Assessing the immediate impact of COVID-19 on surgical oncology practice: Experience from an NCI-designated Comprehensive Cancer Center in the Northeastern United States.

BACKGROUND: The effects of the coronavirus disease 2019 (COVID-19) pandemic on surgical oncology practice are not yet quantified. The aim of this study was to measure the immediate impact of COVID-19 on surgical oncology practice volume. METHODS: A retrospective study of patients treated at an NCI-Comprehensive Cancer Center was performed. "Pre-COVID" era was defined as January-February 2020 and "COVID" as March-April 2020. Primary outcomes were clinic visits and operative volume by surgical oncology subspecialty. RESULTS: Abouyt 907 new patient visits, 3897 follow-up visits, and 644 operations occurred during the study period. All subspecialties experienced significant decreases in new patient visits during COVID, though soft tissue oncology (Mel/Sarc), gynecologic oncology (Gyn/Onc), and endocrine were disproportionately affected. Telehealth visits increased to 11.4% of all visits by April. Mel/Sarc, Gyn/Onc, and Breast experienced significant operative volume decreases during COVID (25.8%, p = 0.012, 43.6% p < 0.001, and 41.9%, p < 0.001, respectively), while endocrine had no change and gastrointestinal oncology had a slight increase (p = 0.823) in the number of cases performed. CONCLUSIONS: The effects of the COVID-19 pandemic are wide-ranging within surgical oncology subspecialties. The addition of telehealth is a viable avenue for cancer patient care and should be considered in surgical oncology practice.

Regional Changes in Patterns of Stroke Presentation During the COVID-19 Pandemic.

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The HIV Care Continuum in Small Cities of Southern New England: Perspectives of People Living with HIV/AIDS, Public Health Experts, and HIV Service Providers.

The HIV care continuum (HCC), comprised of five steps (screening, linkage to care, treatment initiation, retention, and viral suppression), is used to monitor treatment delivery to people living with HIV (PLWH). The HCC has primarily focused on large urban or metropolitan areas where the situation may differ from that in smaller cities. Three themes (i.e., knowledge, stigma, stability) that shaped HCC outcomes were identified from analysis of two qualitative studies involving HIV service providers, public health experts, and PLWH in smaller cities of southern New England. The findings suggest that enhancing HCC outcomes require a multiprong approach that targets both the individual and organizational levels and includes interventions to increase health literacy, staff communication skills, universal screening to assess patients' religiosity/spirituality and supplemental service needs. Interventions that further ensure patient confidentiality and the co-location and coordination of HIV and other healthcare services are particularly important in smaller cities.

RESUMEN: El cuidado continuo de VIH (HCC), constado de cinco etapas (pruebas, vinculación al cuidado, inico del tratamiento, retención, y supresión viral), se emplea para monitorizar la entrega de tratamientos a las personas que vivien con VIH (PLWH). El HCC ha enfocado principalmente en áreas grandes y urbanas o áreas metropolitanas, donde la situación podría ser diferente que la de las ciudades más pequeñas. Tres temas (i.e., conocimiento, estigma, estabilidad) que formaron los resultados de HCC fueron identificados con análisis de dos estudios cualitativos que involucraron los proveedores de servicios de VIH, expertos de la salud pública, y PLWH en ciudades más pequeñas en las partes sureñas de Nueva Inglaterra. Los hallazgos sugieren que la mejora de los resultados de HCC requiere un enfoque multidimensional que se dirigen a ambos niveles del individuo y organización, y que incluyen intervenciones para aumentar la alfabetización sanitaria, la habilidad de comunicación del personal, la prueba universal para evaluar la religiosidad/espiritualidad de los pacientes y la necesidad de servicios suplementarios. Intervenciones que aseguran aún más la confidencialidad de los pacientes y el co-ubicación y coordinación de los servicios de VIH y otras asistencias medicas son particularmente importantes en ciudades pequeñas.

Categorizing Cannabis and Alcohol Use Patterns of Emerging Adults in Psychiatric Partial Hospitalization Treatment.

BACKGROUND: Emerging adulthood is a common and problematic time for alcohol and cannabis use. Emerging adulthood also represents a vulnerable time period for anxiety and depression. Substance use and mental health issues are highly comorbid, yet substance use is commonly neglected in psychiatric care. OBJECTIVE: The goal of this study was to categorize the cannabis and alcohol use patterns of emerging adults in psychiatric care and to evaluate relationships with use-related problems, psychiatric symptomatology, and motives for use. METHODS: Participants were emerging adults who were consecutive admissions to a young adult psychiatric partial hospital program from 2017 to 2018. Of 318 participants who completed questionnaires, 244 (76.7%) reported cannabis and/or alcohol use in the previous month. Cluster analyses and analysis of variance tests were conducted to categorize and differentiate between participants who reported use. RESULTS: Results from cluster analyses identified 4 categories of use: low cannabis/high alcohol (35.7%), low cannabis/low alcohol (17.6%), high cannabis/low alcohol (29.1%), and high cannabis/high alcohol (17.6%). Individuals in categories with the highest rates of use and co-use reported more alcohol problems (F=24.31, P<0.001), cannabis problems (F=36.75, P<0.001), depression (F=3.60, P=0.01), and motives: social (F=6.12, P<0.001), coping with anxiety (F=20.43, P<0.001), coping with depression (F=17.80, P<0.001), enhancement (F=7.85, P<0.001), and conformity (F=4.92, P<0.01). CONCLUSIONS/IMPORTANCE: Clear categories of substance use emerged. Participants who were heavier users were more likely to use to alleviate psychiatric symptomatology, yet they also reported greater psychiatric symptomatology and use-related problems. Among a psychiatric sample of emerging adults, cannabis and alcohol use was common and problematic. Thus, substance use should be evaluated for and, if present, targeted with interventions during psychiatric care.

Ischemic Stroke Transfer Patterns in the Northeast United States.

BACKGROUND: Little is known about how hospitals are connected in the transfer of ischemic stroke (IS) patients. We aimed to describe differences in characteristics of transferred versus nontransferred patients and between transferring and receiving hospitals in the Northeastern United States, and to describe changes over time. METHODS: We used Medicare claims data, and a subset linked with the Get with the Guidelines-Stroke registry from 2007 to 2011. Receiving hospitals were those with annual IS volume greater than or equal to 120 and greater than or equal to 15% received as transfers, and transferring hospitals were nonaccepting hospitals that transferred greater than or equal to 15% of their total (ED plus inpatient) IS patient discharges. A transferring-to-receiving hospital connection was identified if greater than or equal to 5 patients per year were shared. ArcGIS 10.3.1 was used for network visualization. RESULTS: Among 177,270 admissions to 402 Northeast hospitals, 6906 (3.9%) patients were transferred. Transferred patients were younger with more severe strokes (78 versus 81 years, P < .001; National Institutes of Health Stroke Severity 7 versus 5, P < .001), and were as likely to receive tissue plasminogen activator as nontransferred (P = .29). From 2007 to 2011, there were more patients transferred (960 [3%] to 1777 [6%], P < .001), and more transferring hospitals (46 [12%] to 91 [24%], P < .001), and receiving hospitals (6 [2%] to 16 [4%], P < .001). Most transferring hospitals were exclusively connected to a single receiving hospital. CONCLUSIONS: From 2007 to 2011, hospitals in the United States Northeast became more connected in the care of IS patients, with increasing patient transfers and hospital connections. Yet most hospitals remained unconnected. Further characterization of this transfer network will be important for understanding and improving regional stroke systems of care.

Chronic pain and depression among primary care patients treated with buprenorphine.

BACKGROUND: Pain and depression are each prevalent among opioid dependent patients receiving maintenance buprenorphine, but their interaction has not been studied in primary care patients. OBJECTIVE: We set out to examine the relationship between chronic pain, depression, and ongoing substance use, among persons maintained on buprenorphine in primary care settings. DESIGN: Between September 2012 and December 2013, we interviewed buprenorphine patients at three practice sites. PARTICIPANTS: Opioid dependent persons at two private internal medicine offices and a federally qualified health center participated in the study. MAIN MEASURES: Pain was measured in terms of chronicity, with chronic pain being defined as pain lasting at least 6 months; and in terms of severity, as measured by self-reported pain in the past week, measured on a 0-100 scale. We defined mild chronic pain as pain severity between 0 and 39 and lasting at least 6 months, and moderate/severe chronic pain as severity ≥ 40 and lasting at least 6 months. To assess depression, we used the Center for Epidemiologic Studies Depression (CESD) ten-item symptom scale and the two-item Patient Health Questionnaire (PHQ-2). KEY RESULTS: Among 328 participants, 169 reported no chronic pain, 56 reported mild chronic pain, and 103 reported moderate/severe chronic pain. Participants with moderate/severe chronic pain commonly used non-opioid pain medications (56.3%) and antidepressants (44.7%), yet also used marijuana, alcohol, or cocaine (40.8%) to help relieve pain. Mean CESD scores were 7.1 (±6.8), 8.3 (±6.0), and 13.6 (±7.6) in the no chronic, mild, and moderate/severe pain groups, respectively. Controlling for covariates, higher CESD scores were associated with a higher likelihood of moderate/severe chronic pain relative to both no chronic pain (OR = 1.09, p < 0.001) and mild chronic pain (OR = 1.06, p = 0.04). CONCLUSION: Many buprenorphine patients are receiving over-the-counter or prescribed pain medications, as well as antidepressants, and yet continue to have significant and disabling pain and depressive symptoms. There is a clear need to address the pain-depression nexus in novel ways.

Mindfulness and alcohol problems in college students: the mediating effects of stress.

OBJECTIVE: To examine the relationship between mindfulness and alcohol problems in college students, as well as the role of stress as a mediator in this relationship. PARTICIPANTS: Participants were 310 students from a small, private college in the Northeast. METHODS: Students completed self-report measures, including the Perceived Stress Scale, the Five Facet Mindfulness Questionnaire, and the Rutgers Alcohol Problems Index. RESULTS: Mindfulness was negatively correlated with alcohol problems and stress, whereas stress positively correlated with alcohol problems. Results implicated stress as fully mediating the relationship between mindfulness and alcohol problems. Alcohol problems were negatively correlated with the Acting With Awareness and Describing Experience facets of mindfulness. CONCLUSION: Mindfulness-based stress reduction or other mindfulness programs may be useful in decreasing alcohol problems on college campuses via the effects on stress.

Prevalence of burnout among doctors of chiropractic in the northeastern United States.

OBJECTIVE: The purpose of this study was to measure the prevalence of burnout among doctors of chiropractic (DCs) in the New York, New Jersey, and Pennsylvania geographical region and compare these results with burnout data from other health care professions. METHODS: This exploratory study applied cross-sectional data collection methods. Using nonprobability convenience sampling, a New York-New Jersey-Pennsylvania chiropractic governance body provided contact information of a randomized sample of licensed DCs from their membership directory. Participants included any DC licensed to practice chiropractic whose primary occupation encompassed the chiropractic profession. The Maslach Burnout Inventory-Human Services Survey (MBI-HSS) and a demographic questionnaire were e-mailed to a randomized sample of licensed DCs. RESULTS: Of the 772 surveys deployed, 90 returned the survey with usable data. Nearly 40% of the DCs reported a moderate (24%) or high (18%) level of emotional exhaustion, whereas the majority of respondents scored a high (72%) level of personal accomplishment. In total, only 2 participants (2%) met the criteria for high burnout, whereas 42 participants (47%) were low. Statistically significant relationships (P < .001) were found between burnout subscales and the effect of time dedicated to administrative duties, the type of practice setting, the varying chiropractic philosophical perspectives, the public's opinion of chiropractic, and the effect of suffering from a work-related injury. When compared with data from previously published studies using the MBI-HSS for other health professions (ie, medical, nursing, physical therapy, occupational therapy, and dentistry), the values for DCs were significantly lower. CONCLUSIONS: The sample of DCs in this study fared more favorably on all 3 dimensions of burnout. They reported lower emotional exhaustion and depersonalization scores and higher personal accomplishment scores than their medical, nursing, physical therapy, occupational therapy, and dentistry colleagues who have been evaluated using the MBI-HSS. However, the levels of emotional exhaustion remain a concern for this professional group.

MRSA nasal carriage patterns and the subsequent risk of conversion between patterns, infection, and death.

BACKGROUND: Patterns of methicillin-resistant S. aureus (MRSA) nasal carriage over time and across the continuum of care settings are poorly characterized. Knowledge of prevalence rates and outcomes associated with MRSA nasal carriage patterns could help direct infection prevention strategies. The VA integrated health-care system and active surveillance program provides an opportunity to delineate nasal carriage patterns and associated outcomes of death, infection, and conversion in carriage. METHODS/FINDINGS: We conducted a retrospective cohort study including all patients admitted to 5 acute care VA hospitals between 2008-2010 who had nasal MRSA PCR testing within 48 hours of admission and repeat testing within 30 days. The PCR results were used to define a baseline nasal carriage pattern of never, intermittently, or always colonized at 30 days from admission. Follow-up was up to two years and included acute, long-term, and outpatient care visits. Among 18,038 patients, 91.1%, 4.4%, and 4.6% were never, intermittently, or always colonized at the 30-day baseline. Compared to non-colonized patients, those who were persistently colonized had an increased risk of death (HR 2.58; 95% CI 2.18;3.05) and MRSA infection (HR 10.89; 95% CI 8.6;13.7). Being in the non-colonized group at 30 days had a predictive value of 87% for being non-colonized at 1 year. Conversion to MRSA colonized at 6 months occurred in 11.8% of initially non-colonized patients. Age >70 years, long-term care, antibiotic exposure, and diabetes identified >95% of converters. CONCLUSIONS: The vast majority of patients are not nasally colonized with MRSA at 30 days from acute hospital admission. Conversion from non-carriage is infrequent and can be risk-stratified. A positive carriage pattern is strongly associated with infection and death. Active surveillance programs in the year following carriage pattern designation could be tailored to focus on non-colonized patients who are at high risk for conversion, reducing universal screening burden.

Dairy foods and nutrients in relation to risk of ovarian cancer and major histological subtypes.

Inconsistent results for the role of dairy food intake in relation to ovarian cancer risk may reflect the potential adverse effects of lactose, which has been hypothesized to increase gonadotropin levels, and the beneficial antiproliferative effects of calcium and vitamin D. Using data from the New England case-control study (1,909 cases and 1,989 controls), we examined dairy foods and nutrients in relation to risk of ovarian cancer overall, histological subtypes and rapidly fatal versus less aggressive disease. We used logistic regression and polytomous logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (CIs). In models that were simultaneously adjusted for total (dietary plus supplements) calcium, total vitamin D and lactose, we observed a decreased overall risk of ovarian cancer with high intake of total calcium [Quartile 4 (Q4, >1,319 mg/day) vs. Quartile 1 (Q1, <655 mg/day), OR = 0.62, 95% CI = 0.49-0.79]; the inverse association was strongest for serous borderline and mucinous tumors. High intake of total vitamin D was not associated overall with ovarian cancer risk, but was inversely associated with risk of serous borderline (Q4, >559 IU/day vs. Q1, <164 IU/day, OR = 0.51, 95% CI = 0.34-0.76) and endometrioid tumors (Q4 vs. Q1, OR = 0.55, 95% CI = 0.39-0.80). We found no evidence that lactose intake influenced ovarian cancer risk or that risk varied by tumor aggressiveness in the analyses of intake of dairy foods and nutrients. The overall inverse association with high intake of calcium and the inverse associations of calcium and vitamin D with specific histological subtypes warrant further investigation.

Microbial spectrum and resistance patterns in endophthalmitis: a 21-year (1988-2008) review in northeast United States.

PURPOSE: To study the microbial spectrum and antibacterial susceptibility of vitreous cultures in a tertiary referral center in Northeast United States. METHODS: All vitreous samples sent to the microbiology laboratory at a tertiary referral center from January 1988 to December 2008 were included in the study. The distribution and antibiotic susceptibility of all isolates from culture-positive samples were compared across 3 equal time periods 1988-1994, 1995-2001, and 2002-2008. RESULTS: One hundred forty-three positive cultures, where 11.9% (n=17) were polymicrobial, yielded a total of 160 isolates that consisted of 80.6% (n=129) gram-positive isolates, 12.5% (n=20) gram-negative isolates, and 6.9% (n=11) fungal isolates. The most prevalent organisms were coagulase-negative Staphylococcus (CoNS) (37.5%, n=60), Viridans Streptococcus (11.3%, n=18), and Streptococcus pneumoniae (6.9%, n=11). Other common gram-positive isolates include Propionibacterium acnes (5.6%, n=9), other Streptococcus species (4.4%, n=7), Staphylococcus aureus (4.4%, n=7), and Enterococcus faecalis (3.8%, n=6). The most common gram-negative isolates were Klebsiella species (3.1%, n=5), Moraxella species (3.1%, n=5), and Haemophilus species (2.5%, n=4). Vancomycin was effective against all CoNS, Sta. aureus, Viridans Streptococcus, and E. faecalis tested, and all Sta. aureus isolates were oxacillin sensitive. Of all CoNS isolates, 83.3% during 1988-1994, 73.1% during 1995-2001, and 100% during 2002-2008 were resistant to at least 1 of the antibiotics tested in the study with the last time period showing an increase in resistance (P=0.021, adjusted standard residual=2.0). CoNS showed a decreasing resistance over time to chloramphenicol and gentamicin (P=0.010, P=0.007, respectively) and an increase in resistance to penicillin and tetracycline during 2002-2008 (P=0.003, P=0.040, respectively). Susceptibility to other antibiotics did not show significant dependence on time. CONCLUSION: Bacteria causing endophthalmitis showed variable resistance to antibiotics over time. The importance of adequately treating endophthalmitis in the setting of these resistance pattern changes stresses the importance of periodic evaluation of causative organisms to ensure appropriate empiric treatment.

Perspectives about depression: explanatory models among African-American women.

Depression is a costly illness, with broad social, economic and personal consequences. It affects many black women, yet only 7% of them receive traditional treatment. Given the chronic nature of depression and its broad impact on women's wellness, there is a need for more research examining both the conceptualization and the interpretation of depression within a socio-cultural context. This qualitative descriptive study used Kleinman's explanatory framework to capture focus group data from 14 African-American women recruited from a primary care center. Data was organized and managed with Atlas/ti 5.12, while content analysis was used to disclose the relevant themes presented in the paper.

Activities of daily living in women with advanced breast cancer.

PURPOSE/OBJECTIVES: To detail the daily activities of women with advanced breast cancer. DESIGN: Descriptive, qualitative. SETTING: Six clinical sites in New England. Of the six sites, three were urban, one was suburban, and two were rural, with three sites being comprehensive cancer centers. SAMPLE: 84 women with a confirmed diagnosis of stage IV breast cancer with a life expectancy of four months or more. METHODS: A secondary analysis of an expressive writing intervention study control group. As part of the control writing group, participants kept handwritten activity logs for four consecutive days. Standard content analysis procedures were used to analyze the transcribed activity logs. MAIN RESEARCH VARIABLES: Activities of daily living in women with advanced breast cancer. FINDINGS: 22 codes were identified that depicted the daily activities of participants. Subsequent analysis merged the 22 codes into six themes. CONCLUSIONS: Findings demonstrated that patients with advanced breast cancer are living very full, active lives despite numerous symptoms and cancer treatments. IMPLICATIONS FOR NURSING: The study serves as a foundation for the development of interventions to enhance daily functioning. Oncology nurses should counsel women with advanced cancer regarding pacing and self-care activities.

Variations of pollen and mold concentrations in 1998 during the strong El Niño event of 1997-1998 and their impact on clinical exacerbations of allergic rhinitis, asthma, and sinusitis.

Previous studies of pollen and mold dispersal have not correlated meteorological phenomena with clinical exacerbations of asthma, allergic rhinitis, and sinusitis. We utilized the resources of 11 New England Society of Allergy (NESA) pollen collectors, a certified palynologist, over a dozen weather stations for meteorological data, and 10 emergency rooms to explore the effects of the strong "El Niño" of 1997-1998 on our region during the 1998 pollen season. There was a marked increase in the number of clinical exacerbations of asthma, allergic rhinitis, and sinusitis in April, May, and June of 1998. Several emergency rooms reported a greater increase in visits for sinusitis as compared to asthma. In addition, maximum mold counts occurred two to three months earlier than in 1997. Maximum pollen counts were also higher than in 1997, and occurred two to four weeks earlier for most tree pollen types.

Entry of US medical school graduates into family practice residences: 1993-1994 and 3-year summary.

This is the 13th report prepared by the American Academy of Family Physicians (AAFP) on the percentage of each US medical school's graduates entering family practice residency programs. Approximately 12.3% of the 15,564 medical school graduates between July 1992 and June 1993 were first-year family practice residents in October 1993, compared with 10.8% the previous year. This is the highest percentage since 1983-1984. Medical school graduates from publicly funded medical schools were more than twice as likely to be first-year family practice residents in October 1993 as were residents from privately funded schools, 15.9% compared with 7.1%. The Mountain region again reported the highest percentage of medical school graduates who were first-year residents in family practice programs in October 1993 at 19.1%; the Middle Atlantic and New England regions continued with the lowest percentages at 7.7% and 6.6%, respectively. At least one in four graduates from nine medical schools during the reporting period was in a family practice residency program in October 1993; only two medical schools had this distinction in 1992. Approximately one in two medical school graduates entering a family practice residency program as first-year residents in October 1993 entered a program in the same state where they graduated from medical school. The percentages for each medical school have varied substantially from year to year since the AAFP began reporting this information. The average percentage for each medical school for the last 3 years is reported.(ABSTRACT TRUNCATED AT 250 WORDS)

Maternal heat exposure and neural tube defects.

OBJECTIVE: To determine if exposure to hot tub, sauna, fever, or electric blanket during early pregnancy was associated with an increased risk for neural tube defects (NTDs). DESIGN: Prospective follow-up study. SETTING: Mostly private obstetric practices, primarily in New England. PARTICIPANTS: A cohort of 23,491 women having serum alpha-fetoprotein screening or an amniocentesis were identified. Complete exposure and outcome information was available for 97% of these women. OUTCOME MEASURES: Relative risks (RRs) were used to compare incidence of NTD in those exposed to heat with those who were not exposed to any heat. Crude RRs were calculated directly from the data. Unconfounded RRs were calculated using logistic regression. RESULTS: Women reporting any heat exposure (sauna, hot tub, fever, or electric blanket) in early pregnancy had a crude risk of their fetuses developing NTD of 1.6 (95% CI [confidence interval], 0.9 to 2.9). Women reporting exposure to sauna, hot tub, or fever in early pregnancy had a crude risk of their fetuses developing NTD 2.2 times that of women without heat exposure (95% CI, 1.2 to 4.1). For hot tub use, the crude RR was 2.9 (95% CI, 1.4 to 6.3); for sauna, 2.6 (95% CI, 0.7 to 10.1); for fever, 1.9 (95% CI, 0.8 to 4.1); and for electric blanket, 1.2 (95% CI, 0.5 to 2.6). Multivariate adjusted RRs for individual heat sources, after controlling for maternal age, folic acid supplements, family history of NTD, and exposure to other heat sources, were for hot tub use, 2.8 (95% CI, 1.2 to 6.5); sauna, 1.8 (95% CI, 0.4 to 7.9); fever, 1.8 (95% CI, 0.8 to 4.1); and electric blanket, 1.2 (95% CI, 0.5 to 2.6). When only hot tub, sauna, and fever were considered and the women's exposure to each tallied, compared with no heat exposure, the RR for NTDs increased from 1.9 (95% CI, 0.9 to 3.7) after one type of heat exposure to 6.2 (95% CI, 2.2 to 17.2) after two types of heat exposure. CONCLUSIONS: Exposure to heat in the form of hot tub, sauna, or fever in the first trimester of pregnancy was associated with an increased risk for NTDs. Hot tub exposure appeared to have the strongest effect of any single heat exposure. Exposure to electric blanket was not materially associated with increased risk for NTDs.