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Sexual harassment (SH) and sexual assault (SA) continue to be a focus of prevention efforts in the U.S. military because of the prevalence and potential to affect the health and readiness of service members. Limited research exists on the association of SH and SA with coping behaviors, such as physical activity, within the military. Data including self-reported SA, SH, and physical activity were obtained from the Millennium Cohort Study, a longitudinal cohort study designed to examine the impact of military service on the health and well-being of service members. A hierarchical regression approach was applied to examine the association between SH or SA and subsequent physical activity levels. Hierarchical regression showed that, among those self-reporting recent SA, the odds of medium-high (300-449 min/week) and high physical activity levels (≥450 min/week) were significantly increased. Although the magnitude of these associations was attenuated with an increasing amount of adjustment, the odds of high physical activity levels remained statistically significant in the fully adjusted model (medium-high: odds ratio [OR] = 1.72, 95% confidence interval [CI] = [1.08, 2.73]; high: OR = 1.58, 95% CI = [1.02, 2.44]). We observed statistically significant negative associations between recent SH and medium-high physical activity levels in adjusted models (OR = 0.70, 95% CI = [0.54, 0.91]). The current results demonstrate that SA is generally associated with increased levels of physical activity among military service members. Analyzing the relationship between sexual trauma and physical activity is valuable because of the high prevalence of SH and SA in the military, long-term health implications including physical and emotional well-being, and potential impact on military readiness. [ABSTRACT FROM AUTHOR]

Background: Quality measurement has become a priority for national healthcare reform, and valid measures are necessary to discriminate hospital performance and support value‐based healthcare delivery. The Commission on Cancer (CoC) is the largest cancer‐specific accreditor of hospital quality in the United States and has implemented Quality of Care Measures to evaluate cancer care delivery. However, none has been formally tested as a valid metric for assessing hospital performance based on actual patient outcomes. Methods: Eligibility and compliance with the Quality of Care Measures are reported within the National Cancer Database, which also captures data for robust patient‐level risk adjustment. Hospital‐level compliance was calculated for the core measures, and the association with patient survival was tested using Cox regression. Results: Seven hundred sixty‐eight thousand nine hundred sixty‐nine unique cancer cases were included from 1323 facilities. Increasing hospital‐level compliance was associated with improved survival for only two measures, including a 35% reduced risk of mortality for the gastric cancer measure G15RLN (HR 0.65, 95% CI 0.58–0.72) and a 19% reduced risk of mortality for the colon cancer measure 12RLN (HR 0.81, 95% CI 0.77–0.85). For the lung cancer measure LNoSurg, increasing compliance was paradoxically associated with an increased risk of mortality (HR 1.14, 95% CI 1.08–1.20). For the remaining measures, hospital‐level compliance demonstrated no consistent association with patient survival. Conclusion: Hospital‐level compliance with the CoC's Quality of Care Measures is not uniformly aligned with patient survival. In their current form, these measures do not reliably discriminate hospital performance and are limited as a tool for value‐based healthcare delivery. [ABSTRACT FROM AUTHOR]

Background: Historically, amputation was the primary surgical treatment for osteosarcoma of the extremities; however, with advancements in surgical techniques and chemotherapies limb salvage has replaced amputation as the dominant treatment paradigm. This study assessed the type of surgical resection chosen for osteosarcoma patients in the twenty-first century.Methods: Utilizing the largest registry of primary osteosarcoma, the National Cancer Database (NCDB), we retrospectively analyzed patients with high grade osteosarcoma of the extremities from 2004 through 2015. Differences between patients undergoing amputation and patients undergoing limb salvage are described. Unadjusted five-year overall survival between patients who received limb salvage and amputation was assessed utilizing Kaplan Meier curves. A multivariate Cox proportional hazard model and propensity matched analysis was used to determine the variables independently correlated with survival.Results: From a total of 2442 patients, 1855 underwent limb salvage and 587 underwent amputation. Patients undergoing amputation were more likely to be older, male, uninsured, and live in zip codes associated with lower income. Patients undergoing amputation were also more likely to have larger tumors, more comorbid conditions, and metastatic disease at presentation. After controlling for confounders, limb salvage was associated with a significant survival benefit over amputation (HR: 0.70; p < 0.001). Although this may well reflect underlying biases impacting choice of treatment, this survival benefit remained significant after propensity matched analysis of all significantly different independent variables (HR: 0.71; p < 0.01).Conclusion: Among patients in the NCDB, amputation for osteosarcoma is associated with advanced age, advanced stage, larger tumors, greater comorbidities, and lower income. Limb salvage is associated with a significant survival benefit, even when controlling for significant confounding variables and differences between cohorts. [ABSTRACT FROM AUTHOR]

Background: For many cancer types, survival is improved when patients receive management at treatment centers that encounter high numbers of patients annually. This correlation may be more important with less common malignancies such as sarcoma. Existing evidence, however, is limited and inconclusive as to whether facility volume may be associated with survival in soft tissue sarcoma.Questions/purposes: The purpose of this study was to examine the association between facility volume and overall survival in patients with soft tissue sarcoma of the extremities. In investigating this aim, we sought to (1) examine differences in the treatment characteristics of high- and low-volume facilities; (2) estimate the 5-year survival by facility volume; and (3) examine the association between facility volume and of traveling a further distance to a high-volume center and overall survival when controlling for confounding factors.Methods: The largest sarcoma patient registry to date is contained within the National Cancer Database (NCDB) and captures > 70% of new cancer diagnoses annually. We retrospectively analyzed 25,406 patients with soft tissue sarcoma of the extremities in the NCDB from 1998 through 2012. Patients were stratified based on per-year facility sarcoma volume and we used univariate comparisons and multivariate proportional hazards analyses to correlate survival measures with facility volume and various other patient-, tumor-, and treatment-related factors. First, we evaluated long-term survival for all variables using the Kaplan-Meier method with statistical comparisons based on the log-rank test. Multiple patient, tumor, and treatment characteristics were compared between the two facility-volume groups and then included them in the multivariate proportional hazards model. Of the 25,406 patients analyzed, 3310 were treated at high-volume centers (≥ 20 patients annually) and 22,096 were treated at low-volume centers. Patient demographics were generally not different between both patient cohorts, although patients treated at high-volume centers were more likely to have larger and higher grade tumors (64% versus 56% size ≥ 5 cm, 28% versus 14% undifferentiated grade, p < 0.001).Results: When controlling for patient, tumor, and treatment characteristics in a multivariate proportional hazards analysis, patients treated at high-volume facilities had an overall lower risk of mortality than those treated at low-volume centers (hazard ratio, 0.81 [0.75-0.88], p < 0.001). Patients treated at high-volume centers were also less likely to have positive margins (odds ratio [OR], 0.59 [0.52-0.68], p < 0.001) and in patients who received radiation, those treated at high-volume centers were more likely to have radiation before surgery (40.5% versus 21.7%, p < 0.001); there was no difference in the type of surgery performed (resection versus amputation) (OR, 1.01 [0.84-1.23], p = 0.883).Conclusions: With the largest patient cohort to date, this database review suggests that certain patients with soft tissue sarcoma of the extremities, particularly those with large high-grade tumors, may benefit from treatment at high-volume centers. Further investigation is necessary to help improve the referral of appropriate patients to high-volume sarcoma centers and to increase the treatment capacity of and access to such centers.Level Of Evidence: Level III, therapeutic study. [ABSTRACT FROM AUTHOR]

Objective. This study investigated patterns of utilization of radiation therapy (RT) and correlated this with overall survival by assessing patients with well-differentiated soft tissue sarcoma of the extremity (STS-E) in the National Cancer Database (NCDB). Methods. All patients diagnosed with well-differentiated STS-E between 1998 and 2006 were identified in the NCDB. Patients were stratified by use of surgery alone versus use of adjuvant RT after surgery and analyzed using multivariate analysis, Kaplan-Meier analysis, and propensity matching. Results. 2113 patients with well-differentiated STS-E were identified in the NCDB for inclusion with a mean follow-up time of 74 months. 69% of patients were treated with surgery alone, while 26% were treated with surgery followed by adjuvant RT. Patients undergoing amputation were less likely to receive adjuvant RT. There was no difference in overall survival between patients with well-differentiated STS treated with surgery alone and those patients who received adjuvant RT. Conclusions. In the United States, adjuvant RT is being utilized in a quarter of patients being treated for well-differentiated STS-E. While the use of adjuvant RT may be viewed as a means to facilitate limb salvage, this large national database review confirms no survival benefit, regardless of tumor size or margin status. [ABSTRACT FROM AUTHOR]

The article presents a study regarding the racial and ethnic variations in substance-related disorders among adolescents in the U.S. The study assesses the variations by administering standardized survey questions using the audio computer-assisted self-interviewing method. It reveals that substance abuse is rampant among adolescents of Native American, white, Hispanic, and multiple race and ethnicity.

The author discusses the "Hearing Health Care for Adults: Priorities for Improving Access and Affordability" report from the National Academies of Sciences, Engineering, and Medicine which focuses on the hearing capacity of adults. Topics discussed include the impact of hearing loss to quality of life, recommendations to improve the affordability of hearing health care, and the significant role of technological advances to persons with hearing loss.

Objective: The purpose of this article was to estimate the prevalence, distribution, and correlates of at-risk alcohol use (especially binge drinking) among middle-aged and elderly persons in the United States and to compare at-risk alcohol use between women and men. Method: Secondary analysis of the 2005 and 2006 National Survey on Drug Use and Health was conducted for 10,953 respondents aged 50 years and older. Among respondents, 6,717 were 50 to 64 years of age and 4,236 were ⩾65 years. Social and demographic variables, alcohol use (including at-risk use), binge drinking, serious psychological distress, and self-rated health were assessed. Results: Overall, 66% of male respondents and 55% of female respondents reported alcohol use during the past year. At-risk alcohol use and binge drinking were more frequent among respondents 50 to 64 years of age relative to respondents aged 65 years or older. In the ⩾65 years old age group, 13% of men and 8% of women reported at-risk alcohol use, and more than 14% of men and 3% of women reported binge drinking. Among male subjects, binge drinking compared with no alcohol use was associated with higher income and being separated, divorced, or widowed, while being employed and nonmedical use of prescription drugs were associated with binge drinking compared with no alcohol use among women. For all respondents, binge drinking relative to no alcohol use was associated with the use of tobacco and illicit drugs. Among women who reported using alcohol, being African American and less educated were associated with binge drinking, but race/ethnicity and educational level were not associated with binge drinking in men who reported using alcohol. Conclusions: At-risk and binge drinking are frequently reported by middle-aged and elderly adults nationwide and are therefore of public health concern. Clinicians working with middle-aged and older adults should screen for binge drinking and coexisting use of other substances. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To estimate the frequency, distribution, and correlates of nonprescription use of pain relievers by middle-aged and elderly persons in the United States. DESIGN: Cross-sectional data analysis of a national community survey. SETTING: The 2005 and 2006 National Surveys on Drug Use and Health. PARTICIPANTS: Ten thousand nine hundred fifty-three respondents aged 50 and older (6,717 aged 50–64 and 4,236 aged ≥65). MEASUREMENTS: Social and demographic variables, detailed assessment of nonprescription use (and abuse) of prescription pain relievers (e.g., acetaminophen with codeine, morphine), substance use, major depression, self-reported medical illnesses, and self-rated health. RESULTS: A small proportion of the sample (1.4%) reported nonprescription use of prescription pain relievers during the previous year. Combinations of acetaminophen and hydrocodone or propoxyphene were the most commonly used drugs. Use was associated with younger age (odds ratio (OR)=2.39, 95% confidence interval (CI)=1.31–4.36), American Indian and Alaska native (OR=8.78, 95% CI=2.50–30.85), and use of marijuana (OR=7.07, 95% CI=3.99–12.53). Fewer than 10% of nonprescription users were abusing these medications or dependent upon them. CONCLUSION: In a representative sample of middle-aged and older adults, nonprescription use of prescription pain relievers is relatively uncommon, but the much higher use by middle-aged adults suggests that, as this cohort ages, the problem may increase in elderly people. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To determine whether there are racial/ethnic differences regarding the relationship of level of blood pressure to change in cognitive function in older people. DESIGN: Longitudinal data 1986 to 1989 on representative, older, community-residing African Americans and whites. Blood pressure levels were assessed and a brief screen of cognitive functioning, the Short Portable Mental Status Questionnaire (SPMSQ), was performed at baseline and 3 years later. SETTING: Five contiguous counties in the Piedmont area of North Carolina. PARTICIPANTS: African-American (n = 2,260) and white (n = 1,876) participants in the Duke Established Populations for Epidemiologic Studies of the Elderly, aged 65 to 105 at baseline. MEASUREMENTS: The outcome measure was change in SPMSQ score over 3 years. Covariates included age; education; gender; self-reported diabetes mellitus, stroke, heart attack, current smoking, and depressive symptomatology; and use of antihypertensive medication. The primary independent variable was measured blood pressure. RESULTS: In unadjusted analyses, a statistically significant U-shaped relationship was found between systolic (but not diastolic) blood pressure levels and change in SPMSQ score over a 3-year period for older white men and women. No such relationships were found between these blood pressure measurements and change in SPMSQ score in older African Americans. These findings remained after adjustment for initial SPMSQ score, demographic characteristics, and use of antihypertensive medication. There were no significant interactions between race and blood pressure on change in cognitive function. CONCLUSION: Decline in cognitive function was associated with extremes of systolic blood pressure in older white people. Although a similar but muted nonsignificant association was found in older African Americans, the curves for the two groups were not significantly different. Further studies in older African Americans are needed. J Am Geriatr... [ABSTRACT FROM AUTHOR]

OBJECTIVES: To determine whether cognitive decline associated with the apolipoprotein E (APOE) ℇ4 allele is different in older African Americans than it is in Caucasians. DESIGN: Performance on a brief screen of cognitive functioning was examined at baseline (N = 1,891) and 4 years later (N = 1,389) to determine the extent to which the presence of APOE ℇ4 affected level of and change in performance, and whether this differed as a function of race, age, initial score, and change in score. SETTING: Five adjacent counties in the Piedmont area of North Carolina. PARTICIPANTS: In 1986, a stratified random household sample of community residents age 65 and older (n = 4,162; 54% African-American, 45% Caucasian, 1% other race) formed the Duke Established Populations for Epidemiologic Studies of the Elderly. Of those available at the sixth annual wave, 76% were genotyped, with 1,891 providing baseline data on this wave, and the available survivors (n = 1,389) providing longitudinal data 4 years later. MEASUREMENTS: The Short Portable Mental Status Questionnaire (SPMSQ), a brief screen of cognitive functioning, was administered to all subjects on both occasions. We examined score at baseline and cognitive decline (i.e., increase of 2+ errors) at follow-up. Control measures included demographic characteristics, health behaviors, health and functional status, and medication use. APOE status was coded as ℇ4 present versus absent. RESULTS: APOE ℇ4 was significantly and uniquely related to lower score at baseline and significantly increased the odds of cognitive decline by 59%. There was no statistically significant interaction between APOE ℇ4 and age, race, initial SPMSQ score, or SPMSQ score at follow-up. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To determine the risk from hypertension for all-cause mortality in a racially mixed sample of community-dwelling older adults. DESIGN: Baseline blood pressure was assessed between 1985 and 1986 in a sample of persons 65 years of age and older from five counties of the Piedmont of North Carolina (N = 4,162). All-cause mortality was monitored annually over the subsequent 6 years as part of the Established Populations for Epidemiologic Studies of the Elderly (EPESE) sponsored by the National Institute on Aging. SETTING: Eighteen percent of all respondents in the sample had a systolic blood pressure of> 160 (17% for whites and 18% for African Americans) and 16% had a diastolic blood pressure of> 90 (14% for whites and 20% for African Americans). During the 6 years of follow-up, 29% of the sample died (with no difference in mortality rates between whites and African Americans). PARTICIPANTS: 4,000 community-dwelling people age 65 years and older; 1,846 were white and 2,154 were African American. MEASUREMENTS: Systolic and diastolic blood pressure and all-cause mortality. RESULTS: Systolic blood pressure positively related to mortality during the 6 years of follow-up (relative risk = 1.05). Among whites the relationship of diastolic pressure to mortality was nonlinear, with those at the upper and lower ends of the distribution at increased risk. Among African Americans, diastolic pressure was unrelated to mortality. The analyses were controlled for age; gender; education; body mass index (BMI); smoking history; taking a medication to manage blood pressure; a history of cancer, diabetes mellitus, heart attack, or stroke; poor subjective health; impaired functional status; and cognitive impairment. CONCLUSIONS: The findings confirm that among older adults there is a significant relationship overall between systolic blood pressure and mortality over 6 years of follow-up in both whites and African Americans. Diastolic pressure was a risk factor for whites only. [ABSTRACT FROM AUTHOR]

Investigates the management of the psychiatric problems of elderly persons from 85 years old and above in the United States. Focus on geriatric syndromes, functional status and multimodal intervention studies; Use on a philosophical approach for patient treatment; Implication of the link between geriatric psychiatry and medicine.

Assesses the sleep complaints of community-dwelling older adults in the United States, using the Duke University Medical Center's Established Populations for Epidemiologic Studies of the Elderly. Association of sleep complaints with various variables; Association between sleep complaints and race in logistic regression analysis.

Background: Previous estimates of the prevalence of seasonal affective disorder (SAD) in community samples have been in the range 2-10%, using methods not derived from DSM algorithms. We report the first community-based study to estimate major and minor depression with a seasonal pattern in a community-based sample using a diagnostic instrument derived from DSM-III-R.Method: A modified version of the Composite International Diagnostic Interview was administered to 8098 subjects in the 48 coterminous states of the USA (the National Comorbidity Survey) to assess the prevalence of major and minor depression with a seasonal pattern.Results: The lifetime prevalence of major depression with a seasonal pattern was 0.4%, and the prevalence of major or minor depression with a seasonal pattern was 1.0%. Among respondents with major depression, male gender and older age were associated with a higher prevalence with a seasonal pattern.Conclusions: Prevalence estimates of major and minor depression with a seasonal pattern are much lower than those found in previous studies of SAD in the community, probably due to the approach to diagnosis used in the present study, which more accurately represents DSM-III-R criteria for major depression with a seasonal pattern. The distribution of the disorder is similar to that found in previous studies except for the higher prevalence among males. [ABSTRACT FROM AUTHOR]

Editorial. Discusses the prevalence of subsyndromal depression among older adults. Depressive symptoms listed in the book `Diagnostic and Statistical Manual of Mental Disorders'; Association between cognitive dysfunction and mood disturbance; Link between motivation and perceived control; Assumption on the comorbidity of depressive symptoms with other psychiatric disorders.

The article reflects on a report from the U.S. National Academies of Sciences, Engineering, and Medicine providing a comprehensive assessment on bringing accessible and affordable hearing health care to people in the U.S. It states the report recommended the Food and Drug Administration (FDA) create a new DFA-regulated device category for wearable hearing devices available over-the-counter to customers. It mentions audiologist services and hearing aids are excluded from Medicare Part B coverage.

Comments on the article "A Brief History of Geriatrics," by John Morley which was published in the November 2004 issue of "The Journals of Gerontology." Significance of Morley's article; Information on geriatrics in the U.S.; Debate about the concept of normal aging.

There are concerns over nonmedical use of prescription stimulants among youths, but little is known about the extent of use among young Asian-Americans, Native Hawaiians/Pacific Islanders (NHs/PIs), and mixed-race individuals--the fastest growing segments of the U.S. population. We examined prevalences and correlates of nonmedical stimulant use (NMSU) and disorder (StiUD) for these underrecognized groups. Whites were included as a comparison. Data were from young individuals aged 12-34 years in the 2005-2012 National Surveys on Drug Use and Health. We used logistic regression to estimate odds of past-year NMSU status. Significant yearly increases in lifetime NMSU prevalence were noted in Whites only. NHs/PIs (lifetime 7.33%, past-year 2.72%) and mixed-race individuals (10.20%, 2.82%) did not differ from Whites in NMSU prevalence (11.68%, 3.15%). Asian-Americans (lifetime 3.83%, past-year 0.90%) had lower prevalences than Whites. In each racial/ethnic group, "Methamphetamine/Desoxyn/Methedrine or Ritalin" was more commonly used than other stimulant groups; "got them from a friend/relative for free" and "bought them from a friends/relative" were among the most common sources. Females had greater odds than males of NMSU (among White, NH/PI, mixed-race individuals) and StiUD (among mixed-race individuals). Young adults (aged 18-25) had elevated odds of NMSU (White, NH/PI); adolescents had elevated odds of StiUD (White, mixed-race). Other substance use (especially marijuana, other prescription drugs) increased odds of NMSU and StiUD. NHs/PIs and mixed-race individuals were as likely as Whites to misuse stimulants. Research is needed to delineate health consequences of NMSU and inform prevention efforts for these understudied, rapidly-growing populations. [ABSTRACT FROM AUTHOR]

Abstract: Objective: The objective was to identify a potential core set of brief screeners for the detection of individuals with a substance use disorder (SUD) in medical settings. Method: Data were from two multisite studies that evaluated stimulant use outcomes of an abstinence-based contingency management intervention as an addition to usual care (National Drug Abuse Treatment Clinical Trials Network trials 006–007). The sample comprised 847 substance-using adults who were recruited from 12 outpatient substance abuse treatment settings across the United States. Alcohol and drug use disorders were assessed by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Checklist. Data were analyzed by factor analysis, item response theory (IRT), sensitivity and specificity procedures. Results: Comparatively prevalent symptoms of dependence, especially inability to cut down for all substances, showed high sensitivity for detecting an SUD (low rate of false negative). IRT-defined severe (infrequent) and low discriminative items, especially withdrawal for alcohol, cannabis and cocaine, had low sensitivity in identifying cases of an SUD. IRT-defined less severe (frequent) and high discriminative items, including inability to cut down or taking larger amounts than intended for all substances and withdrawal for amphetamines and opioids, showed good-to-high values of area under the receiver operating characteristic curve in classifying cases and noncases of an SUD. Conclusion: Findings suggest the feasibility of identifying psychometrically reliable substance dependence symptoms to develop a two-item screen for alcohol and drug disorders. [Copyright &y& Elsevier]

The article discusses the result of the epidemiological study which aims to examine the psychometric properties of diagnostic criteria for prescription analgesic opioid use disorders (OUDs) among adolescents and to identify background predictors of a latent continuum for OUD liability in the U.S. It notes that the study used data from samples of adolescents reporting the nonmedical use of prescription opioids in the use file of the 2006 National Survey of Drug Use and Health (NSDUH). The study examines dependence syndrome DSM-IV criteria for OUDs by using item response theory (IRT) and multiple indicators-multiple cases methods. Results show that abuse symptoms in adolescents are not necessarily less severe that those of dependence on prescription opioids.

Background: Management of clinical stage II or III esophageal cancer requires multidisciplinary care. Multi-institutional care has been associated with worse survival in other malignant diseases. This study aimed to determine the impact of multi-institutional care on survival in patients with stage II or III esophageal cancer., Methods: The 2004 to 2016 National Cancer Database was queried for patients with clinical stage II or III esophageal cancer who received neoadjuvant chemotherapy with or without radiation therapy followed by surgical resection. Patients were stratified into 2 groups: multi-institutional or single-institution care. Survival between groups was compared using Kaplan-Meier and multivariable Cox proportional hazards methods. Multivariable logistic regression was performed to identify factors associated with multi-institutional care., Results: Overall, 11 399 patients met study criteria: 6569 (57.6%) received multi-institutional care and 4,830 (42.4%) received care at a single institution. In a multivariable analysis, factors associated with multi-institutional care were later year of diagnosis, greater distance from treating facility, residence in an urban or rural setting (vs metro), and residence in states without Medicaid expansion. Care at a single institution was associated with Black race, lack of insurance, and treatment at higher-volume or academic centers. Despite these differences, patients who received multi-institutional care had survival comparable to that in patients who received care at a single institution (HR, 0.97; 95% CI, 0.92-1.03; P = .30)., Conclusions: In this National Cancer Database analysis, multi-institutional care was not associated with inferior overall survival. As complex cancer care becomes more regionalized, patients may consider receiving part of their cancer care closer to home, whereas traveling to surgical centers of excellence should be encouraged., (Copyright © 2023 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Religion and spirituality have long been considered important social determinants of human health, and there exists an extensive body of research to support such. End-of-life (EOL) may raise complex questions for individuals about religious and spiritual (R/S) values guiding advance care planning (ACP) and EOL care decisions, including the provision of spiritual care. This commentary will review the history and current national trends of ACP activities for EOL, principally within the United States. It will describe the relationship of religious variables and the attributes of selected research instruments used to study religious variables on ACP and EOL preferences. The review also summarizes unique ACP challenges for patients with neurocognitive disorders and severe mental illness. Findings disclose that higher levels of religiosity, reliance on religious coping, conservative faith traditions, and "belief in God's control over life's length and divine intervention have lower levels of ACP and more intensive EOL care preferences, although the provision of spiritual spiritual care at EOL mitigates intensive EOL care. Based upon the curated evidence, we propose an epistemological justification to consider "faith" as a separately defined religious variable in future ACP and EOL research. This review is relevant to geriatric psychiatrists and gerontological health care professionals, as they may be part of multidisciplinary palliative care teams; provide longitudinal care to patients with neurocognitive disorders and severe mental illness; and may provide diagnostic, emotional, and therapeutic services for patients and families who may struggle with EOL care decisions., (Copyright © 2021 American Association for Geriatric Psychiatry. Published by Elsevier Inc. All rights reserved.)

The great health paradox is that the least expensive and most effective public health measures available for addressing the COVID-19 pandemic-and other society-wide health challenges-have long been ignored and rejected in the United States in favor of more expensive and personalized care. The U.S. medical system is being overwhelmed in part because of this paradox. The authors argue that the country has invested excessively in acute care medical technology while investing insufficiently in its public health infrastructure. In this Invited Commentary, the authors recommend 5 steps that academic medicine should take to increase emphasis on and understanding of public health interventions to address society's health problems: (1) incorporate problem-based learning experiences in the medical school curriculum and community-based clinical rotations in public health departments, (2) better integrate schools of public health and schools of medicine, (3) encourage physicians to pursue public health careers, (4) educate the public about strategies for decreasing chronic illnesses, and (5) increase collaboration with colleagues around the world to identify and track outbreaks., (Copyright © 2022 by the Association of American Medical Colleges.)

Background: Limited data are available to inform the risk of readmission and short-term mortality in musculoskeletal oncology. The goal of this study was to identify factors independently associated with 30-day readmission and 90-day mortality following surgical resection of chondrosarcoma., Methods: We retrospectively reviewed 6653 patients following surgical resection of primary chondrosarcoma in the National Cancer Database (2004-2017). Both demographic and clinicopathologic variables were assessed for correlation with readmission and short-term mortality utilizing univariate and multivariate logistic regression modeling., Results: Of 220 readmissions (3.26%), risk factors independently associated with an increased risk of unplanned 30-day readmission included Charlson-Deyo Comorbidity Index (CDCC) (odds ratio [OR] 1.31; p = 0.027), increasing American Joint Committee on Cancer (AJCC) stage (OR 1.31; p = 0.004), undergoing major amputation (OR 2.38; p = 0.001), and axial skeletal location (OR 1.51; p = 0.028). A total of 137 patients died within 90 days of surgery (2.25%). Risk factors associated with increased mortality included the CDCC (OR 1.60; p = 0.001), increasing age (OR 1.06; p < 0.001), having Medicaid insurance status (OR 3.453; p = 0.005), living in a zip code with a higher educational attainment (OR 1.59; p = 0.003), increasing AJCC stage (OR 2.32; p < 0.001), longer postoperative length of stay (OR 1.015; p = 0.033), and positive surgical margins (OR 2.75; p = 0.001). Although a majority of the cohort did not receive radiation therapy (88.8%), receiving radiotherapy (OR 0.132; p = 0.010) was associated with a decreased risk of short-term mortality., Conclusions: Several tumor, treatment, and patient factors can help inform the risk of readmission and short-term mortality in patients with surgically treated chondrosarcoma., (© 2021. Society of Surgical Oncology.)

Background: There are limited data to inform risk of readmission and short-term mortality in musculoskeletal oncology. The goal of this study was to identify factors independently associated with 30-day readmission and 90-day mortality following surgical resection of osteosarcoma., Methods: We retrospectively reviewed patients (n = 5293) following surgical resection of primary osteosarcoma in the National Cancer Database (2004-2015). Univariate and multivariate methods were used to correlate variables with readmission and short-term mortality., Results: Of 210 readmissions (3.97%), risk factors independently associated with unplanned 30-day readmission included comorbidity burden (odds ratio [OR] 2.4, p = 0.042), Medicare insurance (OR 1.9, p = 0.021), and axial skeleton location (OR 1.5, p = 0.029). A total of 91 patients died within 90 days of their surgery (1.84%). Risk factors independently associated with mortality included age (hazard ratio 1.1, p < 0.001), increasing comorbidity burden (OR 6.6, p = 0.001), higher grade (OR 1.7, p = 0.007), increasing tumor size (OR 2.2, p = 0.03), metastatic disease at presentation (OR 8.5, p < 0.001), and amputation (OR 2.0, p = 0.04). Chemotherapy was associated with a decreased risk of short-term mortality (p < 0.001)., Conclusions: Several trends were clear: insurance status, tumor location and comorbidity burden were independently associated with readmission rates, while age, amputation, grade, tumor size, metastatic disease, and comorbidity burden were independently associated with short-term mortality., (© 2021. Society of Surgical Oncology.)

The coronavirus (COVID-19) pandemic is having profound effects on the lives and well-being of the world's population. All levels of the nation's public health and health care delivery systems are rapidly adjusting to secure the health infrastructure to manage the pandemic in the United States. As the nation's safety net health care systems, academic medical centers (AMCs) are vital clinical and academic resources in managing the pandemic. COVID-19 may also risk the financial underpinnings of AMCs because their cost structures are high, and they may have incurred large amounts of debt over the last decade as they expanded their clinical operations and facilities. This Invited Commentary reviews existing data on AMC debt levels; summarizes relief provided in the Coronavirus Aid, Relief, and Economic Security Act; and suggests policy options to help mitigate risk.

Background: Pancreatic acinar cell carcinoma (pACC) is a rare malignancy and surgical utilization has been historically low in these patients. Contemporary outcomes for this patient population remain unknown., Methods: The 1998-2012 National Cancer Data Base was queried for baseline characteristics in patients with pACC. Patients with potentially operable disease (stage I/II) were grouped by surgical resection. Multivariable logistic regression was used to predict factors associated with resection. Survival was estimated using Kaplan-Meier analysis. A proportional hazards model identified factors associated with overall survival., Results: 980 patients were identified. Mean age at diagnosis was 64 years. Tumors were more common in men (68%), white patients (88%), and within the pancreatic head (57%). Thirty-four percent of patients with localized disease failed to undergo resection. Five-year survival was higher among patients who underwent resection (42% vs. 9%, p < 0.001). In patients with resectable disease, male sex, older age, black race, tumors within the pancreatic head, lower grade tumors and treatment at non-academic centers are associated with failure to undergo surgery., Conclusion: Patients with localized pACC have increased survival after resection. However, in this contemporary analysis, resection continues to be underutilized and new efforts to increase resection rates should be undertaken., (Copyright © 2018 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Background: Current consensus guidelines suggest that gallbladder cancer (GBC) patients with resected T1a disease can be observed while patients with T1b or greater lesions should undergo lymphadenectomy (LNE). The primary aim of this study was to critically explore the impact of LNE in early-stage GBC on overall survival (OS) on a population-based level., Method: The 2004-2014 National Cancer Database was reviewed to identify non-metastatic GBC patients with T1a, T1b, or T2 disease and grouped whether a dedicated LNE was performed. OS and relative survival were assessed using Cox proportional hazard regression analyses before and after propensity score adjustments., Results: 4015 patients were included, 246 (6%) had T1a, 654 (16%) T1b, and 3115 (78%) T2 GBC. The rate of positive lymph nodes was 13%, 12%, and 40% for T1a, T1b, and T2 tumors, respectively. Even after propensity score adjustment, no OS benefit was found if LNE was performed for T1a disease (HR:0.63, 95%CI:0.35-1.13) while OS was improved for T1b (HR:0.65, 95%CI:0.49-0.87) and T2 tumors (HR:0.65, 95%CI:0.57-0.73)., Conclusion: Despite a higher rate of nodal positivity among patients with T1a disease compared to previous reports, there was no impact on survival and current treatment guidelines appear appropriate for the management of T1a disease., (Copyright © 2018 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Background: Gallbladder cancer (GBC) is the most common biliary tract malignancy. Because it commonly metastasizes via lymphatics, portal lymphadenectomy should be included in oncologic resections. This study aimed to compare the oncologic equivalence of the laparoscopic versus open technique by evaluating lymph node (LN) yield., Methods: The 2010-2012 National Cancer Data Base identified patients who underwent laparoscopic or open resection of GBC with dedicated lymphadenectomy. LN yield was compared by resection method. Variables associated with LN yield ≥3 were identified., Results: Of 1524 patients identified, 52% were intended to undergo laparoscopic surgery, with 20% of these patients converted to open. Collection of ≥3 LNs following open resection (47%) was higher than for laparoscopic resection (34%), p < 0.001. Operations performed at high-volume (aOR:1.74, p < 0.001) and/or academic centers (aOR:1.70, p = 0.024) had superior LN yield. LN yield was not associated with overall survival (aHR:0.93, p = 0.493)., Conclusions: In this analysis of national data, LN yield following laparoscopic resection for GBC was significantly lower than following open resection. Open resection is more frequently performed at academic centers, possibly to assure adequate oncologic resection. Enforcing consensus guidelines for lymphadenectomy in gallbladder cancer will optimize outcomes as minimally invasive approaches evolve., (Copyright © 2017 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Importance: Gastrointestinal stromal tumors (GISTs) are the most commonly diagnosed mesenchymal tumors of the gastrointestinal tract. The risk of recurrence following surgical resection of GISTs is typically reported from the date of surgery. However, disease-free survival (DFS) over time is dynamic and changes based on disease-free time already accumulated following surgery., Objectives: To assess the comparative performance of established GIST recurrence risk prognostic scoring systems and to characterize conditional DFS following surgical resection of GISTs., Design, Setting, and Participants: A retrospective cohort study of 502 patients who underwent surgery for a primary, nonmetastatic GIST between January 1, 1998, and December 31, 2012, at 7 major academic cancer centers in the United States and Canada., Main Outcomes and Measures: Disease-free survival of the patients was classified according to 5 prognostic scoring systems, including the National Institutes of Health criteria, modified National Institutes of Health criteria, Memorial Sloan Kettering Cancer Center GIST nomogram, and American Joint Committee on Cancer gastric and nongastric categories. The concordance index (also known as the C statistic or the area under the receiver operating curve) of established GIST recurrence risk prognostic scoring systems. Conditional DFS estimates were calculated., Results: Overall 1-year, 3-year, and 5-year DFS following resection of GISTs was 95%, 83%, and 74%, respectively. All the prognostic scoring systems had fair prognostic ability. For all tumor sites, the American Joint Committee on Cancer gastric category demonstrated the best discrimination (C = 0.79). Using conditional DFS, the probability of remaining disease free for an additional 3 years given that a patient was disease free at 1 year, 3 years, and 5 years was 82%, 89%, and 92%, respectively. Patients with the highest initial recurrence risk demonstrated the greatest increase in conditional survival as time elapsed., Conclusions and Relevance: Conditional DFS improves over time following resection of GISTs. This is valuable information about long-term prognosis to communicate to patients who are disease free after a period following surgery.

Introduction: The drive to improve outcomes and the inevitability of mandated public reporting necessitate uniform documentation and accurate databases. The reporting of wound classification in patients undergoing hepato-pancreatico-biliary (HPB) surgery and the impact of inconsistencies on quality metrics were investigated., Methods: The 2005-2011 National Surgical Quality Improvement Program (NSQIP) participant use file was interrogated to identify patients undergoing HPB resections. The effect of wound classification on post-operative surgical site infection (SSI) rates was determined through logistic regression. The impact of variations in wound classification reporting on perceived outcomes was modelled by simulating observed-to-expected (O/E) ratios for SSI., Results: In total, 27,376 patients were identified with significant heterogeneity in wound classification. In spite of clear guidelines prompting at least 'clean-contaminated' designation for HPB resections, 8% of all cases were coded as 'clean'. Contaminated [adjusted odds ratio (AOR): 1.39, P = 0.001] and dirty (AOR: 1.42, P = 0.02] cases were associated with higher odds of SSI, whereas clean-contaminated were not (P = 0.99). O/E ratios were highly sensitive to modest changes in wound classification., Conclusions: Perceived performance is affected by heterogeneous reporting of wound classification. As institutions work to improve outcomes and prepare for public reporting, it is imperative that all adhere to consistent reporting practices to provide accurate and reproducible outcomes., (© 2014 International Hepato-Pancreato-Biliary Association.)

Background: Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. Adjuvant imatinib therapy has resulted in improved disease-free survival (DFS) following resection of primary GIST. The aim of our study was to create a nomogram to predict DFS following resection of GIST., Method: Using a multi-institutional cohort of patients who underwent surgery for primary GIST at 7 academic hospitals in the USA and Canada between January 1998 and December 2012, a multivariable Cox proportional hazards model predicting DFS was created using backward stepwise selection. A nomogram to predict DFS following surgical resection of GIST was constructed with the variables selected in the multivariable model. We tested nomogram discrimination by calculating the C-statistic and compared the nomogram to four existing GIST prognostic stratification systems., Results: A total of 365 patients who underwent surgery for primary GIST was included in the study. Using backward stepwise selection, sex, tumor size, tumor site, and mitotic rate were selected for incorporation into the nomogram. The nomogram demonstrated superior discrimination compared to the NIH criteria, modified NIH criteria, and Memorial Sloan-Kettering Nomogram and had similar discrimination to the Miettinen criteria (C-statistic 0.77 vs 0.73, 0.71, 0.71, and 0.78, respectively)., Conclusion: Four independent predictors of recurrence following surgery for primary GIST were used to create a nomogram to predict DFS. The nomogram stratified patients into prognostic groups and performed well on internal validation.

Background: Concomitant placement of feeding jejunostomy tubes (FJT) during pancreaticoduodenectomy is common, yet there are limited data regarding catheter-specific morbidity and associated outcomes. This information is crucial to appropriately select patients for feeding tube placement and to optimize perioperative nutrition strategies., Methods: A review of all patients undergoing pancreaticoduodenectomy with FJT placement was completed. Patients were grouped by the occurrence of FJT-related morbidity. Multivariable logistic regression was performed to identify predictors of FJT morbidity; these complications were then further defined. Finally, associated postoperative outcomes were compared between groups., Results: In total, 126 patients were included, of which 18 (14 %) had complications directly related to their FJT, including pericatheter infection (n = 6), pneumatosis intestinalis (n = 4), severe tube feed intolerance (n = 3), and primary catheter malfunction (n = 7). Following adjustment with logistic regression, preoperative hypoalbuminemia was identified as the only independent predictor of FJT complications (OR 2.23, p = 0.035). Patients with FJT complications were more likely to be initiated on total parenteral nutrition (TPN; 55.6 vs. 7.4 %, p -0.035) and to require TPN at discharge (16.7 vs. 0%, p = 0.003). Correspondingly, these patients resumed an oral diet later (14 vs. 8 days, p = 0.06). Both reoperation (50.0 vs. 6.5%, p < 0.001) and readmission (50.0 vs. 22.4%, p = 0.041) rates were higher among patients with FJT complications., Conclusions: FJT-related morbidity is common among patients undergoing pancreaticoduodenectomy and is associated with inferior outcomes and other performance metrics. Preoperative malnutrition appears to predict FJT complications, creating an ongoing dilemma regarding FJT placement. In the future, it will be important to better define criteria for FJT placement during pancreaticoduodenectomy.

Background: The racial/ethnic composition of the United States is shifting rapidly, with non-Hispanic Asian-Americans, Native Hawaiians/Pacific Islanders (NHs/PIs), and mixed-race individuals the fastest growing segments of the population. We determined new drug use estimates for these rising groups. Prevalences among Whites were included as a comparison., Methods: Data were from the 2005-2011 National Surveys on Drug Use and Health. Substance use among respondents aged ≥ 12 years was assessed by computer-assisted self-interviewing methods. Respondents' self-reported race/ethnicity, age, gender, household income, government assistance, county type, residential stability, major depressive episode, history of being arrested, tobacco use, and alcohol use were examined as correlates. We stratified the analysis by race/ethnicity and used logistic regression to estimate odds of drug use., Results: Prevalence of past-year marijuana use among Whites increased from 10.7% in 2005 to 11.6-11.8% in 2009-2011 (P<0.05). There were no significant yearly changes in drug use prevalences among Asian-Americans, NHs/PIs, and mixed-race people; but use of any drug, especially marijuana, was prevalent among NHs/PIs and mixed-race people (21.2% and 23.3%, respectively, in 2011). Compared with Asian-Americans, NHs/PIs had higher odds of marijuana use, and mixed-race individuals had higher odds of using marijuana, cocaine, hallucinogens, stimulants, sedatives, and tranquilizers. Compared with Whites, mixed-race individuals had greater odds of any drug use, mainly marijuana, and NHs/PIs resembled Whites in odds of any drug use., Conclusions: Findings reveal alarmingly prevalent drug use among NHs/PIs and mixed-race people. Research on drug use is needed in these rising populations to inform prevention and treatment efforts., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Background: Non-Hispanic Asian Americans, Native Hawaiians/Pacific Islanders (NHs/PIs), and mixed-race individuals are the fastest growing segments of the US population. We examined prevalences and correlates of tobacco use among these understudied groups. Prevalences among whites were included as a comparison., Methods: Data were drawn from the 2002-2010 National Surveys on Drug Use and Health. Respondents aged ≥12 years were assessed for current (past-month) use of cigarettes, cigars, smokeless tobacco (chewing tobacco, snuff), and pipe tobacco. Respondents' race/ethnicity, age, sex, household income, government assistance, urbanicity of residence, residential stability, self-rated health, alcohol use, and drug use were examined as correlates., Results: Between 2002 and 2010, there was a decline in the prevalence of cigarette smoking among whites (26.9% in 2002; 24.3% in 2010) and Asian Americans (18.0% in 2002; 11.1% in 2010). Prevalence of pipe tobacco use among mixed-race individuals increased from 0.2% in 2002 to 1.6% in 2010; there was little change in the prevalence of cigar and smokeless tobacco use in these racial/ethnic groups. Adjusted analyses showed that, compared with Asian Americans, mixed-race individuals had greater odds of using four tobacco products, and NHs/PIs had greater odds of using cigarettes, cigars, and smokeless tobacco. Regardless of race/ethnicity, male sex was a correlate of use of cigars, smokeless tobacco, and pipe tobacco; alcohol and drug use increased the odds of cigarette and cigar smoking., Conclusions: These new findings show prevalent tobacco use among NHs/PIs and mixed-race individuals, and highlight the importance of including these populations in future research and reporting., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Objective: To examine prevalences of substance use disorders (SUD) and comprehensive patterns of comorbidities among psychiatric patients ages 18-64 years (N = 40,099) in an electronic health records (EHR) database., Method: DSM-IV diagnoses among psychiatric patients in a large university system were systematically captured: SUD, anxiety (AD), mood (MD), personality (PD), adjustment, childhood-onset, cognitive/dementia, dissociative, eating, factitious, impulse-control, psychotic (schizophrenic), sexual/gender identity, sleep, and somatoform diagnoses. Comorbidities and treatment types among patients with a SUD were examined., Results: Among all patients, 24.9% (n = 9984) had a SUD, with blacks (35.2%) and Hispanics (32.9%) showing the highest prevalence. Among patients with a SUD, MD was prevalent across all age groups (50.2-56.6%). Patients aged 18-24 years had elevated odds of comorbid PD, adjustment, childhood-onset, impulse-control, psychotic, and eating diagnoses. Females had more PD, AD, MD, eating, and somatoform diagnoses, while males had more childhood-onset, impulse-control, and psychotic diagnoses. Blacks had greater odds than whites of psychotic and cognitive/dementia diagnoses, while whites exhibited elevated odds of PA, AD, MD, childhood-onset, eating, somatoform, and sleep diagnoses. Women, blacks, and Native American/multiple-race adults had elevated odds of using inpatient treatment; men, blacks, and Hispanics had increased odds of using psychiatric emergency care. Comorbid MD, PD, adjustment, somatoform, psychotic, or cognitive/dementia diagnoses increased inpatient treatment., Conclusion: Patients with a SUD, especially minority members, use more inpatient or psychiatric emergency care than those without. Findings provide evidence for research on understudied diagnoses and underserved populations in the real-world clinical settings., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Study Objective: Improving identification and treatment for substance use disorders is a national priority, but data about various drug use disorders encountered in emergency departments (EDs) are lacking. We examine past-year substance use and substance use disorders (alcohol, 9 drug classes) among adult ED users. Prevalences of substance use and substance use disorders among ED nonusers are calculated for reference purposes., Methods: Using data from the 2007 to 2009 National Surveys on Drug Use and Health, we assessed substance use disorders among noninstitutionalized adults aged 18 years or older who responded to standardized survey questions administered by audio computer-assisted self-interviewing methods., Results: Of all adults (N=113,672), 27.8% used the ED in the past year. ED users had higher prevalences than ED nonusers of coexisting alcohol and drug use (15.2% versus 12.1%), drug use (any drug, 16.9% versus 13.0%; marijuana, 12.1% versus 9.7%; opioids, 6.6% versus 4.1%), and alcohol or drug disorders (11.0% versus 8.5%). Among substance users, the ED group on average spent more days using drugs than the non-ED group; ED users manifested higher conditional rates of substance use disorders than ED nonusers (alcohol or drugs, 15.9% versus 11.7%; marijuana, 16.6% versus 13.2%; cocaine, 33.2% versus 22.3%; opioids, 20.6% versus 10.0%; stimulants, 18.6% versus 9.2%; sedatives, 35.0% versus 4.4%; tranquilizers, 12.4% versus 5.2%). Regardless of ED use status, substance-using young adults, men, and less-educated adults showed increased odds of having a substance use disorder., Conclusion: Drug use is prevalent and combined with high rates of drug use disorders among drug users treated in the ED., (Copyright © 2012. Published by Mosby, Inc.)

While item response theory (IRT) research shows a latent severity trait underlying response patterns of substance abuse and dependence symptoms, little is known about IRT-based severity estimates in relation to clinically relevant measures. In response to increased prevalences of marijuana-related treatment admissions, an elevated level of marijuana potency, and the debate on medical marijuana use, we applied dimensional approaches to understand IRT-based severity estimates for marijuana use disorders (MUDs) and their correlates while simultaneously considering gender- and race/ethnicity-related differential item functioning (DIF). Using adult data from the 2008 National Survey on Drug Use and Health (N = 37,897), Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for MUDs among past-year marijuana users were examined by IRT, logistic regression, and multiple indicators-multiple causes (MIMIC) approaches. Among 6917 marijuana users, 15% met criteria for a MUD; another 24% exhibited subthreshold dependence. Abuse criteria were highly correlated with dependence criteria (correlation = 0.90), indicating unidimensionality; item information curves revealed redundancy in multiple criteria. MIMIC analyses showed that MUD criteria were positively associated with weekly marijuana use, early marijuana use, other substance use disorders, substance abuse treatment, and serious psychological distress. African Americans and Hispanics showed higher levels of MUDs than Whites, even after adjusting for race/ethnicity-related DIF. The redundancy in multiple criteria suggests an opportunity to improve efficiency in measuring symptom-level manifestations by removing low-informative criteria. Elevated rates of MUDs among African Americans and Hispanics require research to elucidate risk factors and improve assessments of MUDs for different racial/ethnic groups., (Copyright © 2012 John Wiley & Sons, Ltd.)

Aim: To address an urgent need for screening of substance use problems in medical settings, we examined substance-specific dependence criteria as potential brief screeners for the detection of patients with a substance use disorder (SUD)., Methods: The sample included 920 opioid-dependent adults who were recruited from outpatient treatment settings at 11 programs in 10 U.S. cities and who completed intake assessments of SUDs for a multisite study of the National Drug Abuse Treatment Clinical Trials Network (CTN003). Data were analyzed by factor analysis, item response theory (IRT), sensitivity, and specificity procedures., Results: Across all substances (alcohol, amphetamines, cannabis, cocaine, sedatives), withdrawal was among the least prevalent symptoms, while taking large amounts and inability to cut down were among the most prevalent symptoms. Items closely related to the latent trait of a SUD showed good-to-high values of area under the receiver operating characteristic curve in identifying cases of a SUD; IRT-defined severe and less discriminative items exhibited low sensitivity in identifying cases of a SUD (withdrawal for all substances; time using for alcohol and sedatives; giving up activities for sedatives)., Conclusions: Study results suggest that withdrawal and time using are much less reliable indicators for a SUD than taking larger amounts than intended and inability to cut down and that the latter two items should be studied further for consideration in developing a simplified tool for screening patients for SUDs in medical settings. These findings have implications for the use of common health indicators in electronic health records systems to improve patient care., (Copyright © 2011 Elsevier Ltd. All rights reserved.)