This report describes and contextualizes the high prevalence of mental health conditions (MHC) among Minnesota 2019 EVALI patients by examining the prevalence of MHC and associations between MHC and e-cigarette or vaping product (EVP) use in Minnesota population surveys. Investigators reviewed medical records for 140 EVALI patients to determine history of MHC. History of MHC and EVP use in the general population was estimated using self-reported measures and screening tools from two population-based surveys, the 2019 Minnesota Student Survey (MSS) and the 2018 Minnesota Behavioral Risk Factor Surveillance Survey (MN-BRFSS). Some 64.3% of EVALI patients had an MHC. In both Minnesota population surveys, MHCs were common among people who used EVP. The odds of MHC among youth aged <18 were higher among those who reported current EVP use compared with those did not report EVP use. Similarly, the odds of depression were higher among adults who reported current EVP use compared with those who did not. Clinicians treating patients with EVALI should consider evaluating the need for, and providing indicated referrals to, post-discharge mental health services for their patients.
The National Lung Screening Trial (NLST) in the United States was the first adequately powered randomized lung cancer screening trial that showed a significant 20% reduction in lung cancer mortality using low dose computed tomography (LDCT) versus standard chest X-ray. The trial studied 53,454 individuals between the ages of 55 to 74 years who smoked 30 pack-years or more and smoked within the past 15 years and recently published the extended follow-up results after a median follow-up of 12.3 years. The study confirmed LDCT screening does not just prolong the time of death from cancer, it prevents lung cancer deaths in a substantial proportion of those screened. The over-diagnosis rate is estimated to be only 3%. The benefit of LDCT screening was greater for those between the ages of 55 to 64 years than those who were older. The mortality reduction benefits became diluted with time suggesting more than 2 rounds of annual surveillance screening is needed. The Multicentric Italian Lung Detection (MILD) trial prospectively randomized 4,099 participants to a screening arm or control arm without intervention. The benefit of LDCT screening was not observed until after the fifth year of screening, with a 58% reduced risk of lung cancer mortality (HR 0.42; 95% CI 0.22–0.79), and 32% reduction of overall mortality (HR 0.68; 95% CI 0.49–0.94). In September of 2018, the results of the second largest randomized trial was presented at the World Conference on Lung Cancer (WCLC 2019). The Dutch-Belgian NELSON trial compared LDCT vs no screening in 15,822 people between the age of 50 to 74 years who smoked an average of at least 15 cigarettes per day for 25 years or at least 10 cigarettes per day for 30 years or more and have smoked within 10 years. The study found a 24% and 33% reduction in lung cancer deaths in men and in women respectively. The greater mortality reduction benefit of LDCT screening in women compared to men was also observed in the randomized German LUSI trial with a similar trend in NLST in univariate analysis. Other studies addressed the issues of implementation at the population level such as how to report large number of screening LDCT efficiently, consistently and accurately as well as personalizing the frequency of surveillance screening using deep learning (a form of artificial intelligence). The Google team reported an automated method to replicate the radiologist workflow to read screening LDCT without human input or assistance. The deep learning algorithm equaled or out-performed radiologist readings with a 94.4% area under the curve performance. When prior CT imaging was not available, the model outperformed all six radiologists in the study with absolute reductions of 11% in false positives and 5% in false negatives. Another deep learning prediction algorithm was reported by an AmericanCanadian team that can estimate an individual’s 3-year risk of lung cancer instead of 1-year risk in the Google study to guide the frequency of surveillance screening LDCT. Using universally available nodule and non-nodule features without computer-aided diagnostic tools, the algorithm identified 10% of the screening population who may benefit from prompt diagnostic workup for a biologically aggressive tumor and 55% of individuals with a very low 2-year risk for lung cancer who could safely undergo the next scheduled screening CT in 2 years instead of annually. The key messages of these publications are: Screening of high-risk smokers with LDCT significantly reduces lung cancer mortality. In contrast to research studies that are limited by the duration of the research grant, organized populationbased screening programs should have more than 2 or 3 rounds of surveillance screening to maintain the benefits of screening. Promising technological advances are available that can change how cancer screening is done. Unfortunately, despite solid scientific evidence that LDCT screening can improve the dismal outcome of lung cancer patients, no Canadian province/territory has implemented large scale lung cancer screening. Considerable advances have also been made in identification of new targetable driver pathways, better treatment options for known targets as well as immunotherapy for tumors without druggable targets in patients with advanced lung cancer to improve progression free survival (PFS) and overall survival (OS).
The National Lung Screening Trial (NLST) in the United States was the first adequately powered randomized lung cancer screening trial that showed a significant 20% reduction in lung cancer mortality using low dose computed tomography (LDCT) versus standard chest X-ray. The trial studied 53,454 individuals between the ages of 55 to 74 years who smoked 30 pack-years or more and smoked within the past 15 years and recently published the extended follow-up results after a median follow-up of 12.3 years. The study confirmed LDCT screening does not just prolong the time of death from cancer, it prevents lung cancer deaths in a substantial proportion of those screened. The over-diagnosis rate is estimated to be only 3%. The benefit of LDCT screening was greater for those between the ages of 55 to 64 years than those who were older. The mortality reduction benefits became diluted with time suggesting more than 2 rounds of annual surveillance screening is needed. The Multicentric Italian Lung Detection (MILD) trial prospectively randomized 4,099 participants to a screening arm or control arm without intervention. The benefit of LDCT screening was not observed until after the fifth year of screening, with a 58% reduced risk of lung cancer mortality (HR 0.42; 95% CI 0.22–0.79), and 32% reduction of overall mortality (HR 0.68; 95% CI 0.49–0.94). In September of 2018, the results of the second largest randomized trial was presented at the World Conference on Lung Cancer (WCLC 2019). The Dutch-Belgian NELSON trial compared LDCT vs no screening in 15,822 people between the age of 50 to 74 years who smoked an average of at least 15 cigarettes per day for 25 years or at least 10 cigarettes per day for 30 years or more and have smoked within 10 years. The study found a 24% and 33% reduction in lung cancer deaths in men and in women respectively. The greater mortality reduction benefit of LDCT screening in women compared to men was also observed in the randomized German LUSI trial with a similar trend in NLST in univariate analysis. Other studies addressed the issues of implementation at the population level such as how to report large number of screening LDCT efficiently, consistently and accurately as well as personalizing the frequency of surveillance screening using deep learning (a form of artificial intelligence). The Google team reported an automated method to replicate the radiologist workflow to read screening LDCT without human input or assistance. The deep learning algorithm equaled or out-performed radiologist readings with a 94.4% area under the curve performance. When prior CT imaging was not available, the model outperformed all six radiologists in the study with absolute reductions of 11% in false positives and 5% in false negatives. Another deep learning prediction algorithm was reported by an AmericanCanadian team that can estimate an individual’s 3-year risk of lung cancer instead of 1-year risk in the Google study to guide the frequency of surveillance screening LDCT. Using universally available nodule and non-nodule features without computer-aided diagnostic tools, the algorithm identified 10% of the screening population who may benefit from prompt diagnostic workup for a biologically aggressive tumor and 55% of individuals with a very low 2-year risk for lung cancer who could safely undergo the next scheduled screening CT in 2 years instead of annually. The key messages of these publications are: Screening of high-risk smokers with LDCT significantly reduces lung cancer mortality. In contrast to research studies that are limited by the duration of the research grant, organized populationbased screening programs should have more than 2 or 3 rounds of surveillance screening to maintain the benefits of screening. Promising technological advances are available that can change how cancer screening is done. Unfortunately, despite solid scientific evidence that LDCT screening can improve the dismal outcome of lung cancer patients, no Canadian province/territory has implemented large scale lung cancer screening. Considerable advances have also been made in identification of new targetable driver pathways, better treatment options for known targets as well as immunotherapy for tumors without druggable targets in patients with advanced lung cancer to improve progression free survival (PFS) and overall survival (OS).
Approximately 80 species of nontuberculous mycobacteria (NTM) that cause disease are found environmentally and in animal reservoirs. Typically, pulmonary NTM infections are sporadic; extrapulmonary NTM (ENTM) infections are commonly outbreak associated. Recent sources of ENTM outbreaks in Minnesota include contaminated heater-cooler units used during cardiac surgery and contaminated hormone injections. We examined patient demographics and characteristics of ENTM isolates characterized by four Minnesota reference laboratories during 2013-2017 to assess potential value of systematic laboratory-based ENTM surveillance in Minnesota. Laboratories characterized 490 ENTM isolates, representing an estimated burden of 1.8/100,000 people/year in Minnesota. Thirty-one species or complexes were identified; most common were M. avium complex (31%), M. chelonae (22%), M. fortuitum (11%), and M. abscessus (4%). Most common specimen collection sites included skin and soft tissue (38%), blood (15%), neck lymph node or tissue (12%), sinus (8%), joint or bone (5%), device or implant (4%), and eye (3%). Median age of patients was 55 years (range: 2-98 years); 18% were from patients aged <18 years, 20% aged 18-44 years, 28% aged 45-64 years and 34% aged >65 years. Sex was documented for 238 (49%) patients; 127 (53%) were males. County information was available for 313 patients (64%); approximately half (49%) resided in metropolitan Minneapolis-Saint Paul. Laboratory data can be used for ENTM surveillance in Minnesota. Implementing laboratory-based surveillance can detect ENTM cases, provide a mechanism for obtaining clinical and epidemiological information, and enable earlier identification of potential health care transmission or community clusters.
Last spring, the Star Tribune shared the story of Alec Smith, a 26-year-old from Minnesota who died from diabetic ketoacidosis due to rationing insulin. Smith, who had just turned 26, lost the health care coverage he had through his parents’ health plan and could not afford the costs associated with managing his type 1 diabetes. Smith’s story is both heartbreaking and alarming, prompting consideration of the wide range of challenges faced by young adults living with diabetes amid circumstances and systems that do not support good control. Most stories don’t end in death, but the struggle to manage and control diabetes is more common among younger adults and the external factors that complicate management are distinct from those faced by older adults. A recent study conducted by the Minnesota Department of Health and the University of Minnesota found that hospitalization rates associated with severe hypoglycemia and hyperglycemia, especially ketoacidosis, are three to five times greater for young adults with diabetes (those 18-44 years old) than for their older counterparts. Young adults also were less likely to achieve agespecific hemoglobin A1c (HbA1c) goals, whether they had type 1 or type 2 diabetes. Young adults were also more likely to have depression and to use tobacco, and less likely to see a primary care provider, than older adults. The study was published in Preventing Chronic Disease. Lack of access to health care contributes to poor diabetes management and outcomes. Despite relatively high rates of insurance among young Minnesota adults with diabetes, young adults with diabetes may still experience gaps in insurance coverage that can lead to inadequate HbA1c control and contribute to acute hypoglycemic and hyperglycemic events. Minnesotans 18-34 years old are the least likely to have paid sick time available to them, which can prevent them from seeking and obtaining care needed to manage their diabetes. These findings are consistent with earlier research in different populations demonstrating high rates of hospitalizations for severe hypoglycemia and hyperglycemia among young adults. Young adults are also more likely to be re-hospitalized for such acute diabetes complications, particularly if their treatment regimen is not evaluated, modified and adjusted to their blood glucose response. This pattern is consistent with poor and progressively worsening glycemic control among young adults with diabetes.
Clinicians, particularly primary care clinicians, often ask how to approach vaccine hesitancy or outright vaccine refusal, especially with the human papillomavirus (HPV) vaccine. The Advisory Committee on Immunization Practices recommends HPV vaccination for males and females at 11 to 12 years of age, giving clinicians permission to vaccinate as early as 9 or 10 years of age and recommendations for catch-up through age 21 years for males and 26 years for females.
To do this job well, we may need to reanalyze our attitudes toward the potpourri of humanity we encounter in the exam room.
Family members are integral to the care, safety and overall well-being of persons with Alzheimer's disease and related dementias. Being a caregiver is often associated with significant isolation as well as emotional, psychosocial and financial burden. In recognition of the toughness of this job and the increasing prevalence of dementia, there has been growing momentum among public policy makers and within communities and the health care system to address the challenges caregivers face. This article describes efforts in Minnesota communities to do so. The authors make recommendations for communities and health care systems.
The Medicare Access and Children's Health Insurance Program (CHIP) Reauthorization Act of 2015 fundamentally changes how physicians who care for Medicare patients will be paid. Although physicians won't see changes in their payments in 2017, they need to understand that their performance in 2017 will be the basis for the payments made to them starting in 2019. This article summarizes the two paths for determining future Medicare payments established by the law: the merit-based incentive payment system and advanced alternative payment models.
A campaign to raise the minimum legal sale age for tobacco products from 18 to 21 years known as Tobacco 21 is having a nationwide impact, with at least 200 localities in 14 states having already implemented a Tobacco 21 policy. A 2015 report from the Institute of Medicine (IOM) estimated the effects of such policy on cigarette use at the national level; however, little is known about the expected effects for individual states. The purpose of this study was to consider the effect on smoking initiation in Minnesota if the minimum sale age were 21 in 2015. Estimates from the Minnesota Adolescent Community Cohort and Minnesota Adult Tobacco Survey were used to calculate the uptake of smoking in a hypothetical cohort of Minnesota adolescents 15 to 20 years of age. Expected reductions in initiation in the IOM report were used to calculate the effects of Tobacco 21 policy on smoking uptake in this cohort. Results revealed that raising the sale age to 21 in 2015 would prevent 3,355 young Minnesotans from starting to smoke.
Mayo uses pharmacogenomics to help match medications to patients' genetic makeup.
