Factors influencing surgical choice and anxiety in patients with pulmonary nodules smaller than 8 mm

Background

The detection of pulmonary nodules significantly impacts the lives and mental health of patients. Although the 2020 National Comprehensive Cancer Network (NCCN) guidelines recommend scheduled surveillance for nodules ≤8 mm, patients often opt to have their nodules surgically removed.

Methods

A cross-sectional questionnaire was administered to patients with small pulmonary nodules who presented to a local grade 3 hospital with small pulmonary nodules and decided to receive surgery versus prescribed monitoring. The questionnaire included four aspects: (I) patient characteristics; (II) nodule-specific knowledge; (III) doctor-patient communication; and (IV) nodular-specific distress. Nodular-specific distress was measured by the Impact of Event Scale-Revised (IES-R).

Results

A total of 234 (69%) patients responded to the survey and were included in the final analysis. Poor performance in activities of daily living (ADLs), the presence of solid nodules, multifocal disease, and a family history of lung cancer were significantly associated with reported anxiety. Most notably, facilitating patient choice for surgery was the computed tomography (CT) scan results, with reference to lung nodule size and number of nodules, where concerns related to lung nodule, cancer risk, and fear of surgery or death had a significant psychological impact on patients.

Conclusions

In this cohort of patients who elected to have their small pulmonary nodules surgically removed, we identified key factors underlying their anxiety toward guideline recommended surveillance. Our findings will be useful for clinicians when discussing treatment options with their patients.

The Inverse Log-Rank Test: A Versatile Procedure for Late Separating Survival Curves

Often in the planning phase of a clinical trial, a researcher will need to choose between a standard versus weighted log-rank test (LRT) for investigating right-censored survival data. While a standard LRT is optimal for analyzing evenly distributed but distinct survival events (proportional hazards), an appropriately weighted LRT test may be better suited for handling non-proportional, delayed treatment effects. The "a priori" misspecification of this alternative may result in a substantial loss of power when determining the effectiveness of an experimental drug. In this paper, the standard unweighted and inverse log-rank tests (iLRTs) are compared with the multiple weight, default Max-Combo procedure for analyzing differential late survival outcomes. Unlike combination LRTs that depend on the arbitrary selection of weights, the iLRT by definition is a single weight test and does not require implicit multiplicity correction. Empirically, both weighted methods have reasonable flexibility for assessing continuous survival curve differences from the onset of a study. However, the iLRT may be preferable for accommodating delayed separating survival curves, especially when one arm finishes first. Using standard large-sample methods, the power and sample size for the iLRT are easily estimated without resorting to complex and timely simulations.

A Centralized EHR-Based Model for the Recruitment of Rural and Lower Socioeconomic Participants in Pragmatic Trials: A Secondary Analysis of the Diuretic Comparison Project

Importance

Participant diversity is important for reducing study bias and increasing generalizability of comparative effectiveness research.

Objective

Demonstrate the operational efficiency of a centralized electronic health record (EHR)-based model for recruiting difficult-to-reach participants in a pragmatic trial.

Design, Setting, and Participants

This comparative effectiveness study was a secondary analysis of Diuretic Comparison Project, a randomized clinical trial conducted between 2016 and 2022 (mean [SD] follow-up, 2.4 [1.4] years) comparing 2 commonly prescribed antihypertensives, which used an EHR-based recruitment model. Electronic study workflows, in tandem with routine clinical practice, were adapted by 72 Veteran Affairs (VA) primary care networks. Data were analyzed from August to December 2022.

Main Outcomes and Measures

Measures reflecting recruitment capacity (monthly rate), operational efficiency (median time for completion of electronic procedures), and geographic reach (percentage of patients recruited from rural areas) were examined.

Results

A total of 13 523 patients with hypertension (mean [SD] age, 72 [5.4] years; 13 092 male [96.8%]) were recruited from 537 outpatient clinics. Approximately 205 patients were randomized per month and a median of 35 days (Q1-Q3, 23-80 days) was needed to complete electronic recruitment. The annual income was below the national median for 69% of the cohort. Patients from all 50 states, Puerto Rico, and the District of Columbia were included and 45% resided in rural areas.

Conclusions and Relevance

In this secondary analysis of a multicenter pragmatic trial, a centralized EHR-based recruitment model was associated with improved participation from underrepresented groups. These participants often are difficult to reach, with their exclusion potentially biasing trial results; eliminating in-person study visits and local site involvement can minimize barriers for the recruitment of patients from rural and lower socioeconomic areas.

Trial Registration

The Diuretic Comparison Project (DCP) was registered on ClinicalTrials.gov Identifier: NCT02185417.

Self-reported gastrointestinal disorders among veterans with gulf war illness with and without posttraumatic stress disorder

BACKGROUND

Gulf War Illness (GWI) is a chronic, multi-symptom disorder affecting 25%-32% of Gulf War veterans. Veterans with GWI disproportionately suffer from gastrointestinal (GI) disorders. Given the increasing evidence supporting a gut-brain axis, we explore the relationship between post-traumatic stress disorder (PTSD), GWI, and self-reported GI disorders among GW veterans.

METHODS

Veterans from the Gulf War Era Cohort and Biorepository responded to a mail-based survey (N = 1058). They were stratified by GWI (Centers for Disease Control definition) and PTSD status. This yielded three groups: GWI-, GWI+/PTSD-, and GWI+/PTSD+. Multivariable logistic regression adjusting for demographic and military characteristics examined associations between GWI/PTSD groups and GI disorders. Results were expressed as adjusted odds ratios (aOR) with 95% confidence intervals (95% CI).

KEY RESULTS

The most frequently reported GI disorders were irritable bowel syndrome (IBS), gastroesophageal reflux disease (GERD), and colon polyps (CP). The GWI+/PTSD+ group had a higher odds of these disorders than the GWI+/PTSD- group (aOR_IBS  = 3.12, 95% CI: 1.93-5.05; aOR_GERD  = 2.04, 95% CI: 1.44-2.90; aOR_CP  = 1.85, 95% CI: 1.23-2.80), which had a higher odds of these disorders than the GWI- group (aOR_IBS  = 4.38, 95% CI: 1.55-12.36; aOR_GERD  = 2.51 95% CI: 1.63-3.87; aOR_CP  = 2.57, 95% CI: 1.53-4.32).

CONCLUSIONS & INFERENCES

GW veterans with GWI and PTSD have significantly higher odds of specific self-reported GI disorders than the other groups. Given the known bidirectional influences of the gut and brain, these veterans may benefit from a holistic healthcare approach that considers biopsychosocial contributors to the assessment and management of disease.

The evidence for Mycobacterium avium subspecies paratuberculosis (MAP) as a cause of nonsolar uveal melanoma: a narrative review

Background and Objective

Animal microorganisms have been proposed as a cause of human cancers associated with farming, agricultural occupation or residence, and related downstream exposures. Several studies have described uveal melanoma (UvM) as a farming-associated cancer. A possible suspect is the animal microorganism Mycobacterium avium subspecies paratuberculosis (MAP), the causative agent of paratuberculosis in dairy cows. This microbe is transmitted to humans through various means, including contact with animal faeces, contaminated dust and soil, organic fertilizers, and as workers in slaughterhouses/animal processing facilities. The objective of the current manuscript was to examine the putative association between Mycobacterium avium sub-species paratuberculosis and non-solar UvM.

Methods

Online data sources (PubMed, Scopus, Cochrane Library, and Google) published in English between 1980 to present were searched for key words pertaining to MAP exposure, farming-related occupations and activities, and locations with or in the vicinity of dairy cattle.

Key Content and Findings

While higher than expected rates of eye cancer have been suggested among dairy farmers, with MAP being ubiquitous in their environment, the involvement of MAP in the aetiology of non-solar UvMs (which account for ~97% of UvM cases) remains uncertain.

Conclusions

Alternative explanations exist and future cause-and-effect research is needed to answer this hypothesis. A precautionary approach to exposure continues to be a prudent strategy.

Self-management program and Black women with hypertension: Randomized controlled trial substudy

The prevalence of hypertension (HTN) among Black women in the United States has increased over the past 10 years with a decline in levels of HTN awareness, treatment, and control. Higher death rates occur in Black women from HTN-related diseases when compared with women of other racial/ethnic groups. Although interventions aimed at self-care/self-management are vital to adults becoming the cornerstone of their own health and well-being, there is a paucity of research in Black women. This randomized controlled pilot trial substudy examined the influence of a Chronic Disease Self-Management Program (CDSMP) with tailored coaching versus the CDSMP alone on blood pressure (BP), weight, and scores on self-care questionnaires and medication adherence for Black women with HTN over 9 months. Eighty-three women who had completed the CDSMP were randomly assigned to coaching or no coaching. Median age was 54 years and the time since the HTN diagnosis was 9 years. Significant differences were noted in self-care maintenance and management over time with better self-care in the treatment group. Though not significant, both groups denoted a trend toward better medication adherence. Almost 60% of the participants in both groups showed improvements in their systolic and/or diastolic BP. However, there was no significant difference between the study groups' BP and weight variables. The CDSMP was effective in decreasing BP and improving medication adherence. Further research is needed to evaluate effective coaching strategies that motivate Black women with HTN toward self-care management.

Use of coaching and technology to improve blood pressure control in Black women with hypertension: Pilot randomized controlled trial study

Hypertension is the main cause of cardiovascular disease, especially in women. Black women (58%) are affected by higher rates of hypertension than other racial/ethnic groups contributing to increased cardio-metabolic disorders. To decrease blood pressure (BP) in this population, a pilot randomized controlled trial was conducted to examine the effects of Interactive Technology Enhanced Coaching (ITEC) versus Interactive Technology (IT) alone in achieving BP control, adherence to antihypertensive medication, and adherence to lifestyle modifications among Black women diagnosed with and receiving medication for their hypertension. Participants completed a 6-week Chronic Disease Self-Management Program (CDSMP), and 83 participants were randomly assigned to ITEC versus IT. Participants were trained to use three wireless tools and five apps that were synchronized to smartphones to monitor BP, weight, physical activity (steps), diet (caloric and sodium intake), and medication adherence. Fitbit Plus, a cloud-based collaborative care platform was used to collect, track, and store data. Using a mixed-effects repeated measures model, the main effect of group means indicated no significant difference between the treatment and referent groups on study variables. The main effect of time indicated significant differences between repeated measures for systolic BP (p < .0001), weight (p < .0001), and steps (p = .018). An interaction effect revealed differences over time and was significant for study measures except diastolic BP. An important goal of this preliminary analysis is to help Black women prioritize self-care management in their everyday environment. Future research is warranted in a geographically broader population of hypertensive Black women.

Association Between Social Determinants of Health and Glycemic Control Among African American People with Type 2 diabetes: The Jackson Heart Study

BACKGROUND

Social determinants of health have a significant impact on health outcomes. However, the complexity and interaction of multiple factors influencing glycemic control remain understudied.

PURPOSE

This study examined associations of socioeconomic position (income, education, and occupation), environmental (physical activity facilities, neighborhood social cohesion, neighborhood problem, and violence), behavioral (physical activity, nutrition, and smoking), and psychological factors (depressive symptoms, stress, and discrimination) with glycemic control (hemoglobin A1c [A1c]) using the World Health Organization Social Determinants of Health framework in African American adults with type 2 diabetes.

METHODS

A secondary data analysis was conducted using a longitudinal cohort of 1,240 African American adults with type 2 diabetes who participated in the community-based Jackson Heart Study. Socioeconomic position, environmental, behavioral, and psychological factors were measured using validated instruments in the Jackson Heart Study. Longitudinal structural equation modeling was used with glycemic control (A1c) collected over time (Exams 1-3) as the study outcome.

RESULTS

Our study presents the complex interplay of socioeconomic determinants of health and glycemic control over time. Higher socioeconomic position (higher income, higher level of education, and professional occupation) was directly associated with improvement in glycemic control over time. An association of socioeconomic position on glycemic control mediated through health behavior factors was also observed.

CONCLUSIONS

In this analysis, socioeconomic position components were determinants of glycemic control in African American adults with type 2 diabetes. Future studies aimed at reducing health disparities and achieving equality of outcomes in this population will benefit from embedding socioeconomic position components into their design.

Dermatological Autoimmune Considerations of Immune Checkpoint Therapy

The most common immune-related adverse events (irAEs) involve the skin, and several serve as predictors of response to immune checkpoint inhibitor (ICI) therapy, especially in melanoma. Patients with pre-existing skin autoimmune diseases (ADs) have been excluded from ICI studies for safety concerns, yet recent research has shown that dermatological ADs can be managed without discontinuing ICI therapy. Patients with ADs respond as well or better to ICIs and can be included as candidates in clinical trials. Frequently taken during ICI therapy, steroids impair immunotherapy efficacy in certain anatomical sites of tumors but not others, including the brain. ICI efficacy can be enhanced by radiotherapy without increasing adverse events, as neoadjuvant radiotherapy is thought to sensitize tumors to ICIs. This perspective highlights clinical autoimmune considerations of ICI therapy in melanoma and discusses important areas for future exploration.

Immediate impact of coronary artery bypass graft surgery on regional myocardial perfusion: Results from the Collaborative Pilot Study to Determine the Correlation Between Intraoperative Observations Using Spy Near-Infrared Imaging and Cardiac Catheterization Laboratory Physiological Assessment of Lesion Severity

Objectives

Coronary artery bypass grafting (CABG) is performed using anatomic guidance. Data connecting the physiologic significance of the coronary vessel stenosis to the acute physiologic response to grafting are lacking. The Collaborative Pilot Study to Determine the Correlation Between Intraoperative Observations Using Spy Near-Infrared Imaging and Cardiac Catheterization Laboratory Physiological Assessment of Lesion Severity study is the first to compare preintervention coronary physiology with the acute regional myocardial perfusion change (RMP-QC) at CABG in a per-graft analysis.

Methods

Non-emergent patients undergoing diagnostic catheterization suitable for multivessel CABG were enrolled. Synergy between Percutaneous Coronary Intervention with Taxus score, fractional flow reserve (FFR), instantaneous wave free ratio (iFR), and quantitative coronary angiography was documented in 75 epicardial coronary arteries, with 62 angiographically intermediate and 13 severe stenoses. At CABG, near-infrared fluorescence analysis quantified the relative change (post- vs pregrafting, termed RMP-QC) in the grafted vessel's perfusion territory. Scatter plots were constructed for RMP-QC versus quantitative coronary angiography and RMP-QC versus FFR/iFR. Exact quadrant randomization test for randomness was used.

Results

There was no relationship between RMP-QC and quantitative coronary angiography percent diameter stenosis, whether all study vessels were included (P = .949) or vessels with core-lab quantitative coronary angiography only (P = .922). A significant nonrandom association between RMP-QC and FFR (P = .025), as well as between RMP-QC and iFR (P = .008), was documented. These associations remained when excluding vessels with assigned FFR and iFR values (P = .0092 and P = .0006 for FFR and iFR, respectively).

Conclusions

The Collaborative Pilot Study to Determine the Correlation Between Intraoperative Observations Using Spy Near-Infrared Imaging and Cardiac Catheterization Laboratory Physiological Assessment of Lesion Severity study demonstrates there is no association between angiographic coronary stenosis severity and the acute perfusion change after grafting; there is an association between functional stenosis severity and absolute increase in regional myocardial perfusion after CABG.

Abstract P211: Use Of Coaching And Technology To Improve Blood Pressure Control In Black Women With Hypertension

Introduction: Hypertension (HTN) is the main cause of cardiovascular disease, especially in women. Black females (58%) are disproportionately affected by higher rates of HTN than White (41%), Hispanic (41%), and Asian (42%) females, contributing to higher death rates from myocardial infarction, heart failure, stroke, and renal failure. Active involvement in self-care is key to preventing and controlling HTN.

Aim: To test the effects of Interactive Technology Enhanced Coaching (ITEC) on achieving blood pressure (BP) control, adherence to antihypertensive medication, and adherence to lifestyle modifications (physical activity, healthy diet, and weight management) at 3-, 6-, and 9-months post Chronic Disease Self-Management Program (CDSMP) compared with Interactive Technology (IT) alone.

Methods: Black women in this RCT pilot study were prescribed antihypertensive medication and had BPs ≥ 130/80. All participants completed a 6-week CDSMP and afterwards were randomly assigned to the ITEC or IT group. Participants were trained to use equipment and apps that were synced to smartphones to daily monitor (over a 9-month period) BP, weight, physical activity (steps), diet (caloric intake), and medication adherence in real-time, though the Fitbit Plus Platform.

Results: A total of 90 women were recruited. Data were analyzed from 77 participants aged 24 to 70 years. A hierarchical, mixed-effects repeated measures design was used to measure changes over time. The main effect of group means indicated no significant difference between the treatment and control groups on all study variables. The main effect of time indicated significant differences between repeated measures for SBP ( p < .0001 and steps ( p = .012). An interaction effect was significant for all measures except DBP and calories. SBP decreased to <130 following CDSMP and remained stable thereafter for both groups.

Conclusions: Participant engagement declined as coaching decreased in the treatment group. Enhancing motivation and making self-care a priority in this population warrants further exploration.

Longitudinal assessment of colonoscopy adverse events in the prospective Cooperative Studies Program no. 380 colorectal cancer screening and surveillance cohort

BACKGROUND AND AIMS

Data are limited regarding colonoscopy risk during long-term, programmatic colorectal cancer screening and follow-up. We aimed to describe adverse events during follow-up in a colonoscopy screening program after the baseline examination and examine factors associated with increased risk.

METHODS

Cooperative Studies Program no. 380 includes 3121 asymptomatic veterans aged 50 to 75 years who underwent screening colonoscopy between 1994 and 1997. Periprocedure adverse events requiring significant intervention were defined as major events (other events were minor) and were tracked during follow-up for at least 10 years. Multivariable odds ratios (ORs) were calculated for factors associated with risk of follow-up adverse events.

RESULTS

Of 3727 follow-up examinations in 1983 participants, adverse events occurred in 105 examinations (2.8%) in 93 individuals, including 22 major and 87 minor events (examinations may have had >1 event). Incidence of major events (per 1000 examinations) remained relatively stable over time, with 6.1 events at examination 2, 4.8 at examination 3, and 7.2 at examination 4. Examinations with major events included 1 perforation, 3 GI bleeds requiring intervention, and 17 cardiopulmonary events. History of prior colonoscopic adverse events was associated with increased risk of events (major or minor) during follow-up (OR, 2.7; 95% confidence interval, 1.6-4.6).

CONCLUSIONS

Long-term programmatic screening and surveillance was safe, as major events were rare during follow-up. However, serious cardiopulmonary events were the most common major events. These results highlight the need for detailed assessments of comorbid conditions during routine clinical practice, which could help inform individual decisions regarding the utility of ongoing colonoscopy follow-up.

Breast Cancer Disparities in Asian Women: The Need for Disaggregated Research

Asian (AZN) women are a heterogeneous group, comprising a wide array of cultural beliefs, languages, and healthcare needs. Yet, studies of breast cancer (BCa) risks and outcomes predominately consider AZNs in aggregate, assuming that the distinct ethnicities have similar disease profiles and homogeneous responses to treatment. This stereotypical portrayal of AZNs as a homogenous group tends to mask disparities. For example, healthcare-seeking behaviors and attitudes of medical providers toward AZN BCa patients frequently differ within this group and from other races. Misconceptions may arise that significantly influence the prevention, detection, treatment, and post-therapeutic care of AZN women. In addition to low BCa screening rates among AZN women, disparities also exist in various stages of BCa treatment-omission of radiation after breast-conserving surgery, less access to hypofractionation, underutilization of hormonal therapy, and higher-cost treatment owing to high HER2+ incidence. In this perspective, we highlight the need for disaggregated research of BCa among AZN women and advocate for comprehensive, culturally sensitive strategies to address health disparities in this priority population. Improving BCa literacy and awareness, access to care, and equitable recruitment into clinical trials are a few amelioratory goals to consider in the future.

Interaction of Vitamin D and Corticosteroid Use in Hospitalized COVID-19 Patients: A Potential Explanation for Inconsistent Findings in the Literature

Vitamin D is an important immune-modulator with anti-inflammatory properties. While this prohormone has been studied extensively in the prevention and treatment of COVID-19, findings have been inconsistent regarding its overall benefit in patients hospitalized with COVID-19. Most studies to date have been observational in nature, not accounting for the use of corticosteroids. Furthermore, the few randomized clinical trials designed to examine the effect of vitamin D supplementation on COVID-19 outcomes have been relatively small and thus insufficiently powered to assure a balance of corticosteroid use between study arms. The current perspective addresses the interaction of vitamin D and corticosteroids as a potential explanation for the divergent results reported in the literature. Future research on vitamin D and COVID-19 will benefit by considering this interaction, especially among hospitalized patients requiring oxygen and mechanical ventilation.

A Phenome-Wide Association Study of genes associated with COVID-19 severity reveals shared genetics with complex diseases in the Million Veteran Program

The study aims to determine the shared genetic architecture between COVID-19 severity with existing medical conditions using electronic health record (EHR) data. We conducted a Phenome-Wide Association Study (PheWAS) of genetic variants associated with critical illness (n = 35) or hospitalization (n = 42) due to severe COVID-19 using genome-wide association summary data from the Host Genetics Initiative. PheWAS analysis was performed using genotype-phenotype data from the Veterans Affairs Million Veteran Program (MVP). Phenotypes were defined by International Classification of Diseases (ICD) codes mapped to clinically relevant groups using published PheWAS methods. Among 658,582 Veterans, variants associated with severe COVID-19 were tested for association across 1,559 phenotypes. Variants at the ABO locus (rs495828, rs505922) associated with the largest number of phenotypes (nrs495828 = 53 and nrs505922 = 59); strongest association with venous embolism, odds ratio (ORrs495828 1.33 (p = 1.32 x 10-199), and thrombosis ORrs505922 1.33, p = 2.2 x10-265. Among 67 respiratory conditions tested, 11 had significant associations including MUC5B locus (rs35705950) with increased risk of idiopathic fibrosing alveolitis OR 2.83, p = 4.12 × 10-191; CRHR1 (rs61667602) associated with reduced risk of pulmonary fibrosis, OR 0.84, p = 2.26× 10-12. The TYK2 locus (rs11085727) associated with reduced risk for autoimmune conditions, e.g., psoriasis OR 0.88, p = 6.48 x10-23, lupus OR 0.84, p = 3.97 x 10-06. PheWAS stratified by ancestry demonstrated differences in genotype-phenotype associations. LMNA (rs581342) associated with neutropenia OR 1.29 p = 4.1 x 10-13 among Veterans of African and Hispanic ancestry but not European. Overall, we observed a shared genetic architecture between COVID-19 severity and conditions related to underlying risk factors for severe and poor COVID-19 outcomes. Differing associations between genotype-phenotype across ancestries may inform heterogenous outcomes observed with COVID-19. Divergent associations between risk for severe COVID-19 with autoimmune inflammatory conditions both respiratory and non-respiratory highlights the shared pathways and fine balance of immune host response and autoimmunity and caution required when considering treatment targets.

Screening Colonoscopy Findings Are Associated With Noncolorectal Cancer Mortality

INTRODUCTION

Controversy exists regarding the impact of various risk factors on noncolorectal cancer (CRC) mortality in healthy screening populations. We examined the impact of known CRC risk factors, including baseline colonoscopy findings, on non-CRC mortality in a screening population.

METHODS

Cooperative Studies Program (CSP) #380 is comprised of 3,121 veterans aged 50-75 years who underwent screening colonoscopy from 1994 to 97 and were then followed for at least 10 years or until death. Hazard ratios (HRs) for risk factors on non-CRC mortality were estimated by multivariate Cox proportional hazards.

RESULTS

Current smoking (HR 2.12, 95% confidence interval [CI] 1.78-2.52, compared with nonsmokers) and physical activity (HR 0.89, 95% CI 0.84-0.93) were the modifiable factors most associated with non-CRC mortality in CSP#380. In addition, compared with no neoplasia at baseline colonoscopy, non-CRC mortality was higher in participants with ≥3 small adenomas (HR 1.43, 95% CI 1.06-1.94), advanced adenomas (HR 1.32, 95% CI 0.99-1.75), and CRC (HR 2.95, 95% CI 0.98-8.85). Those with 1-2 small adenomas were not at increased risk for non-CRC mortality (HR 1.15, 95% CI 0.94-1.4).

DISCUSSION

In a CRC screening population, known modifiable risk factors were significantly associated with 10-year non-CRC mortality. Furthermore, those who died from non-CRC causes within 10 years were more likely to have had high-risk findings at baseline colonoscopy. These results suggest that advanced colonoscopy findings may be a risk marker of poor health outcomes. Integrated efforts are needed to motivate healthy lifestyle changes during CRC screening, particularly in those with high-risk colonoscopy findings and unaddressed risk factors.

Genetic Loci Associated With COVID-19 Positivity and Hospitalization in White, Black, and Hispanic Veterans of the VA Million Veteran Program

SARS-CoV-2 has caused symptomatic COVID-19 and widespread death across the globe. We sought to determine genetic variants contributing to COVID-19 susceptibility and hospitalization in a large biobank linked to a national United States health system. We identified 19,168 (3.7%) lab-confirmed COVID-19 cases among Million Veteran Program participants between March 1, 2020, and February 2, 2021, including 11,778 Whites, 4,893 Blacks, and 2,497 Hispanics. A multi-population genome-wide association study (GWAS) for COVID-19 outcomes identified four independent genetic variants (rs8176719, rs73062389, rs60870724, and rs73910904) contributing to COVID-19 positivity, including one novel locus found exclusively among Hispanics. We replicated eight of nine previously reported genetic associations at an alpha of 0.05 in at least one population-specific or the multi-population meta-analysis for one of the four MVP COVID-19 outcomes. We used rs8176719 and three additional variants to accurately infer ABO blood types. We found that A, AB, and B blood types were associated with testing positive for COVID-19 compared with O blood type with the highest risk for the A blood group. We did not observe any genome-wide significant associations for COVID-19 severity outcomes among those testing positive. Our study replicates prior GWAS findings associated with testing positive for COVID-19 among mostly White samples and extends findings at three loci to Black and Hispanic individuals. We also report a new locus among Hispanics requiring further investigation. These findings may aid in the identification of novel therapeutic agents to decrease the morbidity and mortality of COVID-19 across all major ancestral populations.

The Interaction of Vitamin D and Corticosteroids: A Mortality Analysis of 26,508 Veterans Who Tested Positive for SARS-CoV-2

This data-based cohort consisted of 26,508 (7%) United States veterans out of the 399,290 who tested positive for SARS-CoV-2 from 1 March to 10 September 2020. We aimed to assess the interaction of post-index vitamin D (Vit D) and corticosteroid (CRT) use on 30-day mortality among hospitalized and non-hospitalized patients with coronavirus disease 2019 (COVID-19). Combination Vit D and CRT drug use was assessed according to four multinomial pairs (-|+, -|-, +|+, +|-). Respective categorical effects were computed on a log-binomial scale as adjusted relative risk (aRR). Approximately 6% of veterans who tested positive for SARS-CoV-2 died within 30 days of their index date. Among hospitalized patients, a significantly decreased aRR was observed for the use of Vit D in the absence of CRTs relative to patients who received CRTs but not Vit D (aRR = 0.30; multiplicity corrected, p = 0.0004). Among patients receiving systemically administered CRTs (e.g., dexamethasone), the use of Vit D was associated with fewer deaths in hospitalized patients (aRR = 0.51) compared with non-hospitalized patients (aRR = 2.5) (P-for-Interaction = 0.0071). Evaluating the effect of modification of these compounds in the context of hospitalization may aid in the management of COVID-19 and provide a better understanding of the pathophysiological mechanisms underlying this and future infectious disease outbreaks.

Gene-Toxicant Interactions in Gulf War Illness: Differential Effects of the PON1 Genotype

About 25-35% of United States veterans who fought in the 1990-1991 Gulf War report several moderate or severe chronic systemic symptoms, defined as Gulf War illness (GWI). Thirty years later, there is little consensus on the causes or biological underpinnings of GWI. The Gulf War Era Cohort and Biorepository (GWECB) was designed to investigate genetic and environmental associations with GWI and consists of 1343 veterans. We investigate candidate gene-toxicant interactions that may be associated with GWI based on prior associations found in human and animal model studies, focusing on SNPs in or near ACHE, BCHE, and PON1 genes to replicate results from prior studies. SOD1 was also considered as a candidate gene. CDC Severe GWI, the primary outcome, was observed in 26% of the 810 deployed veterans included in this study. The interaction between the candidate SNP rs662 and pyridostigmine bromide (PB) pills was found to be associated with CDC Severe GWI. Interactions between PB pill exposure and rs3917545, rs3917550, and rs2299255, all in high linkage disequilibrium in PON1, were also associated with respiratory symptoms. These SNPs could point toward biological pathways through which GWI may develop, which could lead to biomarkers to detect GWI or to better treatment options for veterans with GWI.

Pretreatment neutrophil-to-lymphocyte ratio as an important prognostic marker in stage III locally advanced non-small cell lung cancer: confirmatory results from the PROCLAIM phase III clinical trial

Background

Neutrophil-to-lymphocyte ratio (NLR) is an important pretreatment marker of systemic inflammation and tumor aggressiveness. Increased levels of this ratio have been associated with reduced survival in several observational studies of lung cancer. However, supporting analyses from large clinical trial data are lacking.

Methods

To validate the prognostic role of NLR, the current study evaluated data from a randomized phase III study (PROCLAIM; clinicaltrial.gov ID: NCT00686959) of patients with stage IIIA/B, unresectable, non-squamous, non-small cell lung cancer (NSCLC), originally comparing combination pemetrexed-cisplatin chemoradiotherapy with etoposide-cisplatin chemoradiotherapy. Adjusted hazard ratios (aHR) and 95% confidence intervals (CI) for survival were estimated using a Cox proportional hazards model. Models were adjusted for age, race, sex, stage, treatment, and body mass index (BMI). Patients were followed for a median of 24 months.

Results

Increased NLR levels at baseline were associated with reduced overall (P_Trend <0.0001) and progression-free survival (P_Trend <0.005). A similar but decreasing linear trend was not observed for lymphocytes count alone.

Conclusions

These findings provide substantiating evidence that NLR, which is routinely available from standard blood testing of patients diagnosed with NSCLC, is an important inflammation-based prognostic marker for survival among patients with locally advanced disease undergoing chemoradiation. Future research will benefit by assessing the prognostic potential of NLR in the context of genetic mutations and molecular markers.

A Phenome-Wide Association Study of genes associated with COVID-19 severity reveals shared genetics with complex diseases in the Million Veteran Program

The study aims to determine the shared genetic architecture between COVID-19 severity with existing medical conditions using electronic health record (EHR) data. We conducted a Phenome-Wide Association Study (PheWAS) of genetic variants associated with critical illness (n=35) or hospitalization (n=42) due to severe COVID-19 using genome-wide association summary from the Host Genetics Initiative. PheWAS analysis was performed using genotype-phenotype data from the Veterans Affairs Million Veteran Program (MVP). Phenotypes were defined by International Classification of Diseases (ICD) codes mapped to clinically relevant groups using published PheWAS methods. Among 658,582 Veterans, variants associated with severe COVID-19 were tested for association across 1,559 phenotypes. Variants at the ABO locus (rs495828, rs505922) associated with the largest number of phenotypes (n_rs495828=53 and n_rs505922=59); strongest association with venous embolism, odds ratio (ORrs495828 1.33 (p=1.32 × 10^-199), and thrombosis OR_rs505922 1.33, p=2.2 × 10^-265. Among 67 respiratory conditions tested, 11 had significant associations including MUC5B locus (rs35705950) with increased risk of idiopathic fibrosing alveolitis OR 2.83, p=4.12 × 10^-191; CRHR1 (rs61667602) associated with reduced risk of pulmonary fibrosis, OR 0.84, p=2.26 × 10^-12. The TYK2 locus (rs11085727) associated with reduced risk for autoimmune conditions, e.g., psoriasis OR 0.88, p=6.48 × 10^-23, lupus OR 0.84, p=3.97 × 10^-06. PheWAS stratified by genetic ancestry demonstrated differences in genotype-phenotype associations across ancestry. LMNA (rs581342) associated with neutropenia OR 1.29 p=4.1 × 10^-13 among Veterans of African ancestry but not European. Overall, we observed a shared genetic architecture between COVID-19 severity and conditions related to underlying risk factors for severe and poor COVID-19 outcomes. Differing associations between genotype-phenotype across ancestries may inform heterogenous outcomes observed with COVID-19. Divergent associations between risk for severe COVID-19 with autoimmune inflammatory conditions both respiratory and non-respiratory highlights the shared pathways and fine balance of immune host response and autoimmunity and caution required when considering treatment targets.

Enhanced Catecholamine Flux and Impaired Carbonyl Metabolism Disrupt Cardiac Mitochondrial Oxidative Phosphorylation in Diabetes Patients

Aims: Catecholamine metabolism via monoamine oxidase (MAO) contributes to cardiac injury in models of ischemia and diabetes, but the pathogenic mechanisms involved are unclear. MAO deaminates norepinephrine (NE) and dopamine to produce H₂O₂ and highly reactive "catecholaldehydes," which may be toxic to mitochondria due to the localization of MAO to the outer mitochondrial membrane. We performed a comprehensive analysis of catecholamine metabolism and its impact on mitochondrial energetics in atrial myocardium obtained from patients with and without type 2 diabetes. Results: Content and maximal activity of MAO-A and MAO-B were higher in the myocardium of patients with diabetes and they were associated with body mass index. Metabolomic analysis of atrial tissue from these patients showed decreased catecholamine levels in the myocardium, supporting an increased flux through MAOs. Catecholaldehyde-modified protein adducts were more abundant in myocardial tissue extracts from patients with diabetes and were confirmed to be MAO dependent. NE treatment suppressed mitochondrial ATP production in permeabilized myofibers from patients with diabetes in an MAO-dependent manner. Aldehyde dehydrogenase (ALDH) activity was substantially decreased in atrial myocardium from these patients, and metabolomics confirmed lower levels of ALDH-catalyzed catecholamine metabolites. Proteomic analysis of catechol-modified proteins in isolated cardiac mitochondria from these patients identified >300 mitochondrial proteins to be potential targets of these unique carbonyls. Innovation and Conclusion: These findings illustrate a unique form of carbonyl toxicity driven by MAO-mediated metabolism of catecholamines, and they reveal pathogenic factors underlying cardiometabolic disease. Importantly, they suggest that pharmacotherapies targeting aldehyde stress and catecholamine metabolism in heart may be beneficial in patients with diabetes and cardiac disease. Antioxid. Redox Signal. 35, 235-251.

Role of radiation in extensive stage small cell lung cancer: a National Cancer Database registry analysis

The role of prophylactic cranial irradiation (PCI) and thoracic radiation therapy (TRT) in extensive-stage small cell lung cancer remains controversial. The authors examined the National Cancer Database and identified patients with extensive-stage small cell lung cancer with no brain metastasis. Patients were excluded if they died 30 days from diagnosis, did not receive polychemotherapy, had other palliative radiation or had missing information. A propensity score-matched analysis was also performed. A total of 21,019 patients were identified. The majority of patients did not receive radiation (69%), whereas 10% received PCI and 21% received TRT. The addition of PCI and TRT improved median survival and survival at 1 and 2 years (p ≤ 0.05). The propensity score-matched analysis confirmed the same overall survival benefit with both PCI and TRT. This registry-based analysis of >1500 accredited cancer programs shows that PCI and TRT are not commonly utilized for extensive-stage small cell lung cancer patients who are treated with multiagent chemotherapy. The addition of PCI and TRT significantly improves overall survival in this otherwise poor prognostic group. Further research is needed to confirm the role of PCI and TRT, especially in the era of improved systemic therapy.

Goldilocks Rounding: Achieving Balance Between Accuracy and Parsimony in the Reporting of Relative Effect Estimates

Researchers often report a measure to several decimal places more than what is sensible or realistic. Rounding involves replacing a number with a value of lesser accuracy while minimizing the practical loss of validity. This practice is generally acceptable to simplify data presentation and to facilitate the communication and comparison of research results. Rounding also may reduce spurious accuracy when the extraneous digits are not justified by the exactness of the recording instrument or data collection procedure. However, substituting a more explicit or simpler representation for an original measure may not be practicable or acceptable if an adequate degree of accuracy is not retained. The error introduced by rounding exact numbers may result in misleading conclusions and the interpretation of study findings. For example, rounding the upper confidence interval for a relative effect estimate of 0.996 to 2 decimal places may obscure the statistical significance of the result. When presenting the findings of a study, authors need to be careful that they do not report numbers that contain too few significant digits. Equally important, they should avoid providing more significant figures than are warranted to convey the underlying meaning of the result.

Slow Burns: A Qualitative Study of Burn Pit and Toxic Exposures Among Military Veterans Serving in Afghanistan, Iraq and Throughout the Middle East

During deployment to the Persian Gulf War and Southwest Asia theatre of operations, Veterans often experienced various hazards, foremost being open-air burn pits and oil well fires. While over 23 presumptive conditions (ranging from brain cancer, interstitial lung disease, and lymphomas to sleep/mood disorders, depression, and cognitive impairment) have been studied in connection with their military-related exposures, there is a paucity of qualitative research on this topic. This is especially true in the context of explanatory models and health belief systems, vis-à-vis underlying social and cultural factors. The current paper provides a balanced conceptual framework (summarizing causal virtues and shortcomings) about the challenges that Veterans encounter when seeking medical care, screening assessments and subsequent treatments.

Systematic analysis of ferroptosis-related long non-coding RNA predicting prognosis in patients with lung squamous cell carcinoma

Background

Ferroptosis is a novel iron-dependent cell death, and an increasing number of studies have shown that long non-coding RNA (lncRNAs) are involved in the ferroptosis process. However, studies on ferroptosis-related lncRNAs in lung squamous cell carcinoma (LUSC) are limited. In addition, the prognostic role of ferroptosis-related lncRNAs and their relationship with the immune microenvironment and methylation of LUSC is unclear. This study aimed to investigate the potential prognostic value of ferroptosis-related lncRNAs and their involved biological functions in LUSC.

Methods

The Cancer Genome Atlas (TCGA) database and the FerrDb website were used to obtain ferroptosis-related genes for LUSC. The “limma” R package and Pearson analysis were used to find ferroptosis-related lncRNAs. The biological functions of the characterized lncRNAs were analyzed by Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG). We evaluated the prognostic power of this model using Kaplan-Meier analysis, receiver operating characteristic (ROC), and decision curve analysis (DCA). Univariate and multifactor Cox (proportional-hazards) risk model and a nomogram were produced using risk models and clinicopathological parameters for further verification. In addition, the relationship between characterized lncRNAs and tumor immune infiltration and methylation was also discussed.

Results

We identified 29 characterized lncRNAs to produce prognostic risk models. Kaplan-Meier analysis revealed the high-risk group was associated with poor prognosis in LUSC (P<0.001), and ROC (AUC =0.658) and DCA suggested that risk models could predict prognosis. Univariate and multifactorial Cox as well as nomogram further validated the prognostic model (P<0.001). Gene set enrichment analysis (GSEA) showed that the high-risk group was associated with pro-tumor pathways and high-frequency mutations in TP53 were present in both groups. Single sample gene set enrichment analysis (ssGSEA) showed significant differences in immune cell infiltration subtypes and corresponding functions between the two groups. Some immune checkpoint and methylation-related genes were significantly different between the two groups (P<0.05).

Conclusions

We investigated the potential mechanisms of LUSC development from the perspective of ferroptosis-related lncRNAs, providing new insights into LUSC research, and identified 29 lncRNAs as biomarkers to predict the prognosis of LUSC patients.

Using the Systemic Immune-Inflammation Index (SII) as a Mid-Treatment Marker for Survival among Patients with Stage-III Locally Advanced Non-Small Cell Lung Cancer (NSCLC)

The Systemic Immune-Inflammation Index (SII) is an important marker of immune function, defined as the product of neutrophil-to-lymphocyte ratio (NLR) and platelet count (P). Higher baseline SII levels have been associated with improved survival in various types of cancers, including lung cancer. Data were obtained from PROCLAIM, a randomized phase III trial comparing two different chemotherapy regimens pemetrexed + cisplatin (PEM) vs. etoposide + cisplatin (ETO), in combination with radiotherapy (RT) for the treatment of stage III non-squamous non-small cell lung cancer (NSCLC). We aimed to determine if SII measured at the mid-treatment window for RT (weeks 3-4) is a significant predictor of survival, and if the effect of PEM vs. ETO differs by quartile (Q) level of SII. Hazard-ratios (HR) for survival were estimated using a proportional hazards model, accounting for the underlying correlated structure of the data. A total of 548 patients were included in our analysis. The median age at baseline was 59 years. Patients were followed for a median of 24 months. Adjusting for age, body mass index, sex, race, and chemotherapy regimen, SII was a significant mid-treatment predictor of both overall (adjusted HR (aHR) = 1.6, p < 0.0001; OS) and progression-free (aHR = 1.3, p = 0.0072; PFS) survival. Among patients with mid-RT SII values above the median (6.8), those receiving PEM (vs. ETO) had superior OS (p = 0.0002) and PFS (p = 0.0002). Our secondary analysis suggests that SII is an informative mid-treatment marker of OS and PFS in locally advanced non-squamous NSCLC.

The Prevention and Management of COVID-19: Seeking a Practical and Timely Solution

We read with interest several manuscripts recently published in the International Journal of Environmental Research and Public Health (IJERPH) on the ongoing coronavirus pandemic. While these articles provide a well-rounded overview on the risk and current status of this virus, we herein add some relevant information on its etiology, prevention and management, especially for resource-limited healthcare systems. The use of protective actions is both complex and expensive. Affordable options are essential to respond to this and future viral outbreaks.

Transitioning of older Australian women into and through the long-term care system: a cohort study using linked data

Background

Over two-thirds of older Australians use different types/levels of aged care at some point in later life. Our aims were to estimate transitional probabilities and to identify risk factors influencing the movement between different levels of long-term care.

Methods

The sample consisted of 9007 women from the 1921-26 birth cohort of the Australian Longitudinal Study on Women’s Health. Transitional probabilities between different levels of long-term care were estimated using a continuous-time Markov model.

Results

An 11-fold transition rates ratio was observed for the movement from non-user to home and community care (HACC) versus non-user to residential aged care (RAC). The predicted probabilities of remaining in the non-user state, HACC, and RAC after 10 years from the baseline were .28, .24, and .11, respectively. While the corresponding probabilities of dying from these states were .36, .65, and .90. The risk of transitioning from the non-user state to either HACC or RAC was greater for participants who were older at baseline, widowed, living outside of major cities, having difficulties in managing income, or having chronic condition, poor/fair self-rated health, or lower SF-36 scores (p < .05).

Conclusion

Women spend a substantial period of their later life using long-term care. Typically, this will be in the community setting with a low level of care. The transition to either HACC or RAC was associated with several demographic and health-related factors. Our findings are important for the planning and improvement of long-term care among future generations of older people.

Trial registration

Not applicable.

Patterns of home and community care use among older participants in the Australian Longitudinal Study of Women's Health

The aims of this study were to investigate patterns of home and community care (HACC) use and to identify factors influencing first HACC use among older Australian women. Our analysis included 11,133 participants from the Australian Longitudinal Study of Women's Health (1921-1926 birth cohort) linked with HACC use and mortality data from 2001 to 2011. Patterns of HACC use were analysed using a k-median cluster approach. A multivariable competing risk analysis was used to estimate the risk of first HACC use. Approximately 54% of clients used a minimum volume and number of HACC services; 25% belonged to three complex care use clusters (referring to higher volume and number of services), while the remainder were intermediate users. The initiation of HACC use was significantly associated with (1) living in remote/inner/regional areas, (2) being widowed or divorced, (3) having difficulty in managing income, (4) not receiving Veterans' Affairs benefits, (5) having chronic conditions, (6) reporting lower scores on the SF-36 health-related quality of life, and (7) poor/fair self-rated health. Our findings highlight the importance of providing a range of services to meet the diverse care needs of older women, especially in the community setting.

A simple matrix to predict treatment success and long-term survival among patients undergoing pancreatectomy

BACKGROUND

A more accurate measure of long-term survival among patients who have undergone a successful resection for pancreatic adenocarcinoma may be computed by accounting for time already survived during the initial treatment window.

METHODS

Patients diagnosed with pancreatic adenocarcinoma, from 2004 through 2013, were identified from the American College of Surgeons National Cancer Database (NCDB). A risk-stratification matrix was constructed including age, histopathologic factors and the use of adjuvant therapy, given successful treatment and survival at 3-month following diagnosis.

RESULTS

A total of 25,897 patients (50% male, 53% >65 years of age) presented with stage I-III pancreatic cancer. The majority of patients had tumors >2 cm size (82%), grade I/II (65%), lymphatic invasion (LI) (66%), and negative margins (76%). A survival advantage for adjuvant therapy was observed among all patients, independent of their risk-profile. For example, a patient ≤65 years of age, with early stage cancer (size ≤2 cm, grade I/II, -ve LI, -ve margins) who received adjuvant therapy had a 62% probability of being alive beyond three years (95%CI = 59%-66%). In contrast, the survival probability decreased to 53% (95%CI = 59%-66%) without adjuvant therapy.

CONCLUSIONS

These results provide surgeons and patients with more accurate information regarding long-term survival, as well as the benefit of opting for adjuvant therapy after successful pancreatic surgery.

Mitral annular calcification progression and the risk of atrial fibrillation: results from MESA

Aims

To determine if progression of mitral annular calcium (MAC) detected by cardiac computed tomography (CT) predicts incident atrial fibrillation (AF).

Methods and results

This analysis included 5683 participants (mean age 64 ± 10 years; 52% women; 40% whites; 27% blacks; 21% Hispanics; 12% Chinese-Americans) from the Multi-Ethnic Study of Atherosclerosis. MAC was measured by cardiac CT at baseline and at a follow-up CT scan over a mean time of 2.4 ± 0.84 years. AF was ascertained by review of hospital discharge records and from Medicare claims data through 31 December 2012. Cox regression was used to compute hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between MAC progression and AF. Over a median follow-up of 8.6 years, a total of 533 (9.4%) incident AF cases were detected. In a model adjusted for age, sex, race/ethnicity, education, income, baseline MAC, systolic blood pressure, body mass index, diabetes, smoking, total cholesterol, high-density lipoprotein cholesterol, antihypertensive medications, lipid-lowering therapies, and aspirin, any MAC progression (>0/year) was associated with an increased risk for AF (HR = 1.50, 95% CI = 1.20-1.87). Multiplicative interactions were not significant between MAC progression and AF by age (<65 year vs. older), sex, or race/ethnicity (whites vs. non-whites).

Conclusion

Important prognostic information regarding AF risk is obtained with follow-up MAC measurement, as the risk for participants with any MAC progression was substantively greater than participants without progression. MAC progression may detect underlying left atrial abnormalities that predispose to AF.

Patterns of aged care use among older Australian women: A prospective cohort study using linked data

BACKGROUND

Women live longer than men and have an increased need for long-term care. The objective of this study was to identify patterns of aged care use among older Australian women and to examine how these patterns were associated with their demographic and health-related characteristics.

METHODS

The sample consisted of 8768 women from the 1921-1926 birth cohort of the Australian Longitudinal Study on Women's Health (ALSWH), who had survived to age 75-80 years. ALSWH survey and linked administrative aged care and death datasets from 2001 to 2011 were utilized. Patterns of aged care use were identified using a repeated measure latent class analysis.

RESULTS

We identified four patterns of aged care use over time, differentiated by timing of service onset, types of service use and time of death. Approximately 41% of the sample were non-users or using basic home and community care (HACC), while 24% were at high risk of using moderate to high-level HACC/community aged care package (CACP). Only 11% had a greater risk of using residential aged care (RAC) over time. Being widowed, residing in remote/regional areas, having difficulty in managing income, having a chronic condition, reporting poor/fair self-rated health, and lower SF-36 quality of life scores were associated with an increased odds of being a member of the following classes: 1) moderate to high-level HACC/CACP, 2) increasing RAC, and 3) early mortality, compared with the non-user class.

CONCLUSIONS

Distinct patterns of aged care use were identified. These results will facilitate future capacity planning for aged care systems in Australia.

Knowledge Management for Fostering Biostatistical Collaboration within a Research Network: The RTRN Case Study

Purpose: While the intellectual and scientific rationale for research collaboration has been articulated, a paucity of information is available on a strategic approach to facilitate the collaboration within a research network designed to reduce health disparities. This study aimed to (1) develop a conceptual model to facilitate collaboration among biostatisticians in a research network; (2) describe collaborative engagement performed by the Network’s Data Coordinating Center (DCC); and (3) discuss potential challenges and opportunities in engaging the collaboration. Methods: Key components of the strategic approach will be developed through a systematic literature review. The Network’s initiatives for the biostatistical collaboration will be described in the areas of infrastructure, expertise and knowledge management and experiential lessons will be discussed. Results: Components of the strategic approach model included three Ps (people, processes and programs) which were integrated into expert management, infrastructure management and knowledge management, respectively. Ongoing initiatives for collaboration with non-DCC biostatisticians included both web-based and face-to-face interaction approaches: Network’s biostatistical capacities and needs assessment, webinar statistical seminars, mobile statistical workshop and clinics, adjunct appointment program, one-on-one consulting, and on-site workshop. The outreach program, as a face-to-face interaction approach, especially resulted in a useful tool for expertise management and needs assessment as well as knowledge exchange. Conclusions: Although fostering a partnered research culture, sustaining senior management commitment and ongoing monitoring are a challenge for this collaborative engagement, the proposed strategies centrally performed by the DCC may be useful in accelerating the pace and enhancing the quality of the scientific outcomes within a multidisciplinary clinical and translational research network.

The Association between Age, Comorbidities and Use of Radiotherapy in Women with Breast Cancer: Implications for Survival

Background: Radiotherapy (RT) plays an important role in the management and survival of patients with breast cancer. The aim of this study was to examine the association between age, comorbidities and use of RT in this population. Methods: Patients diagnosed with breast cancer from 2004⁻2013 were identified from the American College of Surgeons National Cancer Database (NCDB). Follow-up time was measured from the date of diagnosis (baseline) to the date of death or censoring. Adjusted hazard ratios (aHR) and 95% confidence intervals (95% CI) were used as the measure of association. Results: Independently of comorbidities and other important outcome-related factors, patients >65 years of age who received RT survived significantly longer than those who did not receive RT (aHR = 0.53, 95% CI = 0.52⁻0.54). However, as women aged, those with comorbidities were less likely to receive RT (adjusted p-trend by age < 0.0001). Conclusions: The development of decision-making tools to assist clinicians, and older women with breast cancer and comorbidities, are needed to facilitate personalized treatment plans regarding RT. This is particularly relevant as the population ages and the number of women with breast cancer is expected to increase in the near future.

Increased risk of atrial fibrillation among patients undergoing coronary artery bypass graft surgery while receiving nitrates and antiplatelet agents

Background

Postoperative atrial fibrillation (POAF) is a frequent complication of coronary artery bypass graft (CABG) surgery. This arrhythmia occurs more frequently among patients who receive perioperative inotropic therapy (PINOT). Administration of nitrates with antiplatelet agents reduces the conversion rate of cyclic guanosine monophosphate to guanosine monophosphate. This process is associated with increased concentrations of free radicals, catecholamines, and blood plasma volume. We hypothesized that patients undergoing CABG surgery who receive PINOT may be more susceptible to POAF when nitrates are administered with antiplatelet agents.

Methods

Clinical records were examined from a prospectively maintained cohort of 4,124 patients undergoing primary isolated CABG surgery to identify POAF-associated factors.

Results

POAF risk was increased among patients receiving PINOT, and the greatest effect was observed when nitrates were administered with antiplatelet therapy. Adjustment for comorbidities did not substantively change the study results.

Conclusions

Administration of nitrates with certain antiplatelet agents was associated with an increased POAF risk among patients undergoing CABG surgery. Additional studies are needed to determine whether preventive strategies such as administration of antioxidants will reduce this risk.

Refugee Policy Implications of U.S. Immigration Medical Screenings: A New Era of Inadmissibility on Health-Related Grounds

Refugees frequently face extended delays in their efforts to enter the United States (U.S.) and those who are successful, in many cases, encounter overwhelming obstacles, inadequate resources, and a complex system of legal barriers. Travel restrictions based on equivocal health concerns and a drop in refugee admittance ceilings have complicated the situation. The authors retrieved and analyzed peer-reviewed journal articles, government agency press releases, media postings, epidemiologic factsheets, and relevant lay publications to critically assess U.S. policy regarding refugee resettlement based on health-related grounds. While refugees arguably exhibit an increased incidence of measles and tuberculosis compared with the U.S. population, the legitimacy of the medical examination will be undermined if other diseases that are endemic to refugee populations, yet currently deemed admissible, are used to restrict refugees from entering the U.S. This paper addressees the historic refugee policy of the U.S. and its consequent effect on the health of this vulnerable population. The needs of refugees should be carefully considered in the context of increased disease burden and the associated health care challenges of the country as a whole.

Trauma Affecting Asian-Pacific Islanders in the San Francisco Bay Area

Trauma is a transgenerational process that overwhelms the community and the ability of family members to cope with life stressors. An anthropologist trained in ethnographic methods observed three focus groups from a non-profit agency providing trauma and mental health services to Asian Americans living in the San Francisco Bay Area of United States. Supplemental information also was collected from staff interviews and notes. Many of the clients were immigrants, refugees, or adult children of these groups. This report consisted of authentic observations and rich qualitative information to characterize the impact of trauma on refugees and immigrants. Observations suggest that collective trauma, direct or indirect, can impede the success and survivability of a population, even after many generations.

Trapped in Statelessness: Rohingya Refugees in Bangladesh

The Rohingya people are one of the most ill-treated and persecuted refugee groups in the world, having lived in a realm of statelessness for over six generations, and who are still doing so. In recent years, more than 500,000 Rohingyas fled from Myanmar (Burma) to neighboring countries. This article addresses the Rohingya refugee crisis in Bangladesh, with special emphasis on the living conditions of this vulnerable population. We reviewed several documents on Rohingya refugees, visited a registered refugee camp (Teknaf), collected case reports, and conducted a series of meetings with stakeholders in the Cox’s Bazar district of Bangladesh. A total of 33,131 registered Rohingya refugees are living in two registered camps in Cox’s Bazar, and up to 80,000 additional refugees are housed in nearby makeshift camps. Overall, the living conditions of Rohingya refugees inside the overcrowded camps remain dismal. Mental health is poor, proper hygiene conditions are lacking, malnutrition is endemic, and physical/sexual abuse is high. A concerted diplomatic effort involving Bangladesh and Myanmar, and international mediators such as the Organization of Islamic Countries and the United Nations, is urgently required to effectively address this complex situation.

Prognostic potential of neutrophil-to-lymphocyte ratio and lymphocyte nadir in stage III non-small-cell lung cancer

AIM

Studies have shown increased pretreatment neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios to be predictive of survival in various cancers. Our aim was to evaluate the prognostic role of such inflammatory markers in non-small-cell lung cancer (NSCLC).

METHODS

One hundred and sixty-three patients with stage III NSCLC who received definitive treatment were included. Survival analysis was performed using Kaplan-Meier method. Hazard ratios for overall and recurrence-free survival were estimated using Cox proportional hazards model.

RESULTS

Both neutrophil-to-lymphocyte >Q75 (4.5) and lymphocyte nadir values <Q25 (0.25) and their unified values were associated with 90% increased overall mortality risk (p = 0.040) and a nonsignificant 50% decreased recurrence-free survival risk.

CONCLUSION

Our exploratory analysis showed markers of systemic inflammation predicted survival outcomes in advanced NSCLC. Future prospective data analyses are needed to confirm this potential.