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Objective: The aim of the present study is to determine similarities between patients with type 2 diabetes not on metformin therapy compared to patients on metformin therapy at a resident-led primary care clinic. Methods: An exploratory, single-center retrospective chart review was performed on patients 18 years and older with a documented diagnosis of type 2 diabetes seen at the University of Arkansas for Medical Sciences Family Medicine Clinic in Little Rock, Arkansas. Of the 2452 patients who met criteria for the study, 1085 patients did not have a documented metformin allergy. A subset of 216 patients who were not currently prescribed metformin and had no documented metformin allergy were further examined and compared to the 869 patients who were prescribed metformin. We sought to determine reasons for nonuse by evaluating their EPIC electronic health record. Information on these patients such as race, gender, hemoglobin A1c (A1c), kidney function, stated metformin intolerance, and comorbid disease states such as neuropathy, chronic kidney disease (CKD), ulcerative colitis, and irritable bowel syndrome were collected. Further examination was performed to determine why patients were not on metformin therapy and potential similarities between metformin intolerant patients. Results: The results of the study indicated a significant difference between metformin users and non-users in relation to body mass index (BMI) and diagnosis of CKD. Metformin non-users were found to have significantly lower mean BMI (30.87 vs. 35.43; p-value <0.0001), and significantly higher rates of CKD (25.93% vs 14.73%; p-value <0.0001) as compared to metformin users. BMI value of patients (coefficient: 0.2033, p value: <0.0001) was found to be significantly and positively correlated with metformin use, and CKD (coefficient: - 0.1191, p-value: <0.0001) was found to be significantly and negatively correlated with metformin use. A1c levels for patients not on metformin therapy were evaluated. Most non-metformin patients fell in prediabetic A1c levels ranging from 5-6.4% (84 patients; 38.89%), and 31 patients (14.35%) should be on insulin therapy according to guidelines. Conclusion: The results demonstrated that patients with lower BMI, CKD, or A1c in the prediabetic range were less likely to be prescribed metformin., (© Individual authors.)

Gastrectomy and esophagectomy are the most performed surgeries in the treatment of both esophageal and gastric cancers. The type of esophagectomy depends on the type of malignancy, site of the tumor, criteria of resection, and field of resection. The three standard approaches to esophagectomy are the transhiatal approach, the left thoracoabdominal approach, and a three-stage procedure. The transhiatal approach involves abdominal and cervical incisions, while the left thoracoabdominal approach is a one-stage procedure that utilizes a single incision exposing the dissection field. The Ivor Lewis and McKeown esophagectomies are two-stage and three-stage surgeries that include laparotomy with right thoracotomy. Malabsorption often emerges as a significant postoperative complication following esophagectomy and gastrectomy surgeries. Malnutrition linked with these cancers has detrimental effects, including heightened rates of postoperative complications, elevated infection risks, delayed wound healing, reduced tolerance to treatment, diminished quality of life, and heightened mortality rates. Our narrative review summarizes and sheds light on solutions to treat malabsorption disorders and malnutrition after gastric bypass surgery. These solutions include methods such as adjustments, supplements, and treatment. Although more research is needed to confirm their effectiveness, these methods indicate potential for lowering the impact on patients' diets. By considering the beneficial implications of these effects and considering solutions, we aim to improve the management of these adverse effects, ultimately improving the overall health and postoperative outcomes of patients., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Daniel et al.)

Purpose: This study assessed real-world survival among older patients with non-small-cell lung cancer (NSCLC) and brain metastases (BMs) at diagnosis (synchronous BM [SBM]) receiving first-line immune checkpoint inhibitors (ICIs) compared with chemotherapy only., Methods: Patients with NSCLC and SBM age 65 years or older at diagnosis from 2010 to 2019 SEER-Medicare database and received US Food and Drug Administration-approved ICIs (pembrolizumab/nivolumab/ipilimumab/atezolizumab/durvalumab/cemiplimab) and/or chemotherapy (platinum-based doublets/taxane/pemetrexed/gemcitabine) as first-line systemic treatment were included, excluding those with no cranial radiation or ever being treated with targeted therapies. Overall survival time was from the start of systemic treatment (ICI/chemotherapy) to death, censored at disenrollment from Medicare part A/B, enrollment in part C, or end of the study period (December 31, 2019). Kaplan-Meier (KM) survival curves were compared between treatment groups using the log-rank test. Multivariable Cox proportional hazards (CPH) model was used to estimate hazard ratio (HR) between groups, adjusting for patients' sociodemographic and clinical characteristics., Results: The study included 1,481 patients (1,303 chemotherapy and 178 ICI). The median (range) age was 71 (65-91) years. First-line ICI patients were more likely to be older, live in urban areas, and less likely to be non-White than the chemotherapy group. KM estimates showed that survival curves initially overlapped but diverged approximately 6 months after initiating first-line systemic treatment (median survival [95% CI]: ICI, 190 [131 to 303] days versus chemotherapy, 189 [177 to 201] days), with ICI showing a better survival than the chemotherapy group (log-rank test P < .0001). First-line ICI was associated with a lower risk of death compared with chemotherapy in adjusted CPH model (HR [95% CI], 0.67 [0.55 to 0.80]; P < .0001)., Conclusion: Among older patients with NSCLC and SBM, first-line ICI use was associated with improved survival occurring 6 months after treatment initiation compared with chemotherapy only.

Background : To compare healthcare expenditure, utilization and access between nonelderly adult cancer survivors enrolled in a high deductible health plan with a health savings account ("HDHP+HSA"), HDHP without HSA ("HDHP alone") and low deductible health plan ("LDHP"). Methods : 1735 cancer survivors, aged 18-64 years, with continuous private coverage identified from the 2012-2017 Medical Expenditure Panel Survey: HDHP alone (n = 353), HDHP+HSA (n = 242) and LDHP (n = 1140). Healthcare expenditures, utilization and inability/delay obtaining medical care were analyzed using generalized linear regressions with inverse propensity score weighting and doubly robust estimation. Results : HDHP alone group (23,255 USD) had significantly higher total healthcare expenditure compared to HDHP+HSA (15,580 USD, p = 0.012) and LDHP (16,261 USD, p = 0.016). HDHP alone (6089 USD; p = 0.002) and HDHP+HSA (5743 USD; p = 0.012) groups had significantly higher out-of-pocket (OOP) expenditure compared to LDHP (4853 USD). HDHP alone (17,128 USD, p = 0.010) and LDHP (12,645 USD, p = 0.045) had significantly higher private insurer payments compared to HDHP+HSA (9216 USD). No differences were found in utilization or inability/delay obtaining medical care across groups. Conclusions : Non-elderly adult cancer survivors with continuous coverage and comparable sociodemographic characteristics enrolled in HDHP with HSA displayed the lowest healthcare costs compared to HDHP without HSA and LDHP. HDHP+HSA had a significantly higher OOP expenditure than LDHP. No significant differences were observed in utilization or access among groups.

Background and objectives  Sleep medicine has been one of the fastest-growing medical fields in recent years. The industry plays a big role in developing new medications and devices for both diagnosis and treatment of sleep-related problems. We analyzed payments made by industry to physicians from 2014 through 2018 based on the Open Payments Program data. Methods Centers for Medicare and Medicaid Services Open Payment Program and American Board of Psychiatry and Neurology databases were explored to elicit financial relationships between industry and sleep neurologists. Results Payments made by industry to sleep neurologists have been steadily increasing from 2014 through 2018. Approximately 16% to 22% of sleep certified neurologists received payments from industry during the study period. Interestingly, the payments made to the top 10% of the sleep physicians contributed approximately 85% to 96% of the total payments. The top two categories to which the highest payments were made were compensation for services and royalty and/or licensing fees. Silenor® (doxepin), Xyrem® (sodium oxybate), Aptiom® (eslicarbazepine acetate), Belsomra® (suvorexant), and Fycompa® (perampanel) were most of the drugs, which made the highest payments, that got approved by the Food and Drug Administration in the last decade. Conclusions  It seems that the industry is spending significant amounts of money in educating the physicians and in marketing the newer drugs. This analysis of the data on payments from industry is very useful in identifying any potential conflicts of interest from physicians. Further analyses are needed to study the trends of physician practice behavior and decision making., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Dandu et al.)

Background and Purpose- Industry payments to physicians raise concerns regarding conflicts of interest that could impact patient care. We explored nonresearch and nonownership payments from industry to vascular neurologists to identify trends in compensation. Methods- Using Centers for Medicare and Medicaid Services and American Board of Psychiatry and Neurology data, we explored financial relationships between industry and US vascular neurologists from 2013 to 2018. We analyzed payment characteristics, including payment categories, payment distribution among physicians, regional trends, and biomedical manufacturers. Furthermore, we analyzed the top 1% (by compensation) of vascular neurologists with detailed payment categories, their position, and their contribution to stroke guidelines. Results- The number of board certified vascular neurologist increased from 1169 in 2013 to 1746 in 2018. The total payments to vascular neurologist increased from $99 749 in 2013 to $1 032 302 in 2018. During the study period, 16% to 17% of vascular neurologists received industry payments. Total payments from industry and mean physician payments increased yearly over this period, with consulting fee (31.1%) and compensation for services other than consulting (30.7%) being the highest paid categories. The top 10 manufacturers made the majority of the payments, and the top 10 products changed from drug or biological products to devices. Physicians from south region of the United States received the highest total payment (38.72%), which steadily increased. Payments to top 1% vascular neurologists increased from 64% to 79% over the period as payments became less evenly distributed. Among the top 1%, 42% specialized in neuro intervention, 11% contributed to American Heart Association/American Stroke Association guidelines, and around 75% were key leaders in the field. Conclusions- A small proportion of US vascular neurologists consistently received the majority of industry payments, the value of which grew over the study period. Only 11% of the top 1% receiving industry payments have authored American Heart Association/American Stroke Association guidelines, but ≈75% seem to be key leaders in the field. Whether this influences clinical practice and behavior requires further investigation.

Background: The craniocervical flexion test (CCFT) is generally undertaken using a pressure biofeedback unit. However, the high costs of the device limits its availability in poorly resourced healthcare settings. The use of alternate measures such as the aneroid sphygmomanometer to undertake CCFT need to be investigated., Objective: The objective of this study was to establish the concurrent validity, intra- and inter-rater reliability of the aneroid sphygmomanometer using a paediatric size cuff for CCFT in asymptomatic adults., Methods: This cross-sectional observational study involved 300 asymptomatic participants randomly allocated to either validity (n = 100), intra-rater (n = 100) or inter-rater (n = 100) testing. Participants were asked to perform CCFT to assess craniocervical flexors performance using the pressure biofeedback unit and the aneroid sphygmomanometer with a paediatric cuff. Inter-rater reliability test was performed by two different raters on the same day with rest of 30 min between tests. An independent observer checked and recorded the pressures noted on the pressure dial thus ensuring blinded outcome measurement. Correlation between the two instruments was determined by computing the stability coefficient (Pearson product moment correlation) and associated P-values for statistical significance. Intra-class correlation coefficients and its 95% confidence intervals (CIs) were calculated to determine the intra- and inter-rater reliability., Results: The concurrent validity of aneroid sphygmomanometer as per Pearson's product moment correlation was r = 0.856 for activation score. The intra-class correlation coefficients for intra-rater reliability was 0.92 (95% CI 0.89-0.94), and inter-rater reliability was 0.87 (95% CI 0.80-0.91)., Conclusion: This study has confirmed high concurrent validity, intra- and inter-rater reliability of the aneroid sphygmomanometer using a paediatric cuff for CCFT in asymptomatic adults. Its use in people with neck pain warrants investigation., (© 2013 The Authors. International Journal of Evidence-Based Healthcare © 2013 The Joanna Briggs Institute.)