Colorectal Cancer Screening Rates at Federally Qualified Health Centers From 2014 to 2022: Incomplete Recovery From COVID-19 and Worsening Disparities.

INTRODUCTION: Federally Qualified Health Centers (FQHC) provide preventive health services such as colorectal cancer (CRC) screening to low-income and underinsured individuals. Overall CRC screening participation in the United States declined during the COVID-19 pandemic and recovered by 2021; however, trends in underresourced settings are unknown. METHODS: Using Uniform Data System data from 2014 to 2022, we assessed trends in FQHC CRC screening rates nationally, in California, and in Los Angeles County and determined clinic-level factors associated with recent screening rate changes. For each FQHC, we calculated the screening rate change from 2019 to 2020, 2020 to 2021, and 2020 to 2022. We used mixed-effects linear regression to determine clinic-level characteristics associated with each screening rate change. RESULTS: Across all FQHC (n = 1,281), 7,016,181 patients were eligible for CRC screening in 2022. Across the United States and in California, median screening rates increased from 2014 to 2019, severely declined in 2020, and failed to return to prepandemic levels by 2022. Both nationally and in California, CRC screening declined most dramatically from 2019 to 2020 in FQHC serving majority Hispanic/Latino patients or a high proportion of patients experiencing homelessness. From 2020 to 2022, screening rates did not recover completely in US FQHC, with disproportionate recovery among FQHC serving majority non-Hispanic Black patients. DISCUSSION: CRC screening rates at FQHC did not return to prepandemic levels by 2022, and recovery varied by FQHC patient characteristics. Tailored interventions addressing low and decreasing CRC screening rates in FQHC are urgently needed to mitigate worsening CRC disparities.

Health and Well-Being at the Transition to Adulthood Among Individuals With Disabilities: An Analysis of the Panel Study of Income Dynamics.

PURPOSE: To describe positive mental health, or "flourishing," and self-reported health trajectories among transition-aged young adults (TAYA) with developmental/learning and physical disabilities over a 12-year period, utilizing a population-based sample. METHODS: This study features a secondary analysis of national data from the Panel Study of Income Dynamics Transition to Adulthood Supplement. The analytic sample included all TAYA with (n = 487) and without (n = 810) disabilities, including developmental/learning disabilities (DD/LD), attention deficit hyperactivity disorder (ADHD), and speech, hearing, and vision impairments who participated in 2017 Transition to Adulthood Supplement data collection (n = 1,297; M age = 24.5, standard deviation = 2.40). We utilized linear mixed modeling to retrospectively describe flourishing and self-reported health trajectories across 12 years among TAYA with and without disabilities between ages 18 to 28, adjusting for demographic and developmental characteristics. RESULTS: Relative to TAYA without disabilities, TAYA with speech [0.10, 0.85] and vision impairments [0.10, 0.92], DD/LD [0.38, 1.11], and ADHD [0.27, 0.97] demonstrated lower flourishing. TAYA with speech [0.07, 0.36] and vision impairments [0.08, 0.38], DD/LD [0.15, 0.411], and ADHD [0.14, 0.93] reported lower health. Relative to TAYA with other disabilities, TAYA with ADHD [0.14, 0.93] and DD/LD [0.01, 0.29] reported lower flourishing and health, respectively. Interaction effects and descriptive analyses revealed distinct patterns of change for TAYA with ADHD. DISCUSSION: TAYA with disabilities report lower flourishing and health, relative to TAYA without disabilities. TAYA with specific disabilities differ in their flourishing and health trajectories. Findings can inform the development of interventions for TAYA with disabilities.

Specific domains of positive childhood experiences (PCEs) associated with improved adult health: A nationally representative study.

Background: Positive childhood experiences (PCEs) are supportive relationships and environments associated with improved health when aggregated into composite scores. Adverse childhood experiences (ACEs), a reciprocal measure to PCEs, are associated with worse health in aggregate scores and when disaggregated into measures of specific ACE types (hereafter domains). Understanding the associations between specific PCE domains and health, while accounting for ACEs, may direct investigations and intervention planning to foster PCE exposure. Methods: We analyzed data from the nationally representative United States longitudinal Panel Study of Income Dynamics. Five PCE domains were examined: (i) peer support and healthy school climate, (ii) neighborhood safety, (iii) neighborhood support, and nurturing relationships with (iv) maternal and (v) paternal figures. Survey weighted logistic regression models tested associations between each PCE domain measure and adult general health rating, controlling for demographic covariates and nine ACE exposures: physical, emotional, or sexual abuse/assault; emotional neglect; witnessing intimate partner violence or household substance use; having a parent with mental illness; any parental separation or divorce; and/or having a deceased or estranged parent. Secondary outcomes included adult functional status and mental and physical health diagnoses. We also tested for statistical interactions between PCE domain and ACE score measures. Results: The sample included 7105 adults. Higher scores for the "peer support and healthy school climate" and "neighborhood safety" domain measures showed the most protective relationships with the adverse health conditions tested, most notably for mental illness. The relationship between PCE domain measures and health outcomes was attenuated, but not statistically moderated by ACE exposure. Conclusion: Experiencing childhood peer support, a healthy school climate, and neighborhood safety were especially protective against multiple adult health conditions, including for ACE exposed individuals. Interventions that promote PCEs may yield population health gains.

Panhypopituitarism as the first sign of paraneoplastic limbic encephalitis in a patient with cured testicular cancer: a case report.

BACKGROUND: Paraneoplastic limbic encephalitis is a rare neurologic syndrome that affects patients with cancer and commonly presents with symptoms of personality changes, visual disturbances, seizures, vertigo, and memory loss. It has an immune-mediated pathophysiology and is associated with antibodies directed against both the tumor and limbic structures in the nervous system. Here, we report a case of paraneoplastic limbic encephalitis with an unusual presentation with initial symptoms of panhypopituitarism. CASE PRESENTATION: A 28-year-old Caucasian man with history of testicular cancer in remission for almost 2 years was admitted to our hospital for altered mental status, syncope, vertical gaze palsy, ataxia, and tremor. Three months prior to admission, he began to have initial symptoms of fatigue, weight gain, and hypogonadism. A few weeks before admission, he also developed worsening neurological symptoms that led him to present to the hospital. While hospitalized, he had an episode of syncope. Evaluation of his syncope revealed that he was hypovolemic due to polyuria, concerning for diabetes insipidus. While the patient did not meet criteria for diabetes insipidus, further endocrine laboratory testing to evaluate his central hormonal axes revealed panhypopituitarism. He also underwent a neurologic work-up with brain magnetic resonance imaging and lumbar puncture, with results consistent with encephalitis. He received high-dose steroids, plasmapheresis, and intravenous immunoglobulin, which did not significantly improve his physical examination or mental status. Extensive testing did not show any recurrence of his testicular cancer. Paraneoplastic antibodies were also ordered, with anti-Ma2 antibodies eventually returning positive, consistent with anti-Ma2 paraneoplastic limbic encephalitis. CONCLUSION: Paraneoplastic limbic encephalitis is often a difficult diagnosis due to its variable presentation and timeline of presentation, leading to delays in both diagnosis and treatment. While paraneoplastic limbic encephalitis usually presents with neurological symptoms, it may also present with panhypopituitarism. A high index of suspicion is warranted for paraneoplastic syndromes in patients with history of malignancy, even if the malignancy is in remission.

Do you mind if I record?: Perceptions and practice regarding patient requests to record clinic visits in oncology.

BACKGROUND: Audio recordings of oncology clinic discussions can help patients retain and understand information about their disease and treatment decisions. Access to this tool relies on acceptance of recordings by oncologists. This is the first study to evaluate experience and attitudes of oncologists toward patients recording clinic visits. METHODS: Medical, radiation, and surgical oncologists from 5 US cancer centers and community affiliates were surveyed to evaluate clinicians' experience, beliefs, and practices regarding patient-initiated recordings. RESULTS: Among 360 oncologists (69% response rate), virtually all (93%) have experienced patients seeking to record visits. Although 75% are comfortable with recording, 25% are uncomfortable and 56% report concerns ranging from less thorough discussions to legal liability. Most (85%) always agree when patients ask to record, but 15% never or selectively allow recording. Although 51% believe recording is positive for the patient-physician relationship, a sizable minority report that it can lead to less detailed conversations (28%) or avoidance of difficult topics, including prognosis (33%). Views did not vary based on subspecialty, practice setting, or geographic region, but older age and years in practice were associated with more positive views of recording. The majority of clinicians (72%) desire institutional policies to govern guidelines about recordings. CONCLUSIONS: Most oncologists are comfortable with patient requests to record visits, but a sizable minority remain uncomfortable, and access to recording varies solely on physician preference. This difference in care delivery may benefit from institutional policies that promote access while addressing legitimate physician concerns over privacy and appropriate use of recordings.

Discrimination and Subsequent Mental Health, Substance Use, and Well-being in Young Adults.

OBJECTIVES: Discrimination has been shown to have profound negative effects on mental and behavioral health and may influence these outcomes early in adulthood. We aimed to examine short-term, long-term, and cumulative associations between different types of interpersonal discrimination (eg, racism, sexism, ageism, and physical appearance discrimination) and mental health, substance use, and well-being for young adults in a longitudinal nationally representative US sample. METHODS: We used data from 6 waves of the Transition to Adulthood Supplement (2007-2017, 1834 participants) of the Panel Study of Income Dynamics. Outcome variables included self-reported health, drug use, binge drinking, mental illness diagnosis, Languishing and Flourishing score, and Kessler Psychological Distress Scale score. We used logistic regression with cluster-robust variance estimation to test cross-sectional and longitudinal associations between discrimination frequency (overall, cumulative, and by different reason) and outcomes, controlling for sociodemographics. RESULTS: Increased discrimination frequency was associated with higher prevalence of languishing (relative risk [RR] 1.34 [95% CI 1.2-1.4]), psychological distress (RR 2.03 [95% CI 1.7-2.4]), mental illness diagnosis (RR 1.26 [95% CI 1.1-1.4]), drug use (RR 1.24 [95% CI 1.2-1.3]), and poor self-reported health (RR 1.26 [95% CI 1.1-1.4]) in the same wave. Associations persisted 2 to 6 years after exposure to discrimination. Similar associations were found with cumulative high-frequency discrimination and with each discrimination subcategory in cross-sectional and longitudinal analyses. CONCLUSIONS: In this nationally representative longitudinal sample, current and past discrimination had pervasive adverse associations with mental health, substance use, and well-being in young adults.

BET inhibitors repress expression of interferon-stimulated genes and synergize with HDAC inhibitors in glioblastoma.

BACKGROUND: The development of rational combination therapies is key to overcome inherent treatment resistance of glioblastoma (GBM). We aim at identifying new druggable targets by disturbing GBM cells with inhibitors of bromodomain and extra-terminal motif (BET) proteins to reveal cancer-relevant vulnerabilities that may sensitize to a second drug. BET proteins are epigenetic modulators and have been associated with proto-oncogene overexpression in cancer. METHODS: A GBM-derived sphere-line was treated with the BET inhibitor (BETi) JQ1 over a time-course of 48 hours, followed by RNA-sequencing. Four chromatin marks were investigated by chromatin immunoprecipitation followed by sequencing (ChIP-seq). Signatures of interest were functionally validated in vitro and in orthotopic xenografts. Combination therapies were evaluated for synergistic effects. RESULTS: Cancer-relevant pathways significantly modulated by JQ1 comprised interferon alpha (IFN-α) response genes and response signatures to histone deacetylase inhibitors (HDACi). The IFN-signature was reminiscent of a GBM-derived IFN-signature comprising CD274 (PD-L1). Functional pathway analysis suggested that JQ1 was acting directly on the transcriptional level of IFN-response genes and not via the canonical JAK/STAT pathway. This was in line with JQ1 modulated expression and BRD4 and Pol II occupancy at IFN-signature genes, supporting a direct mechanistic interaction. Finally, we showed that combining HDACi with JQ1 acts synergistically in reducing cell viability of GS-lines. CONCLUSIONS: Our approach identified BETi-induced vulnerabilities in cancer-relevant pathways, potentially amenable to synergistic combinatorial therapy, such as combination with HDACi. The direct inhibitory effect of BETi on IFN-responsive genes in GBM cells, including CD274, indicates modulation of the tumor immune landscape and warrants further studies.

Implementation of a Brief Screening Tool to Identify Needs of Breast Cancer Survivors.

BACKGROUND: Innovation in health care delivery is needed to improve care for cancer survivors. We report our experience with adapting screening questions from the National Comprehensive Cancer Network (NCCN) guideline to evaluate the needs of breast cancer survivors. MATERIALS AND METHODS: We adapted the NCCN-recommended screening questions into a plain language, self-administered 1-page intake questionnaire. The tool was administered to a convenience sample of female breast cancer survivors at follow-up oncology and primary care visits. Domains included symptoms, lifestyle concerns, and financial issues. Frequency of concerns was assessed as "never," "rarely," "sometimes," "very frequently," and "always." We evaluated feasibility and utility of administration and the prevalence and frequency of patient-reported concerns. RESULTS: The questionnaire was highly acceptable to patients and enhanced visits for clinicians. Clinicians reported that it led to discussion of issues that may not otherwise be addressed in the visit and did not find it burdensome. The most commonly endorsed patient concerns were desire to improve fitness or nutrition, worry about cancer recurrence, and insomnia. A majority also reported feeling anxiety and aches or pains in joints or extremities. Several issues known to be underreported in clinic visits were frequently endorsed, included sexual dissatisfaction and memory impairments. Clinicians suggested incorporating the tool into the electronic health record to increase utility and awareness. CONCLUSION: Screening for individual needs among breast cancer survivors is feasible, efficient, and may identify prevalent issues that otherwise can be missed in routine survivorship care.

Practice, Preferences, and Practical Tips From Primary Care Physicians to Improve the Care of Cancer Survivors.

PURPOSE: There is a need to improve the coordination of care and communication between primary care physicians (PCPs) and oncology after completion of initial cancer treatment. We sought to evaluate PCP experiences and perspectives in cancer survivorship and to identify practical opportunities to improve care within an integrated health care system with a shared electronic health record (EHR). METHODS: We conducted a self-administered, anonymous, electronic survey of PCPs in practices affiliated with an academic medical center to evaluate practices, the sense of preparedness, and preferences in the delivery of survivorship care and communication with oncology. RESULTS: One hundred seventeen of 225 PCPs responded (response rate, 52%). A majority were engaged in survivorship care, with 94% reporting managing psychological sequelae of cancer, 84% managing chronic physical complications, 71% screening for cancer recurrence, and 60% screening for late complications. However, few PCPs felt prepared to manage these issues: 65% felt unprepared to screen for late complications, and 36% felt unprepared to screen for recurrence. Common barriers to survivorship care were uncertainty about delegation of responsibility (73%) and a lack of training (72%). PCPs expressed strong interest in survivorship care plans, preferring active tracking of ongoing care needs and delegation of care responsibility in the EHR active problem list over traditional summary documents. CONCLUSION: Most PCPs are engaged in cancer survivorship care but report barriers to optimal care delivery. Opportunities to improve care could include targeted education to increase preparedness to deliver survivorship care, and optimization of communication among providers, including active survivorship care plans in the EHR.

Microanalysis of the antiretroviral nevirapine in human hair from HIV-infected patients by liquid chromatography-tandem mass spectrometry.

Sufficient drug exposure is crucial for maintaining durable responses to HIV treatments. However, monitoring drug exposure using single blood samples only provides short-term information and is highly subject to intra-individual pharmacokinetic variation. Drugs can accumulate in hair over a long period of time, so hair drug levels can provide drug exposure information over prolonged periods. We now report on a specific, sensitive, and reproducible liquid chromatography-tandem mass spectrometry method for measuring nevirapine (NVP), a widely used antiretroviral drug, levels in human hair using even a single short strand of hair. Hair samples are cut into small segments, and the drug is extracted in methanol/trifluoroacetic acid (v/v, 9:1) shaken at 37 °C in a water bath overnight, followed by liquid-liquid extraction under alkaline conditions. The extracted samples are then separated on a BDS-C(18) column with a mobile phase composed of 50% acetonitrile containing 0.15% acetic acid and 4 mM ammonium acetate with an isocratic elution for a total run time of 3 min and detected by triple quadrupole electrospray multiple reaction mode at precursor/product ion at 267.0 > 225.9 m/z. Deuterated nevirapine-d5 was used as an internal standard. This method was validated from 0.25 to 100 ng/mg using 2 mg hair samples. The accuracies for spiked NVP hair control samples were 98-106% with coefficients of variation (CV) less than 10%. The CV for incurred hair control samples was less than 7%. The extraction efficiency for incurred control hair samples was estimated at more than 95% by repeated extractions. This method has been successfully applied to analyze more than 1,000 hair samples from participants in a large ongoing cohort study of HIV-infected participants. We also showed that NVP in human hair can easily be detected in a single short strand of hair. This method will allow us to identify drug non-adherence using even a single strand of hair.