Identifying Cancer-Related Cognitive Impairment Using the FACT-Cog Perceived Cognitive Impairment.

Cancer-related cognitive impairment (CRCI) is a concerning problem for many cancer survivors. Evaluating patients for CRCI has been a challenge, in part because of a lack of standardized practices. Self-report instruments are often used to assess CRCI, but there are no validated cutpoints. We present the results of receiver operating characteristic curve analysis identifying cutpoints of the Functional Assessment of Cancer Therapy-Cognition perceived cognitive impairment (PCI) in female breast cancer survivors for identifying CRCI cases. We defined presence of CRCI based on elevated complaints on the Patient's Assessment of Own Functioning Inventory compared with healthy control scores. Our results indicate that scores less than 54 in PCI scores using 18 items and scores less than 60 in PCI scores using 20 items exhibited good ability to discriminate CRCI cases from noncases (area under the receiver operating characteristic curve was 0.84 [95% CI = 0.73 to 0.94]). These preliminary results represent an important contribution toward standardizing practices across CRCI studies

Estimating cost savings from regionalizing cardiac procedures using hospital discharge data

<p>Abstract</p> <p>Background</p> <p>We examined whether higher procedure volumes for coronary artery bypass graft (CABG) surgery or percutaneous coronary interventions (PCI) were associated with lower costs per patient, and if so, estimated the financial savings from regionalizing cardiac procedures.</p> <p>Methods</p> <p>Cost regressions with hospital-specific dummy variables measured within-hospital cost reductions associated with increasing hospital volume. We used the regression estimates to predict the change in total costs that would result from moving patients in low-volume hospitals to higher volume facilities.</p> <p>Results</p> <p>A 10% increase in PCI procedure volume lowered costs per patient by 0.7%. For the average hospital performing CABG in 2000, a 10% increase in volume was associated with a 2.8% reduction in average costs. Despite these lower costs, the predicted savings from regionalizing all PCI procedures in the sample from lower to high-volume hospitals amounted to only 1.1% of the entire costs of performing PCI procedures for the sample in 2000. Similarly, the cost savings for CABG were estimated to be only 3.5%.</p> <p>Conclusion</p> <p>Higher volumes were associated with lower costs per procedure. However, the total potential savings from regionalizing cardiac procedures is relatively minor, and may not justify the risks of reducing access to needed services.</p

Childhood maltreatment, psychological resources, and depressive symptoms in women with breast cancer.

Childhood maltreatment is associated with elevated risk for depression across the human lifespan. Identifying the pathways through which childhood maltreatment relates to depressive symptoms may elucidate intervention targets that have the potential to reduce the lifelong negative health sequelae of maltreatment exposure. In this cross-sectional study, 271 women with early-stage breast cancer were assessed after their diagnosis but before the start of adjuvant treatment (chemotherapy, radiation, endocrine therapy). Participants completed measures of childhood maltreatment exposure, psychological resources (optimism, mastery, self-esteem, mindfulness), and depressive symptoms. Using multiple mediation analyses, we examined which psychological resources uniquely mediated the relationship between childhood maltreatment and depressive symptoms. Exposure to maltreatment during childhood was robustly associated with lower psychological resources and elevated depressive symptoms. Further, lower optimism and mindfulness mediated the association between childhood maltreatment and elevated depressive symptoms. These results support existing theory that childhood maltreatment is associated with lower psychological resources, which partially explains elevated depressive symptoms in a sample of women facing breast cancer diagnosis and treatment. These findings warrant replication in populations facing other major life events and highlight the need for additional studies examining childhood maltreatment as a moderator of treatment outcomes

Biomarkers of aging associated with past treatments in breast cancer survivors.

Radiation and chemotherapy are effective treatments for cancer, but are also toxic to healthy cells. Little is known about whether prior exposure to these treatments is related to markers of cellular aging years later in breast cancer survivors. We examined whether past exposure to chemotherapy and/or radiation treatment was associated with DNA damage, telomerase activity, and telomere length 3-6 years after completion of primary treatments in breast cancer survivors (stage 0-IIIA breast cancer at diagnosis). We also examined the relationship of these cellular aging markers with plasma levels of Interleukin (IL)-6, soluble TNF-receptor-II (sTNF-RII), and C-reactive protein (CRP). Ninety-four women (36.4-69.5 years; 80% white) were evaluated. Analyses adjusting for age, race, BMI, and years from last treatment found that women who had prior exposure to chemotherapy and/or radiation compared to women who had previously received surgery alone were more likely to have higher levels of DNA damage (P = .02) and lower telomerase activity (P = .02), but did not have differences in telomere length. More DNA damage and lower telomerase were each associated with higher levels of sTNF-RII (P's &lt; .05). We found that exposure to chemotherapy and/or radiation 3-6 years prior was associated with markers of cellular aging, including higher DNA damage and lower telomerase activity, in post-treatment breast cancer survivors. Furthermore, these measures were associated with elevated inflammatory activation, as indexed by sTNF-RII. Given that these differences were observed many years after the treatment, the findings suggest a long lasting effect of chemotherapy and/or radiation exposure

Effect of a Patient-Centered Phone Call by a Clinical Officer at Time of HIV Testing on Linkage to Care in Rural Kenya.

In a randomized controlled trial, we tested whether a structured, patient-centered phone call from a clinical officer after HIV testing improved linkage to/re-engagement in HIV care. Among 130 HIV-positive persons, those randomized to the phone call were significantly more likely to link to care by 7 and 30 days (P = .04)

Improving follow-up of abnormal cancer screens using electronic health records: trust but verify test result communication

BACKGROUND: Early detection of colorectal cancer through timely follow-up of positive Fecal Occult Blood Tests (FOBTs) remains a challenge. In our previous work, we found 40% of positive FOBT results eligible for colonoscopy had no documented response by a treating clinician at two weeks despite procedures for electronic result notification. We determined if technical and/or workflow-related aspects of automated communication in the electronic health record could lead to the lack of response. METHODS: Using both qualitative and quantitative methods, we evaluated positive FOBT communication in the electronic health record of a large, urban facility between May 2008 and March 2009. We identified the source of test result communication breakdown, and developed an intervention to fix the problem. Explicit medical record reviews measured timely follow-up (defined as response within 30 days of positive FOBT) pre- and post-intervention. RESULTS: Data from 11 interviews and tracking information from 490 FOBT alerts revealed that the software intended to alert primary care practitioners (PCPs) of positive FOBT results was not configured correctly and over a third of positive FOBTs were not transmitted to PCPs. Upon correction of the technical problem, lack of timely follow-up decreased immediately from 29.9% to 5.4% (p\u3c0.01) and was sustained at month 4 following the intervention. CONCLUSION: Electronic communication of positive FOBT results should be monitored to avoid limiting colorectal cancer screening benefits. Robust quality assurance and oversight systems are needed to achieve this. Our methods may be useful for others seeking to improve follow-up of FOBTs in their systems

Notification of abnormal lab test results in an electronic medical record: do any safety concerns remain?

BACKGROUND: Follow-up of abnormal outpatient laboratory test results is a major patient safety concern. Electronic medical records can potentially address this concern through automated notification. We examined whether automated notifications of abnormal laboratory results (alerts) in an integrated electronic medical record resulted in timely follow-up actions. METHODS: We studied 4 alerts: hemoglobin A1c \u3e or =15%, positive hepatitis C antibody, prostate-specific antigen \u3e or =15 ng/mL, and thyroid-stimulating hormone \u3e or =15 mIU/L. An alert tracking system determined whether the alert was acknowledged (ie, provider clicked on and opened the message) within 2 weeks of transmission; acknowledged alerts were considered read. Within 30 days of result transmission, record review and provider contact determined follow-up actions (eg, patient contact, treatment). Multivariable logistic regression models analyzed predictors for lack of timely follow-up. RESULTS: Between May and December 2008, 78,158 tests (hemoglobin A1c, hepatitis C antibody, thyroid-stimulating hormone, and prostate-specific antigen) were performed, of which 1163 (1.48%) were transmitted as alerts; 10.2% of these (119/1163) were unacknowledged. Timely follow-up was lacking in 79 (6.8%), and was statistically not different for acknowledged and unacknowledged alerts (6.4% vs 10.1%; P =.13). Of 1163 alerts, 202 (17.4%) arose from unnecessarily ordered (redundant) tests. Alerts for a new versus known diagnosis were more likely to lack timely follow-up (odds ratio 7.35; 95% confidence interval, 4.16-12.97), whereas alerts related to redundant tests were less likely to lack timely follow-up (odds ratio 0.24; 95% confidence interval, 0.07-0.84). CONCLUSIONS: Safety concerns related to timely patient follow-up remain despite automated notification of non-life-threatening abnormal laboratory results in the outpatient setting

Waldo Lake Research in 2003

This report summarizes the first year of an effort to develop a more complete understanding of the physical, chemical, and biological characteristics that drive the ecological processes of Waldo Lake. Modern limnology recognizes the importance of watershed processes as well as in- lake processes in lake ecosystem functioning. Therefore, the approach included consideration of watershed hydrology and forcing functions that determine hydrodynamics of the system as well physical and chemical factors that may be important in regulating primary production in the lake. Data collected since 1998 was summarized and bathymetry of the basin was mapped using state-of-the-art digital depth sounding and GPS technology. A hypothesis that UV light may play an important role in regulating phytoplankton efficiency was examined in an effort to move toward more hypothesis-driven investigations to elucidate the factors controlling productivity. A Quality Assurance/Quality Control Plan was developed to guide data collection for long-term monitoring of the lake. Lastly, initial steps were made in the development of a model of lake hydrodynamics and primary production to aid in integration of the physical, chemical, and biological data that has been collected on the lake

Timely follow-up of abnormal diagnostic imaging test results in an outpatient setting: are electronic medical records achieving their potential?

BACKGROUND: Given the fragmentation of outpatient care, timely follow-up of abnormal diagnostic imaging results remains a challenge. We hypothesized that an electronic medical record (EMR) that facilitates the transmission and availability of critical imaging results through either automated notification (alerting) or direct access to the primary report would eliminate this problem. METHODS: We studied critical imaging alert notifications in the outpatient setting of a tertiary care Department of Veterans Affairs facility from November 2007 to June 2008. Tracking software determined whether the alert was acknowledged (ie, health care practitioner/provider [HCP] opened the message for viewing) within 2 weeks of transmission; acknowledged alerts were considered read. We reviewed medical records and contacted HCPs to determine timely follow-up actions (eg, ordering a follow-up test or consultation) within 4 weeks of transmission. Multivariable logistic regression models accounting for clustering effect by HCPs analyzed predictors for 2 outcomes: lack of acknowledgment and lack of timely follow-up. RESULTS: Of 123 638 studies (including radiographs, computed tomographic scans, ultrasonograms, magnetic resonance images, and mammograms), 1196 images (0.97%) generated alerts; 217 (18.1%) of these were unacknowledged. Alerts had a higher risk of being unacknowledged when the ordering HCPs were trainees (odds ratio [OR], 5.58; 95% confidence interval [CI], 2.86-10.89) and when dual-alert (\u3e1 HCP alerted) as opposed to single-alert communication was used (OR, 2.02; 95% CI, 1.22-3.36). Timely follow-up was lacking in 92 (7.7% of all alerts) and was similar for acknowledged and unacknowledged alerts (7.3% vs 9.7%; P = .22). Risk for lack of timely follow-up was higher with dual-alert communication (OR, 1.99; 95% CI, 1.06-3.48) but lower when additional verbal communication was used by the radiologist (OR, 0.12; 95% CI, 0.04-0.38). Nearly all abnormal results lacking timely follow-up at 4 weeks were eventually found to have measurable clinical impact in terms of further diagnostic testing or treatment. CONCLUSIONS: Critical imaging results may not receive timely follow-up actions even when HCPs receive and read results in an advanced, integrated electronic medical record system. A multidisciplinary approach is needed to improve patient safety in this area

Association between physical activity and longitudinal change in body mass index in middle-aged and older adults

Background: In middle-aged and particularly older adults, body mass index (BMI) is associated with various health outcomes. We examined associations between physical activity (PA) and longitudinal BMI change in persons aged ≥ 50 years. Methods: The sample included 5159 community-dwelling individuals aged ≥ 50 years (50.5% males, mean (SD) age 73.0 (10.2) years at baseline) who were enrolled in the Mayo Clinic Study of Aging (MCSA). Participants had information on PA within one year of baseline assessment, BMI at baseline, and potential follow-up assessments (mean (SD) follow-up 4.6 (3.7) years). Linear mixed-effect models were used to calculate the association between PA (moderate-vigorous physical activity, MVPA; and all PA composite score) and the longitudinal change in BMI, adjusted for baseline age, sex, education and medical comorbidities. In addition to interactions between years since baseline and PA, we also included 2- and 3-way interactions with baseline age to further assess whether age modifies the trajectory of BMI over time. Results: We observed a decrease in BMI among participants engaging at a mean amount of PA (i.e., MVPA: 2.7; all PA: 6.8) and with a mean age (i.e., 73 years) at baseline (MVPA: estimate = -0.047, 95% CI -0.059, -0.034; all PA: estimate = -0.047, 95% CI -0.060, -0.035), and this decline is accelerated with increasing age. Participants with a mean age (i.e., 73 years) that engage at an increased amount of MVPA or all PA at baseline (i.e., one SD above the mean) do not decrease as fast with regard to BMI (MVPA: estimate = -0.006; all PA: estimate = -0.016), and higher levels of MVPA or all PA at baseline (i.e., two SD above the mean) were even associated with an increase in BMI (MVPA: estimate = 0.035; all PA: estimate = 0.015). Finally, MVPA but not all PA is beneficial at slowing BMI decline with increasing age. Conclusion: PA, particularly at moderate-vigorous intensity, is associated with slower decline in longitudinal BMI trajectories. This implies that engaging in PA may be beneficial for healthy body weight regulation in middle and late adulthood