Representativeness of breast cancer cases in an integrated health care delivery system.

BackgroundIntegrated health care delivery systems, with their comprehensive and integrated electronic medical records (EMR), are well-poised to conduct research that leverages the detailed clinical data within the EMRs. However, information regarding the representativeness of these clinical populations is limited, and thus the generalizability of research findings is uncertain.MethodsUsing data from the population-based California Cancer Registry, we compared age-adjusted distributions of patient and neighborhood characteristics for three groups of breast cancer patients: 1) those diagnosed within Kaiser Permanente Northern California (KPNC), 2) non-KPNC patients from NCI-designated cancer centers, and 3) those from all other hospitals.ResultsKPNC patients represented 32 % (N = 36,109); cancer center patients represented 7 % (N = 7805); and all other hospitals represented 61 % (N = 68,330) of the total breast cancer patients from this geographic area during 1996-2009. Compared with cases from all other hospitals, KPNC had slightly fewer non-Hispanic Whites (70.6 % versus 74.4 %) but more Blacks (8.1 % versus 5.0 %), slightly more patients in the 50-69 age range and fewer in the younger and older age groups, a slightly lower proportion of in situ but higher proportion of stage I disease (41.6 % versus 38.9 %), were slightly less likely to reside in the lowest (4.2 % versus 6.5 %) and highest (36.2 % versus 39.0 %) socioeconomic status neighborhoods, and more likely to live in suburban metropolitan areas and neighborhoods with more racial/ethnic minorities. Cancer center patients differed substantially from patients from KPNC and all other hospitals on all characteristics assessed. All differences were statistically significant (p < .001).ConclusionsAlthough much of clinical research discoveries are based in academic medical centers, patients from large, integrated medical centers are likely more representative of the underlying population, providing support for the generalizability of cancer research based on electronic data from these centers

Self-management support for chronic disease in primary care: frequency of patient self-management problems and patient reported priorities, and alignment with ultimate behavior goal selection.

BackgroundTo enable delivery of high quality patient-centered care, as well as to allow primary care health systems to allocate appropriate resources that align with patients' identified self-management problems (SM-Problems) and priorities (SM-Priorities), a practical, systematic method for assessing self-management needs and priorities is needed. In the current report, we present patient reported data generated from Connection to Health (CTH), to identify the frequency of patients' reported SM-Problems and SM-Priorities; and examine the degree of alignment between patient SM-Priorities and the ultimate Patient-Healthcare team member selected Behavioral Goal.MethodsCTH, an electronic self-management support system, was embedded into the flow of existing primary care visits in 25 primary care clinics and was used to assess patient-reported SM-Problems across 12 areas, patient identified SM-Priorities, and guide the selection of a Patient-Healthcare team member selected Behavioral Goal. SM-Problems included: BMI, diet (fruits and vegetables, salt, fat, sugar sweetened beverages), physical activity, missed medications, tobacco and alcohol use, health-related distress, general life stress, and depression symptoms. Descriptive analyses documented SM-Problems and SM-Priorities, and alignment between SM-Priorities and Goal Selection, followed by mixed models adjusting for clinic.Results446 participants with ≥ one chronic diseases (mean age 55.4 ± 12.6; 58.5% female) participated. On average, participants reported experiencing challenges in 7 out of the 12 SM-Problems areas; with the most frequent problems including: BMI, aspects of diet, and physical activity. Patient SM-Priorities were variable across the self-management areas. Patient- Healthcare team member Goal selection aligned well with patient SM-Priorities when patients prioritized weight loss or physical activity, but not in other self-management areas.ConclusionParticipants reported experiencing multiple SM-Problems. While patients show great variability in their SM-Priorities, the resulting action plan goals that patients create with their healthcare team member show a lack of diversity, with a disproportionate focus on weight loss and physical activity with missed opportunities for using goal setting to create targeted patient-centered plans focused in other SM-Priority areas. Aggregated results can assist with the identification of high frequency patient SM-Problems and SM-Priority areas, and in turn inform resource allocation to meet patient needs.Trial registrationClinicalTrials.gov ID: NCT01945918

New Insights Into The Narrow-Line Seyfert 1 Phenomenon

I briefly review the X/UV absorber models and show that the observations of NLS1s are generally consistent with the models. The covering factor of absorbers in NLS1s is likely to be high and there is some evidence of super-solar metallicities. I argue that NLS1s may be active galaxies in the early stage of their evolution and as such, may be low luminosity, low redshift analogues of the high redshift quasars. NLS1s may reside in rejuvenated gas-rich galaxies. I also propose that the high Fe II emission in NLS1s may be a direct consequence of their large accretion rate and so a collisional ionization origin of FeII is favored.Comment: Invited talk presented at the Joint MPE,AIP,ESO workshop on NLS1s, Bad Honnef, Dec. 1999, to appear in New Astronomy Reviews; also available at http://wave.xray.mpe.mpg.de/conferences/nls1-worksho

Novel Use of a Social-Media-Based Survey to Detect Regional Differences in Management of Monochorionic-Diamniotic Twins.

ObjectiveThis study aims to evaluate the utility of social media to distribute a patient survey on differences in management and outcomes of monochorionic-diamniotic (MCDA) pregnancies.Study designA cross-sectional survey was posted to an English-language MCDA twins patient-centered support group within the social media site, Facebook from April 2, 2018 to June 26, 2018. Subjects were recruited through a technique called "snowballing," whereby individuals shared the survey to assist with recruiting. Patient reported data were analyzed using Chi-square and Kruskal-Wallis's tests to explore characteristics associated with surveillance and outcomes as related to region and provider type.ResultsOver 3 months, the post "reached" 14,288 Facebook users, among which 5,653 (40%) clicked on the post. A total of 2,357 respondents with MCDA pregnancies completed the survey. Total 1,928 (82%) were from the United States (US) and 419 (18%) from other countries. Total 85% of patients had co-management with maternal-fetal medicine (MFM), more in the US compared with the rest of the world (87 vs. 74%, p < 0.01). MFM involvement led to increased adherence to biweekly ultrasounds (91 vs. 65%, p < 0.01), diagnosis of monochorionicity by 12 weeks (74 vs. 69%, p < 0.01) and better education about twin-twin transfusion syndrome (90 vs. 66%, p < 0.01). Pregnancies with MFM involvement had a higher take-home baby rate for both babies (92 vs. 89%, p < 0.01) or for at least one baby (98 vs. 93%, p < 0.01) compared with those without MFM involvement.ConclusionA survey distributed via social media can be effective in evaluating real-life management and outcomes of an uncommon obstetrical diagnosis. This survey elucidates wide international variation in adherence to guidelines, management, and outcomes

Water treatment for hemodialysis

AbstractWater treatment plays a vital role in the delivery of safe and effective hemodialysis (HD). Ensuring that water quality meets the American Association for the Advancement of Medical Instrumentation standards and recommendations (or equivalent) is necessary to reduce the incidence of chemical hazards and endotoxemia associated with the use of water for HD. This review will discuss the principles of water treatment for HD, the essential components of water purification, the recommended system monitoring and maintenance procedures, and some of the historical incidents of adverse reactions that resulted from the use of contaminated dialysis water

Cosmic-Enu: An emulator for the non-linear neutrino power spectrum

Cosmology is poised to measure the neutrino mass sum $M_\nu$ and has identified several smaller-scale observables sensitive to neutrinos, necessitating accurate predictions of neutrino clustering over a wide range of length scales. The FlowsForTheMasses non-linear perturbation theory for the massive neutrino power spectrum, $\Delta^2_\nu(k)$, agrees with its companion N-body simulation at the $10\%-15\%$ level for $k \leq 1~h/$Mpc. Building upon the Mira-Titan IV emulator for the cold matter, we use FlowsForTheMasses to construct an emulator for $\Delta^2_\nu(k)$ covering a large range of cosmological parameters and neutrino fractions $\Omega_{\nu,0} h^2 \leq 0.01$, which corresponds to $M_\nu \leq 0.93$~eV. Consistent with FlowsForTheMasses at the $3.5\%$ level, it returns a power spectrum in milliseconds. Ranking the neutrinos by initial momenta, we also emulate the power spectra of momentum deciles, providing information about their perturbed distribution function. Comparing a $M_\nu=0.15$~eV model to a wide range of N-body simulation methods, we find agreement to $3\%$ for $k \leq 3 k_\mathrm{FS} = 0.17~h/$Mpc and to $19\%$ for $k \leq 0.4~h/$Mpc. We find that the enhancement factor, the ratio of $\Delta^2_\nu(k)$ to its linear-response equivalent, is most strongly correlated with $\Omega_{\nu,0} h^2$, and also with the clustering amplitude $\sigma_8$. Furthermore, non-linearities enhance the free-streaming-limit scaling $\partial \log(\Delta^2_\nu / \Delta^2_{\rm m}) / \partial \log(M_\nu)$ beyond its linear value of 4, increasing the $M_\nu$-sensitivity of the small-scale neutrino density.Comment: 17 pages, 14 figures, 3 tables. Emulator code available at: https://github.com/upadhye/Cosmic-En

INCIDENCE OF HIGH GRADE QTCF PROLONGATION AND ITS MANAGEMENT AMONG PATIENTS UNDERGOING TREATMENT FOR DRUG RESISTANT TUBERCULOSIS (DR-TB): CASE SERIES.

Background: The World Health Organization (WHO) has approved the use of two new drugs, namely Bedaquiline (Bdq) and Delamanid (Dlm), for treatment of Drug Resistant Tuberculosis (DR-TB). One of the concerns raised with the use of these drugs was QT-interval prolongation. This condition could be serious and life threatening. Hence, knowing the magnitude and its management is very important. This case series identifies the incidence and discusses the management of clinically significant QT-interval prolongation amongst a cohort of patients who have been on these medicines. Materials and Methods: Patients with reports of high grade QT-Interval prolongation (i.e. Grade-3 and Grade-4) were identified from the cohort of 265 patients enrolled on bedaquiline and/delamanid and discussion is made on the pattern, severity and management of each cases identified. Results: Only 4 (1.5%) out of all 265 patients enrolled on Bedaquiline and/or Delamanid have developed high grade QT-Interval prolongation. And all are managed without permanent discontinuation of both drugs. Conclusion: The Incidence of clinically significant QTcF-interval prolongation among DR-TB patients taking bedaquiline and delamanid in Lesotho is low. And almost all cases can be managed with more frequent Electrocardiogram (ECG) monitoring and management of other possible causes of QT-interval prolongation without the need to stop one or both drugs permanentl