Evaluating analytic models for individually randomized group treatment trials with complex clustering in nested and crossed designs.

Many individually randomized group treatment (IRGT) trials randomly assign individuals to study arms but deliver treatments via shared agents, such as therapists, surgeons, or trainers. Post-randomization interactions induce correlations in outcome measures between participants sharing the same agent. Agents can be nested in or crossed with trial arm, and participants may interact with a single agent or with multiple agents. These complications have led to ambiguity in choice of models but there have been no systematic efforts to identify appropriate analytic models for these study designs. To address this gap, we undertook a simulation study to examine the performance of candidate analytic models in the presence of complex clustering arising from multiple membership, single membership, and single agent settings, in both nested and crossed designs and for a continuous outcome. With nested designs, substantial type I error rate inflation was observed when analytic models did not account for multiple membership and when analytic model weights characterizing the association with multiple agents did not match the data generating mechanism. Conversely, analytic models for crossed designs generally maintained nominal type I error rates unless there was notable imbalance in the number of participants that interact with each agent.

Edetate Disodium-Based Chelation for Patients With a Previous Myocardial Infarction and Diabetes: TACT2 Randomized Clinical Trial.

Importance: In 2013, the Trial to Assess Chelation Therapy (TACT) reported that edetate disodium (EDTA)-based chelation significantly reduced cardiovascular disease (CVD) events by 18% in 1708 patients with a prior myocardial infarction (MI). Objective: To replicate the finding of TACT in individuals with diabetes and previous MI. Design, Setting, and Participants: A 2 × 2 factorial, double-masked, placebo-controlled, multicenter trial at 88 sites in the US and Canada, involving participants who were 50 years or older, had diabetes, and had experienced an MI at least 6 weeks before recruitment compared the effect of EDTA-based chelation vs placebo infusions on CVD events and compared the effect of high doses of oral multivitamins and minerals with oral placebo. This article reports on the chelation vs placebo infusion comparisons. Interventions: Eligible participants were randomly assigned to 40 weekly infusions of an EDTA-based chelation solution or matching placebo and to twice daily oral, high-dose multivitamin and mineral supplements or matching placebo for 60 months. This article addresses the chelation study. Main Outcomes and Measures: The primary end point was the composite of all-cause mortality, MI, stroke, coronary revascularization, or hospitalization for unstable angina. Median follow-up was 48 months. Primary comparisons were made from patients who received at least 1 assigned infusion. Results: Of the 959 participants (median age, 67 years [IQR, 60-72 years]; 27% females; 78% White, 10% Black, and 20% Hispanic), 483 received at least 1 chelation infusion and 476 at least 1 placebo infusion. A primary end point event occurred in 172 participants (35.6%) in the chelation group and in 170 (35.7%) in the placebo group (adjusted hazard ratio [HR], 0.93; 95% CI, 0.76-1.16; P = .53). The 5-year primary event cumulative incidence rates were 45.8% for the chelation group and 46.5% for the placebo group. CV death, MI, or stroke events occurred in 89 participants (18.4%) in the chelation group and in 94 (19.7%) in the placebo group (adjusted HR, 0.89; 95% CI, 0.66-1.19). Death from any cause occurred in 84 participants (17.4%) in the chelation group and in 84 (17.6%) in the placebo group (adjusted HR, 0.96; 95% CI, 0.71-1.30). Chelation reduced median blood lead levels from 9.03 µg/L at baseline to 3.46 µg/L at infusion 40 (P < .001). Corresponding levels in the placebo group were 9.3 µg/L and 8.7 µg/L, respectively. Conclusions and Relevance: Despite effectively reducing blood lead levels, EDTA chelation was not effective in reducing cardiovascular events in stable patients with coronary artery disease who have diabetes and a history of MI. Trial Registration: ClinicalTrials.gov Identifier: NCT02733185.

Disruption of the primary salicylic acid hydroxylases in rice enhances broad-spectrum resistance against pathogens.

Salicylic acid (SA) is a crucial hormone involved in plant immunity. Rice (Oryza sativa) maintains high SA levels that are not induced by pathogens. However, the roles of SA in rice immunity and yield remain largely unknown. Here, we identified SA 5-hydroxylases 1 (OsS5H1) and 2 (OsS5H2) as the primary enzymes engaged in catalysing SA to 2,5-dihydroxybenzoic acid (2,5-DHBA) in rice. SA levels were significantly increased in the oss5h mutants, while they were dramatically decreased in the OsS5H1 and OsS5H2 overexpression lines. The mutants were resistant, whereas the overexpression lines were susceptible to Pyricularia oryzae and Xanthomonas oryzae pv. Oryzae. Moreover, the pathogen-associated molecular patterns-triggered immunity responses, including reactive oxygen species burst and callose deposition, were enhanced in all the mutants and compromised in the overexpression lines. Quantification of the agronomic traits of the oss5h mutants grown in the paddy fields demonstrated that the grain number per panicle was decreased as the SA levels increased; however, the tiller number and grain size were enhanced, resulting in no significant yield penalty. Collectively, we reveal that mildly increasing SA content in rice can confer broad-spectrum resistance without yield penalty and put new insights into the roles of SA in immunity and growth.

Harmonizing Cigar Survey Data Across Tobacco Centers of Regulatory Science, Center for Tobacco Products, and Population Assessment of Tobacco and Health Studies: The Cigar Collaborative Research Group.

INTRODUCTION: Cigars are a popular tobacco product of choice for youth and young adults. Despite growing interest in cigar research, there are gaps in the available literature limiting an ability to set evidence-based policies. Too small research samples, the heterogeneity of types of cigars when asking a single question about use, makes analyzing data difficult. Given the Food and Drug Administration's (FDA's) authority granted in 2016 to regulate cigars, and its popularity, data to better understand use and preference for cigars will help FDA set appropriate regulatory policies. METHODS: We harmonized cigar survey data previously collected by five independent tobacco regulatory science survey research projects. Data supplying participants included three Tobacco Centers of Regulatory Science, one Center for Tobacco Products grantee, and data from Population Assessment of Tobacco and Health (PATH) study's public use dataset. RESULTS: Analyzing 92 data variables from across five studies, and applying a rigorous data harmonization protocol, we report findings on 24 key cigar use variables. The step by step protocol for harmonizing is presented. Selected findings showing strict reproducibility across all five studies reveal youth 17-19 years at highest risk for cigar initiation; relative reproducibility shows males more likely to try cigars than females but with significant differences in magnitude across studies; and areas of inconsistent reproducibility are revealed when evaluating brand preferences. CONCLUSION: Harmonizing data from multiple sources fosters a broader view of the robustness and generalizability of survey data than that from a single source. These observations raise awareness to look for the highest degree of reproducibility among and across data sources to inform policy. IMPLICATIONS: Harmonizing data from discrete datasets provides insights into cigar initiation and use and is presented showing opportunities, challenges, and solutions. Comparing observational data from PATH and four independent research studies provides a best-practices approach and example of data synthesis for the tobacco research community. The dataset of five studies offers a look at the degree of confidence in analyzing harmonized survey results. Variable conclusions raise the need to strive for the highest degree of reproducibility, to best understand the behaviors of cigar users, and allow for the future development of the most effective interventions to alter tobacco use patterns.

Senior services in US hospitals and readmission risk in the Medicare population.

BACKGROUND: There is a little understanding of the association between hospital organizational characteristics and hospital readmissions. We previously developed a Senior Care Services Scale (SCSS) that describes hospital availability of services relevant to the care of older adults. OBJECTIVE: Determine whether hospitals' SCSS scores were associated with risk of readmission among Medicare beneficiaries. DESIGN: Retrospective cohort analysis. SETTING AND PARTICIPANTS: Medicare beneficiaries ≥65 years of age (n = 3 553 367), admitted to 5568 US acute-care hospitals in 2006, discharged alive. Medicare data were linked to the American Hospital Association database of hospital characteristics. MEASUREMENTS: All-cause non-elective hospital readmission, or death without readmission, within 30 days of hospital discharge. RESULTS: We examined the association between high and low scores of each of two hospital SCSS service groups: inpatient specialty care (IP) and post-acute (PA) community care. There was no association between high IP scores and readmission (RR 1.00, 95% CI 0.98-1.02). Older adults admitted to hospitals with high PA scores had lower risk of experiencing hospital readmission when compared to older adults admitted to hospitals with low PA scores (RR 0.97, 95% CI 0.95-0.98). High PA scores were associated with increased mortality (RR 1.09, 95% CI 1.06-1.13). In sensitivity analyses exploring relationships at 90 days, both the IP and PA subcomponents were associated with older adults' reduced risk of hospital readmission (IP: RR 0.97, 95% CI 0.95-0.99; PA: RR 0.97, 95% CI 0.95-0.99). CONCLUSION: Senior services at the hospital-level represents a modifiable risk factor with important impact. Employing organization-level characteristics in readmission risk prediction tools should be expanded.

A randomized controlled trial of cognitive-behavioral stress management in breast cancer: survival and recurrence at 11-year follow-up.

Non-metastatic breast cancer patients often experience psychological distress which may influence disease progression and survival. Cognitive-behavioral stress management (CBSM) improves psychological adaptation and lowers distress during breast cancer treatment and long-term follow-ups. We examined whether breast cancer patients randomized to CBSM had improved survival and recurrence 8-15 years post-enrollment. From 1998 to 2005, women (N = 240) 2-10 weeks post-surgery for non-metastatic Stage 0-IIIb breast cancer were randomized to a 10-week, group-based CBSM intervention (n = 120) or a 1-day psychoeducational seminar control (n = 120). In 2013, 8-15 years post-study enrollment (11-year median), recurrence and survival data were collected. Cox Proportional Hazards Models and Weibull Accelerated Failure Time tests were used to assess group differences in all-cause mortality, breast cancer-specific mortality, and disease-free interval, controlling for biomedical confounders. Relative to the control, the CBSM group was found to have a reduced risk of all-cause mortality (HR = 0.21; 95 % CI [0.05, 0.93]; p = .040). Restricting analyses to women with invasive disease revealed significant effects of CBSM on breast cancer-related mortality (p = .006) and disease-free interval (p = .011). CBSM intervention delivered post-surgery may provide long-term clinical benefit for non-metastatic breast cancer patients in addition to previously established psychological benefits. Results should be interpreted with caution; however, the findings contribute to the limited evidence regarding physical benefits of psychosocial intervention post-surgery for non-metastatic breast cancer. Additional research is necessary to confirm these results and investigate potential explanatory mechanisms, including physiological pathways, health behaviors, and treatment adherence changes.

Prevalence, Geographic Variation, and Trends in Hospital Services Relevant to the Care of Older Adults: Development of the Senior Care Services Scale and Examination of Measurement Properties.

BACKGROUND: The availability of hospital services for older adults nationwide is not well understood. OBJECTIVE: To present the development of the Senior Care Services Scale (SCSS) through: (1) identification of hospital services relevant to the care of older adults; (2) development of a taxonomy classifying these services; and (3) description of prevalence, geographic variation, and trends in service provision in US hospitals over time. DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study of US hospitals in 1999 and 2006 rounds of American Hospital Association Annual Survey of Hospitals (n=4998 and 4831 hospitals, respectively). Exploratory factor analysis was used to create the SCSS, and confirmatory factor analysis was used to examine services over time. The paper reports prevalence of services nationwide. RESULTS: The SCSS consisted of 2 service groups: (1) Inpatient Specialty Care (IP): geriatrics, palliative care, psychiatric geriatrics, pain management, social work, case management, rehabilitation, and hospice; and (2) Postacute Community Care (PA): skilled nursing, intermediate care, other long-term care, assisted living, retirement housing, adult day care, and home health services. Over time, hospitals offered more IP services and fewer PA services. The distribution of services did not mirror the distribution of where older adults reside in the United States. CONCLUSIONS: The development of the SCSS provides important information about senior care services before the passage of the Affordable Care Act. The apparent mismatch of hospital services and demographic trends suggests that many US hospitals may not provide a seamless continuum of care for an increasing population of older adults.

Risk factors for hepatitis B and C infection among blood donors in five Chinese blood centers.

BACKGROUND: Few studies were conducted on hepatitis B and C virus (HBV and HCV, respectively) risk factors among Chinese blood donors in recent years since voluntary donors replaced commercial donors. STUDY DESIGN AND METHODS: A case-control survey was conducted in HBV- or HCV-positive and -negative donors from five blood centers in China between September 2009 and April 2011. Case status was defined by having a reactive result on Monolisa HBsAg Ultra (Bio-Rad) for HBV and Ortho anti-HCV EIA 3.0 (Johnson & Johnson) for HCV. Controls were randomly selected qualified blood donors matched to cases by donation month and blood center. Specific test-seeking, medical-related, and behavioral risk factors were compared by HBV and HCV status using chi-square tests or Fisher's exact tests with Bonferroni correction. RESULTS: A total of 364 HBV cases, 174 HCV cases, and 689 controls completed the survey; response rates were 66.2, 47.3, and 82%, respectively. HCV-positive donors were significantly more likely to report having a blood transfusion history (23.4% vs. 3.0%, p < 0.0001) and ever living with a person with illegal drug injection (6.0% vs. 0.5%, p < 0.0001) than controls. Having intravenous and intramuscular injections in the past 12 months and ever having a tattoo are marginal risk factors for HCV (p values < 0.01). No specific risk factor for HBV was identified. CONCLUSION: History of previous transfusion and living with illegal drug users are risk factors for HCV infection among Chinese blood donors from five regions. Test-seeking behavior is not associated with HBV or HCV infections.

Human viruses and viral indicators in marine water at two recreational beaches in Southern California, USA.

Waterborne enteric viruses may pose disease risks to bather health but occurrence of these viruses has been difficult to characterize at recreational beaches. The aim of this study was to evaluate water for human virus occurrence at two Southern California recreational beaches with a history of beach closures. Human enteric viruses (adenovirus and norovirus) and viral indicators (F+ and somatic coliphages) were measured in water samples over a 4-month period from Avalon Beach, Catalina Island (n = 324) and Doheny Beach, Orange County (n = 112). Human viruses were concentrated from 40 L samples and detected by nested reverse transcriptase polymerase chain reaction (PCR). Detection frequencies at Doheny Beach were 25.5% (adenovirus) and 22.3% (norovirus), and at Avalon Beach were 9.3% (adenovirus) and 0.7% (norovirus). Positive associations between adenoviruses and fecal coliforms were observed at Doheny (p = 0.02) and Avalon (p = 0.01) Beaches. Human viruses were present at both beaches at higher frequencies than previously detected in the region, suggesting that the virus detection methods presented here may better measure potential health risks to bathers. These virus recovery, concentration, and molecular detection methods are advancing practices so that analysis of enteric viruses can become more effective and routine for recreational water quality monitoring.

Mammalian PIWI-piRNA-target complexes reveal features for broad and efficient target silencing.

The PIWI-interacting RNA (piRNA) pathway is an adaptive defense system wherein piRNAs guide PIWI family Argonaute proteins to recognize and silence ever-evolving selfish genetic elements and ensure genome integrity. Driven by this intensive host-pathogen arms race, the piRNA pathway and its targeted transposons have coevolved rapidly in a species-specific manner, but how the piRNA pathway adapts specifically to target silencing in mammals remains elusive. Here, we show that mouse MILI and human HILI piRNA-induced silencing complexes (piRISCs) bind and cleave targets more efficiently than their invertebrate counterparts from the sponge Ephydatia fluviatilis. The inherent functional differences comport with structural features identified by cryo-EM studies of piRISCs. In the absence of target, MILI and HILI piRISCs adopt a wider nucleic-acid-binding channel and display an extended prearranged piRNA seed as compared with EfPiwi piRISC, consistent with their ability to capture targets more efficiently than EfPiwi piRISC. In the presence of target, the seed gate-which enforces seed-target fidelity in microRNA RISC-adopts a relaxed state in mammalian piRISC, revealing how MILI and HILI tolerate seed-target mismatches to broaden the target spectrum. A vertebrate-specific lysine distorts the piRNA seed, shifting the trajectory of the piRNA-target duplex out of the central cleft and toward the PAZ lobe. Functional analyses reveal that this lysine promotes target binding and cleavage. Our study therefore provides a molecular basis for the piRNA targeting mechanism in mice and humans, and suggests that mammalian piRNA machinery can achieve broad target silencing using a limited supply of piRNA species.

Prevalence, incidence, and residual risks for transfusion-transmitted human immunodeficiency virus Types 1 and 2 infection among Chinese blood donors.

BACKGROUND: There are little data on human immunodeficiency virus (HIV) prevalence, incidence, or residual risks for transfusion-transmitted HIV infection among Chinese blood donors. STUDY DESIGN AND METHODS: Donations from five Chinese blood centers in 2008 to 2010 were screened using two rounds of enzyme-linked immunosorbent assay for anti-HIV-1/2. A reactive result in either or both rounds led to Western blot confirmatory testing. HIV prevalence among first-time donors and incidence among repeat donors were examined. Weighted multivariable logistic regression analysis examined correlates of HIV confirmatory status among first-time donors. Residual risks were evaluated based on incidence among repeat donors. RESULTS: Among 821,320 donations, 40% came from repeat donors. A total of 1837 (0.34%) first-time and 577 (0.17%) repeat donations screened reactive, among which 1310 and 419 were tested by Western blot. A total of 233 (17.7%) first-time and 44 (10.5%) repeat donations were confirmed positive. Prevalence was 66 infections per 100,000 (95% confidence interval [CI], 59-74) first-time donors. Incidence was 9 of 100,000 (95% CI, 7-12) person-years among repeat donors. Multivariable logistic regression analysis indicates that first-time donors 26 to 45 years old were 1.6 to 1.8 times likely to be HIV positive than those 25 years and younger. Donors with some college or above education were less likely to be HIV positive than those with middle school education, odds ratios (ORs) ranging from 0.35 to 0.60. Minorities were 1.5 times likely to be HIV positive than Han majority donors (OR, 1.6; 95% CI, 1.2-2.1). HIV residual risk was 5.4 (95% CI, 1.2-12.5) infections per million whole blood donations. CONCLUSION: Despite the declining HIV epidemic in China, estimated residual risks for transfusion-transmitted HIV infection are still high.

An analysis of risk factors for human immunodeficiency virus infection among Chinese blood donors.

BACKGROUND: Information regarding the risk factors for human immunodeficiency virus (HIV) infection among Chinese donors is important for understanding the trend of HIV transmission routes and for developing effective donor behavioral screening policies. STUDY DESIGN AND METHODS: In 2009 to 2011, a total of 77 HIV-positive and 649 HIV-negative consented donors who screened nonreactive for hepatitis B virus, hepatitis C virus, syphilis, and alanine aminotransferase in four Retrovirus Epidemiology Donor Study-II Chinese regions received and completed a questionnaire by mail regarding their recent and past medical procedures, drug use, and sexual behaviors, etc. Exploratory and confirmatory factor analyses grouped questions into three risk factors. Multivariable logistic regression analysis examined the relationship between risk factors and HIV status adjusting for center, age, sex, and education. RESULTS: The three risk factors were test-seeking tendency, medical-related risks, and behavioral risks. In multivariable logistic regression analysis, greater test-seeking tendency and behavioral risks were associated with HIV infection, with the adjusted odds ratios (ORs) being 2.2 (95% confidence interval [CI], 1.2-4.1) and 3.8 (95% CI, 1.8-7.9), respectively, but medical risks were not (OR, 1.2; 95% CI, 0.6-2.2). In comparison to less high school education, high school and more education was associated with lower risks for HIV infection, with the ORs being 0.35 (95% CI, 0.17-0.70) and 0.17 (95% CI, 0.09-0.33), respectively. CONCLUSIONS: Test-seeking tendency and high-risk sexual behaviors are important predictors of HIV infection in Chinese blood donors, suggesting that the health history inquiry used in donor selection process needs improvement to defer high-risk donors more effectively.

Long-term return behavior of Chinese whole blood donors.

BACKGROUND: It is important to understand donor return behavior to maintain sufficient numbers of blood donors in developing countries where blood supplies are often inadequate. STUDY DESIGN AND METHODS: A total of 54,267 whole blood (WB) donors who donated between January 1 and March 31, 2008, at the five blood centers in China were followed for 2.5 years. Logistic regression was conducted to identify factors associated with their return behavior. A recurrent-event Cox proportional-hazard model was used to evaluate the overall effect of demographic variables and return behavior among first-time donors. RESULTS: Donors with previous donation history were more likely to return and the number of previous returns was positively associated with future return (odds ratios, 3.31, 4.82, and 8.16 for one, two to three, and more than three times compared to none). Thirty-four percent of donors (first-time donor, 21%; repeat donor, 54%) made at least one return donation, with 14% returning in the first 9 months. The multivariable logistic regression model for all WB donors and the Cox proportional hazard model for first-time donors showed consistent predictors for return: female sex, older age (≥ 25 years), larger volume (300 or 400 mL), and donating in satellite collection site. CONCLUSION: Encouraging first-time donors to make multiple donations is important for keeping adequate blood supply. The finding that first-time and repeat donors shared the same predictors for return indicates that retention strategies on repeat donors may be effective on first-time donors. Studies on motivators and barriers to return are needed, so that successful retention strategies can be tailored.

The persistence of hepatitis C virus transmission risk in China despite serologic screening of blood donations.

BACKGROUND: A total of 2%-2.9% of the population in China is infected with hepatitis C virus (HCV). This study estimated the prevalence and incidence of HCV among Chinese blood donors. STUDY DESIGN AND METHODS: We examined whole blood and apheresis platelet donations at five Chinese blood centers in 2008 to 2010. All donations were screened using two rounds of testing for alanine aminotransferase, antibody to human immunodeficiency virus Types 1 and 2, hepatitis B surface antigen, anti-HCV, and syphilis. Screening reactivity is defined by a reactive result in one or both rounds of screening tests. Confirmatory tests (Ortho third-generation HCV enzyme immunoassay, Johnson & Johnson) were performed on anti-HCV screening-reactive samples. Confirmatory positive rates among first-time donors (prevalence) and repeat donors (incidence) were calculated by blood center and demographic categories. Donor characteristics associated with HCV confirmatory status among first-time donors were examined using trend test and multivariable logistic regression analysis. RESULTS: Among 821,314 donations, 40% came from repeat donors. The overall anti-HCV screening-reactive rate was 0.48%. Estimated HCV prevalence was 235 per 100,000 first-time donors; incidence was 10 per 100,000 person-years in repeat donors. In multivariable logistic regression analysis, first-time donors older than 25 years displayed higher HCV prevalence than the younger donors. Less education is associated with higher HCV prevalence. Donors 26 to 35 years old and those above 45 years displayed the highest incidence rate. CONCLUSION: High prevalence and incidence in donors indicate high residual risks for transfusion-transmitted HCV in Chinese patients. Implementation of minipool nucleic acid testing in routine donation screening may prevent a substantial number of transfusion-transmitted HCV infections.

Plasma neopterin level as a marker of peripheral immune activation in amnestic mild cognitive impairment and Alzheimer's disease.

OBJECTIVE: Alterations of the immune system play important roles in Alzheimer's disease (AD). The primary purpose of this study was to compare the plasma levels of neopterin, a marker of cellular immune activity, in amnestic mild cognitive impairment (aMCI), early (mild to moderate) AD, and cognitively normal controls. In addition, the correlation of plasma neopterin with interferon-gamma (IFN-γ) and interleukin-6 (IL-6) was also examined. METHODS: Plasma samples from patients with mild-to-moderate AD (N = 34), aMCI (N = 27), and cognitively normal controls (N = 30) were obtained from the Johns Hopkins Alzheimer's Disease Research Center. Plasma neopterin, IFN-γ, and IL-6 levels were measured using commercially available ELISAs. Multiple linear regression was performed to study differences in the baseline neopterin levels between normal, aMCI, and AD patients. Pearson correlation coefficients were estimated for neopterin and IFN-γ and IL-6 levels. All analyses were conducted using SAS (SAS Institute, Inc., Cary, NC) and GraphPad Prism version 5.00 for Window (GraphPad Software, San Diego, CA, USA). RESULTS: AD subjects had significantly higher neopterin values compared with aMCI (ß = 0.202, p = 0.004) and normal (ß = 0.263, p = 0.0004) subjects. There was no statistically significant difference between normal and aMCI subjects. Significant associations between neopterin and IFN-γ (r = 0.41, p < 0.0001) and IL-6 (r = 0.35, p = 0.0006) levels were found. CONCLUSIONS: Our study demonstrates that peripheral immune response may be stronger in later stages of AD pathophysiology, when dementia has developed.

Considerations for the prediction of survival time in pancreatic cancer based on registry data.

Semi-parametric and parametric survival models in patients with pancreatic adenocarcinoma (PC) using data from Surveillance, Epidemiology, and End Result (SEER) registry were developed to identify relevant covariates affecting survival, verify against external patient data and predict disease outcome. Data from 82,251 patients was extracted using site and histology codes for PC in the SEER database and refined based on specific cause of death. Predictors affecting survival were selected from SEER database; the analysis dataset included 2,437 patients. Survival models were developed using both semi-parametric and parametric approaches, evaluated using Cox-Snell and deviance residuals, and predictions were assessed using an external dataset from Saint Louis University (SLU). Prediction error curves (PECs) were used to evaluate prediction performance of these models compared to Kaplan-Meier response. Median overall survival time of patients from SEER data was 5 months. Our analysis shows that the PC data from SEER was best fitted by both semi-parametric and the parametric model with log-logistic distribution. Predictors that influence survival included disease stage, grade, histology, tumor size, radiation, chemotherapy, surgery, and lymph node status. Survival time predictions from the SLU dataset were comparable and PECs show that both semi-parametric and parametric models exhibit similar predictive performance. PC survival models constructed from registry data can provide a means to classify patients into risk-based subgroups, to predict disease outcome and aide in the design of future prospective randomized trials. These models can evolve to incorporate predictive biomarker and pharmacogenetic correlates once adequate causal data is established.

Senior Services in US Hospitals and Readmission Risk or Mortality Among Medicare Beneficiaries Since the Affordable Care Act.

Background: The Senior Care Services Scale (SCSS) describes hospital provision of older adult services before the passage of the Affordable Care Act. Objectives: Since act passage, (1) update SCSS service groups; and (2) investigate hospital SCSS scores' relationship to readmission or mortality among Medicare beneficiaries. Methods: Retrospective cohort analysis of older adults ≥65 years (n = 1,416,669), admitted to 2570 US acute-care hospitals from 2014 to 2015. Outcomes: Hospital readmission, or death, within 30 and 90 days of discharge. Results: The updated SCSS had three service groups: Inpatient Specialty Care, Post-Acute Community Care, and Home Care and Hospice. Older adults admitted to high Inpatient-Specialty-Care-scoring hospitals had lower risk of death within 30 days (RR .94, 95% CI .91-.98), and 90 days (RR .94, 95% CI .91-.97). There was no significant association between Home-Care-and-Hospice and Post-Acute-Community-Care scores and study outcomes. Conclusion: Greater provision of hospital-level senior services may be associated with mortality reduction among Medicare beneficiaries.

Intervention Fidelity in Pain Pragmatic Trials for Nonpharmacologic Pain Management: Nuanced Considerations for Determining PRECIS-2 Flexibility in Delivery and Adherence.

Nonpharmacological treatments are considered first-line pain management strategies, but they remain clinically underused. For years, pain-focused pragmatic clinical trials (PCTs) have generated evidence for the enhanced use of nonpharmacological interventions in routine clinical settings to help overcome implementation barriers. The Pragmatic Explanatory Continuum Indicator Summary (PRECIS-2) framework describes the degree of pragmatism across 9 key domains. Among these, "flexibility in delivery" and "flexibility in adherence," address a key goal of pragmatic research by tailoring approaches to settings in which people receive routine care. However, to maintain scientific and ethical rigor, PCTs must ensure that flexibility features do not compromise delivery of interventions as designed, such that the results are ethically and scientifically sound. Key principles of achieving this balance include clear definitions of intervention core components, intervention monitoring and documentation that is sufficient but not overly burdensome, provider training that meets the demands of delivering an intervention in real-world settings, and use of an ethical lens to recognize and avoid potential trial futility when necessary and appropriate. PERSPECTIVE: This article presents nuances to be considered when applying the PRECIS-2 framework to describe pragmatic clinical trials. Trials must ensure that patient-centered treatment flexibility does not compromise delivery of interventions as designed, such that measurement and analysis of treatment effects is reliable.

Delayed and unsuccessful endoscopic retrograde cholangiopancreatography are associated with worse outcomes in patients with acute cholangitis.

BACKGROUND & AIMS: Acute ascending cholangitis usually is treated with antibiotics, and biliary drainage is treated by endoscopic retrograde cholangiopancreatography (ERCP). We investigated the effects of the timing of ERCP on outcomes of patients with acute cholangitis factors that predict prolonged hospital stays, increased costs of hospitalization, and composite clinical outcomes (death, persistent organ failure, and admission to the intensive care unit). METHODS: We performed a retrospective analysis of data from 90 patients (mean age, 60 y; 48% female) admitted to Johns Hopkins Hospital from January 1994 to June 2010 who were diagnosed with acute cholangitis and underwent ERCP. A delayed ERCP was defined as one performed more than 72 hours after admission. Electronic and paper medical records were reviewed, and relevant data were abstracted. RESULTS: ERCP was performed successfully in 92% of the patients, at a mean time period of 38 hours after admission (14% of ERCPs were delayed). Factors that were associated independently with prolonged length of hospital stay (top 10%) included unsuccessful ERCP (odds ratio [OR], 52.5; P = .002) and delayed ERCP (OR, 19.8; P = .008). Factors associated with increased hospitalization cost (top 10%) included unsuccessful ERCP (OR, 33.8; P = .004) and delayed ERCP (OR, 11.3; P = .03). Factors associated with composite clinical outcome included age (OR, 1.1; P = .01), total level of bilirubin (OR, 1.36; P = .002), and delayed ERCP (OR, 7.8; P = .04). CONCLUSIONS: Delayed and failed ERCP are associated with prolonged hospital stays and increased costs of hospitalization. Delayed ERCP is associated with composite clinical outcome (death, persistent organ failure, and/or intensive care unit stay). Older age and higher levels of bilirubin also are associated with patients' composite end point.

Potential long-term benefits of acute hypothermia after spinal cord injury: assessments with somatosensory-evoked potentials.

OBJECTIVE: Neuroprotection by hypothermia has been an important research topic over last two decades. In animal models of spinal cord injury, the primary focus has been assessing the effects of hypothermia on behavioral and histologic outcomes. Although a few studies have investigated electrophysiological changes in descending motor pathways with motor-evoked potentials recorded during cooling, we report here hypothermia induced increased electrical conduction in the ascending spinal cord pathways with somatosensory-evoked potentials in injured rats. In our experiments, these effects lasted long after the acute hypothermia and were accompanied by potential long-term improvements in motor movement. DESIGN: Laboratory investigation. SETTING: University medical school. SUBJECTS: Twenty-one female Lewis rats. INTERVENTIONS: Hypothermia. MEASUREMENTS AND MAIN RESULTS: All animals underwent spinal cord contusion with the NYU-Impactor by a 12.5-mm weight drop at thoracic vertebra T8. A group (n = 10) was randomly assigned for a systemic 2-hr hypothermia episode (32 ± 0.5°C) initiated approximately 2.0 hrs postinjury. Eleven rats were controls with postinjury temperature maintained at 37 ± 0.5°C for 2 hrs. The two groups underwent preinjury, weekly postinjury (up to 4 wks) somatosensory-evoked potential recordings and standard motor behavioral tests (BBB). Three randomly selected rats from each group were euthanized for histologic analysis at postinjury day 3 and day 28. Compared with controls, the hypothermia group showed significantly higher postinjury somatosensory-evoked potential amplitudes with longer latencies. The BBB scores were also higher immediately after injury and 4 wks later in the hypothermia group. Importantly, specific changes in the Basso, Beattie, Bresnahan scores in the hypothermia group (not seen in controls) indicated regained functions critical for motor control. Histologic evaluations showed more tissue preservation in the hypothermia group. CONCLUSIONS: After spinal cord injury, early systemic hypothermia provided significant neuroprotection weeks after injury through improved sensory electrophysiological signals in rats. This was accompanied by higher motor behavioral scores and more spared tissue in acute and postacute periods after injury.