Factors Associated with Opting Out of an Unrelated Hematopoietic Stem Cell Donor Registry: Differences and Similarities across Five Key Groups of Young Race/Ethnically Diverse Potential Donors in the United States.

Young adults from underserved racial/ethnic groups are critically needed as unrelated hematopoietic stem cell (HSC) donors, yet they are more likely than other groups to opt out of donation after having matched a patient. Understanding which factors are most strongly associated with opting out among young underserved racial/ ethnic registered donors compared with their White counterparts will provide the basis for specific interventions to improve donor retention. We sought to determine the key, modifiable psychosocial, registry-related, and donation-related characteristics that are uniquely associated with opting out across 5 key racial/ethnic groups of young HSC donor registry members who had been contacted as a potential match for a patient. This study examines data from a large cross-sectional survey of young (age 18 to 30) registry members shortly after they preliminarily matched a patient (CT-stage) and continued toward or opted out of donation (CT-C and CT-NI), stratified by racial/ethnic group and sex. We assessed psychosocial, registry-related, and donation-related characteristics for all participants. We used chi-squared and F tests to assess differences between racial/ethnic groups. A separate logistic regression analysis for each racial/ethnic group was conducted to quantify adjusted associations between each variable and opting out. Then, we compared these associations across the racial/ethnic groups by evaluating the interaction effect between each variable and racial/ethnic group, with the same outcome (CT-C versus CT-NI) in question. Nine hundred thirty-five participants were surveyed, including 284 White, 165 Hispanic, 191 Black, 192 Asian/Pacific Islander, and 103 Multiracial/multiethnic participants. There were significant differences across racial/ethnic groups in values/goals, religious objections to donation, HSC-related medical mistrust, and parental involvement in donation decisions. Adjusted logistic regression subgroup analyses indicated that ambivalence was strongly associated with opting out across all racial/ethnic groups. Greater focus on intrinsic life goals (e.g., raising a family, becoming a community leader, influencing social values) was associated with opting out in the Multiracial/multiethnic, Hispanic, and Asian/Pacific Islander groups. Healthcare mistrust and insufficient registry contact was a significant factor for Hispanic participants. Protective factors against opting out included remembering joining the registry (Black participants), and parental support for donation decision (Asian/Pacific Islander participants). The performance of each logistic regression model was strong, with area-under-the curve ≥.88, CT-stage outcome classification accuracy ≥89%, and good fit between expected and observed opt-out probabilities. In the analysis across different racial/ethnic groups, the only significant interaction was race/ethnicity by whether more contact with the registry would have changed the decision at CT-stage; this variable was significant only for the Hispanic group. In the within-group analysis for Hispanic participants, the "more registry contact" variable was strongly associated with opting out (odds ratio 5.8, P = .03). Consistent with a growing body of HSC donor research, ambivalence was a key factor associated with opting-out for all racial/ethnic groups. Other key variables were differentially associated with opting-out depending on racial/ethnic group. Our study highlights key variables that registries should focus on as they develop targeted and tailored strategies to enhance commitment and reduce attrition of potential donors.

Women's Reactions to Breast Density Information Vary by Sociodemographic Characteristics.

BACKGROUND: Breast density information aims to increase awareness of breast density and its risks and to foster more informed future breast screening decisions among women with dense breasts. We explored associations between such information and outcomes including anxiety, confusion, or feeling informed, and whether they varied by race/ethnicity or literacy, or differentially affected future mammography plans. METHODS: A national telephone survey of a diverse sample of women previously informed of personal breast density (N = 1,322) assessed reactions to receipt of breast density information and future mammography plans. RESULTS: Most women (86%) felt informed after receiving personal breast density information; however, some felt anxious (15%) or confused (11%). Reactions varied significantly by sociodemographics; non-Hispanic Black, Asian, and Hispanic women and women with low literacy were nearly two to three times more likely to report anxiety than non-Hispanic White women (all ps < .05). Asian women and those with low literacy less often felt informed and more often felt confused. Non-Hispanic Black and Asian women were nearly twice as likely to report that knowing their breast density made them more likely to have future mammograms. Women with low literacy were more likely to change mammography plans, with some being more likely and others less likely to plan to have future mammograms. Greater anxiety and confusion were associated with higher likelihood of planning future mammograms; those feeling informed were less likely to plan future mammography. CONCLUSIONS: Differential reactions to breast density information are concerning if associated with disparate future screening plans. Future breast density education efforts should ensure that such information is readily accessible and understandable to all women in order to lead to desired effects.

A sociogenia fanoniana e a formação em psicologia: uma aposta clínica política e negra / Fanonian sociogeny and training in psychology: a political and black clinical bid / La sociogenia fanoniana y la formación en psicología: una apuesta clínica política y negra

Resumo Em 2020, recebíamos, no Brasil, a tradução do livro Écrits sur l´aliénation et la liberté de Frantz Fanon que, aliado a outras obras como Pele negra, máscaras brancas e Os condenados da terra, apresentava a sociogenia como condição imprescindível para compreensão das vidas negras em sua relação com o sofrimento físico e psíquico e a possibilidade de um fazer clínico que não se pautasse apenas na dimensão filogenética e ontogenética dos estados mentais e físicos. Partindo da sociogenia fanoniana como princípio e método, este artigo objetiva refletir sobre a possibilidade de construção de um processo de formação em Psicologia que tome a dimensão sociogênica como espaço vital para que o cuidado possa ser pensado em relação às comunidades negras nos diferentes contextos brasileiros. Defendemos a necessidade urgente de a formação e a práxis em Psicologia assumirem a discussão da sociogênese fanoniana como imprescindível.

Resumen En 2020 recibimos la traducción brasileña del libro Écrits sur l´aliénation et la liberté, de Frantz Fanon. Combinado con otras obras como Piel negra, máscaras blancas y Los condenados de la tierra, el libro presenta la sociogenia como condición esencial para comprender las vidas negras en su relación con el sufrimiento físico y psíquico y la posibilidad de una práctica clínica que no se basa únicamente en la dimensión filogenética y ontogenética de los estados físicos y mentales. A partir de la sociogenia fanoniana como principio y método, este artículo tiene como objetivo principal reflexionar sobre las posibilidades de construir un proceso de formación en Psicología que aborde la dimensión sociogénica como un espacio vital para pensar el cuidado en relación con las comunidades negras en diferentes contextos brasileños. Defendemos la urgente necesidad de formación y praxis en Psicología para asumir como imprescindible la discusión de la sociogénesis fanoniana.

Abstract In 2020, we received the Brazilian translation of the book Écrits sur l´aliénation et la liberté (Alienation and freedom), by Frantz Fanon. Combined with other works such as Black skin, white masks and The wretched of the earth, the book presents sociogeny as an essential condition for understanding black lives in their relationship with physical and psychological suffering and the possibility of a clinical practice that is not based solely on the phylogenetic and ontogenetic dimension mental and physical states. Starting from Fanonian sociogeny as a principle and method, this paper aims to reflect on the possibility of building a training process in Psychology that takes the sociogenic dimension as a vital space so that care can be thought of in relation to black communities in different Brazilian contexts. We defend the urgent need for training and praxis in Psychology to assume the discussion of Fanonian sociogenesis as essential.

The association between lung cancer stigma and race: A descriptive correlational study.

BACKGROUND: Stigma is a formidable burden for survivors of lung cancer that can reduce the quality of life (QOL), resulting in physical, social and psychological challenges. This study investigates associations between stigma and depression, QOL and demographic and health-related characteristics, including race. DESIGN: An adapted conceptual model derived from the Cataldo Lung Cancer Stigma Scale guided this descriptive correlation study assessing stigma in African American and Caucasian survivors of lung cancer. Self-reported, written surveys measuring depression, QOL, lung cancer stigma and demographics were administered. Statistical analysis was conducted to assess associations between stigma and depression, stigma and QOL and stigma and race, while adjusting for demographic characteristics. RESULTS: Participants (N = 56) included 30 Caucasian and 26 African American survivors of lung cancer recruited from a cancer registry of an American College of Surgeons-accredited programme, a survivors' support club and an ambulatory oncology practice in the southeastern United States. Statistical analysis yielded (1) a significant moderate positive association between depression and lung cancer stigma; (2) a significant moderate negative association between QOL and lung cancer stigma; and (3) significant relationships between race and lung cancer stigma, specifically higher degree of stigma among African Americans compared to Caucasians. CONCLUSION: Stigma affects many aspects of survivors' lives. Healthcare professionals need to consider how health-related stigma may further complicate the physical burdens, psychological distresses and social challenges that accompany the disease, especially among African American survivors. Additional enquiry and interventions are needed to assist with mitigating the negative effects of stigma on survivors and their family members and friends. PATIENT OR PUBLIC CONTRIBUTION: Fifty-six survivors of lung cancer participated in this descriptivecorrelation study. They completed written surveys measuring depression, QOL, and lung cancer stigma, plus an investigator-developed demographic information form.

Standardized oral examinations allow for assessment of medical student clinical knowledge and decrease racial grading differences in a surgery clerkship.

BACKGROUND: Oral examinations are not consistently included in third-year medical student clerkships. When included, they are often unstructured, leaving room for variations in difficulty or scoring. Previous research has demonstrated differences in clinical grade achievement, with underrepresented in medicine students receiving significantly lower grades than White students. METHODS: We designed a structured oral examination for third-year medical students on the surgery clerkship. Students completed 2 oral examination scenarios and were evaluated on their ability to complete a history and diagnostic workup, interpret laboratory and imaging results, and devise a treatment plan. Scores from our examination were compared to previous, unstructured oral examination scores and to student demographics. Students and faculty were surveyed regarding their experience. RESULTS: Third-year medical students demonstrated strong knowledge of multiple surgical diseases. The greatest number of errors occurred in treatment planning (P < .001). Third-year medical students receiving honors clerkship grades achieved higher percentages of correct items on their oral examination. (94.8% vs 90.4%) (P = .02). Evaluation of prior unstructured oral examinations found underrepresented in medicine students received lower scores than White students (P = .04). After implementation of our structured examination, no difference was seen between the scores of underrepresented in medicine and White students (P = .99). CONCLUSION: We implemented a standardized oral examination for third-year medical students on the surgery clerkship with student and faculty satisfaction and demonstrated the ability to determine domains of knowledge weakness. The application of our structured oral examination helped to address nonspecific grading practices and eliminate oral examination grade differences between underrepresented in medicine and White students.

Changes of Exercise, Screen Time, Fast Food Consumption, Alcohol, and Cigarette Smoking during the COVID-19 Pandemic among Adults in the United States.

OBJECTIVE: To investigate the impact of the COVID-19 pandemic on multiple lifestyle changes among adults in the United States (USA). METHODS: We conducted a survey, the Health, Ethnicity, and Pandemic (HEAP) Study, in October 2020 among USA adults. Participants were selected from the United States using 48 sampling strata, including age, race, ethnicity, education, and gender, and were asked to report five lifestyle behaviors (i.e., exercise time, screen time, fast-food meal consumption, alcohol drinking, and cigarette smoking) before and during the COVID-19 pandemic. The associations of sociodemographic factors with each lifestyle change were estimated using weighted multivariable logistic regression models. RESULTS: All 2709 HEAP participants were included in this study. Compared to pre-pandemic, the time spent on exercise decreased (32.06 vs. 38.65 min/day; p < 0.001) and screen time increased (6.79 vs. 5.06 h/day; p < 0.001) during the pandemic. The percentage of individuals who reported consuming fast-food meals ≥3 times/week decreased from 37.7% before the pandemic to 33.3% during the pandemic. The percentage of heavy drinkers (≥5 times/week) increased from 20.9% before the pandemic to 25.7% during the pandemic. Among smokers, heavy smoking (≥11 cigarettes/day) increased from 5.8% before the pandemic to 7.9% during the pandemic. We also identified subgroups who were more vulnerable to adverse influences from the pandemic, including racial/ethnic minority groups and young adults. CONCLUSIONS: The COVID-19 pandemic had negative impacts on multiple lifestyle behaviors among Americans. Mitigating such negative impacts of COVID-19 requires effective interventions, particularly for some vulnerable subgroups.

Is physician implicit bias associated with differences in care by patient race for metastatic cancer-related pain?

RATIONALE: Implicit racial bias affects many human interactions including patient-physician encounters. Its impact, however, varies between studies. We assessed the effects of physician implicit, racial bias on their management of cancer-related pain using a randomized field experiment. METHODS: We conducted an analysis of a randomized field experiment between 2012 and 2016 with 96 primary care physicians and oncologists using unannounced, Black and White standardized patients (SPs)who reported uncontrolled bone pain from metastatic lung cancer. We assessed implicit bias using a pain-adaptation of the race Implicit Association Test. We assessed clinical care by reviewing medical records and prescriptions, and we assessed communication from coded transcripts and covert audiotapes of the unannounced standardized patient office visits. We assessed effects of interactions of physicians' implicit bias and SP race with clinical care and communication outcomes. We conducted a slopes analysis to examine the nature of significant interactions. RESULTS: As hypothesized, physicians with greater implicit bias provided lower quality care to Black SPs, including fewer renewals for an indicated opioid prescription and less patient-centered pain communication, but similar routine pain assessment. In contrast to our other hypotheses, physician implicit bias did not interact with SP race for prognostic communication or verbal dominance. Analysis of the slopes for the cross-over interactions showed that greater physician bias was manifested by more frequent opioid prescribing and greater discussion of pain for White SPs and slightly less frequent prescribing and pain talk for Black SPs with the opposite effect among physicians with lower implicit bias. Findings are limited by use of an unvalidated, pain-adapted IAT. CONCLUSION: Using SP methodology, physicians' implicit bias was associated with clinically meaningful, racial differences in management of uncontrolled pain related to metastatic lung cancer. There is favorable treatment of White or Black SPs, depending on the level of implicit bias.

Mechanisms of socioeconomic differences in COVID-19 screening and hospitalizations.

BACKGROUND: Social and ecological differences in early SARS-CoV-2 pandemic screening and outcomes have been documented, but the means by which these differences have arisen are not well understood. OBJECTIVE: To characterize socioeconomic and chronic disease-related mechanisms underlying these differences. DESIGN: Observational cohort study. SETTING: Outpatient and emergency care. PATIENTS: 12900 Cleveland Clinic Health System patients referred for SARS-CoV-2 testing between March 17 and April 15, 2020. INTERVENTIONS: Nasopharyngeal PCR test for SARS-CoV-2 infection. MEASUREMENTS: Test location (emergency department, ED, vs. outpatient care), COVID-19 symptoms, test positivity and hospitalization among positive cases. RESULTS: We identified six classes of symptoms, ranging in test positivity from 3.4% to 23%. Non-Hispanic Black race/ethnicity was disproportionately represented in the group with highest positivity rates. Non-Hispanic Black patients ranged from 1.81 [95% confidence interval: 0.91-3.59] times (at age 20) to 2.37 [1.54-3.65] times (at age 80) more likely to test positive for the SARS-CoV-2 virus than non-Hispanic White patients, while test positivity was not significantly different across the neighborhood income spectrum. Testing in the emergency department (OR: 5.4 [3.9, 7.5]) and cardiovascular disease (OR: 2.5 [1.7, 3.8]) were related to increased risk of hospitalization among the 1247 patients who tested positive. LIMITATIONS: Constraints on availability of test kits forced providers to selectively test for SARS-Cov-2. CONCLUSION: Non-Hispanic Black patients and patients from low-income neighborhoods tended toward more severe and prolonged symptom profiles and increased comorbidity burden. These factors were associated with higher rates of testing in the ED. Non-Hispanic Black patients also had higher test positivity rates.

Attitudes toward deprescribing among adults with heart failure with preserved ejection fraction.

BACKGROUND/OBJECTIVES: Attitudes toward deprescribing could vary among subpopulations. We sought to understand patient attitudes toward deprescribing among patients with heart failure with preserved ejection fraction (HFpEF). DESIGN: Retrospective cohort study. SETTING: Academic medical center in New York City. PARTICIPANTS: Consecutive patients with HFpEF seen in July 2018-December 2019 at a program dedicated to providing care to older adults with HFpEF. MEASUREMENTS: We assessed the prevalence of vulnerabilities outlined in the domain management approach for caring for patients with heart failure and examined data on patient attitudes toward having their medicines deprescribed via the revised Patient Attitudes Toward Deprescribing (rPATD). RESULTS: Among 134 patients with HFpEF, median age was 75 (interquartile range 69-82), 60.4% were women, and 35.8% were nonwhite. Almost all patients had polypharmacy (94.0%) and 56.0% had hyperpolypharmacy; multimorbidity (80.6%) and frailty (78.7%) were also common. Overall, 90.3% reported that they would be willing to have one or more of their medicines deprescribed if told it was possible by their doctors; and 26.9% reported that they would like to try stopping one of their medicines to see how they feel without it. Notably, 91.8% of patients reported that they would like to be involved in decisions about their medicines. In bivariate logistic regression, nonwhite participants were less likely to want to try stopping one of their medicines to see how they feel without it (odds ratio 0.25, 95% confidence interval [0.09-0.62], p = 0.005). CONCLUSIONS: Patients with HFpEF contend with many vulnerabilities that could prompt consideration for deprescribing. Most patients with HFpEF were amenable to deprescribing. Race may be an important factor that impacts patient attitudes toward deprescribing.

Racial and Ethnic Differences in COVID-19 Outcomes, Stressors, Fear, and Prevention Behaviors Among US Women: Web-Based Cross-sectional Study.

BACKGROUND: In the United States, racial and ethnic minorities are disproportionately affected by COVID-19, with persistent social and structural factors contributing to these disparities. At the intersection of race/ethnicity and gender, women of color may be disadvantaged in terms of COVID-19 outcomes due to their role as essential workers, their higher prevalence of pre-existing conditions, their increased stress and anxiety from the loss of wages and caregiving, and domestic violence. OBJECTIVE: The purpose of this study is to examine racial and ethnic differences in the prevalence of COVID-19 outcomes, stressors, fear, and prevention behaviors among adult women residing in the United States. METHODS: Between May and June 2020, women were recruited into the Capturing Women's Experiences in Outbreak and Pandemic Environments (COPE) Study, a web-based cross-sectional study, using advertisements on Facebook; 491 eligible women completed a self-administered internet-based cross-sectional survey. Descriptive statistics were used to examine racial and ethnic differences (White; Asian; Native Hawaiian or other Pacific Islander; Black; Hispanic, Latina, or Spanish Origin; American Indian or Alaskan Native; multiracial or some other race, ethnicity, or origin) on COVID-19 outcomes, stressors, fear, and prevention behaviors. RESULTS: Among our sample of women, 16% (73/470) reported COVID-19 symptoms, 22% (18/82) were concerned about possible exposure from the people they knew who tested positive for COVID-19, and 51.4% (227/442) knew where to get tested; yet, only 5.8% (27/469) had been tested. Racial/ethnic differences were observed, with racial/ethnic minority women being less likely to know where to get tested. Significant differences in race/ethnicity were observed for select stressors (food insecurity, not enough money, homeschooling children, unable to have a doctor or telemedicine appointment) and prevention behaviors (handwashing with soap, self-isolation if sick, public glove use, not leaving home for any activities). Although no racial/ethnic differences emerged from the Fear of COVID-19 Scale, significant racial/ethnic differences were observed for some of the individual scale items (eg, being afraid of getting COVID-19, sleep loss, and heart racing due to worrying about COVID-19). CONCLUSIONS: The low prevalence of COVID-19 testing and knowledge of where to get tested indicate a critical need to expand testing for women in the United States, particularly among racial/ethnic minority women. Although the overall prevalence of engagement in prevention behaviors was high, targeted education and promotion of prevention activities are warranted in communities of color, particularly with consideration for stressors and adverse mental health.

Racial and ethnic variations in caregiving-related physical, emotional, and financial strain during COVID-19 among those caring for adult cancer patients.

PURPOSE: Cancer caregiving is shown to be a burdensome experience in typical times. The purpose of this study was to describe cancer caregivers' emotional, physical, and financial strain during the COVID-19 pandemic and compared to preCOVID-19, and explore racial and ethnic variations in caregiver strain. METHODS: We conducted a cross-sectional online survey using Lucid, LLC, incorporating quotas for race, ethnicity, gender and age. Caregivers had to be adults living in the USA and currently providing unpaid care to an adult cancer patient (i.e., during COVID-19) and prior to the pandemic. We assessed the caregivers' emotional, physical, and financial strain and asked them to compare to preCOVID-19 caregiving. Analyses included descriptive and linear regression adjusting for sociodemographic and caregiving-related variables. RESULTS: A total of 285 caregivers met eligibility, and most were nonHispanic white (72.3%) and female (59.6%). Based on a scale of "1: Much lower" to "5: Much higher", the financial, physical and emotional strain/stress experienced by caregivers compared to preCOVID-19 was, on average, 3.52 (SD: 0.82; range: 1-5) for financial strain, 3.61 (SD: 0.86; range: 1-5) for physical strain, and 3.88 (SD: 0.89; range: 1-5) for emotional stress. NonHispanic black caregivers were significantly more likely than nonHispanic white caregivers to indicate that caregiving-related financial strain was higher than preCOVID-19. Moreover, Hispanic caregivers compared to nonHispanic white caregivers reported caregiving-related emotional stress was higher than preCOVID-19. CONCLUSION: These findings suggest a need to be attentive to racial and ethnic variations in emotional and financial strain and provide targeted support in clinical care and via public policy during a public health crisis.

Comparison of the Modified Checklist for Autism in Toddlers, Revised with Follow-Up (M-CHAT-R/F) Positive Predictive Value by Race.

The Modified Checklist for Autism in Toddlers, Revised, with Follow-Up (M-CHAT-R/F) is the most widely used screener for ASD. Despite the comparable rate of ASD in Black and White children, the M-CHAT-R/F was validated on a primarily White, Non-Hispanic sample. Few studies have assessed whether the screener performs adequately with racial minorities. This study compared the M-CHAT-R/F Positive Predictive Value (PPV), for ASD, and for any developmental condition, in Black and White children. We also examined M-CHAT-R/F item-level PPV by race. The PPVs for ASD and other developmental disorders were similar in both racial groups for total score and individual items. Therefore, our findings support the use of the M-CHAT-R/F with Black and White children.

The Association of Race/Ethnicity, Dietary Intake, and Physical Activity with Depression.

OBJECTIVE: This study investigated the association of race/ethnicity, dietary intake, and physical activity with depression and potential other barriers associated with the use of mental health services among depressed people. METHODS: We used the nationally representative data, 2011-2016 National Health and Nutrition Examination Survey. Depression status was defined using a Patient Health Questionnaire. Multivariable logistic regressions were conducted on depression status and the use of mental health specialists among depressed adults, accounting for the complex sampling design. RESULTS: The prevalence of depression was 8.3% with substantial racial/ethnic differences (8.0% for white, 3.1% for Asian, 9.2% for black, 7.6% for Mexican Hispanics, 13.0% for other Hispanics). Good/acceptable diet and a high level of physical activity were negatively associated with depression. Among depressed people, no significant racial/ethnic differences were observed in using mental health specialists. CONCLUSION: Prevalence for depression was lower among people who have good or acceptable diet and moderate physical activity. These modifiable factors as well as race/ethnicity should be incorporated into psychotherapeutic interventions to improve depression.

How Do Medical Students Perceive Diversity in Orthopaedic Surgery, and How Do Their Perceptions Change After an Orthopaedic Clinical Rotation?

BACKGROUND: A diverse physician workforce improves the quality of care for all patients, and there is a need for greater diversity in orthopaedic surgery. It is important that medical students of diverse backgrounds be encouraged to pursue the specialty, but to do so, we must understand students' perceptions of diversity and inclusion in orthopaedics. We also currently lack knowledge about how participation in an orthopaedic clinical rotation might influence these perceptions. QUESTIONS/PURPOSES: (1) How do the perceptions of diversity and inclusion in orthopaedic surgery compare among medical students of different gender identities, races or ethnicities, and sexual orientations? (2) How do perceptions change after an orthopaedic clinical rotation among members of demographic groups who are not the majority in orthopaedics (that is, cis-gender women, underrepresented racial minorities, other racial minorities, and nonheterosexual people)? METHODS: We surveyed students from 27 US medical schools who had completed orthopaedic rotations. We asked about their demographic characteristics, rotation experience, perceptions of diversity and inclusion in orthopaedics, and personal views on specialty choice. Questions were derived from diversity, equity, and inclusion climate surveys used at major academic institutions. Cis-gender men and cis-gender women were defined as those who self-identified their gender as men or women, respectively, and were not transgender. Forty-five percent (59 of 131) of respondents were cis-men and 53% (70 of 131) were cis-women; 49% (64 of 131) were white, 20% (26 of 131) were of underrepresented racial minorities, and 31% (41 of 131) were of other races. Eighty-five percent (112 of 131) of respondents were heterosexual and 15% (19 of 131) reported having another sexual orientation. We compared prerotation and postrotation perceptions of diversity and inclusion between majority and nonmajority demographic groups for each demographic domain (for example, cis-men versus cis-women). We also compared prerotation to postrotation perceptions within each nonmajority demographic group. To identify potential confounding variables, we performed univariate analysis to compare student and rotation characteristics across the demographic groups, assessed using an alpha of 0.05. No potential confounders were identified. Statistical significance was assessed at a Bonferroni-adjusted alpha of 0.0125. Our estimated response percentage was 26%. To determine limitations of nonresponse bias, we compared all early versus late responders and found that for three survey questions, late responders had a more favorable perception of diversity in orthopaedic surgery, whereas for most questions, there was no difference. RESULTS: Before rotation, cis-women had lower agreement that diversity and inclusion are part of orthopaedic culture (mean score 0.96 ± 0.75) compared with cis-men (1.4 ± 1.1) (mean difference 0.48 [95% confidence interval 0.16 to 0.81]; p = 0.004), viewed orthopaedic surgery as less diverse (cis-women 0.71 ± 0.73 versus cis-men 1.2 ± 0.92; mean difference 0.49 [95% CI 0.20 to 0.78]; p = 0.001) and more sexist (cis-women 1.3 ± 0.92 versus cis-men 1.9 ± 1.2; mean difference 0.61 [95% CI 0.23 to 0.99]; p = 0.002), believed they would have to work harder than others to be valued equally (cis-women 2.8 ± 1.0 versus cis-men 1.9 ± 1.3; mean difference 0.87 [95% CI 0.45 to 1.3]; p < 0.001), and were less likely to pursue orthopaedic surgery (cis-women 1.4 ± 1.4 versus cis-men 2.6 ± 1.1; mean difference 1.2 [95% CI 0.76 to 1.6]; p < 0.001). Before rotation, underrepresented minorities had less agreement that diversity and inclusion are part of orthopaedic surgery culture (0.73 ± 0.72) compared with white students (1.5 ± 0.97) (mean difference 0.72 [95% CI 0.35 to 1.1]; p < 0.001). Many of these differences between nonmajority and majority demographic groups ceased to exist after rotation. Compared with their own prerotation beliefs, after rotation, cis-women believed more that diversity and inclusion are part of orthopaedic surgery culture (prerotation mean score 0.96 ± 0.75 versus postrotation mean score 1.2 ± 0.96; mean difference 0.60 [95% CI 0.22 to 0.98]; p = 0.002) and that orthopaedic surgery is friendlier (prerotation 2.3 ± 1.2 versus postrotation 2.6 ± 1.1; mean difference 0.41 [95% CI 0.14 to 0.69]; p = 0.004), more diverse (prerotation 0.71 ± 0.73 versus postrotation 1.0 ± 0.89; mean difference 0.28 [95% CI 0.08 to 0.49]; p = 0.007), less sexist (prerotation 1.3 ± 0.92 versus postrotation 1.9 ± 1.0; mean difference 0.63 [95% CI 0.40 to 0.85]; p < 0.001), less homophobic (prerotation 2.1 ± 1.0 versus postrotation 2.4 ± 0.97; mean difference 0.27 [95% CI 0.062 to 0.47]; p = 0.011), and less racist (prerotation 2.3 ± 1.1 versus postrotation 2.5 ± 1.1; mean difference 0.28 [95% CI 0.099 to 0.47]; p = 0.003). Compared with before rotation, after rotation cis-women believed less that they would have to work harder than others to be valued equally on the rotation (prerotation 2.8 ± 1.0 versus postrotation 2.5 ± 1.0; mean difference 0.31 [95% CI 0.12 to 0.50]; p = 0.002), as did nonheterosexual students (prerotation 2.4 ± 1.4 versus postrotation 1.8 ± 1.3; mean difference 0.56 [95% 0.21 to 0.91]; p = 0.004). Underrepresented minority students saw orthopaedic surgery as less sexist after rotation compared with before rotation (prerotation 1.5 ± 1.1 versus postrotation 2.0 ± 1.1; mean difference 0.52 [95% CI 0.16 to 0.89]; p = 0.007). CONCLUSION: Even with an estimated 26% response percentage, we found that medical students of demographic backgrounds who are not the majority in orthopaedics generally perceived that orthopaedic surgery is less diverse and inclusive than do their counterparts in majority groups, but these views often change after a clinical orthopaedic rotation. CLINICAL RELEVANCE: These perceptions may be a barrier to diversification of the pool of medical student applicants to orthopaedics. However, participation in an orthopaedic surgery rotation is associated with mitigation of many of these negative perceptions among diverse students. Medical schools have a responsibility to develop a diverse workforce, and given our findings, schools should promote participation in a clinical orthopaedic rotation. Residency programs and orthopaedic organizations can also increase exposure to the field through the rotation and other means. Doing so may ultimately diversify the orthopaedic surgeon workforce and improve care for all orthopaedic patients.

Marital status, partner acknowledgment of paternity, and neighborhood influences on smoking during first pregnancy: findings across race/ethnicity in linked administrative and census data.

BACKGROUND: Improving prediction of cigarette smoking during pregnancy (SDP), including differences by race/ethnicity and geography, is necessary for interventions to achieve greater and more equitable SDP reductions. METHODS: Using individual-level data on singleton first births, 2010-2017 (N = 182,894), in a US state with high SDP rates, we predicted SDP risk as a function of reproductive partner relationship (marital status, paternity acknowledgement), maternal and residential census tract sociodemographics, and census tract five-year SDP rate. RESULTS: SDP prevalence was 12.7% (white non-Hispanics, WNH), 6.8% (Black/African Americans, AA), 19.5% (Native American, NA), 4.7% (Hispanic, H), and 2.8% (Asian, AS). In WNH and AA, with similar trends in other groups, after adjustment for non-linear effects of maternal age and education and for census tract risk-factors, there was a consistent risk-ordering of SDP rates by reproductive partner relationship: married/with paternity acknowledged < unmarried/acknowledged < unmarried/unacknowledged < married/unacknowledged. Associations with census tract SDP rate, adjusted for maternal and census tract sociodemographics, were stronger for AA and H (OR 2.65-2.67) than for NA (OR = 1.91), WNH (OR = 1.75), or AS (NS). AA SDP was increased in tracts having a higher proportion of WNH residents and was reduced in comparison with WNH at every combination of age, education and partner relationship. CONCLUSIONS: Inattention to differences by race/ethnicity may obscure SDP risk factors. Despite marked race/ethnic differences in unmarried-partner cohabitation rates, failure to acknowledge paternity emerged as an important and consistent risk-predictor. Census-tract five-year SDP rates have heterogeneous origins, but the association of AA SDP risk with increased racial heterogeneity suggests an important influence of neighbor risk behaviors.

Types of Cosmetic Procedures Requested by Different Types of Patients and the Reasons for These Preferences.

BACKGROUND: The type of cosmetic dermatologic procedures patients' desire may be influenced by demographic factors. OBJECTIVE: To better understand the type of cosmetic procedures requested by patients of different age, gender, education, race, and geographic location. To understand the most common motivations of patients who requested particular types of treatments. MATERIALS AND METHODS: Multicenter data from the Cosmetic Motivation Database were analyzed. Bivariable analyses and linear regressions were undertaken to determine whether patient demographic features were associated with particular procedures of interest. RESULTS: Patients younger than 45 years were more interested in acne scar treatment, laser hair removal, liposuction, and tattoo removal. Older patients were more likely to want soft-tissue fillers and wrinkles and jowls tightening treatment. Non-White patients were more likely to be interested in laser hair removal, liposuction, cellulite treatment, and tattoo removal. Types of procedures desired varied by the geographic region but not by the educational level. Different motivations drove patients who wanted different types of treatments. CONCLUSION: Different types of patients demand different types of cosmetic treatments, and the motivations of patients who ask for particular procedures also differ. Better understanding of patient preferences may help physicians allocate resources and meet patient needs.

Substance Use Disparities at the Intersection of Sexual Identity and Race/Ethnicity: Results from the 2015-2018 National Survey on Drug Use and Health.

Purpose: Lesbian, gay, and bisexual (LGB) racial/ethnic minority individuals experience minority stress due to both their sexual identity and race/ethnicity and may be at elevated substance use risk (relative to heterosexuals) compared with their White LGB peers. We examined differences in the presence and magnitude of substance use disparities among LGB adults across race/ethnicity. Methods: Using data on 168,560 adults (including 11,389 LGB adults) from the 2015-2018 National Survey on Drug Use and Health, we examined disparities in cigarette smoking, heavy episodic drinking (HED), and marijuana use by race/ethnicity (White, Black, Hispanic, and other race/multiracial). Analyses compared lesbian/gay and bisexual adults, respectively, with heterosexual adults of the same gender and race/ethnicity. We also tested the magnitude of racial/ethnic minority disparities relative to the corresponding White disparity. Results: Significant disparities in smoking, HED, and marijuana use were observed for lesbian/gay and bisexual women across nearly all racial/ethnic groups. Disparities were consistently greater in magnitude for Black and Hispanic LGB women compared with White LGB women. Few disparities were observed among men; the magnitude of observed disparities did not differ by race/ethnicity. Conclusion: Disparities were most pronounced among racial/ethnic minority LGB women, which may reflect their unique experiences of discrimination at the intersection of multiple minority idenities. However, racial/ethnic minority gay and bisexual men were not at elevated risk relative to their White counterparts. Future research on substance use disparities among LGB individuals using an intersectional framework is warranted to elucidate differential minority stress processes that contribute to the observed heterogeneity across race/ethnicity, sexual identity, and gender.

Racial and ethnic disparities in melanoma awareness: A cross-sectional survey.

BACKGROUND: Hispanics are among the fastest growing population in the United States and are predicted to account for one third of the nation by 2060. Although melanoma is more common among white patients, Hispanic individuals are at greater risk of late-stage diagnosis, increased tumor thickness, and poorer survival. OBJECTIVE: To better understand public awareness of melanoma and evaluate change over the last 21 years, particularly among high-risk minority populations. METHODS: A cross-sectional survey collecting information on knowledge and awareness of melanoma was conducted on 285 participants from May through November 2017. RESULTS: Approximately 39% of participants were unaware of melanoma. Sixty-five percent successfully identified early signs of disease. Approximately 86% of Fitzpatrick skin types (FST) I and II identified melanoma as a cancer, compared to 46.3% of FST III and IV and 57.6% of FST V and VI. Hispanic particiapnts were less likely to know what melanoma was compared to white participants (odds ratio [OR], 0.27; 95% confidence interval [CI], 0.65-0.11; P = .0037). US natives (OR, 2.38; 95% CI, 5.56-1.04; P = .0403) and patients with any college education (OR, 2.86; 95% CI, 5.26-1.54; P = .0007) were more likely to know the meaning of melanoma. CONCLUSION: White participants and those with any college education were more likely to know the meaning of melanoma. Individuals of racial and ethnic minorities would benefit from educational programs geared toward early detection.

Screen to Save: Results from NCI's Colorectal Cancer Outreach and Screening Initiative to Promote Awareness and Knowledge of Colorectal Cancer in Racial/Ethnic and Rural Populations.

BACKGROUND: The Center to Reduce Cancer Health Disparities (CRCHD), NCI, implemented Screen to Save, NCI's Colorectal Cancer Outreach and Screening Initiative to promote awareness and knowledge of colorectal cancer in racial/ethnic and rural populations. METHODS: The initiative was implemented through CRCHD's National Outreach Network (NON). NON is a national network of Community Health Educators (CHE), aligned with NCI-designated Cancer Centers across the nation. In phases I and II, the CHEs focused on the dissemination of cancer-related information and implementation of evidence-based educational outreach. RESULTS: In total, 3,183 pre/post surveys were obtained from male and female participants, ages 50 to 74 years, during the 347 educational events held in phase I. Results demonstrated all racial/ethnic groups had an increase in colorectal cancer-related knowledge, and each group strongly agreed that the educational event increased the likelihood that they would engage in colorectal cancer-related healthful behaviors (e.g., obtain colorectal cancer screening and increase physical activity). For phase II, Connections to Care, event participants were linked to screening. Eighty-two percent of the participants who obtained colorectal cancer screening during the 3-month follow-up period obtained their screening results. CONCLUSIONS: These results suggest that culturally tailored, standardized educational messaging and data collection tools are key change agents that can serve to inform the effectiveness of educational outreach to advance awareness and knowledge of colorectal cancer. IMPACT: Future initiatives should focus on large-scale national efforts to elucidate effective models of connections to care, related to colorectal cancer screening, follow-up, and treatments that are modifiable to meet community needs.