Angiotensin blockade therapy and survival in pancreatic cancer: a population study.

BACKGROUND: Pancreatic cancer (PC) is one of the most aggressive and challenging cancer types to effectively treat, ranking as the fourth-leading cause of cancer death in the United States. We investigated if exposures to angiotensin II receptor blockers (ARBs) or angiotensin I converting enzyme (ACE) inhibitors after PC diagnosis are associated with survival. METHODS: PC patients were identified by ICD-9 diagnosis and procedure codes among the 3.7 million adults living in the Emilia-Romagna Region from their administrative health care database containing patient data on demographics, hospital discharges, all-cause mortality, and outpatient pharmacy prescriptions. Cox modeling estimated covariate-adjusted mortality hazard ratios for time-dependent ARB and ACE inhibitor exposures after PC diagnosis. RESULTS: 8,158 incident PC patients were identified between 2003 and 2011, among whom 20% had pancreas resection surgery, 36% were diagnosed with metastatic disease, and 7,027 (86%) died by December 2012. Compared to otherwise similar patients, those exposed to ARBs after PC diagnosis experienced 20% lower mortality risk (HR=0.80; 95% CI: 0.72, 0.89). Those exposed to ACE inhibitors during the first three years of survival after PC diagnosis experienced 13% lower mortality risk (HR=0.87; 95% CI: 0.80, 0.94) which attenuated after surviving three years (HR=1.14; 95% CI: 0.90, 1.45). CONCLUSIONS: The results of this large population study suggest that exposures to ARBs and ACE inhibitors after PC diagnosis are significantly associated with improved survival. ARBs and ACE inhibitors could be important considerations for treating PC patients, particularly those with the worst prognosis and most limited treatment options. Considering that these common FDA approved drugs are inexpensive to payers and present minimal increased risk of adverse events to patients, there is an urgent need for randomized clinical trials, large simple randomized trials, or pragmatic clinical trials to formally and broadly evaluate the effects of ARBs and ACE inhibitors on survival in PC patients.

Data Enhancement via Low-Rank Matrix Reconstruction in Pulsed Thermography for Carbon-Fibre-Reinforced Polymers.

Pulsed thermography is a commonly used non-destructive testing method and is increasingly studied for the assessment of advanced materials such as carbon fibre-reinforced polymer (CFRP). Different processing approaches are proposed to detect and characterize anomalies that may be generated in structures during the manufacturing cycle or service period. In this study, matrix decomposition using Robust PCA via Inexact-ALM is investigated as a pre- and post-processing approach in combination with state-of-the-art approaches (i.e., PCT, PPT and PLST) on pulsed thermography thermal data. An academic sample with several artificial defects of different types, i.e., flat-bottom-holes (FBH), pull-outs (PO) and Teflon inserts (TEF), was employed to assess and compare defect detection and segmentation capabilities of different processing approaches. For this purpose, the contrast-to-noise ratio (CNR) and similarity coefficient were used as quantitative metrics. The results show a clear improvement in CNR when Robust PCA is applied as a pre-processing technique, CNR values for FBH, PO and TEF improve up to 164%, 237% and 80%, respectively, when compared to principal component thermography (PCT), whilst the CNR improvement with respect to pulsed phase thermography (PPT) was 77%, 101% and 289%, respectively. In the case of partial least squares thermography, Robust PCA results improved not only only when used as a pre-processing technique but also when used as a post-processing technique; however, this improvement is higher for FBHs and POs after pre-processing. Pre-processing increases CNR scores for FBHs and POs with a ratio from 0.43% to 115.88% and from 13.48% to 216.63%, respectively. Similarly, post-processing enhances the FBHs and POs results with a ratio between 9.62% and 296.9% and 16.98% to 92.6%, respectively. A low-rank matrix computed from Robust PCA as a pre-processing technique on raw data before using PCT and PPT can enhance the results of 67% of the defects. Using low-rank matrix decomposition from Robust PCA as a pre- and post-processing technique outperforms PLST results of 69% and 67% of the defects. These results clearly indicate that pre-processing pulsed thermography data by Robust PCA can elevate the defect detectability of advanced processing techniques, such as PCT, PPT and PLST, while post-processing using the same methods, in some cases, can deteriorate the results.

Robust Principal Component Thermography for Defect Detection in Composites.

Pulsed Thermography (PT) data are usually affected by noise and as such most of the research effort in the last few years has been directed towards the development of advanced signal processing methods to improve defect detection. Among the numerous techniques that have been proposed, principal component thermography (PCT)-based on principal component analysis (PCA)-is one of the most effective in terms of defect contrast enhancement and data compression. However, it is well-known that PCA can be significantly affected in the presence of corrupted data (e.g., noise and outliers). Robust PCA (RPCA) has been recently proposed as an alternative statistical method that handles noisy data more properly by decomposing the input data into a low-rank matrix and a sparse matrix. We propose to process PT data by RPCA instead of PCA in order to improve defect detectability. The performance of the resulting approach, Robust Principal Component Thermography (RPCT)-based on RPCA, was evaluated with respect to PCT-based on PCA, using a CFRP sample containing artificially produced defects. We compared results quantitatively based on two metrics, Contrast-to-Noise Ratio (CNR), for defect detection capabilities, and the Jaccard similarity coefficient, for defect segmentation potential. CNR results were on average 40% higher for RPCT than for PCT, and the Jaccard index was slightly higher for RPCT (0.7395) than for PCT (0.7010). In terms of computational time, however, PCT was 11.5 times faster than RPCT. Further investigations are needed to assess RPCT performance on a wider range of materials and to optimize computational time.

Metformin exposure and survival in head and neck cancer: A large population-based cohort study.

WHAT IS KNOWN AND OBJECTIVE: Observational clinical studies of metformin for prevention and treatment of several cancer types have reported mixed findings. Although preclinical studies have suggested metformin may reduce head and neck cancer (HNC) proliferation, clinical evidence is limited. The objective of this large population-based study was to evaluate the relationship between metformin exposure following HNC diagnosis and all-cause mortality. METHODS: We conducted a retrospective cohort study using the Italian Emilia-Romagna Regional administrative healthcare database, which includes demographic, hospital and outpatient prescription information for ~4.5 million residents. Included patients were followed from the first hospital discharge (index) during the study period (01/2003-12/2012) with a diagnosis of HNC. Metformin exposure and select covariates were operationalized in a time-dependent manner during follow-up. Cox proportional hazards models estimated the covariate-adjusted time-dependent association between metformin exposure and all-cause mortality. RESULTS AND DISCUSSION: Among 7872 patients diagnosed with HNC, 708 (9.0%) were exposed to metformin after HNC diagnosis, and 3626 (46.1%) died during follow-up (median follow-up: 35.2 months). In the covariate-adjusted model, the all-cause mortality rate appeared lower (HR: 0.81, 95% CI: 0.61-1.09) among metformin exposed patients during the 2 years post-diagnosis, while the all-cause mortality rate appeared higher (HR: 1.20, 95% CI: 0.94-1.53) among exposed patients after 2 years post-diagnosis. Metformin was protective among patients ≤60 years of age (HR for the period of 0-2 years post-diagnosis: 0.22, 95% CI 0.09-0.56; HR for the period ≥2 years post-diagnosis: 0.56, 95% CI 0.26-1.22) but not in those >60 years. WHAT IS NEW AND CONCLUSION: In this population-based study of metformin in HNC, we found a modest protective association between metformin exposure and all-cause mortality in the 2-year post-diagnosis period. Age appeared to modify the association between metformin and HNC survival.

Fascia Iliaca Compartment Block Efficacy in Resource-poor Emergency Departments.

INTRODUCTION: Although the fascia iliaca compartment block (FICB) seems to be an ideal technique for femoral neck and shaft fractures occurring in resource-poor settings, it has been unclear how effective it is when used by emergency physicians (EP) with little training in the technique, using equipment, medications and methods that differ from those commonly available in developed countries. This series was designed to demonstrate that EPs in a resource-poor setting can provide effective analgesia for femur fractures with anatomic landmark-guided FICBs, clinician-compounded lidocaine-epinephrine (1:100,000), and a standard injection needle. METHODS: Over a three-month period, patients ≥12 years old presenting to the emergency department with hip or femur fractures and a Likert visual analogue scale >4 had an EP-administered FICB. EPs used a standard intramuscular needle and a lidocaine-epinephrine solution they compounded at the bedside and located the injection site using only anatomic landmarks. EPs evaluated the patient's pain level at 30 minutes and at two hours post-FICB. We also reviewed articles since 2016 that describe the FICB. RESULTS: We enrolled a non-consecutive sample of 10 patients in the case series. Five had femoral neck (hip) fractures and five had femoral shaft fractures. All patients had a reduction in their pain levels after the FICB. On average, the block took effect about three minutes after injection. At 30 minutes all patients reported clinically meaningful pain reduction. The analgesic effect of the compounded agent lasted approximately 200 minutes. No adverse effects were reported. No published journal articles about FICB since 2016 were from resource-poor settings, and only one was from a developing country. CONCLUSION: This series suggests that the FICB is effective even when performed with the minimal materials that are usually available in resource-poor settings. Methods such as this, which use simplified clinical tests and techniques applicable in resource-poor settings, can assist global emergency medicine (EM). We can assist global EM by similarly finding methods to simplify useful clinical tests and techniques that can be used in resource-poor settings.

Effectiveness of palliative care services: A population-based study of end-of-life care for cancer patients.

BACKGROUND: Multiple studies demonstrate substantial utilization of acute hospital care and, potentially excessive, intensive medical and surgical treatments at the end-of-life. AIM: To evaluate the relationship between the use of home and facility-based hospice palliative care for patients dying with cancer and service utilization at the end of life. DESIGN: Retrospective, population-level study using administrative databases. The effect of palliative care was analyzed between coarsened exact matched cohorts and evaluated through a conditional logistic regression model. SETTING/PARTICIPANTS: The study was conducted on the cohort of 34,357 patients, resident in Emilia-Romagna Region, Italy, admitted to hospital with a diagnosis of metastatic or poor-prognosis cancer during the 6 months before death between January 2013 and December 2015. RESULTS: Patients who received palliative care experienced significantly lower rates of all indicators of aggressive care such as hospital admission (odds ratio (OR) = 0.05, 95% confidence interval (CI): 0.04-0.06), emergency department visits (OR = 0.23, 95% CI: 0.21-0.25), intensive care unit stays (OR = 0.29, 95% CI: 0.26-0.32), major operating room procedures (OR = 0.22, 95% CI: 0.21-0.24), and lower in-hospital death (OR = 0.11, 95% CI: 0.10-0.11). This cohort had significantly higher rates of opiate prescriptions (OR = 1.27, 95% CI: 1.21-1.33) ( p < 0.01 for all comparisons). CONCLUSION: Use of palliative care at the end of life for cancer patients is associated with a reduction of the use of high-cost, intensive services. Future research is necessary to evaluate the impact of increasing use of palliative care services on other health outcomes. Administrative databases linked at the patient level are a useful data source for assessment of care at the end of life.

Predicting risk of hospitalisation: a retrospective population-based analysis in a paediatric population in Emilia-Romagna, Italy.

OBJECTIVES: Develop predictive models for a paediatric population that provide information for paediatricians and health authorities to identify children at risk of hospitalisation for conditions that may be impacted through improved patient care. DESIGN: Retrospective healthcare utilisation analysis with multivariable logistic regression models. DATA: Demographic information linked with utilisation of health services in the years 2006-2014 was used to predict risk of hospitalisation or death in 2015 using a longitudinal administrative database of 527 458 children aged 1-13 years residing in the Regione Emilia-Romagna (RER), Italy, in 2014. OUTCOME MEASURES: Models designed to predict risk of hospitalisation or death in 2015 for problems that are potentially avoidable were developed and evaluated using the C-statistic, for calibration to assess performance across levels of predicted risk, and in terms of their sensitivity, specificity and positive predictive value. RESULTS: Of the 527 458 children residing in RER in 2014, 6391 children (1.21%) were hospitalised for selected conditions or died in 2015. 49 486 children (9.4%) of the population were classified in the 'At Higher Risk' group using a threshold of predicted risk >2.5%. The observed risk of hospitalisation (5%) for the 'At Higher Risk' group was more than four times higher than the overall population. We observed a C-statistic of 0.78 indicating good model performance. The model was well calibrated across categories of predicted risk. CONCLUSIONS: It is feasible to develop a population-based model using a longitudinal administrative database that identifies the risk of hospitalisation for a paediatric population. The results of this model, along with profiles of children identified as high risk, are being provided to the paediatricians and other healthcare professionals providing care to this population to aid in planning for care management and interventions that may reduce their patients' likelihood of a preventable, high-cost hospitalisation.

Cholecystectomy in Emilia-Romagna region (Italy): A retrospective cohort study based on a large administrative database.

BACKGROUND: The aim of this study was to ascertain the variability and to identify a trend for the outcome of cholecystectomy surgery when used to treat cholelithiasis and acute cholecystitis. METHODS: This was a large retrospective cohort study following patients up to 11 years post surgery, based on administrative data collected from 2002 to 2012 in the Emilia-Romagna Region (Northern Italy) and comparing the effectiveness and efficiency of surgical activity (laparoscopic (LC) and open cholecystectomy (OC)). Analyses included patient characteristics, length of hospital stay, type of admission and mortality risk. Outcomes considered were death from all causes (during the index hospital admission or thereafter), hospital readmissions with cholecystitis or cholelithiasis as principal diagnosis and time to surgery. RESULTS: A total of 84,628 cholecystomies were performed from 2002 to 2012 out of 123,061 admissions with primary diagnostic category of cholecystitis or cholelitiasis. Laparoscopic procedure was used in 69,842 patients. Over time there was a rising linear statistically significant trend in the use of LC. Mortality rate at 1 year of OC treated patients showed a statistically significant difference compared to LC treated patients (using a cohorts match with propensity score). Only a small number of patients with acute cholecystitis was operated according guidelines within 72 hours. CONCLUSIONS: The analysis of aggregate administrative data is a powerful tool to support regional health management, improve the quality of medical care, and assess the appropriateness of therapeutic or diagnostic approaches. It is important to stress a short hospital stay for laparoscopic cholecystectomy patients (50% less than open surgery): this shorter hospital stay leads to a significant economic advantage. Moreover, mortality is significantly higher in open surgery for acute cholecystitis. Interestingly, the same finding was confirmed after 30 days and 1 year, probably due to comorbidities that are more evident in open surgery. KEY WORDS: Cholecystitis, Cholelithiasis, Delivery of health care, Disease management, Surgical.

Variation in hospital utilization at the end of life for patients with cancer in the Emilia-Romagna region of Italy.

INTRODUCTION: Despite the preference of many patients to die at home, high proportions of patients with advanced cancer undergo major procedures, receive intensive care, and die in the hospital. The goal of this study is to examine variation in hospital utilization and site of death for patients dying with poor-prognosis cancer in the Regione Emilia-Romagna (RER), Italy. METHODS: We conducted a retrospective, population-level study using administrative data. Patients were included if they died in 2012 and had at least one hospital admission for metastatic or poor-prognosis cancer within 180 days of death. Variations in the use of the hospital, intensive care, and procedures performed were evaluated. RESULTS: 11,470 patients died with metastatic or poor-prognosis cancer in 2012. Seventy-eight percent of patients were hospitalized in the last month of life while 50.7% of patients died in the hospital. Results varied by local health authority from 38.3% to 69.3%. Of patients who had an ICU stay, 55.1% in the community hospitals and 59.8% in the teaching hospitals were admitted to the ICU on the day of death or the day before death. 7.5% of patients underwent a major procedure in the last 30 days of life. CONCLUSIONS: The overall high rate, and substantial variation, in hospital care at the end of life offers the RER the opportunity to evaluate if increasing availability of palliative care, along with provider and patient education, could reduce utilization of high-cost hospital care and increase patient and family satisfaction.

Assessing adverse events of postprostatectomy radiation therapy for prostate cancer: evaluation of outcomes in the Regione Emilia-Romagna, Italy.

PURPOSE: Although the likelihood of radiation-related adverse events influences treatment decisions regarding radiation therapy after prostatectomy for eligible patients, the data available to inform decisions are limited. This study was designed to evaluate the genitourinary, gastrointestinal, and sexual adverse events associated with postprostatectomy radiation therapy and to assess the influence of radiation timing on the risk of adverse events. METHODS: The Regione Emilia-Romagna Italian Longitudinal Health Care Utilization Database was queried to identify a cohort of men who received radical prostatectomy for prostate cancer during 2003 to 2009, including patients who received postprostatectomy radiation therapy. Patients with prior radiation therapy were excluded. Outcome measures were genitourinary, gastrointestinal, and sexual adverse events after prostatectomy. Rates of adverse events were compared between the cohorts who did and did not receive postoperative radiation therapy. Multivariable Cox proportional hazards models were developed for each class of adverse events, including models with radiation therapy as a time-varying covariate. RESULTS: A total of 9876 men were included in the analyses: 2176 (22%) who received radiation therapy and 7700 (78%) treated with prostatectomy alone. In multivariable Cox proportional hazards models, the additional exposure to radiation therapy after prostatectomy was associated with increased rates of gastrointestinal (rate ratio [RR] 1.81; 95% confidence interval [CI] 1.44-2.27; P<.001) and urinary nonincontinence events (RR 1.83; 95% CI 1.83-2.80; P<.001) but not urinary incontinence events or erectile dysfunction. The addition of the time from prostatectomy to radiation therapy interaction term was not significant for any of the adverse event outcomes (P>.1 for all outcomes). CONCLUSION: Radiation therapy after prostatectomy is associated with an increase in gastrointestinal and genitourinary adverse events. However, the timing of radiation therapy did not influence the risk of radiation therapy-associated adverse events in this cohort, which contradicts the commonly held clinical tenet that delaying radiation therapy reduces the risk of adverse events.

Predicting risk of hospitalisation or death: a retrospective population-based analysis.

OBJECTIVES: Develop predictive models using an administrative healthcare database that provide information for Patient-Centred Medical Homes to proactively identify patients at risk of hospitalisation for conditions that may be impacted through improved patient care. DESIGN: Retrospective healthcare utilisation analysis with multivariate logistic regression models. DATA: A population-based longitudinal database of residents served by the Emilia-Romagna, Italy, health service in the years 2004-2012 including demographic information and utilisation of health services by 3,726,380 people aged ≥18 years. OUTCOME MEASURES: Models designed to predict risk of hospitalisation or death in 2012 for problems that are potentially avoidable were developed and evaluated using the area under the receiver operating curve C-statistic, in terms of their sensitivity, specificity and positive predictive value, and for calibration to assess performance across levels of predicted risk. RESULTS: Among the 3,726,380 adult residents of Emilia-Romagna at the end of 2011, 449,163 (12.1%) were hospitalised in 2012; 4.2% were hospitalised for the selected conditions or died in 2012 (3.6% hospitalised, 1.3% died). The C-statistic for predicting 2012 outcomes was 0.856. The model was well calibrated across categories of predicted risk. For those patients in the highest predicted risk decile group, the average predicted risk was 23.9% and the actual prevalence of hospitalisation or death was 24.2%. CONCLUSIONS: We have developed a population-based model using a longitudinal administrative database that identifies the risk of hospitalisation for residents of the Emilia-Romagna region with a level of performance as high as, or higher than, similar models. The results of this model, along with profiles of patients identified as high risk are being provided to the physicians and other healthcare professionals associated with the Patient Centred Medical Homes to aid in planning for care management and interventions that may reduce their patients' likelihood of a preventable, high-cost hospitalisation.

A predictive model of hospitalization risk among disabled medicaid enrollees.

OBJECTIVES: To identify Medicaid patients, based on 1 year of administrative data, who were at high risk of admission to a hospital in the next year, and who were most likely to benefit from outreach and targeted interventions. STUDY DESIGN: Observational cohort study for predictive modeling. METHODS: Claims, enrollment, and eligibility data for 2007 from a state Medicaid program were used to provide the independent variables for a logistic regression model to predict inpatient stays in 2008 for fully covered, continuously enrolled, disabled members. The model was developed using a 50% random sample from the state and was validated against the other 50%. Further validation was carried out by applying the parameters from the model to data from a second state's disabled Medicaid population. RESULTS: The strongest predictors in the model developed from the first 50% sample were over age 65 years, inpatient stay(s) in 2007, and higher Charlson Comorbidity Index scores. The areas under the receiver operating characteristic curve for the model based on the 50% state sample and its application to the 2 other samples ranged from 0.79 to 0.81. Models developed independently for all 3 samples were as high as 0.86. The results show a consistent trend of more accurate prediction of hospitalization with increasing risk score. CONCLUSIONS: This is a fairly robust method for targeting Medicaid members with a high probability of future avoidable hospitalizations for possible case management or other interventions. Comparison with a second state's Medicaid program provides additional evidence for the usefulness of the model.

Variation among local health units in follow-up care of breast cancer patients in Emilia-Romagna, Italy.

AIMS AND BACKGROUND: This study examines the patterns of follow-up care for breast cancer survivors in one region in Italy. METHODS AND STUDY DESIGN: This retrospective analysis included 10,024 surgically treated women, with incident cases of breast cancer in the years 2002-2005 who were alive 18 months after their incidence date. Rates of use of follow-up mammograms, abdominal echogram, bone scans and chest x-rays were estimated from administrative data and compared by Local Health Unit (LHU) of residence. Logistic regression analyses were performed to assess possible "overuse", accounting for patient age, cancer stage, type of surgery and LHU of residence. RESULTS: A total of 7168 (72.1%) women received a mammogram within 18 months of their incidence date, while 6432 (64.2%) had an abdominal echogram, 3852 (38.4%) had a bone scan and 5231 (52.2%) had a chest x-ray. The rates of use of abdominal echograms, bone scans and chest x-rays were substantially higher in the population of breast cancer survivors than in the general female population. Taking account of patient age, cancer stage at diagnosis and type of surgery, multivariate analyses demonstrated significant variation in the use of these tests by LHU of residence. CONCLUSIONS: The observed variation in the use of abdominal echograms, bone scans and chest x-rays supports the conclusion that there is substantial misuse of these tests in the population of postsurgical breast cancer patients in the Emilia-Romagna region in Italy. In the absence of a documented survival benefit, overtesting has both a human and financial cost. We recommend additional review of the methods of follow-up care in breast cancer patients in the LHUs of Emilia-Romagna, with the aim of developing, disseminating and evaluating the implementation of specific guidelines targeting primary care physicians and oncologists providing care to breast cancer survivors. Patient education materials may also help to reduce unnecessary testing.

The relationship between physician empathy and disease complications: an empirical study of primary care physicians and their diabetic patients in Parma, Italy.

PURPOSE: To test the hypothesis that scores of a validated measure of physician empathy are associated with clinical outcomes for patients with diabetes mellitus. METHOD: This retrospective correlational study included 20,961 patients with type 1 or type 2 diabetes mellitus from a population of 284,298 adult patients in the Local Health Authority, Parma, Italy, enrolled with one of 242 primary care physicians for the entire year of 2009. Participating physicians' Jefferson Scale of Empathy scores were compared with occurrence of acute metabolic complications (hyperosmolar state, diabetic ketoacidosis, coma) in diabetes patients hospitalized in 2009. RESULTS: Patients of physicians with high empathy scores, compared with patients of physicians with moderate and low empathy scores, had a significantly lower rate of acute metabolic complications (4.0, 7.1, and 6.5 per 1,000 patients, respectively, P < .05). Logistic regression analysis showed physicians' empathy scores were associated with acute metabolic complications: odds ratio (OR) = 0.59 (95% confidence interval [CI], 0.37-0.95, contrasting physicians with high and low empathy scores). Patients' age (≥69 years) also contributed to the prediction of acute metabolic complications: OR = 1.7 (95% CI, 1.2-1.4). Physicians' gender and age, patients' gender, type of practice (solo, association), geographical location of practice (mountain, hills, plain), and length of time the patient had been enrolled with the physician were not associated with acute metabolic complications. CONCLUSIONS: These results suggest that physician empathy is significantly associated with clinical outcome for patients with diabetes mellitus and should be considered an important component of clinical competence.

Using administrative data to identify and stage breast cancer cases: implications for assessing quality of care.

AIMS AND BACKGROUND: The study evaluated the use of Italian hospital discharge data (SDO, scheda di dimissione ospedaliera) for identifying women with incident breast cancer, determining stage at diagnosis and assessing quality of care. STUDY DESIGN: Women aged 20+ years residing in the Regione Emilia-Romagna, Italy, between 2002 and 2005 were studied. Case identification using algorithms based on ICD-9-CM codes on hospital discharge data were compared with AIRTUM-accredited cancer registry data. Sensitivity, specificity and positive predictive value were computed overall, by age and cancer stage. Compliance with guidelines for radiation therapy using registry and hospital data were compared. RESULTS: A total of 11,615 women was identified by AIRTUM-accredited cancer registries as incident cases, whereas 10,876 women were identified by the SDO algorithm. Sensitivity was 84.8%, specificity was 99.9%, and the positive predictive value was 90.6%. Of the 1,022 who were false positives, 363 (35.5%) were women identified in registry data as having an incident case prior to 2002 and therefore were not included in the analysis. There were 1,761 false negatives; nearly 50% were over 70 years of age or did not undergo a surgical procedure and therefore were not included in our SDO-based case finding. Sensitivity declined as the patient population became older. However, we observed relatively good positive predictive value for all age groups. Algorithms using the SDO data did not clearly identify specific cancer stages. However, the algorithm may have utility where stages are grouped together for use in quality measures. CONCLUSIONS: Cases were identified with good sensitivity, specificity and positive predictive value with SDO data, with better rates than similar previously published algorithms based on Italian data. These hospital claims-based algorithms facilitate quality of care analyses for large populations when registry data are not available by identifying individual women and their subsequent use of health care services.

Mechanisms of melanocortin-2 receptor (MC2R) internalization and recycling in human embryonic kidney (hek) cells: identification of Key Ser/Thr (S/T) amino acids.

ACTH is the most important stimulus of the adrenal cortex. The precise molecular mechanisms underlying the ACTH response are not yet clarified. The functional ACTH receptor includes melanocortin-2 receptor (MC2R) and MC2R accessory proteins (MRAP). In human embryonic kidney 293/Flp recombinase target cells expressing MC2R, MRAP1 isoforms, and MRAP2, we found that ACTH induced a concentration-dependent and arrestin-, clathrin-, and dynamin-dependent MC2R/MRAP1 internalization, followed by intracellular colocalization with Rab (Ras-like small guanosine triphosphate enzyme)4-, Rab5-, and Rab11-positive recycling endosomes. Preincubation of cells with monensin and brefeldin A revealed that 28% of the internalized receptors were recycled back to the plasma membrane and participated in total accumulation of cAMP. Moreover, certain intracellular Ser and Thr (S/T) residues of MC2R were found to play important roles not only in plasma membrane targeting and function but also in promoting receptor internalization. The S/T residues T131, S140, T204, and S280 were involved in MRAP1-independent cell-surface MC2R expression. Other mutants (S140A, S208A, and S202D) had lower cell-surface expressions in absence of MRAPß. In addition, T143A and T147D drastically impaired cell-surface expression and function, whereas T131A, T131D, and S280D abrogated MC2R internalization. Thus, the modification of MC2R intracellular S/T residues may positively or negatively regulate its plasma membrane expression and the capacity of ACTH to induce cAMP accumulation. Mutations of T131, T143, T147, and S280 into either A or D had major repercussions on cell-surface expression, cAMP accumulation, and/or internalization parameters, pointing mostly to the second intracellular loop as being crucial for MC2R expression and functional regulation.

A brief instrument to measure patients' overall satisfaction with primary care physicians.

BACKGROUND AND OBJECTIVES: A brief and psychometrically sound scale to measure patients' overall satisfaction with their primary care physicians would be useful in studies where a longer instrument is impractical. The purpose of this study was to develop and examine the psychometrics of a brief instrument to measure patients' overall satisfaction with their primary care physicians. METHODS: Research participants included 535 outpatients (between 18--75 years old, 66% female) who completed a mailed survey that included 10 items for measuring overall satisfaction with their primary care physician who was named on the survey. Patients were also asked about their perceptions of physician empathy, preventive tests recommended by the physician (colonoscopy, mammogram, and prostate-specific antigen (PSA) for age and gender appropriate patients) and demographic information. RESULTS: Factor analysis of the patient satisfaction items resulted in one prominent component. Corrected item-total score correlations of the patient satisfaction scale ranged from 0.85 to 0.96; correlation between patient satisfaction scores and patient perception of physician empathy was 0.93, and correlation with recommending the physician to family and friends was 0.92. Criterion-related validity coefficients were mostly in the 0.80s and 0.90s. Patient satisfaction scores were significantly higher for those whose physicians recommended preventive tests (colonoscopy, mammogram, and PSA-compliance rates >.80). Cronbach's coefficient alpha for patient satisfaction scale was 0.98. CONCLUSIONS: Empirical evidence supported the validity and reliability of a brief patient satisfaction scale that has utility in the assessments of educational programs aimed at improving patient satisfaction, medical services, and patient outcomes in primary care settings.

Empathic and sympathetic orientations toward patient care: conceptualization, measurement, and psychometrics.

PURPOSE: To develop instruments for measuring empathic and sympathetic orientations in patient care and to provide evidence in support of their psychometrics. METHOD: Third-year medical students at Jefferson Medical College responded to four clinical vignettes in 2010. For each vignette, students indicated the extent of their agreement with an empathic response (conveying their understanding of patients' concerns) and with a sympathetic response (sharing patients' feelings). The authors calculated, based on students' responses to the clinical vignettes, two measures of empathic and sympathetic orientation. Students also completed the Jefferson Scale of Empathy (JSE) and the Interpersonal Reactivity Index (IRI). RESULTS: Of the 258 students in the class, 201 (78%) responded to all four vignettes and completed the JSE and IRI. The authors confirmed construct validity of the measures of empathic and sympathetic orientation through factor analysis. The empathic orientation was significantly associated with the measure of empathy (as measured by the JSE) but not with measures of sympathy (as measured by specific scales of the IRI). Conversely, sympathetic orientation was significantly associated with measures of sympathy. Thus, these results support the validity of the empathic and sympathetic orientation measures as assessed by four clinical vignettes. Coefficient alphas for the two measures were, respectively, 0.79 and 0.84. CONCLUSIONS: The validated measures of empathic and sympathetic orientation provide research opportunities to enhance the understanding of the contributions of empathy and sympathy to physicians' competence and patient outcomes.