A cross-sectional study of the practice types of US adult primary care physician specialists.

BACKGROUND: Many physicians listed as primary care in databases such as the American Medical Association (AMA) Masterfile do not provide traditional ambulatory primary care. OBJECTIVE: To compare physicians listed in the AMA Masterfile as primary care physician (PCPs) specialists for adult patients with their actual practice type. METHODS: We conducted a cross-sectional study of the AMA Masterfile report for PCPs who care for adults (listed as family medicine, internal medicine, medicine-paediatrics, and geriatrics) in the summer and fall of 2018 (spring of 2019 for Hartford, CT) in the primary counties of 8 metropolitan areas across the United States. We searched multiple websites to determine the actual practice type of each physician in the study counties. We correlated the 2 datasets: the AMA Masterfile list vs the results of our searches. RESULTS: Family physicians were more likely to function as traditional ambulatory PCPs than internists [1,738/2,101 (82.7%) vs 1,241/2,025 (60.9%), P < 0.001], and less likely to be hospitalists [83/2,101 (4.0%) vs 631/2,025 (31.0%), P < 0.001]. Other practice types included urgent care [105 (5.0%) family physicians, 16 (0.8%) internists] and emergency medicine [49 (2.3%) family physicians, 20 (1.0%) internists]. The AMA Masterfile identified 4,892 practicing PCPs for adult patients in the study counties, of which 3,084 (63.0%) matched by location and ambulatory PCP practice type [3,695 (75.5%) for ambulatory PCP practice type only]. CONCLUSIONS: We provide an updated estimate using a unique methodology to estimate how to correct the AMA Masterfile for PCPs who actually provide traditional ambulatory primary care to adult patients.

Primary Care's Historic Role in Vaccination and Potential Role in COVID-19 Immunization Programs.

PURPOSE: Coronavirus disease 2019 (COVID-19) pandemic recovery will require a broad and coordinated effort for infection testing, immunity determination, and vaccination. With the advent of several COVID-19 vaccines, the dissemination and delivery of COVID-19 immunization across the nation is of concern. Previous immunization delivery patterns may reveal important components of a comprehensive and sustainable effort to immunize everyone in the nation. METHODS: The delivery of vaccinations were enumerated by provider type using 2017 Medicare Part B Fee-For-Service data and the 2013-2017 Medical Expenditure Panel Survey. The delivery of these services was examined at the service, physician, and visit level. RESULTS: In 2017 Medicare Part B Fee-For-Service, primary care physicians provided the largest share of services for vaccinations (46%), followed closely by mass immunizers (45%), then nurse practitioners/physician assistants (NP/PAs) (5%). The Medical Expenditure Panel Survey showed that primary care physicians provided most clinical visits for vaccination (54% of all visits). CONCLUSIONS: Primary care physicians have played a crucial role in delivery of vaccinations to the US population, including the elderly, between 2012-2017. These findings indicate primary care practices may be a crucial element of vaccine counseling and delivery in the upcoming COVID-19 recovery and immunization efforts in the United States.

Has Female Authorship in Family Medicine Research Evolved Over Time?

PURPOSE: Studies conducted in medical fields other than family medicine show that gender differences in publication rates are pronounced in many, but not all, fields of medicine. Our objective was to assess possible gender differences in publication rates in family medicine journals. METHODS: Using MEDLINE, we collected information on all journal articles published in 3 family medicine journals in the United States (Family Medicine, Journal of the American Board of Family Medicine, and Annals of Family Medicine) during the period 2008 to 2017. Gender of first and last author for each article was assigned using first names. The gender breakdown of the editorial boards during this time period was also examined. RESULTS: For the 3 journals combined during the period 2008 to 2017, 46.1% (1,209/2,623) of first authors were female, and 38.6% (857/2,223) of last authors were female. For all journals combined, there was a statistically significant increase in first authorship (43.2% in 2008 vs 52.1% in 2017; P<.001) and last authorship (28.8% in 2008 vs 41.8% in 2017; P <.001) over time. The editorial boards of the journals combined were 37.2% (279/749) female, and this did not increase significantly over the time period studied (35.5% in 2008 vs 39.2% in 2017; P=.49). CONCLUSIONS: Representation of female authors in family medicine journals is increasing, yet last authorship remains low, and there is variation between journals in terms of gender equity. Future studies can evaluate the reason for these differences and offer solutions to publications as they try to increase their female authorship.

Trends in the Gender Ratio of Authorship at the Robert Graham Center.

Gender disparities in medical publication have been demonstrated in several specialties. This descriptive bibliometric analysis aims to determine the gender ratio of scholarly authorship at the Robert Graham Center (RGC) over an 11-year period. We examined publications by RGC researchers and assessed first, second, and last author gender. Of 229 publications, 65.5% had a male first author and 34.5% had a female first author. Of the 217 publications with a last author, 13.4% had a female last author. This study aims to inform the broader discussion about authorship gender parity in academic medicine using a one-site case-study approach.

Retention of a Foreign Body in the Vagina of an Adult for 13 Years: A Case Report.

Cases in which foreign bodies have been inserted into the vagina predominately occur in the pediatric population. This report presents the case of an adult woman with a retained foreign body for 13 years. A duplicated ureter suggestive of a Mullerian anomaly was incidentally identified on intraoperative cystoscopy. Mullerian anomalies may be associated with complex patient presentations and are associated with reproductive implications that should be discussed based on patient-specific characteristics.

Test accuracy of artificial intelligence-based grading of fundus images in diabetic retinopathy screening: A systematic review.

OBJECTIVES: To systematically review the accuracy of artificial intelligence (AI)-based systems for grading of fundus images in diabetic retinopathy (DR) screening. METHODS: We searched MEDLINE, EMBASE, the Cochrane Library and the ClinicalTrials.gov from 1st January 2000 to 27th August 2021. Accuracy studies published in English were included if they met the pre-specified inclusion criteria. Selection of studies for inclusion, data extraction and quality assessment were conducted by one author with a second reviewer independently screening and checking 20% of titles. Results were analysed narratively. RESULTS: Forty-three studies evaluating 15 deep learning (DL) and 4 machine learning (ML) systems were included. Nine systems were evaluated in a single study each. Most studies were judged to be at high or unclear risk of bias in at least one QUADAS-2 domain. Sensitivity for referable DR and higher grades was ≥85% while specificity varied and was <80% for all ML systems and in 6/31 studies evaluating DL systems. Studies reported high accuracy for detection of ungradable images, but the latter were analysed and reported inconsistently. Seven studies reported that AI was more sensitive but less specific than human graders. CONCLUSIONS: AI-based systems are more sensitive than human graders and could be safe to use in clinical practice but have variable specificity. However, for many systems evidence is limited, at high risk of bias and may not generalise across settings. Therefore, pre-implementation assessment in the target clinical pathway is essential to obtain reliable and applicable accuracy estimates.

Pulmonary artery pressure increases during commercial air travel in healthy passengers.

BACKGROUND: It is not known whether the mild hypoxia experienced by passengers during commercial air travel triggers hypoxic pulmonary vasoconstriction and increases pulmonary artery pressure in flight. Insidious pulmonary hypertensive responses could endanger susceptible passengers who have cardiopulmonary disease or increased hypoxic pulmonary vascular sensitivity. Understanding these effects may improve pre-flight assessment of fitness-to-fly and reduce in-flight morbidity and mortality. METHODS: Eight healthy volunteers were studied during a scheduled commercial airline flight from London, UK, to Denver, CO. The aircraft was a Boeing 777 and the duration of the flight was 9 h. Systolic pulmonary artery pressure (sPAP) was assessed by portable Doppler echocardiography during the flight and over the following week in Denver, where the altitude (5280 ft/1610 m) simulates a commercial airliner environment. RESULTS: Cruising cabin altitude ranged between 5840 and 7170 ft (1780 to 2185 m), and mean arterial oxygen saturation was 95 +/- 0.6% during the flight. Mean sPAP increased significantly in flight by 6 +/- 1 mmHg to 33 +/- 1 mmHg, an increase of approximately 20%. After landing in Denver, sPAP was still 3 +/- 1 mmHg higher than baseline and remained elevated at 30 +/- 1 mmHg for a further 12 h. CONCLUSIONS: Pulmonary artery pressure increases during commercial air travel in healthy passengers, raising the possibility that hypoxic pulmonary hypertension could develop in susceptible individuals. A hypoxia altitude simulation test with simultaneous echocardiography ('HAST-echo') may be beneficial in assessing fitness to fly in vulnerable patients.

Family Medicine Residencies: How Rural Training Exposure in GME Is Associated With Subsequent Rural Practice.

Background: Rural US populations face a chronic shortage of physicians and an increasing gap in life expectancy compared to urban US populations, creating a need to understand how to increase residency graduates' desire to practice in such areas. Objective: This study quantifies associations between the amount of rural training during family medicine (FM) residencies and subsequent rural work. Methods: American Medical Association (AMA) Masterfile, AMA graduate medical education (GME) supplement, American Board of Family Medicine certification, Accreditation Council for Graduate Medical Education (ACGME), and Centers for Medicare and Medicaid Services hospital costs data were merged and analyzed. Multiple logistic regression measured associations between rural training and rural or urban practice in 2018 by all 12 162 clinically active physicians who completed a US FM residency accredited by the ACGME between 2008 and 2012. Analyses adjusted for key potential confounders (age, sex, program size, region, and medical school location and type) and clustering by resident program. Results: Most (91%, 11 011 of 12 162) residents had no rural training. A minority (14%, 1721 of 12 162) practiced in a rural location in 2018. Residents with no rural training comprised 80% (1373 of 1721) of those in rural practice in 2018. Spending more than half of residency training months in rural areas was associated with substantially increased odds of rural practice (OR 5.3-6.3). Only 4% (424 of 12 162) of residents spent more than half their training in rural locations, and only 5% (26 of 436) of FM training programs had residents training mostly in rural settings or community-based clinics. Conclusions: There is a linear gradient between increasing levels of rural exposure in FM GME and subsequent rural work.

Factors affecting live birth rates in donor oocytes from commercial egg banks vs. program egg donors: an analysis of 40,485 cycles from the Society for Assisted Reproductive Technology registry in 2016-2018.

OBJECTIVE: To examine the differences in live birth rates (LBRs), with single embryo transfer (SET), using oocytes from program generated egg donors vs. commercial egg bank donors and other factors affecting LBRs using donor oocytes. DESIGN: Retrospective cohort study. SETTING: Not applicable. PATIENT(S): A total of 40,485 in vitro fertilization cycles using donor oocytes reported to the Society for Assisted Reproductive Technology registry in 2016-2018. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Live birth rate and cumulative LBR for SET using donor oocytes. RESULT(S): Multivariate results from the first SET from 19,128 cycles, including 15,429 from program generated egg donors and 3,699 from commercial egg banks, showed, when controlling for all other variables, the following: the LBR in the first SET cycle using commercial egg banks was 53.3% compared with 55.4% using program recruited egg donors (odds ratio [OR], 0.92); a reduction in the LBR with increasing recipient age, ages 40-44 years (OR, 0.80), 45-49 years (OR, 0.77), and >49 years (OR, 0.65); a steady decline in the LBR with increases in recipient body mass index above normal; and a steady increase in the LBR in association with >16 oocytes retrieved. Double embryo transfer increased the LBR (SET, 52%, vs. double embryo transfer, 58%) but also significantly increased the multiple pregnancy LBR, with 43% twins and 0.9% triplets. Blastocyst transfer had a higher LBR than cleavage stage embryos (52.5% vs. 39.5%). Intracytoplasmic sperm injection vs. conventional insemination when using fresh oocytes from program donors had similar LBRs. CONCLUSION(S): When performing in vitro fertilization using donor oocytes with SET, the LBR is affected by oocyte source, recipient age, recipient body mass index, stage of embryo at transfer, and number of oocytes retrieved.

Dendrimer-Conjugated nSMase2 Inhibitor Reduces Tau Propagation in Mice.

Alzheimer's disease (AD) is characterized by the progressive accumulation of amyloid-ß and hyperphosphorylated tau (pTau), which can spread throughout the brain via extracellular vesicles (EVs). Membrane ceramide enrichment regulated by the enzyme neutral sphingomyelinase 2 (nSMase2) is a critical component of at least one EV biogenesis pathway. Our group recently identified 2,6-Dimethoxy-4-(5-Phenyl-4-Thiophen-2-yl-1H-Imidazol-2-yl)-Phenol (DPTIP), the most potent (30 nM) and selective inhibitor of nSMase2 reported to date. However, DPTIP exhibits poor oral pharmacokinetics (PK), modest brain penetration, and rapid clearance, limiting its clinical translation. To enhance its PK properties, we conjugated DPTIP to a hydroxyl-PAMAM dendrimer delivery system, creating dendrimer-DPTIP (D-DPTIP). In an acute brain injury model, orally administered D-DPTIP significantly reduced the intra-striatal IL-1ß-induced increase in plasma EVs up to 72 h post-dose, while oral DPTIP had a limited effect. In a mouse tau propagation model, where a mutant hTau (P301L/S320F) containing adeno-associated virus was unilaterally seeded into the hippocampus, oral D-DPTIP (dosed 3× weekly) significantly inhibited brain nSMase2 activity and blocked the spread of pTau to the contralateral hippocampus. These data demonstrate that dendrimer conjugation of DPTIP improves its PK properties, resulting in significant inhibition of EV propagation of pTau in mice. Dendrimer-based delivery of DPTIP has the potential to be an exciting new therapeutic for AD.

Gender Concordance of First and Senior Authors in Family Medicine Journals.

BACKGROUND AND OBJECTIVES: Women have increased in presence within academic family medicine over time yet remain underrepresented among senior faculty. Mentorship is a mechanism by which senior faculty support scholarly achievements, accelerating advancement of junior faculty. METHODS: We analyzed 10 years (2008-2017) of original research articles in three peer-reviewed family medicine journals. We examined first author/last author pairs by gender as a proxy for mentorship of junior faculty by senior faculty. We compiled family medicine faculty data across 9 years to compare trends in scholarly mentorship with faculty advancement. RESULTS: Female last authorship increased from 28.8% (55/191) of original research articles with a first and last author in 2008 to 41.8% (94/225) in 2017. The share of female first authors on articles with a female last author was 56.4% in 2008 and 2017. The share of female first authors on articles with a male last author increased from 41.2% (56/136) to 55.7% (73/131) between 2008 and 2017. From 2009-2017, the proportion of women increased for assistant, associate, and full professor roles, but remained under 50% for the associate professor role and at 35% for professorship in 2017. CONCLUSIONS: Despite disproportionate rates of last authorship and senior faculty positions in family medicine departments, senior female authors have equal if not greater rates of mentorship of female first authors in family medicine literature. The increase in first authorship, last authorship, and faculty position indicates that improvements have occurred in gender advancement over the study period, but gains are still needed to improve gender equity within the field.

United States Family Medicine research collaborations associated with higher citation and funding rates.

INTRODUCTION Among academic medical disciplines, Family Medicine (FM) research is notable for its breadth of health-care content areas, making it particularly susceptible to interdisciplinary collaboration. AIM This study characterises the degree and typology of such collaborations, and determines whether collaboration patterns are associated with citation frequency and funding. METHODS This cross-sectional study describes collaboration patterns for publications from 2015 indexed in Web of Science and authored by faculty from United States (US) departments of family medicine (DFMs). We determined mean number of total and FM authors per publication, and percentage of publications with FM first or last authors. Publications were categorised by inclusion of non-FM faculty author(s) and number of DFMs represented. RESULTS Overall, 919 FM faculty from 109 DFMs authored a total of 1872 unique publications in 2015. There was an average of 6.8 authors per publication with 1.4 authors being FM faculty. FM faculty were first author on 26.2% and last author on 29.2% of publications. Of all publications, 0.9% were single FM Author; 1.0% were same DFM; 0.3% were multiple DFMs; 72.4% were single FM Author+non-FM; 19.3% were same DFM+non-FM; 6.0% were multiple DFMs+non-FM. FM publications with non-FM faculty authors showed higher citation rates, higher rates of funding, and lower rates of having no funding source. DISCUSSION Most FM publications involved non-FM faculty authors. Collaborations involving non-FM authors were correlated with higher impact publications and projects that were more likely to have been funded.

The Role of the Private Sector in Advancing Antimicrobial Stewardship: Recommendations from the Global Chief Medical Officers' Network.

Antimicrobial resistance (AMR) occurs when microorganisms develop the ability to defeat the drugs designed to kill them. If allowed to increase at the current rate, AMR could kill an estimated 10 million people per year and cost society approximately 100-200 trillion USD globally by 2050. The slow development of novel antimicrobials further exacerbates the problem. Most human antibiotic use occurs in homes and workplaces, where antibiotic-resistant infections may contribute to diminished performance and loss of work productivity. Employers in the private sector have the ability to reach large populations of employees and their families, raise awareness about AMR, and promote antimicrobial stewardship (AMS) among their workforce. The authors describe 4 steps a company can take to help advance AMS: (1) sign the AMR Pledge, (2) perform a gap analysis, (3) implement and/or modify standard practices, and (4) measure and report outcomes. Real-world examples are provided, including barriers faced, in order to successfully implement initiatives to promote better AMS. Behavioral methods to influence change in the workplace are also presented. Both large and small companies can make a difference to support responsible use of antibiotics and improve the health and well-being of their employees.

Gender Differences in Reported Weekly Work Hours Among Family Physicians.

While women are entering family medicine at higher rates than men, little is known about the present differences in practice patterns between male and female family physicians (FPs). We used 2017 and 2018 American Board of Family Medicine Family Medicine Certification Examination practice demographic questionnaires to assess average weekly total hours and direct patient care hours by age and gender reported by FPs. We found a gender gap between both overall hours worked and direct patient care hours, with female FPs reporting fewer hours across age groups.