Interactive multidisciplinary pilot workshop to improve medical student perception of and interest in breast surgical oncology

BACKGROUND

Exposure to breast surgical oncology (BSO) and the multidisciplinary management of patients with breast cancer is limited in medical school. The purpose of this study was to assess changes in student perceptions of BSO as a career following an interactive multidisciplinary workshop.

METHODS

Pre-clinical medical students participated in a multidisciplinary, hands-on workshop, composed of breast radiology (BR), breast surgical oncology (BSO) and breast plastic reconstructive surgery (B-PRS). BR presented students screening and diagnostic breast imaging followed by hands-on ultrasound-guided biopsy on phantom simulators. BSO demonstrated lumpectomy, mastectomy, sentinel lymph node biopsy, and axillary lymph node dissections while B-PRS demonstrated oncoplastic techniques and autologous flap reconstruction with cadavers. Pre-and post-workshop surveys assessed student opinions on surgery and BSO. Results were compared using Wilcoxon Signed Rank, Wilcoxon Rank Sum, and Fisher's Exact.

RESULTS

The workshop was attended by twenty-four students. There was a statistically significant increase in interest in BSO from 52% to 86% after the workshop (p = 0.003). The event improved understanding of the work and lifestyle in BSO for 79% (19/24). All students (100%) expressed interest to further explore BSO. The most common attractors to a career in BSO were impacts on patients' lives (N = 23), intellectual stimulation (N = 22), and earnings (N = 20). The most reported deterrents were lack of personal time (N = 18) and stress (N = 15).

CONCLUSION

An interactive, anatomically based exposure to multidisciplinary breast cancer surgery improves medical student perception and interest in BSO. Medical schools should consider incorporating similar events to foster interest in BSO and other surgical subspecialties.

Desirability of Outcome Ranking and Response Adjusted for Antibiotic Risk (DOOR/RADAR) Post Hoc Analysis Supports Equipoise for Antibiotic Initiation Strategies in Intensive Care Unit-Acquired Pneumonia

Background: Pneumonia is the most common intensive care unit (ICU)-acquired infection and source of potential sepsis in ICU populations but can be difficult to diagnose in real-time. Despite limited data, rapid initiation of antibiotic agents is endorsed by society guidelines. We hypothesized that a post hoc analysis of a recent randomized pilot study would show no difference between two antibiotic initiation strategies. Patients and Methods: The recent Trial of Antibiotic Restraint in Presumed Pneumonia (TARPP) was a pragmatic cluster-randomized pilot of antibiotic initiation strategies for patients with suspected ICU-acquired pneumonia. Participating ICUs were cluster-randomized to either an immediate initiation protocol or a specimen-initiated protocol where a gram stain was required for initiation of antibiotics. Patients in the study were divided into one of seven mutually exclusive outcome rankings (desirability of outcome ranking; DOOR): (1) Survival, No Pneumonia, No adverse events; (2) Survival, Pneumonia, No adverse events; (3) Survival, No Pneumonia, ventilator-free-alive days ≤14; (4) Survival, Pneumonia, ventilator-free-alive days ≤14; (5) Survival, No Pneumonia, Subsequent episode of suspected pneumonia; (6) Survival, Pneumonia, Subsequent episode of suspected pneumonia; and (7) Death. These rankings were further refined using the duration of antibiotics prescribed for pneumonia (response adjusted for antibiotic risk; RADAR). Results: There were 186 patients enrolled in the study. After applying the DOOR analysis, a randomly selected patient was equally likely to have a better outcome in specimen-initiated arm as in the immediate initiation arm (DOOR probability: 50.8%; 95% confidence interval [CI], 42.7%-58.9%). Outcome probabilities were similar after applying the RADAR analysis (52.5%; 95% CI, 44.2%-60.6%; p = 0.31). Conclusions: We found that patients for whom antibiotic agents were withheld until there was objective evidence (specimen-initiated group) had similar outcome rankings to patients for whom antibiotic agents were started immediately. This supports the findings of the TARPP pilot trial and provides further evidence for equipoise between these two treatment strategies.

Assessing Second Debridement Timing and Mortality in Necrotizing Soft Tissue Infections

BACKGROUND

Patients with necrotizing soft tissue infection undergo an average of 4-5 debridements per hospital admission. Optimal timing for initial debridement is emergent. Second debridement is universally recommended to occur within 24 hours of the first, but no studies have successfully evaluated this time frame. Prior work has suggested that delays in second debridement are associated with increased mortality, and that few patients receive second debridement within 24 hours.

METHODS

We performed a retrospective cohort study at a single center from 01/01/08 to 09/01/2021. The explanatory variable was whether the subject received second debridement within 24 hours of initial debridement. The primary outcome was in-hospital mortality. Baseline characteristics were collected. Subjects were stratified into 2 groups by time between first and second debridement: <24 and ≥24 hours. Variables were compared using Fisher's exact and Wilcoxon rank-sum tests.

RESULTS

77 patients met inclusion criteria. The median overall time to second debridement was 40 hours. 12 subjects received second debridement within 24 hours (15.6%). There was no difference in in-hospital mortality between the <24 (n = 3, 25.0%) and ≥24-hour second debridement groups (n = 4, 6.2%; P = .07). The 2 groups did not differ by secondary outcomes, including total number of debridements, ICU LOS, or wound closure.

CONCLUSION

No difference in mortality was observed between subjects undergoing second debridement within 24 vs after 24 hours. Only 16% of subjects received second debridement within the recommended 24-hour time interval. Further study is required to identify the optimal timing of second debridement.

Provider Perceptions of Antibiotic Initiation Strategies for Hospital-Acquired Pneumonia

Background: The practice of rapidly initiating antibiotic therapy for patients with suspected infection has recently been criticized yet remains commonplace. Provider comfort level has been an understudied aspect of this practice. Hypothesis: We hypothesized that there would be no significant differences in provider comfort level between the two treatment groups. Methods: We prospectively surveyed critical care intensivists who provided care for patients enrolled in the Trial of Antibiotic Restraint in Presumed Pneumonia (TARPP), which was a multicenter cluster-randomized crossover trial that evaluated an immediate antibiotic initiation protocol compared with a protocol of specimen-initiated antibiotic initiation in ventilated patients with suspected new-onset pneumonia. At the end of each enrollment arm, physicians at each center were surveyed regarding their overall comfort level with the recently completed treatment arm, and perception of adherence. Both a paired and unpaired analysis was performed. Results: We collected 51 survey responses from 31 unique participants. Providers perceived a higher rate of adherence to the immediate initiation arm than the specimen-initiated arm (Always Adherent: 37.5% vs. 11.1%; p = 0.045). Providers were less comfortable waiting for objective evidence of infection in the specimen-initiated arm than with starting antibiotic agents immediately (Very Comfortable: 83.3% vs. 40.7%; p = 0.004). For the smaller paired analysis, there was no longer a difference in comfort level. Conclusions: There may be differences in provider comfort levels and perceptions of adherence when considering two different antibiotic initiation strategies for suspected pneumonia in ventilated patients. These findings should be considered when planning future studies.

Advanced degrees, gender, and professional rank in surgery, disparities in academic medicine

INTRODUCTION

Women comprise nearly half of all residents in training, yet there is a significant disparity of women in academic leadership. Surgical subspecialties are dominated by men in both percentages of physicians and leadership positions. We sought to examine the association of advanced non-medical degrees with academic rank and gender in academic surgery departments.

METHODS

Faculty from 126 ACGME-accredited academic medical centers were analyzed to identify faculty gender as described in online biographical information, advanced non-medical degrees, academic rank, and additional leadership positions held. Descriptive statistics and logistic regression models were used for statistical analyses.

RESULTS

4536 surgeons were identified, 69.3% men, 27.3% female, and 3.3% unlisted. Female surgeons were more likely to hold advanced non-doctoral degrees than men (18.2% vs. 13.8%, p ​< ​0.002). Among those with advanced degrees, PhDs were held by 3.3% of women and 5.7% of men (p ​< ​0.001). Female surgeons were less likely to hold the rank of Professor than male surgeons (15.8% vs 30.3%, p ​< ​0.001), and more likely to hold the rank of Assistant Professor than male surgeons (51.9% vs 36.1%, p ​< ​0.001). This likelihood remained true when analyzing only surgeons with one or more advanced non-medical degrees. Men were more likely to be Chair of Surgery (3.0%), Division Chief (9.6%), and Research Chair (0.5%); compared to women (1.3%; 4.8%; 0.2%; p ​= ​0.001, <0.001, 0.21 respectively).

CONCLUSIONS

There continues to be a significant male predominance in general surgery. Gender discrepancy is also seen in professional rank and academic title despite women holding more advanced degrees. Advanced degrees are currently considered academic qualifications, but this does not reflect surgical academic leadership roles or rank.

US tobacco companies selectively disseminated hyper-palatable foods into the US food system: Empirical evidence and current implications

BACKGROUND AND AIMS

US tobacco companies owned leading US food companies from 1980 to 2001. We measured whether hyper-palatable foods (HPF) were disproportionately developed in tobacco-owned food companies, resulting in substantial tobacco-related influence on the US food system.

DESIGN

The study involved a review of primary industry documents to identify food brands that were tobacco company-owned. Data sets from the US Department of Agriculture were integrated to facilitate longitudinal analyses estimating the degree to which foods were formulated to be hyper-palatable, based on tobacco ownership.

SETTING AND CASES

United States Department of Agriculture data sets were used to identify HPF foods that were (n = 105) and were not (n = 587) owned by US tobacco companies from 1988 to 2001.

MEASUREMENTS

A standardized definition from Fazzino et al. (2019) was used to identify HPF. HPF items were identified overall and by HPF group: fat and sodium HPF, fat and sugar HPF and carbohydrates and sodium HPF.

FINDINGS

Tobacco-owned foods were 29% more likely to be classified as fat and sodium HPF and 80% more likely to be classified as carbohydrate and sodium HPF than foods that were not tobacco-owned between 1988 and 2001 (P-values = 0.005-0.009). The availability of fat and sodium HPF (> 57%) and carbohydrate and sodium HPF (> 17%) was high in 2018 regardless of prior tobacco-ownership status, suggesting widespread saturation into the food system.

CONCLUSIONS

Tobacco companies appear to have selectively disseminated hyper-palatable foods into the US food system between 1988 and 2001.

Evaluation of learning curve with Indocyanine Green (IcG) versus blue dye for sentinel lymph node biopsy in breast cancer

BACKGROUND

Indocyanine green (IcG) is an alternative to isosulfan blue (IB) for sentinel lymph node (SLN) mapping in breast cancer (BC). IcG carries improved cost and safety, but oncologic data upon implementation in practice is limited. We evaluated the learning curve defined as oncologic yield and operative (OR) time for IcG in SLN mapping in BC.

METHODS

Retrospective review of patients >18 years with cTis-2 cN0 BC undergoing surgery first with SLN biopsy using IB or IcG. Analysis compared IB versus IcG across three time cohorts.

RESULTS

Of 278 patients, 77 received IB and 201 received IcG. OR time was longer for IcG (p ​= ​0.022). There was no difference in oncologic yield between groups (p ​= ​0.35, p ​= ​0.61).

CONCLUSIONS

Surgeons may be able to safely transition from IB to IcG for patients with early-stage breast cancer undergoing surgery first. Individuals should track their own data to confirm safety of the technique.

The rural mortality penalty in U.S. hospital patients with COVID-19

Background

The COVID-19 pandemic brought greater focus to the rural mortality penalty in the U.S., which describes the greater mortality rate in rural compared to urban areas. Although it is understood that issues such as access to care, age structure of the population, and differences in behavior are likely drivers of the rural mortality penalty, it is critical to try and understand these factors to enable more effective public health policy.

Methods

We performed a cross-sectional analysis of a population of patients with COVID-19 who were admitted to hospitals in the United States between 3/1/2020 and 2/26/2023 to better understand factors leading to outcome disparities amongst groups that all had some level of access to hospital care, hypothesizing that deteriorated patient condition at admission likely explained some of the observed difference in mortality between rural and urban populations.

Results

Our results supported our hypothesis, showing that the rural mortality penalty persists in this population and that by multiple measures, rural patients were likely to be admitted in worse condition, had worse overall health, and were older.

Conclusions

Although the pandemic threw the rural mortality penalty into sharp relief, it is important to remember that it existed prior to the pandemic and will continue to exist until effective interventions are implemented. This study demonstrates the critical need to address the underlying factors that resulted in rural-dwelling patients being admitted to the hospital in worse condition than their urban-dwelling counterparts during the COVID-19 pandemic, which likely affected other healthcare outcomes as well.

Breast Cancer-Related Lymphedema (BCRL) and Bioimpedance Spectroscopy: Long-Term Follow-Up, Surveillance Recommendations, and Multidisciplinary Risk Factors

BACKGROUND

Early detection and intervention for breast cancer-related lymphedema (BCRL) significantly decreases progression to persistent BCRL (pBCRL). We aimed to provide long-term follow-up on our early detection with bioimpedance spectroscopy (BIS) and early home intervention demonstrating reduced pBCRL to guide surveillance recommendations.

PATIENTS AND METHODS

In total, 148 female patients with breast cancer who had axillary lymph node dissection (ALND) from November 2014 to December 2017 were analyzed. Baseline BIS measurements and postoperative follow-up occurred every 3 months for 1 year, biannual for 1 year, and then annually. An elevated BIS triggered evaluation and initiation of at-home interventions with reassessment for resolution versus persistent BCRL (pBCRL). High-risk factors and timing were analyzed.

RESULTS

Mean follow-up was 55 months, and 65 (44%) patients had an abnormal BIS. Of these, 54 (82%) resolved with home intervention. The overall pBCRL rate was 8%. Average time to first abnormal BIS was 11.7 months. None of the stage 0 patients (0/34) and only 5/25 (20%) of stage 1 patients had pBCRL. All of stage 2 and stage 3 patients (7/7) had pBCRL. pBCRL correlated with number of positive nodes, percentage of positive nodes, stage of lymphedema at diagnosis, and recurring abnormal BIS measurements (p < 0.05).

CONCLUSIONS

We have shown that patients undergoing ALND with early BCRL identified by BIS who performed home interventions had an 8% pBCRL rate. Patients at high risk for pBCRL should have routine surveillance starting at 9 months postoperatively to identify an opportunity for early intervention.

Iodine Intake From Diet and Supplements and Urinary Iodine Concentration in a Cohort of Pregnant Women in the United States

BACKGROUND

The DRI Estimated Average Requirement (EAR) in pregnancy for Iodine (I), an essential nutrient for fetal neurodevelopment, is 160 μg/d. Supplementation with 150 μg/d I/day is recommended during pregnancy, however, neither dietary intake or the combination of diet and supplement intake has been reported in US pregnant women.

OBJECTIVE

Determine iodine intake from diet and supplements and iodine status in pregnancy by urinary iodine concentration in a large cohort of pregnant women.

DESIGN

Pregnant women (n=750) completed the Diet History Questionnaire 2.0 from the National Institute of Cancer or multiple 24-hour recalls at baseline and identified their prenatal supplement(s). Dietary iodine intake was estimated using the USDA, FDA and ODS-NIH Database for the Iodine Content of Common Foods at enrollment, supplemental iodine intake throughout the study using content databases, and urinary iodine concentration (UIC) by the modified Sandell-Kolthoff reaction in samples collected between 14-20 weeks gestation (n=966).

RESULTS

The median intake of iodine from diet was 108.8 μg/d, and 63% (473/750) were below the Estimated Average Requirement (EAR). Furthermore, 65% (529/818) took a supplement containing iodine, however, only 32% (259/818) took ≥150 μg/d. Median intake increased to 188.5 μg/d with the inclusion of I from supplements, however , 41% (380/925) remained below the EAR even after supplementation suggesting inadequate intake in nearly half of the cohort. A similar 48% (467/966) had UIC ≤150 μg/L.

CONCLUSIONS

Assessment of iodine status by UIC and intake of iodine from diet and supplements support a high prevalence of iodine insufficiency during pregnancy in this large cohort of US women.

Hyper-palatable foods in elementary school lunches: Availability and contributing factors in a national sample of US public schools

BACKGROUND

School cafeterias are a major point of influence for child nutrition. United States federal legislation requires the presence of important nutrients in school meals. However, legislation overlooks the potential presence of hyper-palatable foods in school lunches, a hypothesized factor that may influence children's eating behavior and obesity risk. The study sought to 1) quantify the prevalence of hyper-palatable foods (HPF) served in US elementary school lunches; and 2) determine whether food hyper-palatability varied based on school geographic region (East/Central/West), urbanicity (urban/micropolitan/rural), or meal item (entrée/side/fruit or vegetable).

METHODS

Lunch menu data (N = 18 menus; N = 1160 total foods) were collected from a sample of six states that represented geographic regions of the United States (Eastern/Central/Western; Northern/Southern) and that had variability in urbanicity (urban, micropolitan, and rural) within each state. A standardized definition from Fazzino et al (2019) was used to identify HPF in lunch menus.

RESULTS

HPF comprised almost half of foods in school lunches (M = 47%; SD = 5%). Compared to fruit/vegetable items, entrées were >23 times more likely to be hyper-palatable and side dishes were >13 times more likely to be hyper-palatable (p values < .001). Geographic region and urbanicity were not significantly associated with food item hyper-palatability (p values >.05). The majority of entrée and side items contained meat/meat alternatives and/or grains and likely aligned with the US federal reimbursable meal components of meat/meat alternatives and/or grains.

CONCLUSIONS AND IMPLICATIONS

HPF comprised almost half of foods offered in elementary school lunches. Entrées and side items were most likely to be hyper-palatable. US school lunches may be a key point of regular exposure to HPF among young children, a risk factor that may elevate child obesity risk. Public policy regulating HPF in school meals may be needed to protect children's health.

Dietary Habits of Children 0 - 23 Months in Rural Kansas: Early Life Diets of Rural Children

Introduction

Children in rural areas face increased rates of obesity compared to their urban counterparts, and diet in early childhood may influence the development of diseases related to food intake. This study sought to determine current diet of children 0-23 months of age in rural Kansas.

Methods

Medical students participating in 6-week, summer, rural clinical experiences offered the survey to caregivers of children 0-23 months, born at term as singletons without a specialized diet. The survey asked respondents to answer with the child's diet over the last seven days. The survey was in the style of a validated Food Frequency Questionnaire for infants with an image for estimating portion sizes. Diets were compared to guidelines set by the Dietary Guidelines for Americans, 2020-2025.

Results

Of 44 responses, 21 children were aged 0-5 months, 7 aged 6-11 months, and 16 aged 12-23 months. Breastfeeding rates were nearly double reported national averages. All children aged 0-5 months met guidelines. None of the children 6-11 months or 12-23 months met guidelines. In the 6-11 month group, four consumed food in addition to breastmilk or formula (complementary foods). In the 12-23 month group, protein and dairy foods were lower than, and whole grains and vegetables were higher than, reported national averages, respectively.

Conclusions

Children may fall short of meeting dietary recommendations due to foods consumed in addition to breastmilk. There is a need for improved survey methods to capture the diets of young children in the rural United States.

DHA Supplementation During Pregnancy Enhances Maternal Vagally Mediated Cardiac Autonomic Control in Humans

BACKGROUND

DHA is an essential omega-3 (ω-3; n-3) fatty acid that has well-established benefits for the fetus. DHA also has the potential to influence the health of the mother, but this area is understudied.

OBJECTIVES

The objective of this secondary analysis was to determine if DHA was related to maternal heart rate (HR) and heart rate variability (HRV) metrics in a large cohort of pregnant women.

METHODS

In the parent trial (1R01HD086001) eligible participants (≥18 y old, English speaking, carrying a singleton pregnancy, 12-20 wk of gestation) were randomly assigned to consume 200 mg/d or 800 mg/d DHA for the duration of their pregnancy (n = 300). Weight, blood pressure, and magnetocardiograms (MCGs) were collected at 32 wk and 36 wk of gestation (n = 221). Measures of HR and HRV in time-, frequency-, and nonlinear-domains were determined from the isolated maternal MCG. Treatment group and timepoint were examined as predictors in association with HR and HRV metrics using random-intercept mixed-effects ANOVA unadjusted and adjusted models accounting for weight and dietary DHA intake.

RESULTS

Women receiving the higher dose of DHA (800 mg/d) during pregnancy had lower HR, lower sympathetic index, higher vagally mediated HRV indices, and greater HRV complexity when compared with the women who received the lower dose (200 mg/d; all P < 0.05). All the dose relations remained significant even after controlling for the effect of time, maternal weight, and dietary DHA intake.

CONCLUSIONS

DHA supplementation increases vagal tone in pregnant women. Longitudinal studies examining the potential link between DHA, enhanced vagal tone, and reported reduction in early preterm birth are warranted.

Comparison of two validated instruments to measure financial hardship in cancer survivors: comprehensive score for financial toxicity (COST) versus personal financial wellness (PFW) scale

PURPOSE

Financial distress and financial toxicity are recognized challenges in cancer survivorship. Financial toxicity includes both objective measures of hardship and subjective distress. We hypothesized that subjective financial distress is correlated to overall holistic financial toxicity. We compared two widely accepted instruments to measure financial distress and financial toxicity.

METHODS

Patients in the follow-up phase of care at a single institution were surveyed regarding demographic and economic status. Financial toxicity was measured using the comprehensive score for financial toxicity-functional assessment of chronic illness (COST-FACIT) and financial distress using the personal financial wellness (PFW) scale. Surveys were analyzed for correlation and internal consistency. Patient score distributions were compared. Associations between survey scores and patient factors were assessed using multivariable linear regression models.

RESULTS

A total of 116 patients were included. Scores from the COST-FACIT showed a strong correlation with PFW scores (r = 0.90, p < 0.0001). Scale reliability was high for both the COST-FACIT (α = 0.92) and PFW (α = 0.97) surveys. Score distributions exhibited left skew for both surveys, with 9.5% of patient scores falling in the worst quartile of possible scores on each respective survey. The strongest predictors of financial distress and financial toxicity included young age, lower monetary savings, lower household income, and less perceived social support during cancer treatment.

CONCLUSIONS

The COST-FACIT measure of financial toxicity correlated strongly with PFW measure of financial distress. Although these instruments were designed to assess different concepts (financial distress vs financial toxicity), they gave strikingly similar results. Either instrument may be used as a meaningful patient-reported outcome for study of financial distress in cancer survivors. However, the COST-FACIT construct of financial toxicity does not appear to add additional information beyond financial distress.

Analysis of Research Productivity and Assessment of Geographical Region in the General Surgery Match: How Much is Enough?

OBJECTIVES

The number of publications of prospective surgical residents has steadily increased over the past decade as the emphasis on research output has become paramount. However, the reported data from the National Resident Matching Program (NRMP) does not discriminate amongst impact, author position, and region of matched residents. This study aimed to evaluate categorical general surgery postgraduate year 1 (PGY-1) residents' research productivity by programs' research impact and region of the United States and support the need for additional public data on research metrics of accepted applicants. We hypothesize that residents accepted to top quartile schools will have more total and first author publications and higher h-index compared to residents in the other quartiles, and research metrics would not differ amongst the regions.

DESIGN

The Doximity Residency Navigator was used to sort general surgery programs based on research output, which was determined by the average h-index of residents. All 2021 matriculating PGY-1 categorical residents from the top two programs from each region and quartile that met study criteria were included in the analysis. Web of Science (WoS) citation database was used to collect prior to residency and current total publications, and the first, last, and corresponding author positions of these publications. Residents' h-index and various research metrics reported by WoS were recorded. Descriptive statistics were used to examine the association between quartile and region.

SETTING

Categorical general surgery residency programs throughout the United States.

PARTICIPANTS

Categorical PGY-1 general surgery residents.

RESULTS

The median total number of publications prior to residency was 1 (IQR = 0-5). The median total number of first-author publications prior to residency was 0 (IQR = 0-1), and the current h-index was 0 (IQR = 0-2). The top quartile had more total and first author publications prior to residency, while the other quartiles had similar metrics. Each region had similar total publications and h-index.

CONCLUSIONS

Research output is significant for applicants applying to top-quartile research programs compared to the other 3 quartiles and is relatively similar throughout all regions of the United States. Public data is limited to future applicants.

Intake of eggs, choline, lutein, zeaxanthin, and DHA during pregnancy and their relationship to fetal neurodevelopment

BACKGROUND

Maternal intake of eggs and nutrients contained within eggs during pregnancy have the potential to impact fetal neurodevelopment; however, this area is understudied. The purpose of this study was to determine whether maternal egg and choline intake and nutrient interactions between choline, lutein and zeaxanthin (L/Z), and DHA predict fetal neurodevelopment in a large cohort of pregnant women (n = 202). NCT02709239.

METHODS

Food frequency questionnaires were used to assess egg and nutrient intake during pregnancy. Fetal neurodevelopment was measured using fetal biomagnetometry at 32 and 36wks gestation, and fetal autonomic indices (SDNN, RMSSD) and brain maturation indices (fABAS) were calculated. Generalized linear models tested the relationships between choline intake, egg intake, and nutrient interactions with fetal neurodevelopment.

RESULTS

Maternal egg intake predicted RMSSD at 32wks and fABAS at 36wks. The interaction between choline and L/Z intake predicted fABAS at 32wks and 36wks and the interaction between choline intake, L/Z intake, and DHA predicted fABAS at 36wks. At 36wks, SDNN was predicted by L/Z intake and interactions between choline and L/Z, L/Z and DHA, and choline, L/Z, and DHA.

CONCLUSION

Eggs and the nutrients contained within eggs showed synergistic associations with fetal neurodevelopment, and consumption should be encouraged among pregnant women.

Iodine Status, Fluoride Exposure, and Thyroid Function in Pregnant Women in the United States

Objectives

Iodine (I) is an essential nutrient for fetal neurodevelopment through its role in thyroid function. Like I, fluoride (F) is a halogen and urinary F concentration (UFC) has been linked to increased thyroid stimulating hormone (TSH) in non-pregnant adults with I deficiency. We hypothesize that F and I may interact in their role on thyroid function among pregnant women.

Methods

Pregnant women (n = 966) provided urine between 12- and 20-weeks gestation. UIC was measured by the modified Sandell-Kolthoff reaction and UFC by a F-sensitive electrode. Enzyme-linked immunosorbent assay (ELISA) was used to measure plasma TSH. Associations between 1) UIC and TSH, 2) UFC and TSH, and 3) I status, UFC, and TSH were estimated using generalized linear models with gamma distribution and log link. Potential interactions between I status and UFC in association with TSH was also investigated.

Results

The cohort UIC (median: 154.2 µg/L, IQR: 92.9,271.7) indicated a population with marginally adequate I status by WHO criteria. Nearly half (n = 464, 48%) were I insufficient (UIC ≤ 150 µg/L). Median UFC (0.832 mg/L, IQR: 0.495, 1.29) was above the benchmark used to determine risk for child cognition (0.2 mg/L) (Grandjean et al., Risk Anal 2021; doi: 10.1111/risa.13767). Higher UIC was associated with increased TSH (β = 0.0003, SE = 0.0001, p = 0.01). UFC was not related to TSH (p = 0.13); however, a significant interaction between UIC and UFC was observed (p = 0.01). When analyzing only I insufficient participants, UFC and TSH were inversely associated (β = 0.1488, p = 0.0004). No association between UFC and TSH was observed for I adequate participants (p = 0.63).

Conclusions

Changes in TSH in relation to UIC and UFC were counter to our hypothesis as the relationship between UFC and TSH was inverse and only in I insufficient participants. Future research should explore if TSH is the best indicator of thyroid function in pregnancy and the mechanisms underlying the effects of pre-and postnatal F exposure on child cognition.

Funding Sources

The Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) (R01 HD083292).

Dietary and Supplemental Iodine Intake and Urinary Iodine Concentration in a Large Pregnancy Cohort in the United States

Objectives

The EAR and RDA for iodine (I) intake in pregnancy are 160 and 220 µg/d, respectively; however, dietary I intake by United States (US) pregnant women is unknown. Several professional organizations have recommended a supplement of 150 µg/d during pregnancy, though, the current use of prenatal supplements with I is also unknown. Our objective was to determine I intake from diet and supplements and relate I intake to I status, measured by urinary I concentration (UIC).

Methods

Pregnant women (n = 966) were interviewed about their dietary intake by the Diet History Questionnaire 2.0 or multiple 24-hour recalls at baseline and their dietary I intake was estimated using the USDA, FDA and ODS-NIH Database for the Iodine Content of Common Foods (ICCF). Participants were interviewed monthly until delivery to assess I intake from prenatal supplements. Urine samples were collected between 12–20 weeks of gestation, and UIC was measured by the modified Sandell-Kolthoff reaction. A chi-square test compared groups with insufficient and adequate I status to the proportion who met the EAR for I intake.

Results

The group median intake of I from diet was below the EAR (108.8 µg/d) however, median intake increased to 188.5 µg/day when supplemental I was included. Seventy-three % of participants (707/966) had a dietary intake below the EAR and 45% (436/966) remained below the EAR after including supplemental I. The group median UIC of 154.2 µg/L indicated a population with marginally adequate I status by WHO standards. Almost half (48%) had a UIC considered to be I insufficient (≤150 µg/L) by WHO. Although slightly more than half (55%, 529/966) were taking a supplement containing I, only 27% (259/966) were taking the recommended 150 µg/d. Iodine status was significantly associated with EAR intake, with 52.1% (227/436) of those with an intake below the EAR being I insufficient (UIC ≤ 150 µg/L) compared to 44.7% (237/530) of those with an I intake above the EAR (p = 0.0229).

Conclusions

While consuming a prenatal supplement with I improved the proportion of participants with an intake above the EAR, nearly 45% of the group who consumed more than the EAR had insufficient I status.

Funding Sources

The Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) (HD R01083292).

Rural–Urban Disparities in Health Access Factors Over Time: Implications for Cancer Prevention and Health Equity in the Midwest

Purpose:

Population-level environmental and socioeconomic factors may influence cancer burden within communities, particularly in rural and urban areas that may be differentially impacted by factors related to health care access.

Methods:

The University of Kansas (KU) Cancer Center serves a geographically large diverse region with 75% of its 123 counties classified as rural. Using County Health Rankings data and joinpoint regression, we examined trends in four factors related to the socioeconomic environment and health care access from 2009 to 2017 in rural and urban counties across the KU Cancer Center catchment area.

Findings:

The adult health uninsurance rate declined significantly in rural and urban counties across the catchment area (rural annual percent change [APC]=−5.96; 95% CI=[−7.71 to −4.17]; urban APC=−5.72; 95% CI=[−8.03 to −3.35]). Childhood poverty significantly decreased in rural counties over time (APC=−2.94; 95% CI=[−4.52 to −1.33]); in contrast, urban childhood poverty rates did not significantly change before 2012 (APC=3.68; 95% CI=[−15.12 to 26.65]), after which rates declined (APC=−5.89; 95% CI=[−10.01 to −1.58]). The number of primary care providers increased slightly but significantly in both rural and urban counties (APC=0.54; 95% CI=[0.28 to 0.80]), although urban counties had more primary care providers than rural areas (76.1 per 100K population vs. 57.1 per 100K population, respectively; p=0.009). Unemployment declined significantly faster in urban counties (APC=−10.33; 95% CI=[−12.16 to −8.47]) compared with rural counties (APC=−6.71; 95% CI=[−8.22 to −5.18]) (p=0.02).

Conclusion:

Our findings reveal potential disparities in systemic factors that may contribute to differences in cancer prevention, care, and survivorship in rural and urban regions.

shinyOPTIK, a User-Friendly R Shiny Application for Visualizing Cancer Risk Factors and Mortality Across the University of Kansas Cancer Center Catchment Area

PURPOSE

The University of Kansas Cancer Center (KU Cancer Center) recently developed a data warehouse to Organize and Prioritize Trends to Inform KU Cancer Center (OPTIK). The OPTIK database aggregates and standardizes data collected across the bistate catchment area served by the KU Cancer Center. To improve the usability of the OPTIK database, we developed shinyOPTIK, a user-friendly, interactive web application for visualizing cancer risk factor and mortality rate data across the KU Cancer Center Catchment area.

METHODS

Data in the OPTIK database were first consolidated at the county level across the KU Cancer Center catchment area. Next, the shinyOPTIK development team met with the KU Cancer Center leadership to discuss the needs and priorities of the shinyOPTIK web application. shinyOPTIK was developed under the R Shiny framework and consists of a user interface (ui.R) and a web server (server.R). At present, shinyOPTIK can be used to generate county-level geographical heatmaps; bar plots of demographic, screening, and risk factors; and line plots to visualize temporal trends at different Rural-Urban Continuum Codes (RUCCs), rural-urban status, metropolitan, or county levels across the KU Cancer Center catchment area.

RESULTS

Two examples, adult obesity prevalence and lung cancer mortality, are presented to illustrate how researchers can use shinyOPTIK. Each example is accompanied by post hoc visualizations to help explain key observations in terms of rural-urban disparities.

CONCLUSION

Although shinyOPTIK was developed to improve understanding of spatial and temporal trends across the population served by the KU Cancer Center, our hope is that the description of the steps involved in the creation of this tool along with open-source code for our application provided herein will serve as a guide for other research centers in the development of similar tools.

The need to study rural cancer outcome disparities at the local level: a retrospective cohort study in Kansas and Missouri

Background

Rural residence is commonly thought to be a risk factor for poor cancer outcomes. However, a number of studies have reported seemingly conflicting information regarding cancer outcome disparities with respect to rural residence, with some suggesting that the disparity is not present and others providing inconsistent evidence that either urban or rural residence is associated with poorer outcomes. We suggest a simple explanation for these seeming contradictions: namely that rural cancer outcome disparities are related to factors that occur differentially at a local level, such as environmental exposures, lack of access to care or screening, and socioeconomic factors, which differ by type of cancer.

Methods

We conducted a retrospective cohort study examining ten cancers treated at the University of Kansas Medical Center from 2011 to 2018, with individuals from either rural or urban residences. We defined urban residences as those in a county with a U.S. Department of Agriculture Urban Influence Code (UIC) of 1 or 2, with all other residences defines a rural. Inverse probability of treatment weighting was used to create a pseudo-sample balanced for covariates deemed likely to affect the outcomes modeled with cumulative link and weighted Cox-proportional hazards models.

Results

We found that rural residence is not a simple risk factor but rather appears to play a complex role in cancer outcome disparities. Specifically, rural residence is associated with higher stage at diagnosis and increased survival hazards for colon cancer but decreased risk for lung cancer compared to urban residence.

Conclusion

Many cancers are affected by unique social and environmental factors that may vary between rural and urban residents, such as access to care, diet, and lifestyle. Our results show that rurality can increase or decrease risk, depending on cancer site, which suggests the need to consider the factors connected to rurality that influence this complex pattern. Thus, we argue that such disparities must be studied at the local level to identify and design appropriate interventions to improve cancer outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12190-w.

FOXA1 and adaptive response determinants to HER2 targeted therapy in TBCRC 036

Inhibition of the HER2/ERBB2 receptor is a keystone to treating HER2-positive malignancies, particularly breast cancer, but a significant fraction of HER2-positive (HER2+) breast cancers recur or fail to respond. Anti-HER2 monoclonal antibodies, like trastuzumab or pertuzumab, and ATP active site inhibitors like lapatinib, commonly lack durability because of adaptive changes in the tumor leading to resistance. HER2+ cell line responses to inhibition with lapatinib were analyzed by RNAseq and ChIPseq to characterize transcriptional and epigenetic changes. Motif analysis of lapatinib-responsive genomic regions implicated the pioneer transcription factor FOXA1 as a mediator of adaptive responses. Lapatinib in combination with FOXA1 depletion led to dysregulation of enhancers, impaired adaptive upregulation of HER3, and decreased proliferation. HER2-directed therapy using clinically relevant drugs (trastuzumab with or without lapatinib or pertuzumab) in a 7-day clinical trial designed to examine early pharmacodynamic response to antibody-based anti-HER2 therapy showed reduced FOXA1 expression was coincident with decreased HER2 and HER3 levels, decreased proliferation gene signatures, and increased immune gene signatures. This highlights the importance of the immune response to anti-HER2 antibodies and suggests that inhibiting FOXA1-mediated adaptive responses in combination with HER2 targeting is a potential therapeutic strategy.

Stroma modifies relationships between risk factor exposure and age-related epithelial involution in benign breast

Delayed age-related lobular involution has been previously associated with elevated breast cancer risk. However, intraindividual variability in epithelial involution status within a woman is undefined. We developed a novel measure of age-related epithelial involution, density of epithelial nuclei in epithelial areas using digital image analysis in combination with stromal characteristics (percentage of section area comprising stroma). Approximately 1800 hematoxylin and eosin stained sections of benign breast tissue were evaluated from 416 participants having breast surgery for cancer or benign conditions. Two to sixteen slides per woman from different regions of the breast were studied. Epithelial involution status varied within a woman and as a function of stromal area. Percentage stromal area varied between samples from the same woman (median difference between highest and lowest stromal area within a woman was 7.5%, but ranged from 0.01 to 86.7%). Restricting to women with at least 10% stromal area (N = 317), epithelial nuclear density decreased with age (-637.1 cells/mm² per decade of life after age 40, p < 0.0001), increased with mammographic density (457.8 cells/mm² per increasing BI-RADs density category p = 0.002), and increased non-significantly with recent parity, later age at first pregnancy, and longer and more recent oral contraceptive use. These associations were attenuated in women with mostly fat samples (<10% stroma (N = 99)). Thirty-one percent of women evaluated had both adequate stroma (≥10%) and mostly fat (<10% stroma) regions of breast tissue, with the probability of having both types increasing with the number breast tissue samplings. Several breast cancer risk factors are associated with elevated age-related epithelial content, but associations depend upon stromal context. Stromal characteristics appear to modify relationships between risk factor exposures and breast epithelial involution.

Intra-individual Gene Expression Variability of Histologically Normal Breast Tissue

Several studies have sought to identify novel transcriptional biomarkers in normal breast or breast microenvironment to predict tumor risk and prognosis. However, systematic efforts to evaluate intra-individual variability of gene expression within normal breast have not been reported. This study analyzed the microarray gene expression data of 288 samples from 170 women in the Normal Breast Study (NBS), wherein multiple histologically normal breast samples were collected from different block regions and different sections at a given region. Intra-individual differences in global gene expression and selected gene expression signatures were quantified and evaluated in association with other patient-level factors. We found that intra-individual reliability was relatively high in global gene expression, but differed by signatures, with composition-related signatures (i.e., stroma) having higher intra-individual variability and tumorigenesis-related signatures (i.e., proliferation) having lower intra-individual variability. Histological stroma composition was the only factor significantly associated with heterogeneous breast tissue (defined as > median intra-individual variation; high nuclear density, odds ratio [OR] = 3.42, 95% confidence interval [CI] = 1.15–10.15; low area, OR = 0.29, 95% CI = 0.10–0.86). Other factors suggestively influencing the variability included age, BMI, and adipose nuclear density. Our results underscore the importance of considering intra-individual variability in tissue-based biomarker development, and have important implications for normal breast research.

Biology and Etiology of Young-Onset Breast Cancers among Premenopausal African American Women: Results from the AMBER Consortium

Background: African American (AA) women have higher incidence of aggressive, young-onset (<40 years) breast cancers. Young- and older-onset disease may have distinct tumor biologies and etiologies; however, studies investigating age differences among AA women have been rare and generally underpowered.Methods: We examined tumor characteristics and breast cancer risk factors associated with premenopausal young (<40) vs. older (≥40) AA women's breast cancer in the African American Breast Cancer Epidemiology and Risk Consortium (2,008 cases and 5,144 controls). Unconditional logistic regression models assessed heterogeneity of tumor biology and risk factor associations by age, overall, and by estrogen receptor status.Results: Premenopausal AA women <40 years had higher frequency of poorer-prognosis tumor characteristics compared with older women, including negative estrogen and progesterone receptor status, triple-negative subtype, higher grade, higher stage, and larger tumors. Adiposity (i.e., waist-to-hip ratio) and family history of breast cancer were more strongly associated with young-onset disease [case-control OR = 1.46, 95% confidence interval (CI) = 1.04-2.05; OR = 3.10, 95% CI = 2.08-4.63, respectively] compared with older-onset disease (OR = 1.11, 95% CI = 0.91-1.35; OR = 1.57, 95% CI = 1.26-1.94). Breastfeeding showed a slight inverse risk association among young women (OR = 0.70, 95% CI = 0.43-1.16). Oral contraceptive use was associated with increased risk regardless of age. Considering various cutoff points for young age (<40, <45, <50), age-related heterogeneity was greatest when <40 was used.Conclusions: Among premenopausal AA women, diagnosis before age 40 is associated with more aggressive breast tumor biology and some etiologic differences.Impact: Modifiable risk factors including breastfeeding, adiposity, and oral contraceptive use may be important targets for mitigating harms of young-onset breast cancer. Cancer Epidemiol Biomarkers Prev; 26(12); 1722-9. ©2017 AACR.

Breast cancer biologic and etiologic heterogeneity by young age and menopausal status in the Carolina Breast Cancer Study: a case-control study

BACKGROUND

Young-onset breast cancer (<40 years) is associated with worse prognosis and higher mortality. Breast cancer risk factors may contribute to distinct tumor biology and distinct age at onset, but understanding of these relationships has been hampered by limited representation of young women in epidemiologic studies and may be confounded by menopausal status.

METHODS

We examined tumor characteristics and epidemiologic risk factors associated with premenopausal women's and young women's breast cancer in phases I-III of the Carolina Breast Cancer Study (5309 cases, 2022 control subjects). Unconditional logistic regression was used to assess heterogeneity by age (<40 vs. ≥40 years) and menopausal status.

RESULTS

In both premenopausal and postmenopausal strata, younger women had more aggressive disease, including higher stage, hormone receptor-negative, disease as well as increased frequency of basal-like subtypes, lymph node positivity, and larger tumors. Higher waist-to-hip ratio was associated with reduced breast cancer risk among young women but with elevated risk among older women. Parity was associated with increased risk among young women and reduced risk among older women, while breastfeeding was more strongly protective for young women. Longer time since last birth was protective for older women but not for young women. In comparison, when we stratified by age, menopausal status was not associated with distinct risk factor or tumor characteristic profiles, except for progesterone receptor status, which was more commonly positive among premenopausal women.

CONCLUSIONS

Age is a key predictor of breast cancer biologic and etiologic heterogeneity and may be a stronger determinant of heterogeneity than menopausal status. Young women's breast cancer appears to be etiologically and biologically distinct from that among older women.

Digital histologic analysis reveals morphometric patterns of age-related involution in breast epithelium and stroma

Complete age-related regression of mammary epithelium, often termed postmenopausal involution, is associated with decreased breast cancer risk. However, most studies have qualitatively assessed involution. We quantitatively analyzed epithelium, stroma, and adipose tissue from histologically normal breast tissue of 454 patients in the Normal Breast Study. High-resolution digital images of normal breast hematoxylin and eosin-stained slides were partitioned into epithelium, adipose tissue, and nonfatty stroma. Percentage area and nuclei per unit area (nuclear density) were calculated for each component. Quantitative data were evaluated in association with age using linear regression and cubic spline models. Stromal area decreased (P = 0.0002), and adipose tissue area increased (P < 0.0001), with an approximate 0.7% change in area for each component, until age 55 years when these area measures reached a steady state. Although epithelial area did not show linear changes with age, epithelial nuclear density decreased linearly beginning in the third decade of life. No significant age-related trends were observed for stromal or adipose nuclear density. Digital image analysis offers a high-throughput method for quantitatively measuring tissue morphometry and for objectively assessing age-related changes in adipose tissue, stroma, and epithelium. Epithelial nuclear density is a quantitative measure of age-related breast involution that begins to decline in the early premenopausal period.

Three dimensional structure of the anthrax toxin translocon-lethal factor complex by cryo-electron microscopy

We have visualized by cryo-electron microscopy (cryo-EM) the complex of the anthrax protective antigen (PA) translocon and the N-terminal domain of anthrax lethal factor (LF(N) inserted into a nanodisc model lipid bilayer. We have determined the structure of this complex at a nominal resolution of 16 Å by single-particle analysis and three-dimensional reconstruction. Consistent with our previous analysis of negatively stained unliganded PA, the translocon comprises a globular structure (cap) separated from the nanodisc bilayer by a narrow stalk that terminates in a transmembrane channel (incompletely distinguished in this reconstruction). The globular cap is larger than the unliganded PA pore, probably due to distortions introduced in the previous negatively stained structures. The cap exhibits larger, more distinct radial protrusions, previously identified with PA domain three, fitted by elements of the NMFF PA prepore crystal structure. The presence of LF(N), though not distinguished due to the seven-fold averaging used in the reconstruction, contributes to the distinct protrusions on the cap rim volume distal to the membrane. Furthermore, the lumen of the cap region is less resolved than the unliganded negatively stained PA, due to the low contrast obtained in our images of this specimen. Presence of the LF(N) extended helix and N terminal unstructured regions may also contribute to this additional internal density within the interior of the cap. Initial NMFF fitting of the cryoEM-defined PA pore cap region positions the Phe clamp region of the PA pore translocon directly above an internal vestibule, consistent with its role in toxin translocation.