PrEP and Behavioral Health Treatment Referral Among HIV Test Counselors in Miami-Dade County: A Rapid Qualitative Study Using the Consolidated Framework for Implementation Research

HIV test counselors are well positioned to refer individuals to pre-exposure prophylaxis (PrEP) and behavioral health treatments. HIV test counselors in Miami-Dade County (N = 20), a priority jurisdiction for Ending the HIV Epidemic, completed interviews to assess determinants of PrEP and behavioral health treatment referrals. To identify determinants, we used a rapid deductive qualitative analysis approach and the Consolidated Framework for Implementation Research (CFIR). Identified determinants sometimes served as facilitators (e.g., relative priority, leadership importance) and sometimes as barriers (e.g., lack of access to knowledge and information, available resources for referrals) to making referrals. We also observed differences in determinants between PrEP and behavioral health referrals. For example, complexity (perceived difficulty of the referral) was a barrier to behavioral health more often than PrEP referral. Our findings suggest that determinants across many CFIR domains affect referral implementation, and the corresponding need for multiple implementation strategies to improve implementation of PrEP and behavioral health referrals in the context of HIV testing.

Stimulant use, HIV, and immune dysregulation among sexual minority men

BACKGROUND

Sexual minority men (SMM) report high rates of stimulant use (e.g., crystal methamphetamine, cocaine) and HIV infection. Stimulant use contributes to immune dysfunction, which enhances risk for HIV acquisition and pathogenesis. Research is needed to examine the independent and interactive relationships of stimulant use and HIV infection with systemic immune dysregulation among SMM, especially during the COVID-19 pandemic.

METHODS

From 2020-2022, 75 SMM in Miami, Florida with and without HIV completed an online survey and provided biospecimens to assess HIV status and viral load (VL), recent stimulant use, and soluble markers of immune activation and inflammation in plasma, including soluble CD14 (sCD14) and elevated high-sensitivity C-reactive protein (hs-CRP > 1.0mg/L). Sociodemographics and prior SARS-CoV-2 infection were compared across HIV status/stimulant use groups. Moderation models examined the independent and interactive associations of stimulant use and HIV status with sCD14 and elevated hs-CRP.

RESULTS

Thirty participants were persons living with HIV (PWH) (50% with stimulant use), and 45 were HIV-negative (44% with stimulant use). SARS-CoV-2 infection was not associated with stimulant use/HIV groups or immune outcomes. HIV-negative SMM without stimulant use had lower sCD14 compared to other SMM, as well as lower odds of elevated hs-CRP compared to PWH who used stimulants. Stimulant use showed independent associations with immune dysregulation that persisted after controlling for HIV status and VL, whereas HIV status was only independently associated with elevated hs-CRP in one model not controlling for VL.

CONCLUSIONS

Among SMM, stimulant use was independently associated with elevated immune activation and inflammation.

Predictors of outcomes in patients with obesity following mitral valve surgery

Objective

Few studies have assessed the outcomes of mitral valve surgery in patients with obesity. We sought to study factors that determine the in-hospital outcomes of this population to help clinicians provide optimal care.

Methods

A retrospective analysis of adult patients with obesity who underwent open mitral valve replacement or repair between January 1, 2012, and December 31, 2020, was conducted using the National Inpatient Sample. Weighted logistic regression and random forest analyses were performed to assess factors associated with mortality and the interaction of each variable.

Results

Of the 48,775 patients with obesity, 34% had morbid obesity (body mass index ≥40), 55% were women, 66% underwent elective surgery, and 55% received isolated open mitral valve replacement or repair. In-hospital mortality was 5.0% (n = 2430). After adjusting for important covariates, a greater risk of mortality was associated with older patients (adjusted odds ratio [aOR], 1.24; 95% CI, 1.08-1.43), higher Elixhauser comorbidity score (aOR, 2.10; 95% CI, 1.87-2.36), prior valve surgery (aOR, 1.63; 95% CI, 1.01-2.63), and more than 2 concomitant procedures (aOR, 2.83; 95% CI, 2.07-3.85). Lower mortality was associated with elective admissions (aOR, 0.70; 95% CI, 0.56-0.87) and valve repair (aOR, 0.58; 95% CI, 0.46-0.73). Machine learning identified several interactions associated with early mortality, such as Elixhauser score, female sex, body mass index ≥40, and kidney failure.

Conclusions

The complexity of presentation, comorbidities in older and female patients, and morbid obesity are independently associated with an increased risk of mortality in patients undergoing open mitral valve replacement or repair. Morbid obesity and sex disparity should be recognized in this population, and physicians should consider older patients and females with multiple comorbidities for earlier and more opportune treatment windows.

Factors associated with latino sexual minority men's likelihood and motivation for obtaining a COVID-19 vaccine: a mixed-methods study

Minoritized communities are underreached by biomedical interventions, such as the COVID-19 vaccine. This mixed-methods study identified factors associated with vaccine likelihood (VL) and uptake (VU) among 187 Latino sexual minority men (LSMM) in South Florida. Regression models with LASSO variable selection and Classification and Regression Trees (CART) assessed determinants of VL and VU while open-ended questions were evaluated using thematic content analysis. VL (range 1-7; M = 6.00, SD = 1.84) and VU (63.6%) was high. LASSO modeling identified being insured, worrying about others, fear of transmitting COVID-19, and financial stress as the most influential factors for VL; working remotely from home was important for VU. Time (weeks) since addition of COVID-19 vaccination-related questions (December 2nd, 2020) was associated with both outcomes across both modeling techniques. Convergence between data suggests capitalizing on altruistic motivations and improving accessibility to vaccine campaigns are valuable assets to increase LSMM's vaccine confidence.

How Trust in Cancer Information Has Changed in the Era of COVID-19: Patterns by Race and Ethnicity

COVID-19 emerged during an era of heightened attention to systemic racism and the spread of misinformation. This context may have impacted public trust in health information about chronic diseases like cancer. Here, we examine data from the 2018 and 2020 Health Information National Trends Survey (N = 7,369) to describe how trust in cancer information from government health agencies, doctors, family and friends, charitable organizations, and religious organizations changed after COVID-19 became a pandemic, and whether that change varied by race/ethnicity. Statistical methods included chi-square tests and multiple logistic regression modeling. Overall, the proportion of respondents who reported a high degree of trust in cancer information from doctors increased (73.65% vs. 77.34%, p = .04). Trends for trust in information from government health agencies and family and friends varied significantly by race/ethnicity, with substantial declines observed among non-Hispanic Blacks (NHB) only. The odds of reporting a high degree of trust in cancer information from government health agencies and friends and family decreased by 53% (OR = 0.47, 95% CI = 0.24-0.93) and 73% (OR = 0.27, 95% CI = 0.09-0.82), respectively, among NHB, but were stable for other groups. Future studies should monitor whether recent declines in trust among NHB persist and unfavorably impact participation in preventive care.

Impact of COVID-19 on HIV service delivery in Miami-Dade County: a mixed methods study

BACKGROUND

Facilitating access to HIV prevention and treatment is imperative in Miami-Dade County (MDC), a U.S. HIV epicenter. With COVID-19, disruptions to these services have occurred, leading HIV organizations to innovate and demonstrate resilience. This study documented COVID-19 related disruptions and resilient innovations in HIV services within MDC.

METHODS

This mixed methods cross-sectional study included HIV test counselors in MDC. In the quantitative component (N=106), participants reported COVID-19 impacts on HIV service delivery. Data visualization examined patterns within organizations and throughout the study period. Generalized estimating equation modeling examined differences in service disruptions and innovations. In the qualitative component, participants (N=20) completed interviews regarding COVID-19 impacts on HIV services. Rapid qualitative analysis was employed to analyze interviews.

RESULTS

Quantitative data showed that innovations generally matched or outpaced disruptions, demonstrating resilience on HIV service delivery during COVID-19. HIV testing (36%, 95%CI[28%, 46%]) and STI testing (42%, 95%CI[33%, 52%]) were most likely to be disrupted. Sexual/reproductive health (45%, 95%CI[35%, 55%]), HIV testing (57%, 95%CI[47%,66%]), HIV case management (51%, 95%CI[41%, 60%]), PrEP initiation (47%, 95%CI[37%,57%]), and STI testing (47%, 95%CI[37%, 57%]) were most likely to be innovated. Qualitative analysis revealed three orthogonal themes related to 1) disruptions (with five sub-components), 2) resilient innovations (with four sub-components), and 3) emerging and ongoing health disparities.

CONCLUSIONS

HIV organizations faced service disruptions during COVID-19 while also meaningfully innovating. Our findings point to potential changes in policy and practice that could be maintained beyond the immediate impacts of COVID-19 to enhance the resilience of HIV services. Aligning with the US Ending the HIV Epidemic Plan and the National Strategy for HIV/AIDS, capitalizing on the observed innovations would facilitate improved HIV-related health services for people living in MDC and beyond.

Racial and Ethnic Disparities in Breast Cancer Survival: Emergence of a Clinically Distinct Hispanic Black Population

OBJECTIVE

To understand the impact of Black race on breast cancer (BC) presentation, treatment, and survival among Hispanics.

SUMMARY OF BACKGROUND DATA

It is well-documented that non-Hispanic Blacks (NHB) present with late-stage disease, are less likely to complete treatment, and have worse survival compared to their non-Hispanic White (NHW) counterparts. However, no data evaluates whether this disparity extends to Hispanic Blacks (HB) and Hispanic Whites (HW). Given our location in Miami, gateway to Latin America and the Caribbean, we have the diversity to evaluate BC outcomes in HB and HW.

METHODS

Retrospective cohort study of stage I-IV BC patients treated at our institution from 2005-2017. Kaplan-Meier survival curves were generated and compared using the log-rank test. Multivariable survival models were computed using Cox proportional hazards regression.

RESULTS

Race/ethnicity distribution of 5951 patients: 28% NHW, 51% HW, 3% HB, and 18% NHB. HB were more economically disadvantaged, had more aggressive disease, and less treatment compliant compared to HW. 5-year OS by race/ethnicity was: 85% NHW, 84.8% HW, 79.4% HB, and 72.7% NHB (P < 0.001). After adjusting for covariates, NHB was an independent predictor of worse OS [hazard ratio:1.25 (95% confidence interval: 1.01-1.52), P < 0.041)].

CONCLUSIONS

In this first comprehensive analysis of HB and HW, HB have worse OS compared to HW, suggesting that race/ethnicity is a complex variable acting as a proxy for tumor and host biology, as well as individual and neighborhood-level factors impacted by structural racism. This study identifies markers of vulnerability associated with Black race and markers of resiliency associated with Hispanic ethnicity to narrow a persistent BC survival gap.

Cervical cancer risk and access: Utilizing three statistical tools to assess Haitian women in South Florida

Although decreasing rates of cervical cancer in the U.S. are attributable to health policy, immigrant women, particularly Haitians, experience disproportionate disease burden related to delayed detection and treatment. However, risk prediction and dynamics of access remain largely underexplored and unresolved in this population. This study seeks to assess cervical cancer risk and access of unscreened Haitian women. Extracted and merged from two studies, this sample includes n = 346 at-risk Haitian women in South Florida, the largest U.S. enclave of Haitians (ages 30–65 and unscreened in the previous three years). Three approaches (logistic regression [LR]; classification and regression trees [CART]; and random forest [RF]) were employed to assess the association between screening history and sociodemographic variables. LR results indicated women who reported US citizenship (OR = 3.22, 95% CI = 1.52–6.84), access to routine care (OR = 2.11, 95%CI = 1.04–4.30), and spent more years in the US (OR = 1.01, 95%CI = 1.00–1.03) were significantly more likely to report previous screening. CART results returned an accuracy of 0.75 with a tree initially splitting on women who were not citizens, then on 43 or fewer years in the U.S., and without access to routine care. RF model identified U.S. years, citizenship, and access to routine care as variables of highest importance indicated by greatest mean decreases in Gini index. The model was .79 accurate (95% CI = 0.74–0.84). This multi-pronged analysis identifies previously undocumented barriers to health screening for Haitian women. Recent US immigrants without citizenship or perceived access to routine care may be at higher risk for disease due to barriers in accessing U.S. health-systems.

Who Aren't We Reaching? Young Sexual Minority Men's Non-participation in an HIV-Prevention and Mental Health Clinical Trial

Despite many successful clinical trials to test HIV-prevention interventions for sexual minority men (SMM), not all SMM are reached by these trials. Identifying factors associated with non-participation in these trials could help to ensure the benefits of research extend to all SMM. Prospective participants in New York City and Miami were screened to determine eligibility for a baseline assessment for a mental health/HIV-prevention trial (N = 633 eligible on screen). Logistic regression and classification and regression tree (CART) analysis identified predictors of non-participation in the baseline, among those who were screened as eligible and invited to participate. Individuals who reported unknown HIV status were more likely to be non-participators than those who reported being HIV-negative (OR = 2.39; 95% CI 1.41, 4.04). In New York City, Latinx SMM were more likely to be non-participators than non-Latinx white SMM (OR = 1.81; 95% CI, 1.09, 2.98). A CART model pruned two predictors of non-participation: knowledge of HIV status and age, such that SMM with unknown HIV status and SMM ages 18-19 were less likely to participate. Young SMM who did not know their HIV status, and thus are more likely to acquire and transmit HIV, were less likely to participate. Additionally, younger SMM (18-19 years) and Latinx SMM in New York City were less likely to participate. The findings suggest the importance of tailored recruitment to ensure HIV-prevention/mental health trials reach all SMM.

Racial/Ethnic Disparities in the Incidence of Epithelial Ovarian Cancer in Florida by Histology, 2001-2015: Analysis of Trends

OBJECTIVES

Because the population in Florida is 25.6% Hispanic, it is possible to evaluate the influence of race and ethnicity within clinically relevant subgroups of women with epithelial ovarian cancer (EOC), including histology and tumor grade. This study explores racial/ethnic disparities in the incidence of EOC in Florida by histology and tumor grade.

METHODS

This study is an analysis of the Florida Cancer Database System. All incidence EOC cases from 2001 through 2015 were identified. Age-adjusted incidences were calculated and trends modeled by race/ethnicity and histology using Joinpoint and Poisson regression.

RESULTS

In total, 80% of the 21,731 women with EOC were White, followed by Hispanic (13.1%) and non-Hispanic Black (7.9%). All races/ethnicities had statistically significant declines in incidence, with non-Hispanic White and non-Hispanic Black women having the steepest declines (annual percentage change -2.5, 95% confidence interval [CI] -5.9 to -2.1 and annual percentage change -2.8, 95% CI -4.8 to -1.5, respectively). A decreased incidence trend across the time period was seen for all subgroups (relative risk 0.97 [95% CI 0.96-0.98], 0.96 [95% CI 0.96-0.99], and 0.98 [95% CI 0.96-0.99] for non-Hispanic White, non-Hispanic Black, and Hispanic). High-grade EOC incidence for all groups did not change with time.

CONCLUSIONS

We found significant declines in the incidence of EOC for all races/ethnicities, but not for high-grade EOC. The observed incidence decline in Hispanic women differs from previous research. More research is needed to understand women the causes of overall racial/ethnic differences and the decline in EOC.

SCAN360: A Resource for a 360-Degree View of Cancer Prevention, Risk, and Survival

SCAN360, an interactive web platform aiming to provide a "360-degree view" of factors that drive cancer, calculates and integrates several measures of cancer burden from the Florida Cancer Data System, the state's cancer registry, from 2012 to 2016 with cancer risk factors, clinical factors, and social determinants of health on multiple levels of geography - ranging from the entire state to the neighborhood. Integrating various sources of data, the web platform visualizes numerous indicators, including sociodemographic characteristics, cancer histology and staging, risk behaviors, screening behavior, environmental factors, hazardous sites, health insurance access, prevalence of potential comorbidities, housing characteristics, and levels of residential segregation, through maps and easy-to-interpret graphs. By walking through an example of a practical use, we show that SCAN360 provides data that are easily accessible to public health professionals, decision makers, and researchers and can assist them with identifying potential drivers of cancer burden on a localized level.

Racial and ethnic disparities in the overall survival of women with epithelial ovarian cancer in Florida, 2001-2015

Many studies have focused on white and black disparities in epithelial ovarian cancer (EOC) but fewer include Hispanics. Florida presents a unique opportunity to study racial/ethnic disparities. This study examined racial/ethnic disparities in the overall survival of women with EOC in Florida by histology. All EOC cases from 2001 through 2015 were identified in the Florida Cancer Database System (FCDS). Survival curves by race/ethnicity and histology were generated by Kaplan-Meier methods. Cox regression evaluated the associations between race/ethnicity, histology, and survival. Eligible EOC cases (n = 21,721) identified in the 2001-2015 FCDS were included in the study. The median survival for non-Hispanic whites (NHWs), non-Hispanic blacks (NHBs), and Hispanics was 31, 21, and 35 months, respectively (p < 0.001). NHB had an increased [AHR 1.23 (95% CI 1.15, 1.30)] and Hispanics a nonsignificant decreased hazard [AHR 0.96 (95% CI 0.91, 1.02)] of death compared to NHW after controlling for other demographic, treatment, and tumor characteristics. Relative to NHWs, NBH had worse survival while Hispanics had equivalent survival. Future research should consider evaluating genetic and epigenetic modifications, and prevalence of cancer syndromes to further elucidate the etiologies of disease in these disparate populations.

Emergent high fatality lung disease in systemic juvenile arthritis

OBJECTIVE

To investigate the characteristics and risk factors of a novel parenchymal lung disease (LD), increasingly detected in systemic juvenile idiopathic arthritis (sJIA).

METHODS

In a multicentre retrospective study, 61 cases were investigated using physician-reported clinical information and centralised analyses of radiological, pathological and genetic data.

RESULTS

LD was associated with distinctive features, including acute erythematous clubbing and a high frequency of anaphylactic reactions to the interleukin (IL)-6 inhibitor, tocilizumab. Serum ferritin elevation and/or significant lymphopaenia preceded LD detection. The most prevalent chest CT pattern was septal thickening, involving the periphery of multiple lobes ± ground-glass opacities. The predominant pathology (23 of 36) was pulmonary alveolar proteinosis and/or endogenous lipoid pneumonia (PAP/ELP), with atypical features including regional involvement and concomitant vascular changes. Apparent severe delayed drug hypersensitivity occurred in some cases. The 5-year survival was 42%. Whole exome sequencing (20 of 61) did not identify a novel monogenic defect or likely causal PAP-related or macrophage activation syndrome (MAS)-related mutations. Trisomy 21 and young sJIA onset increased LD risk. Exposure to IL-1 and IL-6 inhibitors (46 of 61) was associated with multiple LD features. By several indicators, severity of sJIA was comparable in drug-exposed subjects and published sJIA cohorts. MAS at sJIA onset was increased in the drug-exposed, but was not associated with LD features.

CONCLUSIONS

A rare, life-threatening lung disease in sJIA is defined by a constellation of unusual clinical characteristics. The pathology, a PAP/ELP variant, suggests macrophage dysfunction. Inhibitor exposure may promote LD, independent of sJIA severity, in a small subset of treated patients. Treatment/prevention strategies are needed.

Perioperative outcomes and complication predictors associated with open and minimally invasive nephroureterectomy

INTRODUCTION

Minimally invasive nephroureterectomy (MINU) and open nephroureterectomy (ONU) have similar oncological outcomes for treatment of upper tract urothelial carcinoma (UTUC). We investigated perioperative outcomes and predictors of complications associated with MINU and ONU.

MATERIAL AND METHODS

Using the National Surgical Quality Improvement Program (NSQIP) database, 912 patients were identified that underwent radical nephroureterectomy for UTUC between 2005 and 2013. Logistic regression and contingency table methods used preoperative covariates to predict rates of major (Clavien-Dindo grade ≥ 3) and 16 common perioperative complications. Additional comparisons between treatment groups were performed using unpaired t-tests, Wilcoxon rank-sum tests, or Fisher's Exact tests. P values were adjusted to maintain an experiment-wise p < 0.05.

RESULTS

A total of 625 (69%) and 287 (31%) patients underwent MINU and ONU, respectively. ONU was associated with a higher rate of major complications (OR: 2.5, CI: 1.2-5.1, p < 0.03). The incidence of pulmonary embolism (bias adjusted OR: 24, CI: 1.3-441, p < 0.003), postoperative pneumonia (OR: 4.9, CI: 1.7-16, p < 0.0016), and transfusion (OR: 2.7, CI: 1.8-4.0, p < 0.0001) was higher for ONU compared to MINU. There were no significant differences in the incidence of other complications. MINU took longer on average (median 223 versus 213 mins, p < 0.02). Time to discharge was longer for ONU (median 5 versus 4 days, p < 0.0001). No other covariates were independent predictors of major complications regardless of surgical approach.

CONCLUSIONS

Occurrence of major complications were higher for ONU compared to MINU. These data suggest that MINU is an acceptable surgical option with lower morbidity compared to ONU for the management of UTUC.

Obstacles to successful treatment of hepatitis C in uninsured patients from a minority population

BACKGROUND

Hepatitis C virus (HCV) treatment regimens (DAAs) are well tolerated, efficacious but costly. Their high cost and restricted availability, raises concerns about the outcome of treatment in uninsured patients. This study investigated sustained virologic response (SVR) outcomes in a predominately uninsured patient population and completion of four steps along the HCV treatment cascade.

METHODS

A retrospective chart review was conducted to characterize the patient population and analyze covariates to determine association with insurance status, attainment of SVR and progression through the HCV treatment cascade.

RESULTS

Out of a total of 216 patients, 154 (71%) were uninsured. Approximately 50% of patients (109 of 216 patients) were male and 57% were Hispanic (123 of 216 patients). Sex, race, ethnicity, treatment compliance, and rates of complications were not associated with insurance status. Insured patients were older (median 60 years vs 57 years, p-value < 0.001) and had higher rates of cirrhosis: 32 out of 62 patients (52%) vs 48 out of 154 patients (31%) (p-value = 0.005). Insured patients were tested for SVR at similar rates as uninsured patients: 84% (52 of 62 patients) vs 81% (125 of 154 patients), respectively. Of those tested for SVR, the cure rate for insured patients was 98% (51 out of 52 patients) compared to 97% (121 out of 125 patients) in the uninsured. Out of those who completed treatment, 177 of 189 (94%) were tested for attainment of SVR. Compliance rates were significantly different between tested and untested patients: 88% (156 of 177 patients) vs 0% (0 of 12 patients), respectively (p-value < 0.001). However, insurance status, race ethnicity, cirrhosis, and complications were not associated with being tested for SVR.

CONCLUSIONS

These results demonstrate that insured and uninsured patients with chronic HCV infection, with access to patient assistance programs, can be treated and have comparable clinical outcomes. In addition, testing for SVR remains an important obstacle in completion of the HCV treatment cascade. Nevertheless, patient assistance programs remove a significant barrier for treatment access in real-world HCV infected populations.

African-American Men with Gleason Score 3+3=6 Prostate Cancer Produce Less Prostate Specific Antigen than Caucasian Men: A Potential Impact on Active Surveillance

PURPOSE

We assess the difference in prostate specific antigen production between African-American and Caucasian men with Gleason score 3+3=6 prostate cancer.

MATERIALS AND METHODS

We measured tumor volume in 414 consecutive radical prostatectomies from men with National Comprehensive Cancer Network(®) low risk prostate cancer (348 Caucasian, 66 African-American) who had Gleason score 3+3=6 disease at radical prostatectomy. We then compared clinical presentation, pathological findings, prostate specific antigen, prostate specific antigen density and prostate specific antigen mass (an absolute amount of prostate specific antigen in patient's circulation) between African-American and Caucasian men. The t-test and Wilcoxon rank sum were used for comparison of means.

RESULTS

African-American and Caucasian men had similar clinical findings based on age, body mass index and prostate specific antigen. There were no statistically significant differences between the dominant tumor nodule volume and total tumor volume (mean 0.712 vs 0.665 cm(3), p=0.695) between African-American and Caucasian men. Prostates were heavier in African-American men (mean 55.4 vs 46.3 gm, p <0.03). Despite the significantly greater weight of benign prostate tissue contributing to prostate specific antigen in African-American men, prostate specific antigen mass was not different from that of Caucasian men (mean 0.55 vs 0.558 μg, p=0.95). Prostate specific antigen density was significantly less in African-American men due to larger prostates (mean 0.09 vs 0.105, p <0.02).

CONCLUSIONS

African-American men with Gleason score 3+3=6 prostate cancer produce less prostate specific antigen than Caucasian men. African-American and Caucasian men had equal serum prostate specific antigen and prostate specific antigen mass despite significantly larger prostates in African-American men with all other parameters, particularly total tumor volume, being the same. This finding has practical implications in T1c cases diagnosed with prostate cancer due to prostate specific antigen screening. Lowering the prostate specific antigen density threshold in African-American men may account for this disparity, particularly in selecting patients for active surveillance programs.

Markedly improved overall survival in 10 consecutive patients with metastatic basal cell carcinoma

BACKGROUND

Metastatic basal cell carcinoma (BCC) is a rare but life-threatening condition. Prior estimates of overall survival (OS) from time of diagnosis of distant metastasis to death are approximately 8-14 months. However, these estimates are based on analyses of case reports published prior to 1984.

OBJECTIVES

To assess an updated OS in patients with metastatic BCC at a single academic institution.

METHODS

Using patients seen from 1997 to 2011, a retrospective chart review was performed on biopsy-confirmed cases of distant metastatic BCC at Stanford University School of Medicine. Kaplan-Meier analysis was used to determine OS and progression-free survival (PFS).

RESULTS

Ten consecutive cases of distant metastatic BCC were identified. Median OS was 7·3 years [95% confidence interval (CI) 1·6-∞]; median PFS was 3·4 years (95% CI 1·1-5·2).

CONCLUSIONS

Our findings suggest that OS in patients with distant metastatic BCC may be more favourable than previously reported.

Response to valganciclovir in chronic fatigue syndrome patients with human herpesvirus 6 and Epstein-Barr virus IgG antibody titers

Valganciclovir has been reported to improve physical and cognitive symptoms in patients with chronic fatigue syndrome (CFS) with elevated human herpesvirus 6 (HHV-6) and Epstein-Barr virus (EBV) IgG antibody titers. This study investigated whether antibody titers against HHV-6 and EBV were associated with clinical response to valganciclovir in a subset of CFS patients. An uncontrolled, unblinded retrospective chart review was performed on 61 CFS patients treated with 900 mg valganciclovir daily (55 of whom took an induction dose of 1,800 mg daily for the first 3 weeks). Antibody titers were considered high if HHV-6 IgG ≥ 1:320, EBV viral capsid antigen (VCA) IgG ≥ 1:640, and EBV early antigen (EA) IgG ≥ 1:160. Patients self-rated physical and cognitive functioning as a percentage of their functioning prior to illness. Patients were categorized as responders if they experienced at least 30% improvement in physical and/or cognitive functioning. Thirty-two patients (52%) were categorized as responders. Among these, 19 patients (59%) responded physically and 26 patients (81%) responded cognitively. Baseline antibody titers showed no significant association with response. After treatment, the average change in physical and cognitive functioning levels for all patients was +19% and +23%, respectively (P < 0.0001). Longer treatment was associated with improved response (P = 0.0002). No significant difference was found between responders and non-responders among other variables analyzed. Valganciclovir treatment, independent of the baseline antibody titers, was associated with self-rated improvement in physical and cognitive functioning for CFS patients who had positive HHV-6 and/or EBV serologies. Longer valganciclovir treatment correlated with an improved response.

Risk of therapy-related secondary leukemia in Hodgkin lymphoma: the Stanford University experience over three generations of clinical trials

PURPOSE

To assess therapy-related acute myeloid leukemia/myelodysplastic syndrome (t-AML/MDS) risk in patients treated for Hodgkin lymphoma (HL) on successive generations of Stanford clinical trials.

PATIENTS AND METHODS

Patients with HL treated at Stanford with at least 5 years of follow-up after completing therapy were identified from our database. Records were reviewed for outcome and development of t-AML/MDS.

RESULTS

Seven hundred fifty-four patients treated from 1974 to 2003 were identified. Therapy varied across studies. Radiotherapy evolved from extended fields (S and C studies) to involved fields (G studies). Primary chemotherapy was mechlorethamine, vincristine, procarbazine, and prednisone (MOPP) or procarbazine, mechlorethamine, and vinblastine (PAVe) in S studies; MOPP, PAVe, vinblastine, bleomycin, and methotrexate (VBM), or doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) in C studies; and VbM (reduced dose of bleomycin compared with VBM) or mechlorethamine, doxorubicin, vinblastine, vincristine, bleomycin, etoposide, and prednisone (Stanford V) in G studies. Cumulative exposure to alkylating agent (AA) was notably lower in the G studies compared with the S and C studies, with a 75% to 83% lower dose of nitrogen mustard in addition to omission of procarbazine and melphalan. Twenty-four (3.2%) of 754 patients developed t-AML/MDS, 15 after primary chemotherapy and nine after salvage chemotherapy for relapsed HL. The incidence of t-AML/MDS was significantly lower in the G studies (0.3%) compared with the S (5.7%) or C (5.2%) studies (P < .001). Additionally, in the G studies, no t-AML/MDS was noted after primary therapy, and the only patient who developed t-AML/MDS did so after second-line therapy.

CONCLUSION

Our data demonstrate the relationship between the cumulative AA dose and t-AML/MDS. Limiting the dose of AA and decreased need for secondary treatments have significantly reduced the incidence of t-AML/MDS, which was extremely rare in the G studies (Stanford V era).

Early outcomes after extracardiac conduit Fontan operation without cardiopulmonary bypass

Cardiopulmonary bypass is associated with a systemic inflammatory response. The authors hypothesized that avoiding cardiopulmonary bypass would lead to improved postoperative outcomes for patients undergoing the extracardiac Fontan operation, the final stage in surgical palliation of univentricular congenital heart defects. A review of the Children's Heart Center Database showed a total of 73 patients who underwent an initial Fontan operation at Lucile Packard Children's Hospital at Stanford between 1 November 2001 and 1 November 2006. These patients were divided into two groups: those who underwent cardiopulmonary bypass (n = 26) and those who avoided cardiopulmonary bypass (n = 47). Preoperative demographics, hemodynamics, and early postoperative outcomes were analyzed. The two groups had comparable preoperative demographic characteristics and hemodynamics except that the average weight of the off-bypass group was greater (17.9 ± 9.1 vs 14.2 ± 2.7 kg; P = 0.01). Intraoperatively, the off-bypass group trended toward a lower rate of Fontan fenestration (4.3 vs 19.2%; P = 0.09), had lower common atrial pressures (4.6 ± 1.4 vs 5.5 ± 1.5 mmHg; P = 0.05), and Fontan pressures (11.9 ± 2.1 vs 14.2 ± 2.4 mmHg; P ≤ 0.01), and required less blood product (59.1 ± 37.6 vs 91.9 ± 49.4 ml/kg; P ≤ 0.01). Postoperatively, there were no significant differences in hemodynamic parameters, postoperative colloid requirements, duration of mechanical ventilation, volume or duration of pleural drainage, or duration of cardiovascular intensive care unit or hospital stay. Avoiding cardiopulmonary bypass influenced intraoperative hemodynamics and the incidence of fenestration but did not have a significant impact on the early postoperative outcomes of children undergoing the Fontan procedure.

Variations in normal serum alpha-fetoprotein (AFP) levels in patients with testicular cancer on surveillance

BACKGROUND

The aim of this study was to assess fluctuations in normal serum alpha-fetoprotein (AFP) levels in patients with germ cell cancer. Marked variations occur after serum AFP levels normalize, creating anxiety among patients and physicians during surveillance.

PATIENTS AND METHODS

We conducted a retrospective review of patients with germ cell tumors in clinical remission, who had normal AFP levels and were followed at our center from 1991 to 2009. 72 patients, with a median follow-up of 50 months, were identified.

RESULTS

Of the 72 patients, 57 (79%) had a non-seminomatous germ cell histology, and 15 (21%) had seminomas. Seminomas were included as controls as serum AFP levels do not increase in this group. 68 patients underwent orchiectomy, and 50 patients received systemic chemotherapy. The majority of patients (93%) demonstrated fluctuations in serum AFP. There was no difference in the mean AFP values between patients with seminona (2.95 ng/ml) and those with non-seminomatous germ cell tumors (3.3 ng/ml) (standard deviation 1.01 ng/ml).

CONCLUSION

Marked variations occur after serum AFP levels normalize in patients undergoing surveillance. Fluctuating AFP levels within normal limits did not result in relapse in our cohort of patients with extended follow-up.

Correlation of subjective questionnaires with cardiac function as determined by exercise testing in a pediatric population

BACKGROUND

Although exercise testing is an important objective method used to assess cardiopulmonary function, subjective assessment often is used as a proxy in the clinical setting. This study aimed to determine whether responses to a subjective functional capacity questionnaire administered to parents and patients in a pediatric exercise laboratory correlate with objective assessment of functional capacity, measured by peak oxygen consumption during maximal voluntary exercise testing.

METHODS

Subjective questionnaire responses and exercise test results collected over 10 years were retrospectively analyzed. Symptoms and physical capabilities were assessed using a 6-point Likert scale regarding the ability to attend school/work, walk, climb stairs, and run, as well as the frequency of fatigue, palpitations, and chest pain. Values of 0 to 3 were considered abnormal, whereas values of 4-5 were regarded as normal. Exercise testing was performed on a stationary cycle ergometer with a continuous ramping protocol. Heart rate and oxygen saturation were continuously monitored. Blood pressures and electrocardiograms (ECGs) were obtained at 2-min intervals. Metabolic gas analysis was performed using a breath-by-breath method. The results of the exercise testing were normalized for body size and expressed as a percentage of predicted peak oxygen consumption (%pVO(2)).

RESULTS

Very weak but statistically significant correlations (τ < 0.25; P < 0.05) between the scores of the school/work, walking, stair climbing, running, and fatigue items and %pVO(2) were found using Kendall's rank correlations.

CONCLUSIONS

The subjective Likert scales used to assess basic physical capacity and cardiac-associated symptoms have limited ability to predict actual functional capacity as measured by %pVO(2) achieved. The very weak rank-order correlation between %pVO(2) achieved and the subjective reporting of the ability to attend school/work, walk, climb stairs, and run has low clinical significance and will not be useful in predicting functional capacity within the clinic setting.

Improving alertness and performance in emergency department physicians and nurses: the use of planned naps

STUDY OBJECTIVE

We examine whether a 40-minute nap opportunity at 3 AM can improve cognitive and psychomotor performance in physicians and nurses working 12-hour night shifts.

METHODS

This is a randomized controlled trial of 49 physicians and nurses working 3 consecutive night shifts in an academic emergency department. Subjects were randomized to a control group (no-nap condition=NONE) or nap intervention group (40-minute nap opportunity at 3 AM=NAP). The main outcome measures were Psychomotor Vigilance Task, Probe Recall Memory Task, CathSim intravenous insertion virtual reality simulation, and Profile of Mood States, which were administered before (6:30 PM), during (4 AM), and after (7:30 AM) night shifts. A 40-minute driving simulation was administered at 8 AM and videotaped for behavioral signs of sleepiness and driving accuracy. During the nap period, standard polysomnographic data were recorded.

RESULTS

Polysomnographic data revealed that 90% of nap subjects were able to sleep for an average of 24.8 minutes (SD 11.1). At 7:30 AM, the nap group had fewer performance lapses (NAP 3.13, NONE 4.12; p<0.03; mean difference 0.99; 95% CI: -0.1-2.08), reported more vigor (NAP 4.44, NONE 2.39; p<0.03; mean difference 2.05; 95% CI: 0.63-3.47), less fatigue (NAP 7.4, NONE 10.43; p<0.05; mean difference 3.03; 95% CI: 1.11-4.95), and less sleepiness (NAP 5.36, NONE 6.48; p<0.03; mean difference 1.12; 95% CI: 0.41-1.83). They tended to more quickly complete the intravenous insertion (NAP 66.40 sec, NONE 86.48 sec; p=0.10; mean difference 20.08; 95% CI: 4.64-35.52), exhibit less dangerous driving and display fewer behavioral signs of sleepiness during the driving simulation. Immediately after the nap (4 AM), the subjects scored more poorly on Probed Recall Memory (NAP 2.76, NONE 3.7; p<0.05; mean difference 0.94; 95% CI: 0.20-1.68).

CONCLUSION

A nap at 3 AM improved performance and subjective report in physicians and nurses at 7:30 AM compared to a no-nap condition. Immediately after the nap, memory temporarily worsened. The nap group did not perform any better than the no-nap group during a simulated drive home after the night shift.