James R. Beal

Obesity increases the likelihood of total joint replacement surgery among younger adults

We conducted a retrospective review of medical charts of patients, aged 18 to 59 years old, who underwent either a total knee replacement (TKR) or total hip replacement (THR) from January 2002 to December 2004. Of the 204 study subjects, 52% had a TKR while 48% had a THR. Obesity was significantly associated with the need for a TKR or THR when comparing the study group to adults of similar age in the general population (P< 0.0001). Seventy-two percent (146) of the study group was obese and 21% (42) overweight (BMI 25.0 to 29.9 kg/m2) compared to only 26% (596) obese and 34% (732) overweight in the general population. Patients undergoing a TKR were significantly more likely to be obese (BMI>30 kg/m2) than those having a THR, 83% (89) compared to 59% (57) (P< .0006). Our findings support those previously observed in the elderly population. Primary and secondary prevention programs aimed at reducing obesity are strongly recommended.RésuméNous avons réalise une étude rétrospective chez les patients âgés de 18 à 59 ans et ayant nécessité la mise en place d’une prothèse totale de hanche ou du genou de janvier 2002 à décembre 2004. 204 patients ont été étudiés : 52% pour une prothèse du genou, 48% pour une prothèse de hanche. L’obésité est un facteur significativement associé à la nécessité de la mise en place d’une prothèse totale du genou ou d’une prothèse de hanche. Si l’on compare ce groupe, à un groupe similaire de personnes du même âge dans la population générale (p<0.001). 70% soit 146 patients du groupe étudié étaient obèses et 21%, soit 42 patients, en surpoids (BMI 25.0–29.9 Kg/m2) comparé à 26%, soit 596 patients obèses et 34% soit 732 patients en surpoids de la population générale. Les patients nécessitant un remplacement du genou étaient en surcharge pondérale plus importante que les patients nécessitant une prothèse de hanche (BMI> 30 kg/m2) 83% soit 89 patients contre 59% soit 57 patients. Il nous apparaît donc important à la lumière de ces constatations de préconiser une prévention de réduction de l’obésité dans la population.

A model for clinical estimation of perioperative hemorrhage

The purpose of this study was to assess the accuracy of estimated blood loss (EBL) as a reliable predictor of actual blood loss during orthopedic procedures. Between 1999 and 2002, 198 orthopedic cases were reviewed. A retrospective review compiled preoperative and postoperative demographic and laboratory data from the surgical patients. Estimated blood loss data was-collected from the perioperative and anesthesia reports. Statistical nalysis of EBL vs. change in hemoglobin yielded a correlation e6efficient of 0.189 and a p value of 0.008. We used multiple linear regression to obtain a model to predict change in hemoglobin based on EBL and the intravenous fluids received. The model is as follows: predicted change in hemoglobin = 1.001 x estimated blood loss (in liters) + 0.441 x intravenous fluids received (in liters) + 2.334. The study population included 198 patients, 126 males and 72 females, who met our inclusion criteria. The mean age was 68.1 years (range: SD 12.5), induding 126 males (64%) and 72 females (37%). The mean amount of perioperative intravenous fluids given was 1,732 mL (SD: 773). The mean surgical time was 64.8 minutes (SD: 23.1). The mean preoperative hematocrit and hemoglobin levels were 40.9 g/dL (SD: 4.3) and 13.9 g/dL (SD: 1.6), respectively. The mean postoperative hematocrit and hemoglobin levels were 32.0 g/dL (SD: 6.0) and 10.7 g/dL (SD: 1.6), respectively. The mean difference of preoperative hemoglobin vs. postoperative hemoglobin was 3.3 g/dL (SD 2.1). In this retrospective study, clinical estimation of blood loss was closely correlated with actual change in perioperative hemoglobin. Accurately predicting the postoperative hemoglobin level may prevent many unnecessary blood transfusions and related complications.

Prevalence of SIDS Risk Factors: Before and After the “Back to Sleep” Campaign in North Dakota Caucasian and American Indian Infants

The objective of this study was to compare rates of infant sleeping position and other risk factors for sudden infant death syndrome from 1991 before the “Back to Sleep” campaign to rates in 1998 after the campaign. We used a cross-sectional risk factor prevalence study of risk factors for the years 1991 and 1998. In North Dakota the prevalence rates of prone sleeping declined 72% for American Indian infants and 62% for Caucasian infants. We were unable to identify a corresponding decline in SIDS in North Dakota for this time period. The relationship between sleeping position and SIDS may be more complex in rural and frontier settings and in American Indian populations than in urban and majority populations. The generalizability of this study is limited by the rural setting and small sample size. Longer term surveillance and additional reports from sites with pre “Back to Sleep” data as a baseline for both SIDS rates and sleeping position will be important to clarify the rate of prone sleeping position and SIDS.

Impact of a Comprehensive Smoke-Free Law Following a Partial Smoke-Free Law on Incidence of Heart Attacks at a Rural Community Hospital

INTRODUCTION Secondhand smoking (passive smoking) is associated with many negative health effects, primarily respiratory and cardiovascular diseases. Approximately, 46,000 deaths from cardiovascular disease are associated with secondhand smoke exposure annually in the United States, which is roughly 150 deaths in North Dakota. Studies show that passage of smoke-free laws at the community level can reduce the incidence of heart attack. METHODS We conducted a retrospective review of electronic medical records of patients admitted for heart attacks 4 months prior (April 15, 2010 through August 14, 2010) to implementation of the smoke-free ordinance and 4 months following (August 15, 2010 through December 14, 2010) implementation of the comprehensive smoke-free ordinance in Grand Forks, ND, United States. RESULTS We found an association between the heart attack rate and implementation of the comprehensive smoke-free law. The heart attack rate prior to the ban was 0.5% (83/16,702) compared with 0.3% (63/18,513) after the ban (p = .023). Thus, the rate of heart attacks decreased 30.6% and number of heart attack admissions decreased 24.1%, from 83 to 63, after implementation of a comprehensive smoke-free law. CONCLUSIONS We found an implementation of the comprehensive smoke-free law was associated with a decrease in the heart attack rate. The heart attack rate decreased 30.6%. Our finding was similar to previous community level smoke-free law implementation studies and notable for the change going from a partial smoke-free law to a comprehensive smoke-free law.

Risk-awareness of cutaneous malignancies among rural populations

The prevention of skin cancer relies not only on the knowledge of the risks of ultraviolet rays, but also on the appropriate measures to minimize solar exposure. We conducted a questionnaire-based survey among a rural population to evaluate perceptions regarding (i) sun-related behaviors, (ii) measures taken to protect themselves, and (iii) self-skin assessment knowledge. Questions included data on patients’ knowledge of deleterious effects of sun exposure, their habits and perceptions about adequate protection, their knowledge of a suspicious cutaneous lesion, and if a physician had spoken to them about the risks of ultraviolet/solar exposure. One hundred and six adults (38 males and 68 females) seen in a primary care clinic were enrolled in our study. Of these, only 38.7% of our patients were concerned about their risk of cutaneous malignancies. On analysis of the sun-protection variables, we found an increased use of tanning beds among women and an increased use of hats in men. Interestingly, we also found that only 18% of respondents used sunscreen when anticipating sun exposure. With suspicious skin lesions, color of the lesion appeared to be the most concerning factor for the subjects, with increasing size being the second most likely factor of concern. Only 11.3% of respondents had a physician-performed skin assessment and only 19.8% performed self-skin assessments at least yearly. There seems to be a lack of appropriate knowledge regarding precancerous and cancerous skin lesions among rural communities. Increased patient education is urgently necessary in rural populations to decrease the growing incidence of cutaneous malignancies.

Do Diametric Measurements Provide Sufficient and Reliable Tumor Assessment? An Evaluation of Diametric, Areametric, and Volumetric Variability of Lung Lesion Measurements on Computerized Tomography Scans

Diametric analysis is the standard approach utilized for tumor measurement on medical imaging. However, the availability of newer more sophisticated techniques may prove advantageous. An evaluation of diameter, area, and volume was performed on 64 different lung lesions by three trained users. These calculations were obtained using a free DICOM viewer and standardized measuring procedures. Measurement variability was then studied using relative standard deviation (RSD) and intraclass correlation. Volumetric measurements were shown to be more precise than diametric. With minimal RSD and variance between different users, volumetric analysis was demonstrated as a reliable measurement technique. Additionally, the diameters were used to calculate an estimated area and volume; thereafter the estimated area and volume were compared against the actual measured values. The results in this study showed independence of the estimated and actual values. Estimated area deviated an average of 43.5% from the actual measured, and volume deviated 88.03%. The range of this variance was widely scattered and without trend. These results suggest that diametric measurements cannot be reliably correlated to actual tumor size. Access to appropriate software capable of producing volume measurements has improved drastically and shows great potential in the clinical assessment of tumors. Its applicability merits further consideration.

Intravitreal bevacizumab and aflibercept for the treatment of exudative age-related macular degeneration.

BACKGROUND AND OBJECTIVE To compare treatment of exudative age-related macular degeneration (AMD) with bevacizumab versus aflibercept in terms of central retinal thickness (CRT) and best corrected visual acuity (BCVA). PATIENTS AND METHODS A retrospective cohort study examining changes in CRT and BCVA over 12 months of follow-up in 111 patients treated with bevacizumab and 91 treated with aflibercept for exudative AMD. RESULTS Treatment with bevacizumab and aflibercept reduced CRT from baseline to 12 months. Aflibercept significantly reduced the mean change from baseline CRT at 12 months compared to bevacizumab. However, mean CRT at 12 months was not significantly different after aflibercept versus bevacizumab (271.6 ± 74.0 μm vs 257.9 ± 48.5 μm). BCVA was significantly better at 6 months in the aflibercept group. At baseline, 18.5% of bevacizumab and 26.4% of aflibercept patients had BCVA better than 20/40. At 12 months, 34.8% of bevacizumab and 38.9% of aflibercept patients had BCVA better than 20/40. CONCLUSION CRT decreased and BCVA improved after treatment with bevacizumab and aflibercept for exudative AMD.

Statins Use and Risk for Brain Metastasis From Lung Cancer

Laboratory data suggest an association between statins and risk of brain metastasis (BM) in patients diagnosed with lung cancer. Our retrospective cohort included 252 patients diagnosed with lung cancer and 55 (22%) patients subsequently developed BM. The risk of BM was significantly higher in younger patients (p < .0007). The multivariable Cox model did not show a significant association between statin use and BM from lung cancer (Hazard-Ratio (HR) = 1.20, 95% confidence interval (CI): 0.68–2.13). Future studies should focus on late stage NSCLC and examine the incidence of BM among statin users at the time of death.

Pre-eclampsia and risk of subsequent hypertension: in an American Indian population.

ABSTRACT Background and Objectives: Pre-eclampsia (PE) shares a number of proposed pathophysiologic mechanisms related to those implicated in cardiovascular disease (CVD), such as endothelial dysfunction, inflammation, insulin resistance, and impaired renal regulation. PE has also been associated with subsequent hypertension, CVD, and related mortality in later life. Methods: At follow-up, the four most recent blood pressures, body mass index (BMI), and use of hypertensive medications were recorded from clinic visits of 130 PE cases and 289 normal pregnancies. Student’s t test, Chi-square testing, multivariate linear, and logistic regression were used in analysis. Results: Follow-up measurements occurred a mean of 13.11 years post PE pregnancy. Multivariate linear regression showed a significant and independent association between current systolic blood pressure and previous history of PE (β = 4.47, p = 0.04), while adjusting for age, BMI, and blood pressure from 1 year prior to and up to the 20th week of gestation. A similarly adjusted multivariate logistic regression model found an odds ratio of 3.43, 95% CI 1.83–6.43, p = 0.001 for subsequent hypertension. Logistic regression analysis of the quartile with follow-up of less than 7.19 years also shows independent association of prior PE with subsequent hypertension. Discussion and Conclusions: PE appears to confer risk of subsequent hypertension on this cohort of American Indian women within as little as 8 years. This risk is independent of additional risk factors such as increased age, BMI, and blood pressure prior to 20 weeks of gestation. There is evidence of increased risk among those with more severe PE.

Abstract B15: Association between travel distance to a comprehensive cancer center and breast cancer stage, treatment, and outcomes in a rural state

Purpose: The purpose of this study was to investigate the association between travel distance to a comprehensive cancer center on initial stage of breast cancer diagnosis, treatment, and survival. Women with breast cancer living in rural locations in the Midwest may be at an increased risk by having to travel longer distances, often in inclement weather, to receive screening and treatment. Methods: A hospital-based retrospective chart review was conducted of women (n=260) diagnosed with incident breast cancer from January 1, 2007 through December 31, 2007 and receiving treatment at a comprehensive cancer center in Fargo, ND. The women resided predominantly from southeastern North Dakota and southwestern Minnesota. Women aged 29-94 years were included in the study. Women were excluded if they were non-white or had a prior cancer history. Demographic and clinical data recorded included: age at diagnosis, zip code, diagnosis, stage of disease at diagnosis, radiation, surgery, mortality and history of previous cancer. Travel distance was categorized as follows: 0- 60 miles. Stage at diagnosis was categorized as Early (0-2) and Late (3-4). Surgery was categorized as breast-conserving surgery and mastectomy. SPSS 20.0 for Windows was used to perform analysis. Chi-square test was used and Mantel-Haenszel test for linear association was used to compare distance category to stage and treatment. ANOVA was used to compare age. A P value Results: The mean age at diagnosis was 60 years (range 29-94). The 5-year survival rate was 95.5%. There were 38.1% (n=99) women residing within 15 miles of the cancer center, 12.6% (33) between 15-44 miles, 21.5% (56) between 45-59 miles, and 27.7% (72) greater than 60 miles. The distribution of staging was 17.1% (42) stage 0, 46.9% (115) stage 1, 25.3% (62) stage 2, 7.8% (19) stage 3, and 2.9% (7) stage 4. Surgical resection was performed on 98% (255) of women, with 59.2% (151) receiving breast-conserving surgery, and 40.3% (104) receiving mastectomy. Radiotherapy was performed on 61.5% (160) women. A linear trend association was found between travel distance and stage of diagnosis (p=0.03). The further the distance the more likely women were to have a later stage of diagnosis. Similarly, linear trend association was found between travel distance and surgery type (p=0.005). The further the distance the more likely women were to have a mastectomy. No association was found between travel distance and age of diagnosis, receipt of radiotherapy, or 5-year survival. Conclusion: This study indicates that women with increased travel distances are more likely to have a later stage at diagnosis and mastectomy at surgery. Improvements in access to cancer treatment may be necessary for women in rural areas. Citation Format: Krishan Jethwa, Brooke Settergren, Brittany Berg, James Beal. Association between travel distance to a comprehensive cancer center and breast cancer stage, treatment, and outcomes in a rural state. [abstract]. In: Proceedings of the Twelfth Annual AACR International Conference on Frontiers in Cancer Prevention Research; 2013 Oct 27-30; National Harbor, MD. Philadelphia (PA): AACR; Can Prev Res 2013;6(11 Suppl): Abstract nr B15.