Clinical Factors Affecting Bevacizumab Efficacy With and Without Conventional Chemotherapy in Metastatic Colon Cancer.

PURPOSE: Bevacizumab (BZ) combined with first line chemotherapy (CC) has shown good clinical outcomes in metastatic colorectal cancer (mCRC). Overall survival (OS) and/or progression free survival in mCRC patients receiving BZ with or without 5FU-based CC is thought to be affected by clinical and morphological factor(s). PATIENTS AND METHODS: We reviewed retrospective medical records of all consecutive mCRC patients treated with BZ with or without CC at tertiary care center between 2003 and 2009 out of which149 patients (m = 77, f = 72) were eligible. RESULTS: Our study population had a mean age at diagnosis of 63.5 years (SD = 11) with median follow-up period of 19.4 months. On initial radiological evaluation following BZ therapy, 56 patients (m = 31, f = 25) had complete or partial response categorized as "early responders." Remaining patients (m = 46, f = 47) who were either stable or showed progressive disease were categorized as "non-responders." Fifty percent among early responders and 60% among non-responders [relative risk (RR) 0.67 (95% confidence interval (CI), 0.43-1.06)] demonstrated disease progression on follow up. There was a slightly better OS among early responders compared to non-responders (median 21.5 months days versus 16.8 months, P = 0.07). Cox regression analysis suggested male sex (RR 0.65, 95% CI, 0.43-0.98), hematochezia (RR 0.63, 95% CI, 0.4-0.98), resectable primary tumor (RR 0.42, 95% CI, 0.24-0.72) and resectable metastatic mass (RR 0.32, 95% CI, 0.14-0.74) were found to be associated with longer OS. Abdominal pain (RR 1.76, 95% CI, 1.1-2.8), accompanying diabetes (RR 1.76, 95% CI, 1.09-2.85), and unexplained weight loss (RR 2.73, 95% CI, 1.73-4.29) were associated with poor OS. CONCLUSIONS: Better OS among mCRC patients with resectable primary and metastatic tumors was seen. This is the first study to demonstrate slightly better outcome in males and negative influence of diabetes on outcome in mCRC treated with BZ.

Feasibility of establishing tele-dental approach to non-traumatic dental emergencies in medical settings.

PURPOSE: Non-traumatic dental condition visits (NTDCs) represent about 1.4% to 2% of all Emergency Department (ED) visits and are limited to palliative care only, while associated with high cost of care. Feasibility of establishing a tele-dental approach to manage NTDCs in ED and Urgent care (UC) settings was undertaken to explore the possibility of utilizing remote tele-dental consults. METHODS: Participants with NTDCs in ED/UCs were examined extra and intra-orally: (1) directly by ED provider, (2) remotely by tele-dental examiner (trained dentist) using intra-oral camera and high-definition pan-tilt-zoom (PTZ) camera, (3) directly by treating dentist post ED/UC visit (if applicable) and, (4) secondary assessment by tele-dental reviewer. Comparisons were drawn between differential diagnoses and recommended managements provided by ED/UC providers, tele-dental examiner, treating dentist, and tele-dental reviewer. RESULTS: 13 patients participated in the study. The overall inter-rater agreement between the tele-dental examiner and tele-dental reviewer was high while it was low between tele-dentists and the ED providers. The preliminary testing of tele-dental intervention in the ED/UC setting demonstrated potential feasibility in addressing the NTDC landing in ED/UC. Larger interventional studies in multi-site setting are needed to validate this approach and especially evaluate impact on cost, ED/UC workflow and patient outcomes. CLINICAL SIGNIFICANCE: Using tele-dentistry to triage non-traumatic dental visits to the emergency room may be a promising approach. Once this approach is validated through a larger study, tele-dental outreach could help in directing non-traumatic dental emergency patients to the appropriate dental setting to provide treatment for the patients.

Patient Awareness of Association of Diabetes and Periodontal Disease.

This cross-sectional study sought to assess the current awareness, knowledge, and behavior regarding diabetes mellitus (DM) and periodontal disease (PD) association among a convenience sample of patients from a large Wisconsin-based integrated medical-dental health care organization serving largely rurally based communities. An anonymous 10-question survey was distributed at regional medical and dental centers of dental and medical clinics of a single health care institution over a 4-week period, to achieve a cross-sectional sampling of patients aged 18 to 80 years. Among 946 respondents, 616 were female. Patient-reported periodicity for dental visits was highest between 6 months and 1 year (56.4%). Respondents reporting "poor-fair" knowledgeability surrounding DM-PD association correlated with highest interest in learning more about DM-PD relationship (p <.0001). While over 80% of respondents correctly answered questions about gum disease symptomology and contribution of oral health practices on diabetes prevention, only 51% knew that PD affected blood sugar control. Willingness to comply with medical screening conducted by dental providers for diseases affecting oral health was indicated by 44% of respondents (p < .0001). Study results indicated that knowledgeability levels among patients surrounding the effect of PD on DM needed improvement. Strategic educational interventions targeting improved health literacy among patients may further promote prevention of DM-PD complications. Health literacy gaps remain to be addressed in patient understanding of the importance of detecting and managing dysglycemia for maintenance of periodontal health, creating opportunities for patient education.

Patient awareness/knowledge towards oral cancer: a cross-sectional survey.

BACKGROUND: Oral cancer (OC) is associated with multiple risk factors and high mortality rates and substantially contributes to the global cancer burden despite being highly preventable. This cross-sectional study sought to assess current knowledge, awareness, and behaviors of patients in rural communities surrounding OC risk. METHODS: An anonymous 21-question survey was distributed to patients in waiting rooms of a large integrated medical-dental health system serving north-central Wisconsin. Survey results were summarized via descriptive statistics. Odds ratios surrounding health literacy on OC risk factors were obtained using unconditional univariate logistic regression analysis. RESULTS: Of 504 dental and 306 medical patients completing the survey, 62.2% were female, Caucasian/White (92%) with 41% having a ≤ high school diploma/equivalent. Current smoker/smokeless tobacco use was reported by 34%, while 39% reported former tobacco exposure. Alcohol use was reported by 54% of respondents at the following frequencies: < once/week, (35%); 1-2 times/week, (16%); 3-4 times/week, (6%); 5-6 times/week, (2%); and daily, (23%). Knowledge about tobacco and alcohol use and increased OC risk was reported by 94 and 40%, respectively. About 50% reported knowledgeability regarding cancer-associated symptomology. Tobacco cessation was reported by 20% of responders. Receipt of education on OC from healthcare providers and human papilloma virus links to OC causation was reported by 38 and 21%, respectively. CONCLUSION: Patients who smoked > 20+ cigarettes per day were more knowledgeable about tobacco and OC risk compared to non-smokers and those who smoked ≤ 19 cigarettes/day (p = 0.0647). Patients who were alcohol consumers exhibited higher knowledgeability surrounding increased OC risk with alcohol and tobacco exposures compared to alcohol abstainers (p = 0.06). We concluded that patients recognized links between tobacco and OC risk but demonstrated lower knowledge of other causal factors. Strategic patient education by providers could increase awareness of OC risk.

Understanding patients' oral health information needs: Findings of a survey on use of patient portals in dentistry.

BACKGROUND: Patient engagement through web-based patient health portals (PHP) can offer important benefits to patients and provider organizations by improving both quality and access to care. The authors studied the most relevant, patient-identified, oral health information available in the PHP to inform their assessment of patient-centered care. METHODS: The authors distributed a 17-question, paper-based survey to patients aged 18 through 80 years in the waiting rooms of 8 dental centers in Wisconsin. Descriptive statistics, along with differences in percentages by sex, age group, and metropolitan status were reported using the χ2 and Wilcoxon rank sum test. RESULTS: A 75% (813 of 1,090) response rate was achieved. More than one-third of patients selected access to previous dental procedures, dental history, routine dental appointment reminders, date of last dental visit, tooth chart, date of last full-mouth radiograph, and dental problem list via the PHP. CONCLUSIONS AND PRACTICAL IMPLICATIONS: Patients identified and recommended incorporation of different types of oral health data for access via the PHP as vital to strengthening the communication between patients and dental professionals. Incorporating patient-identified oral health information in the PHP will inform strategies for improving patient engagement, strengthen patient-provider communication, and offer a venue for increasing oral health literacy and awareness.

Knowledgeability, Attitude and Behavior of Primary Care Providers Towards Oral Cancer: a Pilot Study.

The objective of this study was to assess current knowledgeability, attitudes, and practice behaviors of primary care providers (PCPs) towards oral cancer screening. Applying a cross-sectional design, a 14-question survey was emailed to 307 PCPs practicing at a large, multi-specialty, rurally based healthcare system. Survey data were collected and managed using REDCap and analyzed applying descriptive statistics. A 20 % response rate (n = 61/307) was achieved for survey completion. Approximately 70 % of respondents were physicians, 16 % were nurse practitioners, and 13 % were physician assistants. Nearly 60 % of respondents were family medicine practitioners. Limited training surrounding oral cancer screening during medical training was reported by 64 %. Although 78 % of respondents reported never performing oral cancer screening on patients in their practice, >90 % answered knowledge-based questions correctly. Frequency rate for specialist referral for suspicious lesions by PCPs was 56 % "frequently". Optimal periodicity for oral cancer screening on all patients selected by respondents was 61 % "annually", 3 % "every 6 months", 3 % "every visit", 2 % "not at all", and 31 % "unsure". This study established a baseline surrounding current knowledgeability, practice patterns, and opinions of PCPs towards oral cancer screening at a single, large, regional healthcare system. In the absence of evidence-based support for population-based cancer screening, this study result suggests a need for better integration of oral cancer surveillance into the medical setting, supplemented by education and training with emphasis on assessment of high-risk patients to achieve early detection. Prospectively, larger studies are needed to validate these findings.

Update on Electronic Dental Record and Clinical Computing Adoption Among Dental Practices in the United States.

This study sought to re-characterize trends and factors affecting electronic dental record (EDR) and technologies adoption by dental practices and the impact of the Health Information Technology for Economic and Clinical Health (HITECH) act on adoption rates through 2012. A 39-question survey was disseminated nationally over 3 months using a novel, statistically-modeled approach informed by early response rates to achieve a predetermined sample. EDR adoption rate for clinical support was 52%. Adoption rates were higher among: (1) younger dentists; (2) dentists ≤ 15 years in practice; (3) females; and (4) group practices. Top barriers to adoption were EDR cost/expense, cost-benefit ratio, electronic format conversion, and poor EDR usability. Awareness of the Federal HITECH incentive program was low. The rate of chairside computer implementation was 72%. Adoption of EDR in dental offices in the United States was higher in 2012 than electronic health record adoption rates in medical offices and was not driven by the HITECH program. Patient portal adoption among dental practices in the United States remained low.

Noninvasive Testing for Nonalcoholic Steatohepatitis and Hepatic Fibrosis in Patients With Psoriasis Receiving Long-term Methotrexate Sodium Therapy.

IMPORTANCE: The long-term implications of hepatotoxic effects in patients with psoriasis remains uncharacterized, and a method is needed for the noninvasive monitoring of the development and progression of hepatic fibrosis in patients with psoriasis receiving long-term methotrexate therapy. OBJECTIVE: To evaluate if NASH FibroSure, a noninvasive test for nonalcoholic steatohepatitis (NASH) and hepatic fibrosis, can be used for patients with psoriasis to aid in determining eligibility for methotrexate sodium (MTX) therapy, monitor for the development of MTX-induced hepatotoxic effects, and monitor for worsening of hepatic fibrosis scores during MTX therapy. DESIGN, SETTING, AND PARTICIPANTS: A retrospective descriptive analysis was conducted among a cohort of patients with psoriasis treated with MTX who underwent NASH FibroSure testing between January 1, 2007, and December 31, 2013, at a dermatology referral center at a single institution. Data analysis was performed from January 1 to December 31, 2014. MAIN OUTCOMES AND MEASURES: NASH FibroSure risk scores suggesting the development and progression of hepatic fibrosis in patients with psoriasis receiving long-term MTX therapy. RESULTS: Included in the institutional experience portion of the study were 129 patients with psoriasis undergoing treatment with MTX, while 107 patients (57 women and 50 men; mean [SD] age, 83.3 [13.5] years) underwent NASH FibroSure testing during MTX therapy and were eligible for correlation analysis. Of the 129 patients with psoriasis undergoing treatment with MTX, 69 (53.5%) underwent NASH FibroSure testing prior to starting MTX; 19 of those patients (27.5%) had elevated fibrosis scores, and 54 (78.3%) had elevated steatosis scores. Among the 107 patients who underwent NASH FibroSure testing during MTX therapy, the cumulative MTX dose corresponded to a statistically significant association of a higher NASH FibroSure hepatic fibrosis score in women (Spearman ρ = 0.21; P = .02) but not in men (Spearman ρ = 0.17; P = .11). All patients in the cohort except 1 were managed without a liver biopsy. CONCLUSIONS AND RELEVANCE: The patients with psoriasis in this study had a high prevalence of elevated hepatic steatosis scores. The NASH FibroSure test can be used to monitor changes in fibrosis score in patients with psoriasis receiving MTX. In a single-institution cohort, these results suggest that NASH FibroSure may be used, especially among female patients, to help monitor for risk of worsening fibrosis during MTX therapy.

Employers' Perspective on Childcare Services for Hired Farm Workers.

The goal of this project was to protect children while parents work in agriculture by improving off-farm services for children of migrant and seasonal farm workers. Large agricultural enterprises have policies forbidding children in the worksite. At the same time, their employees, who are trying to generate income, seek as many work hours as possible but often lack viable options for childcare services. As employers strive to increase their labor pool, and workers seek off-farm childcare, there is mutual interest in improving access to childcare services in agricultural regions dependent on large numbers of full-time and seasonal workers. This report describes the employers' perspectives on childcare needs of hired farm workers' families and their barriers and motivators to facilitating off-farm childcare services. Using descriptive survey research methodology, data were collected from a convenience sample of 102 agribusiness owners and Human Resource directors attending an agricultural conference regarding labor laws or personnel management. Results revealed significant differences for those companies employing more than 25 workers compared to their counterparts. Primary motivators for offering childcare as an employment benefit were improved employee morale, enhanced company reputation, and a more stable workforce. A major barrier was that half of large-scale enterprises lack guidance on how to provide childcare options for their workers. Survey results are being used to facilitate collaboration among employers, farm workers, and childcare providers to offer a safe, nurturing environment for children while their parents work in agriculture.

Treatment-Related Cardiovascular Outcomes in Patients with Symptomatic Subclavian Artery Stenosis.

BACKGROUND: Subclavian artery stenosis (SAS) is narrowing of the subclavian artery most commonly caused by atherosclerosis. It serves as a marker for cerebrovascular and myocardial ischemic events. METHODS: A retrospective cohort study was conducted to determine the association of treatment via combination therapy (antiplatelet drug plus either by-pass surgery or percutaneous transluminal angioplasty (PTA) with or without stent implantation) versus antiplatelet drug therapy alone on cardiovascular events and all-cause mortality in Marshfield Clinic patients diagnosed with symptomatic SAS from January 1, 1995 to December 31, 2009. RESULTS: Of the total 2153 cases, 100 patients were identified as eligible to be included in the study. Of these 100 patients that met inclusion criteria, 30 underwent combination therapy while 70 were managed only with drug treatment. A median length of follow-up was 8.45 years. Adverse cardiovascular events occurred in 5/30 (17%) of combination therapy patients compared to 28/70 (40%) of antiplatelet drug therapy only patients (p = 0.0355). Accordingly, all-cause mortality was higher (47%) in the antiplatelet drug therapy only group than the combination therapy group (13%) [hazard ratio = 3.45, p = 0.0218]. CONCLUSIONS: Preliminary findings in this pilot data set suggest that combination therapy (medications plus either surgical or interventional repair) of subclavian artery stenosis is associated with less cardiovascular adverse events and higher survival rates. However, prospective randomized studies with larger number of patients are needed to validate these findings.

Statistical Application and Cost Saving in a Dental Survey.

OBJECTIVE: To effectively achieve a robust survey response rate in a timely manner, an alternative approach to survey distribution, informed by statistical modeling, was applied to efficiently and cost-effectively achieve the targeted rate of return. DESIGN: A prospective environmental scan surveying adoption of health information technology utilization within their practices was undertaken in a national pool of dental professionals (N=8000) using an alternative method of sampling. The piloted approach to rate of cohort sampling targeted a response rate of 400 completed surveys from among randomly targeted eligible providers who were contacted using replicated subsampling leveraging mailed surveys. METHODS: Two replicated subsample mailings (n=1000 surveys/mailings) were undertaken to project the true response rate and estimate the total number of surveys required to achieve the final target. Cost effectiveness and non-response bias analyses were performed. RESULTS: The final mailing required approximately 24% fewer mailings compared to targeting of the entire cohort, with a final survey capture exceeding the expected target. An estimated $5000 in cost savings was projected by applying the alternative approach. Non-response analyses found no evidence of bias relative to demographics, practice demographics, or topically-related survey questions. CONCLUSION: The outcome of this pilot study suggests that this approach to survey studies will accomplish targeted enrollment in a cost effective manner. Future studies are needed to validate this approach in the context of other survey studies.

Medical Providers' Oral Health Knowledgeability, Attitudes, and Practice Behaviors: An Opportunity for Interprofessional Collaboration.

OBJECTIVE: Evaluation of current knowledgeability, attitudes, and practice behaviors of medical providers from a large health care system toward oral health was undertaken as a pilot effort to better understand and integrate oral health into the overall health care delivery. METHODS: Invitations to complete a 28-question survey, designed in a web-based platform (SurveyMonkey(®)), were emailed to 1407 medical multispecialty physicians, residents, and nurses within the health system. The questionnaire included sections on provider demographics, oral health knowledgeability and attitudes, and current practice conducting oral health screenings. RESULTS: A 14% (n = 199/1407) response rate was achieved for survey completion. There were 16% who reported good coverage of oral/dental health topics in their medical training curriculum. Competency level was <30% for identifying tooth decay and oral pathology. There were 95% who reported never applying fluoride varnish in their practice, while >80% answered knowledge-based questions correctly. Frequency rates for dental referral by the medical providers were 32% 'frequently' and 68% 'infrequently.' Perceptions of optimal frequency for conducting oral health assessment in their professional practices ranged from 69% indicating 'frequently' to 25% indicating 'infrequently.' CONCLUSION: Overall, positive attitudes were observed toward incorporation of oral health examination into medical practice. The study identified lack of oral health treatment and infrequent referral by medical providers to dental providers. Results support likelihood for acceptance of care models that incorporate a medical/dental team-based approach complemented by oral health training for medical providers to enhance holistic health care delivery. Limitations of this pilot study include potential selection bias and lack of generalizability beyond our institution; further studies are planned in additional settings statewide to validate findings.

Web Camera Use in the Neonatal Intensive Care Unit: Impact on Nursing Workflow.

BACKGROUND: Many neonatal intensive care units (NICU) are using web camera systems to allow virtual visitation of the infant by family members. Generally, families appreciate the web camera and utilize this service. However, no one has looked into the change on nursing workload after implementation of a web camera. OBJECTIVE: This study was designed to explore the perception of nurses and their workflow and identify determinants that may disrupt or facilitate the use of a commercially available camera service. Our primary goal was to see if the camera system interferes with the nursing care. STUDY DESIGN: This was a prospective, questionnaire-based study conducted between March and September 2014. Parents were offered the camera service and signed a consent form before use. Parents who refused the camera were the group designated as "off camera." There were two infant groups; one cared for using the cameras and the other not. The camera service was used continuously during the study period, except during procedures, baby care, and feedings. Demographic information on nursing staff and neonates was collected weekly. Questionnaires were placed at each bedside for nurses to complete on each shift for each infant once weekly. The questionnaires for infants off-camera did not have questions regarding the camera. However, the rest of the questions were similar regarding time spent interacting with family members, face to face, or on the phone. Data on time spent manipulating the camera per shift were also obtained. RESULTS: Surveys for 623 on-camera and 130 off-camera infants were completed by 42 nursing staff. Findings showed that caring for multiple infants while using the web camera increased nurses' workload and stress, which they perceived as having an adverse effect on the ability to provide quality care. Family decisions not to utilize the camera service were mainly cultural, and noted among Mennonite, Amish, and Hmong families. Some families residing close to the hospital also preferred visiting the baby personally rather than using the camera service. CONCLUSION: Parents and nurses perceived web cameras as beneficial in the NICU setting. However, nurses spent significant time manipulating cameras and addressing parental concerns over the phone, causing disruption in their workflow, which had the potential to decrease quality of care for infants. To compensate for these disruptions, we recommend increasing awareness of the potential issues with both cameras and families and providing multiple training sessions to nursing staff before systems are implemented.

Risk factors for recurrent spontaneous epistaxis.

OBJECTIVE: To identify risk factors associated with spontaneous recurrent epistaxis. PATIENTS AND METHODS: This was a retrospective cohort study assessing patients in the Marshfield Clinic system diagnosed as having epistaxis between January 1, 1991, and January 1, 2011. There were 461 cases with at least 2 episodes of spontaneous epistaxis within 3 years and 912 controls with only 1 episode in the same time frame. More than 50 potential risk factors were investigated, including demographic features, substance use, nasal anatomical abnormalities, nasal infectious and inflammatory processes, medical comorbidities, medications, and laboratory values. A Cox proportional hazards regression modeling approach was used to calculate hazard ratios of epistaxis recurrence. RESULTS: Traditional risk factors for epistaxis, including nasal perforation, nasal septum deviation, rhinitis, sinusitis, and upper respiratory tract infection, did not increase the risk of recurrence. Significant risk factors for recurrent epistaxis included congestive heart failure, diabetes mellitus, hypertension, and a history of anemia. Warfarin use increased the risk of recurrence, independent of international normalized ratio. Aspirin and clopidogrel were not found to increase the risk of recurrence. Few major adverse cardiovascular events were observed within 30 days of the first epistaxis event. CONCLUSION: Congestive heart failure is an underappreciated risk factor for recurrent epistaxis. Hypertension and diabetes mellitus may induce atherosclerotic changes in the nasal vessels, making them friable and more at risk for bleeding. Patients with recurrent epistaxis may also be more susceptible to developing anemia. Physicians should promote antiplatelet and antithrombotic medication adherence despite an increased propensity for recurrent epistaxis to prevent major adverse cardiovascular events.

Finding the key to a better code: code team restructure to improve performance and outcomes.

Code teams respond to acute life threatening changes in a patient's status 24 hours a day, 7 days a week. If any variable, whether a medical skill or non-medical quality, is lacking, the effectiveness of a code team's resuscitation could be hindered. To improve the overall performance of our hospital's code team, we implemented an evidence-based quality improvement restructuring plan. The code team restructure, which occurred over a 3-month period, included a defined number of code team participants, clear identification of team members and their primary responsibilities and position relative to the patient, and initiation of team training events and surprise mock codes (simulations). Team member assessments of the restructured code team and its performance were collected through self-administered electronic questionnaires. Time-to-defibrillation, defined as the time the code was called until the start of defibrillation, was measured for each code using actual time recordings from code summary sheets. Significant improvements in team member confidence in the skills specific to their role and clarity in their role's position were identified. Smaller improvements were seen in team leadership and reduction in the amount of extra talking and noise during a code. The average time-to-defibrillation during real codes decreased each year since the code team restructure. This type of code team restructure resulted in improvements in several areas that impact the functioning of the team, as well as decreased the average time-to-defibrillation, making it beneficial to many, including the team members, medical institution, and patients.

Modeling efficacy of bevacizumab treatment for metastatic colon cancer.

PURPOSE: Bevacizumab, an FDA-approved adjuvant treatment for metastatic colon cancer, has extended survival for many patients. However, factors predicting response to treatment remain undefined. PATIENTS AND METHODS: Relevant clinical and environmental data were abstracted from medical records of 149 evaluable patients treated with bevacizumab for metastatic colon cancer at a multi-specialty clinic. Tumor response was calculated from radiologic reports using Response Evaluation Criteria in Solid Tumors (RECIST) criteria and verified by oncologist review. Patients with at least one occurrence of complete or partial response or stable disease were classified as responders; those exhibiting progressive disease were classified as non-responders. RESULTS: Univariate analysis demonstrated that blood in stool (P<0.05), unexplained weight loss (P<0.05), primary colon cancer site (P<0.05), chemotherapy treatment of primary tumor site (P<0.05), and adenocarcinoma versus adenoma subtype (P<0.05) was associated with tumor responsiveness. Factors remaining statistically significant following multivariate modeling included adenocarcinoma as tumor cell type versus other adenocarcinoma subtypes (OR=6.35, 95% CI: 1.08-37.18), chemotherapy treatment applied to primary tumor (OR= 0.07, 95% CI: 0.0-0.76,), tumor localization to cecal/ascending colon (OR=0.061, 95% CI: 0.006-0.588,), and unexplained weight loss (OR=0.1, 95% CI: 0.02-0.56,). Chemotherapy treatment of primary tumor, unexplained weight loss, and cecal/ascending localization of the tumor were associated with poorer outcomes. Adenocarcinoma as cell type compared to other adenocarcinoma subtypes was associated with better response to bevacizumab treatment. CONCLUSION: RESULTS suggest that response to bevacizumab therapy may be predicted by modeling clinical factors including symptomology on presentation, tumor location and type, and initial response to chemotherapy.

Tamoxifen-induced venothromboembolic events: exploring validation of putative genetic association.

OBJECTIVE: A pilot study to examine accrual rates, efficiency of data capture approaches, study design and genotyping capacity for a future genetic validation study was undertaken. DESIGN: The process pilot evaluated feasibility of applying a matched case-control design to validate association of two candidate estrogen receptor (ER) single nucleotide polymorphisms (SNPs) with incidence of venothromboembolic events (VTE) in breast cancer patients treated with tamoxifen where criteria included frequency matching by age, number of years diagnosed with breast cancer within 4-year intervals, and geographic residency. SETTING: The study was conducted at Marshfield Clinic, in central Wisconsin. PARTICIPANTS: Study-eligible cases with a breast cancer diagnosis between 1994 and 2006 who experienced a VTE within 5 years of last tamoxifen exposure were matched at a ratio of 1:4 to controls with a breast cancer diagnosed between 1994 and 2006 with no VTE history following tamoxifen exposure for ≥2 years. METHODS: Feasibility of enrolling, phenotyping, and genotyping 20% of the total number of validated eligible cases and controls was tested in order to project enrollment rates and assess probability of enrolling the projected sample size for the prospective validation study and adequacy of planned data capture. Conditional logistic regression analysis was conducted for the matched case-control study design. RESULTS: Enrollment accruals included 19 of 24 targeted cases (79%), and 74 of 96 (77%) targeted controls. Electronic data capture for most variables was nearly 100%. No unexpected statistically significant differences were observed between cases and controls. Capacity to conduct in-house screening for rs2234689 (ER1 PvuII), rs9340799 (ER1 XbaI), rs13146272 (CYP4V2), rs2227589 (SERPINC 1) and rs1613662 (GP6) was successfully established. Association of GP6 with VTE was further validated (P=0.0403; OR, 0.19). CONCLUSION: Accrual rates to the larger prospective study will require a multi-center design to ensure enrollment of adequate numbers of cases and controls for achieving the projected sample size required to validate association of the ER SNPs. To prevent study failure due to poor accrual, the importance of conducting feasibility studies before launching large scale validation studies of genetic association and adverse drug events, is discussed.

A simple and robust way of concluding meta-analysis results using reported P values, standardized effect sizes, or other statistics.

Meta-analysis is a powerful tool to estimate measures of associations or effects based on published or unpublished reports. However, problems exist in many meta-analyses, particularly related to study heterogeneity. This article proposes a way of concluding meta-analysis results using P values, taking heterogeneity into account. There is little published research focused on evaluating conclusiveness of summary results of reported meta-analyses. Generally, a P value is directly linked to the test statistic z=b/s(b) following a standard normal distribution with mean zero and unit variance, where b is an estimator of ß and s(b) is the estimated standard error of b for any study included in a meta-analysis. This forms the basis of the proposed method for deriving overall test statistics and corresponding P values used for comparing results of meta-analyses. Two published meta-analyses were chosen and specific software was applied. Results are consistent with the two published meta-analysis reports in terms of P values for significance and direction of summary measure of treatment effect. This proposed method can be utilized to safeguard against improper conclusions of published meta-analyses due to heterogeneity. Exploring more sophisticated statistical methods for situations when the key assumption applied to this proposed method is violated could be pursued and could expand the scope of applications beyond this method.

Medical providers' dental information needs: a baseline survey.

Articulation of medical and dental practices has been strongly called for based on the many oral-systemic connections. With the rapid development and adoption of electronic health records, the feasibility of integrating medical and dental patient data should be strongly considered. The objective of this study was to develop an initial understanding of the medical providers' core dental information needs and opinion of integrated medical-dental electronic health record (iEHR) environment in their workflow. This was achieved by administering a 13 question survey to a group of 1,197 medical care providers employed by Marshfield Clinic in Wisconsin, United States. The survey received a response rate of 35%. The responses were analyzed based on provider 'Role' and 'Specialty'. The majority of the respondents felt the need for patient's dental information to coordinate or provide effective medical care. An integrated electronic health record environment could facilitate this holistic patient care approach.

Virulence genes and genotypic associations in nasal carriage, community-associated methicillin-susceptible and methicillin-resistant USA400 Staphylococcus aureus isolates.

It is not well understood why strains of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA), a major cause of skin and soft tissue infections, became successful so quickly, overtaking the place of methicillin-sensitive S. aureus (MSSA) in many communities. To evaluate the genetic basis of differences in their virulence traits, 293 S. aureus isolates consisting of three cohorts, genotypically defined clinical CA-MRSA (n = 77), clinical MSSA (n = 103), and nasal carriage MSSA (n = 113), collected over a 19-year period in two Midwestern states in the United States, were (i) extensively genotyped and (ii) screened for 40 known virulence genes which included those for enterotoxins, leukocidins, hemolysins, and surface proteins and several newly identified putative toxin genes from the USA400 lineage of CA-MRSA. Genotypically, nasal carriage and clinical MSSA isolates were much more diverse than was the CA-MRSA group, which was found to be of USA400 lineage only. Virulence gene profiles of the three groups showed that CA-MRSA strains harbored significantly higher percentages (≥95%; P value, <0.05) of the sea, sec, sec4, seg2, seh, sek, sel, sel2, ear, ssl1, lpl10, lukSF-PV, lukD, lukE, and clfA genes than did the carriage and the clinical MSSA group (range, 0% to 58%). Genes of the enterotoxin gene cluster, seg, sei, sem, sen, and seo, were present in the clinical and carriage isolates but not in the CA-MRSA group. These results suggest that the presence of additional virulence factors in USA400 CA-MRSA strains compared to the nasal carriage and clinical MSSA strains probably contributed to their enhanced virulence.