The Clinical and Economic Implications of Different Treatment Pathways for Patients With Rapidly Recurrent Malignant Pleural Effusion.

BACKGROUND: Malignant pleural effusion (MPE) is a common cancer complication. Clinical and economic implications of different recurrent MPE treatment pathways have not been evaluated fully. RESEARCH QUESTION: What clinical outcomes, complications, health care resource use, and costs are associated with various rapidly recurrent MPE treatment pathways? STUDY DESIGN AND METHODS: This retrospective cohort study using Surveillance, Epidemiology and End Results Medicare data (2011-2015) included patients 66 to 90 years of age with rapidly recurrent MPE. Rapid recurrence was defined as receipt of a second pleural procedure within 14 days of the first thoracentesis, including nondefinitive repeated thoracentesis or a definitive treatment option including chest tube, indwelling pleural catheter (IPC), or thoracoscopy. RESULTS: Among 8,378 patients with MPE, 3,090 patients (36.9%) had rapidly recurrent MPE (mean ± SD age, 75.9 ± 6.6 years; 45.6% male; primary cancer, 62.9% lung and 37.1% other). Second pleural procedures were nondefinitive thoracentesis (62.3%), chest tube (17.1%), IPC (13.2%), or thoracoscopy (7.4%). A third pleural procedure was required more frequently if the second pleural procedure was nondefinitive thoracentesis vs chest tube placement, IPC placement, or thoracoscopy (70.3% vs 44.1% vs 17.9% vs 14.4%, respectively). The mean number of subsequent pleural procedures over the patient's lifetime varied significantly among the procedures (1.74, 0.82, 0.31, and 0.22 procedures for patients receiving thoracentesis, chest tube, IPC, and thoracoscopy, respectively; P < .05). Average total costs after the second pleural procedure to death adjusted for age at primary cancer diagnosis, race, year of second pleural procedure, Charlson comorbidity index, cancer stage at primary diagnosis, and time from primary cancer diagnosis to diagnostic thoracentesis were lower with IPC ($37,443; P < .0001) or chest tube placement ($40,627; P = .004) vs thoracentesis ($47,711). Patients receiving thoracoscopy ($45,386; P = .5) incurred similar costs as patients receiving thoracentesis. INTERPRETATION: Early definitive treatment was associated with fewer subsequent procedures and lower costs in patients with rapidly recurrent MPE.

Prevalence of Hospital-Onset Bacteremia Pre- and Post-Implementation of a Needleless Blood Sampling Device From Existing Peripheral Catheters.

Repeated access of peripheral intravenous (IV) devices theoretically increases the risk of bacterial exposure. PIVO™ (VelanoVascular) is a needleless, single-use device that enables blood sampling from an existing peripheral IV. The goal of this retrospective observational exploratory study was to evaluate the influence of PIVO use on rates of hospital-onset bacteremia and fungemia (HOB) by comparing HOB rates in the year before and after PIVO introduction in hospitals implementing PIVO and over similar time periods in "control" hospitals with no PIVO. Two hospitals implementing PIVO (Hospital 1, a large community hospital; Hospital 2, a tertiary oncology center), and 71 control hospitals were included. During the 1-year period before and after PIVO introduction, HOB rates decreased in hospitals 1 and 2 by 31.9% and 41.8%, respectively. Control hospitals that did not use PIVO had a 12.4% decrease in HOB rates. Multivariable logistic regression analyses found that PIVO was associated with a lower risk (Hospital 1 odds ratio [OR]: 0.63; 95% CI, 0.42-0.94) or no change (Hospital 2 OR: 1.05; 95% CI, 0.72-1.52) in HOB rates. Control hospitals also showed no change in HOB rates between the 2 time periods. These data do not support concerns about increased risk of bacteremia with PIVO.

Unplanned 120-Day ED Visits and Readmission Rates Following Common Stone Procedures.

OBJECTIVE: To quantify emergency department (ED) visits and hospital admissions (HA) after common urologic stone procedures including ureteroscopy (URS), shockwave lithotripsy (SWL), and percutaneous nephrolithotomy (PCL) which are a concern of payors, providers, and patients. MATERIALS AND METHODS: This is a retrospective cohort study using claims data from the IBM MarketScan Commercial and Medicare Supplement databases. Adults with a urologic stone diagnosis and no history of stone procedure in prior 12 months who underwent stone procedures between 2012 and 2017 were included. All-cause ED visits and HA were evaluated during 30, 60, 90, and 120-day periods following the index urologic stone procedure. RESULTS: A total of 166,287 patients were included in the analytic cohort. For inpatient-indexed procedures, cumulative ED visits rates following stone procedure at 120 days was 18.8% for URS, 19.2% for SWL, and 23.6% for PCL. A similar trend was observed with ED visit rates, following outpatient indexed procedures at 120 days with a cumulative rate of 14.2% of SWL patients, 14.9% of URS patients, and 17.3% of PCL. A similar trend was found when examining HA. ED and HA rates increased steadily through the 120-day time period. CONCLUSION: Rates of ED visits and HA following common stone procedures continue to rise at least up to 120 days following the index procedure whether in the outpatient or inpatient settings. While rates of unplanned care are similar for URS and SWL, patients undergoing PCL return to the hospital at higher rates.

Association of systemic inflammation, adiposity, and metabolic dysregulation with asthma burden among Hispanic adults.

RATIONALE: Obesity-related asthma is associated with higher disease burden than normal-weight asthma among Hispanics. Adiposity, metabolic dysregulation, and inflammation are all implicated in pathogenesis of obesity-related asthma, but their independent contributions are poorly understood. OBJECTIVE: To examine the independent contributions of body fat distribution, metabolic abnormalities and inflammation on asthma symptoms and pulmonary function among Hispanics. METHODS: Participants of the Hispanic Community Health Study/Study of Latinos with doctor-diagnosed asthma who completed an asthma symptom questionnaire and performed a valid spirometry were included in the analysis (n = 1126). Multivariate analysis was used to examine the independent association of general adiposity (assessed using body mass index), truncal adiposity (assessed by waist circumference), metabolic dysregulation (presence of insulin resistance and low HDL) and inflammation (high-sensitivity C-Reactive Protein≥3 mg/L) with reported asthma symptoms or pulmonary function measures (FEV1, and FVC) while adjusting for demographic and clinical covariates. RESULTS: Of the 1126 participants, 334 (29.5%) were overweight, and 648 (57.8%) were obese. FEV1 and FVC were lower in obese compared to normal-weight asthmatics. In analyses controlling for metabolic and adiposity factors, high hs-CRP (>7 mg/L) was associated with more symptoms (prevalence-ratio 1.27 (95%CI 1.05, 1.54), and lower FVC (ß -138 ml (95%CI -27 ml, -249 ml)) and FEV1 (ß -155 ml (95% CI -38 ml, -272 ml). Low HDL was also associated with lower FVC (ß -111 ml (-22 ml, -201 ml) and FEV1 (ß -100 ml (-12 ml, -188 ml)). Results were similar in men and women. CONCLUSIONS: Our findings suggest that hs-CRP and low HDL, rather than general and truncal adiposity, are associated with asthma burden among overweight and obese Hispanic adults.

Trends in Nonlipid Cardiovascular Disease Risk Factor Management in the Women's Interagency HIV Study and Association with Adherence to Antiretroviral Therapy.

Cardiovascular disease (CVD) is increasingly common among women with HIV, but literature on nonlipid CVD risk factor management is lacking. We examined semiannual trends from 2006 to 2014 in hypertension treatment and control (blood pressure <140/90 mmHg), diabetes treatment and control (fasting glucose <130 mg/dL), and smoking quit rates in the Women's Interagency HIV Study. Unadjusted and adjusted Poisson regression models tested time trends and differences between HIV+ and HIV- women. Among antiretroviral therapy (ART) users, we examined the association of ART adherence and virologic suppression with each outcome. We evaluated 1636 HIV+ and 683 HIV- women, with a hypertension prevalence of 40% and 38%, respectively; diabetes prevalence of 21% and 22%; and smoking prevalence of 37% and 48%. Hypertension treatment was higher among HIV+ than HIV- women (77% vs. 67%, p < 0.001) and increased over time with no difference in trend by HIV status. Hypertension control was greater among HIV+ women (56% vs. 43%, p < 0.001) and increased over time among HIV+ but not HIV- women. Diabetes treatment was similar among HIV+ and HIV- women (48% vs. 49%) and increased over time in both groups. Diabetes control was greater among HIV+ women (73% vs. 64%, p = 0.03) and did not change over time. The percent of recent smokers who reported no longer smoking was similar between HIV+ and HIV- women (10% vs. 9%), with no differences over time. Virologic suppression was significantly associated with increased hypertension treatment and greater control. HIV+ women have better control of hypertension and diabetes than HIV- women, but many are still not at target levels.

Perceived discrimination and cancer screening behaviors in US Hispanics: the Hispanic Community Health Study/Study of Latinos Sociocultural Ancillary Study.

PURPOSE: Perceived discrimination has been associated with lower adherence to cancer screening guidelines. We examined whether perceived discrimination was associated with adherence to breast, cervical, colorectal, and prostate cancer screening guidelines in US Hispanic/Latino adults. METHODS: Data were obtained from the Hispanic Community Health Study/Study of Latinos Sociocultural Ancillary Study, including 5,313 Hispanic adults aged 18­74 from Bronx, NY, Chicago, IL, Miami, FL, and San Diego, CA, and those who were within appropriate age ranges for specific screening tests were included in the analysis. Cancer screening behaviors were assessed via self-report. Perceived discrimination was measured using the Perceived Ethnic Discrimination Questionnaire. Confounder-adjusted multivariable polytomous logistic regression models assessed the association between perceived discrimination and adherence to cancer screening guidelines. RESULTS: Among women eligible for screening, 72.1 % were adherent to cervical cancer screening guidelines and 71.3 %were adherent to breast cancer screening guidelines. In participants aged 50­74, 24.6 % of women and 27.0 % of men were adherent to fecal occult blood test guidelines; 43.5 % of women and 34.8 % of men were adherent to colonoscopy/sigmoidoscopy guidelines; 41.0 % of men were adherent to prostate-specific antigen screening guidelines. Health insurance coverage, rather than perceived ethnic discrimination,was the variable most associated with receiving breast, cervical,colorectal, or prostate cancer screening. CONCLUSIONS: The influence of discrimination as a barrier to cancer screening may be modest among Hispanics/Latinos in urban US regions. Having health insurance facilitates cancer screening in this population. Efforts to increase cancer screening in Hispanics/Latinos should focus on increasing access to these services, especially among the uninsured.

Body mass index, sex, and cardiovascular disease risk factors among Hispanic/Latino adults: Hispanic community health study/study of Latinos.

BACKGROUND: All major Hispanic/Latino groups in the United States have a high prevalence of obesity, which is often severe. Little is known about cardiovascular disease (CVD) risk factors among those at very high levels of body mass index (BMI). METHODS AND RESULTS: Among US Hispanic men (N=6547) and women (N=9797), we described gradients across the range of BMI and age in CVD risk factors including hypertension, serum lipids, diabetes, and C-reactive protein. Sex differences in CVD risk factor prevalences were determined at each level of BMI, after adjustment for age and other demographic and socioeconomic variables. Among those with class II or III obesity (BMI ≥35 kg/m(2), 18% women and 12% men), prevalences of hypertension, diabetes, low high-density lipoprotein cholesterol level, and high C-reactive protein level approached or exceeded 40% during the fourth decade of life. While women had a higher prevalence of class III obesity (BMI ≥40 kg/m(2)) than did men (7% and 4%, respectively), within this highest BMI category there was a >50% greater relative prevalence of diabetes, hypertension, and hyperlipidemia in men versus women, while sex differences in prevalence of these CVD risk factors were ≈20% or less at other BMI levels. CONCLUSIONS: Elevated BMI is common in Hispanic/Latino adults and is associated with a considerable excess of CVD risk factors. At the highest BMI levels, CVD risk factors often emerge in the earliest decades of adulthood and they affect men more often than women.