National guidelines may reduce socioeconomic disparities in treatment selection for esophageal cancer.

The 2011 National Comprehensive Cancer Network guidelines first incorporated the results of the landmark CROSS trial, establishing induction therapy (chemotherapy ± radiation) and surgery as the treatment standard for locoregional esophageal cancer in the United States. The effect of guideline publication on socioeconomic status (SES) inequalities in cancer treatment selection remains unknown. Patients diagnosed with Stage II/III esophageal cancer between 2004 and 2013 who underwent curative treatment with definitive chemoradiation or multimodality treatment (induction and surgery) were identified from the Surveillance, Epidemiology and End Results (SEER)-Medicare registry. Clinicopathologic characteristics were compared between the two therapies. Multivariable regression analysis was used to adjust for known factors associated with treatment selection. An interaction term with respect to guideline publication and SES was included Of the 2,148 patients included, 1,478 (68.8%) received definitive chemoradiation and 670 (31.2%) induction and surgery. Guideline publication was associated with a 16.1% increase in patients receiving induction and surgery in the low SES group (21.4% preguideline publication vs. 37.5% after). In comparison, a 4.5% increase occurred during the same period in the high SES status group (31.8% vs. 36.3%). After adjusting for factors associated with treatment selection, guideline publication was associated with a 78% increase in likelihood of receiving induction and surgery among lower SES patients (odds ratio 1.78; 95% confidence interval (CI): 1.05,3.03). Following the new guideline publication, patients living in low SES areas were more likely to receive optimal treatment. Increased dissemination of guidelines may lead to increased adherence to evidence-based treatment standards.

Gestational diabetes in the United States: temporal changes in prevalence rates between 1979 and 2010.

OBJECTIVE: To examine age-period-cohort effects on trends in gestational diabetes mellitus (GDM) prevalence in the US, and to evaluate how these trends have affected the rates of stillbirth and large for gestational age (LGA)/macrosomia. DESIGN: Retrospective cohort study. SETTING: USA, 1979-2010. POPULATION: Over 125 million pregnancies (3 337 284 GDM cases) associated with hospitalisations. METHODS: Trends in GDM prevalence were examined via weighted Poisson models to parse out the extent to which GDM trends can be attributed to maternal age, period of delivery, and maternal birth cohort. Multilevel models were used to assess the contribution of population effects to the rate of GDM. Log-linear Poisson regression models were used to estimate the contributions of the increasing GDM rates to changes in the rates of LGA and stillbirth between 1979-81 and 2008-10. MAIN OUTCOME MEASURES: Rates and rate ratios (RRs). RESULTS: Compared with 1979-1980 (0.3%), the rate of GDM has increased to 5.8% in 2008-10, indicating a strong period effect. Substantial age and modest cohort effects were evident. The period effect is partly explained by period trends in body mass index (BMI), race, and maternal smoking. The increasing prevalence of GDM is associated with a 184% (95% CI 180-188%) decline in the rate of LGA/macrosomia and a 0.75% (95% CI 0.74-0.76) increase in the rate of stillbirths for 2008-10, compared with 1979-81. CONCLUSIONS: The temporal increase in GDM can be attributed to period of pregnancy and age. Increasing BMI appears to partially contribute to the GDM increase in the US. TWEETABLE ABSTRACT: The increasing prevalence of GDM can be attributed to period of delivery and increasing maternal age.

Serious maternal complications in relation to severe pre-eclampsia: a retrospective cohort study of the impact of hospital volume.

OBJECTIVE: We examined rates of serious maternal complications in relation to severe pre-eclampsia based on the delivering hospital's annualised volume. DESIGN: Retrospective cohort study. POPULATION AND SETTING: Singleton deliveries (n = 25 782 235) in 439 hospitals in the USA. METHODS: Annualised hospital volume was categorised as 25-500, 501-1000, 1001-2000 and >2000. MAIN OUTCOME MEASURES: Rates of in-hospital maternal death and serious maternal complications, including puerperal cerebrovascular disorders, pulmonary oedema, disseminated intravascular coagulation, acute renal, heart and liver failure, sepsis, haemorrhage and intubation in relation to severe pre-eclampsia. We derived adjusted risk ratio (RR) and 95% confidence interval (CI), from hierarchical Poisson regression models. RESULTS: Severe pre-eclampsia was associated with an 8.7-fold (95% CI 7.6, 10.1) risk of composite maternal complications, with similar RRs across levels of hospital volumes. However, compared with hospitals with low annual volume (<2000), maternal mortality rates in relation to severe pre-eclampsia were lower in high volume hospitals. The rates of serious maternal complications were 410.7 per 10 000 to women who delivered in hospitals with a high rate of severe pre-eclampsia (≥2.12%) and 584.8 per 10 000 to women who delivered in hospitals with low severe pre-eclampsia rates (≤0.41; RR 1.75, 95% CI 1.24, 2.45). CONCLUSIONS: While the risks of serious maternal complications in relation to severe pre-eclampsia was similar across hospital delivery volume categories, deaths showed lower rates in large delivery volume hospitals than in smaller volume hospitals. The risk of complications was increased in hospitals with low compared with high severe pre-eclampsia rates. TWEETABLE ABSTRACT: Hospital volume had little impact on the association between severe pre-eclampsia and maternal complications.

Neurodevelopmental outcomes in children in relation to placental abruption.

OBJECTIVE: Placental abruption has a profound impact on perinatal mortality, but implications for neurodevelopment during childhood remain unknown. We examined the association between abruption and neurodevelopment at 8 months and 4 and 7 years and evaluated the extent to which these associations were mediated through preterm delivery. DESIGN: Secondary analysis of a multicenter prospective cohort study. SETTING: Multicenter US National Collaborative Perinatal Project (1959-76). POPULATION: Women that delivered singleton live births. METHODS: Analyses of IQ scores were based on marginal structural models (MSM) to account for losses to follow-up. We also carried out a causal mediation analysis to evaluate if the association between abruption and cognitive deficits was mediated through preterm delivery, and performed a sensitivity analysis for unobserved confounding. MAIN OUTCOME MEASURES: We evaluated cognitive development based on the Bayley scale at 8 months (Mental and Motor Scores), and intelligent quotient (IQ) based on the Stanford-Binet scale at 4 years and the Wechsler Intelligence Scale for Children at 7 years. RESULTS: The confounder and selection-bias adjusted risk ratio (RR) of abnormal 8-month Motor and Mental assessments were 2.35 (95%CI 1.39, 3.98) and 2.03 (95%CI 1.13, 3.64), respectively, in relation to abruption. The associations at 4 years were attenuated and resolved at 7 years. The proportion of children with abruption-associated neurological deficits mediated through preterm delivery ranged from 27 to 75%. Following adjustment for unobserved confounding the proportion mediated through preterm delivery was attenuated. CONCLUSION: The effect of abruption on neurodevelopmental outcomes appears restricted to an effect that is largely mediated through preterm delivery. TWEETABLE ABSTRACT: Increased risk of cognitive deficits in relation to abruption appears to be mediated through preterm delivery.

The effect of maternal haematocrit on offspring IQ at 4 and 7 years of age: a secondary analysis.

OBJECTIVE: To determine whether maternal haematocrit during pregnancy is associated with offspring IQ. DESIGN/SETTING/POPULATION: A secondary analysis of the Collaborative Perinatal Project, which enrolled women between 1959 and 1966 at 12 university hospitals in the United States. METHODS: We evaluated the relation between maternal haematocrit and IQ at 4 and 7 years of age. Linear and log-linear regression models were used to adjust for possible confounders. Marginal structural models with stabilised weights were used to account for selection bias due to children lost to follow up. MAIN OUTCOME MEASURES: Offspring IQ at 4 and 7 years of age. RESULTS: Of 35 959 patients, 1521 (4.2%) had moderate anaemia, 13 769 (38.3%) had mild anaemia, 18 227 (50.7%) had a normal haematocrit, and 2442 (6.8%) had a high haematocrit. The mean IQ at 4 and 7 years was significantly lower in the moderate and mild anaemia groups than in the normal haematocrit group (92.3 and 94.7 versus 100.6, respectively, P < 0.01, at 4 years; and 90.2 and 93.4 versus 99.1 at 7 years, P < 0.01). The high haematocrit group had a significantly higher mean IQ (104.5 at 4 years; 103.2 at 7 years) when compared with the normal haematocrit group (P < 0.01). Women with moderate anaemia were more likely to have children with IQ of 70-84 at 4 years (RR 1.22, 95% CI 1.08-1.38) and <70 at 7 years (RR 1.59, 95% CI 1.14-2.23). Women with a high haematocrit were more likely to have children with an IQ ≥120 at 7 years (RR 1.22, 95% CI 1.08-1.39). CONCLUSIONS: Maternal haematocrit is associated with offspring IQ at 4 and 7 years of age. TWEETABLE ABSTRACT: There is a nonlinear relation between maternal haematocrit and offspring IQ at 4 and 7 years of age.