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Given the role of inflammation in cancer progression, neutrophil-lymphocyte ratio (NLR) from peripheral blood has been suggested as a read-out of systemic inflammation and a prognostic marker in several solid malignancies. However, optimal threshold for NLR in North American head and neck cancer patients remains unclear. We performed an observational cohort study to determine the optimal NLR threshold as a prognostic biomarker for survival outcomes. A single-institution, retrospective database was queried for patients with non-metastatic head and neck cancer who underwent radiation therapy from January 2005 to April 2021. A threshold for NLR was determined by Cox proportional hazard model for OS using restricted cubic splines (RCS), and patients were then stratified into two cohorts by above versus below the model-derived threshold for their NLR. Cox multivariable analysis (MVA) and Kaplan-Meier method were used to analyze overall survival (OS) and disease-specific survival (DSS) outcomes. Logistic MVA was performed to identify variables associated with elevated NLR. To reduce selection bias, propensity score matching was used based on nearest neighbor method in a 1:1 ratio without replacements. A total of 753 patients were included for analysis. Median follow up was 29.7 months (interquartile range 17.8-57.8). Cox MVA using RCS showed a threshold of NLR at 4.82, with worsening OS in a continuous fashion without plateau as NLR increases. High NLR above 4.82 was associated with worse OS (adjusted hazards ratio [aHR] 1.73, 95% confidence interval [CI] 1.26-2.37, p<0.001) and DSS (aHR 1.77, 95% CI 1.22-2.56, p=0.003). Similar findings were noted in 103 matched pairs (OS: aHR 1.85, 95% CI 1.19-2.90, p=0.007; DSS: aHR 1.91, 95% CI 1.11-3.28, p=0.02). On logistic MVA, patients were more likely to have high NLR if they had a higher T staging (adjusted odds ratio [aOR] 1.75, 95% CI 1.14-2.73, p=0.01), but less likely if they had a good performance status (aOR 0.45, 95% CI 0.29-0.69, p<0.001). Among 466 patients with available HPV data, high NLR was not associated with OS (aHR 1.38, 0.89-2.15, p=0.15) and DSS (aHR 1.15, 95% CI 0.67-1.97, p=0.62). High NLR based on a model-derived threshold was associated with worse survival. Patients with significant primary disease burden and poor performance status were more likely to have high NLR. Further studies would be warranted to investigate the role of such prognostic marker to identify patients at risk to tailor interventions. [ABSTRACT FROM AUTHOR]

Context: The existence of different types of accreditation legal frameworks, embedded in complex and varying state legal infrastructures and political environments, raises important legal implications for the national voluntary accreditation program., Objective: To increase an understanding of accreditation-enabling laws nationwide., Design: In 2010 to 2011, the North Carolina Institute for Public Health conducted a study of state legal frameworks supporting public health department accreditation or related programs (ie, certification/assessment, performance management, and quality improvement). First, a mapping study was conducted to identify current programs and their legal frameworks. Ten states were then selected for in-depth qualitative case study. Data were gathered through semistructured interviews with public health practitioners and key stakeholders., Results: The findings from the mapping study delineate the accreditation, certification/assessment, performance management, or quality improvement program currently in place and the type of legal framework supporting it. The citations for statutes and regulations are also included. Among the 18 states in the sample, 4 have accreditation programs, 6 have certification/assessment programs, and 8 have performance management/quality improvement programs. Accreditation programs were most likely to have a statutory basis, while performance management and quality improvement programs were most often supported via health department policy. The findings from the case study provide greater detail about each state, reflecting public health structures, programs, legal frameworks, approaches to Public Health Accreditation Board (PHAB) accreditation, and legal strategies for achieving accreditation., Conclusions: Early adopter states have pursued a variety of legal frameworks to develop their accreditation, certification/assessment, performance management, and quality improvement programs. With the voluntary national accreditation program scheduled to go live in late 2011, these 10 states have also carefully considered options for aligning their activities with PHAB accreditation. Lessons derived from this examination can inform public health practitioners, advocates, and elected officials about how to best structure legal frameworks to support accreditation and related activities.