Treatment and outcomes of hepatocellular carcinoma in patients with Sickle cell disease: a population-based study in the U.S.

BACKGROUND: Sickle cell disease (SCD) is a rare hemoglobinopathy which can result in chronic liver disease and cirrhosis. Patients with SCD have an increased risk of hematologic malignancy, but the prevalence of hepatocellular carcinoma (HCC) in this population is unknown. Herein, the association of SCD with HCC was examined using registry data. METHODS: The SEER-Medicare database was queried to identify patients diagnosed with HCC between 2000 and 2015, and further stratified by SCD status. Propensity matching was performed to examine cancer-related survival and treatment outcomes. RESULTS: Overall 56,934 patients with HCC were identified, including 81 patients with SCD. Patients with SCD more frequently had cirrhosis [48.1% (39/81) vs 23.5% (13,377/56,853), p < 0.01] yet presented with smaller tumors [<5 cm: 51.9% (42/81) vs 38.5% (21,898/56,853), p = 0.01]. After propensity matching, SCD was not associated with attenuated survival (aHR 0.73 95%CI 0.52-1.01). When stratified by treatment, patients with SCD had equivalent outcomes to chemotherapy (p = 0.65), TACE/TARE (p = 0.35), resection (p = 0.15) and transplantation (p = 0.67) when compared to non-SCD patients. CONCLUSION: This study confirms that a subset of patients with SCD will develop HCC. Importantly, therapeutic options for HCC should not be limited by pre-existing SCD, and similar survival should be expected when compared to non-SCD patients.

The Psychology of Entrenched Privilege: High Socioeconomic Status Individuals From Affluent Backgrounds Are Uniquely High in Entitlement.

As rates of intergenerational social mobility decline, it is increasingly important to understand the psychological consequences of entrenched socioeconomic privilege. Here, we explore whether current and childhood socioeconomic status (SES) are interactively related to entitlement, such that among currently high SES individuals, those from affluent backgrounds are likely to feel uniquely high levels of entitlement, whereas currently low SES individuals feel low entitlement regardless of their backgrounds. A meta-analysis of four exploratory studies (total N = 3,105) found that currently high SES individuals who were also raised in high SES households were especially inclined to report feeling entitled, a pattern that was robust across three indicators of SES: income, education, and subjective SES. Results of a preregistered, confirmatory study (N = 1,058) replicated this interactive pattern for education and subjective SES, though not for income. Our findings highlight the importance of considering current and childhood SES jointly to understand the psychological consequences of SES.

An Examination of Applicants and Factors Associated with Matriculation to Complex General Surgical Oncology Fellowship Training Programs.

BACKGROUND: The demand for training in complex general surgical oncology (CGSO) fellowships currently exceeds the number of positions offered; however, there are scarce data defining the applicant pool or characteristics associated with successful matriculation. Our study described the applicant population and to determine factors associated with acceptance into the fellowship. STUDY DESIGN: Data were extracted from the Electronic Residency Application System for applicants in 2015 and 2016 and stratified based on matriculation status. Applicant demographics, including medical education, residency, and research achievements, were analyzed. Academic productivity was quantified using the number of peer-reviewed publications as well as the journal with the highest impact factor in which an applicant's work was published. RESULTS: Data were gathered on a total of 283 applicants, of which 105 matriculated. The overall population was primarily male (63.2%), Caucasian (40.6%), educated at a U.S. allopathic medical school (53.4%), and trained at a university-based General Surgery residency (55.5%). Education at a U.S. allopathic school (OR = 5.63, p < 0.0001), university-based classification of the applicant's surgical residency (OR = 4.20, p < 0.0001), and a residency affiliation with a CGSO fellowship (OR = 2.61, p = 0.004) or National Cancer Institute designated Comprehensive Cancer Center (OR = 3.16, p < 0.001) were found to be associated with matriculation. Matriculants published a higher number of manuscripts than nonmatriculants (median of 10 vs. 4.5, p < 0.0001) and more frequently achieved publication in journals with higher impact factors (p < 0.0001). CONCLUSIONS: This study represents the first objective description of the CGSO fellowship applicant pool. Applicants' medical school, residency, and research data points correlated with successful matriculation.

Suitability of the Epworth Sleepiness Scale (ESS) for Economic Evaluation: An Assessment of Its Convergent and Discriminant Validity.

OBJECTIVE: To assess the suitability for use within economic evaluation of a widely used sleep-related instrument (the Epworth Sleepiness Scale [ESS]) by examining its convergent and discriminant validity with two widely used generic preference-based instruments (Short-Form 36 [SF-36] and the Assessment of Quality of Life 4 dimensions [AQoL-4D]). METHODS: Data from a cross-section of 2,236 community-dwelling Australian men were analyzed. Convergent validity was investigated using Spearman's correlation, intraclass correlation, and modified Bland-Altman plots, while discriminant validity was examined using Kruskal Wallis tests. RESULTS: All instruments showed good discriminant validity. The ESS was weakly correlated to the Short Form 6 dimension, or SF-6D (derived from the SF-36) and AQoL-4D utilities (r = 0.20 and r = 0.19, respectively). Correlations between ESS and SF-36/AQoL-4D dimensions measuring the same construct were all in the hypothesized directions but also weak (range of absolute r = 0.00 to 0.18). The level of agreement between the ESS and AQoL-4D was the weakest, followed by that between the ESS and SF-6D. Moderate convergent validity was seen between the utilities. CONCLUSIONS: The lack of convergent validity between the ESS and the preference-based instruments shows that sleep-related constructs are not captured by the latter. The ESS has, however, demonstrated good discriminant validity comparable to that of the AQoL-4D and the SF-36/SF-6D and would therefore be equally useful for measuring subgroup differences within economic evaluation. We therefore recommend using the ESS within cost-effectiveness analysis as a complement to preference-based instruments in order to capture sleep-specific constructs not measured by the latter.

International Prostate Symptom Score Should Be Considered a Complement Rather Than a Substitute to Generic Preference-Based Measures for Measuring Lower Urinary Tract Symptoms Within Economic Evaluation.

OBJECTIVE: To determine the suitability of using the International Prostate Symptom Score (IPSS), a condition-specific instrument, within economic evaluation of lower urinary tract symptom (LUTS) interventions. METHODS: Data were obtained from a cohort of 2236 community-dwelling Australian men. Using correlations and a modified Bland-Altman plot, we investigated the convergent validity of the IPSS with two generic quality of life (GQol) instruments: the Assessment of Quality of Life 4 Dimensions (AQoL-4D) and the Short-Form 36 (SF-36). Discriminant validity was investigated using Wilcoxon-Mann-Whitney and Kruskal-Wallis tests, comparing instrument scores and utilities between subgroups varying in age, marital status, history of illness, smoking status and self-assessed general health. RESULTS: Discriminant validity was confirmed for all instruments by finding statistically significant differences in summary scores and utilities between nearly all subgroups. Convergent validity between the summary scores/utilities of the IPSS and the GQoL instruments was weak (absolute correlation value range, 0.11-0.23) but differed considerably between dimensions of the instruments (absolute correlation value range, 0.01-0.24). Weak to moderate correlation between the GQoL instruments was seen (absolute correlation value range, 0.01-0.49). CONCLUSION: Our findings suggest that the IPSS has comparable discriminant validity to the GQoL instruments and therefore useful for assessing subgroup differences related to urinary symptoms. The weak convergence between the IPSS and the GQoL instruments however suggests that, within economic evaluation, the IPSS should be viewed as a complement rather than a substitute to the GQoL instruments because it captures different quality of life constructs.

Social class, leaders and leadership: a critical review and suggestions for development.

The consideration of social class in leadership research presents many exciting directions for research. In this review, we describe and summarize how social class research has been applied to the study of leaders and the leadership process, noting that while evidence suggests those from higher social classes are more likely to occupy formal leader roles in organizations, there is little evidence suggesting that they are more effective in these roles than those from lower social classes. We conclude with a discussion of important, unanswered theoretical questions about how social class relates to the process of leadership-most notably, whether those from different classes internalize different beliefs and expectations about how people in leader and follower roles should act, and how matches or mismatches in those beliefs and expectations shape leader-follower interactions and outcomes.

Routine radiographs one day after anterior cervical discectomy and fusion are neither necessary nor cost-effective.

OBJECTIVES: Anterior cervical discectomy and fusion (ACDF) is a common operative treatment of compressive pathology of the cervical spinal cord, when caused by one or more degenerated intervertebral discs or related osteophytes. In addition to intra-operative radiographs to confirm spinal level before discectomy and implant position after insertion, traditional practice is to obtain post-operative antero-posterior and lateral plain radiographs (XR) before hospital discharge, despite a paucity of evidence supporting their benefit to patient care. Minimising unnecessary radiation to radiosensitive neck structures is desirable, and furthermore, with increasing financial pressure on healthcare resources, routine investigations should be clinically justified and evidence-based. We aim to compare the utility of routine post-operative cervical spine X-rays following ACDF. METHODS: We compare two groups of consecutive patients undergoing ACDF in a single UK neurosurgical centre. The first group (n = 109) received routine post-operative XR imaging, and the second group (n = 113) received radiographs only when clinically indicated. RESULTS: There were no differences in post-operative complication rates (4.6% vs. 5.3%), or requirement for further imaging or of further operative intervention (1.8% vs. 0.9%). The group that did not have routine post-operative radiographs had a significantly shorter stay in hospital (median two days vs. three days). There were no patients in either group where post-operative XR changed clinical management and mandated revision surgery or further imaging. All cases requiring surgery or further imaging were identified by clinical deterioration. CONCLUSIONS: We suggest that the practice of obtaining routine radiographs of the cervical spine following ACDF should be abandoned, unless there is a clear clinical indication.

Predictive value of serum testosterone for type 2 diabetes risk assessment in men.

BACKGROUND: Effective prevention of type 2 diabetes (T2D) requires early identification of high-risk individuals who might benefit from intervention. We sought to determine whether low serum testosterone, a novel risk factor for T2D in men, adds clinically meaningful information beyond current T2D risk models. METHODS: The Men Androgen Inflammation Lifestyle Environment and Stress (MAILES) study population consists of 2563 community-dwelling men aged 35-80 years in Adelaide, Australia. Of the MAILES participants, 2038 (80.0 %) provided information at baseline (2002-2006) and follow-up (2007-2010). After excluding participants with diabetes (n = 317), underweight (n = 5), and unknown BMI status (n = 11) at baseline; and unknown diabetes status (n = 50) at follow-up; 1655 participants were followed for 5 years. T2D at baseline and follow-up was defined by self-reported diabetes, or fasting plasma glucose (FPG) ≥7.0 mmol/L (126.1 mg/dL), or glycated haemoglobin (HbA1c) ≥6.5 %, or diabetes medications. Risk models were tested using logistic regression models. Sensitivity, specificity, positive predictive values (PPV) were used to identify the optimal cut-off point for low serum testosterone for incident T2D and the area under the receiver operating characteristic (AROC) curve was used to summarise the predictive power of the model. 15.5 % of men had at least one missing predictor variable; addressed through multiple imputation. RESULTS: The incidence rate of T2D was 8.9 % (147/1655) over a median follow-up of 4.95 years (interquartile range: 4.35-5.00). Serum testosterone level predicted incident T2D (relative risk 0.96 [95 % CI: 0.92,1.00], P = 0.032) independent of current risk models including the AUSDRISK, but did not improve corresponding AROC statistics. A cut-off point of <16 nmol/L for low serum testosterone, which classified about 43 % of men, returned equal sensitivity (61.3 % [95 % CI: 52.6,69.4]) and specificity (58.3 % [95 % CI: 55.6,60.9) for predicting T2D risk, with a PPV of 12.9 % (95 % CI: 10.4,15.8). CONCLUSIONS: Low serum testosterone predicts an increased risk of developing T2D in men over 5 years independent of current T2D risk models applicable for use in routine clinical practice. Screening for low serum testosterone in addition to risk factors from current T2D risk assessment models or tools, including the AUSDRISK, would identify a large subgroup of distinct men who might benefit from targeted preventive interventions.

Food Habits, Lifestyle Factors and Mortality among Oldest Old Chinese: The Chinese Longitudinal Healthy Longevity Survey (CLHLS).

There are few studies reporting the association between lifestyle and mortality among the oldest old in developing countries. We examined the association between food habits, lifestyle factors and all-cause mortality in the oldest old (≥80 years) using data from the Chinese Longitudinal Healthy Longevity Survey (CLHLS). In 1998/99, 8959 participants aged 80 years and older took part in the baseline survey. Follow-up surveys were conducted every two to three years until 2011. Food habits were assessed using an in-person interview. Deaths were ascertained from family members during follow-up. Cox and Laplace regression were used to assess the association between food habits, lifestyle factors and mortality risk. There were 6626 deaths during 31,926 person-years of follow-up. Type of staple food (rice or wheat) was not associated with mortality. Daily fruit and vegetable intake was inversely associated with a higher mortality risk (hazard ratios (HRs): 0.85 (95% CI (confidence interval) 0.77-0.92), and 0.74 (0.66-0.83) for daily intake of fruit and vegetables, respectively). There was a positive association between intake of salt-preserved vegetables and mortality risk (consumers had about 10% increase of HR for mortality). Fruit and vegetable consumption were inversely, while intake of salt-preserved vegetables positively, associated with mortality risk among the oldest old. Undertaking physical activity is beneficial for the prevention of premature death.

Defending a traditional practice in the modern era: The use of lumbar puncture in the investigation of subarachnoid haemorrhage.

INTRODUCTION: Acute severe headache is a common medical presentation, and a common area of diagnostic uncertainty. Subarachnoid haemorrhage (SAH) is the cause in a minority of patients and has a high rate of morbidity and mortality. Therefore, its conclusive diagnosis with computed tomography (CT) or lumbar puncture (LP) is paramount. With advancement in imaging technology, emerging evidence now suggests that LP is no longer required for a subset of patients as CT has 100% sensitivity in detecting SAH, when performed under specific conditions. OBJECTIVES: To assess the proportion of patients with conclusive CSF xanthochromia results following a negative CT scan in suspected SAH to determine the diagnostic efficacy of LP. METHODS: CSF bilirubin and oxyhaemoglobin spectrophotometric absorbance data from all centres in a regional health board were identified for consecutive patients over a 6-month period. Results were stratified as conclusive (positive or negative), or inconclusive according to national guidelines. RESULTS: 239 of 255 (93.7%) results were conclusive: 89.0% were negative (227 of 255). 4.7% of results were positive (12 of 255), revealing 4 cerebral aneurysms requiring treatment. 16 out of 255 (6.3%) samples were inconclusive, yielding 1 aneurysm requiring treatment. In the same period, there were 27 CT-positive cases of SAH. CONCLUSIONS: LP has a high diagnostic yield, eliminating the need for neurosurgical opinion or investigation in almost 90% of cases. The test is both cost and time efficient and subjects only a small number of patients to the radiation and contrast risks of angiography.

The association of socio-demographic status, lifestyle factors and dietary patterns with total urinary phthalates in Australian men.

OBJECTIVE: To investigate the associations between socio-demographic status, lifestyle factors, dietary patterns and urinary total phthalate concentration in a cohort of South Australian men. METHOD: We randomly selected 1527 males aged 39 to 84 from wave two of the Men Androgen Inflammation Lifestyle Environment and Stress (MAILES) study. Total phthalate concentration was examined in fasting morning urine samples. Socio-demographic and lifestyle factors were assessed by questionnaire. Food intake was assessed by food frequency questionnaire (FFQ). Dietary patterns were constructed using factor analysis. RESULTS: Total phthalates were detected in 99.6% of the urine samples. The overall geometric mean (95% CI) of total phthalate concentration was 112.4 (107.5-117.5) ng/mL. The least square geometric means (LSGMs) of total phthalate concentration were significantly higher among people who were obese (127.8 ng/mL), consuming less than two serves fruit per day (125.7 ng/mL) and drinking more than one can (375mL) of carbonated soft drink per day (131.9 ng/mL). Two dietary patterns were identified: a prudent dietary pattern and a western dietary pattern. Both the western dietary pattern (p = 0.002) and multiple lifestyle risk factors including smoking, obesity, insufficient physical activity and the highest quartile of the western dietary pattern (p<0.001), were positively associated with total phthalate levels. There was no significant relationship between total phthalate concentration and socio-demographic status. CONCLUSION: Phthalate exposure is ubiquitous and positively associated with lifestyle risk factors in urban dwelling Australian men.

American Medical Society for Sports Medicine recommended sports ultrasound curriculum for sports medicine fellowships.

The following sports ultrasound (SPORTS US) curriculum is a revision of the curriculum developed by the American Medical Society for Sports Medicine (AMSSM) in 2010. Several changes have been made to the curriculum with the primary aim of providing a pathway by which a sports medicine fellow can obtain sufficient SPORTS US training to become proficient in the core competencies of SPORTS US. The core competencies of SPORTS US are outlined in the learning objectives section of this document. The term "SPORTS US" was purposefully chosen rather than "musculoskeletal ultrasound" (MSK US) because it was recognized by the panel that the evolving field of SPORTS US encompasses non-MSK applications of ultrasound such as the FAST examination (focused assessment with sonography for trauma). Although the SPORTS US core competencies in this curriculum are all MSK in nature, they represent the minimum SPORTS US knowledge a sports medicine fellow should acquire during fellowship. However, additional training in more advanced MSK and non-MSK applications of ultrasound can be provided at the fellowship director's discretion. Completion of this SPORTS US curriculum fulfills the American Institute of Ultrasound in Medicine's (AIUM) requirements to perform an MSK US examination and the prerequisites for the American Registry for Diagnostic Medical Sonography's (ARDMS) MSK sonography certification examination.

American Medical Society for Sports Medicine recommended sports ultrasound curriculum for sports medicine fellowships.

The American Medical Society for Sports Medicine (AMSSM) developed a musculoskeletal ultrasound curriculum for sports medicine fellowships in 2010. As the use of diagnostic and interventional ultrasound in sports medicine has evolved, it became clear that the curriculum needed to be updated. Furthermore, the name 'musculoskeletal ultrasound' was changed to 'sports ultrasound' (SPORTS US) to reflect the broad range of diagnostic and interventional applications of ultrasound in sports medicine. This document was created to outline the core competencies of SPORTS US and to provide sports medicine fellowship directors and others interested in SPORTS US education with a guide to create a SPORTS US curriculum. By completing this SPORTS US curriculum, sports medicine fellows and physicians can attain proficiency in the core competencies of SPORTS US required for the practice of sports medicine.

Testosterone is associated with self-employment among Australian men.

Testosterone has pronounced effects on men's physiological development and smaller, more nuanced, impacts on their economic behavior. In this study of 1199 Australian adult males, we investigate the relationship between the self-employed and their serum testosterone levels. Because prior studies have identified that testosterone is a hormone that is responsive to external factors (e.g. competition, risk-taking), we explicitly control for omitted variable bias and reverse causality by using an instrumental variable approach. We use insulin as our primary instrument to account for endogeneity between testosterone and self-employment. This is because prior research has identified a relationship between insulin and testosterone but not between insulin and self-employment. Our results show that there is a positive association between total testosterone and self-employment. Robustness checks using bioavailable testosterone and another similar instrument (daily alcohol consumption) confirm this positive finding.

Chronic disease prevalence and associations in a cohort of Australian men: the Florey Adelaide Male Ageing Study (FAMAS).

BACKGROUND: An increasing proportion of Australia's chronic disease burden is carried by the ageing male. The aim of this study was to determine the prevalence of asthma, cancer, diabetes, angina and musculoskeletal conditions and their relationship to behavioural and socio-demographic factors in a cohort of Australian men. METHODS: Self-reports of disease status were obtained from baseline clinic visits (August 2002-July 2003 & July 2004-May 2005) from 1195 randomly selected men, aged 35-80 years and living in the north-west regions of Adelaide. Initially, relative risks were assessed by regression against selected variables for each outcome. Where age-independent associations were observed with the relevant chronic disease, independent variables were fitted to customized multiadjusted models. RESULTS: The prevalence of all conditions was moderately higher in comparison to national data for age-matched men. In particular, there was an unusually high rate of men with cancer. Multiadjusted analyses revealed age as a predictor of chronic conditions (type 2 diabetes mellitus, angina, cancer & osteoarthritis). A number of socio-demographic factors, independent of age, were associated with chronic disease, including: low income status (diabetes), separation/divorce (asthma), unemployment (cancer), high waist circumference (diabetes), elevated cholesterol (angina) and a family history of obesity (angina). CONCLUSION: Socio-demographic factors interact to determine disease status in this broadly representative group of Australian men. In addition to obesity and a positive personal and family history of disease, men who are socially disadvantaged (low income, unemployed, separated) should be specifically targeted by public health initiatives.

Delays in cancer diagnosis in underinsured young adults and older adolescents.

BACKGROUND: In the U.S., adolescents and young adults diagnosed with cancer have had less survival improvement than older or younger patients, a deficit that may be a result of delays in diagnosis in an age group with the lowest rates of health insurance. METHODS: The relationship between health insurance status and the time from the onset of first cancer-specific symptom or sign to definitive diagnosis (lagtime) was retrospectively compared with other sociodemographic factors in newly diagnosed cancer patients aged 15-29 years who were evaluated between June 2001 and June 2003. Data on 270 patients with the six most common cancer types in this cohort (leukemia, Hodgkin's and non-Hodgkin's lymphoma, sarcoma, brain tumors, thyroid cancer) were retrospectively collected in 2004. RESULTS: Lagtimes were evaluable in 235 (88%) patients. In multivariate analysis, the type of cancer and health insurance were significantly associated with lagtime, whereas race/ethnicity, age, gender, marital status, and surrogate measures of socioeconomic status were not. The mean lagtime in patients with public or no health insurance was 13.1 weeks longer than in patients with private health insurance, and longer in four of six evaluable histology-specific types of cancer. In cancers evaluable for stage at diagnosis, advanced stage was associated with longer lagtimes. CONCLUSION: In the U.S., older adolescents and young adults with cancer are likely to have a delay in diagnosis because of inadequate health insurance and consequently present with a more advanced stage of disease.

The Florey Adelaide Male Ageing Study (FAMAS): design, procedures & participants.

BACKGROUND: The Florey Adelaide Male Ageing Study (FAMAS) examines the reproductive, physical and psychological health, and health service utilisation of the ageing male in Australia. We describe the rationale for the study, the methods used participant response rates, representativeness and attrition to date. METHODS: FAMAS is a longitudinal study involving approximately 1200 randomly selected men, aged 35-80 years and living in the north-west regions of Adelaide. Respondents were excluded at screening if they were considered incapable of participating because of immobility, language, or an inability to undertake the study procedures. Following a telephone call to randomly selected households, eligible participants were invited to attend a baseline clinic measuring a variety of biomedical and socio-demographic factors. Beginning in 2002, these clinics are scheduled to reoccur every five years. Follow-up questionnaires are completed annually. Participants are also invited to participate in sub-studies with selected collaborators. RESULTS: Of those eligible to participate, 45.1% ultimately attended a clinic. Non-responders were more likely to live alone, be current smokers, have a high prevalence of self-reported diabetes and stroke, and lower levels of hypercholesterolemia. Comparisons with the Census 2001 data showed that participants matched the population for most key demographics, although younger groups and never married men were under-represented and elderly participants were over-represented. To date, there has been an annual loss to follow-up of just over 1%. CONCLUSION: FAMAS allows a detailed investigation into the effects of bio-psychosocial and behavioural factors on the health and ageing of a largely representative group of Australian men.