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BackgroundAccurately assessing the regional activity of diseases such as COVID-19 is important in guiding public health interventions. Leveraging electronic health records (EHRs) to monitor outpatient clinical encounters may lead to the identification of emerging outbreaks. ObjectiveThe aim of this study is to investigate whether excess visits where the word “cough” was present in the EHR reason for visit, and hospitalizations with acute respiratory failure were more frequent from December 2019 to February 2020 compared with the preceding 5 years. MethodsA retrospective observational cohort was identified from a large US health system with 3 hospitals, over 180 clinics, and 2.5 million patient encounters annually. Data from patient encounters from July 1, 2014, to February 29, 2020, were included. Seasonal autoregressive integrated moving average (SARIMA) time-series models were used to evaluate if the observed winter 2019/2020 rates were higher than the forecast 95% prediction intervals. The estimated excess number of visits and hospitalizations in winter 2019/2020 were calculated compared to previous seasons. ResultsThe percentage of patients presenting with an EHR reason for visit containing the word “cough” to clinics exceeded the 95% prediction interval the week of December 22, 2019, and was consistently above the 95% prediction interval all 10 weeks through the end of February 2020. Similar trends were noted for emergency department visits and hospitalizations starting December 22, 2019, where observed data exceeded the 95% prediction interval in 6 and 7 of the 10 weeks, respectively. The estimated excess over the 3-month 2019/2020 winter season, obtained by either subtracting the maximum or subtracting the average of the five previous seasons from the current season, was 1.6 or 2.0 excess visits for cough per 1000 outpatient visits, 11.0 or 19.2 excess visits for cough per 1000 emergency department visits, and 21.4 or 39.1 excess visits per 1000 hospitalizations with acute respiratory failure, respectively. The total numbers of excess cases above the 95% predicted forecast interval were 168 cases in the outpatient clinics, 56 cases for the emergency department, and 18 hospitalized with acute respiratory failure. ConclusionsA significantly higher number of patients with respiratory complaints and diseases starting in late December 2019 and continuing through February 2020 suggests community spread of SARS-CoV-2 prior to established clinical awareness and testing capabilities. This provides a case example of how health system analytics combined with EHR data can provide powerful and agile tools for identifying when future trends in patient populations are outside of the expected ranges.

BACKGROUND: Breast cancer risk models guide screening and chemoprevention decisions, but the extent and effect of variability among models, particularly at the individual level, is uncertain. OBJECTIVE: To quantify the accuracy and disagreement between commonly used risk models in categorizing individual women as average vs. high risk for developing invasive breast cancer. DESIGN: Comparison of three risk prediction models: Breast Cancer Risk Assessment Tool (BCRAT), Breast Cancer Surveillance Consortium (BCSC) model, and International Breast Intervention Study (IBIS) model. SUBJECTS: Women 40 to 74 years of age presenting for screening mammography at a multisite health system between 2011 and 2015, with 5-year follow-up for cancer outcome. MAIN MEASURES: Comparison of model discrimination and calibration at the population level and inter-model agreement for 5-year breast cancer risk at the individual level using two cutoffs (≥ 1.67% and ≥ 3.0%). KEY RESULTS: A total of 31,115 women were included. When using the ≥ 1.67% threshold, more than 21% of women were classified as high risk for developing breast cancer in the next 5 years by one model, but average risk by another model. When using the ≥ 3.0% threshold, more than 5% of women had disagreements in risk severity between models. Almost half of the women (46.6%) were classified as high risk by at least one of the three models (e.g., if all three models were applied) for the threshold of ≥ 1.67%, and 11.1% were classified as high risk for ≥ 3.0%. All three models had similar accuracy at the population level. CONCLUSIONS: Breast cancer risk estimates for individual women vary substantially, depending on which risk assessment model is used. The choice of cutoff used to define high risk can lead to adverse effects for screening, preventive care, and quality of life for misidentified individuals. Clinicians need to be aware of the high false-positive and false-negative rates and variation between models when talking with patients.

BackgroundSevere acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused one of the worst pandemics in recent history. Few reports have revealed that SARS-CoV-2 was spreading in the United States as early as the end of January. In this study, we aimed to determine if SARS-CoV-2 had been circulating in the Los Angeles (LA) area at a time when access to diagnostic testing for coronavirus disease 2019 (COVID-19) was severely limited.MethodsWe used a pooling strategy to look for SARS-CoV-2 in remnant respiratory samples submitted for regular respiratory pathogen testing from symptomatic patients from November 2019 to early March 2020. We then performed sequencing on the positive samples.ResultsWe detected SARS-CoV-2 in 7 specimens from 6 patients, dating back to mid-January. The earliest positive patient, with a sample collected on January 13, 2020 had no relevant travel history but did have a sibling with similar symptoms. Sequencing of these SARS-CoV-2 genomes revealed that the virus was introduced into the LA area from both domestic and international sources as early as January.ConclusionsWe present strong evidence of community spread of SARS-CoV-2 in the LA area well before widespread diagnostic testing was being performed in early 2020. These genomic data demonstrate that SARS-CoV-2 was being introduced into Los Angeles County from both international and domestic sources in January 2020.

Although pathologists have their own viewing habits while diagnosing, viewing behaviors leading to the most accurate diagnoses are under-investigated. Digital whole slide imaging has enabled investigators to analyze pathologists visual interpretation of histopathological features using mouse and viewport tracking techniques. In this study, we provide definitions for basic viewing behavior variables and investigate the association of pathologists characteristics and viewing behaviors, and how they relate to diagnostic accuracy when interpreting whole slide images. We use recordings of 32 pathologists actions while interpreting a set of 36 digital whole slide skin biopsy images (5 sets of 36 cases; 180 cases total). These viewport tracking data include the coordinates of a viewport scene on pathologists screens, the magnification level at which that viewport was viewed, as well as a timestamp. We define a set of variables to quantify pathologists viewing behaviors such as zooming, panning, and interacting with a consensus reference panels selected region of interest (ROI). We examine the association of these viewing behaviors with pathologists demographics, clinical characteristics, and diagnostic accuracy using cross-classified multilevel models. Viewing behaviors differ based on clinical experience of the pathologists. Pathologists with a higher caseload of melanocytic skin biopsy cases and pathologists with board certification and/or fellowship training in dermatopathology have lower average zoom and lower variance of zoom levels. Viewing behaviors associated with higher diagnostic accuracy include higher average and variance of zoom levels, a lower magnification percentage (a measure of consecutive zooming behavior), higher total interpretation time, and higher amount of time spent viewing ROIs. Scanning behavior, which refers to panning with a fixed zoom level, has marginally significant positive association with accuracy. Pathologists training, clinical experience, and their exposure to a range of cases are associated with their viewing behaviors, which may contribute to their diagnostic accuracy. Research in computational pathology integrating digital imaging and clinical informatics opens up new avenues for leveraging viewing behaviors in medical education and training, potentially improving patient care and the effectiveness of clinical workflow.

BackgroundShareable e-scooters have become popular, but injuries to riders and bystanders have not been well characterized. The goal of this study was to describe e-scooter injuries and estimate the rate of injury per e-scooter trip.Methods and findingsRetrospective review of patients presenting to 180 clinics and 2 hospitals in greater Los Angeles between January 1, 2014 and May 14, 2020. Injuries were identified using a natural language processing (NLP) algorithm not previously used to identify injuries, tallied, and described along with required healthcare resources. We combine these tallies with municipal data on scooter use to report a monthly utilization-corrected rate of e-scooter injuries. We searched 36 million clinical notes. Our NLP algorithm correctly classified 92% of notes in the testing set compared with the gold standard of investigator review. In total, we identified 1,354 people injured by e-scooters; 30% were seen in more than one clinical setting (e.g., emergency department and a follow-up outpatient visit), 29% required advanced imaging, 6% required inpatient admission, and 2 died. We estimate 115 injuries per million e-scooter trips were treated in our health system.ConclusionsOur observed e-scooter injury rate is likely an underestimate, but is similar to that previously reported for motorcycles. However, the comparative severity of injuries is unknown. Our methodology may prove useful to study other clinical conditions not identifiable by existing diagnostic systems.

IMPORTANCE: Many patients presently have access to their pathologic test result reports via online patient portals, yet little is known about pathologists perspective on this topic. OBJECTIVE: To examine dermatopathologists experience and perceptions of patient online access to pathology reports. DESIGN, SETTING, AND PARTICIPANTS: A survey of 160 dermatopathologists currently practicing in the United States who are board certified and/or fellowship trained in dermatopathology was conducted between July 15, 2018, and September 23, 2019. Those who reported interpreting skin biopsies of melanocytic lesions within the previous year and expected to continue interpreting them for the next 2 years were included. MAIN OUTCOMES AND MEASURES: Dermatopathologists demographic and clinical characteristics, experiences with patient online access to pathologic test result reports, potential behaviors and reactions to patient online access to those reports, and effects on patients who read their pathologic test result reports online. RESULTS: Of the 160 participating dermatopathologists from the 226 eligible for participation (71% response rate), 107 were men (67%); mean (SD) age was 49 (9.7) years (range, 34-77 years). Ninety-one participants (57%) reported that patients have contacted them directly about pathologic test reports they had written. Some participants noted that they would decrease their use of abbreviations and/or specialized terminology (57 [36%]), change the way they describe lesions suspicious for cancer (29 [18%]), and need specialized training in communicating with patients (39 [24%]) if patients were reading their reports. Most respondents perceived that patient understanding would increase (97 [61%]) and the quality of patient-physician communication would increase (98 [61%]) owing to the availability of online reports. Slightly higher proportions perceived increased patient worry (114 [71%]) and confusion (116 [73%]). However, on balance, most participants (114 [71%]) agreed that making pathologic test result reports available to patients online is a good idea. CONCLUSIONS AND RELEVANCE: Dermatopathologists in this survey study perceived both positive and negative consequences of patient online access to pathologic test result reports written by the respondents. Most participants believe that making pathologic test result reports available to patients online is a good idea; however, they also report concerns about patient worry and confusion increasing as a result. Further research regarding best practices and the effect on both patients and clinicians is warranted.

Digital whole slide images are Food and Drug Administration approved for clinical diagnostic use in pathology; however, integration is nascent. Trainees from 9 pathology training programs completed an online survey to ascertain attitudes toward and experiences with whole slide images for pathological interpretations. Respondents (n = 76) reported attending 63 unique medical schools (45 United States, 18 international). While 63% reported medical school exposure to whole slide images, most reported ≤ 5 hours. Those who began training more recently were more likely to report at least some exposure to digital whole slide image training in medical school compared to those who began training earlier: 75% of respondents beginning training in 2017 or 2018 reported exposure to whole slide images compared to 54% for trainees beginning earlier. Trainees exposed to whole slide images in medical school were more likely to agree they were comfortable using whole slide images for interpretation compared to those not exposed (29% vs 12%; P = .06). Most trainees agreed that accurate diagnoses can be made using whole slide images for primary diagnosis (92%; 95% CI: 86-98) and that whole slide images are useful for obtaining second opinions (93%; 95% CI: 88-99). Trainees reporting whole slide image experience during training, compared to those with no experience, were more likely to agree they would use whole slide images in 5 years for primary diagnosis (64% vs 50%; P = .3) and second opinions (86% vs 76%; P = .4). In conclusion, although exposure to whole slide images in medical school has increased, overall exposure is limited. Positive attitudes toward future whole slide image diagnostic use were associated with exposure to this technology during medical training. Curricular integration may promote adoption.

ObjectivesThe objective of this study was to analyze outcomes for patients with soft tissue sarcoma of the extremities using neoadjuvant ifosfamide-based chemotherapy and hypofractionated reduced dose radiotherapy, followed by limb-sparing surgery.Materials and methodsAn Institutional Review Board (IRB)-approved retrospective review of patients treated at a single institution between 1990 and 2013 was performed. In total, 116 patients were identified who received neoadjuvant ifosfamide-based chemotherapy and 28 Gy in 8 fractions of preoperative radiation (equivalent dose in 2 Gray fractions, 31.5 Gy [α/β 10] 36.4 Gy [α/β 3]) followed by limb-sparing surgery. Local recurrence (LR), distant failure (DF), and overall survival (OS) were calculated. Univariate and multivariate analysis for LR, DF, and OS were performed using Cox analysis. Statistical significance was set at a P

PurposeThe practice of deliberately sparing the ipsilateral parotid gland with intensity modulated radiation therapy (IMRT) in patients with node-positive head and neck cancer is controversial. We sought to compare the clinical outcomes among consecutive cohorts of patients with head and neck cancer who were treated with differing strategies to spare the parotid gland that is ipsilateral to the involved neck using IMRT.Methods and materialsA total of 305 patients were treated with IMRT for node-positive squamous cell carcinoma of the head and neck. The first 139 patients were treated with IMRT whereby the ipsilateral parotid gland was delineated and intentionally designated as an avoidance structure during planning. The subsequent 166 patients were treated by IMRT without the deliberate sparing of the ipsilateral parotid gland.ResultsThe 2-year estimates of overall survival, local-regional control, and distant metastasis-free survival were 84%, 73%, and 87%, respectively. The 2-year estimates of overall survival were 77% and 86% among patients who were treated by IMRT with and without the sparing of the ipsilateral parotid gland, respectively (P = .01). The respective rates of 2-year regional control were 76% and 90% (P

BackgroundHead and neck cancers positive for human papillomavirus (HPV) are exquisitely radiosensitive. We investigated whether chemoradiotherapy with reduced-dose radiation would maintain survival outcomes while improving tolerability for patients with HPV-positive oropharyngeal carcinoma.MethodsWe did a single-arm, phase 2 trial at two academic hospitals in the USA, enrolling patients with newly diagnosed, biopsy-proven stage III or IV squamous-cell carcinoma of the oropharynx, positive for HPV by p16 testing, and with Zubrod performance status scores of 0 or 1. Patients received two cycles of induction chemotherapy with 175 mg/m2 paclitaxel and carboplatin (target area under the curve of 6) given 21 days apart, followed by intensity-modulated radiotherapy with daily image guidance plus 30 mg/m2 paclitaxel per week concomitantly. Complete or partial responders to induction chemotherapy received 54 Gy in 27 fractions, and those with less than partial or no responses received 60 Gy in 30 fractions. The primary endpoint was progression-free survival at 2 years, assessed in all eligible patients who completed protocol treatment. This study is registered with ClinicalTrials.gov, numbers NCT02048020 and NCT01716195.FindingsBetween Oct 4, 2012, and March 3, 2015, 45 patients were enrolled with a median age of 60 years (IQR 54-67). One patient did not receive treatment and 44 were included in the analysis. 24 (55%) patients with complete or partial responses to induction chemotherapy received 54 Gy radiation, and 20 (45%) with less than partial responses received 60 Gy. Median follow-up was 30 months (IQR 26-37). Three (7%) patients had locoregional recurrence and one (2%) had distant metastasis; 2-year progression-free survival was 92% (95% CI 77-97). 26 (39%) of 44 patients had grade 3 adverse events, but no grade 4 events were reported. The most common grade 3 events during induction chemotherapy were leucopenia (17 [39%]) and neutropenia (five [11%]), and during chemoradiotherapy were dysphagia (four [9%]) and mucositis (four [9%]). One (2%) of 44 patients was dependent on a gastrostomy tube at 3 months and none was dependent 6 months after treatment.InterpretationChemoradiotherapy with radiation doses reduced by 15-20% was associated with high progression-free survival and an improved toxicity profile compared with historical regimens using standard doses. Radiotherapy de-escalation has the potential to improve the therapeutic ratio and long-term function for these patients.FundingUniversity of California.

BackgroundThe long natural history of prostate cancer (CaP) limits comparisons of efficacy between radical prostatectomy (RP) and external beam radiotherapy (EBRT), since patients treated years ago received treatments considered suboptimal by modern standards (particularly with regards to androgen deprivation therapy [ADT] and radiotherapy dose-escalation]. Gleason score (GS) 9-10 CaP is particularly aggressive, and clinically-relevant endpoints occur early, facilitating meaningful comparisons.ObjectiveTo compare outcomes of patients with GS 9-10 CaP following EBRT, extremely-dose escalated radiotherapy (as exemplified by EBRT+brachytherapy [EBRT+BT]), and RP.Design, setting, participantsRetrospective analysis of 487 patients with biopsy GS 9-10 CaP treated between 2000 and 2013 (230 with EBRT, 87 with EBRT+BT, and 170 with RP). Most radiotherapy patients received ADT and dose-escalated radiotherapy.Outcome measurements and statistical analysisKaplan-Meier analysis and multivariate Cox regression estimated and compared 5-yr and 10-yr rates of distant metastasis-free survival, cancer-specific survival (CSS), and overall survival (OS).Results and limitationsThe median follow-up was 4.6 yr. Local salvage and systemic salvage were performed more frequently in RP patients (49.0% and 30.1%) when compared with either EBRT patients (0.9% and 19.7%) or EBRT+BT patients (1.2% and 16.1%, p

PurposeTo determine the ability of image-guided high-dose-rate brachytherapy (IG-HDR) to provide local control (LC) of lesions in non-traditional locations for patients with heavily pre-treated malignancies.Material and methodsThis retrospective series included 18 patients treated between 2012 and 2014 with IG-HDR, either in combination with external beam radiotherapy (EBRT; n = 9) or as monotherapy (n = 9). Lesions were located in the pelvis (n = 5), extremity (n = 2), abdomen/retroperitoneum (n = 9), and head/neck (n = 2). All cases were performed in conjunction between interventional radiology and radiation oncology. Toxicity was graded based on CTCAE v4.0 and local failure was determined by RECIST criteria. Kaplan-Meier analysis was performed for LC and overall survival.ResultsThe median follow-up was 11.9 months. Two patients had localized disease at presentation; the remainder had recurrent and/or metastatic disease. Seven patients had prior EBRT, with a median equivalent dose in 2 Gy fractions (EQD2) of 47.0 Gy. The median total EQD2s were 34 Gy and 60.9 Gy for patients treated with monotherapy or combination therapy, respectively. Image-guided high-dose rate brachytherapy was delivered in one to six fractions. Six patients had local failures at a median interval of 5.27 months with a one-year LC rate of 59.3% and a one-year overall survival of 40.7%. Six patients died from their disease at a median interval of 6.85 months from the end of treatment. There were no grade ≥ 3 acute toxicities but two patients had serious long term toxicities.ConclusionsWe demonstrate a good one year LC rate of nearly 60%, and a favorable toxicity profile when utilizing IG-HDR to deliver high doses of radiation with high precision into targets not readily accessible by other forms of local therapy. These preliminary results suggest that further studies utilizing this approach may be considered for patients with difficult to access lesions that require LC.

INTRODUCTION:Uveal melanoma is a rare intraocular tumor with heterogeneous biological behavior, and additional noninvasive markers that may predict outcome are needed. Diffusion- and perfusion-weighted imaging may prove useful but have previously been limited in their ability to evaluate ocular tumors. Our purpose was to show the feasibility and potential value of a multiparametric (mp-) MRI protocol employing state of the art diffusion- and perfusion-weighted imaging techniques. METHODS:Sixteen patients with uveal melanoma were imaged with mp-MRI. Multishot readout-segmented echoplanar diffusion-weighted imaging, quantitative dynamic contrast-enhanced (DCE) MR perfusion imaging, and anatomic sequences were obtained. Regions of interest (ROIs) were drawn around tumors for calculation of apparent diffusion coefficient (ADC) and perfusion metrics (K (trans) , v e , k ep , and v p ). A generalized linear fit model was used to compare various MRI values with the American Joint Commission on Cancer (AJCC) tumor group and monosomy 3 status with significance set at P 33 % monosomy 3 had higher K (trans) and higher v e values than those with disomy 3 or ≤33 % monosomy (P

BACKGROUND: Despite results of the Intergroup 0116 (INT-0116) study showing an overall survival benefit of adjuvant chemoradiotherapy in gastric adenocarcinoma, its use in the United States remains controversial. The Surveillance Epidemiology of End Results (SEER) database was used to compare cause-specific survival outcomes in resected gastric adenocarcinoma with various adjuvant therapies and patterns of care. METHODS: Individual data from 1988 to 2008 were selected for patients with resected, nonmetastatic gastric adenocarcinoma. These patients were stratified by stage (American Joint Committee on Cancer [AJCC], 6th edition), as well as treatment modalities (surgery alone, S; surgery followed by radiotherapy, SR; surgery with chemotherapy, SC; surgery followed by radiotherapy with chemotherapy, SRC; and radiotherapy followed by surgery with chemotherapy, RSC). Overall 21,472 patients (8335 stages IA and 1B; 5944 stage II, 4594 stage III, and 2599 stage IV) were included in this study. RESULTS: The median age of the cohort was 66 years, with 63.0% male and 66.4% white. The median number of lymph nodes examined was 17.6. Median survival by stage was 96 months for stage I, 30 months for stage II, 20 months for stage III, and 14 months for stage IV. Using the SRC group as the reference group, for stage I patients, S had the most favorable cause-specific survival (hazard ratio [HR], 0.67; confidence interval, [CI] 0.60-0.76). For patients with stage II, III, or IV, those treated with SRC had the best outcome compared with the other treatment modalities. After 1999, the number of patients treated with surgery alone decreased by at least 14%, whereas the number treated with SRC increased by approximately 12%. CONCLUSIONS: This large SEER database analysis showed that stage I patients benefited most from surgery alone, whereas those at more advanced stages benefited most from adjuvant radiotherapy with chemotherapy. This result is consistent with INT-0116 for gastric adenocarcinoma in support of trimodality therapy and is reflected by the increased fraction of patients receiving chemotherapy and adjuvant radiation.

PurposeTo assess the ability of multiparametric (mp) MRI (mp-MRI) to identify, stratify, and localize biopsy-proven prostate cancer lesions in a risk-stratified patient population.Methods and materialsWe retrospectively analyzed 57 patients who had mp-MRI and core needle biopsy during diagnostic prostate cancer evaluation. The MRI sequences were scored for suspicion of cancer with a previously described system. Distributions of mp-MRI scores were compared across National Comprehensive Cancer Network prostate cancer risk groups. The mp-MRI-identified lesions were compared with the location of positive core needle biopsies to assess mp-MRI localization of true lesions.ResultsThe mp-MRI scoring system identified lesions in 84% (48/57) of the patients, including 100% (12/12) in the high-risk group. Scores assigned to lesions in patients in intermediate- and high-risk groups were statistically higher than those in the low-risk group, with a relative risk of 6.72 (95% confidence interval: 2.32-19.51, p

Background. Physical activity is associated with better physical health, possibly by changing biological markers of health such as waist circumference and inflammation, but these relationships are unclear and even less understood among older Latinos-a group with high rates of sedentary lifestyle. Methods. Participants were 120 sedentary older Latino adults from senior centers. Community-partnered research methods were used to recruit participants. Inflammatory (C-reactive protein) and metabolic markers of health (waist circumference, HDL-cholesterol, triglycerides, insulin, and glucose), physical activity (Yale physical activity survey), and physical performance (short physical performance NIA battery) were measured at baseline and 6-month followup. Results. Eighty percent of the sample was female. In final adjusted cross-sectional models, better physical activity indices were associated with faster gait speed (P < 0.05). In adjusted longitudinal analyses, change in self-reported physical activity level correlated inversely with change in CRP (β = -0.05; P = 0.03) and change in waist circumference (β = -0.16; P = 0.02). Biological markers of health did not mediate the relationship between physical activity and physical performance. Conclusion. In this community-partnered study, higher physical activity was associated with better physical performance in cross-sectional analyses. In longitudinal analysis, increased physical activity was associated with improvements in some metabolic and inflammatory markers of health.

Introduction. Patients with high-grade sarcoma (HGS) frequently develop metastatic disease thus limiting their long-term survival. Lung metastases (LM) have historically been treated with surgical resection (metastasectomy). A potential alternative for controlling LM could be stereotactic body radiation therapy (SBRT). We evaluated the outcomes from our institutional experience utilizing SBRT. Methods. Sixteen consecutive patients with LM from HGS were treated with SBRT between 2009 and 2011. Routine radiographic and clinical follow-up was performed. Local failure was defined as CT progression on 2 consecutive scans or growth after initial shrinkage. Radiation pneumonitis and radiation esophagitis were scored using Common Toxicity Criteria (CTC) version 3.0. Results. All 16 patients received chemotherapy, and a subset (38%) also underwent prior pulmonary metastasectomy. Median patient age was 56 (12-85), and median follow-up time was 20 months (range 3-43). A total of 25 lesions were treated and evaluable for this analysis. Most common histologies were leiomyosarcoma (28%), synovial sarcoma (20%), and osteosarcoma (16%). Median SBRT prescription dose was 54 Gy (36-54) in 3-4 fractions. At 43 months, local control was 94%. No patient experienced G2-4 radiation pneumonitis, and no patient experienced radiation esophagitis. Conclusions. Our retrospective experience suggests that SBRT for LM from HGS provides excellent local control and minimal toxicity.

BackgroundKi-67 is a robust predictive/prognostic marker in prostate cancer; however, tumor heterogeneity in prostate biopsy samples is not well studied.MethodsUsing an MRI/US fusion device, biopsy cores were obtained systematically and by targeting when indicated by MRI. Prostate cores containing cancer from 77 consecutive men were analyzed. The highest Ki-67 was used to determine interprostatic variation. Ki-67 range (highest minus lowest) was used to determine intraprostatic and intralesion variation. Apparent diffusion coefficient (ADC) values were evaluated in relation to Ki-67.ResultsInterprostatic Ki-67 mean ± standard deviation (SD) values for NCCN low (L), intermediate (I), and high (H) risk patients were 5.1 ± 3.8%, 7.4 ± 6.8%, and 12.0 ± 12.4% (ANOVA P = 0.013). Intraprostatic mean ± SD Ki-67 ranges in L, I, and H risk patients were 2.6 ± 3.6%, 5.3 ± 6.8%, and 10.9 ± 12.3% (ANOVA P = 0.027). Intralesion mean ± SD Ki-67 ranges in L, I, and H risk patients were 1.1 ± 0.9%, 5.2 ± 7.9%, and 8.1 ± 10.8% (ANOVA P = 0.22). ADC values at Ki-67 > and

The prevalence of urinary incontinence (UI) has varied in the literature and is reflective of the definition and sampling methodologies used, as well as the age, ethnicity, and sex being studied. The aim of the current study was to measure the prevalence and correlates of UI in a sample of 572 older Latinos participating in Caminemos, a trial of a behavioral intervention to increase walking. Participants completed an in-person survey and physical performance measures. UI was measured using the International Consultation on Incontinence item: "How often do you leak urine?" Potential correlates of UI included sociodemographic variables, body mass index, smoking, physical activity, medical comorbidity, physical performance, activity of daily living (ADL) impairment, use of assistive ambulatory devices, health-related quality of life (HRQoL), and depressive symptoms. The prevalence of UI in this sample was 26.9%. Women were more likely to report UI, as were those who were less physically active; used assistive ambulatory devices; and had depressive symptoms, greater medical comorbidity, worse physical performance, greater ADL impairment, worse cognitive function, and lower HRQoL. Multivariate logistic regression revealed that medical comorbidity was independently associated with higher rates of UI (odds ratio (OR)=1.66, 95% confidence interval (CI)=1.30-2.12), whereas better cognitive function (OR=0.73, 95% CI=0.57-0.93) and higher weighted physical activity scores (OR=0.77, 95% CI=0.60-0.98) were independently associated with lower rates of UI. UI is highly prevalent but not ubiquitous among community-residing older Latinos, suggesting that UI is not an inevitable consequence of aging. Future studies should examine whether interventions that decrease comorbidity and cognitive decline and increase physical activity improve continence status.

Background: Breast cancer risk models guide screening and chemoprevention decisions, but the extent and effect of variability among models, particularly at the individual level, is uncertain. Objective: To quantify the accuracy and disagreement between commonly used risk models in categorizing individual women as average vs. high risk for developing invasive breast cancer. Design: Comparison of three risk prediction models: Breast Cancer Risk Assessment Tool (BCRAT), Breast Cancer Surveillance Consortium (BCSC) model, and International Breast Intervention Study (IBIS) model. Subjects: Women 40 to 74 years of age presenting for screening mammography at a multisite health system between 2011 and 2015, with 5-year follow-up for cancer outcome. Main Measures: Comparison of model discrimination and calibration at the population level and inter-model agreement for 5-year breast cancer risk at the individual level using two cutoffs (≥ 1.67% and ≥ 3.0%). Key Results: A total of 31,115 women were included. When using the ≥ 1.67% threshold, more than 21% of women were classified as high risk for developing breast cancer in the next 5 years by one model, but average risk by another model. When using the ≥ 3.0% threshold, more than 5% of women had disagreements in risk severity between models. Almost half of the women (46.6%) were classified as high risk by at least one of the three models (e.g., if all three models were applied) for the threshold of ≥ 1.67%, and 11.1% were classified as high risk for ≥ 3.0%. All three models had similar accuracy at the population level. Conclusions: Breast cancer risk estimates for individual women vary substantially, depending on which risk assessment model is used. The choice of cutoff used to define high risk can lead to adverse effects for screening, preventive care, and quality of life for misidentified individuals. Clinicians need to be aware of the high false-positive and false-negative rates and variation between models when talking with patients. [ABSTRACT FROM AUTHOR]

Objective: We describe the performance of Single Item Literacy Screener (SILS) questions, and educational attainment, as screening for inadequate health literacy (IHL) in older monolingual Spanish speakers. Design: We used a cross-sectional design, interviewing participants once at the time of their arrival for a clinic appointment. Setting: We conducted this study in primary care and geriatrics clinics in an urban US safety-net hospital. Method: We conducted in-person interviews with older monolingual Spanish-speaking diabetes patients, comparing responses to three SILS questions, and education, to shortened Test of Functional Health Literacy in Adults (sTOFHLA) scores. We calculated sensitivities, specificities and areas under the receiving-operator characteristic (AUROC) curve. Results: We interviewed 160 patients--134 (84%) had IHL by sTOFHLA scores. The best performing SILS question, "How confident are you filling out medical forms by yourself?" had an AUROC curve of 0.82 (95% CI 0.75-0.89). Using this question's most stringent cut-off, sensitivity was 0.93 (95% CI 0.89-0.97); specificity was 0.27 (95% CI 0.20-0.34). The other two SILS questions had AUROC curves less than 0.50. The educational achievement AUROC curve was 0.88 (95% CI 0.78-0.97); using an education cut-off of six years or less had a specificity to 0.81 (95% CI 0.75-0.87) and sensitivity of 0.83 (95% CI 0.77-0.89). Conclusion: Clinicians and investigators considering using single items as screeners for IHL in older US monolingual Spanish speakers should either use the "confidence with forms" SILS, being aware of its specificity limitations, or a single question assessing educational achievement. (Contains 2 tables and 2 figures.)