Mortality risk from comorbidities independent of triple-negative breast cancer status: NCI-SEER-based cohort analysis.

PURPOSE: A comparatively high prevalence of comorbidities among African-American/Blacks (AA/B) has been implicated in disparate survival in breast cancer. There is a scarcity of data, however, if this effect persists when accounting for the adverse triple-negative breast cancer (TNBC) subtype which occurs at threefold the rate in AA/B compared to white breast cancer patients. METHODS: We reviewed charts of 214 white and 202 AA/B breast cancer patients in the NCI-SEER Connecticut Tumor Registry who were diagnosed in 2000-2007. We employed the Charlson Co-Morbidity Index (CCI), a weighted 17-item tool to predict risk of death in cancer populations. Cox survival analyses estimated hazard ratios (HRs) for all-cause mortality in relation to TNBC and CCI adjusting for clinicopathological factors. RESULTS: Among patients with SEER local stage, TNBC increased the risk of death (HR 2.18, 95 % CI 1.14-4.16), which was attenuated when the CCI score was added to the model (Adj. HR 1.50, 95 % CI 0.74-3.01). Conversely, the adverse impact of the CCI score persisted when controlling for TNBC (Adj. HR 1.49, 95 % CI 1.29-1.71; per one point increase). Similar patterns were observed in SEER regional stage, but estimated HRs were lower. AA/B patients with a CCI score of ≥3 had a significantly higher risk of death compared to AA/B patients without comorbidities (Adj. HR 5.65, 95 % CI 2.90-11.02). A lower and nonsignificant effect was observed for whites with a CCI of ≥3 (Adj. HR 1.90, 95 % CI 0.68-5.29). CONCLUSIONS: comorbidities at diagnosis increase risk of death independent of TNBC, and AA/B patients may be disproportionately at risk.

Social Determinants and COVID-19 in a Community Health Center Cohort.

Associations between social determinants of health (SDOH), demographic factors including preferred language, and SARS-CoV-2 detection are not clear. We conducted a retrospective cohort study among those seeking testing for SARS-CoV-2 at a multi-site, urban community health center. Logistic regression and exact matching methods were used to identify independent predictors of SARS-CoV-2 detection among demographic, SDOH, and neighborhood-level variables. Of 1,361 included individuals, SARS-CoV-2 was detected among 266 (19.5%). Logistic regression demonstrated that SARS-CoV-2 detection was less likely in White participants relative to Hispanic participants (adjusted odds ratio [aOR] 0.18, 95% confidence interval [CI] 0.05-0.46). and more likely in patients who prefer Spanish relative to those that prefer English (aOR 2.04, 95% CI 1.43-2.96). No observed SDOH predicted SARS-CoV-2 detection in adjusted models. A robustness analysis using a matched subset of the study sample produced findings similar to those in the main analysis. Preferring to receive care in Spanish is an independent predictor of SARS-CoV-2 detection in a community health center cohort.

Patterns of Opioid Prescribing and Predictors of Chronic Opioid Use in an Industrial Cohort, 2003 to 2013.

OBJECTIVE: To appreciate the impact of the opioid epidemic in workers, we described opioid prescription patterns in a US industrial cohort over a 10-year period and assessed predictors of chronic prescription. METHODS: A multiyear (2003 to 2013) cross-sectional analysis of employer-sponsored health care claims for enrolled workers (N: 21,357 to 44,769) was performed. RESULTS: The proportion of workers prescribed opioids nearly doubled in the 10-year period. The strongest predictor of chronic opioid prescribing was year, with an increase in prescriptions each year from 2003 to 2013 (odds ratio = 2.90, 95% confidence interval: 2.41 to 3.48). Additional predictors included older age, white race, hourly wage, low back pain, and osteoarthritis. CONCLUSIONS: Opioid prescribing for industrial workers substantially increased from 2003 to 2013. Occupational health professionals should be aware of the potential for chronic opioid use among workers to assess job safety and appropriate treatment of work-related injuries.

Responsibilities of the Occupational and Environmental Medicine Provider in the Treatment and Prevention of Climate Change-Related Health Problems.

: Workers are uniquely susceptible to the health hazards imposed by environmental changes. Occupational and environmental medicine (OEM) providers are at the forefront of emerging health issues pertaining to working populations including climate change, and must be prepared to recognize, respond to, and mitigate climate change-related health effects in workers. This guidance document from the American College of Occupational and Environmental Medicine focuses on North American workers health effects that may occur as a result of climate change and describes the responsibilities of the OEM provider in responding to these health challenges.

Community-based Participatory Research Is Needed to Address Pulmonary Health Disparities.

Socioeconomic and racial disparities in the outcomes of medical management remain common across pulmonary diseases in the United States and worldwide. Acknowledging this, the American Thoracic Society recently put forth recommendations to advance respiratory health equity. Through engagement of vulnerable communities in search of collaborative solutions to improve health disparities, community-based participatory research embodies concepts essential to the American Thoracic Society mission for respiratory health equity. The purpose of this commentary is to provide an overview of the principles of community-based participatory research and the application of this approach to addressing inequity in the outcomes of treatment for lung disease. Community-based participatory research aims to decrease health disparities by recognizing the social and ecological paradigms of health care and by partnering community members with academic researchers in all aspects of the research process. Community partners are uniquely poised to offer insight into local culture, circumstances that guide health behaviors, and other challenges to improve their own community's health. Sustainable interventions, either through strengthening existing community assets or through community empowerment and local capacity building throughout the research process, are essential to the success of community-based participatory research. The National Institutes of Health and other funding agencies offer funding opportunities to support specific interventions aimed at engaging community members in the research process. In pulmonary medicine, community-based initiatives have focused primarily on improving pediatric asthma outcomes. Using a community-based approach in adult asthma and other pulmonary diseases could be an ideal manner in which to decrease pulmonary health disparities.

Trophic transition in a lake on the Virginia coastal plain.

To examine possible connections between lake trophic status and runoff from surrounding subwatersheds, we determined patterns of sediment and nutrient deposition in a hypereutrophic, 16-ha impoundment on the Virginia coastal plain. Spatial survey of nutrients in surface sediments documented a strong correlation between total P and extractable Fe (r2 = 0.53). Elevated biogenic silica concentrations up to 0.25% by weight were measured in sections of the lake receiving perennial stream discharge. Sediment C to N ratios were > 20 in those same sections, suggesting a large allochthonous contribution to organic matter deposition. Sediment cores 0.9 to 2.3 m in length, representing 70 years of deposition, were analyzed to develop vertical profiles of changes in sediment and nutrient deposition in deltas downstream from two more-developed and three less-developed subwatersheds (with 49 and 9% commercial and residential development, respectively). The average sediment weight percent +/- standard deviation of biogenic silica (0.027 +/- 0.037 vs. 0.009 +/- 0.006%) and total P (0.040 +/- 0.025 vs. 0.024 +/- 0.019%) was significantly higher downstream of more-developed subwatersheds. Using elevated P loadings and biogenic silica deposition as proxies for algal production, transition of the lake to its current hypereutrophic state appears to have occurred in the last 70 yr. Changes in trophic status as revealed by sediment analysis of this small lake on the Virginia coastal plain reflect a common pattern of eutrophication observed for the entire Chesapeake Bay drainage basin. Analysis of sediments from stream deltas appears to be a reasonable strategy for identifying and targeting subwatershed areas needing better management of nutrient runoff that otherwise would lead to eutrophication of downstream waters.

Integrating improvement learning into a family medicine residency curriculum.

BACKGROUND AND OBJECTIVES: Knowledge of improvement practices is a critical skill for family medicine residents who will lead patient-centered medical homes. The Accreditation Council for Graduate Medical Education includes systems-based practice and improvement knowledge as a core competency for residency education. The objective of this report is to describe the 6-year implementation and development of our practice-based improvement curriculum in a family medicine residency. METHODS: In 2006, Oregon Health and Science University Family Medicine Residency implemented an improvement curriculum that focused on clinic-based improvement and involved longitudinal didactics. Over the course of 6 years, the curriculum has been refined to include longitudinal instruction of improvement principles according to the levels of training and clinic-based didactics and experientials that are team oriented. Residents complete ambulatory improvement projects over the cycle of 12 months and present outcomes each year. Residents evaluated their knowledge, experience, confidence, and satisfaction at the end of the academic year. RESULTS: Ninety percent of residents designed and lead improvement projects upon graduation from residency in 2011. Resident confidence to make a change in local health care settings at the end of the curriculum was high and improved from 2009/2010 to 2010/2011. Upon graduation from the program, 100% of residents reported competence or proficiency in their ability to apply knowledge to an improvement project and present results. CONCLUSIONS: We describe a longitudinal, practical, developmental, and clinically based experiential improvement curriculum that has been successfully integrated into a family medicine residency program.

Prevalence and prognostic role of triple-negative breast cancer by race: a surveillance study.

INTRODUCTION: Emerging research suggests a substantially greater prevalence of the adverse triple-negative (TN) subtype (human epidermal growth factor receptor [HER]2(-), estrogen receptor [ER](-), and progesterone receptor [PR])(-)) among black patients with breast cancer. No reports however have been generated from a statewide cancer registry. PATIENTS AND METHODS: The study consisted of all black patients (N = 643) and a random sample of white patients (n = 719) diagnosed with primary invasive breast cancer (2000-2003) listed in the National Cancer Institute-Surveillance Epidemiology and End Results (NCI-SEER) Connecticut Tumor Registry (CTR). HER2 status was obtained from pathology reports submitted to the registry. Remaining data were obtained from the registry database. RESULTS: TN tumors were more prevalent in black compared with white patients (30.8% vs. 11.2%, respectively; P < .001.) There was a 2-fold greater frequency of ER(-) and PR(-) phenotypes among black patients, but HER2 status did not differ by race. Patients with lobular cancer were less likely to have TN breast cancer compared with patients with ductal tumors (odds ratio [OR] = 0.23; 95% confidence interval [CI], 0.10-0.58). Among patients with regional disease, black patients exhibited increased risk of death (relative risk [RR] = 2.71; 95% CI, 1.48-4.97) independent of TN status. No survival disparity was found among patients with local disease. DISCUSSION: These registry-based data corroborate reports that TN breast cancer varies substantially by race and histologic subtype. A survival disparity among patients with advanced disease, but not local disease, casts some doubt on TN status as an explanation for differences. CONCLUSION: More research is warranted to understand why black patients with advanced breast cancer may be at increased risk for death whether or not their tumors express the TN phenotype.

Patterns of HER2 testing in the management of primary breast cancer.

BACKGROUND: Women with invasive breast cancer should be tested for human epidermal growth factor receptor-2 (HER2) status at the time of diagnosis. To date, no population-based patterns of use studies have examined demographic and clinicopathologic factors associated with decisions by clinicians to test patients. METHODS: We reviewed summary pathology reports submitted to the Connecticut Tumor Registry for all Black/African American (B/AA) women (n=644) and a 7% random sample (n=720) of White women diagnosed in 2000-2003 with primary invasive breast carcinoma. Receipt of a HER2 test (yes vs. no) was examined in relation to patient race, age, socioeconomic status, year of diagnosis, estrogen receptor (ER) status, tumor grade, lymph node status, size and stage at diagnosis. RESULTS: A greater proportion of tumors from B/AA patients were tested compared to those of White women (69.5% vs. 61.9%, p<0.05). Tumors of patients under the age of 60 were 1.50-times more likely than older women to have been tested, and B/AA women were 1.40-times more likely than White patients to be tested. HER2 testing was more likely to be observed when information also was reported about ER status (OR=15.9, p<0.001), tumor grade (OR=2.28, p<0.05), tumor size (OR=2.16, p<0.05), and lymph node status (OR=2.06, p<0.05). CONCLUSIONS: Variation in which breast cancer patients received HER2 testing appears to reflect expectations about a woman's prognosis. Discrepancies in receipt of testing deserve further study as current guidelines call for all tumors to be assessed in order to adequately characterize prognosis and determine eligibility for HER2-targeted therapy.

Oral Bromelain Attenuates Inflammation in an Ovalbumin-induced Murine Model of Asthma.

Bromelain, a widely used pineapple extract with cysteine protease activity, has been shown to have immunomodulatory effects in a variety of immune system models. The purpose of the present study was to determine the effects of orally administered bromelain in an ovalbumin (OVA)-induced murine model of acute allergic airway disease (AAD). To establish AAD, female C57BL/6J mice were sensitized with intraperitoneal (i.p.) OVA/alum and then challenged with OVA aerosols for 3 days. Mice were gavaged with either (phosphate buffered saline)PBS or 200 mg/kg bromelain in PBS, twice daily for four consecutive days, beginning 1 day prior to OVA aerosol challenge. Airway reactivity and methacholine sensitivity, bronchoalveolar lavage (BAL) cellular differential, Th2 cytokines IL-5 and IL-13, and lung histology were compared between treatment groups. Oral bromelain-treatment of AAD mice demonstrated therapeutic efficacy as evidenced by decreased methacholine sensitivity (P