Triage of HPV positivity in a high HIV prevalence setting: A prospective cohort study comparing visual triage methods and HPV genotype restriction in Botswana

OBJECTIVE

Guidelines for effective triage following positive primary high-risk human papillomavirus (HPV) screening in low- and middle-income countries with high human immunodeficiency virus (HIV)-prevalence have not previously been established. In the present study, we evaluated the performance of three triage methods for positive HPV results in women living with HIV (WLHIV) and without HIV in Botswana.

METHODS

We conducted baseline enrollment of a prospective cohort study from February 2021 to August 2022 in South-East District, Botswana. Non-pregnant women aged 25 or older with an intact cervix and no prior diagnosis of cervical cancer were systematically consented for enrollment, with enrichment of the cohort for WLHIV. Those who consented completed a questionnaire and then collected vaginal self-samples for HPV testing. Primary HPV testing for 15 individual genotypes was conducted using Atila AmpFire® HPV assay. Those with positive HPV results returned for a triage visit where all underwent visual inspection with acetic acid (VIA), colposcopy, and biopsy. Triage strategies with VIA, colposcopy and 8-type HPV genotype restriction (16/18/31/33/35/45/52/58), separately and in combination, were compared using histopathology as the gold standard in diagnosing cervical intraepithelial neoplasia (CIN) 2 or worse (CIN2+).

RESULTS

Among 2969 women enrolled, 1480 (50%) tested HPV positive. The cohort included 1478 (50%) WLHIV; 99% were virologically suppressed after a mean of 8 years on antiretroviral therapy. In total, 1269 (86%) women had histopathology data for analysis. Among WLHIV who tested positive for HPV, 131 (19%) of 688 had CIN2+ compared with 71 (12%) of 581 in women without HIV. Screening by 8-type HPV genotype restriction was more sensitive as triage to detect CIN2+ in WLHIV 87.79% (95% CI: 80.92-92.85) and women without HIV 85.92% (95% CI: 75.62-93.03) when compared with VIA (WLHIV 62.31% [95% CI: 53.39-70.65], women without HIV 44.29% [95% CI: 32.41-56.66]) and colposcopy (WLHIV 70.77% [95% CI: 62.15-78.41], women without HIV 45.71% [95% CI: 33.74-58.06]). However, 8-type HPV genotype restriction had low specificity in WLHIV of 30.88% (95% CI: 27.06-34.90) and women without HIV 37.06% (95% CI: 32.85-41.41). These results were similar when CIN3+ was used as the outcome. When combining 8-type HPV genotype restriction with VIA as the triage strategy, there was improved specificity to detect CIN2+ in WLHIV of 81.65% (95% CI: 78.18-84.79) but dramatically reduced sensitivity of 56.15% (95% CI: 47.18-64.84).

CONCLUSIONS

Eight-type HPV genotype restriction is a promising component of effective triage for HPV positivity. However, novel triage strategies in LMICs with high HIV prevalence may be needed to avoid the trade-off between sensitivity and specificity with currently available options.

CLINICAL TRIALS REGISTRATION

This study is registered on Clinicaltrials.gov no. NCT04242823, https://clinicaltrials.gov/ct2/show/NCT04242823.

Training in the implementation of sex and gender research policies: an evaluation of publicly available online courses

BACKGROUND

Recently implemented research policies requiring the inclusion of females and males have created an urgent need for effective training in how to account for sex, and in some cases gender, in biomedical studies.

METHODS

Here, we evaluated three sets of publicly available online training materials on this topic: (1) Integrating Sex & Gender in Health Research from the Canadian Institutes of Health Research (CIHR); (2) Sex as a Biological Variable: A Primer from the United States National Institutes of Health (NIH); and (3) The Sex and Gender Dimension in Biomedical Research, developed as part of "Leading Innovative measures to reach gender Balance in Research Activities" (LIBRA) from the European Commission. We reviewed each course with respect to their coverage of (1) What is required by the policy; (2) Rationale for the policy; (3) Handling of the concepts "sex" and "gender;" (4) Research design and analysis; and (5) Interpreting and reporting data.

RESULTS

All three courses discussed the importance of including males and females to better generalize results, discover potential sex differences, and tailor treatments to men and women. The entangled nature of sex and gender, operationalization of sex, and potential downsides of focusing on sex more than other sources of variation were minimally discussed. Notably, all three courses explicitly endorsed invalid analytical approaches that produce bias toward false positive discoveries of difference.

CONCLUSIONS

Our analysis suggests a need for revised or new training materials that incorporate four major topics: precise operationalization of sex, potential risks of over-emphasis on sex as a category, recognition of gender and sex as complex and entangled, and rigorous study design and data analysis.

Intersectional race and gender disparities in kidney transplant access in the United States: a scoping review

BACKGROUND

Gender and racial disparities in kidney transplant access are well established, however how gender and race interact to shape access to kidney transplant is less clear. Therefore, we examined existing literature to assess what is known about the potential interaction of gender and race and the impact on access to kidney transplantation in the US.

METHODS

Following PRISMA guidelines, we conducted a scoping review and included quantitative and qualitative studies published in English between 1990 and May 31, 2023 among adult end-stage kidney disease patients in the US. All studies reported on access to specific transplant steps or perceived barriers to transplant access in gender and race subgroups, and the intersection between the two. We narratively synthesized findings across studies.

RESULTS

Fourteen studies met inclusion criteria and included outcomes of referral (n = 4, 29%), evaluation (n = 2, 14%), waitlisting (n = 4, 29%), transplantation (n = 5, 36%), provider perceptions of patient transplant candidacy (n = 3, 21%), and patient preferences and requests for a living donor (n = 5, 36%). Overall, we found that White men have the greatest access at all steps of the transplant process, from referral to eventual living or deceased donor transplantation. In contrast, women from racial or ethnic minorities tend to have the lowest access to kidney transplant, in particular living donor transplant, though this was not consistent across all studies.

CONCLUSIONS

Examining how racism and sexism interact to shape kidney transplant access should be investigated in future research, in order to ultimately shape policies and interventions to improve equity.

Feasibility and acceptability of an HPV self-testing strategy: lessons from a research context to assess for ability to implement into primary care at a national level in Botswana

Background

The WHO strategy for cervical cancer elimination strives to achieve 70% coverage with high-performance cervical screening. While few low- and middle-income countries have achieved this, high-risk human papillomavirus (hrHPV) self-testing creates the possibility to rapidly upscale access to high-performance cervical screening across resource settings. However, effective hrHPV screening requires linkage to follow-up, which has been variable in prior studies. This study developed and tested an implementation strategy aimed at improving screening and linkage to follow-up care in South East District in Botswana.

Methods

This study performed primary hrHPV self-testing; those with positive results were referred for a triage visit. Withdrawals for any reason, loss-to follow-up between hrHPV test and triage visit, and number of call attempts to give hrHPV results were also documented. Acceptability of the program to patients was measured as the proportion of patients who completed a triage visit when indicated, meeting the a priori threshold of 80%. Feasibility was defined as the proportion of participants receiving the results and attending follow-up. To assess the associations between participant characteristics and loss-to-follow-up we used log-binomial regressions to estimate risk ratios and 95% confidence intervals (CI).

Results

Enrollment of 3,000 women occurred from February 2021 to August 2022. In total, 10 participants withdrew and an additional 33 were determined ineligible after consent, leaving a final cohort of 2,957 participants who underwent self-swab hrHPV testing. Half (50%) of participants tested positive for hrHPV and nearly all (98%) of participants received their hrHPV results, primarily via telephone.  Few calls to participants were required to communicate results: 2,397 (82%) required one call, 386 (13%) required 2 calls, and only 151 (5%) required 3-5 calls. The median time from specimen collection to participant receiving results was 44 days (IQR, 27-65). Of all hrHPV positive participants, 1,328 (90%) attended a triage visit.

Discussion

In a large cohort we had low loss-to-follow-up of 10%, indicating that the strategy is acceptable. Telephonic results reporting was associated with high screening completion, required few calls to participants, and supports the feasibility of hrHPV self-testing in primary care followed by interval triage.

A Gender Hypothesis of sex disparities in adverse drug events

Pharmacovigilance databases contain larger numbers of adverse drug events (ADEs) that occurred in women compared to men. The cause of this disparity is frequently attributed to sex-linked biological factors. We offer an alternative Gender Hypothesis, positing that gendered social factors are central to the production of aggregate sex disparities in ADE reports. We describe four pathways through which gender may influence observed sex disparities in pharmacovigilance databases: healthcare utilization; bias and discrimination in the clinic; experience of a drug event as adverse; and pre-existing social and structural determinants of health. We then use data from the U.S. FDA Adverse Event Reporting System (FAERS) to explore how the Gender Hypothesis might generate novel predictions and explanations of sex disparities in ADEs in existing widely referenced datasets. Analyzing more than 3 million records of ADEs between 2014 and 2022, we find that patient-reported ADEs show a larger female skew than healthcare provider-reported ADEs and that the sex disparity is markedly smaller for outcomes involving death or hospitalization. We also find that the sex disparity varies greatly across types of ADEs, for example, cosmetically salient ADEs are skewed heavily female and sexual dysfunction ADEs are skewed male. Together, we interpret these findings as providing evidence of the promise of the Gender Hypothesis for identifying intervenable mechanisms and pathways contributing to sex disparities in ADEs. Rigorous application of the Gender Hypothesis to additional datasets and in future research studies could yield new insights into the causes of sex disparities in ADEs.

Sex/Gender-Based Disparities in Early Transplant Access by Attributed Cause of Kidney Disease-Evidence from a Multiregional Cohort in the Southeast United States

Introduction

We examined sex/gender disparities across the continuum of transplant care by attributed cause of end-stage kidney disease (ESKD).

Methods

All adults (18-79 years; N = 43,548) with new-onset ESKD in Georgia, North Carolina, or South Carolina between 2015 and 2019 were identified from the United States Renal Data System (USRDS). Individuals were linked to the Early Steps to Transplant Access Registry (E-STAR) to obtain data on referral and evaluation. Waitlisting data was ascertained from USRDS. Using a Cox-proportional hazards model, with follow-up through 2020, we assessed the association between sex/gender and referral within 12 months (among all incident dialysis patients), evaluation start within 6 months (among referred patients), and waitlisting (among all evaluated patients) by attributed cause of ESKD (type 1 diabetes mellitus, type 2 diabetes mellitus, hypertension, glomerulonephritis, cystic disease, and other).

Results

Overall, women (vs. men) with type 2 diabetes-attributed ESKD were 13% (crude hazard ratio [HR]: 0.87 [0.83-0.91]), 14% (crude HR: 0.86 [0.81-0.91]), and 14% (crude HR: 0.86 [0.78-0.94]) less likely to be referred, evaluated, and waitlisted, respectively. Women (vs. men) with hypertension-attributed ESKD were 14% (crude HR: 0.86 [0.82-0.90]) and 8% (crude HR: 0.92 [0.87-0.98]) less likely to be referred and evaluated, respectively, but similarly likely to be waitlisted once evaluated (crude HR: 1.06 [0.97-1.15]). For all other attributed causes of ESKD, there was no sex/gender disparity in referral, evaluation, or waitlisting rates.

Conclusion

In the Southeast United States, sex/gender disparities in early access to kidney transplantation are specific to people with ESKD attributed to type 2 diabetes and hypertension.

Financial toxicity in pregnancy and postpartum

INTRODUCTION

The financial burden of pregnancy in the United States can be high and is associated with worse mental health and birth outcomes. Research on the financial burden of health care, such as the development of the COmprehensive Score for Financial Toxicity (COST) tool, has been conducted primarily among patients with cancer. This study aimed to validate the COST tool and use it to measure financial toxicity and its impacts among obstetric patients.

METHODS

We used survey and medical record data from obstetric patients at a large medical center in the United States. We validated the COST tool using common factor analysis. We used linear regression to identify risk factors for financial toxicity and to investigate associations between financial toxicity and patient outcomes including satisfaction, access, mental health, and birth outcomes.

RESULTS

The COST tool measured two distinct constructs of financial toxicity in this sample: current financial toxicity and concern over future financial toxicity. Racial/ethnic category, insurance, neighborhood deprivation, caregiving, and employment were associated with current financial toxicity (P < 0.05 for all). Only racial/ethnic category and caregiving were associated with concern over future financial toxicity (P < 0.05 for all). Both current and future financial toxicity were associated with worse patient-provider communication, depressive symptoms, and stress (P < 0.05 for all). Financial toxicity was not associated with birth outcomes or keeping obstetric visits.

CONCLUSIONS

The COST tool captures two constructs among obstetric patients, current and future financial toxicity, both of which are associated with worse mental health and patient-provider communication.

Antepartum depressive symptoms are associated with significant postpartum opioid use

BACKGROUND

Antepartum depression is common, and outside of childbirth preoperative anxiety and depression have been associated with heightened postoperative pain. In light of the national opioid epidemic, the relationship between antepartum depressive symptoms and postpartum opioid use is particularly relevant.

OBJECTIVE

This study evaluated the association between antepartum depressive symptoms and significant postpartum opioid use during birth hospitalization.

STUDY DESIGN

This retrospective cohort study at an urban academic medical center from 2017 to 2019 included patients who received prenatal care at the medical center and linked pharmacy and billing data with electronic medical records. The exposure was antepartum depressive symptoms, defined as Edinburgh Postnatal Depression Scale ≥10 during the antepartum period. The outcome was significant opioid use, defined as: (1) any opioid use following vaginal birth and (2) the top quartile of total opioid use following cesarean delivery. Postpartum opioid use was quantified using standard conversions for opioids dispensed on postpartum days 1 to 4 to calculate morphine milligram equivalents. Poisson regression was used to calculate risk ratios and 95% confidence intervals, stratified by mode of delivery and adjusted for suspected confounders. Mean postpartum pain score was a secondary outcome.

RESULTS

The cohort included 6094 births; 2351 births (38.6%) had an antepartum Edinburgh Postnatal Depression Scale score. Of these, 11.5% had a maximum score ≥10. Significant opioid use was observed in 10.6% of births. We found that individuals with antepartum depressive symptoms were more likely to have significant postpartum opioid use, with an adjusted risk ratio of 1.5 (95% confidence interval, 1.1-2.0). When stratified by mode of delivery, this association was more pronounced for cesarean births, with an adjusted risk ratio of 1.8 (95% confidence interval, 1.1-2.7), and was no longer significant for vaginal births. Mean pain scores after cesarean delivery were significantly higher in parturients with antepartum depressive symptoms.

CONCLUSION

Antepartum depressive symptoms were associated with significant postpartum inpatient opioid use, especially following cesarean delivery. Whether identifying and treating depressive symptoms in pregnancy may impact the pain experience and opioid use postpartum warrants further investigation.

Adverse Drug Events by Sex After Adjusting for Baseline Rates of Drug Use

This cross-sectional study examines adverse drug events reported by sex in the US Food and Drug Administration (FDA) database after adjusting for drug use by males and females.

Cross-Sectional Study of Resident-Reported Surgical Experience in Female Pelvic Medicine and Reconstructive Surgery

IMPORTANCE

Comprehensive surgical training is an essential component of obstetrics and gynecology residency, yet subspecialty experience may be declining.

OBJECTIVE

The objective of this study was to describe trends in reported obstetrics and gynecology resident experience in female pelvic medicine and reconstructive surgery (FPMRS).

STUDY DESIGN

This study was a retrospective analysis of national case log reports from the Accreditation Council for Graduate Medical Education (ACGME) for obstetrics and gynecology residents.

RESULTS

From 2013 through 2019, ACGME collected data from a median of 241 programs (range, 239-242) with a median of 1,259 residents (range, 1,213-1,286) reporting annually. There was a 26% decrease in resident-reported experience with incontinence and pelvic floor procedures from 74 ± 38 in 2013 to 55 ± 34 in 2019 ( P < 0.001). Cystoscopy increased by 19% from 43 ± 25 in 2013 to 51 ± 29 in 2019 ( P < 0.001). From 2014 to 2019, vaginal hysterectomy cases decreased by 12% ( P < 0.001).

CONCLUSIONS

There was a significant decrease in resident-reported FPMRS surgical experience from 2013 to 2019, while cystoscopy numbers increased. After laparoscopic and vaginal hysterectomies were unbundled in 2013, resident vaginal hysterectomy cases decreased from 2014 to 2019. Given that the ACGME Incontinence and Pelvic Floor designation comprises a wide range of procedures, future investigation is needed to elucidate the gaps in FPMRS-specific surgical training during residency and its implication in comprehensive resident surgical training.

Factors associated with increased financial toxicity after the completion of radiation treatment for gynecologic cancer

PURPOSE

We evaluated financial toxicity (FT) in patients with gynecologic cancer treated with radiation and assessed the impact of the COVID-19 pandemic on patients' financial wellbeing.

METHODS

Patients completed a survey 1 month after completing radiation from August 2019-March 2020 and November 2020-June 2021. The survey included the COmprehensive Score for Financial Toxicity (COST) tool, EQ-5D to measure quality of life (QOL) and pandemic-related questions for the second survey period. High FT was COST score ≤ 23.

RESULTS

Of 97 respondents (92% response rate), 49% completed the survey pre-pandemic and 51% after; the majority were white (76%) and had uterine cancer (64%). Sixty percent received external beam radiation with or without brachytherapy; 40% had only brachytherapy. High FT was associated with worse QOL (r = -0.37, P < 0.001), younger age and type of insurance (both p ≤ 0.03). Respondents with high FT were 6.0 (95% CI 1.0-35.9) times more likely to delay/avoid medical care, 13.6 (95% CI 2.9-64.3) times more likely to borrow money, and 6.9 (95% CI 1.7-27.2) times as likely to reduce spending on basic goods. The pandemic cohort had a smaller proportion of respondents with high FT than the pre-pandemic cohort (20% vs. 35%, p = 0.10) and a higher median COST score (32 (IQR 25-35) vs. 27 (IQR 19-34), p = 0.07).

CONCLUSION

Privately insured, younger respondents who received radiation for gynecologic cancer were at risk for FT. High FT was associated with worse QOL and economic cost-coping strategies. We observed less FT in the pandemic cohort, though not statistically different from the pre-pandemic cohort.

A wound-induced differentiation trajectory for neurons

Animals capable of whole-body regeneration can replace any missing cell type and regenerate fully-functional new organs, de novo . The regeneration of a new brain requires the formation of diverse neuronal cell types and their assembly into an organized structure and correctly-wired circuits. Recent work in various regenerative animals has revealed transcriptional programs required for the differentiation of distinct neuronal subpopulations, however how these transcriptional programs are initiated upon amputation remains unknown. Here, we focused on the highly regenerative acoel worm, Hofstenia miamia , to study wound-induced transcriptional regulatory events that lead to the production of neurons. Footprinting analysis using chromatin accessibility data on an improved genome assembly revealed that binding sites for the NFY transcription factor complex were significantly bound during regeneration, showing a dynamic increase in binding within one hour upon amputation specifically in tail fragments, which will regenerate a new brain. Strikingly, NFY targets were highly enriched for genes with neuronal functional. Single-cell transcriptome analysis combined with functional studies identified sox4 ⁺ stem cells as the likely progenitor population for multiple neuronal subtypes. Further, we found that wound-induced sox4 expression is likely under direct transcriptional control by NFY, uncovering a mechanism for how early wound-induced binding of a transcriptional regulator results in the initiation of a neuronal differentiation pathway.

Highlights

A new chromosome-scale assembly for Hofstenia enables comprehensive analysis of transcription factor binding during regeneration NFY motifs become dynamically bound by 1hpa in regenerating tail fragments, particularly in the loci of neural genes A sox4 ⁺ neural-specialized stem cell is identified using scRNA-seq sox4 is wound-induced and required for differentiation of multiple neural cell types NFY regulates wound-induced expression of sox4 during regeneration.

Surgical Adaptation of the Situation Awareness Rating Technique (S-SART): Assessing Situational Awareness Among Medical Students

OBJECTIVE

Situational awareness (SA) impacts team dynamics and patient care. However, few formal curricula and tools exist to teach and assess longitudinal SA in surgical environments. We sought to evaluate medical students' SA in the operating room (OR) during surgical clerkships over time.

DESIGN

We prospectively administered pre- and post-rotation surveys using a surgical adaptation of the previously validated Situation Awareness Rating Technique (SART). Surgical SART (S-SART) scores were calculated as: Situational Awareness = Understanding - (Attentional Demand - Attentional Supply) + 14. Each of 10 questions was scored from 1 to 7, with a maximum possible score of 60. Two-tailed two-sample and paired t-tests were conducted to determine differences in S-SART scores.

PARTICIPANTS/SETTING

Sixty-nine of 75 second- and third-year medical students rotating in Surgery and Obstetrics/Gynecology clerkships at a tertiary academic medical center from September 2018 to September 2019 completed the surveys for a response rate of 92.0%.

RESULTS

The mean baseline pre-rotation baseline S-SART score was 29.5 (SD=8.3), which increased by 20.9% to 35.9 (SD=6.9) post-rotation (p<0.001). Significant predictors of higher baseline S-SART scores included age ≥25 (p=0.02), surgical career interest (p=0.01), completion of prior surgical rotations (p<0.001), confidence about pre-procedural OR steps (p<0.001), and knowledge of OR item locations (p<0.001). There were increases in each of the subdomains of Understanding-including OR familiarity (3.2 to 4.3, p<0.001), knowledge of the medical student OR role (3.5 to 5.7, p<0.001), and knowledge of others' OR roles (4.1 to 5.9, p<0.001)-along with increases in alertness within Attentional Supply (5.1 to 5.5, p=0.001).

CONCLUSIONS

SA is a learnable skill with increases in S-SART scores from pre- to post-rotation, with the greatest gains in the domain of Understanding. More advanced aspects of SA such as Attentional Demand may require further surgical training or curricular innovations to address these needs.

Postmenopausal Vaginal and Cervical Cancer Risk Related to In Utero Diethylstilbestrol Exposure

OBJECTIVES

Women exposed to diethylstilbestrol (DES) in utero have an increased risk of clear cell adenocarcinoma of the lower genital tract, requiring lifelong cervical and vaginal cancer screening. We examined the incidence of DES-related cancers in postmenopausal women 50 years and older.

MATERIALS AND METHODS

We conducted a retrospective chart review of patients 50 years and older exposed to DES in utero who received care at our institution. Patients were identified using billing codes and/or searching through the electronic record for the word DES. With this 2-pronged approach, we reviewed a total of 503 charts with confirmed DES exposure to identify gynecologic cancer occurrence.

RESULTS

Within the 503 selected charts, 28 cases of gynecologic cancer occurrence were identified. Ten patients had cervical cancer and one patient had vaginal cancer. Only 1 woman of 503 developed a DES-related cervical or vaginal malignancy after age 50 years. No patients were diagnosed with cervical or vaginal cancer after age 65 years.

CONCLUSIONS

Diethylstilbestrol-related malignancies are rare in those older than 50 years. Current cervical cancer screening guidelines recommend cessation of screening in an average risk, adequately screened patient at age 65 years, but patients exposed to DES have historically received lifelong screening. However, we found no cases of cervical or vaginal cancer related to DES after age 65 years, suggesting that screening recommendations could be changed for these patients to align with current screening guidelines.

The future of sperm: a biovariability framework for understanding global sperm count trends

The past 50 years have seen heated debate in the reproductive sciences about global trends in human sperm count. In 2017, Levine and colleagues published the largest and most methodologically rigorous meta-regression analysis to date and reported that average total sperm concentration among men from 'Western' countries has decreased by 59.3% since 1973, with no sign of halting. These results reverberated in the scientific community and in public discussions about men and masculinity in the modern world, in part because of scientists' public-facing claims about the societal implications of the decline of male fertility. We find that existing research follows a set of implicit and explicit assumptions about how to measure and interpret sperm counts, which collectively form what we term the Sperm Count Decline hypothesis (SCD). Using the study by Levine and colleagues, we identify weaknesses and inconsistencies in the SCD, and propose an alternative framework to guide research on sperm count trends: the Sperm Count Biovariability hypothesis (SCB). SCB asserts that sperm count varies within a wide range, much of which can be considered non-pathological and species-typical. Knowledge about the relationship between individual and population sperm count and life-historical and ecological factors is critical to interpreting trends in average sperm counts and their relationships to health and fertility.

How Cumulative Statistics Can Mislead: The Temporal Dynamism of Sex Disparities in COVID-19 Mortality in New York State

Overall, men have died from COVID-19 at slightly higher rates than women. But cumulative estimates of mortality by sex may be misleading. We analyze New York State COVID-19 mortality by sex between March 2020 and August 2021, demonstrating that 72.7% of the total difference in the number of COVID-19 deaths between women and men was accrued in the first seven weeks of the pandemic. Thus, while the initial surge in COVID-19 mortality was characterized by stark sex disparities, this article shows that disparities were greatly attenuated in subsequent phases of the pandemic. Investigating changes over time could help illuminate how contextual factors contributed to the development of apparent sex disparities in COVID-19 outcomes.

Coronavirus Disease 2019 Messenger RNA Vaccine Immunogenicity in Immunosuppressed Individuals

Individuals on immunosuppressive (IS) therapy have increased mortality from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, and delayed viral clearance may lead to new viral variants. IS therapy reduces antibody responses following coronavirus disease 2019 (COVID-19) messenger RNA (mRNA) vaccination; however, a comprehensive assessment of vaccine immunogenicity is lacking. Here we show that IS therapy reduced neutralizing, binding, and nonneutralizing antibody functions in addition to CD4 and CD8 T-cell interferon-γ responses following COVID-19 mRNA vaccination compared to immunocompetent individuals. Moreover, IS therapy reduced cross-reactivity against SARS-CoV-2 variants. These data suggest that the standard COVID-19 mRNA vaccine regimens will likely not provide optimal protection in immunocompromised individuals.

Sex disparities in COVID-19 outcomes in the United States: Quantifying and contextualizing variation

This paper presents the first longitudinal study of sex disparities in COVID-19 cases and mortalities across U.S. states, derived from the unique 13-month dataset of the U.S. Gender/Sex COVID-19 Data Tracker. To analyze sex disparities, weekly case and mortality rates by sex and mortality rate ratios were computed for each U.S. state, and a multilevel crossed-effects conditional logistic binomial regression model was fitted to estimate the variation of the sex disparity in mortality over time and across states. Results demonstrate considerable variation in the sex disparity in COVID-19 cases and mortalities over time and between states. These data suggest that the sex disparity, when present, is modest, and likely varies in relation to context-sensitive variables, which may include health behaviors, preexisting health status, occupation, race/ethnicity, and other markers of social experience.

Crowdsourcing to measure financial toxicity in gynecologic oncology

OBJECTIVE

To utilize a novel crowdsourcing method to measure financial toxicity and its effects among a national cohort of gynecologic cancer patients.

METHODS

Crowdsourcing methods were used to administer an online survey to women in the United States with gynecologic cancers. We used the Comprehensive Score for Financial Toxicity (COST) tool to measure financial toxicity and the EQ-5D-3L to measure quality of life (QOL). Based on prior work, we defined high financial toxicity as a COST score ≤ 23. We assessed correlation of COST scores with QOL. We used log-binomial regression to examine associations between high financial toxicity and cost-coping strategies.

RESULTS

Among the final study sample of 334 respondents, 87% were white, median age at diagnosis was 55 (interquartile range 47-63), 52% had stage III or IV disease and 90% had private insurance or Medicare. Median COST score was 24 (interquartile range 15-32) and 49% of respondents reported high financial toxicity. Greater financial toxicity was correlated with worse QOL (p < 0.001). Participants reporting high financial toxicity were more likely to use cost-coping strategies, including spending less on basic goods (RR: 3.3; 95% CI: 2.1-5.1), borrowing money or applying for financial assistance (RR: 4.0; 95% CI: 2.4-6.9), and delaying or avoiding care (RR: 5.6; 95% CI: 2.6-12.1).

CONCLUSIONS

Crowdsourcing is an effective tool to measure financial toxicity. Nearly half of respondents reported high financial toxicity, which was significantly associated with worse QOL, utilization of cost-coping strategies and delays or avoidance of care.

Evaluating meaningful levels of financial toxicity in gynecologic cancers

OBJECTIVE

The Comprehensive Score for Financial Toxicity (COST) is a validated instrument measuring the economic burden experienced by patients with cancer. We evaluated the frequency of financial toxicity at different COST levels and stratified risk factors and associations with cost-coping strategies by financial toxicity severity.

METHODS

We analyzed previously collected survey data of gynecologic oncology patients from two tertiary care institutions. Both surveys included the COST tool and questions assessing economic and behavioral cost-coping strategies. We adapted a proposed grading scale to define three groups: no/mild, moderate, and severe financial toxicity and used χ², Fisher's exact test, and Wilcoxon rank sum test to compare groups. We used Poisson regression to calculate crude and adjusted risk ratios for cost-coping strategies, comparing patients with moderate or severe to no/mild financial toxicity.

RESULTS

Among 308 patients, 14.9% had severe, 32.1% had moderate, and 52.9% had no/mild financial toxicity. Younger age, non-white race, lower education, unemployment, lower income, use of systemic therapy, and shorter time since diagnosis were associated with worse financial toxicity (all p<0.05). Respondents with moderate or severe financial toxicity were significantly more likely to use economic cost-coping strategies such as changing spending habits (adjusted risk ratio (aRR) 2.7, 95% CI 1.8 to 4.0 moderate; aRR 3.6, 95% CI 2.4 to 5.4 severe) and borrowing money (aRR 5.5, 95% CI 1.8 to 16.5 moderate; aRR 12.7, 95% CI 4.3 to 37.1 severe). Those with severe financial toxicity also had a significantly higher risk of behavioral cost-coping through medication non-compliance (aRR 4.6, 95% CI 1.2 to 18.1).

CONCLUSIONS

Among a geographically diverse cohort of gynecologic oncology patients, nearly half reported financial toxicity (COST <26), which was associated with economic cost-coping strategies. In those 14.9% of patients reporting severe financial toxicity (COST <14) there was also an increased risk of medication non-compliance, which may lead to worse health outcomes in this group.

Acoel genome reveals the regulatory landscape of whole-body regeneration

Whole-body regeneration is accompanied by complex transcriptomic changes, yet the chromatin regulatory landscapes that mediate this dynamic response remain unexplored. To decipher the regulatory logic that orchestrates regeneration, we sequenced the genome of the acoel worm Hofstenia miamia, a highly regenerative member of the sister lineage of other bilaterians. Epigenomic profiling revealed thousands of regeneration-responsive chromatin regions and identified dynamically bound transcription factor motifs, with the early growth response (EGR) binding site as the most variably accessible during Hofstenia regeneration. Combining egr inhibition with chromatin profiling suggests that Egr functions as a pioneer factor to directly regulate early wound-induced genes. The genetic connections inferred by this approach allowed the construction of a gene regulatory network for whole-body regeneration, enabling genomics-based comparisons of regeneration across species.