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Background: Heart failure is a leading cause of death in the USA, contributing to high expenditures near the end of life. Evidence remains lacking on whether billed advance care planning changes patterns of end-of-life healthcare utilization among patients with heart failure. Large-scale claims evaluation assessing billed advance care planning and end-of-life hospitalizations among patients with heart failure can fill evidence gaps to inform health policy and clinical practice., Objective: Assess the association between billed advance care planning delivered and Medicare beneficiaries with heart failure upon the type and quantity of healthcare utilization in the last 30 days of life., Design: This retrospective cross-sectional cohort study used Medicare fee-for-service claims from 2016 to 2020., Participants: A total of 48,466 deceased patients diagnosed with heart failure on Medicare., Main Measures: Billed advance care planning services between the last 12 months and last 30 days of life will serve as the exposure. The outcomes are end-of-life healthcare utilization and total expenditure in inpatient, outpatient, hospice, skilled nursing facility, and home healthcare services., Key Results: In the final cohort of 48,466 patients (median [IQR] age, 83 [76-89] years; 24,838 [51.2%] women; median [IQR] Charlson Comorbidity Index score, 4 [2-5]), 4406 patients had an advance care planning encounter. Total end-of-life expenditure among patients with billed advance care planning encounters was 19% lower (95% CI, 0.77-0.84) compared to patients without. Patients with billed advance care planning encounters had 2.65 times higher odds (95% CI, 2.47-2.83) of end-of-life outpatient utilization with a 33% higher expected total outpatient expenditure (95% CI, 1.24-1.42) compared with patients without a billed advance care planning encounter., Conclusions: Billed advance care planning delivery to individuals with heart failure occurs infrequently. Prioritizing billed advance care planning delivery to these individuals may reduce total end-of-life expenditures and end-of-life inpatient expenditures through promoting use of outpatient end-of-life services, including home healthcare and hospice., (© 2024. The Author(s).)

Background: Early efforts at risk-adapted therapy for neuroblastoma are predicted to result in differential late effects; the magnitude of these differences has not been well described., Methods: Late mortality, subsequent malignant neoplasms (SMNs), and severe/life-threatening chronic health conditions (CHCs), graded according to CTCAE v4.03, were assessed among 5-year Childhood Cancer Survivor Study (CCSS) survivors of neuroblastoma diagnosed 1987-1999. Using age, stage at diagnosis, and treatment, survivors were classified into risk groups (low [n = 425]; intermediate [n = 252]; high [n = 245]). Standardized mortality ratios (SMRs) and standardized incidence ratios (SIRs) of SMNs were compared with matched population controls. Cox regression models estimated hazard ratios (HRs) and 95% confidence intervals for CHC compared with 1029 CCSS siblings., Results: Among survivors (49.8% male; median age = 21 years, range = 7-42; median follow-up = 19.3 years, range = 5-29.9), 80% with low-risk disease were treated with surgery alone, whereas 79.1% with high-risk disease received surgery, radiation, chemotherapy ± autologous stem cell transplant (ASCT). All-cause mortality was elevated across risk groups (SMRhigh = 27.7 [21.4-35.8]; SMRintermediate = 3.3 [1.7-6.5]; SMRlow = 2.8 [1.7-4.8]). SMN risk was increased among high- and intermediate-risk survivors (SIRhigh = 28.0 [18.5-42.3]; SIRintermediate = 3.7 [1.2-11.3]) but did not differ from the US population for survivors of low-risk disease. Compared with siblings, survivors had an increased risk of grade 3-5 CHCs, particularly among those with high-risk disease (HRhigh = 16.1 [11.2-23.2]; HRintermediate = 6.3 [3.8-10.5]; HRlow = 1.8 [1.1-3.1])., Conclusion: Survivors of high-risk disease treated in the early days of risk stratification carry a markedly elevated burden of late recurrence, SMN, and organ-related multimorbidity, whereas survivors of low/intermediate-risk disease have a modest risk of late adverse outcomes., (© The Author(s) 2024. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Over 4 million survivors of breast cancer live in the United States, 35% of whom were treated before 2009. Approximately half of patients with breast cancer receive radiation therapy, which exposes the untreated contralateral breast to radiation and increases the risk of a subsequent contralateral breast cancer (CBC). Radiation oncology has strived to reduce unwanted radiation dose, but it is unknown whether a corresponding decline in actual dose received to the untreated contralateral breast has occurred. The purpose of this study was to evaluate trends in unwanted contralateral breast radiation dose to inform risk assessment of second primary cancer in the contralateral breast for long-term survivors of breast cancer. Individually estimated radiation absorbed doses to the four quadrants and areola central area of the contralateral breast were estimated for 2,132 women treated with radiation therapy for local/regional breast cancers at age <55 years diagnosed between 1985 and 2008. The two inner quadrant doses and two outer quadrant doses were averaged. Trends in dose to each of the three areas of the contralateral breast were evaluated in multivariable models. The population impact of reducing contralateral breast dose on the incidence of radiation-associated CBC was assessed by estimating population attributable risk fraction (PAR) in a multivariable model. The median dose to the inner quadrants of the contralateral breast was 1.70 Gy; to the areola, 1.20 Gy; and to the outer quadrants, 0.72 Gy. Ninety-two percent of patients received ≥1 Gy to the inner quadrants. For each calendar year of diagnosis, dose declined significantly for each location, most rapidly for the inner quadrants (0.04 Gy/year). Declines in dose were similar across subgroups defined by age at diagnosis and body mass index. The PAR for CBC due to radiation exposure >1 Gy for women <40 years of age was 17%. Radiation dose-reduction measures have reduced dose to the contralateral breast during breast radiation therapy. Reducing the dose to the contralateral breast to <1 Gy could prevent an estimated 17% of subsequent radiation-associated CBCs for women treated under 40 years of age. These dose estimates inform CBC surveillance for the growing number of breast cancer survivors who received radiation therapy as young women in recent decades. Continued reductions in dose to the contralateral breast could further reduce the incidence of radiation-associated CBC., (©2023 by Radiation Research Society. All rights of reproduction in any form reserved.)

Shellfish, such as the Eastern oyster (Crassostrea virginica), are an important agricultural commodity. Previous research has demonstrated the importance of the native microbiome of oysters against exogenous challenges by non-native pathogens. However, the taxonomic makeup of the oyster microbiome and the impact of environmental factors on it are understudied. Research was conducted quarterly over a calendar year (February 2020 through February 2021) to analyze the taxonomic diversity of bacteria present within the microbiome of consumer-ready-to-eat live Eastern oysters. It was hypothesized that a core group of bacterial species would be present in the microbiome regardless of external factors such as the water temperature at the time of harvest or post-harvesting processing. At each time point, 18 Chesapeake Bay (eastern United States) watershed aquacultured oysters were acquired from a local grocery store, genomic DNA was extracted from the homogenized whole oyster tissues, and the bacterial 16S rRNA gene hypervariable V4 region was PCR-amplified using barcoded primers prior to sequencing via Illumina MiSeq and bioinformatic analysis of the data. A core group of bacteria were identified to be consistently associated with the Eastern oyster, including members of the phyla Firmicutes and Spirochaetota, represented by the families Mycoplasmataceae and Spirochaetaceae, respectively. The phyla Cyanobacterota and Campliobacterota became more predominant in relation to warmer or colder water column temperature, respectively, at the time of oyster harvest., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Hines et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Mental health among low-income Latinx women in the United States (US), including those in farmworker families, is a health equity concern. This analysis (1) describes the depressive symptoms among Latinx women in rural farmworker families and urban non-farmworker families and (2) delineates immigration and acculturation, family composition and disruption, and financial characteristics associated with depressive symptoms experienced by these women., Methods: Data are from a 2019-2020 cross-sectional survey of 66 rural farmworker and 52 urban non-farmworker women with a child participating in a study of pesticide exposure and neurocognitive development. Depressive symptoms were measured with the CES-D Short Form., Results: The median (25th-75th percentiles) depressive symptom score reported was 2.0 (1.0-4.0), with 10 (8.5%) women having depressive symptom scores of 10 or greater. In bivariate analysis, among immigration and acculturation characteristics, women born in the USA and who spoke English fluently had lower depressive symptom scores. Among family composition and disruption characteristics, married women, and those with two adults in the household had lower depressive symptom scores. No financial status characteristic had statistically significant associations with depressive symptom score. In multivariate analysis, rural farmworker women had an expected median score one point lower than did urban non-farmworker women., Conclusion: Addressing mental health among immigrant women, particularly those in farmworker families, is a complex undertaking. Rural versus urban locality provides a context for mental health. Determining the proximal determinants of locality requires further analysis., (© 2021. W. Montague Cobb-NMA Health Institute.)

Purpose: To determine the incidence of serious chronic health conditions among survivors of pediatric Hodgkin lymphoma (HL), compare by era of therapy and by selected cancer therapies, and provide estimates of risks associated with contemporary therapy., Methods: Assessing 2,996 5-year HL survivors in the Childhood Cancer Survivor Study diagnosed from 1970 to 1999, we examined the cumulative incidence of severe to fatal chronic conditions (grades 3-5) using self-report conditions, medically confirmed subsequent malignant neoplasms, and cause of death based on the National Death Index. We used multivariable regression models to estimate hazard ratios (HRs) per decade and by key treatment exposures., Results: HL survivors were of a mean age of 35.6 years (range, 12-58 years). The cumulative incidence of any grade 3-5 condition by 35 years of age was 31.4% (95% CI, 29.2 to 33.5). Females were twice as likely (HR, 2.1; 95% CI, 1.8 to 2.4) to have a grade 3-5 condition compared with males. From the 1970s to the 1990s, there was a 20% reduction (HR, 0.8; 95% CI, 0.7 to 0.9) in decade-specific risk of a grade 3-5 condition ( P trend = .002). In survivors who had a recurrence and/or hematopoietic cell transplant, the risk of a grade 3-5 condition was substantially elevated, similar to that of survivors treated with high-dose, extended-field radiotherapy (HR, 1.2; 95% CI, 0.9 to 1.5). Compared with survivors treated with chest radiotherapy ≥ 35 Gy in combination with an anthracycline or alkylator, a contemporary regimen for low-intermediate risk HL was estimated to lead to a 40% reduction in risk of a grade 3-5 condition (HR, 0.6; 95% CI, 0.4 to 0.8)., Conclusion: This study demonstrates that risk-adapted therapy for pediatric HL has resulted in a significant reduction in serious long-term outcomes.

Building a culture of precision public health requires research that includes health delivery model with innovative systems, health policies, and programs that support this vision. Health insurance mandates are effective mechanisms that many state policymakers use to increase the utilization of preventive health services, such as colorectal cancer screening. This study estimated the effects of health insurance mandate variations on colorectal cancer screening post Affordable Care Act (ACA) era. The study analyzed secondary data from the Behavioral Risk Factor Surveillance System (BRFSS) and the NCI State Cancer Legislative Database (SCLD) from 1997 to 2014. BRFSS data were merged with SCLD data by state ID. The target population was U.S. adults, age 50 to 74, who lived in states where health insurance was mandated or nonmandated before and after the implementation of ACA. Using a difference-in-differences (DD) approach with a time-series analysis, we evaluated the effects of health insurance mandates on colorectal cancer screening status based on U.S. Preventive Services Task Force guidelines. The adjusted average marginal effects from the DD model indicate that health insurance mandates increased the probability of up-to-date screenings versus noncompliance by 2.8% points, suggesting that an estimated 2.37 million additional age-eligible persons would receive a screening with such health insurance mandates. Compliant participants' mean age was 65 years and 57% were women ( n = 32,569). Our findings are robust for various model specifications. Health insurance mandates that lower out-of-pocket expenses constitute an effective approach to increase colorectal cancer screenings for the population, as a whole. PREVENTION RELEVANCE: The value added includes future health care reforms that increase access to preventive services, such as CRC screening, are likely with lower out-of-pocket costs and will increase the number of people who are considered "up-to-date". Such policies have been used historically to improve health outcomes, and they are currently being used as public health strategies to increase access to preventive health services in an effort to improve the nation's health., (©2020 American Association for Cancer Research.)

Purpose: We previously developed an age-scalable 3D computational phantom that has been widely used for retrospective whole-body dose reconstructions of conventional two-dimensional historic radiation therapy (RT) treatments in late effects studies of childhood cancer survivors. This phantom is modeled in the FORTRAN programming language and is not readily applicable for dose reconstructions for survivors treated with contemporary RT whose treatment plans were designed using computed tomography images and complex treatment fields. The goal of this work was to adapt the current FORTRAN model of our age-scalable computational phantom into Digital Imaging and Communications in Medicine (DICOM) standard so that it can be used with any treatment planning system (TPS) to reconstruct contemporary RT. Additionally, we report a detailed description of the phantom's age-based scaling functions, information that was not previously published., Method: We developed a Python script that adapts our phantom model from FORTRAN to DICOM. To validate the conversion, we compared geometric parameters for the phantom modeled in FORTRAN and DICOM scaled to ages 1 month, 6 months, 1, 2, 3, 5, 8, 10, 15, and 18 years. Specifically, we calculated the percent differences between the corner points and volume of each body region and the normalized mean square distance (NMSD) between each of the organs. In addition, we also calculated the percent difference between the heights of our DICOM age-scaled phantom and the heights (50th percentile) reported by the World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC) for male and female children of the same ages. Additionally, we calculated the difference between the organ masses for our DICOM phantom and the organ masses for two reference phantoms (from International Comission on Radiation Protection (ICRP) 89 and the University of Florida/National Cancer Institute reference hybrid voxel phantoms) for ages newborn, 1, 5, 10, 15 and adult. Lastly, we conducted a feasibility study using our DICOM phantom for organ dose calculations in a commercial TPS. Specifically, we simulated a 6 MV photon right-sided flank field RT plan for our DICOM phantom scaled to age 3.9 years; treatment field parameters and age were typical of a Wilms tumor RT treatment in the Childhood Cancer Survivor Study. For comparison, the same treatment was simulated using our in-house dose calculation system with our FORTRAN phantom. The percent differences (between FORTRAN and DICOM) in mean dose and percent of volume receiving dose ⩾5 Gy were calculated for two organs at risk, liver and pancreas., Results: The percent differences in corner points and the volumes of head, neck, and trunk body regions between our phantom modeled in FORTRAN and DICOM agreed within 3%. For all of the ages, the NMSDs were negliglible with a maximum NMSD of 7.80 × 10 -2 mm for occiptital lobe of 1 month. The heights of our age-scaled phantom agreed with WHO/CDC data within 7% from infant to adult, and within 2% agreement for ages 5 years and older. We observed that organ masses in our phantom are less than the organ masses for other reference phantoms. Dose calculations done with our in-house calculation system (with FORTRAN phantom) and commercial TPS (with DICOM phantom) agreed within 7%., Conclusion: We successfully adapted our phantom model from the FORTRAN language to DICOM standard and validated its geometric consistency. We also demonstrated that our phantom model is representative of population height data for infant to adult, but that the organ masses are smaller than in other reference phantoms and need further refinement. Our age-scalable computational phantom modeled in DICOM standard can be scaled to any age at RT and used within a commercial TPS to retrospectively reconstruct doses from contemporary RT in childhood cancer survivors.

Background: Venous congestion in heart failure (HF) may lead to worsening renal failure (WRF). We hypothesised that WRF in patients hospitalised for left ventricular assist device (LVAD) implantation is associated with increased 1-year mortality. There is limited data regarding WRF in HF patients with mechanical support. The objective of this paper is to determine whether WRF in HF patients hospitalised for LVAD implantation is associated with increased 1-year mortality and to identify risk factors for WRF., Methods: We performed a single centre retrospective chart analysis of 162 patients who received an LVAD between August 2006 and December 2014 with pre-LVAD right heart catheterisation data. We stratified patients to those who demonstrated WRF and the use of haemodialysis (HD) or ultrafiltration (UF)., Results: Patients with a higher central venous pressure (CVP) >16 mmHg (17-24 mmHg range) developed WRF (29.7% vs. 14.1%, p=0.019). A CVP ≥16 and glomerular filtration rate (GFR) <30 ml/min/1.74m 2 increased the odds of WRF. Worsening renal failure and HD/UF use were associated with increased 1-year mortality. Furthermore GFR <30, atherosclerosis, and right ventricular failure were independent predictors for increased 1-year mortality. A GFR <30 increased the odds of developing WRF five-fold (OR 4.14, CI [1.95-8.78], p<0.0001), and GFR <30 and central venous pressure (CVP) >16 increased the odds of requiring HD/UF., Conclusions: Worsening renal failure is associated with a higher CVP at the time of LVAD implantation and increases the risk of 1-year mortality and the odds of requiring HD/UF. Careful evaluation of renal function and comorbid conditions during LVAD implantation is critical to reduce mortality and for risk stratification., (Copyright © 2019 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Importance: Chest irradiation for childhood cancer is associated with increases in breast cancer risk. Growing evidence suggests that anthracyclines increase this risk, but the outcome of combined anthracycline use and radiotherapy has not been studied., Objectives: To evaluate breast cancer risk in childhood cancer survivors following radiotherapy and chemotherapy and assess whether risks varied by estrogen receptor (ER) status., Design, Setting, and Participants: In a North American hospital-based nested case-control study, a retrospective cohort of 14 358 five-year survivors of childhood cancer, diagnosed from 1970 to 1986 and followed up through December 31, 2016, was analyzed. Cases (n = 271) were defined as women with subsequent breast cancer. Controls (n = 1044) were matched 4:1 to cases by age at first cancer and duration of follow-up (± 2 years). Data analysis was conducted from September 2017 to July 2018., Exposures: Radiation dose to breast tumor site and ovaries and cumulative chemotherapy doses, including anthracyclines and alkylating agents., Main Outcomes and Measures: Odds ratios (ORs) for subsequent breast cancer by ER status., Results: A total of 271 women served as breast cancer cases (median age at first cancer diagnosis, 15 years [range, 3-20]; median age at breast cancer diagnosis, 39 years [range, 20-57]): 201 invasive (113 ER positive [ER+], 41 ER negative [ER-], and 47 unknown) and 70 in situ breast cancers. The OR for breast cancer increased with increasing radiation dose to the breast (OR per 10 Gy, 3.9; 95% CI, 2.5-6.5) and was similar for ER+ (OR per 10 Gy, 5.5; 95% CI, 2.8-12.6) and ER- (OR per 10 Gy, 4.8; 95% CI, 1.7-22.3) cancers. For women who received ovarian doses less than 1 Gy, the OR per 10 Gy to the breast was higher (OR, 6.8; 95% CI, 3.9-12.5) than for women who received ovarian doses greater than or equal to 15 Gy (OR, 1.4; 95% CI, 1.0-6.4). The OR for breast cancer increased with cumulative anthracycline dose (OR per 100 mg/m2, 1.23; 95% CI, 1.09-1.39; P < .01 for trend), and was 1.49 (95% CI, 1.21-1.83) for ER+ cancer vs 1.10 (95% CI, 0.84-1.45) for ER- cancers (P value for heterogeneity = .47). There was an additive interaction between radiotherapy and anthracycline treatment (P = .04) with the OR for the combined association between anthracycline therapy and breast radiation dose of 10 Gy or more (compared with 0 to less than 1 Gy) of 19.1 (95% CI, 7.6-48.0) vs 9.6 (95% CI, 4.4-20.7) without anthracycline use., Conclusions and Relevance: This study provides the first evidence to date that the combination of anthracyclines and radiotherapy may increase breast cancer risks compared with use of neither treatment with a similar radiation dose response for ER+ and ER- cancers and possibly higher anthracycline risks for ER+ cancers. These results might help inform surveillance guidelines for childhood cancer survivors.

This goal of this study was to highlight the importance of minerals in the diet of fish for meeting micronutrient requirements in the human diet. First arsenic, calcium, cadmium, copper, iron, molybdenum, magnesium, manganese, sodium, phosphorus, potassium, selenium, and zinc concentrations of twelve commercially available tilapia samples were measured. The nutritional value of fillets in regard to their mineral content were assessed to establish potential health benefits or risks for consumers. The health benefit value of selenium was also calculated. Positive health benefit values indicate that tilapia fillets in the United States marketplace of this study do not pose health risks associated with mercury exposures. Selenium was the trace mineral of interest. After the market study, a seven-week fish feeding trial was conducted to study the influence of organic versus inorganic dietary selenium on Nile tilapia (Oreochromis niloticus). Fish were fed two different diets enriched with the same concentration (0.01g kg-1) of selenium in form of inorganic (sodium selenite) or organic (seleno-L-methionine) selenium in triplicate groups. There were no significant differences between growth and biometrics of fish fed different diets (p>0.05). At the end of trial twelve fish from each treatment were collected. Fillets of fish fed organic selenium had selenium concentrations of 0.55 ± 0.01 μg g-1 which were significantly (p<0.05) higher than fish fed inorganic selenium at levels of 0.22 ± 0.008 μg g-1 or fish samples from the marketplace with a selenium level of 0.2 ± 0.03 μg g-1. Fish fed organic selenium also had significantly higher (p<0.05) plasma and kidney selenium in comparison to fish fed inorganic selenium. No significant differences (p>0.05) were observed in glutathione peroxidase activities in either the plasma or liver of Nile tilapia in the different treatment groups. This study shows that organic selenium is a better option for production of Nile tilapia fillets rich in selenium., Competing Interests: The authors have declared that no competing interests exist.

Purpose: The impacts of radiotherapy dose and exposed cardiac volume, select chemotherapeutic agents, and age at exposure on risk for late-onset cardiac disease in survivors of childhood cancer remain unresolved., Patients and Methods: We determined the rates of severe to fatal cardiac disease in 24,214 5-year survivors in the Childhood Cancer Survivor Study diagnosed between 1970 and 1999 at a median age of 7.0 years (range, 0 to 20.9 years), with a median attained age of 27.5 years (range, 5.6 to 58.9 years). Using piecewise exponential models, we evaluated the association between cardiac disease rates and demographic and treatment characteristics., Results: The cumulative incidence of cardiac disease 30 years from diagnosis was 4.8% (95% CI, 4.3 to 5.2). Low to moderate radiotherapy doses (5.0 to 19.9 Gy) to large cardiac volumes (≥ 50% of heart) were associated with an increased rate of cardiac disease (relative rate, 1.6; 95% CI, 1.1 to 2.3) compared with survivors without cardiac radiotherapy exposure. Similarly, high doses (≥ 20 Gy) to small cardiac volumes (0.1% to 29.9%) were associated with an elevated rate (relative rate, 2.4; 95% CI, 1.4 to 4.2). A dose-response relationship was observed between anthracycline chemotherapy and heart failure with younger children (age ≤ 13 years) at the greatest risk for heart failure after comparable dosing., Conclusion: These observations support advances in radiation field design and delivery technology to reduce cardiac dose/volume and should guide future treatment protocols. They also inform clinical practice guidelines for post-therapy surveillance and risk-reducing strategies.

There are significant health disparities among Southeast Asian Americans. As an initial step toward understanding the psychosocial factors associated with these disparities, the present study examined primary care providers' perspectives of health status, healthcare utilization, health-related behaviors, and stressors among one subset of Southeast Asian Americans-Cambodian American women between the ages of 18 and 24 years. Interviews with five primary care providers indicated that cultural, historical, psychological and social issues were associated with health outcomes and health behaviors. Results also pointed to clinical considerations and research directions that would improve treatment and understanding of health problems among young Cambodian American women.

Precision public health requires research that supports innovative systems and health delivery approaches, programs, and policies that are part of this vision. This study estimated the effects of health insurance mandate (HiM) variations and the effects of physician utilization on moderating colorectal cancer (CRC) screening rates. A time-series analysis using a difference-in-difference-in-differences (DDD) approach was conducted on CRC screenings (1997-2014) using a multivariate logistic framework. Key variables of interest were HiM, CRC screening status, and physician utilization. The adjusted average marginal effects from the DDD model indicate that physician utilization increased the probability of being "up-to-date" vs. non-compliance by 9.9% points (p = 0.007), suggesting that an estimated 8.85 million additional age-eligible persons would receive a CRC screening with HiM and routine physician visits. Routine physician visits and mandates that lower out-of-pocket expenses constitute an effective approach to increasing CRC screenings for persons ready to take advantage of such policies., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Geographic disparities in survival after heart transplantation have received mixed support in prior studies, and specific geographic characteristics that might be responsible for these differences are unclear. We tested for differences in heart transplant outcomes across United States (US) counties after adjustment for individual-level covariates. Our secondary aim was to evaluate whether specific county-level socioeconomic characteristics explained geographic disparities in survival., Methods: Data on patients aged ≥18 years undergoing a first-time heart transplant between July 2006 and December 2014 were obtained from the United Network for Organ Sharing. Residents of counties represented by <5 patients were excluded. Patient survival (censored in March 2016) was analyzed using multivariable Cox regression. Shared frailty models were used to test for residual differences in overall all-cause mortality across counties after adjusting for recipient and donor characteristics. Measures of county economic disadvantage, inequality, and racial segregation were obtained from US Census data and coded into quintiles. A likelihood ratio test determined whether adjusting for each county measure improved the fit of the Cox model., Results: Multivariable analysis of 10,879 heart transplant recipients found that, adjusting for individual-level characteristics, there remained statistically significant variation in mortality hazard across US counties (P=.004). Adjusting for quintiles of community disadvantage, economic inequality, or racial segregation did not significantly improve model fit (likelihood ratio test P=.092, P=.273, and P=.107, respectively) and did not explain residual differences in patient survival across counties., Conclusions: Heart transplantation outcomes vary by county, but this difference is not attributable to county-level socioeconomic disadvantage., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: In the USA, race and socioeconomic status are well-known factors associated with colorectal cancer incidence and mortality rates. These are higher among blacks than whites and other racial/ethnic groups., Methods: In this article, we review opportunities to address disparities in colorectal cancer incidence, mortality, and survivorship among African Americans., Results: First, we summarize the primary prevention of colorectal cancer and recent advances in the early detection of the disease and disparities in screening. Then, we consider black-white disparities in colorectal cancer treatment and survival including factors that may contribute to such disparities and the important roles played by cultural competency, patient trust in one's physician, and health literacy in addressing colorectal cancer disparities, including the need for studies involving the use of colorectal cancer patient navigators who are culturally competent., Conclusion: To reduce these disparities, intervention efforts should focus on providing high-quality screening and treatment for colorectal cancer and on educating African Americans about the value of diet, weight control, screening, and treatment. Organized approaches for delivering colorectal cancer screening should be accompanied by programs and policies that provide access to diagnostic follow-up and treatment for underserved populations., Competing Interests: The authors declare that they have no competing interests.

Objective: The consumption of an agrarian diet is associated with a reduced risk for many diseases associated with a 'Westernised' lifestyle. Studies suggest that diet affects the gut microbiota, which subsequently influences the metabolome, thereby connecting diet, microbiota and health. However, the degree to which diet influences the composition of the gut microbiota is controversial. Murine models and studies comparing the gut microbiota in humans residing in agrarian versus Western societies suggest that the influence is large. To separate global environmental influences from dietary influences, we characterised the gut microbiota and the host metabolome of individuals consuming an agrarian diet in Western society., Design and Results: Using 16S rRNA-tagged sequencing as well as plasma and urinary metabolomic platforms, we compared measures of dietary intake, gut microbiota composition and the plasma metabolome between healthy human vegans and omnivores, sampled in an urban USA environment. Plasma metabolome of vegans differed markedly from omnivores but the gut microbiota was surprisingly similar. Unlike prior studies of individuals living in agrarian societies, higher consumption of fermentable substrate in vegans was not associated with higher levels of faecal short chain fatty acids, a finding confirmed in a 10-day controlled feeding experiment. Similarly, the proportion of vegans capable of producing equol, a soy-based gut microbiota metabolite, was less than that was reported in Asian societies despite the high consumption of soy-based products., Conclusions: Evidently, residence in globally distinct societies helps determine the composition of the gut microbiota that, in turn, influences the production of diet-dependent gut microbial metabolites., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Background: There has been a steady increase of patients living in the community with Left Ventricular Assist Devices (LVADs). There is a significant gap in our fund of knowledge with respect to the impact that insurance and socioeconomic status has on outcomes for LVAD patients. We thus hypothesize that low neighborhood socioeconomic status and receipt of Medicaid, respectively, lead to earlier readmissions, earlier death, as well as longer time to transplantation among LVAD patients., Methods: This was a retrospective review of 101 patients using existing data in the medical information warehouse database at The Ohio State University Medical Center. Primary outcomes measured included time to first event (first readmission or death), death, and time to rehospitalization. Our secondary outcome of interest included time from LVAD implantation to cardiac transplantation., Results: Recipients of Medicaid did not have an increased risk of adverse events compared with patients without Medicaid coverage. Low Median Household Income (MHI) was associated with an increased risk of readmission (log-rank P = 0.0069) and time to first event (log-rank P = 0.0088). Bridge to transplantation was the only independent predictor of time to death (Hazard Ratio 2.1, [95% confidence interval = 1.03-4.37]). Low MHI and a history of atherosclerosis were both significant predictors for readmission and time to first event. Aldosterone antagonist use decreased the risk of readmission or time to first event by 46%., Conclusions: LVAD recipients with a low MHI were more likely to be readmitted to the hospital after LVAD implantation. Whether these patients are adequately monitored on an outpatient basis remains unclear., (Copyright © 2014 Elsevier Inc. All rights reserved.)

The GenBank database contains essentially all of the nucleotide sequence data generated for published molecular systematic studies, but for the majority of taxa these data remain sparse. GenBank has value for phylogenetic methods that leverage data-mining and rapidly improving computational methods, but the limits imposed by the sparse structure of the data are not well understood. Here we present a tree representing 13,093 land plant genera--an estimated 80% of extant plant diversity--to illustrate the potential of public sequence data for broad phylogenetic inference in plants, and we explore the limits to inference imposed by the structure of these data using theoretical foundations from phylogenetic data decisiveness. We find that despite very high levels of missing data (over 96%), the present data retain the potential to inform over 86.3% of all possible phylogenetic relationships. Most of these relationships, however, are informed by small amounts of data--approximately half are informed by fewer than four loci, and more than 99% are informed by fewer than fifteen. We also apply an information theoretic measure of branch support to assess the strength of phylogenetic signal in the data, revealing many poorly supported branches concentrated near the tips of the tree, where data are sparse and the limiting effects of this sparseness are stronger. We argue that limits to phylogenetic inference and signal imposed by low data coverage may pose significant challenges for comprehensive phylogenetic inference at the species level. Computational requirements provide additional limits for large reconstructions, but these may be overcome by methodological advances, whereas insufficient data coverage can only be remedied by additional sampling effort. We conclude that public databases have exceptional value for modern systematics and evolutionary biology, and that a continued emphasis on expanding taxonomic and genomic coverage will play a critical role in developing these resources to their full potential.

Population health data are used to profile local conditions, call attention to areas of need, and evaluate health-related programs. Demand for data to inform health care decision making has spurred development of data sources and online systems, but these are often poorly integrated or limited in scope. Our objective was to identify existing data about diabetes mellitus-related conditions in Minnesota, build an online data resource, and identify what data are currently missing that, if available, would better inform assessment of health conditions in the state. A Web site was developed and populated with existing data and data not available elsewhere. It features functionality identified as most important by users, such as maps and county profiles. The site could serve as a flexible tool for stakeholder engagement, but issues were identified during development, including concerns about interpreting map data and open questions about sustainability, that need to be addressed.

Patient satisfaction with care is an important indicator of quality of care. As of 2013-2014, 30% of the Value-Based Purchasing score Medicare is using to determine hospital reimbursement is based on patient reports of care. This study determined whether significant relationships exists between Magnet (N = 160), Magnet-in-progress (N = 99), and non-Magnet hospital (N = 1,742) status and the highest ratings on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey questions related to patient satisfaction with care. This study was a secondary analysis of data collected and compiled from three sources (the American Hospital Association, American Nurses Credentialing Center, and HCAHPS databases). Analysis revealed that Magnet and Magnet-in-progress hospitals have significantly (p < .007) higher scores than non-Magnet hospitals on six of the seven questions regarding patient-reported satisfaction with care. The implications of these results for nursing are discussed., (© The Author(s) 2014 Reprints and permissions:]br]sagepub.co.uk/journalsPermissions.nav.)

Purpose: Treatment-related stomach cancer is an important cause of morbidity and mortality among the growing number of Hodgkin lymphoma (HL) survivors, but risks associated with specific HL treatments are unclear., Patients and Methods: We conducted an international case-control study of stomach cancer nested in a cohort of 19,882 HL survivors diagnosed from 1953 to 2003, including 89 cases and 190 matched controls. For each patient, we quantified cumulative doses of specific alkylating agents (AAs) and reconstructed radiation dose to the stomach tumor location., Results: Stomach cancer risk increased with increasing radiation dose to the stomach (Ptrend < .001) and with increasing number of AA-containing chemotherapy cycles (Ptrend = .02). Patients who received both radiation to the stomach ≥ 25 Gy and high-dose procarbazine (≥ 5,600 mg/m(2)) had strikingly elevated stomach cancer risk (25 cases, two controls; odds ratio [OR], 77.5; 95% CI, 14.7 to 1452) compared with those who received radiation < 25 Gy and procarbazine < 5,600 mg/m(2) (Pinteraction < .001). Risk was also elevated (OR, 2.8; 95% CI, 1.3 to 6.4) among patients who received radiation to the stomach ≥ 25 Gy but procarbazine < 5,600 mg/m(2); however, no procarbazine-related risk was evident with radiation < 25 Gy. Treatment with dacarbazine also increased stomach cancer risk (12 cases, nine controls; OR, 8.8; 95% CI, 2.1 to 46.6), after adjustment for radiation and procarbazine doses., Conclusion: Patients with HL who received subdiaphragmatic radiotherapy had dose-dependent increased risk of stomach cancer, with marked risks for patients who also received chemotherapy containing high-dose procarbazine. For current patients, risks and benefits of exposure to both procarbazine and subdiaphragmatic radiotherapy should be weighed carefully. For patients treated previously, GI symptoms should be evaluated promptly.

Purpose: To fully characterize the risk of contralateral breast cancer (CBC) in patients with breast cancer with a family history who test negative for BRCA1 and BRCA2 mutations., Patients and Methods: From our population-based case-control study comparing women with CBC to women with unilateral breast cancer (UBC), we selected women who tested negative for BRCA1 and BRCA2 mutations (594 patients with CBC/1,119 control patients with UBC). Rate ratios (RRs) and 95% CIs were estimated to examine the association between family history of breast cancer and risk of asynchronous CBC. Age- and family history-specific 10-year cumulative absolute risks of CBC were estimated., Results: Family history of breast cancer was associated with increased CBC risk; risk was highest among young women (< 45 years) with first-degree relatives affected at young ages (< 45 years; RR, 2.5; 95% CI, 1.1 to 5.3) or women with first-degree relatives with bilateral disease (RR, 3.6; 95% CI, 2.0 to 6.4). Women diagnosed with UBC before age 55 years with a first-degree family history of CBC had a 10-year risk of CBC of 15.6%., Conclusion: Young women with breast cancer who have a family history of breast cancer and who test negative for deleterious mutations in BRCA1 and BRCA2 are at significantly greater risk of CBC than other breast cancer survivors. This risk varies with diagnosis age, family history of CBC, and degree of relationship to an affected relative. Women with a first-degree family history of bilateral disease have risks of CBC similar to mutation carriers. This has important implications for the clinical management of patients with breast cancer with family history of the disease.

Background: Basal cell carcinoma (BCC) is the most common malignancy in the United States. Ionizing radiation is an established risk factor in certain populations, including cancer survivors. We quantified the association between ionizing radiation dose and the risk of BCC in childhood cancer survivors., Methods: Participants in the Childhood Cancer Survivor Study who reported a BCC (case subjects, n = 199) were matched on age and length of follow-up to three study participants who had not developed a BCC (control subjects, n = 597). The radiation-absorbed dose (in Gy) to the BCC location was calculated based on individual radiotherapy records using a custom-designed dosimetry program. Conditional logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) for associations between demographic and treatment factors, therapeutic radiation dose, and surrogate markers of sun sensitivity (skin and hair color) and the risk of BCC. A linear dose-response model was fitted to evaluate the excess odds ratio per Gy of radiation dose., Results: Among case subjects, 83% developed BCC between the ages of 20 and 39 years. Radiation therapy, either alone or in combination with chemotherapy, was associated with an increased risk of BCC compared with no chemotherapy or radiation. The odds ratio for subjects who received 35 Gy or more to the skin site vs no radiation therapy was 39.8 (95% CI = 8.6 to 185). Results were consistent with a linear dose-response relationship, with an excess odds ratio per Gy of 1.09 (95% CI = 0.49 to 2.64). No other treatment variables were statistically significantly associated with an increased risk of BCC., Conclusions: Radiation doses to the skin of more than 1 Gy are associated with an increased risk of BCC.

Background: Childhood cancer survivors develop gastrointestinal cancer more frequently and at a younger age than the general population, but the risk factors have not been well-characterized., Objective: To determine the risk and associated risk factors for gastrointestinal subsequent malignant neoplasms (SMNs) in childhood cancer survivors., Design: Retrospective cohort study., Setting: The Childhood Cancer Survivor Study, a multicenter study of childhood cancer survivors diagnosed between 1970 and 1986., Patients: 14 358 survivors of cancer diagnosed when they were younger than 21 years of age who survived for 5 or more years after the initial diagnosis., Measurements: Standardized incidence ratios (SIRs) for gastrointestinal SMNs were calculated by using age-specific population data. Multivariate Cox regression models identified associations between risk factors and gastrointestinal SMN development., Results: At median follow-up of 22.8 years (range, 5.5 to 30.2 years), 45 cases of gastrointestinal cancer were identified. The risk for gastrointestinal SMNs was 4.6-fold higher in childhood cancer survivors than in the general population (95% CI, 3.4 to 6.1). The SIR for colorectal cancer was 4.2 (CI, 2.8 to 6.3). The highest risk for gastrointestinal SMNs was associated with abdominal radiation (SIR, 11.2 [CI, 7.6 to 16.4]). However, survivors not exposed to radiation had a significantly increased risk (SIR, 2.4 [CI, 1.4 to 3.9]). In addition to abdominal radiation, high-dose procarbazine (relative risk, 3.2 [CI, 1.1 to 9.4]) and platinum drugs (relative risk, 7.6 [CI, 2.3 to 25.5]) independently increased the risk for gastrointestinal SMNs., Limitation: This cohort has not yet attained an age at which risk for gastrointestinal cancer is greatest., Conclusion: Childhood cancer survivors, particularly those exposed to abdominal radiation, are at increased risk for gastrointestinal SMNs. These findings suggest that surveillance of at-risk childhood cancer survivors should begin at a younger age than that recommended for the general population., Primary Funding Source: National Cancer Institute.

Objectives: We examined how National Cancer Institute-funded Community Network Programs (CNPs) operationalized principles of community-based participatory research (CBPR)., Methods: We reviewed the literature and extant CBPR measurement tools. On the basis of that review, we developed a 27-item questionnaire for CNPs to self-assess their operationalization of 9 CBPR principles. Our team comprised representatives of 9 of the National Cancer Institute's 25 CNPs., Results: Of the 25 CNPs, 22 (88%) completed the questionnaire. Most scored well on CBPR principles of recognizing community as a unit of identity, building on community strengths, facilitating colearning, embracing iterative processes in developing community capacity, and achieving a balance between data generation and intervention. CNPs varied in the extent to which they employed CBPR principles of addressing determinants of health, sharing power among partners, engaging the community in research dissemination, and striving for sustainability., Conclusions: Although the development of assessment tools in this field is in its infancy, our findings suggest that fidelity to CBPR processes can be assessed in a variety of settings.

Background: Although ionizing radiation is an established environmental risk factor for thyroid cancer, the effect of chemotherapy drugs on thyroid cancer risk remains unclear. We evaluated the chemotherapy-related risk of thyroid cancer in childhood cancer survivors and the possible joint effects of chemotherapy and radiotherapy., Methods: The study included 12,547 five-year survivors of childhood cancer diagnosed during 1970 through 1986. Chemotherapy and radiotherapy information was obtained from medical records, and radiation dose was estimated to the thyroid gland. Cumulative incidence and relative risks were calculated with life-table methods and Poisson regression. Chemotherapy-related risks were evaluated separately by categories of radiation dose., Results: Histologically confirmed thyroid cancer occurred in 119 patients. Thirty years after the first childhood cancer treatment, the cumulative incidence of thyroid cancer was 1.3% (95% CI, 1.0-1.6) for females and 0.6% (0.4-0.8) for males. Among patients with thyroid radiation doses of 20 Gy or less, treatment with alkylating agents was associated with a significant 2.4-fold increased risk of thyroid cancer (95% CI, 1.3-4.5; P = 0.002). Chemotherapy risks decreased as radiation dose increased, with a significant decrease for patients treated with alkylating agents (P(trend) = 0.03). No chemotherapy-related risk was evident for thyroid radiation doses more than 20 Gy., Conclusions: Treatments with alkylating agents increased thyroid cancer risk, but only in the radiation dose range less than 20 Gy, in which cell sparing likely predominates over cell killing., Impact: Our study adds to the evidence for chemotherapy agent-specific increased risks of thyroid cancer, which to date, were mainly thought to be related to prior radiotherapy.

Public health encompasses a broad array of programs designed to prevent the occurrence of disease and injury within communities. But policy makers have little evidence to draw on when determining the value of investments in these program activities, which currently account for less than 5 percent of US health spending. We examine whether changes in spending by local public health agencies over a thirteen-year period contributed to changes in rates of community mortality from preventable causes of death, including infant mortality and deaths due to cardiovascular disease, diabetes, and cancer. We found that mortality rates fell between 1.1 percent and 6.9 percent for each 10 percent increase in local public health spending. These results suggest that increased public health investments can produce measurable improvements in health, especially in low-resource communities. However, more money by itself is unlikely to generate significant and sustainable health gains; improvements in public health practices are needed as well.

We assessed online sexual health information quality and accuracy and the utility of web site quality indicators. In reviewing 177 sexual health web sites, we found below average quality but few inaccuracies. Web sites with the most technically complex information and/or controversial topics contained the most inaccuracies. We found no association between inaccurate information and web site quality., ((c) 2010 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Context: Policy discussions about improving the U.S. health care system increasingly recognize the need to strengthen its capacities for delivering public health services. A better understanding of how public health delivery systems are organized across the United States is critical to improvement. To facilitate the development of such evidence, this article presents an empirical method of classifying and comparing public health delivery systems based on key elements of their organizational structure., Methods: This analysis uses data collected through a national longitudinal survey of local public health agencies serving communities with at least 100,000 residents. The survey measured the availability of twenty core public health activities in local communities and the types of organizations contributing to each activity. Cluster analysis differentiated local delivery systems based on the scope of activities delivered, the range of organizations contributing, and the distribution of effort within the system., Findings: Public health delivery systems varied widely in organizational structure, but the observed patterns of variation suggested that systems adhere to one of seven distinct configurations. Systems frequently migrated from one configuration to another over time, with an overall trend toward offering a broader scope of services and engaging a wider range of organizations., Conclusions: Public health delivery systems exhibit important structural differences that may influence their operations and outcomes. The typology developed through this analysis can facilitate comparative studies to identify which delivery system configurations perform best in which contexts.

Background: Radiotherapy for breast cancer reduces disease recurrence and breast cancer mortality. However, it has also been associated with increased second cancer risks in exposed sites., Methods: We evaluated long-term second cancer risks among 182 057 5-year survivors of locoregional invasive breast cancer diagnosed between 1973 and 2000 and reported to US NCI-SEER Program cancer registries. Multivariate Poisson regression was used to estimate the relative risk (RR) and excess cases of second cancer in women who had surgery and radiotherapy, compared with those who had surgery alone. Second cancer sites were grouped according to doses received from typical tangential breast fields., Results: By the end of 2005 (median follow-up=13.0 years), 15 498 second solid cancers had occurred, including 6491 contralateral breast cancers. The RRs for radiotherapy were 1.45 (95% confidence interval (CI)=1.33-1.58) for high-dose second cancer sites (1+ Gy: lung, oesophagus, pleura, bone and soft tissue) and 1.09 (1.04-1.15) for contralateral breast cancer ( approximately 1 Gy). These risks decreased with increasing age and year of treatment. There was no evidence of elevated risks for sites receiving medium (0.5-0.99 Gy, RR=0.89 (0.74-1.06)) or low doses (<0.5 Gy, RR=1.01 (0.95-1.07)). The estimated excess cases of cancer in women treated with radiotherapy were as follows: 176 (95% CI=69-284) contralateral breast cancers or 5% (2-8%) of the total in all 1+year survivors, and 292 (222-362) other solid cancers or 6% (4-7%) of the total., Conclusions: Most second solid cancers in breast cancer survivors are not related to radiotherapy.

Objectives: To examine the extent of variation in public health agency spending levels across communities and over time, and to identify institutional and community correlates of this variation., Data Sources and Setting: Three cross-sectional surveys of the nation's 2,900 local public health agencies conducted by the National Association of County and City Health Officials in 1993, 1997, and 2005, linked with contemporaneous information on population demographics, socioeconomic characteristics, and health resources., Study Design: A longitudinal cohort design was used to analyze community-level variation and change in per-capita public health agency spending between 1993 and 2005. Multivariate regression models for panel data were used to estimate associations between spending, institutional characteristics, health resources, and population characteristics., Principal Findings: The top 20 percent of communities had public health agency spending levels >13 times higher than communities in the lowest quintile, and most of this variation persisted after adjusting for differences in demographics and service mix. Local boards of health and decentralized state-local administrative structures were associated with higher spending levels and lower risks of spending reductions. Local public health agency spending was inversely associated with local-area medical spending., Conclusions: The mechanisms that determine funding flows to local agencies may place some communities at a disadvantage in securing resources for public health activities.

Background: Statin Choice is a decision aid about taking statins. The optimal mode of delivering Statin Choice (or any other decision aid) in clinical practice is unknown., Methods: To investigate the effect of mode of delivery on decision aid efficacy, the authors further explored the results of a concealed 2 x 2 factorial clustered randomized trial enrolling 21 endocrinologists and 98 diabetes patients and randomizing them to 1) receive either the decision aid or pamphlet about cholesterol, and 2) have these delivered either during the office visit (by the clinician) or before the visit (by a researcher). We estimated between-group differences and their 95% confidence intervals (CI) for acceptability of information delivery (1-7), knowledge about statins and coronary risk (0-9), and decisional conflict about statin use (0-100) assessed immediately after the visit. Follow-up was 99%., Results: The relative efficacy of the decision aid v. pamphlet interacted with the mode of delivery. Compared with the pamphlet, patients whose clinicians delivered the decision aid during the office visit showed significant improvements in knowledge (difference of 1.6 of 9 questions, CI 0.3, 2.8) and nonsignificant trends toward finding the decision aid more acceptable (odds ratio 3.1, CI 0.9, 11.2) and having less decisional conflict (difference of 7 of 100 points, CI -4, 18) than when a researcher delivered the decision aid just before the office visit., Conclusions: Delivery of decision aids by clinicians during the visit improves knowledge and shows a trend toward better acceptability and less decisional conflict.

The authors review empirical studies published between 1990 and 2007 on the topics of public health organization, financing, staffing, and service delivery. A summary is provided of what is currently known about the attributes of public health delivery systems that influence their performance and outcomes. This review also identifies unanswered questions, highlighting areas where new research is needed. Existing studies suggest that economies of scale and scope exist in the delivery of public health services, and that key organizational and governance characteristics of public health agencies may explain differences in service delivery across communities. Financial resources and staffing characteristics vary widely across public health systems and have expected associations with service delivery and outcomes. Numerous gaps and uncertainties are identified regarding the mechanisms through which organizational, financial, and workforce characteristics influence the effectiveness and efficiency of public health service delivery. This review suggests that new research is needed to evaluate the effects of ongoing changes in delivery system structure, financing, and staffing.

Purpose: To quantify the risk of second primary breast cancer in the contralateral breast (CB) after radiotherapy (RT) for first breast cancer., Methods and Materials: The study population included participants in the Women's Environmental, Cancer, and Radiation Epidemiology study: 708 cases (women with asynchronous bilateral breast cancer) and 1399 controls (women with unilateral breast cancer) counter-matched on radiation treatment. Participants were <55 years of age at first breast cancer. Absorbed doses to quadrants of the CB were estimated. Rate ratios (RR) and 95% confidence intervals (CI) were calculated using multivariable-adjusted conditional logistic regression models., Results: Across all patients, the mean radiation dose to the specific quadrant of the CB tumor was 1.1 Gy. Women <40 years of age who received >1.0 Gy of absorbed dose to the specific quadrant of the CB had a 2.5-fold greater risk for CB cancer than unexposed women (RR = 2.5, 95% CI 1.4-4.5). No excess risk was observed in women >40 years of age. Women <40 years of age with follow-up periods >5 years had a RR of 3.0 (95% CI 1.1-8.1), and the dose response was significant (excess RR per Gy of 1.0, 95% CI 0.1-3.0)., Conclusions: Women <40 years of age who received a radiation dose >1.0 Gy to the CB had an elevated, long-term risk of developing a second primary CB cancer. The risk is inversely related to age at exposure and is dose dependent.

Objective: To assess the effect of a specialist telemedicine intervention for improving diabetes care using the chronic care model (CCM)., Participants and Methods: As part of the CCM, 97 primary care physicians at 6 primary care practices in Rochester, MN, referred 639 patients to an on-site diabetes educator between July 1, 2001, and December 31, 2003. On first referral, physicians were centrally randomized to receive a telemedicine intervention (specialty advice and evidence-based messages regarding medication management for cardiovascular risk) or no intervention, keeping outcome assessors and data analysts blinded to group assignment. After each subsequent clinical encounter, endocrinologists reviewed an abstract from the patient's electronic medical record and provided management recommendations and supporting evidence to intervention physicians via e-mail. Control physicians received e-mail with periodic generic information about cardiovascular risk reduction in diabetes. Outcome measures included diabetes care processes (diabetes test completion), outcomes (metabolic and cardiovascular risk factors, estimated coronary artery disease risk), and patient costs (payer perspective)., Results: During the intervention, 951 (70%) of the 1361 endocrinology reviews detected performance gaps and resulted in a message; primary care physicians reported using 49% of messages in patient care. With a mean of 21 months' follow-up, the intervention, compared with control, did not significantly enhance metabolic outcomes or reduce estimated risk of coronary artery disease (adjusted mean difference, -1%; 95% confidence interval, -19% to 17%). The intervention group incurred lower costs (P=.02) but not in diabetes-related costs., Conclusion: Specialty telemedicine did not significantly enhance the value of CCM in primary care.

Fundamental to dealing with the problems associated with attracting and retaining nurses during a tight labour market are issues centreing upon attrition from the field. In the United States, attrition has become such a significant issue that efforts to attract individuals to the field and recruit them to positions in the health care industry are not adequate to offset the flow of individuals from the field, much less bring in the additional nurses who are needed for an ageing population with increasing health care needs. As an example of the seriousness of the problem, it is probably safe to say that of the students who graduate from nursing schools each year and who enter the field of nursing, a significant number will no longer be practicing after 5 years in the profession. In a high attrition environment, even if many individuals were entering nursing, these losses will potentially offset any gains that are made. From the perspective of this study, it is important to know what is leading nurses to leave their careers. Do all nurses face the same challenges in the course of their careers, or is the pattern of turnover somewhat different for different groups of nurses or those in different stages of their careers? In this study, we consider what career differences may exist between the two major groups of nurses in the USA today -- Black and White nurses -- and ask whether there are differences between the two groups in terms of 'whether' and 'why' they may be leaving the field. Our primary purpose was to determine if differences in attrition exist between Black and White nurses, and if so, where in the career process are those differences most pronounced. Based on our analysis of data from the National Science Foundation, we do find significant differences in patterns of attrition for the two groups and we suggest what we believe may be their implications for policy.

Radiation exposure at a young age is a strong risk factor for thyroid cancer. We conducted a nested case-control study of 69 thyroid cancer cases and 265 controls from a cohort of 14,054 childhood cancer survivors to evaluate the shape of the radiation dose-response relationship, in particular at high doses, and to assess modification of the radiation effects by patient and treatment characteristics. We considered several types of statistical models to estimate the excess relative risk (ERR), mainly guided by radiobiological models. A two-parameter model with a term linear in dose and a negative exponential in dose squared provided the best parsimonious description with an ERR of 1.3 per gray (95% confidence interval 0.4-4.1) at doses below 6 Gy and a relative decrease in ERR of 0.2% per unit dose squared with increasing dose, that is, decreases in the ERR/Gy of 53% at 20 Gy and 95% at 40 Gy. Further analyses using spline models suggested that the significant nonlinearity at high doses was characterized most appropriately as a true downturn rather than a flattening of the dose-response curve. We found no statistically significant modification of the dose-response relationship by patient characteristics; however, the linear parameter (i.e., the ERR/ Gy at doses less than 6 Gy) did decrease consistently and linearly with increasing age at childhood cancer diagnosis, from 4.45 for 0-1-year-olds to 0.48 for 15-20-year-olds. In summary, we applied models derived from radiobiology to describe the radiation dose-response curve for thyroid cancer in an epidemiological study and found convincing evidence for a downturn in risk at high doses.

Background: Although strong scientific evidence has shown that screening for colorectal cancer saves lives, most U.S. adults who are at the recommended age are not being screened. Prior studies suggest that barriers to routine screening vary by race, ethnicity, socioeconomic status, urban/rural residence, health insurance status, and factors related to health care providers and the health care environment. Relatively few studies, however, have identified and tested intervention approaches to promote routine colorectal cancer screening among diverse populations., Methods: The Division of Cancer Prevention and Control at CDC has funded ongoing projects to develop and test interventions to promote routine colorectal cancer screening among medically underserved populations in Appalachia, the Lower Rio Grande Valley in Texas, the High Plains region of Colorado, and other U.S. communities., Results: This article provides an overview of colorectal cancer screening intervention studies currently funded by CDC that focus on a wide range of populations, including medically underserved persons who live in predominately rural areas, Hispanic and non-Hispanic persons, urban African Americans, persons with low health literacy, and persons enrolled in managed care organizations., Conclusions: These CDC-funded intervention research projects are likely to contribute importantly to evidence about what works to promote colorectal cancer screening in diverse U.S. communities. .

Objective: This study assessed the implementation of state Preadmission Screening and Resident Review (PASRR) programs with respect to identification of serious mental illness among nursing facility applicants and residents and access to mental health services., Methods: A national survey was conducted with representatives from agencies that implement PASRR in all 50 states and the District of Columbia. Also, 44 states sent PASRR data for review. Four states were selected for an in-depth study; six nursing homes per state were selected and one staff member from each facility was interviewed (N=24). Medical records were reviewed for 30 to 40 residents from each facility who met criteria for potentially having a disabling serious mental illness (N=786)., Results: Medical records showed that 50 percent of patients at the time of admission and 68 percent of patients at the time of the record review had a psychiatric diagnosis, typically a diagnosis of depressive disorder. At the time of admission, fewer records identified individuals with a serious mental illness (9 to 20 percent) or a primary diagnosis of any psychiatric illness (5 to 12 percent). Many records indicated that in-depth, required PASRR screens were not performed. Ninety percent of the states reported that Medicaid covers only basic psychiatric consultation services, such as medication monitoring, in nursing facilities. Between 30 and 32 percent of national survey respondents also characterized access to facilities that provide mental health services as limited and of variable quality. Although all 24 nursing facilities reported providing psychiatric consultation services, access to other mental health services, such as psychosocial rehabilitation or individual counseling, varied considerably., Conclusions: Nursing facility compliance with administration and documentation of PASRR screens appears problematic. Nevertheless, there do not appear to be excessively high numbers of residents with serious mental illness, suggesting that state PASRR programs may contribute positively to the identification of people with serious mental illness. However, many nursing facility residents have some type of psychiatric illness, and PASRR legislation does not appear to have enhanced their ability to gain access to mental health services beyond standard psychiatric consultation and medication therapy.

Problems with attracting and retaining nurses during a tight labor market are compounded by some fundamental issues related to attrition from the field. It is important to recognize that, of the students who graduate from nursing schools each year and enter the field of nursing, significant attrition occurs during the first 5 years in the profession [www.aacn.nche.edu/media/backgrounders/shortagefacts.htmaacn.nche.edu (2002)]. This article uses data from the National Science Foundation's National Survey of College Graduates to examine various scenarios and possible reasons for why some nurses abandon their careers [www.nsf.gov/sbe/srs/snscg/start.htm (2003)]. In doing so, we consider entry into, and attrition from, the nursing profession at various stages. Using data from the National Survey of College Graduates, the initial evaluation suggests that, at points during the career, the individual confronts potential problems and issues which can lead to career attrition.

This article explores the associations among sexual need fulfillment, partner selection, and risky sexual behavior, using a functional/motivational perspective. The authors suggest that sexual needs influence partner selection (e.g., steady versus nonsteady), and engaging in UAI is influenced by sexual needs and partner selection. A sample of 108 HIV-positive gay men completed measures of sexual frequency, sexual risk-taking behaviors, and sexual need fulfillment. Results indicated support for both objectives. These men were more likely to choose a steady partner when they possessed greater relationship needs, whereas while men with higher substitution and pleasure needs were more likely to select nonsteady partners. In addition, only men who reported greater substitution needs were more likely to engage in UAI. The results suggest that certain sexual needs influence partner selection, but that sexual needs also influence what activities occur in the encounter.

If effective preventive behavioral health services were available to the millions of Americans enrolled in managed care organizations, the public health impact could be significant. This project sought to summarize published research-based information about effective preventive interventions for mental health and substance use (tobacco, alcohol, and other drugs) shown or likely to have no negative cost impact. Fifty-four studies satisfied seven screening criteria. Their findings demonstrated that preventive behavioral health interventions appropriate for managed care settings have been evaluated and have been shown to be effective. Some produced cost savings or offset costs. Six preventive behavioral health interventions are therefore recommended for managed care.

Objective: To define the optimal approach to identify patients with thyroid dysfunction., Participants: The 8-member Standards of Care Committee of the American Thyroid Association prepared a draft, which was reviewed by the association's 780 members, 50 of whom responded with suggested revisions., Evidence: Relevant published studies were identified through MEDLINE and the association membership's personal resources., Consensus Process: Consensus was reached at group meetings. The first draft was prepared by a single author (P.W.L.) after group discussion. Suggested revisions were incorporated after consideration by the committee., Conclusions: The American Thyroid Association recommends that adults be screened for thyroid dysfunction by measurement of the serum thyrotropin concentration, beginning at age 35 years and every 5 years thereafter. The indication for screening is particularly compelling in women, but it can also be justified in men as a relatively cost-effective measure in the context of the periodic health examination. Individuals with symptoms and signs potentially attributable to thyroid dysfunction and those with risk factors for its development may require more frequent serum thyrotropin testing.

The emergence of drug-resistant organisms has promoted increased calls for judicious use of antibiotics in cases of pediatric pharyngitis. Although these recommendations are largely justified, the case of a 16-year-old girl with pharyngitis is reported to alert readers to an unusual complication, Lemierre's syndrome. This complication of pharyngitis and its relevance to changing practice habits are discussed.

Objective: To investigate the potential role of a store-and-forward (SAF) telemedicine system in specialty consultations initiated by primary care physicians., Materials and Methods: In this pilot telemedicine study, patients needing consultations in cardiology, dermatology, endocrinology, and orthopedics had both standard face-to-face (FTF) consultations and SAF consultations., Results: Fifteen patients had both FTF and SAF consultations, 4 had echocardiograms transmitted for an SAF consultation only, and 1 had an SAF consultation but no FTF appointment. Of 19 diagnoses made, all were essentially the same in both types of consultations; 14 of 15 FTF consultations and 15 of 19 SAF consultations resulted in additional treatment recommendations., Conclusions: While it was possible to develop a desktop system for SAF consultations, the equipment was not adequately integrated. Without total digital input, including electronic patient medical records, packaging of information is laborious and impractical. Seamlessly adapting to existing clinical practice is vital. Issues such as increasing work for the physicians or office staff, gathering adequate patient information, and designing a referral process were more difficult than we had anticipated. Patient acceptance was high, but the clinical pilot had very small numbers.

DCI Laboratory, Nashville TN compared INCSTAR N-tact PTH SP Kit (INCSTAR Corp., Stillwater, MN, USA) results from renal dialysis patients analyzed on frozen versus unfrozen samples; unfrozen samples were analyzed at 24, 48, and 72 hours post-collection. There was no statistical or clinical difference in the results of the frozen samples and unfrozen samples analyzed at 24 hours. Clinics may now ship unfrozen samples if they arrive within 24 hours.

The nature and number of indicator and pathogenic microbes in fish reared using recirculating and nonrecirculating water systems were compared. For each system, 20 samples of rainbow trout (Oncorhynchus mykiss), tilapia (Oreochromis spp.), hybrid striped bass (Morone saxatilis x M. chrysops), and pacu (Piaractus mesopotamicus) were randomly selected and gutted, and microbial analyses were performed using AOAC procedures. Five fish were subsampled and analyzed for indicative microbial quality with 3M Petrifilm (). The general microbial quality differed significantly (P < 0.05) among the production systems, except for total coliform counts. Rainbow trout cultured in recirculating and nonrecirculating water systems had lower counts for aerobes (2.00 to 3.11 log CFU/g) (p < 0.05), than other species, whereas trout reared in a recirculating water system had significantly lower psychrotrophic numbers (0.86 to 1.85 log CFU/g). Pacu had the highest fecal coliform counts (2.74 to 3.70 log CFU/g), whereas hybrid striped bass and rainbow trout grown in nonrecirculating systems had lower fecal coliform counts (0.00 to 1.39 log CFU/g). Rainbow trout grown in a nonrecirculating system had significantly higher Escherichia coli counts (0.00 to 2.11 log CFU/g). The human bacterial pathogens Listeria monocytogenes, Yersinia enterocolitica, Escherichia coli O157:H7 and Salmonella spp. were not isolated form the fish sampled. However, Clostridium botulinum botulinum was isolated from all the aquacultured fish sampled except pacu and tilapia grown in a recirculating aquaculture system. However, the counts were very low, ranging from 0.0 to 2.3 MPN/g.