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The direct current bias for photovoltaic (PV) modules interconnected in series‐strings may include both high voltage negative ("HV−") and positive ("HV+") polarity with respect to the electrical ground. Multiple degradation modes, resulting in quantifiable optical loss, were found to occur during HV−/HV+ sequential stress, including corrosion of the external glass surface, encapsulant delamination (at its interfaces with the glass and the PV cell), internal haze formation (resulting from a chemical interaction between the glass and the encapsulant), corrosion and migration of the gridlines, and corrosion of the silicon nitride (SixNy) antireflective coating on the cell. The effects of these separate modes were examined using monolithic (e.g., glass or PV cell) and laminated‐coupon (glass/encapsulant/glass or glass/encapsulant/cell/encapsulant/backsheet) specimens. Characterizations during and after unbiased accelerated testing at 85°C/85% relative humidity included spectrophotometry, optical microscopy, electron microscopy, and ellipsometry. For some module components (i.e., the glass and the SixNy coating), the optical performance was determined through iterative analysis of empirical measurements. Concentrating on just their spectral effect, a novel model was then developed to estimate the transfer of light to the PV cell and the return of light from the PV module with simultaneous degradation mechanisms, which was compared with a mini‐module previously subjected to HV−/HV+ stress. The model suggests that one third of the current loss observed for the mini‐module can be attributed to the optical degradation of the packaging materials. The dominant degradation modes include encapsulant delamination and corrosion of the SixNy coating. Recommendations are given so that the optical model may be improved relative to accelerated testing and validated relative to field aging. [ABSTRACT FROM AUTHOR]

Combined‐accelerated stress testing (C‐AST) is developed to establish the durability of photovoltaic (PV) products, including for degradation modes that are not a priori known or examined in standardized tests. C‐AST aims to comprehensively represent the sample, stress factors, and their combinations using levels at the statistical tails of the natural environment. Acceleration factors for relevant climate sequences within the C‐AST cycle with respect to the Florida USA climate are estimated for selected degradation mechanisms. It is found that for degradation of the outer backsheet polymer layer, the acceleration factor of the tropical climate sequence (the longest of the climate sequences) is f (T, G) = 17.3 with ultraviolet photodegradation; for polyethylene terephthalate hydrolysis (backsheets), f (T, RH) = 426; for electrochemical corrosion (PV cell), f (I) = 14.1; and for PbSn solder fatigue f (ΔT, r (T)) = 17.3. Here, T is the module temperature, G is the broadband spectrum irradiance on the plane of array of the module, RH is the relative humidity on the module surface, I is the leakage current through the module packaging, and r(T), the number of temperature reversals. The methods discussed herein are generally applicable for evaluating acceleration factors in other accelerated test methods. [ABSTRACT FROM AUTHOR]

Degradation from ultraviolet (UV) radiation has become prevalent in the front of solar cells due to the introduction of UV‐transmitting encapsulants in photovoltaic (PV) module construction. Here, we examine UV‐induced degradation (UVID) in various commercial, unencapsulated crystalline silicon cell technologies, including bifacial silicon heterojunction (HJ), interdigitated back contact (IBC), passivated emitter and rear contact (PERC), and passivated emitter rear totally diffused (PERT) solar cells. We performed UV exposure tests using UVA‐340 fluorescent lamps at 1.24 W·m−2 (at 340 nm) and 45°C through 4.02 MJ·m−2 (2000 h). Our results showed that modern cell architectures are more vulnerable to UVID, leading to a significant power decrease (−3.6% on average; −11.8% maximum) compared with the conventional aluminum back surface field (Al‐BSF) cells (<−1% on average). The power degradation is largely caused by the decrease in short‐circuit current and open‐circuit voltage. A greater power decrease is observed in bifacial cells with rear‐side exposure compared with those with front‐side exposure, indicating that the rear side is more susceptible to UV damage. Secondary ion mass spectroscopy (SIMS) confirmed an increase in hydrogen concentration near the Si/passivation interface in HJ and IBC cells after UV exposure; the excess of hydrogen could result in hydrogen‐induced degradation and subsequently cause higher recombination losses. Additionally, surface oxidation and hot‐carrier damage were identified in PERT cells. Using a spectral‐based analysis, we obtained an acceleration factor of 5× between unpackaged cells (containing a silicon nitride antireflective coating on the front) in the UV test and an encapsulated module (with the front glass and encapsulant blocking 90% of the UV at 294 nm and 353 nm, respectively) in outdoor conditions. From the analytical calculations, we show that a UV‐blocking encapsulant can reduce UV transmission in the module by an additional factor of ~50. [ABSTRACT FROM AUTHOR]

Accurate thermodynamic properties of electrolyte systems are critical for the design and operation of many chemical processes. A comprehensive description of the thermodynamic framework for multielectrolyte mixed solvent systems is presented, where the parameter structure of the symmetric electrolyte‐non‐random two liquid (e‐NRTL) model is reformulated and a thermodynamically consistent and analytically derived formulation for the excess enthalpy is developed from the e‐NRTL model. The refined parameter structure of the e‐NRTL model avoids numerical singularities of the analytical formulation for the excess enthalpy in the absence of ionic species and extends the derived excess enthalpy formulation to non‐electrolyte systems. The thermodynamic framework is demonstrated for the MEA‐H2O‐CO2 case study using experimental data on thermodynamic quantities for the binary MEA‐H2O system and the ternary MEA‐H2O‐CO2 system. The model is implemented in Pyomo and will be available for release in the Institute for the Design of Advanced Energy Systems (IDAES) computational platform. [ABSTRACT FROM AUTHOR]

Accurate, predictive reaction models are critical for the design and optimization of chemical looping combustion (CLC) reactors. The formulation and estimation of kinetic parameters for these reaction models using a first‐principles equation‐oriented (EO) approach is particularly beneficial as large amounts of experimental data spanning process‐relevant conditions can be used to estimate parameters in a computationally tractable way. This work demonstrates the application of a novel EO framework to develop reduction reaction kinetic models of an iron‐based CLC oxygen carrier (OC). An optimization problem is formulated to estimate kinetic parameters that provide the best fit to the experimental data. The model predicts the state of the OC with mean square error values of 2.5%–4.4% across the full range of validation data, including multiple reduction cycles. [ABSTRACT FROM AUTHOR]

Commercial backsheets based on polyvinylidene fluoride (PVDF) can experience premature field failures in the form of outer layer cracking. This work seeks to provide a better understanding of the changes in material properties that lead to crack formation and find appropriate accelerated tests to replicate them. The PVDF-based backsheet outer layer can have a different structure and composition, and is often blended with a poly(methyl methacrylate) (PMMA) polymer. We observed depletion of PMMA upon aging with sequential (MAST) and combined (C-AST) accelerated stress testing. In field-aged samples from Arizona and India, where PVDF crystallizes in its predominant α-phase, the degree of crystallinity greatly increased. MAST and C-AST protocols were, to some extent, able to replicate the increase in crystallinity seen in PVDF after ~ 7 years in the field, but no single-stress test condition (UV, damp heat, thermal cycling) resulted in significant changes in the material properties. The MAST regimen used here was too extreme to produce realistic degradation, but the test was useful in discovering weaknesses of the particular PVDF-based outer layer structure studied. No excessive β-phase formation was observed after aging with any test condition; however, the presence of β-phase was identified locally by Fourier transform infrared spectroscopy (FTIR). We conclude that both MAST and C-AST are relevant tests for screening outdoor failure mechanisms in PVDF backsheets, as they were successful in producing material degradation that led to cracking. [ABSTRACT FROM AUTHOR]

The optical degradation of encapsulants from ultraviolet (UV) radiation has historically resulted in a significant loss in performance throughout the life of a photovoltaic (PV) module. International Electrotechnical Commission (IEC) test methods have recently been developed to screen for PV encapsulants prone to loss in optical performance. The present study was performed to benchmark polymeric packaging materials relative to IEC 62788‐1‐4 (covering the measurement of optical transmittance) and IEC 62788‐1‐7 (on the durability of transmittance), provide feedback toward improvement of the methods, and develop insight regarding optical degradation. Contemporary materials were examined, including poly(ethylene‐co‐vinyl acetate) (EVA), thermoplastic polyolefin (TPO), polyolefin elastomer (POE), and polyvinyl butyral (PVB) encapsulants; a poly(ethene‐co‐tetrafluoroethene)/poly(ethylene terephthalate) (ETFE/PET) transparent backsheet; and a polystyrene (PS) working reference material. The use of silica‐, specialty‐, and rolled‐glass was also compared in laminated coupons. Specimen size was separately examined from 2.5 to 12.5 cm. Weathering was performed with a xenon source, using IEC TS 62788‐7‐2 methods A2, A3, A4, and A5 (chamber temperature of 55°C, 65°C, 75°C, or 85°C), respectively. Characterizations were made using a UV–visible–near‐infrared (UV–VIS–NIR) spectrophotometer (transmittance and reflectance, with and without an integrating sphere), a UV–VIS fluorescence spectrophotometer, a camera, and an optical microscope. Performance was analyzed, including solar weighted transmittance, yellowness index, UV cut‐off wavelength, and haze (scattering). Separate Arrhenius analyses were performed to assess retention of transmittance and changes in yellowness index. The activation energy for both characteristics was found to range from 15–80 kJ·mol−1, with an average of 48 kJ·mol−1, similar to the average of 45 kJ·mol−1 identified in the previous international PV Quality Assurance Task Force (PVQAT) Task Group 5 (TG5) study of more traditional encapsulants. The separate degradation modes of discoloration and scattering were distinguished in the encapsulants using a comprehensive spectral characterization. Based on these results, the IEC 62788‐1‐7 pass/fail criteria of 5% change in transmittance was confirmed to identify a known bad encapsulant. [ABSTRACT FROM AUTHOR]

Reference points are used in fisheries management to infer stock status and inform future fishing opportunities. They can be estimated externally to the assessment model assuming attributes such as stock size to be known without error, or internally where the uncertainty can be accounted for in the estimation. Little is known about the effect of choosing one approach over another on reference point estimates. We compare maximum sustainable yield (MSY) reference points obtained internally in the assessment model (SAM) with those obtained by external estimation (EqSim) via simulations using 11 stocks with known and unknown stock–recruitment relationships (SRRs). Internal estimation of reference points does better on average than external estimation in terms of bias, variance, and SRR selection. Coverage probability of the reference point confidence intervals is good for the internal approach. Stochasticity considerations via re-sampling in the external approach can lead to bias. Bias in reference points have consequences on future yield, stock development, and status. However, it is difficult to predict them by solely looking at bias because they depend on current stock status, recruitment, and extent of bias, but also bias direction since a harvest control rule might compensate for the bias in the future. [ABSTRACT FROM AUTHOR]

Background: Little data exist regarding inpatient opioid prescriptions as a potential contribution to the current opioid crisis. While pain management is essential to inpatient care, the ease of which opioids may be prescribed for all levels of pain may contribute to unnecessary inpatient exposure and new outpatient prescriptions. The aim of this study was to observe patterns of opioid prescribing potentially leading to new opioid prescriptions at hospital discharge for previously opioid-naive patients. Methods: This study was a single-center observational study of opioid-naïve internal medicine patients who were prescribed inpatient opioids. Patient charts were reviewed to assess the patterns of inpatient opioid and non-opioid analgesic use, new opioid prescriptions upon discharge and medical record documentation justifying the need for outpatient therapy. Results: Among the 101 patients included in this study, 71 were prescribed IV opioids and 45 were prescribed both IV and oral opioids. Non-opioid analgesics were available for 78 patients. Twenty patients were discharged with a new prescription. The mean duration of outpatient prescriptions was 3.85 +/- 1.85 days with mean morphine milligram equivalents (MME) of 44.25 +/- 22.16. Among patients receiving these outpatient prescriptions, 11 had reference to the therapy in the discharge summary. Conclusions: This observational study describes an opportunity to improve inpatient opioid prescribing practices which may reduce new prescriptions for continued outpatient therapy. Further work should focus on optimizing use of non-opioid analgesia, minimizing use of IV opioids and requiring prescribers to justify the indication for new opioid prescriptions upon hospital discharge. [ABSTRACT FROM AUTHOR]

Background: Despite the increasing use of high flow nasal cannula oxygenation systems (HFNC) in clinical practice, little is known about its role in all cause respiratory failure as compared to traditional non-invasive ventilation (BiPAP). Furthermore, the effect of HFNC on mortality is unknown. Methods: We conducted a retrospective analysis of 49,853 patients with respiratory failure treated with non-invasive respiratory support (HFNC or BiPAP) and/or invasive mechanical ventilation (IMV) between 2017 and 2018. Results: Patients initially treated with HFNC who underwent subsequent intubation and IMV had a higher mortality rate as compared to patients who were initially treated with BiPAP and underwent subsequent intubation and IMV (34.8% vs 26.3%, p < 0.0001, OR 1.49, 95% CI 1.26,1.76). Patients first treated with HFNC who underwent subsequent intubation and IMV had a significantly increased mortality compared to patients who underwent immediate intubation and IMV (34.8% vs. 21.5%, p ≤ 0.0001, OR 1.94, 95% CI 1.67, 2.27). Stratified based on ICD-10 diagnosis, patients with a diagnosis of COPD exacerbation or heart failure treated with HFNC and subsequent intubation and IMV had higher mortality as compared to those treated with immediate IMV alone. This trend did not hold true for patients with a diagnosis of pneumonia. Conclusion: In a real-world retrospective analysis, use of HFNC was associated with increased mortality as compared to BiPAP and IMV alone. Further study is needed to confirm these associations. [ABSTRACT FROM AUTHOR]

Background: Dual‐eligible beneficiaries, who qualify for Medicare and Medicaid, are a vulnerable population with much to gain from efforts to improve quality. Integrated delivery networks and cancer centers, with their emphasis on care coordination and communication, may improve quality of care for dual‐eligible patients with cancer at the end of life. Methods: This study used Surveillance, Epidemiology, and End Results registry data linked with Medicare claims to evaluate quality for beneficiaries who died of cancer and were diagnosed from 2009 to 2014. High‐intensity care was evaluated with 7 end‐of‐life quality measures according to dual‐eligible status with multivariable logistic regression models. Regression‐based techniques were used to assess the effect of delivery system affiliation (ie, cancer center or integrated delivery network vs no affiliation). Results: Among 100,549 beneficiaries who died during the study interval, 22% were dually eligible. Inferior outcomes were identified for dual‐eligible beneficiaries in comparison with nondual beneficiaries across nearly every quality measure assessed, including >1 hospitalization in the last 30 days (12.6% vs 11.3%; P <.001) and a greater proportion of deaths occurring in a hospital setting (30.2% vs 26.2%; P <.001). Receipt of care in an affiliated delivery system was associated with reduced deaths in a hospital setting and increased hospice utilization for dual‐eligible beneficiaries. Conclusions: Dual‐eligible status is associated with higher intensity care at the end of life. Delivery system affiliation has a modest impact on quality at the end of life, and this suggests that targeted efforts may be needed to optimize quality for this group of vulnerable patients. Dual‐eligible beneficiaries dying of cancer have higher utilization at the end of life in comparison with nondual beneficiaries across most end‐of‐life quality measures. Some of these differences in utilization are mitigated in part by receipt of care at an affiliated delivery system such as a cancer center or an integrated delivery network. [ABSTRACT FROM AUTHOR]

Energy systems and manufacturing processes of the 21st century are becoming increasingly dynamic and interconnected, which require new capabilities to effectively model and optimize their design and operations. Such next generation computational tools must leverage state‐of‐the‐art techniques in optimization and be able to rapidly incorporate new advances. To address these requirements, we have developed the Institute for the Design of Advanced Energy Systems (IDAES) Integrated Platform, which builds on the strengths of both process simulators (model libraries) and algebraic modeling languages (advanced solvers). This paper specifically presents the IDAES Core Modeling Framework (IDAES‐CMF), along with a case study demonstrating the application of the framework to solve process optimization problems. Capabilities provided by this framework include a flexible, modifiable, open‐source platform for optimization of process flowsheets utilizing state‐of‐the‐art solvers and solution techniques, fully open and extensible libraries of dynamic unit operations models and thermophysical property models, and integrated support for superstructure‐based conceptual design and optimization under uncertainty. [ABSTRACT FROM AUTHOR]

We propose a novel computational framework for the robust optimization of highly nonlinear, non‐convex models that possess uncertainty in their parameter data. The proposed method is a generalization of the robust cutting‐set algorithm that can handle models containing irremovable equality constraints, as is often the case with models in the process systems engineering domain. Additionally, we accommodate general forms of decision rules to facilitate recourse in second‐stage (control) variables. In particular, we compare and contrast the use of various types of decision rules, including quadratic ones, which we show in certain examples to be able to decrease the overall price of robustness. Our proposed approach is demonstrated on three process flow sheet models, including a relatively complex model for amine‐based CO2 capture. We thus verify that the generalization of the robust cutting‐set algorithm allows for the facile identification of robust feasible designs for process systems of practical relevance. [ABSTRACT FROM AUTHOR]

We used data-analytics approaches to develop, calibrate, and validate predictive models, to help urologists in a large statewide collaborative make prostate cancer staging decisions on the basis of individual patient risk factors. The models were validated using statistical methods based on bootstrapping and evaluation on out-of-sample data. These models were used to design guidelines that optimally weigh the benefits and harms of radiological imaging for the detection of metastatic prostate cancer. The Michigan Urological Surgery Improvement Collaborative, a statewide medical collaborative, implemented these guidelines, which were predicted to reduce unnecessary imaging by more than 40% and limit the percentage of patients with missed metastatic disease to be less than 1%. The effects of the guidelines were measured after implementation to confirm their impact on reducing unnecessary imaging across the state of Michigan. [ABSTRACT FROM AUTHOR]

Myth Corticosteroid injection for the treatment of pain and inflammation is known to decrease the efficacy of the messenger ribonucleic acid (mRNA) vaccines for coronavirus disease 2019 (COVID-19). Fact There is currently no direct evidence to suggest that a corticosteroid injection before or after the administration of an mRNA COVID-19 vaccine decreases the efficacy of the vaccine. However, based on the known timeline of hypothalamic-pituitary-adrenal (HPA) axis suppression following epidural and intraarticular corticosteroid injections, and the timeline of the reported peak efficacy of the Pfizer-BioNTech and Moderna vaccines, physicians should consider timing an elective corticosteroid injection such that it is administered no less than 2 weeks prior to a COVID-19 mRNA vaccine dose and no less than 1 week following a COVID-19 mRNA vaccine dose, whenever possible. [ABSTRACT FROM AUTHOR]

Novel methods for advancing reliability testing of photovoltaic (PV) modules and materials have recently been developed. Combined-accelerated stress testing (C-AST) is one such method which has demonstrated reliable reproduction of some field-failures which were not reproducible by standard certification tests. To increase confidence and assist in the development of C-AST, and other new testing protocols, it is important to validate that the failure modes observed and mechanisms induced are representative of those observed in the field, and not the product of unrealistic stress conditions. Here we outline a method using appropriate materials characterization and modelling to validate the failure mechanisms induced in C-AST such that we can increase confidence in the test protocol. The method is demonstrated by applying it to a known cracking failure of a specific polyamide (PA)-based backsheet material. We found that the failure of the PA-based backsheet was a result of a combination of stress factors. Photo-oxidation from ultra-violet (UV) radiation exposure caused a reduction in fracture toughness, which ultimately lead to the cracking failure. We show that the chemical and structural changes observed in the backsheet following C-AST aging were also observed in field-aged samples. These results increase confidence that the conditions applied in C-AST are representative of the field and demonstrates our approach to validating the failure mechanisms induced. [ABSTRACT FROM AUTHOR]

Previously undiscovered failure modes in photovoltaic (PV) modules continue to emerge in field installations despite passing protocols for design qualification and quality assurance. Failure to detect these modes prior to widespread use could be attributed to the limitations of present‐day standard accelerated stress tests (ASTs), which are primarily designed to identify known degradation or failure modes at the time of development by applying simultaneous or sequential stress factors (usually two at most). Here, we introduce an accelerated testing method known as the combined‐accelerated stress test (C‐AST), which simultaneously combines multiple stress factors of the natural environment. Simultaneous combination of multiple stress factors allows for improved identification of failure modes with better ability to detect modes not known a priori. A demonstration experiment was conducted that reproduced the field‐observed cracking of polyamide‐ (PA‐) and polyvinylidene fluoride (PVDF)–based backsheet films, a failure mode that was not detected by current design qualification and quality assurance testing requirements. In this work, a two‐phase testing protocol was implemented. The first cycle ("Tropical") is a predominantly high‐humidity and high‐temperature test designed to replicate harsh tropical climates. The second cycle ("Multi‐season") was designed to replicate drier and more temperate conditions found in continental or desert climates. Testing was conducted on 2 × 2‐cell crystalline‐silicon cell miniature modules constructed with both ultraviolet (UV)–transmitting and UV‐blocking encapsulants. Cracking failures were observed within a cumulative 120 days of the Tropical condition for one of the PA‐based backsheets and after 84 days of Tropical cycle followed by 42 days of the Multi‐season cycle for the PVDF‐based backsheet, which are both consistent with failures seen in fielded modules. In addition to backsheet cracking, degradation modes were observed including solder/interconnect fatigue, various light‐induced degradation modes, backsheet delamination, discoloration, corrosion, and cell cracking. The ability to simultaneously apply multiple stress factors may allow many of the test sequences within the standardized design qualification procedure to be performed using a single test setup. [ABSTRACT FROM AUTHOR]

Objective: In the schematic design phase of a new freestanding children's hospital, Simulation-based Hospital Design Testing (SbHDT) was used to evaluate the proposed design of 11 clinical areas. The purpose of this article is to describe the SbHDT process and how it can help identify and mitigate safety concerns during the facility design process. Background: In the design of new healthcare facilities, the ability to mitigate risk in the preconstruction period is imperative. SbHDT in a full-scale cardboard mock-up can be used to proactively test the complex interface between people and the built environment. Method: This study was a prospective investigation of SbHDT in the schematic design planning phase for a 400-bed freestanding children's hospital where frontline staff simulated episodes of care. Latent conditions related to design were identified through structured debriefing. Failure mode and effect analysis was used to categorize and prioritize simulation findings and was used by the architect team to inform design solutions. A second round of testing was conducted in order to validate design changes. Results: A statistically significant reduction in criticality scores between Round 1 (n = 201, median = 16.14, SD = 5.8) and Round 2 (n = 201, median score of 7.68, SD = 5.26, p <.001) was identified. Bivariate analysis also demonstrated a statistically significant reduction in very high/high criticality scores between Round 1 and Round 2. Conclusions: SbHDT in the schematic phase of design planning was effective in mitigating risk related to design prototypes through effective identification of latent conditions and validation of design changes. [ABSTRACT FROM AUTHOR]

The article examines whether a corticosteroid injection increases the risk of contracting COVID-19 or alters the clinical course of a subsequent infection. It mentions that therapeutic corticosteroids have wide-ranging physiologic effects. It also mentions that intra-articular corticosteroid injections are known to have systemic endocrine effects similar to those of epidural corticosteroid injections.

Purpose: Video assessment is an emerging tool for understanding surgical technique. Patient outcomes after robot-assisted radical prostatectomy (RARP) may be linked to technical aspects of the procedure. In an effort to refine surgical approaches and improve outcomes, we sought to understand technical variation for the key steps of RARP in a surgical collaborative. Methods: The Michigan Urological Surgery Improvement Collaborative (MUSIC) is a statewide quality improvement collaborative with the aim of improving prostate cancer care. MUSIC surgeons were invited to submit representative complete videos of nerve-sparing RARP for blinded analysis. We also analyzed peri-operative outcomes from these surgeons in the registry. Results: Surgical video data from 20 unique surgeons identified many variations in technique and time to complete different steps. Common to all surgeons was a transperitoneal approach and a running urethrovesical anastomosis. Prior to anastomosis, 25% surgeons undertook a posterior reconstruction and 30% employed urethral suspension. 65% surgeons approached the seminal vesicle anteriorly. For control of the dorsal vein complex, suture ligation was used in 60%, and vascular stapler was 15%. The majority (80%) of surgeons employed clips for managing pedicles. In examining patient outcomes for surgeons, peri-operative outcomes were not correlated with surgeon's operative time; however, surgeons with an EBL > 400 ml had significant difference among the five different techniques employed. Conclusions: Despite the worldwide popularity of RARP, the operation is still far from standardized. Correlating variation in technique with clinical outcomes may help provide objective data to support best practices with the goal to improve patient outcomes. [ABSTRACT FROM AUTHOR]

Delamination of the encapsulant in photovoltaic (PV) module technology results in immediate optical loss and may enable subsequent corrosion or mechanical damage. The effects of artificial weathering were not previously known; therefore, an empirical study was performed to survey the factors most affecting adhesion, including the ultraviolet (UV) source (ie, Xe or fluorescent lamp[s]), the optical filters for the lamp, the chamber temperature, and the relative humidity. Natural weathering was also performed at locations, including the following: Golden, Colorado; Miami, Florida; Phoenix, Arizona; QiongHai, China; Riyadh, Saudi Arabia; and Turpan, China. Specimens were constructed using a laminated glass/poly (ethylene‐co‐vinyl acetate)/glass geometry. The compressive shear test (CST) was used to quantify the mechanical strength of attachment, taken as a proxy for adhesion. The fractography of select specimens (including cross‐sectional optical microscopy) was used to verify the failure mode (delamination or decohesion). Additional analysis of the local solar spectrum as well as the specimen temperature was performed to interpret the results of natural weathering. The goals of this study include to identify the most significant stressors, clarify where strong coupling may occur between stressors, and validate accelerated test results relative to natural weathering. The importance of specimen conditioning (for moisture) and hygrometric degradation as well as the effects of UV degradation are identified in this study. [ABSTRACT FROM AUTHOR]

PURPOSE To determine whether the type of delivery system is associated with intensity of care at the end of life for Medicare beneficiaries with cancer. PATIENTS AND METHODS We used SEER registry data linked with Medicare claims to evaluate intensity of end-of-life care for patients who died of one of ten common cancers diagnosed from 2009 through 2014. Patients were categorized as receiving the majority of their care in an integrated delivery system, designated cancer center, health system that was both integrated and a certified cancer center, or health system that was neither. We evaluated adherence to seven nationally endorsed end-of-life quality measures using generalized linear models across four delivery system types. RESULTS Among 100,549 beneficiaries who died of cancer during the study interval, we identified only modest differences in intensity of end-of-life care across delivery system structures. Health systems with no cancer center or integrated affiliation demonstrated higher proportions of patients with multiple hospitalizations in the last 30 days of life (11.3%), death in an acute care setting (25.9%), and lack of hospice use in the last year of life (31.6%; all 푃 < .001). Patients enrolled in hospice had lower intensity care across multiple end-of-life quality measures. CONCLUSION Intensity of care at the end of life for patients with cancer was higher at delivery systems with no integration or cancer focus. Maximal supportive care delivered through hospice may be one avenue to reduce high-intensity care at the end of life and may impact quality of care for patients dying from cancer. [ABSTRACT FROM AUTHOR]

High-flow nasal oxygen systems are rapidly being adopted as an initial noninvasive treatment for acute respiratory failure. However, the term "high-flow nasal cannula" is nonspecific and leads to imprecise communication between physicians, respiratory therapists, and nurses with the potential for patient harm. In this viewpoint and a brief review of the technology, we argue for a change in nomenclature in order to reduce the chance for future clinical, administrative, and research misunderstanding surrounding high-flow nasal oxygen systems. [ABSTRACT FROM AUTHOR]

Introduction: The prevalence of childhood trauma, as measured by the Adverse Childhood Experiences (ACE) Study questionnaire, has been studied in a wide variety of community settings. However, little is known about physicians' familiarity with and use of the ACE questionnaire or the prevalence of childhood trauma in the physician community. Objective: To survey a convenience sample of community-based physicians and resident physicians to assess for familiarity with and use of the ACE questionnaire in clinical practice and to measure the prevalence of their own ACEs. Methods: An electronic survey was created and disseminated that included demographic questions, questions about physician awareness and use of the ACE questionnaire in clinical practice, and the 10-point ACE questionnaire. Results: Most physicians surveyed (81%) reported they had never heard of the ACE questionnaire. Even fewer (3%) reported using the questionnaire in clinical practice. Most physicians (55.5%) reported no personal history of ACEs. Physicians reporting a history of childhood trauma reported a wide range of ACE scores (1-9). Compared with men, women reported a statistically higher number of ACEs (p < 0.001). Conclusion: In this sample of community physicians, familiarity with and clinical use of the ACE questionnaire was low. Most physicians surveyed reported no personal history of childhood trauma. Of physicians reporting a history of childhood trauma, women were disproportionately affected. Physicians in this study reported a lower prevalence of ACEs than the population they serve. Physicians must become better educated and actively address the effects of ACEs on their patients and on themselves. [ABSTRACT FROM AUTHOR]

The article examines American citizen-soldier Charles Humke's transitioning into mid-nineteenth century America by placing emphasis on three overlapping aspects of his wartime service including his military life and the bonds developed with fellow soldiers; confrontations with southern civilians and slaves, which served as potent reminders of the stark alterity or otherness presented by the Old South; and the traumatic incarceration endured in the notorious Andersonville prisoner of- war camp.

The mechanical robustness of atomic layer deposited alumina and recently developed molecular layer deposited aluminum alkoxide (“alucone”) films, as well as laminated composite films composed of both materials, was characterized using mechanical tensile tests along with a recently developed fluorescent tag to visualize channel cracks in the transparent films. All coatings were deposited on polyethylene naphthalate substrates and demonstrated a similar evolution of damage morphology according to applied strain, including channel crack initiation, crack propagation at the critical strain, crack densification up to saturation, and transverse crack formation associated with buckling and delamination. From measurements of crack density versus applied tensile strain coupled with a fracture mechanics model, the mode I fracture toughness of alumina and alucone films was determined to be KIC=1.89±0.10 and 0.17±0.02 MPa m0.5, respectively. From measurements of the saturated crack density, the critical interfacial shear stress was estimated to be τc=39.5±8.3 and 66.6±6.1 MPa, respectively. The toughness of nanometer-scale alumina was comparable to that of alumina thin films grown using other techniques, whereas alucone was quite brittle. The use of alucone as a spacer layer between alumina films was not found to increase the critical strain at fracture for the composite films. This performance is attributed to the low toughness of alucone. The experimental results were supported by companion simulations using fracture mechanics formalism for multilayer films. To aid future development, the modeling method was used to study the increase in the toughness and elastic modulus of the spacer layer required to render improved critical strain at fracture. These results may be applied to a broad variety of multilayer material systems composed of ceramic and spacer layers to yield robust coatings for use in chemical barrier and other applications. [ABSTRACT FROM AUTHOR]

Many microsystems fabrication technologies currently employ a metallic overlayer, such as gold, in electrical contact with silicon structural layers. During postprocessing in hydrofluoric-based acid solutions, a galvanic cell is created between the silicon and the metallic layer. Micromachined tensile specimens reveal that such etching in the presence of a galvanic cell can cause a catastrophic reduction in the tensile strength and apparent modulus of silicon. Detailed failure analysis was also used to compare fractured corroded Si to otherwise identical reference specimens via surface based (electron and scanning probe) microscopy as well as cross-section based structural- and composition-characterization techniques. For both polycrystalline and single-crystal silicon, galvanic corrosion can result in a thick corroded surface layer created via porous silicon formation, and/or generalized material removal depending on the etch chemistry and conditions. Under certain etching conditions, the porous silicon formation process results in cavity formation as well as preferential grain-boundary attack leading to intergranular fracture. The nature and severity of corrosion damage are shown to be influenced by the surface wetting characteristics of the etch chemistry, with poor wetting resulting in localized attack facilitated by the microstructure and good wetting resulting in generalized attack. The measured stiffness of the tensile specimens can be used to determine the effective modulus and porosity of the corroded surface layer. Extending beyond previous investigations, the present work examines the quantitative connection between the choice of chemical etchant, the corresponding damage morphology, and the resulting degradation in strength and apparent modulus. The present work also uniquely identifies important differences in polycrystalline and single-crystal Si based on their disparate damage evolution and related mechanical performance. [ABSTRACT FROM AUTHOR]

Reduced optical transmittance of encapsulants resulting from ultraviolet (UV) degradation is frequently identified as a cause of decreased performance through the service life of photovoltaic modules. However, the present module safety and qualification standards apply short UV doses, only capable of examining design robustness and "infant mortality" failures. Furthermore, essential information remains unknown that might be used to screen encapsulants through product lifetime. We conducted an interlaboratory study to provide the understanding that will be used toward developing a higher‐fidelity, more‐rigorous UV weathering test. Five representative known formulations of poly (ethylene‐co‐vinyl acetate) were studied, in addition to one thermoplastic polyurethane material. Replicate laminated silica/polymer/silica specimens were examined at seven institutions using a variety of indoor chambers (including xenon, UVA‐340, and metal‐halide light sources). Specimens were artificially weathered for 180 cumulative days at steady‐state accelerated test conditions, predesignated relative to the default irradiance of 1.0 W·m−2·nm−1 at 340 nm, chamber temperature of 60°C, and chamber relative humidity of 30%. The solar‐weighted transmittance, yellowness index, and the UV cut‐off wavelength—each determined from the measured hemispherical transmittance—are examined to provide understanding and guidance for the UV light source (type lamp and filters), temperature, and humidity used in accelerated UV aging tests. The relative efficacy of xenon‐arc and UVA‐340 fluorescent sources and the typical range of activation energy for degradation is quantified from the experiments. A variety of ultraviolet (UV) light sources, optical filters, temperatures, and humidity conditions were explored to help prescribe test conditions for accelerated aging.The activation energy for photodegradation, attributed to interaction between the formulation additives, was quantified for the six materials examined.An alternate weathering regime, attributed to the loss of the UV absorber additive, was identified for the hottest experiments. [ABSTRACT FROM AUTHOR]

Objective: To examine the association between National Comprehensive Cancer Network (NCCN) risk, number of positive biopsy cores, age, and early confirmatory test results on pathological upgrading at radical prostatectomy (RP), in order to better understand whether early confirmatory testing and better risk stratification are necessary for all men with Grade Group (GG) 1 cancers who are considering active surveillance (AS). Patients and Methods: We identified men in Michigan initially diagnosed with GG1 prostate cancer, from January 2012 to November 2017, who had a RP within 1 year of diagnosis. Our endpoints were: (i) ≥GG2 cancer at RP and (ii) adverse pathology (≥GG3 and/or ≥pT3a). We compared upgrading according to NCCN risk, number of positive biopsy cores, and age. Last, we examined if confirmatory test results were associated with upgrading or adverse pathology at RP. Results: Amongst 1966 patients with GG1 cancer at diagnosis, the rates of upgrading to ≥GG2 and adverse pathology were 40% and 59% (P < 0.001), and 10% and 17% (P = 0.003) for patients with very‐low‐ and low‐risk cancers, respectively. Upgrading by volume ranged from 49% to 67% for ≥GG2, and 16% to 23% for adverse pathology. Generally, more patients aged ≥70 vs <70 years had adverse pathology. Unreassuring confirmatory test results had a higher likelihood of adverse pathology than reassuring tests (35% vs 18%, P = 0.017). Conclusions: Upgrading and adverse pathology are common amongst patients initially diagnosed with GG1 prostate cancer. Early use of confirmatory testing may facilitate the identification of patients with more aggressive disease ensuring improved risk classification and safer selection of patients for AS. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the effect of Accountable Care Organizations (ACOs) on the use of vertebroplasty and arthroscopic partial meniscectomy, 2 procedures for which randomized controlled trials suggest similar outcomes to sham surgery and therefore may provide low value. Medicare Shared Savings Program ACOs aim to improve quality and decrease health care spending. Reducing the use of potentially low-value procedures can accomplish both of these goals.Methods: We performed a retrospective cohort study of patients who underwent potentially low-value orthopedic procedures (vertebroplasty and partial meniscectomy) and a control (hip fracture) from 2010 to 2015 using a 20% sample of national Medicare claims. We performed an interrupted time-series analysis using linear spline models to evaluate the count of each procedure per 1000 patients, stratified by ACO participation.Results: We identified 76 256 patients who underwent arthroscopic partial meniscectomy, 44 539 patients who underwent vertebroplasty, and 50 760 patients who underwent hip fracture admission. Arthroscopic partial meniscectomy rates decreased, vertebroplasty rates remained stable, and hip fracture rates increased for both groups during the study period, with similar trends among ACO and non-ACO patients. After January 1, 2013, ACO and non-ACO populations had similar trends for vertebroplasty (ACO incidence rate ratio [IRR] = 1.15 [1.08-1.23] vs non-ACO IRR = 1.11 [1.05-1.16]), meniscectomy (ACO IRR = 1.06 [1.01-1.12] vs non-ACO IRR = 1.03 [0.99-1.07]), and hip fracture (ACO IRR = 1.08 [1.01-1.14] vs non-ACO IRR = 1.08 [1.03-1.13]).Conclusions: ACOs were not associated with a reduction in the frequency of vertebroplasty and arthroscopic partial meniscectomy. [ABSTRACT FROM AUTHOR]

Purpose: To determine the need for a standardized renal mass reporting template by analyzing reports of indeterminate renal masses and comparing their contents to stated preferences of radiologists and urologists.Methods: The host IRB waived regulatory oversight for this multi-institutional HIPAA-compliant quality improvement effort. CT and MRI reports created to characterize an indeterminate renal mass were analyzed from 6 community (median: 17 reports/site) and 6 academic (median: 23 reports/site) United States practices. Report contents were compared to a published national survey of stated preferences by academic radiologists and urologists from 9 institutions. Descriptive statistics and Chi-square tests were calculated.Results: Of 319 reports, 85% (271; 192 CT, 79 MRI) reported a possibly malignant mass (236 solid, 35 cystic). Some essential elements were commonly described: size (99% [269/271]), mass type (solid vs. cystic; 99% [268/271]), enhancement (presence vs. absence; 92% [248/271]). Other essential elements had incomplete penetrance: the presence or absence of fat in solid masses (14% [34/236]), size comparisons when available (79% [111/140]), Bosniak classification for cystic masses (54% [19/35]). Preferred but non-essential elements generally were described in less than half of reports. Nephrometry scores usually were not included for local therapy candidates (12% [30/257]). Academic practices were significantly more likely than community practices to include mass characterization details, probability of malignancy, and staging. Community practices were significantly more likely to include management recommendations.Conclusions: Renal mass reporting elements considered essential or preferred often are omitted in radiology reports. Variation exists across radiologists and practice settings. A standardized template may mitigate these inconsistencies. [ABSTRACT FROM AUTHOR]

Presents a study that examined the solid state reaction of cobalt-titanium with an epitaxially grown silicon-germanium strained layer. Use of rapid thermal annealing system; Measurement of electrical resistivity and Hall effect of the compound; Background of crystalline silicon-germanium.

Purpose: Tissue-based gene expression classifiers (GECs) may assist with management decisions in patients with newly diagnosed prostate cancer. We sought to assess the current use of GEC tests and determine how the test results are associated with primary disease management. Methods: In this observational study, patients diagnosed with localized prostate cancer were tracked through the Michigan Urological Surgery Improvement Collaborative registry. The utilization and results of three GECs (Decipher Prostate Biopsy, Oncotype DX Prostate, and Prolaris) were prospectively collected. Practice patterns, predictors of GEC use, and effect of GEC results on disease management were investigated. Results: Of 3,966 newly diagnosed patients, 747 (18.8%) underwent GEC testing. The rate of GEC use in individual practices ranged from 0% to 93%, and patients undergoing GEC testing were more likely to have a lower prostate-specific antigen level, lower Gleason score, lower clinical T stage, and fewer positive cores (all P <.05). Among patients with clinical favorable risk of cancer, the rate of active surveillance (AS) differed significantly among patients with a GEC result above the threshold (46.2%), those with a GEC result below the threshold (75.9%), and those who did not undergo GEC (57.9%; P <.001 for comparison of the three groups). This results in an estimate that, for every nine men with favorable risk of cancer who undergo GEC testing, one additional patient may have their disease initially managed with AS. On multivariable analysis, patients with favorable-risk prostate cancer who were classified as GEC low risk were more likely to be managed on AS than those without testing (odds ratio, 1.84; P =.006). Conclusion: There is large variability in practice-level use and GEC tests ordered in patients with newly diagnosed, localized prostate cancer. In patients with clinical favorable risk of cancer, GEC testing significantly increased the use of AS. Additional follow-up will help determine whether incorporation of GEC testing into initial patient care favorably affects clinical outcomes. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate a 12-month long-distance prostate MRI quality assurance (QA) program.Methods: The need for IRB approval was waived for this prospective longitudinal QA effort. One academic institution experienced with prostate MRI [~ 1000 examinations/year (Site 2)] partnered with a private institution 240 miles away that was starting a new prostate MRI program (Site 1). Site 1 performed all examinations (N = 249). Four radiologists at Site 1 created finalized reports, then sent images and reports to Site 2 for review on a rolling basis. One radiologist at Site 2 reviewed findings and exam quality and discussed results by phone (~ 2-10 minutes/MRI). In months 1-6 all examinations were reviewed. In months 7-12 only PI-RADS ≤ 2 and ‘difficult’ cases were reviewed. Repeatability was assessed with intra-class correlation (ICC). ‘Clinically significant cancer’ was Gleason ≥ 7.Results: Image quality significantly (p < 0.001) improved after the first three months. Inter-rater agreement also improved in months 3-4 [ICC: 0.849 (95% CI 0.744-0.913)] and 5-6 [ICC: 0.768 (95% CI 0.619-0.864)] compared to months 1-2 [ICC: 0.621 (95% CI 0.436-0.756)]. PI-RADS ≤ 2 examinations were reclassified PI-RADS ≥ 3 in 19% (30/162); of these, 23 had post-MRI histology and 57% (13/23) had clinically significant cancer (5.2% of 249). False-negative examinations [N = 18 (PI-RADS ≤ 2 and Gleason ≥ 7)] were more common at Site 1 during months 1-6 [9% (14/160) vs. 4% (4/89)]. Positive predictive values for PI-RADS ≥ 3 were similar.Conclusion: Remote quality assurance of prostate MRI is feasible and useful, enabling new programs to gain durable skills with minimal risk to patients. [ABSTRACT FROM AUTHOR]

Objectives: We present a pilot study exploring the effects of a brief, 30-minute educational intervention targeting resident communication surrounding dying in the intensive care unit (ICU). We sought to determine whether simulation or didactic educational interventions improved resident-reported comfort, preparation, and skill acquisition. We also sought to identify resident barriers to using the word “dying.” Methods: In this mixed-methods prospective study, second- and third-year medical residents were randomized to participate in a simulation-based communication training or a didactic session. Residents completed a pre–post survey after the sessions evaluating the sessions and reflecting on their use of the word “dying” in family meetings. Results: Forty-five residents participated in the study. Residents reported increases in comfort (Mean [M]-pre = 3.3 [standard deviation: 0.6], M-post = 3.7 [0.7]; P < .01, Cohen d = 0.75) and preparation (M-pre = 3.4 [0.7], M-post = 3.9 [0.6]; P < .01, d = 1.07) using the word “dying” after both the simulation and didactic versions. Residents randomized to the simulation reported they were more likely to have learned new skills as compared to residents in the didactic (M-simulation = 2.2 [0.4], M-didactic = 1.9 [0.3]; P = .015, d = 0.80). They estimated that they used the word “dying” in 50% of their end-of-life (EOL) conversations and identified uncertain prognosis as the main barrier to explicitly stating the word “dying.” Conclusion: A 30-minute educational intervention improves internal medicine residents’ self-reported comfort and preparation in talking about death and dying in the ICU. Residents in simulation-based training were more likely to report they learned new skills as compared to the didactic session. Residents report multiple barriers to using the word “dying” EOL conversations. [ABSTRACT FROM AUTHOR]

BACKGROUND: Accountable care organizations (ACOs) have been shown to reduce prostate cancer treatment among men unlikely to benefit because of competing risks (ie, potential overtreatment). This study assessed whether the level of engagement in ACOs by urologists affected rates of treatment, overtreatment, and spending. METHODS: A 20% sample of national Medicare data was used to identify men diagnosed with prostate cancer between 2012 and 2014. The extent of urologist engagement in an ACO, as measured by the proportion of patients in an ACO managed by an ACO‐participating urologist, served as the exposure. The use of treatment, potential overtreatment (ie, treatment in men with a ≥75% risk of 10‐year noncancer mortality), and average payments in the year after diagnosis for each ACO were modeled. RESULTS: Among 2822 men with newly diagnosed prostate cancer, the median rates of treatment and potential overtreatment by an ACO were 71.3% (range, 23.6%‐79.5%) and 53.6% (range, 12.4%‐76.9%), respectively. Average Medicare payments among ACOs in the year after diagnosis ranged from $16,523.52 to $34,766.33. Stronger urologist‐ACO engagement was not associated with treatment (odds ratio, 0.87; 95% confidence interval, 0.6‐1.2; P = .4) or spending (9.7% decrease in spending; P = .08). However, urologist engagement was associated with a lower likelihood of potential overtreatment (odds ratio, 0.29; 95% confidence interval, 0.1‐0.86; P = .03). CONCLUSIONS: ACOs vary widely in treatment, potential overtreatment, and spending for prostate cancer. ACOs with stronger urologist engagement are less likely to treat men with a high risk of noncancer mortality, and this suggests that organizations that better engage specialists may be able to improve the value of specialty care. Cancer 2018. © 2018 American Cancer Society. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: The aim of this study was to estimate Medicare payments for cancer care during the initial, continuing, and end‐of‐life phases of care for 10 malignancies and to examine variation in expenditures according to patient characteristics and cancer severity. Materials and Methods: We used linked Surveillance, Epidemiology and End Results‐Medicare data to identify patients aged 66–99 years who were diagnosed with one of the following 10 cancers: prostate, bladder, esophageal, pancreatic, lung, liver, kidney, colorectal, breast, or ovarian, from 2007 through 2012. We attributed payments for each patient to a phase of care (i.e., initial, continuing, or end of life), based on time from diagnosis until death or end of study interval. We summed payments for all claims attributable to the primary cancer diagnosis and analyzed the overall and phase‐based costs and then by differing demographics, cancer stage, geographic region, and year of diagnosis. Results: We identified 428,300 patients diagnosed with one of the 10 malignancies. Annual payments were generally highest during the initial phase. Mean expenditures across cancers were $14,381 during the initial phase, $2,471 for continuing, and $13,458 at end of life. Payments decreased with increasing age. Black patients had higher payments for four of five cancers with statistically significant differences. Stage III cancers posed the greatest annual cost burden for four cancer types. Overall payments were stable across geographic region and year. Conclusion: Considerable differences exist in expenditures across phases of cancer care. By understanding the drivers of such payment variations across patient and tumor characteristics, we can inform efforts to decrease payments and increase quality, thereby reducing the burden of cancer care. Implications for Practice: Considerable differences exist in expenditures across phases of cancer care. There are further differences by varying patient characteristics. Understanding the drivers of such payment variations across patient and tumor characteristics can inform efforts to decrease costs and increase quality, thereby reducing the burden of cancer care. [ABSTRACT FROM AUTHOR]

Background: Integrated delivery systems (IDSs) are postulated to reduce spending and improve outcomes through successful coordination of care across multiple providers. Nonetheless, the actual impact of IDSs on outcomes for complex multidisciplinary care such as major cancer surgery is largely unknown.Methods: Using 2011-2013 Medicare data, this study identified patients who underwent surgical resection for prostate, bladder, esophageal, pancreatic, lung, liver, kidney, colorectal, or ovarian cancer. Rates of readmission, 30-day mortality, surgical complications, failure to rescue, and prolonged hospital stay for cancer surgery were compared between patients receiving care at IDS hospitals and those receiving care at non-IDS hospitals. Generalized estimating equations were used to adjust results by cancer type and patient- and hospital-level characteristics while accounting for clustering of patients within hospitals.Results: The study identified 380,053 patients who underwent major resection of cancer, with 38% receiving care at an IDS. Outcomes did not differ between IDS and non-IDS hospitals regarding readmission and surgical complication rates, whereas only minor differences were observed for 30-day mortality (3.5% vs 3.2% for IDS; p < 0.001) and prolonged hospital stay (9.9% vs 9.2% for IDS; p < 0.001). However, after adjustment for patient and hospital characteristics, the frequencies of adverse perioperative outcomes were not significantly associated with IDS status.Conclusions: The collective findings suggest that local delivery system integration alone does not necessarily have an impact on perioperative outcomes in surgical oncology. Moving forward, stakeholders may need to focus on surgical and oncology-specific methods of care coordination and quality improvement initiatives to improve outcomes for patients undergoing cancer surgery. [ABSTRACT FROM AUTHOR]

Background: Active surveillance (AS) for prostate cancer includes follow-up with serial prostate biopsies. The optimal biopsy frequency during follow-up has not been determined. The goal of this investigation was to use longitudinal AS biopsy data to assess whether the frequency of biopsy could be reduced without substantially prolonging the time to the detection of disease with a Gleason score ≥ 7.Methods: With data from 1375 men with low-risk prostate cancer enrolled in AS at Johns Hopkins, a hidden Markov model was developed to estimate the probability of undersampling at diagnosis, the annual probability of grade progression, and the 10-year cumulative probability of reclassification or progression to Gleason score ≥ 7. It simulated 1024 potential AS biopsy strategies for the 10 years after diagnosis. For each of these strategies, the model predicted the mean delay in the detection of disease with a Gleason score ≥ 7.Results: The model estimated the 10-year cumulative probability of reclassification from a Gleason score of 6 to a Gleason score ≥ 7 to be 40.0%. The probability of undersampling at diagnosis was 9.8%, and the annual progression probability for men with a Gleason score of 6 was 4.0%. On the basis of these estimates, a simulation of an annual biopsy strategy estimated the mean time to the detection of disease with a Gleason score ≥ 7 to be 14.1 months; however, several strategies eliminated biopsies with only small delays (<12 months) in detecting grade progression.Conclusions: Although annual biopsy for low-risk men on AS is associated with the shortest time to the detection of disease with a Gleason score ≥ 7, several alternative strategies may allow less frequent biopsying without sizable delays in detecting grade progression. Cancer 2018;124:698-705. © 2017 American Cancer Society. [ABSTRACT FROM AUTHOR]

Objectives: To determine whether a needle disinfectant step during transrectal ultrasonography (TRUS)‐guided prostate biopsy is associated with lower rates of infection‐related hospitalisation. Patients and Methods: We conducted a retrospective analysis of all TRUS‐guided prostate biopsies taken across the Michigan Urological Surgery Improvement Collaborative (MUSIC) from January 2012 to March 2015. Natural variation in technique allowed us to evaluate for differences in infection‐related hospitalisations based on whether or not a needle disinfectant technique was used. The disinfectant technique was an intra‐procedural step to cleanse the biopsy needle with antibacterial solution after each core was sampled (i.e., 10% formalin or 70% isopropyl alcohol). After grouping biopsies according to whether or not the procedure included a needle disinfectant step, we compared the rate of infection‐related hospitalisations within 30 days of biopsy. Generalised estimating equation models were fit to adjust for potential confounders. Results: During the evaluated period, 17 954 TRUS‐guided prostate biopsies were taken with 5 321 (29.6%) including a disinfectant step. The observed rate of infection‐related hospitalisation was lower when a disinfectant technique was used during biopsy (0.60% vs 0.90%; P = 0.04). After accounting for differences between groups the adjusted hospitalisation rate in the disinfectant group was 0.85% vs 1.12% in the no disinfectant group (adjusted odds ratio 0.76, 95% confidence interval 0.50–1.15; P = 0.19). Conclusions: In this observational analysis, hospitalisations for infectious complications were less common when the TRUS‐guided prostate biopsy included a needle disinfection step. However, after adjusting for potential confounders the effect of needle disinfection was not statistically significant. Prospective evaluation is warranted to determine if this step provides a scalable and effective method to minimise infectious complications. [ABSTRACT FROM AUTHOR]

Background: Accountable care organizations (ACOs) can improve prostate cancer care by decreasing treatment variations (ie, avoidance of treatment in low-value settings). Herein, the authors performed a study to understand the effect of Medicare Shared Savings Program ACOs on prostate cancer care.Methods: Using a 20% Medicare sample, the authors identified men with newly diagnosed prostate cancer from 2010 through 2013. Rates of treatment, potential overtreatment (ie, treatment in men with a ≥75% chance of 10-year mortality from competing risks), and Medicare payments were measured using regression models. The impact of ACO participation was assessed using difference-in-differences analyses.Results: Before implementation of ACOs, the treatment rate was 71.8% (95% confidence interval [95% CI], 70.2%-73.3%) for ACO-aligned beneficiaries and 72.3% (95% CI, 71.7%-73.0% [P = .51]) for non-ACO-aligned beneficiaries. After implementation, this rate declined to 68.4% (95% CI, 66.1%-70.7% [P = .017]) for ACO-aligned beneficiaries and 69.3% (95% CI, 68.5%-70.1% [P<.001]) for non-ACO-aligned beneficiaries. There was no differential effect noted for ACO participation. The rate of potential overtreatment decreased from 48.2% (95% CI, 43.1%-53.3%) to 40.2% (95% CI, 32.4%-48.0% [P = .087]) for ACO-aligned beneficiaries and increased from 44.3% (95% CI, 42.1%-46.5%) to 47.0% (95% CI, 44.5%-49.5% [P = .11]) for non-ACO-aligned beneficiaries. These changes resulted in a significant relative decrease in overtreatment of 17% for ACO-aligned beneficiaries (difference-in-differences, 10.8%; P = .031). Payments were not found to be differentially affected by ACO alignment.Conclusions: The treatment of prostate cancer and annual payments decreased significantly between 2010 and 2013, but ACO participation did not appear to impact these trends. Among men least likely to benefit, Medicare Shared Savings Program ACO alignment was associated with a significant decline in prostate cancer treatment. Cancer 2018;124:563-70. © 2017 American Cancer Society. [ABSTRACT FROM AUTHOR]

Background: The Hospital Readmission Reduction Program (HRRP) penalizes hospitals for high all-cause unplanned readmission rates. Many have expressed concern that hospitals serving patient populations with more comorbidities, lower incomes, and worse self-reported health status may be disproportionately penalized by readmissions that are not clinically related to the index admission. The impact of including clinically unrelated readmissions on hospital performance is largely unknown. We sought to determine if a clinically related readmission measure would significantly alter the assessment of hospital performance.Methods: We analyzed Medicare claims for beneficiaries in Michigan admitted for pneumonia and joint replacement from 2011 to 2013. We compared each hospital's 30-day readmission rate using specifications from the HRRP's all-cause unplanned readmission measure to values calculated using a clinically related readmission measure.Results: We found that the mean 30-day readmission rates were lower when calculated using the clinically related readmission measure (joint replacement: all-cause 5.8%, clinically related 4.9%, p < 0.001; pneumonia: all cause 12.5%, clinically related 11.3%, p < 0.001)). The correlation of hospital ranks using both methods was strong (joint replacement: 0.95 (p < 0.001), pneumonia: 0.90 (p < 0.001)).Conclusions: Our findings suggest that, while greater specificity may be achieved with a clinically related measure, clinically unrelated readmissions may not impact hospital performance in the HRRP. [ABSTRACT FROM AUTHOR]

Background: Both the Centers for Medicare and Medicaid Services' (CMS) Hospital Compare star rating and surgical case volume have been publicized as metrics that can help patients to identify high-quality hospitals for complex care such as cancer surgery. The current study evaluates the relationship between the CMS' star rating, surgical volume, and short-term outcomes after major cancer surgery.Methods: National Medicare data were used to evaluate the relationship between hospital star ratings and cancer surgery volume quintiles. Then, multilevel logistic regression models were fit to examine the association between cancer surgery outcomes and both star rankings and surgical volumes. Lastly, a graphical approach was used to compare how well star ratings and surgical volume predicted cancer surgery outcomes.Results: This study identified 365,752 patients undergoing major cancer surgery for 1 of 9 cancer types at 2,550 hospitals. Star rating was not associated with surgical volume (P < .001). However, both the star rating and surgical volume were correlated with 4 short-term cancer surgery outcomes (mortality, complication rate, readmissions, and prolonged length of stay). The adjusted predicted probabilities for 5- and 1-star hospitals were 2.3% and 4.5% for mortality, 39% and 48% for complications, 10% and 15% for readmissions, and 8% and 16% for a prolonged length of stay, respectively. The adjusted predicted probabilities for hospitals with the highest and lowest quintile cancer surgery volumes were 2.7% and 5.8% for mortality, 41% and 55% for complications, 12.2% and 11.6% for readmissions, and 9.4% and 13% for a prolonged length of stay, respectively. Furthermore, surgical volume and the star rating were similarly associated with mortality and complications, whereas the star rating was more highly associated with readmissions and prolonged length of stay.Conclusions: In the absence of other information, these findings suggest that the star rating may be useful to patients when they are selecting a hospital for major cancer surgery. However, more research is needed before these ratings can supplant surgical volume as a measure of surgical quality. Cancer 2017;123:4259-4267. © 2017 American Cancer Society. [ABSTRACT FROM AUTHOR]