Factors associated with pediatric drowning admissions and outcomes at a trauma center, 2010-2017.

BACKGROUND: Drowning is a leading cause of preventable mortality and morbidity in children. Its high fatality rate and frequent severe sequelae (e.g. brain damage and permanent loss of functioning) place a premium on preventive efforts. METHODS: A retrospective analysis of patients ≤21 years of age admitted between 2010 and 2017 to a pediatric trauma center was conducted to identify factors associated with drowning admissions, fatal drowning, and severe outcome (ventilator use, ICU admission, or death). Outcomes were modeled and estimated by use of logistic regression and Poisson regression. RESULTS: Drowning accounted for 153/4931 (3.1%) trauma admissions between 2010 and 2017. The risk of death (13.1% vs. 1.5%, p < .01), and severe outcome (24.8% vs. 7.8%, p < .01) was significantly higher for drownings vs. other causes. All 20 drowning deaths occurred among children left unattended. In Poisson regression analysis, weekends, summer breaks, and hotter days were independently associated with a higher probability of drowning admissions. Additionally, in analyses excluding indicators of severity, the odds of severe outcome were higher for children age ≤ 2 years [adjusted odds ratio (AOR) = 3.88 95% CI (1.58, 9.53)], and injury downtime of >5 min or unknown length [AOR = 6.66 95% CI (2.74-16.15)]. Immediate intervention after the discovery was associated with ~70% lower odds of a severe outcome. CONCLUSIONS: Drowning admissions were both more severe and more often fatal compared to other pediatric injury causes of admission. Enhanced and targeted educational messages for parents of young children, focused on prevention behaviors on high-risk days and immediate bystander intervention, may reduce the occurrence and severity of these tragic accidents. TABLE OF CONTENTS SUMMARY: A retrospective multi-year cohort study to identify modifiable factors associated with drowning admissions, severe complications, and death from a large trauma registry database. WHAT'S KNOWN ON THIS SUBJECT: Drowning is a leading cause of unintentional injury that results in severe morbidity and a high rate of mortality. Children are disproportionately affected by drowning and have a higher risk of long term sequelae and death. WHAT THIS STUDY ADDS: This study identified high-risk populations and periods for drowning, the importance of supervision, and the effectiveness of immediate intervention in reducing unfavorable outcomes after drowning. It also highlights a need for heightened local intervention for drowning prevention.

Temporal trends in patient characteristics, injury mechanisms and outcomes in pediatric trauma admissions between 2010 and 2017.

INTRODUCTION: Injuries are a leading cause of preventable morbidity and mortality in children. Mechanisms of injuries and presentations are diverse in pediatric injuries and require special attention. Dedicated pediatric trauma care centers are ideal for management of children with injuries simultaneously serving as sources of research data. The objective of the current study was to identify changes in injury mechanisms, modifiable risk factors, and outcomes independently associated with admissions at a large pediatric trauma center in Tampa, Florida. METHODS: We conducted retrospective analysis of 8-years (2010-2017) of pediatric trauma admissions to a large trauma center. Demographic factors and injury characteristics were examined for temporal trends over two year increments. Temporal changes in admissions with major trauma, admission to ICU, and length of stay were examined using logistic regression analysis, and factors associated with independent temporal trends were identified using ordinal logistic regression modeling. RESULTS: During the study period, there were 4,934 trauma admissions with a predominance of falls (45.1%) and traffic injuries (20.5%). Trends were observed with less frequent head injuries (2010-2011: 35.7% vs 2016-2017: 28.3%, p < .01) and abdominal injuries (2010-2011:10.3% vs 2016-2017: 8.2%, p = .03), and more frequent chest injuries (2010-2011: 9.0% vs 2016-2017: 11.4%, p < .01). Over the study period, evaluated in 2-year increments, higher use of private insurance (Adjusted Odds Ratio (AOR)=1.44, 95% Confidence Interval (CI) 95% CI: 1.29-1.61) and helicopter transport (AOR=1.91, 95% CI: 1.58 -2.30) was observed. Admissions for drownings (AOR=1.50, 95% CI: 1.10 -2.02) and animal bites (AOR=1.99, 95% CI: 1.46 -2.71) increased during the study period. Improvement in patient outcomes (adjusted for injury severity) were observed with shorter, ≤1 day length of stay (LOS) (AOR=1.19, 95% CI: 1.06 -1.33), reduction in complications (AOR=0.47, 95% CI: 0.33 -0.66), and more admissions without an intensive care unit (ICU) stay (AOR=1.6 95% CI = 1.36 -1.88). CONCLUSIONS: Significant reductions in LOS, ICU stay, and complications were temporally observed despite an increase in admissions with higher use of helicopter transport. These results can most likely be attributed to dedicated pediatric trauma experts and resources available at an integrated pediatric trauma center.

Increasing Minority Enrollment Onto Clinical Trials: Practical Strategies and Challenges Emerge From the NRG Oncology Accrual Workshop.

Racial and ethnic diversity has historically been difficult to achieve in National Cancer Institute-sponsored clinical trials, even while as many as 80% of those trials have faced difficulty in meeting overall recruitment targets. In an attempt to address these issues, NRG Oncology recently convened a comprehensive workshop titled "Clinical Trials Enrollment: Challenges and Opportunities." Discussants at the workshop included representatives of the three legacy groups of the NRG (ie, Gynecologic Oncology Group, National Surgical Adjuvant Breast and Bowel Program, and Radiation Therapy Oncology Group), a minority-based community clinical oncology program, a large integrated health care system, the leadership of the National Cancer Institute, and a large patient advocacy group. This article summarizes the concepts discussed at the workshop, which included: needs assessments, infrastructural support, training of investigators and research staff, specific clinical trial recruitment strategies (both system and community based), and development and mentoring of young investigators. Many new, more specific tactics, including use of diverse cancer care settings, direct-to-consumer communication, and the need for centralized information technology such as the use of software to match trials to special populations, are presented. It was concluded that new, innovative trial designs and the realities of limited funding would require the adoption of effective and efficient recruiting strategies, specialized training, and stakeholder engagement. US clinical research programs must generate and embrace new ideas and pilot test novel recruitment strategies if they are to maintain their historic role as world leaders in cancer care innovation and delivery.

Patient and physician factors associated with participation in cervical and uterine cancer trials: an NRG/GOG247 study.

PURPOSE: The aim of this study was to identify patient and physician factors related to enrollment onto Gynecologic Oncology Group (GOG) trials. METHODS: Prospective study of women with primary or recurrent cancer of the uterus or cervix treated at a GOG institution from July 2010 to January 2012. Logistic regression examined probability of availability, eligibility and enrollment in a GOG trial. Odds ratios (OR) and 95% confidence intervals (CI) for significant (p<0.05) results reported. RESULTS: Sixty institutions, 781 patients, and 150 physicians participated, 300/780 (38%) had a trial available, 290/300 had known participation status. Of these, 150 women enrolled (59.5%), 102 eligible did not enroll (35%), 38 (13%) were ineligible. Ethnicity and specialty of physician, practice type, data management availability, and patient age were significantly associated with trial availability. Patients with >4 comorbidities (OR 4.5; CI 1.7-11.8) had higher odds of trial ineligibility. Non-White patients (OR 7.9; CI 1.3-46.2) and patients of Black physicians had greater odds of enrolling (OR 56.5; CI 1.1-999.9) in a therapeutic trial. Significant patient therapeutic trial enrollment factors: belief trial may help (OR 76.9; CI 4.9->1000), concern about care if not on trial (OR12.1; CI 2.1-71.4), pressure to enroll (OR .27; CI 0.12-.64), caregiving without pay (OR 0.13; CI .02-.84). Significant physician beliefs were: patients would not do well on standard therapy (OR 3.6; CI 1.6-8.4), and trial would not be time consuming (OR 3.3; CI 1.3-8.1). CONCLUSIONS: Trial availability, patient and physician beliefs were factors identified that if modified could improve enrollment in cancer cooperative group clinical trials.

Mobile mammography in underserved populations: analysis of outcomes of 3,923 women.

Mobile health units are increasingly utilized to address barriers to mammography screening. Despite the existence of mobile mammography outreach throughout the US, there is a paucity of data describing the populations served by mobile units and the ability of these programs to reach underserved populations, address disparities, and report on outcomes of screening performance. To evaluate the association of variables associated with outcomes for women undergoing breast cancer screening and clinical evaluation on a mobile unit. Retrospective analysis of women undergoing mammography screening during the period 2008-2010. Logistic regression was fitted using generalized estimating equations to account for potential repeat annual visits to the mobile unit. In total, 4,543 mammograms and/or clinical breast exams were conducted on 3,923 women with a mean age of 54.6, 29 % of whom had either never been screened or had not had a screening in 5 years. Age < 50 years, lack of insurance, Hispanic ethnicity, current smoking, or having a family relative (<50 years of age) with a diagnosis of cancer were associated with increased odds of a suspicious mammogram finding (BIRADS 4,5,6). Thirty-one breast cancers were detected. The mobile outreach initiative successfully engaged many women who had not had a recent mammogram. Lack of insurance and current smoking were modifiable variables associated with abnormal screens requiring follow up.

Influence of race on tolerance of platinum-based chemotherapy and clinical outcomes in women with advanced and recurrent cervical cancer: a pooled analysis of 3 Gynecologic Oncology Group studies.

OBJECTIVE: This study was undertaken to compare toxicity and outcomes from cisplatin-based combination chemotherapy for black and white women with advanced /recurrent cervical cancer. STUDY DESIGN: Frequencies of grade 3 and 4 toxicities, response, and survival were compared by race using data from 3 Gynecologic Oncology Group studies. RESULTS: Black women experienced significantly less grade 3 and 4 neutropenia (63% vs 82%), leukopenia (58% vs 79%), thrombocytopenia (10% vs 23%), and adverse events of any nature (84% vs 93%) compared with white women. Black patients were not at increased risk of disease progression (adjusted relative risk, 1.11; 95% confidence interval, 0.88-1.38; P = .382) or death (adjusted relative risk, 1.02; 95% confidence interval, 0.82-1.26; P = .893). CONCLUSION: Cisplatin-based chemotherapy delivered in a protocol setting for advanced/recurrent carcinoma of the cervix appears better tolerated by black women.

Maryland's Special Populations Network. A model for cancer disparities research, education, and training.

The unequal burden of cancer in minority and underserved communities nationally and in Maryland is a compelling crisis. The Maryland Special Populations Cancer Research Network (MSPN) developed an infrastructure covering Maryland's 23 jurisdictions and Baltimore City through formal partnerships between the University of Maryland School of Medicine, University of Maryland Statewide Health Network, University of Maryland Eastern Shore, and community partners in Baltimore City, rural Eastern Shore, rural Western Maryland, rural Southern Maryland, and Piscataway Conoy Tribe and statewide American Indians. Guided by the community-based participatory framework, the MSPN undertook a comprehensive assessment (of needs, strengths, and resources available) that laid the foundation for programmatic efforts in community-initiated cancer awareness and education, research, and training. The MSPN infrastructure was used to implement successful and innovative community-based cancer education interventions and technological solutions; conduct education and promotion of clinical trials, cancer health disparities research, and minority faculty cancer research career development; and leverage additional resources for sustainability. MSPN engaged in informed advocacy among decision- and policymakers at state and national levels, and its community-based clinical trials program was recognized by the U.S. Department of Health and Human Services as a Best Practice Award. The solutions to reduce and eliminate cancer health disparities are complex and require comprehensive and focused multidisciplinary cancer health disparities research, training, and education strategies implemented through robust community-academic partnerships. Cancer 2006. (c) American Cancer Society.

Maryland's Special Populations Cancer Network: cancer health disparities reduction model.

Cancer in Maryland is a serious health concern for minority and underserved populations in rural and urban areas. This report describes the National Cancer Institute (NCI) supported Maryland Special Populations Cancer Network (MSPN), a community-academic partnership. The MSPN's priority populations include African Americans, Native Americans, and other medically underserved residents of rural and urban areas. The MSPN has established a community infrastructure through formal collaborations with several community partners located in Baltimore City, the rural Eastern Shore, and Southern and Western Maryland, and among the Piscataway Conoy Tribe and the other 27 Native American Tribes in Maryland. Key partners also include the University of Maryland Eastern Shore and the University of Maryland Statewide Health Network. The MSPN has implemented innovative and successful programs in cancer health disparities research, outreach, and training; clinical trials education, health disparities policy, and resource leveraging. The MSPN addresses the goal of the NCI and the Department of Health and Human Services (DHHS) to reduce and eventually eliminate cancer health disparities. Community-academic partnerships are the foundation of this successful network.

Surveillance, epidemiology, and end results analysis of 2677 cases of uterine sarcoma 1989-1999.

OBJECTIVES: To determine the association of race with incidence, histology, treatment, and survival in women with uterine sarcoma during the period 1989-1999. METHODS: Uterine sarcomas were defined as leiomyosarcoma, carcinosarcoma, high-grade endometrial stromal sarcoma (HGESS), adenosarcoma, and sarcoma not otherwise specified (NOS). We used cases from Surveillance, Epidemiology, and End Results (SEER) program to compare uterine sarcoma among women >35 years of age. Using data from 1989 to 1999, we compared race-specific age-adjusted incidences, histological distributions, extent of disease at diagnosis, and race-specific survival. RESULTS: During the period of 1989-1999, 2677 women were diagnosed with uterine sarcoma, 2098 (78%) of whom were white and 420 (16%) of whom were black, and 159 (6%) of whom were of other races. The overall age-adjusted incidence for blacks was twice that of whites and more than twice that of women of other races (7/10(5) vs. 3.6/10(5) vs. 2.7/10(5), P < 0.0001). Racial differences in the incidence of uterine sarcoma existed for leiomyosarcoma (1.51/10(5) for blacks vs. 0.91/10(5) for whites, and 0.89 for women of other races, P < 0.01) and carcinosarcoma (4.3/10(5) for blacks, vs. 1.7/10(5) for whites, and 0.99 for women of other races, P < 0.001), but not for other histological types. Blacks with stage II disease were less likely to receive radiation in addition to surgery compared to whites (33% vs. 54%, P < 0.05). Five-year relative survival of patients with disease beyond the uterus was significantly longer for those that received radiation and surgery compared to those that received surgery alone. There were no racial differences in survival for women that received similar therapy. CONCLUSIONS: Adjuvant therapy improved survival for women with stage II-IV disease. Survival of black and white patients who received comparable treatment was similar.

Early detection and screening for ovarian cancer: does physician specialty matter?

OBJECTIVE: To examine physician factors associated with ovarian cancer screening. METHODS: Postal questionnaires to Maryland primary care physicians. Bivariate tests for statistical significance used X-Square and Student's t tests. Multivariate analysis and logistic regression were used to analyze responses based on specialty type, gender, and work experience. RESULTS: Fifty-six percent of the 375 were male, 44%, females; 33%, OB/GYN; and 67%, family/internal medicine (FM/IM). The mean age was 47 and the mean number of years in practice was 16. OB/GYNs provided more ovarian cancer counseling, OR 2.64 (CI 1.55, 4.48) and were more likely to respond correctly to knowledge questions--i.e., reduction of ovarian cancer risk with oral contraceptive (OCP) use than IM/FM, OR 8.57 (CI 3.54, 20.8). Overall, there were few gender differences in approach to evaluation, but male physicians were less likely to be aware of the relationship of OCP use to ovarian cancer risk than females, OR 0.48 (CI 0.25, 0.91). IF/FM physicians were less likely to order CA-125 for patients (of any age) based upon symptoms of bloating or physical examination alone. OB/GYN physicians, OR 4.77 (2.73, 8.34) and physicians with > 15 years in practice, OR 2.79 (1.46, 5.35) attended more meetings on ovarian cancer than non OB/GYNs or those with less experience. Although 74% indicated access to the Internet, just 16% to 26% used the Internet for cancer information; OB/GYNs used the Internet less frequently than FM/IMs, OR 0.53 (0.28, 0.97). CONCLUSIONS: Specialty was more predictive of knowledge, approach to evaluation, and counseling than gender or experience.

Resources and use of the intensive care unit in patients who undergo surgery for ovarian carcinoma.

BACKGROUND: The objective of the current study was to determine the association of age, comorbid illness, and length of stay (LOS) in the intensive care unit (ICU) in women who underwent oophorectomy for ovarian carcinoma. METHODS: The authors conducted a population-based analysis of all women with a primary or secondary diagnosis of ovarian carcinoma who underwent oophorectomy between 1994-1999. Chi-square tests and Student t tests were used to determined differences in means or proportions. Multivariate regression methods were used to build predictive models. RESULTS: Of 8109 women who were admitted, 1412 women underwent oophorectomy, 1045 of 1412 women (74%) underwent hysterectomy, 325 of 1412 women (23%) underwent intestinal surgery, and 296 of 1412 women (21%) were admitted to the ICU. Overall (+/- standard deviation) LOS was 8.3 days +/- 6.90 days, and the total charges were $16,675 +/- $15,590 (1999 dollars). Patients who underwent intestinal surgery were older (62.5 years vs. 57.1 years; P = 0.01), had a longer LOS (11.62 days vs. 7.33 days; P = 0.01), had a longer ICU stay (1.15 days vs. 0.58 days; P = 0.01), and had a higher mean Charlson Comorbidity Index (CCI) (16.01 vs. 8.73; P = 0.01) compared with patients who did not undergo intestinal surgery. Multivariate regression analysis revealed that age, intestinal surgery, CCI, ICU stay, and African-American race were associated with LOS and contributed indirectly to total charges, whereas age and ICU say were the two most important direct determinants of total charges. CONCLUSIONS: Advancing age, ICU stay, intestinal surgery, African-American race, and comorbid illness were the most prominent predictors of LOS, whereas age and ICU stay were the most important factors predicting total charges in women who underwent oophorectomy for ovarian carcinoma.

Resource utilization for patients undergoing hysterectomy with or without lymph node dissection for endometrial cancer.

OBJECTIVE: The objective was to study the association of age, comorbid illness, race, and type of hospital with resource use in patients undergoing hysterectomy and lymph node dissection for endometrial cancer. METHODS: The study was a population-based analysis of patients undergoing hysterectomy with a diagnosis of endometrial cancer in Maryland 1994-1996. Chi-square and t tests determined differences in means or proportions. Multivariate logistic regression methods were used to build predictive models. RESULTS: The 1281 women underwent total abdominal hysterectomy, 91%; total vaginal hysterectomy, 6%; radical hysterectomy, 2.5%, laparoscopically assisted total vaginal hysterectomy, 0.3%; 32% also underwent lymph node dissection. Neither age, nor race, nor comorbid illness influenced admission to teaching hospitals. Co-morbidity was documented in 56% of cases. African Americans were more likely to have one (P = 0.002) or >1 co-morbid illness (P = 0.045) than Caucasians. The most common complications were anemia (13.6%), infection/fever (12%), cardiac (9.4%), pneumonia (8%), ileus (5%), and bowel obstruction (5%). These complications occurred with higher frequency in teaching hospitals (P = 0.0001), In large hospitals (P = 0.0001), and in African American patients compared to Caucasians (P = 0.028). Multivariate regression analysis revealed that older age, admission to teaching or large hospitals, lymph node dissection, heart disease, and African American race were associated with significantly higher resource use. CONCLUSION: We documented age and racial/ethnic differences in comorbid illness, complications, and resource utilization for patients undergoing hysterectomy for endometrial cancer. The differences in resource use for teaching hospitals may be reflective of the severity of complications, which are indirectly determined by length of stay. Given the higher costs and skills required to care for elderly women with comorbid disease and complications, quantification of the complexity of care is of utmost importance for allocation of sufficient resources for the care of women with endometrial cancer.

Choriocarcinoma and epithelial trophoblastic tumor: successful treatment of relapse with hysterectomy and high-dose chemotherapy with peripheral stem cell support: a case report.

BACKGROUND: Post-termchoriocarcinoma is a rare complication of pregnancy. The presence of epithelioid trophoblastic elements may lead to the persistence of locally invasive disease which is unresponsive to multiagent chemotherapy. Relapse is associated with an estimated mortality rate of 30%. CASE: We present a case of Stage IC post-term choriocarcinoma and epithelioid trophoblastic tumor. While the metastatic sites in the lungs responded to multiagent chemotherapy, a hysterectomy was required to treat persistent disease in the uterus. The patient relapsed within 4 months of completion of chemotherapy. Relapse was treated with high-dose chemotherapy with peripheral stem cell support. The patient is alive with no evidence of disease 23 months posttransplant. CONCLUSIONS: The application of multimodality treatment and high-dose chemotherapy resulted in a successful outcome for this patient, indicating a potential role for high-dose therapy in patients who suffer a relapse of choriocarcinoma.

Association of knowledge, anxiety, and fear with adherence to follow up for colposcopy.

OBJECTIVES: To evaluate the association of pre-visit anxiety with pre- and post-visit knowledge, satisfaction, and adherence to colposcopy follow-up visits. METHODS: A group of 122 women presenting for colposcopy between July 1999 and May 2000 were studied. Immediately prior to their appointment, 98% of eligible patients participated in a self-administered questionnaire. Patients were sent a follow-up questionnaire within two weeks of the appointment. Statistical analyses included Chi-Square and Fisher's exact tests for categorical variables. RESULTS: The mean follow up was 112 days (SE 9.47). Although the mean fear score was 7.3 (SE 3, range 1-10) and mean anxiety score was 7.8 (SE 2.8, range 1-10), there was no significant association with pre-visit fear and adherence to follow up. Pre-evaluation knowledge was positively associated with fear, anxiety, post-visit knowledge, and adherence to follow up. CONCLUSIONS: Pre-visit intervention may improve adherence and reduce anxiety associated with colposcopy.

Use of ICD-9 coding as a proxy for stage of disease in lung cancer.

OBJECTIVE: To determine the validity of using ICD-9-CM codes indicating metastases as a proxy to classify lung cancer patients by stage of disease. RESEARCH DESIGN: This retrospective database analysis used diagnosis codes to classify subjects to either localized or advanced-stage disease and then compared this classification to the tumor registry staging, which was considered as the 'gold standard.' SUBJECTS AND MEASURES: Study subjects included all lung cancer patients treated at our academic institution during 1996-1997, who were also members of a large insurance company. Data were derived from inpatient cancer-related claims linked with our institution's tumor registry data. Advanced-stage disease (stages II to IV) was defined by claims indicating lymph node involvement or metastases (ICD-9 codes 196-199.1). The tumor registry stagings of the disease for these patients were clustered into two groupings, stages 0-I (localized) and stages II-IV (advanced). RESULTS: Tumor registry entries were identified for 66/77 (85.7%) patients. A total of 19 out of 22 local disease patients (sensitivity of 86.4%) and 30 out of 44 advanced disease patients (sensitivity of 68.2%) were classified correctly by ICD-9 code. A total of 19 out of 33 patients with local disease codes (PPV of 57.6%) and 30 out of 33 patients with advanced disease codes (PPV = 90.9%) were properly identified. CONCLUSIONS: For a population of lung cancer patients in an academic institution who were under a private insurance plan, the ICD-9 coding was associated with a sensitivity and positive predictive values that were consistent with previously reported estimates using Medicare-SEER data. The use of such data to classify patients to disease stages should be executed with caution as under-reporting might exist. Continued attention to discharge abstracting will be needed to improve the validity of this technique.