Breathe.

This is a personal essay about breasts. It focuses on my experiences as a young girl, moving through adolescence to a history of breast cancer in my family, including my mother's breast cancer diagnosis. As a physician, patient, and wife, I reflect on the choices that I have to make and what this means for my identity as a woman and mother.

The Association Between Past Sexual Abuse and Depression in Older Adults From Colombia.

To explore the association between past sexual abuse and depression in elders living in Bogotá, Colombia, we used data from the SABE (Salud, Bienestar y Envejecimiento [Health, Well-being, and Aging]) Bogotá Study. Participants were 2000 community-dwelling adults aged 60 years and older in 2012. Sexual abuse was assessed by self-report. Depression was measured by the Geriatric Depression Scale. The weighted prevalence estimate was 2.6% for past sexual abuse and 23.4% for depression. Multivariate data analyses showed significantly higher odds of depression for past sexual abuse (odds ratio [OR] = 3.91, 95% confidence interval [CI]: 2.13-7.16). Other characteristics associated with depression were history of being displaced by violence (OR = 1.77, 95% CI: 1.30-2.40), low socioeconomic status, low education, poor self-rated health status, and poor self-rated memory. Thus, past sexual abuse and history of being displaced by violence were strongly associated with depression among Colombian elderly individuals.

Impact of Fall Risk and Direct Oral Anticoagulant Treatment on Quality-Adjusted Life-Years in Older Adults with Atrial Fibrillation: A Markov Decision Analysis.

BACKGROUND AND OBJECTIVE: The decision to initiate anticoagulation in older adults with atrial fibrillation is complicated by the benefit of ischemic stroke prevention vs the risk of falls resulting in major bleeds. The objective of this study was to assess the impact of different treatments including direct oral anticoagulants on quality-adjusted life-years (QALYs) in patients aged 75 years and older with atrial fibrillation in the context of falls. METHODS: A Markov decision process was constructed for older patients with atrial fibrillation taking no anti-thrombotic, aspirin, warfarin, rivaroxaban, and apixaban. Input probabilities for clinical events were estimated from the available literature. One-way and two-way sensitivity analyses were performed by measuring the impact of varying input probabilities of clinical events on QALY outcomes. RESULTS: The base-case scenario estimated that older adults treated with no anti-thrombotic, aspirin, warfarin, rivaroxaban, and apixaban had QALYs of 8.03, 8.69, 10.38, 11.02, and 11.56, respectively. The sensitivity analysis estimated that an older adult would need to fall over 45 (rivaroxaban) and 458 (apixaban) times per year for the QALY of a direct oral anticoagulant to be lower than that of aspirin. CONCLUSIONS: Older adults with atrial fibrillation benefit from stroke protection of anticoagulants, especially direct oral anticoagulants, even if they are at high risk of falls. Clinicians should not consider fall risk as a deciding factor for withholding anticoagulation in this population of patients.

Stemming the Tide of Elder Mistreatment: A Medical School-State Agency Collaborative.

In 1995, the Texas Department of Family and Protective Services: Adult Protective Service Agency began a partnership with the Baylor College of Medicine geriatrics program to form the Texas Elder Abuse and Mistreatment (TEAM) Institute. The medical school-state agency partners overcame institutional and bureaucratic barriers to work collaboratively on mutually beneficial projects, including research and publications. Interprofessional students gained first-hand experience about abuse and neglect cases. As of 2019, there are 4 divisions: Clinical and Forensic Evaluation, Education and Outreach, Research and Program Evaluation, and Senior Justice. TEAM members have published numerous articles and chapters, educated members from multiple disciplines, and served thousands of mistreated older patients. In 2017, TEAM launched the first statewide telecommunication program for elder mistreatment to improve practice for the entire state. Perseverance, teamwork, and dedication to the mission of the intervention and prevention of elder mistreatment have sustained this program for over 30 years. This article describes the steps to forming TEAM, the institute's early struggles, and the subsequent community and academic contributions of this medical school-state agency collaboration.

Bridging the Gap: Holistic Review to Increase Diversity in Graduate Medical Education.

PROBLEM: Racial and ethnic disparities in health outcomes remain pervasive in the U.S. health care system. Increasing the diversity of the physician workforce is recognized as an important component of addressing these disparities. Holistic review, which gives balanced consideration to applicants' academic metrics, experiences, and attributes, has gained popularity in undergraduate medical education and led to improvement in student diversity. Limited research has investigated how holistic review and other strategies can be implemented in graduate medical education to enhance diversity. APPROACH: The internal medicine (IM) residency program of the John P. and Kathrine G. McGovern Medical School implemented a pilot intervention in academic years (AY) 2016-2017 and 2017-2018 aimed at increasing the number of matriculating residents who are underrepresented in medicine (URM). The intervention included (1) using holistic review in the process of selecting applicants for interview, (2) standardizing the interview encounters, and (3) explicitly highlighting the program's commitment to diversity on interview days. OUTCOMES: From AY 2015-2016 (preintervention) to AY 2017-2018, the percentage of URM applications reviewed increased from 14.1% (180/1,276) to 20.4% (183/897), the proportion of URM applicants interviewed rose from 16.0% (60/374) to 24.5% (95/388), and the proportion of URM residents matriculating increased from 12.5% (5/40) to 31.7% (13/41). NEXT STEPS: Further efforts are needed to expand the pool of URM applicants at McGovern and elsewhere and to identify how holistic review can be widely employed in other IM residency programs and in other specialties.

Medication Regimen Complexity and Low Adherence in Older Community-Dwelling Adults With Substantiated Self-Neglect.

OBJECTIVE: Determine whether medication regimen complexity predicts medication adherence levels in a sample of community-dwelling adults 65 years and older with Adult Protective Services-substantiated self-neglect. METHODS: A cross-sectional analysis of baseline data ( N = 31 participants) from a pilot intervention to increase medication adherence among the target group was performed. The Medication Regimen Complexity Index (MRCI) and the 8-item Morisky Medication Adherence Scale (MMAS-8)™ were the primary independent and dependent measures, respectively. A multivariable linear regression analysis, adjusting for potential confounders, was conducted to estimate the association between complexity and adherence. RESULTS: Regimen complexity was high (mean MRCI = 19.6) and adherence was low (mean MMAS = 5.1). Even after controlling for confounders, increased complexity was significantly associated with lower adherence. DISCUSSION: Older community-dwelling adults who self-neglect have complex medication regimens that contribute to low medication adherence. Medication regimen complexity may be a modifiable contributor to low adherence that can be targeted by future interventions to reduce self-neglect and its consequences.