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Abstract: Intensity Modulated Radiation Therapy (IMRT) is a technique widely used in the treatment of patients with prostate cancer, the most commonly occurring male cancer in the United States and Western Europe. The technique has many attractive features, promising improved radiotherapy over that provided by conventional techniques, including enabling the tumour to be treated with a uniform high dose, capability for shaping the radiation beams to match the shape of the tumour and potentially improving patient outcome. However, there are a number of concerns involving high photon energy IMRT (>10MV), including greater radiation leakage and the possibility of photo-neutron production. The aim of the present study is to investigate the potential of Ge-doped optical fibre thermoluminescent (TL) dosimetry in determining typical out-of-field doses for high energy IMRT. Commercial Ge-doped optical fibres have been employed as the TL dosimeters, offering features such as high sensitivity, cost-effectiveness and small size. Extensive measurements have been made, examining reproducibility, sensitivity, energy response and linearity with dose. Screening for sensitivity to dose of the individual fibres and subsequent selection has led to an overall coefficient of variation (CV) of better than 4 %. Use has been made of an anthropomorphic phantom (RANDO) for photon irradiation measurements delivered over the range of nominal energies 6–15MV as typically used in IMRT treatment of prostate cancer. Comparison has been made with TLD-100 measurements, the latter being corrected at 15MV for their response to thermal neutrons. The study has demonstrated the Ge-doped optical fibre TL dosimeters to offer good potential for use in IMRT radiotherapy when using 6MV photons, also indicating a need to correct their response to neutrons when conducting 15MV irradiations. [Copyright &y& Elsevier]

Reviews the experiences of the authors in managing patients who sustained penetrating neck trauma at Grady Memorial Hospital, Atlanta, Georgia. Potential of transcervical neck injuries; Classification of zones of the neck; Types of neck injuries.

Reports on gastric cancer and pernicious anemia appearing as pseudoachlasia in the United States. Infiltration of gastric adenocarcinoma in gastric cardia; Risk of patients with pernicious anemia for gastrointestinal neoplasms; Surveillance with upper gastrointestinal endoscopy.

Presents information on the Edwin Smith Surgical Papyrus, the oldest known surgical treatise. Physical description; Surgical importance; Scientific significance.

Aims Previously, a retrospective cohort study found no increased risk of acute pancreatitis with current or recent use of exenatide twice daily compared with use of other anti-diabetic drugs. This follow-up study investigated incident acute pancreatitis, with the use of a different data source and analytic method, in patients exposed to exenatide twice daily compared with patients exposed to other anti-diabetic medications. Methods A large US health insurance claims database was used. Eligible patients had ≥ 9 months continuous enrollment without a claim for pancreatitis and a claim for a new anti-diabetic medication on or after 1 June 2005 to 31 March 2009. Cases of acute pancreatitis were defined as hospitalized patients with an Internation Classification of Disease 9 code of 577.0 in the primary position. A discrete time survival model was used to evaluate the relationship between exenatide twice daily and acute pancreatitis. Results Of 482 034 eligible patients, 24 237 initiated exenatide twice daily and 457 797 initiated another anti-diabetic medication. Initiators of exenatide twice daily had more severe diabetes compared with initiators of other anti-diabetic medications. After adjustments for propensity score, insulin and use of medication potentially associated with acute pancreatitis, the odds ratio with exenatide twice daily exposure was 0.95 (95% CI 0.65-1.38). A secondary analysis that examined current, recent and past medication exposure found no increased risk of acute pancreatitis with exenatide twice daily, regardless of exposure category. Conclusion This study indicates that exposure to exenatide twice daily was not associated with an increased risk of acute pancreatitis compared with exposure to other anti-diabetic medications. These results should be interpreted in light of potential residual confounding and unknown biases. [ABSTRACT FROM AUTHOR]

Background: With coronavirus disease 2019 (COVID-19) vaccination no longer mandated by many businesses/organizations, it is now up to individuals to decide whether to get any new boosters/updated vaccines going forward., Methods: We developed a Markov model representing the potential clinical/economic outcomes from an individual perspective in the United States of getting versus not getting an annual COVID-19 vaccine., Results: For an 18-49 year old, getting vaccinated at its current price ($60) can save the individual on average $30-$603 if the individual is uninsured and $4-$437 if the individual has private insurance, as long as the starting vaccine efficacy against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is ≥50% and the weekly risk of getting infected is ≥0.2%, corresponding to an individual interacting with 9 other people in a day under Winter 2023-2024 Omicron SARS-CoV-2 variant conditions with an average infection prevalence of 10%. For a 50-64 year old, these cost-savings increase to $111-$1278 and $119-$1706 for someone without and with insurance, respectively. The risk threshold increases to ≥0.4% (interacting with 19 people/day), when the individual has 13.4% preexisting protection against infection (eg, vaccinated 9 months earlier)., Conclusions: There is both clinical and economic incentive for the individual to continue to get vaccinated against COVID-19 each year., Competing Interests: Potential conflicts of interest . P. J. H., M. E. B., and U. S. are coinventors of a COVID-19 recombinant protein vaccine technology owned by Baylor College of Medicine (BCM) that was recently licensed by BCM nonexclusively and with no patent restrictions to several companies committed to advance vaccines for low- and middle-income countries. The coinventors have no involvement in license negotiations conducted by BCM. Similar to other research universities, a long-standing BCM policy provides its faculty and staff, who make discoveries that result in a commercial license, a share of any royalty income, according to BCM policy. All other authors report no potential conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (© The Author(s) 2024. Published by Oxford University Press on behalf of Infectious Diseases Society of America. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Objectives: To detect the association between psoriasis as an exposure and oral health conditions as outcomes represented by periodontal and dentition status. This was addressed by analysis of a large number of adults in the United States., Methods: By using The National Health and Nutrition Examination Survey datasets from 2009 to 2014, we performed a cross-sectional analysis of 11,726 participants included in our study population. For participants aged ≥ 30 years, the psoriasis status was assessed from the medical questionnaire. We used data from periodontal and oral examinations to assess the oral conditions of our participants. We examined the association between psoriasis as exposure and moderate/severe periodontitis and non-functional dentition as outcomes., Results: The weighted prevalence of psoriasis was 3%, 44% for moderate/severe periodontitis, and 20.5% for non-functional dentition. The fully adjusted model showed no significant association between psoriasis and moderate/severe periodontitis (Prevalence Ratio 1.02, 95% CI 0.9-1.2, p = 0.8). There was no statistically significant association between psoriasis and non-functional dentition except in the fully adjusted model it became statistically significant (Prevalence Ratio 0.8, 95% CI 0.7-0.9, p = 0.04)., Conclusion: Our results showed no association between psoriasis and periodontal or dentition status except in a fully adjusted model for non-functional dentition., (© 2023. The Author(s).)

Importance: Amitriptyline is an established medication used off-label for the treatment of fibromyalgia, but pregabalin, duloxetine, and milnacipran are the only pharmacological agents approved by the US Food and Drug Administration (FDA) to treat fibromyalgia., Objective: To investigate the comparative effectiveness and acceptability associated with pharmacological treatment options for fibromyalgia., Data Sources: Searches of PubMed/MEDLINE, Cochrane Library, Embase, and Clinicaltrials.gov were conducted on November 20, 2018, and updated on July 29, 2020., Study Selection: Randomized clinical trials (RCTs) comparing amitriptyline or any FDA-approved doses of investigated drugs., Data Extraction and Synthesis: This study follows the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline. Four independent reviewers extracted data using a standardized data extraction sheet and assessed quality of RCTs. A random-effects bayesian network meta-analysis (NMA) was conducted. Data were analyzed from August 2020 to January 2021., Main Outcomes and Measures: Comparative effectiveness and acceptability (defined as discontinuation of treatment owing to adverse drug reactions) associated with amitriptyline (off-label), pregabalin, duloxetine, and milnacipran (on-label) in reducing fibromyalgia symptoms. The following doses were compared: 60-mg and 120-mg duloxetine; 150-mg, 300-mg, 450-mg, and 600-mg pregabalin; 100-mg and 200-mg milnacipran; and amitriptyline. Effect sizes are reported as standardized mean differences (SMDs) for continuous outcomes and odds ratios (ORs) for dichotomous outcomes with 95% credible intervals (95% CrIs). Findings were considered statistically significant when the 95% CrI did not include the null value (0 for SMD and 1 for OR). Relative treatment ranking using the surface under the cumulative ranking curve (SUCRA) was also evaluated., Results: A total of 36 studies (11 930 patients) were included. The mean (SD) age of patients was 48.4 (10.4) years, and 11 261 patients (94.4%) were women. Compared with placebo, amitriptyline was associated with reduced sleep disturbances (SMD, -0.97; 95% CrI, -1.10 to -0.83), fatigue (SMD, -0.64; 95% CrI, -0.75 to -0.53), and improved quality of life (SMD, -0.80; 95% CrI, -0.94 to -0.65). Duloxetine 120 mg was associated with the highest improvement in pain (SMD, -0.33; 95% CrI, -0.36 to -0.30) and depression (SMD, -0.25; 95% CrI, -0.32 to -0.17) vs placebo. All treatments were associated with inferior acceptability (higher dropout rate) than placebo, except amitriptyline (OR, 0.78; 95% CrI, 0.31 to 1.66). According to the SUCRA-based relative ranking of treatments, duloxetine 120 mg was associated with higher efficacy for treating pain and depression, while amitriptyline was associated with higher efficacy for improving sleep, fatigue, and overall quality of life., Conclusions and Relevance: These findings suggest that clinicians should consider how treatments could be tailored to individual symptoms, weighing the benefits and acceptability, when prescribing medications to patients with fibromyalgia.

Objective: Studies showed that a lack of insurance is associated with worse trauma outcomes. We examine insurance status and trauma mortality in a diverse metropolitan city and hypothesize that the higher risk of mortality in uninsured patients is due to insurance status and other factors., Methods: A retrospective analysis of patients admitted to a Level 1 Trauma center for emergent surgery in a diverse metropolitan city from Jan 2016-May 2020 was conducted. Patients of different insurance statuses were analyzed for their injury mechanism and surgical intervention outcomes. Multivariate logistic regression was performed and the results were presented as odds ratio with 95% confidence intervals and P values. Statistical significance was set at P < .05., Results: 738 patients met study criteria. Medicaid patients made up the largest proportions of injury mechanisms: 65.1% of gunshot wound cases, sharp object (41.7%), and falls (32.5%). Private insurance (OR = .13, 95% CI: .05-.35, P = .000), Medicaid (OR = .19, 95% CI: .10-.35, P = .000), Medicare (OR = .65, 95% CI: 0.28-1.51, P = .31), and other insurance (OR = .44, 95% CI 0.22-.87, P = .01) were associated with survival. Uninsured patients had the highest mortality rate resulting from trauma at 32.6% ( P < .001), and the lowest mortality rate belonged to the private insurance cohort (6.3%, P < .001). Uninsured patients accounted for 10.5% of gunshot wound cases, 8.5% of motor vehicle accident cases, 25% of sharp object cases, and 6.6% of falls., Conclusion: Being uninsured was independently associated with mortality, while having insurance improved outcomes. Underlying mechanisms should be further elucidated to improve health equity and trauma outcomes in diverse patient populations.

Objective: We aimed to describe the surgical outcomes and readmissions rates in patients with psychological comorbidities who underwent surgical intervention for cancer., Background: The Hospital Readmission Reduction Program, a campaign by the Affordable Care Act, penalizes hospitals for greater readmission rates. One prevalent patient risk factor associated with hospital readmission is a comorbid psychiatric condition. Currently, no studies exist identifying psychiatric comorbidities and their effects on patients with cancer undergoing surgical intervention., Methods: A cross-sectional analysis was performed using the Nationwide Readmissions Database for 2010-2014 and included adult patients undergoing cancer resection operations. Multivariable logistic regression analyses were utilized to assess determinants of surgical outcomes and readmissions., Results: Of 1 016 636 eligible patients, 11.6% had psychiatric comorbidities. Patients with psychiatric disorders had greater risks of mortality (odds ratio [OR] = 1.21, 95% confidence interval [CI] = 1.18-1.25), complications (OR = 1.51, 95%CI = 1.50-1.52), extended length of stay (OR = 1.21, 95%CI = 1.20-1.22), and incurred healthcare expenditure at primary admission (OR = 1.16, 95% CI = 1.15-1.18). Psychiatric comorbidities were associated with an increased likelihood of readmission (OR = 1.13, 95%CI = 1.11-1.15)., Conclusions: Concomitant psychiatric conditions were attributed to poor surgical outcomes and a higher risk of readmissions. Multidisciplinary care within the perioperative setting should be encouraged for patients with psychiatric disorders., (© 2021 Wiley Periodicals LLC.)

Background: The need for extensive surgical debridement with necrotizing soft tissue infections (NSTIs) may put patients at high risk for unplanned readmission. However, there is a paucity of data on the burden of readmission in patients afflicted with NSTI. We hypothesized that unplanned readmission would significantly contribute to the burden of disease after discharge from initial hospitalization., Methods: The Nationwide Readmission Database was used to identify adults undergoing debridement for NSTI hospitalizations from 2010 to 2017. Risk factors for 90-day readmission were assessed by Cox proportional hazards regression., Results: There were a total of 82,738 NSTI admissions during the study period, of which 25,076 (30.3%) underwent 90-day readmissions. Median time to readmission was 25 days (interquartile range, 9-49 days). Fragmentation of care, longer length of index stay (>2 weeks), and Medicaid status were independent risk factors for readmission. Median cost of a readmission was US $10,543. Readmission added 174,640 hospital days to episodes of care over the study period, resulting in an estimated financial burden of US $1.4 billion., Conclusion: Unplanned readmission caused by NSTIs is common and costly. Interventions that target patients at risk for readmission may help decrease the burden of disease., Level of Evidence: Economic/Epidemiological, level IV., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

This manuscript outlines the progress of education in the field of medical oncology in Egypt over the past 50 years. The manuscript illustrates the origin of the Egyptian medical oncology program since the creation of the only specialized cancer center in the country, the National Cancer Institute of Cairo University (NCI-Cairo) in 1969, from Cairo University Medical School. The manuscript also outlines the NCI-Cairo's educational program for developing a cadre of academic medical oncologists for NCI-Cairo, other Egyptian medical institutions, and countries in the Middle East and Africa. We also emphasize the capacity building that resulted over the past 50 years from academic and professional standpoints, the changing curriculum in medical oncology, and the differences between the medical oncology and clinical oncology education programs in the country. Medical oncology research resulted from international collaborations and highlighted needs for cancer prevention and control. Finally, we propose possible future directions for medical oncology education and research in the country and a roadmap for low- and middle-income countries (LMICs) that are developing their medical oncology programs., (© 2021. American Association for Cancer Education.)

Social justice, inclusion and equity are everyone's responsibility. We achieve these values when we recognize and accept the characteristics of every person as a unique individual. Professional case managers, or other healthcare practitioners and leaders, have an obligation to advance the health, human and social outcomes of the people they serve, regardless of the social group they belong to and irrespective of their determinants of diversity. It is time to address social justice, inclusion and equity as ethical principles of practice for the professional case manager.

Objectives: This is the second of a 2-part article that discusses essential case management practices and strategies amidst the novel coronavirus disease 2019 (COVID-19). The series showcases the potential professional case managers have in support of managing during a crisis such as a global pandemic. Part II continues to describe reenvisioned roles and responsibilities of case managers and their leaders to meet the needs of patients/support systems during the crisis. It focuses on the increased need for end-of-life care, impact on workers' compensation case management practice, and the self-care needs of the professional case manager., Primary Practice Settings: Applicable to the various case management practice settings across the continuum of health and human services, with special focus on acute care., Findings/conclusions: The COVID-19 global pandemic has resulted in a crisis case managers and other health care professionals never faced something like it before. At the same time, it has provided opportunities for innovation and creativity including use of digital and telecommunication technology in new ways to ensure the continued delivery of health and human services to those who need them regardless of location. It has also resulted in the development of necessary and impactful partnerships within and across different health care organizations and diverse professional disciplines. Most importantly, this pandemic has required special attention to the increased need of patients for timely palliative and end-of-life care. In addition, it has prompted a focus on the safety, health, and well-being of case managers and other health care professionals, resulting in expanded workers' compensation case management practice coupled with the need for self-care and resilience., Implications for Case Management Practice: Professional case managers are integral members of interprofessional health care teams. Their roles and responsibilities are even more necessary during the uncertainty of a global pandemic such as COVID-19. So far, the experience of this crisis has resulted in a deliberate need to ensure the safety of both, those who are the recipients of health care services and those who are responsible for the provision of care. Self-care and resilience of health care professionals and case managers, especially due to the complex dynamics of the COVID-19 pandemic, have advanced a desirable and necessary view of remote/virtual practice and as a strategy for enhancing the person's health and well-being. This pandemic has forced the development of impactful partnerships and collaborations among the diverse contexts of health care organizations and support service providers. These contexts of care delivery have also emphasized the necessary legal and ethical practice of case managers and the other involved parties. Experts agree that the innovative care delivery methods practiced during the pandemic will undoubtedly remain as desirable beyond the current crisis period.

Objectives: Our study aims to explore the differential impact of this pandemic on clinical presentations and outcomes in African Americans (AAs) compared to white patients., Background: AAs have worse outcomes compared to whites while facing heart diseases, stroke, cancer, asthma, influenza and pneumonia, diabetes, and HIV/AIDS. However, there is no current study to show the impact of COVID-19 pandemic on the AA communities., Methods: This is a retrospective study that included patients with laboratory-confirmed COVID-19 from 2 tertiary centers in New Orleans, LA. Clinical and laboratory data were collected. Multivariate analyses were performed to identify the risk factors associated with adverse events., Results: A total of 157 patients were identified. Of these, 134 (77%) were AAs, whereas 23.4% of patients were Whites. Interestingly, AA were younger, with a mean age of 63 ± 13.4 compared to 75.7 ± 23 years in Whites (P < 0.001). Thirty-seven patients presented with no insurance, and 34 of them were AA. SOFA Score was significantly higher in AA (2.57 ± 2.1) compared to White patients (1.69 ± 1.7), P = 0.041. Elevated SOFA score was associated with higher odds for intubation (odds ratio = 1.6, 95% confidence interval = 1.32-1.93, P < 0.001). AA had more prolonged length of hospital stays (11.1 ± 13.4 days vs 7.7 ± 23 days) than in Whites, P = 0.01., Conclusion: AAs present with more advanced disease and eventually have worse outcomes from COVID-19 infection. Future studies are warranted for further investigations that should impact the need for providing additional resources to the AA communities., Competing Interests: The authors declare there are no conflicts of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: The purpose of the national role and function study was to identify the essential activities and necessary knowledge areas for effective professional case management practice from the perspective of those directly involved. The study also aimed to inform the relevance and currency of the blueprint for the case management certification examination., Primary Practice Settings: The national study covered the diverse case management practices and/or work settings across the full continuum of health and human services and numerous professional disciplines., Methodology and Sample: This cross-sectional descriptive study used the practice analysis method and online survey research design. It employed a purposive sample of 2,810 certified and not yet certified case managers who responded to an open participation link made available as an online survey. The final study sample supported the conduct of meaningful statistical analyses including multiple subgroup comparisons., Results: The study identified the common activities (6 domains) and knowledge areas (5 domains) necessary for effective performance by professional case managers. Part I of this 2-part article series described the background of the participants and their perspectives of the practice and the knowledge applied by those responsible for the case manager's role. Part II, as shared in this article, reports on the factor/principal component analysis and how such activity informed the needed update of the test specifications for the Certified Case Manager (CCM) certification examination. The update reflects the continued evolution of the professional case management practice and ensures that the examination remains current and relevant. Of special note is the maturation of the case management practice; for example, greater emphasis on quality, safety, and outcomes; baccalaureate or higher education; and recognition of the value of certification. In addition, the 2019 role and function study has revealed that utilization review/management is evolving potentially as a function that is separate from that of the case manager., Implications for Case Management Practice: The study has identified the essential activities and knowledge areas of case management practice at both the micro and macro levels. These findings represent the substantive evidence of practice, keeping the CCM credentialing examination evidence-based and maintaining its validity for evaluating the competency of professional case managers. They have also documented the evolution of the practice over the past 5 years. Moreover, the findings may inform the development of programs and curricula for the training and advancement of case managers. The study instrument also is beneficial for use in further research into professional case management practice.

Purpose: The purpose of the national role and function study was to identify the essential activities and necessary knowledge areas for effective professional case management practice from the perspective of those currently functioning in such roles in various care settings and across diverse professional disciplines., Primary Practice Settings: The national study covered the diverse case management practices and/or work settings across the full continuum of health and human services., Methodology and Sample: This cross-sectional descriptive study used the practice analysis method and online survey research design. It employed a purposive sample of case managers, in which an open participation link was e-mailed to nearly 60,000 case managers, both certified and not yet certified. A total of 5,416 responses were received, of which 2,810 were found to be acceptable for consideration in the study. A representative group of individuals engaged in case management completed the survey in sufficient numbers to meet the requirements for conducting meaningful statistical analyses including subgroup comparisons., Results: The study identified the common activities (6 domains) and knowledge areas (5 domains) necessary for competent and effective performance by professional case managers, as highlighted in this article, which is the first of a 2-part series on the 2019 role and function study. The results informed the needed update of the test specifications for the Certified Case Manager (CCM) certification examination, as will be delineated in Part II of this article series. The update was necessary because case management practice has continued to evolve and to ensure the examination reflects current practices., Implications for Case Management Practice: The study identified essential activities and knowledge topics at both the micro- and macro levels that define competent and effective professional case management practice, also referred to as the substantive evidence of practice. It helps keep the CCM credentialing examination evidence-based and maintain its validity for evaluating the competency of professional case managers. In addition, the findings document how the practice has evolved over the past 5 years since the conduct of the last national study. Moreover, findings inform the development of programs and curricula for the training and advancement of case managers. The study instrument also is beneficial for further research into professional case management practice-most importantly linking the roles and functions of case managers to client care outcomes.

Background: The Affordable Care Act (ACA) was enacted to enhance access to care primarily among nonelderly and low-income populations; however, several provisions addressed key determinants of emergency department (ED) and inpatient visits among Medicare beneficiaries over age 65 years. We take stock of the overall changes in these visits among older Medicare beneficiaries, focusing on those with multiple chronic conditions (MCCs), and provide a nationally representative post-reform update., Methods: We analyzed a sample of 32,919 older adults (65+) on Medicare from the 2006-2015 Medical Expenditure Panel Survey (MEPS). Using a survey-weighted two-part model, we examined changes in ED visits, inpatient visits, and length of stay (LOS) by MCC status, before (2006-2010), during (2011-2013), and after the ACA (2014-2015)., Results: Prior to the ACA, 18.1% of Medicare older adults had ≥1 ED visit, whereas 17.1% had ≥1 inpatient visits, with an average of 5.1 nights/visit. Following ACA reforms, among those with 2+ chronic conditions, the rate of ever having an ED visit increased by 4.3 percentage points [95% confidence intervals [CI]: 2.5, 6.1, p < 0.01], whereas the rate of inpatient visits decreased by 1.4 percentage points [95%CI: - 2.9, 0.2, p < 0.1], after multivariable adjustment., Conclusions: We found sizable increases in ED visits and nontrivial decreases in inpatient visits among older Medicare beneficiaries with MCCs, underscoring the continuing need for improving access to and quality of care among older adults with MCCs to decrease reliance on the ED and reduce preventable hospitalizations.

Physicians are infrequently selected to serve in the yearlong role of Jefferson Science Fellow (JSF) as senior science advisor for the U.S. Department of State or the United States Agency for International Development. The authors discuss the role of a JSF in promoting "science diplomacy" from the perspective of one alumnus, who sites examples of ongoing, long-term collaborative projects including one focusing on medical education reform in Iraq that would not have been possible without the JSF program. More than 3 decades of political and social unrest, terrorism, the internal displacement of millions of Iraqi citizens, the arrival of Syrian refugees, international sanctions, and the effect of fluctuating oil prices that fund education in Iraq have all led to a standstill in modernizing educational systems and the need for reform. In 2016, new opportunities for international collaboration and travel allowed faculty from the Al Kindy College of Medicine, University of Baghdad, Iraq, to visit the United States, explore U.S. medical school teaching methods, interact with U.S. faculty and students, and then implement their vision of a revised medical curriculum. These faculty members shared their observations with the Iraqi Council of Deans, which represents all 30 Iraqi medical schools. Structural changes in curriculum content and teaching methods have been implemented with the goal of restoring quantifiable excellence in education and health care in Iraq. The authors close with lessons learned to encourage other physicians to participate in the JSF program, which offers a unique opportunity to influence foreign policy through science diplomacy.

Background: Pneumatic dilation (PD) is often billed as a "short term" treatment for achalasia but anecdotally can last years. This study sought to explore how long a single pneumatic dilation may induce symptom remission in a treatment-naïve achalasia patient., Methods: A single center, retrospective chart review of patients with an ICD-9 or - 10 code of achalasia between 2005 and 2017 was performed. Treatment naïve patients with manometric diagnosis of primary achalasia were included. Outcomes (success or failure); single vs multiple PD; age; and estimated duration of effect were evaluated. Each patient underwent a single PD unless re-intervention was required for relapse., Results: 83 patients (52% female, median 51.6 ± 3.6 years) were included. 43% underwent 2 PD and 13% underwent 3 PD. There was no significant relation between age, gender, and number of PDs. After 1 PD, 87.5% of patients reported > 1 year of symptom remission. 80.5% of relapsed patients reported success after a 2nd dilation. 1 PD was more likely to result in success than multiple PDs (p < 0.001). The measured median duration of remission after 1 PD was 4.23 years, and for 2 PDs, 3.71 years. The median estimated remission time after 1 PD was 8.5 years (CI 7.3-9.7, p = 0.03)., Conclusions: PD is a safe, durable treatment for achalasia. A single PD is likely to last years. A second PD, if required, also has a high likelihood of success.

Research has shown that taxi drivers are at risk for numerous health concerns, such as low back and leg pain, linked to their highly sedentary occupation, long work hours and stressors related to the job (e.g. low income, safety threats). The goal of this study was to explore occupational health risks and opportunities for health interventions with taxi drivers using community-based participatory research (CBPR) methods. A mixed methods approach included first a convenience sample of 19 East African taxi drivers participating in focus group discussions. Second, a convenience sample of 75 current taxi drivers (M age = 45.7 years) and 25 non-driver comparison participants (M age = 40.3 years) were recruited to complete a structured self-reported questionnaire and objective measures of health. Health education was provided alongside the research to address common health concerns and to ensure mutual benefit and an action orientation. The focus groups described numerous health concerns that drivers attributed to their occupation, including chronic pain, sleep deprivation, cardiovascular disease, diabetes, kidney disease and eye problems, as the most common. Participants offered ideas for health interventions that include workplace reform and driver education. Quantitative data indicate that 44% of drivers reported their health as 'fair' or 'poor'. Drivers were more likely to report musculoskeletal pain, less sleep, more fatigue and less physical activity as compared to non-drivers. The majority of drivers reported financial and job dissatisfaction. The research provides data to inform targeted health interventions that support the health and safety of taxi drivers., (© The Author 2017. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Introduction: Black men are diagnosed with prostate cancer at nearly twice the rate of white men and are underrepresented in prostate cancer research, including validation studies of new clinical tools (e.g., genomic testing). Because healthcare system mistrust has contributed to these disparities for centuries, black men may be less inclined to pursue novel testing, and identification of facilitators to their participation in prostate cancer research studies remains warranted., Methods: A community-engaged approach involving a partnership with a community organization was used to conduct seven focus groups in Minnesota, Alabama, and California to explore black men's attitudes toward prostate cancer research participation and genomic testing for prostate cancer. Data were collected and analyzed from April 2015 to April 2017., Results: Identified genomic testing barriers included a lack of terminology understanding, healthcare system mistrust, reluctance to seek medical care, and unfavorable attitudes toward research. Facilitators included family history, value of prevention, and the desire for health education. Lack of prostate cancer knowledge, prostate-specific antigen testing confusion, healthcare system distrust, and misuse of personal health information were barriers to research study participation. Some black men were motivated to participate in research if it was seen as constructive and transparent., Conclusions: Disparities for black men can both motivate and disincentivize participation depending upon a positive or negative view of research. Confusion over prostate cancer clinical care has fueled some mistrust among black men affecting both clinical care and research participation. With increased education, health literacy, and assurances of research integrity and transparency, black men may be more willing to participate in prostate cancer testing and research., Supplement Information: This article is part of a supplement entitled African American Men's Health: Research, Practice, and Policy Implications, which is sponsored by the National Institutes of Health., (Copyright © 2018. Published by Elsevier Inc.)

Risk factors can drive socioeconomic inequalities in cardiovascular disease (CVD) through differential exposure and differential vulnerability. In this paper, we show how econometric decomposition directly enables simultaneous, policy-oriented assessment of these 2 mechanisms. We specifically estimate contributions of neighborhood environment and proximal risk factors to socioeconomic inequality in CVD incidence via these mechanisms. We followed 5,608 participants in the Multi-Ethnic Study of Atherosclerosis (2000-2012) to their first CVD event (median length of follow-up, 12.2 years). We used a summary measure of baseline socioeconomic position (SEP). Covariates included baseline demographics, neighborhood characteristics, and psychosocial, behavioral, and biomedical risk factors. Using Poisson models, we decomposed the difference (inequality) in incidence rates between low- and high-SEP groups into contributions of 1) differences in covariate means (differential exposure) and 2) differences in CVD risk associated with covariates (differential vulnerability). Notwithstanding large uncertainty in neighborhood estimates, our analysis suggested that differential exposure to poorer neighborhood socioeconomic conditions, adverse social environment, diabetes, and hypertension accounted for most of the inequality. Psychosocial and behavioral contributions were negligible. Further, neighborhood SEP, female sex, and white race were more strongly associated with CVD among low-SEP (vs. high-SEP) participants. These differentials in vulnerability also accounted for nontrivial portions of the inequality and could have important implications for intervention.

Medicare Part D improved medication adherence among the elderly, but to date, its effect on disparities in adherence remains unknown. We estimated Part D impact on racial/ethnic disparities in adherence to cardiovascular medications among seniors, using pooled data from the Medical Expenditure Panel Survey (2002-2010) on 14,221 Medicare recipients (65+ years) and 3,456 near-elderly controls (60-64 years). Study sample included White, Black, or Hispanic respondents who used at least one cardiovascular medication. Twelve-month adherence was measured as having an overall proportion of days covered ≥80%. Adherence disparities were defined according to the Institute of Medicine framework. Using difference-in-differences logistic regression, we found Part D to be associated with a 16-percentage-point decrease in the White-Hispanic disparity in overall adherence among seniors, net of the change among controls. Black-White disparities worsened only among men, by 21 percentage points. Increasing access and improving quality of medication use among disadvantaged seniors should remain a policy priority., (© The Author(s) 2015.)

Background: Retail prescription fill data have consistently shown wide variation in prescription drug utilization across states, with state-level rates ranging from 8.5 to 19.3 filled prescriptions per capita per year. Empirical explanations for this wide variation have not yet been sought., Objectives: To examine which factors potentially explain the wide variation in prescription drug utilization across US states., Methods: Summary data (proportions, counts, rates, etc) on sociodemographics, health, insurance, provider density, health service use, and retail prescription drug fills for each of the 50 states and the District of Columbia, from 2008 to 2010, were retrieved from multiple national data sources, such as the Kaiser Family Foundation's "State Health Facts" Web Portal. Pooled cross-sectional linear, negative binomial, and ordered logit multivariable regressions were used to model states' prescription utilization as a function of the aforementioned possible explanatory variables. Principal components analysis also was employed so as to overcome high correlations among some of the covariates., Results: Among US states, higher levels of employer-sponsored insurance or Medicaid coverage were associated with both higher levels of prescription utilization and a higher likelihood of being in upper utilization quartiles. A higher density of nurse practitioners was also positively associated with both the level of utilization and the likelihood of higher utilization, whereas a higher density of active physicians was associated with opposite effects. Higher prevalence of physical activity was associated with lower utilization levels as well as a lower likelihood of high utilization. State-level prevalence of chronic conditions and poor health mattered only for the level of prescription utilization. States' sociodemographics were not significantly associated with prescription utilization., Conclusions: This study suggests that higher prescription utilization across states was associated with the variations in provider types, Medicaid and private insurance coverage, as well as the prevalence of chronic diseases. Further investigation of how each of these factors may contribute to a particular state's prescription drug utilization level is needed., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Statins are a class of cholesterol-lowering drugs that affect many intracellular pathways that may have implications for chemoprevention against cancer. Epidemiologic data on statins and breast cancer are conflicting. We analyzed updated data from the Women's Health Initiative (WHI) to assess the relationship between statins and breast cancer risk., Methods: The population included 154,587 postmenopausal women ages 50 to 79 years, with 7,430 pathologically confirmed cases of breast cancer identified over an average of 10.8 (SD, 3.3) years. Information on statins was collected at baseline and years one, three, six, and nine. Self- and interviewer-administered questionnaires were used to collect information on risk factors. Cox proportional hazards regression was used to calculate HRs with 95% confidence intervals (CI) to evaluate the relationship between statin use and cancer risk. Statistical tests were two-sided., Results: Statins were used by 11,584 (7.5%) women at baseline. The annualized rate of breast cancer was 0.42% among statin users and 0.42% among nonusers. The multivariable adjusted HR of breast cancer for users versus nonusers was 0.94 (95% CI, 0.83-1.06). In the multivariable-adjusted, time-dependent model, the HR for simvastatin was 0.87 (95% CI, 0.71-1.07). There was no significant trend by overall duration of use (P value for trend 0.68). There was no effect of tumor stage, grade, or hormone receptor status., Conclusion: Overall, statins were not associated with breast cancer risk., Impact: Our study is one of the largest prospective observational studies on this topic, and substantially adds to the literature suggesting no relationship between statins and breast cancer risk.

Purpose: To calculate and compare the direct medical costs of guideline-recommended prophylaxis with prophylaxis that does not fully adhere with guideline recommendations in a large, real-world population., Methods: Discharge records were retrieved from the US Premier Perspective™ database (January 2003-December 2003) for patients aged≥40 years with a primary diagnosis of cancer, chronic heart failure, lung disease, or severe infectious disease who received some form of thromboprophylaxis. Univariate analysis and multivariate regression modeling were performed to compare direct medical costs between discharges who received appropriate prophylaxis (correct type, dose, and duration based on sixth edition American College of Chest Physicians [ACCP] recommendations) and partial prophylaxis (not in full accordance with ACCP recommendations). Market segmentation analysis was used to compare costs stratified by hospital and patient characteristics., Results: Of the 683 005 discharges included, 148,171 (21.7%) received appropriate prophylaxis and 534,834 (78.3%) received partial prophylaxis. The total direct unadjusted costs were $15,439 in the appropriate prophylaxis group and $17,763 in the partial prophylaxis group. After adjustment, mean adjusted total costs per discharge were lower for those receiving appropriate prophylaxis ($11,713; 95% confidence interval [CI], $11,675-$11,753) compared with partial prophylaxis ($13,369; 95% CI, $13,332-$13 406; P<0.01). Appropriate prophylaxis appeared to be associated with numerically lower unadjusted costs than partial prophylaxis, regardless of hospital size, rural/urban location, teaching status, and patient age and gender., Conclusion: This large, real-world analysis suggests that appropriate prophylaxis, in adherence with ACCP guidelines, is potentially cost-saving compared with partial prophylaxis in at-risk medical patients.

Introduction: Few studies have investigated current practices in the USA relating to warfarin use and monitoring, or the effects of warfarin discontinuation on risk of venous thromboembolism (VTE) and bleeding complications. This study investigated the effect of warfarin discontinuation on rates of VTE recurrence in a real-world setting., Methods: Integrated Healthcare Information Services database records from January 2003 to September 2007 from patients aged at least 18 years, hospitalized for VTE, and with at least two prescriptions or 60 days of warfarin treatment were reviewed, with warfarin discontinuation and international normalized ratio (INR) data collated., Results: A total of 1027 of 8380 (12.3%) patients discontinued warfarin within 3 months. Overall, 1656 (19.8%) patients had no INR monitoring, with 38.1% of INR values being inside the therapeutic range (INR 2-3). Recurrent VTE was observed in 915 (10.9%) patients. Significant predictors of recurrent VTE (at any time) included discontinuation of warfarin within 3 months, time from index VTE to warfarin initiation, previous VTE-related hospitalization, and duration of index hospitalization., Conclusion: This study found that in a real-world population, less than 50% of warfarin patients achieved INR values within the therapeutic range. Warfarin discontinuation within 3 months was associated with a higher rate of recurrent VTE.

Objective: To evaluate patient-reported reasons for discontinuing antimuscarinic prescription medications for overactive bladder (OAB)., Patients and Methods: A phase 1 screening survey was sent to a representative sample of 260 000 households in the USA to identify patients using antimuscarinic agents for OAB. A detailed phase-2 follow-up survey was sent to 6577 respondents with one or more antimuscarinic prescriptions for OAB in the 12 months before the phase 1 survey. The follow-up survey included questions about demographics, clinical characteristics, antimuscarinic use, beliefs about OAB, treatment expectations, OAB symptom bother, and pre-coded reasons for discontinuation. Patients who reported discontinuing one or more OAB medication during the 12 months before phase 2 were grouped by reason, using latent class analysis (LCA); the Lo-Mendell-Rubin likelihood statistical test was used to determine the number of classes. Conditional probabilities of reasons for discontinuation were calculated for each class. Multivariable logistic regression was used to assess the influence of demographic and clinical characteristics on class assignment., Results: In all, 162 906 (63%) and 5392 (82%) useable responses were returned in phases 1 and 2, respectively; the demographics were similar in respondents and nonrespondents in both phases. In all, 1322 phase 2 respondents (24.5%) reported discontinuing one or more antimuscarinic drugs during the 12 months before phase 2. LCA identified two classes (Lo-Mendell-Rubin statistic, P = 0.01) based on reasons for discontinuation. Most respondents (89%) reported discontinuing OAB medication primarily due to unmet treatment expectations and/or tolerability; many respondents in this class switched to a new antimuscarinic agent. A smaller group (11%) indicated a general aversion to taking medication. Age, sex, race, income, and history of incontinence were not predictive of class assignment., Conclusions: Expectations about treatment efficacy and side-effects are the most important considerations in discontinuing OAB medications for most patients. Interventions to promote realistic expectations about treatment efficacy and side-effects might enhance adherence.

US national performance measures may reduce the burden of venous thromboembolism (VTE) in surgical patients. To characterize the VTE rate in US surgical patients, and identify real-world independent VTE risk-factors, a national managed-care database was analyzed. 172,320 eligible surgical discharges (23.9% orthopedic, 76.1% abdominal surgery) from the PharMetrics database (January 2001-December 2005) were evaluated. The rate of thromboprophylaxis was low in orthopedic (40.5%) and abdominal (1.8%) surgery discharges, with the event rates of symptomatic VTE in these groups being 4.7% and 3.1%, respectively. The median time to VTE was 51 days: the majority of VTE events occurred post-discharge. Independent predictors of VTE included prior VTE (odds ratio [OR] 10.2; 95% CI: 9.2-11.4), and orthopedic versus abdominal surgery (OR 1.4; 95% CI: 1.4-1.6). Patients undergoing orthopedic or abdominal surgery remain at-risk for VTE. Implementation of national performance measures may help reduce the burden of VTE.

The burden of venous thromboembolism (VTE) remains high in the United States (US). This study assesses the rate of VTE prophylaxis in a large real-world population of medically ill patients and identifies factors which confer VTE risk to this population. Discharges from the PharMetrics database were included if they were aged > or =40 years and had a hospitalisation claim (Jan 2001-Dec 2005) for cancer, congestive heart failure (CHF), severe infectious disease (SID), or lung disease. Discharges with incomplete records in the prior year to the index hospitalisation claim date were excluded. VTE rate, type (deep venous thrombosis [DVT] or pulmonary embolism [PE]), and time to VTE were compared between groups. Multivariate logistic regression analysis was used to identify independent predictors of VTE occurrence. A total of 158,325 patients were included in the study. Cancer patients had the highest incidence of VTE (7.6%), with the average for all patients being 5.6% (1.5% PE). VTE occurred most frequently post discharge, with the median time being 74 days. Post-discharge prophylaxis was provided to 13.1% of CHF patients and < 5% of all other patients. Independent predictors of VTE included a pre-index VTE (odds ratio [OR] 9.06, 95% confidence interval [CI] 8.28-9.91) and a primary diagnosis of cancer compared with a diagnosis of SID (OR 1.34, 95% CI 1.24-1.46). In conclusion, commercially insured medical patients in the US are at high risk of VTE following hospital discharge. One-quarter of medical patients who developed a VTE are at high risk of developing the more severe form of the disease, namely PE, with independent predictors of VTE in the post-discharge period including previous VTE and cancer.

Introduction: Atrial fibrillation (AF) has been shown to be associated with high healthcare costs; however, limited data are available from large-scale studies quantifying the overall cost burden of AF in the USA. We therefore aimed to provide an up to date estimate of the overall per-patient costs of AF in managed care organizations across the USA., Methods: This retrospective cohort study used claims data from the Integrated Healthcare Information Systems National Managed Care Benchmark Database from January 2005 to December 2006. Patients included in the analysis were aged > or =20 years and had at least two outpatient AF-related claims without hospitalization, or a hospitalization with a primary or secondary discharge diagnosis of AF in 2005. AF-related inpatient and outpatient costs over 12 months from the initial outpatient claim or first hospitalization were examined. For secondary AF hospitalizations, incremental costs associated with AF were measured by comparing costs for patients with AF with a group of matched controls hospitalized without AF., Results: In total, 35,255 patients diagnosed as having AF (5008 with a primary AF diagnosis, 10,776 with a secondary AF diagnosis, 19,471 with outpatient-managed AF), and 20,571 controls without AF, were included in the analysis. Over 12 months, for primary AF hospitalization patients, inpatient costs were $11,306.53 and outpatient costs were $2826.78 (total $14,133.30) per patient. For hospitalized patients with secondary AF, incremental AF-related inpatient costs were $5181.19 and outpatient costs were $1376.33 (total $6557.52). For AF patients with outpatient management in 2005, 12-month AF-related costs were $2177.30 ($175.47 for AF hospitalizations in 2006 and $2001.85 for outpatient costs)., Conclusions: Overall costs of AF in the US managed care organizations are high. Costs are primarily due to inpatient expenses. Improved disease management strategies to reduce AF-related hospitalizations and decrease the overall cost burden of AF are needed.

Objectives: To determine adherence rates, transition probabilities, and factors associated with transition from higher to lower adherence in antihypertensive (AH) and lipid-lowering (LL) medications., Methods: California Medicaid data (1995-2003) were used to identify hypertensive patients with prescriptions for both AH and LL medications. Proportion of days covered (PDC) was used to define three adherence classifications: fully adherent (FA, PDC >or= 0.8), partially adherent (PA, 0.2

Purpose: The long-term impact of thalidomide plus dexamethasone (thal/dex) as primary therapy for newly diagnosed multiple myeloma (MM) is unknown. The goal of this study was to compare thalidomide plus dexamethasone versus placebo plus dexamethasone (placebo/dex)as primary therapy for newly diagnosed MM., Patients and Methods: In this double-blind, placebo-controlled trial, patients with untreated symptomatic MM were randomized to thal/dex (arm A) or to placebo plus dexamethasone (dex) (arm B). Patients in arm A received oral thalidomide 50 mg daily, escalated to 100 mg on day 15, and to 200 mg from day 1 of cycle 2 (28-day cycles). Oral dex 40 mg was administered on days 1 through 4, 9 through 12, and 17 through 20 during cycles 1 through 4 and on days 1 through 4 only from cycle 5 onwards. Patients in arm B received placebo and dex, administered as in arm A. The primary end point of the study was time to progression. This study is registered at http://ClinicalTrials.gov (NCT00057564)., Results: A total of 470 patients were enrolled (235 randomly assigned to thal/dex and 235 to placebo/dex). The overall response rate was significantly higher with thal/dex compared with placebo/dex (63% v 46%), P < .001. Time to progression (TTP) was significantly longer with thal/dex compared with placebo/dex (median, 22.6 v 6.5 months, P < .001). Grade 4 adverse events were more frequent with thal/dex than with placebo/dex (30.3% v 22.8%)., Conclusion: Thal/dex results in significantly higher response rates and significantly prolongs TTP compared with dexamethasone alone in patients with newly diagnosed MM.