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Introduction: Guidelines recommend individualized breast cancer screening and prevention interventions for women in their 40s. Yet, few primary care clinicians assess breast cancer risk.Study Design: Pretest-Posttest trial.Setting/participants: Women aged 40-49 years were recruited from one large Boston-based academic primary care practice between July 2017 and April 2019.Intervention: Participants completed a pretest, received a personalized breast cancer risk report, saw their primary care clinician, and completed a posttest.Main Outcome Measures: Using mixed effects models, changes in screening intentions (0-100 scale [0=will not screen to 100=will screen]), mammography knowledge, decisional conflict, and receipt of screening were examined. Analyses were conducted from June 2019 to February 2020.Results: Patient (n=337) mean age was 44.1 (SD=2.9) years, 61.4% were non-Hispanic white, and 76.6% were college graduates; 306 (90.5%) completed follow-up (203 with 5-year breast cancer risk <1.1%). Screening intentions declined from pre- to post-visit (79.3 to 68.0, p<0.0001), especially for women with 5-year risk <1.1% (77.2 to 63.3, p<0.0001), but still favored screening. In the 2 years prior, 37.6% had screening mammography compared with 41.8% over a mean 16 months follow-up (p=0.17). Mammography knowledge increased and decisional conflict declined. Eleven (3.3%) women met criteria for breast cancer prevention medications (ten discussed medications with their clinicians), 22 (6.5%) for MRI (19 discussed MRI with their clinician), and 67 (19.8%) for genetic counseling (47 discussed with the clinician).Conclusions: Receipt of a personalized breast cancer report was associated with women in their 40s making more-informed and less-conflicted mammography screening decisions and with high-risk women discussing breast cancer prevention interventions with clinicians.Trial Registration: This study is registered at www.clinicaltrials.govNCT03180086. [ABSTRACT FROM AUTHOR]

Adults with mood disorders frequently use prescription opioids. The factors associated with this increased use remain unclear. We used the Medical Expenditure Panel Surveys from 2005 to 2011 to measure the association of mood disorders with new opioid use and the transition to longer-term opioid use for a variety of pain conditions before and after controlling for patient characteristics and clinical disability. We analyzed 33,450 adults with likely acute or potentially chronic pain conditions who were not using opioids at baseline. Among respondents with likely acute pain conditions, those with mood disorders initiated opioids more frequently for that pain condition compared with those without mood disorders (19.3%, vs 17.2%, P = 0.01). After initiation, they also transitioned to longer-term opioid therapy more frequently (11.7% vs 5.3%, P < 0.01). Among respondents with potentially chronic pain conditions, adults with mood disorders initiated opioid therapy more frequently for their chronic pain condition (11.5% vs 9.2%, P < 0.01) and transitioned to longer-term therapy more frequently (36.8% vs 19.9%, P < 0.01). After adjusting for sociodemographics and clinical disability, there was no association between mood disorders and new opioid use for likely acute (adjusted odds ratio [aOR] 1.05 [0.92-1.20]) or potentially chronic pain (aOR 0.91 [0.80-1.03]). However, there remained a strong association between mood disorders and the transition to longer-term opioid use for likely acute (aOR 1.77 [1.15-2.72]) and potentially chronic pain (aOR 1.95 [1.42-2.68]). Targeting the transition to longer-term opioid use may help clinicians reduce potentially inappropriate opioid prescriptions in this high-risk population. [ABSTRACT FROM AUTHOR]

OBJECTIVES:Use of complementary and alternative medicine (CAM) has increased over the past two decades, and a growing body of evidence suggests that some CAM modalities may be useful in addressing gastrointestinal (GI) conditions. However, the overall pattern of CAM use for GI conditions remains unknown. We sought to elucidate the prevalence and patterns of CAM use among US adults with GI conditions.METHODS:We used the 2012 National Health Interview Survey (n=34,525), a nationally representative survey of the civilian, noninstitutionalized US population, to estimate the prevalence of CAM use among adults with GI conditions (abdominal pain, acid reflux/heartburn, digestive allergy, liver condition, nausea and/or vomiting, stomach or intestinal illness, and ulcer). We also examined the reasons for CAM use, perceived helpfulness, and disclosure of use to health-care providers among individuals who specifically used CAM to address a GI condition. Prevalence estimates were weighted to reflect the complex sampling design of the survey.RESULTS:Of the 13,505 respondents with a GI condition in the past year, 42% (n=5629) used CAM in the past year and 3% (n=407) used at least one CAM modality to address a GI condition. The top three modalities among those using CAM to address GI conditions were herbs and supplements, mind body therapies, and manipulative therapies. Of those using CAM to address a GI condition, 47% used three or more CAM therapies, and over 80% felt that it was helpful in addressing a GI condition and was important in maintaining health and well-being. Respondents told their health-care providers about use of these therapies 70% of the time.CONCLUSIONS:CAM was used by 42% of respondents with a GI condition in the past year. A small proportion use CAM specifically to address their GI condition, but the majority who do find it helpful. The most commonly used modalities in this group are herbs and supplements, and mind body and manipulative therapies. [ABSTRACT FROM AUTHOR]

BACKGROUND: Although pain is common among patients with advanced cancer, little is known about longitudinal variability in pain intensity. For this report, the authors examined variability in pain intensity over 24 months among ambulatory patients with advanced stage cancers, associations between patient characteristics and within-patient pain variability, and the relation of pain variability to overall survival. METHODS: The sample comprised 949 patients with solid tumors who received care and reported pain scores in at least 3 different months within 24 months of their initial stage IV diagnosis during the period from 2004 to 2006. Pain intensity was measured using a scale ranging from 0 (no pain) to 10 (worst pain). Pain variability was defined as the standard deviation of the maximum monthly pain scores and was dichotomized at the 50th percentile into high and low variability groups. RESULTS: Considerable between-patient differences in pain variability (range, 0-5.77) were observed. Nonwhites, patients with a stage IV cancer diagnosed within the previous 3 months, and those with moderate or severe pain at baseline were more likely to experience high pain variability. Although patients with head and neck cancer generally had the highest pain variability, the intensity of their pain typically decreased over the disease course. High pain variability with worsening pain trajectory was associated with increased risk of death. CONCLUSIONS: Longitudinally, pain intensity was highly variable among patients with stage IV cancer. Minority patients, newly diagnosed patients, patients with head and neck cancer, and patients with moderate or severe pain at baseline were at higher risk of large fluctuations in pain intensity. Cancer 2012. © 2012 American Cancer Society. [ABSTRACT FROM AUTHOR]

Abstract: Background: Peripheral artery disease (PAD) is a debilitating condition involving atherosclerosis. Although saturated, monounsaturated and polyunsaturated fatty acids have strong associations with atherosclerosis, it is unclear if diets high in these fatty acids affect PAD. Methods: We studied 6352 adults aged 40 years and older who participated in the U.S. National Health and Nutrition Examination Survey between 1999 and 2004. Ankle brachial index (ABI) was assessed by standardized blood pressure measurements, and we defined PAD as an ABI<0.9. Fatty acid intake was assessed by validated 24-h dietary recall. We used multivariable linear and logistic regression to estimate associations between intakes of dietary saturated fatty acids (SFAs), monounsaturated fatty acids (MFAs), marine omega-3 fatty acids (N-3), linolenic acid (LNA), and omega-6 fatty acids (N-6) and ABI/PAD. Results: The prevalence and 95% confidence interval (CI) of PAD was 5.2% (95% CI 4.6–5.8). There were no associations between ABI and intakes of marine N-3 (p =0.83) or N-6 (p =0.19) in adjusted models. In contrast, LNA was associated with higher ABI (p =0.04) and SFA tended to be associated with lower ABI (p =0.06) in adjusted models. In addition, higher SFA was associated with a higher prevalence of PAD: adjusted odds ratio 1.30 (95% CI 1.01–1.67; p =0.04) and a trend toward slower gait speed (p =0.08). Conclusion: In this nationally representative sample, higher dietary intakes of LNA and SFAs were associated with higher and lower ABI, respectively. Prospective studies are needed to confirm the potential protective effects of dietary LNA and detrimental effects of dietary SFAs on PAD. [Copyright &y& Elsevier]

The article discusses a study of the effectiveness of electronic medical record (EMR) reminders in patients 65 years of age or older. The study was conducted at Beth Israel Deaconess General Medicine and Primary Care Division in Massachusetts in 2009 and 2010. Health care proxy designation, initial bone density scan, and influenza and pneumococcal vaccinations were the primary outcome measures examined in the study. Improvement in vaccination rates is attributed to EMR.

OBJECTIVES: To further validate an index predicting mortality in community-dwelling older adults. DESIGN: A comparison of the performance of the index in predicting mortality among new respondents to the National Health Interview Survey (NHIS, 2001-2004) with that of respondents from the original development and validation cohorts (1997-2000) and a test of its performance over extended follow-up (up to 9 years) using the original cohorts. Follow-up mortality data were available through 2006. SETTING: NHIS. PARTICIPANTS: Twenty-two thousand fifty-seven new respondents to the NHIS (2001-2004) and 24,139 respondents from the original development and validation cohorts (1997-2000). MEASUREMENTS: A risk score was calculated for each respondent based on the presence or absence of 11 factors (function, illnesses, behaviors, demographics) that make up the index. Using the Kaplan-Meier method, 5-year mortality estimates were computed for the new and original cohort respondents and 9-year mortality estimates for the original cohorts. RESULTS: New respondents were similar to original cohort respondents but were slightly more likely to be aged 85 and older, report diabetes mellitus, and have a body mass index of 25.0 kg/m2 or greater. The model performed as well in the new cohort as it had in the original cohort. New respondents with risk scores of 0 to 1 had a 2% risk of 5-year mortality, whereas respondents who scored 18 or higher had a 69% risk of 5-year mortality (range 3-71% risk of 5-year mortality in the development cohort). The index also demonstrated excellent calibration and discrimination in predicting 9-year mortality (range 7% risk for scores of 0-1 to 92% risk for scores of ≥18, original validation cohort extended). CONCLUSION: These results further justify use of this index to estimate life expectancy in clinical decision-making. [ABSTRACT FROM AUTHOR]

Background: Despite the absence of conclusive evidence of effectiveness, complementary and alternative medicine (CAM) is used by 4 of 10 adults in the US; little is known about the association between CAM use and health status.Objective: To determine the relation between CAM use and self-reported health status and health improvement over time.Design and Participants: We performed a secondary database analysis using data from the 2007 National Health Interview Survey of non-institutionalized US residents conducted by the National Center of Health Statistics of the Center for Disease Control. We identified CAM users and compared them to non-users. We used multivariable logistic regression to model the health status of respondents. We controlled for confounders including socio-demographic, clinical, and behavioral factors. The models were evaluated for discrimination and calibration.Main Measures: The likelihood of respondents to report 'Excellent' current health and 'Better' health than in the prior year.Key Results: Based on 23,393 respondents, we found 37% of U.S. adults used complementary and alternative medicine and 63% did not use any CAM. Compared to those who did not use CAM, CAM users were more likely to rate their health as 'Excellent' (adjusted-odds ratio (AOR) = 1.14, 95% CI = [1.03,1.26]). Similarly, CAM users were more likely to report their health as 'Better' than in the prior year (AOR = 1.64, 95% CI = [1.49,1.83]). The c-statistics for the two models were 0.755 and 0.616, respectively.Conclusion: We found a significant association between CAM use and self-rated excellent health and health improvement over the prior year. Prospective trials are required to determine whether CAM use is causally related to excellent health status and better health than in the prior year. [ABSTRACT FROM AUTHOR]

We used the 2012 National Health Interview Survey to compare homeopathy users with supplement users and those using other forms of complementary and integrative medicine. Among US adults, 2.1 % used homeopathy within the past 12 months. Respiratory and otorhinolaryngology complaints were most commonly treated (18.5%). Homeopathy users were more likely to use multiple complementary and integrative medicine therapies and to perceive the therapy as helpful than were supplement users. US homeopathy use remains uncommon; however, users perceive it as helpful. [ABSTRACT FROM AUTHOR]

Objective Patient-physician language discordance is associated with worse quality of healthcare for patients with limited English proficiency. Patients with language-discordant physicians have more problems understanding medical situations. The impact of patient-physician language concordance on lifestyle counseling among Spanish-speaking patients is not known. Methods We performed a retrospective medical record review and identified 306 Spanish-speaking patients who used interpreter services between June 2001 and June 2006 in two Boston-based primary care practices. Our primary outcome was counseling on exercise, diet, and smoking. Our main predictor of interest was patient-physician language concordance. Results Patients with language-concordant physicians were more likely to be counseled on diet and physical activity compared to patients with language-discordant physicians. After adjustment for age, sex, insurance status, number of primary care visits, and comorbidity score, these differences in counseling persisted for diet [odds ratio (OR) = 2.2, CI 1.3–3.7] and physical activity (OR = 2.3, CI 1.4–3.8). There was no significant difference with regard to discussion of smoking (OR = 1.3, CI 0.8–2.1). Conclusions Spanish-speaking patients are more likely to discuss diet and exercise modification if they have a Spanish-speaking physician compared to those having a non-Spanish-speaking physician. Further research is needed to explore whether matching Spanish-speaking patients with Spanish-speaking providers may improve lifestyle counseling. [ABSTRACT FROM AUTHOR]

Background: Prognostic information is becoming increasingly important for clinical decision-making.Objective: To develop and validate an index to predict 5-year mortality among community-dwelling older adults.Design and Participants: A total of 24,115 individuals aged >65 who responded to the 1997-2000 National Health Interview Survey (NHIS) with follow-up through 31 December 2002 from the National Death Index; 16,077 were randomly selected for the development cohort and 8,038 for the validation cohort.Measurements: 39 risk factors (functional measures, illnesses, behaviors, demographics) were included in a multivariable Cox proportional hazards model to determine factors independently associated with mortality. Risk scores were calculated for participants using points derived from the final model's beta coefficients. To evaluate external validity, we compared survival by quintile of risk between the development and validation cohorts.Results: Seventeen percent of participants had died by the end of the study. The final model included 11 variables: age (1 point for 70-74 up to 7 points for >85); male: 3 points; BMI <25: 2 points; perceived health (good: 1 point, fair/poor: 2 points); emphysema: 2 points; cancer: 2 points; diabetes: 2 points; dependent in instrumental activities of daily living: 2 points; difficulty walking: 3 points; smoker-former: 1 point, smoker-current: 3 points; past year hospitalizations-one: 1 point, >2: 3 points. We observed close agreement between 5-year mortality in the two cohorts; which ranged from 5% in the lowest risk quintile to 50% in the highest risk quintile in the validation cohort.Conclusions: This validated mortality index can be used to account for participant life expectancy in analyses using NHIS data. [ABSTRACT FROM AUTHOR]

Background: Muscle effects are the most common reported adverse effects of 3-hydroxy-3-methylglutaryl coenzyme A inhibitors (statins). However, in placebo-controlled trials the incidence of muscle pain is most often similar for placebo and active control groups.Objective: We sought to evaluate whether statin use was associated with a higher prevalence of musculoskeletal pain in a nationally representative sample.Methods: Cross-sectional analysis using data from the National Health and Nutrition Examination Survey (NHANES) 1999-2002. Participants were 3,580 adults > or =40 years without arthritis who were interviewed at home and examined in a mobile examination center. Participants were asked about sociodemographic characteristics, health conditions, medication use, and musculoskeletal pain. Height, weight, blood pressure, ankle brachial index, and cholesterol were measured.Measurements and Main Results: Prevalence and adjusted odds ratios (OR) of any musculoskeletal pain and musculoskeletal pain in 4 different anatomical regions (neck/upper back, upper extremities, lower back, and lower extremities) by statin use during the last 30 days. Among statin users (n = 402), 22.0% (95%CI 18.0-26.7%) reported musculoskeletal pain in at least 1 anatomical region during the last 30 days, compared with 16.7% (95%CI 15.1-18.4%) of those who did not use a statin. Compared to persons who did not use statins, those who used statins had multivariable-adjusted odds ratios (95%CI; p value) of 1.50 (1.07-2.11; p = .01) for any musculoskeletal pain, 1.59 (1.04-2.44, p = .03) for lower back pain, and 1.50 (1.02-2.22, p = .03) for lower extremity pain.Conclusion: Musculoskeletal pain is common in adults > or =40 years without arthritis. In this nationally representative sample, statin users were significantly more likely to report musculoskeletal pain. [ABSTRACT FROM AUTHOR]

Objective: To assess how well the SF-36, a well-validated generic quality of life (QOL) instrument, compares with its shorter adaptation, the SF-12, in capturing differences in QOL among patients with and without obesity. Methods: We compared the correlation between the physical (PCS) and mental (MCS) component summary measures of the SF-12 and SF-36 among 356 primary care patients using Pearson coefficients (r) and conducted linear regression models to see how these summary measures captures the variation across BMI. We used model R² to assess qualitatively how well each measure explained the variation across BMI. Results: Correlations between SF-12 and SF-36 were higher for the PCS in obese (r = 0.89) compared to overweight (r = 0.73) and normal weight patients (r = 0.75), p < 0.001, but were similar for the MCS across BMI. Compared to normal weight patients, obese patients scored 8.8 points lower on the PCS-12 and 5.7 points lower on the PCS-36 after adjustment for age, sex, and race; the model R² was higher with PCS-12 (R² = 0.22) than with PCS-36 (R² = 0.16). BMI was not significantly associated with either the MCS-12 or MCS-36. Conclusion: The SF-12 correlated highly with SF-36 in obese and non-obese patients and appeared to be a better measure of differences in QOL associated with BMI. [ABSTRACT FROM AUTHOR]

Background: Little is known about the quality of the patient-physician relationship for terminally ill African Americans.Objective: To compare the quality of the patient-physician relationship between African-American and white patients and examine the extent to which relationship quality contributes to differences in advance care planning (ACP) and preferences for intensive life-sustaining treatment (LST).Design: Cross sectional survey of 803 terminally ill African-American and white patients.Measurements: Patient-reported quality of the patient-physician relationship (degree of trust, perceived respect, and joint decision making; skill in breaking bad news and listening; help in navigating the medical system), ACP, preferences for LST (cardiopulmonary resuscitation, major surgery, mechanical ventilation, and dialysis).Results: The quality of the patient-physician relationship was worse for African Americans than for white patients by all measures except trust. African Americans were less likely to have an ACP (adjusted relative risk [aRR] = 0.66, 95%CI = 0.52-0.84), and were more likely to have a preference for cardiopulmonary resuscitation and dialysis (aRR = 1.28, 95%CI = 1.03-1.58; aRR = 1.25, 95%CI = 1.07-1.47, respectively). Additional adjustment for the quality of the patient-physician relationship had no impact on the differences in ACP and treatment preferences.Conclusions: Lower reported patient-physician relationship quality for African-American patients does not explain the observed differences between African Americans and whites in ACP and preferences for LST. [ABSTRACT FROM AUTHOR]

Purpose: To determine the recruitment goals that investigators set for racial/ethnic minorities and the factors associated with failure to meet those goals. Methods: Four hundred forty principal investigators (PIs) conducting clinical research funded by the National Heart, Lung, and Blood Institute (NHLBI) in 2001 completed a mailed survey providing their minority recruitment goals and enrollment data for their most recent NHLBI-funded study. Results: Ninety-two percent of PIs set goals for African Americans, 68% for Hispanics, 55% for Asian Americans, 35% for Native Hawaiians/Pacific Islanders, and 23% of PIs set recruitment goals for American Indians/Native Alaskans. Among those PIs who did set minority recruitment goals, the mean goal for the recruitment of African Americans was 31%, 16% for Hispanics, and 9% for Asian Americans. Twenty-seven percent of PIs failed to meet their recruitment goals for African Americans, 23% for Asian Americans, and 23% for Hispanics. After adjusting for multiple investigator and trial characteristics, the type of study (odds ratio [OR] 1.8; 95% confidence interval [CI] 1.2, 3.4 for observational vs. phase III trial) completion of study enrollment (OR 2.0; 95% CI 1.2, 3.4), and PI identification of a larger number of major barriers to participation (OR 1.8; 95% CI 1.1, 3.0) were all associated with failure to meet recruitment goals for African Americans. However, no factors were consistently associated with failure to meet recruitment goals across different racial/ethnic groups. Conclusions: Investigators often do not set recruitment goals for some racial/ethnic groups. Factors associated with failure to meet recruitment goals vary in the recruitment of different minority groups. [Copyright &y& Elsevier]

Previous studies have suggested that patients with chronic medical conditions use complementary and alternative medicine (CAM) at a higher rate than the general population. Despite recent interest in CAM for cardiovascular disease, few data are available regarding patterns of use in patients with cardiovascular disease in the United States. This study used the 2002 National Health Interview Survey and analyzed data on CAM use in 10,572 respondents with cardiovascular disease. Among those with cardiovascular disease, 36% had used CAM (excluding prayer) in the previous 12 months. The most commonly used therapies were herbal products (18%) and mind–body therapies (17%). Among herbs, echinacea, garlic, ginseng, ginkgo biloba, and glucosamine with or without chondroitin were most commonly used. Among mind–body therapies, deep-breathing exercises and meditation were most commonly used. Overall, CAM was used most frequently for musculoskeletal complaints (24% of respondents who used mind–body therapies, 22% who used herbs, 45% who used any CAM). Mind–body therapies were also used for anxiety or depression (23%) and stress or emotional health and wellness (16%). Herbs were commonly used for head and chest colds (22%). Fewer respondents (10%) used CAM specifically for their cardiovascular conditions (5% for hypertension, 2% for coronary disease, 3% for vascular insufficiency, <1% for heart failure or stroke). Most, however, who used CAM for their cardiovascular condition perceived the therapies to be helpful (80% for herbs, 94% for mind–body therapies). CAM use was more common in younger respondents, women, Asians, and those with more education and greater incomes. In conclusion, CAM use, particularly herbs and mind-body therapies, is common in the United States in patients with cardiovascular disease and mirrors use in the general population. CAM use specifically to treat cardiovascular conditions, however, is less common. [Copyright &y& Elsevier]

Objective: To describe decision making and trust of women who were on hormone therapy (estrogen and progestin or estrogen alone) when the Women’s Health Initiative findings were initially released July 9, 2002. Methods: Telephone surveys of 204 patients randomly selected from a large academic primary care practice (66% response rate) were conducted from July to September 2003. Women age 50 years and older who were taking hormone therapy on July 9, 2002, were included. The survey assessed: prevalence of discontinuing hormone therapy; knowledge of and reactions to the Women’s Health Initiative; trust in medical recommendations; and future prevention behavior. Results: Of 204 women, their mean age was 61 years, 70% were white, 56% were college educated, and 54% were taking both estrogen and progestin. Most (94%) had heard of the Women’s Health Initiative and the majority (70%) stopped hormone therapy. Being nonwhite (adjusted RR 1.37, 95% CI [1.16–1.48]) and having taken estrogen and progestin (1.37, [1.18–1.49]) were significantly associated with stopping hormone therapy. Among women who had heard of the Women’s Health Initiative (n = 191), 26% reported losing trust in medical recommendations generally and 34% were less willing than before the Women’s Health Initiative to take new drugs to prevent heart disease. Nonwhites were less willing than whites to take new drugs for heart disease prevention (aRR 1.58 [1.02–2.18]). Conclusions: Most women discontinued hormone therapy after the Women’s Health Initiative results were published. Given their experience with hormone therapy, some women, particularly nonwhites, are now less trusting of medical recommendations and less likely to take drugs for cardiovascular disease prevention. [Copyright &y& Elsevier]

Background: While the majority of adults are attempting weight loss at any given time, few engage in optimal diet and exercise. We examined factors associated with being in advanced stages of behavior change for weight loss, diet, and exercise.Methods: We surveyed primary care patients about their health, health habits, and perception and advice about weight as health risk, and about stage of readiness to lose weight, improve diet (control food portions, limit fat intake, increase fruits and vegetables), and increase planned exercise using the Prochaska Stage of Behavior Change model. We conducted bivariable analyses to describe the association between being at the preparation (change in 1 month), action (changing now), and maintenance (maintaining change) stages of change for weight loss and being at 1 of these 3 advanced stages for improving diet and exercise. We also conducted multivariable analyses to examine factors associated with being at these advanced stages of readiness to concurrently lose weight, improve diet, and increase exercise.Results: Of 365 patients (response rate of 60%), 33% were overweight (body mass index [BMI], 25.0-29.9 kg/m(2)) and 27% were obese (BMI, 30.0+kg/m(2)). Of 199 respondents at the preparation, action, or maintenance stage of losing weight, 61% were also at an advanced stage for improving diet and exercise. Those perceiving weight as a health risk were more likely to be at advanced stages of readiness to concurrently lose weight, improve diet, and increase exercise (adjusted odds ratio [AOR], 5.6; 95% CI, 2.5 to 12.5) after adjustment for confounders; this perception was associated with BMI ([AOR, 1.2; 95% CI, 1.1 to 1.3 for each unit increment in BMI]) and being advised by a physician about weight as a health risk (AOR, 6.7; 95% CI, 3.0 to 15.1). Demographic factors, having obesity-related comorbidities, and mental and physical functioning did not appear important.Conclusions: A large proportion of primary care patients are at advanced stages of readiness to lose weight, improve diet, and increase exercise. Future studies should examine the effectiveness of primary care interventions to help patients optimize weight-related behavior. [ABSTRACT FROM AUTHOR]

Context Complementary and alternative medicine (CAM) use by US adults increased substantially between 1990 and 1997, yet little is known about more recent trends. Objective Compare CAM therapy use by US adults in 2002 and 1997. Design Comparison of two national surveys of CAM use by US adults: (1) the Alternative Health/Complementary and Alternative Medicine supplement to the 2002 National Health Interview Survey (NHIS, N=31,044) and (2) a 1997 national survey (N = 2055), each containing questions about 15 common CAM therapies. Main Outcome Measures Prevalence, sociodemographic correlates, and insurance coverage of CAM use. Results The most commonly used CAM modalities in 2002 were herbal therapy (18,6%, representing over 38 million US adults) followed by relaxation techniques (14.2%, representing 29 million US adults) and chiropractic (7.4%, representing 15 million US adults). Among CAM users, 41% used two or more CAM therapies during the prior year. Factors associated with highest rates of CAM use were ages 40-64, female gender, non-black/non-Hispanic race, and annual income of $65,000 or higher. Overall CAM use for the 15 therapies common to both surveys was similar between 1997 and 2002 (36.5%, vs. 35.0%, respectively, each representing about 72 million US adults). The greatest relative increase in CAM use between 1997 and 2002 was seen for herbal medicine (12.1% vs. 18.6%, respectively), and yoga (3.7% vs. 5.1%, respectively), while the largest relative decrease occurred for chiropractic (9.9 % to 7.4%, respectively). Conclusions The prevalence of CAM use has remained stable from 1997 to 2002. Over one in three respondents used CAM in the past year, representing about 72 million US adults. Although this work was made possible in part by grants from the National Center for Complementary and Alternative Medicine (T32-AT0051-03 [Dr. Tindle), K24-AT000589 [Dr. Phillips], U24-AR43441 [Drs. Davis and Eisenberg]) and by private foundation grants (Horton Family Fund, Seattle Foundation (Dr. Tindle) John E. Fetzer Institute, American Society of Actuaries, Friends of Beth Israel Deaconess Medical Center, Kenneth J. Germeshausen Foundation, and the J.E. and Z.B. Butler Foundation (Drs. Davis and Eisenberg), its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NCCAM, National Institutes of Health, or private foundations. [ABSTRACT FROM AUTHOR]

To determine whether those persons whose sensory or physical functioning improved or worsened over one year are more or less satisfied with their health care.1996 and 1997 Medicare Current Beneficiary Survey (MCBS).The MCBS surveys a nationally representative, longitudinal panel of Medicare beneficiaries about their sociodemographic attributes; vision, hearing, and various mobility functions; and 10 items representing satisfaction with and access to health care. Using multivariable logistic regression and controlling for sociodemographic factors, we computed adjusted odds ratios of dissatisfaction with care, examining the effects of changes in sensory or physical functioning. Analyses accounted for MCBS sampling weights.We identified 9,974 community-dwelling respondents, 18 years old and over who answered the 1996 and 1997 MCBS. We assessed five categories of sensory or physical functioning (vision; hearing; walking; reaching overhead; and grasping and writing) and compared 1996 and 1997 responses to identify those whose functioning improved or worsened.Worsened functioning was strongly associated with older age, low income, and low educational attainment. Improved functioning was rarely significantly associated with satisfaction; an exception involved substantially lower rates of dissatisfaction with“ease and convenience” of getting to physicians. Worsened functioning was often statistically significantly associated with dissatisfaction, always with adjusted odds ratios>1.0. Across all five functional categories, persons whose functioning worsened displayed significantly greater dissatisfaction with overall quality, ease, and costs or care.Persons whose functioning improved rarely reported better satisfaction than did those whose functioning did not improve, while those whose functioning worsened expressed more systematic reservations about their care. [ABSTRACT FROM AUTHOR]

To determine factors that influence patient willingness to accept a medication change to a unified, restrictive formulary.Prospective cohort study.University-affiliated hospital-based primary care internal medicine practice.Two hundred ninety-seven members of a managed care plan who had received a prescription for a nonformulary medication in the previous 4 months and whose primary care physician approved a conversion to a formulary medication.Clinical nurses invited patients to change to a formulary medication at the time of a telephone refill request based on a standard script.The overall conversion rate to the formulary medication was 59.8%. Seventy-four percent of patients who requested a refill by telephone converted to the formulary (odds ratio[OR], 2.24; 95% confidence interval[CI], 1.02 to 4.72). Patient age (OR, 1.03; CI, 1.01 to 1.05) and male gender (OR, 2.00; CI, 1.09 to 3.67) were each significant correlates of conversion. After adjustment in a multivariable model, only telephone refill request (adjusted OR, 2.31; CI, 1.07 to 4.97) and age (adjusted OR, 1.03; CI, 1.01 to 1.06) remained significant. Among the patients who made a telephone refill request, those who converted were more likely to completely trust their physician's judgment (P= .04) and to trust their physician to put their health over cost concerns (P= .05). Formulary conversion reduced costs beginning 3 months after the conversion date.A protocol for encouraging conversion to a unified formulary at the point of a telephone refill request increases formulary compliance rates and reduces medication costs. Patients who decline to convert medications are less likely to trust their physician.J GEN INTERN MED 2004;19:1212 – 1219. [ABSTRACT FROM AUTHOR]

Background: People with physical and sensory disabilities face important challenges in obtaining high-quality health care. We examined whether persons who are blind or have low vision, who are deaf or hard of hearing, or who have mobility impairments or manual dexterity problems are satisfied with the technical and interpersonal aspects of their care. Methods: By using a 1996 nationally representative survey of 16 403 community-dwelling elderly and disabled Medicare beneficiaries, we identified persons with disabling conditions. Adjusted odds ratios (AORs) and 95% confidence intervals (CIs) controlled for demographic characteristics and managed care membership in predicting dissatisfaction with 12 dimensions of care. Results: Of an estimated 33.58 million noninstitutionalized Medicare beneficiaries, 64.1% (an estimated 21.51 million) reported at least 1 potential disability and 29.5% (an estimated 9.89 million) reported more than 1 potential disability. Roughly 98% of people with and without disabilities believed their physicians were competent and well trained. But statistically significantly more people with disabilities reported dissatisfaction with care for 10 of the 12 quality dimensions. Persons reporting any major disability were more likely to be dissatisfied with physicians completely understanding their conditions (AOR, 2.4; 95% CI, 1.9-3.1), physicians completely discussing patients' health problems (AOR, 2.4; 95% CI, 1.9-2.9), physicians answering all patients' questions (AOR, 2.3; 95% CI, 1.7-3.1), and physicians often seeming hurried (AOR, 1.6; 95% CI, 1.4-1.9). Conclusions: Persons with disabilities generally reported positive views of their care, although they were significantly more likely to report poor communication and lack of thorough care. These findings held regardless of the disabling condition. Thoughtful systematic approaches are required to improve communication and to reduce time pressures that might compromise the health care experiences of people with disabilities. [ABSTRACT FROM AUTHOR]

Satellite data have demonstrated that the areal extent of the Arctic ice canopy has decreased over the past few decades, however, whether sea ice thickness in the Arctic Ocean has substantially decreased remains controversial because of limited information available for the base of the ice canopy. Studies of sea ice thickness to date have involved analysis of ice draft data acquired by single-beam ice profiling sonars on US and British Navy submarines or single-beam moored sonars. During 1998 and 1999, a seafloor-mapping sonar mounted on the hull of the US Navy nuclear submarine USS Hawkbill serendipitously acquired sonar returns from the base of the arctic ice canopy despite design features intended to minimize such returns. Standard topographic processing of the data revealed coherent signals collected between the outgoing sonar pulse and the first returned bottom echoes. Existing processing software was modified to produce swath maps of the information collected from the beginning of ping transmission until the seafloor echoes were detected. These images demonstrate that the recorded water-column signals are different on the port and starboard sides of the system and that individual features can be traced from one side of the submarine to the other. Further software modification allowed us to produce the first wide-swath (2–6 km) sidescan images of the base of the Arctic ice canopy. Although the resultant maps cannot resolve the debate regarding changes in Arctic sea ice thickness, the approach will have far-reaching impact on the design of future systems, whether based on submarines or unmanned vehicles. Our analyses demonstrate that system performance is regulated by the ratio between sonar operating depth and height of the sonar above the seafloor. Where the ratio approaches 1, echoes from the seabed interfere with echoes from the ice canopy, preventing the creation of ice maps. When the sonar is operated below 135 m, signal attenuation results in ice maps with little useful information. However, where the sonar operational depth is less than 135 m and the total water depth ranges between 500 and 1200 m, our approach produces swaths up to 6 km wide exhibiting detailed lineations similar to those observed in higher frequency upward-looking sidescan sonar data. [Copyright &y& Elsevier]

Objective: To identify and characterize discrepancies between explicit and implicit medical record review of complications and quality of care.Setting: Forty-two acute-care hospitals in California and Connecticut in 1994.Study Design: In a retrospective chart review of 1,025 Medicare beneficiaries age >65, we compared explicit (nurse) and implicit (physician) reviews of complications and quality in individual cases. To understand discrepancies, we calculated the kappa statistic and examined physicians' comments.Data Collection: With Medicare discharge abstracts, we used the Complications Screening Program to identify and then select a stratified random sample of cases flagged for 1 of 15 surgical complications, 5 medical complications, and unflagged controls. Peer Review Organization nurses and physicians performed chart reviews.Principal Findings: Agreement about complications was fair (kappa = 0.36) among surgical and was moderate (kappa = 0.59) among medical cases. In discordant cases, physicians said that complications were insignificant, attributable to a related diagnosis, or present on admission. Agreement about quality was poor among surgical and medical cases (kappa = 0.00 and 0.13, respectively). In discordant cases, physicians said that quality problems were unavoidable, small lapses in otherwise satisfactory care, present on admission, or resulted in no adverse outcome.Conclusions: We identified many discrepancies between explicit and implicit review of complications and quality. Physician reviewers may not consider process problems that are ubiquitous in hospitals to represent substandard quality. [ABSTRACT FROM AUTHOR]

Background: Residents planning careers in primary care have unique training needs that are not addressed in traditional internal medicine training programs, where there is a focus on inpatient training. There are no evidence-based approaches for primary care training. Objectives: Design and test the effect of a novel immersive primary care training program on educational and clinical outcomes. Design: Nested intervention study. Setting, Participants: Twelve primary care residents, 86 of their categorical peers, and an 11-year historical cohort of 69 primary care trainees in a large urban internal medicine residency training program. Interventions: Two 6-month blocks of primary care immersion alternating with two 6-month blocks of standard residency training during the second and third post-graduate years. Main Measures: Total amount of ambulatory and inpatient training time, subjective and objective educational outcomes, clinical performance on cancer screening, and chronic disease management outcomes. Key Results: Participants in the intervention increased ambulatory training in both general medicine and specialty medicine and still met all ACGME training requirements. Residents reported improved subjective educational outcomes on a variety of chronic disease management topics and ambulatory care skills. They reported higher satisfaction with the amount of ambulatory training (4.3/5 vs. 3.6/5, p=0.008), attended more ambulatory clinics (242 vs. 154, p<0.001), and carried larger, more complicated panels (173 vs. 90 patients, p<0.001). They also performed better on diabetes management (86% vs. 76% control, p<0.001). Alumni who completed the intervention reported higher primary care career preparation (79% response rate) than those who did not (85% response rate) among an 11-year cohort of primary care alumni (4/5 vs. 3/5, p<0.001). Conclusions: A primary care training program that provides clinical immersion in the ambulatory setting improved educational outcomes for trainees and clinical outcomes for their patients. Providing more training in the ambulatory environment should be a priority in graduate medical education. [ABSTRACT FROM AUTHOR]

Presents data on time trends in complementary and alternative medical (CAM) therapy use in the United States. Percentage of respondents who used at least one CAM therapy in their lifetime; Increase in lifetime use with age across the age cohorts; Similarity of the growth in CAM use across sociodemographic sectors of the study sample.

We surveyed 241 board-certified internists affiliated with a large teaching hospital (Boston, Mass) before implementing a hospitalist service to determine attitudes towards providing inpatient care and the hospitalist model. Of physicians surveyed, 66% responded. Most disagreed that inpatient care is "an inefficient use of my time," only 10% felt a hospitalist service would improve patient satisfaction, and 54% felt it would hurt patient-doctor relationships. Multivariable analyses suggest that physicians physically furthest from their inpatient site were had more favorable attitudes toward the hospitalist model; more experienced and busier physicians were more negative. Future investigations should determine strategies for implementing the hospitalist model which address physicians' concerns. [ABSTRACT FROM AUTHOR]

Ideal cardiovascular health is associated with a decrease in adverse cardiovascular events. The My Research Legacy study examined ideal cardiovascular health using the Life's Simple 7 survey and data from digital health devices. We hypothesized that digital devices provide a more objective view of overall cardiovascular health status than self-reported measures. Therefore, we analyzed weight and activity data recorded by digital devices to recalculate the Life's Simple 7 Health Score. All study participants (n = 1561) answered the survey, while a subgroup (n = 390) provided data from digital devices. Individuals with digital devices had a lower body mass index (BMI) and higher weekly minutes of vigorous exercise than participants without digital devices (p < 0.01). Baseline Health Scores were higher in individuals with digital devices compared to those without (7.0 ± 1.6 vs. 6.6 ± 1.6, p < 0.01). Data from digital devices reveal both increases and decreases in measured vs. self-reported BMI (p < 0.04) and weekly minutes of moderate and vigorous exercise activity (p < 0.01). Using these data, a significant difference was found between the recalculated and the self-reported Life's Simple 7 Health Score (p < 0.05). These findings suggest that incorporation of digital health devices should be considered as part of a precision medicinal approach to assessing ideal cardiovascular health. [ABSTRACT FROM AUTHOR]

Examines a survey conducted in an effort o document trends in alternative medicine used in the United States between 1990 and 1997, focusing on the high prevalence and costs of alternative medicine. Increase in alternative medicine used and expenditures between 1990 and 1997; Methodology employed in this survey; Total number of persons who participated in the survey; Results of the survey.

Determines the relationship of age with short-term survival and aggressiveness of care. Average survival of participants in 6 months; Characteristics of hospitalized patients with serious illness; Correlation of age and survival rates of participants; Effect of acute physiology and diagnosis on prognosis.

This study compares the demographic features and hospital course of all 472 patients discharged against medical advice from the general medicine service of an urban teaching hospital between 1984 and 1995 and 1,113 control patients discharged with physician approval. In the multivariate analysis, younger age (odds ratio [OR] 0.97 per year; 95% confidence interval [CI] 0.96, 0.98), male gender (OR 1.9; 95% CI 1.4, 2.4), lack of health insurance (OR 2.0; 95% CI 1.3, 3.1), Medicaid applicant or recipient status (OR 2.2; 95% CI 1.6, 3.1), admission through the emergency department (OR 2.2; 95% CI 1.4, 3.5), and lack of a personal attending physician at the time of admission (OR 2.1; 95% CI 1.6, 2.8) increased the odds of discharge against medical advice. Fifty-four percent of patients who left against medical advice were readmitted to the hospital during the study period; 98% were then discharged with physician approval. Patients who left the hospital against medical advice included many disadvantaged individuals without ongoing primary care. [ABSTRACT FROM AUTHOR]

Investigates the effect of lack in patient-physician communication in the quality of discharge planning in Beth Israel Hospital, Boston, Massachusetts. Specific inclusion criteria for patients; Patient and physician interviews; Discussion of post-discharge plans; Overestimation of patients' understanding of post-discharge plans.

Examines the clinical utility of the antinuclear antibody (ANA) testing test as a diagnostic tool for systemic lupus erythematosus (SLE). Estimated sensitivity and specificity of ANA; Description of the sensitivity and specificity of the ANA test across a range of ANA titers; Variability of the quality and content of the data.

A response from the authors of the article "Complementary and Alternative Medicine Use by U.S. Adults With Gastrointestinal Conditions: Results From the 2012 National Health Interview Survey" published in the journal in 2014 is presented.

An abstract of the study "Use of Meditation and Breathing Exercises in Mind-Body Exercise in the U.S.," by Sara A. Chacko, Christina C. Wee, Roger B. Davis and Gloria Y. Yeh is presented.

Background: Prior to the COVID‐19 pandemic there were many barriers to telemedicine primary care for adults ≥65 years including insurance coverage restrictions and having lower digital access and literacy. With the pandemic, insurance coverage broadened and many older adults utilized telemedicine creating an opportunity to learn from their experiences to inform future policy. Methods: Between April 2020 and June 2021, we conducted a cross‐sectional multimethod study of English‐speaking, cognitively‐intact, adults ≥65, who had a phone‐only and/or video telemedicine visit with their primary care physician within one large Massachusetts health system (10 different practices) since March 2020. The study questionnaire asked participants their overall satisfaction with telemedicine (7‐point scale) and to compare telemedicine with in‐person care. We used linear regression to examine the association between participants' demographics, Charlson comorbidity score, and survey completion date with their satisfaction score. The questionnaire also included open‐ended questions on perceptions of telemedicine; which were analyzed using qualitative methods. Results: Of 278 eligible patients reached, 208 completed the questionnaire; mean age was 74.4 years (±4.4), 61.5% were female, 91.4% were non‐Hispanic White, 64.4% had ≥1 comorbidity, and 47.2% had a phone‐only visit. Regardless of their age, participants reported being satisfied with telemedicine; median score was 6.0 on the 7‐point scale (25th percentile = 5.0 and 75th percentile = 7.0). Non‐Whites satisfaction scores were on average 1 point lower than those of non‐Hispanic Whites (p = 0.02). Those with comorbidity reported scores that on average were 0.5 points lower than those without comorbidity (p = 0.07). Overall, 39.5% felt their telemedicine visit was worse than in‐person care; 4.9% thought it was better. Participants appreciated telemedicine's convenience but described frustrating technical challenges. While participants preferred in‐person care, most wanted telemedicine to remain available. Conclusions: Adults ≥65 reported being satisfied with primary care telemedicine during the pandemic's first 14 months and wanted telemedicine to remain available. See related Editorial by Biese et al. in this issue. [ABSTRACT FROM AUTHOR]

Background: Many physicians believe that advanced practice clinicians (APCs [nurse practitioners and physician assistants]) provide care of relatively lower value.Objective: To compare use of low-value services among U.S. APCs and physicians.Design: Service use after primary care visits was evaluated for 3 conditions after adjustment for patient and provider characteristics and year. Patients with guideline-based red flags were excluded and analyses stratified by office- versus hospital-based visits, acute versus nonacute presentations, and whether clinicians self-identified as the patient's primary care provider (PCP).Setting: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS), 1997 to 2011.Patients: Patients presenting with upper respiratory infections (URIs), back pain, or headache.Measurements: Use of guideline-discordant antibiotics (for URIs), radiography (for URIs and back pain), computed tomography (CT) or magnetic resonance imaging (MRI) (for headache and back pain), and referrals to other physicians (for all 3 conditions).Results: 12 170 physician and 473 APC office-based visits and 13 359 physician and 2947 APC hospital-based visits were identified. Although office-based clinicians saw similar patients, hospital-based APCs saw younger patients (mean age, 42.6 vs. 45.0 years; P < 0.001), and practiced in urban settings less frequently (49.7% vs. 81.7% of visits; P < 0.001) than hospital-based physicians. Unadjusted and adjusted results revealed that APCs ordered antibiotics, CT or MRI, radiography, and referrals as often as physicians in both settings. Stratification suggested that self-identified PCP APCs ordered more services than PCP physicians in the hospital-based setting.Limitation: NHAMCS reflects hospital-based APC care; NAMCS samples physician practices and likely underrepresents office-based APCs.Conclusion: APCs and physicians provided an equivalent amount of low-value health services, dispelling physicians' perceptions that APCs provide lower-value care than physicians for these common conditions.Primary Funding Source: U.S. Health Services and Research Administration, Ryoichi Sasakawa Fellowship Fund, and National Institutes of Health. [ABSTRACT FROM AUTHOR]

Objectives: Little is known about Traditional Vietnamese Medicine (TVM) and its use among Vietnamese immigrants in the United States. This study aimed to characterize TVM and improve understanding of its use among Vietnamese outpatients attending an urban clinic. Methods: This cross-sectional observation study was performed by mailing bilingual surveys to a stratified random sample of 400 Vietnamese adult patients (≥18 years of age) who had visited a community health center in Boston, Massachusetts, at least once in the prior 12 months. The data were analyzed by using descriptive and multivariable regression statistics. The use of TVM and the factors influencing their use were reported. Results: Among the 216 respondents, 68% reported using TVM. Of those users, the median age was 56 years and 68% were female, 51% had lived in the United States for less than 13 years, and 91% spoke English 'not well or not at all.' Among the 89% who reported using TVM of indigenous origin, 62% used 'wind scraping,' 35% used herbal pills/products, and 30% used 'wind snatching.' Sixty-one percent used therapies of foreign origin; of those, 51% used Asian-originated TVM (herbs, 25%; Eastern massage, 23%) and 38% used Western-influenced TVM (diet supplements, 28%; Western massage, 8%). TVM was mostly used for pain conditions (57%), 'staying well' (38%), and cough/colds (27%). Forty-five percent ignored the question on revealing TVM use to providers; of those who answered, 57% said 'no.' Fifty-one percent of TVM users reported using Western medicine for the same problem, while 46% used TVM and Western medicine within 2 days of each other. Self-rated health (odds ratio [OR], 2.61; 95% confidence interval [CI], 1.34-5.06), household size (OR, 2.09; 95% CI, 1.04-4.22), and education (OR, 2.65; 95% CI, 1.03-6.80) were associated with TVM use. Conclusion: TVM is an important component of the healthcare of urban Vietnamese and needs to be further investigated. Healthcare providers need to encourage open discussion to better care for this population. [ABSTRACT FROM AUTHOR]

Background: It is unclear whether the benefits that some patients derive from complementary and integrative medicine (CIM) are related to the therapies recommended or to the consultation process as some CIM provider visits are more involved than conventional medical visits. Many patients with gastrointestinal conditions seek out CIM therapies, and prior work has demonstrated that the quality of the patient-provider interaction can improve health outcomes in irritable bowel syndrome, however, the impact of this interaction on gastroesophageal reflux disease (GERD) is unknown. We aimed to assess the safety and feasibility of conducting a 2x2 factorial design study preliminarily exploring the impact of the patient-provider interaction, and the effect of an over-the-counter homeopathic product, Acidil, on symptoms and health-related quality of life in subjects with GERD. Methods: 24 subjects with GERD-related symptoms were randomized in a 2x2 factorial design to receive 1) either a standard visit based on an empathic conventional primary care evaluation or an expanded visit with questions modeled after a CIM consultation and 2) either Acidil or placebo for two weeks. Subjects completed a daily GERD symptom diary and additional measures of symptom severity and health-related quality of life. Results: There was no significant difference in GERD symptom severity between the Acidil and placebo groups from baseline to follow-up (p = 0.41), however, subjects who received the expanded visit were significantly more likely to report a 50% or greater improvement in symptom severity compared to subjects who received the standard visit (p = 0.01). Total consultation length, perceived empathy, and baseline beliefs in CIM were not associated with treatment outcomes. Conclusion: An expanded patient-provider visit resulted in greater GERD symptom improvement than a standard empathic medical visit. CIM consultations may have enhanced placebo effects, and further studies to assess the active components of this visit-based intervention are warranted. Trial Registration: ClinicalTrials.gov [ABSTRACT FROM AUTHOR]

A response by Robert J. Mayer, Roger B. Davis and Deborah T. Berg to a letter to the editor about their article "Post-Remission Chemotherapy for Acute Myeloid Leukemia,"

Background: About 65 percent of previously untreated adults with primary acute myeloid leukemia (AML) enter complete remission when treated with cytarabine and an anthracycline. However, such responses are rarely durable when conventional postremission therapy is administered. Uncontrolled trials have suggested that intensive postremission therapy may prolong these complete remissions. Methods: We treated 1088 adults with newly diagnosed AML with three days of daunorubicin and seven days of cytarabine and randomly assigned patients who had a complete remission to receive four courses of cytarabine at one of three doses: 100 mg per square meter of body-surface area per day for five days by continuous infusion, 400 mg per square meter per day for five days by continuous infusion, or 3 g per square meter in a 3-hour infusion every 12 hours (twice daily) on days 1, 3, and 5. All patients then received four courses of monthly maintenance treatment. Results: Of the 693 patients who had a complete remission, 596 were randomly assigned to receive postremission cytarabine. After a median follow-up of 52 months, the disease-free survival rates in the three treatment groups were significantly different (P = 0.003). Relative to the 100-mg group, the hazard ratios were 0.67 for the 3-g group (95 percent confidence interval, 0.53 to 0.86) and 0.75 for the 400-mg group (95 percent confidence interval, 0.60 to 0.94). The probability of remaining in continuous complete remission after four years for patients 60 years of age or younger was 24 percent in the 100-mg group, 29 percent in the 400-mg group, and 44 percent in the 3-g group (P = 0.002). In contrast, for patients older than 60, the probability of remaining disease-free after four years was 16 percent or less in each of the three postremission cytarabine groups. Conclusions: These data support the concept of a dose-response effect for cytarabine in patients with AML who are 60 years of age or younger. The results with the high-dose schedule in this age group are comparable to those reported in similar patients who have undergone allogeneic bone marrow transplantation during a first remission. (N Engl J Med 1994;331:896-903.) [ABSTRACT FROM AUTHOR]

Background: The Gail, Breast Cancer Surveillance Consortium (BCSC), and Tyrer-Cuzick breast cancer risk prediction models are recommended for use in primary care. Calculating breast cancer risk is particularly important for women in their 40s when deciding on mammography, with some guidelines recommending screening for those with 5-year risk similar to women age 50 (≥1.1%). Yet, little is known about risk estimate agreement among models for these women. Materials and Methods: Four hundred nine Boston-area women 40–49 years of age completed a risk questionnaire before a primary care visit to compute their breast cancer risk. The kappa statistic was used to examine when (1) Gail and BCSC agreed on 5-year risk ≥1.1%; (2) Gail estimated 5-year risk ≥1.7% and Tyrer-Cuzick estimated 10-year risk ≥5% (guideline thresholds for recommending prevention medications); and when (3) Gail and Tyrer-Cuzick agreed on lifetime risk ≥20% (threshold for breast MRI using Tyrer-Cuzick). Results: Participant mean age was 44.1 years, 56.7% were non-Hispanic white, and 7.8% had a first-degree relative with breast cancer. Of 266 with breast density information to estimate both Gail and BCSC, the models agreed on 5-year risk being ≥1.1% for 36 women, kappa = 0.34 (95% confidence interval: 0.23–0.45). Gail and Tyrer-Cuzick estimates led to agreement about prevention medications for 8 women, kappa 0.41 (0.20–0.61), and models agreed on lifetime risk ≥20% for 3 women, kappa 0.08 (−0.01 to 0.16). Conclusions: There is weak agreement on breast cancer risk estimates generated by risk models recommended for primary care. Using different models may lead to different clinical recommendations for women in their 40s. [ABSTRACT FROM AUTHOR]

The article discusses a survey focusing on the perspectives of primary care physicians (PCPs) who provided telemedicine to older adults since March 2020. Results from the email survey, sent out to PCPs from September 2020 to January 2021, are presented and discussed. Self-efficacy and attitudes towards the use of telemedicine are also mentioned.

Objectives To determine whether a bundled intervention can increase detection of delirium and facilitate safer use of high-risk medications. Design Pre-post interventional trial. Setting Large academic medical center. Participants Individuals aged 70 and older (n = 19,949) admitted between May 1, 2008, September 30, 2011. Individuals aged 80 and older admitted after April 26, 2010, received the intervention, those aged 80 and older admitted before were primary controls, and those aged 70 to 79 were concurrent controls. Intervention The intervention uses a checklist promoting delirium prevention, recognition and management, and modifies the computerized provider order entry system to provide care focused on elderly adults. Measurements Frequency of orders for activating the rapid response team for altered mental status, frequency of orders for haloperidol in excess of 0.5 mg or intravenous ( IV) morphine in excess of 2 mg, and discharge disposition. Results Participants receiving the intervention had a mean age of 86.1 ± 4.6; 58.2% were female. The number of orders to activate the rapid response team for altered mental status increased in participants receiving the bundle and in controls (odds ratio ( OR) for the difference of differences = 1.23 (95% confidence interval ( CI) = 0.68-2.24, P = .49)). Participants receiving the bundle were less likely to receive more than 0.5 mg of IV, intramuscular, or oral haloperidol ( OR = 0.60, 95% CI = 0.39-0.91, P = .02) and more than 2 mg of IV morphine ( OR = 0.52, 95% CI = 0.42-0.63, P < .001). Participants who received the bundle were more likely to be discharged home than to extended care facilities ( OR = 1.18, 95% CI = 1.04-1.35, P = .01). Conclusion An intervention focused on delirium prevention and recognition by bedside staff combined with computerized decision support facilitates safer prescribing of high-risk medications and possibly results in less need for extended care. [ABSTRACT FROM AUTHOR]

Background: To help inform screening decisions, a mammography screening decision aid (DA) for women aged 75 years and older was tested in a cluster randomized clinical trial of 546 women. DA use increased women's knowledge of the benefits and harms of mammography and lowered screening rates. In the current study, the objective was to examine whether participants' views of the DA and/or its effects differed by educational attainment. Methods: A secondary analysis was conducted of 283 women who received the DA before a personal care provider (PCP) visit during the trial to examine the acceptability of the DA and its effects on knowledge of the benefits and harms of mammography, screening intentions, and receipt of screening by educational attainment. Adjusted analyses accounted for clustering by PCP. Results: Of the 283 participants, 43% had a college education or less. Regardless of educational attainment, 87.2% found the DA helpful. Women with lower educational attainment were less likely to understand all of the DA's content (46.3% vs 67.5%; P <.001), had less knowledge of the benefits and harms of mammography (adjusted mean ± standard error knowledge score, 7.1 ± 0.3 vs 8.1 ± 0.3; P <.001), and were less likely to lower screening intentions (adjusted percentage, 11.4% vs 19.4%; P =.01). Receipt of screening did not differ by educational attainment. Conclusions: A mammography DA for women aged 75 years and older was helpful to women regardless of their educational attainment; however, those with a college degree or greater understood the DA and, possibly as a result, lowered their screening intentions. Future studies need to examine how to better support informed decision making around mammography screening in older women with lower educational attainment. Lay Summary: The authors examined data from a previous study to learn the effects of a mammography decision aid (DA) for women aged 75 years and older according to their level of education.Overall, women found the DA helpful, but women with lower educational attainment found it harder to understand the benefits and harms of mammography screening and were less likely to lower their screening intentions than women with a college degree.The findings suggest that women aged 75 years and older who have lower educational attainment may need an even lower literacy DA and/or more support from health care professionals. It is important to examine whether there are differential effects of a mammography screening decision aid (DA) for women aged 75 years and older based on older women's educational attainment. If the effects of the DA are better understood, they can inform the implementation of this DA and the development of other DAs. [ABSTRACT FROM AUTHOR]

Objectives: The study objectives were to determine the feasibility and effects of providing therapeutic massage at home for patients with metastatic cancer. Design: This was a randomized controlled trial. Settings/location: Patients were enrolled at Oncology Clinics at a large urban academic medical center; massage therapy was provided in patients' homes. Subjects: Subjects were patients with metastatic cancer. Interventions: There were three interventions: massage therapy, no-touch intervention, and usual care. Outcome measures: Primary outcomes were pain, anxiety, and alertness; secondary outcomes were quality of life and sleep. Results: In this study, it was possible to provide interventions for all patients at home by professional massage therapists. The mean number of massage therapy sessions per patient was 2.8. A significant improvement was found in the quality of life of the patients who received massage therapy after 1-week follow-up, which was not observed in either the No Touch control or the Usual Care control groups, but the difference was not sustained at 1 month. There were trends toward improvement in pain and sleep of the patients after therapeutic massage but not in patients in the control groups. There were no serious adverse events related to the interventions. Conclusions: The study results showed that it is feasible to provide therapeutic massage at home for patients with advanced cancer, and to randomize patients to a no-touch intervention. Providing therapeutic massage improves the quality of life at the end of life for patients and may be associated with further beneficial effects, such as improvement in pain and sleep quality. Larger randomized controlled trials are needed to substantiate these findings. [ABSTRACT FROM AUTHOR]

Background: Hemoglobin A1c (HbA1c) levels are known to be consistently higher In black persons than in white persons at any given glycemic level. Whether the optimal diagnostic threshold of HbA1c should differ between blacks and whites is unclear. Objective: To compare the relationships between HbA1c level and the prevalence of retinopathy in black and white U.S. adults. Design: Cross-sectional study. Setting: A nationally representative sample of the National Health and Nutrition Examination Survey from 2005 through 2008. Patients: 2804 white persons and 1008 black persons aged 40 years or older in the United States. Measurements: Prevalence of retinopathy. Logistic regression models and restricted cubic spline models were constructed sepa-rately for white and black populations to test the HbA1c levels at which risk for retinopathy begins to increase. Results: After adjustment for age, sex, hypertension, body mass index, family history of diabetes, and use of antidiabetes medications or insulin, the lowest HbA1c category for which the prevalence of retinopathy was significantly higher than the reference category (<5.5%) was 6.0% to 6.4% for white persons (risk difference, 4.8% [95% CI, 0.5% to 9.1%]) and 5.5% to 5.9% for black persons (risk difference, 5.3% [CI, 1.0% to 9.5%]). The restricted cubic spline models Indicated that the risk for retinopathy Increased at lower HbA1c levels in black persons than in white persons. Limitation: The cross-sectional design of the study precluded ex-amining the effect of the duration at each HbA1c level. Conclusion: The prevalence of retinopathy begins to increase at a lower HbA1c level in black Americans than In white Americans. The findings do not support increasing the diagnostic threshold of HbA1c in black persons. Primary Funding Source: None. [ABSTRACT FROM AUTHOR]

Abstract: It is commonly believed that blinding to treatment assignment is necessary for placebos to have an effect. However, placebos administered without concealment (ie, open-label placebos [OLPs]) have recently been shown to be effective in some conditions. This study had 2 objectives: first, to determine whether OLP treatment is superior to no-pill control (NPC) in irritable bowel syndrome (IBS) and, second, to compare the efficacy of OLP against double-blind placebo (DBP). In a 6-week, 3-arm, randomized clinical trial, participants were randomized in equal proportions to 3 arms: OLP, DBP, or NPC. Two hundred sixty-two adults (72.9% women), with a mean age of 42.0 (SD = 18.1) years, participated in the primary study. The mean improvement on the IBS Severity Scoring System from baseline to the 6-week end point was significantly greater in OLP compared with that in NPC (90.6 vs 52.3, P = 0.038). Open-label placebo and DBP did not differ significantly on IBS Severity Scoring System improvement (100.3 vs 90.6, P = 0.485). Standardized effect sizes were moderate for OLP vs NPC (d = 0.43) and small for OLP vs DBP (d = 0.10). Participants treated with OLP reported clinically meaningful improvements in IBS symptoms that were significantly greater than those on NPC. Open-label placebo and DBP had similar effects that did not differ significantly, suggesting that blinding may not be necessary for placebos to be effective and that OLP could play a role in the management of patients with refractory IBS. [ABSTRACT FROM AUTHOR]

Abstract: Introduction: Dysphagia is a common side effect following chemoradiation therapy (CRT) in head and neck cancer (HNC) patients. Current dysphagia management includes swallowing therapy and dilation procedures, but these treatments have limitations. While acupuncture has been reported to positively impact swallowing function and quality of life (QOL) in patients with dysphagia, current evidence is inconclusive. Material and methods: In an ongoing trial, 42 squamous cell carcinoma HNC patients, who are receiving platinum-based CRT with curative intent, are being recruited from a comprehensive cancer center. They are randomized to 12 sessions of either active acupuncture or to sham acupuncture during and following CRT over a 24-week period. Blinded research staff assesses outcomes at baseline, 20weeks post-CRT (end of acupuncture), and 12months after baseline (6-month follow-up). The primary outcome is change in M.D. Anderson Dysphagia Inventory score from baseline to 12months. Secondary outcomes include QOL measures pertaining to HNC patients. In addition, a subset of study patients are tested for salivary flow rates and cytokines, including plasma transforming growth factor-β1 and interleukin 6 (n=10 per arm), to preliminarily explore the biological mechanisms of acupuncture for dysphagia. Discussion: This paper addresses unique challenges related to study design in nonpharmacological, sham-controlled acupuncture trials including development of evidence-based credible verum and sham treatment protocols, blinding, and assuring fidelity of treatment. Results of this study will inform the feasibility of conducting a large scale trial and will provide preliminary evidence regarding the value of acupuncture for dysphagia in HNC patients. [Copyright &y& Elsevier]