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Aim: The aim of the study was to evaluate crestal bone loss around immediate loading compression screw implants. Study Design: A Randomized controlled clinical trial. Method: In this randomized study, 15 subjects with 30 edentulous sites in the maxillary and mandibular anterior regions (incisors and canines) willing for replacement were taken into consideration. A total of 14 implants were placed in healed sites and 16 implants were placed in freshly extracted sockets and immediately loaded in both groups. Provisional restoration was delivered on the same day of implant placement. Crestal bone loss was evaluated at baseline (immediately after implant placement), 1 month, and 4 months. The final prosthetic restoration was delivered after 4 months following implant placement. Results: No statistically significant difference for crestal bone loss was observed between delayed and immediate implant placement at 4 months interval. Conclusion: Within the limitations of this study, immediate placement of one-piece implant produced crestal bone loss comparable to delayed placement. The unique design of a one-piece implants eliminates the fixture abutment interface (microgap) and resembles the natural tooth with a seamless transition of the radicular unit to the coronal unit. Therefore, in the maxillary and mandibular anterior regions, one-piece implants with immediate loading can be considered as a viable solution for the replacement of missing teeth with better esthetics.

Background Healthcare inequity drives high costs, worse outcomes and is heavily influenced by social determinants of health (SDOH). Addressing health behaviors and SDOH through a culturally competent community-based exposure may be effective in improving value for Medicaid enrollees. This study aims to evaluate whether such an exposure lowers costs at equal or improved quality. Methods A retrospective cohort study leveraging claims data was conducted in Detroit, Michigan from April 2021 to April 2022 to examine the impact of a community-based peer support program on clinical, utilization and financial outcomes. A one-to-one propensity matching of 738 pairs of African American Medicaid enrollees was generated, and compared the difference of differences between inpatient, emergency department, prescription and outpatient paid amounts, utilization, and available claims-based quality metrics. Results Compared to controls, peer support recipients generated significantly lower per member per month costs ($115, (95% CI $20.2 to $210)). Recipients showed a significant increase in the Adult Access to Preventative/Ambulatory Health Services 20–44 year old quality metric (8.31% (95% CI 0.35–16.3%)). Member retention in the health insurance plan was significantly higher for peer support recipients vs. the control group by 3.62% (p Conclusions Among a population of African American Medicaid enrollees, a culturally competent community-based intervention was associated with lower cost and better member retention with preserved or improved quality.

Chethan Sarabu,1,2 Sandra Steyaert,1 Nirav R Shah1– 3 1Sharecare Inc., Atlanta, GA, USA; 2Stanford Medicine, Palo Alto, CA, USA; 3Clinical Excellence Research Center, Stanford, CA, USACorrespondence: Chethan SarabuSharecare Inc., 255 East Paces Ferry Road NE, GA, Atlanta, 30305, USATel +1 315-794-2354Email chethan.sarabu@gmail.com

We conducted a 16-week randomized controlled trial in psychiatric outpatients with a lifetime diagnosis of a mood and/or anxiety disorder to measure the impact of a first of its kind precision digital intervention based on social rhythm regulation principles (Cue). The full intent to treat (ITT) sample consisted of 133 individuals, aged 18 to 65. The primary sample of interest were individuals with moderately severe to severe depression at study entry (baseline PHQ-8 score greater than or equal to 15; N=28).Cue is a novel digital intervention platform that capitalizes on the smartphone’s ability to continuously monitor depression relevant behavior patterns and use each patient’s behavioral data to provide timely, personalized micro interventions, making this the first example of a digital precision intervention that we are aware of. Participants were randomly allocated to receive Cue plus care as usual or digital monitoring only plus care as usual.Within the depressed and full ITT samples, we fit a mixed effects model to test for group differences in the slope of depressive symptoms over 16 weeks. To account for the nonlinear trajectory with more flexibility, we also fit a mixed effects model considering week as a categorical variable and used the resulting estimates to test the group difference in PHQ change from baseline to 16 weeks.In the depressed at entry sample, we found evidence for benefit of Cue. The large group difference in the slope of PHQ-8 (Cohen’s d= -0.72) indicated a meaningfully more rapid rate of improvement in the intervention group than in the control group. The Cue group also demonstrated significantly greater improvement in PHQ-8 from baseline to 16 weeks (p=0.009). In the full sample, the group difference in the slope of PHQ-8 was negligible (Cohen’s d=-0.10); however, the Cue group again demonstrated significantly greater improvement from baseline to 16 weeks (p=0.040).We are encouraged by the size of the intervention effect in those who were acutely ill at baseline and by the finding that across all participants, 80% of whom were receiving pharmacotherapy, we observed significant benefit of Cue at 16 weeks of treatment. These findings suggest that a social rhythm focused digital intervention platform may represent a useful and accessible adjunct to antidepressant treatment.(https://clinicaltrials.gov/ct2/show/NCT03152864?term=ellen+frank&draw=2&rank=3)

Environmental allergies cause significant morbidity across a wide range of demographic groups. This morbidity could be mitigated through individualized predictive models capable of guiding personalized preventive measures. We developed a predictive model by integrating smartphone sensor data with symptom diaries maintained by patients. The machine learning model was found to be highly predictive, with an accuracy of 0.801. Such models based on real-world data can guide clinical care for patients and providers, reduce the economic burden of uncontrolled allergies, and set the stage for subsequent research pursuing allergy prediction and prevention. Moreover, this study offers proof-of-principle regarding the feasibility of building clinically useful predictive models from “messy,” participant derived real-world data.

Pediatric practice increasingly involves providing care for children with medical complexity. Telehealth offers a strategy for providers and health care systems to improve care for these patients and their families. However, lack of awareness related to the unintended negative consequences of telehealth on vulnerable populations--coupled with failure to intentional design best practices for telehealth initiatives--implies that these novel technologies may worsen health disparities in the long run. This article reviews the positive and negative implications of telehealth. In addition, to achieve optimal implementation of telehealth, it discusses 10 considerations to promote optimal care of children using these technologies.

BACKGROUND: Programs addressing social determinants of health for high-utilizing patients are gaining interest among health systems as an avenue to promote health and decrease utilization. OBJECTIVE: To evaluate impacts of a social needs screening and navigation program for adult predicted high utilizers on total medical visit utilization. DESIGN: A prospective, quasi-experimental study using an intent-to-treat propensity-weighted difference-in-differences approach. Stratified analyses assessed intervention effects among three low–socioeconomic status sub-samples: patients in low-income areas, in low-education areas, and with Medicaid insurance. PARTICIPANTS: Predicted high utilizers—patients predicted to be in the highest 1% for total utilization in a large integrated health system. INTERVENTION: A telephonic social needs screening and navigation program. MAIN MEASURES: Primary difference-in-difference analyses compared total visit count utilization, including outpatient, emergency department (ED), and inpatient utilization, between the intervention and control groups at both in-network and out-of-network facilities. Prevalence of social needs among sample patients and their connection rates to social needs resources are also described. KEY RESULTS: The study included 34,225 patients (7107 intervention, 27,118 control). Most (53%) patients screened reported social needs, but only a minority (10%) of those with a need were able to connect with resources to address these needs. Primary analysis found total utilization visits decreased 2.2% (95% CI − 4.5%, 0.1%; p = 0.058) in the intervention group. Stratified analyses showed decreases in total utilization for all low–socioeconomic status subgroups receiving the intervention compared with controls: − 7.0% (95% CI − 11.9%, − 1.9%; p = 0.008) in the low-income area group, − 11.5% (− 17.6%, 5.0%; p

Objectives Pneumonia severity tools were primarily developed in cohorts of hospitalized patients, limiting their applicability to the emergency department (ED). We describe current community ED admission practices and examine the accuracy of the CURB-65 to predict 30-day mortality for patients, either discharged or admitted with community-acquired pneumonia (CAP). Methods A retrospective, observational study of adult CAP encounters in 14 community EDs within an integrated healthcare system. We calculated CURB-65 scores for all encounters and described the use of hospitalization, stratified by each score (0–5). We then used each score as a cutoff to calculate sensitivity, specificity, positive predictive value, negative predictive value (NPV), positive likelihood ratios, and negative likelihood ratios for predicting 30-day mortality. Results The sample included 21,183 ED encounters for CAP (7,952 discharged and 13,231 admitted). The C-statistic describing the accuracy of CURB-65 for predicting 30-day mortality in the full sample was 0.761 (95% confidence interval [CI], 0.747–0.774). The C-statistic was 0.864 (95% CI, 0.821–0.906) among patients discharged from the ED compared with 0.689 (95% CI, 0.672–0.705) among patients who were admitted. Among all ED encounters a CURB-65 threshold of ≥1 was 92.8% sensitive and 38.0% specific for predicting mortality, with a 99.9% NPV. Among all encounters, 62.5% were admitted, including 36.2% of those at lowest risk (CURB-65 = 0). Conclusions CURB-65 had very good accuracy for predicting 30-day mortality among patients discharged from the ED. This severity tool may help ED providers risk stratify patients to assist with disposition decisions and identify unwarranted variation in patient care.

Armed with just the rules of the game, Google's AlphaZero mastered chess after 9 hours of training. The program showed an awesome new kind of intelligence, creativity, beauty, and perhaps even play...

Context While hospitals remain important centers of gravity in the health system, services are increasingly being delivered through ambulatory care. This shift to ambulatory care is giving rise to new delivery structures, such as retail clinics and urgent care centers, as well as reinventing existing ambulatory care capacity, as seen with the patient-centered medical home model and the movement toward team-based care. To protect the public's interests, oversight of ambulatory care services must keep pace with these rapid changes. With this purpose, in January 2013 the New York Public Health and Health Planning Council undertook a redesign of the regulatory framework for the state's ambulatory care services. This article describes the principles undergirding the framework as well as the regulatory recommendations themselves.

The New York State Department of Health (DOH) has a long history of biomedical research, public health policy and program development, peer-reviewed scholarship, and teaching. Its evolution as an academic health department advanced significantly when the University at Albany and DOH formed the School of Public Health Sciences in 1985 to further develop these functions while formally training the next generation of public health workers. The School, renamed in 1990 as the School of Public Health (SPH), was initially located within the DOH with its staff as the founding faculty. The curriculum was heavily influenced by public health practice imperatives. The SPH has evolved to have an independent campus and full-time academic faculty, but the DOH remains closely linked. The relationship is governed by a memorandum of understanding that commits both partners to provide substantial and continuing resources to the SPH. The SPH brings value to the DOH's mission to improve the health of the state's citizens by providing an academic focus to problems faced in health department practice settings. The opportunity to teach and be involved in an academic environment increases the DOH's ability to recruit, retain, and improve the skill level of its professional and scientific staff and thereby improve its ability to assess health problems and to design and evaluate public health programs. The SPH also provides training and support to county health departments and nongovernment organizations, which further the DOH's mission, through continuing education programs and an online MPH degree program. International exchanges including those with China, Vietnam, and the Republic of Georgia have enriched the academic environment. Challenges include maintaining sufficient full-time faculty members, the need for the SPH to take on broader public health issues than those applicable to New York, and the shrinkage of the DOH's workforce and departure of many senior scientists who served as faculty.

A freestanding, 911-receiving emergency department was implemented at Bellevue Hospital Center during the recovery efforts after Hurricane Sandy to compensate for the increased volume experienced at nearby hospitals. Because inpatient services at several hospitals remained closed for months, emergency volume increased significantly. Thus, in collaboration with the New York State Department of Health and other partners, the Health and Hospitals Corporation and Bellevue Hospital Center opened a freestanding emergency department without on-site inpatient care. The successful operation of this facility hinged on key partnerships with emergency medical services and nearby hospitals. Also essential was the establishment of an emergency critical care ward and a system to monitor emergency department utilization at affected hospitals. The results of this experience, we believe, can provide a model for future efforts to rebuild emergency care capacity after a natural disaster such as Hurricane Sandy. (Disaster Med Public Health Preparedness. 2014;0:1-4)

The role of social determinants of health, and the business case for addressing them, is clear when it comes to homelessness and housing. New York State is undertaking an experiment that uses Medicaid funds for supportive housing for high-risk, homeless Medicaid recipients.

In patients aged ≥80 years without previous coronary artery disease, peripheral vascular disease, or cerebrovascular disease, no evidence has shown a benefit from statin therapy. We examined the prevalence of statin use in patients aged ≥80 years for the indication of primary prevention. We reviewed the comprehensive electronic health records at the Geisinger Health System in Pennsylvania for all patients aged >55 years with ≥1 primary care encounter from January 24, 2004 and December 31, 2009. The records were scrutinized for the use of a statin, active medical diagnoses, and laboratory values. Patients without a previous diagnosis of coronary artery disease, peripheral vascular disease, or cerebrovascular disease were considered to have a primary prevention indication for statin therapy. The prevalence of statin use was examined, and a multivariate analysis was conducted to determine the predictors of use. A total of 89,086 patients were included in the analysis, with 22,646 patients aged ≥80 years. Of all the patients, 26% were prescribed a statin, of whom, 71% (n = 16,687) received it for primary prevention. Of the 14,604 patients aged ≥80 years with a primary prevention indication, 3,145 (22%) received a statin. A plot of 5-year age cohorts from 55 to >90 years demonstrated an n-shaped relation between age and statin use for primary prevention (18%, 23%, 27%, 29%, 28%, 26%, 21%, and 12%, p

In 1988, the New York State Health Commissioner was confronted with hospital-level data demonstrating very large, multiple-year, interhospital variations in short-term mortality and complications for cardiac surgery. The concern with the extent to which these differences were due to variations in patients' pre-surgical severity of illness versus hospitals' quality of care led to the development of clinical registries for cardiac surgery in 1989 and for percutaneous coronary interventions in 1992 in New York. In 1990, the Department of Health released hospitals' risk-adjusted cardiac surgery mortality rates for the first time, and shortly thereafter, similar data were released for hospitals and physicians for percutaneous coronary interventions, cardiac valve surgery, and pediatric cardiac surgery (only hospital data). This practice is still ongoing. The purpose of this communication is to relate the history of this initiative, including changes or purported changes that have occurred since the public release of cardiac data. These changes include decreases in risk-adjusted mortality, cessation of cardiac surgery in New York by low-volume and high-mortality surgeons, out-of-state referral or avoidance of cardiac surgery/angioplasty for high-risk patients, alteration of contracting choices by insurance companies, and modifications in market share of cardiac hospitals. Evidence related to these impacts is reviewed and critiqued. This communication also includes a summary of numerous studies that used New York's cardiac registries to examine a variety of policy issues regarding the choice and use of cardiac procedures, the comparative effectiveness of competing treatment options, and the examination of the relationship among processes, structures, and outcomes of cardiac care.

J Clin Hypertens (Greenwich). 2012; 14:407–414. ©2012 Wiley Periodicals, Inc. Important questions concerning the comparative effectiveness of angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) remain unanswered, including whether they are equally effective in reducing clinical end points and in which populations. An incident cohort of adult patients 18 years and older prescribed an ACE inhibitor or ARB between 2001 and 2008 was identified from Geisinger Clinic, a large community-based set of medical practices that uses a common electronic health record. Propensity score matching was used to balance the groups on baseline factors. The authors examined differences in mortality and new-onset coronary disease, chronic kidney disease, stroke, and diabetes for different patient subgroups based on sex and age. A total of 25,035 hypertensive patients newly prescribed an ACE inhibitor or ARB were identified. No differences were found in risk of death, coronary disease, chronic kidney disease, or stroke between those prescribed ACE inhibitors and those prescribed ARBs. Patients prescribed ARBs had a greater rate of new-onset diabetes (hazard ratio [HR], 1.28; confidence interval [CI], 1.08–1.52), and this was especially true for women (HR, 1.93; CI, 1.22–3.07). Within a large medical-practice based population, there was no evidence of differential effectiveness between ACE inhibitors and ARBs for most outcomes, with diabetes being the notable exception.

Quantitative risk (QR) formulas have been developed for multiple conditions but are not routinely used in clinical practice. Tests were made of the feasibility of an automated clinical care process for using QR in routine primary care. Several modifications were made to the Framingham Risk Score (FRS) and it was applied to routine care in three areas: (1) for risk-stratification, (2) patient education about care options, and (3) guidance on optimizing choice of care options. Evidence-based methods were used to convert the smoking status variable from a binary- to a continuous-scale format and to add variables for alcohol use and HbA1c. An automated protocol tested in 2008-2010 was successful for all three applications. At-risk patients (defined according to criteria from the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure [JNC]-7 or the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults [adult treatment panel/ATP-III]) were automatically identified during routine encounters. Patient-reported data were obtained (n = 1826) by touchscreen questionnaire and automatically used with electronic health record (EHR) data to calculate risks on 1068 patients who had complete data. Patients were risk-stratified. Higher-risk patients viewed an interactive web-based tool and chose options to modify risk factors. Feasibility was successful for use of the FRS in the interactive web tool.

The role of social determinants of health, and the business case for addressing them, is clear when it comes to homelessness and housing. New York State is undertaking an experiment that uses Medicaid funds for supportive housing for high-risk, homeless Medicaid recipients.

Latino immigrants face a higher burden of colorectal cancer (CRC) and screening rates are low.To assess the effectiveness of a multilevel intervention in increasing the rate of CRC screening among Latino immigrants.A randomized controlled trial, with randomization at the physician level.Pairs of 65 primary care physicians and 65 Latino immigrant patients participated, 31 in the intervention and 34 in the control group.CRC educational video in Spanish on a portable personal digital video display device accompanied by a brochure with key information for the patient, and a patient-delivered paper-based reminder for their physician.Completed CRC screening, physician recommendation for CRC screening, and patient adherence to physician recommended CRC screening.The overall rate of completed screening for CRC was 55% for the intervention and 18% for the control group (p = 0.002). Physicians recommended CRC screening for 61% of patients in the intervention group versus 41% in the control group (p = 0.08). Of those that received a recommendation, 90% in the intervention group adhered to it versus 26% in the control group (p = 0.007).The intervention was successful in increasing rates of completed CRC screening primarily through increasing adherence after screening was recommended. Additional efforts should focus on developing new strategies to increase physician recommendation for CRC screening, while employing effective patient adherence interventions.

The concept of the medical home has existed since the 1960s, but has recently become a focus for discussion and innovation in the health care system. The most prominent definitions of the medical home are those presented by the Patient-Centered Primary Care Collaborative, the National Committee for Quality Assurance, and the Commonwealth Fund. These definitions share: adoption of health information technology and decision support systems, modification of clinical practice patterns, and ensuring continuity of care. Each of these components is a complex undertaking, and there is scant evidence to guide assessment of diverse strategies for achieving their integration into a medical home. Without a shared vocabulary and common definitions, policy-makers seeking to encourage the development of medical homes, providers seeking to improve patient care, and payers seeking to develop appropriate systems of reimbursement will face challenges in evaluating and disseminating the medical home model.

Our goal was to examine colorectal cancer (CRC) screening, referral, and follow-up practices in a population of Chinese and Latino immigrant patients. We conducted a nested cohort study within a larger randomized trial in a primary care clinic of a large municipal hospital. Participants were patients born in China and Latin America, new to the clinic and eligible for screening colonoscopy. The main outcome measures were physician referral for screening colonoscopy and patients’ adherence to referral. One hundred and forty-six (146) patients met inclusion criteria; 92 were born in Latin America and 54 in China. Of those born in Latin America, 27% received a referral for screening colonoscopy and 80% adhered to the provider referral. Of those born in China, 24% received a referral for colonoscopy and 92% of those adhered to it. No significant associations were found between patient characteristics, referral for colonoscopy and completion of screening. Rates of CRC screening among Chinese and Latino patients...

Purpose We conducted a systematic review of the literature to summarize the available data on reconstructive surgeries involving pinch reconstruction and elbow extension restoration in people with tetraplegia. Methods English-language and French-language articles and abstracts published between 1966 and February 2007, identified through MEDLINE and EMBASE searches, bibliography review, and expert consultation, were reviewed for original reports of outcomes with pinch reconstruction and elbow extension restoration in tetraplegic patients after a spinal cord injury. Two reviewers independently extracted data on patient characteristics, surgical methods, and patient outcomes. Results Our search identified 765 articles, of which 37 met eligibility criteria (one article contained information on both elbow and pinch procedures). Results from 377 pinch reconstructions in 23 studies and 201 elbow extension restorations in 14 studies were summarized. The mean Medical Research Council score for elbow extension went from 0 to 3.3 after reconstruction. The overall mean postoperative strength measured after surgery for pinch reconstruction was 2 kg. Conclusions More than 500 patients having these procedures experienced a clinically important improvement for both procedures—one restoring elbow extension, and the other, pinch strength. Upper-limb surgeries markedly improved the hand function of people with tetraplegia. Type of study/level of evidence Therapeutic IV.

Evaluation of: Lyytinen H, Pukkala E, Ylikorkala O: Breast cancer risk in postmenopausal women using estrogen-only therapy. Obstet. Gynecol. 108(6), 1354–1360 (2006) [ 1 ]. A cohort study of 84,729 Finnish women over the age of 50 years who used oral or transdermal estradiol for at least 6 months, followed for the incidence of breast cancer using a national cancer registry. The study was conducted to evaluate whether the risk of breast cancer with estrogen-only therapy varies by dose, constituents or route of administration. A total of 2171 women developed breast cancer, with no increased risk observed for less than 5 years of use, and some risk for greater than 5 years of use for both oral and transdermal routes of administration.

Most clinical decisions involve bridging the inferential gap: Clinicians are required to “fill in” where they lack knowledge or where no knowledge yet exists. In this context we consider how the inferential gap is a product, in part, of how knowledge is created, the limits to gaining access to such knowledge, and the variable ways in which knowledge is translated into decisions. We consider how electronic health records (EHRs) will help narrow this gap by accelerating the creation of evidence relevant to everyday practice needs and facilitating real-time use of knowledge in practice.

The controversies surrounding hormone replacement therapy have left many women confused and afraid. Providers have been faced with long-standing assumptions challenged by an abundance of new data in the past few years, with little guidance on how to interpret these findings. The objective of this paper is to provide a framework for understanding breast cancer risk associated with postmenopausal hormone replacement therapy, with a particular focus on how observational studies and randomised trials provide complementary information. This framework considers the data on risks of various hormonal preparations, the profiles of women at risk, and ends with an expert opinion in this context.

Background. With recent improvements in medical and device therapy, the benefit of cardiac transplantation for UNOS Status 2 patients has been questioned. No randomized trial has been performed to compare transplantation versus contemporary medical therapy.Methods. Between January 1996 and December 2003, 203 patients were listed at our institution for heart transplantation as UNOS Status 2. We performed a retrospective review to determine outcomes in these patients.Results. Demographics of this cohort revealed a mean age of 52 years, female sex in 28%, and ischemic etiology in 47%. Eighty-one patients (40%) had an implantable cardiac defib-rillator. A total of 64 patients (32%) had to be upgraded in their UNOS status, with 9 requiring a left ventricular assist device. Of the entire group, 95 (47%) underwent transplantation at a mean time of 303 days, 45 (22%) died while waiting at a mean time of 397 days, and 24 (12%) were removed from the waiting list due to deterioration in medical condition such that transplantation was no longer an option. The remaining patients continue to wait or have been removed from consideration due to improved condition. Survival at 1- and 3-years postlisting was 94% and 87% for patients who received transplants compared to 81% and 57% for patients who did not receive transplants (P < .01).Conclusion. A significant number of patients listed as Status 2 are upgraded in UNOS status or die while on the waiting list. Early and midterm survival is significantly better with transplantation. Identification of variables associated with deterioration may allow for better risk stratification in the future. At this point, transplantation offers the best outcome.

There is a rapidly evolving debate on the indications and appropriate duration of therapy for postmenopausal hormone therapy. The objective of this meta-analysis was to examine the specific relationships of postmenopausal estrogen therapy (ET), postmenopausal combined (estrogen-progestogen) hormone therapy (CHT), and the incidence of breast cancer.We performed computerized searches of MEDLINE and CancerLit through September 2003 and reviewed reference lists of retrieved studies and meta-analyses. We included English-language studies that identified noncontraceptive postmenopausal hormone use; reported on the risks of "current use" of ET and/or CHT and breast cancer incidence; were case-control, cohort, or experimental; and reported either an odds ratio (OR), relative risk (RR), or HR with CIs. Two investigators were involved during all stages of study selection and independently extracted all data selected for inclusion in meta-analyses.Meta-analysis of 13 studies of ET and breast cancer (700,000 women) resulted in an OR of 1.16 (95% confidence limits [CL] 1.06, 1.28), with estimates for less than 5 years use 1.16 (1.02, 1.32) and more than 5 years use 1.20 (1.06, 1.37). Meta-analysis of eight studies of CHT and breast cancer (650,000 women) resulted in an OR of 1.39 (95% CL 1.12, 1.72), with estimates for less than 5 years use 1.35 (1.16, 1.57) and more than 5 years use 1.63 (1.22, 2.18).Data from observational studies support the association of increased but considerably different risks for breast cancer incidence among current users of ET and CHT. These represent the first pooled estimates for ET. CHT estimates correspond to those from randomized trials.

Background The University of Wisconsin (UW) solution is the gold standard for heart preservation but has limitations in terms of both duration and adequacy of protection. Our laboratory has been interested in a more physiologic approach to heart preservation by maintaining the heart at its resting membrane potential (hyperpolarized arrest) with the KATP channel agonist pinacidil. This study compared our extracellular solution (WashU) with the UW intracellular depolarizing solution and quantified the protective effect of pinacidil in both solutions. Methods Thirty-two rabbit hearts received 1 of 4 solutions in a crystalloid-perfused Langendorff apparatus: (1) UW, (2) WashU containing 0.5 mmol/liter pinacidil, (3) UW with 0.5 mmol/liter pinacidil, or (4) WashU without pinacidil. Thirty minutes of perfusion was followed by data acquisition consisting of left ventricular pressure-volume curves generated by inflating an intraventricular balloon. All hearts were placed in cold storage for 8 hours, followed by 1 hour of reperfusion before data acquisition. Results Post-ischemic developed pressure (DP) was better preserved by WashU (76.8% ± 3.8%) than by UW (48.3% ± 2.5%). Diastolic compliance was better preserved by WashU (239.9% ± 77.2%) compared with UW (711.1% ± 193.1%). Removing pinacidil from our solution resulted in decreased DP (46.6% ± 3.2%) and diastolic compliance (688.8% ± 158.2%) Adding pinacidil to UW had a limited effect on DP and compliance. Conclusions Our results support the superiority of the WashU hyperpolarizing solution for heart preservation over UW. Pinacidil was beneficial in maintaining cardiac function and compliance. This benefit was not observed when pinacidil was placed into the UW depolarizing solution.

SummaryEvaluation of the accuracy of ultrasound has yielded heterogeneous results. Our objective was to summarize the evidence on the accuracy of ultrasound compared to venography in asymptomatic patients, taking into account the variation due to threshold differences. Searches of journal table of contents, computer databases (Medline, Embase, Biomed, Cochrane) and conference proceedings were performed. A study was eligible if it prospectively compared ultrasound to venography for the diagnosis of DVT in asymptomatic patients. Data of studies selected for inclusion were extracted independently by two authors. High quality studies with consecutive patient enrollment, blind evaluation of the two techniques, and absence of verification bias are summarized as Level 1, while those not fulfilling one or more of these criteria are considered Level 2. Original study authors were contacted to confirm accuracy and to provide missing data. A pooled estimate of the accuracy of ultrasound was obtained according to the method of Moses and coworkers. This method gives a summary diagnostic odds ratio (DOR). The DOR is a single indicator of test performance. It varies between 0 and infinity and exceeds 1, only when ultrasound is more often positive in patients with DVT relative to those without DVT. Higher DOR indicates better discriminatory test performance. Thirty one studies were rated as potentially unbiased and graded as Level 1.The mean prevalence of DVT as determined by venography was 22%. In Level 1 studies, the odds of positive ultrasound in proximal veins was 379 times higher (95% confidence limits 65, 2,200) and in distal veins 32 times higher (7.5, 135) among patients with DVT than those without. Our results suggest that, particularly for proximal veins, ultrasound is accurate for the diagnosis of DVT in asymptomatic postoperative orthopedic patients. More research is needed in other clinical settings.

Public health surveillance conducted by health departments in the United States has improved in completeness and timeliness owing to electronic laboratory reporting. However, the collection of detailed clinical information about reported cases, which is necessary to confirm the diagnosis, to understand transmission, or to determine disease-related risk factors, is still heavily dependent on manual processes. The increasing prevalence and functionality of electronic health record (EHR) systems in the United States present important opportunities to advance public health surveillance. EHR data have the potential to further increase the breadth, detail, timeliness, and completeness of public health surveillance and thereby provide better data to guide public health interventions. EHRs also provide a unique opportunity to expand the role and vision of current surveillance efforts and to help bridge the gap between public health practice and clinical medicine.

Policy Points: The landscape of ambulatory care services in the United States is rapidly changing on account of payment reform, primary care transformation, and the rise of convenient care options such as retail clinics. New York State has undertaken a redesign of regulatory policy for ambulatory care rooted in the Triple Aim (better health, higher-quality care, lower costs)-with a particular emphasis on continuity of care for patients. Key tenets of the regulatory approach include defining and tracking the taxonomy of ambulatory care services as well as ensuring that convenient care options do not erode continuity of care for patients.While hospitals remain important centers of gravity in the health system, services are increasingly being delivered through ambulatory care. This shift to ambulatory care is giving rise to new delivery structures, such as retail clinics and urgent care centers, as well as reinventing existing ambulatory care capacity, as seen with the patient-centered medical home model and the movement toward team-based care. To protect the public's interests, oversight of ambulatory care services must keep pace with these rapid changes. With this purpose, in January 2013 the New York Public Health and Health Planning Council undertook a redesign of the regulatory framework for the state's ambulatory care services. This article describes the principles undergirding the framework as well as the regulatory recommendations themselves.We explored and analyzed the regulation of ambulatory care services in New York in accordance with the available gray and peer-reviewed literature and legislative documents. The deliberations of the Public Health and Health Planning Council informed our review.The vision of high-performing ambulatory care should be rooted in the Triple Aim (better health, higher-quality care, lower costs), with a particular emphasis on continuity of care for patients. There is a pressing need to better define the taxonomy of ambulatory care services. From the state government's perspective, this clarification requires better reporting from new health care entities (eg, retail clinics), connections with regional and state health information technology hubs, and coordination among state agencies. A uniform nomenclature also would improve consumers' understanding of rights and responsibilities. Finally, the regulatory mechanisms employed-from mandatory reporting to licensure to regional planning to the certificate of need-should remain flexible and match the degree of consensus regarding the appropriate regulatory path.Few other states have embarked on a wide-ranging assessment of their regulation of ambulatory care services. By moving toward adopting the regulatory approach described here, New York aims to balance sound oversight with pluralism and innovation in health care delivery.

In the era of “comparative effectiveness” research, each of the major stakeholders in healthcare—payors, patients, providers, and government—face a similar challenge. When making a decision about whether a new device, drug, or a diagnostic modality should be considered for use or coverage, what choices are best supported by the evidence? Medical evidence is defined by randomized controlled trials and by observational studies that vary greatly in their design, the accuracy of their analyses, and the relevance of their conclusions and recommendations. Hence, key decision makers increasingly rely on systematic reviews and meta-analyses to facilitate the interpretation and application of research evidence. Knowing how to evaluate meta-analyses and understanding the potential pitfalls of the method are crucial for those involved in designing drug benefits. The authors highlight the process, strengths, and weaknesses of meta-analysis and explain how to judge the value of the results.

Nonadherence to asthma medications is associated with increased emergency department visits and hospitalizations. If adherence is to be improved, first-fill adherence is the first goal to meet after the physician and patient have decided to begin treatment. Little is known about first-fill adherence with asthma medications and the factors for no-fill.The goal of the study was to examine the proportion of patients who fill a new prescription for an asthma medication and analyze characteristics associated with this first-fill.This retrospective cohort study linked electronic health records with pharmacy claims. The cohort was comprised of 2023 patients aged 18 years or older who sought care from the Geisinger Clinic, had Geisinger Health Plan pharmacy benefits, and were prescribed an asthma medication for the first time between 2002 and 2006. The primary outcome of interest was first-time prescription filled by the patient within 30 days of the prescription order date. Covariates examined included factors related to the patient (ie, age, sex, and ethnicity), comorbidities and utilization (ie, Charlson comorbidity index, number of office visits, number of additional medications), asthma treatment (ie, delivery route, pharmacologic class), and pharmacy copay amount. A logistic-regression model was used to determine covariates associated with first-fill.The overall first-fill rate for new asthma medications was 78%. First-fill rate was lower for patients with a copay above the mean of $12 (odds ratio = 0.76; 95% confidence interval, 0.58-0.99) and higher for patients prescribed oral plus inhaled medications (versus inhaled only, odds ratio = 3.91; 95% confidence interval, 2.15-7.11).SEVERAL FACTORS ASSOCIATED WITH FAILING TO FILL AN INITIAL PRESCRIPTION FOR ASTHMA CAN BE ADDRESSED THROUGH SIMPLE INTERVENTIONS: screening for difficulties a patient may have in filling prescriptions, avoiding nonformulary medications, and recognizing the barrier that high copays present. In addition, for employers and policymakers, decreasing copay may improve adherence and, therefore, asthma control.

Background In the hierarchy of research designs, the results of randomized, controlled trials are considered to be evidence of the highest grade, whereas observational studies are viewed as having less validity because they reportedly overestimate treatment effects. We used published meta-analyses to identify randomized clinical trials and observational studies that examined the same clinical topics. We then compared the results of the original reports according to the type of research design. Methods A search of the Medline data base for articles published in five major medical journals from 1991 to 1995 identified meta-analyses of randomized, controlled trials and meta-analyses of either cohort or case–control studies that assessed the same intervention. For each of five topics, summary estimates and 95 percent confidence intervals were calculated on the basis of data from the individual randomized, controlled trials and the individual observational studies. Results For the five clinical topics and 99 r...

We have attempted to quantify the most up-to-date estimate of the association between cigarette smoking by the mother and preterm delivery. Studies were selected for inclusion in this review if they were prospective, reported data stratified across at least two levels of maternal smoking, and defined preterm delivery on the basis of gestational age. In a meta-analysis we combined results from multiple studies that reported on preterm delivery and maternal smoking during pregnancy. Pooled odds ratios were computed for various strata of smoking intensity with the Mantel-Haenszel fixed-effects model. Twenty studies met all inclusion criteria and were included in meta-analysis. The pooled point estimate from 20 prospective studies on any maternal smoking versus no maternal smoking was 1.27 (95% confidence interval, 1.21-1.33). Subgroup analyses stratifying maternal smoking on number of cigarettes per day suggest a dose-response relationship at low to moderate levels of smoking, which was not further increased at high levels of smoking. A nonsignificant level of publication bias appears to exist in the smoking-preterm delivery literature. Cigarette smoking is a preventable risk factor that is associated with preterm delivery. Consistent results across many study populations and research designs and evidence of a dose-response relationship support its causal role in preterm delivery.

Chronic pain affects more than 50 million Americans and results in more than 25 million physician visits a year for lower back pain alone.1 The burden is particularly great in the elderly, in whom associated cardiovascular disease is the leading cause of death. Nonselective, nonaspirin, nonsteroidal antiinflammatory agents (NSAIDs) are effective analgesic, antiinflammatory, and antipyretic agents, but associated gastrointestinal toxicity led to the development and widespread use of selective cyclooxygenase (COX)-2 inhibitors. Originally introduced for use in chronic conditions such as osteoarthritis, they are today used to mitigate acute pain in numerous conditions. Their benefit was presumed to be from their selective inhibition of COX 2, which along with COX-1 is responsible for the conversion of arachidonic acid to prostaglandin H2. Adverse events associated with NSAIDs were attributed to their inhibition of COX 1, which downstream would normally result in the production of prostaglandins responsible for maintenance of gastrointestinal integrity.2 More recent investigations, however, have identified that both COX-1 and COX-2 are involved in vascular hemostasis, and selective COX-2 inhibitors can have net prothrombotic effects. COX-2 inhibitors lower levels of prostacyclin, a platelet inhibitor and vasodilator, whereas uninhibited COX-1 action results in continued thromboxane A2 production, which promotes platelet aggregation.3 There is mounting evidence that nonselective NSAIDs, previously thought to be neutral or beneficial for risk of cardiovascular disease, may also confer harm because of each agent’s relative COX-1/COX-2 prothrombotic effects and potential to reduce glomerular filtration, exacerbate congestive heart failure, and raise blood pressure.4 Article p 2906 In this issue of Circulation , Gislason and colleagues5 report on the risk of death and reinfarction associated with the use of both nonselective, nonaspirin NSAIDs and selective COX-2 inhibitors in post–myocardial infarction (MI) patients in Denmark. The advanced database system in Denmark is …