A systematic review and meta-analysis of English language online patient education materials in breast cancer: Is readability the only story?

BACKGROUND: Online patient education materials (OPEMs) are an increasingly popular resource for women seeking information about breast cancer. The AMA recommends written patient material to be at or below a 6th grade level to meet the general public's health literacy. Metrics such as quality, understandability, and actionability also heavily influence the usability of health information, and thus should be evaluated alongside readability. PURPOSE: A systematic review and meta-analysis was conducted to determine: 1) Average readability scores and reporting methodologies of breast cancer readability studies; and 2) Inclusion frequency of additional health literacy-associated metrics. MATERIALS AND METHODS: A registered systematic review and meta-analysis was conducted in Ovid MEDLINE, Web of Science, Embase.com, CENTRAL via Ovid, and ClinicalTrials.gov in June 2022 in adherence with the PRISMA 2020 statement. Eligible studies performed readability analyses on English-language breast cancer-related OPEMs. Study characteristics, readability data, and reporting of non-readability health literacy metrics were extracted. Meta-analysis estimates were derived from generalized linear mixed modeling. RESULTS: The meta-analysis included 30 studies yielding 4462 OPEMs. Overall, average readability was 11.81 (95% CI [11.14, 12.49]), with a significant difference (p < 0.001) when grouped by OPEM categories. Commercial organizations had the highest average readability at 12.2 [11.3,13.0]; non-profit organizations had one of the lowest at 11.3 [10.6,12.0]. Readability also varied by index, with New Fog, Lexile, and FORCAST having the lowest average scores (9.4 [8.6, 10.3], 10.4 [10.0, 10.8], and 10.7 [10.2, 11.1], respectively). Only 57% of studies calculated average readability with more than two indices. Only 60% of studies assessed other OPEM metrics associated with health literacy. CONCLUSION: Average readability of breast cancer OPEMs is nearly double the AMA's recommended 6th grade level. Readability and other health literacy-associated metrics are inconsistently reported in the current literature. Standardization of future readability studies, with a focus on holistic evaluation of patient materials, may aid shared decision-making and be critical to increased screening rates and breast cancer awareness.

Portable cerebral blood flow monitor to detect large vessel occlusion in patients with suspected stroke.

BACKGROUND: Early detection of large vessel occlusion (LVO) facilitates triage to an appropriate stroke center to reduce treatment times and improve outcomes. Prehospital stroke scales are not sufficiently sensitive, so we investigated the ability of the portable Openwater optical blood flow monitor to detect LVO. METHODS: Patients were prospectively enrolled at two comprehensive stroke centers during stroke alert evaluation within 24 hours of onset with National Institutes of Health Stroke Scale (NIHSS) score ≥2. A 70 s bedside optical blood flow scan generated cerebral blood flow waveforms based on relative changes in speckle contrast. Anterior circulation LVO was determined by CT angiography. A deep learning model trained on all patient data using fivefold cross-validation and learned discriminative representations from the raw speckle contrast waveform data. Receiver operating characteristic (ROC) analysis compared the Openwater diagnostic performance (ie, LVO detection) with prehospital stroke scales. RESULTS: Among 135 patients, 52 (39%) had an anterior circulation LVO. The median NIHSS score was 8 (IQR 4-14). The Openwater instrument had 79% sensitivity and 84% specificity for the detection of LVO. The rapid arterial occlusion evaluation (RACE) scale had 60% sensitivity and 81% specificity and the Los Angeles motor scale (LAMS) had 50% sensitivity and 81% specificity. The binary Openwater classification (high-likelihood vs low-likelihood) had an area under the ROC (AUROC) of 0.82 (95% CI 0.75 to 0.88), which outperformed RACE (AUC 0.70; 95% CI 0.62 to 0.78; P=0.04) and LAMS (AUC 0.65; 95% CI 0.57 to 0.73; P=0.002). CONCLUSIONS: The Openwater optical blood flow monitor outperformed prehospital stroke scales for the detection of LVO in patients undergoing acute stroke evaluation in the emergency department. These encouraging findings need to be validated in an independent test set and the prehospital environment.

Effect of a Technology-Integrated Curriculum on Sugary Drink and Snack Intake of Elementary-Aged Youth Experiencing Low Income.

OBJECTIVE: To describe the results of a technology-integrated intervention on sugar-sweetened beverage (SSB) and energy-dense snack intake with third graders experiencing low income. DESIGN: A 2 × 2 quasi-randomized cluster-block, parallel-group experimental research design. SETTING: Low-income schools in Rhode Island. PARTICIPANTS: Two-hundred seventeen intervention and 242 control third-grade students in low-income (89.6% and 88.2% free/reduced meals, respectively), ethnically and racially diverse (63% Hispanic/20% Black and 62% Hispanic/18% Black, respectively) schools. INTERVENTION(S): A 13-week in-school program held once per week for 1 hour. The hands-on, technology-integrated program used a modified version of the Body Quest: Food of the Warrior curriculum. MAIN OUTCOME MEASURE(S): Intake of SSB and energy-dense snacks, both salty and sweet snacks, using baseline (week 1) and postassessment (week 13) previous day self-recall. ANALYSIS: Generalized mixed modeling with nesting. RESULTS: Intervention students significantly reduced their SSB intake by 38% (0.5 times/d; F[1, 540] = 4.26; P = 0.04) and salty snack intake by 58% (0.8 times/d; F[1, 534] = 6.58, P < 0.01) from baseline to postassessment as compared with the control students. CONCLUSIONS AND IMPLICATIONS: Findings suggest a technology-integrated curriculum is effective in decreasing SSB and salty snacks in elementary-aged students of low-income, minoritized populations. Improved dietary habits can potentially influence other facets of students' lives.

Modeling diffusion-weighted imaging lesion expansion between 2 and 24 h after endovascular thrombectomy in acute ischemic stroke.

PURPOSE: Diffusion-weighted imaging (DWI) lesion expansion after endovascular thrombectomy (EVT) is not well characterized. We used serial diffusion-weighted magnetic resonance imaging (MRI) to measure lesion expansion between 2 and 24 h after EVT. METHODS: In this single-center observational analysis of patients with acute ischemic stroke due to large vessel occlusion, DWI was performed post-EVT (< 2 h after closure) and 24-h later. DWI lesion expansion was evaluated using multivariate generalized linear mixed modeling with various clinical moderators. RESULTS: We included 151 patients, of which 133 (88%) had DWI lesion expansion, defined as a positive change in lesion volume between 2 and 24 h. In an unadjusted analysis, median baseline DWI lesion volume immediately post-EVT was 15.0 mL (IQR: 6.6-36.8) and median DWI lesion volume 24 h post-EVT was 20.8 mL (IQR: 9.4-66.6), representing a median change of 6.1 mL (IQR: 1.5-17.7), or a 39% increase. There were no significant associations among univariable models of lesion expansion. Adjusted models of DWI lesion expansion demonstrated that relative lesion expansion (defined as final/initial DWI lesion volume) was consistent across eTICI scores (0-2a, 0.52%; 2b, 0.49%; 2c-3, 0.42%, p = 0.69). For every 1 mL increase in lesion volume, there was 2% odds of an increase in 90-day mRS (OR: 1.021, 95%CI [1.009, 1.034], p < 0.001). CONCLUSION: We observed substantial lesion expansion post-EVT whereby relative lesion expansion was consistent across eTICI categories, and greater absolute lesion expansion was associated with worse clinical outcome. Our findings suggest that alternate endpoints for cerebroprotectant trials may be feasible.

Should I Stay, or Should I Go? Early Phase Instrument Development of Workforce Movement-A Pilot Study with Breast Radiologists.

OBJECTIVE: The goal of this study was to develop a psychometrically valid survey on workplace satisfaction and examine predictors of workforce movement among breast radiologists. METHODS: Actively practicing members of the Society of Breast Imaging were invited to complete a survey on workplace satisfaction. Radiologists also indicated whether they had recently left their practice or were thinking of leaving their practice. RESULTS: In total, 228 breast radiologists provided valid responses (8.7% response rate); 45% were thinking of leaving or had left their practice. Factor analysis yielded five factors, and discriminant function analysis found six main aspects associated with workforce movement in breast radiologists: (1) not enough work-life balance; (2) salary too low; (3) not feeling valued; (4) wanting a different challenge and/or more growth opportunity; (5) safety concerns; and (6) not feeling respected by physician leadership. CONCLUSIONS: Pending further validation in larger and different cohorts, the survey created here can be administered by radiology practices to predict when breast radiologists are vulnerable to quitting. Atlhough this measure was designed for breast radiologists specifically, it could be adapted for other subspecialties.

Prospective Margin Estimates Predict Local Tumor Progression Following Microwave Ablation of Small Renal Masses.

PURPOSE: To evaluate the relationship between prospectively generated ablative margin estimates and local tumor progression (LTP) among patients undergoing microwave ablation (MWA) of small renal masses (SRMs). MATERIALS AND METHODS: Between 2017 and 2020, patients who underwent MWA for SRM were retrospectively identified. During each procedure, segmented kidney and tumor shapes were coregistered with intraprocedural helical CT images obtained after microwave antenna placement. Predicted ablation zone shape and size were then overlaid onto the resultant model, and a model-to-model distance algorithm was employed to calculate multiple ablative margin estimates. LTP was modeled as a function of each margin estimate by hazard regression. Models were evaluated using hazard ratios and Akaike information criterion. Receiver operating characteristic curve area under the curve was also estimated using Harrell's and Uno's C indices (HI and UI, respectively). RESULTS: One hundred and twenty-eight patients were evaluated (median age 72.1 years). Mean tumor diameter was 2.4 ± 0.9 cm. LTP was observed in nine (7%) patients. Analysis showed that decreased estimated margin size as measured by first quartile (Q1; 25th percentile), maximum, and average ablative margin metrics was significantly associated with risk of LTP. For every one millimeter increase in Q1, maximum, and mean ablative margin, the hazard of LTP increased 67% (HR: 1.67; 95% CI = 1.25-2.20, UI = 0.93, HI = 0.77), 32% (HR: 1.32; 95% CI 1.09-1.60; UI = 0.93; HI = 0.76), and 48% (HR: 1.48; 95% CI 1.18-1.85; UI = 0.83; HI = 0.75), respectively. CONCLUSION: Prospectively generated ablative margin estimates can be used to predict the risk of local tumor progression following microwave ablation of small renal masses. LEVEL OF EVIDENCE 3: Retrospective cohort study.

Diversity in interventional radiology: Survey of medical student interest with focus on women and members of underrepresented in medicine racial and ethnic groups.

PURPOSE: To assess: 1) the percentage of female and underrepresented in medicine (URiM) medical students interested in interventional radiology (IR), and 2) the motivations for and deterrents from IR for female and URiM students. METHODS: The study was IRB exempt. Data from a 19-item survey sent to 5 US medical schools were collected from 10/2018-01/2019 using REDCap and analyzed with SAS GLIMMIX. RESULTS: 16% (56/346) of women and 27% (69/258) of men strongly considered IR. 21% (19/89) of URiM versus 21% (105/508) of non-URiM students, p = .88, seriously considered IR. On a 0-to-4 scale (0 = not a motivator, 4 = strong motivator), women rated "Female mentorship" "2.5" versus males' "0.4", p < .0001, independent of IR interest URiM students uninterested in IR rated "Lack of ethnic diversity in training""2.3" versus "1.2" for IR-interested URiM, p < .01. 18% (9/50) of IR-interested women reported adequate gender-specific mentorship in IR in medical school. Of IR-interested URiM students 5% (1/19) reported adequate ethnicity/race-specific mentorship. CONCLUSION: Fewer female medical students considered IR compared to males. Female mentorship was a significant motivator for women. Similar numbers of URiM and non-URiM students consider IR. Few women and URiM students report adequate gender/ethnicity/race-specific mentorship. For students not interested in IR, lack of ethnic diversity in training was a significant deterrent. Increasing numbers and visibility of female and URiM interventional radiologists in mentoring and clinical practice may improve recruitment of medical students from these underrepresented groups.

Readability and reliability of online patient education materials about statins.

Objective: Statins are the cornerstone for the prevention and treatment of cardiovascular disease. Patients often consult online patient education materials (OPEMs) to inform medical decision-making. We therefore aimed to assess the readability and reliability of OPEMs related to statins. Methods: A total of 17 statin-related terms were queried using an online search engine to identify the top 20 search results for each statin-related term. Each OPEM was then grouped into the following categories based on 2 independent reviewers: government OPEMs (national, state, or local government agencies); healthcare/nonprofit OPEMs (major health systems and nonprofit organizations with a specific cardiovascular health focus); industry/commercial OPEMs (pharmaceutical manufacturers and online pharmacies); lay press OPEMs (healthcare-oriented news organizations); and dictionary/encyclopedia OPEMs. Grade-level readability for each OPEM was calculated using 5 standard readability metrics and compared with AMA-recommended readability recommendations. Reliability of each OPEM was evaluated using the JAMA benchmark criteria for online health information and certification from Health on the Net (HONCode). Results: A total of 340 websites were identified across the 17 statin search terms. There were 211 statin OPEMs after excluding non-OPEM results; 172 OPEMs had unique content. Statin OPEM readability exceeded the recommended 6th grade AMA reading level (average reading grade level of 10.9). The average JAMA benchmark criteria score was 2.13 (on a scale of 0-4, with higher scores indicating higher reliability), and only 60% of statin OPEMs were HONCode-certified. There was an inverse association between readability and reliability. The most readable results were from industry and commercial sources, while the most reliable sites were from lay press sources. Conclusions: Statin OPEMs are written at an overall averaging reading grade level of 10.9. There was an inverse association between readability and reliability. Lack of accessible, high-quality online health information may contribute to statin nonadherence.

A pre-post study of stressors and burnout affecting breast radiologists before and during the COVID-19 pandemic.

Rationale and objective: To compare burnout and stressors of breast radiologists prior to and during the COVID-19 pandemic. Materials and methods: Members of the Society of Breast Imaging were emailed an IRB-approved survey in January 2021 during the COVID-19 pandemic. Survey included questions from the Maslach Burnout Inventory and specific stressors including work pace, work-life balance, care of dependents, and financial strain. Data were compared to previous surveys prior to the pandemic. Results: The response rate was 25% (261/1061) for those who opened the email. Of the respondents, 74% (194/261) were female, 82% (214/261) were white, 73% (191/261) were full time, 71% (185/261) were fellowship trained, 41% (106/261) had more than 20 years of experience, and 30% (79/261) were in academic practice.Respondents in 2021 reported frequent levels of depersonalization (2.2) and emotional exhaustion (3.4) while reporting frequent levels of personal accomplishment (5.3), a protective factor. These values were nearly identical before the pandemic in 2020: (2.2, 3.5, 5.3, respectively, p = .9). Respondents rated practicing faster than they would like as the highest stressor; however, 5 of the 6 stressors improved after the pandemic onset (p < .05). Conversely, participants perceived these stresses had gotten slightly worse since the pandemic (p < .01). Almost 50% of respondents reported they were considering leaving their practice; the most common reason was work/life balance. Conclusion: Burnout in breast radiologists remains frequent but unchanged during the COVID-19 pandemic. While participants perceived that some stressors were worse during the pandemic, there was slight improvement in most stressors between the pre-pandemic and pandemic cohorts.

Can incorrect artificial intelligence (AI) results impact radiologists, and if so, what can we do about it? A multi-reader pilot study of lung cancer detection with chest radiography.

OBJECTIVE: To examine whether incorrect AI results impact radiologist performance, and if so, whether human factors can be optimized to reduce error. METHODS: Multi-reader design, 6 radiologists interpreted 90 identical chest radiographs (follow-up CT needed: yes/no) on four occasions (09/20-01/22). No AI result was provided for session 1. Sham AI results were provided for sessions 2-4, and AI for 12 cases were manipulated to be incorrect (8 false positives (FP), 4 false negatives (FN)) (0.87 ROC-AUC). In the Delete AI (No Box) condition, radiologists were told AI results would not be saved for the evaluation. In Keep AI (No Box) and Keep AI (Box), radiologists were told results would be saved. In Keep AI (Box), the ostensible AI program visually outlined the region of suspicion. AI results were constant between conditions. RESULTS: Relative to the No AI condition (FN = 2.7%, FP = 51.4%), FN and FPs were higher in the Keep AI (No Box) (FN = 33.0%, FP = 86.0%), Delete AI (No Box) (FN = 26.7%, FP = 80.5%), and Keep AI (Box) (FN = to 20.7%, FP = 80.5%) conditions (all ps < 0.05). FNs were higher in the Keep AI (No Box) condition (33.0%) than in the Keep AI (Box) condition (20.7%) (p = 0.04). FPs were higher in the Keep AI (No Box) (86.0%) condition than in the Delete AI (No Box) condition (80.5%) (p = 0.03). CONCLUSION: Incorrect AI causes radiologists to make incorrect follow-up decisions when they were correct without AI. This effect is mitigated when radiologists believe AI will be deleted from the patient's file or a box is provided around the region of interest. CLINICAL RELEVANCE STATEMENT: When AI is wrong, radiologists make more errors than they would have without AI. Based on human factors psychology, our manuscript provides evidence for two AI implementation strategies that reduce the deleterious effects of incorrect AI. KEY POINTS: • When AI provided incorrect results, false negative and false positive rates among the radiologists increased. • False positives decreased when AI results were deleted, versus kept, in the patient's record. • False negatives and false positives decreased when AI visually outlined the region of suspicion.

ACR Lung CT Screening Reporting and Data System, a Systematic Review and Meta-Analysis Before Change in US Preventative Services Taskforce Eligibility Criteria: 2014 to 2021.

OBJECTIVE: To review Lung CT Screening Reporting and Data System (Lung-RADS) scores from 2014 to 2021, before changes in eligibility criteria proposed by the US Preventative Services Taskforce. METHODS: A registered systematic review and meta-analysis was conducted in MEDLINE, Embase, CINAHL, and Web of Science in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines; eligible studies examined low-dose CT (LDCT) lung cancer screening at institutions in the United States and reported Lung-RADS from 2014 to 2021. Patient and study characteristics, including age, gender, smoking status, pack-years, screening timeline, number of individual patients, number of unique studies, Lung-RADS scores, and positive predictive value (PPV) were extracted. Meta-analysis estimates were derived from generalized linear mixed modeling. RESULTS: The meta-analysis included 24 studies yielding 36,211 LDCT examinations for 32,817 patient encounters. The meta-analysis Lung-RADS 1-2 scores were lower than anticipated by ACR guidelines, at 84.4 (95% confidence interval [CI] 83.3-85.6) versus 90% respectively (P < .001). Lung-RADS 3 and 4 scores were both higher than anticipated by the ACR, at 8.7% (95% CI 7.6-10.1) and 6.5% (95% CI 5.707.4), compared with 5% and 4%, respectively (P < .001). The ACR's minimum estimate of PPV for Lung-RADS 3 to 4 is 21% or higher; we observed a rate of 13.1% (95% CI 10.1-16.8). However, our estimated PPV rate for Lung-RADS 4 was 28.6% (95% CI 21.6-36.8). CONCLUSION: Lung-RADS scores and PPV rates in the literature are not aligned with the ACR's own estimates, suggesting that perhaps Lung-RADS categorization needs to be reexamined for better concordance with real-world screening populations. In addition to serving as a benchmark before screening guideline broadening, this study provides guidance for future reporting of lung cancer screening and Lung-RADS data.

A Pilot Study of Accelerometer-Based Biometric Data Collection among Patients Undergoing Locoregional Therapies.

This study evaluated the feasibility of measuring patient recovery after locoregional therapies (LRTs) using a wearable activity tracker (WAT). Twenty adult patients with cancer were provided with a WAT device to wear for a minimum of 7 days prior to their procedure (baseline) and for up to 30 days after their procedure (recovery). Daily step counts were continuously recorded. Patient responses to the Short Form 36-Item Health Survey (SF-36) were also collected before and after LRT. Analysis of WAT data demonstrated a mean of 4,850 daily steps taken at baseline, which decreased to 2,000 immediately after LRT and then rapidly increased to approximately 4,300 daily steps over an average of 10 days (P < .001). No significant changes were observed in SF-36 responses between baseline and follow-up assessments (P > .10). These results suggest that WAT devices capture dynamic periprocedural data not reflected in survey-based assessments and may be used to monitor patient recovery after interventional oncologic procedures.

Clinician-rated outcomes of patients with functional neurological disorders treated in an outpatient clinic.

BACKGROUND: Patients with functional neurological (conversion) disorder (FND) have historically been difficult to treat. Outcomes have been studied in research trials, documenting improvements; however, limited information is available from a community-treated FND cohort. OBJECTIVES: We aimed to examine clinical outcomes in outpatients with FND treated with the Neuro-Behavioral Therapy (NBT) approach. These uncontrolled setting treatment data could complement more structured clinical studies results. METHODS: We conducted a retrospective chart review of consecutive patients diagnosed with FND, ages 17 to 75, who were treated with the NBT workbook at the Rhode Island Hospital Behavioral Health clinic between 2014 and 2022. NBT consisted of 45-minute, individual, outpatient sessions, in clinic or via telehealth with one clinician. Global Assessment of Functioning (GAF), and Clinical Global Impression (CGI) -Severity, and -Improvement were scored for every appointment. RESULTS: Baseline characteristics are available for 107 patients. Mean age at FND symptom onset was 37 years. Patients had a mix of FND semiologies, which included Psychogenic Nonepileptic Seizures (71%), Functional Movement Disorder (24.3%), Functional Sensory Disorder (14%), Functional Weakness (6.5%), and Functional Speech Disorder (5.6%). Clinical evaluation scores revealed improvements over time. CONCLUSIONS: We describe a well-characterized sample of patients with various and mixed FND semiologies, who received manualized therapy, NBT, in an outpatient clinic. Patients had similar psychosocial profiles to those in clinical studies and displayed improvement in clinical measures. These results demonstrate the practicability of NBT for motor FND semiologies and for PNES, in a "real-world" outpatient practice, extending care beyond structured clinical trials.

Burnout Is the Symptom, Moral Injury Is the Cause: The Need for Systems-Level Changes in Radiology.

Burnout. Wellness. Resiliency. Self-care. These buzzwords have become commonplace and the topics of articles, webinars, and lectures in medicine. Opinions vary about the most effective initiatives to optimize radiologist wellness and mitigate burnout. Despite ongoing efforts, burnout continues to grow. Although individual-directed interventions play a role, the greater leverage lies with practice- and organization-led initiatives.

Long-term effect of field triage on times to endovascular treatment for emergent large vessel occlusion.

BACKGROUND: Delays to endovascular therapy (EVT) for stroke may be mitigated with direct field triage to EVT centers. We sought to compare times to treatment over a 5.5 year span between two adjacent states, one with field triage and one without, served by a single comprehensive stroke center (CSC). METHODS: During the study period, one of the two states implemented severity-based triage for suspected emergent large vessel occlusion, while in the other state, patients were transported to the closest hospital regardless of severity. We compared times to treatment and clinical outcomes between these two states. We also performed a matched pairs analysis, matching on date treated and distance from field to CSC. RESULTS: 639 patients met the inclusion criteria, 407 in State 1 (with field triage) and 232 in State 2 (without field triage). In State 1, scene to EVT decreased 6% (or 8.13 min, p=0.0004) every year but no decrease was observed for State 2 (<1%, p=0.94). Cumulatively over 5.5 years, there was a reduction of 43 min in time to EVT in State 1, but no change in State 2. Lower rates of disability were seen in State 1, both for the entire cohort (all OR 1.22, 95% CI 1.07 to 1.40, p=0.0032) and for those independent at baseline (1.36, 95% CI 1.15 to 1.59, p=0.0003). CONCLUSIONS: Comparing adjacent states over time, the implementation of severity-based field triage significantly reduced time to EVT.

Baseline Sex Differences in Pulmonary Arterial Hypertension Randomized Clinical Trials.

Rationale: Sex-based differences in pulmonary arterial hypertension (PAH) are known, but the contribution to disease measures is understudied. Objectives: We examined whether sex was associated with baseline 6-minute-walk distance (6MWD), hemodynamics, and functional class. Methods: We conducted a secondary analysis of participant-level data from randomized clinical trials of investigational PAH therapies conducted between 1998 and 2014 and provided by the U.S. Food and Drug Administration. Outcomes were modeled as a function of an interaction between sex and age or sex and body mass index (BMI), respectively, with generalized mixed modeling. Results: We included a total of 6,633 participants from 18 randomized clinical trials. A total of 5,197 (78%) were female, with a mean age of 49.1 years and a mean BMI of 27.0 kg/m2. Among 1,436 males, the mean age was 49.7 years, and the mean BMI was 26.4 kg/m2. The most common etiology of PAH was idiopathic. Females had shorter 6MWD. For every 1 kg/m2 increase in BMI for females, 6MWD decreased 2.3 (1.6-3.0) meters (P < 0.001), whereas 6MWD did not significantly change with BMI in males (0.31 m [-0.30 to 0.92]; P = 0.32). Females had lower right atrial pressure (RAP) and mean pulmonary artery pressure, and higher cardiac index than males (all P < 0.03). Age significantly modified the sex by RAP and mean pulmonary artery pressure relationships. For every 10-year increase in age, RAP was lower in males (0.5 mm Hg [0.3-0.7]; P < 0.001), but not in females (0.13 [-0.03 to 0.28]; P = 0.10). There was a significant decrease in pulmonary vascular resistance (PVR) with increasing age regardless of sex (P < 0.001). For every 1 kg/m2 increase in BMI, there was a 3% decrease in PVR for males (P < 0.001), compared with a 2% decrease in PVR in females (P < 0.001). Conclusions: Sexual dimorphism in subjects enrolled in clinical trials extends to 6MWD and hemodynamics; these relationships are modified by age and BMI. Sex, age, and body size should be considered in the evaluation and interpretation of surrogate outcomes in PAH.