Differences In Initial Presentation Research Articles

No Survival Differences among Germ-Cell Cancer Patients from Urban and Rural Areas

Introduction: Germ-cell cancer (GCC) is curable in the majority of men. However, previous reports have described inferior outcomes in men living in rural as compared to urban residential areas. Methods: We identified all GCC patients treated at two large university hospitals in Zürich and Bern, both in Switzerland, between 2010 and 2020 by retrospective chart review. In 400 patients from Zürich and 274 patients from Bern, details on presentation, diagnosis, treatment, and outcomes were abstracted from medical records. For follow-up, we contacted referring centers or private physicians. Residential region was allocated according to the Federal Statistical Office of Switzerland. Results: We found no differences in initial presentation (clinical stage I [CSI] versus de novo metastatic), relapse rate in CSI patients, response in metastatic patients (favorable vs. unfavorable), progression-free survival (PFS) or overall survival (OS) between patients from urban as compared to suburban or rural residential areas. PFS at 3 years for CSI patients was 78% (95% confidence interval 72–82%) and OS at 5 years was 98% (95% confidence interval 96–99%). PFS at 3 years for de novo metastatic patients was 74% (95% confidence interval 68–79%) and OS at 5 years was 86% (95% confidence interval 80–90%). Conclusion: Treatment outcomes in GCC patients were excellent and comparable to international standards at both centers irrespective of the residential area of patients documenting equal access to high-level oncological care at both centers.

Impact of pre-ictal antiplatelet therapy use in aneurysmal subarachnoid hemorrhage

ObjectiveThere is limited evidence on the use of antiplatelet therapy (APT) to reduce the risk and morbidity of cerebral aneurysmal rupture. This analysis retrospectively assessed APT use in patients presenting to our institution with aneurysmal subarachnoid hemorrhage (aSAH). MethodsWe evaluated the records of 186 patients over 7 years of retrospective data from our tertiary care center and an existing database of patients with aSAH. A total of 18 cases with patients on APT and 168 patients not on APT (controls) were identified. Primary outcomes measured were clinical grade (Hunt and Hess score), radiographic grade (Fisher score), and presence of delayed cerebral ischemia (DCI). Secondary outcomes were modified Rankin score at discharge and at 3 months. DCI from cerebral vasospasm was defined as the occurrence of focal neurological impairment or a decrease in at least 2 points on the Glasgow Coma Scale. Logistic regression models were generated. ResultsWe found that APT use did not appear to lead to statistically significant differences in initial presentation, including Hunt-Hess score and Fisher grade (2.91 vs 3.06, p = 0.66, and 3.23 vs 3.22, p = 0.96 respectively). In addition, APT use was not associated with increased rates of delayed cerebral ischemia (DCI) (OR 0.27 p = 0.12). Our analysis showed that increased Hunt Hess score and the presence of DCI are both associated with increased mRS at 90 days (OR 2.32 p < 0.001; OR 2.91 p = 0.002). ConclusionThe patients in this retrospective observational study did not demonstrate worse outcomes from their aSAH despite APT therapy. Larger prospective studies should be performed to see if this relationship holds and if decreased rates of DCI can be observed.

Clinical Profiles of Black and White Children Referred for Autism Diagnosis.

Black children with autism are diagnosed at an older age. Whether or not late detection is paralleled by differing clinical presentation is not known. We evaluated symptom profiles of 245 Black and 488 sex- and age-matched White non-Hispanic participants (82.8% male; mean age: 4.2years) referred for ASD diagnosis. Both groups showed similar overall levels of autistic symptoms. Black children had significantly but slightly lower scores on cognitive tests and on the Vineland communication domain than White children. Groups were comparable on internalizing and externalizing co-occurring problems. Given the largely similar clinical profiles, clinical differences in initial presentation may not be a primary reason for Black/White disparities in diagnostic and services use. Limitations of a cross-sectional referred sample are acknowledged.

Gender Differences in Gastric Cancer Survival: 99,922 Cases Based on the SEER Database

ObjectivesTo evaluate gender differences in initial presentation, pathology and outcomes with GC (GC). MethodsThe 1973–2013 Surveillance Epidemiology and End Results (SEER) 17-registry database was analysed for renal tumours from 1973 to 2013 coded as primary site “stomach”. After various exclusions, a final study group of 99,922 cases with complete data was obtained. Demographic variables analysed included age, sex, marital status and race. Tumour variables included size, stage at diagnosis, grade, primary site, treatment and histology. Primary outcome variables included overall survival (OS) and cancer-specific survival (CSS). ResultsOverall, 96,501 gastric cancer patients were identified. Of those, 34,862 (36.2%) were women. For woman, log-rank test showed that OS and CSS were significantly longer in man (p < 0.0001). In Cox regression analysis, woman was associated with a significantly improved OS [(HR of death in 1973 to 2003 = 0.87, 95% CI = 0.85–0.89, P < 0.001) (HR of death in 2004 to 2013 = 0.94, 95% CI = 0.91–0.97, P < 0.001)] and cancer-specific survival [(HR of death in 1973 to 2003 = 0.90, 95% CI = 0.87–0.92, P < 0.001) (HR of death in 2004 to 2013 = 0.90, 95% CI = 0.87–0.93, P < 0.001)]. When performing a Kaplan-Meier curve analysis after propensity score matching, gender persisted to be a significant survival of woman for OS and CSS. ConclusionsMen present with larger, higher stage, higher grade GC than women. OS and CSS are better in women, which is significantly different.

Sex-specific Differences in the Quality of Treatment of Muscle-invasive Bladder Cancer Do Not Explain the Overall Survival Discrepancy

BackgroundWhile bladder cancer is less common among women, female sex is associated with worse oncological outcomes. ObjectiveTo evaluate sex-specific differences in initial presentation and treatment patterns of muscle-invasive bladder cancer. Design, setting, and participantsA retrospective study using the National Cancer Database to identify individuals diagnosed with muscle-invasive bladder cancer (cT2-T4aN0M0) between 2004 and 2013. Outcome measurements and statistical analysisMultivariable logistic regression and negative binomial regression with Bonferroni correction were used to investigate seven treatment measures: care at a high-volume facility, receipt of definitive therapy, delayed treatment, receipt of neoadjuvant or adjuvant chemotherapy, receipt of pelvic lymph node dissection, and number of lymph nodes removed. The secondary outcome was overall survival. Results and limitationsWe identified 27525 patients, 27.4% of whom were females. Females were diagnosed significantly more often with nonurothelial carcinoma (15.1% vs 9.9%, p<0.001), with squamous carcinoma being the most prevalent variant (46.9%). After Bonferroni correction, there was no difference in six out of seven treatment quality measures. Females were significantly less likely to experience delayed treatment (odds ratio 0.89, 95% confidence interval [CI] 0.84–0.93, p<0.001). Females had significantly worse overall survival compared with males (hazard ratio 1.04, 95% CI 1.00–1.07, p=0.030). Limitations arise from the retrospective design of the study. ConclusionsDespite little difference in treatment quality measures, female sex is associated with worse overall survival among individuals with muscle-invasive bladder cancer. Our findings suggest that differences in treatment patterns are unlikely to explain the differences in overall survival. Future initiatives should focus on root causes for gender-specific differences in pathological staging and features at diagnosis. Patient summaryIn this study, we did not find differences in the treatment of bladder cancer between men and women that could readily explain why women diagnosed with this disease are more likely to die.

Ethnicity and the first diagnosis of a wide range of cardiovascular diseases: Associations in a linked electronic health record cohort of 1 million patients.

BackgroundWhile the association of ethnic group with individual cardiovascular diseases has been studied, little is known about ethnic differences in the initial lifetime presentation of clinical cardiovascular disease in contemporary populations.Methods and resultsWe studied 1,068,318 people, aged ≥30 years and free from diagnosed CVD at baseline (90.9% White, 3.6% South Asian and 2.9% Black), using English linked electronic health records covering primary care, hospital admissions, acute coronary syndrome registry and mortality registry (CALIBER platform). During 5.7 years median follow-up between 1997–2010, 95,224 people experienced an incident cardiovascular diagnosis. 69.9% (67.2%-72.4%) of initial presentation in South Asian <60 yrs were coronary heart disease presentations compared to 47.8% (47.3%-48.3%) in White and 40.1% (36.3%-43.9%) in Black patients. Compared to White patients, Black patients had significantly lower age-sex adjusted hazard ratios (HRs) for initial lifetime presentation of all the coronary disease diagnoses (stable angina HR 0.80 (95% CI 0.68–0.93); unstable angina– 0.75 (0.59–0.97); myocardial infarction 0.49 (0.40–0.62)) while South Asian patients had significantly higher HRs (stable angina– 1.67 (1.52–1.84); unstable angina 1.82 (1.56–2.13); myocardial infarction– 1.67 (1.49–1.87). We found no ethnic differences in initial presentation with heart failure (Black 0.97 (0.79–1.20); S Asian 1.04(0.87–1.26)). Compared to White patients, Black patients were more likely to present with ischaemic stroke (1.24 (0.97–1.58)) and intracerebral haemorrhage (1.44 (0.97–2.12)). Presentation with peripheral arterial disease was less likely for Black (0.63 (0.50–0.80)) and South Asian patients (0.70 (0.57–0.86)) compared with White patients.DiscussionWhile we found the anticipated substantial predominance of coronary heart disease presentations in South Asian and predominance of stroke presentations in Black patients, we found no ethnic differences in presentation with heart failure. We consider the public health and research implications of our findings.Trial RegistrationNCT02176174, www.clinicaltrials.gov

Race Differences in Initial Presentation, Early Treatment, and 1-year Outcomes of Pediatric Crohnʼs Disease: Results from the ImproveCareNow Network

Race Differences in Initial Presentation, Early Treatment, and 1-year Outcomes of Pediatric Crohnʼs Disease: Results from the ImproveCareNow Network

Holocarboxylase synthetase deficiency pre and post newborn screening

Holocarboxylase synthetase deficiency is an autosomal recessive disorder of biotin metabolism resulting in multiple carboxylase deficiency. The typical presentation described in the medical literature is of neonatal onset within hours to weeks of birth with emesis, hypotonia, lethargy, seizures, metabolic ketolactic acidosis, hyperammonemia, developmental delay, skin rash and alopecia. The condition is screened for by newborn screening (NBS) tandem mass spectroscopy by elevated hydroxypentanoylcarnitine on dried blood spots. Urine organic acid profile may demonstrate elevated lactic, 3-OH isovaleric, 3-OH propionic, 3-MCC, methylcitric acids, and tiglylglycine consistent with loss of function of the above carboxylases. Here we describe a cohort of patients, 2 diagnosed pre-NBS and 3 post-NBS with broad differences in initial presentation and phenotype. In addition, prior to the advent of NBS, there are isolated reports of late-onset holocarboxylase synthetase deficiency in the medical literature, which describe patients diagnosed between 1 and 8years of life, however to our knowledge there are no reports of late-onset HCLS being missed by NBS. Also we report two cases, each with novel pathogenic variants HCLS, diagnosed at age 3years and 21months respectively. The first patient had a normal newborn screen whilst the second had an abnormal newborn screen but was misdiagnosed as 3-methylcrotonylcarboxylase (3-MCC) deficiency and subsequently lost to follow-up until they presented again with severe metabolic acidosis.

P-207 Racial Differences in Initial Presentation, Early Treatment, and 1-Year Outcomes of Pediatric Crohnʼs Disease

Racially disparate care has been shown to contribute to suboptimal healthcare outcomes for minorities in some settings. Using data from the ImproveCareNow (ICN) network, we sought to investigate differences in the medical management and outcomes of pediatric patients with Crohn's disease (CD) at time of diagnosis and 1-year post-diagnosis. ICN is a learning health network for children with inflammatory bowel disease. It contains data collected prospectively and longitudinally during outpatient encounters. Inclusion criteria: all CD patients ≤21 years of age with a visit between September 2006 and October 2014, with the first recorded encounter ≤90 days from the date of CD diagnosis and an encounter 1-year post diagnosis (within 60 days). Analyses were conducted at 2 time periods: baseline (diagnosis) and the 1-year encounter. Analyses included summary statistics, nonparametric Kruskal-Wallis test, Χ2, and Fisher's exact tests as appropriate. Baseline: 976 patients (Black = 118 [12%], White = 858 [88%], mean age = 13 years, 63% male) from 39 sites were included. Black children had a higher percentage of Medicaid insurance (44% versus 11%, P < 0.001). There were no race differences in gender, age at diagnosis, BMI, disease behavior or disease location. Black children had more active disease according to Physician Global Assessment (PGA) at diagnosis (remission 29% versus 35%, mild 37% versus43%, moderate/severe 34% versus 22%; P = 0.027), though there was no difference according to the short Pediatric Crohn's Disease Activity Index (sPCDAI) (P = 0.67). Black children had a lower hematocrit (34.8 versus 36.7, P < 0.001) and albumin level (3.6 versus 3.9, P = 0.001). There were no differences in initial treatment (Black versus White: anti-TNFα 12% versus 11%, P = 0.94; thiopurines 32% versus 34%, P = 0.75); corticosteroids 58% versus 61%, P = 0.71). Black children had more psychosocial concerns noted at diagnosis (30% versus 12%, P = 0.021). At 1 year following diagnosis, Black children had more active disease according to PGA (remission 63% versus 75%, mild 26% versus 29%, moderate/severe 11% versus 6%; P = 0.016); however, there was no difference in disease activity based on the sPCDAI (P = 0.060). Black children had a lower hematocrit (36.6 versus 37.9, P = 0.004), lower albumin level (3.9 versus 4.2, P <0.001), and higher erythrocyte sedimentation rate (20.0 versus 15.2, P = 0.03). There were no differences in treatment (Black versus White: anti-TNFα 35% versus 33%, P = 0.69; thiopurines 47% versus 44%, P = 0.52); corticosteroids 7% versus 10%, P = 0.32). In this cohort, minor differences were identified between Black and White children at baseline and 1-year, with Black children having slightly worse disease activity by some measures. Specifically, statistical differences were identified with respect to hematocrit, albumin, and erythrocyte sedimentation rate (at 1-year), although these differences may not have been clinically meaningful. Remission rates were lower in Black children according to PGA, although not according to C-reactive protein and sPCDAI, suggesting that either Black children were perceived to be more ill despite similar disease activity, or that Black children actually were more ill, but this was not adequately reflected by the sPCDAI. Racial differences in treatment were not identified.

320 Racial Differences in Initial Presentation and Early Treatment of Pediatric Crohn's Disease - Preliminary Results From the Improvecarenow Network

320 Racial Differences in Initial Presentation and Early Treatment of Pediatric Crohn's Disease - Preliminary Results From the Improvecarenow Network

A retrospective cohort study examining the association between body mass index and mortality in severe sepsis.

Body mass index (BMI) is an easily calculated indicator of a patient’s body mass including muscle mass and body fat percentage and is used to classify patients as underweight or obese. This study is to determine if BMI extremes are associated with increased 28-day mortality and hospital length of stay (LOS) in emergency department (ED) patients presenting with severe sepsis. We performed a retrospective chart review at an urban, level I trauma center of adults admitted with severe sepsis between 1/2005 and 10/2007, and collected socio-demographic variables, comorbidities, initial and most severe vital signs, laboratory values, and infection sources. The primary outcome variables were mortality and LOS. We performed bivariable analysis, logistic regression and restricted cubic spline regression to determine the association between BMI, mortality, and LOS. Amongst 1,191 severe sepsis patients (median age, 57 years; male, 54.7 %; median BMI, 25.1 kg/m2), 28-day mortality was 19.9 % (95 % CI 17.8–22.4) and 60-day mortality was 24.4 % (95 % CI 21.5–26.5). Obese and morbidly obese patients were younger, less severely ill, and more likely to have soft tissue infections. There was no difference in adjusted mortality for underweight patients compared to the normal weight comparator (OR 0.74; CI 0.42–1.39; p = 0.38). The obese and morbidly obese experienced decreased mortality risk, vs. normal BMI; however, after adjustment for baseline characteristics, this was no longer significant (OR 0.66; CI 0.42–1.03; p = 0.06). There was no significant difference in LOS across BMI groups. Neither LOS nor adjusted 28-day mortality was significantly increased or decreased in underweight or obese patients with severe sepsis. Morbidly obese patients may have decreased 28-day mortality, partially due to differences in initial presentation and source of infection. Larger, prospective studies are needed to validate these findings related to BMI extremes in patients with severe sepsis.

Gender differences in presentation, management, and in-hospital outcomes for patients with AMI in a lower-middle income country: evidence from Egypt.

BackgroundMany studies in high-income countries have investigated gender differences in the care and outcomes of patients hospitalized with acute myocardial infarction (AMI). However, little evidence exists on gender differences among patients with AMI in lower-middle-income countries, where the proportion deaths stemming from cardiovascular disease is projected to increase dramatically. This study examines gender differences in patients in the lower-middle-income country of Egypt to determine if female patients with AMI have a different presentation, management, or outcome compared with men.Methods and FindingsUsing registry data collected over 18 months from 5 Egyptian hospitals, we considered 1204 patients (253 females, 951 males) with a confirmed diagnosis of AMI. We examined gender differences in initial presentation, clinical management, and in-hospital outcomes using t-tests and χ2 tests. Additionally, we explored gender differences in in-hospital death using multivariate logistic regression to adjust for age and other differences in initial presentation.We found that women were older than men, had higher BMI, and were more likely to have hypertension, diabetes mellitus, dyslipidemia, heart failure, and atrial fibrillation. Women were less likely to receive aspirin upon admission (p<0.01) or aspirin or statins at discharge (p = 0.001 and p<0.05, respectively), although the magnitude of these differences was small. While unadjusted in-hospital mortality was significantly higher for women (OR: 2.10; 95% CI: 1.54 to 2.87), this difference did not persist in the fully adjusted model (OR: 1.18; 95% CI: 0.55 to 2.55).ConclusionsWe found that female patients had a different profile than men at the time of presentation. Clinical management of men and women with AMI was similar, though there are small but significant differences in some areas. These gender differences did not translate into differences in in-hospital outcome, but highlight differences in quality of care and represent important opportunities for improvement.

Long-Term Follow-Up of Children with Periodic Fever, Aphthous Stomatitis, Pharyngitis, and Cervical Adenitis Syndrome

To assess the long-term outcomes of patients with periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome. Patients enrolled in a PFAPA registry were contacted and surveyed. Patients in the registry (n = 59) were surveyed with a follow-up time ranging from 12 to 21 years. Fifty patients had complete symptom resolution, with mean symptom duration of 6.3 years (95% CI, 5.4-7.3), and no sequelae developed. Nine patients continued to have persistent symptoms for a mean duration of 18.1 years (95% CI, 17.4-18.8). There were no differences in initial presentation between subjects with resolved PFAPA and subjects with persistent PFAPA. In subjects with persistent PFAPA, the mean duration of fever >38.3°C decreased from 3.6 days at onset to 1.8 days at follow-up (P = .01), and the mean symptom-free interval between episodes increased from 29 to 159 days (P < .005). Thirty-seven of 44 patients treated with corticosteroids reported prompt symptom resolution. Twelve patients underwent tonsillectomy or adenotonsillectomy; 9 of these patients experienced markedly reduced symptoms, and 6 patients had resolution of symptoms. Two subjects received other diagnoses. In long-term follow-up, most patients with PFAPA experienced spontaneous symptom resolution without sequelae. Patients with persistent symptoms had episodes of shorter duration and reduced frequency.

Impact of Gender in Renal Cell Carcinoma: An Analysis of the SEER Database

ObjectiveTo evaluate gender differences in initial presentation, pathology, and outcomes with renal cell carcinoma (RCC). Materials and methodsThe 1973–2004 Surveillance Epidemiology and End Results (SEER) 17-registries database was analyzed for renal tumors from 1988 to 2004 coded as primary site “kidney and renal pelvis.” After various exclusions, a final study group of 35,336 cases with complete data was obtained. Demographic variables analyzed included age, sex, and race. Tumor variables included size, stage at diagnosis, grade, and histology. Primary outcome variables included overall and cancer-specific survival. ResultsOf the patients, 22,288 were male (63%). Females presented with smaller tumors (5.9 vs. 6.1cm, p<0.0001) of lower grade (p<0.0001). Males had a higher incidence of regional or metastatic spread of renal carcinoma (p<0.0001). Median overall survival from time of diagnosis was 130 mo for females versus 110 mo for males (p<0.0001). In comparisons of males and females, 5-yr cancer-specific survival was 78% versus 81%, and 5-yr overall survival was 65% versus 69% (p<0.0001). On multivariate analysis, cancer-specific survival was similar (HR, 1.00, p=0.960), whereas overall survival was significantly longer for females (HR, 0.92, p<0.0001). Older age at diagnosis, larger tumor size, higher grade, higher SEER historic stage, and sarcomatoid, collecting duct, or “other” histology were related to worse cancer-specific and overall survival. ConclusionsMen present with larger, higher stage, higher grade RCC than women. Overall survival is better in women, whereas cancer-specific survival is not significantly different.

PROSTATE SPECIFIC ANTIGEN KINETICS AT TUMOR RECURRENCE AFTER RADICAL PROSTATECTOMY DO NOT SUGGEST A WORSE DISEASE PROGNOSIS IN BLACK MEN

It has been shown that black men with clinically localized prostate adenocarcinoma treated with radical prostatectomy have poorer disease-free and disease specific survival than white men with similar tumors. These findings suggest that a potentially more aggressive variant of prostate cancer exists in black men. Because prostate specific antigen (PSA) velocity at tumor recurrence is a good indicator of disease aggressiveness, we determine whether there was evidence that PSA velocity at biochemical recurrence after radical prostatectomy is faster in black men. Our retrospective data search at 2 university centers resulted in 127 white and 37 black men with clinical stage cT1 to 2 prostate adenocarcinoma who underwent radical prostatectomy between 1990 and 1994 and had evidence of biochemical recurrence (PSA greater than 0.2 ng./ml.) on followup available for analysis. No neoadjuvant or adjuvant treatments were given before or after radical prostatectomy, and all PSA relapses and subsequent treatments were recorded. PSA velocity modeling was performed in patients before any form of treatment for PSA failure. Preoperative PSA, Gleason score and pathological stage were also included in the model to assess the impact on PSA velocity after recurrence. Our data suggested that PSA velocity at tumor recurrence was related to preoperative PSA on a continuous scale (p = 0.063). However, in our analysis there was little evidence that race had any effect on PSA velocity at tumor recurrence in our patient cohort (p = 0.58). Likewise, little difference in PSA velocity was seen in regard to Gleason score (p = 0.89) or pathological stage (p = 0.23) in these patients. With data on 37 black men available for analysis it was likely that only large or extreme trends could be detected. Results could be used to estimate required sample sizes for assessment of less extreme trends. Our data on tumor growth rate at recurrence, as reflected by PSA velocity kinetics, do not support the hypothesis that prostate tumors in black men are necessarily more aggressive due to enhanced growth. Further studies comparing the molecular and biological differences between prostate cancers in black and white males are needed to clarify reasons for the apparent differences in initial presentation, as compared to that at tumor recurrence in these 2 groups.