Cancer Incidence and Mortality in a Cohort of US Blood Donors: A 20-Year Study

Blood donors are considered one of the healthiest populations. This study describes the epidemiology of cancer in a cohort of blood donors up to 20 years after blood donation. Records from donors who participated in the Retroviral Epidemiology Donor Study (REDS, 1991–2002) at Blood Centers of the Pacific (BCP), San Francisco, were linked to the California Cancer Registry (CCR, 1991–2010). Standardized incidence ratios (SIR) were estimated using standard US 2000 population, and survival analysis used to compare all-cause mortality among donors and a random sample of nondonors with cancer from CCR. Of 55,158 eligible allogeneic blood donors followed-up for 863,902 person-years, 4,236 (7.7%) primary malignant cancers were diagnosed. SIR in donors was 1.59 (95% CI = 1.54,1.64). Donors had significantly lower mortality (adjusted HR = 0.70, 95% CI = 0.66–0.74) compared with nondonor cancer patients, except for respiratory system cancers (adjusted HR = 0.93, 95% CI = 0.82–1.05). Elevated cancer incidence among blood donors may reflect higher diagnosis rates due to health seeking behavior and cancer screening in donors. A “healthy donor effect” on mortality following cancer diagnosis was demonstrated. This population-based database and sample repository of blood donors with long-term monitoring of cancer incidence provides the opportunity for future analyses of genetic and other biomarkers of cancer

Real-world data on the incidence, mortality, and cost of ischaemic stroke and major bleeding events among non-valvular atrial fibrillation patients in England

Rationale, Aims, and Objectives: Several novel oral anticoagulants (NOACs) are licensed for atrial fibrillation (AF) treatment in the United Kingdom. We describe the incidence and mortality from ischaemic stroke and major bleeding in non-valvular atrial fibrillation (NVAF) patients in England, including treatment patterns before/following introduction of NOACs, healthcare resource utilization (HRU), and costs post-onset of these events. Method: Data were extracted from the UK Clinical Practice Research Datalink linked to Hospital Episode Statistics secondary care and Office for National Statistics mortality data. Results: Of 42 966 patients with a first AF record between 2011 and 2016, 9143 patients (21.3%) remained without AF (antiplatelets/antithrombotics) treatment post-index diagnosis. The proportion of patients receiving aspirin for ≥3 months post-index declined during the study (50.6%-5.5%), irrespective of CHA2DS2-VASc score, while the proportion prescribed NOACs increased (2.0%-70.1%). Rates of ischaemic stroke per 1000 patient-years (95% CI) were 9.4 (3.8-15.0) with NOACs, 10.4 (8.0-12.9) with warfarin, 20.1 (16.4-23.8) with aspirin, 21.3 (5.3-37.2) with other antiplatelets and 43.6 (39.3-47.8) in patients without AF prescription. Major bleeding occurred at a similar rate with different treatments. All-cause mortality rates were 42.8 (31.4-54.3) with NOACs, 46.3 (41.1-51.5) with warfarin, 56.5 (50.5-62.4) with aspirin, 102.2 (76.2-128.3) with other antiplatelets and 412.8 (399.6-426.0) with no AF prescription. Mean annual National Health Service healthcare costs up to 1 year post-index were lowest in patients receiving aspirin plus other antiplatelets without an event (£6152), and highest in patients with an event without AF prescriptions (£17 957). By extrapolation, national AF HRU in the United Kingdom in 2016 was estimated at £8-16 billion annually. Conclusions: These data provide temporal insights into AF treatment patterns and outcomes for NVAF patients in England and highlight the need to review higher stroke risk AF patients not receiving antiplatelet/antithrombotic prescriptions

Inability to predict postpartum hemorrhage: insights from Egyptian intervention data

<p>Abstract</p> <p>Background</p> <p>Knowledge on how well we can predict primary postpartum hemorrhage (PPH) can help policy makers and health providers design current delivery protocols and PPH case management. The purpose of this paper is to identify risk factors and determine predictive probabilities of those risk factors for primary PPH among women expecting singleton vaginal deliveries in Egypt.</p> <p>Methods</p> <p>From a prospective cohort study, 2510 pregnant women were recruited over a six-month period in Egypt in 2004. PPH was defined as blood loss ≥ 500 ml. Measures of blood loss were made every 20 minutes for the first 4 hours after delivery using a calibrated under the buttocks drape. Using all variables available in the patients' charts, we divided them in ante-partum and intra-partum factors. We employed logistic regression to analyze socio-demographic, medical and past obstetric history, and labor and delivery outcomes as potential PPH risk factors. Post-model predicted probabilities were estimated using the identified risk factors.</p> <p>Results</p> <p>We found a total of 93 cases of primary PPH. In multivariate models, ante-partum hemoglobin, history of previous PPH, labor augmentation and prolonged labor were significantly associated with PPH. Post model probability estimates showed that even among women with three or more risk factors, PPH could only be predicted in 10% of the cases.</p> <p>Conclusions</p> <p>The predictive probability of ante-partum and intra-partum risk factors for PPH is very low. Prevention of PPH to all women is highly recommended.</p

GB Virus Type C (HGV) and Human Immunodeficiency Virus (HIV) Co-Infection: Incidence and Impacts on Survival in a Cohort of HIV-Infected Transfusion Recipients

GB virus C (GBV-C), an RNA virus closely related to hepatitis C virus (HCV), is transmitted through sexual, parenteral, and vertical routes. GBV-C is highly prevalent among patients receiving blood products and those at high risk of sexual or parenteral exposure. Unlike HCV, GBV-C replicates mainly in lymphocytes; many attempts to find an association between GBV-C infection and human disease have been unsuccessful. Therefore, donated blood is not routinely screened for GBV-C infection. In vitro and clinical studies have suggested that GBV-C co-infection may inhibit human immunodeficiency virus (HIV) replication by several different biological mechanisms. Some previous studies, but not all, have shown an association between GBV-C infection and both lower HIV viral load (VL) and better survival among HIV-infected patients. Few studies describe predictors of acute GBV-C infection following transfusion in HIV-infected patients. Reports on survival benefits associated with co-infection after advent of highly active retroviral therapy (HAART) are inconclusive. An open question in many previous reports is the temporal relationship between GBV-C infection and HIV disease markers. To address some of the currently unanswered questions concerning GBV-C and HIV co-infection, we used a limited access database obtained from the National Heart, Lung, and Blood Institute. The Viral Activation Transfusion Study (VATS) was a randomized controlled trial comparing leukoreduced (LR) vs. non-LR transfusions given to anemic HIV-infected transfusion-naïve patients. Pre- and post-transfusion samples from 489 subjects were tested for GBV-C markers. We used the VATS dataset and the results of GBV-C testing to examine two hypotheses. First, we tested the hypothesis that GBV-C is transmitted to HIV-infected VATS subjects (n=294) via transfusion. We estimated the risk of acquiring GBV-C RNA per unit of blood transfused and examined the predictors of GBV-C acquisition. We found an incidence of 39 GBV-C infections per 100 person-years during follow-up in this population and an 8% increased risk of acquiring GBV-C associated with each additional unit of blood transfused, controlling for HAART status and baseline HIV VL. A lower HIV VL, use of HAART and white race were associated with an increased risk of subsequent GBV-C acquisition. Second, we examined the hypothesis that GBV-C co-infection is associated with lower mortality and lower HIV VL in 489 HIV-infected VATS subjects and in two VATS sub-cohorts. GBV-C viremia was associated with significantly lower mortality and HIV VL in unadjusted analyses. We found a non-significant trend towards lower mortality and lower HIV VL among HIV-infected VATS subjects, after adjusting for HIV risk behavior and time-updated E2 antibody, HAART status, HIV VL, and CD4 cell count. Acquisition of GBV-C was associated with lower mortality in the sub-cohort of individuals who were GBV-C RNA and antibody negative at baseline (n=294), adjusting for time-updated covariates (HR= 0.31, 95% CI 0.11, 0.86). Our results suggest high rates of GBV-C transmission by transfusion among HIV-infected subjects and an increased hazard of GBV-C acquisition with lower pre-transfusion HIV VL and current use of HAART. Our results also indicate that GBV-C viremia is associated with a trend towards lower mortality and lower HIV VL, and GBV-C acquisition via transfusion is associated with a significant reduction in mortality in HIV-infected individuals, after adjusting for HIV disease markers. These findings confirm previous reports that GBV-C infection inhibits HIV replication in vitro and in vivo

Cost-Effectiveness of Traffic Safety Interventions in the United States

OBJECTIVE: In order to demonstrate the results of all available studies on cost-effectiveness and traffic safety, and report them in a comparable format, we conducted a comprehensive review of the literature on the subject.Knowledge of cost-effective (CE) traffic safety programs that result in reduced motor vehicle crashes and fatalities is essential to city planners, managers, and police.METHOD: Using a systematic approach to literature review, the relevant literature has been identified through the use of electronic databases, hand searching of journals, scanning reference lists, and consultation with corresponding authors and experts. Target populations were drivers, passengers and pedestrians in urban and rural roads. Studies on passenger vehicles, busses, and light trucks are included in this review. Studies were included with outcome measure such as cost per year of life saved (LYS), and cost per quality-adjusted life-year saved (QALY), or enough data on cost and benefit to estimate these measures. We followed the recommendations of the Panel on Cost Effectiveness in Health and Medicine (PCEHM) in our recalculations. Interventions are categorized based on the Haddon matrix.RESULTS: We found that despite the specific framework recommended by the PCEHM, the methods used to derive CE measures vary considerably among studies. The CE for these interventions vary enormously, from those that cost more than $1 million per QALY saved i.e. lap/shoulder belts in rear-center occupant; to those that save money i.e. mandatory use of daytime running lights, painting lines on roads, and compulsory helmet use in motorcyclists. Cost saving interventions are compared according to the major components of crash causation as demonstrated in the Haddon matrix.CONCLUSION: The design of cost benefit evaluations in road safety needs to be improved so that more comparable evidence can be obtained. Literature reviews on CE should be updated regularly to ensure relevance. Many life saving traffic safety programs are cost saving and many are more CE than other interventions to prevent cancer, heart disease, and other causes of morbidity and mortality. Investment in traffic safety measures can have a greater impact on population health than investment in other chronic diseases

Cost-Effectiveness of Traffic Safety Interventions in the United States

OBJECTIVE: In order to demonstrate the results of all available studies on cost-effectiveness and traffic safety, and report them in a comparable format, we conducted a comprehensive review of the literature on the subject.Knowledge of cost-effective (CE) traffic safety programs that result in reduced motor vehicle crashes and fatalities is essential to city planners, managers, and police.METHOD: Using a systematic approach to literature review, the relevant literature has been identified through the use of electronic databases, hand searching of journals, scanning reference lists, and consultation with corresponding authors and experts. Target populations were drivers, passengers and pedestrians in urban and rural roads. Studies on passenger vehicles, busses, and light trucks are included in this review. Studies were included with outcome measure such as cost per year of life saved (LYS), and cost per quality-adjusted life-year saved (QALY), or enough data on cost and benefit to estimate these measures. We followed the recommendations of the Panel on Cost Effectiveness in Health and Medicine (PCEHM) in our recalculations. Interventions are categorized based on the Haddon matrix.RESULTS: We found that despite the specific framework recommended by the PCEHM, the methods used to derive CE measures vary considerably among studies. The CE for these interventions vary enormously, from those that cost more than $1 million per QALY saved i.e. lap/shoulder belts in rear-center occupant; to those that save money i.e. mandatory use of daytime running lights, painting lines on roads, and compulsory helmet use in motorcyclists. Cost saving interventions are compared according to the major components of crash causation as demonstrated in the Haddon matrix.CONCLUSION: The design of cost benefit evaluations in road safety needs to be improved so that more comparable evidence can be obtained. Literature reviews on CE should be updated regularly to ensure relevance. Many life saving traffic safety programs are cost saving and many are more CE than other interventions to prevent cancer, heart disease, and other causes of morbidity and mortality. Investment in traffic safety measures can have a greater impact on population health than investment in other chronic diseases

The July Effect: Is Emergency Department Length of Stay Greater at the Beginning of the Hospital Academic Year?

Introduction: There has been concern of increased emergency department (ED) length of stay (LOS) during the months when new residents are orienting to their roles. This so-called “July Effect” has long been thought to increase LOS, and potentially contribute to hospital overcrowding and increased waiting time for patients. The objective of this study is to determine if the average ED LOS at the beginning of the hospital academic year differs for teaching hospitals with residents in the ED, when compared to other months of the year, and as compared to non-teaching hospitals without residents.Methods: We performed a retrospective analysis of a nationally representative sample of 283,621 ED visits from the National Hospital Ambulatory Medical Care Survey (NHAMCS), from 2001 to 2008. We stratified the sample by proportion of visits seen by a resident, and compared July to the rest of the year, July to June, and July and August to the remainder of the year. We compared LOS for teaching hospitals to non-teaching hospitals. We used bivariate statistics, and multivariable regression modeling to adjust for covariates.Results: Our findings show that at teaching hospitals with residents, there is no significant difference in mean LOS for the month of July (275 minutes) versus the rest of the year (259 min), July and August versus the rest of the year, or July versus June. Non-teaching hospital control samples yielded similar results with no significant difference in LOS for the same time periods. There was a significant difference found in mean LOS at teaching hospitals (260 minutes) as compared to non-teaching hospitals (185 minutes) throughout the year (p<0.0001).Conclusion: Teaching hospitals with residents in the ED have slower throughput of patients, no matter what time of year. Thus, the “July Effect” does not appear to a factor in ED LOS. This has implications as overcrowding and patient boarding become more of a concern in our increasingly busy EDs. These results question the need for additional staffing early in the academic year. Teaching hospitals may already institute more robust staffing during this time, preventing any significant increase in LOS. Multiple factors contribute to long stays in the ED. While patients seen by residents stay longer in the ED, there is little variability throughout the academic year. [West J Emerg Med. 2014;15(1):88–93.

Cost-Effectiveness of Traffic Safety Interventions in the United States

OBJECTIVE: In order to demonstrate the results of all available studies on cost-effectiveness and traffic safety, and report them in a comparable format, we conducted a comprehensive review of the literature on the subject. Knowledge of cost-effective (CE) traffic safety programs that result in reduced motor vehicle crashes and fatalities is essential to city planners, managers, and police. METHOD: Using a systematic approach to literature review, the relevant literature has been identified through the use of electronic databases, hand searching of journals, scanning reference lists, and consultation with corresponding authors and experts. Target populations were drivers, passengers and pedestrians in urban and rural roads. Studies on passenger vehicles, busses, and light trucks are included in this review. Studies were included with outcome measure such as cost per year of life saved (LYS), and cost per quality-adjusted life-year saved (QALY), or enough data on cost and benefit to estimate these measures. We followed the recommendations of the Panel on Cost Effectiveness in Health and Medicine (PCEHM) in our recalculations. Interventions are categorized based on the Haddon matrix. RESULTS: We found that despite the specific framework recommended by the PCEHM, the methods used to derive CE measures vary considerably among studies. The CE for these interventions vary enormously, from those that cost more than $1 million per QALY saved i.e. lap/shoulder belts in rear-center occupant; to those that save money i.e. mandatory use of daytime running lights, painting lines on roads, and compulsory helmet use in motorcyclists. Cost saving interventions are compared according to the major components of crash causation as demonstrated in the Haddon matrix. CONCLUSION: The design of cost benefit evaluations in road safety needs to be improved so that more comparable evidence can be obtained. Literature reviews on CE should be updated regularly to ensure relevance. Many life saving traffic safety programs are cost saving and many are more CE than other interventions to prevent cancer, heart disease, and other causes of morbidity and mortality. Investment in traffic safety measures can have a greater impact on population health than investment in other chronic diseases.traffic safety interventions, traffic safety programs, cost-effectiveness, cost-benefit

The July Effect: Is Emergency Department Length of Stay Greater at the Beginning of the Hospital Academic Year?

Introduction: There has been concern of increased emergency department (ED) length of stay (LOS) during the months when new residents are orienting to their roles. This so-called “July Effect” has long been thought to increase LOS, and potentially contribute to hospital overcrowding and increased waiting time for patients. The objective of this study is to determine if the average ED LOS at the beginning of the hospital academic year differs for teaching hospitals with residents in the ED, when compared to other months of the year, and as compared to non-teaching hospitals without residents.Methods: We performed a retrospective analysis of a nationally representative sample of 283,621 ED visits from the National Hospital Ambulatory Medical Care Survey (NHAMCS), from 2001 to 2008. We stratified the sample by proportion of visits seen by a resident, and compared July to the rest of the year, July to June, and July and August to the remainder of the year. We compared LOS for teaching hospitals to non-teaching hospitals. We used bivariate statistics, and multivariable regression modeling to adjust for covariates.Results: Our findings show that at teaching hospitals with residents, there is no significant difference in mean LOS for the month of July (275 minutes) versus the rest of the year (259 min), July and August versus the rest of the year, or July versus June. Non-teaching hospital control samples yielded similar results with no significant difference in LOS for the same time periods. There was a significant difference found in mean LOS at teaching hospitals (260 minutes) as compared to non-teaching hospitals (185 minutes) throughout the year (p&lt;0.0001).Conclusion: Teaching hospitals with residents in the ED have slower throughput of patients, no matter what time of year. Thus, the “July Effect” does not appear to a factor in ED LOS. This has implications as overcrowding and patient boarding become more of a concern in our increasingly busy EDs. These results question the need for additional staffing early in the academic year. Teaching hospitals may already institute more robust staffing during this time, preventing any significant increase in LOS. Multiple factors contribute to long stays in the ED. While patients seen by residents stay longer in the ED, there is little variability throughout the academic year. [West J Emerg Med. 2014;15(1):88–93.