Integrating Palliative Care Into Self-management of Breast Cancer: A Pilot Randomized Controlled Trial.

BACKGROUND: Breast cancer patients may not be well-informed about palliative care, hindering its integration into cancer self-management. OBJECTIVE: The aim of this study was to test Managing Cancer Care: A Personal Guide (MCC-PT), an intervention to improve palliative care literacy and cancer self-management. METHODS: This was a single-blind pilot randomized controlled trial to evaluate the feasibility/acceptability and intervention effects of MCC-PT on palliative care literacy, self-management behaviors/emotions, and moderation by demographic/clinical characteristics. We enrolled 71 stages I to IV breast cancer patients aged at least 21 years, with >6-month prognosis at an academic cancer center. Patients were randomized to MCC-PT (n = 32) versus symptom management education as attention-control (n = 39). At baseline, 1 month, and 3 months, participants completed the Knowledge of Care Options Test (primary outcome), Control Preferences Scale, Goals of Care Form, Medical Communication Competence Scale, Measurement of Transitions in Cancer Scale, Chronic Disease Self-efficacy Scale, Hospital Anxiety and Depression Scale, and the Mishel Uncertainty in Illness Scale. RESULTS: Mean participant age was 51.5 years (range, 28-74 years); 53.5% were racial/ethnic minority patients, and 40.8% had stage III/IV cancer. After adjusting for race/ethnicity, MCC-PT users improved their palliative care literacy with a large effect size (partial η2 = 0.13). Patients at late stage of disease showed increased self-management (partial η2 = 0.05) and reduced anxiety (partial η2 = 0.05) and depression (partial η2 = 0.07) with medium effect sizes. CONCLUSIONS: Managing Cancer Care: A Personal Guide is feasible and appears most effective in late-stage cancer. Research is needed to elucidate relationships among cancer stage, race/ethnicity, and self-management outcomes. IMPLICATIONS FOR PRACTICE: Integration of palliative care into cancer care can assist in creation of appropriate self-management plans and improve emotional outcomes.

Neonates With Right Aortic Arch Requiring Arch Reconstruction: A Single-Institution Experience.

BACKGROUND: Reconstruction of a right aortic arch is rarely required in the newborn period and has rarely been reported. METHODS: All patients who underwent a right aortic arch repair in the neonatal period from a single institution were retrospectively reviewed. The primary outcome measures included survival, complications, and reintervention. RESULTS: Between 1984 and 2020, 15 patients were identified. Nine patients (60%) presented with an interrupted aortic arch, 5 with a hypoplastic arch (33%), and 1 with anomalous origin of the brachiocephalic vessels (7%). All patients had associated complex congenital heart disease. Median age at surgery was 6 days (range, 2-29 days); median weight was 3.11 kg (range, 2.5-4.18 kg). Genetic syndromes were prevalent and 77% of interrupted aortic arch patients had DiGeorge syndrome. Surgical techniques included end-to-side (27%), end-to-end (27%), or side-to-side anastomosis (13%) and placement of an interposition graft (7%); 65% required patch augmentation. Median intensive care unit and total hospital length of stay were 20 days (range, 7-92 days) and 28 days (range, 10-240 days), respectively. At a median follow-up of 3.97 years (range, 0.19-36 years), 13 of 15 patients were alive (87%). We found vocal cord paralysis in 27%, hemidiaphragm paralysis in 13%, and considerable airway compression in 27%. Overall, 27% patients required reintervention on the aortic arch: 2 surgical and 2 percutaneous balloon dilation. CONCLUSIONS: Right aortic arch reconstruction in the newborn period is rare and associated with complex lesions with an acceptable reintervention rate.

Childhood Bullying Victimization, Substance Use and Criminal Activity among Adolescents: A Multilevel Growth Model Study.

BACKGROUND: This study aims to examine the effects of childhood bullying victimization (CBV) on substance use and criminal activity among adolescents over time. In addition, it identifies the moderating effects of gender and race/ethnicity on the associations of CBV with substance abuse and criminal activity in adolescence and young adulthood. METHODS: This study included 8984 adolescents aged 12 to 18 years (Mage = 14.22 years) assessed biennially at four time points utilizing the National Longitudinal Survey of Youth 1997. The two-level hierarchical linear modeling was employed to test the effects of CBV on substance use and criminal activity. RESULTS: The incidence of substance use increased over time throughout adolescence to young adulthood, while that of criminal activity decreased. CBV increased the risks of cigarette use, marijuana use, and criminal activity. Gender and race/ethnicity significantly moderated the effect of CBV on alcohol use and alcohol binges. The effect of CBV on alcohol use was stronger among females than males. Among Hispanic adolescents, CBV was more strongly related to alcohol use and binges compared to non-Hispanic White. CONCLUSION: Findings suggest the need for early intervention for children at high risk of being bullied to reduce later substance abuse and involvement in criminal activities. Considering the moderating effects of gender and ethnicity on the associations, target-specified intervention and prevention programs are also required. Further studies focusing on the lifelong effects of CBV beyond adolescence are recommended.

Maternal Experiences of Racial Discrimination, Child Indicators of Toxic Stress, and the Minding the Baby Early Home Visiting Intervention.

BACKGROUND: Racism is a significant source of toxic stress and a root cause of health inequities. Emerging evidence suggests that exposure to vicarious racism (i.e., racism experienced by a caregiver) is associated with poor child health and development, but associations with biological indicators of toxic stress have not been well studied. It is also unknown whether two-generation interventions, such as early home visiting programs, may help to mitigate the harmful effects of vicarious racism. OBJECTIVE: The purpose of this study was to examine associations between maternal experiences of racial discrimination and child indicators of toxic stress and to test whether relationships are moderated by prior participation in Minding the Baby (MTB), an attachment-based early home visiting intervention. METHODS: Ninety-seven maternal-child dyads (n = 43 intervention dyads, n = 54 control dyads) enrolled in the MTB Early School Age follow-up study. Mothers reported on racial discrimination using the Experiences of Discrimination Scale. Child indicators of toxic stress included salivary biomarkers of inflammation (e.g., C-reactive protein, panel of pro-inflammatory cytokines), body mass index, and maternally reported child behavioral problems. We used linear regression to examine associations between maternal experiences of racial discrimination and child indicators of toxic stress and included an interaction term between experiences of discrimination and MTB group assignment (intervention vs. control) to test moderating effects of the MTB intervention. RESULTS: Mothers identified as Black/African American (33%) and Hispanic/Latina (64%). In adjusted models, maternal experiences of racial discrimination were associated with elevated salivary interleukin-6 and tumor necrosis factor-α levels in children, but not child body mass index or behavior. Prior participation in the MTB intervention moderated the relationship between maternal experiences of discrimination and child interleukin-6 levels. DISCUSSION: Results of this study suggest that racism may contribute to the biological embedding of early adversity through influences on inflammation, but additional research with serum markers is needed to better understand this relationship. Improved understanding of the relationships among vicarious racism, protective factors, and childhood toxic stress is necessary to inform family and systemic-level intervention.

Repair of Anomalous Left Anterior Descending Coronary Artery Arising From the Pulmonary Artery Using a Dacron Interposition Bypass Graft.

An anomalous left anterior descending artery arising from the pulmonary artery (ALADAPA) is exceedingly rare. We present an adult case of ALADAPA that was repaired using a Dacron interposition graft.

Changes in Functional Status and Health-Related Quality of Life in Older Adults After Surgical, Interventional, or Medical Management of Acute Myocardial Infarction.

Functional status and health-related quality of life (HRQoL) are important outcomes, particularly among older patients. However, data on such patient-centered outcomes after cardiac surgery are limited. We evaluated the incidence and predictors of decline in functional status and HRQoL among older patients hospitalized for acute myocardial infarction (AMI). Participants were age 75 years or older hospitalized for AMI at 94 US sites. We examined decline in functional status (defined as decline in 1 or more activities of daily living, ADLs), as well as mental (MCS) and physical component scales (PCS) of the SF-12 to assess HRQoL (5-point decline or greater in each scale) between 1 month prior to the hospitalization and 6 months after. Multivariable model compared the risk of decline after coronary artery bypass graft (CABG), percutaneous coronary intervention (PCI) and medical management. Among 3041 patients (1708 PCI, 362 CABG, and 971 medical management), 1525 (50.2%) experienced decline in 1 or more domain: 633 (20.8%) declined in ADLs, 786 (25.9%) declined in the MCS, and 1078 (35.5%) declined in the PCS. The unadjusted incidence of ADL decline was the lowest among patients who underwent CABG (n = 50, 13.8%) compared with PCI (n = 271, 15.9%) or medical management (n = 312, 32.1%). Patients who underwent CABG and PCI had lower adjusted risk of decline in functional and HRQoL compared with those who received medical therapy. The risks after CABG and PCI were not significantly different. Over half of older patients significantly declined in function or HRQoL after AMI. Compared with medical management, risk of decline was lower in those who underwent revascularization.

Characteristics of Hospice and Palliative Care Programs in US Prisons: An Update and 5-Year Reflection.

Individuals with terminal illness are dying behind bars and many state prison administrators have incorporated on-site hospice and palliative care services. Little is known, however, about these programs since a 2010 study of prison hospice characteristics. We provide an updated description and reflection of current hospice and palliative care programs in state prisons serving incarcerated persons with terminal illness. A cross-sectional survey was sent to representatives of all known prisons offering hospice and palliative care programs and services (N = 113). Questions were drawn from an earlier iteration regarding interdisciplinary team (IDT) membership, training length and topics, peer caregivers, visitation policies, bereavement services, perceived stakeholder support, and pain management strategies. Additional questions were added such as estimated operational costs, peer caregiver input in patient care, and the strengths and weaknesses of such programs. Frequency distributions were calculated for all study variables. Responding representatives (n = 33) indicated IDTs remain integral to care, peer caregivers continue to support dying patients, and perceived public support for these programs remains low. Reduced enthusiasm for the programs may negatively influence administrative decision-making and program resources. Further, peer caregiver roles appear to be changing with caregivers charged with fewer of the identified tasks, compared with the 2010 study.

Associations Between Maternal Experiences of Discrimination and Biomarkers of Toxic Stress in School-Aged Children.

OBJECTIVE: To examine associations between maternal experiences of discrimination and child biomarkers of toxic stress in a multiethnic, urban sample of mothers and children (4-9 years). METHODS: Data were drawn from a cross-sectional study of maternal-child dyads (N = 54) living in low-income neighborhoods in New Haven, Connecticut, USA. Mothers reported experiences of discrimination. Noninvasive biomarkers of toxic stress were collected to assess neuroendocrine (hair cortisol), immune (salivary cytokines, c-reactive protein), and cardiovascular (blood pressure) functioning in children. RESULTS: Maternal experiences of discrimination were associated with increased log-transformed salivary interleukin-6 (IL-6) levels in children (ß = 0.15, p = 0.02). CONCLUSIONS: Vicarious racism, or indirect exposure to discrimination experienced by caregivers, is associated with poor health outcomes for children. Immune pathways may be a biological mechanism through which racial discrimination "gets under the skin," but additional research is needed to fully understand these relationships. Uncovering the physiological mechanisms linking vicarious racism with child health is an important step towards understanding possible early roots of racial and ethnic health inequities.

Influence of Socioeconomic Status on Stage at Presentation of Laryngeal Cancer in the United States.

OBJECTIVE: Identify socioeconomic predictors of stage at diagnosis of laryngeal cancer in the United States. STUDY DESIGN: Retrospective analysis of the North American Association of Central Cancer Registries' Incidence Data-Cancers in North America Deluxe Analytic File for expanded races. SETTING: All centers reporting to the US Centers for Disease Control and Prevention's National Program of Cancer Registries. SUBJECTS AND METHODS: All cases of laryngeal cancer in adult patients from 2005 to 2013 were reviewed. Ordinal logistic regression models were used to evaluate odd ratios (ORs) for socioeconomic indicators potentially predictive of advancing American Joint Committee on Cancer stage at diagnosis. RESULTS: A total of 72,472 patients were identified and included. Analysis revealed significant correlation between advanced stage at diagnosis and: Medicaid insurance, lack of insurance, female sex, older age, black race, and certain states of residence. The strongest predictor of advanced stage was lack of insurance (OR, 2.212; P < .001; 95% CI, 2.035-2.406). The strongest protective factor was residing in the state of Utah (OR, 0.571; P < .001; 95% CI, 0.536-0.609). Once adjusted for regional price and wage disparities, relative income was not a significant predictor of stage at presentation across multiple analyses. CONCLUSION: Multiple socioeconomic factors were predictive of severity of disease at presentation of laryngeal cancer in the United States. This study demonstrated that insurance type was strongly predictive, whereas relative income had surprisingly little influence.

Does Socioeconomic Status Affect Stage at Presentation for Larynx Cancer in Canada's Universal Health Care System?

OBJECTIVE: Diagnosis of laryngeal cancer is dependent on awareness that persistent hoarseness needs to be investigated as well as access to an otolaryngologist. This study aimed to better classify and understand 3 factors that may lead to variability in stage at presentation of laryngeal cancer: (1) socioeconomic status (SES), (2) differences in access to health care by location of residence (rural vs urban or by province), and (3) access to an otolaryngologist (by otolaryngologists per capita). STUDY DESIGN: Registry-based multicenter cohort analysis. SETTING: This was a national study across Canada, a country with a single-payer, universal health care system. SUBJECTS: All persons 18 years or older who were diagnosed with laryngeal cancer from 2005 to 2013 inclusive were extracted from the Canadian Cancer Registry (CCR). METHODS: Ordered logistic regression was used to determine the effect of income, age, sex, province of residence, and rural vs urban residence on stage at presentation. RESULTS: A total of 1550 cases were included (1280 males and 265 females). The stage at presentation was earlier in the highest income quintile (quintile 5) compared to the lower income quintiles (quintiles 1-4) (odds ratio [OR], 0.68; P < .05). There was a statistically significant difference in stage at presentation based on rural or urban residence within the highest income quintile (OR, 1.73; P < .005). CONCLUSION: There is a relationship between SES and stage at presentation for laryngeal cancer even in the Canadian universal health care system.

Breastfeeding and Exposure to Past, Current, and Neighborhood Violence.

Objectives Breastfeeding has short- and long-term health benefits for children and mothers, but US breastfeeding rates are suboptimal. Exposure to violence may contribute to these low rates, which vary by race/ethnicity. We studied: (1) whether patterns of violence exposure differ by race/ethnicity and (2) whether these patterns are associated with breastfeeding outcomes. Methods We conducted a secondary analysis of data drawn from self-report surveys completed by a convenience sample of low-income postpartum women (n = 760) in upstate New York. Latent class analysis was used to identify groups of women with similar responses to seven violence measures, including childhood physical and/or sexual violence, experience of partner violence during or just after pregnancy (physical, emotional, verbal), and neighborhood violence (perceived or by ZIP code). Logistic regression and survival analysis were utilized to determine if classes were associated with breastfeeding initiation, duration, and exclusivity, controlling for demographics. Results Exposure to at least one form of violence was high in this sample (87%). We identified 4 classes defined by violence exposure (combining current and historical exposures). Violence exposure patterns differed between racial/ethnic groups, but patterns were inconsistently associated with breastfeeding plans or outcomes. For White women, history of violence exposure increased the likelihood of earlier breastfeeding cessation. By contrast, among Black women, history of violence exposure increased the likelihood of having a breastfeeding plan and initiating breastfeeding. Conclusions for Practice Some differences between violence exposure classes are likely due to the correlation between race/ethnicity and socioeconomic status in the community studied. Additional studies are warranted to better understand how exposure to violence is related to breastfeeding and how best to support women making decisions about intention, initiation, and duration of breastfeeding.

Gestational weight gain of pregnant African American adolescents affects body mass index 18 years later.

OBJECTIVE: To determine if gestational weight gain (GWG) in adolescents is associated with long-term weight increases 12 years and 18 years after delivery of a first child and the differential effects of weight gain during pregnancy that is inadequate, the appropriate amount, and excessive based on the 2009 Institute of Medicine (IOM) recommendations. DESIGN: Secondary data analysis of data from a randomized controlled trial. SETTING: Memphis, Tennessee. PARTICIPANTS: Two hundred ninety-eight (298) primiparous low-income Black women who were adolescents at the time of their first pregnancies. METHOD: Linear regression was used to examine the relationship between body mass index (BMI) at 12 and 18 years postdelivery and GWG, parity, prepregnancy BMI, and smoking. RESULTS: The total sample experienced a significant BMI increase from prepregnancy to 12 years and 18 years postdelivery. More than 50% of the women had a BMI increase greater than 10 kg/m(2) . By 18 years postdelivery, 85% were overweight or obese. Prepregnancy BMI and GWG had a positive significant effect on BMI 12 and 18 years later, whereas smoking had a negative effect. Those who gained excessive weight based on the IOM recommendations had a significantly higher BMI compared with those who gained appropriately. CONCLUSION: Gestational weight gain had long-term effects on BMI in a minority adolescent population. Excessive pregnancy weight gain is likely to contribute to long-term weight retention, especially if adolescents are overweight or obese when they become pregnant with their first children. Intervention during pregnancy to limit GWG has the potential of limiting long-term negative health consequences that result from overweight and obesity in minority women.

Adhesive-enhanced sternal closure to improve postoperative functional recovery: a pilot, randomized controlled trial.

BACKGROUND: We previously established a proof-of-concept in a human cadaveric model where conventional wire cerclage was augmented with a novel biocompatible bone adhesive that increased mechanical strength and early bone stability. We report the results of a single-center, pilot, randomized clinical trial of the effects of adhesive-enhanced closure of the sternum on functional postoperative recovery. METHODS: In 55 patients undergoing primary sternotomy, 26 patients underwent conventional wire closure and were compared with 29 patients who underwent adhesive-enhanced closure, which consisted of Kryptonite biocompatible adhesive (Doctors Research Group Inc, Southbury, CT) applied to each sternal edge in addition to conventional 7-wire cerclage. Patients were monitored postoperatively at 72 hours, weekly for 12 weeks, and then after 12 months for incisional pain, analgesic use, and maximal inspiratory capacity measured by spirometry. Standardized assessment tools measured postoperative physical disability and health-related quality of life. RESULTS: No adverse events or sternal complications from the adhesive were observed early or after 12 months. Incisional pain and narcotic analgesic use were reduced in adhesive-enhanced closure patients. Inspiratory capacity was significantly improved, postoperative health-related quality of life scores normalized more rapidly, and physical disability scores were reduced. Computed tomography imaging was suggestive of sternal healing. CONCLUSIONS: Adhesive-enhanced closure is a safe and simple addition to conventional wire closure, with demonstrated benefits on functional recovery, respiratory capacity, incisional pain, and analgesic requirements. A large, multicenter, randomized controlled trial to examine the potential of the adhesive to prevent major sternal complications in higher risk patients is warranted.

Virgin olive oil authentication by multivariate analyses of 1H NMR fingerprints and delta13C and delta2H data.

(1)H NMR fingerprints of virgin olive oils (VOOs) from the Mediterranean basin (three harvests) were analyzed by principal component analysis, linear discriminant analysis (LDA), and partial least-squares discriminant analysis (PLS-DA) to determine their geographical origin at the national, regional, or PDO level. Further delta(13)C and delta(2)H measurements were performed by isotope ratio mass spectrometry (IRMS). LDA and PLS-DA achieved consistent results for the characterization of PDO Riviera Ligure VOOs. PLS-DA afforded the best model: for the Liguria class, 92% of the oils were correctly classified in the modeling step, and 88% of the oils were properly predicted in the external validation; for the non-Liguria class, 90 and 86% of hits were obtained, respectively. A stable and robust PLS-DA model was obtained to authenticate VOOs from Sicily: the recognition abilities were 98% for Sicilian oils and 89% for non-Sicilian ones, and the prediction abilities were 93 and 86%, respectively. More than 85% of the oils of both categories were properly predicted in the external validation. Greek and non-Greek VOOs were properly classified by PLS-DA: >90% of the samples were correctly predicted in the cross-validation and external validation. Stable isotopes provided complementary geographical information to the (1)H NMR fingerprints of the VOOs.

Cost-effectiveness of testing for breast cancer susceptibility genes.

OBJECTIVES: Genetic mutations in breast cancer susceptibility genes BRCA1/2 are associated with an increased risk of breast/ovarian cancers. Cost-effective preventive measures are available for women who test positive. The objective of this study was to determine at what risk of mutation it is cost-effective to test women for BRCA1/2 mutations. METHODS: A semi-Markov model accrued costs and quality-adjusted life years (QALYs) annually from the societal perspective. The estimates of health-care costs, life expectancy, likelihood of obtaining a mastectomy or oophorectomy, and patient preferences for treatment and certainty about their BRCA1/2 status were based on the literature. RESULTS: At a 10% probability of mutation (the current guideline), the test strategy generated 22.9 QALYs over the lifetime and cost $118k, while the no-test strategy generated 22.7 QALYs and cost $117k. The incremental cost-effectiveness ratio of the test strategy was $9k and the differences between costs and effects were not substantial. The test strategy remained cost-effective to a probability of mutation of 0%, as long as utility gained from a negative test result was 0.006 or greater. These results were sensitive to the frequency of inconclusive test results and utility gain from a negative test result. CONCLUSIONS: The costs and effectiveness of both the test and no-test strategies are very similar even when there is a small probability of mutation. Current guidelines, which can be used by insurance companies to refuse coverage, could deny some women a cost-effective approach. Further research to decrease the frequency of inconclusive results could improve the cost-effectiveness of this test.