Nevin Manimala

Plast Reconstr Surg. 2022 Sep 1. doi: 10.1097/PRS.0000000000009639. Online ahead of print.

ABSTRACT

Previously, surgeons believed that after total glossolaryngectomy (TGL), swallowing is mainly dependent on gravity. However, swallowing function after TGL varies widely between patients, and a thorough analysis is lacking. We aimed to clarify the post-TGL swallowing function and determine whether it is primarily dependent on gravity. We retrospectively analyzed videofluorographic examinations (VFs) of patients who underwent TGL and free or pedicle flap reconstruction. We enrolled 20 patients (male, n=12; mean age, 61 years; age range, 43 to 89 years). All patients demonstrated constriction of the reconstructed pharynx to some degree, and no patient’s ability to swallow was dependent on gravity alone. VF showed excellent barium clearance in eight patients and poor clearance in 12. All patients with excellent clearance showed strong constriction of the posterior pharyngeal wall, whereas only 8.3% of the patients with poor clearance showed adequate constriction, which was significantly different (p=0.0007). Velopharyngeal closure and lip closure also contributed significantly to excellent clearance (p=0.041). The shape of the reconstructed pharynx (depressed, flat, protuberant) showed no statistically significant association with excellent clearance. Contrary to our previous understanding, the constriction of the remnant posterior pharyngeal wall played an important role in post-TGL swallowing, and gravity played a secondary role. Dynamic posterior pharyngeal wall movement might result from the increased power of the pharyngeal constrictor muscle and compensate for the immobility of the transferred flap. A well-functioning pharyngeal constrictor muscle and complete velopharyngeal and lip closures can contribute to excellent barium clearance in patients after TGL.

PMID:36067466 | DOI:10.1097/PRS.0000000000009639

J Clin Oncol. 2022 Sep 6:JCO2200365. doi: 10.1200/JCO.22.00365. Online ahead of print.

ABSTRACT

Clinical trials frequently include multiple end points that mature at different times. The initial report, typically based on the primary end point, may be published when key planned co-primary or secondary analyses are not yet available. Clinical Trial Updates provide an opportunity to disseminate additional results from studies, published in JCO or elsewhere, for which the primary end point has already been reported.Acquired genomic alterations (Acq-GAs), specifically RAS, BRAF, and EGFR-ectodomain mutations and ERBB2 and MET amplifications, are recognized as major mechanisms of resistance to later-line anti-EGFR-antibody therapy in metastatic colorectal cancer (mCRC). However, data regarding emergence of these Acq-GAs under the selective pressure of first-line anti-EGFR-chemotherapy are lacking. We performed next-generation sequencing (Guardant360) on circulating tumor DNA obtained from paired plasma samples (pretreatment and postprogression) from the CALGB/SWOG-80405 trial, which randomly assigned patients with mCRC between first-line chemotherapy with cetuximab (anti-EGFR-chemotherapy) or bevacizumab (anti-VEGF-chemotherapy). The primary objective was to determine the prevalence of Acq-GAs on anti-EGFR-chemotherapy and compare this to the prevalence with anti-VEGF-chemotherapy on trial and pooled estimates (N = 292) seen with later-line anti-EGFR-antibody therapy as reported in the literature. Among the 61 patients on anti-EGFR-chemotherapy, only four (6.6%) developed ≥ 1 Acq-GAs of interest compared with 10.1% (7) on anti-VEGF-chemotherapy (odds ratio, 0.62; 95% CI, 0.20 to 2.11) and 62.0% on anti-EGFR-antibody therapy in later lines (odds ratio, 0.09; 95% CI, 0.03 to 0.23). Acq-GAs, classically associated with anti-EGFR-antibody resistance in later lines (RAS, BRAF, and EGFR-ectodomain mutations; ERBB2 and MET amplifications), were rare with up-front use of anti-EGFR-chemotherapy indicating divergent resistance mechanisms. These findings have critical translational relevance to timing and value of circulating tumor DNA-guided anti-EGFR rechallenge in patients with mCRC, especially those treated with anti-EGFR therapy upfront.

PMID:36067452 | DOI:10.1200/JCO.22.00365

JCO Oncol Pract. 2022 Sep 6:OP2200110. doi: 10.1200/OP.22.00110. Online ahead of print.

ABSTRACT

PURPOSE: Limited English-proficient (LEP) patients with non-small-cell lung cancer (NSCLC) may receive less palliative care services and more likely to receive aggressive end-of-life (EoL) care. Goals of this retrospective cohort study are to compare access to community palliative home care (CPHC), do not resuscitate (DNR) form completion, place of death, and health resource utilization at EoL between English-proficient (EP) and LEP patients with NSCLC in Vancouver, Canada.

METHODS: All patients with advanced NSCLC referred in 2016 and received medical care were included. Patients were classified as LEP if seen with a medical interpreter. Descriptive statistics and univariate and multivariate analyses were used to compare the outcomes between the two groups.

RESULTS: One hundred eighty-six patients were referred, 66% EP. Rates of CPHC referral and DNR form completion were the same for both groups (84% and 92%, P = 1.00). LEP patients received earlier access to CPHC (15 v 10 weeks before death, P = .039). Rates of ER visits within 6 months and 30 days of death were 0.89 for EP patients and 0.7 for LEP patients, P = .374, and 0.1 for EP patients and 0.13 for LEP patients, P = .244. Hospitalization rates within 6 months and 30 days of death were 1.4 for EP patients and 1.59 for LEP patients, P = .640, and 0.67 for EP patients and 0.81 for LEP patients, P = .091. EP patients were more likely to have a home death (26% v 14%), whereas LEP patients died in acute care (23% v 14%) or a tertiary palliative care unit (24% v 19%). This was not statistically significant (P = .335). LEP patients had better median overall survival (8.5 v 5.4 months, P < .001), but when controlled by age, mutation, and EP status, only receipt of palliative-intent systemic therapy was statistically significant.

CONCLUSION: EP and LEP patients with NSCLC have similar referral rates to CPHC, DNR form completion, and EoL health resource utilization. The measured EoL variables did not demonstrate significant disparities between EP and LEP patients.

PMID:36067447 | DOI:10.1200/OP.22.00110

Health Aff (Millwood). 2022 Sep;41(9):1291-1298. doi: 10.1377/hlthaff.2021.01904.

ABSTRACT

Ambulatory surgical centers (ASCs) are increasingly being acquired by private equity firms, yet the implications for patients remain understudied. In this study we employed a quasi-experimental difference-in-differences design within an event study framework to assess changes in outcomes associated with the acquisition of ASCs by private equity entities. Using a two-way fixed effects model, we assessed the baseline probability of an unplanned hospital visit, total costs, and total encounters three years preacquisition compared with three years postacquisition in ASCs acquired by private equity versus those acquired by non-private equity entities. We identified ninety-one ASCs acquired by private equity and fifty-seven ASCs acquired by non-private equity entities during the period 2011-14. There was no statistically significant observed change in the probability of an unplanned hospital visit, total costs, or total encounters after acquisition by private equity relative to acquisition by non-private equity entities. When we compared private equity-acquired ASCs with matched ASCs that were never acquired, we also found no statistically significant relative change in the probability of an unplanned hospital visit, total costs, or total encounters. Regulators should ensure that data on private equity acquisitions are transparent and that data are available to track the long-term quality and financial implications of these acquisitions.

PMID:36067436 | DOI:10.1377/hlthaff.2021.01904

Health Aff (Millwood). 2022 Sep;41(9):1333-1341. doi: 10.1377/hlthaff.2022.00182.

ABSTRACT

Between 2008 and 2018, six states and Washington, D.C., began contracting with enrollment brokers to facilitate enrollment into Medicaid, joining the eighteen states that already had such contracts in place as of 2008. Using newly collected data covering all contracts between state Medicaid agencies and independent enrollment brokers during this period, we compared changes in Medicaid participation following the initiation of contracts with enrollment brokers with contemporaneous changes in Medicaid participation in states that never contracted with brokers. We found that contract initiation had no statistically significant effects on state-level Medicaid participation. We further found no evidence of other enrollment-related benefits, such as improved application processing times.

PMID:36067426 | DOI:10.1377/hlthaff.2022.00182

JMIR Form Res. 2022 Sep 2. doi: 10.2196/39109. Online ahead of print.

ABSTRACT

BACKGROUND: Vaccination remains one of the most effective ways to limit the spread of infectious diseases such as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus responsible for coronavirus disease-2019 (COVID-19. Unfortunately, vaccination hesitancy continues to be a threat to national and global health. Further research is necessary to determine the modifiable and non-modifiable factors contributing to COVID-19 vaccine hesitancy in under resourced, under-served, and at risk rural and urban communities.

OBJECTIVE: To identify, understand, and address modifiable barriers and factors contributing to COVID-19 vaccine hesitancy among vaccine eligible individuals with access to the vaccine in Alaska and Idaho.

METHODS: An electronic survey based on the World Health Organization (WHO) Strategic Advisory Group on Experts (SAGE) on Immunization survey tool and investigators’ previous work was created and distributed in June-July 2021. To be eligible to participate in the survey, individuals had to be ≥18 years of age and reside in Alaska or Idaho. Responses were grouped into four mutually exclusive cohorts for data analysis and reporting based on intentions to be vaccinated. Respondent characteristics and vaccine influences between cohorts were compared using chi-square tests and ANOVA. Descriptive statistics were also used.

RESULTS: There were data from 736 usable surveys with 40 respondents that did not intend to be vaccinated, 27 unsure of their intentions, 8 that intended to be fully vaccinated with no doses received, and 661 fully vaccinated or that intended to be with one dose received. There were significant difference in characteristics and influences between those that were COVID-19 vaccine hesitant and those who have been vaccinated. Concerns related to possible side effects, enough information on long-term side effects, and enough information that is specific to respondent’s health conditions were seen in those that did not intend to be fully vaccinated and unsure about vaccination. In all cohorts except those that did not intend to be fully vaccinated, more information about how well the vaccine works was a likely facilitator to vaccination.

CONCLUSIONS: These survey results from two rural states indicate that recognition of individual characteristics may influence vaccine choices. However, these individual characteristics represent only a starting point in delivering tailored messages that should come from trusted sources to address vaccination barriers.

PMID:36067411 | DOI:10.2196/39109

Menopause. 2022 Sep 6. doi: 10.1097/GME.0000000000002061. Online ahead of print.

ABSTRACT

OBJECTIVE: Previous studies provide little data on the role of race in acceptance and utilization of hormone therapy. Our primary objective was to examine differences in hormone therapy acceptance between self-reported racial groups, whereas our secondary objective was to assess patient comorbidities and reported symptom frequency at presentation in these cohorts in a menopause-focused care clinic.

METHODS: We conducted a retrospective medical record review of patients presenting to a menopause clinic at an urban university-affiliated academic medical center in the Midsouth between July 2018 and July 2021. Statistical analysis was performed with Student t tests and odds ratios and P values ≤ 0.05 were considered statistically significant. During the 3-year study period, 113 patients presented with menopausal symptoms and were included in the study.

RESULTS: The cohort’s self-reported racial composition was 51% Black (58 patients), and 42% White (47), and 7% unknown/declined to answer (8). Of the 42 patients who presented to the clinic with a primary complaint of vasomotor symptoms, 55% (23 patients) accepted lifestyle modification therapy, and 45% (19 patients) accepted hormone therapy. Of 34 patients who presented with a primary complaint of vaginal dryness, 85% (29 patients) accepted the recommendation of moisturizers or lubricants, whereas only 15% (5) accepted vaginal hormone therapy. Of patients with vasomotor symptoms, 10 (25%) were excluded from eligibility for systemic hormone therapy due to medical comorbidities. Thirty-seven individuals were eligible for systemic hormone therapy; 18 (49%) White patients accepted hormone therapy; however, only 9 (24%) Black patients accepted with similar clinical criteria (P = 0.01). Black patients were 24% less likely to accept hormones for menopausal symptom management. The odds ratio was 0.24 (95% confidence interval, 0.09-0.64).

CONCLUSIONS: Our pilot study suggests a racial disparity in acceptance of both systemic and local hormonal therapy among perimenopausal and postmenopausal patients. The presence of racial disparity in acceptance of these treatment modalities can inform clinicians about patient factors affecting treatment choice for menopausal symptoms and opportunities to explore racial differences in quality of care.

PMID:36067406 | DOI:10.1097/GME.0000000000002061

Menopause. 2022 Sep 6. doi: 10.1097/GME.0000000000002051. Online ahead of print.

ABSTRACT

IMPORTANCE: Perimenopausal and postmenopausal women commonly report sleep disruption and insomnia. Behavioral interventions may be safe alternatives for patients who are unwilling to begin pharmacological treatments because of adverse effects, contraindications, or personal preference.

OBJECTIVE: The primary objective is to assess the efficacy of behavioral interventions on sleep outcomes among perimenopausal and postmenopausal women, as measured using standardized scales and objective methods (polysomnography, actigraphy). The secondary objective is to evaluate the safety of these methods through occurrence of adverse events.

EVIDENCE REVIEW: Searches were performed within MEDLINE (OVID interface, 1946 onward), Embase (OVID interface, 1974 onward), Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, and Web of Science (Core collection) using a search strategy developed in consultation with a health sciences librarian. Title/abstract and full-text screenings were performed in duplicate, and relevant studies were selected based on inclusion and exclusion criteria set to identify randomized controlled trials evaluating the effects of behavioral interventions on sleep quality. Risk of bias assessments were done using the Cochrane Risk of Bias 2 tool, and the Grading of Recommendations Assessment, Development and Evaluation approach was used to assess the certainty of the body of evidence. Data were pooled in a meta-analysis using a random-effects model.

FINDINGS: Nineteen articles reporting results from 16 randomized controlled trials were included, representing a total of 2,108 perimenopausal and postmenopausal women. Overall, behavioral interventions showed a statistically significant effect on sleep outcomes (standardized mean difference [SMD], -0.62; 95% confidence interval [CI], -0.88 to -0.35; I2 = 93.4%). Subgroup analyses revealed that cognitive behavioral therapy (SMD, -0.40; 95% CI, -0.70 to -0.11; I2 = 72.7%), physical exercise (SMD, -0.57; 95% CI, -0.94 to -0.21; I2 = 94.0%), and mindfulness/relaxation (SMD, -1.28; 95% CI, -2.20 to -0.37; I2 = 96.0%) improved sleep, as measured using both subjective (eg, Pittsburg Sleep Quality Index) and objective measures. Low-intensity (SMD, -0.91; 95% CI, -1.59 to -0.24; I2 = 96.8) and moderate-intensity exercise (SMD, -0.21; 95% CI, -0.34 to -0.08; I2 = 0.0%) also improved sleep outcomes. No serious adverse events were reported. Overall risk of bias ranged from some concern to serious, and the certainty of the body of evidence was assessed to be of very low quality.

CONCLUSIONS AND RELEVANCE: This meta-analysis provides evidence that behavioral interventions, specifically, cognitive behavioral therapy, physical exercise, and mindfulness/relaxation, are effective treatments for improving sleep outcomes among perimenopausal and postmenopausal women.

PMID:36067398 | DOI:10.1097/GME.0000000000002051

Cannabis Cannabinoid Res. 2022 Sep 6. doi: 10.1089/can.2022.0189. Online ahead of print.

ABSTRACT

Aim: The primary aim was to determine the prevalence of marijuana use among patients hospitalized for gastroparesis. The secondary aim was to identify independent variables associated with marijuana use compared with nonmarijuana-related gastroparesis hospitalization. Methods: We use the nationwide inpatient sample database from January 2012 to December 2014. The patients included in this study were the ones with primary diagnosis of gastroparesis and marijuana use. The analysis was performed using the Statistical Package for the Social Sciences 27 (SPSS) and a multivariable regression was conducted to identify independent variables. Results: We found 50,170 patients with a primary diagnosis of gastroparesis. The prevalence of marijuana use among patients hospitalized for gastroparesis was 4.2%. Multivariate regression analysis was performed, adjusting for confounders. The variables found to increase the odds of cannabis use in gastroparesis populations independently were age interval of 18-35 and 36-50 years, male, Black and Asian, median household income 1-25th percentile, Medicaid insurance, no charge hospitalization, and smoking. Cannabis use was associated with lower odds of vomiting. Conclusion: Patients who used marijuana were younger and of African American, Asian, or Pacific Islander descent. They had Medicaid insurance and a lower median household income.

PMID:36067326 | DOI:10.1089/can.2022.0189

Proc Natl Acad Sci U S A. 2022 Sep 13;119(37):e2210639119. doi: 10.1073/pnas.2210639119. Epub 2022 Sep 6.

ABSTRACT

In Europe, differences among countries in the overall change in happiness since the early 1980s have been due chiefly to the generosity of welfare state programs-increasing happiness going with increasing generosity and declining happiness with declining generosity. This is the principal conclusion from a time-series study of 10 Northern, Western, and Southern European countries with the requisite data. In the present study, cross-section analysis of recent data gives a misleading impression that economic growth, social capital, and/or quality of the environment are driving happiness trends, but in the long-term, time-series data, these variables have no relation to happiness.

PMID:36067317 | DOI:10.1073/pnas.2210639119