BACKGROUND: Melanoma surveillance serves to identify new primary melanomas and curable locoregional or early distant recurrences. Although an optimal melanoma surveillance strategy has not been determined, several clinical guidelines exist. OBJECTIVE: The aim of this study was to identify demographic and clinico-pathologic variables associated with poor adherence to National Comprehensive Cancer Network (NCCN) melanoma surveillance guidelines. DESIGN: We retrospectively reviewed the initial five-year dermatology follow-up visit frequencies of melanoma patients and extracted basic demographic and clinical data from their medical records. PARTICIPANTS: Of 186 patients included, the mean age was 55 (standard deviation=15); 47.5 percent (n=85) were female, 93.0 percent (n=173) were white, and 76.2 percent (n=141) were married. Sixty percent of patients lived at locations more than 10 miles from the clinic, and 58.6 percent had private insurance. MEASUREMENTS: "Aggressive" and "conservative" surveillance schedules were adapted from National Comprehensive Cancer Network visit frequency guidelines. RESULTS: Between 58.4 and 74.5 percent of patients adhered to "aggressive" surveillance, with decreasing rates over the five-year period. Annual rates of poor surveillance adherence (7.3-23.6%) increased over time. Based on adjusted odds ratios, patients younger than 50 years of age (odds ratios 2.11 [95% CI 1.13-3.93], p<0.05), those lacking health insurance (odds ratios 3.08 [95% CI 1.09-8.68], p<0.05), and those with at least Stage IIB disease (odds ratios 3.21 [95% CI 1.36-7.58], p<0.01) are more likely to be poorly adherent to melanoma surveillance. CONCLUSION: This study's findings highlight some variables associated with poor surveillance adherence among melanoma survivors that could help to guide efforts in counseling this at-risk population.
Gastrointestinal bleeding (GIB) is a common cause of morbidity among patients supported by left ventricular assist devices (LVADs). The aim of this study was to identify if pre-LVAD right ventricular (RV) dysfunction is associated with risk of GIB after LVAD implantation. Of 398 patients implanted with LVADs between July 2008 and July 2016, 130 (33%) developed GIB at a median of 2.6 months following LVAD implantation. Arteriovenous malformations (AVMs) were found in 42 (34%) GIB patients. Patients with GIB were older and more likely to have hypertension, diabetes, and ischemic cardiomyopathy. On pre-LVAD echocardiography, GIB patients had increased RV diastolic dimension (4.7 ± 0.8 vs. 4.4 ± 0.9 cm, p = 0.02), a higher rate of greater than mild tricuspid valve (TV) regurgitation (73 [60%] vs. 120 [47%], p = 0.006), and underwent TV repair more often (38 [30%] vs. 43 [16%], p = 0.0006) during LVAD implantation. After multivariable adjustment, preoperative greater than mild RV enlargement (hazard ratio [HR] 2.32, 95% CI 1.12-5.03; p = 0.03), TV regurgitation (HR 1.83, CI 1.02-3.44; p = 0.01), and TV repair (HR 3.76, confidence interval [CI] 1.02-4.44; p = 0.01) remained associated with risk of GIB. This finding was driven by the AVM-GIB subgroup. Preoperative RV enlargement and TV regurgitation are associated with post-LVAD AVM-related GIB.
The effect of vaccination on emergency department (ED) utilization for herpes zoster (HZ) has not been examined to date.To determine trends in US ED utilization and costs associated with HZ.The Nationwide Emergency Department Sample data set was examined for temporal trends in the number of visits and costs for treatment of HZ in EDs in the United States from January 1, 2006, through December 31, 2013. Cases of HZ were identified using validated International Classification of Diseases, Ninth Revision-Clinical Modification diagnosis codes. Patients were stratified by age: less than 20 years (varicella vaccine recommended), 20 to 59 years (no vaccine recommended), and 60 years or older (HZ vaccine recommended). Population-based rates were estimated using sampling weights.Population-based incidence rates of HZ-related ED visits, charge for ED services, and total charges.A total of 1 350 957 ED visits for HZ were identified between 2006 and 2013, representing 0.13% of all US ED visits. Of these patients, 563 200 (51.7%) were male; mean (SE) age was 54.0 (0.1) years. Between 2006 and 2013, the percentage of HZ-related ED visits increased from 0.13% to 0.14% (8.3%). This growth was driven by patients aged 20 to 59 years (increase of 22.8% [from 0.12% to 0.14% of ED visits]) while the proportion of ED HZ visits decreased for patients aged less than 20 years and 60 years or older, from 0.03% to 0.02% (-39.6%) and from 0.28% to 0.25% (-10.9%), respectively. For all age groups, there was an increase from 2006 to 2013 in overall adjusted total (from $92.83 to $202.47 million) and mean charges (from $763 to $1262) for HZ-related ED visits.The number of ED visits and total cost associated with HZ increased between 2006 and 2013. Greater use was driven by an increased number of visits by patients aged 20 to 59 years, but populations recommended for vaccination (<20 and ≥60 years) demonstrated decreased ED utilization. Per-visit and total costs increased across all age groups. Vaccination may be associated with a reduction of ED utilization. Further research is required to confirm these results and examine the drivers of increased ED costs.
ABSTRACT OBJECTIVE Current etiology of interstitial cystitis/painful bladder syndrome (IC/PBS) is poorly understood and multifactorial. Recent studies suggest the female urinary microbiota (FUM) contribute to IC/PBS symptoms. This study was designed to determine if the FUM, analyzed using mid-stream voided urine samples, differs between IC/PBS patients and controls. MATERIALS AND METHODS This prospective case-controlled study compared the voided FUM of women with symptoms of urinary frequency, urgency, and bladder pain for greater than 6 months to the voided FUM of healthy female controls without pain. Bacterial identification was performed using 16S rRNA gene sequencing and EQUC, a validated enhanced urine culture approach. Urotype was defined by a genus present at >50% relative abundance. If no genus was present above this threshold, the urotype was classified as ‘mixe’. Chi-square and Fisher’s exact tests were performed. P -values <0.05 were considered significant. RESULTS A mid-stream voided specimen was collected from 21 IC/PBS patients and 20 asymptomatic controls. Both groups had similar demographics. Urotypes did not differ between cohorts as assessed by either EQUC or 16S rRNA gene sequencing. We detected no significant differences between cohorts in terms of alpha-diversity. Cohorts also were not distinct using Principle Component Analysis or hierarchical clustering. Detection by EQUC of bacterial species considered uropathogenic was high in both cohorts, but detection of these uropathogenic species did not differ between groups ( p =0.10). CONCLUSIONS Enhanced culture and modern DNA sequencing methods provide evidence that IC/PBS symptoms may not be related to differences in the FUM, at least not its bacterial components. Future larger studies are needed to confirm this preliminary finding.
Intermediate-risk pulmonary embolism (PE) has variable outcomes. Current risk stratification models lack the positive predictive value to identify patients at highest risk of PE-related mortality. We identified intermediate-risk PE patients who underwent catheter-based interventions and right heart catheterization (RHC) and identified those with low cardiac index (CI < 2.2 L/min/m2). We utilized regression models to identify echocardiographic predictors of low CI and Kaplan Meier curve to evaluate PE-related mortality when stratified by the echocardiographic predictor. Of 174 intermediate-risk PE patients, 41 underwent RHC. Within this cohort, 46.3% had low CI. Univariable linear regression identified right ventricular outflow tract velocity time integral (RVOT VTI), right/left ventricular ratio, S prime, inferior vena cava diameter, and pulmonary artery systolic pressure as potential predictors of low CI. Multivariable linear regression identified RVOT VTI as significant predictor of low CI (β coefficient 0.124, 95% confidence interval [CI]: 0.01-0.24, P = .034). Right ventricular outflow tract velocity time integral <9.5 cm was associated with increased PE-related mortality, P = .002. A substantial proportion of intermediate-risk PE patients referred for catheter-based interventions had low CI despite normotension. Right ventricular outflow tract velocity time integral was a significant predictor of low CI. Low RVOT VTI was associated with increased PE-related mortality.
