Stigma manifestations in cardiomyopathy care impact outcomes for black patients: a qualitative study

INTRODUCTION

Inequities in clinical care may contribute to racial disparities observed in studies of heart disease morbidity and cardiogenetic testing outcomes. There is a lack of research aimed at understanding the complexity of those inequities, but stigma likely contributes. This qualitative exploratory study helps close that gap in the literature by describing intersectional stigma manifestations perceived by the Black cardiomyopathy patient population at one academic medical center.

METHODS

Qualitative interviews were conducted with 14 Black cardiomyopathy patients. Interviews aimed to elicit patients' experiences with discrimination related to diagnosis, symptoms, genetic testing, knowledge of genetic results, genetic counseling, providers' actions, and providers' communication. The interview guide was informed by The Health Stigma and Discrimination Framework. Data were also collected about participant demographics, type of cardiomyopathy, age of diagnosis, documentation of relevant family history, and completion of genetic counseling and/or genetic testing.

RESULTS

More than half of participants reported intersectional stigma manifestations related to their race, age, and/or weight while receiving care from cardiologists, nurse practitioners, genetic counselors, or clinical support staff. Stigma manifestations included physical roughness during patient care, withholding diagnostically-relevant information from the patient, impersonal care, coercion, and use of offensive stereotyped language by providers. These stigma manifestations impacted access to care, uptake of genetic testing, timeline to diagnosis, patient emotion, patient-provider trust, and adherence to medical recommendations.

CONCLUSIONS

This study provides nuanced qualitative descriptions of stigma manifestations that affect patient and clinical outcomes in cardiology care and genetic services in one medical center in the Southeastern United States. The results of this study suggest that provider bias and stigma manifestations have an adverse effect on cardiogenetic and clinical outcomes among Black cardiomyopathy patients. Clinical interventions are suggested to assist health professionals in providing culturally-competent and respectful care. These results help inform patient-provider communication, clinical policies, and evidence-based practice in cardiology care and genetics. Continued study of this topic across more institutions and with a larger sample size is needed to confirm the generalizability of the conclusions.

Obesity Increases the Risk of Hospital Readmission Following Intestinal Surgery for Children With Crohn Disease

OBJECTIVES

Obese habitus can lead to adverse outcomes for colorectal surgeries due to technical challenges and pro-inflammatory immune mediators associated with excess adipose tissue. Surgical planning, pre-operative risk stratification, and patient counseling of pediatric Crohn disease (CD) patients are limited by the scarcity of data on this topic. We sought to determine the association between obesity and hospital readmission in children with CD undergoing intestinal resection.

METHODS

We used the National Surgical Quality Improvement Program-Pediatric (NSQIP-P) database to identify pediatric CD patients undergoing intestinal resection between 2012 and 2018. We calculated age- and sex-adjusted body mass index (BMI) z scores using CDC population statistics. We used logistic regression to evaluate the association between obesity and readmission compared to average-BMI patients adjusting for age, race, sex, steroid exposure, disease activity, and surgery type.

RESULTS

We evaluated 1258 pediatric CD intestinal resections occurring between 2012 and 2018. Patients were predominantly adolescent (91%), white (84%), and male (56%). Those with average BMI comprised 50% of the cohort, 31% were underweight, 11% overweight, and 8% obese. The overall 30-day hospital readmission rate was 8.8%. Compared to those with average BMI, obese children had a 2-fold (adjusted odds ratio 1.9, 95% confidence interval 1.0-3.8) increase in risk of hospital readmission.

CONCLUSIONS

Obese patients undergoing intestinal resection face a higher risk of 30-day hospital readmission compared to average-BMI patients. These results can inform pre-surgical risk counseling and underscore the need for long-term weight management strategies to aid in risk reduction for obese children with CD at risk of future surgery.

Bridging Endocrine Therapy for HR+/HER2- Resectable Breast Cancer: Is it Safe?

BACKGROUND

The COVID-19 pandemic has required new treatment paradigms to limit exposures and optimize hospital resources, including the use of neoadjuvant endocrine therapy (NAET) as bridging therapy for HR+/HER2-invasive tumors and DCIS. While this approach has been used in locally advanced disease, it is unclear how it may affect outcomes in resectable HR+/HER2- tumors.

METHODS

Women ≥18 years diagnosed with in situ (Tis) or non-metastatic HR+/HER2- breast cancer from March-May 2019 and 2020 were included. Fisher's exact test and two-sample t test were used to compare baseline characteristics and surgical outcomes between strata. Sub-analysis was performed between patients who received primary surgery vs a bridging NAET approach.

RESULTS

Despite similar clinical characteristics, patients in 2019 were more likely to have a surgery-first approach (75% vs 42%, P-value = .0007), receive surgery sooner (22 vs 29 days, P-value < .001), and within 60 days from diagnosis date (100% vs 85%, P-value = .0301). Neoadjuvant endocrine therapy was a more prevalent approach in 2020 (48% vs 7%, P-value < .0001). Rates of clinical to pathologic up-staging remained consistent across primary surgery vs bridging NAET subgroups (P-value = .9253).

DISCUSSION

Pandemic-driven treatment protocols provide a unique opportunity to assess the utility of bridging endocrine therapy for resectable HR+/HER2- tumors. Differences in clinical and pathologic staging were similar across groups and did not appear to be affected by receipt of NAET. Our limited cohort demonstrates this strategic therapeutic avenue can optimize health care utilization and may be a reasonable approach when delaying surgery is preferred.

Use and disparities in parathyroidectomy for symptomatic primary hyperparathyroidism in the Medicare population

BACKGROUND

Few studies assess use of parathyroidectomy among older adults with symptomatic primary hyperparathyroidism. Our objective was to determine national usage and disparities in parathyroidectomy for symptomatic primary hyperparathyroidism among insured older adults.

METHODS

We identified older adult patients with symptomatic primary hyperparathyroidism using Medicare claims (2006-2017). Primary study variables were race/ethnicity, rurality, and zip-code socioeconomic status. We calculated cumulative incidence of parathyroidectomy and used multivariable Cox proportional hazards regression models to assess the adjusted association of our study variables with parathyroidectomy.

RESULTS

We included 94,803 patients. The median age at primary hyperparathyroidism diagnosis was 76 years (interquartile range 71-82). The majority of patients were female (72%), non-Hispanic White (82%), from metropolitan areas (82%), and had a Charlson Comorbidity score ≥3 (62%). Nine percent of patients (n = 8,251) underwent parathyroidectomy during follow-up. After adjustment, non-Hispanic Black patients, compared to non-Hispanic White (hazard ratio 0.80; 95% confidence interval 0.74, 0.87), and living in a low socioeconomic status neighborhood (low socioeconomic status vs highest socioeconomic status hazard ratio 0.89; 95% confidence interval 0.83, 0.95) were both associated with lower incidences of parathyroidectomy. Patients from non-metropolitan areas were more likely to undergo parathyroidectomy.

CONCLUSION

Parathyroidectomy is underused for symptomatic primary hyperparathyroidism in older adults. Quality improvement efforts, rooted in equitable care, should be undertaken to increase access to parathyroidectomy for this disease.

Effectiveness of Fresh to You, a Discount Fresh Fruit and Vegetable Market in Low-Income Neighborhoods, on Children's Fruit and Vegetable Consumption, Rhode Island, 2010-2011

Introduction

Eating fruits and vegetables is associated with lowered risk for many chronic diseases. However, most Americans, especially members of low-income and minority populations, do not eat adequate amounts. Fresh to You is a public–private partnership program that brings discount fresh produce markets into low-income neighborhoods. We conducted a mixed-methods evaluation of Fresh to You to assess the effect of the program on children’s consumption of fruits and vegetables.

Methods

A local produce distributor brought the Fresh to You markets to 6 community organizations serving low-income families in Rhode Island. The markets, held weekly for 5 months at each site, sold fresh produce at below-retail prices. Parents (N = 480) of children aged 3 to 13 years were recruited at the markets to participate in a 5-month cohort study. The primary outcome was change in children’s fruit and vegetable intake, measured by a validated screener. We also conducted postintervention focus groups at each site with parents and qualitative interviews with site contacts to collect feedback about Fresh to You.

Results

From baseline to 5 months, there was a significant increase in children’s daily fruit and vegetable consumption of 0.48 cups (t = 4.16, P < .001). Data from follow-up parent surveys, focus groups, and site contact interviews provided positive feedback about Fresh to You and recommendations for improvement.

Conclusion

Fresh to You was effective at increasing consumption of fruits and vegetables among racially and ethnically diverse low-income children aged 3 to 13 years whose parents shopped at the markets. The intervention could serve as a model program for replication in other cities. Refinements and a more rigorous evaluation are needed.

Substituent effects on the oxidation and reduction potentials of phenylthiyl radicals in acetonitrile

Oxidation (E(1/2)(ox)) and reduction potentials (E(1/2)(red)) of a series of para-substituted phenylthiyl radicals XC(6)H(4)S* generated from the pertinent disulfides or thiophenols have been measured by means of photomodulated voltammetry in acetonitrile. The values of E(1/2)(ox) are of particular interest as they give access to the hitherto unknown thermochemistry of short-lived phenylsulfenium cations in solution. Both E(1/2)(OX) and E(1/2)(red) decrease as the electron-donating power of the substituent raises, resulting in linear correlations with the Hammett substituent coefficient sigma(+) with slopes rho(+) of 4.7 and 6.4, respectively. The finding of a larger substituent effect on than is a consequence of a corresponding development in the electron affinities and ionization potentials of XC(6)H(4)S* as revealed by quantum-chemical calculations. Solvation energies extracted for XC(6)H(4)S(+) and XC(6)H(4)S(-) from thermochemical cycles show the expected substituent dependency; i.e., the absolute values of the solvation energies decrease as the charge becomes more delocalized in the ions. Acetonitrile is better in solvating XC(6)H(4)S(+) than XC(6)H(4)S(-) for most substituents, even if there is a substantial delocalization of the charge in the series of phenylsulfenium cations. The substituent effect on is smaller in aqueous solution than acetonitrile, which is attributed to the ability of water to stabilize in particular localized anions through hydrogen bonding.

Catalytic enantioselective 1,3-dipolar cycloaddition reactions of cyclic nitrones: a simple approach for the formation of optically active isoquinoline derivatives

The first highly diastereo- and enantioselective catalytic 1, 3-dipolar cycloaddition reaction of cyclic nitrones activated by chiral Lewis acids with electron-rich alkenes has been developed. The nitrones, mainly 3,4-dihydroisoquinoline N-oxides, are activated by chiral 3,3'-aryl BINOL-AlMe complexes and undergo a regio-, diastereo-, and enantioselective 1,3-dipolar cycloaddition reaction with especially alkyl vinyl ethers, giving the exo diastereomer of the cycloaddition products in high yield, >90% de and up to 85% ee. The reaction has been investigated under various conditions, and it is demonstrated that the reaction is an attractive synthetic procedure for the introduction of a chiral center in the 1-position of the isoquinoline skeleton. The mechanism of the reaction is discussed on the basis of the assignment of the absolute configuration of the cycloaddition product and theoretical calculations.

Development of an unusually highly enantioselective hetero-Diels-Alder reaction of benzaldehyde with activated dienes catalyzed by hypercoordinating chiral aluminum complexes

The effect of Lewis acid catalysis of the hetero-Diels-Alder reaction between benzaldehyde and activated dienes (e.g. the Danishefsky's diene) has been investigated. In the present work we decided to study a series of chiral aluminum complexes as potential catalysts for the hetero-Diels-Alder reaction in order to gain a better understanding of the effect on the chiral induction of varying the steric and electronic environment of the metal ion. The results of this study prompted us to conclude that steric effects in the ligand coordination sphere and hypercoordination are strongly contributing factors to the optical yield of the reaction. Optimization of the reaction culminated in the synthesis of the hetero-Diels-Alder product in 99.4% ee and 97% yield of the isolated product. Based on the experimental results the mechanism for the hetero-Diels-Alder reaction is discussed and it is postulated that hypercoordination to the chiral aluminum Lewis acid center is of importance for the reaction.

Neural tube defect prevalence in California (1990-1994): eliciting patterns by type of defect and maternal race/ethnicity

This study presents race/ethnicity-specific prevalence estimates of neural tube defects (NTDs) in California using 5 years of population-based data. NTD prevalence estimates include prenatally diagnosed cases, as well as cases diagnosed at birth. The California NTD Registry contains NTD case reports identified through the California Maternal Serum Alpha-Feto Protein (AFP) Screening Program, the California Birth Defects Monitoring Program, and additional reports from clinicians and clinics throughout the state. These data were used to estimate NTD prevalence in a large population-based study (n = 1,618,279). The overall NTD prevalence among White, Black, Hispanic, and Asian women are reported, as well as race/ethnic prevalence, for anencephaly, spina bifida, and encephalocele. Rates are expressed as the number of cases per 1,000 women screened between 1990 and 1994. Among 1,457 women with an NTD-affected pregnancy, the overall rate for anencephaly, spina bifida, and encephalocele was 0.49 (95% CI 0.46-0.53), 0.42 (95% CI 0.38-0.45), and 0.08 (95% CI 0.07-0.09), respectively. When these types of NTDs are combined, Hispanic women had the highest overall rate (1.12, 95% CI 1.04-1.21), followed by Whites (0.96, 95% CI 0.89-1.04), Blacks (0.75, 95% CI 0.59-0.91), and Asians (0.75, 95% CI 0.60-0.90). Hispanic women were 45% more likely than White women to have a pregnancy affected with anencephaly (odds ratio = 1.45, 95% CI 1.24-1.70), while Asian women were over two times less likely to have a pregnancy affected with spina bifida (odds ratio = 0.44, 95% CI 0.29-0.65). Considerable variation exists in the prevalence of NTDs by race/ethnicity and by type of NTD, with Hispanic women exhibiting the highest overall NTD rate.

The dishonest dean's letter: an analysis of 532 dean's letters from 99 U.S. medical schools

PURPOSE

To quantify the censure of potentially negative information in dean's letters.

METHOD

Concordance between 532 dean's letters and the corresponding transcripts was determined for six variables (failing grade in a preclinical course, marginal preclinical course grade, failing grade for a clinical rotation, marginal clinical rotation grade, leave of absence, and requirement to repeat an entire year of medical school).

RESULTS

The evaluated variables were not found in the dean's letters 27% to 50% of the time that they were present on the transcripts. In three of nine instances (33%), a failing grade in a clinical rotation was not included. Four students had been required to repeat an entire year, but this was noted in only two cases. In toto, 35 of 104 (34%) of the variables identified on the transcripts were not reported. In addition, deans were significantly less likely to report a student's USMLE 1 score if the score was at or below the 20th percentile (p = .03).

CONCLUSION

Some deans suppress negative information in their letters and potentially obfuscate the residency selection process.

Where does it hurt? Stability of recordings of pain location using the McGill Pain Map

OBJECTIVE

To evaluate the validity and reliability of recordings of pain location among patients with pain from 2 different sources, using the McGill Pain Map (MPM).

METHODS

Consecutive outpatients from a rheumatology clinic and inpatients recovering from surgical interventions participated in a structured interview during which the McGill Pain Questionnaire and the MPM were administered. After an interval of 3 to 6 weeks for the rheumatology patients and 1 to 2 days for the postoperative patients, a 2nd identical interview was administered. Criterion related validity was examined by testing whether the extent [total number of painful areas (NPA)] and distribution (individual body areas affected) of pain differed significantly between the 2 patient groups and whether, among postoperative patients, the distribution of pain was consistent with the site of surgical incision. Test-retest reliability of the recordings on the MPM was measured by calculating a kappa coefficient for each individual body area on the MPM, and an intraclass correlation coefficient for the NPA.

RESULTS

51 rheumatology and 47 postoperative patients were interviewed. Significant differences in the total NPA (4.1 +/- 3.0 vs 11.5 +/- 6.2; p < 0.001) and in the distribution of the painful areas were observed between the 2 groups. Among postoperative patients, there was no significant difference in the NPA between the 2 interviews (4.1 +/- 3.0 vs 4.3 +/- 3.5; p = 0.53), while among rheumatology patients, there was a reduction in the NPA at the second interview (11.5 +/- 6.2 vs 9.8 +/- 5.3; p = 0.007). Reliability of the recordings of pain location by individual areas averaged 0.50 (range 0.04 to 0.76). The reliability of the NPA was 0.82 for the combined group of patients (0.71 and 0.84, respectively).

CONCLUSION

Recordings of pain location using the MPM are valid and reliable. The MPM is a valuable instrument for studies of the distribution of pain in populations.

Properties of single chloride selective channel from sarcoplasmic reticulum

The behavior of single chloride channels in sarcoplasmic reticulum of rabbit and trout skeletal muscle was examined by fusing isolated vesicle fractions into planar lipid bilayers. The channel exhibited a full open state with a unit conductance of 65 pS (in 100 mM Cl-) and several subconductance states with reversal potentials which were dependent on the chloride gradient across the bilayer. Open probability was 0.6-0.95 for membrane potentials ranging from -60 to +60 mV. The kinetic behaviour could be described by assuming one time constant for the fully conducting channel, and at least two time constants for the non-conducting channel. In the presence of methane sulfonate, sulfate and phosphate anions, a decrease in the unit current amplitude but not open time argued in favor of a competition between these anions and Cl- at the transport site of the channel. Chloride channel activity was not affected by variations of Ca2+ concentration in both chambers or by the presence of Mg2+. Similarly, neither millimolar ATP nor the presence of the drugs taurine (up to 10 mM), lidocaine (2-40 microM) or the calmodulin antagonist W7 (5-150 microM), modified channel behavior. Finally, pH variations between 6.8 to 8 were without effect.

Adhesive and non-adhesive membrane domains of amphibian embryo cells

Superficial blastomeres of mid-cleavage stage amphibian embryos (32- and 64-cell stage) display regional cell-surface differences in adhesiveness. The cells are adhesive on the lateral and basal cell surfaces and non-adhesive on the apical surface. These adhesive differences are maintained by single cells which have been dissociated from the intact embryo. Pigmentation differences afford a means of distinguishing apical surface from basal/lateral surface in dissociated cells. The apical surface is underlain by melanin granules and so appears dark, whereas the lateral and basal surfaces lack pigment and are white. Scanning electron-micrograph observations of isolated superficial cells reveal striking morphological differences between the adhesive and non-adhesive regions. The apical (non-adhesive) portion of the cell surface has a convoluted appearance and is almost entirely devoid of microvilli. The lateral and basal (adhesive) surfaces lack the convolutions of the apical surface and bear scattered microvilli. The isolated superficial cells continue to divide in culture. The cells display a unilateral or one-sided furrow which begins in the basal surface and progresses toward the apical surface. The plane of cleavage of most of the cells is oriented such that the pigmented cap is bisected, with very few cells having the plane of the furrow pass parallel to the apical surface. The direction of furrowing in the isolated cells from the 32- to 64-cell embryo represents a direction of furrow progression in the intact embryo from the interior to the surface. Since the early cleavages are initiated at the surface and progress into the interior, it is suggested that a reversal in direction of furrowing occurs by mid-cleavage stages.

Distribution of concanavalin A receptor sites on specific populations of embryonic cells

The early 32- to 64-cell stage of the sea urchin embryo consists of three cell types, easily distinguishable by size: micromeres, mesomeres, and macromeres. Only the micromeres are migratory. Treatment of dissociated sea urchin embryo cells with fluorescein-labeled concanavalin A (Con A) revealed a Con A-induced highly clustered or capped distribution of receptor sites on the micromeres. Concanavalin A did not induce significant clustering or capping of receptor sites on the mesomeres or macromeres. The results indicate that Con A receptor sites are more mobile on specific population of malignant-like migratory embryonic cells.