Identification of patient characteristics associated with survival benefit from metformin treatment in patients with stage I non-small cell lung cancer.

BACKGROUND: Non-small cell lung cancer (NSCLC) continues to be a major cause of cancer deaths. Previous investigation has suggested that metformin use can contribute to improved outcomes in NSCLC patients. However, this association is not uniform in all analyzed cohorts, implying that patient characteristics might lead to disparate results. Identification of patient characteristics that affect the association of metformin use with clinical benefit might clarify the drug's effect on lung cancer outcomes and lead to more rational design of clinical trials of metformin's utility as an intervention. In this study, we examined the association of metformin use with long-term mortality benefit in patients with NSCLC and the possible modulation of this benefit by body mass index (BMI) and smoking status, controlling for other clinical covariates. METHODS: This was a retrospective cohort study in which we analyzed data from the Veterans Affairs (VA) Tumor Registry in the United States. Data from all patients with stage I NSCLC from 2000 to 2016 were extracted from a national database, the Corporate Data Warehouse that captures data from all patients, primarily male, who underwent treatment through the VA health system in the United States. Metformin use was measured according to metformin prescriptions dispensed to patients in the VA health system. The association of metformin use with overall survival (OS) after diagnosis of stage I NSCLC was examined. Patients were further stratified according to BMI and smoking status (previous vs current) to examine the association of metformin use with OS across these strata. RESULTS: Metformin use was associated with improved survival in patients with stage I NSCLC (average hazard ratio, 0.82; P < .001). An interaction between the effect of metformin use and BMI on OS was observed (χ2 = 3268.42; P < .001) with a greater benefit of metformin use observed in patients as BMI increased. Similarly, an interaction between smoking status and metformin use on OS was also observed (χ2 = 2997.05; P < .001) with a greater benefit of metformin use observed in previous smokers compared with current smokers. CONCLUSIONS: In this large retrospective study, we showed that a survival benefit is enjoyed by users of metformin in a robust stage I NSCLC patient population treated in the VA health system. Metformin use was associated with an 18% improved OS. This association was stronger in patients with a higher BMI and in previous smokers. These observations deserve further mechanistic study and can help rational design of clinical trials with metformin in patients with lung cancer.

Temporal trends of inpatient C. difficile infections within the Veterans Health Administration hospitals: An analysis of the effect of molecular testing, time to testing, and mandatory reporting.

BACKGROUND: Clostridium difficile infection (CDI) is a reportable hospital metric associated with significant healthcare expenditures. The epidemiology of CDI is pivotal to the implementation of preventative measures. OBJECTIVE: To portray temporal CDI trends in Veterans Health Administration (VA) hospitals. DESIGN: A retrospective analysis of veterans who had stool testing for C. difficile. SETTING: VA acute-care hospitals within the continental United States. METHODS: Data were mined from the VA's Corporate Data Warehouse. CDI is reported per 10,000 patient days. RESULTS: From 2006 to 2016, 472,346 patients had C. difficile testing. Overall, decreases in incidence of total CDI (16.81 to 13.66) and hospital-onset healthcare facility-associated (HO-HCFA) CDI (10.87 to 6.41) were observed. Temporal increases in the incidence of total and HO-HCFA CDI were associated with the increased use of molecular testing (P < .0001). Decreased use of fluoroquinolones (P < .0001), clindamycin (P = .0006), and third-generation cephalosporins (P = .0002) correlated with decreased rates of CDI, but VA mandatory reporting did not influence CDI rates (P = .24). The overall crude 30-day mortality of patients with CDI decreased from 2.17 deaths per 10,000 patient days in 2006 to 1.41 in 2016. The frequency of International Classification of Disease, Ninth/Tenth Revision (ICD-9/10) discharge diagnosis for CDI was 73.3%. CONCLUSION: Molecular testing was associated with increased incidence of CDI. Controlling CDI is likely multifactorial. Although the VA initiative to report cases of hospital-acquired CDI was not significant in our model, the advent of stewardship programs throughout the VA and reductions in the use of third-generation cephalosporins, fluoroquinolones, and clindamycin were significantly associated with reduced rates of CDI.

Superior safety of direct oral anticoagulants compared to Warfarin in patients with atrial fibrillation and underlying cancer: a national veterans affairs database study.

BACKGROUND: Studies evaluating safety of warfarin and direct oral anticoagulants (DOACs) for prevention of stroke in patients with atrial fibrillation (AF) are lacking. METHODS & RESULTS: All patients (n = 196,521) receiving care at veteran's affairs with active cancer and AF from 2010-2015 were included. One-year mortality was significantly higher in unadjusted analysis with warfarin (44.9%) compared to dabigatran (25%, P < 0.001), rivaroxaban (24.4%, P < 0.001) and apixaban (30%, P < 0.001) and after adjusting for age, sex and type of cancer mortality (OR = 2.66, 95% CI: 2.52-2.82, P < 0.001). Risk of ischemic stroke (13.5% vs. 11.1%, 12.0%, 14.0%) was similar, however risk of hemorrhagic stroke was significantly higher among patients receiving warfarin (1.2%) compared to patients receiving dabigatran (0.5%), rivaroxaban (0.7%) and apixaban (0.8%) respectively, P = 0.04. CONCLUSIONS: We demonstrated the superior safety profile of DOACs compared to warfarin among patients with underlying cancer and AF. Warfarin was associated with higher mortality, similar ischemic stroke risk but higher risk of hemorrhagic stroke.

Healthy Lifestyle Behaviors of Breast Cancer Survivors.

The purpose of this secondary analysis was to describe the extent to which women with breast cancer, who participated in a randomized control trial on exercise, adopted American Cancer Society (ACS) guidelines for healthy lifestyle behaviors. Women in the study exercised during cancer treatment and for 6 months after completion of treatment. The sample included 106 women, average age 50.7 years (SD = 9.6). Adherence to guidelines for 5 servings of fruits and vegetables ranged from 36% (n = 28) to 39% (n = 36). Adherence with alcohol consumption guidelines was 71% (n = 28) to 83% (n = 30). Adherence with meeting a healthy weight ranged from 52% (n = 33) to 61% (n = 31). Adherence with physical activity guidelines ranged from 13% (n = 30) to 31% (n = 35). Alcohol and healthy weight guidelines were followed by more than half of the participants, but physical activity and dietary guidelines were followed by far fewer women. Further prospective clinical studies are indicated to determine whether interventions are effective in producing a healthy lifestyle in cancer survivors.

Reliability and validity of the Fear of Intimacy Scale in China.

Participants in China (n = 343) and the United States (n = 283) completed measures to assess the reliability and validity of the Fear of Intimacy Scale (Descutner & Thelen, 1991) with a Chinese population. Internal consistency was strong in both cultures, and the factor structure was also similar between cultures, with confirmatory factor analysis (CFA) identifying three-factor models in both samples. As evidence of convergent validity, the scale was positively correlated with depression and negatively correlated with social support and self-esteem. There were gender differences between cultures, but low levels of femininity were predictive of fear of intimacy in both cultures. The influence of individualism and collectivism varied, with high levels of individualism more predictive of a fear of intimacy in China than in the United States.