L-2-hydroxyglutarate remodeling of the epigenome and epitranscriptome creates a metabolic vulnerability in kidney cancer models.

Tumor cells are known to undergo considerable metabolic reprogramming to meet their unique demands and drive tumor growth. At the same time, this reprogramming may come at a cost with resultant metabolic vulnerabilities. The small molecule L-2-hdroxyglutarate (L-2HG) is elevated in the most common histology of renal cancer. Similar to other oncometabolites, L-2HG has the potential to profoundly impact gene expression. Here, we demonstrate that L-2HG remodels amino acid metabolism in renal cancer cells through the combined effects on histone methylation and RNA N6-methyladenosine (m6A). The combined effects of L-2HG result in a metabolic liability that renders tumors cells reliant on exogenous serine to support proliferation, redox homeostasis, and tumor growth. In concert with these data, high L-2HG kidney cancers demonstrates reduced expression of multiple serine biosynthetic enzymes. Collectively, our data indicate that high L-2HG renal tumors could be specifically targeted by strategies that limit serine availability to tumors.

Short- and Long-Term Survival of Metastatic Biliary Tract Cancer in the United States From 2000 to 2018.

INTRODUCTION: Information about survival outcomes in metastatic biliary tract cancer (BTC) is sparse, and the numbers often quoted are based on reports of clinical trials data that may not be representative of patients treated in the real world. Furthermore, the impact of more widespread adoption of a standardized combination chemotherapy regimen since 2010 on survival is unclear. METHODS: We performed an analysis of the Surveillance, Epidemiology, and End Results database to determine the real-world overall survival trends in a cohort of patients with metastatic BTC diagnosed between the years 2000 and 2017 with follow-up until 2018. We analyzed data for the entire cohort, evaluated short-term and long-term survival rates, and compared survival outcomes in the pre-2010 and post-2010 periods. Survival analysis was performed using the Kaplan-Meier method, and Cox proportional hazard models were used to evaluate factors associated with survival. RESULTS: Among 13, 287 patients, the median age was 68 years. There was a preponderance of female (57%) and white (77%) patients. Forty-one percent died within 3 months of diagnosis (short-term survivors) and 20% were long-term survivors (12 months or longer). The median overall survival (OS) for the entire cohort was 4.5 months. Median OS improved post-2010 (4.5 months) compared to pre-2010 (3.5 months) (P < .0001). On multivariate analysis, age <55 years, intrahepatic cholangiocarcinoma, surgical resection, and diagnosis post-2010 were associated with lower hazard of death. CONCLUSION: The real-world prognosis of metastatic BTC is remarkably poorer than described in clinical trials because a large proportion of patients survive less than three months. Over the last decade, the improvement in survival has been minimal.

Evaluating the consistency with guideline recommendations for diagnosis and management of idiopathic pulmonary fibrosis in non-academic settings.

BACKGROUND: Idiopathic pulmonary fibrosis (IPF) is a progressive lung disease with elevated mortality. Delay in diagnosis lead to worse outcomes. Guidelines developed at academic medical centers are difficult to replicate in the community. OBJECTIVES: Our primary objective was to ascertain consistency with the 2011 IPF guidelines. Our secondary objective was to conduct an interdisciplinary review to ascertain whether the evidence supported the original diagnosis of IPF or not. METHODS: We asked permission from pulmonologists to review records of patients diagnosed with IPF after 2011. We collected physician demographics and training data; patient demographics, clinical and diagnostic/management data. The clinical data and available images were reviewed by the interdisciplinary review panel. RESULTS: 26 practicing pulmonologists located in the Southeast of the United States consented to participate. Mean age was 48, 70% were male and all had current certification. We reviewed data from 96 patients. The mean age was 71.4 and most were male. Only 23% had the recommended screening for a connective tissue disease and 42.6% were screened for exercise-induced hypoxemia. Among patients with available images for review (n=66), only 50% had a high-resolution CT scan. 22% of patients underwent a surgical biopsy and in only 33% of the cases three lobes were sampled. No patient had documentation that a multidisciplinary discussion occurred. In 20% of the cases with available images, the evidence supported an alternative diagnosis. 56% of eligible candidates were ever started on anti-fibrotics. CONCLUSIONS: Our findings suggest that consistency with the IPF guidelines is low in non-academic settings.

Time to treatment initiation and its impact on real-world survival in metastatic colorectal cancer and pancreatic cancer.

BACKGROUND: Given the dearth of data regarding the time to treatment initiation (TTI) in the palliative setting, and its impact on survival outcomes, we sought to determine TTI in a real-world cohort of metastatic colorectal cancer (mCRC) and metastatic pancreatic cancer (mPC) patients and evaluate the impact of TTI on real-world survival outcomes. METHODS: We collected survival and treatment data for mCRC and mPC from the Flatiron Health electronic health records (EHR) derived database. We divided TTI into 3 categories: < 2 weeks, 2-< 4 weeks, and 4-8 weeks, from diagnosis to first-line therapy. Outcome measures were median TTI, real-world overall survival (RW-OS) based on TTI categories by Kaplan-Meier method, and impact of TTI on survival using cox proportional hazard models. RESULTS: Among 7108 and 3231 patients with mCRC and mPC treated within 8 weeks of diagnosis, the median TTI were 28 days and 20 days. Median RW-OS for mCRC was 24 months; 26.9 months versus 22.6 and 18.05 months in the 4-8-week, 2-< 4 week (control) and < 2-week groups, respectively (p < 0.0001). For mPC, median RW-OS was 8 months, without significant difference in RW-OS among the groups (p = 0.05). The 4-8-week group was associated with lower hazard of death (HR 0.782, 95% CI 0.73-0.84, p < 0.0001) and the < 2-week group was associated with a higher hazard of death (HR 1.26, 95% CI 1.15-1.38, p < 0.0001) in mCRC. The 4-8-week group was associated with lower hazard of death for mPC (HR 0.88, 95% CI 0.8-0.97, p = 0.0094). CONCLUSION: In a real-world cohort of patients treated within 8 weeks of diagnosis, and with the limitations of a retrospective study, later TTI did not have a negative impact on survival outcomes in mCRC and mPC.

Disparities in Healthcare Utilization: Superfund Site vs. Neighboring Comparison Site.

Inequities in pollution-attributable health disparities are similar in most urban areas throughout the United States, and appear to encompass racial and socio-demographic differences, thereby suggesting increased health risks for those living in these areas. Individuals residing in close proximity to Superfund sites, predominantly people of color, are increasingly stricken with lung diseases. The prevalence of chronic lung diseases, such as chronic obstructive pulmonary disease (COPD), asthma in children, and lower respiratory tract infections (LRTI), is significantly higher in the affected area compared to the neighboring control area, irrespective of smoking, socio-economic status, or demographics. We conducted a retrospective analysis using data collected from patients who obtained healthcare from the University of Alabama at Birmingham (UAB) Health System. The data were procured from the Enterprise Data Warehouse (UAB Informatics for Integrating Biology and the Bedside (i2b2)). We evaluated healthcare utilization and classification of disease (defined by ICD-10 codes) of patients residing in zip codes: affected (35207, 35217) and neighboring comparison (35214). The results of the analysis may provide evidence that can be used for risk mitigation strategies or outreach education campaign(s) for those who live in the affected area.

Dietary Patterns and Prevalent NAFLD at Year 25 from the Coronary Artery Risk Development in Young Adults (CARDIA) Study.

The prevalence of nonalcoholic fatty liver disease is rapidly rising. We aimed to investigate associations of diet quality and dietary patterns with nonalcoholic fatty liver disease (NAFLD) in Black and White adults. We included 1726 participants who attended the Year 20 Exam of the Coronary Artery Risk Development in Young Adults (CARDIA) study and had their liver attenuation (LA) measured using computed tomography at Year 25 (2010-2011). NAFLD was defined as an LA of ≤51 Hounsfield units after the exclusion of other causes of liver fat. The a priori diet-quality score (APDQS) was used to assess diet quality, and dietary patterns were derived from principal components analysis. Univariate and multivariable logistic regression models were used to evaluate the association between the APDQS, dietary patterns, and NAFLD, and were adjusted for Year 20 covariates. NAFLD prevalence at Year 25 was 23.6%. In a model adjusted for age, race, sex, education, alcohol use, physical activity, smoking, and center at Year 25, the APDQS was inversely associated (p = 0.004) and meat dietary pattern was positively associated (p < 0.0001) with NAFLD, while the fruit-vegetable dietary pattern was not significantly associated (p = 0.40). These associations remained significant when additionally adjusting for comorbidities (type 2 diabetes mellitus, dyslipidemia, hypertension), however, significant associations were diminished after additionally adjusting for body mass index (BMI). Overall, this study finds that the APDQS and meat dietary patterns are associated with prevalent NAFLD in mid-life. The associations appear to be partially mediated through higher BMI.

Impact of Smoking Cessation Interventions Initiated During Hospitalization Among HIV-Infected Smokers.

INTRODUCTION: Smoking is a key determinant of mortality among people living with HIV (PLWH). METHODS: To better understand the effects of smoking cessation interventions in PLWH, we conducted a pooled analysis of four randomized controlled trials of hospital-initiated smoking interventions conducted through the Consortium of Hospitals Advancing Research on Tobacco (CHART). In each study, cigarette smokers were randomly assigned to usual care or a smoking cessation intervention. The primary outcome was self-reported past 30-day tobacco abstinence at 6-month follow-up. Abstinence rates were compared between PLWH and participants without HIV and by treatment arm, using both complete-case and intention-to-treat analyses. Multivariable logistic regression was used to determine the effect of HIV status on 6-month tobacco abstinence and to determine predictors of smoking cessation within PLWH. RESULTS: Among 5550 hospitalized smokers, there were 202 (3.6%) PLWH. PLWH smoked fewer cigarettes per day and were less likely to be planning to quit than smokers without HIV. At 6 months, cessation rates did not differ between intervention and control groups among PLWH (28.9% vs. 30.5%) or smokers without HIV (36.1% vs. 34.1%). In multivariable regression analysis, HIV status was not significantly associated with smoking cessation at 6 months. Among PLWH, confidence in quitting was the only clinical factor independently associated with smoking cessation (OR 2.0, 95% CI = 1.4 to 2.8, p < .01). CONCLUSIONS: HIV status did not alter likelihood of quitting smoking after hospital discharge, whether or not the smoker was offered a tobacco cessation intervention, but power was limited to identify potentially important differences. IMPLICATIONS: PLWH had similar quit rates to participants without HIV following a hospital-initiated smoking cessation intervention. The findings suggest that factors specific to HIV infection may not influence response to smoking cessation interventions and that all PLWH would benefit from efforts to assist in quitting smoking. TRIAL REGISTRATION: (1) Using "warm handoffs" to link hospitalized smokers with tobacco treatment after discharge: study protocol of a randomized controlled trial: NCT01305928. (2) Web-based smoking cessation intervention that transitions from inpatient to outpatient: NCT01277250. (3) Effectiveness of smoking-cessation interventions for urban hospital patients: NCT01363245. (4) Effectiveness of Post-Discharge Strategies for Hospitalized Smokers (HelpingHAND2): NCT01714323.

Centrilobular emphysema and coronary artery calcification: mediation analysis in the SPIROMICS cohort.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is associated with a two-to-five fold increase in the risk of coronary artery disease independent of shared risk factors. This association is hypothesized to be mediated by systemic inflammation but this link has not been established. METHODS: We included 300 participants enrolled in the SPIROMICS cohort, 75 each of lifetime non-smokers, smokers without airflow obstruction, mild-moderate COPD, and severe-very severe COPD. We quantified emphysema and airway disease on computed tomography, characterized visual emphysema subtypes (centrilobular and paraseptal) and airway disease, and used the Weston visual score to quantify coronary artery calcification (CAC). We used the Sobel test to determine whether markers of systemic inflammation mediated a link between spirometric and radiographic features of COPD and CAC. RESULTS: FEV1/FVC but not quantitative emphysema or airway wall thickening was associated with CAC (p = 0.036), after adjustment for demographics, diabetes mellitus, hypertension, statin use, and CT scanner type. To explain this discordance, we examined visual subtypes of emphysema and airway disease, and found that centrilobular emphysema but not paraseptal emphysema or bronchial thickening was independently associated with CAC (p = 0.019). MMP3, VCAM1, CXCL5 and CXCL9 mediated 8, 8, 7 and 16% of the association between FEV1/FVC and CAC, respectively. Similar biomarkers partially mediated the association between centrilobular emphysema and CAC. CONCLUSIONS: The association between airflow obstruction and coronary calcification is driven primarily by the centrilobular subtype of emphysema, and is linked through bioactive molecules implicated in the pathogenesis of atherosclerosis. TRIAL REGISTRATION: ClinicalTrials.gov: Identifier: NCT01969344 .

The Relationships of Expectancies With E-cigarette Use Among Hospitalized Smokers: A Prospective Longitudinal Study.

Background: Expectancies demonstrate cross-sectional associations with e-cigarette use, but the prospective relationships between expectancies and e-cigarette use are unknown. This study examined the longitudinal associations of expectancies with e-cigarette use among hospitalized tobacco cigarette smokers. Methods: E-cigarette expectancies (e-cigarette-specific Brief Smoking Consequences Questionnaire-Adult [BSCQ-A]), tobacco cigarette expectancies (tobacco-specific BSCQ-A), and number of days used e-cigarettes in the past 30 days were assessed at baseline hospitalization, 6-months post-hospitalization, and 12-months post-hospitalization among 978 hospitalized tobacco cigarette smokers. Expectancy difference scores (e-cigarette-specific expectancies minus tobacco-specific expectancies) were computed for each of the 10 BSCQ-A scales. Cross-lagged panel models tested the relationships between expectancy difference scores and number of days used e-cigarettes in the past 30 days for each of the 10 BSCQ-A scales. Results: Though some models revealed partial associations between expectancies and e-cigarette use, only one yielded results consistent with hypotheses. Greater e-cigarette use at baseline predicted greater expectancies that e-cigarettes taste pleasant as compared to tobacco cigarettes at 6 months, which then predicted greater e-cigarette use at 12 months. To a lesser degree greater expectancies that e-cigarettes taste pleasant as compared to tobacco cigarettes at baseline predicted greater e-cigarette use at 6 months, which then predicted greater expectancies that e-cigarettes taste pleasant as compared to tobacco cigarettes at 12 months. Conclusions: Expectancies that e-cigarettes provide similar or more pleasant taste sensations as compared to tobacco cigarettes may be both a cause and consequence of e-cigarette use. Focusing on the taste experience may prove most effective in modifying e-cigarette use behavior. Implications: The current study offers the first longitudinal examination of expectancies and e-cigarette use. Results suggest expectancies that e-cigarettes provide similar or more pleasant taste sensations relative to tobacco cigarettes are both a cause and consequence of e-cigarette use. Efforts that focus on the e-cigarette taste experience may prove most effective in modifying e-cigarette use behavior.

Persisting Racial Disparities in Total Shoulder Arthroplasty Utilization and Outcomes.

OBJECTIVE: The purpose was to study whether racial disparities in total shoulder arthroplasty (TSA) utilization and outcomes have declined over time. METHODS: We used the US Nationwide Inpatient Sample from 1998 to 2011. We used chi-squared test to compare characteristics, Cochran-Armitage test to compare utilization rates, and Cochran-Armitage test and logistic regression to compare time-trends in outcomes by race. RESULTS: From 1998 to 2011, 176,141 Whites and 7694 Blacks underwent TSA. Compared to Whites, Blacks who underwent TSA were younger (69.1 vs. 64.2 years; p < 0.0001), more likely to be female (54.9 vs. 71.0 %; p < 0.0001), and have rheumatoid arthritis or avascular necrosis as the underlying diagnosis (1.7 vs. 3.0 % and 1.7 vs. 6.1 %; p < 0.0001 for both) and a Deyo-Charlson index of 2 or higher (8.5 vs. 16.7 %; p < 0.0001). Compared to Whites, Blacks had much lower TSA utilization rate/100,000 in 1998 (2.97 vs. 0.83; p < 0.0001) and in 2011 (12.27 vs. 3.33; p < 0.0001); racial disparities increased from 1998 to 2011 (p < 0.0001). A higher proportion of Blacks than Whites had a hospital stay greater than median in 1998-2000, 62 vs. 51.4 % (p = 0.02), and in 2009-2011, 34.4 vs. 27.3 % (p < 0.0001); disparities did not change over time (p = 0.31). These disparities in utilization were borderline significant in adjusted analyses. There were no racial differences in proportion discharged to inpatient medical facility in 1998-2000, 15.2 vs. 15.0 % (p = 0.95), and in 2009-2011, 12.3 vs. 11.1 % (p = 0.37), respectively. CONCLUSIONS: We found increasing racial disparities in TSA utilization. Some disparities in outcomes exist as well. Patients, surgeons, and policy-makes should be aware of these findings and take action to reduce racial disparities.

A bundled care approach to patients with idiopathic pulmonary fibrosis improves transplant-free survival.

BACKGROUND: Idiopathic pulmonary fibrosis (IPF) is a chronic lung disease with poor prognosis and limited therapeutic options. The 2011 ATS/ERS/JRS/ALAT consensus statement provided a number of recommendations for the management of IPF patients. The primary objective of this study was to determine if "bundling" these recommendations in the management of patients with IPF impacts clinical outcomes. METHODS: We conducted a single center, retrospective cohort study of 284 patients diagnosed with IPF. The proposed bundle of care (BOC) components were: (1) visits to a specialized interstitial lung diseases clinic with evaluation of pulmonary function tests at least twice yearly; (2) referral to pulmonary rehabilitation yearly; (3) timed walk test yearly; (4) echocardiogram yearly; and (5) gastroesophageal reflux therapy. Each component of the BOC was given a score of "1" per year of follow up, and the average sum of the scores (ranging from 0 to 5) was determined for the entire period of follow-up (BOCS), as well as during the first year of follow-up (BOCY1). The primary outcome measure was transplant-free survival. RESULTS: Age, gender, smoking status, BMI, %FVC, %DLCO did not differ between levels of BOCS and BOCY1. Lowest BOCS (≤1) was associated with a lower transplant-free survival independent of age and %FVC compared to patients with the highest BOCS (>4) (HR 2.274, CI 1.12-4.64, p = 0.024). Lower BOCY1 was associated with a higher risk for transplant or death independent of age and %FVC in comparison to patients with highest BOCY1 (≤1 vs. >4, HR 2.23, p = 0.014; >1 to 2 vs. >4, HR 1.87, p = 0.011; >2 to 3 vs. >4, HR 1.72, p = 0.019). CONCLUSION: IPF patients with higher BOC scores had improved transplant-free survival. Prospective studies are needed to confirm these findings and determine the best strategies for the management of patients with IPF.

Sex differences in characteristics, utilization, and outcomes of patient undergoing total elbow arthroplasty: a study of the US nationwide inpatient sample.

The aim of this study was to compare patient characteristics, utilization rates, and outcomes after total elbow arthroplasty (TEA) by sex. We used the nationwide inpatient sample from 1998 to 2011 to study sex-related time trends in patient characteristics, comorbidity, and outcomes after TEA. We used chi-squared test, analysis of variance, and the Cochran-Armitage test to assess differences in utilization rates and characteristics over time by sex and logistic regression to compare mortality, discharge disposition, and the length of hospital stay by sex. Overall TEA utilization 0.45 in 1998 to 0.96 per 100,000 in 2011 (p < 0.0001). The utilization rates were significantly higher in females compared to males throughout the study period: 0.62 vs. 0.29 in 1998 (p < 0.0001) and 1.31 vs. 0.70 in 2011 (p < 0.0001). Compared to males, females undergoing TEA were more likely to be white (79.7 vs. 71.4 %; p < 0.0001), have rheumatoid arthritis (16.7 vs. 8.1 %; p < 0.0001), and have Deyo-Charlson index of 2 or more (11.3 vs. 5.9 %; p < 0.0001) and were older (63.5 vs. 51.4 years; p < 0.0001). Compared to males undergoing TEA, females had significantly lower mortality, 0.1 vs. 0.4 % (p = 0.03); lower proportion were discharged to home, 81.9 vs. 89.6 % (p < 0.0001), and fewer had has index hospital stay above the median, 30.0 vs. 33.0 % (p = 0.01); most differences were significant after multivariable adjustment. TEA utilization in the USA more than doubled in the last 14 years, with rates higher in females than males. Females had better outcomes after TEA than men. Preoperative risk communication should be sex-specific based on these data.

Time trends in total ankle arthroplasty in the USA: a study of the National Inpatient Sample.

The objective of this study was to assess the time trends in utilization, clinical characteristics, and outcomes of patients undergoing total ankle arthroplasty (TAA) in the USA. We used the Nationwide Inpatient Sample (NIS) data from 1998 to 2010 to examine time trends in the utilization rates of TAA. We used the Cochran Armitage test for trend to assess time trends across the years and the analysis of variance (ANOVA), Wilcoxon test, or chi-squared test (as appropriate) to compare the first (1998-2000) and the last time periods (2009-2010). TAA utilization rate increased significant from 1998 to 2010: 0.13 to 0.84 per 100,000 overall, 0.14 to 0.88 per 100,000 in females, and from 0.11 to 0.81 per 100,000 in males (p < 0.0001 for each comparison for time trends). Compared to the 1998-2000 period, those undergoing TAA in 2009-2010 were older (41% fewer patients <50 years, p < 0.0001), less likely to have rheumatoid arthritis as the underlying diagnosis (55% fewer patients, p = 0.0001), more likely to have Deyo-Charlson index of 2 or more (197% more, p = 0.0010), and had a shorter length of stay at 2.5 days (17% reduction, p < 0.0001). Mortality was rare ranging from 0 to 0.6% and discharge to inpatient facility ranged 12.6-14.1%; we noted no significant time trends in either (p > 0.05). The utilization rate of TAA increased rapidly in the USA from 1998 to 2010, but post-arthroplasty mortality rate was stable. Underlying diagnosis and medical comorbidity changed over time and both can impact outcomes after TAA. Further studies should examine how the outcomes and complications of TAA have evolved over time.

Persisting Racial Disparities in Total Shoulder Arthroplasty Utilization and Outcomes.

OBJECTIVE: The purpose was to study whether racial disparities in total shoulder arthroplasty (TSA) utilization and outcomes have declined over time. METHODS: We used the US Nationwide Inpatient Sample from 1998 to 2011.We used chi-squared test to compare characteristics, Cochran-Armitage test to compare utilization rates, and Cochran-Armitage test and logistic regression to compare time-trends in outcomes by race. RESULTS: From 1998 to 2011, 176,141 Whites and 7694 Blacks underwent TSA. Compared to Whites, Blacks who underwent TSA were younger (69.1 vs. 64.2 years; p<0.0001), more likely to be female (54.9 vs. 71.0 %; p<0.0001), and have rheumatoid arthritis or avascular necrosis as the underlying diagnosis (1.7 vs. 3.0%and 1.7 vs. 6.1 %; p<0.0001 for both) and a Deyo-Charlson index of 2 or higher (8.5 vs. 16.7 %; p<0.0001). Compared to Whites, Blacks had much lower TSA utilization rate/100,000 in 1998 (2.97 vs. 0.83; p<0.0001) and in 2011 (12.27 vs. 3.33; p<0.0001); racial disparities increased from 1998 to 2011 (p<0.0001). A higher proportion of Blacks than Whites had a hospital stay greater than median in 1998-2000, 62 vs. 51.4 % (p=0.02), and in 2009-2011, 34.4 vs. 27.3 % (p<0.0001); disparities did not change over time (p=0.31). These disparities in utilization were borderline significant in adjusted analyses. There were no racial differences in proportion discharged to inpatient medical facility in 1998-2000, 15.2 vs. 15.0 % (p=0.95), and in 2009-2011, 12.3 vs. 11.1%(p=0.37), respectively. CONCLUSIONS: We found increasing racial disparities in TSA utilization. Some disparities in outcomes exist as well. Patients, surgeons, and policy-makes should be aware of these findings and take action to reduce racial disparities.

Racial disparities in total ankle arthroplasty utilization and outcomes.

INTRODUCTION: The objective of this study was to examine the racial disparities in total ankle arthroplasty (TAA) utilization and outcomes. METHODS: We used the National Inpatient Sample (NIS) to study the time-trends. Race was categorized as White and Black. Utilization rates were calculated for the U.S. general population per 100,000. Hospital length of stay, discharge disposition and mortality after TAA were assessed. We used the Cochran Armitage trend test to assess time-trends from 1998 to 2011 and chi-square test to compare TAA utilization. We used analysis of variance or chi-squared test to compare the characteristics of Whites and Blacks undergoing TAA and logistic regression to compare mortality, length of stay and discharge to home versus medical facility. RESULTS: The mean ages for Whites undergoing TAA were 62 years and for Blacks was 52 years. Significant racial disparities were noted in TAA utilization rates (/100,000) in 1998, 0.14 in Whites vs. 0.07 in Blacks (P<0.0001; 2-fold) and in 2011, 1.17 in Whites vs. 0.33 in Blacks (P<0.0001; 4-fold). Racial disparities in TAA utilization increased significantly from 1998 to 2011 (P<0.0001). There was a trend towards statistical significance for the difference in the length of hospital stay in Blacks vs. Whites (52.9% vs. 44.3% with length of hospital stay higher than the median; P=0.08). Differences in the proportion discharged to an inpatient medical facility after TAA, 16.6% Blacks vs. 13.4% Whites, were not significant (P=0.36). CONCLUSIONS: This study demonstrated significant racial disparities with lower TAA utilization and suboptimal outcomes in Blacks compared to Whites. Further studies are needed to understand the mediators of these disparities and to assess whether these mediators can be targeted to reduce racial disparities in TAA.

Are there racial disparities in utilization and outcomes after total elbow arthroplasty?

The aim of the study was to assess racial disparities in utilization rates and outcomes after primary total elbow arthroplasty (TEA). We used the National Inpatient Sample from 1998 to 2010, a US national database. Patient characteristics, comorbidity and outcomes after TEA were assessed over time and differences by race studied over the study period. Cochran-Armitage test was used for time trends and logistic regression for the comparison of outcomes by race. In 1998, TEA utilization rate was 0.38/100,000 in Whites and 0.24/100,000 in Blacks (p = 0.002); in 2010, it was 0.91 and 0.59/100,000, respectively (p < 0.0001). White-Black disparity in TEA utilization was significant across 13 years (p = 0.03). Compared with White patients, Black patients undergoing TEA were younger (61.9 vs. 52 years; p < 0.0001), less likely to be female (70.6 vs. 61.4 %; p = 0.0007) and more likely to have rheumatoid arthritis as the underlying diagnosis (13.0 vs. 17.2 %; p = 0.036). Mortality was rare, 0.26 % in Blacks and 0.32 % in Whites (p = 0.83). Discharge to an inpatient facility was higher in White versus Black patients in unadjusted analyses (16.8 vs. 10.4 %; p = 0.003), but in analyses adjusted for age, sex, Deyo-Charlson index and the underlying diagnosis, the differences were no longer significant (p = 0.79). The length of hospital stay greater than the median stay was noted in 29.8 % Whites versus 31.2 % Blacks, respectively (p = 0.61). There was no evidence of White-Black disparity in hospital length of stay in 1998-2000 (p = 0.66) or 2009-2010 (p = 0.59) periods. In this study, we found persisting racial disparities in TEA utilization rates. No White-Black disparities were noted in TEA outcomes, except slight differences in discharge disposition.

Does hospital volume predict outcomes and complications after total shoulder arthroplasty in the US?

OBJECTIVE: To assess the association of hospital procedure volume for total shoulder arthroplasty (TSA) with patient outcomes and complications. METHODS: We used the US Nationwide Inpatient Sample from 1998-2011 to study the association of hospital annual TSA procedure volume with patient characteristics and TSA outcomes, including discharge disposition (home versus inpatient facility), length of index hospitalization, postarthroplasty periprosthetic fracture, and revision. Annual hospital TSA volume was categorized as <5, 5-9, 10-14, 15-24, and ≥25 TSA procedures annually. RESULTS: Patients receiving TSA at higher volume hospitals were more likely to be female (P < 0.0001) and white (P < 0.0001). Compared to low volume hospitals (<5, 5-9, or 10-14 procedures annually), patients receiving TSA at higher volume hospitals (15-24 or ≥25 procedures annually) had significantly lower likelihood of being discharged to an inpatient medical facility: 16.5%, 13.4%, 13.0%, 12.7%, and 11.5%, respectively (P < 0.0001); hospital stay above the overall median: 46.6%, 40.4%, 36.6%, 34.4%, and 29.2%, respectively (P < 0.0001); postarthroplasty fracture: 1.2%, 0.8%, 0.9%, 0.6%, and 0.8%, respectively (P = 0.0004); blood transfusion: 8%, 7.1%, 6.7%, 7.1%, and 5.5%, respectively (P = 0.006); and TSA revision: 0.5%, 0.3%, 0.2%, 0.3%, 0.3%, respectively (P = 0.045). CONCLUSION: In this study, we found that higher annual hospital TSA volume was associated with better TSA outcomes in the US. These findings document the impact of annual hospital TSA volume on TSA outcomes. Patients, surgeons, and policy-makers should be aware of these findings and take them into account in decision-making, policy decisions, and resource allocation.

Validity of claims-based stroke algorithms in contemporary Medicare data: reasons for geographic and racial differences in stroke (REGARDS) study linked with medicare claims.

BACKGROUND: The accuracy of stroke diagnosis in administrative claims for a contemporary population of Medicare enrollees has not been studied. We assessed the validity of diagnostic coding algorithms for identifying stroke in the Medicare population by linking data from the REasons for Geographic And Racial Differences in Stroke (REGARDS) Study to Medicare claims. METHODS AND RESULTS: The REGARDS Study enrolled 30 239 participants ≥45 years in the United States between 2003 and 2007. Stroke experts adjudicated suspected strokes, using retrieved medical records. We linked data for participants enrolled in fee-for-service Medicare to claims files from 2003 through 2009. Using adjudicated strokes as the gold standard, we calculated accuracy measures for algorithms to identify incident and recurrent strokes. We linked data for 15 089 participants, among whom 422 participants had adjudicated strokes during follow-up. An algorithm using primary discharge diagnosis codes for acute ischemic or hemorrhagic stroke (International Classification of Diseases, Ninth Revision, Clinical Modification codes: 430, 431, 433.x1, 434.x1, 436) had a positive predictive value of 92.6% (95% confidence interval, 88.8%-96.4%), a specificity of 99.8% (99.6%-99.9%), and a sensitivity of 59.5% (53.8%-65.1%). An algorithm using only acute ischemic stroke codes (433.x1, 434.x1, 436) had a positive predictive value of 91.1% (95% confidence interval, 86.6%-95.5%), a specificity of 99.8% (99.7%-99.9%), and a sensitivity of 58.6% (52.4%-64.7%). CONCLUSIONS: Claims-based algorithms to identify stroke in a contemporary Medicare cohort had high positive predictive value and specificity, supporting their use as outcomes for etiologic and comparative effectiveness studies in similar populations. These inpatient algorithms are unsuitable for estimating stroke incidence because of low sensitivity.