An Evidence-Based Process Change to Improve Mammography Adherence

Breast cancer is a significant disease—affecting 12% of American women in a lifetime. Breast cancer costs $180 billion annually in healthcare expenditures and productivity. Mammography has been identified as the greatest tool to mitigate morbidity, yet in many organizations, mammography compliance rates are decreasing. This process improvement was conducted to address the barriers to patient follow through with mammography and to recommend strategies to improve the current breastscreening process. Principles of the Six Sigma DMAIC framework were utilized to analyze the breast-screening clinic process. Chart reviews and organization databases were applied to determine mammography adherence. The opportunities to improve current practices were identified by outlining the current practice flow, chart reviews, data mining of mammography adherence, and obtaining a baseline analysis of a sample of clinic patients who did not follow up with mammography. Informal interviews with providers were conducted as well. The structure of the organization was outlined and internal and external resources were identified. An extensive review of the literature was conducted to identify best practices and barriers to mammography screening to elicit strategies to improve the breast-screening process. The interventions include assessing barriers to mammography during registration of clinic visit, alert staff and providers of participants that meet criteria for mammography by flagging or marking the patients’ charts, then providing a tailored provider message regarding the importance of mammography and relevance of all steps of the screening process, with an emphasis on financial counseling, and streamlining the current process. The usual care will be compared with the process change. The outcome measure of mammography proportion was calculated using a two-sample proportion test. The mammography proportion for the pre-intervention group was 22% and 51% for the post-intervention group. There was a statistically significant difference (p = 0.01) in mammography adherence between the pre-intervention group and the post intervention group. Ultimately, as evidenced by the significant increase in mammography utilization, the breast-screening clinic will positively impact the disease burden of breast cancer through early detection

Racial/Ethnic Differences in Glycemic Control in Older Adults with Type 2 Diabetes: United States 2003-2014

The aim of this study was to determine whether racial differences in HbA1c persist in older adults (≥65 years) living with type 2 diabetes. Data from The National Health and Nutrition Examination Survey (NHANES) 2003-2014 were used to examine the association between HbA1c and older adults (≥65 years) over time. Compared to non-Hispanic Whites, Mexican Americans had the greatest difference in average HbA1c among minority groups, followed by those with unspecified/mixed ethnicities and non-Hispanic Blacks. In the adjusted linear model, racial minorities had a statistically significant relationship with HbA1c. There was no relationship between HbA1c and older age and insulin use. Trends in mean HbA1c over time increased for non-Hispanic Blacks and Mexican Americans and decreased for non-Hispanic Whites. The findings suggest that racial differences in HbA1c persist into older age and compared to non-Hispanic Whites, non-Hispanic Blacks and Mexican Americans are at an increased risk of morbidity, mortality, and disability due to high HbA1c. Furthermore, alternate measures of glycemic control may be needed to screen and manage T2DM in racial minorities

Use of Social Adaptability Index to Explain Self-Care and Diabetes Outcomes

Background: To examine whether the social adaptability index (SAI) alone or components of the index provide a better explanatory model for self-care and diabetes outcomes. Methods: Six hundred fifteen patients were recruited from two primary care settings. A series of multiple linear regression models were run to assess (1) associations between the SAI and diabetes self-care/outcomes, and (2) associations between individual SAI indicator variables and diabetes self-care/outcomes. Separate models were run for each self-care behavior and outcome. Two models were run for each dependent variable to compare associations with the SAI and components of the index. Results: The SAI has a significant association with the mental component of quality of life (0.23, p \u3c 0.01). In adjusted analyses, the SAI score did not have a significant association with any of the self-care behaviors. Individual components from the index had significant associations between self-care and multiple SAI indicator variables. Significant associations also exist between outcomes and the individual SAI indicators for education and employment. Conclusions: In this population, the SAI has low explanatory power and few significant associations with diabetes self-care/outcomes. While the use of a composite index to predict outcomes within a diabetes population would have high utility, particularly for clinical settings, this SAI lacks statistical and clinical significance in a representative diabetes population. Based on these results, the index does not provide a good model fit and masks the relationship of individual components to diabetes self-care and outcomes. These findings suggest that five items alone are not adequate to explain or predict outcomes for patients with type 2 diabetes

Prevalence and Correlates of Diagnosed and Undiagnosed Hypertension in the Indigenous Kuna Population of Panamá

Background: To determine the prevalence of hypertension and investigate sociodemographic correlates in an indigenous Kuna community living on the San Blas islands of Panama. Methods: Data was collected from adults using a paper-based survey using a cross sectional study design. Blood pressure was measured, and hypertension defined at two cut-points: 130/80 mmHg and 140/90 mmHg. Individuals with undiagnosed hypertension had a blood pressure measurement that indicated hypertension, however, the individual had not been told by a doctor they had hypertension. Whereas individuals with diagnosed hypertension had been told by a healthcare provider that they had hypertension. Univariate tests compared diagnosed and undiagnosed hypertension by sociodemographic categories and logistic regression models tested individual correlates adjusting for all sociodemographic factors. Results: Two hundred and eleven adult indigenous Kuna participated in the study. Overall prevalence of hypertension was 6.2% (95%CI:3.32–10.30) as defined by 140/90 mmHg, and 16.6% (95%CI:11.83–22.31) as defined by 130/80 mmHg. Hypertension was significantly higher in men (31.6, 95% CI:19.90–45.24, compared to 11.0, 95% CI:6.56–17.09). Individuals with low income were 3 times more likely to be hypertensive (OR = 3.13, 95% CI:1.02–9.60) and 3.5 times more likely to have undiagnosed hypertension (OR = 3.42, 95% CI:1.01–11.52); while those with moderate income were 6 times more likely to be hypertensive (OR = 7.37, 95% CI:1.76–30.90) compared to those who were poor. Conclusion: The prevalence of diagnosed and undiagnosed hypertension is higher in men and those with higher income. Investigating these factors remains vitally important in helping improve the health of the Kuna through targeted interventions to address chronic disease

SARS-CoV-2 (COVID-19) Vaccine Intentions in Kentucky

Background: At the time of our writing, the COVID-19 pandemic continues to cause significant disruption to daily lives. In Kentucky, the burdens from this disease are higher, and vaccination rates for COVID-19 are lower, in comparison to the U.S. as a whole. Understanding vaccine intentions across key subpopulations is critical to increasing vaccination rates. Purpose: This study explores COVID-19 vaccine intentions in Kentucky across demographic subpopulations and also investigates the influences on vaccine intention of attitudes and beliefs about COVID-19. Methods: A population-based survey of 1,459 Kentucky adults was conducted between January 26 and March 20, 2021, with over-sampling of black/African American and Latino/a residents, using online and telephonic modalities. Descriptive statistics characterize the sample and overall vaccine intentions and beliefs. Multivariable linear regression models probed relationships between demographics and vaccination intentions, as well as relationships between vaccination beliefs and vaccination intention. Results: Of the 1,299 unvaccinated respondents, 53% reported intent to get vaccinated, 16% had not decided, and 31% felt they would not get vaccinated. Lower vaccination intention was independently associated with age, lower educational attainment, black/African American race, lower income, Republican political affiliation, rural residence, and several beliefs: low vaccine safety, low vaccine efficacy, the rapidity of vaccine development, and mistrust of vaccine producers. Implications: Increasing COVID-19 vaccination rates will help end this pandemic. Findings from this study can be used to tailor information campaigns aimed at helping individuals make informed decisions about COVID-19 vaccination

The Mediating/Moderating Role of Cultural Context Factors on Self-Care Practices among Those Living with Diabetes in Rural Appalachia

Background The aim of this study was to examine whether cultural factors, such as religiosity and social support, mediate/moderate the relationship between personal/psychosocial factors and T2DM self-care in a rural Appalachian community. Methods Regression models were utilized to assess for mediation and moderation. Multilevel linear mixed effects models and GEE-type logistic regression models were fit for continuous (social support, self-care) and binary (religiosity) outcomes, respectively. Results The results indicated that cultural context factors (religiosity and social support) can mediate/moderate the relationship between psychosocial factors and T2DM self-care. Specifically, after adjusting for demographic variables, the findings suggested that social support may moderate the effect of depressive symptoms and stress on self-care. Religiosity may moderate the effect of distress on self-care, and empowerment was a predictor of self-care but was not mediated/moderated by the assessed cultural context factors. When considering health status, religiosity was a moderately significant predictor of self-care and may mediate the relationship between perceived health status and T2DM self-care. Conclusions This study represents the first known research to examine cultural assets and diabetes self-care practices among a community-based sample of Appalachian adults. We echo calls to increase the evidence on social support and religiosity and other contextual factors among this highly affected population. Trial registration US National Library of Science identifier NCT03474731. Registered March 23, 2018, www.clinicaltrials.gov

Phosphorus in the landscape: diffuse sources to surface waters. Land and Water Resources Research and Development Corporation. Occasional Paper 16/98

The National Eutrophication Management Program (NEMP) and Environment Australia convened a workshop to develop a coherent overview of the sources and transport of diffuse phosphorus in Australian catchments based on the latest knowledge. The Land and Water Resources Research and Development Corporation (LWRRDC) and the Murray–Darling Basin Commission (MDBC) jointly fund NEMP. A select group of scientists attended the workshop and developed a coherent statement about phosphorus sources and transport in Australian catchments. The group did not extend this statement to include recommended management practices. This paper reports the findings from the workshop. State governments have developed algal and nutrient management strategies in response to concerns about the frequency and severity of algal blooms, including cyanobacterial blooms, in Australian rivers and estuaries. There is an emphasis on phosphorus management, particularly in rural environments, now that nutrients are recognised as fundamental drivers of algal growth. Best management practices (BMPs) were developed for these strategies on the basis of the limited scientific evidence that was available at the time. The absence of a significant body of Australian information meant that there was a reliance on overseas research findings to develop such BMPs. A number of research projects have been completed in recent years on the sources and transport of nutrients in Australian catchments that challenge the Northern Hemisphere model of nutrient behaviour and will have implications for future development of BMPs. Principal conclusions 1. The studies presented in the workshop demonstrate that control of phosphorus entering surface waters must start with land management that minimises accelerated erosion and overland flow of water potentially rich in phosphorus. Heavily grazed lands, irrigation areas and intensive animal and horticultural industries are at risk, especially at the onset of rainy seasons and during periods of high rain intensity. 2. The transport of phosphorus from diffuse sources in landscapes can occur in both dissolved and particulate form. This can be due to different mobilisation and delivery mechanisms operating in different environments. Phosphorus mobilisation and delivery 1. Diffuse sources of phosphorus are the dominant component in most Australian catchments. Episodic rainfall is responsible for the bulk of phosphorus loss from the landscape. The mechanisms vary with each catchment. 2. Particulate phosphorus is carried by overland flow, resulting from run-off and erosion. In high to medium rainfall environments most is carried as filterable reactive phosphorus of less than 0.45 microns. Although most of the coarser materials from high parts of the landscape are deposited before they reach a watercourse, the particles ultimately carried into drainage lines are phosphorus-enriched by processes of sorting and filtration. 3. In river systems studied in the Murray–Darling Basin river sediments that originate from gully erosion and stream-bank collapse of readily dispersible soils carry most of the diffuse-source phosphorus. It is very likely that most of the phosphorus on these sediments is ‘native’ phosphorus coming from subsoils. 2 Phosphorus in the landscape: diffuse sources to surface waters Although the major episodes of gully formation occurred several decades ago, inputs of sediments and phosphorus from these sources continue at a high rate. Reduced input rates can best be achieved by targeting the gullies themselves and stabilising them by conservation works—particularly in small headwater catchments. 4. In larger dry-land catchments, fertiliser phosphorus is generally not an important component of phosphorus loss/export, although it may be locally significant. 5. Local soil, vegetation, terrain and climate conditions dictate whether surface erosion is the dominant source of phosphorus into a watercourse. To describe phosphorus exports from a specific landscape by surface erosion requires local studies. However, guidelines can be developed for management purposes to identify and minimise sources of phosphorus carried by overland flow. 6. Potential sources of diffuse phosphorus run-off occur wherever fertilisers are applied to soils that are already wet at the surface, or that may become wet by seasonally emerging groundwater. The magnitude of the loss will be greater if the application occurs on bare soils, or if it is next to a waterbody. 7. Dissolved phosphorus (from fertilisers and other sources) is readily mobilised and transported directly where the soil has both little ability to bind the phosphorus and a high leaching rate, as occurs in sandy regions of high rainfall around the continent. Phosphorus-laden water then travels via overland or shallow sub-surface flow to surface waterbodies quite quickly, unless other processes impede the movement. If the dissolved phosphorus moves via deep groundwater the time scales for its reappearance in surface water are generally large. 8. Dissolved phosphorus may also enter tributary waterbodies in headwater catchments via shortcircuit pathways, such as macropores, but this is only likely to be important over distances of hundreds of metres. However, these sub-surface pathways may reduce the effectiveness of local management practices that do not take them into account. 9. Large amounts of dissolved phosphorus are also being produced from irrigated dairy pastures (and possibly from other irrigation enterprises also). There is little or no sub-surface movement because soils are generally high in clay and flat. Phosphorus-laden water is pumped or drained across the land surface to channels. The time scale of dissolved phosphorus movement is comparable with the time with which the water itself moves. Once within drainage channels and streambeds the dissolved phosphorus fraction may be partially re-adsorbed onto particulates. 10. Large quantities of dissolved phosphorus are found in surface waters next to areas where animal excreta or over-fertilised market gardens give rise to phosphorus in surface wastewater that flows directly into waterways. These situations are most likely to arise in catchments that contain mixtures of horticultural, dairying, hobby-farming and similar land uses. Where farm dams are abundant a significant fraction of this phosphorus will not enter streams but will be retarded or retained in the landscape

The Effect of Travel Burden on Depression and Anxiety in African American Women Living with Systemic Lupus

The United States has a deficit of rheumatology specialists. This leads to an increased burden in accessing care for patients requiring specialized care. Given that most rheumatologists are located in urban centers at large hospitals, many lupus patients must travel long distances for routine appointments. The present work aims to determine whether travel burden is associated with increased levels of depression and anxiety among these patients. Data for this study were collected from baseline visits of patients participating in a lupus study at MUSC. A travel/economic burden survey was assessed as well as the 8-item Patient Health Questionnaire (PHQ-8) and the 7-item Generalized Anxiety Disorder (GAD-7) survey as measures of depression and anxiety, respectively. Linear regression models were used to assess the relationship between travel burden and depression and anxiety. Frequency of healthcare visits was significantly associated with increased depression (β = 1.3, p = 0.02). Significant relationships were identified between anxiety and requiring time off from work for healthcare appointments (β = 4, p = 0.02), and anxiety and perceived difficulty in traveling to primary care providers (β = 3.1, p = 0.04). Results from this study provide evidence that travel burden can have an effect on lupus patients’ anxiety and depression levels

Histone Deacetylase Inhibitor Romidepsin Induces HIV Expression in CD4 T Cells from Patients on Suppressive Antiretroviral Therapy at Concentrations Achieved by Clinical Dosing

Persistent latent reservoir of replication-competent proviruses in memory CD4 T cells is a major obstacle to curing HIV infection. Pharmacological activation of HIV expression in latently infected cells is being explored as one of the strategies to deplete the latent HIV reservoir. In this study, we characterized the ability of romidepsin (RMD), a histone deacetylase inhibitor approved for the treatment of T-cell lymphomas, to activate the expression of latent HIV. In an in vitro T-cell model of HIV latency, RMD was the most potent inducer of HIV (EC50 = 4.5 nM) compared with vorinostat (VOR; EC50 = 3,950 nM) and other histone deacetylase (HDAC) inhibitors in clinical development including panobinostat (PNB; EC50 = 10 nM). The HIV induction potencies of RMD, VOR, and PNB paralleled their inhibitory activities against multiple human HDAC isoenzymes. In both resting and memory CD4 T cells isolated from HIV-infected patients on suppressive combination antiretroviral therapy (cART), a 4-hour exposure to 40 nM RMD induced a mean 6-fold increase in intracellular HIV RNA levels, whereas a 24-hour treatment with 1 μM VOR resulted in 2- to 3-fold increases. RMD-induced intracellular HIV RNA expression persisted for 48 hours and correlated with sustained inhibition of cell-associated HDAC activity. By comparison, the induction of HIV RNA by VOR and PNB was transient and diminished after 24 hours. RMD also increased levels of extracellular HIV RNA and virions from both memory and resting CD4 T-cell cultures. The activation of HIV expression was observed at RMD concentrations below the drug plasma levels achieved by doses used in patients treated for T-cell lymphomas. In conclusion, RMD induces HIV expression ex vivo at concentrations that can be achieved clinically, indicating that the drug may reactivate latent HIV in patients on suppressive cART

Expression profile of human Fc receptors in mucosal tissue: implications for antibody-dependent cellular effector functions targeting HIV-1 transmission

The majority of new Human Immunodeficiency Virus (HIV)-1 infections are acquired via sexual transmission at mucosal surfaces. Partial efficacy (31.2%) of the Thai RV144 HIV-1 vaccine trial has been correlated with Antibody-dependent Cellular Cytotoxicity (ADCC) mediated by non-neutralizing antibodies targeting the V1V2 region of the HIV-1 envelope. This has led to speculation that ADCC and other antibody-dependent cellular effector functions might provide an important defense against mucosal acquisition of HIV-1 infection. However, the ability of antibody-dependent cellular effector mechanisms to impact on early mucosal transmission events will depend on a variety of parameters including effector cell type, frequency, the class of Fc-Receptor (FcR) expressed, the number of FcR per cell and the glycoslyation pattern of the induced antibodies. In this study, we characterize and compare the frequency and phenotype of IgG (CD16 [FcγRIII], CD32 [FcγRII] and CD64 [FcγRI]) and IgA (CD89 [FcαR]) receptor expression on effector cells within male and female genital mucosal tissue, colorectal tissue and red blood cell-lysed whole blood. The frequency of FcR expression on CD14+ monocytic cells, myeloid dendritic cells and natural killer cells were similar across the three mucosal tissue compartments, but significantly lower when compared to the FcR expression profile of effector cells isolated from whole blood, with many cells negative for all FcRs. Of the three tissues tested, penile tissue had the highest percentage of FcR positive effector cells. Immunofluorescent staining was used to determine the location of CD14+, CD11c+ and CD56+ cells within the three mucosal tissues. We show that the majority of effector cells across the different mucosal locations reside within the subepithelial lamina propria. The potential implication of the observed FcR expression patterns on the effectiveness of FcR-dependent cellular effector functions to impact on the initial events in mucosal transmission and dissemination warrants further mechanistic studies