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Background A cancer diagnosis may lead to existential despair but potentially also to perceived inner growth. This growth may be fostered through meaningful connections with others. We sought to describe existential and related psychosocial outcomes and their association with a sense of connection with others in individuals with gynecological and breast cancers. Methods We used cross-sectional data from two ongoing cohort studies of gynecologic (N = 236) and breast (N = 62) cancer survivors at the University of Minnesota. We summarized self-reported post-traumatic growth (PTG), sense of meaning, peace, spirituality, hopelessness, loneliness, and three exploratory measures of sense of connections with others, and used multivariate linear regression models to describe the associations between them. Results Hope, sense of meaning, peace, and spirituality were generally high among participants, but PTG and loneliness scores varied more. Sense of connection with others was consistently associated with greater PTG and decreased loneliness with medium effect sizes: for example having positive interactions with most/all versus nobody on one’s medical team, PTG (coefficient 10.49, 95% CI: 4.10, 16.87, Cohen’s D 0.44); loneliness (coefficient − 0.85, 95% CI: − 1.36, − 0.34, Cohen’s D 0.43). Those who knew someone in a similar life situation felt a strong sense of connection with such a person; however, 28% of participants had not met anyone in a similar situation. Conclusions There may be untapped opportunities to nurture beneficial existential outcomes in cancer survivors. Potential interventions include connecting survivors with one another and creating opportunities for more authentic patient-provider relationships, for example, within palliative care. Supplementary Information The online version contains supplementary material available at 10.1007/s00520-021-06784-8.

To describe fear of cancer recurrence in a cohort of women with gynecologic cancers and to identify psychosocial predictors of elevated fear of recurrence.Survey data from an ongoing cohort study of gynecologic cancer survivors were used (n = 154). Relationships between fear of cancer recurrence measured by the 6-item Cancer Worry Scale in the most recent survey and psychosocial factors (cancer-related distress, depression, anxiety, hopelessness, and posttraumatic growth) assessed 6-18 months prior were examined using univariate and multivariate linear regression models, adjusting for age, cancer stage, cancer type, and time since diagnosis.Most participants were ≥60 years old, diagnosed with early-stage cancer, and 2-5 years post-diagnosis. The mean score on the Cancer Worry Scale was 10.31 (SD = 3.01), and 46 individuals (30.0%) scored ≥12, indicating high fear of recurrence. In univariate analyses, greater distress (p = 0.007), anxiety (p = 0.006), hopelessness (p = 0.007), and posttraumatic growth (p = 0.0006) were significantly associated with higher scores on the Cancer Worry Scale. The associations of hopelessness and posttraumatic growth with higher Cancer Worry Scale scores remained significant after adjustment for covariates.Fear of recurrence is frequent among gynecologic cancer survivors. Women who reported more distress, hopelessness, anxiety and, surprisingly, more post-traumatic growth reported more fear. These results contribute to our understanding of which cancer survivors are most at risk of elevated fear of recurrence and highlight the importance of continued focus on psychosocial well-being among cancer survivors.

Introduction Cardiovascular risk factors in midlife have been linked to late life risk for Alzheimer's disease and related dementias (ADRD). The relation of vascular risk factors on cognitive decline within midlife has been less studied. Methods Using data from the Study of Women's Health Across the Nation, we examined associations of midlife hypertension, elevated lipid levels, diabetes, fasting glucose, central adiposity, and Framingham heart age with rates of cognitive decline in women who completed multiple cognitive assessments of processing speed, and working and verbal memory during midlife. Results Diabetes, elevated fasting glucose, central obesity, and heart age greater than chronological age were associated with rate of decline in processing speed during midlife. Vascular risk factors were not related to rate of decline in working or verbal memory. Discussion Midlife may be a critical period for intervening on cardiovascular risk factors to prevent or delay later life cognitive impairment and ADRD.

Objective To assess self-reported emotional health in a cohort of women with early stage gynecologic cancers and to explore differences based on primary cancer type. Methods We analyzed survey data from a cohort study of gynecological cancer patients treated at an academic cancer center. Measures of emotional health included cancer-related quality of life, distress, depression, anxiety, posttraumatic stress disorder (PTSD), and posttraumatic growth. Univariate and multivariate linear regression models examined differences in emotional health measures by primary cancer site. Potential confounders considered for inclusion in the final models were age, stage, education, income, partner status, treatment status, and race. Results 242 patients with early stage disease completed the survey. Patients with cervical and vaginal/vulvar cancers reported greater cancer-related distress, anxiety and PTSD symptoms. Patients with endometrial cancer reported the lowest posttraumatic growth scores, which remained statistically significant after adjustment for demographic and clinical differences. No significant differences in cancer-related quality of life were observed among individuals with different primary cancer sites Conclusions These data suggest patients with early-stage gynecologic cancer face different psychosocial sequelae based on primary cancer site, though underlying clinical and sociodemographic factors may play a significant role in this observed relationship. Further research is needed to assess poorer emotional health among individuals with vaginal/vulvar cancers and the lower posttraumatic growth among patients with endometrial cancer as posttraumatic growth is considered a potentially beneficial psychosocial outcome of cancer.

Women remain underrepresented in key leadership positions and advanced ranks in academic medicine. This study examines the numbers of men and women letter writers for promotion candidates during a 5-year period across departments, tracks, ranks, and candidate gender.A descriptive study characterized the gender of evaluation letter writers for candidates for promotion to associate or full professor at the University of Minnesota Medical School between 2015 and 2020. Letter writer and candidate gender were characterized by self-identified pronouns in the faculty biography or dossier. Letter writer gender was described by candidate department, promotion track, rank, terminal degree, and gender.Among 299 candidates for promotion, 172 (58%) were men and 127 (42%) were women; dossiers included 3,995 evaluation letters. Across all years, men wrote more letters than women (external letters, range, 69% in 2019-2020 to 75% in 2015-2016; internal letters, range, 67% in 2018-2019 to 77% in 2015-2016). Candidates in the family medicine and pediatrics departments had the highest percentages of letters written by women (44% and 40%, respectively). No differences were found in the number of women letter writers by candidate promotion track; however, differences were found by candidate rank (associate professor, 30%; full professor, 23%) and terminal degree (MD/DO, 25%; PhD, 33%; MD-PhD, 20%). Regardless of candidate gender, most evaluation letters were written by men. Women candidates had 15% to 20% more letters authored by women than men candidates (34%-40% vs 18%-23%).The gender pattern of letter writers may reflect implicit biases regarding gender and perceived leadership status, expertise, and success. Adopting policies that promote or require gender diversity among letter writers for promotion candidates may provide an opportunity to encourage faculty to seek diverse networks and recognize the achievements of women faculty.

PURPOSE: The Distress Thermometer (DT) includes a measure of cancer-related distress and a list of self-reported problems. This study evaluated the utility of the DT problem list in identifying concerns most associated with distress and poorer quality of life (QOL) in survivors of gynecologic cancer. METHODS: Demographic, clinical, psychosocial functioning, and DT data were described among 355 women participating in a gynecologic cancer cohort. Problems from the DT list were ranked by prevalence, distress, and QOL. Logistic regression models explored factors associated with problems that were common (≥ 25% prevalence) and associated with distress and QOL. RESULTS: The average age of participants was 59.9 years (standard deviation [SD], 10.8 years). Most participants were non-Hispanic white (97%) and had ovarian (44%) or uterine (42%) cancer. The mean DT score was 2.7 (SD, 2.7); participants reported a mean of 7.3 problems (SD, 5.9 problems). The most common problems were fatigue (53.6%), worry (49.9%), and tingling (46.3%); least common problems were childcare (2.1%), fevers (2.1%), and substance abuse (1.1%). Report of some common problems, including tingling, sleep, memory, skin issues, and appearance, was not associated with large differences in distress or QOL. In contrast, some rarer problems such as childcare, treatment decisions, eating, housing, nausea, and bathing/dressing were associated with worse distress or QOL. Younger age, lower income, and chemotherapy were risk factors across common problems that were associated with worse distress or QOL (fatigue, nervousness, sadness, fears, and pain). CONCLUSION: The DT problem list did not easily identify concerns most associated with distress and low QOL in patients with gynecologic cancer. Adaptations that enable patients to report their most distressing concerns would enhance clinical utility of this commonly used tool.

Introduction Research is increasingly exploring interventions for patient-care-partner dyads, but little has been reported regarding challenges of implementing dyad-focused interventions. This article reports the lessons learned in a pilot feasibility study of problem-solving therapy versus stroke education in stroke survivor-care partner dyads. Challenges and lessons learned Challenges arose in numerous aspects of intervention delivery. These ranged from personalizing the intervention to meet individual needs and balancing participation between dyad members to maintaining focus, managing conflict, and addressing ethical concerns, all of which required attention from the nurse researcher. These anticipated and unanticipated challenges were addressed using a variety of solutions, including engagement, active listening, redirection, and structured adaptation. Implications for practice The knowledge gained and lessons learned in this study may be applied to other patient-care-partner dyads and other behavioral therapies. Nurses may also identify opportunities to increase inclusion of care partners in other interventions. Awareness of these challenges may lead to greater success in working with dyads. Conclusions Dyad-focused behavioral interventions hold promise for use with stroke survivors and their care partners. They also present unique implementation challenges compared with survivor-only interventions.

Background: Limited health literacy (HL) is associated with individual cardiovascular risk factors and poor risk factor control. The association of HL to composite indices of cardiovascular health (CVH) has not been documented. Hypothesis: Limited HL is associated with suboptimal achievement of ideal CVH as identified by Life’s Simple 7 (LS7). Methods: Included in this analysis are 3766 participants of the Multi-Ethnic Study of Atherosclerosis who completed four HL questionnaire items via follow-up phone calls (2016-2018). Item scores were summed and dichotomized into adequate (≤10) or limited HL (>10). Clinical measures of BMI, total cholesterol, blood pressure, and fasting blood glucose, along with self-reported smoking status, physical activity, and healthy diet were measured at baseline (2000-2002) and categorized by LS7 achievement criteria (poor, inadequate, ideal). LS7 metrics were incorporated into overall CVH (low, medium, high). Poisson regression with robust variance estimation was used to compute prevalence risk ratios and 95% confidence intervals (PRR[95% CI]) of high/medium CVH as well as intermediate/ideal LS7 comparing limited HL to adequate HL. Results: Participants were on average(SD) 59.4(9.13) years old at baseline, 46.0% male, and 58.0% non-white. Prevalence of limited HL was 15.0%. Compared to adequate HL, participants with limited HL were less likely to have medium CVH (0.90[0.84-0.97]) and high CVH achievement (0.53[0.39-0.73]) after adjusting for age, sex, race/ethnicity and field center ( Table ). These associations attenuated with further adjustment for education and income, to 0.94[0.88-1.02] for medium and 0.68[0.50-0.94] for high CVH. Of individual LS7 metrics, limited HL was significantly associated with high glucose levels. Conclusion: Limited HL was associated with suboptimal overall CVH as well as elevated blood glucose levels independent of education. Clinical trials are needed to assess whether improving health literacy enhances CVH.

Objectives: Increase in LDL-C occurs within 1 year of the final menstrual period (FMP), and this increase has been linked to a greater plaque risk. LDL subclasses have been linked to CAD beyond LDL-C, promising a better risk stratification. We aim to characterize changes in LDL subclasses over the menopause transition (MT) and assess associations of these changes with presence of coronary artery calcification (CAC Agatston score ≥10) and carotid intima-media thickness (cIMT), and test the effect modification of time relative to FMP on these associations. Design: Midlife women with nuclear magnetic resonance spectroscopy LDL subclasses measured over the MT for a maximum of 5 timepoints were included (n=471; baseline age 50.19 ± 2.7 years; 81.0% Pre-/Early perimenopausal). A subset of women had CAC and cIMT measured for a maximum of 2 timepoints (n=221). LOESS plots were used to characterize changes in LDL subclasses over the MT in the full sample. Inflection points identified from the LOESS plots suggested timing of changes in slope (Figure). Linear mixed effect models or generalized estimating equation was used for analysis. Effect modification by time relative to FMP was tested. Results: All LDL metrics increased around the FMP except for Intermediate LDL Particles (IDL-P), which declined (Figure). Higher total LDL particles (LDL-P) and greater ApoB independently associated with higher CAC prevalence and greater cIMT. Although none of the associations of LDL metrics with cIMT or CAC were modified by time relative to FMP, higher LDL-C, ApoB and total LDL-P were associated with higher cIMT during peri- or postmenopausal stages (Table), while higher LDL-C, small LDL-P and large LDL-P were associated with greater CAC prevalence, mainly during perimenopause stage in adjusted models (Table). Conclusions: During the MT women experience significant increases in LDL subclasses found to be related to greater cIMT levels and CAC prevalence. Monitoring LDL subclasses over the MT may help in identifying women at greater risk for future CAD.

Background: Poststroke depression is common in stroke survivors. Evidence suggests that caregivers of stroke survivors also experience depression, at rates similar to survivors (30-40%). While much research has focused on developing better understanding of poststroke depression in stroke survivors, stroke caregiver depression has received less attention. Available research suggests that characteristics of the survivor such as age, gender, relation to caregiver, mental health, and physical or cognitive deficits correlate with and may be contributing factors for caregiver depression. Knowledge of risk factors for stroke caregiver depression could translate to better screening, management, and prevention, but further investigation is needed. Objectives: To examine the existing literature and synthesize evidence surrounding survivor characteristics and their association with poststroke depressive symptoms in caregivers. Methods: Medline, PsychInfo, and CINAHL databases were searched with variations of keywords: "stroke," "caregiver" and "depression." Studies analyzing associations between at least one stroke survivor characteristic and caregiver depressive symptoms were included. Results: Seventeen studies met eligibility criteria. They analyzed a wide range of survivor characteristics. Many survivor characteristics lacked convincing evidence of an association with caregiver depressive symptoms. However, a trend emerged supporting an association between survivor depressive symptoms and caregiver depressive symptoms. Conclusions: Health-care providers should be aware that depressive symptoms in one member of a stroke survivor-caregiver dyad may indicate risk for depressive symptoms in the other. Screening both individuals may lead to earlier detection and provide information to guide interventions. Knowing risk factors for stroke caregiver depression may improve prevention/management, but further investigation is needed.

Homeless populations have high rates of smoking and unique barriers to quitting. General cessation strategies have been unsuccessful in this population. Smoking reduction may be a good intermediate goal. We conducted a secondary analysis to identify predictors of smoking reduction in a cohort of homeless smokers enrolled in a 26-week randomized clinical trial (RCT) targeting smoking cessation.Data are from an RCT comparing motivational interviewing counseling plus nicotine replacement therapy (NRT) to brief advice to quit (standard care) plus NRT among homeless smokers. Using bivariate analyses and multinomial logistic regression, we compared demographics, health and psychosocial variables, tobacco use, substance use, and NRT adherence among those who reported: quitting; reducing smoking by 50-99%; and not reducing smoking by 50%.Of 324 participants who completed 26-week follow-up, 18.8% and 63.9% self-reported quitting and reducing, respectively. Compared to those who did not reduce smoking, participants reporting reducing indicated higher baseline cigarette use (OR=1.08; CI:1.04-1.12) and menthol use (OR=2.24; CI:1.05-4.77). Compared to participants who reduced, participants reporting quitting were more likely to be male (OR=1.998; CI:1.00-3.98), experience more housing instability (OR=1.97; CI:1.08-3.59), indicate higher importance of quitting (OR=1.27; CI:1.041.55), have higher NRT adherence (OR=1.75; CI:1.00-3.06), and lower odds of reported illicit drug use (OR=0.48; CI:0.24-0.95).Over half of participants reduced smoking by at least 50%, indicating reduction is feasible among homeless smokers. Further research is required to understand the impact of reduction on future cessation attempts in homeless smokers. This study shows that reduction is achievable and may be a valid intermediate goal.

Introduction: Increasing research demonstrates psychosocial factors are associated with blood pressure control (BPC) among individuals with hypertension. To date, little research has examined multiple psychosocial factors simultaneously to identify distinguishing profiles among individuals with hypertension. The association of psychosocial profiles and BPC remains unknown. Thus, the goal of this study was to characterize the psychosocial profiles of individuals with hypertension and assess whether they are associated with BPC over 14 years. Hypothesis: We hypothesize that discrete psychosocial profiles will emerge, and they will be associated with BPC longitudinally. Methods: We included 2,665 MESA participants (38.57% Black; 55.43% Female) with prevalent hypertension in 2002-2004. Latent Profile Analysis (LPA) was used to identify distinct psychosocial profiles based on a combination of nine psychosocial variables (Table). We used generalized estimating equations to determine associations of the psychosocial profiles with BPC, defined as systolic blood pressure (SBP) < 140 mm Hg and diastolic blood pressure (DBP) < 90 mm Hg. Results: The LPA revealed an optimal model of three psychosocial profile groups (AIC 121,229; entropy = .88) namely “Healthy”, “Depressed Mood” and “Discriminated Against”. There were no significant differences in BPC of both targets (SBP and DBP) combined across the profiles. Examining SBP and DBP separately, participants in the “Depressed Mood” profile group were 60% less likely [95% CI: 0.43, 0.84] to have their DBP < 90 mm Hg as compared to the “Healthy” profile in the unadjusted model, but there was no association with covariate adjustment. Conclusions: Discrete psychosocial profiles exist among individuals with hypertension, but were not associated with BPC after full covariate adjustment.

Objective: Higher levels of high-density lipoprotein cholesterol (HDL-C) may not always be cardio-protective in midlife women. Novel metrics of HDL including nuclear magnetic resonance (NMR) spectroscopy subclasses (large, medium and small HDL particles (HDL-P), and size), HDL content of phospholipids (HDL-PL) and triglycerides (HDL-Tg), and HDL function as measured by cholesterol efflux capacity (HDL-CEC) show strong associations with cardiovascular disease (CVD) risk beyond HDL-C. Women experience increases in carotid Intima-media thickness (cIMT), a subclinical measure of atherosclerosis, over the menopause transition. Associations of novel metrics of HDL with cIMT have not been well characterized in midlife women. Our objective was to assess the associations of HDL subclasses, HDL-PL, HDL-Tg, and HDL-CEC with cIMT and to determine whether these associations vary by age at menopause. Design: We assessed 303 women (at baseline: age 51.0 ± 2.8 years; 67.8% White and 32.2% Black; 56.6% Pre-/Early perimenopausal) who had HDL metrics and cIMT measured once (N=37 [12%]) or twice (N=266 [88%]) over the menopause transition. Age at menopause was observed prospectively among 73% of women (defined as no menses for 12 consecutive months) and imputed among the rest. Linear mixed effect models were used to individually assess the association of each HDL metric with cIMT, and to test whether the association varied by age at menopause (53 years old). Final models were adjusted for race, education, and time varying: age, systolic blood pressure, body mass index, menopausal status, triglycerides, low density lipoprotein cholesterol and HDL-C. Results: In unadjusted analyses, higher concentrations of large HDL-P, medium HDL-P, HDL-PL, and HDL-CEC, and larger HDL size, and lower concentrations of small HDL-P were associated with lower cIMT; all p 53 had thicker cIMT(β(SE): 6.72(6.27) μm) than those with age at menopause Conclusions: In midlife women, higher concentrations of medium HDL-P and greater content of HDL phospholipids were associated with thinner cIMT beyond traditional CVD risk factors including HDL-C. Associations of HDL triglycerides content with thicker cIMT was more pronounced in women who reached menopause at older ages. Findings support utilizing other metrics of HDL rather than HDL-C to better characterize CVD risk in midlife women.

Background The menopausal transition is characterized by increased cardiovascular risk, weight gain, and increased adiposity for many women. The adipose‐derived secretory proteins adiponectin and leptin are associated with insulin resistance, metabolic syndrome, and cardiovascular disease but their role in subclinical atherosclerotic disease is unclear. This cross‐sectional study evaluated the associations of adiponectin and leptin with carotid artery intima‐media thickness, adventitial diameter, presence of carotid plaques, and brachial‐ankle pulse wave velocity (baPWV) in women aged 54 to 65 years. Methods and Results Participants were 1399 women from SWAN (Study of Women's Health Across the Nation), a community‐based study of women transitioning through menopause. Carotid ultrasound and baPWV measures were obtained at SWAN follow‐up visits 12 or 13, when 97% of participants were post‐menopausal. Adipokines were assayed from serum specimens obtained concurrently at these visits. Linear and logistic regression models were used to evaluate adiponectin or leptin, both log‐transformed attributable to skewness, in relationship to carotid artery intima‐media thickness, adventitial diameter, baPWV, and presence of carotid plaque. Covariates included age, race, study site, smoking, alcohol use, obesity, cardiovascular disease risk factors, and menopausal status. Lower levels of adiponectin were related to greater carotid artery intima‐media thickness, wider adventitial diameter, and faster baPWV; associations were attenuated after adjusting for cardiovascular disease risk factors. Higher levels of leptin were associated with greater carotid artery intima‐media thickness and wider adventitial diameter in minimally and fully adjusted models, and contrary to expectation, with slower baPWV, particularly among women with diabetes mellitus or obesity. Conclusions Adiponectin and leptin are 2 important inflammatory pathways that may contribute to adverse subclinical cardiovascular disease risk profiles in women at midlife.

The cardioprotective association of high-density lipoprotein cholesterol (HDL-C) may vary by menopause stage or estradiol level. We tested whether associations of comprehensive HDL metrics (HDL subclasses, phospholipid and triglyceride content, and HDL cholesterol efflux capacity [HDL-CEC]) with coronary artery calcium (CAC) score and density vary by menopause stage or estradiol level in women transitioning through menopause. Participants (N = 294; mean age [SD]: 51.3 [2.9]) had data on HDL metrics and CAC measures at one or two time points during the menopause transition. Generalized estimating equations were used for analyses. Effect modifications by menopause stage or estradiol level were tested in multivariable models. In adjusted models, menopause stage modified the associations of specific HDL metrics with CAC measures. Higher small HDL particles (HDL-P) concentrations (p-interaction = 0.008) and smaller HDL size (p-interaction = 0.02) were associated with greater odds of CAC presence in late perimenopause than in pre/early perimenopause stage. Women in the highest estradiol tertile, but not the lower tertiles, showed a protective association of small HDL-P with CAC presence (p-interaction = 0.007). Lower large HDL-P concentrations (p-interaction = 0.03) and smaller HDL size (p-interaction = 0.03) were associated with lower CAC density in late perimenopause than in postmenopause stage. Associations of HDL phospholipid and triglyceride content and HDL-CEC with CAC measures did not vary by menopause stage or estradiol level. We concluded that HDL subclasses may impact the likelihood of CAC presence and the stability of coronary plaque differently over the menopause transition. Endogenous estradiol levels may contribute to this observation.

BackgroundSuboptimal treatment of hypertension remains a widespread problem, particularly among minorities and socioeconomically disadvantaged groups. We present a health system–based intervention with diverse patient populations using readily available smartphone technology. This intervention is designed to empower patients and create partnerships between patients and their provider team to promote hypertension control.ObjectiveThe mGlide randomized controlled trial is a National Institutes of Health–funded study, evaluating whether a mobile health (mHealth)-based intervention that is an active partnership between interprofessional health care teams and patients results in better hypertension control rates than a state-of-clinical care comparison.MethodsWe are recruiting 450 participants including stroke survivors and primary care patients with elevated cardiovascular disease risk from diverse health systems. These systems include an acute stroke service (n=100), an academic medical center (n=150), and community medical centers including Federally Qualified Health Centers serving low-income and minority (Latino, Hmong, African American, Somali) patients (n=200). The primary aim tests the clinical effectiveness of the 6-month mHealth intervention versus standard of care. Secondary aims evaluate sustained hypertension control rates at 12 months; describe provider experiences of system usability and satisfaction; examine patient experiences, including medication adherence and medication use self-efficacy, self-rated health and quality of life, and adverse event rates; and complete a cost-effectiveness analysis.ResultsTo date, we have randomized 107 participants (54 intervention, 53 control).ConclusionsThis study will provide evidence for whether a readily available mHealth care model is better than state-of-clinical care for bridging the guideline-to-practice gap in hypertension treatment in health systems serving diverse patient populations.Trial RegistrationClinicaltrials.gov NCT03612271; https://clinicaltrials.gov/ct2/show/NCT03612271International Registered Report Identifier (IRRID)DERR1-10.2196/25424

Background In the United States, eighty percent of the adult homeless population smokes cigarettes compared to 15 percent of the general population. In 2017 Power to Quit 2 (PTQ2), a randomized clinical trial, was implemented in two urban homeless shelters in the Upper Midwest to address concurrent smoking cessation and alcohol treatment among people experiencing homelessness. A subset of this study population were interviewed to assess their experiences of study intervention. The objective of this study was to use participants’ experiences with the intervention to inform future implementation efforts of combined smoking cessation and alcohol abstinence interventions, guided by the Consolidated Framework for Implementation Research (CFIR). Methods Qualitative semi-structured interviews were conducted with 40 PTQ2 participants between 2016–2017 and analyzed in 2019. Interviews were audio-recorded, transcribed, and analyzed using a socially constructivist approach to grounded theory. Results Participants described the PTQ2 intervention in positive terms. Participants valued the opportunity to obtain both counseling and nicotine-replacement therapy products (intervention characteristics) and described forming a bond with the PTQ2 staff and reliance on them for emotional support and encouragement (characteristics of individuals). However, the culture of alcohol use and cigarette smoking around the shelter environment presented a serious challenge (outer setting). The study setting and the multiple competing needs of participants were reported as the most challenging barriers to implementation (implementation process). Conclusion There are unique challenges in addressing smoking cessation with people experiencing homelessness. For those in shelters there can be the difficulty of pro-smoking norms in and around the shelter itself. Considering pairing cessation with policy level interventions targeting smoke-free spaces, or pairing cessation with housing support efforts may be worthwhile.. Participants described a discord in their personal goals of reduction compared with the study goals of complete abstinence, which may pose a challenge to the ways in which success is defined for people experiencing homelessness. Trial registration Clinicaltrials.gov, NCT01932996, registered 08/30/2013.

BACKGROUND Suboptimal treatment of hypertension remains a widespread problem, particularly among minorities and socioeconomically disadvantaged groups. We present a health system–based intervention with diverse patient populations using readily available smartphone technology. This intervention is designed to empower patients and create partnerships between patients and their provider team to promote hypertension control. OBJECTIVE The mGlide randomized controlled trial is a National Institutes of Health–funded study, evaluating whether a mobile health (mHealth)-based intervention that is an active partnership between interprofessional health care teams and patients results in better hypertension control rates than a state-of-clinical care comparison. METHODS We are recruiting 450 participants including stroke survivors and primary care patients with elevated cardiovascular disease risk from diverse health systems. These systems include an acute stroke service (n=100), an academic medical center (n=150), and community medical centers including Federally Qualified Health Centers serving low-income and minority (Latino, Hmong, African American, Somali) patients (n=200). The primary aim tests the clinical effectiveness of the 6-month mHealth intervention versus standard of care. Secondary aims evaluate sustained hypertension control rates at 12 months; describe provider experiences of system usability and satisfaction; examine patient experiences, including medication adherence and medication use self-efficacy, self-rated health and quality of life, and adverse event rates; and complete a cost-effectiveness analysis. RESULTS To date, we have randomized 107 participants (54 intervention, 53 control). CONCLUSIONS This study will provide evidence for whether a readily available mHealth care model is better than state-of-clinical care for bridging the guideline-to-practice gap in hypertension treatment in health systems serving diverse patient populations. CLINICALTRIAL Clinicaltrials.gov NCT03612271; https://clinicaltrials.gov/ct2/show/NCT03612271 INTERNATIONAL REGISTERED REPORT DERR1-10.2196/25424

Objective: Higher levels of high-density lipoproteins cholesterol (HDL-C) may not always be cardio-protective in midlife women. Nuclear magnetic resonance (NMR) spectroscopy HDL subclasses have shown strong associations with CVD risk beyond HDL-C. Preliminary work suggests significant declines in large HDL particles (HDL-P) and overall HDL size, but increases in small HDL-P during the perimenopause stage. Our objective was to assess whether associations between NMR HDL subclasses and risk of coronary artery calcification (CAC) vary by menopausal stage. Design: We assessed 283 women (at baseline : age 51.4 ± 3.0 years; 56.6% Pre-/Early peri-, 8.8% late peri-, 34.6% post-menopausal) who had NMR HDL subclasses and CAC Agatston score measured once (N=48 [17%]) or twice (N=235 [83%]) around menopause. CAC presence was defined as CAC>0. Effect modifications of menopausal stage on associations between HDL subclasses and CAC presence overtime were tested using generalized estimating equation for binary outcome. Final models were adjusted for study site, race and time varying: age, body mass index, physical activity, alcohol consumption, insulin resistance, triglycerides and low-density lipoprotein cholesterol. Results: In final models, menopausal stage modified the associations of small HDL-P (p=.009), large HDL-P (p=.05) and overall HDL size (p=.007) with CAC presence ( Table ). Higher concentration of small HDL-P, lower concentration of large HDL-P, and smaller overall HDL size significantly associated with greater risk of CAC presence during the late-peri stage compared to pre-/early peri-menopausal stage ( Table) . Conclusions: Changes in HDL subclasses during the menopause transition may increase the likelihood of measurable CAC developing in women, particularly during the later peri-menopausal stage. Characterizing associations of HDL composition and function metrics with CVD risk over the menopause transition is critical to better understand the relationship of HDL to coronary disease in midlife women.

Purpose Reduced access to care and barriers have been shown in rural populations and in publicly insured populations. Barriers limiting health care access in publicly insured populations living in rural areas are not understood. This study investigates rural-urban differences in system-, provider-, and individual-level barriers and access to preventive care among adults and children enrolled in a public insurance program in Minnesota. Methods This was a secondary analysis of a 2008 statewide, cross-sectional survey of publicly insured adults and children (n = 4,388) investigating barriers associated with low utilization of preventive care. Sampling was stratified with oversampling of racial/ethnic minorities. Results Rural enrollees were more likely to report no past year preventive care compared to urban enrollees. However, this difference was no longer statistically significant after controlling for demographic and socioeconomic factors (OR: 1.37, 95% CI: 1.00-1.88). Provider- and system-level barriers associated with low use of preventive care among rural enrollees included discrimination based on public insurance status (OR: 2.26, 95% CI: 1.34-2.38), cost of care concerns (OR: 1.72, 95% CI: 1.03-2.89) and uncertainty about care being covered by insurance (OR: 1.70, 95% CI: 1.01-2.85). These and additional provider-level barriers were also identified among urban enrollees. Conclusions Discrimination, cost of care, and uncertainty about insurance coverage inhibit access in both the rural and urban samples. These barriers are worthy targets of interventions for publicly insured populations regardless of residence. Future studies should investigate additional factors associated with access disparities based on rural-urban residence.

Currently, exercise-based cardiac rehabilitation (CR) is the only recommended secondary prevention strategy for cardiac patients that attempts to tackle stress and psychosocial wellbeing, but it is under-utilized and lacks a comprehensive curriculum for this purpose; hence there is a critical gap to address psychosocial needs of cardiac patients after an event. Mindfulness-based stress reduction (MBSR) has shown benefits in the general population but its role in cardiac patients is not clear. We conducted a pilot randomized controlled trial (RCT) of MBSR in CR-eligible cardiac patients during their initial year of recovery. Patients were allocated 2:1 (intervention:control) to an 8-week MBSR group intervention or usual care. Standard measures of depression, anxiety, perceived stress, health related quality of life (HRQOL), blood pressure, biomarkers (lipids, HbA1c, CRP) and 24-hour Holter monitoring were obtained at baseline, 3- and 9-months post-randomization. Sub-group analyses were performed for participants with at least mild depression (PHQ-9 ≥ 5). 47 patients [mean age 58.6 years; 38% female; 77% white] were enrolled in 2 cohorts. 87% of MBSR patients completed the intervention; study retention was >95% at each follow-up visit. At 3 months, compared to controls, MBSR patients showed improvements in depression [p = 0.01] and anxiety [p = 0.04] with a similar trend in HRQOL [p = 0.06]. The MBSR group showed greater improvement or less worsening of most CV risk factors, with an attenuation of treatment effects at 9 months. Participants with at PHQ-9 scores ≥5 at baseline showed greater improvement in psychosocial and CV outcomes, that persisted at 9 months. MBSR is a safe and well received secondary prevention strategy. This pilot RCT provides preliminary evidence of MBSR’s potential to improve short term psychosocial well-being in cardiac patients during their first year of recovery.

Background: Breast cancer survivors on aromatase inhibitors (AIs) can develop endothelial dysfunction, a measure of increased CV risk. Stress modifying techniques such as MBSR may improve CV function and quality of life (QOL). We present data of a pilot study assessing the impact of MBSR on endothelial dysfunction and psychosocial outcomes. Methods: 31 women with locally advanced breast cancer and taking an AI were randomized 1:1 to 8 weekly MBSR classes or wait-list control. Subjects with tobacco use, known hypertension or hyperlipidemia were excluded. Participants completed surveys and vascular testing at baseline and 10 weeks. With the COVID 19 pandemic, MBSR classes were held on a virtual platform. Endothelial function was measured using the Endo-PAT2000 system;reductions in EndoPAT ratio (

BACKGROUND The apolipoprotein E (APOE) e4 allele and stroke increase the risk of cognitive decline. However, the association of the APOE e4 allele before and after stroke is not well understood. METHODS Using a prospective sample of 3444 (66% African Americans, 61% females, mean age=71.9 y) participants, we examined cognitive decline relative to stroke among those with and without the APOE e4 allele. RESULTS In our sample, 505 (15%) had incident stroke. Among participants without stroke, the e4 allele was associated with increased cognitive decline compared to noncarriers (0.080 vs. 0.036 units/year; P

Background Childhood maltreatment has been linked to adulthood cardiovascular disease (CVD). Little is known about the relationship between intimate partner violence (IPV) in late adolescence and young adulthood and CVD risk later in adulthood. Purpose To examine whether IPV perpetration and victimization experienced in late adolescence and young adulthood are associated with CVD risk among adults in the United States and whether this relationship differs by sex. Methods Data include 9976 participants (50% female) in the National Longitudinal Study of Adolescent to Adult Health. Physical and sexual IPV were measured at wave 3 (2001/02) with items from the revised Conflict Tactics Scales. Participants'30-year risk of CVD was calculated at wave 4 (2008/09) using a Framingham prediction model. Linear regression models adjusted for confounders and IPV by sex interaction terms were tested to examine the relationship. Results The mean CVD risk score was 13.18% (95% CI: 12.71, 13.64). Aone-standard deviation increase in the victimization score was associated with a 0.28% (95% CI: 0.03, 0.54) increase in CVD risk. Perpetration was similarly positively associated with CVD risk (beta: 0.33, 95% CI: 0.03, 0.62). When measured as a composite, all violence types were associated with increased CVD risk but only prior exposure to both victimization and perpetration reached statistical significance (0.62%, 95% CI: 0.01, 1.22). No differences by sex were detected. Conclusions Effect sizes are not large, but early detection of increased CVD risk in this relatively young population is notable and worthy of further study to inform the clinical response.

BackgroundHigher perivascular adipose tissue (PVAT) contributes to adverse physiologic alterations in the vascular wall, and thus could potentially limit normal physical function later in life. We hypothesize that higher PVAT volume at midlife is prospectively associated with slower gait speed later in life, independent of overall adiposity and other risk factors.MethodsParticipants from the Study of Women’s Health Across the Nation (SWAN) cardiovascular fat ancillary study were included. PVAT volume around the descending aorta was quantified using existing computed tomography scans at midlife, while gait speed was measured after an average of 10.4 ± 0.7 years.ResultsTwo hundred and seventy-six women (aged 51.3 ± 2.8 years at PVAT assessment) were included. Mean gait speed was 0.96 ± 0.21 m/s. Adjusting for study site, race, education level, menopausal status, and length of descending aorta at PVAT assessment, and age, body mass index, difficulty paying for basics, overall health and smoking status at gait speed assessment, a higher midlife PVAT volume was associated with a slower gait speed later in life (p = .03). With further adjustment for presence of any comorbid conditions by the time of gait speed assessment, the association persisted; every 1SD increase in log-PVAT was associated with 3.3% slower gait speed (95% confidence interval: 0.3–6.3%; p = .03).ConclusionGreater PVAT in midlife women may contribute to poorer physical function in older age supporting a potential role of midlife PVAT in multiple domains of healthy aging. Additional research is needed to fully elucidate the physiologic changes associated with PVAT that may underlie the observed associations.

Cardiovascular disease risk increases in women after the menopausal transition; why this inflection point occurs remains uncertain. We aimed to characterize the influence of menopause on vascular aging by prospective assessment of change in indexes of subclinical atherosclerosis across the menopausal transition. We evaluated 411 healthy women from SWAN Heart, an ancillary study of SWAN (Study of Women's Health Across the Nation), for subclinical atherosclerosis at baseline and again after an average of 2.3 years. Carotid intima-media thickness and aortic pulse wave velocity were measured by ultrasound. Coronary artery calcium scores were obtained by computed tomography. Women were grouped by menopausal status as premenopausal, postmenopausal, or having undergone the transition during follow-up. Analyses of changes were adjusted for age at baseline and time between scans. Mean age at baseline was 51 ± 3 years; 93 (23%) subjects transitioned to menopause (Pre-Post), 147 (36%) remained premenopausal (Pre-Pre), while 171 (41%) were postmenopausal at baseline (Post-Post). Blood pressure readings did not differ between groups with similar increase noted in carotid intima-media thickness and log coronary artery calcium + 1 from baseline to follow-up. Change in aortic pulse wave velocity from baseline to follow-up was higher in Pre-Post (121 ± 23 cm/s) compared with Pre-Pre (38 ± 250 cm/s, p = 0.029) and Post-Post (41 ± 228 cm/s, p = 0.045). In conclusion, changes in aortic stiffness were more sensitive measures of perimenopausal vascular aging than morphologic indexes of subclinical atherosclerosis in women undergoing the menopausal transition. Serial assessment of such changes could potentially elucidate mechanisms of disease and identify women to target for aggressive lifestyle risk factor modification.

Copyright © 2015 by the Endocrine Society. Context: Cardiovascular risk increases in women after menopause. Mounting evidence demonstrates a role of cardiovascular fat (CF) in the pathogenesis of coronary heart disease, but no research has examined CF in relation to sex hormones or menopausal status in women. Objective: The objective was to determine the relationship between CF depots, menopausal status, and endogenous sex hormones. Design: Cross-sectional and longitudinal study designs were used. Setting: The setting included the Study of Women's Health Across the Nation (SWAN) Heart and Cardiovascular Fat Ancillary Study. Participants: A total of 456 women (mean age, 50.75 y); 62% premenopausal/early perimenopausal, and 38% late peri-/postmenopausal. Intervention: Menopausal status, endogenous sex hormones measured simultaneously with CF volumes, and circulating estradiol available 4.80 years (median) before CF measures. MainOutcomeMeasures: Volumes of CF (epicardial adipose tissue [EAT], paracardial adipose tissue [PAT], total heart adipose tissue [TAT=EAT=PAT], and aortic perivascular adipose tissue [PVAT]). Results: In final models, late peri-/postmenopausal women had 9.88% more EAT, 20.72% more PAT, and 11.69% more TAT volumes than pre-/early perimenopausal women (P < .05). PVAT was not associated with menopausal status. In final models, lower estradiol concentrations were associated with greater volumes of PAT and TAT (P < .05). Women with the greatest reduction in estradiol since baseline had greater volumes of PAT compared to women with the least reduction (P = .02). Conclusions: Late peri-/postmenopausal women have greater volumes of heart fat compared with pre-/early perimenopausalwomenindependent of age, obesity, and other covariates. Endogenous sex hormones are associated with CF. Perhaps CF plays a role in the higher risk of coronary heart disease reported in women after menopause.

Perceived discrimination is positively related to cardiovascular disease (CVD) risk factors; its relationship with incident CVD is unknown. Using data from the Multi-Ethnic Study of Atherosclerosis, a population-based multiethnic cohort study of 6,508 adults aged 45-84 years who were initially free of clinical CVD, we examined lifetime discrimination (experiences of unfair treatment in 6 life domains) and everyday discrimination (frequency of day-to-day occurrences of perceived unfair treatment) in relation to incident CVD. During a median 10.1 years of follow-up (2000-2011), 604 incident events occurred. Persons reporting lifetime discrimination in ≥2 domains (versus none) had increased CVD risk, after adjustment for race/ethnicity and sociodemographic factors, behaviors, and traditional CVD risk factors (hazard ratio (HR) = 1.36, 95% confidence interval (CI): 1.09, 1.70) and after control for chronic stress and depressive symptoms (HR = 1.28, 95% CI: 1.01, 1.60). Reported discrimination in 1 domain was unrelated to CVD (HR = 1.05, 95% CI: 0.86, 1.30). There were no differences by race/ethnicity, age, or sex. In contrast, everyday discrimination interacted with sex (P = 0.03). Stratified models showed increased risk only among men (for each 1-standard deviation increase in score, adjusted HR = 1.14, 95% CI: 1.03, 1.27); controlling for chronic stress and depressive symptoms slightly reduced this association (HR = 1.11, 95% CI: 0.99, 1.25). This study suggests that perceived discrimination is adversely related to CVD risk in middle-aged and older adults.

Small clinical studies suggest depression is associated with alterations in adiponectin and leptin, adipocyte-derived secretory proteins involved in metabolic regulation; however, longitudinal data on these association are lacking. This study examined cross-sectional and longitudinal associations of depressive symptoms and major depressive disorder (MDD) with adiponectin and leptin in healthy middle-aged women (mean (SD) age, 45.6 (2.5) years). Cross-sectional analyses included 575 women with baseline adipokine data; longitudinal analyses included 262 women with 2-4 adipokine measurements over 5 years. The 20-item Center for Epidemiologic Studies Depression scale (CES-D) was used to assess depressive symptoms; history of MDD was determined by the Structured Clinical Interview for DSM-IV. Adipokines were assayed from stored serum specimens; values were log-transformed for analyses. Linear and repeated measure random effects regression models evaluated associations of baseline CES-D scores with baseline adipokine concentrations and changes over time, respectively. Secondary analyses evaluated the relation of MDD history with adipokine concentrations. Mean (SD) baseline concentrations of adiponectin and leptin were 9.90 (4.92) μg/mL and 27.02 (20.06) ng/mL; both increased over time (p .0001). CES-D scores were associated with lower adiponectin at baseline (per 1-SD: estimate=-0.04, SE=.02, p=.03) and over time (per 1-SD: estimate=-0.055, SE = .024, p=.02). Associations were unchanged in risk factor-adjusted models. Women with elevated CES-D scores (≥16) had 6.9% (95% CI: -1.1%, 14.3%; p = .089) lower median adiponectin at baseline and 11.5% (95% CI: 1.5%, 20.4%, p = .025) lower median adiponectin over time in adjusted models, compared to women with CES-D16. Rate of change in adipokines did not vary by baseline depressive symptoms or MDD history. Depressive symptoms and MDD history were unrelated to leptin. In women at midlife, depressive symptoms are associated with lower adiponectin, a critical anti-inflammatory biomarker involved in metabolic and cardiovascular conditions.

A growing literature links discrimination to key markers of biobehavioral health. While racial or ethnic differences in pain are seen in experimental and clinical studies, the authors were interested in how chronic discrimination contributes to pain within multiple racial or ethnic groups over time. Participants were 3056 African American, Caucasian, Chinese, Hispanic, and Japanese women from the Study of Women's Health Across the Nation. The Everyday Discrimination Scale was assessed from baseline through 13 follow-up examinations. The bodily pain subscale of the MOS 36-Item Short-Form Health Survey (SF-36) was assessed annually. There were large racial or ethnic differences in reports of discrimination and pain. Discrimination attributions also varied by race or ethnicity. In linear mixed model analyses, initially adjusted for age, education, and pain medications, chronic everyday discrimination was associated with more bodily pain in all ethnic groups (beta = -5.84; P0.002 for Japanese; beta = -6.17; P0.001 for African American; beta = -8.74; P0.001 for Chinese; beta = -10.54; P0.001 for Caucasians; beta = -12.82; P0.001 for Hispanic). Associations remained significant in all ethnic groups after adjusting for additional covariates in subsequent models until adding depressive symptoms as covariate; in the final fully-adjusted models, discrimination remained a significant predictor of pain for African American (beta = -4.50; P0.001), Chinese (beta = -6.62; P0.001), and Caucasian (beta = -7.86; P0.001) women. In this longitudinal study, experiences of everyday discrimination were strongly linked to reports of bodily pain for the majority of women. Further research is needed to determine if addressing psychosocial stressors, such as discrimination, with patients can enhance clinical management of pain symptoms.

Experiences of discrimination are associated with increased risk of adverse health outcomes; however, it is unknown whether discrimination is related to incident type 2 diabetes mellitus (diabetes). We investigated the associations of major experiences of discrimination (unfair treatment in 6 situations) and everyday discrimination (frequency of day-to-day experiences of unfair treatment) with incident diabetes among 5,310 participants from the Multi-Ethnic Study of Atherosclerosis, enrolled in 2000-2002. Using Cox proportional hazards models, we estimated hazard ratios and confidence intervals, adjusting for demographic factors, depressive symptoms, stress, smoking, alcohol, physical activity, diet, waist circumference, and body mass index. Over a median follow-up of 9.4 years, 654 diabetes cases were accrued. Major experiences of discrimination were associated with greater risk of incident diabetes when modeled continuously (for each additional experience of discrimination, hazard ratio = 1.09, 95% confidence interval: 1.01, 1.17) or categorically (for ≥2 experiences vs. 0, hazard ratio = 1.34, 95% confidence interval: 1.08, 1.66). Similar patterns were observed when evaluating discrimination attributed to race/ethnicity or to a combination of other sources. Everyday discrimination was not associated with incident diabetes. In conclusion, major experiences of discrimination were associated with increased risk of incident diabetes, independent of obesity or behavioral and psychosocial factors. Future research is needed to explore the mechanisms of the discrimination-diabetes relationship.

Objectives. We estimated the distribution of predicted long-term cardiovascular disease (CVD) risk among young adults in the United States. Methods. Our data were derived from National Longitudinal Study of Adolescent Health participants (n = 14 333; average age: 28.9 years). We used a Framingham-derived risk prediction function to calculate 30-year risks of “hard” and “general” CVD by gender and race/ethnicity. Results. Average 30-year risks for hard and general CVD were 10.4% (95% confidence interval [CI] = 10.1%, 10.7%) and 17.3% (95% CI = 17.0%, 17.7%) among men and 4.4% (95% CI = 4.3%, 4.6%) and 9.2% (95% CI = 8.9%, 9.5%) among women. Average age-adjusted risks of hard and general CVD were higher among Blacks and American Indians than among Whites and lower among Asian/Pacific Islander women than White women. American Indian men continued to have a higher risk of general CVD after adjustment for socioeconomic status. Four percent of women (95% CI = 3.6%, 5.0%) and 26.2% of men (95% CI = 24.7%, 27.8%) had a 20% or higher risk of general CVD. Racial differences were detected but were not significant after adjustment for socioeconomic status. Conclusions. Average CVD risk among young adults is high. Population-based prevention strategies and improved detection and treatment of high-risk individuals are needed to reduce the future burden of CVD.