Structural competency in New Mexico: Moving outside of medical education.

ABSTRACTIn 2019, the Doña Ana Wellness Institute (DAWI), Doña Ana County, New Mexico's health council, sponsored two trainings in structural competency by the Structural Competency Working Group. One focused on health care professionals and learners; the other focused on government, non-profit organisations, and elected officials. DAWI and New Mexico Human Services Department (HSD) representatives attended the trainings and identified the structural competency model as useful for the health equity work both groups were already engaging. These trainings provided the foundation for DAWI and HSD to develop additional trainings, programmes, and curricula founded on structural competency and focused on supporting health equity work.This article describes how DAWI and HSD used the structural competency framework to deepen our work, including how we have expanded the concept beyond its original orientation to support strategic planning, improve communication, and build structurally competent communities. We illustrate how the framework strengthened our existing community and state work and how we adapted the model to better fit our work. Adaptations included changes in language, the use of the lived experiences of organisation members as a foundation for structural competency education, and a recognition that policy work happens at multiple levels and in multiple ways for organisations.

Systematic review of smoking relapse rates among cancer survivors who quit at the time of cancer diagnosis.

BACKGROUND: Tobacco cessation, at the time of cancer diagnosis, has been associated with better oncologic outcomes. Cancer diagnosis has been shown to serves as a "teachable moment," inspiring tobacco cessation. However, the sustainability of abstinence from smoking is understudied. Similarly, there is a paucity of data regarding the utility of behavioral/pharmacologic intervention to support continued smoking cessation. METHODS: A systematic literature review was conducted in August 2021 with no date limits. Relevant studies that reported tobacco smoking relapse rates for patients who quit at the time of cancer diagnosis were included. Our literature search identified 1620 articles and 29 met inclusion criteria. The primary endpoint of the study was smoking relapse rate. Secondary outcome was a descriptive assessment of behavioral and pharmacologic interventions to promote continued cessation. Exploratory outcomes included a regression analysis to examine associations between study factors and relapse rates. RESULTS: There were 3021 smokers who quit at the time of cancer diagnosis. Weighted overall relapse rate for the study population was 44 % (range 5-57 %). Interventions to support smoking cessation were employed in 17 of the 29 included studies and protocols were heterogenous, including behavioral, pharmacologic, or mixed intervention strategies. Exploratory analysis demonstrated no association between relapse rates and publication year, gender, or study type. Relapse rates were indirectly associated with age (p = .003), suggesting that younger patients were more likely to relapse. CONCLUSION: The sustainability of smoking cessation after a cancer diagnosis is understudied, and existing literature is difficult to interpret due to heterogeneity. Relapse rates remain significant and, although many studies have included the employment of an intervention to promote continued cessation, few studies have measured the effect of a protocolized intervention to support abstinence.

Upper pole pathologies in duplex kidneys: an analysis of predictive factors for surgery and urinary tract infections from the Mid-Atlantic Pediatric Academic Consortium.

BACKGROUND/OBJECTIVE: While there is significant data on the natural history and outcomes for prenatal hydronephrosis in simplex kidneys, duplex kidneys tend to be less studied. Management can be quite variable based on provider preference. We aimed to describe practice patterns from several tertiary academic institutions, identify clinical predictors for surgical intervention and urinary tract infection (UTI) for upper pole pathology, and demonstrate the natural history of lower pole vesicoureteral reflux (VUR). METHODS: We conducted a retrospective review of patients from 4 Mid-Atlantic institutions between 2015 and 2020. Inclusion criteria included patients with a duplex kidney with upper pole pathology and/or lower pole VUR. The primary outcome was predictive factors for surgical intervention and UTI. The secondary outcome was to assess the natural history of lower pole VUR including resolution rates by grade. Linear regression identified clinical predictors for UTI events. Multivariate logistic regression identified predictors of surgical intervention, UTI, and lower pole VUR resolution. Descriptive statistics and regression modeling analyses were performed using SAS. RESULTS: Two hundred forty-two patients were included with a total of 271 duplex renal units. Hydronephrosis grade (both SFU and UTD grading) and number of prior UTI events were statistically significant predictors for surgical intervention (p = 0.03/0.001 and p = 0.002 respectively). Ectopic ureter (p = 0.004), ureterocele (p = 0.02), and obstruction (p = 0.04) were the only pathologies predictive for surgery. Male gender and circumcision were significantly associated with decreased UTI risk (p = 0.03 and p = 0.01). On linear regression modeling, antibiotic prophylaxis after the first year of life was associated with decreased risk of further UTI events (p = 0.03); however, antibiotic prophylaxis within the first year of life did not decrease UTI risk (p = 0.14). For VUR outcomes, 65.0% of grades 1-3 VUR and 52.2% of grades 4-5 had resolution/improvement at mean time of 2.1 years. There were no predictive factors for resolution/improvement of VUR. CONCLUSIONS: Hydronephrosis grade and UTI events were significant predictors for surgical intervention for upper pole pathology. Pathologies that were predictive for surgery included ectopic ureter, ureterocele and obstruction. Male gender, circumcision and antibiotic prophylaxis after the first year of life were associated with a decreased UTI risk. Roughly 58% of lower pole VUR spontaneously improved/resolved. Identification of these risk factors aids in standardization of care practices to reduce long-term UTI risk and inform counseling with families about possible need for surgical intervention and expectations for long term outcomes.

Does histologic subtype impact overall survival in observed T1a kidney cancers compared with competing risks? Implications for biopsy as a risk stratification tool.

OBJECTIVES: We sought to assess if adding a biopsy proven histologic subtype to a model that predicts overall survival that includes variables representing competing risks in observed, biopsy proven, T1a renal cell carcinomas, enhances the model's performance. METHODS: The National Cancer Database was assessed (years 2004-2015) for patients with observed T1a renal cell carcinoma who had undergone renal mass biopsy. Kaplan-Meier curves were utilized to estimate overall survival stratified by histologic subtype. We utilized C-index from a Cox proportional hazards model to evaluate the impact of adding histologic subtypes to a model to predict overall survival for each stage. RESULTS: Of 132 958 T1a renal masses identified, 1614 had biopsy proven histology and were managed non-operatively. Of those, 61% were clear cell, 33% papillary, and 6% chromophobe. Adjusted Kaplan-Meier curves demonstrated a difference in overall survival between histologic subtypes (P = 0.010) with greater median overall survival for patients with chromophobe (85.1 months, hazard rate 0.45, P = 0.005) compared to clear cell (64.8 months, reference group). Adding histology to a model with competing risks alone did not substantially improve model performance (C-index 0.65 vs 0.64 respectively). CONCLUSIONS: Incorporation of histologic subtype into a risk stratification model to determine prognostic overall survival did not improve modeling of overall survival compared with variables representing competing risks in patients with T1a renal cell carcinoma managed with observation. These results suggest that performing renal mass biopsy in order to obtain tumor histology may have limited utility. Future studies should further investigate the overall utility of renal mass biopsy for observed T1a kidney cancers.

Current Opinion on the Use of Magnetic Resonance Imaging in Staging Prostate Cancer: A Narrative Review.

Accurate staging is critical for treatment planning and prognosis in men with prostate Cancer. Prostate magnetic imaging resonance (MRI) may aid in the staging evaluation by verifying organ-confined status, assessing the status of the pelvic lymph nodes, and establishing the local extent of the tumor in patients being considered for therapy. MRI has a high specificity for diagnosing extracapsular extension, and therefore may impact the decision to perform nerve sparing prostatectomy, along with seminal vesicle invasion and lymph node metastases; however, its sensitivity remains limited. Current guidelines vary significantly regarding endorsing the use of MRI for staging locoregional disease. For high-risk prostate cancer, most guidelines recommend cross sectional imaging, including MRI, to evaluate for more extensive disease that may merit change in radiation field, extended androgen deprivation therapy, or guiding surgical planning. Although MRI offers reasonable performance characteristics to evaluate bone metastases, guidelines continue to support the use of bone scintigraphy. Emerging imaging technologies, including coupling positron emission tomography (PET) with MRI, have the potential to improve the accuracy of prostate cancer staging with the use of novel radiotracers.

Overall Survival of Biopsy-confirmed T1B and T2A Kidney Cancers Managed With Observation: Prognostic Value of Tumor Histology.

INTRODUCTION: The natural history of T1b (4-7 cm) or T2a (> 7-10 cm) kidney cancers managed with observation is not well-understood. The aim of our study was to determine if the addition of histologic subtype to a predictive model of overall survival (OS) that includes covariates for competing risks in observed, biopsy-proven, T1b and T2a renal cell carcinomas (RCCs) improves the model's performance. MATERIALS AND METHODS: We queried the National Cancer Database for patients with biopsy-proven stage T1b or T2a RCC and managed nonoperatively between 2004 and 2015. OS was estimated by Kaplan-Meier curves based on histologic subtype. The concordance index (c-index) from a Cox proportional hazards model was used to estimate the extent to which histologic subtypes predict survival for each stage when included in a model along with competing risks of age, gender, race/ethnicity, insurance status, area-level socioeconomic indicators, Charlson-Deyo index, and tumor grade. RESULTS: A total of 937 patients (754 with T1b and 185 with T2a) with biopsy-proven RCC were identified. Kaplan-Meier analysis suggested differences in OS by histologic subtype where sarcomatoid, followed by clear cell, papillary, and chromophobe, had the highest mortality risk at 1, 3, and 5 years. However, there was marginal improvement in the multivariable model of OS using competing risks and histology (c-index, 0.64 and 0.697) compared with competing risks alone (c-index, 0.631 and 0.671) for T1b and T2a RCCs, respectively. CONCLUSIONS: In patients with T1b or T2a RCC managed with observation, incorporation of histologic subtype into a risk-stratification model to determine prognostic OS did not improve modeling of OS compared with variables representing competing risks. Histologic subtype of observed T1b and T2a RCC appears to have prognostic OS value when not considering competing risks. These findings may impact the usefulness of renal biopsy to inform decision-making when managing patients with T1b and T2a renal tumors with observation.

Patterns of Recurrence, Detection Rates, and Impact of 18-F Fluciclovine PET/CT on the Management of Men With Recurrent Prostate Cancer.

OBJECTIVE: To evaluate the characteristics of FACBC PET/CT in detecting recurrent prostate cancer after radiation or prostatectomy. The secondary aim was to determine the impact of FACBC PET/CT on radiation treatment recommendations in men with biochemical recurrence postprostatectomy. METHODS: This is a single center retrospective study of men who underwent an FACBC PET/CT for rising PSA after definitive prostate cancer therapy. Detection rates in men with recurrence following any definitive treatment were compared at different PSA levels and anatomical sites. Radiotherapy treatment recommendations for patients postprostatectomy based on conventional imaging findings were compared to recommendations based on FACBC PET/CT findings. RESULTS: A total of 103 men underwent imaging with FACBC PET/CT. 74.8% (77) had lesions consistent with sites of prostate cancer recurrence. At PSA thresholds of <1, 1-2, and >2 ng/mL lesions were detected in 35.5%, 63.6%, and 95.2% of patients respectively (P <.001). The most common site of recurrence was outside of the pelvis (37). Detection of extraprostatic or extrapelvic recurrence was observed in 45.5% of men in the PSA tertile <1ng/mL. FACBC PET/CT results led to changes to the recommended radiotherapy treatment plan in 44.1% (15/34) of men with recurrence following radical prostatectomy. CONCLUSION: FACBC PET/CT demonstrated increased detection of recurrent prostate cancer with increasing PSA levels. Most recurrences were found outside the pelvis. Results of FACBC PET/CT changed radiotherapy management decisions in men treated with prostatectomy, supporting its use in localizing sites of disease recurrence in men with prostate cancer.

Inclusion of surgical antibiotic regimens in pediatric urology publications: A systematic review.

BACKGROUND: Perioperative antibiotics prevent infections after surgery. Guidelines for antibiotic use allow the surgeon to balance the risks of adverse events and drug resistance with the benefit of reduced infection rates. However, due to a lack of evidence-based guidelines within pediatric urology, antibiotic practices vary widely. We performed a systematic literature review to investigate when and how authors report their antibiotic usage and infectious outcomes. Our aim was to analyze the available data on perioperative antibiotics and infection rates within pediatric urology. METHODS: This systematic review was conducted in line with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. A search strategy was devised to identify reports of pediatric urology surgery and use of antibiotics or infectious outcomes. Embase and Medline were queried with no year restrictions with subject heading terms to identify publications on common pediatric urology surgeries. The procedures studied were hypospadias repair, pyeloplasty, orchidopexy, ureteral reimplant, and circumcision. Two independent reviewers screened all titles and abstracts, followed by relevant full texts, for eligibility. Articles were included if the procedure was performed on the majority of study patients, the procedure was performed by urologic surgeons, and the population studied was a pediatric population defined as 0-18 years of age. Case reports, meta-analyses, and editorials were excluded. Data was extracted by one independent reviewer into a preformatted database. Collected data included journal type, date of publication, patient demographics, preoperative and postoperative antibiotic details including regimens, and infection outcomes. The primary outcome was reporting of antibiotic use preoperatively or postoperatively. Secondary outcomes included: reporting of infection, antibiotic class and dosage. Since all studies were diverse, only qualitative analysis was conducted. RESULTS: We identified 1483 publications with 297 meeting inclusion criteria. Of these, 9% reported their use of preoperative antibiotics, and 34% reported their use of postoperative antibiotics. Only 6% of studies reported the specific antibiotic class, 15% reported duration, and 1% reported dosage and frequency. Infection outcomes were reported in 58% of studies. Only 57% of studies that reported on infection outcomes described their antibiotics practices. CONCLUSIONS: Surgical antibiotic regimens and infection outcomes are infrequently included in pediatric urology studies, limiting the data available for development of evidence-based guidelines. Routine incorporation of antibiotic regimens, infection outcomes and adverse events in the pediatric urology literature will increase our ability to identify indications for antibiotics. Reporting of perioperative antibiotic outcomes in pediatric urology procedures will allow the eventual development of strong evidence-based guidelines.

The modern testicular prosthesis: patient selection and counseling, surgical technique, and outcomes.

The testicular prosthesis can be an afterthought for providers when performing an orchiectomy for testicular cancer, torsion, atrophic testis, or trauma. However, data suggest that patients find the offer of a testicular prosthesis and counseling regarding placement to be extremely important from both a pragmatic and a psychosocial perspective. Only two-thirds of men undergoing orchiectomy are offered an implant at the time of orchiectomy and of those offered about one-third move forward with prosthesis placement. The relatively low acceptance rate is in stark contrast with high patient satisfaction and low complication rates for those who undergo the procedure. The most common postoperative patient concerns are minor and involve implant positioning, size, and weight. Herein, we provide an up-to-date review of modern preoperative evaluation, patient selection, expectation management, surgical technique, and expected outcomes for testicular prostheses.

Interplay between exercise and BMI; results from an equal access, racially diverse biopsy study.

PURPOSE: It is unclear if exercise and BMI interact to influence prostate cancer (PC) risk. We hypothesized BMI is linked with increased aggressive PC risk but this link will be attenuated with increased exercise. METHODS: Men undergoing prostate biopsy completed a questionnaire and metabolic equivalent (MET) hours of exercise was calculated. Of 695 men, 349 had PC; 161 low-grade, and 188 high-grade. We assessed the link between exercise and PC risk, high-grade PC (Gleason 7-10), and low-grade PC (Gleason 2-6) using logistic and multinomial logistic regression. Analysis was stratified by BMI. Link between BMI and PC risk and aggressive PC was similarly tested. RESULTS: On multivariable analysis, there was no link between exercise and PC diagnosis in the entire cohort (p trend = 0.18-0.71) or across BMI groups (p trend = 0.15-0.97). For the entire cohort, higher BMI was linked with increased risk of high-grade PC (OR 1.06, p = 0.008). When stratified by exercise groups, the trend for higher BMI and increased risk of high-grade PC remained (OR 1.03-1.15, p = 0.02-0.66). There were no interactions between exercise and BMI in predicting PC risk (all p ≥ 0.31). CONCLUSIONS: Regardless of exercise, higher BMI was linked with higher risk of aggressive PC, while exercise was unrelated to PC risk. Confirmatory studies are needed.

Early-Life Alcohol Intake and High-Grade Prostate Cancer: Results from an Equal-Access, Racially Diverse Biopsy Cohort.

Epidemiologic evidence for an association between alcohol and prostate cancer is mixed. Moreover, there is a lack of research investigating early-life alcohol intake as a risk factor for either overall or high-grade prostate cancer. We examined lifetime alcohol intake in association with prostate cancer diagnosis in an equal-access, racially diverse prostate biopsy cohort. Men undergoing prostate biopsy at the Durham Veterans Affairs Medical Center from 2007 to 2018 completed a survey indicating average number of alcoholic beverages consumed per week [categorized as none (ref), 1-6, ≥7] during each decade of life. Multivariable logistic regression was used to test the association between alcohol intake across decades and diagnosis of overall, low-grade [grade group (GG) 1-2] and high-grade prostate cancer (GG 3-5). Of 650 men ages 49-89 who underwent biopsy, 325 were diagnosed with prostate cancer, 238 with low-grade and 88 with high-grade disease. Relative to nondrinkers, men who consumed ≥7 drinks/week at ages 15 to 19 had increased odds of high-grade prostate cancer diagnosis (OR = 3.21, P trend = 0.020), with similar findings for ages 20 to 29, 30 to 39, and 40 to 49. Consistent with these results, men in the upper tertile of cumulative lifetime intake had increased odds of high-grade prostate cancer diagnosis (OR = 3.20, P trend = 0.003). In contrast, current alcohol intake was not associated with prostate cancer. In conclusion, among men undergoing prostate biopsy, heavier alcohol intake earlier in life and higher cumulative lifetime intake were positively associated with high-grade prostate cancer diagnosis, while current intake was unrelated to prostate cancer. Our findings suggest that earlier-life alcohol intake should be explored as a potential risk factor for high-grade prostate cancer. Cancer Prev Res; 11(10); 621-8. ©2018 AACR.

Threat distractor and perceptual load modulate test-retest reliability of anterior cingulate cortex response.

Accumulating data from fMRI studies implicate the rostral anterior cingulate cortex (rACC) in inhibition of attention to threat distractors that compete with task-relevant goals for processing resources. However, little data is available on the reliability of rACC activation. Our aim in the current study was to examine test-retest reliability of rACC activation over a 12-week period, in the context of a validated emotional interference paradigm that varied in perceptual load. During functional MRI, 23 healthy volunteers completed a task involving a target letter in a string of identical letters (low load) or in a string of mixed letters (high load) superimposed on angry, fearful, and neutral face distractors. Intraclass correlation coefficients (ICCs) indicated that under low, but not high perceptual load, rACC activation to fearful vs. neutral distractors was moderately reliable. Conversely, regardless of perceptual load, rACC activation to angry vs. neutral distractors was not reliable. Regarding behavioral performance, ICCs indicated that accuracy was not reliable regardless of distractor type or perceptual load. Although reaction time (RT) was similarly not reliable regardless of distractor type under low perceptual load, RT to angry vs. neutral distractors and to fearful vs. neutral distractors was reliable under high perceptual load. Together, results indicate the test-retest reliability of rACC activation and corresponding behavioral performance are context dependent; reliability of the former varies as a function of distractor type and level of cognitive demand, whereas reliability of the latter depends on behavioral index (accuracy vs. RT) and level of cognitive demand but not distractor type.

Anomalous bodily experiences and perceived social isolation in schizophrenia: An extension of the Social Deafferentation Hypothesis.

BACKGROUND: Disturbances of the bodily self are fundamental to the phenomenological experience of individuals with schizophrenia, a population at risk for social isolation. Both proprioception and exteroception contribute to a sense of consistent body boundary that contains the self across time and space, and this process is influenced by self-other (social) interactions. However, the relationship between social isolation, exteroception, and in-the-moment changes in body representation has not been elucidated. We investigated susceptibility to anomalous bodily experiences with a phantom nose induction procedure that elicits a sensation that one's nose is changing (Pinocchio Illusion: PI) in relation to exteroceptive awareness and social isolation. METHODS: 25 individuals with schizophrenia (SZ) and 15 matched controls (CO) participated in a PI induction procedure to quantify susceptibility to bodily aberrations and a tactile discrimination task to assess exteroception. Clinical symptoms in SZ and schizotypy in CO were assessed, in addition to a self-report measure of perceived social isolation. RESULTS: Compared to CO, SZ showed increased PI and impaired tactile discriminability. SZ reported greater loneliness than CO. PI scores were correlated with increased loneliness and decreased tactile discriminability. CONCLUSIONS: Greater susceptibility to anomalous bodily experiences, together with reduced exteroceptive awareness and increased loneliness, is compatible with the framework of Hoffman's Social Deafferentation Hypothesis, which posits that a functional "amputation" from one's social environment could lead to a reorganization of the social brain network, resulting in hallucinations and delusions. These findings underscore the importance of the relationship between social isolation and self-disturbances in schizophrenia.