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Management of occult primary breast cancer (OPBC), including the role of magnetic resonance imaging (MRI), is controversial. We conducted a pooled analysis of OPBC patients and a meta-analysis of MRI accuracy in OPBC in order to elucidate current practices.A literature search yielded 201 studies. Patient-level data for clinically/mammographically OPBC from studies published after 1993 and from our institution were pooled; logistic regression examined associations between patient/study data and outcomes, including treatments and recurrence. We report adjusted odds ratios (OR) and 95 % confidence intervals (95 % CI) significant at 2-tailed p0.05. Meta-analysis included data for patients who received MRIs for workup of clinically/mammographically OPBC. We report pooled sensitivity and specificity with 95 % CIs.The pooled analysis included 92 patients (15 studies [n = 85] plus our institution [n = 7]). Patients from Asia were more likely to receive breast surgery (OR = 5.98, 95 % CI = 2.02-17.65) but not chemotherapy (OR = 0.32, 95 % CI = 0.13-0.82); patients from the United States were more likely to receive chemotherapy (OR = 13.08, 95 % CI = 2.64-64.78). Patients from studies published after 2003 were more likely to receive radiotherapy (OR = 3.86, 95 % CI = 1.41-10.55). Chemotherapy recipients were more likely to have distant recurrence (OR = 9.77, 95 % CI = 1.10-87.21). More patients with positive MRIs received chemotherapy than patients with negative MRIs (10 of 12 [83.3 %] vs 5 of 13 [38.5 %]; p = 0.0414). In the MRI-accuracy meta-analysis (10 studies, n = 262), pooled sensitivity and specificity were 96 % (95 % CI = 91-98 %) and 63 % (95 % CI = 42-81 %), respectively.OPBC management varied geographically and over time. We recommend establishing an international OPBC patient registry to facilitate longitudinal study and develop global treatment standards.

The purpose of this study was to describe hospital and geographic variation in 30-day risk of surgical complications and death among colorectal cancer (CRC) patients and the extent to which patient-, hospital-, and census-tract-level characteristics increased risk of these outcomes.We included patients at least 66 years old with first primary stage I-III CRC from the 2000-2005 National Cancer Institute's Surveillance, Epidemiology, and End Results data linked with 1999-2005 Medicare claims. A multilevel, cross-classified logistic model was used to account for nesting of patients within hospitals and within residential census tracts. Outcomes were risk of complications and death after a complication within 30 days of surgery.Data were analyzed for 35,946 patients undergoing surgery at 1,222 hospitals and residing in 12,187 census tracts; 27.2 % of patients developed complications, and of these 13.4 % died. Risk-adjusted variability in complications across hospitals and census tracts was similar. Variability in mortality was larger than variability in complications, across hospitals and across census tracts. Specific characteristics increased risk of complications (e.g., census-tract-poverty rate, emergency surgery, and being African-American). No hospital characteristics increased complication risk. Specific characteristics increased risk of death (e.g. census-tract-poverty rate, being diagnosed with colon (versus rectal) cancer, and emergency surgery), while hospitals with at least 500 beds showed reduced death risk.Large, unexplained variations exist in mortality after surgical complications in CRC across hospitals and geographic areas. The potential exists for quality improvement efforts targeted at the hospital and/or census-tract levels to prevent complications and augment hospitals' ability to reduce mortality risk.

The prevalence of hearing loss (HL) in adolescents has grown over the past decade, but hearing-related quality of life (QOL) has not been well-measured. We sought to develop a reliable, valid measure of hearing-related QOL for adolescents and the Hearing Environments And Reflection on Quality of Life (HEAR-QL).Multisite observational study.Adolescents with HL and siblings without HL were recruited from five centers. Participants completed the HEAR-QL and validated questionnaires measuring generic pediatric QOL (PedsQL), depression and anxiety (RCADS-25), and hearing-related QOL for adults (HHIA) to determine construct and discriminant validity. Participants completed the HEAR-QL 2 weeks later for test-retest reliability. We used exploratory principal components analysis to determine the HEAR-QL factor structure and measured reliability. Sensitivity and specificity of the HEAR-QL, PedsQL, HHIA, and RCADS-25 were assessed. We compared scores on all surveys between those with normal hearing, unilateral, and bilateral HL.A total of 233 adolescents (13-18 years old) participated: 179 with HL, 54 without HL. The original 45-item HEAR-QL was shortened to 28 items after determining factor structure. The resulting HEAR-QL-28 demonstrated excellent reliability (Cronbach's alpha = 0.95) and construct validity (HHIA: r = .845, PedsQL: r = .587; RCADS-25: r = .433). The HEAR-QL-28 displayed excellent discriminant validity, with higher area under the curve (0.932) than the PedsQL (0.597) or RCADS-25 (0.529). Teens with bilateral HL using hearing devices reported worse QOL on the HEAR-QL and HHIA than peers with HL not using devices.The HEAR-QL is a sensitive, reliable, and valid measure of hearing-related QOL for adolescents.2b.

In patients with breast cancer, higher levels of social support have been linked to positive outcomes, such as improved overall health status (Ganz et al., 2003), higher quality of life (Hoyer et al., 2011), and better adjustment to a cancer diagnosis (Helgeson & Cohen, 1996), as well as fewer psychosocial problems (Patten, Williams, Lavorato, & Bulloch, 2010; Helgeson, Snyder, & Seltman, 2004; Simpson, Carlson, Beck, & Patten, 2002). High social support is associated with lower risk of recurrence (Epplein et al., 2011) and longer survival (Chou, Stewart, Wild, & Bloom, 2010; Epplein et al., 2011). In patients with breast cancer, psychosocial variables such as perceived social support are often more strongly correlated with psychosocial distress than clinical variables related to disease and treatment (Andreau et al., 2011; Helgeson, Snyder, & Seltman, 2004; Schmidt & Andrykowski, 2004). The construct of social support has been measured in a variety of ways (e.g., as perceived availability of support, social network size, and actual receipt of certain types of support), and these different measures can be poorly correlated with each other (Mickelson & Kubzansky, 2003; Uchino, 2009). The current study focuses on perceived social support, which has been strongly linked to positive psychosocial and health outcomes (Uchino, 2009). Previous studies have identified a variety of demographic and psychosocial predictors of perceived social support including age (Sammarco, 2009; Schroevers, Helgeson, Sanderman, & Ranchor, 2010) and income (Mickelson & Kubzansky, 2003). Findings on race have been mixed, with some researchers finding that social support differs by race (Lincoln, Chatters, & Taylor, 2003) and others finding that racial differences in social support were accounted for by income and education (Mickelson & Kubzansky, 2003). In addition, psychological symptoms and social support have been closely linked, with some researchers finding that low social support is a strong predictor of future depression (Patten, Williams, Lavorato, & Bulloch, 2010) and others finding that more severe psychological symptoms are a strong predictor of lower future social support (Simpson, Carlson, Beck, & Patten, 2002). Previous research also has indicated that perceived social support in patients with breast cancer tends to decrease over time (Den Oudsten, Van Heck, Van der Steeg, Roukema, & DeVries, 2010; Courtens, Stevens, Crebolder, & Philipsen, 1996; Bloom & Kessler, 1994; Levy et al., 1992). The question remains whether such decreases in perceived social support are of concern. It is plausible that social support might be transiently higher in breast cancer patients at the time of initial detection and treatment (e.g., as friends and relatives rally to support the patient), resulting in perceived social support that is higher than that of controls (Schroevers, Ranchor, & Sanderman, 2003) but that support would decline over time. This decline in social support might leave breast cancer patients with similar quality of life to controls many years after cancer is detected (e.g., Helgeson & Tomich, 2005). However, it is also possible that even years after detection and initial treatment, breast cancer survivors need more social support than women without breast cancer. Although cross-sectional findings about perceived social support are generally consistent with the conclusion that more perceived social support is associated with better outcomes, some researchers have concluded that women with breast cancer both need and seek less support in the years after their diagnosis (Danhauer, Crawford, Farmer, & Avis, 2009; Badger, Braden, Longman, & Mishel, 1999), which might suggest that decreases in social support are unrelated to decreases in functioning and quality of life. The available literature has not, to our knowledge, considered that perceived social support may have a trajectory over time. That is, at any given time point, a person’s level of perceived social support may be a combination of her long-term tendency toward a certain average level of perceived social support as well as her more recent downward or upward trajectory of support, if any. A level of social support at one time may be a point on a line (trajectory), which may or may not be stable. Measurement of perceived social support at one or two time points, as is often done, cannot distinguish between these features of the construct. It is possible that many years after diagnosis, perceived social support reported by patients and controls does not differ, whereas the slope that brought patients to that point could be quite different from the slope shown by controls. Furthermore, it could be that patients’ slope predicts future negative outcomes that are independent of their current level of perceived social support. A steeper drop in support might be more important than the level of support at any given point. Examination of the social support trajectory can be undertaken using a latent trajectory model, which requires at least three waves of data and allows researchers to distinguish between systematic change in a construct over time (i.e., the slope) and general tendencies toward a certain level on a construct (i.e., the intercept, which is typically expressed in terms of the participant’s starting point) (Curran & Hussong, 2003). We propose that a clear understanding of how perceived social support changes for women with breast cancer is only possible through separating and examining these two parts of the construct of social support. Similarly, we propose that it is particularly important to understand what predicts change in perceived social support for breast cancer patients over and above their general tendencies for perceived support. We also contend that longitudinal changes in social support in patients with breast cancer must be analyzed in conjunction with data from same-age women without breast cancer in order to determine which predictors are specific to women with breast cancer. We used longitudinal data from a cohort of 1096 early-stage patients with breast cancer and age-matched controls to analyze the degree of change (slope) and the starting point level (intercept) of perceived social support measured four times over the course of two years. Quality of life research using similar methods has analyzed breast cancer patients as a heterogeneous group with different trajectories of depressive symptoms (Helgeson, Snyder, & Seltman, 2004; Dunn et al., 2011). However, rather than attempt to find empirically derived groups of patients, we used latent trajectory modeling (Curran & Hussong, 2003) to examine predictors of women’s social support trajectories. A latent trajectory model can be used to derive the estimated underlying trajectory of change in longitudinal data collected over several time points (Curran & Hussong, 2003). Including age-matched controls helped us determine whether slope and intercept of social support differed for breast cancer patients compared to controls, as well as which psychosocial, demographic, and clinical variables contribute to social support slope and intercept. We tested four hypotheses: Hypothesis 1: Social support is higher in patients than controls at baseline and decreases over time in patients but not controls. Hypothesis 2: Predictors of slope and intercept of social support differ from each other, and they differ between patients and controls. Because this is, to our knowledge, the first analysis of change in social support to examine slope and intercept separately, we expected that some predictors for slope might differ from predictors previously noted in the literature; thus we did not predict in which direction variables might influence social support. Hypothesis 3: Decrease in social support among patients is related to poorer psychosocial adjustment, as measured by higher levels of depressive symptoms. Hypothesis 4: Predictors of social support slope in patients exert indirect effects on depressive symptom severity through the slope of social support.

Background: Breast cancer survivors who consume alcohol excessively are at increased risk of recurrence and have worse prognosis. Because the environments in which people live shape many health behaviors, there has been increased attention to how neighborhood environments (eg, alcohol outlet availability) may influence alcohol consumption. The authors hypothesized that proximity to alcohol outlets increases the likelihood of excessive consumption (ie, more than 1 drink/day) among breast cancer survivors independent of their personal or neighborhood characteristics. Methods: With the Missouri Cancer Registry, the authors conducted a cross-sectional study of 1047 female breast cancer survivors (aged 27-96 years) 1 year after diagnosis. Using telephone interviews, the authors obtained data regarding survivors’ alcohol consumption during the past 30 days and several covariates of alcohol use. They also obtained street addresses of all licensed alcohol outlets in Missouri and calculated the road network distance between a participant’s address of residence and the nearest alcohol outlet, using a geographic information system. Logistic regression was used to determine if distance was independently associated with excessive alcohol consumption. Results: Eighteen percent of participants reported consuming more than 1 drink on average per day. Women who lived within 3 miles of the nearest outlet were more likely to report excessive alcohol consumption (odds ratio: 2.09; 95% confidence interval: 1.08, 4.05) than women who lived at least 3 miles from the nearest outlet in adjusted analysis. Discussion: Opportunities exist to reduce excessive alcohol use among breast cancer survivors through policy (eg, restricting number of alcohol outlets) and behavioral (eg, counseling) interventions.

Objectives We aimed to evaluate Latin American primary care physicians’ knowledge and attitudes about obstructive sleep apnea (OSA) using a Spanish-language version of the OSA Knowledge and Attitudes (OSAKA) questionnaire and to evaluate its psychometric properties. Methods We used a cross-sectional survey of general practice physicians in Ecuador, Peru, and Venezuela who completed the Spanish-language version OSAKA questionnaire. Results Of 684 primary care physicians surveyed, 367 (65%) responded (mean age, 45 years; range, 21–75 years). Mean total knowledge (proportion of 18 items correctly answered) was 60% (range, 0–100%). Less than half of physicians correctly answered the questions about the association between OSA and hypertension. We found no significant differences in overall knowledge in gender or time since graduation (⩽5 years vs >5 years). Although 73.5% of the physicians felt confident in identifying patients at risk for OSA, only 35.4% felt confident in managing those patients and 22.1% felt confident in managing patients with continuous positive airway pressure (CPAP) therapy. The Spanish-language version of the OSAKA questionnaire had comparable psychometric properties to the English-language version. Conclusions This Spanish-language version of the OSAKA yielded considerable variance in Spanish-speaking physicians’ knowledge about OSA and confidence in identifying and managing patients with OSA. Focused OSA education for Latin American general physicians is needed.

Type 2 diabetes is associated with low-grade systemic inflammation, increasing the risk for various adverse health outcomes.Our objective was to investigate the association between C-reactive protein (CRP), a marker for systemic inflammation, and lifestyle factors in a national sample of people with type 2 diabetes.This study analyzed data from 1,086 men and women with diabetes, who completed the 1999-2004 NHANES. Lifestyle factors included diet quality, body mass index (BMI), smoking, and physical activity.Stratified logistic regression showed that for both men and women, BMI was a strong predictor of elevated CRP after adjusting for age, energy intake, race/ethnicity, medications, diabetes duration, and glycosylated hemoglobin. However, among men, but not among women, the likelihood of elevated CRP increased with lower diet quality and physical inactivity.Among people with type 2 diabetes, higher levels of CRP were associated with lower diet quality and physical inactivity among men, and with obesity among both men and women.

The perception that girls historically have had a difficult time in science and math is commonly accepted by educators and laypeople alike. Yet the historical nature of these difficulties is questionable. Current debates on sex-segregated science and math classes, receiving considerable attention in the popular press and academic-education circles in recent months, seem to be founded on a misunderstanding of what girls’ “historical difficulties” actually were. The historical, social, and political con -text of women's experience in science serves to challenge the stereotype that girls “historically” have had a difficult time in math and science. Further alluding to the nature of women's difficulties as historical and personal, without a critical analysis of the sociopolitical parameters of women's experience, serves to perpetuate stereo -types about women rather than militate against obstacles created by them.

Aspiring junior investigators from groups underrepresented in the biomedical sciences face various challenges as they pursue research independence. However, the biomedical research enterprise needs their participation to effectively address critical research issues such as health disparities and health inequities. In this article, we share a research education and mentoring initiative that seeks to address this challenge: Programs to Increase Diversity among Individuals Engaged in Health Related Research (PRIDE), funded by the National Heart, Lung, and Blood Institute (NHLBI). This longitudinal research-education and mentoring program occurs through summer institute programs located at US-based academic institutions. Recruited participants are exposed to didactic and lab-based research-skill enhancement experiences, with year-round mentoring over the course of two years. Mentor-mentee matching is based on shared research interests to promote congruence and to enhance skill acquisition. Program descriptions and sample narratives of participants’ perceptions of PRIDE’s impact on their career progress are showcased. Additionally, we highlight the overall program design and structure of four of seven funded summer institutes that focus on cardiovascular disease, related conditions, and health disparities. Mentees’ testimonials about the value of the PRIDE mentoring approach in facilitating career development are also noted. Meeting the clinical and research needs of an increasingly diverse US population is an issue of national concern. The PRIDE initiative, which focuses on increasing research preparedness and professional development of groups underrepresented in the biomedical research workforce, with an emphasis on mentoring as the critical approach, provides a robust model that is impacting the careers of future investigators. Ethn Dis. 2016;26(3):379- 386; doi:10.18865/ed.26.3.379

Breast cancer patients whose tumors achieve a pathological complete response (pCR) with neoadjuvant chemotherapy have a prognosis which is better than that predicted for the stage of their disease. However, within this subgroup of patients, recurrences have been observed. We sought to examine factors associated with recurrence in a population of breast cancer patients who achieved a pCR with neoadjuvant chemotherapy. A retrospective chart review was conducted of all patients with unilateral breast cancer treated with neoadjuvant chemotherapy from January 1, 2000 to December 31, 2010 at one comprehensive cancer center. A pCR was defined as no residual invasive cancer in the breast in the surgical specimen following neoadjuvant therapy. Recurrence was defined as visceral or bony reappearance of cancer after completion of all therapy. Of 818 patients who completed neoadjuvant chemotherapy, 144 (17.6 %) had pCR; six with bilateral breast cancer were excluded from further analysis. The mean time to follow-up was 47.2 months. Among the 138 patients with unilateral breast cancer, there were 14 recurrences (10.1 %). Using a binary multiple logistic regression model, examining types of chemotherapy and surgery, race, lymph node assessment, and lymph node status, breast cancer side, triple-negative status, and radiation receipt, only African-American patients (OR: 5.827, 95 % CI: 1.280–26.525; p = 0.023) were more likely to develop distant recurrence. The mean time to recurrence was 31.9 months. In our study, race was the only independent predictor of recurrence after achieving pCR with neoadjuvant chemotherapy. The reasons for this observation require further study.

A diverse workforce is essential to academic medicine’s mission of excellence in teaching, patient care, and research.1 However, the academic medicine workforce in the United States remains lacking in racial and ethnic diversity. Historically underrepresented minorities (URMs)--which we defined as including non-Hispanic African Americans, Hispanics (any race), and Native Americans/Alaska Natives--comprised about 29% of the total U.S. population in 20102 but made up only 7.0% (9,635/137,925) of all full-time faculty at U.S. Liaison Committee on Medical Education (LCME)–accredited medical schools in 2011.3 Medical graduates holding MD degrees (with or without other advanced degrees) comprised 71.4% of the U.S. medical school faculty in 20104 and 71.7% in 2011.3 Therefore, faculty racial/ethnic diversity reflects, at least in part, the diversity of U.S. medical school graduates. URMs accounted for 14.6% (2,247/15,338) of U.S. medical graduates in 2008,5 whereas in 2011, only 8.3% (8,256/98,904) of U.S. medical school faculty holding MD degrees were URMs.3 Thus, the representation of URM medical graduates in academic medicine faculty remains well below even their relatively low representation among U.S. medical school graduates. We conducted a retrospective, national cohort study in 2011 to test two hypotheses related to racial/ethnic disparities in academic medicine faculty appointments in the United States. First, we hypothesized that among U.S. medical graduates, the proportion of URM graduates appointed to full-time faculty positions would be lower than the proportion of non-URM graduates appointed to such positions. Second, as participation in research is among the variables reportedly associated with choosing academic medicine as a career,6,7 racial/ethnic disparities in research participation may contribute to disparities in the academic medicine workforce.8,9 Thus, we also hypothesized that participation in formal research experiences during college, medical school, and graduate medical education (GME) would mediate the association between race/ethnicity and full-time academic medicine faculty appointment among U.S. medical school graduates.

Background Breast cancer is the most commonly diagnosed cancer and the second leading cause of cancer death among women in the United States. It is unclear how county-level primary care physician (PCP) availability and socioeconomic deprivation affect the spatial and temporal variation of breast cancer incidence and mortality. Methods We used the 1988–2008 public-use county-based data from nine Surveillance, Epidemiology, and End Results (SEER) programs to analyze the temporal and spatial disparity of PCP availability and socioeconomic deprivation on early-stage incidence, advanced-stage incidence and breast cancer mortality. The spatio-temporal analysis was implemented by a novel structural additive modeling approach. Results Greater PCP availability was significantly associated with higher early-stage incidence, advanced-stage incidence and mortality during the entire study period while socioeconomic deprivation was significantly negatively associated with early-stage incidence, advanced-stage incidence, and mortality up to 1992. However, the observed influence of PCP availability and socioeconomic deprivation varied by county. Conclusions We showed important associations of PCP availability and socioeconomic deprivation with the three breast cancer indicators. However, the effect of these associations varied over time and across counties. The association of PCP availability and socioeconomic deprivation was stronger in selected counties.

Passing scores on all steps of the United States Medical Licensing Examination (USMLE) sequence are among the requirements for MD-degree graduates for permanent medical licensure in every state in the United States.1 Step l in the USMLE sequence is designed to assess the examinee’s understanding and application of the basic sciences relevant to medical practice2 and is typically taken by students in U.S. medical schools after they have completed the preclinical curriculum but before they have entered third-year clinical clerkships. Most examinees pass Step l on the first attempt. However, as reported annually from 1998–2010 by the National Board of Medical Examiners (NBME), the first-attempt failure rate among examinees at MD-degree granting medical schools has ranged from a low of 5% in 20073 to a high of 9% in 2001.4 Medical school policies regarding Step l requirements for student advancement and graduation have changed substantially since the introduction of the USMLE sequence. The percentage of medical schools that require a passing score on Step l for advancement and/or graduation has steadily increased from 63.5% (80/126) in 1992-1993,5 when the USMLE sequence was introduced, to 90.0% (117/130) in 2009-2010.6 Thus, increasingly greater numbers of students who initially failed Step 1 are subject to policies that stipulate a passing score must be achieved before they can advance along the medical education continuum. An understanding of the variables associated with attempting, and with passing, Step 2 Clinical Knowledge (CK) on the first attempt among students who initially failed Step l can inform medical schools’ efforts both to assess the risk for experiencing subsequent difficulties for the students who initially fail Step l and to provide support for those students who are at risk for experiencing continued difficulties with the USMLE sequence. Thus, we examined these educational outcomes (attempting Step 2CK and passing it on the first attempt) for students who were enrolled in U.S. medical schools accredited by the Liaison Committee on Medical Education (LCME) and who initially failed Step l of the USMLE sequence. Because Step 2CK is typically taken only after students have advanced through the third-year clinical clerkships, we hypothesized that, among students who initially failed Step l, a more recent matriculation year would be associated with a lower likelihood of attempting Step 2CK. Because Step 2CK first-attempt 3-digit scores correlate with Step 1 first-attempt 3-digit scores,7-9 we also hypothesized that, among those students who initially failed Step l and attempted Step 2CK, lower Step 1 failing scores would be associated with a lower likelihood of passing Step 2CK on the first attempt. We report here the results of a retrospective, national cohort study that tested these two hypotheses.

Context Certification by an American Board of Medical Specialties (ABMS) member board is emerging as a measure of physician quality. Objective To identify demographic and educational factors associated with ABMS member board certification of US medical school graduates. Design, Setting, and Participants Retrospective study of a national cohort of 1997-2000 US medical school graduates, grouped by specialty choice at graduation and followed up through March 2, 2009. In separate multivariable logistic regression models for each specialty category, factors associated with ABMS member board certification were identified. Main Outcome Measure ABMS member board certification. Results Of 42 440 graduates in the study sample, 37 054 (87.3%) were board certified. Graduates in all specialty categories with first-attempt passing scores in the highest tertile (vs first-attempt failing scores) on US Medical Licensing Examination Step 2 Clinical Knowledge were more likely to be board certified; adjusted odds ratios (AORs) varied by specialty category, with the lowest odds for emergency medicine (87.4% vs 73.6%; AOR, 1.82; 95% CI, 1.03-3.20) and highest odds for radiology (98.1% vs 74.9%; AOR, 13.19; 95% CI, 5.55-31.32). In each specialty category except family medicine, graduates self-identified as underrepresented racial/ethnic minorities (vs white) were less likely to be board certified, ranging from 83.5% vs 95.6% in the pediatrics category (AOR, 0.44; 95% CI, 0.33-0.58) to 71.5% vs 83.7% in the other nongeneralist specialties category (AOR, 0.79; 95% CI, 0.64-0.96). With each $50 000 unit increase in debt (vs no debt), graduates choosing obstetrics/gynecology were less likely to be board certified (AOR, 0.89; 95% CI, 0.83-0.96), and graduates choosing family medicine were more likely to be board certified (AOR, 1.13; 95% CI, 1.01-1.26). Conclusion Demographic and educational factors were associated with board certification among US medical school graduates in every specialty category examined; findings varied among specialty categories.

The aims of this study were to characterize trauma exposure and posttraumatic stress disorder (PTSD) in female drug court participants and test for differences in socioeconomic status and familial status between women with: (i) no trauma exposure, (ii) trauma exposure without PTSD, and (iii) trauma exposure resulting in PTSD. Three hundred and nineteen women were recruited from drug courts. Rates of exposure and likelihood of traumatic events leading to PTSD were examined, sociodemographic characteristics were compared across groups, and a logistic regression analysis was conducted to test for differences in PTSD risk for assaultive vs. non-assaultive events. Twenty percent of participants met PTSD criteria, 71% had trauma exposure without PTSD, and 9% did not endorse any traumatic events. Prostitution and homelessness were more prevalent in women with vs. without a history of trauma, but among trauma-exposed women prevalences did not vary by PTSD status. No differences in risk for PTSD were found between assaultive and non-assaultive events (OR=0.91; 95%CI: 0.48-1.75). Women sentenced to drug court represent a heavily trauma-exposed population, for whom risk for PTSD is not limited to assaultive events. Within this high-risk population, trauma is associated with elevated rates of homelessness and prostitution, even in the absence of PTSD.

We examined the extent of changes in absolute and relative geographic disparities in six colorectal cancer (CRC) indicators using data about persons aged 50 and older from 195 counties in the 1988-2006 Surveillance, Epidemiology, and End Results Program database.County-level trends in six colorectal cancer indicators (overall CRC incidence, descending colon cancer incidence, proximal colon cancer incidence, late-stage CRC incidence, CRC mortality, and 5-year probability of CRC death) were summarized using the estimated annual percentage change. Observed county rates were smoothed using Bayesian hierarchical spatiotemporal methods to calculate measures of absolute and relative geographic disparity and their changes over time.During the study period, absolute disparity for all six indicators decreased (CRC incidence: 43.2%; proximal colon cancer: 31.9%; descending colon cancer: 52.8%; late-stage CRC: 50.0%; CRC mortality: 57.8%; 5-year CRC-specific probability of death: 12.2%). Relative disparity remained stable for all six indicators over the entire study period.Important progress has been made toward achieving the Healthy People 2010 and NCI strategic objectives for reducing geographic disparities, although absolute and relative disparities remain in CRC.

Purpose To estimate the effect of hypothetical changes in modifiable predictors on the incidence of fair-to-poor self-rated health (SRH) in breast cancer survivors. Methods In 2007–2008, we interviewed 832 breast cancer survivors 1 year after diagnosis (baseline) and 1 year later. First, multivariable logistic regression models estimated the association between the predictors (sociodemographic factors, access to medical care, comorbid conditions, psychosocial factors, perceived neighborhood conditions, cancer-related behaviors, clinical factors) and SRH. Second, we estimated the probabilities of fair-to-poor SRH for values of the predictors for each breast cancer survivor. Third, we estimated the population-wide effect of potential changes in modifiable predictors on the incidence of fair-to-poor SRH. Results A total of 7.6% of participants (92.4% white; mean age, 58.0 years) whose SRH was rated good-to-excellent at baseline reported fair-to-poor SRH 1 year later. The largest potential reduction in incidence of fair-to-poor SRH could be obtained by eliminating surgical side effects (27.8% reduction) and comorbidity (21.8% reduction) and by engaging in any physical activity (19.6% reduction). Conclusions A significant portion of the decline in SRH can be avoided by reducing surgical side effects, preventing comorbidity, and improving physical activity with the use of evidence-based strategies.

Fear of cancer recurrence (FCR) is a common and persistent concern among breast cancer survivors. Little is known about factors associated with FCR in women with ductal carcinoma in situ (DCIS) or early invasive breast cancer (EIBC). Women with first primary DCIS, or stages I–IIA breast cancer were prospectively enrolled in a quality-of-life study and completed interviews at 4–6 weeks, 6 months, and 2 years after definitive surgical treatment. In three stepwise multivariable linear regression models, including both time-independent and time-varying variables measured at each respective interview, we identified independent correlates of mean FCR scores (range 1–6) using four items from the Concern About Recurrence Scale (CARS) at 2-year follow-up. Of 506 disease-free patients at 2-year follow-up (mean [SD] age, 58 [10] years; 81% White; 34% DCIS), the average FCR score of 2.0 was low. However, 145 (29%) reported moderate-to-high levels of FCR (scores 3.0–6.0). All three models showed that younger age, stage IIA breast cancer (vs. DCIS), lower social support, and elevated anxiety were consistently associated with higher FCR at 2-year follow-up (each P < 0.05; final models R2 = 0.25–0.32). DCIS patients reported lower FCR than stage IIA patients (each P ≤ 0.01) but had similar FCR as stage I patients. Although mean FCR was low, 29% of DCIS and EIBC survivors reported moderate-to-high levels of FCR at 2-year follow-up. Management of anxiety, provision of social support, and patient education may help reduce FCR among DCIS and EIBC survivors, especially among younger survivors.

The purpose of this study was to measure change in clinical research self‐efficacy after participating in KL2, postdoctoral and predoctoral clinical research training programs at Washington University School of Medicine. We surveyed program participants using a 76‐item version of the Clinical Research Appraisal Inventory (CRAI). Principal components analysis (PCA) examined the CRAI’s underlying factor structure; Cronbach alpha measured the internal consistency of items on each subscale and the overall CRAI. CRAI score changes from baseline to 1‐year follow‐up were assessed using repeated‐measures analysis of variance. All 29 KL2, 47 postdoctoral, and 31 TL1 scholars enrolled 2006–2009 (mean age 31.6 years, range 22–44; 59.6% female; 65.4% white) completed baseline surveys. Of these participants, 22 KL2, 17 postdoctoral, and 21 TL1 scholars completed the 1‐year follow‐up assessment. PCA resulted in a seven‐factor solution with 69 items (alphas > 0.849 for each subscale and 69‐item CRAI). Significant improvements at 1‐year follow‐up were observed across all programs for Study Design/Data Analysis (p= .016), Interpreting/Reporting/Presenting (p= .034), and overall CRAI (p= .050). Differences between programs were observed for all but one subscale (each p < .05). Clinical research self‐efficacy increased 1 year after clinical research training. Whether this short‐term outcome correlates with long‐term clinical research productivity, requires further study. Clin Trans Sci 2010; Volume 3: 243–248.

PURPOSE To identify factors associated with U.S. medical school matriculants' postbaccalaureate premedical program participation and to determine whether participation was associated with plans at medical school graduation to practice in underserved areas. METHOD Deidentified, individualized records of Association of American Medical Colleges (AAMC) Matriculating Student Questionnaire responses for the 1996- 2000 cohort of U.S. medical school matriculants were analyzed using multivariable logistic regression for associations with postbaccalaureate premedical program participation. Postbaccalaureate premedical program participation was analyzed for associations with plans at medical school graduation to practice in underserved areas. Adjusted odds ratios (ORs) significant at P < .05 are reported for independent predictors of postbaccalaureate program participation among matriculants and of graduates' plans to practice in underserved areas. RESULTS The sample of 57,276 matriculants included 3,561 (6.2%) academic record enhancer (ARE), 3,931 (6.9%) career changer (CC), and 1,354 (2.4%) career changer/academic record enhancer program participants (ARE/CC). Matriculants who participated in summer academic enrichment programs (OR = 1.35), had premedical debt (OR = 1.25), and were underrepresented minorities (OR = 1.21) were more likely to report ARE participation. Women (OR = 1.46) were more likely to report CC participation. Compared with nonparticipants, ARE, CC, and ARE/CC participants were each more likely to plan, at medical school graduation, to practice in underserved areas (OR = 1.14, 1.48, and 1.47, respectively). CONCLUSIONS Among medical school matriculants, postbaccalaureate premedical program participants were demographically diverse and, at medical school graduation, were more likely than nonparticipants to plan to practice in underserved areas.

Background Limited psychometric research has examined the reliability of self-reported measures of neighbourhood conditions, the effect of measurement error on associations between neighbourhood conditions and health, and potential differences in the reliabilities between neighbourhood strata (urban vs rural and low vs high poverty). We assessed overall and stratified reliability of self-reported perceived neighbourhood conditions using five scales (social and physical disorder, social control, social cohesion, fear) and four single items (multidimensional neighbouring). We also assessed measurement error-corrected associations of these conditions with self-rated health. Methods Using random-digit dialling, 367 women without breast cancer (matched controls from a larger study) were interviewed twice, 2–3 weeks apart. Test–retest (intraclass correlation coefficients (ICC)/weighted κ) and internal consistency reliability (Cronbach9s α) were assessed. Differences in reliability across neighbourhood strata were tested using bootstrap methods. Regression calibration corrected estimates for measurement error. Results All measures demonstrated satisfactory internal consistency (α≥0.70) and either moderate (ICC/κ=0.41–0.60) or substantial (ICC/κ=0.61–0.80) test–retest reliability in the full sample. Internal consistency did not differ by neighbourhood strata. Test–retest reliability was significantly lower among rural (vs urban) residents for two scales (social control, physical disorder) and two multidimensional neighbouring items; test–retest reliability was higher for physical disorder and lower for one multidimensional neighbouring item among the high (vs low) poverty strata. After measurement error correction, the magnitude of associations between neighbourhood conditions and self-rated health were larger, particularly in the rural population. Conclusion Research is needed to develop and test reliable measures of perceived neighbourhood conditions relevant to the health of rural populations.

Surgical-treatment outcomes for melanoma in African Americans are poorly characterized as a result of low incidence of melanoma among African Americans. We examined differences by race in overall and melanoma-specific survival, stratified by receipt of surgical treatment and by specific types of surgical treatment. Data from the 1973–2004 public-use Surveillance, Epidemiology and End Results Program (SEER) were analyzed by Cox proportional hazard models to compare the effects of surgical treatments on overall and melanoma-specific survival in blacks, whites, and other race, controlling for confounding demographic and tumor-related variables. Of 151,154 patients with first primary melanoma (148,883 whites, 789 blacks and 1,532 other race), 142,653 (94.4%) received surgical treatment. Among patients who received surgical treatment, 10-year melanoma-specific survival was lower in blacks (73%) than in whites (88%) and other race (85%); black patients were at significantly higher risk of overall and melanoma-specific mortality when compared with white (hazard ratio [HR] = 1.64, 95% confidence interval [CI] 1.44–1.86, P

PURPOSE To describe trends in specialty choice and to identify predictors of primary care specialty choices among graduates of U.S. MD-granting medical schools. METHOD A longitudinal study evaluated 1997-2006 medical school graduates who completed the Association of American Medical Colleges' Matriculating Student Questionnaire and Graduation Questionnaire. Multivariate logistic regression identified significant predictors of graduates' choice of primary care specialty (general internal medicine, general pediatrics, internal medicine subspecialties, pediatrics subspecialties, family medicine, and obstetrics-gynecology) or "no-board-certification specialty," compared with all other specialties (reference). RESULTS The sample included 102,673 graduates (64.9% of all 1997-2006 graduates). General internal medicine, family medicine, general pediatrics, and obstetrics-gynecology choice decreased, whereas internal medicine subspecialties, pediatrics subspecialties, and no-board-certification specialty choice increased over time (each: P < .001). Female graduates and those who planned to practice in underserved communities, espoused more-altruistic beliefs about health care, and ascribed greater importance to social responsibility in their choice of medicine at matriculation were more likely to choose general internal medicine, general pediatrics, family medicine, or obstetrics-gynecology, whereas graduates who had a physician parent and who planned full-time academic medicine careers were less likely to do so (each: P < .01). Graduates with higher debt were less likely to choose internal medicine and pediatrics specialties (each: P < .001) and more likely to choose obstetrics-gynecology (P = .001). CONCLUSIONS Generalist-primary care specialty choices declined since 1997, whereas primary care subspecialty and no-board-certification specialty choices increased. Associations between primary care specialty choices and demographic, attitudinal, and career intention variables can inform the design of interventions to address expected primary care workforce shortages.

Breast cancer patients' perceived risk of recurrence has been associated with psychological distress. Little is known about the change of patients' perceived risk of recurrence over time and factors associated with their recurrence-risk perceptions. We prospectively recruited 549 newly diagnosed early-stage breast cancer patients; patients completed interviews at 6 weeks, 6 months, 1 year, and 2 years after definitive surgical treatment. A random-effects regression model with repeated ordinal measurements was used to estimate the relationship between perceived risk of recurrence and demographic, medical, and psychosocial factors. We analyzed data from 535 patients [34% ductal carcinoma in situ (DCIS); 20% non-white] who reported their perceived risk at one or more interviews. At the first interview, 16% reported having no lifetime risk of recurrence, and another 16% reported ≥ 50% risk of recurrence, including 15% of DCIS patients. Patients who were white (OR = 5.88, 95% CI 3.39-10.19) and had greater state anxiety (OR = 1.04, 95% CI 1.02-1.07) were more likely, while patients who received radiotherapy (OR = 0.72, 95% CI 0.54-0.96) and had more social support (OR = 0.59, 95% CI 0.46-0.75) were less likely to report higher risk of recurrence. Cancer stage was not significantly associated with perceived risk of recurrence. Perceived risk of recurrence did not change significantly over time. Educating early-stage breast cancer patients about their actual risk could result in more realistic recurrence-risk perceptions, and increasing social support could help alleviate anxiety associated with exaggerated risk perceptions.

Background: Accurate breast cancer recurrence risk perceptions might motivate health-promoting behaviors and alleviate undue anxiety. Although a few studies have examined early-stage breast cancer survivors' perceived risk of recurrence, none have assessed the accuracy of survivors' perceived risk of recurrence. Methods: First primary ductal carcinoma in situ and early-invasive breast cancer survivors reported their perceived risk of recurrence during 6- and 12-month postsurgery interviews. We estimated the patients' 10-year risk of recurrence from published clinical trials, and for early-invasive breast cancer patients, risk of distant recurrence was based on their breast cancer–specific mortality calculated using Adjuvant! Online. Patients' perceived risk was compared with their calculated risk and categorized as “Accurate,” “Underestimated,” “Overestimated,” and “Uncertain.” Multinomial logit marginal effect models were fitted using Accurate as the reference. Results: Only 17% of 531 patients accurately perceived their risk at 6 months, most of whom inaccurately perceived their risk at 12 months (P = 0.0143). Patients who were nonwhite [odds ratio (OR), 1.70; 95% confidence interval (95% CI), 1.12-2.56] and received radiation therapy (OR, 2.01; 95% CI, 1.07-3.77) were more likely to underestimate their risk. Patients with ductal carcinoma in situ (OR, 1.69; 95% CI, 1.08-2.70), lower social support (OR, 0.71; 95% CI, 0.53-0.95), and anxiety (OR, 1.58; 95% CI, 1.01-2.47) were more likely to overestimate their risk. Conclusion: Few breast cancer survivors accurately perceived their risk of recurrence. Impact: The accuracy of perceived risk may be increased by better physician-patient communications about their prognosis, provision of social support, and treatment for coexisting anxiety. Cancer Epidemiol Biomarkers Prev; 19(3); 675–80

Recently published articles have established that a substantial number of cancer patients utilize the Internet to gather information about their respective diagnoses. The challenges for medical providers include understanding the prevalence and characteristics of patients using the Internet, reasons for Internet use, and the effectiveness of currently available websites in providing useful health-related information to patients.Adults with cancer were asked to complete a self-administered, anonymous, 21-item questionnaire upon registration at the Alvin J. Siteman Cancer Center at the Washington University School of Medicine.There were 500 respondents (mean age 58 years (range 18-90), 83% Caucasian and 15% African-American). Three hundred ninety-eight participants (80%) reported access to the Internet, and 315 (63%) reported searching for information about cancer on the Internet. Patients accessing the Internet for cancer information were younger than those who did not (median age 56 vs. 63 years; p 0.001). Internet usage for cancer information also differed by race (p 0.0001) and education (p 0.0001). Among patients who searched the Internet for cancer information, 13.3% of patients had their decisions towards treatments affected or changed, and 11.4% of patients had their choice in physicians affected or changed because of Internet use; 23.5% of patients sought information on clinical trials, and 9.5% of patients were influenced or changed their decision regarding clinical trial enrollment due to Internet information.Approximately two thirds of patients with cancer used the Internet to obtain information about their disease. Factors affecting Internet use for cancer information included age, race, and education. Clinical decisions can be affected by Internet use.

Since an overarching goal of Healthy People 2010 was to eliminate health disparities, we determined temporal trends in socioeconomic disparities in five breast-cancer indicators (in situ, stage I, lymph-node positive, and locally advanced breast-cancer incidence, and breast-cancer mortality) by county socioeconomic deprivation using 1988–2005 population-based breast-cancer data. Using 1988–2005 data from women aged 40 and older from 200 counties in the Surveillance, Epidemiology, and End Results program, we examined trends in temporal disparities in the five breast-cancer indicators across quartiles of county socioeconomic deprivation. County-level trends were summarized using the estimated annual percentage change. Observed county rates were smoothed using Bayesian hierarchical spatiotemporal methods to calculate measures of absolute and relative disparity (using absolute and relative concentration indices) and their changes over time. Large increases in in situ breast cancer rates since 1988 were observed for each of the deprivation quartiles. Absolute and relative disparity both increased over time, suggesting increasing disparities across levels of county deprivation. Absolute and relative concentration indices were near zero for the other four breast-cancer indicators, suggesting no disparities among the four quartiles of county deprivation during 1988–2005. Efforts to target counties aimed at increasing breast-cancer screening based on their level of deprivation will not likely be beneficial.

Objective: Evaluate the effectiveness of the 2005 to 2007 National Pediatric Emergency Medicine (PEM) Fellows Conference series in achieving predefined objectives in the domains of scholarship, leadership, and partnership. Methods: Conference attendees included fellows in the existing PEM fellowship programs. Self-administered preconference and postconference questionnaires measured knowledge, research-related confidence, beliefs about institutional support for Emergency Medical Services for Children (EMSC) research, and intentions to engage in 7 specific behaviors relating to scholarship, leadership, and partnership. Pearson product-moment correlations measured relationships among continuous variables. Repeated-measures analysis of variance measured change between preconference and postconference measures. Hierarchical multiple linear regression models identified predictors of postconference intentions to engage in each of the 7 specific behaviors, controlling for preconference intention. Results: Approximately one third of all PEM fellows attended the conference each year. Preconference and postconference questionnaires were completed by at least 70% of attendees each year. Because several fellows attended more than one conference, data were analyzed from the first conference that a fellow attended. In each year, we observed significant increases in attendees' conference-specific knowledge, confidence, and intentions to continue in EMSC research, join national collaborative research networks, and establish national mentoring relationships. Conclusions: The National PEM Fellows' Conference is an effective means to increasing fellows' knowledge about scholarship, leadership, and partnership in EMSC and increasing their confidence and intentions to conduct research in EMSC.

We investigated characteristics associated with axillary lymph node (LN) status in patients with T3 breast cancers and hypothesized that LN status is an independent predictor of survival.Characteristics associated with axillary LN metastasis among women with T3 breast cancers were identified from the 1988-2003 Surveillance, Epidemiology, and End Results (SEER) database. The primary outcome was breast cancer-specific mortality. Cox models were used to calculate adjusted hazard ratios (aHR) and 95% confidence intervals (CI).A total of 12,778 patients with T3 breast cancers were analyzed (8201 LN+, 3695 LN-, 882 unknown). LN+ patients were more likely to be50 y, married, and have ER+/PR+, grade 3 invasive ductal cancers (P0.01 for each). Most patients underwent mastectomy (87.4%). Post-mastectomy radiation was more commonly used in LN+ patients (P0.01). LN+ patients had higher breast cancer-specific mortality (36.2% versus 16.4%, P0.01) and were more likely to die during the follow-up period (aHR = 2.87, 95% CI: 2.62-3.15) compared with LN- patients.Analysis of the SEER database indicated that several patient and tumor characteristics predict a higher likelihood of axillary LN involvement in patients with T3 breast cancers. LN status was an independent predictor of survival in women with T3 breast cancers.

Background: We developed a 50-item questionnaire to assess emergency department (ED) staff members' knowledge of bloodborne pathogen transmission, compliance with Universal Precautions, and the use of personal protective equipment. Method: A questionnaire was administered to 103 ED staff members including physicians, nurses, and technicians at Barnes-Jewish Hospital in St Louis, a Level-I trauma center. Results: ED personnel had inadequate knowledge of bloodborne pathogen infection risk, underreported exposures, and underused personal protection equipment during trauma cases. Conclusion: Further educational interventions for ED personnel are needed to increase their compliance with Universal Precautions. (AJIC Am J Infect Control 1999;27:453-5)

The authors examined disparities in survival among women aged 66 years or older in association with census-tract-level poverty rate, racial distribution, and individual-level factors, including patient-, treatment-, and tumor-related factors, utilization of medical care, and mammography use. They used linked data from the 1992-1999 Surveillance, Epidemiology, and End Results (SEER) programs, 1991-1999 Medicare claims, and the 1990 US Census. A geographic information system and advanced statistics identified areas of increased or reduced breast cancer survival and possible reasons for geographic variation in survival in 2 of the 5 SEER areas studied. In the Detroit, Michigan, area, one geographic cluster of shorter-than-expected breast cancer survival was identified (hazard ratio (HR) = 1.60). An additional area where survival was longer than expected approached statistical significance (HR = 0.4; P = 0.056). In the Atlanta, Georgia, area, one cluster of shorter- (HR = 1.81) and one cluster of longer-than-expected (HR = 0.72) breast cancer survival were identified. Stage at diagnosis and census-tract poverty (and patient's race in Atlanta) explained the geographic variation in breast cancer survival. No geographic clusters were identified in the 3 other SEER programs. Interventions to reduce late-stage breast cancer, focusing on areas of high poverty and targeting African Americans, may reduce disparities in breast cancer survival in the Detroit and Atlanta areas.

To identify predictors of attrition during graduate medical education (GME) in a single medical school cohort of contemporary US medical school graduates.Retrospective cohort study.Single medical institution.Recent US allopathic medical school graduates.Attrition from initial GME program.Forty-seven of 795 graduates (6%) did not complete the GME in their initial specialty of choice. At bivariate analysis, attrition was associated with election to the Alpha Omega Alpha Honor Medical Society, being an MD-PhD degree holder, and specialty choice (all P.05). Attrition was not associated with graduation year (P = .91), sex (P = .67), or age (P = .12). In a multivariate logistic regression model, MD-PhD degree holder (odds ratio, 3.43; 95% confidence interval, 1.27-9.26; P = .02), election to Alpha Omega Alpha (2.19; 1.04-4.66; P = .04), choice of general surgery for GME (5.32; 1.98-14.27; P.001), and choice of 5-year surgical specialty including those surgical specialties with a GME training requirement of 5 years or longer (2.74; 1.16-6.44; P = .02) each independently predicted greater likelihood of attrition.Academically highly qualified graduates and graduates who chose training in general surgery or in a 5-year surgical specialty were at increased risk of attrition during GME.

We investigated differences in breast cancer mortality between younger (younger than 40 years of age) and older (40 years of age and older) women by stage at diagnosis to identify patient and tumor characteristics accounting for disparities.We conducted a retrospective study of women diagnosed with breast cancer in the 1988 to 2003 Surveillance, Epidemiology, and End Results Program data. Multivariate Cox regression models calculated adjusted hazard ratios (aHR) and 95% confidence intervals to compare overall and stage-specific breast cancer mortality in women younger than 40 years old and women 40 years and older, controlling for potential confounding variables identified in univariate tests.Of 243,012 breast cancer patients, 6.4% were younger than 40 years old, and 93.6% were 40 years of age or older. Compared with older women, younger women were more likely to be African American, single, diagnosed at later stages, and treated by mastectomy. Younger women had tumors that were more likely to be higher grade, larger size, estrogen receptor/progesterone receptor-negative, and lymph-node positive (p0.001). Younger women were more likely to die from breast cancer compared with older women (crude HR = 1.39; CI, 1.34 to 1.45). Controlling for confounders, younger women were more likely to die compared with older women if diagnosed with stage I (aHR = 1.44; CI, 1.27 to 1.64) or stage II (aHR = 1.09; CI, 1.03 to 1.15) disease and less likely to die if diagnosed with stage IV disease (aHR = 0.85; CI, 0.76 to 0.95).Higher breast cancer mortality in younger women was attributed to poorer outcomes with early-stage disease. Additional studies should focus on specific tumor biology contributing to the increased mortality of younger women with early-stage breast cancer.

Context MD/PhD program participants represent only a small proportion of all US medical students, yet they are expected to play a major role in the future physician-scientist workforce. The characteristics and career intentions of recent MD/PhD program and other MD program graduates have not been compared. Objective To identify factors associated with MD/PhD program graduation among recent medical graduates. Design, Setting, and Participants Deidentified data were obtained from a nationally representative sample of 88 575 US medical graduates who completed the national Association of American Medical Colleges Graduation Questionnaire from 2000-2006. Multivariate logistic regression was used to test responses to items regarding graduates' characteristics and career plans in association with program graduation, reporting adjusted odds ratios (ORs). Main Outcome Measure MD/PhD program graduation. Results Of the 79 104 respondents with complete data (71.7% of all 2000-2006 graduates), 1833 (2.3%) were MD/PhD program graduates. Variables associated with greater likelihood of MD/PhD program graduation included planned substantial career involvement in research (OR, 10.30; 95% confidence interval [CI], 8.89-11.93); lower educational debt (compared with ≥$150 000: $100 000-$149 999, OR, 1.85; 95% CI, 1.35-2.52; $50 000-$99 999, OR, 5.50; 95% CI, 4.14-7.29; $1-$49 999, OR, 17.50; 95% CI, 13.30-23.03; no debt, OR, 17.41; 95% CI, 13.22-22.92); and receipt of medical school scholarships or grants (OR, 3.22; 95% CI, 2.82-3.69). Compared with planned training in internal medicine, MD/PhD graduation was positively associated with planned training in dermatology, neurology, ophthalmology, pathology, pediatrics, or radiology. Variables associated with lower likelihood of MD/PhD graduation included female sex (OR, 0.68; 95% CI, 0.60-0.77); race/ethnicity underrepresented in medicine (OR, 0.64; 95% CI, 0.52-0.80); and, compared with internal medicine, planned training in emergency medicine (OR, 0.58; 95% CI, 0.40-0.84) or surgery (OR, 0.70; 95% CI, 0.57-0.85). Conclusion Compared with graduates of other MD degree programs, MD/PhD graduates tend to be less demographically diverse, have a lower debt burden, favor different medical specialties, and have greater planned career involvement in research.

Objective We sought to identify risk factors for attrition among obstetrics and gynecology residents. Study Design We analyzed 2001-2006 American Medical Association Graduate Medical Education (GME) Census data for all residents who entered obstetrics and gynecology in 2001 to characterize residents who did not complete a 4-year training period in their initial programs ("attrition"). Multivariable logistic regression models identified predictors of attrition from among age, gender, race, Hispanic ethnicity, medical school type, and medical school graduation year. Results Of 1055 residents entering obstetrics and gynecology in 2001, 228 (21.6%) were in the "attrition" group (133 changed obstetrics and gynecology programs and/or completed training on atypical cycles; 75 changed specialty; 20 discontinued GME). Residents who were older, underrepresented minority race, Asian race, osteopathic- or international medical school graduates were more likely to be in the "attrition" group (each P Conclusion Analysis of a national cohort of obstetrics and gynecology residents identified substantial attrition and demographic risk factors.

To examine racial differences in mammography use and its determinants in the City of St. Louis, MO, USA, we recruited women age 40 or older using random-digit dialing to (1) examine the difference in mammography use between white women and African American women and (2) identify individual- and census-tract-level risk factors of nonadherence to mammography. During telephone interviews, we inquired about mammography use and several demographic, psychosocial, and health behavior variables. We determined the residential census tracts of study subjects using a geographic information system. The rate of mammography use was 68.0% among white women and 74.7% among African American women (P = 0.022). African American women were more likely to have mammograms than white woman (adjusted odds ratio [OR] = 1.71; 95% confidence interval [CI] = 1.09–2.69). System-level barriers to mammography and heavy smoking were associated with lower mammography use among both white and African American women. Personal-experience barriers to mammography and no physician recommendation also were independently associated with mammography use among white women. White women residing within a historic geographic cluster area of late-stage breast cancer were less likely to have mammograms (adjusted OR = 0.42, 95% CI = 0.22–0.80), while African American women residing within a historic geographic cluster area of late-stage breast cancer were equally likely to have mammograms (adjusted OR = 0.79, 95% CI = 0.28–2.24). Neither individual- nor census-tract-level socioeconomic status was associated with mammography screening. These findings suggest that there may be a greater need for increasing mammography use among white women, especially in the historic cluster area of late-stage breast cancer in St. Louis.

OBJECTIVES: Because clinical clerkship grades are associated with resident selection and performance and are largely based on residents'/attendings' subjective ratings, it is important to identify variables associated with clinical clerkship grades. METHODS: U.S. medical students who completed > or =1 of the following required clinical clerkships--internal medicine, surgery, obstetrics/gynecology, pediatrics, neurology and psychiatry--were invited to participate in an anonymous online survey, which inquired about demographics, degree program, perceived quality of clerkship experiences, assertiveness, reticence and clerkship grades. RESULTS: A total of 2395 medical students (55% women; 57% whites) from 105 schools responded. Multivariable logistic regression models identified factors independently associated with receiving lower clerkship grades (high pass/pass or B/C) compared with the highest grade (honors or A). Students reporting higher quality of clerkship experiences were less likely to report lower grades in all clerkships. Older students more likely reported lower grades in internal medicine (P = 0.02) and neurology (P < 0.001). Underrepresented minorities more likely reported lower grades in all clerkships (P < 0.001); Asians more likely reported lower grades in obstetrics/gynecology (P = 0.007), pediatrics (P = 0.01) and neurology (P = 0.01). Men more likely reported lower grades in obstetrics/gynecology (P < 0.001) and psychiatry (P = 0.004). Students reporting greater reticence more likely reported lower grades in internal medicine (P = 0.02), pediatrics (P = 0.02) and psychiatry (P < 0.05). Students reporting greater assertiveness less likely reported lower grades in all clerkships (P < 0.03) except IM. CONCLUSIONS: The independent associations between lower clerkship grades and nonwhite race, male gender, older age, lower quality of clerkship experiences, and being less assertive and more reticent are concerning and merit further investigation.

During the last 15 years, the proportion of U.S. allopathic medical graduates planning to pursue alternative careers (other than full-time clinical practice) has been increasing. The authors sought to identify factors associated with contemporary medical graduates' career-setting plans.The authors obtained anonymous data from the 108,408 U.S. allopathic medical graduates who completed the 1997-2004 national Association of American Medical Colleges Graduation Questionnaire (GQ). Using multinomial logistic regression, responses to eight GQ items regarding graduates' demographics, medical school characteristics, and specialty choice were tested in association with three career-setting plans (full-time university faculty; other, including government agencies, non-university-based research, or medical or health care administration; or undecided) compared with full-time (nonacademic) clinical practice.The sample included 94,101 (86.8% of 108,408) GQ respondents with complete data. From 1997 to 2004, the proportions of graduates planning full-time clinical practice careers decreased from 51.3% to 46.5%; the proportions selecting primary care and obstetrics-gynecology specialties also decreased. Graduates reporting Hispanic race/ethnicity or no response to race/ethnicity, lower debt, dual advanced degrees at graduation, and psychiatric-specialty choice were consistently more likely to plan to pursue alternative careers. Graduates selecting an obstetrics-gynecology specialty/ subspecialty were consistently less likely to plan to pursue alternative careers. Being female, Asian/Pacific Islander, Black or Native American/Alaskan, and selecting non-primary-care specialties were variably associated with alternative career plans.As the medical student population becomes more demographically diverse, as graduates increasingly select non-primary-care specialties, and as dual-degree-program graduates and alternative career opportunities for physicians expand, the proportion of U.S. graduates planning full-time clinical practice careers likely will continue to decline.

The relationship between US Medical Licensing Examination Step 1 scores and core surgical-specialty match outcomes has not been well defined.With IRB approval, we measured associations between aggregate Step 1 scores and other specialty-specific, match-process variables for 3 surgical-specialty matches. Chi-square tests measured differences between proportions of US students and independent applicants (ie, all non-US allopathic student applicants) who matched. Independent samples t-tests compared differences in Step 1 scores between matched- and unmatched-applicant groups. Pearson correlations measured the magnitude and direction of associations between matched-applicants' Step 1 scores and other variables of interest and between Step 1 scores for all match participants and percentage of positions filled by US students (two-tailed p values).Step 1 scores were lower for unmatched- than matched-applicant groups for each specialty examined (each p0.0001). Matched-applicant groups' Step 1 scores positively correlated with each unmatched-applicant groups' Step 1 scores (r =.82, p0.0001), Step 1 gap between matched- and unmatched-applicant groups' scores (r = .40, p = 0.035), percentage of positions filled by US students (r = .62, p0.0001), and mean number of applications filed/applicant (r = .50, p0.0001). Step 1 scores for all match participants correlated with percentage of positions filled by US students (r = .61, p = 0.0006).Step 1 scores were closely related to match process outcomes and match participation itself, with increasing Step 1 scores among both matched- and unmatched-applicant groups as specialty selectivity increased.

We administered a knowledge and attitudes questionnaire regarding a technology assisted pharmacist mediated academic detailing intervention designed to improve physician adherence to coronary heart disease (CHD) secondary-prevention guidelines. Questionnaires were administered in two settings: an academic hospital and a community hospital. More knowledgeable physicians reported being more likely to prescribe a pharmacists' recommended medication and to agree that lipid profiles should be automatically performed for inpatients with elevated troponin.

Objective We compared demographic characteristics of first-year residents entering obstetrics/gynecology with those entering primary care and surgery. Study Design We analyzed first-year residents from the 1997-2004 National Graduate Medical Education Census. Multivariable logistic regression models identified independent associations between obstetrics/gynecology residency (compared with primary care and surgery) and demographic predictor variables. Results More than 90% of studied programs completed the National Graduate Medical Education Census for 146,174 first-year residents. Graduates of US allopathic medical schools, women, African Americans, and entering residents in 2003 and 2004 were more likely to enter obstetrics/gynecology than primary care; Asians were less likely to enter obstetrics/gynecology than primary care. Women, African Americans, and Hispanics were more likely to enter obstetrics/gynecology than surgery; trainees who were Asian, “other” race/ethnicity, and entered residency from 1999-2004 were less likely to enter obstetrics/gynecology than surgery. Conclusion Demographic characteristics of incoming obstetrics/gynecology-residents differed significantly from both primary care and surgery residents. Obstetrics/gynecology should be a unique category in physician workforce studies.

Primary treatments for stage IV breast cancer are chemotherapy and radiation, with surgery usually reserved for tumor-related complications. We sought to determine whether surgical removal of the primary tumor provides a survival advantage for women with metastatic breast cancer.We conducted a retrospective, population-based cohort study by using the 1988-2003 Surveillance, Epidemiology, and End Results (SEER) program data. By use of multivariate Cox regression models, overall survival in women with stage IV disease was compared between women who underwent surgical excision of their breast tumor with women who did not, controlling for potential confounding demographic, tumor- and treatment-related variables, and propensity scores (accounting for variables associated with the likelihood of having surgery).Of 9734 SEER patients with stage IV breast cancer, 47% underwent breast cancer surgery and 53% did not. Median survival was longer for women who had surgery than for women who did not, both among women who were alive at the end of the study period (36.00 vs. 21.00 months; P.001) and among women who had died during follow-up (18.00 vs. 7.00 months; P.001). After controlling for potential confounding variables and propensity scores, patients who underwent surgery were less likely to die during the study period compared with women who did not undergo surgery (adjusted hazard ratio, .63, 95% confidence interval, .60-.66).Analysis of the 1988-2003 SEER data indicated that extirpation of the primary breast tumor in patients with stage IV disease was associated with a marked reduction in risk of dying after controlling for variables associated with survival.

10072 Background: Previous studies of rhabdomyosarcoma (RMS) survivors have focused on outcomes related to chronic health conditions. We evaluated neurocognitive, emotional, and quality of life (QOL) outcomes of > 5-year survivors. Methods: 482 survivors diagnosed 1970-1986 (mean age [SD] 7.2 [5.4] years at diagnosis; 24.3 [4.8] years of follow-up) and 393 siblings from the CCSS rated their neurocognition, emotions, and QOL using the Neurocognitive Questionnaire (NCQ), Brief Symptom Inventory-18 (BSI-18), and Medical Outcomes Short Form-36 (SF-36). Based on normative data, impairment was defined as the bottom 10th percentile of performance on the NCQ, the top 10th percentile of symptom prevalence on the BSI-18, and the bottom 15th percentile on each SF-36 subscale. Odds ratios (OR) and 95% confidence intervals (CI) were calculated using multivariable logistic regression. Results: Survivors reported more impairment than siblings on NCQ task efficiency (p < 0.001), higher symptom prevalence on BSI-18 depres...

Objective : We sought to determine the prevalence of college laboratory research apprenticeship (CLRA) participation among students considering medical careers and to examine the relationship between CLRA participation and medical-school acceptance among students who applied to medical school. Methods : We used multivariate logistic regression to identify predictors of: 1) CLRA participation in a national cohort of 2001–2006 Pre-Medical College Admission Test (MCAT) Questionnaire (PMQ) respondents and 2) among those PMQ respondents who subsequently applied to medical school, medical-school acceptance by June 2013, reporting adjusted odds ratios (aOR) and 95% confidence intervals (95% CI). Results : Of 213,497 PMQ respondents in the study sample (81.2% of all 262,813 PMQ respondents in 2001–2006), 72,797 (34.1%) reported CLRA participation. Each of under-represented minorities in medicine (URM) race/ethnicity (vs. white, aOR: 1.04; 95% CI: 1.01–1.06), Asian/Pacific Islander race/ethnicity (vs. white, aOR: 1.20; 95% CI: 1.17–1.22), and high school summer laboratory research apprenticeship (HSLRA) participation (aOR: 3.95; 95% CI: 3.84–4.07) predicted a greater likelihood of CLRA participation. Of the 213,497 PMQ respondents in the study sample, 144,473 (67.7%) had applied to medical school and 87,368 (60.5% of 144,473 medical-school applicants) had been accepted to medical school. Each of female gender (vs. male, aOR: 1.19; 95% CI: 1.16–1.22), URM race/ethnicity (vs. white, aOR: 3.91; 95% CI: 3.75–4.08), HSLRA participation (aOR: 1.11; 95% CI: 1.03–1.19), CLRA participation (aOR: 1.12; 95% CI: 1.09–1.15), college summer academic enrichment program participation (aOR: 1.26; 95% CI: 1.21–1.31), and higher MCAT score (per point increase, aOR: 1.31; 95% CI: 1.30–1.31) predicted a greater likelihood of medical-school acceptance. Conclusions : About one-third of all PMQ respondents had participated in CLRAs prior to taking the MCAT, and such participation was one of the several variables identified that were independently associated with medical-school acceptance. Keywords: student research apprenticeships; medical-school admissions; medical-student diversity; pre-medical education; medical-student selection criteria (Published: 23 June 2015) Citation: Med Educ Online 2015, 20: 27231 - http://dx.doi.org/10.3402/meo.v20.27231

We sought to determine the extent to which recent increases in levels of gender and racial diversity in the overall resident-physician workforce were evident among core-surgical specialty resident workforces.Chi-square tests for trend assessed the importance of changes from 1996 to 2004 in proportions of women and African Americans in the surgery-resident workforce. Surgery-resident trends were compared with overall resident workforce trends using two-tailed t-tests to compare regression slopes that quantified rates of change over time. Chi-square tests assessed differences between proportions of women and African Americans in the current overall board-certified workforce and their proportions in the surgery board-certified workforce.From 1996 to 2004, proportions of women increased in all seven surgical specialties studied. Compared with the overall trend toward increasing proportions of women in the resident workforce, the trend in one surgical specialty was larger (obstetrics/gynecology, p0.01), four were similar (each p0.05), and two were smaller (each p0.001). Proportions of African Americans increased in four specialties. Compared with the overall trend, trends in two specialties were larger (obstetrics/gynecology and neurologic surgery, each p0.01) and two were similar (each p0.05). Proportions of African Americans decreased in three specialties (each p0.01). Proportions of women and African Americans in every board-certified specialty workforce, except obstetrics/gynecology, remained lower than in the overall board-certified workforce (each p0.01).Many demographic disparities between the surgery-resident and overall-resident workforces have persisted since 1996 and will likely perpetuate ongoing surgery board-certified workforce disparities.

Background Predictors of U.S. allopathic medical-school graduates' board-certification plans have not been characterized. Method Using multivariable logistic regression, graduates' responses to 11 questions on the 1997-2004 Association of American Medical Colleges Graduation Questionnaire were analyzed to identify independent predictors of plans for specialty-board certification. Results The proportion of 108,408 graduates planning specialty-board certification decreased from 97.3% in 1997 to 88.4% in 2004. Among 101,805 (93.9%) graduates with complete data, graduates who were Hispanic, rated their clinical clerkships, quality of medical education, and confidence in clinical skills more highly, had any debt, and planned "University-faculty" careers were more likely to plan becoming board certified. Females, Asians/Pacific Islanders, and graduates who planned to practice in underserved areas, planned "other" nonclinical-practice careers, and graduated with MD/other (non-PhD) degrees were less likely to plan becoming board certified. Conclusion Specialty-board certification does not appear to be among the professional goals for a growing proportion of U.S. medical graduates.

Radiotherapy following breast-conserving surgery for the treatment of first primary breast cancer is the standard of care and is widely used despite its small survival benefit. The effects of radiotherapy in metachronous contralateral breast cancer are unknown. We examined the use of radiotherapy and its effect on cause-specific and all-cause mortality among women with metachronous contralateral breast cancer treated with breast-conserving surgery in community settings. Using data from the 1985-2000 Surveillance, Epidemiology, and End Results program, we identified women with stage 0-III metachronous contralateral breast cancer that occurred at least six months after stage 0-III first primary breast cancer. Cause-specific and all-cause mortality of women age 40-69 who did and who did not receive radiotherapy following breast-conserving surgery for metachronous contralateral breast cancer were compared in proportional hazard models using propensity scores to balance covariates by radiotherapy use. We adjusted for misclassification of radiotherapy use. Based on misclassification-corrected analyses, 43.2 percent of 1,083 women with metachronous contralateral breast cancer did not receive radiotherapy after BCS. After adjustment for propensity scores and radiotherapy misclassification, women who did not receive radiotherapy had 2.2 times greater risk of cause-specific and 1.7 times greater risk of all-cause mortality. In community settings, a high percentage of women with stage 0-III metachronous contralateral breast cancer did not receive radiotherapy following breast-conserving surgery. Unlike the small survival benefit of radiotherapy after first primary breast cancer, omission of radiotherapy after metachronous contralateral breast cancer significantly increased the risk of cause-specific and all-cause mortality.