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Purvis SJ, Armstrong K, Isaacson MJ, Soltoff A, Duran T, Johnson G, LaPlante JR, Daubman BR, Tobey M. Factors Associated with COVID-19 Vaccination Uptake in Great Plains American Indian Communities. J Racial Ethn Health Disparities 2023:10.1007/s40615-023-01818-9. [PMID: 37796431 DOI: 10.1007/s40615-023-01818-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 09/20/2023] [Accepted: 09/23/2023] [Indexed: 10/06/2023]
Abstract
With the development of the COVID-19 vaccine in late 2020, the importance of understanding the drivers of vaccine acceptance and vaccine hesitancy is important for the health of American Indian and Alaska Native communities. We conducted a cross-sectional, anonymous survey in October 2021 using established quantitative methods of virtual surveys to reach tribal members living on three reservations in the Great Plains (N = 679). We conducted multivariate analyses using logistic regression to assess the association between independent variables and COVID-19 vaccination status after adjusting for confounding. Respondents were more likely to have received a COVID-19 vaccine if they were older, had a full-time job, had previously received a flu vaccination, reported a higher level of trust in the health care system, had increased access to vaccinations, were able to isolate, or if they held a desire to keep their family safe. This study is one of the first to offer insights into the associations and possible determinants of COVID-19 vaccine uptake among American Indians in the Great Plains and was completed as part of the National Institutes of Health Rapid Acceleration of Diagnostics of Underserved Populations consortium. We identified a set of demographic, socioeconomic, and motivational factors that are associated with COVID-19 vaccination uptake among Great Plains American Indians and Alaska Natives. It is possible that future vaccine uptake may be enhanced through economic development, strengthening health care operations and care quality, and focusing vaccination messaging on family and community impact.
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Affiliation(s)
- Sara J Purvis
- Department of Medicine, Massachusetts General Hospital, 100 Cambridge Street, 16th Floor, Boston, MA, 02114, USA.
| | | | - Mary J Isaacson
- College of Nursing South Dakota State University, Rapid City, SD, USA
| | | | - Tinka Duran
- Great Plains Tribal Epidemiology Center, Great Plains Tribal Leaders' Health Board, Rapid City, SD, USA
| | - Gina Johnson
- Community Health Prevention Programs, Great Plains Tribal Leaders' Health Board, Rapid City, SD, USA
| | - J R LaPlante
- American Indian Health Initiative, Avera Health, Sioux Falls, SD, USA
| | - Bethany-Rose Daubman
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Matthew Tobey
- Department of Medicine, Massachusetts General Hospital, 100 Cambridge Street, 16th Floor, Boston, MA, 02114, USA
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Purvis SJ, Soltoff A, Isaacson MJ, Duran T, Johnson G, LaPlante JR, Tobey M, Armstrong K. COVID-19 Testing Factors Among Great Plains American Indians. J Racial Ethn Health Disparities 2023; 10:2528-2539. [PMID: 36271192 PMCID: PMC9589717 DOI: 10.1007/s40615-022-01433-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 10/07/2022] [Accepted: 10/12/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND COVID-19 created unparalleled challenges for vulnerable communities, especially among American Indians and Alaska Natives. An effective COVID-19 response requires a tribally driven effort to understand the perspectives of Tribal members on testing and to ensure that delivery strategies are grounded in the cultural values, traditions, and experiences of the Tribes. METHODS We conducted a cross-sectional, anonymous survey in October 2021 using established methods to reach Tribal members residing in three Reservations in the Great Plains (N = 679). Multivariate analyses were conducted using logistic regression to assess the association between independent variables and COVID-19 testing uptake after adjusting for confounding. RESULTS After multivariate adjustment, a respondent's employment status, ability to isolate if diagnosed with COVID-19, and endorsing that COVID-19 testing is only needed if one has symptoms were significantly correlated with having been previously tested for COVID-19. Participants without a full-time job were about half as likely to have been tested for COVID-19 compared to those with full-time jobs. Participants who reported not being able to isolate if they tested positive for COVID-19 and participants who did not think testing was needed if asymptomatic were also half as likely to be tested. CONCLUSIONS Ensuring that everyone has the ability to isolate, that people who are not working have easy access to testing, and that everyone understands the value of testing after exposure are key steps to maximizing testing uptake. Efforts will only be successful if there is continued investment in programs that provide free testing access for everyone on Reservations.
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Affiliation(s)
- Sara J Purvis
- Department of Medicine, Massachusetts General Hospital, 100 Cambridge Street, 16th Floor, Boston, MA, 02114, USA.
| | - Alexander Soltoff
- Department of Medicine, Massachusetts General Hospital, 100 Cambridge Street, 16th Floor, Boston, MA, 02114, USA
| | - Mary J Isaacson
- College of Nursing South, Dakota State University, Rapid City, SD, USA
| | - Tinka Duran
- Great Plains Tribal Epidemiology Center, Great Plains Trifbal Leaders' Health Board, Rapid City, SD, USA
| | - Gina Johnson
- Community Health Prevention Programs, Great Plains Tribal Leaders' Health Board, Rapid City, SD, USA
| | - J R LaPlante
- American Indian Health Initiative, Avera Health, Sioux Falls, SD, USA
| | - Matthew Tobey
- Department of Medicine, Massachusetts General Hospital, 100 Cambridge Street, 16th Floor, Boston, MA, 02114, USA
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Daubman BR, Duran T, Johnson G, Soltoff A, Purvis S, Sargent M, LaPlante JR, Petereit D, Armstrong K, Isaacson MJ. "You Can't Record That!" Engaging American Indian Traditional Healers in Qualitative Research. J Pain Symptom Manage 2023; 65:e507-e509. [PMID: 36682674 PMCID: PMC10229072 DOI: 10.1016/j.jpainsymman.2023.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 12/29/2022] [Accepted: 01/06/2023] [Indexed: 01/22/2023]
Affiliation(s)
- Bethany-Rose Daubman
- Division of Palliative Care and Geriatric Medicine (B.R.D.), Massachusetts General Hospital, Boston, Massachusetts, USA.
| | - Tinka Duran
- Great Plains Tribal Leaders Health Board (T.D., G.J.), Rapid City, South Dakota, USA
| | - Gina Johnson
- Great Plains Tribal Leaders Health Board (T.D., G.J.), Rapid City, South Dakota, USA
| | | | - Sara Purvis
- Department of Medicine (S.P.), Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Michele Sargent
- Walking Forward, Avera Research Institute, Avera Health (M.S.), Rapid City, South Dakota, USA
| | - J R LaPlante
- American Indian Health Initiative, Avera Health (J.R.L.), Sioux Falls, South Dakota, USA
| | - Daniel Petereit
- Department of Radiation Oncology (D.P.), Monument Health Cancer Care Institute, Walking Forward, Avera Research Institute, Avera Health, Rapid City, South Dakota, USA
| | - Katrina Armstrong
- Vagelos College of Physicians and Surgeons (K.A.), Columbia University, New York, New York, USA
| | - Mary J Isaacson
- College of Nursing (M.J.I), South Dakota State University, Rapid City, South Dakota, USA
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Isaacson MJ, Duran T, Johnson GR, Soltoff A, Jackson SM, Purvis SJ, Sargent M, LaPlante JR, Petereit DG, Armstrong K, Daubman BR. Great Plains American Indians' Perspectives on Patient and Family Needs Throughout the Cancer Journey. Oncol Nurs Forum 2023; 50:279-289. [PMID: 37155972 PMCID: PMC10233750 DOI: 10.1188/23.onf.279-289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
PURPOSE To explore the perspectives on patient and family needs during cancer treatment and survivorship of American Indian (AI) cancer survivors, caregivers, Tribal leaders, and healers. PARTICIPANTS & SETTING 36 AI cancer survivors from three reservations in the Great Plains region. METHODOLOGIC APPROACH A community-based participatory research design was employed. Postcolonial Indigenous research techniques of talking circles and semistructured interviews were used to gather qualitative data. Data were analyzed using content analysis to identify themes. FINDINGS The overarching theme of accompaniment was identified. The following themes were intertwined with this theme: (a) the need for home health care, with the subthemes of family support and symptom management; and (b) patient and family education. IMPLICATIONS FOR NURSING To provide high-quality cancer care to AI patients in their home communities, oncology clinicians should collaborate with local care providers, relevant organizations, and the Indian Health Service to identify and develop essential services. Future efforts must emphasize culturally responsive interventions in which Tribal community health workers serve as navigators to accompany patients and families during treatment and in survivorship.
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Palumbi SR, Walker NS, Hanson E, Armstrong K, Lippert M, Cornwell B, Nestor V, Golbuu Y. Small-scale genetic structure of coral populations in Palau based on whole mitochondrial genomes: Implications for future coral resilience. Evol Appl 2023; 16:518-529. [PMID: 36793699 PMCID: PMC9923468 DOI: 10.1111/eva.13509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 09/21/2022] [Accepted: 09/26/2022] [Indexed: 01/07/2023] Open
Abstract
The ability of local populations to adapt to future climate conditions is facilitated by a balance between short range dispersal allowing local buildup of adaptively beneficial alleles, and longer dispersal moving these alleles throughout the species range. Reef building corals have relatively low dispersal larvae, but most population genetic studies show differentiation only over 100s of km. Here, we report full mitochondrial genome sequences from 284 tabletop corals (Acropora hyacinthus) from 39 patch reefs in Palau, and show two signals of genetic structure across reef scales from 1 to 55 km. First, divergent mitochondrial DNA haplotypes exist in different proportions from reef to reef, causing PhiST values of 0.02 (p = 0.02). Second, closely related sequences of mitochondrial Haplogroups are more likely to be co-located on the same reefs than expected by chance alone. We also compared these sequences to prior data on 155 colonies from American Samoa. In these comparisons, many Haplogroups in Palau were disproportionately represented or absent in American Samoa, and inter-regional PhiST = 0.259. However, we saw three instances of identical mitochondrial genomes between locations. Together, these data sets suggest two features of coral dispersal revealed by occurrence patterns in highly similar mitochondrial genomes. First, the Palau-American Samoa data suggest that long distance dispersal in corals is rare, as expected, but that it is common enough to deliver identical mitochondrial genomes across the Pacific. Second, higher than expected co-occurrence of Haplogroups on the same Palau reefs suggests greater retention of coral larvae on local reefs than predicted by many current oceanographic models of larval movement. Increased attention to local scales of coral genetic structure, dispersal, and selection may help increase the accuracy of models of future adaptation of corals and of assisted migration as a reef resilience intervention.
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Affiliation(s)
- Stephen R Palumbi
- Department of Biology and Oceans Department Hopkins Marine Station of Stanford University Pacific Grove California USA
| | - Nia S Walker
- Department of Biology and Oceans Department Hopkins Marine Station of Stanford University Pacific Grove California USA.,Hawaii Institute of Marine Biology, University of Hawaii Honolulu Hawaii USA
| | - Erik Hanson
- Department of Biology and Oceans Department Hopkins Marine Station of Stanford University Pacific Grove California USA
| | - Katrina Armstrong
- Department of Biology and Oceans Department Hopkins Marine Station of Stanford University Pacific Grove California USA
| | - Marilla Lippert
- Department of Biology and Oceans Department Hopkins Marine Station of Stanford University Pacific Grove California USA
| | - Brendan Cornwell
- Department of Biology and Oceans Department Hopkins Marine Station of Stanford University Pacific Grove California USA
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Dawson R, Wands DIF, Logan M, Bremner G, Efklides S, Benn L, Henderson P, Grant H, Meredith J, Armstrong K, Wilson DC, Gerasimidis K, Alex G, Russell RK. Comparing Effectiveness of a Generic Oral Nutritional Supplement With Specialized Formula in the Treatment of Active Pediatric Crohn's Disease. Inflamm Bowel Dis 2022; 28:1859-1864. [PMID: 35259266 DOI: 10.1093/ibd/izac039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND Exclusive enteral nutrition (EEN) is the recommended induction treatment of mild to moderate active pediatric Crohn's disease (CD). This study compared outcomes of 2 proprietary polymeric formulas. Treatment effectiveness was examined along with practical aspects of formula delivery and differences in estimated treatment costs. METHODS Data were retrospectively collected from patients with CD who received a generic oral nutritional supplement (Fortisip) across 2 centers (RCH, Melbourne and RHSC, Edinburgh). This was compared with a prospective cohort (RHC, Glasgow) that used a specialized formula (Modulen IBD). The data collected included patient demographics, remission rates, biochemical markers, administration method, and anthropometrics. The estimated treatment cost was performed by comparing price per kcal between each formula. RESULTS One hundred seventy-one patients were included (106 Fortisip, 65 Modulen IBD, 70 female; median age 13.3 yrs). No difference was demonstrated in remission rate (Fortisip n = 67 of 106 [63%] vs Modulen IBD n = 41 of 64 [64%], P = .89), nonadherence rate (Fortisip n = 7 of 106 [7%] vs Modulen IBD 3 of 64 [5%], P = .57) or method of administration (NGT Fortisip use n = 16 of 106 [12%] vs Modulen IBD 14 of 65 [22%]; P = .31). There was no difference in reduction of biochemical disease markers between the groups (C-reactive protein , P = .13; erythrocyte sedimentation rate, P = .49; fecal calprotectin, P = .94). However, there was a cost-saving of around £500/patient/course if the generic oral nutritional supplement was used. CONCLUSIONS The generic oral nutritional supplement and specialized formulas both had similar clinical effectiveness in induction of remission in pediatric CD. However, there is considerable cost-saving when using a generic oral nutritional supplement.
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Affiliation(s)
- R Dawson
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Children & Young people, Edinburgh, UK
| | - D I F Wands
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Children & Young people, Edinburgh, UK
- Department of Gastroenterology, Hepatology and Clinical Nutrition, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - M Logan
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
| | - G Bremner
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Children & Young people, Edinburgh, UK
| | - S Efklides
- Department of Nutrition and Food Services, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - L Benn
- Department of Nutrition and Food Services, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - P Henderson
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Children & Young people, Edinburgh, UK
- Child Life and Health, University of Edinburgh, Royal Hospital for Children & Young people, Edinburgh, UK
| | - H Grant
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Children & Young people, Edinburgh, UK
| | - J Meredith
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Children & Young people, Edinburgh, UK
| | - K Armstrong
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Children & Young people, Edinburgh, UK
| | - D C Wilson
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Children & Young people, Edinburgh, UK
- Child Life and Health, University of Edinburgh, Royal Hospital for Children & Young people, Edinburgh, UK
| | - K Gerasimidis
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
| | - G Alex
- Department of Gastroenterology, Hepatology and Clinical Nutrition, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - R K Russell
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Children & Young people, Edinburgh, UK
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
- Child Life and Health, University of Edinburgh, Royal Hospital for Children & Young people, Edinburgh, UK
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Abohashem S, Osborne M, Choi K, Liu Z, Zureigat H, Mezue K, Gharios C, Armstrong K, Smoller J, Tawakol A. Genetic sensitivity to stress modifies the relationship between socioeconomic status and major adverse cardiovascular events. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Lower socioeconomic status (SES) associates with major adverse cardiovascular events (MACE), in part through stress-related neural pathways that elicit inflammation. However, it is unknown whether genes that heighten stress sensitivity modify the association between lower SES and MACE.
Purpose
To assess whether genetic predisposition to stress sensitivity would modify the link between low SES and MACE
Methods
13,154 participants (median age 60 yrs, 41% male) from the Mass General Brigham Biobank were studied. A polygenic risk score for neuroticism (nPRS) was used as a measure of genetic predisposition to stress sensitivity (GSS). Using home addresses, SES was evaluated as median income and area deprivation index (ADI). Stress-related neural activity (SNA) was assessed (N=978) using validated FDG PET/CT imaging methods. MACE, and cardiovascular disease (CVD) risk factors were evaluated. Mediation analyses were employed.
Results
Over median (IQR) 4.9 (4.1–5.9) years of follow-up, 1,030 (7.8%) individuals had MACE. Lower SES (as low income, or alternatively as high ADI) associated with incident MACE among individuals with higher GSS (nPRS ≥ median) but not lower GSS (Fig. 1A and 1B). Similarly, lower SES associated with SNA among individuals with higher but not lower GSS (Fig. 1C). SNA mediated the relationship between income and MACE (P<0.05**) among those with higher GSS.
Conclusions
Genetic predisposition to stress sensitivity appears to heighten CVD risk associated with lower SES. This relationship may result from differential activation of stress-related neural pathways.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- S Abohashem
- Massachusetts General Hospital - Harvard Medical School , Boston , United States of America
| | - M Osborne
- Massachusetts General Hospital - Harvard Medical School , Boston , United States of America
| | - K Choi
- Massachusetts General Hospital - Harvard Medical School , Boston , United States of America
| | - Z Liu
- Massachusetts General Hospital - Harvard Medical School , Boston , United States of America
| | - H Zureigat
- Massachusetts General Hospital - Harvard Medical School , Boston , United States of America
| | - K Mezue
- Massachusetts General Hospital - Harvard Medical School , Boston , United States of America
| | - C Gharios
- Massachusetts General Hospital - Harvard Medical School , Boston , United States of America
| | - K Armstrong
- Massachusetts General Hospital - Harvard Medical School , Boston , United States of America
| | - J Smoller
- Massachusetts General Hospital - Harvard Medical School , Boston , United States of America
| | - A Tawakol
- Massachusetts General Hospital - Harvard Medical School , Boston , United States of America
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Rodenas-Alesina E, Aleksova N, Armstrong K, Kozuszko S, Moayedi Y, Duero-Posada J, McDonald M, Ross H, Dipchand A. CARDIAC ALLOGRAFT VASCULOPATHY AND SURVIVAL IN PEDIATRIC HEART TRANSPLANT RECIPIENTS TRANSITIONED TO ADULT CARE. Can J Cardiol 2022. [DOI: 10.1016/j.cjca.2022.08.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Isaacson MJ, Duran T, Johnson G, Soltoff A, Jackson S, Petereit D, Armstrong K, Daubman BR. "Calling the Spirit Back:" Spiritual Needs Among Great Plains American Indians. J Pain Symptom Manage 2022; 64:268-275. [PMID: 35618248 PMCID: PMC9378634 DOI: 10.1016/j.jpainsymman.2022.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 05/06/2022] [Accepted: 05/09/2022] [Indexed: 11/17/2022]
Abstract
CONTEXT American Indians (AIs) are disproportionately affected by serious illness such as cancer. Colonization, cultural genocide, and trauma have adversely affected AIs' ability to attain health and well-being, and in many cases led to the loss of the right to practice traditional ceremonies and rituals. Still many AIs describe well-being as being rooted in spirituality. OBJECTIVES The purpose of this project was to learn about the perspectives of AI cancer survivors, caregivers, and Tribal leaders and healers specific to spirituality while on the cancer journey. METHODS Qualitative interviews and Indigenous talking circle methodologies were used to explore AIs cancer survivors, caregivers, and Tribal leaders and healers' perspectives on spirituality while on the cancer journey. A data analysis team consisting of AI and non-AI members analyzed the narrative data. RESULTS Qualitative analysis of interviews and talking circles revealed 4 major themes related to spirituality: the chasm of colonialism, coexistence of Traditional and Christian religions, calling the Spirit back, and prayer as sacred energy. CONCLUSION It is critical that clinicians caring for AIs with serious illness seek to understand their patients' spiritual beliefs about disease treatment and death and work with them and their families to support quality of life throughout their illness journey. In addition, clinicians must recognize the systemic racism inherent in our healthcare systems, and dismantle cultural clashes and bias for all patients, particularly AIs, who have long suffered from poorer health outcomes.
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Affiliation(s)
- Mary J Isaacson
- South Dakota State University, College of Nursing (M.J.I.), Rapid City, South Dakota, USA.
| | - Tinka Duran
- Great Plains Tribal Leaders Health Board (T.D., G.J., S.J.), Rapid City, South Dakota, USA
| | - Gina Johnson
- Great Plains Tribal Leaders Health Board (T.D., G.J., S.J.), Rapid City, South Dakota, USA
| | - Alexander Soltoff
- Department of Medicine (A.S.), Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sean Jackson
- Great Plains Tribal Leaders Health Board (T.D., G.J., S.J.), Rapid City, South Dakota, USA
| | - Daniel Petereit
- Department of Radiation Oncology (D.P.), Monument Health Cancer Care Institute, Walking Forward, Avera Research Institute, Avera Health, Rapid City, South Dakota, USA
| | - Katrina Armstrong
- Dean, Vagelos College of Physicians and Surgeons, Columbia University, New York
| | - Bethany-Rose Daubman
- Division of Palliative Care and Geriatric Medicine (B.-R. D.), Massachusetts General Hospital, Boston, Massachusetts, USA
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Soltoff A, Purvis S, Ravicz M, Isaacson MJ, Duran T, Johnson G, Sargent M, LaPlante JR, Petereit D, Armstrong K, Daubman BR. Factors Influencing Palliative Care Access and Delivery for Great Plains American Indians. J Pain Symptom Manage 2022; 64:276-286. [PMID: 35618250 PMCID: PMC10230738 DOI: 10.1016/j.jpainsymman.2022.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 05/06/2022] [Accepted: 05/09/2022] [Indexed: 11/22/2022]
Abstract
CONTEXT Despite the known importance of culturally tailored palliative care (PC), American Indian people (AIs) in the Great Plains lack access to such services. While clinicians caring for AIs in the Great Plains have long acknowledged major barriers to serious illness care, there is a paucity of literature describing specific factors influencing PC access and delivery for AI patients living on reservation land. OBJECTIVES This study aimed to explore factors influencing PC access and delivery on reservation land in the Great Plains to inform the development culturally tailored PC services for AIs. METHODS Three authors recorded and transcribed interviews with 21 specialty and 17 primary clinicians. A data analysis team of seven authors analyzed transcripts using conventional content analysis. The analysis team met over Zoom to engage in code negotiation, classify codes, and develop themes. RESULTS Qualitative analysis of interview data revealed four themes encompassing factors influencing palliative care delivery and access for Great Plains American Indians: health care system operations (e.g., hospice and home health availability, fragmented services), geography (e.g., weather, travel distances), workforce elements (e.g., care continuity, inadequate staffing, cultural familiarity), and historical trauma and racism. CONCLUSION Our findings emphasize the importance of addressing the time and cost of travel for seriously ill patients, increasing home health and hospice availability on reservations, and improving trust in the medical system. Strengthening the AI medical workforce, increasing funding for the Indian Health Service, and transitioning the governance of reservation health care to Tribal entities may improve the trustworthiness of the medical system.
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Affiliation(s)
- Alexander Soltoff
- Department of Medicine (A.S., S.P., M.R.), Massachusetts General Hospital, Boston, MA, USA.
| | - Sara Purvis
- Department of Medicine (A.S., S.P., M.R.), Massachusetts General Hospital, Boston, MA, USA
| | - Miranda Ravicz
- Department of Medicine (A.S., S.P., M.R.), Massachusetts General Hospital, Boston, MA, USA
| | - Mary J Isaacson
- College of Nursing South Dakota State University (M.J.I.), Rapid City, SD, USA
| | - Tinka Duran
- Community Health Prevention Programs (T.D., G.J.), Great Plains Tribal Leaders Health Board, Rapid City, SD, USA
| | - Gina Johnson
- Community Health Prevention Programs (T.D., G.J.), Great Plains Tribal Leaders Health Board, Rapid City, SD, USA
| | - Michele Sargent
- Walking Forward (M.S., D.P.), Avera Research Institute, Avera Health, Rapid City, SD, USA
| | - J R LaPlante
- American Indian Health Initiative (J.R.L.), Avera Health, Sioux Falls, SD, USA
| | - Daniel Petereit
- Walking Forward (M.S., D.P.), Avera Research Institute, Avera Health, Rapid City, SD, USA
| | | | - Bethany-Rose Daubman
- Massachusetts General Hospital, Division of Palliative Care and Geriatric Medicine (B.R.D.), Boston, MA, USA
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Begin AS, Hidrue MK, Lehrhoff S, Lennes IT, Armstrong K, Weilburg JB, del Carmen MG, Wasfy JH. Association of Self-reported Primary Care Physician Tolerance for Uncertainty With Variations in Resource Use and Patient Experience. JAMA Netw Open 2022; 5:e2229521. [PMID: 36048444 PMCID: PMC9437748 DOI: 10.1001/jamanetworkopen.2022.29521] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
IMPORTANCE Inappropriate variations in clinical practice are a known cause of poor quality and safety, with variations often associated with nonclinical factors, such as individual differences in cognitive processing. The differential response of physicians to uncertainty may explain some of the variations in resource use and patient experience. OBJECTIVE To examine the association of physician tolerance for uncertainty with variations in resource use and patient experience. DESIGN, SETTING, AND PARTICIPANTS This survey study linked physician survey data (May to June 2019), patient experience survey data (January 2016 to December 2019), and billing data (January 2019 to December 2019) among primary care physicians (PCPs) at Massachusetts General Hospital with at least 10 visits in 2019. The statistical analysis was performed in 2021. MAIN OUTCOMES AND MEASURES The analysis examined associations of PCP tolerance for uncertainty with the tendency to order diagnostic tests, the frequency of outpatient visits, hospital admissions, emergency department visits, and patient experience data (focused on physician communication and overall rating). A 2-stage hierarchical framework was used to account for clustering of patients under PCPs. Binary outcomes were modeled using a hierarchical logistic model, and count outcomes were modeled using hierarchical Poisson or negative binomial models. The analysis was adjusted for patient demographic variables (age, sex, and race and ethnicity), socioeconomic factors (payer and neighborhood income), and clinical comorbidities. RESULTS Of 217 included physicians, 137 (63.1%) were women, and 174 (80.2%) were adult PCPs. A total of 62 physicians (28.6%) reported low tolerance, 59 (27.2%) reported medium tolerance, and 96 (44.2%) reported high tolerance for uncertainty. Physicians with a low tolerance for uncertainty were less likely to order complete blood cell counts (odds ratio [OR], 0.66; 95% CI, 0.50-0.88), thyroid tests (OR, 0.67; 95% CI, 0.52-0.88), a basic metabolic profile (OR, 0.78; 95% CI, 0.60-1.00), and liver function tests (OR, 0.72; 95% CI, 0.53-0.99) than physicians with a high tolerance for uncertainty. Physicians who reported higher tolerance for uncertainty were more likely to receive higher patient experience scores for listening to patients carefully (OR, 0.65; 95% CI, 0.50-0.83) and higher overall ratings (OR, 0.80; 95% CI, 0.66-0.98) than physicians with medium tolerance. Conversely, no association was found between physician tolerance for uncertainty and patient outpatient visits, hospital admissions, or emergency department visits. CONCLUSIONS AND RELEVANCE In clinical practice, identifying and effectively managing inappropriate variations and improving patient experience have proven to be difficult, despite increased attention to these issues. This study supports the hypothesis that physicians' tolerance for uncertainty is associated with differences in resource use and patient experience. Whether enhancing physicians' tolerance for uncertainty could help reduce unwarranted practice variations, improve quality and patient safety, and improve patient's experience remains to be established.
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Affiliation(s)
- Arabella S. Begin
- Department of Medicine, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | | | - Sara Lehrhoff
- Massachusetts General Physicians Organization, Boston
| | | | - Katrina Armstrong
- Department of Medicine, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
- Columbia University Irving Medical Center, New York, New York
| | - Jeffrey B. Weilburg
- Massachusetts General Physicians Organization, Boston
- Department of Psychiatry, Massachusetts General Hospital, Boston
| | - Marcela G. del Carmen
- Harvard Medical School, Boston, Massachusetts
- Massachusetts General Physicians Organization, Boston
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology and Reproductive Biology, Massachusetts General Hospital, Boston
| | - Jason H. Wasfy
- Department of Medicine, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston
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12
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Schroeder PH, Brenner LN, Kaur V, Cromer SJ, Armstrong K, LaRocque RC, Ryan ET, Meigs JB, Florez JC, Charles RC, Mercader JM, Leong A. Proteomic analysis of cardiometabolic biomarkers and predictive modeling of severe outcomes in patients hospitalized with COVID-19. Cardiovasc Diabetol 2022; 21:136. [PMID: 35864532 PMCID: PMC9301894 DOI: 10.1186/s12933-022-01569-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 07/08/2022] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The high heterogeneity in the symptoms and severity of COVID-19 makes it challenging to identify high-risk patients early in the disease. Cardiometabolic comorbidities have shown strong associations with COVID-19 severity in epidemiologic studies. Cardiometabolic protein biomarkers, therefore, may provide predictive insight regarding which patients are most susceptible to severe illness from COVID-19. METHODS In plasma samples collected from 343 patients hospitalized with COVID-19 during the first wave of the pandemic, we measured 92 circulating protein biomarkers previously implicated in cardiometabolic disease. We performed proteomic analysis and developed predictive models for severe outcomes. We then used these models to predict the outcomes of out-of-sample patients hospitalized with COVID-19 later in the surge (N = 194). RESULTS We identified a set of seven protein biomarkers predictive of admission to the intensive care unit and/or death (ICU/death) within 28 days of presentation to care. Two of the biomarkers, ADAMTS13 and VEGFD, were associated with a lower risk of ICU/death. The remaining biomarkers, ACE2, IL-1RA, IL6, KIM1, and CTSL1, were associated with higher risk. When used to predict the outcomes of the future, out-of-sample patients, the predictive models built with these protein biomarkers outperformed all models built from standard clinical data, including known COVID-19 risk factors. CONCLUSIONS These findings suggest that proteomic profiling can inform the early clinical impression of a patient's likelihood of developing severe COVID-19 outcomes and, ultimately, accelerate the recognition and treatment of high-risk patients.
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Affiliation(s)
- Philip H Schroeder
- Diabetes Unit, Endocrine Division, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA.,Programs in Metabolism and Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Laura N Brenner
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA.,Programs in Metabolism and Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA.,Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Varinderpal Kaur
- Diabetes Unit, Endocrine Division, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA.,Programs in Metabolism and Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Sara J Cromer
- Diabetes Unit, Endocrine Division, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Programs in Metabolism and Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA.,Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Katrina Armstrong
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Regina C LaRocque
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Edward T Ryan
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - James B Meigs
- Programs in Metabolism and Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA.,Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, 100 Cambridge St 16th Floor, Boston, MA, 02114, USA
| | - Jose C Florez
- Diabetes Unit, Endocrine Division, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA.,Programs in Metabolism and Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA.,Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Richelle C Charles
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Josep M Mercader
- Diabetes Unit, Endocrine Division, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA.,Programs in Metabolism and Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA.,Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Aaron Leong
- Diabetes Unit, Endocrine Division, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA. .,Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA. .,Programs in Metabolism and Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA. .,Department of Medicine, Massachusetts General Hospital, Boston, MA, USA. .,Harvard Medical School, Boston, MA, USA. .,Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, 100 Cambridge St 16th Floor, Boston, MA, 02114, USA.
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13
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Schroeder P, Brenner L, Kaur V, Cromer S, Armstrong K, Larocque R, Ryan E, Meigs J, Florez J, Charles R, Mercader J, Leong A. Proteomic analysis of cardiometabolic biomarkers and predictive modeling of severe outcomes in patients hospitalized with COVID-19.. [PMID: 35677078 PMCID: PMC9176658 DOI: 10.21203/rs.3.rs-1657002/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Background: The high heterogeneity in the symptoms and severity of COVID-19 makes it challenging to identify high-risk patients early in the disease. Cardiometabolic comorbidities have shown strong associations with COVID-19 severity in epidemiologic studies. Cardiometabolic protein biomarkers, therefore, may provide predictive insight regarding which patients are most susceptible to severe illness from COVID-19. Methods: In plasma samples collected from 343 patients hospitalized with COVID-19 during the first wave of the pandemic, we measured 92 circulating protein biomarkers previously implicated in cardiometabolic disease. We performed proteomic analysis and developed predictive models for severe outcomes. We then used these models to predict the outcomes of out-of-sample patients hospitalized with COVID-19 later in the surge (N=194). Results: We identified a set of seven biomarkers predictive of admission to the intensive care unit and/or death (ICU/death) within 28 days of presentation to care. Two of the biomarkers, ADAMTS13 and VEGFD, were associated with a lower risk of ICU/death. The remaining biomarkers, ACE2, IL-1RA, IL6, KIM1, and CTSL1, were associated with higher risk. When used to predict the outcomes of the future, out-of-sample patients, the predictive models built with these biomarkers outperformed all models built from standard clinical data, including known COVID-19 risk factors. Conclusions: These findings suggest that proteomic profiling can inform the early clinical impression of a patient’s likelihood of developing severe COVID-19 outcomes and, ultimately, accelerate the recognition and treatment of high-risk patients.
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14
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Begin AS, Hidrue M, Lehrhoff S, Del Carmen MG, Armstrong K, Wasfy JH. Factors Associated with Physician Tolerance of Uncertainty: an Observational Study. J Gen Intern Med 2022; 37:1415-1421. [PMID: 33904030 PMCID: PMC8074695 DOI: 10.1007/s11606-021-06776-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 03/29/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Physicians need to learn and work amidst a plethora of uncertainties, which may drive burnout. Understanding differences in tolerance of uncertainty is an important research area. OBJECTIVE To examine factors associated with tolerance of uncertainty, including well-being metrics such as burnout. DESIGN Online confidential survey. SETTING The Massachusetts General Physicians Organization (MGPO). PARTICIPANTS All 2172 clinically active faculty in the MGPO. MAIN MEASURES We examined associations for tolerance of uncertainty with demographic information, personal and professional characteristics, and physician well-being metrics. KEY RESULTS Two thousand twenty (93%) physicians responded. Multivariable analyses identified significant associations of lower tolerance of uncertainty with female gender (OR, 1.23; 95% CI, 1.03-1.48); primary care practice (OR, 1.56; 95% CI, 1.22-2.00); years since training (OR, 0.99; 95% CI, 0.98-0.995); and lacking a trusted advisor (OR, 1.25; 95% CI, 1.03-1.53). Adjusting for demographic and professional characteristics, physicians with low tolerance of uncertainty had higher likelihood of being burned-out (OR, 3.06; 95% CI, 2.41-3.88), were less likely to be satisfied with career (OR, 0.37; 95% CI, 0.26-0.52), and less likely to be engaged at work (RR, 0.87; 95% CI, 0.84-0.90). CONCLUSION At a time when concern about physician well-being is high, with much speculation about causes of burnout, we found a strong relationship between tolerance of uncertainty and physician well-being, across specialties. Particular attention likely needs to be paid to those with less experience, those in specialties with high rates of undifferentiated illness and uncertainty, such as primary care, and ensuring all physicians have access to a trusted advisor. These results generate the potential hypothesis that efforts focused in understanding and embracing uncertainty could be potentially effective for reducing burnout. This concept should be tested in prospective trials.
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Affiliation(s)
- Arabella Simpkin Begin
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA. .,Harvard Medical School, Boston, MA, USA. .,Department of Pharmacology, University of Oxford, Oxford, UK. .,Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.
| | - Michael Hidrue
- Massachusetts General Physicians Organization, Boston, USA
| | - Sara Lehrhoff
- Massachusetts General Physicians Organization, Boston, USA
| | - Marcela G Del Carmen
- Harvard Medical School, Boston, MA, USA.,Massachusetts General Physicians Organization, Boston, USA.,Division of Gynecologic Oncology, Department of Obstetrics and Gynecology and Reproductive Biology, Massachusetts General Hospital, Boston, MA, USA
| | - Katrina Armstrong
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Jason H Wasfy
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
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15
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Ward J, Gill S, Armstrong K, Fogarty T, Tan D, Scott A, Yahya A, Dhaliwal S, Jacques A, Tang C. PO-1384 Simethicone use to Reduce Rectal Variability During Prostate Cancer Radiotherapy, a Randomised Trial. Radiother Oncol 2022. [DOI: 10.1016/s0167-8140(22)03348-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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16
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Affiliation(s)
- Felippe O Marcondes
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Katrina Armstrong
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
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17
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Soltoff AE, Isaacson MJ, Stoltenberg M, Duran T, LaPlante LJR, Petereit D, Armstrong K, Daubman BR. Utilizing the Consolidated Framework for Implementation Research to Explore Palliative Care Program Implementation for American Indian and Alaska Natives throughout the United States. J Palliat Med 2022; 25:643-649. [PMID: 35085000 DOI: 10.1089/jpm.2021.0451] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: A significant shortage of palliative care (PC) services exists for American Indian and Alaska Native people (AI/ANs) across the United States. Using an implementation science framework, we interviewed key individuals associated with AI/AN-focused PC programs to explore what is needed to develop and sustain such programs. Objectives: To identify facilitators of implementation and barriers to sustainability associated with the development of PC programs designed for AI/ANs across the United States. Methods: We interviewed 12 key individuals responsible for the implementation of AI/AN-focused PC services. The Consolidated Framework for Implementation Research (CFIR) guided data coding and interpretation of themes. Results: We identified nine themes that map to CFIR constructs. Facilitators of implementation include high tension for change and respecting cultural values. Barriers to program sustainability include a lack of administrative leadership support. Discussion: AI/AN-focused PC programs should be congruent with community needs. PC program developers should focus on sustainability well before initial implementation.
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Affiliation(s)
- Alexander E Soltoff
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Mary J Isaacson
- College of Nursing, South Dakota State University, Rapid City, South Dakota, USA
| | - Mark Stoltenberg
- Division of Palliative Care and Geriatrics, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Tinka Duran
- Community Health Prevention Programs, Great Plains Tribal Leaders Health Board, Rapid City, South Dakota, USA
| | - Leroy J R LaPlante
- American Indian Health Initiative, Avera Health, Sioux Falls, South Dakota, USA
| | - Daniel Petereit
- Department of Radiation Oncology, Monument Health Cancer Care Institute, Rapid City, South Dakota, USA
- Walking Forward, Avera Research Institute, Avera Health, Rapid City, South Dakota, USA
| | - Katrina Armstrong
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Bethany-Rose Daubman
- Division of Palliative Care and Geriatrics, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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18
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Lage DE, Armstrong K. Accountable care in oncology: Where do we go from here? Cancer 2022; 128:950-952. [PMID: 34767645 PMCID: PMC9466300 DOI: 10.1002/cncr.34021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 10/21/2021] [Indexed: 11/08/2022]
Abstract
The study by Erfani et al. confirms that ACOs did not achieve the promise
of cancer care cost reduction, but leaves open important questions about the
impacts of accountable care on the quality, coordination, and equity of cancer
care delivery. While the inability of ACOs to deliver cost reductions for
patients with cancer may feel like a step backwards for accountable care in
oncology, the work of Erfani et al. actually represents an important step
forward in the field, settling the important cost question in order to open a
broader conversation on the goals of ACOs and value-based care delivery models
in oncology, the means to evaluate them in a comprehensive, patient-centered
manner, and the urgency of incorporating the needs and voices of diverse
populations in the important work of cancer care delivery reform. The study by Erfani et al. confirms that ACOs did not achieve the promise
of cancer care cost reduction, but leaves open important questions about the
impacts of accountable care on the quality, coordination, and equity of cancer
care delivery.
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Affiliation(s)
- Daniel E. Lage
- Department of Medicine, Massachusetts General Hospital,
Boston, MA, USA,Department of Medicine, Harvard Medical School, Boston, MA,
USA
| | - Katrina Armstrong
- Department of Medicine, Massachusetts General Hospital,
Boston, MA, USA,Department of Medicine, Harvard Medical School, Boston, MA,
USA
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19
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McCarthy AM, Manning AK, Hsu S, Moy B, Lehman CD, Armstrong K. Abstract P3-13-01: Association of polygenic risk score with 2 year risk of poor prognosis breast cancer. Cancer Res 2022. [DOI: 10.1158/1538-7445.sabcs21-p3-13-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Introduction: Mammography reduces breast cancer mortality, however, there is controversy surrounding when and how often women should undergo mammography screening. Knowledge of short-term risk of developing breast cancer, particularly poor prognosis breast cancer, would help direct more intensive screening to those at highest risk. Polygenic risk scores (PRS) are emerging as a powerful tool to predict breast cancer risk, however, few studies have evaluated the associations of breast cancer PRS with short-term risk or with risk of poor prognosis breast cancers specifically. Methods: Using a mammography screening cohort at Massachusetts General Hospital, we identified women who had a negative mammogram (BI-RADS assessment 1 or 2) from 2006 to 2015. We linked the cohort to a research biobank to obtain genetic information. In addition, we recruited 205 patients who developed breast cancer within 2 years of a negative mammogram to provide a DNA sample. Women with a prior history of breast cancer, with breast implants, and who were not residents of Massachusetts were excluded. Samples were genotyped using the Illumina Multi-Ethnic GWAS/Exome SNP (MEGA) array. Genotypes were imputed using TOPMed (Version r2 2020). Patients whose saliva DNA samples had low concentration or that failed quality control procedures were excluded. Ancestry specific principal components were generated and used as a covariate. We generated the 313-SNP breast cancer PRS, the estrogen receptor positive (ER+) PRS and the estrogen receptor negative (ER-) PRS using established methods. (PMID: 30554720) Breast cancers were defined as poor prognosis if they were metastatic, had positive lymph nodes, were ER/PR+HER2- and > 2cm or ER/PR/HER2- or HER2+ and > 1cm. (PMID: 33169794) Logistic regression was used to estimate the odds ratios for standardized PRS measures, adjusted for age, breast density, race/ethnicity, year of screening, and ancestry principal components. Results: After exclusions, 308 breast cancers and 3329 non-cases were analyzed. Of the breast cancers, 86% were ER/PR+ (264/308) and 14% were ER/PR- (42/308), and 137 (44%) were poor prognosis. The majority of patients were non-Hispanic White (87%) and the mean age was 57 years and was similar for cancers and non-cancers. Cancer cases were more likely than non-cases to have higher breast density and a family history of breast cancer. First, we examined the overall breast cancer PRS, and found the PRS was significantly associated with breast cancer diagnosed within two years of a negative mammogram (OR=1.39, 95% CI 1.23-1.57, p < 0.001). The PRS was also significantly associated specifically with diagnosis of poor prognosis disease (OR=1.21, 95% CI 1.01-1.45, p=0.037). In addition, the ER+ PRS was significantly associated with ER/PR+ breast cancer (OR=1.41, 95% CI 1.24-1.61, p < 0.001), and the ER- PRS was significantly associated with ER- breast cancer (OR=1.48, 95% CI 1.08-2.02, p=0.015). Conclusion: Even after adjusting for breast density and other risk factors, breast cancer PRS was significantly associated with diagnosis of both breast cancer overall and poor prognosis breast cancer within two years of a negative mammogram. Furthermore, the subtype specific PRS were significantly associated with short-term risk of ER+ and ER- disease. These results suggest that PRS may be useful in guiding decisions about screening interval and supplemental screening, given the association of PRS with risk of poor prognosis disease in the short term.
Table 1.Logistic Regression of PRS and cancer diagnosis within 2 years of a negative mammogramOR95% CIp-valueAll Cancers (N=308), Overall PRS1.391.23-1.571.78x10-7Poor prognosis (N=147), Overall PRS1.211.01-1.450.037ER+ cancers (N=264), ER+ PRS1.421.24-1.621.87x10-7ER- cancers (N=42), ER- PRS1.521.11-2.090.008
Citation Format: Anne Marie McCarthy, Alisa K. Manning, Sarah Hsu, Beverly Moy, Constance D. Lehman, Katrina Armstrong. Association of polygenic risk score with 2 year risk of poor prognosis breast cancer [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P3-13-01.
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Affiliation(s)
| | | | - Sarah Hsu
- Massachusetts General Hospital, Boston, MA
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20
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Affiliation(s)
- Katrina Armstrong
- From the Department of Medicine, Massachusetts General Hospital, Boston
| | - Christine Ritchie
- From the Department of Medicine, Massachusetts General Hospital, Boston
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21
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McCarthy AM, Friebel-Klingner T, Ehsan S, He W, Welch M, Chen J, Kontos D, Domchek SM, Conant EF, Semine A, Hughes K, Bardia A, Lehman C, Armstrong K. Relationship of established risk factors with breast cancer subtypes. Cancer Med 2021; 10:6456-6467. [PMID: 34464510 PMCID: PMC8446564 DOI: 10.1002/cam4.4158] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 07/02/2021] [Accepted: 07/07/2021] [Indexed: 01/07/2023] Open
Abstract
Background Breast cancer is a heterogeneous disease, divided into subtypes based on the expression of estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2). Subtypes have different biology and prognosis, with accumulating evidence of different risk factors. The purpose of this study was to compare breast cancer risk factors across tumor subtypes in a large, diverse mammography population. Methods Women aged 40–84 without a history of breast cancer with a screening mammogram at three United States health systems from 2006 to 2015 were included. Risk factor questionnaires were completed at mammogram visit, supplemented by electronic health records. Invasive tumor subtype was defined by immunohistochemistry as ER/PR+HER2−, ER/PR+HER2+, ER, and PR−HER2+, or triple‐negative breast cancer (TNBC). Cox proportional hazards models were run for each subtype. Associations of race, reproductive history, prior breast problems, family history, breast density, and body mass index (BMI) were assessed. The association of tumor subtypes with screen detection and interval cancer was assessed using logistic regression among invasive cases. Results The study population included 198,278 women with a median of 6.5 years of follow‐up (IQR 4.2–9.0 years). There were 4002 invasive cancers, including 3077 (77%) ER/PR+HER2−, 300 (8%) TNBC, 342 (9%) ER/PR+HER2+, and 126 (3%) ER/PR−HER2+ subtype. In multivariate models, Black women had 2.7 times higher risk of TNBC than white women (HR = 2.67, 95% CI 1.99–3.58). Breast density was associated with increased risk of all subtypes. BMI was more strongly associated with ER/PR+HER2− and HER2+ subtypes among postmenopausal women than premenopausal women. Breast density was more strongly associated with ER/PR+HER2− and TNBC among premenopausal than postmenopausal women. TNBC was more likely to be interval cancer than other subtypes. Conclusions These results have implications for risk assessment and understanding of the etiology of breast cancer subtypes. More research is needed to determine what factors explain the higher risk of TNBC for Black women.
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Affiliation(s)
- Anne Marie McCarthy
- University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | | | - Sarah Ehsan
- University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Wei He
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Jinbo Chen
- University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Despina Kontos
- University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Susan M Domchek
- University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Emily F Conant
- University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Alan Semine
- Newton Wellesley Hospital, Newton, Massachusetts, USA
| | - Kevin Hughes
- Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Aditya Bardia
- Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Constance Lehman
- Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Katrina Armstrong
- Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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Cornwell B, Armstrong K, Walker NS, Lippert M, Nestor V, Golbuu Y, Palumbi SR. Widespread variation in heat tolerance and symbiont load are associated with growth tradeoffs in the coral Acropora hyacinthus in Palau. eLife 2021; 10:64790. [PMID: 34387190 PMCID: PMC8457836 DOI: 10.7554/elife.64790] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 08/06/2021] [Indexed: 12/20/2022] Open
Abstract
Climate change is dramatically changing ecosystem composition and productivity, leading scientists to consider the best approaches to map natural resistance and foster ecosystem resilience in the face of these changes. Here, we present results from a large-scale experimental assessment of coral bleaching resistance, a critical trait for coral population persistence as oceans warm, in 221 colonies of the coral Acropora hyacinthus across 37 reefs in Palau. We find that bleaching-resistant individuals inhabit most reefs but are found more often in warmer microhabitats. Our survey also found wide variation in symbiont concentration among colonies, and that colonies with lower symbiont load tended to be more bleaching-resistant. By contrast, our data show that low symbiont load comes at the cost of lower growth rate, a tradeoff that may operate widely among corals across environments. Corals with high bleaching resistance have been suggested as a source for habitat restoration or selective breeding in order to increase coral reef resilience to climate change. Our maps show where these resistant corals can be found, but the existence of tradeoffs with heat resistance may suggest caution in unilateral use of this one trait in restoration.
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Affiliation(s)
- Brendan Cornwell
- Department of Biology, Hopkins Marine Station of Stanford University, Pacific Grove, United States
| | - Katrina Armstrong
- Department of Biology, Hopkins Marine Station of Stanford University, Pacific Grove, United States
| | - Nia S Walker
- Department of Biology, Hopkins Marine Station of Stanford University, Pacific Grove, United States
| | - Marilla Lippert
- Department of Biology, Hopkins Marine Station of Stanford University, Pacific Grove, United States
| | - Victor Nestor
- Research, Palau International Coral Reef Center, Koror, Palau
| | - Yimnang Golbuu
- Director, Palau International Coral Reef Center, Koror, Palau
| | - Stephen R Palumbi
- Department of Biology, Hopkins Marine Station of Stanford University, Pacific Grove, United States
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23
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Affiliation(s)
- Sudhakar V Nuti
- Department of Medicine, Massachusetts General Hospital, Boston
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24
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Affiliation(s)
- Katrina Armstrong
- From the Department of Medicine, Massachusetts General Hospital, Boston
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McCarthy AM, Ehsan S, Appel S, Welch M, He W, Bahl M, Chen J, Lehman CD, Armstrong K. Risk factors for an advanced breast cancer diagnosis within 2 years of a negative mammogram. Cancer 2021; 127:3334-3342. [PMID: 34061353 DOI: 10.1002/cncr.33661] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 04/29/2021] [Accepted: 04/30/2021] [Indexed: 11/11/2022]
Abstract
BACKGROUND Identifying women at risk for advanced interval cancers would allow better targeting of mammography and supplemental screening. The authors assessed risk factors for advanced breast cancer within 2 years of a negative mammogram. METHODS The authors included 293,520 negative mammograms performed from 2006 to 2015 among 74,736 women. Breast cancers were defined as advanced if they were >2 cm, were >1 cm and triple-negative or human epidermal growth factor receptor 2-positive, had positive lymph nodes, or were metastatic. Cox proportional hazards modeling was used to evaluate associations of age, breast density, menopause, mammogram type, prior breast biopsy, body mass index (BMI), and a family history of breast cancer with a cancer diagnosis within 2 years of a negative mammogram. Models were stratified by year since a negative mammogram. RESULTS Among 1345 breast cancers, 357 were advanced (26.5%), and 988 (73.5%) were at an early stage. Breast density, prior biopsy, and family history were associated with an increased risk of both advanced and early-stage cancers. Overweight and obese women had a 40% higher risk of early-stage cancer only in year 2 (overweight hazard ratio [HR], 1.41; 95% confidence interval [CI], 1.19-1.67; P < .001; obese HR, 1.41; 95% CI, 1.17-1.70; P < .001). Obese women had a 90% increased risk of advanced cancer in year 1 (HR, 1.90; 95% CI, 1.14-3.18; P = .014), and both overweight and obese women had a 40% or greater increased risk in year 2 (overweight HR, 1.55; 95% CI, 1.14-2.07; P = .005; obese HR, 1.42; 95% CI, 1.00-2.01; P = .051). CONCLUSIONS A higher BMI was associated with an advanced breast cancer diagnosis within 2 years of a negative mammogram. These results have important implications for risk assessment, screening intervals, and use of supplemental screening.
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Affiliation(s)
| | - Sarah Ehsan
- University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Scott Appel
- University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | | | - Wei He
- Massachusetts General Hospital, Boston, Massachusetts
| | - Manisha Bahl
- Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Jinbo Chen
- University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Constance D Lehman
- Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Katrina Armstrong
- Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
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Lynch A, Ahuja S, Miron A, Nakano S, Howard T, Villa C, Armstrong K, Kaufman B, Gardin L, Whitehill R, Parent J, Godown J, Henderson H, Aziz P, Colan S, Seshadri B, Kantor P, Russell M, Lal A, Butts R, Richmond M, Conway J, Weintraub R, Rossano J, Mital S. Sudden Cardiac Death and ICD Use in Rasopathy-Associated Hypertrophic Cardiomyopathy. J Heart Lung Transplant 2021. [DOI: 10.1016/j.healun.2021.01.1821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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27
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Armstrong K, Soltoff A, Rieu-Werden M, Metlay J, Haas J. Use of angiotensin converting enzyme inhibitors and angiotensin receptor blockers associated with lower risk of COVID-19 in household contacts. PLoS One 2021; 16:e0247548. [PMID: 33651840 PMCID: PMC7924745 DOI: 10.1371/journal.pone.0247548] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 02/09/2021] [Indexed: 01/08/2023] Open
Abstract
Background Use of angiotensin converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) has been hypothesized to affect COVID-19 risk. Objective To examine the association between use of ACEI/ARB and household transmission of COVID-19. Methods We conducted a modified cohort study of household contacts of patients who tested positive for COVID-19 between March 4 and May 17, 2020 in a large Northeast US health system. Household members were identified by geocoding and full address matching with exclusion of addresses with >10 matched residents or known congregate living functions. Medication use, clinical conditions and sociodemographic characteristics were obtained from electronic medical record (EMR) data on cohort entry. Cohort members were followed for at least one month after exposure to determine who tested positive for SARS-CoV-2. Mixed effects logistic regression and propensity score analyses were used to assess adjusted associations between medication use and testing positive. Results 1,499 of the 9,101 household contacts were taking an ACEI or an ARB. Probability of COVID-19 diagnosis during the study period was slightly higher among ACEI/ARB users in unadjusted analyses. However, ACEI/ARB users were older and more likely to have clinical comorbidities so that use of ACEI/ARB was associated with a decreased risk of being diagnosed with COVID-19 in mixed effect models (OR 0.60, 95% CI 0.44–0.81) or propensity score analyses (predicted probability 18.6% in ACEI/ARB users vs. 24.5% in non-users, p = 0.03). These associations were similar within age and comorbidity subgroups, including patients with documented hypertension, diabetes or cardiovascular disease, as well as when including other medications in the models. Conclusions In this observational study of household transmission, use of ACEIs or ARBs was associated with a decreased risk of being diagnosed with COVID-19. While causality cannot be inferred from these observational data, our results support current recommendations to continue ACEI/ARB in individuals at risk of COVID-19 exposure.
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Affiliation(s)
- Katrina Armstrong
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- * E-mail:
| | - Alex Soltoff
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Meghan Rieu-Werden
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Joshua Metlay
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Jennifer Haas
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
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McCarthy AM, Friebel T, He W, Welch M, Ehsan S, Hughes K, Semine A, Chen J, Kontos D, Domchek S, Conant E, Bardia A, Lehman C, Armstrong K. Abstract PS7-02: The relationship of established breast cancer risk factors with breast cancer subtypes. Cancer Res 2021. [DOI: 10.1158/1538-7445.sabcs20-ps7-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Molecular characterization of breast tumors has revealed four subtypes which differ in expression of estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2). Breast cancer subtypes have different prognosis and unique risk factors. Breast cancer risk assessment models mainly reflect risk of ER/PR+ HER2- tumors, the most common subtype, and may not reflect risk of other subtypes. The study objective was to compare associations of established breast cancer risk factors across invasive breast cancer subtypes.
Methods: The study population included women aged 40-84 years who had a screening mammogram at Massachusetts General Hospital, Newton Wellesley Hospital, or the University of Pennsylvania from 2006-2015. Patients completed a risk factor questionnaire and additional risk factors were ascertained from clinical records. Women with prior breast cancer, breast implants, or BRCA1/2 mutations were excluded. Women diagnosed with breast cancer within 6 months were excluded to remove those with cancer at the time of risk assessment. Tumor characteristics were obtained from linkage with hospital and state cancer registries. For invasive tumors, subtype was defined based on immunohistochemistry as ER and/or PR+ HER2-, ER and/or PR+HER2+, ER and PR- HER2+, or ER and PR and HER2- (triple negative breast cancer, TNBC). Cox proportional hazards models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI) for breast cancer using time from mammogram to cancer diagnosis or censoring. Separate Cox models were fit for each subtype, and patients who developed DCIS or another subtype, died, or were alive and cancer free on December 31, 2017 were censored. Age, biopsy history, atypical hyperplasia, age at menarche, age at first live birth, family history, race, BMI, and breast density at the time of screening were included in the models.
Results: The study population (N=197,836) had a mean age of 54 years and 74% of patients were white, 15% were Black, and 11% were other races. During a mean follow-up of 6.3 years, 4,510 (2.3%) women developed breast cancer. Of these cancers, 1068 (24%) were DCIS. Of the invasive cancers, 2675 (77%) were ER/PR+HER2-, 290 (8%) were ER/PR+HER2+, 108 (3%) were ER/PR-HER2+, 264 (8%) were TNBC and 105 (3%) had missing subtype. For ER/PR+HER2- cancers, all risk factors were consistent with the literature and statistically significant. Breast density was associated with increased risk of all four subtypes compared to women with less dense breasts. Atypical hyperplasia was strongly associated with HER2+ cancers (HR=2.97 CI 1.63-5.40 p<0.01), less strongly associated with ER/PR+HER2- cancers, and not significantly associated with TNBC. Black women had higher risk of TNBC than white women (HR=2.61 CI 1.91-3.57 p<0.01).
Conclusion Our results highlight both similarities and heterogeneity in risk factors across breast cancer subtypes. Prior diagnosis of atypical hyperplasia was more strongly associated with HER2+ compared to HER2- tumors. While it is well known that Black women have higher risk of TNBC, it is striking that the more than two-and-a-half-fold increased risk persisted even with comprehensive adjustment for breast cancer risk factors in a screened population. These results suggest that additional factors, such as genetics, biomarkers, and environmental exposures should be included in risk assessment to better capture risk of less common breast cancer subtypes such as TNBC.
Risk factors for breast cancer subtypes among 197,836 women undergoing screening mammography*ER/PR+ HER2- N=2674ER/PR+ HER2+ N=290ER/PR-HER2+ N=108ER/PR/HER2- N=264HR,95% CIpHR,95% CIpHR,95% CIpHR,95% CIpBlack vs. white unadjusted0.67,0.58-0.77<0.010.73,0.48-1.090.120.91,0.49-1.680.772.61,1.96-3.46<0.01Black vs. white multivariate*0.72,0.63-0.83<0.010.75,0.49-1.150.191.23,0.65-2.330.532.61,1.91-3.57<0.01Atypical Hyperplasia*1.38,1.02-1.870.042.77,1.42-5.42<0.013.89,1.03-14.70.040.43,0.06-3.140.401 FDR** vs. none1.46,1.32-1.63<0.011.16,0.82-1.650.391.93,1.18-3.160.011.11,0.75-1.630.602 FDR** vs. none2.12,1.67-2.71<0.011.17,0.44-3.150.751.90,0.47-7.760.372.81,1.44-5.49<0.01BMI ≥25 vs. <25 kg/m2*1.37,1.25-1.50<0.011.35,1.04-1.750.031.07,0.71-1.640.741.29,0.97-1.730.08Dense vs. non-dense breasts1.55,1.42-1.69<0.011.75,1.34-2.29<0.011.97,1.25-3.10<0.011.65,1.26-2.17<0.01*Adjusted for all factors in the table and additionally age, biopsy, age at menarche, age at first live birth**FDR= first degree relative with breast cancer
Citation Format: Anne Marie McCarthy, Tara Friebel, Wei He, Michaela Welch, Sarah Ehsan, Kevin Hughes, Alan Semine, Jinbo Chen, Despina Kontos, Susan Domchek, Emily Conant, Aditya Bardia, Constance Lehman, Katrina Armstrong. The relationship of established breast cancer risk factors with breast cancer subtypes [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS7-02.
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Affiliation(s)
| | - Tara Friebel
- 1University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Wei He
- 2Massachusetts General Hospital, Boston, MA
| | | | - Sarah Ehsan
- 1University of Pennsylvania School of Medicine, Philadelphia, PA
| | | | | | - Jinbo Chen
- 1University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Despina Kontos
- 1University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Susan Domchek
- 1University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Emily Conant
- 1University of Pennsylvania School of Medicine, Philadelphia, PA
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McCarthy AM, Armstrong K. Genetic Testing May Help Reduce Breast Cancer Disparities for African American Women. J Natl Cancer Inst 2020; 112:1179-1180. [PMID: 32427327 PMCID: PMC7735768 DOI: 10.1093/jnci/djaa042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 03/19/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Anne Marie McCarthy
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Katrina Armstrong
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Affiliation(s)
- Yukari C Manabe
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Joshua S Sharfstein
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Barlow WE, Beaber EF, Geller BM, Kamineni A, Zheng Y, Haas JS, Chao CR, Rutter CM, Zauber AG, Sprague BL, Halm EA, Weaver DL, Chubak J, Doria-Rose VP, Kobrin S, Onega T, Quinn VP, Schapira MM, Tosteson ANA, Corley DA, Skinner CS, Schnall MD, Armstrong K, Wheeler CM, Silverberg MJ, Balasubramanian BA, Doubeni CA, McLerran D, Tiro JA. Evaluating Screening Participation, Follow-up, and Outcomes for Breast, Cervical, and Colorectal Cancer in the PROSPR Consortium. J Natl Cancer Inst 2020; 112:238-246. [PMID: 31292633 DOI: 10.1093/jnci/djz137] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 04/11/2019] [Accepted: 07/03/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Cancer screening is a complex process encompassing risk assessment, the initial screening examination, diagnostic evaluation, and treatment of cancer precursors or early cancers. Metrics that enable comparisons across different screening targets are needed. We present population-based screening metrics for breast, cervical, and colorectal cancers for nine sites participating in the Population-based Research Optimizing Screening through Personalized Regimens consortium. METHODS We describe how selected metrics map to a trans-organ conceptual model of the screening process. For each cancer type, we calculated calendar year 2013 metrics for the screen-eligible target population (breast: ages 40-74 years; cervical: ages 21-64 years; colorectal: ages 50-75 years). Metrics for screening participation, timely diagnostic evaluation, and diagnosed cancers in the screened and total populations are presented for the total eligible population and stratified by age group and cancer type. RESULTS The overall screening-eligible populations in 2013 were 305 568 participants for breast, 3 160 128 for cervical, and 2 363 922 for colorectal cancer screening. Being up-to-date for testing was common for all three cancer types: breast (63.5%), cervical (84.6%), and colorectal (77.5%). The percentage of abnormal screens ranged from 10.7% for breast, 4.4% for cervical, and 4.5% for colorectal cancer screening. Abnormal breast screens were followed up diagnostically in almost all (96.8%) cases, and cervical and colorectal were similar (76.2% and 76.3%, respectively). Cancer rates per 1000 screens were 5.66, 0.17, and 1.46 for breast, cervical, and colorectal cancer, respectively. CONCLUSIONS Comprehensive assessment of metrics by the Population-based Research Optimizing Screening through Personalized Regimens consortium enabled systematic identification of screening process steps in need of improvement. We encourage widespread use of common metrics to allow interventions to be tested across cancer types and health-care settings.
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Affiliation(s)
| | - Elisabeth F Beaber
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Berta M Geller
- Departments of Family Medicine, and the University of Vermont Cancer Center, University of Vermont, Burlington, VT
| | - Aruna Kamineni
- Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - Yingye Zheng
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Jennifer S Haas
- Division of General Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Dana Farber, Harvard Cancer Institute, Harvard School of Public Health, Boston, MA
| | - Chun R Chao
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | | | - Ann G Zauber
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Brian L Sprague
- Departments of Surgery and Radiology, University of Vermont, Burlington, VT
| | - Ethan A Halm
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX.,Simmons Comprehensive Cancer Center, Dallas, TX
| | - Donald L Weaver
- Department of Pathology and the UVM Cancer Center, University of Vermont, Burlington, VT
| | - Jessica Chubak
- Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - V Paul Doria-Rose
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA.,Healthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD
| | - Sarah Kobrin
- Healthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD
| | - Tracy Onega
- Departments of Biomedical Data Science, Epidemiology, and the Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | | | - Marilyn M Schapira
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, and CMC VA Medical Center, Philadelphia, PA
| | - Anna N A Tosteson
- The Dartmouth Institute for Health Policy and Clinical Practice and Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Douglas A Corley
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Celette Sugg Skinner
- Simmons Comprehensive Cancer Center, Dallas, TX.,Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX
| | - Mitchell D Schnall
- Department of Radiology, University of Pennsylvania, Perelman School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Katrina Armstrong
- General Medicine Division, MA General Hospital, Harvard Medical School, Boston, MA
| | - Cosette M Wheeler
- Departments of Pathology and Obstetrics and Gynecology, University of New Mexico Health Science Center, Albuquerque, NM.,University of New Mexico Comprehensive Cancer Center, Albuquerque, NM
| | | | - Bijal A Balasubramanian
- Simmons Comprehensive Cancer Center, Dallas, TX.,UTHealth School of Public Health, Dallas, TX
| | - Chyke A Doubeni
- Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Dale McLerran
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Jasmin A Tiro
- Simmons Comprehensive Cancer Center, Dallas, TX.,Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX
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McSweeney SM, Christou EAA, Dand N, Boalch A, Holmes S, Harries M, Palamaras I, Cunningham F, Parkins G, Kaur M, Farrant P, McDonagh A, Messenger A, Jones J, Jolliffe V, Ali I, Ardern-Jones M, Mitchell C, Burrows N, Atkar R, Banfield C, Alexandroff A, Champagne C, Cooper HL, Patel GK, Macbeth A, Page M, Bryden A, Mowbray M, Wahie S, Armstrong K, Cooke N, Goodfield M, Man I, de Berker D, Dunnil G, Takwale A, Rao A, Siah TW, Sinclair R, Wade MS, Bhargava K, Fenton DA, McGrath JA, Tziotzios C. Frontal fibrosing alopecia: a descriptive cross-sectional study of 711 cases in female patients from the UK. Br J Dermatol 2020; 183:1136-1138. [PMID: 32652611 DOI: 10.1111/bjd.19399] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- S M McSweeney
- St John's Institute of Dermatology, Guy's Hospital, London, SE1 9RT, UK
| | - E A A Christou
- St John's Institute of Dermatology, Guy's Hospital, London, SE1 9RT, UK
| | - N Dand
- Department of Medical and Molecular Genetics, King's College London, Guy's Hospital, London, SE1 9RT, UK
| | - A Boalch
- Greenwich and Lewisham NHS Foundation Trust, London, SE13 6LH, UK
| | - S Holmes
- Alan Lyell Centre for Dermatology, Queen Elizabeth University Hospital, Glasgow, G51 4TF, UK.,UK FFA Consortium
| | | | | | - F Cunningham
- Alan Lyell Centre for Dermatology, Queen Elizabeth University Hospital, Glasgow, G51 4TF, UK.,UK FFA Consortium
| | - G Parkins
- Alan Lyell Centre for Dermatology, Queen Elizabeth University Hospital, Glasgow, G51 4TF, UK.,UK FFA Consortium
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - K Bhargava
- St John's Institute of Dermatology, Guy's Hospital, London, SE1 9RT, UK.,UK FFA Consortium
| | - D A Fenton
- St John's Institute of Dermatology, Guy's Hospital, London, SE1 9RT, UK.,UK FFA Consortium
| | - J A McGrath
- St John's Institute of Dermatology, Guy's Hospital, London, SE1 9RT, UK
| | - C Tziotzios
- St John's Institute of Dermatology, Guy's Hospital, London, SE1 9RT, UK
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Lobitz G, Armstrong K, Concato J, Singer BH, Horwitz RI. The Biological and Biographical Basis of Precision Medicine. Psychother Psychosom 2020; 88:333-340. [PMID: 31578017 DOI: 10.1159/000502486] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 08/04/2019] [Indexed: 11/19/2022]
Abstract
Construction of a patient narrative (case history) is a core strategy in the care of patients. Recent advances in biomarker identification and digital sensors to monitor physiological and behavioral features have made constructing a case history more complex. Notably, however, although a biological profile is increasingly a part of the patient's profile, an analogous patient-based biographical (life experience) profile is typically overlooked. Evolving concepts such as allostasis and allostatic load refer to processes promoting stability of physiological systems in the presence of diverse life experiences. Integrating details of both biology and biography is a goal of "precision medicine." In this review, we describe how complex interactions between biology and biography affect disease risk and treatment response and highlight a strategy to develop narratives that establish the integration of biology and biography as the scientific basis for precision medicine.
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Affiliation(s)
- Gabriella Lobitz
- Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania, USA
| | - Katrina Armstrong
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - John Concato
- Research Center, VA Connecticut HealthCare System, Cooperative Studies Program, Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | | | - Ralph I Horwitz
- Temple Transformative Medicine Institute, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania, USA,
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McCarthy AM, Kumar NP, He W, Regan S, Welch M, Moy B, Iafrate AJ, Chan AT, Bardia A, Armstrong K. Different associations of tumor PIK3CA mutations and clinical outcomes according to aspirin use among women with metastatic hormone receptor positive breast cancer. BMC Cancer 2020; 20:347. [PMID: 32326897 PMCID: PMC7181475 DOI: 10.1186/s12885-020-06810-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 03/31/2020] [Indexed: 01/05/2023] Open
Abstract
Introduction The relationships among PIK3CA mutations, medication use and tumor progression remains poorly understood. Aspirin use post-diagnosis may modify components of the PI3K pathway, including AKT and mTOR, and has been associated with lower risk of breast cancer recurrence and mortality. We assessed time to metastasis (TTM) and survival with respect to aspirin use and tumor PIK3CA mutations among women with metastatic breast cancer. Methods Patients with hormone receptor positive, HER2 negative (HR+/HER2-) metastatic breast cancer treated in 2009–2016 who received tumor genotyping were included. Aspirin use between primary and metastatic diagnosis was extracted from electronic medical records. TTM and survival were estimated using Cox proportional hazards regression. Results Among 267 women with metastatic breast cancer, women with PIK3CA mutated tumors had longer TTM than women with PIK3CA wildtype tumors (7.1 vs. 4.7 years, p = 0.008). There was a significant interaction between PIK3CA mutations and aspirin use on TTM (p = 0.006) and survival (p = 0.026). PIK3CA mutations were associated with longer TTM among aspirin non-users (HR = 0.60 95% CI:0.44–0.82 p = 0.001) but not among aspirin users (HR = 1.57 0.86–2.84 p = 0.139). Similarly, PIK3CA mutations were associated with reduced mortality among aspirin non-users (HR = 0.70 95% CI:0.48–1.02 p = 0.066) but not among aspirin users (HR = 1.75 95% CI:0.88–3.49 p = 0.110). Conclusions Among women who develop metastatic breast cancer, tumor PIK3CA mutations are associated with slower time to progression and mortality only among aspirin non-users. Larger studies are needed to confirm this finding and examine the relationship among aspirin use, tumor mutation profile, and the overall risk of breast cancer progression.
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Affiliation(s)
- Anne Marie McCarthy
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, USA. .,Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, 833 Blockley Hall, 423 Guardian Drive, Philadelphia, PA, 19104, USA.
| | | | - Wei He
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, USA
| | - Susan Regan
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, USA
| | - Michaela Welch
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, USA
| | - Beverly Moy
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, USA
| | - A John Iafrate
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, USA
| | - Andrew T Chan
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, USA
| | - Aditya Bardia
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, USA
| | - Katrina Armstrong
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, USA
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García-Albéniz X, Hernán MA, Logan RW, Price M, Armstrong K, Hsu J. Continuation of Annual Screening Mammography and Breast Cancer Mortality in Women Older Than 70 Years. Ann Intern Med 2020; 172:381-389. [PMID: 32092767 DOI: 10.7326/m18-1199] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Randomized trials have shown that initiating breast cancer screening between ages 50 and 69 years and continuing it for 10 years decreases breast cancer mortality. However, no trials have studied whether or when women can safely stop screening mammography. An estimated 52% of women aged 75 years or older undergo screening mammography in the United States. OBJECTIVE To estimate the effect of breast cancer screening on breast cancer mortality in Medicare beneficiaries aged 70 to 84 years. DESIGN Large-scale, population-based, observational study of 2 screening strategies: continuing annual mammography, and stopping screening. SETTING U.S. Medicare program, 2000 to 2008. PARTICIPANTS 1 058 013 beneficiaries aged 70 to 84 years who had a life expectancy of at least 10 years, had no previous breast cancer diagnosis, and underwent screening mammography. MEASUREMENTS Eight-year breast cancer mortality, incidence, and treatments, plus the positive predictive value of screening mammography by age group. RESULTS In women aged 70 to 74 years, the estimated difference in 8-year risk for breast cancer death between continuing and stopping screening was -1.0 (95% CI, -2.3 to 0.1) death per 1000 women (hazard ratio, 0.78 [CI, 0.63 to 0.95]) (a negative risk difference favors continuing). In those aged 75 to 84 years, the corresponding risk difference was 0.07 (CI, -0.93 to 1.3) death per 1000 women (hazard ratio, 1.00 [CI, 0.83 to 1.19]). LIMITATIONS The available Medicare data permit only 8 years of follow-up after screening. As with any study using observational data, the estimates could be affected by residual confounding. CONCLUSION Continuing annual breast cancer screening past age 75 years did not result in substantial reductions in 8-year breast cancer mortality compared with stopping screening. PRIMARY FUNDING SOURCE National Institutes of Health.
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Affiliation(s)
- Xabier García-Albéniz
- Harvard T.H. Chan School of Public Health and Massachusetts General Hospital, Boston, Massachusetts, and RTI Health Solutions, Barcelona, Spain (X.G.)
| | - Miguel A Hernán
- Harvard T.H. Chan School of Public Health and Harvard-MIT Division of Health Sciences and Technology, Boston, Massachusetts (M.A.H.)
| | - Roger W Logan
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts (R.W.L.)
| | - Mary Price
- Massachusetts General Hospital, Boston, Massachusetts (M.P., K.A.)
| | | | - John Hsu
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (J.H.)
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Affiliation(s)
- Katrina Armstrong
- From the Department of Medicine, Massachusetts General Hospital, and Harvard Medical School - both in Boston (K.A.); and the University of Pennsylvania and the Corporal Michael J. Crescenz VA Medical Center - both in Philadelphia (D.A.A.)
| | - David A Asch
- From the Department of Medicine, Massachusetts General Hospital, and Harvard Medical School - both in Boston (K.A.); and the University of Pennsylvania and the Corporal Michael J. Crescenz VA Medical Center - both in Philadelphia (D.A.A.)
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38
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Parikh AR, Asch DA, Armstrong K. The Unintentional Perpetuation of the Gender Divide. J Gen Intern Med 2020; 35:910-912. [PMID: 31637648 PMCID: PMC7080880 DOI: 10.1007/s11606-019-05360-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 09/12/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Aparna R Parikh
- Massachusetts General Hospital Cancer Center and Department of Medicine, Harvard Medical School, Boston, MA, USA.
| | - David A Asch
- University of Pennsylvania and Cpl Michael J Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Katrina Armstrong
- Massachusetts General Hospital Cancer Center and Department of Medicine, Harvard Medical School, Boston, MA, USA
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Abstract
With the USPSTF reaffirming the importance of screening, counseling, and testing appropriate women for BRCA1/2 mutations, primary care has both an opportunity and a responsibility to lead in the implementation of these recommendations. Since the last UPSTF recommendations about preventing BRCA-related cancers in 2013, progress in incorporating risk assessment, counseling, and testing into primary care has been slow. There are multiple barriers to implementation outside of primary care, including limitations of the electronic medical record, availability of genetic counseling, and the administrative burden associated with obtaining insurance coverage. However, the early imbalance between hype and evidence in genomics led to a general skepticism among primary care providers about the importance of genomic medicine-a sharp contrast with many other areas of internal medicine. As a growing number of companies offer genetic testing directly to consumers and new models of genetic counseling are developed, primary care should capitalize on the opportunity to lead in the prevention of BRCA-related cancers-both to ensure that these services are delivered appropriately and in coordination with ongoing primary care and that primary care is not left behind as genomic medicine becomes a reality across internal medicine.
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Affiliation(s)
- Katrina Armstrong
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
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40
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Tanguturi VK, Kennedy KF, Virani SS, Maddox TM, Armstrong K, Wasfy JH. Association Between Poverty and Appropriate Statin Prescription for the Treatment of Hyperlipidemia in the United States: An Analysis From the ACC NCDR PINNACLE Registry. Cardiovasc Revasc Med 2020; 21:1016-1021. [PMID: 31992531 DOI: 10.1016/j.carrev.2019.12.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 12/19/2019] [Accepted: 12/19/2019] [Indexed: 01/23/2023]
Abstract
BACKGROUND Poverty is associated with a higher risk of myocardial infarction and cardiac death, both of which are decreased by treatment of hyperlipidemia. There may be differences in the appropriate treatment of hyperlipidemia between richer and poorer Americans. In this study, we aimed to evaluate the association between income level and appropriate lipid-lowering therapy. METHODS We identified outpatient visits in the National Cardiovascular Data Registry's Practice Innovation and Clinical Excellence (PINNACLE) Registry and determined appropriateness of lipid-lowering therapy among patients in different income quintiles (Quintile 5 being the highest income quintile). Logistic regression at the patient level was performed to evaluate the independent association of income and the primary outcome of appropriate statin therapy. The analysis was repeated before and after November 2013 given a change in guideline definitions. RESULTS The study included 1,655,723 patients. Overall, 68-73% of patients were treated appropriately under the ATP III Guidelines and 57-62% of patients were treated appropriately under the ACC/AHA Guidelines. Patients in the wealthiest quintile had higher odds of appropriate statin therapy under both guidelines relative to patients in the poorest quintile (OR 1.06 [1.05-1.07] for ATP III and OR 1.03 [1.01-1.04] for ACC/AHA). In the whole sample, patients with higher estimated income had a small but significant increased likelihood of appropriate statin therapy (point-biserial correlation 0.035 [p < 0.001] for ATP III and 0.026 [p < 0.001] for ACC/AHA). CONCLUSIONS Here we describe a small association between appropriate statin use and income. Further investigation into barriers in the use of evidence-based therapies in poorer populations is needed.
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Affiliation(s)
- Varsha K Tanguturi
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America; Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America.
| | - Kevin F Kennedy
- St. Luke's Mid-America Heart Institute, Kansas City, MO, United States of America
| | - Salim S Virani
- Michael E. DeBakey Veterans Affairs Medical Center, Baylor College of Medicine, Houston, TX, United States of America
| | - Thomas M Maddox
- Cardiology Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO, United States of America
| | - Katrina Armstrong
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Jason H Wasfy
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America; Massachusetts General Physicians Organization, Boston, MA, United States of America.
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41
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Tobey M, Armstrong K, Warne D. The 2019 Partial Government Shutdown and Its Impact on Health Care for American Indians and Alaska Natives. J Health Care Poor Underserved 2020; 31:75-80. [PMID: 32037318 DOI: 10.1353/hpu.2020.0009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The 2018-9 partial government shutdown created a 35-day gap in federal appropriations for the Indian Health Service and tribal health programs. With ongoing challenges for American Indian and Alaska Native health systems, including clinician shortages and poor health outcomes, the funding gap engendered substantial health risks. Other federal health systems have been sheltered from this and past shutdowns through receiving their appropriations in advance. Several approaches exist to implementing advance appropriations, including instituting advance appropriations across Bureau of Indian Affairs and Indian Health Service programs; or by moving Indian Health Service funding to the same appropriation as the Department of Health and Human Services. Furthermore, building and strengthening health partnerships with non-federal institutions, such as academic medical centers, may help distribute financial risk and strengthen care systems.
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42
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Middleton D, Armstrong K, Baba Y, Balslev H, Chayamarit K, Chung R, Conn B, Fernando E, Fujikawa K, Kiew R, Luu H, Aung MM, Newman M, Tagane S, Tanaka N, Thomas D, Tran T, Utteridge T, van Welzen P, Widyatmoko D, Yahara T, Wong K. Progress on Southeast Asia’s Flora projects. ACTA ACUST UNITED AC 2019. [DOI: 10.26492/gbs71(2).2019-02] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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43
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Travers N, Dean A, Armstrong K, Peeperkorn L, Tan M, Das A. The tolerability and efficacy of FOLFIRINOX in gastro-oesophageal carcinoma. Ann Oncol 2019. [DOI: 10.1093/annonc/mdz422.072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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44
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McCarthy AM, Barlow WE, Conant EF, Haas JS, Li CI, Sprague BL, Armstrong K. Breast Cancer With a Poor Prognosis Diagnosed After Screening Mammography With Negative Results. JAMA Oncol 2019; 4:998-1001. [PMID: 29801067 DOI: 10.1001/jamaoncol.2018.0352] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Anne Marie McCarthy
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston
| | | | - Emily F Conant
- Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Jennifer S Haas
- Department of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts
| | - Christopher I Li
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Brian L Sprague
- Departments of Radiology and Surgery and the University of Vermont Cancer Center, University of Vermont, Burlington
| | - Katrina Armstrong
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston
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Abstract
This cross-sectional survey study examines the factors associated with satisfaction at work in academic health care centers.
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Affiliation(s)
- Arabella L Simpkin
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston.,Harvard Medical School, Boston, Massachusetts
| | - Yuchiao Chang
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston.,Harvard Medical School, Boston, Massachusetts
| | - Liyang Yu
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston
| | - Eric G Campbell
- Center for Bioethics and Humanities, University of Colorado, Denver.,Department of Medicine, University of Colorado School of Medicine, Denver
| | - Katrina Armstrong
- Harvard Medical School, Boston, Massachusetts.,Department of Medicine, Massachusetts General Hospital, Boston
| | - Rochelle P Walensky
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston.,Harvard Medical School, Boston, Massachusetts.,Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston
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46
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Dean A, Peeperkorn L, Armstrong K, De Marie A, Watanabe Y, Tan M, Travers N. Prospective evaluation of FOLFIRINOX in Neo-adjuvant treatment of gastro-oesophageal junction carcinomas. Ann Oncol 2019. [DOI: 10.1093/annonc/mdz155.301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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47
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Tanguturi VK, Bhambhani V, Picard MH, Armstrong K, Wasfy JH. Echocardiographic Surveillance of Valvular Heart Disease in Different Sociodemographic Groups. JACC Cardiovasc Imaging 2019; 12:751-752. [PMID: 30121267 DOI: 10.1016/j.jcmg.2018.05.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 05/30/2018] [Accepted: 05/31/2018] [Indexed: 10/28/2022]
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Abdelbaky A, Patrich T, Osborne MT, Tung B, Oberfeld B, Armstrong K, Tawakol A, Ay H. Abstract 191: Socioeconomic Disparity Independently Predicts Initial Ischemic Stroke Severity. Stroke 2019. [DOI: 10.1161/str.50.suppl_1.191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Lower socioeconomic status (SES) associates independently with poorer outcomes after stroke. We have previously demonstrated that the relationship between low SES and worse stroke outcomes is mediated by larger infarct size on presentation. Here, we tested the hypothesis that the relationship between SES and initial stroke severity varies across stroke subtypes.
Methods:
Consecutive patients (N=1168) presenting to Massachusetts General Hospital with acute ischemic stroke (mean age= 68, 55.1% male) underwent brain MRI within 24 hrs of admission. Infarct volume on DWI and admission NIH stroke scale (NIHSS) score were recorded. Stroke etiology was classified using the causative classification system. SES was assessed using local median household income as a proxy (by home zip code, using U.S. Census Bureau Fact Finder).
Results:
Both infarct volume and admission NIHSS score increased with decreasing SES tertiles: [NIHSS median (IQR): 5.0 (2.0, 12.0) vs. 4.0 (2.0, 11.0), vs. 3.0 (1.0, 9.0), p = 0.002], [Infarct volume median (IQR): 7.2 (1.5, 28.2) vs. 5.9 (1.5, 30.2) vs. 4.6 (1.0, 19.9), p = 0.02]. This relationship was mainly driven by LAA and CE categories (Figure). Lower SES predicted infarct volume and NIHSS score in combined group of LAA and CE after adjusting for traditional stroke risk factors and history of previous stroke (standardized β [95% CI]) NIHSS: -0.15 [-1.6, - 0.5] p < 0.001, infarct size: - 0.10 [-10.6, -1.8], p = 0.006).
Conclusions:
While disparities in post stroke care may play an important role in the relationship between lower SES and worse outcomes, we show that this association is also significantly driven by a tendency towards developing larger, more severe strokes on presentation, mainly caused by LAA and CE.
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Affiliation(s)
| | | | | | | | | | | | | | - Hakan Ay
- Massachusetts General Hosp, Boston, MA
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Schapira MM, Hubbard RA, Seitz HH, Conant EF, Schnall M, Cappella JN, Harrington T, Inge C, Armstrong K. The Impact of a Risk-Based Breast Cancer Screening Decision Aid on Initiation of Mammography Among Younger Women: Report of a Randomized Trial. MDM Policy Pract 2019; 4:2381468318812889. [PMID: 30729166 PMCID: PMC6350139 DOI: 10.1177/2381468318812889] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 09/19/2018] [Indexed: 02/03/2023] Open
Abstract
Background. Guidelines recommend that initiation of breast cancer
screening (BCS) among women aged 40 to 49 years include a shared decision-making
process. The objective of this study is to evaluate the effect of a breast
cancer screening patient decision-aid (BCS-PtDA) on the strength of the
relationship between individual risk and the decision to initiate BCS,
knowledge, and decisional conflict. Methods. We conducted a
randomized clinical trial of a BCS-PtDA that included individual risk estimates
compared with usual care. Participants were women 39 to 48 years of age with no
previous mammogram. Primary outcomes were strength of association between breast
cancer risk and mammography uptake at 12 months, knowledge, and decisional
conflict. Results. Of 204 participants, 65% were Black, the median
age (interquartile range [IQR]) was 40.0 years (39.0–42.0), and median (IQR)
breast cancer lifetime risk was 9.7% (9.2–11.1). Women who received mammography
at 12 months had higher breast cancer lifetime risk than women who had not in
both intervention (mean, 95% CI): 12.2% (10.8–13.6) versus 10.5% (9.8–11.2),
P = 0.04, and control groups: 11.8% (10.4–13.1) versus 9.9%
(9.2–10.6), P = 0.02. However, there was no difference between
groups in the strength of association between mammography uptake and breast
cancer risk (P = 0.87). Follow-up knowledge (0–5) was greater
in the intervention versus control group (mean, 95% CI): 3.84 (3.5–4.2) versus
3.17 (2.8–3.5), P = 0.01. There was no change in decisional
conflict score (1–100) between the intervention versus control group (mean, 95%
CI): 24.8 (19.5–30.2) versus 32.4 (25.9–39.0), P = 0.07.
Conclusions. The BCS-PtDA improved knowledge but did not affect
risk-based decision making regarding age of initiation of BCS. These findings
indicate the complexity of changing behaviors to incorporate objective risk in
the medical decision-making process.
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Affiliation(s)
| | - Rebecca A Hubbard
- Center for Clinical Epidemiology and Biostatistics and Department of Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Holli H Seitz
- Department of Communication, Social Science Research Center, Mississippi State University, Starkville, Mississippi
| | | | | | - Joseph N Cappella
- Annenberg School of Communication, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Carrie Inge
- Department of Medicine, Perelman School of Medicine
| | - Katrina Armstrong
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
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50
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Armstrong K. Learning From Temporal Relationships: Childbirth and Breast Cancer Risk. Ann Intern Med 2019; 170:66-67. [PMID: 30535335 DOI: 10.7326/m18-3455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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