High Community-Level Social Vulnerability is Associated with Worse Recurrence-Free Survival (RFS) After Resection of Extremity and Truncal Soft Tissue Sarcoma.

BACKGROUND: Although social vulnerability has been associated with worse postoperative and oncologic outcomes in other cancer types, these effects have not been characterized in patients with soft tissue sarcoma. This study evaluated the association of social vulnerability and oncologic outcomes. METHODS: The authors conducted a single-institution cohort study of adult patients with primary and locally recurrent extremity or truncal soft tissue sarcoma undergoing resection between January 2016 and December 2021. The social vulnerability index (SVI) was measured on a low (SVI 1-39%, least vulnerable) to high (60-100%, most vulnerable) SVI scale. The association of SVI with overall survival (OS) and recurrence-free survival (RFS) was evaluated by Kaplan-Meier analysis and Cox proportional hazard regression. RESULTS: The study identified 577 patients. The median SVI was 44 (interquartile range [IQR], 19-67), with 195 patients categorized as high SVI and 265 patients as low SVI. The median age, tumor size, histologic subtype, grade, comorbidities, stage, follow-up time, and perioperative chemotherapy and radiation utilization were similar between the high and low SVI cohorts. The patients with high SVI had worse OS (p = 0.07) and RFS (p = 0.016) than the patients with low SVI. High SVI was independently associated with shorter RFS in the multivariate analysis (hazard ratio, 1.64; 95% confidence interval, 1.06-2.54) but not with OS (HR, 1.47; 95% CI 0.84-2.56). CONCLUSION: High community-level social vulnerability appears to be independently associated with worse RFS for patients undergoing resection of extremity and truncal soft tissue sarcoma. The effect of patient and community-level social risk factors should be considered in the treatment of patients with extremity sarcoma.

Simplified Post-stroke Functioning Assessment Based on ICF via Dichotomous Mokken Scale Analysis and Rasch Modeling.

Purpose: This study aims to accomplish two tasks for International Classification of Functioning, Disability and Health (ICF) application among persons with stroke: (1) to make an ICF tool for measuring personal abilities with simplified assessment operations; (2) to quantitatively evaluate ICF categories for being functioning rather than being disabled. Methods: A total of 130 inpatients with stroke via convenience sampling were evaluated by the extended comprehensive ICF core set for stroke, modified Rankin scale, and modified Barthel index (MBI). This study investigated the responses to 118 stroke-related ICF items (59 items in b and d domains individually) using Mokken scale analysis followed with Rasch modeling. Results: A Mokken scale with 47 items was extracted from the binary data (1 as no-impairment or mild-impairment and 0 as moderate to complete impairment). A Rasch model with 45 items was derived from the Mokken scale. The conversion chart was available involving the original ordinal scores to Rasch-transformed scores from 0 to 100 (interval scale). Total scores exhibited a high correlation with the personal abilities estimated by the Rasch model. The personal ability also demonstrated a significantly strong correlation with the score of the MBI. Thus, the 45 ICF items were suggested to rate potential functional ability as a single measurement. Conclusion: Based on simple "functioning or disabled" judgment tasks, ICF assessment can be simplified to a questionnaire with answering "yes-or-no" questions for each category. Functioning level for each person and difficulty of being functioning for each category can be estimated by the Rasch model of this questionnaire.

Assessment of Cardiopulmonary Bypass Duration Improves Novel Biomarker Detection for Predicting Postoperative Acute Kidney Injury after Cardiovascular Surgery.

Urinary liver-type fatty acid binding protein (L-FABP) is a novel biomarker with promising performance in detecting kidney injury. Previous studies reported that L-FABP showed moderate discrimination in patients that underwent cardiac surgery, and other studies revealed that longer duration of cardiopulmonary bypass (CPB) was associated with a higher risk of postoperative acute kidney injury (AKI). This study aims to examine assessing CPB duration first, then examining L-FABP can improve the discriminatory ability of L-FABP in postoperative AKI. A total of 144 patients who received cardiovascular surgery were enrolled. Urinary L-FABP levels were examined at 4 to 6 and 16 to 18 h postoperatively. In the whole study population, the AUROC of urinary L-FABP in predicting postoperative AKI within 7 days was 0.720 at 16 to 18 h postoperatively. By assessing patients according to CPB duration, the urinary L-FABP at 16 to 18 h showed more favorable discriminating ability with AUROC of 0.742. Urinary L-FABP exhibited good performance in discriminating the onset of AKI within 7 days after cardiovascular surgery. Assessing postoperative risk of AKI through CPB duration first and then using urinary L-FABP examination can provide more accurate and satisfactory performance in predicting postoperative AKI.

Analysis of the Government Health Expenditure in the First Decade of Chinese New Medical Reform (2009-2018): Xinjiang Uygur Autonomous Region as an Example.

OBJECTIVE: To analyze the status of government health expenditure in Xinjiang Uygur Autonomous Region since the first 10 years from the new medical reform, and find the existing problems in order to provide evidence for the government to formulate medical and health policies. METHODS: Based on the health expenditure monitoring data of Xinjiang Uygur Autonomous Region government from Urumqi Central Sub-branch of the People's Bank of China, combined with the relevant data in Xinjiang statistical yearbook, Excel2013 and SPSS19.0 were used to conduct a comparative analysis of government expenditure data from 2009 to 2018. RESULTS: The average annual growth rate of the government's health expenditure in Xinjiang Uygur Autonomous Region was 12.25%, which was similar to the national level. The proportion of government health expenditure in gross domestic product increased from 0.97% to 1.07%, while the proportion in the total fiscal expenditure decreased from 3.06% to 2.63%, which led to far behind the national and even western area level. The Gini Coefficient of per capita government health expenditure in every city (state) of the autonomous region fell from 0.46 to 0.32 between 2014 and 2018. In the past decade, the ratio between public health expenditure and medical institution expenditure has decreased from 1.01 to 0.42, led to insufficient proportion of public health expenditure. The health expenditure level of the four prefectures especially Kashgar and Hotan in Southern Xinjiang was still far lower than the whole autonomous region and the national average level. CONCLUSION: The government of Xinjiang Uygur Autonomous Region should continuously strengthen the financial expenditure in health, maintain the current situation of preferential policy implementation for rural and grassroots expenditure, constantly optimize the proportion of various financial expenditures, and strive for the transfer payment from the central and autonomous regional governments to the four prefectures in Southern Xinjiang.

Preoperative risk assessment improves biomarker detection for predicting acute kidney injury after cardiac surgery.

BACKGROUND: Although urinary neutrophil gelatinase-associated lipocalin (NGAL) has emerged as a promising biomarker for the early detection of kidney injury, previous studies of adult patients who underwent cardiac surgery have reported only moderate discrimination. The age, creatinine, and ejection fraction (ACEF) score is a preoperative validated risk model with satisfactory accuracy for predicting AKI following cardiac surgery. It remains unknown whether combining preoperative risk assessment through ACEF scores followed by urinary NGAL test in a population of high-risk individuals is an optimal approach with improved predictive performance. MATERIAL AND METHODS: A total of 177 consecutive patients who underwent cardiac surgery were enrolled. Clinical characteristics, prognostic model scores, and outcomes were assessed. Urinary NGAL were examined within 6 hours after cardiac surgery. Patients were stratified according to preoperative ACEF scores, and comparisons were made using the area under the receiver operator characteristic curve (AUROC) for the prediction of AKI. RESULTS: A total of 45.8% (81/177) of the patients had AKI. As expected, patients with ACEF scores ≥ 1.1 were older and more likely to have class III or IV heart failure. They were also more likely to have diabetes mellitus, myocardial infarction, and peripheral arterial disease. Urinary NGAL alone moderately predicted AKI, with an AUROC of 0.732. Risk stratification by ACEF scores ≥ 1.1 substantially improved the AUROC of urinary NGAL to 0.873 (95% confidence interval, 0.784-0.961; P < .001). CONCLUSIONS: Risk stratification by preoperative ACEF scores ≥ 1.1, followed by postoperative urinary NGAL, provides more satisfactory risk discrimination than does urinary NGAL alone for the early detection of AKI after cardiac surgery. Future studies should investigate whether this strategy could improve the outcomes and cost-effectiveness of care in patients undergoing cardiac surgery.

Sequential organ failure assessment score predicts mortality after coronary artery bypass grafting.

BACKGROUND: Mortality after coronary artery bypass grafting (CABG) is generally associated with underlying disease and surgical factors overlooked in preoperative prognostic models. Sequential Organ Failure Assessment (SOFA) and Acute Physiology and Chronic Health Evaluation (APACHE II) scores are widely used in intensive care units for outcome prediction. This study investigated the accuracy of these models in predicting mortality. METHODS: Between January 2010 and April 2013, 483 patients who underwent isolated CABG were enrolled. The clinical characteristics, outcomes, and prognostic model scores of the patients were collected. Discrimination was assessed using the area under the curve approach. RESULTS: Both SOFA and APACHE II scores were effective for predicting in-hospital mortality. Among the organ systems examined in the SOFA, the cardiac and renal systems were the strongest predictors of CABG mortality. Multivariate analysis identified only the SOFA score as being an independent risk factor for mortality. CONCLUSION: In summary, the SOFA score can be used to accurately identify mortality after isolated CABG.

Cost-effectiveness of neoadjuvant concurrent chemoradiotherapy versus esophagectomy for locally advanced esophageal squamous cell carcinoma: A population-based matched case-control study.

BACKGROUND: Neoadjuvant concurrent chemoradiotherapy (NCCRT) is often considered for locally-advanced esophageal squamous cell carcinoma (LA-ESCC) patients; however, no data regarding the cost-effectiveness of this treatment is available. Our study aimed to evaluate the cost-effectiveness of NCCRT versus esophagectomy for LA-ESCC at population level. METHODS: We identified LA-ESCC patients diagnosed within 2008-2009 and treated with either NCCRT or esophagectomy through the Taiwan Cancer Registry. We included potential confounding covariables (age, gender, residency, comorbidity, social-economic status, disease stage, treating hospital level and surgeon's experience, and the use of endoscopic ultrasound before treatment) and used propensity score (PS) to construct a 1:1 population. The duration of interest was three years within the date of diagnosis. Effectiveness was measured as overall survival. We took the payer's perspective and converted the cost to 2014 United States dollars (USD). In sensitivity analysis, we evaluated the potential impact of an unmeasured confounder on the statistical significance of incremental net benefit at suggested willingness-to-pay. RESULTS: Our study population constituted 150 PS matched subjects. The mean cost (2014 USD) and survival (year) were higher for NCCRT compared with esophagectomy (US$91,460 vs. $75,836 for cost; 2.2 vs. 1.8 for survival) with an estimated incremental cost-effectiveness ratio of US$39,060/life-year. CONCLUSIONS: When compared to esophagectomy, NCCRT is likely to improve survival and is probably more cost-effective. Cost-effectiveness results should be interpreted with caution given our results were sensitive to potential unmeasured confounder(s) in sensitivity analysis.

Problems and health needs of adult extracorporeal membrane oxygenation patients following hospital discharge: A qualitative study.

OBJECTIVES: To explore problems and health needs of adult extracorporeal membrane oxygenation (ECMO) patients during a one-year period following hospital discharge. BACKGROUND: ECMO functions as life support during treatment of advanced cardiac and respiratory failure. Knowledge regarding the problems and health needs of discharged adult patients who have undergone ECMO is lacking. METHODS: This study used a qualitative descriptive interview design. Fourteen adult ECMO patients were recruited by purposive sampling prior to discharge. Data were generated from semi-structure in-depth interviews at 3-month intervals following hospital discharge. RESULTS: Four themes described problems and needs post-discharge: stress resulting from ECMO surgery; making health a priority; support from family friends and health care professionals; and emotional support. CONCLUSIONS: Multidisciplinary evidence-based interventions should be implemented prior to or soon after discharge to help with the physical, psychological and social problems that ECMO survivors experience, which can help improve their quality of life.

A preliminary study of acoustic radiation force impulse quantification for the assessment of skin in diffuse cutaneous systemic sclerosis.

OBJECTIVE: To investigate skin elasticity using acoustic radiation force impulse (ARFI) quantification in systemic sclerosis (SSc), and compare the modified Rodnan skin score (mRSS) with measured shear wave velocity (SWV) and thickness of the skin. METHODS: Fifteen patients with diffuse cutaneous SSc (dcSSc) and 15 age-matched and sex-matched healthy controls were evaluated. The SWV and thickness of skin were measured at 17 sites corresponding to those assessed in the mRSS in each participant. The SWV measurements of skin were compared between patients with dcSSc and healthy controls. The correlations between the mRSS and the skin SWV and thickness were explored using Spearman's correlation. RESULTS: The SWV values were higher in patients with dcSSc compared with healthy controls at right hand dorsum, right forearm, left hand dorsum, left forearm, right foot dorsum, and left foot dorsum (p < 0.05). In patients with dcSSc, the SWV values of uninvolved skin were higher than those of controls (p < 0.001), and the SWV values increased with increasing skin scores except for skin score 3 (p < 0.05). The sum of the SWV values correlated with total clinical skin score (r = 0.841, p < 0.001), and the sum of the skin thickness correlated with total clinical skin score (r = 0.740, p = 0.002). CONCLUSION: ARFI quantification is feasible and reliable for assessing the skin involvement in dcSSc. ARFI quantification could identify early skin change that may precede palpable skin involvement, and may be a valuable adjunct to skin evaluation in patients with SSc.

Use of Chinese medicine among colorectal cancer patients: a nationwide population-based study.

BACKGROUND: Traditional Chinese medicine (CM) appears to be used worldwide, especially by cancer patients. The aim of the present study was to explore CM uses and CM non-users by patients with colorectal cancer (CRC). MATERIALS AND METHODS: A retrospective study was conducted using registration and claims data sets for 2007 from the National Health Insurance Research Database. Patients with colorectal cancer were identified from the Registry for Catastrophic illness Patients. Binary logistic regression was used to estimate odds ratios as the measure of association with the use of CM. RESULTS: A total of 61,211 CRC patients diagnosed in 2007 were analysis. Most CM users preferred to visit private clinics (46.9%) with 306,599 visits. In contrast, the majority of CM non-users preferred to visit private hospitals (42.2%) with 538,769 visits. Among all 176,707 cancer-specific CM visit, there were 66.6% visits to CM outpatient department (OPD) of private hospitals, while in 477,612 non-cancer-specific CM visits, 62.0% was for private clinics. The proportion of expenses for diagnostic fees for CM user in CM visits was much less than that for WM visits and CM non-users (US$4.6 vs. 29.3 vs. 33.5). The average cost for CM user in CM was less than that for WM visits and CM non-users (US$6.3 vs. 25.9 vs. 30.3). Female patients, younger age, and patients not living in the northern region, with higher EC or more comorbidities were more likely to receive CM treatment. CONCLUSION: The prevalence and costs of insurance-covered CM among CRC patients were low. Further longer longitudinal study is needed to follow up this trend.

Benefits, costs, and livelihood implications of a regional payment for ecosystem service program.

Despite broad interest in using payment for ecosystem services to promote changes in the use of natural capital, there are few expost assessments of impacts of payment for ecosystem services programs on ecosystem service provision, program cost, and changes in livelihoods resulting from program participation. In this paper, we evaluate the Paddy Land-to-Dry Land (PLDL) program in Beijing, China, and associated changes in service providers' livelihood activities. The PLDL is a land use conversion program that aims to protect water quality and quantity for the only surface water reservoir that serves Beijing, China's capital city with nearly 20 million residents. Our analysis integrates hydrologic data with household survey data and shows that the PLDL generates benefits of improved water quantity and quality that exceed the costs of reduced agricultural output. The PLDL has an overall benefit-cost ratio of 1.5, and both downstream beneficiaries and upstream providers gain from the program. Household data show that changes in livelihood activities may offset some of the desired effects of the program through increased expenditures on agricultural fertilizers. Overall, however, reductions in fertilizer leaching from land use change dominate so that the program still has a positive net impact on water quality. This program is a successful example of water users paying upstream landholders to improve water quantity and quality through land use change. Program evaluation also highlights the importance of considering behavioral changes by program participants.

Cost-effectiveness analysis of a randomized study comparing radiosurgery with radiosurgery and whole brain radiation therapy in patients with 1 to 3 brain metastases.

BACKGROUND: In this study, we compare 2 treatment options and determine cost-effectiveness and cost-utility. METHODS: We carried out a decision analysis populated with data from patients with brain metastasis in a concurrent trial randomized to either stereotactic radiosurgery (SRS) and observation or SRS and whole brain radiation therapy. Outcomes included actual life years saved (LYS), quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio (ICER). Costs used were from the healthcare perspective and utilities were captured through a time-trade-off method, using 10-year, 5-year, and 1-year time horizons. One-way sensitivity analyses were carried out to determine robustness of the decision analysis model. RESULTS: Compared with SRS and whole brain radiation therapy, SRS and observation not only had a higher average cost ($74,000 vs $119,000, respectively) but also a higher average effectiveness (0.60 LYS vs 1.64 LYS, respectively) with an ICER of $44,231/LYS or $41,783/QALY (with utilities captured using a 10-year horizon). Slightly higher ICER estimates were achieved with utilities captured using the other time horizons ($43,280/QALY and $44,064/QALY, respectively). Sensitivity analysis showed that the following variables had the highest impact on the ICER: probability of no recurrence in recursive-partitioning analysis class 2 after SRS and observation; probability of being alive after SRS and observation in recursive-partitioning analysis class 2 and being treated for recurrence. CONCLUSIONS: Compared with other interventions in the $50,000 to $100,000/QALY cost-effectiveness range, the application of SRS and observation, with subsequent neurosurgical management of recurrences, is shown to be a reasonable treatment modality for brain metastases.

The safety and effectiveness of a chloroform/methanol extract of Tripterygium wilfordii Hook F (T2) plus methotrexate in treating rheumatoid arthritis.

OBJECTIVES: The objective of the study was to assess the safety and effectiveness of the chloroform/methanol extract of Tripterygium wilfordii Hook F (T2) plus methotrexate (MTX) in treating patients with rheumatoid arthritis (RA). METHODS: One hundred sixty-six patients with RA, who started the combination therapy of T2 (20 mg b.i.d. or t.i.d.) and MTX (10-12.5 mg/wk), were enrolled, and these patients were followed up for at least 1 year. Demographics, disease severity, markers of disease activity before and after the combination therapy, and incidence of adverse events were evaluated. RESULTS: The patients were predominantly female (n = 134, 81%) with a mean age of 58.0 (SD, 7.9) years (range, 39-79 years) and a mean disease duration of 55.0 (SD, 72.2) months (range, 0-456 months). A total of 161, 161, 146, and 85 patients had received at least 1, 3, 12, and 24 months of the combination of T2 and MTX, with a total of 4162 patient-months' exposure to the combination therapy. The combination therapy reduced tender and swollen joint counts, morning stiffness, inflammatory indices such as ESR and CRP, and improved disease activity as measured by the DAS28 significantly by 3 months as well as 12 months (P < 0.05). Most of the adverse events noted during this study were mild. Menstrual irregularity occurred in 72.7% (16/22) of premenopausal female. Only 10 (6.0%) and 8 (4.8%) subjects withdrew because of adverse events or lack of efficacy, respectively. Severe infections were very rare. CONCLUSION: T2 plus MTX is an effective and relatively safe treatment for RA patients.

Disparities in outpatient antidepressant prescribing patterns and determinants of resource utilization at a tertiary care cancer center.

Our objective was to assess the prevalence of use of different classes of antidepressants, prescribing patterns, and determinants of exposure to specific types of antidepressants and resource utilization at a comprehensive cancer center from 2001 to 2006. Data were collected from the institution's outpatient pharmacy database and cross-referenced with the institution's electronic medical record system. Data collected included demographic characteristics, cancer diagnosis, comorbidities, prescribing physician and service, type and number of antidepressant prescriptions, and resource utilization. Significant differences in the usage and prescribing patterns of the type of antidepressants were found in the analysis by gender and ethnicity, with women seeing a psychiatrist more often than men (P = 0.001) and Caucasians receiving more selective serotonin reuptake inhibitors (SSRIs) than other ethnic groups (P = 0.002). In terms of resource utilization, men had significantly more hospital admissions (P < 0.0001) and emergency room visits (P = 0.004) than women, whereas non-Caucasian ethnic groups had more emergency room visits (P < 0.0001) and clinic visits (P = 0.001) than Caucasians. Further investigation of men and non-Caucasians in the screening, evaluation, and treatment of depression is necessary to confirm disparities and evaluate their possible causes.

[Risk factor assessment of cardiocerebrovascular diseases in patients with rheumatoid arthritis].

OBJECTIVE: To assess the prevalence of cardiocerebrovascular diseases (CCVDs) in the patients with rheumatoid arthritis (RA) and analyzed the risk factors. METHODS: The clinical data of 568 RA patients hospitalized 1995 - 2005, were analyzed retrospectively. RESULTS: (1) The total prevalence of CCVD was 16.2% (92/568). The prevalence rate of coronary heart disease, cerebrovascular disease, hypertensive heart disease together with coronary heart disease including 2 cases of heart failure, atherogenesis in large and medium-size arteries proved by color Doppler ultrasonic examination, and gangrene of extremities were 53.26% (49/92), 22.83% (21/92), 13.04% (12/92), 6.52% (6/92), and 4.34% (4/92) respectively. (2) Complication of CCVD in RA patients was associated with age, DAS28 disease activity score, number of involved extra-articular organs, platelet count, hyperfibrinogenemia, and C-reactive protein; and was not associated with sex, auto-antibody, hereditary factor, other traditional CCBVD risk factors, and the number of risk factors. (3) The occurrence of CCVD in RA patients was significantly correlated with poor therapeutic response, lack of persistent effective prevention of the traditional risk factors, use of cyclooxygenase (Cox)-2 specific inhibitors, and long-term medication of high-dosage glucocorticoid. CONCLUSION: Activity of the disease of RA, high inflammatory index, extra-articular involvement, poor response to treatment, lack of persistent effective prevention of the traditional risk factors, use of Cox-2 specific inhibitor, and long-term medication of high-dosage glucocorticoid are risk factors of CCVD-co-morbidities in RA pate.