Propensity score analysis of 18-FDG PET/CT-enhanced staging in patients undergoing surgery for esophageal cancer.

PURPOSE: PET/CT is now integral to the staging pathway for potentially curable esophageal cancer (EC), primarily to identify distant metastases undetected by computed tomography. The aim of this study was to analyze the effect of PET/CT introduction on survival and assess patterns of recurrence after esophagectomy. METHODS: A longitudinal cohort of EC patients staged between 1998 and 2016 were considered for inclusion. After co-variate adjustment using propensity scoring, a cohort of 496 patients (273 pre-PET/CT and 223 post-PET/CT) who underwent esophagectomy [median age 63 years (31-80), 395 males, 425 adenocarcinomas, 71 squamous cell carcinomas, 325 neoadjuvant therapy] were included. The primary outcome measure was overall survival (OS) based on intention to treat. RESULTS: Three-year OS pre-PET/CT was 42.5% compared with 57.8% post-PET/CT (Chi2 6.571, df 1, p = 0.004). On multivariable analysis, pT stage (HR 1.496 [95% CI 1.28-1.75], p < 0.0001), pN stage (HR 1.114 [95% CI 1.04-1.19], p = 0.001) and PET/CT staging (HR 0.688 [95% CI 0.53-0.89] p = 0.004) were independently associated with OS. Recurrent cancer was observed in 125 patients (51.4%) pre-PET/CT, compared with 74 patients post-PET/CT (37.8%, p = 0.004), and was less likely to be distant recurrence after PET/CT introduction (39.5 vs. 27.0%, p = 0.006). CONCLUSIONS: Enhanced PET/CT staging is an important modality and independent factor associated with improved survival in patients undergoing esophagectomy for cancer.

The family physician as medical review officer.

BACKGROUND: The medical review officer is a position established by federal statute in 1988. The role of the medical review officer is to interpret positive urine drug tests in view of the donor's medical history. With more than 4 million workers affected by the Department of Transportation guidelines for workplace drug testing, and many private employers having urine drug screening programs, there is a need for medical review officers. METHODS: Materials for this report were collected while the first author was pursuing certification from the Medical Review Officer Certification Council. Much of the data was published in the Federal Register from 1988 through 1993. RESULTS AND CONCLUSIONS: Urine drug testing is divided into three stages: collection, laboratory analysis,and medical review of results. Because the workplace urine drug test is a forensic test, the urine is collected under strict chain of custody. Analysis of specimens is conducted by laboratories that have met stringent technical criteria and are approved by the Substance Abuse and Mental Health Services Administration (formerly the National Institute on Drug Abuse). Family physicians are in a unique position to become medical review officers because of their training and professional roles. Educational programs are available for physicians interested in becoming a medical review officer.

The family physician and industrial hygiene.

Family physicians are increasingly being called on to become involved in the health care of workers in local industries. Many family physicians are the sole providers of occupational health care in their communities, yet their formal training is usually deficient in some of the more specialized aspects of occupational medicine. Treating work-related injuries and exposures to hazardous substances may require analyses of work sites that many family physicians have neither the time nor the expertise to perform adequately. Industrial hygienists are the consultants who are qualified to assess potential occupational hazards and are trained to perform a comprehensive analysis of the work environment as it relates to worker health. This analysis may include the measurement of potentially hazardous substances, such as ambient air concentrations of particulate matter and toxic gases, and recommendations for prevention of exposures. Two cases are presented to illustrate how valuable a consultation with an industrial hygienist can be to the family physician.

Does workplace health promotion decrease medical claims?

We examined the relationship between workplace health promotion and medical claims in 38 textile plants, considering also the effects of demographic and contextual variables (i.e., average worker age, sex ratio, racial composition, plant product, and access to medical services). Number of claims per worker varied threefold among plants but was independent of plant workforce's sex ratio, racial composition, and access to medical services. Worker age predicted claims; in a linear regression model, age, sex, race, plant product, and access explained 23% of variance in claims. Health promotion was also related to claims, and its inclusion in the model (with interaction terms involving plant product) explained 54% of variance in claims, with the deletion of race, sex, and access from the reduced model. We concluded that effective health promotion must address the contexts of different types of plant product.

Physician breach of patient confidentiality among individuals with human immunodeficiency virus (HIV) infection: patterns of decision.

To determine whether the sex, race, or sexual preference of a patient infected with immunodeficiency virus (HIV) influences a physician's decision to breach patient confidentiality, Tennessee primary care physicians were mailed a questionnaire containing a case study in which an HIV-infected patient presented a risk to a third party. Eight different descriptions of the sex, race, and sexual preference of the hypothetical patient were distributed randomly among the physicians, one description to each physician. The physicians were asked to decide whether to maintain confidentiality, notify the health department, or inform the patient's partner. Responses of 199 White male physicians were analyzed using an unconditional saturated logistic regression model. The odds ratios for these physicians saying they would send the patient's antibody status to the health department extend from 18.4 (95 percent confidence interval: 1.3, 260.1) for Black homosexual males to .5 (95 percent CI: 0, 11.5) for White homosexual females. The odds ratios for White male physicians saying they would inform the patient's partner range from 7.5 (95 percent CI: .8, 69.2) for Black heterosexual males to 1.0 (reference category) for Black homosexual females. The results suggest that when physicians decide to protect a third party by breaching an HIV-infected patient's confidentiality, their decision may be influenced in some cases by the race, sex, and sexual preference of the patient.