Adam C. Bartley

Association Between Treatment Facility Volume and Mortality of Patients With Multiple Myeloma

Purpose To determine the association between the number of patients with multiple myeloma (MM) treated annually at a treatment facility (volume) and all-cause mortality (outcome). Methods Using the National Cancer Database, we identified patients diagnosed with MM between 2003 and 2011. We classified the facilities by quartiles (Q; mean patients with MM treated per year): Q1: < 3.6; Q2: 3.6 to 6.1, Q3: 6.1 to 10.3, and Q4: > 10.3. We used random intercepts to account for clustering of patients within facilities and Cox regression to determine the volume-outcome relationship, adjusting for demographic (sex, age, race, ethnicity), socioeconomic (income, education, insurance type), geographic (area of residence, treatment facility location, travel distance), and comorbid (Charlson-Deyo score) factors and year of diagnosis. Results There were 94,722 patients with MM treated at 1,333 facilities. The median age at diagnosis was 67 years, and 54.7% were men. The median annual facility volume was 6.1 patients per year (range, 0.2 to 109.9). The distribution of patients according to facility volume was: Q1: 5.2%, Q2: 12.6%, Q3: 21.9%, and Q4: 60.3%. The unadjusted median overall survival by facility volume was: Q1: 26.9 months, Q2: 29.1 months, Q3: 31.9 months, and Q4: 49.1 months ( P < .001). Multivariable analysis showed that facility volume was independently associated with all-cause mortality. Compared with patients treated at Q4 facilities, patients treated at lower-quartile facilities had a higher risk of death (Q3 hazard ratio [HR], 1.12 [95% CI, 1.08 to 1.16]; Q2 HR, 1.17 [95% CI, 1.12 to 1.21]; Q1 HR, 1.22 [95% CI, 1.17 to 1.28]). Conclusion Patients who were treated for MM at higher-volume facilities had a lower risk of mortality compared with those who were treated at lower-volume facilities.

Prevalence, incidence and survival of smoldering multiple myeloma in the United States

Smoldering multiple myeloma (SMM) is currently defined as MM without evidence of impending (⩾60% clonal bone marrow plasma cells, serum involved to uninvolved free light chain ratio of ⩾100 with absolute involved light chain level of ⩾100 mg/L, or >1 focal lesion on magnetic resonance imaging ⩾5 mm in size) or active (hypercalcemia, renal insufficiency, anemia or bone lesion – crab signs) end organ damage, which are considered indications for treatment.1 Although institutional studies show that ~8–20% of patients with MM are smoldering at the time of diagnosis,2 the actual prevalence of SMM in the United States (US) is unknown. Epidemiologic studies have been difficult to perform due to the lack of International Classification of Diseases (ICD) codes differentiating smoldering from active MM.

Effect of Menstrual Cycle Phase on Background Parenchymal Uptake at Molecular Breast Imaging

RATIONALE AND OBJECTIVES The level of Tc-99m sestamibi uptake within normal fibroglandular tissue on molecular breast imaging (MBI), termed background parenchymal uptake (BPU), has been anecdotally observed to fluctuate with menstrual cycle. Our objective was to assess the impact of menstrual cycle phase on BPU appearance. MATERIALS AND METHODS Premenopausal volunteers who reported regular menstrual cycles and no exogenous hormone use were recruited to undergo serial MBI examinations during the follicular and luteal phase. A study radiologist, blinded to cycle phase, categorized BPU as photopenic, minimal mild, moderate, or marked. Change in BPU with cycle phase was determined, as well as correlations of BPU with mammographic density and hormone levels. RESULTS In 42 analyzable participants, high BPU (moderate or marked) was observed more often in luteal phase compared to follicular (P = .016). BPU did not change with phase in 30 of 42 participants (71%) and increased in the luteal phase compared to follicular in 12 (29%). High BPU was more frequent in dense breasts compared to nondense breasts at both the luteal (58% [15 of 26] vs. 13% [2 of 16], P = .004) and follicular phases (35% [9 of 26] vs. 6% [1 of 16], P = .061). Spearman correlation coefficients did not show any correlation of BPU with hormone levels measured at either cycle phase and suggested a weak correlation between change in BPU and changes in estrone and estradiol between phases. CONCLUSIONS We observed variable effects of menstrual cycle on BPU among our cohort of premenopausal women; however, when high BPU was observed, it was most frequently seen during the luteal phase compared to follicular phase and in women with dense breasts compared to nondense breasts.

Emergency Department Rotational Patient Assignment

STUDY OBJECTIVE We compare emergency department (ED) operational metrics obtained in the first year of a rotational patient assignment system (in which patients are assigned to physicians automatically according to an algorithm) with those obtained in the last year of a traditional physician self-assignment system (in which physicians assigned themselves to patients at physician discretion). METHODS This was a pre-post retrospective study of patients at a single ED with no financial incentives for physician productivity. Metrics of interest were length of stay; arrival-to-provider time; rates of left before being seen, left subsequent to being seen, early returns (within 72 hours), and early returns with admission; and complaint ratio. RESULTS We analyzed 23,514 visits in the last year of physician self-assignment and 24,112 visits in the first year of rotational patient assignment. Rotational patient assignment was associated with the following improvements (percentage change): median length of stay 232 to 207 minutes (11%), median arrival to provider time 39 to 22 minutes (44%), left before being seen 0.73% to 0.36% (51%), and complaint ratio 9.0/1,000 to 5.4/1,000 (40%). There were no changes in left subsequent to being seen, early returns, or early returns with admission. CONCLUSION In a single facility, the transition from physician self-assignment to rotational patient assignment was associated with improvement in a broad array of ED operational metrics. Rotational patient assignment may be a useful strategy in ED front-end process redesign.

The impact of postpartum hemorrhage on hospital length of stay and inpatient mortality: a National Inpatient Sample–based analysis

Background Postpartum hemorrhage is a major cause of maternal morbidity and mortality, but the association between postpartum hemorrhage and hospital length of stay has not been rigorously investigated. Objective We explored the impact of postpartum hemorrhage on hospital length of stay and inpatient mortality, as these outcomes have both clinical and economic significance. Study Design We performed a retrospective analysis using data from the National Inpatient Sample database during the 2012 through 2013 time period. Deliveries were classified as postpartum hemorrhage due to uterine atony, nonatonic postpartum hemorrhage, or not complicated by postpartum hemorrhage (nonpostpartum hemorrhage). Average length of stay and inpatient mortality rates were compared between groups. Results Over the study interval, postpartum hemorrhage occurred in 3% of deliveries. Among deliveries complicated by postpartum hemorrhage, 76.6% were attributed to uterine atony and 23.4% were nonatonic. Women with nonatonic postpartum hemorrhage had the highest average length of stay (3.67 days) followed by atonic postpartum hemorrhage (2.98 days) and nonpostpartum hemorrhage (2.63 days); P < .001, all comparisons. Inpatient mortality rate of nonatonic postpartum hemorrhage over the entire study period was 104 per 100,000 compared to 019 per 100,000 for atonic postpartum hemorrhage and 3 per 100,000 for nonpostpartum hemorrhage deliveries (P < .001). Conclusion From 2012 through 2013, women with postpartum hemorrhage experienced significantly longer length of stay and higher inpatient mortality rates than women without postpartum hemorrhage, largely attributable to nonatonic causes of postpartum hemorrhage. As hospital length of stay and inpatient mortality are important outcomes from both clinical and societal perspectives, interventions to reduce morbidity and mortality related to postpartum hemorrhage may simultaneously facilitate delivery of more cost‐effective care and improve both maternal and population health.

Effect of the type of treatment facility on the outcome of acute myeloid leukemia in adolescents and young adults

Effect of the type of treatment facility on the outcome of acute myeloid leukemia in adolescents and young adults

Low-dose CT for the detection and classification of metastatic liver lesions: Results of the 2016 Low Dose CT Grand Challenge

Purpose: Using common datasets, to estimate and compare the diagnostic performance of image‐based denoising techniques or iterative reconstruction algorithms for the task of detecting hepatic metastases. Methods: Datasets from contrast‐enhanced CT scans of the liver were provided to participants in an NIH‐, AAPM‐ and Mayo Clinic‐sponsored Low Dose CT Grand Challenge. Training data included full‐dose and quarter‐dose scans of the ACR CT accreditation phantom and 10 patient examinations; both images and projections were provided in the training data. Projection data were supplied in a vendor‐neutral standardized format (DICOM‐CT‐PD). Twenty quarter‐dose patient datasets were provided to each participant for testing the performance of their technique. Images were provided to sites intending to perform denoising in the image domain. Fully preprocessed projection data and statistical noise maps were provided to sites intending to perform iterative reconstruction. Upon return of the denoised or iteratively reconstructed quarter‐dose images, randomized, blinded evaluation of the cases was performed using a Latin Square study design by 11 senior radiology residents or fellows, who marked the locations of identified hepatic metastases. Markings were scored against reference locations of clinically or pathologically demonstrated metastases to determine a per‐lesion normalized score and a per‐case normalized score (a faculty abdominal radiologist established the reference location using clinical and pathological information). Scores increased for correct detections; scores decreased for missed or incorrect detections. The winner for the competition was the entry that produced the highest total score (mean of the per‐lesion and per‐case normalized score). Reader confidence was used to compute a Jackknife alternative free‐response receiver operating characteristic (JAFROC) figure of merit, which was used for breaking ties. Results: 103 participants from 90 sites and 26 countries registered to participate. Training data were shared with 77 sites that completed the data sharing agreements. Subsequently, 41 sites downloaded the 20 test cases, which included only the 25% dose data (CTDIvol = 3.0 ± 1.8 mGy, SSDE = 3.5 ± 1.3 mGy). 22 sites submitted results for evaluation. One site provided binary images and one site provided images with severe artifacts; cases from these sites were excluded from review and the participants removed from the challenge. The mean (range) per‐lesion and per‐case normalized scores were −24.2% (−75.8%, 3%) and 47% (10%, 70%), respectively. Compared to reader results for commercially reconstructed quarter‐dose images with no noise reduction, 11 of the 20 sites showed a numeric improvement in the mean JAFROC figure of merit. Notably two sites performed comparably to the reader results for full‐dose commercial images. The study was not designed for these comparisons, so wide confidence intervals surrounded these figures of merit and the results should be used only to motivate future testing. Conclusion: Infrastructure and methodology were developed to rapidly estimate observer performance for liver metastasis detection in low‐dose CT examinations of the liver after either image‐based denoising or iterative reconstruction. The results demonstrated large differences in detection and classification performance between noise reduction methods, although the majority of methods provided some improvement in performance relative to the commercial quarter‐dose images with no noise reduction applied.

Low-Dose CT for Craniosynostosis: Preserving Diagnostic Benefit with Substantial Radiation Dose Reduction

BACKGROUND AND PURPOSE: Given the positive impact of early intervention for craniosynostosis, CT is often performed for evaluation but radiation dosage remains a concern. We evaluated the potential for substantial radiation dose reduction in pediatric patients with suspected craniosynostosis. MATERIALS AND METHODS: CT projection data from pediatric patients undergoing head CT for suspected craniosynostosis were archived. Simulated lower-dose CT images corresponding to 25%, 10%, and 2% of the applied dose were created using a validated method. Three neuroradiologists independently interpreted images in a blinded, randomized fashion. All sutures were evaluated by using 3D volume-rendered images alone, and subsequently with 2D and 3D images together. Reference standards were defined by reader agreement by using routine dose and 2D and 3D images. Performance figures of merit were calculated based on reader response and confidence. RESULTS: Of 33 pediatric patients, 21 had craniosynostosis (39 positive sutures and 225 negative sutures). The mean volume CT dose index was 15.5 ± 2.3 mGy (range, 9.69–19.38 mGy) for the routine dose examination. Average figures of merit for multireader analysis ranged from 0.92 (95% CI, 0.90–0.95) at routine pediatric dose to 0.86 (95% CI, 0.79–0.94) at 2% dose using 3D images alone. Similarly, pooled reader figures of merit ranged from 0.91 (95% CI, 0.89–0.95) at routine pediatric dose to 0.85 (95% CI, 0.76–0.95) at 2% dose using 2D and 3D images together. At 25% and 10% dose, 95% CI of the difference in figures of merit from routine dose included 0, suggesting similar or noninferior performance. CONCLUSIONS: For pediatric head CT for evaluation of craniosynostosis, dose reductions of 75%–90% were possible without compromising observer performance.

Association between atopic dermatitis and squamous cell carcinoma: a case–control study

Conflicting data have been published on whether an association exists between atopic dermatitis (AD) and nonmelanoma skin cancer. This study aimed to determine whether individuals with AD had an increased risk of squamous cell carcinoma (SCC) development.

Impact of Multiple Chronic Conditions in Patients Hospitalized with Stroke and Transient Ischemic Attack

BACKGROUND The prevalence and clinical impact of chronic conditions (CCs) have increasingly been recognized as an important public health concern. We evaluated the prevalence of coexisting CCs and their association with 30-day mortality and readmission in hospitalized patients with stroke and transient ischemic attack (TIA). METHODS In a retrospective study of patients aged ≥18 years hospitalized for first-ever stroke and TIA, we assessed the prevalence of coexisting CCs and their predictive value for subsequent 30-day mortality and readmission. RESULTS Study cohort comprised 6771 patients, hospitalized for stroke (n = 4068) and TIA (n = 2703), 51.4% men, with mean age of 68.2 years (standard deviation: ±15.6), mean number of CCs of 2.9 (±1.7), 30-day mortality rate of 8.6% (entire cohort), and 30-day readmission rate of 9.7% (in 2498 patients limited to Olmsted and surrounding counties). In multivariable models, significant predictors of (1) 30-day mortality were coexisting heart failure (HF) (odds ratio [OR]: 1.45, 95% confidence interval [CI]: 1.09-1.92), cardiac arrhythmia (OR: 1.74, 95% CI: 1.40-2.17), coronary artery disease (CAD) (OR: 1.64, 95% CI: 1.29-2.08), cancer (OR: 1.67, 95% CI: 1.31-2.14), and diabetes (HR: 1.28, 95% CI: 1.01-1.62); and (2) 30-day readmission (n = 2498) were CAD (OR: 1.50, 95% CI: 1.09-2.07), cancer (OR: 1.46, 95% CI: 1.01-2.10), and arthritis (OR: 1.62, 95% CI: 1.09-2.40). CONCLUSIONS In patients hospitalized with stroke and TIA, CCs are highly prevalent and influence 30-day mortality and readmission. Optimal therapeutic and lifestyle interventions for CAD, HF, cardiac arrhythmia, cancer, diabetes, and arthritis may improve early clinical outcome.