Suboptimal Access Research Articles

Abstract P1-06-01: Associations of historic and contemporary “redlining” with breast cancer stage at diagnosis

Abstract Breast cancer is the most commonly diagnosed cancer among US women across all racial/ethnic groups. Stage at diagnosis is one of the major factors determining breast cancer prognosis. The 5-year relative survival for breast cancer ranges from 99% for localized stage at diagnosis, to 84% for regional stage, and to 27% for distant (metastatic) stage breast cancer. The proportion of women diagnosed with breast cancer at later stages (regional and distant) in the US are higher among women with lower socio-economic status and among non-Hispanic Black women. Historic mortgage security redlining, implemented by the Home Owners’ Loan Corporation (HOLC) in the 1930s across numerous US cities, continues to have a negative influence on breast cancer stage at diagnosis, largely due to continued social and economic isolation and poor living environments resulting in many adverse consequences, including lower education, limited job opportunities, no/limited health insurance coverage, and suboptimal access to care, including cancer screening services. Additionally, studies have reported that living in areas with greater contemporary mortgage lending bias towards the non-Hispanic Black population (measured as higher odds of mortgage denial) is associated with late-stage breast cancer diagnosis in several US metropolitan areas. In this study, we aim to examine the association between the historic HOLC-based “redlining” and contemporary mortgage lending bias and stage of breast cancer at diagnosis among women aged 18 years and older in New Jersey diagnosed with first primary invasive breast cancer in 2010-2015 (N= 32,939). The study population was derived from the New Jersey State Cancer Registry. Historic “redlining” data based on 1930s neighborhood boundaries and transformed to corresponding 2010 census tracts borders were obtained from Inter-university Consortium for Political and Social Research. Mortgage lending bias score for the study period was calculated at the census tract level following methodology developed by Beyers and colleagues. Associations between census tract-level historic “redlining”, contemporary mortgage lending bias and breast cancer stage at diagnosis were evaluated using multinomial logistic regression models after adjusting for age alone, and then for age, race/ethnicity, marital status, and health insurance status. The study included 21,038 local, 9,765 regional, and 2,136 distant stage breast cancer cases. After adjusting for age, race/ethnicity, marital status, and health insurance, women living in historically redlined census tracts were more likely to be diagnosed with regional (OR=1.23; 95% CI 1.03-1.48) and distant (OR=1.55; 95% CI 1.09-2.22) stage breast cancer compared to women living in other census tracts. Odds for regional (OR=1.14; 95% CI 1.06-1.23) and distant (OR=1.33; 95% CI 1.16-1.53) stage breast cancer were also significantly higher for women living in areas with highest mortgage lending bias score. Stratifying by age (< 65 and >=65 years) showed similar patterns (data not shown). Both historic “redlining” and contemporary mortgage lending bias were associated with being diagnosed with breast cancer at later stages, notably distant stage. Targeting the legacy of systematic racism and addressing any contemporary discriminatory policies may help reduce breast cancer disparities in the diagnosis stage and thus mortality. Association between the historic redlining and contemporary mortgage lending bias and stage of breast cancer at diagnosis among women aged ≥18 years in New Jersey, 2010-2015 Note: For contemporary mortgage lending bias, highest score is indicative of highest bias (highest proportion of mortgage denial) towards Black people. *Fully adjusted model includes covariates: age, race/ethnicity, marital status, health insurance status ^Areas designated ”Best” were individual housing markets with sufficient levels of financing and were preserved exclusively for White and wealthy population. Areas defined as “Hazardous” were those lacking financial resources and were designated for Black and poor population. Citation Format: Daniel Wiese, Antoinette M. Stroup, Ahmedin Jemal, Kevin A. Henry, Farhad Islami. Associations of historic and contemporary “redlining” with breast cancer stage at diagnosis [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P1-06-01.

Precarious Housing Associated with Unsuppressed Viral load, sub-optimal Access to HIV Treatment and Unmet Health care Needs, Among Women Living with HIV in Metro Vancouver, Canada.

We investigated associations between (1)housing status (four categories measuring housing stability) and outcomes along the HIV care continuum (not currently on antiretroviral therapy [ART]; sub-optimal ART adherence [< 95% in the last 3-4 weeks]; unsuppressed viral load [> 200 copies/ml], median CD4 < 200 in the last six months), and (2) housing status and unmet primary, dental and mental health care needs in the last six months among WLWH. Housing status was defined according to the Canadian Definition of Homelessness and had four categories: unsheltered (i.e., living in ≥ 1 unsheltered location [e.g., street, abandoned buildings]), unstable (i.e., living in ≥ 1 unstable location [e.g., shelter, couch surfing]), supportive housing (i.e., only living in supportive housing), and stable housing (i.e., only living in one's own housing; reference). At baseline, in the last six months, 47.3% of participants reported unstable housing, followed by 24.4% unsheltered housing, 16.4% stable housing, and 11.9% supportive housing. Overall, 19.1% of the full sample (N = 336, 2010-2019) reported not currently on ART; among participants on ART, 28.0% reported sub-optimal ART adherence. Overall, 32.1% had recent unsuppressed viral load. Among a subsample (n = 318, 2014-2019), 15.7% reported unmet primary care needs, 26.1% unmet dental care needs, and 16.4% unmet mental health care needs. In adjusted models, being unsheltered (vs. stable housing) was associated with not currently on ART, unsuppressed viral load, and unmet primary and dental care needs. Housing and health services need to be developed with and for WLWH to address structural inequities and fulfill basic rights to housing and health.

Efficient Optimal and Suboptimal Joint Access Point Association and Radio Resource Allocation in WLANs

Efficient Optimal and Suboptimal Joint Access Point Association and Radio Resource Allocation in WLANs

Diagnostic and treatment concordance in primary care participants and dermatologists utilizing Extension for Community Health Outcomes (ECHO)

Introduction Suboptimal access to dermatologic care is dependent on patient location and insurance type. Although there have been attempts to address access issues, barriers to providing excellent dermatologic care to all patients at the right time still exist. The objective of this study was to investigate the clinical impact of Dermatology Extension for Community Healthcare Outcomes (ECHO) project participation on primary care providers’ diagnostic and treatment tendencies and accuracy. Methods This was a retrospective cohort study constructed using Dermatology Extension for Community Healthcare Outcomes case and recommendation data from November 2015 to June 2021. The University of Missouri-based Dermatology Extension for Community Healthcare Outcomes specialty hub team offers regularly scheduled live interactive tele-mentoring sessions for primary care providers who practice in rural and underserved areas. 524 patient cases presented by 25 primary care providers were included in the analysis. Of those, 449 cases were included in diagnostic concordance, and 451 in treatment concordance analysis. Results Less than 40% of all diagnoses were fully concordant with an expert panel. Over 33% of patients were misdiagnosed, and over 26% received partially correct diagnosis. Only 16% of all treatment recommendations were fully concordant with an expert panel. Discussion Diagnostic and treatment accuracy of participants is low, and Dermatology Extension for Community Healthcare Outcomes platform ensured patients received correct diagnosis and treatment quickly. Although tele-dermatology models are effective, they continue to be underutilized. Dermatologists in practice and training should be encouraged to adopt innovative clinical educational models, like Dermatology ECHO, to expand access to dermatologic expertise for the most marginalized populations.

An equitable vaccine delivery system: Lessons from the COVID-19 vaccine rollout in Canada.

The COVID-19 pandemic exacerbated existing health disparities and disproportionately affected vulnerable individuals and communities (e.g., low-income, precariously housed or in institutional settings, racialized, migrant, refugee, 2SLBGTQ+). Despite their higher risk of infection and sub-optimal access to healthcare, Canada's COVID-19 vaccination strategy focused primarily on age, as well as medical and occupational risk factors. We conducted a mixed-methods constant comparative qualitative analysis of epidemiological data from a national database of COVID-19 cases and vaccine coverage in four Canadian jurisdictions. Jurisdictional policies, policy updates, and associated press releases were collected from government websites, and qualitative data were collected through 34 semi-structured interviews of key informants from nine Canadian jurisdictions. Interviews were coded and analyzed for themes and patterns. COVID-19 vaccines were rolled out in Canada in three phases, each accompanied by specific challenges. Vaccine delivery systems typically featured large-venue mass immunization sites that presented a variety of barriers for those from vulnerable communities. The engagement and targeted outreach that featured in the later phases were driven predominantly by the efforts of community organizations and primary care providers, with limited support from provincial governments. While COVID-19 vaccine rollout in Canada is largely considered a success, such an interpretation is shaped by the metrics chosen. Vaccine delivery systems across Canada need substantial improvements to ensure optimal uptake and equitable access for all. Our findings suggest a more equitable model for vaccine delivery featuring early establishment of local barrier-free clinics, culturally safe and representative environment, as well as multi-lingual assistance, among other vulnerability-sensitive elements.

Self-reported factors contributing to delay in ALS diagnosis among primary care providers in a large Ohio-based US healthcare network

ObjectiveThis study's primary objective is to identify self-reported factors that contribute to diagnostic delay in ALS among Primary Care Providers (PCPs). MethodsA de novo email-based survey was deployed to Ohio-based PCPs in the Cleveland Clinic Health System. ResultsOf the 77 PCP participants [including 30 Advance Practice Providers (APPs)] only: (a) 18% of physicians, and 3% of APPs were very confident or confident with recognizing signs and symptoms of ALS, (b) 13% of physicians, and 21% of APP s felt very confident or confident with distinguishing between a neurologic cause of dysfunction from other possible causes, and (c) 23% of physicians, and 11% of APPs felt very confident or confident with distinguishing between upper and lower motor neuron signs. If presented with a weak patient without a specific diagnosis, PCPs most frequently ordered electrodiagnostic testing, brain MRI, cervical or thoracic spine MRI, and serum creatine kinase. PCPs identified top reasons for delayed ALS diagnosis as: (a) patient's delay in seeking medical help, (b) diagnostic uncertainty (c) waiting time for neurology/neuromuscular medicine (NM) consultation. The most desired strategies to shorten diagnostic delay involved: (a) educating PCPs and other non-neurologist “gatekeeper” providers, (b) improving access to specialist neurology care, and (c) developing a reliable diagnostic test for ALS. DiscussionSelf-reported factors that increase ALS diagnostic delay among PCPs primarily comprise gaps in clinical knowledge and skills required to detect key symptoms and signs, and suboptimal referral access to a neurology/NM provider. These areas represent important opportunities for targeted improvement efforts.

Factors Associated with Zero-Dose Childhood Vaccination Status in a Remote Fishing Community in Cameroon: A Cross-Sectional Analytical Study.

Background: Cameroon's suboptimal access to childhood vaccinations poses a significant challenge to achieving the Immunization Agenda 2030 goal-ranking among the top 15 countries with a high proportion of zero-dose (unvaccinated) children worldwide. There are clusters of zero-dose children in pockets of communities that traditionally miss essential healthcare services, including vaccination. The Manoka Health District (MHD) is home to such settlements with consistently low vaccination coverages (DPT-HepB-Hib-1: 19.8% in 2021) and frequent outbreaks of vaccine-preventable diseases (VPD). Therefore, the absence of literature on zero-dose children in this context was a clarion call to characterize zero-dose children in fragile settings to inform policy and intervention design. Methodology: This cross-sectional analytical study involved 278 children, 0-24 months of age, selected from a 2020 door-to-door survey conducted in the two most populous health areas in an archipelago rural district, MHD (Cap-Cameroon and Toube). We used R Statistical Software (v4.1.2; R Core Team 2021) to run a multivariable logistic regression to determine zero-dose associated factors. Results: The survey revealed a zero-dose proportion of 91.7% (255) in MHD. Children who were delivered in health facilities were less likely to be zero-dose than those born at home (AOR: 0.07, 95% CI: 0.02-0.30, p = 0.0003). Compared to children born of Christian mothers, children born to minority non-Christian mothers had higher odds of being zero-dose (AOR: 6.55, 95% CI: 1.04-41.25, p = 0.0453). Children born to fathers who are immigrants were more likely to be zero-dose children than Cameroonians (AOR: 2.60, 95% CI = 0.65-10.35, p = 0.0016). Younger children were likely to be unvaccinated compared to older peers (AOR: 0.90, 95% CI: 0.82-1.00, p = 0.0401). Conclusions: In the spirit of "leaving no child behind," the study highlights the need to develop context-specific approaches that consider minority religious groups, immigrants, and younger children, including newborns, often missed during vaccination campaigns and outreaches.

Evolution of Treatment Patterns and Prognostic Biomarkers in Latin American Patients with Chronic Lymphocytic Leukemia: A Study By the Grupo De Estudio Latinoamericano De Linfoproliferativos (GELL)

Introduction: Chronic Lymphocytic Leukemia (CLL), the most frequent leukemia in adult patients in Western countries, has an incidence that varies according to the geographical region. LATAM is a very heterogeneous region regarding ethnicity and access to care. This translates into differences in the availability of diagnostic and prognostic tools as well as therapeutic options for patients throughout the continent. In the last years, the treatment of CLL has shifted toward the use of targeted agents in first- and second-line therapy. The differences in the access to such agents results in inequality when it comes to offer treatment options. In this observational, retrospective, international study we aim to describe the epidemiological data of patients with CLL in Latin America, the access to and use of biomarkers and treatment patterns. Methods: Patients with 18 years or older, diagnosed with or treated for CLL between 2005-2022 in centers participating in the GELL were included. Patients treated in clinical trials were excluded. Results: 470 patients were analyzed from 6 countries (Peru, Mexico, Paraguay, Chile, Venezuela and Uruguay). 78% were treated at private institutions. The median age was 69 years (35-97), and 193 (41%) were women. According to race, 416 (89%) were white, 2 (0.4%) were black, 2 (0.4%) were indigenous, and 50 (11%) were of mixed race. 337 (72%) had ECOG 0-1. Stage distribution was Rai 0: 183 (39%), I: 120 (26%), II: 61 (13%), III: 34 (7%), IV 26 (6%), and unclassified 46 (9%). Regarding prognostic factors: 11% were CD38 positive. B2-microglobulin data were available in 233 patients (49.5%) and in 124 was high (53%), IgVH mutational status in 41 (9%) of whom 27 (6%) were mutated and 14 (3%) were unmutated. 355 (76%) of patients were observed at time of diagnosis. 220 (47%) patient required treatment with median time to first line treatment of 6 months (range 0-204). Among patients who received treatment, 50 (23%) had cytogenetic and 57 (26%) FISH studies performed. Del17p was detected in 5 patients. P53 mutational status was studied in 12 patients, 1 was found mutated. First line treatment was as follows: Chemotherapy: (Chlorambucil +/- prednisone 46 patients, FC 15, CHOP-like 8), Chemoimmunotherapy (FCR 56, R-CHOP-like 40, BR 24, Chlorambucil + AntiCD20 MoAb 17, FR 1), Ibrutinib 9, Venetoclax + Obinutuzumab 3. Treatment strategies according to date of treatment is shown in Figure 1. 146 (78%) of patients who received chemotherapy or chemoimmunotherapy did not have a previous cytogenetic analysis (Figure 2). According to the country, Uruguay 37%, Mexico 74%, Chile 82%, Peru 83%, Paraguay 89% and Venezuela 96% did not have genetic studies before therapy. Conclusions: Our study shows real-world data in CLL patients from LATAM. The median age at diagnosis is comparable to those reported in developed countries moreover, we report a high percentage of patients with early-stage disease at diagnosis related to the higher diagnosis of asymptomatic patients in routine exams.Most patients treated with chemotherapy or chemoimmunotherapy did not have a cytogenetic testing to guide treatment selection. Also, there are differences in access to cytogenetic testing between the countries analyzed. We show a slight change in treatment patterns in the last years, chemoimmunotherapy remains the most used first line treatment, and a suboptimal access to novel agents is evident. We plan to expand our study cohort with data from the other LATAM countries to have a deeper understanding of the reality of our region and help overcome inequalities. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Abstract 13924: Impact of a Pandemic on Women Diagnosed With Peripartum Cardiomyopathy

Background: Peripartum cardiomyopathy (PPCM) is a dilated form of cardiomyopathy that occurs during the last month of pregnancy or up to five months postpartum. Approximately 1,100 women develop PPCM in the United States each year. The aim of our study is to compare the incidence of PPCM prior to the start of the Coronavirus Disease 2019 (COVID) pandemic to afterwards and to determine the impact of COVID on hospitalized patients with PPCM. Methods: This was a retrospective study of 2,286 patients with a diagnosis of PPCM who were admitted to a private hospital system across the United States between the year 2017 and year 2021. There was 1,790 patients in the pre-COVID cohort, and 496 patients in the COVID era cohort. Demographics of patients were collected, with t-test and chi square p-values utilization for statistical description. Results: The mean age of women was 32.13 years. In the COVID era cohort, the percentage of Hispanic patients was significantly higher than the pre-COVID era (16.84% vs. 12.34%, p=0.012). In the COVID era, patients were more likely to have preeclampsia (20.16% vs. 13.52%, p&lt;0.001), HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome (2.62% vs. 0.61%, p&lt;0.001), respiratory failure (19.56% vs. 10.57%, p&lt;0.001), and myocardial infarction (3.63% vs. 1.90%, p=0.022). There was no significant difference in troponin and d-dimer values between the two era cohorts. The average length of stay, percentage of patients admitted to the intensive care unit (ICU), and death did not significantly differ between the pre-COVID and COVID era cohorts. Conclusion: In our study, although there was no significant difference in length of stay, ICU admission, or death in the COVID era cohort, myocardial infarction, preeclampsia, HELLP syndrome, and respiratory failure were each more prevalent in women with PPCM during the COVID era. These findings might indicate suboptimal access to outpatient and inpatient medical care during the COVID pandemic, which could have led to these more serious diagnoses.

The Outcomes of Patients with Haemoglobin Disorders in Cyprus: A Joined Report of the Thalassaemia International Federation and the Nicosia and Paphos Thalassaemia Centres (State Health Services Organisation)

Haemoglobinopathies, including thalassaemias and sickle-cell syndromes, are demanding, lifelong conditions that pose a significant burden to patients, families, and healthcare systems. Despite the therapeutic advances and the resulting improvements in prognosis accomplished in past decades, these patients still face important challenges, including suboptimal access to quality care in areas with developing economies, changing epidemiology due to massive migration flows, an evolving clinical spectrum due to ageing in well-treated patients, and limited access to novel high-cost therapies. We herein describe the organization of healthcare services for haemoglobinopathies in Cyprus—with particular focus on beta-thalassaemia, the most prevalent condition in this region—along with selected patient outcomes. This report aims at underscoring the fact that nationally funded and well-coordinated prevention and care programmes for chronic and complex conditions, such as haemoglobinopathies, with active involvement from patient organizations lead to effective disease control and excellent outcomes in survival, quality of life, social adaptation, and public health savings, and allow timely and effective responses to emerging crises, such as the COVID-19 pandemic. The Cyprus paradigm could therefore serve as a blueprint for the organization or adaptation of haemoglobinopathy programs in other countries since these disorders are still widely occurring.

O073 / #772 ELIMINATION OF SURGICAL SITE INFECTION ASSOCIATED WITH SPINAL CORD STIMULATION THERAPY: LESSONS LEARNED FROM OVER 300 CONSECUTIVE SURGICAL PADDLE IMPLANTS: TRACK 1: SPINAL CORD STIMULATION, BEST PRACTICES, AND STUDIES

Spinal Cord Stimulation (SCS) has revolutionized the field of neuromodulation in pain control; however, infection rates ranging from 2-14% remain, associated with sub-optimal clinical outcomes, cost-effectiveness and patient access to this therapy. The primary goal of this report is to analyze factors that have helped eliminate deep surgical site infections (SSIs) in a large cohort of patients implanted with surgical paddle leads.

Is the Australian primary healthcare system ready for the Rheumatic Heart Disease Endgame strategy? Data synthesis and recommendations

Is the Australian primary healthcare system ready for the Rheumatic Heart Disease Endgame strategy? Data synthesis and recommendations

Underinsurance And Multiple Surgical Treatments for Kidney Stones

To further elucidate the relationship between low socioeconomic status (SES) and larger, more complex stones requiring staged surgical interventions. Specifically, we aimed to determine if underinsurance (Medicaid, Medicare, and self-pay insurance types) is associated with multiple surgeries within one year. Weperformed a retrospectivelongitudinal analysis of prospectively collected datafrom the California statewide Department of Health Care Access and Information (HCAI) dataset. We includedadult patients who had their first recorded kidney stone encounter between 2009-2018 and underwent at least one urologic stone procedure. We followed these patients within the dataset for one year after their initial surgeryto assess for factors predicting multiple surgical treatments for stones. A total of 156,319 adults were included in the study. The proportions of individuals in private insurance, Medicaid, Medicare and self-pay/indigent groups differed by the presence or absence of additional surgeries (64.0%, 13.5%, 19.4%, and 0.1%, vs. 70.3%, 10.1%, 16.6%, and 0.1%, respectively). Compared to private insurance, Medicaid (1.46 [1.40-1.53] p < 0.001) and Medicare (1.15 [1.10-1.20] p < 0.001) insurance types were associated with significantly greater odds of multiple surgeries, whereas no significant association was seen in the self-pay/indigent insurance type (1.35 [0.83-2.19], p = 1.0). In a statewide, California database from 2009-2018, underinsured adults had higher odds of undergoing a second procedure for kidney stones within one year of initial surgical treatment. This study adds to the expanding body of literature linking suboptimal healthcare access and disparate outcomes for kidney stone patients.

Community perspectives on ideal bacterial STI testing services for gay, bisexual, and other men who have sex with men in Toronto, Canada: a qualitative study

BackgroundInnovation is needed to produce sustained improvements in bacterial sexually transmitted infections (STI) testing given suboptimal access and uptake among sexually active gay, bisexual or other men who have sex with men (GBM). Yet, the STI testing processes and technologies that best address local testing barriers among GBM in Toronto is unknown. We aimed to explore men’s perspectives regarding STI testing services for GBM to identify and prioritize new STI testing interventions in Toronto, Ontario, Canada.MethodsWe conducted four focus groups with twenty-seven GBM in 2017: two with cisgender men living with HIV, one with cisgender HIV-negative men, and one with transgender men. Twenty-seven men participated in the focus groups with 40% 18–30 years of age, 48% self-identifying as white, and the remainder self-identifying as Middle Eastern, Latino/Hispanic, Asian/Pacific Islander, South Asian, First Nations, African/Caribbean/Black, or mixed race. 59% of participants self-identified as living with HIV. Participants were asked about their STI testing experiences in Toronto, barriers and facilitators to testing, and ideal STI testing process. Focus groups were audio recorded, transcribed verbatim, and analyzed using thematic analysis.ResultsCore concepts included how clinical context, bacterial STI testing delivery, and interactions with healthcare providers can create barriers and recommendations for ways to improve. Regarding clinical context, participants desired more clinics with accessible locations/hours; streamlined testing that minimized use of waiting rooms and wait times; and improved clinic ambience. Bacterial STI testing delivery recommendations included standardization to ensure consistency in sexual history intake, tests offered, follow-up and public health reporting between clinics. Men also recommended reducing the multistep process testing by offering components such as lab requisitions and results online. Participants also recommended interactions with healthcare providers be professional and non-judgmental, offer compassionate and competent care with destigmatizing and lesbian, gay, bisexual and trans (LGBT) affirming communication.ConclusionConcrete and practical solutions for improving existing sexual health services and facilitating optimal STI testing include streamlining testing options and providing patient-centred, LGBT-affirming care to enable optimal STI testing.

Join us on an amazing journey towards next-generation treatments for CNS disorders: Launch of Neuroprotection, a new high-quality journal in translational neuroscience.

Join us on an amazing journey towards next-generation treatments for CNS disorders: Launch of Neuroprotection, a new high-quality journal in translational neuroscience.

Synthesis-Aware Generation of Structural Analogues

In modern drug design, one of the main issues is the optimization of an initial lead structure toward a drug candidate by modifying specific properties in the desired direction. The synthetic feasibility of the target structure is often neglected during this process, resulting in structures with low or suboptimal synthetic accessibility. In this work, we present a novel approach for synthesis-aware lead optimization called Synthesia. In contrast to the traditional approaches, Synthesia integrates the preservation of the synthesizability of the target structure into the lead structure modification process. Synthesia is able to create structural diversity for a lead structure that matches user-defined molecular properties without losing the applicability of a particular synthetic pathway. The methodology is validated by demonstrating that Synthesia is capable of providing structural analogues of DrugBank compounds that meet generic modification goals and maintain their synthetic pathways. In addition, Synthesia is used to cluster compounds from two different patent structure series (CDK7, Daurismo) according to their compatibility with the same synthetic pathways, maximizing the synthetic efficiency and providing an initial estimation of the effort of synthesizing the entire series. Altogether, we demonstrate Synthesia's ability to modify compound properties while maintaining in silico synthesizability.

DNA-Programmed Orientation-Ordered Multivalent Microfluidic Interface for Liquid Biopsy.

Aptamer-functionalized microfluidic interfaces hold great potential for liquid biopsies owing to their programmable nature. However, most previous studies have focused on development of multivalent aptamers to improve binding affinity, while ignoring aptamer orientation on microfluidic interfaces, resulting in suboptimal accessibility and affinity. Herein, we report a Cubic DNA Nanostructure (CDN)-programmed strategy to precisely control the orientation and valency of the Aptamer on a microfluidic interface (CDN-Apt-Chip) for enhancing the capture and release of circulating tumor cells (CTCs). We demonstrate that the ordered orientation and multivalent configuration can synergistically increase the binding affinity of aptamers toward CTCs. By using CDN-Apt-Chip, we successfully isolated CTCs from the peripheral blood of T-cell leukemia patients and discriminated T-cell leukemia patients from healthy volunteers. Furthermore, the captured CTCs were nondestructively released via nuclease treatment. We then performed T-cell receptor sequencing on the released cells to demonstrate the compatibility with downstream analysis. Overall, this study provides a new paradigm for interface regulation of functional microfluidic chips and advances the clinical translation of aptamer-based liquid biopsy.

Are We Ready for a New Approach to Comparing Coverage and Reimbursement Policies for Medical Nutrition in Key Markets: An ISPOR Special Interest Group Report

ObjectivesHealthcare policy makers should ensure optimal patient access to medical nutrition (MN) as part of the management of nutrition-related disorders and conditions. Questions remain whether current healthcare policies reflect the clinical and economic benefits of MN. The objective of this article is to characterize coverage and reimbursement of MN, defined as food for special medical purposes/medical food for a diverse set of countries, including Australia, Belgium, Brazil, Canada, China, France, Germany, Hong Kong, Italy, Japan, The Netherlands, Singapore, Spain, United Kingdom, and United States. MethodsData sources included published literature and online sources. ISPOR’s Nutrition Economics Special Interest Group developed a data collection form to guide data extraction that included reimbursement coverage, years that reimbursement policies were established, and presence of a formal health technology assessment (HTA) for MN technologies. ResultsReimbursement coverage of MN technologies varied across the countries that were reviewed. All but 3 countries limited coverage to specific formulations of products, regardless of demonstrated clinical benefit. The year that reimbursement policies were established varied across countries (ranging from 1984 to 2017), and only 4 countries regularly update policies. France and Brazil are the only countries with a formal HTA process for MN technologies. ConclusionsMost countries have limited MN reimbursement, have not updated reimbursement policies, and lack HTA for MN technologies. These limitations may lead to suboptimal access to MN technologies where they are indicated to manage nutrition-related disorders and conditions, with the potential of negatively affecting patient and healthcare system outcomes.

Locked out of healthcare: A descriptive context of migrant health considerations in pediatrics.

Over the past year, we have seen many migrant pediatric patients with significant resource limitations admitted to the Johns Hopkins Hospital. These patients are medically fragile with challenging psychosocial circumstances. They are ineligible for resources and services given their immigration status yet are in dire need of them. Our United States healthcare infrastructure is poorly designed to serve these patients. Resources are increasingly scarce, and fragmentation exists in continuity of care provided to these patients that compromises their health and safety. This global health crisis is surrounded by immense controversy especially with respect to high‐cost healthcare. Experiences from the field provide a descriptive context on the circumstances surrounding migration attributed to suboptimal access to healthcare across many developing countries. We present global health, immigration policy, and human rights implications of migration. We also propose recommendations to build a comprehensive global health network that accounts for ample disparities across healthcare systems.

Association of Medicaid Expansion With Mortality Disparity by Race and Ethnicity Among Patients With De Novo Stage IV Breast Cancer

Patients who are uninsured and belong to racial and ethnic minority groups or have low socioeconomic status have suboptimal access to health care, likely affecting outcomes. The association of the Affordable Care Act's Medicaid expansion with survival among patients with metastatic breast cancer is unknown. To examine the association between Medicaid expansion and mortality disparity among patients with de novo stage IV breast cancer. Cross-sectional, population-based study of survival using Cox proportional hazards regression and difference-in-difference (DID) analysis of data from the National Cancer Database and patients diagnosed as having de novo stage IV breast cancer between January 1, 2010, and December 31, 2016, residing in states that underwent Medicaid expansion on January 1, 2014. The preexpansion period was January 1, 2010, to December 31, 2013; the postexpansion period was January 1, 2014, to December 31, 2016. Data were analyzed between September 4, 2020, and November 16, 2021. Comparison of survival improvement between patients of racial and ethnic minority groups and White patients in the preexpansion and postexpansion periods. Because of small numbers in the specific racial and ethnic minority groups, these patients were combined into 1 category for comparisons. Overall survival (OS) and 2-year mortality rate. Among 9322 patients included (mean [SD] age, 55 [7] years), 5077 were diagnosed in the preexpansion and 4245 in the postexpansion period. The racial and ethnic minority group comprised 2545 (27.3%), which included 500 (5.4%) Hispanic (any race), 1515 (16.3%) non-Hispanic Black, and 530 (5.7%) non-Hispanic other including 25 (0.3%) American Indian or Alaska Native, 357 (3.8%) Asian or Pacific Islander, and 148 (1.6%) unknown, and 6777 (72.7%) were in the White patient group. In the preexpansion period, White patients had increased OS compared with patients of racial and ethnic minority groups (adjusted hazard ratio [aHR], 1.22; 95% CI, 1.10-1.35); this difference was not observed in the postexpansion period (aHR, 0.96; 95% CI, 0.86-1.08). A reduction in 2-year mortality was observed between the preexpansion and postexpansion periods (32.2% vs 26.0%). The adjusted 2-year mortality decreased from 40.6% to 36.3% among White patients and from 45.6% to 35.8% among patients of racial and ethnic minority groups (adjusted DID, -5.5%; 95% CI, -9.5 to -1.6; P = .006). Among patients in the lowest income quartile (n = 1510), patients of racial and ethnic minority groups had an increased risk of death in the preexpansion period (aHR, 1.28; 95% CI, 1.01-1.61) but lower risk in the postexpansion period (aHR, 0.75; 95% CI, 0.59-0.95). In this subset of patients, those of racial and ethnic minority groups had a greater reduction in 2-year mortality compared with White patients (adjusted DID, -12.8%; 95% CI, -22.2 to -3.5; P = .007). In this cross-sectional study, survival differences observed between patients of racial and ethnic minority groups and White patients in the preexpansion period were no longer present in the postexpansion period. A greater reduction in 2-year mortality was observed among patients of racial and ethnic minority groups compared with White patients. These results suggest that policies aimed at improving equity and increasing access to health care may reduce racial and ethnic disparities in breast cancer outcomes.