Racial and Ethnic Inequities in Cancer Care Continuity During the COVID-19 Pandemic Among Those With SARS-CoV-2

Importance

Racially and ethnically minoritized US adults were disproportionately impacted by the COVID-19 pandemic and experience poorer cancer outcomes, including inequities in cancer treatment delivery.

Objective

To evaluate racial and ethnic disparities in cancer treatment delays and discontinuations (TDDs) among patients with cancer and SARS-CoV-2 during different waves of the COVID-19 pandemic in the United States.

Design, Setting, and Participants

This cross-sectional study used data from the American Society of Clinical Oncology Survey on COVID-19 in Oncology Registry (data collected from April 2020 to September 2022), including patients with cancer also diagnosed with SARS-CoV-2 during their care at 69 US practices. Racial and ethnic differences were examined during 5 different waves of the COVID-19 pandemic in the United States based on case surge (before July 2020, July to November 2020, December 2020 to March 2021, April 2021 to February 2022, and March to September 2022).

Exposures

Race and ethnicity.

Main Outcomes and Measures

TDD was defined as any cancer treatment postponed more than 2 weeks or cancelled with no plans to reschedule. To evaluate TDD associations with race and ethnicity, adjusted prevalence ratios (aPRs) were estimated using multivariable Poisson regression, accounting for nonindependence of patients within clinics, adjusting for age, sex, body mass index, comorbidities, cancer type, cancer extent, and SARS-CoV-2 severity (severe defined as death, hospitalization, intensive care unit admission, or mechanical ventilation).

Results

A total of 4054 patients with cancer and SARS-CoV-2 were included (143 [3.5%] American Indian or Alaska Native, 176 [4.3%] Asian, 517 [12.8%] Black or African American, 469 [11.6%] Hispanic or Latinx, and 2747 [67.8%] White; 2403 [59.3%] female; 1419 [35.1%] aged 50-64 years; 1928 [47.7%] aged ≥65 years). The analysis focused on patients scheduled (at SARS-CoV-2 diagnosis) to receive drug-based therapy (3682 [90.8%]), radiation therapy (382 [9.4%]), surgery (218 [5.4%]), or transplant (30 [0.7%]), of whom 1853 (45.7%) experienced TDD. Throughout the pandemic, differences in racial and ethnic inequities based on case surge with overall TDD decreased over time. In multivariable analyses, non-Hispanic Black (third wave: aPR, 1.56; 95% CI, 1.31-1.85) and Hispanic or Latinx (third wave: aPR, 1.35; 95% CI, 1.13-1.62) patients with cancer were more likely to experience TDD compared with non-Hispanic White patients during the first year of the pandemic. By 2022, non-Hispanic Asian patients (aPR, 1.51; 95% CI, 1.08-2.12) were more likely to experience TDD compared with non-Hispanic White patients, and non-Hispanic American Indian or Alaska Native patients were less likely (aPR, 0.37; 95% CI, 0.16-0.89).

Conclusions and Relevance

In this cross-sectional study of patients with cancer and SARS-CoV-2, racial and ethnic inequities existed in TDD throughout the pandemic; however, the disproportionate burden among racially and ethnically minoritized patients with cancer varied across SARS-CoV-2 waves. These inequities may lead to downstream adverse impacts on cancer mortality among minoritized adults in the United States.

Support Through Remote Observation and Nutrition Guidance (STRONG), a digital health intervention to reduce malnutrition among pancreatic cancer patients: A study protocol for a pilot randomized controlled trial

Background

Malnutrition is a common and distressing condition among pancreatic cancer patients. Fewer than a quarter of pancreatic cancer patients receive medical nutrition therapy (MNT), important for improving nutritional status, weight maintenance, quality of life and survival. System, provider, and patient level barriers limit access to MNT. We propose to examine the feasibility of a 12-week multi-level, digital health intervention designed to expand MNT access among pancreatic cancer patients.

Methods

Individuals with advanced pancreatic cancer starting chemotherapy (N = 80) will be 1:1 randomized to the intervention or usual care. The Support Through Remote Observation and Nutrition Guidance (STRONG) intervention includes system-level (e.g., routine malnutrition and screening), provider-level (e.g., dietitian training and web-based dashboard), and patient-level strategies (e.g., individualized nutrition plan, self-monitoring of dietary intake via Fitbit, ongoing goal monitoring and feedback). Individuals receiving usual care will be referred to dietitians based on their oncologists' discretion. Study assessments will be completed at baseline, 4-, 8-, 12-, and 16-weeks.

Results

Primary outcomes will be feasibility (e.g., recruitment, retention, assessment completion) and acceptability. We will collect additional implementation outcomes, such as intervention adherence, perceived usability, and feedback on intervention quality via an exit interview. We will collect preliminary data on outcomes that may be associated with the intervention including malnutrition, quality of life, treatment outcomes, and survival.

Conclusion

This study will advance our knowledge on the feasibility of a digital health intervention to reduce malnutrition among individuals with advanced pancreatic cancer. Trial registration: NCT05675059, registered on December 9, 2022.

Social and Demographic Influences of Trust in Cancer Information Among Brooklyn, New York Residents

Little is known regarding the patterns of trust sources for cancer information among diverse populations in the US, which is particularly poignant during the current era of misinformation. Our objective to assess trust from different sources among a sample of Brooklyn, New York residents. Using data from the NCI funded Brooklyn Cancer Health Impact Program, we examined HINTS validated questions examining trust in cancer information across 9 sources. Logistic regression models were used to examine associations with cancer information trust sources. For trust in government health agencies, participants who had less than a college degree were almost 30% less likely to report high levels of trust (aOR: 0.71; 95% CI: 0.52-0.98), participants who reported a household income under $50,000 were 35% less likely report high levels of trust (aOR: 0.65; 95% CI: 0.47-0.89). Participants whose primary language was Spanish were significantly less likely to trust government (aOR: 0.45; 95% CI: 0.29-0.70), newspapers and magazines (aOR: 0.54; 95% CI, 0.34-0.84), and charitable organizations (aOR: 0.48; 95% CI, 0.31-0.75) compared to participants whose primary was English. New York is the most populous city in the US, a city of immigrants, and it is important for healthcare and public health professionals to explore how they can utilize media to provide accurate scientific evidence to combat cancer misinformation.

Optimizing presurgical education for patients with head and neck cancer receiving laryngectomy and free flap surgery: A qualitative study

BACKGROUND

There has been limited study of oncology professionals' perspectives on optimizing delivery of presurgical education for individuals with head and neck cancer (HNC). Therefore, we assessed oncology professionals' perspectives about presurgical education for laryngectomy and free flap surgeries, which have a significant impact on patients' quality of life.

METHODS

Interviews were conducted with 27 oncology professionals from an NCI-designated Comprehensive Cancer Center and a community oncology setting.

RESULTS

Participants identified six recommendations to improve presurgical education: (1) establishing preoperative consultations with allied health professionals; (2) educating patients and providers on the concept of team-based care; (3) optimizing education through multimodal strategies; (4) connecting patients with other HNC surgical patients; (5) preparing caregivers for their role; and (6) educating patients on insurance navigation.

CONCLUSIONS

Study findings demonstrate gaps in the timing, content, and mode of delivery for presurgical education and suggest strategies for further evaluation in future studies.

Breast density analysis of digital breast tomosynthesis

Mammography shifted to digital breast tomosynthesis (DBT) in the US. An automated percentage of breast density (PD) technique designed for two-dimensional (2D) applications was evaluated with DBT using several breast cancer risk prediction measures: normalized-volumetric; dense volume; applied to the volume slices and averaged (slice-mean); and applied to synthetic 2D images. Volumetric measures were derived theoretically. PD was modeled as a function of compressed breast thickness (CBT). The mean and standard deviation of the pixel values were investigated. A matched case-control (CC) study (n = 426 pairs) was evaluated. Odd ratios (ORs) were estimated with 95% confidence intervals. ORs were significant for PD: identical for volumetric and slice-mean measures [OR = 1.43 (1.18, 1.72)] and [OR = 1.44 (1.18, 1.75)] for synthetic images. A 2nd degree polynomial (concave-down) was used to model PD as a function of CBT: location of the maximum PD value was similar across CCs, occurring at 0.41 × CBT, and PD was significant [OR = 1.47 (1.21, 1.78)]. The means from the volume and synthetic images were also significant [ORs ~ 1.31 (1.09, 1.57)]. An alternative standardized 2D synthetic image was constructed, where each pixel value represents the percentage of breast density above its location. Several measures were significant and an alternative method for constructing a standardized 2D synthetic image was produced.

Financial toxicity among head and neck cancer patients and their caregivers: A cross‐sectional pilot study

Objectives

Head and neck cancer (HNC) patients experience greater financial toxicity than other cancer patients. Research on financial toxicity has concentrated on patients despite many informal caregivers sharing finances and reducing work hours to provide patient care. Thus, our pilot study: (1) assessed the feasibility of financial toxicity screening of HNC patients and their caregivers, and (2) described financial toxicity levels of HNC patients and their caregivers.

Methods

We surveyed English-speaking adult HNC patients initiating treatment at a National Cancer Institute-designated Comprehensive Cancer Center and their informal caregivers. This survey assessed demographics and financial toxicity through the Comprehensive Score for Financial Toxicity (COST) measure (0-44 range; lower score indicates higher financial toxicity). Screening feasibility was defined as ≥50% consent rate and ≥60% data completion rate.

Results

Our sample included 27 HNC patients and 9 caregivers. They both had slightly lower consent and completion rates than our goals. Patients reported a median COST score of 27 while caregivers reported a median COST score of 16. Approximately 25.9% of patients and 44.4% of caregivers reported high financial toxicity (COST < 17.5). Caregivers reported high concerns about their future financial health and their ability to control the amount of their financial contributions to the patient's care.

Conclusions

Patients and caregivers may require additional outreach approaches beyond emailed questionnaires to screen for their financial toxicity systematically. Future research is needed to replicate our results to determine whether differences in financial toxicity occur between patients and caregivers and identify areas of focus for interventions.

Level of evidence

IV.

Breast Density Analysis Using Digital Breast Tomosynthesis

We evaluated an automated percentage of breast density (BD) technique (PDa) with digital breast tomosynthesis (DBT) data. The approach is based on the wavelet expansion followed by analyzing signal dependent noise. Several measures were investigated as risk factors: normalized volumetric; total dense volume; average of the DBT slices (slice-mean); a two-dimensional (2D) metric applied to the synthetic images; and the mean and standard deviations of the pixel values. Volumetric measures were derived theoretically, and PDa was modeled as a function of compressed breast thickness. An alternative method for constructing synthetic 2D mammograms was investigated using the volume results. A matched case-control study (n = 426 pairs) was analyzed. Conditional logistic regression modeling, controlling body mass index and ethnicity, was used to estimate odds ratios (ORs) for each measure with 95% confidence intervals provided parenthetically. There were several significant findings: volumetric measure [OR = 1.43 (1.18, 1.72)], which produced an identical OR as the slice-mean measure as predicted; [OR =1.44 (1.18, 1.75)] when applied to the synthetic images; and mean of the pixel values (volume or 2D synthetic) [ORs ~ 1.31 (1.09, 1.57)]. PDa was modeled as 2nd degree polynomial (concave-down): its maximum value occurred at 0.41×(compressed breast thickness), which was similar across case-control groups, and was significant from this position [OR = 1.47 (1.21, 1.78)]. A standardized 2D synthetic image was produced, where each pixel value represents the percentage of BD above its location. The significant findings indicate the validity of the technique. Derivations supported by empirical analyses produced a new synthetic 2D standardized image technique. Ancillary to the objectives, the results provide evidence for understanding the percentage of BD measure applied to 2D mammograms. Notwithstanding the findings, the study design provides a template for investigating other measures such as texture.

Oncology Providers' and Professionals' Experiences With Suicide Risk Screening Among Patients With Head and Neck Cancer: A Qualitative Study

PURPOSE

There has been limited study of the implementation of suicide risk screening for patients with head and neck cancer (HNC) as a part of routine care. To address this gap, this study assessed oncology providers' and professionals' perspectives about barriers and facilitators of implementing a suicide risk screening among patients with HNC.

MATERIALS AND METHODS

All patients with HNC with an in-person visit completed a suicide risk screening on an electronic tablet. Patients reporting passive death wish were then screened for active suicidal ideation and referred for appropriate intervention. Interviews were conducted with 25 oncology providers and professionals who played a key role in implementation including nurses, medical assistants, patient access representatives, advanced practice providers, physicians, social workers, and informatics staff. The interview guide was based on the Consolidated Framework for Implementation Research. Interviews were transcribed and analyzed for themes.

RESULTS

Participants identified multilevel implementation barriers, such as intervention level (eg, patient difficulty with using a tablet), process level (eg, limited nursing engagement), organizational level (eg, limited clinic Wi-Fi connectivity), and individual level (eg, low clinician self-efficacy for interpreting and acting upon patient-reported outcome scores). Participants noted facilitators, such as effective care coordination across nursing and social work staff and the opportunity for patients to be screened multiple times. Participants recommended strengthening patient and clinician education and providing patients with other modalities for data entry (eg, desktop computer in the waiting room).

CONCLUSION

Participants identified important intervention modifications that may be needed to optimize suicide risk screening in cancer care settings.

Health insurance literacy among head and neck cancer patients and their caregivers: A cross-sectional pilot study

Objective

Health insurance literacy interventions may reduce financial burden and its effects on cancer patients and their caregivers. However, little is known about the health insurance literacy levels of head and neck cancer (HNC) patients and their caregivers. We assessed the feasibility of screening for health insurance literacy in a pilot study and described the health insurance literacy levels of HNC patients and their caregivers.

Methods

We administered a survey that assessed demographics and subjective and objective health insurance literacy to HNC patients and their caregivers. Subjective health insurance literacy was measured through the Health Insurance Literacy Measure (score range: 0-84). Objective health insurance literacy was measured through correct answers to a previously developed 10-question knowledge test. Due to a small sample size, inferential statistics were not used; we instead descriptively reported findings.

Results

The pilot included 48 HNC patients and 13 caregivers. About 44.4% of patients and 30.8% of caregivers demonstrated low health insurance literacy (HILM ≤60). On the 10-item knowledge test, patients had an average of 6.8 (SD: 2.3) correct responses and caregivers had 7.8 (SD: 1.1) correct responses. Calculating out-of-pocket costs for out-of-network services was challenging; only 9.5% of patients and 0% of caregivers answered correctly.

Conclusion

Additional outreach strategies may be needed to supplement screening for health insurance literacy. Areas of focus for interventions include improving understanding of how to calculate financial responsibility for health care services and filing an appeal for health insurance claim denial.

Level of Evidence

IV.

Implementing suicide risk screening as a part of routine cancer care

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Background: Head and neck cancer (HNC) patients are at increased risk for suicide. Few studies have tested approaches to preventing suicide in this population, such as routine suicide risk screening. To address this issue, the current study pilots and assesses the feasibility and implementation of a suicide risk screening program for HNC patients at a National Cancer Institute (NCI)-designated Comprehensive Cancer Center. Methods: Routine screening was implemented at all in-person visits in the HNC clinic from February 1, 2021 – January 31, 2022 using the PHQ-9. Patients with passive suicidal ideation were consequently screened by social work for active suicidal ideation. Results: Most (92.6% or 1519/1641) HNC patients with a scheduled in-person visit completed at least one suicide risk screening; 9,968 screenings were completed (mean: 3.7; SD: 3.8 per patient) in total. Among patients who were screened, 3% (49/1519) of HNC patients reported passive suicidal ideation and 0.3% (5/1519) were identified as having active suicidal ideation. Patients with five or more visits were more likely to participate in screening compared with patients who only had one visit during the study period (100% vs. 82.7%; P <.0001). Other patient factors, such as race/ethnicity and socioeconomic status, were not associated with screening participation. Conclusions: Findings suggest suicide screening was feasible and effective at identifying patients at an increased risk for suicide. Longitudinal studies are needed to evaluate the impact of suicide screening on suicide prevention and further research is required to scale up suicide screening to reach additional cancer patients.

Abstract 3585: Disparities in cancer treatment delays or discontinuation among cancer patients diagnosed with SARS-CoV-2 infection: An analysis of the U.S. ASCO COVID-19 and cancer registry

Background: Due to societal factors in the US, racial/ethnic minority adults are disproportionately impacted by the COVID-19 pandemic, particularly those with existing comorbid conditions such as cancer. It is currently unknown whether disparities exist in cancer treatment delivery among racial/ethnic minority patients with cancer and SARS-CoV-2.

Methods: Data were obtained from the ASCO COVID-19 and Cancer Registry (March 2020-July 2021), including data from cancer patients diagnosed with SARS-CoV-2 during their care (n=3193) at 60 practices across the US. Data included patient demographics, SARS-CoV-2 diagnosis and treatment, cancer clinical characteristics, and modifications to cancer treatment plans. Cancer treatment delay or discontinuation (TDD) was defined as any treatment postponed more than two weeks from the original scheduled date. We descriptively evaluated demographic and clinical characteristics, compared disparities in TDD by race/ethnicity and urban/rural residency, and evaluated reasons for TDD as reported by the clinics. We computed adjusted odds ratios (aOR) using multivariable logistic regression, accounting for non-independence of patients within hospitals to evaluate racial/ethnic disparities of TDD. Multivariable models were adjusted for age, sex, body mass index, number of comorbidities, cancer type, cancer extent, cancer status at SARS-CoV-2 diagnosis (progressing/stable) and SARS-CoV-2 severity (death/hospitalization/ICU admission/mechanical ventilation).

Results: Cancer patients with SARS-CoV-2were mostly female (57%), urban residents (84%), and NH-White (66%); 49% were 65+ years old. Most patients had solid tumors (75%). At SARS-CoV-2 diagnosis, 2403 patients (76%) were scheduled to receive drug-based therapy (69%), radiation therapy (7%), surgery (4%), or transplant (0.7%), of whom 49% experienced TDD. The most reported TDD reason from the clinic perspective was the patient’s COVID-19 disease (90%). Overall, NH-Black (64%) and Hispanic (57%) with SARS-CoV-2 were more likely to experience TDD versus NH-White adults (46%) (p&lt;0.001). This disparity was also observed across urban residing adults (p&lt;0.001). Among rural adults, NH-AI/AN (75%) and NH-Black (61%) were more likely to experience TDD versus NH-White patients (39%). In multivariable analyses, disparities persisted, by NH-Black cancer patients with 92% (aOR:1.92, 95% CI:1.24-2.96) and Hispanic patients with 41% (aOR:1.41, 95% CI:1.03-1.91) higher odds of experiencing TDD. We observed consistent results among urban and rural subgroups.

Conclusion: Racial/ethnic disparities exist in TDD among cancer patients with SARS-CoV-2 in urban and rural care settings. Future studies should evaluate the impacts of delays to cancer treatment delivery on cancer outcomes among minoritized communities in the US.

Citation Format: Jessica Yasmine Islam, Cassandra A. Hathaway, Emma Hume, Kea Turner, Julie Hallanger-Johnson, Shelley S. Tworoger, Marlene Camacho-Rivera. Disparities in cancer treatment delays or discontinuation among cancer patients diagnosed with SARS-CoV-2 infection: An analysis of the U.S. ASCO COVID-19 and cancer registry [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 3585.

Cancer Screening Among Rural and Urban Clinics During COVID-19: A Multistate Qualitative Study

PURPOSE

The effects of COVID-19 have been understudied in rural areas. This study sought to (1) identify cancer screening barriers and facilitators during the pandemic in rural and urban primary care practices, (2) describe implementation strategies to support cancer screening, and (3) provide recommendations.

METHODS

A qualitative study was conducted (N = 42) with primary care staff across 20 sites. Individual interviews were conducted through videoconference from August 2020 to April 2021 and recorded, transcribed, and analyzed using deductive and inductive coding (hybrid approach) in NVivo 12 Plus. Practices included federally qualified health centers, tribal health centers, rural health clinics, hospital/health system-owned clinics, and academic medical centers across 10 states including urban (55%) and rural (45%) sites. Staff included individuals serving in the dual role of health care provider and administrator (21.4%), health care administrator (23.8%), physician (19.0%), advanced practice provider (11.9%), or resident (23.8%). The interviews assessed perceptions about cancer screening barriers and facilitators, implementation strategies, and future recommendations.

RESULTS

Participants reported multilevel barriers to cancer screening including policy-level (eg, elective procedure delays), organizational (eg, backlogs), and individual (eg, patient cancellation). Several facilitators to screening were noted, such as home-based testing, using telehealth, and strong partnerships with referral sites. Practices used strategies to encourage screening, such as incentivizing patients and providers and expanding outreach. Rural clinics reported challenges with backlogs, staffing, telehealth implementation, and patient outreach.

CONCLUSION

Primary care staff used innovative strategies during the pandemic to promote cancer screening. Unresolved challenges (eg, backlogs and inability to implement telehealth) disproportionately affected rural clinics.

Racial/ethnic disparities of cancer treatment disruptions among patients with breast cancer with SARS-CoV-2 infection: An analysis of the ASCO Survey on COVID-19 in Oncology Registry

6556

Background: The COVID-19 pandemic has led to disruptions in cancer treatment delivery among breast cancer patients in the U.S. However, it is currently unknown whether racial/ethnic disparities exist in cancer treatment disruptions among patients with breast cancer and SARS-CoV-2 infection. Methods: We obtained data from the ASCO Survey on COVID-19 in Oncology Registry (March 2020-July 2021) describing breast cancer patients diagnosed with SARS-CoV-2 during their care treated at 46 practices across the US. Data included patient demographics, SARS-CoV-2 diagnosis and treatment, breast cancer characteristics, and modifications to cancer treatment plans. Breast cancer treatment delay or discontinuation (TDD) was defined as any treatment postponed more than two weeks from the originally scheduled date. We computed adjusted odds ratios (aOR) using multivariable logistic regression, accounting for non-independence of patients within hospitals to evaluate racial/ethnic disparities of TDD. Multivariable models were adjusted for age, sex, number of comorbidities, cancer extent, ECOG performance score, pandemic period based on case peaks ( < 06/2020, 06-12/2020, 01-07/2021), and COVID-19 severity (death/hospitalization/ICU admission/mechanical ventilation). Results: Breast cancer patients (n = 804) with SARS-CoV-2 were mostly aged 50 years and above (75%) and urban residents (83%). The racial/ethnic makeup of the sample included: 13.3% non-Hispanic Black/African American (NH-Black), 11.7% Hispanic/Latinx, 4.9% American Indian/Alaskan Native (NH-AI/AN), 4.6% NH-Asian, and 65% NH-White. At SARS-CoV-2 diagnosis, 736 patients (91%) were scheduled to receive drug-based therapy (78%), radiation therapy (8%), or surgery (6%), of whom 39% experienced TDD. Across treatment modalities, the most commonly reported TDD reason from the clinic perspective was the patient’s COVID-19 disease (̃90%). Overall, NH-Black (62%), Hispanic/Latinx (44%), and NH-Asian (42%) adults with breast cancer and SARS-CoV-2 were more likely to experience TDD versus NH-White adults (34%) (p < 0.001). In multivariable analyses, NH-Black cancer patients were more likely to experience TDD compared to NH-White patients (aOR: 3.12, 95% CI: 1.96-5.47). The data suggest Hispanic/Latinx (aOR: 1.34, 95% CI: 0.78-2.30) breast cancer patients may also experience TDD, although not statistically significant. No association was observed among NH-Asian (aOR: 1.16, 95% CI: 0.50-2.73) or NH-AI/AN (aOR: 0.64, 95% CI: 0.28-1.52) breast cancer patients with TDD. Conclusions: Black or African American breast cancer patients are more likely to experience cancer care disruptions during the pandemic. Future research should evaluate the long-term impacts of care disruptions on breast cancer outcomes among minoritized US communities.

The role of rurality in cancer treatment disruptions among patients with cancer diagnosed with SARS-CoV-2: An analysis of the ASCO Survey on COVID-19 in Oncology Registry

6554

Background: U.S. rural cancer patients experience multifactorial barriers to cancer treatment; however, little is known about the impact of the pandemic on cancer treatment delays or discontinuations (TDD) in the rural context. Our objective was to evaluate the role of rurality at both the patient and clinic level on cancer TDD among patients living with cancer with SARS-CoV-2 infection. Methods: We used data from the ASCO Survey on COVID-19 in Oncology Registry (March 2020-July 2021), which includes cancer patients diagnosed with SARS-CoV-2 (n = 3193). Data included patient demographics, SARS-CoV-2 treatment, cancer characteristics, and modifications to cancer treatment plans. Cancer-related TDD was defined as any treatment postponed > two weeks from the original scheduled date. Rurality was defined using the USDA Rural-Urban Commuting Area schema. We compared cancer characteristics, COVID-19 outcomes, and TDD by rurality of cancer patients, and TDD by rurality of oncology practices. We computed adjusted odds ratios (aOR) using multivariable logistic regression to evaluate rurality with TDD adjusting for age, race/ethnicity, sex, comorbidities, ECOG score, cancer extent, pandemic time period based on case peaks ( < 06/2020, 06-12/2020, 01-07/2021), and COVID-19 severity. Results: Rural cancer patients (n = 499, 16%) with SARS-CoV-2 were mostly over 50 years (87%), female (57%), and NH-White (81%) with solid tumors (76%). Most rural patients received oncology treatment in urban areas (65%, p < 0.001). Rural patients were less likely to receive care through telemedicine (18%) compared to urban patients (26%) (p < 0.001). At SARS-CoV-2 diagnosis, rural patients were scheduled to receive drug-based therapy (72%), radiation therapy (8%), surgery (4%), or transplant (1%). Rural versus urban cancer patients with SARS-CoV-2 were less likely to experience TDD (41% vs. 51%) (p < 0.001). Among patients treated at rural oncology clinics, urban cancer patients were more likely to experience TDD (65%) compared with rural patients (47%) (p < 0.001). Similarly, among patients treated at urban oncology clinics, urban cancer patients were also more likely to experience TDD (51%) compared with rural patients (38%) (p < 0.001). In multivariable analyses, rural cancer patients were 28% less likely to experience TDD (aOR:0.72, 95% CI: 0.55-0.94) than urban cancer patients. Oncology practice rurality was not associated with TDD (aOR: 1.19, 95% CI: 0.81-1.76). Conclusions: Rural cancer patients were less likely to experience TDD than urban patients supporting the urban-rural paradox i.e., geographic distance to cancer care facilities is not consistently associated with treatment delivery in expected ways. Future work should focus on area-level factors of the rural cancer patient experience to disentangle potential reasons for TDD during the pandemic.

Role of relativistic laser intensity on isochoric heating of metal wire targets

In a recent experimental campaign, we used laser-accelerated relativistic hot electrons to ensure heating of thin titanium wire targets up to a warm dense matter (WDM) state [EPL114, 45002 (2016)10.1209/0295-5075/114/45002]. The WDM temperature profiles along several hundred microns of the wire were inferred by using spatially resolved X-ray emission spectroscopy looking at the Ti K_α characteristic lines. A maximum temperature of ∼30 eV was reached. Our study extends this work by discussing the influence of the laser parameters on temperature profiles and the optimisation of WDM wire-based generation. The depth of wire heating may reach several hundreds of microns and it is proven to be strictly dependent on the laser intensity. At the same time, it is quantitatively demonstrated that the maximum WDM temperature doesn't appear to be sensitive to the laser intensity and mainly depends on the deposited laser energy considering ranges of 6×10¹⁸-6×10²⁰ W/cm² and 50-200 J.

‘Hot Joints’ infection protocol reduces unnecessary post-operative re-admissions following total hip and knee arthroplasty

Aims

To evaluate the effectiveness of an institutionally developed algorithm for evaluation and diagnosis of prosthetic joint injection and to determine the impact of this protocol on overall hospital re-admissions.p

Patients and Methods

We retrospectively evaluated 2685 total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients prior to (1263) and following (1422) the introduction of an infection detection protocol. The protocol used conservative thresholds for C-reactive protein to direct the medical attendant to aspirate the joint. The protocol incorporated a clear set of laboratory and clinical criteria that allowed a patient to be discharged home if all were met. Patients were included if they presented to our emergency department within 120 days post-operatively with concerns for swelling, pain or infection and were excluded if they had an unambiguous infection or if their chief complaint was non-orthopaedic in nature.

Results

Concern for infection was the single most common (32%) reason for presentation. A total of 296 patients made an emergency visit and were included following THA or TKA. In the pre-protocol cohort, 11 of 27 patients were formally re-admitted to the hospital with concern for infection but only five (45%) patients had actual infections and received additional treatment. In comparison, in the post-protocol cohort, 11 patients were admitted for suspected infection, nine (82%) of whom were truly infected (p = 0.04). Sensitivity increased from 83% to 100% and specificity increased from 71% to 96%. Implementation of this protocol did not miss any infections.

Conclusion

A standardised protocol for evaluation of THA and TKA infections significantly reduced unnecessary hospital re-admissions. The protocol was both sensitive and specific and did not compromise quality of care. Cite this article: Bone Joint J 2017;99-B:1603–10.

Effect of Salicylic Acid on the Membrane Proteome and Virulence of Pseudomonas aeruginosa

PURPOSE

This study aimed to determine the effect of salicylic acid on the membrane proteome, sensitivity to antibiotics, and production of microbial keratitis by Pseudomonas aeruginosa.

METHODS

P. aeruginosa 6294 was grown in the presence or absence of 30 mM salicylic acid. Bacterial membrane proteins were extracted in carbonate buffer, separated using two-dimensional gel electrophoresis and identified by mass spectrometry. The minimum inhibitory concentration (MIC) of various antibiotics was determined using P. aeruginosa 6294 grown in presence or absence of salicylic acid. The scratch mouse model of microbial keratitis was used to determine whether treatment with 30 mM salicylic acid could improve the outcome of infection.

RESULTS

Growth in salicylic acid altered the membrane proteome of P. aeruginosa 6294. Eighteen proteins, including OprF, OprD, MexA, OprG, PilQ, and flagellin-type A protein, were downregulated, six proteins, including OprM and OprB, were upregulated, and nine proteins were unaffected by growth in salicylic acid. Growth in salicylic acid slightly increased the resistance to carbapenem antibiotics but did not affect MICs of the other antibiotics tested. Salicylic acid treatment significantly reduced the clinical score of eyes and bacterial load in eyes during microbial keratitis but had no effect on numbers of infiltrating neutrophils.

CONCLUSION

Salicylic acid altered the membrane proteins of P. aeruginosa, slightly increased the resistance of the bacterium to carbapenem antibiotics only, and was able to reduce the pathogenicity associated with P. aeruginosa infection of mouse corneas. Salicylic acid may be useful as an antimicrobial agent in the treatment of Pseudomonas keratitis.

Effects of α-Toxin-DeficientStaphylococcus aureuson the Production of Peripheral Corneal Ulceration in an Animal Model

PURPOSE

To examine the role of Staphylococcus aureus alpha-toxin in contact lens-induced peripheral ulceration (CLPU).

MATERIALS AND METHODS

Proteolytic enzyme, hyaluronidase, alpha-toxin, and beta-toxin production by S. aureus 8325-4 and its alpha-toxin-deficient mutant (S. aureus DU1090) were examined. Using a rabbit model of CLPU, animals were fitted with hydrogel contact lenses colonized by either S. aureus 8325-4 or the mutant strain. The clinical presentation, bacterial cultures, and histology of the ulceration were examined.

RESULTS

Both strains of S. aureus produced similar levels of caseinase, gelatinase, elastase, hyaluronidase, and beta-toxin. S. aureus DU1090 induced weaker haemolysis of rabbit blood cells than S. aureus 8325-4. Ulceration in the S. aureus DU1090 eye was less frequent and less severe than that caused by S. aureus 8325-4.

CONCLUSIONS

The enzyme production profile of S. aureus DU1090 was similar to the parent strain. S. aureus strains may produce CLPU-like lesions irrespective of alpha-toxin production, but severe infectious lesions are produced only in the presence of alpha-toxin.

Mediators of neovascularization and the hypoxic cornea

The maintenance of corneal avascularity is essential to vision. The mechanisms by which the cornea becomes vascularized in response to inflammation or hypoxic stress are beginning to be elucidated. A detailed understanding of the molecular responses of the cornea to hypoxia is critical for prevention and development of novel treatments for neovascularization in a range of disease states. Here, we have examined the current literature on the major mediators of angiogenesis, which have previously been reported during hypoxia in the cornea in order to better understand the mechanisms by which corneal angiogenesis occurs in circumstances where the available oxygen is reduced. The normal cornea produces angiogenic factors that are regulated by the production of anti-angiogenic molecules. The various cell types of the cornea respond differentially to inflammatory and hypoxic stimuli. An understanding of the factors that may predispose patients to development of corneal blood vessels may provide an opportunity to develop novel prophylactic strategies. The difficulties with extrapolating data from other cell types and animal models to the cornea are also examined.

Contribution of the cornea to cytokine levels in the whole eye induced during the early phase of Pseudomonas aeruginosa challenge

Pseudomonas aeruginosa keratitis is one of the most destructive diseases of the cornea. The host response to this infection is critical to the outcome, and is regulated by cytokines produced in the ocular tissue. In this study, we assessed the relative contribution of the cytokines produced in the cornea to the inflammatory response of the whole eye to gain a better understanding of the inflammatory and regulatory processes in the ocular environment during localized corneal infection. C57BL/6 mice were challenged by topical application of P. aeruginosa to wounded corneas. Corneas and whole eyes were harvested 24 h post-challenge and bacterial numbers, myeloperoxidase levels and the levels of cytokines known to be important in keratitis were determined. The site of production of IL-6 and KC in the retina was determined by in situ hybridization. Before infection, 90% of macrophage inflammatory protein (MIP)-2 and approximately 80% of all IFN-gamma and IL-10 produced constitutively in the eye was found outside the cornea. Twenty-four hours after infection, bacterial numbers, levels of myeloperoxidase, and levels of MIP-2 and IL-1 were not different, whether measured in cornea or whole eye. However, expression of IL-6, KC, IFN-gamma and IL-10 was significantly greater in whole eyes than in the corneas of infected eyes. The cells expressing IL-6 and KC in the retina were identified by in situ hybridization. This study indicates that during corneal inflammation, the response of the whole eye as well as the cornea needs to be considered.

Interleukin-4 is not critical to pathogenesis in a mouse model of Pseudomonas aeruginosa corneal infection

PURPOSE

To determine the contribution of interleukin-4 (IL-4) to the initial host response during corneal infection with Pseudomonas aeruginosa in a mouse model.

METHODS

Corneas of 6- to 8-week-old IL-4(-/-) and wild-type mice were topically challenged with P. aeruginosa. Ocular tissue was collected 24 hr and 7 days postchallenge. Viable bacterial counts, myeloperoxidase assays, cytokine levels, and clinical and histological examinations were performed.

RESULTS

During challenge with P. aeruginosa, no differences were observed clinically, histologically, or in bacterial load between IL-4(-/-) and wild-type mice at either time point. However, differences in cytokine levels of IL-6, KC, and IL-10 were observed.

CONCLUSIONS

The data presented indicate that IL-4, a central Th2 cytokine, may not be critical to the pathogenesis or bacterial clearance in this model of P. aeruginosa bacterial keratitis during the early stages of the infectious process.

Induction of cytokines from polymorphonuclear leukocytes and epithelial cells by ocular isolates of Serratia marcescens

PURPOSE

During contact lens wear, bacterial contamination of the lens can lead to the development of microbial keratitis (MK) or contact lens induced acute red eye (CLARE). Inflammatory mediators released by the host may heighten the response. We have examined the ability of human corneal epithelial cells and polymorphonuclear leukocytes (PMNs) to release cytokines upon stimulation with bacteria.

METHODS

Serratia marcescens strains were added to corneal epithelial cells or PMNs. After incubations of up to 20 hours, supernatants were assayed for the presence of inflammatory mediators by ELISA.

RESULTS

All strains stimulated PMNs to release IL-8 and LTB(4). Epithelial cells did not release LTB(4). IL-8 was released after exposure to most S. marcescens isolates. A sub-group of strains stimulated the release of TNF-alpha from corneal epithelial cells.

CONCLUSIONS

S. marcescens can stimulate the release of inflammatory mediators from both PMNs and corneal epithelial cells. This release could be important in the progression and resolution of MK and CLARE.

Experimental Pseudomonas aeruginosa keratitis in interleukin-10 gene knockout mice

Pseudomonas aeruginosa keratitis is one of the most destructive diseases of the cornea. The host response to this infection is critical to the outcome. The cytokine interleukin-10 (IL-10) is thought to play an important role in modulating excessive inflammation and antimicrobial defenses. We have found that in IL-10(-/-) mice there is a significant decrease in bacterial load in corneas at 7 days postchallenge with P. aeruginosa. This decrease was accompanied by a reduction in neutrophil numbers in the cornea and changes in cytokine levels compared to those of wild-type mice. A characteristic increase in neovascularization in the cornea was found in the IL-10(-/-) mice. This increased angiogenesis correlated with an increased expression of KC, whereas the kinetics of macrophage inflammatory peptide 2 expression correlated with neutrophil numbers. This finding suggests that KC may play a role in corneal angiogenesis. The source of IL-10 in mouse corneas was identified as a subpopulation of infiltrating cells and keratocytes. This study demonstrates that IL-10 plays an important role in regulating the balance of inflammatory mediators during P. aeruginosa infection of the cornea.

Tibia fracture after fibula resection for distal peroneal bypass

The lateral approach to the distal peroneal artery has been used by vascular surgeons for 25 years. No complications specifically related to this approach have previously been reported. We reviewed 18 cases of peroneal bypass for limb salvage using the lateral approach with fibula resection and found that two of these cases had ipsilateral tibia fractures within 1 year of the bypass. Eight out of 18 cases were women, and two of these eight had tibia fracture. Both women suffered from osteoporosis. We conclude that tibia fracture is a possible complication of this approach, especially in elderly women with osteoporosis.

MRI in patients with intraspinal bullets

The purpose of this study was to determine whether neurologic sequelae occur in patients with intraspinal bullets or bullet fragments who undergo magnetic resonance imaging (MRI). Nineteen patients with bullets or bullet fragments adjacent to the cord or nerve roots underwent clinical MRI studies at 1.5 T. Sequences included conventional spin echo, fast spin echo, gradient-recalled echo, and inversion recovery. Patients were queried during scanning for symptoms of discomfort, pain, or change in neurologic status. Detailed neurologic examinations were performed prior to MRI (baseline), post MRI, and at the patients' discharge. Sixteen patients were completely paralyzed (ASIA-A), and three were not paralyzed. The length of time from injury was 2-24 months. No patients experienced pain or discomfort during the procedure. No change in neurologic status occurred. Follow-up radiographic studies showed no bullet movement following the scanning. We conclude that in patients with complete spinal cord injury, MRI in patients with intraspinal bullets may be performed.

Osteomyelitis of the pelvis/hips in paralyzed patients: accuracy and clinical utility of MRI

PURPOSE

The goal of our study was to determine the accuracy and clinical utility of MRI in the diagnosis of osteomyelitis of the pelvis/hips in paralyzed patients.

METHOD

In 44 paralyzed patients, 59 consecutive MR examinations of the pelvis/hips were evaluated prospectively. Criteria for diagnosis of osteomyelitis were based on those established in previous studies of complex, nonhematogenous osteomyelitis (diabetic foot). Average follow-up was 3 years. The standard of reference for the diagnosis of osteomyelitis was histologic/microbiologic results of surgical biopsy specimens or clinical follow-up. Note was made if decubitus ulcers, sinus tract, fistula, fluid collection, abscess, septic arthritis, joint effusion, bursitis, or heterotopic ossification was present on MRI. Comparison of the extent of infection by MRI and surgical margins was performed. Effect on surgical treatment was defined by absence of recurrent infection at the surgical site within 6 weeks of limited resection.

RESULTS

The criteria for diagnosis of osteomyelitis were fulfilled in 49 of 57 MR studies for an overall accuracy of 97%. There was one false-negative MR study. MRI for the diagnosis of osteomyelitis yielded a sensitivity of 98% and a specificity of 89%. There were 41 decubitus ulcers, 28 sinus tracts, 2 fistulae, 14 fluid collections, 15 abscesses, 9 hips with septic arthritis, 10 "bland" hip effusions, 5 cases of trochanteric bursitis, and 30 patients with heterotopic ossification. Twenty-one patients underwent limited surgical resection guided by MR findings in which only the enhancing area was resected. There was only one recurrence of osteomyelitis at the surgical margins.

CONCLUSION

MRI is accurate in the diagnosis of osteomyelitis and associated soft tissue abnormalities in spinal cord-injured patients. MRI can delineate the extent of infection in guiding limited surgical resection and preserving viable tissue.

CpG-rich sequences close to the site of duplication within the human IGH constant region

Human immunoglobulin heavy chains are encoded by a highly complex locus, IGH, which encompasses many transcriptional units, including nine alternative constant region genes. Much of the constant region gene cluster was duplicated during hominoid evolution. In rodents, IGH is known to be regulated by multiple elements, including several enhancers 3' of the alpha chain-encoding A constant region gene, CA, the last transcribed region. Sequences downstream of the two human CA genes, possibly containing homologous enhancer elements, have not yet been reported. By long-range mapping of genomic DNA, a cluster of unmethylated rare restriction sites, representing a potential CpG island, was previously reported downstream of each CA gene, close to the 3' end of the duplicated region. Such potential CpG islands are candidates for additional IGH regulatory elements. We isolated bacteriophage clones containing these clusters of methylation-sensitive restriction sites, which lie within short CpG-rich stretches. Some of these sites showed tissue-specific methylation. 3' of the unmethylated CpG-rich sequences, clones derived from the 5' (telomeric) copy of the duplicated region, contained, in order, endogenous retroviral sequences, a processed ELK1 pseudogene, and the pseudogene IGHGP. Comparison with the presumed 3' (centromeric) copy of the duplicated region showed that similarity was lost exactly at the end of the retroviral long terminal repeat sequences. These results imply that an endogenous retroviral integration was present immediately 3' of IGH in the common hominoid ancestor and suggest models for the duplication of the region.

BCL6 encodes a sequence-specific DNA-binding protein

Chromosomal rearrangements of BCL6 are commonly associated with diffuse large-cell lymphomas. We set out to determine the DNA-binding site of a glutathione-S-transferase fusion protein containing the BCL6 zinc finger region by employing cyclic amplification and selection of targets (CASTing). From oligonucleotides containing 16 central random bases, sequences binding to the protein on glutathione-coated beads were repeatedly selected and amplified by polymerase chain reaction (PCR). The binding sites were cloned and sequenced. A consensus, TTTNNNGNNATNCTTT, was obtained. Protein binding studies of double-stranded oligomers containing point mutations within the 3' CTTT confirmed the binding specificity of this part of the consensus. In addition, evidence indicated that some of the base pairs held constant in the oligonucleotides used for CASTing also contributed to binding.

Genomic structure of the candidate proto-oncogene BCL3

We previously reported the identification of a novel candidate proto-oncogene involved in the translocation t(14;19)(q32;q13) found in some cases of human B-cell chronic lymphocytic leukemia. This gene, BCL3, is a member of the I kappa B family, whose encoded proteins regulate the NF-kappa B family of transcription factors. Here we describe the genomic structure of BCL3. The gene contains nine exons, spanning 11.5 kb. In comparison to other members of the I kappa B family, there is a remarkable conservation of the exon-intron boundaries in relation to the coding sequences, consistent with an origin from a common ancestral gene. BCL3 is unusual in containing two CpG islands, a 5' island encompassing the first exon, the other lying within the gene. Southern blot analysis using methylation-sensitive restriction enzymes revealed that while the 5' CpG is unmethylated in all tissues tested, the degree of methylation of the internal CpG island varies.

Mutation analysis of coding sequences for type I procollagen in individuals with low bone density

Mutations in one of the two genes encoding type I procollagen (COL1A1 and COL1A2) are frequently the cause of osteogenesis imperfecta (OI), a disorder characterized by brittle bones. Here we tested whether patients with low bone density also have mutations in these genes. The 26 patients studied had no apparent metabolic bone disease, but most had a positive family history of osteopenia or osteoporosis. Although a diagnosis of OI was considered by the clinician in some cases, the clinical criteria for OI were not satisfied. Our strategy for mutation analysis consisted of PCR amplification of cDNA made to fibroblast mRNA using primers specific for the coding regions of COL1A1 and COL1A2. The PCR products were then sequenced directly with primers located within each PCR product. We found that 3 of 26 patients had mutations that altered the encoded amino acid. One mutation, at position alpha 2(I)-661 has been reported (Spotila et al. 1991 Proc Natl Acad Sci USA PNAS 88:5423). The other 2 patients, who were not related to each other, had a mutation that altered the proline codon at alpha 1(I)-27 to alanine. This mutation was not found in 81 normal individuals or in 37 additional osteopenic individuals. However, its effect on the biologic function of type I collagen, as well as its role in osteopenia, is uncertain. In addition to the two mutations, we found a polymorphism in codon alpha 2(I)-459. Although this polymorphism involved an amino acid substitution, it was present with equal frequency in the patient and the normal population. By analyzing this and previously reported neutral sequence variants in the COL1A2 gene, we determined that all patients expressed both alleles of the COL1A2 gene. The 12 patients who were heterozygous for a COL1A1 neutral sequence variant also expressed both alleles. Here we present all PCR primer and sequencing primer information. The results suggest that surveying a larger group of similarly selected individuals may reveal additional mutations in the COL1A1 or COL1A2 genes.