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Cardiac surgery utilization has increased after passage of the Affordable Care Act. This multistate study examined whether changes in access after Medicaid expansion (ME) have led to improved outcomes, overall and particularly among ethnoracial minorities. State Inpatient Databases were used to identify nonelderly adults (ages 18-64 years) who underwent coronary artery bypass grafting, aortic valve replacement, mitral valve replacement, or mitral valve repair in 3 expansion (Kentucky, New Jersey, Maryland) vs 2 nonexpansion states (North Carolina, Florida) from 2012 to 2015. Linear and logistic interrupted time series were used with 2-way interactions and adjusted for patient-level, hospital-level, and county-level factors to compare trends and instantaneous changes at the point of ME implementation (quarter 1 of 2014) for mortality, length of stay, and elective status. Interrupted time series models estimated expansion effect, overall and by race-ethnicity. Analysis included 22 038 cardiac surgery patients from expansion states and 33 190 from nonexpansion states. In expansion states, no significant trend changes were observed for mortality (odds ratio, 1.01; P =.83) or length of stay (β = -0.05, P =.20), or for elective surgery (odds ratio, 1.00; P =.91). There were similar changes seen in nonexpansion states. Among ethnoracial minorities, ME did not impact outcomes or elective status. Despite an increase in cardiac surgery utilization after ME, outcomes remained unchanged in the early period after implementation, overall and among ethnoracial minorities. Future research is needed to confirm long-term trends and examine reasons behind this lack of improved outcomes. [ABSTRACT FROM AUTHOR]

Medicaid expansion (ME) under the Affordable Care Act has reduced the number of uninsured patients, although its preferential effects on vulnerable populations have been mixed. This study examined whether ME preferentially improved cardiac surgery use by insurance strata, race, and income level. Non-elderly adults (aged 18-64 years) who underwent coronary artery bypass grafting, aortic valve replacement, mitral valve replacement, or mitral valve repair were identified in the State Inpatient Databases for 3 expansion states (Kentucky, New Jersey, and Maryland) and 2 non-expansion states (North Carolina and Florida) from 2012 to the third quarter of 2015. We used adjusted Poisson interrupted time series to determine the impact of ME on cardiac surgery use for Medicaid or uninsured (MCD/UIS) patients, racial and ethnic minorities, and individuals from low-income areas. In expansion states, use among non-White MCD/UIS patients had a positive trend after ME (2.3%/quarter; P =.156), whereas use for White MCD/UIS patients fell (–1.7%/quarter; P =.117). In contrast, use among non-White MCD/UIS in non-expansion states decreased by 4.4% (P <.001) which was a greater decline than among White MCD/UIS patients (–1.8%/quarter; P =.057). There was no substantial effect of ME on cardiac surgery use for MCD/UIS patients from low- versus high-income areas. These findings demonstrate that the use of cardiac surgical procedures was generally unchanged after ME; however, nonsignificant trend differences suggest a narrowing gap between vulnerable and non-vulnerable groups in ME states. These preliminary findings help describe the association of insurance coverage as a driver of cardiac surgery use among vulnerable patients. [Display omitted] [ABSTRACT FROM AUTHOR]

Given the rarity of retroperitoneal soft tissue sarcoma, few studies have assessed if radical excision of retroperitoneal soft tissue sarcoma with adjacent organs improves survival outcomes. This propensity score–matched study aimed to evaluate the impact of radical excision versus resection of tumor alone. The National Cancer Database 2004 to 2015 was used to assess short- and long-term outcomes of resection of tumor alone versus radical excision (tumor plus ≥1 adjacent organs) via 1:1 propensity-matched analyses. Subgroup analyses included low-grade, high-grade, liposarcoma, leiomyosarcoma, adjacent organ involvement alone, localized tumors alone, and high-volume hospitals (≥10 resections/y). Multivariable logistic regression models identified factors associated with radical excision. Comparison of propensity-matched groups (N = 1,139/group) revealed no significant differences in 30-day mortality, 90-day mortality, or overall survival (for all, P >.580). For all subgroup analyses comparing resection of tumor alone with radical excision, including localized tumors without organ invasion (N = 208/group), there were no identified differences in short- or long-term survival. Although it yielded lower R2 resection rates (P =.007), radical excision was associated with greater mean length of stay (P <.001). Radical excision was not associated with improved retroperitoneal soft tissue sarcoma survival irrespective of grade, histology, hospital volume, or adjacent organ involvement. Resection of ostensibly involved adjacent viscera may increase morbidity without survival benefit. These results inform ongoing discussion regarding histology-tailored, situation-specific extent of retroperitoneal soft tissue sarcoma resections. [ABSTRACT FROM AUTHOR]

There are still gaps in the field of reference electrode that is needed to assist electrolysis in high temperature electrolytes (e.g. molten hydroxides) for H 2 gas production. This research aims to fill the gaps by preparing Ni/Ni(OH) 2 reference electrode and more importantly testing its effectiveness against important performance factors including; ion conducting membrane (e.g. mullite tubes), internal electrolyte composition, working temperature and electrochemical control (e.g. potential scan rate). Then, this reference electrode was used to study the electrocatalytic activity various cheaper working electrode materials including; stainless steel (St.st), Ni, Mo and Ag in comparison with Pt by the means of chronoamperometry and voltammetry. The effect of introducing steam into electrolyte (eutectic mixture of NaOH and KOH) on the electrocatalytic activity of these working electrodes was also studied. It was observed that the potential of hydrogen evolution with different working electrodes followed an order as; Pt > Ni > St. st > Ag > Mo (positive to negative). The performance of each working electrode was confirmed through chronoamperometry for hydrogen evolution at a constant potential of −0.7 V. It was also found in cyclic voltammetry and confirmed by chronoamperometry that the introduction of steam was apparent as increasing the current density at cathodic limit for hydrogen evolution. This study could help to develop non-precious metal electrodes for the production of hydrogen fuel. In future, there will be a potential in the threshold concentration of steam for H 2 gas production. Image 1 • Fabrication of cheap and novel Ni/Ni(OH) 2 reference electrode is carried out. • Electrocatalytic activity of Ni, Pt, Ag, Mo and St. st vs Ni/Ni(OH) 2 is evaluated. • Cyclic voltammetry (CV) and chronoamperometry techniques are applied. • Effect of steam and temperature at electrocatalytic activity is studied. • Chronoamperometry analyses of hydrogen evolution reaction are carried out. [ABSTRACT FROM AUTHOR]

Obesity disproportionately affects vulnerable populations. Bariatric surgery is an effective long-term treatment for obesity-related complications; however, bariatric surgical rates are lower among racial minorities and low-income and publicly insured patients. The Affordable Care Act's Medicaid expansion improved access to health insurance, but its impact on bariatric surgical disparities has not been evaluated. We sought to determine the impact of the Affordable Care Act's Medicaid expansion on disparate utilization rates of bariatric surgery. A total of 47,974 nonelderly adult bariatric surgical patients (ages 18–64 years) were identified in 2 Medicaid-expansion states (Kentucky and Maryland) versus 2 nonexpansion control states (Florida and North Carolina) between 2012 and 2015 using the Healthcare Cost and Utilization Project's State Inpatient Database. Poisson interrupted time series were conducted to determine the adjusted incidence rates of bariatric surgery by insurance (Medicaid/uninsured versus privately insured), income (high income versus low income), and race (African American versus white). The difference in the counts of bariatric surgery were then calculated to measure the gap in bariatric surgery rates. The adjusted incidence rate of bariatric surgery among Medicaid or uninsured and low-income patients increased by 15.8% and 5.1% per quarter, respectively, after the Affordable Care Act in expansion states (P <.001). No marginal change was seen in privately insured and high-income patients in expansion states. The adjusted incidence rates increased among African American and white patients, but these rates did not change significantly before and after the Affordable Care Act in expansion states. The gap in bariatric surgery rates by insurance and income was reduced after the Affordable Care Act's Medicaid expansion, but racial disparities persisted. Future research should track these trends and identify factors to reduce racial disparity in bariatric surgery. [ABSTRACT FROM AUTHOR]

Background: Adequate lymphadenectomy (AL) of 15+ lymph nodes comprises an important component of gastric cancer surgical therapy. Despite endorsement by the National Comprehensive Cancer Network and the Committee on Cancer, initial adoption of this paradigm has been relatively slow. The current analysis sought to perform an adjusted time-trend evaluation of the factors associated with AL and its dissemination.Methods: Utilizing the 2004-2015 National Cancer Database, 28,985 patients were identified who underwent gastrectomy for adenocarcinoma. An adjusted time-trend analysis was performed to estimate the adoption of AL overall. Multivariable logistic regression was utilized to assess factors associated with these observed trends. Interactions and stratified models determined disparate effects in vulnerable populations (older adults, ethnic minorities, low socioeconomic status).Results: The adjusted time-trend analysis demonstrated an overall 30% increase (28.8 to 58.7%) in receipt of AL (OR 1.10 increase/year; 95%CI 1.09-1.10) from 2004 to 2015. This trend persisted even after stratifying the models by age, race/ethnicity, and income (OR 1.07-1.12; p < 0.05). Slowest rates of adoption were seen amongst hospitals in the Midwest census region (OR 1.08, CI 1.06-1.90) and comprehensive community hospitals (OR 1.08, CI 1.06-1.91) and with African-American patients (OR 1.09, CI 1.06-1.11) (all p < 0.05).Conclusion: This multi-center evaluation demonstrates increased adoption of AL during gastric cancer surgery in the USA overall and amongst vulnerable populations, although regional and racial disparities were observed. Future studies are needed to investigate reasons underlying racial and regional differences in receipt of AL. [ABSTRACT FROM AUTHOR]

An efficient and green energy carrier hydrogen (H 2) generation via water splitting reaction has become a major area of focus to meet the demand of clean and sustainable energy sources. In this research, the splitting steam via eutectic molten hydroxide (NaOH–KOH; 49–51 mol%) electrolysis for hydrogen gas production has been electrochemically investigated at 250–300 °C. Three types of reference electrodes such as a high-temperature mullite membrane Ni/Ni(OH) 2 , quasi-silver and quasi-platinum types were used. The primary purpose of this electrode investigation was to find a suitable, stable, reproducible and reusable reference electrode in a molten hydroxide electrolyte. Cyclic voltammetry was performed to examine the effect on reaction kinetics and stability to control the working electrode at different scan rate and molten salt temperature. The effect of introducing water to the eutectic molten hydroxide via the Ar gas stream was also investigated. When the potential scan rate was changed from 50 to 150 mV s−1, the reduction current for the platinum wire working electrode was not changed with newly prepared nickel reference electrode that designates its stability and reproducibility. Furthermore, increasing the operating temperature of molten hydroxides from 250 to 300 °C the reduction potential of the prepared nickel reference electrode is slightly positive shifted about 0.02 V. This suggests that it has good stability with temperature variations. The prepared nickel and Pt reference electrode exhibited stable and reliable cyclic voltammetry results with and without the presence of steam in the eutectic molten hydroxide while Ag reference electrode exposed positive shifts of up to 0.1 V in the reduction potential. The designed reference electrode had a more stable and effective performance towards controlling the platinum working electrode as compared to the other quasi-reference electrodes. Consequently, splitting steam via molten hydroxides for hydrogen has shown a promising alternative to current technology for hydrogen production that can be used for thermal and electricity generation. Image 1 • Development of the novel reference electrode, Ni/Ni(OH) 2 in eutectic molten hydroxides. • Fabrication conditions: eutectic molten hydroxide (NaOH–KOH; 49–51 mol%), temperature 300 °C. • Cyclic voltammetry was performed to examine the stability and reusability of the prepared nickel electrode. • Silver and platinum quasi−reference electrodes were used for comparison. • Novel designed reference electrode showed high stability and performance. [ABSTRACT FROM AUTHOR]

The Affordable Care Act Medicaid expansion demonstrated inconsistent effects on cancer surgery utilization rates among racial and ethnic minorities and low-income Americans. This quasi-experimental study examines whether Medicaid expansion differentially increased the utilization of surgical cancer care for low-income groups and racial minorities in states that expanded their Medicaid programs. A cohort of more than 81,000 patients 18 to 64 years of age who underwent cancer surgery were examined in Medicaid expansion versus nonexpansion states. This evaluation utilized merged data from the State Inpatient Database, American Hospital Association, and the Area Resource File for the years 2012 to 2015. Poisson interrupted time series analysis were performed to examine the impact of Medicaid expansion on the utilization of cancer surgery for the uninsured overall, low-income persons, and racial minorities, adjusting for age, sex, Elixhauser comorbidity score, population-level characteristics, and provider-level characteristics. For persons from low-income ZIP codes, Medicaid expansion was associated with an immediate 24% increase in utilization (P =.002) relative to no significant change in nonexpansion states. No significant trends, however, were observed after the Affordable Care Act expansion for racial and ethnic minorities in expansion versus nonexpansion states. Medicaid expansion was associated with greater utilization of cancer surgery by low-income Americans but provided no preferential effects for racial minorities in expansion states. Beyond the availability of coverage, these findings highlight the need for additional investigation to uncover other factors that contribute to race-ethnic disparities in surgical cancer care. [ABSTRACT FROM AUTHOR]

ABSTRACT Background While pre-Affordable Care Act expansions in Medicaid eligibility led to increased utilization of elective inpatient procedures, the impact of the Affordable Care Act on such preference-sensitive procedures (also known as discretionary procedures) versus time-sensitive non-discretionary procedures remains unknown. As such, we performed a hospital-level quasi-experimental evaluation to measure the differential effects of the Affordable Care Act's Medicaid expansion on utilization of discretionary procedures versus non-discretionary procedures. Methods The State Inpatient Database (2012–2014) yielded 476 hospitals providing selected discretionary procedures or non-discretionary procedures performed on 288,446 non-elderly, adult patients across 3 expansion states and 2 non-expansion control states. Discretionary procedures included non-emergent total knee and hip arthroplasty, while non-discretionary procedures included nine cancer surgeries. Mixed Poisson interrupted time series analyses were performed to determine the impact of the Affordable Care Act's Medicaid expansion on the number of discretionary procedures versus non-discretionary procedures provided among non–privately insured patients (Medicaid and uninsured patients) and privately insured patients. Results Analysis of the number of non–privately insured procedures showed an increase in discretionary procedures of +15.1% (IRR 1.15, 95% CI:1.11–1.19) vs –4.0% (IRR 0.96, 95% CI:0.94–0.99) and non-discretionary procedures of +4.1% (IRR 1.04, 95% CI:1.0–1.1) vs –5.3% (IRR 0.95, 95% CI:0.93–0.97) in expansion states compared to non-expansion states, respectively. Analysis of privately insured procedures showed no statistically meaningful change in discretionary procedures or non-discretionary procedures in either expansion or non-expansion states. Conclusion In this multi-state evaluation, the Affordable Care Act's Medicaid expansion preferentially increased utilization of discretionary procedures versus non-discretionary procedures in expansion states compared to non-expansion states among non–privately insured patients. These preliminary findings suggest that increased Medicaid coverage may have contributed to the increased use of inpatient surgery for discretionary procedures. [ABSTRACT FROM AUTHOR]

Background Minority-serving hospitals have greater readmission rates after operative procedures including colectomy; however, little is known about the contribution of hospital factors to readmission risk and mortality in this setting. This study evaluated the impact of hospital factors on readmissions and inpatient mortality after colorectal resections at minority-serving hospitals in the context of patient- and procedure-related factors. Methods More than 168,000 patients who underwent colorectal resections in 374 California hospitals (2004–2011) were analyzed using the State Inpatient Database and American Hospital Association Hospital Survey data. Sequential logistic regression analyses were performed to determine the associations between minority-serving hospital status and 30-day, 90-day, and repeated readmissions. Results Thirty-day, 90-day, and repeated readmission rates were 11.2%, 16.9%, and 2.9%, respectively. Odds for 30-day, 90-day, and repeated readmissions after colorectal resections were 19%, 20%, and 38% more likely at minority-serving hospitals versus non-minority-serving hospitals, respectively ( P < .01), after controlling for age, sex, comorbidities, year, and procedure type. Patient factors accounted for up to 65% of the observed increase in odds for readmission at minority-serving hospitals while hospital-level factors contributed roughly 40%. Inpatient mortality was significantly greater at minority-serving hospitals versus non-minority-serving hospitals (4.9% vs 3.8%; P < .001). Risk factors significantly associated with readmissions and inpatient mortality included Medicaid/Medicare primary insurance, emergent operation, and ostomy creation. Low procedure volume was significantly associated with increased odds for inpatient mortality. Conclusion Patient-level factors seemed to dominate the increased readmission risk after colorectal resections at minority-serving hospitals while hospital factors were less contributory. These findings need to be further validated to shape quality improvement interventions to decrease readmissions. [ABSTRACT FROM AUTHOR]

Background Decreasing readmissions has become a focus of emerging efforts to improve the quality and affordability of health care. However, little is known about reasons for readmissions after major cancer surgery in the expanding elderly population (≥65 years) who are also at increased risk of adverse operative events. We sought to identify (1) the extent to which older age impacts readmissions and (2) factors predictive of 30- and 90-day readmissions after major cancer surgery among older adults. Methods We identified 2,797 older adults who underwent 1 of 7 types of major thoracic or abdominopelvic cancer surgery within a large multihospital system from 2003 to 2012. Multivariate logistic regression analyses were conducted to identify predictors of 30- and 90-day readmission controlling for covariates. Results Overall 30- and 90-day readmission rates were 16% and 24% with the majority of readmissions occurring within 15-days of discharge. Principal diagnoses of 30-day readmissions included gastrointestinal, pulmonary, and infections complications. The 30-day readmissions were associated with >2 comorbid conditions and ≥2 postoperative complications. Readmissions varied significantly according to cancer surgery type and across treating hospitals. Readmissions did not vary by increasing age. Factors associated with 90-day readmission were comparable to those observed at 30 days. Conclusion In this large, multihospital study of older adults, multiple morbidities, procedure type, greater number of complications, and the treating hospital predicted 30- and 90-day readmissions. These findings point toward the potential impact of hospital-level factors behind readmission. Our results also heighten the importance of assessing the influence of readmission on other important cancer care metrics, namely, patient-reported outcomes and the completion of adjuvant systemic therapies. [ABSTRACT FROM AUTHOR]

Abstract: We present the case of a 63-year-old white male with bilateral chronic leg ulcers due to polycythemia vera and hydroxyurea therapy who demonstrated dramatic healing of his wounds in response to ruxolitinib (Jakafi®, Novartis), a novel Janus kinase-1 and -2 inhibitor. This patient's wound had previously been refractory to multiple surgical interventions and immunosuppression. After the initiation of ruxolitinib, the patient underwent successful split-thickness skin grafting, with resultant healing of his wounds. He was stable without prednisone and other immunosuppressant therapy and had healed at 6 months. Ruxolitinib therapy could represent a novel option for patients who develop persistent inflammatory wounds in the setting of polycythemia vera and hydroxyurea therapy. [ABSTRACT FROM AUTHOR]

Abstract: We present the case of a 63-year-old white male with bilateral chronic leg ulcers due to polycythemia vera and hydroxyurea therapy who demonstrated dramatic healing of his wounds in response to ruxolitinib (Jakafi®, Novartis), a novel Janus kinase-1 and -2 inhibitor. This patient's wound had previously been refractory to multiple surgical interventions and immunosuppression. After the initiation of ruxolitinib, the patient underwent successful split-thickness skin grafting, with resultant healing of his wounds. He was stable without prednisone and other immunosuppressant therapy and had healed at 6 months. Ruxolitinib therapy could represent a novel option for patients who develop persistent inflammatory wounds in the setting of polycythemia vera and hydroxyurea therapy. [Copyright &y& Elsevier]

Type 2 diabetes is highly prevalent and is the major cause of progressive chronic kidney disease in American Indians. Genome-wide association studies identified several loci associated with diabetes but their impact on susceptibility to diabetic complications is unknown. We studied the association of 18 type 2 diabetes genome-wide association single-nucleotide polymorphisms (SNPs) with estimated glomerular filtration rate (eGFR; MDRD equation) and urine albumin-to-creatinine ratio in 6958 Strong Heart Study family and cohort participants. Center-specific residuals of eGFR and log urine albumin-to-creatinine ratio, obtained from linear regression models adjusted for age, sex, and body mass index, were regressed onto SNP dosage using variance component models in family data and linear regression in unrelated individuals. Estimates were then combined across centers. Four diabetic loci were associated with eGFR and one locus with urine albumin-to-creatinine ratio. A SNP in the WFS1 gene (rs10010131) was associated with higher eGFR in younger individuals and with increased albuminuria. SNPs in the FTO, KCNJ11, and TCF7L2 genes were associated with lower eGFR, but not albuminuria, and were not significant in prospective analyses. Our findings suggest a shared genetic risk for type 2 diabetes and its kidney complications, and a potential role for WFS1 in early-onset diabetic nephropathy in American Indian populations. [ABSTRACT FROM AUTHOR]

Improved accuracy in predicting coronary heart disease (CHD) risk in patients with diabetes and kidney disease is needed. The addition of albuminuria to established methods of CHD risk calculation was reported in the Strong Heart Study (SHS) cohort. In this study, the addition of estimated glomerular filtration rate (eGFR) was evaluated using data from 4,549 American Indian SHS participants aged 45 to 74 years. After adjustment for Framingham CHD risk factors, hazard ratios for eGFR as a predictor of CHD were 1.69 (95% confidence interval 1.34 to 2.13) in women and 1.41 (95% confidence interval 0.94 to 2.13) in men. Models including albuminuria, eGFR, or both scored higher in discriminatory power than models using conventional risk factors alone in women; in men, the improvement was seen only for albuminuria and the combination of albuminuria and eGFR. Hosmer-Lemeshow assessments showed good calibration for the models using eGFR alone in both genders, followed by models including albuminuria alone in both genders. Adding eGFR improved the net reclassification improvement (NRI) in women (0.085, p = 0.0004) but not in men (0.010, p = 0.1967). NRI and integrated discrimination improvement (IDI) were improved in both genders using albuminuria and eGFR (NRI 0.135, p <0.0001, and IDI 0.027, p <0.0001 in women; NRI 0.035, p <0.0196, and IDI 0.008, p <0.0156 in men). Therefore, a risk calculator including albuminuria enhances CHD prediction compared to a calculator using only standard risk factors in men and women. Including eGFR alone improves risk prediction in women, but for men, it is preferable to include eGFR and albuminuria. In conclusion, this enhanced calculator should be useful in estimating CHD risk in populations with high prevalence of diabetes and renal disease. [ABSTRACT FROM AUTHOR]

Rationale and Objectives: Lung cancer is caused primarily by repeated exposure to carcinogenic particulate matter and noxious gasses with high particulate deposition localized to airway bifurcations and the lung periphery. The quantitative measurement and analysis of these sites has the potential to stratify lung cancer risk. The aim of this preliminary study was to assess the performance of a new method for estimating individual lung cancer risk based on the analysis of airway bifurcations on high-resolution (HR) computed tomographic (CT) scanning and spirometry. Materials and Methods: One hundred eight subjects with spirometry and thin-slice CT data were selected from a CT screening study including 15 patients with early lung cancer and 93 age-matched and pack-year–matched controls. A subset of seven patients with cancer and 72 controls were scanned with 1-mm CT slice thickness, representing an HR case subset. A quantitative lung cancer risk index method was developed on the basis of airway bifurcation x-ray attenuation combined with the ratio of forced expiratory volume in 1 second to forced vital capacity. Cochran-Mantel-Haenszel and conditional logistic regression tests were used to analyze performance. Results: Cochran-Mantel-Haenszel crude analysis revealed a cancer detection sensitivity and specificity of 67% and 72% for all cases and 100% and 73% for the HR case subset, respectively. Conditional logistic regression showed that a 0.0328 increase in lung cancer risk index was associated with odds ratios of 1.84 (95% confidence interval, 1.18–2.85) for the full data set (P = .0067) and 2.89 (95% confidence interval, 1.02-8.19) for the HR subset (P = .0467). Conclusions: A preliminary evaluation of a new lung cancer risk estimation method based on thin slice CT and spirometry showed a statistically significant association with lung cancer. [Copyright &y& Elsevier]

Background: The Stop Atherosclerosis in Native Diabetics Study (SANDS) reported cardiovascular benefit of aggressive versus standard treatment targets for both low-density lipoprotein cholesterol (LDL-C) and blood pressure (BP) in diabetic individuals. Objective: In this analysis, we examined within trial cost-effectiveness of aggressive targets of LDL-C ≤70 mg/dL and systolic BP ≤115 mmHg versus standard targets of LDL-C ≤100 mg/dL and systolic BP ≤130 mmHg. Design: Randomized, open label blinded-to-endpoint 3-year trial. Data Sources: SANDS clinical trial database, Quality of Wellbeing survey, Centers for Medicare and Medicaid Services, Wholesale Drug Prices. Target Population: American Indians ≥age 40 years with type 2 diabetes and no previous cardiovascular events. Time Horizon: April 2003 to July 2007. Perspective: Health payer. Interventions: Participants were randomized to aggressive versus standard groups with treatment algorithms defined for both. Outcome Measures: Incremental cost-effectiveness. Results of Base-Case Analysis: Compared with the standard group, the aggressive group had slightly lower costs of medical services (−$116) but a 54% greater cost for BP medication ($1,242) and a 116% greater cost for lipid-lowering medication ($2,863), resulting in an increased cost of $3,988 over 3 years. Those in the aggressively treated group gained 0.0480 quality-adjusted life-years (QALY) over the standard group. When a 3% discount rate for costs and outcomes was used, the resulting cost per QALY was $82,589. Results of Sensitivity Analysis: The use of a 25%, 50%, and 75% reduction in drug costs resulted in a cost per QALY of $61,329, $40,070, and $18,810, respectively. Limitations: This study was limited by use of a single ethnic group and by its 3-year duration. Conclusions: Within this 3-year study, treatment to lower BP and LDL-C below standard targets was not cost-effective because of the cost of the additional medications required to meet the lower targets. With the anticipated availability of generic versions of the BP and lipid-lowering drugs used in SANDS, the cost-effectiveness of this intervention should improve. [Copyright &y& Elsevier]

Background: There have been no studies that use longitudinal data with more than 2 measurements and methods of longitudinal data analysis to identify risk factors for incident albuminuria over time more effectively.Study Design: Longitudinal study.Settings& Participants: A subgroup of participants in the Strong Heart Study, a population-based sample of American Indians, in central Arizona, Oklahoma, and North and South Dakota. Participants with diabetes without albuminuria were followed up for a mean of 4 years.Predictors: Age, sex, study center, high-density lipoprotein and low-density lipoprotein cholesterol levels, triglyceride level, body mass index, systolic blood pressure, use of antihypertensive medication, smoking, hemoglobin A(1c) level, fasting glucose level, type of diabetes therapy, diabetes duration, plasma creatinine level, and urinary albumin-creatinine ratio (UACR).Outcomes& Measurements: Albuminuria was defined as UACR of 30 mg/g or greater. Urine creatinine and albumin were measured by using the picric acid method and a sensitive nephelometric technique, respectively.Results: Of 750 and 568 participants with diabetes without albuminuria and with normal plasma creatinine levels at the first and second examinations, 246 and 132 developed albuminuria by the second and third examinations, respectively. Incident albuminuria was predicted by baseline UACR, fasting glucose level, systolic blood pressure, plasma creatinine level, study center, current smoking, and use of angiotensin-converting enzyme inhibitors and antidiabetic medications. UACR of 10 to 30 mg/g increased the odds of developing albuminuria 2.7-fold compared with UACR less than 5 mg/g.Limitations: Single random morning urine specimen.Conclusions: Many risk factors identified for incident albuminuria can be modified. Control of blood pressure and glucose level, smoking cessation, and use of angiotensin-converting enzyme inhibitors may reduce the incidence of albuminuria. [ABSTRACT FROM AUTHOR]

The loading of novel bi-and tri-metallic bifunctional catalysts such as Pt–Ru, Pt–Zr, and Pt–Ru–Zr over original zeolites (H-MOR and H-ZSM-5) and new cations modified zeolites (Sr-MOR, Ba-MOR, Sr-ZSM-5, and Ba-ZSM-5) by supercritical CO 2 method are investigated for n-hexane isomerization. A fixed bed micro-reactor unit was used for catalytical hydro-isomerization of n-hexane at different temperature ranges (250–325 °C), H 2 /HC ratios of 3, 6, and 9 mol and pressure of 5 bar. The chemical and physical properties of prepared zeolite nanoparticles were characterized by Fourier transform infrared spectroscopy (FT-IR), X-ray diffraction (XRD), Brunauer–Emmett–Teller (BET), and thermogravimetric analysis (TGA). It is reported that the metal loaded in scCO 2 , results in more uniform and tiny metal nanoparticle (1.37 nm) dispersion with high stability and revealed that high loading pressure in scCO 2 (280–300 bar) results in higher catalytic activity and surface area. H-MOR and H-ZSM-5 possess the maximum BET surface area of 539.21 and 403 m2/g and pore size of 90.73 and 105.06 Å respectively. The finding also revealed the maximum n-hexane conversion and selectively of about 99.10% and 32.23% for Pt–Ru/H-ZSM-5%, 93.55%, and 99.72% for Pt-Zr/H-ZSM-5, and 97% and 29.74% for Pt–Ru–Zr/H-MOR catalysts respectively at H 2 /HC ratio of 9 and 250–325 °C. Moreover, Pt–Ru/H-ZSM-5, Pt–Zr/Ba-ZSM-5, and Pt–Ru–Zr/Ba-ZSM-5 showed the maximum yield of 11.5% and 17.7%, 40.58% and 33.19%, and 11.5% and 9.1% of 2-methyl-pentane (2-MP) and 3-methyl-pentane (3-MP) respectively at H 2 /HC ratio 9 and 250–325 °C. Based on results, it is concluded that Pt–Zr catalyst over ZSM-5 showed better catalytical activity among all for n-hexane isomerization, while Pt–Ru and Pt–Ru–Zr demonstrated better hydrocracking reactions. [Display omitted] • n-Hexane hydro-isomerization was accomplished by bi-and tri-metallic catalysts loaded over zeolites by scCO 2 method. • For the first time, H-ZSM-5 and H-MOR zeolites were modified with barium and strontium cations. • A maximum yield of 40.15% and 38.56% was reported for 2-MP and 3-MP respectively with Pt-Zr/Sr-ZSM-5 at 300 °C. • Pt-Zr loaded over ZSM-5 (in both Ba and Sr forms) showed better n-hexane conversion and isomerization at 300 °C. • ZSM-5 catalysts are the most selective that gave better selectivity, while MOR is more active for n-hexane conversion. [ABSTRACT FROM AUTHOR]

Background: Optimization of health care delivery in different settings with the goal of improving quality of life and reduction of heart failure (HF) morbidity continues to be an unmet need. Digital engagement between patients and providers is becoming more prevalent for care coordination and management of heart failure.Aims: To design and test a customized and interactive heart failure disease specific functionality with activated technology (Amazon's Echo Dot or an Avatar) as a tool for management of HF patients at home. To identify the effect of a voice activated technology in the reduction of heart failure hospitalizations, improvement of medication adherence, improvement in health-related quality of life and increase in comfort with voice activated technologies. We compared two types of conversational agent technologies to standard of care, using speech recognition, to evaluate patient engagement in HF patients. The first technologyutilized the Amazon Echo Dot Alexa technology and only communicated with the patient through audio and the second was an application on a tablet using an Avatar, combining audio and visual. The conversational agent asks the HF patients a series of 11 questions, divided into three components: compliance (questions 1-3), mild HF symptoms (questions 4-6) and moderate/severe HF symptoms (questions 7-11). Participants completed questions regarding their use and comfort with technology. Inclusion criteria: admitted or treated for HF;18 or older; and resides with access to wifi. Exclusion criteria: heart transplant or ventricular assist device recipients. Participants were monitored for three months.Results: Thirty patients were enrolled in each intervention arm of the two studies with the Alexa or Avatar. Mean age was 54 years in the Alexa group and 56 years in the Avatar group. There were predominately males 61% and 63%, Alexa and Avatar, respectively. In the Alexa and Avatar groups race was predominately black, 64% and 63% followed by white 21% and 30%. The Alexa group was statistically more likely to complete the three compliance factors of weight checking (p=.030), salt monitoring (p=0.016) and medication adherence (p=0.005). Initial results suggest that older people and individuals using the smart phone answer the questionnaire at higher rates, and individuals taking an increased number of medications to treat HF had lower participation.Conclusion: Voice enabled, internet connected devices are poised to have profound impacts on the quality of life for in-home, independent, and assisted-living patients by vastly increasing the connectivity to healthcare providers. [ABSTRACT FROM AUTHOR]

Background: The Affordable Care Act's Medicaid expansion has been heavily debated due to skepticism about Medicaid's ability to provide high-quality care. Particularly, little is known about whether Medicaid expansion improves access to surgical cancer care at high-quality hospitals. To address this question, we examined the effects of the 2001 New York Medicaid expansion, the largest in the pre-Affordable Care Act era, on this disparity measure.Study Design: We identified 67,685 nonelderly adults from the New York State Inpatient Database who underwent select cancer resections. High-quality hospitals were defined as high-volume or low-mortality hospitals. Disparity was defined as model-adjusted difference in percentage of patients receiving operations at high-quality hospitals by insurance type (Medicaid/uninsured vs privately insured) or by race (African American vs white). Levels of disparity were calculated quarterly for each comparison pair and then analyzed using interrupted time series to evaluate the impact of Medicaid expansion.Results: Disparity in access to high-volume hospitals by insurance type was reduced by 0.97 percentage points per quarter after Medicaid expansion (p < 0.0001). Medicaid/uninsured beneficiaries had similar access to low-mortality hospitals as the privately insured; no significant change was detected around expansion. Conversely, racial disparity increased by 0.87 percentage points per quarter (p < 0.0001) in access to high-volume hospitals and by 0.48 percentage points per quarter (p = 0.005) in access to low-mortality hospitals after Medicaid expansion.Conclusions: Pre-Affordable Care Act Medicaid expansion reduced the disparity in access to surgical cancer care at high-volume hospitals by payer. However, it was associated with increased racial disparity in access to high-quality hospitals. Addressing racial barriers in access to high-quality hospitals should be prioritized. [ABSTRACT FROM AUTHOR]

Background: Centralization of complex surgical care has led patients to travel longer distances. Emerging evidence suggested a negative association between increased travel distance and mortality after pancreatectomy. However, the reason for this association remains largely unknown. We sought to unravel the relationships among travel distance, receiving pancreatectomy at high-volume hospitals, delayed surgery, and operative outcomes.Study Design: We identified 44,476 patients who underwent pancreatectomy for neoplasms between 2004 and 2013 at the reporting facility from the National Cancer Database. Multivariable analyses were performed to examine the independent relationships between increments in travel distance mortality (30-day and long-term survival) after adjusting for patient demographics, comorbidity, cancer stage, and time trend. We then examined how additional adjustment of procedure volume affected this relationship overall and among rural patients.Results: Median travel distance to undergo pancreatectomy increased from 16.5 to 18.7 miles (p for trend < 0.001). Although longer travel distance was associated with delayed pancreatectomy, it was also related to higher odds of receiving pancreatectomy at a high-volume hospital and lower postoperative mortality. In multivariable analysis, difference in mortality among patients with varying travel distance was attenuated by adjustment for procedure volume. However, longest travel distance was still associated with a 77% lower 30-day mortality rate than shortest travel among rural patients, even when accounting for procedure volume.Conclusions: Our large national study found that the beneficial effect of longer travel distance on mortality after pancreatectomy is mainly attributable to increase in procedure volume. However, it can have additional benefits on rural patients that are not explained by volume. Distance can represent a surrogate for rural populations. [ABSTRACT FROM AUTHOR]

Background: Although the Affordable Care Act (ACA) expanded Medicaid access, it is unknown whether this has led to greater access to complex surgical care. Evidence on the effect of Medicaid expansion on access to surgical cancer care, a proxy for complex care, is sparse. Using New York's 2001 statewide Medicaid expansion as a natural experiment, we investigated how expansion affected use of surgical cancer care among beneficiaries overall and among racial minorities.Study Design: From the New York State Inpatient Database (1997 to 2006), we identified 67,685 nonelderly adults (18 to 64 years of age) who underwent cancer surgery. Estimated effects of 2001 Medicaid expansion on access were measured on payer mix, overall use of surgical cancer care, and percent use by racial/ethnic minorities. Measures were calculated quarterly, adjusted for covariates when appropriate, and then analyzed using interrupted time series.Results: The proportion of cancer operations paid by Medicaid increased from 8.9% to 15.1% in the 5 years after the expansion. The percentage of uninsured patients dropped by 21.3% immediately after the expansion (p = 0.01). Although the expansion was associated with a 24-case/year increase in the net Medicaid case volume (p < 0.0001), the overall all-payer net case volume remained unchanged. In addition, the adjusted percentage of ethnic minorities among Medicaid recipients of cancer surgery was unaffected by the expansion.Conclusions: Pre-ACA Medicaid expansion did not increase the overall use or change the racial composition of beneficiaries of surgical cancer care. However, it successfully shifted the financial burden away from patient/hospital to Medicaid. These results might suggest similar effects in the post-ACA Medicaid expansion. [ABSTRACT FROM AUTHOR]

Background: Despite national emphasis on care coordination, little is known about how fragmentation affects cancer surgery outcomes. Our study examines a specific form of fragmentation in post-discharge care-readmission to a hospital different from the location of the operation-and evaluates its causes and consequences among patients readmitted after major cancer surgery.Study Design: We used the State Inpatient Database of California (2004 to 2011) to identify patients who had major cancer surgery and their subsequent readmissions. Logistic models were used to examine correlates of non-index readmissions and to assess associations between location of readmission and outcomes, measured by in-hospital mortality and repeated readmission.Results: Of 9,233 readmissions within 30 days of discharge after major cancer surgery, 20.0% occurred in non-index hospitals. Non-index readmissions were associated with emergency readmission (odds ratio [OR] = 2.63; 95% CI, 2.26-3.06), rural residence (OR = 1.81; 95% CI, 1.61-2.04), and extensive procedures (eg hepatectomy vs proctectomy; OR = 2.77; CI, 2.08-3.70). Mortality was higher during non-index readmissions than index readmissions independent of patient, procedure, and hospital factors (OR = 1.31; 95% CI, 1.03-1.66), but was mitigated by adjusting for conditions present at readmission (OR = 1.24; 95% CI, 0.98-1.58). Non-index readmission predicted higher odds of repeated readmission within 60 days of discharge from the first readmission (OR = 1.16; 95% CI, 1.02-1.32), independent of all covariates.Conclusions: Non-index readmissions constitute a substantial proportion of all readmissions after major cancer surgery. They are associated with more repeated readmissions and can be caused by severe surgical complications and increased travel burden. Overcoming disadvantages of non-index readmissions represents an opportunity to improve outcomes for patients having major cancer surgery. [ABSTRACT FROM AUTHOR]

Background: Penalties from the Hospital Readmission Reduction Program can push financially strained, vulnerable patient-serving hospitals into additional hardship. In this study, we quantified the association between vulnerable hospitals and readmissions and examined the respective contributions of patient- and hospital-related factors.Methods: A total of 110,857 patients who underwent major cancer operations were identified from the 2004-2011 State Inpatient Database of California. Vulnerable hospitals were defined as either self-identified safety net hospitals (SNHs) or hospitals with a high percentage of Medicaid patients (high Medicaid hospitals [HMHs]). We used multivariable logistic regression to determine the association between vulnerable hospitals and readmission. Patient and hospital contributions to the elevation in odds of readmission were assessed by comparing estimates from models with different subsets of predictors.Results: Of the 355 hospitals, 13 were SNHs and 31 were HMHs. After adjusting for Hospital Readmission Reduction Program variables, SNHs had higher 30-day (odds ratio [OR] = 1.32; 95% CI, 1.18-1.47), 90-day (OR = 1.28; 95% CI, 1.18-1.38), and repeated readmissions (OR = 1.33; 95% CI, 1.18-1.49); HMHs also had higher 30-day (OR = 1.18; 95% CI, 1.05-1.32), 90-day (OR = 1.28; 95% CI, 1.16-1.42), and repeated readmissions (OR = 1.24; 95% CI, 1.01-1.54). Compared with patient characteristics, hospital factors accounted for a larger proportion of the increase in odds of readmission among SNHs (60% to 93% vs 24% to 39%), but a smaller proportion among HMHs (9% to 15% vs 60% to 115%).Conclusions: Vulnerable status of hospitals is associated with higher readmission rates after major cancer surgery. These findings reinforce the call to account for socioeconomic variables in risk adjustments for hospitals who serve a disproportionate share of disadvantaged patients. [ABSTRACT FROM AUTHOR]

Objectives: This study sought to investigate into the biologically plausible interaction between the common haptoglobin (Hp) polymorphism rs#72294371 and glycosylated hemoglobin (HbA1c) on risk of coronary heart disease (CHD). Background: Studies of the association between the Hp polymorphism and CHD report inconsistent results. Individuals with the Hp2-2 genotype produce Hp proteins with an impaired ability to prevent oxidative injury caused by elevated HbA1c. Methods: HbA1c concentration and Hp genotype were determined for 407 CHD cases matched 1:1 to controls (from the NHS [Nurses'' Health Study]) and in a replication cohort of 2,070 individuals who served as the nontreatment group in the ICARE (Prevention of Cardiovascular Complications in Diabetic Patients With Vitamin E Treatment) study, with 29 CHD events during follow-up. Multivariate models were adjusted for lifestyle and CHD risk factors as appropriate. A pooled analysis was conducted of NHS, ICARE, and the 1 previously published analysis (a cardiovascular disease case-control sample from the Strong Heart Study). Results: In the NHS, Hp2-2 genotype (39% frequency) was strongly related to CHD risk only among individuals with elevated HbA1c (≥6.5%), an association that was similar in the ICARE trial and the Strong Heart Study. In a pooled analysis, participants with both the Hp2-2 genotype and elevated HbA1c had a relative risk of 7.90 (95% confidence interval: 4.43 to 14.10) for CHD compared with participants with both an Hp1 allele and HbA1c <6.5% (p for interaction = 0.004), whereas the Hp2-2 genotype with HbA1c <6.5% was not associated with risk (relative risk: 1.34 [95% confidence interval: 0.73 to 2.46]). Conclusions: Hp genotype was a significant predictor of CHD among individuals with elevated HbA1c. [Copyright &y& Elsevier]

American Indians have a disproportionately high rate of kidney disease likely due to a combination of environmental and genetic factors. We performed a genome wide scan of estimated glomerular filtration rate in 3665 participants of the Strong Heart Family Study to localize genes influencing kidney disease risk factors. The participants were men and women from 13 American Indian tribes recruited from 3 centers located in Arizona, the Dakotas and Oklahoma. Multipoint variance component linkage analysis was performed for each center and on the entire cohort after controlling for center effects. Modeling strategies that incorporated age, gender and interaction terms (model 1) and another that also controlled for diabetes mellitus, systolic and diastolic blood pressure, body mass index, low density and high density lipoproteins, triglycerides and smoking status (model 2) were used. Significant evidence for linkage in the Arizona group was found on chromosome 12p12.2 at 39cM (nearest marker D12S310) using model 1. Additional loci with very suggestive evidence for linkage were detected at 1p36.31 for all groups using both models and at 2q33.3 and 9q34.2 for the Dakotas group each using model 1. No significant evidence for additive interaction with diabetes, hypertension or obesity was noted. This evidence for linkage of a quantitative trait locus influencing estimated glomerular filtration rate to a region of chromosome 12p in a large cohort of American Indians will be worth studying in more detail in the future.Kidney International (2008) 74, 1185–1191; doi:10.1038/ki.2008.410; published online 13 August 2008 [ABSTRACT FROM AUTHOR]

Background: The complexity of retroperitoneal soft tissue sarcoma (RPS) surgery has prompted international recommendations to regionalize it to high-volume hospitals (HVHs). A minimum procedural volume threshold for RPS is not yet defined, hampering effective referral and regionalization in the US. This multihospital study sought to establish an HVH threshold informed by national data and international expert opinion.Study Design: The 2004-2015 National Cancer Database identified 8,721 surgically treated RPS patients. Multivariable models, using linear splines, identified annual volume thresholds predictive of overall and 90-day mortality. Transatlantic Australasian Retroperitoneal Soft Tissue Sarcoma Working Group members (n = 48) completed a 15-item survey regarding these data.Results: Overall mortality risk was reduced by 4% per additional case (hazard ratio [HR] 0.96, 95% CI 0.95 to 0.98) up to a threshold of 13 cases/year; no further reduction was observed over 13 (HR 0.99, 95% CI 0.97 to 1.01). After revealing the results from our statistical analysis, 71.4% of respondents who initially chose >30 cases/year as a cutoff shifted their response to a lower value. More than 56% cited 11 to 20 procedures/year as the cutoff for an HVH. Median survival in hospitals with <13 vs >13 cases/year was 94 vs 139 months, respectively (p < 0.001). Forty percent of respondents cited 1% to 2% as an acceptable 90-day mortality. This was achieved with a minimum of 13 cases/year based on risk-adjusted survival analysis.Conclusions: This is the first multicenter analysis to merge data-driven RPS surgery volume thresholds to clinically meaningful sarcoma expert opinions. These findings will help inform national/international consensus recommendations, a practical volume threshold, trial design, and motivate evidence-based hospital referral. [ABSTRACT FROM AUTHOR]

Background: The Affordable Care Act (ACA)'s Medicaid expansion has increased access to surgical care overall. Whether it was associated with reduced disparities in use of regionalized surgery at high-volume hospitals (HVH) remains unknown. Quasi-experimental evaluations of this expansion were performed to examine the use of regionalized surgery at HVH among racial/ethnic minorities and low-income populations.Study Design: Data from State Inpatient Databases (2012 to 2014), the American Hospital Association Annual Survey Database, and the Area Resource File from Health Resources and Services Administration, were used to examine 166,558 nonelderly (ages 18 to 64) adults at 468 hospitals, who underwent 1 of 4 regionalized surgical procedures in 3 expansion (KY, MD, NJ) and 2 nonexpansion states (NC, FL). Thresholds of HVH were defined using the top quintile of visits per year. Interrupted time series were performed to measure the impact of expansion on use rates of regionalized surgery at HVH overall, by race/ethnicity, and by income.Results: Overall, ACA's expansion was not associated with accelerated use rates of regionalized surgical procedures at HVH (odds ratio [OR] 1.016, p = 0.297). Disparities in use of regionalized surgical procedures at HVH among ethnic/racial minorities and low-income populations were unchanged; minority vs white (OR 1.034 p = 0.100); low-income vs high-income (OR 1.034, p = 0.122).Conclusions: Early findings from ACA's Medicaid expansion revealed no impact on the use rates of regionalized surgery at HVH overall or on disparities among vulnerable populations. Although these results need ongoing evaluation, they highlight potential limitations in ACA's expansion in reducing disparities in use of regionalized surgical care. [ABSTRACT FROM AUTHOR]