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Background In behavioral studies of weight loss programs, participants typically receive interventions free of charge. Understanding an individuals’ willingness to pay for weight loss programs could be helpful when evaluating potential funding models. Objective To assess willingness to pay for the continuation of a weight loss program at the end of a weight loss study. Methods We assessed willingness to pay for the continuation of a weight loss program with monthly coaching contacts at the end of the two year Hopkins POWER trial. Interview administered questionnaires determined the amount participants were willing to pay for continued intervention. Estimated maximum payment was calculated among those willing to pay and was based on quantile regression adjusted for age, body mass index, race, sex, household income, treatment condition, and weight change at 24 months. Results Among the participants (N=234), 95% were willing to pay for continued weight loss intervention; the adjusted median payment was $45 per month. Blacks had a higher adjusted median willingness to pay ($65/month) compared to Non-Blacks ($45/month), p=.021. Conclusions A majority of participants were willing to pay for a continued weight loss intervention with a median monthly amount that was similar to the cost of commercial weight loss programs.

BackgroundWebsites and phone apps are increasingly used to track weights during weight loss interventions, yet the longitudinal accuracy of these self-reported weights is uncertain. ObjectiveOur goal was to compare the longitudinal accuracy of self-reported weights entered online during the course of a randomized weight loss trial to measurements taken in the clinic. We aimed to determine if accuracy of self-reported weight is associated with weight loss and to determine the extent of misclassification in achieving 5% weight loss when using self-reported compared to clinic weights. MethodsThis study examined the accuracy of self-reported weights recorded online among intervention participants in the Hopkins Practice-Based Opportunities for Weight Reduction (POWER) trial, a randomized trial examining the effectiveness of two lifestyle-based weight loss interventions compared to a control group among obese adult patients with at least one cardiovascular risk factor. One treatment group was offered telephonic coaching and the other group was offered in-person individual coaching and group sessions. All intervention participants (n=277) received a digital scale and were asked to track their weight weekly on a study website. Research staff used a standard protocol to measure weight in the clinic. Differences (self-reported weight – clinic weight) indicate if self-report under (-) or over (+) estimated clinic weight using the self-reported weight that was closest in time to the clinic weight and was within a window ranging from the day of the clinic visit to 7 days before the 6-month (n=225) and 24-month (n=191) clinic visits. The absolute value of the differences (absolute difference) describes the overall accuracy. ResultsUnderestimation of self-reported weights increased significantly from 6 months (mean -0.5kg, SD 1.0kg) to 24 months (mean -1.1kg, SD 2.0kg; P=.002). The average absolute difference also increased from 6 months (mean 0.7kg, SD 0.8kg) to 24 months (mean 1.3, SD 1.8kg; P

To investigate whether pre-existing diabetes modifies racial disparities in colorectal cancer (CRC) survival.We analyzed prospective data from 16 977 patients (age ≥ 67 years) with CRC from the Surveillance Epidemiology and End Results (SEER)-Medicare database. SEER registries included data on demographics, tumor characteristics, and treatment. Medicare claims were used to define pre-existing diabetes and comorbid conditions. Mortality was confirmed in both sources.At baseline, 1332 (8%) were African Americans and 26% had diabetes (39% in blacks; 25% in whites). From 2000 to 2005, more than half of the participants died (n = 8782, 52%). This included 820 (62%) deaths (23.8 per 100 person-years) among blacks, and 7962 (51%) deaths (16.6 per 100 person-years) among whites. Among older adults with diabetes, blacks had significantly higher risk of all-cause and CRC mortality after adjustments for demographic characteristics (hazard ratio [HR], 95% confidence interval [CI]: 1.21 [1.08-1.37] and 1.21 [1.03-1.42]), respectively, but these associations attenuated to null after additional adjustments for cancer stage and grade. Among adults without diabetes, the risk of all-cause mortality (HR [95% CI]: 1.14 [1.04-1.25]) and CRC mortality (HR [95% CI]: 1.21 [1.08-1.36]) remained higher in blacks than whites in fully adjusted models that included demographic variables, cancer stage, grade, treatments, and comorbidities.Among older adults with CRC, diabetes is an effect modifier on the relationship between race and mortality. Racial disparities in survival were explained by demographics, cancer stage, and grade in patients with diabetes.

A population from a hearing clinic in Washington County, Maryland, in 1943-1960 was followed to assess the risk of developing neoplasms from radium treatment of the nasopharynx for adenoid hypertrophy. Of the 2,925 subjects who attended the clinic, 904 received radium treatment. A nonconcurrent prospective study compared the cancer incidence among the irradiated persons with that among persons with other treatments. Seven brain tumor cases (three malignant and four benign) were identified in the irradiated group versus none in the nonirradiated group (relative risk = 14.8, 95% confidence interval: 0.76, 286.3). A nonsignificant excess risk of thyroid cancer was detected in the irradiated group based on two cases in the exposed group and one case in the nonexposed group (relative risk = 4.2, 95% confidence interval: 0.38, 46.6). Decreased risks of breast cancer, female genital cancers, and prostate cancer were observed among the irradiated individuals, although these deficits were not statistically significant individually. The decreased risk of sex hormone-related cancers in the irradiated group suggests possible radiation damage to the pituitary, with consequent reduction in pituitary hormone output and alterations in sexual and other hormonal development in early life. This hypothesis needs further evaluation.

Thrombocytopenia is common in patients with HIV infection. However, given the number of potential etiologies of low-platelet counts in this patient population, it is often difficult to determine the underlying cause. The immature platelet fraction (IPF) measures the number of reticulated platelets in peripheral blood and can be used to help determine if thrombocytopenia is secondary to low-platelet production or increased platelet turnover. We studied the performance characteristics of the IPF% in 50 inpatients with HIV-related thrombocytopenia and compared the results with 34 inpatients with HIV and normal platelet counts. The mean IPF% in the HIV thrombocytopenic group was 10.2% as compared with 6.8% in the HIV normal platelet count group (P = 0.001) and 3.1% in historical non-HIV controls (P < 0.001). In multivariate analyses, the presence of ITP, active infection, log CD4 count, platelet count, and diabetes mellitus were significantly associated with a higher IPF%. These findings suggest that increased platelet turnover plays an important role in the pathogenesis of HIV thrombocytopenia. Platelet turnover is also increased in patients with HIV in general, even when overt thrombocytopenia is absent.

Cardiovascular disease (CVD) disparities continue to have a negative impact on African Americans in the United States, largely because of uncontrolled hypertension. Despite the availability of evidence-based interventions, their use has not been translated into clinical and public health practice. The Johns Hopkins Center to Eliminate Cardiovascular Health Disparities is a new transdisciplinary research program with a stated goal to lower the impact of CVD disparities on vulnerable populations in Baltimore, Maryland. By targeting multiple levels of influence on the core problem of disparities in Baltimore, the center leverages academic, community, and national partnerships and a novel structure to support 3 research studies and to train the next generation of CVD researchers. We also share the early lessons learned in the center’s design.

BACKGROUND Previous studies found normal weight compared to overweight/obese adults with type 2 diabetes had a higher mortality risk, and body-mass index (BMI)–mortality studies do not typically account for baseline diabetes status.

Background The 2011 US Accreditation Council for Graduate Medical Education (ACGME) mandates reaffirm the need to design residency schedules to augment patient safety and minimise resident fatigue. Objectives To evaluate which elements of the residency schedule were associated with resident burnout and fatigue and whether resident burnout and fatigue were associated with lower perceived quality of patient care. Methods A cross-sectional survey of first-year medicine residents at three hospitals in May–June 2011 assessed residency schedule characteristics, including hours worked, adherence to 2003 work-hour regulations, burnout and fatigue, trainee-reported quality of care and medical errors. Results Response rate was 55/76 (72%). Forty-two of the 55 respondents (76%) met criteria for burnout and 28/55 (51%) for fatigue. After adjustment for age, gender and residency programme, an overnight call was associated with higher burnout and fatigue scores. Adherence to the 80 h working week, number of days off and leaving on time were not associated with burnout or fatigue. Residents with high burnout scores were more likely to report making errors due to excessive workload and fewer reported that the quality of care provided was satisfactory. Conclusions Burnout and fatigue were prevalent among residents in this study and associated with undesirable personal and perceived patient-care outcomes. Being on a rotation with at least 24 h of overnight call was associated with higher burnout and fatigue scores, but adherence to the 2003 ACGME work-hour requirements, including the 80 h working week, leaving on time at the end of shifts and number of days off in the previous month, was not. Residency schedule redesign should include efforts to reduce characteristics that are associated with burnout and fatigue.

Evidence indicates a positive association between liver enzymes and the risk of death in Western countries; however, the evidence in Asian populations is scarce. We investigated the association between liver enzymes and total, cardiovascular (CVD), cancer and hepatocellular carcinoma (HCC) mortality in a cohort of Taiwanese male free of cancer at baseline.From 1996 to 2003, 54,751 Taiwanese male aged 40-80 years without cancer completed a health screening and were followed through 2005 (5.8 ± 2.5 years of follow-up). A random cohort of 3,961 male was selected to compare to 1,864 male who died. We used Cox proportional hazards regression models to assess the risk of all-cause, cardiovascular and cancer mortality associated with alanine aminotransferase (ALT), aspartate aminotransferase (AST) and gamma glutamyl transferase (GGT).In this population, higher levels of ALT, AST and GGT were significantly associated with all-cause mortality [hazard ratio (HR) 1.2, 1.8 and 1.6 for ALT, AST and GGT, respectively; all p 0.05], cancer mortality (HR 1.8-2.8) and HCC mortality (HR 5.5-36.1). GGT was significantly associated with CVD mortality (HR 1.2).In Taiwanese male free of cancer at baseline, elevations of ALT, AST and GGT were associated with future risk of all-cause death, all cancer and HCC mortality, independent of conventional risk factors, and could be used to identify male who would benefit from HCC screening.

Importance Inpatient care providers often order laboratory tests without any appreciation for the costs of the tests. Objective To determine whether we could decrease the number of laboratory tests ordered by presenting providers with test fees at the time of order entry in a tertiary care hospital, without adding extra steps to the ordering process. Design Controlled clinical trial. Setting Tertiary care hospital. Participants All providers, including physicians and nonphysicians, who ordered laboratory tests through the computerized provider order entry system at The Johns Hopkins Hospital. Intervention We randomly assigned 61 diagnostic laboratory tests to an “active” arm (fee displayed) or to a control arm (fee not displayed). During a 6-month baseline period (November 10, 2008, through May 9, 2009), we did not display any fee data. During a 6-month intervention period 1 year later (November 10, 2009, through May 9, 2010), we displayed fees, based on the Medicare allowable fee, for active tests only. Main Outcome Measures We examined changes in the total number of orders placed, the frequency of ordered tests (per patient-day), and total charges associated with the orders according to the time period (baseline vs intervention period) and by study group (active test vs control). Results For the active arm tests, rates of test ordering were reduced from 3.72 tests per patient-day in the baseline period to 3.40 tests per patient-day in the intervention period (8.59% decrease; 95% CI, −8.99% to −8.19%). For control arm tests, ordering increased from 1.15 to 1.22 tests per patient-day from the baseline period to the intervention period (5.64% increase; 95% CI, 4.90% to 6.39%) (P Conclusions and Relevance Presenting fee data to providers at the time of order entry resulted in a modest decrease in test ordering. Adoption of this intervention may reduce the number of inappropriately ordered diagnostic tests.

Traditional risk factors, particularly obesity, do not completely explain the excess risk of diabetes among African Americans compared to whites.We sought to quantify the impact of recently identified, non-traditional risk factors on the racial disparity in diabetes risk.Prospective cohort study.We analyzed data from 2,322 African-American and 8,840 white participants without diabetes at baseline from the Atherosclerosis Risk in Communities (ARIC) Study.We used Cox regression to quantify the association of incident diabetes by race over 9 years of in-person and 17 years of telephone follow-up, adjusting for traditional and non-traditional risk factors based on literature search. We calculated the mediation effect of a covariate as the percent change in the coefficient of race in multivariate models without and with the covariate of interest; 95 % confidence intervals (95 % CI) were calculated using boot-strapping.African American race was independently associated with incident diabetes. Body mass index (BMI), forced vital capacity (FVC), systolic blood pressure, and serum potassium had the greatest explanatory effects for the difference in diabetes risk between races, with mediation effects (95 % CI) of 22.0 % (11.7 %, 42.2 %), 21.7 %(9.5 %, 43.1 %), 17.9 % (10.2 %, 37.4 %) and 17.7 % (8.2 %, 39.4 %), respectively, during 9 years of in-person follow-up, with continued effect over 17 years of telephone follow-up.Non-traditional risk factors, particularly FVC and serum potassium, are potential mediators of the association between race and diabetes risk. They should be studied further to verify their importance and to determine if they mark causal relationships that can be addressed to reduce the racial disparity in diabetes risk.

To evaluate effects of two behavioral weight-loss interventions (in-person, remote) on health-related quality of life (HRQOL) compared to a control intervention. Four hundred and fifty-one obese US adults with at least one cardiovascular risk factor completed five measures of HRQOL and depression: MOS SF-12 physical component summary (PCS) and mental component summary; EuroQoL-5 dimensions single index and visual analog scale; PHQ-8 depression symptoms; and PSQI sleep quality scores at baseline and 6 and 24 months after randomization. Change in each outcome was analyzed using outcome-specific mixed-effects models controlling for participant demographic characteristics. PCS-12 scores over 24 months improved more among participants in the in-person active intervention arm than among control arm participants (P

Increasing the use of electronic medical records (EMR) has been suggested as an important strategy for improving healthcare safety.To sequentially measure, evaluate, and respond to safety culture and practice safety concerns following EMR implementation.Safety culture was assessed using a validated tool (Safety Attitudes Questionnaire; SAQ), immediately following EMR implementation (T1) and at 1.5 (T2) and 2.5 (T3) years post-implementation. The SAQ was supplemented with a practice-specific assessment tool to identify safety needs and barriers.A large medical group practice with a primary care core of 17-18 practices, staffed by clinicians in family medicine, pediatrics, internal medicine.Survey results were used to define and respond to areas of need between assessments with system changes and educational programs.Change in safety culture over time; perceived impact of EMR on practice.Responses were received from 103 of 123 primary care providers in T1 (83.7 % response rate), 122 of 143 in T2 (85.3 %) and 142 of 181 in T3 (78.5 %). Safety culture improved over this period, with statistically significant improvement in all domains except for stress recognition. Time constraints, communications and patient adherence were perceived to be the most important safety issues. The majority of respondents in both T2 (77.9 %) and T3 (85.4 %) surveys agreed that the EMR improved their ability to provide care more safely.Implementation of an EMR in a large primary care practice required redesign of many organizational processes, and was associated with improvements in safety culture. Most primary care providers agreed that the EMR allowed them to provide care more safely.

Background: Increased intake of fruits and vegetables (F/V) may protect against adiposity, but effects on weight have been inconsistent. Our objective was to examine the relationship between fruit and vegetable intake and weight, using direct and indirect measures of dietary intake: self-reported 24-hour recall and serum carotenoid levels. Methods: Participants from the PREMIER lifestyle intervention trial were included in this analysis (n=554). Dietary measures included 24-hour dietary recalls and serum carotenoid levels, from a fasting blood sample. The outcome was weight in pounds. Nested linear mixed models were used to examine the association between F/V and weight. Results: Mean F/V increased from 4.6 (SD 2.4) to 5.6 (SD 3.2) (p= Conclusions: Greater fruit and vegetable consumption was associated with decreased body weight. Results were consistent for both objective and self-reported measures of fruit and vegetable intake.

Background Trials that attempt to increase fruit and vegetable (F/V) intake commonly rely on self-reported dietary intake data that are prone to bias. Our primary objective was to assess the magnitude of the effect of a dietary intervention on F/V consumption, using two different measures: serum carotenoids and 24-hour dietary recall. A secondary goal was to explore the use of serum carotenoid levels as an indicator of F/V consumption. Methods Three intervention groups in the PREMIER trial (n=554) consisted of an Advice Only control group, an Established group that received counseling on weight loss, physical activity and sodium reduction (but no advice on F/V intake), and an Established +DASH group that also received counseling on the DASH diet (with advice to increase F/V intake). Self-reported F/V consumption was measured via two 24-hour dietary recalls administered at baseline, 6- and 18-months. Serum carotenoids were collected via fasting blood samples at each time point. Linear mixed models were used to examine the relationship between intervention assignment and F/V consumption. Pearson correlation and ROC curves informed the secondary objective. Results Compared to the control group, F/V consumption was highest in the Established+DASH group measured by recall (2.95 servings greater, 95% CI 2.43 to 3.47) and serum carotenoids (20.51 ug/dl greater, 95% CI 12.72 to 28.29). However, only 34% (57/167) of the Established+DASH group met the recommended level of 9 servings of F/V per day at 6 months. F/V intake and serum carotenoid levels were similarly and modestly correlated across each time point, ranging from .34 to .42. ROC curves indicated poor or fair performance of carotenoids as indicators of adequate F/V consumption. The area under the curve (AUC) was .692 for 5 servings of F/V, and .697 for 9 servings. Conclusions The PREMIER dietary intervention was successful in increasing F/V consumption as measured by serum carotenoids or self-report, but only a minority of study participants achieved recommended levels. Table 1. Mean fruit and vegetable consumption over study duration, by intervention assignment Intervention Assignment Advice Only (n 1 =186) Established (n=185) Established +DASH (n=183) p-value 2 24-Hour Recall (servings/day: mean, SD) 18 months 4.6 (2.7) 4.8 (2.5) 7.5 (3.5) Total Carotenoid Levels 3 (ug/dl: mean, SD) 18 months 61.1 (37.0) 63.8 (38.3) 79.8 (49.2) Total Carotenoid Levels+Lycopene, (ug/dl: mean, SD) 18 months 85.4 (41.3) 85.3 (40.1) 102.3 (51.4) 1 Sample sizes are from baseline visit 2 P-values correspond to difference in mean values across intervention groups 3 Total carotenoids defined as the sum of -carotene, -carotene, -cryptoxanthin and lutein/zeaxanthin

Background Online medical education curricula offer new tools to teach and evaluate learners. The effect on educational outcomes of using learner feedback to guide curricular revision for online learning is unknown. Methods In this study, qualitative analysis of learner feedback gathered from an online curriculum was used to identify themes of learner feedback, and changes to the online curriculum in response to this feedback were tracked. Learner satisfaction and knowledge gains were then compared from before and after implementation of learner feedback. Results 37,755 learners from 122 internal medicine residency training programs were studied, including 9437 postgraduate year (PGY)1 residents (24.4 % of learners), 9864 PGY2 residents (25.5 %), 9653 PGY3 residents (25.0 %), and 6605 attending physicians (17.0 %). Qualitative analysis of learner feedback on how to improve the curriculum showed that learners commented most on the overall quality of the educational content, followed by specific comments on the content. When learner feedback was incorporated into curricular revision, learner satisfaction with the instructive value of the curriculum (1 = not instructive; 5 = highly instructive) increased from 3.8 to 4.1 (p Conclusions Learners give more feedback on the factual content of a curriculum than on other areas such as interactivity or website design. Incorporating learner feedback into curricular revision was associated with improved educational outcomes. Online curricula should be designed to include a mechanism for learner feedback and that feedback should be used for future curricular revision.

A review of 223 reports of case-control studies carried out in 34 countries and published in 25 journals during 1992 is the basis for an analysis of methods currently used to measure exposure in such studies. 58.6% of the studies concerned cancer with reproductive infectious and cardiovascular diseases accounting for 5.3% to 11.5%. 67.4% of the studies were based on surveys and another 15.7% also employed biomonitoring environmental measurement medical records or other sources. The prevalence of surveys reflects the relative ease of data collection degree of detail possible and flexibility of administration in face to face interviews telephone interviews or self-administered questionnaires. Permanent registers of information on individuals or environmental contamination and occupational exposure are relatively seldom used despite their potentially rich prospective data. Almost all of the surveys indicated whether the subject or another person supplied the information. Most reports indicated whether the interview was face to face by telephone or another type but few offered information on relevant interview techniques used. There was often detailed information on the intensity of exposure but little on the duration or period of exposure despite the potential significance of this data. The published reports often lacked documentation concerning the degree of standardization of methods of data collection and the quality of exposure measurements. Exposures vary in form origin intensity and duration for each subject. Variations should be measured because of their potential relevance to the risk of disease. But the limited number of studies that provided detailed information on exposure measurement suggests that the full potential of the questionnaire as a measurement tool has not been realized. The scarcity of information concerning the quality of exposure data demonstrates the need for research on ways to improve measurement.

OBJECTIVE To quantify the association of treated diabetes with cancer incidence and cancer mortality as well as cancer case fatality and all-cause mortality in adults who subsequently develop cancer and to calculate attributable fractions due to diabetes on various cancer outcomes. RESEARCH DESIGN AND METHODS Prospective data on 599 diabetic and 17,681 nondiabetic adults from the CLUE II (Give Us a Clue to Cancer and Heart Disease) cohort in Washington County, Maryland, were analyzed. Diabetes was defined by self-reported use of diabetes medications at baseline. Cancer incidence was ascertained using county and state cancer registries. Mortality data were obtained from death certificates. RESULTS From 1989 to 2006, 116 diabetic and 2,365 nondiabetic adults developed cancer, corresponding to age-adjusted incidence of 13.25 and 10.58 per 1,000 person-years, respectively. Adjusting for age, sex, education, BMI, smoking, hypertension treatment, and high cholesterol treatment using Cox proportional hazards regression, diabetes was associated with a higher risk of incident cancer (hazard ratio 1.22 [95% CI 0.98–1.53]) and cancer mortality (1.36 [1.02–1.81]). In individuals who developed cancer, adults with diabetes had a higher risk of cancer case fatality (1.34 [1.002–1.79]) and all-cause mortality (1.61 [1.29–2.01]). For colorectal, breast, and prostate cancers, the attributable fractions resulting from diabetes were larger for cancer fatality and mortality than cancer incidence. CONCLUSIONS In this prospective cohort, diabetes appears to exert a greater influence downstream on the risk of mortality in people with cancer than on upstream risk of incident cancer.

Obesity and its cardiovascular complications are extremely common medical problems, but evidence on how to accomplish weight loss in clinical practice is sparse.We conducted a randomized, controlled trial to examine the effects of two behavioral weight-loss interventions in 415 obese patients with at least one cardiovascular risk factor. Participants were recruited from six primary care practices; 63.6% were women, 41.0% were black, and the mean age was 54.0 years. One intervention provided patients with weight-loss support remotely--through the telephone, a study-specific Web site, and e-mail. The other intervention provided in-person support during group and individual sessions, along with the three remote means of support. There was also a control group in which weight loss was self-directed. Outcomes were compared between each intervention group and the control group and between the two intervention groups. For both interventions, primary care providers reinforced participation at routinely scheduled visits. The trial duration was 24 months.At baseline, the mean body-mass index (the weight in kilograms divided by the square of the height in meters) for all participants was 36.6, and the mean weight was 103.8 kg. At 24 months, the mean change in weight from baseline was -0.8 kg in the control group, -4.6 kg in the group receiving remote support only (P0.001 for the comparison with the control group), and -5.1 kg in the group receiving in-person support (P0.001 for the comparison with the control group). The percentage of participants who lost 5% or more of their initial weight was 18.8% in the control group, 38.2% in the group receiving remote support only, and 41.4% in the group receiving in-person support. The change in weight from baseline did not differ significantly between the two intervention groups.In two behavioral interventions, one delivered with in-person support and the other delivered remotely, without face-to-face contact between participants and weight-loss coaches, obese patients achieved and sustained clinically significant weight loss over a period of 24 months. (Funded by the National Heart, Lung, and Blood Institute and others; ClinicalTrials.gov number, NCT00783315.).

The rising incidence and prevalence of Type 2 diabetes worldwide requires us to try to identify the determinants of this epidemic and to identify improved measures to prevent and treat this condition. While obesity is a major risk factor for diabetes, there are other risk factors that could potentially be corrected more easily. Potassium, both serum levels and to a lesser extent dietary intake levels, has been associated with incident diabetes. Lower levels of potassium have been found to be associated with a higher risk of diabetes in some studies. This article will review the literature available describing these associations and will help to identify where further research is needed.

To determine whether medical students and faculty perceive differences in the effectiveness of interactions with real patients versus simulated patients (SPs) in communication skills training.In 2008, the authors recruited volunteer outpatients (VOs) from the Johns Hopkins University School of Medicine internal medicine practice to participate in communication skills training for all first-year medical students. VOs and SPs were assigned to clinic rooms in the simulation center. Each group of five students and its preceptor rotated through randomly assigned rooms on two of four session days; on both days, each student interviewed one patient for 15 minutes, focusing on past medical and family history or social history. Patients used their own histories, not scripts; students were not blinded to patient type. Students and faculty then rated aspects of the interview experience. Generalized linear latent and mixed-models analysis was used to compare ratings of communication skills training with VOs versus SPs.All 121 first-year students participated in 242 interviews, resulting in 237 usable questionnaires (98%). They rated their experiences with VOs significantly higher than those with SPs on comfort, friendliness, amount of learning, opportunity to build relationships, and overall meeting of communication skills training needs. The 24 faculty preceptors' ratings of the 242 interactions did not differ significantly between VOs and SPs.Use of VOs was well received by students and faculty for teaching communication skills. Expanding and further studying VOs' participation will allow greater understanding of their potential role in communication skills training of preclinical medical students.

BACKGROUND: Low serum potassium appears to be independently associated with incident type 2 diabetes, and low dietary potassium is more common in African Americans than in whites. OBJECTIVE: We hypothesized that low serum potassium contributes to the excess risk of diabetes in African Americans. DESIGN: We analyzed data collected from 1987 to 1996 from the Atherosclerosis Risk in Communities (ARIC) Study. At baseline, we identified 2716 African American and 9493 white participants without diabetes. We used multivariate Cox models to estimate the relative hazards (RHs) of incident diabetes related to baseline serum potassium during 9 y of follow-up. RESULTS: Mean serum potassium concentrations were lower in African Americans than in whites at baseline (4.2 compared with 4.5 mEq/L; P < 0.01), and African Americans had a greater incidence of diabetes than did whites (26 compared with 13 cases/1000 person-years). The adjusted RHs (95% CI) of incident diabetes for those with serum potassium concentrations of

Background Serum potassium levels affect insulin secretion by pancreatic β-cells, and hypokalemia associated with diuretic use has been associated with dysglycemia. We hypothesized that adults with lower serum potassium levels and lower dietary potassium intake are at higher risk for incident diabetes mellitus (DM), independent of diuretic use. Methods We analyzed data from 12 209 participants from the Atherosclerosis Risk in Communities (ARIC) Study, an ongoing prospective cohort study, beginning in 1986, with 9 years of in-person follow-up and 17 years of telephone follow-up. Using multivariate Cox proportional hazard models, we estimated the hazard ratio (HR) of incident DM associated with baseline serum potassium levels. Results During 9 years of in-person follow-up, 1475 participants developed incident DM. In multivariate analyses, we found an inverse association between serum potassium and risk of incident DM. Compared with those with a high-normal serum potassium level (5.0-5.5 mEq/L), adults with serum potassium levels lower than 4.0 mEq/L, 4.0 to lower than 4.5 mEq/L, and 4.5 to lower than 5.0 mEq/L had an adjusted HR (95% confidence interval [CI]) of incident DM of 1.64 (95% CI, 1.29-2.08), 1.64 (95% CI, 1.34-2.01), and 1.39 (95% CI, 1.14-1.71), respectively. An increased risk persisted during an additional 8 years of telephone follow-up based on self-report with HRs of 1.2 to 1.3 for those with a serum potassium level lower than 5.0 mEq/L. Dietary potassium intake was significantly associated with risk of incident DM in unadjusted models but not in multivariate models. Conclusions Serum potassium level is an independent predictor of incident DM in this cohort. Further study is needed to determine if modification of serum potassium could reduce the subsequent risk of DM.

Background The National Heart, Lung, and Blood Institute (NHLBI) funded three institutions to conduct effectiveness trials of weight loss interventions in primary care settings. Unlike traditional multi-center clinical trials, each study was established as an independent trial with a distinct protocol. Still, efforts were made to coordinate and standardize several aspects of the trials. The three trials formed a collaborative group, the ‘Practice-based Opportunities for Weight Reduction (POWER) Trials Collaborative Research Group.’ Purpose We describe the common and distinct features of the three trials, the key characteristics of the collaborative group, and the lessons learned from this novel organizational approach. Methods The Collaborative Research Group consists of three individual studies: ‘Be Fit, Be Well’ (Washington University in St. Louis/Harvard University), ‘POWER Hopkins’ (Johns Hopkins), and ‘POWER-UP’ (University of Pennsylvania). There are a total of 15 participating clinics with ~1100 participants. The common primary outcome is change in weight at 24 months of follow-up, but each protocol has trial-specific elements including different interventions and different secondary outcomes. A Resource Coordinating Unit at Johns Hopkins provides administrative support. Results The Collaborative Research Group established common components to facilitate potential cross-site comparisons. The main advantage of this approach is to develop and evaluate several interventions, when there is insufficient evidence to test one or two approaches, as would be done in a traditional multi-center trial. Limitations The challenges of the organizational design include the complex decision-making process, the extent of potential data pooling, time intensive efforts to standardize reports, and the additional responsibilities of the DSMB to monitor three distinct protocols.

To summarize the influence of pre-existing diabetes on mortality and morbidity in men with prostate cancer. We searched MEDLINE and EMBASE from inception through 1 October 2008. Search terms were related to diabetes, cancer and prognosis. Studies were included if they reported an original data analysis of prostate cancer prognosis, compared outcomes between men with and without diabetes and were in English. Titles, abstracts and articles were reviewed independently by two authors. Conflicts were settled by consensus or third review. We abstracted data on study design, analytic methods, outcomes and quality. We summarized mortality and morbidity outcomes qualitatively and conducted a preliminary meta-analysis to quantify the risk of long-term (>3 months), overall mortality. In total, 11 articles were included in the review. Overall, one of four studies found increased prostate cancer mortality, one of two studies found increased nonprostate cancer mortality and one study found increased 30-day mortality. Data from four studies could be included in a preliminary meta-analysis for long-term, overall mortality and produced a pooled hazard ratio of 1.57 (95% CI: 1.12-2.20). Diabetes was also associated with receiving radiation therapy, complication rates, recurrence and treatment failure. Our analysis suggests that pre-existing diabetes affects the treatment and outcomes of men with prostate cancer.

Background: Cigarette smoking is an established predictor of incident type 2 diabetes mellitus, but the effects of smoking cessation on diabetes risk are unknown. Objective: To test the hypothesis that smoking cessation increases diabetes risk in the short term, possibly owing to cessation-related weight gain. Design: Prospective cohort study. Setting: The ARIC (Atherosclerosis Risk in Communities) Study. Patients: 10 892 middle-aged adults who initially did not have diabetes in 1987 to 1989. Measurements: Smoking was assessed by interview at baseline and at subsequent follow-up. Incident diabetes was ascertained by fasting glucose assays through 1998 and self-report of physician diagnosis or use of diabetes medications through 2004. Results: During 9 years of follow-up, 1254 adults developed type 2 diabetes. Compared with adults who never smoked, the adjusted hazard ratio of incident diabetes in the highest tertile of pack-years was 1.42 (95% CI, 1.20 to 1.67). In the first 3 years of follow-up, 380 adults quit smoking. After adjustment for age, race, sex, education, adiposity, physical activity, lipid levels, blood pressure, and ARIC Study center, compared with adults who never smoked, the hazard ratios of diabetes among former smokers, new quitters, and continuing smokers were 1.22 (CI, 0.99 to 1.50), 1.73 (CI, 1.19 to 2.53), and 1.31 (CI, 1.04 to 1.65), respectively. Further adjustment for weight change and leukocyte count attenuated these risks substantially. In an analysis of long-term risk after quitting, the highest risk occurred in the first 3 years (hazard ratio, 1.91 [CI, 1.19 to 3.05]), then gradually decreased to 0 at 12 years. Limitation: Residual confounding is possible even with meticulous adjustment for established diabetes risk factors. Conclusion: Cigarette smoking predicts incident type 2 diabetes, but smoking cessation leads to higher short-term risk. For smokers at risk for diabetes, smoking cessation should be coupled with strategies for diabetes prevention and early detection. Primary Funding Source: National Heart, Lung, and Blood Institute and National Institute of Diabetes and Digestive and Kidney Diseases.

Diabetes mellitus increases the risk of incident colorectal cancer, but it is less clear if pre-existing diabetes mellitus influences mortality outcomes, recurrence risk, and/or treatment-related complications in persons with colorectal cancer.We performed a systematic review and meta-analysis comparing colorectal cancer mortality outcomes, cancer recurrence, and treatment-related complications in persons with and without diabetes mellitus. We searched MEDLINE and EMBASE through October 1, 2008, including hand-searching references of qualifying articles. We included studies in English that evaluated diabetes mellitus and cancer treatment outcomes, prognosis, and/or mortality. The initial search identified 8,208 titles, of which 15 articles met inclusion criteria. Each article was abstracted by one author using a standardized form and re-reviewed by another author for accuracy. Authors graded quality based on pre-determined criteria.We found significantly increased short-term perioperative mortality in persons with diabetes mellitus. In the meta-analysis of long-term mortality, persons with diabetes mellitus had a 32% increase in all-cause mortality compared to those without diabetes mellitus (95% CI: 1.24, 1.41). Although data on other outcomes are limited, available studies suggest that pre-existing diabetes mellitus predicts increased risk of some post-operative complications as well as 5-year cancer recurrence. In contrast, there is little evidence that diabetes confers increased risk for long-term cancer-specific mortality.Patients with colorectal cancer and pre-existing diabetes mellitus have an increased risk of short- and long-term mortality. Future research should determine whether improvements in prevention and treatment of diabetes mellitus will improve outcomes for colorectal cancer patients.

Context Diabetes mellitus appears to be a risk factor for some cancers, but the effect of preexisting diabetes on all-cause mortality in newly diagnosed cancer patients is less clear. Objective To perform a systematic review and meta-analysis comparing overall survival in cancer patients with and without preexisting diabetes. Data Sources We searched MEDLINE and EMBASE through May 15, 2008, including references of qualifying articles. Study Selection English-language, original investigations in humans with at least 3 months of follow-up were included. Titles, abstracts, and articles were reviewed by at least 2 independent readers. Of 7858 titles identified in our original search, 48 articles met our criteria. Data Extraction One reviewer performed a full abstraction and other reviewers verified accuracy. We contacted authors and obtained additional information for 3 articles with insufficient reported data. Results Studies reporting cumulative survival rates were summarized qualitatively. Studies reporting Cox proportional hazard ratios (HRs) or Poisson relative risks were combined in a meta-analysis. A random-effects model meta-analysis of 23 articles showed that diabetes was associated with an increased mortality HR of 1.41 (95% confidence interval [CI], 1.28-1.55) compared with normoglycemic individuals across all cancer types. Subgroup analyses by type of cancer showed increased risk for cancers of the endometrium (HR, 1.76; 95% CI, 1.34-2.31), breast (HR, 1.61; 95% CI, 1.46-1.78), and colorectum (HR, 1.32; 95% CI, 1.24-1.41). Conclusions Patients diagnosed with cancer who have preexisting diabetes are at increased risk for long-term, all-cause mortality compared with those without diabetes.

Background A wide variety of oral diabetes medications are currently available for the treatment of type 2 diabetes mellitus, but it is unclear how these agents compare with respect to long-term cardiovascular risk. Our objective was to systematically examine the peer-reviewed literature on the cardiovascular risk associated with oral agents (second-generation sulfonylureas, biguanides, thiazolidinediones, and meglitinides) for treating adults with type 2 diabetes. Methods We searched MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials, from inception through January 19, 2006. Forty publications of controlled trials that reported information on cardiovascular events (primarily myocardial infarction and stroke) met our inclusion criteria. Using standardized protocols, 2 reviewers serially abstracted data from each article. Trials were first described qualitatively. For comparisons with 4 or more independent trials, results were pooled quantitatively using the Mantel-Haenszel method. Results are presented as odds ratios (ORs) and corresponding 95% confidence intervals (CIs). Results Treatment with metformin hydrochloride was associated with a decreased risk of cardiovascular mortality (pooled OR, 0.74; 95% CI, 0.62-0.89) compared with any other oral diabetes agent or placebo; the results for cardiovascular morbidity and all-cause mortality were similar but not statistically significant. No other significant associations of oral diabetes agents with fatal or nonfatal cardiovascular disease or all-cause mortality were observed. When compared with any other agent or placebo, rosiglitazone was the only diabetes agent associated with an increased risk of cardiovascular morbidity or mortality, but this result was not statistically significant (OR, 1.68; 95% CI, 0.92-3.06). Conclusions Meta-analysis suggested that, compared with other oral diabetes agents and placebo, metformin was moderately protective and rosiglitazone possibly harmful, but lack of power prohibited firmer conclusions. Larger, long-term studies taken to hard end points and better reporting of cardiovascular events in short-term studies will be required to draw firm conclusions about major clinical benefits and risks related to oral diabetes agents.

Low birthweight is associated with increased risk of hypertension, but underlying mechanisms are obscure. We hypothesized structural microvascular alterations may be one such mechanism. We examined the association of birthweight and retinal arteriolar caliber in 3800 persons aged 51 to 72 years participating in a population-based study in 4 US communities (the Atherosclerosis Risk in Communities study). Participants reported full-term birth and their birthweight and had retinal photography. Retinal arteriolar and venular calibers were measured from digitized retinal photographs using a validated computer-assisted method. Lower birthweight was associated with narrower retinal arteriolar caliber, with each kg lower birthweight associated with 2.4 μm (95% confidence intervals, 1.3 to 3.5, P P

OBJECTIVE—Although tight blood pressure (BP) control is proven to reduce diabetes-related cardiovascular risk, it has been difficult to achieve in practice, perhaps in part because of low-quality monitoring data. We hypothesized that low-quality BP data, reflected in end-digit preference (EDP), remains common in primary care of diabetic adults. RESEARCH DESIGN AND METHODS—Data were abstracted from the charts of 404 adults with type 2 diabetes seen at 16 academically affiliated clinics from 1999 to 2001. End-digits of systolic and diastolic BPs taken with nonautomated sphygmomanometers were extracted, and prevalence of EDP for zero was calculated. Associations between EDP and selected patient characteristics were determined using multiple logistic regressions. RESULTS—EDP was highly prevalent in the BP measurements taken by nonphysicians (4,333 BPs; 50% of systolic, 50% of diastolic readings ended in zero; P < 0.001) and physicians (1,347 BPs; 69% of systolic, 64% of diastolic readings ended in zero; P < 0.001). In multivariate analysis, nonphysicians showed greater EDP for systolic BP in older patients (odds ratio [OR] 1.07 per 5 years) and women (OR 1.36 vs. men) and for diastolic BP in African-Americans (OR 1.25 vs. whites; all P < 0.05); physicians showed greater EDP for diastolic BP in less obese patients (OR 0.97 per 5 kg/m2 increment in BMI; P = 0.02). CONCLUSIONS—Low-quality BP measurement is common in primary care of diabetic adults. Procedural and technological improvements to BP measurement deserve attention as part of an overall strategy to tighten BP control and reduce cardiovascular risk.

Although tight blood pressure control is crucial in reducing vascular complications of diabetes, primary care providers often fail to appropriately intensify antihypertensive medications.To identify novel visit-based factors associated with intensification of antihypertensive medications in adults with diabetes.Non-concurrent prospective cohort study.A total of 254 patients with type 2 diabetes and hypertension enrolled in an academically affiliated managed care program. Over a 24-month interval (1999-2001), we identified 1,374 visits at which blood pressure was suboptimally controlled (systolic BP/= 140 mmHg or diastolic BP/= 90 mmHg).Intensification of antihypertensive medications at each visit was the primary outcome. Primary care providers intensified antihypertensive treatment in only 176 (13%) of 1,374 visits at which blood pressure was elevated. As expected, higher mean systolic and mean diastolic blood pressures were important predictors of intensification. Treatment was also more likely to be intensified at visits that were "routine" odds ratio (OR) 2.08; 95% Confidence Interval [95% CI] 1.36-3.18), or that paired patients with their usual primary care provider (OR 1.84; 95% CI 1.11-3.06). In contrast, several factors were associated with failure to intensify treatment, including capillary glucose150 mg/dL (OR 0.54; 95% CI 0.31-0.94) and the presence of coronary heart disease (OR 0.61; 95% CI 0.38-0.95). Co-management by a cardiologist accounted partly for this failure (OR 0.65; 95% CI 0.41-1.03).Failure to appropriately intensify antihypertensive treatment is common in diabetes care. Clinical distractions and shortcomings in continuity and coordination of care are possible targets for improvement.

Given new technologies in insulin delivery and glucose monitoring, clinicians are now faced with determining which patient populations benefit most from the use of continuous subcutaneous insulin infusion with a pump and/or real-time continuous glucose monitoring (rt-CGM). A previous systematic review identified important gaps in the evidence on the effectiveness of insulin delivery and glucose monitoring methods.1,2 We sought to elucidate the highest-priority questions to focus future research endeavors. We adapted the Delphi method via a seven-step, four-phase process for consensus building.3 Following suggestions from a previous report,4 we identified and invited 14 experts to serve as expert stakeholders until we had at least 5 stakeholders who were able to participate in the consensus-building process. The final five-member stakeholder panel included one academic pediatric endocrinologist, three adult endocrinologists, and one patient with type 1 diabetes mellitus for more than 50 years. Stakeholders were asked to rate high priorities for future research on potential populations (children, adolescents, adult, or elderly), insulin delivery (continuous subcutaneous insulin infusion, reactive low glucose suspend pump, artificial pancreas, or sensor-augmented insulin pump), glucose monitoring methods (self-monitoring of blood glucose, retrospective continuous glucose monitoring, or rt-CGM), and outcomes [hemoglobin A1c (HbA1c), adherence, nonsevere hypoglycemia, severe hypoglycemia, hyperglycemia, or weight gain] based on the 2012 evidence report.1,2 In the final assessment of the panel, all five stakeholders agreed that rt-CGM was the highest priority for research on glucose monitoring methods for type 1 diabetes, while the majority agreed that the artificial pancreas was the highest priority for research on insulin delivery methods for type 1 diabetes. The majority of the panel also agreed that adolescents were the highest-priority age group for such research. The highest-priority outcomes were adherence for the younger population and severe hypoglycemia for adults and elderly. For insulin-requiring type 2 diabetes, the majority of the panel agreed that rt-CGM was the highest priority for future research on glucose monitoring methods and that the sensor-augmented insulin pump was the highest priority for research on insulin delivery methods. The majority also agreed that adults were the highest-priority age group and that HbA1c was the highest-priority outcome. Based on stakeholders’ judgments regarding populations, interventions, comparisons, and outcomes of interest, four research questions were identified as high priorities for future research (Table 1). Complete details are in the full report.5 Table 1. High Priorities for Future Research on Insulin Delivery and Glucose Monitoring Methods Our consensus-building exercise had limitations. First, stakeholders did not independently identify research gaps on the basis of populations, interventions, and outcomes but rather by the limited options that we provided according to our analytic framework.1 Second, due to the abundance of outcomes gaps in the literature, it was prohibitive to present all potential outcomes to the stakeholders for prioritization. Long-term clinical outcomes were not specifically included for prioritization by the stakeholders. While prevention of long-term macrovascular and microvascular complications is the ultimate goal of interventions for type 1 and type 2 diabetes, such trials would need an extremely long time for follow-up. Third, our small group may not be representative of all those who have a stake in research on insulin delivery and glucose monitoring. Nevertheless, in the absence of a large survey of stakeholders, our efficient consensus-building exercise helps to identify specific priorities for future research that should be pursued.

The goal of this study was to determine whether depressive symptoms predict type 2 diabetes.We analyzed data on depressive symptoms (including recent fatigue, sleep disturbance, feelings of hopelessness, loss of libido, and increased irritability) in a longitudinal, biracial cohort study of 11,615 initially nondiabetic adults aged 48-67 years, who were subsequently followed for 6 years for the development of type 2 diabetes.At baseline, depressive symptoms were positively associated with BMI, fasting insulin, systolic blood pressure, caloric intake, physical inactivity, and current smoking (all P0.05). In prospective analyses, after adjusting for age, race, sex, and education, individuals in the highest quartile of depressive symptoms had a 63% increased risk of developing diabetes compared with those in the lowest quartile (relative hazard [RH] 1.63, 95% CI 1.31-2.02). This relation persisted after adjustment for stress-associated lifestyle factors (smoking, physical activity, caloric intake, and adiposity) (1.28, 1.02-1.60) and metabolic covariates (fasting insulin and glucose, lipids, blood pressure, and adiposity) (1.38, 1.10-1.73).In this cohort, depressive symptoms predicted incident type 2 diabetes. This relation is only partially explained by demographic, metabolic, and lifestyle factors. Possible neuroendocrine mediators of the stress-obesity-diabetes relationship require further evaluation in prospective cohort studies that use an established tool to assess depression and incorporate neurohormonal measurements.

The objective of the study was to determine the effectiveness and cost-effectiveness of primary care and community-oriented interventions in managing HbA1c, blood pressure, and lipids, and reducing hospitalizations and emergency room visits over 2 years. We describe an ongoing, randomized controlled trial of 542 urban African-Americans with type 2 diabetes ages 25 years and older who are members of a university-affiliated managed-care organization in Baltimore, MD. The participants are 74% female, have a mean age of 58 years, and 35% have yearly incomes greater than 7500 US dollars. Participants were randomized to one of two intervention groups for a period of 2 years: (1) usual medical care plus minimal telephone intervention implemented by a trained lay health educator (control group) or (2) usual medical care plus intensive intervention implemented by a nurse case manager (NCM)/community health worker (CHW) team. The intensive NCM/CHW team executes individual plans of care using evidence-based algorithms that focus on traditional diabetes self-management, screening and management of diabetes-related complications, and social issues surrounding diabetes care. Face-to-face NCM visits are conducted in the clinic once per year and CHW visits are conducted in the participant's home one to three times per year, both with additional follow-up contacts as needed. Written and verbal feedback (when necessary) is provided to the participant's primary care physician. All participants are expected to attend a 24-month follow-up visit where data are collected by interviewers blinded to intervention assignment. As of May 1, 2003, recruitment is complete, interventions are being fully implemented, and 24-month follow-up visits are beginning. Baseline sociodemographic characteristics, health-care utilization, health behaviors, and clinical characteristics of the study population are reported. This study is designed to test the hypothesis that a primary-care-based NCM plus CHW team approach is an effective, practical, and economically feasible strategy for translating current knowledge about type 2 diabetes into high-quality health care for urban African-Americans.

Background Patients with chronic kidney disease (CKD) have high prevalence of elevated serum troponin levels, which makes diagnosis of acute coronary syndrome (ACS) challenging. Purpose To evaluate the utility of troponin in ACS diagnosis, treatment, and prognosis among patients with CKD. Data sources MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials through May 2014. Study selection Studies examining elevated versus normal troponin levels in terms of their diagnostic performance in detection of ACS, effect on ACS management strategies, and prognostic value for mortality or cardiovascular events after ACS among patients with CKD. Data extraction Paired reviewers selected articles for inclusion, extracted data, and graded strength of evidence (SOE). Data synthesis Twenty-three studies met inclusion criteria. The sensitivity of troponin T for ACS diagnosis ranged from 71% to 100%, and specificity ranged from 31% to 86% (6 studies; low SOE). The sensitivity and specificity of troponin I ranged from 43% to 94% and from 48% to 100%, respectively (8 studies; low SOE). No studies examined how troponin levels affect management strategies. Twelve studies analyzed prognostic value. Elevated levels of troponin I or troponin T were associated with higher risk for short-term death and cardiac events (low SOE). A similar trend was observed for long-term mortality with troponin I (low SOE), but less evidence was found for long-term cardiac events for troponin I and long-term outcomes for troponin T (insufficient SOE). Patients with advanced CKD tended to have worse prognoses with elevated troponin I levels than those without them (moderate SOE). Limitation Studies were heterogeneous in design and in ACS definitions and adjudication methods. Conclusion In patients with CKD and suspected ACS, troponin levels can aid in identifying those with a poor prognosis, but the diagnostic utility is limited by varying estimates of sensitivity and specificity. Primary funding source Agency for Healthcare Research and Quality.

Importance On July 1, 2011, the Accreditation Council for Graduate Medical Education implemented further restrictions of its 2003 regulations on duty hours and supervision. It remains unclear if the 2003 regulations improved trainee well-being or patient safety. Objective To determine the effects of the 2011 Accreditation Council for Graduate Medical Education duty hour regulations compared with the 2003 regulations concerning sleep duration, trainee education, continuity of patient care, and perceived quality of care among internal medicine trainees. Design and Setting Crossover study design in an academic research setting. Participants Medical house staff. Intervention General medical teams were randomly assigned using a sealed-envelope draw to an experimental model or a control model. Main Outcome Measures We randomly assigned 4 medical house staff teams (43 interns) using a 3-month crossover design to a 2003-compliant model of every fourth night overnight call (control) with 30-hour duty limits or to one of two 2011-compliant models of every fifth night overnight call (Q5) or a night float schedule (NF), both with 16-hour duty limits. We measured sleep duration using actigraphy and used admission volumes, educational opportunities, the number of handoffs, and satisfaction surveys to assess trainee education, continuity of patient care, and perceived quality of care. Results The study included 560 control, 420 Q5, and 140 NF days that interns worked and 834 hospital admissions. Compared with controls, interns on NF slept longer during the on call period (mean, 5.1 vs 8.3 hours; P = .003), and interns on Q5 slept longer during the postcall period (mean, 7.5 vs 10.2 hours; P = .05). However, both the Q5 and NF models increased handoffs, decreased availability for teaching conferences, and reduced intern presence during daytime work hours. Residents and nurses in both experimental models perceived reduced quality of care, so much so with NF that it was terminated early. Conclusions and Relevance Compared with a 2003-compliant model, two 2011 duty hour regulation–compliant models were associated with increased sleep duration during the on-call period and with deteriorations in educational opportunities, continuity of patient care, and perceived quality of care.

Background Patients with diabetes mellitus need information about the effectiveness of innovations in insulin delivery and glucose monitoring. Purpose To review how intensive insulin therapy (multiple daily injections [MDI] vs. rapid-acting analogue-based continuous subcutaneous insulin infusion [CSII]) or method of monitoring (self-monitoring of blood glucose [SMBG] vs. real-time continuous glucose monitoring [rt-CGM]) affects outcomes in types 1 and 2 diabetes mellitus. Data sources MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials through February 2012 without language restrictions. Study selection 33 randomized, controlled trials in children or adults that compared CSII with MDI (n=19), rt-CGM with SMBG (n=10), or sensor-augmented insulin pump use with MDI and SMBG (n=4). Data extraction 2 reviewers independently evaluated studies for eligibility and quality and serially abstracted data. Data synthesis In randomized, controlled trials, MDI and CSII showed similar effects on hemoglobin A1c (HbA1c) levels and severe hypoglycemia in children or adults with type 1 diabetes mellitus and adults with type 2 diabetes mellitus. In adults with type 1 diabetes mellitus, HbA1c levels decreased more with CSII than with MDI, but 1 study heavily influenced these results. Compared with SMBG, rt-CGM achieved a lower HbA1c level (between-group difference of change, 0.26% [95% CI, 0.33% to 0.19%]) without any difference in severe hypoglycemia. Sensor-augmented insulin pump use decreased HbA1c levels more than MDI and SMBG did in persons with type 1 diabetes mellitus (between-group difference of change, 0.68% [CI, 0.81% to 0.54%]). Little evidence was available on other outcomes. Limitation Many studies were small, of short duration, and limited to white persons with type 1 diabetes mellitus. Conclusion Continuous subcutaneous insulin infusion and MDI have similar effects on glycemic control and hypoglycemia, except CSII has a favorable effect on glycemic control in adults with type 1 diabetes mellitus. For glycemic control, rt-CGM is superior to SMBG and sensor-augmented insulin pumps are superior to MDI and SMBG without increasing the risk for hypoglycemia. Primary funding source Agency for Healthcare Research and Quality.

Background: Prostate specific antigen (PSA) testing is frequently used for early detection of prostate cancer, including among older adults. Since both race and socioeconomic status are associated with prostate cancer incidence and outcomes, it is often difficult to separate race from socioeconomic status as a determinant of prostate cancer screening. We sought to describe the relationship between socioeconomic status and PSA testing in a sample of urban, African American Medicare beneficiaries, and to examine factors that may contribute to this relationship. Methods: We examined baseline questionnaire data collected from the Cancer Prevention and Treatment Demonstration, a community-based randomized, controlled trial in Baltimore, MD. The study population consisted of 511 community-dwelling African-American men, age 65–75, without a history of prostate cancer. Our main outcome was PSA testing within the past year. Sequential multivariate logistic regression models were performed to study factors that may mediate the relationship between socioeconomic status and PSA screening. Results: Eighty percent of participants reported having had at least one PSA test in their lifetime, and approximately 50% reported having one within the past year. About half of the sample population reported a household income of less than $30,000 a year and one-third reported education past high school, but only 14% reported a bachelor's degree or higher. In bivariate analyses both higher income ($30,000 vs. < $10,000) (Odds Ratio [OR] 3.14, 95% Confidence Interval [CI] 1.79, 5.52) and higher levels of education (Bachelor's degree vs. less than high school) (OR 3.19, CI 1.72, 5.71) were associated with screening in the past year. In a multivariable regression model, which controlled for marital status, family history, and self-reported health status, income was no longer a significantly associated with PSA testing while the association between educational attainment and PSA testing was reduced (OR 2.13, 95% CI 1.07–4.22). The addition of increased healthcare access and patient-provider relationship measures in sequential models did not alter the relationship between educational attainment and screening. However, upon inclusion of cancer knowledge and belief measures the association between education and PSA testing was no longer significant (OR 1.84, 95% CI 0.90–3.75). Conclusions: In this urban, African American Medicare population, socioeconomic status was associated with PSA testing. This relationship may be explained, in part, by demographic factors and cancer knowledge and beliefs. Citation Information: Cancer Epidemiol Biomarkers Prev 2011;20(10 Suppl):B23.

Background Several residency program characteristics have been suggested as measures of program quality, but associations between these measures are unknown. We set out to determine associations between these potential measures of program quality. Methods Survey of internal medicine residency programs that shared an online ambulatory curriculum on hospital type, faculty size, number of trainees, proportion of international medical graduate (IMG) trainees, Internal Medicine In-Training Examination (IM-ITE) scores, three-year American Board of Internal Medicine Certifying Examination (ABIM-CE) first-try pass rates, Residency Review Committee-Internal Medicine (RRC-IM) certification length, program director clinical duties, and use of pharmaceutical funding to support education. Associations assessed using Chi-square, Spearman rank correlation, univariate and multivariable linear regression. Results Fifty one of 67 programs responded (response rate 76.1%), including 29 (56.9%) community teaching and 17 (33.3%) university hospitals, with a mean of 68 trainees and 101 faculty. Forty four percent of trainees were IMGs. The average post-graduate year (PGY)-2 IM-ITE raw score was 63.1, which was 66.8 for PGY3s. Average 3-year ABIM-CE pass rate was 95.8%; average RRC-IM certification was 4.3 years. ABIM-CE results, IM-ITE results, and length of RRC-IM certification were strongly associated with each other (p < 0.05). PGY3 IM-ITE scores were higher in programs with more IMGs and in programs that accepted pharmaceutical support (p < 0.05). RRC-IM certification was shorter in programs with higher numbers of IMGs. In multivariable analysis, a higher proportion of IMGs was associated with 1.17 years shorter RRC accreditation. Conclusions Associations between quality indicators are complex, but suggest that the presence of IMGs is associated with better performance on standardized tests but decreased duration of RRC-IM certification.