Abstract available in the JACC Cardiovascular Interventions.

BACKGROUND: Approximately one-third of community dwelling elderly people (age ≥65 years) falls each year contributing to over 2 million elderly emergency department (ED) visits for falls annually. The cost of care for fatal falls by elderly patients in the US was $179 million in 2000, and was $19 billion for non-fatal falls. The risk of falling increases with various risk factors including advancing age. Despite the frequency and costs associated with elderly falls, it is not clear what evaluation elderly fallers receive in the ED, after the ED, and the outcomes of the care provided. OBJECTIVES: We sought to examine the ED and post-ED workup of elderly fallers, and to compare this evaluation to that recommended by published ED fall evaluation and treatment guidelines. We also examined the disposition of these patients and the rate of adverse events which occurred within 1 year of discharge. METHODS: This study was a retrospective chart review of elderly ED fall patients from one urban teaching hospital with >90,000 visits per year. Patients aged ≥65 years who had an ED visit in 2012 with fall related ICD-9 codes E880-886, E888 and who had been seen by a primary care physician (PCP) within our hospital network during the past 3 years were included. We excluded patients who were transferred to our hospital and subsequent visits related to the original fall. We randomly selected 350 eligible patients for chart review. We adapted our data collection instrument from published fall evaluation recommendations including the American Geriatric Society. Categorical data were presented as percentages and continuous data were recorded as mean with standard deviation (SD) if normally distributed or medians with inter-quartile ranges (IQR) if non-normally distributed. RESULTS: A random sample of 450 charts were taken, 100 were subsequently excluded for erroneous identification. The average age was 80 (SD±9) years; 124 (35%) were male, with an average Charlson comorbidity index of 7.6 (SD 2.9). In terms of history, 251/350 (72%) took 5 or more medications, 144/350 (41%) had their visual acuity checked in the past 12 months, and 34/350 (10%) had fallen two or more times in the past 3 months. In the physical exam, only 43/350 (12%) had orthostatics done. 168/350 (48%) patients had their extremity strength recorded, of these 16/168 (10%) had decreased muscle strength. Only 128/350 (37%) patients had their gait recorded, of which 108/128 (84%) were noted to have an abnormal gait. Basic chemistry laboratory tests and hematology were sent on 199/350 (57%) of patients in the ED. X-rays were taken of 275/350 (79%) patients, and CTs were taken of 184/350 (53%) patients in the ED. 277/350 (79%) patients were discharged to their place of preadmission residence from the ED, ED observation unit, or hospital while 70/350 (20%) were discharged to a skilled rehab facility, all after being admitted to the hospital. 196/350 (56%) patients returned to the ED for any reason within 1 year of discharge, averaging 2.4 ± 1.9 visits. 161/350 (46%) patients were hospitalized within 1 year after discharge, averaging 2 ± 1.4 hospital admissions. 23 (7%) of patients died within 1 year after discharge. CONCLUSION: The comprehensive evaluation of falls for well-established risk factors and causes appears to be poor in this academic medical center ED. While results may not be generalizable to other EDs, the results suggest that standardized evaluation and treatment guidelines are needed.

The need for higher skill levels in South Africa’s labour market warranted an investigation into why some learners from poor communities make the decision to leave high school at the end of Grade 9, whilst other learners continue to Grade 12 or tertiary education. This exploratory, longitudinal study investigated the Educational Decision Making (EDM) of 16 Grade 9, Coloured, male learners from poor neighbourhoods in Cape Town. This study identified the socio-economic factors that influenced participants’ EDM to consider leaving the school system at the end of Grade 9, or continue their education. The study applied Miles and Huberman’s (1994) approach to identify links between the socio-economic factors that influenced EDM, and to understand the learners’ educational context. These interactions were investigated using Bronfenbrenner’s Ecological Systems Framework, comprising 5 traversing and Huberman’s (1994) approach to identify links between the socio-economic factors that influenced EDM, and to understand the learners’ educational context. These interactions were investigated using Bronfenbrenner’s Ecological Systems Framework, comprising 5 traversing layers, namely, the micro-system, meso-system, exo-system, macro-system, and chronosystem (Watts, Cockcroft & Duncan, 2009). This qualitative study drew on semi-structured, one-on-one interviews with learners in their Grade 9 year in 2015, and makes use of followup telephonic interviews (2016) and enrolment records (2017) to verify the findings. All learners made the decision to continue to Grade 12 or tertiary education. Examples of negative influences on EDM included socio-economic challenges presented by South Africa’s transition to democracy (Chrono-system), which impacted on other systems, including inadequate school facilities (exo-system), a family history of school dropout (mesosystem), and financial instability (micro-system). Examples of positive influences on EDM included financial stability in the household (mesosystem), and the resilience and agency of learners (microsystem).

The objective of this study was to examine possible correlations between sleep duration and sleep quality on health outcomes in the Marshallese community members in Northwest Arkansas. Little research has been conducted on the association between sleep health and health outcomes in Native Hawaiian Pacific Islanders, and even less so in the Marshallese populations. Using cross sectional date from a cluster randomized controlled trial study (n=374), I will examine whether sleep duration and sleep quality are associated with hypertension, type 2 diabetes, body mass index, and overall self-reported health rating in the Marshallese. Systolic and diastolic blood pressure, HbA1c levels, and height and weight were all measured for hypertension, type II diabetes, and BMI, respectively. General health status was determined by self-reported measures from the National Health and Nutritional Examination survey-derived questions. Sleep duration was categorized as very short sleep (0-4 hours), short sleep (4-7 hours), normal sleep (7-9 hours), and long sleep (9 or more hours). Sleep quality was determined by answers to the question: “Over the last two weeks, how many days have you had trouble sleeping or staying asleep?” For the continuous dependent variables (BMI, blood pressure, and HbA1c), median and interquartile range values were examined. For non-continuous variable (general health outcomes), the Spearman Correlation Coefficient was examined to determine association. Statistically significant associations were found between sleep duration and diastolic blood pressure and HbA1c, and sleep quality and general health. These associations among the Marshallese provide foundation for further longitudinal and intervention research on health disparities in Marshallese residents of the United States.

Management of very low rectal cancer is one of the most challenging issues faced by colorectal surgeons. For tumors in the mid and upper rectum, procedures can be done to resect the cancer while maintaining continence, a major determinant of post-operative quality of life. In the low rectum, however, to optimize oncologic outcomes, many surgeons feel compelled to pursue abdominoperineal (APR) over low anterior resection (LAR), a sphincter-preserving procedure. It was hypothesized that after robust adjustment, procedure choice will not be associated with a difference in disease-free survival in the resection of tumors in the low rectum. To analyze this, the US Rectal Cancer Collaborative Database, a comprehensive, multi-center dataset obtained from six institutions between 2010 and 2016, was queried. Patients undergoing TME resection for Stage I-III very low rectal cancers (involvement) were selected for this study. Patients were categorized by procedure- LAR vs APR. Primary outcome was five-year disease-free survival. Secondary outcomes included overall survival, recurrence, length of stay, and complications. An adjusted analysis was performed to account for all known potential confounders. 431 patients with very low rectal cancer treated by either APR or LAR were identified. 154 (35.7%) underwent APR. The overall recurrence rate was 19.6%. Median follow-up time was 42.5 months. An analysis adjusted for age, gender, BMI, ASA class, and pathologic stage observed no difference in disease free survival between operative types (HR=0.90, 95% CI [0.53-1.52], p=0.70). Similarly, secondary outcomes demonstrated no significant difference between operation types, including length of stay (Beta: 0.04, Std. error = 0.25, p = 0.54), overall survival (HR=1.29, 95% CI [0.71-2.32], p=0.39), or complications (OR = 1.53, 95% CI [0.94 - 2.50], p=0.09). In this analysis, no significant difference in disease-free survival or overall survival was observed between patients undergoing APR or LAR for very low rectal cancer. This comprehensive study supports the treatment of very low rectal cancer, less than 5cm from the anorectal ring with no sphincter involvement, by either abdominal perineal or low anterior resection. Further studies may focus on patient-reported and quality of life outcomes which may influence decision-making.

A community-based interdisciplinary health professions education project, involving the Colleges of Medicine, Nursing and Public and Allied Health, was implemented at the undergraduate level at East Tennessee State University from 1990 to the present. The outcomes of this project and the extension of the project into graduate health profession programs are described. Committed leadership, effective communication, and genuine community involvement are identified as essential to the success of community-based, interdisciplinary health professions training programs.

Lung cancer is the deadliest cancer in women. In the last decade, the first measurable decline in disease-related mortality has occurred and in the last 5 years, the first decline in lung cancer incidence in women in the United States has been reported. Five-year survival rates are much higher in early-stage disease, making effective screening a priority. Data on screening with low-dose computed tomography are controversial; existing guidelines are not sex specific and recommend testing only for patients at high risk for the disease. Although cigarette smoking remains the predisposing factor that is most often associated with tumor development, the advent of molecularly targeted therapy and the growing evidence that susceptible targets are more prevalent in never-smoking women have brought more attention to this particular subpopulation. Studies of both surgery and systemic therapy suggest that not only never-smoking women but also women overall experience better outcomes than men. Identifying all of the factors contributing to these sex differences presents us with an opportunity to identify potentially a distinct tumor biology in women who would warrant a distinct personalized treatment approach.

Lung cancer is the deadliest cancer in women. In the last decade, the first measurable decline in disease-related mortality has occurred and in the last 5 years, the first decline in lung cancer incidence in women in the United States has been reported. Five-year survival rates are much higher in early-stage disease, making effective screening a priority. Data on screening with low-dose computed tomography are controversial; existing guidelines are not sex specific and recommend testing only for patients at high risk for the disease. Although cigarette smoking remains the predisposing factor that is most often associated with tumor development, the advent of molecularly targeted therapy and the growing evidence that susceptible targets are more prevalent in never-smoking women have brought more attention to this particular subpopulation. Studies of both surgery and systemic therapy suggest that not only never-smoking women but also women overall experience better outcomes than men. Identifying all of the factors contributing to these sex differences presents us with an opportunity to identify potentially a distinct tumor biology in women who would warrant a distinct personalized treatment approach.

Purpose: In the United States, motor-vehicle crashes are the leading cause of death for individuals 18–24 years of age. Multiple factors place young drivers at an increased risk including risky and aggressive driving behaviors. Aggressive driving has been shown to account for more than half of the driving fatalities in the United States. Driving anger is predictive of aggressive driving and adverse driving outcomes. Research outside the context of driving has demonstrated associations between multiple dimensions of forgiveness and anger, aggressive behaviors, and health outcomes. A very small body of research suggests a modest relationship between forgiveness and both driving anger and aggressive driving. The current study expands on previous research to examine the impact of multiple dimensions of forgiveness on adverse driving outcomes. Methods: Undergraduate students (N = 446) completed, self-report measures of forgiveness, driving anger, driving anger expression, aggressive driving behaviors, and aversive driving outcomes. Results: Bivariate correlations indicated a significant negative relationship between each dimension of forgiveness and driving anger, driving anger expression, and aggressive driving. Forgiveness (of others and of uncontrollable situations) was found to have a significant indirect only effect on traffic violations through the mediators of driving anger and aggressive driving. Discussion: Current findings support and expand on previous research examining the association of forgiveness with adverse driving outcomes. Forgiveness of others and forgiveness of uncontrollable situations, but not forgiveness of self, were shown to indirectly impact traffic violations/warnings, but not crashes, within the past five years through reduced driving-related anger, anger expression, and/or aggression. Implications, limitations, and future research are discussed.

Purpose of review Transgender individuals experience unique health disparities but are the subject of little focused health research. This manuscript reviews current literature on transgender medical and mental health outcomes and proposes research priorities to address knowledge gaps. Recent findings Published research in transgender healthcare consists primarily of case reports, retrospective and crosssectional studies, involving largely European settings. Challenges to US-based transgender health research include a diverse population where no single center has sufficient patient base to conduct clinical research with statistical rigor. Treatment regimens are heterogeneous and warrant study for best practices. Current research suggests increased mortality and depression in transgender individuals not receiving optimal care, and possibly a modest increase in cardiovascular risk related to hormone therapy. Current evidence does not support concerns for hormone-related malignancy risk. Summary The priorities for transgender medical outcomes research should be to determine health disparities and comorbid health conditions over the life span, along with the effects of mental health, medical, and surgical interventions on morbidity and mortality. Specific outcomes of interest based on frequency in the literature, potential severity of outcome, and patient-centered interest, include affective disorders, cardiovascular disease, malignancies, fertility, and time dose-related responses of specific interventions.