Missed Opportunities: Documentation and Referral Rates Among Children and Adults with Obesity

Introduction: Our study reports rates of obesity documentation on the problem list (PL) and numbers of referrals to obesity medicine specialists and dietitians among pediatric and adult patients with obesity. Methods: All pediatric and adult patients with obesity seen at 14 primary care clinics between 7/1/2017 and 6/30/2019 were evaluated for inclusion of obesity on the PL and referrals to obesity medicine specialists or dietitians. Results: For children with BMI \u3e95% for age, obesity was documented in 31.2%, and 12.5% received a referral. For adults with BMI \u3e30, obesity was documented in 54.2%, and 8.4% received a referral. Significantly more subjects received referrals when obesity was on the PL (both age-groups) compared to those without (children: 20.2% vs 9.0%; adults: 12.12% vs 3.9%, p values \u3c 0.0001). Higher BMI and more comorbidities were also associated with higher referral rates (children: 26.6% vs 8.6% for those with a BMI ≥ 99 percentile; adults: 19.9% vs 5.8% for those with a BMI ≥ 40; children: 20.2% vs 10.7% for ≥ 1 comorbidity vs 1 or fewer; adults: 22.7% vs 5.1% with ≥ 3 comorbidities compared to 0 comorbidities). Discussion: The low rates of documentation of obesity and low rates of referral raise concern that providers may be missing opportunities to identify and manage their patients affected by obesity. Conclusions: Children and adults with obesity are more likely to be referred to a dietitian or obesity medicine specialist if obesity is on the PL, they have a higher BMI, and they have more medical comorbidities

Effect of Socioeconomic Status and Comorbidities on Thyroid Cancer Survival Outcomes

Purpose/Objectives: Thyroid cancer ranks among the most common head and neck malignancies and makes up 3% of new cancer cases per year, having increased in overall incidence in the last several decades. This study investigates patient characteristics, socioeconomic status (SES), and medical comorbidities as independent predictors of survival in patients with thyroid cancer, treated at a tertiary care hospital with a diverse, primarily low SES patient population. Materials/Methods: The Henry Ford Health System’s Virtual Data Warehouse Tumor Registry was used to identify patients with thyroid cancers from 1997 to 2016. Socioeconomic data was obtained from 2010 US Census. Comorbidities were quantified using the Charlson Comorbidity Index (CCI). Statistical analysis was performed using Kaplan-Meier estimator and Cox proportional hazards models. Results: There were 1042 patients with thyroid cancer. 5- and 10-year survival probabilities decreased with age \u3e=60 years (p\u3c0.001), stage 3/4 (p\u3c0.001), clinical N stage 1-3 (p\u3c0.001), black race (p=0.001), CCI\u3e1 (p\u3c0.001), and lowest quartile median household income (p\u3c0.001). In multivariate analysis, age (1-year increase HR: 1.97, 95% CI: 1.06-1.09), sex (female vs. male HR: 0.67, 95% CI: 0.48-0.95), and CCI (1-point increase HR: 1.26, 95% CI: 1.19-1.34) were significantly associated with survival outcomes. A CCI cutoff of \u3e1 was a reliable predictor of mortality (AUC: 0.759, 95% CI: 0.716-0.801). CCI was significantly correlated with stage (r=0.166, p=0.004) and median household income (r=-0.175, p\u3c0.001). Conclusion: Increased age, male sex, and medical comorbidities predicted significantly worse survival in thyroid cancer. Race and median household income were not independent significant prognostic indicators

Remote physiological monitoring: Clinical, financial, and behavioral outcomes in a heart failure population

This article reports on the outcomes associated with remote physiological monitoring (RPM) conducted as part of a heart failure disease management program. Claims data, medical records, data transmission records, and survey results for 91 individuals ages 50–92 (mean 74 years) successfully completing a heart failure RPM program were analyzed for time periods before, during, and after the monitoring intervention. The program was associated with significant reductions in per member per month costs and emergency room and hospital utilization. More detailed analyses were performed for specific gender and age subgroups. Participant surveys indicated high levels of satisfaction, and improvements in self-perceived health status, self-efficacy, and self-management behaviors. This study is the first to assess the impact of a RPM program following removal of the monitoring equipment. The results indicate that RPM, as a component of a traditional disease management program, has a sustained, beneficial effect on participants’ lifestyles after the monitoring period has ended

Evaluating Quality of Life and Functional Outcomes in Salvage Surgery for Head and Neck Cancer

INTRODUCTION Unique challenges surround treatment for residual or recurrent head and neck squamous cell carcinoma (HNSCC). Of the limited treatment options for residual or recurrent HNSCC, salvage surgery is often the best option. However, salvage surgery can result in significant morbidity, affecting both quality of life (QoL) and functional outcomes. Few studies have examined QoL outcomes following salvage surgery in the setting of HNSCC. Our goal is to analyze the head and neck related quality of life, and functional outcomes in patients with head and neck cancer who underwent salvage surgery. METHODS In this study, FACT-HN Version 4 was administered pre-operatively and 6 months post-operatively to patients undergoing salvage surgery for HNSCC between November 4, 2014 and March 30, 2020. Retrospective cohort analysis was performed on this population with major outcome being postoperative QoL score. Functional outcomes included post-operative tracheostomy and feeding tube status. Simple logistic regression was used to determine characteristics associated with presence of permanent tracheostomy and feeding tube, defined as presence greater than 30 days. Chi-square fisher’s exact test was used to assess tumor characteristics with functional outcomes greater than 30 days. QoL outcomes were compared using paired t-tests and ANOVAs. RESULTS Overall, 39 patients undergoing salvage surgery for HNSCC and were included in this analysis. Salvage surgeries consisted of total laryngectomy (36.0%), definitive neck dissection (24.0%), mandibulectomy (16.0%), parotidectomy (8.0%), with total laryngectomy/total glossectomy, radical tonsillectomy, TORS base of tongue excision, and transoral laser laryngeal excision all comprising 4% of cases. Statistically significant differences between salvage and non-salvage patients were observed with alcohol use, with 5 (12.8%) salvage patients reporting no alcohol use, 10 (25.6%) reporting some, and 24 (61.5%) reporting abuse, when compared to 15 (17.7%), 39 (45.9%), and 31 (36.5%) in non-salvage patients, respectively. Preoperative scores for salvage patients were not found to be associated with functional outcomes of having a feeding tube and/or tracheostomy for more than 30 days. For non-salvage patients, the odds of having a tracheostomy more than 30 days decreases with higher pre-op HNCS score (p=0.0462). Of the patients with a feeding tube for more than 30 days, 52.14% do not have a secondary total laryngectomy versus 42.86%, 18% did not use systemic therapy while 81.82% did, and 57.14% had a neck dissection while 42.85% did not. Patients with tertiary total laryngectomy have higher Social Well-Being (SWB) postoperative scores (mean 27.33 vs 21.75) and higher Functional Well-Being (FWB) postoperative scores (mean 25.50 vs 17.39). Patients with salvage surgery and use of systemic therapy had lower HNCS post scores with means 19.39 vs 23.96 and 19.65 vs 26.82, respectively. Salvage patients also have a lower preoperative HNCS mean of 25.8 vs. 29.1. There is a statistically significant positive association between preoperative Physical Well-being (PWB) score and postoperative PWB score (correlation coefficient of 0.56), preoperative SWB score and postoperative SWB score (correlation coefficient of 0.56), and preoperative Emotional Well-Being (EWB) score and postoperative EWB score (correlation coefficient of 0.90) in salvage patients. In non-salvage patients, a similar positive correlation was found between preoperative and postoperative PWB (correlation coefficient of 0.51) and FWB (correlation coefficient of 0.64). Using a regression model we found that in salvage patients, for every one-point increase on preoperative PWB score, SWB score, and EWB score, the predicted postoperative score would be 0.63, 0.47, and 0.97 points higher, respectively. Similarly, in non-salvage patients, for every one-point increase in PWB, FWB, and HNCS pre-op score, the predicted postoperative was 0.86, 0.42, and 0.73 points higher, respectively. CONCLUSIONS This study provides important information about quality of life and functional outcomes for patients undergoing salvage surgery for HNSCC. There is a lower rate of long-term tracheostomy and feeding tube dependence in non-salvage patients when preoperative HNSC score was higher, and of the patients who had permanent feeding tube, a significant percent used secondary therapy and had a neck dissection. Patients who underwent salvage surgery had positive association between preoperative and postoperative social well-being, physical well-being and emotional well-being, with the preoperative value being a strong predictor for postoperative well-being. This information should be taken into consideration when counselling and managing patients with residual or recurrent HNSCC

Effectiveness of Two Frequently Used Screening Tools in Identifying Depression and Anxiety in Collegiate Athletes

Introduction: To determine whether the Electronic Pre-participation Physical Examination (EPPE), a proprietary and frequently used tool, is an effective method for depression and anxiety screening in the collegiate athlete population as compared to the Patient Health Questionnaire-4 (PHQ-4). Methods: College athletes at a Division III university completed PHQ-4 questionnaires and a proprietary EPPE. Positive reponse rates to depression and/or anxiety for both questionnaires were collected and analyzed with a kappa (κ) statistic. Results: Among 420 students, we found that 9 (2%) reported depression and/or anxiety via the EPPE. Of the 26 students (6%) who answered positively on the PHQ-4, we found that 2 reported depression and/or anxiety on the EPPE. Of the 9 students who reported a history of depression and/or anxiety on the EPPE, we found that 2 scored positively on the PHQ-4. Agreement between the 2 methods was poor (κ = 0.08). Discussion: Reporting depression or anxiety among collegiate athletes with the EPPE screening question related to the nervous system is low compared to the PHQ-4. Conclusions: Colleges should consider adding additional depression and anxiety screening tools during the pre-participation exam to ensure they identify and treat at-risk student athletes

GRIT: Women in Medicine Leadership Conference Participants’ Perceptions of Gender Discrimination, Disparity, and Mitigation

Objective: To assess demographic characteristics and perceptions of female physicians in attendance at a medical conference for women with content focused on growth, resilience, inspiration, and tenacity to better understand major barriers women in medicine face and to find solutions to these barriers. Patients and Methods: A Likert survey was administered to female physicians attending the conference (September 20 to 22, 2018). The survey consisted of demographic data and 4 dimensions that are conducive to women’s success in academic medicine: equal access, work-life balance, freedom from gender biases, and supportive leadership. Results: All of the 228 female physicians surveyed during the conference completed the surveys. There were 70 participants (31.5%) who were in practice for less than 10 years (early career), 111 (50%) who were in practice for 11 to 20 years (midcareer), and 41 (18.5%) who had more than 20 years of practice (late career). Whereas participants reported positive support from their supervisors (mean, 0.4 [SD 0.9]; P<.001), they did not report support in the dimensions of work-life balance (mean, −0.2 [SD 0.8]; P<.001) and freedom from gender bias (mean, −0.3 [SD 0.9]; P<.001). Conclusion: Female physicians were less likely to feel support for work-life balance and did not report freedom from gender bias in comparison to other dimensions of support. Whereas there was no statistically significant difference between career stage, trends noting that late-career physicians felt less support in all dimensions were observed. Future research should explore a more diverse sample population of women physicians

Treatment Plan Adherence to Guidelines in Senior Adult Oncology Patients

Materials & Methods: Review of 287 records Patients ≥ 65 years old with new diagnosis of cancer Seen by 6, dual-boarded hematologists/ oncologists practicing in an urban academic cancer center Treatment plans compared to national guidelines to determine plan adherence status Patients were recommended: Adherent plan (AP) or Non-adherent plan (N-AP

Tenecteplase versus standard of care for minor ischaemic stroke with proven occlusion (TEMPO-2): a randomised, open label, phase 3 superiority trial

Background: Individuals with minor ischaemic stroke and intracranial occlusion are at increased risk of poor outcomes. Intravenous thrombolysis with tenecteplase might improve outcomes in this population. We aimed to test the superiority of intravenous tenecteplase over non-thrombolytic standard of care in patients with minor ischaemic stroke and intracranial occlusion or focal perfusion abnormality. Methods: In this multicentre, prospective, parallel group, open label with blinded outcome assessment, randomised controlled trial, adult patients (aged ≥18 years) were included at 48 hospitals in Australia, Austria, Brazil, Canada, Finland, Ireland, New Zealand, Singapore, Spain, and the UK. Eligible patients with minor acute ischaemic stroke (National Institutes of Health Stroke Scale score 0–5) and intracranial occlusion or focal perfusion abnormality were enrolled within 12 h from stroke onset. Participants were randomly assigned (1:1), using a minimal sufficient balance algorithm to intravenous tenecteplase (0·25 mg/kg) or non-thrombolytic standard of care (control). Primary outcome was a return to baseline functioning on pre-morbid modified Rankin Scale score in the intention-to-treat (ITT) population (all patients randomly assigned to a treatment group and who did not withdraw consent to participate) assessed at 90 days. Safety outcomes were reported in the ITT population and included symptomatic intracranial haemorrhage and death. This trial is registered with ClinicalTrials.gov, NCT02398656, and is closed to accrual. Findings: The trial was stopped early for futility. Between April 27, 2015, and Jan 19, 2024, 886 patients were enrolled; 369 (42%) were female and 517 (58%) were male. 454 (51%) were assigned to control and 432 (49%) to intravenous tenecteplase. The primary outcome occurred in 338 (75%) of 452 patients in the control group and 309 (72%) of 432 in the tenecteplase group (risk ratio [RR] 0·96, 95% CI 0·88–1·04, p=0·29). More patients died in the tenecteplase group (20 deaths [5%]) than in the control group (five deaths [1%]; adjusted hazard ratio 3·8; 95% CI 1·4–10·2, p=0·0085). There were eight (2%) symptomatic intracranial haemorrhages in the tenecteplase group versus two (&lt;1%) in the control group (RR 4·2; 95% CI 0·9–19·7, p=0·059). Interpretation: There was no benefit and possible harm from treatment with intravenous tenecteplase. Patients with minor stroke and intracranial occlusion should not be routinely treated with intravenous thrombolysis