Cardiovascular disease risk in long-term breast cancer survivors: A population-based cohort study.

BACKGROUND: Breast cancer survival is increasing, making late effects such as cardiovascular disease (CVD) more relevant. The purpose of this study was to evaluate incident CVD following breast cancer diagnosis among long-term survivors and to investigate possible risk factors for CVD. METHODS: A population-based cohort of 6641 breast cancer survivors diagnosed between 1997 and 2009 who survived at least 10 years was identified within the Utah Cancer Registry. In addition, 36,612 cancer-free women from the general population, matched by birth year and state, were identified within the Utah Population Database. Cox proportional hazards models were used to calculate CVD hazard ratios (HRs) for >10 to 15 and >15 years. RESULTS: Long-term breast cancer survivors had an increased risk of newly diagnosed diseases of the circulatory system (HR, 1.32; 99% confidence interval [CI], 1.00-1.75) from 10 to 15 years following cancer diagnosis compared with the general population. No increased CVD risks were observed after 15 years. Breast cancer survivors with Charlson Comorbidity Index score ≥2 had a significantly higher risk of diseases of the circulatory system (HR, 2.64; 95% CI, 1.08-6.45) beyond 10 years following breast cancer diagnosis. Similarly, older age, obesity, lower education, and family history of CVD and breast cancer were risk factors for heart and circulatory system diseases among long-term breast cancer survivors. CONCLUSION: Risk of CVD compared to the general population was moderate among this cohort of long-term breast cancer survivors between 10 to 15 years since cancer diagnosis. Awareness of CVD risks is important for breast cancer survivors.

Mental health disorders are more common in patients with Hodgkin lymphoma and may negatively impact overall survival.

BACKGROUND: Long-term mental health outcomes were characterized in patients who were diagnosed with Hodgkin lymphoma (HL), and risk factors for the development of mental health disorders were identified. METHODS: Patients who were diagnosed with HL between 1997 and 2014 were identified in the Utah Cancer Registry. Each patient was matched with up to five individuals from a general population cohort identified within the Utah Population Database, a unique source of linked records that includes patient and demographic data. RESULTS: In total, 795 patients who had HL were matched with 3575 individuals from the general population. Compared with the general population, patients who had HL had a higher risk of any mental health diagnosis (hazard ratio, 1.77; 95% confidence interval, 1.57-2.00). Patients with HL had higher risks of anxiety, depression, substance-related disorders, and suicide and intentional self-inflicted injuries compared with the general population. The main risk factor associated with an increased risk of being diagnosed with mental health disorders was undergoing hematopoietic stem cell transplantation, with a hazard ratio of 2.06 (95% confidence interval, 1.53-2.76). The diagnosis of any mental health disorder among patients with HL was associated with a detrimental impact on overall survival; the 10-year overall survival rate was 70% in patients who had a mental health diagnosis compared with 86% in those patients without a mental health diagnosis (p < .0001). CONCLUSIONS: Patients who had HL had an increased risk of various mental health disorders compared with a matched general population. The current data illustrate the importance of attention to mental health in HL survivorship, particularly for patients who undergo therapy with hematopoietic stem cell transplantation.

Identifying patients who access musculoskeletal physical therapy: a retrospective cohort analysis.

BACKGROUND: Musculoskeletal conditions are common and cause high levels of disability and costs. Physical therapy is recommended for many musculoskeletal conditions. Past research suggests that referral rates appear to have increased over time, but the rate of accessing a physical therapist appears unchanged. OBJECTIVE: Our retrospective cohort study describes the rate of physical therapy use after referral for a variety of musculoskeletal diagnoses while comparing users and non-users of physical therapy services after referral. METHODS: The study sample included patients in the University of Utah Health system who received care from a medical provider for a musculoskeletal condition. We included a comprehensive set of variables available in the electronic data warehouse possibly associated with attending physical therapy. Our primary analysis compared differences in patient factors between physical therapy users and non-users using Poisson regression. RESULTS: 15 877 (16%) patients had a referral to physical therapy, and 3812 (24%) of these patients accessed physical therapy after referral. Most of the factors included in the model were associated with physical therapy use except for sex and number of comorbidities. The receiver operating characteristic curve was 0.63 suggesting poor predictability of the model but it is likely related to the heterogeneity of the sample. CONCLUSIONS: We found that obesity, ethnicity, public insurance and urgent care referrals were associated with poor adherence to physical therapy referral. However, the limited predictive power of our model suggests a need for a deeper examination into factors that influence patients access to a physical therapist.

Evaluation of the literature: evidence assessment tools for clinicians.

The progressive improvement in the quality of scientific articles has led to an increase in difficulty in reading and interpreting them so that now clinical knowledge and experience must be complemented by methodological, statistical and computer skills. The aim of this article is to offer practitioners the tools, the simplest keys, that will allow them to understand and critically judge the results of scientific studies. The "peer-review" process of a clinical article submitted to a journal is described and the Science Citation Index and the Impact Factor are presented to the reader as essential instruments to evaluate a specific article's impact and the impact of a given journal on the scientific world, respectively. An article should be evaluated on the basis of some key issues which include, at least, an assessment of methodological aspects, a critical analysis of the statistical component and a proper understanding of the clinical impact of the study outcomes. The standard approach for evaluating the quality of individual studies is based on a hierarchical grading system of research design which represents an essential tool to identify the strength of the evidence of an article. Many different biases may affect the reliability of study results. Randomized Control Trials (RCTs) and Systematic Reviews (SRs) are able to minimize the number of biases and thus are at the highest level of the scale of evidence representing the final steps of a treatment's "career." Finally, moving from research to clinical practice, attention on the clinical impact of study's outcomes is of paramount importance as the literature contains studies (including RCTs) that present statistically significant results but which, from the clinical standpoint, are only relatively or not at all significant. Clinical Practice Guidelines represent a useful tool for practitioners assisting the decision-making process when choosing the most appropriate treatment for their patients.

Cumulative Incidence of All-Cause Knee Injury, Concussion, and Stress Fracture among Transgender Patients on Gender-Affirming Hormone Therapy: An Exploratory Retrospective Cohort Study.

Previous research has shown a discrepancy in incidences of knee injuries, stress fractures, and concussions between cisgender men and women. Little is known regarding the incidence of musculoskeletal injuries among patients on gender-affirming hormone therapy (GAHT). This retrospective cohort study examines cumulative incidence of knee injuries, concussions, and stress fracture injuries among transgender patients on GAHT at one health system from 2011-2020. Using relevant ICD-9 and 10 codes, incidences of knee injury, concussion, and stress fracture were calculated. Cohorts included 1971 transgender and 3964 cisgender patients. Transgender patients had significantly higher incidence of all-cause knee injuries over the study period, 109 (5.5%) versus 175 (4.4%) (p < 0.001; OR: 2.14, 95% CI [1.17-3.92]). Subgroup analysis showed significantly higher incidence of knee injuries among cisgender men (5.6%) versus cisgender women (4.1%) (p = 0.042) and among transgender women (6.6%) versus cisgender women (4.1%) (p = 0.005). There were no significant differences between incidences of concussion and stress fracture between groups. This sample showed that patients on GAHT had increased cumulative incidences of all-cause knee injury compared to controls but similar cumulative incidences of concussion and bone-stress injuries. Transgender women on exogenous estrogen had significantly higher cumulative incidences of all-cause knee injuries compared to cisgender women.

Generating Older Adult Multimorbidity Trajectories Using Various Comorbidity Indices and Calculation Methods.

Background and Objectives: Older adult multimorbidity trajectories are helpful for understanding the current and future health patterns of aging populations. The construction of multimorbidity trajectories from comorbidity index scores will help inform public health and clinical interventions targeting those individuals that are on unhealthy trajectories. Investigators have used many different techniques when creating multimorbidity trajectories in prior literature, and no standard way has emerged. This study compares and contrasts multimorbidity trajectories constructed from various methods. Research Design and Methods: We describe the difference between aging trajectories constructed with the Charlson Comorbidity Index (CCI) and Elixhauser Comorbidity Index (ECI). We also explore the differences between acute (single-year) and chronic (cumulative) derivations of CCI and ECI scores. Social determinants of health can affect disease burden over time; thus, our models include income, race/ethnicity, and sex differences. Results: We use group-based trajectory modeling (GBTM) to estimate multimorbidity trajectories for 86,909 individuals aged 66-75 in 1992 using Medicare claims data collected over the following 21 years. We identify low-chronic disease and high-chronic disease trajectories in all 8 generated trajectory models. Additionally, all 8 models satisfied prior established statistical diagnostic criteria for well-performing GBTM models. Discussion and Implications: Clinicians may use these trajectories to identify patients on an unhealthy path and prompt a possible intervention that may shift the patient to a healthier trajectory.

Design of an interface to communicate artificial intelligence-based prognosis for patients with advanced solid tumors: a user-centered approach.

OBJECTIVES: To design an interface to support communication of machine learning (ML)-based prognosis for patients with advanced solid tumors, incorporating oncologists' needs and feedback throughout design. MATERIALS AND METHODS: Using an interdisciplinary user-centered design approach, we performed 5 rounds of iterative design to refine an interface, involving expert review based on usability heuristics, input from a color-blind adult, and 13 individual semi-structured interviews with oncologists. Individual interviews included patient vignettes and a series of interfaces populated with representative patient data and predicted survival for each treatment decision point when a new line of therapy (LoT) was being considered. Ongoing feedback informed design decisions, and directed qualitative content analysis of interview transcripts was used to evaluate usability and identify enhancement requirements. RESULTS: Design processes resulted in an interface with 7 sections, each addressing user-focused questions, supporting oncologists to "tell a story" as they discuss prognosis during a clinical encounter. The iteratively enhanced interface both triggered and reflected design decisions relevant when attempting to communicate ML-based prognosis, and exposed misassumptions. Clinicians requested enhancements that emphasized interpretability over explainability. Qualitative findings confirmed that previously identified issues were resolved and clarified necessary enhancements (eg, use months not days) and concerns about usability and trust (eg, address LoT received elsewhere). Appropriate use should be in the context of a conversation with an oncologist. CONCLUSION: User-centered design, ongoing clinical input, and a visualization to communicate ML-related outcomes are important elements for designing any decision support tool enabled by artificial intelligence, particularly when communicating prognosis risk.

Comparative effectiveness research in evidence-based dental practice.

Will evidence-based dental practice (EBDP) benefit from the projected new drive for comparative effectiveness research (CER)? Optimists may answer Yes certainly, because CER and EBDP are intertwined, and benefit and feed on each other. Others may be more cautious. Any differences in opinion likely arise because the similarities and the differences between CER and EBDP are not clear cut.

Antibiotic Treatment of Suspected and Confirmed Neonatal Sepsis Within 28 Days of Birth: A Retrospective Analysis.

Neonatal sepsis causes significant mortality and morbidity worldwide. Diagnosis is usually confirmed via blood culture results. Blood culture sepsis confirmation can take days and suffer from contamination and false negatives. Empiric therapy with antibiotics is common. This study aims to retrospectively describe and compare treatments of blood culture-confirmed and unconfirmed, but suspected, sepsis within the University of Utah Hospital system. Electronic health records were obtained from 1,248 neonates from January 1, 2006, to December 31, 2017. Sepsis was categorized into early-onset (≤3 days of birth, EOS) and late-onset (>3 and ≤28 days of birth, LOS) and categorized as culture-confirmed sepsis if a pathogen was cultured from the blood and unconfirmed if all blood cultures were negative with no potentially contaminated blood cultures. Of 1,010 neonates in the EOS cohort, 23 (2.3%) were culture-confirmed, most with Escherichia coli (42%). Treatment for unconfirmed EOS lasted an average of 6.1 days with primarily gentamicin and ampicillin while confirmed patients were treated for an average of 12.3 days with increased administration of cefotaxime. Of 311 neonates in the LOS cohort, 62 (20%) were culture-confirmed, most culturing coagulase negative staphylococci (46%). Treatment courses for unconfirmed LOS lasted an average of 7.8 days while confirmed patients were treated for an average of 11.4 days, these patients were primarily treated with vancomycin and gentamicin. The use of cefotaxime for unconfirmed EOS and LOS increased throughout the study period. Cefotaxime administration was associated with an increase in neonatal mortality, even when potential confounding factors were added to the logistic regression model (adjusted odds ratio 2.8, 95%CI [1.21, 6.88], p = 0.02). These results may not be generalized to all hospitals and the use of cefotaxime may be a surrogate for other factors. Given the low rate of blood culture positive diagnosis and the high exposure rate of empiric antibiotics, this patient population might benefit from improved diagnostics with reevaluation of antibiotic use guidelines.

External Validation of a Machine Learning Model to Predict 6-Month Mortality for Patients With Advanced Solid Tumors.

This prognostic study performed external validation of a machine learning model to predict 6-month mortality among patients with advanced solid tumors.

Clinical decision support complements evidence-based decision making in dental practice.

Dental professionals as well as consumers of dental health care are driving the demand for access to reliable information so they can make more informed decisions. Clinical decision support (CDS) includes a variety of printed and electronic tools, systems, products, and services that make knowledge and information available to the user. CDS is the main way people will be able to access important facts, ideas, concepts, and the latest thinking about personal and population-based health subjects. CDS has its greatest potential at the point of care where it can facilitate good-quality evidence-based decision-making.

The translational clinical practice system: a way to implement the evidence-based approach in the dental office.

Evidence-based decision-making in dental practice is challenging and rewarding. But for many clinicians, the evidence-based approach is an abstract and even theoretical idea that sounds good, but is not very practical. The Translational Clinical Practice System provides an overriding domain and a system within which the evidence-based approach may be more effectively utilized in clinical practice. Most would agree that using good evidence, information, and data as the basis for decisions are the starting points toward reaching the best results for the patient. However, there are clearly insufficiencies in the currently available best scientific evidence for many of the procedures patients need. The good news is that the evidence environment is improving and better quality information is becoming available in the office where it is needed. This article describes a logical and straightforward approach for clinicians to use in order to put together complex and often interwoven factors involved with patient care. Specific clinical examples are provided.

Evaluation of a porcine collagen matrix used to augment keratinized tissue and increase soft tissue thickness around existing dental implants.

Implant-supported prostheses often present with mucogingival deficiencies that may cause esthetic or hygienic issues. These issues may present as limited or no keratinized tissue, irregular soft tissue contour or concavity, and gray "showthrough" of the implant abutment and root forms. An interpositional soft tissue graft substitute that generates keratinized tissue and increases soft tissue thickness would be beneficial, as it would reduce donor site morbidity and be available in unlimited, off-the-shelf supply. Thirty patients were assessed as part of a multicenter, practice-based evaluation of the material. A xenogeneic collagen matrix was placed as an interpositional graft on the buccal aspect of implant sites; sites were reassessed at 6 months posttreatment. Results indicated that the collagen matrix increased tissue thickness and keratinized tissue around existing dental implants.