Grady Hospital Research Articles

485 Investigating the Impact of Inflammation on White Matter Tracts using Diffusion Tensor Imaging that may Contribute to Motivational Deficits and Negative Symptoms in Patients with Schizophrenia

OBJECTIVES/GOALS: Previous research has linked inflammation to changes in brain reward circuitry and subsequent negative symptoms in patients with schizophrenia. This project aims to understand brain-immune interactions using diffusion tensor imaging (DTI) to investigate the impact of inflammatory markers on white matter (WM) tracts. METHODS/STUDY POPULATION: Patients with schizophrenia, ages 18 to 45, were recruited at Grady Hospital in Atlanta, GA. All subjects were stable outpatients and underwent extensive medical screening to rule out medical causes of acute inflammation. DTI data was collected from 39 participants on a 3-Tesla Siemens scanner. Blood was collected between 9-11AM for later assay of serum inflammatory markers. Negative symptoms were assessed using the Brief Negative Symptom Scale (BNSS). A diffusion tensor imaging model will be fitted with the data to generate well-known diffusion tensor measures (fractional anisotropy and mean diffusivity). Linear regression will be used to analyze the relationship between DTI measures and inflammation (C-Reactive Protein, CRP), controlling for possible confounders. RESULTS/ANTICIPATED RESULTS: The hypothesis of this proposal is that decreased microstructural integrity in WM tracts between the nucleus accumbens (NAc) and insula will be associated with increased inflammation, which in turn are associated with increased negative symptoms. Negative symptoms include deficits in motivation/pleasure as well as diminished expressivity, and are strongly associated with poor functional outcomes. Based on previous data from this sample demonstrating relationships between CRP and negative symptoms as well as CRP and fMRI functional connectivity between the NAc and insula, we anticipate results that demonstrate similar relationships with WM microstructural integrity, such as functional anisotropy and mean diffusivity. DISCUSSION/SIGNIFICANCE: Given the lack of treatment options for negative symptoms, this research will provide key data to further our understanding of the potential role of inflammation on neural circuits that underlie these symptoms, including WM integrity. This research also has the potential to inform future anti-inflammatory therapies for patients with schizophrenia.

Homocysteine-induced Barrier Dysfunction and Hyperpermeability in the Blood-Brain and Blood-Retinal Barrier: Role of NLRP3 Inflammasome Pathway

Prolonged exposure to microgravity during long- and short-duration spaceflight has been found to produce many pathophysiological changes. Of these, a set constellation of changes called “Spaceflight Associated Neuro-ocular Syndrome” (SANS) induces neuro-ophthalmic changes. Recent evidence suggests astronauts who experienced SANS generally had higher concentrations of one-carbon pathway intermediate homocysteine (Hcy) prior to spaceflight. Hcy is a known inducer of inflammatory mediators and vascular endothelial dysfunction, leading to blood-brain barrier (BBB) breakdown. Mechanisms behind this dysfunction/hyperpermeability are not clearly known, but recent studies show evidence for loss of BBB integrity following microgravity/simulated microgravity. Recent studies from our lab suggest that activation of the nucleotide-binding domain leucine-rich repeat and pyrin domain containing receptor 3 (NLRP3) inflammasome plays a role in mediating BBB dysfunction and related microvascular hyperpermeability. Our main objective was to understand the mechanism(s) by which Hcy could induce BBB dysfunction/hyperpermeability, and potential association with SANS. We hypothesized that Hcy-mediated dysfunction/BBB hyperpermeability occurs via NLRP3 inflammasome activation and subsequent proteolytic breakdown of tight junction proteins. Understanding this pathway is critical to devise protection against SANS at a microvascular level. To study this relationship, human brain microvascular endothelial cells (HBMECs) were treated with various concentrations of Hcy. The monolayer permeability was evaluated using Transwell permeability assays with fluorescence tracer FITC-dextran (10-kDa). Matrixmetalloproteinase (MMP-9) and calpain activities were measured fluorometrically. Hcy induced endothelial monolayer hyperpermeability dose-dependently (p<0.05). NLRP3 inhibitor MCC950 decreased Hcy-induced hyperpermeability (p<0.05). Hcy treatment showed no significant effect on cell viability at lower concentration but decreased cell viability at higher concentrations. MCC950 inhibited Hcy-induced MMP-9 and calpain 1 activity. These results suggest a possible mechanism of BBB dysfunction/hyperpermeability by Hcy via activation of the NLRP3 inflammasome pathway. The proteolytic enzymes MMP-9 and calpain 1 are potential downstream mediators of Hcy-induced BBB dysfunction/hyperpermeability. Seeing that the blood-retinal barrier (BRB) shares structural-functional similarity with the BBB, human retinal microvascular endothelial cells (HRMEC) were examined for comparisons of barrier permeability. The results suggest Hcy-induced hyperpermeability in HRMEC monolayers and decreased expression of tight junction protein zonula occludens-1. Expression and effects were attenuated by NLRP3 inhibition. Our results suggest that NLRP3 inflammasome signaling may play an important role in promoting Hcy-induced barrier dysfunction and hyperpermeability in the blood-brain and blood-retinal barriers. Morehouse School of Medicine, Grady Hospital Surgery Dept, NASA This is the full abstract presented at the American Physiology Summit 2023 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

214 Relationships between Childhood Trauma Exposure, Mental Health, and Black-Identity in Black Pregnant Persons

OBJECTIVES/GOALS: Racial identity, one’s perception of that identity, and their perception of how others view their racial identity influences mental health. We aimed to assess the relationship between childhood trauma exposure, post-traumatic stress disorder (PTSD), and postpartum depression symptoms with individual Black identity in adulthood. METHODS/STUDY POPULATION: We examined whether racial identity, as measured by the regard subsection of the Multidimensional Inventory of Black Identity (MIBI), was impacted by childhood trauma exposure and related to PTSD and depressive symptoms in a sample of pregnant persons (N= 215, Mage=27.5, SDage=5.3) who identified within the Black diaspora, seeking prenatal care at Grady Hospital in Atlanta, GA. The regard subsection of the MIBI determines extent to which individuals feel positively about membership within the Black group (private regard) and the extent to which they think others feel positively about the Black group (public regard). We assessed childhood trauma using Childhood Trauma Questionnaire (CTQ) and depression and PTSD symptoms with Edinburgh Postnatal Depression Scale, and PTSD Checklist for DSM-5, respectively. RESULTS/ANTICIPATED RESULTS: Public regard (pubR) and private regard (privR) were significantly negatively correlated with childhood emotional abuse, emotional neglect, and overall childhood trauma exposure (all p’s.05). PrivR was significantly negatively correlated with both postpartum depression and PTSD symptoms (p DISCUSSION/SIGNIFICANCE: Ethnic-racial identity formation is a critical aspect of our psychological well-being, beginning in childhood and continuing across one’s lifespan. Our findings suggest that childhood trauma impacts racial identity in persons of the Black diaspora, which may contribute to negative mental health outcomes, including PTSD and depression.

Is uterine cancer screening indicated or possible in high risk special populations?

e17126 Background: Uterine cancer (UC) is being considered for screening by the CDC due to its relative ascendancy in incidence. We sought to determine its potential for screening using a vanguard of contemporary cancer risk with high non-communicable disease rates (American Samoa [AS]) as a model sample set, and then Grady Hospital (GH) as a test population for screening. Methods: Public access de-identified databases covering the entire national population of AS over several time periods and de-identified GH tumor registry data. Results: In 2014 AS reported 258 new cancers (9.4/10,000 women/yr) including UC (36%), breast (37.6%), cervix (6.6%), ovary (5.1%), and others (14.7%). UC was the leading cause of gynecologic deaths (1.6x > ovarian or cervical). From 2004 - 14 the incidence of UC increased 78.9% to 3.4 cases/10,000 women/yr while breast cancer increased 52.2% to 3.5 cases/10,000. In the most recent 24 months, UC was 2.5x more likely to be diagnosed than breast, 3.6x more than colon, 8x more than cervical and 10.7x more than ovarian cancers. Gyn cancers were the leading cause of cancer death among women after lung. Based on this high incidence of UC, we sought to determine if it would be possible to reach US patients for potential screening using an urban population with health disparities in a test sample of potential beneficiaries of screening for UC the GH Morehouse service (79% black; mean age 58 (33 - 88). From 2010-6, 197 UCs were treated at GH; 96% were GH patients prior to diagnosis with an average time from earliest hospital encounter to the UC diagnosis of 1.75 years (0 – 5.5). Changes from 1st GH encounter to UC diagnosis and treatment including BMI, age, co-morbidities, etc will be presented. Conclusions: Uterine cancer has similar characteristics to currently screened cancers with an incidence in some high-risk population just under breast and prostate, but ahead of lung and colon. An enriched population, eg. BMI combined with age, especially with disparities, could benefit most from changes in screening strategy and management. Patients with UC are accessible in the hospital of their treatment for potential screening years before diagnosis. This may be an opportunity to reduce cost and morbidity from a rapidly increasing cancer.

Accuracy of Prehospital Identification of Stroke in a Large Stroke Belt Municipality

Objective: Strokes are a leading cause of morbidity and mortality in the United States, especially in the “stroke belt” of the southeast. Up to 65% of stroke patients access care by calling 9–1-1. The primary objective of this study is to measure the accuracy of emergency medical dispatchers (EMD) and paramedics, in the prehospital identification of stroke. Methods: The study was based at Grady Emergency Medical Services, which is Atlanta, Georgia's public emergency medical services (EMS) provider. A retrospective analysis of all medically related 9–1-1 calls to Grady EMS classified as “stroke” between January 1, 2012, and December 31, 2012 was performed. A database was created using deterministic linkage between records from Grady EMS, Grady Hospital Emergency Department (ED), and the Grady Hospital Stroke Registry. Patients excluded were less than 18 years of age, had previous or concurrent head injuries, were transferred from another inpatient facility, and/or had incomplete patient records in any one of the three databases. Descriptive analysis, linear regression, and logistic multivariable regression were performed to discover the accuracy of stroke identification and contributory prehospital factors. Results: A total of 548 patients were included: 475 were transported with EMS impression of stroke and 73 with an impression other than stroke. The median age was 59 years, 87.4% were black, and 52.6% were female. Paramedics adhered to all seven elements of the Grady EMS stroke protocol in 76.4% (n = 363) of suspected stroke cases. Sensitivity and positive predictive value for paramedic stroke identification was 76.2% and 49.3%, respectively, and for EMD, was 48.9% and 24%, respectively. Identification of hemorrhagic strokes had a relatively lower sensitivity. Paramedics were more likely to positively identify strokes when the Cincinnati Prehospital Stroke Scale (CPSS) screen was positive, or when classified by EMD as stroke. Paramedics were less likely to identify stroke in female patients. Paramedics' diagnostic accuracy was similar regardless of their adherence to the EMS stroke care protocol. Conclusions: EMD and EMS personnel in a large city in the Southeastern United States, with high stroke prevalence, had a relatively high sensitivity in identifying acute stroke patients. Paramedic accuracy was augmented by positive CPSS screening and by EMD recognition of stroke.

77 Patterns of Emergency Department High Utilizers at Grady Memorial Hospital

High utilizers of emergency care represent an area of unmet need and can be a financial burden on the health care system. We aimed to identify emergency department (ED) high utilizers at Grady and determine the relationship between high utilizer patients and total visits. Previous studies have identified predictive factors associated with ED high utilizers at a specific setting. The demographics and clinical features of Grady high utilizers are also described. This retrospective study examined the electronic medical records of 216,522 patients with a total of 492,766 (ED) visits at Grady Hospital from November 2010 to March 2015. High utilizers were defined as patients with at least six ED visits in one year during the study period. Patient characteristics, diagnostic information, and ED operational measures were also examined. Data analysis was performed using descriptive statistics, chi-square tests, and independent samples t-tests. In this study, 2.6% of patients were high utilizers accounting for 25% of all visits. Of high utilizers, 69% were only high utilizers during one of the six calendar years included in the study period. High utilizers were more likely to be male (67% vs. 53%, p<.0001) and older than non-high utilizers (48.0 vs. 41.5, p<.0001). Sickle cell disease, substance abuse, chronic disease and mental health conditions were more frequent diagnoses in high-utilizer ED visits. The rate of leaving without being seen was significantly higher in the high utilizer group (21.3% vs. 11.2%, p<.0001). A small percentage (2.6%) of high utilizers made up one quarter of ED visits at Grady during the study period. These patients have a higher frequency of certain diagnoses than their non-high utilizer counterparts and tend to have transient patterns of high utilization. Further study is warranted to better understand and meet the unique needs of these patients.

Simulating clinical trial visits yields patient insights into study design and recruitment.

PurposeWe elicited patient experiences from clinical trial simulations to aid in future trial development and to improve patient recruitment and retention.Patients and methodsTwo simulations of draft Phase II and Phase III anifrolumab studies for systemic lupus erythematosus (SLE)/lupus nephritis (LN) were performed involving African-American patients from Grady Hospital, an indigent care hospital in Atlanta, GA, USA, and white patients from Altoona Arthritis and Osteoporosis Center in Altoona, PA, USA. The clinical trial simulation included an informed consent procedure, a mock screening visit, a mock dosing visit, and a debriefing period for patients and staff. Patients and staff were interviewed to obtain sentiments and perceptions related to the simulated visits.ResultsThe Atlanta study involved 6 African-American patients (5 female) aged 27–60 years with moderate to severe SLE/LN. The Altoona study involved 12 white females aged 32–75 years with mild to moderate SLE/LN. Patient experiences had an impact on four patient-centric care domains: 1) information, communication, and education; 2) responsiveness to needs; 3) access to care; and 4) coordination of care; and continuity and transition. Patients in both studies desired background material, knowledgeable staff, family and friend support, personal results, comfortable settings, shorter wait times, and greater scheduling flexibility. Compared with the Altoona study patients, Atlanta study patients reported greater preferences for information from the Internet, need for strong community and online support, difficulties in discussing SLE, emphasis on transportation and child care help during the visits, and concerns related to financial matters; and they placed greater importance on time commitment, understanding of potential personal benefit, trust, and confidentiality of patient data as factors for participation. Using these results, we present recommendations to improve study procedures to increase retention, recruitment, and compliance for clinical trials.ConclusionInsights from these two studies can be applied to the development and implementation of future clinical trials to improve patient recruitment, retention, compliance, and advocacy.

Willingness to Pay in Dermatology: Assessment of the Burden of Skin Diseases

Willingness to pay (WTP) is a monetary, preference-based, burden-of-disease measure with a potential role in dermatology, where many conditions are temporary and/or mild, and many treatments are inexpensive and one might be able to imagine paying out of pocket. We assessed construct validity by interviewing 254 consecutive dermatology patients at Stanford Medical Center, Grady Hospital, and Parkland Hospital. Instruments asked about an individual's own health status and elicited WTP, time-trade-off (TTO) utilities, and health status quality of life (QOL). We measured WTP cure (short treatment course to eliminate disease) and WTP control (lifelong medication). Our data indicate greater construct validity in non-Medicaid (n=163) than Medicaid (n=91) patients. Non-Medicaid subjects had greater WTP as percent of income for cure (median: 2%) than control (median: 1.6%), P<0.01; Medicaid WTP amounts for control and cure did not differ. Non-Medicaid subjects with verrucae had little QOL impact, no measurable burden by TTO, and a correspondingly low WTP. Medicaid subjects with basal cell carcinoma had a strong, negative QOL impact and high burden by TTO, but had relatively moderate WTP. WTP appears promising in certain income categories. More studies are needed for conclusions about specific diagnoses.

The explosion at a Glock Plant in Georgia

Dedicated to Rep. Gabrielle Giffords of Tucson, Arizona > Left one man dead, though he arrived at Grady Hospital, > > “in critical condition,” another man in “satisfactory,” > > according to the spokesman, and a woman, unhurt > > though dazed, like the witness to a sniper’s spree

Recurrent Diabetic Ketoacidosis in Inner-City Minority Patients

OBJECTIVETo conduct a bedside study to determine the factors driving insulin noncompliance in inner-city patients with recurrent diabetic ketoacidosis (DKA).RESEARCH DESIGN AND METHODSWe analyzed socioeconomic and psychological factors in 164 adult patients with DKA who were admitted to Grady Hospital between July 2007 and August 2010, including demographics, diabetes treatment, education, and mental illness. The Patient Health Questionnaire-9 and the Short Form-36 surveys were used to screen for depression and assess quality of life.RESULTSThe average number of admissions was 4.5 ± 7 per patient. A total of 73 patients presented with first-time DKA, and 91 presented with recurrent DKA; 96% of patients were African American. Insulin discontinuation was the leading precipitating cause in 68% of patients; other causes were new-onset diabetes (10%), infection (15%), medical illness (4%), and undetermined causes (3%). Among those who stopped insulin, 32% gave no reasons for stopping, 27% reported lack of money to buy insulin, 19% felt sick, 15% were away from their supply, and 5% were stretching insulin. Compared with first-time DKA, those with recurrent episodes had longer duration of diabetes (P < 0.001), were a younger age at the onset of diabetes (P = 0.04), and had higher rates of depression (P = 0.04), alcohol (P = 0.047) and drug (P < 0.001) abuse, and homelessness (P = 0.005). There were no differences in quality-of-life scores, major psychiatric illnesses, or employment between groups.CONCLUSIONSPoor adherence to insulin therapy is the leading cause of recurrent DKA in inner-city patients. Several behavioral, socioeconomic, psychosocial, and educational factors contribute to poor compliance. The recognition of such factors and the institution of culturally appropriate interventions and education programs might reduce DKA recurrence in minority populations.

Assessment of clinical trials knowledge and beliefs in cancer patients treated in an urban public hospital serving predominantly African American patients.

e16511 Background: The Georgia Cancer Center for Excellence (GCCE) at Grady Hospital is committed to reducing health disparities by improving access to cancer clinical trials. We conducted an asses...

Fear potentiation is associated with hypothalamic–pituitary–adrenal axis function in PTSD

A central problem in posttraumatic stress disorder (PTSD) is the inability to suppress fear under safe conditions. We have previously shown that PTSD patients cannot inhibit conditioned fear. Another relevant finding in PTSD is the hypersensitivity of the hypothalamic-pituitary-adrenal (HPA) axis feedback. Given their common neurobiological pathways, alterations in HPA function in PTSD may be associated with impaired fear inhibition. The present study examined the relationship between HPA axis function and fear-potentiated startle and inhibition of conditioned fear in trauma-exposed individuals. We used a conditional discrimination procedure (AX+/BX-), in which one set of shapes (AX+) was paired with aversive airblasts to the throat (danger signal), and the same X shape with a different shape (BX-) were presented without airblasts (safety signal). The paradigm also included a transfer of fear inhibition test (AB). In addition to fear-potentiated startle, blood was drawn for neuroendocrine analysis and the dexamethasone suppression test (DEX) was performed; cortisol and ACTH were assessed at baseline and post-DEX. Ninety highly traumatized individuals recruited from Grady Hospital in Atlanta, GA participated in the study. The sample was divided into those who met DSM-IV criteria for PTSD (n=29) and Non-PTSD controls (n=61) using the PTSD symptom scale (PSS). Both groups showed significant reduction in cortisol and ACTH levels after DEX. Subjects with PTSD had higher fear-potentiated startle to the safety signal, BX- (F(1,88)=4.44, p<0.05) and fear inhibition trials, AB (F(1,88)=5.20, p<0.05), both indicative of less fear inhibition in the presence of B, compared to control subjects. In addition, fear-potentiated startle to AX+, BX-, and AB was positively correlated with baseline and post-DEX ACTH in PTSD subjects. These results suggest that impaired fear inhibition and associated alterations in HPA feedback may reflect amygdala hyperactivity in subjects with PTSD.

Wnt Signaling Prognosticates Outcome in Breast Cancer Cohorts.

Abstract Background: Wnt signaling is highly conserved in Metazoan species. Wnt activation and inactivation have been well studied for their roles in development and tumorigenesis, and has emerged as one the most important core pathways in cancer biology. Wnt activation has long been associated with breast cancer, but has only recently been shown to be specifically upregulated in triple negative (TN) breast cancers.Material and Methods: FFPE specimens were obtained from St. Mary's Hospital, Montreal, QC (Quebec cohort) and Grady Hospital, Atlanta, GA (Georgia cohort). RNA was extracted from FFPE sections or cores using the RNA High Pure Kit (Roche) and quality analyzed as described previously (Abramovitz et al. Biotechniques, 2008). Quebec and Georgia cohort mRNAs were quantified using DASL assays, including a 502-gene panel of cancer related genes and a custom 512-gene panel targeting breast cancer pathologies. After quality control the Quebec cohort composed 97 patients and the Georgia cohort 142. Differential mRNA regulation was assessed by Significance Analysis of Microarrays. Meta-analysis included a cohort from Memorial Sloan-Kettering Cancer Center (MSKCC; GEO Series GSE2603), two cohorts from the UNC Lineberger Cancer Center (UNCCC; GSE6128 and GSE10886) and a study from the Netherlands Cancer Institute (NKI). Survival analysis utilized Kaplan-Meier curves and p-values derived from log-rank tests.Results: In the annotation of differentially expressed genes between TN tumors and other subtypes, a significant number of Wnt transcriptional targets and transducers were overexpressed, whereas Wnt attenuators were downregulated in the TN tumors. Meta-analysis in MSKCC and UNCCC cohorts yielded 9 Wnt-related mRNAs differentially regulated between TN (basal-like in the UNCCC case) and other subtypes. To determine if this 9-gene Wnt signature was a driver of breast cancer pathology, we developed a bioinformatic discriminator to bifurcate patients into high (Wnt+) and low (Wnt-) Wnt-expressing categories and applied this to MSKCC, UNCCC, and NKI published data sets composing 625 tumor profiles. Patients classified as Wnt+ exhibited worse outcome in bone metastasis free survival (BMFS), lung metastasis free survival (LMFS), recurrence free survival (RFS) and overall survival (OS). LMFS (p ≤ 0.001), RFS (p ≤ 0.001), and OS (p ≤ 0.01) were statistically significant, whereas BMFS was not. Furthermore, reapplying this bioinformatic discriminator on ER+ patients yielded similar results with Wnt+ patients experiencing worse metastasis-free survival (MFS) and OS (p ≤ 0.025).Discussion: Characterization of mRNAs in breast tumors from 864 patients across multiple microarray platforms indicated Wnt signaling as upregulated in TN breast cancers. A 9-gene Wnt signature was found to be indicative of outcome with respect to LMFS, RFS, and OS. A separate analysis of luminal patients will be presented which indicates that Wnt signaling, as a key mediator of breast cancer pathogenesis, segregates ER+ patients into good and poor prognoses. Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 109.

Health literacy and health care in an inner-city, total laryngectomy population

Background Literacy in the head and neck cancer patient has been understudied. Health literacy (HL) is “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health care decisions.” Limited HL skills reduce access to health care. We surveyed our patients who underwent total laryngectomy (TL) to evaluate their HL. Methods Patients who had undergone TL at Grady Hospital (Atlanta, GA), an inner-city hospital, between 1988 and 1992 were identified. Sociodemographics, general health quality of life, HL, and alaryngeal voice assessment were performed. Results Thirty patients were eligible but 14 could not be located, 4 refused, and 4 were deceased or too ill to participate. More than one third of the remaining patients had severely inadequate HL scores. Conclusion Patients who underwent TL have a high incidence of becoming lost in the system as well as having inadequate health care literacy. Health literacy may be important when considering TL.

Molecular differences in triple negative breast cancer between race/ethnicities.

Abstract Abstract #2089 Background: A disparity in prognosis of triple negative (TN) breast cancer (BC) has been observed between African American (AA) and Caucasian (CAU) race/ethnicities afflicted with this aggressive and invasive BC subtype. Etiological understanding of these differences involves accounting for several factors associated with phenotype and genotype. Here, we address the latter using the Illumina DASL (cDNA mediated, Annealing, Selection, Extension, and Ligation) assay to quantify mRNA expression of 512 breast cancer related genes in a cohort of 24 CAU and 56 AA TN BC tissues sourced from formalin-fixed, paraffin-embedded (FFPE) blocks.&amp;#x2028; Material and Methods: The DASL assay was used to measure mRNA expression levels from FFPE sourced tissues in both cohorts of self-identified patients. CAU BC patients were obtained from St. Mary's Hospital, Montreal, Quebec and AA BC patients were obtained from Grady Hospital, Atlanta, Georgia. RNA extraction used the RNA High Pure Kit (Roche) and was taken from archival FFPE tissues either 5µm tissue sections or cores. Differential mRNA regulation was identified by Significance Analysis of Microarrays (SAM) software using a false discover rate (FDR) less than 1% and a two fold-change criteria to determine differential regulation.&amp;#x2028; Results: In all, 33 genes were found differentially expressed between AA and CAU TN BC tumor samples, 32 of which were upregulated in the AA cohort, only 1 of which was upregulated in the CAU group. The upregulated gene in CAU TN BC was TFF1. Upregulated genes in the AA cohort (order of statistical significance according to SAM software) were KIF20A, EP300, AURKB, FGF4, C14orf155, USP22, EPOR, ZNF668, SCNN1G, MAPT, FLNB, EP400, LTA, ACOT11, RBP3, CSF3, E2F2, TGFB1, CCNE1, L1CAM, NDP, VWF, RHOB, FEN1, BIN1, KRT17, CDC42EP4, SERPINF1, CHI3L2, NES, BCL2, and RERG.&amp;#x2028; Discussion: TFF1 upregulated in the CAU population, has been indicated as biomarker of favorable prognosis in endocrine therapy in clinical studies which is consistent with race/ethnicity disparities. The remaining genes upregulated in the AA cohort include transcription factors E2F2 and RBP3/E2F1 both with cyclin binding domains which may interact with CCNE1, extracellular and adhesion related genes KRT17, L1CAM and FGF4, genes associated with cell cycle AURKB, EP400, and EP300 (activator of HIF-1A). Several RAS related genes were also found differentially expressed in the AA cohort including RHOB, RERG, BIN1, and EPOR. Moreover, it is worth mentioning that BCL2 which is expressed in the aggressive mammary cancer cell line MCF-7 was also found upregulated in the AA cohort. These initial findings suggest that several differentially regulated genes between AA and CAU race/ethnicities may account for the disparity in outcomes resultant in these populations. These initial data warrant further investigation which is currently ongoing. Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 2089.

High prevalence of triple‐negative tumors in an urban cancer center

A disparate proportion of breast cancer deaths occur among young women, those of African-American (AA) ancestry, and particularly young AA women. Estrogen receptors (ER), progesterone receptors (PR), and human epidermal growth factor receptor-2 (HER-2) are key clinically informative biomarkers. The triple-negative (ER-/PR-/HER-2-) tumor subgroup is intrinsically resistant to treatment and portends a poor prognosis. Age, race, and socioeconomic status have been associated with triple-negative tumors (TNT). In the current study, the authors investigated breast cancer subgroups among patients in an urban cancer center serving a multiracial, low socioeconomic population. This case series analyzed female invasive breast cancers diagnosed and/or treated between 2003 and 2004 in the AVON Comprehensive Breast Center at Grady Hospital in Atlanta, Georgia. Data were obtained from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program, and augmented by the hospital registry and pathology reports. Statistical analyses utilized frequency distributions and logistic regression. Of 190 breast cancers; 167 (88%) were diagnosed among AA and 23 (12%) were diagnosed among non-AA women. The median age at diagnosis in the 2 groups was 58 years and 57 years, respectively. TNT prevalence was found to differ by race (29.3% among AA women and 13.0% among non-AA women; P = .010). Differences persisted after adjustment for age and stage (odds ratio [OR] of 3.1; 95%confidence interval [95% CI], 0.8-11.6). The majority of recurrences (40.0%) occurred among women with TNT, who were also most likely to experience a fatal event (OR of 3.7; 95%CI, 1.1-13.0). Despite a similarity in their age at diagnosis, AA women in our urban cancer center presented with a higher prevalence of TNT and TNT was found to predict the poorest outcomes. Institutional interactive breast conferences and intervention/navigation programs could help to dispel breast cancer disparities and improve outcomes.

Charles Gerkin's Practical Theology: A Qualitative Study of Theological Reflection in the Praxis of Pastoral Care and Counselling

Charles Gerkm (1922-2005) was an American practical theologian and a United Methodist clergy. He taught for over twenty years at Candler Theological School at Emory University in Atlanta, Georgia. Gerkin was also a chaplain, pastoral counsellor and family therapist, serving. as chaplain at the Boys Industrial Home in Topeka, Kansas and then Grady Hospital in Atlanta, Georgia before teaching at Emory in the late 1960s. He published numerous articles and five books. Gerkin believed that practical theology ought to be rooted in praxis. His practical theology was based in the praxis of pastoral care and counselling. Praxis, for Gerkin, is the critical reflection on practice with the assumption that all practice is theory laden, and he identified his praxis as a narrative hermeneutical approach. He argued that practical theology has its own theological methods and is not applied systematic theology. In fact, Gerkin was against any applied theory, be it theological or social scientific. Applied theory, in his view, was reductionistic in that it reduced the practice of ministry to the categories of a particular theory. For Gerkin, there was always more to experience in a case or a pastoral situation than anyone theory could adequately explain.

Recognizing, assessing, and intervening with problems of professional competence.

THIS ARTICLE WAS AUTHORED by members of a workgroup on students with competence problems associated with the Council of Chairs of Training Councils, which is affiliated with the Education Directorate of the American Psychological Association. Nadine J. Kaslow and Nancy J. Rubin took primary responsibility for crafting this manuscript. Nadine J. Kaslow is the workgroup chair. To the extent possible, the remaining authors are listed in the order of their contributions: Nadine J. Kaslow, Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine; Nancy J. Rubin, Department of Psychiatry and Behavioral Medicine, University of Alabama School of Medicine—Tuscaloosa Campus; Linda Forrest, Counseling Psychology and Human Services, University of Oregon; Nancy S. Elman, Psychology in Education, University of Pittsburgh; Barbara A. Van Horne, Department of Psychology, University of Wisconsin-Madison; Sue C. Jacobs, Applied Health and Educational Psychology, Oklahoma State University; Stephen K. Huprich, Department of Psychology, Eastern Michigan University; Sherry A. Benton, Counseling Services, Kansas State University; Victor F. Pantesco, Department of Clinical Psychology, Antioch University New England; Stephen J. Dollinger, Department of Psychology, Southern Illinois University; Catherine L. Grus, Education Directorate, American Psychological Services; Stephen H. Behnke, Ethics Office, American Psychological Association; David S. Shen Miller, Counseling Psychology and Human Services, University of Oregon; Craig N. Shealy, Department of Graduate Psychology, James Madison University; Laurie B. Mintz, Educational, School, and Counseling Psychology, University of Missouri-Columbia; Rebecca Schwartz-Mette, Department of Psychology, University of Missouri-Columbia; Kristi Van Sickle, Department of Psychology, James A. Haley VA Hospital in Tampa; Beverly E. Thorn, Department of Psychology, University of Alabama. CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Nadine J. Kaslow, Emory University School of Medicine, Department of Psychiatry and Behavioral Sciences, Grady Hospital, 80 Jesse Hill Jr. Drive, Atlanta, GA 30303. E-mail: nkaslow@emory.edu Professional Psychology: Research and Practice Copyright 2007 by the American Psychological Association 2007, Vol. 38, No. 5, 479–492 0735-7028/07/$12.00 DOI: 10.1037/0735-7028.38.5.479

Injection treatment of internal hæmorrhoids. By Marion C. Pruitt, M.D., Associate in Surgery, Medical Department, Emory University, Georgia Baptist Hospital and Grady Hospital, etc. Crown 8vo. Pp. 137, illustrated. 1929. St. Louis, U.S.A.: The C. V. Mosby Company. 12s. 6d. net

Journal Article Injection treatment of internal hæmorrhoids. By Marion C. Pruitt, M.D., Associate in Surgery, Medical Department, Emory University, Georgia Baptist Hospital and Grady Hospital, etc. Crown 8vo. Pp. 137, illustrated. 1929. St. Louis, U.S.A.: The C. V. Mosby Company. 12s. 6d. net Get access Injection Treatment of Internal Hæmorrhoids. By Pruitt Marion C, M.D., Associate in Surgery, Medical Department, Emory University, Georgia Baptist Hospital and Grady Hospital, etc. Crown 8vo. Pp. 137, illustrated. 1929. St. Louis, U.S.A.: The C. V. Mosby Company. 12s. 6d. net. British Journal of Surgery, Volume 17, Issue 66, October 1929, Page 358, https://doi.org/10.1002/bjs.1800176642 Published: 06 December 2005

A catalog of dermatology utilities: a measure of the burden of skin diseases.

Utilities are measures of quality of life that reflect the strength of individuals' preferences or values for a particular health outcome. As such, utilities represent a measure of disease burden. The aim of this article is to introduce the concept of utilities to the dermatology community and to present a catalog of dermatology utilities obtained from direct patient interviews. Our data are based on 236 total subjects from Grady Hospital (Atlanta, GA), Stanford Medical Center (Palo Alto, CA), and Parkland Hospital (Dallas, TX). The mean time trade-off utilities ranged from 0.640 for blistering disorders to 1.000 for alopecia, cosmetic, and urticaria. The mean utility across all diagnoses was 0.943. We present utilities for 17 diagnostic categories and discuss the underlying reasons for the significant disease burden that these utilities represent. We also present these dermatology categories relative to noncutaneous diseases to place the cutaneous utilities in perspective and to compare the burden of disease. We have demonstrated that skin diseases have considerable burden of disease and provided a preliminary repository of utility data for future researchers and policy makers.