Gender-based Disparity Research Articles

Gender Bias Trends in Implantable Cardioverter-Defibrillator Therapy

The use of implantable cardioverter defibrillator (ICD) therapy for primary prevention in patients with heart failure (HF) and left ventricular systolic function less than 35 % has a known benefit in preventing sudden cardiac death. Despite evidence-based practice guidelines including class I recommendations from major cardiology associations, many eligible patients are not receiving ICDs. Furthermore, there is an apparent gender-based disparity such that women are receiving ICDs far less than men. This is evident from review of data regarding ICD utilization over the last 10 years. The advent of programs such as GWTG-HF and IMPROVE-HF has improved monitoring and adherence to guideline-based therapy. However, review of recent temporal trends in ICD use in eligible patients has revealed that while overall utilization has improved and the gender gap has been significantly narrowed, a gender-based disparity still persists. This review outlines gender disparities in ICD therapy, temporal trends, and future endeavors to further address the differences.

Abstract 1320: Effects of selective androgen-receptor and estrogen-receptor modulators on telomerase activity in melanoma and prostate cancer cells.

Abstract Male hormones and the androgen receptor (AR) are well-known key targets for prostate cancer therapy. The potential cause of a gender-based disparity in melanoma has been suspected for many years. A recent analysis suggests that female patients have a 30% survival advantage in cutaneous melanoma. Telomerase has been shown to add protective telomere repeats to chromosome endings and cause cancer cells to become immortal. We have recently discovered that the AR is expressed in melanoma cell lines. In current report, we tested the telomerase activity in lysates of both melanoma and prostate cancer cell lines. Telomeric repeat amplification protocol (TRAP) was carried out to test the activity of telomerase in melanoma A375, androgen-sensitive prostatic cancer LNCap and androgen-insensitive prostatic cancer PC-3 cell lines under treatments of steroid hormones, SARM and SERM compounds. The effects of sex hormones, selective androgen-receptor modulators (SARMs), and estrogen-receptor modulators (SERMs) on telomerase activity in both melanoma and prostate cells were investigated. Citation Format: Yan Lu, Ramesh Narayanan, Jin Wang, Wei Li, Murali Yepuru, Lingling Liu, Vivian S. Loveless, Duane D. Miller. Effects of selective androgen-receptor and estrogen-receptor modulators on telomerase activity in melanoma and prostate cancer cells. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 1320. doi:10.1158/1538-7445.AM2013-1320

Impact of Diabetes Mellitus on Treatment Outcomes of Tuberculosis Patients in Tertiary Care Setup

BackgroundConcurrent diabetes mellitus (DM) with tuberculosis (TB) has an increased risk of treatment failure. This study was aimed to evaluate treatment outcomes in patients with TB with and without DM. MethodsA retrospective cohort study was conducted at respiratory clinic of Hospital Pulau Pinang, Malaysia. All TB-registered patients from January 2006 to December 2007 were included in the study. A validated data collection form was used for collecting data. World Health Organization’s criterion was used for categorizing treatment outcomes. Data were analyzed by using SPSS 16. ResultsOf 1267 patients, 338 patients (26.7%) had concurrent TB-DM. In multivariate analysis, TB-DM was more likely to be present in Chinese (odds ratio [OR]=1.401, P=0.011), patients having age of 46 to 60 years (OR=3.168, P < 0.001) and >60 years (OR=2.524, P < 0.001) and patients with pulmonary TB (OR=2.079, P < 0.001). Nine hundred and eighty-five (78.8%) patients were successfully treated. No statistically significant difference was observed between 2 groups: patients with TB-DM and patients with only TB. Successful treatment outcomes were observed in patients having age of 46 to 60 (OR=1.567, P=0.001), whereas male gender (OR=0.721, P=0.049) and patients with relapse TB (OR=0.494, P=0.002) were less likely to have successful treatment outcome. ConclusionsHigh prevalence of TB-DM in the study signifies the fact that patients with DM are at high risk of developing TB. Treatment outcomes in both groups were comparable. The gender-based and age-based disparity in TB treatment outcomes in this study indicates the importance of gender-specific and age-specific strategies of TB management.

Gender Disparities in Patients With Melanoma: Breaking the Glass Ceiling

The past decade has seen increased attention to gender and racial disparities in outcome for a wide variety of malignancies, and melanoma is no exception. Although cutaneous melanoma is predominantly a disease of whites, when it does occur in darker-skinned peoples, outcomes are clearly inferior stage for stage. There are also gender disparities in melanoma incidence and outcome. In the United States in 2011, there were an estimated 70,230 cases of invasive cutaneous melanoma, of which 43% (30,220 cases) occurred in women. However, of the 8,790 melanoma-related deaths, only 35% (3,040 deaths) occurred in women. In Journal of Clinical Oncology, Joosse et al add prospective clinical trial data to the large amount of retrospective information suggesting women with melanoma fare better, stage for stage, than men. In a pooled analysis of 2,672 patients with clinically localized (stage I/II) melanoma enrolled onto four European Organisation for Research and Treatment of Cancer prospective trials, women had observed advantages in overall survival, melanomaspecific survival, and time to lymph node and distant metastases. These advantages were consistently in the 30% range, even when adjusted for other prognostic factors, and were consistent across various subgroups and in younger (presumably premenopausal) and older (postmenopausal) age groups. As is so often the case in melanoma, these observations generate at least as many questions as they answer. A few of the most cogent questions are addressed herein. 1. Is this gender-based disparity real or artifactual? As previously alluded to, a great deal of prior retrospective single-institution and pooled data support improved outcomes for women with melanoma. Population-based data from most countries demonstrate similar trends, such as a recent study from Germany, which showed that women with melanoma were 38% more likely to survive than men and 32% less likely to have melanoma progression (with reduced risk for both nodal and visceral metastases). These results closely mirror those of Joosse et al and seem to strongly support that the gender-based disparity is real rather than artifactual. 2. If real, what is the cause of the disparity? Is the benefit confined to only a subset of women? Available data have addressed the potential cause(s) of a gender-based outcome disparity in melanoma by evaluating estrogen and estrogen-related factors—the contribution of which has been suspected for many years. Whereas previously the only known estrogen receptor (ER) was ER, now ERexpression has been shown to be significantly associated with mortality in melanoma. Furthermore, methylation of ERseems to be associated strongly with progression in melanoma. Additionally,otherdifferencesinhost-tumorinteractions, including potentialprotectivefactorsinwomenormelanoma-stimulatingfactorsin men, have been hypothesized. If the difference was purely based on hormonal influences, the age of onset should affect outcomes in women, in contrast to the findings of Joosse et al. Etiologic and site-specific differences could play a role, given different patterns of occupational and recreational ultraviolet light exposure between men and women. But perhaps most importantly, men consistently demonstrate lower awareness, resistance to screening, and less knowledgeseeking behavior when it comes to skin malignancies. Possibly as a direct consequence of these behavioral traits, men—especially older men—present with thicker tumors and an attendant increased mortality risk. Available data are limited and somewhat conflicting on whether there are subsets of women who fare better or worse. Pregnancy status at diagnosis or afterward was inversely associated with melanoma survival in Sweden. Inverse associations with parity were observed for melanoma and nonmelanoma skin cancer outcomes in a prospective Norwegian case-control study and for choroidal melanoma outcome in a single-institution study in Massachusetts. The possible influence of parity bears further scrutiny, because it could implicate either hormonal or immunologic influences on melanoma outcomes. 3. What if any therapeutic implications are there for this observation? Should men be treated differently than women (eg, more aggressively)? Should we revisit hormone receptor analysis and/or hormonal therapies such as tamoxifen? At present, the lack of definitive data implicating hormonal or other specific factors in melanoma outcome disparities makes any consideration of different therapeutic interventions for men and women with cutaneous melanoma premature. At one point, tamoxifen was frequently used along with systemic cytotoxic chemotherapy for stage IV melanoma, but prospective clinical trials have not supported its use. An intriguing area that should be further explored is whether the indications for sentinel lymph node biopsy should be different for men and women, given the observed greater propensity for lymphatic metastases in men. JOURNAL OF CLINICAL ONCOLOGY E D I T O R I A L VOLUME 30 NUMBER 18 JUNE 2

Prior Incarceration and Barriers to Receipt of Services among Entrants to Alternative to Incarceration Programs: A Gender-Based Disparity

The high levels of health and psychosocial needs among correctional populations strongly shape the well-being of the urban communities from which a large number of criminal justice-involved individuals come or to which they return. The benefits of providing services to correction-involved individuals and linking them to providers such as with alternative to incarceration (ATI) programs may be limited if they encounter difficulties accessing such services. This study identified the types of barriers that have prevented entrants into ATI programs from receiving health and psychosocial services. We then tested the association between number of prior incarcerations and number of barriers by gender. From a random sample of adults (N = 322; 83 women and 239 men) entering ATI programs in New York City, data were collected via structured interviews that elicited self-reported sociodemographics, substance use, prior incarcerations, and barriers that had actually prevented a participant from visiting or returning to a service provider. Participants reported an average of 3.0 barriers that have prevented them from receiving health and psychosocial services. The most prevalent barriers predominantly concerned service providers' inability to accommodate constraints on participants' time availability or flexibility, transportation, and money. Compared to women, men had a significantly different association that was in the adverse direction--i.e., more prior incarcerations was associated with more barriers--between prior incarcerations and encountering service barriers. Findings indicate that ATI program entrants experience many barriers that have prevented them from receiving health and/or psychosocial services. Furthermore, men with more extensive incarceration histories particularly are disadvantaged. ATI programs can improve the public health of urban communities if such programs are prepared and resourced to facilitate the receipt of services among program participants, especially men who have more extensive incarceration histories.

Policy Implications for Female Combat Medic Assignment

The current military assignment policy of United States prohibits the assignment of females to billets with high risk of combat exposure. As part of an Army review of this policy, the authors analyzed deployment and promotion risk for combat medics. The effect of current policy on male deployment and female promotion risk was unknown. In light of other countries’ policies and current operational considerations, senior military leaders sought to understand the effects of existing policy on a low-density, high-value occupational specialty, the combat medic. The authors found evidence that male medics deployed 2.07 times more frequently than female medics. The authors also found evidence that senior male medics (staff sergeants) deployed even more frequently (3.65–1) than their female counterparts. Perhaps as a result, the male combat medics experience higher likelihood of promotion from staff sergeant (E-6) to the rank of sergeant first class (E-7); however, the magnitude of that benefit was about one-third of the deployment risk. The results confirm the existence of gender-based deployment risk and promotion disparity. Based upon this analysis, the authors recommended the deprecation of current gender coding for combat medics to the senior levels of the US Army.

A Failed Pregnancy Stress Test: A New and Under-Recognized Cardiovascular Risk Factor

Cardiovascular diseases (CVD) are the world’s leading cause of morbidity and mortality in women. However, most of the studies about physiologic factors, preventive strategies, and therapeutic interventions have been conducted mainly in men. Consequently, in the past few years, there has been a decline in the prevalence of CVD in men but not in women. One of the reasons for this difference could be gender-based disparity in cardiovascular care; women have been under-evaluated and under-treated for cardiovascular prevention. In addition, in the past decade, important information regarding specific female conditions, such as body composition, use of sex hormones, and long-term consequences of complications during the pregnancy, suggested that they may affect the onset, clinical course, and prognosis of CVD. Pregnancy is a state where significant physiologic adaptation occurs; from the cardiovascular point of view, these changes include an increase in blood volume, a decrease in total vascular resistance, and a small increase in heart rate and stroke volume maintaining a stable mean arterial pressure. In addition to those cardiovascular changes, pregnancy exhibits a relative insulin resistance and up-regulation of proinflammatory cytokines such as interleukin-6 and blood clotting factors. The magnitude of these changes has led some authors to consider pregnancy as a “maternal stress test,” in which some women do not tolerate the associated hemodynamic and metabolic changes and develop complications such as recurrent pregnancy loss, stillbirth, premature labor, gestational diabetes, or preeclampsia. Epidemiologic studies provide evidence that women with the above-mentioned complications of pregnancy are at increased risk for CVD later in life. The results of the European Prospective Investigation into Cancer and Nutrition (EPIC) cohort in Heidelberg showed that women who experience spontaneous pregnancy loss/stillbirth are at higher risk of myocardial infarction later in life, independent of the other known factors of CVD. Women who had recurrent pregnancy loss had a hazard ratio (HR) for myocardial infarction of 8.9 (95% CI, 3.18–24.9). In the same cohort, patients who had a stillbirth exhibited a myocardial infarction HR of 2.32 (95% CI, 1.19–4.5). For preterm labor, the CVD risk was increased by 2.0 (95% CI, 1.22–3.47). In addition, several studies have shown that hypertensive pregnancies are at greater risk of CVD (including cardiac, cerebrovascular, and peripheral arterial disease). Population-based studies link preeclampsia to an increased risk of later chronic hypertension (relative risk, 1.3– 8.0) and cardiovascular morbidity/mortality (relative risk, 1.3– 3.07) compared with normotensive pregnancy. Gestational diabetes mellitus (GDM) has also been associated with a greater risk of cardiovascular events, but the direct link between GDM and CVD has not been as clear as for hypertension. Nevertheless, women with previous GDM exhibit higher values of endothelial dysfunction, higher C-reactive protein levels, and higher levels of inflammatory markers, as well as a strong association with intimal media thickness, all of which are conditions that increase the risk for CVD. It has been shown that a high proportion of women with GDM will develop type 2 diabetes within 2–5 years, which in turn will increase the woman’s risk for CVD. These results highlight the importance of early identification and A. M. Cuevas (*) Department of Clinical Nutrition and Metabolism, Clinica Las Condes, Santiago, Chile e-mail: acuevas@clc.cl

An evaluation of gender and racial disparity in the decision to treat surgically arterial disease

In 1994, our hospital reported a significant gender disparity in the treatment of peripheral artery disease (PAD). The objective of this study was to determine if this gender-based treatment disparity still persists after 15 years. A retrospective review of patients with PAD and carotid artery disease based on vascular laboratory studies was performed from January 2006 to February 2008. PAD was identified by ankle-brachial index <or= 0.9 or abnormal waveform. Treatable carotid artery disease was identified by symptomatic stenosis 60%-99% or asymptomatic stenosis 80%-99%. Patients with interventions before January 2006 were excluded. Demographics, risk factors, and interventions were recorded. Univariate and multivariate analyses were performed to identify risk factors and independent predictors of intervention. Of 2,313 peripheral artery studies, 592 patients with PAD and no prior intervention were identified. Sixty-five (21.7%) of 299 men and 47 (16.0%) of 293 women underwent angioplasty, stenting, endarterectomy, or bypass grafting. This difference was not significant (P = .077). However, by multivariate analysis of patients with critical limb ischemia, Caucasian race was an independent predictor of intervention (P = .010; odds ratio [OR] 3.363). Of 3,505 carotid duplex studies, 253 patients with treatable carotid artery disease and no prior intervention were identified. Seventy-eight (52.7%) of 148 men and 43 (41.0%) of 105 women underwent carotid endarterectomy (CEA) or stenting. This difference was not significant (P = .065). However, by multivariate analysis, Caucasian race was identified as an independent predictor of intervention (P = .015, OR 3.033). Insurance status was not a predictor of intervention in either the PAD (P = .70) or carotid artery disease cohort (P = .99). Our data reveal that gender was not an independent predictor of intervention for PAD or carotid artery disease; however, Caucasian race independently predicted a greater likelihood of intervention in PAD patients with critical limb ischemia and in the carotid artery disease cohort. This study demonstrates the importance of performance assessments in uncovering unsuspected treatment disparities.

Assessment Of The Contribution Of Women To The Agricultural Production In A Developing Economy

Despite the significant contribution of women to agricultural production in developing countries, they have not been given the opportunity to realize their full economic potential in the agricultural sector. This is as a result oftraditional gender-based subordination and disparity between men and women in the size of landholdings and other agricultural resources. Women’s subordination has limited their access to and control over productive resources. Women are the key resources in farm production, but their productivity depends on the rate of their involvement in farm decision-making. In Nigeria, the decisions and responsibilities taken by women are related to the farm tasks they perform. Men take more of the decisions with regards to selection of enterprises, sizes of enterprises, buying and using of farm inputs. This is because they are economically able and have access to credit facilities more than women. Most of the agricultural development programmes of developing countries in the past failed because womenwere not adequately recognized and involved in the planning and executing of development programmes.

Analysis of gender-based disparity in Treg populations in young lupus-prone mice (99.30)

Abstract Females have a higher incidence of autoimmune disease than males. There is a consistently greater disparity in Foxp3+ Treg% between young females and males in autoimmune- vs non-autoimmune prone strains of mice, i.e., lupus-prone BWF1 female mice had lower Treg% than males. This disparity was not due to differences between female and male BWF1 mice in thymic production or homeostatic proliferation of Tregs in vivo, or the ability to convert Tregs in response to TGFβ, but could be due to the significantly higher rates of non-Treg CD4+ cell proliferation in vivo in female mice. These data also raised the interesting possibility that female BWF1 Tregs are less effective at controlling CD4 cell proliferation in vivo than males. However, Tregs from female and male BWF1 mice exhibited no differences in regulatory function in vitro. Likewise, no differences in the sensitivity of female and male CD4+ responders to suppression by Tregs or in the ability of splenic APC from female and male mice to activate regulatory cell function in vitro were detected. These data suggest that the failure to control CD4 cell activation in female BWF1 mice very likely contributes to disease development; this failure is due not to defects inherent in either the cells that regulate or are regulated, but rather to environmental factors that actively and transiently affect either or both cellular components of the response. Supported by LRI

Off-Pump Techniques Disproportionately Benefit Women and Narrow the Gender Disparity in Outcomes After Coronary Artery Bypass Surgery

Women experience greater morbidity and mortality than men after conventional coronary artery bypass grafting (CABG) on cardiopulmonary bypass (CPB). The objective of this study was to determine whether off-pump CABG (OPCAB) alters this gender-based disparity. Retrospective review of risk factors and clinical outcomes for 11 413 consecutive patients having isolated CABG between January 1, 1997, and May 31, 2005, at a US academic center. Interventions were OPCAB or CABG/CPB, performed at the discretion of 14 faculty surgeons. Main outcome measures included in-hospital death, stroke, myocardial infarction or combined major adverse cardiac events (MACE = death or stroke or myocardial infarction). Odds ratios of adverse events, adjusted for 31 risk factors, were compared between women and men who had OPCAB versus CABG/CPB. Covariates included Propensity Score, Society of Thoracic Surgeons' Predicted Risk, surgeon and body habitus. Female patients (n=3248) and those treated with OPCAB (n=4492) were older, had more comorbidities and higher predicted risk than male patients (n=8165) and those treated with conventional CABG/CPB (n=6921), respectively. Women treated with CABG/CPB had a risk-adjusted odds ratio of 1.60 for death (P=0.01), 1.71 for stroke (P=0.007), 2.26 for myocardial infarction (P=0.008) and 1.71 for MACE (P<0.001) compared with men who had CABG/CPB. In contrast, women treated with OPCAB had outcomes statistically similar to men who had either OPCAB or CABG/CPB. Among women, OPCAB was associated with a significant reduction in death (OR 0.39, P=0.001), stroke (OR 0.43, P=0.002) and MACE (OR 0.43, P<0.001). OPCAB is associated with fewer major adverse cardiac events and benefits women disproportionately, thereby narrowing the gender disparity in clinical outcomes after CABG.

Gender Differences in the Annual Income of Psychiatrists

Female physicians have traditionally earned less than their male counterparts, even after adjustment for specialty, workload, and physician characteristics. In the 1980s female psychiatrists earned incomes that were 13% lower than those of their male counterparts; however, important explanatory variables for such differences were not incorporated into that analysis. This study examined whether a gender income gap among psychiatrists persisted in the 1990s. Survey responses were used that were obtained between 1992 and 2001 from 976 actively practicing white psychiatrists (weighted N=941). Because of low numbers of black respondents to the surveys, we were unable to examine the influence of race on psychiatrists' incomes. Linear regression modeling was performed to determine the association between gender and annual incomes after controlling for workload, provider characteristics, and practice characteristics. Among white psychiatrists, women reported working 13% fewer annual hours than their male counterparts, and women had practiced medicine for fewer years than men. Also, women were more likely to be employees of the practice, as opposed to having an ownership interest in the practice, and were more likely to be board certified, although these findings were not significant. After adjustment for workload, provider characteristics, and practice characteristics, the mean annual income for women was $140,615, or $31,962 (19%) lower than that of men (95% confidence interval of $41,834-$22,090 lower, p<.001). During the 1990s female gender was associated with lower annual incomes among white psychiatrists; compared with previous reports from earlier periods the income disparity appears to be widening. These findings warrant further exploration.

Gender Differences in the Annual Income of Psychiatrists

Gender Differences in the Annual Income of Psychiatrists

Impact of gender on access to the renal transplant waiting list for pediatric and adult patients.

While the public and policy-makers place a priority on equity in the organ allocation process, several studies suggest that women may be less likely than men to receive a renal transplant. However, the cause of this disparity and whether it exists among children with end-stage renal disease (ESRD) are unknown. To address these issues, two nationally representative cohorts of incident patients were examined: (1) 7594 adults with ESRD onset between 1986 and 1993 for whom detailed data were available from the medical record on health status; and (2) 3217 patients <20 yr old who developed ESRD between 1988 and 1993. Patients were followed from initiation of dialysis for up to 10 yr until first activation on the United Network of Organ Sharing renal transplant waiting list. Access to the list for female and male patients with ESRD was compared using Cox proportional hazards models with adjustment for demographic, socioeconomic, and clinical factors. Crude rates of wait-listing per 100 person-years of ESRD were lower for female patients than male patients in both the pediatric (28.89 versus 34.18) and adult (3.94 versus 6.54) populations. Despite adjustment for numerous confounding factors, this gender-based disparity persisted in multivariate analysis. Among children with ESRD, female patients were 14% less likely to be listed than male patients (relative hazard [RH] 0.86; 95% confidence interval [CI], 0.78 to 0.93), and in the adult group, women were 18% less likely to be activated for transplant than men (RH 0.82; 95% CI, 0.72 to 0.93). These findings suggest that female patients of all ages with ESRD face barriers in being activated for cadaveric renal transplantation. Greater attention to this issue is necessary to improve equity in the organ allocation system and potentially improve the outcomes of female patients with ESRD.

Cracks in the Glass Ceiling? An Empirical Study of Gender Differences in Income in the Hospitality Industry

Previous empirical research has substantiated the presence of significant gender-based differences in income within the hospitality industry. However, relatively little research has identified the extent to which the income gap is attributable to differences between men and women in educational preparation, part-time versus full-time employment, or occupation. Furthermore, previous research has relied on relatively small samples drawn from segments of the industry rather than on a true population sample of the industry as a whole from which to draw inferences. The authors examined whether there are gender differences in income when controlling for the effects of human capital (education), workforce participation, and occupational crowding among hospitality industry employees. Findings were drawn from a random sample comprising 1% of all of the employees of the hospitality industry in the United States. The authors found that gender-based income disparity persists, suggesting that more pernicious forms of sex discrimination continue in the industry.

THE ROLE OF GENDER IN DETENTION DISPOSITIONING OF JUVENILE PROBATION VIOLATORS

ABSTRACT Although youth detention facilities were originally intended for the temporary care and custody of minors awaiting court adjudication, they have become settings for punishing juvenile probationers who misbehave. This article examines the determinants of detention outcomes for juvenile probation violators. Specifically, it focuses on the relationship between gender and detention length. Data were derived from case files of youths ordered into detention by an Illinois juvenile court for technical probation infractions. Statistical results indicate that females are incarcerated longer than males for disobeying probation rules. Interviews with probation staff illuminate both personal and contextual factors that may account for the gender-based disparity in the application of detention.