Improving cancer patient emergency room utilization: A New Jersey state assessment

IntroductionDue to its increasing incidence and its major contribution to healthcare costs, cancer is a major public health problem in the United States. The impact across different services is not well documented and utilization of emergency departments (ED) by cancer patients is not well characterized. The aim of our study was to identify factors that can be addressed to improve the appropriate delivery of quality cancer care thereby reducing ED utilization, decreasing hospitalizations and reducing the related healthcare costs.MethodsThe New Jersey State Inpatient and Emergency Department Databases were used to identify the primary outcome variables; patient disposition and readmission rates. The independent variables were demographics, payer and clinical characteristics. Multivariable unconditional logistic regression models using clinical and demographic data were used to predict hospital admission or emergency department return.ResultsA total of 37,080 emergency department visits were cancer related with the most common diagnosis attributed to lung cancer (30.0%) and the most common presentation was pain. The disposition of patients who visit the ED due to cancer related issues is significantly affected by the factors of race (African American OR = 0.6, p value = 0.02 and Hispanic OR = 0.5, p value = 0.02, respectively), age aged 65 to 75 years (SNF/ICF OR 2.35, p value = 0.00 and Home Healthcare Service OR 5.15, p value = 0.01, respectively), number of diagnoses (OR 1.26, p value = 0.00), insurance payer (SNF/ICF OR 2.2, p value = 0.02 and Home Healthcare Services OR 2.85, p value = 0.07, respectively) and type of cancer (breast OR 0.54, p value = 0.01, prostate OR 0.56, p value = 0.01, uterine OR 0.37, p value = 0.02, and other OR 0.62, p value = 0.05, respectively). In addition, comorbidities increased the likelihood of death, being transferred to SNF/ICF, or utilization of home healthcare services (OR 1.6, p value = 0.00, OR 1.18, p value = 0.00, and OR 1.16, p value = 0.04, respectively). Readmission is significantly affected by race (American Americans OR 0.41, standard error 0.08, p value = 0.001 and Hispanics OR 0.29, standard error 0.11, p value = 0.01, respectively), income (Quartile 2 OR 0.98, standard error 0.14, p value 0.01, Quartile 3 OR 1.07, standard error 0.13, p value 0.01, and Quartile 4 OR 0.88, standard error 0.12, p value 0.01, respectively), and type of cancer (prostate OR 0.25, standard error 0.09, p value = 0.001).ConclusionWeb based symptom questionnaires, patient navigators, end of life nursing and clinical cancer pathways can identify, guide and prompt early initiation of treat before progression of symptoms in cancer patients most likely to visit the ED. Thus, improving cancer patient satisfaction, outcomes and reduce health care costs.     

The role of optimal control in assessing the most cost-effective implementation of a vaccination programme: HPV as a case study

Consider a population that develops over units of time labelled by zero and the negative integers. It is assumed that at any time r ? 0 there are respectively N(m, a) males of age a and N(f, b) of females of age b, where a = 1, … , A_m and b = 1, … , A_f. At time 0 a sample of n copies of a gene are assumed to be observed, where n ? min_ab(N(m, a), N(f, b)). It is assumed that at any particular time r any possible mating is equally probable and that numbers of gametes contributed to offspring of age 1 and sex u by parents of sex v are exchangeable within age groups and independently distributed among age-groups. Coalescent theory is then derived, with time measured in multiples 2N_eC of the effective population size N_eC, which depends on a measure T of the generation interval. Theory is developed for both autosomal and sex-linked loci in two special cases.     

How air pollution influences clinical management of respiratory diseases. A case-crossover study in Milan

Background

Environmental pollution is a known risk factor for multiple diseases and furthermore increases rate of hospitalisations. We investigated the correlation between emergency room admissions (ERAs) of the general population for respiratory diseases and the environmental pollutant levels in Milan, a metropolis in northern Italy.

Methods

We collected data from 45770 ERAs for respiratory diseases. A time-stratified case-crossover design was used to investigate the association between air pollution levels and ERAs for acute respiratory conditions. The effects of air pollutants were investigated at lag 0 to lag 5, lag 0–2 and lag 3–5 in both single and multi-pollutant models, adjusted for daily weather variables.

Results

An increase in ozone (O₃) levels at lag 3–5 was associated with a 78% increase in the number of ERAs for asthma, especially during the warm season. Exposure to carbon monoxide (CO) proved to be a risk factor for pneumonia at lag 0–2 and in the warm season increased the risk of ERA by 66%. A significant association was found between ERAs for COPD exacerbation and levels of sulphur dioxide (SO₂), CO, nitrate dioxide (NO₂), and particulate matter (PM₁₀ and PM_2.5). The multipollutant model that includes all pollutants showed a significant association between CO (26%) and ERA for upper respiratory tract diseases at lag 0–2. For chronic obstructive pulmonary disease (COPD) exacerbations, only CO (OR 1.19) showed a significant association.

Conclusions

Exposure to environmental pollution, even at typical low levels, can increase the risk of ERA for acute respiratory diseases and exacerbation of obstructive lung diseases in the general population.     

Validity of initial cancer diagnoses in the Diagnosis Procedure Combination data in Japan

BackgroundIn Japan, the Diagnosis Procedure Combination (DPC) data have been used as a nationwide administrative hospital discharge database for clinical studies. However, few studies have evaluated the validity of recorded diagnoses of cancer in the database.MethodsWe compared the DPC data with hospital-based cancer registries in Osaka Prefecture, Japan to assess the validity of the recorded cancer diagnoses in the DPC data. Fifteen types of cancer were included in the analysis. Cancer stage with tumor-node-metastasis (TNM) classification was assessed for eight cancer types with >400 patients. We evaluated concordance and positive predictive value of cancer diagnosis, and concordance of cancer stage between the DPC data and the hospital-based cancer registry.ResultsIn total, we identified 29,180 eligible patients. The five types of cancer with the highest number of patients were as follows: 6,765 (23.2 %) colorectal, 6,476 (22.2 %) stomach, 4,862 (16.7 %) breast, 4,445 (15.2 %) lung, and 2,257 (7.7 %) liver. Concordance of diagnosis ranged from 63.9 %–99.5 %, and twelve of the fifteen types of cancers had concordance of over 90 %. Positive predictive values of diagnosis ranged from 86.8 %–100 %. Regarding cancer stage, the overall degree of concordance was 67.2 % in all patients and the concordance was over 70 % in four types of cancers.ConclusionsThe DPC data had high validity of cancer diagnosis. However, the potential impact of the misclassifications and low concordance in cancer stage among specific type of cancers in the DPC data should be considered.     

Geographic variation in diagnostic and treatment interval,cancer stage and mortality among colorectal patients – An international comparison between Denmark and Scotland using data-linked cohorts

BackgroundRurald wellers with colorectal cancer have poorer outcomes than their urban counterparts. The reasons why are not known but are likely to be complex and be determined by an interplay between geography and health service organization. By comparing the associations related to travel-time to primary and secondary healthcare facilities in two neighbouring countries, Denmark and Scotland, we aimed to shed light on potential mechanisms.MethodsAnalysis was based on two comprehensive cohorts of patients diagnosed with colorectal cancer in Denmark (2010−16) and Scotland (2007−14). Associations between travel-time and cancer pathway intervals, tumour stage at diagnosis and one-year mortality were analysed using generalised linear models. Travel-time was modelled using restricted cubic splines for each country and combined. Adjustments were made for key confounders.ResultsTravel-time to key healthcare facilities influenced the diagnostic experience and outcomes of CRC patients from Scotland and Denmark to some extent differently. The longest travel-times to a specialised hospital appeared to afford the most rapid secondary care interval, whereas moderate travel-times to hospital (about 20−60 min) appeared to impact on later stage and greater one-year mortality in Scotland, but not in Denmark. A U-shaped association was seen between travel-time to the GP and one year-mortality.ConclusionsThis is the first international data-linkage study to explore how different national geographies and health service structures may determine cancer outcomes. Future research should compare more countries and more cancer sites and evaluate the impact and implications of differences in national health service organisation.     

具核梭杆菌对结直肠癌诊疗作用的研究进展

口腔菌群作为人体的第二大微生物群,对人体健康具有非常重要的作用。具核梭杆菌是口腔中的常驻菌之一,与其他菌共同维持机体的稳态,现已被证实是结直肠癌最相关的菌属之一,参与结直肠癌的发生、发展以及预后。很多学者根据具核梭杆菌在结直肠癌中的致病机制,寻找以具核梭杆菌为靶点的对结直肠癌进行早期诊断和治疗的新方法。本文阐述了具核梭杆菌在结直肠癌中的致病机制,着重探讨其在结直肠癌的诊断和治疗中的潜在作用,以期为临床诊疗提供参考。

     

The role of microalgae in aquaculture: situation and trends

Algae are utilized diversely in aquaculture, but theirmain applications are related to nutrition. They areused in toto, as a sole component or as a foodadditive to supply basic nutrients, color the flesh ofsalmonids or for other biological activities. The needfor nutritional sources safer than traditional animalproducts has renewed interest in plants in general andalgae in particular. This report deals principallywith the nutritional role of microalgae inaquaculture.The larvae of molluscs, echinoderms andcrustaceans as well as the live prey of some fishlarvae feed on microalgae. Though attempts have beenmade to substitute inert particles for thesemicro-organisms which are difficult to produce,concentrate and store, only shrimp and live prey forfish will accept inert food, and only shrimp accept itfully. Several studies have confirmed that a live,multi-specific, low-bacteria microalgal biomassremains essential for shellfish hatcheries. Majoradvances are expected from new production systemdesigns and operations, from batch-run open tanks tomore sophisticated continuously run and closed loopreactors. Studies are underway to simplify hatcheryoperations by replacing biomass produced on-site withrun-times by that produced and preserved elsewhere.Although still promising, they have not given rise, sofar, to any application for molluscs. Otherapplications of microalgae in aquaculture, from greenwater to making salmon flesh pinker, are examined.Whether produced on or off-site, there remains thequestion of cost effectiveness of microalgalproduction systems. This can only be achieved bysubstantial upscaling and improved quality control.     

Building the Infrastructure, Modeling the Nation: The Case of Birth in Palestine

This article explores the intersection between the professional politics of medicine and national politics during the second Palestinian uprising, which erupted in 2000. Through an analysis of stories about childbirth from actors in the birth process--obstetricians, midwives and birth mothers--it examines two overlapping movements that contributed to building the public health infrastructure, the movement of sumud or steadfastness (1967-87) and the popular health movement (1978-94), as well as their contemporary afterlife. Finally, it deals with relations between medicine and governance through an analysis of the interpenetration of medical and political authority. The birth stories bring to light two contrasting visions of a nation in the context of restrictions on mobility and a ground chopped up by checkpoints. The quasi-postcolonial condition of Palestine as popular construct, institutional protostate organism, and the lived experience of its experts and of its gendered subjects underlie the ethnographic accounts.     

Wireless vitals—Proof of concept for wireless patient monitoring in an emergency department setting

Vital sign assessment is a common task in emergency medicine, but resources for continuous monitoring are restricted, data is often recorded manually, and entangled wires cause frustration. Therefore, we designed a small, wireless photoplethysmographic device capable of continuously assessing pulse, respiratory frequency and oxygen saturation on the sternum and tested the performance and feasibility in an emergency department setting. Fifty (56.3 ± 20.2 years), consenting emergency patients (29 male) were recruited. Heart rate, respiratory rate and oxygen saturation were recorded simultaneously using the device and standard monitoring equipment. Data was compared using Bland‐Altman plotting (heart rate, respiratory rate) and mean difference (oxygen saturation). The bias for heart‐ and respiratory rate was 0.4 (limits of agreements ?11.3, 12.2 and ?6.1, 7.0). Mean difference for oxygen saturation was ?0.21 ± 2.35%. This may be the first wireless device to use photoplethysmography on the sternum for vital sign assessment. We noted good agreement with standard monitors, but lack of standardization in data processing between monitoring systems may limit the generalizability of these findings. Although further improvements are needed, the feasibility of this approach provides proof of concept for a new paradigm of large scale, wireless patient monitoring.      

Application of Ethical Principles to Research using Public Health Data in The Global South: Perspectives from Africa

Existing ethics guidelines, influential literature and policies on ethical research generally focus on real‐time data collection from humans. They enforce individual rights and liberties, thereby lowering need for aggregate protections. Although dependable, emerging public health research paradigms like research using public health data (RUPD) raise new challenges to their application. Unlike traditional research, RUPD is population‐based, aligned to public health activities, and often reliant on pre‐collected longitudinal data. These characteristics, when considered in relation to the generally lower protective ethico‐legal frameworks of the Global South, including Africa, highlight ethical gaps. Health and demographic surveillance systems are examples of public health programs that accommodate RUPD in these contexts. We set out to explore the perspectives of professionals with a working knowledge of these systems to determine practical ways of appropriating the foundational principles of health research to advance the ever growing opportunities in RUPD. We present their perspectives and in relation to the literature and our ethical analysis, make context relevant recommendations. We further argue for the development of a framework founded on the discussions and recommendations as a minimum base for achieving optimal ethics for optimal RUPD in the Global South.     

The breast cancer paradox: A systematic review of the association between area-level deprivation and breast cancer screening uptake in Europe

Breast cancer rates are lower amongst women from more socio-economically deprived areas. However, their mortality rates are higher. One explanation of this breast cancer paradox is that women from more deprived areas are less likely to attend breast cancer screening programmes. This systematic review is the first to examine this issue in Europe. A systematic review of Embase, Medline and PsychINFO (from 2008 to 2019) was undertaken (PROSPERO registration number: CRD42018083703). Observational studies were included if they were based in Europe, measured breast cancer screening uptake, compared at least two areas, included an area-level measure of socio-economic deprivation and were published in the English language. The Joanna Briggs Institute critical appraisal checklist was used to assess study quality and risk of bias. Thirteen studies from seven different European countries met our inclusion criteria and were included in the review. In ten of the thirteen studies, there was a significant negative association between screening uptake and area-level socio-economic deprivation – with women living in more socio-economically deprived neighbourhoods less likely to attend breast cancer screening. Although universal screening programmes were provided in most studies, there were still strong negative associations between screening uptake and area-level socio-economic deprivation. Future breast cancer screening strategies should acknowledge these challenges, and consider developing targeted interventions in more deprived areas to increase screening participation.     

Vitamin D: its role in cancer prevention and treatment

Vitamin D, the sunshine vitamin, has been recognized for almost 100 years as being essential for bone health. Vitamin D provides an adequate amount of calcium and phosphorus for the normal development and mineralization of a healthy skeleton. Vitamin D made in the skin or ingested in the diet, however, is biologically inactive and requires obligate hydroxylations first in the liver to 25-hydroxyvitamin D, and then in the kidney to 1,25-dihydroxyvitamin D. 25-Hydroxyvitamin D is the major circulating form of vitamin D that is the best indicator of vitamin D status. 1,25-dihydroxyvitamin D is the biologically active form of vitamin D. This lipid-soluble hormone interacts with its specific nuclear receptor in the intestine and bone to regulate calcium metabolism. It is now recognized that the vitamin D receptor is also present in most tissues and cells in the body. 1,25-dihydroxyvitamin D, by interacting with its receptor in non-calcemic tissues, is able to elicit a wide variety of biologic responses. 1,25-dihydroxyvitamin D regulates cellular growth and influences the modulation of the immune system. There is compelling epidemiologic observations that suggest that living at higher latitudes is associated with increased risk of many common deadly cancers. Both prospective and retrospective studies help support the concept that it is vitamin D deficiency that is the driving force for increased risk of common cancers in people living at higher latitudes. Most tissues and cells not only have a vitamin D receptor, but also have the ability to make 1,25-dihydroxyvitamin D. It has been suggested that increasing vitamin D intake or sun exposure increases circulating concentrations of 25-hydroxyvitamin D, which in turn, is metabolized to 1,25-dihydroxyvitamin D(3) in prostate, colon, breast, etc. The local cellular production of 1,25-dihydroxyvitamin D acts in an autocrine fashion to regulate cell growth and decrease the risk of the cells becoming malignant. Therefore, measurement of 25-hydroxyvitamin D is important not only to monitor vitamin D status for bone health, but also for cancer prevention.     

Wrong place,wrong time: The long-run effects of in-utero exposure to malaria on educational attainment

This paper investigates the long-term relationship between early life exposure to malaria and human capital accumulation in Brazil. The identification strategy relies on exogenous variation in the risk of malaria outbreaks in different states and seasons of the year to identify in utero exposure according to the timing and location of birth. I find consistent negative treatment effects of in utero exposure to malaria on educational attainment. The effects are stronger for exposure during the first trimester of pregnancy than during other periods of gestation. Effective anti-malaria policies can, thus, be an important factor contributing to reducing the educational inequality by targeting pregnant women, especially those in their first months of gestation.     

The Microwave Syndrome: A Preliminary Study in Spain

A health survey was carried out in Murcia, Spain, in the vicinity of a Cellular Phone Base Station working in DCS‐1800 MHz. This survey contained health items related to “microwave sickness” or “RF syndrome.” The microwave power density was measured at the respondents' homes. Statistical analysis showed significant correlation between the declared severity of the symptoms and the measured power density. The separation of respondents into two different exposure groups also showed an increase of the declared severity in the group with the higher exposure.     

The role of public policy in biological control: Some global trends

The past decade has been a rapid development in the view that contemporary agricultural practices should meet the needs of the present without compromising the ability of future generations. This philosophy has broadened the priorities for research and development in primary production systems. Now there is reduced emphasis on efficiency and productivity, and an increased concern for ecological sustainability. This has had an impact on policies relating to biological control technologies and associated policies have been developed to enhance the uptake of biopesticides. At the same time international agreements on climate change, biodiversity and global trading have potential influences on the use of biological control agents and biological technologies. In this review some of these trends in public policy are highlighted as well as the likely effect they may have in the adoption, implementation and ongoing development of biological control technologies.