Differences In Clinical Presentation Research Articles

Regional Differences in Clinical Presentation and Prognosis of Patients With Post–Sustained Virologic Response Hepatocellular Carcinoma

Widespread use of direct-acting antivirals for hepatitis C virus infection has been paralleled with increased numbers of patients with hepatocellular carcinoma (HCC) after achieving sustained virologic response (post-SVR HCC) worldwide. Few data compare regional differences in the presentation and prognosis of patients with post-SVR HCC. We identified patients with advanced fibrosis (F3/F4) who developed incident post-SVR HCC between March 2015 and October 2021 from 30 sites in Europe, North America, South America, the Middle East, South Asia, East Asia, and Southeast Asia. We compared patient demographics, liver dysfunction, and tumor burden by region. We compared overall survival by region using Kaplan-Meier analysis and identified factors associated with survival using multivariable Cox regression analysis. Among 8796 patients with advanced fibrosis or cirrhosis who achieved SVR, 583 (6.6%) developed incident HCC. There was marked regional variation in the proportion of patients detected by surveillance (range: 59.5%-100%), median maximum tumor diameter (range, 1.8-5.0 cm), and the proportion with multinodular HCC (range, 15.4%-60.8%). The prognosis of patients highly varied by region (hazard ratio range, 1.82-9.92), with the highest survival rates in East Asia, North America, and South America, and the lowest survival rates in the Middle East and South Asia. After adjusting for geographic region, HCC surveillance was associated with early stage detection (Barcelona Clinic Liver Cancer stage 0/A, 71.0% vs 21.3%; P < .0001) and lower mortality rates (adjusted hazard ratio, 0.29; 95% CI, 0.18-0.46). Clinical characteristics, including early stage detection, and prognosis of post-SVR HCC differed significantly across geographic regions. Surveillance utilization appears to be a high-yield intervention target to improve prognosis among patients with post-SVR HCC globally.

Molecular differences in colon cancer according to location: A literature review

Differences in clinical presentation, epidemiology, prognosis, and molecular mechanisms between left-sided colon cancer (LCC) and right-sided colon cancer (RCC) have been widely studied in recent years. Indeed, mutations seen in LCC differ in nature and frequency compared to LCC. Furthermore, the differences in the biological environment, including histopathological, microbiological, and biochemical differences of the two regions promote different gene expressions in carcinomas. These molecular differences distinguish the nature of colorectal cancer according to the primary site of formation. In this narrative review, all such differences have been explored in detail with the aim of providing further insights into the topic, since in the era of individualised treatment, sidedness is a major factor in the treatment of colorectal cancer.

Clinical Characteristics and Management of Snake Bite Injuries in the Jerusalem Area.

Venomous snake bites can constitute medical emergencies, and without immediate care may be life-threatening. This study describes the characteristics and management of patients suffering from snake bite injuries (SNIs) in the Jerusalem area. A retrospective analysis of all patients who were admitted to the Hadassah Medical Center emergency departments (EDs) due to SNIs between 1 January 2004 and 31 March 2018 was conducted. During this period, 104 patients were diagnosed with SNIs, of whom 32 (30.7%) were children. Overall, 74 (71.1%) patients were treated with antivenom, 43 (41.3%) were admitted to intensive care units, and 9 (8.6%) required treatment with vasopressors. No mortality was recorded. On ED admission, none of the adult patients presented with an altered mental state compared to 15.6% of the children (p < 0.00001). Cardiovascular symptoms were observed in 18.8% and 5.5% of the children and adults, respectively. Fang marks appeared in all of the children. These findings underscore the severity of SNIs and the differences in clinical presentation between children and adults in the Jerusalem region.

Complete genomic characterization of bovine papillomavirus type 1 and 2 strains infers ongoing cross-species transmission between cattle and horses

Infection with bovine papillomavirus (BPV) types 1 and 2 results in the most common skin tumor of horses, termed equine sarcoid. The persistent and recurrent nature of this tumor stands in contrast to the regressive nature of BPV-1/− 2 induced cutaneous papillomas in cattle. The circulation of horse-specific BPV-1/− 2 variants within equine populations has been suggested as a possible explanation for the difference in clinical presentation of BPV-1/− 2 infection between horses and cattle. In order to investigate this hypothesis, we identified 98 complete BPV-1/− 2 genomes using a Nanopore sequencing approach. Separate BPV-1/− 2 alignments were used to infer Bayesian phylogenetic trees. Phylogeny-trait association concerning host species was investigated using Bayesian Tip-association Significance software (BaTS) Overall, 179 unique BPV-1 and 128 BPV-2 substitutions were found. The E2 coding region in the viral genome exhibited an exceptionally high rate of non-synonymous mutations (81 %, n = 13/16). Interestingly, extensive deletions in the L1/L2 region (up to 1.5 kb) were found exclusively in horse-derived samples. Nevertheless, the most frequently detected single nucleotide polymorphisms were shared between equine and bovine hosts, which is in agreement with BaTS results indicating no phylogeny-host correlation. We found indications that horse-specific mutations might exist in subpopulations of equine derived BPV-1/− 2, but these did not result in horse-adapted genetic variants. Based on these observations, cross-species transmission from cattle to horses seems to be an ongoing process, rather than an ancient occurrence that has been followed by the circulation of horse-adapted BPV variants in the horse population..

#6660 HERPES ZOSTER IN LUPUS NEPHRITIS: AN UNDERESTIMATED COMPLICATION

Abstract Background and Aims Herpes zoster (HZ) is a known complication of lupus nephritis (LN) because of the drug-related immunosuppression. In fact, high dose corticosteroids (CS) and immunosuppressive (IS) therapy are almost always used in this setting. Our aim is to evaluate the predisposing factors for the development of HZ in patients with LN. Method Retrospective cohort study on 292 LN patients. Demographic and clinical data are expressed as numbers or percentages in case of discrete variables, whereas, in case of continuous variables, they are expressed as median and interquartile range (IQR). The demographic characteristics have been analyzed with Mann-Whitney U test and Fisher's test where appropriated. A univariate and multivariate logistic regression has been performed to identify potential risk factors. Results The incidence of HZ in our cohort is 22.6% (66/226). The patients’ characteristics are shown in Table 1. HZ patients are older (54 vs 45 yo, p&amp;lt;0.001). No differences were found in the clinical characteristics at LN diagnosis, except for higher chronicity index in HZ patients (2 vs 1, p = 0.03). No difference was found in the initial IS therapy. Higher cumulative dose of CS was used in patients with HZ (48.9 vs 21.5 grams, p&amp;lt;0.0001). At univariate and multivariate logistic regression (Table 2) age, female sex, the presence of a proliferative form at renal biopsy (class III or IV) and cumulative CS dose greater than 100 grams are linked to a higher risk for HZ. Conclusion Incidence of HZ in our LN cohort is high (22.6%). HZ patients are older, while non-significative differences in clinical presentation or initial IS therapy are present. Age, female sex, the presence of a proliferative form at biopsy and greater cumulative CS dose seems to be a risk factor for HZ development in LN patients. According to these data and to the possible evolution of HZ infection in disseminated forms, HZ vaccination should be strongly recommended in LN patients.

Are there differences in clinical presentation, radiologic findings, and outcomes in female patients with cavernous malformation?

Little data exist regarding sex differences in cavernous malformations (CM) patients. From an ongoing, prospective registry of consenting adults with CM, we assessed the differences between male and female patients in regard toage at presentation, type of presentation, radiologic characteristics and prospective, symptomatic hemorrhage and or focal neurologic deficit (FND) risk and functional outcome. Cox proportional-hazard ratios and 95% confidence intervals with P values < 0.05 were considered significant in the outcome analysis. Familial form CM female patients were compared to sporadic form. As of 1/1/2023, our cohort comprised 386 people (58.0% female) after excluding radiation-induced CM. There were no demographic or clinical presentation differences between male and female patients. Radiological features did not differ between sexes, except that female, sporadic patients were more likely to have an associated developmental venous anomaly (DVA) (43.2% male vs. 56.2% female; p = 0.03). Overall, there was no difference in prospective symptomatic hemorrhage or functional outcome between sexes. Female sex was a predictor of symptomatic hemorrhage or FND in sporadic patients with ruptured CM (39.6% males versus 65.7% females; p = 0.02). The latter was not due to presence or absence of DVA. Familial CM females were more likely to have a spinal cord CM (15.2% familial female vs. 3.9% sporadic female; p = 0.001) and had a longer time to recurrent hemorrhage than sporadic female (2.2years sporadic vs. 8.2years familial; p = 0.0006). Minimal differences in clinical, radiologic, and outcomes were found in male versus female patients and familial versus sporadic females in the overall CM patient group. The finding that sporadic form female patients with history of prior hemorrhage had increased rates of prospective hemorrhage or FND compared to male patients raise the question whether to "lump" or "split" ruptured versus unruptured CM patients when analyzing risk factors for prospective hemorrhage in natural history studies.

Characteristics of Multiple Acute Concomitant Cerebral Infarcts Involving Different Arterial Territories.

(1) Background: Multiple acute concomitant cerebral infarcts (MACCI) are relatively uncommon. Data regarding the characteristics and outcomes of patients with MACCI are lacking. We, therefore, aimed to characterize the clinical features of MACCI. (2) Methods: Patients with MACCI were identified from a prospective registry of stroke patients admitted to a tertiary teaching center. Patients with an acute single embolic stroke (ASES) involving only one vascular bed served as controls. (3) Results: MACCI was diagnosed in 103 patients who were compared to 150 patients with ASES. MACCI patients were significantly older (p = 0.010), more often had a history of diabetes (p = 0.011) and had lower rates of ischemic heart disease (p = 0.022). On admission, MACCI patients had significantly higher rates of focal signs (p < 0.001), an altered mental state (p < 0.001) and seizures (p = 0.036). The favorable functional outcome was significantly less common in patients with MACCI (p = 0.006). In the multivariable analysis, MACCI was associated with lower chances of achieving favorable outcomes (odds ratio: 0.190, 95% CI: 0.070-0.502). (4) Conclusions: There are important differences in clinical presentation, comorbidities and outcomes between MACCI and ASES. MACCI is less often associated with favorable outcomes and could represent a more severe form of a stroke compared with a single embolic stroke.

Sex differences in the clinical presentation of early psychosis in a primary care setting.

Primary care is an important part of the help-seeking pathway for young people experiencing early psychosis, but sex differences in clinical presentation in these settings are unexplored. We aimed to identify sex differences in clinical presentation to primary care services in the 1-year period prior to a first diagnosis of psychotic disorder. We identified first-onset cases of non-affective psychotic disorder over a 10-year period (2005-2015) using health administrative data linked with electronic medical records (EMRs) from primary care (n = 465). Detailed information on encounters in the year prior to first diagnosis was abstracted, including psychiatric symptoms, other relevant behaviours, and diagnoses recorded by the family physician (FP). We used modified Poisson regression models to examine sex differences in the signs, symptoms, and diagnoses recorded by the FP, adjusting for various clinical and sociodemographic factors. Positive symptoms (PR = 0.76, 95%CI: 0.58, 0.98) and substance use (PR = 0.54, 95%CI: 0.40, 0.72) were less prevalent in the medical records of women. Visits by women were more likely to be assigned a diagnosis of depression or anxiety (PR = 1.18, 95%CI: 1.00, 1.38), personality disorder (PR = 5.49, 95%CI: 1.22, 24.62), psychological distress (PR = 11.29, 95%CI: 1.23, 103.91), and other mental or behavioral disorders (PR = 3.49, 95%CI: 1.14, 10.66) and less likely to be assigned a diagnosis of addiction (PR = 0.33, 95%CI: 0.13, 0.87). We identified evidence of sex differences in the clinical presentation of early psychosis and recorded diagnoses in the primary care EMR. Further research is needed to better understand sex differences in clinical presentation in the primary care context, which can facilitate better understanding, detection, and intervention for first-episode psychotic disorders.

AQP4-IgG NMOSD, MOGAD, and double-seronegative NMOSD: is it possible to depict the antibody subtype using magnetic resonance imaging?

There is clinical and radiological overlap among demyelinating diseases. However, their pathophysiological mechanisms are different and carry distinct prognoses and treatment demands. To investigate magnetic resonance imaging (MRI) features of patients with myelin-oligodendrocyte glycoprotein associated disease (MOGAD), antibody against aquaporin-4(AQP-4)-immunoglobulin G-positive neuromyelitis optica spectrum disorder (AQP4-IgG NMOSD), and double-seronegative patients. A cross-sectional retrospective study was performed to analyze the topography and morphology of central nervous system (CNS) lesions. Two neuroradiologists consensually analyzed the brain, orbit, and spinal cord images. In total, 68 patients were enrolled in the study (25 with AQP4-IgG-positive NMOSD, 28 with MOGAD, and 15 double-seronegative patients). There were differences in clinical presentation among the groups. The MOGAD group had less brain involvement (39.2%) than the NMOSD group (p = 0.002), mostly in the subcortical/juxtacortical, the midbrain, the middle cerebellar peduncle, and the cerebellum. Double-seronegative patients had more brain involvement (80%) with larger and tumefactive lesion morphology. In addition, double-seronegative patients showed the longest optic neuritis (p = 0.006), which was more prevalent in the intracranial optic nerve compartment. AQP4-IgG-positive NMOSD optic neuritis had a predominant optic-chiasm location, and brain lesions mainly affected hypothalamic regions and the postrema area (MOGAD versus AQP4-IgG-positive NMOSD, p= 0 .013). Furthermore, this group had more spinal cord lesions (78.3%), and bright spotty lesions were a paramount finding to differentiate it from MOGAD (p = 0.003). The pooled analysis of lesion topography, morphology, and signal intensity provides critical information to help clinicians form a timely differential diagnosis.

Differentiating Characteristics and Responses to Treatment of New-Onset Heart Failure With Preserved and Reduced Ejection Fraction in Ambulatory Patients.

Differences in clinical presentation and therapy outcomes between heart failure with preserved ejection fraction (HFpEF) and heart failure with reduced ejection fraction (HFrEF) have been reported but described mainly among hospitalized patients. Because the population of outpatients with heart failure (HF) is increasing, we sought to discriminate the clinical presentation and responses to medical therapy in ambulatory patients with new-onset HFpEF vs. HFrEF. We retrospectively included all patients with new-onset HF treated at a single HF clinic in the past 4 years. Clinical data and electrocardiography (ECG) and echocardiography findings were recorded. Patients were followed up once weekly, and treatment response was evaluated according to symptoms resolution within 30 days. Univariate and multivariate regression analyses were performed. A total of 146 patients were diagnosed with new-onset HF: 68 with HFpEF and 78 with HFrEF. The patients with HFrEF were older than those with HFpEF (66.9 vs. 62 years, respectively, P = 0.008). Patients with HFrEF were more likely to have coronary artery disease, atrial fibrillation, or valvular heart disease than those with HFpEF (P < 0.05 for all). Patients with HFrEF rather than HFpEF were more likely to present with New York Heart Association class 3 - 4 dyspnea, orthopnea, paroxysmal nocturnal dyspnea or low cardiac output (P < 0.007 for all). Patients with HFpEF were more likely than those with HFpEF to have normal ECG at presentation (P < 0.001), and left bundle branch block (LBBB) was observed only in patients with HFrEF (P < 0.001). Resolution of symptoms within 30 days occurred in 75% of patients with HFpEF and 40% of patients with HFrEF (P < 0.001). Ambulatory patients with new-onset HFrEF were older, and had higher incidence of structural heart disease, in comparison to those with new-onset HFpEF. Patients presenting with HFrEF had more severe functional symptoms than those with HFpEF. Patients with HFpEF were more likely than those with HFpEF to have normal ECG at the time of presentation, and LBBB was strongly associated with HFrEF. Outpatients with HFrEF rather than HFpEF were less likely to respond to treatment.

Impact of age on survival according to molecular tumor findings in children and adolescents with soft-tissue and bone sarcoma: The BIOSCA project

BackgroundAdolescents (15–19 years) with sarcoma are known to have significantly worse survival than children (0–14 years). One possible reason may be that the adolescent sarcomas exhibit specific biological characteristics resulting in differences in clinical presentation and treatment resistance behaviors. The BIOSCA project aims to further explore these age-related differences in survival accounting for molecular tumor characteristic in children and adolescents with sarcoma. MethodsA retrospective national population-based observational study with documented somatic genetic analyses was conducted between 2011 and 2016 of all patients aged from 0 to 17 years with a diagnosis of sarcoma using the National Registry of Childhood Cancers Database. ResultsA total of 1637 children (0–9years: 40%), preadolescents (10–14years: 35%) and adolescents (15–17 years: 25%) with a diagnosis of bone (N = 845) or soft-tissue (N = 792) sarcoma were included. Adolescents had significantly worse outcome for undifferentiated small round cell sarcoma (USRCS), alveolar rhabdomyosarcoma (ARMS), and epithelioid sarcoma. Five-year overall survivals were worse among CIC-rearranged USRCS cases (47% [95%CI:21–69]) as compared to other USRCS, and PAX3::FOXO1 ARMS patients (44% [95%CI:32–55]) as compared to other ARMS. Adjusting for stage and genomic-profiling status, adolescents with USRCS were 1.6-fold more likely to die than children (P = 0.05), while the difference in survival between age of ARMS patients was weaken. Indeed, the prevalence of PAX3::FOXO1 increased significantly with age. ConclusionAge was an independent prognostic factor of outcome only in patients with USRCS, while the association between age and survival of patients with ARMS could be partly explained by differences in prevalence of PAX3::FOXO1.

0444 Racial Differences in Positive Airway Pressure Requirements Amongst Obstructive Sleep Apnea Patients (The RACE-PAP Study)

Abstract Introduction Prior studies of patients with obstructive sleep apnea (OSA) show racial differences in clinical presentation. When compared with White patients, Black patients present with more severe OSA and greater sleepiness. Racial differences in upper airway collapsibility could explain these differences. Here, we investigated whether mean positive airway pressure (PAP) levels, a clinically accessible measure of upper airway collapsibility, differed by race in a cohort of patients adherent to PAP. Methods We conducted a retrospective analysis of White and Black adults with OSA who were prescribed auto-adjusting PAP (aPAP) therapy at a single academic center between January 2018 and January 2020. The analysis included adherent patients (usage on &amp;gt;70% of nights for ≥4 hours per night) with well-controlled OSA (defined as ≥50% reduction in apnea-hypopnea index [AHI] on aPAP and residual AHI&amp;lt; 10). Mean PAP level was compared between White and Black patients using linear regression controlled for age, gender, body mass index (BMI), AHI, O2 nadir, and mask type (full face, nasal, or unknown). Results Overall, 148 Black (56% women) and 230 White (36% women) patients were included. On average, Black patients were younger (50.7±14.6 vs. 53.8±12.7 years; p=0.037) with higher BMI (40.4±9.5 vs. 34.9±7.6 kg/m2; p&amp;lt; 0.0001). Black patients had less severe OSA on average, but this difference was not statistically significant (AHI of 33.9±25.5 vs 38.6±24.9 events/hour; p=0.077). After adjusting for covariates, Black patients had a 0.62 cm H2O (95% CI: 0.21 to 1.03) higher mean PAP level than White patients (p=0.003). There was a larger racial difference in mean PAP level among men (0.76 [0.16, 1.35] cm H2O; p=0.013) compared to a non-significant difference among women (0.34 [-0.23, 0.91] cm H2O; p=0.242). While statistically significant, differences were &amp;lt; 1 cm H2O and, thus, not clinically meaningful. Conclusion Black patients with OSA had a statistically significant but clinically insignificant difference in mean PAP level when compared with White patients. There was evidence of stronger differences in men than women. Further studies are needed to explore other potential mechanisms, including craniofacial anatomy, which may underlie racial differences in OSA presentation and outcomes. Support (if any) National Institutes of Health R01 1R01HL144859 (PIs: Schwartz, Dedhia)

Impact of lipid lowering therapies after an acute coronary syndrome, applied through telematic consultation, in a cohort of elderly patients

Abstract Funding Acknowledgements Type of funding sources: None. Introduction After Covid-19 pandemic, telematic cardiology consultations are a reality in most developed countries. However, the impact and safety of telemedicine in the elderly population needs to be clarified. Elderly patients may need help to understand and use telemedicine effectively, being thus its benefits differential. Objetives: To assess the impact of lipid lowering therapies, after an acute coronary syndrome (ACS), applied through telematic consultation, in a cohort of elderly patients (≥70 years). Methods We performed a prospective cohort study that consecutively recruited all patients admitted to our centre with an ACS from January 1, 2020 to December 31, 2020. All patients were discharged with high-intensity statins and other currently recommended cardiovascular drugs. Lipid profile was evaluated one month after discharge. Patients were then contacted by phone, treatment was confirmed, and their lipid- lowering therapy was adjusted according to the results of the blood test. This procedure was repeated every month until LDL-c target (≤ 55 mg/dl) was achieved in accordance with current European clinical practice guidelines. Results 346 patients, 32% women, were included. Mean age was 67.3 ± 12.4 years, being 48% ≥ 70 years. Mean follow-up was 17.3 months. Patient’s main characteristics are summarized in Table 1. Comparing both subgroups, patients ≥ 70 years more frequently were women, and had past history of hypertension, diabetes, heart failure and myocardial infarction. There were no differences in clinical presentation at admission (predominantly non-ST elevation myocardial infarction). Patients ≥70 years reached the goal of LDL ≤55 mg/dl in a similar proportion to the younger subgroup (80.1% vs 82.8% p 0.051). There were no statistically significant differences in prescription between groups, with a tendency to a higher prescription of statins and ezetimibe in younger patients (62.8% vs 50.6%, p = 0.05). At follow-up, overall mortality was higher in the subgroup ≥70 years (7.8% vs 1.2%, p 0.026) at the expense of non-cardiovascular mortality (4.8% vs 0.6% p 0.013). There were no differences in cardiovascular mortality, stroke, non-fatal myocardial infarction, or non-urgent angioplasty. Conclusion Lipid lowering therapies applied through telematic consultation in a population ≥ 70 years old after an ACS is as effective and safe as in younger patients. There is however a higher mortality in this subgroup, predominantly because of non-cardiovascular causes.

Sex-related differences regarding results of lipid-lowering therapies, implemented through telematic consultation, after an acute coronary syndrome

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Women are less likely than men to receive guideline-recommended therapies. There is thus little real world information on possible sex-related differences regarding results of lipid lowering therapies when guidelines are correctly applied. Understanding possible sex-related differences in lipid profile’s response to treatment after an acute coronary syndrome (ACS) might provide important information in order to improve clinical outcomes. Objetives: To assess, in a real world cohort, if there are any sex-related differences regarding results of lipid-lowering therapies, implemented through telematic consultation, after an ACS. Methods A prospective cohort study that consecutively recruited all patients admitted to our centre for an ACS from January 1, 2020 to December 31, 2020, was performed. All patients were discharged with high-intensity statins and other currently recommended cardiovascular drugs. Lipid profile was evaluated 1-month after discharge. Patients were then contacted by phone and their lipid-lowering therapy adjusted according to blood test’s results. This procedure was repeated every month until LDL-c target (≤ 55 mg/dl) was achieved in accordance with current European clinical practice guidelines. Descriptive statistics of patient characteristics at baseline and end of follow up were calculated for the overall population and then compared between men and women. We determined statistical differences between women and men using chi-squared and Student's t. Results 346 patients were included, of which 32% were women. Patient characteristics are summarized in Table 1. Women were significantly older than men (72 ± 12 vs 65 ± 12 years, p&amp;lt;0.001) and had more past history of hypertension and dyslipidemia. There were no differences in clinical presentation at admission (predominantly non-ST elevation myocardial infarction). Mean follow-up was 17.3 months. Even though there were no statistically significant differences in treatment prescription at discharge or after follow up, women reached the goal of LDL ≤55 mg/dl in a lower proportion to men (75.5% vs 84.3%, p 0.031) and required more time (3.69 ±2.24 vs 2.92 ± 1.95 months, p &amp;lt; 0.001). During follow up, total mortality was similar between groups, however women presented a higher cardiovascular mortality (4.5% vs 0.4%, p 0.014). Conclusion Our findings suggest that, applying the same guideline-recommended therapies in both women and men, there might be sex-related differences regarding lipid-lowering therapies’. Results Women reach the goal of LDL ≤55 mg/dl in a lower proportion to men and require more time. These results suggest that women might therefore need more aggressive treatment at discharge. Clinical significance of these findings is yet to be determined as our cohort is limited.

Association Between SARS-CoV-2 Variants and Frequency of Acute Symptoms: Analysis of a Multi-institutional Prospective Cohort Study-December 20, 2020-June 20, 2022.

While prior work examining severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variants of concern focused on hospitalization and death, less is known about differences in clinical presentation. We compared the prevalence of acute symptoms across pre-Delta, Delta, and Omicron. We conducted an analysis of the Innovative Support for Patients with SARS-CoV-2 Infections Registry (INSPIRE), a cohort study enrolling symptomatic SARS-CoV-2-positive participants. We determined the association between the pre-Delta, Delta, and Omicron time periods and the prevalence of 21 coronavirus disease 2019 (COVID-19) acute symptoms. We enrolled 4113 participants from December 2020 to June 2022. Pre-Delta vs Delta vs Omicron participants had increasing sore throat (40.9%, 54.6%, 70.6%; P < .001), cough (50.9%, 63.3%, 66.7%; P < .001), and runny noses (48.9%, 71.3%, 72.9%; P < .001). We observed reductions during Omicron in chest pain (31.1%, 24.2%, 20.9%; P < .001), shortness of breath (42.7%, 29.5%, 27.5%; P < .001), loss of taste (47.1%, 61.8%, 19.2%; P < .001), and loss of smell (47.5%, 55.6%, 20.0%; P < .001). After adjustment, those infected during Omicron had significantly higher odds of sore throat vs pre-Delta (odds ratio [OR], 2.76; 95% CI, 2.26-3.35) and Delta (OR, 1.96; 95% CI, 1.69-2.28). Participants infected during Omicron were more likely to report symptoms of common respiratory viruses, such as sore throat, and less likely to report loss of smell and taste. NCT04610515.

Racial, Ethnic, and Socioeconomic Disparities in Out-of-Hospital Pain Management for Patients With Long Bone Fractures

To evaluate racial and ethnic disparities in out-of-hospital analgesic administration, accounting for the influence of clinical characteristics and community socioeconomic vulnerability, among a national cohort of patients with long bone fractures. Using the 2019-2020 ESO Data Collaborative, we retrospectively analyzed emergency medical services (EMS) records for 9-1-1 advanced life support transport of adult patients diagnosed with long bone fractures at the emergency department. We calculated adjusted odds ratios (aOR) and 95% confidence intervals (CI) for out-of-hospital analgesic administration by race and ethnicity, accounting for age, sex, insurance, fracture location, transport time, pain severity, and scene Social Vulnerability Index. We reviewed a random sample of EMS narratives without analgesic administration to identify whether other clinical factors or patient preferences could explain differences in analgesic administration by race and ethnicity. Among 35,711 patients transported by 400 EMS agencies, 81% were White, non-Hispanic, 10% were Black, non-Hispanic, and 7% were Hispanic. In crude analyses, Black, non-Hispanic patients with severe pain were less likely to receive analgesics compared with White, non-Hispanic patients (59% versus 72%; Risk Difference: -12.5%, 95% CI: -15.8% to -9.9%). After adjustment, Black, non-Hispanic patients remained less likely to receive analgesics compared with White, non-Hispanic patients (aOR:0.65, 95% CI:0.53 to 0.79). Narrative review identified similar rates of patients declining analgesics offered by EMS and analgesic contraindications across racial and ethnic groups. Among EMS patients with long bone fractures, Black, non-Hispanic patients were substantially less likely to receive out-of-hospital analgesics compared with White, non-Hispanic patients. These disparities were not explained by differences in clinical presentations, patient preferences, or community socioeconomic conditions.

Melanoma: Does It Present Differently in Darker Skin Tones?

There are vast differences in clinical presentations of melanoma across skin tones. Individuals with darker skin tones tend to have a higher prevalence of advanced-stage melanoma, which correlates with increased mortality. We designed this interactive workshop to increase nursing and medical trainees' awareness of the epidemiology, prevention, and treatment of melanoma in individuals of darker skin tones. The Kern model was used in the design, implementation, and evaluation of the workshop. The 75-minute workshop consisted of a PowerPoint presentation, video-based reflection activities, and case studies. Evaluation consisted of pre- and postworkshop questionnaires. The workshop was implemented two times among 63 nursing students, 11 medical students/residents, and six medical faculty. Seventy-one participants completed the pre- and postworkshop evaluations. A comparison of pre- and postworkshop responses utilizing the Wilcoxon matched-pair signed rank test showed a statistically significant increase in learners' confidence to address each learning objective. Through this interactive educational presentation, medical and nursing trainees can gain heightened awareness of melanoma across various skin tones, especially unique presentations in darker skin tones.

Sex Differences in Clinical Presentation and Management in Eosinophilic Esophagitis

Background: Eosinophilic esophagitis (EoE) is a male predominant disease, typically presenting with dysphagia. Our goal was to investigate sex differences in clinical presentation and management of EoE. Methods: We performed a retrospective cross-sectional review of 489 EoE patients seen at NewYork Presbyterian Weill Cornell from August 2015 to August 2019. Charts were queried for age at diagnosis, symptoms at presentation, endoscopic findings, need for dilations, and medical therapy. Student t and χ2 tests were implemented to compare outcome variables of the 2 independent groups (males vs females) and logistic regressions for invariable and multivariable analyses. Results: 489 EoE patients (226 Female [F] [46.2%], 263 Male [M] [53.8%]) were reviewed. Males were more likely to present with food impaction (92 [35.8%] vs 44 [19.7%], M vs F, P &lt; .001), have a fibrostenotic phenotype on initial endoscopy (140 [54.1%] vs 98 [45.0%], M vs F, P = .043) and undergo dilation (odds ratio [OR] = 1.985, 95% confidence interval [CI] = 1.209-3.328, P &lt; .01). Female patients were more likely to have atopic disease (153 [67.6%] vs 153 [58.8%], F vs M, P = .044) and a reported normal index endoscopy (79 [36.2%] vs 69 [26.6%], F vs M, P = .026). Conclusion: This large retrospective review highlights clinically important differences in presentation between sexes. Increasing awareness of these differences, especially history of atopic disease, impaction, and the need for dilation, can help clinicians better identify EoE in female patients and therefore, guide initial therapy. The mechanistic underpinnings of these discrepancies are not evident from this data and will require future studies.

Revealing Individual Neuroanatomical Heterogeneity in Alzheimer Disease Using Neuroanatomical Normative Modeling.

Alzheimer disease (AD) is highly heterogeneous, with marked individual differences in clinical presentation and neurobiology. To explore this, we used neuroanatomical normative modeling to index regional patterns of variability in cortical thickness. We aimed to characterize individual differences and outliers in cortical thickness in patients with AD, people with mild cognitive impairment (MCI), and controls. Furthermore, we assessed the relationships between cortical thickness heterogeneity and cognitive function, β-amyloid, phosphorylated-tau, and ApoE genotype. Finally, we examined whether cortical thickness heterogeneity was predictive of conversion from MCI to AD. Cortical thickness measurements across 148 brain regions were obtained from T1-weighted MRI scans from 62 sites of the Alzheimer's Disease Neuroimaging Initiative. AD was determined by clinical and neuropsychological examination with no comorbidities present. Participants with MCI had reported memory complaints, and controls were cognitively normal. A neuroanatomical normative model indexed cortical thickness distributions using a separate healthy reference data set (n = 33,072), which used hierarchical Bayesian regression to predict cortical thickness per region using age and sex, while adjusting for site noise. Z-scores per region were calculated, resulting in a Z-score brain map per participant. Regions with Z-scores <-1.96 were classified as outliers. Patients with AD (n = 206) had a median of 12 outlier regions (out of a possible 148), with the highest proportion of outliers (47%) in the parahippocampal gyrus. For 62 regions, over 90% of these patients had cortical thicknesses within the normal range. Patients with AD had more outlier regions than people with MCI (n = 662) or controls (n = 159) (F(2, 1,022) = 95.39, p = 2.0 × 10-16). They were also more dissimilar to each other than people with MCI or controls (F(2, 1,024) = 209.42, p = 2.2 × 10-16). A greater number of outlier regions were associated with worse cognitive function, CSF protein concentrations, and an increased risk of converting from MCI to AD within 3 years (hazard ratio 1.028, 95% CI 1.016-1.039, p = 1.8 × 10-16). Individualized normative maps of cortical thickness highlight the heterogeneous effect of AD on the brain. Regional outlier estimates have the potential to be a marker of disease and could be used to track an individual's disease progression or treatment response in clinical trials.

Impact of COVID-19-related health care disruptions on pathologic cancer staging during the first pandemic year: a retrospective cohort study from March 2018 to March 2021.

The COVID-19 pandemic has created major disruptions in cancer care, with reductions in diagnostic tests and treatments. We evaluated the impact of these health care-related changes on cancer staging by comparing cancers staged before and during the pandemic. We performed a retrospective cohort study at London Health Sciences Centre and St. Joseph's Health Care London, London, Ontario, Canada. We evaluated all pathologically staged breast, colorectal, prostate, endometrial and lung cancers (the 5 most common cancers by site, excluding nonmelanoma skin cancer) over a 3-year period (Mar. 15, 2018-Mar. 14, 2021). The pre-COVID-19 group included procedures performed between Mar. 15, 2018, and Mar. 14, 2020, and the COVID-19 group included procedures performed between Mar. 15, 2020, and Mar. 14, 2021. The primary outcome was cancer stage group, based on the pathologic tumour, lymph node, metastasis system. We performed univariate analyses to compare demographic characteristics, pathologic features and cancer stage between the 2 groups. We performed multivariable ordinal regression analyses using the proportional odds model to evaluate the association between stage and timing of staging (before v. during the pandemic). There were 4055 cases across the 5 cancer sites. The average number of breast cancer staging procedures per 30 days increased during the pandemic compared to the yearly average in the pre-COVID-19 period (41.3 v. 39.6), whereas decreases were observed for endometrial cancer (15.9 v. 16.4), colorectal cancer (21.8 v. 24.3), prostate cancer (13.6 v. 18.5) and lung cancer (11.5 v. 15.9). For all cancer sites, there were no statistically significant differences in demographic characteristics, pathologic features or cancer stage between the 2 groups (p > 0.05). In multivariable regression analysis, for all cancer sites, cases staged during the pandemic were not associated with higher stage (breast: odds ratio [OR] 1.071, 95% confidence interval [CI] 0.826-1.388; colorectal: OR 1.201, 95% CI 0.869-1.661; endometrium: OR 0.792, 95% CI 0.495-1.252; prostate: OR 1.171, 95% CI 0.765-1.794; and lung: OR 0.826, 95% CI 0.535-1.262). Cancer cases staged during the first year of the COVID-19 pandemic were not associated with higher stage; this likely reflects the prioritization of cancer procedures during times of reduced capacity. The impact of the pandemic period on staging procedures varied between cancer sites, which may reflect differences in clinical presentation, detection and treatment.