Physician marriage survey reveals sex and specialty differences in marital satisfaction factors.

Physician marriage is a valuable indicator of how vocational factors (e.g. work hours, stressors) impact satisfaction in relationships and physician wellness overall. Previous studies suggest that gender and specialty influence marriage satisfaction for physicians, though these often come from limited, local, cohorts. A cross-sectional survey was designed and distributed to publicly available email addresses representing academic and private practice physician organizations across the United States, receiving 321 responses (253 complete). Responses included data on demographics, medical specialty, age at marriage, stage of training at marriage, number of children, and factors leading to marital satisfaction/distress. A multivariable ordinal logistic regression was conducted to find associations between survey variables and marriage satisfaction. Survey results indicated that 86.5% of physicians have been married (average age at first marriage was 27.8 years old), and the rate of first marriages ending is at least 14.7%. Men had significantly more children than women. Physicians married at least once averaged 1.98 children. "Other" specialty physicians had significantly more children on average than psychiatrists. Marrying before medical school predicted practicing in private practice settings. Job stress, work hours, children, and sex were most frequently sources of marital distress, while strong communication, finances, and children were most frequently sources of marital stability. Sex differences were also found in distressing and stabilizing marital factors: Female physicians were more likely to cite their spouse's work hours and job stress as sources of marital distress. Finally, surgery specialty and Judaism were associated with higher marriage satisfaction, whereas possession of an M.D. degree was associated with lower marriage satisfaction. This study elucidated new perspectives on physician marriage and families based on specialty, practice setting, and stage of training at marriage. Future studies may focus on factors mediating specialty and sex's impact on having children and marriage satisfaction. To our knowledge, this study is the first physician marriage survey which integrates multiple factors in the analysis of physician marriages.

The benefit of early-stage diagnosis: A registry-based survey evaluating the quality of life in patients with melanoma.

Background: The morbidity associated with advanced stage melanoma is an important consideration in the dialog surrounding early detection and overdiagnosis. Few studies have stratified melanoma patient quality of life (QoL) by stage at diagnosis. Objective: We sought to investigate if melanoma stage is independently associated with changes in QoL within a large, community-based melanoma registry. Secondarily, we investigated whether demographic factors such as age, geographic location or level of education are associated with changes in QoL in the same population. Methods: 1108 melanoma patients were surveyed over a three-month period using the QoL in Adult Cancer Survivors Survey, consisting of 47 items on a 7-point frequency scale. Data were analysed using both descriptive statistical models and adjusted multivariate logistic regression. Results: There were 677 respondents generating a 61% response rate. Overall, higher stage at diagnosis correlated with the largest decreases in QoL as it pertained to both general (p = 0.001) and Cancer-Specific stressors (p < 0.001). Education level (p = 0.020), age (p < 0.001), rural area code designation (p = 0.020) and family history of melanoma (p = 0.017) were also independently associated with changes in QoL. Conclusion: Earlier stage at melanoma diagnosis is associated with better QoL and thus represents a crucial intervention in patient care. Given our findings and the growing body of evidence surrounding morbidity in late-stage melanoma, it is essential that QoL be included in assessing the benefits of early detection.

A content analysis of marketing on the packages of dietary supplements for weight loss and muscle building.

Most dietary supplements for weight loss and muscle growth lack scientific evidence in support of product claims and contain ingredients that can be harmful to health. Many people, however, still use these products. This paper aims to address a gap in the knowledge of the number and types of marketing claims appearing on dietary supplements for weight loss and muscle building and how they relate to the presence of an FDA disclaimer. We identified all products (n = 110) found in the weight loss and muscle building section of three stores (a pharmacy, supermarket, and superstore) in the Boston, MA area during 2013. We performed a content analysis to assess the presence of marketing claims displayed on product packaging, including claims about weight loss, safety, quality, and scientific evidence. Warnings and the FDA disclaimer were also coded. We found that, on average, products displayed 6.5 claims. Among weight loss- and muscle building- related claims, claims about reducing weight, BMI, or body fat were most common (60.9%), followed by protein claims (40.0%). Nearly half of the products made claims that scientific research supported product use. Products with the FDA disclaimer (53.6%) or a warning for vulnerable populations (56.4%) had a higher average number of claims compared to products without the disclaimer or warning (p < 0.001). Dietary supplements for weight loss and muscle building displayed many marketing claims promising weight loss despite a lack of scientific evidence that such products can be used safely and effectively. Greater FDA regulation of these marketing claims are needed.

Nivolumab in patients with advanced hepatocellular carcinoma and Child-Pugh class B cirrhosis: Safety and clinical outcomes in a retrospective case series.

BACKGROUND: Nivolumab demonstrated durable responses and safety in patients with hepatocellular carcinoma (HCC) with Child-Pugh class A cirrhosis in the CheckMate 040 trial, with rates of hepatotoxicity that were similar to those of non-HCC populations. To the authors' knowledge, the safety and efficacy of nivolumab has not been established in patients with Child-Pugh class B (CPB) cirrhosis, a population with limited therapeutic options and a poor prognosis. METHODS: The authors conducted a retrospective case series of patients with advanced HCC and CPB cirrhosis who were treated with nivolumab and enrolled in the University of California at San Francisco Hepatobiliary Tissue Bank and Registry. Safety endpoints included rates of grade ≥3 adverse events (AEs) (graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events [version 4.03]) and serious AEs, immune-related AEs (irAE), steroid requirement, and discontinuation. Efficacy endpoints included time on treatment, the objective response rate according to Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1, overall survival, and progression-free survival. RESULTS: A total of 18 patients were included, with 72% of them (13 of 18 patients) previously treated with sorafenib. The majority of patients (94%; 17 of 18 patients) experienced a grade ≥3 AE, with treatment-related grade ≥3 AEs reported in 28% of patients (5 of 18 patients). irAEs were reported to occur in approximately 50% of patients (9 of 18 patients), and 28% (5 of 18 patients) required steroids. Treatment-related AEs required discontinuation in 4 patients (22%). The median time on treatment was 2.3 months (95% CI, 1.9 months to upper bound not estimable). The objective response rate was 17% (3 of 18 patients), including 2 partial responses and 1 complete response. The median overall survival from the time of nivolumab initiation was 5.9 months (95% CI, 3 months to upper bound not estimable), with a median progression-free survival of 1.6 months (95% CI, 1.4-3.5 months). CONCLUSIONS: Patients with CPB HCC experienced high rates of AEs, although the frequency of irAEs was similar to that of patients with Child-Pugh class A HCC in the CheckMate 040 trial. A subset of patients experienced prolonged tumor responses. Nivolumab warrants further study in patients with CPB HCC.

Nontuberculous Mycobacterium Infections Associated With Heater-Cooler Devices.

BACKGROUND: Disseminated nontuberculous mycobacterium infections have occurred following surgical procedures involving extracorporeal circulation; contaminated water from heater-cooler devices (HCDs) has been implicated as the source. The purpose of this review was to evaluate the public health concern and to educate physicians who care for this patient population. METHODS: The Food and Drug Administration Medical Device Reporting (MDR) database was queried for reports received between January 2010 and August 2016 for patient infections and device contaminations associated with the use of HCDs. Reports were reviewed for type of infection, patient demographics or outcome, reporting country, HCD manufacturer, and the time to event occurrence. RESULTS: A total of 339 MDR reports involving 99 facilities and 5 HCD manufacturers were found. MDR reports originated within (n = 154) and outside the United States (n = 185), and included 107 MDR reports describing patient infections involving at least 86 patients and 232 MDR reports describing HCD contamination without known patient infections. The MDR reports identified the surgical procedure in 94 reports and infection location in 83 reports. The time from surgical procedure using an HCD to infection diagnosis was calculable in 67 reports and was reported up to 60 months following the initial surgery. Nontuberculous mycobacterium was the most frequent organism identified, with M. chimaera being the predominate isolate. CONCLUSIONS: Nontuberculous mycobacterium infections associated with HCDs used during cardiothoracic surgery may have a long latency period and may be lethal. Cardiothoracic surgeon awareness or involvement in this issue is critical in helping to mitigate this emerging public health concern.

Febrile Ulceronecrotic Mucha-Habermann Disease: Two Cases with Excellent Response to Methotrexate.

Febrile ulceronecrotic Mucha-Habermann disease (FUMHD), a severe form of pityriasis lichenoides et varioliformis acuta (PLEVA), featuring large, ulcerative, necrotic skin plaques, high fever, and other systemic symptoms, is a rare disorder of unknown etiology. No randomized controlled trials have established treatment guidelines and multiple modalities are often employed, making it difficult to assess the efficacy of any single agent. We report two cases of this condition in which treatment with methotrexate plus antibiotic treatment for superinfection led to rapid improvement.

Chronic ulcerative herpes simplex virus infection of the vulva.

Herpes simplex virus infections in HIV-infected individuals can be clinically unusual and difficult to treat due to underlying problems with cell-mediated immunity and the occurrence of antiviral resistance. Additionally, partial or incomplete restoration of immune function may result in chronic ulcerations that require rotational treatments. In this report, we describe the case of a 38-year-old HIV-positive woman who developed the ulcerative form of chronic herpes simplex infection despite highly active antiretroviral therapy and valacyclovir prophylaxis. Repeated intravenous courses of foscarnet and topical cidofovir finally controlled her erosions as her cell-mediated immunity was slowly restored. This case highlights the challenges that still exist in diagnosing and managing this rare presentation of herpes simplex virus.

The perimenopausal atherosclerosis transition: relationships between calcified and noncalcified coronary, aortic, and carotid atherosclerosis and risk factors and hormone levels.

OBJECTIVE: Women of perimenopause age experience an upward transition of cardiovascular risk possibly in association with changing hormonal status. We examined the cross-sectional relationships between the atherosclerotic plaque within the coronary and carotid arteries and aorta and the menopausal hormone levels among asymptomatic perimenopausal women. METHODS: The Assessment of the Transition of Hormonal Evaluation with Noninvasive Imaging of Atherosclerosis was a prospective substudy of the Prospective Army Coronary Calcium project. We screened 126 asymptomatic perimenopausal women (mean age, 50 y) using contrast-enhanced CT angiography (multidetector CT) and carotid ultrasound. Women had coronary calcium data from 5 to 10 years earlier. The measures included cardiovascular risk factors, serum hormone levels, 64-slice multidetector CT, and carotid ultrasound. RESULTS: The prevalence of any coronary plaque was 35.5%. The prevalence of noncalcified plaque was 30.2%, and noncalcified plaque was the only manifestation of coronary artery disease in 10.7%. Markers of androgenicity (increased free testosterone and reduced sex hormone-binding globulin) were associated with an increased extent of calcified and noncalcified coronary artery plaque and aortic plaque. However, these relationships were not independent of cardiovascular risk factors. Follicle-stimulating hormone was directly associated with the number of aortic plaques. The levels of estrogen hormones were unrelated to plaque presence or extent. CONCLUSIONS: Coronary, aortic, and carotid arterial plaque is prevalent in perimenopausal women without cardiac symptoms. The assessment of perimenopausal hormone status was not independently associated with subclinical atherosclerosis beyond standard cardiovascular risk factors.

Relation between the Framingham Risk Score, coronary calcium, and incident coronary heart disease among low-risk men.

The Prospective Army Coronary Calcium Project is evaluating the predictive value of coronary artery calcium (CAC) in unselected, healthy, lower-risk, 40- to 50-year-old men. Although this study has found that coronary calcium is predictive of future coronary heart disease (CHD), criteria are needed to narrow the screening population to those in whom CAC measurement is most efficient (vs unselected screening of low-risk men). In 1,634 unselected volunteer men (mean age 42 years, mean 10-year CHD Framingham risk score [FRS] 4.6%, CAC prevalence 22.4%), we evaluated the independent relation between CAC and incident CHD over 5.6 years including hard events (hospitalized unstable angina, myocardial infarction, and CHD death) and coronary revascularization. The cohort was analyzed in tertiles of FRS for the relation between CAC and CHD outcomes. FRS tertile cutpoints were 0% to 3% (n = 547), >3% to 5% (n = 547), and >5% (n = 540) 10-year CHD risk. Over a mean follow-up of 5.6 +/- 1.5 years (range 1.0 to 8.3), there were 22 total CHD events, including 14 hard events and 8 revascularizations. Most events occurred in the highest FRS tertile (n = 14) versus the middle (n = 6) and lowest (n = 2) risk tertiles (p = 0.005). CAC and CHD events increased across FRS tertiles. Only in the highest FRS tertile was there a significant relation between CAC and CHD outcomes (hazard ratio 9.3). In conclusion, CAC screening could be of benefit in refining risk assessment of low-risk men, but only when the FRS exceeds approximately 5%.

Impact of coronary calcium on arterial age and coronary heart disease risk estimation using the MESA arterial age calculator.

BACKGROUND: We evaluated the impact of arterial age calculation on reclassification of global coronary heart disease risk using the Framingham risk score. METHODS: We applied CHD risk factor data from the Prospective Army Coronary Calcium Project to the MESA arterial age calculator (available at http://www.mesa-nhlbi.org). Subjects (N=1998) were studied with measured CHD risk factors and electron beam computed tomography for the identification of coronary artery calcium. Framingham risk scores (FRS), using the 10-year CHD risk model with and without arterial age, were calculated using the MESA arterial age calculator. RESULTS: The mean FRS of the cohort (42.9 + or - 2.7 years, male gender 82%) was 4.5 + or - 3.6%. Coronary calcium was present in 394 subjects (19.7%). Application of the arterial age calculator increased mean age from 42.9 + or - 2.7 to 43.6 + or - 10.4 years (P<.001), and the mean FRS increased from 4.5 + or - 3.6 to 7.3 + or - 8.1% (P<.001). Reclassification was seen primarily among male subjects, in whom the mean age (chronological vs. arterial age) increased from 42.9 + or - 2.7 to 44.2 + or - 11.0 (P<.001) and the prevalence of high CHD risk increased from 0.6% (10 of 1639) to 10% (165 of 1639; P<.001). CONCLUSION: Among healthy individuals ages 40-50, application of the MESA arterial age calculator reclassifies 1 in 10 men from low to intermediate risk and 1 in 15 men from low to high risk.

The relationship between the cardiometabolic syndrome and coronary artery calcium progression.

J Clin Hypertens (Greenwich). 2009;11:505-511. (c)2009 Wiley Periodicals, Inc.Cardiometabolic syndrome has been associated with increased likelihood and extent of coronary artery calcium (CAC). The authors examined the relationship of cardiometabolic syndrome to CAC progression in 200 healthy men who volunteered to undergo repeated electron beam tomography separated by 4.2+/-1.3 years. Prediction of clinically significant CAC progression (>/=15% per year) was evaluated using multivariable logistic regression models and principal component analysis. Clinically significant CAC progression was observed in 52.5% of the cohort, with the mean and median rate of annual progression 41.3% and 18.3%, respectively. The cardiometabolic syndrome in clinically significant CAC progression participants was significantly higher compared with those without CAC progression (24.8% vs 11.6%; P=.016). Cardiometabolic syndrome was a significant independent predictor of clinically significant CAC progression (odds ratio, 2.65; P=.022). Cardiometabolic syndrome is associated with the baseline CAC score, and independently associated with the progression of CAC over 4 years.

Comparison of coronary artery calcium progression in African American and white men.

BACKGROUND: Although African Americans have a lower prevalence and extent of coronary artery calcium (CAC) than whites, the relationship between ethnicity and CAC progression is unknown. In a prospective rescan substudy of the Prospective Army Coronary Calcium (PACC) Project, we evaluated ethnic differences in the rates of CAC progression over 4 years. METHODS: Two hundred healthy male PACC Project participants (age, 47.8 +/- 2.8 years) with CAC on their original scan volunteered to undergo a second electron beam tomography (EBT) scan and cardiovascular risk factor assessment (interscan interval, 4.3 +/- 1.2 y). All results were independently examined and blinded to baseline data. A change in CAC score >or=15%/y was defined as clinically significant progression. The relationship between race and CAC progression was evaluated with multivariable linear and logistic regression models controlling for age and other cardiovascular risk factors. RESULTS: African Americans had significantly lower baseline CAC scores (34.3 vs 101.5; P = 0.004); lower follow-up CAC scores (56.6 vs 180.6; P = 0.001); and worse cardiovascular risk profiles. The annualized CAC progression rate was not significantly related to race in the multivariable linear regression model controlling for age, the Framingham risk score, and other cardiovascular risk factors. Significant CAC progression occurred in 43.5% of all participants. The incidence of significant progression of CAC for African American and white men was similar (53.1% vs 52.4%; P = 0.94), even when controlling for age, the Framingham risk score, and other cardiovascular risk factors. CONCLUSION: Although African American men have less CAC than white men, CAC progression occurs at a comparable rate over 4 years.

Community-based provision of statin and aspirin after the detection of coronary artery calcium within a community-based screening cohort.

OBJECTIVES: We examined the association of coronary artery calcium (CAC) detected on a screening exam with subsequent statin and aspirin usage in a healthy male screening cohort. BACKGROUND: Whether the presence of CAC, an independent predictor of coronary heart disease outcomes, alters clinical management, such as the use of preventive medications, is unknown. METHODS: Men (n = 1,640) ages 40 to 50 years (mean 42 years) were screened for coronary heart disease risk factors and CAC. The CAC scores and risk factors were reported to patients, and results were made available in the electronic medical record; however, medications were not prescribed or recommended by the study. During up to 6 years of subsequent annual structured telephone follow-up, we observed the community-based initiation and persistence of aspirin and statin therapy. RESULTS: A progressive increase in the incidence of pharmacotherapy was noted over time such that those with CAC were 3 times more likely to receive a statin (48.5% vs. 15.5%, p < 0.001) and also significantly more likely to receive aspirin (53.0% vs. 32.3%; p < 0.001) than those without CAC. In multivariable models controlling for National Cholesterol Education Program risk variables and baseline medication use, CAC was strongly and independently associated with use of either statin (odds ratio [OR] 3.53; 95% confidence interval [CI] 2.66 to 4.69), aspirin (OR 3.05; 95% CI 2.30 to 4.05) or both (OR 6.97; 95% CI 4.81 to 10.10). CONCLUSIONS: In this prospective cohort, the presence of coronary calcification was associated with an independent 3-fold greater likelihood of statin and aspirin usage.

Progression of calcified coronary atherosclerosis: relationship to coronary risk factors and carotid intima-media thickness.

BACKGROUND: The determinants of coronary artery calcium (CAC) progression are not well understood. Prior studies have shown a limited relationship between CAC progression and traditional coronary risk factors. We hypothesized that the extent of non-calcified atherosclerosis detected using carotid intima-media thickness (CIMT) would predict progression of calcified atherosclerosis. METHODS: One hundred and eighty healthy male participants (mean age 47.9) with CAC from the Prospective Army Coronary Calcium (PACC) project volunteered to undergo a second EBCT scan, risk factor assessment, lab testing, and CIMT assessment 4.2+/-1.3 years after their original scan. All results were independently examined, blinded to baseline data. A change in CAC score >or=15% per year was defined as clinically significant progression. RESULTS: CAC progression occurred in 60.2%. Compared to participants without progression, those with progression had higher triglycerides, LDL and total cholesterol and Framingham risk scores, but similar blood pressure, HDL cholesterol, blood glucose, C-reactive protein, fibrinogen, and body mass index. CIMT was significantly higher among those with versus without CAC progression (0.660 mm versus 0.603 mm; P=0.001). Each quintile of increasing CIMT was independently associated with a 35% increase in the odds of CAC progression (P=0.01), after controlling for the Framingham risk score and C-reactive protein. CONCLUSION: Among middle-aged men with coronary calcium, increasing extent of non-calcified atherosclerosis is strongly associated with coronary artery calcium progression over 4 years.