Publications by authors named "Katharine Thomas"

27 Publications

  • Page 1 of 1

Loeys-Dietz syndrome in pregnancy.

Obstet Med 2021 Mar 15;14(1):42-45. Epub 2019 Jun 15.

Oxford University Hospitals NHS Foundation Trust, Oxford, UK.

Loeys-Dietz syndrome is a recently described condition which causes cardiovascular, craniofacial, neurocognitive and skeletal abnormalities due to mutations in components of the transforming growth factor-β signalling pathway. Associated vascular abnormalities include vessel tortuosity and an increased incidence of vascular dissection. Pregnancy increases the risk of aortic dissection compared to non-pregnant individuals and an underlying condition such as Loeys-Dietz syndrome increases this further. While aortic dissection is well described in pregnancy in Loeys-Dietz syndrome, some women can have uncomplicated deliveries, particularly when the risks of the condition are actively managed. Such pregnancies should be considered high-risk, and women should be counselled and managed accordingly. Here we describe two pregnancies in one woman, both with successful outcomes, followed by a summary of the key management principles.
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http://dx.doi.org/10.1177/1753495X19852819DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8107958PMC
March 2021

Utilization of Nivolumab in Adenoid Cystic Carcinoma After Progression on Platinum-Based Chemotherapy.

Perm J 2021 May;25

Ochsner Cancer Institute, New Orleans, LA.

Introduction: Adenoid cystic carcinoma (ACC) is a rare malignant neoplasm within the secretory glands of the head and neck. Clinical findings include a lump on the palate, tongue, or bottom of the mouth. Because symptoms can be mild, patients go for long periods of time without investigation. ACC is diagnosed using histology. Treatment is by surgical resection because there is no effective chemotherapy. Radiation can be effective adjuvant therapy, and proton therapy and stereotactic irradiation can be used for those who are ineligible for surgery. Immunotherapy has clinical activity for those with metastatic head and neck cancers who progress on proton therapy. This case reviews the use of immunotherapy in a patient with ACC.

Case Presentation: A man in his 20s presented with a 6-month history of nasal congestion, epistaxis, and sinus tenderness. Noncontrast computed tomography of the sinuses revealed a mass of the lateral wall of the nasal cavity, lateral wall of the maxillary sinus, and pterygoid plates. Positron emission tomography confirmed metastatic disease in the right iliac crest and right cervical lymph node; biopsy of the nasopharynx confirmed ACC. The patient received proton therapy and intensity-modulated radiotherapy and completed 2 Phase 1 trails but continued to have progressive disease. The patient started nivolumab and died 12 weeks later.

Conclusion: The patient recently received proton therapy, intensity-modulated radiotherapy, and completed 2 Phase 1 trials but continued to have progressive disease.
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http://dx.doi.org/10.7812/TPP/20.229DOI Listing
May 2021

Orthopaedic corticosteroid injections and risk of acute coronary syndrome: a cohort study.

Br J Gen Pract 2021 28;71(703):e128-e133. Epub 2021 Jan 28.

Healthcare Quality Indicators Program for Clalit Health Services Hospitals, Department of Quality Measurements and Research, Clalit Health Services, Tel Aviv; Sial Research Center, Division of Community Health, Ben-Gurion University of the Negev, Beer-Sheva, Israel.

Background: Corticosteroid injections (CSIs) are a common treatment for arthritis and other musculoskeletal conditions.

Aim: To determine whether there is an increased incidence of acute coronary syndrome (ACS) following intra-articular and soft-tissue CSI.

Design And Setting: Cohort study in an urban primary care orthopaedic clinic.

Method: Data were reviewed from all patients aged ≥50 years and seen by orthopaedic specialists between April 2012 and December 2015, including CSI, hospital admission in the week following the orthopaedic visit, and cardiovascular risk factors. The incidence of an ACS-associated hospital admission was compared between visits in which patients received CSIs and visits in which patients did not.

Results: A total of 60 856 orthopaedic visits were reviewed (22 131 individual patients). The mean age was 70.9 years (standard deviation [SD] = 10.8), and 66.5% were female. Injections were administered in 3068 visits (5.1%). In the week following the visit there were 25 ACS hospital admissions (41 per 100 000 visits); seven events were after visits with an injection, and 18 were after non-injection visits. Patients who had received an injection were more likely to experience a subsequent ACS. (227 versus 31 events per 100 000 visits, odds ratio [OR] = 7.3; 95% confidence interval [CI] = 2.8 to 19.1). The association between receiving a CSI and ACS remained similar when the analysis was restricted to subgroups defined by age, sex, and cardiovascular risk factors.

Conclusion: CSI for musculoskeletal conditions may substantially increase the risk of ACS in the week following the injection. Although the absolute risk of ACS is small, the effect size appears to be clinically significant.
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http://dx.doi.org/10.3399/bjgp20X713945DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7805411PMC
January 2021

Hemophagocytic Lymphohistiocytosis as the Initial Presentation of Subcutaneous Panniculitis-Like T-Cell Lymphoma: A Rare Case Responding to Cyclosporine A and Steroids.

J Investig Med High Impact Case Rep 2020 Jan-Dec;8:2324709620981531

Louisiana State University, New Orleans, LA, USA.

Subcutaneous panniculitis-like T-cell lymphoma (SPTCL) is a rare peripheral cytotoxic T-cell lymphoma, clinically resembling panniculitis. Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening syndrome of immune overactivation, triggered by underlying conditions. SPTCL presenting with HLH may represent a severe and rapidly progressive disease course. Currently, there is no standardized approach to treatment of HLH secondary to underlying SPTCL. A 34-year-old Asian male presented with a several months history of high fevers, weight loss, and nonpruritic purple discoloration of the skin. He had a skin biopsy showing atypical lymphohistiocytic panniculitis with dermal mucinosis and erythrophagocytosis consistent with SPTCL. The patient was initiated on treatment with dexamethasone and cyclosporine A. Almost immediate improvement of his skin lesions was noted and laboratory abnormalities trended toward baseline within 2 weeks. He noted complete symptom resolution after 3 months on therapy. SPTCL may be treated effectively with cyclosporine A and steroids to achieve rapid clinical and symptom management of this rare malignancy.
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http://dx.doi.org/10.1177/2324709620981531DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7750743PMC
December 2020

Poor Bone Quality is Associated With Greater Arterial Stiffness: Insights From the UK Biobank.

J Bone Miner Res 2021 01 22;36(1):90-99. Epub 2020 Sep 22.

Medical Research Council (MRC) Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK.

Osteoporosis and ischemic heart disease (IHD) represent important public health problems. Existing research suggests an association between the two conditions beyond that attributable to shared risk factors, with a potentially causal relationship. In this study, we tested the association of bone speed of sound (SOS) from quantitative heel ultrasound with (i) measures of arterial compliance from cardiovascular magnetic resonance (aortic distensibility [AD]); (ii) finger photoplethysmography (arterial stiffness index [ASI]); and (iii) incident myocardial infarction and IHD mortality in the UK Biobank cohort. We considered the potential mediating effect of a range of blood biomarkers and cardiometabolic morbidities and evaluated differential relationships by sex, menopause status, smoking, diabetes, and obesity. Furthermore, we considered whether associations with arterial compliance explained association of SOS with ischemic cardiovascular outcomes. Higher SOS was associated with lower arterial compliance by both ASI and AD for both men and women. The relationship was most consistent with ASI, likely relating to larger sample size available for this variable (n = 159,542 versus n = 18,229). There was no clear evidence of differential relationship by menopause, smoking, diabetes, or body mass index (BMI). Blood biomarkers appeared important in mediating the association for both men and women, but with different directions of effect and did not fully explain the observed effects. In fully adjusted models, higher SOS was associated with significantly lower IHD mortality in men, but less robustly in women. The association of SOS with ASI did not explain this observation. In conclusion, our findings support a positive association between bone and vascular health with consistent patterns of association in men and women. The underlying mechanisms are complex and appear to vary by sex. © 2020 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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http://dx.doi.org/10.1002/jbmr.4164DOI Listing
January 2021

Elder Abuse Education Using Standardized Patient Simulation in an Undergraduate Nursing Program.

J Nurs Educ 2020 Jun;59(6):331-335

Background: With more than 1 million older adults being abused each year, it is imperative for nurses to be knowledgeable about signs and symptoms of elder abuse, assessment, and interventions. This article describes a three-part learning strategy consisting of lecture, simulation using standardized patients (SPs), and debriefing to educate prelicensure nursing students about how to identify, assess, and report elder abuse. Furthermore, the effects of the teaching strategies were assessed.

Method: Students received a lecture on elder abuse, followed by a simulation with an SP and debriefing. Pre- and posttests were used to assess knowledge, skills, and attitudes about elder abuse.

Results: Significant differences were found in pre- and posttest results for knowledge and skills. There were no significant differences in attitude. Teaching strategies affected learning, and students reported increased knowledge and skills in identifying abuse and advocating for vulnerable older adults.

Conclusion: Lecture and SP simulation followed by debriefing was an effective approach to educate prelicensure nursing students about elder abuse. [J Nurs Educ. 2020;59(6):331-335.].
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http://dx.doi.org/10.3928/01484834-20200520-06DOI Listing
June 2020

Outcomes of Capecitabine and Temozolomide (CAPTEM) in Advanced Neuroendocrine Neoplasms (NENs).

Cancers (Basel) 2020 Jan 14;12(1). Epub 2020 Jan 14.

Ochsner Medical Center-Kenner, Neuroendocrine Tumor Clinic, Kenner, LA 70065, USA.

Capecitabine and temozolomide (CAPTEM) have shown promising results in the treatment of neuroendocrine neoplasms (NEN). The aim of this study was to evaluate the outcome and role for CAPTEM in malignant neuroendocrine neoplasms. Data were obtained from NEN patients who received at least one cycle of CAPTEM between November 2010 and June 2018. The average number of cycles was 9.5. For analysis, 116 patients were included, of which 105 patients (91%) underwent prior treatment. Median progression free survival (PFS) and overall survival (OS) were 13 and 38 months, respectively. Overall response rate (ORR) was 21%. Disease control rate (DCR) was 73% in all patients. PFS, median OS, ORR, and DCR for pancreatic NENs (pNEN) vs. non-pNEN was 29 vs. 11 months, 35 vs. 38 months, 38% vs. 9%, and 77% vs. 71%, respectively. Patients with pNEN had a 50% lower hazard of disease progression compared to those with non-pNEN (adjusted Hazard Ratio: 0.498, = 0.0100). A significant difference in PFS was found between Ki-67 < 3%, Ki-67 3-20%, Ki-67 > 20-54%, and Ki-67 ≥ 55% (29 vs. 12 vs. 7 vs. 5 months; = 0.0287). Adverse events occurred in 74 patients (64%). Our results indicate that CAPTEM is associated with encouraging PFS, OS, and ORR data in patients with NENs.
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http://dx.doi.org/10.3390/cancers12010206DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7017154PMC
January 2020

A novel machine learning-derived radiotranscriptomic signature of perivascular fat improves cardiac risk prediction using coronary CT angiography.

Eur Heart J 2019 11;40(43):3529-3543

Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, John Radcliffe Hospital, Headley Way, Oxford, UK.

Background: Coronary inflammation induces dynamic changes in the balance between water and lipid content in perivascular adipose tissue (PVAT), as captured by perivascular Fat Attenuation Index (FAI) in standard coronary CT angiography (CCTA). However, inflammation is not the only process involved in atherogenesis and we hypothesized that additional radiomic signatures of adverse fibrotic and microvascular PVAT remodelling, may further improve cardiac risk prediction.

Methods And Results: We present a new artificial intelligence-powered method to predict cardiac risk by analysing the radiomic profile of coronary PVAT, developed and validated in patient cohorts acquired in three different studies. In Study 1, adipose tissue biopsies were obtained from 167 patients undergoing cardiac surgery, and the expression of genes representing inflammation, fibrosis and vascularity was linked with the radiomic features extracted from tissue CT images. Adipose tissue wavelet-transformed mean attenuation (captured by FAI) was the most sensitive radiomic feature in describing tissue inflammation (TNFA expression), while features of radiomic texture were related to adipose tissue fibrosis (COL1A1 expression) and vascularity (CD31 expression). In Study 2, we analysed 1391 coronary PVAT radiomic features in 101 patients who experienced major adverse cardiac events (MACE) within 5 years of having a CCTA and 101 matched controls, training and validating a machine learning (random forest) algorithm (fat radiomic profile, FRP) to discriminate cases from controls (C-statistic 0.77 [95%CI: 0.62-0.93] in the external validation set). The coronary FRP signature was then tested in 1575 consecutive eligible participants in the SCOT-HEART trial, where it significantly improved MACE prediction beyond traditional risk stratification that included risk factors, coronary calcium score, coronary stenosis, and high-risk plaque features on CCTA (Δ[C-statistic] = 0.126, P < 0.001). In Study 3, FRP was significantly higher in 44 patients presenting with acute myocardial infarction compared with 44 matched controls, but unlike FAI, remained unchanged 6 months after the index event, confirming that FRP detects persistent PVAT changes not captured by FAI.

Conclusion: The CCTA-based radiomic profiling of coronary artery PVAT detects perivascular structural remodelling associated with coronary artery disease, beyond inflammation. A new artificial intelligence (AI)-powered imaging biomarker (FRP) leads to a striking improvement of cardiac risk prediction over and above the current state-of-the-art.
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http://dx.doi.org/10.1093/eurheartj/ehz592DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6855141PMC
November 2019

Medical record review of transition to lanreotide following octreotide for neuroendocrine tumors.

J Gastrointest Oncol 2019 Aug;10(4):674-687

University of New Mexico Comprehensive Cancer Center, Albuquerque, NM, USA.

Background: Octreotide has been used for decades in the United States (US) and Europe to treat patients with advanced neuroendocrine tumors (NETs). Lanreotide was approved in 2014 to improve progression-free survival (PFS) in patients with unresectable, well- or moderately-differentiated, locally advanced or metastatic gastroenteropancreatic NETs. Therefore, clinicians and patients may consider sequencing therapy from octreotide to lanreotide. However, current real-world outcomes data on patients who have made this transition is limited.

Methods: We conducted a multicenter, noninterventional, retrospective medical record review of patients with locally advanced or metastatic gastroenteropancreatic NETs (NCT03112694). Included patients had been treated with long-acting octreotide monotherapy for ≥90 days before transitioning to lanreotide monotherapy and continued on lanreotide for ≥90 days. Abstractors entered patient demographic and clinical data into a customized, web-based case report form. We assessed clinically defined PFS and other tumor-related outcomes while patients were treated with lanreotide. Outcomes were analyzed according to level of response at the time of transition from octreotide to lanreotide: progressive disease, nonprogressive disease, or unknown. Statistical analyses were descriptive. Clinically defined PFS and duration of treatment with lanreotide were estimated using the Kaplan-Meier method.

Results: Data were abstracted for 91 patients with gastroenteropancreatic NETs who received long-acting octreotide followed by lanreotide at six US based sites. At initial diagnosis, 71.4% of patients had stage IV disease. Small intestine (63.7%) and pancreas (14.3%) were the most common primary tumor sites. Mean [standard deviation (SD)] duration of follow-up from diagnosis was 70.6 (41.3) months. Patients received long-acting octreotide for a mean (SD) of 38.4 (32.8) months. When patients transitioned to lanreotide, 57.1% had nonprogressive disease on octreotide, 30.8% had progressive disease, and the remainder had unknown disease status. The most common reasons for switching from octreotide to lanreotide were progressive disease (22.0%), formulary change (15.4%), and patient preference (9.9%). Patients received lanreotide for a median (95% CI) duration of 24.7 (16.7-59.9) months. At the end of follow-up, 74% of patients remained on lanreotide monotherapy. Progression occurred in 24.2% of patients during lanreotide treatment. Overall median (95% CI) clinician-defined PFS following the transition to lanreotide was estimated to be 23.7 months [20.2 months-NE (not estimable)]. Patients with nonprogressive disease when they transitioned to lanreotide experienced a median clinician-defined PFS of 24.7 (17.0-NE) months. Among patients reported to have progressive disease when they transitioned to lanreotide, median (95% CI) clinician-defined PFS was estimated to be 15.2 (11.4-NE) months. There were no material differences in adverse events recorded during the long-acting octreotide and lanreotide treatment periods.

Conclusions: Our study suggests that lanreotide monotherapy is well tolerated and may contribute to stabilization of disease in a subset of patients with locally advanced or metastatic gastroenteropancreatic NETs previously treated with long-acting octreotide.
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http://dx.doi.org/10.21037/jgo.2019.03.11DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6657323PMC
August 2019

Chemotherapy Toxicity Confirms Diagnosis of Urachal Carcinoma.

Clin Genitourin Cancer 2019 10 2;17(5):e913-e915. Epub 2019 Jul 2.

Ochsner Cancer Institute, New Orleans, LA. Electronic address:

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http://dx.doi.org/10.1016/j.clgc.2019.06.017DOI Listing
October 2019

Automated localization and quality control of the aorta in cine CMR can significantly accelerate processing of the UK Biobank population data.

PLoS One 2019 14;14(2):e0212272. Epub 2019 Feb 14.

Oxford Centre for Clinical Magnetic Resonance Research (OCMR), Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom.

Introduction: Aortic distensibility can be calculated using semi-automated methods to segment the aortic lumen on cine CMR (Cardiovascular Magnetic Resonance) images. However, these methods require visual quality control and manual localization of the region of interest (ROI) of ascending (AA) and proximal descending (PDA) aorta, which limit the analysis in large-scale population-based studies. Using 5100 scans from UK Biobank, this study sought to develop and validate a fully automated method to 1) detect and locate the ROIs of AA and PDA, and 2) provide a quality control mechanism.

Methods: The automated AA and PDA detection-localization algorithm followed these steps: 1) foreground segmentation; 2) detection of candidate ROIs by Circular Hough Transform (CHT); 3) spatial, histogram and shape feature extraction for candidate ROIs; 4) AA and PDA detection using Random Forest (RF); 5) quality control based on RF detection probability. To provide the ground truth, overall image quality (IQ = 0-3 from poor to good) and aortic locations were visually assessed by 13 observers. The automated algorithm was trained on 1200 scans and Dice Similarity Coefficient (DSC) was used to calculate the agreement between ground truth and automatically detected ROIs.

Results: The automated algorithm was tested on 3900 scans. Detection accuracy was 99.4% for AA and 99.8% for PDA. Aorta localization showed excellent agreement with the ground truth, with DSC ≥ 0.9 in 94.8% of AA (DSC = 0.97 ± 0.04) and 99.5% of PDA cases (DSC = 0.98 ± 0.03). AA×PDA detection probabilities could discriminate scans with IQ ≥ 1 from those severely corrupted by artefacts (AUC = 90.6%). If scans with detection probability < 0.75 were excluded (350 scans), the algorithm was able to correctly detect and localize AA and PDA in all the remaining 3550 scans (100% accuracy).

Conclusion: The proposed method for automated AA and PDA localization was extremely accurate and the automatically derived detection probabilities provided a robust mechanism to detect low quality scans for further human review. Applying the proposed localization and quality control techniques promises at least a ten-fold reduction in human involvement without sacrificing any accuracy.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0212272PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6375606PMC
November 2019

Current Treatment Options in Gastroenteropancreatic Neuroendocrine Carcinoma.

Oncologist 2019 08 11;24(8):1076-1088. Epub 2019 Jan 11.

Division of Hematology/Oncology, Department of Internal Medicine, Ochsner Medical Center, New Orleans, Louisiana, USA

Poorly differentiated gastroenteropancreatic neuroendocrine carcinomas (GEPNECs) are a rare neoplasm with a bleak prognosis. Currently there are little prospective data available for optimal treatment. This review discusses the current available regimens and the future direction for the treatment of GEPNECs. Treatment plans for GEPNECs are often adapted from those devised for small cell lung cancer; however, differences in these malignancies exist, and GEPNECs require their own treatment paradigms. As such, current first-line treatment for GEPNECs is platinum-based chemotherapy with etoposide. Studies show that response rate and overall survival remain comparable between cisplatin and carboplatin versus etoposide and irinotecan; however, prognosis remains poor, and more efficacious therapy is needed to treat this malignancy. Additional first-line and second-line treatment options beyond platinum-based chemotherapy have also been investigated and may offer further treatment options, but again with suboptimal outcomes. Recent U.S. Food and Drug Administration approval of peptide receptor radionuclide therapy in low- and intermediate-grade neuroendocrine tumors may open the door for further research in its usefulness in GEPNECs. Additionally, the availability of checkpoint inhibitors lends promise to the treatment of GEPNECs. This review highlights the lack of large, prospective studies that focus on the treatment of GEPNECs. There is a need for randomized control trials to elucidate optimal treatment regimens specific to this malignancy. IMPLICATIONS FOR PRACTICE: There are limited data available for the treatment of poorly differentiated gastroenteropancreatic neuroendocrine carcinomas (GEPNECs) because of the rarity of this malignancy. Much of the treatment regimens used in practice today come from research in small cell lung cancer. Given the poor prognosis of GEPNECs, it is necessary to have treatment paradigms specific to this malignancy. The aim of this literature review is to summarize the available first- and second-line GEPNEC therapy, outline future treatments, and highlight the vast gap in the literature.
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http://dx.doi.org/10.1634/theoncologist.2018-0604DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6693730PMC
August 2019

Comparison Between Pediatricians and Physicians in Other Medical Specialties in Promoting Smoking Cessation in the Clinic.

Ochsner J 2018 ;18(4):326-331

The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA.

Background: Louisiana has one of the highest rates of smoking in the country, putting its children at high risk of secondhand and third-hand smoke exposure and subsequent morbidity. Pediatricians have an important role to play by including smoking cessation promotion (SCP) in their discussions with patient caregivers. The purpose of this study was to examine SCP trends at Ochsner Health System and to determine if pediatricians are less likely to express confidence in and performance of SCP activities than physicians in other specialties.

Methods: We distributed a survey to pediatricians and to physicians in the departments of obstetrics and gynecology, internal medicine, and psychiatry in the Ochsner Health System. The survey assessed physician confidence in and performance of several SCP behaviors. We analyzed pediatrician confidence in and performance of 3 behaviors (screening, counseling, and referring) and compared pediatrician responses to the responses of the physicians in the other specialties.

Results: Twenty-eight pediatrician and 33 other physician responses were included in the analysis. No significant correlation 0.2785) was found between pediatrician confidence and performance in screening for smoking behavior. A significant correlation was found in counseling ( = 0.0159) and referring 0.0214). In the comparison of pediatrician responses to other physician responses, the physicians in the other specialties had higher medians and/or quartiles for both confidence and performance of all 3 behaviors, and the differences were significant.

Conclusion: The physicians in other specialties showed consistently higher rates of confidence and performance of SCP behaviors than the pediatricians. Intervention is necessary to encourage pediatricians at Ochsner Health System to promote smoking cessation in their practices.
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http://dx.doi.org/10.31486/toj.18.0043DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6292464PMC
January 2018

Comparison of antidepressant use between adult populations living in urban and rural communities in Israel.

Fam Pract 2019 01;36(1):21-26

Clalit Health Services, The Family Medicine Department, Rabin Medical Center, Beilinson Campus, Petah Tikva, Israel.

Background: Depression and anxiety are among the most prevalent disorders in primary care. City dwelling is commonly cited as a risk factor for mental disorders, but epidemiological evidence for this relationship is inconclusive.

Objective: To compare the prevalence of antidepressant use, as a proxy for the level of depressive disorders, between patients in Israeli urban and rural communities.

Methods: A cross-sectional study, based on data drawn from the registry of the largest health maintenance organization in Israel. The prevalence of antidepressant purchase during 2014 was evaluated for 581291 patients living in urban and rural communities. Data were also collected for potential confounding variables: age, gender, comorbidity, socioeconomic status and being a holocaust survivor.

Results: Results showed higher rates of antidepressant use among patients living in urban (11.8%) compared with rural communities (8.1%; <0.001). A particularly high rate of antidepressant use was found on kibbutz (15.9%), a collective rural community in Israel, compared with both urban and other rural communities. Kibbutz compared with other rural communities: odds ratio (OR) = 1.73, P < 0.001; urban communities compared with non-kibbutz rural communities: OR = 1.21, P < 0.001. A significantly lower rate of antidepressant use was found in urban and rural Arab-majority communities (3.9% and 3.8%, respectively).

Conclusions: Antidepressant use varies significantly between different communities in Israel. The highest rate of antidepressant use in our study was found on kibbutz, followed by that in urban communities, with the lowest rates in non-kibbutz rural communities. This difference may derive from different depression rates, stigma of mental illness and awareness of mental disorders.
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http://dx.doi.org/10.1093/fampra/cmy085DOI Listing
January 2019

Non-invasive detection of coronary inflammation using computed tomography and prediction of residual cardiovascular risk (the CRISP CT study): a post-hoc analysis of prospective outcome data.

Lancet 2018 09 28;392(10151):929-939. Epub 2018 Aug 28.

Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK; Oxford Centre of Research Excellence, British Heart Foundation, Oxford, UK; Oxford Biomedical Research Centre, National Institute of Health Research, Oxford, UK. Electronic address:

Background: Coronary artery inflammation inhibits adipogenesis in adjacent perivascular fat. A novel imaging biomarker-the perivascular fat attenuation index (FAI)-captures coronary inflammation by mapping spatial changes of perivascular fat attenuation on coronary computed tomography angiography (CTA). However, the ability of the perivascular FAI to predict clinical outcomes is unknown.

Methods: In the Cardiovascular RISk Prediction using Computed Tomography (CRISP-CT) study, we did a post-hoc analysis of outcome data gathered prospectively from two independent cohorts of consecutive patients undergoing coronary CTA in Erlangen, Germany (derivation cohort) and Cleveland, OH, USA (validation cohort). Perivascular fat attenuation mapping was done around the three major coronary arteries-the proximal right coronary artery, the left anterior descending artery, and the left circumflex artery. We assessed the prognostic value of perivascular fat attenuation mapping for all-cause and cardiac mortality in Cox regression models, adjusted for age, sex, cardiovascular risk factors, tube voltage, modified Duke coronary artery disease index, and number of coronary CTA-derived high-risk plaque features.

Findings: Between 2005 and 2009, 1872 participants in the derivation cohort underwent coronary CTA (median age 62 years [range 17-89]). Between 2008 and 2016, 2040 patients in the validation cohort had coronary CTA (median age 53 years [range 19-87]). Median follow-up was 72 months (range 51-109) in the derivation cohort and 54 months (range 4-105) in the validation cohort. In both cohorts, high perivascular FAI values around the proximal right coronary artery and left anterior descending artery (but not around the left circumflex artery) were predictive of all-cause and cardiac mortality and correlated strongly with each other. Therefore, the perivascular FAI measured around the right coronary artery was used as a representative biomarker of global coronary inflammation (for prediction of cardiac mortality, hazard ratio [HR] 2·15, 95% CI 1·33-3·48; p=0·0017 in the derivation cohort, and 2·06, 1·50-2·83; p<0·0001 in the validation cohort). The optimum cutoff for the perivascular FAI, above which there is a steep increase in cardiac mortality, was ascertained as -70·1 Hounsfield units (HU) or higher in the derivation cohort (HR 9·04, 95% CI 3·35-24·40; p<0·0001 for cardiac mortality; 2·55, 1·65-3·92; p<0·0001 for all-cause mortality). This cutoff was confirmed in the validation cohort (HR 5·62, 95% CI 2·90-10·88; p<0·0001 for cardiac mortality; 3·69, 2·26-6·02; p<0·0001 for all-cause mortality). Perivascular FAI improved risk discrimination in both cohorts, leading to significant reclassification for all-cause and cardiac mortality.

Interpretation: The perivascular FAI enhances cardiac risk prediction and restratification over and above current state-of-the-art assessment in coronary CTA by providing a quantitative measure of coronary inflammation. High perivascular FAI values (cutoff ≥-70·1 HU) are an indicator of increased cardiac mortality and, therefore, could guide early targeted primary prevention and intensive secondary prevention in patients.

Funding: British Heart Foundation, and the National Institute of Health Research Oxford Biomedical Research Centre.
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http://dx.doi.org/10.1016/S0140-6736(18)31114-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6137540PMC
September 2018

Quality of life for non-small cell lung cancer patients in the age of immunotherapy.

Transl Lung Cancer Res 2018 Apr;7(Suppl 2):S149-S152

Department of Internal Medicine, Section of Hematology/Oncology, Ochsner Medical Center, Kenner, LA, USA.

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http://dx.doi.org/10.21037/tlcr.2018.03.10DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5943233PMC
April 2018

Leptomeningeal Disease and the Evolving Role of Molecular Targeted Therapy and Immunotherapy.

Ochsner J 2017 ;17(4):362-378

The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA.

Background: Leptomeningeal disease (LMD) is a complication that results from solid tumor metastasis. Prognosis is extremely poor. As therapeutic options for solid tumors improve, the rate of LMD continues to increase. Until recently, treatment has been limited to radiation therapy, intrathecal chemotherapy, and systemic chemotherapy, with an overall survival of 2-3 months. Targeted molecular therapy and immunotherapies are promising new options for increasing overall survival and clinical improvement; however, optimal clinical management remains unknown.

Methods: In this review, we discuss targeted molecular therapy and immunotherapy treatment options for LMD resulting from primary lung, breast, and melanoma tumors. In addition, we summarize dosing strategies, overall survival, clinical outcomes, and novel approaches to treatment.

Results: Our review indicates a deficiency in the current literature. Presently, intrathecal trastuzumab administration may be an effective option for patients with HER2-positive breast cancer. BRAF inhibitors and cytotoxic T lymphocyte-associated antigen-4 targets have shown promising results in LMD resulting from melanoma. Finally, tyrosine kinase inhibitors may increase overall survival in epidermal growth factor receptor (EGFR)-mutant non-small cell lung cancer. Pulsatile drug administration or dual therapy may be beneficial for patients who progress to LMD while being treated with EGFR targets for their primary malignancy.

Conclusion: Targeted molecular therapy and immunotherapy in LMD may provide favorable treatment options. Current literature is lacking in safety, efficacy, and overall response rates from the use of targeted therapy. Research is needed to draw significant conclusions about the most appropriate therapy for patients with LMD.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5718449PMC
January 2017

Procedural and thirty-day outcomes following transfemoral implantation of the fully repositionable and retrievable Lotus valve without routine pre-dilatation in a consecutive patient cohort: a single-center experience.

Cardiovasc Revasc Med 2018 Jan - Feb;19(1 Pt B):78-82. Epub 2017 Nov 4.

Oxford Heart Centre, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, United Kingdom.

Background / Purpose: The Lotus valve (Boston Scientific, Natick, MA, USA) is a contemporary transcatheter aortic valve implantation (TAVI) device that is fully repositionable and retrievable to aid implantation and optimise procedural results. The ability to implant the device without routine pre-dilatation is another possible advantage reducing associated risks and procedure times. The aim of this study is to report procedural and 30-day outcomes following TAVI in a consecutive patient group presenting with severe symptomatic aortic stenosis with the Lotus valve system without routine pre-dilatation.

Methods / Materials: 146 consecutive patients that underwent TAVI at the John Radcliffe Hospital, Oxford between January 2015 - December 2016 were retrospectively analysed.

Results: The mean age was 81.1±7.4 years and the mean logistic EuroSCORE was 14.6±10. 134 (91.8%) of patients were treated under conscious sedation. 144 (98.6%) of procedures were successful. Two patients (1.4%) died during the follow-up period. None or mild residual aortic regurgitation was achieved in 98.6% of patients. The mean and peak transvalvular gradients were 8.6±3.6mmHg and 16.6±6.6mmHg respectively. Eight patients (5.5%) suffered a stroke. Over time, there was a reduction in major vascular complications (14.3% vs. 2.2%, p=0.03) and a trend toward shorter procedure times (97.6±44.3 vs. 86.8±31.4 minutes, p=0.14) and the administration of less contrast (104.4±45.2 vs. 91.7±37.6 millilitres, p=0.16). The overall new pacemaker implantation rate was 36.3%.

Conclusions: The use of the Lotus valve as a 'workhorse' device without routine pre-dilatation is safe and efficacious and is associated with a very low incidence of residual aortic regurgitation and acceptable transvalvular haemodynamics.
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http://dx.doi.org/10.1016/j.carrev.2017.10.017DOI Listing
March 2019

Management of pulmonary neuroendocrine tumors.

Rev Endocr Metab Disord 2017 Dec;18(4):433-442

Louisiana State University Health Sciences Center, New Orleans, LA, 70112, USA.

Neuroendocrine tumors (NETs) of the lung are divided into 4 major types: small cell lung cancer (SCLC), large cell neuroendocrine carcinoma (LCNEC), atypical carcinoid (AC) or typical carcinoid (TC). Each classification has distinctly different treatment paradigms, making an accurate initial diagnosis essential. The inconsistent clinical presentation of this disease, however, makes this difficult. The objective of this manuscript is to detail the diagnosis and management of the well differentiated pulmonary carcinoid (PC) tumors. A multidisciplinary approach to work up and treatment should be utilized for each patient. A multimodal radiological work-up is used for diagnosis, with contrast enhanced CT predominantly utilized and functional imaging techniques. A definitive diagnosis is based on tissue findings. Surgical management remains the mainstay of therapy and can be curative. In those with advanced disease, medical treatments consist of somatostatin analog (SSA) therapy, targeted therapy, chemotherapy or peptide receptor radionuclide therapy. SSAs are the standard of care in those with metastatic NETs, using either Octreotide long acting repeatable (LAR) or lanreotide as reasonable options, despite a scarcity of prospective data in PCs. Targeted therapies consist of everolimus which is approved for use in PCs, with various studies showing mixed results with other targeted agents. Additionally, radionuclide therapy may be used and has been shown to increase survival and to reduce symptoms in some studies. Prospective trials are needed to determine other strategies that may be beneficial in PCs as well as sequencing of therapy. Successful diagnosis and optimal treatment relies on a multidisciplinary approach in patients with lung NETs. Clinical trials should be used in appropriate patients.
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http://dx.doi.org/10.1007/s11154-017-9429-9DOI Listing
December 2017

Transfemoral Transcatheter Aortic Valve-in-Valve Implantation for Aortic Valve Bioprosthesis Failure With the Fully Repositionable and Retrievable Lotus Valve: A Single-Center Experience.

J Invasive Cardiol 2017 Sep 15;29(9):315-319. Epub 2017 Jul 15.

Oxford Heart Centre, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, United Kingdom.

Objective: To report a first case series of the Lotus valve (Boston Scientific) for the treatment of surgical aortic bioprosthesis failure.

Background: Valve-in-valve (VIV) transcatheter aortic valve implantation (TAVI) is an established management option for surgical aortic bioprosthesis failure. Although TAVI has proven efficacious, complications relating to suboptimal valve implantation have been reported in approximately 5% of patients. The Lotus valve is fully repositionable and retrievable, and therefore enables complete assessment of valve function prior to definitive deployment. However, data supporting its use for this indication are limited.

Methods: Consecutive patients who underwent transfemoral VIV-TAVI at John Radcliffe Hospital between January 2015 and December 2016 were retrospectively analyzed. Procedural and 30-day outcomes were reported in accordance with Valve Academic Research Consortium-2 (VARC-2) definitions.

Results: Seven patients underwent VIV-TAVI with the Lotus valve. Device success according to VARC-2 criteria was achieved in 6 of the 7 patients. Following implantation, transvalvular hemodynamics were acceptable, with a mean gradient of 11.9 ± 6.6 mm Hg. All patients had mild or no residual aortic regurgitation. Specifically, no patient required further valve-related intervention, or suffered myocardial infarction, stroke, or acute kidney injury stage 2 or 3. There were no deaths during the follow-up period.

Conclusions: Transfemoral VIV-TAVI for the treatment of surgical aortic bioprosthesis failure with the Lotus device appears to be safe and is associated with no significant residual aortic regurgitation, and offers favorable transvalvular hemodynamics at 30-day follow-up.
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September 2017

Are Pediatricians Diagnosing Obese Children?

Ochsner J 2017 ;17(1):80-82

The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA ; Department of Pediatric Pulmonology, Ochsner Health Center for Children, Ochsner Clinic Foundation, New Orleans, LA.

Background: Pediatric obesity is the most prevalent nutritional disorder in American children. The detrimental social, psychological, and physiological effects of obesity call for pediatricians to address this health concern. The literature demonstrates that clinicians are underreporting the diagnosis of obesity in the pediatric setting. The primary purpose of this study was to determine if pediatricians at one pediatrics clinic in the Ochsner Health System are documenting the presence of an overweight or obese body mass index (BMI) as a diagnosis in the medical record. A secondary purpose of this study was to determine the demographics of all pediatric patients in the Ochsner Health System to be used for program development.

Methods: A retrospective medical record review was conducted. Records from April 1, 2012 to April 1, 2016, were reviewed for the presence of the diagnosis of BMI classified as obese or overweight.

Results: We analyzed a total of 175,066 records in this study. Of these records, 1.32% documented a diagnosis of obesity, and 0.5% documented a BMI score indicating overweight. The percentages of patient visits that met the Centers for Disease Control and Prevention criteria to be classified as obese or overweight were 28.66% and 30.41%, respectively. The majority of our pediatric patients were male (51.76%), white (43.31%), and 5-12 years old (43.80%).

Conclusion: This study demonstrates that pediatricians at Ochsner Health Center for Children are not diagnosing patients who have unhealthy BMI scores as overweight or obese. Interventions are needed to increase the identification of children who may benefit from receiving resources that encourage a healthy lifestyle and optimal weight maintenance.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5349642PMC
January 2017

Electronic Heath Record Prompts May Increase Screening for Secondhand Smoke Exposure.

Clin Pediatr (Phila) 2018 Jan 30;57(1):27-30. Epub 2017 Jan 30.

3 Ochsner Children's Health Center, New Orleans, LA. USA.

Introduction: The American Academy of Pediatrics recommends that pediatricians promote smoking cessation among caregivers at every visit. Currently, there are inconsistencies between recommendations and clinical practice. This study aims to compare results generated from 3 intervention methods on the rate at which pediatricians screen for secondhand smoke exposure (SHSe).

Methods: Pediatricians were randomly assigned to 1 of 3 intervention groups: no lecture, changes in electronic health record (EHR) (G1); lecture, no changes in the EHR (G2); or a lecture and EHR changes (G3). Data between groups were compared using a 1-way analysis of variance.

Results: Documentation of SHSe was statistically significantly greater in G3, when compared with G1 and G2 ( P < .01). Documentation of SHSe was statistically significantly greater in G1, when compared with G2 ( P < .05).

Conclusion: A brief lecture with EHR prompts may be a simple way to increase screening for SHSe in the pediatric primary care setting.
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http://dx.doi.org/10.1177/0009922816688261DOI Listing
January 2018

A Tale of Smoking Cessation Promotion: The Utilization of a Children's Book to Increase Screening and Counseling in the Pediatric Clinic.

Clin Pediatr (Phila) 2017 Oct 5;56(12):1142-1147. Epub 2017 Jan 5.

3 Ochsner Children's Health Center, New Orleans, LA, USA.

Objectives: The rate at which pediatricians promote smoking cessation in clinical settings is low. The literature demonstrates that interventions paired with tangible health promotion materials may significantly increase screening rates to the pediatric office. The aim of this study was to investigate whether the addition of a children's book in the pediatric clinic could result in an increase in the rate in which pediatricians screened for secondhand smoke exposure (SHSe) and counseled caregivers to stop smoking.

Study Design: This randomized controlled study was performed at 7 pediatric clinics.

Methods: Seven pediatric clinic sites were randomly assigned to either an intervention or control group. Pediatricians in the intervention group were given children's books about SHSe to distribute to their patients while the control group did not receive any materials.

Results: At baseline, there was no difference between the control group and intervention group in rates at which pediatricians screened for SHSe ( P = .8728) and counseled caregivers to stop smoking ( P = .29). After the intervention, screening for SHSe and counseling caregivers to stop smoking were statistically significantly greater in the intervention group, when compared to controls ( P < .01 and P < .001, respectively).

Conclusions: The use of a health promotion children's book in the pediatric setting can increase the rate at which pediatricians screen for SHSe and counsel caregivers to stop smoking. Future research should examine the effect of the storybook on various parameters of smoking cessation and future smoking behaviors.
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http://dx.doi.org/10.1177/0009922816684607DOI Listing
October 2017

Increasing Pediatricians' Smoking Cessation Promotion and Knowledge of the Smoking Cessation Trust.

Clin Pediatr (Phila) 2017 May 26;56(5):461-466. Epub 2016 Jul 26.

3 Ochsner Children's Health Center, New Orleans, LA, USA.

The link between second hand smoke exposure (SHSe) and health issues in children has been well established. The objective of this study was to determine if a short intervention implemented among pediatricians promotes improvement in the promotion of smoking cessation to caregivers and increase pediatricians' awareness of the Smoking Cessation Trust (SCT). Pediatricians from 6 clinics were randomly assigned to the control or intervention group. All pediatricians received a survey to assess baseline knowledge, confidence and behaviors in smoking cessation promotion and utilization of the SCT. Pediatricians in intervention group received an educational lecture delivered by a physician. Two months post intervention, pediatricians in the control and intervention group received a survey to assess changes from baseline. Out of 36 general pediatricians, 27 completed the surveys for use in the analysis of this study (75%). Intervention group made more referrals to the SCT, compared to controls (p=0.048) and to baseline (p=0.0065). Pediatricians in the intervention group were more confident in recommending the use of NRT (0.040) and schedule a follow up to discuss smoking cessation (p=0.029) after the intervention. The intervention group was more likely to refer caregivers to smoking cessation programs (p=0.027), discuss a child's health risk from SHSe (0.031) and recommending the use of NRT to help quit (p=0.047) post intervention. The results from this study indicate that a short intervention can increase confidence and behavior in various parameters of smoking cessation promotion and significantly improve the rate in which pediatricians refer smoking caregivers to the SCT.
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http://dx.doi.org/10.1177/0009922816660542DOI Listing
May 2017

Encouraging breastfeeding: financial incentives.

Pract Midwife 2015 Feb;18(2):18-21

The NOSH (Nourishing Start for Health) three-phase research study is testing whether offering financial incentives for breastfeeding improves six-eight-week breastfeeding rates in low-rate areas. This article describes phase one development work, which aimed to explore views about practical aspects of the design of the scheme. Interviews and focus groups were held with women (n = 38) and healthcare providers (n = 53). Overall both preferred shopping vouchers over cash payments, with a total amount of £200-250 being considered a reasonable amount. There was concern that seeking proof of breastfeeding might impact negatively on women and the relationship with their healthcare providers. The most acceptable method to all was that women sign a statement that their baby was receiving breast milk: this was co-signed by a healthcare professional to confirm that they had discussed breastfeeding. These findings have informed the design of the financial incentive scheme being tested in the feasibility phase of the NOSH study.
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February 2015

Will stem cell therapies be safe and effective for treating spinal cord injuries?

Br Med Bull 2011 17;98:127-42. Epub 2011 May 17.

Wolfson Centre for Age-Related Diseases, King's College London, UK.

Introduction: A large number of different cells including embryonic and adult stem cells have been transplanted into animal models of spinal cord injury, and in many cases these procedures have resulted in modest sensorimotor benefits. In October 2010 the world's first clinical trial using human embryonic stem cells began, using stem cells converted into oligodendrocyte precursor cells.

Sources Of Data: In this review we examine some of the publically available preclinical evidence that some of these cell types improve outcome in animal models of spinal cord injury. Much evidence is not available for public scrutiny, however, being private commercial property of various stem cell companies.

Areas Of Agreement: Transplantation of many different types of stem and progenitor cell enhances spontaneous recovery of function when transplanted acutely after spinal cord injury in animal models. AREAS OF DISAGREEMENT: The common mechanism(s) whereby the generic procedure of cellular transplantation enhances recovery of function are not well understood, although a range of possibilities are usually cited (including preservation of tissue, remyelination, axon sprouting, glial cell replacement). Only in exceptional cases has it been shown that functional recovery depends causally on the survival and differentiation of the transplanted cells. There is no agreement about the optimal cell type for transplantation: candidate stem cells have not yet been compared with each other or with other cell types (e.g. autologous Schwann cells) in a single study.

Areas Timely For Developing Research: Transplantation of cells into animals with a long lifespan is important to determine whether or not tumours will eventually form. It will also be important to determine whether long-term survival of cells is required for functional recovery, and if so, how many are optimal.
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http://dx.doi.org/10.1093/bmb/ldr013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5583428PMC
August 2011

Current primary care physician interventions to promote smoking cessation in Israel: an observational study.

Isr Med Assoc J 2007 Sep;9(9):645-8

Department of Family Medicine, Rabin Medical Center (Beilinson Campus), Petah Tikva, Israel.

Background: Smoking continues to be the most significant preventable cause of morbidity and early mortality in the developed world. Primary care physicians are not fufilling their potentially vital and effective role with regard to tobacco use and dependence.

Objectives: To evaluate current primary care physician practise in promoting smoking cessation.

Methods: This observational study evaluated physician recording of smoking status by analysis of patients' electronic medical records. The 126 primary care physicians were based in 23 Tel Aviv clinics treating 144,811 patients. We also assessed additional physician anti-smoking activities by a telephone questionnaire of 178 randomly selected patients.

Results: Analysis of the EMRs revealed that an average of 4.4% of patients per physician were recorded as smokers (as compared to a known smoking rate in this patient population of 24%). Male physicians recorded a significantly higher proportion of their patients as smokers in the EMR compared to female physicians (P < 0.05). A non-significantly higher rate of recording smokers was found in doctors who had completed postgraduate specialization in family medicine as compared to non-specialists. The questionnaire results show that 41% of patients interviewed recalled being asked if they smoked and 31% of smoking patients had been advised to quit. A non-significantly higher proportion of male as compared to female patients reported being questioned if they smoked, and if they were smokers, being advised to quit.

Conclusions: This study shows low rates of physician intervention to promote smoking cessation. It appears that a large proportion of the primary care physicians surveyed do not follow recommendations to promote smoking cessation among their patients. Intervention among adolesent smokers was particularly inadequate. Further action is needed to improve the performance of physicians in aiding smoking cessation.
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September 2007