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Background The objective of the current study was to provide insight into the effect of coronavirus disease 2019 (COVID‐19) on breast cancer screening, breast surgery, and genetics consultations. Methods User data from a risk assessment company were collected from February 2 to April 11, 2020. The use of risk assessment was used as a proxy for the use of 3 breast cancer services, namely, breast imaging, breast surgery, and genetics consultation. Changes in the use of these services during the study period were analyzed. Results All 3 services experienced significant declines after the COVID‐19 outbreak. The decline in breast surgery began during the week of March 8, followed by breast imaging and genetics consultation (both of which began during the week of March 15). Breast imaging experienced the most significant reduction, with an average weekly decline of 61.7% and a maximum decline of 94.6%. Breast surgery demonstrated an average weekly decline of 20.5%. When surgical consultation was stratified as breast cancer versus no breast cancer, the decrease among in non–breast cancer patients was more significant than that of patients with breast cancer (a decline of 66.8% vs 11.5% from the pre‐COVID average weekly volume for non–breast cancer patients and patients with breast cancer, respectively). During the week of April 5, use of genetics consultations dropped to 39.9% of the average weekly volumes before COVID‐19. Conclusions COVID‐19 has had a significant impact on the number of patients undergoing breast cancer prevention, screening, diagnosis, and treatment., Coronavirus disease 2019 (COVID‐19) has had a significant impact on the number of patients undergoing breast cancer prevention, screening, diagnosis, and treatment in the United States. In the current study, user data from a risk assessment company were collected from February 2 to April 11, 2020, with the use of risk assessment used as a proxy to analyze changes in the use of 3 breast cancer services: breast imaging, breast surgery, and genetics consultation.

This study seeks to bring international histories of human rights into closer dialogue with military histories of insurgent movements and counterinsurgency warfare. Both military historians and historians of human rights have largely ignored the role of rights activists in shaping wartime policies and practices. This book examines the effects of human rights activism during British counterinsurgency campaigns in Cyprus (1955-1959), Aden (1963-1967), and Northern Ireland (emphasizing 1969-1976). The book argues that in response to human rights activism, British officials developed new ways of covering up their abuses by denying allegations, deflecting criticism, and evading attempts to enforce accountability. Consequently, activists’ efforts and government responses to them linked the metaphorical battlefield of law, diplomacy, propaganda, and public opinion with the physical battlefield of ambushes, house searches, arrests, and interrogations. Focusing the analytical lens on activists and the officials with whom they interacted places human rights activists on the counterinsurgency “battlefield”—not as traditional arms-bearing combatants, but as actors who nonetheless influenced counterinsurgency policies and practices.

In the age of genomic medicine, family health history (FHH) remains an important tool for personalized risk assessment as it can inform approaches to disease prevention and management. In primary care, including in prenatal settings, providers recognize that FHH enables them to assess the risk for birth defects and complex conditions that not only affect the fetus health, but also the mother’s. However, many providers lack the time to gather FHH or the knowledge to confidently interpret the data. Electronic tools providing clinical decision support using FHH data can aid the busy provider with data collection and interpretation. We describe the scope of conditions included in a patient-entered FHH tool that provides clinical decision support and point-of-care education to assist with patient management. This report details how we selected the conditions for which it is appropriate to use FHH as a means to promote personalized medicine in primary prenatal care.

The second chapter examines British responses to two sets of events: the two European Commission of Human Rights cases filed by the Greek government on behalf of Greek Cypriots; and Greek Cypriot allegations of British atrocities. The Cyprus government reacted by establishing a counterpropaganda organization, the Special Investigations Group (SIG), which existed to defend British actions rather than investigate the validity of Greek Cypriot claims. Furthermore, colonial authorities manipulated the results of government inquiries into two controversial incidents in order to deflect criticism from the security forces. When faced with challenges from within Cyprus and abroad, British officials found new ways to cover up evidence of rights abuses.

Chapter one analyzes how Greek Cypriot lawyers from the Cyprus Bar Council attempted to restrain British actions during the Cyprus Emergency. In line with other post-war counterinsurgencies, colonial governor John Harding enacted strict emergency regulations designed to facilitate counterinsurgency operations by restricting the population rather than the security forces. In response, Greek Cypriot lawyers contested this legislation by lobbying colonial officials and British politicians—with help from British lawyers such as Peter Benenson—to limit repressive regulations; defending accused insurgents in court; and documenting British abuses—including torture during interrogation. By challenging the extent and applicability of emergency laws, Greek Cypriot lawyers forced British officials to defend Britain’s reputation in public.

Chapter three examines the 1964 Radfan campaign. During the campaign, security forces purposefully targeted civilian livelihoods by driving the population from their homes, burning food stores, destroying crops, and killing livestock. These actions created a humanitarian crisis as thousands of refugees fled the violence. With help from a new NGO led by Peter Benenson called Amnesty International, representatives from the International Committee of the Red Cross (ICRC) sought permission to provide humanitarian aid in the Radfan, but British officials tried to prevent the ICRC from accessing the region. When ICRC access proved impossible to prevent, British authorities reacted by taking advantage of it by promoting the propaganda value of ICRC prison inspections that allowed British officials to claim that they treated detainees humanely.

Chapter four explains how allegations that British forces used torture during interrogations led to colonial officials’ efforts to evade scrutiny, deny that abuses had occurred, and impugn the character of those making accusations. In 1966, Amnesty International advocated for a government investigation of these torture allegations. When ministers proved uninterested in investigating the allegations, Amnesty dispatched an investigator of its own and publicized his findings. In response to potential public embarrassment, the Foreign Secretary ordered a limited inquiry that produced a tactful semi-admission that abuses had occurred and recommended several reforms. Officials in Aden appeared to cooperate by implementing the reforms but simultaneously manipulated oversight mechanisms to ensure that the interrogation system remained shielded from scrutiny. Protected by the High Commissioner and other senior officials in Aden, interrogators resumed the use of torture.

Chapter five examines how British officials responded to rights activism in Northern Ireland, with an emphasis on the period from the army’s initial deployment in 1969 to 1976. Rights activists criticized the government for permitting repressive measures such as internment without trial and torture during interrogation (the “five techniques”), but the results of this activism differed from past conflicts. Activism fostered more open and frank discussions of counterinsurgency practices than in the Cyprus or Aden campaigns which led to numerous government inquiries. Although the results of some inquiries—such as the Compton Report and the Widgery Tribunal—reflected a desire to justify or downplay British actions, others dug deeper into the issues and evidence. These inquiries resulted in a substantive and persistent public debate over rights issues related to detention and interrogation in which government brutality and repression was frequently contested, albeit with mixed results.

This introduction examines recent historiographical trends in the writing of human rights history and military histories of counterinsurgency. Much of the current human rights historiography has focused on finding the origins of contemporary human rights movements rather than engaging with the ways in which human rights activists thought of themselves at the time. Secondly, the introduction addresses the myths of supposedly “humane” British counterinsurgency methods such as the use of minimum force, winning hearts and minds, and obeying the rule of law. But during the wars in Cyprus, Aden, and Northern Ireland, human rights activists tried to expose the brutality and repression of British counterinsurgency to public scrutiny.

The conclusion begins by surveying the legacies of human rights activism during the Northern Ireland Troubles and reviews the book’s arguments regarding the Cyprus and Aden emergencies. Next, this section asserts that the consistent pattern of thwarting activism and the frequent circulation of officials from one campaign to the next suggests that, like torture, the ability to hide abuses from public scrutiny emerged as a key, but unspoken, element of British counterinsurgency during the era of decolonization. Finally, the conclusion addresses the contemporary relationship between counterinsurgency warfare and human rights—including the influence of the UK Human Rights Act and the importance of strategic narratives—during conflicts associated with the post-9/11 “war on terror” in Iraq and Afghanistan.

“The Pregnancy and Health Profile,” (PHP) is a free genetic risk assessment software tool for primary prenatal providers that collects patient-entered family (FHH), personal, and obstetrical health history, performs risk assessment, and presents the provider with clinical decision support during the prenatal encounter. The tool is freely available for download at www.hughesriskapps.net. We evaluated the implementation of PHP in four geographically diverse clinical sites. Retrospective chart reviews were conducted for patients seen prior to the study period and for patients who used the PHP to collect data on documentation of FHH, discussion of cystic fibrosis (CF) and hemoglobinopathy (HB) carrier screening, and CF and HB interventions (tests, referrals). Five hundred pre-implementation phase and 618 implementation phase charts were reviewed. Documentation of a 3-generation FHH or pedigree improved at three sites; patient race/ethnicity at three sites, father of the baby (FOB) race/ethnicity at all sites, and ancestry for the patient and FOB at three sites (P

Electronic health record (EHR) problem lists are extremely important, and yet they are often incomplete and out of date. We compared the EHR problem list to a self-reported problem list obtained via a tablet-administered questionnaire to identify potential synergy. We conducted a retrospective review comparing the EHR problem list to the patients’ self-reported problem list during the year of 2011. To confirm the accuracy of patient self-reports, we also analyzed medication lists, and laboratory results for two selected conditions, hypercholesterolemia and diabetes mellitus. Overall, 1472 patients at the Massachusetts General Hospital (MGH) used the tablet questionnaire. Of these, 843 (57.27%) had no problem reported in the EHR and some problem reported on the tablet (“Tablet Only”); 42 patients (2.85%) had no problem reported on the tablet or in the EHR (“None”); 17 patients (1.15%) had some problem reported in the EHR and no problem reported on the tablet (“LMR Only”); and 570 patients (38.72%) had some problem reported both on the tablet and in the LMR (“Both”). Overall, we studied 59 conditions, of which twelve had enough patients to run Chi Square analysis. Of the 12 conditions analyzed, 10 were significant, and 9 out of 10 conditions favored the tablet-administered questionnaire. Medication lists and laboratory results were reviewed to confirm the presence of the selected conditions. We reviewed the EHR problem list one year after the study was initiated to update the conditions under study. The additional data corroborated 107 additional self-reported conditions in 97 patients. In summary, a self-administered tablet questionnaire is an acceptable method for collecting the medical history. When combined with the EHR problem list, self-reported medical history is optimal for obtaining the most accurate problem list possible.

Purpose and Methods. Most patients who harbor a genetic mutation for hereditary breast cancer have not been identified, despite the availability of genetic testing. Developing an effective approach to the identification of high-risk individuals is the key to preventing and/or providing early diagnosis of cancer in this patient population. This educational review addresses these issues. Results and Discussion. Using data available on the internet, and making assumptions regarding the types and results of genetic testing, we have estimated the number of mutation carriers in the country and the number who have been tested and identified as such. Overall, our ability to fund and more effectively manage carriers is weak. A technological solution is discussed.

Family history of cancer is critical for identifying and managing patients at risk for cancer. However, the quality of family history data is dependent on the accuracy of patient self reporting. Therefore, the validity of family history reporting is crucial to the quality of clinical care. A retrospective review of family history data collected at a community hospital between 2005 and 2009 was performed in 43,257 women presenting for screening mammography. Reported numbers of breast, colon, prostate, lung, and ovarian cancer were compared in maternal relatives vs. paternal relatives and in first vs. second degree relatives. Significant reporting differences were found between maternal and paternal family history of cancer, in addition to degree of relative. The number of paternal family histories of cancer was significantly lower than that of maternal family histories of cancer. Similarly, the percentage of grandparents' family histories of cancer was significantly lower than the percentage of parents' family histories of cancer. This trend was found in all cancers except prostate cancer. Self-reported family history in the community setting is often influenced by both bloodline of the cancer history and the degree of relative affected. This is evident by the underreporting of paternal family histories of cancer, and also, though to a lesser extent, by degree. These discrepancies in reporting family history of cancer imply we need to take more care in collecting accurate family histories and also in the clinical management of individuals in relation to hereditary risk.

Currently, management strategies exist that can decrease the morbidity and mortality associated with having a BRCA1 or BRCA2 mutation. Unfortunately, the task of identifying these patients at high risk is a daunting challenge. This problem is intensified because Electronic Health Records (EHRs) today lack the functionality needed to identify these women and to manage those women once they have been identified. Numerous niche software programs have been developed to fill this gap. Unfortunately, these extremely valuable niche programs are prevented from being interoperable with the EHRs, on the premise that each EHR vendor will build their own programs. Effectively, in our efforts to adopt EHRs, we have lost sight of the fact that they can only have a major impact on quality of care if they contain structured data and if they interact with robust Clinical Decision Support (CDS) tools. We are at a cross roads in the development of the health care Information Technology infrastructure. We can choose a path where each EHR vendor develops each CDS module independently. Alternatively, we can choose a path where experts in each field develop external niche software modules that are interoperable with any EHR vendor. We believe that the modular approach to development of niche software programs that are interoperable with current EHRs will markedly increase the speed at which useful and functional EHRs that improve quality of care become a reality. Thus, in order to realize the benefits of CDS, we suggest vendors develop means to become interoperable with external modular niche programs.

Despite advances in identifying genetic markers of high risk patients and the availability of genetic testing, it remains challenging to efficiently identify women who are at hereditary risk and to manage their care appropriately. HughesRiskApps, an open-source family history collection, risk assessment, and Clinical Decision Support (CDS) software package, was developed to address the shortcomings in our ability to identify and treat the high risk population. This system is designed for use in primary care clinics, breast centers, and cancer risk clinics to collect family history and risk information and provide the necessary CDS to increase quality of care and efficiency. This paper reports on the first implementation of HughesRiskApps in the community hospital setting. HughesRiskApps was implemented at the Newton-Wellesley Hospital. Between April 1, 2007 and March 31, 2008, 32,966 analyses were performed on 25,763 individuals. Within this population, 915 (3.6%) individuals were found to be eligible for risk assessment and possible genetic testing based on the 10% risk of mutation threshold. During the first year of implementation, physicians and patients have fully accepted the system, and 3.6% of patients assessed have been referred to risk assessment and consideration of genetic testing. These early results indicate that the number of patients identified for risk assessment has increased dramatically and that the care of these patients is more efficient and likely more effective.

The self-reporting of cancer history is becoming increasingly important, as it frequently guides medical decision-making. We studied the accuracy of personal cancer history using a self-administered questionnaire, comparing the results with the Tumor Registry at our institution. Among 39,662 records, we identified 3614 women with a single cancer in the Tumor Registry who reported none or one cancer on their questionnaire. The sensitivity in self-reporting cancers was 85.7%, ranging from 92.1% for breast cancer to 42.9% for leukemia. The accuracy for breast cancer and Hodgkin's Lymphoma was significantly better than other cancers (p=0.00027, CI: 1.4-3.88). Analysis of patient's characteristics showed that Caucasians reported breast cancer more accurately than Asian/Pacific Islanders (p=0.008), and those with Jewish ancestry more accurately than non-Jewish (p=0.0435). These results will help us to improve data collection and thus improve medical decision-making.

This article analyzes the 1812 Russian campaign using Clausewitz’s concept of the trinitarian nature of war. This approach uses a case study to delve deeply into understanding the subtle, philosophical nature of Clausewitz’s trinity. The article is serialized into two parts; the first discusses each of the trinity’s elements. The second part applies each trinitarian element to the Russian campaign.

"The Pregnancy and Health Profile," (PHP) is a free genetic risk assessment software tool for primary prenatal providers that collects patient-entered family (FHH), personal, and obstetrical health history, performs risk assessment, and presents the provider with clinical decision support during the prenatal encounter. The tool is freely available for download at www.hughesriskapps.net. We evaluated the implementation of PHP in four geographically diverse clinical sites. Retrospective chart reviews were conducted for patients seen prior to the study period and for patients who used the PHP to collect data on documentation of FHH, discussion of cystic fibrosis (CF) and hemoglobinopathy (HB) carrier screening, and CF and HB interventions (tests, referrals). Five hundred pre-implementation phase and 618 implementation phase charts were reviewed. Documentation of a 3-generation FHH or pedigree improved at three sites; patient race/ethnicity at three sites, father of the baby (FOB) race/ethnicity at all sites, and ancestry for the patient and FOB at three sites (P 0.001-0001). CF counseling improved for implementation phase patients at one site (8% vs. 48%, P 0.0001) and CF screening/referrals at two (2% vs. 14%, P 0.0001; 6% vs. 14%; P = 0.05). Counseling and intervention rates did not increase for HB. This preliminary study suggests that the PHP can improve documentation of FHH, race, and ancestry, as well as the compliance with current CF counseling and intervention guidelines in some prenatal clinics. Future evaluation of the PHP should include testing in a larger number of clinical environments, assessment of additional performance measures, and evaluation of the system's overall clinical utility.

The use of genetics to personalize health care has been a goal and ambition of clinicians for several years. If used appropriately, such an approach could lead to improved quality of care and reduced costs. However, several barriers exist to the effective and efficient use of genetics in medicine which include the magnitude and complexity of genetic information, the limited training of clinicians in genetics, and the limited number of genetics experts. Many thought leaders are looking to health IT and in particular CDS to overcome these barriers to realize personalized health care. This chapter will review several aspects of personalized health care including family health history, genetic testing, pharmacogenomics, and whole genome sequencing, as well as how CDS has and can support personalized health care. The chapter will also describe efforts that are ongoing or required to make CDS for personalized health care available on a widespread scale.

“The Pregnancy and Health Profile” (PHP) is a free prenatal genetic screening and clinical decision support (CDS) software tool for prenatal providers. PHP collects family health history (FHH) during intake and provides point-of-care risk assessment for providers and education for patients. This pilot study evaluated patient and provider responses to PHP and effects of using PHP in practice. PHP was implemented in four clinics. Surveys assessed provider confidence and knowledge and patient and provider satisfaction with PHP. Data on the implementation process were obtained through semi-structured interviews with administrators. Quantitative survey data were analyzed using Chi square test, Fisher’s exact test, paired t tests, and multivariate logistic regression. Open-ended survey questions and interviews were analyzed using qualitative thematic analysis. Of the 83 % (513/618) of patients that provided feedback, 97 % felt PHP was easy to use and 98 % easy to understand. Thirty percent (21/71) of participating physicians completed both pre- and post-implementation feedback surveys [13 obstetricians (OBs) and 8 family medicine physicians (FPs)]. Confidence in managing genetic risks significantly improved for OBs on 2/6 measures (p values ≤0.001) but not for FPs. Physician knowledge did not significantly change. Providers reported value in added patient engagement and reported mixed feedback about the CDS report. We identified key steps, resources, and staff support required to implement PHP in a clinical setting. To our knowledge, this study is the first to report on the integration of patient-completed, electronically captured and CDS-enabled FHH software into primary prenatal practice. PHP is acceptable to patients and providers. Key to successful implementation in the future will be customization options and interoperability with electronic health records.

The American Cancer Society (ACS) guidelines define the appropriate use of MRI as an adjunct to mammography for breast cancer screening. Three risk assessment models are recommended to determine if women are at sufficient risk to warrant the use of this expensive screening tool, however, the real-world application of these models has not been explored. We sought to understand how these models behave in a community setting for women undergoing mammography screening. We conducted a retrospective analysis of 5,894 women, who received mammography screening at a community hospital and assessed their eligibility for MRI according to the ACS guidelines. Of the 5,894 women, 342 (5.8%) were eligible for MRI, but we found significant differences in the number of eligible women identified by each model. Our results indicate that these models identify very different populations, implying that the ACS guidelines deserve further development and consideration. Cancer Epidemiol Biomarkers Prev; 22(1); 146–9. ©2012 AACR.

Objective: The opportunity to integrate clinical decision support systems into clinical practice is limited due to the lack of structured, machine readable data in the current format of the electronic health record. Natural language processing has been designed to convert free text into machine readable data. The aim of the current study was to ascertain the feasibility of using natural language processing to extract clinical information from >76,000 breast pathology reports. Approach and Procedure: Breast pathology reports from three institutions were analyzed using natural language processing software (Clearforest, Waltham, MA) to extract information on a variety of pathologic diagnoses of interest. Data tables were created from the extracted information according to date of surgery, side of surgery, and medical record number. The variety of ways in which each diagnosis could be represented was recorded, as a means of demonstrating the complexity of machine interpretation of free text. Results: There was widespread variation in how pathologists reported common pathologic diagnoses. We report, for example, 124 ways of saying invasive ductal carcinoma and 95 ways of saying invasive lobular carcinoma. There were >4000 ways of saying invasive ductal carcinoma was not present. Natural language processor sensitivity and specificity were 99.1% and 96.5% when compared to expert human coders. Conclusion: We have demonstrated how a large body of free text medical information such as seen in breast pathology reports, can be converted to a machine readable format using natural language processing, and described the inherent complexities of the task.