Objective The goal of this pilot study was to evaluate adherence to the 2012 cervical cancer screening guidelines among health care providers in a large health maintenance organization. Study Design ...A cross-sectional survey evaluating knowledge, reported practices, and views of the 2012 cervical cancer screening guidelines was distributed to 325 health care providers within HealthPartners. The survey was divided into 3 sections: (1) provider demographics; (2) knowledge of the 2012 age-specific cancer screening guidelines; and (3) provider practice. Comparisons based on appropriate knowledge and practice of the guidelines were made using Fisher exact tests. Results The response rate was 42%. Of 124 respondents, 15 (12.1%) reported they were not aware of the 2012 guideline changes. Only 7 (5.7%) respondents answered all the knowledge questions correctly. A majority of respondents reported correct screening practices in the 21-29 year patient age group (65.8%) and in the >65 year patient age group (74.3%). Correct screening intervals in the 30-65 year patient age group varied by modality, with 89.3% correctly screening every 3 years with Pap smear alone, but only 57.4% correctly screening every 5 years with Pap smear + human papillomavirus cotesting. The most frequently cited reasons for not adhering were lack of knowledge of the guidelines and patient demand for a different screening interval. Conclusion Adherence to the 2012 cervical cancer screening guidelines is poor due, in part, to a lack of knowledge of the guidelines. Efforts should focus on improved provider and patient education, and methods that facilitate adherence to the guidelines such as electronic health record order sets.
...lack of SDB data in the National Health and Nutrition Examination Survey sample limits our ability to compare fully our 2 study populations, and our relatively small sample size limits more ...complex analyses. Table 1 Baseline Demographics and Characteristics Data are presented as mean ± SD for continuous variable and as percentages for categorical variables.BMI = body mass index; HDL = high-density lipoprotein; LDL = low-density lipoprotein; NFL = National Football League; NHANES = National Health and Nutrition Examination Survey; SDB = sleep-disordered breathing.
Aerobic activity performed on a regular basis is 1 of several lifestyle recommendations endorsed to reduce risk of coronary disease. However, 1 potential concern of arduous aerobic activity is ...exercise-induced hypertension. This is the first case to our knowledge, of accelerated coronary calcification in an otherwise asymptomatic middle-aged male marathon runner devoid of traditional cardiovascular risk factors. As a consequence of exercise-induced hypertension and associated oxidative stress, improvement of endothelial dysfunction occurred after antioxidant supplementation. In conclusion, vigorous aerobic activity in susceptible individuals may promote oxidative stress and coronary atherosclerosis.
Abstract Background: High-dose estrogens (HDEs) are an efficacious but widely overlooked treatment option for patients with metastatic breast cancer (MBC). This is due in part to the introduction of ...tamoxifen in the 1970s, which was proven to be equivalent in efficacy and associated with fewer adverse events (AEs). Objective: The aim of this study was to report our experience with the use of HDE in postmenopausal women with advanced breast cancer. Methods: Local institutional review board approval was obtained to conduct a retrospective chart review of patients with MBC treated with HDEs at the Boca Raton Comprehensive Cancer Center, Boca Raton, Florida, from 2001 through March 2009. Demographic information, response rates, and tolerability profiles were collected. Results: Of the 426 patients with MBC identified, we found 26 patients with MBC who were prescribed HDEs as a treatment in any line of therapy for advanced breast cancer. The median age at the start of HDE therapy was 59 years (range, 42–92 years). Three of the 26 patients (11.5%) were human epidermal growth factor receptor 2-positive determined via fluorescent in situ hybridization analysis. With the exception of 1 patient who had received no prior systemic treatment for metastatic disease, all patients received multiple lines of treatment (both chemotherapy and hormonal treatments) in the advanced setting (median, 7 lines; range, 0–12) prior to the initiation of HDE. Five of 20 patients (25%) with measurable metastatic disease (visceral and/or soft tissue metastases) had objective antitumor responses defined as either a partial response (PR) or a complete response (CR). Four additional patients (20%) had prolonged stable disease (SD) for ≥6 months. Three of 6 patients (50%) with nonmeasurable metastatic disease (bone-only) had prolonged SD for ≥6 months. Clinical benefit rate (defined as CR + PR + SD ≥6 months) for all patients was 46% (12/26), with a median duration of 10 months. Overall median progression-free survival for the 26 subjects was 5 months. Median survival from the start of HDE was 17 months (range, 3–54 months). AEs included fluid retention (8 31%), vaginal bleeding (7 27%), and nausea (4 15%). Two patients discontinued therapy after 1 month. Three of the remaining 24 patients discontinued estrogen therapy due to AEs. Conclusions: This retrospective chart review details our facility's experience with the use of HDE in patients with advanced breast cancer, most of whom had received multiple prior treatments. Our data suggest that this treatment is another option for heavilytreated patients in whom further endocrine manipulation might still be appropriate.
Chronic chest pain can arise from a variety of etiologies. However, of those potential causes, the most life-threatening include cardiac disease. Chronic cardiac chest pain may be caused either by ...ischemia or atherosclerotic coronary artery disease or by other cardiac-related etiologies, such as pericardial disease. To consider in patients, especially those who are at low risk for coronary artery disease, are etiologies of chronic noncardiac chest pain. Noncardiac chest pain is most commonly related to gastroesophageal reflux disease or other esophageal diseases. Alternatively, it may be related to costochondritis, arthritic or degenerative diseases, old trauma, primary or metastatic tumors, or pleural disease. Rarely, noncardiac chest pain may be referred pain from organ systems below the diaphragm, such as the gallbladder. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.
Tuberous sclerosis complex (TSC) is a genetic neurocutaneous syndrome in which cognitive and social-behavioral outcomes for patients vary widely in an unpredictable manner. The cause of adverse ...neurologic outcome remains unclear. The aim of this study was to investigate the hypothesis that disordered white matter and abnormal neural connectivity are associated with adverse neurologic outcomes.
Structural and diffusion magnetic resonance imaging was carried out in 40 subjects with TSC (age range, 0.5-25 years; mean age, 7.2 years; median age, 5 years), 12 of whom had autism spectrum disorders (ASD), and in 29 age-matched controls. Tractography of the corpus callosum was used to define a three-dimensional volume of interest. Regional averages of four diffusion scalar parameters of the callosal projections were calculated for each subject. These were the average fractional anisotropy (AFA) and the average mean, radial, and axial diffusivity.
Subjects with TSC had significantly lower AFA and higher average mean, radial, and axial diffusivity values compared to controls. Subjects with TSC and ASD had significantly lower AFA values compared to those without ASD and compared to controls. Subjects with TSC without ASD had similar AFA values compared to controls.
Diffusion tensor scalar parameters provided measures of properties of the three-dimensional callosal projections. In TSC, changes in these parameters may reflect microstructural changes in myelination, axonal integrity, or extracellular environment. Alterations in white matter microstructural properties were associated with TSC, and larger changes were associated with TSC and ASD, thus establishing a relationship between altered white matter microstructural integrity and brain function.
One possible way for spiral galaxies to internally evolve would be for gas to flow to the center and form stars in a central disk (pseudo-bulge). If the inflow rate is faster than the rate of star ...formation, a central concentration of gas will form. In this paper we present radial profiles of stellar and 8 km emission from polycyclic aromatic hydrocarbons (PAHs) for 11 spiral galaxies to investigate whether the interstellar medium in these galaxies contains a central concentration above that expected from the exponential disk. In general, we find that the two-dimensional CO and PAH emission morphologies are similar, and that they exhibit similar radial profiles. We find that in 6 of the 11 galaxies there is a central excess in the 8 km and CO emission above the inward extrapolation of an exponential disk. In particular, all four barred galaxies in the sample have strong central excesses in both 8 km and CO emission. These correlations suggest that the excess seen in the CO profiles is, in general, not simply due to a radial increase in the CO emissivity. In the inner disk, the ratio of the stellar to the 8 km radial surface brightness is similar for 9 of the 11 galaxies, suggesting a physical connection between the average stellar surface brightness and the average gas surface brightness at a given radius. We also find that the ratio of the CO to 8 km PAH surface brightness is consistent over the sample, implying that the 8 km PAH surface brightness can be used as an approximate tracer of the interstellar medium.
Background Recommendations for the use of real-time ultrasonography for placement of central venous catheters in children are based on studies involving adults treated by nonsurgeons. Our purpose was ...to determine the frequency of use of real-time ultrasonography use by pediatric surgeons during central venous catheter placement, patient and procedure factors associated with real-time ultrasonography use, and adverse event rates. Methods Using data gathered from 14 institutions, we performed a retrospective cohort study of patients <18 years old who underwent central venous catheter placement. Patient demographics and operative details were collected. We used a logistic regression model to evaluate factors associated with real-time ultrasonography use. Results Real-time ultrasonography was used in 33% of attempts ( N = 1,146). The subclavian vein (64%) was accessed preferentially for first site insertion. Real-time ultrasonography was less likely to be used for subclavian vein (odds ratio = 0.002; P < .0001) and more likely to be used when coagulopathy (international normalized ratio >1.5) was present (odds ratio = 11.1; P = .03). The rate of mechanical complications was 3.5%. Real-time ultrasonography use was associated with greater procedural success rates on first-site attempt, but also with a greater risk of hemothorax. Conclusion Pediatric surgeons access preferentially the subclavian vein for central venous access, yet are less likely to use real-time ultrasonography at this site. Real-time ultrasonography was superior to the landmark techniques for the first-site procedure success, yet was associated with greater rates of hemothorax. Prospective trials involving children treated by pediatric surgeons are needed to generate more definitive data.
Background The etiology of cardiovascular disease (CVD) is multifactorial. Efforts to identify genes influencing CVD risk have met with limited success to date, likely because of the small effect ...sizes of common CVD risk alleles and the presence of gene by gene and gene by environment interactions. Methods The HAPI Heart Study was initiated in 2002 to measure the cardiovascular response to 4 short-term interventions affecting cardiovascular risk factors and to identify the genetic and environmental determinants of these responses. The measurements included blood pressure responses to the cold pressor stress test and to a high salt diet, triglyceride excursion in response to a high-fat challenge, and response in platelet aggregation to aspirin therapy. Results The interventions were carried out in 868 relatively healthy Amish adults from large families. The heritabilities of selected response traits for each intervention ranged from 8% to 38%, suggesting that some of the variation associated with response to each intervention can be attributed to the additive effects of genes. Conclusions Identifying these response genes may identify new mechanisms influencing CVD and may lead to individualized preventive strategies and improved early detection of high-risk individuals.
Background Most patients with Zollinger-Ellison Syndrome (ZES), even those in whom gastrinoma is found and resected at initial operation, will suffer from persistent or recurrent disease in longterm ...followup. There is currently no consensus about managing patients with recurrent or persistent ZES. Our unit has historically maintained an aggressive approach toward monitoring and reoperation for patients with sporadic ZES. Study Design We performed a review of a consecutive series of patients evaluated and managed at our institution between 1970 and 2007 for ZES. “Biochemical cure” was defined as normal serum gastrin assays and negative imaging studies. Reoperations were performed for elevations in serum gastrin assays and positive findings on imaging studies. Results Fifty-two patients with sporadic ZES were analyzed. Median followup was 14 years. Among patients with sporadic ZES, 37 patients underwent operative management. The most common operations were resection of duodenal gastrinoma (n = 8) and total gastrectomy (n = 7). Nine patients underwent 15 reoperations for recurrent or persistent disease. “Biochemical cure” was obtained in four patients (44%) undergoing reoperation for ZES. Three of these patients remained without evidence of recurrence at 4, 9, and 12 years after their curative re-resection. Only one of nine patients who underwent reoperation died of metastatic gastrinoma. Conclusions Primary and reoperative surgery in patients with sporadic ZES results in a significant rate of “biochemical cure.” In selected patients with recurrent or persistent disease, reoperation for resection of gastrinoma is associated with excellent longterm survival and is warranted.
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