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The American College of Surgeons National Surgery Quality Improvement Program (ACS NSQIP) has improved operative outcomes in the USA. However, its applicability to oncologic resections at ACS NSQIP hospitals has not been fully explored. We assessed the ability of factors currently collected by ACS NSQIP to predict adverse operative events after major cancer surgery. Using pre- and intraoperative factors gathered by the 2005–2008 ACS NSQIP, we constructed logistic regression models to determine their ability to predict 30-day mortality, prolonged length of stay (LOS), major complications or increased number of complications in 15,709 patients who underwent major cancer surgery at 211 hospitals. We assessed each model’s predictive ability using the c-index. While the mortality rate was relatively low (2.5%), nearly 24% of patients experienced major adverse events. However, up to 43% of patients with prolonged LOS did not have any major complication captured by NSQIP. Furthermore, our model predicting complications showed poor overall predictive ability compared with those predicting mortality and LOS (c-index

Scholars indicate significant interest in business models that support entrepreneurial behavior in developing markets [Wankel C., editor. Alleviating Poverty through Business Strategy. New York: Palgrave Macmillan 2008]—particularly as they relate to job creation. This research introduces microfranchising as a business model adaptation that helps low-income individuals overcome non credit-related barriers to entry in obtaining employment. This study reveals a clear challenge for researchers—to better understand microfranchising and the extent to which the practice creates employment and enables individual business success. Largely unanswered questions concern the profiles of typical microfranchisees as well as the impacts of microfranchising on low-income individuals in subsistence marketplaces. This preliminary research focuses on one type of microfranchise operating in Accra, Ghana. Using data from microfranchises enables the exploration of whether workers in subsistence markets benefit from the microfranchise model. In comparing a microfranchise business with comparably-sized non-franchised businesses, this analysis finds preliminary evidence that the microfranchise creates starter jobs. Baseline results highlight microfranchisee characteristics and indicate that this form of microfranchising positively impacts savings and profits.

Although surgical studies have reported inconsistent associations between increased body mass index (BMI) and operative outcomes, the accuracy of BMI for measuring obesity has been questioned in previous epidemiologic studies. Simultaneously, BMI has known comorbidities, which may mediate the effect of BMI if included in multivariable models. We sought to examine the effect of BMI on operative outcomes after adjusting for preoperative factors.We identified 8858 patients who underwent major thoracic, abdominal, and pelvic surgery for solid organ tumors in American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) centers from 2005 to 2007. We used multivariable analyses to assess the effect of BMI on short-term operative outcomes after controlling for covariates.Increased BMI was not associated with worse short-term operative outcomes in our bivariable analyses. However, patients with BMIor = 35 had higher American Society of Anesthesiologists scores, longer operative times, and an increased number of postoperative complications (P0.0001). After adjusting for pre- and intraoperative factors, BMI did not predict any short-term operative outcome except for an increased total number of complications in BMIor = 35. These results persisted after removing potential mediators from the multivariable analysis.In ACS NSQIP, BMI has minimal association with short-term operative outcomes after major cancer surgery. Although these findings may suggest a lack of association between obesity and cancer surgery outcomes, it confirms the previously examined limitations of BMI. Because of the rising incidence of obesity in the United States and its challenging effect on surgeon's practice, ACS NSQIP should consider exploring alternative measures of general and abdominal obesity.

To examine the association between older age and short-term outcomes after major oncologic resections.The effect of older age on outcomes from major cancer surgery remains conflicting because of limitations in measuring coexisting comorbidities. Given the critical role of surgery, older patients and their surgeons often question decisions regarding major cancer surgery.We identified 8781 patients who underwent elective or emergent major thoracic, abdominal, or pelvic resections for neoplasms in the 2005 to 2007 American College of Surgeons National Surgical Quality Improvement Program database. Pre, intra-, and postoperative characteristics were compared by age groups. Multivariable techniques were used to predict adjusted short-term operative outcomes.Older patients were more likely to have preoperative comorbidities and to receive intraoperative blood transfusions, but at the same time have shorter operative times. Increased age was also associated with higher operative mortality (4.83% foror=75 years vs. 1.09% for ages 40-55 years), a greater frequency of major complications, and more prolonged hospital stays-all of which persisted after multivariable adjustments. Despite its strong association with 30-day operative mortality, the impact of older age was comparable to other preoperative risk-factors predictive of short-term operative outcomes.The present study, which is one of the largest multihospital studies, showed that older age is independently associated with worse short-term outcomes after major oncologic resections. However, the effect of age was not prohibitively worse, and is comparable to the effects of other preoperative risk factors. These findings support the use of risk-based treatment decision-making in older patients.

Background. There has been major concern about the ‘over-representation’of Black and ethnic minority groups amongst people detained under the Mental Health Act (MHA). We explored the effect of patient ethnicity on detention following an MHA assessment, once confounding variables were controlled for. Method. Prospective data were collected for all MHA assessments over 4-month periods in the years 2008, 2009, 2010 and 2011 each in three regions in England: Birmingham, West London and Oxfordshire. Logistic regression modelling was conducted to predict the outcome of MHA assessments–either resulting in ‘detention’ or ‘no detention’. Results. Of the 4423 MHA assessments, 2841 (66%) resulted in a detention. A diagnosis of psychosis, the presence of risk, female gender, level of social support and London as the site of assessment predicted detention under the MHA. Ethnicity was not an independent predictor of detention. Conclusions. There is no evidence for that amongst those assessed under the MHA, ethnicity has an independent effect on the odds of being detained.

To test the feasibility and assess the preliminary impact of a unique statewide quality improvement (QI) training program designed for public health departments.One hundred and ninety-five public health employees/managers from 38 local health departments throughout Minnesota were selected to participate in a newly developed QI training program and 65 of those engaged in and completed eight expert-supported QI projects over a period of 10 months from June 2007 through March 2008.As part of the Minnesota Quality Improvement Initiative, a structured distance education QI training program was designed and deployed in a first large-scale pilot. To evaluate the preliminary impact of the program, a mixed-method evaluation design was used based on four dimensions: learner reaction, knowledge, intention to apply, and preliminary outcomes.Subjective ratings of three dimensions of training quality were collected from participants after each of the scheduled learning sessions. Pre- and post-QI project surveys were administered to collect participant reactions, knowledge, future intention to apply learning, and perceived outcomes. Monthly and final QI project reports were collected to further inform success and preliminary outcomes of the projects.The participants reported (1) high levels of satisfaction with the training sessions, (2) increased perception of the relevance of the QI techniques, (3) increased perceived knowledge of all specific QI methods and techniques, (4) increased confidence in applying QI techniques on future projects, (5) increased intention to apply techniques on future QI projects, and (6) high perceived success of, and satisfaction with, the projects. Finally, preliminary outcomes data show moderate to large improvements in quality and/or efficiency for six out of eight projects.QI methods and techniques can be successfully implemented in local public health agencies on a statewide basis using the collaborative model through distance training and expert facilitation. This unique training can improve both core and support processes and lead to favorable staff reactions, increased knowledge, and improved health outcomes. The program can be further improved and deployed and holds great promise to facilitate the successful dissemination of proven QI methods throughout local public health departments.

NMR spectroscopy remains one of the primary analytical approaches in metabolomics. Although 1D (1)H NMR spectroscopy is versatile, highly reproducible and currently the most widely used technique in NMR metabolomics, analysis of complex biological samples typically yields highly congested spectra with severely overlapping signals making unambiguous metabolite identification and quantification almost impossible. Consequently there is a growing use of 2D NMR methods, in particular (1)H J-resolved (JRES) spectroscopy, which spreads the high signal density into a second dimension. One potentially powerful method to deconvolute these JRES spectra, facilitating metabolite quantification, is via line-shape fitting. However, the mathematical functions describing the JRES NMR line-shape, in particular after applying apodisation functions and JRES specific processing, including tilting and symmetrisation, remain uncharacterised. Furthermore, possible quantitation errors arising from processing JRES spectra have not been evaluated, nor have the potentially adverse quantitative effects of overlapping dispersive tails of closely spaced signals in the 2D spectrum. Here we address these issues and evaluate the suitability of the JRES experiment for accurate complex mixture analysis. Specifically, we have examined changes in NMR line-shape and signal intensity after application of different apodisation functions (SINE and SEM) and JRES specific processing (tilting and symmetrising), comparing simulated and experimental data. We also report a significant quantitation error of up to 33%, dependent upon apodisation, due to overlap of the dispersive tails of closely spaced resonances. Finally, we have validated the use of these mathematical line-shape functions for metabolite quantitation of 2D JRES spectra, by comparison to corresponding 1D NMR datasets, using both gravimetrically-prepared chemically defined mixtures as well as biological tissue extracts.

Two dimensional (2D) homonuclear (1)H J-resolved (JRES) nuclear magnetic resonance spectroscopy is increasingly used in metabolomics. This approach visualises metabolite chemical shifts and scalar couplings along different spectral dimensions, thereby increasing peak dispersion and facilitating spectral assignments and accurate quantification. Here, we optimise the processing of 2D JRES spectra by evaluating different window functions, a traditional sine-bell (SINE) and a combined sine-bell-exponential (SEM) function. Furthermore, we evaluate different projection methods for generating 1D projected spectra (pJRES). Spectra were recorded from three disparate types of biological samples and evaluated in terms of sensitivity, reproducibility and resolution. Overall, the SEM window function yielded considerably higher sensitivity and comparable spectral reproducibility and resolution compared to SINE, for both 1D pJRES and 2D JRES datasets. Furthermore, for pJRES spectra, the highest spectral quality was obtained using SEM combined with skyline projection. These improvements lend further support to utilising 2D J-resolved spectroscopy in metabolomics.

Summary Objective Cam hip shape morphology is a recognised cause of femoroacetabular impingement (FAI) and is associated with hip osteoarthritis. Our aim was to systematically review the available epidemiological evidence assessing the prevalence of cam hip shape morphology in the general population and any studied subgroups including subjects with and without hip pain. Design All studies that reported the prevalence of cam morphology, measured by alpha angles, in subjects aged 18 and over, irrespective of study population or presence of hip symptoms were considered for inclusion. We searched AMED, MEDLINE, EMBASE, CINAHL and CENTRAL in October 2015. Two authors independently identified eligible studies and assessed risk of bias. We planned to pool data of studies considered clinically homogenous. Results Thirty studies met inclusion criteria. None of the included studies were truly population-based: three included non-representative subgroups of the general population, 19 included differing clinical populations, while eight included professional athletes. All studies were judged to be at high risk of bias. Due to substantial clinical heterogeneity meta analysis was not possible. Across all studies, the prevalence estimates of cam morphology ranged from 5 to 75% of participants affected. We were unable to demonstrate a higher prevalence in selected subgroups such as athletes or those with hip pain. Conclusions There is currently insufficient high quality data to determine the true prevalence of cam morphology in the general population or selected subgroups. Well-designed population-based epidemiological studies that use homogenous case definitions are required to determine the prevalence of cam morphology and its relationship to hip pain.

Background: Previous studies documented racial/ethnic and socioeconomic disparities in survival after Hodgkin lymphoma among adolescents and young adults (AYA), but did not consider the influence of combined-modality treatment and health insurance. Methods: Data for 9,353 AYA patients ages 15 to 39 years when diagnosed with Hodgkin lymphoma during 1988 to 2011 were obtained from the California Cancer Registry. Using multivariate Cox proportional hazards regression, we examined the impact of sociodemographic characteristics [race/ethnicity, neighborhood socioeconomic status (SES), and health insurance], initial combined-modality treatment, and subsequent cancers on survival. Results: Over the 24-year study period, we observed improvements in Hodgkin lymphoma–specific survival by diagnostic period and differences in survival by race/ethnicity, neighborhood SES, and health insurance for a subset of more recently diagnosed patients (2001–2011). In multivariable analyses, Hodgkin lymphoma–specific survival was worse for Blacks than Whites with early-stage [HR: 1.68; 95% confidence interval (CI): 1.14–2.49] and late-stage disease (HR: 1.68; 95% CI, 1.17–2.41) and for Hispanics than Whites with late-stage disease (HR: 1.58; 95% CI, 1.22–2.04). AYAs diagnosed with early-stage disease experienced worse survival if they also resided in lower SES neighborhoods (HR: 2.06; 95% CI, 1.59–2.68). Furthermore, more recently diagnosed AYAs with public health insurance or who were uninsured experienced worse Hodgkin lymphoma–specific survival (HR: 2.08; 95% CI, 1.52–2.84). Conclusion: Our findings identify several subgroups of Hodgkin lymphoma patients at higher risk for Hodgkin lymphoma mortality. Impact: Identifying and reducing barriers to recommended treatment and surveillance in these AYAs at much higher risk of mortality is essential to ameliorating these survival disparities. Cancer Epidemiol Biomarkers Prev; 25(2); 264–73. ©2016 AACR.

BackgroundIndividual variables and area-level variables have been identified as explaining much of the variance in rates of compulsory in-patient treatment.AimsTo describe rates of voluntary and compulsory psychiatric in-patient treatment in rural and urban settings in England, and to explore the associations with age, ethnicity and deprivation.MethodSecondary analysis of 2010/11 data from the Mental Health Minimum Dataset.ResultsAreas with higher levels of deprivation had increased rates of in-patient treatment. Areas with high proportions of adults aged 20–39 years had the highest rates of compulsory in-patient treatment as well as the lowest rates of voluntary in-patient treatment. Urban settings had higher rates of compulsory in-patient treatment and ethnic density was associated with compulsory treatment in these areas. After adjusting for age, deprivation and urban/rural setting, the association between ethnicity and compulsory treatment was not statistically significant.ConclusionsAge structure of the adult population and ethnic density along with higher levels of deprivation can account for the markedly higher rates of compulsory in-patient treatment in urban areas.

Supplemental security income (SSI) and social security disability insurance (DI) are federal programs that provide disability benefits. We report on SSI/DI enrollment in a random sample of adult, long-term survivors of childhood cancer (n = 698) vs a comparison group without cancer (n = 210) from the Childhood Cancer Survivor Study who completed a health insurance survey. A total of 13.5% and 10.0% of survivors had ever been enrolled on SSI or DI, respectively, compared with 2.6% and 5.4% of the comparison group. Cranial radiation doses of 25 Gy or more were associated with a higher risk of current SSI (relative risk [RR] = 3.93, 95% confidence interval [CI] = 2.05 to 7.56) and DI (RR = 3.65, 95% CI = 1.65 to 8.06) enrollment. Survivors with severe/life-threatening conditions were more often enrolled on SSI (RR = 3.77, 95% CI = 2.04 to 6.96) and DI (RR = 2.73, 95% CI = 1.45 to 5.14) compared with those with mild/moderate or no health conditions. Further research is needed on disability-related financial challenges after childhood cancer.

Background This research explores the healthy soldier effect (HSE) – a lower mortality risk among veterans relative to the general population—in United States (US) veterans deployed in support of operations in Iraq and Afghanistan (OEF/OIF/OND). While a HSE has been affirmed in other OEF/OIF/OND populations, US veterans of OEF/OIF/OND have not been systematically studied. Methods Using US Department of Veterans Affairs (VA) administrative data, we identified veterans who (1) had been deployed in support of OEF/OIF/OND between 2002 and 2011 and (2) were enrolled in the VA health care system. We divided the VA population into VA health care utilizers and non-utilizers. We obtained Department of Defense (DOD) administrative data on the OEF/OIF/OND population and obtained VA and DOD mortality data excluding combat deaths from the analyses. Indirect standardization was used to compare VA and DOD cohorts to the US population using total population at risk to compute the Standardized Mortality Ratio (SMR). A directly standardized relative risk (DSRR) was calculated to enable comparisons between cohorts. To compare VA enrollee mortality on military specific characteristics, we used a DOD population standard. Results The overall VA SMR of 2.8 (95% Confidence Interval [CI] 2.8-2.9), VA utilizer SMR of 3.2 (95% CI 3.1-3.3), VA non-utilizer SMR of 0.9 (95% CI 0.8-1.1), and DOD SMR of 1.5 (95% CI 1.4-1.5) provide no evidence of a HSE in any cohort relative to the US standard population. Relative to DOD, both the total VA population SMR of 2.1 (95% CI 2.0-2.2) and the SMR for VA utilizers of 2.3 (95% CI 2.3-2.4) indicate mortality twice what would be expected given DOD mortality rates. In contrast, the VA enrollees who had not used clinical services had 40% lower than expected mortality relative to DOD. Conclusions No support was found for the HSE among US veterans of OEF/OIF/OND. These findings may be attributable to a number of factors including post-deployment risk-taking behavior, an abbreviated follow up period, and the nature of the OEF/OIF/OND conflict.

Background:\ud Studies demonstrate ethnic variations in pathways to care during first episode psychosis (FEP). There are no extant studies, however, that have statistically examined the influence of culturally mediated illness attributions on these variations.\ud \ud Methods:\ud We conducted an observational study of 123 (45 White; 35 Black; 43 Asian) patients recruited over a two-year period from an Early Intervention Service (EIS) in Birmingham, UK. Sociodemographic factors (age; sex; education; country of birth; religious practice; marital status; living alone), duration of untreated psychosis (DUP), service contacts (general practitioner; emergency services; faith-based; compulsory detention; criminal justice) and illness attributions (“individual;” “natural;” “social;” “supernatural;” “no attribution”) were assessed.\ud \ud Results:\ud Ethnic groups did not differ in DUP (p = 0.86). Asian patients were more likely to report supernatural illness attributions in comparison to White (Odds Ratio: 4.02; 95 % Confidence Intervals: 1.52, 10.62) and Black (OR: 3.48; 95 % CI: 1.25, 9.67) patients. In logistic regressions controlling for confounders and illness attributions, Black (OR: 14.00; 95 % CI: 1.30, 151.11) and Asian (OR: 13.29; 95 % CI: 1.26, 140.47) patients were more likely to consult faith-based institutions than White patients. Black patients were more likely to be compulsorily detained than White patients (OR: 4.56; 95 % CI: 1.40, 14.85).\ud \ud Conclusion:\ud Illness attributions and sociodemographic confounders do not fully explain the ethnic tendency to seek out faith-based institutions. While Asian and Black patients are more likely to seek help from faith-based organisations, this does not appear to lead to a delay in contact with mental health services.

Recent studies from large nationwide cancer databases have consistently shown that Hispanic women with breast cancer have delays in treatment initiation compared with non-Hispanic white women. However, time to treatment initiation has not been studied in a community where Hispanics are the majority.We conducted a retrospective, observational study of 362 female patients with breast cancer treated at a large National Cancer Institute (NCI) -designated cancer center with a largely Hispanic population. We examined the relationship between race/ethnicity and time from mammogram to biopsy as well as time from biopsy to treatment initiation using Kaplan-Meier analyses and multivariable Cox proportional hazards regression.Half of the female patients with breast cancer were of Hispanic descent (50.0%; n = 181). Hispanic patients were more likely to be obese, have an Eastern Cooperative Oncology Group functional status ≥ 1, and have higher histologic grade disease (all P ≤ .05); no differences in American Joint Committee on Cancer stage at diagnosis were observed. After comprehensive adjustment for demographic and clinical characteristics, we found no significant differences between Hispanic versus non-Hispanic white patients in time from mammogram to biopsy (hazard ratio [HR], 0.91; 95% CI, 0.68 to 1.21) or time from biopsy to treatment (HR, 1.13; 95% CI, 0.69 to 1.88).Hispanic women and Non-Hispanic white women with breast cancer treated at an NCI-designated cancer center had similar times to biopsy and treatment initiation. These findings suggest that in majority minority communities with large cancer centers, racial disparities can be reduced. With a growing Hispanic population throughout the United States, future studies should examine the long-term impact on improved breast cancer survival in this population.

e18037 Background: Stagnant outcomes for AYAs (15 to 39 years) with cancer are partly attributed to poor enrollment onto clinical trials. Initiatives have focused on increasing accrual, but changes at the population-level are unknown. We examined patterns of clinical trial participation over time in AYA cancer patients. Methods: We utilized medical record data from AYAs in two National Cancer Institute Patterns of Care Studies identified through the Surveillance, Epidemiology and End Results (SEER) Program. Among 1,358 AYAs diagnosed with non-Hodgkin lymphoma (NHL), Hodgkin lymphoma (HL), acute lymphoblastic leukemia (ALL), germ cell cancer, and sarcoma in 2006 and 3,560 AYAs diagnosed with NHL, HL, ALL, sarcoma, and breast cancer in 2012/2013, we used unconditional logistic regression to evaluate patient and provider characteristics associated with enrollment by year of diagnosis. Analyses were weighted to reflect the SEER populations and associations are summarized as adjusted odds ratios (OR) with 95% confidence intervals (CI). Results: From 2006 to 2012/2013, clinical trial participation increased from 14.8% to 17.9% among AYAs diagnosed with NHL, HL, ALL and sarcoma (p < 0.0001), primarily due to increased participation among ALL patients (2006: 37.4%; 2012/2013: 42.3%). In 2012/2013, participation varied by type of cancer, with the highest among those with ALL and sarcoma (31.2%), followed by HL (9.4%), NHL (6.9%) and breast cancer (4.3%). In both study years, multivariate analyses demonstrated that younger patients and those treated by pediatric oncologists (OR = 3.5; CI: 2.6-4.7) were more likely to enroll onto clinical trials. Uninsured AYAs were less likely to enroll in 2006 but no association was observed in 2012/2013. Hispanic (OR = 0.5; CI: 0.4-0.6), Black (OR = 0.6; CI: 0.5-0.9) and Asian (OR = 0.4; CI: 0.3-0.6) AYAs were less likely to enroll in 2012/2013 but not 2006. Conclusions: Our study identified increasing overall clinical trial participation over time. Disparities in likelihood of participating for racial/ethnic minority groups increased suggesting the need to improve access to clinical trials for all racial/ethnic groups to improve care and outcomes.

257 Background: Hospital Episode Statistics (HES) are routinely collected data describing National Health Service (NHS) hospital visits in England, with procedure & disease codes. This study, embedded in STAMPEDE, aimed to build a model using HES, linked to primary medical records & trial case report forms (CRFs) to identify progressive disease events (PDEs), including skeletal-related events (SREs). Methods: Analysis of 5 STAMPEDE patients (pts) in 2 stages (data to Jul 16). 1: Detailed manual note review of 3 pts’ PDEs were compared to HES & CRFs to build model. 2: Used model to use HES to identify possible PDEs in 2 pts, verified by note review & compared to CRFs. Created algorithm rules to identify PDEs per 8 week interval plus further analysis of HES coding to find SREs. Results: Prostate cancer PDEs coincided with clustering of HES events. HES found 4 PDEs omitted from CRFs but missed 2 (total PDEs: HES 10, CRFs 8). HES found a false positive CRF PDE. Compared with note review HES missed 4 PDEs (false negatives), with 2 missed & 2 upgraded to PDEs post-standard query procedures, plus HES found 3 false positives (1 STAMPEDE treatment & 2 delayed treatments post-PDE). Hence HES found 71% of PDEs in note review (HES 10, note review 14).CRFs found 57% of PDEs compared to note review (CRFs 8, note review 14). Hence HES found 14% more PDEs than were recorded in CRFs compared to note review. HES identified 4 additional SREs not recorded in CRFs but missed 2. Conclusions: Hospital record review revealed site staff may miss reporting major clinical efficacy outcome events on CRFs, especially nearer end-of-life. HES successfully identified most PDEs (often found as a cluster of SREs), plus additional trial events not reported on CRFs compared to note review and as predicted HES & CRFs found less PDEs. PDEs & SREs missed from CRF recording can be identified in HES.This confirmed use of HES to detect PDEs is feasible. HES-identified events have potential as a primary data source when subsequently verified by standard data queries. Future work will test this model prospectively in the forthcoming BladderPath trial. It may offer a superior, cost-effective method of primary data collection compared to traditional CRF recording.

We report our experience with cannulated hip screws and analyse the risk factors associated with their early failure.All patients undergoing cannulated hip screws at a single UK Major Trauma Centre between November 2009 and November 2011 were retrospectively identified. Radiographs were analysed for fracture displacement, successful reduction, and screw configuration. Risk factors predicting early failure, defined as re-operation within 6 months, were identified using logistic regression models.340 patients were included in the study, 70% were female and the mean age was 81 years. After six months 23% patients had undergone revision surgery. Initial fracture displacement (p = 0.02) and unsuccessful lateral reduction (p = 0.04) were significant predictors of early failure.Initial fracture displacement and successful fracture reduction are the most important factors related to the risk of early re-operation. We found no evidence that screw configuration is an important predictor of outcome.

10086 Background: Young adults have historically been the least likely to have health insurance in the United States. Previous studies of childhood cancer survivors found lower rates of insurance a...

The primary aim of this study was to analyse our painful metal-on-metal (MoM) hip resurfacing revisions with evidence of ‘adverse reactions to metal debris’ (ARMD). In our series of 35 revisions the median whole blood Cobalt levels were 58 nmols/l (range 12-1407 nmols/l), and whole blood Chromium levels were 73 nmols/l (range 2-353 nmols/l). Thirty-four of our 35 patients had abnormal imaging on Ultrasound scanning (USS). The mean histological Campbell grading of ARMD was 4, and ranged from 0-9. The mean Oxford Hip Score (OHS) increased from 19 pre-revision (range 4-46) to 33 post-revision surgery (range 23-47). We found no correlation between the preoperative metal ion levels, and the severity of the disease or the outcome. Pain following hip resurfacing may arise from a number of causes and when groin pain arises in conjunction with abnormal cross sectional imaging we have offered our patients revision surgery regardless of raised metal ions or grossly abnormal imaging, with good results.

Objectives. Human papillomavirus (HPV) vaccines have been approved since 2006, yet vaccination rates remain low. We investigated HPV vaccination trends, interest, and reasons for nonvaccination in young adult women. Methods. We used data from the 2008–2012 National Health Interview Survey to analyze HPV vaccine uptake trends (≥ 1 dose) in women aged 18 to 26 years. We used data from the 2008 and 2010 National Health Interview Survey to examine HPV vaccination interest and reasons for nonvaccination among unvaccinated women. Results. We saw significant increases in HPV vaccination for all young women from 2008 to 2012 (11.6% to 34.1%); however, Hispanics and women with limited access to care continued to have lower vaccination rates. Logistic regression demonstrated lower vaccination interest among unvaccinated women in 2010 than 2008. Respondents in 2010 were significantly less likely to give lack of knowledge as a primary reason for nonvaccination. Conclusions. Uptake of HPV vaccine has increased from 2008 to 2012 in young women. Yet vaccination rates remain low, especially among women with limited access to care. However, unvaccinated women with limited health care access were more likely to be interested in receiving the vaccine.

Background:\ud Despite scientific advances in typing of C. difficile strains very little is known about how hospital staff use typing results during periods of increased incidence (PIIs). This qualitative study, undertaken alongside a randomised controlled trial (RCT), explored this issue. The trial compared ribotyping versus more rapid genotyping (MLVA or multilocus variable repeat analysis) and found no significant difference in post 48 hour cases (C difficile transmissions).\ud \ud Methods:\ud In-depth qualitative interviews with senior staff in 11/16 hospital trusts in the trial (5 MLVA and 6 Ribotyping). Semi-structured interviews were conducted at end of the trial period. Transcripts were content analysed using framework analysis supported by NVivo-8 software. Common sub-themes were extracted by two researchers independently. These were compared and organised into over-arching categories or ‘super-ordinate themes’.\ud \ud Results:\ud The trial recorded that 45% of typing tests had some impact on infection control (IC) activities. Interviews indicated that tests had little impact on initial IC decisions. These were driven by hospital protocols and automatically triggered when a PII was identified. To influence decision-making, a laboratory turnaround time < 3 days (ideally 24 hours) was suggested; MLVA turnaround time was 5.3 days. Typing results were predominantly used to modify initiated IC activities such as ward cleaning, audits of practice or staff training; major decisions (e.g. ward closure) were unaffected. Organisational factors could limit utilisation of MLVA results. Results were twice as likely to be reported as ‘aiding management’ (indirect benefit) than impacting on IC activities (direct effect). Some interviewees considered test results provided reassurance about earlier IC decisions; others identified secondary benefits on organisational culture. An underlying benefit of improved discrimination provided by MLVA typing was the ability to explore epidemiology associated with CDI cases in a hospital more thoroughly.\ud \ud Conclusions:\ud Ribotyping and MLVA are both valued by users. MLVA had little additional direct impact on initial infection control decisions. This would require reduced turnaround time. The major impact is adjustments to earlier IC measures and retrospective reassurance. For this, turnaround time is less important than discriminatory power. The potential remains for wider use of genotyping to examine transmission routes.

Adolescent and young adult (AYA) cancer survivors experience barriers to utilizing healthcare, but the determinants of cancer-related medical care of AYAs has not been fully explored.We studied factors associated with medical care utilization among 465 AYA cancer survivors in the AYA Health Outcomes and Patient Experience Study, a cohort of 15 to 39 year olds recently diagnosed with germ cell cancer, lymphoma, sarcoma, or acute lymphocytic leukemia. Descriptive statistics and multivariate logistic regression methods were used.Most AYA cancer survivors (95%), who were 15-35 months post diagnosis, received medical care in the past 12 months and 17% were undergoing cancer treatment. In multivariate analyses, compared with AYAs with no cancer-related medical visits in the previous year, AYAs receiving cancer-related care were more likely to currently have health insurance (odds ratio (OR) = 4.9; 95% confidence interval (CI) = 1.7-13.8) or have had health insurance in the past year (OR = 4.0; 95% CI = 0.99-16.3). Cancer recurrence, lacking employment, and negative changes in self-reported general health were associated with ongoing cancer treatment versus other cancer-related medical care. Eleven percent of all AYAs and 25% of AYAs who did not receive medical care in the past 12 months lost health insurance between the initial and follow-up surveys.AYA cancer survivors with health insurance were much more likely to receive cancer-related medical care than those without insurance.Despite the need for post-treatment medical care, lacking health insurance is a barrier to receiving any medical care among AYAs.

BACKGROUND: X-ray mammography remains the predominant test for screening for breast cancer, with the aim of reducing breast cancer mortality. In the English NHS Breast Screening Programme each woman's mammograms are examined separately by two expert readers. The two readers read each batch in the same order and each indicates if there should be recall for further tests. This is a highly skilled, pressurised, repetitive and frequently intellectually unchallenging activity where readers examine one or more batches of 30-50 women's mammograms in each session. A vigilance decrement or performance decrease over time has been observed in similar repetitive visual tasks such as radar operation. METHODS/DESIGN: The CO-OPS study is a pragmatic, multi-centre, two-arm, double blind cluster randomised controlled trial of a computer software intervention designed to reduce the effects of a vigilance decrement in breast cancer screening. The unit of randomisation is the batch. Intervention batches will be examined in the opposite order by the two readers (one forwards, one backwards). Control batches will be read in the same order as one another, as is current standard practice. The hypothesis is that cancer detection rates will be higher in the intervention group because each readers' peak performance will occur when examining different women's mammograms. The trial will take place in 44 English breast screening centres for 1 year and 4 months. The primary outcome is cancer detection rate, which will be extracted from computer records after 1 year of the trial. The secondary outcomes include rate of disagreement between readers (a more statistically powerful surrogate for cancer detection rate), recall rate, positive predictive value, and interval cancer rate (cancers found between screening rounds which will be measured three years after the end of the trial). DISCUSSION: This is the first trial of an intervention to ameliorate a vigilance decrement in breast cancer screening. TRIAL REGISTRATION: ISRCTN46603370 (submitted: 24 October 2012, date of registration: 26 March 2013).

A growing body of research on US Veterans from Afghanistan and Iraq [Operations Enduring and Iraqi Freedom, and Operation New Dawn (OEF/OIF)] has described the polytrauma clinical triad (PCT): traumatic brain injury (TBI), posttraumatic stress disorder (PTSD), and pain. Extant research has not explored comorbidity clusters in this population more broadly, particularly co-occurring chronic diseases.The aim of the study was to identify comorbidity clusters among diagnoses of deployment-specific (TBI, PTSD, pain) and chronic (eg, hypertension, diabetes) conditions, and to examine the association of these clusters with health care utilization and adverse outcomes.This was a retrospective cohort study.The cohort comprised OEF/OIF Veterans who received care in the Veterans Health Administration in fiscal years (FY) 2008-2010.We identified comorbidity using validated ICD-9-CM code-based algorithms and FY08-09 data, followed by which we applied latent class analysis to identify the most statistically distinct and clinically meaningful patterns of comorbidity. We examined the association of these clusters with process measures/outcomes using logistic regression to correlate medication use, acute health care utilization, and adverse outcomes in FY10.In this cohort (N=191,797), we found 6 comorbidity clusters. Cluster 1: PCT+Chronic Disease (5%); Cluster 2: PCT (9%); Cluster 3: Mental Health+Substance Abuse (24%); Cluster 4: Sleep, Amputation, Chronic Disease (4%); Cluster 5: Pain, Moderate PTSD (6%); and Cluster 6: Relatively Healthy (53%). Subsequent health care utilization patterns and adverse events were consistent with disease patterns.These comorbidity clusters extend beyond the PCT and may be used as a foundation to examine coordination/quality of care and outcomes for OEF/OIF Veterans with different patterns of comorbidity.

Background/Introduction The purpose of this study was to describe the basic demographic characteristics, and analyze the response and survival experience of advanced renal cancer subjects treated in a phase I trial. Patients and Methods We conducted a retrospective observational study in 70 renal cancer patients participating in 25 phase I trials. Descriptive statistics, Kaplan-Meier, and multivariate Cox proportional hazards analyses were used to examine factors associated with time from study entry to treatment failure (TTF) and survival. Results The median age at diagnosis was 56.50 years. Eastern Cooperative Oncology Group (ECOG) performance status was 0 for 23.19% (n = 16) of the patients; 49.18% (n = 30) had received 2 or more previous lines of systemic therapy; and 84.29% (n = 59) of patients had 2 or more metastatic sites. A median number of 4.00 cycles of treatment was delivered. Four partial responses (6.25%) and 38 cases of stable disease lasting > 4 months (43.75%) were observed. The median TTF was 16.00 weeks. In multivariate analyses, men and patients with lactate dehydrogenase > 1.5 times the upper limit of normal had a shorter TTF. The median overall survival was 45.57 weeks (319.00 days). In multivariate analysis, factors predicting shorter survival were ECOG performance status ≥ 1 ( P = .023), age younger than 60 years ( P = .015), albumin P = .042), and liver metastases ( P = .010). Conclusion Advanced renal cancer patients with select clinical characteristics could consider phase I trials after exhausting standard therapeutic options.

BackgroundBlack and minority ethnic (BME) service users experience adverse pathways into care. Ethnic differences are evident even at first-episode psychosis (FEP); therefore, contributory factors must operate before first presentation to psychiatric services. The ENRICH programme comprised three interlinked studies that aimed to understand ethnic and cultural determinants of help-seeking and pathways to care.Aims and objectivesStudy 1: to understand ethnic differences in pathways to care in FEP by exploring cultural determinants of illness recognition, attribution and help-seeking among different ethnic groups. Study 2: to evaluate the process of detention under the Mental Health Act (MHA) and determine predictors of detention. Study 3: to determine the appropriateness, accessibility and acceptability of generic early intervention services for different ethnic groups.MethodsStudy 1: We recruited a prospective cohort of FEP patients and their carers over a 2-year period and assessed the chronology of symptom emergence, attribution and help-seeking using semistructured tools: the Nottingham Onset Schedule (NOS), the Emerging Psychosis Attribution Schedule and the ENRICH Amended Encounter Form. A stratified subsample of user–carer NOS interviews was subjected to qualitative analyses. Study 2: Clinical and sociodemographic data including reasons for detention were collected for all MHA assessments conducted over 1 year (April 2009–March 2010). Five cases from each major ethnic group were randomly selected for a qualitative exploration of carer perceptions of the MHA assessment process, its outcomes and alternatives to detention. Study 3: Focus groups were conducted with service users, carers, health professionals, key stakeholders from voluntary sector and community groups, commissioners and representatives of spiritual care with regard to the question: ‘How appropriate and accessible are generic early intervention services for the specific ethnic and cultural needs of BME communities in Birmingham?’ResultsThere were no ethnic differences in duration of untreated psychosis (DUP) and duration of untreated illness in FEP. DUP was not related to illness attribution; long DUP was associated with patients being young (ConclusionsStatutory health-care organisations need to work closely with community groups to improve pathways to care for BME service users. Rather than universal public education campaigns, researchers need to develop and evaluate public awareness programmes that are specifically focused on BME groups.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.

In the 1990s, several organizations began recommending evaluation of12 lymph nodes during colon resection because of its association with improved survival. We examined practice implications of multispecialty quality guidelines over the past 20 years recommending evaluation of ≥ 12 lymph nodes during colon resection for adequate staging.We used the 1988 to 2009 Surveillance, Epidemiology, and End Results program to conduct a retrospective observational cohort study of 90,203 surgically treated patients with colon cancer. We used Cochran-Armitage tests to examine trends in lymph node examination over time and multivariate logistic regression to identify patient characteristics associated with guideline-recommended lymph node evaluation.The introduction of practice guidelines was associated with gradual increases in guideline-recommended lymph node evaluation. From 1988 to 1990, 34% of patients had12 lymph nodes evaluated, increasing to 38% in 1994 to 1996 and to75% from 2006 to 2009. Younger, white patients and those with more-extensive bowel penetration (T3/4 nonmetastatic) and high tumor grade saw more-rapid increases in lymph node evaluation (P.001). Multivariate analyses demonstrated a significant interaction between year of diagnosis and both T stage and grade, indicating that those with higher T stage and higher grade were more likely to receive guideline-recommended care earlier.The implementation of lymph node evaluation guidelines was accepted gradually into practice but adopted more quickly among higher risk patients. By identifying patients who are least likely to receive guideline-recommended care, these findings present a starting point for promoting targeted improvements in cancer care and further understanding underlying contributors to these disparities.

Importance Optimization of surgical outcomes after colectomy continues to be actively studied, but most studies group right-sided and left-sided colectomies together. Objective To determine whether the complication rate differs between right-sided and left-sided colectomies for cancer. As a secondary analysis, we investigated hospital length of stay. Design We identified patients who underwent colectomy for colon cancer in the 2005-2008 American College of Surgeons National Surgical Quality Improvement Program database and stratified cases by right and left side. Preoperative, intraoperative, and postoperative factors were compared. Multivariable techniques were used to assess the impact of the side of colectomy on operative outcome measures, adjusting for covariates. Setting Hospitals within the American College of Surgeons National Surgical Quality Improvement Program database. Patients We identified 4875 patients who underwent elective laparoscopic or open colectomy for right-sided or left-sided colon cancer in the database. Main Outcomes and Measures Major complications and surgical site infection (SSI) rates. Results In the 4875 colectomies studied, a laparoscopic approach was used in 42% of cases and at similar frequency in right-sided and left-sided colectomies. Thirty-day mortality (1.5%) was similar in both groups. Major complications were seen in 17% of patients in each group. Superficial SSI was more likely to occur in patients who underwent left-sided colectomy (8.2% vs 5.9%). Among patients with postoperative sepsis or deep or organ space SSIs, more patients in the left-sided colectomy group underwent reoperation compared with the right-sided colectomy group (56% vs 30%). Laparoscopic right-sided colectomy patients were more likely to have a prolonged hospital length of stay than laparoscopic left-sided colectomy patients (odds ratio, 1.39; 95% CI, 1.09-1.78). Conclusions and Relevance The outcomes after colectomy for cancer are comparable in right-sided and left-sided resections, except for in the case of superficial SSI, which is less common in right-sided resections. Further research on SSI after colectomy should incorporate right vs left side as a potential preoperative risk factor.

No studies have looked at the rotator cuff dimensions in the young healthy population using ultrasonography. Our aim is to define the ultrasound dimensions of the rotator cuff in the healthy young adult population and explore correlations with other patient characteristics.Thirty male and 30 female healthy volunteers (aged 18-40 years), with no shoulder problems, underwent ultrasound assessment of both shoulders by a musculoskeletal radiologist. The dimensions of the rotator cuff, deltoid, and biceps were measured in a standardized manner.A total of 120 shoulders were scanned. The mean maximum width of the supraspinatus footprint was 14.9 mm in men and 13.5 mm in women (P .001). The mean thickness of the supraspinatus tendon was 4.9 mm in women and 5.6 mm in men. The mean thickness of the subscapularis was 4.4 in men and 3.8 mm in women and for the infraspinatus was 4.9 mm in men and 4.4 mm in women. There was no correlation between height, weight, biceps, or deltoid thickness with any tendon measurements. Apart from supraspinatus tendon thickness, the difference between dominant and nondominant shoulders in the same sex was not significant for any other tendon dimensions.This study has defined the dimensions of the rotator cuff in the young healthy adult, which has not been previously published. This is important for the documentation of normal ultrasound anatomy of the rotator cuff and also demonstrates that the asymptomatic contralateral shoulder can and should be used to estimate the expected dimensions.

Slipped capital femoral epiphysis (SCFE) is a rare adolescent hip disease that leads to a hip shape abnormality. Typical treatment involves in-situ fixation. It is not known if the degree of initial hip shape abnormality associated with SCFE has a significant effect on long-term hip function. A cohort of patients aged 18-50 who had undergone in-situ fixation for SCFE from 1970 onwards in our institution provided IHOT-33 (hip function) outcome data. Frog lateral radiographs from the time of surgery were used to measure radiological hip shape using both Southwick angle and alpha angle. There were 38 patients (46 hips) SCFE patients who met the eligibility criteria. We obtained follow-up data for 32 patients (38 hips), 83% follow-up. Ten patients (20 hips) had bilateral SCFE. The mean follow-up was 12.7 years (95% CI 10.7-14.7). 32 patients matched for age and sex who had no history of SCFE provided control IHOT-33 outcome data. There was a significant difference (p0.05) in long-term hip function between patients undergoing in-situ fixation for SCFE and the control population (mean IHOT-33 scores of 71.8 and 95.8 respectively). There was no significant (p0.05) correlation between long-term hip function and Southwick angle or lateral alpha angle. The initial severity of hip shape abnormality due to SCFE was not a strong predictor of long-term hip function. Other extraneous factors not related to hip shape may have an equally if not more important role to play in the subsequent long-term outcome of SCFE.

Introduction: Cancer for adolescents and young adults (AYA) differs from younger and older patients; AYA face medical challenges while navigating social and developmental transitions. Research suggests that these patients are under or inadequately served by current support services, which may affect health-related quality of life (HRQOL). Methods: We examined unmet service needs and HRQOL in the National Cancer Institute’s Adolescent and Young Adult Health Outcomes and Patient Experience (AYA HOPE) study, a population-based cohort (n = 484), age 15–39, diagnosed with cancer 6–14 months prior, in 2007–2009. Unmet service needs were psychosocial, physical, spiritual, and financial services where respondents endorsed that they needed, but did not receive, a listed service. Linear regression models tested associations between any or specific unmet service needs and HRQOL, adjusting for demographic, medical, and health insurance variables. Results: Over one-third of respondents reported at least one unmet service need. The most common were financial (16%), mental health (15%), and support group (14%) services. Adjusted models showed that having any unmet service need was associated with worse overall HRQOL, fatigue, physical, emotional, social, and school/work functioning, and mental health (p’s

Aims and methodTo develop a self-report questionnaire to measure mental health recovery from the service user viewpoint. Literature searches and scoping exercises indicated that psychological, social and spiritual issues should be included. The resultant provisional scale was completed by 107 service users.ResultsThe provisional scale was shortened as a result of factor analysis. The finalised version was highly reliable (Cronbach's alpha 0.911) and valid, correlating significantly with an already established recovery scale. It contained nine recognisable subscales, the first two describing existential and religious well-being. Separate well-being and ill-being factors were also identified.Clinical implicationsAn inclusive tool for service users' assessment of their own recovery, the Service User Recovery Evaluation (SeRvE) scale, has been validated. This can be used both as a research tool and clinically to monitor interventions. The importance of spiritual care for service users is highlighted.

44 Background: We examined changes in financial worry for working-aged cancer survivors compared to individuals without a cancer history (controls) after ACA-mandated health insurance enrollment and caps on cost-sharing were implemented in 2014. We hypothesized that cancer survivors would be more likely to report financial worry, and that ACA implementation would reduce financial worry. Methods: We pooled data from the 2013-2014 National Health Interview Survey for adults aged 21-64 years. Cancer survivors were identified based on self-report of ever being told by a physician that they had cancer (excluding non-melanoma skin cancer). Reports of worry about eight financial matters were dichotomized as “very worried” vs. “less worried”; a summary measure captured reports of being “very worried” about any item. Linear probability regressions assessed the impact of being a cancer survivor and the post-ACA period on high financial worry, controlling for demographics and health status. Interaction terms between cancer and post-ACA tested for differential ACA effects for cancer survivors. Results: Compared to controls (n = 50,304), cancer survivors (n = 2,192) were more likely to report being very worried about finances pre-ACA (46.7% vs. 39.6%) and post-ACA (42.3% vs. 36.0%). The ACA was associated with an adjusted 3.9 (CI: 2.9-4.9) percentage point (PPT) decrease in the probability of financial worry overall. Being a cancer survivor was associated with increased likelihood of being very worried about finances overall (PPT = 3.5, CI: 0.8-6.2), medical costs associated with a serious illness (PPT = 3.4, CI: 0.9-5.9) and normal healthcare (PPT = 3.4, CI: 1.1-5.7), having enough money for retirement (PPT = 2.4, CI: 0.0-4.8), and being able to maintain an enjoyable standard of living (PPT = 2.5, CI: 0.3-4.7). The ACA did not affect financial worry for cancer survivors differently than for controls. Conclusions: The ACA was associated with small but significant reductions in financial worry for working-aged adults, with similar effects for cancer survivors and controls. Cancer survivors were more likely to report financial worry, and worried about both paying for healthcare and the ability to maintain an adequate financial position in the short and longer run.

The timing of surgical resection for stage IV colon cancer with liver metastasis and the safety of simultaneous colon and liver resection remains controversial. The purpose of our study was to evaluate short-term outcomes after combined colon and liver resection (CCLR) versus colon resection (CR) or liver resection alone (LR) using a population database.The National Inpatient Sample was used to select patients who had surgery for colon cancer from 2002 to 2006. We evaluated for in-hospital morbidity, mortality, and prolonged length of stay (PLOS). Our analysis was done using design-weighted unadjusted analysis and logistic regression.We identified 361,096 patients during our study period (CCLR 3,625; CR 322,286; LR 35,185). CCLR was not associated with an increased risk of complications (odds ratio (OR) 1.12; 95% confidence interval (CI) 0.94-1.33; P=0.21) or PLOS (OR 1.19; 95% CI 0.99-1.4; P=0.06) compared with CR. In-hospital mortality occurred in 3.5% of patients who underwent CCLR and was not significantly associated with mortality compared with CR alone (OR 1.17; 95% CI 0.79-1.74; P=0.43). Liver lobectomy with CR was associated with a PLOS and a trend toward increased morbidity and mortality. Significant predictors of complications, mortality, and PLOS included: age70 years, male gender, nonprivate health insurance, and Elixhauser score1.CCLR with limited liver resection can be performed with similar morbidity and mortality to colectomy alone. For patients who require hepatic lobectomy, however, strong consideration should be given to a staged approach.

Background Among surgically treated patients with colon cancer, lower long-term mortality has been demonstrated in those with 12 or more lymph nodes evaluated. We examined whether patients receiving adequate lymph node evaluation were also more likely to receive comprehensive postsurgical care, leading to lower mortality. Study Design We used the 1992 to 2007 Surveillance, Epidemiology, and End Results (SEER)-Medicare data to identify surgically treated American Joint Committee on Cancer (AJCC) stage III colon cancer patients. We used chi-square analyses and logistic regression to evaluate the association between adequate (≥12) lymph node evaluation and receipt of postsurgical care (adjuvant chemotherapy, surveillance colonoscopy, CT scans, and CEA testing) and Cox proportional hazards regression to evaluate 10-year all-cause mortality, adjusting for postsurgical care. Results Among 17,906 surgically treated stage III colon cancer patients, adequate (≥12) lymph node evaluation was not associated with receiving comprehensive postsurgical care after adjustment for patient and tumor characteristics (p > 0.05 for all). Initially, adequate lymph node evaluation was associated with lower all-cause mortality (hazard ratio [HR] 0.88; 95% CI [0.85 to 0.91]), but among 3-year survivors, the impact of adequate lymph node evaluation on lower mortality was diminished (HR 0.94; 95% CI [0.88 to 1.01]). However, receiving comprehensive postsurgical care was associated with continued lower mortality in 3-year survivors. Conclusions Adequate lymph node evaluation for colon cancer was associated with lower mortality among all patients. However, among 3-year survivors, the association between lymph node evaluation and lower hazard of death was no longer significant, while postsurgical care remained strongly associated with lower long-term mortality, indicating that postsurgical care may partially explain the relationship between lymph node evaluation and mortality.

Background The adverse effects of blood transfusion after cancer surgery have been recently challenged in older anemic persons or those with substantial intraoperative blood loss. We hypothesized that intraoperative blood transfusions continue to adversely impact short-term cancer surgery outcomes regardless of age or preoperative hematocrit levels. Methods Using the 2005 to 2008 American College of Surgeons National Surgical Quality Improvement Program, we identified 38,926 patients who underwent cancer surgery. Pre-, intra-, and postoperative factors were compared by units of blood transfusion a patient received. Stratified multivariable analyses, by age and hematocrit level, were performed to assess the impact of blood transfusion on operative outcomes, adjusting for covariates. Results Fourteen percent of patients received an intraoperative blood transfusion. Of those, >60% received only 1 to 2 units of blood. Receipt of intraoperative blood transfusion was associated with higher rates of 30-day operative mortality, major complications, total number of complications, and prolonged length of stay across age groups and in persons with low to normal hematocrit levels. Conclusion The present study shows that intraoperative blood transfusion adversely impacts short-term operative cancer surgery outcomes across all age groups and in those with low to normal hematocrit levels. These findings provide insightful implications on the patterns of blood transfusion during cancer surgery that deserve further investigation.

Introduction: Total knee arthroplasty (TKA) surgery causes postoperative pain. The use of perioperative injections around the knee containing local anaesthetic, opiates and non-steroidal anti-inflammatory drugs has increased in popularity to manage pain. Theoretical advantages include reduced requirements for analgesia and earlier mobilisation. We propose a single-centre randomised controlled trial of multimodal periarticular anaesthetic infiltration versus femoral nerve anaesthetic blockade as analgesia for TKA. The aim is to determine, in patients undergoing TKA, if there is a difference in patient-reported pain scores on the visual analogue scale (VAS) prior to physiotherapy on day 1 postoperatively between treatment groups.\ud \ud Methods and analysis: Patients undergoing a primary unilateral TKA at University Hospitals Coventry and Warwickshire Hospitals will be assessed for eligibility. A total of 264 patients will provide 90% power to detect a difference of 12 mm on the VAS on day 1 postoperatively at the 5% level. The trial will use 1:1 randomisation, stratified by mode of anaesthetic. Primary outcome measure will be the VAS for pain prior to physiotherapy on day 1. Secondary outcome measures include VAS on day 2, total use of opiate analgesia up to 48 h, ordinal pain scores up to 40 min after surgery, independent functional knee physiotherapist assessment on days 1 and 2. Oxford knee Scores (OKS), EuroQol (EQ-5D) and Douleur Neuropathic Pain Scores (DN2) will be recorded at baseline, 6 weeks and 12 months. Adverse events will be recorded up to 12 months. Analysis will investigate differences in VAS on day 1 between the two treatment groups on an intention-to-treat basis. Tests will be two-sided and considered to provide evidence for a significant difference if p values are less than 0.05.\ud \ud Ethics and dissemination: NRES Committee West Midlands, 23 September 2013 (ref: 13/WM/0316). The results will be disseminated via peer-reviewed publications and conference presentations.\ud \ud Trial registration numbers: ISRCTN 60611146 and EUDRACT Number 2013-002439-10 (protocol code number PAKA-33601-AS117013); Pre-results.

Among patients surgically treated for colon cancer, better survival has been demonstrated in those with more lymph nodes evaluated. The presumed mechanism behind this association suggests that a more extensive lymph node evaluation reduces the risk of understaging, leading to improved survival.To further evaluate the mechanism behind lymph node evaluation and survival by examining the association between more extensive lymph node evaluation, identification of lymph node-positive cancers, and hazard of death.Observational cohort study.Surveillance, Epidemiology, and End Results (SEER) program data from 1988 through 2008.86,394 patients surgically treated for colon cancer.We examined the relationship between lymph node evaluation and node positivity using Cochran-Armitage tests and multivariate logistic regression. The association between lymph node evaluation and hazard of death was evaluated using Cox proportional hazards modeling.The number of lymph nodes evaluated increased from 1988 to 2008 but did not result in a significant overall increase in lymph node positivity. During 1988-1990, 34.6% of patients (3875/11,200) had 12 or more lymph nodes evaluated, increasing to 73.6% (9798/13,310) during 2006-2008 (P.001); however, the proportion of node-positive cancers did not change with time (40% in 1988-1990, 42% in 2006-2008, P = .53). Although patients with high levels of lymph node evaluation were only slightly more likely to be node positive (adjusted odds ratio for 30-39 nodes vs 1-8 nodes, 1.11; 95% CI, 1.02-1.20), these patients experienced significantly lower hazard of death compared with those with fewer nodes evaluated (adjusted hazard ratio for 30-39 nodes vs 1-8 nodes, 0.66; 95% CI, 0.62-0.71; unadjusted 5-year mortality, 35.3%).The number of lymph nodes evaluated for colon cancer has markedly increased in the past 2 decades but was not associated with an overall shift toward higher-staged cancers, questioning the upstaging mechanism as the primary basis for improved survival in patients with more lymph nodes evaluated.

Federal policies have been implemented to mitigate underenrollment in cancer trials in the United States. We sought to identify patterns and predictors of enrollment patterns to cancer trials in a contemporary era using a real world setting.The 2001-2008 California Cancer Registry was used to determine patterns and predictors of enrollment in clinical trials for stage 0 to IV solid organ malignant tumors. Multivariate techniques were used to identify predictors of enrollment in cancer protocols, controlling for covariates.Less than a percent (0.64%) of patients enrolled in clinical trials (1566 of 244,528). Black patients were less likely than whites to enroll in trials (0.48% vs 0.67%, P0.05). On multivariate analysis, older persons (65 years), early stage cancer, and those with lung or gastrointestinal cancers were less likely to be enrolled in cancer trials. Results were consistent when evaluated among only nonbreast cancer protocols. Though approaching significance, black, underinsured, and uninsured patients showed trends toward underenrollment.In addition to profoundly low overall cancer trial accrual, vast underrepresentation by age, cancer stage, and site continue to exist. The generalizability of these trials to a real world perspective remains an open question. Physicians, payers, the National Cancer Institute, and other stakeholders need to develop broader cancer trials to benefit the millions of patients with cancer in the United States.

OBJECTIVE: Surgical morbidity may influence long-term cancer survival. Because resection of early stage nonsmall cell lung cancer (NSCLC) is primary therapy, we sought to determine the survival impact of surgical complications for elderly patients undergoing resection of stage I NSCLC. METHODS: Using the linked Surveillance Epidemiology and End Results-Medicare database (2000-2005), we identified elderly patients who underwent lobectomy for stage I NSCLC. We then assessed the unadjusted association between in-hospital, postoperative complications, and long-term survival for patients who survived more than 30 days after resection using the Kaplan-Meier method. Finally, we used Cox proportional hazards regression to evaluate the relationship between postoperative complications and 5-year cancer-specific (CSS) and overall survival (OS) after adjusting for patient, tumor, and treatment characteristics. RESULTS: We identified 3996 eligible patients. The overall in-hospital, postoperative complication rate was 54.2%. Pulmonary complications were the most common (n = 1464) followed by cardiac (n = 916). Unadjusted 5-year CSS was significantly worse for those who had an in-hospital, postoperative complication (70.9%) compared to those who did not (78.9%, P < 0.001). OS was also significantly worse (P < 0.001) for patients who developed a complication. Complications continued to predict worse 5-year CSS and OS after adjusting for patient, tumor, and treatment characteristics (HR: 1.38, 95% CI, 1.17-1.64). CONCLUSIONS: The occurrence of in-hospital postoperative complications was an independent predictor of worse 5-year CSS after resection of stage I NSCLC. Importantly, the impact of surgical complications extends well after the initial perioperative period. These findings may help identify important targets for best practice guidelines and quality-of-care measures.

Resections for elderly colorectal cancer (CRC) are forecasted to grow, particularly in those beyond the age limit of screening (80 years). However, literature on operative outcomes after CRC procedures in the oldest old is focused primarily on operative mortality. We hypothesize that older age will additionally impact operative morbidity after CRC resections in a multihospital, risk-adjusted database.We identified 19,375 patients40 years who underwent CRC procedures in the 2005 to 2008 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. Pre-, intra-, and postoperative factors were compared by age groups. Multivariable techniques were used to assess the effects of older age on operative outcome measures, adjusting for covariates.Over 20% of our cohort was older than 80 years. Of those, 17% developed major complications and 29% experienced prolonged length of stay (LOS). Older patients also experienced higher rates of 30-day operative mortality (80 years vs. 45-55 years; 6% vs.1%), major complications (80 years vs. 45-55 years; 21% vs. 14%), and prolonged LOS after open (80 years vs. 45-55 years; 37% vs. 24%) and laparoscopic procedures (80 years vs. 45-55 years; 40.5% vs. 18%). These unadjusted comparisons persisted in multivariable analyses demonstrating that older age independently predicted worse operative outcomes after CRC procedures.The effects of older age extend to other important outcome measures after CRC procedures beyond operative mortality. As one of the largest multihospital studies, our study identified increased morbidity in the oldest old, a growing population. Our results should stimulate review of current policy and resource allocation.

Purpose After the National Institutes of Health Consensus Statement in 1990, breast-conserving surgery (BCS) became more common while mastectomy rates decreased. However, several recently published single-institution studies have reported an increase in mastectomy rates in the past decade. We conducted a population-based study to evaluate national trends in the surgical treatment of breast cancer from 2000 through 2006. Patients and Methods Using the Surveillance, Epidemiology, and End Results database, we conducted a retrospective cohort analysis of women undergoing surgical treatment for breast cancer. We evaluated variation in mastectomy rates by demographic and tumor factors and calculated differences in mastectomy rates across time. We utilized logistic regression to identify time trends and patient and tumor factors associated with mastectomy, testing for significance using two-sided methods. Results We identified 233,754 patients diagnosed with ductal carcinoma in situ or stage I to III unilateral breast cancer from 2000 to 2006. The proportion of women treated with mastectomy decreased from 40.8% in 2000 to 37.0% in 2006 (P < .001). These patterns were maintained across patient and tumor factors. Although the unilateral mastectomy rate decreased during the study period, the contralateral prophylactic mastectomy rate increased. Women were less likely to receive mastectomy over time (odds ratio, 1.18 for 2000 v 2006; 95% CI, 1.14 to 1.23; P < .0001), after adjusting for patient and tumor factors. Conclusion In contrast to single-institution studies, our population-based analysis found a decrease in unilateral mastectomy rates from 2000 to 2006 in the United States. Variations in referral patterns and patient selection are potential explanations for these differences between single institutions and national trends.

Objective This article discusses the specific components necessary to achieve transformational change within public health departments as a means for creating sustained performance improvement and better outcomes in the health of the community. Design This article provides a review of transformation change concepts and application to public health departments. Results Transformational change for public health departments must be intentionally designed to achieve high performance. While all improvement requires change, not all change results in improvement. Conclusion The successful transformational change effort always occurs from the top-down, while the process improvement occurs from the bottom-up. Transformational change is possible in public health departments when small incremental improvements are linked with large-scale management changes to continually improve public health performance resulting in better population outcomes.

Local public health agencies are challenged to continually improve service delivery, yet they frequently operate with constrained resources. Quality improvement methods and techniques such as statistical process control are commonly used in other industries, and they have recently been proposed as a means of improving service delivery and performance in public health settings. We analyzed a quality improvement project undertaken at a local Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) clinic to reduce waiting times and improve client satisfaction with a walk-in nutrition education service. We used statistical process control techniques to evaluate initial process performance, implement an intervention, and assess process improvements. We found that implementation of these techniques significantly reduced waiting time and improved clients' satisfaction with the WIC service.

Metabolomics datasets, by definition, comprise of measurements of large numbers of metabolites. Both technical (analytical) and biological factors will induce variation within these measurements that is not consistent across all metabolites. Consequently, criteria are required to assess the reproducibility of metabolomics datasets that are derived from all the detected metabolites. Here we calculate spectrum-wide relative standard deviations (RSDs; also termed coefficient of variation, CV) for ten metabolomics datasets, spanning a variety of sample types from mammals, fish, invertebrates and a cell line, and display them succinctly as boxplots. We demonstrate multiple applications of spectral RSDs for characterising technical as well as inter-individual biological variation: for optimising metabolite extractions, comparing analytical techniques, investigating matrix effects, and comparing biofluids and tissue extracts from single and multiple species for optimising experimental design. Technical variation within metabolomics datasets, recorded using one- and two-dimensional NMR and mass spectrometry, ranges from 1.6 to 20.6% (reported as the median spectral RSD). Inter-individual biological variation is typically larger, ranging from as low as 7.2% for tissue extracts from laboratory-housed rats to 58.4% for fish plasma. In addition, for some of the datasets we confirm that the spectral RSD values are largely invariant across different spectral processing methods, such as baseline correction, normalisation and binning resolution. In conclusion, we propose spectral RSDs and their median values contained herein as practical benchmarks for metabolomics studies.