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Background Team debriefing is an important teamwork development intervention for improving team outputs in healthcare. Debriefing is a key component of experiential team training teamwork development interventions such as simulation-based training. Improving the quality of debriefing of healthcare teams, therefore, has multiple benefits. We investigated whether the quality of student-led debriefing improved using a shortened guide. Methods Senior medical students, nurse anesthesia students, and senior undergraduate nursing students participated in student operating room team training at a health sciences center in the southeastern United States. Student teams participated in a dual-scenario simulation-based training session with immediate after-action debriefings after each scenario. In 2018, student teams conducted the second debriefing using as a guide the teamwork assessment scale, an 11-item, 3-subscale, 6-point Likert-type instrument. In 2019, they used a shortened, revised, 5-item version of the teamwork assessment scale, the quick teamwork assessment scale. Trained observers rated the quality of the student-led debriefings using the Objective Structured Assessment of Debriefing, an 8-item, 5-point instrument. The Wilcoxon-Mann-Whitney test was used to compare the teamwork assessment scale-guided and the quick teamwork assessment scale-guided mean item debriefing scores. Results Two observers rated 3 student-led team debriefings using the teamwork assessment scales as a guide in 2018, and 6 such debriefings happened using the quick teamwork assessment scale as a guide in 2019. For each debriefing, observer scores were averaged for each Objective Structured Assessment of Debriefing item; these mean scores were then averaged with other mean scores for each year. The use of the quick teamwork assessment scale resulted in a statistically significant higher mean score for the Analysis Objective Structured Assessment of Debriefing item compared with the use of the teamwork assessment scale (4.92 [standard deviation 0.20] versus 3.83 [standard deviation 0.76], P = .023). Conclusion The use of a shortened teamwork assessment instrument as a debriefing guide for student teams in student operating room team training was more effective in analysis of actions than the original, longer tool. Next steps include determining the efficacy of the quick teamwork assessment scale in an actual clinical setting.

Purpose Radiographic tumor volume (RTV) of oral squamous cell carcinoma (SCC) is seldom measured in practice. Aims of the study are to estimate RTV of SCC and to investigate its relationship with clinical and pathological stage, tumor margin status, recurrence, and need for chemo/radiation. Methods The design is a retrospective cohort study. The predictor variable is SCC RTV. The primary outcome variables are clinical and pathological tumor size. The secondary outcomes are margin status and postoperative chemo/radiation. Tumor dimensions were measured on preoperative maxillofacial or neck computer tomography images with contrast. Information on patient and tumor characteristics was obtained. Pearson correlation, t test, ANOVA and log rank test were used for statistical analysis. The significance level was set at .05. Results Thirty-six subjects aged 36 to 86 were included in the study. Positive association was found between clinical T stage and RTV (P = .0003) and between pathologic T stage and RTV (P = .002). Mean value of RTV was significantly higher in the group with positive margins (P = .0004). RTV was significantly higher in cancers requiring adjuvant chemo/radiation (P = .033). Mean RTV for patients with recurrence was 1.86 cm3 as compared to 1.29 cm3 for patients with no recurrence. Higher tumor volumes were more likely to be associated with recurrence. Conclusions RTV is a variable that is readily available to head and neck surgeons. RTV is associated with clinical and pathological tumor sizes, margin status, need for adjuvant chemo/radiation and tumor recurrence.

Immune-checkpoint inhibitor (ICI) therapy has been widely used to treat different human cancers, particularly advanced solid tumors. However, clinical studies have reported that ICI immunotherapy benefits only ∼15% of patients with colorectal cancer, specifically those with tumors characterized by microsatellite instability (MSI), a molecular marker of defective DNA mismatch repair (dMMR). For the majority of patients with colorectal cancer who carry proficient MMR (pMMR), ICIs have shown little clinical benefit. In this study, we examined the efficacy of sulindac to enhance the response of pMMR colorectal cancer to anti–PD-L1 immunotherapy. We utilized a CT26 syngeneic mouse tumor model to compare the inhibitory effects of PD-L1 antibody (Ab), sulindac, and their combination on pMMR colorectal cancer tumor growth. We found that mice treated with combination therapy showed a significant reduction in tumor volume, along with increased infiltration of CD8+ T lymphocytes in the tumor tissues. We also demonstrated that sulindac could downregulate PD-L1 by blocking NF-κB signaling, which in turn led to a decrease in exosomal PD-L1. Notably, PD-L1 Ab can be bound and consumed by exosomal PD-L1 in the blood circulation. Therefore, in combination therapy, sulindac downregulating PD-L1 leads to increased availability of PD-L1 Ab, which potentially improves the overall efficacy of anti–PD-L1 therapy. We also show that low-dose sulindac does not appear to have a systemic inhibitory effect on prostaglandin E2 (PGE2). In conclusion, our findings provide unique insights into the mechanism of action and efficacy for sulindac as an immunomodulatory agent in combination with anti–PD-L1 therapy for the treatment of pMMR colorectal cancer.

Background: Previous studies have shown that smoking tobacco significantly increases both incidence and mortality rates for many diseases. Social media has become one of the most influential platforms for various smoking cessation interventions. However, results from smoking cessation interventions have differed from study to study. Limited studies have summarised cessation outcomes from social media–based interventions. Therefore, the objective of this review is to explore the effectiveness of using social media for smoking cessation. Methods: We searched PubMed, MEDLINE, PsycINFO, and CINAHL for articles between June 2008 and June 2018, and also assessed the references of selected articles. We included studies that used social media as intervention platforms, provided a baseline assessment before the intervention, and provided smoking cessation outcomes after the intervention. Results: We identified 13 original studies that enrolled between 16 and 1698 participants; 7-day Point Prevalence Abstinence (PPA) rate was the most frequently used measure of abstinence, with a range of 7%–75%, regardless of the measurement time, study design, and analysis methods. Social media–based smoking cessation interventions were effective, because (1) smokers reported higher 7-day PPA rates after intervention compared to baseline and (2) smokers reported higher 7-day PPA rates in intervention groups than in control groups. Moreover, at each time point, approximately half of all smokers in studies reporting abstinence were found to be biochemically abstinent. There were no significant differences in the effectiveness of smoking cessation outcomes between those that used existing popular social networking platforms (e.g. Pechmann et al’s studies) and those that used individually designed interactive platforms (e.g. MyLastDip, iQuit system, Quitxt system). Conclusions: This review highlights the effectiveness of social media–based smoking cessation intervention studies. Due to the widespread use of social media, as well as its low cost, we suggest embedding smoking cessation interventions within existing popular social media platforms.

Background Vulvovaginal candidiasis (VVC) is a common infection affecting women worldwide. Reports of patterns/risk factors/trends for episodic/recurrent VVC (RVVC) are largely outdated. The purpose of this study was to obtain current patient perspectives of several aspects of VVC/RVVC. Methods Business cards containing on-line survey information were distributed to healthy volunteers and patients seeking standard, elective, or referral gynecologic care in university-affiliated Obstetrics/Gynecology clinics. The internet-based questionnaire was completed by 284 non-pregnant women (78% Caucasian, 14% African American, 8% Asian). Results The majority of the participants (78%) indicated a history of VVC with 34% defined as having RVVC. The most common signs/symptoms experienced were itching, burning and redness with similar ranking of symptoms among VVC and RVVC patients. Among risk factors, antibiotic use ranked highest followed by intercourse, humid weather and use of feminine hygiene products. A high number of respondents noted ‘no known cause’ (idiopathic episodes) that was surprisingly similar among women with a history of either VVC or RVVC. VVC/RVVC episodes reported were primarily physician-diagnosed (73%) with the remainder mostly reporting self-diagnosis and treating with over-the-counter (OTC) medications. Most physician-diagnosed attacks utilized a combination of pelvic examination and laboratory tests followed by prescribed antifungals. Physician-treated cases achieved a higher level of symptom relief (84%) compared to those who self-medicated (57%). The majority of women with RVVC (71%) required continual or long-term antifungal medication as maintenance therapy to control symptoms. Conclusions Current patient perspectives closely reflect historically documented estimates of VVC/RVVC prevalence and trends regarding symptomatology, disease management and post-treatment outcomes. Electronic supplementary material The online version of this article (10.1186/s12905-019-0748-8) contains supplementary material, which is available to authorized users.

Third variable effect refers to the effect from a third variable that explains an observed relationship between an exposure and an outcome. Depending on whether there is causal relationship, typically, a third variable takes the format of a mediator or a confounder. A moderation effect is a special case of the third-variable effect, where the moderator and other variables have an interactive effect on the outcome. In this paper, we extend the R package 'mma' for moderation analysis so that third-variable effects can be reported at different levels of the moderator. The proposed moderation analysis use tree-structured models to automatically detect moderation effects and can handle both categorical and numerical moderators. We propose algorithms and graphical methods for making inference on moderation effects and illustrate the method under different scenarios of moderation effects. Finally, we apply the proposed method to explore the trend of racial disparities in the use of Oncotype DX recurrence tests among breast cancer patients. We found that the unexplained racial differences in using the tests have decreased from 2010 to 2015.

Research has shown cigarette smoking is a major risk factors for many type of cancer or cancer prognosis. Tobacco related health disparities were addressed continually in cancer screening, diagnosis, treatment, prevention and control. The present study evaluated the health disparities in attendance of smoking cessation counseling classes for 4,826 patients scheduled to attend between 2005 and 2007. Of 3,781 (78.4%) patients with records to calculate the distance from their home domicile to counseling sites using Geographic Information System technology, 1,435 (38%) of smokers who attended counseling had shorter travel distances to counseling sites (11.6 miles, SD = 11.29) compared to non-attendees (13.4 miles, SD = 16.72). When the travel distance was >20 miles, the estimated odds of attending decreased with greater travel distance. Smokers who actually attended were more likely to be older, female, White, living in urban areas, and receiving free healthcare. After controlling for other socio-demographic factors, shorter distances were associated with greater class attendance, and individuals more likely to attend included those that lived closer to the counseling site and in urban settings, were female, White, commercially insured, and older than their counterparts. These findings have the potential to provide important insights for reducing health disparities for cancer prevention and control, and to improve shared decision making between providers and smokers.

Third-Variable effect refers to the intervening effect from a third variable (called mediators or confounders) to the observed relationship between an exposure and an outcome. The general multiple third-variable effect analysis method (TVEA) allows consideration of multiple mediators/confounders (MC) simultaneously and the use of linear and non-linear predictive models for estimating MC effects. Previous studies have found that compared with non-Hispanic White population, Blacks and Hispanic Whites suffered disproportionally more with obesity and related chronic diseases. In this paper, we extend the general TVEA to deal with multivariate/multicategorical predictors and multivariate response variables. We designed algorithms and an R package for this extension and applied MMA on the NHANES data to identify MCs and quantify the indirect effect of each MC in explaining both racial and ethnic disparities in obesity and the body mass index (BMI) simultaneously. We considered a number of socio-demographic variables, individual factors, and environmental variables as potential MCs and found that some of the ethnic/racial differences in obesity and BMI were explained by the included variables.

Background: Studies on symptomatic osteoarthritis suggest that Black patients report worse pain and symptoms compared with White patients with osteoarthritis. In this study, we aimed to quantify the relationship among variables such as overall health and socioeconomic status that may contribute to disparities in patient-reported outcomes. Methods: A total of 223 patients were enrolled. A mediation analysis was used to evaluate cross-sectional associations between race and the Knee injury and Osteoarthritis Outcome Score (KOOS) questionnaire, which was administered to patients prior to undergoing primary total knee arthroplasty. Results: Black patients had worse KOOS pain, symptoms, and activities of daily living subscale scores than White patients. In our cohort, Black patients were younger, more likely to be female, and more likely to report lower educational status. We identified age, sex, Charlson Comorbidity Index, and education as partial mediators of racial disparities in KOOS subscale scores. Insurance status, deformity, radiographic (Kellgren-Lawrence) grade, C-reactive protein level, marital status, body mass index, and income did not show mediating effects. We found that, if age and sex were equal in both cohorts, the racial disparity in KOOS symptom scores would be reduced by 20.7% and 9.1%, respectively (95% confidence intervals [CIs], −5.1% to 47% and −5.5% to 26.3%). For KOOS pain scores, age and education level explained 18.9% and 5.1% of the racial disparity (95% CIs, −0.6% to 37% and −10.8% to 22.9%). Finally, for KOOS activities of daily living scores, education level explained 3.2% of the disparity (95% CI, −19.4% to 26.6%). Conclusions: No single factor in our study completely explained the racial disparity in KOOS scores, but our findings did suggest that several factors can combine to mediate this disparity in outcome scores. Quantification of variables that mediate racial disparity can help to build models for risk adjustment, pinpoint vulnerable populations, and identify primary points of intervention. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

To date, no study has evaluated blood pressure following administration of each carpule given for dental procedures using a computerized dental anesthesia system. Blood pressures taken prior to performing invasive periodontal procedures were compared with those readings measured following delivery of each of up to three consecutive carpules of Marcaine or Xylocaine in varying order. Pressure differences were also adjusted for age, sex, race, and whether a prescribed anxiolytic was taken beforehand. Neither systolic nor diastolic blood pressures changed significantly as compared to initial blood pressure readings. However, compared with Whites, Hispanics, and Middle Easterners, Blacks had significantly higher systolic pressure at the third carpule delivery, the cause being unknown. Blood pressure in patients being anesthetized for root planing and various periodontal surgical procedures will not increase significantly when administering up to three carpules, whether Marcaine or Xylocaine, in varying order, using controlled flow dental anesthesia, and this method may be preferable to syringes in managing dental procedural stress.

Background The study aimed to examine racial/ethnic differences in chemotherapy utilization by breast cancer subtype. Methods Data on female non-Hispanic white (NHW), non-Hispanic black (NHB), and Hispanic stage I-III breast cancer patients diagnosed in 2011 were obtained from a project to enhance population-based National Program of Cancer Registry data for Comparative Effectiveness Research. Hormone receptor (HR) and human epidermal growth factor receptor 2 (HER2) were used to classify subtypes: HR+/HER2-; HR+/HER2+; HR-/HER2-; and HR-/HER2 + . We used multivariable logistic regression models to examine the association of race/ethnicity with three outcomes: chemotherapy (yes, no), neo-adjuvant chemotherapy (yes, no), and delayed chemotherapy (yes, no). Covariates included patient demographics, tumor characteristics, Charlson Comorbidity Index, other cancer treatment, and participating states/areas. Results The study included 25,535 patients (72.1% NHW, 13.7% NHB, and 14.2% Hispanics). NHB with HR+/HER2- (adjusted odds ratio [aOR] 1.22, 95% CI 1.04–1.42) and Hispanics with HR-/HER2- (aOR 1.62, 95% CI 1.15–2.28) were more likely to receive chemotherapy than their NHW counterparts. Both NHB and Hispanics were more likely to receive delayed chemotherapy than NHW, and the pattern was consistent across each subtype. No racial/ethnic differences were found in the receipt of neo-adjuvant chemotherapy. Conclusions Compared to NHW with the same subtype, NHB with HR+/HER2- and Hispanics with HR-/HER2- have higher odds of using chemotherapy; however, they are more likely to receive delayed chemotherapy, regardless of subtype. Whether the increased chemotherapy use among NHB with HR+/HER2- indicates overtreatment needs further investigation. Interventions to improve the timely chemotherapy among NHB and Hispanics are warranted.

Background: The objective of this study was to determine the effect of an adhesive layer and its photopolymerization on the microleakage of sealants. Study design: 0.5mm-deep standardized fissurectomies were performed on extracted molars (n = 72). Teeth were randomly assigned to 3 different sealant materials (n = 24/group). Teeth were further divided to receive sealants with or without an adhesive layer. Each sealant with adhesive was also divided into two groups: adhesive was light-cured separately or light cured together with the sealant. Following thermocycling, microleakage was assessed using dye penetration and image analysis. Data was analyzed using ANOVA and Tukey's studentized ranged HSD tests. Results: Microleakage was not affected by type of sealant material (p>0.05) but was significantly influenced by application (p0.05). Conclusion: An adhesive layer should be placed beneath sealants, but whether it should be light cured or left uncured before sealant placement varies by the sealant type.

Objectives Micro-invasive resin-infiltration has shown to inhibit lesion progression of proximal non-cavitated carious lesions, suggesting an alternative to early operative treatment. This split-mouth, randomized placebo-controlled clinical trial evaluated the effects of proximal lesion infiltration supplementary to standard-of-care management in high caries risk (HCR)-patients. Methods Forty-two HCR-subjects with two similar interproximal posterior lesions received professional HCR-regimen including repeated F-varnish applications. Two affected E2/D1-surfaces were randomized and concurrently treated by resin-infiltration or mock-infiltration (control). Individually standardized digital radiographs provided visual determination of lesion-size distribution at baseline and 2-year follow-up. Data were analyzed by logistic regression and McNemar’s test. Results Thirty-two lesion pairs (76%) were evaluated after 2 years. Categorical lesion depths were not different between groups (P > .5). Comparative pairwise assessment (image sets BL-2 yr) showed significantly more progression in control (7) versus infiltration (1) lesions (P = .035). Cumulative prevented fraction after two years was 97% for infiltrated lesions versus 74% for control lesions. Conclusions Two-year follow-up showed resin infiltration to be a highly efficacious (RRR: 86–89%) therapy. Long-term follow-up is needed to strengthen the evidence for efficacy of resin-infiltration as an adjunct to standard-of-care HCR-regimen including F-varnish. Clinical significance Showing 24% more stabilized lesions, the resin-infiltrated group performed significantly better than their controls, confirming successful early lesion management. Adjunct resin-infiltration provided an effective micro-invasive approach to inhibit short-term lesion progression.

Mediation analysis allows the examination of effects of a third variable in the pathway between an exposure and an outcome. The general multiple mediation analysis method, proposed by Yu et al, improves traditional methods (eg, estimation of natural and controlled direct effects) to enable consideration of multiple mediators/confounders simultaneously and the use of linear and nonlinear predictive models for estimating mediation/confounding effects. In this paper, we extend the method for time-to-event outcomes and apply the method to explore the racial disparity in breast cancer survivals. Breast cancer is the most common cancer and the second leading cause of cancer death among women of all races. Despite improvement of survival rates of breast cancer in the US, a significant difference between white and black women remains. Previous studies have found that more advanced and aggressive tumors and less than optimal treatment may explain the lower survival rates for black women as compared to white women. Due to limitations of current analytic methods and the lack of comprehensive data sets, researchers have not been able to differentiate the relative effect each factor contributes to the overall racial disparity. We use the CDC-funded Patterns of Care study to examine the determinants of racial disparities in breast cancer survival using a novel multiple mediation analysis. Using the proposed method, we applied the Cox hazard model and multiple additive regression trees as predictive models and found that all racial disparity in survival among Louisiana breast cancer patients were explained by factors included in the study.

Mediation analysis allows the examination of effects of a third variable (mediator/confounder) in the causal pathway between an exposure and an outcome. The general multiple mediation analysis method (MMA), proposed by Yu et al., improves traditional methods (e.g., estimation of natural and controlled direct effects) to enable consideration of multiple mediators/confounders simultaneously and the use of linear and nonlinear predictive models for estimating mediation/confounding effects. Previous studies find that compared with non-Hispanic cancer survivors, Hispanic survivors are more likely to endure anxiety and depression after cancer diagnoses. In this paper, we applied MMA on MY-Health study to identify mediators/confounders and quantify the indirect effect of each identified mediator/confounder in explaining ethnic disparities in anxiety and depression among cancer survivors who enrolled in the study. We considered a number of socio-demographic variables, tumor characteristics, and treatment factors as potential mediators/confounders and found that most of the ethnic differences in anxiety or depression between Hispanic and non-Hispanic white cancer survivors were explained by younger diagnosis age, lower education level, lower proportions of employment, less likely of being born in the USA, less insurance, and less social support among Hispanic patients.

Introduction Limited field cone-beam computed tomography (CBCT) imaging has become a modality frequently used by endodontists to evaluate the teeth and surrounding tissues of their patients. Accurate image interpretation is vital to obtain needed treatment information as well as to discern coincidental findings that could be present. The goal of this study was to determine the accuracy of CBCT volume interpretation when performed by endodontists and endodontic residents. Methods Eighteen deidentified limited field CBCT scans were obtained and evaluated by an oral and maxillofacial radiologist and an endodontist experienced in reading CBCT images. Their collective findings were combined as the “gold standard” of interpretation for this investigation. Using standard CBCT software, 4 practicing endodontists and 5 second-year endodontic residents evaluated each scan and recorded any notable findings and whether or not each scan warranted referral to a radiology specialist. Their interpretations were then compared with the gold standard to determine accuracy and any significant differences among the groups. Results The overall accuracy was 58.3% for endodontists and 64.3% for residents. Paired t tests showed no statistically significant differences in accuracy between the 2 groups for findings in teeth or in bone, but residents were significantly better for maxillary sinus findings. Endodontists agreed with the gold standard 38.9% of the time and residents 49.8% of the time on necessity of referral. The Cohen kappa coefficient showed moderate agreement between the groups. Conclusions Endodontists and residents had similar accuracy in CBCT scan evaluation. More training and experience are warranted for both groups in order to maximize image assessment accuracy.

Objective: The purpose of this study was to determine if changes in dental development are associated with Attention Deficit Hyperactivity Disorder (ADHD) or ADHD medications. Study Design: This retrospective chart review evaluated the dental age of 128 patients between 6 and 16 years of age using the Demirjian method from the following two groups a) children with ADHD b) unaffected children. The ADHD group was further stratified into four groups according to the medication type. The impact of ADHD on dental age difference (the difference between dental age and chronologic age) was analyzed using T-test and the association between medication type and dental age difference was analyzed through one way ANOVA. Results: The mean difference between estimated dental age and chronologic age (dental age difference) for all subjects was 0.80 years. There was no significant dental age difference in subjects with ADHD and the control group (0.78±1.28vs. 0.84 ±1.09 years respectively; P=0.75) and there was no significant difference in dental age difference and type of medication (P=0.84). Conclusion: No significant difference was found between children with ADHD and unaffected children with respect to dental age difference. No significant differences were found in dental age difference in the four medication groups.

Background The aim of this study was to assess one-year implant survival after lateral window sinus augmentation using PRGF combined with various bone grafting materials. Material and Methods This was a retrospective chart review and radiographic analysis of patients that had undergone lateral window sinus augmentation with PRGF and had dental implants placed at least 6 months post augmentation. All implants included were followed up for at least one year after placement. Demographic, sinus and implant related characteristics (residual ridge height, sinus membrane perforation, type of graft material, implant length and width and ISQ at placement) were analyzed. Results A total of 31 patients with 39 sinus augmentations and 48 implants were included. The mean follow up was 22.8 ± 9.9 months. Implant survival was 95.8%, with 2 implants overall failing. Among all the variables assessed, the only one found to be associated with an increased risk for implant failure was the use of xenograft as bone grafting material in the sinus. Conclusions Within the limitations of this study, dental implants placed in maxillary sinuses grafted with PRGF in combination with bone grafting materials, exhibit high implant survival rates after at least one year follow up. Key words:PRGF, sinus graft, growth factors, implant survival, platelet concentrates.

Key Points Question What is the increase in the colorectal cancer incidence rate from 49 to 50 years of age when large segments of the population begin average-risk screening? Findings This cross-sectional analysis of colorectal cancer incidence rates in 1-year age increments (30-60 years) from 2000 to 2015 in the Surveillance, Epidemiology, and End Results 18 registries found an incidence rate increase of 46.1% from 49 to 50 years of age. A total of 92.9% of the cases of colorectal cancer diagnosed at 50 years of age were invasive (beyond in situ stage). Meaning Steep incidence increases from 49 to 50 years of age are consistent with preexisting colorectal cancers diagnosed via screening uptake, supporting the presence of a large undetected preclinical case burden in patients younger than 50 years that is not reflected in observed Surveillance, Epidemiology, and End Results incidence rates., Importance Early-onset colorectal cancer incidence rates among patients aged 45 to 49 years have been considered much lower compared with the rates among patients aged 50 to 54 years, prompting debate about earlier screening benefits at 45 years. However, the observed incidence rates in the Surveillance, Epidemiology, and End Results (SEER) registries may underestimate colorectal cancer case burdens in those younger than 50 years compared with those older than 50 years because average-risk screening is generally not performed to detect preclinical cases of colorectal cancer. Finding steep incidence increases of invasive stage (beyond in situ) cases of colorectal cancer from age 49 to 50 years would be consistent with high rates of preexisting, undetected cancers in younger patients ultimately receiving a diagnosis of colorectal cancer after undergoing screening at 50 years. Objective To assess the preclinical burden of colorectal cancer by analyzing its incidence in 1-year age increments, focusing on the transition between ages 49 and 50 years. Design, Setting, and Participants Data from the SEER 18 registries, representing 28% of the US population, were used to conduct a cross-sectional study of colorectal cancer incidence rates from January 1, 2000, to December 31, 2015, in 1-year age increments (ages 30-60 years) stratified by US region (South, West, Northeast, and Midwest), sex, race, disease stage, and tumor location. Statistical analysis was conducted from November 1, 2018, to December 15, 2019. Main Outcomes and Measures Incidence rates of colorectal cancer. Results A total of 170 434 cases of colorectal cancer were analyzed among 165 160 patients (92 247 men [55.9%]; mean [SD] age, 51.6 [6.7] years). Steep increases in the incidence of colorectal cancer in the SEER 18 registries were found from 49 to 50 years of age (46.1% increase: 34.9 [95% CI, 34.1-35.8] to 51.0 [95% CI, 50.0-52.1] per 100 000 population). Steep rate increases from 49 to 50 years of age were also seen in all US regions, men and women, white and black populations, and in colon and rectal cancers. The rate ratio incidence increase in the SEER 18 registries from 49 to 50 years of age (1.46 [95% CI, 1.43-1.51]) was significantly higher than earlier 1-year age transitions. Steep rate increases in the SEER 18 registries were found from 49 to 50 years of age in localized-stage (75.9% increase: 11.2 [95% CI, 10.7-11.7] to 19.7 [95% CI, 19.0-20.3] per 100 000) and regional-stage (30.3% increase: 13.2 [95% CI, 12.7-13.8] to 17.2 [95% CI, 16.7-17.8] per 100 000) colorectal cancers. A total of 8799 of the 9474 cases (92.9%) of colorectal cancer in the SEER 18 registries from 2000 to 2015 that were diagnosed among individuals aged 50 years were invasive. Conclusions and Relevance Steep incidence increases between 49 and 50 years of age are consistent with previously undetected colorectal cancers diagnosed via screening uptake at 50 years. These cancers are not reflected in observed rates of colorectal cancer in the SEER registries among individuals younger than 50 years. Hence, using observed incidence rates from 45 to 49 years of age alone to assess potential outcomes of earlier screening may underestimate cancer prevention benefits., This cross-sectional study uses data from the Surveillance, Epidemiology, and End Results registries to assess the preclinical burden of colorectal cancer by analyzing its incidence in 1-year age increments, focusing on the transition between 49 and 50 years of age.

Introduction Quitting smoking has been proven to benefit smokers with diabetes. However, among older patients with diabetes, the evidence regarding an association between smoking status and the risk of type 2 diabetes mellitus-related emergency department (ED) visits has not been well investigated. Methods A retrospective cohort study was performed by using the Louisiana State University Health Care Services Division electronic health records from 2009 to 2011. Patients aged 65 years or older with type 2 diabetes and smoking status recorded at least twice in 2010 were selected. Selected patients with diabetes were classified into nonsmokers, former smokers, continuing smokers, and relapsed smokers. Cox proportional hazards regression models were used to estimate the adjusted hazard ratio (aHR) of 1-year type 2 diabetes-related ED visits for each group compared with nonsmokers. Results There were 174 (8.2%) continuing smokers and 77 (3.6%) relapsed smokers in 2,114 patients with diabetes who were studied. Rates of type 2 diabetes-related ED visits were highest in relapsed smokers (28.6%). Compared with nonsmokers, relapsed smokers had a significantly higher risk of type 2 diabetes-related ED visits (aHR = 1.62; 95% confidence interval [CI], 1.04-2.50). After stratifying by sex, a significantly increased risk of type 2 diabetes-related ED visits was shown only in male relapsed smokers (aHR = 2.05; 95% CI, 1.13-3.71) and female continuing smokers (aHR = 1.65; 95% CI, 1.10-2.47) compared with nonsmokers. Conclusion Older men with diabetes who were relapsed smokers had a higher risk of type 2 diabetes-related ED visits. Future research and clinical practice should focus on these patients and create more effective interventions for smoking cessation and diabetes management.

PURPOSE: To examine (1) the trend and associated factors of Oncotype DX (ODX) use among hormone receptor-positive (HR+) breast cancer (BC) patients in 2004–2015; (2) the trend of reported chemotherapy by Recurrence Score (RS); and (3) the survival differences associated with ODX use. METHODS: ODX data from Genomic Health Inc. were linked with 17 SEER registries data. HR + BC cases with lymph node negative (N0) or 1–3 positive LNs (N1) from 2004–2015 were analyzed. The Cochrane-Armitage trend test, logistic regression, Kaplan–Meier survival curve, and stratified Cox model were performed. Survival analysis was restricted to HR+/HER2− patients from 2010 to 2014, matched on propensity score. RESULTS: ODX use increased substantially from 2004 to 2015 (N0: 2.0% to 42.7%; N1: 0.3% to 27.9%). Non-Hispanic black and Medicaid insured patients had lower odds of receiving ODX. N0 patients with moderately differentiated or 2.1–5.0 cm tumor and N1 patients with well-differentiated or < 2.0 cm tumor had higher odds of using ODX. The reported chemotherapy use decreased significantly with low and intermediate RS, and increased for high RS among N0 patients. ODX use was associated with better breast cancer-specific survival [hazard ratio (95% CI) N0 1.96 (1.60–2.41), N1 1.90 (1.42–2.54)] and overall survival [N0 2.06 (1.83–2.31), N1 1.72 (1.42–2.09)], especially in the first 36 months. CONCLUSION: ODX use has increased significantly since 2004, nonetheless disparities remain, especially for racial/ethnic minorities and Medicaid insured patients. Administering chemotherapy based on ODX results has been improved among N0 patients. Patients receiving ODX had better survival than those not.

Background The aim of this study was to identify any associations between predictor variables, mainly clinician training and dental implant outcome, among the residents in different departments and to compare statistical analysis with the use of MATLAB R2017a™ to SAS version 9.4. Methods Dental records were reviewed from January 1, 2011, to December 31, 2015. Two thousand forty-eight dental implants were placed on 471 patients seen by residents from the departments of Periodontics, Prosthodontics, and Oral and Maxillofacial Surgery (OMFS) at Louisiana State University Health Sciences Center School of Dentistry. The following parameters were investigated by means of multilevel logistic regression analysis: demographics, implant parameters, department, and residents’ year of training. Results A total of 1449 implants were included in the study. Overall, within a 1–5-year time period, 1343 (92.6%) implants had survived and 106 (7.4%) implants failed. Discipline (p = 0.0004), residents’ year of training (p

BACKGROUND Facial cellulitis of odontogenic origin (FCOO) can lead to systemic complications in children. Research on factors leading to improvement of outcomes is limited. AIM The aim of this study was to investigate patient characteristics, treatment modalities (antibiotics and route of administration), length of stay in the hospital, time till definitive treatment, and factors related to early treatment of FCOO. DESIGN A retrospective review was performed to identify children presenting to the emergency department of a paediatric hospital with FCOO over a 5-year period. Data were extracted from records of included patients. RESULTS Sixty-four records were included for analysis with mean age of 8.19 ± 4.5 years. Significantly more patients received clindamycin (79.7%) than penicillin-based antibiotic (18.8%) with P

Objectives To investigate the race-specific second primary bladder cancer (SPBC) risk following prostatic irradiation. Methods Louisiana residents who were diagnosed with localized prostate cancer (PCa) in 1996–2013 and received surgery or radiation were included. Patients were followed until SPBC diagnosis, death, or Dec. 2018. The exposure variable was type of treatment (radiation only vs. surgery only). The outcome was time from PCa diagnosis to SPBC diagnosis, stratified by race. Fine and Gray’s competing risk model was applied with death as a competing event and adjustment of sociodemographic and tumor characteristics. We used 5 years and 10 years as lag time in the analyses. Results A total of 26,277 PCa patients with a median follow-up of 10.7 years were analyzed, including 18,598 white and 7679 black patients. About 42.9 % of whites and 45.7 % of blacks received radiation. SPBC counted for 1.84 % in the radiation group and 0.90 % in the surgery group among white patients and for 0.91 % and 0.58 %, respectively, among black patients. The adjusted subdistribution hazard ratio of SPBC was 1.80 (95 % CI: 1.30–2.48) for radiation recipients compared to surgery recipients among white patients; 1.93 (95 % CI: 1.36–2.74) if restricted to external beam radiation therapy (EBRT). The SPBC risk was not significantly different between irradiated and surgically treated among blacks. Conclusions The SPBC risk is almost two-fold among white irradiated PCa patients compared to their counterparts treated surgically. Our findings highlight the need for enhanced surveillance for white PCa survivors receiving radiotherapy, especially those received EBRT.

Introduction: Tobacco use, which is directly responsible for 10% of total deaths per year globally, remains consistently high, with approximately 20% of the population reporting regular consumption globally. Moreover, health disparities regarding tobacco consumption and smoking cessation are growing between rural and urban populations worldwide. Social media interventions for tobacco cessation may effectively reach both groups. The objective of this study was to evaluate the efficacy of a WeChat-delivered smoking cessation intervention among rural and urban Chinese smokers, and to assess moderating variables that may contribute to differential intervention efficacy. Methods: WeChat was used to recruit smokers into this intervention study between 1 July and 5 August 2019. Participants were randomized to one of three intervention schedules: participants in the Standard Group and the Enhanced Group received 20 smoking-related messages over 2 weeks, whereas participants in the Enhanced Group received an extra 6 oral health-related messages for one week. Participants in the control group received 20 smoking-related messages after the post-intervention assessment. Participants completed questionnaires at baseline and at 4 weeks follow-up. Our primary outcome was smoking cessation stage of change and secondary outcome was 24-h point prevalence abstinence (PPA). Urban and rural areas were based on self-reported living areas. Chi-squared test, Fisher’s exact test, ANOVA test, linear regression, and logistic regression were used for analysis. Results: Overall, 403 participants completed the intervention (233 rural, 107 suburban, 63 urban). Compared to urban participants, rural participants were more likely to have progressed to a later stage of change (β = 0.40, 95% CI: 0.13, 0.67) and to report higher 24-h PPA rates at follow-up (aOR = 3.23, 95% CI: 1.36, 7.68). After stratification by living area, the intervention effects in stage of change and 24-h PPA rate at follow-up were only found in the urban subgroup. Discussion: Smokers who lived in rural areas reported better smoking cessation outcomes compared with urban smokers, however, the efficacy of a WeChat-based smoking cessation intervention was only found for participants living in an urban area. WeChat based smoking cessation interventions should be used to promote smoking cessation in urban, suburban, and rural areas.

Background We evaluated the effectiveness of implementing a proficiency-driven, simulation-based knot tying and suturing curriculum for medical students during their 3rd-year surgery clerkship. Methods Medical students on the 3rd-year surgical clerkship completed a proficiency-driven, simulation-based knot tying and suturing curriculum consisting of 6 tasks. The effectiveness was evaluated by comparing the initial presession scores to the final postsession scores on an 8-item self-efficacy scale and evaluating pass rates on end of clerkship skills testing. A paired t test was used to analyze data. Results Sixty-five students had matched preintervention and postintervention questionnaires for analysis. Pass rates approached 100% by the 3rd attempt on all tasks. Significant gains on all 8 items of the self-efficacy questionnaire from pretraining to post-training were noted. Timing of the general surgery rotation did not impact results. Conclusions Implementation of a simulation-based training, proficiency-driven knot tying and suturing curriculum for 3rd-year medical students during the surgery clerkship is feasible and effective in improving student self-efficacy and objective proficiency toward performance of the tasks taught.

Study Objective The adolescent pregnancy rate in Louisiana (LA) and Mississippi (MS) is one of the highest in the United States. One approach to decrease that rate is to increase contraceptive use. We sought to characterize LA and MS family physicians' (FPs) contraception counseling for adolescents with a focus on the intrauterine contraceptive device (IUD). Design, Setting, Participants, Interventions, and Main Outcome Measures Online survey of resident and practicing physician members of the LA and MS Academy of FPs. Results Three hundred ninety-eight of 1616 invited FPs responded; 244 were included in our analysis. When counseling adolescents about contraception, respondents “frequently discussed” oral contraceptives and condoms 87.5% (210/240) and 83.8% (202/241) of the time, respectively. Newer and more highly effective contraceptives such as the ring, patch, IUD, and implant were “frequently discussed” only 34.6% (82/237)-39.3% (92/234) of the time. In the previous 6 months, 56% (136/243) of respondents ever discussed an IUD with an adolescent. Respondents were more likely to have discussed IUDs if they learned IUD insertion during residency, had on-site access to IUD inserters, believed they were competent and/or comfortable with IUD counseling. In 5 clinical scenarios asking whether the respondent would recommend an IUD to a 17- or a 27-year-old patient (in all scenarios patients were eligible for an IUD), respondents were restrictive overall and significantly fewer would recommend an IUD for the adolescent. Conclusion Our results suggest that there are missed opportunities for full-scope contraception counseling by LA and MS FPs. When these FPs counsel adolescents about contraception they less frequently discuss newer methods and more highly effective methods. Additionally many LA and MS FPs use overly restrictive eligibility criteria when considering IUDs.

Introduction: Triple-negative breast cancer (TNBC) is an aggressive, heterogeneous subtype of breast cancer. TNBC patients have generally high risk of recurrence and metastasis, and treatment options remain limited, as there are no effective targeted therapies available. In USA, TNBC is diagnosed disproportionately more frequently in African American (AA) women than in European American (EA) women. We set out to investigate the role of social determinants in racial disparities in TNBC. Methods: TNBC patients diagnosed in Louisiana from 2010-2012 were identified from the Louisiana Tumor Registry. Patients were geocoded to census tract of residence at time of diagnosis. Census tract population and socioeconomic measures were obtained from the US Census American Community Survey. We used multilevel statistical models to analyze the role of neighborhood concentrated disadvantage index (CDI), a robust measure of physical and social environment, in racial disparities in TNBC incidence, stage at diagnosis, and stage-specific survival for the study population. CDI scores were calculated according to the PhenX Toolkit protocol. Results: We identified 1,216 women with TNBC for the study. Controlling for age, we found that AA women had a 2.21-fold risk of TNBC incidence compared to EA in Louisiana. Results from multivariate analyses indicated that the incidence of TNBC was independent of neighborhood CDI, as was the racial disparity. However, CDI did explain existing racial disparities in both stage at diagnosis and stage-specific survival. The odds of diagnosis at later stages were 42% higher for black women. A single standard deviation increase in CDI increased the hazard of breast cancer-related death by 19%. Overall, our results suggest that the increased incidence of TNBC in black women is independent of CDI, while neighborhood environment has a greater impact than race on the promotion and progression of the disease. The socioeconomic disadvantage experienced by black women coupled with increased biologic risk for TNBC contribute to the large racial disparity in breast cancer mortality in Louisiana. Further research is needed to determine the mechanisms through which social determinants affect the promotion and progression of this disease and guide efforts to improve overall survival. Citation Format: Fokhrul Hossain, Denise Danos, Aubrey Gilliland, Claudia Leonardi, Tekeda Ferguson, Neal Simonsen, Qingzhao Yu, Om Prakesh, Richard Scribner, Lucio Miele. Social determinants of health disparities in triple-negative breast cancer in Louisiana [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr C070.

Mediation effect refers to the effect conveyed by a third variable, the mediator, to an observed relationship between an exposure and a response variable of interest. Mediation analysis is used widely in fields such as social science, prevention study, behavior research, and epidemiology. For example, it has been well established that low socioeconomic status is associated with poor health status. To reduce this health disparity, investigators would need to quantify the effects, called mediation effects, from different risk factors that intervene in the relationship between the socioeconomic status and health outcomes, so that efficient interventions can be carried out. The general multiple mediation analysis method, proposed by Yu et al., improved traditional methods (e.g., estimation of natural and controlled direct effects) to enable consideration of multiple mediators simultaneously and the use of linear and nonlinear predictive models for estimating mediation effects. A big data set includes a large number of variables. Within big data mediation analysis, the number of potential mediators is big. For example, in explaining the racial disparity in breast cancer survival, there are a lot of risk factors that need to be considered such as individual behaviors, environmental factors, social-economic status, treatment effects, diagnosis characters, and even gene expression variables. In this study, we propose to use a regularized mediation analysis method that identifies significant mediators and estimates their indirect effects simultaneously. Breast cancer is the most common cancer and the second leading cause of cancer death among women of all races. Despite the improvement of survival rates of breast cancer in the U.S., a significant difference between white and black women remains. Due to limitations of current analytic methods and the lack of comprehensive data sets, researchers have not been able to differentiate the relative effect that each factor contributes to the overall racial disparity. We use the CDC-funded Patterns of Care study and Enhancing Cancer Registry Data for Comparative Effectiveness Research study to examine the determinants of racial disparities in breast cancer survival using the propose regularized multiple mediation analysis. Using the proposed method, we identified important factors that explain the racial disparity in breast cancer survival, which includes the cancer stage-related variables (stage, tumor size, lymph nodes involvement, extension, and tumor size), molecular subtype, treatment methods such as surgery and hormonal therapy, and tumor grade. Age also contributed to the racial differences, but in an opposite direction. Black patients are more likely to be diagnosed at a younger age, which is related with better survival outcomes. Overall, we found that all racial disparity in survival among Louisiana breast cancer patients was explained by factors included in the study. Citation Format: Qingzhao Yu, Lu Zhang, Meichin Hsieh, Xiaocheng Wu, Richard A Scribner, Bin Li. Regularized multiple mediation analysis for big data set—With an application to explore racial disparity in breast cancer survival [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr C020.

Triple Negative Breast Cancer (TNBC) is an aggressive, heterogeneous subtype of breast cancer, which is more frequently diagnosed in African American (AA) women than in European American (EA) women. The purpose of this study is to investigate the role of social determinants in racial disparities in TNBC. Data on Louisiana TNBC patients diagnosed in 2010–2012 were collected and geocoded to census tract of residence at diagnosis by the Louisiana Tumor Registry. Using multilevel statistical models, we analyzed the role of neighborhood concentrated disadvantage index (CDI), a robust measure of physical and social environment, in racial disparities in TNBC incidence, stage at diagnosis, and stage-specific survival for the study population. Controlling for age, we found that AA women had a 2.21 times the incidence of TNBC incidence compared to EA women. Interestingly, the incidence of TNBC was independent of neighborhood CDI and adjusting for neighborhood environment did not impact the observed racial disparity. AA women were more likely to be diagnosed at later stages and CDI was associated with more advanced stages of TNBC at diagnosis. CDI was also significantly associated with poorer stage-specific survival. Overall, our results suggest that neighborhood disadvantage contributes to racial disparities in stage at diagnosis and survival among TNBC patients, but not to disparities in incidence of the disease. Further research is needed to determine the mechanisms through which social determinants affect the promotion and progression of this disease and guide efforts to improve overall survival.

Background and objectives: Smoking is associated with a lower health-related quality of life (HRQOL). However, there is little information about the association between HRQOL in relation to race, income, and smoking status. The present study aimed to assess the association between HRQOL and smoking status for those of different races and income levels. Materials and Methods: This study applied a cross-sectional design using data from the 2017 patient survey of the Louisiana Tobacco Control Initiative. We obtained 1108 responses from patients at eight Louisiana public hospitals. The EuroQol (EQ-5D) US index score assessed HRQOL. Smoking status was classified into four groups: never smoked, former smoker, current smoker with a quit attempt, and current smoker without a quit attempt. Multivariate linear regression analyses were used to estimate the HRQOL for black or African Americans and whites. Results: The patients were predominantly black or African American (58.9%) with lower-income (71.2%). Bivariate analyses showed that there were differences in income levels between black or African Americans and whites (p = 0.006). Moreover, black or African Americans (median = 0.80) had a higher mean of HRQOL than whites (median = 0.76). Among lower-income black or African Americans, current smokers with a quit attempt had a lower HRQOL than current smokers (coefficient = &minus, 0.12, p &lt, 0.01). Conclusions: Racial and income disparities were evident with regards to HRQOL, with lower-income black or African Americans who were current smokers with a quit attempt having a lower HRQOL. Intervention programs for smoking cessation should target lower-income black or African American smokers who have a prior quit attempt and provide effective cessation services to help them quit smoking and improve their HRQOL.

High-fidelity simulation-based training is used increasingly for prelicensure student teams. Such sessions rely on faculty who are able to provide quality prebriefing and debriefing to foster learning among participants. We investigated how well faculty conducted prebriefing and debriefing as part of high-fidelity simulation-based training for interprofessional education.Two trained observers independently rated 38 video-recorded sessions of combinations of 4 faculty conducting prebriefings and debriefings of prelicensure student teams after high-fidelity simulation-based training. Assessment was undertaken using the Objective Structured Assessment of Debriefing, an 8-item tool using a 5-point Likert scale (1 as minimum and 5 as maximum). Mean scores for each item were calculated. Inter-rater agreement was determined using Cohen's kappa. A one-way between-subjects analysis of variance with post-hoc Tukey's studentized range procedure was conducted to compare the effect of team facilitator grouping on the quality of team performance of each Objective Structured Assessment of Debriefing element during a prebriefing or a debriefing. Trend analyses of teams with 4 or more observations were performed using Kendall's Tau coefficient test and linear regression analyses to identify whether teams showed improvement through time. Statistical significance was set at P.05.A total of 7 combinations of faculty conducted between 1 to 14 prebriefings or debriefings. In general, faculty combinations performed better during debriefings compared with prebriefings, with only 1 team having 1 mean item score3.50. Statistically significant differences between faculty combinations in mean item scores was more pronounced during the prebriefings (2 of 3 Objective Structured Assessment of Debriefing items rated) than during debriefings (1 of 8 Objective Structured Assessment of Debriefing items rated). Effect sizes were strong for all differences. Linear regression analysis revealed a statistically significant change through time for the 3 rated prebriefing items and for 7 of the 8 rated debriefing items.Interprofessional faculty combinations in this study tended to have good quality prebriefings and debriefings. The quality of the prebriefings and debriefings can, however, be influenced by the composition of the facilitator teams, most prominently for prebriefings, and team performance does appear to change through time, especially during the debriefing. Future work will focus on whether the quality of prebriefings and debriefings influences learning by trainees.

There is increasing interest in Bayesian group sequential design because of its potential to improve efficiency in clinical trials, to shorten drug development time, and to enhance statistical inference precision without undermining the clinical trial’s integrity or validity. We propose a Bayesian sequential design for clinical trials with time-to-event outcomes and use alpha spending functions to control the overall Type I error rate. Bayes factor is adapted for decision-making at interim analyses. Algorithms are presented to make decision rules and to calculate power of the proposed tests. Sensitivity analysis is implemented to evaluate the impact of different choices of prior parameters on choosing critical values. The power of tests, the expected event size of the proposed design, and the quality of estimators are studied through simulations, and compared with the frequentist group sequential design. Simulations show that at fixed total number of events, the proposed design can achieve greater power and require smaller expected event size when appropriate priors are chosen, compared with the frequentist group sequential design. The feasibility of the proposed design is further illustrated on a real dataset. Supplementary materials for this article are available online.

High-fidelity simulation (HFS) operating room (OR) inter-professional team training improves healthcare students' team-based attitudes and behaviours. Such improvements can diminish tribalism among the professions in the OR by overcoming entrenched perceptions of team members. We investigated whether simulation-based interprofessional student OR team training impacts students differently based on their professional background. From 2010 to 2013, HFS OR interprofessional student team training sessions were conducted involving senior medical students, senior undergraduate nursing students, and nurse anaesthesia students. The training involved a two-scenario format, each followed by a structured debriefing focusing on team-based competencies. Before and after each session, students completed a 15-item teamwork competencies self-efficacy survey as well as, from 2012-2013, the Readiness for Interprofessional Learning Scale (RIPLS). At the end of each session, they also completed a 6-item rating scale assessing overall team function during the session. Mean scores were calculated for each student professional group, post/pre mean differences were determined, and student t-test and ANOVA analyses were employed to compare within and between-group differences, respectively. Response rates were over 80% for each scale used. Medical students and undergraduate nursing students had significant improvements in team-based attitudes post- to pre-session. Medical students and nurse anaesthesia students had significant improvements in RIPLS scores. Statistically significant improvements from post- to pre-session were seen overall for both team-based attitudes (effect size = 0.83) and RIPLS (effect size = 0.37). The difference between the team-based scores between professions was significant; RIPLS differences were not. No significant difference existed between professions related to overall teamwork scores. HFS OR team training of healthcare students has beneficial but variable benefits for each professional group.

Purpose: Over the past three decades, Hepatocellular Carcinoma (HCC) is one of few cancers for which incidence has increased in the United States (US). It is likely social determinants at the population level are driving this increase. We designed a population-based study to explore whether social determinants at the neighborhood level are geographically associated with HCC incidence in Louisiana by examining the association of HCC incidence with neighborhood concentrated disadvantage. Methods: Primary HCC cases diagnosed from 2008 to 2012 identified from the Louisiana Tumor Registry were geocoded to census tract of residence at the time of diagnosis. Neighborhood concentrated disadvantage index (CDI) for each census tract was calculated according to the PhenX Toolkit data protocol based on population and socioeconomic measures from the US Census. The incidence of HCC was modeled using multilevel binomial regression with individuals nested within neighborhoods. Results: The study included 1,418 HCC cases. Incidence of HCC was greater among males than females and among black than white. In multilevel models controlling for age, race, and sex, neighborhood CDI was positively associated with the incidence of HCC. A one standard deviation increase in CDI was associated with a 22% increase in HCC risk [Risk Ratio (RR) = 1.22; 95% CI (1.15, 1.31)]. Adjusting for contextual effects of an individual's neighborhood reduced the disparity in HCC incidence. Conclusion: Neighborhood concentrated disadvantage, a robust measure of an adverse social environment, was found to be a geographically associated with HCC incidence. Differential exposure to neighborhoods characterized by concentrated disadvantage partially explained the racial disparity in HCC for Louisiana. Our results suggest that increasing rates of HCC, and existing racial disparities for the disease, are partially explained by measures of an adverse social environment.

Introduction This study compared images displayed on 1 desktop monitor, 1 laptop monitor, and 2 tablets for the detection of contrast and working length interpretation, with a null hypothesis of no differences between the devices. Methods Three aluminum blocks, with milled circles of varying depth, were radiographed at various exposure levels to create 45 images of varying radiographic density. Six observers viewed the images on 4 devices: Lenovo M92z desktop (Lenovo, Beijing, China), Lenovo Z580 laptop (Lenovo), iPad 3 (Apple, Cupertino, CA), and iPad mini (Apple). Observers recorded the number of circles detected for each image, and a perceptibility curve was used to compare the devices. Additionally, 42 extracted teeth were imaged with working length files affixed at various levels (short, flush, and long) relative to the anatomic apex. Observers measured the distance from file tip to tooth apex on each device. The absolute mean measurement error was calculated for each image. Analysis of variance tests compared the devices. Observers repeated their sessions 1 month later to evaluate intraobserver reliability as measured with weighted kappa tests. Interclass correlation coefficients compared interobserver reliability. Results There was no significant difference in perceptibility detection between the Lenovo M92z desktop, iPad 3, and iPad mini. However, on average, all 3 were significantly better than the Lenovo Z580 laptop (P values ≤.015). No significant difference in the mean absolute error was noted for working length measurements among the 4 viewing devices (P = .3509). Conclusions Although all 4 viewing devices seemed comparable with regard to working length evaluation, the laptop computer screen had lower overall ability to perceive contrast differences.

PURPOSE: To investigate the impact of chemotherapy relative dose intensity (RDI) on cause-specific and overall survival for stage I–III breast cancer: estrogen receptor or progesterone receptor positive, human epidermal-growth factor receptor negative (ER+/PR+ and HER2−) vs. triple-negative (TNBC) and to identify the optimal RDI cut-off points in these two patient populations. METHODS: Data were collected by the Louisiana Tumor Registry for two CDC-funded projects. Women diagnosed with stage I–III ER+/PR+, HER2− breast cancer, or TNBC in 2011 with complete information on RDI were included. Five RDI cut-off points (95, 90, 85, 80, and 75%) were evaluated on cause-specific and overall survival, adjusting for multiple demographic variables, tumor characteristics, comorbidity, use of granulocyte-growth factor/cytokines, chemotherapy delay, chemotherapy regimens, and use of hormone therapy. Cox proportional hazards models and Kaplan–Meier survival curves were estimated and adjusted by stabilized inverse probability treatment weighting (IPTW) of propensity score. RESULTS: Of 494 ER+/PR+, HER2− patients and 180 TNBC patients, RDI < 85% accounted for 30.4 and 27.8%, respectively. Among ER+/PR+, HER2− patients, 85% was the only cut-off point at which the low RDI was significantly associated with worse overall survival (HR = 1.93; 95% CI 1.09–3.40). Among TNBC patients, 75% was the cut-off point at which the high RDI was associated with better cause-specific (HR = 2.64; 95% CI 1.09, 6.38) and overall survival (HR = 2.39; 95% CI 1.04–5.51). CONCLUSIONS: Higher RDI of chemotherapy is associated with better survival for ER+/PR+, HER2− patients and TNBC patients. To optimize survival benefits, RDI should be maintained ≥ 85% in ER+/PR+, HER2− patients, and ≥ 75% in TNBC patients.

ObjectiveIn surgery, dysfunctional teamwork is perpetuated by a ‘silo’ mentality modelled by students. Interprofessional education using high-fidelity simulation-based training (SBT) may counteract such modelling. We sought to determine whether SBT of interprofessional student teams (1) changes long-term teamwork attitudes and (2) is an effective form of team training.DesignA quasiexperimental, pre/postintervention comparison design was employed at an academic health sciences institution. High-fidelity simulation-based training of 42 interprofessional teams of third year surgery clerkship medical students and senior undergraduate nursing students was undertaken using a two-scenario format with immediate after action debriefing. Pre/postintervention TeamSTEPPS Teamwork Attitudes questionnaires (5 subscales, 30 items, Likert type) were given to the medical student and undergraduate nursing student classes. Pre/postsession Readiness for Inter-Professional Learning (RIPL; 19 items, Likert type) surveys and postscenario participant-rated and observer-rated Teamwork Assessment Scales (3 subscales, 11 items, Likert type) were given during each training session. Mean TeamSTEPPS Teamwork Attitudes Questionnaire, RIPL and Teamwork Assessment Scales scores were calculated; matched pre/postscore differences and trained versus non-trained TeamSTEPPS Teamwork Attitudes Questionnaire scores were compared using paired t-test or analysis of variance.ResultsBoth student groups had 10 significantly improved RIPL items as well as TeamSTEPPS Teamwork Attitudes Questionnaire (TTAQ) mutual support subscales. Medical students had a significantly improved TTAQ team structure subscale. Over a simulation-based training session, each observer-rated Teamwork Assessment Scales subscale and two self-rated Teamwork Assessment Scales subscales significantly improved. Trained students had significantly higher TTAQ team structure subscales than non-trained students.ConclusionsInterprofessional education using high-fidelity simulation-based training of students is effective at teaching teamwork, changing interprofessional attitudes and improving long-term teamwork attitudes.

Persistent postconcussion syndrome (PPCS) after mild traumatic brain injury (mTBI) is a significant public health and military problem for which there is limited treatment evidence. The aim of this study was to determine whether forty 150 kPa hyperbaric oxygen therapies (HBOTs) can improve symptoms and cognitive function in subjects with the PPCS of mTBI, using a randomized controlled crossover design with 2-month follow-up. Sixty-three civilian and military subjects with mTBI/PPCS were randomized to either 40 HBOTs at 150 kPa/60 minutes, once daily, 5 days per week in 8 weeks or an equivalent no-treatment control period. The Control Group was then crossed over to HBOT. Subjects underwent symptom, neuropsychological, and psychological testing, before and after treatment or control with retesting 2 months after the 40th HBOT. Fifty subjects completed the protocol with primary outcome testing. HBOT subjects experienced significant improvements in Neurobehavioral Symptom Inventory, Memory Index, Automated Neuropsychological Assessment Metrics, Hamilton Depression Scale, Hamilton Anxiety Scale, Post-Traumatic Stress Disorder Checklist, Pittsburgh Sleep Quality Index, and Quality Of Life after Brain Injury compared to the Control Group. After crossing over to HBOT the Control Group experienced near-identical significant improvements. Further improvements were experienced by both groups during the 2-month follow-up period. These data indicate that 40 HBOTs at 150 kPa/60 minutes demonstrated statistically significant improvements in postconcussion and Post-Traumatic Stress Disorder symptoms, memory, cognitive functions, depression, anxiety, sleep, and quality of life in civilian and military subjects with mTBI/PPCS compared to controls. Improvements persisted at least 2 months after the 40th HBOT. The study was registered on ClinicalTrials.gov (NCT02089594) on March 18, 2014 and with the U.S. Food and Drug Administration under Investigational New Drug #113823. The Institutional Review Boards of the United States Army Medical Research and Materiel Command Office of Research Protections Human Research Protection Office and the Louisiana State University School of Medicine (approval No. 7381) approved the study on May 13, 2014 and December 20, 2013, respectively.

Purpose: Radiation therapy has been found associated with increased risk of secondary bladder cancer diagnosis among prostate cancer patients. It is unknown whether this association varies by race. This study aimed to investigate whether the association between radiation and secondary bladder cancer differs for white vs. black prostate cancer patients. Methods: Data on white or black men who were diagnosed with primary localized prostate cancer in Louisiana between 2004 and 2013 and received radiation only or surgery only were obtained from Louisiana Tumor Registry. We excluded those who developed secondary bladder cancer within 180 days of the prostate cancer diagnosis or had follow-up less than 180 days or with unknown tumor size or Gleason score. Every patient was followed up until the end of 2016. The exposure variable was treatment (radiation only vs. surgery only). The outcome variable was the diagnosis of secondary bladder cancer and the time from prostate cancer diagnosis to secondary bladder cancer diagnosis or to loss to or end of follow-up. Covariates included age at diagnosis, marital status, insurance, census tract level poverty, tumor size, and Gleason score group. The competing risk survival analysis was applied. Death during follow-up was considered as competing event. Analysis was stratified by race. Results: Of 10,861 white and 5,117 black prostate cancer patients, 52.7% and 56.8% received only radiation respectively. Regardless of race, patients who only received surgery were younger, more likely to be married, privately insured, live in low poverty census tract, and have smaller or lower grade tumor (P Conclusions: Radiation is associated with increased risk of secondary bladder cancer among white prostate cancer patients, but not among black patients. Early screening of secondary bladder cancer need to be emphasized among white prostate cancer patients who received radiation therapy. Citation Format: Lu Zhang, Mei-Chin Hsieh, Qingzhao Yu, Xiao-Cheng Wu. Racial difference in the risk of secondary bladder cancer following radiation therapy among prostate cancer patients [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 4204.

Clustering Lasso, a new regularization method for linear regressions is proposed in the paper. The Clustering Lasso can select variable while keeping the correlation structures among variables. In addition, Clustering Lasso encourages selection of clusters of variables, so that variables having the same mechanism of predicting the response variable will be selected together in the regression model. A real microarray data example and simulation studies show that Clustering Lasso outperforms Lasso in terms of prediction performance, particularly when there is collinearity among variables and/or when the number of predictors is larger than the number of observations. The Clustering Lasso paths can be obtained using any established algorithm for Lasso solution. An algorithm is proposed to construct variable correlation structures and to compute Clustering Lasso paths efficiently.

Background Adherence to self-management recommendations is critical for patients with chronic disease. Compared to nonsmokers, smokers with conditions such as diabetes, HIV, and heart disease are less likely to adhere to provider recommendations. Regarding lung disease, asthma and COPD can be caused and/or exacerbated by smoking, however little is known on the relationship between adherence and smoking status in these patients. The purpose of this study was to characterize the relationship between smoking status and adherence to multiple measures of self-care- including medication taking, medication filling, appointment keeping, yearly vaccinations, carrying medical supplies, and healthcare utilization- in patients with asthma and/or COPD. In addition to smoking status, we also included an examination of these measures by race/ethnicity, gender, and diagnosis. Methods This study employed a cross-sectional design on a convenience sample of n = 84 patients (40–64 years old) with a diagnosis of asthma and/or COPD. The study was conducted between November 2015 and February 2016 in the waiting rooms of the outpatient pulmonary clinics at the University Medical Center of New Orleans. Patients completed surveys while awaiting their clinic appointments. Smoking status, gender, race, and diagnosis were explored as predictors of adherence using descriptive statistics, chi square, and regression analyses. Results Compared to nonsmokers, smokers were less adherent to medication filling (p

Introduction This study aimed to determine the feasibility of using electronic health record (EHR) data from a federally qualified health center (FQHC) to assess the association between street connectivity, a measure of walkability for the local environment, and BMI obtained from EHRs. Methods The study included patients who visited Daughters of Charity clinics in 2012–2013. A total of 31,297 patients were eligible, of which 28,307 were geocoded. BMI and sociodemographic information were compiled into a de-identified database. The street connectivity measure was intersection density, calculated as the number of three-way or greater intersections per unit area. Multilevel analyses of BMI, measured on 17,946 patients who were aged ≥20 years, not pregnant, had complete sociodemographic information, and a BMI value that was not considered an outlier, were conducted using random intercept models. Results Overall, on average, patients were aged 44.1 years, had a BMI of 30.2, and were mainly non-Hispanic black (59.4%). An inverse association between BMI and intersection density was observed in multilevel models controlling for age, gender, race, and marital status. Tests for multiple interactions were conducted and a significant interaction between race and intersection density indicated the decrease in BMI was strongest for non-Hispanic whites (decreased by 2) compared with blacks or Hispanics (decreased by 0.6) ( p =0.0121). Conclusions EHRs were successfully used to assess the relationship between street connectivity and BMI in a multilevel framework. Increasing street connectivity levels measured as intersection density were inversely associated with directly measured BMI obtained from EHRs, demonstrating the feasibility of the approach.

Computer experiments have become increasingly important in several different industries. These experiments save resources by exploring different designs without necessitating real hardware manufacturing. However, computer experiments usually require lengthy simulation times and powerful computational capacity. Therefore, it is often pragmatically impossible to run experiments on a complete design space. In this paper, we propose an adaptive sampling scheme that interactively works with predictive models to sequentially select design points for computer experiments. The selected samples are used to build predictive models, which in turn guide further sampling and predict the entire design space. For illustration, we use Bayesian additive regression trees (BART), multiple additive regression trees (MART), treed Gaussian process and Gaussian process to guide the proposed sampling method. Both real data and simulation studies show that our sampling method is effective in that (i) it can be used with different predictive models; (ii) it can select multiple design points without repeatedly refitting the predictive models, which makes parallel simulations possible and (iii) the predictive model built on its generated samples gives more accurate predictions on the unsampled points than the models built on samples from other methods such as random sampling, space-filling designs and some adaptive sampling methods. © 2012 Wiley Periodicals, Inc. Statistical Analysis and Data Mining, 2012 © 2012 Wiley Periodicals, Inc.

Purpose: Over the past three decades, hepatocellular carcinoma (HCC) is one of the few cancers for which incidence has increased in the United States (U.S.). While chronic infection with hepatitis C virus is a leading risk factor for HCC, other known risks that are more prevalent in the U.S. population, including alcohol abuse, metabolic disease, and obesity, have also contributed to increasing rates. There is growing recognition that social and/or nutritive stress represent exposures that negatively affect individual health. These factors are believed to be socially determined by conditions in an individual's neighborhood environment. We designed a population-based study to identify potential social determinants of the increase in HCC by investigating the association of HCC incidence with neighborhood environments characterized by concentrated disadvantage. Methods: Data from the Louisiana Tumor Registry, a participant of the National Cancer Institute's Surveillance and Epidemiology End Results (SEER) program, were used in the analysis of primary HCC diagnosed from 2008 to 2012. Cases were geocoded to census tract of residence by address at the time of diagnosis. Average annual incidence rates were calculated for age, race, and sex groups within census tracts based on 2010 US Census data. Neighborhood concentrated disadvantage index (CDI) for each census tract was calculated in accordance with the PhenX Toolkit protocol. We excluded census tracts outside of metropolitan statistical areas, as well as any tract with less than 500 people or zero households, from the analyses. Multilevel log-binomial models were used to evaluate neighborhood variation and quantify the degree of association of CDI with HCC incidence. Results: The study included 1,407 cases of HCC diagnosed from 2008 to 2012. Univariate analyses indicated significantly greater incidence of HCC among males (p Discussion/Conclusion: We have found neighborhood concentrated disadvantage to be a significant risk factor for the development of HCC. We also determined that differential exposure to neighborhoods of concentrated disadvantage contributed to observed racial disparities in HCC in Louisiana. Our results suggest that increasing rates of HCC, and existing racial disparities in the disease, are partially driven by social contexts of adverse living environments. Citation Format: Denise M. Danos, Tekeda F. Ferguson, Neal Simonsen, Claudia Leonardi, Qingzhao Yu, Xiao-Cheng Wu, Richard Scribner. Social determinants of hepatocellular carcinoma in Louisiana [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr A41.

Purpose Colorectal cancer (CRC) continues to demonstrate racial disparities in incidence and survival in the United States. This study investigates the role of neighborhood concentrated disadvantage in racial disparities in CRC incidence in Louisiana. Methods Louisiana Tumor Registry and U.S. Census data were used to assess the incidence of CRC diagnosed in individuals 35 years and older between 2008 and 2012. Neighborhood concentrated disadvantage index (CDI) was calculated based on the PhenX Toolkit protocol. The incidence of CRC was modeled using multilevel binomial regression with individuals nested within neighborhoods. Results Our study included 10,198 cases of CRC. Adjusting for age and sex, CRC risk was 28% higher for blacks than whites (risk ratio [RR] = 1.28; 95% confidence interval [CI] = 1.22–1.33). One SD increase in CDI was associated with 14% increase in risk for whites (RR = 1.14; 95% CI = 1.10–1.18) and 5% increase for blacks (RR = 1.05; 95% CI = 1.02–1.09). After controlling for differential effects of CDI by race, racial disparities were not observed in disadvantaged areas. Conclusion CRC incidence increased with neighborhood disadvantage and racial disparities diminished with mounting disadvantage. Our results suggest additional dimensions to racial disparities in CRC outside of neighborhood disadvantage that warrants further research.

Given the growing availability of multilevel data from national surveys, researchers interested in contextual effects may find themselves with a small number of individuals per group. Although there is a growing body of literature on sample size in multilevel modelling, few have explored the impact of group sizes of less than five.In a simulated analysis of real data, the impact of a group size of less than five was examined on both a continuous and dichotomous outcome in a simple two-level multilevel model. Models with group sizes one to five were compared with models with complete data. Four different linear and logistic models were examined: empty models; models with a group-level covariate; models with an individual-level covariate and models with an aggregated group-level covariate. The study evaluated further whether the impact of small group size differed depending on the total number of groups.When the number of groups was large (N=459), neither fixed nor random components were affected by small group size, even when 90% of tracts had only one individual per tract and even when an aggregated group-level covariate was examined. As the number of groups decreased, the SE estimates of both fixed and random effects were inflated. Furthermore, group-level variance estimates were more affected than were fixed components.Datasets in which there is a small to moderate number of groups, with the majority of very small group size (n5), size may fail to find or even consider a group-level effect when one may exist and also may be underpowered to detect fixed effects.

We suggest a classification and feature extraction method on functional data where the predictor variables are curves. The method, called functional segment discriminant analysis (FSDA), combines the classical linear discriminant analysis and support vector machine. FSDA is particularly useful for irregular functional data, characterized by spatial heterogeneity and local patterns like spikes. FSDA not only reduces the computation and storage burden by using a fraction of the spectrum, but also identifies important predictors and extracts features. FSDA is highly flexible, easy to incorporate information from other data sources and/or prior knowledge from the investigators. We apply FSDA to two public domain data sets and discuss the understanding developed from the study.