Comparison of clinical and economic outcomes between high-intensity care and hospice care for the end-of-life melanoma patients

The intensity of care for patients at the end-of-life is increasing in recent years. Publications have focused on intensity of care for many cancers, but none on melanoma patients. Substantial gaps exist in knowledge about intensive care and its alternative, hospice care, among the advanced melanoma patients at the end of life. End-of-life care may be used in quite different patterns and induce both intended and unintended clinical and economic consequences. We used the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked databases to identify patients aged 65 years or older with metastatic melanoma who died between 2000 and 2007. We evaluated trends and associations between sociodemographic and health services characteristics and the use of hospice care, chemotherapy, surgery, and radiation therapy and costs. Survival, end-of-life costs, and incremental cost-effectiveness ratio were evaluated using propensity score methods. Costs were analyzed from the perspective of Medicare in 2009 dollars. In the first journal Article we found increasing use of surgery for patients with metastatic melanoma from 13% in 2000 to 30% in 2007 (P=0.03 for trend), no significant fluctuation in use of chemotherapy (P=0.43) or radiation therapy (P=0.46). Older patients were less likely to receive radiation therapy or chemotherapy. The use of hospice care increased from 61% in 2000 to 79% in 2007 (P =0.07 for trend). Enrollment in short-term (1-3 days) hospice care use increased, while long-term hospice care (≥ 4 days) remained stable. Patients living in the SEER Northeast and South regions were less likely to undergo surgery. Patients enrolled in long-term hospice care used significantly less chemotherapy, surgery and radiation therapy. In the second journal article, of 611 patients identified for this study, 358 (59%) received no hospice care after their diagnosis, 168 (27%) received 1 to 3 days of hospice care, and 85 (14%) received 4 or more days of hospice care. The median survival time was 181 days for patients with no hospice care, 196 days for patients enrolled in hospice for 1 to 3 days, and 300 days for patients enrolled for 4 or more days (log-rank test, P < 0.001). The estimated hazard ratios (HR) between 4 or more days hospice use and survival were similar within the original cohort Cox proportional hazard model (HR, 0.62; 95% CI, 0.49-0.78, P < 0.0001) and the propensity score-matched model (HR, 0.61; 95% CI, 0.47-0.78, P = 0.0001). Patients with ≥ 4 days of hospice care incurred lower end-of-life costs than the other two groups ($14,298 versus $19,380 for the 1- to 3-days hospice care, and $24,351 for patients with no hospice care; p < 0.0001). In conclusion, Surgery and hospice care use increased over the years of this study while the use of chemotherapy and radiation therapy remained consistent for patients diagnosed with metastatic melanoma. Patients diagnosed with advanced melanoma who enrolled in ≥ 4 days of hospice care experienced longer survival than those who had 1-3 days of hospice or no hospice care, and this longer overall survival was accompanied by lower end-of-life costs.^

Comparison of Bispectral Index (BIS) and Patient State Index (PSI) as objective measures of sedation and analgesia in critically ill/injured patients

Critically ill and injured patients require pain relief and sedation to reduce the body's stress response and to facilitate painful diagnostic and therapeutic procedures. Presently, the level of sedation and analgesia is guided by the use of clinical scores which can be unreliable. There is therefore, a need for an objective measure of sedation and analgesia. The Bispectral Index (BIS) and Patient State Index (PSI) were recently introduced into clinical practice as objective measures of the depth of analgesia and sedation. ^ Aim. To compare the different measures of sedation and analgesia (BIS and PSI) to the standard and commonly used modified Ramsay Score (MRS) and determine if the monitors can be used interchangeably. ^ Methods. MRS, BIS and PSI values were obtained in 50 postoperative cardiac surgery patients requiring analgesia and sedation from June to December 2004. The MRS, BIS and PSI values were assessed hourly for up to 6-h by a single observer. ^ The relationship between BIS and PSI values were explored using scatter plots and correlation between MRS, BIS and PSI was determined using Spearman's correlation coefficient. Intra-class correlation (ICC) was used to determine the inter-rater reliability of MRS, BIS and PSI. Kappa statistics was used to further evaluate the agreement between BIS and PSI at light, moderate and deep levels of sedation. ^ Results. There was a positive correlation between BIS and PSI values (Rho = 0.731, p<0.001). Intra-class correlation between BIS and PSI was 0.58, MRS and BIS 0.43 and MRS and PSI 0.27. Using Kappa statistics, agreement between MRS and BIS was 0.35 (95% CI: 0.27–0.43) and for MRS and PSI was 0.21 (95% CI: 0.15–0.28). The kappa statistic for BIS and PSI was 0.45 (95% CI: 0.37–0.52). Receiver operating characteristics (ROC) curves constructed to detect undersedation indicated an area under the curve (AUC) of 0.91 (95% CI = 0.87 to 0.94) for the BIS and 0.84 (95% CI = 0.79 to 0.88) for the PSI. For detection of oversedation, AUC for the BIS was 0.89 (95% CI = 0.84 to 0.92) and 0.80 (95% CI = 0.75 to 0.85) for the PSI. ^ Conclusions. There is a statistically significant positive correlation between the BIS and PSI but poor correlation and poor test agreement between the MRS and BIS as well as MRS and PSI. Both the BIS and PSI demonstrated a high level of prediction for undersedation and oversedation; however, the BIS and PSI can not be considered interchangeable monitors of sedation. ^

Food advertisements during children's television programming in 2007: Comparison with ads in 1994 and the 2005 dietary recommendations

Childhood overweight and obesity are two major public health problems that are of economic and medical concern in the world today (Lobstein, Baur, & Uauy, 2004). Overweight conditions in childhood are important because they are widely prevalent, serious, and carry lifetime consequences for health and well being (Lobstein et al., 2004). Several studies have shown an association between television viewing and obesity in all age groups (Caroli, Argentieri, Cardone, & Masi, 2004; Harper, 2006; Vandewater & Huang, 2006; Wiecha et al., 2006). One mechanism that potentially links television viewing to childhood obesity is food advertising (Story, 2003). ^ The purpose of this study was to examine the types of foods advertised on children's television programming and to determine if there have been any changes in the number and types of commercials over the last 13 years. In addition, the food content of the advertisements was compared to the 2005 Dietary Guidelines to determine if the foods targeted were consistent with the current recommendations. Finally, each television network was analyzed individually to determine any differences between advertising on cable and regular programming. ^ A descriptive analysis was conducted on the most commonly advertised commercials during children's television programming on Saturday morning from 7 a.m. to 10:30 a.m. A total of 10 major television networks were viewed on three different Saturday mornings during June and July 2007. Commercial advertising accounted for approximately 19% of children's total viewing time. Of the 3,185 commercials, 28.5% were for foods, 67.7% were for non-food items, and 3.8% were PSAs. On average, there were 30 commercial advertisements and PSAs per hour, of which approximately nine were for food. ^ Of the 907 food advertisements, 72.0% were for foods classified in the fats, oils, and sugar group. The next largest group (17.3%) was for restaurant food of which 15.3% were for unhealthy/fast food restaurant fare. The most frequently advertised food product on Saturday morning television was regular cereal, accounting for 43.9% of all food advertisements. ^ Cable and regular programming stations varied slightly in the amount, length, and category of commercials. Cable television had about 50% less commercials and PSAs (1098) than regular programming (2087), but only had approximately 150 minutes less total commercial and PSA time; therefore, cable, in general, had longer commercials than regular programming. Overall, cable programming had more advertisements encouraging increased physical activity and positive nutrition behavior with less commercials focusing on the fats, oils, and sugar groups, compared to regular programming. ^ During the last 13 years, food advertisements have not improved, despite the recent IOM report on marketing foods to children (Institute of Medicine-Committee on Food Marketing and the Diets of Children and Youth, 2005), although the frequency of food advertisements has improved slightly. Children are now viewing an average of one food advertisement every 7 minutes, compared to one food advertisement every 5 minutes in 1994 (Kotz & Story, 1994). Therefore, manufacturers are putting a greater emphasis on advertising other products to children. Despite the recent attention to the issue of marketing unhealthy foods to children through television advertisements, not much progress has been noted since 1994. Further advocacy and regulatory issues concerning the content of advertisements during Saturday morning TV need to be explored. ^

COMPARISON OF THE ORGANIZATIONAL STRUCTURES AND EFFECTIVENESS OF THE INVESTOR-OWNED AND VOLUNTARY MULTIHOSPITAL SECTORS

Objectives. The central objective of this study was to systematically examine the internal structure of multihospital systems, determining the management principles used and the performance levels achieved in medical care and administrative areas.^ The Universe. The study universe consisted of short-term general American hospitals owned and operated by multihospital corporations. Corporations compared were the investor-owned (for-profit) and the voluntary multihospital systems. The individual hospital was the unit of analysis for the study.^ Theoretical Considerations. The contingency theory, using selected aspects of the classical and human relations schools of thought, seemed well suited to describe multihospital organization and was used in this research.^ The Study Hypotheses. The main null hypotheses generated were that there are no significant differences between the voluntary and the investor-owned multihospital sectors in their (1) hospital structures and (2) patient care and administrative performance levels.^ The Sample. A stratified random sample of 212 hospitals owned by multihospital systems was selected to equally represent the two study sectors. Of the sampled hospitals approached, 90.1% responded.^ The Analysis. Sixteen scales were constructed in conjunction with 16 structural variables developed from the major questions and sub-items of the questionnaire. This was followed by analysis of an additional 7 structural and 24 effectiveness (performance) measures, using frequency distributions. Finally, summary statistics and statistical testing for each variable and sub-items were completed and recorded in 38 tables.^ Study Findings. While it has been argued that there are great differences between the two sectors, this study found that with a few exceptions the null hypotheses of no difference in organizational and operational characteristics of non-profit and for-profit hospitals was accepted. However, there were several significant differences found in the structural variables: functional specialization, and autonomy were significantly higher in the voluntary sector. Only centralization was significantly different in the investor owned. Among the effectiveness measures, occupancy rate, cost of data processing, total manhours worked, F.T.E. ratios, and personnel per occupied bed were significantly higher in the voluntary sector. The findings indicated that both voluntary and for-profit systems were converging toward a common hierarchical corporate management approach. Factors of size and management style may be better descriptors to characterize a specific multihospital group than its profit or nonprofit status. (Abstract shortened with permission of author.) ^

A case comparison study of dietary factors and risk of colorectal polyps

Little is known about the etiology of colorectal adenomatous polyps, although they are generally considered to be precursor lesions to colorectal carcinoma. To investigate the associations of colorectal adenomatous polyps with dietary intake of calcium, total fat and fiber, a case comparison study was conducted among 98 persons who had first occurrences of adenomatous polyps and 408 persons who did not have colorectal polyps.^ The study population comprised Black, White and Hispanic males and females ages 35 to 80 inclusive, who underwent a sigmoidoscopy or total colonoscopy at collaborating clinics in the Texas Medical Center at Houston between September 1991 and November 1992, and met the eligibility criteria. Case participants were those who had a first-time diagnosis of adenomatous polyps. Comparison participants were individuals who underwent the same diagnostic procedure as the cases and met the same eligibility criteria but had no colorectal polyps. A food frequency questionnaire was administered by interview to obtain information about diet during the 28 days preceding the interview.^ Dietary intake of total fiber was inversely associated with risk of adenomatous polyps. An increment of 15 gm/day in energy-adjusted intake of fiber was associated with a relative odds of 0.39 with a 95% confidence interval of 0.20 to 0.79, after adjustment for age, sex, ethnicity, body mass index, cigarette smoking, family history of colorectal cancer and intake of nonsteroidal anti-inflammatory drugs. No association between dietary intake of total fat and risk of adenomatous polyps was observed. When total fat was analyzed as percent of energy, an increment of 15.3% in intake was associated with a relative odds of 0.98 with a 95% confidence interval of 0.53 to 1.80. However, few persons in the study group had intakes below 25% of energy from total fat. An inverse association was observed between energy-adjusted intake of dietary calcium and risk of adenomatous polyps, but this was not statistically significant; an increment of 638 mg/day was associated with a relative odds of 0.77 with a 95% confidence interval of 0.41 to 1.38. Intake of calcium did not appear to strongly modify the association between intake of fat and risk of adenomatous polyps, perhaps because the study group included few people with calcium intake below 400 mg/day.^ These results support the idea that dietary fiber decreases risk of adenomatous polyps. Further studies are needed on the association of dietary calcium and fat with risk of colorectal adenomatous polyps in populations where individuals vary widely in intake of these nutrients. ^

THE MOLECULAR INTERACTION BETWEEN TYPE II DIABETES AND ALZHEIMER’S DISEASE THROUGH CROSS-SEEDING OF PROTEIN MISFOLDING

With the population of the world aging, the prominence of diseases such as Type II Diabetes (T2D) and Alzheimer’s disease (AD) are on the rise. In addition, patients with T2D have an increased risk of developing AD compared to age-matched individuals, and the number of AD patients with T2D is higher than among aged-matched non-AD patients. AD is a chronic and progressive dementia characterized by amyloid-beta (Aβ) plaques, neurofibrillary tangles (NFTs), neuronal loss, brain inflammation, and cognitive impairment. T2D involves the dysfunctional use of pancreatic insulin by the body resulting in insulin resistance, hyperglycemia, hyperinsulinemia, pancreatic beta cell (β-cell) death, and other complications. T2D and AD are considered protein misfolding disorders (PMDs). PMDs are characterized by the presence of misfolded protein aggregates, such as in T2D pancreas (islet amyloid polypeptide - IAPP) and in AD brain (amyloid– Aβ) of affected individuals. The misfolding and accumulation of these proteins follows a seeding-nucleation model where misfolded soluble oligomers act as nuclei to propagate misfolding by recruiting other native proteins. Cross-seeding occurs when oligomers composed by one protein seed the aggregation of a different protein. Our hypothesis is that the pathological interactions between T2D and AD may in part occur through cross-seeding of protein misfolding. To test this hypothesis, we examined how each respective aggregate (Aβ or IAPP) affects the disparate disease pathology through in vitro and in vivo studies. Assaying Aβ aggregates influence on T2D pathology, IAPP+/+/APPSwe+/- double transgenic (DTg) mice exhibited exacerbated T2D-like pathology as seen in elevated hyperglycemia compared to controls; in addition, IAPP levels in the pancreas are highest compared to controls. Moreover, IAPP+/+/APPSwe+/- animals demonstrate abundant plaque formation and greater plaque density in cortical and hippocampal areas in comparison to controls. Indeed, IAPP+/+/APPSwe+/- exhibit a colocalization of both misfolded proteins in cerebral plaques suggesting IAPP may directly interact with Aβ and aggravate AD pathology. In conclusion, these studies suggest that cross-seeding between IAPP and Aβ may occur, and that these protein aggregates exacerbate and accelerate disease pathology, respectively. Further mechanistic studies are necessary to determine how these two proteins interact and aggravate both pancreatic and brain pathologies.