Understanding Barriers and Distress Experienced Among Cancer Patients: Analysis from an Urban Academic Emergency Department.

The purpose of this study was to examine barriers and facilitators to compliance for cancer care in patients utilizing an emergency department (ED)-based assessment. Adult ED patients who either had active cancer or a history of cancer were enrolled between August 2020 and Jan 2022 for this prospective cohort study. We piloted the National Comprehensive Cancer Network (NCCN) Distress Thermometer. Multivariable regression analyses were used to assess the predictors of high distress. Of the 152 patients enrolled, 73% were Black patients, 11% were non-Hispanic White, and 16% included patients from other racial and ethnic groups (including 10.5% Hispanic patients); 73% of the sample had active cancer. The current ED visit was cancer related for 44%. The mean score on the Distress Thermometer was 4 (SD = 2; range 0-8) with 30% having a high distress level of ≥ 6. Having an active cancer and race/ethnicity were significant predictors of high distress. Patients who had active cancer had three times (aOR = 3.01; 95% CI 1.12-8.10) higher odds of experiencing high distress in the past week compared to those who did not have active cancer, after adjusting for race/ethnicity and reason for visit. Practical problems and physical problems were the most common, with 43% (n = 66) and 40% (n = 61) of the patients reporting these problems, respectively. Despite significant progress in cancer care, cancer patients/survivors face difficulty in transitioning between care environments and end up seeking episodic care in the ED and experience a high level of distress.

Expanding Outcomes in Cancer Screening Safety Net Programs: Promoting Sustainability and Policy Reform.

Community-engaged patient navigation safety net programs are established as an evidence-based approach to address cancer prevention and early detection efforts, but barriers to expand and sustain such programs persist. In addition, few studies describe how these programs impact buy-in among communities and policy change within health care systems and government. We describe how we used the Capacity for Sustainability Framework to guide efforts for program sustainability and community, institutional, and policy level change in a breast cancer screening and patient navigation safety net program. The nine domains of the Capacity for Sustainability Framework were used to develop program logic models, to inform program implementation and quality improvement agendas, and to guide multi-level partner and stakeholder engagement, outreach, and dissemination of outcomes. The program is currently in its seventh year and continues to be annually funded by a city public health department. In 2021, additional 5-year renewable funding from a state public health department was secured. In addition, institutional program support was expanded for patients diagnosed with breast cancer. Program leaders worked with policymakers to draft legislation to support training certification and third-payor reimbursement for patient navigators and community health workers. The program is well-known and trusted among community members, community-based organizations, and providers. Community, organizational, and policy-level outcomes demonstrate that community-engaged patient navigation safety net programs can influence more than individual and interpersonal outcomes and can be sustained over time.

Implementation of an integrated framework for a breast cancer screening and navigation program for women from underresourced communities.

BACKGROUND: Trends in breast cancer mortality in the United States are decreasing, but racial disparities persist. Using an implementation science framework to inform evidence-based breast cancer screening and navigation within federally qualified health centers (FQHCs) with community stakeholders can mitigate barriers to screening. METHODS: Using an integrated theoretical framework of the Practical, Robust Implementation and Sustainability Model and the Social Ecological Model, the University of Illinois Cancer Center and Mile Square Health Centers (MSHC) FQHC developed a breast cancer screening and navigation program, known as the Mile Square Accessible Mammogram Outreach and Engagement (Mi-MAMO) program, to tackle breast cancer disparities in Chicago among underresourced communities. To increase access to screening, patient navigators conducted community outreach activities. Partnerships were forged with community-based organizations, health care systems, and insurers. Outcomes were monitored with standardized performance measures. RESULTS: Between January and December 2017, 103 women received a screening mammogram at MSHC. To increase screening rates, Mi-MAMO was started in August 2017. Between January and December 2018, the number of women who received a screening mammogram increased to 567. From August 2017 to December 2018, 779 women received navigation to screening and/or diagnostic services through the Mi-MAMO program. The majority of women were uninsured (63.9%), and 95.5% were racial/ethnic minorities. Twenty-four percent (n = 185) completed diagnostic services, and 10 women received positive breast cancer diagnoses (mean age, 49.7 years); all successfully navigated to treatment. The Mi-MAMO program is ongoing. CONCLUSIONS: Deploying an integrated framework for patient navigation programs can increase breast cancer screening utilization and awareness among underresourced populations at higher risk for breast cancer.

The effects of vitamin D2 or D3 supplementation on glycaemic control and related metabolic parameters in people at risk of type 2 diabetes: protocol of a randomised double-blind placebo-controlled trial.

BACKGROUND: The global prevalence of type 2 diabetes is increasing. Effective strategies to address this public health challenge are currently lacking. A number of epidemiological studies have reported associations between low concentrations of 25-hydroxy vitamin D and the incidence of diabetes, but a causal link has not been established. We investigate the effect of vitamin D supplementation on the metabolic status of individuals at increased risk of developing type 2 diabetes. METHODS/DESIGN: In a randomised double-blind placebo-controlled trial individuals identified as having a high risk of type 2 diabetes (non-diabetic hyperglycaemia or positive diabetes risk score) are randomised into one of three groups and given 4 doses of either placebo, or 100,000 IU Vitamin D2 (ergocalciferol) or 100,000 IU Vitamin D3 (cholecalciferol) at monthly intervals. The primary outcome measure is the change in glycated haemoglobin level between baseline and 4 months. Secondary outcome measures include blood pressure, lipid levels, apolipoproteins, highly sensitive C-reactive protein, parathyroid hormone (PTH) and safety of supplementation. and C-reactive protein. The trial is being conducted at two sites (London and Cambridge, U.K.) and a total of 342 participants are being recruited. DISCUSSION: Trial data examining whether supplementation of vitamin D improves glycaemic status and other metabolic parameters in people at risk of developing type 2 diabetes are sparse. This trial will evaluate the causal role of vitamin D in hyperglycaemia and risk of type 2 diabetes. Specific features of this trial include recruitment of participants from different ethnic groups, investigation of the relative effectiveness and safety of vitamin D2 and D3 and an evidence based approach to determination of the dose of supplementation. TRIAL REGISTRATION: EudraCT2009-011264-11; ISRCTN86515510.

Vitamin D metabolism in peripheral blood mononuclear cells is influenced by chewing "betel nut" (Areca catechu) and vitamin D status.

CONTEXT: Vitamin D deficiency, common in South Asians, is a risk factor for metabolic syndrome, type 2 diabetes, and ischemic heart disease. Vitamin D receptor (VDR) activation depends on activated vitamin D [1,25-dihydroxyvitamin D (1,25(OH)(2)D)] concentration, reflecting opposing actions of 25-hydroxyvitamin D-1alpha-hydroxylase [1-alpha(OH)ase] for formation and 25(OH)D-24-hydroxylase [24(OH)ase] for catabolism. We previously reported that circulating 1,25(OH)(2)D contributed to determination of VDR-protein levels and VDR genotype was a determinant of both VDR mRNA and VDR-protein in South Asians. OBJECTIVE: We hypothesized that chewing betel nut, an addictive habit common throughout South Asian communities, contributes to hypovitaminosis-D by modulating the enzymes regulating circulating 1,25(OH)(2)D concentration. DESIGN: Peripheral blood mononuclear cell (PBMC) 1-alpha(OH)ase and 24(OH)ase mRNA concentrations were measured and examined in relation to cross-sectional data on the vitamin-D axis, diet, smoking, and betel usage, including PBMC VDR-RNA and VDR-protein content in a pilot study of 33 healthy British Bangladeshis. RESULTS: PBMC 24(OH)ase mRNA correlated positively and serum 1,25(OH)(2)D negatively with betel quids per day (r = 0.49, P = 0.006 and r = -0.486, P = 0.006, respectively). Independent determinants for 24(OH)ase included betel quids per day (P < 0.0001) and serum 25-OHD (P = 0.024). Independent determinants for serum 1,25(OH)(2)D were gender, smoking, and betel quids per day. PBMC 1-alpha(OH)ase mRNA correlated inversely with VDR mRNA (r = -0.44; P = 0.013); its independent determinants were serum 1,25(OH)(2)D and VDR TaqI and BsmI polymorphisms (P = 0.03-0.0001). CONCLUSIONS: Betel chewing is a more powerful independent determinant of increased 24(OH)ase expression and of decreased serum calcitriol than serum 25-OHD, supporting the hypothesis that this habit could aggravate the effects of vitamin-D deficiency.

Hypovitaminosis D is associated with reductions in serum apolipoprotein A-I but not with fasting lipids in British Bangladeshis.

BACKGROUND: Although hypovitaminosis D has been suggested to increase the risk of heart disease, its relation to components of the fasting lipid profile has not been clarified for specific ethnic groups. OBJECTIVE: The objective was to determine the relation of circulating 25-hydroxyvitamin D [25(OH)D] concentrations to fasting lipid concentrations in South Asian subjects at risk of hypovitaminosis D. DESIGN: The present study was conducted in 170 British Bangladeshi adults, 69 men and 101 women, from east London who were free of known diabetes or chronic disorders. Vitamin D repletion was assessed by measuring fasting serum 25(OH)D concentrations. Fasting lipid profiles were measured as part of a study of the risk factors for type 2 diabetes and ischemic heart disease, which included hypovitaminosis D. RESULTS: A univariate analysis showed that total cholesterol, LDL cholesterol, and both apolipoprotein (apo) A-I and apo B concentrations correlated directly with serum 25(OH)D concentrations. However, a multiple regression analysis, which included all the documented risk factors for diabetes and ischemic heart disease, showed that the 25(OH)D concentration (vitamin D status) was an independent predictor of increasing apo A-I concentrations (standardized coefficient beta = 0.3; P < 0.001) but not of fasting lipid concentrations. CONCLUSIONS: In this study of British South Asians, the data showed a positive relation of fasting apo A-I concentrations to serum 25(OH)D concentrations, independent of glycemia and other dietary, anthropometric, and lifestyle risk factors for type 2 diabetes and ischemic heart disease after multiple regression analyses. Subjects with hypovitaminosis D are likely to have an increased risk of ischemic heart disease independent of their increased risk of type 2 diabetes.