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Introduction Primary care provider (PCP) competency in dermatology is inadequate despite the high volume of patients with skin conditions. Better education and access to dermatology expertise is vital to improve patient care. We present a comprehensive case-based evaluation of Dermatology Extension for Community Healthcare Outcomes (ECHO) sessions, an innovative videoconferencing educational model, by determining the diagnostic and treatment accuracy of dermatological conditions by PCPs over a 2-year period. Methods This is a retrospective cross-sectional study evaluating the use and impact of Dermatology ECHO over a 2-year period. Outcomes assessed include patient demographics, PCPs’ diagnostic accuracy, and expert treatment impact. Results were analysed using summary statistics and Pearson’s chi-square test to describe the adult and paediatric populations. Results One hundred and sixty-seven adult cases and 56 paediatric cases were presented in 2016–2017. Among the 223 cases, 137 adult and 44 paediatric cases were complete and eligible for analysis. The mean lesion duration was 3.3 years in adults and 2.9 years in children prior to presentation. Upon case presentation, almost half (43.8%) of the adult cases were incorrectly diagnosed by their PCP with 18.8% receiving a partially correct diagnosis. PCPs had greater diagnostic accuracy in children (45% correct diagnosis, 27.5% partially correct, 27.5% incorrect). Expert treatment recommendations benefited 83.6% of adult cases and 72.5% of paediatric cases. Discussion This study highlights the need for better dermatology access and teaching opportunities among PCPs in Missouri. Dermatology ECHO provides a platform for didactic learning and case presentations to improve dermatology competency among PCPs.

Objective Our objective was to determine whether 15 min yogic breathing exercises practiced 5 times a week can lower blood pressure in uncontrolled hypertensive patients. Design Take a deep Breath study was a 3-arm randomized controlled blood pressure trial, 2016–2017 with in-class instruction, home DVD/YouTube instruction, and a control arm. Blood pressure measurements with a 1-month follow-up. Methods A list of uncontrolled hypertensive patients (n = 5507) generated from Family Medicine Department’s Electronic Medical Record registry was given to their respective providers to recommend. After chart review of the 1682 recommended patients, the number reduced to 984 of which 610 were contacted and 22% of 610 (n = 133) were enrolled. Eligible participants were randomly assigned to in-class instruction (n = 44), DVD/YouTube group (n = 57), or control (n = 32). The outcome measured was at least 5 mm Hg systolic blood pressure reduction. Results Participants were predominately white (89%), approximately half male (52%) with a mean age of 61 years (sd = 12 years). Of the 133 participants who were allocated to a study arm, 30 never participated in any aspect of the study, 20 partially completed and 83 completed the study. Compared to those who completed the study, no differences were noted in demographics or initial blood pressure for those who partially completed. From chart review 6% of participants made a change to their blood pressure medications during the study. Intervention participants were significantly more likely to have ≥5 mm Hg decrease in systolic blood pressure (OR = 4.49, 95% CI: 1.18–17.0) compared to controls in the multivariable logistics model. DVD/YouTube instruction did just as well as in-class instruction group. Conclusions In this RCT, statistically significant systolic blood pressure reduction was noted in the intervention groups. Yogic breathing exercises may provide an additional non- pharmacologic tool to treat uncontrolled blood pressure.

Inpatient coronavirus disease 2019 (COVID‐19) cases present enormous costs to patients and health systems in the United States. Many hospitalized patients may continue testing COVID‐19 positive even after the resolution of symptoms. Thus, a pressing concern for clinicians is the safety of discharging these asymptomatic patients if they have any remaining infectivity. This case report explores the viral viability in a patient with persistent COVID‐19 over the course of a 2‐month hospitalization. Positive nasopharyngeal swab samples were collected and isolated in the laboratory and analyzed by quantitative reverse‐transcription polymerase chain reactions (qRT‐PCR), and serology was tested for neutralizing antibodies throughout the hospitalization period. The patient experienced waning symptoms by hospital day 40 and had no viable virus growth by hospital day 41, suggesting no risk of infectivity, despite positive RT‐PCR results which prolonged his hospital stay. Notably, this case showed infectivity for at least 24 days after disease onset, which is longer than the discontinuation of transmission‐based precautions recommended by the Center for Disease Control and Prevention. Thus, our findings suggest that the timeline for discontinuing transmission‐based precautions may need to be extended for patients with severe and prolonged COVID‐19 disease. Additional large‐scale studies are needed to draw definitive conclusions on the appropriate clinical management for these patients. ​, Highlights A patient with severe COVID‐19 disease demonstrated infectivity at least 24 days after disease onset, which is longer than the current discontinuation of transmission‐based precautions guidelines in the United States.The patient had no viable virus growth by hospital day 41, suggesting no risk of infectivity despite a positive RT‐PCR test result.Our findings suggest that the timeline for discontinuation of transmission‐based precautions may require an extension for patients with severe and prolonged COVID‐19 illness.

This study evaluated how breast cancer diagnoses were shared with patients. Current members of the Dr. Susan Love Research Foundation’s Army of Women cohort were sent one email with a link to a survey assessing how their breast cancer diagnosis was communicated, a description of their support system during treatment, basic demographic information, and breast cancer diagnosis details. Participants (n = 2896) were more likely to be given their diagnosis over the telephone in more recent years (OR 1.07, 95% CI 1.06–1.08). Up until about 10 years ago (1967–2006), breast cancer diagnoses were communicated in person more often than by telephone. Since 2006, more than half of participants learned about their diagnosis over the telephone. From 2015 to 2017, almost 60% of participants learned about their diagnosis over the telephone. Among those who heard the news in person, a steady 40% were alone. Characteristics of those who received the news over the telephone included having identified support members, heterosexual identity, and a diagnosis of in situ breast cancer. Receiving a telephone call about breast cancer diagnosis may be the norm rather than the exception in health care today. Trends in practice, as well as current best practices based primarily on expert opinion, may not provide optimal care for women diagnosed with breast cancer. Patient outcome research to guide future practice, such as the impact of modes of delivery of bad news, is urgently needed to determine appropriate patient-centered approaches for notification of breast cancer diagnoses.

Background: Childhood obesity in the United States is a critical public health issue. Although multiple child and parental factors are associated with childhood obesity, few models evaluate how socioeconomic status influences these risk factors. We aimed to create a model to examine how socioeconomic status modifies risk factors for child obesity. Methods: We conducted a secondary data analysis of the Early Childhood Longitudinal Birth Cohort. Using logistic regression, we modeled childhood obesity status from known parental and child risk factors for childhood obesity and tested interactions with socioeconomic status. Results: Compared with healthy-weight children, socioeconomic status, race, birth weight, parental smoking, and not eating dinner as a family were associated with kindergarten-aged children being overweight or obese. Parental smoking increased the odds of a child being overweight or obese by 40%, and eating dinner as a family reduced the odds of a child being overweight or obese by 4%. In addition, black or Hispanic children had a 60% increased odds of being overweight or obese when compared with their white counterparts. Native American children had almost double the odds of being overweight or obese compared with white children. Socioeconomic status did not modify any of these associations. Conclusion: Parental smoking, birth weight, and not eating dinner as a family were two modifiable factors associated with overweight and obesity in kindergarten-age children, regardless of socioeconomic status. Changing these life-style factors could reduce the child9s risk for obesity.

This study explored sources of stress and support experienced by sexual and gender minority (SGM) breast cancer survivors and the impact of treatment on their lives. SGM breast cancer survivors were identified through purposive and referral sampling and invited to participate in a web-based survey containing both closed- and open-ended items. Sixty-eight SGM breast cancer survivors aged 18–75 years completed the survey between May 2015 and January 2016. Bivariate analyses of quantitative data reveal that queer-identified (in either sexual orientation or gender identity (SOGI)) SGM survivors are more likely to report having bilateral mastectomy without reconstruction and to think that disclosing SOGI to providers affected their care. Queer-identified SGM survivors are also more likely to use LGBT-specific support groups and to report that their current level of social support is below average. Thematic analysis of qualitative comments revealed themes related to self-disclosure of SOGI to providers, need for recognition and support of partners, need for appropriate social supports for patients and partners, and impact of breast cancer treatment on intimate relationships. This study provides quantitative and qualitative evidence that many SGM breast cancer patients face a dearth of appropriate social supports, both from breast cancer survivor organizations and from within the medical system. These findings confirm the need for research on the physical and emotional effects of breast cancer treatment on SGM breast cancer survivors, as well as further exploration of the social support needs and experiences of SGM breast cancer patients and their partners.

Background Lesbian and bisexual women are more likely to be overweight or obese than heterosexual women, leading to increased weight-related health risks. Methods Overweight women aged 40 or older who self-identified as lesbian, bisexual, or "something else" participated in five pilot interventions of 12 or 16 weeks' duration. These tailored interventions took place at lesbian and bisexual community partner locations and incorporated weekly group meetings, nutrition education, and physical activity. Three sites had non-intervention comparison groups. Standardized questionnaires assessed consumption of fruits and vegetables, sugar-sweetened beverages, alcohol, physical activity, and quality of life. Weight and waist-to-height ratio were obtained through direct measurement or self-report. Analytical Plan Within-person changes from pre-intervention to post-intervention were measured using paired comparisons. Participant characteristics that influenced the achievement of nine health objectives were analyzed. Achievement of health objectives across three program components (mindfulness approach, gym membership, and pedometer use) was compared with the comparison group using generalized linear models. Results Of the 266 intervention participants, 95% achieved at least one of the health objectives, with 58% achieving three or more. Participants in the pedometer ( n = 43) and mindfulness ( n = 160) programs were more likely to increase total physical activity minutes (relative risk [RR], 1.67; 95% confidence interval [CI], 1.18–2.36; p = .004; RR, 1.38; 95% CI, 1.01–1.89; p = .042, respectively) and those in the gym program ( n = 63) were more likely to decrease their waist-to-height ratio (RR, 1.89; 95% CI, 0.97–3.68, p = .06) compared with the comparison group ( n = 67). Conclusion This effective multisite intervention improved several healthy behaviors in lesbian and bisexual women and showed that tailored approaches can work for this population.

Research in the sexual and gender minority population (SGM) tends to focus on describing risk factors for negative health outcomes and identification of stressors, which tend to be higher in this population compared to the non-SGM (i.e., mainstream heterosexual) population. This study examines the intersection between perceived stress and resilience associated with self-reported depressive symptoms using standardised instruments, such as the Patient Health Questionnaire (PHQ-2), among SGM adults (n = 3017) and youths (n = 232). A higher proportion of SGM individuals are stressed and report depressive symptoms compared to non-SGM individuals, whereas the mean resilience scores were similar to the general population. For SGM adults, but not youths, we found an association between lower resilience scores and higher perceived stress scores. SGM adults who had a ‘higher’ depressive symptom score (PHQ-2 ≥ 3) were more likely to have a lower resilience score, a higher stress score, be unemployed or disabled, and...

Background: Cadmium is a human lung carcinogen, and recent evidence suggests it may play a role in hormone-related cancers because of its estrogenic activity. Case-control studies consistently show higher cadmium concentrations in urine from women diagnosed with breast cancer compared with control women. Our aim was to investigate the association between urinary cadmiumand breast cancer in a prospective design.Methods: We conducted a case-cohort study using the population-based Danish Diet Cancer and Health Cohort. Women age 50 to 64 years were recruited in 1993-1997 and provided urine for analysis. We identified 900 incident case patients in the Danish Cancer Registry and compared with 898 individuals in a subcohort. Urine samples collected at enrollment into the cohort were analyzed for cadmium and creatinine. We estimated incidence rate ratios (IRRs) for breast cancer in Cox proportional hazards models with age as time axis and calculated 95% confidence intervals (CIs).Results: The linear analysis showed no association between urinary cadmiumand risk for breast cancer (IRR = 1.00, 95% CI = 0.81 to 1.24 per ng Cd/mL urine). The categorical analyses showed a slightly higher risk for breast cancer for the second (IRR = 1.10, 95% CI = 0.86 to 1.42) and third (IRR = 1.14, 95% CI = 0.83 to 1.55) exposure tertiles compared with the lowest tertile. Results were similar in analyses of breast cancer subtypes defined by estrogen and progesterone receptor status and by histology, and analyses stratified by years from baseline to diagnosis.Conclusions: This large prospective study showed no association between urinary concentration of cadmium and subsequent risk for development of postmenopausal breast cancer.

We examined the association of nitrate-nitrogen exposure from rural private drinking water and incidence of age-related macular degeneration (AMD). Participants of the Beaver Dam Eye Study living in rural areas within the 53916 zone improvement plan code but outside the city limits of Beaver Dam, Wisconsin (Beaver Dam Township) completed a questionnaire and ocular examination including standardized, graded fundus photographs at five examinations. Data from an environmental monitoring study with probabilistic-based agro-chemical sampling, including nitrate-nitrogen, of rural private drinking water were available. Incidence of early AMD was associated with elevated nitrate-nitrogen levels in rural private drinking water supply (10.0% for low, 19.2% for medium, and 26.1% for high nitrate-nitrogen level in the right eye). The odds ratios (ORs) were 1.77 (95% confidence interval [CI]: 1.12–2.78) for medium and 2.88 (95% CI: 1.59–5.23) for high nitrate-nitrogen level. Incidence of late AMD was increased for those with medium or high levels of nitrate-nitrogen compared to low levels (2.3% for low and 5.1% for the medium or high nitrate-nitrogen level, for the right eye). The OR for medium or high nitrate-nitrogen groups was 2.80 (95% CI: 1.07–7.31) compared to the low nitrate-nitrogen group.

Chemoprevention agents are medications or vitamins taken to reduce the risk for development of a specific cancer. Early phase clinical research of chemoprevention agents has many unique challenges. In particular, the effect of a potential chemoprevention agent is ideally evaluated not only in normal tissue, but also in malignant tissue. At the same time, the usual parameters of pharmacokinetics, toxicity, and drug tolerance must be evaluated. As assessing target tissue for effect of the agent is a primary goal of these studies, one must also consider the best approach to obtain adequate tissue samples while limiting the amount of risk and discomfort to the study participant. Although study designs vary depending on the organ sites of interest, in breast cancer chemoprevention studies, the most common techniques for obtaining breast tissue in patients without a breast cancer diagnosis have included nipple aspiration, ductal lavage, or four-quadrant fine needle aspirations.1 These techniques have varying strengths, but significant limitations of all of these techniques include the relatively low volume of cell/tissue retrieval, mixing of both normal epithelial cells and neoplastic cells (if present) during the collection procedure, and the limited stromal tissue acquisition.1–4 The treatment of solid tumors frequently involves a 2- to 6-week evaluation period between a diagnostic biopsy and the medically necessary surgical resection of the neoplasm, called the preoperative window. Research groups have leveraged the preoperative window for early phase studies of novel chemoprevention agents in various organs (ie, breast, prostate, and bladder).5–7 In these window-of-opportunity studies, patients receive study drug or placebo during the preoperative window. Then, at the time of the planned surgical resection of the identified neoplasm, extra neoplastic and normal tissues are obtained and subsequently analyzed for changes in surrogate endpoint biomarkers. While there are drawbacks to this window-of-opportunity approach, the main advantages are the ability to obtain relatively large sections of normal and neoplastic tissue that can be used for assessment of the chemoprevention agent’s effects on multiple biomarkers. In addition, the researcher can obtain this tissue without exposing the participant to the risk and discomfort of an additional invasive procedure. This window-of-opportunity approach is also being used to study the biologic effect of new targeted agents for the treatment of various cancers.8–12 It is worthwhile to note that for chemoprevention agents, the access to pre-treatment normal and tumor tissue continues to be limited with this approach, as core biopsies are the mainstay for diagnosis for the majority of cancers. Thus, placebo-controlled studies are often utilized. One common critique of the preoperative window-of-opportunity model is that it can lead to delays in potentially curative surgery that may affect survival outcomes. A review published in the International Journal of Clinical Practice13 summarized the published evidence about diagnostic evaluation leading to delays in breast cancer treatment. The review concluded that there was mixed evidence about whether delay in curative surgery may affect outcomes, but the main evidence supports that less than a 12-week delay has little to no effect on survival from breast cancer. However, one main issue with many of the reviewed studies was a failure to control for lead-time bias, which is the variability in delay between the patient detecting a symptom, presenting to the physician, diagnosis, and finally treatment. Another analysis specifically evaluating the impact of window-of-opportunity studies across multiple tumor types did not note any impact on survival.14 However, to limit any risk, window-of-opportunity clinical trial designs often incorporate a flexible treatment window to allow for variation in the surgical waiting period seen at different institutions and to enroll all participants who would take the minimum amount of treatment. Other designs may ask directly for a woman to delay surgery for a period while taking the study treatment for a fixed period of time. Although early phase clinical research trials for preventive drug development is critical, enrollment of a sufficient number of eligible patients to preoperative early phase chemoprevention studies has been a challenge across many different tumor types.15 Barriers to participation are multiple and may include protocol requirements or exclusions, alternative therapeutic research studies excluding prior neoplastic therapies, concerns about delay of standard therapy, or because the participant is not interested in participating in the specific research study or any research study. Our own experience in preoperative chemoprevention trials for prostate and bladder cancer has observed approximately 10% of screened participants were subsequently enrolled in the trial.16 Several breast cancer window-of-opportunity trials have been conducted with novel chemopreventive agents.10, 17–19 In these trials, the main factors that contribute to nonparticipation seem to be primarily related to protocol requirements or exclusions. However, also important to these studies are the large numbers of potential participants that are screened by recruiters or referred to the study but do not have any evidence of cancer in subsequent follow-up evaluations. In a preoperative trial of tamoxifen, 46% of screened potential participants with a suspicious mammogram did not have any evidence of cancer on a follow-up core biopsy. Only 1% of screened patients were enrolled in this study.20 Thus, despite literature that supports window-of-opportunity studies as being safe and providing ideal access both to normal and tumor tissue, enrollment in these studies remains low. The purpose of this current study was to determine predictors of willingness to participate in a preoperative chemoprevention study at our center, the University of Wisconsin Carbone Cancer Center (UWCCC), using a prospective survey of women recently recommended to undergo curative breast surgery for breast neoplasia.

Objective The purpose of this study is to explore the associations between smoke-free policies, current and former smoking status, personal smoking restrictions, and intention to quit among sexual and gender minority (SGM) and non-SGM individuals in Missouri. Aims and Methods The current analysis derives from the Out, Proud and Healthy project. Chi-squares examined differences between SGM (N = 2210) and non-SGM (N = 586) respondents and former (N = 836) and current (N = 1960) smokers on smoking-related variables. Odds ratios and 95% confidence intervals from logistic regression identified variables associated with former (vs. current) smoking. Results SGM current smokers (25%) were significantly more likely than SGM former smokers (19%) to live in a community without a smoke-free policy. Among SGM current smokers, significantly greater intention to quit was seen in those living in a smoke-free community with a smoke-free policy of two or more years (94%) compared with those living in a community without a smoke-free policy (76%). Conclusions Living in an area with smoke-free policies is related to greater intention to quit among SGM current smokers, greater support for smoke-free policies, and lower smoking prevalence for this community. The SGM community may collectively accrue greater public health benefits from the adoption of smoke-free policies than the non-SGM community. Implications Prior to this study, no data are available regarding current and former smoking status among SGM individuals following the implementation of a local smoke-free policy. The purpose of this study was to explore the relationship between smoke-free policies, current and former smoking status, and intention to quit among SGM and non-SGM individuals in Missouri. This study finds evidence of lower current smoking prevalence and greater intentions to quit among SGM current smokers who live in communities with smoke-free policies. The SGM community may collectively accrue greater public health benefits from the adoption of smoke-free policies than the non-SGM community.

Approximately one third of US patients are diagnosed with pre-hypertension, associated with significant health risks. Current treatment guidelines recommend lifestyle modification as first-line therapy for pre-hypertension, and a few recent studies have indicated the potential for mind-body therapies to reduce blood pressure in pre-hypertensive patients. Our study investigated the effect of daily practice of Pranayama, a group of yogic breathing exercises, on blood pressure of eight pre-hypertensive individuals. Participants received weekly Pranayama instruction and blood pressure measurements were obtained. Daily Pranayama practice resulted in statistically significant blood pressure reduction of 11 points (systolic) and 8 points (diastolic) between baseline and week six. Blood pressure measurements at week nine were similar to week six. The ease with which the technique of Pranayama can be learned and practiced by patients and its potential to significantly lower blood pressure makes this technique a promising non-pharmacologic tool for blood pressure reduction in pre-hypertensive patients. The small study presented here provides a discussion of the possible physiological basis for the effectiveness of analyzing Pranayama breathing in the care of pre-hypertensive patients. Such an approach to examining the logic behind and evidence for or against any intervention should be a permanent aspect of education and training of all health care providers.

Background: Lead is a toxic nonessential metal with widespread exposure starting in utero. Lead has been reclassified in 2004 by the International Agency for Research on Cancer Working Group from a “possible” to a “probable” human carcinogen. Lead may be a facilitative or permissive carcinogen, which means that lead may permit or augment the genotoxic effects of other exposures. Methods: This population-based study in Wisconsin gathered survey data and home-collected urine specimens from 246 women, ages 20 to 69 years, with incident invasive breast cancer identified from the Wisconsin state registry and 254 age-matched control subjects from population lists from September 2004 to February 2005. We measured urinary lead concentrations by inductively coupled plasma mass spectrometry, adjusted the values by specific gravity, and conducted interviews by telephone to obtain information on known and suspected breast cancer risk factors. Results: Women in the highest quartile of specific gravity–adjusted lead level (≥1.10 μg/L) had twice the breast cancer risk of those in the lowest quartile ( Conclusion: Our population-based case-control study suggests that lead exposure, as determined by specific gravity–adjusted urinary lead concentrations, is not associated with a significant increased risk for breast cancer. (Cancer Epidemiol Biomarkers Prev 2008;17(9):2311–7)

One unintentional result of widespread adoption of nitrogen application to croplands over the past 50 years has been nitrate contamination of drinking water with few studies evaluating the risk of colorectal cancer. In our population-based case-control study of 475 women age 20–74 years with colorectal cancer and 1447 community controls living in rural Wisconsin, drinking water nitrate exposure were interpolated to subjects residences based on measurements which had been taken as part of a separate water quality survey in 1994. Individual level risk factor data was gathered in 1990–1992 and 1999–2001. Logistic regression models estimated the risk of colorectal cancer for the study period, separately and pooled. In the pooled analyses, an overall colorectal cancer risk was not observed for exposure to nitrate-nitrogen in the highest category (≥10 ppm) compared to the lowest category (

Background Cadmium is a known carcinogen that can disrupt endocrine signalling. Cigarette smoking and food are the most common routes of non-occupational exposure to cadmium. Cadmium accumulates in the kidney and can be measured in urine, making urine cadmium (U-Cd) a biomarker of long-term exposure. However dietary-cadmium (D-Cd) intake estimates are often used as surrogate indicator of cadmium exposure in non-smoking subjects. It is therefore important to investigate the concordance between D-Cd estimates obtained with Food Frequency Questionnaires and U-Cd. Methods U-Cd levels were compared with estimated dietary-cadmium (D-Cd) intake in 1764 postmenopausal women from the Danish Diet, Cancer and Health cohort. For each participant, a food frequency questionnaire, and measures of cadmium content in standard recipes were used to judge the daily intake of cadmium, normalized by daily caloric intake. Cadmium was measured by ICP-MS in spot urine sampled at baseline and normalized by urinary creatinine. Information on diet, socio-demographics and smoking were self-reported at baseline. Results Linear regressions between U-Cd and D-Cd alone revealed minimal but significant positive correlation in never smokers (R2 = 0.0076, β = 1.5%increase per 1 ng Cd kcal-1, p = 0.0085, n = 782), and negative correlation in current smokers (R2 = 0.0184, β = 7.1%decrease per 1 ng Cd kcal-1 change, p = 0.0006, n = 584). In the full study population, most of the variability in U-Cd was explained by smoking status (R2 = 0.2450, n = 1764). A forward selection model revealed that the strongest predictors of U-Cd were age in never smokers (δ R2 = 0.04), smoking duration in former smokers (δ R2 = 0.06) and pack-years in current smokers (δ R2 = 0.07). Food items that contributed to U-Cd were leafy vegetables and soy-based products, but explained very little of the variance in U-Cd. Conclusions Dietary-Cd intake estimated from food frequency questionnaires correlates only minimally with U-Cd biomarker, and its use as a Cd exposure indicator may be of limited utility in epidemiologic studies.

One important function of sleep may be its contribution to the maintenance of the immune system and regulation of the circadian rhythms by melatonin. Researchers have speculated that disruption of immune functions involving cortisol levels and natural killer cell activity may increase breast cancer risk whereas increased melatonin exposure may protect against breast cancer. We conducted a multistate population-based case-control study of 4,033 women with invasive breast cancer and 5,314 community women without breast cancer in which we inquired about women's sleep habits in the recent past and during adult lifetime. Relative to women who slept 7.0-7.9 h/night, the multivariate odds ratio for developing breast cancer among women who slept an average of 9 h or more per night approximately 2 years prior to interview was 1.13 (95% CI 0.93-1.37). The multivariate-adjusted odds ratio for the continuous term was 1.06 (95% CI 1.01-1.11), suggesting a 6% increase in risk for every additional hour of sleep. Similar patterns were observed for average lifetime adult sleep duration. We found little evidence that sleeping few hours per night was associated with breast cancer risk. The results of this study suggest that increasing sleep duration is modestly associated with an increased breast cancer risk. In contrast, short duration of sleep (

Women are at higher risk of breast cancer if they have higher socioeconomic status (SES) or live in higher SES or urban communities. We examined whether women living in such communities remained at greater risk of breast cancer after controlling for individual education and other known individual-level risk factors.Data were from a population-based, breast cancer case-control study conducted in Wisconsin from 1988 to 1995 (n = 14,667). Data on community SES and urbanicity come from the 1990 census, measured at the census tract and zip code levels. We evaluated relationships between individual- and community-level variables and breast cancer risk using multilevel logistic regression models with random community intercepts.After controlling for individual education and other individual-level risk factors (age, mammography use, family history of breast cancer, parity, age at first birth, alcohol intake, body mass index, hormone replacement use, oral contraceptive use, and menopausal status), women living in the highest SES communities had greater odds of having breast cancer than women living in the lowest SES communities (1.20; 95% confidence interval = 1.05-1.37). Similarly, the odds were greater for women in urban versus rural communities (1.17; 1.06-1.28).Community SES and urbanicity are apparently not simply proxies for individual SES. Future research should examine why living in such communities itself is associated with greater risk of breast cancer.

In Wisconsin, consumption of Great Lakes fish is an important source of exposure to polychlorinated biphenyls (PCBs), dichlorodiphenyltrichloroethane (DDT), polybrominated diphenyl ethers (PBDEs), and other halogenated hydrocarbons, all of which may act as potential risk factors for breast cancer. We examined the association between sport-caught fish consumption and breast cancer incidence as part of an ongoing population-based case-control study. We identified breast cancer cases 20-69 years of age who were diagnosed in 1998-2000 (n = 1,481) from the Wisconsin Cancer Reporting System. Female controls of similar age were randomly selected from population lists (n = 1,301). Information about all sport-caught (Great Lakes and other lakes) fish consumption and breast cancer risk factors was obtained through telephone interviews. After adjustment for known and suspected risk factors, the relative risk of breast cancer for women who had recently consumed sport-caught fish was similar to women who had never eaten sport-caught fish [relative risk (RR) = 1.00; 95% confidence interval (CI), 0.86-1.17]. Frequency of consumption and location of sport-caught fish were not associated with an increased risk of breast cancer. Recent consumption of Great Lakes fish was not associated with postmenopausal breast cancer (RR = 0.78; 95% CI, 0.57-1.07), whereas risk associated with premenopausal breast cancer was elevated (RR = 1.70; 95% CI, 1.16-2.50). In this study we found no overall association between recent consumption of sport-caught fish and breast cancer, although there may be an increased breast cancer risk for subgroups of women who are young and/or premenopausal.

Endometrial cancer is associated with endogenous and exogenous estrogen excess. Some investigators have posited that electromagnetic fields may influence cancer risk through estrogenic hormonal mechanisms; however, there have been no studies reporting on electric blanket exposure in relation to endometrial cancer. The authors examined this possible association between endometrial cancer risk and electric blanket or mattress cover use as part of a population-based, case-control study. This analysis included incident endometrial cancer cases 40-79 years of age, interviewed during 1994 (n = 148; response rate, 87%) and identified from the Wisconsin tumor registry. Female controls of similar age were randomly selected from population lists (n = 659; response rate, 85%). Information regarding electric blanket and mattress cover use and endometrial cancer risk factors was obtained through structured telephone interviews approximately 1 year after diagnosis. After adjustment for age, body mass index, and postmenopausal hormone use, the risk of endometrial cancer was similar among ever users (odds ratio = 1.04, 95% confidence interval: 0.70, 1.55) and among current users (odds ratio = 0.87, 95% confidence interval: 0.49, 1.54) as compared with never users. Despite its small size and potential misclassification of exposure, this study provides evidence against an association between electric blanket or mattress cover use and endometrial cancer.

Estrogen-mimicking chemicals, such as cadmium, may be associated with increased susceptibility to hormone-dependent cancers, though supporting data are sparse, particularly for endometrial cancer. The Health and Environmental Exposure Research (HEER) study worked with the Arkansas Central Cancer Registry, Iowa Cancer Registry and Missouri Cancer Registry to obtain names of women diagnosed with endometrial cancer who were willing to be contacted for participation in our case control study. Voter registration lists from Iowa and Missouri were used to randomly select similarly aged women as represented in the case population. Participants were interviewed by telephone to obtain information on known or suspected endometrial risk factors. Urine kits were sent to participants for home collection and returned for analysis. Our case-control study consisted of 631 incident cases of endometrial cancer diagnosed from January 2010 to October 2012 and 879 age-matched population-based controls, ages 18-81 years (mean age 65 years). We quantified cadmium amounts in urine and standardized these values through creatinine adjustment. Using data from all survey completers, we developed a multivariable model for endometrial cancer. Creatinine-adjusted cadmium concentration was added to this model. Odds ratio (OR) and 95% confidence intervals (CIs) for endometrial cancer were calculated. After multivariable adjustment, higher creatinine-adjusted cadmium exposure was associated with a statistically significant increase of endometrial cancer risk (OR: 1.22; 95% CI: 1.03-1.44). Our results provide evidence that cadmium may increase the risk of endometrial cancer, possibly through estrogenic effects.

Background: Human Papillomavirus (HPV) is associated with multiple cancers and remains the most common sexually transmitted infection in the United States. Each year, approximately seven million U.S. women are newly infected with HPV, and about 17,000 develop new HPV-associated cancers. Three HPV vaccines have been licensed for use in preventing 70% to 90% of HPV strains associated with cervical and other anogenital cancers. Although vaccination provides an opportunity for the primary prevention of HPV associated cancers, uptake of the vaccine has been slow. Sexual minority women (i.e. lesbians and bisexuals, referred to as LB in our study) are at increased risk of acquiring HPV and HPV associated cancers from both female and male sexual partners. However, there is a dearth of research investigating HPV vaccination among sexual minorities. Therefore, the aim of this project was to compare HPV vaccine initiation and completion between straight/heterosexual and lesbian/bisexual women. Methods: We aggregated National Health and Nutrition Examination Survey data from 2009-2014 for 2,305 women aged 18 to 34 years. The censored upper age reflects availability of the HPV vaccine, which began in 2006. HPV vaccine initiation was defined as self-reported receipt of at least one dose of the vaccine. HPV vaccine completion was defined as self-reported receipt of all three recommended doses. Self-reported sexual orientation was dichotomized as straight/heterosexual vs. LB. Weighted percentages and multivariable logistic regression models were used to examine differences in HPV vaccine initiation and completion between straight/heterosexual and LB women. Covariates in the adjusted model included age, race, marital status, education, and household income. Results: Approximately 11% of respondents identified themselves as LB women. Respondents had initiated the HPV vaccine (22% of heterosexuals vs. 32% of LB women, p=0.0039) significantly more than had completed (15% of heterosexuals vs. 22% of LB women, p=0.0109). After adjusting for covariates, compared to straight/heterosexual women, LB women were 59% more likely to initiate HPV vaccine (aOR=1.59, 95% CI: 1.05-2.42). A one year increase in age was associated with lower odds of initiating HPV vaccination (aOR=0.81, 95% CI: 0.78-0.85). Compared to non-Hispanic White women, Hispanic women were less likely to initiate HPV vaccine (aOR=0.63, 95% CI: 0.42-0.94), and so were women with high school degree or less compared to those with college degree or higher (aOR=0.27, 95% CI: 0.17-0.42). A similar pattern was observed for HPV vaccine completion. In the adjusted model, LB women were 78% more likely to complete the HPV vaccine compared to straight/heterosexual women (aOR=1.78, 95% CI: 1.07-2.96). The same sociodemographic characteristics associated with decreased likelihood of HPV initiation were also significantly associated with HPV completion. Conclusion: We found that LB women had higher odds of HPV vaccine initiation and completion compared with straight/heterosexual women, although for both groups the vaccine uptake falls well below the target. Our finding that younger age predicts uptake of this vaccine is particularly promising for the LB population, wherein numerous reports indicate barriers to cancer screening such as access to care and physician's lack of knowledge regarding risk of HPV among LB women. We found LB women more likely to initiate and complete the HPV vaccination protocol, so understanding the drivers of vaccine uptake in the LB population may inform for use among the straight/heterosexual population. Citation Format: Eric Adjei Boakye, Nosayaba Osazuwa-Peters, Leping Wan, Betelihem B. Tobo, Vy Pham, Mario Schootman, Jane A. McElroy. Disparities in HPV vaccine initiation and completion based on sexual orientation among women in the United States. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr B79.

Background: Environmental contaminants that mimic the effects of estrogen have been suggested to contribute to the high incidence of breast cancer in Western populations. The toxic metal cadmium ha...

Previous research has demonstrated inconsistent associations between electromagnetic radiation, especially from electric blanket use, and breast cancer. Breast cancer risk according to electric blanket or mattress cover use was examined as part of a multicenter population-based case-control study. Breast cancer patients 50-79 years of age (N = 1949) were identified from statewide tumor registries in Massachusetts, New Hampshire, and Wisconsin from the period June 1994 to July 1995. Women of similar age were randomly selected from population lists as controls. Information regarding electric blanket and mattress cover use and breast cancer risk factors was obtained through telephone interviews. After adjustment for age, body mass index, and other breast cancer risk factors, the risk of breast cancer was similar among ever-users (relative risk = 0.93; 95% confidence interval = 0.82-1.06) and lower among current users than among never-users (relative risk = 0.79; 95% confidence interval = 0.66-0.95). There was no evidence of a dose-response relation with increasing number of months that electric blankets had been used. This study provides evidence against a positive association between electric blanket or mattress cover use and breast cancer.

We describe adverse pregnancy outcomes, including congenital anomalies, fetal, neonatal, and infant mortality among a Missouri population of low-income, rural mothers who participated in two randomized smoking cessation trials. In the Baby BEEP (BB) trial, 695 rural women were recruited from 21 WIC clinics with 650 women's pregnancy outcomes known (93.5% retention rate). Following the BB trial, 298 women who had a live infant after November 2004 were recruited again into and completed the Baby Beep for Kids (BBK) trial. Simple statistics describing the population and perinatal and postneonatal mortality rates were calculated. Of the adverse pregnancy outcomes (n = 79), 29% were spontaneous abortions of less than 20 weeks' gestation, 23% were premature births, and 49% were identified birth defects. The perinatal mortality rate was 15.9 per 1000 births (BB study) compared with 8.6 per 1000 births (state of Missouri) and 8.5 per 1000 births (United States). The postneonatal infant mortality rate was 13.4 per 1000 live births (BBK) compared with 2.1 per 1000 live births (United States). The health disparity in this population of impoverished, rural, pregnant women who smoke, particularly in regard to perinatal and infant deaths, warrants attention.

Background Evidence-based public health requires the existence of reliable information systems for priority setting and evaluation of interventions. Existing data systems in the United States are either too crude (e.g., vital statistics), rely on administrative data (e.g., Medicare) or, because of their national scope (e.g., NHANES), lack the discriminatory power to assess specific needs and to evaluate community health activities at the state and local level. This manuscript describes the rationale and methods of the Survey of the Health of Wisconsin (SHOW), a novel infrastructure for population health research. Methods/Design The program consists of a series of independent annual surveys gathering health-related data on representative samples of state residents and communities. Two-stage cluster sampling is used to select households and recruit approximately 800-1,000 adult participants (21-74 years old) each year. Recruitment and initial interviews are done at the household; additional interviews and physical exams are conducted at permanent or mobile examination centers. Individual survey data include physical, mental, and oral health history, health literacy, demographics, behavioral, lifestyle, occupational, and household characteristics as well as health care access and utilization. The physical exam includes blood pressure, anthropometry, bioimpedance, spirometry, urine collection and blood draws. Serum, plasma, and buffy coats (for DNA extraction) are stored in a biorepository for future studies. Every household is geocoded for linkage with existing contextual data including community level measures of the social and physical environment; local neighborhood characteristics are also recorded using an audit tool. Participants are re-contacted bi-annually by phone for health history updates. Discussion SHOW generates data to assess health disparities across state communities as well as trends on prevalence of health outcomes and determinants. SHOW also serves as a platform for ancillary epidemiologic studies and for studies to evaluate the effect of community-specific interventions. It addresses key gaps in our current data resources and increases capacity for etiologic, applied and translational population health research. It is hoped that this program will serve as a model to better support evidence-based public health, facilitate intervention evaluation research, and ultimately help improve health throughout the state and nation.

Our objective was to evaluate women who were occupationally exposed to electromagnetic fields (EMF) and breast cancer risk.Women diagnosed with breast cancer (n=6213) and randomly selected age-matched control subjects (n=7390) provided breast cancer risk factor information and occupational history. A qualified industrial hygienist classified each job for EMF exposure as background, low, medium, or high.When compared with the referent of background exposure, the odds ratio adjusted for age and state of residence was 1.06 (95% CI=0.99-1.14) for low exposure, 1.09 (95% CI=0.96-1.23) for medium exposure, and 1.16 (95% CI=0.90-1.50) for high exposure.Our findings, taken together with previous epidemiological studies, suggest that exposure to EMF in the workplace may be associated with a slight elevation in breast cancer risk.

Cadmium, a highly persistent heavy metal, has been categorized as a probable human carcinogen by the U.S. Environmental Protection Agency. Primary exposure sources include food and tobacco smoke. We carried out a population-based case-control study of 246 women, aged 20-69 years, with breast cancer and 254 age-matched control subjects. We measured cadmium levels in urine samples by inductively coupled plasma mass spectrometry and conducted interviews by telephone to obtain information on known breast cancer risk factors. Odds ratios (ORs) and 95% confidence intervals (CIs) for breast cancer by creatinine-adjusted cadmium levels were calculated by multivariable analysis. Statistical tests were two-sided. Women in the highest quartile of creatinine-adjusted cadmium level (> or = 0.58 microg/g) had twice the breast cancer risk of those in the lowest quartile (

Purpose Cadmium is a human lung carcinogen and possesses estrogen-like activity. This combination of carcinogenic and estrogenic activity makes cadmium a contaminant of high concern for hormone-related cancers. Diet and smoking are the main sources of cadmium exposure. The aim of this study was to investigate the association between dietary cadmium intake and risk of breast, endometrial and ovarian cancer in Danish postmenopausal woman. Methods We estimated dietary cadmium intake in the Diet, Cancer and Health cohort at enrolment 1993-97. The estimates were based on food frequency questionnaires and cadmium contents in all foods. Among 23,815 postmenopausal women we identified 1390 breast, 192 endometrial, and 146 ovarian cancer cases from enrolment through December 31, 2010 using the Danish Cancer Registry. Cox regression was used to analyse the association between dietary cadmium intake and cancer risk. Results Mean dietary cadmium intake was 14 µg/day. Cadmium was not associated with breast cancer, incidence rate ratio (IRR) = 0.99, 95% confidence interval (CI): 0.87–1.13 per 10 µg higher dietary cadmium intake/day; endometrial cancer, IRR = 1.08, 95% CI: 0.76–1.53; or ovarian cancer, IRR = 1.15, 95% CI: 0.78–1.70. We found a positive association between cadmium and endometrial cancer for the women with BMI

The purpose of this study was to evaluate the influence of a student-run clinic on the diversification of a medical student class. We distributed a two-page, 20-item, paper survey to students of the University of Missouri School of Medicine (MU SOM) class of 2015 in July of 2011. The survey gathered information on general demographics, opinions on the importance of medical education opportunities, and opinions on the importance of medical school characteristics in applying to and attending MU SOM. A total of 104 students responded to the survey. A majority of the students identified the MedZou Community Health Clinic, a student-run, free health clinic affiliated with MU SOM, and simulated-patient encounters as important educational experiences (81% and 94%, respectively). More than half of the self-identified non-white??students reported MedZou as an important factor in their choice to apply to (60%; 95% confidence interval [CI], 32 to 88) and attend (71%; 95% CI, 44 to 98) MU SOM, over half of the females reported MedZou as important in their choice to apply (59%; 95% CI, 43 to 76) and attend (57%; 95% CI, 40 to 74), and over half of non-Missouri residents reported MedZou as important in their choice to apply (64%; 95% CI, 36 to 93) and attend (71%; 95% CI, 44 to 98). According to the above results, it can be said that students clearly value both MedZou and simulated-patient encounters as important educational experiences. Women, minorities, and non-Missouri residents value MedZou more highly than their peers who are First Year Medical Students who are Missouri residents, suggesting that MedZou may provide a promising opportunity to advance diversity within MU SOM. These results highlight the need for additional research to further explore MedZou?占퐏 potential to enhance the recruitment of a diverse medical student class.

In utero and early life environmental exposure programming may be critical to the onset of many diseases and dysfunctions in adulthood (Barker, 2007; Heindel, 2006), such as an increased risk of hypertension, cardiovascular disease (Palinski et al. 2007), diabetes (Armitage et al. 2008), and breast cancer (Xue and Michels, 2007). Some in utero and early life environmental exposures have demonstrated unequivocal harmful effects to children, such as thalidomide (Speirs, 1962), ionizing radiation (Doll and Wakeford, 1997), methylmercury (Watanabe and Satoh, 1996), lead (Gardella, 2001), environmental tobacco smoke (Herrmann et al. 2008), cigarette smoking and high alcohol consumption during pregnancy (Krulewitch, 2005; Shea and Steiner, 2008). Whereas other in utero and early life environmental exposures have come under scrutiny without consensus as to the degree of influence on child or adult health, such as exposure to pesticides (Eskenazi et al. 1999), polybrominated biphenyls (PCBs) (Guo et al. 1995), nitrates (Mueller et al. 2004), bisphenol A (vom Saal and Hughes, 2005), and phytoestrogens (Damgaard et al. 2002).

Background Cadmium is classified as a human lung carcinogen based on evidence from high-exposure occupational settings. Though cadmium has no physiological role, increasing evidence suggests cadmium may mimic steroid hormones. This dual ability of being carcinogenic and hormone-like makes cadmium a concern for hormone-related cancers. Causes of prostate cancer are not clear, but steroid hormones, particularly androgens and probably estrogens, may be involved. Cadmium has been positively associated with prostate cancer in occupationally exposed men. In non-occupationally exposed populations, diet and smoking are the main sources of cadmium exposure. The aim of this study was to investigate the association between dietary cadmium intake and prostate cancer risk in Danish men. Methods Dietary cadmium intake was estimated in the Danish Diet, Cancer and Health cohort at baseline 1993–97. The estimates were based on a 192 item semi-quantitative food frequency questionnaire and cadmium contents in all food items. Among 26,778 men we identified 1,567 prostate cancer cases from baseline through December 31, 2010 using the Danish Cancer Registry. The association between dietary cadmium intake and prostate cancer risk was analysed using Cox regression models. Results We did not find an association between dietary cadmium intake and prostate cancer risk (adjusted incidence rate ratio per 10 μg day−1 = 0.98 (95% CI = 0.88-1.10)). The association did not differ according to aggressiveness of prostate cancer. Educational level, smoking status, BMI, zinc or iron intake did not modify the association. Conclusions In our study, we did not find an association between dietary cadmium intake and prostate cancer risk in a cohort of Danish men.