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Background: Immune checkpoint inhibitors (ICI) are increasingly used across multiple cancer types and stages and little is known about real-world outcomes. This study sought to determine healthcare utilization, costs, immune-related adverse events (irAEs), and all-cause mortality of single-agent versus combination ICI in the USA. Materials and methods: This is a retrospective study conducted with 2016–2018 data from the HealthCore Integrated Research Database, consisting of commercial and Medicare-insured adult patients with a cancer diagnosis using ICI in the USA. Outcomes were healthcare utilization, costs, and irAEs (FDA-recognized and others) up to 1-year post-index between patients using ICI monotherapy (mono, PD-1/PD-L1 inhibitor) and combination therapy (combo, PD-1/PD-L1 with CTLA-4 inhibitors). Results: In total, 9084 patients received monotherapy and 904 patients received combo therapy. Mean age 65 years for mono and 58 years for combo. Overall, the combo arm had higher rates of FDA-recognized irAEs (67.4% vs. 45.9%), especially endocrinopathies (27.7% vs 14.7%) and dermatitis (25.9% vs. 12.4%). All-cause mortality over 1-year follow-up was similar, 30.7% in mono vs 30.8% in combo arms. The combo group had higher rates of all-cause inpatient hospitalizations (55.4% mono vs 65.6% combo) and emergency department (ED) visits (33.7% mono vs 41.4% combo). IrAE-related hospitalizations were higher in combo (55.2% vs 42.1%). IrAE-related ED visits were 15.7% mono vs 22.7% combo. This increased toxicity and health care utilization was reflected in significant differences in healthcare costs. Stark differences were seen in all-cause medical costs as well as costs related to inpatient and ED utilization and costs attributed to irAEs. Conclusions: Higher rates of irAEs, healthcare utilization, and costs occur with combination immunotherapy. As further indications are approved for combination ICI, our study highlights the real-world tradeoffs involved with combination therapy regarding burdens of toxicity and increased healthcare utilization. [ABSTRACT FROM AUTHOR]

Background: Age-related macular degeneration (AMD) is a leading cause of visual loss among the elderly. A key cell type involved in AMD, the retinal pigment epithelium, expresses a G protein-coupled receptor that, in response to its ligand, L-DOPA, up-regulates pigment epithelia-derived factor, while down-regulating vascular endothelial growth factor. In this study we investigated the potential relationship between L-DOPA and AMD.Methods: We used retrospective analysis to compare the incidence of AMD between patients taking vs not taking L-DOPA. We analyzed 2 separate cohorts of patients with extensive medical records from the Marshfield Clinic (approximately 17,000 and approximately 20,000) and the Truven MarketScan outpatient and databases (approximately 87 million) patients. We used International Classification of Diseases, 9th Revision codes to identify AMD diagnoses and L-DOPA prescriptions to determine the relative risk of developing AMD and age of onset with or without an L-DOPA prescription.Results: In the retrospective analysis of patients without an L-DOPA prescription, AMD age of onset was 71.2, 71.3, and 71.3 in 3 independent retrospective cohorts. Age-related macular degeneration occurred significantly later in patients with an L-DOPA prescription, 79.4 in all cohorts. The odds ratio of developing AMD was also significantly negatively correlated by L-DOPA (odds ratio 0.78; confidence interval, 0.76-0.80; P <.001). Similar results were observed for neovascular AMD (P <.001).Conclusions: Exogenous L-DOPA was protective against AMD. L-DOPA is normally produced in pigmented tissues, such as the retinal pigment epithelium, as a byproduct of melanin synthesis by tyrosinase. GPR143 is the only known L-DOPA receptor; it is therefore plausible that GPR143 may be a fruitful target to combat this devastating disease. [ABSTRACT FROM AUTHOR]

Background: The COVID-19 pandemic has brought about immense change in health care. Surgical specialties in particular have had to make major adjustments because of the cancellation of nonemergent surgeries. Aesthetic surgery fellowships are uniquely affected because of the high number of elective cases and the length of the fellowship. The impact of the COVID-19 pandemic on current and upcoming aesthetic surgery fellows has not been studied., Objective: The aim of this article was to study the potential impact of the COVID-19 pandemic on both American Society for Aesthetic Plastic Surgeons-endorsed and nonendorsed aesthetic fellowship programs., Methods: A 23-question anonymous web-based survey was sent to aesthetic surgery fellowship directors with an active program in the United States. Surveys were collected from April 18, 2020, through May 14, 2020, with Qualtrics and then analyzed with Microsoft Excel. A 7-question follow-up survey was sent to directors, and a 23-question survey was sent to aesthetic surgery fellows. Data for these surveys were collected from June 6, 2020, through August 18, 2020. The surveys asked questions pertaining to adjustments and impact on current fellow training, as well as possible impact on fellows starting in 2020 and 2021., Results: There was a 65.5% (19 of 29) response rate for the initial director survey, a 31% (9 of 29) rate for the director follow up survey, and a 28% (9 of 32) rate for the fellow-specific survey. All directors and fellows reported that the pandemic had some impact on aesthetic fellow training. A total of 5.3% of directors reported that they believe COVID-19 would have a "significant impact" on their fellows becoming well-trained aesthetic surgeons, whereas 66.7% of fellows reported that it will have a "mild impact." Predicted impact on future fellows was not as significant., Conclusion: Telemedicine, educational efforts, and standardization of guidelines can be increased to minimize loss of training due to COVID-19. Ongoing evaluation and shared experiences can assist fellowships in customizing programs to provide well-rounded education during the pandemic., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: Cannabis legalization has increased its use. The incidence of acute pancreatitis (AP) and severe acute pancreatitis (SAP) has also increased. In this study, data on pancreatitis were obtained from 2 states before and after cannabis legalization and compared with 2 states without legalized cannabis., Methods: Data were extracted from State Inpatient Databases from the states of Colorado and Washington before recreational cannabis legalization (2011) and after legalization (2015). Arizona and Florida were used as the nonlegalized cannabis states. Multivariable logistic regression models were fit for AP and SAP to determine a trend difference between legalized and nonlegalized cannabis states., Results: Cannabis use, AP, and SAP increased in all states. The increase in AP and SAP was not significantly different between the states that legalized cannabis use and those that did not. Legalized cannabis states had lower charges for AP and SAP and shorter length of hospitalizations., Conclusions: The trend of AP and SAP increased during the study period, but this was not correlated to cannabis use. Cannabis users had lower hospitalization costs and hospital stay. The effects of other confounders such as cannabis dose and delivery methods, alcohol, tobacco, and others need to be studied further as use increases., Competing Interests: The other authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: This study was performed to outline and analyze the overall Medicare landscape with respect to otolaryngologists and beneficiaries, services, and reimbursements., Methods: This is a retrospective analysis of publicly available Medicare utilization and payment data for all otolaryngologists in facility and nonfacility practice settings who provided services to Medicare beneficiaries between January 1, 2012, and December 31, 2016., Results: In 2016, a total of $701,195,375 was distributed to 8572 otolaryngology physician providers for 815 unique Healthcare Common Procedure Coding System codes for 13,942,536 procedure claims. Of specialty care, otolaryngology ranks 20th among 54 subspecialties for total Medicare payments. The average number of services coded per provider was 1627. The average otolaryngologist was paid $81,800.67. Thirty-two percent of otolaryngologists did not receive reimbursement for services from Medicare in 2016., Discussion: In 2016, the most significant contributors to Medicare payments to otolaryngologists were large-scale, low-cost events that are relatively short procedures done in clinic. Utilization of nasal endoscopy was up trending from 2012 to 2016. Some of the Current Procedural Terminology codes with the greatest discrepancies between submitted charge and Medicare payment among nonfacility otolaryngology providers are more involved than simple office procedures., Implications for Practice: It is increasingly valuable for physicians to know factors that affect reimbursement for procedures and operations in different settings and to be aware of the trends in variation in their specialty. Otolaryngologists should communicate with policy makers in efforts toward sustainable reimbursement models.

Objectives: To evaluate whether patients with persistent muscle-invasive bladder cancer (MIBC) after undergoing neoadjuvant chemotherapy (NAC) and radical cystectomy (RC) have worse overall survival (OS) and cancer-specific survival (CSS) than patients with similar pathology who undergo RC alone., Materials and Methods: Using the Surveillance, Epidemiology and End Results (SEER)-Medicare database, we identified the records of patients with pT2-4N0M0 disease who underwent RC, with and without NAC, for MIBC between 2004 and 2011. To evaluate survival outcomes in those with MIBC after NAC vs patients with MIBC who underwent RC alone, we used Kaplan-Meier time-to-event analysis and Cox proportional hazard regression modelling. Landmark analysis was conducted to mitigate immortal time bias. Propensity scoring was used to decrease the risk of selection bias., Results: Of the 1 886 patients with persistent pT2-4 disease at the time of RC, 1505 underwent RC alone and 381 received NAC + RC. After adjusting for confounders, the propensity-weighted risk of death from bladder cancer after diagnosis did not differ between the groups (hazard ratio [HR] 0.72, 95% confidence interval [CI] 0.72-1.08; P = 0.23); however, the risk of death from all causes was worse in the RC-alone group (HR 0.79, 95% CI0.67-0.94; P = 0.006)., Conclusions: Patients who had persistent MIBC after platinum-based NAC + RC vs RC alone derived an OS benefit but not a CSS benefit from NAC. This may represent a selection bias favouring patients who were selected for NAC; however, the OS benefit was not evident in patients with persistent pT3-T4N0M0 disease. This study underscores the importance of future research investigating methods to identify patients who will respond to NAC for bladder cancer. It also highlights the need to consider adjuvant therapy in patients who have persistent MIBC after NAC., (© 2018 The Authors BJU International © 2018 BJU International Published by John Wiley & Sons Ltd.)

Purpose: To characterize anterior urinary fistulae following radiotherapy for prostate cancer., Methods: Over 10 years, 31 men were identified to have an anterior urinary fistula. A retrospective database was created to evaluate patient demographics, presentation, diagnostic procedures, operative interventions, outcomes, and complications. Comparisons between men who underwent cystectomy versus bladder-sparing surgeries were performed., Results: At a median age of 73 (interquartile range (IQR) 68.5, 79) years, presenting symptoms included as follows: pubic pain (19/31, 61%), urine drainage via fistula (10/31, 32%), or a superficial wound infection (6/31, 19%). Recent instrumentation prior to diagnosis of anterior urinary fistula was reported by 18/31 (58%) at a median of 14.9 months (IQR 7.9, 103.8) after manipulation. Anterior fistula formation was either isolated to the pubic symphysis (19/31, 61%) or the thigh (12/31, 38%). Nineteen men underwent a cystectomy, whereas 12 men underwent a fistula repair. Excluding grades 1 and 2, 30- and 90-day postoperative complications were limited to four and two men, respectively, all of whom had a grade 3 complication. At 6-month follow-up, 26/31 (84%) men reported their pain had resolved. There was one fistula recurrence managed with subsequent cystectomy., Conclusions: Complex anterior urinary fistulae to the pubic symphysis and thigh are devastating yet treatable conditions. Universally, these men have a history of radiotherapy and repeated endoscopic interventions. Surgical intervention with either cystectomy or primary repair was highly successful.

Purpose: Active surveillance protocols track low risk prostate cancer progression over time. However, given the lack of uniform criteria for managing low risk prostate cancer, men who qualify for active surveillance might have less intensive surveillance and, thus, experience poorer outcomes. In this study we examined racial disparities in the frequency and intensity of active surveillance between African-American and Caucasian men., Materials and Methods: Using the linked SEER-Medicare data set we identified 13,374 men with low risk prostate cancer (defined by the D'Amico criteria) diagnosed from 2004 to 2009 and then followed through 2011. A total of 2,916 men did not receive any treatment (radiation, hormonal therapy or surgery) within 1 year after diagnosis. Men were considered to be on active surveillance if they had at least 1 of the following 3 surveillance strategies within 2 years after diagnosis, namely 1 or more prostate biopsies, 4 or more prostate specific antigen tests, and/or 4 or more visits to the doctor with prostate cancer listed as the diagnosis. To compare the frequency of active surveillance between the groups (African-American vs Caucasian) we used the chi-square test. To estimate the odds ratio of active surveillance we used multivariable logistic regression after adjusting for possible confounders such as year of diagnosis, age at diagnosis, socioeconomic status and Charlson score., Results: Of the 2,916 untreated men 1,141 (39%), including 963 (37%) Caucasian men and 178 (58%) African-American men (p <0.0001), did not undergo any of the 3 surveillance strategies but instead were essentially on watchful waiting. Caucasian men (vs African-American) were more likely to be on active surveillance, with 1,646 (63.1%) vs 129 (42.0%) opting for 1 surveillance strategy (p <0.0001), 783 (30.0%) vs 50 (16.3%) opting for any 2 strategies (p <0.0001) and 193 (7.4%) vs 11 (3.6%) going through all 3 (p=0.01). On multivariable analysis African-American men had significantly lower odds of being on active surveillance than Caucasian men (OR 0.52, 95% CI 0.40-0.67). Men with more comorbidities (Charlson score 1 or greater) had significantly higher odds of being placed on active surveillance than watchful waiting (OR 1.7, 95% CI 1.46-2.12)., Conclusions: Among those not treated for low risk prostate cancer, Caucasian men were placed on active surveillance more frequently than African-American men, who often defaulted to de facto watchful waiting after an initial period of active surveillance. This discrepancy raises questions about the factors favoring watchful waiting over active surveillance. Moreover, given the lack of consensus regarding the most efficient active surveillance strategy, we anticipate that racial disparities in the use of active surveillance will persist, especially in African-American patients., (Copyright © 2017 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Background: On April 9, 2014, the Centers for Medicare and Medicaid Services released 10 million billing records of over 880,000 physicians and other health care providers and accounts for over $1 billion in Medicare payments distributed in 2012. This action was part of an effort to improve the transparency, accountability, and affordability of the U.S. health care system. This study was performed to mine this unprecedented data set to delineate patterns of billing and reimbursement for plastic surgeons., Methods: The Centers for Medicare and Medicaid Services Provider Utilization and Payment Database was accessed to analyze 2012 plastic surgery claims data with respect to providers and beneficiaries, services, and reimbursements. Pivot tables and other methods were used by means of Microsoft Excel., Results: In 2012, a total of $133,472,772 was distributed to 3726 plastic surgery physician providers for 735 unique Healthcare Common Procedure Coding System codes for 1,399,404 procedure claims. Of specialty care, plastic surgery ranks twenty-sixth among 29 subspecialties for total Medicare payments. The average plastic surgeon was paid $35,821.58 by the Centers for Medicare and Medicaid Services in 2012. Forty-six percent of plastic surgeons did not receive reimbursement for services from Medicare., Conclusions: The release of an enormous amount of provider level claims data by the Centers for Medicare and Medicaid Services may serve as a new tool for locating potential fraud, pinpointing needs, and assessing levels of growth in care. Plastic surgeons need to understand implications of changes to Medicare, which will likely affect patient mix, physician documentation, billing, coding, reimbursement, and active participation in quality reporting.

Purpose: To evaluate rates of reoperation and retinal detachment (RD) after macular hole surgery., Design: Retrospective cross-sectional study., Participants: Patients in the insurance claim-based MarketScan databases from 2007 through 2013 with a record of macular hole surgery., Methods: Patients with macular hole surgery were identified. Cases of definite (the same eye was coded both times) and presumed (the eye laterality was not coded) macular hole reoperations within 2, 3, and 12 months were queried. In addition, cases of postoperative RD within 2, 3, and 12 months were captured., Main Outcome Measures: Rates of macular hole reoperation and postoperative RD, including subgroup analysis based on presence or absence of internal limiting membrane (ILM) peeling., Results: Records of 23465 macular hole surgeries among 20 764 patients were analyzed. Among presumed reoperations, the rates of reoperation were 4.3% (4.1% after ILM peeling and 5.0% after no ILM peeling; P = 0.01) within 2 months of surgery, 5.5% (5.3% after ILM peeling and 6.2% after no ILM peeling; P = 0.03) within 3 months of surgery, and 9.5% (9.0% after ILM peeling and 11.0% after no ILM peeling; P = 0.01) within 12 months of surgery. The rates for definite reoperations were 1.3% (1.2% after ILM peeling and 1.8% after no ILM peeling; P = 0.04) at 2 months, 1.7% (1.6% after ILM peeling and 2.5% after no ILM peeling; P = 0.004) at 3 months, and 4.1% (3.3% after ILM peeling and 7.5% after no ILM peeling; P < 0.001) at 12 months. The cumulative rate of postoperative RD was 1.81±0.09% to 2.18±0.5% after 2 months, 2.27±0.10% to 3.18±0.67% after 3 months, and 3.92±0.16% to 5.70±1.1% after 12 months. Internal limiting membrane peeling was associated negatively with postoperative RD at 2 months (2.3% vs. 1.7%; P = 0.007), 3 months (2.8% vs. 2.1%; P = 0.004), and 12 months (4.7% vs. 3.3%; P < 0.001)., Conclusions: In this sample, reoperations for macular hole were performed at low rates. Internal limiting membrane peeling was associated with lower rates of reoperation and RD., (Copyright © 2016 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Background: Plastic surgery is among the most competitive specialties in medicine, but little is known about the attributes of programs that are most attractive to successful applicants. This study aimed to understand and provide insights regarding program characteristics that are most influential to students when ranking plastic surgery programs., Methods: An anonymous online survey was conducted with newly matched plastic surgery residents for the integrated and combined Match in 2012 and 2013. Subjects were queried regarding their demographics, qualifications, application experiences, and motivations for residency program selection., Results: A total of 92 of 245 matched plastic surgery residents (38 percent) responded to the survey. The perception of resident happiness was the most positive factor influencing program ranking, followed by high operative volume, faculty mentorship, and strong research infrastructure. Perception of a program as "malignant" was the most negative attribute. Applicants with Step 1 scores greater than 245 received significantly more interviews (p =0.001) and considered resident benefits less important (p < 0.05), but geographic location more important (p =0.005). Applicants who published more than two articles also received more interviews (p =0.001) and ranked a strong research infrastructure and program reputation as significantly more important (p < 0.05). Forty-two percent of applicants completed an away rotation at the program with which they matched, and these applicants were more likely to match at their number one ranked program (p = 0.001)., Conclusions: Plastic surgery applicants have differing preferences regarding the ideal training program, but some attributes resonate. These trends can guide programs for improvement in attracting the best applicants.

Objectives: Historically, mediastinoscopy has been the gold standard for the staging of lung cancer. A practice gap exists as the result of a variation in knowledge concerning current trends and practice patterns of mediastinoscopy usage. In addition, there are regional variations in practice-based learning and patient care. Lessons learned during surgeries performed on patients with lung cancer and other advances such as positron emission tomography and endobronchial ultrasound could be universally applied to improve surgeons' management of patient care. The purpose of this study was to assess contemporary practices in the staging of lung cancer., Methods: We queried the Society of Thoracic Surgeons National Database for data regarding mediastinoscopy usage, yield, and variation, both by year and region., Results: Cases with mediastinoscopy, as a percentage of all cases performed in the database, have significantly decreased from 14.6% in 2006 to 11.4% in 2010 (P < 0.001). The 5-year median rate of mediastinoscopy in lung cancer patients at 163 centers was 15.3% (interquartile range 5.2%-31.7%), indicating significant variation among centers. The overall median center rate also decreased over time from 21.4% (2006) to 10.0% (2010)., Conclusions: With advances in minimally invasive procedures and imaging, mediastinoscopy usage has declined significantly. Our findings are likely to be relevant to both clinical practice and practice guidelines.

Context: National databases can be used to investigate diabetes prevalence and health care use. Guideline-based care can reduce diabetes complications and morbidity. Yet little is known about the prevalence of diabetes and compliance with diabetes care guidelines among rural residents and whether different national databases provide similar results., Purpose: To examine rural-urban differences in the prevalence of diabetes and compliance with guidelines, and to compare the Behavioral Risk Factor Surveillance System (BRFSS) and the Medical Expenditures Panel Survey (MEPS)., Methods: Data for 2001-2002 were analyzed and compared by rural-urban status. Prevalence was calculated as simple unadjusted, weighted unadjusted, and weighted adjusted using a multivariate approach. Results from the 2 databases were compared., Findings: A slightly higher prevalence of diabetes among rural residents, 7.9% versus 6.0% in MEPS and 7.6% versus 6.6% in BRFSS, was found and persisted after adjustment for age, BMI, insurance coverage, and other demographic characteristics (adjusted OR 1.16 [1.02-1.31] in MEPS; 1.19 [1.01-1.20] in BRFSS). Rural persons in MEPS were less likely to receive an annual eye examination (aOR = 0.85) and a feet check (aOR = 0.89). A significantly (P < .05) smaller proportion of rural residents in BRFSS received an annual eye examination (aOR = 0.88), feet check (aOR = 0.85), or diabetes education (aOR = 0.83). Rural residents in both datasets were more likely to get a quarterly HbA1c test done., Conclusion: Rural residents in both datasets had higher prevalence of diabetes. Though not always statistically significant, the trend was to less guideline compliance in rural areas.

Background: Listeria monocytogenes is among the most virulent foodborne pathogens, with 20% of clinical infections resulting in death. To explore listeriosis-associated mortality in the United States and to evaluate prevention efforts, we reviewed vital records over a 16-year period to assess demographic, temporal, and seasonal trends., Methods: Nonperinatal listeriosis-associated deaths from 1990 through 2005 were identified from multiple-cause-coded death records and were combined with US census data to calculate mortality rates. Poisson regression was used to model time trends, and logistic regression was used to identify comorbid conditions associated with listeriosis on the death record., Results: Of the 37,267,946 deaths occurring in the United States during the 16-year study period, 1178 included listeriosis on the death record. Listeriosis-related mortality rates decreased annually by 10.74% from 1990 through 1996 and by 4.26% from 1996 through 2005. Seasonal trends show a distinct peak in mortality from July through October. After adjustment for age, sex, and race/ethnicity, listeriosis was positively associated with human immunodeficiency virus (HIV) infection (odds ratio, 4.19; 95% confidence interval, 3.06-5.73), lymphoid and hematopoietic cancers (odds ratio, 5.27; 95% confidence interval, 4.47-6.22), and liver disease (odds ratio, 2.05; 95% confidence interval, 1.54-2.73) on the death record., Conclusions: Nonperinatal listeriosis-associated deaths in the United States have decreased, paralleling a decreasing trend in incidence. Strict monitoring of food manufacturing processes, as well as improved treatment for HIV infection, may have played influential roles in preventing human infections. Health care providers should be aware of seasonal listeriosis patterns, as well as conditions predisposing individuals to severe infection and death due to L. monocytogenes infection, to guide strategies for disease management and prevention.

Reducing risks and improving benefits to the patients are requirements health professionals are faced with in their daily work. Furthermore, cuts in health funds and the competition for budgets require to enhancing efficacy and efficiency of health services. For meeting both challenges, adequate information and knowledge is needed, which can be gathered from documentation systems such as Electronic Health Records or Personal Health Records (PHRs), but also by performing dedicated clinical studies such as randomized controlled trials (RCTs) or cohort studies. Based on a literature analysis, quality of, and benefits from, RCTs have been analyzed. The benefits from connecting public health and PHRs are discussed in some details.

Diabetes is a chronic disease that causes a great deal of morbidity and mortality and poor quality of life for millions of people. Continuing care and patient education help maintain a good control of the disease and prevent complications. Since current available resources are limited to providing such an education during clinic or physician visits only, alternative ways to educate people about diabetes need to be identified. In this article we discuss the implementation of an automated diabetes education call center, we define the evaluation procedures we adopted, we summarize general guidelines for the implementation of the entire system based on our experience, and we present preliminary results about the use of the call center. We believe our system is providing "active health" since we deliver educational messages to patients at regular intervals and at the time of their choice without waiting for their actions.

Historically, public health has been at the forefront of data processing applications but it is lagging behind other areas of health care in the application of advanced interconnected and mobile information technologies. Ready to use technologies are lacking not only for the management of emerging infections or bio-terrorism but also for the coordination of prevention and chronic care initiatives. Advanced information and knowledge management for community health should expedite the transfer of research evidence to practice and provide essential logistical support for action. We need to find ways to integrate new scientific knowledge into our environment in order to expedite the translation of research to practice.