Adapting and implementing breast cancer follow-up in primary care: protocol for a mixed methods hybrid type 1 effectiveness-implementation cluster randomized study.

BACKGROUND: Advances in detection and treatment for breast cancer have led to an increase in the number of individuals managing significant late and long-term treatment effects. Primary care has a role in caring for patients with a history of cancer, yet there is little guidance on how to effectively implement survivorship care evidence into primary care delivery. METHODS: This protocol describes a multi-phase, mixed methods, stakeholder-driven research process that prioritizes actionable, evidence-based primary care improvements to enhance breast cancer survivorship care by integrating implementation and primary care transformation frameworks: the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework and the Practice Change Model (PCM). Informed by depth interviews and a four round Delphi panel with diverse stakeholders from primary care and oncology, we will implement and evaluate an iterative clinical intervention in a hybrid type 1 effectiveness-implementation cluster randomized design in twenty-six primary care practices. Multi-component implementation strategies will include facilitation, audit and feedback, and learning collaboratives. Ongoing data collection and analysis will be performed to optimize adoption of the intervention. The primary clinical outcome to test effectiveness is comprehensive breast cancer follow-up care. Implementation will be assessed using mixed methods to explore how organizational and contextual variables affect adoption, implementation, and early sustainability for provision of follow-up care, symptom, and risk management activities at six- and 12-months post implementation. DISCUSSION: Study findings are poised to inform development of scalable, high impact intervention processes to enhance long-term follow-up care for patients with a history of breast cancer in primary care. If successful, next steps would include working with a national primary care practice-based research network to implement a national dissemination study. Actionable activities and processes identified could also be applied to development of organizational and care delivery interventions for follow-up care for other cancer sites. TRIAL REGISTRATION: Registered with ClinicalTrials.gov on June 2, 2022: NCT05400941.

Destination Transplant: Protocol for a Parallel-group Randomized Trial of an Educational Intervention to Increase Kidney Transplant Among Black People on the Transplant Waiting List.

For most patients with kidney failure, living donor kidney transplant (LDKT) is their best treatment option. Compared with White people, Black people are more likely to have kidney failure but less likely to receive LDKTs. In this study, the investigators will test an educational intervention, Destination Transplant, designed to reduce this disparity, among Black people already listed for kidney transplant. METHODS: The investigators will conduct a parallel group, 2-arm randomized clinical trial among 500 Black kidney transplant candidates. The main objective of this study is to test an educational and behavioral intervention that is designed to increase receipt of LDKT among transplant candidates (persons active on the deceased donor kidney transplant waiting list) who are Black. Candidates on the kidney transplant waiting list will be randomly assigned to 1 of 2 conditions: (1) a control group that will receive Usual Care, or (2) an Intervention group that will receive Destination Transplant, a 9-month intervention that includes an in-person group-based education session, postcards at monthly intervals, and a follow-up phone call from a transplant educator. At baseline and during 18 months of follow-up, demographic and clinical variables will be collected, as well as variables such as transplant derailers (factors that might be sources of delay, difficulty, or challenge to pursuing transplant), transplant knowledge, and health literacy, small steps taken to pursue LDKT, readiness for LDKT, decisional balance and self-efficacy LDKT, decisional conflict, family support, availability of potential living donors, and general health status. CONCLUSIONS: This educational intervention aims to increase both readiness to pursue LDKT and actual receipt of LDKTs among Black and African American patients who are already on the kidney transplant waiting list. The aim of the intervention is to reduce racial disparities in access to LDKT.

Educational Attainment of Grandmothers and Preterm Birth in Grandchildren.

BACKGROUND: Maternal education has been shown repeatedly to be inversely associated with preterm birth. Both preterm birth and educational level of families are correlated across generations, but it is not clear if educational level of grandparents affects the risk of preterm delivery of their grandchildren, and, if so, if the association with grandmother's education is independent of mother's education. METHODS: We used New Jersey birth certificates to create a transgenerational dataset to examine the effect of grandmother's education on risk of PTB in White, Black and Hispanic grandchildren. We matched birth certificates of girls born in 1979-1983 to mothers listed on NJ birth certificates for the years 1999-2011. Thus, grandmothers were the women delivering in 1979-1983, and mothers were those born to the grandmothers who in turn delivered grandchildren in 1999-2011. We performed descriptive tabulations and multivariate logistic regression to develop risk estimates. RESULTS: Overall, maternal education was associated inversely with PTB in each of the demographic groups. There was a substantial inter-generational increase in education between grandmothers and mothers in each group, which was most striking in Hispanics After adjusting for maternal age and education, grandmother's education continued to be associated with preterm birth of her grandchildren. CONCLUSIONS: Grandmother's education was an additional, independent predictor of PTB in her grandchildren. This result supports the idea that mother's childhood and preconception socioeconomic environment, including the educational level of her childhood household affect her reproductive health.

Feasibility and potential efficacy of commercial mHealth/eHealth tools for weight loss in African American breast cancer survivors: pilot randomized controlled trial.

Weight management after breast cancer (BC) treatment in African American (AA) women is crucial to reduce comorbid conditions and health disparities. We examined feasibility and potential efficacy of commercial eHealth/mHealth tools for weight management in AA BC survivors in New Jersey. Participants (N = 35) were randomized to an intervention (SparkPeople) plus activity tracker, Fitbit Charge (n = 18), or wait-list active control group (Fitbit only, n = 17). Anthropometric, behavioral, and quality of life (QOL) outcomes were collected at baseline, 3, 6, and 12 months. Differences in outcomes were assessed using intent-to-treat analysis. Retention was 97.1%. Both groups lost weight, with no significant differences between groups. At month 6, mean weight change was: intervention: -1.71 kg (SD 2.33; p = .006), 33.3% lost ≥3% of baseline weight; control: -2.54 kg (SD 4.00, p = .002), 23.5% lost ≥3% weight. Intervention participants achieved significant improvements in waist circumference (-3.56 cm, SD 4.70, p = .005), QOL (p = .030), and use of strategies for healthy eating (p = .025) and decreasing calories (p < .001). Number of days logged food per week was associated with decreases in waist circumference at 6 months (ß -0.79, 95% CI, -1.49, -0.09, p = .030) and 12 months (ß -2.16, 95% CI, -4.17, -0.15, p = .038). Weight loss was maintained at 12 months. This is the first study to demonstrate potential efficacy of commercial eHealth/mHealth tools for weight loss in AA BC survivors, without additional counseling from the research team. If effective, they may be convenient weight loss tools that can be easily and widely disseminated. Clinical Trials registration: ClinicalTrials.gov NCT02699983.

The Impact of E-Cigarette Warnings, Warning Themes and Inclusion of Relative Harm Statements on Young Adults' E-Cigarette Perceptions and Use Intentions.

Although e-cigarettes in the United States are required to carry one nicotine addiction warning, little is known about the impact of other potential e-cigarette warning themes, nor about pairing warnings with messages that communicate e-cigarettes' reduced-harm potential relative to cigarettes. We randomly assigned 876 young adults (ages 18⁻29) to view e-cigarette ads in a 3 × 2 plus control online experiment that varied by warning theme (i.e., nicotine addiction; nicotine's impact on adolescent brain development; presence of harmful chemicals) and warning type-i.e., the presence ("relative harm warning") or absence ("standard warning") of a relative harm (RH) statement in the warning label ("e-cigarettes may cause harm to health but are less harmful than cigarettes"). Warning believability, informativeness, understandability and support were high across conditions and there were no significant differences by warning theme on e-cigarette harm perceptions or use intentions nor on nicotine (mis)perceptions. Perceived warning effectiveness for discouraging youth initiation was higher for the "brain" and "chemicals" warnings compared to the addiction warning. Warnings with the included RH statement were perceived as less believable and credible and were less frequently correctly recalled. Research should continue to investigate the impact of different e-cigarette warning themes and formats with priority audiences.

Improved outcomes after blastocyst-stage frozen-thawed embryo transfers compared with cleavage stage: a Society for Assisted Reproductive Technologies Clinical Outcomes Reporting System study.

OBJECTIVE: To investigate whether there is a difference in obstetrical and perinatal outcomes in blastocyst frozen-thawed embryo transfers (FETs) compared with cleavage-stage FET. DESIGN: A retrospective cohort study. SETTING: Not applicable. PATIENT(S): Women undergoing autologous FETs at either the blastocyst stage (n = 118,572) or the cleavage stage (n = 117,619) reported to the Society for Assisted Reproductive Technology in the years 2004-2013. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Live birth, gestational age, birth weight, miscarriage. RESULT(S): After controlling for confounders, there were a 49% increased odds of live birth after blastocyst-stage FET compared with cleavage-stage FET (odds ratio [OR] = 1.49; 95% confidence interval [CI], 1.44, 1.54). Additionally, blastocyst FET was associated with a 68% (OR = 1.68; 95% CI, 1.63, 1.74) increased odds of clinical pregnancy and an 7% (OR = 0.93; 95% CI, 0.88, 0.92) decreased odds of miscarriage. There was also a 16% increased odds of preterm delivery (OR = 1.16; 95% CI, 1.06, 1.27) after blastocyst FET but no difference in birth weights. CONCLUSION(S): In patients undergoing FET, blastocyst-stage transfer is associated with higher live-birth rates when compared with cleavage-stage transfers. Furthermore, perinatal outcomes are similar between the groups.

Determinants of patient activation in a community sample of breast and prostate cancer survivors.

BACKGROUND: Patient activation-the knowledge, skills, and confidence to manage one's health-is associated with improved self-management behaviors for several chronic conditions. This study assesses rates of patient activation in breast and prostate cancer survivors and explores the characteristics associated with patient activation. METHODS: A cross-sectional study of survivors with localized (Stage I or II) breast and prostate cancers who were post-treatment (between 1-10+ years) were recruited from 4 community hospital sites in New Jersey. Survey data on patient characteristics (demographic and psychosocial) and clinical factors were assessed to explore the relationships with patient activation using the Patient Activation Measure-13. RESULTS: Among 325 survivors (112 prostate; 213 breast), overall patient activation was high (M = 3.25). Activation was significantly lower among prostate survivors when compared with breast cancer survivors (M = 3.25 [SD, 0.38] vs M = 3.34 [SD, 0.37], P<.05). For prostate survivors, race (P < .05), marital status (P < .001), employment status (P < .01), household income (P < .05), and fear of recurrence (P < .01) were significantly associated with patient activation. For both groups, ease of access to oncology team and primary care physicians (PCPs) (all P values < .001) and perceptions of time spent with oncologists' team and PCPs (all P values < .01) were positive predictors of activation. CONCLUSIONS: In both breast and prostate survivors, access to providers (both PCPs and oncologists) and perception that adequate time spent with providers were associated with activation. Therefore, clinical interventions maybe a promising avenue to improve patient activation. Research is needed to develop and test tailored patient activation interventions to improve self-management among cancer survivors.

A Preoperative Scale for Determining Surgical Readmission Risk After Total Knee Arthroplasty.

BACKGROUND: Total knee arthroplasty (TKA) is one of the most common orthopaedic procedures performed in the U.S. The purpose of this study was to develop and verify a scale to preoperatively stratify a patient's risk of being readmitted to the hospital following a TKA. METHODS: Discharge data on 433,638 patients from New York and California (derivation cohort) and 269,934 patients from Florida and Washington (validation cohort) who underwent TKA were collected from the State Inpatient Database, a part of the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality (2006 to 2011). Demographic and clinical characteristics of patients were abstracted and analyzed to develop the Readmission After Total Knee Arthroplasty (RATKA) Scale. RESULTS: Overall 30-day readmission rates in the derivation and validation cohorts were 5.11% and 4.98%, respectively. The following factors were significantly associated with increased 30-day readmission rates in the derivation cohort: age of 41 to 50 years (odds ratio [OR] = 1.13), age of 71 to 80 years (OR = 1.21), age of 81 to 90 years (OR = 1.70), male sex (OR = 1.19), African-American race (OR = 1.37), "other" race/ethnicity (OR = 1.08), Medicaid payer (OR = 1.43), Medicare payer (OR = 1.27), anemia (OR = 1.19), chronic obstructive pulmonary disease (OR = 1.29), coagulopathy (OR = 1.22), congestive heart failure (OR = 1.64), diabetes (OR = 1.19), fluid and electrolyte disorder (OR = 1.25), hypertension (OR = 1.10), liver disease (OR = 1.27), renal failure (OR = 1.33), and rheumatoid arthritis (OR = 1.14). These factors were used to create the RATKA Scale. The RATKA score was then used to define 3 levels of risk for readmission: low (RATKA score of <13; 3.7% readmission rate), moderate (RATKA score of 13 to 16; 5.4% readmission rate), and high (RATKA score of >16; 7.6% readmission rate). The relative risk of readmission was 2.06 for the high-risk group compared with the low-risk group. CONCLUSIONS: The RATKA Scale derived from patient data from the derivation cohort was reliably able to explain readmission variability after TKA for patients in the validation cohort at a rate of >95%. Models such as the RATKA Scale will enable identification of the risk of readmission following TKA based on a patient's risk profile prior to surgery. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Association of Ozone Exposure With Cardiorespiratory Pathophysiologic Mechanisms in Healthy Adults.

Importance: Exposure to ozone has been associated with cardiovascular mortality, but the underlying biological mechanisms are not yet understood. Objective: To examine the association between ozone exposure and cardiopulmonary pathophysiologic mechanisms. Design, Setting, and Participants: A longitudinal study involving 89 healthy adult participants living on a work campus in Changsha City, China, was conducted from December 1, 2014, to January 31, 2015. This unique quasiexperimental setting allowed for better characterization of air pollutant exposure effects because the participants spent most of their time in controlled indoor environments. Concentrations of indoor and outdoor ozone, along with the copollutants particulate matter, nitrogen dioxide, and sulfur dioxide, were monitored throughout the study period and then combined with time-activity information and filtration conditions of each residence and office to estimate 24-hour and 2-week combined indoor and outdoor mean exposure concentrations. Associations between each exposure measure and outcome measure were analyzed using single-pollutant and 2-pollutant linear mixed models controlling for ambient temperature, secondhand smoke exposure, and personal-level time-varying covariates. Main Outcomes and Measures: Biomarkers indicative of inflammation and oxidative stress, arterial stiffness, blood pressure, thrombotic factors, and spirometry were measured at 4 sessions. Results: Of the 89 participants, 25 (28%) were women and the mean (SD) age was 31.5 (7.6) years. The 24-hour ozone exposure concentrations ranged from 1.4 to 19.4 parts per billion (ppb), corresponding to outdoor concentrations ranging from 4.3 to 47.9 ppb. Within this range, in models controlling for a second copollutant and other potential confounders, a 10-ppb increase in 24-hour ozone was associated with mean increases of 36.3% (95% CI, 29.9%-43.0%) in the level of platelet activation marker soluble P-selectin, 2.8% (95% CI, 0.6%-5.1%) in diastolic blood pressure, 18.1% (95% CI, 4.5%-33.5%) in pulmonary inflammation markers fractional exhaled nitric oxide, and 31.0% (95% CI, 0.2%-71.1%) in exhaled breath condensate nitrite and nitrate as well as a -9.5% (95% CI, -17.7% to -1.4%) decrease in arterial stiffness marker augmentation index. A 10-ppb increase in 2-week ozone was associated with increases of 61.1% (95% CI, 37.8%-88.2%) in soluble P-selectin level and 126.2% (95% CI, 12.1%-356.2%) in exhaled breath condensate nitrite and nitrate level. Other measured biomarkers, including spirometry, showed no significant associations with either 24-hour ozone or 2-week ozone exposures. Conclusions and Relevance: Short-term ozone exposure at levels not associated with lung function changes was associated with platelet activation and blood pressure increases, suggesting a possible mechanism by which ozone may affect cardiovascular health.

Uncoupling genotoxic stress responses from circadian control increases susceptibility to mammary carcinogenesis.

We previously demonstrated that chemopreventive methylselenocysteine (MSC) prevents N-Nitroso-N-methylurea (NMU)-induced mammary carcinogenesis in the susceptible Fischer 344 (F344) rats by enhancing NAD+-dependent SIRT1 activity, restoring circadian expression of Period 2 (Per2) and circadian controlled genes. Here, we show that compared to the genetically resistant Copenhagen (COP) rat strain, mammary glands of the F344 rats have a 4-hour phase delay in circadian expression of Per2. Consequently, F344 rats failed to increase SIRT1 activity and circadian expression of Per2 and DDRR genes after exposure to NMU. Exposure of COP rats to NMU had the opposite effect, enhancing SIRT1 activity, increasing circadian expression of Per2 and DDRR genes. Significantly, SIRT1 activity and circadian expression of Per2 and DDRR genes in NMU-treated F344 rats on a chemopreventive regimen of MSC approximated those in NMU-treated COP rats. These results indicated that COP rats have an increased capacity to maintain NAD+-dependent SIRT1 activity under genotoxic stress. This contention was supported by increased stability of the period and phase of circadian locomotor activity in COP vs F344 rats exposed to changing light conditions. The increased sensitivity and rapid response of COP to changing light were correlated with the enhanced circadian response of this strain to carcinogen. Disturbance of circadian rhythm by jet lag also disrupted circadian expression of Per2 and DDRR genes, and accelerated mammary tumorigenesis in rodent models. These results suggested that uncoupling of DDRR responses from circadian control by environmental stresses and endogenous factors increases susceptibility to mammary carcinogenesis, possibly by inducing a promutagenic state.

Perceptions of Cancer Risk: Differences by Weight Status.

Despite the strong link between obesity and cancer development, individuals are less likely to identify obesity as a risk factor for cancer than family history. Family history of cancer has been documented to influence perceived risk of developing cancer, yet it is unclear if excess weight impacts cancer risk perceptions. The purpose of this study was to examine absolute and relative risk perceptions for cancer by weight status. Cross-sectional data were obtained from the National Cancer Institute's 2011 Health Information National Trends Survey (n = 2585). Demographics, anthropometric data, family history of cancer, health behaviors, and absolute and relative cancer risk perceptions were evaluated. The effect of weight and family history on absolute and relative cancer risk perceptions was analyzed through weighted descriptive and logistic regression analyses. 22.8 and 28.6 % of subjects reported that they were very unlikely/unlikely to develop cancer in their lifetime (absolute risk) and when compared to others their age (relative risk), respectively. Findings indicated differences in risk perceptions between those with and without a family history of cancer (p < 0.0001). No significant differences were found between BMI categories for absolute cancer risk perceptions despite stratification by family history. Obese subjects were more likely to have an increased relative risk perception of cancer compared to healthy weight subjects (p = 0.0066); this association remained significant when stratified by family history (p = 0.0161). Educating individuals, especially those who are overweight/obese, about the impact of excess weight on cancer risk may improve risk accuracy and promote cancer risk reduction through weight management.

Associations of Anthropometric, Behavioral, and Social Factors on Level of Body Esteem in Peripubertal Girls.

OBJECTIVE: Lower body esteem may decrease self-esteem and lead to adverse health effects in children. This study explored the role of anthropometric, behavioral, and social factors on body esteem in peripubertal girls. METHOD: We evaluated associations of body esteem (measured by the Revised Body Esteem Scale) with body mass index (BMI), mother's BMI, puberty, physical activity, role models for appearance, and screen time among girls (ages 9 and 10) participating in the Jersey Girl Study (n = 120). Linear models were used to evaluate differences in body esteem scores. RESULTS: Overweight/obese girls had a significantly lower mean body esteem score compared with underweight/healthy weight girls {14.09 (95% confidence interval [CI]: 12.53-15.27) vs. 17.17 (95% CI: 16.87-17.43)}. Girls who were physically active for at least 7 hours per week had a significantly higher body esteem score than those who were less active, after adjusting for BMI (17.00 [95% CI: 16.62-17.32] vs. 16.39 [95% CI: 15.82-16.86]). Girls whose mothers were overweight/obese, who had entered puberty, and who cited girls at school or females in the media as role models had lower body esteem scores, but differences disappeared after adjusting for girl's BMI. A trend of higher body esteem scores was found for girls whose mothers were role models. CONCLUSION: Lower BMI and higher levels of physical activity are independently associated with higher body esteem score. Having classmates or girls/women in the media as role models may detrimentally affect girls' body esteem, but having mothers as role models may have a positive effect.

Breast and prostate cancer survivors' experiences of patient-centered cancer follow-up care from primary care physicians and oncologists.

PURPOSE: Patient-physician relationships impact health care seeking and preventive screening behaviors among patients. At the end of active treatment some cancer survivors report feeling disconnected from their care team. This study explores cancer survivors' experiences of patient-centered cancer follow-up care provided by primary care physicians (PCP) and oncologists (ONC). METHODS: Three hundred five early stage, breast and prostate cancer survivors at least 2 years post treatment were surveyed from four community hospital oncology programs in New Jersey. Participants reported receipt of patient-centered care measured by care coordination, comprehensiveness of care, and personal relationship with PCPs and ONCs. RESULTS: PCPs received higher ratings for coordination of care and comprehensive care than ONCs from all survivors (P < 0.01). However, prostate and breast cancer survivors rated strengths of their personal bonds with the physicians differently. While prostate cancer survivors rated PCPs significantly higher for all items (P < 0.028), breast cancer survivors rated ONCs significantly higher on four out of seven items including having been through a lot together, understanding what is important regarding health, knowing their medical history and taking their beliefs and wishes into account (P < 0.036). CONCLUSIONS: Prostate and breast cancer survivors report different experiences with their PCPs and oncologists around the comprehensiveness and coordination of their cancer follow-up care in addition to the strength of their relationships with their physicians. IMPLICATIONS FOR CANCER SURVIVORS: There are important differences in the experience of patient-centered care among cancer survivors that should be considered when planning care models and interventions for these different populations.

Follow-up Care Education and Information: Identifying Cancer Survivors in Need of More Guidance.

Cancer survivors engage in cancer screenings and protective health behaviors at suboptimal rates despite their increased risk for future illness. Survivorship care plans and other educational strategies to prepare cancer survivors to adopt engaged roles in managing long-term follow-up care and health risks are needed. In a sample of cancer survivors, we identified patient characteristics and psychosocial predictors associated with increased follow-up care informational needs. Cross-sectional surveys were administered to early-stage breast and prostate survivors (N = 278; 68 % breast) at least 2 years post treatment from four community hospital programs in New Jersey between May 2012 and July 2013. Patient demographics, medical history, psychosocial characteristics (i.e., worries about the future, fear of disease recurrence, and patient activation), and perceptions of oncology and primary care were assessed. African-American survivors (AOR = 2.69, 95 % confidence interval [CI] 1.27-5.68) and survivors with higher comorbidity (AOR =1.16, CI 1.01-1.33) were more likely to want additional information to guide follow-up care. Adjusting for race and comorbidities, survivors who wanted more information to guide their follow-up care reported greater worries about the future (p < 0.05) and fears about disease recurrence (p < 0.05) compared to those who did not want additional information. Results emphasize the need to develop cancer survivorship educational strategies that are both responsive to the needs of specific populations (e.g., African-American survivors and patients with multiple comorbidities) and the psychosocial profiles that motivate requests for more extensive follow-up guidance.

Modulation of Human Macrophage Responses to Mycobacterium tuberculosis by Silver Nanoparticles of Different Size and Surface Modification.

Exposure to silver nanoparticles (AgNP) used in consumer products carries potential health risks including increased susceptibility to infectious pathogens. Systematic assessments of antimicrobial macrophage immune responses in the context of AgNP exposure are important because uptake of AgNP by macrophages may lead to alterations of innate immune cell functions. In this study we examined the effects of exposure to AgNP with different particle sizes (20 and 110 nm diameters) and surface chemistry (citrate or polyvinlypyrrolidone capping) on cellular toxicity and innate immune responses against Mycobacterium tuberculosis (M.tb) by human monocyte-derived macrophages (MDM). Exposures of MDM to AgNP significantly reduced cellular viability, increased IL8 and decreased IL10 mRNA expression. Exposure of M.tb-infected MDM to AgNP suppressed M.tb-induced expression of IL1B, IL10, and TNFA mRNA. Furthermore, M.tb-induced IL-1ß, a cytokine critical for host resistance to M.tb, was inhibited by AgNP but not by carbon black particles indicating that the observed immunosuppressive effects of AgNP are particle specific. Suppressive effects of AgNP on the M.tb-induced host immune responses were in part due to AgNP-mediated interferences with the TLR signaling pathways that culminate in the activation of the transcription factor NF-κB. AgNP exposure suppressed M.tb-induced expression of a subset of NF-κB mediated genes (CSF2, CSF3, IFNG, IL1A, IL1B, IL6, IL10, TNFA, NFKB1A). In addition, AgNP exposure increased the expression of HSPA1A mRNA and the corresponding stress-induced Hsp72 protein. Up-regulation of Hsp72 by AgNP can suppress M.tb-induced NF-κB activation and host immune responses. The observed ability of AgNP to modulate infectious pathogen-induced immune responses has important public health implications.

How Does Emergency Department Crowding Affect Medical Student Test Scores and Clerkship Evaluations?

INTRODUCTION: The effect of emergency department (ED) crowding has been recognized as a concern for more than 20 years; its effect on productivity, medical errors, and patient satisfaction has been studied extensively. Little research has reviewed the effect of ED crowding on medical education. Prior studies that have considered this effect have shown no correlation between ED crowding and resident perception of quality of medical education. OBJECTIVE: To determine whether ED crowding, as measured by the National ED Overcrowding Scale (NEDOCS) score, has a quantifiable effect on medical student objective and subjective experiences during emergency medicine (EM) clerkship rotations. METHODS: We collected end-of-rotation examinations and medical student evaluations for 21 EM rotation blocks between July 2010 and May 2012, with a total of 211 students. NEDOCS scores were calculated for each corresponding period. Weighted regression analyses examined the correlation between components of the medical student evaluation, student test scores, and the NEDOCS score for each period. RESULTS: When all 21 rotations are included in the analysis, NEDOCS scores showed a negative correlation with medical student tests scores (regression coefficient= -0.16, p=0.04) and three elements of the rotation evaluation (attending teaching, communication, and systems-based practice; p<0.05). We excluded an outlying NEDOCS score from the analysis and obtained similar results. When the data were controlled for effect of month of the year, only student test score remained significantly correlated with NEDOCS score (p=0.011). No part of the medical student rotation evaluation attained significant correlation with the NEDOCS score (p≥0.34 in all cases). CONCLUSION: ED overcrowding does demonstrate a small but negative association with medical student performance on end-of-rotation examinations. Additional studies are recommended to further evaluate this effect.

Reduced Hospital Duration of Stay Associated with Revised Emergency Department-Intensive Care Unit Admission Policy: A before and after Study.

BACKGROUND: Emergency department (ED) and hospital crowding adversely impacts patient care. Although reduction methods for duration of stay in the ED have been explored, few focus on medical intensive care unit (MICU) patients. OBJECTIVE: To quantify duration of stay or mortality changes associated with a policy intervention that changed the role of an MICU resident to "screen" and write MICU admission orders in the ED to instead meet the patient and write orders in the MICU if there was an available bed. The intervention moved "screening" bed management-appropriateness discussions to the MICU attending or fellow level. METHODS: We performed a retrospective before and after study at an urban, level 1 trauma center of adults admitted to the MICU from the ED during the first 6 months in 2009 before, and the corresponding 6 months in 2010, after the intervention. We collected demographics, ED, MICU, and hospital duration of stay, duration of mechanical ventilation, Acute Physiology and Chronic Health Evaluation (APACHE) scores, and mortality from electronic medical records. Linear models compared duration of stay differences; logistic regression compared in-hospital mortality. T-tests assessed APACHE score changes before and after the policy change. Analyses were adjusted for age and sex. RESULTS: We included 498 patients, average age 66 years (±18), 52% male. Hospital duration of stay decreased 18% from 6.8 to 5.6 days (unadjusted p = 0.029). MICU duration of stay decreased from 3.5 to 3.3 days (unadjusted p = 0.34) and ED duration of stay from arrival to physical transfer decreased 40 min (375 to 324 min; unadjusted p = 0.006). Mortality and APACHE scores were unchanged. CONCLUSIONS: A streamlined admission intervention from the ED to the MICU was associated with decreased ED and hospital duration of stay without altering mortality.

Perceptions of Primary Care Among Breast Cancer Survivors: The Effects of Weight Status.

BACKGROUND: Obese breast cancer survivors (BCSs) are impacted by diminished quality of life (QOL), multiple comorbid conditions, and poor disease outcomes. Despite national guidelines recommending a healthy weight to improve QOL and outcomes posttreatment, support and education are not routinely provided to BCSs in primary care. To fill this gap, we assessed perceptions of primary care received among BCSs by weight status. METHODS: Cross-sectional surveys were administered to early-stage BCSs (N = 188) from 2 New Jersey cancer centers between May 2012 and July 2013. Sociodemographics, medical history, functional health status, perceived satisfaction with one's primary care provider (PCP), and PCP involvement in follow-up care were assessed. RESULTS: In total, 82% of overweight BCSs and 30% of obese BCSs reported not being told by their doctor that they were overweight or obese, despite these conditions being highly prevalent (35% and 35%, respectively). Obese BCSs were more likely than healthy weight BCSs to be African American, have a higher comorbidity score, poorer functional health, and greater satisfaction with their PCPs. CONCLUSION: The PCP-patient encounter may represent an opportunity for PCPs to correct misperceptions and promote weight reduction efforts among BCSs, thus improving QOL and disease outcomes.

Vitamin D deficiency is associated with pulmonary dysfunction in cystic fibrosis.

BACKGROUND: Vitamin D deficiency is common in CF. Whether vitamin D affects pulmonary function in CF is unknown. METHODS: Data were abstracted from clinically stable CF patients who had pulmonary function studies and serum 25-hydroxyvitamin D [25(OH)D, ng/ml] levels drawn within 2 months of each other. Findings were adjusted for multiple variables known to affect pulmonary function in CF. RESULTS: Enrollees totaled 597. Overall mean 25(OH)D level was 29.6±12.8 ng/ml (SD). Serum 25(OH)D levels showed a significant correlation with forced expiratory volume in 1s (FEV1) % predicted (r=0.20, p<0.0001) and forced vital capacity % predicted (r=0.13, p=0.0019). Multivariate analysis revealed that serum 25(OH)D remained an independent predictor of FEV1 % predicted even after controlling for multiple other factors known to affect CF lung function. CONCLUSIONS: Serum 25(OH)D levels are significantly associated with pulmonary function in CF. Further study is required to determine whether this association is causal.

Plasma nitrite is an indicator of acute changes in ambient air pollutant concentrations.

CONTEXT: Endothelial dysfunction has been suggested as a potential mechanism by which ambient air pollution may cause acute cardiovascular events. Recently, plasma nitrite has been developed as a marker of endothelial dysfunction. OBJECTIVES: We examined the changes in plasma nitrite concentration associated with increases in ambient air pollutant concentrations in the previous 7 d. MATERIALS AND METHODS: We linked up to three measurements of plasma nitrite concentrations obtained from 49 students to 24-h average concentrations of five criteria air pollutants [particle mass < 2.5 µm in aerodynamic diameter (PM(2.5)), carbon monoxide (CO), sulfur dioxide (SO2), nitrogen dioxide (NO2), and ozone (O3)] measured at two monitoring sites closest to Rutgers University campus (6-15 miles) in New Jersey during the years 2006-2009. We examined the change in plasma nitrite associated with each interquartile-range (IQR) increase in pollutant concentration in the previous 24 h and six preceding 24- h periods, using linear mixed models. RESULTS: IQR increases in mean PM(2.5) (7.0 µg/m³) and CO (161.7 parts per billion) concentrations in the first 24 h before the plasma nitrite measurement were associated with increased plasma nitrite concentrations (PM(2.5): 15.5 nanomolar; 95% confidence interval (CI): 2.4, 28.5; CO: 15.6 nanomolar; 95% CI: 2.4, 28.9). Increased plasma nitrite associated with IQR increases in O3 and SO2 concentrations over longer lags were observed. DISCUSSION AND CONCLUSION: Rapid increases in plasma nitrite following exposure to ambient air pollutants support the hypothesis that ambient air pollution is associated with inducible nitric oxide synthase-mediated systemic inflammation in humans.