Disparities in Access to Mental Health Services Among Children Diagnosed with Anxiety and Depression in the United States.

Child and adolescent mental health are major public health concerns in the US. Overall, 20% of US children have a reported mental health condition, while an estimated 40% will be diagnosed with one by age 18. Despite these concerns, little is known about factors associated with access to mental health services among children and adolescents. We analyzed data from a sample of 6655 children (aged 6 to 17 years) with either anxiety and/or depression drawn from the 2020-2021 National Survey of Children's Health (NSCH). A multivariable logistic regression model was fit to investigate predisposing, enabling, and need factors associated with caregiver's (i.e., parent or other guardian) perceived access to mental health services for their children. Approximately 50.8% of caregivers perceived obtaining mental health services for their children to be somewhat difficult, very difficult, or impossible. Children meeting criteria for having a medical home had lower odds of experiencing such difficulties (adjusted [a]OR = 0.38; 95% CI: 0.30-0.49). Further, compared to children who sometimes or never had health insurance coverage for mental or behavioral health needs, children who were always insured (aOR: 0.19; 95% CI 0.14, 0.25) and those who usually had coverage (aOR: 0.38; 95% CI 0.28, 0.51) had lower odds of experiencing perceived difficulties in obtaining care. The results indicate several enabling and need predictors of perceived access to mental health services--highlighting potential structural barriers to care access. Efforts to address access challenges should adopt a multifaceted approach and be tailored to families living in poverty, those with limited health coverage, and minoritized children with less than optimal general health.

Predictors of U.S. Adults' Opinion Toward an R-Rating Policy for Movies With Cigarette Smoking.

Recently, multiple health organizations and advocacy groups have pushed for giving an R-rating for movies depicting tobacco imagery. This study examined several predictors of U.S. adults' opinion toward an R-rating policy for movies depicting cigarette smoking. We used data from the Health Information National Trends Survey (2020 cycle), for a nationally representative sample of 3,865 US adults (aged ≥ 18). The outcome variable was opinion toward an R-rating policy (support, neutral, and oppose) for movies depicting cigarette smoking. A weighted adjusted multinomial logistic regression analysis with comparisons of support versus oppose, support versus neutral, and neutral versus oppose was performed. About 48.2% of respondents were supportive of, 31.1% were neutral toward, and 20.7% were opposed to an R-rating policy. Adults aged 50 to 64 years (adjusted odds ratio [aOR] = 2.28, p = .008) and ≥65 years (aOR = 4.54, p <.001) (vs. 18-34 years) were more likely to support the R-rating policy than oppose it. Non-Hispanic Black respondents (vs. non-Hispanic Whites) were 1.74 times more likely to support than oppose the policy (aOR = 1.74, p = .04), whereas adults with a household annual income of US$75,000 or more (vs. <$20,000) and those with moderate (vs. liberal) political viewpoints were more likely to be neutral than oppose the policy. Former and current e-cigarette users (vs. never users) were less likely to support than oppose the policy. Tailored messaging addressing the rationale behind R-rating policy should be directed towards communities based on age, race/ethnicity, household income, e-cigarette usage, and political ideologies.

Applications of the partial-order continual reassessment method in the early development of treatment combinations.

Combination therapy is increasingly being explored as a promising approach for improving cancer treatment outcomes. However, identifying effective dose combinations in early oncology drug development is challenging due to limited sample sizes in early-phase clinical trials. This task becomes even more complex when multiple agents are being escalated simultaneously, potentially leading to a loss of monotonic toxicity order with respect to the dose. Traditional single-agent trial designs are insufficient for this multi-dimensional problem, necessitating the development and implementation of dose-finding methods specifically designed for drug combinations. While, in practice, approaches to this problem have focused on preselecting combinations with a known toxicity order and applying single-agent designs, this limits the number of combinations considered and may miss promising dose combinations. In recent years, several novel designs have been proposed for exploring partially ordered drug combination spaces with the goal of identifying a maximum tolerated dose combination, based on safety, or an optimal dose combination, based on toxicity and efficacy. However, their implementation in clinical practice remains limited. In this article, we describe the application of the partial order continual reassessment method and its extensions for combination therapies in early-phase clinical trials. We present completed trials that use safety endpoints to identify maximum tolerated dose combinations and adaptively use both safety and efficacy endpoints to determine optimal treatment strategies. We discuss the effectiveness of the partial-order continual reassessment method and its extensions in identifying optimal treatment strategies and provide our experience with executing these novel adaptive designs in practice. By utilizing innovative dose-finding methods, researchers and clinicians can more effectively navigate the challenges of combination therapy development, ultimately improving patient outcomes in the treatment of cancer.

A Pilot Study of the Combination of Entinostat with Capecitabine in Advanced Breast Cancer.

Background: Breast cancer has an unacceptably high recurrence rate when any residual disease is found following neoadjuvant treatment of high-risk disease. Based on clinical data suggesting an adjuvant role for epigenetic modifying agents in breast cancer and preclinical data suggesting synergistic activity of entinostat combined with capecitabine, we conducted a phase I, open-label study of these agents in metastatic breast cancer (MBC). Both agents have published doses for use in combination therapy, but the agents had not previously been combined with each other in a human trial. Methods: A multisite phase I dose escalation study was performed at two academic centers. Patients with pretreated, HER2-negative MBC, and measurable disease were enrolled. Dual dose escalation was performed via a Bayesian partial order continual assessment method. Dose levels ranged from entinostat 3 mg to 5 mg and capecitabine 800 mg/m2 to 1000 mg/m2. Results: Thirteen patients with MBC and a median of 4 lines of prior therapy were enrolled across four dose level combinations. The most common toxicities were neutropenia, thrombocytopenia, and palmar-plantar dysesthesia, which were expected toxicities. No new safety signals were observed. One dose-limiting toxicity was observed, which did not exceed a prespecified toxicity rate of 25%. The median treatment duration was 2.37 months. No partial nor complete responses were observed. The study was halted early prior to entering an expansion phase, due to drug supply limitations. Conclusion: The tested dosing combinations of entinostat and capecitabine are likely safe in heavily pretreated metastatic breast cancer. This study's clinical investigation of entinostat in breast cancer was halted, but drug development of this agent continues outside the US. There remains a need for postoperative adjuvant drug therapy for the subpopulation of breast cancer patients with high-risk residual cancer after curative therapy. This trial is registered with NCT03473639.

Slimmer's Palsy Following Weight Loss Associated With Metastatic Breast Cancer: A Case Report.

Common peroneal neuropathy (CPN), also known as Slimmer's Palsy, is an isolated peripheral neuropathy typically associated with rapid weight loss resulting in loss of adipose tissue and subsequent nerve compression at the fibular head and is up to three times more common in individuals with malignancy. In this case report, we describe the diagnosis of CPN in a 54-year-old female with a 2.5-month history of atraumatic left foot drop and left ankle paresthesias, preceded by a 35-40 pound weight loss over the prior 3.5 month period in the setting of metastatic breast cancer.

Phase I study targeting newly diagnosed grade 4 astrocytoma with bispecific antibody armed T cells (EGFR BATs) in combination with radiation and temozolomide.

PURPOSE: The purpose of this study was to determine the safety, feasibility, and immunologic responses of treating grade 4 astrocytomas with multiple infusions of anti-CD3 x anti-EGFR bispecific antibody (EGFRBi) armed T cells (EGFR BATs) in combination with radiation and chemotherapy. METHODS: This phase I study used a 3 + 3 dose escalation design to test the safety and feasibility of intravenously infused EGFR BATs in combination with radiation and temozolomide (TMZ) in patients with newly diagnosed grade 4 astrocytomas (AG4). After finding the feasible dose, an expansion cohort with unmethylated O6-methylguanine-DNA methyltransferase (MGMT) tumors received weekly EGFR BATs without TMZ. RESULTS: The highest feasible dose was 80 × 109 EGFR BATs without dose-limiting toxicities (DLTs) in seven patients. We could not escalate the dose because of the limited T-cell expansion. There were no DLTs in the additional cohort of three patients with unmethylated MGMT tumors who received eight weekly infusions of EGFR BATs without TMZ. EGFR BATs infusions induced increases in glioma specific anti-tumor cytotoxicity by peripheral blood mononuclear cells (p < 0.03) and NK cell activity (p < 0.002) ex vivo, and increased serum concentrations of IFN-γ (p < 0.03), IL-2 (p < 0.007), and GM-CSF (p < 0.009). CONCLUSION: Targeting AG4 with EGFR BATs at the maximum feasible dose of 80 × 109, with or without TMZ was safe and induced significant anti-tumor-specific immune responses. These results support further clinical trials to examine the efficacy of this adoptive cell therapy in patients with MGMT-unmethylated GBM. CLINICALTRIALS: gov Identifier: NCT03344250.

Predictors of Adolescents' Transition Through the Stages of Change for Quitting E-Cigarettes: Findings From the Population Assessment of Tobacco and Health Study.

PURPOSE: To identify predictive factors associated with US adolescents' transition through the stages of change for potentially quitting e-cigarettes using the Trans-theoretical model of behavior change. DESIGN: Prospective cohort study. SETTING: United States. SUBJECTS: We utilized data from adolescents (12-17 years) in Wave 3 of the Population Assessment of Tobacco and Health study who used e-cigarettes exclusively over the past 30 days (n = 177) and were followed up with in Wave 4. MEASURES: Outcome variables were 3 transition categories: those who remained stagnant, those who progressed, and those who regressed in their stage of quitting e-cigarettes. Predictor variables were socio-demographics, e-cigarette harm perception, e-cigarette use at home or by important people, social norms, e-cigarette and anti-tobacco advertisements, and e-cigarette health warnings. ANALYSIS: Weighted-adjusted multinomial regression analysis was performed to determine the association between predictor and outcome variables. RESULTS: From Wave 3 to Wave 4, 19% of adolescents remained stagnant; 73.3% progressed; and 7.7% regressed. Adolescents were less likely to progress in their stage of change if they perceived nicotine in e-cigarettes to be "not at all/slightly harmful" (AOR = .26 [95% CI: .25, .27], P < .001); reported important people's use of e-cigarettes (AOR = .18 [95% CI: .05, .65, P = .009); and "rarely" noticed e-cigarette health warnings (AOR = .28 [95% CI: .08, .98, P = .054). CONCLUSION: Intervention efforts must target specific predictive factors that may help adolescents quit e-cigarettes.

Disparities in E-Cigarette Harm and Addiction Perceptions Among Adolescents in the United States: a Systematic Review of the Literature.

BACKGROUND: Health disparities associated with e-cigarette use are increasingly apparent among US adolescents. Perceptions of e-cigarette harm and addiction play an important role in understanding adolescents' e-cigarette use behavior. The objective of this systematic review is to examine racial/ethnic and socio-economic disparities in e-cigarette harm and addiction perceptions among US adolescents. METHODS: We searched five databases to identify cross-sectional or longitudinal studies that focused on adolescents (≤ 18 years of age) who were ever, current, or never e-cigarettes users; we then examined how race/ethnicity and/or socio-economic status (SES) impacted e-cigarette harm and/or addiction perceptions. Two co-authors independently identified relevant studies, extracted data, and assessed the risk of bias. RESULTS: Adhering to PRISMA guidelines, eight of 226 identified studies met the inclusion criteria. These eight studies examined either perceptions regarding absolute e-cigarette harm and/or addiction (i.e., assessing perception of only e-cigarette) or relative e-cigarette harm and/or addiction (i.e., comparative perceptions to traditional cigarettes) by race and ethnicity. Two of the eight studies assessed absolute harm and/or addiction perceptions of e-cigarettes by SES. Our results indicate that, compared to all other racial/ethnic groups, relative e-cigarette harm and addiction perceptions were lower among Non-Hispanic White adolescents; however, absolute e-cigarette harm perception was higher among these groups. No clear patterns of racial/ethnic differences in absolute e-cigarette addiction perceptions and SES differences in absolute e-cigarette harm perceptions were reported. CONCLUSION: More research is needed to explicitly assess perceptions of e-cigarette harm and addiction among US adolescents by race/ethnicity and SES to develop subgroup appropriate public health messaging.

mHealth Apps Use and Their Associations With Healthcare Decision-Making and Health Communication Among Informal Caregivers: Evidence From the National Cancer Institute's Health Information National Trends Survey.

PURPOSE: The current study investigates associations between mHealth apps and healthcare decision-making and health communication among informal caregivers in the US. DESIGN: Cross-sectional study employing secondary data. SETTING: The Health Information National Trends Survey (HINTS5, Cycles 2 through 4, 2018 - 2020). SAMPLE: Self-identified informal caregivers (n = 1386; had mHealth apps = 61.3%, female = 63.2%, some college or more in education = 80.3%) who reported owning at least a smartphone or a tablet computer (i.e., ownership of a "smart device"). MEASURES: Sociodemographic characteristics, reports of having mHealth apps, smart device utilization in healthcare decision-making and health communication. ANALYSIS: Accounting for the complex design features of the HINTS data, we constructed multiple hierarchical logistic regressions to compute adjusted odds ratios (aOR) and their 95% confidence intervals (CI). RESULTS: Compared to caregivers without mHealth apps, those with the apps had higher odds of utilizing their smart devices to make a health-related decision, such as how to treat a disease or a medical condition (aOR = 1.65; 95% CI: 1.13-2.39, P < .01), or engage in health-related discussions with a healthcare provider (aOR = 2.36; 95% CI: 1.54-3.61, P < .001). CONCLUSION: Having mHealth apps was associated with a higher likelihood of using smart devices in healthcare decision-making and health communication by informal caregivers. Empowering caregivers to make informed health-related decisions and communicate effectively with healthcare providers are both crucial to health promotion and well-being. Future studies should investigate facilitators as well as barriers to using mHealth apps and smart devices in health-promoting strategies involving informal caregivers.

Diagnostic Performance of Magnetic Resonance Imaging for Pediatric Ovarian Neoplasms: A Multi-Institutional Review.

STUDY OBJECTIVE: To assess the diagnostic performance of MRI to predict ovarian malignancy alone and compared with other diagnostic studies. METHODS: A retrospective analysis was conducted of patients aged 2-21 years who underwent ovarian mass resection between 2009 and 2021 at 11 pediatric hospitals. Sociodemographic information, clinical and imaging findings, tumor markers, and operative and pathology details were collected. Diagnostic performance for detecting malignancy was assessed by calculating sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for MRI with other diagnostic modalities. RESULTS: One thousand and fifty-three patients, with a median age of 14.6 years, underwent resection of an ovarian mass; 10% (110/1053) had malignant disease on pathology, and 13% (136/1053) underwent preoperative MRI. MRI sensitivity, specificity, PPV, and NPV were 60%, 94%, 60%, and 94%. Ultrasound sensitivity, specificity, PPV, and NPV were 31%, 99%, 73%, and 95%. Tumor marker sensitivity, specificity, PPV, and NPV were 90%, 46%, 22%, and 96%. MRI and ultrasound concordance was 88%, with sensitivity, specificity, PPV, and NPV of 33%, 99%, 75%, and 94%. MRI sensitivity in ultrasound-discordant cases was 100%. MRI and tumor marker concordance was 88% with sensitivity, specificity, PPV, and NPV of 100%, 86%, 64%, and 100%. MRI specificity in tumor marker-discordant cases was 100%. CONCLUSION: Diagnostic modalities used to assess ovarian neoplasms in pediatric patients typically agree. In cases of disagreement, MRI is more sensitive for malignancy than ultrasound and more specific than tumor markers. Selective use of MRI with preoperative ultrasound and tumor markers may be beneficial when the risk of malignancy is uncertain. CONCISE ABSTRACT: This retrospective review of 1053 patients aged 2-21 years who underwent ovarian mass resection between 2009 and 2021 at 11 pediatric hospitals found that ultrasound, tumor markers, and MRI tend to agree on benign vs malignant, but in cases of disagreement, MRI is more sensitive for malignancy than ultrasound.

Cryotherapy for prevention of chemotherapy induced peripheral neuropathy in breast cancer.

Peripheral neuropathy is a well-described complication of chemotherapy. There are no known treatments to reverse peripheral neuropathy. Chemotherapy-induced peripheral neuropathy is a dose-limiting toxicity in cancer treatment and is debilitating. Cryotherapy, or the use of cold garments/ice bags applied to extremities during chemotherapy, is a method to prevent or minimize treatment related neuropathy. There is no standard method of providing cryotherapy currently. A review of the literature was performed revealing that a variety of cryotherapy methods exist. While small studies suggest potential preventive effect of some forms of cryotherapy, consistent results from well-designed randomized studies are lacking. A small benefit from the use of cryotherapy to prevent peripheral neuropathy might exist, but conflicting studies exist. In light of the low cost to implement ice bags during chemotherapy and the low risk of toxicity, the use of ice bags may be reasonable during taxane chemotherapy for the treatment of breast cancer.

Estrogen receptor positive breast cancer: contemporary nuances to sequencing therapy.

The treatment landscape of hormone receptor-positive, human epidermal growth factor receptor 2-negative metastatic breast cancer has evolved dramatically in recent years. While the combination of endocrine therapy and a cyclin-dependent kinase 4/6 inhibitor is accepted as standard first-line treatment in most settings without visceral crisis, newer therapies have challenged traditional treatment models where cytotoxic chemotherapy was previously felt to be the only second-line option at time of progression. The incorporation of next-generation sequencing has led to the identification of molecular targets for therapeutic agents, including phosphatidylinositol 3-kinase and ESR1, though similar pathways can be targeted even in the absence of a mutation, such as with use of inhibitors of mammalian target of rapamycin. Current data also supports the use of cyclin-dependent kinase inhibitors beyond progression, even prior to the patient's first introduction to chemotherapy. The abundance of therapeutic options not only delay time to cytotoxic chemotherapy and antibody-drug conjugate initiation, but has resulted in improvement in breast cancer survivorship. Many unanswered questions remain, however, as to the most efficacious way to sequence these novel agents. To assist in this decision-making, we will review the existing data on systemic therapy and propose a treatment paradigm.

Association Between Adverse Childhood Experiences and Opioid Use-Related Behaviors: A Systematic Review.

As opioid use-related behaviors continue at epidemic proportions, identifying the root causes of these behaviors is critical. Adverse childhood experiences (ACEs) are shown to be an important predictor of opioid initiation, opioid dependence, and lifetime opioid overdose. The purpose of this systematic review is to examine the association between ACEs and opioid use-related behaviors later in life and to discuss implications for policy, practice, and research regarding ACEs and opioids. Five databases (PubMed, PsycINFO, CINAHL, Medline, and Scopus) were used to identify studies investigating the association between ACEs and opioid use-related behaviors. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, 20 studies out of the initial 428 met the inclusion criteria for this review. Among the included 20 studies, 15 focused on the relationship between ACEs and lifetime opioid use-related behaviors, and five focused on current opioid use-related behaviors. All studies found statistical associations between ACEs and lifetime or current opioid use-related behaviors. Five studies found a significant gradient effect; that is, as the number of ACEs increased, the risk of opioid use-related behaviors also increased. A significant dose-response relationship exists between ACEs and opioid use-related behaviors. Hence, it is essential for clinicians to screen for ACEs before prescribing opioid medications, for opioid treatment to incorporate trauma-informed methods, and for messaging around opioid use interventions to include information about ACEs. The current review points to a critical need to implement standardized ACE screening instruments in clinical and research settings.

Complete Response of Triple-Negative Metaplastic Carcinoma of the Breast Using Pembrolizumab.

Metaplastic breast cancer (MpBC) is a rare form of breast malignancy with a poor prognosis and limited treatment guidance. Here, we report on a case of triple-negative MpBC that was successfully treated following the Keynote-522 clinical algorithm using pembrolizumab, paclitaxel, carboplatin, adriamycin, and cyclophosphamide in a neo-adjuvant fashion. The radiographic and histologic findings of the tumor are reviewed here along with the treatment regimen and response. No major toxicities associated with pembrolizumab were observed in this case. This case report serves as an example of complete pathological response of triple-negative MpBC with pembrolizumab plus chemotherapy and demonstrates the need for further research on chemoimmunotherapy for MpBC.

Reducing Unnecessary Oophorectomies for Benign Ovarian Neoplasms in Pediatric Patients.

Importance: Although most ovarian masses in children and adolescents are benign, many are managed with oophorectomy, which may be unnecessary and can have lifelong negative effects on health. Objective: To evaluate the ability of a consensus-based preoperative risk stratification algorithm to discriminate between benign and malignant ovarian pathology and decrease unnecessary oophorectomies. Design, Setting, and Participants: Pre/post interventional study of a risk stratification algorithm in patients aged 6 to 21 years undergoing surgery for an ovarian mass in an inpatient setting in 11 children's hospitals in the United States between August 2018 and January 2021, with 1-year follow-up. Intervention: Implementation of a consensus-based, preoperative risk stratification algorithm with 6 months of preintervention assessment, 6 months of intervention adoption, and 18 months of intervention. The intervention adoption cohort was excluded from statistical comparisons. Main Outcomes and Measures: Unnecessary oophorectomies, defined as oophorectomy for a benign ovarian neoplasm based on final pathology or mass resolution. Results: A total of 519 patients with a median age of 15.1 (IQR, 13.0-16.8) years were included in 3 phases: 96 in the preintervention phase (median age, 15.4 [IQR, 13.4-17.2] years; 11.5% non-Hispanic Black; 68.8% non-Hispanic White); 105 in the adoption phase; and 318 in the intervention phase (median age, 15.0 [IQR, 12.9-16.6)] years; 13.8% non-Hispanic Black; 53.5% non-Hispanic White). Benign disease was present in 93 (96.9%) in the preintervention cohort and 298 (93.7%) in the intervention cohort. The percentage of unnecessary oophorectomies decreased from 16.1% (15/93) preintervention to 8.4% (25/298) during the intervention (absolute reduction, 7.7% [95% CI, 0.4%-15.9%]; P = .03). Algorithm test performance for identifying benign lesions in the intervention cohort resulted in a sensitivity of 91.6% (95% CI, 88.5%-94.8%), a specificity of 90.0% (95% CI, 76.9%-100%), a positive predictive value of 99.3% (95% CI, 98.3%-100%), and a negative predictive value of 41.9% (95% CI, 27.1%-56.6%). The proportion of misclassification in the intervention phase (malignant disease treated with ovary-sparing surgery) was 0.7%. Algorithm adherence during the intervention phase was 95.0%, with fidelity of 81.8%. Conclusions and Relevance: Unnecessary oophorectomies decreased with use of a preoperative risk stratification algorithm to identify lesions with a high likelihood of benign pathology that are appropriate for ovary-sparing surgery. Adoption of this algorithm might prevent unnecessary oophorectomy during adolescence and its lifelong consequences. Further studies are needed to determine barriers to algorithm adherence.

Methamphetamine-Induced Wakefulness and Sleep Management: A Qualitative Analysis of Online Narratives.

While much attention has been given to methamphetamine's wake-promoting properties and the concept of using methamphetamine to increase energy, little is known about the ways people who use methamphetamine manage their use to pursue their functional goals or the challenges they encounter doing so. This qualitative study explores the experiences of people who used methamphetamine to manage wakefulness and reduce sleep as a means to achieve functional goals. We conducted a grounded theory analysis of 202 anonymous letters submitted to an online forum. Five themes emerged from this process: (1) Using methamphetamine to extend wakefulness and reduce the need for sleep; (2) Losing control over wakefulness and the need for sleep; (3) Managing wakefulness and the need for sleep while on methamphetamine; (4) Getting caught in a cycle of wakefulness and sleep; and (5) Sleep disruptions even after ceasing methamphetamine use. Participants believed methamphetamine was critical to meeting their functional goals, and they went to great lengths to try to manage the substance's ill effects. Thus, clients in treatment for methamphetamine use disorder may benefit from interventions addressing their underlying motivations and perceived associations between methamphetamine and meeting functional goals.

Driving under the influence of substances and motor vehicle fatalities among older adults in the United States.

OBJECTIVE: This study examines contribution of substance use (including alcohol, cannabinoids, stimulants, narcotics, depressants, and hallucinogens) on the probability of drivers being at-fault for a crash on U.S. public roads, with specific emphasis on older adult drivers. METHODS: Data from the National Highway Traffic Safety Administration's Fatality Analysis Reporting System (FARS) for the years 2010-2018 were employed for 87,060 drivers (43,530 two-vehicle crash pairs) involved in two moving vehicle crashes. The quasi-induced exposure (QIE) method was used to compute the relative crash involvement ratios (CIRs) for each relevant substance and illicit drug. Mixed-effect generalized linear regression models were fit to examine the effect of substance use on the probability of a driver being at-fault for a crash. RESULTS: There were 75.51% males and 73.88% Non-Hispanic Whites in our sample. The CIR for those aged 70-79 years was 1.17, and more than double (2.56) for the ≥80 years old drivers, while being relatively low among drivers of ages 20 to 69. Substance use, in general, disproportionately increased the probability of being at-fault during a crash, regardless of driver's age. Though older drivers are less likely than other age groups to report substance use, presence of substances among older drivers increased the probability of their being at-fault two to four times during a crash across almost all substances. The regression models, after adjusting for driver's sex, road grade, weather, light conditions, distraction, and speeding at time of crash, revealed that older drug-impaired drivers were twice as likely to be at fault in a fatal crash (aOR = 1.947; 95% CI = 1.821, 2.082; <0.0001) compared to their middle-aged counterparts. Similarly, most substance use categories were responsible for the probabilities of higher CIRs among the drivers. CONCLUSION: These findings necessitate continued efforts to bring awareness to the deadly consequences of "drugged driving," especially among older adult drivers.

Systematic review of the management of brain metastases from hormone receptor positive breast cancer.

INTRODUCTION: Brain metastases are a common cause of morbidity and mortality in patients with breast cancer. Local central nervous system (CNS) directed therapies are usually the first line treatment for breast cancer brain metastases (BCBM), but those must be followed by systemic therapies to achieve long-term benefit. Systemic therapy for hormone receptor (HR+) breast cancer has evolved in the last 10 years, but their role when brain metastases occur is uncertain. METHODS: We performed a systematic review of the literature focused on management of HR+ BCBM by searching Medline/PubMed, EBSCO, and Cochrane databases. The PRISMA guidelines were used for systematic review. RESULTS: Out of 807 articles identified, 98 fulfilled the inclusion criteria in their relevance to the management of HR+ BCBM. CONCLUSIONS: Similar to brain metastases from other neoplasms, local CNS directed therapies are the first line treatment for HR+ BCBM. Although the quality of evidence is low, after local therapies, our review supports the combination of targeted and endocrine therapies for both CNS and systemic management. Upon exhaustion of targeted/endocrine therapies, case series and retrospective reports suggest that certain chemotherapy agents are active against HR+ BCBM. Early phase clinical trials for HR+ BCBM are ongoing, but there is a need for prospective randomized trials to guide management and improve patients' outcome.

Challenges to Help-Seeking Among Women of Color Exposed to Intimate Partner Violence.

Women exposed to intimate partner violence (IPV) often rely on support from their informal support networks to obtain resources that may mitigate IPV. This study explored the challenges women of color encounter in seeking advice and information from their informal support networks (i.e., family, friends, neighbors, community members) regarding IPV support services. In-depth interviews were conducted with 29 IPV survivors who self-identified as Black or Hispanic. Data were analyzed using grounded theory methodology. Results showed that participants lacked informational support, both in their communities and in their interpersonal relationships with family and friends. Communities treated IPV as normal and propagated the belief that women's responsibilities were to men and family. Family and friends discouraged IPV information seeking and advised that IPV should be kept private to avoid community shaming. The community environments also lacked information about resources for women experiencing IPV. The lack of information from their informal support networks appeared to delay participants' help-seeking. As the frequency and severity of violence escalated, some participants engaged in independent information searching, using social media and online information sources as well as conventional media like radio and newspapers. Others received information from first responders in the wake of a violent emergency. Participants described the information they received online or from first responders as empowering, encouraging them to engage in support services. Similarly, they felt empowered by the information they received from social workers, counselors, and victims' advocates, and they wished to use what they learned to help other women in similar circumstances. Women experiencing IPV and their communities need more information regarding IPV support services. Successful interventions for IPV survivors and their support networks may necessitate community-level education and altering biased perceptions of gender-appropriate behaviors.

Desmoid Tumor and Implant-Based Breast Reconstruction.

Desmoid tumors are rare locally aggressive myelodysplastic tumors that are usually abdominally based. They account for 0.2% of breast tumors. Certain factors like prior surgery, familial adenomatous polyposis, pregnancy, and high estrogen states are associated with chest wall desmoid tumor occurrence. We present a patient with a history of intraductal carcinoma of the left breast who underwent mastectomy with implant-based reconstruction who had a desmoid tumor of the breast detected during workup for cardiac transplantation for chemotherapy-induced heart failure. The tumor was originally thought to be recurrent breast cancer during workup with imaging obscured by the implant. Excisional biopsy demonstrated a desmoid tumor with a positive deep margin requiring rib resection, synthetic mesh, and pectoralis major flap reconstruction. Breast desmoid tumors are reactive malignancies that have been diagnosed after prior breast implant surgery but without an established risk associated with breast implants. Excision with microscopically negative margins and chest wall reconstruction when indicated is the current established treatment protocol; however, recent paradigm shifts include "watchful waiting" and medical management among treatment strategies.