Linking crash and breathalyzer data in Connecticut.

OBJECTIVES: To document the process of linking breathalyzer and motor vehicle crash (MVC) data for the State of Connecticut using a unique identifier in the place of personal and private information. METHODS: Deterministic linkage methodologies were utilized in Microsoft SQL Server to join 5,634 (of 6,650) breathalyzer records to corresponding MVC driver records for the period of January 1, 2017 to December 31, 2022. Differences between the linked and original datasets were documented by comparing the consistency of frequency and proportion distributions of key variables. RESULTS: Proportions of annual records, alcohol breath tests, and refusals were nearly unchanged when comparing linked and original breathalyzer data. When examining variables in the original MVC driver records, there were differences in the within-group proportions for sex and age, with an overrepresentation of males and drivers aged 26-to-40 years old. For crash and injury severity, the linked dataset had lower proportions of more severe injury records when compared to the original MVC data. Additionally, 1,007 breathalyzer records were not matched with an associated MVC record. CONCLUSIONS: Linkage methodology is sound and produced quality matches. The use of a unique identifier provided a strong match qualifier in the absence of personal and private data. Changes in proportions for age, sex, crash and injury severity align with previous research. Potential missed matches may be attributed to several factors outside of the linkage process, including data discrepancies and varied reporting practices. Future studies will further explore these differences and incorporate additional toxicology data as part of a continued effort to fuze crash, citation, toxicology, and public health data. The end result will be a holistic, comprehensive, and multifaceted database for transportation research and education.

Workforce Survey of Connecticut Midwives.

INTRODUCTION: Midwives in Connecticut lack resources for current, state-specific data regarding compensation, benefits, work hours, and scope of practice. The primary purpose of this study was to provide detailed information about the work and services provided by midwives in Connecticut and how they are compensated. METHODS: Certified nurse-midwives (CNMs) licensed in Connecticut were recruited for a 53-question online survey between October 2021 and February 2022. The survey included topics such as compensation, benefits, practice patterns, and precepting. RESULTS: For full-time salaried CNMs in Connecticut, compensation was higher than the national average for midwives. A majority of CNMs in the state work 40 hours per week or less in physician-owned private practices and are preceptors. DISCUSSION: For midwives planning to negotiate contracts in Connecticut, this report provides important information to ensure fair compensation and work hours. The survey also serves as a roadmap for midwives in other states who wish to collect and disseminate similar workforce data.

Recognition and Treatment of Wounds in Persons Using Xylazine: A Case Report From New Haven, Connecticut.

BACKGROUND: Xylazine is an α 2 -adrenergic agonist that is commonly used as a veterinary tranquilizer and is increasingly present in the unregulated US drug supply since at least 2019. There are many suspected clinical complications of xylazine use, including unusual skin wounds, atypical overdose presentations, and possible dependence and withdrawal syndromes. However, there are few reports of cutaneous manifestations of xylazine in patients who inject drugs that can guide diagnosis and management in patients with confirmed xylazine toxicology. CASE SUMMARY: We present the cases of 3 stably housed patients in Connecticut with opioid use disorder and intravenous use of fentanyl who presented with atypical, chronic wounds at the site of injection drug use. Xylazine toxicology sent on all 3 patients was positive. All patients were seen by wound care and dermatology, and 1 patient was followed by infectious diseases. Wound care management strategies are discussed as well as harm reduction strategies. For all patients, the dose of their medication for opioid use disorder was increased to decrease frequency of drug use given concern that patients were exposed to a drug supply containing xylazine. CLINICAL SIGNIFICANCE: This case report presents wound characteristics that raise the index of suspicion for xylazine-involved injection wounds and might assist in their diagnosis and management. There is urgent need for more reporting of such cases as well as rigorous research to understand the potential impact of xylazine on people who use drugs. Multidisciplinary best practices should be established.

Pesticide residues in honey bee (Apis mellifera) pollen collected in two ornamental plant nurseries in Connecticut: Implications for bee health and risk assessment.

Honey bees (Apis mellifera L.) are one of the most important managed pollinators of agricultural crops. While potential effects of agricultural pesticides on honey bee health have been investigated in some settings, risks to honey bees associated with exposures occurring in the plant nursery setting have received little attention. We sought to identify and quantify pesticide levels present in honey bee-collected pollen harvested in two ornamental plant nurseries (i.e., Nursery A and Nursery B) in Connecticut. From June to September 2018, pollen was collected weekly from 8 colonies using bottom-mounted pollen traps. Fifty-five unique pesticides (including related metabolites) were detected: 24 insecticides, 20 fungicides, and 11 herbicides. Some of the pesticide contaminants detected in the pollen had not been applied by the nurseries, indicating that the honey bee colonies did not exclusively forage on pollen at their respective nursery. The average number of pesticides per sample was similar at both nurseries (i.e., 12.9 at Nursery A and 14.2 at Nursery B). To estimate the potential risk posed to honey bees from these samples, we utilized the USEPA's BeeREX tool to calculate risk quotients (RQs) for each pesticide within each sample. The median aggregate RQ for nurse bees was 0.003 at both nurseries, well below the acute risk level of concern (LOC) of ≥0.4. We also calculated RQs for larvae due to their increased sensitivity to certain pesticides. In total, 6 samples had larval RQs above the LOC (0.45-2.51), resulting from the organophosphate insecticide diazinon. Since 2015, the frequency and amount of diazinon detected in pollen increased at one of our study locations, potentially due to pressure to reduce the use of neonicotinoid insecticides. Overall, these data highlight the importance of considering all life stages when estimating potential risk to honey bee colonies from pesticide exposure.

An Exploratory Approach to Deriving Nutrition Information of Restaurant Food from Crowdsourced Food Images: Case of Hartford.

Deep learning models can recognize the food item in an image and derive their nutrition information, including calories, macronutrients (carbohydrates, fats, and proteins), and micronutrients (vitamins and minerals). This technology has yet to be implemented for the nutrition assessment of restaurant food. In this paper, we crowdsource 15,908 food images of 470 restaurants in the Greater Hartford region on Tripadvisor and Google Place. These food images are loaded into a proprietary deep learning model (Calorie Mama) for nutrition assessment. We employ manual coding to validate the model accuracy based on the Food and Nutrient Database for Dietary Studies. The derived nutrition information is visualized at both the restaurant level and the census tract level. The deep learning model achieves 75.1% accuracy when compared with manual coding. It has more accurate labels for ethnic foods but cannot identify portion sizes, certain food items (e.g., specialty burgers and salads), and multiple food items in an image. The restaurant nutrition (RN) index is further proposed based on the derived nutrition information. By identifying the nutrition information of restaurant food through crowdsourced food images and a deep learning model, the study provides a pilot approach for large-scale nutrition assessment of the community food environment.

Intraoperative electroencephalographic changes during transcarotid artery revascularization are more frequent than previously reported.

OBJECTIVE: Up to 14% of patients undergoing carotid endarterectomy with continuous electroencephalographic (EEG) neuromonitoring will require shunt placement because of EEG changes. However, the initial studies of transcarotid artery revascularization (TCAR) found only one patient with temporary EEG changes. We report our experience with intraoperative EEG monitoring during TCAR. METHODS: We conducted a retrospective review of patients who underwent TCAR at two urban hospitals within an integrated healthcare network from May 2017 to January 2020. The data included demographic information, patient comorbidities, symptom status, previous carotid interventions, anatomic details, contralateral disease, intraoperative vital signs and EEG changes, and postoperative major adverse events (transient ischemic attack, stroke, myocardial infarction [MI], and death) both initially and at 30 days postoperatively. The Fisher exact test was used for categorical data and the Wilcoxon rank sum test for continuous data. RESULTS: A total of 89 patients underwent TCAR during the study period, of whom 71 (79.8%) received intraoperative EEG neuromonitoring. Of the 89 patients, 70.8% were men and 29.2% were women. The median age was 75 years (IQR, 68-82.5 years). Symptomatic patients accounted for 41.6% of the cohort. Of the 71 patients who received continuous neuromonitoring, 9 experienced EEG changes during TCAR (12.7%). The changes resolved in seven patients with pressure augmentation in three and switching to a low flow toggle in three. One patient who had sustained EEG changes had a new postoperative neurologic deficit. The median carotid stenosis percentage on preoperative computed tomography angiography was lower for patients with EEG changes than for those without (67% vs 80%; P = .01). No correlation was found between symptom status or 30-day stroke in patients with and without EEG changes (P = .49 and P = .24, respectively). Overall, three postoperative strokes, two postoperative deaths, and one MI occurred, for a composite 30-day stroke, death, and MI rate of 6.7%. CONCLUSIONS: Changes in continuous EEG monitoring were more frequent in our study than previously reported. Less severe carotid stenosis might be associated with a greater incidence of EEG changes. Limited data are available on the prognostic ability of EEG to detect clinically relevant changes during TCAR, and further studies are warranted.

Survey of Pharmacists' Knowledge of Connecticut's Medical Cannabis Program.

Introduction: Over the last few years, a growth in research and interest in medical cannabis (most often referred to as medical marijuana) use have occurred nationally. Medical cannabis has become a treatment option for disease conditions, such as epilepsy, wasting syndrome associated with AIDs, and post-traumatic stress disorder, when traditional medication is ineffective. Objectives: The objectives were to identify knowledge deficits of the medical cannabis program (MCP) in Connecticut among Connecticut pharmacists and the impact of MCP on Connecticut pharmacy practice and concerns Connecticut pharmacists have regarding medical cannabis use. Methods: A cross-sectional survey through an online platform, Google forms, was administered for 2 months (October 15, 2017-December 15, 2017). An e-mail containing the link to the survey was e-mailed to all pharmacists whose e-mail addresses were available from the State of Connecticut's Commission of Pharmacy database (n = 6182). Of those with available e-mail addresses, only 5653 pharmacists received the e-mail; the others were rejected upon receipt of our e-mail. Our survey consists of 16 items related to pharmacist demo- graphic information, knowledge assessment, impact on pharmacists' practice, and concerns stemming from medical cannabis. Results: Only 51 (15.2%) respondents believed that Connecticut MCP would impact their practice. Only 39 (11.6%) respondents selected the two correct requirements for patient registration and correctly identified the wrong choices. Only 81 (24.2%) respondents identified the correct approved dose (maximum allowable monthly amount of 2.5 ounces) of medical cannabis. Sixty-eight (20.2%) respondents correctly identified all three approved conditions and all other incorrect conditions. Sixty-five (19.40%) respondents correctly identified all roles of dispensary pharmacists. Majority of respondents, 243 (72.5%), expressed their concern about federal laws regarding cannabis. A total of 98 (29.3%) respondents thought that they were knowledgeable enough about the side effects of medical cannabis to provide appropriate counseling to patients. Conclusion: Overall, the results of our survey found that Connecticut licensed pharmacists had lack of complete and accurate knowledge regarding the state's MCP. As more states legalize medical cannabis, it will be imperative that education of pharmacists and other health care professionals about the MCP and the clinical use of cannabis occur.

COVID-19 infections and outcomes in a live registry of heart failure patients across an integrated health care system.

BACKGROUND: Patients with comorbid conditions have a higher risk of mortality with SARS-CoV-2 (COVID-19) infection, but the impact on heart failure patients living near a disease hotspot is unknown. Therefore, we sought to characterize the prevalence and outcomes of COVID-19 in a live registry of heart failure patients across an integrated health care system in Connecticut. METHODS: In this retrospective analysis, the Yale Heart Failure Registry (NCT04237701) that includes 26,703 patients with heart failure across a 6-hospital integrated health care system in Connecticut was queried on April 16th, 2020 for all patients tested for COVID-19. Sociodemographic and geospatial data as well as, clinical management, respiratory failure, and patient mortality were obtained via the real-time registry. Data on COVID-19 specific care was extracted by retrospective chart review. RESULTS: COVID-19 testing was performed on 900 symptomatic patients, comprising 3.4% of the Yale Heart Failure Registry (N = 26,703). Overall, 206 (23%) were COVID- 19+. As compared to COVID-19-, these patients were more likely to be older, black, have hypertension, coronary artery disease, and were less likely to be on renin angiotensin blockers (P<0.05, all). COVID-19- patients tended to be more diffusely spread across the state whereas COVID-19+ were largely clustered around urban centers. 20% of COVID-19+ patients died, and age was associated with increased risk of death [OR 1.92 95% CI (1.33-2.78); P<0.001]. Among COVID-19+ patients who were ≥85 years of age rates of hospitalization were 87%, rates of death 36%, and continuing hospitalization 62% at time of manuscript preparation. CONCLUSIONS: In this real-world snapshot of COVID-19 infection among a large cohort of heart failure patients, we found that a small proportion had undergone testing. Patients found to be COVID-19+ tended to be black with multiple comorbidities and clustered around lower socioeconomic status communities. Elderly COVID-19+ patients were very likely to be admitted to the hospital and experience high rates of mortality.

Access and Outcomes Among Hypertrophic Cardiomyopathy Patients in a Large Integrated Health System.

Background Hypertrophic cardiomyopathy (HCM) is the most common inherited cardiomyopathy. Current guidelines endorse management in expert centers, but patient socioeconomic status can affect access to specialty care. The effect of socioeconomic status and specialty care access on HCM outcomes has not been examined. Methods and Results We conducted a retrospective cohort study that examined outcomes among HCM patients receiving care in the Yale New Haven Health System between June 2011 and December 2017. Patients were assigned to lower or higher socioeconomic status groups (LSES/HSES) based on medical insurance provider and to receivers of specialty care (SC) at Yale's Inherited Cardiomyopathy clinic or general cardiology care (GC). The primary outcome was all-cause death, and the secondary outcome was all-cause hospitalization. We identified 953 HCM patients; 820 (86%) were HSES and 133 (14%) were LSES. Forty-three (4.5%) patients died from cardiac and noncardiac causes. LSES patients within the general cardiology care cohort had significantly higher all-cause mortality compared with HSES patients (adjusted hazard ratio, [95% CI]=10.06 [4.38-23.09]; P<0.001). This was not noted in the specialty care cohort (adjusted hazard ratio, [95% CI]=2.87 [0.56-14.73]; P=0.21). The moderator effect of specialty care on mortality difference between LSES versus HSES, however, did not reach statistical significance (hazard ratio, 0.29 [0.05-1.77]; P=0.18). Specialist care was associated with increased hospitalization (adjusted hazard ratio, [95% CI]=3.28 [1.11-9.73]; P=0.03 for LSES; 2.19 [1.40-3.40]; P=0.001 for HSES). Conclusions Socioeconomically vulnerable HCM patients had higher mortality when not referred to specialty care. Further study is needed to understand the underlying causes.

A Colocalized Hepatitis C Virus Clinic in a Primary Care Practice Improves Linkage to Care in a High Prevalence Population.

BACKGROUND: There is an urgent need to increase patient access to treatment of chronic hepatitis C virus (HCV) infection. We developed a colocalized HCV clinic integrated within a primary care practice. We report the prevalence of HCV and evaluate the impact of the integrated clinic on the HCV cascade of care. METHODS: We performed a retrospective study of patients with chronic HCV infection from 2 clinic practices, an integrated clinic practice and a similar nonintegrated clinic practice, between July 2015 and July 2016. Demographic, clinical, and HCV testing data were reviewed to estimate the prevalence of chronic HCV and to construct a cascade of care. RESULTS: A total of 8405 primary care patients were included; 4796 (57.1%) received an HCV antibody test and 390 (8.1%) were positive. A total of 310 patients with chronic HCV were included in the analysis. There were 119 patients eligible for linkage to care in the nonintegrated clinic, of which 80 (67.2%) were referred, 38 (31.9%) were linked, and 18 (15.1%) initiated treatment during the study period. Among the 70 patients eligible for linkage to care in the integrated clinic practice, 51 (72.9%) were referred, 38 (54.3%) were linked, and 16 (22.9%) initiated treatment. In a multivariable analysis, patients in the integrated clinic practice had significantly higher odds of being linked to care than patients in the nonintegrated clinic practice (adjusted odds ratio [OR] 2.5, 95% confidence interval [CI] = 1.3-4.8). CONCLUSIONS: We found a high seroprevalence of chronic HCV within our clinic population and demonstrate that a HCV clinic integrated into a primary care center increases linkage to care for patients with chronic HCV.

Phytoestrogens and Thyroid Cancer Risk: A Population-Based Case-Control Study in Connecticut.

BACKGROUND: Very few previous studies have examined the relationship between thyroid cancer risk and intake of phytoestrogens (PE); furthermore, these studies have reached inconsistent results. METHODS: We analyzed data from a population-based case-control study in Connecticut from 2010 to 2011, including 387 histologically confirmed thyroid cancer cases and 433 population-based controls, with compound data available concerning specific PEs. Multivariate unconditional logistic regression models were used to estimate the associations between specific PEs and the risk of thyroid cancer, adjusting for potential confounders. RESULTS: An elevated risk of thyroid cancer was associated with moderate to high levels of coumestrol intake [OR = 2.48, 95% confidence interval (CI), 1.39-4.43 for 40-80 µg/day; OR = 2.41, 95% CI, 1.32-4.40 for 80-130 µg/day; and OR = 2.38, 95% CI, 1.26-4.50 for >200 µg/day compared with <40 µg/day], and the main elevation in risk appeared among microcarcinomas (≤1 cm). A decreased risk of papillary macrocarcinomas (>1 cm; OR = 0.26, 95% CI, 0.08-0.85 for 1,860-3,110 µg/day compared with <760 µg/day) was associated with moderate genistein intake among women. CONCLUSIONS: Our study suggests that high coumestrol intake increases the risk of thyroid cancer, especially microcarcinomas, whereas moderate amounts of genistein intake appear to be protective for females with thyroid macrocarcinomas. IMPACT: The study highlights the importance of distinguishing between microcarcinomas and macrocarcinomas in future research on the etiology of thyroid cancer.

Service-Related Barriers and Facilitators in an Early Childhood System of Care: Comparing the Perspectives of Parents and Providers.

Systems of care (SOCs) have the potential to enhance underserved families' access to integrated health and support services. Most scholarship on SOCs has involved school-aged children and adolescents. Thus, research is needed to better understand barriers to, and facilitators of, families' access to services during early childhood. The present study included a community-based participatory approach in understanding services for families of children under age six years with severe emotional and behavioral problems. We analyzed data from two focus groups with caregivers (n = 7) and three focus groups with service providers (n = 22). Our thematic analysis of participants' responses revealed five primary barriers to family service access, including challenges associated with transition planning. In comparison, participants described four primary facilitators of family service access, including providers' adoption of "whole-family" service delivery approaches. Findings indicated areas of convergence and divergence in caregivers' and providers' responses. We discuss limitations and potential implications.

Facilitating accurate health provider directories using natural language processing.

BACKGROUND: Accurate information in provider directories are vital in health care including health information exchange, health benefits exchange, quality reporting, and in the reimbursement and delivery of care. Maintaining provider directory data and keeping it up to date is challenging. The objective of this study is to determine the feasibility of using natural language processing (NLP) techniques to combine disparate resources and acquire accurate information on health providers. METHODS: Publically available state licensure lists in Connecticut were obtained along with National Plan and Provider Enumeration System (NPPES) public use files. Connecticut licensure lists textual information of each health professional who is licensed to practice within the state. A NLP-based system was developed based on healthcare provider taxonomy code, location, name and address information to identify textual data within the state and federal records. Qualitative and quantitative evaluation were performed, and the recall and precision were calculated. RESULTS: We identified nurse midwives, nurse practitioners, and dentists in the State of Connecticut. The recall and precision were 0.95 and 0.93 respectively. Using the system, we were able to accurately acquire 6849 of the 7177 records of health provider directory information. CONCLUSIONS: The authors demonstrated that the NLP- based approach was effective at acquiring health provider information. Furthermore, the NLP-based system can always be applied to update information further reducing processing burdens as data changes.

Prevalence and Correlates of Unhealthy Alcohol and Drug Use Among Men Who Have Sex with Men Prescribed HIV Pre-exposure Prophylaxis in Real-World Clinical Settings.

Pre-exposure prophylaxis (PrEP) is effective in preventing HIV acquisition among men who have sex with men (MSM). However, little is known about unhealthy substance use among MSM initiating PrEP in real-world settings. Unhealthy substance use is a risk factor for HIV acquisition and non-adherence to treatment, and may also impact PrEP use. MSM who were prescribed PrEP from 2015 to 2017 at clinics in Providence, Rhode Island and New Haven, Connecticut were recruited to participate in a prospective observational study. Structured clinical assessments were used to assess demographics, HIV risk behaviors, and unhealthy alcohol (alcohol use disorders identification test [AUDIT]-C scores ≥ 4) and drug use (use of any drugs in the past 3 months). Bivariate and multivariate analyses were performed to determine demographics and behaviors associated with unhealthy alcohol and drug use. Among 172 MSM initiating PrEP, 64% were white and 40% were 25-34 years old. Participants reported a median of 3 (IQR 2-7) sexual partners in the last 3 months; 20% reported an HIV positive partner. Unhealthy alcohol and any drug use were reported by 54 and 57%, respectively, and 76% reported at least one of the two. The majority of drug use reported was marijuana and poppers (41 and 26% of participants, respectively). Relative to those without unhealthy alcohol use, unhealthy alcohol use was independently associated with any drug use (adjusted odds ratio [AOR] = 2.57, 95% CI 1.32-5.01). Frequent drug use was associated with younger age (< 25 years, AOR 4.27, 95% CI 1.51-12.09). Unhealthy alcohol use is common among MSM taking PrEP. Drug use other than marijuana and poppers was uncommon among our cohort. Further efforts may be needed to understand the influence of unhealthy alcohol and other substance use on PrEP outcomes and to engage MSM who use drugs for PrEP.

Mindfulness and emotion regulation: promoting well-being during the transition to college.

BACKGROUND AND OBJECTIVES: Managing stress is very important for first-year college students adjusting to undergraduate life. Aspects of emotion regulation, including mindfulness and the ability to regulate distressing emotion adaptively, often correlate positively with well-being. However, little research has examined overlapping and/or distinct effects of these constructs in predicting changes in adjustment over a stressful transition. Thus, the present study examined the contributions of mindfulness and adaptive emotion regulation abilities in maintaining well-being during the transition to college. We further examined experience with mind-body practices, which may promote mindfulness and positive adjustment. DESIGN: Online surveys were administered to 158 undergraduates near the beginning and end of their first semester. METHODS: Near semester start and end, students reported levels of mindfulness, adaptive emotion regulation abilities, emotional and spiritual well-being, and experience with mind-body practices. RESULTS: Compared to mindfulness, adaptive emotion regulation abilities largely demonstrated stronger cross-sectional and longitudinal associations with well-being. However, mindfulness uniquely protected against changes in depression for students with greater emotion regulation difficulties. Over half of participants reported having tried mind-body practices, but just 1% reported current use. CONCLUSIONS: Promoting mindfulness practices and adaptive emotion regulation abilities at the start of college may build resilience in undergraduate students.

Effects of Freeze-Dried Grape Powder on High-Density Lipoprotein Function in Adults with Metabolic Syndrome: A Randomized Controlled Pilot Study.

BACKGROUND: High-density lipoprotein (HDL) particles are protective against atherosclerosis. However, HDL function is impaired in metabolic syndrome (MetS) due to low-grade inflammation and dyslipidemia. Foods containing polyphenols, such as grapes, may prevent HDL dysfunction via antioxidant or anti-inflammatory effects. We evaluated the effects of grape powder ingestion on measures of HDL function in adults with MetS. METHODS: Twenty adults (age: 32-70 years; body mass index: 25.3-45.4 kg/m2) consumed either 60 grams/day of freeze-dried grape powder (GRAPE) or a placebo for 4 weeks, separated by a 3-week washout period, in a randomized, double-blind crossover study. The primary outcome was serum paraoxonase-1 (PON1) arylesterase activity, a measure of HDL antioxidant function. Secondary outcomes included PON1 lactonase activity, plasma lipids, metabolic markers, cholesterol efflux capacity, and other HDL functional markers. RESULTS: After 4 weeks, GRAPE did not alter the serum PON1 activity or other markers of HDL function compared with placebo. Measures of HDL function were positively correlated with each other and inversely with measures of insulin resistance and inflammation. GRAPE intake led to a significant reduction in fasting plasma triglycerides compared with placebo (P = 0.032). No other significant effects of GRAPE were observed for other plasma lipids, anthropometrics, or metabolic measures. CONCLUSIONS: Grape powder consumption did not impact HDL function in this cohort of adults with MetS. However, it was shown to improve fasting triglycerides, a risk factor for cardiovascular disease.

Qualitative study of perspectives concerning recent rehospitalisations among a high-risk cohort of veteran patients in Connecticut, USA.

OBJECTIVES: Veterans Affairs (VA) patients are at risk for rehospitalisation due to their lower socioeconomic status, older age, poor social support or multiple comorbidities. The study explored inpatients' perceptions about factors contributing to their rehospitalisation and their recommendations to reduce this risk. DESIGN: Thematic qualitative data analysis of interviews with 18 VA inpatients. SETTING: VA Connecticut Healthcare System, West Haven Hospital medical inpatient units. PARTICIPANTS: All were aged 18+ years, rehospitalised within 30 days of most recent discharge, medically stable and competent to provide consent. MEASUREMENTS: Interviews assessed inpatients' health status after last discharge, reason for rehospitalisation, access to and support from primary care providers (PCP), medication management, home support systems and history of substance use or mental health disorders. RESULTS: The mean age was 71.6 years (11.1 SD); all were Caucasian, living on limited budgets, and many had serious medical conditions or histories of mental health disorders. Participants considered structural barriers to accessing PCP and limited PCP involvement in medical decision-making as contributing to their rehospitalisation, although most believed that rehospitalisation had been inevitable. Peridischarge themes included beliefs about premature discharge, inadequate understanding of postdischarge plans and insufficiently coordinated postdischarge services. Most highly valued their VA healthcare but recommended increasing PCPs' involvement and reducing structural barriers to accessing primary and specialty care. CONCLUSIONS: Increased PCP involvement in medical decision-making about rehospitalisation, expanded clinic hours, reduced travel distances, improved communications to patients and their families about predischarge and postdischarge plans and proactive postdischarge outreach to high-risk patients may reduce rehospitalisation risk.

Nuclear shape and orientation features from H&E images predict survival in early-stage estrogen receptor-positive breast cancers.

Early-stage estrogen receptor-positive (ER+) breast cancer (BCa) is the most common type of BCa in the United States. One critical question with these tumors is identifying which patients will receive added benefit from adjuvant chemotherapy. Nuclear pleomorphism (variance in nuclear shape and morphology) is an important constituent of breast grading schemes, and in ER+ cases, the grade is highly correlated with disease outcome. This study aimed to investigate whether quantitative computer-extracted image features of nuclear shape and orientation on digitized images of hematoxylin-stained and eosin-stained tissue of lymph node-negative (LN-), ER+ BCa could help stratify patients into discrete (<10 years short-term vs. >10 years long-term survival) outcome groups independent of standard clinical and pathological parameters. We considered a tissue microarray (TMA) cohort of 276 ER+, LN- patients comprising 150 patients with long-term and 126 patients with short-term overall survival, wherein 177 randomly chosen cases formed the modeling set, and 99 remaining cases the test set. Segmentation of individual nuclei was performed using multiresolution watershed; subsequently, 615 features relating to nuclear shape/texture and orientation disorder were extracted from each TMA spot. The Wilcoxon's rank-sum test identified the 15 most prognostic quantitative histomorphometric features within the modeling set. These features were then subsequently combined via a linear discriminant analysis classifier and evaluated on the test set to assign a probability of long-term vs. short-term disease-specific survival. In univariate survival analysis, patients identified by the image classifier as high risk had significantly poorer survival outcome: hazard ratio (95% confident interval) = 2.91(1.23-6.92), p = 0.02786. Multivariate analysis controlling for T-stage, histology grade, and nuclear grade showed the classifier to be independently predictive of poorer survival: hazard ratio (95% confident interval) = 3.17(0.33-30.46), p = 0.01039. Our results suggest that quantitative histomorphometric features of nuclear shape and orientation are strongly and independently predictive of patient survival in ER+, LN- BCa.