The association of pre-cancer diagnosis cardiovascular risk factors with memory aging after a cancer diagnosis, overall and by race/ethnicity

PURPOSE

Cardiovascular risk factors (CVRFs) are associated with increased risk for cognitive impairment and decline in the general population, but less is known about how CVRFs might influence cognitive aging among older cancer survivors. We aimed to determine how CVRFs prior to a cancer diagnosis affect post-cancer diagnosis memory aging, compared to cancer-free adults, and by race/ethnicity.

METHODS

Incident cancer diagnoses and memory (immediate and delayed recall) were assessed biennially in the US Health and Retirement Study (N = 5,736, 1998-2018). CVRFs measured at the wave prior to a cancer diagnosis included self-reported cigarette smoking, obesity, diabetes, heart disease, hypertension, and stroke. Multivariable-adjusted linear mixed-effects models evaluated the rate of change in standardized memory score (SD/decade) post-cancer diagnosis for those with no, medium, and high CVRFs, compared to matched cancer-free adults, overall and stratified by sex and race/ethnicity.

RESULTS

Higher number of CVRFs was associated with worse baseline memory for both men and women, regardless of cancer status. Cancer survivors with medium CVRFs had slightly slower rates of memory decline over time relative to cancer-free participants (0.04 SD units/decade [95% CI: 0.001, 0.08]). Non-Hispanic Black (NHB) and Hispanic cancer-free participants and cancer survivors had worse baseline memory than their Non-Hispanic White (NHW) counterparts.

CONCLUSIONS

CVRFs were associated with worse baseline memory function, but not decline, for cancer-free adults and cancer survivors. Racial disparities were largely similar between cancer survivors and cancer-free adults.

IMPLICATIONS FOR CANCER SURVIVORS

These findings may inform hypotheses about pre-diagnosis multimorbidity and cognitive aging of cancer survivors from diverse groups.

Does neighborhood socioeconomic status alter memory change associated with a cancer diagnosis? Preliminary evidence from the US Health and Retirement Study

BACKGROUND

Neighborhood disadvantage has been linked to cognitive impairment, but little is known about the effect of neighborhood disadvantage on long-term cancer-related memory decline.

METHODS

Incident cancer diagnosis and memory (immediate and delayed recall, combined with proxy-reported memory) were assessed at biennial interviews in the U.S. Health and Retirement Study (N=13,293, 1998-2016). Neighborhood disadvantage was measured using the National Neighborhood Data Archive disadvantage index, categorized into tertiles (T1: least disadvantaged - T3: most disadvantaged). Linear mixed-effects models estimated the standardized memory trajectories in participants with or without cancer, by neighborhood disadvantage.

RESULTS

Living in more disadvantaged neighborhoods was associated with worse mean memory function and steeper memory declines, regardless of cancer status. An incident cancer diagnosis was associated with an acute memory drop for those living in least disadvantaged neighborhoods but not more disadvantaged neighborhoods (T1: -0.05, 95% CI: -0.08, -0.01; T3: -0.13, 95% CI: -0.06, 0.03). Cancer survivors in the least disadvantaged neighborhoods had a slight memory advantage in the years prior to diagnosis (T1: 0.09, 95% CI: 0.04, 0.13) and after diagnosis (T1: 0.07, 95% CI: 0.01, 0.13).

CONCLUSIONS

An incident cancer diagnosis among those living in the least disadvantaged neighborhoods was associated with an acute memory drop at the time of diagnosis and a long-term memory advantage before and after diagnosis compared to cancer-free individuals in similar neighborhoods.

IMPACT

These findings could inform interventions to promote cancer survivor's long-term aging. Future studies should investigate the social and biological pathways through which nSES could influence cancer-related memory changes.

Cognition and Wealth Changes in Mid-to-later Life: A Latent Class Trajectories Approach Using the Health and Retirement Study

ObjectivesTo assess how cognitive trajectories from mid-to-later life relate to wealth change, overall and by mid-life income. Methods: Data were from participants (51-64 years) in the 2000-2018 U.S. Health and Retirement Study who were cognitively healthy at baseline (year 2000; unweighted n = 3821). Longitudinal latent class analyses generated cognitive and wealth trajectories, independently, and multinomial logistic regressions estimated the association between cognitive trajectories and wealth profiles, overall and by median income. Results: We identified three cognitive: cognitively healthy (CH), increasing cognitive impairment (ICI), and increasing dementia (ID) and four wealth profiles: stable wealth loss (SWL), delayed gradual wealth loss (DGWL), stable wealth gain (SWG), and gradual wealth gain (GWG). The ID group had higher probability of being in the SWL group and lower probability of SWG, which was more pronounced in respondents with greater median income. Discussion: Individuals with ID may be vulnerable to wealth loss, particularly for middle-class households.

Associations Between Neighborhood-Level Income and Triple-Negative Breast Cancer in a Majority-Minority Population

BACKGROUND

Previous studies on disparities in triple-negative breast cancer (TNBC) focus on race/ethnicity, with few exploring the impact of contextual factors such as neighborhood-level income. This study evaluates the effect of neighborhood-level income on disparities in TNBC among a racially and ethnically diverse cohort, after accounting for granular individual-level risk factors of TNBC.

PATIENTS AND METHODS

Patients with stage I-IV breast cancer from 2005 to 2017 were identified from our local tumor registry. The primary outcome was diagnosis of TNBC. Using 5-years estimates from the American Community Survey, we obtained median household income for each census tract which was categorized into quartiles. Mixed effects logistic regression was conducted and stratified by race and ethnicity, controlling for individual-level sociodemographic, comorbidities, and tumor characteristics.

RESULTS

Among 5377 breast cancer registry patients, 16.5% were diagnosed with TNBC. The majority were Hispanic (50.1%) followed by non-Hispanic Black (NHB) (28.0%). After controlling for individual-level covariables including race and ethnicity, comorbidities, and tumor characteristics, women from low-income neighborhoods had increased odds of TNBC compared with other breast cancer subtypes, compared with those in high-income neighborhoods [odds ratio (OR) 1.33; 95% confidence interval (CI) 1.04, 1.70, p < 0.001]. In stratified analyses, NHB patients from low-income neighborhoods had two times the odds of TNBC diagnosis compared with those from high-income neighborhoods (OR 2.11; 95% CI 1.02, 4.37).

CONCLUSION

We found that living in a low-income neighborhood is associated with an increased odds of TNBC independent of granular individual-level TNBC risk factors, particularly NHB race. More striking, NHB living in low-income neighborhoods had increased odds of TNBC compared with NHB living in high-income neighborhoods. Our results suggest potential unaccounted gene-environment and/or social (api)genomic interactions between neighborhood-level income and TNBC subtype development.

Does education moderate gender disparities in later-life memory function? A cross-national comparison of harmonized cognitive assessment protocols in the United States and India

INTRODUCTION

We compared gender disparities in later-life memory, overall and by education, in India and the United States (US).

METHODS

Data (N = 7443) were from harmonized cognitive assessment protocols (HCAPs) in the Longitudinal Aging Study of India-Diagnostic Assessment of Dementia (LASI-DAD; N = 4096; 2017-19) and US Health and Retirement Study HCAP (HRS-HCAP; N = 3347; 2016-17). We derived harmonized memory factors from each study using confirmatory factor analysis. We used multivariable-adjusted linear regression to compare gender disparities in memory function between countries, overall and by education.

RESULTS

In the United States, older women had better memory than older men (0.28 SD-unit difference; 95% CI: 0.22, 0.35). In India, older women had worse memory than older men (-0.15 SD-unit difference; 95% CI: -0.20, -0.10), which attenuated with increasing education and literacy.

CONCLUSION

We observed gender disparities in memory in India that were not present in the United States, and which dissipated with education and literacy.

Association of cumulative loneliness with all-cause mortality among middle-aged and older adults in the United States, 1996 to 2019

Loneliness is a growing public health concern worldwide. We characterized the association between cumulative loneliness and subsequent all-cause mortality, using data from 9,032 participants aged 50+ in the population-based US Health and Retirement Study (HRS) from 1996 to 2019. Loneliness status (yes; no) was measured biennially from 1996 to 2004, and we categorized the experience of cumulative loneliness over the 8-y period as never, one time point, two time points, and ≥three time points. A multivariable-adjusted age-stratified Cox proportional hazards regression model was fitted to examine the association between cumulative loneliness from 1996 to 2004 and all-cause mortality from 2004 to 2019. Excess deaths due to each category of cumulative loneliness were calculated. Compared to those who never reported loneliness from 1996 to 2004, participants experiencing loneliness at one time point, two time points, and ≥three time points respectively had 1.05 (95% CI: 0.96 to 1.15), 1.06 (95% CI: 0.95 to 1.19), and 1.16 (95% CI: 1.02 to 1.33) times higher hazards of mortality from 2004 to 2019 (P trend = 0.01). These results correspond to 106 (95% CI: 68 to 144), 202 (95% CI: 146 to 259), and 288 (95% CI: 233 to 343) excess deaths per 10,000 person-years, for those experiencing loneliness at each of one, two, or ≥three time points from 1996 to 2004. Cumulative loneliness in mid-to-later life may thus be a mortality risk factor with a notable impact on excess mortality. Loneliness may be an important target for interventions to improve life expectancy in the United States.

Neighborhood Built Environments and Health in Later Life: A Literature Review

Objectives: This literature review aims to assess the current state of the field linking neighborhood environments to later-life health and wellbeing. Methods: We used electronic databases (e.g., PubMed, Google Scholar, and ProQuest) to search for studies published between 2010 and 2022 examining associations between neighborhood built environmental variables and later-life physical, cognitive, mental, and social health outcomes. Results: Among 168 studies reviewed, the majority were quantitative (n = 144) and cross-sectional (n = 122). Neighborhood environmental variables significantly associated with later-life health outcomes included population density/rurality, walkability/street connectivity, access to services and amenities, neighborhood quality and disorder, and parks/green/blue/open space. Neighborhoods operated through behavioral and biological pathways including hazardous exposures, affective states (e.g., stress and restoration), and lifestyle (e.g., exercise, socialization, and diet). Discussion: Neighborhoods and healthy aging research is a burgeoning interdisciplinary and international area of scholarship. Findings can inform upstream community interventions and strengthen clinical care.

The Joys and Stresses of Social Relationships and the Effect on Resiliency During the Covid-19 Pandemic: A National Survey of US Older Adults

BACKGROUND AND OBJECTIVES

The COVID-19 pandemic placed unprecedented stress on older adults. Resiliency could mitigate deleterious effects of pandemic stressors. We described trends in resilience among US adults aged 50-80 years approximately one and half years after the onset of the pandemic, compared with before the pandemic, and evaluated associations between relationships and resilience.

RESEARCH DESIGN AND METHODS

Data were from the National Poll on Healthy Aging (N=2,100) in August 2021. Respondents rated their resiliency as compared with before the pandemic (more, about the same, or less) and different types of relationships (spouse/partner, friends, neighbors) as sources of joy and/or stress during the pandemic (a lot, some, very little, and not at all). Multinomial logistic regressions (complete-case analysis) estimated the relationships between each joyful and stressful relationships and resiliency.

RESULTS

Most participants reported feeling as resilient as before the pandemic (70.6%) with 14.5% feeling less resilient. More women than men felt less resilient than before the pandemic (16.7% vs. 12.8%, p=0.006). Feeling a lot of stress from one's spouse or neighbors was associated with increased likelihood of feeling less resilient than before the pandemic (OR=3.7; 95% CI: 1.8, 7.7 and OR=4.5; 95% CI: 1.5, 13.9, respectively) which was stronger among women (OR=15.1; 95% CI: 4.8, 45.6) than men (OR=1.03; 95% CI: 0.4, 2.7).

DISCUSSION AND IMPLICATIONS

Social relationships may have been more important for women than for men in supporting resiliency during the pandemic. Understanding patterns of resiliency can help to inform policymaking and support the well-being of older adults.

Functional aging trajectories of older cancer survivors: a latent growth analysis of the US Health and Retirement Study

PURPOSE

We aimed to identify prototypical functional aging trajectories of US cancer survivors aged 50 and older, overall and stratified by sociodemographic and health-related characteristics.

METHODS

Data were from 2986 survivors of a first incident cancer diagnosis (except non-melanoma skin cancer) after age 50 in the population representative U.S. Health and Retirement Study from 1998-2016. Cancer diagnoses, episodic memory function, and activity of daily living (ADL) limitations were assessed at biennial study interviews. Using time of cancer diagnosis as the baseline, we used group-based trajectory modeling to identify trajectories of memory function and ADL limitations following diagnosis.

RESULTS

We identified five memory loss trajectories (high: 8.4%; medium-high: 18.3%; medium-low: 21.5%; low: 25.5%; and, very low: 26.2%), and four ADL limitation trajectories (high/increasing limitations: 18.7%; medium limitations: 18.7%; low limitations: 8.14%; no limitations: 60.0). The high memory loss and high/increasing ADL limitation trajectories were both characterized by older age, being female (52% for memory, 58.9% for ADL), having lower pre-cancer memory scores, and a higher prevalence of pre-cancer comorbidities including stroke (30.9% for memory and 29.7% for ADL), hypertension (64.7% for memory and 69.8 for ADL), and depressive symptoms. In joint analyses, we found that generally those with higher memory were more likely to have fewer ADL limitations and vice versa.

CONCLUSION

Older cancer survivors experience heterogeneous trajectories of functional aging that are largely characterized by comorbidities prior to diagnosis.

IMPLICATION FOR CANCER SURVIVORS

Results can help identify older cancer survivors at increased risk for accelerated functional decline.

Cumulative loneliness and subsequent memory function and rate of decline among adults aged ≥50 in the United States, 1996 to 2016

INTRODUCTION

The study objective was to investigate the association between loneliness duration and memory function over a 20-year period.

METHODS

Data were from 9032 adults aged ≥50 in the Health and Retirement Study. Loneliness status (yes vs. no) was assessed biennially from 1996 to 2004 and its duration was categorized as never, 1 time point, 2 time points, and ≥3 time points. Episodic memory was assessed from 2004 to 2016 as a composite of immediate and delayed recall trials combined with proxy-reported memory. Mixed-effects linear regression models were fitted.

RESULTS

A longer duration of loneliness was associated with lower memory scores (P < 0.001) and a faster rate of decline (P < 0.001). The association was stronger among adults aged ≥65 than those aged <65 (three-way interaction P = 0.013) and was stronger among women than men (three-way interaction P = 0.002).

DISCUSSION

Cumulative loneliness may be a salient risk factor for accelerated memory aging, especially among women aged ≥65.

HIGHLIGHT

A longer duration of loneliness was associated with accelerated memory aging. The association was stronger among women than men and among older adults than the younger. Reducing loneliness in mid- to late life may help maintain memory function.

The association of health behaviors prior to cancer diagnosis and functional aging trajectories after diagnosis: Longitudinal cohort study of middle-aged and older US cancer survivors

We aimed to determine the influence of modifiable health behaviors prior to a cancer diagnosis on functional aging trajectories after diagnosis among middle-aged and older cancer survivors in the United States. Data were from biennial interviews with 2,717 survivors of a first incident cancer diagnosis after age 50 in the population-based US Health and Retirement Study from 1998 to 2016. Smoking status, alcohol use, and vigorous physical activity frequency were assessed at the interview prior to cancer diagnosis. Confounder-adjusted multinomial logistic regression was used to determine the associations between each pre-diagnosis health behavior and post-diagnosis trajectories of memory function and limitations to activities of daily living (ADLs), which were identified using group-based trajectory modeling. Overall, 20.7 % of cancer survivors were current smokers, 30.6 % drank alcohol, and 27.1 % engaged in vigorous physical activity >=once a week prior to their diagnosis. In the years following diagnosis, those who had engaged in vigorous physical activity > once a week were less likely to have a medium-high (OR: 0.5; 95 % CI: 0.2-0.9) or medium-low memory loss trajectories (OR: 0.6; 95 % CI: 0.3-1.0) versus very low memory loss trajectory, and were less likely to have a high, increasing ADL limitation trajectory (OR: 0.3; 95 % CI: 0.2, 0.6) versus no ADL limitation trajectory. Vigorous physical activity, but not smoking or alcohol use, was associated with better post-diagnosis functional aging trajectories after a first incident cancer diagnosis in mid-to-later life in this population-based study. Identification of modifiable risk factors can inform targeted interventions to promote healthy aging among cancer survivors.

Does a Cancer Diagnosis in Mid-to-Later Life Modify Racial Disparities in Memory Aging?

BACKGROUND

It is unknown whether an incident cancer diagnosis differentially impacts acute and long-term memory aging between older White and Black Americans.

METHODS

Incident cancer diagnoses and memory (immediate and delayed recall, combined with proxy-reported memory) were assessed at biennial study interviews in the US Health and Retirement Study (N=14,235, 1998-2016). We used multivariable segmented linear mixed-effects models to evaluate the rate of change in standardized memory score (SD/decade) in the years before, acutely at the time of, and in the years following an incident cancer diagnosis, compared to cancer-free adults, by race.

RESULTS

Black participants experienced faster memory decline than White participants (cancer-free group: -1.211 vs. -1.077; P<0.0001). An incident cancer diagnosis was associated with an acute memory drop in White, but not Black participants (-0.065 vs. 0.024; P<0.0001). However, White cancer survivors experienced slower memory decline than cancer-free White adults before and after diagnosis, but this memory advantage was not observed among Black cancer survivors.

CONCLUSIONS

Racial disparities in memory aging are not modified by an incident cancer diagnosis. The acute cancer-related memory decline and long-term memory advantage experienced by White, but not Black, cancer survivors relative to cancer-free older adults, requires further investigation.

Structural Racism and Breast Cancer-specific Survival: Impact of Economic and Racial Residential Segregation

OBJECTIVE

To analyze the effect of economic and racial/ethnic residential segregation on breast cancer-specific survival (BCSS) in South Florida, a diverse metropolitan area that mirrors the projected demographics of many United States regions.

SUMMARY BACKGROUND DATA

Despite advances in diagnosis and treatment, racial and economic disparities in BCSS. This study evaluates these disparities through the lens of racial and economic residential segregation, which approximate the impact of structural racism.

METHODS

Retrospective cohort study of stage I to IV breast cancer patients treated at our institution from 2005 to 2017. Our exposures include index of concentration at the extremes, a measurement of economic and racial neighborhood segregation, which was computed at the census-tract level using American Community Survey data. The primary outcome was BCSS.

RESULTS

Random effects frailty models predicted that patients living in low-income neighborhoods had higher mortality compared to those living in high-income neighborhoods [hazard ratios (HR): 1.56, 95% confidence interval (CI): 1.23-2.00]. Patients living in low-income non-Hispanic Black and Hispanic neighborhoods had higher mortality compared to those living in high-income non-Hispanic White (NHW) neighborhoods (HR: 2.43, 95%CI: 1.72, 3.43) and (HR: 1.99, 95%CI: 1.39, 2.84), after controlling for patient characteristics, respectively. In adjusted race-stratified analysis, NHWs living in low-income non-Hispanic Black neighborhoods had higher mortality compared to NHWs living in high-income NHW neighborhoods (HR: 4.09, 95%CI: 2.34-7.06).

CONCLUSIONS

Extreme racial/ethnic and economic segregation were associated with lower BCSS. We add novel insight regarding NHW and Hispanics to a growing body of literature that demonstrate how the ecological effects of structural racism-expressed through poverty and residential segregation-shape cancer survival.

New directions in cancer and aging: State of the science and recommendations to improve the quality of evidence on the intersection of aging with cancer control

Background

The global population of older cancer survivors is growing. However, the intersections of aging‐related health risks across the cancer control continuum are poorly understood, limiting the integration of aging into cancer control research and practice. The objective of this study was to review the state of science and provide future directions to improve the quality of evidence in 6 priority research areas in cancer and aging.

Methods

The authors identified priority research areas in cancer and aging through an evidence‐based Research Jam process involving 32 investigators and trainees from multiple disciplines and research centers in aging and cancer; then, they conducted a narrative review of the state of the science and future directions to improve the quality of evidence in these research areas. Priority research areas were defined as those in which gaps in scientific evidence or clinical practice limit the health and well‐being of older adults with cancer.

Results

Six priority research areas were identified: cognitive and physical functional outcomes of older cancer survivors, sampling issues in studies of older cancer survivors, risk and resilience across the lifespan, caregiver support and well‐being, quality of care for older patients with cancer, and health disparities. Evidence in these areas could be improved through the incorporation of bias reduction techniques into longitudinal studies of older cancer survivors, novel data linkage, and improved representation of older adults in cancer research.

Conclusions

The priority research areas and methodologies identified here may be used to guide interdisciplinary research and improve the quality of evidence on cancer and aging.

The population of older cancer survivors is growing, yet the effects of aging‐related health risks across the cancer control continuum remain poorly understood. This article identifies research areas that may be used to guide interdisciplinary research and improve the quality of evidence on cancer and aging.

Prescription Drug and Cannabis Use among Recent Latinx Immigrants Pre- and Post-Immigration to the US

Introduction: Shifts in the sociopolitical context of Latin America have led to steep increases in recent Latinx immigrants (RLI) arriving in the US within the context of forced migration. Yet, little is known about how adverse experiences of RLIs before and after immigration may impact their health including drug use. The purpose of this study was to examine prescription drug and cannabis use before and just after immigration among RLIs and how this drug use is influenced by pre-and post-immigration factors. Methods: This study utilized baseline data from a study examining pre- to post-immigration drinking and driving trajectories among RLI in the United States (US). Baseline criteria included: self-identifying as a Latinx immigrant, 18 - 34 years old, who recently immigrated from a Latin American country. Multivariate logistic regression was conducted to determine predictors of drug use both prior to and after immigrating. Results: There were 540 RLI, 50.2% male and 47.8% subjected to forced migration. Prescription and illicit drug use decreased post-immigration with sedatives being the most common. Higher levels of education was associated with increased odds of pre-immigration prescription drug use and cannabis use. Those experiencing forced migration were more likely to engage in prescription drug use before and after immigration, while no associations were found for cannabis use. Conclusion: Findings suggest a need for increased substance use and mental health services among RLIs arriving within the context of forced migration. More research is needed to understand the trajectories of drug use among RLI as their time in the US increases.

Alcohol use severity among recent Latino immigrants: Associations of acculturation, family history of alcohol use and alcohol outcome expectancies

Having a family history of alcohol (FH+) use is a well-documented risk factor for alcohol use and alcohol related problems. However, there are limited studies examining the impact of FH + on current alcohol use among Latino immigrants. This study aimed to determine the influence of having a FH + on current alcohol use among Latino immigrants and the influence of alcohol outcome expectancies (AOEs) and acculturation on this relationship. This is a longitudinal secondary data analysis of data from the Recent Latino Immigrant Study (RLIS), the first community-based cohort study to examine pre- to post-immigration alcohol use trajectories of young adult Latino immigrants. Linear mixed models were performed to assess the association between various pre- and post-immigration factors and alcohol use among Latino immigrants. There were 518 young adult Latino immigrants with 18.7% reporting a FH + with those with a FH + having higher mean AUDIT score compared to those without (4.74 vs. 3.81; p = 0.028). Positive AOEs were associated with increase AUDIT scores. FH + individuals with greater positive AOEs experienced higher AUDIT scores compared to FH- individuals. Family cohesion was protective against alcohol use while endorsement of Americansism was associated with increased alcohol use. Theses results provide the framework for more in-depth exploration regarding the influences of FH+, AOEs, and acculturation have on the alcohol use among Latino immigrants. Future longitudinal research studies should account for whether traditional cultural values mediate or moderate the relationship between a FH+, AOE, and alcohol use of Latino immigrants.

Associations of Objective and Perceived Neighborhood Ethnic Density on Hazardous Alcohol Use among Latinx Emerging Adults

Background/Purpose: Emerging adulthood is an important time where substance use often peaks. Neighborhood Latinx ethnic density could be protective against negative health behaviors. Most studies on neighborhood ethnic density have focused on census-level aggregate measures, however perception of the neighborhood ethnic density could differ from objectively measured neighborhood density. This study investigated the effects of neighborhood ethnic density, both perceived ethnic and objectively measured ethnic density, on hazardous alcohol use among Latinx emerging adults in Maricopa County Arizona and Miami-Dade County Florida by gender. Methods: 200 Latinx emerging adults residing in Arizona and Florida completed a cross-sectional survey. Inclusion criteria were being age 18-25, self-identify as Latinx, and currently living in Maricopa County or Miami-Dade County. Data were analyzed using multivariate logistic regression and moderation analyses. Results: There was a statistically significant difference between perceived and objective ethnic density (Kappa = 0.353, p < 0.001). When ethnic density was measured objectively, alcohol use severity was statistically significantly lower for individuals living in highly ethnically dense neighborhoods (OR: 0.34, 95% CI: 0.12, 0.92). However, this association was only found for women in moderation analyses. There was no statistically significant association between perceived ethnic density and alcohol use severity. Conclusion: The present study found a statistically significant decrease in alcohol use severity among Latinx emerging adults who live in highly ethnically dense neighborhoods after adjusting for covariates. Future research should investigate the potential mechanisms in which these neighborhoods protect against alcohol use severity among Latinx emerging adults.

Residential segregation and overall survival of women with epithelial ovarian cancer

BACKGROUND

To the authors' knowledge, the etiology of survival disparities in patients with epithelial ovarian cancer (EOC) is not fully understood. Residential segregation, both economic and racial, remains a problem within the United States. The objective of the current study was to analyze the effect of residential segregation as measured by the Index of Concentration at the Extremes (ICE) on EOC survival in Florida by race and/or ethnicity.

METHODS

All malignant EOC cases were identified from 2001 through 2015 using the Florida Cancer Data System (FCDS). Census-defined places were used as proxies for neighborhoods. Using 5-year estimates from the American Community Survey, 5 ICE variables were computed: economic (high vs low), race and/or ethnicity (non-Hispanic white [NHW] vs non-Hispanic black [NHB] and NHW vs Hispanic), and racialized economic segregation (low-income NHB vs high-income NHW and low-income Hispanic vs high-income NHW). Random effects frailty models were conducted.

RESULTS

A total of 16,431 malignant EOC cases were diagnosed in Florida among women living in an assigned census-defined place within the time period. The authors found that economic and racialized economic residential segregations influenced EOC survival more than race and/or ethnic segregation alone in both NHB and Hispanic women. NHB women continued to have an increased hazard of death compared with NHW women after controlling for multiple covariates, whereas Hispanic women were found to have either a similar or decreased hazard of death compared with NHW women in multivariable Cox models.

CONCLUSIONS

The results of the current study indicated that racial and economic residential segregation influences survival among patients with EOC. Research is needed to develop more robust segregation measures that capture the complexities of neighborhoods to fully understand the survival disparities in EOC.

Identification of Low Cardiac Output Syndrome at the Bedside: A Pediatric Cardiac Intensive Care Unit Survey

BACKGROUND

Low cardiac output syndrome is a transient constellation of signs and symptoms that indicate the heart's inability to supply sufficient oxygen to tissues and end-organs to meet metabolic demand. Because the term lacks a standard clinical definition, the bedside diagnosis of this syndrome can be difficult.

OBJECTIVE

To evaluate concordance among pediatric cardiac intensive care unit nurses in their identification of low cardiac output syndrome in pediatric patients after cardiac surgery.

METHODS

An anonymous survey was distributed to 69 pediatric cardiac intensive care unit nurses. The survey described 10 randomly selected patients aged 6 months or younger who had undergone corrective or palliative cardiac surgery at a freestanding children's hospital in a tertiary academic center. For each patient, data were presented corresponding to 5 time points (0, 6, 12, 18, and 24 hours postoperatively). The respondent was asked to indicate whether the patient had low cardiac output syndrome (yes or no) at each time point on the basis of the data presented.

RESULTS

The response rate was 46% (32 of 69 nurses). The overall Fleiss k value was 0.30, indicating fair agreement among raters. When the results were analyzed by years of experience, agreement remained only slight to fair.

CONCLUSIONS

Regardless of years of experience, nurses have difficulty agreeing on the presence of low cardiac output syndrome. Further research is needed to determine whether the development of objective guidelines could improve recognition and facilitate communication between the pediatric cardiac intensive care unit nurse and the medical team.

Racial differences in adult-onset MRI-negative temporal lobe epilepsy

OBJECTIVE

We recently detected a significant racial difference in our population with temporal lobe epilepsy (TLE) at the University of Alabama at Birmingham (UAB) seizure monitoring unit. We found that Black patients were more likely than their White counterparts to carry a TLE diagnosis. Using this same patient population, we focus on the patients with TLE to better describe the relationship between race and epidemiology in this population.

METHODS

We analyzed the data from patients diagnosed with TLE admitted to the UAB seizure monitoring unit between January 2000 and December 2011. For patients with a video electroencephalography (EEG) confirmed diagnosis of TLE (n = 385), basic demographic information including race and magnetic resonance imaging (MRI) findings were collected. Descriptive statistics and multivariate logistic regression were used to explore the relationship between MRI findings, demographic data, and race.

RESULTS

For Black patients with TLE, we found that they were more likely to be female (odds ratio [OR] = 1.91, 95% confidence interval [CI]: 1.14-3.19), have seizure onset in adulthood (OR = 2.39, 95% CI: 1.43-3.19), and have normal MRIs (OR = 1.69, 95% CI: 1.04-2.77) compared to White counterparts with TLE after adjusting for covariates.

CONCLUSIONS

These data suggest that Black race (compared to White) is associated with higher expression of adult-onset MRI-negative TLE, an important subtype of epilepsy with unique implications for evaluation, treatment, and prognosis. If validated in other cohorts, the findings may explain the lower reported rates of epilepsy surgery utilization among Blacks. The racial differences in surgical utilization could be due to a greater prevalence of an epilepsy that is less amenable to surgical resection rather than to cultural differences or access to care.

Racial disparities in temporal lobe epilepsy

OBJECTIVE

This study reports on epilepsy type period prevalence and black-white racial differences in a large patient population in the Southeastern United States.

METHODS

For all patients visiting the University of Alabama at Birmingham's seizure monitoring unit between 2000 and 2011 (n = 3240), video EEG diagnosis was recorded along with basic demographic information. Descriptive statistics and multivariate logistic regression were used to identify factors associated with temporal lobe epilepsy (TLE) diagnosis.

RESULTS

The racial distribution was 77.3% white, and 20.0% black (other races were only 2.3% of the population). Most patients had either TLE (n = 630) or PNES (n = 1150) compared to other focal (n = 424) or generalized epilepsies (n = 224). The diagnosis of TLE was significantly greater for blacks than whites (odds ratio [OR] = 1.87, 95% confidence interval [CI] 1.47-2.37). The period prevalence measures for the other conclusively diagnosed epilepsies were not significantly different. Women were disproportionately represented in the study population, and black women carried the most statistical weight for the TLE prevalence difference.

INTERPRETATION

The nearly two-fold larger period prevalence of TLE among black patients is a striking finding that merits explanation. Although some selection bias exists due to a moderately lower than expected representation of blacks, socioeconomic status or access to care should not be assumed to be the only factors that might be responsible for the prevalence difference. Rather, all clues for distinct pathophysiological racial differences should be explored.

Neonatal Aortic Arch Reconstruction With Direct Splanchnic Perfusion Avoids Deep Hypothermia

BACKGROUND

Neonatal aortic arch reconstruction, typically performed with deep hypothermia and selective cerebral perfusion, leaves splanchnic organ protection dependent on hypothermia alone. A simplified method of direct in-field descending aortic perfusion during neonatal arch reconstruction permits the avoidance of deep hypothermia. We hypothesize that direct splanchnic perfusion at mild hypothermia provides improved or equivalent safety compared with deep hypothermia and may contribute to postoperative extracardiac organ recovery.

METHODS

Included were 138 biventricular patients aged younger than 90 days undergoing aortic arch reconstruction with cardiopulmonary bypass. Patients were grouped according to perfusion method A (selective cerebral perfusion with deep hyperthermia at 18° to 20°C) or method B (selective cerebral perfusion and splanchnic perfusion at 30° to 32°C). Patient characteristics and perioperative clinical and serologic data were analyzed. Significance was assigned for p of less than 0.05.

RESULTS

Of the 138 survivors, 63 underwent method A and 75 underwent method B. The median age at operation was 8.5 days (range, 6 to 15 days), and median weight was 3.2 kg (range, 2.8 to 3.73 kg), with no significant differences between groups. Cardiopulmonary bypass times were comparable between the two perfusion methods (p = 0.255) as were the ascending aortic cross-clamp times (p = 0.737). The postoperative glomerular filtration rate was significantly different between our groups (p = 0.028 to 0.044), with method B achieving a higher glomerular filtration rate. No significant differences were seen in ventilator time, postoperative length of stay, fractional increase of postoperative serum creatinine over preoperative serum creatinine, and postoperative lactate.

CONCLUSIONS

A simplified method of direct splanchnic perfusion during neonatal aortic arch reconstruction avoids the use of deep hypothermia and provides renal protection at least as effective as deep hypothermia.

Review of 1,000 consecutive extracorporeal membrane oxygenation runs as a quality initiative

BACKGROUND

Extracorporeal membrane oxygenation is a resource-intensive mode of life-support potentially applicable when conventional therapies fail. Given the initial success of extracorporeal membrane oxygenation to support neonates and infants in the 1980s, indications have expanded to include adolescents, adults, and selected moribund patients during cardiopulmonary resuscitation. This single-institution analysis was conducted to evaluate programmatic growth, outcomes, and risk for death despite extracorporeal membrane oxygenation across all ages and diseases.

METHODS

Beginning in 1989, we registered prospectively all extracorporeal membrane oxygenation patient data with the Extracorporeal Life Support Organization. We queried this registry for our institution-specific data to compare the parameter of "discharge alive" between age groups (neonatal, pediatric, adult), disease groups (respiratory, cardiac, cardiopulmonary resuscitation), and modes of extracorporeal membrane oxygenation (veno-venous; veno-arterial). Extracorporeal membrane oxygenation-specific complications (mechanical, hemorrhagic, neurologic, renal, cardiovascular, pulmonary, infectious, metabolic) were analyzed similarly. Descriptive statistics, Kaplan-Meier, and linear regression analyses were conducted.

RESULTS

After 1,052 extracorporeal membrane oxygenation runs, indications have expanded to include adults, to supplement cardiopulmonary resuscitation, to support hemodialysis in neonates and plasmapheresis in children, and to bridge all age patients to heart and lung transplant. Overall survival to discharge was 52% and was better for respiratory diseases (P < .001). Probability of individual survival decreased to <50% if pre-extracorporeal membrane oxygenation mechanical ventilation exceeded respectively 123 hours for cardiac, 166 hours for cardiopulmonary resuscitation, and 183 hours for respiratory diseases (P = .013). Complications occurred most commonly among cardiac and cardiopulmonary resuscitation runs (P < .001), the veno-arterial mode (P < .001), and in adults (P = .044).

CONCLUSION

Our extracorporeal membrane oxygenation program, an Extracorporeal Life Support Organization-designated Center of Excellence, has experienced substantial growth in volume and indications, including increasing age and disease severity. Considering the entire cohort, pre-extracorporeal membrane oxygenation ventilation exceeding 7 days was associated with an increased probability of death.

Racial disparities in health care access among pediatric patients with craniosynostosis

OBJECTIVE Disparities in surgical access and timing to care result from a combination of complex patient, social, and institutional factors. Due to the perception of delayed presentation for overall health care services and treatment in African American patients on the part of the senior author, this study was designed to identify and quantify these differences in access and care between African American and Caucasian children with craniosynostosis. In addition, hypotheses regarding reasons for this difference are discussed. METHODS A retrospective study was conducted of 132 children between the ages of 0 and 17 years old who previously underwent operations for craniosynostosis at a tertiary pediatric care facility between 2010 and 2013. Patient and family characteristics, age at surgical consultation and time to surgery, and distance to primary care providers and the tertiary center were recorded and analyzed. RESULTS Of the 132 patients in this cohort, 88% were Caucasian and 12% were African American. The median patient age was 5 months (interquartile range [IQR] 2-8 months). African Americans had a significantly greater age at consult compared with Caucasians (median 341 days [IQR 192-584 days] vs median 137 days [IQR 62-235 days], respectively; p = 0.0012). However, after being evaluated in consultation, there was no significant difference in time to surgery between African American and Caucasian patients (median 56 days [IQR 36-98 days] vs median 64 days [IQR 43-87 days], respectively). Using regression analysis, race and type of synostoses were found to be significantly associated with a longer wait time for surgical consultation (p = 0.01 and p = 0.04, respectively, using cutoff points of ≤ 180 days vs > 180 days). Distance traveled to primary care physicians and to the tertiary care facility did not significantly differ between groups. Other factors such as parental education, insurance type, household income, and referring physician type also showed no significant difference between racial groups. CONCLUSIONS This study identified a correlation between race and age at consultation, but no association with time to surgery, distance, or family characteristics such as household income, parental education, insurance type, and referring physician type. This finding implies that delays in early health-seeking behaviors and subsequent referral to surgical specialists from primary care providers are the main reason for this delay among African American craniofacial patients. Future studies should focus on further detail in regards to these barriers, and educational efforts should be designed for the community and the health care personnel caring for them.

Health-related quality of life in pediatric Chiari Type I malformation: the Chiari Health Index for Pediatrics

OBJECT The purpose of this study was to design and validate a patient-reported health-related quality of life (HRQOL) instrument for pediatric Chiari Type I malformation (CM-I), the Chiari Health Index for Pediatrics (CHIP). METHODS The CHIP has 45 items with 4 components making up 2 domain scores, physical (pain frequency, pain severity, nonpain symptoms) and psychosocial; physical and psychosocial scores are combined to create an overall HRQOL score. Increasing scores (0 to 1) represent increasing HRQOL. Fifty-five patients with CM-I (mean age 12 ± 4 years, 53% male) were enrolled and completed the CHIP and Health Utilities Index Mark 3 (HUI3). Twenty-five healthy controls (mean age 11.9 ± 4 years, 40% male) also completed the CHIP. CHIP scores were compared between these groups via the Mann-Whitney U-test. For CHIP discriminative function, subscore versus presence of CM-I was compared via receiver operating characteristic curve analysis. CHIP scores in the CM-I group were stratified by symptomatology (asymptomatic, headaches, and paresthesias) and compared via Kruskal-Wallis test with Mann-Whitney U-test with Bonferroni correction (p < 0.0167). CHIP was compared with HUI3 (Health Utilities Index Mark 3) via univariate and multivariate linear regression. RESULTS CHIP physical and psychosocial subscores were, respectively, 24% and 18% lower in CM-I patients than in controls (p < 0.001); the overall HRQOL score was 23% lower as well (p < 0.001). The area under the curve (AUC) for CHIP physical subscore versus presence of CM-I was 0.809. CHIP physical subscore varied significantly with symptomatology (p = 0.001) and HUI3 pain-related quality of life (R(2) = 0.311, p < 0.001). The AUC for CHIP psychosocial subscore versus presence of CM-I was 0.754. CHIP psychosocial subscore varied significantly with HUI3 cognitive- (R(2) = 0.324, p < 0.001) and emotion-related (R(2) = 0.155, p = 0.003) quality of life. The AUC for CHIP HRQOL versus presence of CM-I was 0.820. Overall CHIP HRQOL score varied significantly with symptomatology (p = 0.001) and HUI3 multiattribute composite HRQOL score (R(2) = 0.440, p < 0.001). CONCLUSIONS The CHIP is a patient-reported, CM-I-specific HRQOL instrument, with construct validity in assessing pain-, cognitive-, and emotion-related quality of life, as well as symptomatic features unique to CM-I. It holds promise as a discriminative HRQOL index in CM-I outcomes assessment.

Identifying Characteristics in Abusive Head Trauma: A Single-Institution Experience

Abusive head trauma (AHT) is a significant cause of childhood morbidity and mortality. The purpose of this study was to better understand the trends centered on AHT patients treated at Vanderbilt Children's Hospital. A retrospective study of 139 children undergoing treatment and management for traumatic brain injury due to abuse between January 2006 and April 2013 at Vanderbilt Children's Hospital was conducted. Caucasian males made up 61% and the youngest sibling represented 86.3% of our cohort. The median age was 5 months with injuries occurring during summertime and on weekdays, 31 and 63%, respectively. Seventy-nine percent were diagnosed with subdural hematomas, and 42% had a Glasgow Coma Scale (GCS) of 8 or less. A total of 25 patients, median age 8.6 months, died during our study period. The results of this study describe the AHT population at Vanderbilt Children's Hospital. Future studies should prospectively assess this population to better understand social factors involved in AHT.

Incidence and trends in the diagnosis of traumatic extracranial cerebrovascular injury in the nationwide inpatient sample database, 2003-2010

Patients with traumatic extracranial cerebrovascular injury (TCVI) comprise about 1% of all blunt trauma admissions according to numerous single-center studies. However, previous studies have used aggressive screening protocols; these studies may not reflect common practice and the overall incidence of TCVI. The annual incidence of the diagnosis of TCVI from 2003 to 2010 was estimated using the Nationwide Inpatient Sample (NIS). For comparison, a systematic review of previous studies of the incidence of the diagnosis of TCVI was conducted. The estimated total number of admissions with TCVI ranged from 1283 to 2652; these admissions represented 0.46-0.95% of all blunt trauma admissions. There was a significant increase in the incidence of TCVI during the study period. A total of 49 studies of TCVI reported incidences of diagnosis ranging from 0.03% to 4.8%. In conclusion, the annual nationwide incidence of the diagnosis of TCVI is increasing. Although NIS incidences of the diagnosis of TCVI are at the low end of the range of previous reports, the increasing incidence in the NIS data likely reflects increasing use of aggressive screening protocols.

Reliability of postoperative photographs in assessment of facial nerve function after vestibular schwannoma resection

Object

This study was undertaken to assess the reliability of observations of postoperative photographs in assigning House-Brackmann scores as outcome measures for patients following resection of vestibular schwannomas.

Methods

Forty pictures of differing facial expressions typically elicited from patients for assigning House-Brackmann scores were individually evaluated by neurosurgery residents and faculty members at the University of Alabama at Birmingham; a score was assigned to each picture by the individual raters. The interrater reliability was measured using the Spearman correlation coefficient, Kendall coefficient of concordance, and kappa statistic; internal consistency was calculated using the Cronbach alpha reliability estimate.

Results

The Spearman correlation coefficients showed strong positive association among raters, with a range of values of 0.66 to 0.90. Internal consistency measured by the Cronbach alpha coefficient was excellent (α = 0.97). The Kendall coefficient of concordance for the ordinal grades suggested a substantial degree of agreement among the raters (w = 0.76, p < 0.001).

Conclusions

Static postoperative photographs are a reliable outcome measure for determining facial nerve function after vestibular schwannoma resection and may serve as a surrogate for the dynamic patient interview.