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Background: RNA-based genomic risk assessment estimates chemotherapy benefit in patients with hormone-receptor positive (HR+)/Human Epidermal Growth Factor 2-negative (ERBB2-) breast cancer (BC). It is virtually used in all patients with early HR+/ERBB2- BC regardless of clinical recurrence risk., Patients and Methods: We conducted a retrospective chart review of adult patients with early-stage (T1-3; N0; M0) HR+/ERBB2- BC who underwent genomic testing using the Oncotype DX (Exact Sciences) 21-genes assay. Clinicopathologic features were collected to assess the clinical recurrence risk, in terms of clinical risk score (CRS) and using a composite risk score of distant recurrence Regan Risk Score (RRS). CRS and RRS were compared to the genomic risk of recurrence (GRS)., Results: Between January 2015 and December 2020, 517 patients with early-stage disease underwent genomic testing, and clinical data was available for 501 of them. There was statistically significant concordance between the 3 prognostication methods (P < 0.01). Within patients with low CRS (n = 349), 9.17% had a high GRS, compared to 8.93% in patients with low RRS (n = 280). In patients with grade 1 histology (n = 130), 3.85% had a high GRS and 68.46% had tumors > 1 cm, of whom only 4.49% had a high GRS. Tumor size > 1cm did not associate with a high GRS., Conclusion: Genomic testing for patients with grade 1 tumors may be safely omitted, irrespective of size. Our finds call for a better understanding of the need for routine genomic testing in patients with low grade/low clinical risk of recurrence., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Introduction: There are approximately 60,000 Traditional Bone Setters (TBS) in India, who have no formal education or training in modern medicine but treat approximately 60% of bone related trauma. This study investigated the history of TBS, why they are so popular, and their methods., Methods: From a list of TBS from four states in South India, a purposive and convenience sampling method identified participants. One lead TBS from each state was interviewed. With recommendations from these TBS, a total of six participants were interviewed on Zoom ® in their native dialect and these interviews were transcribed into English. The data were analyzed using a constant comparative method which included several iterations to refine common themes and determine counterfactual and specific focal points from each interview., Results: Six overarching themes emerged: (1) history of traditional bone setters, (2) occupations outside bone setting, (3) training, certification, education, accolades, (4) patient characteristics and success stories, (5) infrastructure and approach to diagnosis/treatment, and (6) limitations of practice, challenges, and social relevance. The history of traditional bone setting is thousands of years old and passed down within families generationally., Conclusions: In rural India, where a large part of the population lives in poverty and without access to modern medicine, traditional healers provide a much-needed service, often without charge, and consequently, the income is not sufficient without other occupations such as farming. They follow a similar approach to diagnosis and treatment of simple fractures and dislocations as modern medical practitioners. Most would like to share their knowledge and collaborate with ayurvedic and allopathic practitioners and simply want to be respected and supported., (© 2022 The University of Kansas Medical Center.)

Background: Liquid biopsy testing offers a significant potential in selecting signal-matched therapies for advanced solid malignancies. The feasibility of liquid biopsy testing in a community-based oncology practice, and its actual impact on selecting signal-matched therapies, and subsequent survival effects have not previously been reported., Patients and Methods: A retrospective chart review was conducted on adult patients with advanced solid cancer tested with a liquid-biopsy assay between December 2018 and 2019, in a community oncology practice. The impact of testing on treatment assignment and survival was assessed at 1-year follow-up., Results: A total of 178 patients underwent testing. A positive test was reported in 140/178 patients (78.7%), of whom 75% had an actionable mutation. The actual overall signal-based matching rate was 17.8%. While 85.7% of patients with no actionable mutation had a signal-based clinical trial opportunity, only 10% were referred to a trial. Survival analysis of lung, breast, and colorectal cancer patients with actionable mutations who received any therapy (n = 66) revealed a survival advantage for target-matched (n = 22) compared to unmatched therapy (n = 44): patients who received matched therapy had significantly longer progression-free survival (PFS) (mPFS: 12 months; 95%CI, 10.6-13.4 vs. 5.0 months; 95%CI, 3.4-6.6; P = .029), with a tendency towards longer overall survival (OS) (mOS: 15 months; 95%CI, 13.5-16.5 vs. 13 months; 95%CI: 11.3-14.7; P = .087)., Conclusions: Implementation of liquid biopsy testing is feasible in a US community practice and impacts therapeutic choices in patients with advanced malignancies. Receipt of liquid biopsy-generated signal-matched therapies conferred added survival benefits., (© The Author(s) 2022. Published by Oxford University Press.)

Introduction: Few studies have quantified the total number of attending and consulting physicians involved in inpatients' care, and no other research quantifies the total number of all providers participating in inpatients' care. The purpose of this study was to calculate the number of attending hand-offs, the attending encounter time, and the total number of providers participating in inpatients' care for all admitted patients at a tertiary urban medical center., Methods: The study design was an observational retrospective cohort. Subjects included pediatric and adult patients who were admitted to and discharged from Ascension Via Christi St. Francis (AVCSF) in Wichita, Kansas between November 1, 2019 and January 31, 2020. Data were abstracted from the Cerner Electronic Medical Record. Variables included: patient demographics, admitting diagnosis, diagnosis related group (DRG), admission service, and duration of inpatient stay. Provider variables abstracted included provider type and provider specialty. Categorical variables were presented as frequencies and percentages, while continuous variables were presented as means ± standard deviation., Results: The sample included information from 200 patient charts. Patients' ages ranged from 5 to 94 years, with a mean of 61 years. Approximately 52% were female and 74.9% were admitted to a surgical service. The length of all inpatients' stays ranged from less than 1 day to 31 days, with a mean of 4 days. Seventy-six different DRGs were recorded. The most frequent attending specialties were hospital medicine, internal medicine, general surgery, and interventional cardiology. Consulting physicians had more patient encounters than any other healthcare provider. For all inpatients, an average of two attending physicians participated in care over the duration of their stay with a range of one to six attending physicians. There was an average of one hand-off between attending physicians. Patients had an average of five consulting physicians, two resident physicians, two physician assistants, and two nurse practitioners during a stay. There was an average of 10 total providers, with a range of one to 46 total providers participating in care., Conclusions: Understanding the provider data surrounding an inpatient stay is a foundational step in assessing the quality of the provider-inpatient encounter and potential areas for improvement. In this study, the average number of attending physicians and handoffs was reasonable; however, the total number of providers involved in care was relatively high. Assessment of staffing and scheduling requirements by hospital administration could identify areas of improvement to reduce the potential for medical error caused by multiple providers being involved in patient care., (© 2021 The University of Kansas Medical Center.)

Electronic cigarettes (E-Cigs) have been advertised as a safer alternative to smoking. However, E-Cigs use, like smoking, delivers ultra-small aerosol particles, which may be associated with cardiovascular disease. This study aimed to look into the association between E-Cigs use and cardiovascular disease outcomes. The study involved self-reported data from 16,855 participants from the National Health Interview Survey data from years 2014, 2016, 2017, and 2018. Results from the logistic regression analysis report E-Cigs users had higher odds of having myocardial infarction (OR 4.09, 95% CI [1.29, 12.98], P<0.05) when compared to non-users. Dual users had higher odds of myocardial infarction (OR 5.44, 95% CI [2.90, 10.22], P<0.05), stroke (OR 2.32, 95% CI [1.44, 3.74], P<0.05), and coronary artery disease (OR 2.27, 95% CI [1.37, 2.44], P<0.05) when compared to non-users., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Vindhyal et al.)

Objective: Medical students should develop skills in assessing their own learning needs and developing strategies to meet those needs. Medical curricula should be designed to provide active and enriching ways to explore medicine beyond the classroom. The program should enrich the elements of motivation, discovery, innovation, social services, cultural exploration, and personal development. The University of Kansas School of Medicine instituted a new curriculum in 2017 called ACE ( A ctive, C ompetency-based, and E xcellence-driven). Eight 1-week courses of enrichment experiences are embedded within the first 2 years of the curriculum., Methods: After each of 8 medical content blocks, students are required to participate in a 1-week, nongraded enrichment experience according to their own learning needs and interests. Students choose the type of enrichment activities including clinical experiences, professional development, leadership development, research and scholarly activity, and community engagement. Students select their top enrichment choices and a computer lottery makes the assignments from their designations. Students engaged in research and scholarly activity are guided to appropriate research mentors., Results: A total of 196 enrichment activities at 3 campuses were developed for 211 students during the first 2 years of medical school. Most students selected clinical experiences with enrichments available in most medical specialties and subspecialties. Students also use enrichment weeks to conduct research/scholarly activity, particularly those students pursuing the Honors Track. A total of 2071 enrichment experiences were completed in the first 2 years., Conclusions: Most enrichments involved clinical experiences, although research/scholarly activity and professional development enrichments also were popular. Evaluations from students and antidotal data suggested enrichments are popular among students and a good change of pace from the usual rigorous activities of the curriculum. Because of the large number of experiences required to conduct the enrichment weeks, a continuous process of evaluation is required to maintain the program. Therefore, flexibility is required to administer the program., Competing Interests: Declaration of conflicting interests:The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2020.)

Background: Recently, some studies suggested that clinical diagnosis of fibromyalgia is inaccurate and does not reflect current definitions. However, this hypothesis has not been tested. We examined whether fibromyalgia was accurately diagnosed in the community., Methods: We surveyed 3276 primary care patients to determine current fibromyalgia status by criteria (CritFM). We also determined whether the patients had a physician's diagnosis of fibromyalgia (MDFM) and the level of symptom severity as measured by the polysymptomatic distress scale (PSD)., Results: The prevalence of MDFM and CritFM was 6.1% (95% confidence interval [CI] 5.3%, 6.9%) and 5.5% (95% CI 4.8%, 6.3%), respectively. However, only 32.2% with MDFM met 2016 criteria (CritFM), and only 35.4% with CritFM also had MDFM. The kappa statistic for diagnostic agreement was 0.296 (minimal agreement). The mean PSD score was 12.4 and 18.4 in MDFM and CritFM, respectively. The odds ratio for being a woman compared with being a man was 3.2 for MDFM versus 1.9 for CritFM, P = 0.023. Of the patients with MDFM, 68.3% received specific fibromyalgia pharmacotherapy., Conclusions: There is little agreement between MDFM and CritFM. Only one-third of MDFM satisfy fibromyalgia criteria, and only one-third of patients who meet the criteria have a clinical diagnosis of fibromyalgia. Physician diagnosis is biased and more likely in women. Fibromyalgia treatment is common in MDFM (70.7%). Overall, MDFM appears subjective and unrelated to fibromyalgia criteria. There appears to be no common definition of fibromyalgia in the community., (© 2019 The Authors. ACR Open Rheumatology published by Wiley Periodicals, Inc. on behalf of American College of Rheumatology.)

A complex cultural dynamic within the Asian and Pacific Islander (APIs) population contributes to barriers in HIV care. This qualitative narrative study investigated how awareness, resource accessibility, and cultural taboo impact HIV care in APIs in Kansas. Eleven HIV-infected API patients were interviewed. Two evaluators independently completed a qualitative themes analysis. Important themes impacting HIV care included lack of awareness, sex as a taboo topic, and misconceptions about HIV infection. These factors create a closed community regarding HIV prevention and care. Clinicians must be aware of these barriers and provide specific culturally sensitive information and care to this population.

Introduction Heart failure (HF) is one of the most common causes of hospitalization and readmissions. Approximately six million Americans are living with HF. Among patients with HF, hospitalization rate in the United States is higher for those over age 65, making it one of the leading causes of hospitalization in this age group. Furthermore, about 15% of those who were hospitalized with HF were readmitted within 30 days and 30% within 60 days. HF and chronic kidney disease (CKD) share many risk factors; therefore, it is expected that CKD is more prevalent in HF. About 50% of patients with HF also have concomitant CKD. Those patients have been found to have an increased risk of mortality and morbidity. This risk increases as glomerular filtration rate (GFR) decreases. Strategies to reduce the hospitalization rate in patients with HF include optimizing evidence-based drug and device therapies, addressing the causes of HF, treating comorbidities, and improving management of care. In our study, we aim to find an association between HF and the patient's renal function as well as the GFR level. This study investigates the effect of renal function on HF morbidity and readmission rate. Methods We performed a retrospective study looking at 132 patients who were admitted to the hospital with HF and compared their measured GFR at three key time periods: admissions, discharges, and readmissions at 30 days. A Pearson product-moment correlation coefficient was calculated to determine the association between the GFR and readmission in HF admission cases. Results There is a statistically significant difference in the readmission rate based on the change in GFR between admission and discharge (Admit GFR - Discharge GFR; t = 2.28; p < 0.05). We found that patients who were readmitted in 30 days had an average decrease in GFR by 2.46 ml/min/1.73 m 2 , whereas patients with a lower readmission rate had an average increase in GFR by 1.92 ml/min/1.73 m 2 . Conclusion A decline in renal function due to hospitalization in patients with renal failure is associated with an increase in readmission for HF. Providers should be cognizant of the need to optimize renal function as well as cardiac function during hospitalization., Competing Interests: The authors have declared that no competing interests exist.

Introduction Atrial fibrillation (AF), the most common cardiac arrhythmia, affects approximately 2.3 million patients in the United States, costing around $26 billion. Atrial fibrillation is associated with a two- to seven-fold increased risk of stroke, one of the most serious complications. Chronic kidney disease affects approximately 13% of the US population and has been associated with higher rates of AF than the general population. In patients with chronic kidney disease (CKD), the risk of stroke increases as the glomerular filtration rate (GFR) decreases, especially in CKD stages three and four. Several risks stratification scores such as CHADS2 (congestive heart failure, hypertension, age, diabetes mellitus, stroke), CHA2DS2VASc (congestive heart failure, hypertension, age, diabetes mellitus, stroke, vascular disease, age, sex), and R2CHADS2 (renal failure, congestive heart failure, age, diabetes, stroke) scores are used for stroke risk assessment in patients with non-valvular atrial fibrillation (NVAF). This study investigates the association between renal functions and risk stratification scoring systems in patients with non-valvular AF presenting with stroke. Methods Using the convenience sampling method, 171 subjects were selected from the eligible population (n = 386). A Pearson product-moment correlation coefficient was calculated to determine the association between the GFR and each of the CHA2DS2VASc and R2CHADS2 scores. In addition, a Pearson product-moment correlation coefficient was calculated to determine the association between the CHA2DS2VASc and R2CHADS2 scores. Results The selected population represented 44.3% of the eligible subjects. Of these, 88% were Caucasian, 60% were female, and the mean age was 78 years. The mean CHA2DS2VASc score was six (range 2-9). The mean eGFR was 69.77 (range 6-108). Both the mode and the median CHA2DS2VASc score was four (range 2-8). A weak, but significant, negative correlation was found between renal function (eGFR) and the CHA2DS2VASc score (r = -0.263; p = 0.0005). There was a stronger negative correlation between the eGFR and R2CHADS2score (r = -0.70; p < 0.00001). The CHA2DS2VASc and R2CHADS2scoring schemes were significantly and positively correlated (r = 0.627; p < 0.00001). Discussion In NVAF patients presenting with stroke, renal failure is associated with higher CHA2DS2VASc and R2CHADS2 scores. One must consider renal failure (end-stage or non-end stage renal failure) as an additional potential risk factor for stroke when recommending anticoagulation in non-valvular atrial fibrillation., Competing Interests: The authors have declared that no competing interests exist.

Non-invasive cardiac monitoring has well-established indications and protocols. Telemetry is often overused leading to a shortage of tele-beds and an increment of hospital expenses. In some cases, patients are kept on telemetry longer than the indicated length because providers are unaware of its ongoing use. We investigated the effect of reminder pop-ups, incorporated into an electronic medical record (EMR), on minimizing the use of telemetry. Three regional hospitals implemented an electronic pop-up reminder for discontinuing the use of telemetry when no longer indicated. A retrospective analysis of data for patients on telemetry, outside of the intensive care unit (ICU), was conducted and comparisons were drawn from pre- and post-implementation periods. A composite analysis of the number of days on telemetry was calculated using the Kruskal-Wallis test. With the implementation of the pop-up reminder, the median number of days on telemetry was significantly lower in 2016 than in 2015 (2.25 vs 3.61 days, p < 0.0001). Overutilization of telemetry is widely recognized, despite not being warranted in non-ICU hospitalizations. The implementation of a pop-up reminder built into the electronic medical record system reduced the overuse of telemetry by 37% between the two time periods studied., Competing Interests: The authors have declared that no competing interests exist.

Introduction: Attitudes of individuals who provide HIV care towards prescribing Preexposure Prophylaxis (PrEP) to at-risk populations have been studied, but few studies indicate if family physicians would be willing to prescribe PrEP as most family physicians do not specialize in HIV medicine. Few data exist on the perceived barriers preventing family physicians from prescribing PrEP. The purpose of this project was to assess the attitudes and perceived barriers of family physicians in Kansas towards prescribing PrEP to high risk patient populations., Methods: This study was a descriptive, observational, and cross-sectional survey of family physicians who respond to email surveys issued through the Family Medicine Research and Data Information Office (FM RADIO)., Results: Fifty-three percent of family physicians take a sexual history on new patients less than frequently, and only 35% frequently ask about the use of safe sex practices. Only 29% frequently ask if the patient has sex with men, women, or both. Seventy-six percent of respondents would be willing to prescribe PrEP to men who have sex with men, and an equal percentage would be willing to prescribe to heterosexually active men and women who are at substantial risk of acquiring HIV. While 59% of participants agreed that PrEP belongs in the primary care domain of treatment, 71% agreed that they had limited or no knowledge of PrEP guidelines., Conclusions: This preliminary study indicated a need for increased family physician screening of new patients for high risk sexual behaviors who would be eligible for PrEP. The limited knowledge of PrEP guidelines and its use in clinical practice are significant limiting factors to increasing prescribing practices in the family medicine community rather than a perceived ethical dilemma of prescribing PrEP to men who have sex with men. As a result, an increase in continuing medical education about PrEP could significantly increase its prescribing in the family medicine community.

Objective: To evaluate the impact of a revised consultation room design on patient-physician interaction in an outpatient setting., Background: The growth of ambulatory medical care makes outpatient facilities the primary point of health care contact for many Americans. However, the outpatient consultation room design remains largely unchanged, despite its increased use and the adoption of technology-mediated information sharing in clinical encounter., Methods: A randomized controlled trial used a postvisit questionnaire to assess six domains of interest (satisfaction with the visit and the consultation room, mutual respect, patient trust in the physician, communication quality, people-room interaction, and interpersonal-room interaction) in two different room designs (a traditional room and an experimental room in which a pedestal table had replaced the examination table)., Results: Interpersonal-room interaction was enhanced in the experimental consultation room when compared to the traditional consultation room (p = .0038). Participants in the experimental consultation room had better access to the computer screen, increased provider information sharing, and more time engaging providers in conversation about information on the monitor., Conclusions: Changing the layout of a consultation room has the potential to improve interpersonal communication through better information sharing. Clinicians who are interested in maximizing the benefits of their clinical encounter should consider changing the layout of their consultation room, especially the positioning of the computer screen., (© The Author(s) 2014.)

Background: Polycystic ovary syndrome (PCOS) is a common endocrine disorder that is associated with increased inflammation, insulin resistance, and elevated risk of metabolic complications. hs-CRP is the most reliable marker of inflammation in PCOS patients. When hs-CRP is elevated, it can indicate increased risk of cardiovascular disease. The purpose of the study was to determine if a certain value of HbA1c in PCOS patients should alert clinicians to increased inflammation (as defined by hs-CRP >2 mg/l), thus potentially be indicative of increased risk of cardiovascular disease., Methods: A cohort study was conducted on female patients between the ages of 20 to 45 years who fulfilled the National Institute of Health criteria for PCOS. De-identified data of 46 patients with PCOS were obtained. All clinical tests were conducted after a 12 hr overnight fast. hs-CRP was measured by latex-enhanced immunonephelometry. Logistic regression analysis was conducted to assess the association between hs-CRP and HbA1c., Results: When various HbA1c levels were considered, a cutoff of 5.3% correctly classified patients with hs-CRP >2 mg/l at 80.4%. Sensitivity was 83.3% and specificity was 75%., Conclusion: An HbA1c cut off of 5.3% may be appropriate to initiate efforts for early detection of increased inflammation as a potential sign of risk for cardiovascular disease.

Aim: In the USA, for both men and women, colorectal cancer (CRC) ranks third in incidence and second in mortality. Despite evidence that it decreases mortality, CRC screening in the USA remains under-utilized. Some European studies have suggested that marital status affects participation in CRC screening, but the effect of marital status on CRC screening participation in the USA is unknown. In this study, the aim was to compare CRC screening participation rates among married and unmarried couples, separated, widowed, never married and divorced adults living in the USA., Method: This was a retrospective data analysis of the 2010 Behavioural Risk Factor Surveillance System survey. The population studied included 239,300 participants, aged 50-75 years, who completed the 2010 survey. Logistic regression analysis was conducted to assess the association between adherence with CRC screening guidelines and marital status while accounting for survey stratum/weight and covariates., Results: Individuals who were divorced or separated, never married or widowed had decreased odds of adherence with CRC screening guidelines compared with individuals who were married and unmarried couples., Conclusion: In this study, individuals living in the USA who were married and unmarried couples had increased odds of undergoing CRC screening compared to individuals in other marital status groups. Public health interventions are needed to promote CRC screening participation in these other groups., (Colorectal Disease © 2015 The Association of Coloproctology of Great Britain and Ireland.)

Oxaliplatin is a common chemotherapy drug used for colon and gastric cancers. Common side effects are peripheral neuropathy, hematological toxicity, and allergic reactions. A rare side effect is seizures which are usually associated with posterior reversible leukoencephalopathy syndrome (PRES). A 50-year-old male patient presented with severe abdominal pain. CT scan of the abdomen showed acute appendicitis. Appendectomy was done and pathology showed mixed adenoneuroendocrine carcinoma. Adjuvant chemotherapy was started with Folinic acid, Fluorouracil, and Oxaliplatin (FOLFOX). During the third cycle of FOLFOX, the patient developed tonic-clonic seizures. Laboratory workup was within normal limits. EEG and MRI of the brain showed no acute abnormality. The patient was rechallenged with FOLFOX but he had tonic-clonic seizures for the second time. His chemotherapy regimen was switched to Folinic acid, Fluorouracil, and Irinotecan (FOLFIRI). After 5 cycles of FOLFIRI, the patient did not develop any seizures, making Oxaliplatin the most likely culprit for his seizures. Oxaliplatin-induced seizures rarely occur in the absence of PRES. One case report has been described in the literature. We present a rare case of tonic-clonic seizures in a patient receiving Oxaliplatin in the absence of PRES.

Background. Posttransplant lymphoproliferative disorders (PTLDs) occur after solid organ transplantation. Treatment guidelines include reduction in immunosuppression (RIS), radiation, rituximab, chemotherapy, and immunological agents. We present a rare case of recurrent diffuse large B-cell lymphoma presenting as a PTLD in a heart transplant patient treated with autologous blood stem cell transplant (ASCT) after failure of conventional therapy. Case Presentation. A 66-year-old male presented with a neck mass. He has a history of Hodgkin's disease status after staging laparotomy with splenectomy and heart transplantation due to dilated nonischemic cardiomyopathy 8 years prior to the development of PTLD. His examination was remarkable for right submandibular swelling. An excisional biopsy confirmed the diagnosis of diffuse large B-cell NHL. Patient received RIS, rituximab, chemotherapy, and radiation therapy with a complete remission. His lymphoma relapsed and he subsequently was treated with RICE salvage chemotherapy and consolidative high-dose chemotherapy with BEAC regimen followed by ASCT resulting in a complete remission. Conclusion. Patients with PTLD present a difficult therapeutic challenge. In this case, the patient's prior history of Hodgkin's disease, splenectomy, and a heart transplant appear to be unique features, the significance of which is unclear. ASCT might be a promising therapy for patients with relapsed or refractory PTLD.

Few adult patients with HIV/AIDS are evaluated for communication disorders. A broad inventory of the communication disorders was obtained in a convenience sample of 82 adult HIV/AIDS patients who presented for medical appointments. Each participant underwent a head and neck exam and a communications skills evaluation. Speech, language, and cognition were assessed using a 10-item test battery. A 14-item hearing test battery was conducted in a separate session. The primary outcomes were the presence and degree of communication disorders. Head and neck exams revealed 40% with ear-related issues. Only 2 participants showed normal findings on all 24 communication skills assessments. Four demonstrated normal findings on all speech-language-cognitive assessments, whereas 8 had normal findings on the complete hearing test battery. A relatively high prevalence of cognitive and language deficits and central auditory disturbances were found. Clinicians must recognize the potential for communication deficits even in a relatively healthy patient with HIV.

Objective: Hemoglobin A1c (A1C) ≥5.7% is now accepted as a biomarker for identifying individuals at risk for diabetes. Compared to the general population, women with polycystic ovary syndrome (PCOS) have a higher risk for diabetes. Our goal was to determine what glucose homeostasis abnormalities can be identified by A1C ≥5.7% in women with PCOS., Methods: In a cross-sectional study, nondiabetic women with PCOS (according to the National Institutes of Health [NIH] criteria) were divided into 2 groups based on A1C (<5.7% [n = 23] and ≥5.7% [n = 25]). Oral glucose tolerance tests (OGTT) and frequently sampled intravenous glucose tolerance tests (FS-IVGTT) were conducted, and body composition, cardiovascular risk factors, and sex steroid levels were assessed., Results: Compared to women with A1C <5.7%, those with A1C ≥5.7% were older (35.1 ± 1.1 years vs. 31.1 ± 1.1 years; P = .04), had higher glucose levels at fasting and during OGTT, and had a lower insulin sensitivity index (SI: 2.0 ± 0.2 vs. 4.2 ± 0.6; P = .0195) and disposition index (DI: 1,014 ± 82 vs. 1,901 ± 217; P = .011) during FS-IVGTT. They also had higher triglycerides, high-sensitivity C-reactive protein (hs-CRP), and fatty acid-binding protein 4 (FABP4) levels. There was no difference in serum androgen levels., Conclusion: A1C ≥5.7% identified the subgroup of PCOS patients with higher insulin resistance, inadequate compensatory insulin response, impaired glucose disposition, and increased cardiovascular risk factors. Thus, A1C represents an inexpensive and informative biomarker to identify PCOS patients at risk for metabolic abnormalities.

Objective: This study described the epidemiology of child abuse homicides in the state of Kansas from 1994 to 2007. It focused on obtaining significant details on all recorded child abuse homicides in Kansas during this time frame to provide critical information that can be used for future preventive measures., Methods: A retrospective case review was conducted on data gathered by the Kansas State Child Death Review Board for all cases of "child abuse homicides" that occurred from 1994 to 2007., Results: A total of 170 child abuse homicide cases in Kansas between 1994 and 2007 were identified. The majority of these cases (63.5%) were considered fatal child physical abuse. There was a predominance of female victims (55.9%). The vast majority of victims were White (78.8%), followed by Black (17.1%). One to 2-year-olds accounted for the largest age group of children who were victimized (33.5%). For cases with known prenatal care status, 74% of mothers received adequate prenatal care. The largest percentage of victims was children of single mothers (40.6%), with no prior history of child abuse (60%). The majority of deaths occurred in the victim's residence (81.8%). The greatest number of deaths occurred secondary to abusive head trauma (42.9%), followed by asphyxia (21.8%). When a trigger was known, 44.2% involved inconsolable crying. The most common perpetrator was the victim's biological father (26.6%), followed by the victim's biological mother (24.9%), then the victim's mother's male paramour (19.8%)., Conclusions: Familiarity with characteristics involved in child abuse homicide allows for opportunities to enlist important preventive measures. Most child abuse homicides occurred at the hands of the victim's biological parents and in the victim's own residence. Prevention should be focused on parent education and coping mechanisms for the frustrating features of crying in normal infants that lead to shaking or abuse., (2011 Elsevier Ltd. All rights reserved.)

Background: The Scholars in Rural Health program is designed to attract and retain young rural Kansans with a high probability of successful careers in rural communities. This program shapes the students' experiences toward rural health in preparation for entry into medical school. Scholars accepted into and satisfactorily completing this program are admitted automatically to the School of Medicine., Methods: A retrospective review of all Scholars program data was completed to evaluate if intended outcomes were achieved. All candidates who were admitted into the program since its inception in 1997 were included. Program data included information from application through residency graduation and establishing a practice., Results: Since 1997, 104 candidates have been selected to participate in the Scholars in Primary Care or Scholars in Rural Health program. Of the 40 who completed medical school, 30 (72%) matched to a primary care residency program; 21 (50%) matched to family medicine. Of the 19 residency graduates, 16 (84%) practice in rural or urban medically underserved communities. Eighteen practice in Kansas., Discussion: As one component of the effort to provide physicians for Kansas, the Scholars in Rural Health program showed beneficial outcomes for attracting applicants who want to practice in rural or other medically underserved communities and who maintain that interest over the long process of medical education. The designation of medical school positions for 14 Scholars in Rural Health enhances the likelihood of success for maintaining a pipeline of physicians for rural Kansas.

The influence of driver licensure on child motor vehicle crash (MVC) deaths in Kansas was investigated. Fatalities from 1994-2000 due to MVCs were extracted from the Kansas State Child Death Review Board and the Fatality Analysis Reporting Systems databases. It was found that 14% (52 of 363) of child fatalities from MVCs in Kansas occurred in vehicles where the driver was not licensed. Driver licence status was associated with use of safety restraints, the victim's age and race, weekend driving and rural county location. All child deaths involving unlicensed drivers were preventable. New legislation on vehicle sanctions may be required to assist law enforcement. Safety restraint laws should be enforced and promoted to the public. Transportation options are necessary for unlicensed drivers, particularly if they have young children and live in a rural community. Thus, a multi-system approach involving law enforcement, accident prevention strategies and transportation options will save the lives of children.

The purpose of this study was to determine the rate of documented counseling on lifestyle modifications in patients presenting to the primary care setting with a diagnosis of gastroesophageal reflux disease. Retrospective chart review was conducted for 502 active patients with a primary or secondary diagnosis of gastroesophageal reflux disease from two internal medicine clinics at the University of Kansas School of Medicine-Wichita. Charts were reviewed for documented counseling on four specific lifestyle modifications: (a) smoking and alcohol cessation, (b) dietary changes, (c) head of bed elevation, and (e) postprandial avoidance of recumbency. Only 12% of patients in this sample received documented counseling on lifestyle modifications. Of those patients receiving documented counseling, 71% were counseled on dietary changes, 41% smoking or alcohol cessation, 28% head of bed elevation, and 21% postprandial avoidance of recumbency. Documentation indicated that patients with gastroesophageal reflux disease are not adequately counseled regarding recommended lifestyle modifications.

While continuing to improve recognition of migraine in your patient population, pay particular attention to the adherence rate among those for whom you have prescribed a triptan. Ask patients who discontinue triptan therapy why they made that decision. Besides adverse effects from the agent, reasons may include medication cost, influence of comorbidities, or triptan interaction with medications you may not have known about.

Context: Barriers to providing optimal palliative care in rural communities are not well understood., Purpose: To identify health care personnel's perceptions of the care provided to dying patients in rural Kansas and Colorado and to identify barriers to providing optimal care., Methods: An anonymous self-administered survey was sent to health care personnel throughout 2 rural practice-based research networks. Targeted personnel included clinicians, nurses, medical assistants, chaplains, social workers, administrators, and ancillary staff, who worked at hospice organizations, hospitals, ambulatory clinics, public health agencies, home health agencies, and nursing homes., Findings: Results from 363 completed surveys indicated that most health care personnel were satisfied with the palliative care being provided in their health care facilities (84%) and that most were comfortable helping dying patients transition from a curative to a palliative focus of care (87%). Yet, many reported that the palliative care provided could be improved and many reported that family members' avoidance of issues around dying (60%) was a barrier to providing optimal care in rural health care facilities., Conclusions: Findings suggest that health care personnel perceive they are effective at providing palliative care in their rural health care facilities, yet face barriers to providing optimal end-of-life care. Results of this study suggest that differences in training and experience may influence health care personnel's perceptions of the existing barriers. It may be important in rural areas to customize interventions to both the professional role and the site of care.

Over 70% of the estimated 5 million office visits per year for migraine headache are to family physicians. Both the number of visits and proportion of migraine patients seeking medical care are increasing rapidly. Patient satisfaction with migraine care by primary care physicians is reported to be low but most data are obtained from patients referred to subspecialists or entered in clinical trials. We surveyed patients who consulted family physicians in 10 Kansas practices during 2002 to assess patient satisfaction and investigate any differences between satisfied and unsatisfied migraine patients. Of our 447 respondents, 74% were "satisfied" or "very satisfied" with migraine care by family physicians. Dissatisfied patients were significantly more likely to report moderate or severe migraine-related disability and less likely to use triptans or to have most medications paid by insurance. Dissatisfied patients were twice as likely to have discontinued taking triptans than satisfied patients. Patient satisfaction with migraine treatment in family practice is substantially higher than generally reported. Statistically significant differences exist between satisfied and dissatisfied patients.

Background: The University of Kansas School of Medicine in Wichita created an Internet-based faculty development curriculum for community-based faculty. Because relatively few physicians use Internet-based continuing medical education (CME), the most cost-effective methods of encouraging use need to be identified., Method: Five interventions intended to increase use of the curriculum were assessed. The number of times the CME curriculum Webpages were accessed was correlated with the interventions., Results: Demonstrating the Website to faculty at a semiannual meeting elicited the most Website "hits." Electronic mail and flyers also appeared to be effective in stimulating interest in the Website. Only four community-based faculty applied for CME credit for completing the curricular modules., Findings: Multiple modalities should be used in advertising and stimulating interest in an Internet-based faculty development curriculum. Demonstrating the Website to faculty at a meeting appeared to achieve the greatest return. Offering CME credit was not helpful in stimulating interest.

Background Objectives: An increasing sector of the American population is seeking health services from alternative practitioners and using alternative therapies. This study investigated whether medical students perceived that information on alternative therapies would be useful to them as future practicing physicians., Methods: A one-page anonymous questionnaire was distributed to the entire first-year medical class of a large, public, Midwestern medical school during their first semester. They responded to a series of five statements concerning alternative medicine and medical school coverage of this topic., Results: The majority (84%) of students reported that knowledge about alternative medical therapies would be important to them as future physicians. The respondents wanted to learn about alternative therapies while in medical school (72%), but very few thought they would receive adequate exposure to this topic (6%). The majority also reported that direct observation of alternative practitioners would be the best method of instruction in this area (58%)., Conclusions: The results suggest that medical students are interested in learning about alternative medical therapies and they perceive this knowledge will be important to them as physicians. As medical schools undertake various curriculum reforms they should be aware of rising student interest in alternative medical therapies.

The annual incidence of acute appendicitis by gender, age, and race in Sedgwick County, Kansas was lower than values reported in most other communities. However, the trends of peak incidence during the second decade, male predominance among all races, and the highest incidence in Caucasians also were noted in the current study. The rates of perforation and gangrenous appendicitis were significantly higher in the elderly. No association was noted between the presence of fecalith and acute appendicitis or perforation. A better understanding of the etiology of acute appendicitis may explain the trends and differences in the incidence of acute appendicitis observed.

Background: Invasive pneumococcal disease is a major cause of morbidity and mortality in elderly patients. This study investigated the impact of a patient education intervention on the pneumococcal vaccination rate in elders., Methods: Charts of all patients aged 65 years or older who visited a university ambulatory care clinic during a 3-month period were reviewed for pneumococcal vaccination status before the patients' arrival for an office visit. Those who did not have the vaccination were provided patient education in the waiting room. Data were collected on age, sex, race, and immunization status. The reasons for refusing the vaccination before or during this intervention also were obtained. The charts of patients who consented were flagged for the attending physician to order the vaccination if appropriate., Results: Charts of 535 patients were reviewed for pneumococcal vaccination status. Of these patients, 291 had had a pneumococcal vaccination before the study. The cumulative vaccination rate increased significantly from 54 percent to 79 percent after the study intervention. The rate of pneumococcal vaccination was significantly lower among African-Americans than whites both before and after the patient education intervention., Conclusion: This study reports a substantial impact of patient education on improving pneumococcal vaccination rates in an elderly population. Most elders accept vaccination, and it can be delivered effectively without an additional visit.

The provision of labor and delivery services by family physicians is especially important in largely rural states such as Kansas. The decline in the number of family physicians offering labor and delivery services threatens those who depend on access to primary health care in rural areas. A survey was mailed to all 370 of the University of Kansas School of Medicine-Wichita (UKSM-W) family practice residency graduates. Two hundred sixty-five (72%) graduates responded, of whom 206 are in private practice. Eighty percent of responding graduates practice in communities of less than 100,000, and 72% of those physicians provide labor and delivery services. Although 48 of 206 graduates have ceased delivering babies, 131 still do so, averaging 41 deliveries per year. Sixty-five graduates perform C-sections, averaging 12 per year. CONCLUSIONS. UKSM-W graduates afford rural patients considerable access to care. Income, work hours, and practice satisfaction were similar in all three groups (no delivery, delivery without cesarean section, and cesarean section). Policy makers are justified in expanding educational programs in family practice that emphasize complete care of the pregnant woman.

One-third (34%) of 2,001 women who sought an abortion in 1991-1992 in Wichita, Kansas, were repeat-abortion patients. Compared with first-time abortion patients, repeat-abortion patients were significantly older, more often black, and younger at their first pregnancy (p < .001). The two groups did not vary significantly by income or age at first intercourse. However, repeat-abortion patients were significantly more likely than first-time patients to have been using a contraceptive method at the time of conception (65% compared with 59%) and more likely to say they always or almost always used a method (63% and 53%, respectively). More than 40% of women in each group reported they had no personal physician. Further, 34% of repeat-abortion patients said they had no follow-up examination after their previous abortion, and 28% said they received no contraceptive counseling. Only half of women whose pregnancy was confirmed by their personal physician obtained an abortion referral from that physician.

Objective: To assess the evaluation and treatment practices of family physicians in regard to attention-deficit hyperactivity disorder (ADHD)., Design, Setting, and Participants: A 20-item survey was developed and mailed to all 940 family and general physicians in Kansas., Main Outcome Measures: Physician practices regarding ADHD., Results: The 471 respondents (50.1%) included 386 physicians in private clinical practice, who constituted the study group. Ninety-eight percent of these physicians regularly saw children and over half suspected four or more cases of ADHD in the past year. When suspecting ADHD, 43% of the physicians referred for diagnosis and treatment; 30% evaluated and treated by themselves; and 27% referred for evaluation but did follow-up treatment themselves. There was no significant difference in these ratios between rural and urban physicians. Family physicians referred to a pediatric psychiatrist most often, with no apparent difference in referral pattern by community size; 75% indicated they were comfortable with their current referral support. Of the physicians who diagnosed and treated ADHD themselves, only 30.6% routinely ordered laboratory work or other tests, only 28.7% used teacher questionnaires, and only 20.4% used parent questionnaires., Conclusions: An important amount of patient care for ADHD is managed by family physicians, without significant differences between rural and urban practices. Most family physicians are satisfied with their current level of referral support. Physicians who treat ADHD themselves usually rely on clinical evaluation rather than special tests or standardized questionnaires.