Mixed Race Patients Research Articles

Regional Disparities in Kidney Transplant Allocation in Brazil: A Retrospective Cohort Study.

Brazil has a large public transplant program, but it remains unclear if the kidney waitlist criteria effectively allocate organs. This study aimed to investigate whether gender, ethnicity, clinical characteristics, and Brazilian regions affect the chance of deceased donor kidney transplant (DDKT). We conducted a retrospective cohort study using the National Transplant System/Brazil database, which included all patients on the kidney transplant waitlist from January 2012 to December 2022, followed until May 2023. The primary outcome assessed was the chance of DDKT, measured using subdistribution hazard and cause-specific hazard models (subdistribution hazard ratio [sHR]). We analyzed 118 617 waitlisted patients over a 10-year study period. Male patients had an sHR of 1.07 ([95% CI: 1.05-1.10], p<0.001), indicating a higher chance of DDTK. Patients of mixed race and Yellow/Indigenous ethnicity had lower rates of receiving a transplant compared to Caucasian patients, with sHR of 0.97 (95% CI: 0.95-1) and 0.89 (95% CI: 0.95-1), respectively. Patients from the South region had the highest chance of DDKT, followed by those from the Midwest and Northeast, compared to patients from the Southeast, with sHR of 2.53 (95% CI: 2.47-2.61), 1.21 (95% CI: 1.16-1.27), and 1.10 (95% CI: 1.07-1.13), respectively. The North region had the lowest chance of DDTK, sHR of 0.29 (95% CI: 0.27-0.31). We found that women and racial minorities faced disadvantages in kidney transplantation. Additionally, we observed regional disparities, with the North region having the lowest chance of DDKT and longer times on dialysis before being waitlisted. In contrast, patients in the South regions had a chance of DDKT and shorter times on dialysis before being waitlisted. It is urgent to implement approaches to enhance transplant capacity in the North region and address race and gender disparities in transplantation.

Total Body Irradiation and Fludarabine with Post-Transplantation Cyclophosphamide for Mismatched Related or Unrelated Donor Hematopoietic Cell Transplantation

Allogeneic hematopoietic cell transplantation (HCT) remains the sole curative treatment for most patients with hematologic malignancies. A well-matched donor (related or unrelated) remains the preferred donor for patients undergoing allogeneic HCT; however, a large number of patients rely on alternative donor choices of mismatched related (haploidentical) or unrelated donors to access HCT. In this retrospective study, we investigated outcomes of patients who underwent mismatched donor (related or unrelated) HCT with a radiation-based myeloablative conditioning MAC regimen in combination with fludarabine, and post-transplantation cyclophosphamide (PTCy) as higher-intensity graft-versus-host disease (GVHD) prophylaxis. We retrospectively assessed HCT outcomes in 155 patients who underwent mismatched donor HCT (related/haploidentical versus unrelated [MMUD]) with fractionated-total body irradiation (fTBI) plus fludarabine and PTCy as GVHD prophylaxis at City of Hope from 2015 to 2021. Diagnoses included acute lymphoblastic leukemia (46.5%), acute myelogenous leukemia (36.1%), and myelodysplastic syndrome (6.5%). The median age at HCT was 38 years, and 126 patients (81.3%) were an ethnic minority. The Hematopoietic Stem Cell Transplantation Comorbidity Index was ≥3 in 36.1% of the patients, and 29% had a Disease Risk Index (DRI) of high/very high. The donor type was haploidentical in 67.1% of cases and MMUD in 32.9%. At 2 years post-HCT, disease-free survival (DFS) was 75.4% and overall survival (OS) was 80.6% for all subjects. Donor type did not impact OS (hazard ratio [HR], .72; 95% confidence interval [CI], .35 to 1.49; P = .37) and DFS (HR, .78; 95% CI, .41 to 1.48; P = .44), but younger donors was associated with less grade III-IV acute GVHD (HR, 6.60; 95% CI, 1.80 to 24.19; P = .004) and less moderate or severe chronic GVHD (HR, 3.53; 95% CI, 1.70 to 7.34; P < .001), with a trend toward better survival (P = .099). The use of an MMUD was associated with significantly faster neutrophil recovery (median, 15 days versus 16 days; P = .014) and platelet recovery (median, 18 days versus 24 days; P = .029); however, there was no difference in GVHD outcomes between the haploidentical donor and MMUD groups. Nonrelapse mortality (HR, .86; 95% CI, .34 to 2.20; P = .76) and relapse risk (HR, .78; 95% CI, .33 to 1.85; P = .57) were comparable in the 2 groups. Patient age <40 years and low-intermediate DRI showed a DFS benefit (P = .004 and .029, respectively). High or very high DRI was the only predictor of increased relapse (HR, 2.89; 95% CI, 1.32 to 6.34; P = .008). In conclusion, fludarabine/fTBI with PTCy was well-tolerated in mismatched donor HCT, regardless of donor relationship to the patient, provided promising results, and increased access to HCT for patients without a matched donor, especially patients from ethnic minorities and patients of mixed race.

Improving Outcomes of Peripheral Blood Stem Cell (PBSC) HLA-Mismatched Unrelated Donor (MMUD) Hematopoietic Cell Transplantation (HCT): Effect of Graft Versus Host Disease (GVHD) Prophylaxis

Human leukocyte antigen (HLA) well matched donor (related or unrelated) has remained the preferred donor source for patients undergoing HCT for hematological disease, but the probability of finding a suitable related or unrelated donor has varied based on ethnic groups. HLA-mismatch unrelated donor (MMUD) transplantation has improved access to HCT in underrepresented minority groups and patients of mixed race. Historically, MMUD HCT has been associated with inferior survival outcomes compared to matched unrelated donor HCT when using conventional platforms of GVHD prophylaxis. (PMID: 31449184, 20538804). Efforts to improve outcomes have investigated the addition of a third agent such as anti-thymocyte globulin (ATG), mini-methotrexate (MTX) or mycophenolate mofetil (MMF). More recently, a study by the National Marrow Donor Program (NMDP) demonstrated the feasibility of post-transplant cyclophosphamide (PTCy) based GVHD prophylaxis in MMUD HCT using bone marrow (BM) grafts (PMID: 33905264). Additionally, our group demonstrated promising overall survival (OS) and GVHD-free/relapse-free-survival (GRFS) rates in peripheral blood stem cell (PBSC) MMUD HCT using PTCy based GVHD prophylaxis (PMID: 34156440). Here, we compare outcomes of PBSC MMUD HCT among patients receiving GVHD prophylaxis with either: (1) tacrolimus plus sirolimus (T/S), (2) T/S plus mini-methotrexate (T/S/MTX), or (3) PTCy, MMF, and tacrolimus or sirolimus (PTCy). Patients with various hematologic malignancies that underwent PBSC MMUD HCT (≥5/8 HLA-matched donors) at City of Hope between January 2005 and December 2021 were included in this retrospective review. Of 390 subjects included, GVHD prophylaxis included T/S (n=114), T/S/MTX (n=160), and PTCy (n=116). The median age was 51 (range:15-79), 53.3% of patients belonged to a racial/ethnic minority, and 34.8% (n=136) patients had disease risk index high or very high. Degree of HLA mismatch was 7/8 (91.3%), 6/8 (8.5%), and 5/8 (0.3%). Hematologic diseases included AML (40.3%), ALL (20.3%), MDS/MPN (15.9%), Lymphoma (16.9%), and CML/CMMol (6.7%). Most common conditioning regimens were fTBI-based (34.4%) and melphalan-based (57.2%). HCT comorbidity index was ≥ 3 in 30.8% (n=120), which was most common in PTCy compared to T/S and T/S/MTX: 48.3% vs. 23.7% vs. 23.1%, P&amp;lt;.001. The rate of neutrophil engraftment (15 days vs. 15 days vs 16 days, P=0.002) and platelet engraftment (15 days vs. 16 days vs 27 days, P=0.004) were shorter in T/S compared to T/S/MTX and PTCy, respectively. With median follow-up of 5.4 years (range: 1.0-16.7) the 5-year OS was superior in PTCy (P=0.045) compared to T/S and T/S/MTX: 58.0% (95% CI: 46.6-67.8) vs. 41.1% (95% CI: 31.9-50.1) and 39.6% (95% CI: 32-47.2). The 5-year disease-free survival (DFS) was superior in PTCy (P=0.042) compared to T/S and T/S/MTX: 54.2% (95% CI: 43.3-63.9) vs. 37.1% (95% CI: 28.2-46.0) vs. 37.2% (95% CI: 29.7-44.6), respectively. There was no significant difference in 5-year cumulative incidence of relapse (CIR) in T/S vs. T/S/MTX vs. T/S vs. PTCy: 29.1% (95% CI: 21.0-37.6) vs. 29.5% (95% CI: 22.6-36.7) vs. 22.1% (95% CI: 14.3-31.0), respectively. Additionally, there was no significant difference in 2-year NRM between the cohorts (P=0.459): 24.6% (95% CI: 17.1-32.9) vs. 23.1% (95% CI: 16.9-29.9) vs. 20.4% (95% CI: 13.5-28.4), respectively. The rate of 100-day Grade III-IV acute GVHD were similar between in the cohorts (P=0.321): 19.3% (95% CI: 12.6-27.0) vs. 18.1% (95% CI: 12.6 -24.5) vs. 12.9% (95% CI: 7.6-19.7). When comparing T/S vs. T/S/MTX and PTCy, the incidence of chronic GVHD was less in the PTCy cohort at both 1-year and 2-years (P&amp;lt;.001) with 1-year incidence of 55.0% (95% CI: 45.1-63.7) vs. 61.9% (95% CI: 53.8-68.9) vs. 38.9% (95% CI: 30-47.8), respectively, and 2-year incidence of 58.9% (95% CI: 49.0-67.6) vs. 66.2% (95% CI: 58.3-73.1) vs. 42.7% (95% CI: 33.4-51.6), respectively. To our knowledge, this is the largest reported single center outcome of PBSC MMUD HCT. In this study, we demonstrate the superiority of PTCy based GVHD prophylaxis compared to T/S and T/S/MTX in outcomes of 5-year OS (P=0.045), 5-year DFS (P=0.042), and incidence of chronic GVHD (P&amp;lt;.001). Our experience further supports the superiority of PTCy as the preferred GVHD prophylaxis in the PBSC MMUD HCT setting achieved by lowering chronic GVHD and associated complications.

Primary nephrotic syndrome in children in Cape Town, South Africa

Background. Histopathological patterns of childhood primary nephrotic syndrome (PNS) and clinical response to steroids have beenassociated with certain race groups in parts of South Africa. However, there are no recent studies of childhood PNS in Cape Town.Objectives. To describe the demographics, histological subtypes and steroid response of patients with PNS who underwent kidney biopsiesat Red Cross War Memorial Children’s Hospital (RCWMCH) over a 10-year period.Methods. Details of patients with PNS who underwent kidney biopsies in the Paediatric Nephrology Department at RCWMCH between2006 and 2015 were retrospectively recorded.Results. A total of 103 patients were included in the study. Most patients were either of mixed race (42%) or black (36%), with a mean age of6.8 years and a male-to-female ratio of 1.19:1. The most identified histopathological subtype was mesangioproliferative glomerulonephritis(MesPGN; 60% (n/N=62/103)). Of the patients with focal segmental glomerulosclerosis (FSGS), MesPGN and minimal change disease(MCD) 45% (n/N=43/95) were steroid-resistant, and 54% (n/N=51/95) were steroid-sensitive. There was no significant associationbetween any race group and steroid response. Patients with FSGS were more likely to be black, while MCD was more common in mixed-race patients (p=0.04). There was no difference in the likelihood of being mixed race or black between patients with FSGS and MesPGN(p=0.472).Conclusion. MesPGN was the most common histopathological subtype found in our study. There was no significant association betweenrace and steroid response. Patients with FSGS were more likely to be black than mixed race when compared with MCD patients. Race wasnot otherwise significantly associated with any histopathological subtype

Situational analysis of syphilis cases taking place between 2015 and 2021 in the state of Rio Grande do Norte - Brazil

Introduction: Syphilis is a sexually transmitted infection that represents a severe public health problem worldwide and in Brazil it has not been different. The national compulsory notifications regarding syphilis cases are significantly increasing, and therefore, this fact alone justifies the study of such a relevant subject. Objective: This work presents a situational analysis of syphilis cases in the state of Rio Grande do Norte, Brazil, between 2015 and 2021, aiming primarily at assisting public healthcare authorities in decision-making processes to cope with the disease. Concomitantly, this research aims to build knowledge as well as to provide awareness to the population. Methods: This study analyzed data from compulsory notifications reports from 2015 to 2021, available in the database of the Brazilian Unified Health System’s Informatics Department, in the Brazilian Information System of Notifiable Diseases and in the Brazilian Health Surveillance Secretariat. Results: In the state, 70% of patients with syphilis are aged 15 to 39 years. The rate of patients affected with acquired syphilis that have low education is 48%, and for pregnant women, this value rises to 77%. The declared mixed-race patients represent 48% of notifications for acquired syphilis, and for mixed-race pregnant women, this value increases to 60%. In congenital syphilis, 98% of compulsory notifications occurred for children aged up to 7 days of birth. Conclusion: Syphilis in Rio Grande do Norte is a public health problem that mainly affects the vulnerable population, predominantly the groups at risk with low education, mixed race, and young-adult people, being of paramount importance to combat the disease through population awareness, as well as through constant and adequate compulsory notification.

Race and Mortality in Hemodialysis Patients in Brazil

Studies in the United States and United Kingdom generally report better survival for Black than White patients undergoing maintenance hemodialysis, a finding not explained by differences in sociodemographics or comorbid conditions. It is not clear if such findings can be generalized to other countries. We investigated the association between race and mortality among a Black, White, and Mixed-Race sample of maintenance hemodialysis patients in Salvador, Brazil. Prospective cohort study. Baseline data collection from July 1, 2005 through December 31, 2010. The follow-up period ended on December 31,2017. The Prospective Study of the Prognosis of Chronic Hemodialysis Patients (PROHEMO) is a cohort of 1,501 patients from 4 dialysis units in Salvador, Brazil. Race categorized as White (12.9%), Mixed-Race (62.4%), and Black (24.8%), using White as the reference category. Survival. Using Cox regression models, we tested the association between race and mortality, with adjustments for age, sex, social factors, laboratory results, and comorbid conditions. The mean age was 49 years for Black and Mixed-Race patients and 55 years for White patients. In a Cox model adjusted for age, mortality did not differ between Black and White patients (HR, 1.10; 95% CI, 0.66-1.83) or between Mixed-Race and White patients (HR, 1.00; 95% CI, 0.65-1.54). Adjustment for sociodemographics and comorbid conditions had minimal impact on these results. Potential residual confounding and lack of adjustment for time-varying variables. Contrary to studies in the United States and United Kingdom, we did not find racial difference in mortality among patients in our Brazilian setting who were being treated by maintenance hemodialysis. These results underscore the importance of investigating racial differences in mortality among patients undergoing maintenance hemodialysis in different populations and countries.

The Demographics and Epidemiology of Infantile, Juvenile, and Adolescent Idiopathic Scoliosis in a Southern California Integrated Health Care System.

Prognostic study, Level III. The aim of this study was to determine the incidence and demographics of idiopathic scoliosis (IS) in a large cohort of children in a Southern California integrated healthcare system, and to identify the demographic or clinical factors associated with the greatest risk of IS. Although many authors have reported on the incidence and prevalence of IS in children, there have been few incidence studies in the United States on large, self-contained populations. A retrospective chart analysis was done on diagnosed cases of IS within our integrated health care system in patients under age 18 years during the entire 2013 calendar year. Patient demographics were recorded and the incidence of IS was determined. Odds ratios (ORs) for having IS and for having more severe initial curve magnitudes based on demographics were determined using logistic regression models. IS Incidence was 3.9, 28.6, and 393 per 100,000, respectively, for the infantile, juvenile, and adolescent group. The female incidence was more than twice that of males in all age groups. Multivariate logistic regression analysis showed Asians and non-Hispanic Whites had the highest OR of IS (OR 1.54 and 1.32 with 95% confidence interval [CI] 1.33-1.79 and 1.19-1.47). Whites, Blacks, and mixed-race patients had a significantly higher initial curve magnitude than Hispanics; females also had a significantly greater initial curve magnitude than boys (18.1° vs. 16.7°). Underweight patients had a 50% increased OR of IS versus normal weight (95% CI 1.16-1.94) with a progressively decreased OR of IS as weight increased. Our study of a large integrated healthcare system sheds light on the incidence of IS and the ORs based on weight, sex, and ethnicity/race. The overall incidence was lower overall than previously thought.Level of Evidence: 3.

Could routine race-adjustment of spirometers exacerbate racial disparities in COVID-19 recovery?

Could routine race-adjustment of spirometers exacerbate racial disparities in COVID-19 recovery?

CYP3A5 polymorphisms and their effects on tacrolimus exposure in an ethnically diverse South African renal transplant population.

Tacrolimus forms the cornerstone for immunosuppression in solid-organ transplantation. It has a narrow therapeutic window with wide inter- and intra-patient variability (IPV). Cytochrome P-450 3A5 (CYP3A5) is the main enzyme involved in tacrolimus metabolism, and rs776746A&gt;G is the most frequently studied polymorphism in the CYP3A5 gene. The rs776746A&gt;G (i.e. CYP3A5*3) single-nucleotide polymorphism in CYP3A5 alters tacrolimus predose trough concentration (C0) and may also affect IPV, which may lead to immune- and/or drug-mediated allograft injury. CYP3A5*3 may result in absent (*3/*3), partial (*1/*3) or normal (*1/*1) CYP3A5 expression. The effect of CYP3A5*3 on tacrolimus exposure and variability has not been examined in South African (SA) transplant recipients. To determine the frequencies and effect of CYP3A5 and adenosine triphosphate-binding cassette subfamily B member 1 (ABCB1) polymorphisms on tacrolimus C0/dose ratios in different ethnic groups attending a tertiary renal transplant clinic in SA, and other factors that may explain inter- and IPV in tacrolimus C0. All consenting stable renal transplant recipients on tacrolimus at the Livingstone Hospital Renal Unit in Port Elizabeth, SA, were included. Tacrolimus concentrations were obtained using a microparticle enzyme immunoassay method (ARCHITECT analyser, Abbott Laboratories). Polymerase chain reaction/restriction fragment length polymorphism was used to genotype for CYP3A5*3 and *6 allelic variants. There were 43 participants (35% black African, 44% mixed ancestry and 21% white), with a mean age of 44.5 years, median duration post-transplant of 47 months and median (interquartile range) creatinine and estimated glomerular filtration rate levels of 118(92- 140) µmol/L and 62 (49 - 76) mL/min at study inclusion. The mean tacrolimus C0 in the study was 6.7 ng/mL, with no difference across the different ethnic groups. However, the mean total daily dose of tacrolimus required was 9.1 mg (0.12 mg/kg), 7.2 mg (0.09 mg/kg) and 4.3 mg (0.06 mg/kg) in black, mixed-ancestry and white patients, respectively (p=0.017). The frequencies for CYP3A5 expressors (i.e. CYP3A5*1/*1 + CYP3A5*1/*3 genotypes) were 72%, 100%, 76% and 12% for all patients combined and black, mixed-ancestry and white patients, respectively. The frequencies for CYP3A5 non-expressors (i.e. CYP3A5*3/*3 genotypes) were 0%, 24% and 88% among the black, mixed-ancestry and white patients, respectively. None of the patients carried the CYP3A5*6 allele. CYP3A5*1/*1 and CYP3A5*1/*3 genotype carriers required a two-fold increase in dose compared with the non-expressor genotype carriers, CYP3A5*3/*3 (p&lt;0.05). CYP3A5*3/*3 carriers also demonstrated higher IPV than CYP3A5*1/*1 and *1/*3 carriers (18.1% v. 14.2%; p=0.125). Compared with global transplant populations, SA renal transplant recipients demonstrated a very high rate of CYP3A5 expression, with a significant impact on tacrolimus pharmacokinetics. Genetic variation in CYP3A5 expression affects tacrolimus dosing requirements, and knowing the CYP3A5 genotype of transplant patients may allow better dose prediction compared with current standard dosing recommendations in a multi-ethnic population. Overall, black African patients required higher doses of tacrolimus than their white counterparts. While further prospective studies are needed to better evaluate dosing algorithms, it would appear that the starting dose of tacrolimus should be higher in black and mixed-race patients.

Cervical scar satisfaction post conventional thyroidectomy.

Thyroidectomy is a commonly performed procedure with large centres performing thousands of thyroid surgeries per year. The traditional Kocher mid-cervical incision has been the standard approach to thyroidectomy since the late 1870s with predictable results. The introduction of minimally invasive and remote access techniques seeks to reduce the morbidity of a mid-cervical scar incision. Ninety-five [95] patients who underwent this approach over the thirty [30] months period from January 2015 to July 2017 were administered the validated Patient Scar Assessment Questionnaire and the collected data analysed. Forty-eight [48] patients, (50.5%) met inclusion criteria and provided responses with a mean time since surgery of 18.9 months. There is a high level of satisfaction with 91.7% of patients in the study having scores consistent with scar satisfaction after conventional thyroidectomy. While patients were satisfied with the appearance of their scars, a majority of patients (n=28, 58.3%) were at least slightly conscious of their incisions, with more than 10% of patients (n=5) reporting significant levels of self-consciousness. Patients of Mixed race were found to have slightly elevated scores on PSAQ compared with IndoTrinidadian and AfroTrinidadian races (P=0.002 and P=0.006). Most patients were satisfied with their scar results in the years after thyroidectomy. Despite the high level of satisfaction, a majority of patients are self-conscious about the presence of a mid-cervical incision. Further research is needed to elucidate causes and the effects of this finding.

Ethnic Rhinoplasty.

Ethnic rhinoplasty traditionally has been used to define this surgical procedure performed on non-Caucasian patients. Because of globalization, massive migrations, and interracial mixing, ethnic patients today are considered mixed race patients. Surgical techniques should be based not on what ethnic group they belong to but on anatomical findings and patients' needs and wishes. Preservation techniques are presented and structural approaches are discussed using sutures and grafts. The final objectives of rhinoplasty are better definition, more refined appearance, and compliance with patients' aesthetic ideals while preserving function.

Aspects of Diode Laser (805 nm) Hair Removal Safety in a Mixed-Race Group of Patients.

Introduction: Laser hair removal (LHR) has become one of the most popular treatments in aesthetics. Side effects are an inevitable part of laser therapy, therefore managing them is crucial for every laser practitioner to ensure patients' safety along with achieving the best results. The available references describe the effectiveness of the diode LHR for all skin types according to the Fitzpatrick scale, but the question of patient safety and minimization of side effects and postoperative complications in mixed-race patients remains unanswered. This study aims to illustrate aspects of specific side effects in patients of mixed ethnicity and the impact of those effects on the results of the treatment. Methods: The study was conducted in Poland and the United Kingdom on 216 patients of various ethnic backgrounds. This study analyses the frequency of side effects in a mixed-race group of 32 participants, taking into account their skin type according to the Fitzpatrick scale. The patients received a course of 6 treatments using diode laser 805 nm. An objective and a subjective method were used to analyse treatment results and side effects, with adverse effects documented, if observed. Treatment settings were adjusted to skin reaction during the patch test. Results: Objective analysis was different from the subjective analysis of the treatment's effectiveness. No adverse effects were observed. Side effects such as hyperpigmentation, skin irritation, skin burns, and skin hypersensitivity were found. Conclusion: 805 nm diode laser is effective and efficient at hair removal in mixed-race patients. It is a safe treatment in terms of skin reaction as only short-term side effects were observed in the treated area and no adverse effects were noted. To achieve the best results and to avoid adverse effects it is necessary to adjust treatment settings according to the individual patient's skin reaction.

Dengue fever in Dar es Salaam, Tanzania: clinical features and outcome in populations of black and non-black racial category

BackgroundAlthough the incidence of dengue across Africa is high, severe dengue is reported infrequently. We describe the clinical features and the outcome of dengue according to raceduring an outbreak in Dar es Salaam, Tanzania that occurred in both native and expatriate populations.MethodsAdults with confirmed dengue (NS1 and/or IgM on rapid diagnostic test and/or PCR positive) were included between December 2013 and July 2014 in outpatient clinics. Seven-day outcome was assessed by a visit or a call. Association between black race and clinical presentation, including warning signs, was assessed by logistic regression adjusted for age, malaria coinfection, secondary dengue and duration of symptoms at inclusion. The independent association between demographic and comorbidities characteristics of the patients and severe dengue was evaluated by multivariate logistic regression that included potential confounders.ResultsAfter exclusion of 3 patients of mixed race, 431 patients with dengue (serotype 2, genotype Cosmopolitan) were included: 241 of black and 190 of non-black race. Black patients were younger (median age 30 versus 41 years; p < 0.001) and attended care after a slightly longer duration of symptoms (median of 2.9 versus 2.7 days; p = 0.01). Malaria coinfection was not significantly different between black (5%) and non-black (1.6%) patients (p = 0.06). The same proportion of patients in both group had secondary dengue (13 and 14%; p = 0.78). Among warning signs, only mucosal bleed was associated with race, black race being protective (adjusted OR 0.44; 95% CI 0.21–0.92). Overall, 20 patients (4.7%) presented with severe dengue. Non-black race (adjusted OR 3.9; 95% CI 1.3–12) and previously known diabetes (adjusted OR 43; 95% CI 5.2–361) were independently associated with severe dengue.ConclusionsAlthough all patients were infected with the same dengue virus genotype, black race was independently protective against a severe course of dengue, suggesting the presence of protective genetic or environmental host factors among people of African ancestry. The milder clinical presentation of dengue in black patients might partly explain why dengue outbreaks are under-reported in Africa and often mistaken for malaria. These results highlight the need to introduce point-of-care tests, beside the one for malaria, to detect outbreaks and orientate diagnosis.Trial registrationClinicaltrials.gov Identifier: NCT01947075, retrospectively registered on the 13 of September 2014.

Caracterización de la salud visual y ocular en niños de un centro de desarrollo infantil de un barrio marginal de Pereira, Colombia

Objective: To describe the conditions of visual and ocular health of children attending a Child Development Center in a marginal neighborhood of the city of Pereira, Colombia.Materials and methods: The sociodemographic, visual and ocular characteristics of children attending a Child Development Center (CDI) in the city of Pereira, between the ages of 9 and 70 months, are described from the information reported in the clinical records. Exam clinics practiced between 2012 and 2013.Results: 352 clinical histories were evaluated, 54.8% corresponded to the masculine gender. The average age in the sample was 49.7 months. Mixed-race patients were presented in 67.32% of the cases, being this group the most common. Emmetropia was observed in 67.05%, of the patients, hyperopia in 23.58%, myopia in 9.38% and astigmatism occurred in 9.1% of cases. The average of the sphere was +0.34 Diopters, of astigmatism 0.17 Diopters and most of the patients presented axes with the rule. Of 704 eyes, 2.98% were found with blepharitis, in mixed and Afro-Colombian races. Physiological exophoria was in 42% of the cases.Conclusions: The most prevalent refractive state in all age groups was emmetropia, followed by hyperopia. The pathologies of the anterior segment and ocular adnexa were more frequent in the mixed and Afro-Colombian ethnic groups, mainly blepharitis and conjunctivitis. The exophoria and within it, the physiological, represents the most frecuent motor state diagnosed in this study.

First Presentation with Psychotic Symptoms to the Emergency Department

BackgroundMental health conditions account for 52.8 million (4.9–6.3%) emergency department (ED) visits in the United States. Psychotic conditions are responsible for approximately 10% of all mental health presentations. ObjectiveWe aimed to determine the underlying etiology and characteristics of patients presenting to the ED with a first episode of psychotic symptoms. MethodsMedical records of 159 African, Asian, white, and mixed-race patients were prospectively reviewed. Subjects were classified into one of three groups; psychosis due to an underlying medical condition (UMC), substance-induced psychotic disorders (SIPDs), and psychosis due to other primary psychiatric disorders (OPD). Demographic details and presenting features were described and compared. ResultsOverall mean (standard deviation [SD]) age of all study subjects was 34.3 (13.4) years. A UMC was responsible for a first presentation with psychotic features in more than half of the study subjects (n = 87 [54.7%]), while SIPD (n = 37 [23.3%]) and OPD (n = 35 [22.0%]) were responsible for the remainder of cases. The majority of subjects were male (n = 95 [59.7%]), unemployed (n = 105 [66.0%]), and had not completed secondary school (n = 109 [68.6%]). More than one-third of subjects tested positive for human immunodeficiency virus infection (n = 63 [39.6%]). Mean (SD) duration of psychotic symptoms before ED presentation was 16.6 (26.3) days. ConclusionsUMC is a common etiology in patients presenting to the ED with a first episode of psychotic symptoms.

Scalp as a donor site in children: Is it really the best option?

BackgroundSince 2003 we have used the scalp as a donor site for split skin grafts (SSGs) in major burns when there was a shortage of conventional donor areas. However, we seen a high incidence of complications, contrary to international experience. ObjectiveThe aim of this study was to analyze the results and complications related to the scalp as a donor site and to determine whether there is an association between our specific patient population and the complications encountered. MethodsA retrospective review of our scalp donor site outcomes over a 12-year period was conducted. The cohort included 25 patients, 15 of black African descent, nine of mixed race and one Caucasian. The various hair types were identified based on ethnicity and classified into eight types. Most of our patients had hair types VI–VIII. None of these patients had scalp burns and all received standard burn treatment. The SSGs were taken with an electric dermatome with a standard micrometric setting of 0.2mm. Complications were categorized into short- or long-term, with a mean follow-up time of 1.59years. ResultsThe mean age of the 25 children was 5.7years. Nineteen sustained flame burns and 6 sustained hot water burns, with a mean total body surface area of 44.9%. A total of 43 scalp procurements were performed in the 25 patients studied. The group of 15 black African patients (hair types VI–VIII) had a total of 22 procurements, the nine patients of mixed race (hair types III–V) had 18 procurements and the single Caucasian patient (hair types II–III) had two procurements. The median healing time was 15days, 11.8days and 8.5days, respectively, per group. Significant complications were encountered, including folliculitis 44%, non-healing wounds 52%, alopecia 16% and visible, hypopigmented scars 3%. One patient had a hypertrophic scar and no hair transfers to the recipient areas were observed. The various hair types correlated with the complications encountered. Five children, with an average burn size of 65.2% (range: 40–85%) died of sepsis. Due to the small sample size, the only statistically significant findings were related to the total body surface area of the burn and the number of times skin was harvested from the scalp, with a p-value of 0.005. The p-values for the healing times related to the first, second and third croppings, were p=0.022, p=0.00032 and p<0.001 respectively. ConclusionOur study suggests that in pediatric patients of black African descent (hair types VI–VIII) the scalp is not an ideal donor area, due to the unacceptably high incidence of complications. Hence, every precaution should be taken when it becomes necessary to harvest donor skin from the scalp.

Inducible Nitric Oxide Synthase Polymorphisms and Nitric Oxide Levels in Individuals with Chronic Periodontitis.

This study aimed to investigate whether the −1026(A>C)(rs2779249) and +2087(A>G)(2297518) polymorphisms in the NOS2 gene were associated with chronic periodontitis (CP) and with salivary levels of nitrite (NO2−) and/or nitrate + nitrite (NOx). A group of 113 mixed-race patients were subjected to periodontal, genetic, and biochemical evaluations (65 CP/48 periodontally healthy subjects). DNA was extracted from oral epithelial cells and used for genotyping by polymerase chain reaction (real-time). Salivary NOx concentrations were determined using an ozone-based chemiluminescence assay. Association of CP with alleles and genotypes of the −1026(A>C) polymorphism was found (X2 test, p = 0.0075; 0.0308), but this was not maintained after multiple logistic regression, performed to estimate the effect of covariates and polymorphisms in CP. This analysis demonstrated, after correction for multiple comparisons, that only the female gender was significantly associated with CP. Polymorphisms analyzed as haplotypes were not associated with CP. NOx levels were significantly higher in the control group of heterozygous individuals for both polymorphisms. In conclusion, the female gender was significantly associated with CP, and higher levels of salivary NOx were found in control subjects and associated with the heterozygous state of the NOS2 polymorphisms, reinforcing the potential of NO metabolites as markers of periodontitis status.

Colorectal Cancer Demographics and Survival in a London Cancer Network

The purpose of this study was to examine whether a relationship exists between age, ethnicity, gender and survival of patients within a London Cancer Network. All patients with non metastatic colorectal cancer diagnosed and treated within the South West London Cancer Network between January 2001 and January 2006 were included for analysis. Consent was gained from all hospitals within the London Cancer Network, and data was subsequently requested from the Thames Cancer Registry. In total, 3151 patients were analysed. The results demonstrated that from 2003 there was a yearly increase in new cancer diagnosis. The ratio of male to female patients was approximately equal over the time period (51.5% male, 48.5% female). The overall mean patient age at diagnosis was 70.76 years. Asian, black and mixed race patients had better survival rates than white European patients (hazard ratios 0.96, 0.87, 0.96 respectively). Patients in the age cohort ‘50-59 years’ had a 5 year survival rate of 57.8 months (hazard ratio 1.63), whilst the ‘under 40 years’ age cohort had the longest 5 year survival rate of 67.4 months. When comparing tumour sites, patients with rectosigmoid tumours had the lowest 5 year survival rate (hazard ratio 1.12), and those with rectal tumours (n=816, hazard ratio 0.88) had the longest 5 year survival rate. Median and overall survival for all patients was 38.84 months and 42.3% respectively. Surgery with neoadjuvant therapy resulted in the longest 5 year survival rate at 62.8%. Surgery alone had a 5 year survival rate of 43%. The results could be used to help design a prognostic indicator tool as a means by which to assist clinicians in providing patients with information on survival outcomes.

Racial and Ethnic Disparities in Utilization Rate, Hospital Volume, and Perioperative Outcomes After Total Knee Arthroplasty.

Previous studies of racial disparities in total joint replacement, particularly total knee arthroplasty, in the U.S. have predominantly focused on disparities between blacks and whites and were limited to Medicare patients or veterans, populations that are not representative of the entire U.S. We sought to study racial disparities in the utilization of total knee arthroplasty, the use of high-volume hospitals, and total knee arthroplasty outcomes, including mortality and complications, using all-payer databases. We analyzed data from 8 years and 8 racially diverse states in the State Inpatient Databases (SID). Patient race was categorized according to the SID as white, black, Hispanic, Asian, Native American, and mixed race. Both crude and adjusted racial and/or ethnic disparities were evaluated. In comparison with whites (4.65 per 1000 population per year), black (3.90), Hispanic (3.71), Asian (3.89), Native American (4.40), and mixed-race (3.69) populations had lower rates of total knee arthroplasty utilization (p < 0.0001). After risk adjustment, the rate of total knee arthroplasty utilization was significantly lower for blacks (odds ratio [OR] = 0.87 [95% confidence interval (CI), 0.85 to 0.89]; p < 0.0001), Hispanics (OR = 0.76 [95% CI, 0.68 to 0.83]; p < 0.0001), Asians (OR = 0.83 [95% CI, 0.78 to 0.89]; p < 0.0001), Native Americans (OR = 0.87 [95% CI, 0.81 to 0.93]; p < 0.0001), and mixed race (OR = 0.84 [95% CI, 0.79 to 0.90]; p < 0.0001) compared with the rate for whites. Lower rates of total knee arthroplasty utilization for blacks, Hispanics, and mixed-race groups became worse over the years. Patients from minority groups were less likely to undergo total knee arthroplasty in high-volume hospitals than were whites. Moreover, the rates of mortality were significantly higher for blacks (OR = 1.52 [95% CI, 1.17 to 1.97]; p = 0.0017), Native Americans (OR = 6.52 [95% CI, 4.63 to 9.17]; p < 0.0001), and mixed-race patients (OR = 4.35 [95% CI, 3.24 to 5.84]; p < 0.0001). Blacks (OR = 1.08 [95% CI, 1.01 to 1.15]; p = 0.01) and mixed-race patients (OR = 1.17 [95% CI, 1.001 to 1.36]; p = 0.04) had higher rates of complications than whites. Minorities had lower rates of total knee arthroplasty utilization but higher rates of adverse health outcomes associated with the procedure, even after adjusting for patient-related and health-care system-related characteristics. Utilization rates were based on overall population as the proportion of the population with osteoarthritis requiring arthroplasty is unknown. Future studies that consider specific patient-level information with psychosocial and behavioral factors are needed. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Ethnic differences in peanut allergy patterns in South African children with atopic dermatitis.

The prevalence of peanut allergy in South Africa is unknown, but previously thought to be low, particularly in black South Africans. This study aimed to determine the prevalence of component patterns and predictive values of screening tests in peanut allergy in South African children with atopic dermatitis (AD). This was a prospective, observational study in a pediatric university hospital in Cape Town. Children with AD, aged 6 months to 10 years, were recruited randomly. They were assessed for sensitization and allergy to peanut by questionnaire, skin prick tests (SPT), Immuno Solid Phase Allergen Chip test, ImmunoCAP component tests to Ara h 1, 2, 3, 8, and 9, and incremental food challenges. A total of 100 participants (59 black Africans and 41 of mixed race) were enrolled, median age 42 months. There was a high and comparable rate of peanut sensitization in both black African (41%) and mixed race patients (50%), but a significantly lower prevalence of peanut allergy in the black African group (15% vs. 38%, p = 0.01). The component Ara h 2 was the most useful in differentiating allergy from tolerance in both ethnic groups, but had a significantly lower predictive value for peanut allergy in blacks (53%) vs. mixed race (93%). Overall, SPT and Ara h 2 produced the highest area under the receiver operating characteristic curve. A total of 95% positive predictive values (PPV) for SPT, peanut-specific IgE, and Ara h 2 levels varied significantly between the two ethnic groups. The prevalence of peanut allergy is high in South African children with AD, but significantly lower in blacks compared to mixed race patients. The component Ara h 2 is useful for differentiating allergy from tolerance in both ethnic groups. Ninety-five% PPV for peanut allergy tests may need to be revised by ethnic group.