Impact of COVID-19-Related Social Distancing on the Incidence of Inpatient Aggression at a Public Psychiatric Hospital.

OBJECTIVE: This study explores the impact of coronavirus disease (COVID) pandemic-related social distancing measures on the incidence of inpatient aggression at a public psychiatric hospital Methods: Data was gathered from the hospital's unusual incident (UI) database for the time period ranging from January 1, 2015, to December 31, 2020. Based on the implementation of major social distancing measures, March 6, 2020, was set as a cutoff time point to categorize aggressive events into pre-COVID and post-COVID groups. Data was analyzed using Chi-square tests and general linear modeling. The p-value was set at ≤0.05. RESULTS: After the implementation of social distancing measures, there was a decrease in the absolute number of inpatient aggressive events from 15.0/week to 12.6/week (mean difference: 2.4/week, p=0.032). However, this decrease was primarily attributable to a decrease in hospital census. There was a decrease in the proportion of seven-day and 14-day post-admission aggressive events by 5.4% and 12.1%, respectively. Concurrently, there was a 4.9% increase in recurrent aggression. Emergency psychiatric medication administration and the use of physical restraint decreased during the COVID-19 pandemic. CONCLUSION: Consistent with previous results, this study reports a decrease in the incidence of inpatient aggression during the COVID-19 pandemic. Social distancing measures can be utilized as a tool to decrease the incidence of inpatient aggression and the use of physical restraints.

Distinguishing Convulsive Syncope From Seizure Induced by Repetitive Transcranial Magnetic Stimulation: A Case Report.

ABSTRACT: Repetitive transcranial magnetic stimulation (rTMS) is Food and Drug Administration cleared for clinical use in treatment-resistant depression and a growing list of other disorders. The clinical uptake of rTMS has been facilitated by its relatively benign adverse-effect profile compared with other treatment modalities. Seizure is a rare but serious adverse event that has been reported with rTMS, when dosage exceeds safety guidelines or in individuals at increased risk for seizure. Fortunately, most rTMS-induced seizures are typically transient, with no adverse sequelae, but they may lead to treatment discontinuation. Seizure is not the only cause of loss of conscious and abnormal movements induced by rTMS. Convulsive syncope, a more common adverse event that involves loss of consciousness associated with myoclonic movements, can be difficult to differentiate from an rTMS-induced seizure. We report the case of a 52-year-old man with no known seizure risk factors, enrolled in an institutional review board-approved research study who developed what appeared to be a convulsive syncopal episode lasting 10 to 15 seconds during day 2 of a 30-day rTMS protocol (10 Hz, 120% of motor threshold, 4-second pulse train, 26-second intertrain interval, 3000 pulses per session), with no adverse sequelae. The patient's history, screening, physical examination, pertinent laboratory, neurology consult, electroencephalogram, and imaging findings are discussed. This case demonstrates that distinguishing between convulsive syncope and rTMS-induced seizure can be a diagnostic challenge. Clinicians and researchers delivering rTMS should be familiar with the risk factors for rTMS-induced seizures and rTMS-induced convulsive syncope, to screen for predisposing factors and to manage these rare adverse events if they occur.

Recent advances in electroconvulsive therapy in clinical practice and research.

Electroconvulsive therapy (ECT), the oldest somatic therapy still in use in psychiatry today, remains one of the most effective therapeutic interventions for a wide variety of psychiatric disorders. In this article, we review some of the recent advances in ECT that are currently being researched and implemented in clinical practice. We explore recent studies that point to the potential therapeutic benefit and safety of ECT in COVID-19-related neuropsychiatric complications and special populations (such as the elderly and pregnant persons) that are generally at higher risk of having adverse effects from psychotropic medications. We highlight studies that performed a head-to-head comparison of ECT and ketamine, which has shown promise for treatment-resistant depression and acute suicidality. Researchers continue to explore different ways of using ECT by modifying the treatment parameters to maintain efficacy and decrease side effects. Neurocognitive side effects remain one of the major drawbacks to its use and contribute to the negative stigma of this highly effective treatment. In this regard, we describe attempts to improve the safety of ECT by modifying dosing parameters, novel electrode placements, and the addition of augmenting agents with the aim of decreasing side effects and improving efficacy. This review identifies some of the recent advances in the last few years in ECT research while also highlighting areas where further research is needed.

Pandemics and Suicide Risk: Lessons From COVID and Its Predecessors.

ABSTRACT: In its mortality and global reach, COVID-19 is among the worst pandemics to hit the globe since the 1918 influenza. During a pandemic, it is not uncommon for deaths from suicide to be downplayed as communities respond to the immediate mortality of the disease. In this analysis, we review pandemic history to uncover its impact on suicide rates, a frequent proxy for community mental health, and whether public health responses were effective. We incorporate lessons from more than 100 years of epidemics to assess whether the current public health response can benefit from the lessons of history.

Decreased Racial and Ethnic Disparities in Emergency Department Wait Time in the United States.

BACKGROUND: Previous data over an extended period indicated that Black and Hispanic patients waited significantly longer than their White counterparts to see a qualified practitioner in US emergency departments (EDs). OBJECTIVE: The objective of this study was to assess recent trends and sources of racial and ethnic disparities in patient wait time to see a qualified practitioner in US EDs. DATA SOURCES: Publicly available ED subsample of the National Hospital Ambulatory Medical Care Survey (NHAMCS), 2003-2017. RESEARCH DESIGN: A retrospective cross-sectional analysis of a nationally representative sample of visits to US EDs from 2003 to 2017. Joinpoint statistical analysis and survey-weighted regression were used to assess changes in ED wait time by race/ethnic group over time. PRINCIPAL FINDINGS: For non-Hispanic White patients, median ED wait time increased annually by 1.3 minutes from 2003 through 2008, decreased by 3.0 minutes from 2008 through 2012, and decreased by 1.7 minutes from 2012 to 2017. For non-Hispanic Black patients, median wait time increased annually by 2.0 minutes from 2003 through 2008, decreased by 3.8 minutes from 2008 through 2015, and remained fairly unchanged from 2015 through 2017. For Hispanic patients, the trend in median wait time remained statistically unchanged from 2003 through 2009. It decreased by annually by 4.7 minutes from 2009 to 2012 and by 1.5 minutes from 2012 through 2017. By the end of 2017, median ED wait time decreased to under 20 minutes across all 3 groups. CONCLUSIONS: Over time, ED wait times decreased to under 20 minutes across all racial and ethnic groups between 2003 and 2017. Observed disparities were largely the result of where minority populations accessed care and disappeared over time.

United States' Performance on Emergency Department Throughput, 2006 to 2016.

STUDY OBJECTIVE: Studies of early data found that US emergency departments (EDs) were characterized by prolonged patient waiting, long visit times, frequent and prolonged boarding (ie, patients kept waiting in ED hallways or other space outside the ED on admission to the hospital), and patients leaving without receiving or completing treatment. We sought to assess recent trends in ED throughput nationally. METHODS: This was a retrospective cross-sectional analysis of data from the National Hospital Ambulatory Medical Care Survey from 2006 to 2016. We used survey-weighted generalized linear models to assess changes over time. The primary outcome variables were the number of visits, wait time to consult a physician, length of visit (time from arrival to leaving for home or hospital ward), boarding time, the proportion of patients leaving without being seen, the proportion treated within recommended waiting times, and the proportion dispositioned within 4, 6, and 8 hours. RESULTS: Between 2006 and 2016, the number of ED visits increased from 119.2 million to 145.6 million. During this period, annual median wait time decreased from 31 minutes (interquartile range 14 to 67) to 17 minutes (interquartile range 6 to 45). The proportion of patients who left without being seen declined from 2.0% (95% confidence interval [CI] 1.7% to 2.4%) to 1.1% (95% CI 0.8% to 1.4%). The proportion treated by a qualified practitioner within recommended waiting times increased from 75.5% (95% CI 72.7% to 78.3%) to 80.8% (95% CI 77.2% to 84.4%). Overall, there was no statistically significant change in median length of visit. However, over time, decreased proportions of the sickest patients were discharged within 4, 6, and 8 hours, whereas increased proportions of low-acuity patients were discharged within 4 hours. The distribution of patient boarding time remained fairly unchanged from 2009 to 2015, with a median of approximately 75 minutes. CONCLUSION: Overall, there was improvement in ED timeliness from 2006 to 2016. However, we observed a decrease in the proportion of the sickest patients discharged within 8 hours of arrival, although this may be due to increased ancillary testing or specially consultation over time.

Determinants of loss to follow-up among people living with HIV on antiretroviral therapy in Nigeria.

Background: Considerable success has been recorded in the global fight against the human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS). Retention in care is the key to the attainment of set goals in the fight against the disease. We aim to determine the factors associated with loss to follow-up (LTFU) among people living with HIV on antiretroviral therapy (ART) in a limited resource setting.Method: This was a retrospective cohort study that included adult patients who accessed ART at the study site between January 2005 and October 2018. A multivariate logistic regression model was used to obtain adjusted odds ratios and 95% confidence intervals of independent determinants of LTFU.Results: Of the 8 679 patients included in the study, 3 716 (43%) were males, 4 009 (46%) were enrolled during the years 2005 to 2008, 8 421 (97%) spent less than two hours travelling from their residence to the treatment centre, and 3 523 (41%) had their first-line ART regimen changed. Among the characteristics that determine LTFU were male patients (OR = 1.167, 95% CI: 1.071-1.272), and World Health Organization clinical stage 3 (OR = 2.091, 95% CI: 1.485-2.944).Conclusion: In our study, male gender, enrolment year 2005 to 2008, no change in first-line ART and nevirapine-based therapy were more likely to be associated with LTFU.

Self-reported obstructive sleep apnea, amyloid and tau burden, and Alzheimer's disease time-dependent progression.

INTRODUCTION: Obstructive sleep apnea (OSA) is associated with Alzheimer's disease (AD) biomarkers in cognitively normal (CN) and mild cognitive impaired (MCI) participants. However, independent and combined effects of OSA, amyloid beta (Aß) and tau-accumulation on AD time-dependent progression risk is unclear. METHODS: Study participants grouped by biomarker profile, as described by the A/T/N scheme, where "A" refers to aggregated Aß, "T" aggregated tau, and "N" to neurodegeneration, included 258 CN (OSA-positive [OSA+] [A+TN+ n = 10, A+/TN- n = 6, A-/TN+ n = 10, A-/TN- n = 6 and OSA-negative [OSA-] [A+TN+ n = 84, A+/TN- n = 11, A-/TN+ n = 96, A-/TN- n = 36]) and 785 MCI (OSA+ [A+TN+ n = 35, A+/TN- n = 15, A-/TN+ n = 25, A-/TN- n = 16] and OSA- [A+TN+ n = 388, A+/TN- n = 28, A-/TN+ n = 164, A-/TN- n = 114]) older-adults from the Alzheimer's Disease Neuroimaging Initiative cohort. Cox proportional hazards regression models estimated the relative hazard of progression from CN-to-MCI and MCI-to-AD, among baseline OSA CN and MCI patients, respectively. Multi-level logistic mixed-effects models with random intercept and slope investigated the synergistic associations of self-reported OSA, Aß, and tau burden with prospective cognitive decline. RESULTS: Independent of TN-status (CN and MCI), OSA+/Aß+ participants were approximately two to four times more likely to progress to MCI/AD (P < .001) and progressed 6 to 18 months earlier (P < .001), compared to other participants combined (ie, OSA+/Aß-, OSA-/Aß+, and OSA-/Aß-). Notably, OSA+/Aß- versus OSA-/Aß- (CN and MCI) and OSA+/TN- versus OSA-/TN- (CN) participants showed no difference in the risk and time-to-MCI/AD progression. Mixed effects models demonstrated OSA synergism with Aß (CN and MCI [ß = 1.13, 95% confidence interval (CI), 0.74 to 1.52, and ß = 1.18, 95%CI, 0.82 to 1.54]) respectively, and with tau (MCI [ß = 1.31, 95% CI, 0.87 to 1.47]), P < .001 for all. DISCUSSION: OSA acts in synergism with Aß and with tau, and all three acting together result in synergistic neurodegenerative mechanisms especially as Aß and tau accumulation becomes increasingly abnormal, thus leading to shorter progression time to MCI/AD in CN and MCI-OSA patients, respectively.

Predictors of civil and forensic inpatient psychiatric readmissions at a Public Mental Health Hospital.

Inpatient psychiatric readmissions are increasingly prevalent and associated with worse prognostic outcomes and high economic costs, regardless of the medicolegal ramifications that necessitate them. Unlike most general medical readmissions, psychiatric readmissions are commonly warranted for both medical and legal purposes. However, studies focusing on analyzing the predictors of inpatient psychiatric readmission and their relationship to civil versus forensic readmission are limited. The purpose of this study was to examine the predictors of psychiatric readmission among civil and forensic patients admitted to a psychiatric hospital. In this retrospective chart review, we extrapolated data from medical records of 741 patients admitted from 2012 to 2017 with follow up until 2019. Analyses involved chi-square tests for comparing the distribution of demographic and clinical variables between forensic and civil readmission, and Cox regression to determine predictors of time to first readmission. Our results show that race, diagnosis, restraint/seclusion, type of admission, and disposition are significantly associated with an increased risk of psychiatric readmission. This study has important implications for healthcare providers and policy makers in revising mental health policies and improving systems-based practices for the mental health system. Future efforts in improving community psychiatric services and enhancing inpatient therapeutic environment may reduce psychiatric readmissions.

Racial/ethnic, age and sex disparities in leukemia survival among adults in the United States during 1973-2014 period.

There has been marked improvement in leukemia survival, particularly among children in recent time. However, the long-term trends in survival among adult leukemia patients and the associated sex and racial survival disparities are not well understood. We, therefore, evaluated the secular trends in survival improvement of leukemia patients from 1973 through 2014, using Surveillance Epidemiology and End-Result Survey Program (SEER) data. ICD-O-3 morphology codes were used to group leukemia into four types: acute lymphoblastic leukemia (ALL), acute myeloid leukemia (AML), chronic lymphocytic leukemia (CLL), chronic myeloid leukemia (CML). Survival analysis for each leukemia type stratified by race/ethnicity, age, sex was performed to generate relative survival probability estimates for the baseline time period of 1973 through 1979. Hazard ratios (HR) and respective 95% confidence intervals (CIs) for survival within subsequent 10-year time periods by race, age and sex were calculated using Cox proportional hazard models. Of the 83,255 leukemia patients for the current analysis, the 5-year survival of patients with ALL, AML, CLL, and CML during 1973-1979 were 42.0%, 6.5%, 66.5%, and 20.9%, respectively. Compared to the baseline, there were substantial improvements of leukemia-specific survival in 2010-2014 among African-American (81.0%) and Asian (80.0%) patients with CML and among 20-49 year of age with CLL (96.0%). African-American patients, those with AML and those older than 75 years of age had the lowest survival improvements. Asians experienced some of the largest survival improvements during the study period. Others, including African-American and the elderly, have not benefited as much from advances in leukemia treatment.

Association between long-term NSAID use and opioid abuse among patients with breast cancer.

BACKGROUND: Improving survival rates among patients with breast cancer has been associated with an increase in the prevalence of co-morbidities like cancer-related pain. Opioids are an important component in the management of pain among these patients. However, the progression from judicious use to abuse defeats the aim of pain control. Non-steroidal anti-inflammatory drugs (NSAIDs) are recommended as the first step in cancer-related pain management. Due to their anti-inflammatory, anti-neoplastic and neuroprotective properties, NSAIDs have been shown to reduce the risk of progression of certain cancers including breast cancers. In this study, we assessed whether an association exists between long-term NSAID use and opioid abuse among breast cancer survivors. We also explored the relationship between long-term NSAID use and inpatient mortality and length of stay (LOS). METHODS: Using ICD-9-CM codes, we identified and selected women aged 18 years and older with breast cancer from the National Inpatient Sample. Our primary predictor was a history of long-term NSAID use. Multivariable regression models were employed in assessing the association between long-term NSAID use and opioid abuse, inpatient mortality and LOS. RESULTS: Among 170,644 women with breast cancer, 7,838 (4.6%) reported a history of long-term NSAID use. Patients with a history of long-term NSAID use had lower odds of opioid abuse (adjusted odds ratio (aOR) 0.53; 95% CI [0.32-0.88]), lower in-hospital mortality (aOR 0.52; 95% CI [0.45-0.60]) and shorter LOS (7.12 vs. 8.11 days). DISCUSSION: Further studies are needed to understand the underlying mechanism of the association between long-term NSAID use and opioid abuse.

Cancer-Related Pain Is an Independent Predictor of In-Hospital Opioid Overdose: A Propensity-Matched Analysis.

BACKGROUND: About 50% of patients with cancer who have undergone surgery suffer from cancer-related pain (CP). The use of opioids for postoperative pain management presents the potential for overdose, especially among these patients. OBJECTIVE: The primary objective of this study was to determine the association between CP and postoperative opioid overdose among inpatients who had undergone major elective procedures. The secondary objective was to assess the relationship between CP and inpatient mortality, total hospital charge, and length of stay in this population. METHODS: Data of adults 18 years and older from the National Inpatient Sample (NIS) were analyzed. Variables were identified using ICD-9 codes. Propensity-matched regression models were employed in evaluating the association between CP and outcomes of interest. RESULTS: Among 4,085,355 selected patients, 0.8% (N = 2,665) had CP, whereas 99.92% (N = 4,082,690) had no diagnosis of CP. We matched patients with CP (N = 2,665) and no CP (N = 13,325) in a 1:5 ratio. We found higher odds of opioid overdose (adjusted odds ratio [aOR] = 4.82, 95% confidence interval [CI] = 2.68-8.67, P < 0.0001) and inpatient mortality (aOR = 1.39, 95% CI = 1.11-1.74, P = 0.0043) in patients with CP vs no CP. Also, patients with CP were more likely to stay longer in the hospital (12.76 days vs 7.88 days) with higher total hospital charges ($140,220 vs $88,316). CONCLUSIONS: CP is an independent risk factor for opioid overdose, increased length of stay, and increased total hospital charges.

Obstructive sleep apnea and longitudinal Alzheimer's disease biomarker changes.

STUDY OBJECTIVES: To determine the effect of self-reported clinical diagnosis of obstructive sleep apnea (OSA) on longitudinal changes in brain amyloid PET and CSF biomarkers (Aß42, T-tau, and P-tau) in cognitively normal (NL), mild cognitive impairment (MCI), and Alzheimer's disease (AD) elderly. METHODS: Longitudinal study with mean follow-up time of 2.52 ± 0.51 years. Data were obtained from the Alzheimer's Disease Neuroimaging Initiative (ADNI) database. Participants included 516 NL, 798 MCI, and 325 AD elderly. Main outcomes were annual rate of change in brain amyloid burden (i.e. longitudinal increases in florbetapir PET uptake or decreases in CSF Aß42 levels); and tau protein aggregation (i.e. longitudinal increases in CSF total tau [T-tau] and phosphorylated tau [P-tau]). Adjusted multilevel mixed effects linear regression models with randomly varying intercepts and slopes was used to test whether the rate of biomarker change differed between participants with and without OSA. RESULTS: In NL and MCI groups, OSA+ subjects experienced faster annual increase in florbetapir uptake (B = .06, 95% CI = .02, .11 and B = .08, 95% CI = .05, .12, respectively) and decrease in CSF Aß42 levels (B = -2.71, 95% CI = -3.11, -2.35 and B = -2.62, 95% CI = -3.23, -2.03, respectively); as well as increases in CSF T-tau (B = 3.68, 95% CI = 3.31, 4.07 and B = 2.21, 95% CI = 1.58, 2.86, respectively) and P-tau (B = 1.221, 95% CI = 1.02, 1.42 and B = 1.74, 95% CI = 1.22, 2.27, respectively); compared with OSA- participants. No significant variations in the biomarker changes over time were seen in the AD group. CONCLUSIONS: In both NL and MCI, elderly, clinical interventions aimed to treat OSA are needed to test if OSA treatment may affect the progression of cognitive impairment due to AD.

Clinical characteristics and survival of patients with multiple metachronous esophageal tumor.

BACKGROUND: The aim of this study is to determine the clinical characteristics and predictors of survival for patients with multiple metachronous esophageal tumors (MMET) and to compare the survival with patients that have single esophageal tumor (SET). METHOD: We identified all cases of primary esophageal cancer from the Surveillance, Epidemiology and End Results program database from 2000 to 2013. The primary outcome was the development of a second esophageal cancer six months after the diagnosis of the first tumor. A secondary outcome was disease-specific death from esophageal cancer. Chi-square test was used to compare the tumor and demographic characteristics of patients with SET versus the first and second tumor characteristics of patients with MMET. Logistic regression was used to obtain the odds ratios between patients with secondary tumors and those with primary tumors. Accelerated life model was performed for patients with MMET to determine the predictors of survival. RESULTS: Patients with MMET were more likely to have localized stage disease compared to those with SET (P < 0.0001). Distant stage disease for both first tumor (ß = -0.402, P = 0.003) and second tumor (ß = -0.301, P = 0.033) were predictors of increased mortality. The interval between the first and second tumor affected survival. Intervals of 2-5 years and > 5 years were associated with a reduced hazard with a ß = 0.53 and 1.13, P < 0.0001, respectively. CONCLUSION: Early development of a second tumor in MMET is associated with poorer survival. Patients with MMET may benefit from regular follow-up and intervention to prevent the development of a second tumor.

Disparities by race, age, and sex in the improvement of survival for lymphoma: Findings from a population-based study.

OBJECTIVE: To evaluate improvement in survival of lymphoma patients from 1990 to 2014, stratified by age, sex and race using Surveillance Epidemiology and End-Result Survey Program (SEER) data. STUDY DESIGN AND SETTING: We identified 113,788 incident lymphoma cases from nine SEER cancer registries were followed up for cause-specific mortality from lymphoma. Cox proportional hazard regression was used to estimate hazard ratios (HRs) and their respective 95% confidence interval (CIs) for various time periods within groups stratified by race, age and sex. RESULTS: Five-year survival for Hodgkin's lymphoma (HL) was 89% for patients 20-49 years of age. For this age group, compared to 1990-1994, survival significantly improved in 2000-2004 (HR = 0.65; 95% CI: 0.54-0.78), 2005-2009 (HR = 0.46, 95% CI: 0.38-0.57) and 2010-2014 (HR = 0.29, 95% CI: 0.20-0.41). Hodgkin's lymphoma patients aged 75-85 years had 5-year survival of 37% and in these patients, compared to 1990-1994, survival only improved from 2005 onward (HR = 0.67, 95% CI: 0.50-0.90). In patients with non-Hodgkin's Lymphoma (NHL), all age groups showed survival improvements between 1990-1994 period and 2010-2014 period. Improvements in HL and NHL survival were seen for all race categories and both genders. CONCLUSION: Survival among US lymphoma patients has improved substantially between 1990-1994 period and 2010-2014 period, though disease-specific mortality was still higher in older age groups.

Change in Pattern of Secondary Cancers After Kaposi Sarcoma in the Era of Antiretroviral Therapy.

IMPORTANCE: Studies performed in the 1980s and early 1990s have shown that people who develop Kaposi sarcoma (KS) are at higher risk of developing other cancers. The demographics of those affected with human immunodeficiency virus (HIV)/AIDS and KS have changed, and individuals with HIV/AIDS and KS now live longer. OBJECTIVES: To test the hypothesis that the secondary cancers developing in patients with KS have changed in recent years and to assess the risk of secondary cancers after KS in different periods. DESIGN, SETTING, AND PARTICIPANTS: Longitudinal data from 9 cancer registries in the Surveillance, Epidemiology, and End Results (SEER) database were used to identify cases of KS diagnosed from January 1973 to December 2013. The dates of the analysis were November 2016 to February 2017. MAIN OUTCOMES AND MEASURES: The primary outcome was the development of secondary cancers in individuals with KS. Secondary cancers were considered only if diagnosed 2 months after a diagnosis of KS. Standardized incidence ratios (SIRs) were calculated for the development of new secondary cancers in the pre-AIDS era (1973-1979), pre-highly active antiretroviral therapy (HAART) era (1980-1995), and HAART era (1996-2013). Stratified analysis was then performed on a subset of the cases diagnosed from 1996 to 2013 based on age at diagnosis (<65 and ≥65 years), latency period between KS and the development of secondary cancers (1 year, 2-5 years, >5 to 10 years, and >10 years), and registries with higher vs lower reported rates of HIV/AIDS. RESULTS: Among 14 905 individuals with diagnosed KS, 13 721 (92.1%) were younger than 65 years at the time of diagnosis, and 14 356 (96.3%) were male. From 1980 to 1995, SIRs were 2.01 (95% CI, 1.00-3.60) for cancer of the rectum, 49.70 (95% CI, 33.53-70.94) for cancer of the anus, 4.98 (95% CI, 2.79-8.22) for cancer of the liver, 13.70 (95% CI, 2.82-40.03) for cancer of the cervix, 6.40 (95% CI, 2.76-12.60) for Hodgkin lymphoma, and 48.97 (95% CI, 44.85-53.36) for non-Hodgkin lymphoma. From 1996 to 2013, cancer of the anus, Hodgkin lymphoma, non-Hodgkin lymphoma, and cancer of the liver remained associated with KS, with the addition of the following significant SIRs: 6.99 (95% CI, 3.20-13.27) for cancer of the tongue, 10.28 (95% CI, 1.24-37.13) for cancer of the penis, and 17.62 (95% CI, 3.63-51.49) for acute lymphocytic leukemia. The SIR of developing any tumor after KS decreased significantly from 3.36 to 1.94 from the pre-HAART era to the HAART era. CONCLUSIONS AND RELEVANCE: There has been a significant decline in the overall risk of secondary cancers after KS. Certain cancers, including acute lymphocytic leukemia, cancer of the tongue, and cancer of the penis, are increasingly becoming more common in the HAART era compared with the pre-HAART era. Close monitoring and screening for these secondary cancers is desirable in patients with KS.

Survival predictors of Burkitt's lymphoma in children, adults and elderly in the United States during 2000-2013.

Burkitt's Lymphoma (BL) has three peaks of occurrence, in children, adults and elderly, at 10, 40 and 70 years respectively. To the best of our knowledge, no study has been conducted to assess predictors of survival in the three age groups. We hypothesized that survival predictors may differ by age group. We, therefore, sought to determine survival predictors for BL in these three groups: children (<15 years of age), adults (40-70 years of age) and elderly (>70 years of age). Using the Surveillance, Epidemiology, and End Results (SEER) database covering the years 2000-2013, we identified 797 children, 1,994 adults and 757 elderly patients newly diagnosed with BL. We used adjusted Cox proportional hazards regression models to determine prognostic factors for survival for each age group. Five-year relative survival in BL for children, adults and elderly were 90.4, 47.8 and 28.9%, respectively. Having at least Stage II disease and multiple primaries were associated with higher mortality in the elderly group. In adults, multiple primaries, Stage III or IV disease, African American race and bone marrow primary were associated with increased mortality whereas Stage IV disease and multiple primaries were associated with worse outcome in children. These findings demonstrate commonalities and differences in predictors of survival that may have implications for management of BL patients.