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1.
Artigo em Inglês | MEDLINE | ID: mdl-32409594

RESUMO

Identifying persons at high risk for gastric cancer (GC) is needed for targeted interventions for prevention and control in low-incidence regions. Combining ethnic/cultural factors with conventional GC-risk factors may enhance identification of high-risk persons. Data from a prior case-control study (40 GC cases, 100 controls) were used. A "conventional model" using risk factors included in the Harvard Cancer Risk Index's GC module was compared to a "parsimonious model" created from the most predictive variables of the conventional model as well as ethnic/cultural and socioeconomic variables. Model probability cut-offs aimed to identify a cohort with at least 10 times the baseline risk using Bayes' Theorem applied to baseline U.S. GC incidence. The parsimonious model included age, U.S. generation, race, cultural food at ages 15-18 years, excessive salt, education, alcohol, and family history. This 11-item model enriched the baseline risk by 10-fold, at the 0.5 probability level cut-off, with an estimated sensitivity of 72% (95% CI 64-80), specificity of 94% (95% CI 90-97) and ability to identify a sub-cohort with GC prevalence of 128.5 per 100,000. The conventional model was only able to reach a risk level of 9.8 times baseline with a corresponding sensitivity of 31% (95% CI 23-39) and specificity of 97% (95% CI 94-99). Cultural and ethnic data may add important information to models for identifying U.S. individuals at high risk for GC, who then could be targeted for interventions to prevent and control GC. The findings of this pilot study remain to be validated in an external dataset.

2.
Am J Hosp Palliat Care ; : 1049909120916126, 2020 Apr 02.
Artigo em Inglês | MEDLINE | ID: mdl-32237996

RESUMO

PURPOSE: Racial and ethnic minority patients receive poorer quality end-of-life (EoL) care compared with white patients. Differences in quality of communication (QOC) with clinicians may contribute to these disparities. We measured differences in satisfaction with communication in the intensive care unit (ICU) by race and ethnicity. MATERIALS AND METHODS: This is a cross-sectional survey of family members of patients in ICUs of an academic medical center serving a diverse urban population using The Family Satisfaction with the ICU (FS-ICU) and QOC scales. RESULTS: One hundred surveys were completed (18.8% white, non-Hispanic; 34.4% black, non-Hispanic; 31.3% Hispanic; 15.6% other race/ethnicity). Mean FS-ICU score was 84.2 (standard deviation [SD] 20.5) for white patients, 83.3 (SD 16.2) for black patients, 82.7 (SD 17.8) for Hispanic or Latino patients, and 80.9 (SD 18.8) for patients with other race/ethnicity (Kruskal-Wallis, P = .92). Differences remained insignificant when controlling for patient and respondent characteristics. The QOC scale was not scored due to nonresponse levels on questions about EoL communication. CONCLUSIONS: Uniformly high ratings may have been influenced by avoidance of EoL discussion. This study is inconclusive regarding whether QOC influences disparities in EoL care since quality of EoL communication was not captured.

3.
Public Health Nutr ; 23(8): 1428-1439, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32223780

RESUMO

OBJECTIVE: Conceptualisations of 'food deserts' (areas lacking healthful food/drink) and 'food swamps' (areas overwhelm by less-healthful fare) may be both inaccurate and incomplete. Our objective was to more accurately and completely characterise food/drink availability in urban areas. DESIGN: Cross-sectional assessment of select healthful and less-healthful food/drink offerings from storefront businesses (stores, restaurants) and non-storefront businesses (street vendors). SETTING: Two areas of New York City: the Bronx (higher-poverty, mostly minority) and the Upper East Side (UES; wealthier, predominantly white). PARTICIPANTS: All businesses on 63 street segments in the Bronx (n 662) and on 46 street segments in the UES (n 330). RESULTS: Greater percentages of businesses offered any, any healthful, and only less-healthful food/drink in the Bronx (42·0 %, 37·5 %, 4·4 %, respectively) than in the UES (30 %, 27·9 %, 2·1 %, respectively). Differences were driven mostly by businesses (e.g. newsstands, gyms, laundromats) not primarily focused on selling food/drink - 'other storefront businesses' (OSBs). OSBs accounted for 36·0 % of all food/drink-offering businesses in the Bronx (more numerous than restaurants or so-called 'food stores') and 18·2 % in the UES (more numerous than 'food stores'). Differences also related to street vendors in both the Bronx and the UES. If street vendors and OSBs were not captured, the missed percentages of street segments offering food/drink would be 14·5 % in the Bronx and 21·9 % in the UES. CONCLUSIONS: Of businesses offering food/drink in communities, OSBs and street vendors can represent substantial percentages. Focusing on only 'food stores' and restaurants may miss or mischaracterise 'food deserts', 'food swamps', and food/drink-source disparities between communities.

4.
Diabetes Care ; 43(4): 743-750, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32132009

RESUMO

OBJECTIVE: Self-management education and support are essential for improved diabetes control. A 1-year randomized telephonic diabetes self-management intervention (Bronx A1C) among a predominantly Latino and African American population in New York City was found effective in improving blood glucose control. To further those findings, this current study assessed the intervention's impact in reducing health care utilization and costs over 4 years. RESEARCH DESIGN AND METHODS: We measured inpatient (n = 816) health care utilization for Bronx A1C participants using an administrative data set containing all hospital discharges for New York State from 2006 to 2014. Multilevel mixed modeling was used to assess changes in health care utilization and costs between the telephonic diabetes intervention (Tele/Pr) arm and print-only (PrO) control arm. RESULTS: During follow-up, excess relative reductions in all-cause hospitalizations for the Tele/Pr arm compared with PrO arm were statistically significant for odds of hospital use (odds ratio [OR] 0.89; 95% CI 0.82, 0.97; P < 0.01), number of hospital stays (rate ratio [RR] 0.90; 95% CI 0.81, 0.99; P = 0.04), and hospital costs (RR 0.90; 95% CI 0.84, 0.98; P = 0.01). Reductions in hospital use and costs were even stronger for diabetes-related hospitalizations. These outcomes were not significantly related to changes observed in hemoglobin A1c during individuals' participation in the 1-year intervention. CONCLUSIONS: These results indicate that the impact of the Bronx A1C intervention was not just on short-term improvements in glycemic control but also on long-term health care utilization. This finding is important because it suggests the benefits of the intervention were long-lasting with the potential to not only reduce hospitalizations but also to lower hospital-associated costs.

5.
J Acquir Immune Defic Syndr ; 83(4): 405-414, 2020 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-31904707

RESUMO

BACKGROUND: Tobacco use has emerged as the leading killer of persons living with HIV (PLWH) in the United States. Little is known about the efficacy of tobacco treatment strategies in PLWH. DESIGN: Randomized controlled trial comparing Positively Smoke Free (PSF), an intensive group therapy intervention targeting HIV-infected smokers, to brief advice to quit. All participants were offered a 12-week supply of nicotine patches. METHODS: A cohort of 450 PLWH smokers, recruited from HIV-care centers in the Bronx, New York, and Washington, DC, were randomized 1:1 into the PSF or brief advice to quit conditions. PSF is an 8-session program tailored to address the needs and concerns of HIV-infected smokers and delivered by a trained smoking cessation counselor and PLWH ex-smoker peer pair. The primary outcome was biochemically confirmed, 7-day point-prevalence abstinence at 6 months. RESULTS: In the intention to treat analysis, PSF condition subjects had nearly double the quit rate of controls, 13% vs. 6.6% [odds ratio = 2.10 (95% confidence interval = 1.10 to 4.14), P = 0.04], at 3 months, but no significant difference in abstinence was observed at 6 months. PSF participants exhibited lower nicotine dependence and higher self-efficacy to resist smoking temptations at both 3 and 6 months compared with controls. Lower educational attainment, current cocaine use, past use of nicotine patches, and higher distress tolerance were significant predictors of continued smoking at 6 months. CONCLUSIONS: These findings suggest a role for group therapy among tobacco treatments for PLWH smokers, but strategies to augment the durability of early effects are needed.

6.
J Natl Cancer Inst ; 112(2): 154-160, 2020 Feb 01.
Artigo em Inglês | MEDLINE | ID: mdl-31165854

RESUMO

BACKGROUND: TAILORx demonstrated that women with node-negative, hormone receptor-positive, HER2-negative breast cancers and Oncotype DX recurrence scores (RS) of 0-25 had similar 9-year outcomes with endocrine vs chemo-endocrine therapy; evidence for women aged 50 years and younger and RS 16-25 was less clear. We estimated how expected changes in practice following the trial might affect US costs in the initial 12 months of care (initial costs). METHODS: Data from Surveillance, Epidemiology, and End Results (SEER), SEER-Medicare, and SEER-Genomic Health Inc datasets were used to estimate Oncotype DX testing and chemotherapy rates and mean initial costs pre- and post-TAILORx (in 2018 dollars), assuming all women received Oncotype DX testing and score-suggested therapy posttrial. Sensitivity analyses tested the impact on costs of assumptions about compliance with testing and score-suggested treatment and estimation methods. RESULTS: Pretrial mean initial costs were $2.816 billion. Posttrial, Oncotype DX testing costs were projected to increase from $115 to $231 million and chemotherapy use to decrease from 25% to 17%, resulting in initial care costs of $2.766 billion, or a net savings of $49 million (1.8% decrease). A small net savings was seen under most assumptions. The one exception was if all women aged 50 years and younger with tumors with RS 16-25 elected to receive chemotherapy, initial care costs could increase by $105 million (4% increase). CONCLUSIONS: Personalizing breast cancer treatment based on tumor genetic profiles could result in small cost decreases in the initial 12 months of care. Studies are needed to evaluate the long-term costs and nonmonetary benefits of personalized cancer care.

7.
Contraception ; 101(3): 199-204, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31862409

RESUMO

PURPOSE: There is a need to improve delivery of family planning services, including preconception and contraception services, in primary care. We assessed whether a clinician-facing clinical decision support implemented in a family medicine staffed primary care network improved provision of family planning services for reproductive-aged female patients, and differed in effect for certain patients or clinical settings. METHODS: We conducted a pragmatic study with difference-in-differences design to estimate, at the visit-level, the clinical decision support's effect on documenting the provision of family planning services 52 weeks prior to and after implementation. We also used logistic regression with a sample subset to evaluate intervention effect on the patient-level. RESULTS: 27,817 eligible patients made 91,185 visits during the study period. Overall, unadjusted documentation of family planning services increased by 2.7 percentage points (55.7% pre-intervention to 58.4% intervention). In the adjusted analysis, documentation increased by 3.4 percentage points (95% CI: 2.24, 4.63). The intervention effect varied across sites at the visit-level, ranging from a -1.2 to +6.5 percentage point change. Modification of effect by race, insurance, and site were substantial, but not by age group nor ethnicity. Additionally, patient-level subset analysis showed that those exposed to the intervention had 1.26 times the odds of having family planning services documented after implementation compared to controls (95% CI: 1.17, 1.36). CONCLUSIONS: This clinical decision support modestly improved documentation of family planning services in our primary care network; effect varied across sites. IMPLICATIONS: Integrating a family planning services clinical decision support into the electronic medical record at primary care sites may increase the provision of preconception and/or contraception services for women of reproductive age. Further study should explore intervention effect at sites with lower initial provision of family planning services.

8.
Public Health Nutr ; : 1-14, 2019 Nov 04.
Artigo em Inglês | MEDLINE | ID: mdl-31680658

RESUMO

OBJECTIVE: To assess the accuracy of government inspection records, relative to ground observation, for identifying businesses offering foods/drinks. DESIGN: Agreement between city and state inspection records v. ground observations at two levels: businesses and street segments. Agreement could be 'strict' (by business name, e.g. 'Rizzo's') or 'lenient' (by business type, e.g. 'pizzeria'); using sensitivity and positive predictive value (PPV) for businesses and using sensitivity, PPV, specificity and negative predictive value (NPV) for street segments. SETTING: The Bronx and the Upper East Side (UES), New York City, USA. PARTICIPANTS: All food/drink-offering businesses on sampled street segments (n 154 in the Bronx, n 51 in the UES). RESULTS: By 'strict' criteria, sensitivity and PPV of government records for food/drink-offering businesses were 0·37 and 0·57 in the Bronx; 0·58 and 0·60 in the UES. 'Lenient' values were 0·40 and 0·62 in the Bronx; 0·60 and 0·62 in the UES. Sensitivity, PPV, specificity and NPV of government records for street segments having food/drink-offering businesses were 0·66, 0·73, 0·84 and 0·79 in the Bronx; 0·79, 0·92, 0·67, and 0·40 in the UES. In both areas, agreement varied by business category: restaurants; 'food stores'; and government-recognized other storefront businesses ('gov. OSB', i.e. dollar stores, gas stations, pharmacies). Additional business categories - 'other OSB' (barbers, laundromats, newsstands, etc.) and street vendors - were absent from government records; together, they represented 28·4 % of all food/drink-offering businesses in the Bronx, 22·2 % in the UES ('other OSB' and street vendors were sources of both healthful and less-healthful foods/drinks in both areas). CONCLUSIONS: Government records frequently miss or misrepresent businesses offering foods/drinks, suggesting caveats for food-environment assessments using such records.

9.
J Natl Cancer Inst ; 2019 Sep 10.
Artigo em Inglês | MEDLINE | ID: mdl-31503283

RESUMO

BACKGROUND: Digital breast tomosynthesis (DBT) is increasingly being used for routine breast cancer screening. We projected the long-term impact and cost-effectiveness of DBT compared to conventional digital mammography (DM) for breast cancer screening in the United States. METHODS: Three Cancer Intervention and Surveillance Modeling Network (CISNET) breast cancer models simulated U.S. women aged ≥40 years undergoing breast cancer screening with either DBT or DM starting in 2011 and continuing for the lifetime of the cohort. Screening performance estimates were based on observational data; in an alternative scenario we assumed 4% higher sensitivity for DBT. Analyses used federal payer perspective; costs and utilities were discounted at 3% annually. Outcomes included breast cancer deaths, quality-adjusted life-years (QALYs), false-positive examinations, costs, and incremental cost-effectiveness ratios (ICERs). RESULTS: Compared to DM, DBT screening resulted in a slight reduction in breast cancer deaths (range across models 0-0.21/1,000 women), small increase in QALYs (1.97-3.27/1,000 women) and a 24-28% reduction in false-positive exams (237-268/1,000 women) relative to DM. ICERs ranged from $195,026-$270,135/QALY for DBT relative to DM. When assuming 4% higher DBT sensitivity, ICERs decreased to $130,533-$156,624/QALY. ICERs were sensitive to DBT costs, decreasing to $78,731-$168,883 and $52,918-$118,048 when the additional cost of DBT was reduced to $36 and $26 (from baseline of $56), respectively. CONCLUSION: DBT reduces false-positive exams while achieving similar or slightly improved health benefits. At current reimbursement rates, the additional costs of DBT screening are likely high relative to the benefits gained; however, DBT could be cost-effective at lower screening costs.

10.
JAMA Pediatr ; 2019 Aug 26.
Artigo em Inglês | MEDLINE | ID: mdl-31449284

RESUMO

Importance: Multiple-birth infants in neonatal intensive care units (NICUs) have nearly identical patient identifiers and may be at greater risk of wrong-patient order errors compared with singleton-birth infants. Objectives: To assess the risk of wrong-patient orders among multiple-birth infants and singletons receiving care in the NICU and to examine the proportion of wrong-patient orders between multiple-birth infants and siblings (intrafamilial errors) and between multiple-birth infants and nonsiblings (extrafamilial errors). Design, Setting, and Participants: A retrospective cohort study was conducted in 6 NICUs of 2 large, integrated health care systems in New York City that used distinct temporary names for newborns per the requirements of The Joint Commission. Data were collected from 4 NICUs at New York-Presbyterian Hospital from January 1, 2012, to December 31, 2015, and 2 NICUs at Montefiore Health System from July 1, 2013, to June 30, 2015. Data were analyzed from May 1, 2017, to December 31, 2017. All infants in the 6 NICUs for whom electronic orders were placed during the study periods were included. Main Outcomes and Measures: Wrong-patient electronic orders were identified using the Wrong-Patient Retract-and-Reorder (RAR) Measure. This measure was used to detect RAR events, which are defined as 1 or more orders placed for a patient that are retracted (ie, canceled) by the same clinician within 10 minutes, then reordered by the same clinician for a different patient within the next 10 minutes. Results: A total of 10 819 infants were included: 85.5% were singleton-birth infants and 14.5% were multiple-birth infants (male, 55.8%; female, 44.2%). The overall wrong-patient order rate was significantly higher among multiple-birth infants than among singleton-birth infants (66.0 vs 41.7 RAR events per 100 000 orders, respectively; adjusted odds ratio, 1.75; 95% CI, 1.39-2.20; P < .001). The rate of extrafamilial RAR events among multiple-birth infants (36.1 per 100 000 orders) was similar to that of singleton-birth infants (41.7 per 100 000 orders). The excess risk among multiple-birth infants (29.9 per 100 000 orders) appears to be owing to intrafamilial RAR events. The risk increased as the number of siblings receiving care in the NICU increased; a wrong-patient order error occurred in 1 in 7 sets of twin births and in 1 in 3 sets of higher-order multiple births. Conclusions and Relevance: This study suggests that multiple-birth status in the NICU is associated with significantly increased risk of wrong-patient orders compared with singleton-birth status. This excess risk appears to be owing to misidentification between siblings. These results suggest that a distinct naming convention as required by The Joint Commission may provide insufficient protection against identification errors among multiple-birth infants. Strategies to reduce this risk include using given names at birth, changing from temporary to given names when available, and encouraging parents to select names for multiple births before they are born when acceptable to families.

11.
JAMA ; 321(18): 1780-1787, 2019 05 14.
Artigo em Inglês | MEDLINE | ID: mdl-31087021

RESUMO

Importance: Recommendations in the United States suggest limiting the number of patient records displayed in an electronic health record (EHR) to 1 at a time, although little evidence supports this recommendation. Objective: To assess the risk of wrong-patient orders in an EHR configuration limiting clinicians to 1 record vs allowing up to 4 records opened concurrently. Design, Setting, and Participants: This randomized clinical trial included 3356 clinicians at a large health system in New York and was conducted from October 2015 to April 2017 in emergency department, inpatient, and outpatient settings. Interventions: Clinicians were randomly assigned in a 1:1 ratio to an EHR configuration limiting to 1 patient record open at a time (restricted; n = 1669) or allowing up to 4 records open concurrently (unrestricted; n = 1687). Main Outcomes and Measures: The unit of analysis was the order session, a series of orders placed by a clinician for a single patient. The primary outcome was order sessions that included 1 or more wrong-patient orders identified by the Wrong-Patient Retract-and-Reorder measure (an electronic query that identifies orders placed for a patient, retracted, and then reordered shortly thereafter by the same clinician for a different patient). Results: Among the 3356 clinicians who were randomized (mean [SD] age, 43.1 [12.5] years; mean [SD] experience at study site, 6.5 [6.0] years; 1894 females [56.4%]), all provided order data and were included in the analysis. The study included 12 140 298 orders, in 4 486 631 order sessions, placed for 543 490 patients. There was no significant difference in wrong-patient order sessions per 100 000 in the restricted vs unrestricted group, respectively, overall (90.7 vs 88.0; odds ratio [OR], 1.03 [95% CI, 0.90-1.20]; P = .60) or in any setting (ED: 157.8 vs 161.3, OR, 1.00 [95% CI, 0.83-1.20], P = .96; inpatient: 185.6 vs 185.1, OR, 0.99 [95% CI, 0.89-1.11]; P = .86; or outpatient: 7.9 vs 8.2, OR, 0.94 [95% CI, 0.70-1.28], P = .71). The effect did not differ among settings (P for interaction = .99). In the unrestricted group overall, 66.2% of the order sessions were completed with 1 record open, including 34.5% of ED, 53.7% of inpatient, and 83.4% of outpatient order sessions. Conclusions and Relevance: A strategy that limited clinicians to 1 EHR patient record open compared with a strategy that allowed up to 4 records open concurrently did not reduce the proportion of wrong-patient order errors. However, clinicians in the unrestricted group placed most orders with a single record open, limiting the power of the study to determine whether reducing the number of records open when placing orders reduces the risk of wrong-patient order errors. Trial Registration: clinicaltrials.gov Identifier: NCT02876588.


Assuntos
Registros Eletrônicos de Saúde , Erros Médicos/estatística & dados numéricos , Centros Médicos Acadêmicos , Adulto , Prestação Integrada de Cuidados de Saúde , Feminino , Humanos , Masculino , Erros Médicos/prevenção & controle , Sistemas Computadorizados de Registros Médicos/organização & administração , Pessoa de Meia-Idade , Comportamento Multitarefa , Near Miss/estatística & dados numéricos , Segurança do Paciente , Carga de Trabalho
12.
JAMA Facial Plast Surg ; 21(4): 271-276, 2019 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-31120473

RESUMO

Importance: Despite advancements, treatment of mandibular body fractures is plagued by complications. Evaluation of a new plating system is needed with the goal of reducing complication rates. Objectives: To evaluate the biomechanical behavior of a vertically oriented box plate vs traditional rigid internal fixation plating techniques for mandibular body fractures and to test if placement of the 3-dimensional plate oriented parallel to the fracture line provides improved rigidity and greater resistance to torsion, resulting in improved outcomes. Design, Setting, and Participants: A mandible fracture model with synthetic replicas was used to compare resistance to torsional forces of different plating configurations. Additionally, a retrospective comparative review of the medical records of 84 patients with mandibular body fractures treated from 2005 to 2018 at Jacobi Medical Center, a level-1 trauma hospital in Bronx, New York, was completed. Exposures: Patients sustained a mandibular body fracture and were treated with open reduction and internal fixation using metal plating. Main Outcomes and Measures: In the comparative study of biomechanical behavior of various plating configurations, maximum torque sustained prior to deformation and loss of alignment was measured. Medical records were reviewed for surgical approach, plating techniques, operative time, length of admission, and rate of complications, including malocclusion, nonunion, infection, neurosensory disturbance, and wound dehiscence. Results: Of the 84 patients included in the retrospective review, 76 (91%) were men, and the mean (SD) age was 29.7 (12.0) years. During biomechanical analysis, the vertical box plate provided greater stability and 150% of the resistance against torsional forces when compared with traditional linear plating. In the retrospective review, analysis showed vertical plating was associated with a lower incidence of postoperative neurosensory disturbance (25 [38%] patients treated with vertical plating vs 0 patients treated with box plating; P = .002) and a lower risk of any complication (41 [62%] vs 6 [33%], respectively; relative risk, 0.54; 95% CI, 0.27-1.06; P = .03). Vertical plating was associated with reduced operative time (134 minutes vs 70 minutes, respectively; P < .001). Conclusions and Relevance: This investigation suggests that vertical box plating is associated with a lower incidence of postoperative complications and reduced operative time compared with traditional plating techniques. The comparative biomechanical component demonstrated that the vertical box plate offered equal or greater resistance to torsional forces. Further studies of greater power and level of evidence are needed to more robustly demonstrate these benefits. Level of Evidence: 3.


Assuntos
Placas Ósseas , Fixação Interna de Fraturas/instrumentação , Fraturas Mandibulares/cirurgia , Adulto , Fenômenos Biomecânicos , Feminino , Humanos , Masculino , Duração da Cirurgia , Complicações Pós-Operatórias , Estudos Retrospectivos
13.
Dis Markers ; 2019: 5853486, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30944667

RESUMO

Background: Bacterium and leucocyte counts in urine can be measured by urine flow cytometry (UFC). They are used to predict significant bacterial growth in urine culture and to diagnose infections of the urinary tract. However, little information is available on appropriate UFC cut-off values for bacterium and leucocyte counts in specific clinical presentations. Objective: To develop, validate, and evaluate adapted cut-off values that result in a high negative predictive value for significant bacterial growth in urine culture in common clinical presentation subgroups. Methods: This is a single center, retrospective, observational study with data from patients of the emergency department of Bern University Hospital, Switzerland, with suspected infections of the urinary tract. The patients presented with different symptoms, and urine culture and urine flow cytometry were performed. For different clinical presentations, the patients were grouped by (i) age (>65 years), (ii) sex, (iii) clinical symptoms (e.g., fever or dysuria), and (iv) comorbidities such as diabetes and immunosuppression. For each group, cut-off values were developed, validated, and analyzed using different strategies, i.e., linear discriminant analysis (LDA) and Youden's index, and were compared with known cut-offs and cut-offs optimized for sensitivity. Results: 613 patients were included in the study. Significant bacterial growth in urine culture depended on clinical presentation and ranged from 32.3% in male patients to 61.5% in patients with urinary frequency. In all clinical presentations, the predictive accuracy of UFC leucocyte and UFC bacterium counts was good for significant bacterial growth in urine culture (AUC ≥ 0.88). The adapted LDA95 equations did not exhibit consistently high sensitivity. However, the in-house cut-offs (test positive if UFC leucocytes > 17/µL or UFC bacteria > 125/µL) were highly sensitive (>90%). In female, younger, and dysuric patients, even higher cut-offs for UFC leucocytes (169/µL, 169/µL, and 205/µL) exhibited high sensitivity. Specificity was insufficient (<0.9) for all tested cut-offs. Conclusions: For various clinical presentations, significant bacterial growth in urine culture can be excluded if flow cytometry measurements give a bacterial count of ≤125/µL or a leucocyte count of ≤17/µL. In female patients, dysuric patients, and patients younger than ≤65 years, the leucocyte cut-off can be increased to 170/µL.


Assuntos
Citometria de Fluxo/normas , Infecções Urinárias/urina , Urina/microbiologia , Idoso , Carga Bacteriana , Feminino , Citometria de Fluxo/métodos , Humanos , Contagem de Leucócitos , Masculino , Pessoa de Meia-Idade , Infecções Urinárias/microbiologia , Infecções Urinárias/patologia , Urina/citologia
14.
Endocr Pract ; 25(7): 689-697, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30865543

RESUMO

Objective: This study aimed to assess the impact of multidisciplinary process improvement interventions on glycemic control in the inpatient setting of an urban community hospital, utilizing the daily simple average as the primary glucometric measure. Methods: From 2010-2014, five process of care interventions were implemented in the noncritical care inpatient units of the study hospital. Interventions included education of medical staff, implementation of hyperglycemia and hypoglycemia protocols, computerized insulin order entry, and coordination of meal tray delivery with finger stick and insulin administration. Unpaired t tests compared pre- and postintervention process measures. Simple average daily glucose measure was the primary glucometric outcome. Secondary outcome measures included frequency of hyperglycemia and hypoglycemia. Glucose outcomes were compared with an in-network hospital that did not implement the respective interventions. Results: A total of 180,431 glucose measurements were reported from 4,705 and 4,238 patients from the intervention and comparison hospitals, respectively. The time between bolus-insulin administration and breakfast tray delivery was significantly reduced by 81.7 minutes (P<.00005). The use of sliding scale insulin was sustainably reduced. Average daily glucose was reduced at both hospitals, and overall rates of hypoglycemia were low. Conclusion: A multidisciplinary approach at an urban community hospital with limited resources was effective in improving and sustaining processes of care for improved glycemic control in the noncritical care, inpatient setting. Abbreviations: IQR = interquartile range; JMC = Jacobi Medical Center; NCBH = North Central Bronx Hospital.


Assuntos
Hiperglicemia , Hipoglicemia , Glicemia , Assistência à Saúde , Humanos , Hipoglicemiantes , Insulina
15.
Diabetes Res Clin Pract ; 148: 212-221, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30641164

RESUMO

AIMS: To describe implementation of diabetes and hypertension program in rural Dominican Republic (DR), and report six years of quality improvement process and health outcomes. METHODS: Dominican teams at two clinics are supported by Chronic Care International with: supervision and continuing education, electronic database, diabetes and hypertension protocols, medications, self-management education materials, behavior change techniques, and equipment and testing supplies (e.g., HbA1c, lipids, blood pressure, BMI). A monthly dashboard for care processes and health outcomes guides problem solving and goal setting. Results were analyzed for quality improvement reports and by fitting the clinical data to random-effects linear models. RESULTS: 1191 adults were enrolled in the program at two clinics (44% men, baseline means: 56.4 years, BMI 27.4 kg/m2, HbA1c 8.8% (73 mmol/mol), BP 133/81 mmHg). Data show steady growth in clinic populations reaching capacity. Protocols for comprehensive foot examinations, BP and HbA1c assessments, and proportions reaching quality measures improved over time, especially after clinic goal setting. Modeling of BP, BMI and HbA1c values revealed important differences in outcomes by clinic over time. CONCLUSIONS: Improvements in process and health outcomes are attainable in rural DR when medical teams have support and access to data. Scalability and sustainability are continuing goals.


Assuntos
Diabetes Mellitus Tipo 2/diagnóstico , Diabetes Mellitus Tipo 2/epidemiologia , Diabetes Mellitus Tipo 2/terapia , Melhoria de Qualidade , Serviços de Saúde Rural , Adulto , Idoso , Pressão Sanguínea/fisiologia , Determinação da Pressão Arterial/métodos , Determinação da Pressão Arterial/normas , Diabetes Mellitus Tipo 2/complicações , República Dominicana/epidemiologia , Feminino , Humanos , Hipertensão/complicações , Hipertensão/diagnóstico , Hipertensão/epidemiologia , Hipertensão/fisiopatologia , Assistência de Longa Duração , Masculino , Pessoa de Meia-Idade , Medidas de Resultados Relatados pelo Paciente , Avaliação de Programas e Projetos de Saúde , Melhoria de Qualidade/normas , Serviços de Saúde Rural/organização & administração , Serviços de Saúde Rural/normas , População Rural/estatística & dados numéricos
16.
Int J Radiat Oncol Biol Phys ; 104(3): 540-552, 2019 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-30496877

RESUMO

PURPOSE: Developing a quantitative decision-support strategy estimating the impact of normal tissue complications from definitive radiation therapy (RT) for head and neck cancer (HNC). We developed this strategy to identify patients with oropharyngeal HNC who may benefit most from receiving proton RT. METHODS AND MATERIALS: Recent normal tissue complication probability (NTCP) models for dysphagia, esophagitis, hypothyroidism, xerostomia, and oral mucositis were used to estimate NTCP for 33 patients with oropharyngeal HNC previously treated with photon intensity modulated radiation therapy (IMRT). Comparative proton therapy plans were generated using clinical protocols for HNC RT at a collaborating proton center. Organ-at-risk (OAR) doses from photon and proton RT plans were used to calculate NTCPs; Monte Carlo sampling 10,000 times was used for each patient to account for model parameter uncertainty. The latency and duration of each complication were modeled from calculated NTCP, accounting for age-, sex-, smoking- and p16-specific conditional survival probability. Complications were then assigned quality-adjustment factors based on severity to calculate quality-adjusted life years (QALYs) lost from each complication. RESULTS: Based on our institutional-delivered photon IMRT doses and the achievable proton therapy doses, the average QALY reduction from all HNC RT complications for photon and proton therapy was 1.52 QALYs versus 1.15 QALYs, with proton therapy sparing 0.37 QALYs on average (composite 95% confidence interval, 0.27-2.53 QALYs). Long-term complications (dysphagia and xerostomia) contributed most to the QALY reduction. The QALYs spared with proton RT varied considerably among patients, ranging from 0.06 to 0.84 QALYs. Younger patients with p16-positive tumors who smoked ≤10 pack-years may benefit most from proton therapy, although this finding should be validated using larger patient series. A sensitivity analysis reducing photon IMRT doses to all OARs by 20% resulted in no overall estimated benefit with proton therapy with -0.02 QALYs spared, although some patients still had an estimated benefit in this scenario, ranging from -0.50 to 0.43 QALYs spared. CONCLUSIONS: This quantitative decision-support strategy allowed us to identify patients with oropharyngeal cancer who might benefit the most from proton RT, although the estimated benefit of proton therapy ultimately depends on the OAR doses achievable with modern photon IMRT solutions. These results can help radiation oncologists and proton therapy centers optimize resource allocation and improve quality of life for patients with HNC.


Assuntos
Sistemas de Apoio a Decisões Clínicas , Órgãos em Risco/efeitos da radiação , Neoplasias Orofaríngeas/radioterapia , Terapia com Prótons/efeitos adversos , Anos de Vida Ajustados por Qualidade de Vida , Radioterapia de Intensidade Modulada/efeitos adversos , Fatores Etários , Idoso , Inibidor p16 de Quinase Dependente de Ciclina/metabolismo , Transtornos de Deglutição/etiologia , Fracionamento da Dose de Radiação , Esofagite/etiologia , Feminino , Humanos , Hipotireoidismo/etiologia , Masculino , Pessoa de Meia-Idade , Método de Monte Carlo , Tratamentos com Preservação do Órgão/métodos , Neoplasias Orofaríngeas/metabolismo , Probabilidade , Dosagem Radioterapêutica , Planejamento da Radioterapia Assistida por Computador , Fumar/efeitos adversos , Estomatite/etiologia , Xerostomia/etiologia
17.
J Community Health ; 44(2): 339-364, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30448877

RESUMO

The overall nutritional quality of foods/drinks available at urban food pantries is not well established. In a study of 50 pantries listed as operating in the Bronx, NY, data on food/drink type (fresh, shelf-stable, refrigerated/frozen) came from direct observation. Data on food/drink sourcing (food bank or other) and distribution (prefilled bag vs. client choice for a given client's position in line) came from semi-structured interviews with pantry workers. Overall nutritional quality was determined using NuVal® scores (range 1-100; higher score indicates higher nutritional quality). Twenty-nine pantries offered zero nutrition at listed times (actually being closed or having no food/drinks in stock). Of the 21 pantries that were open as listed and had foods/drinks to offer, 12 distributed items in prefilled bags (traditional pantries), 9 allowed for client choice. Mean NuVal® scores were higher for foods/drinks available from client-choice pantries than traditional pantries (69.3 vs. 57.4), driven mostly by sourcing fresh items (at 28.3% of client-choice pantries vs. 4.8% of traditional pantries). For a hypothetical 'balanced basket' of one of each fruit, vegetable, grain, dairy and protein item, highest-NuVal® items had a mean score of 98.8 across client-choice pantries versus 96.6 across traditional pantries; lowest-NuVal® items had mean scores of 16.4 and 35.4 respectively. Pantry workers reported lower-scoring items (e.g., white rice) were more popular-appeared in early bags or were selected first-leaving higher-scoring items (e.g., brown rice) for clients later in line. Fewer than 50% of sampled pantries were open and had food/drink to offer at listed times. Nutritional quality varied by item type and sourcing and could also vary by distribution method and client position in line. Findings suggest opportunities for pantry operation, client and staff education, and additional research.

18.
J Community Health ; 44(1): 16-31, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30019196

RESUMO

For individuals who are food insecure, food pantries can be a vital resource to improve access to adequate food. Access to adequate food may be conceptualized within five dimensions: availability (item variety), accessibility (e.g., hours of operation), accommodation (e.g., cultural sensitivity), affordability (costs, monetary or otherwise), and acceptability (e.g., as related to quality). This study examined the five dimensions of access in a convenience sample of 50 food pantries in the Bronx, NY. The design was cross-sectional. Qualitative data included researcher observations and field notes from unstructured interviews with pantry workers. Quantitative data included frequencies for aspects of food access, organized by the five access dimensions. Inductive analysis of quantitative and qualitative data revealed three main inter-related findings: (1) Pantries were not reliably open: only 50% of pantries were open during hours listed in an online directory (several had had prolonged or indefinite closures); (2) Even when pantries were open, all five access dimensions showed deficiencies (e.g., limited inventory, few hours, pre-selected handouts without consideration of preferences, opportunity costs, and inferior-quality items); (3) Open pantries frequently had insufficient food supply to meet client demand. To deal with mismatch between supply and demand, pantries developed rules for food provision. Rules could break down in cases of pantries receiving food deliveries, leading to workarounds, and in cases of compelling client need, leading to exceptions. Adherence to rules, versus implementation of workarounds and/or exceptions, was worker- and situation-dependent and, thus, unpredictable. Overall, pantry food provision was unreliable. Future research should explore clients' perception of pantry access considering multiple access dimensions. Future research should also investigate drivers of mismatched supply and demand to create more predictable, reliable, and adequate food provision.


Assuntos
Assistência Alimentar , Abastecimento de Alimentos , Estudos Transversais , Assistência Alimentar/normas , Assistência Alimentar/estatística & dados numéricos , Humanos , Cidade de Nova Iorque , População Urbana
19.
J Natl Cancer Inst ; 110(12): 1370-1379, 2018 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-30239794

RESUMO

Background: Radiotherapy after breast conservation has become the standard of care. Prior meta-analyses on effects of radiotherapy predated availability of gene expression profiling (GEP) to assess recurrence risk and/or did not include all relevant outcomes. This analysis used GEP information with pooled individual-level data to evaluate the impact of omitting radiotherapy on recurrence and mortality. Methods: We considered trials that evaluated or administered radiotherapy after lumpectomy in women with low-risk breast cancer. Women included had undergone lumpectomy and were treated with hormonal therapy for stage I, ER+ and/or PR+, HER2- breast cancer with Oncotype scores no greater than 18. Recurrence-free interval (RFI), type of RFI (locoregional or distant), and breast cancer-specific and overall survival were compared between no radiotherapy and radiotherapy using adjusted Cox models. All statistical tests were two-sided. Results: The final sample included 1778 women from seven trials. Omission of radiotherapy was associated with an overall adjusted hazard ratio of 2.59 (95% confidence interval [CI] = 1.38 to 4.89, P = .003) for RFI. There was a statistically significant increase in any first locoregional recurrence (P = .001), but not distant recurrence events (P = .90), or breast cancer-specific (P = .85) or overall survival (P = .61). Five-year RFI rate was high (93.5% for no radiotherapy vs 97.9% for radiotherapy; absolute reduction = 4.4%, 95% CI = 0.7% to 8.1%, P = .03). The effects of radiotherapy varied across subgroups, with lower RFI rates for those with Oncotype scores of less than 11 (vs 11-18), older (vs younger), and ER+/PR+ status (vs other). Conclusions: Omission of radiotherapy in hormone-sensitive patients with low recurrence risk may lead to a modest increase in locoregional recurrence event rates, but does not appear to increase the rate of distant recurrence or death.


Assuntos
Neoplasias da Mama/diagnóstico , Neoplasias da Mama/radioterapia , Idoso , Idoso de 80 Anos ou mais , Antineoplásicos Hormonais/uso terapêutico , Neoplasias da Mama/genética , Neoplasias da Mama/mortalidade , Ensaios Clínicos como Assunto , Terapia Combinada , Feminino , Humanos , Pessoa de Meia-Idade , Gradação de Tumores , Recidiva Local de Neoplasia , Estadiamento de Neoplasias , Modelos de Riscos Proporcionais , Radioterapia Adjuvante
20.
J Acad Nutr Diet ; 118(11): 2128-2134, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30227952

RESUMO

BACKGROUND: Local food environments include food stores (eg, supermarkets, grocery stores, bakeries) and restaurants. However, the extent to which other storefront businesses offer food/drink is not well described, nor is the extent to which food/drink availability through a full range of storefront businesses might change over time. OBJECTIVES: This study aimed to assess food/drink availability from a full range of storefront businesses and the change over time and to consider implications for food-environment research. DESIGN: Investigators compared direct observations from 2010 and 2015. PARTICIPANTS/SETTING: Included were all storefront businesses offering foods/drinks on 153 street segments in the Bronx, NY. MAIN OUTCOME MEASURES: The main outcome was change between 2010 and 2015 as determined by matches between businesses. Matches could be strict (businesses with the same name on the same street segment in both years) or lenient (similar businesses on the same street segment in both years). Investigators categorized businesses as general grocers, specialty food stores, restaurants, or other storefront businesses (eg, barber shops/beauty salons, clothing outlets, hardware stores, laundromats, and newsstands). STATISTICAL ANALYSES PERFORMED: Investigators quantified change, specifically calculating how often businesses in 2015 were present in 2010 and vice versa. RESULTS: Strict matches for businesses in 2015 present in 2010 ranged from 29% to 52%, depending on business category; lenient matches ranged from 43% to 72%. Strict matches for businesses in 2010 present in 2015 ranged from 34% to 63%; lenient matches ranged from 72% to 83%. In 2015 compared with 2010, on 22% more of the sampled street segments, 30% more businesses were offering food/drink: 66 vs 46 general grocers, 22 vs 19 specialty food stores, 99 vs 99 restaurants, 98 vs 56 other storefront businesses. CONCLUSIONS: Over 5 years, an urban food environment changed substantially, even by lenient standards, particularly among "other storefront businesses" and in the direction of markedly greater food availability (more businesses offering food on more streets). Failure to consider a full range of food/drink sources and change in food/drink sources could result in erroneous food-environment conclusions.


Assuntos
Comércio/estatística & dados numéricos , Meio Ambiente , Indústria Alimentícia/estatística & dados numéricos , Abastecimento de Alimentos/estatística & dados numéricos , Alimentos/estatística & dados numéricos , População Urbana , Bebidas/estatística & dados numéricos , Dieta , Ingestão de Alimentos , Fast Foods , Humanos , Cidade de Nova Iorque , Características de Residência , Restaurantes/estatística & dados numéricos
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