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Purpose: To create a survey that examines remaining unanswered questions related to the economic and workforce issues in pediatric ophthalmology. Methods: A 12-question survey was distributed to U.S.–based pediatric ophthalmologists on the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) discussion board and various other social media forums. Statistical analysis was performed on the basis of practice setting groups. Results: Two hundred eighty-seven pediatric ophthalmologists completed the survey. Of all respondents, 150 (52.3%) believed pediatric ophthalmology is a prestigious subspecialty, 137 (47.7%) thought that a hybrid fellowship combining pediatric ophthalmology and adult cataract surgery would increase the number of practicing pediatric ophthalmologists, 189 (65.9%) felt that early exposure during medical school would increase the number of residents who ultimately apply to pediatric ophthalmology fellowship, and 81 (28.2%) believed that the lobbyists hired by the AAPOS will be successful in preventing further Centers for Medicare and Medicaid Services reimbursement cuts. Medicaid patients comprised more than 25% of the total practice for 156 (54.4%) respondents. New patient, follow-up, and surgery wait times were greater than 2 months in 50.9%, 46.7%, and 38.7% of respondents, respectively. Conclusions: As the economic crisis in pediatric ophthalmology continues to worsen, questions related to increasing interest in the field through early exposure, hybrid fellowship, prestige, appointment wait times, and belief in the success of AAPOS lobbyists remain. Exceptional measures are required to revitalize the field and improve access to care. [ J Pediatr Ophthalmol Strabismus . 2023;60(3):163–169.]

Purpose: To identify new patient, follow-up, and surgery appointment wait times for children seeking care at academic eye centers/children's hospitals (AEC/CHs) in the setting of very low Medicaid reimbursements and workforce issues in pediatric ophthalmology. Methods: Each state in the United States with AEC/CHs was contacted by phone or email. Using a standardized script, the authors inquired about approximate wait times for non-emergency new patient, follow-up, and surgery appointment times, as well as percentage of patients insured by Medicaid seen at the AEC/CH. Medicaid reimbursements for new patient visits, follow-up visits, sensorimotor examinations, and one-muscle strabismus surgery were examined for each state. Results: The mean percentage of children enrolled in Medicaid across the United States was 38.0%. Appointment and Medicaid inquiry calls were conducted across 41 states. Mean wait times across the United States for new patient, follow-up, and surgery appointments were 3.9, 3.4, and 2.7 months, respectively. Mean percentage of patients insured by Medicaid at AEC/CHs was 57.1%. High Medicaid-insured states offered longer wait times for new patient appointments than low Medicaid-insured states (4.4 versus 3.5 months; P = .20). The lowest Medicaid reimbursements for new patient visit, follow-up visit, sensorimotor examination, and one-muscle strabismus surgery occurred in Illinois, California, Ohio, and Michigan, respectively. Conclusions: Across the United States, states with higher percentages of patients insured by Medicaid exhibited longer new patient appointment wait times, suggesting that challenges related to Medicaid reimbursements directly contribute to disparities in access to pediatric eye care. [ J Pediatr Ophthalmol Strabismus . 2023;60(3):170–177.]

Purpose: To investigate the factors influencing residents' choice to pursue a pediatric ophthalmology fellowship. Methods: A nine-question survey was distributed to third-year (PGY-4) ophthalmology residents of United States—based Accreditation Council for Graduate Medical Education residency training programs in ophthalmology. Results: One hundred two of 502 residents completed the survey. Fifty percent of all respondents had no debt and 14.7% had more than $300,000 in debt. Forty-four (43.1%) rated the quality of pediatric ophthalmology teaching in their residency program as “excellent,” 37 (36.3%) did not enjoy performing clinical ophthalmologic examinations on children, 83 (81.4%) had a clinical role model in pediatric ophthalmology, 29 (28.4%) believed pediatric ophthalmology is a prestigious subspecialty, 47 (46.1%) reported that economic factors influenced their post-residency decisions, 60 (58.8%) believed a hybrid fellowship combining adult cataract surgery and pediatric ophthalmology would be a popular fellowship, and 58 (56.9%) had a first-year (PGY-2) residency rotation of at least 1 month in pediatric ophthalmology. Enjoying the ophthalmologic examination of children most strongly predicted whether a resident would pursue a pediatric ophthalmology fellowship (Phi = 0.482). Conclusions: The desire to work with children overwhelmingly superseded other factors influencing a resident's decision to pursue a pediatric ophthalmology fellowship. Improving economic issues may be one of several factors that increase the attractiveness of the pediatric ophthalmology subspecialty. There is a dilemma in encouraging more residents to pursue pediatric ophthalmology in the setting of fewer technological advances consistent with lower perceived prestige. [ J Pediatr Ophthalmol Strabismus . 2023;60(2):95–100.]

Purpose: To discuss the economic downturn of pediatric ophthalmology in the setting of an alarming decline in the number of residents pursuing pediatric ophthalmology and its impact on limiting access to eye care. Methods: Survey studies and articles examining the recent economic impact of reimbursement cuts and practice pattern changes in pediatric ophthalmology were reviewed. Population data from the 2020 U.S. Census Bureau and the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) were analyzed to illustrate provider-to-population relationships by state. Results: Survey studies demonstrated a deteriorating economic situation marked by progression in reimbursement cuts, reductions in pediatric ophthalmologists accepting Medicaid patients, and dwindling numbers of residents pursuing pediatric ophthalmology fellowships. Provider-to-population relationships revealed that pediatric ophthalmologists are not evenly distributed to meet population demand, and that many states are suffering from a shortage of pediatric ophthalmologists. Furthermore, many states with high percentages of Medicaid coverage simultaneously have lower AAPOS members/million person ratios. Conclusions: The simple economic principles of supply and demand reveal a crisis in access to pediatric eye and adult strabismus care. The economic downtown and change in practice patterns may produce rippling effects outside pediatric ophthalmology in fields such as pediatrics and comprehensive ophthalmology. An interdisciplinary effort among health care providers and governmental officials is needed to revive the field of pediatric ophthalmology and improve access to eye care. [ J Pediatr Ophthalmol Strabismus . 2023;60(1):18–24.]

Obesity is increasingly prevalent worldwide and is becoming an epidemic in many countries, including Canada. We sought to describe and analyze temporal obesity trends in the Canadian adult population from 2005 through 2018 at the national and provincial or territorial levels.We conducted a consecutive, cross-sectional study using data from 7 sequential Canadian Community Health Survey (CCHS) cycles (2005 to 2017/18). We included data from Canadian adults (age ≥ 18 yr) who participated in at least 1 of the 7 consecutive CCHS cycles and who had body mass index values (calculated by Statistics Canada based on respondents' self-reported weight and height). Obesity prevalence (adjusted body mass index ≥ 30) was a primary outcome variable. We analyzed temporal trends in obesity prevalence using Pearson χWe included data from 746 408 (403 582 female and 342 826 male) CCHS participants. Across Canada, the prevalence of obesity increased significantly between 2005 and 2017/18, from 22.2% to 27.2% (In 2017/18, more than 1 in 4 adult Canadians lived with obesity, and from 2005 to 2017/18, the prevalence of obesity among adults in Canada increased substantially across sexes, age groups and all Canadian provinces and territories to 27.2%. Our findings call for urgent actions to identify, implement and evaluate solutions for obesity prevention and management in all Canadian provinces and territories.

Intrinsically disordered regions (IDRs) are protein regions that are unable to fold into stable tertiary structures, enabling their involvement in key signaling and regulatory functions via dynamic interactions with diverse binding partners. An understanding of IDRs and their association with biological function may help elucidate the pathogenesis of inherited retinal diseases (IRDs). The main focus of this work was to investigate the degree of disorder in 14 proteins implicated in IRDs and their relationship with the number of pathogenic missense variants. Metapredict, an accurate, high-performance predictor that reproduces consensus disorder scores, was used to probe the degree of disorder as a function of the amino acid sequence. Publicly available data on gnomAD and ClinVar was used to analyze the number of pathogenic missense variants. We show that proteins with an over-representation of missense variation exhibit a high degree of disorder, and proteins with a high amount of disorder tolerate a higher degree of missense variation. These proteins also exhibit a lower amount of pathogenic missense variants with respect to total missense variants. These data suggest that protein function may be related to the overall level of disorder and could be used to refine variant interpretation in IRDs.

Purpose: To create a survey that assesses the economic factors impacting the viability of pediatric ophthalmology between January 2021 and July 2022. Methods: A 12-question survey was distributed to United States–based pediatric ophthalmologists on the American Association for Pediatric Ophthalmology and Strabismus discussion board and various social media fora. Demographic, economic, and workforce pattern data were collected and analyzed. Results: A total of 243 pediatric ophthalmologists completed the survey. One hundred seven (44.0%) respondents reported a surgical revenue decrease between 10% and 25%, 117 (48.1%) a clinical revenue decrease of less than 10%, 111 (45.6%) an overall income decrease of less than 10%, and 127 (52.2%) an overhead cost increase between 10% and 25%. Seventy-two (29.6%) respondents reported subsidizing income with pursuits outside of pediatric ophthalmology, 27 (11.1%) stopped operating due to reimbursement cuts, 75 (30.8%) limited the number of Medicaid or other public funded patients, 16 (6.5%) retired in the past 3 years, and 92 (37.8%) would not recommend a resident pursue a pediatric ophthalmology fellowship. Conclusions: There is a potential upheaval in the field of pediatric ophthalmology marked by increasing levels of disillusionment among current providers, a progressive decline in the number of trainees pursuing fellowship programs, and workforce issues suggestive of diversification of practice patterns outside of pediatric ophthalmology. The current economic crisis, in conjunction with these complex workforce issues, is and will continue to create a shortage of practicing pediatric ophthalmologists, seriously limiting access to pediatric and adult strabismus eye care. [ J Pediatr Ophthalmol Strabismus . 2022;59(6):362–368.]

Purpose: To create a survey that assesses potential solutions for an economic turnaround in pediatric ophthalmology and the frequency of their use. Methods: A 12-question survey was distributed to United States–based pediatric ophthalmologists on the American Association for Pediatric Ophthalmology and Strabismus discussion board and various social media fora. Demographic, economic, and workforce pattern data were collected and analyzed. Results: Three hundred one pediatric ophthalmologists completed the survey. Thirty-one (10.3%) respondents used optical coherence tomography in children with amblyopia, 81 (26.9%) were a partner in an ambulatory surgery center, 133 (44.2%) had a retinopathy of prematurity financial contract arrangement with a neonatal intensive care unit to examine premature children, and 95 (31.6%) had a financial contract arrangement with an optical shop in their office. Twenty-four (8.0%) respondents were currently in the process of being or had been bought out by a private equity investor, 52 (17.3%) owned a Spot Vision Screener (Welch Allyn) for refraction, 158 (52.5%) had hired a pediatric ophthalmology extender (pediatric optometrist, technician, or orthoptist), 87 (29.5%) had recently increased their marketing profile, and 90 (29.9%) owned the property that their practice occupied. Conclusions: Potential for a revitalization and economic turnaround in pediatric ophthalmology depends on several income-generating suggestions that simultaneously improve workforce and manpower issues, thus increasing access to pediatric eye care. [ J Pediatr Ophthalmol Strabismus. 2023;60(1):25–32.]

Incidental splenic focal findings are commonly encountered in clinical practice and frequently represent a diagnostic dilemma due to nonspecific imaging features. Most are benign, particularly in patients without a history of malignancy and without symptoms of fever, weight loss, or left upper quadrant or epigastric pain. Incidental malignant splenic processes are exceedingly rare. This article reviews imaging characteristics of incidental focal splenic findings, and proposes a practical approach for management of such findings, which can prevent unnecessary workup and its related drawbacks in clinical practice.

Background To assess the performance of imaging features, including radiomics texture features, in predicting histopathologic tumor grade, AJCC stage, and outcomes [time to recurrence (TTR) and overall survival (OS)] in patients with intrahepatic cholangiocarcinoma (ICC). Methods Seventy-three patients (26 M/47F, mean age 63y) with pre-operative imaging (CT, n = 37; MRI, n = 21; CT and MRI, n = 15] within 6 months of resection were included in this retrospective study. Qualitative imaging traits were assessed by 2 observers. A 3rd observer measured tumor apparent diffusion coefficient (ADC), enhancement ratios (ERs), and Haralick texture features. Blood biomarkers and imaging features were compared with histopathology (tumor grade and AJCC stage) and outcomes (TTR and OS) using log-rank, generalized Wilcoxon, Cox proportional hazards regression, and Fisher exact tests. Results Median TTR and OS were 53.9 and 79.7 months. ICC recurred in 64.4% (47/73) of patients and 46.6% (34/73) of patients died. There was fair accuracy for some qualitative imaging features in the prediction of worse tumor grade (maximal AUC of 0.68 for biliary obstruction on MRI, p = 0.032, observer 1) and higher AJCC stage (maximal AUC of 0.73 for biliary obstruction on CT, p = 0.002, observer 2; and AUC of 0.73 for vascular involvement on MRI, p = 0.01, observer 2). Cox proportional hazards regression analysis showed that CA 19–9 [hazard ratio (HR) 2.44/95% confidence interval (CI) 1.31–4.57/p = 0.005)] and tumor size on imaging (HR 1.13/95% CI 1.04–1.22/p = 0.003) were significant predictors of TTR, while CA 19–9 (HR 4.08/95% CI 1.75–9.56, p = 0.001) and presence of metastatic lymph nodes at histopathology (HR 2.86/95% CI 1.35–6.07/p = 0.006) were significant predictors of OS. On multivariable analysis, satellite lesions on CT (HR 2.79/95%CI 1.01–7.15/p = 0.032, observer 2), vascular involvement on MRI (HR 0.10/95% CI 0.01–0.85/p = 0.032, observer 1), and texture feature MRI variance (HR 0.55/95% CI 0.31–0.97, p = 0.040) predicted TTR once adjusted for the independent predictors CA 19–9 and tumor size on imaging. Several qualitative and quantitative features demonstrated associations with TTR, OS, and AJCC stage at univariable analysis (range: HR 0.35–19; p 0.088). Conclusions There was reasonable accuracy in predicting tumor grade and higher AJCC stage in ICC utilizing certain qualitative and quantitative imaging traits. Serum CA 19–9, tumor size, presence of metastatic lymph nodes, and qualitative imaging traits of satellite lesions and vascular involvement are predictors of patient outcomes, along with a promising predictive ability of certain quantitative texture features.

OBJECTIVE. We evaluated the diagnostic utility of CT in emergency department (ED) patients with suspected esophageal perforation and assessed whether subsequent fluoroscopic esophagography is necessary. MATERIALS AND METHODS. This retrospective study included consecutive adult patients presenting to an urban academic tertiary care ED from January 1, 2000, to August 31, 2017, who underwent CT and fluoroscopic esophagography within 1 calendar day (< 27 hours) of each other for suspected esophageal perforation. The use of oral or IV contrast material and the CT findings (i.e., pneumomediastinum, pleural effusion, pneumothorax, unexplained mediastinal fluid or stranding, esophageal wall air or frank esophageal wall disruption, or extraluminal oral contrast material) were documented. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. Surgical or procedural intervention results or clinical follow-up results were the reference standard. RESULTS. One hundred three patients met the inclusion criteria. Sensitivity, specificity, PPV, and NPV for diagnosing esophageal perforation were 100.0%, 79.8%, 32.1%, and 100.0%, respectively, with CT and 77.8%, 98.9%, 87.5%, and 97.9% with fluoroscopic esophagography. Combining CT and fluoroscopic esophagography did not improve sensitivity, specificity, PPV, or NPV relative to using CT alone. The true-positive esophageal perforation rate was 8.7% for CT and 6.8% for fluoroscopic esophagography. When CT showed only pneumomediastinum (n = 51) or no pneumomediastinum (n = 14), the NPV of CT was 100.0%. CT with oral contrast material had a PPV of 38.5%, whereas CT without oral contrast material had a PPV of 26.7%. CONCLUSION. CT has a high NPV similar to that of fluoroscopic esophagography and has greater sensitivity than fluoroscopic esophagography for diagnosing suspected esophageal perforation. Fluoroscopic esophagrams do not provide additional information that changes clinical management beyond the information that CT provides. In ED patients with suspected esophageal perforation, CT with oral contrast material should be considered the initial imaging examination and can obviate fluoroscopic esophagography.

BACKGROUND Before 2011, pegylated interferon plus ribavirin was the standard therapy for chronic hepatitis C. Interferon-free direct-acting antiviral agents were then approved. Although these treatments appear to be more effective, they are substantially more expensive. In anticipation of the need for information regarding the comparative cost-effectiveness of new regimens in a recent therapeutic review, we conducted the analysis to inform listing decision in Canada. METHODS A state-transition model was developed in the form of a cost-utility analysis. Regimens included in the analysis were comprehensive. The cohort under consideration had a mean age of 50 years. The cohort was defined by treatment status and cirrhosis status. Inputs for the model were derived from published sources and validated by clinical experts. RESULTS For each genotype 1 population, at least 1 of the interferon-free agents appeared to be economically attractive compared with pegylated interferon-ribavirin, at a willingness-to-pay of $50 000 per quality-adjusted life-year. The drug that was the most cost-effective varied by population. For genotype 2-4 population, the direct-acting antiviral therapies appeared not to be economically attractive compared with pegylated interferon-ribavirin for the treatment-naive; however, there were direct-acting antiviral therapies that appeared to be attractive when compared with no treatment for the treatment-experienced. INTERPRETATION Public health policy should be informed by consideration of health benefit, social and ethical values, feasibility and cost-effectiveness. Our analysis assists the development of reimbursements and policies for interferon-free direct-acting antiviral agent regimens for chronic hepatitis C infection by informing the last criterion. Considering the rapid development of treatments for chronic hepatitis C, further update and expanded reviews will be necessary.

OBJECTIVE. Optical colonoscopy is a common procedure; more than 14 million are performed annually in the United States. Serious colonoscopy complications are uncommon, but they can be life-threatening if not quickly recognized. CONCLUSION. Optical colonoscopy complications that can be detected at CT include bowel perforation, postprocedural hemorrhage, postpolypectomy syndrome, splenic injury, appendicitis, and diverticulitis. Radiologist awareness of optical colonoscopy complications seen at CT is imperative for appropriate diagnosis and prompt patient management.

This descriptive study explored pastors' beliefs about etiology and treatment of mental illness. Surveys were completed by mail by 202 Korean and Euro-American Presbyterian clergy. Nearly one-third of Korean pastors viewed bad parenting and demon possession as very important causes of mental illness, in contrast to the more than two-thirds of Euro-American pastors who viewed genetics and chemical imbalances as the most important causes. Compared with their Euro-American counterparts, Korean pastors soundly endorsed spiritual treatment of mental illness. The findings of this study suggest the value of understanding the views of pastors working with populations that underutilize formal mental health services.

OBJECTIVE. The purpose of this article is to review infectious, inflammatory, and auto-immune-mediated processes in the gastrointestinal system where diffusion-weighted imaging can be helpful as well as pitfalls associated with its use. CONCLUSION. Diffusion-weighted imaging has become an important and widely used tool in abdominal and pelvic MRI, but it has been used primarily for oncologic applications. As more body MRI protocols are routinely including diffusion-weighted imaging, this sequence can be useful in evaluating an increasing number of nononcologic processes.

Context Because of rising health care costs, wide variations in quality, and increased patient complexity, the US health care system is undergoing rapid changes that include payment reform and movement toward integrated delivery systems. Well-established integrated delivery systems, such as Kaiser Permanente (KP), should work to identify the specific system-level factors that result in superior patient outcomes in response to policymakers' concerns. Comparative health systems research can provide insights into which particular aspects of the integrated delivery system result in improved care delivery. Objective To provide a baseline understanding of comparative health systems research related to integrated delivery systems and KP. Design Systematic literature review. Methods We conducted a literature search on PubMed and the KP Publications Library. Studies that compared KP as a system or organization with other health care systems or across KP facilities internally were included. The literature search identified 1605 articles, of which 65 met the study inclusion criteria and were examined by 3 reviewers. Results Most comparative health systems studies focused on intra-KP comparisons (n = 42). Fewer studies compared KP with other US (n = 15) or international (n = 12) health care systems. Several themes emerged from the literature as possible factors that may contribute to improved care delivery in integrated delivery systems. Conclusions Of all studies published by or about KP, only a small proportion of articles (4%) was identified as being comparative health systems research. Additional empirical studies that compare the specific factors of the integrated delivery system model with other systems of care are needed to better understand the "system-level" factors that result in improved and/or diminished care delivery.

Aim To determine the diagnostic value of pelvic ultrasound following negative abdominal/pelvic computed tomography (CT) in women presenting to the emergency room (ER) with abdominal/pelvic pain, and whether ultrasound altered clinical management in the acute-care setting. Materials and methods Between January 2005 to October 2010, 126 consecutive, non-pregnant women with abdominal/pelvic pain underwent pelvic ultrasound within 24 h following negative abdominal/pelvic CT in the ER. Imaging findings/reports for the CT and ultrasound examinations, and clinical data/outcomes were recorded. The time interval between the CT and ultrasound examinations was calculated. Mean length of stay (LOS) was compared to that of age-matched controls who did not have subsequent ultrasound using the t -test. Results Only 3% (four of 126 cases) of the pelvic ultrasound examinations showed positive findings, all of which were endometrial abnormalities. One patient was diagnosed with an endometrial polyp, whereas the others were lost to follow-up. In none of the four cases was the pelvic ultrasound finding relevant to the acute presentation or altered acute care. The average time between CT to ultrasound was 3 h and 4 min. Mean LOS was 22 h and 13 min for the cohort, and 16 h and 8 min for the age-matched controls, although this was not statistically significant ( p = 0.29). Conclusion Immediate ultrasound re-imaging of the pelvis following negative CT in women with acute abdominal/pelvic pain yields no additional diagnostic information and does not alter acute care.

The purpose of this study was to determine whether additional breast imaging is clinically valuable in the evaluation of patients with gynecomastia incidentally observed on CT of the chest.In a retrospective analysis, 62 men were identified who had a mammographic diagnosis of gynecomastia and had also undergone CT within 8 months (median, 2 months). We compared the imaging findings of both modalities and correlated them with the clinical outcome.Gynecomastia was statistically significantly larger on mammograms than on CT images; however, there was a high level of concordance in morphologic features and distribution of gynecomastia between mammography and CT. In only one case was gynecomastia evident on mammographic but not CT images, owing to cachexia. Two of the 62 men had ductal carcinoma, which was obscured by gynecomastia. Both of these patients had symptoms suggesting malignancy.The appearance of gynecomastia on CT scans and mammograms was highly correlated. Mammography performed within 8 months of CT is unlikely to reveal cancer unless there is a suspicious clinical finding or a breast mass eccentric to the nipple. Men with clinical symptoms of gynecomastia do not need additional imaging with mammography to confirm the diagnosis if they have undergone recent cross-sectional imaging.

The objective of our study was to evaluate the detection rate of central airway stent complications using MDCT as compared with bronchoscopy.A review was performed of all consecutive patients undergoing MDCT and bronchoscopy for suspected complications of airway stents during an 18-month period. MDCT images were interpreted in a blinded fashion by an experienced thoracic radiologist before bronchoscopy was performed, and the accuracy of MDCT was determined using bronchoscopy as the gold standard. MDCT images were specifically assessed for the presence of the following complications: narrowing of stent lumen due to granulation tissue or secretions (or both), stent fracture, stent invasion by adjacent neoplasm, stent migration, and perforation of adjacent airways.The study population was composed of 21 patients, with mean age of 48 years (range, 16-79 years), who underwent tracheal (n = 3), tracheobronchial (n = 7), or bronchial (n = 11) stent placement for benign (n = 13) or malignant (n = 8) airway disorders. Eleven of 21 stents were metallic and the remaining 10 were silicone. Thirty complications were detected in 21 patients, including stent luminal narrowing due to granulation tissue or secretions (or both) (n = 13), stent migration (n = 9), stent fracture (n = 4), stent invasion by adjacent neoplasm (n = 3), and tracheal perforation (n = 1). MDCT accurately detected 29 (97%) of the 30 complications diagnosed by bronchoscopy. There was one false-negative case in which MDCT failed to detect a stent fracture. There were no false-positive diagnoses of stent complications.MDCT is highly accurate for detecting airway stent complications.

The purpose of this study was to describe the MR enterography (MRE) appearance of inflammation of the ileoanal pouch after ileal pouch-anal anastomosis (IPAA) surgery and to correlate it with pouch endoscopic and histopathologic findings.All MRE studies performed between October 1, 2007, and September 30, 2013, for patients who had previously undergone IPAA (n = 54) were retrieved. After review of medical records, the patients who underwent MRE, pouch endoscopy, and biopsy within 90 days (14 men, 14 women; mean age, 42.2 years; range, 24-67 years) were selected for inclusion in the study. Two blinded MRI radiologists in consensus retrospectively evaluated MRE studies for multiple MRI features. Two MRI scores were then calculated: an active and a composite inflammation score. A gastroenterologist retrospectively reviewed the pouch endoscopic images, and a pathologist reviewed the slides; both of these investigators were blinded. Both MRI scores were correlated with the pouch endoscopic and histopathologic findings.The composite MRI score had strong positive correlation with the endoscopic score (r = 0.61; p = 0.0005) but weak positive correlation with the histopathologic score (r = 0.31; p = 0.10, not statistically significant). The active inflammation MRI score had moderate positive correlation with the endoscopic score (r = 0.57; p = 0.0017) and weak positive correlation with the histopathologic score (r = 0.20; p = 0.31, not statistically significant). An MRI score ≥ 4 indicated the best results, with sensitivity of 86%, specificity of 79%, positive predictive value of 80%, negative predictive value of 85%, and accuracy of 82% for pouch inflammation. A positive likelihood ratio of 4.00 and negative likelihood ratio of 0.18 were obtained.In patients who have undergone IPAA surgery, the MRE findings strongly correlate with the pouch endoscopic findings with high sensitivity and positive predictive value for pouch inflammation. Therefore, MRE is a useful noninvasive test performed without ionizing radiation that can be used to evaluate patients with clinical symptoms and possibly alleviate the need for endoscopy in a select patient population.

Spaces that encourage better health are increasingly seen as key to reducing the burden of chronic disease: many larger Canadian public health departments now include built environment (BE) teams, which work with municipalities and land use planners to promote and/or require the development of health-encouraging spaces. In many public health agencies, it is environmental health practitioners who have assumed the new healthy BE role, but at what cost to existing mandates? We argue that reinventing roles to increase BE capacities within environmental health practice would reinforce health protection mandates while building capacity in chronic disease prevention. Significant expansion into the design of healthier built environments may require some reallocation of resources. However, we anticipate that healthier built environments will reduce threats to health and so lessen the need for conventional health protection, while encouraging activities and behaviours that lead to greater population wellness.

Diffusion-weighted imaging (DWI) has become an increasingly used tool in abdominal and pelvic magnetic resonance imaging (MRI), primarily in the oncologic setting. DWI sequences are being added to routine MRI protocols at many institutions, and as its use has spread, more non-oncologic applications have been explored. The purpose of this article is to provide a review of DWI applications in inflammatory, infectious, autoimmune-mediated, and ischemic processes affecting the genitourinary system.

To survey chief residents’ opinion about various aspects of psychotherapy competency determination. Chief residents of various psychiatry residency programs were surveyed. One hundred two chief residents were surveyed. Seventy two (70.58%) completed the survey. Eighty four percent of the respondents reported that they were aware of the competencies. The number of patients required for competency determination in five areas of psychotherapy varied widely among the programs. Global assessment by psychotherapy supervisors was the most commonly used method of competency determination (61%). Nineteen (26%) chief residents opined that not all the faculty members involved in teaching and assessing competencies are qualified to do so. Only 23 (31%) of respondents reported that competency criteria were well integrated into the residency curriculum. The little consistency in psychotherapy competency determination across various programs, the differential preparedness of programs for competencies and the lack of consistent integration of competencies into residency curricula call for development and implementation of more uniform assessment methods. This variability also calls into question the decision to establish a standard in five areas of psychotherapy competency.

Mineral sands mining involves stripping topsoil to access heavy-mineral bearing deposits, which are then rehabilitated to their original state, commonly pasture in south-west Western Australia. Organic amendments such as biosolids (digested sewage sludge) can contribute organic carbon to the rehabilitating system and improve soil chemical fertility and physical conditions. Use of biosolids also introduces the risk of contamination of the soil-plant system with heavy metals, but may be a useful source of trace elements to plants if the concentrations of these elements are low in unamended soil. We expected that biosolids amendment of areas mined for mineral sands would result in increased concentrations of metals in soils and plants, and that metal uptake would be decreased by adding stockpiled topsoil or by liming. A glasshouse experiment growing a mixed annual ryegrass (Lolium rigidum)-subterranean clover (Trifolium subterraneum) sward was conducted using two soil materials (residue sand/clay and conserved topsoil) from a mineral sands mine amended with different rates of biosolids (0, 10, 20, 50 dry t/ha), and including a liming treatment (2 t/ha). Total concentrations of metals (As, Cd, Co, Cr, Cu, Ni, Pb and Zn) in soil increased with increasing rate of biosolids application. Metal uptake was generally lower where topsoil was present and was decreased by liming. With increasing biosolids application, plant metal concentrations increased for Cd, Ni and Zn but decreased or were erratic for other elements. In clover, biosolids application removed the Zn deficiency observed where biosolids were not applied. Plant uptake of all elements increased with increasing biosolids application, suggesting dilution by increased plant biomass was responsible for erratic metal concentration results. Despite the observed increases in uptake of metals by plants, metal concentrations in both species were low and below food standard thresholds. It is unlikely that a single application of biosolids in this system posed a threat from heavy metal contamination of soils or plants, and was beneficial in terms of Zn nutrition of T. subterraneum.

The purpose of this study was to assess changes in accuracy, degree of confidence, and evaluation time in radiography of subtle foot fractures when the text history is supplemented by a graphic indicating the site of pain.Radiographs from 226 foot examinations (three views), including 126 examinations showing one subtle fracture (1-mm displacement) and 100 examinations with normal findings were selected. In the first interpretation session, only a text history was given for 112 examinations, and both text and a graphic indicating the site of pain for 114 examinations. Six months later, a graphic and text history were provided for the 112 cases interpreted without a graphic in the first session, and only text was provided for the other 114 cases. Seven radiologists evaluated the study sets. Sensitivity, specificity, degree of confidence (1-10 scale), and mean interpretation time in seconds were calculated.Use of a graphic increased overall sensitivity for any subtle fracture from 67% to 73% (p0.001), increased degree of confidence from 8.1 without a graphic to 8.4 with a graphic (p0.0001), and decreased the time for interpretation by 6%, from 53 seconds without a graphic to 50 seconds with a graphic (p = 0.006). Specificity changed from 93% without a graphic to 94% with a graphic (p = 0.33). Fractures of the third metatarsal were missed most frequently (74%); this percentage improved to 61% with use of a graphic.A graphic complements the text history by improving sensitivity, degree of confidence, and time for interpretation.

PURPOSE To assess the effects of stage of training, gender, and specialty interest on medical students' breast cancer knowledge, attitudes, and clinical breast examination (CBE) skills as a case study of the progression of physical examination skills during medical education. METHOD In 1996, questionnaires assessing breast cancer knowledge and attitudes were administered to 493 premedical and first-, second-, and third-year medical students at Northwestern University Medical School. Silicone breast models were used to evaluate the CBE proficiency of a subset of 151 students. RESULTS Breast cancer knowledge was positively correlated with stage of training (r = .62), with significant differences between all levels (p < .001). In contrast, first-year medical students attained the highest mean lump-detection sensitivity (61.5%), followed by second-year (53.9%) and third-year (43.5%) students (p < .001, first- vs third-year students; p < .10, second- vs third-year students). There was no significant difference in specificity among the four stages. CONCLUSIONS The results suggest that breast cancer knowledge and attitudes are not related to CBE proficiency, which is a practiced tactile skill. The decline in lump-detection sensitivity with increased stage of training may demonstrate the need for increased attention to palpation skills during the clinical years. These findings are consistent with those of earlier reports that suggest the need for the reinforcement of physical examination skills during clinical education.

OBJECTIVE. 64-MDCT is advantageous for functional imaging because of its high spatial and temporal resolution combined with its length of coverage. Our purpose is to describe the technical aspects of using 64-MDCT for cine CT during coughing and to share our preliminary clinical experience using this method.CONCLUSION. This method is technically feasible and offers a promising alternative to previous cine CT methods for diagnosing tracheomalacia.

The objective of our study was to assess the incidence of associated malignancy when microscopic radial scars and microscopic intraductal papillomas are encountered at percutaneous biopsy for lesions that otherwise reveal benign histopathology.A search of the pathology database for the period from December 14, 2006, through December 21, 2009, identified patients with a microscopic radial scar, a microscopic intraductal papilloma, or both at percutaneous biopsy. Patients whose percutaneous biopsy was performed for a lesion that revealed carcinoma or a high-risk pathology result were excluded to avoid confounding bias, as were patients who had only imaging follow-up. Only patients who underwent surgery solely for the study lesion were included. The lesion type that prompted core biopsy, biopsy guidance and device, sample number, and surgical outcomes were recorded. The incidences of benign, high-risk, and malignant pathology findings from surgery were calculated.The search revealed 35 patients (18 microscopic radial scars, 17 microscopic papillomas) who underwent surgery solely for the study lesion. Stereotactic guidance was used for 15 (43%); ultrasound, for 12 (34%); and MRI, for eight (23%). At surgery, 12 patients (34%) had high-risk histopathology results and 23 (66%) had benign results. No study lesions were upgraded to malignancy.Our study found no evidence of associated malignancy at surgical excision when microscopic radial scars and microscopic intraductal papillomas were encountered at percutaneous biopsy in patients who otherwise had benign histopathology results; thus, routine imaging follow-up may be performed.

Aim To evaluate the diagnostic performance of magnetic resonance urography (MRU) versus retrograde pyelography and/or ureteroscopy (RPU) in the detection of upper urinary tract neoplasms. Materials and methods This retrospective study included 35 patients with suspected upper urinary tract malignancy who underwent MRU and RPU within 6-months in our institution during the study period (February 2002 to January 2007). MRU and RPU reports were reviewed and results recorded. For each patient, the urinary tract was sub-divided into four regions for analysis: left kidney/renal pelvis, left ureter, right kidney/renal pelvis, and right ureter. MRU and RPU results for each patient were compared to a reference standard and the diagnostic performance of both techniques was compared. Results A total of 113 regions were analysed on MRU and 90 regions on RPU. Nineteen neoplasms were identified. Sensitivity, specificity, positive predictive value, and negative predictive value for the detection of urinary tract neoplasms were 63, 91, 60, and 92% for MRU, respectively, and 53, 97, 83, and 88% for RPU, respectively. These differences were not statistically significant ( p >0.05). Conclusion The high negative predictive value of MRU in the present series supports its use as a non-invasive screening examination for excluding the presence of upper urinary tract malignancy.

Epidemiological studies suggest a low incidence of hot flashes in populations that consume dietary soy. The present study examined the effect of soy nuts on hot flashes and menopausal symptoms.Sixty healthy postmenopausal women were randomized in a crossover design to a therapeutic lifestyle changes (TLC) diet alone and a TLC diet of similar energy, fat, and protein content in which one-half cup soy nuts divided into three or four portions spaced throughout the day (containing 25 g soy protein and 101 mg aglycone isoflavones) replaced 25 g of nonsoy protein. During each 8-week diet period, subjects recorded the number of hot flashes and amount of exercise daily. At the end of each 8-week diet period, subjects filled out the menopausal symptom quality of life questionnaire.Compared to the TLC diet alone, the TLC diet plus soy nuts was associated with a 45% decrease in hot flashes (7.5 +/- 3.6 vs. 4.1 +/- 2.6 hot flashes day, respectively, p0.001) in women with4.5 hot flashes/day at baseline and 41% in those withor=4.5 hot flashes/day (2.2 +/- 1.2 vs. 1.3 +/- 1.1, respectively, p0.001). Soy nut intake was also associated with significant improvement in scores on the menopausal symptom quality of life questionnaire: 19% decrease in vasomotor score (p = 0.004), 12.9% reduction in psychosocial score (p = 0.01), 9.7% decrease in physical score (p = 0.045), and a trend toward improvement in the sexual score, with a 17.7% reduction in symptoms (p = 0.129). The amount of exercise had no effect on hot flash reduction.Substituting soy nuts for nonsoy protein in a TLC diet and consumed three or four times throughout the day is associated with a decrease in hot flashes and improvement in menopausal symptoms.

Sarcoidosis is a systemic disease of unknown cause, characterized by widespread non-caseating granulomas. There is a wide spectrum of radiologic manifestations in pulmonary sarcoidosis, providing challenges to radiologists. However, recognition of the key features of sarcoidosis with knowledge of its pathologic background can often allow for specific diagnosis. In this review, we describe the variety of high-resolution CT findings in pulmonary sarcoidosis along with its pathologic features as the basis for radiographic manifestations, and discuss the key features on high-resolution CT for the specific diagnosis of pulmonary sarcoidosis.

To demonstrate that folliculogenesis can be sustained with 200 IU human chorionic gonadotropins (hCG) after FSH-priming and result in pregnancy in women with estrogenic ovulatory dysfunction and risk factors for severe ovarian hyperstimulation syndrome (OHSS).Three women with infertility associated with estrogenic ovulatory dysfunction and hyperinsulinemia who appeared to be at high risk for severe OHSS during gonadotropin therapy.After 10 days of receiving either 150 IU hMG or recombinant FSH, patients were switched to 200 IU hCG/day alone for 2-3 days. 5,000 IU of hCG was then administered followed by either home intercourse, intrauterine insemination or transvaginal oocyte retrieval-embryo transfer.Endovaginal ultrasound measurement of follicle number and size, serum estradiol levels, symptoms of ovarian hyperstimulation, pregnancy test, and evaluation of pregnancy by transvaginal ultrasound.After discontinuation of hMG or recombinant FSH, serum estradiol concentrations continued to rise, and follicles14 mm continued to grow during low-dose hCG administration. All women conceived without developing symptoms of OHSS. Pregnancy outcomes achieved include a term singleton delivery, a term twin delivery, and triplets delivered at 31 weeks gestation.The use of low-dose hCG alone is sufficient for supporting the late stages of folliculogenesis in women with estrogenic ovulatory dysfunction. This ovulation induction regimen appears to support the follicular growth of larger follicles while decreasing the number of smaller preovulatory follicles, thereby reducing a known risk factor for OHSS. We report on the positive pregnancy outcomes in 3 women with estrogenic ovulatory dysfunction and clinically appeared to be at high risk for developing severe OHSS who safely underwent this protocol.

The cytoskeleton plays important roles in cell function and is therefore implicated in the pathogenesis of many human liver diseases, including malignant tumors. The stability of cytokeratin proteins during tumor transformation in human hepatocellular carcinoma has been studied with a molecular approach previously. The results demonstrate that the cytokeratin is modulated in human hepatocellular carcinoma. Besides this, three low molecular weight cytokeratin molecules (named HCC CK) are found.This indicates that these HCC CKs have undergone modulation from the human hepatocyte cytokeratin 18. We also checked the cytokeratin profile of the human hepatoma cell line PLC/PRF/5 with the same methods to ensure the HCC CK molecules are produced by modulation but not protein degradation. The stability of cytokeratin molecules was studied by a different approach. The cytokeratin compositions of human liver cells (Chang cell line) were analysed under the effects of microtubule-disrupting drug (colchicine) by SDS–PAGE, Western blot, immunoprecipitation using a commercially available monoclonal anti-cytokeratin 18 antibody and immunofluorescent staining. Within 1 h of treatment, the microtubule began to collapse and the filamentous structure was shortening. The microtubule had almost collapsed and became fragmented to form a lattice-like network after 24 h of treatment. The cytokeratin was modulated after long-term (24 h) treatment of colchicine, and the molecular weight became 14 kD and the antigenicity was lost. The stability of cytokeratin molecules was related to the intact microtubule network, after disruption of the microtubule the cytokeratin would be modulated. The intact microtubule network was a stabilizing factor of cytokeratin 18 in human liver cells.

To determine the usefulness of a teaching and learning tool used to create structure for advanced pharmacy practice experiences (APPEs) in community pharmacy settings, and to identify differences between respondents' perspectives on the relevance and practicality of implementing specific community pharmacy-related topics during the experience.Community practice faculty members designed a manual that outlined a week-by-week schedule of student activities, consistent with the Center for the Advancement of Pharmaceutical Education (CAPE) outcome-based goals, and included associated teaching, documentation, and assessment tools. The manual was distributed to site preceptors and students.Eighty-six PharmD students responded to a questionnaire upon completion of their community APPE. Student feedback concerning the impact of the manual relative to interactions with site preceptors and their overall learning experience was relatively positive.The manual was an effective teaching and learning tool for students completing a community APPE.

ContextTwo recent reports from the Institute of Medicine cited cross-cultural training as a mechanism to address racial and ethnic disparities in health care, but little is known about residents’ educational experience in this area.ObjectiveTo assess residents’ attitudes about cross-cultural care, perceptions of their preparedness to deliver quality care to diverse patient populations, and educational experiences and educational climate regarding cross-cultural training.Design, Setting, and ParticipantsA survey was mailed in the winter of 2003 to a stratified random sample of 3435 resident physicians in their final year of training in emergency medicine, family practice, internal medicine, obstetrics/gynecology, pediatrics, psychiatry, or general surgery at US academic health centers.ResultsResponses were obtained from 2047 (60%) of the sample. Virtually all (96%) of the residents indicated that it was moderately or very important to address cultural issues when providing care. The number of respondents who indicated that they believed they were not prepared to care for diverse cultures in a general sense was only 8%. However, a larger percentage of respondents believed they were not prepared to provide specific components of cross-cultural care, including caring for patients with health beliefs at odds with Western medicine (25%), new immigrants (25%), and patients whose religious beliefs affect treatment (20%). In addition, 24% indicated that they lacked the skills to identify relevant cultural customs that impact medical care. In contrast, only a small percentage of respondents (1%-2%) indicated that they were not prepared to treat clinical conditions or perform procedures common in their specialty. Approximately one third to half of the respondents reported receiving little or no instruction in specific areas of cross-cultural care beyond what was learned in medical school. Forty-one percent (family medicine) to 83% (surgery and obstetrics/gynecology) of respondents reported receiving little or no evaluation in cross-cultural care during their residencies. Barriers to delivering cross-cultural care included lack of time (58%) and lack of role models (31%).ConclusionsResident physicians’ self-reported preparedness to deliver cross-cultural care lags well behind preparedness in other clinical and technical areas. Although cross-cultural care was perceived to be important, there was little clinical time allotted during residency to address cultural issues, and there was little training, formal evaluation, or role modeling. These mixed educational messages indicate the need for significant improvement in cross-cultural education to help eliminate racial and ethnic disparities in health care.

When normal conscious dogs were given small doses of (NH4)2HPO4 by stomach tube to increase their plasma PO4, the rate of excretion of PO4 increased without change in creatinine clearance. After eating meat, increased PO4 excretion was accompanied by increase in both creatinine clearance and plasma PO4. The calculated rate of tubular reabsorption of PO4 did not change significantly after (NH4)2HPO4 administration, but there was a significant increase in PO4 reabsorption after meat; in comparison there was no change in SO4 reabsorption. Similarly, administration of certain amino acids, which caused an increase in creatinine clearance, also caused a significant increase in PO4 reabsorption. Administration of SO4 with PO4 had no significant effect on PO4 reabsorption. It appears from the results, that PO4 has an apparent tubular maximum rate of reabsorption (Tm) when plasma PO4 alone is varied; but this Tm is not a real maximum because PO4 reabsorption increases above this value after the administration of meat or amino acids, both of which cause an increase in glomerular filtration rate. There is no evidence to suggest that there is any inhibition of PO4 reabsorption by SO4 or amino acids.

Normal conscious dogs were given a meal of meat or doses of individual amino acids by stomach tube. The concentration of amino nitrogen in systemic arterial plasma and the rate of urea production both increased; the magnitude and time course of these increases varied with the individual amino acid administered. There was a relationship between the plasma amino nitrogen concentration and urea production following L-serine, L-alanine, L-proline. dicarboxylic acids and L-cystine similar to that obtained after meat ingestion. It is suggested that these amino acids were transaminated as rapidly as they were absorbed to produce an increase in a general pool of amino acids. Following L-threonine, L-valine, D-serine and immediately after glycine, a small increase in urea production was accompanied by a larger increase in plasma amino nitrogen concentration. It is suggested that these amino acids 'escaped' transamination in the gut wall and liver and that the increase in plasma amino nitrogen was due to a high concentration of the individual amino acid administered.

1-Methyl-1-nitrosourea (MNU) and 1-methyl-3-nitro-1-nitrosoguanidine (MNNG) are carcinogens which methylate nucleic acids and proteins and covalently modify proteins by carbamoylation (MNU) or guanidination (MNNG). Using MNU and MNNG labeled with carbon-14 in the individual carbon positions, the above reactions were quantitated in the isolated guinea pig pancreas, an organ susceptible to tumorigenesis by MNU. Freshly prepared pancreatic lobules were incubated with the labeled drugs (0.03, 0.3 and 1.0 mM) for one hour at 37 degrees C. Alkylated purines from hydrolyzed DNA were separated on Sephadex G10 and acid-soluble nuclear proteins were extracted and separated on polyacrylamide gels. Total uptake of all four labels into lobules was linear with concentration. Acid insoluble radioactivity also increased linearly except for MNNG methylation which plateaued between 0.3 and 1.0 mM. 7-Methylguanine formation by both compounds was approximately ten fold greater than 06-methylation. However, DNA modification by MNU exceeded that by MNNG, especially at the higher drug concentrations. No carbamoylation or guanidination of DNA was detected. Total binding (methylation plus carbamoylation/guanidination) to acid-extractable chromatin proteins was equivalent to DNA modification on a molar basis (approximately 0.35 and 0.08 pmol/microg for exposure to 1.0 mM MNU and MNNG, respectively). All histones were labeled by all drug preparations, with H2A being the principal site of methylation and H2B, H3 and H1 being the major targets of carbamoylation and guanidination. H4 was the least modified histone. Drug binding to cytoplasmic organelles also occurred. These results show a broad spectrum of nuclear and cytoplasmic modification of pancreatic cells by MNU and, to a smaller extent, MNNG.

This essay employs the metagthical theory of emotivism to critique existing theories of presumption, arguing that traditional views have confused the term's emotive force with the criteria for assigning argumentative burdens in any given case.

The effect of a number of structurally related multidentate organic phosphonates on the rate of crystal growth of calcium oxalate was studied as a function of pH. Rate constants were obtained at various concentrations for the phosphonates ethane-1-hydroxy-1,1-diphosphonate (EHDP), nitrilotri(methylenephosphonic acid) (NTMP), N,N,N′,N′-ethylenediaminetetra(methylenephosphonic acid) (ENTNP), and N,N,N′,N′-hexamethylenediaminetetra(methylenephosphonic acid (HMTMP), at pH 5.00, 6.00, and 7.00. The effect of pH on the inhibitory activity of each of the phosphonates was considerable with effective concentrations of inhibitor decreasing two orders of magnitude, in some cases, as the pH was increased. At a given pH the potentially hexadentate ligands, ENTMP and HMTMP, were generally the most effective inhibitors. The results suggested that EHDP, at currently administered doses, provides only a moderate increase in the capacity of human urine to inhibit calcium oxalate crystal growth.

1. The crystal growth inhibitory activity of mixtures of known inhibitors and of mixtures of known inhibitors with normal urine was determined in calcium oxalate monohydrate and hydroxyapatite seeded crystal growth systems. 2. The inhibitory activity of the mixtures was compared with the measured activity of the individual components of the mixtures. All mixtures had inhibitory activity equal to the sum of the activities of their components, with the exception of RNA/urine mixtures in the calcium oxalate monohydrate system. 3. RNA/urine mixtures had inhibitory activity toward calcium oxalate monohydrate crystal growth which was less than would be predicted from the activity of the RNA and of the urine which were added. This reduced inhibitory activity was shown to be due probably to hydrolysis of RNA by the ribonuclease activity normally present in urine. 4. The results of these experiments make it possible to determine quantitatively the contribution of various naturally occurring urinary crystal growth inhibitors to the total measured inhibition observed in urine.