Survival rates in Hispanic/Latinx subpopulations with cervical cancer associated with disparities in guideline-concordant care.

BACKGROUND: Failure to deliver guideline-concordant treatment may contribute to disparities among Hispanic/Latinx cervical cancer patients. This study investigated the association between survival rates in Hispanic/Latinx subpopulations and the provision of guideline-concordant care. METHODS: We analyzed patients with primary cervical cancer from 2004 to 2019 (National Cancer Database). We developed nine quality metrics based on FIGO staging (2009). Clinical and demographic covariates were analyzed using Chi-squared tests. Adjusted associations between receipt of guideline-concordant care and races and ethnicities were analyzed using multivariable marginal Poisson regression models. Adjusted Cox proportional hazard models were utilized to evaluate survival probability. RESULTS: A total of 95,589 patients were included. Hispanic/Latinx and Non-Hispanic Black (NHB) populations were less likely to receive guideline-concordant care in four and five out of nine quality metrics, respectively. Nonetheless, the Hispanic/Latinx group exhibited better survival outcomes in seven of nine quality metrics. Compared to Mexican patients, Cuban patients were 1.17 times as likely to receive timely initiation of treatment in early-stage disease (RR 1.17, 95% CI 1.04-1.37, p < 0.001). Puerto Rican and Dominican patients were, respectively, 1.16 (RR 1.16, 95% CI 1.07-1.27, p < 0.001) and 1.19 (RR 1.19, 95% 1.04-1.37, p > 0.01) times as likely to undergo timely initiation of treatment in early-stage disease. Patients of South or Central American (RR 1.18, 95% CI 1.10-1.27, p < 0.001) origin were more likely to undergo timely initiation of treatment in locally advanced disease. CONCLUSION: Significant differences in survival were identified among our cohort despite the receipt of guideline concordant care, with notably higher survival among Hispanic/Latinx populations.

Demographic reporting and language exclusion in gynecologic oncology clinical trials.

BACKGROUND: Participation in clinical trials may help mitigate disparate cancer outcomes. Thus, ensuring equitable access to clinical trials is a major priority for national cancer organizations. OBJECTIVE: This study aimed to examine clinical trial eligibility criteria that may adversely affect the enrollment of underrepresented groups and assess the availability of demographic information in published gynecologic oncology studies. STUDY DESIGN: ClinicalTrials.gov was searched for gynecologic oncology studies conducted between 1997 and 2021. Each study's inclusion and exclusion criteria were reviewed to determine whether demographic factors were used for enrollment screening. For published studies, demographic variables that were reported were identified. The expected clinical trial enrollment based on disease incidence and mortality was compared with the observed trial enrollment based on race. RESULTS: There were 1597 gynecologic oncology studies: 883 (55%) from ovarian cancer studies, 336 (21%) from cervical cancer studies, 262 (17%) from uterine cancer studies, and 116 (7%) from multisite gynecologic oncology studies. Of the 581 published studies, 554 (95%) reported age, 363 (63%) reported race, and 171 (29%) reported ethnicities. Cervical cancer studies were most likely to report demographic information, including race (P=.026) and ethnicity (P<.001). During the study period, 189 studies (12%) excluded patients based on the language spoken. Industry-sponsored trials (odds ratio, 0.07; 95% confidence interval, 0.02-0.30) and organization-sponsored trials (odds ratio, 0.40; 95% confidence interval, 0.22-0.73) were less likely to exclude patients because of language than investigator-initiated trials. A minority of patients (37%) in cervical cancer trials were of White race, compared with 85% of patients in uterine cancer trials and 82% of patients in ovarian cancer trials. CONCLUSION: Over the last 3 decades, 1 in 10 gynecologic oncology trials excluded patients because of language. Race and ethnicity were reported in more than half of the available studies. Initiatives to increase transparency in recruiting underrepresented patients and reporting demographic data are urgently needed.

Region of origin and cervical cancer stage in multiethnic Hispanic/Latinx patients living in the United States.

BACKGROUND: Hispanic/Latinx people have the second highest cervical cancer incidence rates in the U.S. However, there is a lack of disaggregated data on clinical outcomes for this diverse and populous group, which is critical to direct resources and funding where they are most needed. This study assessed differences in stage at diagnosis of cervical cancer among Hispanic/Latinx subpopulations and associated factors. METHODS: We analyzed patients with primary cervical cancer from 2004 to 2019 in the National Cancer Database. Hispanic/Latinx patients were further categorized into Mexican, Puerto Rican (PR), Cuban, Dominican, and Central/South American, as per standard NCDB categories, and evaluated based on stage at diagnosis and sociodemographic characteristics. Multinomial logistic regression quantified the odds of advanced stage at presentation. Regression models were adjusted for age, education, neighborhood income, insurance status, and additional factors. RESULTS: Hispanic/Latinx cervical cancer patients were more likely to be uninsured (18.9% vs. 6.0%, p < 0.001) and more likely to live in low-income neighborhoods (28.6% vs. 16.9%, p < 0.001) when compared to non-Hispanic White populations. Uninsured Hispanic/Latinx patients had 37.0% higher odds of presenting with regional versus localized disease (OR 1.37; 95% CI, 1.19-1.58) and 47.0% higher odds of presenting with distant versus. Localized disease than insured patients (OR 1.47; 95% CI, 1.33-1.62). When adjusting for age, education, neighborhood income, and insurance status, PR patients were 48% more likely than Mexican patients to present with stage IV versus stage I disease (OR 1.48; 95% CI, 1.34-1.64). CONCLUSION: Disaggregating health data revealed differences in stage at cervical cancer presentation among Hispanic/Latinx subpopulations, with insurance status as a major predictor. Further work targeting structural factors, such as insurance status, within specific Hispanic/Latinx subpopulations is needed.

Emergency department evaluation of nurse triage questions about safe-at-home and abuse or neglect in traumatic ocular injuries.

OBJECTIVES: Approximately 10 million Americans experience acts of physical violence by an intimate partner (IPV). Ocular injuries can present as a symptom of IPV in the emergency department, but IPV remains underreported in the literature. Understanding the incidence and trends in IPV-associated ocular injuries in the emergency department could increase the detection of at-risk patients otherwise overlooked. DESIGN: Retrospective chart review. PARTICIPANTS: Emergency department patients evaluated for traumatic ocular injuries between January 2018 and April 2023 at a large tertiary care health system. METHODS: The study population was identified by ICD-10 code and their responses to being screened at triage for home safety and any nursing concerns for abuse or neglect. Patient screening consisted of a 2-part questionnaire inquiring first about whether the patient feels safe at home ("Yes" or "No") and second regarding nurses' concerns for abuse, neglect, domestic violence, sexual assault, or human trafficking. RESULTS: There were 2,653,993 emergency department visits and 16,737 traumatic ocular injuries in the study period. Of them, 1.1% of patients (154 of 14,457) responded "No" to feeling safe at home. In only 0.6% of patients (82 of 14,457), a nursing concern was documented. Patients responding "No" to feeling safe at home presented with more severe ocular injuries such as maxillary fractures. On regression analysis, married, divorced, and widowed patients as well as patients on private insurance were less likely to report feeling unsafe at home than single patients on public insurance (p < 0.05). CONCLUSION: Traumatic ocular injuries in emergency departments should raise concerns about IPV. Opportunity exists to improve education, screening, and management of these patients.

Complete Resolution of Nonimmune Hydrops Fetalis Secondary to Maternal Syphilis Infection.

Maternal syphilis infection is a common infectious cause of nonimmune hydrops fetalis. Generally, hydrops fetalis is equated with poor prognoses in affected pregnancies. A 38-year-old G5P2114 presented at 28 5/7 weeks' gestation with newly diagnosed primary syphilis infection, sonographic findings of hydrops fetalis, and elevated middle cerebral artery Dopplers concerning for fetal anemia. Following treatment with intramuscular penicillin, the symptoms of hydrops fetalis were resolved and our patient delivered a healthy male neonate with no signs of congenital syphilis at the time of delivery. Routine and early testing for syphilis is an important component of prenatal care. Though not previously documented, the secondary findings of suspected fetal syphilis may be able to completely resolve in utero with penicillin treatment.

Mechanistic Insights on Hyperthermic Intraperitoneal Chemotherapy in Ovarian Cancer.

Epithelial ovarian cancer is an aggressive disease of the female reproductive system and a leading cause of cancer death in women. Standard of care includes surgery and platinum-based chemotherapy, yet patients continue to experience a high rate of recurrence and metastasis. Hyperthermic intraperitoneal chemotherapy (HIPEC) treatment in highly selective patients extends overall survival by nearly 12 months. The clinical studies are highly supportive of the use of HIPEC in the treatment of ovarian cancer, though the therapeutic approach is limited to academic medical centers. The mechanism underlying HIPEC benefit remains unknown. The efficacy of HIPEC therapy is impacted by several procedural and patient/tumor factors including the timing of surgery, platinum sensitivity, and molecular profiling such as homologous recombination deficiency. The present review aims to provide insight into the mechanistic benefit of HIPEC treatment with a focus on how hyperthermia activates the immune response, induces DNA damage, impairs DNA damage repair pathways, and has a synergistic effect with chemotherapy, with the ultimate outcome of increasing chemosensitivity. Identifying the points of fragility unmasked by HIPEC may provide the key pathways that could be the basis of new therapeutic strategies for ovarian cancer patients.

Assessment of Medical Industry Compensation to US Physicians by Gender.

Importance: It has been well established that female physicians earn less than their male counterparts in all specialties and ranks despite controlling for confounding variables. Objective: To investigate payments made from highest-grossing medical industry companies to female and male physicians and to assess compensation and engagement disparities based on gender. Design, Setting, and Participants: This retrospective, population-based cross-sectional study used data from the Open Payments database for the 5 female and 5 male physicians who received the most financial compensation from each of the 15 highest-grossing medical supply companies in the US from January 2013 to January 2019. Main Outcomes and Measures: The primary outcome was total general payments received by female and male physicians from medical industry over time and across industries. The secondary outcome was trends in industry payment to female and male physicians from 2013 to 2019. Results: Among the 1050 payments sampled, 1017 (96.9%) of the 5 highest earners were men and 33 (3.1%) were women. Female physicians were paid a mean (SD) of $41 320 ($88 695), and male physicians were paid a mean (SD) of $1 226 377 ($3 377 957) (P < .001). On multivariate analysis, male gender was significantly associated with higher payment after adjusting for rank, h-index, and specialty (mean [SD], $1 025 413 [$162 578]; P < .001). From 2013 to 2019, the payment gap between female and male physicians increased from $54 343 to $166 778 (P < .001). Conclusions and Relevance: This study found that male physicians received significantly higher payments from the highest-grossing medical industry companies compared with female physicians. This disparity persisted across all medical specialties and academic ranks. The health care industry gender payment gap continued to increase from 2013 to 2019, with a wider compensation gap in 2019.

Association between immigrant status and advanced cancer patients' location and quality of death.

BACKGROUND: Cancer patients often prefer to die at home, a location associated with better quality of death (QoD). Several studies demonstrate disparities in end-of-life care among immigrant populations in the United States. This study aimed to evaluate how immigrant status affects location and quality of death among patients with advanced cancer in the United States. METHODS: Data were derived from Coping with Cancer, a federally funded multi-site prospective study of advanced cancer patients and caregivers. The sample of patients who died during the study period was weighted (Nw  = 308) to reduce statistically significant differences between immigrant (Nw  = 49) and nonimmigrant (Nw  = 259) study participants. Primary outcomes were location of death, death at preferred location, and poor QoD. RESULTS: Analyses adjusted for covariates indicated that patients who were immigrants were more likely to die in a hospital than home (adjusted odds ratio [AOR], 3.33; 95% confidence interval [CI], 1.65-6.71) and less likely to die where they preferred (AOR, 0.42; 95% CI, 0.20-0.90). Furthermore, immigrants were more likely to have poor QoD (AOR, 5.47; 95% CI, 2.70-11.08). CONCLUSIONS: Immigrants, as compared to nonimmigrants, are more likely to die in hospital settings, less likely to die at their preferred location, and more likely to have poor QoD. LAY SUMMARY: Cancer patients typically prefer to die in their own homes, which is associated with improved quality of death. However, disparities in end-of-life care among immigrant populations in the United States remain significant. Our study found that immigrants are less likely to die in their preferred locations and more likely to die in hospital settings, resulting in poorer quality of death.

Misdiagnosis of appendiceal neoplasms as ovarian tumors: Impact of prior gynecologic surgery on definitive cytoreduction and HIPEC.

BACKGROUND: Female patients with pelvic/adnexal masses often undergo gynecologic operations due to presumed ovarian origin. The diagnosis of an appendiceal tumor is often only made postoperatively after suboptimal cytoreduction has been performed. We hypothesized that an index gynecological procedure increases the morbidity of definitive cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) in patients with appendiceal mucinous tumors. METHODS: A single-center retrospective review was performed to identify female patients undergoing CRS/HIPEC for appendiceal tumors from 2012 to 2020. RESULTS: During the 8-year period, CRS/HIPEC was performed in 36 female patients with appendiceal mucinous tumors. Eighteen patients (50.0%) had received a prior pelvic operation by gynecologists (PPO Group) for presumed ovarian origin before referral for definitive CRS/HIPEC. The median peritoneal cancer index (PCI) was higher in the PPO group (21 vs. 9, p = 0.04). The median number of days from gynecologic procedure to definitive CRS/HIPEC was 169 days. Compared to patients who did not undergo a prior gynecologic operation, those in the PPO group had higher intraoperative blood loss (650 vs 100 mL, p < 0.01) during CRS/HIPEC as well as longer length of stay (12 vs 8 days, p = 0.02) and higher overall morbidity (72.3% vs 33.3%, p = 0.02). After controlling for PCI, prior gynecologic operation increased risk of 30-day morbidity after definitive CRS/HIPEC (OR 11.6, p < 0.01). CONCLUSION: A multi-disciplinary approach is needed for the primary evaluation of patients with pelvic masses of undetermined origin. A gynecological resection is associated with increased morbidity during definitive cytoreduction and HIPEC for appendiceal mucinous tumors.

Complicated placenta accreta spectrum: identifying a high-risk cohort.

OBJECTIVE: To assess differences in the perioperative complication rate between patients with placenta accreta spectrum (PAS) with and without complicating factors. METHODS: This retrospective cohort study included subjects who underwent cesarean hysterectomy with histology-proven PAS between 23 0/7 and 42 0/7 weeks gestational age (GA) from 1 July 2008 to 11 April 2017. Perioperative outcomes were compared between those with uncomplicated PAS and "complicated PAS," defined as PAS subjects who experienced ≥2 bleeding episodes, preterm premature rupture of membranes (PPROM), or premature contractions requiring tocolysis. RESULTS: Overall, 26 complicated PAS and 27 uncomplicated PAS cases were compared; no difference in the rate of perioperative complications was identified. An increased proportion of complicated PAS cases required blood product transfusion before delivery: 2 (40%), 3 (27.3%), and 2 patients (20%) for those with PPROM, preterm contractions, and ≥2 bleeding episodes respectively, compared to patients with uncomplicated PAS, having no transfusions (p = .001). Time of delivery was earlier for patients with complicated compared to uncomplicated PAS (median GA 30.9 [Q1 = 27.9; Q3 = 31.9] and 34.9 [Q1 = 32.1; Q3 = 35.7], p < .001). Median birthweights were lower (p < .0144) and maternal length of stay longer (p < .0012) for complicated PAS. CONCLUSION: Patients with complicated PAS were not at higher risk for perioperative complications but were associated with earlier delivery, required more antenatal blood transfusions, and had a longer LOS.

Visual inspection with acetic acid screening for cervical cancer among women receiving anti-retroviral therapy for human immunodeficiency virus infection in northern Tanzania.

AIM: To evaluate visual inspection with acetic acid (VIA) screening for cervical cancer among human immunodeficiency virus (HIV)-positive patients in an East African community. METHODS: During a July 2018 cervical cancer screen-and-treat in Mwanza, Tanzania, participants were offered free cervical VIA screening, cryotherapy when indicated, and HIV testing. Acetowhite lesions and/or abnormal vascularity were designated VIA positive in accordance with current guidelines. The association between VIA results and HIV status was compared using Chi-square and Fisher exact tests. RESULTS: Eight hundred and twenty-four of 921 consented participants underwent VIA screening and 25.0% (n = 206) were VIA positive. VIA-positive nonpregnant women (n = 147) received cryotherapy and 15 (1.8%) with cancerous-appearing lesions were referred to Bugando Hospital. Sixty-six women were HIV-positive and included 25 diagnosed with HIV at the cervical cancer VIA screening and 41 with a prior diagnosis of HIV who were receiving antiretroviral therapy (ART) at the time of cervical cancer VIA screening. Sixty-four of these 66 patients, were screened with VIA. HIV infection was not associated with VIA findings. Abnormal VIA positive screening was observed in 20.3% (n = 13) of HIV-positive patients and in 24.4% (n = 145) of HIV-negative patients (p = 0.508). A nonsignificant trend of higher VIA positive screens among newly diagnosed HIV patients of 26.1% (n = 6) versus patients with preexisting HIV on ART of 17.1% (n = 7) was observed (p = 0.580). CONCLUSION: The unexpected lack of correlation between HIV infection and VIA positivity in a community with access to ART warrants additional research regarding the previously described role of ART in attenuating HPV-mediated neoplasia.

Implementation of human papillomavirus video education for women participating in mass cervical cancer screening in Tanzania.

BACKGROUND: Because the global disease burden of cervical cancer is greatest in Africa, the World Health Organization has endorsed visual inspection with acetic acid screening with cryotherapy triage for the screen-and-treat approach. With the lowest doctor-to-patient ratio worldwide (1:50,000), Tanzania has nearly 10,000 new cases of cervical cancer and 7000 deaths annually. OBJECTIVE: We report on the feasibility of visual inspection with acetic acid in the severely resource-limited Mwanza district and on the impact of intervening education on baseline human papillomavirus and cervical cancer knowledge. STUDY DESIGN: Two 5-day free visual inspection with acetic acid (VIA) clinics in urban Buzuruga and rural Sangabuye on the shores of Lake Victoria were approved by our university institutional review board and local Tanzanian health authorities. Participants completed a demographic survey and a 6-question (1 point per question) multiple choice test written in Kiswahili to assess baseline knowledge. A 15-minute educational video in Kiswahili (MedicalAidFilms: Understanding screening, treatment, and prevention of cervical cancer) was followed by repeated assessment using the same test, visual inspection with acetic acid screening, and optional HIV testing. Pre- and postvideo scores and change of score were analyzed via t test, analysis of variance, and multivariate regression. Significance was considered at P<.05. RESULTS: From July 2, 2018 to July 6, 2018, 825 women were screened, and 207 women (25.1%) were VIA positive (VIA+). One hundred forty-seven VIA+ nonpregnant women received same-day cryotherapy. Seven hundred sixty women participated in an educational intervention-61.6% of whom were from an urban site and 38.2% from a rural site. The mean age was 36.4 (standard deviation, 11.1). Primary languages were Kiswahili (62.2%) and Kisukuma (30.6%). Literacy was approximately 73%, and average education level was equivalent to the seventh grade (United States). Less than 20% of urban and rural women reported access to healthcare providers. Mean score of the participants before watching the video was 2.22 (standard deviation, 1.76) and was not different between VIA+ and VIA negative groups. Mean score of the participants after watching the video was 3.86 (standard deviation, 1.78). Postvideo scores significantly improved regardless of age group, clinic site, primary language, education level, literacy, or access to healthcare provider (P<.0001). Change of score after watching the video was significantly greater in participants from urban areas (1.99±2.07) than in those from rural areas (1.07±1.95) (P<.0001). Multivariate analysis identified urban site as an independent factor in change of score (P=.0211). CONCLUSION: Visual inspection with acetic acid screening for cervical cancer is feasible and accepted in northern Tanzania. Short video-based educational intervention improved baseline knowledge on the consequences of human papillomavirus infection in the studied populations. The impact was greater in the urban setting than in the rural setting.

Diagnosis and Treatment of Chronic Medical Conditions Among Trauma Patients at a Level 1 Trauma Center.

Diabetes mellitus (DM) and hypertension (HTN) are increasing in prevalence in the population. Level 1 trauma facilities are often faced with managing these chronic conditions. Recent studies indicated that 12-44% of patients presenting traumas are found to have incidental findings by imaging representing undiagnosed medical conditions, with 10% reported requiring further management [Surendran A, Mori A, Varma DK, Gruen RL. Systematic review of the benefits and harms of whole-body computed tomography in the early management of multitrauma patients: Are we getting the whole picture? J Trauma and Acute Care Surg. 2014;76(4):1122-1130]. Between 2015 and 2016, 852 patients seen at a level 1 trauma center were analyzed. Patients were evaluated who received a new diagnosis of HTN or DM, or had preexisting diagnosis of HTN or DM whose management was changed. Uncontrolled HTN or DM was defined as a need for either a change in medication or primary care optimization prior to discharge. Among the patients evaluated, 6.3% and 3.0% received new diagnoses of HTN and DM, respectively. Additionally, 34.4% and 35.3% of patients were found to have uncontrolled HTN and DM and required medical optimization, respectively. The high prevalence of undiagnosed or suboptimal management for chronic conditions indicates that more research is warranted for defining, screening for, and treating surgical patients with poorly controlled medical conditions with these comorbidities.

Diffuse subcortical white matter injury and bilateral basal ganglia neuronal loss after acute opioid overdose.

Opiate intoxication has been associated with life-threatening effects of sympathetic suppression and respiratory depression, but current literature is limited in describing its neurotoxic effects on the central nervous system. Here, we present the case of an otherwise high-functioning adolescent male who was found unresponsive after ingestion of approximately 3-4 fake oxycodone 10-325 mg pills laced with fentanyl. Magnetic resonance imaging showed evidence of diffuse T2 hyperintensities in the corpus callosum and bilateral frontal, parietal, and cerebellum indicative of diffuse white matter injury. In addition, there were distinct areas of restricted diffusion in the bilateral basal ganglia concerning for oxidative stress-mediated neuronal loss. His neurological exam improved with supportive treatment over the course of his hospitalization. Although limited literature has shown leukoencephalopathy to be associated with opioid overdose, we present a case of additional involvement of subcortical gray matter.

Robotic versus laparoscopic sleeve gastrectomy: a MBSAQIP analysis.

BACKGROUND: Laparoscopic sleeve gastrectomy has become the procedure of choice for the treatment of morbid obesity. Robotic sleeve gastrectomy is an alternative surgical option, but its utilization has been low. The aim of this study was to evaluate the contemporary outcomes of robotic sleeve gastrectomy (RSG) versus laparoscopic sleeve gastrectomy (LSG) using a national database from accredited bariatric centers. STUDY DESIGN: Using the 2015 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database, clinical data for patients who underwent RSG or LSG were examined. Emergent and revisional cases were excluded. A multivariate logistic regression model was utilized to compare the outcomes between RSG and LSG. RESULTS: A total of 75,079 patients underwent sleeve gastrectomy with 70,298 (93.6%) LSG and 4781 (6.4%) RSG. Preoperative sleep apnea and hypoalbumenia were significantly higher in the RSG group (P < 0.01). Mean length of stay was similar between RSG and LSG (1.8 ± 2.0 vs. 1.7 ± 2.0 days, P = 0.17). Operative time was longer in the RSG group (102 ± 43 vs. 74 ± 36 min, P < 0.01). There was no significant difference in 30-day mortality between the RSG versus LSG group (0.02% vs. 0.01%, AOR 0.85; 95% CI 0.11-6.46, P = 0.88). However, RSG was associated with higher serious morbidity (1.1% vs. 0.8%, AOR 1.40; 95% CI 1.05-1.86, P < 0.01), higher leak rate (1.5% vs. 0.5%, AOR 3.14; 95% CI 2.65-4.42, P < 0.01), and higher surgical site infection rate (0.7% vs. 0.4%, AOR 1.55; 95% CI 1.08-2.23, P = 0.01). CONCLUSIONS: Robotic sleeve gastrectomy has longer operative time and is associated with higher postoperative morbidity including leak and surgical site infections. Laparoscopy should continue to be the surgical approach of choice for sleeve gastrectomy.