Geographic Residence Research Articles

INFLUENCE OF AGE, SEX AND AN OCCURRENCE OF CARDIOVASCULAR EVENT ON SEASONAL VARIATIONS IN BLOOD PRESSURES IN HYPERTENSIVE PATIENTS: INSIGHTS FROM THE ASCOT COHORT

Objective: In hypertensive patients, the extent to which patient-related characteristics influence seasonal blood pressure (BP) variations is unclear. We used repeated BP-measurements in the ASCOT trial to investigate the influence of age, sex, geographical residence and cardiovascular (CV) event occurrence, on the association between month-of-year and BP-level. Design and method: 18,746 hypertensive patients, with 5-year median follow-up and a median (IQR) of 14 [12–17] visits, contributed to these analyses. We developed mixed effects models to estimate mean systolic-BP (SBP) for each month of the year. Models were adjusted for a priori confounders (age, sex, BMI, total cholesterol, presence of diabetes, smoking status, ethnicity, socio-economic status, randomized treatment-allocation) and in-trial period. Subgroup analyses were conducted by age-groups, sex, geographical residence, and occurrence of CV-event or not. Age was appropriately categorised (see figure) and geographical region was split into two-groups: Scandinavian countries and Scotland and England and Ireland. We estimated mean SBP-difference between the coldest pair of months (January/February) and warmest (July/August): overall; and separately by subgroups; evaluating for presence of interactions. Results: Mean SBP differs significantly across months of year, with higher BPs during winter and lower BPs during summer (mean SBP-difference between coldest and warmest pairs: 3.07 [95% CI 2.87, 3.27] mm Hg, p < 0.001). The trend was similar in each age-group, but with a significantly higher mean SBP-difference amongst older (= >75 years) patients (4.59 [3.87, 5.30] mm Hg) vs younger (<55 years) (1.97 [1.47, 2.46]) (interaction p-value < 0.001). The magnitude of mean SBP-difference differs substantially by geographical region with a mean SBP-difference of 1.99 [1.70, 2.27] mm Hg amongst those in Scandinavia and Scotland vs. 4.10 [3.82, 4.39] amongst those in England and Ireland (interaction p-value < 0.001). Those who had a CV-event had significantly higher seasonal BP-variability vs. those who didn’t, and amongst those with a CV-event: the seasonal BP-variability was higher after the event vs before (p-value = 0.034). No interaction with gender was apparent. Conclusions: The magnitude of seasonal BP-variability is influenced by age, residence, and an occurrence of CV-event in hypertensive patients. These findings may have important clinical implications for BP-control strategies.

Applying Latent Class Analysis on Cancer Registry Data to Identify and Compare Health Disparity Profiles in Colorectal Cancer Surgical Treatment Delay.

Colorectal cancer (CRC) surgical treatment delay (TD) has been associated with mortality and morbidity; however, disparities by TD profiles are unknown. This study aimed to identify CRC patient profiles of surgical TD while accounting for differences in sociodemographic, health insurance, and geographic characteristics. We used latent class analysis (LCA) on 2005-2015 Tennessee Cancer Registry data of CRC patients and observed indicators that included sex/gender, age at diagnosis, marital status (single/married/divorced/widowed), race (White/Black/other), health insurance type, and geographic residence (non-Appalachian/Appalachian). The state of Tennessee in the United States that included both Appalachian and non-Appalachian counties. Adult (18 years or older) CRC patients (N = 35 412) who were diagnosed and surgically treated for in situ (n = 1286) and malignant CRC (n = 34 126). The distal outcome of TD was categorized as 30 days or less and more than 30 days from diagnosis to surgical treatment. Our LCA identified a 4-class solution and a 3-class solution for in situ and malignant profiles, respectively. The highest in situ CRC patient risk profile was female, White, aged 75 to 84 years, widowed, and used public health insurance when compared with respective profiles. The highest malignant CRC patient risk profile was male, Black, both single/never married and divorced/separated, resided in non-Appalachian county, and used public health insurance when compared with respective profiles. The highest risk profiles of in situ and malignant patients had a TD likelihood of 19.3% and 29.4%, respectively. While our findings are not meant for diagnostic purposes, we found that Blacks had lower TD with in situ CRC. The opposite was found in the malignant profiles where Blacks had the highest TD. Although TD is not a definitive marker of survival, we observed that non-Appalachian underserved/underrepresented groups were overrepresented in the highest TD profiles. The observed disparities could be indicative of intervenable risk.

Common Treatment, Common Variant: Evolutionary Prediction of Functional Pharmacogenomic Variants.

Pharmacogenomics holds the promise of personalized drug efficacy optimization and drug toxicity minimization. Much of the research conducted to date, however, suffers from an ascertainment bias towards European participants. Here, we leverage publicly available, whole genome sequencing data collected from global populations, evolutionary characteristics, and annotated protein features to construct a new in silico machine learning pharmacogenetic identification method called XGB-PGX. When applied to pharmacogenetic data, XGB-PGX outperformed all existing prediction methods and identified over 2000 new pharmacogenetic variants. While there are modest pharmacogenetic allele frequency distribution differences across global population samples, the most striking distinction is between the relatively rare putatively neutral pharmacogene variants and the relatively common established and newly predicted functional pharamacogenetic variants. Our findings therefore support a focus on individual patient pharmacogenetic testing rather than on clinical presumptions about patient race, ethnicity, or ancestral geographic residence. We further encourage more attention be given to the impact of common variation on drug response and propose a new ‘common treatment, common variant’ perspective for pharmacogenetic prediction that is distinct from the types of variation that underlie complex and Mendelian disease. XGB-PGX has identified many new pharmacovariants that are present across all global communities; however, communities that have been underrepresented in genomic research are likely to benefit the most from XGB-PGX’s in silico predictions.

Factors affecting treatment selection and overall survival for first-line EGFR-tyrosine kinase inhibitor therapy in non-small-cell lung cancer.

Aim: To investigate the factors associated with treatment selection and overall survivalfor first-line EGFR-tyrosine kinase inhibitors (EGFR-TKIs) therapy among patients with non-small-cell lung cancer. Materials & methods: We conducted a retrospective cohort study of linked administrative health databases in Ontario, Canada. Results: A total of 1011 patients received an EGFR-TKI as first-line therapy. Treatment selection and overall survival associated with these treatments were affected by age, sex, geographical residency, comorbiditiesand different sites of metastasis. Conclusion: Though recent approval of osimertinib offers a potential new standard of care in the first-line setting, earlier generation TKIs remain pillars in treatment of non-small-cell lung cancer therapeutic armamentarium. Our findings may contribute to optimizing treatment sequencing of EGFR-TKIs to maximize clinical benefits.

Early Childhood Health-Protective Behavior Against Environmental Tobacco Smoke Exposure in Households

Children who live in agricultural, coastal, and industrial areas are at risk of experiencing diseases due to their exposure to environmental tobacco smoke because a lot of smokers live in these areas. The objective of this study is to determine the differences in health-protective behavior of parents who have children in the geographical residence.
 The study used a quantitative approach, cross-sectional design, and purposive sampling. There are 175 parents with children under five years who live in coastal, agricultural, and industrial areas in Semarang, Central Java, Indonesia. Data collection was performed using a questionnaire. The dependent variable was the health-protective behavior of parents with children against exposure to cigarette smoke, while the independent variable was the geographical residence. The one-way ANOVA test was used to measure differences in the health-protective behavior of parents living in these areas. The results showed that there was no difference in the parental health-protective behavior in an agricultural, coastal, and industrial region (p=0.091, p>0.05). In conclusion, the respondents exhibit health-protective behavior that dies not fully control exposure to environmental tobacco smoke.

Huntington\u2019s disease among immigrant groups and Swedish-born individuals: a cohort study of all adults 18 years of age and older in Sweden

BackgroundThere is a lack of studies of Huntington’s disease (HD) in immigrants.ObjectiveTo study the association between country of birth and incident HD in first-generation immigrants versus Swedish-born individuals and in second-generation immigrants versus Swedish-born individuals with Swedish-born parents.MethodsStudy populations included all adults aged 18 years and older in Sweden, i.e., in the first-generation study 6,042,891 individuals with 1034 HD cases and in the second-generation study 4,860,469 individuals with 1001 cases. HD was defined as having at least one registered diagnosis of HD in the National Patient Register. The incidence of HD in different first-generation immigrant groups versus Swedish-born individuals was assessed by Cox regression, expressed as hazard ratios (HRs) and 95% confidence intervals (CI). The models were stratified by sex and adjusted for age, geographical residence in Sweden, educational level, marital status, and neighborhood socioeconomic status.ResultsMean age-standardized incidence rates per 100,000 person-years were for all Swedish-born 0.82 and for all foreign born 0.53 and for all men 0.73 and for all women 0.81, with the highest incidence rates for the group 80–84 years of age. After adjusting for potential confounders, the HRs were lower in women in the first- and second-generation, i.e., 0.49 (95% CI 0.36–0.67) and 0.63 (95% 0.45–0.87), respectively, and also among women from Finland or with parents from Finland.SignificanceIn general, the risk of HD was lower in first-generation and second-generation immigrant women but not among male immigrants.

Racial Disparities and Diagnosis-to-Treatment Time Among Patients Diagnosed with Breast Cancer in South Carolina.

Diagnosis-to-treatment interval is an important quality measure that is recognized by the National Accreditation Program for Breast Centers, and the American Society of Breast Surgeons and the National Quality Measures for Breast Care. The aim of this study was to assess factors related to delays in receiving breast cancer treatment. This retrospective cohort study (2002 to 2010) used data from the South Carolina Central Cancer Registry (SCCCR) and Office of Revenue and Fiscal Affairs (RFA) to examine racial differences in diagnosis-to-treatment time (in days), with adjuvant hormone receipt, surgery, chemotherapy, and radiotherapy assessed separately. Chi-square tests, and logistic regression and generalized linear models were used to compare diagnosis-to-treatment days. Black women on average received adjuvant hormone therapy, surgery, chemotherapy, and radiotherapy 25, 8, 7, and 3days later than their White counterparts, respectively. Black women with local stage cancer had later time to surgery (OR: 1.6; CI: 1.2-2.2) compared with White women with local stage cancer. Black women living in rural areas had higher odds (OR: 2.0; CI: 1.1-3.7) of receiving late chemotherapy compared with White women living in rural areas. Unmarried Black women also had greater risk (OR: 2.0; CI: 1.0-4.0) of receiving late radiotherapy compared to married White women. To improve timely receipt of effective BrCA treatments, programs aimed at reducing racial disparities may need to target subgroups of Black breast cancer patients based on their social determinants of health and geographic residence.

Rural vs urban inequalities in stage at diagnosis for lung cancer

ObjectivesEarly diagnosis of lung cancer increases the chance of survival. The aim of this study was to measure the relationship between geographic residence in Saskatchewan and stage of lung cancer at the time of diagnosis. Materials and methodsRetrospective cohort analysis of 2,972 patients with a primary diagnosis of either non-small cell cancer (NSCLC) or small cell lung cancer (SCLC) between 2007 and 2012 was performed. Incidence proportion of early and advanced stage cancer, and relative risk of being diagnosed with advanced-stage lung cancer relative to early-stage was calculated. ResultsCompared to urban Saskatchewan, rural Saskatchewan lung cancer patients had a higher relative risk of advanced stage NSCLC (relative risk [RR] = 1.11, 95% confidence interval [CI]: 1.01–1.22). Rural Saskatchewan was further subdivided into north and south. The relative risk of advanced stage NSCLC in rural north Saskatchewan compared to urban Saskatchewan was even greater (RR = 1.17, 95% CI: 1.03–1.31). Although not statistically significant, there was a trend for a higher incidence of advanced stage SCLC in rural and rural north vs urban Saskatchewan (RR = 1.16, 95% CI: 0.95–1.43 and RR = 1.22; 95% CI: 0.94–1.58, respectively). There was a higher incidence proportion of advanced stage NSCLC in rural areas relative to urban (31.6–34.4 vs 29.5 per 10,000 people). ConclusionPatients living in rural Saskatchewan have higher incidence proportion of and were more likely to present with advanced stage NSCLC in comparison to urban Saskatchewan patients at time of diagnosis. This inequality was even greater in rural north Saskatchewan.

Geographical Residency and Quality of Life in Adults with and without Hearing Loss

There is an increased interest in the impact that hearing loss has on general well-being, including overall quality of life (QOL). The Quality of Life Inventory (QOLI), the Charlson Comorbidity Index and an Accessibility to Health Care questionnaire were administered to 108 participants. For adults with hearing loss who did not have access to hearing health care, lower QOL scores were reported compared to those with access to hearing health care, but this finding was not significant. Effect size calculations indicated that adults with hearing loss who lived in the most rural regions of Alabama, had lower reported QOL scores than their counterparts who had hearing within normal limits. Finally, those with higher incomes, who were older, and who had fewer physical disorders reported higher QOL compared to those with lower incomes, were younger, and who had more physical ailments. Part of a symposium sponsored by the Mental Health Practice and Aging Interest Group.

Understanding the messages and motivation of vaccine hesitant or refusing social media influencers

BackgroundWhile anti-vaccine messages on social media have been studied for content, reach, and effectiveness, less is known about those who create and promote the messages. Online influencers, or ‘everyday people who are influential within their online social networks’, are viewed as trusted voices who are often making similar life decisions as their followers. Therefore, their experiences with and perspectives on health issues can be persuasive. MethodsWe collaborated with a formal network of online influencers to interview, using a semi-structured interview guide, vaccine hesitant influencer mothers about their views on vaccination; their process for developing health-related social media content; their motivation to promote anti-vaccine messages; and their opinions on current vaccination messaging. Prescreening ensured a diverse sample by race/ethnicity, age, education, number of children, and geographic residence. Interviews occurred by telephone, were audio recorded, and transcribed. Themes were generated independently by two coders using a deductive coding approach. ResultsWe interviewed 15 online influencer mothers from across the U.S. (average age 39 years old; all married; 13 Caucasian, 1 African American, 1 Hispanic). In some capacity, 5 of the 15 wrote about vaccination on their blog. Those who chose not to post anti-vaccine content did so for fear of alienating followers or having their platform be the site of combative discourse among readers. When researching their social media posts, the influencers did not trust mainstream sources of health information and relied on alternative sources and search engines.Implications: This exploratory study interviewed influential mothers who have the ability to spread anti-vaccine messages on social media. While most do not contribute to the anti-vaccine sentiment, understanding the motivation and practices of those that do assists the public health community in better understanding the online vaccination communication environment, leading to more effective messages to counterbalance anti-vaccine content on social media.

Abstract PO-023: The Virginia Living Well Research and Registry: A community registry to assess cancer screening and lifestyle behaviors among rural Virginia residents

Abstract Background: Rural counties in Virginia have significantly higher overall cancer mortality compared to the state. Virginia is one of a few states that has both breast and colorectal cancer hotspots, driven primarily by mortality rates among African Americans. The Virginia Living Well Research and Registry (VALW), a community registry, was developed in collaboration with community partners to collect critical patient reported outcomes, including cancer protective and risk behaviors that can be tracked longitudinally. We assessed participation in cancer screening and five cancer protective behaviors, with comparison by geographical residence and race. Method: In-person and electronic recruitment by community-based staff enrolled adults (18+ years) living in Virginia, focusing on predominantly rural counties. Surveys were completed in-person, by phone or online. Questions included cancer screening (breast, cervical, colorectal), five cancer protective behaviors (physical activity, sleep, alcohol, BMI, smoking status) and demographics. Rural residence was defined using RUCC codes and calculated from mailing addresses. Results: To date, 586 participants are enrolled; 74% are rural (RUCC 4-9), 47% are Black/African American and 70% identify as female. Rural residents reported significantly lower household income (Χ2=25[1]:p< .000), greater use of Medicare (Χ2=4.5[1]:p=.034) and lower (pre-COVID) unemployment (Χ2=7.1[1]:p=.008) compared to urban participants. White participants reported significantly more alcohol use (Χ2=5.6[1]:p=.003), greater sleep disturbance (Χ2=5.6[1]:p=.018) and lower BMI(Χ2=33.4[1]:p<.000) compared to Black participants. Screening rates among those eligible were 82% biennial mammography, 72.3% pap (every 3yr.), 11% annual FIT tests and 77% colonoscopy. 18% reported current tobacco use. No differences in cancer screening, smoking or physical activity were identified by race or rural residence. Only 26% engaged in 4/5 or 5/5 of the assessed cancer protective behaviors. Conclusion: In this geographically and racially diverse sample, engagement in cancer screening was high with no identified racial or geographical disparities, reflecting in part, our long-term community engagement and strong community partnerships. Overall engagement in multiple cancer protective behaviors was low, while tobacco use was higher than the national rate. In addition to screening promotion, cancer prevention efforts in rural communities could leverage successful approaches used to promote screening to also address modifiable lifestyle factors. Finally, the geographical and racial diversity of this sample is strength. Citation Format: Maria D. Thomson, A. Williams, M.A. Preston, A.L. Sutton, V.B. Sheppard. The Virginia Living Well Research and Registry: A community registry to assess cancer screening and lifestyle behaviors among rural Virginia residents [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-023.

Abstract 14418: Association Between 2018 Unos Heart Transplant Policy Changes and Likelihood of Transplant for Patients in Rural versus Urban Settings

Introduction: United Network for Organ Sharing (UNOS) recently extended the radius for which a heart transplant candidate can be matched with a donor in order to improve transplantation access for the most critically-ill patients. However, this means that smaller transplant centers serving rural populations may not retain the hearts that were donated within their geographic area. It is unknown whether the UNOS policy change of 2018 was associated with differences in likelihood of heart transplantation or death on the waiting list for patients from rural versus urban (metropolitan or micropolitan) settings. Methods: Using the Scientific Registry of Transplant Recipients, we analyzed U.S. adult patients who were listed for heart transplant from January 2017 through January 2020. Patients were stratified by home zipcodes to either metropolitan, micropolitan, or rural settings. Fine and Gray proportional hazard regression models were used to estimate the sub-distribution hazard ratio (SHR) of heart transplantation with death or removal from transplant list as a competing event according to geographic residence with date of UNOS policy change October 18 2018 as a time-varying covariate. Interaction (p-int) tests were performed between geographic setting and time of policy change. Results: Among 8756 patients, 82% were from metropolitan, 9% micropolitan, and 9% rural settings. The 2018 UNOS policy change was associated with increased receipt of heart transplantation within each geographic setting [metropolitan SHR 1.41 (95%CI: 1.33-1.50); micropolitan SHR 1.30 (95%CI: 1.08-1.56); rural SHR 1.33 (95%CI: 1.10-1.62); p-int=0.60]. Policy changes were not significantly associated with death on the transplant list for any geographic setting [metropolitan SHR 0.97 (95%CI: 0.82-1.14); micropolitan SHR 1.25 (95%CI: 0.80-1.96); rural SHR 0.89 (95%CI: 0.55-1.46); p-int=0.52]. Conclusions: Independent of geographic location, the 2018 UNOS policy change for heart transplantation was associated with increased heart transplantation and no significant difference in hazard of death. Additional follow-up is needed to determine whether improvements are sustained.

Impact of Race and Geographic Location on Outcomes in Allogeneic Transplant

Impact of Race and Geographic Location on Outcomes in Allogeneic Transplant

Sex-related trends of cardiovascular risk perception and prevention behaviors: results from the italian society of cardiovascular survey

Abstract Background Recent reports evidenced gender differences in the knowledge, perception and awareness of cardiovascular risk factors and cardiovascular diseases. Purposes To evaluate trends in awareness of cardiovascular risk, as well as knowledge of symptoms and preventive behaviors related to cardiovascular disease (CVD). Methods As part of Vivi con il Cuore (campaign with the goal of raising awareness about women's heart disease) a nationwide survey was conducted. Standardized questions on awareness of CVD risk, as well as prevention behaviors and barriers, were provided through a computer-assisted web interviewing platform to a large sample of Italians citizens ranging from 40 to 70 years old. The sample was representative of the population by age, sex, and area of geographical residence. Results A total of 1,000 subjects were included in this survey, of which 511 (51%) female. About 60% of women indicated cancer as the leading cause of death among female sex, while only 22% indicated cardiovascular disease. Similarly, when the same question was asked to men, 44% indicated cancer and 21% cardiovascular disease, observations that were consistent across age categories. Although a well sizable part of the population (90% of the interviewees) have consulted the general practitioner in the last year, only 45% of women and 56% of men declared to receive information about CVD risk. Almost 84% among men and women, recognized the importance of knowing how to understand the symptoms of a heart attack due to the possibility of survival. An additional survey was conducted among young cardiologists under 40 years old, including a total of 200 young cardiologists, similarly distributed among men and women (47% and 53% respectively). About 24% of young cardiologists indicated breast cancer as the leading cause of death in women, while only 70% reported cardiovascular diseases. Furthermore, 35% of participants reported that they did not have adequate training on the risks of heart disease in women. Conclusions In this survey, only 22% of women were aware that cardiovascular disease is the number one killer of women. Likewise, a well sizable part of young cardiologists (30%) does not recognize cardiovascular disease as the leading cause of death in women. These data should inform public health campaigns to focus on evidence-based strategies to prevent CVD and to help target messages that resonate and motivate women to take action. Funding Acknowledgement Type of funding source: Private company. Main funding source(s): Abbott

Where and When: Sharpening the lens on geographic disparities in mortality.

Life course theories suggest that geographic disparities in mortality may reflect a history of place-based exposures rather than (or in addition to) contemporaneous exposures; yet, few studies examined early life place exposures and later life mortality in the US due to data limitations. The aim of this study is to assess and compare the importance of state of birth and state of residence in predicting mortality for adults over age 50 in the US. Using nationally representative data of nearly 100,000 adults over age 50 from the National Longitudinal Mortality Study, we estimated individual mortality risk using multi-level logistic regression with state of birth and state of residence as second-level random effects. We assessed whether state of residence and state of birth contributed to the variation in adult mortality. We also decomposed state-of-residence random effects to compare “movers” and “stayers.” Our results indicate that state of birth is a stronger predictor of age-, race/ethnicity- and sex-adjusted mortality in the US than state of residence at the time of death. The adult mortality profiles of many states are substantially impacted by the composition of “movers.” Failing to account for residential mobility has clouded our understanding of the patterns and causes of geographic differences in adult mortality. Measures of geographic residence across the life course can improve models of adult mortality in the US and inform interventions to address geographic disparities in longevity.

Is Prostate Brachytherapy a Dying Art? Evidence of Increasing Utilization in Ontario, Canada

A worldwide decline in prostate brachytherapy (BT) utilization has been reported in multiple health care settings/jurisdictions, despite strong evidence for efficacy and safety compared to other alternatives. We sought to evaluate contemporary trends in BT, EBRT and prostatectomy utilization in a publicly funded healthcare system. Men with localized prostate cancer diagnosed and treated between 2007 and 2017 in Ontario, Canada were identified using administrative data from the Institute for Clinical Evaluative Sciences. Men were coded to have received EBRT, BT (monotherapy or boost) or prostatectomy as initial definitive management. Trends were evaluated using the Cochran-Armitage test. Multivariate logistic regression was used to evaluate patient-, tumor-, and provider-factors on treatment utilization over time. There were 57,655 men were included in our study. Prostate BT use increased from 7.5% of all treatments in 2007 to 15.4% in 2017 (p<0.01), primarily due to increased use of BT boost (1.7% in 2007 to 10.4% in 2017, p<0.01). Relative to EBRT, BT use increased from 17.9% in 2007 to 28.1% in 2017 (p<0.01). On multivariate analysis (MVA), BT boost use increased by 28% per year (OR 1.28, 95% CI 1.26–1.31, p<0.01) and BT monotherapy use increased by 12% per year (OR 1.12, 95% CI 1.10–1.14, p<0.01), offset by decreasing prostatectomy use (12% per year, OR 0.88, 95% CI 0.87–0.89, p<0.01). Comparing BT to EBRT, the strongest predictors of receiving BT were geographic residence (OR 27.6, 95% CI: 20.3–37.6, p<0.01 between highest/lowest Local Health Integration Networks) and whether the first consulting radiation oncologist performed BT (OR 3.46, 95% CI: 3.15–3.80, p<0.01). Other significant factors predicting BT use vs. EBRT included lower age, lower PSA, lower Charlson comorbidity score and increasing neighborhood income quintile. Low-intermediate, high-intermediate and high-risk groups were predictive of receiving BT boost, whereas BT monotherapy was predominantly used in low-risk disease. Contrary to trends observed in other jurisdictions, utilization of prostate BT is increasing over time in Ontario. However, substantial variation in BT utilization was found, strongly driven by both geographic region and radiation oncologist BT practice patterns. To our knowledge, this is the first study to report increasing BT utilization in the era of dose-escalated EBRT, with Ontario potentially serving as a model to promote BT utilization elsewhere.

Parents and Children During the COVID-19 Lockdown: The Influence of Parenting Distress and Parenting Self-Efficacy on Children's Emotional Well-Being.

On March 10, 2020, Italy went into lockdown due to the Coronavirus Disease-19 (COVID-19) pandemic. The World Health Organization highlighted how the lockdown had negative consequences on psychological well-being, especially for children. The present study aimed to investigate parental correlates of children’s emotion regulation during the COVID-19 lockdown. Within the Social Cognitive Theory framework, a path model in which parenting self-efficacy and parental regulatory emotional self-efficacy mediated the relationship between parents’ psychological distress and both children’s emotional regulation, and children’s lability/negativity, was investigated. A total of 277 parents of children aged from 6 to 13 years completed an online survey that assessed their psychological distress, regulatory emotional self-efficacy, and parenting self-efficacy. Parents reported also children’s emotional regulation and lability/negativity. A structural equation model (SEM) using MPLUS 8.3 was tested. Results showed that the hypothesized model exhibited excellent fit, chi-square (83) = 140.40, p < 0.01, RMSEA = 0.05, CFI = 0.97, TLI = 0.96, SRMR = 0.04. The influences of parents’ psychological distress and parents’ regulatory emotional self-efficacy on children’s emotional regulation and lability/negativity were mediated by parenting self-efficacy. The mediation model was invariant across children’s biological sex and age, and geographical residence area (high risk vs. low risk for COVID-19). Results suggested how parents’ beliefs to be competent in managing parental tasks might be a protective factor for their children’s emotional well-being. Implications for intervention programs are discussed.

Geospatial Distribution and Predictors of Mortality in Hospitalized Patients With COVID-19: A Cohort Study.

BackgroundThe global coronavirus disease 2019 (COVID-19) pandemic offers the opportunity to assess how hospitals manage the care of hospitalized patients with varying demographics and clinical presentations. The goal of this study was to demonstrate the impact of densely populated residential areas on hospitalization and to identify predictors of length of stay and mortality in hospitalized patients with COVID-19 in one of the hardest hit counties internationally.MethodsThis was a single-center cohort study of 1325 sequentially hospitalized patients with COVID-19 in New York between March 2, 2020, to May 11, 2020. Geospatial distribution of study patients’ residences relative to population density in the region were mapped, and data analysis included hospital length of stay, need and duration of invasive mechanical ventilation (IMV), and mortality. Logistic regression models were constructed to predict discharge dispositions in the remaining active study patients.ResultsThe median age of the study cohort (interquartile range [IQR]) was 62 (49–75) years, and more than half were male (57%) with history of hypertension (60%), obesity (41%), and diabetes (42%). Geographic residence of the study patients was disproportionately associated with areas of higher population density (rs = 0.235; P = .004), with noted “hot spots” in the region. Study patients were predominantly hypertensive (MAP > 90 mmHg; 670, 51%) on presentation with lymphopenia (590, 55%), hyponatremia (411, 31%), and kidney dysfunction (estimated glomerular filtration rate < 60 mL/min/1.73 m2; 381, 29%). Of the patients with a disposition (1188/1325), 15% (182/1188) required IMV and 21% (250/1188) developed acute kidney injury. In patients on IMV, the median (IQR) hospital length of stay in survivors (22 [16.5–29.5] days) was significantly longer than that of nonsurvivors (15 [10–23.75] days), but this was not due to prolonged time on the ventilator. The overall mortality in all hospitalized patients was 15%, and in patients receiving IMV it was 48%, which is predicted to minimally rise from 48% to 49% based on logistic regression models constructed to project disposition in the remaining patients on ventilators. Acute kidney injury during hospitalization (odds ratioE, 3.23) was the strongest predictor of mortality in patients requiring IMV.ConclusionsThis is the first study to collectively utilize the demographics, clinical characteristics, and hospital course of COVID-19 patients to identify predictors of poor outcomes that can be used for resource allocation in future waves of the pandemic.

Influence of broader geographic allograft sharing on outcomes and cost in smaller lung transplant centers

ObjectiveOn November 24, 2017, Organ Procurement and Transplantation Network implemented a change to lung allocation replacing donor service area with a 250 nautical mile radius around donor hospitals. We sought to evaluate the experience of a small to medium size center following implementation. MethodsPatients (47 pre and 54 post) undergoing lung transplantation were identified from institutional database from January 2016 to October 2019. Detailed chart review and analysis of institutional cost data was performed. Univariate analysis was performed to compare eras. ResultsSimilar short-term mortality and primary graft dysfunction were observed between groups. Decreased local donation (68% vs 6%; P < .001), increased travel distance (145 vs 235 miles; P = .004), travel cost ($8626 vs $14,482; P < .001), and total procurement cost ($60,852 vs $69,052; P = .001) were observed postimplementation. We also document an increase in waitlist mortality postimplementation (6.9 vs 31.6 per 100 patient-years; P < .001). ConclusionsFollowing implementation of the new allocation policy in a small to medium size center, several changes were in accordance with policy intention. However, concerning shifts emerged, including increased waitlist mortality and resource utilization. Continued close monitoring of transplant centers stratified by size and location are paramount to maintaining global availability of lung transplantation to all Americans regardless of geographic residence or socioeconomic status.

Access to Hearing Health Care, Geographical Residency, and Quality of Life in Adults with and without Hearing Loss.

There is an increased interest in the impact that hearing loss has on general well-being, including overall quality of life (QOL), to improve and expand care that is provided to individuals with hearing loss. To evaluate QOL in adults with and without access to hearing health care (HHC). A cross-sectional study examined QOL across groups of individuals with and without hearing loss. One hundred eight participants from West Central and South Alabama received pure-tone hearing evaluations. Thirty-two adults had hearing within normal limits and 76 had at least a mild hearing loss in one ear. The Quality of Life Inventory (QOLI), the Charlson Comorbidity Index, and an Accessibility to Health Care questionnaire were administered to all participants. The QOLI outcomes were used as the dependent variable for the analysis of covariance (ANCOVA) statistical procedures. For adults with hearing loss who did not have access to HHC, lower QOL scores were reported compared with those with access to HHC, but this finding was not significant. Although ANCOVA results did not suggest QOL differences across geographical regions, effect size calculations indicated that adults with hearing loss who lived in the most rural regions of Alabama had lower reported QOL scores than their counterparts who had hearing within normal limits. Finally, those with higher incomes, who were older, and who had fewer physical disorders reported higher QOL than those with lower incomes, who were younger, and who had more physical ailments. Adults with hearing loss who live in regions without access to HHC might be at risk for decreased QOL. A number of models for improving access to HHC will be necessary to decrease this potential risk.