Associations of sex hormone ratios with metabolic syndrome and inflammation in US adult men and women

Background

Sex hormones play a critical role in sex differences and cardiovascular disease risk associated with metabolic syndrome (MS) and inflammation. However, the associations of sex hormone ratios with metabolic and inflammatory markers are unclear according to sex and age differences. We evaluated the associations of sex hormone ratios with MS and inflammation among males and females.

Methods

A retrospective cross-sectional study was conducted by including all adults from the National Health and Nutrition Examination Survey cycles 2013-2016 and excluding any pregnant women, heart disease, diabetes, and those currently taking insulin. MS was defined using the National Cholesterol Education Program criteria and a high-sensitivity C-reactive protein (CRP) level>3 mg/L was defined as a high CRP. Measures of MS components and CRP concentrations were also analyzed. The primary exposures were testosterone to estradiol (excess androgen index), testosterone to sex hormone-binding globulin (free androgen index), and estradiol to sex hormone-binding globulin (free estradiol index). The adjusted associations were summarized with a relative risk (RR) and 95% confidence interval (CI).

Results

This study included 9167 subjects with 4360 males and 4807 females. Increases in free estradiol index were positively associated with MS (RR=1.48; 95%CI: 1.39, 1.58; RR=1.31; 95%CI: 1.22, 1.40) and high CRP (RR=1.49; 95%CI: 1.25, 1.77; RR=1.26; 95%CI: 1.06, 1.50) in men with age<50 years and age≥50 years, respectively. Similarly, higher free estradiol index was also robustly associated with increased prevalence of MS (RR=1.22; 95%CI: 1.15, 1.28) and high CRP (RR=1.68; 95%CI: 1.48, 1.90) in women with age ≥50 years. Among women with age<50 years, a higher free androgen index was associated with MS (RR=1.34; 95%CI: 1.25, 1.42) and high CRP (RR=1.13; 95%CI: 1.02, 1.25). These associations were unchanged even after adjusting for all sex hormones.

Conclusion

Free estradiol index was consistently and positively associated with MS and high CRP in males of all ages and older females. Free androgen index was positively associated with MS and high CRP in females with age<50 years.

EXPRESS: Effectiveness of HMG-CoA reductase inhibitors on inflammation and metabolic markers in the US-Mexico border Hispanic population

HMG-CoA reductase inhibitors (statins) are commonly used for dyslipidemia management to reduce the risk of cardiovascular disease (CVD). High-sensitivity C-reactive protein (hs-CRP) is an emerging systematic low-grade inflammatory marker associated with atherosclerotic CVD development. Despite racial/ethnic disparities in the use and response of statins and the anti-inflammatory effects of statins, the effectiveness of statins on inflammation and metabolic markers is unknown among Hispanics. We performed a retrospective cohort study using 150 adult patients scheduled for an annual physical exam at a family medicine clinic between January 1, 2021, and December 31, 2021. Effect size with a 95% confidence interval (CI) was estimated using adjusted regression analyses. Among 150 patients, 52 (34.67%) received statins. Patients who received statins had significantly reduced median hs-CRP (1.9 vs. 3.2, p=0.007), mean low-density lipoprotein (LDL-C) (101.18 vs. 124.6, p<0.001), and total cholesterol (172.6 vs. 194.5, p<0.001) concentrations compared to those who did not receive statins. In the propensity-scores matched analysis, lower concentrations of log-transformed hs-CRP (regression coefficient [RC], -0.48; 95%CI: -0.89, -0.07), LDL-C (RC, -19.57; 95%CI: -33.04, -6.1), and total cholesterol (RC, -23.47; 95%CI: -38.96, -7.98) were associated with statin use. In addition, hepatic steatosis (adjusted relative risk [aRR]=0.25; 95%CI: 0.08, 0.78, p= 0.017) was significantly lower among patients with the use of statins. Our study suggests that HMG-CoA reductase inhibitors may help reduce inflammation among Hispanic patients with dyslipidemia and hypertension. These findings have useful implications for preventing risk and disparities associated with cardiovascular and other inflammatory-induced diseases among the fastest-growing US Hispanic minorities.

Evaluation of Four Validated Risk Scores to Predict Outcomes in Hispanic Patients With Acute Pulmonary Embolism

Risk stratification plays an essential role in the management of acute pulmonary embolism (PE). Several risk scores have been studied to support risk stratification and management. While ethnic differences in acute PE risk factors exist, current risk scores lack validation for Hispanic patients. Therefore, the present study retrospectively investigated the performance of the pulmonary embolism severity index (PESI), simplified PESI (sPESI), the European Society of Cardiology risk assessment (ESC), and the Bova score, to predict 30-day mortality in Hispanic patients presenting with an acute PE. Among 437 patients admitted with acute PE, 30-day mortality was 10.8%; 30-day mortality in low-risk groups ranged from 0% (sPESI, ESC) to 0.2% (PESI, Bova), and 3.0% (Bova) to 5.7% (PESI) in the highest risk groups, respectively. All four scores produced statistically significant discrimination between different risk strata. However, no single scoring system was able to identify all patients with 30-day mortality. The findings of the present study suggest that PESI, sPESI, ESC, and Bova scores provide important information about 30-day mortality in Hispanic in-patients presenting with acute PE. However, additional clinical information could further improve predictability that is not provided by a single scoring system.

Prevalence and clinical significance of deep vein thrombosis in Hispanic patients with acute pulmonary embolism

The prevalence of concomitant deep vein thrombosis (DVT) and its impact on 30-day outcomes in Hispanic patients with acute pulmonary embolism (PE) is unknown. We retrospectively studied a cohort of Hispanic patients admitted for acute PE to determine the relationship of concomitant DVT to clot burden on chest computer tomography (CT), right heart strain, and 30-day mortality. We identified 391 patients admitted with acute PE; 168 (42.9%) had concomitant DVTs on admission; 39 patients (9.9%) died during the 30-day follow-up: 12 patients without concomitant DVT and 27 with concomitant DVT, respectively (p < .001). The presence of a proximal DVT independently predicted 30-day mortality even after adjusting for age, gender and admission PE severity index scores (PESI) (hazard ratio [HR] 2.0; 95% confidence interval [CI]: 1.4-3.0, p = .001). Proximal DVTs remained a significant predictor of 30-day mortality in patients with low and intermediate PESI scores (HR 2.5; 95% CI: 1.1-6.0, p = .035). The prevalence of concomitant DVT in Hispanic patients presenting with acute DVT is relatively lower than other ethnic groups. However, a proximal location of a DVT is of significant prognostic relevance. Hispanic patients with acute PE should routinely undergo compression doppler ultrasonography (CDUS) of the lower extremities.

Association of polycystic ovary syndrome with cardiovascular disease among US female hospitalizations

OBJECTIVE

Polycystic ovary syndrome (PCOS) is a complex disorder characterized by a wide range of symptoms related to ovulatory dysfunction and androgen overproduction. Although PCOS is associated with multiple cardiovascular disease (CVD) risk factors, previous studies have reported controversial associations between PCOS and different types of CVD events. We sought to determine the association of PCOS with various CVD outcomes among hospitalized women.

METHODS

All women hospitalizations between the ages of 15- 65 years recorded in the National Inpatient Sample database, 2017 were analyzed with sampling weighted logistic regression analysis. ICD 10 codes were used to define outcomes including composite CVD, major adverse cardiovascular events (MACE) coronary heart disease (CHD), stroke/cerebrovascular accident (CVA), heart failure (HF), arterial fibrillation (AF) or arrhythmia, pulmonary heart disease (PHD), myocardial infarction (MI), cardiac arrest (CA), and diabetes (DM).

RESULTS

Among the total hospitalizations of women, 13896 (0.64) had a PCOS diagnosis. PCOS was found to be associated with most CVD outcomes including composite CVD (adjusted odds ratio[aOR] = 1.73, 95%CI:1.55-1.93, p < 0.001), MACE(aOR = 1.31, 95%CI: 1.12-1.53, p < 0.001), CHD (aOR = 1.65, 95%CI: 1.35-2.01, p < 0.001), stroke/CVA (aOR = 1.46, 95%CI: 1.08-1.98, p = 0.014), HF (aOR = 1.30, 95%CI: 1.07, 1.57, p = 0.007), AF/arrhythmia (aOR = 2.20, 95%CI:1.88-2.57, p < 0.001), and PHD (aOR = 1.58, 95%CI: 1.23-2.03, p < 0.001) among hospitalized women with age ≤40 years. However, the associations between PCOS and CVD outcomes were mediated by obesity and metabolic syndrome conditions.

CONCLUSIONS

PCOS is associated with CVD events and the association is mediated by obesity and metabolic syndrome conditions, particularly among hospitalized women less than or equal to age 40 years in the US.

A phase 1 open-label trial evaluating focused ultrasound unilateral anterior thalamotomy for focal onset epilepsy

OBJECTIVE

Focused ultrasound ablation (FUSA) is an emerging treatment for neurological and psychiatric diseases. We describe the initial experience from a pilot, open-label, single-center clinical trial of unilateral anterior nucleus of the thalamus (ANT) FUSA in patients with treatment-refractory epilepsy.

METHODS

Two adult subjects with treatment-refractory, focal onset epilepsy were recruited. The subjects received ANT FUSA using the Exablate Neuro (Insightec) system. We determined the safety and feasibility (primary outcomes), and changes in seizure frequency (secondary outcome) at 3, 6, and 12 months. Safety was assessed by the absence of side effects, that is, new onset neurological deficits or performance deterioration on neuropsychological testing. Feasibility was defined as the ability to create a lesion within the anterior nucleus. The monthly seizure frequency was compared between baseline and postthalamotomy.

RESULTS

The patients tolerated the procedure well, without neurological deficits or serious adverse events. One patient experienced a decline in verbal fluency, attention/working memory, and immediate verbal memory. Seizure frequency reduced significantly in both patients; one patient was seizure-free at 12 months, and in the second patient, the frequency reduced from 90-100 seizures per month to 3-6 seizures per month.

SIGNIFICANCE

This is the first known clinical trial to assess the safety, feasibility, and preliminary efficacy of ANT FUSA in adult patients with treatment-refractory focal onset epilepsy.

Ethnic/racial differences in risk factors and clinical outcomes among patients with amyloidosis

BACKGROUND

Cardiac amyloidosis is caused by abnormal extracellular deposition of insoluble fibrils in cardiac tissue. It can be fatal when untreated and is often underdiagnosed. Understanding the ethnic/racial differences in risk factors is critical for early diagnosis and treatment to improve clinical outcomes.

METHODS

We performed a retrospective cross-sectional study utilizing the National Inpatient Sample database from 2015 to 2018 using ICD-10-CM codes. The primary variables of interest were race/ethnicity and amyloidosis subtypes, while the primary outcomes were in-hospital mortality, gastrointestinal bleeding, renal failure, and hospital length-of-stay.

RESULTS

Amyloidosis was reported in 0.17% of all hospitalizations (N  =  19,678,415). Of these, 0.09% were non-Hispanic whites, 0.04% were non-Hispanic blacks, and 0.02% were Hispanic. Hospitalizations with ATTR amyloidosis subtype were frequently observed in older individuals and males with coronary artery disease, whereas AL amyloidosis subtype was associated with non-Hispanic whites, congestive heart failure, and longer hospital length of stay. Renal failure was associated with non-Hispanic blacks (adjusted relative risk [RR]  =  1.31, p < 0.001), Hispanics (RR  =  1.08, p  =  0.028) and had an increased risk of mortality. Similarly, the hospital length of stay was longer with non-Hispanic blacks (RR  =  1.19, p < 0.001) and Hispanics (RR  =  1.05, p  =  0.03) compared to non-Hispanic whites. Hispanics had a reduced risk of mortality (RR  =  0.77, p  =  0.028) compared to non-Hispanic whites and non-Hispanic blacks, and no significant difference in mortality was seen between non-Hispanic whites and non-Hispanic blacks (RR  =  1.00, p  =  0.963).

CONCLUSIONS

Our findings highlight significant ethnic/racial differences in risk factors and outcomes among amyloidosis-related US hospitalizations that can possibly be used for early detection, treatment, and better clinical outcomes.

Frequency of GLP-1 receptor agonists use in diabetic patients diagnosed with delayed gastric emptying and their demographic profile

Advances in the management of diabetes mellitus have come a long way in the 21st century. One of the most important developments in diabetes management has been the discovery of glucagon-like peptide-1 (GLP-1) receptor agonists. The most common side effects of GLP-1 receptor (GLP-1R) agonists are nausea and vomiting which have been attributed to delayed gastric emptying. While the effects of GLP-1R agonists on gastric emptying have prompted further research in this field, there are limited studies evaluating their effects on patients with pre-existing gastroparesis. Additionally, the frequency of GLP-1R agonist use among patients with gastroparesis has not been assessed in the past and this study aims to identify that percentage along with evaluating for possible iatrogenic gastroparesis. A retrospective review of all the gastric emptying studies performed at one academic medical center between January 2019 and January 2021 was performed. We found that although patients on GLP-1R agonists were more likely to have delayed gastric emptying, we could not establish a statistical significance. This could be due to the small sample size in the study. However, GLP-1R agonists use was associated with delayed gastric emptying in patients with diabetes for <10 years. Moreover, a significant proportion (24%) of patients with diabetes with delayed gastric emptying were on a GLP-1R agonist. Recently, semaglutide (GLP-1R agonist) gained Food and Drug Administration approval as a weight loss medication in both patients with and without diabetes. This should prompt further research to evaluate the safety profile of these medications in patients with and without pre-existing gastroparesis.

Common Variables That Influence Sepsis Mortality in Mice

Introduction

Sepsis is characterized by a dysregulated host immune response to infection, leading to organ dysfunction and a high risk of death. The cecal ligation and puncture (CLP) mouse model is commonly used to study sepsis, but animal mortality rates vary between different studies. Technical factors and animal characteristics may affect this model in unanticipated ways, and if unaccounted for, may lead to serious biases in study findings. We sought to evaluate whether mouse sex, age, weight, surgeon, season of experiments, and timing of antibiotic administration influenced mortality in the CLP model.

Methods

We created a comprehensive dataset of C57BL/6J mice that had undergone CLP surgery within our lab during years 2015-2020 from published and unpublished studies. The primary outcome was defined as the time from sepsis induction to death or termination of study (14 days). The Log rank test and Cox regression models were used to analyze the dataset. The study included 119 mice, of which 43% were female, with an average age of 12.6 weeks, an average weight of 25.3 g. 38 (32%) of the animals died.

Results

In the unadjusted analyses, experiments performed in the summer and higher weight predicted a higher risk of mortality. In the stratified Cox model by sex, summer season (adjusted hazard ratio [aHR]=5.61, p=0.004) and delayed antibiotic administration (aHR=1.46, p=0.029) were associated with mortality in males, whereas higher weight (aHR=1.52, p=0.005) significantly affected mortality in females. In addition, delayed antibiotic administration (HR=1.42, p=0.025) was associated with mortality in the non-summer seasons, but not in the summer season.

Discussion

In conclusion, some factors specific to sex and season have a significant influence on sepsis mortality in the CLP model. Consideration of these factors along with appropriate group matching or adjusted analysis is critical to minimize variability beyond the experimental conditions within a study.

Air Pollution and the Heart: Updated Evidence from Meta-analysis Studies

PURPOSE OF REVIEW

Although environmental exposure such as air pollution is detrimental to cardiovascular disease (CVD), the effects of different air pollutants on different CVD endpoints produced variable findings. We provide updated evidence between air pollutants and CVD outcomes including mitigation strategies with meta-analytic evidence.

RECENT FINDINGS

An increased exposure to any class of air pollutants including particulate matter (PM), gas, toxic metals, and disruptive chemicals has been associated with CVD events. Exposure to PM < 2.5 μm has been consistently associated with most heart diseases and stroke as well as CVDs among at-risk individuals. Despite this, there is no clinical approach available for systemic evaluation of air pollution exposure and management. A large number of epidemiological evidence clearly suggests the importance of air pollution prevention and control for reducing the risk of CVDs and mortality. Cost-effective and feasible strategies for air pollution monitoring, screening, and necessary interventions are urgently required among at-risk populations and those living or working, or frequently commuting in polluted areas.

Standardized uptake value of normal organs on routine clinical [18F]FDG PET/CT: impact of tumor metabolism and patient-related factors

BACKGROUND

To evaluate the effect of patient-related factors such as age, gender, body mass index (BMI), blood glucose (BG), diabetes, serum creatinine and injected dose on 18F-Fluorodeoxyglucose ([18F]FDG) uptake of tumor and normal organs, as well impact of [18F]FDG uptake of tumor on normal organs, in clinical positron emission tomography-computed tomography (PET/CT).

MATERIAL AND METHODS

In this retrospective study, data of 200 patients who underwent clinical [18F]FDG PET/CT with (n = 192) and without (n = 8) intravenous contrast was evaluated. Ten target organs and tumor [18F]FDG uptake were measured with a standardized uptake value maximum (SUVmax). Pearson correlation coefficient was calculated for continuous variables while t-test/Wilcoxon rank sum tests were used to compare continuous outcomes. Multivariate linear regression analysis was done to exclude covariates, followed by posthoc multiple linear regression analysis after adjusting the levels of significance.

RESULTS

Significant but weak positive correlation was seen between tumor [18F]FDG uptake with uptake in the pancreas (r = 0.43, p < 0.001) and heart (r = 0.19, p = 0.049), but not other organs. With age, a significant negative correlation was seen with the brain (r = -0.183, p = 0.009) and a positive correlation was seen with the blood pool (r = 0.205, p = 0.003). With BG, significant negative correlation was seen with the brain (r = -0.449, p < 0.0001) and heart (r = -0.15, p = 0.033), while a positive correlation was seen with fat (r = 0.143, p = 0.043). BMI showed a significant positive correlation with [18F]FDG uptake of all organs except the pancreas and heart, as well as tumor. No significant correlation was seen with serum creatinine and injected [18F]FDG dose. Significantly higher uptake was seen in the brain, spleen, and muscles of females. Between obese and non-obese, a significant difference was seen for all organs except for the pancreas and heart, and tumor. Comparison between non-diabetic and diabetic patients showed significant differences only for bone. Multivariate linear analysis adjusting for cofactors showed only BMI (p = 0.0009) and BG (p = 0.0002) to be independently correlated with [18F]FDG uptake. Post-hoc multiple regression analysis showed a significant positive correlation between [18F]FDG uptake of the brain (β = 0.118, p < 0.001), liver (β = 0.02, p = 0.002), and fat (β = 0.01, p < 0.0006) with BMI, and significant negative correlation of brain uptake with BG (β = 0.03, p < 0.0001).

CONCLUSIONS

Tumor [18F]FDG uptake has no significant effect on the uptake in organs, except for the pancreas and heart. Age, gender, BMI, and BG, but not creatinine and injected [18F]FDG dose show correlation with uptake in tumor and organs. BG and BMI are independent significant factors, with a positive correlation of BMI with the brain, hepatic and fat uptake, and a negative correlation of BG with brain uptake.

Effects of statins on outcomes in Hispanic patients with COVID-19

The Hispanic population is regarded among those who are at greater risk of adverse prognoses due to higher rates of diabetes and obesity in the USA during the COVID-19 pandemic. Statin medications are speculated to help treat the infection by decreasing inflammation caused by COVID-19. In this retrospective, observational study, outcomes of statin use were assessed among Hispanic patients with COVID-19 by screening all patients hospitalized between March, 2020 and March, 2021 at a tertiary care hospital in El Paso, Texas, resulting in a total of 1039 patients. The patients were categorized into a group of either being on statins or not. The considered outcomes were mechanical ventilation, intensive care unit (ICU) hospitalization, oxygen supplementation at discharge, hospital length of stay, and mortality. Patients receiving statins were observed to be older with more comorbidities. In the propensity-scores adjusted analysis, no association was found between statin use and: mortality (adjusted risk ratio (aRR)=0.96, p=0.754), mechanical ventilation (aRR=0.91, p=0.503), ICU transfer (aRR=0.96, p=0.395), and O₂ supplementation at discharge (aRR=1.03, p=0.729). These outcomes were also evaluated in patients who had myocardial infarction and stroke with COVID-19. Among these patients, association was found between statin use and: a reduced risk of mortality (aRR=0.61, p=0.005), mechanical ventilation (aRR=0.53, p=0.012) and ICU transfers (aRR=0.81, p=0.005). These results may not give us a reason to start patients on statins for the specific treatment of COVID-19, but it may be sufficient evidence to suggest statins should not be discontinued during hospitalization due to COVID-19.

How to write statistical analysis section in medical research

Reporting of statistical analysis is essential in any clinical and translational research study. However, medical research studies sometimes report statistical analysis that is either inappropriate or insufficient to attest to the accuracy and validity of findings and conclusions. Published works involving inaccurate statistical analyses and insufficient reporting influence the conduct of future scientific studies, including meta-analyses and medical decisions. Although the biostatistical practice has been improved over the years due to the involvement of statistical reviewers and collaborators in research studies, there remain areas of improvement for transparent reporting of the statistical analysis section in a study. Evidence-based biostatistics practice throughout the research is useful for generating reliable data and translating meaningful data to meaningful interpretation and decisions in medical research. Most existing research reporting guidelines do not provide guidance for reporting methods in the statistical analysis section that helps in evaluating the quality of findings and data interpretation. In this report, we highlight the global and critical steps to be reported in the statistical analysis of grants and research articles. We provide clarity and the importance of understanding study objective types, data generation process, effect size use, evidence-based biostatistical methods use, and development of statistical models through several thematic frameworks. We also provide published examples of adherence or non-adherence to methodological standards related to each step in the statistical analysis and their implications. We believe the suggestions provided in this report can have far-reaching implications for education and strengthening the quality of statistical reporting and biostatistical practice in medical research.

Cervical Spinal Lesion, Completeness of Injury, Stress, and Depression Reduce the Efficiency of Mental Imagery in People With Spinal Cord Injury

OBJECTIVES

The aims of this study were to assess the relationships of (1) clinical variables (age, level of injury, time since injury [TSI], and completeness of injury) and (2) psychological variables (stress and depression) with mental imagery ability in individuals with spinal cord injury.

STUDY DESIGN

This was a cross-sectional study. Participants with spinal cord injury (N = 130) were requested to fill the Kinesthetic and Visual Imagery Questionnaire and Vividness of Motor Imagery Questionnaire. They also completed the Perceived Stress Scale and Patient Health Questionnaire 9 for the assessment of stress and depression, respectively.

RESULTS

Mental imagery scores were found to be significantly low in cervical injuries (P < 0.001) as compared with thoracic injuries (P < 0.001). Furthermore, higher levels of spinal injuries resulted in lower mental imagery scores. Completeness of injury (according to Asia Impairment Scale) also had a significant relationship (P < 0.001) with the mental imagery ability among spinal cord injury participants. Presence of stress (P < 0.001) and depression (P < 0.001) also associated with reduced efficiency of mental imagery in these individuals.

CONCLUSIONS

Injury type and psychological factors were associated with mental imagery in SCI patients. Imagery-based interventions should be designed after consideration of identified factors yielding effect on their outcomes.

TO CLAIM CME CREDITS

Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME.

CME OBJECTIVES

Upon completion of this article, the reader should be able to: (1) Determine the impact of clinical variables such as level of injury, completeness and chronicity of injury on mental imagery ability in spinal cord injury; (2) Discuss the role of stress and depression on mental imagery ability in spinal cord injury; and (3) Describe the various dimensions of mental imagery ability and its variability among individuals who have spinal cord injury.

LEVEL

Advanced.

ACCREDITATION

The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Associations of Glycemic Index and Glycemic Load with Cardiovascular Disease: Updated Evidence from Meta-analysis and Cohort Studies

PURPOSE OF REVIEW

Diet and lifestyle patterns are considered major contributory factors for cardiovascular disease (CVD) and mortality. In particular, consuming a diet higher in carbohydrates (not inclusive of fruits and vegetables, but more processed carbohydrates) has been associated with metabolic abnormalities that subsequently may increase the risk of CVD and related mortality. Glycemic index (GI) and glycemic load (GL) are values given to foods based on how fast the body converts carbohydrates into glucose also referred to as the glycemic burden of carbohydrates from foods. Conflicting associations of how high GI and GL influence CVDs have been observed even in high-quality meta-analysis studies. We synthesize and report the associations of high GI and GL with various CVDs by sex, obesity, and geographical locations using an updated review of meta-analysis and observational studies.

RECENT FINDINGS

We identified high GI or high GL is associated with an increased risk of CVD events including diabetes (DM), metabolic syndrome (MS), coronary heart disease (CHD), stroke, and stroke mortality in the general population, and the risk of CVD outcomes appears to be stratified by sex, obesity status, and preexisting CVD. Both high GI and GL are associated with DM and CHD in the general population. However, high GI is strongly associated with DM/MS, while high GL is strongly associated with an increased risk of CHD in females. In addition, high GL is also associated with incident stroke, and appears to be associated with CVD mortality in subjects with preexisting CVD or high BMI and all-cause mortality in non-obese DM subjects. However, high GI appears to be associated with CVD or all-cause mortality only in females without CVD. High GI/GL is an important risk factor for CVD outcomes in the general population. High GI seems to be markedly associated with DM/MS, and it may enhance the risk of CVD or all-cause mortality in both sexes and predominately females. Although both high GI and high GL are risk factors for CHD in females, high GL is associated with CVD outcomes in at-risk populations for CVD. These data suggest that while high GI increases the propensity of CVD risk factors and mortality in healthy individuals, high GL contributes to the risk of severe heart diseases including CVD or all-cause mortality, particularly in at-risk populations. These data indicate dietary interventions designed for focusing carbohydrate quality by lowering both GI and GL are recommended for preventing CVD outcomes across all populations.

Association between tumor mutation profile and clinical outcomes among Hispanic-Latino patients with metastatic colorectal cancer

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Background: According to the World Health Organization GLOBOCAN database, in 2019, approximately 1.8 million new colorectal cancer cases were diagnosed, and almost 861,000 deaths were reported. In the United States, CRC is the third most frequent type of cancer and the second leading cause of cancer-related death. Although the overall incidence of CRC among the Hispanic population has been declining over the last decades, recently, a dramatic increase in CRC incidents among Hispanics younger than 50 years of age (early-onset CRC) has been reported. The increase in the incidence of early-onset CRC is markedly more significant in Hispanic-Latino (HL) patients population (45%) than in non-Hispanic Whites (NHW) (27%) and African-Americans (AA) (15%). Additionally, in contrast to NHW, Hispanics have a worse survival rate. The exact reason for these racial disparities and the biology of CRC in the HL population are not well understood. Therefore, we performed this study to better understand the biology of the disease in HL patients, which might help to identify new directions for targeted therapy. Methods: For the study, 52 formalin-fixed paraffin-embedded (FFPE) tumor tissue samples were collected and analyzed. We compared the results with individual patient clinical histories and outcomes. Of 52 patients with mCRC, 52 (100%) were identified as HL. We identified several commonly altered genes in HL patients ( APC, TP53, KRAS, GNAS, PICK3CA, and NOTCH). Compared to those in other studies. Results: Mutation frequencies in the APC gene were significantly higher among HL patients with mCRC. Moreover, the prevalence of the APC mutation was significantly higher among male HL patients compared to female patients. The combination of mutations in the APC, NOTCH, and KRAS genes in the same tumors was associated with a higher risk of progression after the first-line of chemotherapy and worse overall survival. In addition, mutations in the combination of GNAS and AURKA genes were associated with a significantly higher risk of progression after the first-line of chemotherapy. Conclusions: The data support the notion that the molecular drivers of colon cancer might be different in HL patients compared to other racial/ethnic groups.

Pre-hospitalization proton pump inhibitor use and clinical outcomes in COVID-19

INTRODUCTION

Severe acute respiratory syndrome coronavirus-2 may escape the inactivation by gastric acid because of hypochlorhydria caused by proton pump inhibitors (PPIs), which could predispose the patients to severe COVID-19.

METHODS

We studied the association between prehospitalization PPI exposure and clinical outcomes among hospitalized COVID-19 patients.

RESULTS

A total of 295 hospitalized COVID-19 patients were included in the study. 15.6% of hospitalized COVID-19 patients were on PPIs at home. Mortality among PPI-users was 2.3 times higher than non-users, along with 2.3 times higher risk of acute respiratory distress syndrome after adjusting for confounding variables.

CONCLUSION

We found that prehospitalization PPI-exposure is independently associated with worse clinical outcomes, including mortality in COVID-19 patients, regardless of the presence of cardiovascular comorbidities.

Characteristics of and reasons for electronic cigarette use among adult smokers with schizophrenia/schizoaffective disorder

BACKGROUND

The objective of our study was to determine lifetime and current e-cigarette use among adult cigarette smokers with schizophrenia or schizoaffective disorder, and to describe characteristics of these e-cigarette users.

METHODS

Adult daily tobacco smokers with schizophrenia who were psychiatrically stable in outpatient treatment (n = 162) were enrolled in a motivational intervention study from 2013 to 2015 and followed for 6 months. Approximately 80% (n = 140) completed a 6-month follow-up, including the Population Assessment of Tobacco and Health survey.

RESULTS

Among the 140 participants, 46% (n = 64) reported ever using e-cigarettes and 15% (n = 21) reported current use. Participants were significantly more likely to report ever-use if they were younger (Chi-square = 11.7, P < .01), lesbian/gay/bisexual (LGB) (Chi-square = 4.8, P = .03), or reported recent drug use (Chi-square = 6.5, P = .01). In a multivariate model, only age remained a significant predictor of ever-use (coefficient: 0.03; P = .02). The most common reasons for using e-cigarettes were "helps people quit cigarettes" and "less harmful to me or to people around me than cigarettes." Current e-cigarette users had significantly lower carbon monoxide levels than past e-cigarettes users (T = 2.08, P = .04).

CONCLUSIONS

Almost one-half of smokers with schizophrenia or schizoaffective disorder reported ever using e-cigarettes. Interventions for tobacco use among this demographic should incorporate recognition of e-cigarette use, particularly among younger adults, illicit drug users, and LGB individuals.

Association Between Tumor Mutation Profile and Clinical Outcomes Among Hispanic-Latino Patients With Metastatic Colorectal Cancer

In the United States, CRC is the third most common type of cancer and the second leading cause of cancer-related death. Although the incidence of CRC among the Hispanic population has been declining, recently, a dramatic increase in CRC incidents among HL younger than 50 years of age has been reported. The incidence of early-onset CRC is more significant in HL population (45%) than in non-Hispanic Whites (27%) and African-Americans (15%). The reason for these racial disparities and the biology of CRC in the HL are not well understood. We performed this study to understand the biology of the disease in HL patients. We analyzed formalin-fixed paraffin-embedded tumor tissue samples from 52 HL patients with mCRC. We compared the results with individual patient clinical histories and outcomes. We identified commonly altered genes in HL patients (APC, TP53, KRAS, GNAS, and NOTCH). Importantly, mutation frequencies in the APC gene were significantly higher among HL patients. The combination of mutations in the APC, NOTCH, and KRAS genes in the same tumors was associated with a higher risk of progression after first-line of chemotherapy and overall survival. Our data support the notion that the molecular drivers of CRC might be different in HL patients.

Analysis of the prescription pattern of psychotropics in an outpatient department of a general hospital psychiatry unit

BACKGROUND

World Health Organization has prescribed drug use indicators for evaluating rational prescribing. Very few studies have been conducted on rational prescriptions for psychotropic drugs; hence, this study was undertaken at a tertiary care center of North India.

METHODS

After obtaining approval of the Institutional Ethics Committee, all prescriptions deposited with the dispensary of the psychiatry department of the hospital between 01 October 2017 and 31 December 2017 were included in the study. The prescriptions were analyzed for drug use indicators, namely the average number of drugs per encounter, percentage of prescriptions with generic name, percentage of prescriptions from the essential drug list, percentage of prescriptions with antibiotics, and percentage of prescriptions with an injection. In addition, the prescriptions were analyzed for patterns of psychotropics prescribed.

RESULTS

A total of 3770 prescriptions were analyzed. On an average, 2.35 medicines were prescribed per prescription. Injectable comprised 2.39% of prescriptions and fixed drug combinations were 0.16% of the total. Of all prescriptions, 91.3% were by generic name, while 55.02% of prescriptions were from the essential drug list. Polypharmacy constituted 4.53% of prescriptions. Risperidone, escitalopram, sodium valproate, and clonazepam were the most commonly prescribed drugs.

CONCLUSION

While we fared well with respect to the percentage of prescriptions with injections and those with an antibiotic, we have not been able to achieve the prescribed standards in prescription with generic names, number of drugs per prescription, and prescriptions from the essential drug list. The study emphasizes that there is scope for improvement.

Latin Americans and US Hispanics show differences in IBD phenotype: a systematic review with meta-analysis

Latin America has experienced a rise in the prevalence and incidence of inflammatory bowel disease (IBD). Differences in IBD phenotype between Hispanics in Latin America and those in the USA have not been described. We conducted a systematic review with meta-analysis of population-based and cohort studies comparing the phenotype of ulcerative colitis (UC) and Crohn's disease (CD) in Latin Americans and US Hispanics. A systematic search was conducted up to March 2019 using MEDLINE, EMBASE and Google Scholar. Inclusion criterion includes studies describing IBD phenotype in Latin Americans or in US Hispanics. Exclusion criterion includes prevalence or incidence studies not describing phenotype. A random effects model was chosen "a priori" for analysis of pooled proportions. A total of 46 studies were included from Latin America and 7 studies from the USA. The predominant IBD subtype in Latin America was UC with a more balanced UC:CD ratio noted in Puerto Rico (0.53) and Brazil (0.56). UC-related extensive colitis was more common in US Hispanics (0.64) than in Latin Americans (0.38), p<0.001. CD phenotype was similar between US Hispanics and Latin Americans. UC is the predominant IBD subtype in Latin America, with the exception of Puerto Rico and Brazil which demonstrate a more balanced UC:CD ratio. In UC, extensive colitis was more frequently seen in US Hispanics than in Latin Americans. CD phenotype was similar in both US Hispanics and Latin Americans.

A systematic review and meta-analysis of the association between maternal polycystic ovary syndrome and neuropsychiatric disorders in children

There is emerging evidence demonstrating an association between maternal polycystic ovary syndrome (PCOS) and autism spectrum disorder (ASD) in children, however, the cumulative effect of maternal PCOS on the development of ASD or other neuropsychiatry disorders (NPD) in children and separately for males and females has not been examined. We sought to systematically evaluate the influence of maternal PCOS on a wide range of NPD including ASD, attention deficit hyperactivity disorder (ADHD), chronic tic disorder (CDT), other behavior disorders, anxiety, depression, bipolar disorder, schizophrenia in children as well as in women of reproductive age only. We queried electronic databases including PubMed, EMBASE, and Google Scholar, until March 2021. We used DerSimonian and Laird (D-L) random effects method to compute pooled effect size in terms of odds ratio (OR). Nineteen studies (1667851 mothers, 2260622 children) were included in this study. Mothers with PCOS had an increased odds of children diagnosed with ASD (OR = 1.40, p < 0.001), ADHD (OR = 1.42, p < 0.001), CTD (OR = 1.44, p = 0.001), anxiety (OR = 1.33, p < 0.001), as well as other behavioral symptoms (OR = 1.45, p < 0.001) in the adjusted analysis. The association between maternal PCOS and ASD (OR: 1.43 vs. 1.66), ADHD (OR: 1.39 vs. 1.54), and CTD (OR: 1.42 vs. 1.51) was found to be significantly consistent between males and females, respectively. Our data do not suggest increased fetal testosterone exposure is associated with increased autistic traits in children. However, PCOS was significantly associated with increased odds of a wide range of NPD in women themselves. Maternal PCOS is a risk factor for various NPD with a similar extent in their children regardless of their underlying comorbidities. Managing PCOS is essential for women's health as well as for their children's health. More research is needed to determine the mechanisms and links between maternal PCOS and NPD in children.

Ethnic Differences Between Hispanics and Non-Hispanic Whites in Neuropsychiatric Symptoms Predict Conversion to Mild Cognitive Impairment

The aim of the study is to ascertain the neuropsychiatric symptoms (NPS) subtypes significantly influencing progression to mild cognitive impairment (MCI) by ethnicity. In this retrospective cohort study, we included 386 cognitively normal individuals participating in the longitudinal Texas Alzheimer's Research and Care Consortium between February 2007 and August 2014. The primary outcome was time to incident MCI. Data driven NPS subtypes at baseline were identified and the effects of these subtypes on the outcome were obtained for Hispanic and non-Hispanic ethnic cohorts and summarized with a hazard ratio (HR). Three NPS subtypes were identified and internally validated: psychomotor apathy factor (including agitation, irritability, apathy), affective mood factor (including depression, anxiety), and physical behavior factor (including nighttime behavior, eating/appetite disturbances). In adjusted analysis, a psychomotor apathy score of NPS was the best predictor for MCI (HR = 2.19, p = 0.037) among non-Hispanics whereas physical behavior score was the most predictive of MCI (HR = 2.55, p = 0.029) among Hispanics. A high score of affective mood factor also tended to increase the risk of MCI (HR = 2.09, p = 0.06) in Hispanics. Progression from normal cognition to MCI was differentially predicted by NPS subtypes in Hispanics and non-Hispanic whites. These data may inform the allocation of efforts for monitoring individuals at-risk of MCI.

Late-onset rapid gastric emptying: Identification of a new abnormal finding in patients with otherwise normal results on gastric emptying scintigraphy

BACKGROUND

The 4-h gastric emptying (GE) scintigraphy protocol is the gold standard for assessing GE. Rapid gastric emptying (RGE) is >30% emptied by 30 min and >65% emptied at1 h. We observed that some GE studies demonstrated rapid emptying at a later time although interpreted as normal (NGE) at 4 h. We aimed to establish thresholds to characterize this subset of late-onset rapid gastric emptying (LRGE).

METHODS

We retrospectively analyzed 4-h GE studies of 425 patients with upper GI symptoms who fulfilled the criteria for NGE. We recruited 24 normal subjects to establish GE cutoff values (mean +/- 2SD) at 1-2, 2-3, and 3-4 h. These thresholds were applied to the 425 patients with NGE. During every GE study, patients graded their postprandial symptoms on a scale from 0 to 4.

KEY RESULTS

The mean upper threshold decrement limits were calculated from the normal volunteers as 67.6% at 1-2 h, 48.7% at 2-3 h, and 27.9% at 3-4 h. After applying these values to the NGE patients, 19 (4.5%) were classified as having LRGE; 6 patients (1.4%) for the 2- to 3-h; and 13 (3.1%) for the 3- to 4-h period. Patients with LRGE had abdominal pain, bloating, nausea, or diarrhea beginning more than 1-h postprandial.

CONCLUSION

5% of patients classified as "normal" at 4 h had an abnormal GE pattern based on the proposed criteria for LRGE. This highlights the importance of applying these hourly decrement thresholds to identify LRGE as a new diagnostic entity explaining postprandial symptoms.

ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine) as front-line therapy for Hodgkins lymphoma in Hispanic patients: A single center experience from Texas-Mexico Border

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Background: Population-based studies in Hodgkin Lymphoma (HL) have shown reduced survival in patients of Hispanic ethnicity as compared with non-Hispanic Whites. ABVD is the most commonly used regimen for HL in the United States. We retrospectively reviewed the charts of Hispanic patients with HL treated at a single institution located along the Texas-Mexico border. Methods: We performed a chart review of Hispanic patients with HL treated at our institution over an 8 year period. Prognostic (Stage, International Prognostic Score) and predictive (results of interim and end of therapy PET scan) factors were recorded. Relative dose intensity (RDI: fraction of drug dose administered to the standard dose) of each chemotherapy drug was calculated.Treatment delays and their causes were recorded. Quantitative variables were described using median, inter-quartile range, minimum and maximum observations. Categorical variables were described using frequency and proportions. Kaplan – Meier curves were used to show relapse-free survival. Results: Base line characteristics are shown in table. A total of 24 patients were treated in the time frame of whom 45% were dependent on charity care. All were treated with ABVD or an ABVD-like regimen. After a median follow-up of 43 months, relapse rate for the entire cohort was 45.8%. ( 33.3% in early stage and 53.3% in advanced stage disease). Of the patients who relapsed 45% were unable to receive a stem cell transplant based salvage therapy. The RDI for each chemotherapy drug in ABVD was as follows: Doxorubicin (98.8%), Bleomycin (82.1%), vinblastine (97.9%) and dacarbazine (100%). The mean and median delay in completing chemotherapy was 9.9 and 5.5 days respectively (range 0-56). Conclusions: HL patients of Hispanic ethnicity have a high relapse rate with ABVD despite optimal delivery of the regimen. As medically underserved minority patients face significant barriers in accessing stem cell rescue based salvage treatments, decreasing the relapse rate with upfront therapy can help in addressing the disparity seen in survival. Non ABVD regimens shown to have a higher upfront remission rate like escalated dose BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, prednisone) or A-AVD (brentuximab vedotin, doxorubicin, vinblastine, dacarbazine) should be studied in these patients.[Table: see text]

Factors associated with COVID-19 severity and mortality among Hispanic patients living on the USA-Mexico border

COVID-19 has ravaged the medical, social, and financial landscape across the world, and the USA-Mexico border is no exception. Although some risk factors for COVID-19 severity and mortality have already been identified in various ethnic cohorts, there remains a paucity of data among Hispanics, particularly those living on borders. Ethnic disparities in COVID-19 outcomes in Hispanic and black populations have been reported. We sought to identify the clinical presentation, treatment, laboratory, and imaging characteristics of 82 Hispanic patients in a county hospital and describe the factors associated with rates of hospitalization, intensive care unit (ICU) admission, and mortality. The most common comorbidities were hypertension (48.8%) and diabetes mellitus (DM) (39%), both found to be associated with hospitalization and mortality, while only DM was associated with increased rate of ICU admission. Multivariable analysis showed that individuals with fever, low oxygen saturation (SpO2), nasal congestion, shortness of breath, and DM had an increased risk of hospitalization. Individuals with fever, decreased levels of SpO2, and advanced age were found to be associated with an increased risk of death. The most common cause of death was respiratory failure (28.9%), followed by shock (17.8%) and acute kidney injury (15.6%). Our findings are critical to developing strategies and identifying at-risk individuals in a Hispanic population living on borders. Research aiming to identify key evidence-based prognostic factors in our patient population will help inform our healthcare providers so that best interventions can be implemented to improve the outcomes of patients with COVID-19.

Exposure of U.S. population to endocrine disruptive chemicals (Parabens, Benzophenone-3, Bisphenol-A and Triclosan) and their associations with female infertility

Ubiquitous exposure to endocrine disruptive chemicals (EDC) among women of reproductive age is alarming. Exposure to EDCs could be contributing to infertility. We determined the association between common EDCs and self-reported infertility among U.S. women, 18-45 years of age using the National Health and Nutrition Examination Surveys (NHANES) for periods 2013-2014 and 2015-2016. A cross-sectional study on reproductive age women was conducted. Available important sociodemographic variables, and urinary concentrations of parabens (methyl paraben [MP], ethyl paraben [EP], propyl paraben [PP], and butyl paraben [BP]), Benzophenone-3 (BP-3), Bisphenol-A (BPA), and triclosan (TCS) were obtained from the NHANES databases. Clustering among EDCs were obtained using variable cluster analysis. Relative risk regression models were used to estimate associations of individual and combined EDCs with self-reported infertility after applying appropriate survey weights to account for the complex survey design as well as to compensate for the four-year cycle. Results were summarized using prevalence ratio (PR) with 95% confidence interval (CI). Of total 789 individuals included in the study, 14% (95%CI: 11%-18%) had infertility. MP and PP were detected in 99% of urine samples, BP in 46%, EP and BP-3 in 96%, BPA in 94% and TCS in 73%. Self-reported infertility was significantly associated with combined score of BP-3, BPA and TCS (PR = 1.13, p = 0.007), and above detection level of EP (PR = 1.57, p = 0.025) even after adjusting for potential confounders. Our results suggested the EP and mixtures of benzophenones, TCS, and BPA were associated with infertility among the U.S. women. However, because of the limitations inherent to the cross-sectional study design, prospective cohort studies are warranted to confirm these findings.

Breast Cancer Fear Among Mexican American Women in the United States

Introduction:

Fear has been described as potentially important in affecting breast cancer screening completion. Limited information is available on the prevalence and determinants of fear among Mexican American women. This study describes perceived breast cancer fear and its association with personal characteristics and screening behavior among Mexican American women.

Methods:

This is a secondary analysis of data collected during the implementation of the Breast Cancer Education, Screening and NavigaTion program among eligible uninsured women in two Texas border counties. Participants completed a 26-item survey to assess eligibility, risk status, prior screening, and breast cancer fear. Descriptive statistics and multivariable analyses were used to determine associations between the fear score, personal characteristics, and mammography screening.

Results:

In all, 1916 of 2012 eligible women completed the study. The mean age was 57.3 years, 99.2% were Hispanic, and 88% were born in Mexico; 15% had a family history of breast cancer and 14% had never had a mammogram. The mean breast cancer fear score was 25.5 (standard deviation: 10.52; range: 8-40); 54.0 % (95% confidence interval: 52.1%-56.7%) had a high fear level. In multivariable analyses, better health status (P < .001), older age (P = .039), birth in the United States (P = .020), and having a regular doctor (P = .056) were associated with lower fear scores. There was no association between breast cancer fear and mammography screening.

Conclusion:

Breast cancer fear is high and varies by personal characteristics and health status among uninsured Mexican American border-residing women due for screening, but is not associated with screening behavior. Further research is needed to clarify the effect of interventions designed to help reduce breast cancer fear among these women, including educational interventions to reduce breast cancer fear.

Impact of a Culturally Tailored Diabetes Education and Empowerment Program in a Mexican American Population Along the US/Mexico Border: A Pragmatic Study

Background

The study purpose was to deliver a diabetes education program under real world conditions and evaluate its effect on diabetes-related clinical, self-management and psychosocial outcomes among Mexican Americans residing along the US/Mexico border.

Methods

A pragmatic study was conducted among adult patients with diabetes in three primary care clinics located along the US/Mexico border. A bilingual culturally tailored diabetes education program incorporating hands-on participatory techniques was delivered in 4 - 8 weekly group sessions. Clinical, self-management and psychosocial outcomes were evaluated pre- and post-intervention with surveys and medical record review.

Results

A total of 209 participants were enrolled; mean age was 58.9 years (range 23 - 94, standard deviation: 11.2); 68.4% were female; 91.1% were Hispanic. Significant improvements were observed in glycated hemoglobin (-1.1%, P < 0.001, n = 79), total cholesterol (-17.2 mg/dL, P = 0.041, n = 63), glucose self-monitoring (+1.3 times a week, P = 0.021, n = 115), exercise less than once a week (-18.2%, P < 0.001, n = 129), nutritional behavior (+2.23, P < 0.001, n = 115), knowledge (+1. 83, P < 0.001, n = 141) and diabetes-related emotional distress (-7.32, P = 0.002, n = 111). Benefits were observed with attendance rates as low as 50%.

Conclusion

A clinic-based culturally competent diabetes education/self-management program resulted in significant improvements in outcomes among Hispanic participants. Experimentally tested culturally appropriate interventions adapted for real world situations can benefit Mexican American diabetic patients even when attendance is imperfect.

Evidence-based statistical analysis and methods in biomedical research (SAMBR) checklists according to design features

BACKGROUND

Statistical analysis according to design features and objectives is essential to ensure the validity and reliability of the study findings and conclusions in biomedical research. Heterogeneity in reporting study design elements and conducting statistical analyses is often observed for the same study design and study objective in medical literatures. Sometimes, researchers face a lot of predicaments using appropriate statistical approaches highlighted by methodologists for a specific study design either due to lack of accessibility or understanding of statistical methods or unavailability of checklists related to design and analysis in a concise format. The purpose of this review is to provide the checklist of statistical analysis and methods in biomedical research (SAMBR) to applied researchers.

RECENT FINDINGS

We initially identified the important steps of reporting design features that may influence the choice of statistical analysis in biomedical research and essential steps of data analysis of common studies. We subsequently searched for statistical approaches employed for each study design/study objective available in publications and other resources. Compilation of these steps produced SAMBR guidance document, which includes three parts. Applied researchers can use part (A) and part (B) of SAMBR to describe or evaluate research design features and quality of statistical analysis, respectively, in reviewing studies or designing protocols. Part (C) of SAMBR can be used to perform essential and preferred evidence-based data analysis specific to study design and objective.

CONCLUSIONS

We believe that the statistical methods checklists may improve reporting of research design, standardize methodological practices, and promote consistent application of statistical approaches, thus improving the quality of research studies. The checklists do not enforce the use of suggested statistical methods but rather highlight and encourage to conduct the best statistical practices. There is a need to develop an interactive web-based application of the checklists for users for its wide applications.

Long-Term Effect of a Nonrandomized Psychosocial Mindfulness-Based Intervention in Hispanic/Latina Breast Cancer Survivors

Background: There is a paucity of research on the long-term impact of stress-reduction in Hispanic/Latina breast cancer (BC) survivors, a growing minority. In this article, we assess the long-term efficacy of an 8-week training program in mindfulness-based stress reduction (MBSR) on quality of life (QoL) in Hispanic BC survivors. Methods: Hispanic BC survivors, within the first 5 years of diagnosis, stages I to III BC, were recruited. Participants were enrolled in bilingual, 8-week intensive group training in MBSR and were asked to practice a- home, daily. They were also provided with audio recordings and a book on mindfulness practices. Patient-reported outcomes for QoL and distress were evaluated at baseline, and every 3 months, for 24 months. Results: Thirty-three self-identified Hispanic women with BC completed the MBSR program and were followed at 24 months. Statistically significant reduction was noted for the Generalized Anxiety Disorder measure (mean change −2.39, P=0.04); and Patient Health Questionnaire (mean change −2.27, P=0.04), at 24 months, compared with baseline. Improvement was noted in the Short-Form 36 Health-related QoL Mental Component Summary with an increase of 4.07 (95% confidence interval = 0.48-7.66, P=0.03). However, there was no significant change in the Physical Component Summary. Conclusions: Hispanic BC survivors who participated in an 8-week MBSR–based survivorship program reported persistent benefits with reduced anxiety, depression, and improved mental health QoL over 24 months of follow-up. Stress reduction programs are beneficial and can be implemented as part of a comprehensive survivorship care in BC patients.

C3a receptor antagonist therapy is protective with or without thrombolysis in murine thromboembolic stroke

BACKGROUND AND PURPOSE

Intravenous thrombolysis (IVT) after stroke enhances C3a generation, which may abrogate the benefits of reperfusion. The C3aR antagonist SB290157 is neuroprotective following transient but not permanent middle cerebral artery occlusion (MCAo). SB290157 remains untested in thromboembolic (TE) models, which better approximate human stroke and also facilitate testing in combination with IVT. We hypothesized SB290157 would confer neuroprotection in TE stroke with and without "late" IVT.

EXPERIMENTAL APPROACH

We used two different models of TE stroke to examine the efficacy of SB290157 alone and in combination with late IVT. We evaluated the benefit of SB290157 in attenuating post-ischaemic behavioural deficits, infarction, brain oedema and haemorrhage.

KEY RESULTS

Plasma C3a was elevated 6 hr after TE stroke alongside increased cerebrovascular C3aR expression, which was sustained to 4 weeks. Increased C3aR expression also was visualized in human ischaemic brain. In a photothrombotic (PT) stroke model, which exhibits rapid spontaneous reperfusion, SB290157 given at 1 hr post-PT significantly improved neurofunction and reduced infarction at 48 hr. In an embolic (eMCAo) model, SB290157 administered at 2 hr improved histological and functional outcomes. Conversely, late IVT administered 4.5 hr post-eMCAo was ineffective likely due to increased haemorrhage and brain oedema. However, SB290157 administered prior to late IVT ameliorated haemorrhage and oedema and improved outcomes.

CONCLUSIONS AND IMPLICATIONS

We conclude that SB290157 is safe and effective with and without late IVT following TE stroke. Therefore, C3a receptor antagonist therapy represents a promising candidate for clinical translation in stroke, particularly as an adjuvant to IVT.

Outcomes of Hispanic/Latino women with triple-negative breast cancer who achieve a complete pathologic response after neoadjuvant chemotherapy

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Background: The aim of this study was to determine the efficacy of neoadjuvant chemotherapy (NACT) versus adjuvant chemotherapy (ACT) in Hispanic/Latino (H/L) women with triple negative breast cancer (TNBC). Methods: We retrospectively reviewed 104 records of female patients diagnosed with TNBC, stages I–III, treated at Texas Tech Breast Care Center from 2006 to 2016. Pathological complete response (pCR), overall survival (OS) and progression-free survival (PFS) were estimated and compared between two treatment groups. Kaplan Meier survival curve and Cox proportional hazards regression analyses were conducted to determine unadjusted and adjusted effects of NACT compared to ACT. Results: Of 104 TNBC patients with median duration of follow up of 6 (range 2-11) years, 30 (29%) received NACT and 74 (71%) received ACT. Women undergoing NACT were mostly younger, with a mean age of 50.8 (range 40-67) years, compared with those in the ACT group, mean age of 53 (range 32-80) years. Additionally, women in the NACT group had more advanced cancer, stage III (61%) and stage II (33%), in contrast to the ACT group, who had stage III (23%) and stage II (55%). Of 30 patients received NACT,twelve (40%) had pCR. The (median 6 years/range 2-11 years Women who achieved pCR had better PFS and OS compared with patients who received ACT. On the other hand, women with residual cancer after NACT had worse survival outcomes compared with women who received ACT (Hazards Ratio-HR = 0.1, p = 0.001). Conclusions: In our study, we observed that the patients in the NACT group with residual cancer had statistically significantly worse survival outcomes compared with ACT group. Patients who received NACT and had pCR had no relapse over the observation period. Our study suggests that there is a need of a prospective study to better understand the biology of TNBC among H/L women in order to individualized NACT to population of patients with “chemosensitive” subtype of TNBC.

Statistical issues and methods in designing and analyzing survival studies

BACKGROUND

Cancer studies that are designed for early detection and screening, or used for identifying prognostic factors, or assessing treatment efficacy and health outcome are frequently assessed with survival or time-to-event outcomes. These studies typically require specific methods of data analysis. Appropriate statistical methods in the context of study design and objectives are required for obtaining reliable results and valid inference. Unfortunately, variable methods for the same study objectives and dubious reporting have been noticed in the survival analysis of oncology research. Applied researchers often face difficulties in selecting appropriate statistical methods due to the complex nature of cancer studies.

RECENT FINDINGS

In this report, we describe briefly major statistical issues along with related challenges in planning, designing, and analyzing of survival studies. For applied researchers, we provided flow charts for selecting appropriate statistical methods. Various available statistical procedures in common statistical packages for applying survival analysis were classified according to different objectives of the study. In addition, an illustration of the statistical analysis of some common types of time-to-event outcomes was shown with STATA codes.

CONCLUSIONS

We anticipate that this review article assists oncology researchers in understanding important statistical concepts involved in survival analysis and appropriately select the statistical approaches for survival analysis studies. Overall, the review may help in improving designing, conducting, analyzing, and reporting of data in survival studies.

Silencing growth hormone receptor inhibits estrogen receptor negative breast cancer through ATP-binding cassette sub-family G member 2

Growth hormone receptor (GHR) plays a vital role in breast cancer chemoresistance and metastasis but the mechanism is not fully understood. We determined if GHR could be a potential therapeutic target for estrogen receptor negative (ER-ve) breast cancer, which are highly chemoresistant and metastatic. GHR was stably knocked down in ER-ve breast cancer cells and its effect on cell proliferation, metastatic behavior, and chemosensitivity to docetaxel (DT) was assessed. Microarray analysis was performed to identify potential GHR downstream targets involved in chemoresistance. GHR and ATP-binding cassette sub-family G member 2 (ABCG2) overexpression and knockdown studies were performed to investigate the mechanism of GHR-induced chemoresistance. Patient-derived xenografts was used to study the effect of GHR and ABCG2. Immunohistochemical data was used to determine the correlation between GHR, pAKT, pmTOR, and ABCG2 expressions. GHR silencing drastically reduced the chemoresistant and metastatic behavior of ER-ve breast cancer cells and also inhibited AKT/mTOR pathway. In contrast, activation, or overexpression of GHR increased chemoresistance and metastasis by increasing the expression and promoter activity, of ABCG2. Inhibition of JAK2/STAT5 signaling repressed GHR-induced ABCG2 promoter activity and expression. Further, ABCG2 knockdown significantly increased the chemosensitivity. Finally, patient-derived xenograft studies revealed the role of GHR in chemoresistance. Overall, these findings demonstrate that targeting GHR could be a novel therapeutic approach to overcome chemoresistance and associated metastasis in aggressive ER-ve breast cancers.

Epithelial-Mesenchymal Transition Markers in Breast Cancer and Pathological Responseafter Neoadjuvant Chemotherapy

The association between pathologic complete response (pCR) following to neoadjuvant chemotherapy (NAC) and the improved survival in breast cancer has been previously reported. The aim of this study was is to explore the expression of several biomarkers described during epithelial-mesenchymal transition (EMT) and the achievement of pCR in different molecular subtypes of breast cancer. We identified archived pathology tissue from patients with breast cancer who received NAC during the year 2014. We performed immunohistochemical analysis of vimentin, nuclear factor κB (NF-κB), epidermal growth factor receptor (EGFR), E-cadherin, estrogen receptor (ER), progesterone receptor, and Her2neu and studied the association between the expression of these markers and pCR. A Fisher exact test for categorical cofactors, an unpaired t test and a nonparametric Wilcoxon test for continuous cofactors were used. The results showed a significant expression of vimentin in triple-negative breast cancer (TNBC; P = .023). An inverse correlation between vimentin and the ER expression (P = .032) was observed. No significant association was noted for vimentin, NF-κB, EGFR, and E-cadherin was associated with pCR. This study suggests that the evaluated EMT related biomarkers are not associated with pCR after NAC chemotherapy in an unselected breast cancer population. Vimentin and NF-κB expressions were associated with TNBC and could be further explored as potential therapeutic targets in this subgroup. A prevalence of vimentin and NF-κB among Hispanic patients with breast cancer warrants further investigation as a possibly contributing to the prevalence of TNBC and adverse prognosis in this population.

Post-stroke Movement Disorders: The Clinical, Neuroanatomic, and Demographic Portrait of 284 Published Cases

PURPOSE

Abnormal movements are a relatively uncommon complication of strokes. Besides the known correlation between stroke location and certain movement disorders, there remain uncertainties about the collective effects of age and stroke mechanism on phenomenology, onset latency, and outcome of abnormal movements.

MATERIALS AND METHODS

We systematically reviewed all published cases and case series with adequate clinical-imaging correlations. A total of 284 cases were analyzed to evaluate the distribution of different movement disorders and their association with important cofactors.

RESULTS

Posterolateral thalamus was the most common region affected (22.5%) and dystonia the most commonly reported movement disorder (23.2%). The most common disorders were parkinsonism (17.4%) and chorea (17.4%) after ischemic strokes and dystonia (45.5%) and tremor (19.7%) after hemorrhagic strokes. Strokes in the caudate and putamen were complicated by dystonia in one third of the cases; strokes in the globus pallidus were followed by parkinsonism in nearly 40%. Chorea was the earliest poststroke movement disorder, appearing within hours, whereas dystonia and tremor manifested several months after stroke. Hemorrhagic strokes were responsible for most delayed-onset movement disorders (>6 months) and were particularly overrepresented among younger individuals affected by dystonia.

CONCLUSIONS

This evidence-mapping portrait of poststroke movement disorders will require validation or correction based on a prospective epidemiologic study. We hypothesize that selective network vulnerability and resilience may explain the differences observed in movement phenomenology and outcomes after stroke.

Effects of oral vitamin B12 for the treatment of aromatase inhibitors (AI)-related musculoskeletal symptoms in women with early stage breast cancer

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Background: Breast cancer patients receiving Aromatase Inhibitor (AI) therapy experience many side effects including arthralgias, myalgias and stiffness of joints. The objective of this study was to evaluate the effect of vitamin B12 supplements on pain related symptoms. Methods: In this study, patients taking AIs and experiencing pain at baseline were given 2500 mcg of vitamin B12 sublingually daily for 90 days. The validated Brief Pain Inventory-Short Form (BPI-SF) questionnaire using a 10 scale rating was evaluated prior and post- intervention. The BPI-SF asseses pain level and its interference with other daily life events on a scale from one to ten, one meaning pain does not interfere. Item 9 from the BPI assesses 7 important dimensions that are reported here. Results: 36 patients were recruited and scores were evaluated at baseline and at 90 days after taking vitamin B12 for general activity, mood, walking ability, normal work, relations with people, and for enjoyment of life post interventions as shown in the table. Conclusions: This study suggests that by taking a high dose of vitamin B12, significant improvement was observed in several dimensions related to pain scales in patients with AI -related musculoskeletal symptoms. Preliminary data confirms that vitamin B12 not only help improve pain, but it also aids in improving patient’s mood, well-being and relations with others. Larger randomized studies are warranted to confirm these promising findings. Clinical trial information: NCT03069313. [Table: see text]

Single arm phase II study of oral vitamin B12 for the treatment of musculoskeletal symptoms associated with aromatase inhibitors in women with early stage breast cancer

Breast cancer patients receiving endocrine therapy with aromatase Inhibitors (AIs) often experience musculoskeletal and joint-related side effects. The purpose of this study was to evaluate the effect of Vitamin B12 supplements on musculoskeletal symptoms such as pain and arthralgias induced by AIs and to correlate response with serum and inflammatory biomarkers. Upon receiving approval by the Institutional Review Board (IRB), the majority of the patients consented into the study were treated at the Texas Tech Breast Care Center. Included were patients who had a diagnosis of invasive breast cancer (Stages I-III), and were experiencing significant musculoskeletal symptoms associated to AIs. Only patients with an average pain score ≥ 4, as assessed by the Brief Pain Inventory-Short Form (BPI-SF) questionnaire, were included in the study. Participants received 2500 mcg of sublingual vitamin B12 daily for 90 days. Assessments at baseline and at 3 months included: BPI-SF pain scores, the impact on quality of life determined by Functional Assessment of Cancer Therapy-Endocrine Symptoms (FACT-ES), and correlative serum markers relative to baseline (a pre-post study). A total of forty-one patients were enrolled. Average pain scores were improved by 34% (P < .0001) at 3 months compared to baseline. In addition, a 23% improvement in worst pain was noted (P = .0003). Analysis of the results for the FACT-ES scoring showed improvement on all scales. No significant adverse events were observed. Decrease in pain score was correlated with increased serum B12 levels. This study suggests that Vitamin B12 reduces pain and improves quality of life for patients taking AIs who experienced AI-related musculoskeletal symptoms. If confirmed in large randomized prospective trials, Vitamin B12 would be a safe and cost-effective option for the treatment of AI-related musculoskeletal symptoms.

Proactive coping style and intentional self-harm: A cross-sectional study

BACKGROUND

Coping style adopted by a person has been identified as an important factor in precipitating or preventing an intentional self-harm attempt. While the influence of reactive coping has received lot of research attention, effects of proactive coping on suicidal behavior has not been studied, even though it is known that proactive coping is associated with better mental health. The authors in the current study sought to investigate the relationship of proactive coping style with attempted deliberate self-harm.

MATERIALS AND METHODS

A total of 44 individuals who presented with intentional self-harm were compared with age, sex, marital status, and education-matched healthy controls. Pierce Suicide Intent Scale was used to ascertain suicidal intent, and Proactive Coping Inventory was used to assess proactive coping.

RESULTS

There were no significant differences between subjects and controls for proactive coping, preventive coping, emotional support seeking, avoidance coping, and instrumental support seeking. However, participants scored higher in strategic planning (P = 0.027).

CONCLUSIONS

Proactive coping has no significant relationship with intentional self-harm; however, more studies with better designs are needed to comment conclusively.

Predictive Models in Differentiating Vertebral Lesions Using Multiparametric MRI

BACKGROUND AND PURPOSE

Conventional MR imaging has high sensitivity but limited specificity in differentiating various vertebral lesions. We aimed to assess the ability of multiparametric MR imaging in differentiating spinal vertebral lesions and to develop statistical models for predicting the probability of malignant vertebral lesions.

MATERIALS AND METHODS

One hundred twenty-six consecutive patients underwent multiparametric MRI (conventional MR imaging, diffusion-weighted MR imaging, and in-phase/opposed-phase imaging) for vertebral lesions. Vertebral lesions were divided into 3 subgroups: infectious, noninfectious benign, and malignant. The cutoffs for apparent diffusion coefficient (expressed as 10^-3 mm²/s) and signal intensity ratio values were calculated, and 3 predictive models were established for differentiating these subgroups.

RESULTS

Of the lesions of the 126 patients, 62 were infectious, 22 were noninfectious benign, and 42 were malignant. The mean ADC was 1.23 ± 0.16 for infectious, 1.41 ± 0.31 for noninfectious benign, and 1.01 ± 0.22 mm²/s for malignant lesions. The mean signal intensity ratio was 0.80 ± 0.13 for infectious, 0.75 ± 0.19 for noninfectious benign, and 0.98 ± 0.11 for the malignant group. The combination of ADC and signal intensity ratio showed strong discriminatory ability to differentiate lesion type. We found an area under the curve of 0.92 for the predictive model in differentiating infectious from malignant lesions and an area under the curve of 0.91 for the predictive model in differentiating noninfectious benign from malignant lesions. On the basis of the mean ADC and signal intensity ratio, we established automated statistical models that would be helpful in differentiating vertebral lesions.

CONCLUSIONS

Our study shows that multiparametric MRI differentiates various vertebral lesions, and we established prediction models for the same.

Prebiopsy multiparametric MRI-based risk score for predicting prostate cancer in biopsy-naive men with prostate-specific antigen between 4-10 ng/mL

BACKGROUND

Risk calculators have traditionally utilized serum prostate-specific antigen (PSA) values in addition to clinical variables to predict the likelihood of prostate cancer (PCa).

PURPOSE

To develop a prebiopsy multiparametric MRI (mpMRI)-based risk score (RS) and a statistical equation for predicting the risk of PCa in biopsy-naive men with serum PSA between 4-10 ng/mL that may help reduce unnecessary biopsies.

STUDY TYPE

Prospective cross-sectional study.

SUBJECTS

In all, 137 consecutive men with PSA between 4-10 ng/mL underwent prebiopsy mpMRI (diffusion-weighted [DW]-MRI and MR spectroscopic imaging [MRSI]) during 2009-2015 were recruited for this study.

FIELD STRENGTH/SEQUENCE

1.5T (Avanto, Siemens Health Care, Erlangen, Germany); T₁ -weighted, T₂ -weighted, DW-MRI, and MRSI sequences were used.

ASSESSMENT

All eligible patients underwent mpMRI-directed, cognitive-fusion transrectal ultrasound (TRUS)-guided biopsies.

STATISTICAL TESTS

An equation model and an RS were developed using receiver operating characteristic (ROC) curve analysis and a multivariable logistic regression approach. A 10-fold crossvalidation and simulation analyses were performed to assess diagnostic performance of various combinations of mpMRI parameters.

RESULTS

Of 137 patients, 32 were diagnosed with PCa on biopsy. Multivariable analysis, adjusted with positive pathology, showed apparent diffusion coefficient (ADC), metabolite ratio, and PSA as significant predictors of PCa (P < 0.05). A statistical equation was derived using these predictors. A simple 6-point mpMRI-based RS was derived for calculating the risk of PCa and it showed that it is highly predictive for PCa (odds ratio = 3.74, 95% confidence interval [CI]: 2.24-6.27, area under the curve [AUC] = 0.87). Both models (equation and RS) yielded high predictive performance (AUC ≥0.85) on validation analysis.

DATA CONCLUSION

A statistical equation and a simple 6-point mpMRI-based RS can be used as a point-of-care tool to potentially help limit the number of negative biopsies in men with PSA between 4 and 10 ng/mL.

LEVEL OF EVIDENCE

1 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2018;47:1227-1236.

Moderate and Severe Blood Pressure Elevation Associated with Stroke in the Mexican Hispanic Population

BACKGROUND

Stroke is the fourth leading cause of death in US. Amongst other factors such as age, sex, race, genetics, obesity, diabetes etc., hypertension continues to be the leading contributing factor towards stroke. Studies regarding stroke in Hispanics are sparse and inconclusive.

OBJECTIVES

The objective of the present study is to investigate the potential association between blood pressure elevation and risk of ischemic stroke among the Mexican Hispanic population.

METHODS

A retrospective data analysis was carried out for a planned case-control study with case-control ratios of 1:2. Mexican Hispanic cases were from the ElPasoStroke database with diagnosed hypertension that had sustained an ischemic stroke (n = 505) and Mexican Hispanics diagnosed with hypertension who were stroke-free as controls from the 2005-2010 NHANES databases (n = 1010). In this analysis, we included subjects who had data on systolic, diastolic or mean arterial blood pressures for cases (327) and controls (772). In cases, blood pressure was determined by the initial admission measurement, and in controls, the first measured blood pressure was used. The unadjusted and adjusted effects of continuous measurements of systolic, diastolic and mean arterial blood pressure on stroke were determined using logistic regression analyses. Subjects were further classified into groups based on prehypertension and hypertension ranges, as established by the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7). Unadjusted and adjusted logistic regression models were also used to determine the effect of categorized blood pressures.

RESULTS

Our data indicate that per unit increase in systolic, diastolic or mean arterial blood pressure elevates the odds of stroke among the Mexican Hispanic population. Adjusted analysis of categorized blood pressures showed that mild or moderate/severe high blood pressure significantly associated with odds of stroke. Maintaining and controlling blood pressure at more stringent and lower levels, specifically lowering mean arterial pressure may effectively reduce the odds of ischemic stroke among the Mexican Hispanic population.

CONCLUSION

Elevation of blood pressure increases the odds of stroke among the Mexican Hispanic population. Our results provide new strategies to manage the stroke prevention and health disparity issues among the Mexican Hispanic population.

Cross-Ethnic Differences in the Severity of Neuropsychiatric Symptoms in Persons With Mild Cognitive Impairment and Alzheimer's Disease

In this cross-sectional study, we examined the neuropsychiatric profile of mild cognitive impairment (MCI) and Alzheimer's disease (AD) using the Neuropsychiatric Inventory Questionnaire (NPI-Q). Data were available on 875 controls, 339 MCI cases, and 975 AD participants. Surprisingly, differences in neuropsychiatric symptom (NPS) severity by ethnicity in subjects with AD, but not with MCI, were found. More so, in Hispanics with AD, a higher frequency in most of the individual NPI-Q symptom items of the scale was observed, except for apathy. After adjustment for clinical features, some individual NPI-Q symptoms also showed an association with Hispanic ethnicity in the control group that nearly reached statistical significance. There may be cross-ethnic differences in the neuropsychiatric presentation of AD in Hispanics versus non-Hispanic whites. Future studies are needed to clarify the etiology of these differences, and to assess the need for ethnicity-specific treatment and care-giving interventions.

Analysis of small sample size studies using nonparametric bootstrap test with pooled resampling method

Experimental studies in biomedical research frequently pose analytical problems related to small sample size. In such studies, there are conflicting findings regarding the choice of parametric and nonparametric analysis, especially with non-normal data. In such instances, some methodologists questioned the validity of parametric tests and suggested nonparametric tests. In contrast, other methodologists found nonparametric tests to be too conservative and less powerful and thus preferred using parametric tests. Some researchers have recommended using a bootstrap test; however, this method also has small sample size limitation. We used a pooled method in nonparametric bootstrap test that may overcome the problem related with small samples in hypothesis testing. The present study compared nonparametric bootstrap test with pooled resampling method corresponding to parametric, nonparametric, and permutation tests through extensive simulations under various conditions and using real data examples. The nonparametric pooled bootstrap t-test provided equal or greater power for comparing two means as compared with unpaired t-test, Welch t-test, Wilcoxon rank sum test, and permutation test while maintaining type I error probability for any conditions except for Cauchy and extreme variable lognormal distributions. In such cases, we suggest using an exact Wilcoxon rank sum test. Nonparametric bootstrap paired t-test also provided better performance than other alternatives. Nonparametric bootstrap test provided benefit over exact Kruskal-Wallis test. We suggest using nonparametric bootstrap test with pooled resampling method for comparing paired or unpaired means and for validating the one way analysis of variance test results for non-normal data in small sample size studies. Copyright © 2017 John Wiley & Sons, Ltd.