Women with early-stage breast cancers are expected to have excellent survival rates. It is important to identify factors that predict diagnosis of early-stage breast cancers.
To determine the ...proportion of breast cancers that were identified at an early stage (stage I) in different racial/ethnic groups and whether ethnic differences may be better explained by early detection or by intrinsic biological differences in tumor aggressiveness.
Observational study of women diagnosed with invasive breast cancer from 2004 to 2011 who were identified in the Surveillance, Epidemiology, and End Results (SEER) 18 registries database (N = 452,215). For each of 8 racial/ethnic groups, biological aggressiveness (triple-negative cancers, lymph node metastases, and distant metastases) of small-sized tumors of 2.0 cm or less was estimated. The odds ratio (OR) for being diagnosed at stage I compared with a later stage and the hazard ratio (HR) for death from stage I breast cancer by racial/ethnic group were determined. The date of final follow-up was December 31, 2011.
Breast cancer stage at diagnosis and 7-year breast cancer-specific survival, adjusted for age at diagnosis, income, and estrogen receptor status.
Of 373,563 women with invasive breast cancer, 268,675 (71.9%) were non-Hispanic white; 34,928 (9.4%), Hispanic white; 38,751 (10.4%), black; 25,211 (6.7%), Asian; and 5998 (1.6%), other ethnicities. Mean follow-up time was 40.6 months (median, 38 months). Compared with non-Hispanic white women diagnosed with stage I breast cancer (50.8%), Japanese women (56.1%) were more likely to be diagnosed (OR, 1.23 95% CI, 1.15-1.31, P < .001) and black women (37.0%) were less likely to be diagnosed (OR, 0.65 95% CI, 0.64-0.67, P < .001). Actuarial risk of death from stage I breast cancer at 7 years was higher among black women (6.2%) than non-Hispanic white women (3.0%) (HR, 1.57 95% CI, 1.40-1.75; P < .001), and lower among South Asian women (1.7%) (HR, 0.48 95% CI, 0.20-1.15; P = .10). Black women were more likely to die of breast cancer with small-sized tumors (9.0%) than non-Hispanic white women (4.6%) (HR, 1.96 95% CI, 1.82-2.12; P < .001); the difference remained after adjustment for income and estrogen receptor status (HR, 1.56 95% CI, 1.45-1.69; P < .001).
Among US women diagnosed with invasive breast cancer, the likelihood of diagnosis at an early stage, and survival after stage I diagnosis, varied by race and ethnicity. Much of the difference could be statistically accounted for by intrinsic biological differences such as lymph node metastasis, distant metastasis, and triple-negative behavior of tumors.
Over the past 25 years, the number of women graduating from medical schools in the United States and Canada has increased dramatically to the point where roughly equal numbers of men and women are ...graduating each year. Despite this growth, women continue to face challenges in moving into academic leadership positions. In this Commentary, the authors share lessons learned from their own careers relevant to women's careers in academic medicine, including aspects of leadership, recruitment, editorship, promotion, and work-life balance. They provide brief synopses of current literature on the personal and social forces that affect women's participation in academic leadership roles. They are persuaded that a deeper understanding of these realities can help create an environment in academic medicine that is generally more supportive of women's participation, and that specifically encourages women in medicine to take on academic leadership positions.
Adverse drug reactions (ADRs) are an important cause of morbidity and mortality. Reports on differences in reporting patterns between women and men exist nationally. The goal of the present study was ...to assess the global evidence on spontaneous post-marketing ADR reporting differences between reports for women and men.
We analysed data collected within VigiBase, the WHO global database of individual case safety reports, between 1967-2 January 2018. VigiBase contains more than 18 million reports from the 131 member countries of the WHO Programme for International Drug Monitoring.
Of the reports with information on sex, 9,056,566 (60.1%) concerned female and 6,012,804 (39.9%) male children and adults. More female ADR reports were submitted in all regions of the world and by all types of reporters. A higher proportion of female reports was seen in all age groups from the age group 12-17 years and older. The largest difference was observed in the age group of 18–44 years and could not be explained by hormonal contraceptive use. The proportion of serious and fatal reports was higher for male reports.
Global post marketing surveillance data on spontaneous reports indicate that women, from puberty and onwards and especially in their reproductive years, report more ADRs than men. However, there is a higher proportion of serious and fatal ADRs among male reports. Our results suggest important underlying sex-related differences in ADRs. These findings highlight the importance of considering sex throughout the entire life-cycle of drug development and surveillance and understanding the underlying reasons for reporting ADRs.
Integrating sex and gender in health research is essential to produce the best possible evidence to inform health care. Comprehensive integration of sex and gender requires considering these ...variables from the very beginning of the research process, starting at the proposal stage. To promote excellence in sex and gender integration, we have developed a set of metrics to assess the quality of sex and gender integration in research proposals. These metrics are designed to assist both researchers in developing proposals and reviewers in making funding decisions. We developed this tool through an iterative three-stage method involving 1) review of existing sex and gender integration resources and initial metrics design, 2) expert review and feedback via anonymous online survey (Likert scale and open-ended questions), and 3) analysis of feedback data and collective revision of the metrics. We received feedback on the initial metrics draft from 20 reviewers with expertise in conducting sex- and/or gender-based health research. The majority of reviewers responded positively to questions regarding the utility, clarity and completeness of the metrics, and all reviewers provided responses to open-ended questions about suggestions for improvements. Coding and analysis of responses identified three domains for improvement: clarifying terminology, refining content, and broadening applicability. Based on this analysis we revised the metrics into the Essential Metrics for Assessing Sex and Gender Integration in Health Research Proposals Involving Human Participants, which outlines criteria for excellence within each proposal component and provides illustrative examples to support implementation. By enhancing the quality of sex and gender integration in proposals, the metrics will help to foster comprehensive, meaningful integration of sex and gender throughout each stage of the research process, resulting in better quality evidence to inform health care for all.
The risk of sexual HIV transmission in serodiscordant couples when the HIV-positive partner has full virologic suppression on combination antiretroviral therapy (cART) is debated. This study aims to ...systematically review observational studies and randomized controlled trials (RCTs), evaluating rates of sexual HIV transmission between heterosexual serodiscordant couples when the HIV-positive partner has full suppression on cART.
We searched major bibliographic databases to November 2012 for relevant observational studies and RCTs without language restrictions. Conference proceedings, key journals and bibliographies were also searched. Studies reporting HIV transmission rates, cART histories and viral loads of the HIV-positive partners were included. Two reviewers extracted methodologic characteristics and outcomes. Of 20,252 citations, 3 studies met all eligibility criteria with confirmed full virologic suppression in the HIV-positive partner. We included 3 additional studies (2 cohort studies, 1 RCT) that did not confirm viral suppression in the HIV-positive partner at transmission in a secondary meta-analysis. Methodologic quality was reasonable. The rate of transmission in the 3 studies confirming virologic suppression was 0 per 100 person-years (95% CI = 0-0.05), with low heterogeneity (I(2) = 0%). When we included the 3 studies that did not confirm virologic suppression, the rate of transmission was 0.14 per 100 person-years (95%CI = 0.04-0.31) (I(2) = 0%). In a sensitivity analysis including all 6 studies, the rate of transmission was 0 per 100 person-years (95%CI = 0-0.01) after omitting all transmissions with known detectable or unconfirmed viral loads, as full suppression in these cases was unlikely. Limitations included lack of data on same-sex couples, type of sexual intercourse (vaginal vs. anal), direction of HIV transmission, exact viral load at the time of transmission, sexually transmitted infections (STI) rates, and extent of condom use.
Our findings suggest minimal risk of sexual HIV transmission for heterosexual serodiscordant couples when the HIV-positive partner has full viral suppression on cART with caveats regarding information on sexual intercourse type, STIs, and condom use. These findings have implications when counseling heterosexual serodiscordant couples on sexual and reproductive health. More research is needed to explore HIV transmission risk between same-sex couples.
OBJECTIVES
To systematically describe the resources available on preventing, detecting, and reversing prescribing cascades using a scoping review methodology.
MEASUREMENTS
We searched Medline, ...EMBASE, PsychINFO, CINAHL, Cochrane Library, and Sociological s from inception until July 2017. Other searches (Google Scholar, hand searches) and expert consultations were performed for resources examining how to prevent, detect, or reverse prescribing cascades. We used these three categories along the prescribing continuum as an organizing framework to categorize and synthesize resources.
RESULTS
Of 369 resources identified, 58 met inclusion criteria; 29 of these were categorized as preventing, 20 as detecting, and 9 as reversing prescribing cascades. Resources originated from 14 countries and mostly focused on older adults. The goal of preventing resources was to educate and increase general awareness of the concept of prescribing cascades as a way to prevent inappropriate prescribing and to illustrate application of the concept to specific drugs (e.g., anticholinergics) and conditions (e.g., inflammatory bowel disease). Detecting resources included original investigations or case reports that identified prescribing cascades using health administrative data, patient cohorts, and novel sources such as social media. Reversing prescribing cascade resources focused on the medication review process and deprescribing initiatives.
CONCLUSION
Prescribing cascades are a recognized problem internationally. By learning from the range of resources to prevent, detect, and reverse prescribing cascades, this review contributes to improving drug prescribing, especially in older adults. J Am Geriatr Soc 66:2079–2085, 2018.
Endocrine-based treatments are the mainstay of therapy for postmenopausal women with breast cancer; yet concern has been raised about potential adverse cognitive effects. We performed a systematic ...review of the published literature to evaluate whether endocrine-based treatments for breast cancer are associated with changes in cognitive domains and whether these effects are more pronounced with advanced age. An electronic database search was performed. Original investigations that examined the effects of endocrine treatment on cognitive function were identified. Data were abstracted and studies were assessed for risk of bias. A total of 21 unique studies (
n
= 2398) were identified. Ten were short-term (duration ≤ 2 years) and 11 were long-term (duration > 2 years). Nine (43 %) studies had a sample size ≤100 subjects; 9 (43 %) were longitudinal, with baseline measurement before treatment initiation. No studies were primary randomized clinical trials. While there was heterogeneity in the neuropsychological measures used, tests could be grouped into the cognitive domains that they assessed. Compared to breast cancer or healthy controls, endocrine therapy was associated with impaired performance on neuropsychological testing. No study explored the association between age and changes in cognitive performance. Overall, endocrine therapies were associated with greater cognitive deficits compared to surgical and healthy controls; yet, lack of randomized trial data and heterogeneity in design of many studies limited any definitive conclusions. Despite older women being at highest risk for the development of cognitive impairment, advanced age has not been adequately explored.
Abstract Our aim was to create a clinically useful risk index, administered prior to discharge, for determining the probability of psychiatric readmission within 30 days of hospital discharge for ...general psychiatric inpatients. We used population-level sociodemographic and health administrative data to develop a predictive model for 30-day readmission among adults discharged from an acute psychiatric unit in Ontario, Canada (2008–2011), and converted the final model into a risk index system. We derived the predictive model in one-half of the sample ( n = 32,749) and validated it in the other half of the sample ( n = 32,750). Variables independently associated with 30-day readmission (forming the mnemonic READMIT) were: (R) Repeat admissions; (E) Emergent admissions (i.e. harm to self/others); (D) Diagnoses (psychosis, bipolar and/or personality disorder), and unplanned Discharge; (M) Medical comorbidity; (I) prior service use Intensity; and (T) Time in hospital. Each 1-point increase in READMIT score (range 0–41) increased the odds of 30-day readmission by 11% (odds ratio 1.11, 95% CI 1.10–1.12). The index had moderate discriminative capacity in both derivation (C-statistic = 0.631) and validation (C-statistic = 0.630) datasets. Determining risk of psychiatric readmission for individual patients is a critical step in efforts to address the potentially avoidable high rate of this negative outcome. The READMIT index provides a framework for identifying patients at high risk of 30-day readmission prior to discharge, and for the development, evaluation and delivery of interventions that can assist with optimizing the transition to community care for patients following psychiatric discharge.
Polypharmacy is very common in older adults and increases the risk of inappropriate and unsafe prescribing for older adults. Older adults, particularly women (who make up the majority of this age ...group), are at the greatest risk for drug-related harm. Therefore, optimising drug prescribing for older people is very important. Identifying potentially inappropriate medications and opportunities for judicious deprescribing processes are intrinsically linked, complementary, and essential for optimising medication safety. This Review focuses on optimising prescribing for older adults by reducing doses or stopping drugs that are potentially harmful or that are no longer needed. We explore how sex (biological) and gender (sociocultural) factors are important considerations in safe drug prescribing. We conclude by providing a practical approach to optimising medication safety that clinicians can routinely apply to the care of their older patients, highlighting how sex and gender considerations inform medication decision making.
Potentially inappropriate prescribing of medications in older adults, particular those with dementia, can lead to adverse drug events including falls and fractures, worsening cognitive impairment, ...emergency department visits, and hospitalizations. Educational mailings from health plans to patients and their providers to encourage deprescribing conversations may represent an effective, low-cost, "light touch", approach to reducing the burden of potentially inappropriate prescription use in older adults with dementia.
The objective of the Developing a PRogram to Educate and Sensitize Caregivers to Reduce the Inappropriate Prescription Burden in Elderly with Alzheimer's Disease (D-PRESCRIBE-AD) trial is to evaluate the effect of a health plan based multi-faceted educational outreach intervention to community dwelling patients with dementia who are currently prescribed sedative/hypnotics, antipsychotics, or strong anticholinergics.
The D-PRESCRIBE-AD is an open-label pragmatic, prospective randomized controlled trial (RCT) comparing three arms: 1) educational mailing to both the health plan patient and their prescribing physician (patient plus physician arm, n = 4814); 2) educational mailing to prescribing physician only (physician only arm, n = 4814); and 3) usual care (n = 4814) among patients with dementia enrolled in two large United States based health plans. The primary outcome is the absence of any dispensing of the targeted potentially inappropriate prescription during the 6-month study observation period after a 3-month black out period following the mailing. Secondary outcomes include dose-reduction, polypharmacy, healthcare utilization, mortality and therapeutic switching within targeted drug classes.
This large pragmatic RCT will contribute to the evidence base on promoting deprescribing of potentially inappropriate medications among older adults with dementia. If successful, such light touch, inexpensive and highly scalable interventions have the potential to reduce the burden of potentially inappropriate prescribing for patients with dementia. ClinicalTrials.gov Identifier: NCT05147428.
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