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Backgrounds: Transcatheter edge-to-edge repair (TEER) devices are used for primary mitral regurgitation (MR) and secondary MR. Despite the growing use of TEER devices, there have not been many studies on operator experience or procedure volumes by state., Aims: We aimed to investigate nationwide operator volume trends and geographic variation in access to TEER., Methods: The United States Center for Medicare and Medicaid Services (CMS) National Medicare Provider Utilization and Payment Database (MPUPD) was analyzed between 2015 and 2020 for initial TEER procedures., Results: Procedure volume and total operators increased yearly from 2015 to 2019 but declined in 2020. Mean annual procedure volume per operator varied significantly by state, between 0 in multiple states and 35 in North Dakota. In 2019, 994 unique operators were identified, with 295 operators documented performing 10 or more procedures (29.68%). Operators performing 10 or more TEER procedures provided 68.46% of all operations in 2019, averaging 20.94 procedures per operator., Conclusions: TEER procedures are becoming increasingly common as more operators are being trained. However, significant variability exists in the procedural volume per operator., (© 2023 Wiley Periodicals LLC.)

Background: The Women's Health Initiative (WHI) randomized, controlled Dietary Modification (DM) trial of a low-fat dietary pattern suggested intervention benefits related to breast cancer, coronary heart disease (CHD), and diabetes. Here, we use WHI observational data for further insight into the chronic disease implications of adopting this type of low-fat dietary pattern., Objectives: We aimed to use our earlier work on metabolomics-based biomarkers of carbohydrate and protein to develop a fat intake biomarker by subtraction, to use the resulting biomarker to develop calibration equations that adjusts self-reported fat intake for measurement error, and to study associations of biomarker-calibrated fat intake with chronic disease risk in WHI cohorts. Corresponding studies for specific fatty acids will follow separately., Methods: Prospective disease association results are presented using WHI cohorts of postmenopausal women, aged 50-79 y when enrolled at 40 United States clinical centers. Biomarker equations were developed using an embedded human feeding study (n = 153). Calibration equations were developed using a WHI nutritional biomarker study (n = 436). Calibrated intakes were associated with cancer, cardiovascular diseases, and diabetes incidence in WHI cohorts (n = 81,954) over an approximate 20-y follow-up period., Results: A biomarker for fat density was developed by subtracting protein, carbohydrate, and alcohol densities from one. A calibration equation was developed for fat density. Hazard ratios (95% confidence intervals) for 20% higher fat density were 1.16 (1.06, 1.27) for breast cancer, 1.13 (1.02, 1.26) for CHD, and 1.19 (1.13, 1.26) for diabetes, in substantial agreement with findings from the DM trial. With control for additional dietary variables, especially fiber, fat density was no longer associated with CHD, with hazard ratio (95% confidence interval) of 1.00 (0.88, 1.13), whereas that for breast cancer was 1.11 (1.00, 1.24)., Conclusions: WHI observational data support prior DM trial findings of low-fat dietary pattern benefits in this population of postmenopausal United States women., Trial Registration Number: This study is registered with clinicaltrials.gov identifier: NCT00000611., (Copyright © 2023 American Society for Nutrition. Published by Elsevier Inc. All rights reserved.)

Background: Primary malignant melanomas of the Gastrointestinal mucosa are uncommon. Most cases of gastrointestinal (GI) melanomas are secondary, arising from metastasis at distant sites. The purpose of this study is to assess to what extent the interaction between independent prognostic factors (age and tumor site) of primary GI melanoma influence survival. Furthermore, we also aimed to investigate the clinical characteristics, survival outcomes, and independent prognostic factors of patients with primary GI melanoma in the past decade., Methods: A total of 399 patients diagnosed with primary GI melanoma, between 2008 and 2017, were enrolled in our study by retrieving data from the Surveillance, Epidemiology, and End Results (SEER) database. We analyzed demographics, clinical characteristics, and overall mortality (OM) as well as cancer-specific mortality (CSM) of primary GI melanoma. Variables with a p value < 0.1 in the univariate Cox regression were incorporated into the multivariate Cox model (model 1) to determine the independent prognostic factors, with a hazard ratio (HR) of greater than 1 representing adverse prognostic factors. Furthermore, we analyzed the effect of the interaction between age and primary location on mortality (model 2)., Results: Multivariate cox proportional hazard regression analyses revealed higher OM in age group 80+ (HR = 5.653, 95% CI 2.212-14.445, p = 0), stomach location of the tumor (HR = 2.821, 95% CI 1.265-6.292, p = 0.011), regional lymph node involvement only (HR = 1.664, 95% CI 1.051-2.635, p < 0.05), regional involvement by both direct extension and lymph node involvement (HR = 1.755, 95% CI 1.047-2.943, p < 0.05) and distant metastases (HR = 4.491, 95% CI 3.115-6.476, p = 0), whereas the lowest OM was observed in patients with small intestine melanoma (HR = 0.383, 95% CI 0.173-0.846, p < 0.05). Multivariate cox proportional hazard regression analyses of CSM also revealed higher mortality of the same groups and lower CSM in small intestine and colon melanoma excluding the rectum. For model 2, considering the interaction between age and primary site on mortality, higher OM was found in age group 80+, followed by age group 40-59 then age group 60-79, regional lymph node involvement only, regional involvement by both direct extension and lymph node involvement and distant metastases. The small intestine had a lower OM. The rectum as primary location and the age range 40-59 interacted to lower the OM (HR = 0.14, 95% CI 0.02-0.89, p = 0.038). Age and primary gastric location did not interact to affect the OM. For the CSM, taking into account the interaction between age and the primary location, higher mortality was found in the same groups and the colon location. The primary colon location also interacted with the age group 40-59 to increase the CSM (HR = 1.38 × 10 9 , 95% CI 7.80 × 10 7 -2.45 × 10 10 , p = 0)., Conclusions: In this United States population-based retrospective cohort study using the SEER database, we found that only the age range 40-59 interacted with the rectum and colon to lower and increase mortality respectively. Primary gastric location, which was the single most important location to affect mortality, did not interact with any age range to influence mortality. With those results, we hope to shed some light on this rare pathology with a very dismal prognosis.

Background: Studies have shown that diverse care teams optimize patient outcomes. Describing the current representation of women and minorities has been a critical step in improving diversity across several fields., Objectives: To address the lack of data specific to pediatric cardiology, the authors conducted a national survey., Methods: U.S. academic pediatric cardiology programs with fellowship training programs were surveyed. Division directors were invited (July 2021 to September 2021) to complete an e-survey of program composition. Underrepresented minorities in medicine (URMM) were characterized using standard definitions. Descriptive analyses at the hospital, faculty, and fellow level were performed., Results: Altogether, 52 of 61 programs (85%) completed the survey, representing 1,570 total faculty and 438 fellows, with a wide range in program size (7-109 faculty, 1-32 fellows). Although women comprise approximately 60% of faculty in pediatrics overall, they made up 55% of fellows and 45% of faculty in pediatric cardiology. Representation of women in leadership roles was notably less, including 39% of clinical subspecialty directors, 25% of endowed chairs, and 16% of division directors. URMM comprise approximately 35% of the U.S. population; however, they made up only 14% of pediatric cardiology fellows and 10% of faculty, with very few in leadership roles., Conclusions: These national data suggest a "leaky pipeline" for women in pediatric cardiology and very limited presence of URRM overall. Our findings can inform efforts to elucidate underlying mechanisms for persistent disparity and reduce barriers to improving diversity in the field., Competing Interests: Funding Support and Author Disclosures This work was supported by University of Michigan ADVANCE program. The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Importance: Patients with cancer experience acute declines in physical function, hypothesized to reflect accelerated aging driven by cancer-related symptoms and effects of cancer therapies. No study has examined long-term trajectories of physical function by cancer site, stage, or treatment compared with cancer-free controls., Objective: Examine trajectories of physical function a decade before and after cancer diagnosis among older survivors and cancer-free controls., Design, Setting, and Participants: This prospective cohort study enrolled patients from 1993 to 1998 and followed up until December 2020. The Women's Health Initiative, a diverse cohort of postmenopausal women, included 9203 incident cancers (5989 breast, 1352 colorectal, 960 endometrial, and 902 lung) matched to up to 5 controls (n = 45 358) on age/year of enrollment and study arm., Exposures: Cancer diagnosis (site, stage, and treatment) via Medicare and medical records., Main Outcomes and Measures: Trajectories of self-reported physical function (RAND Short Form 36 [RAND-36] scale; range: 0-100, higher scores indicate superior physical function) estimated from linear mixed effects models with slope changes at diagnosis and 1-year after diagnosis., Results: This study included 9203 women with cancer and 45 358 matched controls. For the women with cancer, the mean (SD) age at diagnosis was 73.0 (7.6) years. Prediagnosis, physical function declines of survivors with local cancers were similar to controls; after diagnosis, survivors experienced accelerated declines relative to controls, whose scores declined 1 to 2 points per year. Short-term declines in the year following diagnosis were most severe in women with regional disease (eg, -5.3 [95% CI, -6.4 to -4.3] points per year in regional vs -2.8 [95% CI, -3.4 to -2.3] for local breast cancer) or who received systemic therapy (eg, for local endometrial cancer, -7.9 [95% CI, -12.2 to -3.6] points per year with any chemotherapy; -3.1 [95% CI, -6.0 to -0.3] with radiation therapy alone; and -2.6 [95% CI, -4.2 to -1.0] with neither, respectively). While rates of physical function decline slowed in the later postdiagnosis period (eg, women with regional colorectal cancer declined -4.3 [95% CI, -5.9 to -2.6] points per year in the year following diagnosis vs -1.4 [95% CI, -1.7 to -1.0] points per year in the decade thereafter), survivors had estimated physical function significantly below that of age-matched controls 5 years after diagnosis., Conclusions and Relevance: In this prospective cohort study, survivors of cancer experienced accelerated declines in physical function after diagnosis, and physical function remained below that of age-matched controls even years later. Patients with cancer may benefit from supportive interventions to preserve physical functioning.

Context: Pediatric obesity is a serious health problem in the United States. While lifestyle modification therapy with dietary changes and increased physical activity are integral for the prevention and treatment of mild to moderate obesity in youth, only a modest effect on sustained weight reduction is observed in children and young adults with severe obesity. This underscores the need for additional evidence-based interventions for children and adolescents with severe obesity, including pharmacotherapy, before considering invasive procedures such as bariatric surgery., Evidence Acquisition: This publication focuses on recent advances in pharmacotherapy of obesity with an emphasis on medications approved for common and rarer monogenic forms of pediatric obesity., Evidence Synthesis: We review medications currently available in the United States, both those approved for weight reduction in children and "off-label" medications that have a broad safety margin., Conclusion: It is intended that this review will provide guidance for practicing clinicians and will encourage future exploration for successful pharmacotherapy and other interventions for obesity in youth., (© The Author(s) 2022. Published by Oxford University Press on behalf of the Endocrine Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Rationale and Objectives: We examined the status of women's representation on radiology journal editorial boards around the world and evaluated temporal trends in female board representation., Materials and Methods: Data on the gender of editorial board members, deputy editors, and editors-in-chief of top general radiology journals from the United States and from five continents outside North America was collected, based on listings in mastheads of each journal at 5-year intervals from 1998 to 2018. Female editorial board representation was compared to female membership in national professional radiology organizations and national physician registries., Results: One of 42 editors-in-chief (2.4%), 24 of 135 deputy editors (17.8%), and 345 of 2545 (13.6%) editorial board members were female for the 20-year period. The overall percentage of female editorial board members increased from 9.7% (41 of 423) in 1998 to 17.0% (97 of 569) in 2018 (p < 0.0001). In 2018, women were less represented on the editorial boards than female professional society membership for all geographic regions except Australia/New Zealand; this difference reached statistical significance in Korea, Brazil, Europe, and China. Female editorial board representation ranged from 11.3% to 33.3%, with no significant difference between the United States (21.5%) and other countries., Conclusion: Although the proportion of female editorial board members of radiology journals worldwide has increased over the past two decades, female editorial board composition generally underrepresents the percentage of female radiologists. Editorial board female representation does not differ significantly between the United States and other countries., (Copyright © 2020 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.)

Purpose: To compare brachytherapy to external beam radiation therapy (EBRT) with respect to overall survival (OS) and disease-specific survival (DSS) among NSCLC patients undergoing limited surgical resection., Methods: All cases of T1-4 N0 M0 NSCLC undergoing limited resection and either brachytherapy or EBRT diagnosed between 2004 and 2014 were extracted from the Surveillance, Epidemiology, and End Results database. Chi-square test and Fisher's exact analysis were used to analyze categorical variables while Student's t-test was used to analyze continuous variables. Univariate analysis to assess for differences in survival with respect to covariates was performed with the log-rank test. Multivariable analysis was performed with Cox proportional hazards regression models among the entire cohort and after sub-stratification by T stage., Results: Among 543 patients, 471 underwent EBRT and 72 underwent brachytherapy. Brachytherapy demonstrated improved OS and DSS on univariate analysis as compared to EBRT (p < 0.05). Cox regression also demonstrated improved OS and DSS with brachytherapy (HR 0.604; 95% CI [0.380; 0.961] and HR 0.524; 95% CI [0.303; 0.908], respectively). Sub-cohort analysis demonstrated significant improvement in survival only among patients with T1 disease with similar survival between brachytherapy and EBRT among higher stage disease., Conclusions: Patients undergoing brachytherapy for T1-T4, N0, M0 NSCLC demonstrated at least similar survival as compared to those undergoing EBRT among patients undergoing limited resection. Improved survival was demonstrated among patients with T1 disease.

Endoscopic Retrograde Cholangiopancreatography (ERCP) remains the conventional method of imaging the pancreatic and biliary tree and is performed by direct injection of iodinated contrast material via the major papilla. This diagnostic procedure gained popularity in the 1970s and subsequently paved way for ERCP guided interventions such as sphincterotomy, stone retrieval and stent placement. Currently, therapeutic ERCP is more widespread than diagnostic ERCP primarily due to the availability of noninvasive imaging. Nevertheless, more than half a million ERCPs are performed annually in the United States and radiologists need to be comfortable interpreting them. The following review will familiarize the reader with the imaging appearances of biliary and pancreatic disorders on conventional ERCP, and elaborate on therapeutic ERCP with illustrative examples., (Copyright © 2020 Elsevier Inc. All rights reserved.)

The coronavirus disease 2019 (COVID-19) pandemic is having a profound effect on the provision of medical care. As the curve progresses and patients are discharged, the rehabilitation wave brings a high number of postacute COVID-19 patients suffering from physical, mental, and cognitive impairments threatening their return to normal life. The complexity and severity of disease in patients recovering from severe COVID-19 infection require an approach that is implemented as early in the recovery phase as possible, in a concerted and systematic way. To address the rehabilitation wave, we describe a spectrum of interventions that start in the intensive care unit and continue through all the appropriate levels of care. This approach requires organized rehabilitation teams including physical therapists, occupational therapists, speech-language pathologists, rehabilitation psychologists or neuropsychologists, and physiatrists collaborating with acute medical teams. Here, we also discuss administrative factors that influence the provision of care during the COVID-19 pandemic. The services that can be provided are described in detail to allow the reader to understand what services may be appropriate locally. We have been learning and adapting real time during this crisis and hope that sharing our experience facilitates the work of others as the pandemic evolves. It is our goal to help reduce the potentially long-lasting challenges faced by COVID-19 survivors., (Copyright © 2020 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To expand an existing validated measure of basic mobility (Activity Measure for Post-Acute Care [AM-PAC]) for patients at the lowest levels of function., Design: Item replenishment for existing item response theory (IRT) derived measure via (1) idea generation and creation of potential new items, (2) item calibration and field testing, and (3) longitudinal pilot test., Setting: Two tertiary acute care hospitals., Participants: Consecutive inpatients (N=502) ≥18 years old, with an AM-PAC Inpatient Mobility Short Form (IMSF) raw score ≤15. For the longitudinal pilot test, 8 inpatients were evaluated., Results: Fifteen new AM-PAC items were developed, 2 of which improved mobility measurement at the lower levels of functioning. Specifically, with the 2 new items, the floor effect of the AM-PAC IMSF was reduced by 19%, statistical power and measurement breadth were greater, and there was greater measurement sensitivity in longitudinal pilot testing., Conclusion: Adding 2 new items to the AM-PAC IMSF lowered the floor and increased statistical power, measurement breadth, and sensitivity., (Copyright © 2020 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: "Curbside consults" are informal opinions provided by one physician to another. In radiology, it often refers to opinions rendered on imaging performed at outside facilities and has evolved from being a targeted response to a discrete clinical question to a complete over-read in recent years. Given that the consults are usually sought for patients with complex conditions, the potential for error increases with informal reads, often due to the time constraint and lack of adequate information. Misinterpretations and inaccurate documentation by the referring clinician are also more likely. This study assesses the policies and views on curbside consults at academic centers in the United States., Materials and Methods: An online survey (via SurveyMonkey.com) was circulated to the 319 active radiologist members of the Association of Program Directors. There were 80 responses, representing a 25% response rate., Results: While most facilities provided second reads (92%), only a few (23%) provided written reports and read the case entirely. The majority (77%) tailored their read to answer specific clinical questions. Approximately two-thirds did not require the outside radiologist's report to be available before their interpretation. Seventy-nine percent were at least mildly concerned about liability. Up to 45% billed for the study; 39% were not aware of the billing practice., Conclusion: Curbside consults are widely provided at U.S. academic institutions with only a minority documenting their opinions. The majority are concerned about the legal implications and this paper puts forth recommendations to minimize the potential for errors in patient care and decrease liability., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background and Aims: Inflammation of the pouch after ileal pouch-anal anastomosis (IPAA) can significantly impact quality of life and be difficult to treat. We assessed the effectiveness and safety of vedolizumab in Crohn's disease (CD) of the pouch and chronic antibiotic-dependent or antibiotic-refractory pouchitis., Methods: This was a retrospective, multicenter cohort study at 5 academic referral centers in the United States. Adult patients with endoscopic inflammation of the pouch who received vedolizumab were included. The primary outcome was clinical response at any time point. Secondary outcomes included clinical remission, endoscopic response, and remission. Univariate analysis and multivariate analysis were performed for the effect of the following variables on clinical response: fistula, onset of pouchitis less than 1 year after IPAA, younger than 35 years old, gender, previous tumor necrosis factor inhibitor-alpha use, and BMI >30., Results: Eighty-three patients were treated with vedolizumab for inflammation of the pouch between January 2014 and October 2017. Median follow-up was 1.3 years (interquartile range 0.7-2.1). The proportion of patients that achieved at least a clinical response was 71.1%, with 19.3% achieving clinical remission. Of the 74 patients with a follow-up pouchoscopy, the proportion of patients with endoscopic response and mucosal healing was 54.1% and 17.6%, respectively. Patients who developed pouchitis symptoms less than 1 year after undergoing IPAA were less likely to respond to vedolizumab, even after controlling for other risk factors., Conclusions: Vedolizumab is safe and effective in the management of CD of the pouch and chronic pouchitis. Further studies are needed to compare vedolizumab with other biologic therapies for pouchitis and CD of the pouch., (© 2019 Crohn’s & Colitis Foundation. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Goals: We aimed to assess use of colorectal cancer screening (CRCS) as per United States Preventive Task Force guidelines among people with mobility disability using a nationally representative data set., Background: Individuals with mobility disability have decreased access to health care services, but the impact of mobility disability on CRCS has not been investigated., Study: Data from the 2013 National Health Interview Survey were used to estimate sociodemographic characteristics of adults with mobility disability, prevalence of CRCS, and odds of CRCS given mobility disability among Americans aged 50 to 75., Results: In total, 56.8% of the entire sample (n=81,953,585) were up-to-date with CRCS. Mobility disability was not associated with CRCS status on univariable analysis but was significantly associated after adjustment for covariates including age and comorbidities, with an inverse relationship between the degree of mobility disability and odds of CRCS. Odds ratio for CRCS given progressively severe disability were 0.78 (0.66 to 0.93), 0.71 (0.53 to 0.94), 0.65 (0.31 to 1.19)., Conclusions: The present study indicates reduced CRCS among people with mobility disability and highlights the need for CRCS to be especially targeted toward this group. Future research should identify the specific systemic, social, and/or physical barriers to CRCS for this subgroup so that they can be addressed.

Although firearm-related homicide-suicides and firearm-related suicides are tragic and catastrophic events, there is increasing evidence that the two events have different precipitants and that understanding these precipitants may help prevention efforts. We aimed to assess the role of interpersonal conflict (IPC) and recent crises in firearm-related homicide-suicides as compared with firearm-related suicides alone. We also assessed whether these differences were consistent across young and old perpetrators. Using an unmatched case-control study, we compared firearm-related homicide-suicides andsuicides alone from 2003 to 2011 in the National Violent Death Registry data to assess the risk associated with IPC and crisis. Survival analysis was performed to compare time-to-incident of homicide-suicide versus suicide only. We derived odds ratios (ORs) and 95% confidence intervals (95%CI) due to IPC and recent crisis from mixed logistic regression models. Stratified analysis by age on the effect of IPC and recent crisis, and type of incident was also performed. After adjusting for relevant covariates, homicide-suicides were more likely than suicide alone following IPC (OR = 20.6, 95%CI = [16.6, 25.7]) and recent crisis (OR = 14.5, 95%CI = [12.4, 16.9]). The risk of firearm homicide-suicide compared with suicide associated with IPC was twice greater among those >30 years compared with those ≤30 years ( p-interaction = .033), and no differential by age associated with recent crisis ( p-interaction = .64). IPC and recent crisis are risk factors for committing homicide-suicides compared with suicides alone, with the risk doubly greater among older than younger perpetrators.

Background: Despite technical advances, bile leak remains a significant complication after hepatectomy. The current study uses a targeted multi-institutional dataset to characterize perioperative factors that are associated with bile leakage after hepatectomy to better understand the impact of bile leak on morbidity and mortality., Methods: Adult patients in the 2014-2015 ACS NSQIP targeted hepatectomy dataset were linked to the ACS NSQIP PUF dataset. Bivariable and multivariable regression analyses were used to assess the associations between clinical factors and post-hepatectomy bile leak., Results: Of 6859 patients, 530 (7.7%) had a postoperative bile leak. Proportion of bile leaks was significantly greater in patients after major compared to minor hepatectomy (12.6 vs. 5.1%, p < 0.001). The proportion of patients with bile leak was significantly greater in patients after major hepatectomy who had concomitant enterohepatic reconstruction (31.8 vs. 10.1%, p < 0.001). Postoperative mortality was significantly greater in patients with bile leaks (6.0 vs. 1.7%, p < 0.001). After adjusting for significant covariates, bile leak was independently associated with increased risk of postoperative morbidity (OR = 4.55; 95% CI 3.72-5.56; p < 0.001). After adjusting for significant effects of postoperative complications, liver failure, and reoperation (all p<0.001), bile leak was not independently associated with increased risk of postoperative mortality (p = 0.262)., Conclusion: Major hepatectomy and enterohepatic biliary reconstruction are associated with significantly greater rates of bile leak after liver resection. Bile leak is independently associated with significant postoperative morbidity. Mitigation of bile leak is critical in reducing morbidity and mortality after liver resection.

The introduction of antiretroviral therapy (ART) in 1995 had a dramatic impact on the morbidity and mortality of the HIV population, and subsequently, the natural history of cancer has changed. The purpose of our study was to review the prevalence of AIDS-defining malignancies and non-AIDS defining cancers (NADC), taking into consideration racial and gender variations. After the institutional review board approval, the study was conducted as a retrospective chart review of 279 HIV-infected patients who were treated at the Moffitt Cancer Center between January 1, 2000 and December 31, 2010. The demographic characteristics included gender, ethnicity, race, presence or absence of ART, and the type of malignancy reviewed. Of 233 men, 78 (33.5%) had AIDS-defining malignancies. AIDS-related non-Hodgkin lymphoma (NHL) was detected in 49 (21%) patients and Kaposi sarcoma (KS) in 29 (12%) patients. Two-thirds of male patients had NADC, with anal cancer being the most prevalent (8.5%), followed by Hodgkin lymphoma (6%). AIDS-related NHL was also the predominant malignancy for women with a prevalence of 19.5% followed by invasive cervical cancer (ICC) and breast cancer, both with a similar prevalence of 11%. Kaposi sarcoma and anal cancer were equally detected in 2% of women. The prevalence rates of AIDS-defining malignancies among those of white race were 34%, ranging from 21% for NHL to 13% for KS and 1.5% for ICC. Twenty-one (7.7%) patients had anal cancer. AIDS-defining malignancies were found in 36% of patients of black race and 60% had NHL. Non-AIDS-related NHL was the second most common malignancy, followed by breast cancer and anal cancer with a similar prevalence of 6.5%. Of 279 patients, 53% were taking ART; 39.4% were not taking ART; and in 7.5% of the patients, it was unknown if they were taking ART. In the ART era, our study found NADC to be more prevalent than AIDS-defining malignancies with 60% versus 40%, respectively. Non-Hodgkin lymphoma remained the most common AIDS-related malignancy in both genders. Among the patients with NADC, anal cancer was the predominant malignancy. The increasing incidence of some of the NADC is expected as this population is living longer with chronic exposure of viral replication of virus with oncogenic potential such as Human papillomavirus (HPV), Hepatitis B virus (HBV), Epstein-Barr virus (EBV), and Human herpesvirus 8 (HHV-8). Early ART initiation, aggressive vaccination, and judicious cancer screening are the cornerstone of cancer prevention of this growing population.

Objectives: To determine the temporal patterns and the difference in trends by race/ethnicity of pediatric firearm hospitalizations (FH) among those aged 15 years or younger in the United States., Methods: Data on pediatric FH was retrieved from the Nationwide Inpatient Sample between 1998 and 2011 (n = 16,998,470) using external cause of injury codes (E-codes) of the International Classification of Diseases, Ninth Revision, Clinical modification, (assault: E9650-E9654, unintentional: E9220-E9224, E9228, and E9229, suicide: E9550-E9554, E9556, and E9559, undetermined: E9850-E9854, and E9856 and legal: E970). Meta-regression was used to determine the significance of temporal trends. Survey logistic regression adjusted for survey year was used to examine association of pediatric FH with social and demographic characteristics., Results: An annual reduction of 1.07 per 100,000 hospitalizations (p-trend = 0.011) was observed between 1998 and 2011. There was reduction in rate of unintentional-FH (p-trend = 0.013), suicide-FH (p-trend = 0.029), and undetermined-FH (p-trend = 0.002), but not assault-FH (p-trend = 0.18). A decline in rates of FH was observed among whites (p-trend = 0.021) and Hispanics (p-trend = 0.03) while an increase in rates of assault-FH was observed among black children. All other intents and all other racial/ethnic groups showed declining rates during this interval., Conclusions: There was an overall decline in rates of pediatric FHs in this time period driven by a decline in unintentional-FHs. However there was an increase in assault FH among black children during this same time period.

Purpose: To better understand the effects of race and/or ethnicity and neighborhood poverty on pediatric firearm injuries in the United States, we compared overall and intent-specific firearm hospitalizations (FH) with those of pedestrian motor vehicle crash hospitalizations (PMVH)., Methods: We used Nationwide Inpatient Sample data (1998-2011) among 0-15 year-olds in a 1:1 case-case study; 4725 FH and 4725 PMVH matched by age, year, and region., Results: Risk of FH versus PMVH was 64% higher among black children, Odds ratio (OR) = 1.64, 95% confidence interval (95% CI) = 1.44-1.87, as compared to white children (P < .0001); this risk did not vary by neighborhood poverty (P interaction = .52). Risk of homicide FH versus PMVH was 842% higher among black (OR = 8.42, 95% CI = 6.27-11.3), 452% higher among Hispanics (OR = 4.52, 95% CI = 3.33-6.13) and 233% higher among other race (OR = 2.33, 95% CI = 1.52-3.59) compared to white children. There was a lower risk for unintentional FH among black OR = 0.73, 95% CI = 0.62-0.87, Hispanics (OR = 0.60, 95% CI = 0.49-0.74), and other (OR = 0.63, 95% CI = 0.47-0.83) compared to whites. These intent-specific risks attributed to race did not vary by neighborhood affluence., Conclusions: Black children were at greater likelihood of FH compared to white children regardless of neighborhood economic status. Minority children had an increased likelihood of intentional FH and a decreased likelihood of unintentional FH as compared to white children irrespective of neighborhood income., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Antifibrinolytic agents, such as tranexamic acid (TA), aprotinin, and E-aminocaproic acid, have been extensively used in the past 2 decades to prevent blood loss from traumatic or postoperative bleeding. For example, the Clinical Randomization of an Antifibrinolytic in Significant Hemorrhage 2 (CRASH-2) trial demonstrated that there was a significant reduction in all-cause mortality in trauma patients treated with TA (relative risk=0.91, P=0.003) and death due to bleeding (relative risk=0.85, P=0.007). This article reports the case of a 56-year-old woman without any previous cardiac history who was admitted to the hospital for an elective right hip arthroplasty and who received 1 dose of 10 mg/kg of TA. Her immediate postoperative course was complicated by hypotension and chest pain, and an electrocardiogram showed ST segment elevation in the inferior leads. Emergent coronary angiography showed complete occlusion of the distal right coronary artery that was successfully treated with thrombectomy and percutaneous coronary intervention. An extensive literature search showed only 4 cases of myocardial infarction in the setting of TA administration, all of which were outside the United States.

Objectives: To document overall, racial, ethnic and intent-specific spatiotemporal trends of firearm-related fatality rates (FRF rates) in the USA., Design: Cross-sectional study per year from 2000 to 2010., Setting Usa Participants: Aggregate count of all people in the USA from 2000 to 2010., Outcome Measures: Data from the Web-based Injury Statistics Query and Reporting System from 2000 to 2010 was used to determine annual FRF rates per 100,000 and by states, race, ethnicity and intent., Results: The average national 11-year FRF rate was 10.21/100,000, from 3.02 in Hawaii to 18.62 in Louisiana: 60% of states had higher than national rates and 41 states showed no temporal change. The average national FRF rates among African-Americans and Caucasians were 18.51 and 9.05/100,000 and among Hispanics and non-Hispanics were 7.13 and 10.13/100,000; Hispanics had a decreasing change of -0.18, p trend<0.0001. In states with increasing trends (Florida and Massachusetts), Caucasians and non-Hispanics drove the rise; while in states with decreasing trends (California, North Carolina, Arizona, Nevada, New York, Illinois, Maryland), Hispanics and African-Americans drove the fall. The average national FRF rates due to homicides (4.1/100,000) and suicides (5.8/100,000) remained constant, but varied between states., Conclusions: Endemic national FRF rates mask a wide variation in time trends between states. FRF rates were twice as high in African-Americans than Caucasians but decreased among Hispanics. Efforts to identify state-specific best practices can contribute to changes in national FRF rates that remain high., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Cardiac arrhythmias are a complication of myocarditis. There are no large studies of in-hospital arrhythmia development and outcomes in pediatric patients with acute myocarditis. This was a retrospective 2-center review of patients ≤21 years hospitalized with acute myocarditis from 1996 to 2012. Fulminant myocarditis was defined as the need for inotropic support within 24 hours of presentation. Acute arrhythmias occurred at presentation and subacute after admission. Eighty-five patients (59% men) presented at a median age of 10 years (1 day to 18 years). Arrhythmias occurred in 38 patients (45%): 16 acute, 12 subacute, and 9 acute and subacute (1 onset unknown). Arrhythmias were associated with low voltages on the electrocardiogram (14 of 34, 41% vs 6 of 47, 13%; odds ratio [OR] 4.78, 95% confidence interval [CI] 1.60 to 14.31) and worse outcome (mechanical support, orthotopic heart transplant, or death; OR 7.59, 95% CI 2.61 to 22.07) but were not statistically significantly associated with a fulminant course, ST changes, initial myocardial function, lactate, creatinine level, C-reactive protein and/or erythrocyte sedimentation rate, or troponin I level, after adjusting for multiple comparisons. Subacute arrhythmias were associated with preceding ST changes (10 of 15, 67% vs 15 of 59, 25%, OR 5.87, 95% CI 1.73 to 19.93). All patients surviving to discharge had arrhythmia resolution or control before discharge (10 on antiarrhythmic), with 1 exception (patient with complete heart block requiring a pacemaker). At 1-year follow-up, there were 3 recurrences of ventricular arrhythmias, but no arrhythmia-related mortality. In conclusion, arrhythmias are common in pediatric patients with myocarditis, occurring in nearly 1/2 of all hospitalized children and are associated with a worse outcome. Early identification of subacute arrhythmias using electrocardiographic changes may help management. A majority of patients do not require continued postdischarge arrhythmia treatment., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Prematurity is one of the leading causes of infant morbidity and mortality globally. Over the years, however, advances in medicine and technology have enhanced the ability to care for babies at very early gestations. There has also been a shift in the distribution of births away from term/post-term gestations and toward earlier gestational ages. These changes have added to the burden of premature births. The focus of this article is to present both sides of the story, one that highlights the many problems and morbidities faced by this subgroup of premature infants and the other that justifies their early delivery., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Past findings indicate that middle-aged adults in the United States tend to be more resistant to attitude change than younger and older adults, but little is known about why this is so. The authors propose that midlife adults' disproportionate occupation of high-power social roles (which call for resoluteness) may partly explain their heightened resistance to persuasion. Using nationally representative data sets, the article first documents that in various domains the possession of social power peaks in midlife. It next documents that middle-aged adults place a high value on resoluteness, which suggests that they have internalized powerful role norms. Next, it shows that directly activating the concept of social power increases the perceived value of resoluteness. Finally, it demonstrates that the possession of powerful social roles partially mediates the relationship between age and resistance to persuasion. This work is the first to uncover a mechanism responsible for changes in attitude strength over the adult life course.

Training medical personnel to maintain readiness for medical emergencies and combat-related operations is a critical problem. Distance learning solutions are required for enabling effective training while minimizing time away from the important on-the-job duties of providing quality medical care. Simulation-based training can significantly benefit learners by providing opportunities for hands on training. A simulation by itself, however, is not sufficient to enable learning. It must be accompanied by opportunities for reflection and a chance for learners to try their skills under different conditions. This means a simulation-based training course should include several scenarios. The high cost of developing and administering training scenarios renders this infeasible. We have developed a simulation-based training framework called SimCore that incorporates intelligent, automated assessment and coaching in support of self-paced learning. This reduces the need for human facilitators. A key feature of this framework is an authoring tool that supports rapid scenario development and customization and is designed for use by subject matter experts and course developers. This brings down the cost of scenario development. The system has been designed to interface easily with third-party simulators, with minimal effort. It also includes a Flash-based simulator that can be played on a web-browser. A beta version of SimCore is currently being distributed for evaluation.

Objective: To report on the identification, recruitment, and enrollment of adolescent survivors of childhood cancer into an ongoing randomized controlled trial (RCT) of health promotion., Methods: A total of 244 adolescents were contacted by mail and telephone to assess their trial eligibility. Data were collected with respect to each adolescent's demographics and trial recruitment efforts (frequency and intensity of telephone call contact); exclusion and randomization status were tracked throughout., Results: Thirty-one percent of adolescents were ultimately randomized in the trial and 69% were excluded from randomization (13% were ineligible, 33% refused to participate, 22% were unreachable or nonresponsive, that is, did not respond to trial mailings or telephone calls, and less than 1% were withdrawn prior to randomization). Among all eligible adolescents, the trial's consent rate was 49%. Adolescents excluded owing to refusal resided the farthest away from the intervention site and experienced the least amount of telephone call contact time. The primary reasons for trial refusal were lack of interest in health promotion (28%) and lack of time to participate (23%)., Conclusions: Health promotion RCTs among adolescent survivors of childhood cancer may help prevent and control the onset and severity cancer-treatment-related late effects. However, trial success may be contingent upon tracing nonresponsive adolescents and reducing and eliminating barriers to participation.