White Patients Research Articles

Outcomes Following Arteriovenous Fistula Creation Among Medicare Beneficiaries with End Stage Kidney Disease

The objective of this study was to measure the contemporary patency rates and frequency of interventions required for arteriovenous fistula (AVF) care among a representative United States (US) population of end stage kidney disease (ESKD) patients, including by age, race and sex. All Medicare beneficiaries >20 years of age who underwent AVF graft creation for ESKD between 2017 through 2019 were included for analysis. The primary endpoints included primary patency, primary assisted patency, post-intervention patency, and fistula functionality up to one year after AVF placement. Secondary endpoint included admission for an associated adverse event following AVF creation. Multivariate analysis of patency rates was also assessed. Of 43,457 patients included in the analysis, the cumulative primary patency at 90 days was 68.4% and at one year was 31.5%. At one year, the primary assisted patency rate, post-intervention patency, and fistula use were 70.4%, 30.2% and 59.1%, respectively. There was no difference in primary patency rates when comparing age groups (age 40 – 59: HR 1.01 [95% CI 0.95 – 1.06], p = 0.84) or age ≥60: HR 0.99 [95% CI 0.93 – 1.04], p = 0.61) to the reference of age group 20 – 39. Women vs men (HR 1.16 [95% CI 1.14 – 1.20], p < 0.001) and Black vs White patients (HR 1.34 [95% CI 1.31 – 1.38], p < 0.001) and were at higher risk of experiencing primary patency failure. The cumulative incidence of admissions for adverse events was 32.6% at 1-year. In conclusion, our findings suggest that the real-world AVF patency rates remain low, with disproportionately low rates among women and Black patients.

Amplification of MYC and Its Enhancer Correlates With Genetic Ancestry in Lung Squamous Cell Carcinoma.

In lung squamous cell carcinoma (LUSC), Black patients show significantly higher incidence and lower overall survival than White patients. Although socioeconomic factors likely contribute to this survival disparity, genomic factors have yet to be elucidated in LUSC. Using 416 LUSC tumor samples in the Cancer Genome Atlas (TCGA), we assessed genomic and transcriptomic profiles by ancestry. We replicated our analyses in pan-cancer data from TCGA, the American Association of Cancer Research (AACR) Genomics Evidence Neoplasia Information Exchange (GENIE), and Columbia University Medical Center. We found increased MYC amplification, LUSC-specific MYC enhancer amplification, and chromosome arm 8q (chr8q) gain to be significantly associated with genetic AFR (African) ancestry in LUSC in TCGA. Furthermore, expression of MYC target genes was significantly enriched in AFR samples. Local ancestry analysis identified correlation of chr8q gain with AFR ancestry at the MYC locus in TCGA. We also found a significant correlation between chr8q and AFR ancestry in multiple cancer types and pan-cancer in TCGA. Similarly, in a pan-cancer subset of AACR GENIE data, we found a significant correlation between chr8q gain and race. Together, our data suggest that ancestry may influence amplification of not only MYC but also its enhancer in LUSC. They also suggest a role for genetic ancestry in chr8q aneuploidy in cancer. These studies further define and expand patients who may benefit from future anti-MYC therapeutic approaches.

Forearm Versus Upper Arm Location of Arteriovenous Access Used at Hemodialysis Initiation: Temporal Trends and Racial Disparities

Racial and ethnic differences exist in the type of arteriovenous access (AVA, including fistulas and grafts) used at hemodialysis (HD) initiation. The preferred anatomic location for the creation of an initial HD AVA is typically in the forearm We evaluated racial and ethnic differences in the use of an AVA in the forearm location at HD initiation. Retrospective cohort study. Using records from DaVita Kidney Care linked to the United States Renal Data System (USRDS), we evaluated patients aged ≥16 years who initiated in-center HD with an AVA between 2006 and 2019. Race/ethnicity, categorized as non-Hispanic White, non-Hispanic Black, Hispanic, or Other. Forearm vs. upper arm AVA location. Multivariable modified Poisson regression to estimate adjusted trends in AVA location over time and racial/ethnic differences in AVA location. Nested models helped assess the relative confounding by groups of variables on estimates of racial/ethnic differences. Among 70,147 patients (51.7% White, 28.8% Black, 12.6% Hispanic, 6.9% Other), White patients were older and more likely to have peripheral vascular disease, but less likely to have diabetes compared to the other groups. The proportion initiating HD using a forearm AVA decreased from 49% in 2006 to 29% in 2019 and by 3.6% (95% CI, 3.3%-3.9%) annually, with no difference in this trend among groups (race/ethnicity by calendar year interaction P=0.32). Black patients were 13% (95% CI, 10%-15%) less likely and Hispanic patients were 5% (95% CI, 1%-9%) less likely than White patients to initiate HD with a forearm AVA. Findings may not apply to home HD. Use of a forearm AVA for HD initiation has declined and racial differences have persisted, with Black and Hispanic patients being less likely than White patients to have an AVA in the forearm location. Research towards understanding the causes and consequences of these trends and disparities is warranted.

Pediatric CSF diversion procedures for treatment of hydrocephalus during the COVID-19 pandemic.

Because there is not a link between COVID-19 and pediatric hydrocephalus, the COVID-19 pandemic should not have altered the incidence of pediatric hydrocephalus or the rate of CSF diversion procedures or shunt failure. Therefore, hydrocephalus-related surgical volume should have remained constant. The goal of this study was to evaluate the rates of hydrocephalus surgeries in the COVID-19 era compared with the baseline pre-COVID-19 era. Ten institutions collected information about all hydrocephalus-related surgeries performed between March 2018 and February 2022. The period after March 1, 2020, was considered the COVID-19 era; the period prior to this date was considered the baseline pre-COVID era. Four COVID surge periods were defined using the New York Times COVID-19 database. Total case volumes were compared between the COVID era and baseline, both overall and for each surge period. Sex, race, ethnicity, insurance status, Area Deprivation Index (ADI), and rural-urban commuter area were collected for each surgery. Proportions of patients were then compared overall and for each surge based on these variables. Of 8056 procedures, 54% were in male patients (n = 4375), 65% in White patients (n = 5247), 18% in Hispanic patients (n = 1423), and 54% in patients with public insurance (n = 4371). There was no change in the number of surgeries per site per month in the COVID era compared with baseline (16.7 vs 17.9, p = 0.113). However, there was a significant decrease in the first surge period (April 2020; 11.5 vs 17.7, p = 0.034). Male sex (p < 0.0039) and Black race (p < 0.001) were found to be associated with a significantly higher proportion of hydrocephalus procedures during the COVID-19 era. Some surge periods showed different proportions of privately insured patient and ADI levels. However, these relationships were inconsistent between surges. Overall average monthly case numbers were not significantly different between the pre-COVID and COVID eras. There was a significant decrease in hydrocephalus surgery during the first COVID surge. More hydrocephalus surgeries were performed in children of male sex and Black race proportionally during the COVID period overall, but not during individual surges.

Race/ethnicity and human epidermal growth hormone receptor 2–targeted therapy for breast cancer.

91 Background: Breast cancer is the most common cancer in the US. Up to 25% of breast cancers are classified as human epidermal growth factor receptor 2 (HER2)-positive and associated with an aggressive tumor burden. HER2-targeting monoclonal antibodies improves survival in patients with HER2-positive breast cancer. Prior work has demonstrated disparities in access to oncologic therapies among older women. Our study seeks to examine racial/ethnic disparities in receiving HER2-targeted therapies for patients with HER2-positive breast cancer and trends in use over time. Methods: In the Surveillance, Epidemiology and End Results (SEER) Medicare-linked database we identified women diagnosed with breast cancer from 2010 to 2019. We included those &gt;66 years old who survived 12 months after diagnosis, were enrolled in Medicare Parts A/B for 12 months pre and post-diagnosis, and had local or regional stage HER2-positive cancer. Our primary outcome was receipt of HER2-targeted therapies in the 12 months after diagnosis. Our independent variable was race/ethnicity as measured by the validated Research Triangle Institute race/ethnicity codes in Medicare. Due to small sample sizes, we focus our analysis on White, Black, or Hispanic women. We used multivariable Modified Poisson regression to evaluate changes in the probability of HER2-targeted therapy receipt by race/ethnicity over time, adjusted for sociodemographics, cancer factors, and medical comorbidities. Results: Our cohort comprised 13,887 patients including 8.7% Black, 7.5% Hispanic, and 83.8% White (mean age 74.9). Overall, 7,351 (52.9%) received HER2-targeted therapies in the 12 months post-diagnosis, with use increasing over time in all racial/ethnic groups (Table). Compared with White patients, Black and Hispanic patients had a 19% (adjusted risk ratio [aRR] 0.81, 95% CI:0.69-0.96) and 27% (aRR 0.73, 95% CI 0.61-0.89) lower likelihood, respectively, of receiving HER2-targeted therapies from 2010-2011 (Table). By 2018-2019, no significant differences in receiving HER2-targeted therapies were observed across racial/ethnic groups. Conclusions: In a national cohort of Medicare enrollees with HER2-positive breast cancer, we observed significant racial/ethnic disparities which narrowed over time. Overall utilization rates were low. Future work is needed to understand how improved access to breast cancer treatments impact downstream outcomes. Use of human epidermal growth hormone receptor 2–targeted therapy from 2010-2011 and 2018-2019 by race/ethnicity. Race and Ethnicity Unadjusted Rates Adjusted Risk Ratios (95% CI)* 2010-2011 2018-2019 2010-2011 2018-2019 Black 36% 62% 0.81 (0.69-0.96) 0.97 (0.87-1.08) Hispanic 31% 68% 0.73 (0.61-0.89) 1.01 (0.92-1.12) White 42% 64% Reference Reference *Adjusted for age, marital status, region, breast cancer stage and year of diagnosis, and medical comorbidities.

Joint Modeling of Longitudinal Ferritin Trajectories and COVID-19 Infections in Native American, Hispanic, and White Patients on Hemodialysis

Joint Modeling of Longitudinal Ferritin Trajectories and COVID-19 Infections in Native American, Hispanic, and White Patients on Hemodialysis

Racial discrepancies in initial presentation and diagnosis of patients with endometrial cancer.

89 Background: Endometrial cancer incidence and mortality are increasing, particularly in Black patients who have more aggressive non-endometrioid subtypes. Racial disparities in mortality may be partially contributable to early clinical factors including recognition of symptoms, type of evaluation, and referral timing. We evaluated differences in factors related to symptom appraisal and delays in diagnosis by race and histology. Methods: In this retrospective cohort study, we included patients diagnosed with endometrial cancer from 01/01/2019 to 09/01/2023 at a single institution who were enrolled in the Discovery and Evaluation of Testing for Endometrial Cancer in Tampons (DETECT) study. Demographic characteristics and factors regarding initial presentation and workup were obtained from the electronic medical record. We evaluated patient-reported length and type of symptoms at initial presentation, diagnostic imaging type, and time from initial presentation to time of imaging, tissue sampling, and referral to gynecologic oncology. We assessed differences by race and histology (endometrioid vs. non-endometroid) using chi-square and Kruskal-Wallis tests and analysis of variance. Results: Of the 335 patients included in our analysis, 237 (70.7%) had endometrioid and 98 (29.3%) had non-endometrioid histology. Patients with endometrioid histology were significantly more likely to be younger, White, non-smokers, and have higher obesity levels by body mass index than those with non-endometrioid histology (p=&lt;0.01). The length of symptoms at time of initial presentation was significantly longer in Black patients overall (p=0.01) and in Black patients with endometrioid histology compared to their White counterparts (p=0.04). A similar trend was seen in patients with non-endometrioid histology but was not statistically significant (p=0.15). There was no difference in type of symptoms reported. The type of imaging (p=0.005) differed significantly between endometrioid and non-endometrioid groups. White patients were more likely to have a transvaginal ultrasound performed at initial presentation (p=0.004). Black patients with endometrioid endometrial cancer were more likely to have a longer time period from initial presentation to referral to gynecologic oncology (p=0.04) despite having a shorter time between initial presentation and endometrial sampling (p=0.04). Conclusions: In our cohort, Black patients with endometrial cancer were more likely to have experienced symptoms for a longer time period prior to presentation, less likely to be evaluated with transvaginal ultrasound, and had a longer time period between initial presentation and referral to gynecologic oncology compared to White patients. Raising awareness and targeting these early steps in evaluation and detection of endometrial cancer may help decrease racial disparities in outcomes.

Racial and Ethnic Differences in Patient Presentation and Treatments in Head and Neck Dermatofibrosarcoma Protuberans

AbstractHead and neck dermatofibrosarcoma protuberans (HNDFSP) is a rare neoplasm with a high rate of local infiltration and local recurrence but a low rate of distant metastasis. Given the limited literature on HNDFSP and existing studies pointing to possible racial and ethnic differences, further research is needed to understand important clinical correlates that may impact treatment and prognosis. The National Cancer Database (NCDB) was queried for all cases of HNDFSP diagnosed from 2004 to 2016. Demographic characteristics of the included patients were compared using chi-squared and t-tests. Kaplan-Meier and Cox multivariable regression analyses were performed to assess survival differences. Of the 778 included patients, 526 (67.6%) patients were white, 113 (14.5%) were black, 33 (4.2%) were Asian, 87 (11.2%) were Hispanic, and 19 (2.4%) were classified as Other. White patients presented at a significantly older age (43.8 years) than did black (38.9 years) and Hispanic patients (37.9 years) (p = 0.02). White patients with HNDFSP had significantly higher income status (p = 0.0001), were more likely to be insured (p = 0.0001), and were more likely to have a high school diploma (p = 0.0001). There were no significant racial differences in 5-year (96.1%) or 10-year (92.0%) overall survival. None of the variables yielded a statistically significant value in Cox analysis. Differences exist in HNDFSP presentation between racial groups. Specifically, differences in income, insurance status, education level, and age of presentation exist between these groups. Future studies focused on morbidity are needed to better understand the consequences of these difference on HNDFSP patients.

Patient Perspectives on Arteriovenous Fistula Placement, Maturation, and Use: A Qualitative Study

Rationale & ObjectiveArteriovenous fistula (AVF) use among U.S. hemodialysis (HD) patients is suboptimal, especially among Black patients. We interviewed a group of predominantly Black HD patients to probe experiences and perspectives surrounding steps along the AVF care continuum, which includes placement, maturation, and use of AVFs. Study DesignIndividual semi-structured interviews. Setting & ParticipantsPatients with kidney failure receiving HD in Birmingham, Alabama. Analytical ApproachTranscripts were coded and thematically analyzed. ResultsWe interviewed 53 Black and 6 White patients at different steps of the AVF care continuum: 29 were dialyzing with a central venous catheter (15 had not undergone AVF placement, 9 had a maturing AVF, and 5 had a non-functional AVF) and 30 were dialyzing with an AVF. We coded transcripts using qualitative thematic analysis. Three themes emerged: (1) the circumstances of dialysis initiation sometimes altered the timeline of AV access placement; (2) patients had variable levels of knowledge of steps along the AVF continuum; and (3) the life impacts of dialysis access were a significant factor in patients’ experience of dialysis. LimitationsSingle-institution study; low number of non-Black participants limited comparison of patient experiences by race. ConclusionsAmong a group of predominantly Black HD patients, perspectives surrounding the AVF care continuum included consideration of the circumstances of dialysis initiation, patient knowledge, and the life impacts of dialysis access. These findings may inform targeted interventions aimed at optimizing dialysis access use and addressing disparities across the AVF continuum.

Optimizing the fairness of survival prediction models for racial/ethnic subgroups: A study on predicting post-operative survival in stage IA and IB non-small cell lung cancer.

380 Background: The recent surge of utilizing machine learning (ML) to develop prediction models for clinical decision-making aids is promising. However, these models can demonstrate racial bias due to inequities in real-world training data. In lung cancer, multiple models have been developed to predict prognosis, but none have been optimized to mitigate bias in performance among racial/ethnic subgroups. We developed a ML model to predict five-year survival in Stage 1A-1B non-small cell lung cancer (NSCLC), ensuring fairness on race. Methods: In the National Cancer Database, we identified patients with histopathologically confirmed stage 1A -1B NSCLC who underwent curative intent lobectomy from 2004 – 2017. We split the study cohort into a training and test sets (70%/30%). We trained and compared various ML models to predict 5-year overall survival. Patient demographic, clinical, and disease characteristics were used as input features for the models. To evaluate model fairness, we used the equalized odds ratio (eOR), which compares the true positive and false positive rates across groups; an eOR value of 1 represents equivalent rates across racial groups. We utilized 3 approaches to mitigate model bias and optimize for fairness of the best “naïve” model: grid search, threshold optimizer, and the exponentiated gradient methods. We evaluated model performance before and after bias mitigation using the area under the curve (AUC). Results: 124,298 patients fit our inclusion/exclusion criteria; 87% of patients were White, 8% were Black/African American, 3% Hispanic, and 2% Asian. Eighty percent of patients were diagnosed with stage 1A cancer; 20% had stage 1B cancer. The best naïve ML model, not optimized for fairness on race, had an eOR of 0.25 with an AUC of 0.66 (95% CI 0.65-0.66) overall. This model demonstrated an AUC of 0.65 (0.65-0.66) among white patients, 0.64 (0.62-0.66) among Black patients, 0.64 (0.60-0.68) among Asian patients, and 0.71 (0.68-0.74) among Hispanic patients. The threshold optimizer bias mitigation strategy improved fairness the most while maintaining similar overall performance of AUC 0.65 (0.64-0.66). With this strategy the eOR improved to 0.83 while AUC remained relatively stable across racial subgroups. Conclusions: We developed a ML model to predict 5-year survival in patients undergoing surgery for stage IA-IB NSCLC and employed model bias mitigation strategies that significantly improved model fairness, without diminishing overall performance. These strategies should be considered when developing prediction models for clinical decision making to avoid perpetuating disparities in care due to algorithm bias. Model performance metrics. Equalized Odds Ratio True Positive Rate False Positive Rate AUC Naive model 0.25 0.61 0.30 0.66 Threshold optimizer mitigated model 0.83 0.62 0.32 0.65

The Impact of Social Determinants of Health on Peripheral T Cell Lymphoma Outcomes: Treatment Center-Type Emerges as a Powerful Prognostic Indicator

BackgroundPrognostic models in peripheral T cell lymphoma (PTCL) have identified biological factors including age, performance status, LDH, and bone marrow involvement as prognostic for survival. The association of nonbiological factors, termed social determinants of health (SDH), on PTCL outcomes remains unexplored. MethodsTo evaluate the impact of actionable SDH on PTCL mortality across race groups, we conducted a retrospective cohort study that included all White, Hispanic, Asian/Pacific Islander (PI) and Black adult patients with PTCL (AITL, ALCL, NKTCL and PTCL, NOS), diagnosed from 2000 to 2020, in California. We utilized Chi2 and Wilcoxon rank-sum tests for descriptive metrics and Kaplan-Meier statistics for mortality estimation. Regression models included patient- (age, sex, race, stage, Charlson Comorbidity Index, histology, treatment type, treatment at an academic center, payer), and neighborhood-level factors (socioeconomic (SES) quintile, proportion without a high school diploma, and rural/urban). Risk factors significant in univariate regression at a P-value < .10 were incorporated into the multivariable model. FindingsOur analysis included 6158 patients: 51.8% White, 25.8% Hispanic, 14.7% Asians/PI, and 7.6% Black. Hispanics exhibited the longest median survival (33 months) followed by Whites, Blacks, and Asian/PI (25, 20, and 14 months, respectively; P = .011). Risk factors independently associated with inferior lymphoma-specific survival (LSS) included Asian/PI compared with NH White race (HR, 1.23; 95% CI, 1.10-1.34; P = .0002), AITL and ALCL compared with PTCL, NOS histology (AITL HR, 1.14; 95% CI, 1.02-1.25; P = .011; ALCL HR, 1.15; 95% CI, 1.04-1.26; P = .004), academic compared to nonacademic facility-type (HR 0.71; 95% CI, 0.64-0.77; P < .01), Medicare compared with uninsured status (HR 1.48, 95% CI, 1.25-1.73; P < .01), and the lowest 3 education quartiles compared to the highest education quartile (Q2 HR 1.13; 95% CI, 1.01-1.25; P = .021; Q3 HR 1.14; 95% CI, 1.02-1.26; P = .018; Q4 HR 1.22; 95% CI, 1.08-1.36; P < .001). In the least resourced patients, histology, treatment, treatment facility-type, payer and education were independently prognostic for LSS. Treatment at an academic institution was associated with a striking improvement in LSS (academic institution: yes = 101 months, no = 17 months; P < .01). InterpretationThese data identify treatment facility-type, payer and education, as an independent actionable SDH for PTCL mortality. Treatment center-type had the strongest prognostic association with LSS in our PTCL cohort, conferring a risk reduction of PTCL mortality by nearly 30%. Interventions targeted at improving access to academic centers may improve outcomes for all PTCL patients.

What explains differences in average wait time in the emergency department among different racial and ethnic populations: A linear decomposition approach.

Non-Hispanic Black (NHB) and Hispanic/Latino (Hispanic) patients wait longer in the emergency department (ED) to see practitioners when compared with non-Hispanic White (NHW) patients. We investigate factors contributing to longer wait times for NHB and Hispanic patients using a linear decomposition approach. This retrospective observational study included patients presenting to one tertiary hospital ED from 2019 to 2021. Median wait times among NHW, NHB, and Hispanic were calculated with multivariable linear regressions. The extent to which demographic, clinical, and hospital factors explained the differences in average wait time among the three groups were analyzed with Blinder‒Oaxaca post-linear decomposition model. There were 310,253 total patients including 34.7% of NHW, 34.7% of NHB, and 30.6% of Hispanic patients. The median wait time in NHW was 9 min (interquartile range [IQR] 4‒47 min), in NHB was 13 min (IQR 4‒59min), and in Hispanic was 19 min (IQR 5‒78 min, p<0.001). The top two contributors of average wait time difference were mode of arrival and triage acuity level. Post-linear decomposition analysis showed that 72.96% of the NHB‒NHW and 87.77% of the Hispanic‒NHW average wait time difference were explained by variables analyzed. Compared to NHW patients, NHB and Hispanic patients typically experience longer ED wait times, primarily influenced by their mode of arrival and triaged acuity levels. Despite these recognized factors, there remains 12%‒27% unexplained factors at work, such as social determinants of health (including implicit bias and systemic racism) and many other unmeasured confounders, yet to be discovered.

Immune-related adverse events, mood disorders, and the impact of social determinants of health among a national cohort of patients receiving immunotherapy.

364 Background: Immune checkpoint inhibitors (ICIs) are increasingly used to treat advanced cancers such as lung, bladder, head and neck, colorectal cancers, and melanoma. Psychological distress may promote pro-inflammatory states which can exacerbate immune-related adverse events (irAEs) among ICI-treated cancer patients. This study assessed the impact of mood disorders (anxiety and depression diagnoses/medications before or during treatment) on the odds of irAEs among advanced cancer patients receiving ICIs, accounting for clinical characteristics and social determinants of health. Methods: This retrospective cohort study used data from a national sample of N=8,058 deceased adult patients diagnosed with advanced melanoma, lung, colorectal, head and neck, and bladder cancers from the nationwide Flatiron Health electronic health record (EHR) derived de-identified database. Diagnostic codes and medication orders were used to assess for mood disorders and auto-immune conditions documented within 2 years of receiving an ICI (irAEs). Bivariate tests and multivariable logistic regressions with interaction terms were conducted in R. Results: Accounting for age at advanced cancer diagnosis, ethnicity, socioeconomic status, baseline performance status, and number of clinic visits, female patients (aOR 1.25, 95% CI=1.07-1.46, p=0.005), patients seen in an academic practice setting only (aOR=2.16, 95% CI=1.80-2.60, p&lt;0.001), and patients receiving combination CTLA-4 and PD-(L)1 inhibitors (aOR 1.47, 95% CI=1.11-1.95, p=0.008) had higher odds of irAEs compared with male patients, patients treated in community settings only, and patients receiving PD1/L1 inhibitors only. Non-White (aOR 0.61, 95% CI=0.49, 0.77, p&lt;0.001), bladder (aOR 0.53, 95% CI= 0.37, 0.78, p=0.001) and colorectal cancer patients (aOR=0.55, 95% CI=0.32, 0.91, p=0.024) had lower odds of irAEs compared with White and melanoma patients. Insurance type moderated the relationship between mood disorders and IrAEs; commercially-insured ICI patients with mood disorders had higher odds of irAEs (aOR 1.65, 95% CI=1.16, 2.35, p=0.006) compared with Medicare-insured ICI patients with mood disorders. Conclusions: Social determinants of health such as insurance access may exacerbate the relationship between mood disorders and irAEs. These findings have implications for health equity and are an area warranting further study. Future analyses will also examine directionality of the associations between mood disorders and irAEs.

Lip and incisor changes in patients with different ethnicities treated with extraction versus nonextraction: A cone-beam computed tomography study

This study used cone-beam computed tomography (CBCT) via voxel-based superimposition to evaluate lip and incisor changes after orthodontic treatment with four premolar extractions (Ext) versus nonextraction (Non-Ext) among African American (AA) and White (W) patients. A total of 240 CBCTs of 120 adolescent orthodontic patients with Class I skeletal/dental relationships were included. Patients were initially divided according to treatment, and then each group was subdivided according to patients' ethnicity (Ext/W = 30, Ext/AA = 30, Non-Ext/W = 30, and Non-Ext/AA = 30). CBCTs were imported into Invivo6 for voxel-based superimposition. Lip and incisor measurements were recorded. Independent t tests and two-way ANOVA were used for statistical assessment. The Non-Ext/W group had a greater increase in all outcome variables compared with the Non-Ext/AA group, with a significant change in volume and position of upper (UL) and lower lips (LL), inclination of upper (U1) and lower incisors (L1), and position of U1. The Ext/AA group had a greater decrease in all measured outcomes compared with the Ext/W group, with significant change in inclination of U1 and L1, and position and volume of LL. W patients had more crowding than AA patients in both treatment approaches. Retraction ratios of 6.5:1 and 2.1:1 were recorded between the U1 and UL positions, and L1 and LL positions, respectively. There were no direct interaction effects between ethnicity and treatment, nor were there any significant effects of ethnicity after controlling for the covariates. Ethnicity alone has no impact on incisor and lip position after treatment. However, ethnicity in the form of initial presentation of malocclusion can have a significant influence.

Factors associated with delays in receipt of neoadjuvant chemotherapy in patients with operable breast cancer.

126 Background: Delays in neoadjuvant chemotherapy initiation (NACTI) after breast cancer (BC) diagnosis have been associated with worse outcomes. We evaluated incidence and predictors of delays of NACTI among high clinical risk patients treated with NACT on a national level. Methods: We conducted a retrospective cohort study using the National Cancer Database. Eligibility included age ≥18 years, diagnosis of non-metastatic BC between 1/1/2010 – 12/31/2020, who were treated with NACT within 180 days of diagnosis. Patients who received neoadjuvant endocrine therapy were excluded. Time to chemotherapy (TTC) in days was recorded. Patients were categorized into sub-cohorts by receptor status and clinical stage: 1) Hormone Receptor positive/HER-2 negative (HR+/HER2-) and were lymph node (LN) LN+; 2) HER-2 positive (HER2+) cT2+ or LN+; and 3) triple negative BC (TNBC) cT2+ or LN+. Multivariable logistic regression, adjusted for demographic, socioeconomic and tumor characteristics, was used to identify characteristics associated with delays &gt; 60 days from diagnosis to NACTI. Multiple imputation was used for missing data. Results: We identified 145,697 eligible patients, 74% were White, 18% were Black, 3.3% were Asian, and 4.6% were Other/Unknown. Across all racial categories, 9.2% were Hispanic. Median age at diagnosis was 52 years (range 18-90), median TTC was 32 days (range 0-180), and 10% had a delay &gt; 60 days. There were 40,345 patients in the HR+/HER2- cohort, 56,868 in the HER2+ cohort, and 48,484 in the TNBC cohort; 12%, 9.0%, and 8.9% (p &lt; 0.001) had a delay in NACTI, respectively. In multivariable analysis among the HR+/HER2- sub-cohort, characteristics associated with delays in NACTI included Black race (OR 1.71, 95%CI 1.57-1.86) and Hispanic ethnicity (OR 1.76, 95%CI 1.60-1.94) compared to White and non-Hispanic patients. Patients with Medicare, Medicaid, or who were uninsured were more likely to be delayed (OR 1.44 95%CI 1.30-1.58, 2.10, 95%CI 1.92-2.29, 2.28, 95%CI 1.99-2.61) compared to those with commercial insurance. Results were similar in the HER2+and TNBC cohorts, as seen (Table). Conclusions: Among patients with operable BC who received NACT, patients who were Black, Hispanic, had Medicaid or no insurance had as high as a twofold increase in odds of a delay in NACTI. Targeted interventions to address these racial and socioeconomic disparities are necessary to ensure equitable care. Multivariable logistic regression adjusted for demographic, socioeconomic, and tumor characteristics variables (n = 145,697). HR+/HER2-N= 40,345 HER2+N= 56,868 TNBCN= 48,484 OR 95%CI OR 95%CI OR 95%CI Black Race 1.71 1.57-1.86 1.89 1.74-2.04 1.90 1.76-2.06 Hispanic Ethnicity 1.76 1.60-1.94 2.18 2.00-2.36 2.00 1.80-2.21 Medicare 1.44 1.30-1.58 1.46 1.34-1.61 1.45 1.32-1.61 Medicaid 2.10 1.92-2.29 2.13 1.96-2.31 2.14 1.96-2.34 No Insurance 2.28 1.99-2.61 2.36 2.07-2.70 2.25 1.96-2.59

Clinical symptoms and psychosocial functioning in patients with schizophrenia spectrum disorders testing seropositive for anti-NMDAR antibodies: a case–control comparison with patients testing negative

Antibodies against the N-methyl-D-aspartate receptor (NMDAR) have been described in the serum of people with schizophrenia spectrum disorders (schizophrenia). However, the prevalence and clinical relevance of these antibodies in schizophrenia is unclear. This knowledge gap includes the possibility of such antibodies being associated with a distinct clinical profile, which in turn might warrant a distinct treatment approach. We aimed to assess the seroprevalence of anti-NMDAR antibodies in schizophrenia, and compare symptoms and psychosocial functioning between patients with schizophrenia who were seropositive and seronegative for these antibodies. In this case-control comparison, by combining new and existing studies, we included patients diagnosed with schizophrenia from four independent cohorts for whom anti-NMDAR serostatus had been assessed (or could be assessed by us) with live cell-based assays. Included cohorts were from the EULAST study (a trial conducted across 15 European countries and Israel), the OPTiMiSE study (an interventional study in Europe), and the PPiP1 and PPiP2 studies (conducted in the UK). Patients from these cohorts were analysed if they had complete Positive and Negative Syndrome Scale (PANSS) data. No participant had been diagnosed with autoimmune encephalitis or received treatment for this condition. After calculating the prevalence of serum anti-NMDAR antibodies, we examined possible differences in PANSS scores (negative, positive, and general symptom subscales, and total score) between anti-NMDAR-seropositive and anti-NMDAR-seronegative patients. Psychosocial functioning as measured by Personal Social Performance (PSP) score was also compared. All analyses were exploratory and no adjustment was done for multiple testing. People with lived experience were not involved in the conduct of this study. We collected individual patient data from 1114 patients with schizophrenia across the four cohorts. The study population had a mean age of 28·6 years (SD 7·6) and comprised 382 (34·3%) women and 732 (65·7%) men, including patients of White (929 [83·4%]), Asian (54 [4·8%]), Black (68 [6·1%]), and other (62 [5·6%]) ethnicities. Overall, 41 (3·7%) participants (range 3·1-4·0% across cohorts) tested positive for serum anti-NMDAR antibodies. Lower symptom severity on the negative symptoms PANSS subscale was observed for anti-NMDAR-seropositive patients (mean score 15·8 [SD 6·4]) than for anti-NMDAR-seronegative patients (18·2 [6·8]; Cohen's d=0·36; p=0·026), as well as on the general symptoms PANSS subscale (32·9 [8·9] vs 36·1 [10·1]; d=0·33; p=0·029) and total PANSS score (65·5 [18·5] vs 72·6 [19·3]; d=0·37; p=0·013). Mean PSP score was better in anti-NMDAR-positive patients (62·0 [17·0]) than in anti-NMDAR-negative patients (53·5 [16·3]; d=0·52; p=0·014). Serum NMDAR antibodies are present in 3-4% of patients with schizophrenia and are associated with relatively low severity of negative symptoms and relatively good psychosocial functioning. Thus, although the findings await replication in cohorts from other geographical regions, serum anti-NMDAR antibodies might be associated with a different form of psychotic illness. These findings could inform future prognostic and interventional studies examining whether anti-NMDAR antibodies are associated with a specific course of illness or with treatment response. None.

Evaluating Bias of Child Maltreatment Referrals in Encounters for Unintentional Ingestions

BackgroundUnintentional ingestions commonly result in presentation to the pediatric emergency department (PED). No standardized recommendations exist regarding when to call Child Protective Services (CPS) for unintentional ingestions, which allows for the possibility of biased decision-making. ObjectiveIdentify patient and visit level characteristics associated with CPS referral status in unintentional ingestion encounters. Participantsand Setting: Retrospective cross-sectional study of children ≤6 years old presenting with unintentional ingestion to a metropolitan PED from 2015 to 2021. MethodsICD-10-CM codes were used to identify unintentional ingestion visits in the electronic health record. CPS referral was determined by manual chart review. Bivariable and multivariable logistic regression models identified patient and visit level characteristics associated with CPS referral. Socioeconomic status (SES) was classified based on zip code, the Child Opportunity Index data, and insurance. ResultsOf 3,836 charts reviewed, 808 met inclusion criteria. CPS referrals were made in 109 (13.5%) visits. Compared to non-Hispanic white patients, non-Hispanic Black patients had 7.37 (95% CI:1.38, 39.26) higher adjusted odds of being referred to CPS after adjusting for triage level, age, and ingestion type. Patients in the Lowest SES group had a 3.01 (95% CI:1.42, 6.40) higher adjusted odds when compared to the Middle/Highest SES group. ConclusionThis study found that CPS referrals in unintentional ingestions occur more often in those identifying as non-Hispanic Black and in those in the Lowest SES group, suggesting clinician bias may impact the decision regarding referrals. To mitigate subjective decision-making, we propose creating standardized, objective CPS referral criteria for unintentional ingestions.

A Real-World Analysis on Access to Triplet and Quadruplet Therapy in Newly Diagnosed Multiple Myeloma Patients in the United States

BackgroundDisparities in access to triplet and quadruplet therapy for multiple myeloma (MM) patients remain a challenge in the United States. We aimed to investigate demographic and socioeconomic factors influencing treatment access using NCDB data. Patients and MethodsWe analyzed 101,867 MM patients diagnosed between 2004 and 2020. Multinomial logistic regression and multivariable cox regression were employed to assess factors influencing treatment access and survival, respectively. ResultsBlack patients exhibited significantly lower odds of receiving triplet and quadruplet therapy compared to White patients. Socioeconomic factors such as insurance status and household income also influenced treatment access. However, Black and Hispanic patients demonstrated better survival outcomes despite disparities in access. ConclusionRacial, socioeconomic, and insurance-related disparities persist in access to optimal MM therapy in the USA. Addressing these barriers is essential for ensuring equitable healthcare delivery and improving patient outcomes.

Midface Skeletal Sexual Dimorphism: Lessons Learned from Advanced Three-dimensional Imaging in the White Population.

Facial shape is significantly influenced by the underlying facial bony skeleton. Sexual dimorphisms in these structures are crucial for craniofacial, aesthetic, and gender-affirming surgery. Previous studies have examined the orbits and upper face, but less is known about the midface. This study aimed to elucidate the sexual dimorphism in the midface region, focusing on the maxilla and zygomatic bones. A retrospective review was conducted using facial computed tomography scans from 101 White patients aged 20-79 years, using Materialise Mimics and 3-Matics for segmentation and 3D reconstruction. Measurements and statistical shape modeling of the midfacial skeleton were performed. Our results show a distinct sexual dimorphism in the midfacial skeletal structure across all age groups. Women typically had a narrower bizygomatic width by 1.5 mm (P = 0.04), a shallower maxillary depth by 1.6 mm (P < 0.01), and a midfacial vertical height that was 4 mm shorter than that of men (P = 0.018). In contrast, men exhibited a greater distance between the frontozygomatic sutures by 5.4 mm (P < 0.01), a 3-mm greater interorbitale distance (P < 0.01), and a 2.1-mm wider infraorbital foramina distance (P = 0.007). There were no significant differences in the pyriform and maxillary angles (P = 0.15 and P = 0.52, respectively). Our analysis of midfacial skeletal anatomy revealed sexual dimorphism differences. Men exhibited more pronounced facial features than women, with a broader horizontal midfacial skeleton, a longer midfacial vertical height, and greater maxillary depths compared with women.

Evaluation of guideline recommended treatment utilization among Black and White men with metastatic prostate cancer.

103 Background: Prostate cancer is the second leading cause of cancer death among men with a disproportionate burden on Black men. 1 Black men are twice as likely to die from prostate cancer compared to White counterparts. 2 Racial disparities in care delivery for early-stage disease are well documented and may contribute to disparate outcomes, 3–6 but less is known about racial gaps in advanced prostate cancer care, a stage where effective therapies can prolong life for years. 7 We sought to evaluate if treatment disparities were evident among Black and White men with metastatic prostate cancer. Methods: We performed a retrospective cohort study of patients with metastatic prostate cancer receiving treatment at a large public tertiary care health system between 2015 and 2020. Demographic, clinical, treatment, and medication prescribing data were extracted from the electronic health record. We excluded patients without ICD codes indicating metastatic disease, those without any documented medication data in our health system, and those who did not identify as Black or White race. We estimated the prevalence ratio (PR) of being prescribed each of the recommended treatment options for metastatic prostate cancer per National Comprehensive Care Network guidelines, including androgen deprivation therapy (ADT), novel anti-androgens, chemotherapy, and bone protection comparing Black men to White men using log-binomial regression. Results: We identified 1,594 patients with metastatic prostate cancer; 485 (30%) were Black. Black patients were younger and had higher Charlson scores compared to White men. Both groups were highly insured, Medicaid was more common for Black men (7.2% vs 2.2%). Prescribing of systemic treatments was similar by race (Table). Combination ADT and novel antiandrogen prescribing was also similar by race (PR 1.04 95% CI:(0.91 - 1.17), p=0.6). About 30% of both Black and White patients interacted with our Patient Navigation team, a group of oncology nurses focused on ensuring patients receive recommended care. Conclusions: In a large public tertiary care health system, we did not observe racial disparities in receipt of guideline recommended therapies for metastatic prostate cancer. High rates of insurance, a robust patient navigation program, and a well-developed pharmacy assistance program may have helped mitigate racial disparities in care. Ongoing analyses are evaluating prescribing patterns among patients with de novo metastatic disease. Future studies should explore delivery of prostate cancer therapies across health systems and the influence of patient navigation and pharmacy assistance programs on medication receipt. Prevalence ratios of treatment by race. Medication PR (95% CI) for Black v White men p-value ADT 1.04 (0.98-1.11) 0.19 Novel Antiandrogen 1.05 (0.95-1.16) 0.31 Bone protection 0.89 (0.76-1.04) 0.13 Chemotherapy 1.09 (0.85-1.39) 0.51