Association of Rurality With Risk of Heart Failure.

Importance: Rural populations experience an increased burden of heart failure (HF) mortality compared with urban populations. Whether HF incidence is greater among rural individuals is less known. Additionally, the intersection between racial and rural health inequities is understudied. Objective: To determine whether rurality is associated with increased risk of HF, independent of cardiovascular (CV) disease and socioeconomic status (SES), and whether rurality-associated HF risk varies by race and sex. Design, Setting, and Participants: This prospective cohort study analyzed data for Black and White participants of the Southern Community Cohort Study (SCCS) without HF at enrollment who receive care via Centers for Medicare & Medicaid Services (CMS). The SCCS is a population-based cohort of low-income, underserved participants from 12 states across the southeastern United States. Participants were enrolled between 2002 and 2009 and followed up until December 31, 2016. Data were analyzed from October 2021 to November 2022. Exposures: Rurality as defined by Rural-Urban Commuting Area codes at the census-tract level. Main Outcomes and Measures: Heart failure was defined using diagnosis codes via CMS linkage through 2016. Incidence of HF was calculated by person-years of follow-up and age-standardized. Sequentially adjusted Cox proportional hazards regression models tested the association between rurality and incident HF. Results: Among 27 115 participants, the median (IQR) age was 54 years (47-65), 18 647 (68.8%) were Black, and 8468 (32.3%) were White; 5556 participants (20%) resided in rural areas. Over a median 13-year follow-up, age-adjusted HF incidence was 29.6 (95% CI, 28.9-30.5) per 1000 person-years for urban participants and 36.5 (95% CI, 34.9-38.3) per 1000 person-years for rural participants (P < .001). After adjustment for demographic information, CV risk factors, health behaviors, and SES, rural participants had a 19% greater risk of incident HF (hazard ratio [HR], 1.19; 95% CI, 1.13-1.26) compared with their urban counterparts. The rurality-associated risk of HF varied across race and sex and was greatest among Black men (HR, 1.34; 95% CI, 1.19-1.51), followed by White women (HR, 1.22; 95% CI, 1.07-1.39) and Black women (HR, 1.18; 95% CI, 1.08-1.28). Among White men, rurality was not associated with greater risk of incident HF (HR, 0.97; 95% CI, 0.81-1.16). Conclusions and Relevance: Among predominantly low-income individuals in the southeastern United States, rurality was associated with an increased risk of HF among women and Black men, which persisted after adjustment for CV risk factors and SES. This inequity points to a need for additional emphasis on primary prevention of HF among rural populations.

Different Patterns of Risk Reducing Decisions in Affected or Unaffected BRCA Pathogenic Variant Carriers.

PURPOSE: The purpose of this study was to investigate decision patterns to reduce the risks of BRCArelated breast and gynecologic cancers in carriers of BRCA pathogenic variants. We found a change in risk-reducing (RR) management patterns after December 2012, when the National Health Insurance System (NHIS) of Korea began to pay for BRCA testing and riskreducing salpingo-oophorectomy (RRSO) in pathogenic-variant carriers. MATERIALS AND METHODS: The study group consisted of 992 patients, including 705 with breast cancer (BC), 23 with ovarian cancer (OC), 10 with both, and 254 relatives of high-risk patients who underwent BRCA testing at the National Cancer Center of Korea from January 2008 to December 2016.We analyzed patterns of and factors in RR management. RESULTS: Of the 992 patients, 220 (22.2%) were carriers of BRCA pathogenic variants. About 92.3% (203/220) had a family history of BC and/or OC,which significantly differed between BRCA1 and BRCA2 carriers (p < 0.001). All 41 male carriers chose surveillance. Of the 179 female carriers, 59 of the 83 carriers (71.1%) with BC and the 39 of 79 unaffected carriers (49.4%) underwent RR management. None of the carriers affected with OC underwent RR management. Of the management types, RRSO had the highest rate (42.5%) of patient choice. The rate of RR surgery was significantly higher after 2013 than before 2013 (46.3% [74/160] vs. 31.6% [6/19], p < 0.001). CONCLUSION: RRSO was the preferred management for carriers of BRCA pathogenic variants. The most important factors in treatment choice were NHIS reimbursement and/or the severity of illness.

Validation of the Korean version of visual analogue scale for irritable bowel syndrome questionnaire for assessment of defecation pattern changes.

PURPOSE: Patients often complain of change of defecation pattern and it is necessary to quantify their symptoms. To quantify symptoms, use of questionnaire is ideal, so we adopted a simple and easily writable visual analogue scale for irritable bowel syndrome questionnaire (VAS-IBS). The aim of this study was to develop and validate the Korean version of VAS-IBS questionnaire (Korean VAS-IBS) that can adequately reflect the defecation pattern. METHODS: This study translated English VAS-IBS into Korean using the forward-and-back translation method. Korean VAS-IBS was performed on 30 patients, who visited the outpatient clinic and had no possibility of special defecation pattern. Detailed past medical history and Bristol stool chart was added to the questionnaire. The survey was conducted twice, and the median interval between the 2 surveys was 10 days (8-11 days). Cronbach α for internal consistency reliability and intraclass correlation coefficients for test-retest reliability were analyzed. RESULTS: Korean VAS-IBS achieved acceptable homogeneity with a Cronbach α coefficient of 0.66-0.79 showing adequate internal consistency reliability. In addition, intraclass correlation coefficients showed significant test-retest reliability with 0.46-0.80 except for the question assessing the "perception of psychological wellbeing." CONCLUSION: The Korean VAS-IBS is a valid and reliable questionnaire for the measurement of the symptoms of defecation pattern changes.

The De Ritis and Neutrophil-to-Lymphocyte Ratios May Aid in the Risk Assessment of Patients with Metastatic Renal Cell Carcinoma.

PURPOSE: This study aimed to determine whether baseline blood inflammatory markers can predict progression-free survival (PFS) and overall survival (OS) in patients with metastatic renal cell carcinoma (mRCC). METHODS: The study included 158 patients with mRCC treated with first-line targeted therapy between 2002 and 2016. A multivariable cox proportional hazards model identified inflammatory factors that predict PFS and OS. Using bootstrap method, new prognostic model compared with Heng and modified MSKCC risk model (mMSKCC). The effect of inflammatory factors were investigated by comparing increased C-index adding significant inflammatory factors to Heng and mMSKCC model. RESULTS: On multivariable analysis, nephrectomy (HR 0.48), NLR (HR 1.04), were significant risk factors for PFS; nephrectomy (HR 0.38), hemoglobin (HR 1.71), alkaline phosphatase (HR 1.73), NLR (HR 1.01) and DRR (HR 1.34), were significant factors for OS (p<0.05). Our new model that incorporated NLR and DRR had higher (though insignificant) predictability (C-index=0.610) than mMSKCC risk model (C-index=0.569) in PFS and significantly better predictability (C-index=0.727) than Heng and mMSKCC risk model (C-index, 0.661, 0.612, respectively) in OS. Adding inflammatory factors to the Heng criteria (C-index, 0.697 for OS) and MSKCC (0.691 for OS) tended to improve their predictive abilities. CONCLUSIONS: The NLR and DRR may increase predictive ability compared to the established Heng and mMSKCC risk models in mRCC.

Assessment of Breast Cancer Patients' Knowledge and Decisional Conflict Regarding Tamoxifen Use.

Breast cancer is the most common type of female cancer. Tamoxifen, a selective estrogen receptor modulator, is widely used to decrease breast cancer recurrence and mortality among patients. However, it also increases the risk of endometrial cancer. This study aimed to assess knowledge and decisional conflict regarding tamoxifen use. Between June and October 2014, breast cancer patients using tamoxifen were consecutively screened and requested to complete a survey including the EQ-5D, Satisfaction with Decision Scale (SWD), Decisional Conflict Scale (DCS), and a self-developed, 15-item questionnaire measuring tamoxifen-related knowledge. The study sample comprised 299 patients. The mean total knowledge score was 63.4 of a possible 100.0 (range, 13.3-93.3). While 73.9% of the participants knew that tamoxifen reduces the risk of breast cancer recurrence, only 57.9% knew that the drug increases endometrial cancer risk. A higher education level (≥ college) was associated with a higher, total knowledge score (ß = 4.291; P = 0.017). A higher knowledge score was associated with a decreased DCS score (ß = -0.366; P < 0.001). A higher SWD score was also associated with decreased decisional conflict (ß = -0.178; P < 0.001). In conclusion, the breast cancer patients with higher levels of tamoxifen-related knowledge showed lower levels of decisional conflict regarding tamoxifen use. Clinicians should provide the exact information about tamoxifen treatment to patients, based on knowledge assessment results, so as to aid patients' decision-making with minimal conflict.

Impact of lower limb lymphedema on quality of life in gynecologic cancer survivors after pelvic lymph node dissection.

OBJECTIVE: To evaluate the impact of lower limb lymphedema (LLL) on quality of life (QOL) in cervical, ovarian, and endometrial cancer survivors after pelvic lymph node dissection. STUDY DESIGN: A cross-sectional case-control study was performed using the Korean version of the Gynecologic Cancer Lymphedema Questionnaire (GCLQ-K) and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30). In total, 25 women with LLL and 28 women without LLL completed both questionnaires. RESULTS: The GCLQ-K total symptom score and scores for swelling-general, swelling-limb, and heaviness were significantly higher in the LLL group than in the control group. In the EORTC QLQ-C30, the LLL group reported more financial difficulties compared to the control group (mean score, 16.0 vs. 6.0; P=0.035). Global health status was poorer in the LLL group with borderline statistical significance (mean score, 62.7 vs. 71.4; P=0.069). Spearman's correlations suggested that global health status in the EORTC QLQ-C30 correlated with the GCLQ-K total symptom score (in the LLL group, R=-0.64, P=0.001; in the control group, R=-0.42, P=0.027). CONCLUSIONS: QOL decreases due to LLL-related symptoms and financial difficulty in women with LLL. Well-designed prospective studies are required to confirm these findings.

Development and evaluation of Korean version of Quality of Sexual Function (QSF-K) in healthy Korean women.

This study was done to develop a Korean version of the Quality of Sexual Function (QSF-K) and evaluate the validity and reliability of the QSF-K. The participants were 220 women who visited the Center for Uterine Cancer at the National Cancer Center in Korea. Participants completed the scale once and then again at a two to four week interval. The QSF-K, Female Sexual Function Index (FSFI) and European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC-QLQ-C30) were used in this study. Receiver operating characteristics (ROC) curve, area under the ROC curve (AUC), intraclass correlation coefficients (ICC), and Cronbach's alpha were analyzed. In the analysis of the reliability, Cronbach's alpha was 0.83 and the ICC was 0.70. The validity measured with the AUC of the QSF-K comparing the FSFI and Global Health/QOL of the EORTC-QLQ-C30 was 0.717 and 0.728, respectively. Specifically, the AUC of the sexual activity level of the QSF-K was 0.838 in the FSFI comparison. The AUC of the psycho-somatic QOL of the QSF-K was 0.758 in the Global Health/QOL of the EORTC-QLQ-C30 comparison. Approximately half of the women (51.8%) had mild complaints/problems. The Korean version of the QSF was developed and validated.

Risk prediction model for colorectal cancer: National Health Insurance Corporation study, Korea.

PURPOSE: Incidence and mortality rates of colorectal cancer have been rapidly increasing in Korea during last few decades. Development of risk prediction models for colorectal cancer in Korean men and women is urgently needed to enhance its prevention and early detection. METHODS: Gender specific five-year risk prediction models were developed for overall colorectal cancer, proximal colon cancer, distal colon cancer, colon cancer and rectal cancer. The model was developed using data from a population of 846,559 men and 479,449 women who participated in health examinations by the National Health Insurance Corporation. Examinees were 30-80 years old and free of cancer in the baseline years of 1996 and 1997. An independent population of 547,874 men and 415,875 women who participated in 1998 and 1999 examinations was used to validate the model. Model validation was done by evaluating its performance in terms of discrimination and calibration ability using the C-statistic and Hosmer-Lemeshow-type chi-square statistics. RESULTS: Age, body mass index, serum cholesterol, family history of cancer, and alcohol consumption were included in all models for men, whereas age, height, and meat intake frequency were included in all models for women. Models showed moderately good discrimination ability with C-statistics between 0.69 and 0.78. The C-statistics were generally higher in the models for men, whereas the calibration abilities were generally better in the models for women. CONCLUSIONS: Colorectal cancer risk prediction models were developed from large-scale, population-based data. Those models can be used for identifying high risk groups and developing preventive intervention strategies for colorectal cancer.