Cigarette Consumption and Cigarette Smoking Prevalence Among Adults in Kansas.

INTRODUCTION: Recent tobacco prevention and cessation activities have focused on nonsmoking ordinances and behavioral changes, and in Kansas, the overall prevalence of cigarette smoking among adults has decreased. The objective of this study was to determine whether overall cigarette consumption (mean annual number of cigarettes smoked) in Kansas also decreased. METHODS: Data on cigarette smoking prevalence for 91,465 adult Kansans were obtained from the Behavioral Risk Factor Surveillance System survey for 1999 through 2010. Data on annual cigarette consumption were obtained from the 2002 and 2006 Kansas Adult Tobacco Survey and analyzed by totals, by sex, and by smoking some days or smoking every day. Linear regression was used to evaluate rate changes over time. RESULTS: Among men, but not women, cigarette smoking prevalence decreased significantly over time. The prevalence of smoking every day decreased significantly among both men and women, whereas the prevalence of smoking on some days increased significantly for women but not men. For current smokers, the mean annual number of cigarettes consumed remained the same. CONCLUSION: The decline in overall smoking prevalence coupled with the lack of change in mean annual cigarette consumption may have resulted in a more intense exposure to cigarettes for the smoking population. The significant increase in some day use among women indicates a need for additional prevention and education activities; the impact on future lung cancer incidence rates needs further investigation.

Colorectal Cancer Identification Methods Among Kansas Medicare Beneficiaries, 2008-2010.

INTRODUCTION: Population-based data are limited on how often colorectal cancer (CRC) is identified through screening or surveillance in asymptomatic patients versus diagnostic workup for symptoms. We developed a process for assessing CRC identification methods among Medicare-linked CRC cases from a population-based cancer registry to assess identification methods (screening/surveillance or diagnostic) among Kansas Medicare beneficiaries. METHODS: New CRC cases diagnosed from 2008 through 2010 were identified from the Kansas Cancer Registry and matched to Medicare enrollment and claims files. CRC cases were classified as diagnostic-identified versus screening/surveillance-identified using a claims-based algorithm for determining CRC test indication. Factors associated with screening/surveillance-identified CRC were analyzed using logistic regression. RESULTS: Nineteen percent of CRC cases among Kansas Medicare beneficiaries were screening/surveillance-identified while 81% were diagnostic-identified. Younger age at diagnosis (65 to 74 years) was the only factor associated with having screening/surveillance-identified CRC in multivariable analysis. No association between rural/urban residence and identification method was noted. CONCLUSION: Combining administrative claims data with population-based registry records can offer novel insights into patterns of CRC test use and identification methods among people diagnosed with CRC. These techniques could also be extended to other screen-detectable cancers.

Intrawound Vancomycin Powder Decreases Staphylococcal Surgical Site Infections After Posterior Instrumented Spinal Arthrodesis.

STUDY DESIGN: A retrospective historical cohort design. OBJECTIVE: To determine what effect the addition of intrawound vancomycin powder to the prophylactic regimen of posterior instrumented spinal arthrodesis procedures has had on acute surgical site infections (SSIs). SUMMARY OF BACKGROUND DATA: SSIs are known complications in instrumented spinal arthrodesis procedures, and are predominately caused by Staphylococcus aureus. Recent reports have suggested that placing vancomycin powder into the surgical wound before closure prevents SSIs in spinal surgery. Risk factors for SSIs in the setting of intrawound vancomycin powder use have not been previously reported on. MATERIALS AND METHODS: SSI rates after 342 posterior instrumented spinal arthrodeses (October 2008-September 2011) in which intrawound vancomycin powder was used in addition to the standard antimicrobial prophylaxis (Vanco cohort) were compared with 341 posterior instrumented spinal arthrodeses (April 2005-October 2008) in which no vancomycin powder was added (non-Vanco cohort). Both 2 sample t test and χ test (Fisher where appropriate) were used for group comparisons. A subanalysis of the Vanco cohort was undertaken to identify risk factors for SSIs despite intrawound vancomycin use. RESULTS: There was a significant reduction in the number of acute staphylococcal SSIs in the Vanco cohort (1.1%) compared with the non-Vanco cohort (3.8%; P=0.029). Deep staphylococcal infections decreased to 0 compared with 7 in the non-Vanco cohort (2.1%; P=0.008). Deep methicillin-resistant S. aureus infections decreased to 0 compared with 5 in the non-Vanco cohort (1.5%; P=0.031). A subanalysis of the Vanco cohort identified that being discharged to an inpatient rehabilitation or skilled nursing facility was associated with developing a SSI. CONCLUSIONS: Intrawound vancomycin powder use has decreased the rate of acute staphylococcal SSIs in our posterior instrumented spine arthrodesis surgeries. Patients who are discharged to skilled nursing or rehabilitation facilities are at an increased risk for developing SSIs despite intrawound vancomycin use.

Urban Rural Differences on Accessing Patient- Centered Medical Home Among Children With Mental/Developmental Health Conditions/Disorders.

INTRODUCTION: To address healthcare spending growth and coordinated primary care, most states in the United States have adopted patient-centered medical homes (PCMHs). To evaluate urban rural difference on accessing PCMH among US children, particularly for children with developmental disabilities (DDs) and mental health disorders (MHDs). METHODS: This cross-sectional study used the 2016-2018 National Survey for Children's Health (NSCH). Multivariable adjusted logistic regression analyses were used to assess the association between accessing PCMHs and rurality and mental/developmental conditions/disorders. RESULTS: Children with both DDs and MHDs were statistically significantly higher in rural areas (10.9% rural vs. 8.3% urban, p ≤ .001). Children in rural areas reported higher odds of accessing PCMHs (14%) among all U.S. children, but no differences by subgroups for children with MHDs and/or DDs. Compared with children without DDs/MHDs, the reduction in access to PCMHs varies by children's health status (41% reduction for children both DDs and MHDs, 25% reduction for children with MHDs without DDs) effects. Children with MHDs/DDs were less likely to receive family-centered care, care coordination, and referrals. CONCLUSIONS: Quality improvements through PCMHs could focus on family-centered care, care coordination, and referrals. Patient-centered medical home performance measurement could be improved to better measure mental health integration and geographical differences.

Infection Is Not Associated With Plasma or Cryoprecipitate Transfusion Volumes in Trauma: A Retrospective Study Using the National Trauma Data Bank.

Background: Packed red blood cell (PRBC) transfusion has been shown to increase nosocomial infection risk in the injured population; however, the post-traumatic infectious risk profiles of non-PRBC blood products are less clear. We hypothesized that plasma (fresh frozen plasma [FFP]), platelet (PLT), and cryoprecipitate administration would not be associated with increased rates of nosocomial infections. Patients and Methods: We performed a retrospective, matched, case-control study utilizing the American College of Surgeons National Trauma Data Bank data for 2019. We included all patients who received any volume of PRBC within four hours of presentation. Our outcome of interest was any infection. Controls were matched to cases using individual matching with a desired 1:3 case:control ratio. Bivariable analysis according to infection status, and multivariable logistic regression modeling the development of infection were then performed upon the matched data. Results: A total of 1,563 infectious cases were matched to 3,920 non-infectious controls. First four-hour transfusion volumes for FFP, PLT, and cryoprecipitate in the infection group exceeded those in the control group. The first four-hour FFP transfusion volume (per unit odds ratio [OR], 1.02; 95% confidence interval [CI], 0.99-1.04; p = 0.28) and cryoprecipitate transfusion volume (per unit OR, 1.01; 95% CI, 0.99-1.02; p = 0.43) were similar in cases and controls whereas PLT transfusion volume (per unit OR, 0.92; 95% CI, 0.86-0.98; p = 0.01) was lower in cases of infection than in controls. Conclusions: Fresh frozen plasma, PLT, and cryoprecipitate transfusion volumes were not independent risk factors for the development of nosocomial infection in a trauma population. PLT transfusion volume was associated with less infection.

Is there an increased risk of hip fracture in Parkinson's disease? A nationwide inpatient sample.

OBJECTIVE: The aim of this study was to determine whether people with Parkinson's disease (PD) are overrepresented in a national cohort of hip-fracture admissions. BACKGROUND: Frequent falls, combined with a higher rate of osteoporosis in people with PD, should lead to an increased risk of hip fracture. METHODS: This work was a retrospective cohort analysis from the Nationwide Inpatient Sample from 1988 to 2007, a stratified sample of 20% of U.S. hospital admissions. Admissions with a primary diagnosis of acute hip fracture were identified, as was a subset with a secondary diagnosis of PD. RESULTS: A total of 3.63% of 1,066,404 hip-fracture admissions had PD. When compared to the population of prevalence among patients with hip fracture, the prevalence of PD was up to 4.48 times (95% confidence interval [CI]: 4.46, 4.49) more than predicted, and when adjusted for gender and age, it was 4.02 (95% CI: 4.00, 4.03). CONCLUSIONS: In this 20-year nationwide sample of hip fractures, patients with PD were overrepresented by a factor of 4.

Variations in Age-Adjusted Prostate Cancer Incidence Rates by Race and Ethnicity After Changes in Prostate-Specific Antigen Screening Recommendation.

Importance: After publication of US Preventive Task Force Prostate-Specific Antigen (PSA) screening guidelines in 2008 and 2012, there have been documented associations with incidence and stage distributions of prostate cancer. It is unclear if these changes were temporary or differed by age or race and ethnicity. Objective: To assess the association of 2008 and 2012 PSA guidelines with prostate cancer incidence by age and race and ethnicity in the US. Design, Setting, and Participants: This cross-sectional study evaluated prostate cancer incidence from 2005 to 2018 in the US using data from the US Cancer Statistics public use database. Data were analyzed from August 2020 through June 2022. Main Outcomes and Measures: The primary outcome was the year when rates of prostate cancer incidence changed directionality by age and race and ethnicity. Age-adjusted incidence rates of prostate cancer and corresponding 95% CIs were created, followed by join point regression analysis to evaluate trends of age-adjusted incidence rates of prostate cancer by age, race, Hispanic ethnicity, and stage of diagnosis. Results: Among 2 944 387 men with prostate cancer, 2 869 943 (97.5%) men were aged 50 years and older. Men aged 50 years and older accounted for 185 476 of 191 533 Hispanic individuals (96.8%) and 2 684 467 of 2 752 854 non-Hispanic individuals (97.5%). Men aged 50 years and older accounted for 427 016 of 447 847 African American individuals (95.4%), 12 141 of 12 470 American Indian or Alaska Native individuals (97.4%), 61 126 of 62 159 Asian or Pacific Islander individuals (98.3%), and 2 294 171 of 2 344 392 White individuals (97.9%). Men with unknown race (77 519 men) were excluded from the analysis. A decrease in age-adjusted rate of prostate cancer after the 2008 guideline change was observed in all age groups by race and ethnicity. For example, among African American men ages 65 to 74 years, 10 784 of 807 080 men (1.34%) had a prostate cancer diagnosis in 2007 vs 10 714 of 835 548 men in 2008 (1.28%). The mean annual age-adjusted incidence rates of prostate cancer per 100 000 men were 157.7 men (95% CI, 157.4-158.0 men) in 2005 to 2008 and 131.9 men (95% CI, 131.6-132.2 men) in 2009 to 2012. The number of inflections and annual percent changes (APCs) for segments separated by inflections varied by age, race, and Hispanic ethnicity. For men ages 65 to 74 years, the APC was -6.53 (95% CI, -9.28 to -3.69) for 2009 to 2014 among African American men (2 join points), -5.96 (95% CI, -6.84 to -5.07) for 2007 to 2018 among American Indian or Alaska Native men (1 join point), -6.52 (95% CI, -9.22 to -3.74) for 2007 to 2014 among Asian or Pacific Islander men (2 join points), -7.92 (95% CI, -11.36 to -4.35) for 2009 to 2014 among Hispanic men (2 join points), and -7.02 (95% CI, -9.41 to -4.57) for 2007 to 2014 among White men (2 join points).‬‬‬‬‬‬‬‬. Conclusions and Relevance: In this study, men in different age, race, and ethnicity groups had different APC patterns after 2008 and 2012 PSA screening guideline changes. These findings may provide important data on the timing and durations of changes in cancer diagnoses that are associated with changes in PSA screening recommendations and may be valuable for targeted strategies to reduce regional- and distant-staged cancers.

Effect of the staging schema on melanoma cancer reporting, 1999 to 2006.

BACKGROUND: Staging schemas have changed multiple times over the past 10 years. OBJECTIVE: We sought to examine the impact of staging schemas on the distribution of stages at diagnosis over time. METHODS: We examined the stage at diagnosis for melanoma cancer cases diagnosed between 1999 and 2006 using data provided by the Surveillance, Epidemiology, and End Results (SEER) and National Program of Cancer Registries (NPCR) programs. The staging schemas were summary staging 1977 (SS1977), summary staging 2000 (SS2000), derived SS2000, and SEER historic staging systems. RESULTS: Melanoma was predominantly staged as a localized disease in all schemas. Using SEER data, the proportion of localized melanomas diagnosed in 2001 to 2003 using SS2000 was about 2.5% lower than the proportion diagnosed in 1999 to 2000 using SS1977, whereas the proportion of cases staged as regional was 2.7% higher using the SS2000 than SS1977. The distribution of stages for cases diagnosed in 2001 to 2003 using SS2000 was similar to that for cases diagnosed in 2004 to 2006 using a derived SS2000. Shift in stage distribution among SS1977, SS2000, and SEER historic staging was found to be about 6% (localized to regional) and about 17.5% (unknown to regional stage). The distribution of changes in stage observed for the SEER cases was not evident for cases from NPCR. LIMITATIONS: SEER historic staging was not available for NPCR cases. CONCLUSION: Changes in staging rules resulted in cases being moved from the localized to the regional stage and from unknown to the regional stage. Without staging rules that have been consistently applied to melanomas over many years, surveillance of prevention, treatment, and control of this condition is difficult.

Association between cutaneous melanoma incidence rates among white US residents and county-level estimates of solar ultraviolet exposure.

BACKGROUND: Recent US studies have raised questions as to whether geographic differences in cutaneous melanoma incidence rates are associated with differences in solar ultraviolet (UV) exposure. OBJECTIVES: We sought to assess the association of solar UV exposure with melanoma incidence rates among US non-Hispanic whites. METHODS: We assessed the association between county-level estimates of average annual solar UV exposure for 1961 to 1990 and county-level melanoma incidence rates during 2004 to 2006. We used Poisson multilevel mixed models to calculate incidence density ratios by cancer stage at diagnosis while controlling for individuals' age and sex and for county-level estimates of solar UV exposure, socioeconomic status, and physician density. RESULTS: Age-adjusted rates of early- and late-stage melanoma were both significantly higher in high solar UV counties than in low solar UV counties. Rates of late-stage melanoma incidence were generally higher among men, but younger women had a higher rate of early-stage melanoma than their male counterparts. Adjusted rates of early-stage melanoma were significantly higher in high solar UV exposure counties among men aged 35 years or older and women aged 65 years or older. LIMITATIONS: The relationship between individual-level UV exposure and risk for melanoma was not evaluated. CONCLUSIONS: County-level solar UV exposure was associated with the incidence of early-stage melanoma among older US adults but not among younger US adults. Additional studies are needed to determine whether exposure to artificial sources of UV exposure or other factors might be mitigating the relationship between solar UV exposure and risk for melanoma.

A Midwest Tri-State Study of Overall Survival in Ovarian Cancer with Adjuvant Chemotherapy.

BACKGROUND: Overall survival associated with National Comprehensive Cancer Network (NCCN) adjuvant chemotherapy treatment guideline using population-based surveillance data is limited. This study examined overall survival and compliance to the NCCN guideline for adjuvant chemotherapy. METHODS: The Midwest Ovarian Cancer Study was a collaborative project between 3 state cancer registries (Iowa, Kansas, and Missouri), Westat, and the Centers for Disease Control and Prevention. A standardized protocol was used to ascertain International Federation of Gynecology and Obstetrics (FIGO) stage-specific adjuvant chemotherapy. Primary epithelial ovarian cancers with FIGO stages IA/IB grade 3, IC, and II-IV with histologies 8000-8576 and 8930-9110 were included in this study. The Kaplan-Meier method was used to calculate survival functions. Adjusted hazard ratio (HR) was analyzed for all-cause mortality associated with NCCN compliance with adjuvant chemotherapy after adjusting for stage at diagnosis and comorbidity. RESULTS: Sixtynine percent (523 of 756 eligible) were compliant with NCCN guidelines. Compliance was significantly different by age at diagnosis and insurance type (both P < .0001). The overall survival was significantly different by age group, census tract median income, histologic subtype, and tumor grade (all P < .0001). The adjusted HR of noncompliance with adjuvant chemotherapy guideline was 3.2 (95% CI, 2.600-3.911). CONCLUSIONS: Better overall survival in patients who had received NCCN-recommended adjuvant chemotherapy was confirmed. IMPACT: The survival benefit was 7% higher over 4 years after diagnosis when considering FIGO stage-specific chemotherapy and the corresponding number of cycles. Using the chemotherapy data field that is collected by statewide cancer registries underestimated the overall survival.

Disparities in ovarian cancer survival at the only NCI-designated cancer center in Kansas.

BACKGROUND: This study examined the impact of geographic distance on survival outcomes for patients receiving treatment for ovarian cancer at the only NCI-designated cancer center (NCI-CC) in Kansas. METHODS: We identified ovarian cancer patients treated at the University of Kansas Cancer Center between 2010 and 2015. Demographic factors and clinical characteristics were abstracted. The main outcome measure was overall survival according to geographic distance from the institution. Kaplan Meier survival curves and Cox proportional hazard models were generated using SAS v9.4. RESULTS: 220 patients were identified. Survival analysis based on distance from the institution demonstrated that patients who lived ≤10 miles from the institution had worse overall survival (p = 0.0207) and were more likely to have suboptimal cytoreductive surgery (p = 0.0276). Lower estimated median income was also associated with a 1.54 increased risk of death, 95% CI (1.031-2.292), p = 0.0347. CONCLUSIONS: We determined that ovarian cancer survival disparities exist in our patient population. Lower rates of optimal cytoreductive surgery has been identified as a possible driver of poor prognosis for patients who lived in proximity to our institution.

Impact of bisphosphonates on the risk of atrial fibrillation.

Osteoporosis is a major public health problem resulting in significant morbidity, mortality, and utilization of healthcare resources. Bisphosphonates are the most widely prescribed drugs for increasing bone mass and preventing osteoporosis-related fractures. Although these drugs have proven efficacy and are generally considered safe, a clinical trial of once-yearly zoledronic acid reported an unexpected increase in the risk of cardiac arrhythmias, primarily due to serious atrial fibrillation (AF). Subsequently, a post hoc analysis of another clinical trial reported a nonsignificant trend toward an increased risk of serious AF. Based on these concerns, the US FDA issued a cautionary advisory and is conducting an ongoing safety review. A major limitation of the clinical trials was the fact that none were designed or powered to evaluate arrhythmia endpoints. In search of more definitive answers, several observational studies using both population-based cohort and case-control designs have attempted to verify this association. However, only two studies, one cohort and one case-control study, have found a positive association, while six additional studies have reported negative findings. While most of the observational studies attempted to control for confounders, the chosen variables have varied considerably, and other key potential confounders such as smoking were not controlled for in any of the studies. Because the occurrence of AF events in the studies was relatively low, four meta-analyses have been conducted to increase sample size by using pooled data from multiple studies. Again, results have been inconsistent, with two of the analyses reporting a significant increase in serious AF and two finding no association. Additionally, no direct evidence has identified any underlying mechanism to explain an increased arrhythmia risk with bisphosphonate therapy. However, several possible mechanisms have been proposed, including an activated inflammatory state, altered electrolytes impacting cardiac conduction, and long-term atrial structural changes. Due to the widespread use of bisphosphonates in a population for whom the baseline risk of AF also increases with advancing age, further prospective assessment of this possible association is clearly warranted. If an association does exist between bisphosphonates and an increased risk for AF, several additional questions will need to be answered including impact of baseline risk, the time course for increased risk, relationship to drug dose, and whether or not this represents a drug-class adverse effect. Until definitive evidence is available, clinicians will continue to have to make clinical judgments based on the available and often inconsistent evidence to date. To provide further perspective on this possible association, we performed a systematic search of the PubMed database from 1966 to 30 June 2010, drug regulatory websites, and drug manufacturer websites. In this review we summarize the findings from clinical trials, observational studies, and meta-analyses evaluating the risk of AF following bisphosphonate exposure, and discuss possible mechanisms that could explain an increased risk.

Can Qigong improve non-motor symptoms in people with Parkinson's disease - A pilot randomized controlled trial?

Non-motor symptoms (NMS) including sleep disorders, anxiety, depression, fatigue, and cognitive decline can significantly impact quality of life in people with PD. Qigong exercise is a mind-body exercise that shows a wide range of benefits in various medical conditions. The purpose of this study was to investigate the effect of Qigong exercise on NMS with a focus on sleep quality. Seventeen participants completed a 12-week intervention of Qigong (n = 8) or sham Qigong (n = 9). Disease severity, anxiety and depression levels, fatigue, cognition, quality of life, and other NMS of the participants were evaluated prior to the intervention and at the end of the 12-week intervention. After the intervention, both Qigong and sham-Qigong group showed significant improvement in sleep quality (p < 0.05) and overall NMS (p < 0.05). No significant difference was found between groups. Qigong exercise has the potential as a rehabilitation method for people with PD, specifically alleviating NMS in PD. However, this finding needs to be carefully considered due to the small sample size and potentially low intervention fidelity of this study.

The therapeutic efficacy of Qigong exercise on the main symptoms of fibromyalgia: A pilot randomized clinical trial.

BACKGROUND: Some of the most debilitating symptoms of fibromyalgia (FM) include widespread chronic pain, sleep disturbances, chronic fatigue, anxiety, and depression. Yet, there is a lack of effective self-management exercise interventions capable of alleviating FM symptoms. The objective of this study is to examine the efficacy of a 10-week daily Qigong, a mind-body intervention program, on FM symptoms. METHODS: 20 participants with FM were randomly assigned to Qigong (experimental) or sham-Qigong (control) groups, with participants blinded to the intervention allocation. The Qigong group practiced mild body movements synchronized with deep diaphragmatic breathing and meditation. The sham-Qigong group practiced only mild body movements. Both groups practiced the interventions two times per day at home, plus one weekly group practice session with a Qigong instructor. Primary outcomes were: pain changes measured by the Short-Form McGill Pain Questionnaire, a visual analog scale for pain, pressure pain threshold measured by a dolorimeter. Secondary outcomes were: the Revised Fibromyalgia Impact Questionnaire the Pittsburgh Sleep Quality Index, the Hospital Anxiety and Depression Scale and the Quality of Life Scale. RESULTS: The experimental group experienced greater clinical improvements when compared to the control group on the mean score differences of pain, sleep quality, chronic fatigue, anxiety, depression, and fibromyalgia impact, all being statistically significant at p < 0.05. CONCLUSION: Daily practice of Qigong appears to have a positive impact on the main fibromyalgia symptoms that is beyond group interaction. TRIAL REGISTRATION: ClinicalTrials.gov NCT03441997.

Longitudinal stability of the Fugl-Meyer Assessment of the upper extremity.

OBJECTIVE: To investigate the longitudinal stability of the Fugl-Meyer Assessment (FMA) of the upper-extremity item difficulties by using Rasch analysis. DESIGN: Secondary analysis of existing data from a cohort longitudinal study of stroke recovery. SETTING: University research center. PARTICIPANTS: A total of 377 people, ages 69.2+/-11.2 years, to whom the assessment was administered at 2 weeks and 6 months poststroke. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Differential item function analysis performed by using the Winsteps software program examined whether the item difficulty hierarchical order of a modified 30-item FMA for the upper extremity (reflex items removed) was invariant across 2 testing occasions. RESULTS: Only 2 items (shoulder flexion to 180 degrees, movement with normal speed) showed large differences in test-retest item difficulty calibration. Item instability had no practical consequences on the longitudinal measurement of person ability. CONCLUSIONS: The 30-item assessment shows a longitudinally stable item difficulty order and is valid for measuring volitional arm motor ability over time.

Improvements in speed-based gait classifications are meaningful.

BACKGROUND AND PURPOSE: Gait velocity is a powerful indicator of function and prognosis after stroke. Gait velocity can be stratified into clinically meaningful functional ambulation classes, such as household ambulation (<0.4 m/s), limited community ambulation (0.4 to 0.8 m/s), and full community ambulation (>0.8 m/s). The purpose of the current study was to determine whether changes in velocity-based community ambulation classification were related to clinically meaningful changes in stroke-related function and quality of life. METHODS: In subacute stroke survivors with mild to moderate deficits who participated in a randomized clinical trial of stroke rehabilitation and had a baseline gait velocity of 0.8 m/s or less, we assessed the effect of success versus failure to achieve a transition to the next class on function and quality of life according to domains of the Stroke Impact Scale (SIS). RESULTS: Of 64 eligible participants, 19 were initially household ambulators, and 12 of them (68%) transitioned to limited community ambulation, whereas of 45 initially limited community ambulators, 17 (38%) became full community ambulators. Function and quality-of-life SIS scores after treatment were significantly higher among survivors who achieved a favorable transition compared with those who did not. Among household ambulators, those who transitioned to limited or full community ambulation had significantly better SIS scores in mobility (P=0.0299) and participation (P=0.0277). Among limited community ambulators, those who achieved the transition to full community ambulatory status had significantly better scores in SIS participation (P=0.0085). CONCLUSIONS: A gait velocity gain that results in a transition to a higher class of ambulation results in better function and quality of life, especially for household ambulators. Household ambulators possibly had more severe stroke deficits, reducing the risk of "ceiling" effects in SIS-measured activities of daily living and instrumental activities of daily living. Outcome assessment based on transitions within a mobility classification scheme that is rooted in gait velocity yields potentially meaningful indicators of clinical benefit. Outcomes should be selected that are clinically meaningful for all levels of severity.

Grading invasive ductal carcinoma of the breast: advantages of using automated proliferation index instead of mitotic count.

Breast carcinomas are graded according to the "Nottingham modification of the Bloom-Richardson system" (SBR). The system is hindered, however, by lack of precision in assessing all three parameters including nuclear grade, mitosis, and tubular formation, leading to an element of subjectivity. Our objective was to evaluate a new grading system [the nuclear grade plus proliferation (N+P) system] for subjectivity, ease, and better representation of tumor biology. Its components are nuclear grade and automated proliferation index. Invasive ductal carcinomas, consisting of 137 SBR grade I, 247 grade II, and 266 grade III, were re-evaluated by the N+P system. The two systems were compared with each other and correlated with patients' overall survival, tumor size, angiolymphatic invasion, lymph node status, and biomarker status including estrogen receptor, progesterone receptor, p53, epidermal growth factor receptor, BCL-2, and Her-2. Although there was an agreement between the two systems with histologic and prognostic parameters studied, there was 37% disagreement when grading individual tumors. Fifty-three percent of SBR grade II tumors were "down-graded" to N+P grade I, and 7% were "up-graded" to N+P grade III. Distinction among the different histologic grades for overall survival curves was better indicated by the N+P than the SBR system.

Expanding Local Cancer Clinical Trial Options: Analysis of the Economic Impact of the Midwest Cancer Alliance in Kansas.

PURPOSE: Patients benefit from receiving cancer treatment closer to home when possible and at high-volume regional centers when specialized care is required. The purpose of this analysis was to estimate the economic impact of retaining more patients in-state for cancer clinical trials and care, which might offset some of the costs of establishing broader cancer trial and treatment networks. METHOD: Kansas Cancer Registry data were used to estimate the number of patients retained in-state for cancer care following the expansion of local cancer clinical trial options through the Midwest Cancer Alliance based at the University of Kansas Medical Center. The 2014 economic impact of this enhanced local clinical trial network was estimated in four parts: Medical spending was estimated on the basis of National Cancer Institute cost-of-care estimates. Household travel cost savings were estimated as the difference between in-state and out-of-state travel costs. Trial-related grant income was calculated from administrative records. Indirect and induced economic benefits to the state were estimated using an economic impact model. RESULTS: The authors estimated that the enhanced local cancer clinical trial network resulted in approximately $6.9 million in additional economic activity in the state in 2014, or $362,000 per patient retained in-state. This estimate includes $3.6 million in direct spending and $3.3 million in indirect economic activity. The enhanced trial network also resulted in 45 additional jobs. CONCLUSIONS: Retaining patients in-state for cancer care and clinical trial participation allows patients to remain closer to home for care and enhances the state economy.

Therapeutic exercise and depressive symptoms after stroke.

OBJECTIVES: To examine the effect of exercise on depressive symptoms and the effect of baseline depressive symptoms on the benefits from exercise in stroke survivors who have completed acute rehabilitation. DESIGN: Planned secondary analysis of the data from a 9-month randomized, controlled trial. SETTING: Participant homes. PARTICIPANTS: One hundred stroke survivors who had completed acute rehabilitation. INTERVENTION: A progressive, structured, 3-month physical exercise program. MEASUREMENTS: Demographics, stroke characteristics, impairments, functional limitations, the Geriatric Depression Scale, the Stroke Impact Scale, and the Medical Outcomes Study 36-Item Short Form. RESULTS: Baseline rates of depressive symptoms and other stroke sequelae were similar between the two arms. Ninety-three participants were assessed immediately after the intervention (3 months after enrollment), and 80 were assessed 9 months after enrollment. Six (14%) of the exercise group and 16 (35.6%) of the usual-care group had depressive symptoms at 3 months (P = .03). At 9 months, three (7.5%) of the exercisers had significant depressive symptoms compared with 10 (25%) who received usual care (P = .07). Participants with and without baseline depressive symptoms had equivalent treatment-related gains in impairments and functional limitations, but only participants with depressive symptoms had improved quality of life. CONCLUSION: Exercise may help reduce poststroke depressive symptoms. Depressive symptoms do not limit gains in physical function due to exercise. Exercise may contribute to improved quality of life in those with poststroke depressive symptoms.

Correction of the angle of trunk inclination utilizing apical wiring techniques and concave rib osteotomy in adolescent idiopathic thoracic scoliosis.

Improving the angle of trunk inclination (ATI) is important for achieving optimum clinical deformity correction in adolescent idiopathic scoliosis. Three concave apical implant techniques were reviewed in combination with the use of concave rib osteotomies. Rib osteotomy improved the ATI correction significantly when using apical wiring techniques.