Predicting Peak Productivity in Urologic Medicare Practice via Work-Relative Value Units.

OBJECTIVE: To explore factors associated with productivity in urologic practice. Work-relative value units (wRVUs), the basis for Center for Medicare & Medicaid Services (CMS) and private payer reimbursements, commonly serve to estimate physician productivity. Limited data describes which practice factors predict increased wRVU productivity. METHODS: The 2017 and 2018 CMS databases were retrospectively queried for urologic Medicare provider demographics and procedural/service details. Medical school graduation year was used to estimate years in practice and generation (Millennial, Gen X, Baby Boomer, or Post-War). Treated patients' demographics were obtained. Adjusted and unadjusted linear mixed models were performed to predict wRVU production. RESULTS: Included were 6773 Medicare-participating urologists across the United States. Millennials produced 1115 wRVUs per year, while Gen X and Baby Boomers produced significantly more (1997 and 2104, respectively, P <.01). Post-War urologists produced numerically more (1287, P = .88). In adjusted analyses, predictors of Medicare wRVU productivity included female and pelvic medicine and reconstructive surgery (exponentiated beta estimate (ß) 1.46, 95% CI 1.32-1.60), men's health (ß 1.22, 95% CI 1.13-1.32), and oncologic subspecialization (ß 1.08, 95% CI 1.02-1.14), female gender (ß 0.87, 95% CI 0.82-0.92), wRVUs generated from inpatient procedures (ß 1.08, 95% CI 1.06-1.09) and office visits (ß 0.88, 95% CI 0.87-0.89), and the level of education (ß 1.10, 95% CI 1.07-1.14) and percent impoverished patients (ß 0.85, 95% CI 0.83-0.88) in provider's practice zip code. CONCLUSION: Urologic experience, specialization, demographics, practice patterns, and patient demographics are significantly associated with wRVU productivity in Medicare settings. Further work should incorporate quality metrics into wRVUs and ensure patient demographics do not affect reimbursement.

Racial disparities in outcomes of patients with stage I-III triple-negative breast cancer after adjuvant chemotherapy: a post-hoc analysis of the E5103 randomized trial.

PURPOSE: Breast cancer mortality is higher in Black women than other racial groups. This difference has been partially attributed to a higher proportion of triple-negative breast cancer (TNBC). However, it is uncertain if survival disparities exist in racially diverse TNBC patients receiving similar treatments. Here, we examine racial differences in disease-related outcomes in TNBC patients treated on the E5103 clinical trial. METHODS: From 2007 to 2011, 4,994 patients with stage I-III HER2-negative breast cancer were randomized to adjuvant chemotherapy with or without bevacizumab. This analysis was limited to the subset of 1,742 TNBC patients with known self-reported race. Unadjusted Kaplan-Meier curves and adjusted Cox-Proportional Hazards models were used to determine breast cancer events and survival outcomes. RESULTS: Of the analysis population, 51 (2.9%) were Asian, 269 (15.4%) Black, and 1422 (81.6%) White. Median age was 51 years. Patient characteristics, treatment arm, and local therapies were similar across racial groups. White women were more commonly node-negative (56% vs. 49% and 44% in Asian and Black women, respectively; p < 0.01). At a median follow-up of 46 months, unadjusted Kaplan-Meier locoregional and distant recurrence, and disease-free and overall survival, did not differ significantly by race. In Cox models adjusted for patient and tumor characteristics and treatment arm, race was not associated with any disease event. Larger tumor size and nodal involvement were consistently associated with breast cancer events. CONCLUSION: This clinical trial population of similarly treated TNBC patients showed no racial differences in breast cancer outcomes. Disease extent, rather than race, was associated with disease events.

Trauma-related shame predicts daily non-medical prescription opioid use among individuals with PTSD symptoms.

Non-medical prescription opioid use (NMPOU) is the use of opioids without a prescription or in a way different from how they were prescribed and is the fourth most common type of drug use in the United States. Separate research has shown that trauma-related shame is linked to posttraumatic stress disorder (PTSD) and, respectively, opioid use. However, no study to date has empirically examined the association between trauma-related shame and NMPOU among individuals with PTSD symptoms. Forty adults with clinical or subclinical PTSD who reported engaging in NMPOU at least one day in the prior month before the study completed 28 days of daily surveys. Trauma-related shame was measured at baseline. NMPOU and underlying motives to engage in NMPOU were assessed once daily via a smartphone app. Twenty-four participants (60 %) reported NMPOU over the 28-day period. After controlling for PTSD symptoms and covariates, mixed models showed that higher trauma-related shame significantly predicted higher risk of daily NMPOU (B = 0.06, SE = 0.03, t = 2.14, p=.03). After controlling for false discovery rates, trauma-related shame also significantly predicted NMPOU due to the following motives (p's < 0.031): to manage depression/sadness, to manage anxiety, to manage other stress/worry, and to get high. Among individuals with PTSD, higher baseline trauma-related shame prospectively and positively predicted greater NMPOU over a four-week daily monitoring period. Findings suggest a need to attend to trauma-related shame and its impact on subsequent motivations to engage in NMPOU. Future research should examine how treatments may effectively target trauma-related shame to reduce NMPOU and more severe PTSD symptoms.

Assessment of Comorbid Obsessive-Compulsive Disorder and Posttraumatic Stress Disorder.

Obsessive-compulsive disorder (OCD) and posttraumatic stress disorder (PTSD) are commonly comorbid and share prominent features (e.g., intrusions, safety behaviors, and avoidance). Excellent self-report and clinician-administered assessments exist for OCD and PTSD individually, but few assess both disorders, and even fewer provide instruction on differential diagnosis or detection of comorbid OCD and PTSD. To address this gap in the literature, the current paper aims to (1) highlight diagnostic and functional similarities and differences between OCD and PTSD to inform differential diagnosis, (2) outline assessment recommendations for individuals with suspected comorbid OCD and PTSD, OCD with a significant trauma history or posttraumatic symptoms, or PTSD with significant obsessive-compulsive symptoms, and (3) explore future directions to evaluate and improve methods for assessing co-occurring OCD and PTSD.

Obsessive-Compulsive Symptoms and Daily Experiences of Posttraumatic Stress and Mental Contamination Following Sexual Trauma.

Although cross-sectional research highlights similarities between symptoms of obsessive-compulsive disorder (OCD) and posttraumatic stress disorder (PTSD) among individuals exposed to sexual trauma, little is known about how these disorders relate over time. The goal of the present study was to examine whether 1) OCD symptoms prospectively predicted daily symptoms of PTSD, and 2) OCD and PTSD symptoms prospectively predicted daily experiences of sexual trauma-related mental contamination (i.e., dirtiness in the absence of a physical pollutant). Forty-one women with a sexual trauma history completed baseline measures of OCD and PTSD, as well as twice-daily assessments of PTSD symptoms and mental contamination over a two-week period. Total OCD symptoms and the unacceptable thoughts dimension significantly predicted daily PTSD symptoms after accounting for other OCD dimensions. Only total OCD symptoms significantly predicted daily mental contamination when examined together with total PTSD symptoms. No individual PTSD or OCD clusters/dimensions significantly predicted daily mental contamination when examined simultaneously. Findings from this study highlight the nuanced associations among OCD symptoms, PTSD symptoms, and experiences of mental contamination. Future research is needed to further understand the development of PTSD, OCD, and mental contamination over time to inform targets for intervention.

Pre-pandemic factors associated with delayed health care among US older adults during the COVID-19 pandemic.

Background: During the first year of the COVID-19 pandemic, more than one-third of US older adults (aged 65 years and older) reported delaying medical care. Delayed health care may exacerbate short- and long-term health changes in older adults. Older adults more likely to delay health care may benefit from targeted follow-up to return these individuals to the health care system. Objective: The aim of this study was to describe pre-pandemic sociodemographic, psychological, cognitive, and medical factors associated with delayed health care among US older adults during the COVID-19 pandemic. Design: We conducted a secondary analysis of 2905 participants from the National Health and Aging Trends Study (NHATS), a nationally representative, prospective cohort of US older adult Medicare beneficiaries. Methods: Pre-pandemic factors were reported at the Round 9 interview (2019). Delayed health care, including medical (e.g. usual doctor) and supplementary (e.g. dental) care, was reported on the COVID-19 questionnaire (2020). We calculated adjusted odds ratios using weighted logistic regression, accounting for the NHATS sampling design. Results: Overall, 40% of participants reported delayed care. After adjustment, female participants and those reporting fair (vs good) health were consistently more likely to delay health care while persons with lower income or excellent health were less likely to delay care. Other associations varied by care type. Conclusion: Women and those with higher income or fair health before the COVID-19 pandemic were more likely to delay care during the pandemic. Our results may inform targeted outreach to older adults who delayed care during the COVID-19 pandemic, or other disruptions to the health care system, to return these individuals to care and promote better management of their health needs.

Racial and Ethnic Disparities in Outcomes After Breast-Conserving Therapy and Endocrine Therapy for DCIS: A Post-Hoc Analysis of the NSABP B-35 Randomized Clinical Trial.

BACKGROUND: Racial and ethnic disparities in outcomes after treatment for ductal carcinoma in situ (DCIS) are largely unknown. The objective of this study was to examine breast cancer outcomes by race and ethnicity in the National Surgical Adjuvant Breast and Bowel Project (NSABP) B-35 clinical trial. PATIENTS AND METHODS: The NSABP B-35 trial randomized postmenopausal women with hormone receptor-positive DCIS treated with breast-conserving therapy to 5 years of tamoxifen or anastrozole. In total, 3104 women were enrolled between 2003 and 2006. For this analysis, patients without complete self-reported race and ethnicity or with immediate trial dropout were excluded. Kaplan-Meier curves and adjusted Cox-proportional hazards models were used for analyses. RESULTS: Of the 3061 women included, 2614 (85.4%) were non-Hispanic white (NHW), 255 (8.3%) were non-Hispanic Black (NHB), 95 (3.1%) were Hispanic, and 96 (3.1%) were Asian or Pacific Islander (API). Endocrine therapy assignment and duration were well balanced between racial and ethnic groups. Median follow-up was 9 years; unadjusted Kaplan-Meier curves did not show any racial differences in disease events. Adjusted Cox-proportional hazards models found API (versus NHW) race to be associated with higher local recurrence [hazard ratio (HzR) 2.45, p = 0.035] and NHB race to be associated with higher distant recurrence (HzR 5.03, p = 0.020) and breast cancer mortality (HzR 3.83, p = 0.046). CONCLUSIONS: Despite similar locoregional treatments and standard endocrine therapy in a clinical trial population, racial and ethnic disparities exist in long-term outcomes for hormone-receptor-positive DCIS. These findings suggest that factors outside of access and treatment may impact DCIS outcomes by race and ethnicity.

Fear of sin and fear of God: Scrupulosity predicts women's daily experiences of mental contamination following sexual trauma.

Mental contamination refers to feelings of dirtiness in response to thoughts, images, or memories. Mental contamination is frequently reported after sexual trauma and is associated with symptoms of posttraumatic stress disorder (PTSD). Differences in individuals' views about morality and purity may influence the severity of mental contamination, though this has been studied primarily outside of samples assessed for trauma and/or PTSD. The present study addressed this gap by investigating scrupulosity as a prospective predictor of daily sexual trauma-related mental contamination and PTSD symptoms. Participants included 40 adult women with a history of sexual trauma and current sexual trauma-related mental contamination who completed baseline diagnostic interviews and questionnaires followed by two assessments every day for 2 weeks. The results indicate that scrupulosity was positively correlated with PTSD symptom severity and sexual trauma-related mental contamination at baseline. Scrupulosity was also a prospective predictor of increased daily sexual trauma-related mental contamination, B = 0.19, SE = 0.07, p = .010, but not daily PTSD symptoms, B = -0.10, SE = .08, p = .198. The findings indicate that scrupulosity may be an important factor in understanding recovery from sexual assault.

Advancing the Measurement of Trauma-Related Shame Among Women With Histories of Interpersonal Trauma.

Shame is a predominant emotion for many interpersonal trauma (IPT) survivors and is associated with more severe posttraumatic stress disorder (PTSD) symptoms. Measurement challenges have led to difficulties in understanding the impact of trauma-related shame. The Trauma-Related Shame Inventory (TRSI) was developed to address this limitation, yet additional psychometric support is needed. The present study evaluated and provided psychometric support for the TRSI among women with IPT histories, although recommendations for improvement are discussed. The impact of trauma-related shame, relative to trait shame and trauma-related guilt, on PTSD symptoms was also studied, with results suggesting that trauma-related shame had the strongest association.

Concurrent and proximal associations among PTSD symptoms, prescription opioid use, and co-use of other substances: Results from a daily monitoring study.

OBJECTIVE: Posttraumatic stress disorder (PTSD) and nonmedical prescription opioid use (NMPOU) are linked. Much of the research documenting this association uses cross-sectional or longitudinal designs that describe patterns of use over extended intervals. The present study used a daily monitoring design to examine how daily fluctuations in PTSD symptoms predicted patterns of prescription opioid use (both medical and nonmedical) and co-use of other substances. This approach has distinct advantages for understanding proximal temporal relations between PTSD symptom variation and substance use patterns. METHOD: Forty adults with clinical or subclinical PTSD and past-month NMPOU completed daily measures of PTSD symptoms, physical pain, prescription opioid use, and other substance use for 28 days using a smartphone application. RESULTS: Same day co-use of prescription opioids and at least one other substance was common. Higher-than-typical PTSD symptoms on a given day (within-person) was associated with an increased likelihood of reporting NMPOU (overall and with co-use of one or more additional substances) on the same day. This association was specific to PTSD alterations in arousal and reactivity symptoms (Criteria E). Neither total PTSD symptoms nor individual PTSD symptom clusters prospectively predicted next-day prescription opioid use (overall or with co-use). Use of prescription opioids also did not predict next-day PTSD symptom severity. CONCLUSION: This is the first study to demonstrate positive associations between day-to-day fluctuations in PTSD symptoms and NMPOU. Results from the current study also highlight the importance of examining polysubstance use patterns among individuals with PTSD who use prescription opioids. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The role of posttraumatic guilt and anger in integrated treatment for PTSD and co-occurring substance use disorders among primarily male veterans.

OBJECTIVE: PTSD and substance use disorders (SUD) frequently co-occur among veterans. Integrated exposure-based treatments, such as Concurrent Treatment of PTSD and SUD Using Prolonged Exposure (COPE), are efficacious in reducing PTSD and SUD symptoms and posttraumatic emotions. This study examines whether guilt and anger (a) decreased in a randomized clinical trial comparing COPE with Relapse Prevention (RP) therapy for SUD and (b) mediated PTSD and SUD symptom reductions or vice versa. METHOD: Veterans (90.1% men) diagnosed with PTSD and SUD were randomized to 12 sessions of COPE (n = 54) or RP (n = 27). Guilt and anger were assessed at 10 time points during treatment. Multilevel linear models assessed changes in guilt and anger across treatments and lagged multilevel mediation analyses assessed within-subject change in guilt and anger predicting PTSD and percent days of substance use, and vice versa. RESULTS: Guilt (B = -.12, SE = .02, p < .001) and anger (B = -.13, SE = .02, p < .001) improved in both treatments, however guilt was significantly lower in Sessions 7 through 11 among veterans receiving COPE. Improvement in guilt mediated PTSD symptom improvement in both treatment groups (B = -.08, SE = .04, 95% CI [-.16, -.01]), and PTSD symptom improvement mediated anger reduction in COPE (B = -.03, SE = .01, 95% CI [-.06, -.01]). The substance use models were insignificant. CONCLUSIONS: Among veterans, integrated, trauma-focused treatments may be associated with greater guilt (directly) and anger (indirectly) reductions due to processing trauma. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Avoidance Coping Partially Accounts for the Relationship Between Trauma-Related Shame and PTSD Symptoms Following Interpersonal Trauma.

Research has demonstrated that individuals experiencing trauma-related shame exhibit greater posttraumatic stress disorder (PTSD) symptoms. However, little research has investigated additional factors relevant to the shame-PTSD relationship. The current study examined the role of avoidance and approach coping in accounting for the trauma-related shame-PTSD association among 60 women who had experienced interpersonal trauma. Indirect effects tests revealed that avoidance coping partially accounted for the association between shame and interviewer-assessed PTSD symptoms, ß = .21, SE = 0.08, 95% confidence interval (CI) = [0.03, 0.36]. These findings offer a novel contribution to the growing literature examining negative outcomes following interpersonal trauma.

Whole-genome sequencing-based phylogeny, antibiotic resistance, and invasive phenotype of Escherichia coli strains colonizing the cervix of women in preterm labor.

BACKGROUND: Escherichia coli is a major neonatal pathogen and the leading cause of early-onset sepsis in preterm newborns. Maternal E. coli strains are transmitted to the newborn causing invasive neonatal disease. However, there is a lack of data regarding the phenotypic and genotypic characterization of E. coli strains colonizing pregnant women during labor. METHODS: This prospective study performed at the University of Oklahoma Medical Center (OUHSC) from March 2014 to December 2015, aimed to investigate the colonization rate, and the phylogeny, antibiotic resistance traits, and invasive properties of E. coli strains colonizing the cervix of fifty pregnant women diagnosed with preterm labor (PTL). Molecular analyses including bacterial whole-genome sequencing (WGS), were performed to examine phylogenetic relationships among the colonizing strains and compare them with WGS data of representative invasive neonatal E. coli isolates. Phenotypic and genotypic antibiotic resistance traits were investigated. The bacteria's ability to invade epithelial cells in vitro was determined. RESULTS: We recruited fifty women in PTL. Cervical samples yielded E. coli in 12 % (n=6). The mean gestational age was 32.5 (SD±3.19) weeks. None delivered an infant with E. coli disease. Phenotypic and genotypic antibiotic resistance testing did not overall demonstrate extensive drug resistance traits among the cervical E. coli isolates, however, one isolate was multi-drug resistant. The isolates belonged to five different phylogroups, and WGS analyses assigned each to individual multi-locus sequence types. Single nucleotide polymorphism-based comparisons of cervical E. coli strains with six representative neonatal E. coli bacteremia isolates demonstrated that only half of the cervical E. coli isolates were phylogenetically related to these neonatal invasive strains. Moreover, WGS comparisons showed that each cervical E. coli isolate had distinct genomic regions that were not shared with neonatal E. coli isolates. Cervical and neonatal E. coli isolates that were most closely related at the phylogenetic level had similar invasion capacity into intestinal epithelial cells. In contrast, phylogenetically dissimilar cervical E. coli strains were the least invasive among all isolates. CONCLUSIONS: This pilot study showed that a minority of women in PTL were colonized in the cervix with E. coli, and colonizing strains were not phylogenetically uniformly representative of E. coli strains that commonly cause invasive disease in newborns. Larger studies are needed to determine the molecular characteristics of E. coli strains colonizing pregnant women associated with an increased risk of neonatal septicemia.

EEG hyperscanning in motor rehabilitation: a position paper.

Studying the human brain during interpersonal interaction allows us to answer many questions related to motor control and cognition. For instance, what happens in the brain when two people walking side by side begin to change their gait and match cadences? Adapted from the neuroimaging techniques used in single-brain measurements, hyperscanning (HS) is a technique used to measure brain activity from two or more individuals simultaneously. Thus far, HS has primarily focused on healthy participants during social interactions in order to characterize inter-brain dynamics. Here, we advocate for expanding the use of this electroencephalography hyperscanning (EEG-HS) technique to rehabilitation paradigms in individuals with neurological diagnoses, namely stroke, spinal cord injury (SCI), Parkinson's disease (PD), and traumatic brain injury (TBI). We claim that EEG-HS in patient populations with impaired motor function is particularly relevant and could provide additional insight on neural dynamics, optimizing rehabilitation strategies for each individual patient. In addition, we discuss future technologies related to EEG-HS that could be developed for use in the clinic as well as technical limitations to be considered in these proposed settings.

Testing encoding specificity and the diagnostic feature-detection theory of eyewitness identification, with implications for showups, lineups, and partially disguised perpetrators.

The diagnostic feature-detection theory (DFT) of eyewitness identification is based on facial information that is diagnostic versus non-diagnostic of suspect guilt. It primarily has been tested by discounting non-diagnostic information at retrieval, typically by surrounding a single suspect showup with good fillers to create a lineup. We tested additional DFT predictions by manipulating the presence of facial information (i.e., the exterior region of the face) at both encoding and retrieval with a large between-subjects factorial design (N = 19,414). In support of DFT and in replication of the literature, lineups yielded higher discriminability than showups. In support of encoding specificity, conditions that matched information between encoding and retrieval were generally superior to mismatch conditions. More importantly, we supported several DFT and encoding specificity predictions not previously tested, including that (a) adding non-diagnostic information will reduce discriminability for showups more so than lineups, and (b) removing diagnostic information will lower discriminability for both showups and lineups. These results have implications for police deciding whether to conduct a showup or a lineup, and when dealing with partially disguised perpetrators (e.g., wearing a hoodie).

Affective Lability Moderates the Associations between Negative and Positive Urgency and Posttraumatic Stress.

Urgency and affective lability are two vulnerabilities that have been linked to posttraumatic stress disorder (PTSD). Urgency refers to rash action when experiencing intense positive or negative affect, whereas affective lability is the tendency to shift rapidly between emotion states. Although individuals high in urgency and affective lability may be more likely to engage in behaviors often exhibited by individuals with PTSD (e.g., substance use, risky behaviors), the extent to which urgency and affective lability interact to impact PTSD symptoms has yet to be examined. The current study hypothesized that the association between urgency (negative and positive) and PTSD symptoms would be stronger among those reporting elevated affective lability. Participants included 232 trauma-exposed college students who completed a series of questionnaires. Among individuals low in affective lability, both positive and negative urgency were positively associated with PTSD symptoms. Contrary to hypotheses, among those high in affective lability, positive and negative urgency were not associated with PTSD symptoms. Models with dimensions of affective lability were also examined. Findings suggest that the association between urgency and PTSD symptoms may only emerge among individuals who do not already possess the vulnerability associated with higher affective lability.

Distress Tolerance Interacts with Peritraumatic Emotions to Predict Posttraumatic Stress Symptoms Following Sexual Victimization.

The intensity of peritraumatic emotions occurring at the time of, and in the hours or days immediately following, a traumatic event prospectively predicts posttraumatic stress symptom severity. However, less is known about how the perception of one's ability to tolerate distressing emotions affects the relation between peritraumatic emotions and posttraumatic stress symptoms. Therefore, the current study investigated how perceived distress tolerance affects the association between peritraumatic emotional intensity and symptoms of posttraumatic stress. Participants included 72 adult women with a history of sexual victimization. Ratings of peritraumatic emotions (e.g., fear, anger, sadness, guilt, and shame), perceived distress tolerance, and posttraumatic stress symptoms were examined. All analyses controlled for general negative affect. Significant interactions emerged for overall peritraumatic emotional intensity, and specifically for peritraumatic anger, sadness, and shame. The associations between these peritraumatic emotions and posttraumatic stress symptoms were stronger for individuals with lower perceived ability to tolerate distress. Our results suggest that peritraumatic emotional experiences may be particularly relevant to understanding the development and maintenance of posttraumatic stress symptoms among individuals who have difficulty tolerating intense negative emotional states. Future research should examine whether perceived distress tolerance might serve as a potential target for posttraumatic stress prevention efforts.