The Adoption of Oncoplastic Surgery Using Breast Reduction or Mastopexy Techniques in an Academic Breast Cancer Center Program Can Increase Breast Conservation Rates.

BACKGROUND: Interest in oncoplastic surgery (OPS), a form of breast conservation surgery (BCS), has grown in the United States over the last decade. Oncoplastic surgery allows for the removal of larger tumors without compromising esthetic outcome or oncologic safety. One of the quality measures on which breast cancer centers in the United States are evaluated is rate of BCS. The purpose of this study was to investigate whether the adoption of OPS increases BCS rates and decreases mastectomy rates at the institutional level. METHODS: Clinicopathologic data were retrospectively collected for breast cancer patients in a single institution database. Rates of BCS vs mastectomy and partial mastectomy versus OPS were measured between 2012 and 2018 to capture 3 years before and 3 years after the hiring of an oncoplastic surgeon in 2015 with subsequent practice adoption of oncoplastic techniques. We compared the 2 periods using χ and Fisher exact test for categorical variables. Rates of breast conservation and mastectomy were further stratified by tumor stage. RESULTS: Four hundred sixty-eight patients underwent breast cancer surgery at Tufts Medical Center between 2012 and 2018.Patients who underwent surgery between 2012-2015 and 2016-2018 were similar in terms of age, histological type, tumor size, receipt of neoadjuvant therapy, receptor status, and Charlson Comorbidity Index. There was a statistically significant (P < 0.0001) increase in BCS rate after 2015 attributable to the practice adoption of OPS. The proportion of patients who were recommended reexcision did not significantly increase with the introduction of OPS suggesting an appropriate and safe patient selection process for patients undergoing these breast conservation techniques. When stratified by T stage (tumor size), rates of mastectomy for T2 tumors (greater than 2 cm but less than 5 cm) decreased precipitously after 2015 and BCS increased proportionately. The rate of BCS for T1 tumors also increased but less drastically. CONCLUSIONS: The adoption of OPS in an academic breast cancer center can result in significantly higher rates of BCS, particularly for those with larger tumors (T2). Academic breast cancer centers should strongly consider incorporating OPS to their treatment paradigm to provide patients with the option to avoid mastectomy.

Impact of Prosthesis Size and Prosthesis-Patient Mismatch on Outcomes in Younger Female Patients Undergoing Aortic Valve Replacement.

The effects of patient-prosthesis mismatch (PPM) after surgical aortic valve replacement (SAVR) suggest worse outcomes with smaller valves. We assessed clinical outcomes of younger females undergoing SAVR, using small and large prostheses, and the incremental risk of PPM. Between January 2002 and June 2015, 451 younger (age ≤65 years) female patients underwent SAVR. Patients were stratified into small prostheses (SP) ≤21 mm (n = 256) and large prostheses (LP) ≥23 mm (n = 195) groups. PPM was classified as moderate if indexed effective orifice area (iEOA) 0.65-0.85 cm2/m2, or severe if iEOA <0.65 cm2/m2. Operative mortality was not statistically different between SP and LP groups (2.4% vs 0.5%; P = 0.146). Unadjusted 10-year survival was 82% (95% confidence interval 77-87%), and was similar in both groups (P = 0.210). When grouped by standard PPM thresholds, only severe PPM was associated with significantly decreased survival (P = 0.007). A significant survival decrease was detected in LP group with iEOA ≤0.75 cm2/m2 (P < 0.001). Among SP patients, iEOA ≤0.65 cm2/m2 was associated with increased mortality (P = 0.075). After adjusting for potential confounders, Cox proportional hazard model identified iEOAs of ≤0.65 cm2/m2 (hazard ratio 1.85; P = 0.066) and ≤0.75 cm2/m2 (hazard ratio 2.3; P ≤ 0.003) as predictors of decreased long-term survival, in SP and LP groups, respectively. Among younger females who underwent SAVR, postoperative complications and in-hospital outcomes were substantially similar between the SP and LP groups. However, patients who received LP were adversely affected at lesser degrees of PPM than those who received SP. While SP patients may tolerate until iEOA ≤0.65 cm2/m2, our results suggest that moderate PPM of iEOA ≤0.75 for LP patients should be avoided.

Healthcare resource utilization and expenditures among newly-diagnosed elderly non-valvular atrial fibrillation patients initiating oral anticoagulants.

Aims: Non-valvular atrial fibrillation (NVAF) prevalence increases with age. Hence, evaluating the economic burden among older-aged patients is vital. This study aimed to compare healthcare resource utilization (HRU) and costs among newly-diagnosed older-aged NVAF patients treated with warfarin, rivaroxaban, or apixaban vs. dabigatran.Materials and Methods: Newly-diagnosed older-aged (aged ≥65 years) NVAF patients initiating dabigatran, warfarin, rivaroxaban, or apixaban (first prescription date = index date) from 01JAN2010-31DEC2015 and with continuous enrollment for ≥12 months pre-index date were included from 100% Medicare database. Patient data were assessed until drug discontinuation/switch/dose change/death/disenrollment/study end (up to 12 months). Dabigatran initiators were 1:1 propensity score-matched (PSM) with warfarin, rivaroxaban, or apixaban initiators. Generalized linear models were used to compare all-cause HRU and costs per-patient-per-month (PPPM) between the matched cohorts.Results: After PSM with dabigatran, 70,531 warfarin, 51,673 rivaroxaban, and 25,209 apixaban patients were identified. Dabigatran patients had significantly fewer generalized-linear-model-adjusted PPPM hospitalizations (0.114 vs. 0.123; 0.111 vs. 0.121), and outpatient visits (2.864 vs. 4.201; 2.839 vs. 2.949) than warfarin and rivaroxaban patients, respectively, but had significantly more PPPM hospitalizations (0.103 vs. 0.090) and outpatient visits (2.780 vs. 2.673) than apixaban patients (all p < .0001). Dabigatran patients incurred significantly lower adjusted total PPPM costs ($3,309 vs. $3,362; $3,285 vs. $3,474) than warfarin and rivaroxaban patients, respectively (all p < .01) but higher total PPPM costs ($3,192 vs. $2,986) than apixaban patients (all p < .0001).Limitations: This study is subject to the inherent limitations of any claims dataset, including potential bias from coding errors and identification of medical conditions using diagnosis codes as opposed to clinical evidence. Medications filled over-the-counter or provided as samples by the physician are never captured in claims data.Conclusions: Newly-diagnosed older-aged NVAF patients initiating dabigatran incurred significantly lower adjusted all-cause HRU and costs than warfarin and rivaroxaban patients but higher adjusted HRU and costs than apixaban patients.

Mitral valve repair using edge-to-edge technique in various situations: real-world experiences.

OBJECTIVES: Edge-to-edge (E2E) mitral valve repair (MVP) is a versatile technique used in various situations for mitral regurgitation (MR). This technique has been regaining attention, given the increasing use of the MitraClip procedure. This real-world study evaluates the durability of the E2E technique in different settings. METHODS: From January 2002 to May 2015, a total of 303 patients with at least moderate MR who underwent E2E MVP were identified. Patients undergoing isolated MVP (n = 133) and concomitant coronary artery bypass grafting or other valvular procedures (N = 170) were included. Cox proportional hazards modelling was used to evaluate the risk factors for cumulative survival, or MV event (i.e. MV reintervention or MR recurrence) while event-free survival-defined as time to composite outcome of either death or MV event-was determined using competing risk Kaplan-Meier analysis. Median follow-up duration was 6.9 (interquartile range 5.8) years. RESULTS: The most common MR aetiology was myxomatous (34%), followed by Barlow's disease (27.7%), and ischaemic (21.5%). E2E MVP was performed for the following indications: persistent MR (51.5%), systolic anterior motion prophylaxis (22.1%), transaortic approach (17.5%) and systolic anterior motion treatment post-MVP (8.9%). Concomitant ring annuloplasty was performed in 224 patients (73.9%). Operative mortality was 3.6% and MV event rate was 18.5%. Significant predictors of decreased survival included age, renal insufficiency, peripheral vascular disease and ischaemic MR aetiology (all P < 0.050). No ring annuloplasty (HR 2.79; P < 0.001) was the only significant predictor of MV events. Estimated event-free survival for the overall cohort was 8.5 years, and shortest for functional (non-ischaemic; 6.6 years) and ischaemic aetiology (5.5 years). CONCLUSIONS: E2E repair is a versatile MVP technique, which can be used in prevention and treatment of systolic anterior motion, transaortic approach or with concomitant techniques, with reasonable outcomes. Ischaemic aetiology and absence of ring annuloplasty were associated with worse cumulative survival and MV event rates, respectively, which raises some concern in light of the expanding indication for MitraClip system.

Clinical Significance of Greater Implantation Height with SAPIEN 3 Transcatheter Heart Valve.

BACKGROUND: A lower rate of permanent pacemaker (PPM) has been linked to a target aortic implantation height (AIH) >0.70, following transcatheter aortic valve replacement (TAVR) with the SAPIEN 3 valve. Based on clinical experience, it was hypothesized that a higher AIH (≥0.85) would lower the rate of PPM implantation. METHODS: A total of 127 patients (66 females, 61 males; mean age 82 ± 8 years) underwent TAVR with the SAPIEN 3 valve between May 2015 and July 2016. AIH was defined as the proportion of the valve frame above the aortic annulus in the post-deployment aortogram. A target AIH (≥0.70) was achieved in 113 patients (89%). Cases were stratified into a High Implantation (HI) group (AIH ≥0.85; 33 patients) or a Standard Implantation (SI) group (AIH <0.85; 94 patients). RESULTS: The mean Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) score of all patients was 6.4 ± 3.5%. Preoperative right bundle branch block (RBBB) was prevalent in 13% of SI patients, and in 18% of HI patients (p = 0.56). There were no significant differences in operative mortality (3.2% versus 0%), median length of stay (2 days versus 3 days) and incidence of moderate-to-severe paravalvular leak (3.2% versus 0%; all p >0.410) between SI and HI patients, respectively. Likewise, the incidence of new PPM did not differ between the two groups (12% in HI versus 13% in SI; p ≥0.99). The mean AIH was similar for patients with PPM implantation (0.80 ± 0.08) compared to those without (0.78 ± 0.06; p = 0.520). Preoperative RBBB was significantly associated with PPM implantation (odds ratio (OR) 10.1; p = 0.002), and patients who underwent PPM implantation had a higher operative mortality (12.5% versus 1%; p = 0.040). CONCLUSIONS: Among TAVR patients who received the SAPIEN 3 heart valve, a higher AIH (≥0.85) was not associated with a lower rate of PPM implantation or increased operative mortality. Prior RBBB was the only independent risk factor for new PPM implantation. Long-term follow up is crucial in determining the clinical significance of PPM implantation.

Propensity Score Adjusted Comparison of Minimally Invasive versus Open Thymectomy in the Management of Early Stage Thymoma.

BACKGROUND: The benefits of minimally invasive versus open thymectomy for the management of thymoma are debatable. Further, patient factors contributing to the selection of operative technique are not well elucidated. We aim to identify the association between baseline patient characteristics with choice of surgical approach. METHODS: Medical records of early stage thymoma (stages I and II) patients undergoing thymectomy between 2005 and 2015 at a single center were identified. Baseline characteristics and surgical outcomes such as prolonged length of stay (LOS ≥ 4 days), 90-day postoperative morbidity, completeness of resection, and recurrence or mortality free rates were compared by surgical approach. RESULTS: Fifty-three patients underwent thymectomy (34 open [64.15%] vs. 19 minimally invasive [35.85%]). There were no statistical differences between the two surgical approaches in demographic variables, smoking status, lung function, comorbidity, tumor size, or staging. Open thymectomy had significantly prolonged LOS (≥4 days) compared with minimally invasive procedures (odds ratio: 11.65; p < 0.01). There were no significant differences in postoperative composite morbidity (p = 0.56), positive margin (p = 0.40), tumor within 0.1 cm of resection margin (p = 0.38), and survival probability estimates (log rank test; p = 0.48) between the two groups. CONCLUSION: Baseline patient characteristics were not associated with surgical approach selected for thymectomy. Minimally invasive thymectomy patients had shorter LOS but no significant differences in 90-day composite morbidity and recurrence or mortality. Larger multicenter studies are needed to evaluate factors contributing to patient selection for each approach, which may include surgeon preference.

Outcomes of surgical and transcatheter aortic valve replacement in the octogenarians-surgery still the gold standard?

BACKGROUND: Contemporary options for aortic valve replacement (AVR) include transcatheter and surgical approaches (TAVR and SAVR). As evidence accrues for TAVR in high and intermediate risk patients, some clinicians advocate that all patients aged over 80 years should only receive TAVR. Our aim was to investigate the utility of SAVR and minimally invasive AVR (mAVR) among octogenarians in the current era of TAVR. METHODS: From 2002 to 2015, 1,028 octogenarians underwent isolated AVR; 306 TAVR and 722 SAVR, of which 378 patients underwent mAVR. Logistic regression and Cox modeling were used to evaluate overall operative mortality and mid-term survival, respectively. Patients were stratified based on procedural approaches (mAVR or full sternotomy for SAVR, and transfemoral or alternate access for TAVR). Median follow-up was 35 [interquartile range (IQR) 14-65] months. RESULTS: Compared to SAVR patients, TAVR patients were relatively older (86.2 versus 84.2 years) with co-morbidities such as chronic kidney disease (CKD), diabetes mellitus (DM), cerebrovascular disease (CVD), and prior myocardial infarction (MI), all P<0.05. The mean STS-PROM for the TAVR group was statistically higher, 6.81 versus 5.58 for the SAVR group (P<0.001). The median in-hospital LOS was statistically higher for the SAVR group (P<0.05). Cox proportional hazard modeling, adjusted for temporal differences in procedure and patient selection, identified age, New York Heart Association (NYHA) class III/IV, preoperative creatinine, severe chronic lung disease, prior cardiac surgery as significant predictors of decreased survival (all P<0.05), while type of intervention (approach) was non-contributory. Adjusted operative mortality stratified by procedure approaches was similar between full sternotomy SAVR and mAVR, and between alternative access and transfemoral TAVR. CONCLUSIONS: After adjusting for confounders, TAVR (regardless of approach), SAVR, and mAVR had comparable operative mortality and mid-term survival. Treatment decisions should be individualized with consensus from a multi-disciplinary heart team, taking into account patient co morbidities, frailty, and quality of life. We believe certain patient groups will still benefit from SAVR even in this elderly population.

Patient driven care in the management of prostate cancer: analysis of the United States military healthcare system.

BACKGROUND: Patient preferences are assumed to impact healthcare resource utilization, especially treatment options. There is limited data exploring this phenomenon. We sought to identify factors associated with patients transferring care for prostatectomy, from military to civilian facilities, and the receipt of minimally invasive radical prostatectomy (MIRP). METHODS: Retrospective review of 2006-2010 TRICARE data identified men diagnosed with prostate cancer (ICD-9 185) receiving open radical prostatectomy (ORP; ICD-9: 60.5) or MIRP (ICD-9 60.5 + 54.21/17.42). Patients diagnosed at military facilities but underwent surgery at civilian facilities were defined as "transferring care". Logistic regression models identified predictors of transferring care for patients diagnosed at military facilities. A secondary analysis identified the predictors of MIRP receipt at civilian facilities. RESULTS: Of 1420 patients, 247 (17.4%) transferred care. These patients were more likely to undergo MIRP (OR = 7.83, p < 0.01), and get diagnosed at low-volume military facilities (OR = 6.10, p < 0.01). Our secondary analysis demonstrated that transferring care was strongly associated with undergoing MIRP (OR = 1.51, p = 0.04). CONCLUSIONS: Patient preferences induced a demand for greater utilization of MIRP and civilian facilities. Further work exploring factors driving these preferences and interventions tailoring them, based on evidence and cost considerations, is required.

The impact of hepatitis C virus infection on 90-day outcomes following major orthopaedic surgery: a propensity-matched analysis.

INTRODUCTION: The impact of hepatitis C virus (HCV) infection on outcomes following major orthopaedic interventions, such as joint arthroplasty or spine surgery, has not been effectively studied in the past. Most prior studies are impaired by small samples, limited surveillance for adverse events, or the potential for selection bias to confound results. In this context, we sought to evaluate the impact of HCV infection on 90-day outcomes following joint arthroplasty or spine surgery using propensity-matched techniques. MATERIALS AND METHODS: This study utilized 2006-2014 claims from TRICARE insurance. Adults who received spine surgical procedures, total knee and hip arthroplasty were identified. Covariates included demographic factors, a diagnosis of HCV and medical co-morbidities defined by International Classification of Disease-9th revision (ICD-9) code. Outcomes consisted of 30- and 90-day mortality, complications and readmission. A propensity score was used to balance the cohorts with logistic regression techniques employed to determine the influence of HCV infection on post-operative outcomes. RESULTS: The propensity-matched cohort consisted of 2262 patients (1131 with and without HCV). Following logistic regression, patients with HCV were found to have increased odds of 30-day complications (OR 1.87; 95% CI 1.33, 2.64; p < 0.001), 90-day complications (OR 1.55; 95% CI 1.16, 2.08; p = 0.003) and 30-day readmission (OR 1.46; 95% CI 1.04, 2.05; p = 0.03). CONCLUSION: HCV infection was found to increase the risk of complication and readmission following spine surgery and total joint arthroplasty. Patients should be counseled on their increased risk prior to surgery. Health systems that treat a higher percentage of patients with HCV need to consider the increased risk of complications and readmission when negotiating with insurance carriers.

Patterns of use and factors associated with early discontinuation of opioids following major trauma.

BACKGROUND: Inappropriate use of prescription opioids is a growing public-health issue. We sought to estimate the proportion of traumatic injury patients using legal prescription opioids up to 1-year after hospitalization. METHODS: We used 2006-2014 claims data from TRICARE insurance to identify adults hospitalized secondary to trauma between 2007 and 2013. Prescription opioid use was evaluated for one-year post-discharge. Risk-adjusted Cox Proportional-hazards models were used to evaluate predictors of opioid discontinuation. RESULTS: Only 1% of patients sustained legal prescription opioid use at 1-year following trauma. Lower socioeconomic status (HR 0.92, 95% CI 0.87-0.98) and higher injury severity (HR 0.88, 95% CI 0.84-0.91) were associated with sustained use. Younger patients (HR 1.12, 95% CI 1.04-1.21) and Black patients (HR 1.09, 95% CI 1.04-1.15) were found to have a higher likelihood of opioid discontinuation. CONCLUSIONS: In this population, adult patients who sustained trauma were not at high risk of sustained legal prescription opioid use.

Length of Stay and Cost in Patients Undergoing Orthognathic Surgery: Does Surgeon Volume Matter?

PURPOSE: The relations among procedure-specific annual surgeon volume, hospital length of stay (LOS), and hospital costs for patients undergoing the 2 most common orthognathic surgical (OGS) procedures, segmental osteoplasty or osteotomy of the maxilla (SOM) or open osteoplasty or osteotomy of the mandibular ramus (SOMR), are not known. The authors hypothesized that treatment by high-volume surgeons would be associated with decreased LOS and costs. MATERIALS AND METHODS: All patients 8 to 64 years old who underwent elective SOM or SOMR were selected from the 2001 to 2009 Nationwide Inpatient Sample. Patients with missing vital status or payment mode status or who underwent more than 1 OGS procedure during the index hospitalization were excluded. Based on year- and procedure-specific annual surgeon volumes, the highest (highest quartile) and lowest (lowest quartile) procedure volume surgeon groups were compared. Multivariable logistic regression was used to study the relation between surgeon volume and extended patient LOS (defined as LOS ≥ 75th percentile). Generalized linear models with a log-link and gamma distribution were used to examine the association between surgeon volume and hospital costs. Models were adjusted for patient- and hospital-level factors and type of procedure (SOM or SOMR). Analysis was weighted to represent national-level estimates and an α value of 0.05 was used for all comparisons. RESULTS: After weighting to the population level, 8,062 patients were included for study. Most were white (80.6%), female (61.4%), and privately insured (84.6%). Mean age was 26 years (standard deviation, 0.38 yr). After adjusting for potential confounders, patients treated by high-volume surgeons showed 40% lower odds of extended LOS (odds ratio = 0.60; 95% confidence interval [CI], 0.38-0.95; P = .032) and incurred substantially lower costs (-$1,484.74; 95% CI, -2,782.76 to -185.58; P = .025) compared with patients treated by low-volume surgeons. CONCLUSION: These findings suggest that regionalization of patients to high-volume surgeons for OGS procedures could decrease LOS and incurred costs.

Incidence and Predictors of Opioid Prescription at Discharge After Traumatic Injury.

IMPORTANCE: In the current health care environment with increased scrutiny and growing concern regarding opioid use and abuse, there has been a push toward greater regulation over prescriptions of opioids. Trauma patients represent a population that may be affected by this regulation, as the incidence of pain at hospital discharge is greater than 95%, and opioids are considered the first line of treatment for pain management. However, the use of opioid prescriptions in trauma patients at hospital discharge has not been explored. OBJECTIVE: To study the incidence and predictors of opioid prescription in trauma patients at discharge in a large national cohort. DESIGN, SETTING, AND PARTICIPANTS: Analysis of adult (18-64 years), opioid-naive trauma patients who were beneficiaries of Military Health Insurance (military personnel and their dependents) treated at both military health care facilities and civilian trauma centers and hospitals between January 1, 2006, and December 31, 2013, was conducted. Patients with burns, foreign body injury, toxic effects, or late complications of trauma were excluded. Prior diagnosis of trauma within 1 year and in-hospital death were also grounds for exclusion. Injury mechanism and severity, comorbid conditions, mental health disorders, and demographic factors were considered covariates. The Drug Enforcement Administration's list of scheduled narcotics was used to query opioid use. Unadjusted and adjusted logistic regression models were used to determine the predictors of opioid prescription. Data analysis was performed from June 7 to August 21, 2016. EXPOSURES: Injury mechanism and severity, comorbid conditions, mental health disorders, and demographic factors. MAIN OUTCOMES AND MEASURES: Prescription of opioid analgesics at discharge. RESULTS: Among the 33 762 patients included in the study (26 997 [80.0%] men; mean [SD] age, 32.9 [13.3] years), 18 338 (54.3%) received an opioid prescription at discharge. In risk-adjusted models, older age (45-64 vs 18-24 years: odds ratio [OR], 1.28; 95% CI, 1.13-1.44), marriage (OR, 1.26; 95% CI, 1.20-1.34), and higher Injury Severity Score (≥9 vs <9: OR, 1.40; 95% CI, 1.32-1.48) were associated with a higher likelihood of opioid prescription at discharge. Male sex (OR, 0.76; 95% CI, 0.69-0.83) and anxiety (OR, 0.82; 95% CI, 0.73-0.93) were associated with a decreased likelihood of opioid prescription at discharge. CONCLUSIONS AND RELEVANCE: The incidence of opioid prescription at discharge (54.3%) closely matches the incidence of moderate to severe pain in trauma patients, indicating appropriate prescribing practices. We advocate that injury severity and level of pain-not arbitrary regulations-should inform the decision to prescribe opioids.

State-level geographic variation in prompt access to care for children after motor vehicle crashes.

BACKGROUND: Motor vehicle crashes (MVCs) are a principal cause of death in children; fatal MVCs and pediatric trauma resources vary by state. We sought to examine state-level variability in and predictors of prompt access to care for children in MVCs. MATERIALS AND METHODS: Using the 2010-2014 Fatality Analysis Reporting System, we identified passengers aged <15 y involved in fatal MVCs (crashes on US public roads with ≥1 death, adult or pediatric, within 30 d). We included children requiring transport for medical care from the crash scene with documented time of hospital arrival. Our primary outcome was transport time to first hospital, defined as >1 or ≤1 h. We used multivariable logistic regression to establish state-level variability in the percentage of children with transport time >1 h, adjusting for injury severity (no injury, possible injury, suspected minor injury, suspected severe injury, fatal injury, and unknown severity), mode of transport (emergency medical services [EMS] air, EMS ground, and non-EMS), and rural roads. RESULTS: We identified 18,116 children involved in fatal MVCs from 2010 to 2014; 10,407 (57%) required transport for medical care. Median transport time was 1 h (interquartile range: [1, 1]; range: [0, 23]). The percent of children with transport time >1 h varied significantly by state, from 0% in several states to 69% in New Mexico. Children with no injuries identified at the scene and crashes on rural roads were more likely to have transport times >1 h. CONCLUSIONS: Transport times for children after fatal MVCs varied substantially across states. These results may inform state-level pediatric trauma response planning.

Factors Associated with Pediatric Mortality from Motor Vehicle Crashes in the United States: A State-Based Analysis.

OBJECTIVE: To examine geographic variation in motor vehicle crash (MVC)-related pediatric mortality and identify state-level predictors of mortality. STUDY DESIGN: Using the 2010-2014 Fatality Analysis Reporting System, we identified passengers <15 years of age involved in fatal MVCs, defined as crashes on US public roads with ≥1 death (adult or pediatric) within 30 days. We assessed passenger, driver, vehicle, crash, and state policy characteristics as factors potentially associated with MVC-related pediatric mortality. Our outcomes were age-adjusted, MVC-related mortality rate per 100 000 children and percentage of children who died of those in fatal MVCs. Unit of analysis was US state. We used multivariable linear regression to define state characteristics associated with higher levels of each outcome. RESULTS: Of 18 116 children in fatal MVCs, 15.9% died. The age-adjusted, MVC-related mortality rate per 100 000 children varied from 0.25 in Massachusetts to 3.23 in Mississippi (mean national rate of 0.94). Predictors of greater age-adjusted, MVC-related mortality rate per 100 000 children included greater percentage of children who were unrestrained or inappropriately restrained (P < .001) and greater percentage of crashes on rural roads (P = .016). Additionally, greater percentages of children died in states without red light camera legislation (P < .001). For 10% absolute improvement in appropriate child restraint use nationally, our risk-adjusted model predicted >1100 pediatric deaths averted over 5 years. CONCLUSIONS: MVC-related pediatric mortality varied by state and was associated with restraint nonuse or misuse, rural roads, vehicle type, and red light camera policy. Revising state regulations and improving enforcement around these factors may prevent substantial pediatric mortality.

Socioeconomic Status and Non-Fatal Adult Injuries in Selected Atlanta (Georgia USA) Hospitals.

BACKGROUND: Injury mortality data for adults in the United States and other countries consistently show higher mortality for those with lower socioeconomic status (SES). Data are sparse regarding the role of SES among adult, non-fatal US injuries. The current study estimated non-fatal injury risk by household income using hospital emergency department (ED) visits. METHODS: A total of 1,308,892 ED visits at 10 Atlanta (Georgia USA) hospitals from 2001-2004 (347,866 injuries) were studied. The SES was based on US census-block group income, with subjects assigned to census blocks based on reported residence. Logistic regression was used to determine risk by SES for injuries versus all other ED visits, adjusting for demographics, hospital, and weather. Supplemental analyses using hospital data from 2010-2013, without data on SES, were conducted to determine whether earlier patterns by race, age, and gender persisted. RESULTS: Risk for many injury categories increased with higher income. Odds ratio by quartiles of increasing income (lowest quartile as referent, 95% confidence interval [CI] given for upper most quartile) were 1.00, 1.23, 1.34, 1.40 (95% CI 1.36-1.45) for motor vehicle accidents; 1.00, 1.03, 1.11, 1.24 (95% CI 1.20-1.29) for being struck by objects; 1.00. 0.99, 1.04, 1.12 (95% CI 1.00-1.25) for suicide; and 1.00, 1.03, 1.05, 1.12 (95% CI 1.09-1.15) for falls. In contrast, decreased injury risk with increased household income was seen for assaults (1.00, 0.83, 0.73, 0.67 [95% CI 0.63-0.72], by increasing quartiles). These trends by income did not differ markedly by race and gender. Whites generally had less risk of injuries, with the exception of assaults and motor vehicle accidents. Males had higher risk of injury than females, with the exception of falls and suicide attempts. Patterns of risk for race, age, and gender were consistent between 2001-2004 and 2010-2013. CONCLUSION: For most non-fatal injuries, those with higher income had more risk of ED visits, although the opposite was true for assault. Hulland E , Chowdhury R , Sarnat S , Chang HH , Steenland K . Socioeconomic status and non-fatal adult injuries in selected Atlanta (Georgia USA) hospitals. Prehosp Disaster Med. 2017;32(4):403-413.

Healthy Worker Effect Phenomenon: Revisited with Emphasis on Statistical Methods - A Review.

Known since 1885 but studied systematically only in the past four decades, the healthy worker effect (HWE) is a special form of selection bias common to occupational cohort studies. The phenomenon has been under debate for many years with respect to its impact, conceptual approach (confounding, selection bias, or both), and ways to resolve or account for its effect. The effect is not uniform across age groups, gender, race, and types of occupations and nor is it constant over time. Hence, assessing HWE and accounting for it in statistical analyses is complicated and requires sophisticated methods. Here, we review the HWE, factors affecting it, and methods developed so far to deal with it.

Race-based differences in duration of stay among universally insured coronary artery bypass graft patients in military versus civilian hospitals.

BACKGROUND: Duration of stay for coronary artery bypass graft operation outcomes differs for black versus white patients, with differences often attributed to insurance. We examined black versus white differences in duration of stay among TRICARE-covered patients undergoing coronary artery bypass graft. METHODS: Patients aged 18-64 years with TRICARE who underwent isolated coronary artery bypass graft (ICD-9CM 36.10-36.20) between 2006-2010 and who identified as black or white race were identified. Negative binomial regression, stratified by sex and military versus civilian facility, examined the duration of stay controlling for patient- and hospital-level factors. RESULTS: Of 3,496 eligible patients, 2,904 underwent coronary artery bypass graft at 682 civilian and 592 at 11 military hospitals. Patients (mean age 56.2 years) were predominantly white (88.9%), male (88.7%), married (88.2%), and retired (87%). Black patients demonstrated longer duration of stay (8.6 vs 7.5 days, P > .001), and overall duration of stay was longer at military facilities (8.1 vs 7.5 days, P = .013). Among the men, mean duration of stay was 14% longer for black patients at civilian hospitals (95% confidence interval 1.07-1.22) with no race-based differences at military facilities. CONCLUSION: Among coronary artery bypass graft patients with TRICARE coverage, black, male patients demonstrated greater duration of stay at civilian facilities. Further work should examine care at military hospitals to elucidate factors that drive the apparent mitigation of race-related variability in duration of stay.

Exercise Capacity, Heart Failure Risk, and Mortality in Older Adults: The Health ABC Study.

INTRODUCTION: Data on the association between exercise capacity and risk for heart failure (HF) in older adults are limited. METHODS: This study examined the association of exercise capacity, and its change over time, with 10-year mortality and incident HF in 2,935 participants of the Health, Aging, and Body Composition Study without HF at baseline (age, 73.6 [SD=2.9] years; 52.1% women; 41.4% black; 58.6% white). This cohort was initiated in 1997-1998 and exercise capacity was evaluated with a long-distance corridor walk test (LDCW) at baseline and Year 4. Outcomes were collected in 2007-2008 and initial analysis performed in 2014. RESULTS: Ten-year incident HF for completers (n=2,245); non-completers (n=331); and those excluded from LDCW for safety reasons (n=359) was 11.4%, 19.2%, and 23.0%, respectively. The corresponding 10-year mortality was 27.9%, 41.1%, and 42.4%. In models accounting for competing mortality, the adjusted subhazard ratio for HF was 1.37 (95% CI=1.00, 1.88; p=0.049) in non-completers and 1.41 (95% CI=1.06, 1.89; p=0.020) in those excluded versus completers. Non-completers (adjusted hazard ratio, 1.49; 95% CI=1.21, 1.84; p<0.001) and those excluded (hazard ratio, 1.27; 95% CI=1.04, 1.55; p=0.016) had elevated mortality. In adjusted models, LDCW performance variables were associated mainly with mortality. Only 20-meter walking speed and resting heart rate retained prognostic value for HF. Longitudinal changes in LDCW did not predict subsequent incident HF or mortality. CONCLUSIONS: Completing an LDCW is strongly associated with lower 10-year mortality and HF risk in older adults. Therefore, walking capacity may serve as an early risk marker.

Posttraumatic Resuscitation Affects Stent Graft Sizing in Patients with Blunt Thoracic Aortic Injury.

Patients with blunt aortic injury often present to the emergency department in a relatively hypovolemic state. These patients undergo extensive inhospital resuscitation. The effect of posttraumatic resuscitation on aortic diameter has implications for stent graft sizing. The potential utility of repeat aortic imaging after resuscitation remains unclear. A retrospective chart review of all adult patients presenting to a Level I trauma center between the years 2007 and 2013 was performed. Fifty-three patients were identified with a diagnosis of traumatic aortic injury. Of those, 10 had 2 CT scans before aortic repair and were selected as the study population for analysis. After resuscitation, there was a significant increase in aortic diameter both proximal and distal to the aortic injury: proximal aortic diameter increase of 1.97 mm and distal aortic diameter increase of 1.48 mm. This retrospective study shows that after resuscitation, there is a significant increase in proximal and distal aortic diameter. Interval reimaging of the thoracic aorta may be beneficial after adequate stabilization of the patient's other injuries. In certain cases, more appropriate sizing may prevent a device-related complication.