Neighborhood economic vulnerability as a predictor for patterns of care and outcomes for patients with uterine cancer.

OBJECTIVE: To quantify the effect of neighborhood socioeconomic vulnerability as it relates to racial disparity in uterine cancer treatment and survival. METHODS: Patients with a diagnosis of uterine cancer who underwent hysterectomy in New York State from 2004 to 2017 were included in this retrospective cohort study. Neighborhood socioeconomic vulnerability as quantified by the Area Deprivation Index was calculated. Primary outcome was guideline adherent treatment; secondary outcome was 5 year overall survival. RESULTS: A total of 34,356 patients were included in the final cohort. Residence within a vulnerable neighborhood was associated with a lower likelihood of receiving appropriate adjuvant chemotherapy (59.7% vs 75.7% with aRR = 0.81; 95% CI, 0.77-0.86) and timely surgery (63.7% vs. 74.5% with aRR = 0.85; 95% CI, 0.82-0.87). All-cause mortality was 24% higher for those who resided in vulnerable neighborhoods compared to affluent neighborhoods (aHR = 1.24; 95% CI, 1.16-1.32). The greatest Black/White racial disparity in 5 year overall survival was seen in the most affluent neighborhoods at 18.6%, with survival being 79.8% for White patients and 61.2% for Black patients (aHR 1.31; 95% CI 1.14-1.51). For patients with advanced stage disease, this disparity was driven by improved survival for White patients with increasing neighborhood affluence but no change in survival for Black patients. On adjusted analysis controlling for age, comorbidities, insurance, tumor histology, stage, and grade, the disparity remained widest in the most affluent neighborhoods in NYC (aHR = 1.59; 95%CI 1.26-1.2.01). CONCLUSIONS: Neighborhood socioeconomic vulnerability is associated with poor outcomes for patients with uterine cancer. The greatest Black/White survival disparities are in the wealthiest neighborhoods. Neighborhood affluence may not affect survival of Black patients with advanced stage endometrial cancer.

Serratus anterior plane block improves pain and incentive spirometry volumes in trauma patients with multiple rib fractures: a prospective cohort study.

Background: Rib fractures are common injuries associated with considerable morbidity, long-term disability, and mortality. Early, adequate analgesia is important to mitigate complications such as pneumonia and respiratory failure. Regional anesthesia has been proposed for rib fracture pain control due to its superior side effect profile compared with systemic analgesia. Our objective was to evaluate the effect of emergency physician-performed, ultrasound-guided serratus anterior plane block (SAPB) on pain and respiratory function in emergency department patients with multiple acute rib fractures. Methods: This was a prospective observational cohort study of adult patients at a level 1 trauma center who had two or more acute unilateral rib fractures. Eligible patients received a SAPB if an emergency physician trained in the procedure was available at the time of diagnosis. Primary outcomes were the absolute change in pain scores and percent change in expected incentive spirometry volumes from baseline to 3 hours after rib fracture diagnosis. Results: 38 patients met eligibility criteria, 15 received the SAPB and 23 did not. The SAPB group had a greater decrease in pain scores at 3 hours (-3.7 vs. -0.9; p=0.003) compared with the non-SAPB group. The SAPB group also had an 11% (CI 1.5% to 17%) increase in percent expected spirometry volumes at 3 hours which was significantly better than the non-SAPB group, which had a -3% (CI -9.1% to 2.7%) decrease (p=0.008). Conclusion: Patients with rib fractures who received SAPB as part of a multimodal pain control strategy had a greater improvement in pain and respiratory function compared with those who did not. Larger trials are indicated to assess the generalizability of these initial findings.

Disadvantaged groups have greater spatial access to pharmacies in New York state.

BACKGROUND: The accessibility of pharmacies has been associated with overall health and wellbeing. Past studies have suggested that low income and racial minority communities are underserved by pharmacies. However, the literature is inconsistent in finding links between area-level income or racial and ethnic composition and access to pharmacies. Here we aim to assess area-level spatial access to pharmacies across New York State (NYS), hypothesizing that Census Tracts with higher poverty rates and higher percentages of Black and Hispanic residents would have lower spatial access. METHODS: The population weighted mean shortest road network distance (PWMSD) to a pharmacy in 2018 was calculated for each Census Tract in NYS. This statistic was calculated from the shortest road network distance to a pharmacy from the centroid of each Census block within a tract, with the mean across census blocks weighted by the population of the census block. Cross-sectional analyses were conducted to assess links between Tract-level socio demographic characteristics and Tract-level PWMSD to a pharmacy. RESULTS: Overall the mean PWMSD to a pharmacy across Census tracts in NYS was 2.07 Km (SD = 3.35, median 0.85 Km). Shorter PWMSD to a pharmacy were associated with higher Tract-level % poverty, % Black/African American (AA) residents, and % Hispanic/Latino residents and with lower Tract-level % of residents with a college degree. Compared to tracts in the lowest quartile of % Black/AA residents, tracts in the highest quartile had a 70.7% (95% CI 68.3-72.9%) shorter PWMSD to a pharmacy. Similarly, tracts in the highest quartile of % poverty had a 61.3% (95% CI 58.0-64.4%) shorter PWMSD to a pharmacy than tracts in the lowest quartile. CONCLUSION: The analyses show that tracts in NYS with higher racial and ethnic minority populations and higher poverty rates have higher spatial access to pharmacies.

Chemical Profiles Differ between Communal Breeding Groups in a Highly Social Bird.

AbstractGregarious species must distinguish group members from nongroup members. Olfaction is important for group recognition in social insects and mammals but rarely studied in birds, despite birds using olfaction in social contexts from species discrimination to kin recognition. Olfactory group recognition requires that groups have a signature odor, so we tested for preen oil and feather chemical similarity in group-living smooth-billed anis (Crotophaga ani). Physiology affects body chemistry, so we also tested for an effect of egg-laying competition, as a proxy for reproductive status, on female chemical similarity. Finally, the fermentation hypothesis for chemical recognition posits that host-associated microbes affect host odor, so we tested for covariation between chemicals and microbiota. Group members were more chemically similar across both body regions. We found no chemical differences between sexes, but females in groups with less egg-laying competition had more similar preen oil, suggesting that preen oil contains information about reproductive status. There was no overall covariation between chemicals and microbes; instead, subsets of microbes could mediate olfactory cues in birds. Preen oil and feather chemicals showed little overlap and may contain different information. This is the first demonstration of group chemical signatures in birds, a finding of particular interest given that smooth-billed anis live in nonkin breeding groups. Behavioral experiments are needed to test whether anis can distinguish group members from nongroup members using odor cues.

Examining racial and ethnic heat exposure disparities in New York City (NYC) across different spatial and political scales through geographic effect measure modification.

Structural racism in the United States has resulted in neighborhoods with higher proportions of non-Hispanic Black (Black) or Hispanic/Latine residents having more features that intensify, and less that cool, the local-heat environment. This study identifies areas of New York City (NYC) where racial/ethnic heat exposure disparities are concentrated. We analyzed data from the 2013-2017 American Community Survey, U.S Landsat-8 Analysis Ready Data on summer surface temperatures, and NYC Land Cover Dataset at the census tract-level (n = 2098). Four cross-sectional regression modeling strategies were used to estimate the overall City-wide association, and associations across smaller intra-city areas, between tract-level percent of Black and percent Hispanic/Latine residents and summer day surface temperature, adjusting for altitude, shoreline, and nature-cover: overall NYC linear, borough-specific linear, Community District-specific linear, and geographically weighted regression models. All three linear regressions identified associations between neighborhood racial and ethnic composition and summer day surface temperatures. The geographically weighted regression models, which address the issue of spatial autocorrelation, identified specific locations (such as northwest Bronx, central Brooklyn, and uptown Manhattan) within which racial and ethnic disparities for heat exposures are concentrated. Through examining the overall effects and geographic effect measure modification across spatial scales, the results of this study identify specific geographic areas for intervention to mitigate heat exposure disparities experienced by Black and Hispanic/Latine NYC residents.

Military accession guidelines: An allergy focus.

Medical evaluation for military applicants is an intricate process that requires an understanding of the terminology, standards, and guidelines. Allergy providers are often called to provide medical evaluations for patients who desire to join the military services. Without understanding the complexities and nuances of military medical evaluations, a provider may delay or not be able to assist their patient in obtaining the desired goal of joining the services. This article reviews the terminology of military medical evaluations and the guidelines and processes for these evaluations. We also focus our discussion on common allergic conditions that may be disqualifying for service and provide expert opinions of the subtleties of these conditions to provide the allergist with a practical approach to medical evaluations. Finally, we provide a list of resources that are accessible to any provider engaged in military medical evaluations for accessions.

Association of physician malpractice claims rates with admissions for low-risk chest pain.

Background: Chest pain accounts for 5% of all emergency department visits and accounts for the highest malpractice payout against emergency physicians. To clarify the impact of defensive medicine, we assessed whether admission rates of low-risk chest pain patients are associated with malpractice claims rates. Methods: A cross-sectional time-series analysis of state-year level malpractice claims rates, admission rates for low-risk chest pain (LRCP; requiring ED physician discretion), and admission rates for acute myocardial infarction (AMI; requiring minimal physician judgment for admission, used as a control) from 2008 to 2017 was performed. Admission rates were derived from Optum's deidentified Clinformatics Data Mart Database. LRCP visits were defined by primary ICD-9 or ICD-10 codes of 786.5, R07.9, or R07.89; length of stay of 2 or fewer days; and no previous major cardiac diagnosis and AMI visits with ICD-9 or ICD-10 codes 410, I21.3, or I121.9. Malpractice claims rates (MPCRs) were derived from the National Practitioner Database (NPD). The association between state-year level MPCR and admission rates for LRCP and AMI was estimated using state fixed-effects models. Standardized costs were inflation adjusted and are expressed in US dollar rate as of 2019. Results: There were 40,482,813 ED visits during the 10-year study period, of which 2,275,757 (5.6%) were for chest pain, and 1,163,881 met LRCP criteria. Mean age of LRCP patients was 67.8 years, 60.9% were female, and 16.6% were hospitalized, at a mean cost of $17,120. During the same period, 75,266 (0.2%) visits were for AMI, with 87% admitted. The MPCR by state-year varied widely, from 2.6 to 8.6 claims per 100,000 population. A state fixed-effects model showed that an additional physician malpractice claim per 100,000 population was associated with a 3.66% (95% CI 2.02%-5.30%) increase in the admission rate of LRCP. An analogous model showed no association between MPCR and admission rates for AMI (-1.52%, 95% CI -4.06% to 1.02%). Conclusion: Higher MPCRs are associated with increased admission rates for LRCP, at substantial cost, which may be attributable to defensive medicine in the ED.

Cirugía coronaria sin circulación extracorpórea / Coronary surgery without extracorporeal circulation

Entre el 20 de marzo y el 30 de abril de 1996 se efectuó revascularización coronaria quirúrgica sin circulación extracorpórea en 12 pacientes, 8 hombres y 4 mujeres, con edad promedio de 64 años (DE 14,4). En la selección de los pacientes se exigió la presencia de enfermedad de 1 ó 2 vasos (ACD y/o ADA), lesiones en arterias superficiales de buen calibre y la ausencia de restricciones para revascularización completa y para uso de conductos arteriales. 5 pacientes tenían reestenosis post angioplastía, 6 pacientes tenían lesiones no tratables por angioplastía, 2 pacientes eligieron la operación con preferencia a angioplastía. En 9 pacientes se pretendía disminuir el riesgo de la circulación extracorpórea dada la existencia de insuficiencia renal, reducción de función ventricular, calcificación severa de la aorta, infarto en evolución o reoperación con arteria mamaria interna funcionante. Se logró revascularización completa en todos los casos: en 5 pacientes con enfermedad de 1 vaso se usó implante de arteria mamaria en 4. En 7 pacientes con enfermedad de 2 vasos se usó un total de 3 arterias mamarias y 10 venas safenas, 3 de las cuales procedían de criopreservado de cadáver. Se usó una esternotomía de 12 cm aproximadamente y se infundió esmolol,diltiazem, milrinona y neosinefrina induciendo bradicardia de 40 a 50 por minuto, sin observar evidencia de isquemia. No hubo mortalidad ni evidencia de infarto perioperatorio. Se efectuó una coronariografía a 6 meses de postoperatorio en todos los pacientes que recibieron arteria mamaria que mostró su permeabilidad de todos ellos. Un paciente debió ser sometido a angioplastía de coronaria derecha por estenosis asociada a un problema intraoperatorio. La estadía promedio en 9 pacientes que no tenían operación previa fue de 3,6 días. En conclusión la cirugía de revascularización coronaria sin circulación extracorpórea en pacientes bien seleccionados puede efectuarse con buenos resultados y con ahorro en el tiempo de estadía hospitalaria