Cancer resection rates, socioeconomic deprivation, and geographical access to surgery among urban, suburban, and rural populations across Canada.

High-risk cancer resection surgeries are increasingly being performed at fewer, more specialised, and higher-volume institutions across Canada. The resulting increase in travel time for patients to obtain treatment may be exacerbated by socioeconomic barriers to access. Focussing on five high-risk surgery types (oesophageal, ovarian/fallopian, liver, lung, and pancreatic cancers), this study examines socioeconomic trends in age-adjusted resection rates and travel time to surgery location for urban, suburban, and rural populations across Canada, excluding Québec, from 2004 to 2012. Significant differences in age-adjusted resection rates were observed between urban (14.9 per 100 000 person-years [95% CI: 12.2, 17.6]), suburban (40.7 [40.1, 41.2]), and rural (32.7 [29.6, 35.9]) populations, with higher rates in suburban and rural areas throughout the study period for all cancer types. Resection rates did not differ between the highest (Q1) and lowest (Q5) socioeconomic strata (Q1: 13.3 [12.2, 14.4]; Q5: 12.0 [10.7, 13.4]), with significantly higher rates among middle-SES patients (Q2: 27.3 [25.6, 29.0]; Q3: 39.6 [37.4, 41.8]; Q4: 37.5 [35.3, 39.7]). Travel times to treatment were consistently higher among the most socioeconomically deprived patients, most notably in suburban and rural areas. The results suggest that the conventional inclusion of suburbs with urban areas in health research may obfuscate important trends for public health policy and programmes.

Development of a clinical score to distinguish malignant from benign esophageal disease in an undiagnosed patient population referred to an esophageal diagnostic assessment program.

BACKGROUND: Esophageal cancer is associated with poor prognosis. Diagnosis is often delayed, resulting in presentation with advanced disease. We developed a clinical score to predict the risk of a malignant diagnosis in symptomatic patients prior to any diagnostic tests. METHODS: We analyzed data from patients referred to a regional esophageal diagnostic assessment program between May 2013 and August 2016. Logistic regression was performed to identify predictors of malignancy based on patient characteristics and symptoms. Predicted probabilities were used to develop a score from 0 to 10 which was weighted according to beta coefficients for predictors in the model. Score accuracy was evaluated using a receiver operating characteristic (ROC) curve and internally validated using bootstrapping techniques. Patients were classified into low (0-2 points), medium (3-6 points), and high (7-10 points) risk groups based on their scores. Pathologic tissue diagnosis was used to assess the effectiveness of the developed score in predicting the risk of malignancy in each group. RESULTS: Of 530 patients, 363 (68%) were diagnosed with malignancy. Factors predictive of malignancy included male sex, family history of cancer and esophageal cancer, fatigue, chest/throat/back pain, melena and weight loss. These factors were allocated 1-2 points each for a total of 10 points. Low-risk patients had 70% lower chance of malignancy (RR =0.28, 95% CI: 0.21-0.38), medium-risk had 50% higher chance of malignancy (RR =1.5, 95% CI: 1.26-1.77), and high-risk patients were 8 times more likely to be diagnosed with malignancy (RR =8.2, 95% CI: 2.60-25.86). The area under the ROC curve for malignancy was 0.82 (95% CI: 0.77-0.87). CONCLUSIONS: A simple score using patient characteristics and symptoms reliably distinguished malignant from benign diagnoses in a population of patients with upper gastrointestinal symptoms. This score might be useful in expediting investigations, referrals and eventual diagnosis of malignancy.

Length of stay and hospital costs among patients admitted to hospital by family physicians.

OBJECTIVE: To compare length of stay and total hospital costs among patients admitted to hospital under the care of family physicians who were their usual health care providers in the community (group A) and patients admitted to the same inpatient service under the care of family physicians who were not their usual health care providers (group B). DESIGN: Retrospective observational study. SETTING: A large urban hospital in Vancouver, BC. PARTICIPANTS: All adult admissions to the family practice inpatient service between April 1, 2006, and June 30, 2008. MAIN OUTCOME MEASURES: Ratio of length of stay to expected length of stay and total hospital costs per resource intensity weight unit. Multivariate linear regression was performed to determine the effect of admitting group (group A vs. group B) on the natural logarithm transformations of the outcomes. RESULTS: The median acute length of stay was 8.0 days (interquartile range [IQR] 4.0 to 13.0 days) for group A admissions and 8.0 days (IQR 4.0 to 15.0 days) for group B admissions. The median (IQR) total hospital costs were $6498 ($4035 to $11,313) for group A admissions and $6798 ($4040 to $12,713) for group B admissions. Aftera djustment for patient characteristics, patients admitted to hospital under the care of their own family physicians did not significantly differ in terms of acute length of stay to expected length of stay ratio (percent change 0.6%, P = .942)or total hospital costs per resource intensity weight unit (percent change -2.0%, P = .722) compared with patients admitted under the care of other family physicians. CONCLUSION: These findings suggest that having networks of family physicians involved in hospital care for patients is not less efficient than having family physicians provide care for their own patients.

Homeless people's perceptions of welcomeness and unwelcomeness in healthcare encounters.

BACKGROUND: Homeless people face many barriers to obtaining health care, and their attitudes toward seeking health care services may be shaped in part by previous encounters with health care providers. OBJECTIVE: To examine how homeless persons experienced "welcomeness" and "unwelcomeness" in past encounters with health care providers and to characterize their perceptions of these interactions. DESIGN: Qualitative content analysis of 17 in-depth interviews. PARTICIPANTS: Seventeen homeless men and women, aged 29-62 years, residing at 5 shelters in Toronto, Canada. APPROACH: Interpretive content analysis was performed using iterative stages of inductive coding. Interview transcripts were analyzed using Buber's philosophical conceptualization of ways of relating as "I-It" (the way persons relate to objects) and "I-You" (the way persons relate to dynamic beings). RESULTS: Most participants perceived their experiences of unwelcomeness as acts of discrimination. Homelessness and low social class were most commonly cited as the perceived basis for discriminatory treatment. Many participants reported intense emotional responses to unwelcoming experiences, which negatively influenced their desire to seek health care in the future. Participants' descriptions of unwelcoming health care encounters were consistent with "I-It" ways of relating in that they felt dehumanized, not listened to, or disempowered. Welcoming experiences were consistent with "I-You" ways of relating, in that patients felt valued as a person, truly listened to, or empowered. CONCLUSIONS: Homeless people's perceptions of welcomeness and unwelcomeness are an important aspect of their encounters with health care providers. Buber's "I-It" and "I-You" concepts are potentially useful aids to health care providers who wish to understand how welcoming and unwelcoming interactions are fostered.

Fibrous long spacing type collagen fibrils have a hierarchical internal structure.

Nanodissection of single fibrous long spacing (FLS) type collagen fibrils by atomic force microscopy (AFM) reveals hierarchical internal structure: Fibrillar subcomponents with diameters of approximately 10 to 20 nm were observed to be running parallel to the long axis of the fibril in which they are found. The fibrillar subcomponent displayed protrusions with characteristic approximately 270 nm periodicity, such that protrusions on neighboring subfibrils were aligned in register. Hence, the banding pattern of mature FLS-type collagen fibrils arises from the in-register alignment of these fibrillar subcomponents. This hierarchical organization observed in FLS-type collagen fibrils is different from that previously reported for native-type collagen fibrils, displaying no supercoiling at the level of organization observed.

Hierarchical assembly and the onset of banding in fibrous long spacing collagen revealed by atomic force microscopy.

The mechanism of formation of fibrillar collagen with a banding periodicity much greater than the 67 nm of native collagen, i.e. the so-called fibrous long spacing (FLS) collagen, has been speculated upon, but has not been previously studied experimentally from a detailed structural perspective. In vitro, such fibrils, with banding periodicity of approximately 270 nm, may be produced by dialysis of an acidic solution of type I collagen and alpha(1)-acid glycoprotein against deionized water. FLS collagen assembly was investigated by visualization of assembly intermediates that were formed during the course of dialysis using atomic force microscopy. Below pH 4, thin, curly nonbanded fibrils were formed. When the dialysis solution reached approximately pH 4, thin, filamentous structures that showed protrusions spaced at approximately 270 nm were seen. As the pH increased, these protofibrils appeared to associate loosely into larger fibrils with clear approximately 270 nm banding which increased in diameter and compactness, such that by approximately pH 4.6, mature FLS collagen fibrils begin to be observed with increasing frequency. These results suggest that there are aspects of a stepwise process in the formation of FLS collagen, and that the banding pattern arises quite early and very specifically in this process. It is proposed that typical 4D-period staggered microfibril subunits assemble laterally with minimal stagger between adjacent fibrils. alpha(1)-Acid glycoprotein presumably promotes this otherwise abnormal lateral assembly over native-type self-assembly. Cocoon-like fibrils, which are hundreds of nanometers in diameter and 10-20 microm in length, were found to coexist with mature FLS fibrils.