Cervical Precancers and Cancers Attributed to HPV Types by Race and Ethnicity: Implications for Vaccination, Screening, and Management

BACKGROUND

Racial and ethnic variations in attribution of cervical precancer and cancer to HPV types may result in different HPV vaccine protection, screening test coverage, and clinical management.

METHODS

Pooling data from seven U.S. studies, we calculated the proportional attribution of precancers and cancers to HPV types using HPV DNA typing from diagnosis. All statistical tests were 2-sided.

RESULTS

For all racial and ethnic groups, most cervical intraepithelial neoplasia grade 3 (CIN3) (n = 5,526) and squamous cell carcinoma (SCC) cases (n = 1,138) were attributed to types targeted by the 9-valent vaccine. A higher proportion of CIN3s were attributed to non-vaccine HPV types among non-Hispanic Black women (15.8%) compared with non-Hispanic Asian or Pacific Islander (9.7%, P=.002), non-Hispanic White (9.2%, P<.001), and Hispanic women (11.3%, P=.004). The proportion of SCCs attributed to 9-valent types was similar by race and ethnicity (90.4%-93.8%, P = .80). A higher proportion of CIN3s were attributed to non-vaccine HPV35 among non-Hispanic Black (9.0%) compared with non-Hispanic Asian or Pacific Islander (2.2%), non-Hispanic White (2.5%), and Hispanic women (3.0%, all P<.001). Compared with CIN3, the proportion of SCCs attributed to HPV35 among Non-Hispanic Black women (3.2%) was lower and closer to other groups (0.3%-2.1%, P = .70).

CONCLUSION

The 9-valent HPV vaccine will prevent nearly all cervical precancers and invasive cancers among major racial and ethnic groups in the United States. Adding HPV35 to vaccines could prevent a small percentage of CIN3s and SCCs, with greater potential impact for CIN3s among Black women. HPV screening tests target high-risk HPV types, including HPV35. Future genotyping triage strategies could consider the importance of HPV35 and other HPV16 related types.

Risk Factors for Reaching Core Body Temperature Thresholds in Florida Agricultural Workers

BACKGROUND

There is a compelling need to identify agricultural workers at risk for heat related illness (HRI).

METHODS

Data from Florida agricultural workers (N = 221) were collected over 3 summer workdays (2015 to 2017) to examine risk factors for exceeding NIOSH-recommended core temperature (Tc) thresholds (38 °C [Tc38] and 38.5 °C [Tc38.5]) using generalized linear mixed models.

RESULTS

On an average workday, 49% of participants exceeded Tc38 and 10% exceeded Tc38.5. On average, participants first exceeded both thresholds early in the day; the Tc38 threshold mid-morning (10:38 AM), and Tc38.5 about a half hour later (11:10 AM). Risk factors associated with exceeding Tc38 included years working in US agriculture, body mass index, time performing moderate-to-vigorous physical activity, increasing heat index, and field crop work.

CONCLUSIONS

The high prevalence of core temperatures exceeding recommended limits emphasizes the serious need for mandated HRI prevention programs for outdoor workers.

Risk of cervical precancer and cancer among uninsured and underserved women from 2009 to 2017

BACKGROUND

New guidelines for managing cervical precancer among women in the United States use risk directly to guide clinical actions for individuals who are being screened. These risk-based management guidelines have previously only been based on risks from a large integrated healthcare system. We present here data representative of women of low income without continuous insurance coverage to inform the 2019 guidelines and ensure applicability.

OBJECTIVE

We examined the risks of high-grade precancer after human papillomavirus and cytology tests in underserved women and assessed the applicability of the 2019 guidelines to this population.

STUDY DESIGN

We examined cervical cancer screening and follow-up data among 363,546 women enrolled in the Centers for Disease Control and Prevention's National Breast and Cervical Cancer Early Detection Program from 2009 to 2017. We estimated the immediate (prevalent) risks of cervical intraepithelial lesion grade 3 or cancer by using prevalence-incidence mixture models. Risks were estimated for each combination of human papillomavirus and cytology result and were stratified by screening history. We compared these risks with published estimates used in new risk-based management guidelines.

RESULTS

Women who were up-to-date with their screening, defined as being screened with cytology within the past 5 years, had immediate risks of cervical intraepithelial neoplasia grade 3 or higher similar to that of women at Kaiser Permanente Northern California, whose data were used to develop the management guidelines. However, women in the Centers for Disease Control and Prevention's National Breast and Cervical Cancer Early Detection Program had greater immediate risks if they were never screened or not up-to-date with their screening.

CONCLUSION

New cervical risk-based management guidelines are applicable for underinsured and uninsured women with a low income in the United States who are up-to-date with their screening. The increased risk observed here among women who received human papillomavirus-positive, high-grade cytology results, who were never screened, or who were not up-to-date with their cervical cancer screening, led to a recommendation in the management guidelines for immediate treatment among these women.

Chronic Kidney Disease Among Workers: A Review of the Literature

For the past two decades, agricultural workers in regions of Central America have reported an epidemic of chronic kidney disease of undetermined etiology (CKDu) that is not associated with established risk factors of chronic kidney disease. Several hypotheses have emerged, but the etiology of CKDu remains elusive and controversial. The aim of this literature review was to describe the potential risk factors of CKDu in Mesoamerica and implications for the U.S. agricultural worker population. PubMed and CINAHL databases were searched for articles published between 2000 and 2018 that examined CKDu in Mesoamerica; 29 original studies were included in this review. CKDu is a multifactorial disease that is often asymptomatic with hallmark characteristics of elevated serum creatinine and blood urea nitrogen (BUN), low glomerular filtration rate, electrolyte abnormalities, and non-nephrotic proteinuria. Reducing the global prevalence of CKDu will require more robust studies on causal mechanisms and on interventions that can reduce morbidity and mortality in vulnerable populations.

Comparing Human Papillomavirus Prevalence in Rectal and Anal Cancer Using US Cancer Registries, 2014-2015

BACKGROUND AND AIMS

Rectal squamous cell carcinoma (SCC) is a rare malignancy, and the causal role of human papillomavirus (HPV) in these cancers is thought to be similar to anal cancer. We compared type-specific prevalence of HPV in rectal SCC to anal cancer. In rectal SCC, we evaluated the agreement between HPV prevalence and positivity for p16, a marker of oncogenic activity.

METHODS

A stratified random sample of rectal SCCs and anal cancers diagnosed between 2014 and 2015 were identified from 3 statewide cancer registries in Iowa, Kentucky, and Louisiana. HPV testing was performed at the HPV laboratory at the Centers for Disease Control and Prevention. HPV types were described using hierarchical attribution to HPV16 and other oncogenic types, weighted for sampling design. In rectal SCC, we computed concordance and Cohen's kappa coefficient (κ) between HPV status and p16 positivity.

RESULTS

A total of 39 rectal and 72 anal cancers were analyzed. HPV16 was the most common type in both rectal and anal cancer and did not differ significantly between sites (71.4% vs 82.1%; P = .32). Concordance between the presence of any HPV type and p16 positivity in rectal SCC was 92% with κ = 0.77.

CONCLUSIONS

Rectal SCC and anal cancer have similar type-specific HPV prevalence, with HPV16 found most frequently. Substantial agreement between p16 and HPV status in rectal SCC lends additional support for the etiologic role of HPV in both anal and rectal cancer. Larger studies could be conducted to replicate these findings.

Impact of Cognition on Burn Inpatient Rehabilitation Outcomes

BACKGROUND

A significant proportion of burn injury patients are admitted to inpatient rehabilitation facilities (IRFs). There is increasing interest in the use of functional variables, such as cognition, in predicting IRF outcomes. Cognitive impairment is an important cause of disability in the burn injury population, yet its relationship to IRF outcomes has not been studied.

OBJECTIVE

To assess how cognitive function affects rehabilitation outcomes in the burn injury population.

DESIGN

Retrospective study.

SETTING

Inpatient rehabilitation facilities in the United States.

PARTICIPANTS

A total of 5347 adults admitted to an IRF with burn injury between 2002 and 2011.

METHODS OR INTERVENTIONS

Multivariable regression was used to model rehabilitation outcome measures, using the cognitive domain of the Functional Independence Measure (FIM) instrument as the independent variable and controlling for demographic, medical, and facility covariates.

MAIN OUTCOME MEASUREMENTS

FIM total gain, readmission to an acute care setting at any time during inpatient rehabilitation, readmission to an acute care setting in the first 3 days of IRF admission, rate of discharge to the community setting, and length of stay efficiency.

RESULTS

Cognitive FIM total at admission was a significant predictor of FIM total gain, length of stay efficiency, and acute readmission at 3 days (P < .05). Cognitive FIM total scores did not have an impact on acute care readmission rate or discharge to the community setting.

CONCLUSIONS

Cognitive status may be an important predictor of rehabilitation outcomes in the burn injury population. Future work is needed to further examine the impact of specific cognitive interventions on rehabilitation outcomes in this population.

LEVEL OF EVIDENCE

II.

Functional Status Outperforms Comorbidities in Predicting Acute Care Readmissions in Medically Complex Patients

OBJECTIVE

To examine functional status versus medical comorbidities as predictors of acute care readmissions in medically complex patients.

DESIGN

Retrospective database study.

SETTING

U.S. inpatient rehabilitation facilities.

PARTICIPANTS

Subjects included 120,957 patients in the Uniform Data System for Medical Rehabilitation admitted to inpatient rehabilitation facilities under the medically complex impairment group code between 2002 and 2011.

INTERVENTIONS

A Basic Model based on gender and functional status was developed using logistic regression to predict the odds of 3-, 7-, and 30-day readmission from inpatient rehabilitation facilities to acute care hospitals. Functional status was measured by the FIM(®) motor score. The Basic Model was compared to six other predictive models-three Basic Plus Models that added a comorbidity measure to the Basic Model and three Gender-Comorbidity Models that included only gender and a comorbidity measure. The three comorbidity measures used were the Elixhauser index, Deyo-Charlson index, and Medicare comorbidity tier system. The c-statistic was the primary measure of model performance.

MAIN OUTCOME MEASURES

We investigated 3-, 7-, and 30-day readmission to acute care hospitals from inpatient rehabilitation facilities.

RESULTS

Basic Model c-statistics predicting 3-, 7-, and 30-day readmissions were 0.69, 0.64, and 0.65, respectively. The best-performing Basic Plus Model (Basic+Elixhauser) c-statistics were only 0.02 better than the Basic Model, and the best-performing Gender-Comorbidity Model (Gender+Elixhauser) c-statistics were more than 0.07 worse than the Basic Model.

CONCLUSIONS

Readmission models based on functional status consistently outperform models based on medical comorbidities. There is opportunity to improve current national readmission risk models to more accurately predict readmissions by incorporating functional data.

Length of Stay at Inpatient Rehabilitation Facility and Stroke Patient Outcomes

PURPOSE

To examine the association of inpatient rehabilitation facility (IRF) length of stay (LOS) with stroke patient outcomes.

DESIGN

A secondary data analysis of the Uniform Data System for Medical Rehabilitation database.

METHODS

Stroke patients discharged from IRFs in the United States between 2009 and 2011 were identified and divided into mild (n = 639), moderate (n = 2,065), and severely (n = 2,077) impaired groups. Study outcomes included cognition and motor functional gains measured by the Functional Independence Measure (FIM) instrument and discharge to the community.

FINDINGS

The average LOS was 8.9, 13.9, and 22.2 days for mild, moderate, and severely impaired stroke patients, respectively. After controlling for FIM admission and other important covariates, a longer LOS was associated with a modest increase in cognition gain (β = 0.038, p = .0045) for the moderately impaired patients, and a modest increase in cognition (β = 0.13, p < .0001) and motor gains (β = 0.25, p < .0001) as well as a tendency for discharge to the community (OR = 1.01, 95% CI = 1.00-1.02) among the severely impaired patients. However, a longer LOS showed a negative association with functional gains among the mildly impaired patients as well as discharge to community for both mild and moderately impaired patients.

CONCLUSION

The association of IRF LOS and patient outcomes varied by stroke impairment severity, positively for more severely impaired patients and negatively for mildly impaired patients.

CLINICAL RELEVANCE

The study provides evidence for the care of stroke patients at the IRF setting.

Functional status and readmissions in unilateral hip fractures

OBJECTIVES

To test whether functional status is a robust predictor of acute care readmission risk in patients who have been discharged to an inpatient rehabilitation facility (IRF) following a unilateral hip fracture.

STUDY DESIGN

Retrospective database study using a large administrative data set.

METHODS

A retrospective analysis of data from the Uniform Data System for Medical Rehabilitation from the years 2002 to 2011 was performed, examining patients with an impairment of unilateral hip fracture. A basic prediction model based on functional status was compared with competing models incorporating medical comorbidities. C statistics were compared to evaluate model performance.

RESULTS

There were a total of 433,154 patients: 32,783 (7.87%) patients were transferred back to an acute hospital, including 7937 (1.91%) transferred within 3 days, 16,150 (3.88%) transferred within 7 days, and 32,607 (7.83%) transferred within 30 days after IRF admission. The C statistics for the Basic Model are 0.710, 0.674, and 0.667 at days 3, 7, and 30, respectively. Compared with the Basic Model, the best performing Basic-Plus model was the Basic+Elixhauser Model with C statistic differences of +0.013, +0.014, and +0.019, and the best performing Age-Comorbidity Model was the Age+Elixhauser Model with C statistic differences of -0.110, -0.079, and -0.065 at days 3, 7, and 30, respectively.

CONCLUSIONS

Functional status is a robust and potentially modifiable risk factor for patients admitted to IRFs following a unilateral hip fracture.

Recurrent finding of the FIP1L1-PDGFRA fusion gene in eosinophilia-associated acute myeloid leukemia and lymphoblastic T-cell lymphoma

The FIP1L1-PDGFRA fusion gene has been described in patients with eosinophilia-associated myeloproliferative disorders (Eos-MPD). Here, we report on seven FIP1L1-PDGFRA-positive patients who presented with acute myeloid leukemia (AML, n=5) or lymphoblastic T-cell non-Hodgkin-lymphoma (n=2) in conjunction with AML or Eos-MPD. All patients were male, the median age was 58 years (range, 40-66). AML patients were negative for common mutations of FLT3, NRAS, NPM1, KIT, MLL and JAK2; one patient revealed a splice mutation of RUNX1 exon 7. Patients were treated with imatinib (100 mg, n=5; 400 mg, n=2) either as monotherapy (n=2), as maintenance treatment after intensive chemotherapy (n=3) or in overt relapse 43 and 72 months, respectively, after primary diagnosis and treatment of FIP1L1-PDGFRA-positive disease (n=2). All patients are alive, disease-free and in complete hematologic and complete molecular remission after a median time of 20 months (range, 9-36) on imatinib. The median time to achievement of complete molecular remission was 6 months (range, 1-14). We conclude that all eosinophilia-associated hematological malignancies should be screened for the presence of the FIP1L1-PDGFRA fusion gene as they are excellent candidates for treatment with tyrosine kinase inhibitors even if they present with an aggressive phenotype such as AML.