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Background: Little is known about whether cannabis legalization impacts cannabis use uptake or has spillover effects on co-use of cannabis and tobacco/nicotine (using both in the past 30 days). We determined associations of cannabis legalization with self-reported (1) current (past 30-day) cannabis use; (2) current ("now") tobacco/nicotine use (smoking or electronic cigarette use); and (3) current co-use of cannabis and tobacco/nicotine and how prevalence is changing over time., Methods: In this longitudinal study, a web-based survey was administered to a nationally representative, population-based panel of US adults in 2017, 2020, and 2021. We used weighted unadjusted binomial logistic GEE models to assess changes in prevalence of cannabis, tobacco/nicotine use and co-use and weighted, adjusted binary logistic GEE models to assess associations of cannabis legalization with cannabis, tobacco/nicotine use and co-use., Results: A total of 9003 participants (age range = 18-94, mean age = 47.9 [±17.4 SD] years; 4696 females [weighted 52.0 %]) completed the survey in 2017; 5979/8529 (70.1 %) in 2020 and 5420/7305 (74.2 %) in 2021 from the original cohort who remained available. Current cannabis use significantly increased +3.3 % between 2017 and 2021, while tobacco/nicotine use significantly declined (-1.9 %); co-use of cannabis and tobacco/nicotine did not change significantly (+0.2 %). Both medical and recreational cannabis legalization was associated with increased current cannabis use; the independent effect of recreational cannabis legalization was 1.13 times larger than medical. There were no statistically significant differences in tobacco/nicotine use and co-use prevalence by legalization status., Conclusion: Cannabis legalization increases cannabis use but is not associated with changes in tobacco/nicotine use or co-use. Legalization should be coupled with public health efforts., Competing Interests: Declaration of competing interest None declared. SG reported receiving personal fees from the World Health Organization outside the submitted work. NN is supported by the California Tobacco-Related Disease Research Program (#T32KT5071) and IPA HSR & D from the US Department of Veterans Affairs Health Services., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Backgrounds: Despite a wide spectrum of contraceptive methods for women, the unintended pregnancy rate remains high (45% in the US), with 50% resulting in abortion. Currently, 20% of global contraceptive use is male-directed, with a wide variation among countries due to limited availability and lack of efficacy. Worldwide studies indicate that >50% of men would opt to use a reversible method, and 90% of women would rely on their partner to use a contraceptive. Additional reasons for novel male contraceptive methods to be available include the increased life expectancy, sharing the reproductive risks among partners, social issues, the lack of pharma industry involvement and the lack of opinion makers advocating for male contraception., Aim: The present guidelines aim to review the status regarding male contraception, the current state of the art to support the clinical practice, recommend minimal requirements for new male contraceptive development and provide and grade updated, evidence-based recommendations from the European Society of Andrology (EAA) and the American Society of Andrology (ASA)., Methods: An expert panel of academicians appointed by the EAA and the ASA generated a consensus guideline according to the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) system., Results: Sixty evidence-based and graded recommendations were produced on couple-centered communication, behaviors, barrier methods, semen analysis and contraceptive efficacy, physical agents, surgical methods, actions before initiating male contraception, hormonal methods, non-hormonal methods, vaccines, and social and ethical considerations., Conclusion: As gender roles transform and gender equity is established in relationships, the male contribution to family planning must be facilitated. Efficient and safe male-directed methods must be evaluated and introduced into clinical practice, preferably reversible, either hormonal or non-hormonal. From a future perspective, identifying new hormonal combinations, suitable testicular targets, and emerging vas occlusion methods will produce novel molecules and products for male contraception., (© 2023 American Society of Andrology and European Academy of Andrology.)

Background: This study characterizes patient and health-care professional perspectives regarding medical cannabis use at a National Cancer Institute-Designated Cancer Center. Data evaluated included the prevalence and patterns of and reasons for cannabis use., Methods: Patients with cancer undergoing treatment were recruited into a cross-sectional survey as part of a national National Cancer Institute-funded effort. Participants completed a survey about cannabis use, reasons for use, and types of cannabis. A health-care professional survey was also conducted to explore perspectives regarding patients' use of cannabis., Results: A total of 313 patients with cancer (mean [SD] age = 60.7 [12.8] years) completed the survey (43% response rate) between 2021 and 2022. Of the respondents, 58% were female; identified as White (61%) and Black (23%); and had diverse cancer diagnoses. Nearly half of respondents (43%) had previously used cannabis, one-quarter (26%) had used cannabis since their cancer diagnosis, and almost 1 in 6 (17%) were actively using cannabis at the time of survey completion. The most common modes of ingestion were gummies (33%) and smoking (30%). The most commonly reported reasons for use were insomnia (46%), pain (41%), and mood (39%). For the 164 health-care professionals who completed the survey (25% response rate), the majority agreed that cannabis use (72%) is safe and beneficial for patients (57%). Four in 10 (39%) health-care professionals felt comfortable providing guidance to patients about cannabis use; however, only 1 in 8 (13%) felt knowledgeable about the topic of cannabis., Conclusions: Approximately one-sixth of patients with cancer receiving treatment actively use cannabis for management of various cancer symptoms. Perceptions about cannabis use and education varied widely among health-care professionals., (© The Author(s) 2024. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: We examined the association between cannabis use and cardiovascular outcomes among the general population, among never-tobacco smokers, and among younger individuals., Methods and Results: This is a population-based, cross-sectional study of 2016 to 2020 data from the Behavioral Risk Factor Surveillance Survey from 27 American states and 2 territories. We assessed the association of cannabis use (number of days of cannabis use in the past 30 days) with self-reported cardiovascular outcomes (coronary heart disease, myocardial infarction, stroke, and a composite measure of all 3) in multivariable regression models, adjusting for tobacco use and other characteristics in adults 18 to 74 years old. We repeated this analysis among nontobacco smokers, and among men <55 years old and women <65 years old who are at risk of premature cardiovascular disease. Among the 434 104 respondents, the prevalence of daily and nondaily cannabis use was 4% and 7.1%, respectively. The adjusted odds ratio (aOR) for the association of daily cannabis use and coronary heart disease, myocardial infarction, stroke, and the composite outcome (coronary heart disease, myocardial infarction, and stroke) was 1.16 (95% CI, 0.98-1.38), 1.25 (95% CI, 1.07-1.46), 1.42 (95% CI, 1.20-1.68), and 1.28 (95% CI, 1.13-1.44), respectively, with proportionally lower log odds for days of use between 0 and 30 days per month. Among never-tobacco smokers, daily cannabis use was also associated with myocardial infarction (aOR, 1.49 [95% CI, 1.03-2.15]), stroke (aOR, 2.16 [95% CI, 1.43-3.25]), and the composite of coronary heart disease, myocardial infarction, and stroke (aOR, 1.77 [95% CI, 1.31-2.40]). Relationships between cannabis use and cardiovascular outcomes were similar for men <55 years old and women <65 years old., Conclusions: Cannabis use is associated with adverse cardiovascular outcomes, with heavier use (more days per month) associated with higher odds of adverse outcomes.

Background/purpose: There has been increasing emphasis on the development of new technology to mitigate unmet clinical needs in cardiovascular disease. This emphasis results in part from recognition that many devices, although being initially developed in the United States, were studied, and then eventually approved abroad before being returned to the U.S. for clinical application. The FDA (Food and Drug Administration) guidance document on Early Feasibility Studies (EFS) and then the 21st Century Cures Act from 2013 to 2016 focused on these issues., Materials/methods: There are multiple components of medical device translational pathways to be considered in continuing to reach the goal of providing early access to safe and effective products to the U.S., Population: This review article documents the various stages from early idea innovation to device design and iteration to clinical testing and then potential approval and application in the wide clinical practice of cardiovascular health care., Results: The CDRH (Centers for Devices and Radiological Health) has focused on key components including EFS, Breakthrough Devices Program, Total Product Life Cycle, the Unique Device Identification Program, the establishment of a Digital Health Center of Excellence, and leveraging Collaborative Communities. Each of these initiatives focuses on improving the Medical Device Development Ecosystem., Conclusions: Major changes in device translational research have improved the device research climate in the United States. Goals remain including increased training and education for constituencies aspiring to work in the field of device development and regulation as part of a continuous health care learning system., Competing Interests: Declaration of competing interest Drs. Holmes, Dib, Jacques, DeMaria, King, and Mr. Rowe declarations of interest: none. Drs. Farb and Zuckerman are employees of the U.S. Food and Drug Administration., (Copyright © 2023. Published by Elsevier Inc.)

Introduction: Resident training in vasectomy, especially in the office setting on the awake patient, may be limited. The aim of this study is to understand resident exposure to vasectomy and to identify barriers to learning., Materials and Methods: An anonymous 18-question survey was distributed to urology residents of the 135 ACGME-accredited urology residencies in the United States. Residents were asked to specify the total number of vasectomies they had performed and in what environment (operating room versus office), their comfort performing vasectomy independently, and any barriers to learning the procedure., Results: In total, 119 residents responded to the survey, representing a 10% response rate. Vasectomy case volumes were variable, with 36.7% of residents logging ≤ 20 vasectomies by their final year of training. Total of 23.4% indicated they did not receive training in perioperative counseling for patients considering vasectomy. Only 64.7% of all residents felt comfortable in the office setting versus 89.1% who felt comfortable in the operating room (p < 0.001). This difference persisted throughout training, and 16.7% of residents in their final year of residency were uncomfortable performing office vasectomy. Total of 60.5% of respondents cited one or more barriers to training, with lack of surgical volume (38.7%), lack of vasectomies in the resident clinic (29.4%), and lack of autonomy when performing the procedure (22.7%) being the most common., Conclusions: Residents are significantly less comfortable performing vasectomy in the office setting versus in the operating room, including in their graduating year. Residents describe low volume and lack of autonomy as barriers to vasectomy training.

Introduction: Feminizing gender-affirming surgery (GAS) has been an increasingly used procedure in the United States and worldwide for transgender women with gender dysphoria. Studies on patient-reported quality of life outcomes in those undergoing GAS remain limited., Objective: To provide recent insights from the literature on sexual metrics in the evaluation of the transgender women., Methods: We queried PubMed to identify studies assessing sexual function metrics in those undergoing feminizing GAS., Results: There is no single validated method to establish preoperative and postoperative sexual function. Assessment currently remains institutionally dependent. Evaluation can involve questionnaires including but not limited to the International Index of Erectile Function, the Female Sexual Function Index, and the Male to Female Sexual Function Index., Conclusion: In this literature review, we discuss considerations for the evaluation of sexual function for patients considering feminizing GAS with vaginoplasty. Although we describe some of the major tools currently used in evaluating sexual function in this patient population, a need for a validated method remains. Syed JS, Honig S. Sexual Metrics in Transgender Women: Transitioning From International Index of Erectile Function to Female Sexual Function Index. Sex Med Rev 2021;9:236-243., (Copyright © 2020 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

Tattoo popularity continues to rise, with 3 in 10 Americans bearing at least one. Among tattoo complications, non-tuberculous mycobacteria (NTM) has emerged as a global public health concern. NTM infections associated with tattooing of immunocompetent individuals have occurred as sporadic cases and community outbreaks. Water sources are considered the major pathogenic reservoirs. Tattoo-related inoculation has been linked to contamination of ink, either during the manufacturing process or during dilution of black ink using non-sterile water. NTM infections have also been documented in a number of cosmetic and surgical procedures, including cutaneous surgery, Mohs micrographic surgery, mesotherapy, liposuction and laser resurfacing. NTM inoculation through exposure to contaminated water or non-sterile instruments remains a challenge for dermatologists and risk to patients. We reported a case of cutaneous Mycobacterium massiliense infection following tattoo placement. This report underscores the importance of clinicians to consider NTM infections in the differential diagnosis of procedure-related reactions., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Purpose: The primary objective of Children's Oncology Group study P9641 was to demonstrate that surgery alone would achieve 3-year overall survival (OS) ≥ 95% for patients with asymptomatic International Neuroblastoma Staging System stages 2a and 2b neuroblastoma (NBL). Secondary objectives focused on other low-risk patients with NBL and on those who required chemotherapy according to protocol-defined criteria., Patients and Methods: Patients underwent maximally safe resection of tumor. Chemotherapy was reserved for patients with, or at risk for, symptomatic disease, with less than 50% tumor resection at diagnosis, or with unresectable progressive disease after surgery alone., Results: For all 915 eligible patients, 5-year event-free survival (EFS) and OS were 89% ± 1% and 97% ± 1%, respectively. For patients with asymptomatic stage 2a or 2b disease, 5-year EFS and OS were 87% ± 2% and 96% ± 1%, respectively. Among patients with stage 2b disease, EFS and OS were significantly lower for those with unfavorable histology or diploid tumors, and OS was significantly lower for those ≥ 18 months old. For patients with stage 1 and 4s NBL, 5-year OS rates were 99% ± 1% and 91% ± 1%, respectively. Patients who required chemotherapy at diagnosis achieved 5-year OS of 98% ± 1%. Of all patients observed after surgery, 11.1% experienced recurrence or progression of disease., Conclusion: Excellent survival rates can be achieved in asymptomatic low-risk patients with stages 2a and 2b NBL after surgery alone. Immediate use of chemotherapy may be restricted to a minority of patients with low-risk NBL. Patients with stage 2b disease who are older or have diploid or unfavorable histology tumors fare less well. Future studies will seek to refine risk classification.

This study models independent associations of state or local strong clean indoor air laws and cigarette prices with current smoker status and consumption in a multilevel framework, including interactions with educational attainment, household income and race/ethnicity and the relationships of these policies to vulnerabilities in smoking behavior. Cross sectional survey data are employed from the February 2002 panel of the Tobacco Use Supplement of the Current Population Survey (54,024 individuals representing the US population aged 15-80). Non-linear relationships between both outcome variables and the predictors were modeled. Independent associations of strong clean indoor air laws were found for current smoker status (OR 0.66), and consumption among current smokers (-2.36 cigarettes/day). Cigarette price was found to have independent associations with both outcomes, an effect that saturated at higher prices. The odds ratio for smoking for the highest versus lowest price over the range where there was a price effect was 0.83. Average consumption declined (-1.16 cigarettes/day) over the range of effect of price on consumption. Neither policy varied in its effect by educational attainment, or household income. The association of cigarette price with reduced smoking participation and consumption was not found to vary with race/ethnicity. Population vulnerability in consumption appears to be structured by non-white race categories, but not at the state and county levels at which the policies we studied were enacted. Clean indoor air laws and price increases appear to benefit all socio-economic and race/ethnic groups in our study equally in terms of reducing smoking participation and consumption.

The 1972 U.S. surgeon general's report The Health Consequences of Smoking was the first to include a warning about exposure to second-hand smoke. Because the tobacco industry has a record of withholding the results of their research from the public, we searched the internal tobacco industry documents and compared internal industry research on second-hand smoke to what the industry published in the open scientific literature through 1972. We found chemical analyses, sensory evaluations, and discussions of sidestream cigarette smoke (the smoke emitted by the cigarette between puffs, the main component of second-hand smoke), beginning in 1929. American Tobacco Company research in the 1930s indicated that, compared with mainstream smoke, sidestream smoke was produced in larger quantities and contained, per cigarette, 2 times more nicotine and 12 times more ammonia. Research funded by the Tobacco Industry Research Committee in the 1950s revealed that sidestream smoke contained, per unit cigarette, higher concentrations of carcinogenic polycyclic aromatic hydrocarbons, per unit mass, including four times more 3,4 benzopyrene. In 1956 and 1957, respectively, Philip Morris and R. J. Reynolds also began to research sidestream smoke. In 1961, Philip Morris began to do sensory evaluation and modification of sidestream odor during product development. This sensory evaluation of sidestream smoke was the first biological testing of sidestream smoke by a tobacco company. Prior to the release of the 1972 U.S. surgeon general's report, the tobacco industry published the majority of its findings in the open scientific literature and does not appear to have perceived second-hand smoke as a threat to human health.

Many companies have succeeded in reengineering their core processes, combining related activities from different departments and cutting out ones that don't add value. Few, though, have aligned their organizations with their processes. The result is a form of cognitive dissonance as the new, integrated processes pull people in one direction and the old, fragmented management structures pull them in another. That's not the way it has to be. In recent years, forward-thinking companies like IBM, Texas Instruments, and Duke Power have begun to make the leap from process redesign to process management. They've appointed some of their best managers to be process owners, giving them real authority over work and budgets. They've shifted the focus of their measurement and compensation systems from unit goals to process goals. They've changed the way they assign and train employees, emphasizing whole processes rather than narrow tasks. They've thought carefully about the strategic trade-offs between adopting uniform processes and allowing different units to do things their own way. And they've made subtle but fundamental cultural changes, stressing teamwork and customers over turf and hierarchy. These companies are emerging from all those changes as true process enterprises--businesses whose management structures are in harmony, rather than at war, with their core processes. And their organizations are becoming much more flexible, adaptive, and responsive as a result.

If physician executives are to be effective in confronting the environmental turbulence and uncertainty facing their organizations, they must effectively manage their stakeholders. This article extends the stakeholder approach described in the May-June 1989 issue of Physician Executive as a tool for the physician executive in the development of practical strategies to cope with turbulence and uncertainty. We suggest four generic strategies physician executives can use: involve supportive stakeholders, monitor marginal stakeholders, defend against nonsupportive stakeholders, and collaborate with mixed-blessing stakeholders. As an overarching strategy, a physician executive should try to change the organization's relationships with a stakeholder from a less favorable category to a more favorable one. The stakeholder can then be managed using the generic strategy most appropriate for the category.

If physician executives are to cope with the environmental turbulence and uncertainty facing their organizations, they must effectively manage their "stakeholders." The stakeholder approach helps integrate managerial concerns that are frequently treated separately, such as strategic management, marketing, human resource management, "organizational politics," and social responsibility. The stakeholder perspective enables medical managers to relate important issues to the development of strategies for handling potentially conflicting demands for effectiveness and efficiency from various stakeholders. Medical managers should minimally satisfy the needs of marginal stakeholders while they maximally satisfy the needs of key stakeholders. To identify key stakeholders, a physician executive should critically assess each stakeholder's potential to threaten the organization and its potential to cooperate. This assessment should account for such factors as the stakeholder's relative power, the specific context and history of the organization's relations with it, the specific issues under consideration, and other key stakeholders influencing the organization.