Race and Genetic Ancestry in Medicine - A Time for Reckoning with Racism

Teaching developmental biology to drive social change: Pedagogy that challenges biologically deterministic views on phenotypic variation

Discrimination against groups of people based on socially-normed phenotypic variations is commonplace in many societies. The stigmatized phenotypic variations are dependent on specific societal norms but might include features that align with social constructs of race, phenotypic variations that may result in different ability levels, or those that align with social constructs of sex and/or gender identity. Science has contributed to this discrimination through biological essentialism, either by assigning specific undesirable biological characteristics to socially-normed phenotypic groupings, or more recently by assigning a genetic basis for these phenotypic differences. Biological essentialism can promote deterministic views lead to alienation and the persistence of social hierarchies. To overcome this, scientists have a responsibility to create positive changes to decenter practices that contribute to such discrimination. The study of developmental biology straddles the intersection of many biological concepts that have social and political ramifications. This paper outlines a pedagogical approach to create connections between concepts central to developmental biology and broader social issues to which they relate using a biocultural perspective. Specifically, the focus will be on understanding how phenotypes are generated through a combination of biological, environmental and social factors; exploring how deterministic views of biological essentialism contribute to social hierarchies and discrimination (such as racism, sexism, genderism and ableism); and understanding how this discrimination can become embodied through negative chronic and transgenerational biological consequences for stigmatized groups.

Predictive Factors of Apparent Treatment Resistant Hypertension Among Patients With Hypertension Identified Using Electronic Health Records

BACKGROUND

Early identification of a patient with resistant hypertension (RH) enables quickly intensified treatment, short-interval follow-up, or perhaps case management to bring his or her blood pressure under control and reduce the risk of complications.

OBJECTIVE

To identify predictors of RH among individuals with newly diagnosed hypertension (HTN), while comparing different prediction models and techniques for managing missing covariates using electronic health records data.

DESIGN

Risk prediction study in a retrospective cohort.

PARTICIPANTS

Adult patients with incident HTN treated in any of the primary care clinics of one health system between April 2013 and December 2016.

MAIN MEASURES

Predicted risk of RH at the time of HTN identification and candidate predictors for variable selection in future model development.

KEY RESULTS

Among 26,953 individuals with incident HTN, 613 (2.3%) met criteria for RH after 4.7 months (interquartile range, 1.2-11.3). Variables selected by the least absolute shrinkage and selection operator (LASSO), included baseline systolic blood pressure (SBP) and its missing indicator (a dummy variable created if baseline SBP is absent), use of antihypertensive medication at the time of cohort entry, body mass index, and atherosclerosis risk. The random forest technique achieved the highest area under the curve (AUC) of 0.893 (95% CI, 0.881-0.904) and the best calibration with a calibration slope of 1.01. Complete case analysis is not a valuable option (AUC = 0.625).

CONCLUSIONS

Machine learning techniques and traditional logistic regression exhibited comparable levels of predictive performance after handling the missingness. We suggest that the variables identified by this study may be good candidates for clinical prediction models to alert clinicians to the need for short-interval follow up and more intensive early therapy for HTN.

Genomic landscape of cancer in racially and ethnically diverse populations

Cancer incidence and mortality rates can vary widely among different racial and ethnic groups, attributed to a complex interplay of genetic, environmental and social factors. Recently, substantial progress has been made in investigating hereditary genetic risk factors and in characterizing tumour genomes. However, most research has been conducted in individuals of European ancestries and, increasingly, in individuals of Asian ancestries. The study of germline and somatic genetics in cancer across racial and ethnic groups using omics technologies offers opportunities to identify similarities and differences in both heritable traits and the molecular features of cancer genomes. An improved understanding of population-specific cancer genomics, as well as translation of those findings across populations, will help reduce cancer disparities and ensure that personalized medicine and public health approaches are equitable across racial and ethnic groups.

HSD3B1, prostate cancer mortality and modifiable outcomes

Androgen receptor stimulation by testosterone and dihydrotestosterone is crucial for prostate cancer progression. Despite the initial effectiveness of androgen deprivation therapy (ADT), castration-resistant prostate cancer eventually develops in most men. A common germline missense-encoding polymorphism in HSD3B1 increases extra-gonadal androgen biosynthesis from adrenal precursors owing to increased availability of the encoded enzyme 3β-hydroxysteroid dehydrogenase 1 (3βHSD1) - hence, it is called the adrenal-permissive enzyme. This mechanism explains the more rapid progression to castration-resistant prostate cancer in men who inherit this allele than in men without it via sustained androgen receptor activation despite ADT. Multiple clinical studies, including data derived from prospective phase III studies, have linked adrenal-permissive allele inheritance to inferior clinical responses to ADT and increased mortality, but reversal is possible with upfront adrenal androgen blockade. The adrenal-permissive allele exhibits divergent frequencies across various groups worldwide, which could contribute to differences in clinical outcomes among these populations. Large-scale data from the Million Veteran Program have shown homozygous HSD3B1 adrenal-permissive allele inheritance to be an independent biomarker of prostate cancer-specific mortality. Together, these observations support the integration of HSD3B1 into germline testing and clinical trials as it might help to identify groups at increased likelihood of benefiting from early, intensified, AR-targeting interventions. Lastly, 3βHSD1 is a promising target for pharmacological inhibition, which enables new strategies for systemic prostate cancer therapy.

Performance of Optic Disc Optical Coherence Tomography Normative Database in a Large, Diverse, Real-World Cohort

PRCIS

Current optical coherence tomography normative sample data may not represent the diversity of human optic nerve anatomy needed to accurately classify all individuals with true glaucomatous optic neuropathy.

PURPOSE

To compare optic nerve head (ONH) measurements between published values from an optical coherence tomography (OCT) normative database and a larger, more diverse cohort of healthy individuals.

PATIENTS AND METHODS

ONH parameters from healthy participants of the Michigan Screening and Intervention for Glaucoma and Eye Health through Telemedicine (MI-SIGHT) program and the Topcon Maestro-1 normative cohort were compared. χ 2 tests compared MI-SIGHT retinal nerve fiber layer (RNFL) quadrant color-code labels with the expected distribution and multinomial logistic regression identified factors associated with label classifications.

RESULTS

In all, 1084 MI-SIGHT and 399 Topcon eyes were evaluated. The MI-SIGHT cohort was older (54 vs. 46 y), with more individuals identifying as black (61% vs. 20%), fewer as Hispanic (4% vs. 18%), and spherical equivalents closer to plano (-0.6 vs. -1.2 diopters) compared to the Topcon cohort (all P <0.001). Black/African American MI-SIGHT participants had larger cup-to-disc ratios and cup volumes, while white MI-SIGHT participants had smaller ONH values, except for rim area and rim volume, compared to Topcon participants (all P <0.001). The MI-SIGHT cohort's RNFL color codes did not follow the expected distribution ( P <0.05); more MI-SIGHT RNFL quadrant measurements were assigned as white (10.6% and 6.3% MI-SIGHT vs. 5% Topcon) and red codes (2.2% and 1.8% MI-SIGHT vs. <1% Topcon) than expected in the superior and inferior quadrants, respectively.

CONCLUSIONS

OCT normative databases should accurately reflect diverse populations to avoid misclassification by RNFL thickness color codes. Larger data sets should be leveraged to encompass the full spectrum of healthy optic nerve anatomy.

Rethinking the use of population descriptors in dermatology trials and beyond: disentangling race and ethnicity from skin color

IMPORTANCE

Race and ethnicity as population descriptors in research and clinical practice have often been a subject of debate, drawing heightened scrutiny in recent years. Criticism focuses on their oversimplification and misapplication, which fail to capture the complexity of human health and genetic diversity. There is growing recognition that these categories, rooted in outdated social constructs, do not accurately reflect biological differences.

OBSERVATIONS

Historically, race and ethnicity have been used as proxies for genetic variation and skin color, despite the understanding that these constructs are not biologically defined. The Skin of Color Society's second Meeting the Challenge Summit, attended by over 100 U.S. and international participants, highlighted several key themes: (1) the need for transparency in the rationale behind using population descriptors and decision-making processes; (2) recognizing the role of race and racism in dermatology; (3) exploring the intersection of dermatology, skin color, and cultural influences; (4) understanding the context of population descriptor usage; (5) developing improved, objective tools for classifying skin color; and (6) advancing research and creating guidelines.

CONCLUSIONS AND RELEVANCE

There is an urgent need to reconsider the use of race and ethnicity as population descriptors in dermatology research. Current systems, which conflate social identity with biological markers, perpetuate health disparities and limit the accuracy of clinical data. Moving forward, more specific descriptors such as skin color, alongside socially determined factors, will be crucial in achieving meaningful diversity and inclusivity in clinical research.

From genes to clinic: Genomic and cross-sectional cohort analysis of oxidative stressors and lipid metabolism in European ancestry

BACKGROUND

The link between oxidative stress and lipid metabolism is widely studied, but their causal relationship in the general population remains unclear.

METHODS

We utilized weighted regression and propensity score matching (PSM) models to investigate the relationship between endogenous oxidative stress markers (serum bilirubin and uric acid) and lipid metabolism in 11,087 participants of European ancestry from the National Health and Nutrition Examination Survey (NHANES) during the period from 2005 to 2018. Additionally, we performed a bidirectional two-sample Mendelian randomization (MR) analysis using Genome-Wide Association Study (GWAS) summary statistics from individuals of European ancestry (n = 997 to 575,531) to explore the genetic causal relationship between oxidative stress markers and lipid metabolism profiles (n = 20,430).

RESULTS

Weighted regression showed that serum uric acid significantly increased high cholesterol (OR = 1.11, 95 % CI = 1.06-1.15, P < 0.001) and high triglycerides (OR = 1.25, 95 % CI = 1.20-1.30, P < 0.001). PSM analysis confirmed that serum uric acid increased the incidence of high triglycerides (OR = 1.57, 95 % CI = 1.35-1.82, P < 0.001). Additionally, a strong bidirectional genetic relationship was found between oxidative stress markers and lipid metabolism. For example, serum uric acid increased serum triglycerides (β = 0.1904, Se = 0.05, P < 0.001) and decreased total cholesterol in very large HDL (β = -0.1298, Se = 0.039, P < 0.001). Conversely, total cholesterol reduced direct bilirubin levels (β = -0.1707, Se = 0.018, P < 0.001). No significant horizontal pleiotropy was detected by MR-Egger intercept.

CONCLUSION

Our findings demonstrate a robust genetic and population-based association between oxidative stress markers and lipid metabolism, suggesting potential therapeutic targets for lipid disorders based on endogenous oxidative stressors.

Association between plausible genetic factors and weight loss from GLP1-RA and bariatric surgery

Obesity is a major public health challenge. Glucagon-like peptide-1 receptor agonists (GLP1-RA) and bariatric surgery (BS) are effective weight loss interventions; however, the genetic factors influencing treatment response remain largely unexplored. Moreover, most previous studies have focused on race and ethnicity rather than genetic ancestry. Here we analyzed 10,960 individuals from 9 multiancestry biobank studies across 6 countries to assess the impact of known genetic factors on weight loss. Between 6 and 12 months, GLP1-RA users had an average weight change of -3.93% or -6.00%, depending on the outcome definition, with modest ancestry-based differences. BS patients experienced -21.17% weight change between 6 and 48 months. We found no significant associations between GLP1-RA-induced weight loss and polygenic scores for body mass index or type 2 diabetes, nor with missense variants in GLP1R. A higher body mass index polygenic score was modestly linked to lower weight loss after BS (+0.7% per s.d., P = 1.24 × 10-4), but the effect attenuated in sensitivity analyses. Our findings suggest known genetic factors have limited impact on GLP1-RA effectiveness with respect to weight change and confirm treatment efficacy across ancestry groups.

Racial Disparities in Septic Shock Outcomes: A Nationwide Analysis (2016-2020)

BACKGROUND

The mortality rate and outcomes of septic shock can vary, depending on the patient's race. The most comprehensive national study on these racial disparities is dated, and recent studies have reported mixed findings.

OBJECTIVE

To gain insight into racial variation in outcomes of septic shock and understand underlying factors.

DESIGN

A retrospective analysis using National Inpatient Sample data (2016-2020). Patients were grouped by race, and patient and hospital characteristics, outcomes, and complications were compared. Multivariable logistic regression analyses were conducted.

PATIENTS

Hospitalized patients aged ≥ 18 years with septic shock.

MAIN MEASURES

In-hospital mortality, mechanical ventilation, vasopressor use, acute kidney injury, need for hemodialysis, acute myocardial infarction, requirement for blood transfusion, length of stay, the financial burden on healthcare, and resource utilization.

KEY RESULTS

Among 2,789,890 patients, 67.5% were White, 14.4% Black, 10.9% Hispanic, 3.3% Asian or Pacific Islander, and 0.8% Native American; 46.2% were aged > 70 years. Compared to White patients, Black patients had 23% higher odds of mortality (adjusted odds ratio [aOR] 1.23, 95% CI 1.21-1.25) and the highest odds of invasive mechanical ventilation (aOR 1.42) and hemodialysis (aOR 1.96). Native American patients had the highest odds of acute respiratory distress syndrome (aOR 2.03), while Asian or Pacific Islander patients had increased odds of blood transfusions (aOR 1.52). Palliative care consultations were less common among Asian, Black, and Hispanic patients compared to White patients.

CONCLUSIONS

Racial disparities persist in septic shock outcomes, with higher mortality and complications among Black, Hispanic, Asian, and Native American patients, along with less utilization of palliative care services compared to White patients.

Childhood triglyceride-glucose index and pre-hypertension in adulthood: a prospective cohort study

Background

The triglyceride-glucose (TyG) index serves as a surrogate marker for insulin resistance. Multiple studies have demonstrated a positive correlation between the TyG index and blood pressure, indicating that a high TyG index is related to a greater risk of developing pre-hypertension (pre-HTN) and hypertension (HTN). However, the relationship between changes in the TyG index during childhood and pre-HTN in adulthood requires further clarification.

Methods

The present prospective study utilized data from the Bogalusa Heart Study, a long-term follow-up study. Data on triglycerides (TG), fasting glucose (Fg), and low-density lipoprotein cholesterol (LDL-C) were collected from cross-sectional examinations of participants during childhood. Blood pressure (BP) in early adulthood was categorized into normotensive and pre-HTN groups. Logistic regression was employed to evaluate the relationship between the TyG index in childhood and pre-HTN in adulthood.

Results

A total of 1,222 participants were included in the study, of whom 258 presented with pre-HTN in adulthood. Significant differences were observed in baseline TyG index, body mass index (BMI), and high-density lipoprotein cholesterol (HDL-C) between the two groups. In both unadjusted logistic regression (Odds Ratio (OR):1.8, 95% CI: 1.4, 2.5, P < 0.001) and simple adjustment (OR: 1.7, 95% CI: 1.2, 2.3, P = 0.003), childhood TyG index were significantly associated with pre-HTN in adulthood. However, this significant relationship disappeared after full adjustment (OR: 1.2, 95% CI: 0.8, 1.9, P = 0.373) which extended Model 1 by including adjustments for baseline BMI, baseline HDL-C, baseline LDL-C, smoking status, drinking status, use of antihypertensive medication and family history of HTN.Stratified analysis in Model 2 showed that gender and race significantly affected the relationship between TyG index and BP. In the male population, elevated TyG index levels increased the probability of pre-HTN, whereas no such relationship was found in female (Male: OR: 1.9, 95% CI: 1.1, 3.5, P = 0.029; Female: OR: 0.8, 95% CI: 0.4, 1.4, P = 0.447; P for interaction = 0.037). Similarly, in American Caucasians, TyG was positively associated with the risk of pre-HTN, but this relationship was not observed in African American (American Caucasian: OR: 1.7, 95% CI: 1.0, 2.9, P = 0.035; African American: OR: 0.5, 95% CI: 0.2, 1.1, P = 0.087; P for interaction = 0.007).

Conclusions

In males and Caucasians, elevated TyG index during childhood can increase the risk of pre-HTN in adulthood. Monitoring the TyG index may help in screening individuals at higher risk of pre-HTN.

Maternal obesity and ancestry distance in influencing birth outcomes

BACKGROUND

Maternal pre-pregnancy obesity has been associated with birth outcomes, but the influence of genetic distance (GD) on this relationship is unclear. Therefore, the objective of this study was to assess the interplay of GD and maternal obesity on birthweight, placental weight, and large for gestational age (LGA).

METHODS

We used data from the NICHD Fetal Growth Studies-Singletons cohort, a prospective cohort study of multi-ancestral pregnant women. GD was estimated using data from 1810 women across four ancestral reference populations. We categorized GD into five quintiles, with quintile one and quintile five representing the closest and farthest distances, respectively. Linear regression models were used to test association between GD and birth outcomes and to estimate the association of interaction of GD and maternal obesity with birth outcomes.

RESULTS

Farther maternal GD from an African reference was significantly associated with higher birthweight and higher odds of LGA, with associations persisting after adjusting for socioeconomic status (SES). The interaction between the third Amerindigenous GD quintile and obesity was significantly associated with a 198 g larger placental weight (95% CI = 51-345, p = 0.009) compared to the first Amerindigenous GD quintile. We also found the interaction between East Asian fourth GD quintile and obesity to be significantly associated with 86.0% lower odds of infants being born LGA (OR = 0.14 g, 95% CI = 0.02-74, p = 0.031) compared to the first quintile. These associations persisted after SES adjustment.

CONCLUSIONS

Interplays between maternal GD from Amerindigenous and East Asian references and pre-pregnancy obesity influence placental weight and risk of LGA. The results underline that consideration of maternal obesity in the context of GD from multiple ancestries and SES may facilitate interventions that will minimize adverse pregnancy outcomes.

CLINICAL TRIAL REGISTRATION

The study has been registered at ClinicalTrials.gov (Trial registration: NCT00912132).

KDIGO 2024 clinical practice guideline on evaluation and management of chronic kidney disease: A primer on what pharmacists need to know

PURPOSE

To review the key updates in the 2024 KDIGO clinical practice guideline for the evaluation and management of chronic kidney disease (CKD) and highlight the essential role of pharmacists in implementing these recommendations.

SUMMARY

The updated guideline introduces significant changes in CKD management, including the use of validated equations for estimating glomerular filtration rate (GFR) for drug dosing, with incorporation of serum cystatin C into GFR estimates for specific patient populations, and an emphasis on a comprehensive approach to delay disease progression. The guideline recommends sodium-glucose cotransporter 2 inhibitor (SGLT2i) therapy for kidney disease with proteinuria, with or without diabetes, renin-angiotensin-aldosterone system inhibitors (RAASi) blood pressure control and proteinuria management, and statins to reduce the risk of atherosclerotic cardiovascular disease. New evidence supports the use of finerenone in patients with type 2 diabetes and CKD, and GLP-1 receptor agonists for their kidney-protective effects. The guidelines also emphasize the importance of nephrotoxin stewardship and prevention of acute kidney injury through patient education on sick day medication management.

CONCLUSION

Pharmacists play a crucial role in implementing these updated guidelines through comprehensive medication management, nephrotoxin stewardship, drug dosing adjustments, and patient education. Their involvement in interprofessional care teams is essential for optimizing health outcomes in patients with CKD.

Racial disparities in prostate cancer in the UK and the USA: similarities, differences and steps forwards

In the USA, Black men are approximately twice as likely to be diagnosed with and to die of prostate cancer than white men. In the UK, despite Black men having vastly different ancestral contexts and health-care systems from Black men in the USA, the lifetime risk of being diagnosed with prostate cancer is two-to-three times higher among Black British men than among white British men and Black British men are twice as likely to die of prostate cancer as white British men. Examination of racial disparities in prostate cancer in the USA and UK highlights systemic, socio-economic and sociocultural factors that might contribute to these differences. Variation by ancestry could affect incidence and tumour genomics. Disparities in incidence might also be affected by screening guidelines and access to and uptake of screening. Disparities in treatment access, continuity of care and outcomes could contribute to survival differences. In both localized and metastatic settings, equal access could diminish the observed disparities in both the USA and the UK. An understanding of behavioural medicine, especially an appreciation of cultural beliefs about illness and treatment, could inform and improve the ways in which health systems can engage with and deliver care to patients in minoritized groups affected by prostate cancer. Methods of promoting equity include targeting systemic barriers including systemic racism, proportional recruitment of patients into clinical trials, diversifying the health-care workforce and facilitating care informed by cultural humility. Actively engaging patients and communities in research and intervention might enable the translation of research into increasingly equitable care for patients with prostate cancer in the UK, the USA and globally.

The Role of Race in Pregnancy, Hypertension, and Long-Term Outcomes

PURPOSE OF REVIEW

This review aims to discuss racial and ethnic differences in the prevalence of hypertensive disorders of pregnancy (HDP), disparities in peripartum and postpartum outcomes, and strategies to improve health equity.

RECENT FINDINGS

Racial disparities in HDP are significant contributors to maternal morbidity and mortality. The prevalence of preeclampsia has increased over the last 20 years, with the highest prevalence among non-Hispanic Black, non-Hispanic American Indian and Alaska Native individuals. Black birthing individuals are at increased risk for cardiovascular-related morbidity and mortality, particularly from complications of HDP. Factors such as social determinants of health and systemic racism have a significant impact on disparities in maternal and fetal outcomes related to HDP. System changes and provider implicit bias training can help address systemic racism. Interventions aimed at improving access to care, such as telehealth and home blood pressure monitoring, as well as incorporating health system navigators that provide peripartum and postpartum support can improve outcomes and promote health equity.

Racial, Ethnic, Sex, and Geographical Diversity in Myositis Clinical Trials

OBJECTIVE

The number of randomized clinical trials (RCTs) with patients with idiopathic inflammatory myopathies (IIMs) has grown exponentially over the last decade. Race, ethnicity, and sex reporting and representation of participants as well as the geographic distribution of enrolling sites in IIM RCTs are unknown. This information can provide critical insights into the current state of enrollment practices and generalizability in IIM RCTs.

METHODS

A systematic literature review assessed IIM RCTs published between 2010 to 2023. Sex and gender reporting was analyzed per Sex and Gender Equity in Research guidelines. Appropriate reporting of race and ethnicity was defined as reporting them for all trial participants. Countries were categorized based on the Human Development Index. US enrollment sites were grouped using the National Center for Health Statistics Urban-Rural Classification Scheme and medically underserved areas (MUAs).

RESULTS

Of the 19 RCTs included, race was appropriately reported in 58%. Black, Asian, and Hispanic or Latino participants represented 3%, 7%, and 2% of the enrollees, respectively. Ethnicity was only reported in 26% of RCTs, and 16% conflated race and ethnicity. Temporal trends showed encouraging results for race and ethnicity representation. Most trials (90%) had greater than 45% women participants. Geographic regions of sites included North America, Europe, Asia, and Australasia, with no sites in South America or Africa. The majority of US sites were located in large metropolitan areas, whereas none were in nonmetropolitan areas, and only 31% in MUAs.

CONCLUSION

Racial, ethnic, and geographic representation in IIM RCTs remains a critical issue. Inadequate reporting of race and ethnicity and limited sociodemographic and geographic representation of participants raise concerns about the generalizability of findings of IIM RCTs.

The ethnic disparity in the diagnostic yield of high-throughput next-generation sequencing in inherited retinal diseases: a systematic review and meta-analysis

OBJECTIVE

Next-generation sequencing (NGS) is the state-of-the-art molecular diagnostics for genetic heterogenous inherited-retinal diseases (IRDs). However, the impact of ethnic discrepancy in NGS diagnostic yields for patients with IRD is unclear. Therefore, we performed a systemic review (SR) and meta-analysis (MA) to delineate this issue.

METHODS

MEDLINE and PubMed databases were searched on 30 January 2024. Original studies published between 2013 and 2024 that reported the IRD diagnostic yield of panel-based sequencing was eligible for inclusion. The diagnostic yield is defined as the proportion of patients with a molecular diagnosis after high-throughput panel screening. Studies were stratified by IRD enrollment phenotype and patient ancestry.

RESULTS

A total of 42 studies comprising 23,324 patients evaluated for diagnosis yield were included in the meta-analysis. The pooled diagnostic yield was 0.570 [0.530,0.610] across studies with IRD-related enrollment and 0.617 [0.568; 0.664] for those with IRD enrollment. The stratification of studies for ancestry produced a diagnostic yield of 0.629 [0.568; 0.688] in Europeans, and the diagnostic yield dropped to 0.549 [0.456; 0.641] for East Asians. There is a lack of available data for Latin American evidence meta-synthesis.

CONCLUSIONS

This review supports the existence of ethnic disparity in panel-based sequencing for IRDs. Specifically, a relatively lower diagnostic yield and a higher inconclusive diagnosis rate are present in East Asian populations compared to the European population. Consequently, our findings should prompt future reclassification of variants of unknown significance (VUS) in non-whites to improve the ethnic inequities of molecular diagnostic yields for IRDs.

Experience using conventional compared to ancestry-based population descriptors in clinical genomics laboratories

Various scientific and professional groups, including the American Medical Association (AMA), American Society of Human Genetics (ASHG), American College of Medical Genetics (ACMG), and the National Academies of Sciences, Engineering, and Medicine (NASEM), have appropriately clarified that certain population descriptors, such as race and ethnicity, are social and cultural constructs with no basis in genetics. Nevertheless, these conventional population descriptors are routinely collected during the course of clinical genetic testing and may be used to interpret test results. Experts who have examined the use of population descriptors, both conventional and ancestry based, in human genetics and genomics have offered guidance on using these descriptors in research but not in clinical laboratory settings. This perspective piece is based on a decade of experience in a clinical genomics laboratory and provides insight into the relevance of conventional and ancestry-based population descriptors for clinical genetic testing, reporting, and clinical research on aggregated data. As clinicians, laboratory geneticists, genetic counselors, and researchers, we describe real-world experiences collecting conventional population descriptors in the course of clinical genetic testing and expose challenges in ensuring clarity and consistency in the use of population descriptors. Current practices in clinical genomics laboratories that are influenced by population descriptors are identified and discussed through case examples. In relation to this, we describe specific types of clinical research projects in which population descriptors were used and helped derive useful insights related to practicing and improving genomic medicine.

The Dermatology Life Quality Index (DLQI) used as the benchmark in validation of 101 quality-of-life instruments: A systematic review

BACKGROUND

The validation of psychometric measures requires use of other established and standardized validated measures. The Dermatology Life Quality Index (DLQI) is the most widely used tool to measure the burden of skin diseases and assess effectiveness of interventions based on patients' perspective.

OBJECTIVES

The objective of this study was to systematically analyse peer-reviewed publications describing use of the DLQI in validation of other patient-reported outcome (PRO) and quality-of-life (QoL) measures.

METHODS

Seven databases were searched for papers published between January 1994 and December 2022 for articles containing data using DLQI in the validation of other PRO/QoL measures. The methodology followed PRISMA guidelines. The protocol was prospectively registered on PROSPERO.

RESULTS

Of 1717 screened publications, 122 articles including 30,727 patients from 34 different countries with 41 diseases met the inclusion criteria. The DLQI was used in validation of 101 measures: 80 dermatology-specific QoL measures, mostly disease-specific, and 21 generic measures. Of these studies, 47 were cross-cultural adaptations, 116 single arm, 100 were cross-sectional, 18 longitudinal and six randomized placebo controlled. DLQI was used for 14 known group, and correlation for 10 construct, 101 convergent, 10 concurrent, 10 divergent/discriminant and three criterion validity tests using Mann-Whitney (2), Spearman's (80), Pearson's correlation (26) and Student's t-test (1). The DLQI was used in responsiveness analysis in 13 studies.

CONCLUSIONS

This review identified widespread use of the DLQI in validation of other dermatology PRO/QoL measures and confirmed the central role that the DLQI plays as a benchmark in instrument development and validation across dermatology and beyond. The use of the DLQI by so many developers of other instruments has provided a common standard for comparability.

Are the Cardiovascular Benefits and Potential Risks of Physical Activity and Exercise Dependent on Race, Ethnicity, or Sex?

Physical activity (PA) is established as a cornerstone of cardiovascular health, however, disparities in participation exist across sociocultural groups, which in turn affect cardiovascular outcomes. Evidence suggests that although the positive cardiovascular effects of exercise are consistent across populations, notable differences in the magnitude of these benefits exist for racial and ethnic minorities and the female sex. Women derive greater protection from PA compared with men, with reduced rates of sudden cardiac death. In this review we examine the complex interplay of race and/or ethnicity and sex on the cardiovascular benefits associated with PA and exercise, cardiovascular adaptations to exercise, risks of sudden cardiac death, and "excessive" volume of exercise. Understanding these factors is crucial for developing targeted interventions to promote cardiovascular health and offset disparities.

Patient perceived weight stigma and patient-centered language use preferences: A cross-sectional mixed methods analysis conducted in a large academic medical center

BACKGROUND

Due to the rising prevalence of obesity and its impact on healthcare, patient-specific context is needed to optimize weight management with an emphasis on reducing health care-associated weight stigma. Our survey aimed to explore institution-specific patient experiences of weight stigma and preferences for patient-centered language use regarding weight management care.

METHODS

This cross-sectional analysis adopted a concurrent mixed methods design with a sample of individuals who opted in to complete patient experience surveys after receiving care at a large academic medical center in the United States (U.S.). Categorical and continuous variables were assessed using Chi-squared and analysis of variance. We used classical content analysis to qualitatively analyze free-text data for thematic coding.

RESULTS

After a 1-week survey fielding period, 3,219 of 16,758 patients completed the survey, yielding a response rate of (19.2%) with 2,816 having available electronic health record body mass index (BMI) data. Patients were comfortable discussing weight with their primary care providers but showed variation in the preferred approach and terms. Female patients with higher BMIs reported higher rates of delayed and canceled care due to prior weight stigma (25.6% and 12.2% for patients with class 3 obesity), and preferred a slower, gentler, and less direct approach with term preferences for "healthy eating plan" and against "obesity." Qualitative analysis yielded 27 themes grouped into three domains: Emotional Hinderances, Perceptual Hinderances, and Perceived Helpfulness.

CONCLUSIONS

Findings from our large single institution cohort expand on the existing weight stigma literature by identifying patient language preferences and healthcare experiences according to patient weight class and sex. Given the potential impact of understanding context-specific patient language use preferences to reduce weight stigma, we recommend other healthcare systems use a similar process to address weight stigma as part of a coordinated health system improvement initiative to enhance patient-centered weight management care.

Racial Differences in ctDNA Profiles, Targeted Therapy Use, and Outcomes in Metastatic Breast Cancer

Importance

Black patients with metastatic breast cancer (mBC) have higher mortality rates than White patients despite advances in treatment.

Objectives

To examine whether Black patients with metastatic breast cancer have different genomic profiles compared with White patients and whether there are inequities in targeted treatment use between these groups.

Design, Setting, and Participants

This retrospective, population-based cohort study assessed adult patients with mBC who underwent genomic profiling at academic institutions in the US between January 1, 2015, and December 31, 2023. Data analysis was performed between July 2023 and July 2024. A validation cohort was also included.

Exposures

Targeted treatment use.

Main Outcomes and Measures

The main outcomes were differences in circulating tumor DNA profiles and use of phosphoinositide 3-kinase (PI3K), mammalian target of rapamycin (mTOR), and cyclin-dependent kinase 4/6 (CDK4/6) inhibitors between Black and White patients with metastatic breast cancer.

Results

The study sample included 1327 women with mBC (mean [SD] age, 58.0 [12.8] years; 140 Black and 1057 White). Black patients had a significantly higher rate of GATA3 single-nucleotide variants (odds ratio, 2.31; 95% CI, 1.17-4.54; P = .02) and CCND2 copy number variants (odds ratio, 4.63; 95% CI, 1.79-11.97; P = .002) on multivariate analysis. These differences were validated in a population-based evidence cohort of 27 224 patients. Black patients with PIK3CA single-nucleotide variants were significantly less likely to receive PI3K inhibitors than White patients (1 of 17 [5.9%] vs 45 of 156 [28.8%]; P = .04), whereas there was no difference in use of CDK4/6 and mTOR inhibitors, which do not require a targetable alteration. Black patients had a shorter overall survival from the time of circulating tumor DNA testing compared with White patients.

Conclusions and Relevance

This cohort study of patients with mBC found somatic differences, shorter overall survival, and targeted treatment disparities in PI3K inhibitor use in Black compared with White patients despite equal incidence of PIK3CA alterations. Researchers should consider these differences when designing future research and interventions to address the striking and persistent outcomes gap between Black and White patients with mBC.

A scoping review of global patterns in reporting race, ethnicity, nationality, or religion in palliative care randomized controlled trials: Recommendations for transparency

BACKGROUND

Though randomized controlled trials of non-pharmacological palliative care interventions have shown positive outcomes, findings are often generalized with limited consideration for the impact of the influence of race, ethnicity, nationality, or religion on said outcomes.

AIM

To identify trends and gaps in global reporting of racial, ethnic, nationality, and religious demographics in non-pharmacological palliative care randomized controlled trials.

DESIGN

We conducted a scoping review guided by the Joanna Briggs methodology.

DATA SOURCES

Global randomized controlled trials published in English, between 1999 and 2021 extracted from databases: Cochrane, PubMed, and Scopus. Inclusion criteria were non-pharmacological palliative care interventions for people with serious conditions reporting on one or more of the demographics of race, ethnicity, nationality, or religion.

RESULTS

Our review included 131 (44%) articles published from 19 countries, predominantly the USA (n = 84, 64%). Most studies focused on cancer (n = 71, 54%) in inpatient settings (n = 85, 64%). Race was the most commonly reported demographic (n = 93, 70%), followed by ethnicity (n = 54, 41%), religion (n = 46, 35%), nationality (n = 20, 15%). Within racial reporting, 86 (92%) indicating a majority White/Caucasian sample. Only 14 (10%) articles provided context connecting participant demographics to intervention outcomes. Demographic data was discussed only as a limitation to generalizability in 18 cases (41%).

CONCLUSIONS

Improving greater transparency in study reporting of social and historical context about population demographics, including specific demographic data collected, may better identify unmet palliative needs, facilitate cross-cultural interpretation, and improve adaptation and implementation of non-pharmacological palliative care interventions.

Associations between maternal plasma concentrations of corticotrophin releasing hormone and the placental transcriptome

INTRODUCTION

The placenta produces corticotrophin releasing hormone (CRH), which rises exponentially in maternal plasma across pregnancy. CRH plays a functional role in fetal development, labor initiation, and the regulation of gestational length. We aimed to understand how maternal plasma CRH during pregnancy reflects placental physiology during parturition by characterizing placental transcriptomic signatures of maternal plasma CRH and comparing to transcriptomic signatures of gestational age at birth.

METHODS

Maternal plasma CRH concentrations were measured via radioimmunoassay at two timepoints and the placental transcriptome was quantified via RNA sequencing in 516 pregnant participants enrolled in the CANDLE cohort. Robust linear models were fitted to estimate associations between CRH and placental gene expression at birth. We conducted a functional validation in primary trophoblast cells before and after syncytialization.

RESULTS

Plasma CRH concentrations in the mid-pregnancy visit were associated with placental expression of 8 differentially expressed genes (DEGs), and concentrations in late pregnancy were associated with 283 DEGs. These genes were involved in several metabolic pathways. Seven genes were significantly associated with both plasma CRH and gestational length. Four genes were concordantly decreased and 7 genes were concordantly increased in primary trophoblasts treated with CRH.

DISCUSSION

Overall, this study reveals potential novel transcriptional mechanisms by which CRH may regulate metabolic pathways important for placental function and identifies genes associated with both CRH and gestational length.

A qualitative study of Black breast cancer previvors' and survivors' experiences after positive genetic testing

Black women have a disproportionately high mortality rate from breast cancer, which is likely influenced by an intersection of environmental, cultural, economic, and social factors. Few published studies capture the experiences of Black women after a genetic diagnosis associated with increased risk for breast cancer. This study aims to explore the perspectives and experiences of Black women who carry a pathogenic variant associated with increased breast cancer risk and identify barriers to care for this population. We conducted semi-structured interviews with 16 participants with and without histories of breast cancer. The sample included representation across a range of demographic groups (e.g., income level, employment status, insurance status, and education level). Reflexive thematic analysis was the methodology used to analyze data. Five major themes emerged from participants' descriptions of their experiences during and after genetic testing: (1) searching for representation; (2) information enabling agency; (3) healthcare providers as facilitators or barriers to care; (4) self-identity impacting disclosure; and (5) evolving mental health and coping strategies. Participants identified barriers to care including challenging or misinformed healthcare providers, medical racism, and a lack of Black representation in the cancer community. This work deepens our understanding of the nuanced experiences of Black women across the continuum of cancer care, illustrates unmet needs, and provides a foundation for future research that includes the perspectives of Black women.

Survival Outcomes of Total Laryngectomy: Evaluating the Intersection of Race and Social Determinants

OBJECTIVE

Analyze joint effects of race and social determinants on survival outcomes for patients undergoing total laryngectomy for advanced or recurrent laryngeal cancer at a tertiary care institute.

METHODS

Retrospective chart review of adult patients undergoing total laryngectomy for laryngeal cancer at a tertiary care center from 2013 to 2020. Extracted data included demographics, pathological staging and features, treatment modalities, and outcomes such as recurrence, fistula formation, and 2- and 5-year disease-free survival (DFS) and overall survival (OS). Area Deprivation Index (ADI) was calculated for each patient.

RESULTS

Among 185 patients identified, 113 were Black (61.1%) and 69 were White (37.3%). No significant differences were observed between racial groups regarding age, gender, ADI, or cancer stage. There was no significant difference in 2-year DFS/OS between groups. ADI was comparable between racial groups, with the majority in the highest deprivation quintile (63.8% of Whites vs. 62.5% of Blacks). No significant differences were observed in gender, race, cancer stage, positive margins, extracapsular extension, or smoking status among ADI quintiles. We observed a significant difference in 2-year DFS stratified by ADI (p = 0.025). Stratifying by ADI and race revealed improved survival of White patients in lower quintiles but higher survival of Black patients in the highest disparity quintile (p = 0.013).

CONCLUSION

Overall, survival outcomes by race were comparable among laryngectomy patients, but there was a significant difference in 2-year DFS when stratified by ADI. Further research into survival outcomes related to social determinants is needed to better delineate their effects on head and neck cancer outcomes.

LEVEL OF EVIDENCE

3 Laryngoscope, 135:716-722, 2025.

Structural racism and racial disparities in stroke mortality in the United States, 2021

OBJECTIVES

To understand place-based drivers of racial disparities in stroke mortality in the United States by investigating the relationship between county-level measures of structural racism and racial disparities in stroke mortality.

METHODS

We constructed an additive structural racism score from census-based indicators of racial disproportionality (income, poverty, unemployment, home ownership, education, health insurance) and residential segregation (evenness, isolation), as well as county-level jail incarceration data from the Vera Institute of Justice. We utilized age-standardized, spatially smoothed stroke death rates in 2021 for Black and White adults aged 35-64 years in the United States. We fit linear regression models, both unadjusted and adjusted for overall county-level conditions, and assessed interaction between structural racism and gender.

RESULTS

Among 935 included counties, median structural racism score was 13.29 (range: 2.83-32.43). In unadjusted models, a 1-unit increase in structural racism was associated with 0.37 (95% CI 0.26, 0.46) additional stroke deaths per 100,000 Black residents compared to White residents of a county. Adjusted results were similar. This association was stronger among men (0.67 [95% CI 0.50, 0.83]) than women (0.35 [95% CI 0.19, 0.51]) (P = 0.003).

CONCLUSIONS

Structural racism may drive racial disparities in stroke mortality, particularly among men.

Advancing Equity in Rare Disease Research: Insights From the Undiagnosed Disease Network

Rare diseases affect 6%-8% of the population and present diagnostic challenges, particularly for historically marginalized ethnic and racial groups. The Undiagnosed Diseases Network (UDN) aims to enhance diagnosis rates and research participation among such minoritized groups. A retrospective review was conducted from 2015 to 2023, analyzing 2235 UDN participants to evaluate its progress toward this objective. Data on demographics, disease phenotypes, diagnostic outcomes, and socioeconomic factors were collected and statistical analyses assessed differences among ethnic and racial groups. This demonstrated that Hispanic and Black non-Hispanic groups were underrepresented, while White non-Hispanic participants were overrepresented in the UDN compared to the US population. Individuals whose primary language was not English were also significantly underrepresented. Diagnosis rates varied, with the highest rates among Asian non-Hispanic (39.5%) and Hispanic (35.3%) groups and the lowest rate in the White non-Hispanic group (26.8%) (p < 0.001). Binomial logistic regression found, however, that only participant age and disease phenotype predicted the likelihood of receiving a diagnosis (p < 0.001). Persistent ethnic and racial disparities in UDN participation appear to be associated with major differences in application rates. Under-enrollment of historically marginalized ethnic and racial groups may be due to economic hardships and language barriers. No differences in the diagnostic yield among ethnic and racial groups were observed after controlling for other factors. This work highlights the value of comprehensive genetic evaluations for addressing healthcare disparities and suggests priorities for advancing inclusion in rare disease research.

Race, ethnicity, and ancestry reporting in genetic counseling research: A focused mapping review and synthesis

Studies on the use of Race, Ethnicity, and Ancestry (REA) concepts and terms in genetic research are limited. We aimed to describe the collection, reporting, and use of REA data in genetic counseling research. We undertook a focused mapping review and synthesis of the Journal of Genetic Counseling 2021 publications. We used a mapping proforma based on the Race, Ethnicity, And Culture in Health checklist to extract data. Of the 177 screened articles, 132 met our inclusion criteria of reporting primary data about participants. The sample REA characteristics were described in 80 (61%) articles, with 6% providing a definition or conceptualization of the REA term/s used and 23% including a rationale for their study in terms of REA factors. Group labels were most often reported using population descriptors, such as "race," "ethnicity," "race/ethnicity," and "ancestry." Several group labels were used under different population descriptors. For instance, the group labels "White" and "Asian" were used under all population descriptors. Most studies (79%) ascertained REA characteristics by participants' self-report. Three (15%) of the 20 qualitative studies mentioned the relevance of the interviewers' REA characteristics in relation to the participants' REA characteristics. Of the 55 quantitative studies, 19 (35%) used REA factors in the data analysis. Of the 80 articles describing the sample REA characteristics, 20% referred moderately or a great deal to any REA factors in the results interpretation, 46% acknowledged the REA factors in the study limitations, and 15% discussed the implications of REA reporting for genetic counseling practice. Our review documents extensive variation in how sample REA characteristics are described and used in genetic counseling research. Our findings provide a baseline against which to evaluate the effects of guidelines and recommendations for the collection, responsible use, and report of participants' REA characteristics in genetic counseling research.

Breaking research silos to achieve equitable precision medicine in rheumatology

Health disparities in rheumatic disease are well established and urgently need addressing. Obstacles to precision medicine equity span both the clinical and the research domains, with a focus placed on structural barriers limiting equitable health care access and inclusivity in research. Less articulated factors include the use of inaccurate population descriptors and the existence of research silos in rheumatology research, which creates a knowledge gap that precludes addressing the health disparities and fulfilling the goals of precision medicine to understand the 'full patient'. The biopsychosocial model is a research framework that intertwines layers of biological and environmental effects to understand disease. However, very limited rheumatology research bridges across molecular and epidemiological studies of environmental exposures, such as physical and social determinants of health. In this Review, we discuss clinical obstacles to health care equity, including access to health care and the use of inaccurate language when labelling population groups. We explore the goals and data needed for research under the biopsychosocial model. We describe results from a rheumatic disease literature search that highlights the paucity of studies investigating the molecular influences of systemic exposures. We conclude with a list of considerations and recommendations to help achieve equitable precision medicine.

APOL1 Bi- and Monoallelic Variants and Chronic Kidney Disease in West Africans

BACKGROUND

Apolipoprotein L1 gene (APOL1) variants are risk factors for chronic kidney disease (CKD) among Black Americans. Data are sparse on the genetic epidemiology of CKD and the clinical association of APOL1 variants with CKD in West Africans, a major group in the Black population.

METHODS

We conducted a case-control study involving participants from Ghana and Nigeria who had CKD stages 2 through 5, biopsy-proven glomerular disease, or no kidney disease. We analyzed the association of CKD with APOL1 variants among participants with high-risk genotypes (two APOL1 risk alleles) and those with low-risk genotypes (fewer than two APOL1 risk alleles) by fitting logistic-regression models that controlled for covariates, including clinical site, age, and sex.

RESULTS

Among 8355 participants (4712 with CKD stages 2 through 5, 866 with glomerular diseases, and 2777 with no kidney disease), the prevalence of monoallelic APOL1 variants was 43.0% and that of biallelic APOL1 variants was 29.7%. Participants with two APOL1 risk alleles had higher odds of having CKD than those with one risk allele or no risk alleles (adjusted odds ratio, 1.25; 95% confidence interval [CI], 1.11 to 1.40), as well as higher odds of focal segmental glomerulosclerosis (adjusted odds ratio, 1.84; 95% CI, 1.30 to 2.61). Participants with one APOL1 risk allele had higher odds of having CKD than those with no risk alleles (adjusted odds ratio, 1.18; 95% CI, 1.04 to 1.33), as well as higher odds of focal segmental glomerulosclerosis (adjusted odds ratio, 1.61; 95% CI, 1.04 to 2.48). The inclusion of covariates did not modify the association of monoallelic and biallelic APOL1 variants with CKD or focal segmental glomerulosclerosis.

CONCLUSIONS

In this study, monoallelic APOL1 variants were associated with 18% higher odds of CKD and 61% higher odds of focal segmental glomerulosclerosis; biallelic APOL1 variants were associated with 25% higher odds of CKD and 84% higher odds of focal segmental glomerulosclerosis. (Funded by the National Human Genome Research Institute and others.).

Association between plausible genetic factors and weight loss from GLP1-RA and bariatric surgery: a multi-ancestry study in 10 960 individuals from 9 biobanks

Obesity is a significant public health concern. GLP-1 receptor agonists (GLP1-RA), predominantly in use as a type 2 diabetes treatment, are a promising pharmacological approach for weight loss, while bariatric surgery (BS) remains a durable, but invasive, intervention. Despite observed heterogeneity in weight loss effects, the genetic effects on weight loss from GLP1-RA and BS have not been extensively explored in large sample sizes, and most studies have focused on differences in race and ethnicity, rather than genetic ancestry. We studied whether genetic factors, previously shown to affect body weight, impact weight loss due to GLP1-RA therapy or BS in 10,960 individuals from 9 multi-ancestry biobank studies in 6 countries. The average weight change between 6 and 12 months from therapy initiation was -3.93% for GLP1-RA users, with marginal differences across genetic ancestries. For BS patients the weight change between 6 and 48 months from the operation was -21.17%. There were no significant associations between weight loss due to GLP1-RA and polygenic scores for BMI or type 2 diabetes or specific missense variants in the GLP1R, PCSK1 and APOE genes, after multiple-testing correction. A higher polygenic score for BMI was significantly linked to lower weight loss after BS (+0.7% for 1 standard deviation change in the polygenic score, P = 1.24×10-4), but the effect was modest and further reduced in sensitivity analyses. Our findings suggest that existing polygenic scores related to weight and type 2 diabetes and missense variants in the drug target gene do not have a large impact on GLP1-RA effectiveness. Our results also confirm the effectiveness of these treatments across all major continental ancestry groups considered.

Addressing health disparities in food allergy: A Position Statement of the AAAAI Prior Authorization Task Force

Self-reported food allergies (FAs) affect approximately 8% of the US pediatric and approximately 10% of the adult population, which reflects potentially disproportionate increases among ethnically and racially minoritized groups. Multiple gaps and unmet needs exist regarding FA disparities. There is reported evidence of disparities in FA outcomes, and the FA burden may also be disproportionate in low-income families. Low family income has been associated with higher emergency care spending and insecure access to allergen-free food. Pharmacoinequity arises in part as a result of structural racism still experienced by historically marginalized populations today. Historically redlined communities continue to experience greater rates of neighborhood-level air pollution and indoor allergen exposure, lack of transportation to medical appointments, poverty, and lower prescription rates of necessary medications. Clinical research needs racially and ethnically diverse participation to ensure generalizability of research findings and equitable access to medical advances, but race reporting in clinical trials has been historically poor. Addressing health disparities in FA is a priority of clinical care, with professional organizations such as the American Academy of Allergy, Asthma & Immunology having a prominent role to play in mitigating the challenges faced by these individuals. In this position statement we recommend some key steps to address this important issue.

Alzheimer's disease plasma biomarkers and physical functioning in a diverse sample of adults

INTRODUCTION

The relationship between Alzheimer's disease (AD) plasma biomarkers, and physical functioning (PF) across diverse races and ethnicities remains unclear. This study aims to explore this association in an ethno-racially diverse sample of cognitively unimpaired community-dwelling adults.

METHODS

Data clinical examinations, neuropsychological tests, blood draws, and PF exams (Timed Up and Go [TUG] and Short Physical Performance Battery [SPPB]) were analyzed. Multivariable linear regressions assessed the association between PF and AD plasma biomarkers (amyloid beta [Aβ]40, Aβ42, total tau [t-tau], neurofiliament light chain [NfL]).

RESULTS

The sample (n = 2358; mean age 64.7 years; 65.9% female), was 20% African American, 41.9% non-Hispanic White, and 38.1% Hispanic. Findings indicate that worse PF is linked to higher biomarker levels (p < 0.05). Associations differed by race and ethnicity group. TUG time was associated (p < 0.05) with Aβ40, Aβ42, and tau among non-Hispanic Whites, whereas SPPB scores were associated (p < 0.05) with t-tau and NfL among African Americans.

DISCUSSION

PF, ethnic/racial, and plasma AD biomarker data should be used to aid in developing risk profiles for neurodegenerative diseases.

HIGHLIGHTS

Alzheimer's disease (AD) biomarkers are associated with physical functioning (PF) Ethno-racial variation exists in AD biomarker and PF associations Race and ethnicity should considered when assessing neurodegenerative disease risk.

The expected polygenic risk score (ePRS) framework: an equitable metric for quantifying polygenetic risk via modeling of ancestral makeup

Polygenic risk scores (PRSs) depend on genetic ancestry due to differences in allele frequencies between ancestral populations. This leads to implementation challenges in diverse populations. We propose a framework to calibrate PRS based on ancestral makeup. We define a metric called "expected PRS" (ePRS), the expected value of a PRS based on one's global or local admixture patterns. We further define the "residual PRS" (rPRS), measuring the deviation of the PRS from the ePRS. Simulation studies confirm that it suffices to adjust for ePRS to obtain nearly unbiased estimates of the PRS-outcome association without further adjusting for PCs. Using the TOPMed dataset, the estimated effect size of the rPRS adjusting for the ePRS is similar to the estimated effect of the PRS adjusting for genetic PCs. Similarly, we applied the ePRS framework to six cardiovascular-related traits in the All of Us dataset, and the results are consistent with those from the TOPMed analysis. The ePRS framework can protect from population stratification in association analysis and provide an equitable strategy to quantify genetic risk across diverse populations.

Inequalities in Healthcare Access, Experience and Outcomes in Adults With Inflammatory Bowel Disease: A Scoping Review

BACKGROUND

Inflammatory bowel diseases (IBDs) are incurable diseases that require lifelong access to health services. Accumulating evidence of inequalities in health care access, experience, and outcomes for individuals with IBD is apparent. This review aimed to describe the inequalities in healthcare access, experiences, and outcomes of care for adults with IBD, to identify research gaps, and to identify future research priorities in this area.

METHODS

A scoping review was conducted to retrieve quantitative, qualitative, and mixed methods evidence from 3 databases (EMBASE, Medline, and CINAHL) published between January 1, 2000, and September 27, 2023.

RESULTS

Fifty-one studies met the criteria for inclusion. The majority (42 of 51) focused on IBD health outcomes, followed by healthcare access (24 of 51). Significantly fewer investigated patient experiences of IBD healthcare (8 of 51). Most available studies reported on race/ethnic disparities of healthcare (33 of 51), followed by inequalities driven by socioeconomic differences (12 of 51), rurality (7 of 51), gender and sex (3 of 51), age (2 of 51), culture (2 of 51), literacy (1 of 51), and sexuality (1 of 51). Inflammatory bowel disease patients from Black, Asian, and Hispanic ethnic groups had significantly poorer health outcomes. A lack of research was found in the sexual and gender minority community (1 of 51). No research was found to investigate inequalities in IBD patients with learning disabilities or autism.

CONCLUSIONS

Further research, particularly utilizing qualitative methods, is needed to understand health experiences of underserved patient populations with IBD. Cultural humility in IBD care is required to better serve individuals with IBD of Black and Asian race/ethnicity. The lack of research amongst sexual and gender minority groups with IBD, and with learning disabilities, poses a risk of creating inequalities within inequalities.

Using multiplexed functional data to reduce variant classification inequities in underrepresented populations

BACKGROUND

Multiplexed Assays of Variant Effects (MAVEs) can test all possible single variants in a gene of interest. The resulting saturation-style functional data may help resolve variant classification disparities between populations, especially for Variants of Uncertain Significance (VUS).

METHODS

We analyzed clinical significance classifications in 213,663 individuals of European-like genetic ancestry versus 206,975 individuals of non-European-like genetic ancestry from All of Us and the Genome Aggregation Database. Then, we incorporated clinically calibrated MAVE data into the Clinical Genome Resource's Variant Curation Expert Panel rules to automate VUS reclassification for BRCA1, TP53, and PTEN.

RESULTS

Using two orthogonal statistical approaches, we show a higher prevalence (p ≤ 5.95e - 06) of VUS in individuals of non-European-like genetic ancestry across all medical specialties assessed in all three databases. Further, in the non-European-like genetic ancestry group, higher rates of Benign or Likely Benign and variants with no clinical designation (p ≤ 2.5e - 05) were found across many medical specialties, whereas Pathogenic or Likely Pathogenic assignments were increased in individuals of European-like genetic ancestry (p ≤ 2.5e - 05). Using MAVE data, we reclassified VUS in individuals of non-European-like genetic ancestry at a significantly higher rate in comparison to reclassified VUS from European-like genetic ancestry (p = 9.1e - 03) effectively compensating for the VUS disparity. Further, essential code analysis showed equitable impact of MAVE evidence codes but inequitable impact of allele frequency (p = 7.47e - 06) and computational predictor (p = 6.92e - 05) evidence codes for individuals of non-European-like genetic ancestry.

CONCLUSIONS

Generation of saturation-style MAVE data should be a priority to reduce VUS disparities and produce equitable training data for future computational predictors.

Contribution of county-level socioeconomic indicators to racial or ethnic differences in neonatal anthropometry in the USA: a prospective cohort study

Introduction

Racial and ethnic differences in fetal growth and birth size in the USA have not been adequately explained by individual-level socioeconomic status (SES) factors. We explored whether differences may be partially explained by county-level indicators of SES.

Methods

We linked participant zip codes from the National Institute of Child Health and Human Development Fetal Growth Studies (2009-2013; n=1614) to county-level US census data to calculate a neighbourhood deprivation index, education isolation index and two indices of segregation: racial isolation and evenness. Using causal mediation methods, we evaluated the extent to which racial/ethnic differences in neonatal anthropometrics could be eliminated in a hypothetical setting where everyone lived in counties with high resource availability and racial/ethnic integration.

Results

Setting racial evenness to levels consistent with the highest diversity eliminated 79.9% of the difference in birth weight between non-Hispanic White and non-Hispanic Black and all the difference (106.3%) in birth weight between Hispanic and non-Hispanic White individuals. Setting racial evenness, racial isolation and education isolation to levels consistent with higher diversity and education was also associated with similar reductions in differences for other anthropometric measures.

Conclusions

Our findings suggest that, in a hypothetical scenario where everyone lived in counties with low deprivation or segregation, race/ethnic differences in neonatal anthropometry may substantially decrease or be eliminated. Our results also highlight the importance of considering community-level and structural factors in analyses of race/ethnic health disparities.

Contextualizing Race and Ethnicity in the Practice of Laboratory Medicine

Race and ethnicity are population descriptors that clinicians and researchers often use to classify humans. The utility of these groupings in research and clinical contexts warrants scrutiny, since these groupings fail to adequately capture genetic diversity and instead, are proxies for the complex interplay of genetic, social, and structural determinants of health. Here, the authors review the concepts of race, ethnicity, and genetics. They also describe laboratory medicine examples where race and ethnicity are used that warrant scrutiny and revision, and areas where greater emphasis on including racialized minorities is necessary to improve health disparities.

Association of genetic ancestry with pre-eclampsia in multi-ethnic cohorts of pregnant women

OBJECTIVES

Maternal self-reported ethnicity is recognised as a risk factor for pre-eclampsia in clinical screening tools and models. This study investigated whether ethnicity is acting as a proxy for genetic variants in this context.

STUDY DESIGN

A total of 436 women from multi-ethnic backgrounds recruited to two UK observational pregnancy hypertension cohort studies were genotyped. Genetically-computed individual ancestry estimates were calculated for each individual through comparison to the multi-ethnic 1000 Genomes reference panel genotypes. Regression models for pre-eclampsia using clinical risk factors including self-reported ethnicity with and without ancestry estimates were built and compared using Likelihood Ratio Tests (LRT).

MAIN OUTCOME MEASURES

Pre-eclampsia (early- and late-onset).

RESULTS

In these multi-ethnic cohorts (mean age 34.9 years; 41.3 % White, 34.2 % Black, 13.1 % Asian ethnic backgrounds; 82.6 % chronic hypertension), discrepancies between self-reported ethnicity and genetically-computed individual ancestry estimates were present in all ethnic groups, particularly minority groups. Genetically-computed pan-African ancestry percentage was associated with early-onset (< 34 weeks) pre-eclampsia in adjusted models (aOR 100 % vs 0 % African ancestry: 3.81, 95 % CI 1.04-14.14, p-value 0.044) independently of self-reported ethnicity and established clinical risk factors. Addition of genetically-computed African ancestry to a clinical risk factor model including self-reported ethnicity, improved model fit (Likelihood ratio test p-value 0.023).

CONCLUSIONS

Self-reported maternal ethnicity is an imperfect proxy for genetically-computed individual ancestry estimates, particularly in ethnic minority groups. Genetically-computed African ancestry percentage was associated with early-onset pre-eclampsia independently of self-reported maternal ethnicity. Well-powered studies in multi-ethnic cohorts are required to delineate the genetic contribution to pre-eclampsia.

Low Hospital Volume Is Associated with Higher All-Cause Mortality in Black Women with Triple Negative Breast Cancer

INTRODUCTION

This study examines the association between hospital volume and all-cause mortality in Black women with triple negative breast cancer (TNBC) who received surgery and chemotherapy.

METHODS

Black women ages 18+ with stage I-III TNBC who received both surgery and chemotherapy were identified in the National Cancer Database (NCDB). Hospital volume was determined using the number of annual breast cancer cases divided by the number of years the hospital participated in the NCDB. Hospital annual volume quartiles ranged from Q1 (lowest) to Q4 (highest). Univariable analysis and multivariable logistic regression modeling with restricted cubic splines examined the effect of hospital volume on all-cause mortality.

RESULTS

Sixteen thousand five hundred fifty-six patients met the study criteria. All-cause mortality incidence was lower at higher volume compared to lower volume hospitals Q1 24.1% (95% CI: 22.8 to 25.4), Q2 21.8% (95% CI: 20.5 to 23.1), Q3 20.9% (95% CI: 19.6 to 22.1), Q4 19.0% (95% CI: 17.7 to 20.1), p<0.001. On multivariable analysis, treatment at the highest hospital volume quartile was associated with a 21% reduction in the odds of death compared to the lowest quartile [Q4 Vs. Q1, OR=0.79 (95% CI: 0.67 to 0.92)]. For every 100-patient increase in annual volume, all-cause mortality was reduced by 4% [OR=0.96 (95% CI: 0.94 to 0.98)]. There was a significant linear dose-dependent relationship between increasing hospital volume and all-cause mortality.

CONCLUSION

Black women treated at high-volume hospitals have lower all-cause mortality than those at low-volume hospitals. Future studies should examine the characteristics of high-volume hospitals associated with improved outcomes.

Reporting Indigenous status, ethnicity, language and country of birth to build equity in international paediatric clinical trials with Australian sites: a scoping review

Objective Ensuring equitable access to clinical trials for children from Indigenous and ethnically and linguistically diverse backgrounds should be central to clinical trial design. This review aims to expansively review the reporting of Indigenous status (Aboriginal and/or Torres Strait Islander origin), ethnicity, culture, location, language and country of birth in paediatric clinical trials with Australian sites. Methods This scoping review systematically searched PubMed, CINAHL and Embase for international clinical trials with Australian sites conducted between 2018 and 2022 involving children (aged <18years) to determine the reporting of Indigenous status, race, ethnicity, language and country of birth. Results Of the 262 studies included, 154 (58.8%) clinical trials did not report any of the variables of interest. When reported, terms used by authors were heterogeneous. 'Indigenous status' was most reported (n =40, 15.3%) and self-identification was the most common method to determine this (n =14, 35.9%). International clinical trials had higher rates of reporting for ethnicity, cultural background and race. Overall, more than 60 terms were used to categorise study participants in relation to 'Indigenous status', 'ethnicity and cultural background', 'race', 'race and ethnicity' or 'natural skin colour'. Conclusions This review demonstrated low rates of reporting of demographic variables in paediatric clinical trials. Clear reporting standards, partnering with consumers to co-design trials and self-identification during collection are required. Ensuring adequate access to clinical trials for Indigenous children and children from ethnically, linguistically and geographically diverse backgrounds is essential in building health equity and ensuring patient safety.

Healthcare Utilization Among Youth with Chronic Illness Receiving Care at a Large Urban Academic Healthcare System

BACKGROUND/OBJECTIVE

We sought to understand healthcare utilization and barriers to care among youth with chronic illness who interact frequently with the healthcare system.

METHODS

This was a retrospective analysis of healthcare utilization for youth ≤25 years of age with chronic illness during one calendar year (1 January 2021-31 December 2021) in a single urban academic healthcare system. Inclusion criteria were (1) having at least one healthcare encounter in the calendar year of 2021 and (2) having at least six healthcare encounters over the preceding 3-year period or having a qualifying chronic illness. Demographic and clinical characteristics were collected along with self-reported and derived social determinants of health. Univariable and multivariable regression models were created to identify predictors of missed clinic visits, telehealth use, and activated patient portal accounts.

RESULTS

The cohort (N = 14,245) was demographically, clinically, and socioeconomically diverse. The youth had frequent clinic visits (median 9, IQR 4-18), multiple subspecialty care referrals (median 4, 1-8), were prescribed multiple medications (median 6, 3-10), and a high proportion received emergency department (18%) or inpatient treatment (15%). Race and public insurance were significant predictors of missed clinic visits and telehealth use. Primary language was a significant predictor of patient portal activation.

CONCLUSIONS

Youth with chronic illness who are high users of the healthcare system face a high burden of clinic, emergency room, and hospital visits, referrals, and medications. Systematic efforts to lower the healthcare burden and improve care access should address existing racial and socioeconomic disparities affecting this patient population, who are likely to need frequent healthcare over their lifetime.

A Systematic Review of 207 Studies Describing Validation Aspects of the Dermatology Life Quality Index

This study systematically analysed peer-reviewed publications describing validation aspects of the Dermatology Life Quality Index (DLQI) and used Naicker's Critically Appraising for Antiracism Tool to assess risk of racial bias. Seven online databases were searched from 1994 until 2022 for articles containing DLQI validation data. Methodology followed PRISMA guidelines, the protocol was registered in PROSPERO, and articles reviewed independently by two assessors. Of 1,717 screened publications, 207 articles including 58,828 patients from >  49 different countries and 41 diseases met the inclusion criteria. The DLQI demonstrated strong test-retest reliability; 43 studies confirmed good internal consistency. Twelve studies were performed using anchors to assess change responsiveness with effect sizes from small to large, giving confidence that the DLQI responds appropriately to change. Forty-two studies tested known-groups validity, providing confidence in construct and use of the DLQI over many parameters, including disease severity, anxiety, depression, stigma, scarring, well-being, sexual function, disease location and duration. DLQI correlation was demonstrated with 119 Patient Reported Outcomes/Quality of Life measures in 207 studies. Only 15% of studies explicitly recruited minority ethnic participants; 3.9% stratified results by race/ethnicity. This review summarizes knowledge concerning DLQI validation, confirms many strengths of the DLQI and identifies areas for further validation.

Race, Neighborhood Disadvantage, and Prehospital Law Enforcement Handcuffing in Children With Behavioral Health Emergencies

Importance

Minoritized youth and children in resource-limited neighborhoods rely on emergency medical services (EMS) for accessing care, including during behavioral health emergencies (BHEs). Law enforcement (LE) officers sometimes use forceful tactics in such settings. Assessing LE actions is needed to ensure safe and equitable care for vulnerable populations.

Objective

To examine whether race and ethnicity, neighborhood disadvantage, sex, and age are associated with LE handcuffing during pediatric BHEs.

Design, Setting, and Participants

This cross-sectional study analyzed LE handcuffing, demographic factors, and neighborhood disadvantage in Alameda County, California. The study population included children younger than 18 years who were evaluated by EMS for BHEs between January 1, 2012, and June 30, 2019. Data analysis was completed between January 1, 2022, and August 30, 2023.

Exposures

Primary exposures included race and ethnicity and Area Deprivation Index (ADI) rank as ADI I (1-3 [lowest]), ADI II (4-6 [moderate]), and ADI III (7-10 [highest]).

Main Outcome and Measure

The primary outcome was LE handcuffing during BHEs. The study calculated handcuffing proportions stratified by race and ethnicity, ADI, and sex.

Results

The final dataset consisted of 6759 pediatric BHE encounters with complete data. Among these, 3864 encounters (57.2%) were with females. The median age was 14.9 (IQR, 13.4-16.2) years. Overall, LE handcuffing occurred in 517 encounters (7.6%); Black children had higher odds than their White peers (adjusted odds ratio [AOR], 1.80; 95% CI, 1.39-2.33). Compared with low neighborhood disadvantage, moderate neighborhood disadvantage was independently associated with increased odds of handcuffing (ADI II: AOR, 1.51; 95% CI, 1.21-1.88), as was highest neighborhood disadvantage (ADI III: AOR, 1.54; 95% CI, 1.19-1.99). Male sex (AOR, 2.31; 95% CI, 1.91-2.79) and age (AOR per 1-year increase, 1.15; 95% CI, 1.10-1.21) were also associated with increased odds of handcuffing. In moderately disadvantaged neighborhoods, the odds were higher for Black children (AOR, 2.52; 95% CI, 1.65-3.86). When stratified by sex, the odds of handcuffing were significantly higher for Black females compared with White females (AOR, 2.59; 95% CI, 1.69-3.98).

Conclusions and Relevance

The findings of this cross-sectional study suggest that accessing EMS for BHEs may expose Black children and youth in disadvantaged neighborhoods to LE use of handcuffing. Emergency medical services should reconsider the role of LE officers in these settings.

Association of Neighborhood Social Determinants of Health with Acute Kidney Injury during Hospitalization

Key Points

AKI is common among hospitalized patients. However, the contribution of neighborhood social determinants of health to AKI risk is not known. We found that among 26,769 hospitalized patients, 26% developed AKI. Patients who lived in the most disadvantaged areas (highest tertile of Area Deprivation Index) had a 10% greater odds of developing AKI than counterparts in the lowest Area Deprivation Index tertile. Patients who lived in rural areas had 25% greater odds of not recovering from AKI by hospital discharge. This study demonstrates an association between neighborhood disadvantage and rurality on the development of AKI and lack of recovery from AKI. Further work is needed to understand the mechanisms of these associations and to develop community-level interventions to mitigate the health care burden of AKI for disadvantaged populations.

Background

AKI is common among hospitalized patients. However, the contribution of social determinants of health (SDOH) to AKI risk remains unclear. This study evaluated the association between neighborhood measures of SDOH and AKI development and recovery during hospitalization.

Methods

This is a retrospective cohort study of adults without ESKD admitted to a large Southern US health care system from October 2014 to September 2017. Neighborhood SDOH measures included (1 ) socioeconomic status: Area Deprivation Index (ADI) scores, (2 ) food access: Low-Income, Low-Access scores, (3 ) rurality: Rural–Urban Commuting Area scores, and (4 ) residential segregation: dissimilarity and isolation scores. The primary study outcome was AKI on the basis of serum creatinine Kidney Disease Improving Global Outcomes criteria. Our secondary outcome was lack of AKI recovery (requiring dialysis or elevated serum creatinine at discharge). The association of SDOH measures with AKI was evaluated using generalized estimating equation models adjusted for demographics and clinical characteristics.

Results

Among 26,769 patients, 26% developed AKI during hospitalization. Compared with those who did not develop AKI, those who developed AKI were older (median 60 versus 57 years), more commonly men (55% versus 50%), and more commonly self-identified as Black (38% versus 33%). Patients residing in most disadvantaged neighborhoods (highest ADI tertile) had 10% (95% confidence interval, 1.02 to 1.19) greater adjusted odds of developing AKI during hospitalization than counterparts in least disadvantaged areas (lowest ADI tertile). Patients living in rural areas had 25% higher adjusted odds of lack of AKI recovery by hospital discharge (95% confidence interval, 1.07 to 1.46). Food access and residential segregation were not associated with AKI development or recovery.

Conclusions

Hospitalized patients from the most socioeconomically disadvantaged neighborhoods and from rural areas had higher odds of developing AKI and not recovering from AKI by hospital discharge, respectively. A better understanding of the mechanisms underlying these associations is needed to inform interventions to reduce AKI risk during hospitalization among disadvantaged populations.