PrEP Uptake and Methamphetamine Use Patterns in a 4-Year U.S. National Prospective Cohort Study of Sexual and Gender Minority People, 2017-2022.

Methamphetamine use is on the rise among sexual and gender minority people who have sex with men (SGMSM), escalating their HIV risk. Despite pre-exposure prophylaxis (PrEP) being an effective biomedical HIV prevention tool, its uptake in relation to methamphetamine use patterns in SGMSM has not been studied. In a U.S. cohort study from 2017 to 2022, 6,253 HIV-negative SGMSM indicated for but not using PrEP were followed for four years. Methamphetamine use was categorized (i.e., newly initiated, persistently used, never used, used but quit), and PrEP uptake assessed using generalized estimating equation (GEE), adjusted for attrition. Participants had a median age of 29, with 51.9% White, 11.1% Black, 24.5% Latinx, and 12.5% other races/ethnicities. Over the four years, PrEP use increased from 16.3 to 27.2%. GEE models identified risk factors including housing instability and food insecurity. In contrast, older age, health insurance, clinical indications, and prior PrEP use increased uptake. Notably, Latinx participants were more likely to use PrEP than Whites. Regarding methamphetamine use, those who newly initiated it were more likely to use PrEP compared to non-users. However, those who quit methamphetamine and those who persistently used it had PrEP usage rates comparable to those of non-users. Though PrEP uptake increased, it remained low in SGMSM. Methamphetamine use was associated with PrEP uptake. Healthcare providers should assess methamphetamine use for harm reduction. Prioritizing younger, uninsured SGMSM and addressing basic needs can enhance PrEP uptake and reduce HIV vulnerabilities.

PrEP Discontinuation In A US National Cohort Of Sexual And Gender Minority Populations, 2017-22.

In the US, sexual and gender minority populations are disproportionately affected by HIV. Pre-exposure prophylaxis (PrEP) is a key prevention method, but its effectiveness relies on consistent usage. Our four-year national cohort study explored PrEP discontinuation among sexual and gender minority people who initiated PrEP. We found a high annual rate of discontinuation (35-40 percent) after PrEP initiation. Multivariable analysis with 6,410 person-years identified housing instability and prior history of PrEP discontinuation as predictors of discontinuation. Conversely, older age, clinical indication for PrEP, and having health insurance were associated with ongoing PrEP use. To promote sustained PrEP use, strategies should focus on supporting those at high risk for discontinuation, such as younger people, those without stable housing or health insurance, and prior PrEP discontinuers.

Sleep disorders and cancer incidence: examining duration and severity of diagnosis among veterans.

Introduction: Sleep disruption affects biological processes that facilitate carcinogenesis. This retrospective cohort study used de-identified data from the Veterans Administration (VA) electronic medical record system to test the hypothesis that patients with diagnosed sleep disorders had an increased risk of prostate, breast, colorectal, or other cancers (1999-2010, N=663,869). This study builds upon existing evidence by examining whether patients with more severe or longer-duration diagnoses were at a greater risk of these cancers relative to those with a less severe or shorter duration sleep disorder. Methods: Incident cancer cases were identified in the VA Tumor Registry and sleep disorders were defined by International Classification of Sleep Disorder codes. Analyses were performed using extended Cox regression with sleep disorder diagnosis as a time-varying covariate. Results: Sleep disorders were present among 56,055 eligible patients (8% of the study population); sleep apnea (46%) and insomnia (40%) were the most common diagnoses. There were 18,181 cancer diagnoses (41% prostate, 12% colorectal, 1% female breast, 46% other). The hazard ratio (HR) for a cancer diagnosis was 1.45 (95% confidence interval [CI]: 1.37, 1.54) among those with any sleep disorder, after adjustment for age, sex, state of residence, and marital status. Risks increased with increasing sleep disorder duration (short [<1-2 years] HR: 1.04 [CI: 1.03-1.06], medium [>2-5 years] 1.23 [1.16-1.32]; long [>5-12 years] 1.52 [1.34-1.73]). Risks also increased with increasing sleep disorder severity using cumulative sleep disorder treatments as a surrogate exposure; African Americans with more severe disorders had greater risks relative to those with fewer treatments and other race groups. Results among patients with only sleep apnea, insomnia, or another sleep disorder were similar to those for all sleep disorders combined. Discussion: The findings are consistent with other studies indicating that sleep disruption is a cancer risk factor. Optimal sleep and appropriate sleep disorder management are modifiable risk factors that may facilitate cancer prevention.

Burden of Chronic and Heavy Opioid Use Among Elderly Community Dwellers in the U.S.

Introduction: Opioid overprescribing may fuel the opioid epidemic and increase the risk of complications of opioid misuse. This study examined trends and determinants of chronic and heavy opioid use among elderly community dwellers in the U.S. Methods: Medicare Current Beneficiary Surveys data from 2006 to 2019 were used. Common opioid medications were identified in the prescription medication files (n=47,264). Patients with Chronic users were defined as those receiving 6 or more opioid prescriptions within a year or on medication for 3 or more months, and heavy users were those having an average daily dose of 90 or more morphine milligram equivalents or 3,780 morphine milligram equivalents or more per continuous treatment episode. Results: One in 6 elderly community dwellers ever used opioids during the study period. Chronic users were more likely to be women than men (68.9% vs 31.1%, p<0.001). Of all survey participants, 4.3% were chronic users, and 2.8% were heavy users. Among ever users, 27.7% were chronic users, and 18.1% were heavy users. The rate of opioid use rose from 12.1% in 2006, peaked at 22.8% in 2013, and decreased to 11.7% in 2019. Chronic use was 5.1%, 10.7%, and 7.6%, respectively. Heavy use was 5.5%, 10.7%, and 7.6%, respectively. However, for chronic and heavy users, there was no significant difference in the median opioid dosage and opioid duration between males and females. Conclusions: Among elderly Medicare beneficiaries, opioid prescriptions have been decreasing since 2013. However, a substantial number of elderly people were chronic and heavy users, calling for better opioid management among them.

Program-Based Lung Cancer Care: A Prospective Observational Tumor Registry Linkage Study.

Introduction: Low-dose computed tomography screening (LDCT) and lung nodule programs (LNP) promote early lung cancer detection, improve survival; Multidisciplinary Care Programs (MDC) promote guideline-concordant care. The impact of such program-based care on "real-world" lung cancer survival is unquantified. We evaluated outcomes of lung cancer care delivered through structured programs in a community health care system. Methods: We conducted a cohort study linking institutional prospective observational LDCT, LNP and MDC databases with Tumor Registry of Baptist Cancer Center facilities. We categorized all patients diagnosed with lung cancer between 2011 and 2021 into program-based care versus non-program-based care cohorts. We compared patient characteristics, stage distribution, treatment modalities, survival and mortality in each pathway of care. Results: Of 12,148 patients, 237, 1,165, 1,140 and 9,606 were diagnosed through the LDCT, LNP, MDC or no program, respectively; non-program-based care sequentially diminished from 96.3% to 66.5%, diagnosis through LDCT increased from 0.5% to 7.1%, LNP from 3.5% to 20.8%; and MDC alone decreased from a high of 12.8% in 2014 to 5.6% in 2021. Program-based care was associated with earlier stage (p < 0.001), higher surgical resection rates (p < 0.001), greater use of adjuvant therapy (p < 0.001), better aggregate and stage-stratified survival (p < 0.001), and lower all-cause and lung cancer-specific mortality (p < 0.001). Recipients of non-program-based care were considerably less likely to receive lung cancer treatment; results remained consistent when patients receiving no treatment were excluded. Conclusions: Program-based care was associated with substantially better survival. Increasing access to program-based care should be explored as a matter of urgent public policy.

Timing of Kidney Replacement Therapy Initiation and Survival during Pediatric Extracorporeal Membrane Oxygenation: An Extracorporeal Life Support Organization Registry Study.

To characterize kidney replacement therapy (KRT) and pediatric extracorporeal membrane oxygenation (ECMO) outcomes and to identify the optimal timing of KRT initiation during ECMO associated with increased survival. Observational retrospective cohort study using the Extracorporeal Life Support Organization Registry database in children (0-18 yo) on ECMO from January 1, 2016, to December 31, 2020. Of the 14,318 ECMO runs analyzed, 26% of patients received KRT during ECMO. Patients requiring KRT before ECMO had increased mortality to ECMO decannulation (29% vs. 17%, OR 1.97, P < 0.001) and to hospital discharge (58% vs. 39%, OR 2.16, P < 0.001). Patients requiring KRT during ECMO had an increased mortality to ECMO decannulation (25% vs. 15%, OR 1.85, P < 0.001) and to hospital discharge (56% vs. 34%, OR 2.47, P < 0.001). Multivariable logistic regression demonstrated that the need for KRT during ECMO was an independent predictor for mortality to ECMO decannulation (OR 1.49, P < 0.001) and to hospital discharge (OR 2.02, P < 0.001). Patients initiated on KRT between 24 and 72 hours after cannulation were more likely to survive to ECMO decannulation and showed a trend towards survival to hospital discharge as compared to those initiated before 24 hours and after 72 hours.

Perceived Health Needs of Church Leaders and Members: A Secondary Data Analysis of the Mid-South Congregational Health Survey.

Needs assessments have been successful in helping communities and congregations focus their health ministry efforts; however, most have used leader perceptions of congregational health needs. The purpose of this study was to examine and compare the self-reported needs of both church leaders and members to be addressed by their congregation. Church leaders (n = 369) and members (n = 459) from 92 congregations completed the 2019 Mid-South Congregational Health Survey. Frequencies and generalized linear mixed models (GLMM) were performed to examine the top 10 self-reported needs and associations by church role, respectively. Of the top 10 congregational needs, anxiety or depression, high blood pressure, stress, and healthy foods were ranked identically regardless of church role. Church leaders perceived obesity and diabetes to be important congregational health needs, whereas members perceived affordable health care and heart disease to be important congregational health needs. GLMM, controlling for within-church clustering and covariates, revealed church leaders were more likely than members to report obesity (odds ratio [OR]: 1.93, 95% confidence interval [CI] = [1.39, 2.67], p < .0001) and diabetes (OR: 1.73, 95% CI = [1.24, 2.41], p = .001) as congregational needs. Findings display similarities and differences in needs reported by church role. Including many perspectives when conducting congregational health needs assessments will assist the development of effective faith-based health promotion programs.

Two Interventions on Pathologic Nodal Staging in a Population-Based Lung Cancer Resection Cohort.

BACKGROUND: Despite its prognostic importance, poor pathologic nodal staging of lung cancer prevails. We evaluated the impact of 2 interventions to improve pathologic nodal staging. METHODS: We implemented a lymph node specimen collection kit to improve intraoperative lymph node collection (surgical intervention) and a novel gross dissection method for intrapulmonary node retrieval (pathology intervention) in nonrandomized stepped-wedge fashion, involving 12 hospitals and 7 pathology groups. We used standard statistical methods to compare surgical quality and survival of patients who had neither intervention (group 1), pathology intervention only (group 2), surgical intervention only (group 3), and both interventions (group 4). RESULTS: Of 4019 patients from 2009 to 2021, 50%, 5%, 21%, and 24%, respectively, were in groups 1 to 4. Rates of nonexamination of lymph nodes were 11%, 9%, 0%, and 0% and rates of nonexamination of mediastinal lymph nodes were 29%, 35%, 2%, and 2%, respectively, in groups 1 to 4 (P < .0001). Rates of attainment of American College of Surgeons Operative Standard 5.8 were 22%, 29%, 72%, and 85%; and rates of International Association for the Study of Lung Cancer complete resection were 14%, 21%, 53%, and 61% (P < .0001). Compared with group 1, adjusted hazard ratios for death were as follows: group 2, 0.93 (95% CI, 0.76-1.15); group 3, 0.91 (0.78-1.03); and group 4, 0.75 (0.64-0.87). Compared with group 2, group 4 adjusted hazard ratio was 0.72 (0.57-0.91); compared with group 3, it was 0.83 (0.69-0.99). These relationships remained after exclusion of wedge resections. CONCLUSIONS: Combining a lymph node collection kit with a novel gross dissection method significantly improved pathologic nodal evaluation and survival.

Incidentally Detected Lung Cancer in Persons Too Young or Too Old for Lung Cancer Screening in a Mississippi Delta Cohort.

INTRODUCTION: Lung cancer risk in screening age-ineligible persons with incidentally detected lung nodules is poorly characterized. We evaluated lung cancer risk in two age-ineligible Lung Nodule Program (LNP) cohorts. METHODS: Prospective observational study comparing 2-year cumulative lung cancer diagnosis risk, lung cancer characteristics, and overall survival between low-dose computed tomography (LDCT) screening participants aged 50 to 80 years and LNP participants aged 35 to younger than 50 years (young) and older than 80 years (elderly). RESULTS: From 2015 to 2022, lung cancer was diagnosed in 329 (3.43%), 39 (1.07%), and 172 (6.87%) LDCT, young, and elderly LNP patients, respectively. The 2-year cumulative incidence was 3.0% (95% confidence intervals [CI]: 2.6%-3.4%) versus 0.79% (CI: 0.54%-1.1%) versus 6.5% (CI: 5.5%-7.6%), respectively, but lung cancer diagnosis risk was similar between young LNP and Lung CT Screening Reporting and Data System (Lung-RADS) 1 (adjusted hazard ratio [aHR] = 0.88 [CI: 0.50-1.56]) and Lung-RADS 2 (aHR = 1.0 [0.58-1.72]). Elderly LNP risk was greater than Lung-RADS 3 (aHR = 2.34 [CI: 1.50-3.65]), but less than 4 (aHR = 0.28 [CI: 0.22-0.35]). Lung cancer was stage I or II in 62.92% of LDCT versus 33.33% of young (p = 0.0003) and 48.26% of elderly (p = 0.0004) LNP cohorts; 16.72%, 41.03%, and 29.65%, respectively, were diagnosed at stage IV. The aggregate 5-year overall survival rates were 57% (CI: 48-67), 55% (CI: 39-79), and 24% (CI: 15-40) (log-rank p < 0.0001). Results were similar after excluding persons with any history of cancer. CONCLUSIONS: LNP modestly benefited persons too young or old for screening. Differences in clinical characteristics and outcomes suggest differences in biological characteristics of lung cancer in these three patient cohorts.

Lung Cancer Patients' and Caregivers' Satisfaction With Multidisciplinary Versus Serial Care in a Community Healthcare Setting: A Prospective Comparative-Effectiveness Cohort Study.

BACKGROUND: Multidisciplinary Care is recommended for complex oncologic conditions. We compared lung cancer patients' and caregivers' satisfaction with Multidisciplinary Care to routine, serial care. MATERIALS AND METHODS: We analyzed validated surveys administered at baseline, 3 and 6 months to patients and their caregivers enrolled in a prospective cohort comparative-effectiveness study of Multidisciplinary versus Serial Care (clinicaltrials.gov NCT02123797). Multivariate mixed linear models examined the cross-group differences, time-related variances, and how interaction between groups and time-periods influenced satisfaction. RESULTS: Compared to serial care (N = 297), the Multidisciplinary Care cohort (N = 159), was older (69 vs. 66 years), had earlier clinical stage (41% vs. 33% stage I/II), and less severe symptoms (45% vs. 35% asymptomatic). Demographic and social-economic characteristics of caregivers (N = 99 for Multidisciplinary and 123 for Serial Care, respectively) were similar. Multidisciplinary Care patients and caregivers were more likely to perceive their care to be better than that of other patients (p < .01). Although Serial Care patients and caregivers expressed greater satisfaction with their treatment plan (p < .01 patients, p = 0.04 caregivers), Multidisciplinary Care patients showed greater improvement at 6-months (p < .01). Multidisciplinary Care patients and caregivers reported better overall satisfaction with team members (p < .01) while Serial Care patients had greater improvement in their satisfaction with team members at 6-months (p = .04). Multidisciplinary Care patients perceived more financial burden at 6-months compared to Serial Care patients (p = .04). CONCLUSION: Patient-caregiver dyads had mixed perceptions of their care experience. Recipients of Multidisciplinary Care perceived better experience with care and team members; Serial Care recipients expressed greater satisfaction with their treatment plan.

Surgeon Quality and Patient Survival After Resection for Non-Small-Cell Lung Cancer.

PURPOSE: The quality and outcomes of curative-intent lung cancer surgery vary in populations. Surgeons are key drivers of surgical quality. We examined the association between surgeon-level intermediate outcomes differences, patient survival differences, and potential mitigation by processes of care. PATIENTS AND METHODS: Using a baseline population-based surgical resection cohort, we derived surgeon-level cut points for rates of positive margins, nonexamination of lymph nodes, nonexamination of mediastinal lymph nodes, and wedge resections. Applying the baseline cut points to a subsequent cohort from the same population-based data set, we assign surgeons into three performance categories in reference to each metric: 1 (<25th percentile), 2 (25th-75th percentile), and 3 (>75th percentile). The sum of performance scores created three surgeon quality tiers: 1 (4-6, low), 2 (7-9, intermediate), and 3 (10-12, high). We used chi-squared, Wilcoxon-Mann-Whitney, and Kruskal-Wallis tests to compare patient characteristics between the baseline and subsequent cohorts and across surgeon tiers. We applied Cox proportional hazards models to examine the association between patient survival and surgeon performance tier, sequentially adjusting for clinical stage, patient characteristics, and four specific processes. RESULTS: From 2009 to 2021, 39 surgeons performed 4,082 resections across the baseline and subsequent cohorts. Among 31 subsequent cohort surgeons, five were tier 1, five were tier 2, and 21 were tier 3. Tier 1 and 2 surgeons had significantly worse outcomes than tier 3 surgeons (hazard ratio [HR], 1.37; 95% CI, 1.10 to 1.72 and 1.19; 95% CI, 1.00 to 1.43, respectively). Adjustment for specific processes mitigated the surgeon-tiered survival differences, with adjusted HRs of 1.02 (95% CI, 0.8 to 1.3) and 0.93 (95% CI, 0.7 to 1.25), respectively. CONCLUSION: Readily accessible intermediate outcomes metrics can be used to stratify surgeon performance for targeted process improvement, potentially reducing patient survival disparities.

Institution-Level Evolution of Lung Cancer Resection Quality With Implementation of a Lymph Node Specimen Collection Kit.

INTRODUCTION: Lung cancer surgery with a lymph node kit improves patient-level outcomes, but institution-level impact is unproven. METHODS: Using an institutional stepped-wedge implementation study design, we compared lung cancer resection quality between institutions in preimplementation and postimplementation phases of kit deployment and, within implementing institutions, resections without versus with the kit. Benchmarks included rates of nonexamination of lymph nodes, nonexamination of mediastinal lymph nodes, and attainment of American College of Surgeons Operative Standard 5.8. We report institution-level adjusted ORs (aORs) for attaining quality benchmarks. RESULTS: From 2009 to 2020, three preimplementing hospitals had 953 resections; 11 implementing hospitals had 4013 resections, 58% without and 42% with the kit. Quality was better in implementing institutions and with kit cases. Compared with preimplementing institutions, the aOR for nonexamination of lymph nodes was 0.62 (0.49-0.8, p = 0.002), nonexamination of mediastinal lymph nodes was 0.56 (0.47-0.68, p < 0.0001), and attainment of Operative Standard 5.8 was 7.3 (5.6-9.4, p < 0.0001); aORs for kit cases were 0.01 (0.001-0.06), 0.08 (0.06-0.11), and 11.6 (9.9-13.7), respectively (p < 0.0001 for all). Surgical quality was persistently poor in preimplementing institutions but sequentially improved in implementing institutions in parallel with kit adoption. In implementing institutions, resections with the kit had a uniformly high level of quality, whereas nonkit cases had a low level of quality, approximating that of preimplementing institutions. Within implementing institutions, 5-year overall survival was 61% versus 51% after surgery with versus without the kit (p < 0.001). CONCLUSIONS: Surgery with a lymph node specimen collection kit improved institution-level quality of curative-intent lung cancer resection.

Food security status and breast cancer screening among women in the United States: Evidence from the Health and Retirement Study and Health Care and Nutrition Study.

PURPOSE: To assess the impact of food insecurity on biennial breast cancer screenings (i.e., mammography or breast X-ray) among older women in the United States (US). METHODS: Data from the 2014 and 2016 waves of the Health and Retirement Study and the 2013 Health Care and Nutrition Study were used. The analyses were limited to a nationally representative sample of 2,861 women between 50 and 74 years of age, residing in the US. We employed a propensity score weighting method to balance observed confounders between food-secure and food-insecure women and fit a binary logistic regression to investigate population-level estimates for the association between food security and breast cancer screening. RESULTS: Food insecurity was significantly associated with failure to obtain a mammogram or breast X-ray within the past two years. Food-insecure women had 54% lower odds of reporting breast cancer screening in the past 2 years (adjusted OR = 0.46; 95% CI 0.30-0.70, p-value < 0.001) as compared to food-secure women. Additional factors associated with a higher likelihood of receiving breast cancer screenings included greater educational attainment, higher household income, regular access to health care/advice, not smoking, and not being physically disabled or experiencing depressive symptoms. CONCLUSION: Results demonstrate a socioeconomic gradient existing in regard to the utilization of regular breast cancer screenings among women. Those who tend to have lower education, lower income, and lack of reliable healthcare access are more likely to be food insecure. Thus, more likely to face the financial, logistical, or environmental barriers in obtaining screening services that accompany food insecurity.

Children with amblyaudia show less flexibility in auditory cortical entrainment to periodic non-speech sounds.

OBJECTIVE: We investigated auditory temporal processing in children with amblyaudia (AMB), a subtype of auditory processing disorder (APD), via cortical neural entrainment. DESIGN AND STUDY SAMPLES: Evoked responses were recorded to click-trains at slow vs. fast (8.5 vs. 14.9/s) rates in n = 14 children with AMB and n = 11 age-matched controls. Source and time-frequency analyses (TFA) decomposed EEGs into oscillations (reflecting neural entrainment) stemming from bilateral auditory cortex. RESULTS: Phase-locking strength in AMB depended critically on the speed of auditory stimuli. In contrast to age-matched peers, AMB responses were largely insensitive to rate manipulations. This rate resistance occurred regardless of the ear of presentation and in both cortical hemispheres. CONCLUSIONS: Children with AMB show less rate-related changes in auditory cortical entrainment. In addition to reduced capacity to integrate information between the ears, we identify more rigid tagging of external auditory stimuli. Our neurophysiological findings may account for domain-general temporal processing deficits commonly observed in AMB and related APDs behaviourally. More broadly, our findings may inform communication strategies and future rehabilitation programmes; increasing the rate of stimuli above a normal (slow) speech rate is likely to make stimulus processing more challenging for individuals with AMB/APD.

The effect of exposure to tobacco smoking-related media messages on youths' smoking behavior in Jordan: A longitudinal, school-based study.

Only a few studies investigated the link between tobacco smoking-related media and youth smoking in the Eastern Mediterranean Region (EMR). This study aimed to assess the influence of both promotional and control messages on cigarette smoking behavior among young Jordanian students. Generalized Linear Mixed Models were analyzed using data from the Irbid Longitudinal Smoking Study that followed a random sample of 2174 students (2008-2011). We examined the associations of media messaging with smoking behavior, as well as intention-to-quit smoking, and intention-to-start smoking, among young adolescents. At baseline, 12.2% and 43.7% of students were exposed to only pro-smoking or only anti-smoking messages, while 41.8% were equally exposed to both. Exposure to anti-smoking messages was associated with lower odds of ever smoking at baseline among girls (AOR = 0.4; 95% CI: 0.2, 0.8). Boys who were exposed to anti-smoking messages were more likely to report an intention to quit, with borderline significance (AOR = 2.0; 95% CI: 0.9, 4.1). The cumulative exposure to anti-smoking messages over time was associated with lower odds of intention to smoke among girls (AOR = 0.5; 95% CI: 0.3, 0.9) but with higher odds among boys (AOR = 1.8; 95% CI: 1.0, 3.1). In both sexes, media messaging was not associated with progression of the smoking habit. In conclusion, this comprehensive analysis of both pro- and anti-smoking messages advances our understanding of their role in influencing youths' smoking behaviors, and could guide the development of evidence-based interventions to address adolescent tobacco smoking in Jordan and the EMR.

Prospective Comparative Effectiveness Trial of Multidisciplinary Lung Cancer Care Within a Community-Based Health Care System.

PURPOSE: Multidisciplinary lung cancer care is assumed to improve care delivery by increasing transparency, objectivity, and shared decision making; however, there is a lack of high-level evidence demonstrating its benefits, especially in community-based health care systems. We used implementation and team science principles to establish a colocated multidisciplinary lung cancer clinic in a large community-based health care system and evaluated patient experience and outcomes within and outside this clinic. METHODS: We conducted a prospective frequency-matched comparative effectiveness study (ClinicalTrials.gov identifier: NCT02123797) evaluating the thoroughness of lung cancer staging, receipt of stage-appropriate treatment, and survival between patients receiving care in the multidisciplinary clinic and those receiving usual serial care. Target enrollment was 150 patients on the multidisciplinary arm and 300 on the serial care arm. We frequency-matched patients by clinical stage, performance status, insurance type, race, and age. RESULTS: A total of 526 patients were enrolled: 178 on the multidisciplinary arm and 348 on the serial care arm. After adjusting for other factors, multidisciplinary patients had significantly higher odds (odds ratio [OR]: 2.3 [95% CI, 1.5 to 3.4]) of trimodality staging compared with serial care. Patients on the multidisciplinary arm also had higher odds of receiving invasive stage confirmation (OR: 2.0 [95% CI, 1.4 to 3.1]) and mediastinal stage confirmation (OR: 1.9 [95% CI, 1.3 to 2.8]). Additionally, patients receiving multidisciplinary care were significantly more likely to receive stage-appropriate treatment (OR: 1.8 [95% CI, 1.1 to 3.0]). We found no significant difference in overall or progression-free survival between study arms. CONCLUSION: The multidisciplinary clinic delivered significant improvements in evidence-based quality care on multiple levels. Even in the absence of a demonstrable survival benefit, these findings provide a strong rationale for recommending this model of care.

Right Atrial Lines as Primary Access for Postoperative Pediatric Cardiac Patients.

To characterize the use of right atrial lines (RALs) as primary access in the postoperative care of neonatal and pediatric patients after cardiothoracic surgery and to identify risk factors associated with RAL complications. Observational retrospective cohort study in pediatric cardiac patients who underwent RAL placement in a tertiary children's hospital from January 2011 through June 2018. A total of 692 children with congenital heart disease underwent 815 RAL placements during the same or subsequent cardiothoracic surgeries during the study period. Median age and weight were 22 days (IQR 7-134) and 3.6 kg (IQR 3.1-5.3), respectively. Neonates accounted for 53.5% of patients and those with single-ventricle physiology were 35.4%. Palliation surgery (shunts, cavo-pulmonary connections, hybrid procedures, and pulmonary artery bandings) accounted for 38%. Survival to hospital discharge was 95.5%. Median RAL duration was 11 days (IQR 7-19) with a median RAL removal to hospital discharge time of 0 days (IQR 0-3). Thrombosis and migration were the most prevalent complications (1.7% each), followed by malfunction (1.4%) and infection (0.7%). Adverse events associated with complications were seen in 12 (1.4%) of these RAL placements: decrease in hemoglobin (n = 1), tamponade requiring pericardiocentesis (n = 3), pleural effusion requiring chest tube (n = 2), and need for antimicrobials (n = 6). Multivariable logistic regression showed that RAL duration (OR 1.01, p = 0.006) and palliation surgery (OR 2.38, p = 0.015) were significant and independent factors for complications. The use of RALs as primary access in postoperative pediatric cardiac patients seems to be feasible and safe. Our overall incidence of complications from prolonged use of RALs remained similar or lower to that reported with short-term use of these lines. While RAL duration and palliation surgeries seemed to be associated with complications, severity of illness could be a confounding factor. A prospective assessment of RAL complications may improve outcomes in this medically complex population.