Improving Quality in Breast Cancer Treatment

Objectives: The goal of this study is to evaluate and compare care received following implementation of the multidisciplinary care tumor board at a community hospital in Detroit, MI. Methods: This is a retrospective chart review of patients who were newly diagnosed with invasive breast cancer one year prior to and one year following the implemenation of the MDC tumor board. Demographic information including race, age, insurance type (private vs public) and hospital site (urban vs suburban) where treatment was received was obtained. Additionally, stage at diagnosis, hormone receptor (HR) status, eligibility for and receipt of breast conserving treatment, neoadjuvant chemotherapy, hormonal therapy, radiation therapy, adjuvant chemotherapy, fertility sparing counseling, oncotype testing and genetic counseling was also obtained. SPSS was used for multivariate analysis. Significance was determined to be p\u3c0.05. Results: A total of 539 patients were eligible for the study. Average age of women in the MDC group was 62 years vs. average age of women in the non-MDC group of 59 years. The racial make up included 57% white, 43% black. There was no significant difference between eligibility and receipt of neoadjuvant chemotherapy, breast conserving therapy, endocrine therapy, radiation therapy or adjuvant chemotherapy in patients who were treated prior to the implementation of the MDC tumor board as compared to those receiving treatment after the implementation of the MDC tumor board. However, there was a significant difference in the frequency of oncotype testing and fertility counseling offered to patients who were diagnosed after the MDC was implemented. In a subset analysis, there was a significant difference in the receipt of breast conserving therapy in black women irrespective of participation in the multidisciplinary group (p=0.016). In fact, all women who received care at the urban facility were less likely to receive breast-conserving therapy (p=0.009) and were less likely to receive and be offered chemotherapy or Herceptin. Conclusions: While the Multidisciplinary care tumor board implementation has not yet established a significant difference in receipt of cancer care among all women, the ability to offer eligible patients fertility counseling and oncotype testing has improved significantly.https://scholarlycommons.henryford.com/merf2019qi/1014/thumbnail.jp

Racial & ethnic disparities in prenatal care & pregnancy outcomes - an ongoing challenge

Objective: The aim of this study is to compare adequacy of prenatal care among various races and ethnicities in the state of Michigan and associated pregnancy and birth outcomes. Study Design: A population-based retrospective cohort study was performed using the state of Michigan’s birth registry data for the years 2019-2020. Inclusion was made for all women who delivered after 20 weeks of gestation. Pregnancy and birth outcomes were compared by race and ethnicity. Results: A total of 211,801 births took place in Michigan between 2019 and 2020. The cohort included 143,400 (67.7%) who identified as non-hispanic White, 39,139 (18.5%) who identified as non-hispanic Black, 14,704 (6.9%) who identified as hispanic, and 14,557 (6.9%) who identified as others. Adequate prenatal care received, defined by the Kessner Index, was highest among non-hispanic White women at 71.9% (n=103,127), followed by hispanic women at 61.2% (n=9,006), followed by non-hispanic Black women at 56.1% (n=21,969), p\u3c 0.0001. The incidence of preterm birth was highest among non-hispanic Black women at 16.7% (n=6,525), followed by non-hispanic White women and hispanic women at 10.0% (n=14,358) and 10.8% (n=1,582) respectively, p\u3c 0.0001. The incidence of preeclampsia was also highest among non-hispanic Black women at 9.1% (n=3,550), followed by hispanic women and non-hispanic White women at 6.4% (n=948) and 1.3% (n=1,858) respectively, p\u3c 0.0001. The incidence of maternal ICU admission was 39% higher among non-hispanic Black women compared to non-hispanic White women (0.17% vs 0.12%). The incidence of neonatal ICU admission was 62% higher among non-hispanic Black women compared to non-hispanic White women (11.4% vs 7.0%). Conclusion: Disparities in prenatal care, pregnancy complications, and birth outcomes remain prevalent to our current day where non-hispanic Black women are receiving the least adequate prenatal care and having the most significant adverse pregnancy outcomes. More efforts should focus on access to care for Black women, as a modifiable step towards improving health outcomes for this population

Reducing Surgical Site Infection and Sepsis after Hysterectomy: Cefazolin Compared with Cefazolin Plus Metronidazole

Study Objective: To evaluate if cefazolin plus metronidazole before a hysterectomy will be more effective in prevention of surgical site infection (SSI) and sepsis compared to the existing recommendation of preoperative cefazolin alone. Design: Retrospective chart review. Setting: Henry Ford Health System (HFHS). Patients or Participants: Data was collected for 1485 adult patients who received hysterectomies within HFHS for benign and malignant conditions. The control group (group 1) was obtained via retrospective chart review to include patients who had a hysterectomy between January 2019 and June 2020 and received cefazolin alone as antibiotic prophylaxis. The treatment group (group 2) included patients who had a hysterectomy between July 2020 and January 2022 and received preoperative cefazolin plus metronidazole. Interventions: Addition of metronidazole to cefazolin as antibiotic prophylaxis prior to hysterectomy. Measurements and Main Results: Of the 1485 patients, 789 (53.1%) were given cefazolin alone and 696 (46.9% were given cefazolin plus metronidazole. There was a total of six (0.4%) patients who experienced sepsis and 37 (2.5%) who had a site infection across both groups. There was a decrease in both sepsis and SSI in group 2, however it did not reach statistical significance. The model for the risk of sepsis is adjusted for obesity (BMI ≥30), procedure length \u3e2 hours, and gynecologic cancer. We found that there were no significant differences in the risk of sepsis between the two treatment groups after adjusting for these risk factors (p=0.736). The model for the risk of site infection is adjusted for diabetes, obesity, smoking status, procedure length, and gynecologic cancer. We found that there were no significant differences in the risk of site of infection between the two treatment groups (p=0.451). Conclusion: The addition of metronidazole to the standard antibiotic prophylaxis regimen for hysterectomy did not significantly reduce the rate of surgical site infections or sepsis within our health system

Partial Molar Pregnancy Presenting as a Tubal Ectopic Pregnancy

Background: Tubal molar pregnancy is extremely rare, with no more than 200 cases reported in the literature. The incidence is approximated at 1.5 per 1,000,000 pregnancies. Case: We report the case of a 22-year-old woman with an overall initial stable clinical presentation who was noted to have a ruptured ectopic pregnancy. She was surgically treated, and pathology revealed partial hydatidiform molar ectopic pregnancy. At the time of surgical intervention, the treating physicians had not considered molar ectopic pregnancy within the differential diagnosis, since this is a very rare presentation. Once the pathology was discovered, the patient was contacted to be scheduled for close follow-up and counseling to reduce progression to choriocarcinomas. Conclusion: This case report highlights the importance of sending, reviewing, and following up on pathologic specimens for all patients undergoing surgical intervention for presumed ectopic pregnancy and ensuring that appropriate follow-up is in place for those patients

Association Between Benign Breast Disease in African American and White American Women and Subsequent Triple-Negative Breast Cancer

Importance: Compared with white American (WA) women, African American (AA) women have a 2-fold higher incidence of breast cancers that are negative for estrogen receptor, progesterone receptor, and ERBB2 (triple-negative breast cancer [TNBC]). Triple-negative breast cancer, compared with non-TNBC, likely arises from different pathogenetic pathways, and benign breast disease (BBD) predicts future non-TNBC. Objective: To determine whether AA identity remains associated with TNBC for women with a prior diagnosis of BBD. Design, Setting, and Participants: This study is a retrospective analysis of data of a cohort of 2588 AA and 3566 WA women aged between 40 and 70 years with a biopsy-proven BBD diagnosis. The data-obtained from the Pathology Information System of Henry Ford Health System (HFHS), an integrated multihospital and multispecialty health care system headquartered in Detroit, Michigan-include specimens of biopsies performed between January 1, 1994, and December 31, 2005. Data analysis was performed from November 1, 2015, to June 15, 2016. Main Outcomes and Measures: Subsequent breast cancer was stratified on the basis of combinations of hormone receptor and ERBB2 expression. Results: Case management, follow-up, and outcomes received or obtained by our cohort of 2588 AA and 3566 WA patients were similar, demonstrating that HFHS delivered care equitably. Subsequent breast cancers developed in 103 (4.1%) of AA patients (mean follow-up interval of 6.8 years) and 143 (4.0%) of WA patients (mean follow-up interval of 6.1 years). More than three-quarters of subsequent breast cancers in each subset were ductal carcinoma in situ or stage I. The 10-year probability estimate for developing TNBC was 0.56% (95% CI, 0.32%-1.0%) for AA patients and 0.25% (95% CI, 0.12%-0.53%) for WA patients. Among the 66 AA patients who developed subsequent invasive breast cancer, 16 (24.2%) developed TNBC compared with 7 (7.4%) of the 94 WA patients who developed subsequent invasive breast cancers and had complete biomarker data (P = .01). Conclusions and Relevance: This study is the largest analysis to date of TNBC in the context of racial/ethnic identity and BBD as risk factors. The study found that AA identity persisted as a significant risk factor for TNBC. This finding suggests that AA identity is associated with inherent susceptibility for TNBC pathogenetic pathways

The physical demands upon (Dutch) fire-fighters in relation to the maximum acceptable energetic workload

The aim of this study was to assess the tasks and activities that make physical demands on Dutch fire-fighters and to compare them with a guideline related to the development of excessive fatigue. The occupational physical demands on Dutch fire-fighters were assessed by conducting a task analysis during 85 24-h shifts. While workplace observations on the duration and frequency of physical tasks and activities were recorded, the heart rate was measured. This was then used to calculate the heart rate reserve percentage (%HRR) for predefined working periods, tasks and activities during 24-h shifts. The findings indicate that actual fire-fighting during 24-h shifts is characterised by a low frequency of incidents, a short 'turn-out' time, short tasks, and activities with a moderate to occasionally high energetic workload. Two tasks which sometimes occur in actual fire-fighting exceeded the guideline on energetic workload. The conclusion was that, though the number of incidents and the occupational demands are low during 24-h shifts, the peak loads for these two tasks are energetically high and could lead to excessive fatigue. Consequently, attention may need to be paid to health surveillance for persons exposed to such energetic peak loads, the development of physical and medical selection procedures, training, and workplace adjustments

Identification of genetic variants associated with Huntington's disease progression: a genome-wide association study

Background Huntington's disease is caused by a CAG repeat expansion in the huntingtin gene, HTT. Age at onset has been used as a quantitative phenotype in genetic analysis looking for Huntington's disease modifiers, but is hard to define and not always available. Therefore, we aimed to generate a novel measure of disease progression and to identify genetic markers associated with this progression measure. Methods We generated a progression score on the basis of principal component analysis of prospectively acquired longitudinal changes in motor, cognitive, and imaging measures in the 218 indivduals in the TRACK-HD cohort of Huntington's disease gene mutation carriers (data collected 2008–11). We generated a parallel progression score using data from 1773 previously genotyped participants from the European Huntington's Disease Network REGISTRY study of Huntington's disease mutation carriers (data collected 2003–13). We did a genome-wide association analyses in terms of progression for 216 TRACK-HD participants and 1773 REGISTRY participants, then a meta-analysis of these results was undertaken. Findings Longitudinal motor, cognitive, and imaging scores were correlated with each other in TRACK-HD participants, justifying use of a single, cross-domain measure of disease progression in both studies. The TRACK-HD and REGISTRY progression measures were correlated with each other (r=0·674), and with age at onset (TRACK-HD, r=0·315; REGISTRY, r=0·234). The meta-analysis of progression in TRACK-HD and REGISTRY gave a genome-wide significant signal (p=1·12 × 10−10) on chromosome 5 spanning three genes: MSH3, DHFR, and MTRNR2L2. The genes in this locus were associated with progression in TRACK-HD (MSH3 p=2·94 × 10−8 DHFR p=8·37 × 10−7 MTRNR2L2 p=2·15 × 10−9) and to a lesser extent in REGISTRY (MSH3 p=9·36 × 10−4 DHFR p=8·45 × 10−4 MTRNR2L2 p=1·20 × 10−3). The lead single nucleotide polymorphism (SNP) in TRACK-HD (rs557874766) was genome-wide significant in the meta-analysis (p=1·58 × 10−8), and encodes an aminoacid change (Pro67Ala) in MSH3. In TRACK-HD, each copy of the minor allele at this SNP was associated with a 0·4 units per year (95% CI 0·16–0·66) reduction in the rate of change of the Unified Huntington's Disease Rating Scale (UHDRS) Total Motor Score, and a reduction of 0·12 units per year (95% CI 0·06–0·18) in the rate of change of UHDRS Total Functional Capacity score. These associations remained significant after adjusting for age of onset. Interpretation The multidomain progression measure in TRACK-HD was associated with a functional variant that was genome-wide significant in our meta-analysis. The association in only 216 participants implies that the progression measure is a sensitive reflection of disease burden, that the effect size at this locus is large, or both. Knockout of Msh3 reduces somatic expansion in Huntington's disease mouse models, suggesting this mechanism as an area for future therapeutic investigation