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Elective abdominal aortic aneurysm (AAA) repair for patients with a diagnosis of cancer has remained controversial. In the present study, we evaluated the in-hospital outcomes for patients who had undergone AAA repair in the setting of a cancer diagnosis. Inpatients (2008-2018) who had undergone elective AAA repair were selected from the Cerner Health Facts database using International Classification of Diseases, ninth and tenth revision, procedure codes. We used χ2 analysis and logistic regression models to evaluate the association of patient characteristics with the medical and vascular outcomes. A total of 8663 patients who had undergone AAA repair were identified (270 with a cancer diagnosis and 8393 without a cancer diagnosis). No significant demographic differences were found between the two groups, except that more patients with a cancer diagnosis had undergone endovascular aneurysm repair (EVAR) than open aneurysm repair (88.2% vs 82.1%; P =.01). Male reproductive organ (24.8%) and lung (24.4%) cancer were the most common cancer diagnoses in the cohort. The unadjusted analysis revealed that patients with a cancer diagnosis were more likely to require remedial EVAR (relative risk, 3.47; 95% confidence interval [CI], 1.18-10.2) or reoperation for bleeding, infection, or thrombosis (relative risk, 1.59; 95% CI, 1.09-2.32). Multivariable analysis demonstrated that, overall, patients with a cancer diagnosis were more likely to require a prolonged length of stay (odds ratio [OR], 2.2; 95% CI, 1.5-3.3) and to have developed respiratory failure (OR, 2.1; 95% CI, 1.3-3.4) or infection (OR, 1.7; 95% CI, 1.2-2.4). Similar point estimates were found for men with and without a cancer diagnosis. However, women with a cancer diagnosis had a greater odds of a prolonged length of stay compared with women without a cancer diagnosis (OR, 2.6; 95% CI, 1.2-5.6). EVAR in the presence of a cancer diagnosis was also significantly associated with poor outcomes. Elective AAA repair for patients with a cancer diagnosis was associated with a prolonged length of stay and the development of infection, respiratory failure, and vascular-specific complications during the inpatient hospitalization. Given that differences in outcomes stratified by gender and treatment modality have been shown for patients with a cancer diagnosis, careful patient selection is important and reinforces the finding that cancer exerts negative systemic postoperative effects even when treated or quiescent. [ABSTRACT FROM AUTHOR]

Background: Identifying individual and neighborhood-level factors associated with worsening cardiometabolic risks despite clinic-based care coordination may help identify candidates for supplementary team-based care. Methods: Secondary data analysis of data from a two-year nurse-led care coordination program cohort of Medicare, Medicaid, dual-eligible adults, Leveraging Information Technology to Guide High Tech, High Touch Care (LIGHT2), from ten Midwestern primary care clinics in the U.S. Outcome Measures: Hemoglobin A1C, low-density-lipoprotein (LDL) cholesterol, and blood pressure. Multivariable generalized linear regression models assessed individual and neighborhood-level factors associated with changes in outcome measures from before to after completion of the LIGHT2 program. Results: 6378 participants had pre-and post-intervention levels reported for at least one outcome measure. In adjusted models, higher pre-intervention cardiometabolic measures were associated with worsening of all cardiometabolic measures. Women had worsening LDL-cholesterol compared with men. Women with pre-intervention HbA1c > 6.8% and systolic blood pressure > 131 mm of Hg had worse post-intervention HbA1c and systolic blood pressure compared with men. Adding individual's neighborhood-level risks did not change effect sizes significantly. Conclusions: Increased cardiometabolic risks and gender were associated with worsening cardiometabolic outcomes. Understanding unresolved gender-specific needs and preferences of patients with increased cardiometabolic risks may aid in tailoring clinic-community-linked care planning. [ABSTRACT FROM AUTHOR]

Abstract Background Maintaining data quality and integrity is important for research studies involving prospective data collection. Data must be entered, erroneous or missing data must be identified and corrected if possible, and an audit trail created. Methods Using as an example a large prospective study, the Missouri Lower Respiratory Infection (LRI) Project, we present an approach to data management predominantly using SAS software. The Missouri LRI Project was a prospective cohort study of nursing home residents who developed an LRI. Subjects were enrolled, data collected, and follow-ups occurred for over three years. Data were collected on twenty different forms. Forms were inspected visually and sent off-site for data entry. SAS software was used to read the entered data files, check for potential errors, apply corrections to data sets, and combine batches into analytic data sets. The data management procedures are described. Results Study data collection resulted in over 20,000 completed forms. Data management was successful, resulting in clean, internally consistent data sets for analysis. The amount of time required for data management was substantially underestimated. Conclusion Data management for prospective studies should be planned well in advance of data collection. An ongoing process with data entered and checked as they become available allows timely recovery of errors and missing data.

Background and Objectives: Parenting during residency is increasingly common, and resident parents face unique demands on their time and emotional and cognitive resources. Physicians at all levels of training perceive negative impacts of parenting on career and family life. Surveys of program directors (PDs) in other specialties reveal concern about performance and quality of life of parenting residents. The primary aims of this study were to examine family medicine PDs' perceptions of parenting residents' performance and the adequacy of parenting support structures.Methods: Data were collected from the 2017 Council of Academic Family Medicine (CAFM) Educational Research Alliance (CERA) Family Medicine Residency Program Directors survey. Directors provided the number and status of parenting residents and rated adequacy of parenting resources, resident performance, and impact of parenting on residents using a Likert scale. Results were compared between male/female PDs and male/female residents.Results: Response rate was 57.1%. Less than half of PDs reported adequate parenting support structures in their program (46%). Over 40% of PDs reported that 81%-100% of female residents who take parental leave end up extending their residency training, the most common response category. PDs did not report gender-based differences in performance of parenting residents. PDs most often reported significantly worse well-being for female parenting residents but perceived improved well-being of male parents.Conclusions: Less than half of family medicine PDs feel their program has adequate parenting resources. Female parenting residents commonly extend residency training. PDs perceive parenting negatively impacts well-being of female residents, but not male residents. [ABSTRACT FROM AUTHOR]

Background and Objectives: Procedural training is integral to family medicine residencies. Although accreditation bodies require that family medicine residency programs train residents in procedures relevant to their practices, there are no standards defining the scope of family medicine. We compared the perceived importance of 31 procedures by faculty, residents, and recent graduates of one institution.Methods: An online survey was sent to current residents and faculty of a large academic family medicine residency, as well as community practitioners who had graduated from that residency within the past 5 years. The survey asked participants to rate how important 31 procedures are for family medicine practices.Results: The overall response rate was 37%. Most respondents provided outpatient care, and few provided or intended to provide obstetric care. Dermatologic and musculoskeletal procedures were rated as having high importance by all groups, whereas obstetric and inpatient procedures received lower ratings. Residents ascribed higher importance than faculty or recent graduates for nearly all procedures.Conclusions: Most residents, faculty, and community practitioners provided outpatient care and rated dermatologic and musculoskeletal procedures as important. Inpatient and obstetric care are less common career paths, and related procedures were rated as less important. Resident physicians ascribed greater importance than community practitioners for many procedures, which may be due misperceptions of their future practice needs or imposed requirements for graduation. [ABSTRACT FROM AUTHOR]

Objective The effect of postoperative hyperglycemia in patients undergoing open and endovascular procedures on the lower extremities has not been fully characterized with regard to associated admission diagnoses, hospital complications, mortality, and 30-day readmission. This study evaluated the relationship of postoperative hyperglycemia on outcomes after lower extremity vascular procedures for peripheral artery disease. Methods Patients with peripheral artery disease admitted for elective lower extremity procedures between September 2008 and March 2014 were selected from the Cerner Health Facts (Cerner Corporation, Kansas City, Mo) database using International Classification of Diseases, Ninth Edition, Clinical Modification diagnosis and procedure codes. Using χ 2 analysis, we evaluated the relationship of postoperative hyperglycemia (>180 mg/dL) with sociodemographic characteristics, acute and chronic diagnoses, infections, hospital length of stay (LOS), and 30-day readmission. An adjusted multivariable logistic model was used to examine the association of postoperative hyperglycemia with infection and LOS. Results Of 3586 patients in the study, 2812 (78%) had optimal postoperative glucose control, and 774 (22%) had suboptimal glucose control (hyperglycemia). On average, patients with postoperative hyperglycemia experienced longer hospital stays (6.9 vs 5.1 days; P < .0001), higher Charlson Comorbidity Index scores (3.4 vs 2.5, P < .0001), higher rates of infection (23% vs 14%, P < .0001), more acute complications (ie, fluid and electrolyte disorders, acute renal failure, postoperative respiratory complications), and chronic problems (ie, anemia, chronic heart disease, chronic kidney disease, and diabetes) than patients with optimal glucose control. Overall 30-day readmission was 10.9% and was similar between the groups (10.9% for both; P = .93). Major amputations did not differ between groups ( P = .21). After adjusting for other risk factors using multivariable logistic regression, patients with hyperglycemia have 1.3-times the odds to have an infectious complication compared with those with optimal glucose control (odds ratio [OR], 1.34; 95% confidence interval [CI], 1.06-1.69) and 1.7-times the odds to have a hospital LOS >10 days (OR, 1.69; 95% CI, 1.32-2.15). As well, patients with postoperative hyperglycemia have 8.4-times the odds of dying in the hospital (OR, 8.40; 95% CI, 3.95-17.9). Conclusions One in five patients undergoing vascular procedures had postoperative hyperglycemia. Postoperative hyperglycemia was associated with adverse events after lower extremity vascular procedures in patients with and without diabetes, including infection, increased hospital utilization, and mortality. No difference was found with respect to hospital readmission. Postprocedure glucose management may represent an important quality marker for improving outcomes after lower extremity vascular procedures. [ABSTRACT FROM AUTHOR]

Estrogen-mimicking chemicals, such as cadmium, may be associated with increased susceptibility to hormone-dependent cancers, though supporting data are sparse, particularly for endometrial cancer. The Health and Environmental Exposure Research (HEER) study worked with the Arkansas Central Cancer Registry, Iowa Cancer Registry and Missouri Cancer Registry to obtain names of women diagnosed with endometrial cancer who were willing to be contacted for participation in our case control study. Voter registration lists from Iowa and Missouri were used to randomly select similarly aged women as represented in the case population. Participants were interviewed by telephone to obtain information on known or suspected endometrial risk factors. Urine kits were sent to participants for home collection and returned for analysis. Our case-control study consisted of 631 incident cases of endometrial cancer diagnosed from January 2010 to October 2012 and 879 age-matched population-based controls, ages 18–81 years (mean age 65 years). We quantified cadmium amounts in urine and standardized these values through creatinine adjustment. Using data from all survey completers, we developed a multivariable model for endometrial cancer. Creatinine-adjusted cadmium concentration was added to this model. Odds ratio (OR) and 95% confidence intervals (CIs) for endometrial cancer were calculated. After multivariable adjustment, higher creatinine-adjusted cadmium exposure was associated with a statistically significant increase of endometrial cancer risk (OR: 1.22; 95% CI: 1.03–1.44). Our results provide evidence that cadmium may increase the risk of endometrial cancer, possibly through estrogenic effects. [ABSTRACT FROM AUTHOR]

Background and Objectives: Little information is available on what competencies family medicine program directors expect of incoming residents and whether those incoming residents can deliver on such expectations. Our aim was to determine whether there is a common set of skills that both family medicine clerkship directors and program directors agree are important for entering residents to possess and how often these are being demonstrated.Methods: This study is an analysis of data obtained in the 2014 CERA Family Medicine Clerkship Director and Program Director surveys. Clerkship directors and program directors were provided with a list of skill areas and professional characteristics and asked to rate how important it is for medical school graduates to demonstrate them as well as how many medical school graduates consistently demonstrate each skill or characteristic.Results: Both groups placed highest importance on honesty, professionalism, and communication skills among incoming residents. Clerkship directors placed higher importance on several skill areas, with program directors emphasizing professional characteristics. This division was also seen in the opinions of the two groups for how well entering residents demonstrated each area.Conclusions: Clerkship directors identify several skill sets as being more important for graduating medical students to possess compared with program directors. Program directors seem to value more personal characteristics as important for entering residents to possess rather than skills. Future implications may include a focus from family medicine clerkships on skills that are valued by program directors but not rated as commonly seen among incoming residents. [ABSTRACT FROM AUTHOR]

BACKGROUND AND OBJECTIVES: Although the benefits of exercise are well known, rates of exercise among residents are much lower than those of attendings or medical students. Little is known about the barriers that prevent residents from exercising regularly. This mixed methodology study identifies and compares these barriers for resident and attending physicians practicing in the same setting. METHODS: We conducted three focus groups with first-year and senior residents and attending physicians in the University of Missouri Department of Family and Community Medicine from April to August 2013. We also administered a survey inquiring about exercise rates and habits to 110 resident and attending physicians in the same department using both paper and electronic versions. RESULTS: During both inpatient and non-inpatient rotations, residents reported exercising less than attending physicians. No residents exercised more than 150 minutes/week during inpatient rotations compared to 18.42% of attendings. Only 6.9% of residents exercised more than 150 minutes/week during non-inpatient rotations, compared to 25% of attendings. Residents and attendings reported different barriers to regular exercise. Residents reported lack of time for a traditional structured workout as a major barrier, which leads to an adversarial relationship between work and exercise. CONCLUSIONS: Residency programs can help residents overcome exercise barriers by reframing exercise expectations to include more frequent but brief periods of exercise during the workday and by developing a supportive exercise culture. Changing worksite environments to support physician exercise may improve physician wellness. [ABSTRACT FROM AUTHOR]

Statins stabilize atherosclerotic plaque, decrease mortality after surgical procedures, and are linked to anti-inflammatory effects. The objective of this study was to evaluate preoperative administration of statins and longitudinal limb salvage after lower extremity endovascular revascularization and lower extremity open surgery.Patients were selected from 2007 to 2008 Medicare claims using the International Classification of Diseases, Ninth Revision, Clinical Modification, diagnosis codes for claudication (N=8128), rest pain (N=3056), and ulceration/gangrene (N=11 770) and Current Procedural Terminology codes for endovascular revascularization (N=14 353) and open surgery (N=8601). Half (N=11 687) were identified as statin users before revascularization using Part D files. Amputations were identified using Current Procedural Terminology codes. Statin users compared with nonusers had lower amputation rates at 30 days (11.5% versus 14.4%; P<0.0001), 90 days (15.5% versus 19.3%; P<0.0001), and 1 year (20.9% versus 25.6%; P<0.0001). Survival analysis demonstrated improved limb salvage during 1 year for statin users compared with nonusers for the diagnosis of claudication (P=0.003), a similar trend for rest pain (P=0.061), and no improvement for ulceration/gangrene (P=0.65).Preoperative statins were associated with improved 1-year limb salvage after lower extremity revascularization. The strongest association was found for patients with the diagnosis of claudication. Statins seem to be underused among Medicare patients with peripheral artery disease. Further evaluation of the use of preoperative statins and the potential benefits for peripheral vascular interventions is warranted. [ABSTRACT FROM AUTHOR]

Background and Objectives: Electronic patient portals are increasingly common, but there is little information regarding attitudes of faculty and residents at academic medical centers toward them.Methods: The primary objective was to investigate attitudes toward electronic patient portals among primary care residents and faculty and changes in faculty attitudes after implementation. The study design included a pre-implementation survey of 39 general internal medicine and family medicine residents and 43 generalist faculty addressing attitudes and expectations of a planned patient portal and also a pre- and post-implementation survey of general internal medicine and family medicine faculty physicians. The survey also addressed email communication with patients.Results: Prior to portal implementation, residents reported receiving much less e-mail from patients than faculty physicians; 68% and 9% of residents and faculty, respectively, reported no email exchange in a typical month. Residents were less likely to agree with allowing patients to view selected parts of their medical record on-line than faculty physicians (57% and 81%, respectively). Physicians who participated in the portal's pilot implementation had expected workload to increase (64% agreed), but after implementation, 87% of those responding were neutral or disagreed that workload had increased. After implementation, only 33% believed quality of care had improved compared to 55% who had expected it to improve prior to implementation.Conclusions: Residents and faculty physicians need to be prepared for a changing environment of electronic communication with patients. Some positive and negative expectations of physicians toward enhanced electronic access by patients were not borne out by experience. [ABSTRACT FROM AUTHOR]

The article presents a study which compares the accuracy of diabetes dashboard screen and conventional approach in accessing multiple electronic health record (EHR) for high-quality diabetes care. The time, accuracy, and number of mouse clicks were measured while 10 primary care physicians searched their EHR using dashboard and conventional approach. Results show that dashboard screen is the most accurate because 100% of the data requested was identified correctly with 3 clicks in the mouse.

Background. Weight-bearing exercise has been discouraged for people with diabetes mellitus and peripheral neuropathy (DM + PN). However, people with diabetes mellitus and insensate feet have an increased risk of falling. Lower-extremity exercise and balance training reduce fall risk in some older adults. It is unknown whether those with neuropathy experience similar benefits. Objective. As part of a study of the effects of weight-bearing exercise on foot ulceration in people with DM+PN, the effects of a lower-extremity exercise and walking intervention on balance, lower-extremity strength (force-generating capacity), and fall incidence were determined. Design. The study was an observer-masked, 12-month randomized controlled trial. Setting. Part I of the intervention took place in physical therapy offices, and part 2 took place in the community. Patients. The participants were 79 people who were mostly sedentary, who had DM + PN, and who were randomly assigned to either a control group (n = 38) or an intervention group (n = 41). Intervention. Part I included leg strengthening and balance exercises and a graduated, self-monitored walking program; part 2 included motivational telephone calls. Both groups received regular foot care, foot care education, and 8 sessions with a physical therapist. Measurements. The measurements collected were strength, balance, and participant-reported falls for the year after enrollment. Results. There were no statistically significant differences between the groups for falls during follow-up. At 12 months, there was a small increase in the amount of time that participants in the intervention group could stand on 1 leg with their eyes closed. No other strength or balance measurements differed between the groups. Limitations. The study was designed to detect differences in physical activity, not falls. The intensity of the intervention was insufficient to improve strength and balance in this population. Conclusions. The training program had a minimal effect on participants balance and lower-extremity strength. Increasing weight-bearing activity did not alter the rate of falling for participants in the intervention group relative to that for participants in the control group. People who are sedentary and who have DM + PN appear to be able to increase activity without increasing their rate of falling. INSET: The Bottom Line. [ABSTRACT FROM AUTHOR]

Background: Maintaining data quality and integrity is important for research studies involving prospective data collection. Data must be entered, erroneous or missing data must be identified and corrected if possible, and an audit trail created. Methods: Using as an example a large prospective study, the Missouri Lower Respiratory Infection (LRI) Project, we present an approach to data management predominantly using SAS software. The Missouri LRI Project was a prospective cohort study of nursing home residents who developed an LRI. Subjects were enrolled, data collected, and follow-ups occurred for over three years. Data were collected on twenty different forms. Forms were inspected visually and sent off-site for data entry. SAS software was used to read the entered data files, check for potential errors, apply corrections to data sets, and combine batches into analytic data sets. The data management procedures are described. Results: Study data collection resulted in over 20,000 completed forms. Data management was successful, resulting in clean, internally consistent data sets for analysis. The amount of time required for data management was substantially underestimated. Conclusion: Data management for prospective studies should be planned well in advance of data collection. An ongoing process with data entered and checked as they become available allows timely recovery of errors and missing data. [ABSTRACT FROM AUTHOR]