Casting light on 25-hydroxyvitamin D deficiency in ovarian cancer: a study from the NHANES.

OBJECTIVES: Ecological studies have long described a higher incidence of ovarian cancer in more extreme latitudes, where sun exposure, and presumably vitamin D exposure, is lower. Basic science studies have also noted polymorphisms of the vitamin D receptor in ovarian cancers. The aim of this study is to examine the relationship of serum vitamin D to ovarian cancer. METHODS: A case-control study of 7273 subjects from the National Health and Nutrition Examination Surveys (NHANES) was performed. Serum 25-hydroxyvitamin D (25[OH]D) levels were examined in both ovarian cancer patients and a control population. Logistic regression examined the odds of ovarian cancer for those with vitamin D levels below the median of the U.S. population. RESULTS: Ovarian cancer cases were more than three times more likely to have low 25[OH]D levels (OR 3.68, 95% CI 1.03-13.21, p=0.04). In the weighted multivariate model, the relationship persisted after adjusting for potential confounders, including age, body mass index, and diet. Adjusting for significant covariates, which included age and dietary calcium intake, ovarian cancer cases were nearly four times more likely to have low 25[OH]D levels (OR 3.92, 95% CI 1.11-13.85, p=0.03). CONCLUSIONS: Prevalent ovarian cancer cases have lower serum 25-hydroxyvitamin D (25[OH]D) than the general population. Deficiency in vitamin D may provide an etiologic link between the long-known ecologic findings regarding latitude and the basic science noting polymorphisms in the vitamin D receptor.

Postexposure prophylaxis for victims of sexual assault: treatments and attitudes of emergency department physicians.

BACKGROUND: Emergency departments (EDs) are the primary source of care for victims of sexual assault (SA). Provision of emergency contraception (EC) to these women has previously been noted to be sporadic. Completeness of care for victims of SA and the barriers to complete care are further investigated in this study. STUDY DESIGN: All ED attending physicians in Maryland, Virginia and the District of Columbia were identified and contacted for participation; 35% completed the survey. Practice patterns were analyzed for the 67% of physicians who do not refer SA victims to other hospitals. RESULTS: We found that 83% of physicians "always" or "usually" offer EC, but only half prescribe EC more than 48 h postassault. While most (89%) typically offer prophylaxis for STDs other than HIV, only 45% offer or counsel on HIV prophylaxis. Physician attitudes and hospital protocols were significant modifiers. CONCLUSION: Sexual assault victims are often not offered comprehensive care including prophylaxis against pregnancy and all STDs including HIV. Additional research is warranted to determine why physicians do not routinely offer HIV prophylaxis after SA.

Psychiatrists' attitudes toward and awareness about racial disparities in mental health care.

OBJECTIVE: Psychiatrists may perpetuate racial-ethnic disparities in health care through racially biased, albeit unconscious, behaviors. Changing these behaviors requires that physicians accept that racial-ethnic disparities exist and accept their own contributions to disparities. The purposes of this study were to assess psychiatrists' awareness of racial disparities in mental health care, to evaluate the extent to which psychiatrists believe they contribute to disparities, and to determine psychiatrists' interest in participating in disparities-reduction programs. METHODS: A random sample of psychiatrists, identified through the American Psychiatric Association's member directory, was invited to complete the online survey. The survey was also distributed to psychiatrists at a national professional conference. RESULTS: Of the 374 respondents, most said they were not familiar or only a little familiar with the literature on racial disparities. Respondents tended to believe that race has a moderate influence on quality of psychiatric care but that race is more influential in others' practices than in their own practices. One-fourth had participated in any type of disparities-reduction program within the past year, and approximately one-half were interested in participating in such a program. CONCLUSIONS: Psychiatrists may not recognize the pervasiveness of racial inequality in psychiatric care, and they may attribute racially biased thinking to others but not to themselves. Interventions to eliminate racial-ethnic disparities should focus on revealing and modifying unconscious biases. Lack of physician interest may be one barrier to such interventions.

Racial differences in the use of adjunctive psychotropic medications for patients with schizophrenia.

BACKGROUND: Antidepressants, mood stabilizers and anxiolytics are frequently used in addition to antipsychotic medications in order to control ancillary symptom complexes among patients with schizophrenia. Although extensive data has demonstrated racial disparities in diagnostic and treatment patterns for schizophrenia, little is known about racial differences in the use of adjunctive medications. Since these adjunctive medications may significantly improve clinical outcomes, further investigation is warranted. AIMS OF THE STUDY: The purpose of this study was to determine the rates at which adjunctive antidepressants, mood stabilizers and anxiolytics were prescribed to black patients and white patients with schizophrenia. The authors hypothesized that black patients would be less likely to receive any adjunctive medication as compared to white patients. METHODS: This cross-sectional study utilized data from an academic medical center in Rochester, New York. Three multivariate logistic regression were performed to model the likelihood of receiving each of the three types of adjunctive medication. The primary independent variable was race, and the models also controlled for clinical and sociodemographic factors such as diagnosis, age, gender, living situation, and insurance status. RESULTS: Of the 456 patients included in the study, 37% received an antidepressant, 33% received a mood stabilizer and 23% received an anxiolytic. All patients received an antipsychotic medication. In each multivariate model, race was significantly associated with likelihood of receiving the adjunctive medication (p<.01 for all). None of the covariates was consistently associated with receipt of an adjunctive medication. DISCUSSION: Even after controlling for potentially confounding clinical and sociodemographic factors, race was strongly associated with receipt of adjunctive medications. This finding is consistent with previous work demonstrating racial disparities in the treatment and management of schizophrenia. The cross-sectional study design, however, limits the conclusions that can be drawn from this study, as length-time bias may have led to a misrepresentation of how many patients receive adjunctive medications. Caution should be observed in interpreting our results and replication is necessary. IMPLICATIONS FOR FURTHER RESEARCH: Differences in the use of adjunctive medications may be due to true differences in the frequency of ancillary symptom complexes. Previous work, however, suggests that differences are more likely to be due to underdiagnosis of affective or anxiety symptoms among black patients. Among patients with recognized ancillary symptoms complexes, black patients may also be less likely than white patients to receive treatment. This may be due to racial differences in accessibility of mental health care, physician perceptions of patients, and patient beliefs and preferences. In future work, use of standardized diagnostic tools may help to determine actual rates of ancillary symptom complexes and to identify racial variations. Additionally, further research is needed to clarify the underlying biases and behaviors that affect use of adjunctive medications among patients with schizophrenia in whom ancillary symptom complexes have been identified.

Vitality, mental health, and satisfaction with information after breast cancer.

OBJECTIVE: The purpose of this study was to investigate the relationship between satisfaction with information about treatment-related and survivorship issues and mental health outcomes, including vitality, in long-term breast cancer survivors. METHODS: Participants who had finished treatment for breast cancer at least 3 months before enrollment completed a survey instrument designed to evaluate satisfaction with diagnostic and treatment information and satisfaction with survivorship information. Mental health and vitality were measured using the Medical Outcomes Study SF-36, and distress was measured using the impact of events scale. Bivariate analyses and linear regression analyses were performed to investigate the relationships between satisfaction with information, mental health, vitality, and distress controlling for clinical and treatment variables. RESULTS: The survey was completed by 231 participants (response rate 83%). More respondents were highly satisfied with treatment information (87%) than with survivorship information (30%, p=0.0001). There was a strong positive relationship between satisfaction with information (both treatment and survivorship issues) and vitality, mental health, and a strong negative relationship with distress. In multivariate analyses, satisfaction with treatment information was independently associated with mental health (p<0.01), and satisfaction with survivorship information was independently associated with vitality (p<0.05). CONCLUSION: Among patients who have completed treatment for breast cancer, satisfaction with diagnosis and treatment information is greater than satisfaction with survivorship issues and satisfaction with information may play an important role in mental health outcomes. PRACTICE IMPLICATIONS: Given the relationship between satisfaction with information and vitality, interventions to improve informational support regarding survivorship issues are warranted.

Attitudes toward life-sustaining interventions among ambulatory black and white patients.

OBJECTIVES: The purpose of this study was to evaluate racial differences in preference for life-sustaining interventions in the context of various physical and mental health scenarios. DESIGN: Data were collected by using an investigator-administered survey. SETTING AND PATIENTS: Consecutive patients who self-identified as African American or Caucasian were recruited from two private primary care practices in Rochester, New York. MAIN OUTCOME MEASURES: Patients were asked to decide whether they would accept or decline life-sustaining intervention in eight scenarios, each involving a different combination of mental and physical disability. Information on religiousness, family integration, and experience with creating a healthcare proxy was also collected, as these variables were believed to be potential confounders of the relationship between race and preference. RESULTS: Data from 77 patients (50 Black patients and 27 White patients) were analyzed. In multivariate log linear modeling, race was a significant predictor of preference for life-sustaining therapy, even after controlling for degree of mental and physical disability. Religiousness, family integration, and experience with creating a healthcare proxy did not explain racial differences in preference for life-sustaining therapy. CONCLUSIONS: We have shown that ambulatory Black patients aged > or = 50 years are more likely than White patients to prefer life-sustaining care, and that these preferences persist across a wide range of mental and physical disabilities. This attitude conflicts with the prevailing ethic regarding end-of-life care, and Black patients and their families may consequently find have difficulty obtaining medical care that is consistent with their cultural values and beliefs. Policy decisions regarding end-of-life care must reflect a culturally diverse perspective.

Racial disparities in the use of second-generation antipsychotics for the treatment of schizophrenia.

OBJECTIVE: Despite recommendations that second-generation antipsychotics be used as first-line treatment for schizophrenia, previous studies have shown that blacks are less likely than whites to receive these newer drugs. This study determined the rate at which second-generation antipsychotics were prescribed to whites and blacks with schizophrenia who were treated as outpatients. METHODS: Data were collected from a community mental health clinic affiliated with an academic center in Rochester, New York. Multivariate logistic regression was used to examine the association between race and the receipt of a second-generation antipsychotic. RESULTS: Data were available for 456 patients: 276 whites and 180 blacks. Ninety-five percent received a second-generation antipsychotic. Whites were approximately six times more likely than blacks to receive a second-generation medication, after the analysis controlled for clinical and sociodemographic factors (p<.001). Most of this difference appeared to be driven by a disparity in the use of clozapine. CONCLUSIONS: In this sample, blacks were less likely than whites to receive second-generation antipsychotics, demonstrating a persistent gap in the quality of care for patients with schizophrenia.

Stability of decisional role preference over the course of cancer therapy.

Cancer patients vary in their preferred level of involvement in medical decision making, and responding to patients' desired level of involvement is a key element of good medical care. While the literature has clearly demonstrated heterogeneity among cancer patients' preferences, less is known about how the preferences of any given patient may change over time. This longitudinal study compared cancer patients' preferences for involvement in medical decision making from the time of diagnosis to the time of completion of therapy. Data from 729 cancer patients with mixed diagnoses were analyzed. Most patients reported a change in preferred level of involvement over time, and multivariate analysis demonstrated that patients tend to prefer a decreasing level of involvement over time (p<0.0001). Stability of patients' preferences was also associated with type of cancer, but not with other sociodemographic characteristics. The results from this study highlight the importance of reevaluating patients' preferences for involvement in medical decision making throughout the course of cancer therapy, as such preferences are likely to change.

Influence of accompanied encounters on patient-centeredness with older patients.

OBJECTIVES: To conduct a pilot study to examine physician patient interaction when elderly patients are accompanied during a medical visit. METHODS: This was a study in which 30 patients were randomly assigned to be accompanied (13) or unaccompanied (17) during a regular medical visit to their physician. Visits were tape recorded, transcribed, and coded with the Measure of Patient-Centered Communication (MPCC) and with the Rochester Participatory Decision-Making Scale (RPAD). RESULTS: We found no differences between the number of words spoken in accompanied versus unaccompanied visits, comparing patients alone with patients and companions combined. Physicians spoke longer without interruption in accompanied encounters (39.9 vs 78.6 words per speech turn). There were no differences in the level of MPCC or in the level of participatory decision making between the 2 types of visits. In accompanied visits, patients introduced most of the concerns and physicians discussed concerns with patients more than with companions. CONCLUSIONS: Previously reported differences in accompanied versus unaccompanied visits may reflect patients' preferences for being accompanied, the role they wish their companion to play, and the patients' health status. Being accompanied by a family member or friend does not result in less attention being paid to patients' concerns.

Patient-centered care and breast cancer survivors' satisfaction with information.

Satisfaction with information is an important patient outcome and may be related to the physician's ability to elicit the patients' concerns, to consider the patients' psychosocial needs, and to involve patients in treatment decision making; these communication techniques have been described under the umbrella of "patient-centered." The aim of this study was to examine the relationship between patient-centered care and satisfaction with information among women with a history of breast cancer. We administered a questionnaire to 182 women who had completed treatment for breast cancer. Our findings suggest that, while breast cancer survivors are highly satisfied with information related to treatment, they are less satisfied with information related to the long-term physical, psychological, and social sequelae of the disease and its treatments. In multivariate analysis, patients' perception of patient-centered behaviors was strongly associated with patients' satisfaction with information. These results provide support for the theory that patient satisfaction is improved when physicians incorporate patient-centered behaviors into their care.