Assessment of the psychometric properties of the Spanish version of EORTC QLQ-MY20 and evaluation of health-related quality of Life outcomes in patients with relapsed and/or refractory multiple myeloma in the real-world setting in Spain: results from the CharisMMa study

We evaluated the psychometric properties of the Spanish version of the European Organization for Research and Treatment of Multiple Myeloma (MM) specific quality-of-life (QoL) questionnaire module (QLQ-MY20) in relapsed/refractory MM (RRMM) patients. This was an observational, cross-sectional, multicenter study using EORTC QLQ-C30 and QLQ-MY20 in RRMM patients (ClinicalTrials.gov ID NCT03188536). We assessed the non-response rate, ceiling/floor effects, internal consistency, test-retest reliability, and validity. The study included 276 patients (53.3% males, mean [SD] age of 67.4 [10.5] years). The EORTC QLQ-MY20 showed a low non-response rate, very low ceiling and floor effects, and good internal consistency. The test-retest reliability assessment revealed good temporary stability, the construct validity analysis stated four main factors similar to the ones of the original version, and the criterion validity assessment showed no differences between groups. In conclusion, the Spanish version of EORTC QLQ-MY20 is a reliable and valid tool for assessing QoL in RRMM patients.

Women's perceptions and preferences for cervical cancer screening in light of updated guidelines

BACKGROUND

Updated risk-based guidelines for cervical cancer screening (CCS) allow for individualized screening that minimizes unnecessary testing. However, these guidelines are complex and may not be easily understandable to patients.

PURPOSE

To describe women's perceptions and preferences about CCS in light of recent guideline changes.

METHODOLOGY

This qualitative study conducted in February 2020 used online, text-based focus groups with a sample of US women ( n = 49) ages 27-45. After participants completed a short demographic survey, an experienced moderator used a semistructured guide to solicit participants' perceptions of routine gynecologic care and CCS. We summarized survey data using descriptive statistics. Two authors analyzed transcripts using conventional content analysis and met with other team members to resolve discrepancies and determine final themes.

RESULTS

Most participants were non-Hispanic White (65%), had health insurance (90%), and reported having a routine gynecologic examination in the past year (70%). We identified four common themes: (1) low perceived risk of human papillomavirus (HPV) coupled with low knowledge about HPV as a causative factor for cervical cancer, (2) confusion about-and mistrust of-recent individual risk-based guidelines that determine the indicated timing and type of CCS test (Pap or HPV testing), (3) mixed opinions about performing a self-swab for HPV testing, and (4) conflicting perceptions of trust toward providers and the health care industry.

CONCLUSIONS

Findings highlight women's uncertainty and hesitancy about updated CCS guidelines.

IMPLICATIONS

Provider-patient communication strategies should consider women's gaps in knowledge about HPV, include the rationale for guidelines and types of tests, and build trust between patients and providers.

Ethnic Enclaves and Incidence of Cancer Among US Ethnic Minorities in the Multi-Ethnic Study of Atherosclerosis

BACKGROUND

Since immigrants and their descendants represent a growing proportion of the US population, there is a strong demographic imperative for scientists to better understand the cancer risk factors at multiple levels that exist for these populations. Understanding the upstream causes of cancer, including neighborhood context, may help prevention efforts. Residence in ethnic enclaves may be one such contextual cause; however, the evidence is mixed, and past research has not utilized prospective designs examining cancer incidence or mortality.

METHODS

We examined the association between residency in ethnic enclaves and cancer events among Hispanic (n = 753) and Chinese (n = 451) participants without a history of cancer in the Multi-Ethnic Study of Atherosclerosis (MESA), a prospective cohort study that enrolled participants ages 45-84 in six US cities. Cancer events included deaths and hospitalization for any cancer diagnosis from 2000-2012. Residency in an ethnic enclave was operationalized as their geocoded baseline census tract having a concentration of residents of the same ethnicity greater than the 75th percentile (compared to non-ethnic enclave otherwise). Potential confounders were blocked into three categories: sociodemographic, acculturation, and biomedical/health behavior variables. To examine the association between ethnic enclaves and cancer, we estimated hazard ratios (HRs) and 95% confidence intervals (CIs) using Cox proportional hazards models.

RESULTS

Among Hispanic participants, residing in ethnic enclaves (vs. not) was associated with a 39% reduction in cancer risk (HR 0.61, 95%CI: 0.31, 1.21) after adjusting for sociodemographic variables. Among Chinese participants, residing in ethnic enclaves was associated with a 2.8-fold increase in cancer risk (HR 2.86, 95%CI; 1.38, 5.94) after adjusting for sociodemographic variables.

CONCLUSIONS

Our results suggest that the association between ethnic enclaves and cancer events differs by ethnic group, suggesting that different social and contextual factors may operate in different communities.

Real-World Health Care Services Utilization Associated With the Management of Patients With Relapsed and Refractory Multiple Myeloma in Spain: The CharisMMa Study

BACKGROUND

Most patients with multiple myeloma (MM) relapse or become refractory, resulting in high health care costs. However, real-world data regarding the utilization of health care services among the relapsed/refractory MM (RRMM) population are scarce.

METHODS

Observational, cross-sectional, multicenter study of the utilization of health care services by RRMM patients who had relapsed within the previous 6 months in Spain in a real-world setting. Data were collected from the clinical records and during a single structured interview and included sociodemographic and clinical characteristics at last relapse, the treatment and health care services nature, and were presented using descriptive statistics.

RESULTS

The 276 patients enrolled (53.3% males), with a mean [SD] age of 67.4 [10.5] years, had experienced their most recent relapse a median (IQR) of 1.61 (0.74, 3.14) months before entering the study. Patients lived a median (IQR) of 9.0 (3.0, 30.0) km away from the hospital and visited the hospital a median (IQR) of 3.0 (2.0, 5.0) times/month to receive treatment for their most recent relapse. They spent a median (IQR) of 15.84 (5.0, 42.0) euros/month on transportation. Since their most recent relapse, most patients had been admitted to a hospital unit (n = 155, 56.2%), had required ≥1 diagnostic tests (n = 227, 82.2%), and had consulted the hematologist (n = 270, 97.8%) a mean (SD) of 5.5 (5.4) times. In half of the visits, patients were accompanied by an actively working caregiver (n = 112, 54.4%).

CONCLUSIONS

RRMM treatments are associated with a high utilization of health care services and pose a significant burden for patients and caregivers.

TRIAL REGISTRATION NUMBER

NCT03188536.

The intersection of sexual orientation with race and ethnicity in cervical cancer screening

BACKGROUND

Cervical cancer screening is recommended for those with a cervix who are 21 to 65 years old, with specific timelines being dependent on individual risk. This study compared rates of ever undergoing Papanicolaou (Pap) testing at the intersection of self-reported sexual minority (SM) status and race/ethnicity.

METHODS

Data from the National Health Interview Survey (2015 and 2018) were used to examine cervical cancer screening disparities. Natal females without a history of hysterectomy who were 21 to 65 years old and had reported their sexual orientation and Pap testing history were included. Demographic and health characteristics were summarized with descriptive statistics. To adjust for differences in confounding variables between groups, propensity score-based inverse probability of treatment weighting (IPTW) was performed. IPTW-adjusted multivariable logistic regression models estimated odds of ever undergoing a Pap test by sexual orientation alone and with race/ethnicity (non-Hispanic White, non-Hispanic Black, and Hispanic).

RESULTS

SM persons (n = 877) had significantly reduced odds of ever undergoing Pap testing (odds ratio, 0.54; 95% confidence interval, 0.42-0.70) in comparison with heterosexual persons (n = 17,760). When the intersection of sexual orientation and race/ethnicity was considered, non-Hispanic White SM participants and Hispanic SM participants had reduced odds of ever undergoing Pap testing in comparison with non-Hispanic White heterosexual participants. No significant differences were observed between non-Hispanic White heterosexual participants and participants of non-Hispanic Black SM or Hispanic heterosexual identities.

CONCLUSIONS

SM participants were significantly less likely to have ever undergone a Pap test in comparison with heterosexual participants, with Hispanic SM participants having the lowest uptake. Future studies should further examine the roles of systemic discrimination and other key drivers of these disparities.

The Immigrant Memory Collaborative: A Community-University Partnership to Assess African Immigrant Families' Experiences with Dementia

Research suggests a disparity in the prevalence of dementia, with Black older adults having double the risk compared to their White counterparts. African immigrants are a fast-growing segment of the U.S. Black population, but the dementia care needs and resources of this population are not fully understood. In this paper, we describe the process of working collaboratively with a community partner and project advisory board to conduct a culturally informed project. Specifically, we describe the process of developing culturally informed instruments to collect data on dementia care needs and resources among African immigrants. Working together with a diverse project advisory board, a guide was developed and used to conduct community conversations about experiences with dementia/memory loss. Transcripts from six conversations with 24 total participants were transcribed and analyzed thematically by two independent coders in Nvivo. These qualitative findings were used to inform the development of a survey for quantitative data collection that is currently ongoing. Themes (e.g., cultural attitudes, challenges, and current resources) from the community conversations that informed the survey are described briefly. Despite the challenges of conducting research during a global pandemic, having trusting relationships with a partnering community organization and project advisory board facilitated the successful development of instruments to conduct preliminary dementia care research in an underserved population. We anticipate that survey results will inform interventions that increase education, outreach, and access to dementia care and caregiving resources for this population. It may serve as a model for community–university partnerships for similar public health efforts in dementia as well as other chronic disease contexts.

Abstract PO-265: The intersection of sexual orientation with race and ethnicity in cervical cancer screening: Results from the National Health Interview Survey

Objectives: Cervical cancer screening is recommended for those with a cervix aged 21-65, with specific timelines dependent on individual risk. Persons belonging to sexual minority (SM) groups may experience greater risk factors for cancer while also being less likely to participate in cancer screening. We compared cervical cancer screening rates by sexual orientation, as well as intersectional analyses with race/ethnicity. Methods: Data from the NHIS years 2015 and 2018, were used to examine cervical cancer screening disparities. Biologic females without history of hysterectomy, ages 21-65 years, who reported sexual orientation and Pap testing history were included. Demographic, health, and cervical cancer screening characteristics were examined using descriptive statistics. Multivariable logistic regression models explored Pap testing rates by sexual orientation alone and with race/ethnicity (non-Hispanic (NH) white, NH Black, Hispanic), adjusting for age, partner status, education, health insurance, and poverty status. Results: SM participants (N=874) were younger, less likely to be living with a partner, had lower income, were less likely to have a medical clinic they go to for regular care, and more likely to delay their medical care due to costs, when compared to heterosexual counterparts (N=17,733). SM persons had significantly reduced odds of ever undergoing Pap testing (OR: 0.57, CI: 0.44-0.74) when compared to heterosexual persons. When considering the intersection of sexual orientation and race/ethnicity, heterosexual Hispanic, SM NH white, and SM Hispanic participants all had reduced odds of ever undergoing Pap testing when compared to NH white heterosexual participants. There were no significant differences observed between heterosexual and SM participants of NH Black or white identities. Conclusions: Participants identifying as SM were significantly less likely to have ever undergone a Pap test when compared to heterosexual participants. When stratifying by race/ethnicity, disparities remained for most participants identifying as SM. These results demonstrate a need for continued effort to increase Pap testing among the SM community. Further research is needed to further examine roles of systemic discrimination and other key drivers of these disparities.

Citation Format: Ashley E. Stenzel, Gabriela Bustamante, Courtney Sarkin, Katherine Harripersaud, Patricia Jewett, Deanna Teoh, Rachel I. Vogel. The intersection of sexual orientation with race and ethnicity in cervical cancer screening: Results from the National Health Interview Survey [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-265.

Availability and Quality of Grief and Bereavement Care in Pediatric Intensive Care Units Around the World, Opportunities for Improvement

Pediatric Intensive Care Units (PICUs) provide multidisciplinary care to critically ill children and their families. Grief is present throughout the trajectory of illness and can peak around the time of death or non-death losses. The objective of this study was to assess how PICUs around the world implement grief and bereavement care (GBC) as part of an integrated model of care. This is a multicenter cross-sectional, prospective survey study. Questionnaires with multiple-choice and open-ended questions focusing on unit infrastructure, personnel, policies, limited patient data, and practices related to GBC for families and health care professionals (HCPs) were completed by on-site researchers, who were HCPs on the direct care of patients. PICU fulfillment of GBC goals was evaluated using a custom scoring based on indicators developed by the Initiative for Pediatric Palliative Care (IPPC). We compared average total and individual items fulfillment scores according to the respective country's World Bank income. Patient characteristics and details of unit infrastructure were also evaluated as potential predictors of total GBC fulfillment scores. Statistical analysis included multilevel generalized linear models (GLM) with a Gaussian distribution adjusted by child age/gender and clustering by center, using high income countries (HICs) as the comparative reference. Additionally, we applied principals of content analysis to analyze and summarize open-ended answers to contextualize qualitative data. The study included 34 PICUs from 18 countries: high-income countries (HICs): 32.4%, upper middle-income countries (UMICs): 44.1%, low middle-income and low-income countries (LMI/LICs): 23.5%. All groups reported some compliance with GBC goals; no group reported perfect fulfillment. We found statistically significant differences in GBC fulfillment scores between HICs and UMICs (specifically, HCP grief support), and between HICs and LMICs (specifically, family grief support and HCP grief support). PICUs world-wide provide some GBC, independent of income, but barriers include lack of financial support, time, and training, overall unit culture, presence of a palliative care consultation service, and varying cultural perceptions of child death. Disparities in GBC for families and HCPs exist and were related to the native countries' income level. Identifying barriers to support families and HCPs, can lead to opportunities of improving GBC in PICUs world-wide.

Pain Assessment and Management in Pediatric Intensive Care Units Around the World, an International, Multicenter Study

The adequate assessment and management of pain remains a challenging task in the Pediatric Intensive Care Unit (PICU). Our goal is to describe how pain is assessed and managed in PICUs around the world and to examine how human and material resources impact achievement of this goal. An international multicenter cross-sectional observational study was designed with the participation of 34 PICUs located in urban, suburban, and rural areas of 18 countries. We evaluated how PICUs around the world assessed and managed pain according to the Initiative for Pediatric Palliative Care recommendations, and how human and material resources impacted achievement of this goal. Data was collected for this study from 2016 to 2018 using questionnaires completed by medical doctors and nurses. In this paper, we focus on the indicators related to how pain is managed and assessed. The average achievement of the goal of pain relief across all centers was 72.2% (SD: 21.1). We found a statistically significant trend of more effective pain management scores, routine assessment, proper documentation, and involvement of pain management experts by increasing country income. While there are efforts being made worldwide to improve the knowledge in pain assessment and management, there is a lack of resources to do so appropriately in low-middle-income countries. There is a mismatch between the existing guidelines and policies, which are mainly designed in high income countries, and the resources available in lower resourced environments.

A real-life overview of a hematopoietic cell transplant program throughout a four-year period, including prospective registry, exclusion causes and final donor selection

Traceability of patients who are candidates for Hematopoietic cell transplant (HCT) is crucial to ensure HCT program quality. Continuous knowledge of both a detailed registry from a HCT program and final exclusion causes can contribute to promoting a real-life vision and optimizing patient and donor selection. We analyzed epidemiological data reported in a 4 year-monocentric prospective registry, which included all patients presented as candidates for autologous (Auto) and/or allogeneic (Allo) HCT. A total of 543 patients were considered for HCT: 252 (42.4%) for Allo and 291 (57.6%) for Auto. A total of 98 (38.9%) patients were excluded from AlloHCT due to basal disease progression more commonly (18.2%). Seventy-six (30.2%) patients had an HLA identical sibling, whereas 147 (58.3%) patients had only Haplo. UD research was performed in 106 (42%) cases, significantly more often in myeloid than lymphoid malignancies (57% vs 28.7%, p < 0.001) but 61.3% were finally canceled, due to donor or disease causes in 72.4%. With respect to Auto candidates, a total of 60 (20.6%) patients were finally excluded; progression was the most common cause (12%). Currently, Haplo is the most frequent donor type. The high cancellation rate of UD research should be revised to optimize further donor algorithms.

Clinical and Sociodemographic Characteristics of Patients With Relapsed and/or Refractory Multiple Myeloma and Their influence on Treatment in the Real-World Setting in Spain: The CharisMMa Study

INTRODUCTION

Treatment of relapsed and/or refractory multiple myeloma (RRMM) should be established based on multiple factors, including previous treatment and the sociodemographic/clinical characteristics of the patients. However, patients enrolled in randomized-controlled trials often do not mirror the scenario encountered in real-world practice, thus challenging therapeutic decisions in day-to-day practice.

PATIENTS AND METHODS

This observational, cross-sectional, multicenter study aimed to investigate the sociodemographic and clinical characteristics of patients with RRMM treated in routine practice in Spain and their influence on treatment regimens.

RESULTS

The study included 276 RRMM patients (median age 69 years; no gender predominance). Seventy-four percent of patients had CRAB features at the time of study inclusion, 65.9% bone lesions, 28.7% high-risk cytogenetics, and 27.0% were at ISS stage III; 65.1% were retired and lived in urban areas (75.7%) with their relatives (85.8%); 28.7% had some dependence degree. Patients had experienced their last relapse in a median of 1.61 months before enrollment and had received a median of 2 treatment lines (range 1-10). Second-and third-line therapies were mostly based on immunomodulatory drugs, followed by proteasome inhibitors (PIs), whereas monoclonal antibodies prevailed in later treatment lines. The presence of extramedullary plasmacytomas, the absence of osteopenia, and being in the second or third treatment line (vs. later lines) significantly increased the odds of receiving PIs.

CONCLUSIONS

RRMM treatment in the real-world setting is highly heterogeneous and is primarily influenced by the number of previous lines. The consideration of patients' clinical and sociodemographic characteristics may support clinicians in making therapeutic decisions.

Disparities in Healthcare Providers' Recommendation of HPV Vaccination for U.S. Adolescents: A Systematic Review

Infrequent provider recommendations continue to be a key barrier to human papillomavirus (HPV) vaccination, including among adolescents at higher risk for future HPV cancers. To inform future interventions, we sought to characterize disparities in health care providers' HPV vaccine recommendation for U.S. adolescents. We systematically reviewed studies published in 2012-2019 that assessed provider HPV vaccine recommendations for adolescents aged 9-17. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we identified 52 eligible studies and used a standardized abstraction form to assess recommendation prevalence by adolescent demographic characteristics. Studies consistently found that fewer parents of boys than girls reported receiving HPV vaccine recommendations (14 studies, range of difference: -11 to -35 percentage points). Studies also found fewer recommendations for adolescents who were younger (2 studies, -3% to -12% points), non-White (3 studies, -5% to -7% points, females only), lower income (3 studies, -1% to -8% points), or uninsured (1 study, -21% points, males only). Studies identified geographic disparities in southern and rural areas. In conclusion, findings from this systematic review identify disparities in HPV vaccine recommendation that may contribute to suboptimal vaccine uptake. Efforts to improve providers' HPV vaccine communication should focus on increasing recommendation consistency, especially for lower-income, non-White, and rural adolescents.

Dementia Caregivers' Experiences and Reactions to Remote Activity Monitoring System Alerts

Technology-based tools, including remote activity monitoring (RAM) systems, have been proposed as valuable aids for family caregivers of people with dementia. Previous analyses have shown limited effects of these systems and highlighted a number of barriers, including false alarms. We used data from an ongoing embedded mixed method randomized controlled intervention to describe patterns of alerts and their association with receipt of the RAM system and caregiver outcomes. Quantitative analyses showed a modest positive association between the number of alerts during the first month and system review score. In addition, qualitative results illustrated the importance of alert context, including utility, accuracy, and type of alert delivery. These findings highlight the relevance of early alerts to engagement with and perceived benefit from the RAM system. [Journal of Gerontological Nursing, 47(1), 13-20.].

Dose intensity and treatment duration of bortezomib in transplant-ineligible newly diagnosed multiple myeloma

BACKGROUND

Bortezomib-related peripheral neuropathy (PN) affects a relevant proportion of multiple myeloma (MM) patients treated with melphalan, prednisone, and bortezomib (VMP). Empirical dose modifications have attempted to reduce toxicity without compromising efficacy.

PATIENTS AND METHODS

We retrospectively evaluated the dose-response and dose-toxicity relationships in 114 unselected untreated MM patients intended for treatment with VMP with subcutaneous bortezomib.

RESULTS

Sixty-two patients (54%) completed the 9 scheduled cycles. Median treatment duration was 48 weeks (range 1-57), cumulative bortezomib dose was 41.8 mg/m² (2.6-67.6) and median dose intensity was 1.0 mg/m² /wk (0.2-2.6). Median progression-free survival (PFS) and overall survival (OS) for the full cohort were 86 weeks (95%CI 77-104) and 209 weeks (95% CI 157-259) respectively. Patients who progressed <60 days after discontinuing bortezomib had received a significantly inferior mean cumulative dose, 34.6 mg/m² than the remaining individuals, 45.5 (P = .023). PFS was significantly improved for patients achieving a very good partial response (VGPR) or better (P = .00007). Additional variables with a prognostic impact on PFS on univariate analysis included completion of the 9 scheduled cycles (P = .00002), patients with at least 50 weeks of treatment (P = .02) and patients receiving a cumulative dose of at least 49 mg/m² (P = .05). Achievement of a VGPR (HR 0.23; 95%CI 0.12-0.46; P = .00002) and a cumulative dose of 49 mg/m² (HR 0.46, 95%CI 0.27-0.78; P = .003) were statistically independent prognostic factors for PFS. Toxicity-related treatment dose reductions occurred in 75 individuals (66%). PN was observed in 50 individuals (44.6%), grade 3 in 9 (8%). The only prognostic factor for emergence of PN in multivariate analysis was the presence of baseline PN.

CONCLUSIONS

Biweekly full-dose treatment in the first cycles has a major impact in depth of response. Depth of response, cumulative bortezomib dose, and treatment duration had an impact in prolongation of PFS.

Treatment patterns and outcomes in real-world transplant-ineligible patients newly diagnosed with multiple myeloma

Despite the significant proportion of older patients with newly diagnosed multiple myeloma (MM), most clinical trials driving therapeutic decisions in routine practice include younger and presumably healthier patients than those in the real world. Furthermore, longitudinal studies suggest that elderly, transplant-ineligible patients with MM are not benefitting enough from new anti-MM agents. We retrospectively analyzed the profile of and treatment patterns and outcomes in 675 transplant-ineligible patients with MM who started frontline therapy in routine practice. The mean (SD) age was 75.6 (6.7) years; 152 (47.4%) had Eastern Cooperative Oncology Group performance status (ECOG PS) 2-4, and 73 (25.1%) had high cytogenetic risk. The most frequent frontline therapy was non-VMP bortezomib-based regimens (n=207; 30.7%), which were more frequent among patients with ECOG PS 0/1 and higher risk (e.g., international staging system (ISS) stage III, severely impaired glomerular filtrate rate (GFR), high lactate dehydrogenase (LDH), and high-risk cytogenetics); 185 patients (27.4%) started an attenuated (lite) VMP regimen, and 159 (23.6%) a VMP (VISTA) regimen. Median progression-free survival and overall survival (OS) were 15.3 months (95%CI 14.0-16.9) and 33.5 months (95%CI 29.1-37.2), respectively; 405 patients (78.2%) achieved partial response or better. Age, ECOG PS, ISS stage, serum LDH, GFR, cytogenetic risk, and treatment regimen significantly influenced OS. In this study, a remarkable proportion of transplant-ineligible patients with MM were older, frontline regimens were highly heterogeneous, and patients at higher risk often received less efficacious combinations. These findings suggest that clinicians have limited objective criteria for therapeutic decisions for this patient group.

Recommending Inequality? Patterns of US Healthcare Providers' HPV Vaccine Recommendations

Purpose: Infrequent provider recommendations continue to be a key barrier to human papillomavirus (HPV) vaccination, including among adolescents at higher risk for future HPV cancers. To inform future provider- training programs, our study sought to synthesize the findings of existing studies of disparities in provider recommendation of HPV vaccination among adolescents. Methods: We conducted a systematic review of studies that quantitatively assessed the prevalence of provider recommendation of HPV vaccination among US parents of adolescents aged 9–17. We excluded studies that were not empirical, not peer-reviewed, or collected data before 2012. Following PRISMA guidelines, two independent coders extracted and screened 3,158 unique titles and abstracts from multiple databases. Next, two independent coders reviewed the full text of eligible studies, systematically collecting data using a standardized abstraction form. We resolved coding disagreements via discussion with the whole team. Results: Fifty-four of 252 reviewed studies met eligibility criteria, including 33 studies of parents and 21 studies of providers. Parental report of receiving a provider recommendation for HPV vaccination ranged from 22% to 78%. These studies most often assessed disparities by adolescents' sex, with almost all finding that provider recommendations were less common for boys vs. girls. Most studies of provider reports confirmed disparate recommendations by sex. Fewer studies stratified recommendation disparities by income or race/ethnicity; these studies found that recommendations were less common among lower-income households, but reported mixed findings by race/ethnicity. Geographic assessments found variation across states and urbanicity, with recommendations being lower including in some Southern states and in rural areas. Conclusion: Findings suggest differences in provider recommendation by sex, household income, geography, and possibly race/ethnicity, in spite of national guidelines for routine HPV vaccination. National efforts to improve provider communication about HPV vaccination should focus on improving recommendation consistency, especially for populations such as lower-income and rural adolescents who are at higher risk for future HPV cancers.

50 Sex ratio at birth in dairy cattle is affected by the invitro embryo production process

Data from a herd of 3,000 high-producing milking dairy cows under an intensive feeding system was analysed. The IVF laboratory at the farm uses a co-culture system (Vivanco-Mackie; page 30-48 in Proc. 2000 Australian Embryo Transfer Society) and transfers ∼1000 embryos per year. The semen used for IVF and for inseminations (AI) in the herd was female-sexed (F-sexed) and non-sexed (conventional). During the 4 years of evaluation (2016–2019) 1123 calves were born to AI with F-sexed semen and 6,456 to AI with conventional semen; the proportion of males born to AI with F-sexed semen was 9% (91% females), which was not different (P&gt;0.05) from the expected ratio of 10% males and 90% females. The proportion of male calves born to AI with conventional semen was 53.2% (46.8% females), which agrees with the expected ratios for the population. During the same period of evaluation, 805 calves were born to IVF embryos transferred; 240 calves were born from embryos produced using F-sexed semen, of which 29.6% were males and 70.4% females, which was different (P&lt;0.05) from the expected ratio of 10% males and 90% females. The proportion of male calves born from embryo transfer of IVF embryos produced with conventional semen was 82.7%, higher (P&lt;0.05) than the expected 53.2% of males for the population; the proportion of females was 17.3%, significantly lower (P&lt;0.05) than the expected 46.8% females for the population. For IVF, the proportion of males was significantly higher (P&lt;0.05) than expected in all cases; for AI, there was no difference (P&gt;0.05) between the observed sex proportion and the expected values. We conclude that the invitro embryo production process affects the sex ratio at birth in this population, and some factor in the IVF process is affecting the survival to calving of female embryos and consequently increasing the proportion of male calves born from invitro-produced embryos. Gutierrez et al. (2001 Reprod. Fertil. Dev. 13, 361–365) found a similar effect in dairy cattle and linked it to glucose imbalance in the media. Larson et al. (2001 PNAS 98, 9677-9682) found that female cattle embryos had a lower ability to progress in development in glucose-rich media, but the mechanism is not yet fully understood. Xu et al. (1992Mol. Reprod. Dev. 31, 249-252) and others indicate that invitro-produced male bovine embryos predominate among blastocysts, expanded and hatched stages. Meanwhile, embryos lagging in development are predominantly female. Kun Tan et al. (2016 Reproduction 151, 443-543) found that IVF in mice favours the birth of males because of dysregulated expression of representative dimorphic genes. Further studies in cattle are necessary to determine the cause of the increased proportion of males born from invitro embryos and to find ways to control it.

The African Immigrant Memory Loss Project: A University-Community Partnership

The few studies on dementia prevalence in immigrant communities show that immigrants from diverse racial/ethnic backgrounds have a higher prevalence of dementia compared with their U.S.-born counterparts. However, this body of work is small, resulting in a lack of reliable estimates of dementia prevalence among African immigrants. The AIMLP is a partnership between the African Career, Education, and Resources, Inc. (ACER) and the Families and Long-Term Care Projects (FLTC) of the University of Minnesota School of Public Health. Guided by an advisory board, the goal of this project is to develop culturally informed instruments, and use these to collect data to identify dementia care needs, knowledge, and resources in the African immigrant community. Study implementation started in August 2019, five advisory board meetings have been convened and 2 pilot focus groups have occurred. Twelve individuals participated in the focus groups. The majority (90%) were from Liberia and 60% were over the age of 55. Two participants currently care for a family member with dementia. Preliminary findings reveal a great need for education on dementia, and general lack of awareness on management, and limited access to services/supports. Focus groups will be finalized in March and the study survey will be developed and administered in the summer. These survey findings will be available and presented at the conference in November 2020. This is the first project to identify the extent of dementia care needs and resources among African immigrants; which will inform interventions for this population.

Cesarean section and risk of allergies in Ecuadorian children: A cross-sectional study

BACKGROUND

Studies have shown an association between cesarean section (CS) and increased prevalence of childhood allergic diseases. While these observations have been consistent in industrialized countries, evidence from developing countries is limited.

OBJECTIVE

To assess the association between the mode of delivery and allergic diseases in children aged 3-12 years in Quito, Ecuador.

METHODS

In this cross-sectional study, parents were surveyed using an anonymous, standardized questionnaire from the International Study of Asthma and Allergies in Childhood project to assess the presence of asthma, allergic rhinitis, atopic dermatitis, and food allergies in their children. The children's age, sex, birthplace, delivery mode (CS/vaginal), socioeconomic status, and ethnicity were recorded. Other parameters included gestational age, breastfeeding, smoking status during pregnancy, and parental allergic diseases.

RESULTS

After adjusting for confounding factors, children delivered via CS were found to have a higher risk of wheezing (odds ratio [OR] = 4.12, 95% confidence interval [CI]: 1.43-11.89), physician-diagnosed asthma (OR = 24.06; 95% CI: 1.98-292.3), and pimples, or eczema with the itching for 6 months (OR = 2.65; 95% CI: 1.06-6.61) than children delivered vaginally. No association was found between the delivery mode and rhinitis or food allergies. After stratifying by socioeconomic status, CS was only associated with allergic disorders in children of medium/high socioeconomic backgrounds.

CONCLUSIONS

As seen in industrialized settings, children born by CS in nonindustrialized countries have an increased risk of developing allergic disorders including asthma and dermatitis, compared to those delivered vaginally.

Beyond Diversity: Focusing on and Enhancing Inclusion in the Society for Epidemiologic Research

Increasing diversity and inclusion among organizational membership has become a focus for many professional societies, including the Society for Epidemiologic Research (SER). In this issue of the Journal, DeVilbiss et al. (Am J Epidemiol. 2020:189(10):998-1010) assessed dimensions of diversity and inclusion within SER to provide baseline data for future evaluations of Society initiatives. In our response, we note that diversity in SER appears strong but there is lag with regard to inclusion. We also highlight some of the major weaknesses of this study that hinder efforts to accurately evaluate inclusion within SER. There is a need to more concretely define inclusion and think broadly about how measures of inclusion should be operationalized in future surveys. Additional limitations of the study include its limited generalizability to the wider SER membership and the lack of questions about barriers to inclusion in SER activities. We conclude with recommendations for SER and other professional societies based on prior literature evaluating successful diversity and inclusion efforts. We also propose a conceptual model to assist with operationalizing and directing future analyses of inclusion measures. It is essential that SER move beyond efforts around diversity to focus on measuring and enhancing inclusion.

HPV vaccine coverage and acceptability among a national sample of sexual minority women ages 18-45

BACKGROUND

Sexual minority women (lesbian, bisexual, and other women who have sex with women) are at risk for human papillomavirus (HPV) infection and HPV-related disease, demonstrating the importance of HPV vaccination for these women.

METHODS

We conducted an online survey of sexual minority women ages 18-45 from the United States (n = 505) in October 2019, about two months after HPV vaccine recommendations were expanded to include ages 27-45. Multivariable Poisson regression identified correlates of HPV vaccine initiation (i.e., receipt of at least one HPV vaccine dose).

RESULTS

Overall, 65% of participants ages 18-26 and 33% of participants ages 27-45 had initiated the HPV vaccine series. Among participants ages 18-26, initiation was more common among those who had received a healthcare provider recommendation (RR = 2.19, 95% CI: 1.64-2.93) or had disclosed their sexual orientation to their primary healthcare provider (RR = 1.33, 95% CI: 1.07-1.65). Among initiators ages 27-45, a large majority (89%) reported receiving their first dose before turning age 27. Initiation was more common among participants ages 27-45 who had received a healthcare provider recommendation (RR = 3.23, 95% CI: 2.31-4.53) or who reported greater perceived social support for HPV vaccination (RR = 1.22, 95% CI: 1.05-1.40). Several reasons for not yet getting HPV vaccine differed by age group (ages 18-26 vs. ages 27-45; all p < 0.05).

CONCLUSIONS

Many sexual minority women, particularly those ages 27-45, remain unvaccinated against HPV. Findings provide early insight into HPV vaccine coverage among adult women and highlight key leverage points for increasing vaccination among this population.

THE PORCHLIGHT PROJECT: COLLABORATING TO ENHANCE THE DEMENTIA CAPABILITY OF COMMUNITY-BASED VOLUNTEERS

Public health efforts to address Alzheimer’ disease and related dementias (ADRD) are limited. Utilization of lay/peer intervention providers in the community to reach older persons and their families may offer a novel method to reach those in need. Such an approach may also serve as a fulcrum around which formal healthcare delivery and community-based LTSS are better integrated. This pragmatic trial, the Porchlight Project, aims to refine a multicomponent training approach for lay volunteers in Minnesota (i.e., Senior Companions) that enhances their capability to deliver dementia care and support to underserved older persons in need. This presentation will highlight the development and collaboration with Lutheran Social Services of Minnesota to refine and deliver a useful and feasible training program to enhance Senior Companions (n = 20) dementia care capability, as well as the potential and challenges of delivering a pragmatic trial of this type across the state of Minnesota.

THE PORCHLIGHT PROJECT: PARTNERING WITH VOLUNTEERS TO ENHANCE COMMUNITY-BASED DEMENTIA CARE AND OUTREACH

Families often remain unaware of long-term services and supports (LTSS) that could help to mitigate the negative effects of Alzheimer’s disease and related dementias (ADRDs). Approaches that: a) identify community-residing older persons with potential memory impairment; b) assist their families in navigating the healthcare system; and c) facilitate the identification of appropriate community-based LTSS could result in more effective management of ADRD. The Porchlight Project is a multicomponent training approach for lay volunteers in Minnesota (i.e., Senior Companions) that enhances their capability to deliver dementia care and support to underserved older persons in need. Mixed methods analysis of qualitative and quantitative data among 20 Senior Companions and up to 25 persons with ADRD and their family caregivers suggest the potential success of the Porchlight Project, as well as areas to refine and enhance prior to large-scale evaluation throughout Minnesota.

Awareness of obstetric warning signs in Ecuador: a cross-sectional study

OBJECTIVE

In Ecuador, the reported maternal death rate was 45.71 per 100,000 live births in 2013. This may be partly due to a lack of maternal knowledge of obstetric warning signs during pregnancy, delivery and the post-partum period. This study sought to evaluate awareness of obstetric warning signs among pregnant women in relation to individual demographic and area-level socio-economic indicators.

STUDY DESIGN

We conducted a cross-sectional analysis of data collected by Ecuador's Ministry of Health at the conclusion of a national maternal health campaign (2014-2015). A nationally representative sample of 3435 pregnant women from the nine administrative zones completed surveys regarding basic demographics and their awareness of obstetric warning signs.

METHODS

We defined eight obstetrical warning signs according to the literature and Ecuadorian practice that could occur during pregnancy, delivery and the post-partum period (severe headache, strong abdominal ache, bleeding or presence of malodorous secretion, rupture of the amniotic sac, high fever, abnormal presentation of the baby, decrease in baby's movements and delayed labour). A woman was considered 'aware' if she recognised at least four of the eight warning signs and stated she would seek immediate healthcare at their presentation. For each administrative zone, four socio-economic indicators (poverty, illiteracy, unemployment and subemployment) were obtained from the National Institute of Statistics and Census. Correlates of awareness of the obstetric warning signs were evaluated using hierarchical logistic models clustered by the administrative zone.

RESULTS

Nationally, 86.9% of women were 'aware' of obstetric warning signs. After adjustment for age, socio-economic indicators and clustering, indigenous participants were 59% less likely to be aware of obstetric warning signs than mestizos (odds ratio [OR] = 0.41, 95% confidence interval [CI] = 0.28-0.59). For every 1% increase in area poverty, participants had a 5% decreased likelihood of being aware of obstetric warning signs (OR = 0.95, 95% CI = 0.93-0.96), adjusting for age, ethnicity and other socio-economic indicators. The most effective source of campaign information about obstetric warning signs was personal communication with a healthcare professional, as opposed to mass media advertisements (OR = 1.90, 95% CI = 1.34-2.71).

CONCLUSIONS

A majority of Ecuadorian pregnant and post-partum women are aware of obstetric warning signs. Indigenous ethnicity and area-level poverty are associated with a lack of awareness. Personal communication with a healthcare professional was the most effective source of information. These findings have implications for improvement of maternal awareness of warning signs.

"I have the right to feel safe": Evaluation of a school-based child sexual abuse prevention program in Ecuador

BACKGROUND

Child sexual abuse (CSA) is a complex public health problem that has lifelong implications for children's wellbeing. Interventions may provide children strategies to protect themselves against CSA, but few have been studied in Latin America.

OBJECTIVE

Evaluate the immediate and medium-term impact of a 10-week educational program on children's knowledge of CSA self-protection strategies in Ecuador.

PARTICIPANTS AND SETTINGS

Children aged 7-12 years from six public elementary schools in Ecuador were cluster-randomized to either receive the intervention between October and November 2016 (Group 1, k = 4) or between March and April 2017 (Group 2, k = 2).

METHODS

To assess CSA knowledge, a random sample of students completed a questionnaire at three time points: 1) initial: before any group received the intervention, 2) intermediate: immediately after Group 1 completed the program but before Group 2 started it, and 3) final: after Group 2 completed the program. We evaluated changes in scores using mixed linear regression models with school as a clustering variable and adjusted degrees of freedom (df = 4).

RESULTS

Pre-post effect estimates at program completion adjusted for age, sex and clustering by school were 6.5% (95% CI: 2.9, 10.0) and 6.8% (95% CI 3.0, 10.7) for Groups 1 and 2, respectively. Scores did not change among children who had not yet received the intervention at intermediate evaluation (0.94%, 95%CI: -6.0, 7.9). Children in Group 1 maintained the scores six months after the program ended.

CONCLUSIONS

The self-protection program increased and maintained CSA knowledge six months after the intervention finished.

Presence of the Carcinogen N'-Nitrosonornicotine in Saliva of E-cigarette Users

Many harmful constituents are present in e-cigarettes at much lower levels than in cigarette smoke, and the results of analysis of urinary biomarkers in e-cigarette users are consistent with these findings. However, understanding the health effects of chronic exposures to e-cigarette aerosols may require thinking beyond these comparisons. In this study, we investigated the endogenous formation of the tobacco-specific oral and esophageal carcinogen N'-nitrosonornicotine (NNN) in e-cigarette users. Salivary NNN, nornicotine, and nicotine as well as urinary tobacco biomarkers, including total NNN, were analyzed in 20 e-cigarette users, 20 smokers, and 19 nonsmokers. Nornicotine and NNN levels in e-cigarettes used by the study participants were also analyzed. The mean of NNN in saliva of e-cigarette users was 14.6 (±23.1) pg/mL, ranging from nonquantifiable (below the limit of quantitation, LOQ) to 76.0 pg/mL. In smokers, salivary NNN ranged from below LOQ to 739 pg/mL, with 80% of smokers having salivary NNN in the range of levels found in e-cigarette users. Consistent with a previous report, very low levels of urinary total NNN were present in only 5 out of 20 e-cigarette users (ranging from 0.001 to 0.01 pmol/mL urine). Only trace levels of NNN were found in e-cigarette liquids. Together, our findings demonstrate that NNN is formed endogenously in e-cigarette users. While the overall exposure to NNN in e-cigarette users is dramatically lower than in smokers, the known carcinogenic potency of NNN warrants further investigations into the potential consequences of its endogenous formation. Salivary NNN, rather than urinary total NNN, which accounts for only 1-3% of the NNN dose, should be used to monitor e-cigarette users' exposure to this carcinogen.

Experimental evidence of accelerated energy transfer in turbulence

We investigate the vorticity dynamics in a turbulent vortex using scattering of acoustic waves. Two ultrasonic beams are adjusted to probe simultaneously two spatial scales in a given volume of the flow, thus allowing a dual channel recording of the dynamics of coherent vorticity structures. Our results show that this allows one to measure the average energy transfer time between different spatial length scales, and that such transfer goes faster at smaller scales.

Cytogenetic monitoring in a population occupationally exposed to pesticides in Ecuador

We analyzed the incidence of structural and numerical chromosomal aberrations (CAs) in workers of a plantation of flowers located in Quito, Ecuador, in South America. This study included 41 individuals occupationally exposed to 27 pesticides, some of which are restricted in many countries and are classified as extremely toxic by the World Health Organization; among these are aldicarb and fenamiphos. The same number of individuals of the same age, sex, and geographic area were selected as controls. Workers exposed to these pesticides showed an increased frequency of CA compared with control group (20.59% vs. 2.73%; p < 0.001). We conclude that screening for CA is an adequate biomarker for evaluating and detecting genotoxicity resulting from exposure to pesticides. Levels of erythrocyte acetylcholinesterase were also determined as a complementary metabolic study. Levels below the optimal (> 28 U/mL blood) were found in 88% of exposed individuals; this clearly shows the effect of organophosphate pesticides. When comparing the levels of acetylcholinesterase and structural CA frequencies, there was a negative linear correlation (r = 0.416; p < 0.01). We conclude that by using both analyses it may be possible to estimate damage produced by exposure to organophosphate pesticides.

Follow up study of chromosome aberrations in lymphocytes in hospital workers occupationally exposed to low levels of ionizing radiation

In the present study we analyzed and followed up on the cytogenetic effects of low levels of ionizing X-radiation on hospital workers at 72 h cultures. Samples of peripheral blood were collected from 10 hospital workers exposed to 1.84 mSv/year, and from 10 non exposed individuals, who were screened simultaneously and used as controls. The chromosomes were prepared using standard techniques. After 12 months, we undertook a second evaluation, this time with exposure to the same workers of 1.67 mSv/year. We observed 100 metaphases per subject, and there was a high percentage of altered metaphases (29.2% in the first sample and 26% in the second samples) The chromosome analysis in the second mitotic division, show aberrations such as gaps, breaks and acentric fragments, as well as other alterations such as dicentrics and rings, as well as chromosome variants (double minutes) in the exposed workers vs. the controls, and the difference was statistically highly significant (p < 0.001). There is no statistically significant difference between the first sample of exposed workers with the second one (p > 0.05). The findings in this study are interesting, because the workers were exposed to doses well below the accepted standards for exposure to radiations. Because of these unusual findings, our results could have potentially major consequences on our views on standards of exposure to radiation.

Cytokines involved in the generation of cytolytic effector T lymphocytes

The differentiation of precursor, antigen-competent, T cells into effective helper and/or cytolytic cells involves a number of different steps that are signaled by soluble molecules termed cytokines. We demonstrate here that subsets of T cells, distinguished on the basis of their expression of cell-surface markers, CD4 and CD8, receive distinct signals for differentiation. The precursor T cells of a T-cell subset that is MHC class II-restricted are readily activated by signals provided by rIL-1, rIL-2, rIL-3, or IFN-gamma. The precursor T cells of the MHC class I-restricted T-cell subset, on the other hand, are not readily activated by signals provided by rIL-1, rIL-3, or IFN-gamma. Recombinant IL-2 apparently functions in a nonrestricted manner, in that it can provide growth signals to both MHC class I- and class II-restricted T cells.