The use of electronic health records to inform cancer surveillance efforts: a scoping review and test of indicators for public health surveillance of cancer prevention and control.

INTRODUCTION: State cancer prevention and control programs rely on public health surveillance data to set objectives to improve cancer prevention and control, plan interventions, and evaluate state-level progress towards achieving those objectives. The goal of this project was to evaluate the validity of using electronic health records (EHRs) based on common data model variables to generate indicators for surveillance of cancer prevention and control for these public health programs. METHODS: Following the methodological guidance from the PRISMA Extension for Scoping Reviews, we conducted a literature scoping review to assess how EHRs are used to inform cancer surveillance. We then developed 26 indicators along the continuum of the cascade of care, including cancer risk factors, immunizations to prevent cancer, cancer screenings, quality of initial care after abnormal screening results, and cancer burden. Indicators were calculated within a sample of patients from the New York City (NYC) INSIGHT Clinical Research Network using common data model EHR data and were weighted to the NYC population using post-stratification. We used prevalence ratios to compare these estimates to estimates from the raw EHR of NYU Langone Health to assess quality of information within INSIGHT, and we compared estimates to results from existing surveillance sources to assess validity. RESULTS: Of the 401 identified articles, 15% had a study purpose related to surveillance. Our indicator comparisons found that INSIGHT EHR-based measures for risk factor indicators were similar to estimates from external sources. In contrast, cancer screening and vaccination indicators were substantially underestimated as compared to estimates from external sources. Cancer screenings and vaccinations were often recorded in sections of the EHR that were not captured by the common data model. INSIGHT estimates for many quality-of-care indicators were higher than those calculated using a raw EHR. CONCLUSION: Common data model EHR data can provide rich information for certain indicators related to the cascade of care but may have substantial biases for others that limit their use in informing surveillance efforts for cancer prevention and control programs.

Carcinogen Biomarkers in the Urine of Electronic Cigarette Users and Implications for the Development of Bladder Cancer: A Systematic Review.

CONTEXT: Use of electronic cigarettes (e-cigarettes) has rapidly increased despite unclear longitudinal health effects. Once thought to be a safer alternative to tobacco smoke, it is possible that e-cigarettes expose the user to similar carcinogenic byproducts during the vaping process. These toxicants are metabolized and excreted in the urine, and may have oncogenic implications for bladder urothelium. OBJECTIVE: To characterize and summarize known urinary carcinogenic biomarkers in e-cigarette users as they relate to the risk of developing bladder cancer. EVIDENCE ACQUISITION: A systematic literature search was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and included PubMed, Embase, Web of Science, and Cochrane Central Register of Controlled Trials (CENTRAL). Relevant articles published in peer-reviewed journals, through January 2019, that reported on urinary biomarkers in e-cigarettes users were included. Parent compounds and urinary biomarkers were classified according to the International Agency for Research on Cancer Monographs on the Evaluation of Carcinogenic Risks to Humans and cross referenced using the Collaborative on Health and the Environment, Toxicant and Disease Database to determine a link to bladder cancer, grouped by strength of evidence. EVIDENCE SYNTHESIS: Our initial search identified 1385 articles, 22 of which met final inclusion criteria and were included for analysis. In summation, these studies described 40 different parent compounds and four metals found in the urine of e-cigarette users. Since each parent compound can be metabolized several different ways, 63 unique toxicant or carcinogenic metabolite biomarkers were identified. Compared with nonuser controls, e-cigarette users had higher concentrations of urinary biomarkers of several carcinogenic compounds linked to bladder cancer. The majority of studies were limited by heterogeneous reporting and a dearth of control individuals who had never smoked. CONCLUSIONS: Biomarkers of carcinogens, several with a strong link to bladder cancer, are present in the urine of e-cigarette users. Long-term implications of urothelial exposure to these toxicants are unknown but concerning, given the similarities to tobacco smoke and its established relationship with bladder cancer. Further study on the urological safety of e-cigarettes is necessary. PATIENT SUMMARY: Our review shows that several carcinogens that have a known link to bladder cancer are present in the urine of electronic cigarette (e-cigarette) users. Further study on the urological safety of e-cigarettes is necessary.

Effectiveness of diet and physical activity interventions among Chinese-origin populations living in high income countries: a systematic review.

BACKGROUND: This review examines the effectiveness of diet and physical activity interventions to reduce cardiometabolic risk among Chinese immigrants and their descendants living in high income countries. The objective of this review is to provide information to help build future interventions aimed at improving diet and increasing physical activity levels among Chinese immigrants. METHODS: Outcomes included BMI, weight, waist circumference (WC), waist-hip ratio (WHR), cholesterol (LDL, HDL), systolic and diastolic blood pressure (SBP, DBP), hemoglobin A1c (HgbA1c), fasting blood glucose (FBG), and HOMA-IR. Six databases were systematically searched from database inception to date of search (February 2020). Meta-analyses used random effect models to estimate pooled effects of outcomes with 95% confidence intervals. The outcomes assessed were changes in mean outcomes (post-intervention versus baseline) among the intervention group versus control groups. RESULTS: Twenty-one articles were included for synthesis, and eight of these were included in the meta-analysis. Among children/adolescents, there were no significant effects of intervention for any of the outcomes having sufficient data for meta-analysis (BMI, WHR, SBP, and DBP). Among adults, the pooled effect including three studies showed significant changes in BMI (effect size = - 1.14 kg/m2; (95% CI: - 2.06, - 0.21), I2 = 31%). There were also significant effects of intervention among adults in terms of changes in SBP and DBP, as the pooled effect across three studies was - 6.08 mmHg (95% CI - 9.42, - 2.73), I2 = 0% and - 3.81 mmHg (95% CI: - 6.34, - 1.28), I2 = 0%, respectively. Among adults there were no other significant effects among the meta-analyses conducted (weight, WC, LDL, HgbA1c, and FBG). CONCLUSIONS: This review is the first to summarize the effectiveness of diet and physical activity interventions specifically designed for Chinese immigrants living in high income countries. There were clinically meaningful changes in BMI and blood pressure among adults, but evidence was weak for other cardiometabolic outcomes (weight, WC, LDL, HgbA1c, and FBG), and among children, there was no evidence of effect for any cardiometabolic outcomes. Given our mixed findings, more work is needed to support the design of successful interventions, particularly those targeting children and their families. TRIAL REGISTRATION: The systematic review protocol was registered in PROSPERO on December 17, 2018, the international prospective register of systematic reviews (registration number: CRD42018117842 ).

Effects of Home Particulate Air Filtration on Blood Pressure: A Systematic Review.

Air pollution is a major contributor to cardiovascular morbidity and mortality. Fine particulate matter <2.5 µm in diameter may be a modifiable risk factor for hypertension. The benefits of in-home air filtration on systolic blood pressure (BP) and diastolic BP are unclear. To examine the effects of in-home personal air cleaner use on fine particulate exposure and BP, we queried PubMed, Web of Science, Cochrane Central Register, Inspec, and EBSCO GreenFILE databases for relevant clinical trials. Included studies were limited to nonsmoking participants in smoke-free homes with active or sham filtration on indoor fine particulate concentrations and changes in systolic and diastolic BP. Of 330 articles identified, 10 trials enrolling 604 participants who met inclusion criteria were considered. Over a median 13.5 days, there was a significant reduction of mean systolic BP by ≈4 mm Hg (-3.94 mm Hg [95% CI, -7.00 to -0.89]; P=0.01) but a nonsignificant difference in mean diastolic BP (-0.95 mm Hg [95% CI, -2.81 to 0.91]; P=0.32). Subgroup analyses indicated no heterogeneity of effect by age, level of particulate exposure, or study duration. Given the variation in study design, additional study is warranted to confirm and better quantify the observed benefits in systolic BP found with personal air cleaner use.

Primary Repair of the Anterior Cruciate Ligament: A Systematic Review.

PURPOSE: To describe the clinical and preclinical research conducted on primary repair of the anterior cruciate ligament (ACL) during the past 10 years. METHODS: A systematic search of PubMed, the Cochrane Central Register of Controlled Trials, and Embase was performed for all English-language studies published between 2003 and April 2014 on primary repair of the ACL. RESULTS: Twenty-six studies met the inclusion and exclusion criteria. In the clinical research group, 8 studies (166 patients; age range, 10 to 71 years) met the inclusion and exclusion criteria and were largely long-term clinical outcome studies, based on the original cohorts from the 1970s and 1980s, and suggested high failure rates, additional surgery, and revision for instability. A subset of patients, however, achieved good to excellent subjective and objective long-term outcomes. In the preclinical research group, 18 studies met the inclusion and exclusion criteria and were based on an ACL transection model; they suggested that (1) stabilization of the knee with an internal suture strut improved the healing and biomechanical properties of the repaired ACL, (2) "enhancing" the repair with biological collagen-platelet composite augmentation improved healing and mechanical strength, (3) younger age and skeletal immaturity seem to correlate with improved histologic healing and biomechanical properties, (4) enhanced primary repair of the ACL may reduce post-traumatic osteoarthritis, and (5) the native ACL biomechanically outperformed the repaired ACL. CONCLUSIONS: Although long-term human studies suggest collectively unacceptable outcomes for open primary repair of the ACL, a subset of patients achieved acceptable long-term results. ACL transection model animal studies showed improved healing and biomechanics with primary suture repair stabilization, early intervention, biological augmentation techniques, and younger age. Primary repair of the ACL may be an effective treatment modality for an appropriately selected subset of patients. LEVEL OF EVIDENCE: Level IV, systematic review of preclinical and clinical Level IV studies.

Meta-analysis of re-operation, nonunion, and infection after open reduction and internal fixation of patella fractures.

BACKGROUND: The subcutaneous location of the patella and the demand for early knee motion contribute to the difficulty in treating patients with patella fractures. The reported rates in the literature for hardware removal after patella open reduction and internal fixation range from 0% to 60%. The wide variability of these reports leaves the true frequency of re-operation and complications after patella open reduction and internal fixation in question. Furthermore, gaining a better understanding of the factors that contribute to re-operation and complications will help to generate hypotheses and research agendas to address these difficult problems. METHODS: We performed a systematic review to identify publications in which adult patients with patella fractures were surgically treated with a minimum of 6-month follow-up. The surgical technique (tension band or other), infection rate, nonunion rate, and re-operation rate (including removal of hardware) were recorded. Meta-regression analysis was used to describe the potential contributory factors for re-operation, nonunion, and infection while controlling for age, gender, open fracture, surgical technique, and date of publication. Separate regression models were constructed for each outcome depending on the number of studies available for inclusion. RESULTS: The frequency of re-operation was 33.6% in a meta-analysis of 24 studies (737 patella fractures). The frequency of infection was 3.2% in a meta-analysis of 18 studies (522 patella fractures). The frequency of nonunion was 1.3% in a meta-analysis of 15 studies (464 patella fractures). There were no significant predictors for re-operation, nonunion, or infection in any of the regression analyses. CONCLUSION: Although the frequencies of nonunion and infection are relatively low after surgical treatment of patella fractures, the modern rate of re-operation is substantial. LEVEL OF EVIDENCE: Meta-analysis, level III+.

The effect of search term on the quality and accuracy of online information regarding distal radius fractures.

PURPOSE: Recent emphasis on shared decision making and patient-centered research has increased the importance of patient education and health literacy. The internet is rapidly growing as a source of self-education for patients. However, concern exists over the quality, accuracy, and readability of the information. Our objective was to determine whether the quality, accuracy, and readability of information online about distal radius fractures vary with the search term. METHODS: This was a prospective evaluation of 3 search engines using 3 different search terms of varying sophistication ("distal radius fracture," "wrist fracture," and "broken wrist"). We evaluated 70 unique Web sites for quality, accuracy, and readability. We used comparative statistics to determine whether the search term affected the quality, accuracy, and readability of the Web sites found. Three orthopedic surgeons independently gauged quality and accuracy of information using a set of predetermined scoring criteria. We evaluated the readability of the Web site using the Fleisch-Kincaid score for reading grade level. RESULTS: There were significant differences in the quality, accuracy, and readability of information found, depending on the search term. We found higher quality and accuracy resulted from the search term "distal radius fracture," particularly compared with Web sites resulting from the term "broken wrist." The reading level was higher than recommended in 65 of the 70 Web sites and was significantly higher when searching with "distal radius fracture" than "wrist fracture" or "broken wrist." There was no correlation between Web site reading level and quality or accuracy. CONCLUSIONS: The readability of information about distal radius fractures in most Web sites was higher than the recommended reading level for the general public. The quality and accuracy of the information found significantly varied with the sophistication of the search term used. CLINICAL RELEVANCE: Physicians, professional societies, and search engines should consider efforts to improve internet access to high-quality information at an understandable level.

Complications after flexor tendon repair: a systematic review and meta-analysis.

PURPOSE: Although outcomes after flexor tendon repair have reportedly improved with modern treatment, complications are common. The purpose of this study was to determine the incidence of these complications and the potential contributory factors within the published literature. METHODS: We performed a systematic review of the available literature to identify publications in which patients with flexor tendon ruptures were surgically treated. We extracted demographics, zone of injury, core suture technique (only modified Kessler or a combination of techniques), use of epitendinous suture, and date of publication (before or after January 1, 2000). We excluded articles if they did not report information on reoperation, rupture, or adhesions. We used unadjusted pooled meta-analysis to report the incidence of complications, and meta-regression to describe the potential contributory factors for each complication while controlling for age, gender, and zone of injury. RESULTS: Unadjusted meta-analysis revealed rates of re-operation of 6%, rupture of 4%, and adhesions of 4%. Meta-regression analysis of 29 studies showed that core suture technique or use of an epitendinous suture does not influence rupture. However, the presence of an epitendinous suture decreases re-operation by 84%. Adhesion development is 57% lower when the modified Kessler technique is used. The incidence of complications did not vary with publication date. CONCLUSIONS: The published literature supports use of the modified Kessler repair technique with an epitendinous suture to minimize complications. Although complication rates are low, our data suggest that there has been no definitive improvement in reported complications before and after 2000.

Does the quality, accuracy, and readability of information about lateral epicondylitis on the internet vary with the search term used?

BACKGROUND: Concern exists over the quality, accuracy, and accessibility of online information about health care conditions. The goal of this study is to evaluate the quality, accuracy, and readability of information available on the internet about lateral epicondylitis. METHODS: We used three different search terms ("tennis elbow," "lateral epicondylitis," and "elbow pain") in three search engines (Google, Bing, and Yahoo) to generate a list of 75 unique websites. Three orthopedic surgeons reviewed the content of each website and assessed the quality and accuracy of information. We assessed each website's readability using the Flesch-Kincaid method. Statistical comparisons were made using ANOVA with post hoc pairwise comparisons. RESULTS: The mean reading grade level was 11.1. None of the sites were under the recommended sixth grade reading level for the general public. Higher quality information was found when using the terms "tennis elbow" and "lateral epicondylitis" compared to "elbow pain" (p < 0.001). Specialty society websites had higher quality than all other websites (p < 0.001). The information was more accurate if the website was authored by a health care provider when compared to non-health care providers (p = 0.003). Websites seeking commercial gain and those found after the first five search results had lower quality information. CONCLUSIONS: Reliable information about lateral epicondylitis is available online, especially from specialty societies. However, the quality and accuracy of information vary significantly with the search term, website author, and order of search results. This leaves less educated patients at a disadvantage, particularly because the information we encountered is above the reading level recommended for the general public.

Localization of transfected B7-1 (CD80) DNA in human melanoma cells after particle-mediated gene transfer.

The purpose of this study was to evaluate stable DNA transfection of M-21 human melanoma cells with particle-mediated gene transfer (PMGT) with B7-1 cDNA and to identify sites of gene integration. Stable B7-1 transfectants (M-21-B7) were obtained with PMGT using a plasmid vector containing cDNA for both B7-1 and neomycin phosphotransferase, with subsequent selection with G418. The transfected cells were flow sorted by B7-1 expression into two populations, bright and dim. The bright population had 85%-90% of cells expressing B7-1; the dim population had less than 50% of cells with B7-1 expression. Chromosome analysis with fluorescence in situ hybridization (FISH) and G-banding showed that 70% of bright cells had two main integration sites, with extensive amplification of the transgene. The dim population had random signal distribution, with little or no amplification, despite G418 selection. Because B7-1 has been mapped to 3q21, FISH was performed using a chromosome 3 painting probe (WCP) together with a probe for B7-1. In transfected bright M-21 cells, amplified genes that hybridized with the B7-1 construct were localized to chromosome 3 material inserted into marker chromosomes. These data suggest that B7-1 insertion may involve homologous recombination, but maintenance of integration and amplification required selection.