Race, Neighborhood Opportunity, and Life-Threatening Complications in Children With Cancer: A Moderated Mediation Approach.

BACKGROUND: Racial disparities exist in the incidence and severity of life-threatening complications of childhood cancer and its treatment. Little research has been conducted to examine the sociocultural pathways that are underlying these inequities. OBJECTIVE: This study examined the association between race and complications and the intermediary pathway of a child's access to opportunity in the neighborhood environment. A secondary objective was to determine if this indirect effect differs as the child becomes older and exposure to the neighborhood environment increases. METHODS: This is an analysis of publicly available data. Regression models estimated direct associations between race and complications, as well as the effect of the mediator, neighborhood opportunity. Moderated-mediation analysis was used to determine the conditional influence of age. RESULTS: Compared with non-Hispanic White children, non-Hispanic Black and Hispanic children are at increased odds of developing 1 or more life-threatening complications when hospitalized with cancer. Neighborhood opportunity is a significant indirect pathway underlying these relationships. This intermediary effect is significant only for older children. CONCLUSIONS: Neighborhood opportunity is a significant indirect pathway underlying the racial inequities in the risk of life-threatening complications. This effect is significant only for older children. IMPLICATIONS FOR PRACTICE: The inclusion of indicators such as inequitable allocation of resources to highly segregated neighborhoods and rigorous statistical model development in outcomes research are critical in addressing and mitigating racial disparities in childhood cancer.

Palliative Care Use in Advanced Cancer in the Garden State.

BACKGROUND: Cancer is the second leading cause of death in the United States. Patients with metastatic cancer have a high symptom burden. Major global and domestic cancer care recommendations advise integration of palliative care services for these patients. Palliative care is specialized care that can decrease cost, improve symptom burden, and improve quality of life. Patient factors driving the use of palliative care remain poorly understood but may include both physiological and psychological needs, namely, pain and depression, respectively. OBJECTIVE: The objective of this study was to identify patient-level predictors associated with inpatient palliative care use in patients with metastatic cancer. METHODS: This was a secondary analysis of the 2018 New Jersey State Inpatient Database. The sample was limited to hospitalized adults with metastatic cancer in New Jersey. Descriptive statistics characterized the sample. Generalized linear modeling estimated the effects of pain and depression on the use of inpatient palliative care. RESULTS: The sample included 28 697 hospitalizations for patients with metastatic cancer. Within the sample, 4429 (15.4%) included a palliative care consultation. There was a 9.3% documented occurrence of pain and a 10.9% rate of depression. Pain contributed to palliative care use, but depression was not predictive of an inpatient care consultation. Age, income category, and insurance status were significant factors influencing use. CONCLUSION: Understanding demographic and clinical variables relative to palliative care use may help facilitate access to palliative care for adults experiencing metastatic cancer. IMPLICATION FOR PRACTICE: Increased screening for pain and depression may expand palliative care use for adults with metastatic cancer receiving inpatient care.

Hospice Referral in Advanced Cancer in New Jersey.

The need for hospice care is increasing in the United States, but insufficient lengths of stay and disparity in access to care continue. Few studies have examined the relationship between the presence of symptoms and hospice referral. The study measured the association between hospice referral and demographic characteristics and the presence of pain and depression in a cohort of people hospitalized with metastatic cancer in New Jersey in 2018. This study was secondary analysis of the 2018 New Jersey State Inpatient Database. The sample was limited to adult patients with metastatic cancer. Descriptive statistics evaluated the composition of the sample. Generalized linear modeling estimated the effect of pain and depression on incidence of hospice referral in a racially and economically diverse population. Absence of pain resulted in lower odds of receiving a referral to hospice upon discharge (adjusted odds ratio [AOR], 0.44; 95% confidence interval [CI], 0.40-0.49; P = .00). Likewise, an absence of depression also resulted in decreased odds of a hospice referral (AOR, 0.85; 95% CI, 0.76-0.96; P = .008). Compared with Whites, Blacks (AOR, 0.86; 95% CI, 0.76-0.97; P = .00) and Hispanics had significantly lower odds of receiving a hospice referral (AOR, 0.84; 95% CI, 0.72-0.96; P = .01). Patients with a primary language other than English, there were significantly lower odds of receiving a hospice referral (AOR, 0.85; 95% CI, 0.73-0.99; P = .03). Patients with pain and depression had increased hospice referrals. Disparities persist in hospice referral, particularly in Black and Hispanic cases and those without a primary language of English.

Racial and Economic Differences in the Risk of Hyperglycemia in Children Hospitalized With Acute Lymphoblastic Leukemia.

Background: The underlying mechanism of hyperglycemia in children with acute lymphoblastic leukemia (ALL) is insulin resistance. Although race and economic status have been linked to increased insulin resistance in children, these have not been explored as predictors of hyperglycemia in children with ALL. The objective of this study was to analyze race and income as predictors of hyperglycemia in a diverse sample of children hospitalized with ALL in the United States in the year 2016. Methods: We performed a secondary analysis of 18,077 hospitalizations of White, Black, and Hispanic children under the age of 21 years with ALL contained in a nationally representative database. Multilevel binary logistic regression models were constructed to estimate the relationships between race, median household income, age, sex, and obesity and the odds of hyperglycemia in hospitalized children with ALL. Results: Hyperglycemia occurred during 5.3% of the hospitalizations. Black children were 37% more likely to develop hyperglycemia than White children. The risk for hyperglycemia did not differ between Hispanic and White children. Residing in areas where annual median income was below $54,000 was associated with 1.4-fold increased odds of hyperglycemia, compared to the wealthiest areas. Older children, females, and those diagnosed with obesity were also at increased risk for hyperglycemia. Discussion: An association has been found between treatment-induced hyperglycemia and increased mortality. For this reason, the racial and economic differences in the risk for hyperglycemia identified in this study deserve further consideration.

Feasibility of Medical Student Mentors to Improve Transition in Sickle Cell Disease.

OBJECTIVE: Advances in medical care have resulted in nearly 95% of all children with sickle cell disease (SCD) living to adulthood. There is a lack of effective transition programming, contributing to high rates of mortality and morbidity among adolescents and young adults (AYAs) during the transition from pediatric to adult healthcare. This nonrandomized study evaluated the feasibility, acceptability, and preliminary outcomes of a novel medical student mentor intervention to improve transition outcomes for AYA with SCD. METHODS: Eligible participants were ages 18-25 years, either preparing for transition or had transferred to adult care within the past year. Twenty-four AYA with SCD (Mage = 20.3, SD = 2.6) enrolled in the program and were matched with a medical student mentor. Feasibility and acceptability of the intervention was assessed through enrollment rates, reasons for refusal, retention rates, engagement with the intervention, satisfaction, and reasons for drop-out. Dependent t-tests were used to evaluate the preliminary effects of the intervention on patient transition readiness, health-related quality of life, self-efficacy, SCD knowledge, medication adherence, and health literacy. RESULTS: Participants (N = 24) demonstrated adequate retention (75.0%), adherence to the intervention (M = 5.3 of 6 sessions), and satisfaction with the intervention components. Participants demonstrated significant improvements in transition readiness (p = .001), self-efficacy (p = .002), medication adherence (p = .02), and health literacy (p = .05). CONCLUSIONS: A medical student mentor intervention to facilitate transition from pediatric to adult care for AYA with SCD is both feasible and acceptable to patients and medical students. Preliminary results suggest benefits for patients, warranting a larger efficacy study.

Hispanic Children Hospitalized With Acute Lymphoblastic Leukemia Are at Increased Risk of Pancreatitis.

BACKGROUND: There have been remarkable advances in overall survival following the diagnosis of acute lymphoblastic leukemia in childhood, but toxicities, including pancreatitis, remain a concern. Pancreatitis occurs early in therapy, before extensive exposure to the chemotherapy agents associated with its development, indicating there are underlying risk factors for some children. The role of race/ethnicity in treatment-related pancreatitis has not been well established. OBJECTIVE: The aim of this study was to examine the relationship between race/ethnicity and pancreatitis in children hospitalized with acute lymphoblastic leukemia in the United States in 2016. METHODS: This was an analysis of a nationally representative database of pediatric hospitalizations. The sample consisted of 21 775 records with documentation of the diagnosis of acute lymphoblastic leukemia. Statistical methods included descriptive statistics, bivariate analyses using the χ2 test, and multilevel logistic regression models. RESULTS: Pancreatitis was documented in 1.6% of hospital discharges. Compared with white children, Hispanic children were at increased risk of pancreatitis during hospitalization (P = .002). There were no differences among black (P = .469), Asian (P = .364), or other-race children (P = .937). CONCLUSIONS: Hispanic children hospitalized with acute lymphoblastic leukemia are at greater risk of pancreatitis than white children. Reasons for this disparity are likely due to both genetic and social factors. IMPLICATIONS FOR PRACTICE: Nurses must be active participants in the research process with the goal of enrolling patients with diverse backgrounds in clinical trials. Inclusive research will provide increased understanding of a holistic toxicity risk profile.

Increased Risk of Severe Sepsis in Hispanic Children Hospitalized With Acute Myeloid Leukemia.

The purpose of this study, a secondary analysis of a publicly available database, was to identify racial and ethnic disparities in the risk of severe sepsis facing children undergoing the intensive therapy necessary to treat acute myeloid leukemia (AML). The sample consisted of 1,913 hospitalizations of children, younger than 21 years, in the United States during the year 2016 with documentation of both AML and at least one infectious complication. Binary logistic regression models were used to examine the association between race/ethnicity and severe sepsis in children with AML and infection. We found that, after controlling for potential confounding variables, the odds of developing severe sepsis were significantly increased for Hispanic children compared with White children. There were no significant differences in the likelihood of the development of sepsis in Black, Asian, or other race children. The increased risk of severe sepsis for Hispanic children may contribute to the disparate rates of overall survival in this group. This inequitable rate of severe sepsis was evident despite the generally accepted practice of retaining children in the hospital throughout recovery of blood counts following AML therapy. Nurses are in a position to identify and eliminate modifiable risk factors contributing to this disparity.

Associations among race, residential segregation, community income, and emergency department use by adults with end-stage renal disease.

OBJECTIVE: The purpose of this study was to examine independent and interactive effects of race, community income, and racial residential segregation on the likelihood of ED revisits by persons with end-stage renal disease (ESRD). DESIGN: A retrospective analysis of de-identified data abstracted from Health Care Utilization and Cost Project's (HCUP) 2014 New Jersey State Emergency Department (ED) Database and American Community Survey (ACS) was conducted. SAMPLE: The analytic sample was comprised of 2,859 ED encounters in 2014 by non-Hispanic Black and White persons over 18 years of age with ESRD who were treated and released from the ED. MEASUREMENTS: The HCUP database was the data source for ED revisit, race, median community income, and covariate (age, gender, marital status, number of chronic conditions) variables in the study. The 2014 ACS was the source for racial segregation Dissimilarity Index scores across NJ counties. RESULTS: Living in communities with lower median income and high racial segregation was associated with a higher likelihood of ED revisits. Black race interacted with community income and racial segregation in its effect on ED revisits. CONCLUSION: Efforts are needed to direct geo-targeted interventions and resources to socially disadvantaged communities to lessen disparities in ED visits among dialysis patients.

Lactate dehydrogenase as a predictor of kidney involvement in patients with sickle cell anemia.

A retrospective chart review of 40 patients with sickle cell anemia (SCA) between the ages of 5-19 years who were seen within a 1-year period was performed to determine clinical and laboratory correlates for microalbuminuria and proteinuria. Age, sex, height, body mass index (BMI), serum creatinine [and estimated glomerular filtration rate (eGFR) by Schwartz and MDRD formulas], type of SCA, hemoglobin (Hb) level [total Hb and hemoglobin F percentage (HbF%)], lactate dehydrogenase (LDH) level, reticulocyte count, blood pressure, history of splenectomy, history of hydroxyurea use, and history of transfusions were correlated with microalbuminuria and proteinuria by univariate and multivariate regression analysis. The prevalence of microalbuminuria and proteinuria among these patients was 15 and 5%, respectively. Univariate analyses revealed a significant correlation between LDH level and microalbuminuria (Pearson r=0.47, p=0.04) and between LDH level and proteinuria (Pearson r=0.48, p=0.035). Multivariate analysis revealed a significant correlation between microalbuminuria and LDH level (p = 0.04) when controlled for age, sex, eGFR, Hb level, HbF%, type of SCA, BMI, history of transfusions, and reticulocyte count. In this pediatric SCA population, LDH was found to correlate with the presence of microalbuminuria and proteinuria. Further studies are needed to confirm LDH as an early marker for the risk of kidney involvement among SCA patients.