Association of Maternal Cervical Cancer Screening Adherence with Adolescent HPV Vaccination Among Adolescent-Mother Pairs.

Less than two-thirds of US adolescents are up-to-date with HPV vaccination. While mothers engaged in preventive care are more likely to seek preventive care for their children, current studies on associations between maternal cervical cancer screening (CCS) and adolescent HPV vaccination are needed. We assessed associations between maternal preventive service utilization and adolescent HPV vaccination using electronic health record data from a healthcare system in Washington State. We included adolescents (11-17 years) and their mothers with ≥ 1 primary care visit between 2018 and 2020. Outcomes were HPV vaccine initiation and completion. The primary exposure was maternal adherence to guideline-recommended CCS. Secondary exposures were maternal breast cancer screening adherence (for mothers ≥ 52 years) and ≥ 1 wellness visit ≤ 2 years. We used Generalized Estimating Equations to estimate prevalence ratios, and explore effect modification by adolescent sex, adolescent provider characteristics, and maternal language interpreter use. Of 4121 adolescents, 66% had a CCS-adherent mother, 82% initiated HPV vaccination, and 49% completed the series. CCS adherence was associated with higher initiation (adjusted prevalence ratio (APR):1.10, 95%CI:1.06-1.13) and completion (APR:1.16, 95%CI:1.08-1.23). Associations were stronger for male vs. female adolescents, adolescents who had a primary care provider in family practice vs. pediatrics, and adolescents who had the same primary care provider as their mother vs. not. Recent maternal wellness visit was also associated with higher initiation (APR:1.04, 95%CI:1.01-1.07) and completion (APR:1.12, 95%CI:1.05-1.20). Results suggest that delivering healthcare through a family-centered approach and engaging mothers in broad preventive care could increase adolescent HPV vaccination coverage.

Prioritizing rural populations in state comprehensive cancer control plans: a qualitative assessment.

PURPOSE: The Centers for Disease Control and Prevention's National Comprehensive Cancer Control Program (NCCCP) requires that states develop comprehensive cancer control (CCC) plans and recommends that disparities related to rural residence are addressed in these plans. The objective of this study was to explore rural partner engagement and describe effective strategies for incorporating a rural focus in CCC plans. METHODS: States were selected for inclusion using stratified sampling based on state rurality and region. State cancer control leaders were interviewed about facilitators and barriers to engaging rural partners and strategies for prioritizing rural populations. Content analysis was conducted to identify themes across states. RESULTS: Interviews (n = 30) revealed themes in three domains related to rural inclusion in CCC plans. The first domain (barriers) included (1) designing CCC plans to be broad, (2) defining "rural populations," and (3) geographic distance. The second domain (successful strategies) included (1) collaborating with rural healthcare systems, (2) recruiting rural constituents, (3) leveraging rural community-academic partnerships, and (4) working jointly with Native nations. The third domain (strategies for future plan development) included (1) building relationships with rural communities, (2) engaging rural constituents in planning, (3) developing a better understanding of rural needs, and (4) considering resources for addressing rural disparities. CONCLUSION: Significant relationship building with rural communities, resource provision, and successful strategies used by others may improve inclusion of rural needs in state comprehensive cancer control plans and ultimately help plan developers directly address rural cancer health disparities.

Euglycemic Diabetic Ketoacidosis Caused by Alcoholic Pancreatitis and Starvation Ketosis.

Starvation ketosis and pancreatitis are uncommon and underrecognized etiologies of euglycemic diabetic ketoacidosis (DKA). Euglycemic DKA is associated commonly with pregnancy, use of insulin en route to the hospital, and use of sodium-glucose cotransporter-2 (SGLT-2) inhibitors. A 58-year-old male with past medical history of type II diabetes mellitus and alcoholism presented with chief complaint of nausea, vomiting, and poor oral intake for several weeks. Despite extensive history of diabetes and no recent SGLT-2 inhibitor use, his labs were consistent with euglycemic DKA. His imaging and clinical history also confirmed alcoholic pancreatitis. The patient was admitted for euglycemic DKA secondary to starvation ketosis and alcoholic pancreatitis. His anion gap and beta-hydroxybutyrate rapidly cleared with initiation of the DKA protocol. This case teaches us that clinicians should consider early initiation of the DKA protocol even in the setting of euglycemia, when a patient presents with high-anion-gap metabolic acidosis, a high beta-hydroxybutyrate level, and a clinical picture of pancreatitis and starvation.

Provider Perspectives on Addressing Firearm Safety with Older Adults in Primary Care.

OBJECTIVES: Chronic conditions, including mild cognitive impairment and depression, place older adults at high risk of firearm suicide. Approximately 40% of older adults have access to a firearm, and many do not store their firearms safely. However, firearm counseling occurs infrequently in clinical settings. Using by the Ottawa Decision Support Framework (ODSF) to conceptualize the decisional support needed by patients and their providers to facilitate firearm counseling, we explore provider perspectives on desired resources for addressing firearm safety with older adult patients. METHODS: From March - August 2022, we conducted 21 semi-structured interviews with primary care providers caring for older adults. We report deductive concepts as well as emergent themes. RESULTS: Major themes were identified from the three components of the ODSF; decisional needs, decision support and decisional outcomes. Themes included: provider self-efficacy to conduct firearm counseling, clinical workflow considerations, stories for change, patient diagnosis implications, and caregiver involvement. CONCLUSIONS: There is a need for decision aids in the clinical setting that facilitate firearm counseling and promotes shared decision-making about firearm storage. CLINICAL IMPLICATIONS: Implementing a decision aid in the clinical setting can improve provider self-efficacy to conduct firearm counseling and help reduce risk factors associated with firearm-related harm among older adults.

How cancer programs identify and address the financial burdens of rural cancer patients.

PURPOSE: Financial toxicity is associated with negative patient outcomes, and rural populations are disproportionately affected by the high costs of cancer care compared to urban populations. Our objective was to (1) understand cancer programs' perceptions of rural-urban differences in cancer patients' experiences of financial hardship, (2) evaluate the resources available to cancer patients across the rural-urban continuum, and (3) determine how rural and urban health care teams assess and address financial distress in cancer patients. METHODS: Seven research teams within the Cancer Prevention and Research Control Network conducted semi-structured interviews with cancer program staff who have a role in connecting cancer patients with financial assistance services in both rural and urban counties. Interviews were audio-recorded and transcribed. We identified themes using descriptive content and thematic analysis. RESULTS: We interviewed 35 staffs across 29 cancer care programs in seven states, with roughly half of respondents from programs in rural counties. Participants identified differences in rural and urban patients' experiences of financial hardship related to distance required to travel for treatment, underinsurance, and low socioeconomic status. Insufficient staffing was an identified barrier to addressing rural and urban patients' financial concerns. CONCLUSIONS: Improved financial navigation services could mitigate the effects of financial toxicity experienced by cancer patients, particularly rural patients, throughout treatment and survivorship. Future research is needed to improve how cancer programs assess financial hardship in patients and to expand financial navigation services to better serve rural cancer patients.

Microglia in the Brain Tumor Microenvironment.

Microglia are the brain resident phagocytes that act as the primary form of the immune defense in the central nervous system. These cells originate from primitive macrophages that arise from the yolk sac. Advances in imaging and single-cell RNA-seq technologies provided new insights into the complexity of microglia biology.Microglia play an essential role in the brain development and maintenance of brain homeostasis. They are also crucial in injury repair in the central nervous system. The tumor microenvironment is complex and includes neoplastic cells as well as varieties of host and infiltrating immune cells. Microglia are part of the glioma microenvironment and play a critical part in initiating and maintaining tumor growth and spread. Microglia can also act as effector cells in treatments against gliomas. In this chapter, we summarize the current knowledge of how and where microglia are generated. We also discuss their functions during brain development, injury repair, and homeostasis. Moreover, we discuss the role of microglia in the tumor microenvironment of gliomas and highlight their therapeutic implications.

Reduced Cell Division Control Protein 42 Activity Compromises Hematopoiesis-Supportive Function of Fanconi Anemia Mesenchymal Stromal Cells.

Hematopoietic stem cells preserve their ability to self-renew and differentiate to different lineages in the bone marrow (BM) niche, which is composed in large part by BM stromal cells. Studies have shown that altered signaling in the BM niche results in leukemia initiation or progression. Fanconi anemia (FA) is an inherited BM failure syndrome associated with extremely high risk of leukemic transformation. By using two FA mouse models, here we have investigated the hematopoiesis-supportive function of FA BM mesenchymal stroma cells (MSCs). We found that MSCs deficient for Fanca or Fancc gene are defective in proliferation and prone to undergo senescence in vitro. Mechanistically, we show that the activity of cell division control protein 42 (Cdc42), a Rho GTPase known to be a critical regulator for cytoskeleton organization, is significantly reduced in FA MSCs. Furthermore, we demonstrate that this reduction in Cdc42 activity plays a causal role in defective hematopoiesis-supportive function of the FA MSCs. The progenies of wild-type hematopoietic stem and progenitor cells cocultured on FA MSCs exhibit compromised self-renewal capacity both in vitro and in vivo. Genetic correction of FA deficiency restores Cdc42 activity and improves the hematopoiesis-supportive capacity of FA MSC. Finally, ectopic expression of a constitutively active Cdc42 mutant, Cdc42F28L, or pretreatment with Wnt5a, increases the active Cdc42 level and rescues the hematopoietic supportive defects of FA MSCs. Taken together, our results identify a novel link between Cdc42 activity and the hematopoiesis-supportive function of MSCs and suggest that a niche-specific increase of Cdc42 activity may be beneficial for FA therapy. Stem Cells 2018;36:785-795.

Patient navigator reported patient barriers and delivered activities in two large federally-funded cancer screening programs.

Few data are available on patient navigators (PNs) across diverse roles and organizational settings that could inform optimization of patient navigation models for cancer prevention. The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) and the Colorectal Cancer and Control Program (CRCCP) are two federally-funded screening programs that support clinical- and community-based PNs who serve low-income and un- or underinsured populations across the United States. An online survey assessing PN characteristics, delivered activities, and patient barriers to screening was completed by 437 of 1002 identified PNs (44%). Responding PNs were racially and ethnically diverse, had varied professional backgrounds and practice-settings, worked with diverse populations, and were located within rural and urban/suburban locations across the U.S. More PNs reported working to promote screening for breast/cervical cancers (BCC, 94%) compared to colorectal cancer (CRC, 39%). BCC and CRC PNs reported similar frequencies of individual- (e.g., knowledge, motivation, fear) and community-level patient barriers (e.g., beliefs about healthcare and screening). Despite reporting significant patient structural barriers (e.g., transportation, work and clinic hours), most BCC and CRC PNs delivered individual-level navigation activities (e.g., education, appointment reminders). PN training to identify and champion timely and patient-centered adjustments to organizational policies, practices, and norms of the NBCCEDP, CRCCP, and partner organizations may be beneficial. More research is needed to determine whether multilevel interventions that support this approach could reduce structural barriers and increase screening and diagnostic follow-up among the marginalized communities served by these two important cancer-screening programs.

An application of the Science Impact Framework to the Cancer Prevention and Control Research Network from 2014-2018.

The Cancer Prevention and Control Research Network (CPCRN) is a strategic collaborative effort focused on accelerating the dissemination and implementation of evidence-based cancer prevention and control interventions to communities. In 2014, the CPCRN Coordinating Center began collecting information in alignment with the Centers for Disease Control and Prevention's (CDC) Science Impact Framework. The Science Impact Framework is a CDC-developed approach to trace and link CDC science to events and/or actions recognized as influential to public health, beyond peer-reviewed publications. The purpose of this paper is to highlight the impact of CPCRN activities using key indicators guided by the CDC's Science Impact Framework. We reviewed annual progress reports submitted by CPCRN centers from 2014 to 2019 to identify the impact indicators. The CPCRN activities were linked to four domains from the Science Impact Framework and its key indicators: Disseminating Science (presentations, training, general communication, and other communication reports), Creating Awareness (requests for expertise, and feedback), Catalyzing Action (grant applications, partnerships and collaborations, research & development, advocacy groups, office practice/point of care changes, and technology creating), and Effecting Change (building public health practice, creation of registries/surveillance, legal/policy changes, and change instilled). Overall, CPCRN activities demonstrate impact beyond peer-reviewed publications and thus should continue building scientific impact to ultimately influence health outcomes.

Flavorings-Related Lung Disease: A Brief Review and New Mechanistic Data.

Flavorings-related lung disease is a potentially disabling and sometimes fatal lung disease of workers making or using flavorings. First identified almost 20 years ago in microwave popcorn workers exposed to butter-flavoring vapors, flavorings-related lung disease remains a concern today. In some cases, workers develop bronchiolitis obliterans, a severe form of fixed airways disease. Affected workers have been reported in microwave popcorn, flavorings, and coffee production workplaces. Volatile α-dicarbonyl compounds, particularly diacetyl (2,3-butanedione) and 2,3-pentanedione, are implicated in the etiology. Published studies on diacetyl and 2,3-pentanedione document their ability to cause airway epithelial necrosis, damage biological molecules, and perturb protein homeostasis. With chronic exposure in rats, they produce airway fibrosis resembling bronchiolitis obliterans. To add to this knowledge, we recently evaluated airway toxicity of the 3-carbon α-dicarbonyl compound, methylglyoxal. Methylglyoxal inhalation causes epithelial necrosis at even lower concentrations than diacetyl. In addition, we investigated airway toxicity of mixtures of diacetyl, acetoin, and acetic acid, common volatiles in butter flavoring. At ratios comparable to workplace scenarios, the mixtures or diacetyl alone, but not acetic acid or acetoin, cause airway epithelial necrosis. These new findings add to existing data to implicate α-dicarbonyl compounds in airway injury and flavorings-related lung disease.

Family Medicine-Specific Practice-Based Research Network Productivity and Clinical and Translational Sciences Award Program Affiliation.

OBJECTIVE: Practice-based research networks (PBRNs) are groups of practices that work together to conduct research. Little is known about the degree to which PBRNs may be achieving success. This is the first general survey of family medicine-based PBRN directors in the United States and Canada to examine research productivity outcomes of PBRNs and explore the association between Clinical and Translational Science Awards (CTSA) program affiliation and PBRN outcomes. METHODS: The Council of Academic Family Medicine Educational Research Alliance conducted the survey and e-mailed it to 102 PBRN directors from the Agency for Healthcare Research and Quality's registration. RESULTS: A total of 54 (56%) PBRN directors responded to the survey. PBRNs with an affiliation with a CTSA program were more likely to report completion of quality improvement research and participation in multiple PBRN collaboration research projects. PBRNs affiliated with CTSA programs were less likely to report maintaining funding as a significant barrier. CONCLUSIONS: CTSA involvement with PBRNs results in family physician scientists' completing research and disseminating this research through publication. Also, PBRNs with CTSA partnerships have more funding availability. PBRN partnership with a CTSA is beneficial in furthering research in family medicine.

Adaptation of an Evidence-Based Colorectal Cancer Screening Program Using the Consolidated Framework for Implementation Research.

INTRODUCTION: Federally Qualified Health Centers (FQHCs) provide primary care to low-income and uninsured patients in the United States. FQHCs are required to report annual measurements and provide evidence of improvement for quality measures; effective methods to improve quality in FQHCs are needed. Systems of Support (SOS) is a proactive, mail-based, colorectal cancer screening program that was developed and tested in an integrated health care system. The objective of this study was to adapt SOS for use in an FQHC system, guided by the Consolidated Framework for Implementation Research (CFIR). METHODS: We conducted qualitative semi-structured interviews in 2014 with organizational leadership, medical staff, and nursing staff to identify facilitators of and barriers to implementation of SOS in an FQHC system. The interview guide was based on the CFIR framework. Interview transcripts were analyzed using Template Analysis. We adapted SOS and planned implementation strategies to address identified barriers. RESULTS: Facilitators of implementation of SOS were previous quality improvement experience and engagement of clinic and administrative leadership. Barriers to implementation were a more diverse patient population, a decentralized administrative structure, and communication challenges throughout the organization. Program adaptations focused on patient instructions and educational materials as well as elimination of follow-up phone calls. Implementation strategies included early and frequent engagement with organizational leadership and a smaller pilot program before organization-wide implementation. CONCLUSIONS: Use of CFIR identified facilitators of and barriers to implementation of the evidence-based colorectal cancer screening program. Program adaptations and implementation strategies based on this study may generalize to other FQHC systems that are considering implementation of a proactive, mail-based colorectal cancer screening program.

Pakikisama: Filipino Patient Perspectives on Health Care Access and Utilization.

PURPOSE: Filipinos have unique social determinants of health, cultural values, and beliefs that contribute to a higher prevalence of cardiovascular comorbidities such as hypertension, diabetes, and dyslipidemia. We aimed to identify Filipino values, practices, and belief systems that influenced health care access and utilization. METHODS: We conducted 1-on-1 semistructured interviews with self-identified Filipino patients. Our qualitative study utilized a constant-comparative approach for data collection, thematic coding, and interpretive analysis. RESULTS: We interviewed 20 Filipinos in a remote rural community to assess structural and social challenges experienced when interacting with the health care system. Our results suggest that Filipinos regard culture and language as pillars of health access. Filipinos trust clinicians who exhibited positive tone and body language as well as relatable and understandable communication. These traits are features of Pakikisama, a Filipino trait/value of "comfortableness and getting along with others." Relatability and intercultural values familiarity increased Filipino trust in a health care clinician. Filipinos may lack understanding about how to navigate the US Health care system, which can dissuade access to care. CONCLUSIONS: For the Filipino community, culture and language are fundamental components of health access. Health care systems have the opportunity to both improve intercultural clinical training and increase representation among clinicians and support staff to improve care delivery and navigation of health services. Participants reported not routinely relying on health care navigators.

Implementation Strategies Used by Facilitators to Improve Control of Cardiovascular Risk Factors in Primary Care.

BACKGROUND: Practice facilitation supports practice change in clinical settings. Despite its widespread use little is known about how facilitators enable change. OBJECTIVE: This study identifies which implementation strategies practice facilitators used and the frequency of their use in a study to improve the quality of cardiovascular care in primary care. DESIGN: Cross-sectional analysis of data collected by practice facilitators in the Healthy Hearts Northwest (H2N) study. PARTICIPANTS: Notes collected by facilitators in the H2N study. APPROACH: We coded these field notes for a purposeful sample of 44 practices to identify Expert Recommendations for Implementation Change (ERIC) strategies used with each practice and calculated the proportion of practices where each implementation strategy was coded at least once. Strategies were categorized as foundational (used in 80% to 100% of practices), moderately used (20%-<80% of practices), rarely used (1-[Formula: see text]% of practices), or absent (0%). KEY RESULTS: We identified 26 strategies used by facilitators. Five strategies were foundational: Develop and/or implement tools for quality monitoring, Assess barriers that may impede implementation, Assess for readiness or progress, Develop and support teams, and Conduct educational meetings. CONCLUSIONS: Commonly used strategies can help guide development of the core components of practice facilitation strategies.

Adherence and Correlates of Cervical Cancer Screening Among East African Immigrant Women in Washington State.

INTRODUCTION: Cervical cancer screening (CCS) among East African immigrants (EAI) in the USA is under explored. This study aimed to investigate adherence to CCS and its correlates among EAI. METHODS: We identified 1664 EAI women (25-65 years) with ≥ 1 primary care clinic visit(s) between 2017 and 2018, using University of Washington (UW) Medicine electronic health record data. CCS adherence was defined as Pap testing within 3 years or human papillomavirus/Pap co-testing within 5 years. We used Poisson regression with robust standard errors to cross-sectionally estimate associations with correlates of adherence. Twelve-month screening uptake was also evaluated among overdue women. RESULTS: CCS adherence was 63%. Factors associated with higher adherence included older age (adjusted prevalence ratios [APRs]:1.47:95%CI:1.14-1.90, 1.38:95%CI:1.05-1.80, respectively, for ages 30-39 and 40-49 vs 25-29 years), longer duration of care at UW Medicine (APR:1.22:95%CI:1.03-1.45, comparing > 10 vs < 5 years), higher visit frequency (APR:1.23:95%CI:1.04-1.44, 1.46:95%CI:1.24-1.72, respectively, for 3-5 and ≥ 6 vs 1-2 visits), index visit in an obstetrics-gynecology clinic (APR:1.26:95%CI:1.03-1.55, vs family practice), having an assigned primary care provider (APR:1.35: 95%CI:1.02-1.79), breast cancer screening adherence (APR:1.66: 95%CI:1.27-2.17), and colorectal cancer screening adherence (APR:1.59:95%CI:1.24-2.03). Low BMI was associated with lower adherence (APR:0.50:95%CI:0.26-0.96, comparing < 18.5 kg/m2 vs 18.5-24.9 kg/m2). Among 608 (37%) overdue women, 9% were screened in the subsequent 12 months. Having commercial health insurance vs Medicare/Medicaid was associated with higher uptake (adjusted risk ratio:2.44:95%CI:1.15-5.18). CONCLUSION: CCS adherence among EAI was lower than the national average of 80%. Interventions focused on increasing healthcare access/utilization or leveraging healthcare encounters to address barriers could increase CCS in EAIs.

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.

MigraineTracker: Examining Patient Experiences with Goal-Directed Self-Tracking for a Chronic Health Condition.

Self-tracking and personal informatics offer important potential in chronic condition management, but such potential is often undermined by difficulty in aligning self-tracking tools to an individual's goals. Informed by prior proposals of goal-directed tracking, we designed and developed MigraineTracker, a prototype app that emphasizes explicit expression of goals for migraine-related self-tracking. We then examined migraine patient experiences in a deployment study for an average of 12+ months, including a total of 50 interview sessions with 10 patients working with 3 different clinicians. Patients were able to express multiple types of goals, evolve their goals over time, align tracking to their goals, personalize their tracking, reflect in the context of their goals, and gain insights that enabled understanding, communication, and action. We discuss how these results highlight the importance of accounting for distinct and concurrent goals in personal informatics together with implications for the design of future goal-directed personal informatics tools.

Improving age-friendly advance care planning in primary care: Outcomes from a Pacific Northwest learning collaborative.

BACKGROUND: Advance care planning (ACP) is the process of having conversations with patients to ensure preferences are known and support patient healthcare goals. ACP and the Age-Friendly Health Systems (AFHS) Initiative's, "What Matters," are synergistic approaches to patient-centered conversations. Implementation and measurement of ACP in primary care (PC) are variables in quality and consistency. We examined whether participation in an ACP learning collaborative (LC) would improve knowledge and ability to conduct ACP discussions and increase the frequency of documented ACP in participating practices. METHODS: The WWAMI (Washington, Wyoming, Alaska, Montana, and Idaho) region Practice and Research Network (WPRN) and the Northwest Geriatrics Workforce Enhancement Center collaboratively organized a 9-month virtual LC. It consisted of 4 synchronous, 1.5-h sessions, technical support, and a panel of ACP experts. A Wilcoxon rank sum test assessed differences in knowledge from a pre-post survey. Documentation of ACP in the EHR was collected after at least one plan-do-study-act cycle. RESULTS: We enrolled 17 participants from 6 PC practices (3 hospital-affiliated; 3 Federally Qualified Health Centers) from the WPRN. Two practices did not complete all LC activities. There was a trend toward increased ACP knowledge and skills overall especially in having discussions patients and families (pre-mean 2.9 [SD = 0.7]/post-mean 4.0[SD = 1.1], p < 0.05). 4/6 practices observed an increase in EHR documentation post-collaborative (median 16.3%, IQR 1.3%-36.9%). CONCLUSIONS: The LC increased PC providers knowledge and skills of ACP and AFHS's What Matters, reported ACP EHR documentation, and contributed to practice change.

From mole to scar: the unintended consequence of treatment with an over-the-counter mole removal cream.

A 26-year-old man presented with a scar at the site of a pigmented lesion treated with DermaTend (Solace Interntational, Inc., Reno, NV), an over-the-counter mole removal cream. According to the patient, the pigmented lesion had been present since childhood, was asymptomatic, and had not changed in appearance. It remained cosmetically displeasing to him. In an effort to remove the lesion, he had applied DermaTend on a daily basis for several weeks, at which point he noticed a scar at the site of treatment.