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Review the current literature regarding the optimal approach to pain control in unstable trauma patients, specifically focusing on the initial management of pain and rapid transition to multi-modal agents. There is a clear benefit to multi-modal analgesia instituted as rapidly as possible in trauma patients. While early management of pain depends upon the use of short-acting IV opioids, the rapid transition to adjunctive pain control strategies is optimal. The benefits include not only improved patient experience but also improved physiologic parameters and lower long-term risk of chronic pain and disability. The initial management of pain in unstable trauma patients is focused on titrating short-acting IV opioids to effect. Rapid institutions of multi-modal pain control, however, can improve short-term pain management while reducing the physiologic load imposed by uncontrolled pain and reduce the risk of long-term chronic pain and opioid misuse.

Purpose of Review Communication skills in the ICU are an essential part of the care of trauma patients. The goal of this review is to summarize key aspects of our understanding of communication with injured patients in the ICU. Recent Findings The need to communicate effectively and empathetically with patients and identify primary goals of care is an essential part of trauma care in the ICU. The optimal design to support complex communication in the ICU will be dependent on institutional experience and resources. The best/worst/most likely model provides a structural model for communication. Summary We have an imperative to improve the communication for all patients, not just those at the end of their life. A structured approach is important as is involving family at all stages of care. Communication skills can and should be taught to trainees.

BACKGROUND AND AIMS Prior cross-sectional research finds that electronic cigarette (e-cigarette) use clusters with higher rates of harmful alcohol consumption in the United States adult population. The current study examined prospectively the association between e-cigarette use, cigarette use and the combined use of e-cigarettes and tobacco cigarettes and alcohol use outcomes. DESIGN A nationally representative multi-wave cohort survey (wave 1: September 2013-December 2014, wave 2: October 2014-October 2015). SETTING United States. PARTICIPANTS A representative sample of civilian, non-institutionalized adults who completed waves 1 and 2 of the Population Assessment of Tobacco and Health survey (n = 26 427). MEASUREMENTS Participants were categorized into exposure groups according to their e-cigarette and cigarette use during wave 1. Past 30-day alcohol use outcomes were (1) National Institute on Alcohol Abuse and Alcoholism (NIAAA)-defined hazardous alcohol use, (2) total alcohol drinks consumed and (3) alcohol-related consequences. FINDINGS After controlling for socio-demographic risk factors and alcohol use at wave 1, all exposure groups showed higher odds of hazardous alcohol use [adjusted odds ratios (aORs) = 2.05-2.12, all P

The International Classification of Diseases: 10th Revision (effective from October 2015) included indoor tanning diagnosis codes for the first time. The majority of data on indoor tanning is self-reported. We used a large claims dataset to investigate the patients and settings in which indoor tanning International Classification of Diseases: 10th Revision codes are being used. We included encounters with the International Classification of Diseases: 10th Revision indoor tanning codes in Truven Health MarketScan data 2016-2018, which contain deidentified commercial insurance claims data for approximately 43 million patients. We used descriptive statistics to evaluate patient and encounter characteristics and normalized results using outpatient dermatology encounters. A total of 4,550 encounters were identified, 99.0% of which were outpatient, and 72.3% were with dermatology. Patients were majority female (85.0%) with ages ranging from 7 to 93. The Midwest region had the most indoor tanning encounters. Destruction of a premalignant lesion was performed in 15.1%, and biopsies were performed in 18.4% of encounters, suggesting that encounters may have been for skin cancer surveillance. Increased usage of indoor tanning International Classification of Diseases: 10th Revision codes in the coming years may strengthen the indoor tanning literature. Claims data are a potential tool to better understand patients who have a history of exposure to indoor tanning and their associated risk factors, comorbidities, behaviors, and healthcare utilization.

Importance There are limited reports on the risks of multiple primary skin cancers in organ transplant recipients (OTRs). Objective To determine the risks over time and risk factors for OTRs developing (1) any skin cancer posttransplant, (2) a subsequent skin cancer after the first posttransplant skin cancer in the data sets used in the study, and (3) 10 or more skin cancers. Design, setting, and participants This retrospective cohort study used data from Optum deidentified electronic health record data set (7.7 million patients) and Truven Health MarketScan insurance claims data set (161 million patients) from 2007 to 2017. Skin cancers were identified using diagnosis plus treatment codes for basal cell carcinoma, squamous cell carcinoma, and melanoma; OTRs were identified using 4 or more diagnosis codes for organ transplant. Data analysis took place from January 1, 2007, to December 31, 2017. Main outcomes and measures Cumulative risks of (1) any skin cancer treatment posttransplant, (2) a subsequent skin cancer treatment after the first posttransplant skin cancer treatment in our data, and (3) 10 or more skin cancer treatments in OTRs. A Wei-Lin-Weissfeld marginal model was used to evaluate risk factors for any skin cancer. Results A total of 7390 OTRs in Optum and 133 651 in MarketScan were identified, 4.5% and 13.3% of which had had at least 1 skin cancer treatment, respectively. At 2 years after the initial posttransplant skin cancer in the data sets, OTRs had a 44.0% to 57.0% risk of a subsequent skin cancer treatment and a 3.7% to 6.6% risk of having 10 or more skin cancer treatments. Statistically significant risk factors for any skin cancer included age, history of skin cancer, and history of actinic keratosis in both data sets, and male sex and thoracic transplant in MarketScan. Conclusions and relevance In this retrospective cohort study, approximately half of the OTRs who developed at least 1 posttransplant skin cancer developed a subsequent skin cancer within 2 years, and approximately 1 in 20 developed 10 or more skin cancers. Identifying OTRs at highest risk for multiple primary skin cancers may help target strategies for prevention and early detection.

Introduction Current cigarette smoking rates among older women remain problematic, especially given that this population experiences increased smoking-related health consequences. Despite these increased health concerns, little research to date has explored smoking patterns across the menopausal transition (pre-, early-peri-, late-peri-, and postmenopausal) or the effect of unique factors such as sex hormones and depression during this transition. Methods This study used 10 yearly waves of data from the Study of Women’s Health Across the Nation, a longitudinal dataset. Data included 1397 women endorsing ever smoking regularly at baseline. Random-effects logistic regression models were used to examine smoking transitions. Results Although there were no associations between menopausal transition stage and smoking behavior, increased estradiol was associated with an increased likelihood of quitting regular smoking (eg, transitioning from regular smoking to non-regular or no smoking; odds ratio [OR] = 1.28), whereas increased testosterone was associated with an increased likelihood of relapsing to regular smoking (eg, transitioning from former or nonregular smoking to regular smoking OR = 2.56). Depression was associated with increased likelihood of continued smoking (OR = 0.97) and relapse (OR = 1.03). Conclusions The results emphasize the need to develop interventions to target initiated or continued smoking among women across the menopausal transition and specifically highlight the importance of developing treatments that target depressive symptoms in this population. In addition, although singular hormone measures were associated with smoking behavior, there is a need for future study of dynamic changes in hormones, as well as the impact of progesterone on smoking behaviors across the menopausal transition. Implications To date, no studies have examined smoking behaviors across the menopausal transition. In this study, although menopausal transition status was not significantly related to transitions in smoking behavior, important relationships between sex hormones and depression were observed. Increased estradiol was associated with an increased likelihood of quitting regular smoking, whereas increased testosterone was associated with an increased likelihood of relapsing to regular smoking behavior. Higher depression scores were related to continued smoking and relapse to regular smoking behavior. These results highlight the need to develop interventions to target smoking cessation among women across the menopausal transition.

Background Previous studies have examined the association of statin therapy and breast cancer outcomes with mixed results. The objective of this study was to investigate the clinical effects of incident statin use among individuals with triple-negative breast cancer (TNBC). Methods Data from the Surveillance, Epidemiology, and End Results-Medicare and Texas Cancer Registry-Medicare databases were used, and women aged ≥66 years who had stage I, II, and III breast cancer were identified. Multivariable Cox proportional hazards regression models were used to examine the association of new statin use in the 12 months after a breast cancer diagnosis with overall survival (OS) and breast cancer-specific survival (BCSS). Results When examining incident statin use, defined as the initiation of statin therapy in the 12 months after breast cancer diagnosis, a significant association was observed between statin use and improved BCSS (standardized hazard ratio, 0.42; 95% confidence interval [CI], 0.20-0.88; P = .022) and OS (hazard ratio, 0.70; 95% CI, 0.50-0.99; P = .046) among patients with TNBC (n = 1534). No association was observed with BCSS (standardized hazard ratio, 0.99; 95% CI, 0.71-1.39; P = .97) or OS (hazard ratio, 1.04; 95% CI, 0.92-1.17; P = .55) among those without TNBC (n = 15,979). The results were consistent when examining statin exposure as a time-varying variable. Conclusions Among women with I, II, and III TNBC, initiation of statin therapy in the 12 months after breast cancer diagnosis was associated with an OS and BCSS benefit. Statins may have a role in select patients with breast cancer, and further investigation is warranted.

Although aggression is related to manic symptoms among those with bipolar disorder, new work suggests that some continue to experience elevations of aggression after remission. This aggression post-remission appears related to a more general tendency to respond impulsively to states of emotion, labelled emotion-related impulsivity. We recently developed the first intervention designed to address aggression in the context of emotion-related impulsivity. Here, we describe feasibility, acceptability, and pilot data on outcomes for 21 persons who received treatment for bipolar disorder and endorsed high levels of aggression and emotion-related impulsivity. As with other interventions for aggression or bipolar disorder, attrition levels were high. Those who completed the intervention showed large changes in aggression using the interview-based Modified Overt Aggression Scale that were sustained through three months and not observed during wait list control. Although they also showed declines in the self-rated Buss-Perry Aggression Questionnaire and in self-rated emotion-related impulsivity as assessed with the Feelings Trigger Action Scale, these self-ratings also declined during the waitlist control. Despite the limitations, the findings provide the first evidence that a brief, easily disseminated intervention could have promise for reducing aggression among those with bipolar disorder.

OBJECTIVE: Opioid use disorder (OUD) is a significant problem among US veterans with increasing rates of OUD and overdose, and thus has substantial importance for service delivery within the Veterans Health Administration (VHA). Among individuals with OUD, several sex-specific differences have begun to emerge regarding co-occurring medical, psychiatric and pain-related diagnoses. The rates of such multimorbidities are likely to vary between men and women with OUD and may have important implications for treatment within the VHA but have not yet been studied. METHODS: The present study utilized a data set that included all veterans receiving VHA health care during Fiscal Year (FY) 2012 (October 1, 2011 through September 30, 2012), who were diagnosed during the year with opioid dependence or abuse. VHA patients diagnosed with OUD nationwide in FY 2012 were compared by sex on proportions with OUD, and among those with OUD, on sociodemographic characteristics, medical, psychiatric and pain-related diagnoses, as well as on service use, and psychotropic and opioid agonist prescription fills. RESULTS: During FY 2012, 48,408 veterans were diagnosed with OUD, 5.77% of whom were women. Among those veterans with OUD, few sociodemographic differences were observed between sexes. Female veterans had a higher rate of psychiatric diagnoses, notably mood, anxiety and personality disorders, as well as higher rates of pain-related diagnoses, such as headaches and fibromyalgia, while male veterans were more likely to have concurrent, severe medical co-morbidities, including hepatic disease, HIV, cancers, peripheral vascular disease, diabetes and related complications, and renal disease. There were few differences in health service utilization, with women reporting greater receipt of prescriptions for anxiolytic/sedative/hypnotics, stimulants and lithium. Men and women did not differ in receipt of opioid agonist medications or mental health/substance use treatments. CONCLUSIONS: There are substantial sex-specific differences in patterns of multimorbidity among veterans with OUD, spanning medical, psychiatric and pain-related diagnoses. These results illustrate the need to view OUD as a multimorbid condition and design interventions to target such multimorbidities. The present study highlights the potential benefits of sex-specific treatment and prevention efforts among female veterans with OUD and related co-occurring disorders.

Mikayla R Thompson,1 Jiangong Niu,2 Xiudong Lei,2 Malgorzata Nowakowska,3 Mackenzie R Wehner,2,4 Sharon H Giordano,2,5 Kevin T Nead6,7 1Department of Epidemiology and Environmental Health, University at Buffalo School of Public Health and Health Professions, Buffalo, NY, USA; 2Department of Health Services Research, University of Texas MD Anderson Cancer Center, Houston, TX, USA; 3Department of Medicine, Baylor College of Medicine, Houston, TX, USA; 4Department of Dermatology, University of Texas MD Anderson Cancer Center, Houston, TX, USA; 5Department of Breast Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA; 6Department of Epidemiology, University of Texas MD Anderson Cancer Center, Houston, TX, USA; 7Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USACorrespondence: Kevin T Nead Tel +1 713 563-5155Email ktnead@mdanderson.orgPurpose: Prior studies have reported differing results regarding the association between endocrine therapy (ET) in the treatment of breast cancer and dementia risk. However, existing findings may be limited by common sources of bias and confounding. Here we investigate the association of ET utilized in the definitive setting to treat non-metastatic breast cancer with dementia risk accounting for multiple potential sources of bias and confounding.Patients and Methods: We conducted a retrospective study in SEER-Medicare of women aged ≥ 66 years with non-metastatic breast cancer. We examined the risk of all-cause dementia among ET users versus non-ET users using multivariable regression models, accounting for the competing risk of death, and using a start of the follow-up period as 12-months following breast cancer diagnosis for both groups to avoid immortal time bias.Results: Among 25,777 individuals there were 2,869 incident dementia cases. We found a statistically significantly decreased risk of any dementia among ET users in unadjusted and adjusted models that completely attenuated when accounting for the competing risk of death (hazard ratio, 0.98; 95% confidence interval, 0.90– 1.07).Conclusion: When accounting for common sources of bias and confounding we did not find evidence to support an association between ET in the definitive treatment of non-metastatic breast cancer and dementia risk. These results suggest that ET may not be associated with dementia risk.Keywords: breast cancer, endocrine therapy, dementia, aromatase inhibitors, selective estrogen receptor modulators

Key Points Question How will the landscape of cancer incidences and deaths change in the next 2 decades? Findings In this cross-sectional study, the results estimate that leading cancer incidences and deaths in the US will be notably different in the year 2040 compared with current rankings. Estimates included increases in melanoma incidence, pancreatic cancer deaths, and liver cancer deaths, and decreases in prostate cancer incidence and breast cancer deaths. Meaning These estimates will be important to guide research, health care, and health policy efforts and emphasize the importance of cancer screening, early detection, and prevention., This cross-sectional study examines recent data from the Surveillance, Epidemiology, and End Results Program and US Census to estimate projections for US cancer incidence and deaths to 2040., Importance Coping with the current and future burden of cancer requires an in-depth understanding of trends in cancer incidences and deaths. Estimated projections of cancer incidences and deaths will be important to guide future research funding allocations, health care planning, and health policy efforts. Objective To estimate cancer incidences and deaths in the United States to the year 2040. Design and Setting This cross-sectional study’s estimated projection analysis used population growth projections and current population-based cancer incidence and death rates to calculate the changes in incidences and deaths to the year 2040. Cancer-specific incidences and deaths in the US were estimated for the most common cancer types. Demographic cancer-specific delay-adjusted incidence rates from the Surveillance, Epidemiology, and End Results Program were combined with US Census Bureau population growth projections (2016) and average annual percentage changes in incidence and death rates. Statistical analyses were performed from July 2020 to February 2021. Main Outcomes and Measures Total cancer incidences and deaths to the year 2040. Results This study estimated that the most common cancers in 2040 will be breast (364 000 cases) with melanoma (219 000 cases) becoming the second most common cancer; lung, third (208 000 cases); colorectal remaining fourth (147 000 cases); and prostate cancer dropping to the fourteenth most common cancer (66 000 cases). Lung cancer (63 000 deaths) was estimated to continue as the leading cause of cancer-related death in 2040, with pancreatic cancer (46 000 deaths) and liver and intrahepatic bile duct cancer (41 000 deaths) surpassing colorectal cancer (34 000 deaths) to become the second and third most common causes of cancer-related death, respectively. Breast cancer (30 000 deaths) was estimated to decrease to the fifth most common cause of cancer death. Conclusions and Relevance These findings suggest that there will be marked changes in the landscape of cancer incidence and deaths by 2040.

A 55-year-old man undergoes emergent exploratory laparotomy and splenectomy following a motorcycle collision. Following surgery, he is found to have a traumatic brain injury requiring decompressive craniectomy and intracranial pressure monitoring. The patient then continues to have complications throughout his hospital course. Using the American College of Surgeons Trauma Quality Improvement Program guidelines, the surgical team has early and ongoing primary palliative care discussions to foster communication and determine goals of care for the patient. As the patient deteriorates, the surgical team continues meeting with the patient’s surrogate decision makers to discuss the best case and worst case scenarios regarding the patient’s prognosis and expected quality of life.

BACKGROUND: Rates of alcohol use disorder (AUD) have increased in women in the last decade. Women may be more likely to engage in alcohol use to regulate stress and negative affect compared to men. Findings from our group found that life event stress was more strongly associated with new AUD in women vs. men. Our aim was to extend these findings to psychological distress, a potentially related construct to stress, using a second nationally representative dataset. METHODS: Using data from the National Survey on Drug Use and Health (NSDUH; 2008–2017, total n=562,072), we examined time-varying associations between gender and past year serious psychological distress (SPD; Kessler-6 distress scale: scores >13 yes

Objectives: Studies suggest that men and women have different vulnerabilities to a number of substance use disorders (SUDs). We examined whether differences between women and men with opioid use disorder (OUD) are significantly different from those without OUD for selected sociodemographic and health outcomes. Methods: We used a cross-sectional survey design using data from 2012 to 2013 National Epidemiological Survey on Alcohol and Related Conditions Wave III, which surveyed nationally representative samples of non-institutionalized adults (n = 36,309 unweighted). Past-year OUD and other behavioral co-morbidities were defined using DSM-5 criteria. In bivariate analyses, we investigated sex differences in socio-demographic factors, behavioral co-morbidities, pain, and health-related quality of life (HRQOL) between women and men with past-year OUD, and then those without past-year OUD. We further used logistic regression analyses to evaluate interactions between effect of sex and past-year OUD status on behavioral co-morbidities, pain, and HRQOL. Results: When extrapolated, about 2.1 million US adults met diagnostic criteria for past-year OUD. Women with OUD had a higher likelihood of having several past-year psychiatric disorders, and a lower likelihood of having any past-year SUDs compared to male counterparts. However, similar relationships were observed among those without OUD and significant interaction effects were not found on behavioral co-morbidities, pain, and HRQOL, indicating that general sex differences are not specific to OUD. Conclusions: Although sex differences are not specific to OUD, concurrent disorders are not uncommon among women, as well as men, with OUD. There is a need to treat concurrent behavioral health conditions from a multimorbidity perspective in the treatment of OUD in both sexes.

Background Recent data suggest that excessive alcohol use is increasing among women and older adults. Such trends are concerning, as women are more vulnerable to alcohol-related health consequences, and such health problems may be exacerbated with age. Furthermore, there are sex-specific factors that may influence alcohol consumption among women, including the hormonal changes associated with the menopausal transition and negative affect. The present study sought to investigate transitions in excessive drinking among women across the menopausal transition and included exploration of sex hormones (estradiol; testosterone) and depression. Methods The present study utilized publicly available data from the Study of Women Across the Nation (SWAN) and included 3302 women (42–52 years old at baseline), who completed 10 years of annual assessments. National Institute on Alcohol Abuse and Alcoholism (NIAAA) criteria were used as guidance when defining excessive drinking within the present dataset. At year 1, 170 women were identified as drinking excessively. Random-effect logistic regressions were used to examine transitions in excessive drinking. Results Women identified as excessive drinkers were more likely to transition to non-excessive drinking across all menopausal transition stages (ORs range = 3.71–5.11), while women were more likely to transition from non-excessive to excessive drinking during the early peri- and postmenopausal stages (OR = 1.52 and 1.98, respectively). Higher testosterone levels were associated with a decreased likelihood of transitioning to non-excessive drinking (OR = 0.59). Depression and estradiol levels were not related to transitions in drinking. Conclusions The present study demonstrates that the menopausal transition marks a period of instability in alcohol use among women. Further research is warranted to understand factors related to transitioning in and out of excessive drinking.

The mechanical microenvironment of primary breast tumors plays a substantial role in promoting tumor progression1. While the transitory response of cancer cells to pathological stiffness in their native microenvironment has been well described2, it is still unclear how mechanical stimuli in the primary tumor influence distant, late-stage metastatic phenotypes across time and space in absentia. Here, we show that primary tumor stiffness promotes stable, non-genetically heritable phenotypes in breast cancer cells. This mechanical memory instructs cancer cells to adopt and maintain increased cytoskeletal dynamics, traction force, and 3D invasion in vitro, in addition to promoting osteolytic bone metastasis in vivo. Furthermore, we established a mechanical conditioning (MeCo) score comprised of mechanically regulated genes as a global gene expression measurement of tumor stiffness response. Clinically, we show that a high MeCo score is strongly associated with bone metastasis in patients. Using a discovery approach, we mechanistically traced mechanical memory in part to ERK-mediated mechanotransductive activation of RUNX2, an osteogenic gene bookmarker and bone metastasis driver3,4. Expanding our conceptual model, we reveal for the first time that a mechanically sensitive transcription factor can maintain a temporal profile of chromatin accessibility in vitro and in vivo. The combination of these distinctive RUNX2 traits permits the stable transactivation of osteolytic target genes that remain upregulated after cancer cells disseminate from their activating microenvironment in order to modify a distant microenvironment. Using genetic, epigenetic, and functional approaches, we could simulate, repress, select and extend RUNX2-mediated mechanical memory and alter cancer cell behavior accordingly. In concert with previous studies detailing the influence of biochemical properties of the primary tumor stroma on distinct metastatic phenotypes5–9, our findings detailing the influence of biomechanical properties support a generalized model of cancer progression in which the integrated properties of the primary tumor microenvironment govern the secondary tumor microenvironment, i.e., soil instructs soil.

Psychiatric conditions and sub-threshold psychiatric temperaments may influence entrepreneurs’ affect, cognition, energy, motivation, circadian rhythms, activity levels, self-concept, creativity, and interpersonal behaviors in ways that influence business outcomes. We used a self-report survey to examine the prevalence and co-occurrence of five psychiatric conditions among 242 entrepreneurs and 93 comparison participants. Mental health differences directly or indirectly affected 72% of the entrepreneurs in this sample, including those with a personal mental health history (49%) and family mental health history among the asymptomatic entrepreneurs (23%). Entrepreneurs reported experiencing more depression (30%), ADHD (29%), substance use (12%), and bipolar disorder (11%) than comparison participants. Furthermore, 32% of the entrepreneurs reported having two or more mental health conditions, while 18% reported having three or more mental health conditions. Asymptomatic entrepreneurs (having no mental health issues) with asymptomatic families constituted only 24% of the entrepreneur participants. Entrepreneurs’ psychiatric issues can affect their functioning and that of their ventures. Therefore, integrating knowledge about psychiatric conditions with research on personality traits can broaden the understanding of how mental health-related traits, states, and family history can influence entrepreneurial outcomes. We discuss methodological limitations as well as implications of our findings for entrepreneurship research and practice.

Background: Women experience greater health consequences of alcohol compared to their male counterparts. In recent years, rates of drinking and heavy alcohol use have increased in women while remaining relatively steady in men. Thus, our aim was to newly examine associations between sex, AUD, and the presence of medical conditions in a large nationally representative, cross-sectional dataset. Methods: Using data from the U.S. National Epidemiologic Survey on Alcohol and Related Conditions (NESARC-III; n = 36,309), we evaluated relationships among sex and DSM-5 AUD, and their association with past year clinician-confirmed medical conditions. Results: Women were 1.5 to 2 times more likely to be diagnosed with a past year cancer, pain, respiratory, or other significant medical condition compared to men (odds ratio [OR] = 1.331–2.027). Individuals with an ongoing DSM-5 AUD were nearly 1.5 to 2 times more likely to report a confirmed past year liver, cardiovascular, cancer, or other significant medical condition compared to those without an AUD (OR = 1.437–2.073). Interactive effects demonstrated that women with an ongoing AUD were 2 to 3 times more likely to report a past year doctor- or health professional-confirmed medical condition compared to men; specifically, respiratory conditions and cancers (OR = 1.767–2.713). Conclusions: Results identify that AUD is a critical factor associated with disease that spans organ systems. Associations between AUD and respiratory conditions or cancers are particularly robust in women. Effective interventions for a broad spectrum of medical conditions should consider the role of problematic alcohol use, especially given that rates of drinking in women are increasing.

This cross-sectional study examines sunburn in claims data as well as the clinical settings and demographic characteristics of patients who receive sunburn diagnoses.

Background No established guidelines exist regarding the role of oral antibiotic therapy (OAT) to treat uncomplicated bloodstream infections (uBSIs) and practices may vary depending on clinician specialty and experience. Methods An IRB-exempt web-based survey was emailed to Nebraska Medicine clinicians caring for hospitalized patients, and widely disseminated using social media. The survey was open access and once disseminated on social media, it was impossible to ascertain the total number of individuals who received the survey. Chi-squared analysis for categorical data was conducted to evaluate the association between responses and demographic groups. Results Of 275 survey responses, 51% were via social media, and 94% originated in the United States. Two-thirds of respondents were physicians, 16% pharmacists, and infectious diseases clinicians (IDC) represented 71% of respondents. The syndromes where most were comfortable using OAT routinely for uBSI were urinary tract infection (92%), pneumonia (82%), pyelonephritis (82%), and skin/soft tissue infections (69%). IDC were more comfortable routinely using OAT to treat uBSIs associated with vertebral osteomyelitis and prosthetic joint infections than non-infectious diseases clinicians (NIDC), but NIDC were more likely to report comfort with routine use of OAT to treat uBSIs associated with meningitis and skin/soft tissue infections. IDC were more likely to report comfort with routine use of OAT for uBSIs due to Enterobacteriaceae and gram-positive anaerobes, while NIDC were more likely to be comfortable with routinely using OAT to treat uBSIs associated with S. aureus, coagulase-negative staphylococci and gram-positive bacilli. In one clinical vignette of S. aureus uBSI due to debrided abscess, 11% of IDC would be comfortable using OAT vs 28% of NIDC; IDC were more likely to report routinely repeating blood cultures (99% vs 83%, p< 0.05). Figure 1: Clinician comfort using oral antibiotic therapy to treat uncomplicated bacteremia due to specific syndromes Figure 2: Clinician comfort using oral antibiotic therapy to treat uncomplicated bacteremia due to specific organisms Conclusion Considerable variation in comfort using OAT for uBSIs among IDC vs NIDC exists, highlighting opportunities for IDC to continue to demonstrate their value in clinical practice. Understanding the reasons for variability may be helpful in creating best practice guidelines to standardize decision making. Disclosures All Authors: No reported disclosures

The mechanical microenvironment of primary breast tumors plays a substantial role in promoting tumor progression. While the transitory response of cancer cells to pathological stiffness in their native microenvironment has been well described, it is still unclear how mechanical stimuli in the primary tumor influence distant, late-stage metastatic phenotypes across time and space in absentia. Here, we show that primary tumor stiffness promotes stable, non-genetically heritable phenotypes in breast cancer cells. This mechanical memory instructs cancer cells to adopt and maintain increased cytoskeletal dynamics, traction force, and 3D invasion in vitro, in addition to promoting osteolytic bone metastasis in vivo. Furthermore, we established a mechanical conditioning (MeCo) score comprised of mechanically-regulated genes as a global gene expression measurement of tumor stiffness response. Clinically, we show that a high MeCo score is strongly associated with bone metastasis in patients. Using a discovery approach, we mechanistically traced mechanical memory in part to ERK-mediated mechanotransductive activation of RUNX2, an osteogenic gene bookmarker and bone metastasis driver. The combination of these RUNX2 traits permits the stable transactivation of osteolytic target genes that remain upregulated after cancer cells disseminate from their activating microenvironment in order to modify a distant microenvironment. Using genetic, epigenetic, and functional approaches, we were able to simulate, repress, select and extend RUNX2-mediated mechanical memory and alter cancer cell behavior accordingly. In concert with previous studies detailing the influence of biochemical properties of the primary tumor stroma on distinct metastatic phenotypes, our findings detailing the influence of biomechanical properties support a generalized model of cancer progression in which the integrated properties of the primary tumor microenvironment govern the secondary tumor microenvironment, i.e., soil instructs soil.

Aim Jansen et al. conducted a randomized trial to compare the efficacy of four field treatments for actinic keratosis (AK). Setting and design This was a multicentre, single-blind, randomized trial conducted in the dermatology departments of four Netherlands hospitals. Patients were not blinded. The investigator who evaluated the trial outcome was blinded. Study exposure This study included adult patients with at least five AKs on the face or vertex scalp. Patients were randomized to treatment with fluorouracil 5% cream, imiquimod 5% cream, methyl aminolaevulinate photodynamic therapy (MAL-PDT) or ingenol mebutate 0·015% gel. Outcomes The primary outcome was whether patients had ≥ 75% reduction in AK count 12 months after treatment. Results In total 624 patients participated. The likelihood of having ≥ 75% reduction in AK count 12 months after treatment was significantly higher (twice as high or greater) for fluorouracil than for any other therapy. Approximately 75% of patients treated with fluorouracil experienced ≥ 75% reduction in AK count at 12 months. Conclusions Jansen et al. conclude that 1 year after treatment, fluorouracil was significantly more effective at AK reduction than imiquimod, MAL-PDT or ingenol mebutate.

Background: Current national prevalence estimates of DSM-5 diagnosed substance use disorders (SUDs) among adults with justice system involvement are lacking. Methods: This study drew from NESARC-III data (n = 36,309; 2012–2013), a nationally representative U.S. sample, to examine current and lifetime alcohol use disorder (AUD) and drug use disorder (DUD) diagnoses among adults reporting current or prior drug-related, alcohol-related, and general legal problems. Results: Adults reporting current alcohol-related legal problems were 22 times more likely to have a current AUD diagnosis (AOR = 22.0, 95% CI = 12.1; 40.1) and 15 times more likely to have had a lifetime AUD diagnosis (AOR = 15.2, 95% CI = 7.5; 30.9) than adults without alcohol-related legal problems. Adults with lifetime drug-related legal problems were 3–5 times more likely to have a current (AOR = 2.6, 95% CI = 2.1; 3.2) and lifetime (AOR = 5.1, 95% CI = 4.3; 6.1) DUD diagnosis, with stimulant use disorder being the most prevalent (AOR = 5.4, 95% CI = 4.5; 6.5). Adults with general legal problems were around 3 times more likely to have a current AUD (AOR = 3.2, 95% CI = 2.6; 4.0) or DUD (AOR = 3.5, 95% CI = 2.8; 4.4). Women with any type of legal problem were more likely to have SUD diagnoses than men. Conclusions: SUD diagnoses are prevalent among adults reporting legal problems, particularly those involving alcohol. There is a continued need for community-based addiction prevention and intervention efforts, especially for women with justice system involvement.

523 Background: Statins have been shown to target pathways related to breast cancer carcinogenesis, specifically in more aggressive breast cancer subtypes such as triple negative breast cancer (TNBC). Given the limited toxicity profile, low cost, and ease of use of statins, an association between statin therapy and improved breast cancer outcomes, particularly in aggressive breast cancers with more limited treatment options, could have important public health implications. Here we examine the association of statin therapy with breast cancer outcomes in women with stage I-III breast cancer, specifically TNBC. Methods: We utilized Surveillance, Epidemiology, and End Results (SEER)-Medicare and Texas Cancer Registry (TCR)-Medicare data. We included women age 66 years or older with histologically confirmed stage I-III breast cancer diagnosed from 2008-2015. We used multivariable Cox proportional hazards regression models to examine the association of statin use with overall survival (OS) and breast cancer specific survival (BCSS) adjusting for age, race, education, state buy-in, residence area, stage, subtype, endocrine therapy, radiation, chemotherapy, surgery, baseline statin use, comorbidity, and baseline hypertension. For BCSS, we accounted for the competing risk of death using the Fine and Grey method. We required all individuals to survive until 12 months post-diagnosis, which we defined as the start of the follow-up period, to account for immortal time bias. Results: We identified 45,063 patients with stage I-III breast cancer meeting inclusion criteria, out of which 22,518 (50.0%) received a statin within one year following diagnosis (statin-users). The 5-year cumulative estimates of breast cancer specific deaths were 5.9% and 6.9% for statin-users and non-users (P

Stress and trauma exposure disturbs stress regulation systems and thus increases the vulnerability for stress-related disorders which are characterized by negative affect, including major depressive disorder, anxiety disorders and posttraumatic stress disorder. Similarly, stress and trauma exposure results in increased vulnerability to problematic alcohol use and alcohol use disorder, especially among women, who are more likely to drink to cope with negative affect than their male counterparts. Given these associations, the relationship between stress-related disorders and alcohol use is generally stronger among women leading to complex comorbidities across these disorders and alcohol misuse. This review highlights the therapeutic potential for progestogen- and androgen-derived neurosteroids, which affect both stress- and alcohol-related disorders, to target the overlapping symptoms related to negative affect. This article is part of the special issue on 'Vulnerabilities to Substance Abuse.'

SUMMARY While the immediate and transitory response of breast cancer cells to pathological stiffness in their native microenvironment has been well explored, it remains unclear how stiffness-induced phenotypes are maintained over time after cancer cell dissemination in vivo. Here, we show that fibrotic-like matrix stiffness promotes distinct metastatic phenotypes in cancer cells, which are preserved after transition to softer microenvironments, such as bone marrow. Using differential gene expression analysis of stiffness-responsive breast cancer cells, we establish a multigenic score of mechanical conditioning (MeCo) and find that it is associated with bone metastasis in patients with breast cancer. The maintenance of mechanical conditioning is regulated by RUNX2, an osteogenic transcription factor, established driver of bone metastasis, and mitotic bookmarker that preserves chromatin accessibility at target gene loci. Using genetic and functional approaches, we demonstrate that mechanical conditioning maintenance can be simulated, repressed, or extended, with corresponding changes in bone metastatic potential., Graphical Abstract, In brief Watson et al. demonstrate that mechanical conditioning by stiff microenvironments in breast tumors is maintained in cancer cells after dissemination to softer microenvironments, including bone marrow. They show that mechanical conditioning promotes invasion and osteolysis and establish a mechanical conditioning (MeCo) score, associated with bone metastasis in patients.

Background: Cocaine users often report a loss of arousal for nondrug-related stimuli, which may contribute to their response to drug-related rewards. However, little is known about users’ neural reactivity to emotional nondrug-related stimuli and the potential influence of gender. Objectives: Test the hypotheses that cocaine-dependent individuals have an attenuated neural response to arousing stimuli relative to controls and that this difference is amplified in women. Methods: The brain response to typically arousing positive and negative images as well as neutral images from the International Affective Picture System was measured in 40 individuals (20 non-treatment seeking cocaine-dependent and 20 age- and gender-matched control participants; 50% of whom were women). Images were displayed for 4 s each in blocks of five across two 270-second runs. General linear models assessed within and between group activation differences for the emotional images. Results: Cocaine-dependent individuals had a significantly lower response to typically arousing positive and negative images than controls, with attenuated neural activity present in the medial prefrontal cortex (mPFC) and anterior cingulate cortex (ACC). Analyses by gender revealed less mPFC/ACC activation among female users, but not males, for both positive and negative images. Conclusion: The dampened neural response to typically arousing stimuli among cocaine-dependent polydrug users suggests decreased salience processing for nondrug stimuli, particularly among female users. This decreased responding is consistent with data from other substance using populations and suggests that this may be a general feature of addiction. Amplifying the neural response to naturally arousing nondrug-related reinforcers may present an opportunity for unique behavioral and brain stimulation therapies.

Rationale: Cigarette smoking has antiestrogenic properties, which may worsen the symptoms and health risks associated with menopause.Objectives: In the present study, it was hypothesised that menopausal symptoms would improve with smoking abstinence.Methods: Postmenopausal smokers (n = 76) were assessed with the Kupperman Index (KI) of menopausal symptoms and smoking-related indices of nicotine dependence, cotinine level, cigarettes per day (CPD), and number of years smoking.Results: Participants were 67% Caucasian, 33% African-American, 52.3(SD = 7.8) mean years of age, follicle stimulating hormone (FSH) level, m = 42.6(SD = 25.7) mlU/ml, mean number of months since last menses was 145.1(SD = 118.9), and mean body mass index (BMI) was 27.4(SD = 6.2). Mean cigarettes smoked per day (CPD) was 20.3(SD = 11.5), for m = 29.4(SD = 10.7) years; m = 6.4(SD = 2.1) Fagerström Test for Nicotine Dependence (FTND), m = 23.8(SD = 13.0) ppm carbon monoxide, and m = 19.7(SD = 12.5) KI total score. Most participants (78.9%) were currently taking hormone therapy (HT). Hierarchical linear regression analyses revealed that FTND (β = 0.48, p = 0.001) and cotinine level (β = −0.27, p = 0.02) predicted KI scores at baseline. Amongst participants (n = 65) who achieved abstinence for 2 weeks, number of years smoking predicted KI scores (β = 0.38, p = 0.01). At 8 weeks postcessation, CPD significantly predicted of KI scores (β = −0.74), p = 0.04).Conclusions: With abstinence from smoking, the overall severity of menopausal symptoms decreased and shared variance with different smoking-related variables. The temporal and cessation-related symptom course identified in this study will be important in informing cessation interventions with this population of smokers.

IMPORTANCE: Until now, most studies on cutaneous squamous cell carcinoma (cSCC) incidence rates concerned only the first cSCC per patient. Given the increase in incidence rates and the frequent occurrence of subsequent cSCCs per patient, population-based data on the incidence rates of both first and multiple cSCCs are needed. OBJECTIVES: To calculate annual age-standardized incidence rates for histopathologically confirmed first and multiple cSCCs per patient and to estimate future cSCC incidence rates up to 2027. DESIGN, SETTING, AND PARTICIPANTS: A nationwide population-based epidemiologic cohort study used cancer registry data on 145 618 patients with a first histopathologically confirmed cSCC diagnosed between January 1, 1989, and December 31, 2017, from the Netherlands Cancer Registry and all patients with multiple cSCCs diagnosed in 2017. MAIN OUTCOMES AND MEASURES: Age-standardized incidence rates for cSCC—standardized to the European Standard Population 2013 and United States Standard Population 2000—were calculated per sex, age group, body site, and disease stage. A regression model with positive slope was fitted to estimate cSCC incidence rates up to 2027. RESULTS: A total of 145 618 patients in the Dutch population (84 572 male patients [58.1%]; mean [SD] age, 74.5 [11.5] years) received a diagnosis of a first cSCC between 1989 and 2017. Based on incident data, European Standardized Rates (ESRs) increased substantially, with the highest increase found among female patients from 2002 to 2017, at 8.2% (95% CI, 7.6%-8.8%) per year. The ESRs for first cSCC per patient in 2017 were 107.6 per 100 000 person-years (PY) for male patients, an increase from 40.0 per 100 000 PY in 1989, and 68.7 per 100 000 PY for female patients, an increase from 13.9 per 100 000 PY in 1989, which corresponds with a US Standardized Rate of 71.4 per 100 000 PY in 2017 for men and 46.4 per 100 000 PY in 2017 for women. Considering multiple cSCCs per patient, ESRs increased by 58.4% for men (from 107.6 per 100 000 PY to 170.4 per 100 000 PY) and 34.8% for women (from 68.7 per 100 000 PY to 92.6 per 100 000 PY). Estimation of ESRs for the next decade show a further increase of 23.0% for male patients (ESR up to 132.4 per 100 000 PY [95% prediction interval, 125.8-139.0 per 100 000 PY]) and 29.4% for female patients (ESR up to 88.9 per 100 000 PY [95% prediction interval, 84.3-93.5 per 100 000 PY]). CONCLUSIONS AND RELEVANCE: This nationwide epidemiologic cohort study suggests that incidence rates of cSCC keep increasing, especially among female patients, and that the occurrence of multiple cSCCs per patient significantly adds to the current and future burden on dermatologic health care. Revision of skin cancer policies are needed to halt this increasing trend.

Despite considerable health risks due to lower levels of estrogen production and the compounding antiestrogenic effects of nicotine, postmenopausal females continue to smoke. These females face significant barriers to cessation, including negative affect, weight concerns, and menopausal symptom severity. The current pilot study explored the effect of negative affect, weight concerns, and menopausal symptom severity on motivation and readiness to quit smoking. Eighteen postmenopausal smokers were randomized to receive brief motivational interviewing (B-MI; n = 8) or control treatment (i.e., a 1-hour video, n = 10). Participants completed measures of negative affect, weight concerns, and menopausal symptoms, as well as measures of motivation and readiness to quit. Motivation and readiness to quit were reassessed one week following treatment. At baseline, weight concerns, specifically surrounding smoking to prevent overeating, were identified as related to increased motivation to quit smoking. Menopausal symptom severity, specifically somatic symptoms, assessed at baseline, was associated with increased readiness for cessation. B-MI did not increase motivation or readiness to quit; however, results indicate that cigarettes per day decreased from baseline to follow-up by approximately 20-30%. These results provide valuable insight into enhancing engagement in a cessation treatment among this population. (PsycINFO Database Record

Despite the need for a strong Science, Technology, Engineering, and Math (STEM) workforce, there is a high attrition rate for students who intend to complete undergraduate majors in these disciplines. Students who leave STEM degree programs often cite uninspiring instruction in introductory courses, including traditional lecturing, as a reason. While undergraduate courses play a critical role in STEM retention, little is understood about the instructional transitions students encounter upon moving from secondary to post-secondary STEM courses. This study compares classroom observation data collected using the Classroom Observation Protocol for Undergraduate STEM (COPUS) from over 450 middle school, high school, introductory-level university, and advanced-level university classes across STEM disciplines. We find similarities between middle school and high school classroom instruction, which are characterized by a large proportion of time spent on active-learning instructional strategies, such as small-group activities and peer discussion. In contrast, introductory and advanced university instructors devote more time to instructor-centered teaching strategies, such as lecturing. These instructor-centered teaching strategies are present in classes regardless of class enrollment size, class period length, or whether or not the class includes a separate laboratory section. Middle school, high school, and university instructors were also surveyed about their views of what STEM instructional practices are most common at each educational level and asked to provide an explanation of those perceptions. Instructors from all levels struggled to predict the level of lecturing practices and often expressed uncertainty about what instruction looks like at levels other than their own. These findings suggest that more opportunities need to be created for instructors across multiple levels of the education system to share their active learning teaching practices and discuss the transitions students are making between different educational levels.

BACKGROUND: Blunt cerebrovascular injuries (BCVI) are rare with nonspecific predictors, making optimal screening critical. Radiation concerns magnify these issues in children. The Eastern Association for the Surgery of Trauma (EAST) criteria, the Utah score (US) and the Denver criteria (DC) have been advocated for pediatric BCVI screening, though direct comparison is lacking. We hypothesized that current screening guidelines inaccurately identify pediatric BCVI. METHODS: This was a retrospective cohort study of pediatric trauma patients treated from 2005-2015 with radiographically confirmed BCVI. Our primary outcome was a false negative screen, defined as a patient with a BCVI who would not have triggered screening. RESULTS: We identified 7440 pediatric trauma admissions and 96 patients (1.3%) had 128 BCVIs. Median age was 16 (13, 17) years. A cervical-spine fracture was present in 41%. There were 83 internal carotid injuries, of which 73% were grade I or II as well as 45 vertebral injuries, of which 76% were grade I or II, p=0.8. More than 1 vessel was injured in 28% of patients. A cerebrovascular accident (CVA) occurred in 17 (18%); 8 were identified on admission and 9 identified thereafter. The CVA incidence was similar in those with and without aspirin use. EAST screening missed injuries in 17% of patients, US missed 36%, and DC missed 2%. Significantly fewer injuries would be missed using DC than either EAST or US, p

Primary care providers and health systems have prominent roles in guiding effective cancer screening. To characterize variation in screening abnormality rates and timely initial follow-up for common cancer screening tests. Population-based cohort undergoing screening in 2011, 2012, or 2013 at seven research centers comprising the National Cancer Institute-sponsored Population-based Research Optimizing Screening through Personalized Regimens (PROSPR) consortium. Adults undergoing mammography with or without digital breast tomosynthesis (n = 97,683 ages 40–75 years), fecal occult blood or fecal immunochemical tests (n = 759,553 ages 50–75 years), or Papanicolaou with or without human papillomavirus tests (n = 167,330 ages 21–65 years). Breast, colorectal, or cervical cancer screening. Abnormality rates per 1000 screens; percentage with timely initial follow-up (within 90 days, except 9-month window for BI-RADS 3). Primary care clinic-level variation in percentage with screening abnormality and percentage with timely initial follow-up. There were 10,248/97,683 (104.9 per 1000) abnormal breast cancer screens, 35,847/759,553 (47.2 per 1000) FOBT/FIT-positive colorectal cancer screens, and 13,266/167,330 (79.3 per 1000) abnormal cervical cancer screens. The percentage with timely follow-up was 93.2 to 96.7 % for breast centers, 46.8 to 68.7 % for colorectal centers, and 46.6 % for the cervical cancer screening center (low-grade squamous intraepithelial lesions or higher). The primary care clinic variation (25th to 75th percentile) was smaller for the percentage with an abnormal screen (breast, 8.5–10.3 %; colorectal, 3.0–4.8 %; cervical, 6.3–9.9 %) than for the percentage with follow-up within 90 days (breast, 90.2–95.8 %; colorectal, 43.4–52.0 %; cervical, 29.6–61.4 %). Variation in both the rate of screening abnormalities and their initial follow-up was evident across organ sites and primary care clinics. This highlights an opportunity for improving the delivery of cancer screening through focused study of patient, provider, clinic, and health system characteristics associated with timely follow-up of screening abnormalities.

The inhalation of toxic substances is a major threat to the health of miners, and dust containing respirable crystalline silica (α-quartz) is of particular concern, due to the recent rise in cases of coal workers' pneumoconiosis and silicosis in some U.S. mining regions. Currently, there is no field-portable instrument that can measure airborne α-quartz and give miners timely feedback on their exposure. The U.S. National Institute for Occupational Safety and Health (NIOSH) is therefore conducting studies to investigate technologies capable of end-of-shift or real-time measurement of airborne quartz. The present study focuses on the potential application of Fourier transform infrared (FT-IR) spectrometry conducted in the diffuse reflection (DR) mode as a technique for measuring α-quartz in respirable mine dust. A DR accessory was used to analyze lab-generated respirable samples of Min-U-Sil 5 (which contains more than 90% α-quartz) and coal dust, at mass loadings in the ranges of 100-600 μg and 600-5300 μg, respectively. The dust samples were deposited onto three different types of filters, borosilicate fiberglass, nylon, and polyvinyl chloride (PVC). The reflectance, R, was calculated by the ratio of a blank filter and a filter with deposited mine dust. Results suggest that for coal and pure quartz dusts deposited on 37 mm PVC filters, measurements of -log R correlate linearly with known amounts of quartz on filters, with R(2) values of approximately 0.99 and 0.94, respectively, for samples loaded up to ∼4000 μg. Additional tests were conducted to measure quartz in coal dusts deposited onto the borosilicate fiberglass and nylon filter media used in the NIOSH-developed Personal Dust Monitor (PDM). The nylon filter was shown to be amenable to DR analysis, but quantification of quartz is more accurate when the filter is "free," as opposed to being mounted in the PDM filter holder. The borosilicate fiberglass filters were shown to produce excessive interference, making quartz quantification impossible. It was concluded that, while the DR/FT-IR method is potentially useful for on-filter measurement of quartz in dust samples, the use of PVC filters produced the most accurate results.

Background Positive Focused Assessment with Sonography in Trauma examination and hypotension often indicate urgent surgery. An abdomen/pelvis computed tomography (apCT) may allow less invasive management but the delay may be associated with adverse outcomes. Methods Patients in the Prospective Observational Multicenter Major Trauma Transfusion study with hypotension and a positive Focused Assessment with Sonography in Trauma (HF+) examination who underwent a CT (apCT+) were compared with those who did not. Results Of the 92 HF+ identified, 32 (35%) underwent apCT during initial evaluation and apCT was associated with decreased odds of an emergency operation (odds ratio .11, 95% confidence interval .001 to .116) and increased odds of angiographic intervention (odds ratio 14.3, 95% confidence interval 1.5 to 135). There was no significant difference in 30-day mortality or need for dialysis. Conclusions An apCT in HF+ patients is associated with reduced odds of emergency surgery, but not mortality. Select HF+ patients can safely undergo apCT to obtain clinically useful information.

© 2017 American Journal of Preventive Medicine The incidence of skin cancer is rising in the U.S., and melanoma, the deadliest form, is increasing disproportionately among young white women. Indoor tanning is a modifiable risk factor for all skin cancers and continues to be used at the highest rates in young white women. Adolescents and young adults report personal appearance–based reasons for using indoor tanning. Previous research has explored the influences on tanning bed use, including individual factors as well as relationships with peers, family, schools, media influences, legislation, and societal beauty norms. Adolescents and young adults also have high rates of social media usage, and research is emerging on how best to utilize these platforms for prevention. Social media has the potential to be a cost-effective way to reach large numbers of young people and target messages at characteristics of specific audiences. Recent prevention efforts have shown that comprehensive prevention campaigns that include technology and social media are promising in reducing rates of indoor tanning among young adults. This review examines the literature on psychosocial influences on indoor tanning among adolescents and young adults, and highlights ways in which technology and social media can be used for prevention efforts.

Importance Population-level disease metrics are critical to guide the distribution of resources and implementation of public health initiatives. Internet search data reflect population interest in health topics and may be an alternative metric of disease characteristics when traditional sources are lacking, such as in basal and squamous cell carcinomas, which are not included in national cancer registries. However, these data are not yet well validated or understood. Objective To evaluate whether state-specific normalized internet search volume correlates with incidence and mortality rates of common cancers in the United States, including melanoma. Design, Setting, and Participants This was a cross-sectional analysis of Google search volume index data and US cancer incidences and mortalities of 8 of the most incident cancers in the United States in 2009 to 2013, at the state level, per the National Program of Cancer Registries. Participants were people performing Google searches and patients diagnosed as having cancers reported to cancer registries. Main Outcomes and Measures Correlation between Google search volumes, normalized to total Google search volume, and National Program of Cancer Registries recorded cancer incidence and mortality rates. Results By state, relative Google search volume statistically significantly correlated with cancer incidence rates in 5 of 8 commonly diagnosed cancers in the United States (colon cancer: R = 0.61; P R = 0.73; P R = 0.51; P R = 0.36; P = .01; and thyroid cancer: R = 0.30; P = .03). For 4 of those 5 cancers (colon cancer: R = 0.61; P R = 0.62; P R = 0.38; P = .006; and melanoma: R = 0.31; P = .03), relative Google search volume also correlated with mortality rates. Conclusions and Relevance Population-level internet search behavior may be a valuable real-time tool to estimate cancer incidence and mortality rates, especially for cancers not included in national registries, such as basal and squamous cell carcinomas.