Race-Conscious Research Using Extracorporeal Life Support Organization Registry Data: A Narrative Review.

Race-conscious research identifies health disparities with 1) rigorous and responsible data collection, 2) intentionality and considered analyses, and 3) interpretation of results that advance health equity. Individual registries must overcome specific challenges to promote race-conscious research, and this paper describes ways to achieve this with a focus on the international Extracorporeal Life Support Organization (ELSO) registry. This article reviews ELSO registry publications that studied race with outcomes to consider whether research outputs align with race-conscious concepts and describe the direction of associations reported. Studies were identified via secondary analysis of a comprehensive scoping review on ECMO disparities. Of 32 multicenter publications, two (6%) studied race as the primary objective. Statistical analyses, confounder adjustment, and inclusive, antibiased language were inconsistently used. Only two (6%) papers explicitly discussed mechanistic drivers of inequity such as structural racism, and five (16%) discussed race variable limitations or acknowledged unmeasured confounders. Extracorporeal Life Support Organization registry publications demonstrated more adverse ECMO outcomes for underrepresented/minoritized populations than non-ELSO studies. With the objective to promote race-conscious ELSO registry research outputs, we provide a comprehensive understanding of race variable limitations, suggest reasoned retrospective analytic approaches, offer ways to interpret results that advance health equity, and recommend practice modifications for data collection.

The effect of fertility treatment and socioeconomic status on neonatal and post-neonatal mortality in the United States.

OBJECTIVE: To determine the association between fertility treatment, socioeconomic status (SES), and neonatal and post-neonatal mortality. STUDY DESIGN: Retrospective cohort study of all births (19,350,344) and infant deaths from 2014-2018 in the United States. The exposure was mode of conception-spontaneous vs fertility treatment. The outcome was neonatal (<28d), and post-neonatal (28d-1y) mortality. Multivariable logistic models were stratified by SES. RESULT: The fertility treatment group had statistically significantly higher odds of neonatal mortality (high SES OR 1.59; CI [1.5, 1.68], low SES OR 2.11; CI [1.79, 2.48]) and lower odds of post-neonatal mortality (high SES OR 0.87, CI [0.76, 0.996], low SES OR 0.6, CI [0.38, 0.95]). SES significantly modified the effect of ART/NIFT on neonatal and post-neonatal mortality. CONCLUSIONS: Fertility treatment is associated with higher neonatal and lower post-neonatal mortality and SES modifies this effect. Socioeconomic policies and support for vulnerable families may help reduce rates of infant mortality.

Child Opportunity Index and Pediatric Intensive Care Outcomes: A Multicenter Retrospective Study in the United States.

OBJECTIVES: To evaluate for associations between a child's neighborhood, as categorized by Child Opportunity Index (COI 2.0), and 1) PICU mortality, 2) severity of illness at PICU admission, and 3) PICU length of stay (LOS). DESIGN: Retrospective cohort study. SETTING: Fifteen PICUs in the United States. PATIENTS: Children younger than 18 years admitted from 2019 to 2020, excluding those after cardiac procedures. Nationally-normed COI category (very low, low, moderate, high, very high) was determined for each admission by census tract, and clinical features were obtained from the Virtual Pediatric Systems LLC (Los Angeles, CA) data from each site. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Among 33,901 index PICU admissions during the time period, median patient age was 4.9 years and PICU mortality was 2.1%. There was a higher percentage of admissions from the very low COI category (27.3%) than other COI categories (17.2-19.5%, p < 0.0001). Patient admissions from the high and very high COI categories had a lower median Pediatric Index of Mortality 3 risk of mortality (0.70) than those from the very low, low, and moderate COI groups (0.71) ( p < 0.001). PICU mortality was lowest in the very high (1.7%) and high (1.9%) COI groups and highest in the moderate group (2.5%), followed by very low (2.3%) and low (2.2%) ( p = 0.001 across categories). Median PICU LOS was between 1.37 and 1.50 days in all COI categories. Multivariable regression revealed adjusted odds of PICU mortality of 1.30 (95% CI, 0.94-1.79; p = 0.11) for children from a very low versus very high COI neighborhood, with an odds ratio [OR] of 0.996 (95% CI, 0.993-1.00; p = 0.05) for mortality for COI as an ordinal value from 0 to 100. Children without insurance coverage had an OR for mortality of 3.58 (95% CI, 2.46-5.20; p < 0.0001) as compared with those with commercial insurance. CONCLUSIONS: Children admitted to a cohort of U.S. PICUs were often from very low COI neighborhoods. Children from very high COI neighborhoods had the lowest risk of mortality and observed mortality; however, odds of mortality were not statistically different by COI category in a multivariable model. Children without insurance coverage had significantly higher odds of PICU mortality regardless of neighborhood.

Contrasting Composition, Diversity and Predictive Metabolic Potential of the Rhizobacterial Microbiomes Associated with Native and Invasive Prosopis Congeners.

Invasive plants are known to alter the soil microbial communities; however, the effects of co-occurring native and invasive congeners on the soil bacterial diversity and their predictive metabolic profiles are not known. Here, we compared the rhizosphere bacterial communities of invasive Prosopis juliflora and its native congener Prosopis cineraria using high-throughput sequencing of the 16S rRNA gene. Unweighted Pair Group Method with Arithmetic mean (UPGMA) based dendrogram revealed significant variation in the communities of these co-occurring Prosopis species. Additionally, Canonical Correspondence Analysis (CCA) based on microbial communities in addition to the soil physiochemical parameters viz. soil pH, electrical conductivity, moisture content and sampling depth showed ~ 80% of the variation in bacterial communities of the rhizosphere and control soil. We observed that Proteobacteria was the predominant phylum of P. juliflora rhizosphere and the control soil, while P. cineraria rhizosphere was dominated by Cyanobacteria. Notably, the invasive P. juliflora rhizosphere showed an enhanced abundance of bacterial phyla like Actinobacteria, Chloroflexi, Firmicutes and Acidobacteria compared to the native P. cineraria as well as the control soil. Predictive metagenomics revealed that the bacterial communities of the P. juliflora rhizosphere had a higher abundance of pathways involved in antimicrobial biosynthesis and degradation, suggesting probable exposure to enemy attack and an active response mechanism to counter it as compared to native P. cineraria. Interestingly, the higher antimicrobial biosynthesis predicted in the invasive rhizosphere microbiome is further corroborated by the fact that the bacterial isolates purified from the rhizosphere of P. juliflora belonged to genera like Streptomyces, Isoptericola and Brevibacterium from the phylum Actinobacteria, which are widely reported for their antibiotic production ability. In conclusion, our results demonstrate that the co-occurring native and invasive Prosopis species have significantly different rhizosphere bacterial communities in terms of composition, diversity and their predictive metabolic potentials. In addition, the rhizosphere microbiome of invasive Prosopis proffers it a fitness advantage and influences invasion success of the species.

Paludisphaera soli sp. nov., a new member of the family Isosphaeraceae isolated from high altitude soil in the Western Himalaya.

A novel strain of Planctomycetes, designated JC670T, was isolated from a high altitude (~ 2900 m above sea level) soil sample collected from Garhwal region in the Western Himalaya. Colonies of this strain were observed to be light pink coloured with spherical to oval shaped cells having crateriform structures distributed all over the cell surface. The cells divide by budding. Strain JC670T was found to grow well at pH 7.0 and pH 8.0 and to tolerate up to 2% NaCl (w/v). MK6 was the only respiratory quinone identified. The major fatty acids of strain JC670T were identified as C18:1ω9c, C18:0 and C16:0, and phosphatidylcholine, two unidentified phospholipids and six unidentified lipids are present as the polar lipids. The polyamines putrescine and sym-homospermidine were detected. Strain JC670T shows high 16S rRNA gene sequence identity (95.4%) with Paludisphaera borealis PX4T. The draft genome size of strain JC670T is 7.97 Mb, with G + C content of 70.4 mol%. Based on phylogenetic analyses with the sequences of ninety-two core genes, low dDDH value (20.6%), low gANI (76.8%) and low AAI (69.1%) results, differential chemotaxonomic and physiological properties, strain JC670T (= KCTC 72850T = NBRC 114339T) is recognised as the type strain of a new species of the genus Paludisphaera, for which we propose the name Paludisphaera soli sp. nov.

Molecular basis of pathogenic parasitic infections: insights from parasite kinome.

Infectious diseases caused by numerous parasitic pathogens represent a global health conundrum. Several animal and plant pathogens are responsible for causing acute illness in humans and deadly plant infections. These pathogens have evolved a diverse array of infection strategies and survival methods within the host organism. Recent research has highlighted the role of protein kinases in the overall virulence and pathogenicity of the pathogens. Protein kinases (Pks) are a group of enzymes known to catalyse the phosphorylation of a wide variety of cellular substrates involved in different signalling cascades. They are also involved in regulating pathogen life cycle and infectivity. In this review, we attempt to address the role of parasite kinome in host infection, pathogen survival within the host tissue and thereby disease manifestation. The understanding of the parasite kinome can be a potential target for robust diagnosis and effective therapeutics.

The Extracellular Protein, Transthyretin Is an Oxidative Stress Biomarker.

The extracellular protein, transthyretin is responsible for the transport of thyroxin and retinol binding protein complex to the various parts of the body. In addition to this transport function, transthyretin has also been involved in cardiovascular malfunctions, polyneuropathy, psychological disorders, obesity and diabetes, etc. Recent developments have evidenced that transthyretin has been associated with many other biological functions that are directly or indirectly associated with the oxidative stress, the common hallmark for many human diseases. In this review, we have attempted to address that transthyretin is associated with oxidative stress and could be an important biomarker. Potential future perspectives have also been discussed.

Universal insurance and an equal access healthcare system eliminate disparities for Black patients after traumatic injury.

BACKGROUND: Although inequities in trauma care are reported widely, some groups have theorized that universal health insurance would decrease disparities in care for disadvantaged minorities after a traumatic injury. We sought to examine the presence of racial disparities in outcomes and healthcare utilization at 30- and 90-days after discharge in this universally insured, racially diverse, American population treated for traumatic injuries. METHODS: This work studied adult beneficiaries of TRICARE treated at both military and civilian trauma centers 2006-2014. We included patients with an inpatient trauma encounter based on International Classification of Diseases, 9th revision (ICD-9) code. The mechanism and severity of injury, medical comorbidities, region and environment of care, and demographic factors were used as covariates. Race was considered the main predictor variable with Black patients compared to Whites. Logistic regression models were employed to assess for risk-adjusted differences in 30- and 90-day outcomes between Blacks and Whites. RESULTS: A total of 87,112 patients met the inclusion criteria. Traditionally encountered disparities for Black patients after trauma, including increased rates of mortality, were absent. We found a statistically significant decrease in the odds of 90-day complications for Blacks (OR 0.91; 95% CI 0.84-0.98; P = 0.01). Blacks also had lesser odds of readmission at 30-days (OR 0.87; 95% CI 0.79-0.94; P = 0.002) and 90-days (OR 0.86; 95% CI 0.79-0.93; P < 0.001). CONCLUSION: Our findings support the idea that in a universally insured, equal access system, historic disparities for racial and ethnic minorities, including increased postinjury morbidity, hospital readmission, and postdischarge healthcare utilization, are decreased or even eliminated.

Universal Health Insurance and its association with long term outcomes in Pediatric Trauma Patients.

BACKGROUND: Racial disparities in mortality exist among pediatric trauma patients; however, little is known about disparities in outcomes following discharge. METHODS: We conducted a longitudinal cohort study of children admitted for moderate to severe trauma, covered by TRICARE from 2006 to 2014. Patients were followed up to 90days after discharge. All children <18 years with a primary trauma diagnosis, an Injury Severity Score >9 and 90days of follow-up after discharge were included. Complications, readmissions and utilization of healthcare services up to 90days after discharge were compared between Black and White patients. RESULTS: Of the 5192 children included, majority were White (74.6%, n=3871), with 15.4% Black (n=800) and 10.0% Other (n=521). Most common injuries involved the extremities or the pelvic girdle followed by the head or neck. Complication and readmission rates were 3.6% and 8.9% within 30days of discharge respectively and 4.4% and 9.3% within 90days of discharge. 99.0% of children had at least one outpatient visit by 90days. After adjusting for patient and injury characteristics no significant differences were detected between Black and White children in outcomes after discharge. CONCLUSIONS: Universal insurance may help mitigate disparities in post discharge care in pediatric trauma populations by increasing access to outpatient services overall and within each racial group. Further studies are required to determine the appropriate timing and frequency of follow up care in order to achieve maximum reduction in use of acute care services after discharge.

Patterns of use and factors associated with early discontinuation of opioids following major trauma.

BACKGROUND: Inappropriate use of prescription opioids is a growing public-health issue. We sought to estimate the proportion of traumatic injury patients using legal prescription opioids up to 1-year after hospitalization. METHODS: We used 2006-2014 claims data from TRICARE insurance to identify adults hospitalized secondary to trauma between 2007 and 2013. Prescription opioid use was evaluated for one-year post-discharge. Risk-adjusted Cox Proportional-hazards models were used to evaluate predictors of opioid discontinuation. RESULTS: Only 1% of patients sustained legal prescription opioid use at 1-year following trauma. Lower socioeconomic status (HR 0.92, 95% CI 0.87-0.98) and higher injury severity (HR 0.88, 95% CI 0.84-0.91) were associated with sustained use. Younger patients (HR 1.12, 95% CI 1.04-1.21) and Black patients (HR 1.09, 95% CI 1.04-1.15) were found to have a higher likelihood of opioid discontinuation. CONCLUSIONS: In this population, adult patients who sustained trauma were not at high risk of sustained legal prescription opioid use.

Incidence and Predictors of Opioid Prescription at Discharge After Traumatic Injury.

IMPORTANCE: In the current health care environment with increased scrutiny and growing concern regarding opioid use and abuse, there has been a push toward greater regulation over prescriptions of opioids. Trauma patients represent a population that may be affected by this regulation, as the incidence of pain at hospital discharge is greater than 95%, and opioids are considered the first line of treatment for pain management. However, the use of opioid prescriptions in trauma patients at hospital discharge has not been explored. OBJECTIVE: To study the incidence and predictors of opioid prescription in trauma patients at discharge in a large national cohort. DESIGN, SETTING, AND PARTICIPANTS: Analysis of adult (18-64 years), opioid-naive trauma patients who were beneficiaries of Military Health Insurance (military personnel and their dependents) treated at both military health care facilities and civilian trauma centers and hospitals between January 1, 2006, and December 31, 2013, was conducted. Patients with burns, foreign body injury, toxic effects, or late complications of trauma were excluded. Prior diagnosis of trauma within 1 year and in-hospital death were also grounds for exclusion. Injury mechanism and severity, comorbid conditions, mental health disorders, and demographic factors were considered covariates. The Drug Enforcement Administration's list of scheduled narcotics was used to query opioid use. Unadjusted and adjusted logistic regression models were used to determine the predictors of opioid prescription. Data analysis was performed from June 7 to August 21, 2016. EXPOSURES: Injury mechanism and severity, comorbid conditions, mental health disorders, and demographic factors. MAIN OUTCOMES AND MEASURES: Prescription of opioid analgesics at discharge. RESULTS: Among the 33 762 patients included in the study (26 997 [80.0%] men; mean [SD] age, 32.9 [13.3] years), 18 338 (54.3%) received an opioid prescription at discharge. In risk-adjusted models, older age (45-64 vs 18-24 years: odds ratio [OR], 1.28; 95% CI, 1.13-1.44), marriage (OR, 1.26; 95% CI, 1.20-1.34), and higher Injury Severity Score (≥9 vs <9: OR, 1.40; 95% CI, 1.32-1.48) were associated with a higher likelihood of opioid prescription at discharge. Male sex (OR, 0.76; 95% CI, 0.69-0.83) and anxiety (OR, 0.82; 95% CI, 0.73-0.93) were associated with a decreased likelihood of opioid prescription at discharge. CONCLUSIONS AND RELEVANCE: The incidence of opioid prescription at discharge (54.3%) closely matches the incidence of moderate to severe pain in trauma patients, indicating appropriate prescribing practices. We advocate that injury severity and level of pain-not arbitrary regulations-should inform the decision to prescribe opioids.

Tympanostomy Tube Placement vs Medical Management for Recurrent Acute Otitis Media in TRICARE-Insured Children.

Objective To compare number of infections and health care utilization in children insured by TRICARE with recurrent acute otitis media (RAOM) managed surgically with tympanostomy tube (TT) placement compared with those managed medically. Study Design Retrospective matched cohort study. Setting TRICARE claims database from 2006 to 2010. Subjects and Methods We matched TRICARE beneficiaries ≤5 years of age diagnosed with RAOM who underwent TT placement with those managed medically using 1:1 coarsened-exact matching on age, sex, race, sponsor rank, and region. We used multivariable negative binomial regression to compare number of infections and health care utilization at 1 and 2 years. Outcomes were adjusted for rate of infection before treatment for RAOM, season of either TT placement or establishment of candidacy for TT placement, and comorbidities. Results Among 6659 pairs identified at 1-year follow-up, the TT group had fewer infections (1.96 vs 2.18, P < .001) and oral antibiotic prescriptions (1.52 vs 1.67, P < .001) but more visits to primary care physicians (4.36 vs 4.06, P < .0001) and otolaryngologists (1.21 vs 0.44, P < .0001) compared with the medically managed group. At 2-year follow-up, the benefits of TT placement were no longer seen. Conclusion TT placement for RAOM is associated with fewer infections and oral antibiotic prescriptions in the first year after surgery but more doctor visits. Benefits of TT placement do not appear to extend through the second year. Future research should investigate costs associated with TT placement vs medical management, as well as real-time health care utilization with impact on patient symptoms and quality of life.

Does Universal Insurance Mitigate Racial Differences in Minimally Invasive Hysterectomy?

STUDY OBJECTIVE: To determine if racial differences exist in receipt of minimally invasive hysterectomy (defined as total vaginal hysterectomy [TVH] and total laparoscopic hysterectomy [TLH]) compared with an open approach (total abdominal hysterectomy [TAH]) within a universally insured patient population. DESIGN: Retrospective data analysis (Canadian Task Force classification II-2). SETTING: The 2006-2010 national TRICARE (universal insurance coverage to US Armed Services members and their dependents) longitudinal claims data. PATIENTS: Women aged 18 years and above who underwent hysterectomy stratified into 4 racial groups: white, African American, Asian, and "other." INTERVENTION: Receipt of hysterectomy (TAH, TVH, or TLH). MEASUREMENTS AND MAIN RESULTS: We used risk-adjusted multinomial logistic regression models to determine the relative risk ratios of receipt of TVH and TLH compared with TAH in each racial group compared with referent category of white patients for benign conditions. Among 33 015 patients identified, 60.82% (n = 20 079) were white, 26.11% (n = 8621) African American, 4.63% (n = 1529) Asian, and 8.44% (n = 2786) other. Most hysterectomies (83.9%) were for benign indications. Nearly 42% of hysterectomies (n = 13 917) were TAH, 27% (n = 8937) were TVH, and 30% (n = 10 161) were TLH. Overall, 36.37% of white patients received TAH compared with 53.40% of African American patients and 51.01% of Asian patients (p < .001). On multinomial logistic regression analyses, African American patients were significantly less likely than white patients to receive TVH (relative risk ratio [RRR], .63; 95% confidence interval [CI], .58-.69) or TLH (RRR, .65; 95% CI, .60-.71) compared with TAH. Similarly, Asian patients were less likely than white patients to receive TVH (RRR, .71; 95% CI, .60-.84) or TLH (RRR, .69; 95% CI, .58-.83) compared with TAH. Analyses by benign indications for surgery showed similar trends. CONCLUSION: We demonstrate that racial minority patients are less likely to receive a minimally invasive surgical approach compared with an open abdominal approach despite universal insurance coverage. Further work is warranted to better understand factors other than insurance access that may contribute to racial differences in surgical approach to hysterectomies.

Parent and Provider Experience and Shared Understanding After a Family-Centered Nighttime Communication Intervention.

OBJECTIVE: To assess parent and provider experience and shared understanding after a family-centered, multidisciplinary nighttime communication intervention (nurse-physician brief, family huddle, family update sheet). METHODS: We performed a prospective intervention study at a children's hospital from May 2013 to October 2013 (preintervention period) and May 2014 to October 2014 (postintervention period). Participants included 464 parents, 176 nurses, and 52 resident physicians of 582 hospitalized 0- to 17-year-old patients. Pre- versus postintervention, we compared parent/provider top-box scores (eg, "excellent") for experience with communication across several domains; and level of agreement (shared understanding) between parent, nurse, and resident reports of patients' reason for admission, overnight medical plan, and overall medical plan, as rated independently by blinded clinician reviewers (agreement = 74.7%, kappa = .60). RESULTS: Top-box parent experience improved for 1 of 4 domains: Experience and Communication With Nighttime Doctors (23.6% to 31.5%). Top-box provider experience improved for all 3 domains, including Communication and Shared Understanding With Families (resident rated, 16.5% to 35.1%; nurse rated, 32.2% to 37.9%) and Experience, Communication, and Shared Understanding With Other Providers (resident rated, 20.3% to 35.0%; nurse rated, 14.7% to 21.5%). Independently rated shared understanding remained unchanged for most domains but improved for parent-nurse composite shared understanding (summed agreement for reason for admission, overall plan, and overnight plan; 36.2% to 48.2%) and nurse-resident shared understanding regarding reason for admission (67.1% to 71.2%) and regarding overall medical plan (45.0% to 58.6%). All P <.05. CONCLUSIONS: A family-centered, multidisciplinary nighttime communication intervention was associated with improvements in some, but not all, domains of parent/provider experience and shared understanding, particularly provider experience and nurse-family shared understanding. The intervention was promising but requires further refinement.

Factors associated with health-related quality of life (HRQOL) in adults with short stature skeletal dysplasias.

INTRODUCTION: Numerous factors associate with health disparities. The extent to which such factors influence health-related quality of life (HRQOL) among adults with short stature skeletal dysplasias (SD) is unknown. In an effort to update and clarify knowledge about the HRQOL of adults with SD, this study aimed to quantify HRQOL scores relative to the American average and assess whether specific indicators are associated with lower scores. METHODS: Members (>18 years) of Little People of America were invited to complete an online survey assessing HRQOL using the SF-12 supplemented with indicator-specific questions. SF-12 components (Physical Component Summary, PCS; Mental Component Summary, MCS) were compared to the standardized national American mean. Scores were divided at the median to identify factors associated with lower scores using multivariable logistic regression, adjusting for age, gender, race, education, and employment. RESULTS: A total of 189 surveys were completed. Mean and median PCS and MCS were below the national mean of 50 (p < 0.001). Advancing decade of age corresponded to a significant decline in PCS (p < 0.001) but not MCS (p = 0.366). Pain prevalence was high (79.4%); however, only 5.9% visited a pain specialist. Significant factors for lower PCS included age >40 years (p = 0.020), having spondyloepiphyseal dysplasia congenita (SED) or diastrophic dysplasia relative to achondroplasia (p = 0.023), pain (p < 0.001), and "partial" versus "full" health insurance coverage (p = 0.034). For MCS, significant factors included a lack of social support (p = 0.002) and being treated differently/feeling stigmatized by health care providers (p = 0.022). CONCLUSIONS: Individuals with SD face documented disparities and report lower HRQOL. Further research and interventions are needed to modify nuanced factors influencing these results and address the high prevalence of pain.