Explore the vast range of titles available.

BackgroundAs ovarian cancer treatment shifts to provide more complex aspects of care at high-volume centers, almost a quarter of patients, many of whom reside in rural counties, will not have access to those centers or receive guideline-based care.ObjectiveTo explore the association between proximity of residential zip code to a high-volume cancer center with mortality and survival for patients with ovarian cancer.MethodsThe National Cancer Database was queried for cases of newly diagnosed ovarian cancer between January 2004 and December 2015. Our predictor of interest was distance traveled for treatment. Our primary outcomes were 30-day mortality, 90-day mortality, and overall survival. The effect of treatment on survival was analyzed with the Kaplan-Meier method. Multiple logistic regression for binary outcomes and Cox proportional hazards regression for overall survival were used to assess the effect of distance on outcome, controlling for potential confounding variables.ResultsA total of 115 540 patients were included. There was no statistically significant difference in 30- or 90-day mortality among any of the travel distance categories. A statistically significant decrease in 30-day re-admission was found among patients who lived further away from the treating facility. A total of 105 529 patients were available for survival analysis, and survival curves significantly differed between distance strata (p<0.0001). The adjusted regression models demonstrated increased long-term mortality in patients who lived farther away from the treating facility after controlling for potential confounding.ConclusionAlthough 30- and 90-day mortality do not differ by travel distance, worse survival is observed among women living >50 miles from a high-volume treatment facility. With a national policy shift toward centralization of complex care, a better understanding of the impact of distance on survival in patients with ovarian cancer is crucial. Our findings inform the practice of healthcare delivery, especially in rural settings.

Abstract Background We sought to describe lung cancer prevalence and mortality in relation to socioeconomic deprivation and rurality. Methods We conducted a population-based cross-sectional analysis of prevalent lung cancers from a statewide all-payer claims dataset from 2012 to 2016, lung cancer deaths in Maine from the state death registry from 2012 to 2016, rurality, and area deprivation index (ADI), a geographic area-based measure of socioeconomic deprivation. Analyses examined rate ratios for lung cancer prevalence and mortality according to rurality (small and isolated rural, large rural, or urban) and ADI (quintiles, with highest reflecting the most deprivation) and after adjusting for age, sex, and area-level smoking rates as determined by the Behavioral Risk Factor Surveillance System. Results Among 1 223 006 adults aged 20 years and older during the 5-year observation period, 8297 received lung cancer care, and 4616 died. Lung cancer prevalence and mortality were positively associated with increasing rurality, but these associations did not persist after adjusting for age, sex, and smoking rates. Lung cancer prevalence and mortality were positively associated with increasing ADI in models adjusted for age, sex, and smoking rates (prevalence rate ratio for ADI quintile 5 compared with quintile 1 = 1.41, 95% confidence interval [CI] =1.30 to 1.54) and mortality rate ratio = 1.59, 95% CI = 1.41 to 1.79). Conclusion Socioeconomic deprivation, but not rurality, was associated with higher lung cancer prevalence and mortality. Interventions should target populations with socioeconomic deprivation, rather than rurality per se, and aim to reduce lung cancer risk via tobacco treatment and control interventions and to improve patient access to lung cancer prevention, screening, and treatment services.

Background Accounting for nearly one-third of all deaths, cardiovascular disease is the leading cause of mortality and morbidity in the United States. Adverse health behaviors are major determinants of this high incidence of disease. Examining local food and physical activity environments and population characteristics in a poor, rural state may highlight underlying drivers of these behaviors. We aimed to identify demographic and environmental factors associated with both obesity and overall poor cardiovascular health (CVH) behaviors in Maine counties. Methods Our cross-sectional study analyzed 40,398 Behavioral Risk Factor Surveillance System (BRFSS) 2011–2014 respondents alongside county-level United States Department of Agriculture (USDA) Food Environment Atlas 2010–2012 measures of the built environment (i.e., density of restaurants, convenience stores, grocery stores, and fitness facilities; food store access; and county income). Poor CVH score was defined as exhibiting greater than 5 out of the 7 risk factors defined by the American Heart Association (current smoking, physical inactivity, obesity, poor diet, hypertension, diabetes, and high cholesterol). Multivariable logistic regression models described the contributions of built environment variables to obesity and overall poor CVH score after adjustment for demographic controls. Results Both demographic and environmental factors were associated with obesity and overall poor CVH. After adjustment for demographics (age, sex, personal income, and education), environmental characteristics most strongly associated with obesity included low full-service restaurant density (OR 1.34; 95% CI 1.24–1.45), low county median household income (OR 1.31; 95% CI 1.21–1.42) and high convenience store density (OR 1.21; 95% CI 1.12–1.32). The strongest predictors of overall poor CVH behaviors were low county median household income (OR 1.30; 95% CI 1.13–1.51), low full-service restaurant density (OR 1.38; 95% CI 1.19–1.59), and low fitness facility density (OR 1.27; 95% CI 1.11–1.46). Conclusions In a rural state, both demographic and environmental factors predict overall poor CVH. These findings may help inform communities and policymakers of the impact of both social determinants of health and local environments on health outcomes.

Acute kidney injury, a common complication of cardiac surgery with cardiopulmonary bypass, is associated with increased morbidity and mortality. Ischemic preconditioning at a remote site mitigates ischemia–reperfusion injury and may prevent acute kidney injury after cardiac surgery, thus providing clinical benefit. To further study this, we enrolled 120 adult patients undergoing elective cardiac surgery for whom cardiopulmonary bypass was anticipated in a randomized, single-blind, and controlled pilot trial. Patients were stratified for the type of surgery and equally assigned to a control group or to receive remote ischemic preconditioning by an automated thigh tourniquet consisting of three 5-min intervals of lower extremity ischemia separated by 5-min intervals of reperfusion. The primary end point was acute kidney injury defined as an elevation of serum creatinine of ≥0.3mg/dl or ≥50% within 48h after surgery. Fifty-nine patients in each group were analyzed on an intention-to-treat basis. Acute kidney injury occurred in 12 remote ischemic preconditioned and 28 control patients, reflecting an absolute risk reduction of 0.27 and a significantly reduced relative risk due to preconditioning of 0.43. Hence, remote ischemic preconditioning prevents acute kidney injury in patients undergoing cardiopulmonary bypass-assisted cardiac surgery.

BackgroundPatients with chronic obstructive pulmonary disease (COPD) often receive burdensome care at end-of-life (EOL) and infrequently complete advance care planning (ACP). The surprise question (SQ) is a prognostic tool that may facilitate ACP.ObjectiveTo assess how well the SQ predicts mortality and prompts ACP for COPD patients.DesignRetrospective cohort study.SubjectsPatients admitted to the hospital for an acute exacerbation of COPD between July 2015 and September 2018.Main MeasuresEmergency department (ED) and inpatient clinicians answered, “Would you be surprised if this patient died in the next 30 days (ED)/one year (inpatient)?” The primary outcome measure was the accuracy of the SQ in predicting 30-day and 1-year mortality. The secondary outcome was the correlation between SQ and ACP (palliative care consultation, documented goals-of-care conversation, change in code status, or completion of ACP document).Key ResultsThe 30-day SQ had a high specificity but low sensitivity for predicting 30-day mortality: sensitivity 12%, specificity 95%, PPV 11%, and NPV 96%. The 1-year SQ demonstrated better accuracy for predicting 1-year mortality: sensitivity 47%, specificity 75%, PPV 35%, and NPV 83%. After multivariable adjustment for age, sex, and prior 6-month admissions, 1-year SQ+ responses were associated with greater odds of 1-year mortality (OR 2.38, 95% CI 1.39–4.08) versus SQ-. One-year SQ+ patients were more likely to have a goals-of-care conversation (25% vs. 11%, p < 0.01) and complete an advance directive or POLST (46% vs. 23%, p < 0.01). After multivariable adjustment, SQ+ responses to the 1-year SQ were associated with greater odds of ACP receipt (OR 2.67, 95% CI 1.64–4.36).ConclusionsThe 1-year surprise question may be an effective component of prognostication and advance care planning for COPD patients in the inpatient setting.

Research has demonstrated that there is lower operative mortality at hospitals with higher surgical volume. Using administrative data from Medicare, this study found lower mortality associated with each of eight procedures when performed by surgeons who undertook the operation more frequently. Lower mortality with surgeons who operate frequently. For many surgical procedures, patients at hospitals where a high number of such procedures are performed (high-volume hospitals) have lower mortality rates than those at hospitals that are less experienced with the procedures. 1 – 4 In one recent study of the national population of Medicare recipients, we found strong relations between hospital volume and operative mortality associated with 14 high-risk cancer resections and cardiovascular procedures. 5 Despite the considerable body of research in this area, little is known about the mechanisms underlying the observed associations between volume and outcome. Because they tend to be much larger facilities, high-volume hospitals have a broader . . .

Increased prevalence of oxidant stress and inflammation in patients with moderate to severe chronic kidney disease. The prevalence of increased oxidative stress and acute-phase inflammation in patients with chronic kidney disease (CKD) has not been thoroughly investigated. Biomarkers of oxidative stress and acute-phase inflammation were measured in a cohort of 60 patients with stage 3–5 CKD compared to a healthy subject cohort. Levels of oxidative stress and inflammation were also compared to estimated glomerular filtration rate (GFR) using the Modification of Diet in Renal Disease (MDRD) formula. All biomarkers of oxidative stress (plasma protein carbonyl group content, plasma free F2-isoprostane content, plasma protein reduced thiol content) and all markers of inflammation [C-reactive protein (CRP), interleukin-6 (IL-6)] differed significantly between CKD patients and healthy subjects. There was no significant relationship between estimated GFR and any oxidative stress or inflammation biomarker. CRP levels were higher in patients with known coronary vascular disease (CVD) and in patients not taking angiotensin II inhibitors. Plasma IL-6 levels were significantly higher in patients with known coronary vascular disease and lower in patients taking statins. Biomarkers of oxidative stress were significantly higher in patients with diabetes and hypercholesterolemia. There is evidence of increased oxidative stress and acute-phase inflammation in patients with stage 3–5 chronic kidney disease compared to healthy subjects that does not closely correlate with estimates of GFR. Among CKD patients, inflammatory biomarkers correlate with known CVD and inversely correlate with the use of angiotensin II inhibitors and statins. A further increase in oxidative stress was noted in diabetic and hypercholesterolemic patients. Inflammation and oxidative stress may contribute to cardiovascular risk in CKD patients.

For surgical procedures, operative mortality varies inversely with the number of procedures performed at a hospital. This study quantified the relation between volume and outcome among Medicare patients for 14 different surgical procedures. The relative effect of surgical volume on outcome varied markedly among types of procedures. For pancreatic resection, the absolute difference in mortality rates between the highest-volume and the lowest-volume hospitals was over 12 percent, whereas for carotid endarterectomy, the difference was only 0.2 percent. This study quantified the relation for 14 surgical procedures in Medicare patients. Over the past three decades, numerous studies have described higher rates of operative mortality with selected surgical procedures at hospitals where few such procedures are performed (low-volume hospitals). 1 – 4 Several recent reviews suggest that thousands of preventable surgical deaths occur each year in the United States because elective but high-risk surgery is performed in hospitals that have inadequate experience with the surgical procedures involved. 5 – 7 As part of a broader initiative aimed at improving hospital safety, a large coalition of private and public purchasers of health insurance — the Leapfrog Group — is encouraging patients undergoing one of five high-risk . . .

Background: Previous studies have documented racial disparities in treatment of acute myocardial infarction (AMI) among Medicare beneficiaries. However, the extent to which unobserved differences between hospitals explains some of these differences is unknown. Objective: The objective of this study was to determine whether the observed racial treatment disparities for AMI narrow when analyses account for differences in where blacks and whites are hospitalized. Research Design: Retrospective observational cohort study using Medicare claims and medical record review. Subjects: This study included 130,709 white and 8286 black Medicare patients treated in 4690 hospitals in 50 US states for confirmed AMI in 1994 and 1995. Measures: Measures in this study were receipt of reperfusion, aspirin, and smoking cessation counseling during hospitalization; prescription of aspirin, angiotensin-converting enzyme inhibitor, and beta-blocker at hospital discharge; receipt of cardiac catheterization, percutaneous coronary intervention (PCI), or bypass surgery (CABG) within 30 days of AMI; and 30-day and 1-year mortality. Results: Within-hospital analyses narrowed or erased black-white disparities for medical treatments received during the acute hospitalization, widened black-white disparities for follow-up surgical treatments, and augmented the survival advantage among blacks. These findings indicate that, on average, blacks went to hospitals that had lower rates of evidence-based medical treatments, higher rates of cardiac procedures, and worse risk-adjusted mortality after AMI. Conclusions: Incorporating the hospital effect altered the findings of racial disparity analyses in AMI and explained more of the disparities than race. A policy of targeted hospital-level interventions may be required for success of national efforts to reduce disparities.

Background Pneumonia is the most common infection after out-of-hospital cardiac arrest (OHCA) occurring in up to 65% of patients who remain comatose after return of spontaneous circulation. Preventing infection after OHCA may (1) reduce exposure to broad-spectrum antibiotics, (2) prevent hemodynamic derangements due to local and systemic inflammation, and (3) prevent infection-associated morbidity and mortality. Methods The ceftriaxone to PRevent pneumOnia and inflammaTion aftEr Cardiac arrest (PROTECT) trial is a randomized, placebo-controlled, single-center, quadruple-blind (patient, treatment team, research team, outcome assessors), non-commercial, superiority trial to be conducted at Maine Medical Center in Portland, Maine, USA. Ceftriaxone 2 g intravenously every 12 h for 3 days will be compared with matching placebo. The primary efficacy outcome is incidence of early-onset pneumonia occurring < 4 days after mechanical ventilation initiation. Concurrently, T cell-mediated inflammation bacterial resistomes will be examined. Safety outcomes include incidence of type-one immediate-type hypersensitivity reactions, gallbladder injury, and C lostridioides difficile -associated diarrhea. The trial will enroll 120 subjects over approximately 3 to 4 years. Discussion The PROTECT trial is novel in its (1) inclusion of OHCA survivors regardless of initial heart rhythm, (2) use of a low-risk antibiotic available in the USA that has not previously been tested after OHCA, (3) inclusion of anti-inflammatory effects of ceftriaxone as a novel mechanism for improved clinical outcomes, and (4) complete metagenomic assessment of bacterial resistomes pre- and post-ceftriaxone prophylaxis. The long-term goal is to develop a definitive phase III trial powered for mortality or functional outcome. Trial registration ClinicalTrials.gov NCT04999592 . Registered on August 10, 2021.