Breast Cancer Knowledge Among Amish and Mennonite Women.

Breast cancer is the most common cancer diagnosis for women in the USA and ranks second in cancer-related deaths. Disproportionately higher breast cancer rates can be found in rural and Appalachian regions due to several social drivers of health, including poverty, access to healthcare, and lack of culturally sensitive health education. Amish and Mennonite communities, religious groups with distinct cultural practices and beliefs, experience lower mammography screening and higher breast cancer mortality rates (among Amish women). This study focuses on knowledge about breast cancer and causes of cancer among Amish and Mennonite women. A total of 473 women participated in the study at 26 separate women's health clinics throughout Ohio, consisting of 348 Amish and 121 Mennonite women, the largest study conducted on breast cancer knowledge spanning dozens of communities. Statistically significant differences were found in total knowledge scores between Amish and Mennonite women (rpb = .178, n = 466, p = .007), with Amish women having lower scores and stronger beliefs in myths associated with breast cancer cause and symptoms (χ(1) = 7.558, p = .006). Both groups often provided scientifically accurate descriptions of cancer etiology. The majority of participants underestimated breast cancer risk, highlighting the need for culturally appropriate health education programs that consider numeracy and health literacy. By implementing targeted interventions and fostering partnerships with community stakeholders using a multifaceted approach that incorporates cultural sensitivity, community engagement, and collaboration, significant progress can be made towards reducing breast cancer disparities and improving health outcomes.

The Role of Telemedicine in Rural Specialty Care: Priorities and Recommendations From Rural Primary Care Physicians.

Introduction: The study goal was to understand telemedicine's role in improving access to rural specialty care. Other outcomes included assessing specialty availability and frequency of referrals at rural sites. Methods: This mixed methods study included surveys and semi-structured interviews of rural primary care physicians (PCPs). Survey data were analyzed with summary statistics and cross-tabulations. Interview transcripts were inductively thematically analyzed. Results: Of the 19 PCPs who completed the survey, 37% agreed/strongly agreed current telemedicine practices connected patients to better specialty care; 90% agreed/strongly agreed it had such potential. Interviews revealed telemedicine could improve care when local specialists were unavailable and provided the most benefit in acute care settings or specialist follow-ups. Most survey respondents reported outreach specialists were highly effective in addressing rural specialty care needs. Respondents reported cardiology, general surgery, orthopedic surgery, ENT/otolaryngology, and dermatology as the most frequently referred-to specialties. In-person neurology, gastroenterology, and dermatology were unavailable in many communities. Respondents identified psychiatry as a high priority for telemedicine and discussed clinic-to-clinic visits to optimize telemedicine use. Conclusions: The perceived discrepancy between the current and potential roles of telemedicine in rural specialty care suggests that telemedicine may not fully align with the needs of rural patients and could be optimized for rural practice settings. While local, in-person access to specialists remains a priority, telemedicine can reduce patient burdens and improve care when in-person specialists are unavailable. Telemedicine proponents can identify high-priority areas for implementation through quantitative assessment of specialty care utilization and access as reported by PCPs.

Distance to endoscopy services amplifies racial inequities in colorectal cancer mortality in Washington state.

BACKGROUND: This study evaluates relationships among race, access to endoscopy services, and colorectal cancer (CRC) mortality in Washington state (WA). METHODS: We overlayed the locations of ambulatory endoscopy services with place of residence at time of death, using Department of Health data (2011-2018). We compared CRC mortality data within and outside a 10 â€‹km buffer from services. We used linear regression to assess the impact of distance and race on age at death while adjusting for gender and education level. RESULTS: Age at death: median 72.9y vs. 68.2y for white vs. non-white (p â€‹< â€‹0.001). The adjusted model showed that non-whites residing outside the buffer died 6.9y younger on average (p â€‹< â€‹0.001). Non-whites residing inside the buffer died 5.2y younger on average (p â€‹< â€‹0.001), and whites residing outside the buffer died 1.6y younger (p â€‹< â€‹0.001). We used heatmaps to geolocate death density. CONCLUSIONS: Results suggest that geographic access to endoscopy services disproportionately impacts non-whites in Washington. These data help identify communities which may benefit from improved access to alternative colorectal cancer screening methods.

Rural-specific identity and associations with lifestyle behaviors and well-being among rural cancer survivors.

BACKGROUND: Disparities in rural cancer survivors' health outcomes are well-documented, yet the role of sociocultural aspects of rurality, such as rural identity, attitudes toward rurality, and social standing on health beliefs and behaviors remain unclear. This study aimed to address these gaps. METHODS: Rural cancer survivors (N = 188) completed a mailed/online survey. Regression analyses identified relationships among rural identity, negative attitudes toward rurality, and social standing with health outcomes, quality of life, cancer fatalism, and cancer information overload. RESULTS: Higher rural identity was associated with believing everything causes cancer (OR = 1.58, p = 0.048), believing "there's not much you can do to lower your chances of getting cancer" (OR = 2.22, p = 0.002), and higher odds of being overloaded with cancer information (OR = 2.05, p  = 0.008). Negative attitudes toward rurality was linked with higher levels of perceived stress (B = 0.83, p = 0.001), and chronic pain (OR = 1.47, p = 0.039). Higher subjective social status was associated with perceived social support (B = 0.09, p = 0.016), better overall health (B = 0.13, p < 0.001), lower levels of perceived stress (B = -0.38, p = 0.007), and chronic pain (OR = 0.80, p = 0.027). CONCLUSION: Sociocultural factors of rurality were associated with indicators of quality of life, cancer fatalism, and information overload. Further exploration of the underlying mechanisms that drive these associations can help improve intervention targets for rural cancer survivors.

The influence of rurality on melanoma diagnosis in Indiana: A retrospective cohort study.

BACKGROUND: Research from across the United States has shown that rurality is associated with worse melanoma outcomes. In Indiana, nearly a quarter of all residents live in rural counties and an estimated 2180 cases of melanoma will be diagnosed in 2023. AIMS: This study examines how geographical location affects the stage of melanoma diagnosis in Indiana, aiming to identify and address rural health disparities to ultimately ensure equitable care. METHODS AND RESULTS: Demographics and disease characteristics of patients diagnosed with melanoma at Indiana University Health from January 2017 to September 2022 were compared using Students t-tests, Wilcoxon tests, chi-squared or Fisher's exact tests. Patients from rural areas presented with more pathological stage T3 melanomas (15.0% vs. 3.5%, p < 0.001) in contrast to their urban counterparts. Additionally, rural patients presented with fewer clinical stage I melanomas (80.8% vs. 89.3%) and more clinical stage II melanomas (19.2% vs. 8.1%), compared to urban patients, with no stage III (p = 0.028). Concerningly, a significantly higher percentage of the rural group (40.7%) had a personal history of BCC compared to the urban group (22.6%) (p = 0.005) and fewer rural patients (78.0%) compared to urban patients (89.4%) received surgical treatment (p = 0.016). CONCLUSION: Patients from rural counties in Indiana have higher pathological and clinical stage melanoma at diagnosis compared to patients from urban counties. Additionally fewer rural patients receive surgical treatment and may be at higher risk of developing subsequent melanomas.

Expanding urological services into regional Australia and reducing interhospital transfers: how the nurse practitioner can help.

BACKGROUND: A visiting urology service has been in existence at Hamilton Base Hospital, Western Victoria, over the past 25 years, serving an unmet need. A Urology Nurse Practitioner (UNP) provides the care and management of urology patients working in close association with visiting urologists. We aim to assess the impact of the UNP's role in the delivery of regional urological care. METHODS: A retrospective analysis of medical records identified all clinical interventions by the UNP between January 2016 and December 2019. Each encounter was graded according to a clinical severity scale from grade 1 to 5 and assessed for UNP management of patients and the prevention of interhospital transfers. RESULTS: One hundred eighty-four patients with 654 individual assessments were identified for inclusion and classified according to the adapted clinical severity scale. Most interventions for category 3 and 4 patients related to major bleeding, catheter difficulties, and haemodynamic instability. A total of 19 patients whose urological issues would typically require interhospital transfer were able to be managed locally. CONCLUSIONS: Transferring an acute patient from a regional to a tertiary hospital for specialist care is often necessary but not ideal for the patient and their family. The presence of a dedicated UNP in a regional centre is important for patient care and has an important role in preventing unnecessary transfers. This is a vital component of a visiting urological service to a rural community.

Exploring 6 years of colorectal cancer surgery in rural Italy: insights from 648 consecutive patients unveiling successes and challenges.

The multidisciplinary management of patients suffering from colorectal cancer (CRC) has significantly increased survival over the decades and surgery remains the only potentially curative option for it. However, despite the implementation of minimally invasive surgery and ERAS pathway, the overall morbidity and mortality remain quite high, especially in rural populations because of urban - rural disparities. The aim of the study is to analyze the characteristics and the surgical outcomes of a series of unselected CRC patients residing in two similar rural areas in Italy. A total of 648 consecutive patients of a median age of 73 years (IQR 64-81) was enrolled between 2017 and 2022 in a prospective database. Emergency admission (EA) was recorded in 221 patients (34.1%), and emergency surgery (ES) was required in 11.4% of the patients. Tumor resection and laparoscopic resection rates were 95.0% and 63.2%, respectively. The median length of stay was 8 days. The overall morbidity and mortality rates were 23.5% and 3.2%, respectively. EA was associated with increased median age (77.5 vs. 71 ys, p < 0.001), increased mean ASA Score (2.84 vs. 2.59; p = 0.002) and increased IV stage disease rate (25.3% vs. 11.5%, p < 0.001). EA was also associated with lower tumor resection rate (87.3% vs. 99.1%, p < 0.001), restorative resection rate (71.5 vs. 89.7%, p < 0.001), and laparoscopic resection rate (36.2 vs. 72.6%, p < 0.001). Increased mortality rates were associated with EA (7.2% vs. 1.2%, p < 0.001), ES (11.1% vs. 2.0%, p < 0.001) and age more than 80 years (5.8% vs. 1.9%, p < 0.001). In rural areas, high quality oncologic care can be delivered in CRC patients. However, the surgical outcomes are adversely affected by a still too high proportion of emergency presentation of elderly and frail patients that need additional intensive care supports beyond the surgical skill and alternative strategies for earlier detection of the disease.

Frailty Syndrome in Rural Communities: A Narrative Review and Interviews With Rural Individuals.

Background With the global increase in aging populations, frailty syndrome, characterized by decreased strength, endurance, and physiological function, has become a critical issue. This study focuses on rural Japanese communities, where the prevalence of frailty syndrome can be notably high due to factors such as multimorbidity, polypharmacy, and a significant population of elderly individuals. This research addresses the gap in understanding frailty's manifestations and impacts in rural settings, considering unique challenges such as social isolation, limited healthcare access, and the broader social determinants of health. Methodology The study employs a narrative review with PubMed and a thematic analysis of semi-structured interviews with 21 elderly community workers in Unnan City. The analysis used the framework of frailty syndrome affected by physiological, social, psychological, and economic factors. The analysis focused on identifying themes related to the social determinants of health affecting frailty and potential solutions. Results The following five themes emerged from the analysis: Aging, Rural Contexts, Isolation, Lack of Knowledge of Frailty Syndrome, and Lack of Help-Seeking Behavior for Frailty Syndrome. Four solution-oriented themes were identified, namely, Public Dialogue and Educational Workshops, Frailty Syndrome Health Meetings, Social Engagement Activities, and Political Advocacy for Accessibility to Community Centers. These findings highlight the critical role of community engagement, education, and infrastructure improvements in addressing frailty syndrome in rural areas. Conclusions This study underscores the complexity of frailty syndrome in rural Japanese communities, emphasizing the need for targeted interventions that address the unique challenges faced by these populations. By fostering public dialogue, improving healthcare access, and enhancing social support, it is possible to mitigate the impacts of frailty syndrome and improve the quality of life for elderly residents in rural settings. This research contributes to a deeper understanding of frailty in aging societies and the importance of considering social determinants of health in developing effective solutions.

Colonoscopy Outreach for Rural Communities (CORC): A study protocol of a pragmatic randomized controlled trial of a patient navigation program to improve colonoscopy completion for colorectal cancer screening.

BACKGROUND: Colonoscopy is one of the primary methods of screening for colorectal cancer (CRC), a leading cause of cancer mortality in the United States. However, up to half of patients referred to colonoscopy fail to complete the procedure, and rates of adherence are lower in rural areas. OBJECTIVES: Colonoscopy Outreach for Rural Communities (CORC) is a randomized controlled trial to test the effectiveness of a centralized patient navigation program provided remotely by a community-based organization to six geographically distant primary care organizations serving rural patients, to improve colonoscopy completion for CRC. METHODS: CORC is a type 1 hybrid implementation-effectiveness trial. Participants aged 45-76 from six primary care organizations serving rural populations in the northwestern United States are randomized 1:1 to patient navigation or standard of care control. The patient navigation is delivered remotely by a trained lay-person from a community-based organization. The primary effectiveness outcome is completion of colonoscopy within one year of referral to colonoscopy. Secondary outcomes are colonoscopy completion within 6 and 9 months, time to completion, adequacy of patient bowel preparation, and achievement of cecal intubation. Analyses will be stratified by primary care organization. DISCUSSION: Trial results will add to our understanding about the effectiveness of patient navigation programs to improve colonoscopy for CRC in rural communities. The protocol includes pragmatic adaptations to meet the needs of rural communities and findings may inform approaches for future studies and programs. TRIAL REGISTRATION: National Clinical Trial Identifier: NCT05453630. TRIAL REGISTRATION: ClinicalTrials.gov. Identifier: NCT05453630. Registered July 6, 2022.

Sociodemographic and Behavioral Factors Associated With Hypertension and Depression in 4 Rural Communities in Northern Ghana: A Cross-Sectional Study.

OBJECTIVES: The prevalences of hypertension and depression in sub-Saharan Africa are substantial and rising, despite limited data on their sociodemographic and behavioral risk factors and their interactions. We undertook a cross-sectional study in 4 communities in the Upper East Region of Ghana to identify persons with hypertension and depression in the setting of a pilot intervention training local nurses and health volunteers to manage these conditions. METHODS: We quantified hypertension and depression prevalence across key sociodemographic factors (age, sex, occupation, education, religion, ethnicity, and community) and behavioral factors (tobacco use, alcohol use, and physical activity) and tested for association by multivariable logistic regression. RESULTS: Hypertension prevalence was higher in older persons (7.6% among 35- to 50-year-olds vs 16.4% among 51- to 70-year-olds) and among those reporting alcohol use (18.9% vs 8.5% between users and nonusers). In multivariable models, only older age (AOR 2.39 [1.02, 5.85]) and residence in the community of Wuru (AOR 7.60 [1.81, 32.96]) were independently associated with hypertension, and residence in Wuru (AOR 23.58 [7.75-78.25]) or Navio (AOR 7.41 [2.30-24.74]) was the only factor independently associated with depression. CONCLUSIONS: We report a high prevalence of both diseases overall and in select communities, a trend that requires further research to inform targeted chronic disease interventions.

Risk of major adverse cardiovascular events in rural vs urban settings among patients with erectile dysfunction: a propensity-weighted retrospective cohort study of 430 621 men.

BACKGROUND: The relationship between erectile dysfunction (ED) and cardiovascular (CV) events has been postulated, with ED being characterized as a potential harbinger of CV disease. Location of residence is another important consideration, as the impact of rural residence has been associated with worse health outcomes. AIM: To investigate whether men from rural settings with ED are associated with a higher risk of major adverse CV events (MACEs). METHODS: A propensity-weighted retrospective cohort study was conducted with provincial health administrative databases. ED was defined as having at least 2 ED prescriptions filled within 1 year. MACE was defined as the first hospitalization for an episode of acute myocardial infarction, heart failure, or stroke that resulted in a hospital visit >24 hours. We classified study groups into ED urban, ED rural, no ED urban, and no ED rural. A multiple logistic regression model was used to determine the propensity score. Stabilized inverse propensity treatment weighting was then applied to the propensity score. OUTCOMES: A Cox proportional hazard model was used to examine our primary outcome of time to a MACE. RESULTS: The median time to a MACE was 2731, 2635, 2441, and 2508 days for ED urban (n = 32 341), ED rural (n = 18 025), no ED rural (n = 146 358), and no ED urban (n = 233 897), respectively. The cohort with ED had a higher proportion of a MACE at 8.94% (n = 4503), as opposed to 4.58% (n = 17 416) for the group without ED. As compared with no ED urban, no ED rural was associated with higher risks of a MACE in stabilized time-varying comodels based on inverse probability treatment weighting (hazard ratio, 1.06-1.08). ED rural was associated with significantly higher risks of a MACE vs no ED rural, with the strength of the effect estimates increasing over time (hazard ratio, 1.10-1.74). CLINICAL IMPLICATIONS: Findings highlight the need for physicians treating patients with ED to address CV risk factors for primary and secondary prevention of CV diseases. STRENGTHS AND LIMITATIONS: This is the most extensive retrospective study demonstrating that ED is an independent risk factor for MACE. Due to limitations in data, we were unable to assess certain comorbidities, including obesity and smoking. CONCLUSIONS: Our study confirms that ED is an independent risk factor for MACE. Rural men had a higher risk of MACE, with an even higher risk among those who reside rurally and are diagnosed with ED.

Facilitators and barriers of HPV vaccination: a qualitative study in rural Georgia.

Introduction: Human papillomavirus (HPV) vaccination protects against HPV-associated cancers and genital warts. Healthy People 2030 goal for HPV vaccine uptake is 80%, but as of 2021, only 58.5% of adolescents are up to date in Georgia. The purpose of the study is to assess the attitudes, vaccine practices, facilitators, and barriers to receiving the HPV vaccine in southwest Georgia. Methods: We conducted 40 semi-structured interviews with three different audiences (young adults, parents, and providers and public health professionals) guided by the P3 (patient-, provider-, practice-levels) model and used deductive coding approach. Young adults and parents were interviewed to assess their perceived benefits, barriers, and susceptibility of the HPV vaccine. Providers and public health professionals were interviewed about facilitators and barriers of patients receiving the HPV vaccine in their communities. Results: Out of the 40 interviews: 10 young adults, 20 parents, and 10 providers and public health professionals were interviewed. Emerging facilitator themes to increase the uptake of the HPV vaccine included existing knowledge (patient level), providers' approach to the HPV vaccine recommendations (provider level) and immunization reminders (practice level). Barrier themes were lack of knowledge around HPV and the HPV vaccine (patient level), need for strong provider recommendation and discussing the vaccine with patients (provider level), and limited patient reminders and information (practice level). Conclusions: These interviews revealed key themes around education, knowledge, importance of immunization reminders, and approaches to increasing the HPV vaccination in rural Georgia. This data can inform future interventions across all levels (patient, provider, practice, policy, etc.) to increase HPV vaccination rates in rural communities.

Long-term outcomes of definitive radiation with volumetric modulated arc therapy and concurrent chemotherapy for squamous cell carcinoma of the anus in a regional Australian cancer centre.

INTRODUCTION: Concurrent chemoradiotherapy is the standard of care in the curative intent treatment of squamous cell carcinoma (SCC) of the anus. Volumetric arc therapy (VMAT) is a highly conformal radiation therapy technique that has been implemented to reduce toxicity for these patients. However, there are few reports evaluating the long-term outcomes of VMAT. Thus, we evaluated the survival and toxicity outcomes of anal cancer patients treated in our regional cancer centre undergoing curative intent chemoradiotherapy using VMAT and following the Australian EviQ guidelines. METHODS: All consecutive patients treated with the VMAT technique for curative-intent definitive chemoradiotherapy for anal SCC at our institution from 2013 until 2022 were retrospectively reviewed for survival and toxicity outcomes. Kaplan-Meier estimates of locoregional control, distant metastasis-free survival, disease-free survival, anal cancer-specific survival and overall survival were obtained. RESULTS: In total, 44 patients were analysed. The median follow-up was 48.9 months (Range 7.8-107). 97.7% of patients completed the prescribed radiation therapy and 88.6% chemotherapy. Five patients (11.4%) recurred. Four (9.1%) had isolated local failures, and one (2.3%) had an isolated distant failure. There were no regional nodal failures. The Kaplan-Meier estimates for locoregional control, distant metastasis-free survival, disease-free survival, anal cancer-specific survival and overall survival were 90.3%, 97.7%, 88.1%, 97.1% and 87% at 3 years, and 90.3%, 97.7%, 88.1%, 93.0% and 72.3% at 5 years, respectively. Acute grade 3 genitourinary (GU), gastrointestinal (GI) and skin toxicities occurred in 2.2%, 6.8% and 13.6% of patients, respectively. There were no acute grade 4 toxicities. Late grade 2 GU and GI toxicities occurred in 6.8% and 11.3% of patients, respectively. There were no late grade 3 or 4 toxicities or treatment-related deaths. The 5 -year colostomy-free survival rate was 86.4%. CONCLUSION: Outcomes for anal SCC after definitive chemoradiotherapy using VMAT in our regional cancer centre results in low rates of grade 3/4 toxicity, high rates of organ preservation and excellent survival outcomes.

Rural patients' experiences with anesthesia and surgical consultations in British Columbia: A survey-based comparison between virtual and in-person modalities.

Introduction: Rural patients face barriers to accessing surgical care and often need to travel long distance for pre- or post-surgical consultations. Although adaptation to the COVID-19 pandemic has demonstrated the efficacy of virtual care, there is minimal data available to evaluate patient satisfaction with this modality and consequent health service utilization if virtual services are not available. Methods: An online survey was conducted with participants living in rural British Columbia, Canada who had undergone surgery within 12 months of data collection and had either virtual or face-to-face pre- or post-surgical consultations. It was supplemented by an in-person survey administered in two rural sites to all patients who had a virtual visit prior to undergoing procedural care. A ten-point scale was used to assess satisfaction. Quantitative and qualitative data were collected and analyzed. Results: Findings from the province-wide survey (n = 163) revealed no significant differences in average satisfaction ratings between people with in-person and virtual surgical consultations (8.03 versus 8.38, p = 0.26). However, most participants indicated that virtual appointments saved them time traveling, energy, and money and made them less dependent on others, accruing significant social benefit.In the community-focused sample (n = 71), 38% said they would not have had the procedure without a virtual visit option and 21% said that they would have delayed the procedure. Virtual consultations saved patients an average of 9 h (range 1-90). Participants traveled an average of 427 kilometers round trip to have the procedures. Conclusion: Findings reveal costs and time saved in accessing care due to the introduction of pre- and post-operative virtual care visits, and further investments in virtual care are warranted. This will contribute to promoting equitable access to healthcare for rural residents.

Satisfaction With Care Among Cancer Survivors With Medicare Coverage: Are There Rural Versus Urban Inequities?

INTRODUCTION: Rural cancer survivors often face greater barriers to treatment, which may translate into worse satisfaction with health care. OBJECTIVE: To examine rural versus urban differences in satisfaction with health care among Medicare cancer survivors. METHODS: Data are from the 2020 Medicare Current Beneficiary Survey (MCBS). Rao-Scott chi-square analyses were conducted to examine rural versus urban inequities in satisfaction with 9 dimensions of health care (health professionals' concern for health, information about what was wrong, ease/convenience from home, ease of obtaining answers over telephone, getting needs taken care of at same location, availability of specialists, overall quality, and out-of-pocket costs, and availability of care at night/on weekends). Multiple logistic regression analyses were conducted to test for rural/urban differences while adjusting for race/ethnicity, gender, marital status, educational attainment, health insurance (traditional Medicare, Medicare Advantage, dual Medicaid coverage, employer, or self-purchased insurance), and self-rated overall health. RESULTS: Rural cancer survivors were less satisfied with the ease/convenience of getting to health professionals (93.35% rural and 96.87% urban) and less satisfied with getting all health care needs taken care of at the same location (88.32% rural and 92.22% urban). These rural/urban differences persisted when adjusting for other factors. CONCLUSIONS: Health care providers serving rural areas may need to consider new strategies to satisfy some of the unique needs of rural cancer survivors, such as better organizing services at single clinic sites and utilizing telehealth when feasible to reduce the need to travel for in-person services.

Urban relatives ameliorate survival disparities for genitourinary cancer in rural patients.

INTRODUCTION: Patients living in rural areas have worse cancer-specific outcomes. This study examines the effect of family-based social capital on genitourinary cancer survival. We hypothesized that rural patients with urban relatives have improved survival relative to rural patients without urban family. METHODS: We examined rural and urban based Utah individuals diagnosed with genitourinary cancers between 1968 and 2018. Familial networks were determined using the Utah Population Database. Patients and relatives were classified as rural or urban based on 2010 rural-urban commuting area codes. Overall survival was analyzed using Cox proportional hazards models. RESULTS: We identified 24,746 patients with genitourinary cancer with a median follow-up of 8.72 years. Rural cancer patients without an urban relative had the worst outcomes with cancer-specific survival hazard ratios (HRs) at 5 and 10 years of 1.33 (95% CI 1.10-1.62) and 1.46 (95% CI 1.24-1.73), respectively relative to urban patients. Rural patients with urban first-degree relatives had improved survival with 5- and 10-year survival HRs of 1.21 (95% CI 1.06-1.40) and 1.16 (95% CI 1.03-1.31), respectively. CONCLUSIONS: Our findings suggest rural patients who have been diagnosed with a genitourinary cancer have improved survival when having relatives in urban centers relative to rural patients without urban relatives. Further research is needed to better understand the mechanisms through which having an urban family member contributes to improved cancer outcomes for rural patients. Better characterization of this affect may help inform policies to reduce urban-rural cancer disparities.

Physician perspectives on clinician-to-clinician telemedical consultation for gynecologic cancers: A qualitative study.

Objective: Approximately fifteen million women in the United States live > 50 miles from a gynecologic oncologist. Telemedical technology allows patients' local physicians to consult with subspecialist gynecologic oncologists without burdening patients with unnecessary in-person visits. Although critical to adoption of this technology, physicians' input into implementation of clinician-to-clinician consultation has not been sought. We therefore gathered feedback about experiences with referrals, communication, and openness to telemedical consultation from gynecologic oncologists, gynecologists, and medical oncologists. Methods: We recruited gynecologic oncologists, gynecologists, and medical oncologists from practices serving rural patients to participate in semi-structured interviews. The Consolidated Framework for Implementation Research and the Theoretical Domains Framework guided the interviews. Questions focused on factors influencing adoption and implementation of clinician-to-clinician telemedicine. Interviews were conducted via WebEx, recorded, and transcribed. Two investigators coded interviews using the combined frameworks and identified salient themes. Results: We conducted 11 interviews (6 gynecologic oncologists, 3 gynecologists, 2 medical oncologists) and identified themes encompassing communication burnout, barriers to sharing patient information, need for further logistical information, and potential benefits to patients. Conclusions: Clinician-to-clinician telemedicine may improve access to gynecologic cancer care by decreasing barriers to subspecialty expertise while simultaneously benefiting referring and consultant clinicians through improved identification and workup of patients who may need in-person consultation. To optimize desired outcomes, telemedical consultation must allow for communication of relevant patient information and records and easy integration into clinical workflow. Importantly, clinicians must perceive the consultation as improving patients' access to specialty care.

Unmet Needs and Care Delivery Gaps Among Rural Cancer Survivors.

Community-based healthcare delivery systems frequently lack cancer-specific survivorship support services. This leads to a burden of unmet needs that is magnified in rural areas. Using sequential mixed methods we assessed unmet needs among rural cancer survivors diagnosed between 2015 and 2021. The Supportive Care Needs Survey (SCNS) assessed 5 domains; Physical and Daily Living, Psychological, Support and Supportive Services, Sexual, and Health Information. Needs were analyzed across domains by cancer type. Survey respondents were recruited for qualitative interviews to identify care gaps. Three hundred and sixty two surveys were analyzed. Participants were 85% White (n = 349) 65% (n = 234) female and averaged 2.03 years beyond cancer diagnosis. Nearly half (49.5%) of respondents reported unmet needs, predominantly in physical, psychological, and health information domains. Needs differed by stage of disease. Eleven interviews identified care gap themes regarding; Finding Support and Supportive Services and Health Information regarding Care Delivery and Continuity of Care. Patients experience persistent unmet needs after a cancer diagnosis across multiple functional domains. Access to community-based support services and health information is lacking. Community based resources are needed to improve access to care for long-term cancer survivors.

Type 2 Myocardial Infarction Caused by Orthostatic Hypotension With Post-transcatheter Aortic Valve Implantation: A Case Report.

This case report delineates the occurrence and management of type 2 myocardial infarction (MI) in an 89-year-old woman following transcatheter aortic valve implantation (TAVI). The patient, with a history of severe aortic stenosis, hypertension, dyslipidemia, and colorectal cancer, presented with nausea and significant hypotension. Initial assessments revealed elevated troponin levels, atrial fibrillation, and ST-segment depression, leading to a diagnosis of type 2 MI. This condition was attributed to the interplay between left ventricular hypertrophy, hypotension-induced dehydration, and increased myocardial oxygen demand. The patient with post-TAVI exhibited dynamic changes in cardiac hemodynamics, with improvements in left ventricular function but persistent hypertrophy and diastolic dysfunction. This state, combined with hypotension due to diuretic-induced dehydration and atrial fibrillation, precipitated a mismatch in myocardial oxygen supply and demand. The cessation of diuretics and initiation of rehydration therapy stabilized her condition, with subsequent normalization of troponin levels and blood pressure. This case highlights the complexity of managing type 2 MI in elderly patients post-TAVI. It underscores the importance of holistic consideration of both myocardial oxygen supply and demand factors, particularly in left ventricular hypertrophy and diastolic dysfunction. The multifactorial nature of type 2 MI necessitates a tailored approach to diagnosis and management, emphasizing the need for comprehensive post-procedural care in patients undergoing TAVI.

Adherence to the National Tobacco-Free School Policy in Selected Schools of Puducherry District in India: A Cross-Sectional Exploratory Study.

INTRODUCTION: The objective of this study was to estimate the level of compliance and the factors associated with high adherence to the Tobacco-Free Educational Institutions (ToFEI) guidelines of the Government of India among schools in the district of Puducherry, India. METHODS: This cross-sectional study was conducted among schools (N=50) in the Puducherry district in 2021-2022 using a "Self-Evaluation Scorecard" of the ToFEI guidelines. The assessment was done through in-person interviews with the schools' heads/representatives. The level of compliance to indicators was presented as proportions, and factors associated with high compliance were assessed using the chi-square test. RESULTS: No school met all the ToFEI indicators. The majority (88%) showed no evidence of the use of tobacco products inside the premises. More than half of the schools (58%) adhered to the criteria of not having tobacco shops within 100 yards and 56% reported the inclusion of the "No Use of Tobacco" norm in their guidelines. Schools located in rural areas (p-value <0.01) and those with teachers who attended any tobacco-related workshop were more likely to comply with the ToFEI indicators (p-value 0.05). After relaxing the criteria for 'High Adherence' to at least four indicators, we found that 20% of schools showed high adherence to the ToFEI indicators. CONCLUSION: Overall compliance of schools to the ToFEI guidelines is low in Puducherry. Sensitizing the relevant stakeholders in the district for implementing ToFEI guidelines and institutionalizing tobacco control activities in the school are the needs of the hour.