Over 1100 Veterans work in the Veterans Health Administration (VHA) as peer specialists (PSs). PSs are Veterans with formal training who provide support to other Veterans with similar diagnoses, ...primarily in mental health settings. A White House Executive Action mandated the pilot reassignment of VHA PSs from mental health to 25 primary care Patient Aligned Care Teams (PACT) in order to broaden the provision of wellness services that can address many chronic illnesses. An evaluation of this initiative was undertaken to assess the impact of outside assistance on the deployment of PS in PACT, as implementation support is often needed to prevent challenges commonly experienced when first deploying PSs in VHA settings. We present the protocol for this cluster-randomized hybrid type II trial to test the impact of standard implementation (receive minimal assistance) vs. facilitated implementation (receive outside assistance) on the deployment of VHA PSs in PACT.
A VHA Office of Mental Health Services work group is recruiting 25 Veterans Affairs Medical Centers to reassign a mental health PSs to provide wellness-oriented care in PACT. Sites in three successive cohorts (n = 8, 8, 9) beginning over 6-month blocks will be matched and randomized to either standard or facilitated implementation. In facilitated implementation, an outside expert works with site stakeholders through a site visit, regular calls, and performance data to guide the planning and address challenges. Standard implementation sites will receive a webinar and access the Office of Mental Health Services work group. The two conditions will be compared on PS workload data, fidelity to the PS model of service delivery, team functioning, and Veteran measures of activation, satisfaction, and functioning. Qualitative interviews will collect information on implementation barriers and facilitators.
This evaluation will provide critical data to guide administrators and VHA policy makers on future deployment of PSs, as their role has been expanding beyond mental health. In addition, development of novel implementation strategies (facilitation tailored to PSs) and the use of new tools (peer fidelity) can be models for monitoring and supporting deployment of PSs throughout VHA.
ClinicalTrials.gov, NCT02732600 (URL: https://clinicaltrials.gov/ct2/show/NCT02732600 ).
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Background: Breast cancer (BC) is the most common malignancy among women. Her2 mutation has historically been associated with more aggressive disease and worse prognosis, however this paradigm ...is changing with Her2-directed therapies. Her2 positive BC presents with de novo metastatic disease more often than other subtypes. Young women are more likely to be diagnosed with Her2 positive BC, however previous studies have not had adequate representation of Black/African American women. We evaluated a diverse group of young women under the age of 40 to determine if Her2+ disease was more likely to present with de novo metastatic disease. Methods: We performed a retrospective chart review and collected data on 746 women diagnosed with BC under the age of 40 from 2012 to 2022. We collected age at diagnosis, Her2 receptor status, self-identified race, and stage at diagnosis. 187 of these patients were Her2 positive, and 276 patients were Black. We stratified patients as Black versus White, and as stage IV at diagnosis versus stages I to III at diagnosis. We performed Fisher's exact test to determine if Her2 positive BC was more or less likely to present as de novo metastatic disease compared to Her2 negative BC. Results: In our population of 746 young women under the age of 40 presenting to our health system in a 10-year period, 48 (6.4%) presented with de novo metastatic BC, and 19 (39.6%) of these were Her2 positive. 36% of our study population was Black, which is representative of the demographics of our region. We performed Fisher's exact test, and found that Her2 positive BC was more likely to present as de novo metastatic disease compared to Her2 negative BC. This was statistically significant (p = 0.024). When divided for race, this was not statistically significant for White patients alone (p = 0.052) or Black patients alone (p = 0.234). Conclusions: Our data shows that Her2 positive BC in women under the age of 40 is statistically more likely to present with de novo metastatic disease. Previous research in this area has not been inclusive of Black patients. Current guidelines only recommend staging imaging among patients with systemic symptoms. Based on this data, consideration should be made for staging scans for young women presenting with new HER2+ breast cancer diagnoses. There is limited data available for breast cancer subtype incidence and prognosis among Black patients, and this study underscores the need for more inclusive study populations.Table: see text
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Background: Obesity is a well-established risk factor for postmenopausal hormone-receptor positive breast cancer (BC). The role of obesity in premenopausal BC, especially in women under the age ...of 40, is not well understood. Multiple studies have shown a decreased rate of premenopausal BC with increasing body mass index (BMI), notably for estrogen receptor positive tumors. Even though there is an inverse association between obesity and premenopausal BC, it has been suggested that obesity has a negative prognostic role in premenopausal BC. This may be explained if premenopausal obese women develop more aggressive tumors. Obesity is associated with triple negative and Luminal B cancers in premenopausal women. We sought to evaluate the relationship between premenopausal breast cancer and obesity in a diverse patient population. Methods: We assembled a 10-year database of women diagnosed with breast cancer before age 40 in a single health system. Data collected included age at diagnosis, self-identified race, breast cancer subtype, BMI, and stage at diagnosis. The control group was all women under the age of 40 presenting to our health system in the same time period. Stratification analysis was performed using Mantel-Haenszel Risk Estimation. Results: The risk ratio between the standardized estimates of BC patients under 40 with BMI ≤ 30 to BMI > 30 is 0.7924, 95% CI (0.683 – 0.920), P = 0.0022. This implies that young BC patients are more likely to be obese than all young women presenting to our health system. There are more obese Black patients compared to White patients. The effect of obesity on BC diagnosis was more pronounced in Black patients, with a risk ratio of 0.59 compared to 0.96. Conclusions: The data presented here challenge previous research which had shown that obesity seemed to be protective against breast cancer in premenopausal women. Here, we see a statistically significant increase in obesity among young women < 40 years presenting with breast cancer. The increased risk of breast cancer diagnosis was particularly pronounced in obese Black women. Previous studies have had a very low proportion of Black women represented, which may cause underestimation of risk in this patient population. These data suggest that obesity is a risk factor for breast cancer in young women, especially in Black patients. Table: see text
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Background: Obesity is a known risk factor for the development of postmenopausal breast cancer, specifically hormone-receptor positive breast cancer, and is associated with poor outcomes and ...decreased overall survival. While obesity in pre-menopausal patients is thought to be protective against the development of breast cancer, application across breast cancer subtypes remains less clear. Methods: We performed a retrospective analysis of 758 patients under 40 years of age diagnosed with breast cancer at our institution over 10 years. Variables including age at diagnosis, breast cancer subtype, race and BMI were evaluated. To assess the association between body mass index (BMI), race and triple negative breast cancer (TNBC), odds ratios (OR) and their associated 95% Confidence interval (CI) OR are reported. Results: Obese patients (BMI >30) were more likely to have TNBC compared with non-obese patients OR=1.46, 95% CI 1.07 – 2.00), P=0.0161. Black patients had a twofold likelihood of having TNBC compared with white patients regardless of BMI OR=2.16, 95% CI 1.56 – 2.97), P<0.0001. Conclusions: Obese patients under 40 years of age were more likely to be diagnosed with TNBC than non-obese patients. Our data highlights ongoing disparities among TNBC diagnosis and emphasizes the importance of weight loss interventions targeted towards premenopausal women at high risk for breast cancer. Table: see text
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Background: Breast cancer (BC) diagnosed under age 40 accounts for approximately 7-9% of all BC diagnoses. Patients diagnosed with BC < age 40 have more aggressive cancers, present at later ...stages, and poorer outcomes. Socioeconomic status (SES), income, and education have been studied in relation to cancer incidence and prognosis. According to data reviewed from 2008 SEER database, there was no major difference in incidence of female BC among patients of varying poverty levels or annual household income and women with college education had a higher incidence of breast cancer diagnosis compared to those without college education. A composite index of these variables is categorized as Area Deprivation Index (ADI). ADI ranks census bureau neighborhoods by SES and disadvantaged metrics including income, education, employment, and housing.
Louisiana and Mississippi have large areas of deprivation in rural and urban areas. Methods: We performed a retrospective chart review and collected data on 746 women diagnosed with BC < age 40 from 2012 to 2022 in single medical system (Ochsner Health System) throughout Louisiana and Mississippi. Data was collected including age at diagnosis, BMI, race, BC subtype, and zip code (to determine ADI). Data was censored for patients without zip codes. We reviewed patients’ BC subtype by ADI to determine if there is a relationship between these young patients’ BC diagnoses and ADI. Cochran-Armitage test was used to determine significance. Results: ADI State Rankings by Quintiles. Conclusions: Young women in regions of lower SES are more likely to be diagnosed with TNBC. As TNBC is an aggressive subtype in a patient population that is predisposed to aggressive BC, this data serves as rationale to increased BC outreach to women in neighborhoods of higher ADI to promote knowledge, risk reduction and early detection. Table: see text Table: see text Table: see text
As Herr and Harry outline in chapter 1, archaeologists have variously defined different kinds of edge regions using criteria that include demography, geographic distance, migration histories, ...economic relationships, and social identities. This diversity in definitions alludes to the wide variety of social experiences characterizing such social settings. In some contexts, the inhabitants of edge regions are seen as marginal members of broader social systems, with limited access to the activities and ideas marking major centers of population and culture. In other cases, the inhabitants of edges serve key roles as intermediates spanning boundaries between multiple centers of population or culture,
Associations between serum levels of polybrominated diphenyl ether (PBDE) and timing of pubertal development in adolescent girls (e.g., menarche) have been reported in both a cross-sectional and in a ...longitudinal study. The associations may be biased by growth dilution and pharmacokinetic changes during pubertal development.
To use a physiologically-based pharmacokinetic (PBPK) model to assess how much of the epidemiologic association between PBDE and altered timing of menarche might be attributable to growth dilution and pubertal maturation.
We developed a PBPK model of BDE-47, a major congener of PBDE, to perform Monte Carlo (MC) simulation of plasma BDE-47 levels in a hypothetical target population aged 2 to 22 years old. The model used realistic distributions of physiological parameters including timing of growth spurts and menarche. The simulated data were analyzed as if they had come from an epidemiologic study. We compared the results based on the simulated population to those reported.
The population characteristics, including age and body mass index (BMI) were similar between the simulated and reported groups. In the cross-sectional study design, the association between proportion of subjects with menarche before age 12 years and BDE-47 serum concentration was inverse in our simulated population, whereas the reported association was positive. In the longitudinal study design, simulated data were not suggestive of an association, whereas a delay in pubertal onset with higher concentrations of BDE-47 was observed in the epidemiologic study.
Results of our simulation suggest that in the previous cross-sectional study there was a small negative bias due to pharmacokinetics in the reported relationship between BDE-47 and age at menarche. However, in the longitudinal study there was little evidence of bias. Our study showed how PBPK modeling can be used to quantify the potential bias in epidemiological studies and also suggested that further studies on the optimal approach to modeling exposure are warranted to better understand and quantify the potential bias in the epidemiological associations with BDE-47 due to pharmacokinetics.
•A PBPK model was developed to simulate plasma BDE-47 in humans.•PBPK modeling was used to quantify the potential bias in epidemiological studies due to PK.•Our approach can be applicable for evaluating other chemicals and health end points associations.
This dissertation explores the interrelationships between periods of rapid social change and regional-scale social identities. Using archaeological data from the Cibola region of the U.S. Southwest, ...I examine changes in the nature and scale of social identification across a period of demographic and social upheaval (A.D. 1150–1325) marked by a shift from dispersed hamlets, to clustered villages, and eventually, to a small number of large nucleated towns. This transformation in settlement organization entailed a fundamental reconfiguration of the relationships among households and communities across an area of over 45,000 km2. This study draws on contemporary social theory focused on political mobilization and social movements to investigate how changes in the process of social identification can influence the potential for such widespread and rapid transformations. This framework suggests that social identification can be divided into two primary modes; relational identification based on networks of interaction among individuals, and categorical identification based on active expressions of affiliation with social roles or groups to which one can belong. Importantly, trajectories of social transformations are closely tied to the interrelationships between these two modes of identification. This study has three components: Social transformation, indicated by rapid demographic and settlement transitions, is documented through settlement studies drawing on a massive, regional database including over 1,500 sites. Relational identities, indicated by networks of interaction, are documented through ceramic compositional analyses of over 2,100 potsherds, technological characterizations of over 2,000 utilitarian ceramic vessels, and the distributions of different types of domestic architectural features across the region. Categorical identities are documented through stylistic comparisons of a large sample of polychrome ceramic vessels and characterizations of public architectural spaces. Contrary to assumptions underlying traditional approaches to social identity in archaeology, this study demonstrates that relational and categorical identities are not necessarily coterminous. Importantly, however, the strongest patterns of relational connections prior to the period of social transformation in the Cibola region largely predict the scale and structure of changes associated with that transformation. This suggests that the social transformation in the Cibola region, despite occurring in a non-state setting, was governed by similar dynamics to well-documented contemporary examples.
Additive manufacturing of functional devices on various rigid and flexible substrates is rising rapidly due to their design flexibility, rapid manufacturing, and lower cost. Current printing ...technologies are ink-based and focused on printing silver (Ag) as conductive lines due to its matured ink formulation process, low sintering temperature, ease of printing, and low oxidation rate. However, Ag is the 68th most abundant element on Earth, while copper (Cu) is the 25th, making it much cheaper (>100×) while having a comparable conductivity to Ag. Therefore, printing Cu has become technologically and economically more attractive than Ag. Nevertheless, Cu printing is still a significant challenge in ink-based printing methods due to the higher sintering temperature relative to the glass-transition temperature of most flexible substrates, the higher oxidation rate, the challenging ink formulation process, and ink stability concerns. Here, we demonstrate printing highly conductive Cu on flexible polyimide substrates using a dry printing technique. Cu nanoparticles (∼3–30 nm) are generated by on-demand laser ablation of a solid Cu target inside the printer head and under argon background gas. These Cu nanoparticles are then transported through a nozzle and onto the substrate, where they are laser-sintered in real time. The argon gas plays three critical roles in laser plume condensation for nanoparticle generation, transport, and sheath gas to avoid oxidation during sintering. The sintered nanoparticles thus show high electrical conductivity and mechanical stability under static and cyclic tests. Our dry printing technique can potentially revolutionize how electronic devices and sensors are additively manufactured for earth and space applications.
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