Faculty Bibliography

SOURCE CITATION:Lancet. 2021;398:1803-10. 34774144.

PURPOSE/OBJECTIVE:The 80-gene molecular subtyping signature (80-GS) reclassifies a proportion of immunohistochemistry (IHC)-defined luminal breast cancers (estrogen receptor-positive [ER+], human epidermal growth factor receptor 2-negative [HER2-]) as Basal-Type. We report the association of 80-GS reclassification with neoadjuvant treatment response and 5-year outcome in patients with breast cancer. METHODS:Neoadjuvant Breast Registry Symphony Trial (NBRST; NCT01479101) is an observational, prospective study that included 1,069 patients with early-stage breast cancer age 18-90 years who received neoadjuvant therapy. Pathologic complete response (pCR) and 5-year distant metastasis-free survival (DMFS) and overall survival (OS) were assessed in 477 patients with IHC-defined ER+, HER2- tumors and in a reference group of 229 patients with IHC-defined triple-negative breast cancer (TNBC). RESULTS:< .001) tumors. The 5-year DMFS (%, [95% CI]) was significantly lower for patients with ER+/Basal tumors (66% [52.6 to 77.3]), compared with those with ER+/Luminal A tumors (92.3% [85.2 to 96.1]) and ER+/Luminal B tumors (73.5% [44.5 to 79.3]). Importantly, patients with ER+/Basal or TNBC/Basal tumors that had a pCR exhibited significantly improved DMFS and OS compared with those with residual disease. By contrast, patients with ER+/Luminal B tumors had comparable 5-year DMFS and OS whether or not they achieved pCR. CONCLUSION/CONCLUSIONS:Significant differences in chemosensitivity and 5-year outcome suggest patients with ER+/Basal molecular subtype may benefit from neoadjuvant regimens optimized for patients with TNBC/Basal tumors compared with patients with ER+/Luminal subtype. These data highlight the importance of identifying this subset of patients to improve treatment planning and long-term survival.

Introduction: Mimicking physiological pan-creatic pulsatile insulin secretion has led to the concept of pulsatile insulin infusion therapy (PIT).
Method(s): This exploratory pilot study investigated the effect of PIT for three months once weekly on kidney function in patients with type 2 diabetes and chronic renal failure (glomerular filtration rate (GFR) < 60 ml/min or GFR < 75 ml/min with mac-roproteinurea).
Result(s): Seventeen type 2 patients com-pleted the trial per protocol (7 women, 10 men, age: 69 +/- 7 yrs., HbA1c: 7.9 +/- 1.0 %). After three months, mean GFR improved by 12 % (from 47.6 +/- 10.0 ml/ min to 53.3 +/- 11.9 ml/min, p < 0.01) while mean serum creatinine decreased by 7 % (1.4 +/- 0.3 mg/dl/1.3 +/- 0.3 mg/dl, p < 0.05). Blood pressure medication was kept constant during the study; systolic blood pressure improved by 6 % (p < 0.05) while HbA1c and body weight remained stable. Treatment satisfaction scores improved from 3.7 +/- 2.7 to 2.7 +/- 2.1 (p < 0.005). The PIT procedures were well tolerated; only few cases of muscle cramps were consid-ered related to the treatments.
Conclusion(s): Improvements in kidney func-tion, systolic blood pressure and treatmensatisfaction were observed. These results will now be used to plan for appropriately designed controlled confirmatory studies.
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Dietary sodium (Na) restriction is universally prescribedfor hemodialysis patients to decrease adverse outcomes.1 However, few studies have investigated the impact of Na restriction on volume status and blood pressure (BP), and none in American community-dwelling populations in prospective, randomized controlled trial (RCT). The purpose of this feasibility RCT was to assess the effects of three levels of Na intake (unrestricted [control group; CG], 1.5G, 2.4G) on interdialytic weight gain (IDWG) and BP in patients undergoing hemodialysis. We conducted a three-group, double-blinded, RCT of 42 individuals living with end stage kidney disease in a domiciled feeding study. We examined the effects of 5 days of unrestricted Na in the control group (CG, n=14) and Na restriction to 1.5G (n=11) or 2.4G (n=14) per day on IDWG and BP. Our sample was overwhelmingly African American (85%), male (52.2%), with hypertension as the primary etiology of kidney disease (45%). The mean IDWG on Day 1 was 2.62kg (SD=1.54) and BP was 143/75.44 (SD=29.77/17.74). There were no significant differences in the change in IDWG regardless of group membership, although the trend demonstrated a decrease by Day 5. Decreases in BP were also not statistically significant across the groups, but there were potentially meaningful differences in systolic BP of 7mmHg and 11mmHg in the 1.5G and 2.4G groups respectfully, and diastolic BP in the 2.4G group of 7.31mmHg Our small pilot study suggests that Na restriction can reduce IDWG and systolic and diastolic BP in potentially clinically meaningful amounts. The optimal Na intake prescription and the long-term impact on hemodialysis-specific variables and cardiovascular disease remains unclear. A prospective, longitudinal study, with a sample sufficient to achieve adequate power is needed to gain a better understanding of the interplay between dietary sodium and outcomes.
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OBJECTIVES/OBJECTIVE:To determine the prevalence of burnout among the midwifery workforce and the association between fixed personal and practice characteristics and modifiable organizational factors, specifically practice environment, to burnout among midwives in the United States. DATA SOURCE/METHODS:Primary data collection was conducted via online survey of the full national roster of certified nurse-midwives and certified midwives over three weeks in April 2017. STUDY DESIGN/METHODS:The study was a cross-sectional observational survey consisting of 95 items about personal and practice characteristics, respondents' practice environments, and professional burnout. DATA COLLECTION METHODS/METHODS:The inclusion criteria was actively practicing midwifery in the US. Data were analyzed with bivariate analyses to determine the association between personal and practice characteristics and burnout. A hierarchal multilinear regression evaluated to the inter-relationship between personal and practice characteristics, practice environment, and burnout. PRINCIPAL FINDINGS/RESULTS:Of the almost one third (30.9%) of certified nurse-midwives and certified midwives who responded to the survey, 40.6% met criteria for burnout. Weak negative correlations existed between burnout and indicators of career longevity: age (r(2256)=-0.09, p<0.01), years as a midwife (r(2267)=-0.07, p=0.01), and years with employer (r(2271)=-0.05, p=0.02). There were significant relationships between burnout score and patient workload indicators: patients per day in out-patient setting [F(5,2292)=13.995, p<0.01], birth volume [F(3,1864)=8.35, p<0.01], and patient acuity [F(2,2295)=20.21, p<0.01]. When the practice environment was entered into the model with personal and practice characteristics, the explained variance increased from 6.4% to 26.5% (F(20,1478)=27.98, p<0.01). CONCLUSIONS:Our findings suggested that a key driver of burnout among US midwives was practice environment, specifically practice leadership and participation and support for the midwifery model of care. Structural and personal characteristics contributed less to burnout score than the practice environment, implying that prevention of burnout may be achieved through organizational support and does not require structural changes to the provision of perinatal health.

BACKGROUND:Breakfast consumption is often associated with improving cardiometabolic parameters and diet quality. However, literature evaluating breakfast consumption with these outcomes between the school and home environments is limited. OBJECTIVE:This study examined relationships between breakfast consumption locations (school vs home) and cardiometabolic parameters, breakfast dietary intake, and daily dietary intake. DESIGN:This cross-sectional study used baseline data from TX Sprouts, a 1-year school-based gardening, nutrition, and cooking cluster-randomized trial, implemented in 16 elementary schools in Austin, TX, during 2016 to 2019. PARTICIPANTS/SETTING:Analyses included 383 low-income, multiracial/ethnic elementary school-aged children (mean age = 9.2 years; 60.6% Hispanic; 70.5% free/reduced lunch; 58.5% home breakfast consumers). MAIN OUTCOME MEASURES:Cardiometabolic parameters were obtained via fasting blood draws, and dietary intake was assessed using one 24-hour dietary recall conducted on a random, unannounced weekday. Cardiometabolic and dietary parameters (ie, energy intake, macronutrients, and food group servings) for breakfast and for the day were evaluated. STATISTICAL ANALYSES PERFORMED:Multivariate analysis of covariance was performed to examine cardiometabolic parameters and dietary intake between school and home breakfasts. RESULTS:School breakfast consumers (SBC) had lower fasting triglyceride levels than home breakfast consumers (HBC) (89.0 mg/dL vs 95.7 mg/dL; P = 0.03) (to convert to mmol/L, multiply by 0.0113). SBC had lower total fat for the day (P = 0.02) and lower total and saturated fat, sodium, and refined grains at breakfast (P ≤ 0.01) than HBC. However, SBC had lower protein at breakfast (P = 0.01) and higher carbohydrates, total sugar, and added sugar for the day and at breakfast (P ≤ 0.03) than HBC. CONCLUSIONS:SBC compared with HBC had lower fat intake, which may have contributed to the lower triglyceride level observed in SBC, but also had lower protein intake at breakfast and higher added sugar intake for the day and at breakfast. These results suggest dietary intake differed between HBC and SBC; that is, the home and school environments, but more research is needed to evaluate if such differences are due to School Breakfast Program guidelines.

BACKGROUND:Palliative care (PC) clinicians are well trained to address physical, psychosocial and spiritual needs of patients who have a serious illness. However, one area that is often overlooked is intimacy and sexuality. OBJECTIVE:To explore patient concerns regarding intimacy as it relates to illness, family reactions, physician conversations, and coping strategies and challenges. METHODS:Eligible subjects (at least 18 years old, capacitated, receiving PC consultation at the lead author's institution) participated in semi-structured interviews between November and December 2017. Transcripts were open-coded and analyzed using Dedoose 3.5.35 software. A constant comparative method was used to identify patterns in the data. RESULTS:21 interviews were analyzed and several themes emerged. Participants described the effect of physical and mental/emotional changes on their relationships. Family relationships, romantic relationships, and sexuality were prominent in patients' experiences of intimacy and how it changed as the illness progressed. Relationships were often noted to strengthen during the course of illness, while sexual activity was frequently reported to be negatively impacted. Patients consistently reported little provider communication on the impact of illness on intimacy beyond instructions about what sexual activities they could or could not engage in. CONCLUSION/CONCLUSIONS:This study underlines the significant impact of serious, progressive illness on relationships, sexuality, and physical and emotional intimacy. It highlights that these topics continue to be priorities for patients with serious illness, and that medical teams frequently fail to address them at all. Future research should further explore these issues across diverse patient populations.

OBJECTIVE/BACKGROUND/OBJECTIVE:To examine the impact of prostate cancer (PCa) on sleep health for patients and caregivers. We hypothesized that sleep disturbances and poor sleep quality would be prevalent among patients with PCa and their caregivers. PATIENTS/METHODS/METHODS:A systematic literature search was conducted according to the Preferred Reporting Items for a Systematic Review and Meta-analysis guidelines. To be eligible for this systematic review, studies had to include: (1) patients diagnosed with PCa and/or their caregivers; and (2) objective or subjective data on sleep. 2431 articles were identified from the search. After duplicates were removed, 1577 abstracts were screened for eligibility, and 315 underwent full-text review. RESULTS AND CONCLUSIONS/CONCLUSIONS:Overall, 83 articles met inclusion criteria and were included in the qualitative synthesis. The majority of papers included patients with PCa (98%), who varied widely in their treatment stage. Only 3 studies reported on sleep among caregivers of patients with PCa. Most studies were designed to address a different issue and examined sleep as a secondary endpoint. Commonly used instruments included the Insomnia Severity Index and European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaires (EORTC-QLQ). Overall, patients with PCa reported a variety of sleep issues, including insomnia and general sleep difficulties. Both physical and psychological barriers to sleep are reported in this population. There was common use of hypnotic medications, yet few studies of behavioral interventions to improve sleep for patients with PCa or their caregivers. Many different sleep issues are reported by patients with PCa and caregivers with diverse sleep measurement methods and surveys. Future research may develop consensus on validated sleep assessment tools for use in PCa clinical care and research to promote facilitate comparison of sleep across PCa treatment stages. Also, future research is needed on behavioral interventions to improve sleep among this population.