Development of a sustainable diet index in US adults

BACKGROUND

A transformation towards healthy diets through a sustainable food system is essential to enhance both human and planet health. Development of a valid, multidimensional, quantitative index of a sustainable diet would allow monitoring progress in the US population. We evaluated the content and construct validity of a sustainable diet index for US adults (SDI-US) based on data collected at the individual level.

METHODS

The SDI-US, adapted from the SDI validated in the French population, was developed using data on US adults aged 20 years and older from the National Health and Nutrition Examination Survey, 2007-2018 (n = 25,543). The index consisted of 4 sub-indices, made up of 12 indicators, corresponding to 4 dimensions of sustainable diets (nutritional quality, environmental impacts, affordability (economic), and ready-made product use behaviors (sociocultural)). A higher SDI-US score indicates greater alignment with sustainable diets (range: 4-20). Validation analyses were performed, including the assessment of the relevance of each indicator, correlations between individual indicators, sub-indices, and total SDI-US, differences in scores between sociodemographic subgroups, and associations with selected food groups in dietary guidelines, the alternative Mediterranean diet (aMed) score, and the EAT-Lancet diet score.

RESULTS

Total SDI-US mean was 13.1 (standard error 0.04). The correlation between SDI-US and sub-indices ranged from 0.39 for the environmental sub-index to 0.61 for the economic sub-index (Pearson Correlation coefficient). The correlation between a modified SDI-US after removing each sub-index and the SDI-US ranged from 0.83 to 0.93. aMed scores and EAT-Lancet diet scores were significantly higher among adults in the highest SDI-US quintile compared to the lowest quintile (aMed: 4.6 vs. 3.2; EAT-Lancet diet score: 9.9 vs. 8.7 p < .0001 for both).

CONCLUSIONS

Overall, content and construct validity of the SDI-US were acceptable. The SDI-US reflected the key features of sustainable diets by integrating four sub-indices, comparable to the SDI-France. The SDI-US can be used to assess alignment with sustainable diets in the US. Continued monitoring of US adults' diets using the SDI-US could help improve dietary sustainability.

Stimulant Patterns, Alone or with Other Psychotropic Classes, in Medicaid-Insured Youth Continuously Enrolled for 3-8 Years

Objective: Little U.S. pharmacoepidemiologic study is based on treatment during continuous enrollment for periods more than a year. This study aims to show pediatric patterns of stimulant use (alone or with other psychotropic classes) from Medicaid administrative claims data for stimulant patterns of 3- to 8-year continuous enrollees. Methods: A retrospective cohort study was derived from Medicaid enrollment, pharmacy, and diagnosis claims data (2007-2014) in a mid-Atlantic state. Youth aged 2-17 years with 3-8 years of continuous enrollment treated with stimulants were compared with a date-matched comparison group treated without stimulants. Major outcomes include prevalence and duration of stimulant use and patterns of stimulant polypharmacy across relatively long enrollments (3-8 years). Results: Among 264,518 unique 2- to 17-year olds with 3-8 years of continuous enrollment, 16.5% had stimulant prescription dispensings, doubling the annual national prevalence of 8.1%. Subgroup analysis showed that the highest prevalence of stimulant use was for 6- to 11-year olds (20.4%), foster care eligible youth (42.3%), and those with 7-8 years of continuous enrollment (20.1%). Externalizing psychiatric disorders were far more common in those treated with stimulants than in those treated without stimulants. The duration of stimulant exposure overall was a median of 487 days, half that of foster care stimulant users. Stimulant polypharmacy with two or more psychotropic classes concomitantly characterized 29.8% of stimulant users. Among those with three or four or more class polypharmacy, 85% and 88%, respectively, had concomitant stimulant and antipsychotic use. The adjusted odds ratio (AOR) of three or more class polypharmacy significantly increased in 12- to 17-year-old age group (AOR = 1.8), foster care eligibility (AOR = 4.5), and among those with the longest enrollment (AOR = 1.7). Conclusions and Relevance: Stimulant prevalence in Medicaid-insured youth with continuous enrollment of 3-8 years was twice as common as in annual data sets. Future research should investigate three to five interclass stimulant polypharmacy effectiveness in reliably diagnosed community populations.

Sustainable dietary patterns and all-cause mortality among US adults

BACKGROUND

Sustainable dietary patterns that incorporate multiple dimensions may have benefits for both human health and the environment. We examined the association between sustainable dietary patterns assessed by using the Sustainable Diet Index-US (SDI-US) and mortality in US adults.

METHODS

This study used data from the National Health and Nutrition Examination Survey 2007-18 (N = 22 414 aged ≥20 years). The SDI-US (range: 4-20) was composed of four sub-indices representing nutritional, environmental, economic and sociocultural dimensions, and was computed using 24-h dietary recalls, food expenditures and food preparation habits. A higher score indicates a more sustainable dietary pattern. All-cause mortality from baseline until 31 December 2019 was obtained through linkage to the National Death Index. Hazard ratios (HRs) with 95% CIs were estimated using Cox proportional-hazards models, adjusting for covariates.

RESULTS

During 150 386 person-years of follow-up, 2100 total deaths occurred and the median SDI-US was 9.8 in Quintile 1 (Q1) and 16.3 in Quintile 5 (Q5). In a multivariable-adjusted model, the highest SDI-US quintile was associated with a 36% reduction in mortality risk (Q5 vs Q1, HR 0.64, 95% CI 0.49-0.84, P = 0.002) compared with the lowest quintile. When stratified by age (P interaction = 0.002), an inverse association between SDI-US and mortality was observed in younger adults (<65 years, HR 0.41, 95% CI 0.25-0.68, P = 0.001) but not in older adults (≥65 years, HR 0.91, 95% CI 0.71-1.16, P = 0.15).

CONCLUSIONS

A higher SDI-US score was associated with lower mortality risk among US adults, particularly in younger adults.

Perinatal health effects of herbicides exposures in the United States: the Heartland Study, a Midwestern birth cohort study

BACKGROUND

The objective of the Heartland Study is to address major knowledge gaps concerning the health effects of herbicides on maternal and infant health. To achieve this goal, a two-phased, prospective longitudinal cohort study is being conducted. Phase 1 is designed to evaluate associations between biomarkers of herbicide concentration and pregnancy/childbirth outcomes. Phase 2 is designed to evaluate potential associations between herbicide biomarkers and early childhood neurological development.

METHODS

People (target enrollment of 2,000) who are seeking prenatal care, are ages 18 or older, and are ≤ 20 + 6 weeks gestation will be eligible for recruitment. The Heartland Study will utilize a combination of questionnaire data and biospecimen collections to meet the study objectives. One prenatal urine and buccal sample will be collected per trimester to assess the impact of herbicide concentration levels on pregnancy outcomes. Infant buccal specimens will be collected post-delivery. All questionnaires will be collected by trained study staff and clinic staff will remain blinded to all individual level research data. All data will be stored in a secure REDCap database. Hospitals in the agriculturally intensive states in the Midwestern region will be recruited as study sites. Currently participating clinical sites include Indiana University School of Medicine- affiliated Hospitals in Indianapolis, Indiana; Franciscan Health Center in Indianapolis, Indiana; Gundersen Lutheran Medical Center in La Crosse, Wisconsin, and University of Iowa in Iowa City, Iowa. An anticipated 30% of the total enrollment will be recruited from rural areas to evaluate herbicide concentrations among those pregnant people residing in the rural Midwest. Perinatal outcomes (e.g. birth outcomes, preterm birth, preeclampsia, etc.) will be extracted by trained study teams and analyzed for their relationship to herbicide concentration levels using appropriate multivariable models.

DISCUSSION

Though decades of study have shown that environmental chemicals may have important impacts on the health of parents and infants, there is a paucity of prospective longitudinal data on reproductive impacts of herbicides. The recent, rapid increases in herbicide use across agricultural regions of the United States necessitate further research into the human health effects of these chemicals, particularly in pregnant people. The Heartland Study provides an invaluable opportunity to evaluate health impacts of herbicides during pregnancy and beyond.

TRIAL REGISTRATION

The study is registered at clinicaltrials.gov, NCT05492708 with initial registration and release 05 August, 2022.

The cross-sectional association between a sustainable diet index and obesity among US adults

OBJECTIVE

Adopting multidimensional sustainable dietary patterns may be beneficial to human and planetary health. The cross-sectional association between a multidimensional sustainable diet index-US (SDI-US) and obesity in US adults was examined.

METHODS

This study used National Health and Nutrition Examination Survey (NHANES) data from 2007 to 2018 (n = 25,262). The SDI-US consisted of four subindices and was calculated using a 24-hour dietary recall, food expenditures, environmental impacts of foods, and food practices. A higher score indicates a more sustainable dietary pattern. Obesity was defined as BMI ≥ 30 kg/m² . Logistic regression models were used to estimate odds ratios (OR) with 95% CI.

RESULTS

Between 2007 and 2018, obesity prevalence in US adults was 38.2% (95% CI 37.0%-39.3%), and mean SDI-US score was 13.2 (range: 4.3-20.0). In a multivariable-adjusted model, a higher SDI-US score was associated with lower odds of obesity (Q5 vs. Q1, OR 0.68, 95% CI 0.58-0.79, p < 0.001). When stratified by sex (p interaction = 0.04), a stronger inverse association was observed in women (OR 0.64, 95% CI 0.53-0.77, p < 0.0001) than in men (OR 0.74, 95% CI 0.60-0.91, p = 0.01).

CONCLUSIONS

More sustainable dietary patterns were inversely associated with obesity among US adults, supporting the potential of sustainable diets in preventing obesity.

Digitally recorded and remotely classified lung auscultation compared with conventional stethoscope classifications among children aged 1-59 months enrolled in the Pneumonia Etiology Research for Child Health (PERCH) case-control study

BACKGROUND

Diagnosis of pneumonia remains challenging. Digitally recorded and remote human classified lung sounds may offer benefits beyond conventional auscultation, but it is unclear whether classifications differ between the two approaches. We evaluated concordance between digital and conventional auscultation.

METHODS

We collected digitally recorded lung sounds, conventional auscultation classifications and clinical measures and samples from children with pneumonia (cases) in low-income and middle-income countries. Physicians remotely classified recordings as crackles, wheeze or uninterpretable. Conventional and digital auscultation concordance was evaluated among 383 pneumonia cases with concurrently (within 2 hours) collected conventional and digital auscultation classifications using prevalence-adjusted bias-adjusted kappa (PABAK). Using an expanded set of 737 cases that also incorporated the non-concurrently collected assessments, we evaluated whether associations between auscultation classifications and clinical or aetiological findings differed between conventional or digital auscultation using χ² tests and logistic regression adjusted for age, sex and site.

RESULTS

Conventional and digital auscultation concordance was moderate for classifying crackles and/or wheeze versus neither crackles nor wheeze (PABAK=0.50), and fair for crackles-only versus not crackles-only (PABAK=0.30) and any wheeze versus no wheeze (PABAK=0.27). Crackles were more common on conventional auscultation, whereas wheeze was more frequent on digital auscultation. Compared with neither crackles nor wheeze, crackles-only on both conventional and digital auscultation was associated with abnormal chest radiographs (adjusted OR (aOR)=1.53, 95% CI 0.99 to 2.36; aOR=2.09, 95% CI 1.19 to 3.68, respectively); any wheeze was inversely associated with C-reactive protein >40 mg/L using conventional auscultation (aOR=0.50, 95% CI 0.27 to 0.92) and with very severe pneumonia using digital auscultation (aOR=0.67, 95% CI 0.46 to 0.97). Crackles-only on digital auscultation was associated with mortality compared with any wheeze (aOR=2.70, 95% CI 1.12 to 6.25).

CONCLUSIONS

Conventional auscultation and remotely-classified digital auscultation displayed moderate concordance for presence/absence of wheeze and crackles among cases. Conventional and digital auscultation may provide different classification patterns, but wheeze was associated with decreased clinical severity on both.

Association between increasing agricultural use of 2,4-D and population biomarkers of exposure: findings from the National Health and Nutrition Examination Survey, 2001-2014

BACKGROUND

2,4-Dichlorophenoxyacetic acid (2,4-D) is one of the most extensively used herbicides in the United States. In 2012, 2,4-D was the most widely used herbicide in non-agricultural settings and the fifth most heavily applied pesticide in the US agricultural sector. The objective of this study was to examine trends in 2,4-D urinary biomarker concentrations to determine whether increases in 2,4-D application in agriculture are associated with increases in biomonitoring levels of urine 2,4-D.

METHODS

Data from the National Health and Nutrition Examination Survey (NHANES) with available urine 2,4-D biomarker measurements from survey cycles between 2001 and 2014 were utilized. Urine 2,4-D values were dichotomized using the highest limit of detection (LOD) across all cycles (0.40 μg/L or 0.4 ppb). Agricultural use of 2,4-D was estimated by compiling publicly available federal and private pesticide application data. Logistic regression models adjusted for confounders were fitted to evaluate the association between agricultural use of 2,4-D and urine 2,4-D level above the dichotomization threshold.

RESULTS

Of the 14,395 participants included in the study, 4681 (32.5%) had urine 2,4-D levels above the dichotomization threshold. The frequency of participants with high 2,4-D levels increased significantly (p < .0001), from a low of 17.1% in 2001-2002 to a high of 39.6% in 2011-2012. The adjusted odds of high urinary 2,4-D concentrations associated with 2,4-D agricultural use (per ten million pounds applied) was 2.268 (95% CI: 1.709, 3.009). Children ages 6-11 years (n = 2288) had 2.1 times higher odds of having high 2,4-D urinary concentrations compared to participants aged 20-59 years. Women of childbearing age (age 20-44 years) (n = 2172) had 1.85 times higher odds than men of the same age.

CONCLUSIONS

Agricultural use of 2,4-D has increased substantially from a low point in 2002 and it is predicted to increase further in the coming decade. Because increasing use is likely to increase population level exposures, the associations seen here between 2,4-D crop application and biomonitoring levels require focused biomonitoring and epidemiological evaluation to determine the extent to which rising use and exposures cause adverse health outcomes among vulnerable populations (particularly children and women of childbearing age) and highly exposed individuals (farmers, other herbicide applicators, and their families).

The Association Between Race, Obesity, and Sperm Quality Among Men Attending a University Physician Practice in Washington, DC

A decades-long decline in sperm counts in Western countries has coincided with an increase in obesity rates, prompting study into their association. Few of these studies have incorporated men of color, the sperm health of whom is relatively unknown. The present exploratory study evaluated the association between body mass index (BMI), race, ethnicity, and sperm parameters among a diverse sample of U.S. men attending a Washington, DC physician practice. Semen samples were collected and processed at a single laboratory and sperm concentration, motility, morphology, and count were evaluated according to World Health Organization (WHO) 5th edition criteria. Multivariate models accounted for covariates related to sperm health. The study population (n = 128) was largely obese (45.3%) or overweight (34.4%), and 36.0% were black or Hispanic. Black men had lower adjusted sperm concentration compared to white men (75.0 million/mL to 107.4 million/mL, p = .01) and were more likely to have oligozoospermia (p = .01), asthenozoospermia (p = .004), and low sperm count (p < .0001). Hispanic men had higher adjusted sperm concentration compared to non-Hispanic men (124.5 million/mL to 62.1 million/mL, p = .007) and were less likely to have teratozoospermia (p = .001). Obesity and BMI were associated with lower sperm motility and count in crude models only. Given the study’s sample size its findings should be interpreted with caution but align with the limited epidemiological literature to date that has evaluated racial and ethnic differences in semen quality. Heightened clinical research attention is needed to ensure men of color are included in representative numbers in studies of urologic and andrologic health.

Dietary Polyphenol Intake in US Adults and 10-Year Trends: 2007-2016

BACKGROUND

Polyphenols are a class of phytochemicals that have antioxidant, anti-inflammatory, anticancer, and antiviral properties. Previous research suggests that dietary polyphenol intake is protective against major chronic diseases. To our knowledge, no data on polyphenol intake for the US adult population are available.

OBJECTIVE

This study explored usual dietary polyphenol intake among US adults in 2013-2016 and examined trends in intake during 2007-2016 by demographic characteristics, and identified major dietary sources of polyphenols.

DESIGN

The National Health and Nutrition Examination Survey is a series of cross-sectional surveys representative of the civilian noninstitutionalized US population.

PARTICIPANTS/SETTING

This study included 9,773 adults aged 20 years and older.

MAIN OUTCOME MEASURES

Dietary and supplement data were obtained from two 24-hour dietary recalls. Polyphenol intake was estimated using the Phenol Explorer Database and adjusted for total energy intake.

STATISTICAL ANALYSIS PERFORMED

Usual intake was estimated both overall and by demographic characteristics using the National Cancer Institute method. Trends in intake on a given day over 10 years were evaluated using regression analysis. The complex survey design was incorporated in all analyses.

RESULTS

In 2013-2016, the usual intake of dietary polyphenols was a mean (standard error) of 884.1 (20.4) mg per 1,000 kcal/d. Polyphenol intake was higher in adults 40 years and older, women, non-Hispanic White adults, and college graduates. During 2007-2016, the mean daily polyphenol intake did not change significantly over time for overall and demographic groups. Main polyphenol classes consumed were phenolic acids (mean [standard error] of 1,005.6 [34.3] mg/d) and flavonoids (mean [standard error] of 379.1 [10.7] mg/d). Foods and beverages contributed 99.8% of polyphenol intake, with coffee (39.6%), beans (9.8%), and tea (7.6%) as major dietary contributors.

CONCLUSION

Findings from this study suggest that polyphenol intake is consistent with the low intake of fruits, vegetables, and whole grains in the US population, and provide more evidence of the need for increased consumption of these food groups.

342. The Impact of Glycemic Control on CD4 Cell Count in Persons Living with HIV and Diabetes Mellitus—Washington, DC

Background

Among persons living with HIV (PLWH) with type 2 diabetes mellitus (DM) there is limited research on the effect of DM control on CD4 count. Current guidelines recommend that PLWH with DM maintain a hemoglobin A1c (HbA1c) <7%. This analysis examined the impact of HbA1c on trends in CD4 count among PLWH receiving care in Washington, DC.

Methods

We used data from the DC Cohort, a longitudinal observational cohort of patients receiving HIV care at 14 clinics between 2011–2018. Participants with DM on an ongoing antiretroviral regimen with ≥1 year of follow-up, ≥2 HbA1c results, and ≥2 CD4 count results were included. Participants were compared based on the most recent HbA1c result categorized into one of three control levels control: strict, HbA1c < 7.5%; moderate, HbA1c between 7.5–9.0%; and uncontrolled, HbA1c >9.0%. All statistical tests were performed within the framework of the linear mixed-effects (LME) model. The rates of increase in CD4 count by DM control were compared using an LME model with random slopes and random intercepts, adjusted for sex, BMI, nadir CD4, a history of AIDS, or cancer diagnosis.

Results

Among 554 participants (median age 53.5; 70.8% male; 82.7% Black), there were 5,138 total CD4 count measurements. In unadjusted analysis, participants with moderate or uncontrolled HbA1c had higher mean CD4 counts over the follow-up period than those with strict HbA1c control (strict: 690 cells/μL, moderate: 712 cells/μL uncontrolled: 711 cells/μL; P = 0.0156 strict vs. moderate, 0.049 strict vs. uncontrolled). All DM control groups had a similar temporal increase over time in CD4 count (P = 0.46). In multivariate analysis, only moderate vs. strict control showed a significant difference in CD4 count (mean difference=18.1; P = 0.02). Results showed CD4 count change was not affected by the duration of HIV diagnosis or diabetes diagnosis. See Table 1 for additional results.

Conclusion

PLWH and DM with moderate HbA1c control had higher CD4 counts than those with strict HbA1c control and similar CD4 counts compared with those with uncontrolled HbA1c levels, while the rate of increase in CD4 count was similar in the three groups. These results show that moderate DM control may benefit CD4 count, which should be considered when revising DM control guidelines for PLWH.

Disclosures

All authors: No reported disclosures.

Pesticide interactions and risks of sperm chromosomal abnormalities

Disentangling the separate and synergistic effects of chemicals poses methodological challenges for accurate exposure assessment and for investigating epidemiologically how chemicals affect reproduction. We investigated combined exposures to ubiquitous contemporary use pesticides, specifically organophosphates (OP) and pyrethroids (PYR), and their association with germ cell abnormalities among adult men. Fluorescence in situ hybridization was used to determine disomy in sperm nuclei and urine was analyzed for concentrations of PYR metabolites (3-phenoxybenzoic acid; 3PBA) and OP dialkyl phosphate (DAP) metabolites. Incidence rate ratios using Poisson models were estimated for each disomy type by exposure quartile of DAP metabolites and 3PBA, controlling for confounders. The shape of the associations between PYRs, OPs and disomy were frequently nonmonotonic. There were consistent interactions between OP and PYR metabolite concentrations and the risk for sperm abnormalities. Taking both chemicals into account simultaneously resulted in quantitatively different associations than what was reported previously for OPs and PYRs separately, demonstrating the importance of modeling multiple concentrations simultaneously. Methods investigating interactions using Poisson models are needed to better quantify chemical interactions and their effects on count-based health outcomes, the importance of which was shown here for germ cell abnormalities.

Image-Based Mobile System for Dietary Management in an American Cardiology Population: Pilot Randomized Controlled Trial to Assess the Efficacy of Dietary Coaching Delivered via a Smartphone App Versus Traditional Counseling

BACKGROUND

Randomized controlled trials conducted in Mediterranean countries have shown that the Mediterranean diet lowers adverse cardiovascular events. In the American population, diet remains the biggest uncontrolled risk factor for cardiovascular disease.

OBJECTIVE

This study aimed to test the hypothesis that asynchronous dietary counseling supplied through a custom smartphone app results in better adherence to a Mediterranean diet in a non-Mediterranean population than traditional standard-of-care (SOC) counseling.

METHODS

In total, 100 patients presenting to the cardiology clinic of an academic medical center were randomized to either the SOC or smartphone app-based experimental (EXP) Mediterranean diet intervention after informed consent and 1 hour of individual face-to-face dietary counseling with a registered dietitian. Participants in EXP received a custom smartphone app that reinforced the Mediterranean diet, whereas participants in SOC received 2 additional sessions of in-person dietary counseling with the registered dietitian-30 min at 1 month and 30 min at 3 months. Preexisting knowledge of a Mediterranean diet was measured by the validated Mediterranean Diet Score (MDS) instrument. Baseline height, weight, blood pressure (BP), and laboratory biomarkers were collected. At 1, 3, and 6 months, participants presented for a follow-up appointment to assess compliance to the Mediterranean diet using the MDS as well as a patient satisfaction survey, BP, and weight. Repeat laboratory biomarkers were performed at 3 and 6 months.

RESULTS

Enrolled participants had a mean age with SE of 56.6 (SD 1.7) for SOC and 57.2 (SD 1.8) for EXP; 65.3% of SOC and 56.9% of EXP were male, and 20.4% of SOC and 35.3% of EXP had coronary artery disease. There were no significant differences between EXP and SOC with regard to BP, lipid parameters, hemoglobin A1c, or C-reactive protein (CRP). Participants in EXP achieved a significantly greater weight loss on average of 3.3 pounds versus 3.1 pounds for participants in SOC, P=.04. Adherence to the Mediterranean diet increased significantly over time for both groups (P<.001), but there was no significant difference between groups (P=.69). Similarly, there was no significant difference in diet satisfaction between EXP and SOC, although diet satisfaction increased significantly over time for both groups. The proportion of participants with high Mediterranean diet compliance (defined as the MDS ≥9) increased significantly over time (P<.001)-from 18.4% to 57.1% for SOC and 27.5% to 64.7% for EXP; however, there was no significant difference between the groups.

CONCLUSIONS

Both traditional SOC counseling and smartphone-based counseling were effective in getting participants to adhere to a Mediterranean diet, and these dietary changes persisted even after counseling had ended. However, neither method was more effective than the other. This pilot study demonstrates that patients can change to and maintain a Mediterranean diet with either traditional or smartphone app-based nutrition counseling.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03897426;https://clinicaltrials.gov/ct2/show/NCT03897426.

Mediation of the association of smoking and microvascular complications by glycemic control in type 1 diabetes

Studies have demonstrated the adverse effects of smoking on the risk of microvascular complications; however, few have also examined the potential mediating effects of glycemic control. Using data from the Diabetes Control and Complications Trial (DCCT 1983–1993), we describe the acute and long-term risks of smoking on glycemic control and microvascular complications in a well-characterized cohort of participants with type 1 diabetes. The DCCT recorded self-reported smoking behaviors, glycemic exposure based on HbA1c, and complications status. Generalized linear mixed models were used to assess whether time-dependent measurements of smoking predict HbA1c levels. Cox proportional hazard models were used to assess time-dependent smoking exposures as predictors of retinopathy and nephropathy. During a mean of 6.5 years of follow-up, current smokers had consistently higher HbA1c values and were at a higher risk of retinopathy and nephropathy compared with former and never smokers. These risk differences were attenuated after adjusting for HbA1c suggesting that the negative association of smoking on glycemic control is partially responsible for the adverse association of smoking on the risk of complications in type 1 diabetes. These findings support the potential for a beneficial effect of smoking cessation on complications in type 1 diabetes.

Semi-automated scoring of triple-probe FISH in human sperm using confocal microscopy

Structural and numerical sperm chromosomal aberrations result from abnormal meiosis and are directly linked to infertility. Any live births that arise from aneuploid conceptuses can result in syndromes such as Kleinfelter, Turners, XYY and Edwards. Multi-probe fluorescence in situ hybridization (FISH) is commonly used to study sperm aneuploidy, however manual FISH scoring in sperm samples is labor-intensive and introduces errors. Automated scoring methods are continuously evolving. One challenging aspect for optimizing automated sperm FISH scoring has been the overlap in excitation and emission of the fluorescent probes used to enumerate the chromosomes of interest. Our objective was to demonstrate the feasibility of combining confocal microscopy and spectral imaging with high-throughput methods for accurately measuring sperm aneuploidy. Our approach used confocal microscopy to analyze numerical chromosomal abnormalities in human sperm using enhanced slide preparation and rigorous semi-automated scoring methods. FISH for chromosomes X, Y, and 18 was conducted to determine sex chromosome disomy in sperm nuclei. Application of online spectral linear unmixing was used for effective separation of four fluorochromes while decreasing data acquisition time. Semi-automated image processing, segmentation, classification, and scoring were performed on 10 slides using custom image processing and analysis software and results were compared with manual methods. No significant differences in disomy frequencies were seen between the semi automated and manual methods. Samples treated with pepsin were observed to have reduced background autofluorescence and more uniform distribution of cells. These results demonstrate that semi-automated methods using spectral imaging on a confocal platform are a feasible approach for analyzing numerical chromosomal aberrations in sperm, and are comparable to manual methods. © 2017 International Society for Advancement of Cytometry.

Sperm Aneuploidy in Faroese Men with Lifetime Exposure to Dichlorodiphenyldichloroethylene (p,p´-DDE) and Polychlorinated Biphenyl (PCB) Pollutants

BACKGROUND

Although it is known that sperm aneuploidy contributes to early pregnancy losses and congenital abnormalities, the causes are unknown and environmental contaminants are suspected.

OBJECTIVES

Our goal was to evaluate associations between lifetime exposure to organochlorines, specifically dichlorodiphenyldicholorethylene (p,p´-DDE) and polychlorinated biphenyls (PCBs), and sperm aneuploidy in men from the general population of the Faroe Islands, a population with a known history of organochlorine exposures.

METHODS

Serum and semen samples from men (n = 90) 22-44 years old who participated in Faroe Islands health studies were analyzed for p,p´-DDE and PCBs 118, 138, 153, and 180 and adjusted for total lipids. Cord blood and age-14 serum were available for a subgroup (n = 40) and were also analyzed for p,p´-DDE and PCBs. Sperm fluorescence in situ hybridization (FISH) for chromosomes X, Y, and 18 was used to determine rates of XX18, XY18, YY18, and total disomy. Multivariable adjusted Poisson models were used to estimate the relationship between organochlorine exposure and sperm disomy outcomes.

RESULTS

Adult p,p´-DDE and total PCB serum concentrations were both associated with significantly increased rates of XX18, XY18, and total disomy. Age-14 p,p´-DDE and PCB concentrations were both associated with significantly increased rates of XX, XY, and total disomy in adulthood. Associations between cord blood concentrations of p,p´-DDE and PCBs and sperm disomy in adulthood were not consistently significant.

CONCLUSIONS

Organochlorine exposures measured at age 14 and in adulthood were associated with sperm disomy in this sample of high-exposure men, suggesting that the impacts of persistent pollutants on testicular maturation and function require further investigation.

CITATION

Perry MJ, Young HA, Grandjean P, Halling J, Petersen MS, Martenies SE, Karimi P, Weihe P. 2016. Sperm aneuploidy in Faroese men with lifetime exposure to dichlorodiphenyldichloroethylene (p,p´-DDE) and polychlorinated biphenyl (PCB) pollutants. Environ Health Perspect 124:951-956; http://dx.doi.org/10.1289/ehp.1509779.

Disparities in achieving and sustaining viral suppression among a large cohort of HIV-infected persons in care - Washington, DC

One goal of the HIV care continuum is achieving viral suppression (VS), yet disparities in suppression exist among subpopulations of HIV-infected persons. We sought to identify disparities in both the ability to achieve and sustain VS among an urban cohort of HIV-infected persons in care. Data from HIV-infected persons enrolled at the 13 DC Cohort study clinical sites between January 2011 and June 2014 were analyzed. Univariate and multivariate logistic regression were conducted to identify factors associated with achieving VS (viral load < 200 copies/ml) at least once, and Kaplan-Meier (KM) curves and Cox proportional hazards models were used to identify factors associated with sustaining VS and time to virologic failure (VL ≥ 200 copies/ml after achievement of VS). Among the 4311 participants, 95.4% were either virally suppressed at study enrollment or able to achieve VS during the follow-up period. In multivariate analyses, achieving VS was significantly associated with age (aOR: 1.04; 95%CI: 1.03-1.06 per five-year increase) and having a higher CD4 (aOR: 1.05, 95% CI 1.04-1.06 per 100 cells/mm(3)). Patients infected through perinatal transmission were less likely to achieve VS compared to MSM patients (aOR: 0.63, 95% CI 0.51-0.79). Once achieved, most participants (74.4%) sustained VS during follow-up. Blacks and perinatally infected persons were less likely to have sustained VS in KM survival analysis (log rank chi-square p ≤ .001 for both) compared to other races and risk groups. Earlier time to failure was observed among females, Blacks, publically insured, perinatally infected, those with longer standing HIV infection, and those with diagnoses of mental health issues or depression. Among this HIV-infected cohort, most people achieved and maintained VS; however, disparities exist with regard to patient age, race, HIV transmission risk, and co-morbid conditions. Identifying populations with disparate outcomes allows for appropriate targeting of resources to improve outcomes along the care continuum.

Author Self-disclosure Compared with Pharmaceutical Company Reporting of Physician Payments

BACKGROUND

Industry manufacturers are required by the Sunshine Act to disclose payments to physicians. These data recently became publicly available, but some manufacturers prereleased their data since 2009. We tested the hypotheses that there would be discrepancies between manufacturers' and physicians' disclosures.

METHODS

The financial disclosures by authors of all 39 American College of Cardiology and American Heart Association guidelines between 2009 and 2012 were matched to the public disclosures of 15 pharmaceutical companies during that same period. Duplicate authors across guidelines were assessed independently. Per the guidelines, payments <$10,000 are modest and ≥$10,000 are significant. Agreement was determined using a κ statistic; Fisher's exact and Mann-Whitney tests were used to detect statistical significance.

RESULTS

The overall agreement between author and company disclosure was poor (κ = 0.238). There was a significant difference in error rates of disclosure among companies and authors (P = .019). Of disclosures by authors, companies failed to match them with an error rate of 71.6%. Of disclosures by companies, authors failed to match them with an error rate of 54.7%.

CONCLUSIONS

Our analysis shows a concerning level of disagreement between guideline authors' and pharmaceutical companies' disclosures. Without ability for physicians to challenge reports, it is unclear whether these discrepancies reflect undisclosed relationships with industry or errors in reporting, and caution should be advised in interpretation of data from the Sunshine Act.

Dialkyl phosphate urinary metabolites and chromosomal abnormalities in human sperm

BACKGROUND

The past decade has seen numerous human health studies seeking to characterize the impacts of environmental exposures, such as organophosphate (OP) insecticides, on male reproduction. Despite an extensive literature on OP toxicology, many hormone-mediated effects on the testes are not well understood.

OBJECTIVES

This study investigated environmental exposures to OPs and their association with the frequency of sperm chromosomal abnormalities (i.e., disomy) among adult men.

METHODS

Men (n=159) from a study assessing the impact of environmental exposures on male reproductive health were included in this investigation. Multi-probe fluorescence in situ hybridization (FISH) for chromosomes X, Y, and 18 was used to determine XX18, YY18, XY18 and total disomy in sperm nuclei. Urine was analyzed using gas chromatography coupled with mass spectrometry for concentrations of dialkyl phosphate (DAP) metabolites of OPs [dimethylphosphate (DMP); dimethylthiophosphate (DMTP); dimethyldithiophosphate (DMDTP); diethylphosphate (DEP); diethylthiophosphate (DETP); and diethyldithiophosphate (DEDTP)]. Poisson regression was used to model the association between OP exposures and disomy measures. Incidence rate ratios (IRRs) were calculated for each disomy type by exposure quartiles for most metabolites, controlling for age, race, BMI, smoking, specific gravity, total sperm concentration, motility, and morphology.

RESULTS

A significant positive trend was seen for increasing IRRs by exposure quartiles of DMTP, DMDTP, DEP and DETP in XX18, YY18, XY18 and total disomy. A significant inverse association was observed between DMP and total disomy. Findings for total sum of DAP metabolites concealed individual associations as those results differed from the patterns observed for each individual metabolite. Dose-response relationships appeared nonmonotonic, with most of the increase in disomy rates occurring between the second and third exposure quartiles and without additional increases between the third and fourth exposure quartiles.

CONCLUSIONS

This is the first epidemiologic study of this size to examine the relationship between environmental OP exposures and human sperm disomy outcomes. Our findings suggest that increased disomy rates were associated with specific DAP metabolites, suggesting that the impacts of OPs on testis function need further characterization in epidemiologic studies.

Risk Factors for Melanoma Among Survivors of Non-Hodgkin Lymphoma

PURPOSE

Previous studies have reported that survivors of non-Hodgkin lymphoma (NHL) have an increased risk of developing cutaneous melanoma; however, risks associated with specific treatments and immune-related risk factors have not been quantified.

PATIENTS AND METHODS

We evaluated second melanoma risk among 44,870 1-year survivors of first primary NHL diagnosed at age 66 to 83 years from 1992 to 2009 and included in the Surveillance, Epidemiology, and End Results-Medicare database. Information on NHL treatments, autoimmune diseases, and infections was derived from Medicare claims.

RESULTS

A total of 202 second melanoma cases occurred among survivors of NHL, including 91 after chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) and 111 after other NHL subtypes (cumulative incidence by age 85 years: CLL/SLL, 1.37%; other NHL subtypes, 0.78%). Melanoma risk after CLL/SLL was significantly increased among patients who received infused fludarabine-containing chemotherapy with or without rituximab (n=18: hazard ratio [HR], 1.92; 95% CI, 1.09 to 3.40; n=10: HR, 2.92; 95% CI, 1.42 to 6.01, respectively). Significantly elevated risks also were associated with T-cell activating autoimmune diseases diagnosed before CLL/SLL (n=36: HR, 2.27; 95% CI, 1.34 to 3.84) or after CLL/SLL (n=49: HR, 2.92; 95% CI, 1.66 to 5.12). In contrast, among patients with other NHL subtypes, melanoma risk was not associated with specific treatments or with T-cell/B-cell immune conditions. Generally, infections were not associated with melanoma risk, except for urinary tract infections (CLL/SLL), localized scleroderma, pneumonia, and gastrohepatic infections (other NHLs).

CONCLUSION

Our findings suggest immune perturbation may contribute to the development of melanoma after CLL/SLL. Increased vigilance is warranted among survivors of NHL to maximize opportunities for early detection of melanoma.

Estimation of cardiac output and pulmonary vascular resistance by contrast echocardiography transit time measurement: a prospective pilot study

Background

Studies with other imaging modalities have demonstrated a relationship between contrast transit and cardiac output (CO) and pulmonary vascular resistance (PVR). We tested the hypothesis that the transit time during contrast echocardiography could accurately estimate both CO and PVR compared to right heart catheterization (RHC).

Methods

27 patients scheduled for RHC had 2D-echocardiogram immediately prior to RHC. 3 ml of DEFINITY contrast followed by a 10 ml saline flush was injected, and a multi-cycle echo clip was acquired from the beginning of injection to opacification of the left ventricle. 2D-echo based calculations of CO and PVR along with the DEFINITY-based transit time calculations were subsequently correlated with the RHC-determined CO and PVR.

Results

The transit time from full opacification of the right ventricle to full opacification of the left ventricle inversely correlated with CO (r = -0.61, p < 0.001). The transit time from peak opacification of the right ventricle to first appearance in the left ventricle moderately correlated with PVR (r = 0.46, p < 0.01). Previously described echocardiographic methods for the determination of CO (Huntsman method) and PVR (Abbas and Haddad methods) did not correlate with RHC-determined values (p = 0.20 for CO, p = 0.18 and p = 0.22 for PVR, respectively). The contrast transit time method demonstrated reliable intra- (p < 0.0001) and inter-observer correlation (p < 0.001).

Conclusions

We describe a novel method for the quantification of CO and estimation of PVR using contrast echocardiography transit time. This technique adds to the methodologies used for noninvasive hemodynamic assessment, but requires further validation to determine overall applicability.

Environmental exposure to pyrethroids and sperm sex chromosome disomy: a cross-sectional study

BACKGROUND

The role of environmental pesticide exposures, such as pyrethroids, and their relationship to sperm abnormalities are not well understood. This study investigated whether environmental exposure to pyrethroids was associated with altered frequency of sperm sex chromosome disomy in adult men.

METHODS

A sample of 75 subjects recruited through a Massachusetts infertility clinic provided urine and semen samples. Individual exposures were measured as urinary concentrations of three pyrethroid metabolites ((3-phenoxybenzoic acid (3PBA), cis- and trans- 3-(2,2-Dichlorovinyl)-1-methylcyclopropane-1,2-dicarboxylic acid (CDCCA and TDCCA)). Multiprobe fluorescence in situ hybridization for chromosomes X, Y, and 18 was used to determine XX, YY, XY, 1818, and total sex chromosome disomy in sperm nuclei. Poisson regression analysis was used to examine the association between aneuploidy rates and pyrethroid metabolites while adjusting for covariates.

RESULTS

Between 25-56% of the sample were above the limit of detection (LOD) for the pyrethroid metabolites. All sex chromosome disomies were increased by 7-30% when comparing men with CDCCA and TDCCA levels above the LOD to those below the LOD. For 3PBA, compared to those below the LOD, those above the LOD had YY18 disomy rates 1.28 times higher (95% CI: 1.15, 1.42) whereas a reduced rate was seen for XY18 and total disomy (IRR = 0.82; 95% CI: 0.77, 0.87; IRR = 0.93; 95% CI: 0.87-0.97), and no association was seen for XX18 and 1818.

CONCLUSIONS

Our findings suggest that urinary concentrations of CDCCA and TDCCA above the LOD were associated with increased rates of aneuploidy. However the findings for 3BPA were not consistent. This is the first study to examine these relationships, and replication of our findings is needed before the association between pyrethroid metabolites and aneuploidy can be fully defined.

Caffeine can decrease subjective energy depending on the vehicle with which it is consumed and when it is measured

RATIONALE

Energy drinks contain glucose and caffeine, although in the longer term both adversely influence blood glucose homeostasis, with the unconsidered potential to have adverse consequences for cognition and mood.

OBJECTIVE

The objective of this study was to consider the influence on interstitial glucose levels, mood and cognition of drinks differing in their caffeine content and glycaemic load.

METHODS

Ninety minutes after a standard breakfast, a yoghurt-, glucose- or water-based drink, with or without 80 mg of caffeine, was consumed.

RESULTS

The consumption of caffeine negatively influenced glucose homeostasis: that is, irrespective of the vehicle, caffeine consumption resulted in elevated levels of blood glucose throughout the study. Thirty minutes after consuming caffeine and water, rather than water alone, greater subjective energy was reported. However, after 90 and 150 min, caffeine administered in water increased tiredness, hostility and confusion. In contrast, combining caffeine with a yoghurt-based drink increased energy, agreeableness and clearheadedness later in the morning. There were no effects of caffeine on ratings of mood when it was taken with glucose. Caffeine, irrespective of vehicle, resulted in better memory, quicker reaction times in the choice reaction time test and the working memory task, and better and quicker responses with the vigilance task.

CONCLUSION

Further research should consider how caffeine interacts with macronutrients and the timescale over which such effects occur.

Sync and Swim

Background: Medication nonadherence is associated with higher cost of care and poor outcomes. Medication refill consolidation (synchronization of refill dates for patients on multiple drugs) is an important component of regimen complexity. We presumed that Medicaid patients with a 30-day medication supply limit would have significant difficulty with refill consolidation. We evaluated regimen complexity and refill consolidation in relation to medication adherence in the Medicaid population. Methods: A survey was administered to 50 Medicaid patients taking 2 or more daily medications in the outpatient setting. The survey included demographics, 13 items related to medication and pharmacy history, and 10 items related to medication regimen complexity and refill consolidation. Chi-square analysis was used to assess the relationship between adherence and missed medication doses due to regimen complexity. Wilcoxon rank sum test was used to determine association between total number of prescribing providers and number of daily medications with various aspects of regimen complexity. Results: 52% were required to go to the pharmacy more than once per month to keep all of their medications filled and 46% missed a day or more of medication because their medications must be refilled on different dates. Those who missed a day or more of medication because of need to refill prescriptions on different days had higher number of prescriptions ( P = .03) and higher number of prescribers ( P = .03). Conclusion: Medicaid patients had low medication adherence in the context of high regimen complexity and poor refill consolidation. This population would benefit from interventions focused on improving synchronization of medication refills.

Patient navigation significantly reduces delays in breast cancer diagnosis in the District of Columbia

BACKGROUND

Patient Navigation (PN) originated in Harlem as an intervention to help poor women overcome access barriers to timely breast cancer treatment. Despite rapid, nationally widespread adoption of PN, empirical evidence on its effectiveness is lacking. In 2005, National Cancer Institute initiated a multicenter PN Research Program (PNRP) to measure PN effectiveness for several cancers. The George Washington Cancer Institute, a project participant, established District of Columbia (DC)-PNRP to determine PN's ability to reduce breast cancer diagnostic time (number of days from abnormal screening to definitive diagnosis).

METHODS

A total of 2,601 women (1,047 navigated; 1,554 concurrent records-based nonnavigated) were examined for breast cancer from 2006 to 2010 at 9 hospitals/clinics in DC. Analyses included only women who reached complete diagnostic resolution. Differences in diagnostic time between navigation groups were tested with ANOVA models including categorical demographic and treatment variables. Log transformations normalized diagnostic time. Geometric means were estimated and compared using Tukey-Kramer P value adjustments.

RESULTS

Average-geometric mean [95% confidence interval (CI)]-diagnostic time (days) was significantly shorter for navigated, 25.1 (21.7, 29.0), than nonnavigated women, 42.1 (35.8, 49.6). Subanalyses revealed significantly shorter average diagnostic time for biopsied navigated women, 26.6 (21.8, 32.5) than biopsied nonnavigated women, 57.5 (46.3, 71.5). Among nonbiopsied women, diagnostic time was shorter for navigated, 27.2 (22.8, 32.4), than nonnavigated women, 34.9 (29.2, 41.7), but not statistically significant.

CONCLUSIONS

Navigated women, especially those requiring biopsy, reached their diagnostic resolution significantly faster than nonnavigated women.

IMPACT

Results support previous findings of PN's positive influence on health care. PN should be a reimbursable expense to assure continuation of PN programs.

The impact of patient navigation on receipt of quality breast cancer treatment in the national patient navigation research program

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Background: The discrepancy in breast cancer outcomes for underserved populations has been linked to lack of receipt of quality treatment. Patient navigation programs are being rapidly adopted as a model to improve cancer outcomes for these vulnerable populations, yet the effect of navigation on their quality of cancer care is unknown. Methods: We conducted a secondary analysis of the National Patient Navigation Research Program (PNRP) data to assess the impact of navigation on receipt of quality care among women diagnosed with breast cancer. Data pooled from 7 PRNP sites were used to determine the proportion of newly diagnosed cancer patients whose care met National Comprehensive Cancer Network (NCCN) quality metrics: 1) hormonal therapy for HR+ patients 2) post-lumpectomy radiation therapy; and 3) chemotherapy for hormone negative, >1cm tumors, in patients <70 years of age. Chi-square tests were performed to compare probability of receiving recommended care among navigated and control patients. Results: A total of 1,006 breast cancer patients eligible for treatment were enrolled across all sites: 491 (49%) in the intervention arm, 515 (51%) in the control arm (mean age: 56 years; 38% African American, 23% Hispanic; 13% uninsured and 38% Medicaid). Among those eligible for hormone therapy, 283/357 (79%) navigated patients received hormonal therapy compared to 237/371 (64%) of controls (p < 0.001). Among those eligible for radiation therapy post lumpectomy, 235/277 (85%) of navigated patients received radiation compared to 270/324 (83%) of controls (p=0.62). Among those eligible for chemotherapy, 79/122 (65%) of navigated patients received chemotherapy compared to 81/100 (81%) of controls (p < 0.007). Logistic regression models to determine the odds of receiving recommended care for navigated and non-navigated patients, adjusting for patient demographics, will be conducted. Conclusions: Navigation had a positive effect for receipt of hormonal therapy, but not for radiation therapy and chemotherapy. Future studies are needed to assess the role navigation may play in ensuring quality care for the most vulnerable.

Selenoproteins reduce susceptibility to DMBA-induced mammary carcinogenesis

Selenium is an essential micronutrient in the diet of humans and other mammals. Based largely on animal studies and epidemiological evidence, selenium is purported to be a promising cancer chemopreventive agent. However, the biological mechanisms by which chemopreventive activity takes place are poorly understood. It remains unclear whether selenium acts in its elemental form, through incorporation into organic compounds, through selenoproteins or any combination of these. The purpose of this study was to determine whether selenoproteins mitigate the risk of developing chemically induced mammary cancer. Selenoprotein expression was ablated in mouse mammary epithelial cells through genetic deletion of the selenocysteine (Sec) tRNA gene (Trsp), whose product, designated selenocysteine tRNA, is required for selenoprotein translation. Trsp floxed and mouse mammary tumor virus (MMTV)-cre mice were crossed to achieve tissue-specific excision of Trsp in targeted mammary glands. Eight- to twelve-week-old second generation Trsp(fl/+);wt, Trsp(fl/+);MMTV-cre, Trsp(fl/fl);wt and Trsp(fl/fl);MMTV-cre female mice were administered standard doses of the carcinogen, 7,12-dimethylbenzylbenz[a]antracene. Our results revealed that heterozygous, Trsp(fl/+);MMTV-cre mice showed no difference in tumor incidence, tumor rate and survival compared with the Trsp(fl/+);wt mice. However, 54.8% of homozygous Trsp(fl/f)(l);MMTV-cre mice developed mammary tumors and exhibited significantly shorter survival than the corresponding Trsp(fl/fl);wt mice, where only 36.4% developed tumors. Loss of the homozygous Trsp alleles was associated with the reduction of selenoprotein expression. The results suggest that mice with reduced selenoprotein expression have increased susceptibility to developing carcinogen-induced mammary tumors and that a major protective mechanism against carcinogen-induced mammary cancer requires the expression of these selenoproteins.

Inhibition of androgen-responsive LNCaP prostate cancer cell tumor xenograft growth by dietary phenethyl isothiocyanate correlates with decreased angiogenesis and inhibition of cell attachment

Phenethyl isothiocyanate (PEITC) is a candidate anticancer compound found in certain cruciferous vegetables. In our tumor cell xenograft model, dietary administration of PEITC (100–150 mg/kg body weight/d) inhibited androgen-responsive LNCaP human prostate cancer cell tumor growth. We found that dietary treatment with PEITC significantly inhibited tumor platelet/endothelial cell adhesion molecule (PECAM-1/CD31) expression, a marker of angiogenesis. By contrast, we did not find the inhibitory effects of PEITC on tumor growth to be associated with alteration of specific markers for apoptosis, cell proliferation or androgen receptor-mediated pathways. Consistent with in vivo results, PEITC exerted little effects on cell proliferation, cell cycle and androgen-dependent pathways. Interestingly, PEITC significantly attenuated LNCaP cell plating efficiency that correlated with inhibition of integrin family proteins integrin β1, α2 and α6 mRNA expression. Thus, PEITC may be a dietary factor that inhibits androgen-responsive prostate tumor growth indirectly by selectively targeting factors involved in the tumor microenvironment.

The successful use of cardiopulmonary support for a transected bronchus

A 20-year-old male was involved in a motor vehicle accident and computed tomography revealed a completely transected right mainstem bronchus. An Emergency Department (ED) right anterior thoracotomy was necessary soon after arrival at our institution secondary to acute desaturation that was unresponsive to ventilator and chest tube management. This allowed direct intubation and ventilation of the right middle and lower lobes directly through the thoracotomy incision, which stabilized the patient for transport to the operating room. Once there, percutaneous cardiopulmonary support (CPS) was initiated to allow primary surgical repair of the transected bronchus. Post surgery, the patient was transported to the surgical intensive care unit on CPS which he required for an additional two days. The patient eventually did well and was discharged home. To our knowledge this is the first successful reported case of using the Avalon Elite dual lumen veno-venous cannula for CPS in a patient with complete right main-stem bronchus transection and bilateral pulmonary contusions.

Interpretation of remotely downloaded pocket-size cardiac ultrasound images on a web-enabled smartphone: validation against workstation evaluation

BACKGROUND

Pocket-size ultrasound has increased echocardiographic portability, but expert point-of-care interpretation may not be readily available. The aim of this study was to test the hypothesis that remote interpretation on a smartphone with dedicated medical imaging software can be as accurate as on a workstation.

METHODS

Eighty-nine patients in a remote Honduran village underwent echocardiography by a nonexpert using a pocket-size ultrasound device. Images were sent for verification of point-of-care diagnosis to two expert echocardiographers in the United States reading on a workstation. Studies were then anonymized, randomly ordered, and reinterpreted on a smartphone with a dedicated, Health Insurance Portability and Accountability Act-compliant application. Point-of-care diagnosis was considered accurate if any abnormal finding was matched and categorized at the same level of severity (mild, moderate, or severe) by either expert interpretation.

RESULTS

The mean age was 54 ± 23 years, and 57% of patients were women. The most common indications for echocardiography were arrhythmia (33%), cardiomyopathy (28%), and syncope (15%). Using the workstation, point-of-care diagnoses were changed in 38% of cases by expert overread (41% left ventricular function correction, 38% valvulopathy correction, 18% poor image quality). Expert interobserver agreement was excellent at 82%, with a Cohen's κ value of 0.82 (95% confidence interval, 0.70-0.94). Intraobserver agreement comparing interpretations on workstations and smartphones was 90%, with a Cohen's κ value of 0.86 (95% confidence interval, 0.76-0.97), signifying excellent intertechnology agreement.

CONCLUSIONS

Remote expert echocardiographic interpretation can provide backup support to point-of-care diagnosis by nonexperts when read on a dedicated smartphone-based application. Mobile-to-mobile consultation may improve access in previously inaccessible locations to accurate echocardiographic interpretation by experienced cardiologists.

Abstract A60: Second primary breast cancer incidence rates among black and white female breast cancer survivors

Background: Breast cancer incidence increases with age and exhibits a Black-to-White incidence crossover around age 45. Breast cancer survivors are at a significantly elevated risk of developing a second primary breast compared with the general population. The purpose of this study was to determine whether a similar crossover occurs in second primary breast cancer incidence in Black and White women.

Methods: The Surveillance, Epidemiology, and End Results’ Registry 9 was used to follow 415,664 White and 39,887 Black female breast cancer survivors, diagnosed at age 19 or older, for a second primary breast cancer between 1973 and 2007. Cumulative incidence curves, which account for the competing risk of death and the occurrence of second primary non-breast cancers, were generated; Pepe and Mori's test was used to test for significance.

Results: A total of 22,290 (40.7%) second primary breast cancers were observed among 450,936 women who had survived 2 months or more after an in situ or invasive breast cancer. The majority, 18,227 (81.7%) cases, occurred in women diagnosed with a first primary breast cancer at age 45 or older. Second primary breast cancer followed the incidence pattern of the first primary breast cancer in Black and White women diagnosed before age 45. It was opposite of the pattern of first primary breast cancer in Black and White women diagnosed at age 45 or later.

Despite the Black-to-White crossover of first primary breast cancer around age 45, the incidence of second primary breast cancer was higher in Blacks than in Whites.

Citation Information: Cancer Epidemiol Biomarkers Prev 2011;20(10 Suppl):A60.

Abstract A74: A dichotomy between the risk and histology in bladder cancer among blacks and whites: An epidemiological study

Background: Urinary bladder cancer, despite being the second most common genitourinary disease in the U.S. still presents a number of as yet unsolved complexities. Known to much of the literature is the 2:1 trend of the White to Black cancer rate, the three main histological types of bladder cancer – transitional cell carcinomas (90%), squamous cell carcinomas (5%), and adenocarcinomas (2%), and that smoking is the main etiologic factor contributing to bladder cancer. Historically, Blacks have been identified as having higher smoking rates than Whites. Therefore, the racial discrepancy in bladder cancer rates remains to be explored at the cellular level in light of the contrasting trend in smoking rates.

Objective: To demonstrate that higher transitional cell carcinoma (TCC) incidences prevail in the bladder in Whites compared with Blacks, even though Blacks have a higher rate of smoking than Whites.

Methods: The National Cancer Institute's SEER*stat program version 7.0.4 was used to collect bladder cancer rates for each histological type by age, sex, race, U.S. county, and year of diagnosis. Additionally, lung cancer rates, used as a surrogate for smoking, by county and overall case-specific data were obtained. SAS 9.1 and Microsoft Excel were used to analyze the data in the production of trend, frequency-density, and log-linear plots, correlation analyses, and linear regressions.

Results: The 1973–2008 age-adjusted incidence of TCC of the bladder among Blacks and Whites was 11 and 21 cases per 100,000 persons respectively. Similarly, Black and White rates for TCCs of the renal pelvis were 0.54 and 0.95 cases per 100,000 persons and were 0.21 and 0.61 cases per 100,000 persons for TCCs of the ureter. However, in contrast, lung cancer rates for Blacks and Whites were 82 and 64 cases per 100,000 persons respectively. Frequency-density plots revealed similarity in curves among Blacks and Whites, peaking once between the ages of 65 and 80 years and showing bell-shaped distribution. Bivariate correlation analysis indicated that bladder and lung cancer rates were significantly correlated at about 77%. A statistically significant linear model (R2=0.75) regressing bladder cancer rates on age group, race, sex, and lung cancer rates, was evaluated and revealed that in a population that does not smoke, there were 105 White and 47 Black cases per 100,000 persons on average.

Conclusions: Regardless of higher smoking rates in Blacks than in Whites, Whites have higher rates of TCCs of the bladder as well as of other sites including the renal pelvis and ureter. Even in a population considered without smoking, the trend persists with Whites having higher incidences of bladder cancer than Blacks.

Citation Information: Cancer Epidemiol Biomarkers Prev 2011;20(10 Suppl):A74.

Abstract B90: Patient navigation significantly reduces delays in breast cancer diagnosis in the District of Columbia

Background: Delays in follow-up after breast cancer screening may contribute to disparities in breast cancer outcomes. To eliminate breast cancer disparities in Washington, D.C., The GW Cancer Institute established the D.C. Citywide Patient Navigation Research Program (DC-PNRP), which is one of nine national PNRP sites funded by the National Cancer Institute and the American Cancer Society to evaluate the effectiveness of patient navigation. The primary objective of this study is to determine the impact of patient navigation in reducing breast cancer diagnostic time, defined as the number of days from abnormal screening to definitive diagnosis.

Methods: This is a prospective study of 1922 women (728 navigated and 1194 concurrent race-matched records-based non-navigated) examined for breast cancer between 1998 and 2010 at nine hospitals and clinics located in Washington, D.C. Analysis of variance (ANOVA) was used to test for significant differences in diagnostic time between navigated and non-navigated women, while controlling for race/ethnicity (non-Hispanic white (NHW), non-Hispanic black (NHB), Hispanic), type of health insurance (private, government, none), and age at abnormal screening (&lt;40, 40–49, 50–59, 60+). Two-way interactions between group and each of the demographic variables race/ethnicity, type of health insurance, and age at abnormal screening were considered. To satisfy model assumptions, diagnostic time was normalized through a log transformation. Geometric means were estimated and compared using a Tukey-Kramer p-value adjustment.

Results: Unadjusted average—geometric mean (95% CI)—diagnostic times (in days) were 23.9 (20.5, 27.8) for navigated and 37.2 (33.0, 41.8) for non-navigated women (p&lt;0.0001). A factorial ANOVA model revealed significant interactions between navigation and both race/ethnicity (p=0.02) and age at abnormal screening (p=0.03) after controlling for type of insurance (p=0.0008). Navigated NHW had a significantly shorter adjusted average diagnostic time, 6.1 (3.5, 10.5) days, than non-navigated NHW, 16.0 (11.5, 22.3) days (p=0.03); and navigated Hispanics had a significantly shorter adjusted average diagnostic time, 26.5 (19.5, 36.0) days, than non-navigated Hispanics, 57.2 (44.8, 73.1) days (p=0.0005). While navigated NHB had a shorter adjusted average diagnostic time, 26.2 (21.5, 31.9) days, than non-navigated NHB, 34.3 (28.4, 41.4) days, this decrease was not statistically significant (p=0.32). Navigation reduced the diagnostic time for women of all ages, but this decrease was statistically significant only for women aged 60+ years (p&lt;0.0001). Navigated women younger than 40 or 60+ had significantly shorter adjusted average diagnostic times than those aged 50–59 (p=0.03 for each). Adjusted average diagnostic times (in days) by age group were 11.2 (7.7, 16.3) for navigated and 22.8 (14.9, 35.0) for non-navigated women &lt;40; 21.6 (15.9, 29.2) for navigated and 33.7 (27.4, 41.4) for non-navigated women 40–49; 23.8 (17.0, 33.5) for navigated and 35.5 (28.4, 44.4) for non-navigated women 50–59; 11.9 (8.4, 16.9) for navigated and 36.2 (28.4, 46.2) for non-navigated women 60+.

Conclusions: The time required for navigated women to reach a definitive diagnosis following an abnormal screening was significantly shorter as compared to non-navigated women. While navigation was effective overall, the program proved to be more helpful for Hispanics and NHW than for NHB, especially among women aged 60+ years. Barriers preventing a rapid diagnostic resolution for NHB need to be explored further.

Citation Information: Cancer Epidemiol Biomarkers Prev 2011;20(10 Suppl):B90.

Effect of electronic prescription on attainment of cholesterol goals

BACKGROUND

Although recent federal mandate provides incentives for physicians to use electronic prescribing (e-prescribing), clinical end points to support its use are lacking.

HYPOTHESIS

E-prescribing should improve low-density lipoprotein (LDL) goal attainment.

METHODS

In this retrospective cohort study, we queried the electronic medical records (Allscripts Electronic Health Record [EHR]) of a multispecialty outpatient academic medical practice to identify patient encounters during which consecutive lipid panels were drawn in 2007 (n = 2218). The EHR did not include a clinical decision tool for guideline adherence but did include formulary decision support (FDS), which informs physicians about drug costs specific to each patient. Logistic regression was used to examine whether the odds of reaching LDL goal were influenced by e-prescribing and adjusted for characteristics known to affect prescribing patterns and goal attainment.

RESULTS

Of 796 patients not at LDL goal at baseline, 49% (n = 393) were at goal at follow-up. Patients receiving an e-prescription with FDS were 59% more likely to achieve LDL goal than those with a manual prescription (95% confidence interval [CI]: 1.12-2.25). Superior LDL goal attainment may be from lower cost of medications; patients with an e-prescription were significantly more likely to receive a generic statin than patients with a manual prescription (38% vs 22.9%; P = 0.0004), and for each $10 increase in prescription price, the likelihood of being at goal decreased by 5% (odds ratio = 0.95; 95% CI: 0.93-0.98).

CONCLUSIONS

Our study is the first to demonstrate that e-prescribing with FDS is associated with improved LDL goal attainment. Therefore, e-prescribing can deliver tangible clinical gains to patients, likely from improved adherence to more affordable treatment.

Having health insurance does not eliminate race/ethnicity-associated delays in breast cancer diagnosis in the District of Columbia

BACKGROUND

Delays in follow-up after breast cancer screening contribute to disparities in breast cancer outcomes. The objective of this research was to determine the impact of race/ethnicity and health insurance on diagnostic time, defined as number of days from suspicious finding to diagnostic resolution.

METHODS

This retrospective cohort study of 1538 women examined for breast abnormalities between 1998-2010 at 6 hospitals/clinics in the District of Columbia measured mean diagnostic times between non-Hispanic whites (NHWs), non-Hispanic blacks (NHBs), and Hispanics with private, government, or no health insurance by using a full-factorial ANOVA model.

RESULTS

Respective average--geometric mean (95% CI)--diagnostic times (in days) for NHWs, NHBs, and Hispanics were 16 (12, 21), 27 (23, 33), and 51 (35, 76) among privately insured; 12 (7, 19), 39 (32, 48), and 71 (48, 105) among government insured; 45 (17, 120), 60 (39, 92), and 67 (56, 79) among uninsured. Government insured NHWs had significantly shorter diagnostic times than government insured NHBs (P = .0003) and Hispanics (P < .0001). Privately insured NHWs had significantly shorter diagnostic times than privately insured NHBs (P = .03) and Hispanics (P < .0001). Privately insured NHBs had significantly shorter diagnostic times than uninsured NHBs (P = .03).

CONCLUSIONS

Insured minorities waited >2 times longer to reach their diagnostic resolution than insured NHWs. Having private health insurance increased the speed of diagnostic resolution in NHBs; however, their diagnostic time remained significantly longer than for privately insured NHWs. These results suggest diagnostic delays in minorities are more likely caused by other barriers associated with race/ethnicity than by insurance status.

Abstract PR-10: Impact of race, ethnicity and health insurance on delays in breast cancer diagnosis in the District of Columbia

Background: Delays in follow-up after breast cancer screening are thought to contribute to disparities in breast cancer outcomes. The primary objective of this study is to determine the impact of race/ethnicity and type of health insurance on the diagnostic delay time, defined as the number of days from abnormal screening to definitive diagnosis.

Methods: This is a retrospective study of 976 women examined for breast cancer between 1998 and 2009 at six hospitals and clinics located in the District of Columbia. We used a full-factorial ANOVA model to test for significant differences in diagnostic delay time among non-Hispanic white (NHW), non-Hispanic black (NHB), and Hispanic women with private, government, or no health insurance. A log transformation was taken on the diagnostic delay time to normalize our data, and geometric means were estimated and compared.

Results: The average geometric mean (95% CI) diagnostic delay times were as follows: among those with private insurance, 15.9 (12.2,20.6) days for NHW, 27.0 (22.4,32.6) days for NHB, and 51.4 (34.8,76.0) days for Hispanic women; among those with government insurance, 11.9 (7.3,19.3) days for NHW, 39.5 (32.2,48.6) days for NHB, and 71.6 (47.8,107.1) days for Hispanic women; and among those without insurance, 44.5 (16.4,120.6) days for NHW, 59.7 (38.8,91.8) days for NHB, and 66.4 (55.8,79.1) days for Hispanic women. In fitting a full-factorial ANOVA model, we found that NHW women with government insurance had a significantly shorter delay in diagnosis than NHB (p=0.0003) and Hispanic (p&lt;0.0001) women with government insurance. We also found that NHW women with private insurance had a significantly shorter delay in diagnosis than NHB (p=0.03) and Hispanic (p&lt;0.0001) women with private insurance. However, there were no significant differences within the uninsured women (p&gt;0.05). Finally, we found that NHB women with private insurance had a significantly shorter delay in diagnosis than uninsured NHB women (p=0.03).

Conclusions: NHB and Hispanic women with government or private insurance waited more than twice as long to reach their definitive diagnosis than NHW women with government or private insurance. Uninsured NHB women waited more than twice as long to reach their definitive diagnosis than NHB women with private insurance. Having private health insurance markedly increased the speed of diagnostic resolution in NHB women; however, the speed of diagnostic resolution remained significantly longer for NHB women with private insurance than for NHW women with private insurance. These results suggest that while both insurance and race/ethnicity affect diagnostic resolution, health insurance may not be the primary barrier to optimal diagnostic resolution in NHB women. It will be important to determine what other factors serve as the primary barriers, as well as if these delays affect the final breast cancer outcome for the patients.

Funding Mechanism: Grant Number 1 U01 CA116937; Patient Navigation Research Program (PNRP), Center for Research on Cancer Health Disparities (CRCHD), National Cancer Institute (NCI).

Citation Information: Cancer Epidemiol Biomarkers Prev 2010;19(10 Suppl):PR-10.

Abstract B79: Racial and socioeconomic disparities in time to treatment for breast cancer in the District of Columbia

The objective of this research was to determine if there were racial and socioeconomic disparities in time to treatment among women diagnosed with breast cancer in the District of Columbia from 1998-2006.

The D.C. Cancer Registry provided a data file containing female breast cancer cases identified from 1998-2006 along with age at diagnosis, census tract, race, ethnicity, diagnosis date, stage, date of first treatment, treatment type, grade, and insurance status. Cancer registry data were linked to 2000 Census data by census tract to create a variable for socioeconomic status based on percentage of the population below the poverty level in each census tract. Analysis of covariance was utilized to determine if the time from diagnosis to first treatment was predicted by race, Hispanic ethnicity, insurance or socioeconomic status while controlling for stage, grade, and age at diagnosis. Time to treatment was also dichotomized into &lt;2 months and &gt;=2months and a multiple logistic regression model using the above variables was utilized to generate odds ratios and 95% confidence intervals to determine if any of the above variables predicted a treatment delay. Finally analysis was stratified by calendar year periods to determine if disparities were reduced or persisted over time.

After controlling for the above variables black women were significantly more likely than white women to have a time from diagnosis of breast cancer to treatment of &gt;=2 months (OR=2.19; 95% CI: 1.57, 3.06). Women who were diagnosed in 2001–;2003 (OR=1.72; 95% CI: 1.20,2.40) and 2004-2006 (OR=2.31; 95% CI: 1.62,3.35) were also significantly more likely to have a time to first treatment of 2 or more months compared to women diagnosed in 1998-2000. The adjusted mean times to treatment were significantly different for black versus white women (26.1 vs. 14.1 days). The mean time to treatment differed significantly by time period as well, at 14.8,19.4, and 26.1 days for 1998-2000,2001–;2003, and 2004-2006 respectively. A subgroup analysis of women with estrogen and progesterone receptor status data yielded similar results to the overall analysis. Lastly, when stratified by calendar period, black women were significantly more likely to experience longer time to treatment if diagnosed in 2001–2003 and 2004-2006 but not in 1998-2000.

Overall, black women with breast cancer in the District of Columbia are more likely to experience delays in treatment regardless of insurance type, socioeconomic status, and cancer characteristics such as stage and grade. Racial disparities in time to treatment have not abated over time and may have increased. Further research should be undertaken to determine the reasons that could underlie these delays and determine if disparities are actually worsening over time.

Citation Information: Cancer Epidemiol Biomarkers Prev 2010;19(10 Suppl):B79.

Abstract B90: The District of Columbia citywide Patient Navigation Research Program (DC-PNRP): Preliminary descriptive findings

Introduction: Minority breast cancer mortality rates in Washington, DC are among the Nation's highest. To address these disparities we instituted the DC Citywide Patient Navigation Research Program (DC-PNRP) - an inter-institutional collaboration that is one of 9 National PNRP sites funded by NCI/ACS to evaluate the effectiveness of patient navigation in reducing time from suspicious finding to diagnostic resolution and time from resolution to treatment initiation.

Study Procedures: A total of 1024 women, mostly minorities, have been enrolled from 8 recruitment sites at the point of suspicious finding. Utilizing a non-randomized design, 1240 concurrent, medical records-based controls were identified from 6 sites for comparison. Subject recruitment ended March 31,2010, but data collection continues on those women already enrolled. A unique framework of “network navigation” emerged whereby services were integrated across a city-wide network of unaffiliated healthcare sites. Navigators from a broad partnership of clinical and community sites were trained to work collaboratively within a city-wide network to enroll patients in the study and assure each receives timely, quality care. This “integrative navigation”model is collecting data addressing not only structural barriers to access to care (i.e., inadequate insurance, lack of transportation, etc.), but also psychosocial barriers (i.e., fear, medical mistrust, acculturation, etc.). Frequent trainings, efforts that promote increased communication between navigators, and sharing of information about community resources were implemented to enhance care coordination and to assure appropriate referral strategies between community outreach, screening, and treatment sites.

Results and Conclusion: Among controls, 7.66% were non-Hispanic whites (NHW), 35.24% were non-Hispanic blacks (NHB), 30.65% were Hispanic, and 26.45% were of other or unknown race/ethnicity. The corresponding percentages for navigated patients were 7.03%, 48.93%, 29.88%, and 14.16% indicating larger numbers of NHB and fewer with other/unknown race/ethnicity among the navigated patients. When examining age of subjects grouped by &lt;40 years, 40-49 years, 50-59 years, 60-69 years, 70-79 years, and &gt;=80 years, respective proportions among controls were 7.10%, 37.98,28.15,16.29, 6.61, and 3.87%, while the distribution for navigated patients was: 20.70%, 32.03,24.41,14.06,5.57, and 3.22%, respectively, suggesting that navigated patients were slightly younger than controls. Household income level was generally unavailable for controls and for 35.54% of navigated patients. Proportions of navigated patients falling into the income categories &lt;$10,000, $10-19,999, $20-29,999, $30-39,999, $40-49,999, and &gt;=$50,000 are 14.06%, 13.38,9.38,9.18,4.59, and 13.87%, respectively, indicating fairly substantial numbers of low income patients. Among controls, 29.27% indicated they had no form of health insurance. The proportion was similar for navigated patients at 33.98%. Our data indicate we have comparable groups based on demographic attributes of navigated and control patients for our future analyses.

Funding Mechanism: Grant Number 1 U01 CA116937; Patient Navigation Research Program (PNRP), Center for Research on Cancer Health Disparities (CRCHD), National Cancer Institute (NCI).

Citation Information: Cancer Epidemiol Biomarkers Prev 2010;19(10 Suppl):B90.

Abstract 862: Network patient navigation: An integrative, longitudinal model to reduce breast cancer disparities

Introduction: Minority breast cancer mortality rates in Washington, DC are among the nation's highest. To address disparities we instituted the DC Citywide Patient Navigation Research Program (DC-PNRP) - an inter-institutional collaboration that is one of 9 National PNRP sites funded by NCI/ACS to evaluate the effectiveness of patient navigation in reducing barriers to obtaining health care while also addressing psychosocial factors.

Study Procedures: More than 1000 minority women have been enrolled from 7 recruitment sites at the point of suspicious finding to investigate whether patient navigation decreases time from suspicious breast finding to diagnostic resolution and time from diagnosis to treatment initiation. Utilizing a non-randomized design, concurrent, medical records-based controls have been identified. Data collection will extend through March 2010. A unique framework of “network navigation” emerged whereby services were integrated across a city-wide network of unaffiliated healthcare sites. Navigators from a broad partnership of clinical and community sites were trained to work collaboratively within a city-wide network to enroll patients in the study and assure each patient receives timely, quality care. This “integrative navigation” model is collecting data addressing not only structural barriers to access to care (i.e., inadequate insurance, lack of transportation, etc.), but also psychosocial barriers (i.e., fear, medical mistrust, acculturation, etc.). Frequent trainings, efforts that promote increased communication between navigators, and sharing of information about community resources were implemented to enhance care coordination and to assure appropriate referral strategies between community outreach, screening, and treatment sites.

Results and Conclusion: Implementation of DC-PNRP led us to broaden the original treatment-oriented navigation model to create a “Longitudinal Navigation” paradigm that follows the patient from outreach through survivorship. Data will be shown describing how this model addresses barriers to access and the underlying fragmentation of services that exist in DC for low-income uninsured or under-insured women. Data on the types and distribution of barriers will also be presented. This city-wide program serves as model for inter-institutional cooperation to improve health care access, particularly for the underserved.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 862.

Abstract 865: Impact of race and health insurance on delays in breast cancer diagnosis and treatment in the District of Columbia

Background: Delays in follow-up after breast cancer screening are thought to contribute to disparities in breast cancer outcomes. The primary objective of this study is to determine the impact of race as well as health insurance status on the diagnostic delay time, defined as the number of days from abnormal screening to definitive diagnosis. In addition, we analyze the effects of race and health insurance status on the treatment delay time, defined as the number of days from definitive breast cancer diagnosis to treatment initiation.

Methods: This is a retrospective study of 695 women examined for breast cancer between 1997 and 2009 at seven hospitals and clinics located in the District of Columbia. The outcomes of interest were the diagnostic delay time and the treatment delay time. We used full-factorial and main-effects ANOVA models to test for significant differences in these outcomes between African-American and white women with and without some type of health insurance.

Results: The mean diagnostic delay time was 37 days for insured white women, 76 days for uninsured white women, 75 days for insured African-American women, and 73 days for uninsured African-American women. In fitting a full-factorial ANOVA model, we found that insured white women had a significantly shorter delay in diagnosis than insured African-American women (p=0.0001) as well as uninsured white women (p=0.0007). Furthermore, a main-effects ANOVA model showed that after controlling for insurance status, African-American women had a mean treatment delay time of 45 days, which was significantly longer than the mean treatment delay time of only 17 days for white women (p&lt;0.0001). Insurance status, however, had no significant effect on the treatment delay time after controlling for race (p=0.72).

Conclusions: Insured African-American women and uninsured white women waited more than twice as long to reach their definitive diagnosis than insured white women. African-American women also waited more than three times as long as white women for treatment initiation following definitive diagnosis. Lack of health insurance markedly decreased the speed of diagnostic resolution in white women, but having health insurance did not increase the speed of diagnostic resolution in African-American women. These results suggest that lack of health insurance may not be the primary barrier to optimal diagnostic resolution and treatment initiation in African-American women. It will be important to determine what other factors serve as the primary barriers, as well as if these delays affect the final breast cancer outcome for the patients.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 865.

Abstract 889: Evaluating the case definition of inflammatory breast cancer

Background: Inflammatory breast cancer (IBC) is recognized as an aggressive form of breast cancer requiring neoadjuvant chemotherapy. Although IBC affects only a small percentage of breast cancer patients, the estimated 4,810 new cases for 2009 exceeds the number of women diagnosed with other cancers, such as acute lymphocytic leukemia and chronic myelocytic leukemia (as reported by the American Cancer Society). Research on IBC is hampered by the absence of an agreed upon case definition. While the American Joint Committee on Cancer (AJCC) relies on clinical features (more than half of the breast being involved with redness, warmth and edema), the National Cancer Institute's Surveillance, Epidemiology and End Results (SEER) Program focuses on pathologic confirmation. This study was undertaken to determine whether the outcome of IBC differs among patients who meet IBC criteria by AJCC, SEER, and private practitioners to try to improve the case definition for research purposes.

Methods: This is a retrospective study of 121 patients in The George Washington University Medical Center IBC Registry who were classified as an IBC case by AJCC, SEER or private practitioners. We grouped these IBC cases into four epidemiological categories: (1) clinical-pathologic presentation of disease involving more than half of the breast, (2) clinical-only presentation of disease involving more than half of the breast, (3) clinical-pathologic presentation of disease involving less than half of the breast, and (4) clinical-only presentation of disease involving less than half of the breast. Note that Categories 1 and 2 meet AJCC criteria, while Categories 1 and 3 meet SEER criteria for IBC. We used an unadjusted Cox proportional hazards model to test the homogeneity of the progression-free survival (PFS) curves among these four epidemiological categories.

Results: Of the 121 IBC cases, 33.1% (n=40) were classified as Category 1, 16.5% (n=20) were Category 2, 25.6% (n=31) were Category 3, and 24.8% (n=30) were Category 4. Using Category 4 as the reference group, the Cox proportional hazards model yielded insignificant hazard ratios (95% CI) of 1.69 (0.82, 3.51), 0.80 (0.28, 2.28), and 1.98 (0.95, 4.12) for Categories 1, 2, and 3, respectively. Applying the Score test, we found no significant difference in the PFS curves among the four epidemiological categories (χ2=5.87, p=0.12).

Conclusions: The case definitions of IBC as proposed by the AJCC and SEER are inadequate. This study suggests that IBC as identified by private practitioners not meeting these criteria have the same poor prognosis as those meeting the case definitions of these national organizations. Preliminary laboratory studies support the conclusion that women with clinical evidence of IBC not involving half of the breast and with no documentation of involvement of the dermal lymphatics have the same disease as those meeting AJCC and SEER diagnostic criteria.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 889.

Thimerosal exposure & increasing trends of premature puberty in the vaccine safety datalink

BACKGROUND & OBJECTIVES

The US Agency for Toxic Substances and Disease Registry (ATSDR) reports that mercury (Hg) is a known endocrine disruptor and it adversely affects the steroid synthesis pathway in animals and humans, and may interact to enhance the risk for a child developing premature puberty. An association between premature puberty and exposure to Hg from thimerosal-containing vaccines (TCVs) was evaluated in computerized medical records within the Vaccine Safety Datalink (VSD).

METHODS

A total of 278,624 subjects were identified in birth cohorts from 1990-1996. The birth cohort prevalence rates of medically diagnosed International Classification of Disease, 9(th) revision (ICD-9) premature puberty and control outcomes were calculated. Exposures to Hg from TCVs were calculated by birth cohort for specific exposure windows from birth-7 months and birth-13 months of age. Poisson regression analysis was used to model the association between the prevalence of outcomes and Hg doses from TCVs.

RESULTS

Significantly increased (P<0.0001) rate ratios were observed for premature puberty for a 100 microg difference in Hg exposure from TCVs in the birth-7 months (rate ratio=5.58) and birth-13 months (rate ratio=6.45) of age exposure windows. By contrast, none of the control outcomes had significantly increased rate ratios with Hg exposure from TCVs.

INTERPRETATION & CONCLUSIONS

Routine childhood vaccination should be continued to help reduce the morbidity and mortality associated with infectious diseases, but efforts should be undertaken to remove Hg from vaccines. Additional studies should be done to evaluate the relationship between Hg exposure and premature puberty.

Enhancing nursing leadership in long-term care. A review of the literature

The quality of care provided to nursing home residents has been the subject of broad criticism for years. Mounting evidence suggests that the quality of nursing home care can be improved by strengthening the roles of nurses in these facilities. This article reviews the literature on programs designed to enhance nursing leadership in long-term care, examines outcomes associated with leadership in long-term care, and outlines recommendations for programs to enhance nursing leadership in nursing home settings. The findings suggest that nursing leadership training programs for nurses working in nursing homes are urgently needed to improve quality in the nation's nursing homes and stabilize the workforce. To maximize their effectiveness, these leadership training programs should be part of a continuum of leadership development that begins in nursing education programs and persists throughout a nurse's career trajectory.