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Interventions to reduce the stigma of substance use disorders by health professionals often include didactic instruction combined with an interactive component that includes a guest speaker in recovery. Few interactive studies have focused on pharmacy students. Community pharmacists are moving to the front lines to battle the opioid epidemic; therefore, pharmacy students should be included in interventions aimed at reducing stigma by health professionals.This study examined the effects of a contact-based interactive intervention delivered by a peer recovery support specialist on perceived stigma of opioid use disorder among third-year pharmacy students (N = 115) enrolled in an integrative psychiatry course. Stigma was measured using the Brief Opioid Stigma Scale.Our study found significant differences in students' perceived stigma, both with their personal beliefs and their beliefs regarding the public, supporting the use of interactive presentations by peer recovery support specialists to decrease perceived stigma of opioid use disorder by health professionals.This type of intervention for pharmacy students shows promise in reducing substance use disorder stigma and should be further explored.

The COVID-19 pandemic disrupted hospital operations. Anecdotal evidence suggests financial performance likewise suffered, yet little empirical research supports this claim. This study aimed to explore the impact of the pandemic on the financial performance of the most prominent academic hospitals in the United States. Data from the 115 largest major teaching hospitals in the United States were extracted from the American Hospital Directory for three years (2019–2021). We hypothesized that the year and region would moderate the relationship between a hospital’s return on assets (financial performance) and specific operational variables. We found evidence through descriptive statistics and multivariate moderated regressions that financial positions rebounded in 2021, mainly through reductions in adjusted full-time employees and liabilities and an increase in non-operating income. Our results also found that the Midwest region significantly outperformed the other three regions, particularly in terms of lower salaries and operational expenses. These findings suggest potential for future initiatives encouraging efficiency and finding alternate sources of income beyond patient income. Hospitals should focus on improving financial reserves, building out non-operational revenue streams, and implementing operational efficiencies to foster better financial resiliency. These suggestions may enable healthcare administrators and facilities to adapt to future pandemics and environmental turbulence.

The coronavirus pandemic shifted in-person environments to virtual environments. Little is known about the effectiveness of fully synchronous, virtual interprofessional education (IPE). This study aims to compare two IPE cases that occurred in-person pre-pandemic and virtual during-pandemic. Two cases are analyzed: a medical error care and a charity care case. Participants were students from various health science disciplines. Assessments were captured through The Interprofessional Collaborative Competency Attainment Survey (ICCAS). Effect sizes were calculated for the pre-and post-surveys and analyzed using Cohen’s d for independent samples. From the in-person collection period, a total of 479 students participated in the medical error simulation and 479 in the charity care simulation. During the virtual collection period, a total of 506 students participated in the medical error simulation and 507 participated in the charity care simulation. In the data for the virtual simulations, the medical error case study maintained a large effect size (0.81) while the charity care simulation had a lesser impact (0.64 effect size). Structural details of the patient cases may be a critical variable. Future research is needed to better understand how health science students can obtain more training to notice the subtle cues from patients assessed through telemedicine modalities.

Purpose The Accreditation Council for Graduate Medical Education (ACGME) restricted the duty hours for residents training in 2004. With less time to learn medicine, residents may not develop the clinical reasoning skills needed. Simulation can provide a remedy for this lack of time by allowing residents to practice skills and develop clinical reasoning in a simulated environment. Simulation Wars (SimWars), a clinical reasoning simulation has been shown to improve clinical reasoning skills. The purpose of the study was to investigate the effect of Simulation Wars on In-Training Examination (ITE) Scores and Global Rating Scale (GRS) Scores in Emergency Medicine (EM) residents. Methods The Quasi-Experimental design was used in this retrospective study. The main comparison was between historical controls, the residents who did not participate in the Simulation Wars, and the intervention group comprised of residents who participated in the SimWars. Results A total of 127 residents were participants in this study including 70 from the intervention and 57 from the historical control group. There were no significant differences found in GRS scores between both groups except for Communication and Professionalism (p

Prior to the COVID-19 pandemic, the United States was facing an epidemic of opioid overdose deaths, clouding accurate inferences about the impact of the pandemic at the population level. We sought to determine the existence of increases in the trends of opioid-related overdose (ORO) deaths in the Greater Houston metropolitan area from January 2015 through December 2021, and to describe the social vulnerability present in the geographic location of these deaths. We merged records from the county medical examiner’s office with social vulnerability indexes (SVIs) for the region and present geospatial locations of the aggregated ORO deaths. Time series analyses were conducted to determine trends in the deaths, with a specific focus on the years 2019 to 2021. A total of 2660 deaths were included in the study and the mean (standard deviation, SD) age at death was 41.04 (13.60) years. Heroin and fentanyl were the most frequent opioids detected, present in 1153 (43.35%) and 1023 (38.46%) ORO deaths. We found that ORO deaths increased during the years 2019 to 2021 (p-value ≤ 0.001) when compared with 2015. Compared to the year 2019, ORO deaths increased for the years 2020 and 2021 (p-value ≤ 0.001). The geographic locations of ORO deaths were not associated with differences in the SVI. The COVID-19 pandemic had an impact on increasing ORO deaths in the metropolitan Houston area; however, identifying the determinants to guide targeted interventions in the areas of greatest need may require other factors, in addition to community-level social vulnerability parameters.

Objective With a significant proportion of individuals with opioid use disorder not currently receiving treatment, it is critical to find novel ways to engage and retain patients in treatment. Our objective is to describe the feasibility and preliminary outcomes of a program that used emergency physicians to initiate a bridge treatment, followed by peer support services, behavioral counseling, and ongoing treatment and follow‐up. Methods We developed a program called the Houston Emergency Opioid Engagement System (HEROES) that provides rapid access to board‐certified emergency physicians for initiation of buprenorphine, plus at least 1 behavioral counseling session and 4 weekly peer support sessions over the course of 30 days. Follow‐ups were conducted by phone and in person to obtain patient‐reported outcomes. Primary outcomes included percentage of patients who completed the 30‐day program and the percentage for successful linkage to more permanent ongoing treatment after the initial program. Results There were 324 participants who initiated treatment on buprenorphine from April 2018 to July 2019, with an average age of 36 (±9.6 years) and 52% of participants were males. At 30 days, 293/324 (90.43%) completed the program, and 203 of these (63%) were successfully connected to a subsequent community addiction medicine physician. There was a significant improvement (36%) in health‐related quality of life. Conclusion Lack of insurance is a predictor for treatment failure. Implementation of a multipronged treatment program is feasible and was associated with positive patient‐reported outcomes. This approach holds promise as a strategy for engaging and retaining patients in treatment.

Background: Palliative care is insufficiently integrated in the continuum of care for older people. It is unclear to what extent healthcare policy for older people includes elements of palliative care and thus supports its integration. Aim: (1) To develop a reference framework for identifying palliative care contents in policy documents; (2) to determine inclusion of palliative care in public policy documents on healthcare for older people in 13 rapidly ageing countries. Design: Directed documentary analysis of public policy documents (legislation, policies/strategies, guidelines, white papers) on healthcare for older people. Using existing literature, we developed a reference framework and data extraction form assessing 10 criteria of palliative care inclusion. Country experts identified documents and extracted data. Setting: Austria, Belgium, Canada, Czech Republic, England, Japan, Mexico, Netherlands, New Zealand, Singapore, Slovenia, South Korea, Spain. Results: Of 139 identified documents, 50 met inclusion criteria. The most frequently addressed palliative care elements were coordination and continuity of care (12 countries), communication and care planning, care for family, and ethical and legal aspects (11 countries). Documents in 10 countries explicitly mentioned palliative care, nine addressed symptom management, eight mentioned end-of-life care, and five referred to existing palliative care strategies (out of nine that had them). Conclusions: Health care policies for older people need revising to include reference to end-of-life care and dying and ensure linkage to existing national or regional palliative care strategies. The strong policy focus on care coordination and continuity in policies for older people is an opportunity window for palliative care advocacy.

Chest x-ray (CXR) has been shown to be an effective detection tool for clinically significant trauma. We evaluated differences in findings between CXR and computed tomography of the chest (CCT), their impact on clinical management and the performance of the CXR.This retrospective study examined children (less than 18 years) who received a CXR and CCT between 2009 and 2015. We compared characteristics of children by conducting univariate analysis, reporting the proportion of additional diagnoses captured by CCT, and using it to evaluate the sensitivity and specificity of the CXR. Outcome variables were diagnoses made by CCT as well as the ensuing changes in the clinical management attributable to the diagnoses reported by the CCT and not observed by the CXR.In 1235 children, CCT was associated with diagnosing higher proportions of contusion or atelectasis (60% vs 31%; p .0001), pneumothorax (23% vs 9%; p .0001), rib fracture (18% vs 7%; p .0001), other fracture (20% vs 10%; p .0001), diaphragm rupture (0.2% vs 0.1%; p = .002), and incidental findings (7% vs 2%; p .0001) as compared to CXR. CCT findings changed the management of 107 children (8.7%) with 32 (2.6%) of the changes being surgical procedures. The overall sensitivity and specificity of the CXR were 57.9% (95% CI: 54.5-61.2) and 90.2% (95% CI: 86.8-93.1), respectively. The positive predictive value and negative predictive value were 93.1% and 48.6%, respectively.CXR is a useful initial screening tool to evaluate pediatric trauma patients along with clinical presentation in the Emergency Department in children.Level III, diagnostic test.

Mortality from overdoses involving opioids in the United States (U.S.) has reached epidemic proportions. More research is needed to examine the underlying factors contributing to opioid-related mortality regionally. This study's objective was to identify and examine the county-level factors most closely associated with opioid-related overdose deaths across all counties in the U.S.

Objective Gastroparesis is a debilitating condition that causes nausea, vomiting, and abdominal pain. Management includes analgesics and antiemetics, but symptoms are often refractory. Haloperidol has been utilized in the palliative care setting for similar symptoms. The study objective was to determine whether haloperidol as an adjunct to conventional therapy would improve symptoms in gastroparesis patients presenting to the emergency department (ED). Study Design and Methods This was a randomized, double-blind, placebo-controlled trial of adult ED patients with acute exacerbation of previously diagnosed gastroparesis. The treatment group received 5 mg of haloperidol plus conventional therapy (determined by the treating physician). The control group received a placebo plus conventional therapy. The severity of each subject's abdominal pain and nausea were assessed before intervention and every 15 minutes thereafter for 1 hour using a 10-point scale for pain and a 5-point scale for nausea. Primary outcomes were decreased pain and nausea 1 hour after treatment. Results Of the 33 study patients, 15 were randomized to receive haloperidol. Before treatment, the mean intensity of pain was 8.5 in the haloperidol group and 8.28 in the placebo group; mean pretreatment nausea scores were 4.53 and 4.11, respectively. One hour after therapy, the mean pain and nausea scores in the haloperidol group were 3.13 and 1.83 compared to 7.17 and 3.39 in the placebo group. The reduction in mean pain intensity therapy was 5.37 in the haloperidol group (p ≤ 0.001) compared to 1.11 in the placebo group (p = 0.11). The reduction in mean nausea score was 2.70 in the haloperidol group (p ≤ 0.001) and 0.72 in the placebo group (p = 0.05). Therefore, the reductions in symptom scores were statistically significant in the haloperidol group but not in the placebo group. No adverse events were reported. Conclusions Haloperidol as an adjunctive therapy is superior to placebo for acute gastroparesis symptoms.

Cross-national understanding of place of death is crucial for health service systems for their provision of efficient and equal access to paediatric palliative care. The objectives of this population-level study were to examine where children with complex chronic conditions (CCC) die and to investigate associations between places of death and sex, cause of death and country. The study used death certificate data of all deceased 1- to 17-year-old children (n = 40,624) who died in 2008, in 11 European and non-European countries. Multivariable logistic regression was performed to determine associations between place of death and other factors. Between 24.4 and 75.3% of all children 1-17 years in the countries died of CCC. Of these, between 6.7 and 42.4% died at home. In Belgium and the USA, all deaths caused by CCC other than malignancies were less likely to occur at home, whereas in Mexico and South Korea, deaths caused by neuromuscular diseases were more likely to occur at home than malignancies. In Mexico (OR= 0.91, 95% CI: 0.83-1.00) and Sweden (OR = 0.35, 95% CI: 0.15-0.83), girls had a significantly lower chance of dying at home than boys. CONCLUSION: This study shows large cross-national variations in place of death. These variations may relate to health system-related infrastructures and policies, and differences in cultural values related to place of death, although this needs further investigation. The patterns found in this study can inform the development of paediatric palliative care programs internationally. What is known: • There is a scarcity of population-level studies investigating where children with CCC die in different countries. • Cross-national understanding of place of death provides information to health care systems for providing efficient and equal access to paediatric palliative care. What is new : • There are large cross-national variations in the place of death of children with CCC, with few deathsoccuring at home in some countries whereas hospital deaths are generally most common. • In general, deaths caused by neuromuscular diseases and malignancies occur at home more often thanother CCC.

Purpose The Accreditation Council for Graduate Medical Education (ACGME) restricted the duty hours for residents training in 2004. With less time to learn medicine, residents may not develop the clinical reasoning skills needed. Simulation can provide a remedy for this lack of time by allowing residents to practice skills and develop clinical reasoning in a simulated environment. Simulation Wars (SimWars), a clinical reasoning simulation has been shown to improve clinical reasoning skills. The purpose of the study was to investigate the effect of Simulation Wars on In-Training Examination (ITE) Scores and Global Rating Scale (GRS) Scores in Emergency Medicine (EM) residents. Methods The Quasi-Experimental design was used in this retrospective study. The main comparison was between historical controls, the residents who did not participate in the Simulation Wars, and the intervention group comprised of residents who participated in the SimWars. Results A total of 127 residents were participants in this study including 70 from the intervention and 57 from the historical control group. There were no significant differences found in GRS scores between both groups except for Communication and Professionalism (p

Objective An overwhelming responsibility for responding to the opioid epidemic falls on hospital emergency departments (ED). We sought to examine the overall prevalence rate and associated charges of opioid-related diagnoses and overdoses. Although charge data do not necessarily represent cost, they are proxy indicators of resource utilization and burden. Methods We conducted a retrospective study of the National Emergency Department Sample (NEDS) dataset, the largest all-payer ED database in the United States. We queried using specific relevant ICD-10 codes to estimate the number of adult ED visits for both opioid poisonings and other opioid-related diagnoses during 2016 and 2017, which was the most recent publicly available data. Prevalence rates and financial charges were calculated by year and odds ratios were used to examine differences. Results Of approximately 234 million adult visits to EDs across 2016 and 2017, 2.88 million (1.23%) were related to opioids, with overdoses comprising nearly 27.5% and visits for other opioid-related diagnoses totaling 72.5%. As the primary diagnosis, opioids were responsible for 37% of all ED visits across both years. Total opioid-related visits for the two years accounted for $9.57 billion in ED charges, or $4.78 billion annually, with Medicaid and Medicare responsible for 66% of all charges. Conclusion and relevance Approximately one of every 80 visits to the ED were opioid-related, leading to financial charges approaching $5 billion per year. Since both prevalence and the economic burden of opioid-related visits are high, targeted interventions to address this epidemic’s impact on healthcare systems should be a national priority.

Current guidelines from the American Society for Parenteral and Enteral Nutrition and the Society of Critical Care Medicine (ASPEN/SCCM) regarding caloric requirements and the provision of nutrition support in critically ill, obese adults may not be suitable for similar patients with cancer. We sought to determine whether the current guidelines accurately estimate the energy requirements, as measured by indirect calorimetry (IC), of critically ill, obese cancer patients.This was a retrospective validation study of critically ill, obese cancer patients from March 1, 2007, to July 31, 2010. All patients ≥18 years of age with a body mass index (BMI) ≥30 kg/m(2) who underwent IC were included. We compared the measured energy expenditure (MEE) against the upper limit of the recommended guideline (25 kcal/kg of ideal body weight [IBW]) and MEE between medical and surgical patients in the intensive care unit.Thirty-three patients were included in this study. Mean MEE (28.7 ± 5.2 kcal/kg IBW) was significantly higher than 25 kcal/kg IBW (P.001), and 78% of patients had nutrition requirements greater than the current guideline recommendations. No significant differences in MEE between medical and surgical patients in the ICU were observed.Critically ill, obese cancer patients require more calories than the current guidelines recommend, likely due to malignancy-associated metabolic variations. Our results demonstrate the need for IC studies to determine the energy requirements in these patients and for reassessment of the current recommendations.

BACKGROUND:Where people die can influence a number of indicators of the quality of dying. We aimed to describe the place of death of people with cancer and its associations with clinical, socio-demographic and healthcare supply characteristics in 14 countries.METHODS:Cross-sectional study using death certificate data for all deaths from cancer (ICD-10 codes C00-C97) in 2008 in Belgium, Canada, Czech Republic, England, France, Hungary, Italy, Mexico, the Netherlands, New Zealand, South Korea, Spain (2010), USA (2007) and Wales (N=1,355,910). Multivariable logistic regression analyses evaluated factors associated with home death within countries and differences across countries.RESULTS:Between 12% (South Korea) and 57% (Mexico) of cancer deaths occurred at home; between 26% (Netherlands, New Zealand) and 87% (South Korea) occurred in hospital. The large between-country differences in home or hospital deaths were partly explained by differences in availability of hospital- and long-term care beds and general practitioners. Haematologic rather than solid cancer (odds ratios (ORs) 1.29-3.17) and being married rather than divorced (ORs 1.17-2.54) were most consistently associated with home death across countries.CONCLUSIONS:A large country variation in the place of death can partly be explained by countries' healthcare resources. Country-specific choices regarding the organisation of end-of-life cancer care likely explain an additional part. These findings indicate the further challenge to evaluate how different specific policies can influence place of death patterns.

Sexual contact has been shown to be a major mode of HIV transmission among people who inject drugs (PWID). This study examined gender and racial differences among PWID' sexual risk behaviors from the perspective of sexual scripts.696 PWID enrolled from Philadelphia on HPTN 037 were classified as engaging in high-risk sex behaviors if they reported having sex in the past 30 days and condomless sex with a non-primary partner, giving/receiving sex for money, or multiple partners. A multivariable logistic regression model was used to assess associations between demographic factors and high risk sex.Findings of the multivariable regression analysis demonstrated that being White (OR = 0.52, p 0.001) and male (OR = 0.59, p = 0.002) were protective of high risk sex, while homelessness (OR = 1.7, p = 0.005), and being single (OR = 1.83, p = 0.006) were positively associated with high risk sex. African American (AA) women were 1.7 times more likely to report high-risk sex than AA men (p = 0.002), 3.28 times more likely than White men (p 0.001), and 1.93 times more likely than White women (p 0.001).Since AA women report high-risk sex behaviors more than other demographic groups, behavioral interventions for HIV risk reduction among PWID may benefit from focusing on sex-risk reduction among AA women.

Chronic obstructive pulmonary disease and lung cancer are leading causes of death with comparable symptoms at the end of life. Cross-national comparisons of place of death, as an important outcome of terminal care, between people dying from chronic obstructive pulmonary disease and lung cancer have not been studied before. We collected population death certificate data from 14 countries (year: 2008), covering place of death, underlying cause of death, and demographic information. We included patients dying from lung cancer or chronic obstructive pulmonary disease and used descriptive statistics and multivariable logistic regressions to describe patterns in place of death. Of 5,568,827 deaths, 5.8% were from lung cancer and 4.4% from chronic obstructive pulmonary disease. Among lung cancer decedents, home deaths ranged from 12.5% in South Korea to 57.1% in Mexico, while hospital deaths ranged from 27.5% in New Zealand to 77.4% in France. In chronic obstructive pulmonary disease patients, the proportion dying at home ranged from 10.4% in Canada to 55.4% in Mexico, while hospital deaths ranged from 41.8% in Mexico to 78.9% in South Korea. Controlling for age, sex, and marital status, patients with chronic obstructive pulmonary disease were significantly less likely die at home rather than in hospital in nine countries. Our study found in almost all countries that those dying from chronic obstructive pulmonary disease as compared with those from lung cancer are less likely to die at home and at a palliative care institution and more likely to die in a hospital or a nursing home. This might be due to less predictable disease trajectories and prognosis of death in chronic obstructive pulmonary disease., Lung disease: improving end-of-life care Structured palliative care similar to that offered to cancer sufferers should be in place for patients with chronic lung disease. Joachim Cohen at Vrije University in Brussels and co-workers examined international death certificate data collected from 14 countries to determine place of death for patients with lung cancer and chronic obstructive pulmonary disease (COPD). While patients with COPD suffer similar symptoms to lung cancer in their final days, few COPD patients receive palliative care or achieve the common wish of dying at home. This may be partly due to the inherent unpredictability of final-stage COPD compared with lung cancer. Cohen’s team found that, with the exception of Italy, Spain, and Mexico, patients with COPD were significantly more likely to die in hospital than at home. They highlight the need for improved COPD palliative care provision.

The outcome of patients with relapsed acute myeloid leukemia (AML) remains unsatisfactory, with few available effective therapies. Increased understanding of the biology of the disease has led to the identification of novel therapeutic agents, several of which have been evaluated in recently conducted clinical trials. We sought to determine whether the introduction of these agents as well as modern supportive care measures has already translated to better outcomes. We examined the outcomes of 1,056 patients with AML in first relapse treated between January 1993 and December 2013 at our institution. As previously reported, the independent prognostic factors for survival after first relapse included age at relapse, cytogenetics, and duration of first complete remission. Upon multivariable analysis, treatment era was an independent predictor of survival, with significant improvement in overall survival between 2008 and 2013 as compared to prior time periods. Modern supportive care measures as well as participation in clinical trials of novel agents are already improving the outcomes in first relapse.

Microcytosis is a relatively frequent finding in primary myelofibrosis (PMF); however its prognostic significance is unknown. We identified factors associated with microcytosis in PMF and measured its impact on outcomes. Among 725 patients with PMF, 140 (19%) showed microcytosis. In multivariate analysis, factors associated with microcytosis were absence of prior therapy, low iron, low transferrin saturation (satTF), and splenomegaly. Among 375 untreated patients, low satTF and splenomegaly were associated with microcytosis. Overall, microcytosis was associated with a higher risk of transformation to leukemia ( p = 0.03), but not shorter leukemia-free survival. Microcytosis in PMF may be related to dysregulation of iron homeostasis.

BACKGROUND Comorbidities have been shown to play an important role in the prognostic assessment of several hematologic conditions; however, the role of comorbidities in primary myelofibrosis has not been studied. The objective of the current study was to evaluate the prevalence and impact of comorbidities in patients with primary myelofibrosis (PMF) using the Adult Comorbidity Evaluation-27 (ACE-27). METHODS In this retrospective observational cohort study, a total of 349 consecutive patients with a confirmed diagnosis of PMF who presented to the study institution from 2000 to 2008 were evaluated. The authors evaluated the frequency and severity of comorbidities in these patients and assessed their impact on survival in a bivariable model that included the ACE-27 and Dynamic International Prognostic Scoring System scores as covariates. RESULTS Approximately 64% of patients had at least 1 comorbid condition, and diseases of the cardiovascular system (63%) were most common. Comorbidities had a significant negative impact on survival (P

Outcomes of patients with acute myeloid leukemia (AML) who are refractory to high-dose Cytarabine (HiDAC)-based induction are dismal. Allogeneic hematopoietic stem cell transplantation (AHSCT) as initial salvage may be effective and potentially superior to conventional salvage chemotherapy. Eighteen percent (285 of 1597) of AML patients were primary refractory to HiDAC-based regimens at the MD Anderson Cancer Center between 1995 and 2009. AHSCT was the initial salvage in 28 cases. These patients were compared against 149 patients who received salvage chemotherapy, but never received AHSCT. Patients receiving salvage chemotherapy were older, had higher bone marrow blasts percentage, and higher incidence of unfavorable cytogenetics (P

Comorbidities significantly affect the prognosis and outcomes of patients with hematological malignancies. We have previously reported the impact of comorbidities on the International Prognostic Scoring System (IPSS) score. The aim of this study was to determine whether comorbidities continued to have a significant impact when patients were reclassified according to the Revised-IPSS (IPSS-R). The medical records of 600 consecutive myelodysplastic syndrome patients who presented to MD Anderson Cancer Center between January 2002 and June 2004 were reviewed. The Adult Comorbidity Evaluation-27 (ACE-27) was used to assess the severity of comorbid conditions. Four hundred and two (67%) patients were male. Median age at presentation was 66.6 years (17-94). Mean duration of follow-up was 54 months (1-100). Five hundred and two (84%) patients died, and 54 (9%) patients underwent stem cell transplantation. Overall median survival was 16.8 months (1-100). Median survival by IPSS-R was 47, 34, 21, 16, and 6 months for patients in very low, low, intermediate, high, and very high-risk groups, respectively (P 65 years (P = 0.18). Assessment of comorbidity may enhance the prognostic ability of the IPSS-R.

Purpose To investigate the prognostic value of the Hematopoietic Cell Transplantation–Specific Comorbidity Index (HCT-CI) in patients who received transplantation admitted to the intensive care unit (ICU). Patients and Methods We investigated the association of HCT-CI with inpatient mortality and overall survival (OS) among 377 patients who were admitted to the ICU within 100 days of allogeneic stem-cell transplantation (ASCT) at our institution. HCT-CI scores were collapsed into four groups and were evaluated in univariate and multivariate analyses using logistic regression and Cox proportional hazards models. Results The most common pretransplantation comorbidities were pulmonary and cardiac diseases, and respiratory failure was the primary reason for ICU admission. We observed a strong trend for higher inpatient mortality and shorter OS among patients with HCT-CI values ≥ 2 compared with patients with values of 0 to 1 in all patient subsets studied. Multivariate analysis showed that patients with HCT-CI values ≥ 2 had significantly higher inpatient mortality than patients with values of 0 to 1 and that HCT-CI values ≥ 4 were significantly associated with shorter OS compared with values of 0 to 1 (hazard ratio, 1.74; 95% CI, 1.23 to 2.47). The factors associated with lower inpatient mortality were ICU admission during the ASCT conditioning phase or the use of reduced-intensity conditioning regimens. The overall inpatient mortality rate was 64%, and the 1-year OS rate was 15%. Among patients with HCT-CI scores of 0 to 1, 2, 3, and ≥ 4, the 1-year OS rates were 22%, 17%, 18%, and 9%, respectively. Conclusion HCT-CI is a valuable predictor of mortality and survival in critically ill patients after ASCT.

Early responses to tyrosine kinase inhibitors (TKIs) in chronic myeloid leukemia (CML)-chronic phase (CP) are associated with improved outcome. We analyzed the impact of such a response on outcomes among patients treated with 4 TKI modalities as frontline therapy in CML-CP. A total of 483 patients who received 400 or 800 mg imatinib, nilotinib, or dasatinib were analyzed. The median follow-up was 72 mo. Landmark analysis at 3 mo by molecular response showed that the cumulative proportions of 3-y event-free survival (EFS) for 3-mo BCR-ABL levels was 95% for those with ≤1%, 98% for >1% to 10%, and 61% for those with >10% (P = .001). The corresponding values by cytogenetic responses were 97% if Ph+ = 0%, 89% if Ph+ = 1% to 35%, and 81% if Ph+ >35% (P = .001). Cytogenetic response at 3 mo significantly discriminated for 3-y overall survival (OS): 98%, 96%, and 92%, respectively (P = .01). In multivariate analysis, young patients, high Sokal index, and treatment with imatinib 400 significantly predicted for poor (>35%) cytogenetic response at 3 mo. Early responses are predictive for EFS and failure-free survival and to a lesser extent OS, regardless of the treatment modality, although therapies other than standard-dose imatinib result in higher rates of deep early responses. This trial was registered at www.clinicaltrials.gov as ID01-151 NCT00038649, ID01-015 NCT00048672, DM00-163 NCT00333840, ID02-534 NCT00050531, 2005-0422 NCT00254423, and 2005-0048 NCT00129740.

To determine the long-term efficacy of FLT3 inhibitors (FLT3i) in the salvage setting for relapsed and refractory (rel/ref) acute myeloid leukemia (AML) with FLT3 internal tandem duplication (AML FLT3-ITD), we conducted a retrospective study of 120 patients with rel/ref AML FLT3-ITD who received salvage therapy with either FLT3i-containing regimen (FLT3i group, N = 45) or conventional cytotoxic regimen (conventional group, N = 75). The median overall survival (OS) after the first salvage in the FLT3i group was 6.9 vs. 4.6 months in the conventional group (P = 0.17). The OS was better in the FLT3i group among patients with initial complete remission (CR) duration ≤12 months or with primary refractory disease (6.9 vs. 3.7 months; P < 0.01). The OS was better when FLT3i was combined with cytotoxic agents versus monotherapy (17 vs. 4.8 months; P = 0.017). Multivariate analysis revealed that the use of FLT3i was an independent predictor of OS (hazard ratio 0.58; 95% confidence interval, 0.38–0.88). Incorporating FLT3i into salvage strategies may improve long-term outcome of patients with AML FLT3-ITD. Prospective studies to validate this conclusion are warranted.

Background:To implement the appropriate services and develop adequate interventions, detailed estimates of the needs for palliative care in the population are needed.Aim:To estimate the proportion of decedents potentially in need of palliative care across 12 European and non-European countries.Design:This is a cross-sectional study using death certificate data.Setting/participants:All adults (⩾18 years) who died in 2008 in Belgium, Czech Republic, France, Hungary, Italy, Spain (Andalusia, 2010), Sweden, Canada, the United States (2007), Korea, Mexico, and New Zealand ( N = 4,908,114). Underlying causes of death were used to apply three estimation methods developed by Rosenwax et al., the French National Observatory on End-of-Life Care, and Murtagh et al., respectively.Results:The proportion of individuals who died from diseases that indicate palliative care needs at the end of life ranged from 38% to 74%. We found important cross-country variation: the population potentially in need of palliative care was lower in Mexico (24%–58%) than in the United States (41%–76%) and varied from 31%–83% in Hungary to 42%–79% in Spain. Irrespective of the estimation methods, female sex and higher age were independently associated with the likelihood of being in need of palliative care near the end of life. Home and nursing home were the two places of deaths with the highest prevalence of palliative care needs.Conclusion:These estimations of the size of the population potentially in need of palliative care provide robust indications of the challenge countries are facing if they want to seriously address palliative care needs at the population level.

Background Primary percutaneous coronary intervention (PCI) is the preferred reperfusion strategy for patients presenting with ST‐segment elevation myocardial infarction; however, to be effective, PCI must be performed in a timely manner. Rural regions are at a severe disadvantage, given the relatively sparse number of PCI hospitals and long transport times. Methods and Results We developed a standardized treatment and transfer protocol for ST‐segment elevation myocardial infarction in the rural state of Wyoming. The study design compared the time‐to‐treatment outcomes during the pre‐ and postintervention periods. Details of the program, changes in reperfusion strategies over time, and outcome improvements in treatment times were reported. From January 1, 2013, to December 31, 2014, 889 patients were treated in 11 PCI‐capable hospitals (4 in Wyoming, 7 in adjoining states). Given the large geographic distance in the state (median of 47 miles between patient and PCI center), 52% of all patients were transfers, and 36% were administered fibrinolysis at the referral facility. Following the intervention, there was a significant shift toward greater use of primary PCI as the dominant reperfusion strategy (from 47% to 60%, P =0.002), and the median total ischemic time from symptom onset to arterial reperfusion was decreased by 92 minutes ( P P Conclusions Rural systems of care for ST‐segment elevation myocardial infarction require increased levels of cooperation between emergency medical services agencies and hospitals. This study confirms that total ischemic times can be reduced through a coordinated rural statewide initiative.

BACKGROUND: Studying where people die across countries can serve as an evidence base for health policy on end-of-life care. This study describes the place of death of people who died from diseases indicative of palliative care need in 14 countries, the association of place of death with cause of death, sociodemographic and healthcare availability characteristics in each country and the extent to which these characteristics explain country differences in the place of death. METHODS: Death certificate data for all deaths in 2008 (age ≥1 year) in Belgium, Canada, the Czech Republic, England, France, Hungary, Italy, Mexico, the Netherlands, New Zealand, South Korea, Spain (Andalusia), the USA and Wales caused by cancer, heart/renal/liver failure, chronic obstructive pulmonary disease, diseases of the nervous system or HIV/AIDS were linked with national or regional healthcare statistics (N=2 220 997). RESULTS: 13% (Canada) to 53% (Mexico) of people died at home and 25% (the Netherlands) to 85% (South Korea) diedin hospital. The strength and direction of associations between home death and cause of death, sociodemographic and healthcare availability factors differed between countries. Differences between countries in home versus hospital death were only partly explained by differences in these factors. CONCLUSIONS: The large differences between countries in and beyond Europe in the place of death of people in potential need of palliative care are not entirely attributable to sociodemographic characteristics, cause of death or availability of healthcare resources, which suggests that countries' palliative and end-of-life care policies may influence where people die.

Purpose To identify whether advanced cancer patients receiving home hospice care and their primary caregivers view artificial hydration (AH) as food or medicine, and the demographic and clinical factors influencing these perceptions. Methods Participants were enrolled in a randomised, double-blind controlled trial examining the efficacy of AH in cancer hospice patients. In-depth interviews at days 1 and 4 of study enrolment explored the meanings attributed to AH at the end of life. Responses to the question, ‘Are these fluids more like food or more like medicine?’ were categorised as ‘food’, ‘medicine’, ‘both’ or ‘other’. χ 2 analyses were conducted with data from 122 interviews (54 patients and 68 caregivers) to identify differences between patients and caregivers, and by gender, age, ethnicity and caregiver relationship. Predictors of perceptions were identified using logistic regression analysis. Results Overall, 47 participants (38%) understood the fluids to be more like food, 41 (34%) as medicine, 17 (14%) as both, and 17 (14%) as ‘other’. Ethnic minority participants (n=34, 66%) were significantly more likely than non-Hispanic European Americans (n=30, 42%) to view AH as food, or both as food and medicine (p=0.034). Ethnic differences persisted in the final regression model (OR 2.7; 95% CI 1.3 to 5.7, p=0.010). No significant differences were detected between patients and caregivers, or across gender, age, caregivers9 relationship to the patients, group assignment, disease severity or cancer type. Conclusions AH was perceived as food/nutrition by many cancer patients and caregivers in the study, particularly among ethnic minorities. This perception may lead to greater distress if fluids are discontinued or withheld. Asking patients/caregivers about their AH perceptions may enhance patient/provider communication and culturally appropriate end-of-life care.

Parenteral hydration at the end of life is controversial and has generated considerable debate for decades.To identify palliative care physician parenteral hydration prescribing patterns and factors that influence prescribing levels (PLs) for patients during their last weeks of life.A cross-sectional, representative online survey of Latin American palliative care physicians was conducted in 2010. Physicians were asked to report the percentage of their terminally ill patients for whom they prescribed parenteral hydration. Predictors of parenteral hydration PLs were identified using logistic regression analysis.Two hundred thirty-eight of 320 physicians completed the survey (74% response rate). Sixty percent of physicians reported prescribing parenteral hydration to 40%-100% of their patients during the last weeks of life. Factors influencing moderate/high PLs were the following: agreeing that parenteral hydration is clinically and psychologically efficacious (odds ratio [OR] 3.5; 95% confidence interval [CI] 1.5-8.3), disagreeing that withholding parenteral hydration alleviates symptoms (OR 3.3, 95% CI 1.3-8.1), agreeing that parenteral hydration is essential for meeting the minimum standards of care (OR 3.2, 95% CI 1.4-7.5), preferring the subcutaneous route of parenteral hydration for patient comfort and home use (OR 2.9, 95% CI 1.3-6.5), and being younger than 45 years of age (OR 2.6, 95% CI 1.3-5.2).The strongest determinant of prescribing patterns was agreement with the clinical/psychological efficaciousness of parenteral hydration. Our results reflect parenteral hydration prescribing patterns and perceptions that substantially differ from the conventional/traditional hospice philosophy. These findings suggest that the decision to prescribe or withhold parenteral hydration is largely based on clinical perceptions and that most palliative care physicians from this region of the world individualize treatment decisions.

Purpose The study aimed to evaluate the relative impact of clinical and demographic factors associated with the prevalence and incidence of anemia (hemoglobin [Hb] Materials and Methods We performed an electronic chart review for demographic and clinical data of adult patients with cancer with or without anemia admitted to the intensive care unit (ICU). Prevalence of anemia was determined at admission, and incidence determined if anemia developed during ICU stay. Anemia was classified as mild, moderate, or severe. The additive impact of clinical and demographic factors was evaluated by using a hierarchical linear regression model. Results A total of 4705 patients were included in the study. The prevalence and incidence of anemia were 68.0% and 46.6%, respectively. In prevalent cases, we found that the clinical covariates modified sequential organ failure assessment score, admission to the medical ICU, prior chemotherapy, diagnosis of hematologic cancer, and length of hospital stay before ICU admission explained 18.7% of the variance in the model, whereas the demographic covariates (age, sex, and race) explained only an additional 0.6%. The pattern was similar for incidence cases. Conclusions Clinical factors are more influential than demographic factors in the observed rates of prevalence and incidence of anemia in the ICU; thus, protocols are needed to identify subgroups of patients with cancer who could benefit from novel management strategies.

▪ ResumenObjetivo.Hemos evaluado el rendimiento de la citologia de Papanicolaou en contextos de cribaje y de diagnostico.Diseno del estudio.Analizamos los resultados de las citologias de 1.850 mujeres reclutadas para un ensayo clinico en el que se evaluo una nueva tecnologia para la deteccion del ca

We evaluated the performance of the Papanicolaou smear in screening and diagnostic settings.We analyzed Papanicolaou smear results of 1,850 women recruited into a clinical trial to evaluate an emerging technology for the detection of cervical cancer. Screening and diagnosis groups were based on the history of previous Papanicolaou smear results. We calculated sensitivities, specificities, positive and negative likelihood ratios (LR+ and LR-), receiver operating characteristic curves, and areas under the receiver operating characteristic curve (AUC).In the screening group, by defining disease as cervical intraepithelial neoplasia (CIN) 2,3/cancer or worse and using high-grade squamous intraepithelial lesion (HSIL) as the test cutpoint, the AUC was 0.689, and the LR+ and LR- were 39.25 and 0.67, respectively. In the diagnosis group, the AUC was 0.764, and the LR+ and LR- were 3.79 and 0.56, respectively. By defining disease as human papillomavirus/CIN 1 or worse and HSIL as the test cutpoint, the AUC was 0.586, and the LR+ and LR- were 17.01 and 0.92 in the screening group; in the diagnosis group, the AUC was 0.686, and the LR+ and LR- were 2.77 and 0.75, respectively.In a screening setting, a Papanicolaou smear result of HSIL or worse is 39 times more likely in a patient with CIN 2,3/cancer than in a patient without it. This compares to 4 times more likely in the diagnostic setting. The magnitude of the positive likelihood ratio observed in the screening group indicated that abnormal Papanicolaou smear results obtained in the screening setting should have more impact on clinical decision making than those from results obtained in the diagnostic setting.

Radical cystectomy is a major surgical procedure associated with significant blood loss and lengthy hospital stays. This surgical procedure is more challenging in women than men due to anatomical-based differences. We evaluated resource utilization and complication rates of patients undergoing radical cystectomy or exenteration using the Texas Hospital In-Patient Discharge Data Collection.This was a retrospective study of 1,493 patients, 35 years of age or older, who underwent radical cystectomy for bladder cancer from January 2000 to December 2003. We evaluated blood product charges, length of stay, and complication rates during hospitalization.In this sample, 24% of the patients (n = 356) were women. Overall, women had significantly increased blood product charges and length of stay compared to men, $1,392.87 vs. $718.21 (P0.001) and 12.72 vs. 11.64 (P = 0.03), respectively. During hospitalization, 26 of the patients died. No differences in mortality or complication rates were observed between men and women. Multivariate analysis showed that female sex (P0.001) and age (P = 0.003) were independent predictors of increased blood product charges. Multivariate analysis showed that female sex (P = 0.015), age (P = 0.003), and Charlson's comorbidity index1 (P = 0.05) were predictors of longer length of stay.Women and older patients with bladder cancer are at risk of increased blood products utilization and length of hospital stay after a radical cystectomy. Appropriate postoperative care and referrals should improve postoperative outcomes for these vulnerable patients.

Objective. In this review, we evaluate the diagnostic efficacy of optical spectroscopy technologies (fluorescence and reflectance spectroscopy) for the in vivo diagnosis of cervical neoplasia using both point probe and multispectral imaging approaches. Methods. We searched electronic databases using the following terms: cervical cancer, cervical intraepithelial neoplasia, squamous intraepithelial lesion, and spectroscopy, fluorescence spectroscopy, or reflectance spectroscopy. We included studies that evaluated fluorescence and reflectance spectroscopy devices for in vivo diagnosis, compared those results with biopsy results, and reported on the sensitivity and specificity of the devices tested. Results. Twenty-six studies, including seven phase II trials and one randomized clinical trial, met our acceptability criteria. We found several important differences across the studies including device approach (multispectral versus point probe), study population, disease classification system, and disease threshold. This heterogeneity prevented formal combination of sensitivity and specificity results. Conclusion. Optical spectroscopy has similar performance to colposcopy and may help localize lesions and therefore be an effective adjunct to colposcopy. Reports on the diagnostic accuracy of these devices should use common thresholds for the construction of receiver operating characteristic curves to enable comparisons with standard technologies and facilitate their adoption. Optical spectroscopy has also been identified for possible use as ASCUS triage and primary screening, yet neither has been sufficiently evaluated to warrant a conclusion as to their suitability in this role. © 2007 Published by Elsevier Inc.

PURPOSE: The places of death for people who died of suicide were compared across eight countries and socio-demographic factors associated with home suicide deaths identified. METHODS: Death certificate data were analyzed; using multivariable binary logistic regression to determine associations. RESULTS: National suicide death rates ranged from 1.4 % (Mexico) to 6.4 % (South Korea). The proportion of suicide deaths occurring at home was high, ranging from 29.9 % (South Korea) to 65.8 % (Belgium). Being older, female, widowed/separated, highly educated and living in an urban area were risk factors for home suicide. CONCLUSIONS: Home suicide deaths need specific attention in prevention programs.

BACKGROUND: Most people prefer to receive end-of-life care in familiar surroundings rather than in hospital. This study examines variation in place of death for people dying from Parkinson's disease (PD) across 11 European and non-European countries.METHODS: Using death certificate data of 2008 for Belgium, France, Italy, Hungary, Czech Republic, New Zealand, USA, Canada, Mexico, South Korea and Spain for all deaths with PD as an underlying cause (ICD-10 code: G20) cross-national differences in place of death were examined. Associations between place of death and patient socio-demographic and regional characteristics were evaluated using multivariable binary logistic regression analyses.RESULTS: The proportion of deaths in hospital ranged from 17% in the USA to 75% in South Korea. Hospital was the most prevalent place of death in France (40%), Hungary (60%) and South Korea; nursing home in New Zealand (71%), Belgium (52%), USA (50%), Canada (48%) and Czech Republic (44%); home in Mexico (73%), Italy (51%) and Spain (46%). The chances of dying in hospital were consistently higher for men (Belgium, France, Italy, USA, Canada), those younger than 80 years (Belgium, France, Italy, USA, Mexico), and those living in areas with a higher provision of hospital beds (Italy, USA).CONCLUSIONS: In several countries a substantial proportion of deaths from PD occurs in hospitals, although this may not be the most optimal place of terminal care and death. The wide variation between countries in the proportion of deaths from PD occurring in hospital indicates a potential for many countries to reduce these proportions.

To improve the care of cancer patients by understanding the factors associated with the place of death. We conducted a retrospective study of death certificates registered in Mexico during 2003. Adult cases were included if the underlying cause of death was cancer, death location was in the Mexico City Metropolitan Area (MCMA), and information was available on sociodemographic characteristics and place of death (home or medical unit). Of the 10,561 cases meeting the inclusion criteria, 54% died at home. More women (55%) than men died of cancer and at a younger age (63 vs 64 years, respectively; p

To compare the survival of women and men with transitional cell bladder cancer.We used the Surveillance Epidemiology and End Results database to identify patients aged 35 years or older diagnosed with bladder cancer between 1991 and 2001 actively followed up. We excluded cases diagnosed by autopsy or death certificates and those of unknown race. We used Cox proportional hazard regression to analyze survival in patients with advanced disease.Of the 31,009 patients meeting eligibility criteria, 26.7% were women. Median age at diagnosis for women and men was 72 and 70 years, respectively. Regional disease was diagnosed in 20.3% of white women and 35.5% of African-American women, compared with only 17.6% of white men and 25.9% of African-American men (P.001). Increased age, African-American race, and being female significantly increased the hazard of death (hazard ratio [HR] 1.037, 95% confidence interval [CI] 1,034-1.041; HR 1.402, 95% CI 1.187-1.656; and HR 1.842, 95% CI 1.158-2.931).Women with bladder cancer, particularly African-Americans, have shorter survival. This is partially explained by higher risk of diagnosis with poorly differentiated tumors, advanced stage, and advanced age. Women should be targeted for timely diagnosis.II-2.

Objective To determine the probabilities of transition of stages in the natural history of cervical cancer by conducting a meta-analysis of published studies on the topic. Study Design We identified health states of interest in the natural history of cervical precancer, identified all possible papers that could meet selection criteria, developed relevance and acceptability criteria for inclusion, then thoroughly reviewed the selected studies. To determine the transition probability data we used a random effects model. Results We determined probabilities for 4 health state transitions. The 6-month mean predictive transition probability (95% confidence intervals with prediction interval in parentheses) for high grade squamous intraepithelial lesions (HSIL) to cancer was 0.0037 (0.00004, 0.03386), for low grade squamous intraepithelial lesions (LSIL) to HSIL was 0.0362 (0.00055, 0.23220), for HSIL to LSIL was 0.0282 (0.00027, 0.35782), and for LSIL to normal was 0.0740 (0.00119, 0.42672). Conclusion The transition probabilities between cervical cancer health states for 6-month intervals are small; however, the cumulative risk of cervical cancer is significant. Markers to identify the cervical precursors that will lead to the transition to cervical cancer are needed.