Leading causes of death in Asian Indians in the United States (2005-2017).

OBJECTIVE: Asian Indians are among the fastest growing United States (US) ethnic subgroups. We characterized mortality trends for leading causes of death among foreign-born and US-born Asian Indians in the US between 2005-2017. STUDY DESIGN AND SETTING: Using US standardized death certificate data, we examined leading causes of death in 73,470 Asian Indians and 20,496,189 non-Hispanic whites (NHWs) across age, gender, and nativity. For each cause, we report age-standardized mortality rates (AMR), longitudinal trends, and absolute percent change (APC). RESULTS: We found that Asian Indians' leading causes of death were heart disease (28% mortality males; 24% females) and cancer (18% males; 22% females). Foreign-born Asian Indians had higher all-cause AMR compared to US-born (AMR 271 foreign-born, CI 263-280; 175.8 US-born, CI 140-221; p<0.05), while Asian Indian all-cause AMR was lower than that of NHWs (AMR 271 Indian, CI 263-278; 754.4 NHW, CI 753.3-755.5; p<0.05). All-cause AMR increased for foreign-born Asian Indians over time, while decreasing for US-born Asian Indians and NHWs. CONCLUSIONS: Foreign-born Asian Indians were 2.2 times more likely to die of heart disease and 1.6 times more likely to die of cancer. Asian Indian male AMR was 49% greater than female on average, although AMR was consistently lower for Asian Indians when compared to NHWs.

Cancer Mortality in U.S.-Born versus Foreign-Born Asian American Groups (2008-2017).

BACKGROUND: Asian Americans (AA) are the fastest growing ethnic group in the United States with high proportions of immigrants. Nativity is important as cancer risk factors vary by country. We sought to understand differences in cancer mortality among AAs by nativity (foreign-born vs. U.S.-born). METHODS: Ninety-eight thousand eight hundred and twenty-six AA (Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese) decedents with cancer-related deaths from U.S. death certificates (2008-2017) were analyzed. Thirteen cancers that contribute significantly to Asian-American cancer mortality were selected and categorized by etiology: tobacco-related, screen-detected, diet-/obesity-related, and infection-related. Ten-year age-adjusted mortality rates [AAMR; 95% confidence interval (CI); per 100,00] and standardized mortality ratios (SMR; 95% CI) using foreign-born as the reference group were calculated. RESULTS: Overall, foreign-born AAs had higher mortality rates than U.S.-born. Japanese U.S.-born males had the highest tobacco-related mortality rates [foreign-born AAMR: 43.02 (38.72, 47.31); U.S.-born AAMR: 55.38 (53.05, 57.72)]. Screen-detected death rates were higher for foreign-born than U.S.-born, except for among Japanese males [SMR 1.28 (1.21-1.35)]. Diet-/obesity-related AAMRs were higher among females than males and highest among foreign-born females. Foreign-born males and females had higher infection-related AAMRs than U.S.-born; the highest rates were foreign-born males-Korean [AAMR 41.54 (39.54, 43.53)] and Vietnamese [AAMR 41.39 (39.68, 43.09)]. CONCLUSIONS: We observed substantial heterogeneity in mortality rates across AA groups and by nativity. Contrary to the Healthy Immigrant Effect, most foreign-born Asians were dying at higher rates than U.S.-born AAs. IMPACT: Disaggregated analysis of AA cancers, targeted and culturally tailored cancer screening, and treatments for infections among foreign-born Asians is critical for cancer prevention efforts.

When it's needed most: a blueprint for resident creative writing workshops during inpatient rotations.

BACKGROUND: Narrative Medicine may mitigate physician burnout by increasing empathy and self-compassion, and by encouraging physicians to deeply connect with patient stories/experiences. However, Narrative Medicine has been difficult to implement on hectic inpatient teaching services that are often the most emotionally taxing for residents. OBJECTIVE: To evaluate programmatic and learner outcomes of a novel narrative medicine curriculum implementation during inpatient medicine rotations for medical residents. Programmatic outcomes included implementation lessons. Learner outcomes included preliminary understanding of impact on feelings of burnout. Additionally, we developed a generalizable narrative medicine framework for program implementation across institutions. METHODS: We developed and implemented a monthly 45-min Narrative Medicine workshop on Stanford's busiest and emotionally-demanding inpatient rotation (medical oncology). Using the Physician Wellbeing Inventory (PWBI, range 1-7; 3-4 = high burnout risk; ≥4, high burnout), we anonymously assessed resident burnout during pre-implementation control year (2017-2018, weeks 1 and 4), and implementation year (2018-2019, weeks 1 and 4). We interviewed program directors and facilitators regarding curriculum implementation challenges/facilitators. RESULTS: Residents highly rated the narrative medicine curriculum, and the residency program renewed the course for 3 additional years. We identified success factors for programmatic success including time neutrality, control of session, learning climate, building trust, staff partnership, and facilitators training. During control year, resident burnout was initially high (n = 16; mean PBWI = 3.0, SD: 1.1) and increased by the final week (n = 15; PBWI = 3.4, SD: 1.6). During implementation year, resident burnout was initially similar (n = 13; PBWI = 3.1, SD: 1.9) but did not rise as much by rotation end (n = 24; PBWI = 3.3, SD: 1.6). Implementation was underpowered to detect small effect sizes. Based on our our experience and literature review, we propose an educational competency framework potentially helpful to facilitate inpatient narrative medicine workshops, as a blueprint for other institutions. CONCLUSIONS: Inpatient Narrative Medicine is feasible to implement during a challenging inpatient rotation and may have important short-term effects in mitigating burnout rise, with more study needed. We share teaching tools and propose a competency framework which may be useful to support development of inpatient narrative medicine curricula across institutions.

Disaggregated mortality from gastrointestinal cancers in Asian Americans: Analysis of United States death records.

Asian Americans (AAs) are heterogeneous, and aggregation of diverse AA populations in national reporting may mask high-risk groups. Gastrointestinal (GI) cancers constitute one-third of global cancer mortality, and an improved understanding of GI cancer mortality by disaggregated AA subgroups may inform future primary and secondary prevention strategies. Using national mortality records from the United States from 2003 to 2017, we report age-standardized mortality rates, standardized mortality ratios and annual percent change trends from GI cancers (esophageal, gastric, colorectal, liver and pancreatic) for the six largest AA subgroups (Asian Indians, Chinese, Filipinos, Japanese, Koreans and Vietnamese). Non-Hispanic Whites (NHWs) are used as the reference population. We found that mortality from GI cancers demonstrated nearly 3-fold difference between the highest (Koreans, 61 per 100 000 person-years) and lowest (Asian Indians, 21 per 100 000 person-years) subgroups. The distribution of GI cancer mortality demonstrates high variability between subgroups, with Korean Americans demonstrating high mortality from gastric cancer (16 per 100 000), and Vietnamese Americans demonstrating high mortality from liver cancer (19 per 100 000). Divergent temporal trends emerged, such as increasing liver cancer burden in Vietnamese Americans, which exacerbated existing mortality differences. There exist striking differences in the mortality burden of GI cancers by disaggregated AA subgroups. These data highlight the need for disaggregated data reporting, and the importance of race-specific and personalized strategies of screening and prevention.

One Size Does Not Fit All: Marked Heterogeneity in Incidence of and Survival from Gastric Cancer among Asian American Subgroups.

BACKGROUND: Asian Americans are at higher risk for noncardia gastric cancers (NCGC) relative to non-Hispanic Whites (NHW). Asian Americans are genetically, linguistically, and culturally heterogeneous, yet have mostly been treated as a single population in prior studies. This aggregation may obscure important subgroup-specific cancer patterns. METHODS: We utilized data from 13 regional United States cancer registries from 1990 to 2014 to determine secular trends in incidence and survivorship from NCGC. Data were analyzed for NHWs and the six largest Asian American subgroups: Chinese, Japanese, Filipino, Korean, Vietnamese, and South Asian (Indian/Pakistani). RESULTS: There exists substantial heterogeneity in NCGC incidence between Asian subgroups, with Koreans (48.6 per 100,000 person-years) having seven-fold higher age-adjusted incidence than South Asians (7.4 per 100,000 person-years). Asians had generally earlier stages of diagnosis and higher rates of surgical resection compared with NHWs. All Asian subgroups also demonstrated higher 5-year observed survival compared with NHWs, with Koreans (41.3%) and South Asians (42.8%) having survival double that of NHWs (20.1%, P < 0.001). In multivariable regression, differences in stage of diagnosis and rates of resection partially explained the difference in survivorship between Asian subgroups. CONCLUSIONS: We find substantial differences in incidence, staging, histology, treatment, and survivorship from NCGC between Asian subgroups, data which challenge our traditional perceptions about gastric cancer in Asians. Both biological heterogeneity and cultural/environmental differences may underlie these findings. IMPACT: These data are relevant to the national discourse regarding the appropriate role of gastric cancer screening, and identifies high-risk racial/ethnic subgroups who many benefit from customized risk attenuation programs.

Contribution of birth weight and adult waist circumference to cardiovascular disease risk in a longitudinal study.

To determine the association of birth weight (BW) and waist circumference (WC) on cardiovascular disease (CVD). The longitudinal cohort study consisted of 745 participants who were able to provide their birth weight information and were followed from 2002 to 2014. During the follow-up, 83 events of CVD were confirmed. After adjusting for confounding factors, subjects with birth weight <2500 g were at a significantly increased CVD risk when compared to subjects with birth weight between 2500-3999 g (OR 2·47, 95%CI, 1·07-5·71). When high waist circumference (HWC), a measurement of adult obesity, was incorporated into stratifying factors according to presence or absence of low birth weight (LBW, birth weight <2500 g), adjusted CVD risk was significantly elevated in -LBW/+ HWC group (OR 1·94, 95%CI, 1·10-3·43) and marginally significantly increased in +LBW/-HWC group (OR 2·94, 95%CI, 1·00-8·64). CVD risk was highest in subjects with LBW and HWC (+LBW/+HWC), OR 4·74 (95%CI, 1·48-15·21). Higher waist circumference in adulthood is an especially strong risk factor for cardiovascular disease among those small at birth. In this cohort, birth size and adiposity in adulthood interact to predict events of cardiovascular disease.