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Tag: Nursing

  • Risk-reducing mastectomies lower breast cancer incidence and mortality in BRCA variant carriers

    Risk-reducing mastectomies lower breast cancer incidence and mortality in BRCA variant carriers

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    A study co-led by Professor Kelly Metcalfe of the Lawrence Bloomberg Faculty of Nursing, and researchers at the Familial Breast Cancer Research Unit at Women’s College Hospital, finds risk-reducing mastectomies (RRM) in women with a BRCA1 or BRCA2 genetic variant, significantly reduces the risk of being diagnosed with breast cancer and lowers the probability of death.

    The study, published in the British Journal of Cancer, examined how RRM affects the rate of death of women with a pathogenic variant but no cancer diagnosis. To date, there has been only one other study published by researchers in the Netherlands that examines the impact of RRM on mortality and quantifies the benefits associated for women.

    “The decision to have a risk reducing mastectomy is often difficult for a woman to make, and the more evidence we are able to provide them with when they are making that decision, the more informed their care plan will be,” says Metcalfe who is also a Senior Scientist with Women’s College Research Institute.

    Women who have an inherited BRCA1 or BRCA2 variant, have an 80 per cent risk of developing breast cancer over the course of their lifetime. Research has shown that an RRM reduces the risk of breast cancer by 90 per cent, and in Canada, 30 per cent of women with a pathogenic variant opt for this surgery. It is, Metcalfe says, one of the most effective ways of preventing breast cancer in women with this risk profile.

    Through a pseudo-randomized trial, Metcalfe, and her team, followed over 1600 participants from a registry of women with a pathogenic BRCA 1/2 variant from nine different countries over the course of six years, with half of the women having a risk-reducing mastectomy.

    At the end of the trial, there were 20 incident breast cancers and two deaths in the group who opted for a RRM, and 100 incident breast cancers and seven deaths in the control group. RRM reduced the risk of breast cancer by 80 per cent, and the probability of dying of breast cancer 15 years after risk-reducing mastectomy was less than one per cent.

    “Although there wasn’t a significant difference in deaths between the two groups in this study, we know that a risk reducing mastectomy significantly reduces the risk of ever developing breast cancer,” says Metcalfe.

    Metcalfe points out that following these participants for an extended period would generate more evidence to assess the true mortality risk with precision and highlight the benefits associated with this type of surgery.

    Right now, we have good screening in place for breast cancer, including breast MRI, so surgery is only offered as an option, not a recommendation. But with more studies being conducted to assess women’s trajectory and risk factors following RRM, we will know whether these guidelines need to be changed in the future.”


    Professor Kelly Metcalfe, Lawrence Bloomberg Faculty of Nursing

    Source:

    Journal reference:

    Metcalfe, K., et al. (2024). Risk-reducing mastectomy and breast cancer mortality in women with a BRCA1 or BRCA2 pathogenic variant: an international analysis. British Journal of Cancer. doi.org/10.1038/s41416-023-02503-8.

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  • Do we simply not care about old people?

    Do we simply not care about old people?

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    The covid-19 pandemic would be a wake-up call for America, advocates for the elderly predicted: incontrovertible proof that the nation wasn’t doing enough to care for vulnerable older adults.

    The death toll was shocking, as were reports of chaos in nursing homes and seniors suffering from isolation, depression, untreated illness, and neglect. Around 900,000 older adults have died of covid-19 to date, accounting for 3 of every 4 Americans who have perished in the pandemic.

    But decisive actions that advocates had hoped for haven’t materialized. Today, most people — and government officials — appear to accept covid as a part of ordinary life. Many seniors at high risk aren’t getting antiviral therapies for covid, and most older adults in nursing homes aren’t getting updated vaccines. Efforts to strengthen care quality in nursing homes and assisted living centers have stalled amid debate over costs and the availability of staff. And only a small percentage of people are masking or taking other precautions in public despite a new wave of covid, flu, and respiratory syncytial virus infections hospitalizing and killing seniors.

    In the last week of 2023 and the first two weeks of 2024 alone, 4,810 people 65 and older lost their lives to covid — a group that would fill more than 10 large airliners — according to data provided by the CDC. But the alarm that would attend plane crashes is notably absent. (During the same period, the flu killed an additional 1,201 seniors, and RSV killed 126.)

    “It boggles my mind that there isn’t more outrage,” said Alice Bonner, 66, senior adviser for aging at the Institute for Healthcare Improvement. “I’m at the point where I want to say, ‘What the heck? Why aren’t people responding and doing more for older adults?’”

    It’s a good question. Do we simply not care?

    I put this big-picture question, which rarely gets asked amid debates over budgets and policies, to health care professionals, researchers, and policymakers who are older themselves and have spent many years working in the aging field. Here are some of their responses.

    The pandemic made things worse. Prejudice against older adults is nothing new, but “it feels more intense, more hostile” now than previously, said Karl Pillemer, 69, a professor of psychology and gerontology at Cornell University.

    “I think the pandemic helped reinforce images of older people as sick, frail, and isolated — as people who aren’t like the rest of us,” he said. “And human nature being what it is, we tend to like people who are similar to us and be less well disposed to ‘the others.’”

    “A lot of us felt isolated and threatened during the pandemic. It made us sit there and think, ‘What I really care about is protecting myself, my wife, my brother, my kids, and screw everybody else,’” said W. Andrew Achenbaum, 76, the author of nine books on aging and a professor emeritus at Texas Medical Center in Houston.

    In an environment of “us against them,” where everybody wants to blame somebody, Achenbaum continued, “who’s expendable? Older people who aren’t seen as productive, who consume resources believed to be in short supply. It’s really hard to give old people their due when you’re terrified about your own existence.”

    Although covid continues to circulate, disproportionately affecting older adults, “people now think the crisis is over, and we have a deep desire to return to normal,” said Edwin Walker, 67, who leads the Administration on Aging at the Department of Health and Human Services. He spoke as an individual, not a government representative.

    The upshot is “we didn’t learn the lessons we should have,” and the ageism that surfaced during the pandemic hasn’t abated, he observed.

    Ageism is pervasive. “Everyone loves their own parents. But as a society, we don’t value older adults or the people who care for them,” said Robert Kramer, 74, co-founder and strategic adviser at the National Investment Center for Seniors Housing & Care.

    Kramer thinks boomers are reaping what they have sown. “We have chased youth and glorified youth. When you spend billions of dollars trying to stay young, look young, act young, you build in an automatic fear and prejudice of the opposite.”

    Combine the fear of diminishment, decline, and death that can accompany growing older with the trauma and fear that arose during the pandemic, and “I think covid has pushed us back in whatever progress we were making in addressing the needs of our rapidly aging society. It has further stigmatized aging,” said John Rowe, 79, professor of health policy and aging at Columbia University’s Mailman School of Public Health.

    “The message to older adults is: ‘Your time has passed, give up your seat at the table, stop consuming resources, fall in line,’” said Anne Montgomery, 65, a health policy expert at the National Committee to Preserve Social Security and Medicare. She believes, however, that baby boomers can “rewrite and flip that script if we want to and if we work to change systems that embody the values of a deeply ageist society.”

    Integration, not separation, is needed. The best way to overcome stigma is “to get to know the people you are stigmatizing,” said G. Allen Power, 70, a geriatrician and the chair in aging and dementia innovation at the Schlegel-University of Waterloo Research Institute for Aging in Canada. “But we separate ourselves from older people so we don’t have to think about our own aging and our own mortality.”

    The solution: “We have to find ways to better integrate older adults in the community as opposed to moving them to campuses where they are apart from the rest of us,” Power said. “We need to stop seeing older people only through the lens of what services they might need and think instead of all they have to offer society.”

    That point is a core precept of the National Academy of Medicine’s 2022 report Global Roadmap for Healthy Longevity. Older people are a “natural resource” who “make substantial contributions to their families and communities,” the report’s authors write in introducing their findings.

    Those contributions include financial support to families, caregiving assistance, volunteering, and ongoing participation in the workforce, among other things.

    “When older people thrive, all people thrive,” the report concludes.

    Future generations will get their turn. That’s a message Kramer conveys in classes he teaches at the University of Southern California, Cornell, and other institutions. “You have far more at stake in changing the way we approach aging than I do,” he tells his students. “You are far more likely, statistically, to live past 100 than I am. If you don’t change society’s attitudes about aging, you will be condemned to lead the last third of your life in social, economic, and cultural irrelevance.”

    As for himself and the baby boom generation, Kramer thinks it’s “too late” to effect the meaningful changes he hopes the future will bring.

    “I suspect things for people in my generation could get a lot worse in the years ahead,” Pillemer said. “People are greatly underestimating what the cost of caring for the older population is going to be over the next 10 to 20 years, and I think that’s going to cause increased conflict.”

    Kaiser Health NewsThis article was reprinted from khn.org, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF – the independent source for health policy research, polling, and journalism.

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  • Stroke survivors exposed to sexual assault face greater recovery challenges

    Stroke survivors exposed to sexual assault face greater recovery challenges

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    Stressors and traumatic events experienced over the course of a lifetime may negatively impact subsequent stroke recovery; specifically, stroke survivors exposed to sexual assault at any point in their life had poorer physical functioning and cognitive outcomes one year after a stroke, according to a preliminary study to be presented at the American Stroke Association’s International Stroke Conference 2024. The meeting will be held in Phoenix, Feb. 7-9, and is a world premier meeting for researchers and clinicians dedicated to the science of stroke and brain health.

    It is important to know what has happened to a patient in their life when taking care of them post-stroke. Screening for lifetime stress and trauma is important when caring for a patient who has had a stroke because those experiences often have far-reaching impact and may predict how well a person does over time.”


    E. Alison Holman, Ph.D., lead study author, professor of nursing and psychological science at the University of California, Irvine

    Researchers examined data from the STRONG (Stroke, sTress, RehabilitatiON, and Genetics) study to investigate specific types of stressors that may contribute to adverse physical function and cognitive outcomes one year after stroke. In the STRONG study, stroke survivors were assessed four times during the year. Assessments included the Lifetime Stress and Trauma Exposure survey, completed approximately 90 days after the stroke. Participants reported their lifetime exposure to 31 different types of stressful and/or traumatic events, including witnessing a loved one being injured or killed; sexual assault; divorce; emotional and physical abuse in childhood; and poverty. Additionally, one year after the stroke, participants were assessed for physical function and cognitive abilities. The researchers evaluated the relationships among lifetime stress and trauma exposure and functional and cognitive outcomes among 763 stroke survivors, average age of 63 years.

    The analysis found:

    • Sexual assault was the traumatic event most strongly associated with a moderate decrease in the ability to perform activities of daily living and lower scores on the modified Rankin Scale (describes a person’s ability to function) and Telephone Montreal Cognitive Assessment scores one year after stroke, after controlling for age, gender, race and National Institutes of Health stroke scale score (a measure of stroke severity) three months after a stroke.

    • Other adverse experiences – witnessing a family member be injured or killed; going through a divorce; and/or suffering childhood physical abuse – were also independently associated with a moderate decrease in ability to perform daily living activities one year after stroke.

    • These associations remained even when early post-stroke acute stress levels were accounted for in the analysis.

    • In contrast, taking care of a seriously ill loved one was associated with better scores on the Telephone Montreal Cognitive Assessment. Holman noted that people taking care of others are more actively engaged in everyday life, which may keep the mind sharper. 

    • Women were significantly more likely to report being sexually assaulted and having a seriously ill loved one.

    Holman emphasized that health care professionals should be aware of the potentially lasting physical health impact of sexual assault and other traumatic events that occur over the course of a person’s life. Understanding that these prior life experiences can shape how patients respond to a subsequent stroke may encourage more compassionate communication.

    “Bad things happen to people, so the goal is to intervene in the immediate aftermath of the stroke to prevent its worst effects. We should be able to use this information to allocate resources in a targeted way to provide better support for people during post-stroke recovery,” she said. “Health care professionals can use psychological first aid strategies to support the patients’ basic needs, help them cope and refer them to resources such as a support group or community agency. Sometimes just acknowledging the experience is itself freeing.”

    “This study raises our awareness of how important it is to manage stressors and to increase our physical and mental resilience,” said Randi Foraker, Ph.D., M.A., FAHA, vice chair of the American Heart Association’s Epidemiology & Cardiovascular Stroke Nursing Prevention Science Committee, and professor of medicine, Institute for Informatics, Data Science and Biostatistics and director, Center for Population Health Informatics at Washington University in St. Louis, School of Medicine, Missouri. “Some of the ways we can bolster our resilience and our wellness is to engage in mindful meditation, social engagement and physical activity. As clinicians, researchers and caregivers, we need to make sure we are giving stroke survivors their best chance at living longer, healthier lives.” Dr. Foraker was not involved in the study.

    Study details and background:

    • The study included 763 stroke survivors (average age of 63; 41.3% female; 60.9% white adults).

    • The STRONG study was conducted at 28 stroke centers across the U.S. from 2016-2021.

    • The current study findings build on the STRONG study, led by Holman and her colleague Steven Cramer, M.D., that was previously published in the American Heart Association’s Stroke journal (Sept. 2023), which also suggested that cumulative traumatic stress exposure impairs recovery from stroke.

    The main study limitations were that patients with a severe stroke and those who did not speak English were excluded, so we do not know whether the findings would apply to those patients. Additional research is needed to investigate the potential mechanisms that link these traumatic events to worse outcomes after stroke. Holman suggests it is important to examine both psychological and physiologic processes that may explain the findings.

    Source:

    American Heart Association

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  • Age-related changes in the brain network may explain why older women feel more pain

    Age-related changes in the brain network may explain why older women feel more pain

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    A new study has found that the brain system enabling us to inhibit our own pain changes with age, and that gender-based differences in those changes may lead females to be more sensitive to moderate pain than males as older adults.

    Researchers used fMRI scans to examine brain responses in men and women who had rated the intensity and unpleasantness of pain during exposure to increasing levels of heat. The results suggested that established gender differences in pain perception could likely be traced at least in part to this brain network, and offered new evidence that those gender differences may become more disparate with age.

    The most novel part of this study is looking at gender by age. Most of the work characterizing which regions in the brain respond to pain have been done in people aged 18 to 40. We want to understand what’s happening between the ages of 30 and 90 years old because that’s when people are beginning to experience chronic pain.”


    Michelle Failla, lead study author, assistant professor in the College of Nursing at The Ohio State University

    The study was published recently in The Journal of Pain.

    Plenty of previous research has shown that females are more sensitive to pain than males, but the brain regions and functions behind the gender differences in pain perception have mostly remained a mystery. And in later adulthood, when risk for chronic pain is higher and our tolerance for pain drops, even less about the brain’s role in pain perception is known.

    In this study, the researchers specified that they holistically examined gender-based differences that may relate not just to biological sex, but also to social factors that influence how people respond to pain.

    The imaging component of the study zeroed in on the descending pain modulatory system (DPMS), a hub of brain regions that communicate with each other to engage signal transmission – including activation of opioid receptors – that enables us to reduce our own pain.

    The study sample included 27 females and 32 males between ages 30 and 86 who were asked to report when applied heat reached levels of just-noticeable, weak and moderate pain and to rate how unpleasant each level felt. Researchers used the fMRI imaging to observe DPMS activity that corresponded with each participant’s individual pain response.

    “There are different brain regions involved in those distinctions between perception of pain intensity and unpleasantness, so we thought it was important to look at both and see how those brain regions are recruited during pain,” said Failla, also an investigator in the Center for Healthy Aging, Self-Management and Complex Care in Ohio State’s College of Nursing.

    Results showed that a few regions within the brain’s pain modulatory system did indicate a gender-by-age difference: At the moderate pain level, men showed an increased DPMS response with older age, while as women aged, the DPMS response decreased. A decreased response in the brain is presumed to translate into a lower ability to harness our own physiological functions to reduce our pain.

    Presumed is a key word: While the DPMS is believed to have a significant role in pain sensitivity and tolerance, researchers are still working toward describing exactly how it works and how an intact versus dysfunctional system shows up in scans.

    “We don’t know exactly what is an optimum DPMS response,” Failla said. “Are we seeing it activated to catch up with your pain, or is it already working, meaning the pain could have been worse?”

    The researchers are continuing this work, which includes investigating brain activity in people who may have a difficult time articulating the pain that they’re feeling – such as people with dementia or autism.

    The more scientists can learn about the brain’s role in pain perception, the better the chances are for more effective pain management, Failla said.

    “Pain is such an individual experience. In science we’re moving toward individual factors that can influence pain specifically and what makes it different for each person,” she said. “This could then identify a mechanism we can target, or even just give us a better understanding that there are different levels of innate abilities to modulate pain.”

    This study was conducted at Vanderbilt University Medical Center and was supported by a National Institute on Aging grant awarded to co-authors Todd Monroe of Ohio State and Ronald Cowan of the University of Tennessee Health Science Center.

    Other co-authors include Paul Beach of Emory University, Sebastian Atalla of the University of North Carolina, and Mary Dietrich and Stephen Bruehl of Vanderbilt University.

    Source:

    Journal reference:

    Failla, M. D., et al. (2023). Gender Differences in Pain Threshold, Unpleasantness, and Descending Pain Modulatory Activation Across the Adult Life Span: A Cross Sectional Study. The Journal of Pain. doi.org/10.1016/j.jpain.2023.10.027.

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