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Hemorrhoid disease is very common problem in the Medicare population. Prior work has shown significant variation in county-level practices of hemorrhoidectomy; however, regional variation of rubber band ligation (RBL) has yet to be assessed. This is important as many different practitioners from different specialties can perform this procedure repeatedly in an office-based setting. We aim to evaluate the variation of RBL and hemorrhoidectomy over a 7-y period. Using Medicare part B claims data, we identified all beneficiaries >65 y seen for hemorrhoid disease between 2006 and 2013. Current Procedural Terminology (CPT) codes were used to identify all events for hemorrhoidectomy (46083, 46250, 46255, 46257, 46260, and 46261) or RBL (46221) by hospital referral region (HRR). We determined HRR-level rates of hemorrhoidectomy and RBL per 1000 beneficiaries adjusted for age, sex, and race. We calculated annual coefficients of variation (SD × 100/mean) for hemorrhoidectomy and RBL. 1.2 to 1.3 million fee-for-service Medicare beneficiaries were seen annually for evaluation of hemorrhoid disease. Mean-adjusted annual rates for hemorrhoidectomy by HRRs varied from 4.34 to 63.03 per 1000 beneficiaries. Mean-adjusted rates of RBL by HRRs varied from 7.06 to 163 per 1000 beneficiaries. Annual procedural coefficients of variation over the study period were 41-48 (high) for hemorrhoidectomy and 69-74 (very high) for RBL. While continued high variation exists for hemorrhoidectomy, there is very high variation for RBL between HRRs in treating hemorrhoid disease among Medicare beneficiaries. There are substantial Medicare expenditures in this high-volume population that are likely unwarranted. [ABSTRACT FROM AUTHOR]

Trauma is a leading cause of morbidity and mortality in low-income countries. Improved health care systems and training are potential avenues to combat this burden. We detail a collaborative and context-specific operative trauma course taught to postgraduate surgical trainees practicing in a low-resource setting and examine its effect on resident practice. Three classes of second year surgical residents participated in trainings from 2017 to 2019. The course was developed and taught in conjunction with local faculty. The most recent cohort logged cases before and after the course to assess resources used during initial patient evaluation and operative techniques used if the patient was taken to theater. Over the study period, 52 residents participated in the course. Eighteen participated in the case log study and logged 117 cases. There was no statistically significant difference in patient demographics or injury severity precourse and postcourse. Postcourse, penetrating injuries were reported less frequently (40 to 21% P < 0.05) and road traffic crashes were reported more frequently (39 to 60%, P < 0.05). There was no change in the use of bedside interventions or diagnostic imaging, besides head CT. Of patients taken for a laparotomy, there was a nonstatistically significant increase in the use of four-quadrant packing 3.4 to 21.7%) and a decrease in liver repair (20.7 to 4.3%). The course did not change resource utilization; however, it did influence clinical decision-making and operative techniques used during laparotomy. Additional research is indicated to evaluate sustained changes in practice patterns and clinical outcomes after operative skills training. [ABSTRACT FROM AUTHOR]

The decisions to routinely place a drain after pancreaticoduodenectomy and how long to leave the drain remain controversial due to conflicting evidence and significant variations in clinical practice. This study aims to address those questions by using a large national database and a rigorous analytical model. The American College of Surgeons National Surgical Quality Improvement Program 2015-2016 Pancreatectomy Participant Use Data Files were used to identify patients who had undergone pancreaticoduodenectomy (n = 7583). Univariable and multivariable binomial regression analyses were performed to control for potential confounders and various preoperative risk factors. Cox regression with drain as a time-dependent covariate, conditional on having a drain placed, was used to examine the association between the drain remaining in place and morbidities. Of 7583 patients, drains were placed in 6666 (87.9%). Drain placement decreased the risk of developing serious morbidity (relative risk [RR] 0.73, 95% confidence interval [CI] 0.65-0.82), overall morbidity (RR 0.79, 95% CI 0.72-0.87), and organ space surgical site infection (RR 0.72, 95% CI 0.61-0.85). Drain placement did not change the risk of developing a clinically relevant postoperative pancreatic fistula (RR 0.96, 95% CI 0.78-1.19). However, for those with drains placed, length of drainage was independently associated with serious morbidity (hazard ratio [HR] 3.06, 95% CI 2.65-3.53), overall morbidity (HR 2.48, 95% CI 2.20-2.80), and organ space surgical site infection (HR 1.47, 95% CI 1.23-1.74). Routine drain placement following pancreaticoduodenectomy may decrease postoperative complications, including serious morbidity, overall morbidity, and organ space surgical site infections; however, length of drainage was associated with increased risk of the previously-named complications. These results support the routine placement and early removal of intraoperative surgical drains in pancreaticoduodenectomy. [ABSTRACT FROM AUTHOR]

A majority of severely injured patients fail to receive care at trauma centers (undertriage), in part, because of physician judgment. We previously developed two educational video games that reduced physicians' undertriage compared with control in two clinical trials. In this secondary analysis, we investigated heterogeneity of treatment effect of the interventions by assessing physicians' preexisting practice patterns in claims data. We hypothesized that physicians with high preexisting undertriage would benefit most from game-based training. Using Medicare claims records from 2010 to 2015, we measured physicians' preexisting triage practices before their participation in one of two trials conducted in 2016 and 2017. We categorized physicians as having received game-based training versus control and noted their postintervention simulation triage performance in the trials. We used multivariable linear regression models to assess the heterogeneity of game-based training effect among physicians with high and low preexisting undertriage. Of the 394 eligible physicians from our trials, we identified 275 (70%) with claims for Medicare fee-for-service beneficiaries suffering severe injury between 2010 and 2015. On average, the physicians were 44 y old (SD 8.4) with 12 y (SD 8.2) of experience. We found significant interaction between preexisting practice and intervention efficacy (P = 0.04). Physicians with high undertriage before enrollment improved significantly with game-based training compared with the control (46% versus 63%, P < 0.001). Those with low preexisting undertriage did not (58% versus 56%, P = 0.76). Using claims-based data, we found heterogeneity of treatment effect of interventions designed to recalibrate physician heuristics. Physicians with high preexisting undertriage benefited most from game-based training. [ABSTRACT FROM AUTHOR]

The mitochondrial medicine society (MMS) has previously highlighted the clinical landscape and physician practice patterns of mitochondrial medicine in the US and attempted to develop consensus criteria for diagnosis and management to improve patient coordinated care. Most recently, and in collaboration with US-based patient advocacy groups, we developed a clinical care network to formally unify US-based clinicians who provide medical care to individuals with mitochondrial disease; to define, design and implement best practices in mitochondrial medicine building on the current consensus guidelines and to improve patients' clinical outcomes. Here we review the steps taken in collaboration with several stakeholders to develop goals and expectations for a mitochondrial care network (MCN), criteria for MCN site selection and formal launch of the network. [ABSTRACT FROM AUTHOR]

Background Physicians from various disciplines encounter patients presenting with psychogenic nonepileptic seizures (PNES) as part of their routine clinical practice. Recommendations towards assessing fitness to drive and reporting are clearer for conditions such as neurocognitive disorders and epilepsy, but such guidelines do not exist for patients with PNES. Here, we assess physicians' attitudes towards driving for patients diagnosed with PNES. Methods Electronic questionnaires were sent to Neurology and Family Medicine physicians practicing at Creighton University Medical Center and Psychiatry physicians practicing at Creighton-Nebraska Psychiatry Residency Program to assess their opinion regarding driving risk when encountering PNES. Results The survey request was sent to 125 physicians, of which close to 60% completed the survey. Eighty-eight percent of participants encountered PNES in their clinical practice, and 69.1% agreed it was a difficult problem to assess, with only 8.3% endorsing a belief that these patients should drive without restrictions. Ninety-three percent felt having guidelines would help them assess the driving risk in this population. Conclusion Psychogenic nonepileptic seizures are common across neurology, psychiatry, and primary care, and most physicians find assessing driving risk in such individuals highly warranted yet difficult. Developing such assessment guidelines and recommendations is of great need for clinicians. [ABSTRACT FROM AUTHOR]

Background There is significant institutional variation in the surgical care of breast cancer, and this may reflect access to services and resultant physician practice patterns. In previous studies, specialty care has been associated with variation in the operative treatment of breast cancer but has not been evaluated in a community setting. This study investigates these issues in a cohort of 59 community hospitals in the United States. Materials and methods Data on patients receiving an operation for breast cancer (2006-2009) in a large, geographically diverse cohort of hospitals were obtained. Administrative data, autoabstracted cancer-specific variables from free text, and multiple other data sets were combined. Polymotous logistic regression with multilevel outcomes identified associations between these variables and surgical treatment. Results At 59 community hospitals, 4766 patients underwent breast conserving surgery (BCS), mastectomy, or mastectomy with reconstruction. The older patients were most likely to receive mastectomy alone, whereas the younger age group underwent more reconstruction (age <50), and BCS was most likely in patients aged 50-65. Surgical procedure also varied according to tumor characteristics. BCS was more likely at smaller hospitals, those with ambulatory surgery centers, and those located in nonmetropolitan areas. The likelihood of reconstruction doubled when there were more reconstructive surgeons in the health services area ( P = 0.02). BCS was more likely when radiation oncology services were available within the hospital or network ( P = 0.04). Conclusions Interpretation of these results for practice redesign is not straightforward. Although access to specialty care is statistically associated with type of breast surgical procedure, clinical impact is limited. It may be more effective to target other aspects of care to ensure each patient receives treatment consistent with her individual preferences. [ABSTRACT FROM AUTHOR]

Background A cost-effective model for open vessel ligation is currently lacking. We hypothesized that a novel, inexpensive vessel ligation simulator can efficiently impart transferrable surgical skills to novice trainees. Materials and methods VesselBox was designed to simulate vessel ligation using surgical gloves as surrogate vessels. Fourth-year medical students performed ligations using VesselBox and were evaluated by surgical faculty using the Objective Structured Assessments of Technical Skills global rating scale and a task-specific checklist. Subsequently, each student was trained using VesselBox in an adaptive practice session guided by cumulative sum. Posttesting was performed on fresh human cadavers by evaluators blinded to pretest results. Results Sixteen students completed the study. VesselBox practice sessions averaged 21.8 min per participant (interquartile range 19.5-27.7). Blinded posttests demonstrated increased proficiency, as measured by both Objective Structured Assessments of Technical Skills (3.23 versus 2.29, P < 0.001) and checklist metrics (7.33 versus 4.83, P < 0.001). Median speed improved from 128.2 s to 97.5 s per vessel ligated (P = 0.001). After this adaptive training protocol, practice volume was not associated with posttest performance. Conclusions VesselBox is a cost-effective, low-fidelity vessel ligation model suitable for graduating medical students and junior residents. Cumulative sum can facilitate an adaptive, individualized curriculum for simulation training. [ABSTRACT FROM AUTHOR]

Objective: To compare four different blood pressure (BP) measurements—systolic BP (SBP), diastolic BP (DBP), mean arterial pressure (MAP), and pulse pressure (PP)—in predicting future metabolic syndrome (MetS) among the normotensive elderly population, and to estimate the optimal cutoff value of the best single measurement for clinical practice. Methods: A total of 2782 non-medicated participants aged ≥ 60 years were enrolled in a standard health examination program in Taiwan from January 2004 to December 2013. Two thirds of the participants were randomly designated as the training group (n = 1855) and the other one third as the validation group (n = 927). The mean follow-up time was 3.60 years for both the training and validation groups. MAP and PP were calculated from SBP and DBP. Results: SBP, DBP, and MAP were associated with future MetS, whereas PP was not. MAP had the largest hazard ratio in Cox regression (men 1.342 [95% CI 1.158–1.555] and women 1.348 [95% CI 1.185–1.534] in the training group; men 1.640 [95% CI 1.317–2.041] and women 1.485 [95% CI 1.230–1.794] in the validation group) and the largest area under the receiver operating characteristic curve (men 0.598 ± 0.021 and women 0.602 ± 0.021 in the training group). Multivariable Cox regression further indicated that a higher MAP level was independently associated with the future occurrence of MetS. Participants with MAP above the cutoff value (84.0 mm Hg for men, 83.3 mm Hg for women) had a higher cumulative incidence of MetS than did their counterparts after four years' follow-up in both the training and validation groups. The results derived from the training data could be replicated in the validation data, indicating that the results were generalizable across distinct samples. Conclusions: MAP is more accurate than SBP, DBP, and PP in predicting future MetS among the normotensive geriatric population. Calculation of MAP is recommended when dealing with normotensive patients aged ≥ 60 years in clinical practice. [ABSTRACT FROM AUTHOR]

Rationale The utility of genetic testing in pediatric drug-resistant epilepsy (PDRE), its yield in “real life” clinical practice, and the practical implications of such testing are yet to be determined. Goal To start to address the above gaps in our knowledge as they apply to a patient population seen in a tertiary care center. Methods We retrospectively reviewed our experience with the use of clinically available genetic tests in the diagnosis and management of PDRE in one clinic over one year. Genetic testing included, depending on clinical judgment, one or more of the following: karyotype, chromosomal microarray, single gene sequencing, gene sequencing panels, and/or whole exome sequencing (WES). Results We were more likely to perform genetic testing in patients with developmental delay, epileptic encephalopathy, and generalized epilepsy. In our unique population, the yield of specific genetic diagnosis was relatively high: karyotype 14.3%, microarray 16.7%, targeted single gene sequencing 15.4%, gene panels 46.2%, and WES 16.7%. Overall yield of diagnosis from at least one of the above tests was 34.5%. Disease-causing mutations that were not clinically suspected based on the patients' phenotypes and representing novel phenotypes were found in 6.9% (2/29), with an additional 17.2% (5/29) demonstrating pharmacologic variants. Three patients were incidentally found to be carriers of recessive neurologic diseases (10.3%). Variants of unknown significance (VUSs) were identified in 34.5% (10/29). Conclusions We conclude that genetic testing had at least some utility in our patient population of PDRE, that future similar larger studies in various populations are warranted, and that clinics offering such tests must be prepared to address the complicated questions raised by the results of such testing. [ABSTRACT FROM AUTHOR]

Objectives This study aimed at determining the current state of practice of treatment for acute generalized convulsive status epilepticus (GCSE) and responsiveness to therapy. Methods This observational study was performed by retrospectively identifying patients with GCSE presenting to an emergency room setting. The primary outcome was seizure cessation following medication administration. Secondary outcomes were rates of intubation and mortality. Results One hundred seventy-seven episodes of GCSE were identified. All patients, except 1, received a benzodiazepine for first-line treatment. Only 11% of these patients, all children, were treated with at least 0.1 mg/kg of lorazepam or an equivalent dose of an alternative benzodiazepine. A first-line treatment was effective in 56% of the patients, a second-line treatment in an additional 28%, and a third-line treatment in 12%. Phenytoin was the most prescribed second-line treatment (41%) but statistically significantly least effective (22% versus 86% seizure cessation, p < 0.0001) compared with all other second-line agents together. Propofol was the most prescribed third-line treatment. Conclusions Results emphasize that, in clinical practice, approximately half of GCSE patients respond to first-line therapy and, among nonresponders, approximately two-thirds respond to second-line and approximately three-quarters respond to third-line therapies. The variations in treatment selection reflect that there are no randomized controlled trials to guide treatment beyond use of benzodiazepines for first-line treatment. The observation that phenytoin is statistically substantially worse than other second-line treatments raises the possibility that the most commonly selected second-line treatment is the least effective and provides equipoise for a large randomized controlled trial of second-line therapies. [ABSTRACT FROM AUTHOR]

Abstract: Objective: The aim of this study is to assess whether family history of coronary heart disease (CHD) and education as proxy of social status improve long-term cardiovascular disease risk prediction in a low-incidence European population. Methods: The 20-year risk of first coronary or ischemic stroke events was estimated using sex-specific Cox models in 3956 participants of three population-based surveys in northern Italy, aged 35–69years and free of cardiovascular disease at enrollment. The additional contribution of education and positive family history of CHD was defined as change in discrimination and Net Reclassification Improvement (NRI) over the model including 7 traditional risk factors. Results: Kaplan–Meier 20-year risk was 16.8% in men (254 events) and 6.4% in women (102 events). Low education (hazard ratio=1.35, 95%CI 0.98–1.85) and family history of CHD (1.55; 1.19–2.03) were associated with the endpoint in men, but not in women. In men, the addition of education and family history significantly improved discrimination by 1%; NRI was 6% (95%CI: 0.2%–15.2%), raising to 20% (0.5%–44%) in those at intermediate risk. NRI in women at intermediate risk was 7%. Conclusion: In low-incidence populations, family history of CHD and education, easily assessed in clinical practice, should be included in long-term cardiovascular disease risk scores, at least in men. [Copyright &y& Elsevier]

Abstract: Objective: This report describes findings from a randomized controlled trial of an intervention to increase colorectal cancer (CRC) screening in primary care practices in Appalachian Kentucky. Methods: Sixty-six primary care practices were randomized to early or delayed intervention groups. The intervention was provided at practices using academic detailing, a method of education where providers receive information on a specific topic through personal contact. Data were collected in cross-sectional surveys of medical records at baseline and six months post-intervention. Results: A total of 3844 medical records were reviewed at baseline and 3751 at the six-month follow-up. At baselines, colonoscopy was recommended more frequently (43.4%) than any other screening modality, followed by fecal occult blood testing (18.0%), flexible sigmoidoscopy (0.4%), and double-contrast barium enema (0.3%). Rates of documented screening results were higher for all practices at the six-month follow-up for colonoscopy (31.8% vs 29.6%) and fecal occult blood testing (12.2% vs 11.2%). For early intervention practices that recommended screening, colonoscopy rates increased by 15.7% at six months compared to an increase of 2.4% in the delayed intervention practices (p=.01). Conclusions: Using academic detailing to reach rural primary care providers with a CRC screening intervention was associated with an increase in colonoscopy. [Copyright &y& Elsevier]

Abstract: Objective: This study aimed to develop a simple risk table of modifiable factors prospectively associated with depression in later life that could be used to guide the assessment, management and introduction of preventive strategies in clinical practice. Methods: This retrospective cohort study included 4636 men aged 65 to 83years living in the community who denied history of past diagnosis or treatment for depression. They self-reported information about their physical activity, weight and height, smoking history, alcohol consumption and dietary habits, as well as history of hypertension, diabetes, coronary heart disease and stroke. We calculated the body mass index (BMI) in kg/m2. Three to 8years later they were assessed with the Geriatric Depression Scale 15 (GDS-15) and those with a total score of 7 or greater were considered to display clinically significant symptoms of depression. We used binomial exponentiated log-linked general linear models to estimate the risk ratio (RR) and 95% confidence interval (95% CI) of incident depression after adjusting for age, education, marital status and prevalent medical illnesses. We calculated the probability of depression for each individual combination of risk factors and displayed the results in a risk table. Results: Two hundred and twenty-nine men (4.5%) showed evidence of incident depression 5.7±0.9 (mean±standard deviation) years later. Measured dietary factors showed no association with incident depression. The probability of depression was the highest for older men who were underweight, overweight or obese, physically inactive, risk drinkers and smokers (12.0%, 95% CI=7.0%, 17.1%), and the lowest for those who had all 4 healthy lifestyle markers: physically active, normal body mass, non-risk drinking and non-smoking (1.6%, 95% CI=0.6%, 2.5%). The probability of incident depression fell between these two extremes for different combinations of lifestyle practices. Conclusion: Four modifiable lifestyle factors can be used in combination to produce a risk table that predicts the probability of incident depression over a period of 3 to 8years. The risk table is simple, informative and can be easily incorporated into clinical practice to guide assessment and risk reduction interventions. [Copyright &y& Elsevier]

Pain is a subjective first-person experience, and self-report is the gold standard for pain assessment in clinical practice. However, self-report of pain is not available in some vulnerable populations (e.g., patients with disorders of consciousness), which leads to an inadequate or suboptimal treatment of pain. Therefore, the availability of a physiology-based and objective assessment of pain that complements the self-report would be of great importance in various applications. Here, we aimed to develop a novel and practice-oriented approach to predict pain perception from single-trial laser-evoked potentials (LEPs). We applied a novel single-trial analysis approach that combined common spatial pattern and multiple linear regression to automatically and reliably estimate single-trial LEP features. Further, we adopted a Naïve Bayes classifier to discretely predict low and high pain and a multiple linear prediction model to continuously predict the intensity of pain perception from single-trial LEP features, at both within- and cross-individual levels. Our results showed that the proposed approach provided a binary prediction of pain (classification of low pain and high pain) with an accuracy of 86.3±8.4% (within-individual) and 80.3±8.5% (cross-individual), and a continuous prediction of pain (regression on a continuous scale from 0 to 10) with a mean absolute error of 1.031±0.136 (within-individual) and 1.821±0.202 (cross-individual). Thus, the proposed approach may help establish a fast and reliable tool for automated prediction of pain, which could be potentially adopted in various basic and clinical applications. [ABSTRACT FROM AUTHOR]

Abstract: It has been estimated that JME (juvenile myoclonic epilepsy), when compared to other adult epilepsy syndromes, is most likely to have a genetic cause. However, decades of research have not brought us closer to finding a single ‘JME gene’ that is important on a population basis. Is this due in part to the genetic complexity of the syndrome, the cryptic nature of the genes of effect, or perhaps because JME is not one condition at all but many? Before we can begin to harness the power of next-generation sequencing techniques, we must first reduce JME down to lacunae of homogeneity — using increasingly more sophisticated phenotyping tools. The current technological advances in gene sequencing have been used to dramatic effect to identify single gene causes in rare syndromes and identify risk variants in malignancies. Filtering the variety of the human exome or genome down into a handful of biologically plausible candidates now relies on a pipeline of biostatistics, software, and functional analyses. It is simply unacceptable to return uncertain findings to the clinical domain and, therefore, it is crucial that pathogenicity is fully determined before families receive genetic counseling and test results. This article is part of a Special Issue entitled “The Future of Translational Epilepsy Research”. [Copyright &y& Elsevier]

Abstract: In May 2012, Health Canada and other participants held a National Summit on Subsequent Entry Biologics (SEBs). Health Canada released a guidance document in March 2010 describing policy positions and data requirements for approval of SEBs. While Health Canada and health agencies in other regulatory jurisdictions are aligned on many scientific principles related to biosimilar drugs, Health Canada''s specific requirements may not be widely understood by many Canadian stakeholders. The Summit provided an opportunity for education and dialog among physicians who prescribe biologics, provincial payers, and industry on the following topics: preclinical and clinical comparability studies; manufacturing and other product differences; extrapolation of indications; substitution and interchangeability of SEBs with reference biologic drugs in clinical practice; payers'' current perspective; pharmacovigilance and naming. It is anticipated that the consensus reached at this meeting will further educate Canadian healthcare professionals, provincial payers, and insurers about the appropriate use of SEBs, and may be of general interest to others internationally. [Copyright &y& Elsevier]

Abstract: A European observational cross-sectional study, ESPERA, was conducted in France and Spain in 2010. A random sample of neurologists, including specialists in epilepsy, prospectively enrolled adult patients treated for focal epilepsy with at least two antiepileptic drugs (AEDs) in combination. Investigators were asked to classify AED responsiveness of each enrolled patient according to the new 2009 ILAE criteria. These classifications were then reviewed by three experts. Potential factors of misclassification were then analyzed in order to evaluate the applicability of the new ILAE criteria for antiepileptic drug resistance in current clinical practice. Because of their complexity, use of the new ILAE criteria needs to be supported by relevant information and training to be adequately applied by neurologists in everyday practice. [Copyright &y& Elsevier]

Abstract: Objective: To assess primary care physicians'' (PCPs) knowledge of energy balance related guidelines and the association with sociodemographic characteristics and clinical care practices. Method: As part of the 2008 U.S. nationally representative National Survey of Energy Balance Related Care among Primary Care Physicians (EB-PCP), 1776 PCPs from four specialties who treated adults (n =1060) or children and adolescents (n =716) completed surveys on sociodemographic information, knowledge of energy balance guidelines, and clinical care practices. Results: EB-PCP response rate was 64.5%. For PCPs treating children, knowledge of guidelines for healthy BMI percentile, physical activity, and fruit and vegetables intake was 36.5%, 27.0%, and 62.9%, respectively. For PCPs treating adults, knowledge of guidelines for overweight, obesity, physical activity, and fruit and vegetables intake was 81.4%, 81.3%, 70.9%, and 63.5%, respectively. Generally, younger, female physicians were more likely to exhibit correct knowledge. Knowledge of weight-related guidelines was associated with assessment of body mass index (BMI) and use of BMI-for-age growth charts. Conclusion: Knowledge of energy balance guidelines among PCPs treating children is low, among PCPs treating adults it appeared high for overweight and obesity-related clinical guidelines and moderate for physical activity and diet, and was mostly unrelated to clinical practices among all PCPs. [Copyright &y& Elsevier]

Abstract: Transplantation is the preferred therapy for the end stage organ disease. Since the introduction of organ transplantation into medical practice in 1953 , significant progress has been achieved in patient and graft survival rates due to improvements in surgical techniques and more targeted immunosuppressive medications . Nevertheless, current gaps in the management of the transplant patient stem from an incomplete understanding about the heterogeneity of the injury response in organ transplantation, at different rates and different time points after transplantation, as well as our inability to monitor the immunologic threshold of risk versus safety in each individual patient. Recent advances in immunology/transplantation biology with the advent of high throughput “omic” assays such as gene microarrays, proteomics, metabolomics, antibiomics, chemical genomics and functional imaging with nanoparticles, offers us unique methods to interrogate and decipher the variability and unpredictability of the immune response in organ transplantation () . Recent studies using these applications have uncovered a critical and pivotal role for specific B cell lineages in organ injury and organ acceptance (). The availability of specific therapies against some of these defined B cell populations provides for an exciting new field of B cell targeted manipulation that can both abrogate the allospecific injury response, as well as promote allospecific graft accommodation and health. [Copyright &y& Elsevier]

Abstract: Assessment of temporal lobe atrophy from magnetic resonance images is a part of clinical guidelines for the diagnosis of prodromal Alzheimer''s disease. As hippocampus is known to be among the first areas affected by the disease, fast and robust definition of hippocampus volume would be of great importance in the clinical decision making. We propose a method for computing automatically the volume of hippocampus using a modified multi-atlas segmentation framework, including an improved initialization of the framework and the correction of partial volume effect. The method produced a high similarity index, 0.87, and correlation coefficient, 0.94, with semi-automatically generated segmentations. When comparing hippocampus volumes extracted from 1.5T and 3T images, the absolute value of the difference was low: 3.2% of the volume. The correct classification rate for Alzheimer''s disease and cognitively normal cases was about 80% while the accuracy 65% was obtained for classifying stable and progressive mild cognitive impairment cases. The method was evaluated in three cohorts consisting altogether about 1000 cases, the main emphasis being in the analysis of the ADNI cohort. The computation time of the method is about 2 minutes on a standard laptop computer. The results show a clear potential for applying the method in clinical practice. [Copyright &y& Elsevier]

Abstract: Objectives : Several controversies surround lymphadenectomy for endometrial cancer; surgical approach, who to stage, and the anatomic borders of the lymphadenectomy. The purpose of this study was to identify practice patterns among gynecologic oncologists when performing a lymph node evaluation during staging for endometrial cancer. Methods : A self-administered survey was sent via email to all SGO members on 3 occasions between 2/09 and 4/09. The survey addressed surgical approach, algorithms used to determine staging, and anatomic landmarks defining lymphadenectomy. Results : Four hundred and six members (40%) responded. Eighty-two percent completed fellowship and 14% were fellows. Thirty-four percent finished fellowship in 2000 or later. Eighty-five percent educate fellows/residents in either academic (65%) or private practice settings (20%). For a majority of cases 40% prefer laparotomy, 31% perform robotic surgery, and 29% use laparoscopy. Minimally invasive surgery was associated with university-based practice (p =0.048). Most (53%) never/rarely use frozen section to determine whether or not to perform lymphadenectomy. A majority perform staging on all grade 2 and grade 3 cancers (66% and 90%, respectively). When performing paraaortic lymphadenectomy, 50% of respondents use the IMA as the upper border and 11% take the dissection to the renal vessels. Participants who completed fellowship in 2000 or later were less likely to go to the renal vessels (p =0.002). Conclusion : Current controversies in surgical staging for endometrial cancer are reflected in the practice patterns among gynecologic oncologists. At this point it is unclear if standardizing surgical practice patterns will improve outcomes for patients with endometrial cancer. [ABSTRACT FROM AUTHOR]

Abstract: This 24-week, multicenter, open-label trial was designed to evaluate the dosing, effectiveness, and safety of topiramate monotherapy for epilepsy and to identify patient and clinical characteristics predictive of optimally effective stabilized monotherapy doses. Of 406 randomized patients, 244 comprised the evaluable-for-efficacy population (⩾12weeks of treatment and stabilized topiramate dose during final 28days); 213 were on topiramate monotherapy at the end of the trial. The mean stabilized daily dose of topiramate over the last 28days of treatment (primary endpoint) was significantly lower for patients reporting one to three seizures (low seizure frequency, n =147) than for those reporting more than three seizures (high seizure frequency, n =66) during a 3-month retrospective baseline period (191mg vs 239mg, P =0.003). Patients in the low-seizure-frequency group reached a stable topiramate dose after a median of 36days, compared with 53days for patients in the high-seizure-frequency group. Linear and stepwise regression analyses showed baseline seizure frequency and lifetime seizure count to be significant (P <0.05) predictors of the stabilized dosage. Most treatment-emergent adverse events (TEAEs) were mild to moderate; those occurring with cumulative incidence rates >10% in either seizure frequency group were paresthesia, fatigue, anorexia, dizziness, somnolence, headache, and hypoesthesia; 18.2% of patients discontinued topiramate because of a TEAE, 5.1% reported serious TEAEs, and no deaths were reported during the study. [Copyright &y& Elsevier]

Abstract: Objectives: Recent data has highlighted the role of PET/CT in the pretreatment evaluation and follow-up of patients with cervical cancer. The objective of our study was to assess the acceptance of PET/CT into the management of patients with cervical cancer. We also explored potential barriers to the use of these imaging modalities in patients with cervical cancer. Methods: A 14-item electronic questionnaire was initially sent to all working addresses of members of the SGO (n =1048). An opt-out option was offered. For members who did not respond within 3 weeks, a second electronic invitation was sent. A third request was finally sent to further improve response rates. Data were collected and analyzed using a commercially available on-line survey database. Results: A total of 305 responses were collected for an overall 30% response rate. PET/CT appears to be widely available (99%) and accessible (75%) in most practices. Although 83% of members order routine CT imaging for all newly diagnosed cervical cancer cases, only 28% routinely order a PET/CT. Conversely, 64% would order a PET/CT for newly diagnosed patients with advanced disease or those at high risk for distant metastatic disease. Most members (82%) do not routinely use PET/CT to assess response to treatment. Twenty percent of members believe that no useful prognostic information can be obtained from routine use of molecular imaging in patients with cervical cancer. The most common barriers for use of PET/CT cited by members were perceived lack of third-party payer coverage and lack of scientific evidence. Conclusions: Despite clear scientific data supporting the use of PET/CT in patients with cervical cancer and apparent widespread availability, this imaging modality remains highly underutilized in clinical practice. Clarifying insurance coverage early in the evaluation process and replicating studies that have shown effectiveness of PET/CT in multiple roles may improve adoption of this potentially useful imaging modality. [Copyright &y& Elsevier]

Abstract: Objective. : This article describes the development, reliability, and validity of the Preventive Medicine Attitudes and Activities Questionnaire (PMAAQ). Method. : From 1995 to 2003, the PMAAQ was administered to 353 residents at six primary care residency programs in the United States. Validity was demonstrated in four ways: content validity through an expert panel, calculation of internal consistency reliabilities, demonstration of divergent validity, and external validation using a pre-existent chart review dataset. Stability measures were also calculated. Results. : High internal consistency reliabilities among the eight scales were seen (Cronbach''s α = 0.74 to 0.98). Divergent validity was demonstrated by low to moderate intercorrelations among scales (r = −0.23 to 0.54). Significant correlations were seen between several PMAAQ scales and scales created from chart review data. Two-month test–retest correlations ranged from r = 0.56 to 0.87. Results suggest that clinicians'' attitudes alone are not directly responsible for behaviors. Conclusion. : The PMAAQ can validly and reliably measure residents'' prevention behaviors and provide insight into their preventive healthcare attitudes. This survey could be useful in targeting areas for interventions to improve delivery of clinical preventive services, as a means of evaluating the effectiveness of such interventions, or as a quality assurance tool to monitor physician prevention activities. [Copyright &y& Elsevier]

Background. The goal of this study is to better understand factors related to physician treatment of tobacco as a chronic medical condition.Methods. In the fall of 2000, we conducted a mail survey of primary care physicians in a large mid-western health plan. The response rate was 61% (750/1235). The survey assessed physician attitude, perceived clinic support, training, and self-reported tobacco treatment practices.Results. Twenty-nine percent of physicians reported incomplete or minimal care. Thirty-nine percent reported providing assistance without follow-up, while 21% reported providing follow-up to tobacco users making quit attempts. Only 12% of physicians reported assistance and follow-up for all tobacco users. Controlling for differences in physician and clinic characteristics, more positive physician attitudes decreased incomplete or minimal care (OR = 4.62 most positive tertile vs. least positive, P < 0.001) but did not increase follow-up activities. Higher perceived clinic support increased follow-up care (OR = 2.69, highest tertile vs. lowest, P < 0.001). Physician training was associated with increased provision of ongoing care (OR = 1.88 per additional hour of training, P < 0.001).Conclusions. Physician attitudes, clinic support, and training are related to different steps in the adoption of more complete tobacco use treatment. These findings support the need for multifaceted approaches to improve tobacco treatment as a chronic medical condition. [Copyright &y& Elsevier]

: BackgroundWhile reminders can promote cancer screening in primary care, little is known about the potential interaction between multiple reminders.: MethodsWe conducted a randomized controlled trial to compare the effect of combined Pap smear plus mammogram reminders and mammogram-only reminders among 2471 women 40 years of age or older enrolled in a health maintenance organization serving a predominately Medicaid-eligible population. Reminders included both a mailed letter for the woman and a medical record prompt.: ResultsIntervention assignment was unassociated with differences in rates of visitation to family medicine or internal medicine or completion of mammography during the study year. Compared to women assigned to mammogram-only reminder treatment, those assigned to the combined Pap smear plus mammogram reminder intervention were more likely to visit a gynecologist (34% compared to 29%, adjusted odds ratio = 1.33, 95% confidence interval 1.08–1.63) and to complete a Pap smear (30% compared to 23%, adjusted odds ratio = 1.39, 95% confidence interval 1.07–1.89).: ConclusionsIn the study setting, the addition of Pap smear to mammography reminders has a procedure-specific effect, increasing gynecology visits and Pap smear use while neither increasing nor decreasing other primary care visits or mammography. We find no evidence of reinforcement or competition between these reminders. [Copyright &y& Elsevier]

: BackgroundThe Agency for Health Care Policy and Research (AHCPR) smoking cessation guideline outlines a set of recommendations for physicians to follow in daily practice. However, the effectiveness of this guideline has not been reported. The goal of this project was to evaluate the effect of the AHCPR smoking cessation guideline on provider practices with smokers and on patient smoking rates.: MethodsPatient survey and chart review data from 138 Veterans Administration (VA) acute care medical centers with outpatient facilities were examined. Data were available from both sources in 1996, 1997, and 1998. At the midpoint of this period (1997), the VA recommended the AHCPR smoking cessation clinical practice guideline for implementation throughout the VA healthcare system.: ResultsFrom 1996 to 1998, both the chart audit and the patient survey showed a significant increase in the percentage of patients in the VA who were counseled about smoking and a significant decrease in the percentage of patients who smoke.: ConclusionsBecause the VA tied the guideline implementation to report cards and other performance-enhancing measures, guideline adherence may have been maximized in this setting. These findings suggest that healthcare systems should take an integrated approach to guideline implementation. [Copyright &y& Elsevier]

Background. Nonphysician health care providers are in an optimal position to provide cancer prevention and screening services.Methods. We conducted a survey of primary care physicians to determine physician use and amenability to use of nonphysician health care providers to perform skin cancer screening in comparison with other cancer screening examinations.Results. A total of 1,363 eligible physicians completed the survey. Of these, 631 physicians (46%) reported a nurse practitioner or physician assistant performing at least one type of cancer screening examination on their patients. Twenty-nine and 22% of all physicians reported nurse practitioners or physician assistants performing skin cancer screening, respectively. Family physicians were more likely to use nurse practitioners and physician assistants to perform these cancer screening examinations than internists (χ2 test, P = 0.001 for each examination). Skin examinations were performed less frequently by nurse practitioners and physician assistants than all other cancer screening examinations. A total of 73–79% of family physicians and 60–70% of internists were amenable to having a nonphysician health care provider perform one or more of these examinations.Conclusions. Primary care physicians are currently utilizing nonphysician health care providers to perform cancer screening examinations and the majority of those surveyed are amenable to the use of these providers for such examinations. This suggests that one possible strategy for increasing skin cancer screening is through an expanded role of nonphysician health care providers. [Copyright &y& Elsevier]

To assess SGO membership knowledge, attitudes, and practice patterns regarding Medical Aid In Dying (MAID). SGO members categorized as full member gynecologic oncologists were surveyed via an anonymous RedCap online survey. The survey included questions regarding demographics, knowledge, attitudes, and practice patterns relating to MAID. Descriptive statistics were calculated. Associations between sociodemographic factors and attitudes related to MAID were analyzed utilizing logistic regression. Of 1,337 invited members, 225 (17%) responded. Median age was 46 years old. Most respondents were female (58%), White (81%), and in academic practice (64%). Over 50% had heard of the term MAID and have had a patient ask about MAID. Few respondents (20%) reported living in a state where MAID is legal and 61% of these respondents provided this service. A total of 60% of respondents reported living in a state that had not legalized MAID and 18% of respondents did not know if MAID was legal in their state. Respondents reporting MAID was either illegal or of unknown legal status in their state were asked if they would provide MAID if it was legal in their state; 36% of this group indicated they would provide the service, 30% would not, and 34% were uncertain. The majority of respondents (69%) believed MAID should be legal. Logistic regression analyses demonstrated that female respondents were more likely to support legalization of MAID (OR 2.44 p=<0.05) and respondents practicing in the South were less likely to support legalization of MAID (OR 0.42 p=<0.05). Over 75% of respondents stated an SGO position statement on MAID would be helpful. MAID is a highly relevant topic for gynecologic oncologists and their patients. Support exists among gynecologic oncologists for legalizing and providing MAID more broadly. Major educational, cultural, and policy barriers remain before wider implementation of MAID. Gaps in MAID-related knowledge exist among the SGO membership and there is a desire for additional education and guidance regarding MAID. These findings suggest that there is significant opportunity for member education initiatives regarding this important topic. [ABSTRACT FROM AUTHOR]

Abstract: Authors report a cross-observational study conducted to determine the awareness and adherence of general practioners (GPs) to pertussis vaccine guidelines; to identify the barriers encountered by GPs to adhering to these guidelines; and to describe diagnosis and case management approaches for adolescent and adult pertussis in France. This study, conducted independently of any pharmaceutical companies, concludes that greater awareness of the public health morbidity and mortality of pertussis, intensive immunization adherence for all those in contact with infants, and adherence to routine immunization schedules are necessary to reduce the burden of disease due to Bordetella pertussis. The barriers encountered (the most important were the incomprehension of patients who are not informed about the circulation of pertussis in the adult population and the fact that pertussis is not commercialized as a monovalent vaccine) should be examined further as they do not seem to be related to a lack of GP knowledge. Public information campaigns are needed. The results emphasize the need of policy development for management of pertussis in France. [Copyright &y& Elsevier]