagnosis in an underserved population.

Prev Med. 2019 Jun 10;:

Authors: Lu Y, Jackson BE, Gehr AW, Cross D, Neerukonda L, Tanna B, Ghabach B, Ojha RP

Abstract
The Patient Protection and Affordable Care Act (ACA) has increased insurance coverage among underserved individuals, but the effect of ACA on cancer diagnosis is currently debated, particularly in Medicaid non-expansion states. Therefore, we aimed to assess the effect of ACA implementation on stage at diagnosis among underserved cancer patients in Texas, a Medicaid non-expansion state. We used data from the institutional registry of the JPS Center for Cancer Care, which serves an urban population of underserved cancer patients. Eligible individuals were aged 18 to 64 years and diagnosed with a first primary invasive solid tumor between 2008 and 2015. We used a natural experiment framework and interrupted time-series analysis to assess level (i.e. immediate) and slope (over time) changes in insurance coverage and cancer stage at diagnosis between pre- and post-ACA periods. Our study population comprised 4808 underserved cancer patients, of whom 51% were racial/ethnic minorities. The prevalence of uninsured cancer patients did not immediately change after ACA implementation but modestly decreased over time (PR = 0.94; 95% CL: 0.90, 0.98). The prevalence of early- and advanced-stage diagnosis did not appreciably change overall or when stratified by screen-detectable cancers. Our results suggest that ACA implementation decreased the prevalence of uninsured cancer patients but had little effect on cancer stage at diagnosis in an underserved population. Given that Texas is a Medicaid non-expansion state, Medicaid expansion and alternative approaches may need to be further explored to improve earlier cancer diagnosis among underserved individuals.

PMID: 31195020 [PubMed - as supplied by publisher]

Rethinking the definition of major trauma: The Need For Trauma Intervention outperforms Injury Severity Score and Revised Trauma Score in 38 adult and pediatric trauma centers.

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Rethinking the definition of major trauma: The Need For Trauma Intervention outperforms Injury Severity Score and Revised Trauma Score in 38 adult and pediatric trauma centers.

J Trauma Acute Care Surg. 2019 Jun 13;:

Authors: Roden-Foreman JW, Rapier NR, Foreman ML, Zagel AL, Sexton KW, Beck WC, McGraw C, Coniglio RA, Blackmore AR, Holzmacher J, Sarani B, Hess JC, Greenwell C, Adams CA, Lueckel SN, Weaver M, Agrawal V, Amos JD, Workman CF, Milia DJ, Bertelson A, Dorlac W, Warne MJ, Cull J, Lyell CA, Regner JL, McGonigal MD, Flohr SD, Steen S, Nance ML, Campbell M, Putty B, Sherar D, Schroeppel TJ

Abstract
BACKGROUND: Patients' trauma burdens are a combination of anatomic damage, physiologic derangement, and the resultant depletion of reserve. Typically, Injury Severity Score (ISS) >15 defines major anatomic injury and Revised Trauma Score (RTS) <7.84 defines major physiologic derangement, but there is no standard definition for reserve. The Need For Trauma Intervention (NFTI) identifies severely depleted reserves (NFTI+) with emergent interventions and/or early mortality. We hypothesized NFTI would have stronger associations with outcomes and better model fit than ISS and RTS.
METHODS: Thirty-eight adult and pediatric U.S. trauma centers submitted data for 88,488 encounters. Mixed models tested ISS >15, RTS <7.84, and NFTI's associations with complications, survivors' discharge to continuing care, and survivors' length of stay (LOS).
RESULTS: NFTI had stronger associations with complications and LOS than ISS and RTS (odds ratios (99.5% CI): NFTI = 9.44 (8.46, 10.53), ISS = 5.94 (5.36, 6.60), RTS = 4.79 (4.29, 5.34); LOS incidence rate ratios (99.5% CI): NFTI = 3.15 (3.08, 3.22), ISS = 2.87 (2.80, 2.94), RTS = 2.37 (2.30, 2.45)). NFTI was more strongly associated with continuing care discharge but not significantly more than ISS (relative risk (99.5% CI): NFTI = 2.59 (2.52, 2.66), ISS = 2.51 (2.44, 2.59), RTS = 2.37 (2.28, 2.46)). Cross-validation revealed that in all cases NFTI's model provided a much better fit than ISS>15 or RTS<7.84.
CONCLUSIONS: In this multicenter study, NFTI had better model fit and stronger associations with the outcomes than ISS and RTS. By determining depletion of reserve via resource consumption, NFTI+ may be a better definition of major trauma than the standard definitions of ISS >15 and RTS <7.84. Using NFTI may improve retrospective triage monitoring and statistical risk adjustments.
LEVEL OF EVIDENCE: III, Therapeutic.

PMID: 31205214 [PubMed - as supplied by publisher]

Affordable Care Act and cancer stage at diagnosis in an underserved population.

Affordable Care Act and cancer stage at diagnosis in an underserved population.

Prev Med. 2019 Jun 10;:

Authors: Lu Y, Jackson BE, Gehr AW, Cross D, Neerukonda L, Tanna B, Ghabach B, Ojha RP

Abstract
The Patient Protection and Affordable Care Act (ACA) has increased insurance coverage among underserved individuals, but the effect of ACA on cancer diagnosis is currently debated, particularly in Medicaid non-expansion states. Therefore, we aimed to assess the effect of ACA implementation on stage at diagnosis among underserved cancer patients in Texas, a Medicaid non-expansion state. We used data from the institutional registry of the JPS Center for Cancer Care, which serves an urban population of underserved cancer patients. Eligible individuals were aged 18 to 64 years and diagnosed with a first primary invasive solid tumor between 2008 and 2015. We used a natural experiment framework and interrupted time-series analysis to assess level (i.e. immediate) and slope (over time) changes in insurance coverage and cancer stage at diagnosis between pre- and post-ACA periods. Our study population comprised 4808 underserved cancer patients, of whom 51% were racial/ethnic minorities. The prevalence of uninsured cancer patients did not immediately change after ACA implementation but modestly decreased over time (PR = 0.94; 95% CL: 0.90, 0.98). The prevalence of early- and advanced-stage diagnosis did not appreciably change overall or when stratified by screen-detectable cancers. Our results suggest that ACA implementation decreased the prevalence of uninsured cancer patients but had little effect on cancer stage at diagnosis in an underserved population. Given that Texas is a Medicaid non-expansion state, Medicaid expansion and alternative approaches may need to be further explored to improve earlier cancer diagnosis among underserved individuals.

PMID: 31195020 [PubMed - as supplied by publisher]

Radiation therapy utilization in Medicare beneficiaries with early-stage breast cancer.

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Radiation therapy utilization in Medicare beneficiaries with early-stage breast cancer.

Cancer. 2018 02 01;124(3):475-481

Authors: Wallace AS, Keene KS, Williams CP, Jackson BE, Pisu M, Partridge EE, Rocque GB

Abstract
BACKGROUND: There is increasing evidence that radiation therapy (RT) can be omitted for select older patients who are compliant with hormonal blockade, but there is no recent claim-based analysis for determining patterns of care and guiding possible treatment recommendations.
METHODS: Medicare beneficiaries who were 65 years old or older and were diagnosed with breast cancer at 1 of 12 cancer centers affiliated with an academic center in the southeastern United States were analyzed. Stage 0 or I patients treated with lumpectomy from 2012 to 2014 were identified. Patient, treatment, and center characteristics were analyzed for the utilization of RT.
RESULTS: Among 800 women treated with lumpectomy, 64% received adjuvant radiation. The median age was 74 years. The omission of RT was more likely in older patients, stage 0 patients, and patients with more comorbidities (P < .01). Hormonal blockade was used in 41% of the patients who did not receive RT. The utilization of hormonal blockade with the omission of RT was more likely in patients with fewer comorbidities (P < .01).
CONCLUSIONS: In an older cohort of patients who otherwise would have qualified for the omission of radiation, two-thirds were treated with radiation. Future guideline recommendations should address omission in the context of hormonal blockade compliance because only 41% of the patients used hormonal blockade when radiation was not delivered. Cancer 2018;124:475-81. © 2017 American Cancer Society.

PMID: 29053170 [PubMed - indexed for MEDLINE]

Role of Empiric Anti-Fungal Therapy in the Treatment of Perforated Peptic Ulcer Disease: Review of the Evidence and Future Directions.

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Role of Empiric Anti-Fungal Therapy in the Treatment of Perforated Peptic Ulcer Disease: Review of the Evidence and Future Directions.

Surg Infect (Larchmt). 2019 Jun 12;:

Authors: Huston JM, Kreiner L, Ho VP, Sanders JM, Duane TM

Abstract
Background: Peptic ulcer disease (PUD) affects four million people worldwide. Perforated peptic ulcer (PPU) occurs in less than 15% of cases but is associated with significant morbidity and mortality rates. Administration of antibiotics is standard treatment for gastrointestinal perforations, including PPU. Although fungal growth is common in peritoneal fluid cultures from patients with PPU, current data suggest empiric anti-fungal therapy fails to improve outcomes. To examine the role of anti-fungal agents in the treatment of PPU, the Surgical Infection Society hosted an Update Symposium at its 37th Annual Meeting. Here, we provide a synopsis of the symposium's findings and a brief review of prospective and retrospective reports on the subject. Methods: A search of Pubmed/MEDLINE, EMBASE, and the Cochrane Library was performed between January 1, 2000, and November 1, 2018, comparing outcomes of PPU following empiric anti-fungal treatment versus no anti-fungal therapy. We used the search terms "perforated peptic ulcer," "gastroduodenal ulcer," "anti-fungal," and "perforated" or "perforation." Results: There are no randomized clinical trials comparing outcomes specifically for patients with PPU treated with or without empiric anti-fungal therapy. We identified one randomized multi-center trial evaluating outcomes for patients with intra-abdominal perforations, including PPU, that were treated with or without empiric anti-fungal therapy. We identified one single-center prospective series and three additional retrospective studies comparing outcomes for patients with PPU treated with or without empiric anti-fungal therapy. Conclusion: The current evidence reviewed here does not demonstrate efficacy of anti-fungal agents in improving outcomes in patients with PPU. As such, we caution against the routine use of empiric anti-fungal agents in these patients. Further studies should help identify specific subpopulations of patients who might derive benefit from anti-fungal therapy and help define appropriate treatment regimens and durations that minimize the risk of resistance, adverse events, and cost.

PMID: 31188069 [PubMed - as supplied by publisher]

Accuracy of point-of-care ultrasound and radiology-performed ultrasound for intussusception: A systematic review and meta-analysis.

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Accuracy of point-of-care ultrasound and radiology-performed ultrasound for intussusception: A systematic review and meta-analysis.

Am J Emerg Med. 2019 Jun 04;:

Authors: Tsou PY, Wang YH, Ma YK, Deanehan JK, Gillon J, Chou EH, Hsu TC, Huang YC, Lin J, Lee CC

Abstract
OBJECTIVE: It is unclear whether point-of-care ultrasound (POCUS) by emergency medicine physicians is as accurate as radiology-performed ultrasound (RADUS). We aim to summarize the diagnostic accuracy of ultrasonography for intussusception and to compare the performance between POCUS and RADUS.
METHODS: Databases were searched from inception through February 2018 using pre-defined index terms. Peer-reviewed primary studies that investigated the diagnostic accuracy of ultrasound for intussusception in children were included. The study is reported using Preferred Reporting Items for a Systematic Review and Meta-analysis of Diagnostic Test Accuracy Studies (PRISMA-DTA). Meta-analysis of the diagnostic accuracy of ultrasound for intussusception was conducted using the random-effects bivariate model. Subgroup analysis (POCUS vs RADUS) was also performed. Meta-regression was utilized to determine if the diagnostic accuracy between POCUS and RADUS was significantly different.
RESULTS: Thirty studies (n = 5249) were included in the meta-analysis. Ultrasonography for intussusception has a sensitivity: 0.98 (95% CI: 0.96-0.98), specificity: 0.98 (95% CI: 0.95-0.99), positive likelihood ratio: 43.8 (95% CI: 18.0-106.7) and negative likelihood ratio: 0.03 (95% CI: 0.02-0.04), with an area under ROC (AUROC) curve of 0.99 (95% CI: 0.98-1.00). Meta-regression suggested no significant difference in the diagnostic accuracy for intussusception between POCUS and RADUS (AUROC: 0.95 vs 1.00, p = 0.128).
CONCLUSIONS: Current evidence suggested POCUS has a high diagnostic accuracy for intussusception not significantly different from that of RADUS.

PMID: 31182360 [PubMed - as supplied by publisher]

Maternal iodine excess: an uncommon cause of acquired neonatal hypothyroidism.

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Maternal iodine excess: an uncommon cause of acquired neonatal hypothyroidism.

J Pediatr Endocrinol Metab. 2018 Sep 25;31(9):1061-1064

Authors: Hamby T, Kunnel N, Dallas JS, Wilson DP

Abstract
Background Excessive iodine exposure is an often overlooked cause of neonatal hypothyroidism. Case presentation We present an infant with iodine-induced hypothyroidism, which was detected at age 15 days by newborn screening. The infant's iodine excess resulted from maternal intake of seaweed soup both during and after pregnancy. Treatment included discontinuation of seaweed soup, temporary interruption of breastfeeding and short-term levothyroxine therapy. By age 4 months, the infant's hypothyroidism had resolved, and her growth and development were normal. Conclusions This case illustrates the importance of considering excess dietary iodine as a possible cause of hypothyroidism in infants.

PMID: 30052521 [PubMed - indexed for MEDLINE]

Vitamin D Screening and Supplementation in Community-Dwelling Adults: Common Questions and Answers.

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Vitamin D Screening and Supplementation in Community-Dwelling Adults: Common Questions and Answers.

Am Fam Physician. 2018 Feb 15;97(4):254-260

Authors: LeFevre ML, LeFevre NM

Abstract
Measurement of vitamin D levels and supplementation with oral vitamin D have become commonplace, although clinical trials have not demonstrated health benefits. The usefulness of serum 25-hydroxyvitamin D levels to assess adequate exposure to vitamin D is hampered by variations in measurement technique and precision. Serum levels less than 12 ng per mL reflect inadequate vitamin D intake for bone health. Levels greater than 20 ng per mL are adequate for 97.5% of the population. Routine vitamin D supplementation does not prolong life, decrease the incidence of cancer or cardiovascular disease, or decrease fracture rates. Screening asymptomatic individuals for vitamin D deficiency and treating those considered to be deficient do not reduce the risk of cancer, type 2 diabetes mellitus, or death in community-dwelling adults, or fractures in persons not at high risk of fractures. Randomized controlled trials of vitamin D supplementation in the treatment of depression, fatigue, osteoarthritis, and chronic pain show no benefit, even in persons with low levels at baseline.

PMID: 29671532 [PubMed - indexed for MEDLINE]

Home-based Physical Activity Coaching, Physical Activity, and Health Care Utilization in Chronic Obstructive Pulmonary Disease. Chronic Obstructive Pulmonary Disease Self-Management Activation Research Trial Secondary Outcomes.

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Home-based Physical Activity Coaching, Physical Activity, and Health Care Utilization in Chronic Obstructive Pulmonary Disease. Chronic Obstructive Pulmonary Disease Self-Management Activation Research Trial Secondary Outcomes.

Ann Am Thorac Soc. 2018 04;15(4):470-478

Authors: Coultas DB, Jackson BE, Russo R, Peoples J, Singh KP, Sloan J, Uhm M, Ashmore JA, Blair SN, Bae S

Abstract
RATIONALE: Physical inactivity among patients with chronic obstructive pulmonary disease is associated with exacerbations requiring high-cost health care utilization including urgent, emergent, and hospital care.
OBJECTIVES: To examine the effectiveness of a behavioral lifestyle physical activity intervention combined with chronic obstructive pulmonary disease self-management education to prevent high-cost health care utilization.
METHODS: This was an analysis of secondary outcomes of the Chronic Obstructive Pulmonary Disease Self-Management Activation Research Trial, a two-arm randomized trial of stable adult outpatients with chronic obstructive pulmonary disease recruited from primary care and pulmonary clinics. Following a 6-week self-management education run-in period, participants were randomized to usual care or to a telephone-delivered home-based health coaching intervention over 20 weeks. Secondary outcomes of physical activity and health care utilization were determined by self-report 6, 12, and 18 months after randomization. Associations between treatment allocation arm and these secondary outcomes were examined using log-binomial and Poisson regression models.
RESULTS: A total of 325 outpatients with stable chronic obstructive pulmonary disease were enrolled in the trial. Their average age was 70.3 years (standard deviation, 9.5), and 50.5% were female; 156 were randomized to usual care and 149 to the intervention. A greater proportion of participants reported being persistently active over the 18-month follow-up period in the intervention group (73.6%) compared with the usual care group (57.8%) (mean difference, 15.8%; 95% confidence interval, 4.0-27.7%). This association varied by severity of forced expiratory volume in 1 second impairment (P for interaction = 0.09). Those in the intervention group with moderate impairment (forced expiratory volume in 1 second, 50-70% predicted), more frequently reported being persistently active compared with the usual care (86.0 vs. 65.1%; mean difference, 20.9%; 95% confidence interval, 5.7-36.1%). Patients with severe and very severe forced expiratory volume in 1 second impairment (forced expiratory volume in 1 second < 50% predicted) in the intervention group also reported being persistently active more frequently compared with usual care (63.3 vs. 50.8%; mean difference, 12.6%; 95% confidence interval, -4.7 to 29.8). The intervention was associated with a lower rate of lung-related utilization (adjusted rate ratio, 0.38; 95% confidence interval, 0.23-0.63) only among participants with severe spirometric impairment.
CONCLUSIONS: Our results demonstrate that a feasible and generalizable home-based coaching intervention may decrease sedentary behavior and increase physical activity levels. In those with severe chronic obstructive pulmonary disease, this intervention may reduce lung disease-related health care utilization. Clinical trial registered with www.clinicaltrials.gov (NCT01108991).

PMID: 29283670 [PubMed - indexed for MEDLINE]

Setting-Based Prioritization for Birth Cohort Hepatitis C Virus Testing in the United States.

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Setting-Based Prioritization for Birth Cohort Hepatitis C Virus Testing in the United States.

Clin Infect Dis. 2019 May 24;:

Authors: MacDonald BR, Chu TC, Stewart RA, Ojha RP

PMID: 31125407 [PubMed - as supplied by publisher]

Lower Abnormal Fecal Immunochemical Test Cutoff Values Improve Detection of Colorectal Cancer in System-Level Screens.

Mark Koch, MD - Thu, 05/16/2019 - 11:20
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Lower Abnormal Fecal Immunochemical Test Cutoff Values Improve Detection of Colorectal Cancer in System-Level Screens.

Clin Gastroenterol Hepatol. 2019 May 11;:

Authors: Berry E, Miller S, Koch M, Balasubramanian B, Argenbright K, Gupta S

Abstract
BACKGROUND & AIMS: Non-invasive tests used in colorectal cancer screening, such as the fecal immunochemical test (FIT), are more acceptable but detect neoplasias with lower levels of sensitivity than colonoscopy. We investigated whether lowering the cutoff concentration of hemoglobin for designation as an abnormal FIT result increased the detection of advanced neoplasia in a mailed outreach program.
METHODS: We performed a prospective study of 17,017 uninsured patients, 50-64 years old, who were not current with screening and enrolled in a safety-net system in Texas. We reduced the cutoff value for an abnormal FIT result from ≥ 20 to ≥ 10 μg hemoglobin/g feces a priori. All patients with abnormal FIT results were offered no-cost diagnostic colonoscopy. We compared proportions with abnormal FIT results and neoplasia yield for standard vs lower cutoff values, as well as absolute hemoglobin concentration distribution among 5838 persons who completed the FIT. Our primary aim was to determine the effects of implementing a lower hemoglobin concentration cutoff on colonoscopy demand and yield, specifically colorectal cancer (CRC) and advanced neoplasia detection, compared to the standard, higher, hemoglobin concentration cutoff value.
RESULTS: The proportions of patients with abnormal FIT results were 12.3% at the ≥ 10 μg hemoglobin/g feces and 6.6% at the standard ≥ 20 μg hemoglobin/g feces cutoff value (P=.0013). Detection rates for the lower vs the standard threshold were 10.2% vs 12.7% for advanced neoplasia (P=.12) and 0.9% vs 1.2% for CRC (P=.718). The positive predictive values were 18.9% for the lower threshold vs 24.4% for the standard threshold for advanced neoplasia (P=.053) and 1.7% vs 2.4% for CRC (P=.659). The number needed to screen to detect 1 case with advanced neoplasia was 45 at the lower threshold compared with 58 at the standard threshold; the number needed to scope to detect 1 case with advanced neoplasia increased from 4 to 5. Most patients with CRC (72.7%) or advanced adenoma (67.3%) had hemoglobin concentrations ≥ 20 μg/g feces. In the 10-19 μg hemoglobin/g feces range, there were 3 patients with CRC (3/11, 27.3%) and 36 with advanced adenoma (36/110, 32.7%) who would not have been detected at the standard positive threshold (advanced neoplasia Pcomparison <.001). The proportion of patients found to have no neoplasia after an abnormal FIT result (false positives) was not significantly higher with the lower cutoff value (44.4%) than the standard cutoff (39.1%) (P=.1103).
CONCLUSION: In a prospective study of 17,017 uninsured patients, we found that reducing the abnormal FIT result cutoff value (to the ≥ 10 μg hemoglobin/g feces) might increase detection of advanced neoplasia, but doubled the proportion of patients requiring a diagnostic colonoscopy. If colonoscopy capacity permits, health systems that use quantitative FITs should consider lowering the abnormal cutoff value, to optimize CRC detection and prevention. ClinicalTrials.gov no: NCT01946282.

PMID: 31085338 [PubMed - as supplied by publisher]

Lower Abnormal Fecal Immunochemical Test Cutoff Values Improve Detection of Colorectal Cancer in System-Level Screens.

Related Articles

Lower Abnormal Fecal Immunochemical Test Cutoff Values Improve Detection of Colorectal Cancer in System-Level Screens.

Clin Gastroenterol Hepatol. 2019 May 11;:

Authors: Berry E, Miller S, Koch M, Balasubramanian B, Argenbright K, Gupta S

Abstract
BACKGROUND & AIMS: Non-invasive tests used in colorectal cancer screening, such as the fecal immunochemical test (FIT), are more acceptable but detect neoplasias with lower levels of sensitivity than colonoscopy. We investigated whether lowering the cutoff concentration of hemoglobin for designation as an abnormal FIT result increased the detection of advanced neoplasia in a mailed outreach program.
METHODS: We performed a prospective study of 17,017 uninsured patients, 50-64 years old, who were not current with screening and enrolled in a safety-net system in Texas. We reduced the cutoff value for an abnormal FIT result from ≥ 20 to ≥ 10 μg hemoglobin/g feces a priori. All patients with abnormal FIT results were offered no-cost diagnostic colonoscopy. We compared proportions with abnormal FIT results and neoplasia yield for standard vs lower cutoff values, as well as absolute hemoglobin concentration distribution among 5838 persons who completed the FIT. Our primary aim was to determine the effects of implementing a lower hemoglobin concentration cutoff on colonoscopy demand and yield, specifically colorectal cancer (CRC) and advanced neoplasia detection, compared to the standard, higher, hemoglobin concentration cutoff value.
RESULTS: The proportions of patients with abnormal FIT results were 12.3% at the ≥ 10 μg hemoglobin/g feces and 6.6% at the standard ≥ 20 μg hemoglobin/g feces cutoff value (P=.0013). Detection rates for the lower vs the standard threshold were 10.2% vs 12.7% for advanced neoplasia (P=.12) and 0.9% vs 1.2% for CRC (P=.718). The positive predictive values were 18.9% for the lower threshold vs 24.4% for the standard threshold for advanced neoplasia (P=.053) and 1.7% vs 2.4% for CRC (P=.659). The number needed to screen to detect 1 case with advanced neoplasia was 45 at the lower threshold compared with 58 at the standard threshold; the number needed to scope to detect 1 case with advanced neoplasia increased from 4 to 5. Most patients with CRC (72.7%) or advanced adenoma (67.3%) had hemoglobin concentrations ≥ 20 μg/g feces. In the 10-19 μg hemoglobin/g feces range, there were 3 patients with CRC (3/11, 27.3%) and 36 with advanced adenoma (36/110, 32.7%) who would not have been detected at the standard positive threshold (advanced neoplasia Pcomparison <.001). The proportion of patients found to have no neoplasia after an abnormal FIT result (false positives) was not significantly higher with the lower cutoff value (44.4%) than the standard cutoff (39.1%) (P=.1103).
CONCLUSION: In a prospective study of 17,017 uninsured patients, we found that reducing the abnormal FIT result cutoff value (to the ≥ 10 μg hemoglobin/g feces) might increase detection of advanced neoplasia, but doubled the proportion of patients requiring a diagnostic colonoscopy. If colonoscopy capacity permits, health systems that use quantitative FITs should consider lowering the abnormal cutoff value, to optimize CRC detection and prevention. ClinicalTrials.gov no: NCT01946282.

PMID: 31085338 [PubMed - as supplied by publisher]

Recovery of Motor Function after Mixed and Motor Nerve Repair with Processed Nerve Allograft.

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Recovery of Motor Function after Mixed and Motor Nerve Repair with Processed Nerve Allograft.

Plast Reconstr Surg Glob Open. 2019 Mar;7(3):e2163

Authors: Safa B, Shores JT, Ingari JV, Weber RV, Cho M, Zoldos J, Niacaras TR, Nesti LJ, Thayer WP, Buncke GM

Abstract
Background: Severe trauma often results in the transection of major peripheral nerves. The RANGER Registry is an ongoing observational study on the use and outcomes of processed nerve allografts (PNAs; Avance Nerve Graft, AxoGen, Inc., Alachua, Fla.). Here, we report on motor recovery outcomes for nerve injuries repaired acutely or in a delayed fashion with PNA and comparisons to historical controls in the literature.
Methods: The RANGER database was queried for mixed and motor nerve injuries in the upper extremities, head, and neck area having completed greater than 1 year of follow-up. All subjects with sufficient assessments to evaluate functional outcomes were included. Meaningful recovery was defined as ≥M3 on the Medical Research Council scale. Demographics, outcomes, and covariate analysis were performed to further characterize this subgroup.
Results: The subgroup included 20 subjects with 22 nerve repairs. The mean ± SD (minimum-maximum) age was 38 ± 19 (16-77) years. The median repair time was 9 (0-133) days. The mean graft length was 33 ± 17 (10-70) mm with a mean follow-up of 779 ± 480 (371-2,423) days. Meaningful motor recovery was observed in 73%. Subgroup analysis showed no differences between gap lengths or mechanism of injury. There were no related adverse events.
Conclusions: PNAs were safe and provided functional motor recovery in mixed and motor nerve repairs. Outcomes compare favorably to historical controls for nerve autograft and exceed those for hollow tube conduit. PNA may be considered as an option when reconstructing major peripheral nerve injuries.

PMID: 31044125 [PubMed]

Real-world data on antiviral treatments for hepatitis C virus infections: Can we define intention to treat or per protocol analyses?

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Real-world data on antiviral treatments for hepatitis C virus infections: Can we define intention to treat or per protocol analyses?

J Hepatol. 2018 08;69(2):551-553

Authors: Ojha RP, Steyerberg EW

PMID: 29843905 [PubMed - indexed for MEDLINE]

Single-stage bilateral distal femur replacement for traumatic distal femur fractures.

Russell Wagner, MD - Thu, 05/02/2019 - 07:44
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Single-stage bilateral distal femur replacement for traumatic distal femur fractures.

Arthroplast Today. 2019 Mar;5(1):26-31

Authors: Neal DC, Sambhariya V, Tran A, Rahman SK, Dean TJ, Wagner RA, Sanchez HB

Abstract
Treatment of periprosthetic distal femur fractures and comminuted intraarticular distal femur fractures with previous arthritis remains a difficult challenge for orthopedic surgeons. Previous case series have shown that distal femur replacement (DFR) can effectively compensate for bone loss, relieve knee pain, and allow for early ambulation in both of these fracture patterns. Owing to the typical low-energy mechanism of these injuries, a bilateral injury treated with DFR is rarely encountered. We present a patient with traumatic open left Rorabeck III/Su III periprosthetic distal femur fracture and closed right intraarticular distal femur fracture (AO fcation 33-C2) with end-stage arthrosis treated with single-stage bilateral DFR. We suggest that in patients with similar injuries, single-stage bilateral DFR can provide the benefits of early mobilization and accelerated recovery.

PMID: 31020017 [PubMed]

Single-stage bilateral distal femur replacement for traumatic distal femur fractures.

Hugo Sanchez, MD - Thu, 05/02/2019 - 07:44
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Single-stage bilateral distal femur replacement for traumatic distal femur fractures.

Arthroplast Today. 2019 Mar;5(1):26-31

Authors: Neal DC, Sambhariya V, Tran A, Rahman SK, Dean TJ, Wagner RA, Sanchez HB

Abstract
Treatment of periprosthetic distal femur fractures and comminuted intraarticular distal femur fractures with previous arthritis remains a difficult challenge for orthopedic surgeons. Previous case series have shown that distal femur replacement (DFR) can effectively compensate for bone loss, relieve knee pain, and allow for early ambulation in both of these fracture patterns. Owing to the typical low-energy mechanism of these injuries, a bilateral injury treated with DFR is rarely encountered. We present a patient with traumatic open left Rorabeck III/Su III periprosthetic distal femur fracture and closed right intraarticular distal femur fracture (AO fcation 33-C2) with end-stage arthrosis treated with single-stage bilateral DFR. We suggest that in patients with similar injuries, single-stage bilateral DFR can provide the benefits of early mobilization and accelerated recovery.

PMID: 31020017 [PubMed]

Large observational study on risks predicting emergency department return visits and associated disposition deviations.

Richard Robinson, MD - Thu, 05/02/2019 - 07:44
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Large observational study on risks predicting emergency department return visits and associated disposition deviations.

Clin Exp Emerg Med. 2019 May 07;:

Authors: Huggins C, Robinson RD, Knowles H, Cizenski J, Mbugua R, Laureano-Phillips J, Schrader CD, Zenarosa NR, Wang H

Abstract
Objective: A common emergency department (ED) patient care outcome metric is 72-hour ED return visits (EDRVs). Risks predictive of EDRV vary in different studies. However, risk differences associated with related versus unrelated EDRV and subsequent EDRV disposition deviations (EDRVDD) are rarely addressed. We aim to compare the potential risk patterns predictive of related and unrelated EDRV and further determine those potential risks predictive of EDRVDD.
Methods: We conducted a large retrospective observational study from September 1, 2015 through June 30, 2016. ED Patient demographic characteristics and clinical metrics were compared among patients of 1) related; 2) unrelated; and 3) no EDRVs. EDRVDD was defined as obvious disposition differences between initial ED visit and return visits. A multivariate multinomial logistic regression was performed to determine the independent risks predictive of EDRV and EDRVDD after adjusting for all confounders.
Results: A total of 63,990 patients were enrolled; 4.65% were considered related EDRV, and 1.80% were unrelated. The top risks predictive of EDRV were homeless, patient left without being seen, eloped, or left against medical advice. The top risks predictive of EDRVDD were geriatric and whether patients had primary care physicians regardless as to whether patient returns were related or unrelated to their initial ED visits.
Conclusion: Over 6% of patients experienced ED return visits within 72 hours. Though risks predicting such revisits were multifactorial, similar risks were identified not only for ED return visits, but also for return ED visit disposition deviations.

PMID: 31036785 [PubMed - as supplied by publisher]

Large observational study on risks predicting emergency department return visits and associated disposition deviations.

Hao Wang, MD - Thu, 05/02/2019 - 07:44
Related Articles

Large observational study on risks predicting emergency department return visits and associated disposition deviations.

Clin Exp Emerg Med. 2019 May 07;:

Authors: Huggins C, Robinson RD, Knowles H, Cizenski J, Mbugua R, Laureano-Phillips J, Schrader CD, Zenarosa NR, Wang H

Abstract
Objective: A common emergency department (ED) patient care outcome metric is 72-hour ED return visits (EDRVs). Risks predictive of EDRV vary in different studies. However, risk differences associated with related versus unrelated EDRV and subsequent EDRV disposition deviations (EDRVDD) are rarely addressed. We aim to compare the potential risk patterns predictive of related and unrelated EDRV and further determine those potential risks predictive of EDRVDD.
Methods: We conducted a large retrospective observational study from September 1, 2015 through June 30, 2016. ED Patient demographic characteristics and clinical metrics were compared among patients of 1) related; 2) unrelated; and 3) no EDRVs. EDRVDD was defined as obvious disposition differences between initial ED visit and return visits. A multivariate multinomial logistic regression was performed to determine the independent risks predictive of EDRV and EDRVDD after adjusting for all confounders.
Results: A total of 63,990 patients were enrolled; 4.65% were considered related EDRV, and 1.80% were unrelated. The top risks predictive of EDRV were homeless, patient left without being seen, eloped, or left against medical advice. The top risks predictive of EDRVDD were geriatric and whether patients had primary care physicians regardless as to whether patient returns were related or unrelated to their initial ED visits.
Conclusion: Over 6% of patients experienced ED return visits within 72 hours. Though risks predicting such revisits were multifactorial, similar risks were identified not only for ED return visits, but also for return ED visit disposition deviations.

PMID: 31036785 [PubMed - as supplied by publisher]

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