Black cancer patients navigating a health-care system of racial discrimination

BACKGROUND

Exposure to racial discrimination may exacerbate disparities throughout the cancer care continuum. Therefore, we explored how experiences of racial discrimination in the health-care setting manifest for Black cancer patients and how it contributes to racial disparities in cancer care.

METHODS

This qualitative analysis used semistructured in-depth interviews with Black cancer survivors not on active treatment from May 2019 to March 2020. All interviews were audio recorded, professionally transcribed, and uploaded into Dedoose software for analysis. We identified major themes and subthemes that highlight exposure to racial discrimination and its consequences for Black cancer patients when receiving cancer care.

RESULTS

Participants included 18 Black cancer survivors, aged 29-88 years. Most patients experienced racial discrimination when seeking care. Participants experienced racial discrimination from their interactions with health-care staff, medical assistants, front desk staff, and health insurance administrators. Exposure to overt racial discrimination in the health-care setting was rooted in racial stereotypes and manifested through verbal insults such as physicians using phrases such as "you people." These experiences impacted the ability of the health-care delivery system to demonstrate trustworthiness. Patients noted "walking out" of their visit and not having their health issues addressed. Despite experiences with racial discrimination, patients still sought care out of necessity believing it was an inevitable part of the Black individual experience.

CONCLUSION

We identified that exposure to racial discrimination in the health-care setting is pervasive, affects health-seeking behaviors, and degrades the patient-clinician relationship, which may likely contribute to racial disparities in cancer care.

Health care experiences of Black cancer survivors: A qualitative study exploring drivers of low and high Consumer Assessment of Healthcare Providers and Systems global ratings of care

BACKGROUND

The purpose of this study was to understand the experiences of Black patients with cancer in health care by comparing drivers of high and low ratings.

METHODS

Semistructured in-depth interviews were conducted with 18 Black patients with cancer recruited from cancer survivorship support groups and Facebook between May 2019 and March 2020. Interviews were coded across all transcripts by using a thematic analysis approach before comparing low- and high-rating groups.

RESULTS

There were three major themes that influenced whether patients rated their care as low or high, which included the patient-provider relationship, health care staff interactions, and cancer care coordination. For example, the high-rating group described good communication with the health care team as physicians listening to their needs, being responsive to their concerns, and providing recommendations on how to address side effects. In contrast, the low-rating group described poor communication with their health care team as their needs being dismissed and being excluded from decision-making processes. Additionally, there were two distinct themes that influenced patients' low ratings: insurance and financial toxicity issues and experiences of health care discrimination.

CONCLUSIONS

In an effort to promote equitable cancer care experiences for Black patients, it is important that health systems work to prioritize patient interactions with health care providers and staff, comprehensive care management for patients with cancer, and reductions in the financial burden of caring for cancer.

General and mental health status following colorectal cancer treatment and its association with mortality among a racially diverse population-based cohort

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Background: Patient-reported outcomes (PROs) are recognized as strong predictors of cancer prognosis, outcomes, and care. However, racial/ethnic minorities with colorectal cancer (CRC) tend to report poorer general health status (GHS) and mental health status (MHS) compared to non-Hispanic whites. The objectives of this study were to determine: (1) if there are racial/ethnic differences in GHS and MHS within 36 months of CRC diagnosis and (2) if poorer GHS and MHS in recently diagnosed CRC patients are associated with mortality. Methods: We used the population-based Surveillance, Epidemiology, and End Results (SEER)-Consumer Assessment of Healthcare Providers and Systems (CAHPS) dataset to analyze Medicare beneficiaries aged ≥65 years who were diagnosed with CRC between 1998 and 2011, received surgical resection for their tumor, and completed a CAHPS survey within 6-36 months post-diagnosis. CAHPS surveys captured patient-reported GHS and MHS on a five-point Likert scale ranging from “poor” to “excellent.” We used stepwise multivariable logistic regression to examine associations between patient race/ethnicity and fair or poor health status, adjusting for clinical and sociodemographic factors. Additionally, a multivariable Cox proportional hazards regression was used to determine the risks of mortality associated with fair or poor GHS and MHS. Results: Of 1,867 patients with CRC, 79.5% were non-Hispanic white (NHW), 6.4% were non-Hispanic black (NHB), 7.5% were Hispanic, and 6.6% were non-Hispanic Asian (NHA). In Model 1 of our stepwise logistic regression, NHB patients had higher unadjusted odds for fair or poor GHS (OR 1.56, 95% CI 1.06-2.28) compared to NHW patients while Hispanic patients had higher unadjusted odds for both fair or poor GHS (1.48, 1.04-2.11) and MHS (1.92, 1.23-3.01). In Model 2, this relationship persisted after adjusting for clinical factors, with NHB patients being more likely to report fair or poor GHS (1.62, 1.10-2.40) and Hispanic patients being more likely to report fair or poor GHS (1.49, 1.04-2.13) and MHS (1.92, 1.22-3.00). In Model 3, after adjusting for both clinical and sociodemographic factors, the association between race/ethnicity and fair or poor GHS ( p = 0.53) and MHS ( p = 0.23) no longer remained. Reporting fair or poor GHS and MHS was associated with a greater risk of mortality among all CRC patients (HR 1.52, 95% CI 1.31-1.76 and 1.62, 1.34-1.99, respectively). Conclusions: Our study illustrates that racial/ethnic differences in PROs are largely driven by sociodemographic factors as opposed to clinical factors. As fair or poor GHS and MHS shortly after diagnosis reflect a higher risk of mortality in CRC patients, efforts to understand unmet biopsychosocial concerns may help further elucidate racial differences in CRC survival that may be otherwise overlooked in standard clinical practice.

Abstract PO-007: “You people”- A qualitative analysis of black cancer patients navigating a healthcare system of discrimination

Background: Black cancer patients face significant disparities in medical care throughout the cancer care continuum. While multilevel factors contribute to these disparities including access to care, socioeconomic status and cultural factors, overt and perceived discrimination in the health care setting may likely exacerbate disparities for black cancer patients. However, little is known about how experiences of racial discrimination unfold for Black cancer patients when navigating care and the consequences of such treatment. Purpose: To explore how experiences of racial discrimination in the health care setting manifests for Black cancer patients and to understand how these experiences might contribute to disparities. Methods: We conducted semi-structured in-depth interviews with 18 Black cancer survivors, lasting between 45 – 60 minutes from 2019-20. All interviews were audio-recorded, professionally transcribed, and uploaded into Dedoose software for analysis. Two independent coders met regularly and analyzed the interview transcripts using a deductive constant comparison approach to establish and modify codes based on facets of the biopsychosocial model of stress. Results: Participants included breast, colorectal, and prostate cancer survivors aged 29 to 88 years old. Most patients expressed experiencing some form of racial discrimination, perceived more than overt when receiving medical care. Participants experienced instances of perceived discrimination from their interactions with healthcare staff, medical assistants, front desk staff, health insurance administrators, or other staff within the facility. Instances of perceived discrimination resulted in patients expressing that they did not trust their provider or was a stressor contributing to their mental well-being. Patients who experienced perceived discrimination noted “walking out” of their visit and not having their health issues addressed, demonstrating a broader link between the two factors. Patients internalized experiences of perceived discrimination, resulting in behavior changes in subsequent visits to mitigate the effects. Overt discrimination in the health care setting was rooted in stereotypes and manifested through verbal microaggressions such recollections of physicians using phrases such as “you people”. Patients still sought care when they experienced discrimination out of necessity and believing it was an inevitable part of the Black experience. Patients who had positive experiences navigating care expressed a personal relationship and emotional connection characterized by mutual respect and compassion between them and their provider. Conclusion: Themes identified in this study support possible mechanisms for discrimination in the health care setting contributing to racial health disparities in cancer care such that discrimination serves as a stressor for Black cancer patients and impacts health-seeking behaviors. Future recommendations for healthcare staff should focus on ensuring patient-centered communication and care to support this vulnerable population.

Citation Format: Elleyse Garrett, Albert Farias, Carol Ochoa, Cindy Ma, Stephanie Navarro, Paul Yoon. “You people”- A qualitative analysis of black cancer patients navigating a healthcare system of discrimination [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-007.

Evaluation measure for group-based record linkage

INTRODUCTION

The robustness of record linkage evaluation measures is of high importance since linkage techniques are assessed based on these. However, minimal research has been conducted to evaluate the suitability of existing evaluation measures in the context of linking groups of records. Linkage quality is generally evaluated based on traditional measures such as precision and recall. As we show, these traditional evaluation measures are not suitable for evaluating groups of linked records because they evaluate the quality of individual record pairs rather than the quality of records grouped into clusters.

OBJECTIVES

We set out to highlight the shortcomings of traditional evaluation measures and then propose a novel method to evaluate clustering quality in the context of group-based record linkage.

METHODS

The proposed linkage evaluation method assesses how well individual records have been allocated into predicted groups/clusters with respect to ground-truth data. We first identify the best representative predicted cluster for each ground-truth cluster and, based on the resulting mapping, each record in a ground-truth cluster is assigned to one of seven categories. These categories reflect how well the linkage technique assigned records into groups.

RESULTS

We empirically evaluated our proposed method using real-world data and showed that it better reflects the quality of clusters generated by three group-based record linkage techniques. We also showed that traditional measures such as precision and recall can produce ambiguous results whereas our method does not.

CONCLUSIONS

The proposed evaluation method provides unambiguous results regarding the assessed group-based record linkage approaches. The method comprises of seven categories which reflect how each record was predicted, providing more detailed information about the quality of the linkage result. This will help to make better-informed decisions about which linkage technique is best suited for a given linkage application.

A transcriptomal analysis of bovine oviductal epithelial cells collected during the follicular phase versus the luteal phase of the estrous cycle

BACKGROUND

Reproductive success depends on a functional oviduct for gamete storage, maturation, fertilization, and early embryonic development. The ovarian-derived steroids estrogen and progesterone are key regulators of oviductal function. The objective of this study was to investigate luteal and follicular phase-specific oviductal epithelial cell function by using microarray-based transcriptional profiling, to increase our understanding of mRNAs regulating epithelial cell processes, and to identify novel genes and biochemical pathways that may be found to affect fertility in the future.

METHODS

Six normally cycling Angus heifers were assigned to either luteal phase (LP, n = 3) or follicular phase (FP, n = 3) treatment groups. Heifers in the LP group were killed between day 11 and 12 after estrus. Heifers in the FP group were treated with 25 mg PGF2α (Lutalyse, Pfizer, NY) at 8 pm on day 6 after estrus and killed 36 h later. Transcriptional profiling by microarray and confirmation of selected mRNAs by real-time RT-PCR analyses was performed using total RNA from epithelial cells isolated from sections of the ampulla and isthmus collected from LP and FP treatment groups. Differentially expressed genes were subjected to gene ontology classification and bioinformatic pathway analyses.

RESULTS

Statistical one-way ANOVA using Benjamini-hochberg multiple testing correction for false discovery rate (FDR) and pairwise comparison of epithelial cells in the ampulla of FP versus LP groups revealed 972 and 597 transcripts up- and down-regulated, respectively (P < 0.05). Within epithelial cells of the isthmus in FP versus LP groups, 946 and 817 transcripts were up- and down-regulated, respectively (P < 0.05). Up-regulated genes from both ampulla and isthmus were found to be largely involved in cholesterol biosynthesis and cell cycle pathways, while down-regulated genes were found in numerous inflammatory response pathways.

CONCLUSIONS

Microarray-based transcriptional profiling revealed phase of the cycle-dependent changes in the expression of mRNA within the epithelium of the oviducts' ampulla and isthmus.

An educational improvement project to track patient encounters: toward a more complete understanding of third-year medical students' experiences

BACKGROUND

At the University of Missouri School of Medicine (MUSOM), "commitment to improving quality and safety in healthcare" is one of eight key characteristics set as goals for our graduates. As educators, we have modelled our commitment to continuous improvement in the educational experiences through the creation of a method to monitor and analyse patient encounters in the third year of medical school. This educational improvement project allowed course directors to (1) confirm adequate clinical exposure, (2) obtain prompt information on student experiences, (3) adjust individual student rotations to meet requirements and (4) ascertain the range of clinical experiences available to students.

DISCUSSION

Data illustrate high levels of use and satisfaction with the educational innovation. We are in our second year using the new Patient Log (PLOG) process and are now considering expanding the use of PLOG into the fourth year of medical school.

Anemia and interleukin-10, tumor necrosis factor alpha, and erythropoietin levels among children with acute, uncomplicated Plasmodium falciparum malaria

Anemia is an important complication of malaria, and its pathogenesis is not well understood. To gain insight into potential age-related relationships between tumor necrosis factor alpha (TNF-alpha), interleukin 10 (IL-10), erythropoietin, and anemia during acute malaria, 273 children of ages 12 to 120 months presenting with acute, uncomplicated malaria in Kampala, Uganda, were monitored at enrollment and 3 and 7 days later. Younger children had higher geometric mean erythropoietin, TNF-alpha, and alpha(1)-acid glycoprotein (AGP) concentrations than older children. Univariate regression analysis revealed that age, log(10) erythropoietin levels, IL-10/TNF-alpha ratio, and AGP levels were each significantly associated with hemoglobin levels at baseline. Hemoglobin concentrations were inversely correlated with the log(10) erythropoietin level at all three visits. For the older age groups, higher levels of TNF-alpha were significantly associated with higher IL-10 levels at all three visits, but this relationship was significant only at baseline for younger children. These data suggest that younger children do not maintain IL-10 production in response to the inflammatory process, and this mechanism may contribute to the more severe anemia found in younger children. Acute malaria is an illness whose incidence and severity are largely age dependent. Further studies are needed to understand the relationships between age-related immune responses to malaria and their role in the pathogenesis of malarial anemia.

Intensive care unit nurse staffing and the risk for complications after abdominal aortic surgery

CONTEXT

We previously found that length of stay in the intensive care unit (ICU) after abdominal aortic surgery increased when fewer ICU nurses were available per patient. We hypothesized that having fewer nurses increases the risk for medical complications.

OBJECTIVE

To evaluate the association between nurse-to-patient ratio in the ICU and risk for medical and surgical complications after abdominal aortic surgery.

DESIGN

Observational study.

SETTING

All nonfederal acute care hospitals in Maryland.

DATA SOURCES

Information about patients came from hospital discharge data on all patients in Maryland with a principal procedure code for abdominal aortic surgery from 1994 through 1996 (n = 2606). The organizational characteristics of ICUs were obtained by surveying ICU medical and nursing directors in 1996 at the 46 Maryland hospitals that performed abdominal aortic surgery. Thirty-nine of the ICU directors (85%) completed the survey.

EXPOSURE

Surgery in hospitals with fewer ICU nurses (in which each nurse cared for three or four patients) compared with hospitals with more ICU nurses (in which each nurse cared for one or two patients).

OUTCOME

Proportion of patients who developed postoperative complications.

RESULTS

Seven hospitals with 478 patients had fewer ICU nurses, and 31 hospitals with 2128 patients had more ICU nurses. Patients in hospitals with fewer nurses were more likely than patients in hospitals with more nurses to have complications: 47% vs. 34% had any complication, 43% vs. 28% had any medical complication, 24% vs. 9% had pulmonary insufficiency after a procedure, and 21% vs. 13% were reintubated (P < 0.001 for all comparisons). After adjustment for patient, hospital, and surgeon characteristics, having fewer versus more ICU nurses was associated with an increased risk for any complication (relative risk, 1.7 [95% CI, 1.3 to 2.4]), any medical complication (relative risk, 2.1 [CI, 1.5 to 2.9]), pulmonary insufficiency after procedure (relative risk, 4.5 [CI, 2.9 to 6.9]) and reintubation (relative risk, 1.6 [CI, 1.1 to 2.5]).

CONCLUSION

Having fewer ICU nurses per patient is associated with increased risk for respiratory-related complications after abdominal aortic surgery.

A FLT3 tyrosine kinase inhibitor is selectively cytotoxic to acute myeloid leukemia blasts harboring FLT3 internal tandem duplication mutations

Internal tandem duplication (ITD) mutations of the receptor tyrosine kinase FLT3 have been found in 20% to 30% of patients with acute myeloid leukemia (AML). These mutations constitutively activate the receptor and appear to be associated with a poor prognosis. Recent evidence that this constitutive activation is leukemogenic renders this receptor a potential target for specific therapy. In this study, dose-response cytotoxic assays were performed with AG1295, a tyrosine kinase inhibitor active against FLT3, on primary blasts from patients with AML. For each patient sample, the degree of cytotoxicity induced by AG1295 was compared to the response to cytosine arabinoside (Ara C) and correlated with the presence or absence of a FLT3/ITD mutation. AG1295 was specifically cytotoxic to AML blasts harboring FLT3/ITD mutations. The results suggest that these mutations contribute to the leukemic process and that the FLT3 receptor represents a therapeutic target in AML. (Blood. 2001;98:885-887)

Elimination of the truncated message from the herpes simplex virus thymidine kinase suicide gene

Introduction of the Herpes simplex virus thymidine kinase (HSV-tk) gene into target cells renders them susceptible to killing by ganciclovir (GCV). We are studying the use of HSV-tk-transduced T lymphocytes in the context of hematopoietic stem cell transplantation. We have previously shown, in vitro and in vivo, the occurrence of transduced cells resistant to GCV due to a deletion within HSV-tk. This deletion, a consequence of the presence of cryptic splice donor and acceptor sites, originates in the retroviral producer cell. Here we adopt two different methods that introduce third-base degenerate changes at the cryptic splice sites and so prevent splicing. Consequently, the HSV-tk protein is unaltered and the sensitivity of the target cells to GCV is preserved. The use of this mutated HSV-tk should reduce the likelihood of the development of resistant genetically modified cells during clinical trials.

Relation of vitamin A and carotenoid status to growth failure and mortality among Ugandan infants with human immunodeficiency virus

Although growth failure is common during pediatric infection with human immunodeficiency virus (HIV) and associated with increased mortality, the relation of specific nutrition factors with growth and mortality has not been well characterized. A longitudinal study was conducted with 194 HIV-infected infants in Kampala, Uganda. Plasma vitamin A, carotenoids (alpha-carotene, beta-carotene, beta-cryptoxanthin, lycopene, and lutein/zeaxanthin), and vitamin E were measured at age 14 wk, and weight and height were followed up to age 12 mo. Vitamin A and low plasma carotenoid concentrations were predictive of decreased weight and height velocity. Between ages 14 wk and 12 mo, 32% of infants died. Underweight, stunting, and low concentrations of plasma carotenoids were associated with increased risk of death in univariate analyses. Plasma vitamin A concentrations were not associated with risk of death. In a final multivariate model adjusting for weight-for-age, plasma beta-carotene was significantly associated with increased mortality (odds ratio: 3.16, 95% confidence interval: 1.38 to 7.21, P < 0.006). These data suggest that low concentrations of plasma carotenoids are associated with increased risk of death during HIV infection among infants in Uganda.

Variations in complication rates and opportunities for improvement in quality of care for patients having abdominal aortic surgery

BACKGROUND

The purpose was to assess the current variation in complication rates and evaluate the association between specific types of complications and in-hospital mortality and total hospital charges for patients having abdominal aortic surgery.

PATIENTS/METHODS

We studied 2987 patients for abdominal aortic surgery in Maryland from 1994 to 1996 and used discharge diagnoses and procedure codes to identify diagnoses that most likely represent major surgery complications. We evaluated how in-hospital mortality and total hospital charges related to specific complications, adjusting for patient demographics, severity of illness, comorbidity, and hospital and surgeon volumes. Discharge data was obtained from the hospital marketing departments.

RESULTS

Complication rates varied widely among hospitals. Complications independently associated with increased risk of in-hospital death include cardiac arrest with an odds ratio (OR) of 90 and a 95% confidence interval (CI) of 32-251, septicemia (OR 6.1, CI 3.3-11.3), acute myocardial infarction (OR 5.7, CI 2.3-14.3), acute renal failure (OR 5.0, CI 2.3-11.0), surgical complications after a procedure (OR 3.1, CI 2.0-4.9), and reoperation for bleeding (OR 2.2, CI 1.1-4.8). The population-attributable risk for in-hospital mortality was 47% for cardiac arrest and 27% for acute renal failure.

CONCLUSIONS

In abdominal aortic surgery on patients in Maryland, the rates of some complications vary widely and are independently associated with increased in-hospital mortality and hospital charges (charges differ from costs). Efforts to reduce these complications should help to decrease both levels.

Impact of vitamin A supplementation on anaemia and plasma erythropoietin concentrations in pregnant women: a controlled clinical trial

INTRODUCTION

Although studies suggest that vitamin A or its metabolites influence the synthesis of erythropoietin in vitro and in animal models, it is unclear whether vitamin A supplementation increases plasma erythropoietin concentrations in humans.

OBJECTIVE

To determine whether daily vitamin A supplementation increases plasma erythropoietin concentrations in pregnant women with a high prevalence of anaemia.

METHODS

A randomized, double-blind, controlled clinical trial was conducted to examine the effect of daily vitamin A (3000 microg retinol equivalent), iron (30 mg), and folate (400 microg) versus iron (30 mg) and folate (400 microg) (control) on haemoglobin and plasma erythropoietin concentrations in 203 pregnant women in Malawi, Africa.

RESULTS

Mean gestational age at enrollment was 23 wk, at which time 50% of the women were anaemic (haemoglobin <110 g/L). Mean (+/-SEM) change in haemoglobin from enrollment to 38 wk was 4.7+/-1.6 g/L (p=0.003) and 7.3+/-2.3 g/L (p=0.003) in the vitamin A and control groups, respectively. Mean change in plasma erythropoietin concentrations from enrollment to 38 wk was 2.39+/-5.00 (p=0.63) and -2.87+/-3.92 IU/L (p=0.46) in the vitamin A and controls groups, respectively. There were no significant differences between vitamin A and control groups in the slope of the regression line between log10 erythropoietin and haemoglobin at enrollment or 38 wk, and between enrollment and follow-up within either group.

CONCLUSIONS

Vitamin A supplementation does not appear to increase haemoglobin and plasma erythropoietin concentrations among pregnant women with a high prevalence of anaemia in Malawi.

Molecular mechanism for ganciclovir resistance in human T lymphocytes transduced with retroviral vectors carrying the herpes simplex virus thymidine kinase gene

The herpes simplex virus thymidine kinase gene type 1 (HSV-Tk) ganciclovir (GCV) system is a novel therapeutic strategy for the modulation of graft-versus-host disease (GVHD), a major complication of allogeneic stem cell transplantation (allo-SCT). Retroviral-mediated gene transfer of the HSV-Tk gene into donor T lymphocytes before allo-SCT may allow their in vivo selective depletion after treatment with GCV. The expression of the HSV-Tk gene was analyzed in vitro in CEM cells, a human lymphoblastoid cell line, transduced with 2 different vectors, each containing the HSV-Tk gene and a selectable marker gene. GCV-resistant clones were identified within the clones expressing the marker gene. Characterization of the molecular events leading to this resistance revealed a 227-bp deletion in the HSV-Tk gene due to the presence of cryptic splice donor and acceptor sites within the HSV-Tk gene sequence. Furthermore, it was confirmed that this deletion was present in human primary T cells transduced with either vector and in 12 patients who received transduced donor T cells, together with a T-cell-depleted allo-SCT. In vivo circulating transduced T cells containing the truncated HSV-Tk gene were identified in all patients immediately after infusion and up to 800 days after transplantation. In patients who received GCV as treatment for GVHD, a progressive increase in the proportion of transduced donor T cells carrying the deleted HSV-Tk gene was observed. These results suggest that the limitations within the HSV-Tk/GCV system can be improved by developing optimized retroviral vectors to ensure maximal killing of HSV-Tk-transduced cells.

Vitamin D deficiency among older women with and without disability

BACKGROUND

Vitamin D deficiency is associated with bone loss and bone fractures, and the identification of vulnerable populations is important to clinical practice and public health.

OBJECTIVE

The objectives of this study were to determine the prevalence of vitamin D deficiency and to examine associated risk factors for vitamin D deficiency in older women.

DESIGN

We measured serum concentrations of 25-hydroxyvitamin D [25(OH)D], 1,25-dihydroxyvitamin D [1, 25(OH)(2)D], intact parathyroid hormone (PTH), osteocalcin, and ionized calcium in women aged >/=65 y who were participating in the Women's Health and Aging Study I, an observational study of women representing the approximately one-third most disabled women living in the community, and women aged 70-80 y who were participating in the Women's Health and Aging Study II, an observational study of women among the two-thirds least disabled women living in the community in Baltimore.

RESULTS

The women were classified into 4 domains of physical disability. Among 371 women with 0 or 1 domain of disability and 682 women with >/=2 domains of disability, 6.2% and 12.6%, respectively, had vitamin D deficiency [serum concentrations of 25(OH)D < 25 nmol/L]. In univariate analyses, risk factors for vitamin D deficiency included increasing age, black race, low educational level, high body mass index, high triceps skinfold thickness, increasing level of disability, winter season, and elevated creatinine concentration. In multivariate models, black race had a strong association with vitamin D deficiency when other risk factors were adjusted for.

CONCLUSIONS

Vitamin D deficiency, a preventable disorder, is a common and important public health problem for older disabled women living in the community; black women are at higher risk than are white women.

Neutrophils infiltrating the endometrium express vascular endothelial growth factor: potential role in endometrial angiogenesis

OBJECTIVE(S)

To identify leukocytes within the human endometrium expressing vascular endothelial growth factor (VEGF).

DESIGN(S)

Prospective cohort study.

SETTING(S)

Healthy volunteers in an academic research environment.

PATIENTS(S)

Twenty-one normal cycling women without abnormal menstrual bleeding or infertility.

INTERVENTION(S)

Endometrial tissue collection by Pipelle de Cornier aspiration.

MAIN OUTCOME MEASURES(S)

Histologic, immunohistochemical (CD3, CD34, CD56, CD68, neutrophil elastase, estrogen and P receptors, VEGF), and simultaneous double immunoenzymatic labeling analysis of VEGF-positive cells within the human endometrium.

RESULT(S)

Ten endometrial samples were obtained in the proliferative (cycle days 5-10) and 11 samples in the secretory phase (cycle days 15-26). Immunohistochemical analyses showed the expected distribution of the different leukocyte cell types. Besides epithelial and stromal endometrial cells, the predominant cells that stained for VEGF were neutrophil granulocytes. Neutrophils were more abundant in the secretory phase but they expressed neither estrogen-a nor P receptors.

CONCLUSION(S)

Neutrophil granulocytes infiltrating the human endometrium express VEGF and regulate cyclical endometrial vascular proliferation. Ovarian steroids indirectly influence neutrophil migration.

The accuracy of self-report of physician diagnosed rheumatoid arthritis in moderately to severely disabled older women. Women's Health and Aging Collaborative Research Group

OBJECTIVE

To determine the accuracy of self-report of physician diagnosed rheumatoid arthritis (RA) in moderately to severely disabled older women.

METHODS

A total of 1002 participants in the Women's Health and Aging Study were included. These women were > or =65 years old, had an average of 4 chronic illnesses, and represented the one-third most disabled women living in the community. Self-report of a physician's diagnosis of RA was compared to cases of "definite" RA that were adjudicated using an algorithm modeled on the American College of Rheumatology criteria for RA.

RESULTS

The sensitivity of self-report of physician diagnosed RA was 77%, with 90.6% specificity and 99% negative predictive value, kappa = 0.46. The positive predictive value was 34% and likely reflected the low prevalence of RA in this sample (3.1%). Five of the 6 women who did not correctly report RA were under the care of a rheumatologist.

CONCLUSION

The accuracy of self-report of a physician's diagnosis of RA in this sample of disabled women with multiple chronic illnesses matched that observed in the general adult population of previous studies. Accuracy was enhanced by including report of receiving care by a rheumatologist.

Characterization of recombination events leading to the production of an ecotropic replication-competent retrovirus in a GP+envAM12-derived producer cell line

Replication-competent retrovirus (RCR) was identified in a GP+envAM12-derived producer cell, containing the MFG-S-Neo retroviral vector, using a marker rescue assay. Studies were undertaken to determine the origin and structure of this RCR. Receptor interference assays demonstrated that the virus was pseudotyped with an ecotropic envelope. Molecular analysis demonstrated the presence of a MoMLV ecotropic env recombinant where the neomycin resistance gene of the MFG-S-Neo vector was replaced by MoMLV ecotropic env. Additional recombinants linking the retroviral pol gene to neo and the neo gene to MoMLV env were also identified. A full-length MoMLV retroviral genome was detected by nested PCR in the contaminated amphotropic producer cells and in cells infected with its supernatant. Unexpectedly, this was also present in the GP+E86 packaging cells together with a previously undescribed envelope construct possessing a full 5' and 3' LTR, although these cells were consistently negative for the presence of RCR. These anomalies in the GP+E86 packaging cell line result in increased homology with the MFG-S-Neo vector, leading to an increased risk for the production of RCR. Our findings point to a need for increased vigilance when using these packaging lines to generate replication-defective retrovirus.

Enhanced retroviral gene transfer into CML and normal bone marrow, and CML and mobilized peripheral blood CD34+ cells using the recombinant fibronectin fragment CH-296

Autologous stem cell transplantation is a therapeutic alternative for many chronic myeloid leukaemia (CML) patients ineligible for the only curative treatment of allogeneic bone marrow transplantation. In this study the retroviral transduction of CD34+ progenitor cells isolated from the bone marrow (BM) and peripheral blood (PB) of patients with CML was compared to that of CD34+ cells isolated from the BM and PB of normal individuals and patients with non-haematological malignancies. A highly significant increase in transduction of all cell types was achieved in the presence of the recombinant fibronectin fragment, CH-296 (P < 0.05). In the absence of fibronectin, centrifugation produced a marginal improvement in the transduction of all cell types, which was significant only for CMLBM progenitor cells (P < 0.05). There was no significant additive effect when centrifugation was included in the fibronectin infection protocol. In the presence of CH-296, combinations of three or more cytokines improved transduction for all cell types. The same degree of transduction was observed for both normal and CML cells, irrespective of the variations employed in the infection protocol, suggesting that both leukaemic and non-leukaemic progenitors are equally susceptible to retroviral infection. These results demonstrate that CH-296 has a universal beneficial effect on the transduction of haemopoietic progenitor cells, with clear potential for future clinical trials.

The association between preoperative patient characteristics and both clinical and economic outcomes after abdominal aortic surgery

OBJECTIVE

To evaluate the association between patient characteristics and both clinical and economic outcomes in patients having abdominal aortic surgery in Maryland between 1994 and 1996.

DESIGN

Retrospective study using an administrative data set.

SETTING

All Maryland hospitals that performed abdominal aortic surgery from 1994 through 1996 (n = 46).

PARTICIPANTS

All patients who had abdominal aortic surgery in Maryland from 1994 through 1996 (n = 2,987).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The authors obtained discharge abstracts from the Maryland Health Services Cost Review Commission for patients with a primary procedure code for abdominal aortic surgery. Primary outcome variables were in-hospital mortality, hospital length of stay, and intensive care unit (ICU) days. The authors evaluated the following groups of independent variables: demographic characteristics, severity of illness, comorbid disease, and preoperative admission days. In multivariate analysis, independent predictors of in-hospital mortality were age 61 to 70 years (odds ratio [OR], 3.1; confidence interval [CI], 1.4 to 6.9), age 71 to 84 years (OR, 7.2; CI, 3.7 to 14.1), age 85 years or older (OR, 9.3; CI, 3.9 to 21.9), ruptured aneurysm (OR, 5.3; CI, 3.5 to 8.2), urgent operation (OR, 2.3; CI, 1.1 to 5.2), emergent operation (OR, 3.0; CI, 1.9 to 4.7), mild liver disease (OR, 4.6; CI, 2.0 to 10.9), and chronic renal disease (OR, 6.9; CI, 3.9 to 12.1). Hospital admission 1 to 2 days preoperatively was not associated with a difference in in-hospital mortality but was associated with a 31% increase in hospital days (CI, 23% to 40%) and a 38% increase in ICU days (CI, 19% to 60%).

CONCLUSION

In patients having aortic surgery, several patient characteristics such as mild liver disease and chronic renal failure, were associated with increased in-hospital mortality and length of stay. The practice of admitting patients to the hospital 1 to 2 days before surgery should be reevaluated because this was not associated with reduced in-hospital mortality but was associated with increased hospital and ICU stay.

Cannabis use and cognitive decline in persons under 65 years of age

The purpose of this study was to investigate possible adverse effects of cannabis use on cognitive decline after 12 years in persons under age 65 years. This was a follow-up study of a probability sample of the adult household residents of East Baltimore. The analyses included 1,318 participants in the Baltimore, Maryland, portion of the Epidemiologic Catchment Area study who completed the Mini-Mental State Examination (MMSE) during three study waves in 1981, 1982, and 1993-1996. Individual MMSE score differences between waves 2 and 3 were calculated for each study participant. After 12 years, study participants' scores declined a mean of 1.20 points on the MMSE (standard deviation 1.90), with 66% having scores that declined by at least one point. Significant numbers of scores declined by three points or more (15% of participants in the 18-29 age group). There were no significant differences in cognitive decline between heavy users, light users, and nonusers of cannabis. There were also no male-female differences in cognitive decline in relation to cannabis use. The authors conclude that over long time periods, in persons under age 65 years, cognitive decline occurs in all age groups. This decline is closely associated with aging and educational level but does not appear to be associated with cannabis use.

Organizational characteristics of intensive care units related to outcomes of abdominal aortic surgery

CONTEXT

Morbidity and mortality rates in intensive care units (ICUs) vary widely among institutions, but whether ICU structure and care processes affect these outcomes is unknown.

OBJECTIVE

To determine whether organizational characteristics of ICUs are related to clinical and economic outcomes for abdominal aortic surgery patients who typically receive care in an ICU.

DESIGN

Observational study, with patient data collected retrospectively and ICU data collected prospectively.

SETTING

All Maryland hospitals that performed abdominal aortic surgery from 1994 to 1996.

PATIENTS AND PARTICIPANTS

We analyzed hospital discharge data for patients in non-federal acute care hospitals in Maryland who had a principal procedure code for abdominal aortic surgery from January 1994 through December 1996 (n = 2987). We obtained information about ICU organizational characteristics by surveying ICU medical directors at the 46 Maryland hospitals that performed abdominal aortic surgery. Thirty-nine (85%) of the ICU directors completed this survey.

MAIN OUTCOME MEASURES

In-hospital mortality and hospital and ICU length of stay.

RESULTS

For patients undergoing abdominal aortic surgery, in-hospital mortality varied among hospitals from 0% to 66%. In multivariate analysis adjusted for patient demographics, comorbid disease, severity of illness, hospital and surgeon volume, and hospital characteristics, not having daily rounds by an ICU physician was associated with a 3-fold increase in in-hospital mortality (odds ratio [OR], 3.0; 95% confidence interval [CI], 1.9-4.9). Furthermore, not having daily rounds by an ICU physician was associated with an increased risk of cardiac arrest (OR, 2.9; 95% CI, 1.2-7.0), acute renal failure (OR, 2.2; 95% CI, 1.3-3.9), septicemia (OR, 1.8; 95% CI, 1.2-2.6), platelet transfusion (OR, 6.4; 95% CI, 3.2-12.4), and reintubation (OR, 2.0; 95% CI, 1.0-4.1). Not having daily rounds by an ICU physician, having an ICU nurse-patient ratio of less than 1:2, not having monthly review of morbidity and mortality, and extubating patients in the operating room were associated with increased resource use.

CONCLUSIONS

Organizational characteristics of ICUs are related to differences among hospitals in outcomes of abdominal aortic surgery. Clinicians and hospital leaders should consider the potential impact of ICU organizational characteristics on outcomes of patients having high-risk operations.

Cytotoxic T lymphocyte recognition of HLA-G in mice

Several features of HLA-G's sequence and expression pattern distinguish HLA-G from its classical counterparts. These features, including HLA-G's limited polymorphism and its expression at the maternal-fetal interface, have been used as a basis for suggesting a distinct functional role for this nonclassical class I HLA molecule. On the other hand, published data do demonstrate that HLA-G has much in common with its classical counterparts. It associates with beta 2-microglobulin and cytosolic peptides, it binds to CD8, and its presence can inhibit NK-cell-mediated lysis of HLA-G-bearing target cells. To develop a model in which HLA-G's function could be more thoroughly studied, we produced several HLA-G-expressing transgenic mouse strains. We report here the results of skin graft experiments which show that nontransgenic mice reject HLA-G-expressing transgenic murine skin as foreign and that this rejection is associated with the presence in the recipient of lymphocytes capable of specifically lysing HLA-G-expressing cells. In addition, experiments are described which demonstrate that HLA-G transgenic mice recognize HLA-G as a "self" molecule. Together the reported data demonstrate that HLA-G is capable of stimulating an HLA-G-restricted CTL response, that HLA-G molecules can serve as target molecules in lytic interactions with CTLs, and that HLA-G is involved in education of the lymphocytic repertoire of HLA-G transgenic mice.

Thinking of England and taking care: family building strategies and infant mortality in England and Wales, 1891-1911

"Debates concerning the origins and development of the late nineteenth- to early twentieth-century declines in marital fertility and infant mortality in England and Wales have been centred largely on the material provided by answers to the ¿special' questions in the 1911 census. In their published form these figures have restricted researchers to an examination of large scale geographic and social class differences in the levels and rates of decline of the two phenomena. This paper outlines research conducted on a sample of individual census returns from the 1911 census. From this data it becomes clear that for Victorian and Edwardian England ¿where one lived' was rather more important than ¿who one was' in determining both family building strategies and the survival of those children born."

Ovarian carcinoma-associated TaqI restriction fragment length polymorphism in intron G of the progesterone receptor gene is due to an Alu sequence insertion

Alu sequences, short, repetitive transposable DNA elements, are factors in a number of genetic diseases. We previously identified a germline TaqI RFLP, located in intron G of the human progesterone receptor gene, that showed an association with the incidence of sporadic ovarian carcinoma. Furthermore, the polymorphism was characterized as a small (approximately 300-bp) insertion that was inherited in a Mendelian fashion. Because of its insertional character, we named this polymorphism PROGINS. We report the identification of PROGINS as a 306-bp Alu element of the PV or HS-1 Alu subfamily.

Activities of the attending physician in the ambulatory setting: what part is teaching?

The attending physician is a valuable resource in the ambulatory care teaching setting. To describe the nature of attending physician activities, seven faculty physicians were observed during 214 three-hour clinic sessions at two sites of a family medicine training program. Only 53% of attending physician time involved clinical teaching activities, with only half of this portion spent in consultation with or seeing the patients of trainees. The patient volume of the clinic session did not affect total time spent in consultation, but the rate at which trainees consulted attending physicians decreased during busier sessions. This study represents a first step toward understanding the educational, organizational, and economic implications of attending physician activities in the ambulatory setting.

Transitions to parenthood: his, hers, and theirs

This study explores marital processes that may underlie the apparent decline in satisfaction with marriage in partners becoming parents for the first time. We assessed 47 couples expecting a first child and 15 couples not yet decided about having children at pretest, post 1 (6 months postpartum or 9 months after pretest) and post 2 (18 months postpartum or 21 months after pretest). Questionnaires examined (1) psychological sense of self; (2) partners' role arrangements and communication; (3) parenting ideology; (4) perceptions of the family of origin; and (5) social support and life stress, including parents' work patterns. Support was found for three hypotheses: (1) In four of the five family domains men and women having a first child showed more negative changes over time than nonparent spouses; (2) New fathers and mothers grew increasingly different from one another in most of these domains; (3) A combination of gender differentiation and change (increasing conflict) apparently contributed to lowered satisfaction with marriage for men and women.