A decade of intraoperative ultrasound guided breast conservation for margin negative resection - Radioactive, and magnetic, and Infrared Oh My…

BACKGROUND

The oncologic goal of margin-negative breast conservation requires adequate localization of tumor. Intraoperative ultrasound remains most feasible but under-utilized method to localize the tumor and assess margins.

METHODS

A prospectively maintained breast cancer database over a decade was queried for margin status in breast cancer patients undergoing breast conservation. Techniques of tumor localization, margin re-excision and closest margins were analyzed. Rate of conversion to mastectomy was determined.

RESULTS

Of the 945 breast cancer patients treated at a university-based Breast Center of Excellence between January 1, 2009 and December 31, 2018, 149(15.8%) had ductal carcinoma in situ; 712(75.3%) had invasive ductal carcinoma, and 63(6.7%) had invasive lobular carcinoma. Clinical stage distribution was: T1 = 372(39.4%); T2 = 257(27.2%); T3 = 87(9.2%). Five hundred and eighty three (61.7%) patients underwent breast conservation. The median (25th -75th centile) closest margin was 6(2.5, 10.0) mm. Thirty five (6.0%) patients underwent margin re-excision, of which 9(25%) were converted to mastectomy. Tumor localization was achieved with ultrasound in 521(89.4%) patients and with wire localization in 62(10.6%) patients. The median (25th-75th centile) closest margin with wire localization was 5.0(2.0, 8.5) mm versus 5.0 (2.0, 8.0) mm with ultrasound guidance [p = 0.6635]. The re-excision rate with wire localization was 14.5% versus 4.9% with ultrasound guidance [p = 0.0073]. The unadjusted Odds Ratio (95% CI) for margin revision in wire localized group compared with ultrasound was 3.2 (7.14, 1.42) [p = 0.0045]; multivariate adjusted OR (95%) was 4(9.09, 1.7) [p = 0.0013].

CONCLUSIONS

Ultrasound guidance for localization of breast cancer remains the most effective option for margin negative breast conservation.

Melatonin Patterns and Levels During the Human Menstrual Cycle and After Menopause

Context

Melatonin may play a role in the regulation of the human menstrual cycle and may decline with menopause and/or aging.

Objective

The objective of this work is to investigate the relations between melatonin and the menstrual cycle, menopause, and aging.

Methods

This was a cross-sectional and longitudinal analysis of 20 participants from the Study of Women’s Health Across the Nation (SWAN) Daily Hormone Study (DHS). The outcome measure was first-morning urine assay of 6-sulfatoxymelatonin (aMT6s), a gauge of melatonin. For each participant, aMT6s was measured daily during one premenopausal cycle with evidence of luteal activity (ELA) and one postmenopausal collection with no evidence of luteal activity (NELA).

Results

In addition to the organized patterns of hormone metabolites (estrone conjugates [E1c], and pregnanediol glucuronide [PdG]) and gonadotropins that characterized ovulatory menstrual cycles, there was a late luteal rise in aMT6s. In NELA collections, there was no periodicity of E1c, PdG, gonadotropins, or aMT6s. The strongest predictors of aMT6s levels were PdG values 11 to 12 days prior to aMT6s (β = 1.46, P = .001 and β = 1.44, P = .001, respectively). E1c and gonadotropins were not statistically significantly associated with aMT6s. Mean aMT6s in premenopause was 53.5 ng/mL, greater than the mean of 37.4 ng/mL in postmenopausal samples from the same women (P = .0002).

Conclusions

This study confirms a late luteal melatonin rise, likely signaled by progesterone, which may influence menstrual cycle pacemaker control. Melatonin declined from premenopause to postmenopause. A high correlation between menopause transition stage and age precludes distinction between the influences of ovarian and chronological aging.

SAT-022 Adrenal Androgen Production Is Maintained While Ovarian Estrogens Fall Following the Final Menstrual Period in the Study of Women’s Health Across the Nation (SWAN)

The aim of this study was to clarify changes in sex steroids at the final menstrual period (FMP). We have shown previously that estradiol (E2) declines substantially in the 4-year period around the FMP, but hypothesize that testosterone (T) declines modestly and adrenal Δ5 androgens dehydroepiandrosterone (DHEA) and androstenediol (Adiol) remain unchanged. Methods: Liquid chromatography tandem mass spectrometry (LC-MS/MS) and immunoassay was used in approximately annual samples collected before and following FMP in 1490 women. We estimated time-related changes in each log-transformed androgen using piecewise linear mixed modeling, with knots (slope changes) at FMP-2 yrs and FMP+2 yrs as seen for E2. These models then were re-estimated for subgroups with different time courses identified using group-based trajectory modeling. Results: In the full sample, T was generally stable, although time course varied by subgroup, with a significant decrease of 5%/year in T in [FMP-2yrs, FMP+2yrs] only in the lowest T women. For DHEA and Adiol, declines were similar across all 3 time segments and across subgroups. Mean circulating androgen concentration declined modestly (P> 0.05) from five years before to five years following FMP. However, when stratified only the lowest 7% of circulating T declined significantly (p< 0.05) in the four years surrounding FMP when mean circulating E2 declined. This trajectory divergence of the lower circulating T suggests a different, non-adrenal source that is decreased at FMP which may be useful in clarifying ovarian versus adrenal testosterone production during the post-menopause. Paired results from samples collected before and following FMP in the same subjects indicate mean circulating E2 is less than 5% of mean circulating T suggesting that a relatively large portion of circulating E2 may be largely a result of peripheral conversion of adrenal androgens. Longitudinal LC-MS/MS analyses of circulating E2 and T indicate that the principal change in sex steroid influence at menopause is largely a decrease and dampening of ovarian and not adrenal steroid production.

SAT-027 Comparison of Estradiol by Mass Spectrometry Versus Immunoassay in Women Undergoing Menopause: Study of Womens Health Across the Nation (SWAN)

Serum estradiol (E2) concentrations in midreproductive women are easily measured using a variety of conventional immunoassays (IA). However, when women approach and traverse menopause, E2 eventually drops below levels where IA lacks sufficient sensitivity to accurately measure E2. Liquid chromatography and tandem mass spectrometry (LC/MS/MS) has become the standard method for assessing steroid hormones, especially when circulating concentrations are low. We evaluated the relationship between IA and LC/MS/MS E2 measurements in a cohort of women taken from the Study of Womens Health Across the Nation (SWAN) to assess the degree of agreement between the two methods and to determine the level of E2 at which IA becomes unreliable.

Methods: 315 serum samples that had been previously measured for E2 using IA were re-analyzed using LC/MS/MS performed by one of the authors (RA). In this original set, E2 levels that were below the limit of assay detection (LLD, 6 pg/ml) were interpolated as a random number between 0 and the LLD. Agreement between all 315 samples was assessed using both Pearson and Spearman correlation. The analysis was repeated excluding the subset of specimens that were below the lower limit of detection (LLD) for the IA E2 assay (6 pg/ml; N=176), and a third set of correlations was obtained for specimens that measured <15 pg/ml by IA but were above the 6 pg/ml LLD (N=82).

Results: The overall dataset (N=315) demonstrated excellent agreement between IA and LC/MS/MS with a Pearson’s r and Spearmans r of 0.98 AND 0.60, respectively. When the subset of 176 samples above the LLD were assessed, Pearson’s r was 0.98 and Spearman’s r was 0.81. In contrast, when specimens measuring 6–15 pg/ml by IA were compared to LC/MS/MS, Pearson’s r was -0.03 and Spearman’s r was 0.09, indicating a complete loss of relationship between the two methods.

Conclusions: The IA used by SWAN (England, Clin Chem 2002; 48: 1584) and LC/MS/MS demonstrate excellent correlation for E2 measurements above 15 pg/ml. However, circulating concentrations of E2 below 15 pg/ml were not accurately measured using IA.

The impact of breast cancer on physical activity from midlife to early older adulthood and predictors of change post-diagnosis

PURPOSE

To examine physical activity (PA) patterns from pre- to post-diagnosis, and compare these changes to women without breast cancer. To determine pre-diagnosis predictors of PA change, post-diagnosis, in breast cancer survivors (BCS).

METHODS

Data were from 2314 Study of Women's Health Across the Nation (SWAN) participants, average age of 46.4 ± 2.7 years at baseline (1996-1997). In Pink SWAN, 151 women who reported an incident breast cancer diagnosis over 20 years were classified as BCS; the remaining 2163 women were controls. LOESS plots and linear mixed models were used to illustrate and compare PA changes (sports/exercise [primary measure] and total PA) from pre- to post-diagnosis (or corresponding period) in BCS versus controls. Adjusted linear regression models were used to determine pre-diagnosis predictors of at-risk post-diagnosis PA change patterns (consistently low and decreased PA).

RESULTS

No differences in pre- to post-diagnosis PA (or corresponding period) were observed in BCS versus controls. Among BCS, the odds of at-risk post-diagnosis PA change patterns was 2.50 (95% CI 0.96-6.48) times higher for those who reported sleep problems at ≥ 50% (compared to 0%) of pre-diagnosis visits and 3.49 (95% CI 1.26-9.65) times higher for those who were overweight or obese at all (compared to no) pre-diagnosis visits. No other statistically significant predictors were noted.

CONCLUSIONS

Age-related declines in PA were not amplified by a breast cancer diagnosis. Given the beneficial role of PA across the cancer control continuum, efforts to increase or maintain adequate PA, post-diagnosis, should be continued.

IMPLICATIONS FOR CANCER SURVIVORS

While age-related physical activity declines were not amplified breast cancer diagnosis, efforts to identify breast cancer survivors at increased risk for post-diagnosis physical activity declines (or maintenance of low activity) may be a high-yield strategy to improve prognosis and quality of life.

Impact of Estradiol Variability and Progesterone on Mood in Perimenopausal Women With Depressive Symptoms

CONTEXT

Women are at increased risk for depressive symptoms during the menopause transition. Changes in estradiol secretion and presence of vasomotor symptoms (VMS) contribute to perimenopausal depressive symptoms, but links with progesterone have not been investigated.

OBJECTIVE

To determine whether estradiol variability, ovulatory levels of progesterone, and VMS burden are independently associated with perimenopausal depressive symptomatology.

DESIGN AND INTERVENTION

Depressive symptoms, serum levels of estradiol and progesterone, and VMS frequency were assessed weekly in an 8-week observational study. Association of mood with estradiol variability, ovulatory levels of progesterone, and VMS frequency were estimated using generalized estimating equation models.

SETTING

Academic medical center.

PATIENTS

Fifty unmedicated perimenopausal women with mild-to-moderate depressive symptoms (mean Montgomery-Åsberg Depression Rating Scale [MADRS] score 15.5 ± 5.3).

MAIN OUTCOME MEASURE

Depressive symptoms (MADRS score).

RESULTS

During the study, 90.0% of participants had varying estradiol levels, 51.1% had ovulatory progesterone levels, and 90% had VMS. Greater estradiol variability and absence of progesterone levels consistent with ovulation, but not VMS frequency, are associated with higher levels of depressive symptoms (β = 0.11 [95% confidence interval (95% CI), 0.04 to 0.18; P = 0.001]; β = -2.62 [95% CI, -4.52 to -0.71; P = 0.007], respectively), after accounting for higher body mass index, lifetime history of depression, and stressful life events.

CONCLUSIONS

Increasing dysregulation of ovarian hormones, but not VMS, associates with more depressive symptom burden during perimenopause. These results suggest that perimenopausal mood instability is driven by the underlying hormonal dysregulation of the menopause transition involving changes in both estradiol and progesterone.

SUPPORT-AF II: Supporting Use of Anticoagulants Through Provider Profiling of Oral Anticoagulant Therapy for Atrial Fibrillation

Background:

Previous provider-directed electronic messaging interventions have not by themselves improved anticoagulation use in patients with atrial fibrillation. Direct engagement with providers using academic detailing coupled with electronic messaging may overcome the limitations of the prior interventions.

Methods and Results:

We randomized outpatient providers affiliated with our health system in a 2.5:1 ratio to our electronic profiling/messaging combined with academic detailing intervention. In the intervention, we emailed providers monthly reports of their anticoagulation percentage relative to peers for atrial fibrillation patients with elevated stroke risk (CHA 2 DS 2 -VASc ≥2). We also sent electronic medical record-based messages shortly before an appointment with an anticoagulation-eligible but untreated atrial fibrillation patient. Providers had the option to send responses with explanations for prescribing decisions. We also offered to meet with intervention providers using an academic detailing approach developed based on knowledge gaps discussed in provider focus groups. To assess feasibility, we tracked provider review of our messages. To assess effectiveness, we measured the change in anticoagulation for patients of intervention providers relative to controls. We identified 85 intervention and 34 control providers taking care of 3591 and 1908 patients, respectively; 33 intervention providers participated in academic detailing. More than 80% of intervention providers read our emails, and 98% of the time a provider reviewed our in-basket messages. Replies to messages identified patient refusal as the most common reason for patients not being on anticoagulation (11.2%). For the group of patients not on anticoagulation at baseline assigned to an intervention versus control provider, the adjusted percent increase in the use of anticoagulation over 6 months was 5.2% versus 7.4%, respectively ( P =0.21).

Conclusions:

Our electronic messaging and academic detailing intervention was feasible but did not increase anticoagulation use. Patient-directed interventions or provider interventions targeting patients declining anticoagulation may be necessary to raise the rate of anticoagulation.

Clinical Trial Registration

URL: http://www.clinicaltrials.gov . Unique identifier: NCT03583008.

Geriatric Conditions Predict Discontinuation of Anticoagulation in Long-Term Care Residents With Atrial Fibrillation

BACKGROUND

Anticoagulation (AC) for stroke prevention in long-term care (LTC) residents with atrial fibrillation (AF) involves a challenging risk-benefit evaluation. We measured the association of geriatric conditions with discontinuation of AC.

DESIGN

Retrospective cohort analysis.

SETTING

LTC facilities across the United States.

PARTICIPANTS

A total of 48 545 individuals residing in LTC facilities in 2015 with AF and sufficient information to establish their status as someone who stopped AC vs someone who continued AC.

MEASUREMENTS

We measured the association of six geriatric conditions-recent fall, severe activity of daily living (ADL) dependency (21-28 on a 28-point scale), mobility impairment, cognitive impairment, body mass index (BMI) less than 18.5 kg/m² , and weight loss (≥5% in 1 month or ≥10% in 6 months)-with discontinuation of AC. To identify cases of discontinuation, we required a pattern of being on AC over two consecutive recordings of the Minimum Data Set, the nursing home quality control data set recorded every 90 days, followed by two assessments being off AC-pattern of "on-on-off-off." By contrast, we required a pattern of "on-on-on-on" for continuers. We then constructed six logistic regression models to measure the independent association between each geriatric condition and discontinuation of AC, adjusted for CHA₂ DS₂ -VASc stroke risk score, recent bleeding hospitalization, and other confounders.

RESULTS

There were 4172 discontinuers and 44 373 continuers. Recent fall predicted a 1.9-fold increase in the odds of discontinuation (odds ratio = 1.91; 95% confidence interval = 1.66-2.20), whereas mobility and cognitive impairment only increased the odds by 14% to 17%. Severe ADL dependency, BMI less than 18.5 kg/m² , and weight loss of 10% each increased odds of discontinuation by 55% to 68%. CHA₂ DS₂ -VASc score did not predict discontinuation.

CONCLUSION

Several geriatric conditions predicted discontinuation of AC, whereas CHA₂ DS₂ -VASc score did not. Future research should examine the association of geriatric conditions and discontinuation of warfarin discrete from newer anticoagulants and association of geriatric conditions with development of stroke and bleeding. J Am Geriatr Soc 68:717-724, 2020.

Assessing Anticoagulation Management and Shared Decision-Making Documentation From Providers Participating in the SUPPORT-AF II Study

BACKGROUND

A previously tested intervention featured educational outreach with modified academic detailing (AD) to increase anticoagulation use in patients with atrial fibrillation. Currently, this study compares providers receiving and not receiving AD in terms of inclusion of AD educational topics and shared decision-making elements in documentation.

METHODS

Physicians reviewed themes discussed with providers during AD and evaluated charts for evidence of shared decision-making. Frequencies of documentation of individual items for providers receiving AD versus non-AD providers were compared. To understand baseline documentation practices of AD providers, encounters of AD providers before their AD participation were randomly selected.

RESULTS

There were 113 eligible encounters in the four months after AD-36 from AD providers and 77 from non-AD providers. Thirty-five encounters were identified from AD providers before participating in the intervention. Providers infrequently documented many reviewed items (% documenting): anticoagulation mentioned (44%), multiple options for anticoagulation (5%), CHA2DS2-VASc score (11%), bleeding risk factors (2%). Compared with non-AD providers, AD providers had statistically significant higher percentages for the following items: mention of anticoagulation (64% versus 35%), stroke risk (11% versus 0%), anticoagulation benefits (8% versus 0%), and patient involvement (17% versus 0%). There was no improvement, however, for AD providers compared with baseline documentation percentages.

DISCUSSION

Providers infrequently documented important items in anticoagulation management and shared decision-making. AD participation did not improve documentation. Improving adoption of AD educational items may require more prolonged interaction with providers. Improving shared decision-making may require an intervention more focused on it and its documentation.

The Effect of Gestational Weight Gain Across Reproductive History on Maternal Body Mass Index in Midlife: The Study of Women's Health Across the Nation

Background: Excessive weight gain during pregnancy is common and has been shown to be associated with increased long-term maternal weight. However, less is known on whether there is a cumulative effect of excessive gestational weight gain (GWG) over multiple pregnancies. Methods: Data from the Study of Women's Health Across the Nation were used, restricted to parous women with no history of stillbirth or premature birth. The effect of the number of excessive GWG pregnancies on body mass index (BMI) in midlife (age 42-53) was analyzed using multivariable linear regression. Fully adjusted models included parity, inadequate GWG, demographic, and behavioral characteristics. Results: The 1181 women included in this analysis reported a total of 2693 births. Overall, 466 (39.5%) were categorized as having at least one pregnancy with excessive GWG. The median BMI at midlife was 26.0 kg/m² (interquartile range 22.5-31.1). In fully adjusted models, each additional pregnancy with excessive GWG was associated with 0.021 higher estimated log BMI (p = 0.031). Among women with 1-3 births, adjusted mean (95% confidence interval) BMI for those with 0, 1, 2, and 3 excessive GWG pregnancies was 25.4 (24.9-25.9), 26.8 (26.1-27.5), 27.5 (26.6-28.4), and 28.8 (27.3-30.5), respectively. Conclusions: In this multiethnic study of women with a history of term live births, the number of pregnancies with excessive GWG was associated with increased maternal BMI in midlife. Our findings suggest that prevention of excessive GWG at any point in a woman's reproductive history can have an impact on long-term maternal health.

Communicating with patients about breakdowns in care: a national randomised vignette-based survey

BACKGROUND

Many patients are reluctant to speak up about breakdowns in care, resulting in missed opportunities to respond to individual patients and improve the system. Effective approaches to encouraging patients to speak up and responding when they do are needed.

OBJECTIVE

To identify factors which influence speaking up, and to examine the impact of apology when problems occur.

DESIGN

Randomised experiment using a vignette-based questionnaire describing 3 care breakdowns (slow response to call bell, rude aide, unanswered questions). The role of the person inquiring about concerns (doctor, nurse, patient care specialist), extent of the prompt (invitation to patient to share concerns) and level of apology were varied.

SETTING

National online survey.

PARTICIPANTS

1188 adults aged ≥35 years were sampled from an online panel representative of the entire US population, created and maintained by GfK, an international survey research organisation; 65.5% response rate.

MAIN OUTCOMES AND MEASURES

Affective responses to care breakdowns, intent to speak up, willingness to recommend the hospital.

RESULTS

Twice as many participants receiving an in-depth prompt about care breakdowns would (probably/definitely) recommend the hospital compared with those receiving no prompt (18.4% vs 8.8% respectively (p=0.0067)). Almost three times as many participants receiving a full apology would (probably/definitely) recommend the hospital compared with those receiving no apology (34.1% vs 13.6% respectively ((p<0.0001)). Feeling upset was a strong determinant of greater intent to speak up, but a substantial number of upset participants would not 'definitely' speak up. A more extensive prompt did not result in greater likelihood of speaking up. The inquirer's role influenced speaking up for two of the three breakdowns (rudeness and slow response).

CONCLUSIONS

Asking about possible care breakdowns in detail, and offering a full apology when breakdowns are reported substantially increases patients' willingness to recommend the hospital.

THE STUDY OF WOMEN’S HEALTH ACROSS THE NATION (SWAN): FROM MIDLIFE ONWARD

The Study of Women’s Health Across the Nation (SWAN) is a multisite, multiracial/ethnic longitudinal study of women initially aged 42-52 (N=3302) designed to characterize the physiological and psychosocial changes that occur during the menopause transition and to assess their relations to subsequent health and age-related diseases. Each of seven clinical sites recruited non-Hispanic white women and women belonging to a predetermined racial/ethnic minority (African American, Hispanic, Chinese, or Japanese). Cohort eligibility was determined from a cross-sectional survey of 16,065 women in 1996-97 aged 40-55 who were aged 42-52, had an intact uterus and at least one ovary, and not using hormone therapy. Cohort participants have been assessed in-person approximately annually through follow-up visit 15 in 2017 using a standardized protocol of detailed questions about medical, reproductive and menstrual history; lifestyle and psychosocial factors; physical and psychological symptoms; and anthropometric measurements, reproductive hormones, bone and body composition, and cardiovascular health.

Adverse Events in Long-term Care Residents Transitioning From Hospital Back to Nursing Home

IMPORTANCE

Transition from hospital to nursing home is a high-risk period for adverse events in long-term care (LTC) residents. Adverse events include harms from medical care, including failure to provide appropriate care.

OBJECTIVE

To report the incidence, type, severity, and preventability of adverse events in LTC residents transitioning from hospital back to the same LTC facility.

DESIGN, SETTING, AND PARTICIPANTS

Prospective cohort study of LTC residents discharged from hospital back to LTC from March 1, 2016, to December 31, 2017, and followed up for 45 days. In a random sample of 32 nursing homes located in 6 New England states, 555 LTC residents were selected, contributing 762 transitions from hospital back to the same LTC facility.

MAIN OUTCOMES AND MEASURES

The main outcome was an adverse event within the 45-day period after transition from hospital back to nursing home. Trained nurse abstractors reviewed nursing home records for the period, and then 2 physicians independently reviewed each potential adverse event to determine whether harm occurred and to characterize the type, severity, and preventability of each event. When reviewers disagreed, they met to reach consensus.

RESULTS

Of the 555 individual residents, 365 (65.6%) were female, and the mean (SD) age at the time of discharge was 82.2 (11.5) years. Five hundred twenty (93.7%) were non-Hispanic white, 21 (3.8%) were non-Hispanic black, 9 (1.6%) were Hispanic, and 5 (0.9%) were of other non-Hispanic race/ethnicity. In the cohort, there were 379 adverse events among 762 discharges. One hundred ninety-seven events (52.0%) related to resident care, with pressure ulcers, skin tears, and falls with injury representing the most common types of events in this category. Health care-acquired infections (108 [28.5%]) and adverse drug events (64 [16.9%]) were the next most common. One hundred ninety-eight (52.2%) adverse events were characterized as less serious. However, 145 (38.3%) events were deemed serious, 28 (7.4%) life-threatening, and 8 (2.1%) fatal. In terms of preventability, 267 (70.4%) adverse events were found to be preventable or ameliorable, with less serious events more often considered preventable or ameliorable (146 [73.7%]) compared with more severe events (121 [66.9%]). In addition, resident care-related adverse events such as fall with injury, skin tear, and pressure ulcer were more commonly deemed preventable (173 of 197 [87.8%]) compared with adverse drug events (39 of 64 [60.9%]) or health care-acquired infections (49 of 108 [45.4%]).

CONCLUSIONS AND RELEVANCE

Adverse events developed in nearly 4 of 10 of discharges from hospital back to LTC. Most were preventable or ameliorable. Standardized reporting of events and better coordination and information transfer across settings are potential ways to prevent adverse events in LTC residents.

Weight Management Counseling (WMC)p07 During Primary Care Clerkships: Preceptors Perceived Skills, Attitudes and Frequency of Modeling WMC to Students (P07-001-19)

Objectives

The United States Preventive Services Task Force (USPSTF) 2018 guideline for the management of adults with obesity continues to support screening and offering or referring patients with obesity to intensive multi-component behavioral intervention. Training the primary care work force is important for implementation of guidelines. It is unclear to what degree medical school preceptors provide weight management counseling (WMC) training during primary care core clerkships. This study seeks to describe preceptors’ perceived skills and attitudes towards providing WMC to patients and the frequency of preceptors modeling WMC to medical students.

Methods

Primary care preceptors (family/community medicine and ambulatory internal medicine) from medical schools participating in a larger multi-modal curriculum intervention were recruited to participate in an anonymous 10-minute cross-sectional survey on their perceived skills, attitudes, and modeling WMC to medical students.

Results

The survey was completed by 77 eligible preceptors (response rate of 33%). Preceptors perceived themselves to be moderately skilled in WMC, with a perceived WMC skills mean of 2.8, sd 0.56 (range 1–4). Their mean attitudes score was 2.1, sd 0.5 (range 1–4). Preceptors agree they have a responsibility to provide WMC and can be effective with patients. Preceptors report sometimes modeling WMC behaviors to medical students, the mean was 3.26, sd 0.48 (range 1–5). Of those preceptors who never/rarely model referrals, the most common reason was lack of resources followed by patient cost barriers.

Conclusions

Preceptors do not consistently model WMC for medical students during primary care core clerkships. Skill perception and resource availability may contribute.

Funding Sources

Research reported in this publication was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under award number TL1-TR001454. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

The association between vascular complications during pregnancy in women with Type 1 diabetes and congenital malformations

AIMS

To assess the association between vascular complications of diabetes and the risk of congenital malformations in pregnant women with Type 1 diabetes.

METHODS

We conducted an observational retrospective cohort study in women with Type 1 diabetes who received care consecutively from three tertiary care diabetes-in-pregnancy clinics in Calgary, Alberta, Canada. Multivariable logistic regression was used to assess the association between vascular complications (retinopathy, nephropathy and pre-existing hypertension) and congenital malformations in offspring of women with Type 1 diabetes.

RESULTS

Of 232 women with Type 1 diabetes, 49 (21%) had at least one vascular complication and there were 52 babies with congenital malformations. Maternal age (31.8 ± 5.0 vs. 29.4 ± 4.7 years, P < 0.01), diabetes duration (20.9 ± 6.7 vs. 11.2 ± 7.4 years, P < 0.01) and pre-eclampsia rate (12.5% vs. 1.3%, P < 0.01) were higher in mothers with vascular complications than in those without. Multivariable analyses showed that vascular complications were not associated with an increased risk of congenital malformations (odds ratio 1.16, 95% confidence interval 0.46 to 2.88).

CONCLUSIONS

Vascular complications are common, occurring in one-fifth of pregnant women with Type 1 diabetes, and in this study do not appear to be associated with an increased risk of congenital malformations in children.

SUPPORT-AF: Piloting a Multi-Faceted, Electronic Medical Record-Based Intervention to Improve Prescription of Anticoagulation

Background Only 50% of eligible atrial fibrillation ( AF ) patients receive anticoagulation ( AC ). Feasibility and effectiveness of electronic medical record (EMR)-based interventions to profile and raise provider AC percentage is poorly understood. The SUPPORT-AF (Supporting Use of AC Through Provider Profiling of Oral AC Therapy for AF) study aims to improve rates of adherence to AC guidelines by developing and delivering supportive tools based on the EMR to providers treating patients with AF. Methods and Results We emailed cardiologists and community-based primary care providers affiliated with our institution reports of their AC percentage relative to peers. We also sent an electronic medical record-based message to these providers the day before an appointment with an atrial fibrillation patient who was eligible but not receiving AC . The electronic medical record message asked the provider to discuss AC with the patient if he or she deemed it appropriate. To assess feasibility, we tracked provider review of our correspondence. We also tracked the change in AC for intervention providers relative to alternate primary care providers not receiving our intervention. We identified 3786, 1054, and 566 patients cared for by 49 cardiology providers, 90 community-based primary care providers, and 88 control providers, respectively. At baseline, the percentage of AC was 71.3%, 63.5%, and 58.3% for these 3 respective groups. Intervention providers reviewed our e-mails and electronic medical record messages 45% and 96% of the time, respectively. For providers responding, patient refusal was the most common reason for patients not being on AC (21%) followed by high bleeding risk (19%). At follow-up 10 weeks later, change in AC was no different for either cardiology or community-based primary care providers relative to controls (0.2% lower and 0.01% higher, respectively). Conclusions Our intervention profiling AC was feasible, but not sufficient to increase AC in our population.

Integrating mindfulness training in school health education to promote healthy behaviors in adolescents: Feasibility and preliminary effects on exercise and dietary habits

Whether mindfulness training (MT) could improve healthy behaviors is unknown. This study sought to determine feasibility and acceptability of integrating MT into school-based health education (primary outcomes) and to explore its possible effects on healthy behaviors (exploratory outcomes). Two high schools in Massachusetts (2014–2015) were randomized to health education plus MT (HE-MT) (one session/week for 8 weeks) or to health education plus attention control (HE-AC). Dietary habits (24-h dietary recalls) and moderate-to-vigorous physical activity (MVPA/7-day recalls) were assessed at baseline, end of treatment (EOT), and 6 months thereafter. Quantile regression and linear mixed models were used, respectively, to estimate effects on MVPA and dietary outcomes adjusting for confounders. We recruited 53 9th graders (30 HEM, 23 HEAC; average age 14.5, 60% white, 59% female). Retention was 100% (EOT) and 96% (6 months); attendance was 96% (both conditions), with moderate-to-high satisfaction ratings. Among students with higher MVPA at baseline, MVPA was higher in HE-MT vs. HE-AC at both EOT (median difference = 81 min/week, p = 0.005) and at 6 months (p = 0.004). Among males, median MVPA was higher (median difference = 99 min/week) in HE-MT vs. HEAC at both EOT (p = 0.056) and at 6 months (p = 0.04). No differences were noted in dietary habits. In sum, integrating school-based MT into health education was feasible and acceptable and had promising effects on MVPA among male and more active adolescents. These findings suggest that MT may improve healthy behaviors in adolescents and deserve to be reproduced in larger, rigorous studies.

•

Integrating mindfulness training into high school health education is feasible.

•

The program is scalable because health education is commonly taught in US schools.

•

Larger studies are needed to establish its efficacy on health behaviors.

Self-Reported Function More Informative than Frailty Phenotype in Predicting Adverse Postoperative Course in Older Adults

BACKGROUND/OBJECTIVE

Current preoperative assessment tools such as the American College of Surgeons Surgical Risk Calculator (ACS Calculator) are suboptimal for evaluating older adults. The objective was to evaluate and compare the performance of the ACS Calculator for predicting risk of serious postoperative complications with the addition of self-reported physical function versus a frailty score.

DESIGN

Prospective cohort.

SETTING

Two tertiary care academic medical centers in Massachusetts.

PARTICIPANTS

Individuals aged 65 and older undergoing any surgery with a risk of serious complication of 5% or greater (N = 403).

MEASUREMENTS

We measured self-reported physical function using the Late-Life Function and Disability Instrument (LLFDI FUNCTION) and frailty phenotype (FP), which has a score ranging from 0 to 5 based on slow gait speed, weak handgrip, exhaustion, weight loss, or low activity. Using c-statistic and net classification improvement (NRI), we then analyzed capability of LLFDI-FUNCTION versus FP to improve the ACS Calculator for predicting an adverse postoperative course (serious complication, discharge to nursing home, readmission, death within 30 days of surgery). Increase in c-statistic and net reclassification improvement (NRI) for LLFDI-FUNCTION versus FP in addition to the ACS Calculator for predicting an adverse postoperative course (serious complication, discharge to nursing home, readmission, death within 30 days of surgery) RESULTS: Over 30 days, 26% of participants developed an adverse postoperative course. The increase in c-statistic for the ACS Calculator (baseline value 0.645) was slightly greater with LLFDI-FUNCTION (0.076) than with FP (0.058), with a bootstrapped difference in c-statistic of 0.005 (95% confidence interval = 0.002-0.007). NRI was also better with LLFDI-FUNCTION.

CONCLUSION

The LLFDI-FUNCTION predicted postoperative complications slightly better than the FP. Further studies are needed to confirm these findings and validate the use of the LLFDI-FUNCTION with the ACS Calculator for preoperative assessments of older adults.