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The Affordable Care Act and change in human papillomavirus (HPV) vaccine uptake in the United States
No full textBACKGROUND: Human papillomavirus (HPV) vaccination uptake has increased in the United States yet continues to fall short of the Healthy People 2030 goal. Cost of care is a known barrier. The Affordable Care Act (ACA) aimed to enhance access to preventive healthcare services, including HPV vaccination. Our study examined the association between the ACA and known vaccination-enabling factors in the United States.
METHODS: We analyzed data from 29,216 adults aged 18-26 in the National Health Interview Survey from 2011 to 2017. Changes in vaccination-enabling factors (regular physician visitation and changes in health insurance status) and HPV vaccination status pre- (2011-2013; n = 13,494) to post-ACA (2014-2017; n = 15,722) were assessed using logistic regression models adjusted for poverty, education, marital status, comorbidities, sex, and geography.
RESULTS: A total of 13,494 and 15,722 eligible individuals were identified pre- and post-ACA, respectively. Post-ACA, the proportion of individuals reporting receipt of one dose of the HPV vaccine increased by 43 % (3.9 % to 5.5 %; OR 1.45, 95 % CI 1.24, 1.70; p \u3c .001), with significant gains among non-Hispanic White (OR 1.55, 95 % CI 1.24, 1.94) and Black individuals (OR 1.59, 95 % CI 1.12, 2.29). Completion of ≥2 doses rose from 12.5 % to 17.8 % (OR 1.62, 95 % CI 1.47, 1.79), notably among Hispanic individuals (7.6 % to 14.7 %, OR(interaction) = 1.36, 95 % CI 1.05, 1.77; p = .020). Post-ACA, there was a significant decrease in uninsured rates and an increase in vaccination completion odds among individuals privately insured (OR 1.36, 95 % CI 1.22, 1.52; p \u3c .001) and those insured by Medicaid (OR 1.81, 95 % CI 1.35, 2.43; p \u3c .001). Regular physician visits also rose pre- to post-ACA (53.1 % to 57.1 %, OR 1.17, 95 % CI 1.09, 1.25; p \u3c .001).
CONCLUSION: The ACA has been associated with increased HPV vaccination uptake, especially among racial/ethnic minorities, gains likely driven by an increase in vaccination-enabling factors such as decreased uninsurance and increased access to physician visits
Management of the Undiagnosed Pleural Effusion
No full textPurpose of Review: Despite a reasonable initial workup, a significant proportion of pleural effusions (PE) remain undiagnosed. We review here the management of the undiagnosed PE with a focus on an evidence-based evaluation of persistent unexplained PEs.
Recent Findings: The pooled sensitivity of pleural fluid cytology for malignancy is low (58.2%) and varies considerably based on tumor type without significant increase upon re-testing. However, pleural tissue biopsy via thoracoscopy carries a much higher diagnostic yield for maligancy, particularly mesothelioma, with a low complication rate. Importantly, the combination of the thoracoscopic visual assessment of the pleura, pleural touch preparations, and the presence of pleural nodules on computed tomography carries a high predictive accuracy for malignant PE (94%). In tuberculosis-endemic countries, thoracoscopy may not be necessary since closed needle pleural biopsy’s diagnostic yield is high. Also, pleural fluid adenosine deaminase carries a good sensitivity (87.5%) and specificity (87.82%). More recently, anti-inflammatory therapy with intravenous dexamethasone for parapneumonic effusions did not improve serum inflammatory markers compared to placebo. The combination of intrapleural tissue plasminogen activator and DNase reduced the frequency of referral for surgical treatment.
Summary: Work up of the undiagnosed PE requires a thorough and systematic approach. Management relies on patient-centered outcomes. Artificial intelligence and machine learning may help provide a new venue in the future to differentiate malignant from non-malignant PEs
Disappearing colorectal liver metastases: the importance of radiographic-pathologic correlation in oncology care
No full textGlobal Andrology Forum Clinical Practice Guidelines on the Management of Premature Ejaculation
No full textPURPOSE: Premature ejaculation (PE) is a commonly encountered male sexual dysfunction (MSD) with various definitions, diagnostic criteria, and treatment options, leading to significant heterogeneity and controversy in its management. This study aimed to explore the global practice patterns of the diagnosis and management of PE.
MATERIALS AND METHODS: A cross-sectional, global, online survey on PE was conducted using a questionnaire developed by an international cohort of experts. Results were analyzed using R version 4.1.2. Additionally, expert recommendations were formulated using a modified Delphi method.
RESULTS: The survey was completed by 264 participants from 41 countries. The majority of respondents were below the age of 45 years and were urologists focusing on andrology and sexual health. PE diagnosis was primarily based (by 61.5%) on an intravaginal ejaculatory latency time of less than one minute. Lifelong PE was the most common category reported (47.7%), and most respondents (84.2%) observed ante-portas PE in less than 25% of cases. Distinguishing PE from erectile dysfunction was challenging for many respondents (60.7%). Diabetes mellitus was the most common comorbidity (17.1%). Pharmacological therapy was the most common treatment method (34.3%), with dapoxetine being the most preferred medication (37.9%). Surgical methods were infrequently used. Emerging treatments like hyaluronic acid gel glans augmentation were favored by only 11.7%. Patient satisfaction was the primary criterion for successful PE treatment (55.9%), and cost was a significant concern for many (35.5%).
CONCLUSIONS: This global survey highlights significant diversity in the diagnostic and treatment strategies for PE. Standard diagnostic criteria are generally accepted, off-label medication is widely used in therapy, and the role of surgery is still controversial. A multi-modal therapy approach, tailored to the patient\u27s specific needs, is favored. Further research into the neurobiology of PE and the development of effective and safe options is crucial for improving the management of PE
Anesthesiology Resident Demographics and the BASIC Examination Pass Rates
No full textBACKGROUND: The BASIC Examination was added to the US examination system for anesthesiology certification in 2014. The American Board of Anesthesiology conducted retrospective analyses to assess whether resident demographics, program characteristics, and/or prior examination performance were associated with first-time BASIC pass rates.
METHODS: Anesthesiology residents who took the BASIC Examination for the first time from July 2014 to November 2022 were eligible to participate, and they had at least 2 more attempts (or opportunities to attempt) through December 2023. First-time and eventual pass rates (ie, based on up to 3 attempts) were calculated for each demographic group. For those residents who had the clinical base year in-training examination (CBY ITE) scores available, demographic group performance differences on this examination were first examined. Mixed-effects logistical regression models assessed how resident demographics, program characteristics, and/or prior CBY ITE scores were associated with the odds of passing the BASIC the first time.
RESULTS: The analyses included 17,286 examination attempts from 15,789 residents. The majority of residents were male (65.8%), non-Hispanic or Latino (76.2%), White (47.8%), and US medical school graduates (87.4%). Differences in the first-attempt BASIC pass rates included male (92.7%) vs female (88.1%), non-Hispanic or Latino (92.0%) vs Hispanic or Latino (85.8%), Asian (92.6%) and White (92.4%) vs Black/African American (81.9%), respectively, and US (91.5%) vs international (88.6%) medical school graduates. Females had significantly lower odds of passing the BASIC the first time than males (odds ratio [OR] = 0.53, 95% confidence interval [CI], 0.47-0.60); Black/African American residents (OR = 0.41, 95% CI, 0.33-0.51) and Middle Eastern or North African residents (OR = 0.64, 95% CI, 0.46-0.91) had lower odds of passing the BASIC on first attempt than White residents; Hispanic or Latino residents had lower odds of passing the BASIC initially than non-Hispanic or Latino residents (OR = 0.52, 95% CI, 0.42-0.64). Nevertheless, all demographic subgroups\u27 eventual pass rates were \u3e99%.Male and White residents outperformed female and Black/African American residents, respectively, in CBY ITEs. The gender and race performance gaps in the first-time BASIC pass rates were attenuated but not eliminated after controlling for their CBY ITE scores-compared to male and White residents, respectively, the odds of passing the BASIC the first time changed from 46% to 56% for female residents, and from 41% to 53% for Black/African American residents.
CONCLUSIONS: Female and nonwhite residents had lower first-time BASIC Examination pass rates. Almost all trainees passed by their up-to-third attempts. Future studies are needed to understand the basis of these differences and identify opportunities for improvement
Best Practices for Imaging of Transcatheter Valve Failure: An Update From the Heart Valve Collaboratory
No full textThis updated Heart Valve Collaboratory framework addresses the growing concern for transcatheter valve failure (TVF) following transcatheter aortic valve replacement (TAVR). With the increasing volume of redo-TAV and surgical TAV explantation, there is a critical need for standardized pathways and protocols for evaluating TVF using echocardiography and cardiac computed tomography (CT) angiography. This document clarifies prior definitions of bioprosthetic valve deterioration and bioprosthetic valve failure in a practical, imaging directed context for TAVR. It discusses various imaging modalities for diagnosing TVF, including echocardiography, cardiac CT angiography, cardiac magnetic resonance, and positron emission tomography/CT. Recommendations are provided on the systematic imaging for: 1) follow-up post-TAVR; 2) procedural planning for redo-TAV; and 3) post-redo-TAV, emphasizing the importance of regular monitoring and the need for comprehensive imaging data to optimize patient outcomes in the lifetime management of aortic valve disease
Over a decade later and Addiction journal is still committed to publishing qualitative research
No full textHere Comes the Sun! A Study on Sun Exposure and Associated Risks in the Canadian Population
No full textOBJECTIVE: To evaluate the awareness of and attitudes toward various aspects of sun-exposure risks and protection methods among Canadians.
METHODS: An online survey conducted from September 28 to October 18, 2021, included 17,001 participants aged 18 years and above from 17 countries across 5 continents; the data presented are those of the Canadian population (n = 1,000). The survey focused on demographics, sun-exposure habits, comprehension of risks, and knowledge of photoprotection. The results were analyzed using descriptive statistics to identify prevalent trends and discrepancies in sun-protective behaviours among Canadians.
RESULTS: The majority of Canadian respondents (93%) acknowledged the health risks associated with sun exposure. While 81% of Canadians reported using some form of sun protection, only 10% systematically implemented all recommended protective measures, highlighting a gap in knowledge translation. Misconceptions regarding the safety of tanned skin and the effectiveness of sunscreens were widespread, particularly in younger demographics and in individuals with darker skin. Knowledge and preventive behaviours were markedly better among individuals who regularly consult dermatologists.
CONCLUSIONS: This study highlights general awareness of sun-protective behaviours but a lack of universal and comprehensive implementation among Canadians. Given the knowledge gaps in younger demographics and darker skin phototypes, targeted educational initiatives are essential to correct prevalent misconceptions about sun exposure and tanned skin. Dermatologists and other health care professionals can play a pivotal role in education and primary prevention strategies for skin cancer and other sun-related comorbidities
S2303: phase II/III trial of paclitaxel + ramucirumab ± nivolumab in gastric and esophageal adenocarcinoma (PARAMUNE)
No full textCancer of the stomach and esophagus is aggressive with poor patient outcomes. Historically, the treatment for such patients has involved the use of combined chemotherapy. In recent years, the addition of immunotherapy to the treatment of patients with advanced cancers of the stomach and esophagus has led to patients living longer with a longer period without tumor growth. However, whether continuing the immunotherapy after the tumor has grown while on treatment is beneficial or not is a question that has not been answered. The standard treatment after patients’ tumor has grown on their initial treatment involves a drug called ramucirumab, which blocks the ability of cancer cells to create abnormal blood vessels around itself to support its own growth. Recent research suggests that drugs like ramucirumab make immunotherapy more effective. To test whether continuing immunotherapy in combination with this “second-line” treatment that includes ramucirumab, we have designed a study to compare whether one group who will receive immunotherapy will live longer versus another group who will not receive immunotherapy