Performance of Staging Systems for Non-Head and Neck Cutaneous Squamous Cell Carcinoma.

BACKGROUND: The performance of staging systems in non-head and neck cutaneous squamous cell carcinomas has not been well established. OBJECTIVE: To evaluate the performance of the American Joint Committee on Cancer 8th Edition and Brigham and Women's Hospital staging systems in non-head and neck squamous cell carcinomas. MATERIALS AND METHODS: Eligible tumors were identified and staged from an existing retrospective database. Cumulative incidence function curves of any poor outcome were generated. Distinctiveness, sensitivity, specificity, positive and negative predictive value, and concordance index were calculated. RESULTS: 1,042 primary tumors were included, with 38 resulting in any poor outcome and 16 in any major poor outcome. High-stage tumors represented 2.2% and 3.5% of tumors; these accounted for 10/38 of the poor outcomes (26.3%) and 8/16 of the major poor outcomes (50%). High-stage tumors predicted major poor outcomes with a sensitivity of 0.5 and specificity of 0.99 for the Brigham and Women's Hospital system, and a sensitivity of 0.5 and specificity of 0.97 for the American Joint Committee on Cancer 8th edition system. The concordance index for both was 0.74. CONCLUSION: Current staging systems can be used to predict poor outcomes in cutaneous squamous cell carcinomas off the head and neck.

Cutaneous Squamous Cell Carcinoma Outcomes in Solid Organ Transplant Recipients: A Matched Retrospective Cohort Study.

BACKGROUND: Solid organ transplant recipients with cutaneous squamous cell carcinoma (CSCC) have an increased risk of poor outcomes. However, a recent study demonstrated that immunosuppression is not an independent risk factor for these poor outcomes after controlling for primary tumor stage. OBJECTIVE: To evaluate whether transplant status is an independent risk factor for poor outcomes in CSCC. MATERIALS AND METHODS: A database of CSCCs treated at an academic center over 10 years was used to perform a retrospective cohort study comparing the risk of poor outcomes (local recurrence, regional and distant metastases, and disease-specific death) in solid organ transplant recipients and controls. Subjects were matched on age, tumor stage, sex, tumor site, and time to poor outcome. RESULTS: There were 316 tumors from 78 transplant patients and 316 tumors from 262 controls. On multivariate analysis, tumor stage and location on the head and neck were predictive of poor outcomes. There was no significant difference in the risk of poor outcomes in the transplant group versus the control group. CONCLUSION: Transplant status was not an independent risk factor for poor squamous cell carcinoma outcomes after controlling for stage, age, sex, site, and time to poor outcome.

Social determinants of health and depressive symptoms before and after cancer diagnosis.

Despite frequent reports of mental health needs among older women with cancer, depressive symptoms often go unrecognized and untreated, particularly in socially vulnerable survivors. Here, we examined associations of sociodemographic factors and social limitations with depressive symptoms from pre-diagnosis to post-diagnosis in older women diagnosed with breast or gynecological cancer. Using the Surveillance, Epidemiology, and End Results-Medicare Health Outcomes Survey (SEER-MHOS) linked dataset, we used logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for associations between sociodemographic factors (race, ethnicity, marital status, rurality) and social limitations (i.e., health interfering with social activities) on depressive symptoms in women aged ≥65 years with breast or gynecologic cancer (n = 1,353). Most participants had breast cancer (82.0%), stage I-II cancer (85.8%), received surgery for their cancer (94.8%), and radiation treatment (50.6%). Prior to diagnosis, 11.8% reported depressive symptoms, which nearly doubled to 22.4% at follow-up. Participants were 2.7 times more likely of reporting depressive symptoms after cancer diagnosis compared with pre-cancer diagnosis (95%CI: 2.10-3.48). Race, ethnicity, rurality, marital status, and social interference were significantly associated with an increased risk of depressive symptoms after cancer diagnosis than before their cancer diagnosis (p < 0.05). In summary, depressive symptoms increased following a cancer diagnosis. Our results suggest potential avenues for intervention that could lead to reduced depressive symptoms among older female cancer survivors.

Reliability of a Wearable Motion Tracking System for the Clinical Evaluation of a Dynamic Cervical Spine Function.

Neck pain is a common cause of disability worldwide. Lack of objective tools to quantify an individual's functional disability results in the widespread use of subjective assessments to measure the limitations in spine function and the response to interventions. This study assessed the reliability of the quantifying neck function using a wearable cervical motion tracking system. Three novice raters recorded the neck motion assessments on 20 volunteers using the device. Kinematic features from the signals in all three anatomical planes were extracted and used as inputs to repeated measures and mixed-effects regression models to calculate the intraclass correlation coefficients (ICCs). Cervical spine-specific kinematic features indicated good and excellent inter-rater and intra-rater reliability for the most part. For intra-rater reliability, the ICC values varied from 0.85 to 0.95, and for inter-rater reliability, they ranged from 0.7 to 0.89. Overall, velocity measures proved to be more reliable compared to other kinematic features. This technique is a trustworthy tool for evaluating neck function objectively. This study showed the potential for cervical spine-specific kinematic measurements to deliver repeatable and reliable metrics to evaluate clinical performance at any time points.

Surgeon Strategies to Patient-Centered Decision-making in Cancer Care: Validation and Applications of a Conceptual Model.

We sought to construct and validate a model of cancer surgeon approaches to patient-centered decision-making (PCDM) and compare applications of that model relative to surgical specialties. Ten PCDM strategies were assessed using a cross-sectional survey administered online to 295 board-certified cancer surgeons. Structural equation modeling was used to empirically validate and compare approaches to PCDM. Within the full sample, 7 strategies comprised a latent construct labeled, "physical & emotional accessibility," associated with surgeon approaches to PCDM (ß = 0.37, p < .05). Three individual strategies were included: "expectations (Q4)" (ß = 0.52, p < .05), "decision preferences (Q5) (ß = 0.47, p < .05), and "access medical information (Q3)" (ß = 0.75). Surgical specialties for subgroup analysis were classified as general/other (67.6%) or hepato-pancreato-biliary and upper gastrointestinal (HPB/UGI) (34.2%). For general/other surgeons, 7 individual strategies composed the model of surgeon approaches to PCDM, with "time (Q6) (ß = 0.70, p < .001) and "therapeutic relationship building (Q9)" (ß = 0.69, p < .001) being the strongest predictors. The HPB/UGI model included 2 latent constructs labeled "physical accessibility" (ß = 0.72, p < .05) and "creating a decision-making dialogue" (ß = 0.62) as well as the individual strategy, "effective communication (Q8)" (ß = 0.51, p < .05). Although models of surgeon PCDM varied, there were 4 overlapping strategies, including effective communication. Tailoring models of PCDM may improve surgeon uptake and thus, overall patient satisfaction with their cancer care.

Do Religious/Spiritual Preferences and Needs of Cancer Patients Vary Based on Clinical- and Treatment-Level Factors?

BACKGROUND: The objective of this study is to characterize the religion and spiritual (R&S) needs of patients who undergo cancer-directed surgery. In addition, we seek to examine how R&S needs vary based on R&S identity and clinical and surgical treatment characteristics. PATIENTS AND METHODS: A cross-sectional survey was administered to potential participants who were recruited through outpatient clinics and online. Respondent desires for R&S resources and engagement with the healthcare team  around R&S topics were assessed. RESULTS: Among 383 potential participants who were identified, 236 respondents were included in the analytic cohort. Mean age was 58.8 (SD 12.10) years, and most participants were female (75.8%) and White/Caucasian (94.1%). The majority (78.4%) identified as currently cancer free. Commonly treated malignancies included breast (43.2%), male reproductive (8.9%), skin (8.5%), and gastrointestinal (GI) (7.2%). Two-thirds of the respondents indicated a desire to have R&S incorporated into their cancer treatment (63.3%). Patients who identified as highly/moderately religious reported wanting R&S more often (highly religious: 95.2% versus moderately religious: 71.4% vs. nonreligious but spiritual: 4.5%). On multivariable analysis, patients who believed their health would improve in the future were more likely to report wanting R&S service (OR 2.2, 95% CI 1.0-4.7) as well as wanting to engage their healthcare providers on R&S topics (OR 2.4, 95% CI 1.2-4.7). In contrast, perception of current or future health status was not associated with patient desire for the actual surgeon/doctor him/herself to be involved in R&S activities (OR 1.83, 95% CI 0.97-3.45). CONCLUSIONS: Two-thirds of patients undergoing cancer-directed surgery expressed a desire to have R&S incorporated into their cancer treatment. Incorporating R&S into cancer treatment can help a subset of patients throughout their cancer experience.

Healthcare provider self-reported observations and behaviors regarding their role in the spiritual care of cancer patients.

PURPOSE: The provision of spiritual care by an interprofessional healthcare team is an important, yet frequently neglected, component of patient-centered cancer care. The current study aimed to assess the relationship between individual and occupational factors of healthcare providers and their self-reported observations and behaviors regarding spiritual care in the oncologic encounter. METHODS: A cross-sectional survey was administered to healthcare providers employed at a large Comprehensive Cancer Center. Pearson's chi-square test and logistic regression were used to determine potential associations between provider factors and their observations and behaviors regarding spiritual care. RESULTS: Among the participants emailed, 420 followed the survey link, with 340 (80.8%) participants completing the survey. Most participants were female (82.1%) and Caucasian (82.6%) with a median age was 35 years (IQR: 31-48). Providers included nurses (64.7%), physicians (17.9%), and "other" providers (17.4%). There was a difference in provider observations about discussing patient issues around religion and spirituality (R&S). Specifically, nurses more frequently inquired about R&S (60.3%), while physicians were less likely (41.4%) (p = 0.028). Also, nurses more frequently referred to chaplaincy/clergy (71.8%), while physicians and other providers more often consulted psychology/psychiatry (62.7%, p < 0.001). Perceived barriers to not discussing R&S topics included potentially offending patients (56.5%) and time limitations (47.7%). CONCLUSION: Removing extrinsic barriers and understanding intrinsic influences can improve the provision of spiritual care by healthcare providers.

The beliefs of cancer care providers regarding the role of religion and spirituality within the clinical encounter.

PURPOSE: To characterize cancer care provider perceptions of the role of religion and spirituality (R&S) within the clinical encounter. METHODS: A cross-sectional survey was administered to healthcare professionals (defined as someone who is authorized to diagnose and/or treat physical or mental health disorders) currently employed at The Ohio State University Comprehensive Cancer Center. Beliefs around the role of R&S within the clinical encounter were assessed using four adapted subscales/dimensions (D1-D4) from the Religion and Spirituality in Medicine: Physicians' Perspectives measure: God actively intervenes in patient health (D1), R&S is beneficial for patient mental health (D2), provider inquires about (D3) and discusses (D4) R&S in the clinical encounter. Logistic (D1) and linear (D2-D4) regression were performed using SAS v9.4 to determine the relationship between provider type and each subscale while controlling for gender, race, relationship status, education, and R&S identity. RESULTS: Among 340 participants, most participants were female (82.1%) or Caucasian (82.6%) and the median age was 35 years (IQR 31-48). Providers included physicians (17.9%), nurses (64.7%), and "other" (17.4%). Most participants identified as religious (57.5%), followed by spiritual (30.2%) and neither religious nor spiritual (12.3%). Nurses and other providers were more likely than physicians to believe that God intervenes in patient health (physician 41.7% vs. nurse 61.8% vs. other 60.3%; p = 0.02). All providers were equally as likely to believe that R&S is beneficial for patient mental health and to discuss R&S with patients within the clinical encounter (both p > 0.05). In contrast, nurses more frequently reported inquiring about R&S (median 1.7; IQR 0.9-2.0) compared with physicians (median 1.0; IQR 0.9-2.0) or other providers (median 1.4; IQR 1.0-2.1) (p < 0.001). CONCLUSIONS: There were differences between providers in beliefs regarding the role of R&S in the clinical cancer encounter. Of note, nurses and other provider types were more likely than physicians to inquire about R&S with patients. Understanding variations in these beliefs will help determine how to best incorporate R&S support for patients during their cancer care.

A mixed-methods approach to comparing perceptions of cancer patients' and cancer care providers' religious and spiritual beliefs, behaviours, and attitudes.

OBJECTIVES: To compare the perceptions of cancer patients' and cancer care providers' religious and spiritual (R&S) beliefs, behaviours, and attitudes. METHODS: A concurrent, nested, quantitative dominant, mixed-methods design was utilised. Data were collected from patient and provider groups via online survey. Analyses include chi-square tests of independence and independent t-tests for quantitative data and content analysis for qualitative data. RESULTS: The final analytic cohort for the study included 576 participants (npatients  = 236, nproviders  = 340) with an average age of 47.4 years (SD = 15.0). Over half of participants were partnered (n = 386, 70.1%), female (n = 317, 57.3%) and had an advanced degree (n = 284, 51.2%). The most common diagnosis for patients was breast cancer (n = 103, 43.2%). The most common provider role was nurse (n = 220; 64.7%), while a smaller subset included physicians (n = 61; 17.9%) and "other" providers (n = 59; 17.4%). There was no difference between patients and providers in relation to R&S identity (p = 0.49) or behaviour (p = 0.28). Providers more frequently indicated that patients should receive R&S resources in the hospital (n = 281, 89.7% vs. n = 111, 49.6%, p < 0.001). For resource type, patients most frequently endorsed written resources (n = 93, 83.8%) while providers endorsed relational resources (n = 281, 97.9%). CONCLUSION: Aligning patient and provider expectations of spiritual care will contribute to provision of optimal patient-centred cancer care.

The religious/spiritual beliefs and needs of cancer survivors who underwent cancer-directed surgery.

OBJECTIVE: We sought to characterize patients' preferences for the role of religious and spiritual (R&S) beliefs and practices during cancer treatment and describe the R&S resources desired by patients during the perioperative period. METHOD: A cross-sectional survey was administered to individuals who underwent cancer-directed surgery. Data on demographics and R&S beliefs/preferences were collected and analyzed. RESULTS: Among 236 participants, average age was 58.8 (SD = 12.10) years; the majority were female (76.2%), white (94.1%), had a significant other or spouse (60.2%), and were breast cancer survivors (43.6%). Overall, more than one-half (55.9%) of individuals identified themselves as being religious, while others identified as only spiritual (27.9%) or neither (16.2%). Patients who identified as religious wanted R&S integrated into their care more often than patients who were only spiritual or neither (p < 0.001). Nearly half of participants (49.6%) wanted R&S resources when admitted to the hospital including the opportunity to speak with an R&S leader (e.g., rabbi; 72.1%), R&S texts (64.0%), and journaling materials (54.1%). Irrespective of R&S identification, 68.0% of patients did not want their physician to engage with them about R&S topics. SIGNIFICANCE OF RESULTS: Access to R&S resources is important during cancer treatment, and incorporating R&S into cancer care may be especially important to patients that identify as religious. R&S needs should be addressed as part of the cancer care plan.

Assessing Differences in Cancer Surgeon Approaches to Patient-Centered Decision-Making Using Vignette-Based Methodology.

BACKGROUND: The objective of this study is to assess surgeon-patient-centered decision-making (PCDM) strategies relative to surgeon and patient factors. METHODS: Approaches to PCDM were evaluated using a cross-sectional survey based on clinical vignettes assessing surgeon likeliness (0 = not at all likely, 100 = very likely) to utilize PCDM strategies. Data were analyzed using repeated-measures mixed-effects linear regression. Adjusted estimates are provided as least-squares mean (LSM) values. RESULTS: The final analytic sample consisted of 208 respondents (58.5% response rate); the majority of respondents were male (67.7%) and Caucasian (82.0%) with an average age of 51.6 years (standard deviation, SD = 9.9 years, range 34.0-78.0 years). Specialties included breast (18.9%), hepatopancreatobiliary (21.4%), and other (59.7%). Surgeons practicing at academic (versus nonacademic) hospitals were less likely to be directive (LSM: 66.2 vs. 70.3, p = 0.004), spend equal time discussing all treatment options (LSM: 77.9 vs. 82.3, p = 0.001), and make explicit treatment recommendations (LSM: 67.7 vs. 71.7, p = 0.005). Surgeons who specialized in breast cancer (versus other specialties), in practice 10+ years (versus < 10 years), and female (versus male) were more likely to spend time discussing all treatment options (LSM: 82.8 vs. 77.3; 81.6 vs. 78.6; and 82.1 vs. 78.0, all p < 0.05). Surgeons perceived patients who had blue-collar (versus white-collar) jobs as less likely to want active participation in decision-making (LSM: 62.9 vs. 65.6, p = 0.02). CONCLUSION: Surgeon approaches to PCDM varied based on a number of surgeon and patient characteristics. Further studies are needed to understand how surgeon PCDM strategies can be tailored to specific care contexts and patient needs.

Incidence and impact of Textbook Outcome among patients undergoing resection of pancreatic neuroendocrine tumors: Results of the US Neuroendocrine Tumor Study Group.

BACKGROUND AND OBJECTIVES: We sought to define the incidence and impact of Textbook Outcome (TO) on disease-free survival [DFS] among patients undergoing resection of pancreatic neuroendocrine tumors (PNET). METHODS: Patients undergoing resection of a PNET between 2000 and 2016 were identified using a multi-institutional database. TO was defined as no postoperative severe complications (Clavien-Dindo grade ≥ III), no 90-day mortality, no prolonged length-of-hospital stay (LOS) (ie, > 75th percentile), no 90-day readmission after discharge, and R0 resection. The 5-year DFS was calculated and the association with TO was examined. RESULTS: Among 821 patients with a PNET, median tumor size was 2.1 cm (IQR 1.4-14.6). Resection consisted of pancreatoduodenectomy (PD) (n = 231, 28.1%), distal pancreatectomy (DP) (n = 492, 59.9%), and enucleation (EN) (n = 98, 11.9%). Overall TO rate was 49.3% (n = 405). The incidence of TO varied by procedure type (PD: 32.5% vs DP: 56.7% vs EN: 52.0%; P < .001). After adjusting for all competing factors, achievement of a TO was independently associated with improved DFS (hazard ratio: 0.54, 95% CI, 0.35-0.81; P = .003). CONCLUSIONS: Only one in two patients undergoing resection of a PNET achieved a TO, which varied markedly based on procedure type. Achievement of a TO was associated with improved DFS.

Characterizing Perceptions Around the Patient-Oncologist Relationship: a Qualitative Focus Group Analysis.

The purpose of the current study was to characterize the experiences of cancer patients and their caregiver/family members around their relationship with their oncologist, health care team, and the hospital environment. Participants were recruited from The Ohio State University Comprehensive Cancer Center. Participant sociodemographic factors were assessed. Focus groups were moderated and recorded by two members of the research team using a semi-structured interview format. The audio recordings were transcribed and uploaded to NViVO 11 for analyses. Four focus groups were conducted with 25 participants. The mean age of participants was 58.4 years (SD = 15.1, range 26.0-76.0). Participants who were identified as patients (84%) reported different malignancy types including breast (56%), gynecologic (16%), skin (6%) oral (6%), and non-Hodgkin's lymphoma (6%). Three major themes that emerged around the patient-oncologist relationship, include (1) choosing a physician and health care location, (2) relationship with the physician, health care team, and hospital environment; and (3) patient engagement and decision-making. Subthemes highlighted the importance of the flexible communication behaviors and trustworthiness of the oncologist, and the impact of other health care team members. Patients also reported the desire to be engaged in making treatment-related decisions and to include the caregiver/spouse in all stages of cancer care. Understanding the experience of cancer patients in a relationship with their oncologist in the context of the health care team and health care environment will be an important area of future research to provide optimal, tailored patient-centered cancer care.

Does spiritual and religious orientation impact the clinical practice of healthcare providers?

The objective of the current study was to assess the religious and spiritual (R&S) beliefs and practices among healthcare providers, compare R&S among provider types, as well as examine the potential relationship between organized/nonorganized religious activities and intrinsic religiosity with the incorporation of R&S into clinical practice. A cross-sectional descriptive online survey methodology was used. There were 387 participants with an average age of 45.5 years. Providers included primary care providers (26.9%), nurses (27.1%), allied health (23.5%), and mental health professionals (22.5%). Most participants reported being "religious and spiritual" (42.9%) or "spiritual and not religious" (36.6%). There was a difference in R&S among provider types (x2(6) = 12.6, p = .05) with mental health providers more often identifying as spiritual, but not religious (46.6%) compared with other providers. No mental health professional indicated almost always/often/sometimes praying with patients versus 9.5% of primary providers, 14.8% of allied providers, and 18.1% of nurses. Results from structural equation modeling showed that intrinsic religiosity was most strongly associated with how a provider interacted with patients around R&S (ß = .644, p < .001) followed by non-organized religious activities (ß = .228, p < .001) and organized religious activities (ß = .092, p = .037). Understanding the role of R&S beliefs and behaviors of healthcare providers is important to patient-centered care.

A systematic review of the methods utilised to measure the relationship between cancer patients and oncologists: Implications for future research and practice.

INTRODUCTION: The patient-physician relationship is a critical component of patient-centred health care. The patient-oncologist relationship is particularly important due to the uncertainties that surround treatment of cancer. The goal of the current review was to summarise current methodological approaches to studying the relationship between cancer patients and oncologists. METHODS: A systematic review using PsychInfo, Ebsco, PubMed and Google Scholar was performed using combinations and variations of the MESH terms: "relationship," "doctor-patient," and "oncology." The included studies explicitly measured the "relationship" as an independent or dependent variable. Data were extracted and analysed. RESULTS: The 13 studies included in the review were published from 2004 to 2018. There was little agreement between studies on the definition of the patient-oncologist relationship. Trust was most frequently measured, but methods varied. Most studies evaluated the patient perspective (n = 10). The few studies that considered the oncologist perspective did not measure their perception of the relationship. CONCLUSIONS: The current review demonstrates that current approaches used to assess the patient-oncologist relationship are inconsistent. These differences may limit our understanding of patient needs in current research and practice. Future research should focus on the use of a relational lens as a theoretical framework to assess the patient-oncologist relationship.

Exploring the influence of short-term temperature patterns on temperature-related mortality: a case-study of Melbourne, Australia.

BACKGROUND: Several studies have identified the association between ambient temperature and mortality; however, several features of temperature behavior and their impacts on health remain unresolved. We obtain daily counts of nonaccidental all-cause mortality data in the elderly (65 + years) and corresponding meteorological data for Melbourne, Australia during 1999 to 2006. We then characterize the temporal behavior of ambient temperature development by quantifying the rates of temperature change during periods designated by pre-specified windows ranging from 1 to 30 days. Finally, we evaluate if the association between same day temperature and mortality in the framework of a Poisson regression and include our temperature trajectory variables in order to assess if associations were modified by the nature of how the given daily temperature had evolved. RESULTS: We found a positive significant association between short-term mortality risk and daily average temperature as mortality risk increased 6 % on days when temperatures were above the 90th percentile as compared to days in the referent 25-75th. In addition, we found that mortality risk associated with daily temperature varied by the nature of the temperature trajectory over the preceding twelve days and that peaks in mortality occurred during periods of high temperatures and stable trajectories and during periods of increasing higher temperatures and increasing trajectories. CONCLUSION: Our method presents a promising tool for improving understanding of complex temperature health associations. These findings suggest that the nature of sub-monthly temperature variability plays a role in the acute impacts of temperature on mortality; however, further studies are suggested.

High-Flow Nasal Cannula Versus Noninvasive Ventilation as Initial Treatment in Acute Hypoxia: A Propensity Score-Matched Study.

IMPORTANCE: Patients presenting to the emergency department (ED) with hypoxemia often have mixed or uncertain causes of respiratory failure. The optimal treatment for such patients is unclear. Both high-flow nasal cannula (HFNC) and noninvasive ventilation (NIV) are used. OBJECTIVES: We sought to compare the effectiveness of initial treatment with HFNC versus NIV for acute hypoxemic respiratory failure. DESIGN SETTING AND PARTICIPANTS: We conducted a retrospective cohort study of patients with acute hypoxemic respiratory failure treated with HFNC or NIV within 24 hours of arrival to the University of Michigan adult ED from January 2018 to December 2022. We matched patients 1:1 using a propensity score for odds of receiving NIV. MAIN OUTCOMES AND MEASURES: The primary outcome was major adverse pulmonary events (28-d mortality, ventilator-free days, noninvasive respiratory support hours) calculated using a win ratio. RESULTS: A total of 1154 patients were included. Seven hundred twenty-six (62.9%) received HFNC and 428 (37.1%) received NIV. We propensity score matched 668 of 1154 (57.9%) patients. Patients on NIV versus HFNC had lower 28-day mortality (16.5% vs. 23.4%, p = 0.033) and required noninvasive treatment for fewer hours (median 7.5 vs. 13.5, p < 0.001), but had no difference in ventilator-free days (median [interquartile range]: 28 [26, 28] vs. 28 [10.5, 28], p = 0.199). Win ratio for composite major adverse pulmonary events favored NIV (1.38; 95% CI, 1.15-1.65; p < 0.001). CONCLUSIONS AND RELEVANCE: In this observational study of patients with acute hypoxemic respiratory failure, initial treatment with NIV compared with HFNC was associated with lower mortality and fewer composite major pulmonary adverse events calculated using a win ratio. These findings underscore the need for randomized controlled trials to further understand the impact of noninvasive respiratory support strategies.

The association of upward economic mobility with textbook outcomes among patients undergoing general and cardiovascular surgery.

BACKGROUND: While disadvantaged neighborhoods may be associated with worse outcomes and earlier death, the relationship between economic opportunity and surgical outcomes remains unexplored. METHODS: Medicare beneficiaries who underwent AAA, CABG, colectomy or cholecystectomy were identified and stratified into quintiles based on upward economic mobility. Risk-adjusted probability of adverse postoperative outcomes were examined relative to economic mobility. RESULTS: Among 1,081,745 Medicare beneficiaries (age: 75.5 years, female: 43.0%, White: 91.3%), risk-adjusted 30-day postoperative mortality decreased in a stepwise fashion from 6.0%(5.9-6.1) in the lowest quintile of upward economic mobility to 5.3%(5.2-5.4) in highest upward economic mobility (lowest vs. highest economic mobilityobility OR:1.14 (95%CI:1.11-1.17)). Similar associations were noted for postoperative complications (OR:1.04, 95%CI:1.02-1.06), extended length-of-stay (OR:1.07, 95%CI:1.06-1.09), and 30-day readmission (OR:1.04, 95%CI:1.02-1.05). Black beneficiaries had a higher risk of post-operative mortality across upward economic mobility quintiles except within the highest upward mobility group (referent, White patients, OR:0.93, 95%CI:0.79-1.09, p=0.355). CONCLUSION: Economic upward mobility was associated with post-operative outcomes. Race-based differences were mitigated at the highest levels of upward economic mobility, highlighting the importance of socioeconomics as a health equity lever.

Patterns of Postpartum Primary Care Follow-up and Diabetes-Related Care After Diagnosis of Gestational Diabetes.

Importance: Gestational diabetes (GD) affects up to 10% of pregnancies and increases lifetime risk of type 2 diabetes 10-fold; postpartum diabetes evaluation and primary care follow-up are critical in preventing and detecting type 2 diabetes. Despite clinical guidelines recommending universal follow-up, little remains known about how often individuals with GD access primary care and type 2 diabetes screening. Objective: To describe patterns of primary care follow-up and diabetes-related care among individuals with and without GD in the first year post partum. Design, Setting, and Participants: This cohort study used a private insurance claims database to compare follow-up in the first year post partum between individuals with GD, type 2 diabetes, and no diabetes diagnosis. Participants included postpartum individuals aged 15 to 51 years who delivered between 2015 and 2018 and had continuous enrollment from 180 days before to 366 days after the delivery date. Data were analyzed September through October 2021 and reanalyzed November 2022. Main Outcomes and Measures: Primary care follow-up visits and diabetes-related care (blood glucose testing and diabetes-associated visit diagnoses) were determined by evaluation and management, Current Procedural Terminology, and International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes, respectively. Results: A total of 280 131 individuals were identified between 2015 and 2018 (mean age: 31 years; 95% CI, 27-34 years); 12 242 (4.4%) had preexisting type 2 diabetes and 18 432 (6.6%) had GD. A total of 50.9% (95% CI, 49.9%-52.0%) of individuals with GD had primary care follow-up, compared with 67.2% (95% CI, 66.2%-68.2%) of individuals with preexisting type 2 diabetes. A total of 36.2% (95% CI, 35.1%-37.4%) of individuals with GD had diabetes-related care compared with 56.9% (95% CI, 55.7%-58.0%) of individuals with preexisting diabetes. Only 36.0% (95% CI, 34.4%-37.6%) of individuals with GD connected with primary care received clinical guideline concordant care with blood glucose testing 12 weeks post partum. Conclusions and Relevance: In this cohort study of postpartum individuals, individuals with GD had lower rates of primary care and diabetes-related care compared with those with preexisting type 2 diabetes, and only 36% of those with GD received guideline-recommended blood glucose testing in the first 12 weeks post partum. This illustrates a missed opportunity for early intervention in diabetes surveillance and prevention and demonstrates the need to develop a multidisciplinary approach for postpartum follow-up.

High-flow nasal cannula vs non-invasive ventilation in acute hypoxia: Propensity score matched study.

RATIONALE: The optimal treatment for early hypoxemic respiratory failure is unclear, and both high-flow nasal cannula and non-invasive ventilation are used. Determining clinically relevant outcomes for evaluating non-invasive respiratory support modalities remains a challenge. OBJECTIVES: To compare the effectiveness of initial treatment with high-flow nasal cannula versus non-invasive ventilation for acute hypoxemic respiratory failure. METHODS: We conducted a retrospective cohort study of patients with acute hypoxemic respiratory failure treated with high-flow nasal cannula or non-invasive ventilation within 24 hours of Emergency Department arrival (1/2018-12/2022). We matched patients 1:1 using a propensity score for odds of receiving non-invasive ventilation. The primary outcome was major adverse pulmonary events (28-day mortality, ventilator-free days, non-invasive respiratory support hours) calculated using a Win Ratio. MEASUREMENTS AND MAIN RESULTS: 1,265 patients met inclusion criteria. 795 (62.8%) received high-flow oxygen and 470 (37.2%) received non-invasive ventilation. We propensity score matched 736/1,265 (58.2%) patients. There was no difference between non-invasive ventilation vs high-flow nasal cannula in 28-day mortality (17.7% vs 23.1%, p=0.08) or ventilator-free days (median [Interquartile Range]: 28 [25, 28] vs 28 [13, 28], p=0.50), but patients on non-invasive ventilation required treatment for fewer hours (median 7 vs 13, p< 0.001). Win Ratio for composite major adverse pulmonary events favored non-invasive ventilation (1.26, 95%CI 1.06-1.49, p< 0.001). CONCLUSIONS: In this observational study of patients with acute hypoxemic respiratory failure, initial treatment with non-invasive ventilation was superior to high-flow nasal cannula for major pulmonary adverse events. Evaluation of composite outcomes is important in the assessment of respiratory support modalities.