Association of Posttraumatic Stress Disorder and Race on Readmissions After Stroke.

BACKGROUND: There is limited research on outcomes of patients with posttraumatic stress disorder (PTSD) who also develop stroke, particularly regarding racial disparities. Our goal was to determine whether PTSD is associated with the risk of hospital readmission after stroke and whether racial disparities existed. METHODS: The analytical sample consisted of all veterans receiving care in the Veterans Health Administration who were identified as having a new stroke requiring inpatient admission based on the International Classification of Diseases codes. PTSD and comorbidities were identified using the International Classification of Diseases codes and given the date of first occurrence. The retrospective cohort data were obtained from the Veterans Affairs Corporate Data Warehouse. The main outcome was any readmission to Veterans Health Administration with a stroke diagnosis. The hypothesis that PTSD is associated with readmission after stroke was tested using Cox regression adjusted for patient characteristics including age, sex, race, PTSD, smoking status, alcohol use, and comorbidities treated as time-varying covariates. RESULTS: Our final cohort consisted of 93 651 patients with inpatient stroke diagnosis and no prior Veterans Health Administration codes for stroke starting from 1999 with follow-up through August 6, 2022. Of these patients, 12 916 (13.8%) had comorbid PTSD. Of the final cohort, 16 896 patients (18.0%) with stroke were readmitted. Our fully adjusted model for readmission found an interaction between African American veterans and PTSD with a hazard ratio of 1.09 ([95% CI, 1.00-1.20] P=0.047). In stratified models, PTSD has a significant hazard ratio of 1.10 ([95% CI, 1.02-1.18] P=0.01) for African American but not White veterans (1.05 [95% CI, 0.99-1.11]; P=0.10). CONCLUSIONS: Among African American veterans who experienced stroke, preexisting PTSD was associated with increased risk of readmission, which was not significant among White veterans. This study highlights the need to focus on high-risk groups to reduce readmissions after stroke.

Assessment of longitudinal changes in body composition of children with lymphoma and rhabdomyosarcoma.

BACKGROUND: Studies examining changes in skeletal muscle and adipose tissue during treatment for cancer in children, adolescents, and young adults and their effect on the risk of chemotherapy toxicity (chemotoxicity) are limited. METHODS: Among 78 patients with lymphoma (79.5%) and rhabdomyosarcoma (20.5%), changes were measured in skeletal muscle (skeletal muscle index [SMI]; skeletal muscle density [SMD]) and adipose tissue (height-adjusted total adipose tissue [hTAT]) between baseline and first subsequent computed tomography scans at the third lumbar vertebral level by using commercially available software. Body mass index (BMI; operationalized as a percentile [BMI%ile]) and body surface area (BSA) were examined at each time point. The association of changes in body composition with chemotoxicities was examined by using linear regression. RESULTS: The median age at cancer diagnosis of this cohort (62.8% male; 55.1% non-Hispanic White) was 12.7 years (2.5-21.1 years). The median time between scans was 48 days (range, 8-207 days). By adjusting for demographics and disease characteristics, this study found that patients undergo a significant decline in SMD (ß ± standard error [SE] = -4.1 ± 1.4; p < .01). No significant changes in SMI (ß ± SE = -0.5 ± 1.0; p = .7), hTAT (ß ± SE = 5.5 ± 3.9; p = .2), BMI% (ß ± SE = 4.1 ± 4.8; p = .3), or BSA (ß ± SE = -0.02 ± 0.01; p = .3) were observed. Decline in SMD (per Hounsfield unit) was associated with a greater proportion of chemotherapy cycles with grade ≥3 nonhematologic toxicity (ß ± SE = 1.09 ± 0.51; p = .04). CONCLUSIONS: This study shows that children, adolescents, and young adults with lymphoma and rhabdomyosarcoma undergo a decline in SMD early during treatment, which is associated with a risk of chemotoxicities. Future studies should focus on interventions designed at preventing the loss of muscle during treatment. PLAIN LANGUAGE SUMMARY: We show that among children, adolescents, and young adults with lymphoma and rhabdomyosarcoma receiving chemotherapy, skeletal muscle density declines early during treatment. Additionally, a decline in skeletal muscle density is associated with a greater risk of nonhematologic chemotoxicities.

ASA Physical Status Determination by General Internists and Impact on Cardiac Risk Assessment.

OBJECTIVES: Estimating cardiac risk is important for preoperative evaluation, and several risk calculators incorporate the American Society of Anesthesiologists (ASA) physical status score. The purpose of this study was to determine the concordance of ASA scores assigned by general internists and anesthesiologists and assess whether discrepancies affected cardiac risk estimation. METHODS: This observational study included military veterans evaluated in a preoperative evaluation clinic at a single center during a 12-month period. ASA scores were recorded by General Internal Medicine residents under the supervision of a General Internal Medicine attending, performing a preoperative medical consultation, and were compared with ASA scores assigned by an anesthesiologist on the day of surgery. ASA scores and Gupta Cardiac Risk Scores incorporating each ASA score were compared. RESULTS: Data were collected on 206 patients, 163 of whom had surgery within 90 days and were included. ASA scores were concordant in 60 patients (37.3%), whereas the ASA scores were rated lower by the general internist in 101 (62.0%) and higher in 2 (1.2%). Interrater reliability was low (κ = 0.08), and general internist scores were significantly lower than anesthesiologist scores (P < 0.01). Gupta Cardiac Risk Scores were calculated for 160 patients, and they exceeded 1% in 14 patients using the anesthesiologist ASA score, compared with 5 patients using the general internist score. CONCLUSIONS: ASA scores assigned by general internists in this study were significantly lower than those assigned by anesthesiologists, and these discrepancies in the ASA score can lead to substantially different conclusions about cardiac risk.

Number of Social Determinants of Health and Fatal and Nonfatal Incident Coronary Heart Disease in the REGARDS Study.

BACKGROUND: Social determinants of health (SDH) are individually associated with incident coronary heart disease (CHD) events. Indices reflecting social deprivation have been developed for population management, but are difficult to operationalize during clinical care. We examined whether a simple count of SDH is associated with fatal incident CHD and nonfatal myocardial infarction (MI). METHODS: We used data from the prospective longitudinal REGARDS cohort study (Reasons for Geographic and Racial Differences in Stroke), a national population-based sample of community-dwelling Black and White adults age ≥45 years recruited from 2003 to 2007. Seven SDH from the 5 Healthy People 2020 domains included social context (Black race, social isolation); education (educational attainment); economic stability (annual household income); neighborhood (living in a zip code with high poverty); and health care (lacking health insurance, living in 1 of the 9 US states with the least public health infrastructure). Outcomes were expert adjudicated fatal incident CHD and nonfatal MI. RESULTS: Of 22 152 participants free of CHD at baseline, 58.8% were women and 42.0% were Black; 20.6% had no SDH, 30.6% had 1, 23.0% had 2, and 25.8% had ≥3. There were 463 fatal incident CHD events and 932 nonfatal MIs over a median of 10.7 years (interquartile range, 6.6 to 12.7). Fewer SDHs were associated with nonfatal MI than with fatal incident CHD. The age-adjusted incidence per 1000 person-years increased with the number of SDH for both fatal incident CHD (0 SDH, 1.30; 1 SDH, 1.44; 2 SDH, 2.05; ≥3 SDH, 2.86) and nonfatal MI (0 SDH, 3.91; 1 SDH, 4.33; ≥2 SDH, 5.44). Compared with those without SDH, crude and fully adjusted hazard ratios for fatal incident CHD among those with ≥3 SDH were 3.00 (95% CI, 2.17 to 4.15) and 1.67 (95% CI, 1.18 to 2.37), respectively; hazard ratios for nonfatal MI among those with ≥2 SDH were 1.57 (95% CI, 1.30 to 1.90) and 1.14 (95% CI, 0.93 to 1.41), respectively. CONCLUSIONS: A greater burden of SDH was associated with a graded increase in risk of incident CHD, with greater magnitude and independent associations for fatal incident CHD. Counting the number of SDHs may be a promising approach that could be incorporated into clinical care to identify individuals at high risk of CHD.

Association between body composition and chemotherapy-related toxicity in children with lymphoma and rhabdomyosarcoma.

BACKGROUND: Body composition is associated with chemotherapy toxicity (chemotoxicity) in adults with cancer; this association remains unexplored in children with cancer. METHODS: Using baseline computed tomography scans of 107 children with Hodgkin lymphoma (n = 45), non-Hodgkin lymphoma (n = 42), or rhabdomyosarcoma (n = 20), this study examined body composition (skeletal muscle index [SMI], skeletal muscle density [SMD], and height-adjusted total adipose tissue [hTAT]) to determine its association with chemotoxicity. Clinical characteristics and chemotoxicities were abstracted from medical records. Primary outcomes included grade 4 or higher hematologic toxicities and grade 3 or higher nonhematologic toxicities within 6 months of the diagnosis. Logistic regression models accounting for repeated measures were constructed to examine the association between body composition indices and chemotoxicities; adjustments were made for age at diagnosis, sex, race/ethnicity, cancer type, risk group, body mass index (measured as a percentile), or body surface area. RESULTS: The median SMI was 41.0 cm2 /m2 (range, 25.8-68.6 cm2 /m2 ), the median SMD was 54.1 HU (range, 35-69.4 HU), and the median hTAT was 19.5 cm2 /m2 (range, 0-226.7 cm2 /m2 ). Grade 4 or higher hematologic toxicities and grade 3 or higher nonhematologic toxicities were observed in 74.7% and 66.3% of the chemotherapy cycles, respectively. A higher SMD at diagnosis was associated with lower odds of grade 4 or higher hematologic toxicity (odds ratio [OR], 0.90; 95% confidence interval [CI], 0.85-0.97; P = .004). SMI (OR, 0.99; 95% CI, 0.95-1.04; P = .7) and hTAT (OR, 1.00; 95% CI, 0.99-1.01; P = .9) were not associated with hematologic toxicities. Nonhematologic toxicities did not show any association with body composition. CONCLUSIONS: The association between low SMD and hematologic toxicities in children with lymphoma or rhabdomyosarcoma could be due to body composition-based biodistribution of chemotherapeutic agents and needs further investigation. LAY SUMMARY: Body composition at cancer diagnosis in children with lymphoma and rhabdomyosarcoma may provide information that could identify those at risk for serious side effects from chemotherapy. Routinely used measures such as body mass index and body surface area show poor correlations with body composition assessed via computed tomography scans.

Implementation of a provider-focused intervention for maximizing human papillomavirus (HPV) vaccine uptake in young cancer survivors receiving follow-up care in pediatric oncology practices: protocol for a cluster-randomized trial of the HPV PROTECT intervention.

BACKGROUND: Childhood cancer survivors are at high risk for developing new cancers (such as cervical and anal cancer) caused by persistent infection with the human papillomavirus (HPV). HPV vaccination is effective in preventing the infections that lead to these cancers, but HPV vaccine uptake is low among young cancer survivors. Lack of a healthcare provider recommendation is the most common reason that cancer survivors fail to initiate the HPV vaccine. Strategies that are most successful in increasing HPV vaccine uptake in the general population focus on enhancing healthcare provider skills to effectively recommend the vaccine, and reducing barriers faced by the young people and their parents in receiving the vaccine. This study will evaluate the effectiveness and implementation of an evidence-based healthcare provider-focused intervention (HPV PROTECT) adapted for use in pediatric oncology clinics, to increase HPV vaccine uptake among cancer survivors 9 to 17 years of age. METHODS: This study uses a hybrid type 1 effectiveness-implementation approach. We will test the effectiveness of the HPV PROTECT intervention using a stepped-wedge cluster-randomized trial across a multi-state sample of pediatric oncology clinics. We will evaluate implementation (provider perspectives regarding intervention feasibility, acceptability and appropriateness in the pediatric oncology setting, provider fidelity to intervention components and change in provider HPV vaccine-related knowledge and practices [e.g., providing vaccine recommendations, identifying and reducing barriers to vaccination]) using a mixed methods approach. DISCUSSION: This multisite trial will address important gaps in knowledge relevant to the prevention of HPV-related malignancies in young cancer survivors by testing the effectiveness of an evidence-based provider-directed intervention, adapted for the pediatric oncology setting, to increase HPV vaccine initiation in young cancer survivors receiving care in pediatric oncology clinics, and by procuring information regarding intervention delivery to inform future implementation efforts. If proven effective, HPV PROTECT will be readily disseminable for testing in the larger pediatric oncology community to increase HPV vaccine uptake in cancer survivors, facilitating protection against HPV-related morbidities for this vulnerable population. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04469569, prospectively registered on July 14, 2020.

SToRytelling to Improve Disease outcomes in Gout (STRIDE-GO): a multicenter, randomized controlled trial in African American veterans with gout.

BACKGROUND: Urate-lowering therapy (ULT) adherence is low in gout, and few, if any, effective, low-cost, interventions are available. Our objective was to assess if a culturally appropriate gout-storytelling intervention is superior to an attention control for improving gout outcomes in African-Americans (AAs). METHODS: In a 1-year, multicenter, randomized controlled trial, AA veterans with gout were randomized to gout-storytelling intervention vs. a stress reduction video (attention control group; 1:1 ratio). The primary outcome was ULT adherence measured with MEMSCap™, an electronic monitoring system that objectively measured ULT medication adherence. RESULTS: The 306 male AA veterans with gout who met the eligibility criteria were randomized to the gout-storytelling intervention (n = 152) or stress reduction video (n = 154); 261/306 (85%) completed the 1-year study. The mean age was 64 years, body mass index was 33 kg/m2, and gout disease duration was 3 years. ULT adherence was similar in the intervention vs. control groups: 3 months, 73% versus 70%; 6 months, 69% versus 69%; 9 months, 66% versus 67%; and 12 months, 61% versus 64% (p > 0.05 each). Secondary outcomes (gout flares, serum urate and gout-specific health-related quality of life [HRQOL]) in the intervention versus control groups were similar at all time points except intervention group outcomes were better for the following: (1) number of gout flares at 9 months were fewer, 0.7 versus 1.3 in the previous month (p = 0.03); (2) lower/better scores on two gout specific HRQOL subscales: gout medication side effects at 3 months, 32.8 vs. 39.6 (p = 0.02); and unmet gout treatment need at 3 months, 30.9 vs. 38.2 (p = 0.003), and 6 months, 29.5 vs. 34.5 (p = 0.03), respectively. CONCLUSIONS: A culturally appropriate gout-storytelling intervention was not superior to attention control for improving gout outcomes in AAs with gout. TRIAL REGISTRATION: Registered at ClinicalTrials.gov NCT02741700.

Psychosocial Determinants of Readmission After Surgery.

BACKGROUND: Quality of life and psychosocial determinants of health, such as health literacy and social support, are associated with increased health care utilization and adverse outcomes in medical populations. However, the effect on surgical health care utilization is less understood. OBJECTIVE: We sought to examine the effect of patient-reported quality of life and psychosocial determinants of health on unplanned hospital readmissions in a surgical population. RESEARCH DESIGN: This is a prospective cohort study using patient interviews at the time of hospital discharge from a Veterans Affairs hospital. SUBJECTS: We include Veterans undergoing elective inpatient general, vascular, or thoracic surgery (August 1, 2015-June 30, 2017). MEASURES: We assessed unplanned readmission to any medical facility within 30 days of hospital discharge. RESULTS: A total of 736 patients completed the 30-day postoperative follow-up, and 16.3% experienced readmission. Lower patient-reported physical and mental health, inadequate health literacy, and discharge home with help after surgery or to a skilled nursing or rehabilitation facility were associated with an increased incidence of readmission. Classification regression identified the patient-reported Veterans Short Form 12 (SF12) Mental Component Score <31 as the most important psychosocial determinant of readmission after surgery. CONCLUSIONS: Mental health concerns, inadequate health literacy, and lower social support after hospital discharge are significant predictors of increased unplanned readmissions after major general, vascular, or thoracic surgery. These elements should be incorporated into routinely collected electronic health record data. Also, discharge plans should accommodate varying levels of health literacy and consider how the patient's mental health and social support needs will affect recovery.

Peer-delivered Cognitive Behavioral Therapy-based Intervention Reduced Depression and Stress in Community Dwelling Adults With Diabetes and Chronic Pain: A Cluster Randomized Trial.

BACKGROUND: Finding effective, accessible treatment options such as professional-delivered cognitive behavioral therapy (CBT) for medically complex individuals is challenging in rural communities. PURPOSE: We examined whether a CBT-based program intended to increase physical activity despite chronic pain in patients with diabetes delivered by community members trained as peer coaches also improved depressive symptoms and perceived stress. METHODS: Participants in a cluster-randomized controlled trial received a 3-month telephonic lifestyle modification program with integrated CBT elements. Peer coaches assisted participants in developing skills related to adaptive coping, diabetes self-management goal-setting, stress reduction, and cognitive restructuring. Attention controls received general health advice with an equal number of contacts but no CBT elements. Depressive symptoms and stress were assessed using the Centers for Epidemiologic Studies Depression and Perceived Stress scales. Assessments occurred at baseline, 3 months, and 1 year. RESULTS: Of 177 participants with follow-up data, 96% were African Americans, 79% women, and 74% reported annual income <$20,000. There was a significant reduction in perceived stress in intervention compared to control participants at 3-months (ß = -2.79, p = .002 [95% CI -4.52, -1.07]) and 1 year (ß = -2.59, p < .0001 [95% CI -3.30, -1.87]). Similarly, intervention participants reported significant decreases in depressive symptoms at 3-months (ß = -2.48, p < .0001 [95% CI -2.48, -2.02]) and at 1 year (ß = -1.62, p < .0001 [95% CI -2.37, -0.86]). CONCLUSIONS: This peer-delivered CBT-based program improved depressive symptoms and stress in individuals with diabetes and chronic pain. Training community members may be a feasible strategy for offering CBT-based interventions in rural and under-resourced communities. CLINICAL TRIAL REGISTRATION: NCT02538055.

The Association of Enhanced Recovery Pathway and Acute Kidney Injury in Patients Undergoing Colorectal Surgery.

BACKGROUND: Acute kidney injury is associated with increased postoperative length of hospital stay and increases the risk of postoperative mortality. The association between the development of postoperative acute kidney injury and the implementation of an enhanced recovery after surgery protocol remains unclear. OBJECTIVE: This study aimed to examine the relationship between the implementation of an enhanced recovery pathway and the development of postoperative acute kidney injury. DESIGN: In this retrospective cohort study, a prospectively maintained database of patients who underwent elective colorectal surgery in an enhanced recovery pathway were compared to a hospital historical National Surgical Quality Improvement Program colorectal registry of patients. SETTINGS: This study was conducted at the University of Alabama at Birmingham, a tertiary referral center. PATIENTS: A total of 1052 patients undergoing elective colorectal surgery from 2012 through 2016 were included. MAIN OUTCOME MEASURES: The development of postoperative acute kidney injury was the primary outcome measured. RESULTS: Patients undergoing an enhanced recovery pathway had significantly greater rates of postoperative acute kidney injury than patients not undergoing an enhanced recovery pathway (13.64% vs 7.08%; p < 0.01). Our adjusted model indicated that patients who underwent an enhanced recovery pathway (OR, 2.31; 95% CI, 1.48-3.59; p < 0.01) had an increased risk of acute kidney injury. Patients who developed acute kidney injury in the enhanced recovery cohort had a significantly longer median length of stay than those who did not (median 4 (interquartile range, 4-9) vs 3 (interquartile range, 2-5) days; p=0.04). LIMITATIONS: This study did not utilize urine output as a modality for detecting acute kidney injury. Data are limited to a sample of patients from a large academic medical center participating in the National Surgical Quality Improvement Program. Interventions or programs in place at our institution that aimed at infection reduction or other initiatives with the goal of improving quality were not accounted for in this study. CONCLUSION: The implementation of an enhanced recovery after surgery protocol is independently associated with the development of postoperative acute kidney injury.See Video Abstract at http://links.lww.com/DCR/B69. LA ASOCIACIÓN DE VÍA DE RECUPERACIÓN MEJORADA Y LESIÓN RENAL AGUDA EN PACIENTES DE CIRUGÍA COLORRECTAL: La lesión renal aguda se asocia con una mayor duración en la estancia hospitalaria y aumenta el riesgo de la mortalidad postoperatoria. La asociación entre el desarrollo de la lesión renal aguda postoperatoria y la implementación de un protocolo de Recuperación Mejorada después de la cirugía, sigue sin ser clara.Examinar la relación entre la implementación de una vía de Recuperación Mejorada y el desarrollo de lesión renal aguda postoperatoria.Estudio de cohorte retrospectivo, de una base de datos mantenida prospectivamente, de pacientes que se sometieron a cirugía colorrectal electiva, en una vía de Recuperación Mejorada, se comparó con el registro histórico de los pacientes colorrectales del Programa Nacional de Mejora de la Calidad Quirúrgica.Universidad de Alabama en Birmingham, un centro de referencia terciario.Un total de 1052 pacientes sometidos a cirugía colorrectal electiva desde 2012 hasta 2016.Desarrollo de lesión renal aguda postoperatoria.Los pacientes sometidos a una vía de Recuperación Mejorada, tuvieron tasas significativamente mayores de lesiones renales agudas postoperatorias, en comparación con los pacientes de Recuperación no Mejorada (13.64% vs 7.08%; p < 0.01). Nuestro modelo ajustado indicó que los pacientes que se sometieron a una vía de Recuperación Mejorada (OR, 2.31; IC, 1.48-3.59; p < 0.01) tuvieron un mayor riesgo de lesión renal aguda. Los pacientes que desarrollaron daño renal agudo en la cohorte de Recuperación Mejorada, tuvieron una estadía mediana significativamente más larga en comparación con aquellos que no [mediana 4 (rango intercuartil (RIC) 4-9) versus 3 (RIC 2-5) días; p = 0.04].Este estudio no utilizó la producción de orina como una modalidad para detectar daño renal agudo. Los datos se limitan a una muestra de pacientes de un gran centro médico académico, que participa en el Programa Nacional de Mejora de la Calidad Quirúrgica. Las intervenciones o programas implementados en nuestra institución, destinados a la reducción de infecciones u otras iniciativas, con el objetivo de mejorar la calidad, no se tomaron en cuenta para este estudio.La implementación de una Recuperación Mejorada después del protocolo de cirugía, se asocia independientemente con el desarrollo de lesión renal aguda postoperatoria.Consulte Video Resumen en http://links.lww.com/DCR/B69. (Traducción-Dr. Fidel Ruiz-Healy).

The Job Demands-Resources Model as a Framework to Identify Factors Associated With Burnout in Surgical Residents.

BACKGROUND: Surgical residents are a population at high risk for burnout. We hypothesized that surgical residents' burnout would be inversely related to emotional intelligence (EI) and job resources and directly related to experiences of disruptive behavior. MATERIALS AND METHODS: All general surgery residents at a single institution were invited to complete a survey in 2018 that included the Maslach Burnout Inventory, Trait EI Questionnaire Short Form, focused questions assessing disruptive behaviors, job resources, and demographic characteristics. Burnout was defined as scoring high in depersonalization (≥10 points) or emotional exhaustion (≥27 points). Student's t-tests and Wilcoxon tests were used to compare continuous variables; chi-square and Fisher's exact tests were used to compare categorical variables. RESULTS: The survey response rate was 87%. The median respondent age was 30, 51.7% were female, and 48.3% were single. Thirty-five met criteria for burnout (58%). Residents with burnout had lower scores for job resources than residents without burnout (19 versus 26, P < 0.01). Job resources subdomain scores for meaningful feedback and professional development had an inverse association with burnout (P < 0.01 for both). Having experienced any disruptive behavior was associated with burnout (68% versus 32%, P = 0.01). Mean EI scores were also lower for those with burnout (5.18 versus 5.64, P < 0.01). Among EI subcategories, burnout was associated with lower well-being and emotionality (P < 0.01 and P = 0.02, respectively). CONCLUSIONS: Burnout is prevalent among surgery residents, including those at our institution. Experiencing disruptive behaviors and lower perceptions of job resources were associated with higher burnout scores, along with lower scores in EI, and may inform future efforts toward interventions.

Peer-Delivered Cognitive Behavioral Training to Improve Functioning in Patients With Diabetes: A Cluster-Randomized Trial.

PURPOSE: Cognitive behavioral therapy (CBT)-based programs delivered by trained community members could improve functioning and pain in individuals who lack access to such programs. We tested the effectiveness of a peer-delivered diabetes self-management program integrating CBT principles in improving physical activity, functional status, pain, quality of life (QOL), and health outcomes in individuals with diabetes and chronic pain. METHODS: In this community-based, cluster-randomized controlled trial, intervention participants received a 3-month, peer-delivered, telephone-administered program. Attention control participants received a peer-delivered general health advice program. Outcomes were changes in functional status and pain (Western Ontario and McMaster Universities Osteoarthritis Index), QOL (Short Form 12), and physiologic measures (hemoglobin A1c, systolic blood pressure, body mass index); physical activity was the explanatory outcome. RESULTS: Of 195 participants with follow-up data, 80% were women, 96% African Americans, 74% had annual income <$20,000, and 64% had high school education or less. At follow-up, compared with controls, intervention participants had greater improvement in functional status (-10 ± 13 vs -5 ± 18, P = .002), pain (-10.5 ± 19 vs -4.8 ± 21, P = .01), and QOL (4.8 ± 8.8 vs 3.8 ± 8.8, P = .001). Physiologic measures did not change significantly in either group. At 3 months, a greater proportion of intervention than control participants reported no pain or did other forms of exercise when pain prevented them from walking for exercise. CONCLUSION: This peer-delivered CBT-based intervention improved functioning, pain, QOL, and self-reported physical activity despite pain in individuals with diabetes and chronic pain. Trained community members can deliver effective CBT-based interventions in rural and under-resourced communities.

Using health-related quality of life to predict cardiovascular disease events.

PURPOSE: Although strong associations between self-reported health and mortality exist, quality of life is not conceptualized as a cardiovascular disease (CVD) risk factor. Our objective was to assess the independent association between health-related quality of life (HRQOL) and incident CVD. METHODS: This study used the REasons for Geographic And Racial Differences in Stroke data, which enrolled 30,239 adults from 2003 to 2007 and followed them over 10 years. We included 22,229 adults with no CVD history at baseline. HRQOL was measured using the SF-12 Physical Component Summary (PCS) and Mental Component Summary (MCS) scores, which range from 0 to 100, with higher scores indicating better HRQOL. Scores were normed to the general US population with mean 50 and standard deviation 10. We constructed a four-level HRQOL variable: (1) individuals with PCS & MCS < 50, (2) PCS < 50 & MCS ≥ 50, (3) MCS < 50 & PCS ≥ 50, and (4) PCS & MCS ≥ 50, which was the reference. The primary outcome was incident CVD (non-fatal myocardial infarction (MI), fatal MI or coronary heart disease (CHD) death, fatal and non-fatal stroke). Cox proportional hazards models examined associations between HRQOL and CVD. RESULTS: Median follow-up was 8.4 (IQR 5.9-10.0) years. We observed 1766 CVD events. Compared to having PCS & MCS ≥ 50, having MCS & PCS < 50 was associated with increased CVD risk (aHR 1.46; 95% 1.24-1.70), adjusting for demographics, comorbidities, and CVD risk factors. Associations between MCS & PCS < 50 and CVD were consistent for CHD (aHR 1.54 [1.26-1.89]) and stroke (aHR 1.35 [1.05-1.72]) endpoints. CONCLUSIONS: Given strong, adjusted associations between poor HRQOL and incident CVD, self-reported health may be an excellent complement to current approaches to CVD risk identification.

Black-White Differences in Incident Fatal, Nonfatal, and Total Coronary Heart Disease.

BACKGROUND: Blacks have higher coronary heart disease (CHD) mortality compared with whites. However, a previous study suggests that nonfatal CHD risk may be lower for black versus white men. METHODS: We compared fatal and nonfatal CHD incidence and CHD case-fatality among blacks and whites in the Atherosclerosis Risk in Communities study (ARIC), the Cardiovascular Health Study (CHS), and the Reasons for Geographic and Racial Differences in Stroke study (REGARDS) by sex. Participants 45 to 64 years of age in ARIC (men=6479, women=8488) and REGARDS (men=5296, women=7822), and ≥65 years of age in CHS (men=1836, women=2790) and REGARDS (men=3381, women=4112), all without a history of CHD, were analyzed. Fatal and nonfatal CHD incidence was assessed from baseline (ARIC=1987-1989, CHS=1989-1990, REGARDS=2003-2007) through up to 11 years of follow-up. RESULTS: Age-adjusted hazard ratios comparing black versus white men 45 to 64 years of age in ARIC and REGARDS were 2.09 (95% confidence interval, 1.42-3.06) and 2.11 (1.32-3.38), respectively, for fatal CHD, and 0.82 (0.64-1.05) and 0.94 (0.69-1.28), respectively, for nonfatal CHD. After adjustment for social determinants of health and cardiovascular risk factors, hazard ratios in ARIC and REGARDS were 1.19 (95% confidence interval, 0.74-1.92) and 1.09 (0.62-1.93), respectively, for fatal CHD, and 0.64 (0.47-0.86) and 0.67 (0.48-0.95), respectively, for nonfatal CHD. Similar patterns were present among men ≥65 years of age in CHS and REGARDS. Among women 45 to 64 years of age in ARIC and REGARDS, age-adjusted hazard ratios comparing blacks versus whites were 2.61 (95% confidence interval, 1.57-4.34) and 1.79 (1.06-3.03), respectively, for fatal CHD, and 1.47 (1.13-1.91) and 1.29 (0.91-1.83), respectively, for nonfatal CHD. After multivariable adjustment, hazard ratios in ARIC and REGARDS were 0.67 (95% confidence interval, 0.36-1.24) and 1.00 (0.54-1.85), respectively, for fatal CHD, and 0.70 (0.51-0.97) and 0.70 (0.46-1.06), respectively, for nonfatal CHD. Racial differences in CHD incidence were attenuated among older women. CHD case fatality was higher among black versus white men and women, and the difference remained similar after multivariable adjustment. CONCLUSIONS: After accounting for social determinants of health and risk factors, black men and women have similar risk for fatal CHD compared with white men and women, respectively. However, the risk for nonfatal CHD is consistently lower for black versus white men and women.

Congestive heart failure in older adults diagnosed with follicular lymphoma: A population-based study.

BACKGROUND: To the authors' knowledge, there is limited information regarding the long-term risk of congestive heart failure (CHF) among patients with follicular lymphoma, a prevalent non-Hodgkin lymphoma diagnosis among those aged >65 years, especially within the context of therapeutic exposures and preexisting comorbidities. METHODS: Using Surveillance, Epidemiology, and End Results-Medicare data from 1999 through 2013, the authors identified 6109 patients with follicular lymphoma who were diagnosed at age ≥66 years between January 1, 2000 and December 31, 2011, and a frequency-matched Medicare noncancer sample. Subdistribution hazards models assessed risks associated with new-onset CHF through December 31, 2013. Propensity score-matched models examined CHF risk in patients receiving anthracyclines when compared with matched noncancer controls. RESULTS: When compared with matched controls, patients with follicular lymphoma receiving anthracyclines at ages 66 to 75 years had a 1.7-fold (95% confidence interval, 1.4-fold to 2.1-fold) higher risk of new-onset CHF; patients diagnosed at age >75 years did not differ from noncancer controls with regard to CHF risk. Preexisting hypertension was associated with a 1.7-fold and 1.35-fold, respectively, increased hazard of CHF for each age group, independent of anthracycline exposure. Preexisting diabetes was associated with 1.5-fold increased hazard of CHF only in those patients aged 66 to 75 years. Patients with new-onset CHF had a 18% lower 10-year survival compared with those without CHF. CONCLUSIONS: Patients with follicular lymphoma who were exposed to anthracyclines between the ages of 66 years and 75 years were found to be at an increased risk of new-onset CHF; preexisting hypertension and diabetes appeared to increase this risk. The findings of the current study support and inform the risk-based follow-up of vulnerable populations.

Enhanced Recovery After Surgery (ERAS) Eliminates Racial Disparities in Postoperative Length of Stay After Colorectal Surgery.

OBJECTIVE: To investigate the effects of enhanced recovery after surgery (ERAS) on racial disparities in postoperative length of stay (pLOS) after colorectal surgery. BACKGROUND: Racial disparities in surgical outcomes exist. We hypothesized that ERAS would reduce disparities in pLOS between black and white patients. METHODS: Patients undergoing ERAS in 2015 were 1:1 matched by race/ethnicity, age, sex, and procedure to a pre-ERAS group from 2010 to 2014. After stratification by race/ethnicity, expected pLOS was calculated using the American College of Surgeons National Surgical Quality Improvement Project Risk Calculator. Primary outcome was the observed pLOS and observed-to-expected difference in pLOS. Secondary outcomes were National Surgical Quality Improvement Project postoperative complications including 30-day readmissions and mortality. Adjusted sensitivity analyses on pLOS were also performed. RESULTS: Of 420 patients (210 ERAS and 210 pre-ERAS) examined, 28.3% were black. Black and white patients were similar in age, body mass index, sex, American Anesthesia Association class, and minimally invasive approaches. Within the pre-ERAS group, black patients stayed a mean of 2.7 days longer than expected compared with white patients (P < 0.05). Overall, ERAS patients had a significantly shorter pLOS (5.7 vs 8 days) and observed-to-expected difference (-0.7 vs 1.4 days) compared with pre-ERAS patients (P < 0.01). In the ERAS group, disparities in pLOS were reduced with no differences in readmissions or mortality between black and white patients. On sensitivity analyses, race/ethnicity remained a significant predictor of pLOS among pre-ERAS patients, but not for ERAS patients. CONCLUSIONS: ERAS eliminated racial differences in pLOS between black and white patients undergoing colorectal surgery. Reduced pLOS occurred without increases in mortality, readmissions, and most postoperative complications. ERAS may provide a practical approach to reducing disparities in surgical outcomes.

N-terminal pro-B-type natriuretic peptide and microsize myocardial infarction risk in the reasons for geographic and racial differences in stroke study.

BACKGROUND: N-terminal pro B-type peptide (NT-proBNP) has been associated with risk of myocardial infarction (MI), but less is known about the relationship between NT-proBNP and very small non ST-elevation MI, also known as microsize MI. These events are now routinely detectable with modern troponin assays and are emerging as a large proportion of all MI. Here, we sought to compare the association of NT-proBNP with risk of incident typical MI and microsize MI in the REasons for Geographic and Racial Differences in Stroke (REGARDS) Study. METHODS: The REGARDS Study is a national cohort of 30,239 US community-dwelling black and white adults aged ≥ 45 years recruited from 2003 to 2007. Expert-adjudicated outcomes included incident typical MI (definite/probable MI with peak troponin ≥ 0.5 µg/L), incident microsize MI (definite/probable MI with peak troponin < 0.5 µg/L), and incident fatal CHD. Using a case-cohort design, we estimated the hazard ratio of the outcomes as a function of baseline NT-proBNP. Competing risk analyses tested whether the associations of NT-proBNP differed between the risk of incident microsize MI and incident typical MI as well as if the association of NT-proBNP differed between incident non-fatal microsize MI and incident non-fatal typical MI, while accounting for incident fatal coronary heart disease (CHD) as well as heart failure (HF). RESULTS: Over a median of 5 years of follow-up, there were 315 typical MI, 139 microsize MI, and 195 incident fatal CHD. NT-proBNP was independently and strongly associated with all CHD endpoints, with significantly greater risk observed for incident microsize MI, even after removing individuals with suspected HF prior to or coincident with their incident CHD event. CONCLUSION: NT-proBNP is associated with all MIs, but is a more powerful risk factor for microsize than typical MI.

The Fifth Vital Sign: Postoperative Pain Predicts 30-day Readmissions and Subsequent Emergency Department Visits.

OBJECTIVE: We hypothesized that inpatient postoperative pain trajectories are associated with 30-day inpatient readmission and emergency department (ED) visits. BACKGROUND: Surgical readmissions have few known modifiable predictors. Pain experienced by patients may reflect surgical complications and/or inadequate or difficult symptom management. METHODS: National Veterans Affairs Surgical Quality Improvement data on inpatient general, vascular, and orthopedic surgery from 2008 to 2014 were merged with laboratory, vital sign, health care utilization, and postoperative complications data. Six distinct postoperative inpatient patient-reported pain trajectories were identified: (1) persistently low, (2) mild, (3) moderate or (4) high trajectories, and (5) mild-to-low or (6) moderate-to-low trajectories based on postoperative pain scores. Regression models estimated the association between pain trajectories and postdischarge utilization while controlling for important patient and clinical variables. RESULTS: Our sample included 211,231 surgeries-45.4% orthopedics, 37.0% general, and 17.6% vascular. Overall, the 30-day unplanned readmission rate was 10.8%, and 30-day ED utilization rate was 14.2%. Patients in the high pain trajectories had the highest rates of postdischarge readmissions and ED visits (14.4% and 16.3%, respectively, P < 0.001). In multivariable models, compared with the persistently low pain trajectory, there was a dose-dependent increase in postdischarge ED visits and readmission for pain-related diagnoses, but not postdischarge complications (χ trend P < 0.001). CONCLUSIONS: Postoperative pain trajectories identify populations at risk for 30-day readmissions and ED visits, and do not seem to be mediated by postdischarge complications. Addressing pain control expectations before discharge may help reduce surgical readmissions in high pain categories.

Reduced disparities and improved surgical outcomes for Asian Americans with colorectal cancer.

BACKGROUND: Studies suggest Asian Americans may have improved oncologic outcomes compared with other ethnicities. We hypothesized that Asian Americans with colorectal cancer would have improved surgical outcomes in mortality, postoperative complications (POCs), length of stay (LOS), and readmissions compared with other racial/ethnic groups. METHODS: We queried the 2011-2014 American College of Surgeons National Surgical Quality Improvement Program for patients who underwent surgery for colorectal cancer and stratified patients by race. Primary outcome was 30-d mortality with secondary outcomes including POCs, LOS, and 30-d readmission. Stepwise backward logistic regression analyses and incident rate ratio calculations were performed to identify risk factors for disparate outcomes. RESULTS: Of the 28,283 patients undergoing colorectal surgery for malignancy, racial/ethnic groups were divided into Caucasian American (84%), African American (12%), or Asian American (4%). On unadjusted analyses, compared with other racial/ethnic groups, Asian Americans were more likely to have normal weight, not smoke, and had lower American Society of Anesthesiologists score of 1 or 2 (P < 0.001). Postoperatively, Asian Americans had the shortest LOS and the lowest rates of complications due to ileus, respiratory, and renal complications (P < 0.001). There were no racial differences in 30-d mortality or readmission. On adjusted analyses, Asian American race was independently associated with less postoperative ileus (odds ratio 0.8, 95% confidence interval 0.66-0.98, P < 0.001) and decreased LOS by 13% and 4% compared with African American and Caucasian American patients, respectively (P < 0.001). CONCLUSIONS: Asian Americans undergoing surgery for colorectal cancer have shorter LOS and fewer POCs when compared with other racial/ethnic groups without differences in 30-d mortality or readmissions. The mechanism(s) underlying these disparities will require further study, but may be a result of patient, provider, and healthcare system differences.

Racial disparities in length-of-stay persist even with no postoperative complications.

BACKGROUND: To determine the contribution of race to postoperative length-of-stay in elective colorectal surgery without complications. METHODS: The 2012-2013 National Surgical Quality Improvement Program Colectomy-Targeted Database was queried for patients undergoing elective colorectal surgery without complications. After stratifying by race, univariate/bivariate comparisons were made. On adjusted comparison, predictors of postoperative length-of-stay were identified along with incident rate ratios and Least Squares Means for predicted length-of-stays. RESULTS: Of 28,480 elective colorectal surgeries, 19,898 patients had no postoperative complications. Patients stratified to white (84%), black (8%), Hispanic (3%), and Asian (3%). Overall mean postoperative length-of-stay was 4.8 d, with black patients having the longest at 5.3 d (P < 0.05). After covariate adjustment, black race increased postoperative length-of-stay by 9%, 7%, and 6% compared to white, Hispanic, and Asian patients, respectively (P < 0.05). No statistical difference existed in postoperative length-of-stay for Hispanic and Asian patients versus white patients. Adjusted postoperative length-of-stay was 5.1 d for black patients compared to 4.7, 4.8, and 4.8 d for white, Hispanic, and Asian patients, respectively (P < 0.05). CONCLUSIONS: Black patients have significantly longer postoperative length-of-stay after elective colorectal surgery even if no postoperative complications occur. Further studies are needed to understand the mechanism(s) for these disparities.