Nationwide Patterns Research Articles

Nationwide Patterns of Pathologic Fractures Among Patients Hospitalized With Bone Metastases.

Pathologic fractures from bone metastases can significantly affect quality-of-life, although it is unclear which patients may be at high risk of this outcome. We aim to determine risk factors for pathologic fracture among patients admitted with bone metastases and to evaluate the association of pathologic fracture with clinical and economic outcomes. The Healthcare Cost and Utilization Project National Inpatient Sample was queried for all patients hospitalized with bone metastases in 2016. Baseline differences between patients with and without pathologic fractures were assessed by χ and analysis of variance testing. Multivariable logistic regression was used to identify factors associated with fractures. In 2016, 272,275 hospital admissions were associated with a diagnosis of bone metastases, of which 11,960 (4.4%) had a primary diagnosis of pathologic fracture. Patients with pathologic fractures had a longer length-of-hospital-stay (mean 7.5 vs. 6.4 d; P<0.001) and higher cost-of-hospital-stay (mean $23,611 vs. $15,942; P<0.001) compared to patients without pathologic fractures. Primary cancers associated with increased likelihood of pathologic fracture included liver and intrahepatic bile duct (odds ratio [OR] 2.34; 95% confidence interval [CI], 1.65-3.32), multiple myeloma (OR 1.94; 95% CI, 1.31-2.86), and kidney and renal pelvis cancer (OR 1.89; 95% CI, 1.50-2.37). Nearly 5% of hospitalizations with bone metastases presented with a concomitant pathologic fracture, which was associated with longer inpatient stay and higher cost. Patients with hepatobiliary, renal cell carcinoma, or multiple myeloma, had a higher likelihood of pathologic fracture. These groups may benefit from increased outpatient monitoring, prophylactic stabilization, or early irradiation.

Nationwide patterns of hemorrhagic stroke among patients hospitalized with brain metastases: influence of primary cancer diagnosis and anticoagulation

Brain metastases can contribute to a decreased quality of life for patients with cancer, often leading to malaise, neurologic dysfunction, or death. Intracerebral hemorrhage (ICH) is an especially feared complication in patients with brain metastases given the potential for significant morbidity and mortality. We aim to characterize patients with cancer and brain metastases admitted to hospitals nationwide and identify factors associated with ICH. The 2016 Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP-NIS) was queried for all patients with cancer hospitalized with a diagnosis of brain metastases. Admissions with a primary or secondary diagnosis of ICH were further identified. Baseline differences in demographic, clinical, socioeconomic, and hospital-related characteristics between patients with and without ICH were assessed by chi-square, Mann–Whitney U, and ANOVA testing. Multivariable logistic regression was used to identify factors associated with ICH. Weighted frequencies were used to create national estimates for all data analysis. In 2016, a total 145,225 hospitalizations were associated with brain metastases, of which 4,145 (2.85%) had a concurrent diagnosis of ICH. Patients with ICH were more likely to have a longer length of stay (median 5 days vs 4 days, p < 0.001) and a higher cost of stay (median $14,241.14 vs $10,472.54, p < 0.001). ICH was found to be positively associated with having a diagnosis of melanoma (odds ratio [OR] 5.01; 95% Confidence Interval [CI] 3.50–7.61) and kidney cancer (OR 2.50; 95% CI 1.69–3.72). Patients on long-term anticoagulation had a higher risk of ICH (OR 1.49; CI 1.15–1.91). Approximately 3% of patients hospitalized with brain metastases also had a diagnosis of ICH, which was significantly associated with longer length of stay and cost. Patients with melanoma, kidney cancer, and on long-term anticoagulation had a higher risk of ICH. Physicians should consider the risks of anticoagulation carefully for patients with brain metastases, especially those with melanoma and kidney cancer.

Nationwide patterns in industry payments to academic vascular surgeons

ObjectiveFinancial relationships between vascular surgeons and industry are essential to the development and adoption of innovative technology. However, these relationships may establish competing interests. Our objective was to describe publicly available financial transactions between industry and academic vascular surgeons. MethodsAcademic vascular surgeons were identified and characterized on the basis of publicly available data correlated with Accreditation Council for Graduate Medical Education and Association of American Medical Colleges data to identify academic practice settings. Vascular surgeons were linked to Open Payments data for 2017 as reported by the Centers for Medicare & Medicaid Services. Univariate and nonparametric tests were used for analysis. ResultsOf 1158 academic vascular surgeons identified, 997 (86%) received industry payments totaling $8,548,034. Overall, the median of total payments received was $814 (interquartile range [IQR], $124-$2863). The top paid decile of vascular surgeons received $29,645 (IQR, $16,128-$61,701). Payments to the top decile accounted for 81% of all payments. Payments did not vary by academic rank but did vary by sex, with male vascular surgeons (n = 954) receiving $889 (IQR, $146-$3217) vs female vascular surgeons (n = 204) receiving $467 (IQR, $87-$1533; P = .002). By leadership role, division chiefs received the highest median payment amount ($1571; IQR, $368-$11,281) compared with department chairs ($424; IQR, $56-$2698) and vascular surgeons without leadership role ($769; IQR, $117-$2592; P = .002). Differences in payments were also seen on the basis of U.S. census region: Northeast, $571 (IQR, $90-2462); Midwest, $590 (IQR, $75-$2364); South, $1085 (IQR, $241-$3405); and West, $1044 (IQR, $161-$4887; P = .001). The most common categories of payments were food and beverage (paid to 85% of all vascular surgeons), travel and lodging (35%), and consulting fees (13%). Among the top decile of vascular surgeons, median payments exceeded $10,000 for three categories: consulting fees, compensation, and honoraria. Payments were made by 178 distinct entities with median total payments of $286 (IQR, $70-$6285). The three top entities paid a total of $5,004,061, which accounted for 59% of all payments. Payments from at least one of the top three entities reached 76% of vascular surgeons. ConclusionsMost academic vascular surgeons receive publicly reported industry payments that are paid by a limited number of entities, typically for food and beverage or travel and lodging. The top 10% of vascular surgeons received higher median payment amounts, totaling 81% of all industry payments. Vascular surgeons should be aware of publicly reported payment information and the potential for conflicts of interest.

P0823CHARACTERISATION OF HISTOLOGY PROVEN GLOMERULAR DISEASES IN THE MALTESE POPULATION: A NATIONAL CROSS-SECTIONAL SURVEY

Abstract Background and Aims The incidence and characterisation of glomerular diseases in Malta has not been investigated. This survey aims at determining the nationwide patterns, incidence and spectrum of biopsy-proven glomerular diseases. Method This is a retrospective analysis of all native kidney biopsy specimens performed in the adult population in Malta between January 2014 and December 2018. Demographic data and clinical variables were extracted from histopathology reports. Pathological diagnosis was based on findings obtained through light microscopy, immunofluorescence and electron microscopy. Results A total of 281 sufficiently sampled and conclusive native kidney biopsies were performed in Malta. The median age at biopsy was 52.9 years (interquartile range: 25), 58.7% were males and 93.1% were Maltese patients. The most common finding on biopsy was diabetic nephropathy (13.5%, n=38). Chronic kidney disease which was progressing faster than expected was the most common reason for performing a biopsy in these cases (65.8%, n=25/38). Ischaemic glomerulopathy was seen in 13.2% of cases (n=37). Podocytopathies accounted for 19.2% (n=54) of biopsies. Focal segmental glomerulosclerosis (FSGS) was seen in 12.8% (n=36); 58.3% (n=21/36) of which considered secondary to other conditions. Minimal change disease (MCD) accounted for 5.7% (n=16), nephrotic syndrome being the most common indication for biopsy (87.5%, n=14/16). Membranous nephropathy (MN) was identified in 11.0% of biopsies (n=31). Anti-Phospholipase A2 antibody status was available for 17 of these patients, 58.8% being positive (n=10/17). Immunoglobulin A nephropathy accounted for 11.7% (n=33). An active urinary sediment was the main indication for biopsy in 78.8% of these cases (n=26/33). Thin basement membrane was present in 2.1% (n=6). Lupus nephritis (LN) was present in 5.7% (n=16) of biopsies; class III LN in 50% (n=8/16), class IV LN in 37.5% (n=6/16); features of class V lupus were present in 31.3% (n=5/16). Only one biopsy showed isolated class V LN. Systemic involvement was present in the vast majority of patients with LN (81.3%, n=13/16). Pauci-immune glomerulonephritis was identified in 5.7% (n=16) of biopsies. Microscopic polyangiitis was the commonest type of pauci-immune ANCA-positive vasculitis (75.0%, n=12/16). Anti-glomerular basement membrane (GBM) disease accounted for only 1.1% (n=3). All patients with anti-GBM disease and 37.5% (n=6/16) of ANCA-positive vasculitis developed a rapidly progressive course requiring dialysis. Interstitial nephritis accounted for 5.7% (n=16) of biopsies; 31.2% (n=5/16) attributed to drugs. Haematological disease related glomerulonephritis accounted for 2.1% (n=6), infection related glomerulonephritis 1.1% (n=3), fibrillary glomerulonephritis 1.4% (n=4), membranoproliferative glomerulonephritis 0.7% (n=2) and other pathologies 6.4% (n=18). Conclusion This is the first nationwide study investigating the histopathological patterns and incidence of biopsy-proven glomerular diseases in Malta. The most common biopsy-proven glomerular disease is diabetic nephropathy, followed by focal segmental glomerulosclerosis. and ischemic glomerulopathy.

Prescription of antibiotics after tooth extraction in adults: a nationwide study in Korea.

ObjectivesThis study aimed to understand the nationwide patterns of antibiotic prescription after tooth extraction in adult patients.Materials and MethodsThis study analyzed dental records from the National Health Insurance Service–National Sample Cohort (NHIS–NSC) database on 503,725 tooth extractions performed in adults (≥19 years) during 2011–2015. Patient sex, age, household income, systemic disease (diabetes mellitus and hypertension), type of dental institution, region of dental institution, year of prescription, and type of tooth extraction procedure were considered. The antibiotic prescription rate and broad-spectrum antibiotic prescription frequency were analyzed using chi-squared tests. Factors affecting the prescription of broad-spectrum antibiotics were evaluated using multivariate logistic regression analysis.ResultsThe rate of antibiotic prescription after tooth extraction was 81.85%. Penicillin was most commonly prescribed (45.25%), followed by penicillin with beta-lactamase inhibitors (18.76%), metronidazole (12.29%), and second- to fourth-generation cephalosporins (11.52%). The proportion of broad-spectrum antibiotics used among all prescribed antibiotics was 45.88%.ConclusionThe findings of this study demonstrate that the rate of antibiotic prescription after tooth extraction is higher in Korea than in other countries. Furthermore, broad-spectrum antibiotics are used more frequently, which may indicate unnecessary drug prescription, an important contributor to antibiotic resistance.

Re: Nationwide Patterns of Care for Stage II Nonseminomatous Germ Cell Tumor of the Testicle.

Re: Nationwide Patterns of Care for Stage II Nonseminomatous Germ Cell Tumor of the Testicle.

Survival After Definitive Chemoradiotherapy With Concurrent Cisplatin or Carboplatin for Head and Neck Cancer.

For definitive chemoradiotherapy (chemoRT) of head and neck squamous cell carcinoma (HNSCC), cisplatin is the preferred concurrent agent, with superiority over cetuximab for HPV-associated oropharyngeal squamous carcinoma recently shown in 2 randomized trials (RTOG 1016 and De-ESCALaTE). Patients who are not candidates for cisplatin may be treated with carboplatin instead, but its comparative efficacy is unclear. We analyzed nationwide patterns of care and cancer-specific outcomes after cisplatin- versus carboplatin-based chemoRT. Patients with locoregionally advanced (stages III-IVB according to the 6th and 7th editions of the AJCC Cancer Staging Manual) squamous cell carcinoma of the oropharynx, larynx, or hypopharynx who received definitive radiotherapy (RT) were identified in the linked SEER-Medicare database. The concurrent chemotherapy regimen was determined through corresponding Medicare claims. Death caused by HNSCC (cancer-specific mortality [CSM]) was analyzed with competing risks. Propensity score analysis and multivariable Fine-Gray regression were used to adjust for baseline differences, including age and comorbidity. We identified 807 patients who received cisplatin-based chemoRT and 342 who received carboplatin-based chemoRT. Most carboplatin recipients (68%) had combination chemotherapy, predominantly with paclitaxel. Carboplatin- and cisplatin-based chemoRT had similar incidences of death attributable to HNSCC (3-year CSM, 29% vs 26%; P=.19), which persisted in propensity score-matched analysis. In addition, no significant difference in overall survival was seen in the matched cohorts. ChemoRT with either cisplatin or carboplatin was superior to RT alone and RT with concurrent cetuximab. In the multivariable model, the adjusted hazard ratio of CSM for carboplatin relative to cisplatin was 1.01 (95% CI, 0.79-1.28; P=.94). Definitive carboplatin-based chemoRT was equivalent to cisplatin-based therapy and superior to RT alone and RT with concurrent cetuximab. In light of recent results of the RTOG 1016 and De-ESCALaTE trials, our findings suggest that carboplatin-based regimens warrant prospective investigation as an alternative to cisplatin for patients who are not cisplatin candidates.

Nationwide Patterns of Pathologic Fractures Among Patients Hospitalized with Bone Metastases

Bone metastases can significantly affect quality-of-life, especially if they lead to pathologic fractures. However, it is unclear which patients are more likely to develop pathologic fractures when they have bone metastases. We aim to determine risk factors for pathologic fracture among those who are admitted with bone metastases and to evaluate the association of pathologic fracture with clinical and economic outcomes. The Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP-NIS) was queried for all patients hospitalized with bone metastases and pathologic fractures in 2016. Baseline differences in demographic, clinical, socioeconomic, and hospital-related characteristics between patients with and without fractures were assessed by chi-square and ANOVA testing. Multivariable logistic regression was used to identify factors associated with fractures. Weighted frequencies were used to create national estimates for all data analysis. In 2016, 272,275 hospital admissions were associated with a diagnosis of bone metastases, of which 11.1% were found to have a pathologic fracture. Patients with fractures have a longer length-of-hospital-stay (mean 8.2 vs 6.3 days, p<0.001), and higher cost-of-hospital-stay (mean $23,526 vs $15,377, p<0.001) compared to patients without pathologic fractures. On multivariable analysis, primary cancers associated with increased risk of pathologic facture included multiple myeloma (odds ratio [OR] 2.91; 95% CI = 2.40-3.53), liver & intrahepatic bile duct (OR 1.72; 95% CI = 1.37-2.16), and kidney and renal pelvis cancer (OR 1.39; 95% CI = 1.21-1.60). Comorbidities significantly associated with fracture included osteoporosis (OR 1.68; 95% CI = 1.44-1.96), paralysis (OR 1.35; 95% CI = 1.18-1.55), and drug (OR 1.35; 95% CI = 1.09-1.66) and alcohol abuse (OR 1.33; 95% CI = 1.07-1.65). Approximately 11% of hospitalized patients with bone metastases presented with a concomitant pathologic fracture, which was associated with longer inpatient stay and higher cost. Multiple myeloma and osteoporosis were associated with higher risk of pathologic fracture. These groups may benefit from increased outpatient monitoring, prophylactic stabilization, or early irradiation.

Nationwide Patterns in Publicly Reported Industry Payments to Academic Vascular Surgeons

Nationwide Patterns in Publicly Reported Industry Payments to Academic Vascular Surgeons

Nationwide Patterns of Care for Stage II Nonseminomatous Germ Cell Tumor of the Testicle

BackgroundManagement strategies for advanced testicular cancer published from a few, high-volume clinical centers may not be generalizable. ObjectiveTo discern treatment patterns for stage II nonseminomatous germ cell tumor (NSGCT) in a nationwide cancer registry. Design, setting, and participantsThe National Cancer Database was queried for patients with a stage II NSGCT from 2004 to 2014. Patients were stratified by clinical nodal status: cN1/stage IIA, cN2/stage IIB, and cN3/stage IIIC. Outcomes measurements and statistical analysisLogistic regression was performed to determine factors independently associated with primary retroperitoneal lymph node dissection (RPLND), primary chemotherapy, and postchemotherapy RPLND (PC-RPLND). Results and limitationsA total of 2203 patients (stages IIA, n=1060; IIB, n=869; and IIC, n=274) met the inclusion criteria. Overall, 83% of patients underwent primary chemotherapy, while 17% underwent primary RPLND. Stratified by stage, use of primary chemotherapy was 78%, 88%, and 86% for stages IIA, IIB, and IIC, respectively. Overall, 24% of patients underwent PC-RPLND. Factors independently associated with a lower likelihood of undergoing primary RPLND were a more recent diagnosis and a higher clinical nodal stage. Conversely, patients treated at high-volume facilities were more likely to receive primary RPLND. Factors associated with a higher likelihood of undergoing PC-RPLND included a higher clinical nodal stage, treatment at a high-volume center, and a greater distance of patient travel. Associations based on serum tumor markers could not be assessed. ConclusionsFor clinical stage II NSGCT, nationwide utilization of primary chemotherapy is increasing compared with RPLND and is the preferred therapy for more advanced nodal disease. Primary RPLND may be underutilized in stage IIA disease. Utilization of PC-RPLND is driven by nodal stage as well as accessibility of a high-volume center. Patient summaryThe use of primary retroperitoneal lymph node dissection (RPLND) in early nodal disease is declining, while upfront chemotherapy is increasingly utilized. Primary RPLND may identify patients who are actually pN0 and would not benefit from systemic chemotherapy. Primary RPLND and postchemotherapy RPLND are performed more frequently at centers of excellence.

P50 - Nationwide Patterns in Hospital Admissions for Bone Metastases and Associated Pathologic Fractures

P50 - Nationwide Patterns in Hospital Admissions for Bone Metastases and Associated Pathologic Fractures

Evaluating Nationwide Practice Patterns in Chemoradiotherapeutic Regimens and Relative Efficacy of Chemoradiation Versus Adjuvant Radiation for Grade III Gliomas

For newly diagnosed Grade III gliomas including anaplastic oligodendrogliomas (AO), anaplastic astrocytomas (AA) and anaplastic oligoastrocytomas (AOA), combined chemoradiotherapy (CRT) remains the current standard of care. Two landmark trials established multiagent (MA) chemoradiotherapy using PCV as first-line for 1p/19q-codeleted tumors. However, single-agent (SA) CRT using temozolomide is an alternative off-label option. Recently, interim analysis of CATNON confirmed that temozolomide-based SA-CRT offers significant survival benefit for 1p/19q-noncodeleted tumors. Here, we evaluated nationwide patterns in receipt of CRT and relative treatment efficacies for Grade III gliomas using the National Cancer Database (NCDB). Patients with a first primary diagnosis of AO, AA or mixed glioma treated from 2006-2014 were identified from the NCDB. WHO Grade III glioma patients were identified whose initial treatment courses involved surgery with or without adjuvant RT (55-63 Gy in 25-34 fractions) or CRT. Factors examined included facility type, location, age, sex, race, Charlson-Deyo score, median income, insurance and extent of resection (EoR). Overall survival was assessed by Kaplan-Meier and Cox proportional hazards modeling. Potential predictors of MA- vs SA-CRT were examined using multivariate logistic regression. Adjusted survival comparison was performed using propensity score matching. From a total of 21,877 AO, AA and mixed gliomas, 4,553 WHO Grade III glioma patients were identified that met inclusion criteria. Median age was 47. Most patients (72.5%) received combined chemoradiotherapy, while a minority received only adjuvant RT (8.1%). At a median follow-up of 4.6 years, median survival was 88.3, 59.1, and 32.5 months for patients treated with chemoradiation, adjuvant RT or surgery alone, respectively (p<0.001), which remained significant on 1- and 3-month landmark analyses. On multivariate analysis, factors associated with improved survival included EoR, adjuvant RT and receipt of chemotherapy along with AO or mixed glioma histology, younger age, non-Medicare status, lower Charlson-Deyo score and higher median income. Among 3200 patients who received chemoradiation using known number of chemotherapeutic agents, 3,088 (96.5%) received SA chemotherapy while only 112 (3.5%) received MA chemotherapy. Only EoR was associated with receipt of multi-agent chemotherapy (OR: 3.22 for STR vs. biopsy). Propensity score matched analysis detected no significant median survival difference between patients receiving SA vs. MA CRT (44.0 months vs. 53.6 months, p=0.36). Independent of WHO Grade III histology, chemoradiation was associated with improved survival. Interestingly, despite only recent randomized data confirming its efficacy, SA-CRT was much more frequently offered than MA-CRT nationwide. Further study is needed regarding relative efficacy, particularly for 1p/19q-codeleted tumors.

Twelve-year trend in the use of zolpidem and physicians' non-compliance with recommended duration: a Korean national health insurance database study.

Abuse of zolpidem has sporadically been reported and little is known regarding nationwide patterns of zolpidem use in Korea. This study investigates the extent of zolpidem usage exceeding the recommended duration and the predictors. We conducted a drug utilization study using the national sample cohort database of the Korea National Health Insurance Corporation between 2002 and 2013. The study subjects were patients treated with zolpidem in the outpatient setting. An episode was defined as a period of continuous zolpidem therapy. The provider-based episode allowed for a gap of up to 3days between two consecutive prescriptions from the same institution. The person-based episode allowed for a gap of up to 3days, regardless of institution. We calculated the proportion of zolpidem use for periods over 30days and conducted logistic regression analyses to investigate the relevant predictors. An adjusted odds ratio (aOR) with a 95% confidence interval (CI) was estimated for each predictor. The usage of zolpidem is dramatically increased by approximately 18 times since zolpidem was authorized in the market (1181 in 2002 vs. 21,399 in 2013). The treatment duration in 8.3% of episodes exceeded 30days out of 75,087 zolpidem users. The odds of zolpidem prescription exceeding 30days were highest in patients aged 65years and older (aOR = 2.13, 95% CI 1.78-2.53) and at tertiary hospitals (aOR = 2.14, 95% CI 1.68-2.72). Women were more likely than men to be treated with zolpidem for over 30days. We found dramatic increase of zolpidem use from 2002 to 2013. In 8.3% of the prescribed episodes of zolpidem, the recommended duration was exceeded. Efforts are required to reduce prescriptions that are inconsistent with the recommended guidelines for older patients, women, and in tertiary hospitals.

Frequency of Opioid Dispensing After Vaginal Delivery.

To describe nationwide patterns in outpatient opioid dispensing after vaginal delivery. Using the Truven Health Analytics MarketScan database, we performed a large, nationwide retrospective cohort study of commercially insured beneficiaries who underwent vaginal delivery between 2003 and 2015 and who were opioid-naive for 12 weeks before the delivery admission. We assessed the proportion of women dispensed an oral opioid within 1 week of discharge, the associated median oral morphine milligram equivalent dose dispensed, and the frequency of opioid refills during the 6 weeks after discharge. We evaluated predictors of opioid dispensing using multivariable logistic regression. Among 1,345,244 women undergoing vaginal delivery, 28.5% were dispensed an opioid within 1 week of discharge. The most commonly dispensed opioids were hydrocodone (44.7%), oxycodone (34.6%), and codeine (13.1%). The odds of filling an opioid were higher among those using benzodiazepines (adjusted odds ratio [OR] 1.87, 95% CI 1.73-2.02) and antidepressants (adjusted OR 1.63, 95% CI 1.59-1.66), smokers (adjusted OR 1.44, 95% CI 1.38-1.51), and among those undergoing tubal ligation (adjusted OR 3.77, 95% CI 3.67-3.87), operative vaginal delivery (adjusted OR 1.52, 95% CI 1.49-1.54), and higher order perineal laceration (adjusted OR 2.15, 95% CI 2.11-2.18). The median (interquartile range, 10th-90th percentile) dose of opioids dispensed was 150 (113-225, 80-345) morphine milligram equivalents, equivalent to 20 tablets (interquartile range 15-30, 10th-90th percentile 11-46) of 5 mg oxycodone. Six weeks after discharge, 8.5% of women filled one or more additional opioid prescriptions. Opioid dispensing after vaginal delivery is common and often occurs at high doses. Given the frequency of vaginal delivery, this may represent an important source of overprescription of opioids in the United States.

Substance Abuse Among Medical Students – A Survey in a Medical College in Nepal

Introduction: Substance use among medical students could impact on the conduct, safety and efficiency of future doctors. Despite serious medico legal, ethical and political ramifications, there is paucity of published article on the subject, especially from Nepal.&#x0D; Objective: We aimed to explore the patterns of substance abuse among a sample of Medical students from Nepalgunj Medical College.&#x0D; Materials and Methods: A cross-sectional survey of medical students from Nepalgunj Medical College was done using a brief questionnaire schedule to identify current and lifetime use of tobacco, alcohol, cannabis and abuse of other drugs. An operational definition of substance abuse was made, 28 % of students fell within that criterion.&#x0D; Results: Male substance abusers 81% exceeded female abusers 19%. Substances most commonly abused were alcohol 60%, minor tranquilizers 48%, and tobacco 35%, and only 11% abused cannabis. While most students were multidrug users, there was a low frequency of daily drug use. A general lifetime (occasional use) prevalence of substance use of 56% was found. Drugs consumed on a daily basis were alcohol 2% and tobacco 6%. The prevalence of drug use was highest among the fourth and final year students.&#x0D; Conclusion: The majority of students were occasional abusers; there was no evidence of physical dependence. This study provides a snapshot of the problem of substance use among medical students of Nepal. Further research is needed to study nationwide patterns of substance use among medical students, and to identify important determinants and reinforce preventive measures. Strategies need to be developed for supporting students with a substance use problem.

Abstract WP319: Continued Nationwide Decline in Stroke Related In-hospital Mortality in United States

Background and Purpose: Previously a downward trend in stroke related in-hospital mortality was noted from 1996 to 2006 reflecting advancements in acute stroke care. Given ongoing improvement in acute stroke care models and therapies, our study assessed nationwide patterns in in-hospital mortality related to acute stroke for next decade. Methods: Patients with acute stroke were identified from the nationwide in-patient sample database for the years 2007 to 2014 using International Classification of Diseases, Ninth Revision procedure codes. Time trends in the proportion of stroke hospitalizations that resulted in death were assessed. Results: Between 2007 and 2014, overall stroke hospitalizations increased from 1017 414 in 2007 to 2008 to 1114 960 in 2013 to 2014, whereas percentage stroke hospitalizations that resulted in death decreased from 8.98% in 2007-2008 to 7.34% in 2013-2014 (P&lt;0.0001). Unadjusted Odds of mortality decreased regardless of stroke type: ischemic stroke (IS) (OR 0.798, 95% CI 0.762 to 0.835), subarachnoid hemorrhage (SAH) (OR 0.885, 95% CI 0.810 to 0.968), and intracerebral hemorrhage (ICH) (OR 0.865, 95% CI 0.824 to 0.908). In multivariate analysis these odds remained significant (IS: OR 0.813, 95% CI 0.770 to 0.859), SAH: OR 0.680, 95% CI 0.611 to 0.757, ICH: OR 0.707, 95% CI 0.664to 0.754) after adjusting with age, gender, race, medical comorbidities, in-hospital complications, insurance status and APRDRG Severity scale). Conclusions: There is continued decline in Nationwide In-Hospital Mortality among hospitalized acute stroke patients. This reflects ongoing improvement in stroke care models and advancement in therapies.

A Century of Demographic Ageing in Arctic Canada (1950–2050)

The aim of this study is to identify the major characteristics of demographic ageing in the Canadian Arctic - Yukon, Nunavut, and Northwest Territories (NWT) - in the period 1950 to 2050. We measure ageing first conventionally, based on "chronological" age, as a point of comparison for results obtained applying new measures of ageing based on "prospective" age. The latter takes into account upward changes in life expectancy and longevity over recent decades. The findings are discussed for the territories with the oldest and youngest average ages, the regions ageing the fastest and slowest, for both sexes and (to some extent) across ethnic differences. The paper considers whether the territories of Arctic Canada are converging or diverging in their ageing pathways and the links between the northern and nationwide patterns were traced. We find that NWT and Nunavut are the youngest and are diverging from nationwide ageing dynamics while Yukon is no longer different from the rest of Canada. The results of this study can help devise policies for coping with the population ageing in the Arctic part of Canada.

(P103) Preoperative Versus Postoperative Radiotherapy in Localized Soft Tissue Sarcoma: Nationwide Patterns of Care and Trends in Utilization

(P103) Preoperative Versus Postoperative Radiotherapy in Localized Soft Tissue Sarcoma: Nationwide Patterns of Care and Trends in Utilization

Preoperative vs postoperative radiation therapy in localized soft tissue sarcoma: Nationwide patterns of care and trends in utilization

PurposeThe timing of perioperative radiation therapy (RT) in the treatment of soft tissue sarcoma (STS) varies among institutions. This study examines patterns of care, trends in utilization, and survival with preoperative versus postoperative RT for primary STS. Methods and materialsUsing the National Cancer Data Base, we identified patients with stage I-III STS who underwent definitive surgery with either preoperative or postoperative RT between 2004 and 2012. Univariate, bivariate, and multivariate analyses were performed to identify factors predicting receipt of preoperative versus postoperative RT. Overall survival (OS) was analyzed using the log-rank test, Kaplan-Meier method, and Cox proportional-hazards model. ResultsThis study included 9604 patients: 7246 (75.4%) received postoperative and 2358 (24.6%)-preoperative RT. Chemotherapy was administered to 27.0% patients in the preoperative and 13.0% in the postoperative cohort. Use of preoperative RT increased over time, from 16.8% in 2004 to 29.7% in 2012. Multivariate analysis revealed that preoperative RT utilization increased with the following factors: higher educational attainment, treatment at an academic facility, further distance from facility (>60 miles), receipt of chemotherapy, tumor originating in lower extremities, >10 cm tumors, and myxoid liposarcoma. OS analysis revealed no difference between the 2 treatment cohorts. ConclusionsPostoperative RT is used much more commonly than preoperative RT in localized STS; however, preoperative RT use has increased in recent years. Multiple demographic and clinicopathologic factors were predictive of preoperative RT use. Consistent with randomized phase 3 data, there was no difference in OS.

Impact of urologists' ownership of radiation equipment in the treatment of prostate cancer.

Physician practices that offer ancillary medical services may refer their patients for such services, a process known as self-referral. We wanted to evaluate how utilization and cost of care differ for men diagnosed with prostate cancer in a self-referral practice (SRP) compared to a traditional urologic practice. A total of 17 982 men aged 66 years and older diagnosed with localized prostate cancer from 2006 to 2009 were identified from the Texas Cancer Registry. A total of 13 SRPs in the state of Texas were evaluated. We used multilevel logistic regression models that evaluated the odds of receiving a specific type of treatment. Men diagnosed in SRPs were more likely to receive upfront treatment (vs watchful waiting/active surveillance) than men diagnosed by traditional practices (92.7% vs 89%; adjusted odds ratio (AOR) 1.61, 95% confidence interval (CI) 1.30-2.00; P<0.001) and were more likely to be treated with external beam radiation (47.4% vs 34.1%; AOR 1.59, 95% CI 1.37-1.84; P<0.001). This persisted for both favorable and unfavorable risk cancer. Median annual prostate cancer care cost was $2460 (95% CI $1663-$3368) higher for men diagnosed by SRPs. Limitations include data limited to men aged 65 years or older and geographic concentration of SRPs in Texas may not depict nationwide patterns. Older men diagnosed with prostate cancer in SRPs are more likely to undergo upfront treatment and to receive radiation treatment. This may increase appropriate treatment of unfavorable disease but contribute to overtreatment of favorable disease.