Predictors and characteristics of Rib fracture following SBRT for lung tumors.

BACKGROUND: The utilization of stereotactic body radiation therapy (SBRT) is increasing for primary and secondary lung neoplasms. Despite encouraging results, SBRT is associated with an increased risk of osteoradionecrosis-induced rib fracture. We aimed to (1) evaluate potential clinical, demographic, and procedure-related risk factors for rib fractures and (2) describe the radiographic features of post-SBRT rib fractures. METHODS: We retrospectively identified 106 patients who received SBRT between 2015 and 2018 for a primary or metastatic lung tumor with at least 12 months of follow up. Exclusion criteria were incomplete records, previous ipsilateral thoracic radiation, or relevant prior trauma. Computed tomography (CT) images were reviewed to identify and characterize rib fractures. Multivariate logistic regression modeling was employed to determine clinical, demographic, and procedural risk factors (e.g., age, sex, race, medical comorbidities, dosage, and tumor location). RESULTS: A total of 106 patients with 111 treated tumors met the inclusion criteria, 35 (32%) of whom developed at least one fractured rib (60 total fractured ribs). The highest number of fractured ribs per patient was five. Multivariate regression identified posterolateral tumor location as the only independent risk factor for rib fracture. On CT, fractures showed discontinuity between healing edges in 77% of affected patients. CONCLUSIONS: Nearly one third of patients receiving SBRT for lung tumors experienced rib fractures, 34% of whom experienced pain. Many patients developed multiple fractures. Post-SBRT fractures demonstrated a unique discontinuity between the healing edges of the rib, a distinct feature of post-SBRT rib fractures. The only independent predictor of rib fracture was tumor location along the posterolateral chest wall. Given its increasing frequency of use, describing the risk profile of SBRT is vital to ensure patient safety and adequately inform patient expectations.

Individual- and neighborhood-level characteristics of lung cancer screening participants undergoing telemedicine shared decision making.

BACKGROUND: Although lung cancer screening (LCS) for high-risk individuals reduces lung cancer mortality in clinical trial settings, many questions remain about how to implement high-quality LCS in real-world programs. With the increasing use of telemedicine in healthcare, studies examining this approach in the context of LCS are urgently needed. We aimed to identify sociodemographic and other factors associated with screening completion among individuals undergoing telemedicine Shared Decision Making (SDM) for LCS. METHODS: This retrospective study examined patients who completed Shared Decision Making (SDM) via telemedicine between May 4, 2020 - March 18, 2021 in a centralized LCS program. Individuals were categorized into Complete Screening vs. Incomplete Screening subgroups based on the status of subsequent LDCT completion. A multi-level, multivariate model was constructed to identify factors associated with incomplete screening. RESULTS: Among individuals undergoing telemedicine SDM during the study period, 20.6% did not complete a LDCT scan. Bivariate analysis demonstrated that Black/African-American race, Medicaid insurance status, and new patient type were associated with greater odds of incomplete screening. On multi-level, multivariate analysis, individuals who were new patients undergoing baseline LDCT or resided in a census tract with a high level of socioeconomic deprivation had significantly higher odds of incomplete screening. Individuals with a greater level of education experienced lower odds of incomplete screening. CONCLUSIONS: Among high-risk individuals undergoing telemedicine SDM for LCS, predictors of incomplete screening included low education, high neighborhood-level deprivation, and new patient type. Future research should focus on testing implementation strategies to improve LDCT completion rates while leveraging telemedicine for high-quality LCS.

The Effect of External Dissociative Stimuli on Plank Duration Performed by Male Collegiate Soccer Players.

ABSTRACT: D'Agata, MN, Staub, JP, Scavone, DJ, and Kane, GM. The effect of external dissociative stimuli on plank duration performed by male collegiate soccer players. J Strength Cond Res 37(5): e341-e345, 2023-Individuals commonly use music as an external auditory stimulus to divert their attention away from aerobic endurance exercise tasks. Music generally results in lower ratings of perceived exertion, which may be the mechanism by which it increases aerobic exercise task duration. However, less is known regarding how music affects the performance of other forms of exercise, such as isometric exercise. Moreover, the effects of different external stimuli on isometric task duration, such as the use of virtual reality (VR), have yet to be investigated. Therefore, the purpose of this study was to investigate the effects of self-selected music (SSM) and VR on isometric exercise task duration using a forearm plank. We hypothesized that both SSM and VR would effectively increase plank duration compared with no external stimuli. Seventeen male collegiate soccer players (19 ± 1 year) completed 3 planks to failure on 3 separate days, with 48-72 hours between the trials. The ordering of each exercise condition (SSM, VR, or None) was randomized for a total of 6 potential orders. A one-way repeated-measures analysis of variance was used to evaluate differences in plank duration and average heart rate (HR avg ) between each trial, and significance was set at p < 0.05. There were no differences in plank duration (SSM: 200 ± 44, VR: 173 ± 38, None: 177 ± 37 seconds) or HR avg (SSM: 96 ± 18, VR: 92 ± 21, None: 87 ± 18 beats per minute) between the conditions. We conclude that there was no effect of external stimuli (SSM or VR) on isometric exercise task duration and the use of these modalities should be based on exerciser preference.

Clinical presentations and outcomes in pulmonary embolism patients with cancer.

To study whether a diagnosis of cancer affects the clinical presentation and outcomes of patients with pulmonary embolism (PE). A retrospective analysis was performed of all consecutive patients diagnosed with PE on a computed tomography scan from 2014 to 2016 at an urban tertiary-referral medical center. Baseline characteristics, treatment decisions, and mortality data were compared between study subjects with and without a known diagnosis of active cancer. There were 581 subjects, of which 187 (33.0%) had a diagnosis of cancer. On average, cancer subjects tended to be older (64.8 vs. 58.5 years, p < 0.01), had lower body mass index (BMI) (29.0 vs. 31.5 kg/m2, p = 0.01), and were less likely to be active smokers (9.2% vs. 21.1%, p < 0.01), as compared to non-cancer subjects. Cancer subjects were also less likely to present with chest pain (18.2% vs. 37.4%, p < 0.01), syncope (2.7% vs. 6.6%, p = 0.05), bilateral PEs (50% vs. 60%, p = 0.025), and evidence of right heart strain (48% vs. 58%, p = 0.024). There was no difference in-hospital length of stay (8.9 vs. 9.4 days, p = 0.61) or rate of intensive care unit (ICU) admission (31.9% vs. 33.3%, p = 0.75) between the two groups. Presence of cancer increased the risk of all-cause one-year mortality (adjusted HR 9.7, 95% CI 4.8-19.7, p < 0.01); however, it did not independently affect in-hospital mortality (adjusted HR 2.9, 95% CI 0.86-9.87, p = 0.086). Patients with malignancy generally presented with less severe PE. In addition, malignancy did not independently increase the risk of in-hospital mortality among PE patients.

Black patients referred to a lung cancer screening program experience lower rates of screening and longer time to follow-up.

BACKGROUND: Racial disparities are well-documented in preventive cancer care, but they have not been fully explored in the context of lung cancer screening. We sought to explore racial differences in lung cancer screening outcomes within a lung cancer screening program (LCSP) at our urban academic medical center including differences in baseline low-dose computed tomography (LDCT) results, time to follow-up, adherence, as well as return to annual screening after additional imaging, loss to follow-up, and cancer diagnoses in patients with positive baseline scans. METHODS: A historical cohort study of patients referred to our LCSP was conducted to extract demographic and clinical characteristics, smoking history, and lung cancer screening outcomes. RESULTS: After referral to the LCSP, blacks had significantly lower odds of receiving LDCT compared to whites, even while controlling for individual lung cancer risk factors and neighborhood-level factors. Blacks also demonstrated a trend toward delayed follow-up, decreased adherence, and loss to follow-up across all Lung-RADS categories. CONCLUSIONS: Overall, lung cancer screening annual adherence rates were low, regardless of race, highlighting the need for increased patient education and outreach. Furthermore, the disparities in race we identified encourage further research with the purpose of creating culturally competent and inclusive LCSPs.

Development of a framework to describe patient and family harm from disrespect and promote improvements in quality and safety: a scoping review.

PURPOSE: Patients and families may experience 'non-physical' harm from interactions with the healthcare system, including emotional, psychological, socio-behavioral or financial harm, some of which may be related to experiences of disrespect. We sought to use the current literature to develop a practical, improvement-oriented framework to recognize, describe and help prevent such events. DATA SOURCES: Searches were performed in PubMed, Embase, PsychINFO, CINAHL, Health Business Elite and ProQuest Dissertations & Theses: Global: Health & Medicine, from their inception through July 2017. STUDY SELECTION: Two authors reviewed titles, abstracts, full texts, references and cited-by lists to identify articles describing approaches to understanding patient/family experiences of disrespect. DATA EXTRACTION: Findings were evaluated using integrative review methodology. RESULTS OF DATA SYNTHESIS: Three-thousand eight hundred and eighty two abstracts were reviewed. Twenty three articles were identified. Components of experiences of disrespect included: (1) numerous care processes; (2) a wide range of healthcare professional and organizational behaviors; (3) contributing factors, including patient- and professional-related factors, the environment of work and care, leadership, policies, processes and culture; (4) important consequences of disrespect, including behavioral changes and health impacts on patients and families, negative effects on professionals' subsequent interactions, and patient attrition from organizations and (5) factors both intrinsic and extrinsic to patients that can modify the consequences of disrespect. CONCLUSION: A generalizable framework for understanding disrespect experienced by patients/families in healthcare may help organizations better prevent non-physical harms. Future work should prospectively test and refine the framework we described so as to facilitate its integration into organizations' existing operational systems.

Women's Health Policy in the United States: An American College of Physicians Position Paper.

In this position paper, the American College of Physicians (ACP) examines the challenges women face in the U.S. health care system across their lifespans, including access to care; sex- and gender-specific health issues; variation in health outcomes compared with men; underrepresentation in research studies; and public policies that affect women, their families, and society. ACP puts forward several recommendations focused on policies that will improve the health outcomes of women and ensure a health care system that supports the needs of women and their families over the course of their lifespans.

Addressing Social Determinants to Improve Patient Care and Promote Health Equity: An American College of Physicians Position Paper.

Social determinants of health are nonmedical factors that can affect a person's overall health and health outcomes. Where a person is born and the social conditions they are born into can affect their risk factors for premature death and their life expectancy. In this position paper, the American College of Physicians acknowledges the role of social determinants in health, examines the complexities associated with them, and offers recommendations on better integration of social determinants into the health care system while highlighting the need to address systemic issues hindering health equity.

Achieving Gender Equity in Physician Compensation and Career Advancement: A Position Paper of the American College of Physicians.

Women comprise more than one third of the active physician workforce, an estimated 46% of all physicians-in-training, and more than half of all medical students in the United States. Although progress has been made toward gender diversity in the physician workforce, disparities in compensation exist and inequities have contributed to a disproportionately low number of female physicians achieving academic advancement and serving in leadership positions. Women in medicine face other challenges, including a lack of mentors, discrimination, gender bias, cultural environment of the workplace, imposter syndrome, and the need for better work-life integration. In this position paper, the American College of Physicians summarizes the unique challenges female physicians face over the course of their careers and provides recommendations to improve gender equity and ensure that the full potential of female physicians is realized.

Health and Public Policy to Facilitate Effective Prevention and Treatment of Substance Use Disorders Involving Illicit and Prescription Drugs: An American College of Physicians Position Paper.

Substance use disorders involving illicit and prescription drugs are a serious public health issue. In the United States, millions of individuals need treatment for substance use disorders but few receive it. The rising number of drug overdose deaths and the changing legal status of marijuana pose new challenges. In this position paper, the American College of Physicians maintains that substance use disorder is a treatable chronic medical condition and offers recommendations on expanding treatment options, the legal status of marijuana, addressing the opioid epidemic, insurance coverage of substance use disorders treatment, education and workforce, and public health interventions.

An Entrustable Professional Activity (EPA)-Based Framework to Prepare Fourth-Year Medical Students for Internal Medicine Careers.

The purpose of the fourth year of medical school remains controversial. Competing demands during this transitional phase cause confusion for students and educators. In 2014, the Association of American Medical Colleges (AAMC) released 13 Core Entrustable Professional Activities for Entering Residency (CEPAERs). A committee comprising members of the Clerkship Directors in Internal Medicine and the Association of Program Directors in Internal Medicine applied these principles to preparing students for internal medicine residencies. The authors propose a curricular framework based on five CEPAERs that were felt to be most relevant to residency preparation, informed by prior stakeholder surveys. The critical areas outlined include entering orders, forming and answering clinical questions, conducting patient care handovers, collaborating interprofessionally, and recognizing patients requiring urgent care and initiating that care. For each CEPAER, the authors offer suggestions about instruction and assessment of competency. The fourth year of medical school can be rewarding for students, while adequately preparing them to begin residency, by addressing important elements defined in the core entrustable activities. Thus prepared, new residents can function safely and competently in supervised postgraduate settings.

The Philadelphia Lung Cancer Learning Community: a multi-health-system, citywide approach to lung cancer screening.

BACKGROUND: Lung cancer screening uptake for individuals at high risk is generally low across the United States, and reporting of lung cancer screening practices and outcomes is often limited to single hospitals or institutions. We describe a citywide, multicenter analysis of individuals receiving lung cancer screening integrated with geospatial analyses of neighborhood-level lung cancer risk factors. METHODS: The Philadelphia Lung Cancer Learning Community consists of lung cancer screening clinicians and researchers at the 3 largest health systems in the city. This multidisciplinary, multi-institutional team identified a Philadelphia Lung Cancer Learning Community study cohort that included 11 222 Philadelphia residents who underwent low-dose computed tomography for lung cancer screening from 2014 to 2021 at a Philadelphia Lung Cancer Learning Community health-care system. Individual-level demographic and clinical data were obtained, and lung cancer screening participants were geocoded to their Philadelphia census tract of residence. Neighborhood characteristics were integrated with lung cancer screening counts to generate bivariate choropleth maps. RESULTS: The combined sample included 37.8% Black adults, 52.4% women, and 56.3% adults who currently smoke. Of 376 residential census tracts in Philadelphia, 358 (95.2%) included 5 or more individuals undergoing lung cancer screening, and the highest counts were geographically clustered around each health system's screening sites. A relatively low percentage of screened adults resided in census tracts with high tobacco retailer density or high smoking prevalence. CONCLUSIONS: The sociodemographic characteristics of lung cancer screening participants in Philadelphia varied by health system and neighborhood. These results suggest that a multicenter approach to lung cancer screening can identify vulnerable areas for future tailored approaches to improving lung cancer screening uptake. Future directions should use these findings to develop and test collaborative strategies to increase lung cancer screening at the community and regional levels.

Detection of lung carcinoma arising from ground glass opacities (GGO) after 5 years - A retrospective review.

Pure ground glass opacities (GGO) may indicate pre-invasive subtypes of lung carcinoma. These neoplasms typically demonstrate indolent patterns of growth; Fleischner Society guidelines recommend up to five years of serial imaging. Our aim was to determine the frequency of diagnosed carcinoma arising from GGO detected beyond 5 years of surveillance. We reviewed pathologic diagnoses of lung carcinoma (n = 442) between 2016 and 2018 of a tertiary academic hospital and National Cancer Institute-designated cancer center to identify all cancers that arose from ground glass opacities detected on CT scan. Of the 442 cases of lung carcinoma, 32 (7%) were found that arose from pure GGOs and were ultimately diagnosed as cancer. Among the subgroup of GGOs, 78% (n = 25) were diagnosed within five years of surveillance, but up to 22% (n = 7) required between five and twelve years of serial follow up prior to definitive diagnosis. In order to detect 95% of cancers, GGOs would need to be followed for 7.9-12.7 years based upon a Kaplan-Meier estimate (p = 0.05). No patients who had lung carcinoma arising from GGOs died (0/32) within a follow-up time of one to three years. These data suggest that a greater number of lung carcinomas would be detected upon routine follow up of GGOs that extended beyond the current recommendation of five years. The overall survival of the cohort was 100%, consistent with existing data that these cancers are indolent. It is unknown whether a higher detection rate from longer interval follow up would impact overall survival.

Volume Doubling Time of Pulmonary Carcinoid Tumors Measured by Computed Tomography.

INTRODUCTION: Pulmonary carcinoid tumor (PCT) is a rare neuroendocrine lung neoplasm comprising approximately 2% of lung cancer diagnoses. It is classified as either localized low-grade (typical) or intermediate-grade (atypical) subtypes. PCT is known clinically to be a slow-growing cancer, however few studies have established its true growth rate when followed over time by computed tomography (CT). Therefore, we sought to determine the volume doubling time for PCTs as visualized on CT imaging. MATERIALS AND METHODS: We conducted a retrospective analysis of all PCTs treated at our institution between 2006 and 2020. Nodule dimensions were measured using a Picture Archiving and Communication System or retrieved from radiology reports. Volume doubling time was calculated using the Schwartz formula for PCTs followed by successive CT scans during radiographic surveillance. Consistent with Fleischner Society guidelines, tumors were considered to have demonstrated definitive growth by CT only when the interval change in tumor diameter was greater than or equal to 2 mm. RESULTS: The median volume doubling time of 13 typical PCTs was 977 days, or 2.7 years. Five atypical PCTs were followed longitudinally, with a median doubling time of 327 days, or 0.9 years. CONCLUSIONS: Typical pulmonary carcinoid features a remarkably slow growth rate as compared to more common lung cancers. Our analysis of atypical pulmonary carcinoid included too few cases to offer definitive conclusions. It is conceivable that clinicians following current nodule surveillance guidelines may mistake incidentally detected typical carcinoids for benign non-growing lesions when followed for less than 2 years in low-risk patients.

Frequency of Statin Prescription Among Individuals with Coronary Artery Calcifications Detected Through Lung Cancer Screening.

Individuals eligible for lung cancer screening (LCS) are at risk for atherosclerotic cardiovascular disease (ASCVD) due to smoking history. Coronary artery calcifications (CAC), a common incidental finding on low-dose CT (LDCT) for LCS, is a predictor of cardiovascular events. Despite findings of high ASCVD risk and CAC, a substantial proportion of LCS patients are not prescribed primary preventive statin therapy for ASCVD. We assessed the frequency of statin prescription in LCS patients with moderate levels of CAC. Among 259 individuals with moderate CAC, 95% had ASCVD risk ≥ 7.5%. Despite this, 27% of patients were statin-free prior to LDCT and 21.2% remained statin-free after LDCT showing moderate CAC. Illustratively, while a substantial proportion of LCS patients are statin-eligible, many lack a statin prescription, even after findings of CAC burden. CAC reporting should be standardized, and interdisciplinary communication should be optimized to ensure that LCS patients are placed on appropriate preventive therapy.

Glucose meter standardization across a large academic hospital system.

BACKGROUND: To select and standardize point-of-care (POC) glucose meters across a multi-hospital system. METHODS: We formed a multidisciplinary POC glucose standardization working group including key stakeholders from each site. A set of selection criteria: usability, clinical and laboratory performance, indications for use, interface connectivity, ease of implementation and ongoing operational costs were used to develop a scoring schemato facilitate a consensus-driven selection process. RESULTS: Method comparison and consensus error grid evaluation against the clinically validated reference methods demonstrated that the analytical performance for all candidate meters was comparable for both the laboratory and clinical evaluation. However, Meter 1 ranked highest in usability evaluations, implementation and streamlined interface connectivity. The meter selection process and implementation were staggered across sites due to complexity of transitioning to a new manufacturer's meter and limitations in vendor support for training and ongoing troubleshooting of interface connectivity. CONCLUSIONS: Standardization of POC glucose meters in a large multi-hospital system is a complex undertaking requiring robust, multidisciplinary organizational structure both system-wide and locally, development of consensus-driven selection tools, usability evaluation by end-users, laboratory and clinical evaluation of the analytical performance, and a strong vendor-laboratory partnership during the implementation process.

Racial Differences in Lung Cancer Screening Beliefs and Screening Adherence.

BACKGROUND: One challenge in high-quality lung cancer screening (LCS) is maintaining adherence with annual and short-interval follow-up screens among high-risk individuals who have undergone baseline low-dose CT (LDCT). This study aimed to characterize attitudes and beliefs toward lung cancer and LCS and to identify factors associated with LCS adherence. METHODS: We administered a questionnaire to 269 LCS participants to assess attitudes and beliefs toward lung cancer and LCS. Clinical data including sociodemographics and screening adherence were obtained from the LCS Program Registry. RESULTS: African-American individuals had significantly greater lung cancer worries compared with Whites (6.10 vs. 4.66, P < .001). In making the decision to undergo LCS, African-American participants described screening convenience and cost as very important factors significantly more frequently than Whites (60% vs. 26.8%, P< .001 and 58.4% vs. 37.8%, P = .001; respectively). African-American individuals with greater than high school education had significantly higher odds of LCS adherence (aOR 2.55; 95% CI, 1.14-5.60) than Whites with less than high school education. Participants who described screening convenience and cost as "very important" had significantly lower odds of completing screening follow-up after adjusting for demographic and other factors (aOR 0.56; 95% CI, 0.33-0.97 and aOR 0.54; 95% CI, 0.33-0.91, respectively). CONCLUSION: Racial differences in beliefs about lung cancer and LCS exist among African-American and White individuals enrolled in an LCS program. Cost, convenience, and low educational attainment may be barriers to LCS adherence, specifically among African-American individuals. IMPACT: More research is needed on how barriers can be overcome to improve LCS adherence.