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Background: Cancer family history is a vital part of cancer genetic counseling (GC) and genetic testing (GT), but increasing indications for germline cancer GT necessitate less labor-intensive models of collection. We evaluated the impact of GC on patient pedigrees generated by an electronic cancer family history questionnaire (eCFHQ)., Methods: An Institutional Review Board-approved review of pedigrees collected through an eCFHQ was conducted. Paired pre-GC and post-GC pedigrees (n=1,113 each group) were analyzed independently by cancer genetic counselors for changes in patient-reported clinical history and to determine whether the pedigrees met NCCN GT criteria. Discrepancy in meeting NCCN GT criteria between pre-GC and post-GC pedigrees was the outcome variable of logistic regressions, with patient and family history characteristics as covariates., Results: Overall, 780 (70%) patients had cancer (affected), 869 (78%) were female, and the median age was 57 years (interquartile range, 45-66 years; range, 21-91 years). Of the 1,113 pairs of pre-GC and post-GC pedigrees analyzed, 85 (8%) were blank, 933 (84%) were not discrepant, and 95 (9%) were discrepant in meeting any NCCN GT criteria. Of the discrepant pedigrees, n=79 (83%) became eligible for testing by at least one of the NCCN GT criteria after GC. Patients with discrepant pedigrees were more likely to report no or unknown history of GT (odds ratio [OR], 4.54; 95% CI, 1.66-18.70; P=.01, and OR, 18.47; 95% CI, 5.04-88.73; P<.0001, respectively) and belonged to racially and/or ethnically underrepresented groups (OR, 1.91; 95% CI, 1.08-3.25; P=.02)., Conclusions: For most patients (84%), a standalone eCFHQ was sufficient to determine whether NCCN GT criteria were met. More research is needed on the performance of the eCFHQ in diverse patient populations.

Objectives: Understanding racial/ethnic disparities in late-life cognitive health is a public health imperative. We used baseline data from the Kaiser Healthy Aging and Diverse Life Experiences (KHANDLE) study to examine how age, education, gender, and clinical diagnosis, a proxy for brain health, are associated with cross-sectional measures of cognition in diverse racial/ethnic groups., Methods: Comprehensive measures of cognition were obtained using the Spanish and English Neuropsychological Assessment Scales and the National Institutes of Health Toolbox Cognitive Health Battery in a sample of 1,695 KHANDLE participants (Asians 24%, Blacks 26%, Latinos 20%, Whites 29%). A 25% random subsample was clinically evaluated and diagnosed with normal cognition, mild cognitive impairment (MCI), or dementia. Cognitive test scores were regressed on core demographic variables and diagnosis in the combined sample and in multiple group analyses stratified by racial/ethnic group., Results: Race/ethnicity and education were variably associated with test scores with strongest associations with tests of vocabulary and semantic memory. Older age was associated with poorer performance on all measures, and gender differences varied across cognitive tests. Clinical diagnosis of MCI or dementia was associated with average decrements in test scores that ranged from -0.41 to -0.84 SD, with largest differences on tests of executive function and episodic memory. With few exceptions, associations of demographic variables and clinical diagnosis did not differ across racial/ethnic groups., Discussion: The robust associations of cognitive test results with clinical diagnosis independent of core demographic variables and race/ethnicity support the validity of cognitive tests as indicators for brain health in diverse older adults., (© The Author(s) 2021. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objectives: Most patients with pancreatic cancer have high symptom burden and poor outcomes. Palliative care (PC) can improve the quality of care through expert symptom management, although the optimal timing of PC referral is still poorly understood. We aimed to assess the association of early PC on health care utilization and charges of care for pancreatic cancer patients., Materials and Methods: We selected patients with pancreatic cancer diagnosed between 2000 and 2009 who received at least 1 PC encounter using the Surveillance, Epidemiology, and End Results (SEER)-Medicare. Patients who had unknown follow-up were excluded. We defined "early PC" if the patients received PC within 30 days of diagnosis., Results: A total of 3166 patients had a PC encounter; 28% had an early PC. Patients receiving early PC were more likely to be female and have older age compared with patients receiving late PC (P<0.001). Patients receiving early PC had fewer emergency department (ED) visits (2.6 vs. 3.0 visits, P=0.004) and lower total charges of ED care ($3158 vs. $3981, P<0.001) compared with patients receiving late PC. Patients receiving early PC also had lower intensive care unit admissions (0.82 vs. 0.98 visits, P=0.006) and total charges of intensive care unit care ($14,466 vs. $18,687, P=0.01). On multivariable analysis, patients receiving early PC were significantly associated with fewer ED visits (P=0.007) and lower charges of ED care (P=0.018) for all patients., Conclusions: Early PC referrals were associated with lower ED visits and ED-related charges. Our findings support oncology society guideline recommendations for early PC in patients with advanced malignancies such as pancreatic cancer., Competing Interests: M.S.B. is a Designated Dedman Family Scholar in Clinical Care. The other authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background Women physicians continue to comprise the minority of leadership roles in Academic Family Medicine (AFM) faculty across North American medical schools. Our study quantified the current state of gender disparity by analyzing academic position, leadership ranking, and research productivity. Methods We generated a database for 6,746 AFM faculty members. Gender and academic profiles were obtained for 2,892 academic ranks and 1,706 leadership roles by searching faculty listings enlisted in Fellowship and Residency Electronic Interactive Database (FREIDA) and Canadian Resident Matching Service (CaRMS). To measure research productivity, we obtained bibliometric data: h-index, citations, and tenure from 2,383 faculty members using Elsevier's SCOPUS archives. Data analysis and h-index were formulated using Stata version 14.2 (StataCorp LP, College Station, TX). Results Our results indicated that women hold 46.11% (3,110/6,746) of faculty positions. The proportional composition decreased with increasing academic ranking (49.84% assistant, 46.78% associate, and 41.5% full professor). The same decreasing trend was demonstrated with leadership rank (57.14% minor leadership, 47.65% second-in-command, and 36.61 first-in-command). Compared to their gender counterparts, women in AFM demonstrated lower publication productivity as measured by citation number (p=0.04) and years of study (p=0.008). The final prediction equation model after multivariable analyses included gender, publications, citations, country of graduation, and years of active research (p<0.05). Conclusions The composition of academic family medicine faculty members included in this study demonstrated gender disparity. Inclusivity initiatives and policies to tackle the issue of female retention, promotion, and recruitment need to be further explored., Competing Interests: Dr. Khosa is the recipient of the May Cohen Equity, Diversity and Gender Award - Association of Faculties of Medicine of Canada (2020); Young Investigator Award - Canadian Association of Radiologists (2019); Rising Star Exchange Scholarship Program Award - French Society of Radiology (2019); and Humanitarian Award - Association of Physicians of Pakistani Descent of North America (2019). The authors did not have any relationship with any organization or individuals that may have influenced this study. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors., (Copyright © 2020, Chen et al.)

Background  Despite the number of female medical-school applicants reaching an all-time high and the increasing number of females in surgical training, males retain an overwhelming majority in senior surgical academic positions and formal leadership positions. This study aims to better understand the extent of and influences for gender disparity in general surgical societies throughout North America, Europe, and Oceania.  Methods  Data collection for this retrospective cross-sectional study took place between June and December 2017. Committee and subcommittee members from the eight selected general surgical societies that met the inclusion criteria (n = 311) were compiled into an Excel spreadsheet in which the data was recorded. Analyzed metrics included university academic ranking, surgical society leadership position, h-index, number of citations, and total publications. SCOPUS database (Elsevier, Amsterdam, Netherlands) was used to generate author metrics, and STATA version 14.0 (StataCorp, College Station, TX) was used for statistical analysis. Results Overall, 83.28% of members of the entities we studied were male and 16.72% were females. Males had significantly higher representation than females in all societies (Pearson chi 2  = 29.081; p-value = 0.010). Females were underrepresented in all society leadership positions and university academic rankings. Male members had a higher median h-index, more number of citations, and more total publications. Conclusions The composition of the general surgical societies included in this study demonstrated significant gender disparity. Female inclusivity initiatives and policies must be initiated to promote greater research productivity and early career opportunities for female surgeons in the specialty of general surgery., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2019, Wu et al.)

Background and Objectives : Previous studies have demonstrated superior patient outcomes for thoracic oncology patients treated at high-volume surgery centers compared to low-volume centers. However, the specific role of overall hospital size in open esophagectomy morbidity and mortality remains unclear. Materials and Methods: Patients aged >18 years who underwent open esophagectomy for primary malignant neoplasia of the esophagus between 2002 and 2014 were identified using the National Inpatient Sample. Minimally invasive procedures were excluded. Discharges were stratified by hospital size (large, medium, and small) and analyzed using trend and multivariable regression analyses. Results : Over a 13-year period, a total of 69,840 open esophagectomy procedures were performed nationally. While the proportion of total esophagectomies performed did not vary by hospital size, in-hospital mortality trends decreased for all hospitals (large (7.2% to 3.7%), medium (12.8% vs. 4.9%), and small (12.8% vs. 4.9%)), although this was only significant for large hospitals ( P < 0.01). After controlling for patient demographics, comorbidities, admission, and hospital-level factors, hospital length of stay (LOS), total inflation-adjusted costs, in-hospital mortality, and complications (cardiac, respiratory, vascular, and bleeding) did not vary by hospital size (all P > 0.05). Conclusions : After risk adjustment, patient morbidity and in-hospital mortality appear to be comparable across all institutions, including small hospitals. While there appears to be an increased push for referring patients to large hospitals, our findings suggest that there may be other factors (such as surgeon type, hospital volume, or board status) that are more likely to impact the results; these need to be further explored in the current era of episode-based care.

In the US, racial disparities in outcomes following coronary artery bypass grafting (CABG) are well documented. TRICARE insurance data represent a large population with universal insurance that allows for the robust assessment of the impact of such insurance on disparities in health care. This study examined racial differences in specific aspects of surgical care quality following CABG, using metrics endorsed by the National Quality Forum that included the prescription of beta-blockers and statins at discharge and thirty-day readmissions. There were no risk-adjusted differences in outcomes between African American and white patients insured through TRICARE. Our study provides a window into the potential impacts of universal insurance and an equal-access health care system on racial disparities in surgical care quality following CABG.

Importance: The increased use of prescription opioid medications has contributed to an epidemic of sustained opioid use, misuse, and addiction. Adults of working age are thought to be at greatest risk for prescription opioid dependence., Objective: To develop a risk score (the Stopping Opioids After Surgery score) for sustained prescription opioid use after surgery in a working-age population using readily available clinical information., Design, Setting, and Participants: In this case-control study, claims from TRICARE (the insurance program of the US Department of Defense) for working-age adult (age 18-64 years) patients undergoing 1 of 10 common surgical procedures from October 1, 2005, to September 30, 2014, were queried. A logistic regression model was used to identify variables associated with sustained prescription opioid use. The point estimate for each variable in the risk score was determined by its β coefficient in the model. The risk score for each patient represented the summed point totals, ranging from 0 to 100, with a lower score indicating lower risk of sustained prescription opioid use. Data were analyzed from September 25, 2018, to February 5, 2019., Exposures: Exposures were age; race; sex; marital status; socioeconomic status; discharge disposition; procedure intensity; length of stay; intensive care unit admission; comorbid diabetes, liver disease, renal disease, malignancy, depression, or anxiety; and prior opioid use status., Main Outcomes and Measures: The primary outcome was sustained prescription opioid use, defined as uninterrupted use for 6 months following surgery. A risk score for each patient was calculated and then used as a predictor of sustained opioid use after surgical intervention. The area under the curve and the Brier score were used to determine the accuracy of the scoring system and the Hosmer-Lemeshow goodness-of-fit test was used to evaluate model calibration., Results: Of 86 356 patients in the analysis (48 827 [56.5%] male; mean [SD] age, 46.5 [14.5] years), 6365 (7.4%) met criteria for sustained prescription opioid use. The sample used for model generation consisted of 64 767 patients, while the validation sample had 21 589 patients. Prior opioid exposure was the factor most strongly associated with sustained opioid use (odds ratio, 13.00; 95% CI, 11.87-14.23). The group with the lowest scores (<31) had a mean (SD) 4.1% (2.5%) risk of sustained opioid use; those with intermediate scores (31-50) had a mean (SD) risk of 14.9% (6.3%); and those with the highest scores (>50) had a mean (SD) risk of 35.8% (3.6%)., Conclusions and Relevance: This study developed an intuitive and accessible opioid risk assessment applicable to the care of working-age patients following surgery. This tool is scalable to clinical practice and can potentially be incorporated into electronic medical record platforms to enable automated calculation and clinical alerts that are generated in real time.

Background: Medicaid expansion has reduced obstacles faced in receiving care. Emergency general surgery (EGS) is a clinical event where delays in appropriate care impact outcomes. Therefore, we assessed the association between non-Medicaid expansion policy and multiple outcomes in homeless patients requiring EGS., Methods: We used 2014 State Inpatient Database to identify homeless individuals admitted with a primary EGS diagnosis who underwent an EGS procedure. States were divided into those that did and did not implement Medicaid expansion. Multivariable quantile regression was used to examine associations between non-Medicaid expansion states and (1) length of stay and (2) total index hospital charges within the homeless population. Multivariable logistic regression was used to assess the associations between non-Medicaid expansion and (1) mortality, (2) surgical complications, (3) discharge against medical advice, and (4) home healthcare., Results: A total of 6930 homeless patients were identified. Of these, 435 (6.2%) were in non-expansion states. Non-Medicaid expansion was associated with higher charges (coef: $46,264, 95% CI 40,388-52,139). There were non-significant differences in mortality (OR 1.4, 95% CI 0.79-2.62; p = 0.2) or surgical complications (OR 1.16, 95% CI 0.7-1.8; p = 0.4). However, homeless individuals living in non-expansion states did have higher odds of being discharged against medical advice (OR 2.1, 95% CI 1.08-4.05; p = 0.02), and lower odds of receiving home healthcare (OR 0.6, 95% CI 0.4-0.8; p = 0.01)., Conclusion: Homeless patients living in Medicaid expansion states had lower odds of being discharged against medical advice, higher likelihood of receiving home healthcare and overall lower total index hospital charges.

Background: Prior opioid use has been shown to be associated with adverse outcomes in surgical and trauma patients. We sought to evaluate the influence of prior opioid use on prescription opioid requirements after orthopedic trauma., Materials and Methods: This was a retrospective review of TRICARE claims (2006-2014). We evaluated the records of 11,752 patients treated for orthopedic injuries. Surveillance for prior opioid exposure extended to 6 mo before the traumatic event, with similar postinjury surveillance. Preinjury opioid use was categorized as unexposed, exposed without sustained use (nonsustained users), and sustained use (6 mo or longer of continuous opioid prescriptions without interruption). Multivariable Cox proportional hazard models were used to adjust for confounding and determine factors independently associated with the discontinuation of prescription opioid use after traumatic injury., Results: Prior opioid exposure among nonsustained users (hazard ratio 0.78; 95% CI 0.74, 0.83) and sustained use at the time of injury (hazard ratio 0.40; 95% CI: 0.35, 0.47) were associated with lower likelihoods of opioid discontinuation. Additional factors associated with lower likelihoods of opioid discontinuation included our proxy for lower socioeconomic status, history of depression or anxiety, injury severity, and intensive care unit admission., Conclusions: Prior opioid use is one of the strongest predictors of continued use following treatment, along with socioeconomic status, behavioral health disorders, and severity of injury. Appropriate discharge planning and early engagement of ancillary services in individuals with one or more of the risk factors identified here may reduce the likelihood of sustained opioid use after injury., (Copyright © 2019 Elsevier Inc. All rights reserved.)

The premise of our study was to identify the 50 most frequently cited articles on the mental and behavioral health of immigrant and refugee populations in the USA using the Thomas Reuters' WOS database. Articles were reviewed for inclusion by a panel comprised of two specialist physicians and a political scientist. Citations ranged from 69 to 520. Almost half of all articles (n = 23) focus on Hispanic populations. 32 articles employed a cross-sectional study design. Sample sizes ranged from 8,000,000 to 20. Over half of all (n = 30) articles were published between 2000 and 2012 in 22 journals, covering 38 research areas. The total number of institutional affiliations was 148, averaging at 3 per article. Our recommendations state: diversify sampling in terms of ethnic and racial backgrounds; develop a uniform instrument for immigrant and refugee mental health; and conduct comparative studies to examine the differences in the mental health among diverse communities.

Background: The Affordable Care Act (ACA) changed the landscape of insurance coverage, allowing young adults to remain on their parents' insurance until age 26 (Dependent Coverage Provision [DCP]) and states to optionally expand Medicaid up to 133% of the federal poverty level. Although both improved insurance coverage, little is known about the ACA's impact on observed receipt of timely access to acute care. The objective of this study was to compare changes in insurance coverage and perforation rates among hospitalized adults with acute appendicitis "after vs before" Medicaid expansion and the DCP using an Agency for Healthcare Research and Quality (AHRQ)-certified metric designed to measure pre-hospital access to care., Study Design: We performed a quasi-experimental, difference-in-difference (DID) analysis of 2008-2015 state-level inpatient claims., Results: Adults, aged 19 to 64, in expansion states experienced an absolute 7.7 percentage point decline in uninsured (95% CI 7.5 to 7.9) after Medicaid expansion compared with nonexpansion states. This coincided with a 5.4 percentage point drop in admissions for perforated appendicitis (95% CI 5.0 to 5.8) that was most pronounced among young adults, aged 26 to 34, just age-ineligible for the DCP (DID: 11.5 percentage points). Medicaid expansion insurance changes were 4.1 times larger than those encountered under the DCP (DID: 1.9). They affected all population subgroups and significantly reduced access-related disparities in race/ethnicity and lower-income communities. Although both Medicaid expansion and the DCP were associated with significant insurance gains, those attributable to the DCP were more concentrated among more privileged patients. Despite this trend, both policies resulted in larger reductions in perforation rates for historically uninsured and underserved groups., Conclusions: Reductions in uninsured after Medicaid expansion and the DCP were associated with significant reductions in perforated appendix admission rates. Improvements in access to acute surgical care suggest that maintained/continued insurance expansion could lead to fewer delays, better patient outcomes, and reductions in disparities among the most at-risk populations., (Copyright © 2018 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Palliative care, as a relatively young field within medicine, has increasingly used original research to validate and standardize its practice. In particular, palliative care has been incorporated into oncology to better address end-of-life decisions and care. The goal of this study is to identify seminal studies in the field of palliative oncology while more broadly characterizing the trends across the literature., Methods: The publication databases Scopus and Web of Science were queried using predefined search terms to identify palliative oncology studies published between 1995 and 2016. The 100 most-cited articles from the time periods 1995-2005 and 2006-2016 were selected and analysed for publication data and study content., Results: Palliative oncology studies were found to primarily examine patients with multiple rather than single cancer types and rarely were randomized controlled trials. Early research topics of pain, symptoms, and survival studies have been replaced by the issues of access to care, healthcare utilization, and religion and spirituality., Conclusions: By identifying and analyzing notable studies in palliative oncology, we found areas of research that are commonly investigated or overlooked and identified model studies that highlight the need for additional disease-specific randomized control trials to provide high quality clinical evidence in the field.

Purpose: The feasibility of using physical activity monitors (PAMs) to measure functional status in patients with cancer is unclear. We aimed to determine the feasibility of using PAMs to longitudinally assess physical activity and performance status (PS) in patients with cancer., Methods: Patients with cancer who had Eastern Cooperative Oncology Group (ECOG) PS of 0 to 2 and were receiving systemic therapy were enrolled in a prospective pilot trial of PAM use. Feasibility was defined as patients using the PAM for > 50% of the observation period. We correlated PAM-reported measures with scores from ECOG PS and quality-of-life tools (Functional Assessment of Cancer Therapy-General [FACT-G], Quick Inventory of Depressive Symptoms-Self-Rated 16 [QIDS-SR16], and Brief Fatigue Inventory [BFI]) using Pearson's correlation test. Patients were surveyed regarding their experience with PAMs at study completion., Results: In all, 24 patients were enrolled; mean age was 54 years, 16 (67%) were women, and 19 (79%) were white. Twenty-three patients (96%) met the primary end point of feasibility. The median duration of follow-up was 69 days. Mean PAM-measured steps for ECOG PS of 0, 1, and 2 were 5,911, 1,890, and 845 steps per day, respectively ( P = .002). Minimum steps per day correlated with BFI ( r = -0.53; P < .01), FACT-G ( r = 0.45; P = .02), and QIDS-SR16 ( r = -0.57; P < .01). Eighteen patients (75%) reported a positive experience with the PAM., Conclusion: PAMs are a feasible tool for measuring long-term physical activity in patients with cancer who are receiving systemic therapy. PAM-derived measures correlated with clinician-assessed PS.

Background: Palliative care has been associated with improved survival and quality of life, with lower rate of end-of-life health care utilization and cost. We examined trends in palliative care utilization in older pancreatic cancer patients., Methods: Pancreatic cancer patients with and without palliative care consults were identified using the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database between 2000 and 2009. Trend of palliative care use was studied. Emergency room/intensive care unit (ICU) utilization and costs in the last 30 days of life were compared between both groups using propensity score-matched (PSM) analysis., Results: Of the 54,130 patients, 3,166 (5.8%) received palliative care and 70% received it in the last 30 days of life. The proportion of patients receiving palliative care increased from 1.4% in 2000 to 7.4% in 2009 (P<0.001). Patients with palliative care were more likely to be older, Asian and women. In the unmatched and PSM population, the average visits to the ER in the last 30 days of life were significantly higher for patients who received palliative care, and had a significantly higher cost of care. Similarly, ICU length of stay in the last 30 days of life was higher in patients who did not receive palliative care in both PSM and unmatched patients. Cost of care and number of ICU admissions were not different between palliative and non-palliative care groups in PSM and unmatched patients., Conclusions: In this study of Medicare patients with pancreatic cancer, palliative care use has increased between 2000 and 2009. Palliative care was largely offered close to the end of life and was not associated with reduced health care utilization or cost., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Purpose: The goal of our study was to compile a list of the top 100 most-cited articles in stroke imaging literature across all peer-reviewed scientific journals. These articles were then analyzed to identify current trends in stroke imaging research and determine the characteristics of highly-cited articles., Materials and Methods: A database of the top 100 most-cited articles was created using Scopus and Web of Science. Articles were reviewed for applicability by 2 fellowship-trained radiologists with over 10 years of combined experience in neuroimaging. The following information was collected from each article: Article Title, Scopus Citations, Year of Publication, Journal, Journal Impact Factor, Authors, Number of Institutions, Country of Origin, Study Topic, Study Design, and Sample Size., Results: Citations for the top 100 most-cited articles ranged from 159-810, and citations per year ranged from 5.7-516.0. Most of articles were published between 1996 and 2000 (n = 43). Articles were published across 18 journals, most commonly in Stroke (n = 40). Magnetic resonance imaging was the focus in 46 articles, computed tomogrphy in 16, and functional magnetic resonance imaging in 10. The most common study topic is prognostic use of an imaging modality (n = 27)., Conclusions: Our study helps to characterize the field and identify the characteristics of most-cited articles., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: There has been an overall decline in intensive care unit mortality over the past 2 decades, including in patients undergoing intubation and mechanical ventilation (MV). Whether this decline extends to patients with metastatic cancer remains unknown. We analyzed the outcomes of patients with metastatic cancer undergoing intubation/MV using the National Hospital Discharge Survey (NHDS) database from 2001 to 2010. Methods: Diagnosis and procedure codes were used to identify patients with metastatic cancer who underwent intubation/MV. Demographics, diagnoses, length of stay (LOS), and discharge information were abstracted. Multivariate linear and logistic regression models with weighted analysis were conducted to study trends in outcomes. Results: During the 10-year study period, 200,350 patients with metastatic cancer and who underwent intubation/MV were identified; the mean age was 65.3 years and 46.2% were men. There was an increase in the total number of patients with metastatic cancer who underwent intubation/MV during the study period, from 36,881 in 2001-2002 to 51,003 in 2009-2010 ( P <.001). The overall inpatient mortality rate was 57.3%, discharge to a care facility (DTCF) rate was 40.9% among patients alive at discharge, and mean LOS was 11.1 days. No significant trends were seen in rates of mortality, DTCF, or LOS from 2001 to 2010. Conclusions: In this national database, there was an increase in the number of patients with metastatic cancer who underwent intubation/MV. These patients had high rates of inpatient mortality and DTCF, which did not improve during the study period. Therefore, novel solutions are required to improve outcomes for these patients., (Copyright © 2018 by the National Comprehensive Cancer Network.)

Our purpose was to identify the top 100 cited articles, which focused on CT colonography (CTC). This list could then be analysed to establish trends in CTC research while also identifying common characteristics of highly cited works. Web of Science search was used to create a database of scientific journals using our search terms. A total of 10,597 articles were returned from this search. Articles were included if they focused on diagnostic imaging, imaging technique, cost-effectiveness analysis, clinical use, patient preference or trends in CTC. Articles were ranked by citation count and screened by two attending radiologists. The following information was collected from each article: database citations, citations per year, year published, journal, authors, department affiliation, study type and design, statistical analysis, sample size, modality and topic. Citations for the top 100 articles ranged from 73 to 1179, and citations per year ranged from 4.5 to 84.21. Articles were published across 22 journals, most commonly Radiology (n = 37) and American Journal of Roentgenology (n = 19). Authors contributed from 1 to 20 articles. 19% of first authors were affiliated with a department other than radiology. Of the 100 articles, the most common topics were imaging technique (n = 40), diagnostic utility of imaging (n = 28) and clinical uses (n = 18). Our study provides intellectual milestones in CTC research, reflecting on the characteristics and quality of published literature. This work also provides the most influential references related to CTC and serves as a guide to the features of a citable paper in this field.

Objective: The objective of our study was to investigate radiology manuscript characteristics that influence citation rate, capturing features of manuscript construction that are discrete from study design., Materials and Methods: Consecutive articles published from January 2004 to June 2004 were collected from the six major radiology journals with the highest impact factors: Radiology (impact factor, 5.076), Investigative Radiology (2.320), American Journal of Neuroradiology (AJNR) (2.384), RadioGraphics (2.494), European Radiology (2.364), and American Journal of Roentgenology (2.406). The citation count for these articles was retrieved from the Web of Science, and 29 article characteristics were tabulated manually. A point-biserial correlation, Spearman rank-order correlation, and multiple regression model were performed to predict citation number from the collected variables., Results: A total of 703 articles-211 published in Radiology, 48 in Investigative Radiology, 106 in AJNR, 52 in RadioGraphics, 129 in European Radiology, and 157 in AJR-were evaluated. Punctuation was included in the title in 55% of the articles and had the highest statistically significant positive correlation to citation rate (point-biserial correlation coefficient [r pb ] = 0.85, p < 0.05). Open access status provided a low-magnitude, but significant, correlation to citation rate (r pb = 0.140, p < 0.001). The following variables created a significant multiple regression model to predict citation count (p < 0.005, R 2 = 0.186): study findings in the title, abstract word count, abstract character count, total number of words, country of origin, and all authors in the field of radiology., Conclusion: Using bibliometric knowledge, authors can craft a title, abstract, and text that may enhance visibility and citation count over what they would otherwise experience.

Background: With limited health care resources, bibliometric studies can help guide researchers and research funding agencies towards areas where reallocation or increase in research activity is warranted. Bibliometric analyses have been published in many specialties and sub-specialties but our literature search did not reveal a bibliometric analysis on Cardiovascular Magnetic Resonance (CMR). The main objective of the study was to identify the trends of the top 100 cited articles on CMR research., Methods: Web of Science (WOS) search was used to create a database of all English language scientific journals. This search was then cross-referenced with a similar search term query of Scopus® to identify articles that may have been missed on the initial search. Articles were ranked by citation count and screened by two independent reviewers., Results: Citations for the top 100 articles ranged from 178 to 1925 with a median of 319.5. Only 17 articles were cited more than 500 times, and the vast majority (n = 72) were cited between 200-499 times. More than half of the articles (n = 52) were from the United States of America, and more than one quarter (n = 21) from the United Kingdom. More than four fifth (n = 86) of the articles were published between the time period 2000-2014 with only 1 article published before 1990. Circulation and Journal of the American College of Cardiology made up more than half (n = 62) of the list. We found 10 authors who had greater than 5 publications in the list., Conclusion: Our study provides an insight on the characteristics and quality of the most highly cited CMR literature, and a list of the most influential references related to CMR.

Background: Procedural skills training forms an essential, yet difficult to assess, component of an Internal Medicine Residency Program. We report the development of process of documentation and assessment of procedural skills training., Method: An explanatory sequential mixed methods design was adopted where both quantitative and qualitative information was collected sequentially. A survey was conducted within the Department of Internal Medicine at The Aga Khan University Hospital, Karachi, Pakistan to determine the optimum number of procedures needed to be performed by residents at each year of residency. Respondents included both faculty and the residents in the Department. Thereafter, all responses were compiled and later scrutinized by a focus group comprising of a mix of faculty from various subspecialties and resident representatives., Results: A total of 64 responses were obtained. A significant difference was found in eight procedural skills' status between residents and faculty, though none of these were significant after accounting for multiple consecutive testing. However, the results were reviewed and a consensus for the procedures needed was developed through a focus group. A finalized procedural list was generated to determine: (a) the minimum number of times each procedure needed to be performed by the resident before deemed competent; (b) the level of competency for each procedure for respective year of residency., Conclusion: We conclude that the opinion of both the residents and the faculty as key stakeholders is vital to determine the number of procedures to be performed during an Internal Medicine Residency. Documentation of procedural competency development during the training would make the system more objective and hence reproducible. A log book was designed consisting of minimum number of procedures to be performed before attaining competency.

Chronic hepatitis C virus (HCV) is a global concern. With the 2014 Food and Drug Administration approvals of two direct-acting antiviral (DAA) regimens, ledipasvir/sofosbuvir regimen and the ombitasvir/paritaprevir/ritonavir and dasabuvir regimen, we may now be in the era of all-pill regimens for HCV. Until this development, interferon-alpha along with Ribavirin has remained part of the standard of care for HCV patients. That regimen necessitates psychosocial assessment of factors affecting treatment eligibility, including interferon-alpha-related depressive symptoms, confounding psychiatric conditions, and social aspects such as homelessness affecting treatment eligibility. These factors have delayed as much as 70% of otherwise eligible candidates from interferon-based treatment, and have required treating physicians to monitor psychiatric as well as medical side effects throughout treatment. All-pill DAA regimens with the efficaciousness that would preclude reliance upon interferon-alpha or ribavirin have been anticipated for years. Efficacy studies for these recently approved DAA regimens provide evidence to assess the degree that psychosocial assessment and monitoring will be required. With shorter treatment timelines, greatly reduced side effect profiles, and easier regimens, psychosocial contraindications are greatly reduced. However, current or recent psychiatric comorbidity, and drug-drug interactions with psychiatric drugs, will require some level of clinical attention. Evidence from these efficacy studies tentatively demonstrate that the era of needing significant psychosocial assessment and monitoring may be at an end, as long as a manageable handful of clinical issues are managed.

Background: The need of having feasible screening tools like Coronary Calcium Scoring (CCS) and CT Coronary Artery (CTCA) for Coronary Artery Disease (CAD) has become paramount. We aimed to evaluate the accuracy of CCS in determining the degree of stenosis of coronary vessels as compared to that determined by CTCA in a South Asian population., Methods: A retrospective study was conducted at The Aga Khan University Hospital. A total of 539 patient records were reviewed who had undergone CCS and CTCA between 2008 and 2010. Patient records were reviewed by comparing their CCS and CTCA results., Results: About 268 out of 301 (89%) patients with a CCS of 0-9 were found to be free of stenosis on CTCA. On a CCS of 10-99, 110 out of 121 (91%) patients were either free of stenosis or had mild stenosis. About 66 out of 79 (84%) patients had moderate or severe stenosis with a calcium score of 100-400 while none of the patients were free of stenosis. Around 28 out of 38 (74%) patients with a CCS of more than 400 had severe stenosis. However, only 04 patients (11%) were found to have mild stenosis. Spearman's rho revealed a correlation coefficient of 0.791 with a p-value of <0.001., Conclusion: Our study reaffirms that in South Asian population, low CCS (<100) is associated with no or minimal stenosis while high CCS warrants further investigation; hence, making it a reliable tool for screening patients with CAD.

Objective: Post-lumbar puncture headaches (PLPHs) are a common complication of diagnostic lumbar punctures (LPs) caused by a persistent leak of spinal fluid from the dural puncture site. We conducted a prospective study to determine risk factors associated with PLPHs in the neurology outpatient setting., Methods: Clinical information from all diagnostic LPs performed at the Johns Hopkins Lumbar Puncture Clinic between September 2008 and June 2009 was reviewed. As standard of care, each patient was contacted by telephone by the attending physician within 2-5 days of having an LP to ascertain health status and the presence of PLPH. We performed multiple logistic regression analysis to evaluate the association between PLPH and needle type (traditional Quincke cutting needle 20 and 22 gauge, 20Q and 22Q, and Sprotte non-traumatic gauge 22 needle, 22S) adjusting for important variables such as traumatic LPs, number of attempts, positioning and volume of CSF drawn., Results: The prevalence of PLPH was 32% with the popular gauge 20Q and 22Q needles compared to 19% with the 22S non-traumatic needle. Compared to the 20Q needle, the non-traumatic 22S needle was associated with 69% decreased odds of PLPH (adjusted OR: 0.31, 95% CI 0.12-0.82). In subset analysis, the odds of PLPH increased 4-fold when the 22Q needle was used compared to the 22S needle (adjusted OR=3.99, 95% CI 1.32-12.0)., Conclusions: Our outpatient findings support the American Academy of Neurology recommendations to use smaller non-traumatic needles to reduce the risk of PLPH., (Copyright © 2011 Elsevier B.V. All rights reserved.)

Prevalence of cancers associated with the use of oral tobacco (OT) is rising very rapidly and prevention of use is the best option to tackle this scenario. This cross-sectional study estimated the proportion of OT use and predictors associated with its initiation and determined the knowledge, attitude and practices of OT users. A total of 231 young adult patients (15-30 years age) were interviewed by medical students in family practice clinics in Karachi, Pakistan. OT use was considered as usage of any of the following: betel quid (paan) with tobacco, betel nuts with tobacco (gutkha), and snuff (naswar). Overall, 49.8% (95% CI=43.3-56.2) subjects had used OT at least in one form. Multivariable analysis demonstrated independent association of OT users with secondary education level (adjusted OR=3.6; 95% CI=1.6-8.1) and use of OT by a family member (OR=2.3; 95% CI=1.3-4.0). Among OT users, 37.4% started after being inspired by friends/peer pressure, 60% using for more than 5 years, 53.2 % users reported getting physical/mental comfort from the use of OT while 31.6% tried to quit this habit but failed. We suggest socially and culturally acceptable educational and behavioral interventions for control of OT usage and hence to prevent its associated cancers.

Objectives: The aims of this study were to assess how closely cardiologists in Pakistan followed published recommendations for lipid management and to identify the factors associated with such behavior., Methods: A cross-sectional survey was delivered in person between September and December 2007 to all cardiologists practicing in 4 major cities in Pakistan (Karachi, Lahore, Quetta, and Peshawar). A standard questionnaire was used to obtain information from cardiologists. Adherence to the guidelines established by the 2004 National Cholesterol Education Program Adult Treatment Panel III was computed based on answers to 14 questions; each correct answer (ie, the answer that followed the guidelines) was assigned 1 point, for a maximum cumulative score of 14. Multivariable linear regression was performed to determine the factors independently associated with guideline knowledge., Results: A total of 295 cardiologists were approached; 239 consented to participate (overall response rate, 81.0%). The median score was 9 out of a maximum of 14 (interquartile range, 8-11). There were important points of divergence from practice recommendations, including suboptimal targets for low-density lipoprotein cholesterol (LDL-C) (< or = 70 mg/dL was the target used by only 16.7% of respondents [40/239]), undertreatment of revascularized patients (31.4% [75/239]), cessation of statin therapy once LDL-C targets were achieved (20.9% [50/239]), and use of different treatment thresholds for patients aged >65 years (41.8% [100/239]) and female patients (46.4% [111/239]). In the adjusted analysis, experienced physicians, interventional cardiologists, and those who pursued continuing medical education activities (journals and conferences) had higher scores (P = 0.005, P = 0.041, P = 0.008, and P = 0.001, respectively)., Conclusion: We found important self-reported departures from recommended lipid-management guidelines among cardiologists in Pakistan.