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Breast cancer survival is increasing, making late effects such as cardiovascular disease (CVD) more relevant. The purpose of this study was to evaluate incident CVD following breast cancer diagnosis among long-term survivors and to investigate possible risk factors for CVD.A population-based cohort of 6641 breast cancer survivors diagnosed between 1997 and 2009 who survived at least 10 years was identified within the Utah Cancer Registry. In addition, 36,612 cancer-free women from the general population, matched by birth year and state, were identified within the Utah Population Database. Cox proportional hazards models were used to calculate CVD hazard ratios (HRs) for10 to 15 and15 years.Long-term breast cancer survivors had an increased risk of newly diagnosed diseases of the circulatory system (HR, 1.32; 99% confidence interval [CI], 1.00-1.75) from 10 to 15 years following cancer diagnosis compared with the general population. No increased CVD risks were observed after 15 years. Breast cancer survivors with Charlson Comorbidity Index score ≥2 had a significantly higher risk of diseases of the circulatory system (HR, 2.64; 95% CI, 1.08-6.45) beyond 10 years following breast cancer diagnosis. Similarly, older age, obesity, lower education, and family history of CVD and breast cancer were risk factors for heart and circulatory system diseases among long-term breast cancer survivors.Risk of CVD compared to the general population was moderate among this cohort of long-term breast cancer survivors between 10 to 15 years since cancer diagnosis. Awareness of CVD risks is important for breast cancer survivors.

BACKGROUND Cesarean birth, especially repeat cesarean, is associated with significantly higher morbidity than vaginal birth. Appropriately counseling women who are candidates for labor after cesarean (LAC) has the potential to confer significant health benefits for women. Little guidance exists about optimal counseling techniques, especially for Latina women. The aim of this study was to evaluate satisfaction among Latinas about how LAC counseling is performed, specifically as it relates to shared decision making. METHODS We conducted a qualitative study of pregnant women at several clinics in a Federally Qualified Health Center system in Utah. We interviewed eleven Latina women about satisfaction with recent LAC counseling with a specific aim of obtaining rich, personal narratives rather than reaching data saturation. A codebook representing the most common themes was developed. RESULTS Three major themes emerged related to LAC counseling including influences on satisfaction, influences on the birth decision process, and preferences surrounding method and timing of counseling. Women experienced greater satisfaction from providers who used jargon-free communication, were perceived as trustworthy, cared about her experiences, and empowered her to make an informed decision. Women's decisions were influenced by prior birth experiences, desire for a safe delivery and easy recovery, and future family planning. CONCLUSIONS Understanding the aspects of LAC counseling that are most meaningful for Latina women can promote effective communication between patient and provider and improve patient satisfaction. Globally, our findings highlight the importance of evaluating the experiences and preferences of minority groups; majority populations cannot be assumed to speak for minority populations.

Indications for genetic testing for inherited cancer syndromes are expanding both in the academic and the community setting. However, only a fraction of individuals who are candidates for testing pursue this option. Therefore, it is important to understand those factors that impact the uptake of genetic testing in individuals affected and unaffected with cancer. A successful translation of genomic risk stratification into clinical care will require that providers of this information are aware of the attitudes, perceived risks and benefits, and concerns of individuals who will be considering testing. The purpose of this study was to assess beliefs, attitudes and preferences for genetic risk information, by personal characteristics of women affected and unaffected by breast cancer enrolled in the Breast Cancer Family Registry Cohort. Data for this analysis came from eight survey questions, which asked participants (N = 9,048, 100% female) about their opinions regarding genetic information. Women reported that conveying the accuracy of the test was important and were interested in information related to personal level of risk, finding out about diseases that could be treated, and information that could be helpful to their families. Young women were most interested in how their own health needs might be impacted by genetic test results, while older women were more interested in how genetic information would benefit other members of the family. Interest in how the genetic test was performed was highest among Asian and Hispanic women. Women affected with breast cancer were more likely to report feeling sad about possibly passing down a breast cancer gene, while unaffected women were more uncertain about their future risk of cancer. The variety of informational needs identified has implications for how genetic counselors can tailor communication to individuals considering genetic testing.

Background A majority of surgical patients are prescribed opioids for pain management. Many patients have pre-existing chronic pain managed with opioids and/or opioid use disorders (OUDs), which can complicate perioperative management. Patients who use opioids prior to surgery are at increased risk of developing OUD after surgery. To date, no studies have examined the prevalence of opioid screening and electronic medical record (EMR) documentation prior to surgery. Materials and methods A 40-item survey was administered to 268 patients at their first postoperative care visit at a single tertiary academic center from October 2017 to July 2018. A chart review of a random sample of 100 patients was performed to determine provider opioid screening prevalence in the presurgical setting. Log-binomial models were used to calculate prevalence ratios (PRs) to determine the provider role (surgeon, advanced practice clinicians [APC], surgical trainee) association with opioid screening documentation. Exploratory qualitative interviews were conducted with surgical providers to identify barriers to screening and screening documentation. Results Only 7% of patients were screened preoperatively for opioid use. A total of 38% of patients self-reported that they had used opioids in the past year. Of that group, only 3% had screening by a surgical provider prior to surgery documented in their EMR. Provider role was not associated with likelihood of opioid screening (surgeon versus trainee, PR = 1.2, 95% CI 0.2-8.5) (surgeons versus APCs, PR = 1.05, 95% CI 0.17-8.53). EMRs were discordant with patient survey results for patients with no ICD-10 codes for opioid use. The most common perceived barriers to preoperative screening were insufficient clinic time; logistics of who should screen/not required as part of their clinical workflow; not perceiving screening as a priority; and lack of expertise in the area of chronic opioid use and OUD. Conclusions Preoperative screening for opioid use is uncommon, and EMRs are often discordant with patient self-reported use. Efforts to increase preoperative screening will need to address barriers screening practices and increasing health system support by incorporating screening into the clinical workflow and adding it to documentation templates.

OBJECTIVE The incidence of melanoma is increasing. Other than limiting UV exposure, few factors prevent or reduce the risk of melanoma. The aim of this study is to evaluate the relationship between vitamin D intake and melanoma risk in the Prostate, Lung, Colorectal, and Ovarian (PLCO) cancer screening trial. METHODS A secondary data analysis was performed on PLCO data. More than 1,300 participants developed melanoma. RESULTS Melanoma risk may be increased among men within the highest quartile of vitamin D intake (HR 1.27, 95% CI 0.99, 1.61). Women in the highest quartile of vitamin D intake had a decreased risk of invasive melanoma (HR 0.63, 95% CI 0.41, 0.96). Higher education and being white corresponded with deeper tumors (P < .001). CONCLUSION High reported vitamin D intake resulted in an increased risk of melanoma among men. Vitamin D intake yielded a protective effect against invasive melanoma in women.

BACKGROUND Patients with stage 1 systolic hypertension have increased risk of cardiovascular disease (CVD) events. METHODS Using Cox models, we assess the effect of targeting an intensive SBP goal of less than 120 mmHg compared with standard SBP goal of less than 140 mmHg on the risk of CVD events in adults with stage 1 systolic hypertension with diabetes mellitus enrolled in Action to Control Cardiovascular Risk in Diabetes Blood Pressure trial (ACCORD BP) (n = 1901) and without diabetes mellitus enrolled in Systolic Blood Pressure Intervention Trial (SPRINT) (n = 3484) that used identical SBP goal interventions. OUTCOMES In ACCORD BP, the primary composite CVD outcome was the first occurrence of myocardial infarction, stroke, or CVD mortality. In SPRINT, the primary composite CVD outcome was the first occurrence of myocardial infarction, other acute coronary syndrome, stroke, heart failure, or CVD mortality. RESULTS In SPRINT, targeting an intensive SBP goal significantly reduced the risk of the primary CVD outcome [hazard ratio 0.75 (95% confidence interval, 0.58-0.98); events 1.78 vs. 2.37%/year]. In ACCORD BP, the relationships of SBP goal with the primary CVD outcome was modified by the glycemia goal intervention (interaction P = 0.039). In the standard glycemia subgroup (A1c target 7-7.9%), intensive SBP goal significantly reduced the risk of the primary CVD outcome [hazard ratio 0.61 (0.40-0.94); events 1.63 vs. 2.56%/year]. In the intensive glycemia subgroup (A1c target

The University of Utah is a publicly funded, R1 university located in the United States, with a mission statement that includes recognition of its global role, asserting that “. . . we engage local and global communities to promote education, health, and quality of life.” As part of that engagement, the University of Utah has offered learning abroad opportunities since 1967. Approximately 1 in 10 students participates in a global learning experience, and 80% of programs are short term (defined as 10 weeks or less). The pedagogical theories that guide these short-term programs are experiential learning, authentic learning, and intentional targeted intervention. We describe three short-term learning abroad programs in public health and social work—for students at the high school, undergraduate, and graduate level—connecting the reported benefits to the pedagogical model and theories used to develop the specific curriculum for these short-term programs. Faculty use a variety of reflective tools to help students learn to function in their new setting (experiential learning); explore and meaningfully construct concepts and relationships as they address real-world problems (authentic learning); and facilitate intercultural growth (intentional targeted learning). The University of Utah has adapted a three-stage model for learning abroad that incorporates principles from these theories to drive program activities: Plan (predeparture), Learn (program participation), and Integrate (postprogram). Immediate benefits to students of participating in a global-learning experience include intercultural learning, personal, and career development. Benefits to faculty include scholarly products in the domains of education and service learning, community-engaged participation, and research.

Background Although maternal mortality has decreased substantially since the 1990s, it remains one of the top priorities in global health, as most deaths can be prevented if women have access to and utilise skilled health personnel for childbirth delivery. While efforts have been made to increase the supply and accessibility of services, the lack of maternal utilisation of skilled health delivery services is a contributing cause of death, particularly among mothers from rural areas. # Methods We conducted interviews in December 2019 in the Eastern Region of Ghana, with 24 rural mothers who had given birth within the past two years, 12 women who had and 12 women who had not given birth utilising skilled health personnel. # Results The main differences between women who did and did not use skilled health personnel for delivery were for Health Belief Model constructs of perceived risk, self-efficacy, and cues to action. Most women who delivered with skilled health personnel believed they were susceptible to complications during childbirth, reported high perceived self-efficacy to overcome barriers to deliver with skilled health personnel, and planned and prepared in advance to deliver with skilled health personnel. In contrast, women who did not deliver with skilled health personnel were less likely to believe in susceptibility to complications, reported low perceived self-efficacy to overcome barriers, and had not planned or prepared in advance for skilled health delivery. # Conclusions There were substantial differences between rural mothers who did and did not deliver with skilled health personnel regarding perceived susceptibility to experience complications, self-efficacy to overcome barriers and cues to action to prepare for birth.

BACKGROUND Acute gastrointestinal illnesses are of the most common problems evaluated by physicians, and some of the most preventable. There is evidence of GI pathogen transmission when people are in close contact. The COVID-19 pandemic led to the sudden implementation of wide spread social distancing measures in the United States. There is strong evidence that social distancing measures impact the spread of SARS-CoV-2, and a growing body of research indicates that these measures also decrease the transmission of other respiratory pathogens. OBJECTIVE To our knowledge, there are no peer-reviewed studies examining the impact of social distancing measures on the transmission of GI pathogens. This study aims to investigate the impact of COVID-19 social distancing mandates on the GI pathogen positivity rates. METHODS De-identified gastrointestinal panel PCR test results from a routinely collected diagnostic database from January 2019 through August 2020 were analyzed for positivity percentage. An interrupted time series was performed, using social distancing mandate issuance dates as the intervention date. Three target organisms were chosen for the final analysis to represent different primary transmission routes: adenovirus F40/41, norovirus GI/GII, and Escherichia coli O157. RESULTS In total, 84,223 total test results from nine states were included in the final dataset. With the exception of E. coli O157 in Kansas, Michigan and Nebraska, we observed an immediate decrease in positivity percentage during the week of social distancing mandates for all other targets and states. Norovirus GI/GII showed the most notable drop in positivity, while E. coli O157 appeared to be least impacted by social distancing mandates. While we acknowledge the analysis has a multiple testing problem, the majority of our significant results showed significance even at the 0.01 level. CONCLUSIONS This study aimed to investigate the impact of social distancing mandates meant for COVID-19 on GI pathogen positivity, and we discovered that social distancing measures did in fact decrease positivity initially. The use of similar measures may prove useful in GI pathogen outbreaks. The use of a unique diagnostic database in this study exhibits the potential for its use as a public health surveillance tool.

Background Acute gastrointestinal (GI) illnesses are of the most common problems evaluated by physicians and some of the most preventable. There is evidence of GI pathogen transmission when people are in close contact. The COVID-19 pandemic led to the sudden implementation of widespread social distancing measures in the United States. There is strong evidence that social distancing measures impact the spread of SARS-CoV-2, and a growing body of research indicates that these measures also decrease the transmission of other respiratory pathogens. Objective This study aims to investigate the impact of COVID-19 social distancing mandates on the GI pathogen positivity rates. Methods Deidentified GI Panel polymerase chain reaction test results from a routinely collected diagnostic database from January 1, 2019, through August 31, 2020, were analyzed for the GI pathogen positivity percentage. An interrupted time series analysis was performed, using social distancing mandate issue dates as the intervention date. The following 3 target organisms were chosen for the final analysis to represent different primary transmission routes: adenovirus F40 and 41, norovirus GI and GII, and Escherichia coli O157. Results In total, 84,223 test results from 9 states were included in the final data set. With the exception of E coli O157 in Kansas, Michigan, and Nebraska, we observed an immediate decrease in positivity percentage during the week of social distancing mandates for all other targets and states. Norovirus GI and GII showed the most notable drop in positivity, whereas E coli O157 appeared to be least impacted by social distancing mandates. Although we acknowledge the analysis has a multiple testing problem, the majority of our significant results showed significance even below the .01 level. Conclusions This study aimed to investigate the impact of social distancing mandates for COVID-19 on GI pathogen positivity, and we discovered that social distancing measures in fact decreased GI pathogen positivity initially. The use of similar measures may prove useful in GI pathogen outbreaks. The use of a unique diagnostic database in this study exhibits the potential for its use as a public health surveillance tool.

Although the protective role of dietary fiber on cancer risk has been reported in several epidemiological studies, the association of fiber intake on head and neck cancer (HNC) risk is still unclear. We investigated the association between fiber intake and the risk of HNC using data from the Prostate, Lung, Colorectal, and Ovarian (PLCO) cancer screening trial. Among 101,700 participants with complete dietary information, 186 participants developed HNC during follow-up (January 1998 to May 2011). Dietary data were collected using a self-administered food-frequency questionnaire (1998–2005). We estimated hazard ratios (HRs) and the corresponding 95% confidence intervals (CI), using the Cox proportional hazards model. Higher intake of total fiber, insoluble fiber and soluble fiber was associated with decreased HNC risks, with a significant trend. The HRs of highest versus the lowest tertile of intake were 0.43 (95%CI: 0.25–0.76) for total fiber, 0.38 (95%CI: 0.22–0.65) for insoluble fiber, and 0.44 (95%CI: 0.25–0.79) for soluble fiber. These inverse association were consistent in oral cavity and pharyngeal cases, but the impact of fiber intake was weaker in laryngeal cases. We did not observe any significant interaction of potential confounders, including smoking and drinking, with total fiber intake on HNC risk. These findings support evidence of a protective role of dietary fiber on HNC risk.

Chronic kidney disease is a strong risk factor for cardiovascular disease (CVD), but clinical kidney measures (estimated glomerular filtration rate and albuminuria) do not fully reflect the multiple aspects of kidney tubules influencing cardiovascular health. Applied methods are needed to integrate numerous tubule biomarkers into useful prognostic scores. In SPRINT (Systolic Blood Pressure Intervention Trial) participants with chronic kidney disease at baseline (estimated glomerular filtration rate cr&cys 2 ), we measured 8 biomarkers from urine (α1M [α1M microglobulin], β2M [β2M microglobulin], umod [uromodulin], KIM-1 [kidney injury molecule-1], MCP-1 [monocyte chemoattractant protein-1], YKL-40 [chitinase-3-like protein-1], NGAL [neutrophil gelatinase-associated lipocalin], and IL-18 [interleukin 18]) and 2 biomarkers from serum (intact parathyroid hormone, iFGF-23 [intact fibroblast growth factor-23]). We used an unsupervised method, exploratory factor analysis, to create summary scores of tubule health dimensions. Adjusted Cox models evaluated each tubule score with CVD events, heart failure, and all-cause mortality. We examined CVD discrimination using Harrell C-statistic. Factor analysis of 10 biomarkers from 2376 SPRINT-chronic kidney disease participants identified 4 unique dimensions of tubular health: tubule injury/repair (NGAL, IL-18, YKL-40), tubule injury/fibrosis (KIM-1, MCP-1), tubule reabsorption (α1M, β2M), and tubular reserve/mineral metabolism (umod, intact parathyroid hormone, iFGF-23). After adjustment for CVD risk factors, estimated glomerular filtration rate, and albumin-to-creatinine ratio, 2 of the 4 tubule scores were associated with CVD (hazard ratio per SD; reabsorption, 1.21 [1.06–1.38]; reserve, 1.24 (1.08–1.38]), 1 with heart failure (reserve, 1.41 [1.13–1.74]), and none with mortality. Compared with a base model (C-statistic=0.674), adding estimated glomerular filtration rate and albumin-to-creatinine ratio improved the C-statistic (C=0.704; P =0.001); further adding tubule scores additionally improved the C-statistic (C=0.719; P =0.009). In the setting of chronic kidney disease, dimensions of tubule health quantified using factor analysis improved CVD discrimination beyond contemporary kidney measures. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT01206062.

Case management is a standard practice for assisting people living with HIV in the United States. While HIV case management has resulted in positive outcomes for clients and their families, clients still face challenges. As part of an evaluation of Utah's Ryan White Part B Program, the Utah Department of Health and researchers from the University of Utah assessed the use of a tiered approach for case management in eight other states to determine the feasibility and potential effectiveness of this approach. Through review of publicly available materials and interviews with health department employees, we examined each state's 1) definitions of tiers, 2) acuity scales, 3) services provided within the tiers, 4) qualifications of case managers, and 5) how evaluations were conducted. This article summarizes how these various features might be combined to create a model that states could use for tiered case management. We developed a three-tiered model using a numeric summary for nine items to assess acuity, with levels defined as maintenance outreach support services, brief-contact management, and medical/non-medical management. Since none of the states reviewed had an existing formal evaluation tool, we propose areas to be covered in an annual formal evaluation.

Background Prescription opioid medications negatively affect postoperative outcomes after lumbar spine surgery. Furthermore, opioid-related overdose death rates in the United States increased by 200% between 2000 and 2014. Thus, alternatives are imperative. Mindfulness-based stress reduction (MBSR), a mind-body therapy, has been associated with improved activity and mood in opioid-using patients with chronic pain. This study assessed whether preoperative MBSR is an effective adjunct to standard postoperative care in adult patients undergoing lumbar spine surgery for degenerative disease. Methods The intervention group underwent a preoperative online MBSR course. The comparison group was matched retrospectively in a 1:1 ratio by age, sex, type of surgery, and preoperative opioid use. Prescription opioid use during hospital admission and at 30 days postoperatively were compared with preoperative use. Thirty-day postoperative patient-reported outcomes for pain, disability, and quality of life were compared with preoperative patient-reported outcomes. Dose-response effect of mindfulness courses was assessed using Mindful Attention Awareness Scale scores. Results In this pilot study, 24 participants were included in each group. Most intervention patients (70.83%) completed 1 session, and the mean Mindful Attention Awareness Scale score was 4.28 ± 0.71 during hospital admission. At 30 days, mean visual analog scale back pain score was lower in the intervention group (P = 0.004) but other patient-reported outcomes did not differ. Conclusions During hospital admission, no significant dose-response effect of mindfulness techniques was found. At 30 days postoperatively, MBSR use was associated with less back pain. Further research is needed to assess the effectiveness of preoperative MBSR on postoperative outcomes in lumbar spine surgery for degenerative disease.

Introduction Understanding the degree to which parents may influence healthy behaviors may provide opportunities to intervene among populations at increased risk of diseases, such as breast cancer. In this study, we examined the association between daughters' healthy eating habits and family lifestyle behaviors among girls and their families by using baseline data from the LEGACY (Lessons in Epidemiology and Genetics of Adult Cancer from Youth) Girls Study. Our objective was to examine the relationship between daughters' healthy eating and family lifestyle behaviors and to compare these associations between families with and without a history of breast cancer. Methods We examined demographic and lifestyle data from a cohort of 1,040 girls aged 6 to 13 years from year 1 (2011) of the LEGACY study. Half had a family history of breast cancer (BCFH). We used mixed-effects linear regression to assess the influence of the mother and father's physical activity, family relationship scores, the mother's diet, the family's income, and the daughter's sports participation, age, body mass index (BMI), and race/ethnicity on the daughter's Healthy Eating Index (HEI) score. Results Daughters' healthy eating was significantly correlated with the mother's diet (r[668] = 0.25, P = .003) and physical activity (r[970] = 0.12, P = .002), the father's physical activity (r[970] = 0.08, P = .01), and the family income (r[854] = 0.13, P = .006). Additionally, the mother's diet (β coefficient = 0.71, 95% CI, 0.46-0.88, P = .005) and family income (β coefficient = 3.28, 95% CI, 0.79-5.78, P = .002) significantly predicted a daughter's healthy eating. Analyses separated by family history status revealed differences in these associations. In families without a history of breast cancer, only the mother's diet (β coefficient = 0.62; 95% CI, 0.29-0.95; P = .001) significantly predicted the daughter's healthy eating. In families with a history of breast cancer, the mother's diet (β coefficient = 0.73, 95% CI, 0.42-1.03, P = .006) and family income (β coefficient = 6.24; 95% CI, 2.68-9.80; P = .004) significantly predicted a daughter's healthy eating. Conclusion A mother's diet and family income are related to the daughter's healthy eating habits, although differences exist among families by family history of breast cancer.

Background Breast cancer is the leading cause of cancer death among Hispanic women. The aim of our study was to estimate cardiovascular disease (CVD) risk among Hispanic and non-Hispanic White (NHW) breast cancer survivors compared with their respective general population cohorts. Methods Cohorts of 17 469 breast cancer survivors (1774 Hispanic and 15 695 NHW) in the Utah Cancer Registry diagnosed between 1997 and 2016, and 65 866 women (6209 Hispanic and 59 657 NHW) from the general population in the Utah Population Database were identified. Cox proportional hazards models were used to estimate hazard ratios (HRs) for CVD. Results The risk of diseases of the circulatory system was higher in Hispanic than NHW breast cancer survivors 1-5 years after cancer diagnosis, in comparison with their respective general population cohorts (HRHispanic = 1.94, 99% confidence interval [CI] = 1.49 to 2.53; HNHW = 1.38, 99% CI = 1.33 to 1.43; 2-sided Pheterogeneity = .01, respectively). Increased risks were observed for both Hispanic and NHW breast cancer survivors for diseases of the heart and the veins and lymphatics, compared with the general population cohorts. More than 5 years after cancer diagnosis, elevated risk of diseases of the veins and lymphatics persisted in both ethnicities. The CVD risk due to chemotherapy and hormone therapy was higher in Hispanic than NHW breast cancer survivors but did not differ for distant stage, higher baseline comorbidities, or baseline smoking. Conclusions We observed a risk difference for diseases of the circulatory system between Hispanic and NHW breast cancer survivors compared with their respective general population cohorts but only within the first 5 years of cancer diagnosis.

Over the past 15 years, right-wing nationalist populist language and ideals have come to the forefront of political and social discussions in the US. The purpose of this type of populism in the US is to increase divisions in the population in such a way that certain groups of people in the general population (i.e. Protestant and white), are valued more than others, such as newly arrived refugees and/or immigrants. This chapter explores the impact of US right-wing nationalist populism on refugee resettlement and the process of integration for newly arrived groups. The role of social work in advocating for support of refugees is examined.

Ultraviolet radiation (UVR) exposure is a primary risk factor for the development of melanoma. However, adults and adolescents often do not engage in preventive behaviors to reduce UVR exposure. Rural residents may be at higher risk for melanoma due to lower use of sun protection strategies, which increases their overall UVR exposure compared to those who live in urban areas. The purpose of this study was to evaluate differences in UVR exposure between rural and urban residents in a geographic area with high incidence of melanoma. Children (aged 8-17 years) and adults (≥18 years) from rural and urban areas of Utah were asked to wear a UVR monitoring device for 14 days. The sample included 97 children and 97 adults. Data was collected from June to October 2018. Non-parametric Mann-Whitney tests and quantile regression were used to compare UVR exposure levels between urban and rural participants, separately for adults and children. For adults, rural residence significantly increased total UVR dose ( β: 24.6; 95% CI: 3.75, 42.74) and the UVR dose during peak UVR hours among participants with the highest UVR doses (β: 16.3; 95% CI: 17.4, 24.63). Rural children exhibited significantly higher UVR doses for peak UVR hours for the entire study period (β: 4.14; 95% CI: 0.83, 7.46) and on weekdays (β: 0.39; 95% CI: 0.05, 0.73). The findings from this study indicate that rural residents may receive higher levels of UVR exposure than urban residents, and that prevention efforts could be tailored to address these geographical differences.

Background Patients living in rural communities and patients with a cancer diagnosis are two areas potentially overlooked in opioid prescribing clinical decision making that may relate to the amount of overprescribed opioids in the postsurgical environment.Methods A 35-item questionnaire was administered to surgeons, residents/ fellows (trainees), and advanced practice clinicians (APCs). Descriptive statistics were generated.Results Surgeons, trainees, and APCs self-reported that they give the same amount of opioids to rural patients as other patients. APCs were more likely to agree that it is easy to e-prescribe (56%) than surgeons (41%) and trainees (35%), so rural patients do not need different consideration. Surgeons (50%) and trainees (50%) agreed compared to APCs (0%) that it is easier to give more opioids so a patient does not have get refills if needed for pain. Compared to APCs (5%), 21% of surgeons and 45% of trainees acknowledged giving more opioid narcotics to patients with cancer than patients without a cancer diagnosis.Conclusions While both groups of prescribing providers reported that they gave the same amount of opioids to rural patients, they differed in their knowledge about e-prescribing and what healthcare access disparities may exist for the rural patient. No differences were reported between provider groups for cancer patients. Responses indicate an opportunity to work with providers to identify potential solutions for improving opioid prescribing practices in rural and cancer patients.

Background We previously reported inpatient and 30-day postoperative patient-reported outcomes (PROs) of a controlled, noncrossover pilot study using preoperative mindfulness-based stress reduction (MBSR) training for lumbar spine surgery. Our goal here was to assess 3-month and 12-month postoperative PROs of preoperative MBSR in lumbar spine surgery for degenerative disease. Methods Intervention group participants were prospectively enrolled in a preoperative online MBSR course. A comparison standard care only group was one-to-one matched retrospectively by age, sex, surgery type, and prescription opioid use. Three-month and 12-month postoperative PROs for pain, disability, quality of life, and opioid use were compared within and between groups. Regression models were used to assess whether MBSR use predicted outcomes. Results Twenty-four participants were included in each group. At 3 months, follow-up was 87.5% and 95.8% in the comparison and intervention groups, respectively. In the intervention group, mean Patient-Reported Outcomes Measurement Information System–Physical Function (PROMIS-PF) was significantly higher, whereas mean Patient-Reported Outcomes Measurement Information System–Pain Interference (PROMIS-PI) and Oswestry Disability Index were significantly lower. The change from baseline in mean PROMIS-PF and PROMIS-PI was significantly greater than in the comparison group. At 12 months, follow-up was 58.3% and 83.3% in the comparison and intervention groups, respectively. In the intervention group, mean PROMIS-PI was significantly lower and change in mean PROMIS-PI from baseline was significantly greater. MBSR use was a significant predictor of change in PROMIS-PF at 3 months and in PROMIS-PI at 12 months. No adverse events were reported. Conclusions Three-month and 12-month results suggest that preoperative MBSR may have pain control benefits in lumbar spine surgery.

Background: Very few studies have investigated cardiovascular disease (CVD) risk among ovarian cancer survivors in a population-based study. We aimed to estimate CVD risk among ovarian cancer survivors compared to women from the general population in a population-based study. Methods: A cohort of 1,271 patients with ovarian cancer diagnosed from 1996 to 2012 in the Utah Cancer Registry and 5,289 age-matched women from the general population in the Utah Population Database was identified. CVD outcomes were available in electronic medical records and statewide healthcare facilities data. Cox Proportional Hazards models were used to estimate hazard ratios (HRs) for CVD at 1-5 years and >5 years after the index date. Findings: Increased risks were observed 1-5 years after cancer diagnosis for ovarian cancer survivors in comparison with the general population for hypertension (HR=1·14, 95% CI, 1·01-1·29), cerebrovascular disease (HR=1·42, 95% CI, 1·06-1·89), and diseases of the heart (HR=1·81, 95% CI, 1·60-2·04), the arteries (HR=1·97, 95% CI, 1·67-2·33), and the veins and lymphatics (HR=2·75, 95% CI, 2·36-3·22). Elevated risks were still observed for diseases of the arteries (HR=1·31, 95% CI, 1·06-1·61) and the veins and lymphatics (HR=1·80, 95% CI, 1·48-2·18) >5 years after cancer diagnosis. Interpretation: Ovarian cancer survivors had higher risks of several CVD outcomes compared with women from the general population. The results support the consideration of monitoring and/or initiation of primary prevention for CVD outcomes among ovarian cancer survivors. Funding: This work was supported by a grant from the NCI (R21 CA185811), the Marian Bishop Award from the Department of Family and Preventive Medicine at the University of Utah and the NCRR grant, “Sharing Statewide Health Data for Genetic Research” (R01 RR021746, G. Mineau, PI) with additional support from the Utah State Department of Health and the University of Utah. Declaration of Interests: None reported. Ethics Approval Statement: We obtained approval from the University of Utah’s Resource for Genetic and Epidemiologic Research (UPDB oversight committee) and the University of Utah Institutional Review Board.

Intensive systolic blood pressure (SBP) control improved outcomes in SPRINT (Systolic Blood Pressure Intervention Trial). Our objective was to expand on reported findings by analysis of baseline characteristics, primary outcomes, adverse events, follow-up blood pressure, and medication use differences by baseline SBP (tertile 1 [T1], 145 mm Hg). Participants with higher baseline SBP tertile were more often women and older, had higher cardiovascular risk, and lower utilization of antihypertensive medications, statins, and aspirin. Achieved SBP in both treatment arms was slightly higher in T2 and T3 compared with T1 and fewer in the T3 groups achieved SBP targets compared with T1 and T2 groups. The primary composite outcome with intensive versus standard SBP treatment was reduced by 30% in T1, 23% in T2, and 17% in T3 with no evidence of an interaction ( P =0.77). Event rates were lower in the intensive arm, and there was no evidence that this benefit differed by SBP tertile. There was no difference in the hazard for serious adverse events in any of the 3 tertiles. Medication utilization differed across the SBP tertiles at baseline with a lesser percentage of diuretics and angiotensin-converting enzyme inhibitors/angiotensin receptor blocker drugs in the higher tertiles—a finding that reversed during the trial. The beneficial effects of intensive SBP lowering were not modified by the level of baseline SBP. Within the parameters of this population, these findings add support for clinicians to treat blood pressure to goal irrespective of baseline SBP.

Background and Objectives: We sought to develop and validate a self-assessment of foundational leadership skills for early-career physicians. Methods: We developed a leadership self-assessment from a compilation of materials on health care leadership skills. A sequential exploratory study was conducted using qualitative and quantitative analysis for face, content, and construct validity of the self-assessment. First, two focus groups were conducted with leaders in medicine and family medicine residents, to refine the pilot self-assessment. The self-assessment pilot was then tested with family medicine residents across the country, and the results were quantitatively evaluated with principal component analysis. This data was used to reduce and group the statements into leadership domains for the final self-assessment. Results: Twenty-two invited family medicine residency programs agreed to distribute the survey. A total of 163 family medicine residents completed the survey, representing 16 to 20 residency programs from 12 states (response rate 28.9% to 34.8%). Analysis showed important differences by residency year, with more advanced residents scoring higher. The analysis reduced the number of items from 33 on the pilot assessment to 21 on the final assessment, which the authors titled the Foundational Healthcare Leadership Self-assessment (FHLS). The 21 items were grouped into five leadership domains: accountability, collaboration, communication, team management, and self-management. Conclusions: The FHLS is a validated 21-item self-assessment of foundational leadership skills for early career physicians. It takes less than 5 minutes to complete, and quantifies skill within five domains of foundational leadership. The FHLS is a first step in developing educational and evaluative assessments for training medical residents as clinician leaders.

Background: Young adult cancer caregivers (YACC) may experience heightened caregiver burden because they take on caregiving during a dynamic time of life. The purpose of this study was to describe YACC experiences, burden, and social support while caregiving. Methods: Grounded by the Cancer Family Caregiving Experience Model and the Stress and Coping Social Support theory, semi-structured interviews were conducted with YACC. Inductive analysis was applied to YACC perceptions of caregiving, and deductive analysis to YACC social networks and social support. Results: YACC (N=34) were primarily between 25 to 29 years of age (38.2%), primarily female (70.6%), non-Hispanic White (91.2%), employed (85.3%), college graduates or higher (53.0%), and caring for a spouse/partner (52.9%). Qualitative analysis of interviews with YACC resulted in 2 themes: cancer caregiving during young adulthood and young adult cancer caregiver social support. In the first theme YACC often did not perceive themselves as caregivers, rather their caregiving responsibilities were viewed as an extension of their relationship with the patient. Further YACC reported developmental-specific responsibilities (eg, caring for young children, being unable to take time off while solidifying careers) which often conflicted with their caregiving responsibilities (eg, managing patient’s medication, attending appointments) and heightened burden. In response, YACC often formed caregiver teams consisting of family, friends, and community members to care for their loved one. In the second theme YACC most commonly reported receiving emotional and instrumental support from their social network. YACC specifically mentioned their appreciation for emotional support provided by other young adults and instrumental support in the form of financial support. Conclusions: YACC faced developmentally specific challenges during caregiving that older adult caregivers may not encounter. The conflict of young adult and caregiving responsibilities resulted in YACC forming caregiver teams. Thus, theoretical approaches to understand and improve caregiver health would benefit from the inclusion of the developmental context of young adulthood. Furthermore, it is crucial that cancer centers tailor supportive services to YACC as the number of young caregivers increases.

Background: Although low levels of folate leads to disturbances in DNA replication, DNA methylation and DNA repair, the association between dietary folate intake and head and neck cancer (HNC) risk remains unclear. Methods: We evaluated the association between folate intake and HNC risk using prospective cohort data from the Prostate, Lung, Colorectal, and Ovarian (PLCO) cancer screening trial. This study included 101 700 participants and 186 cases with confirmed incident HNC. The median follow-up was 12.5 years. We estimated hazard ratios (HRs) and the corresponding 95% confidence intervals (CIs) using Cox proportional hazard model including age, sex, body mass index, education, race, tobacco smoking, alcohol drinking and total fruit and vegetable intake. Results: Higher intake of food folate and fortified folic acid in foods was associated with a decreasing HNC risk in a dose–response manner. The HRs of highest vs the lowest quartile of intake were 0.35 (95%CI: 0.18–0.67) for food folate, and 0.49 (95%CI: 0.30–0.82) for fortified folic acid. Intakes of total folate, natural folate and supplemental folic acid were not associated with the risk of HNC and its subsites. We did not detect any interaction between smoking, drinking and food folate intake on HNC risk. Conclusions: These findings provide evidence of the protective role of dietary folate intake on HNC risk.

Objective: The objective of this study was to understand adolescent girls’ experiences using practical diet and physical activity measurement tools and to explore the food and physical activity settings that influence their lifestyle habits. Design: Mixed methods study using quantitative and qualitative methods. Setting: Large city in the western USA. Participants were recruited from a larger study of girls and families. Methods: A total of 10 girls aged 13–17 years completed a 3-day food diary, a Food Frequency Questionnaire and wore a Fitbit wrist bracelet to measure physical activity for 30 days. Following the data collection period, a structured focus group using a phenomenological approach was held to understand girls’ experiences with the collection tools and to understand the internal and external environments in which they make eating and physical activity decisions. Results: Participants completed an average of 8,459 steps/day. Girls had an average Healthy Eating Index score of 37 (out of 100), with diets being particularly high in added sugars and low in nutrients found in fruits and vegetables. Girls perceived the 3-day food diaries and the Fitbit as representing their lives accurately, and had negative perceptions of the Food Frequency Questionnaire. Finally, girls described influences on their lifestyle behaviours, including boredom, summer-break, part-time work, availability and cost. Conclusion: This study demonstrates the efficacy and willingness of girls to utilise food diaries and activity trackers. Results confirm poor dietary intake and physical activity in this population, and describe influences on lifestyle behaviours unique to adolescent girls.

Objective. This study investigated the association between the presence of a mental health condition (MHC) diagnosis and glycemic control in patients with type 2 diabetes in a primary care clinic network. Methods. This retrospective cross-sectional study compared adequate glycemic control (A1C Results. Of 3,025 patients with type 2 diabetes, 721 (24%) had a diagnosis for one or more MHC. The majority (54.9%) were Conclusion. Patients with diabetes and MHCs had slightly better glycemic control than those without any MHC. However, the presence of substance use disorder may present more barriers to adequate glycemic control. Additional research is needed to identify barriers unique to each MHC to optimize diabetes management in this population.

OBJECTIVE To evaluate the short-term effectiveness of the Intermountain Healthcare (IH) Diabetes Prevention Program (DPP) for patients with prediabetes (preDM) deployed within primary care clinics. STUDY DESIGN A quasi-experimental study design was used to deploy the DPP within the IH system to identify patients with preDM and target a primary goal of a 5% weight loss within 6-12 months of enrollment. STUDY POPULATION Adults (aged 18-75 years) who met the American Diabetes Association criteria for preDM were included for study. Patients who attended DPP counseling between August 2013 and July 2014 were considered as the intervention (or DPP) group. The DPP group was matched using propensity scores at a 1:4 ratio with a control group of patients with preDM who did not participate in DPP. RESULTS Of the 17,142 patients who met the inclusion criteria for preDM, 40% had an in-person office visit with their provider. On average, patients were 58 years old, and greater than 60% were women. Based on multivariate logistic regression, the DPP group was more likely to achieve a 5% weight loss within 6-12 months after enrollment (OR = 1.70; 95% CI = 1.29-2.25; p < .001) when compared with the no-DPP group. CONCLUSIONS Diabetes Prevention Program-based lifestyle interventions demonstrated significant reduction in body weight and incident Type 2 diabetes mellitus when compared with nonenrollees.

Background: Federal agencies have encouraged the use of central institutional review boards (CIRBs) for multi-site clinical trials. There is limited evidence supporting the use of CIRBs. Our aim is to evaluate how SPRINT sites regulated by CIRBs performed regarding informed consent readability and participant trial adherence compared to those regulated by local IRBs. Methods: We conducted a cohort study using the SPRINT clinical trial. We collected the IRB of record from the stamped and approved 2012 informed consents from each of the sites. We defined CIRB as an IRB for more than one SPRINT site. Our outcomes were informed consent readability measured using the Flesch-Kincaid readability scale and trial adherence defined as a loss to follow-up, consent withdrawal, and missed last 3-month visit. Results: Sixty-one percent of all SPRINT sites used a CIRB as their IRB of record. The adjusted mean grade reading level for CIRB consents was 13.4 (95% CI 12.6–13.8) compared to 12.3 (95% CI 12.1–13.1) for non CIRB consents (p = 0.07). CIRB sites had similar rates of withdrawal of consent and loss to follow-up as non-CIRB sites; subjects missing the last appointment of the study were more likely to come from sites regulated by a CIRB. The Veterans Affairs CIRB had the lowest rate of withdrawal of consent (1.9%) and the lowest rate of missed appointments (1.9%) among CIRBs. Conclusions: Niether CIRB-regulated sites nor IRB regulated sites enforce the recommended readability level of the informed consent documents. Sites regulated by both IRBs had similar participant trial adherence. Keywords: Institutional review board, Informed consent, Trial adherence

Background Despite the high burden of pneumococcal disease, pneumococcal vaccine coverage continues to fall short of Healthy People 2020 goals. A quasi-experimental design was used to investigate the impact of pneumococcal-specific best-practice alerts (BPAs) with and without workflow redesign compared to health maintenance notifications only, on pneumococcal vaccination rates in at-risk and high-risk adults, and on series completion in immunocompetent adults aged 65+ years. Methods This retrospective study used electronic health record and administrative data to identify pneumococcal vaccinations using cross sectional and historical cohorts of adults age 19+ years from 2013 to 2017 who attended clinics associated with the University of Utah Health. Difference-in-differences (DD) analyses was used to assess the impact of interventions across three observation periods (Baseline, Interim, and Follow Up). Adherence to the 2-dose vaccination schedule in older adults was measured through a longitudinal analysis. Results In DD analyses, implementing both workflow redesign and the BPA raised the vaccination rate by 8 percentage points (pp) (P

Introduction: Hospitals are in a unique position to promote, protect, and support breastfeeding. However, the association between in-hospital events and breastfeeding success within population-based samples has not been well studied. Materials and Methods: A stratified (by education and birth weight) systematic sample of 5,770 mothers taking part in the Utah Pregnancy Risk Assessment Monitoring System, 2012–2015, were included. Mothers, 2–4 months postpartum, completed the 82-item questionnaire, including if they had ever breastfed their new baby, and if so, current breastfeeding status. Relationships between in-hospital experiences and breastfeeding termination and duration were evaluated via Poisson and Cox proportional hazard regression models, respectively, adjusting for other in-hospital experiences, maternal age, race/ethnicity, maternal education, marital status, smoking, physical activity, delivery method, pregnancy complications, and length of hospital stay. Results: Of all, 94.4% of mothers self-reported breastfeeding initiation, of whom 18.8% had breastfed

Introduction: While chronic kidney disease (CKD) is a strong risk factor for cardiovascular disease (CVD), traditional metrics of kidney function (eGFR and albuminuria) have not improved CVD risk prediction equations. We hypothesize that new measures of kidney tubular function and injury can improve CVD risk prediction. Methods: Of 1971 SPRINT participants with eGFR 2 and without CVD at baseline, we analyzed 1858 with urine and serum biomarkers. We conducted factor analysis on 10 kidney tubule biomarkers using principal-component factor estimation and promax rotation. To examine the association between the factor scores and risk of subsequent cardiovascular events, we used adjusted Cox models. Using Harrell’s C-statistic, we compared a standard CVD risk prediction model to models adding 1) factor scores of kidney tubular health, 2) eGFR and albumin-to-creatinine ratio (ACR), and 3) factor scores, eGFR and ACR. We also conducted these comparisons using ASCVD predicted risk in place of CVD risk factors among those Results: Mean age was 73, 44% female, 29% black, and mean±SD eGFR was 45±12 mL/min/1.73m 2 . Factor analysis identified 4 unique dimensions of kidney tubular health that correspond to hypothesized physiologic processes ( Table ). Three of four factors were associated with CVD in demographic models, and Factors 3 and 4 remained associated in the full model. The C-statistic of the base CVD risk equation was 0.670, and with inclusion of the four kidney tubule factors the C-statistic improved to 0.727 (p for difference Conclusion: Indices of kidney tubular health based on urine and serum biomarkers may improve CVD risk prediction in adults with hypertensive CKD. Further studies are needed in the general, non-CKD population.

In a study of dietary supplementation among women in Ghana, a disproportionately high number of pregnant study participants were found to no longer be pregnant, leading researchers to suspect that the very early identification of pregnancy status made possible by study participation may have contributed to an elevated incidence of elective abortion among study participants. While abortion is legal in Ghana under certain circumstances, misinformation regarding its legality and persistent stigmatization result in many Ghanaian women choosing abortion methods that are unsafe and often illegal. While the study of the potential benefits of dietary supplementation during pregnancy initially appeared to pose very little risk to participants, the unintended and unforeseen consequence of unsafe abortions required researchers to reevaluate study protocol. In the following discussion of this case, we explore the ethical considerations researchers must address when unintended consequences emerge in global health research.

Background:Few have examined predictive relationships between physical activity (PA) and health using electronic health records (EHRs) of patient-reported PA.Objective:Assess initial predictive validity of the Physical Activity “Vital Sign” (PAVS) recorded in EHRs with BMI and disease burden.Methods:EHRs were from November 2011 to November 2013 (n = 34,712). Differences in not meeting Physical Activity Guidelines (PAG) were tested using chi-square analysis between being normal weight versus overweight/obese, and scoring below versus above the 50th percentile of the Charlson Comorbidity Index (CCI). Repeated measures logistic regression was used to determine odds of BMI and CCI classifications according to responses to the PAVS as not meeting PAG.Results:Patients who did not meet PAG according to the PAVS were more likely than normal weight patients to have a higher BMI (BMI 25.0–29.9, OR = 1.19, P = .001; BMI 30.0–34.9, OR = 1.39, P < .0001; BMI 35.0–39.9, OR = 2.42, P < .0001; BMI ≥ 40, OR = 3.7, P < .0001) and also higher disease burden (above 50th percentile for CCI, OR = 1.8, P < .0001).Conclusions:The strong association of the PAVS found with patient BMI and moderately-strong association with disease burden supports initial predictive validity of the PAVS recorded in EHRs. PA recorded in EHRs may be vastly useful for assessing patient disease and cost burdens attributed independently to PA behavior.