Rural-urban difference in female breast cancer diagnosis in Missouri.

INTRODUCTION: The stage at cancer diagnosis has a tremendous impact on type of treatment, recovery and survival. In most cases the earlier the cancer is detected and treated the higher the survival rate for the patient. The purpose of this study was to examine the impact of spatial access to healthcare services on late detection of female breast cancer diagnosis in Missouri, taking into account access and distance to the nearest mammography center and/or hospital. METHODS: This was a cross-sectional retrospective study of female breast cancer diagnosis in different geographic regions of Missouri. The sample was restricted to Missouri women diagnosed with breast cancer, whose cases had been reported to the Missouri Cancer Registry and Research Center between 2003 and 2008. A geographic information system network analysis was used to calculate distance traveled by road from the centroid of each county to the nearest healthcare facility. RESULTS: A total of 28 536 cases of female breast cancers were reported to the Missouri Cancer Registry and Research Center between 2003 and 2008. Of these 25 743 (90.2%) were Caucasian (white) while 2793 (9.8%) were African-American (black). Analysis showed that the proportion of African-Americans with late-stage detection exceeded that of whites in almost all rural and urban locations. From 2003 to 2005 more than 50% of all late-stage diagnoses of African-American women occurred in metropolitan (metro) medium (55.6%) and completely rural counties (66.7%). Other locations recorded a smaller number of late-stage detection among African-American women: metro small (42.3%), urban large (47.4%) and urban small (44.9%) counties. Most of the late-stage diagnoses of white women were reported in urban small (32.2%) and rural (32.3%) counties. Between 2006 and 2008, again, the proportion of late-stage diagnoses among black women was the highest. Access to hospitals is fairly distributed among all counties. Women from disadvantaged non-metro areas have the same level of access to hospitals as those in metro areas within a travel time of 15 to 30 minutes. However, although there are almost 180 mammography screening centers across the state, access to these services is not evenly distributed. A network analysis of the closest facility of the type showed that women living in 19 non-metro rural counties have to travel more than 45 minutes one way by car for mammography services. Thirteen of the 19 counties are classified as completely rural. CONCLUSIONS: Women with breast cancer living in areas with limited access to healthcare services are more likely to have been diagnosed with late-stage breast cancer.

Relation of left ventricular mass to QTc in normotensive severely obese patients.

Prolongation of the corrected QT interval (QTc) has been described in obese subjects. This study assesses the relation of left ventricular (LV) mass to QTc in normotensive severely obese subjects. Fifty normotensive patients whose BMI was ≥40 kg/m(2) (mean age: 38 ± 7 years) were studied. QTc was derived using Bazett's formula. LV mass was calculated using the formula of Devereux et al. and was indexed to height(2.7). Mean QTc was 428.8 ± 19.0 ms and was significantly longer in those with than in those without LV hypertrophy (P < 0.01) QTc correlated positively and significantly with BMI (r = 0.392, P < 0.025), LV mass/height(2.7) (r = 0.793, P < 0.0005), systolic blood pressure (r = 0.742, P < 0.001), LV end - systolic wall stress (r = 0.746, P < 0.001) and LV internal dimension in diastole (r = 0.788, P < 0.0005). Among five variables tested, LV mass/height(2.7) was identified as the sole predictor of QTc by multivariate analysis. In conclusion, LV mass and loading conditions that may affect LV mass are important determinants of QTc in normotensive severely obese subjects.

Effect of weight loss after bariatric surgery on left ventricular mass and ventricular repolarization in normotensive morbidly obese patients.

To assess the effect of weight loss on ventricular repolarization in morbidly obese patients, 39 normotensive subjects whose baseline body mass indexes were ≥40 kg/m(2) before weight loss from bariatric surgery were studied. All patients were free of underlying organic heart disease, heart failure, and conditions that might affect ventricular repolarization. Twelve-lead electrocardiography and transthoracic echocardiography were performed just before surgery and at the nadir of postoperative weight loss. The corrected QT interval (QTc) was derived using Bazett's formula. QTc dispersion was calculated by subtracting the minimum from the maximum QTc on the 12-lead electrocardiogram. Echocardiographic left ventricular (LV) mass was indexed to height(2.7). The mean body mass index decreased from 42.8 ± 2.1 to 31.9 ± 2.2 kg/m(2) (p <0.0005). For the entire group, weight loss was associated with significant reductions in mean QTc (from 428.7 ± 18.5 to 410.5 ± 11.9 ms, p <0.0001) and mean QTc dispersion (from 44.1 ± 11.2 to 33.2 ± 3.3 ms, p <0.0005). Mean QTc and QTc dispersion decreased significantly with weight loss in patients with LV hypertrophy but not in subjects without LV hypertrophy. Multivariate analysis identified pre-weight loss LV mass/height(2.7) as the most important predictor of pre-weight loss QTc and QTc dispersion and also identified weight loss-induced change in LV mass/height(2.7) as the most important predictor of weight loss-induced changes in QTc and QTc dispersion. In conclusion, LV hypertrophy is a key determinant of QTc and QTc dispersion in normotensive morbidly obese patients. Regression of LV hypertrophy associated with weight loss decreases QTc and QTc dispersion.

Assessment of email communication skills of rheumatology fellows: a pilot study.

Physician-patient email communication is gaining popularity. However, a formal assessment of physicians' email communication skills has not been described. We hypothesized that the email communication skills of rheumatology fellows can be measured in an objective structured clinical examination (OSCE) setting using a novel email content analysis instrument which has 18 items. During an OSCE, we asked 50 rheumatology fellows to respond to a simulated patient email. The content of the responses was assessed using our instrument. The majority of rheumatology fellows wrote appropriate responses scoring a mean (±SD) of 10.6 (±2.6) points (maximum score 18), with high inter-rater reliability (0.86). Most fellows were concise (74%) and courteous (68%) but not formal (22%). Ninety-two percent of fellows acknowledged that the patient's condition required urgent medical attention, but only 30% took active measures to contact the patient. No one encrypted their messages. The objective assessment of email communication skills is possible using simulated emails in an OSCE setting. The variable email communication scores and incidental patient safety gaps identified, suggest a need for further training and defined proficiency standards for physicians' email communication skills.