Clinical, Radiological and Pathological Features of a Large American Cohort of Spinocerebellar Ataxia (SCA27B).

OBJECTIVES: Spinocerebellar ataxia 27B due to GAA repeat expansions in the fibroblast growth factor 14 (FGF14) gene has recently been recognized as a common cause of late-onset hereditary cerebellar ataxia. Here we present the first report of this disease in the US population, characterizing its clinical manifestations, disease progression, pathological abnormalities, and response to 4-aminopyridine in a cohort of 102 patients bearing GAA repeat expansions. METHODS: We compiled a series of patients with SCA27B, recruited from 5 academic centers across the United States. Clinical manifestations and patient demographics were collected retrospectively from clinical records in an unblinded approach using a standardized form. Post-mortem analysis was done on 4 brains of patients with genetically confirmed SCA27B. RESULTS: In our cohort of 102 patients with SCA27B, we found that SCA27B was a late-onset (57 ± 12.5 years) slowly progressive ataxia with an episodic component in 51% of patients. Balance and gait impairment were almost always present at disease onset. The principal finding on post-mortem examination of 4 brain specimens was loss of Purkinje neurons that was most severe in the vermis most particularly in the anterior vermis. Similar to European populations, a high percent of patients 21/28 (75%) reported a positive treatment response with 4-aminopyridine. INTERPRETATION: Our study further estimates prevalence and further expands the clinical, imaging and pathological features of SCA27B, while looking at treatment response, disease progression, and survival in patients with this disease. Testing for SCA27B should be considered in all undiagnosed ataxia patients, especially those with episodic onset. ANN NEUROL 2024.

Expenditures and Use of Hypofractionated Radiation Therapy Treating Breast Cancer Among Medicare Advantage Enrollees, 2009 to 2017.

Purpose: Technology advances in cancer care have paralleled rapidly increasing expenditures in radiation therapy. The use and costs of shorter cancer radiation therapy offer potential utility in clinical practice. We evaluate use and expenditures of Medicare Advantage (MA) beneficiaries receiving hypofractionated whole breast irradiation (HF-WBI) compared with conventionally fractionated whole breast irradiation (CF-WBI) in the United States and examine the relationship of patient characteristics with HF-WBI use. Methods and Materials: We performed a retrospective analysis of radiation therapy in MA beneficiaries using private employer-sponsored insurance claims for a pooled cross-sectional evaluation from 2009 to 2017. The study population included female MA beneficiaries with early-stage breast cancer treated with lumpectomy and whole breast irradiation. Results: A total of 9957 women received HF-WBI, and 18,920 received CF-WBI. Older age, greater distance from home to treatment facility, and a higher proportion of college graduates in the community of residence were associated with increased HF-WBI use. Mean insurer-paid radiation therapy expenditures were significantly lower for HF-WBI versus CF-WBI (adjusted difference, $4113; 95% CI, $4030-$4,197). Mean patient out-of-pocket expenditure for HF-WBI was $426 less than that of CF-WBI. Across US states, geographic variation existed in the ratio of costs for HF-WBI relative to CF-WBI (range, 0.41-0.87). Conclusions: HF-WBI use among MA beneficiaries with breast cancer has dramatically increased over time, surpassing CF-HBI as the dominant form of radiation therapy. HF-WBI clinical adoption has outpaced any continual cost decrease, despite wide variation across US states for this shorter radiation therapy treatment. As MA enrollment continues to expand, identifying the drivers of HF-WBI use and the sources of variation in costs of HF-WBI will help direct the quality of cancer care delivered to Medicare beneficiaries.

Geographic and Physician-Level Variation in the Use of Hypofractionated Radiation Therapy for Breast Cancer in the U.S.: A Cross-Classified Multilevel Analysis.

Purpose: We aimed to assess geographic and physician-level variation for hypofractionated whole-breast irradiation (HF-WBI) use for early-stage breast cancer patients in the United States. We further evaluated the association between HF-WBI use and demographic factors after accounting for these variations. Methods and Materials: We performed a retrospective study of early-stage breast cancer patients using private employer-sponsored insurance claims from 2008 to 2017. Patients were clustered according to geographic level and by radiation oncologist. Bayesian cross-classified multilevel logistic models were used to examine the geographic heterogeneity and variation of radiation oncologists simultaneously. Intracluster correlation coefficient (ICC) and median odds ratios (MOR) were calculated to quantify the variation at different levels. We also used the cross-classified model to identify patient demographic factors associated with receiving HF-WBI. Results: The study included 79,747 women (74.0%) who received conventionally fractionated whole-breast irradiation (CF-WBI) and 27,999 women (26.0%) who underwent HF-WBI. HF-WBI adoption increased significantly across time (2008-2017). The variation in HF-WBI utilization was attributed mostly to physician-level variability (MOR = 2.59). The variability of HF-WBI utilization across core-based statistical areas (CBSAs) (MOR = 1.55) was found to be the strongest among all geographic classifications. After accounting for variability in both CBSAs and radiation oncologists, age, receiving chemotherapy, and several community-level factors, including distance from home to facility, community education level, and racial composition, were found to be associated with HF-WBI utilization. Conclusion: This study demonstrated geographic and physician-level heterogeneity in the use of HF-WBI among early-stage breast cancer patients. HF-WBI utilization was also found to be associated with patient and community-level characteristics. Given observed physician-level variability, intervention through continuing medical education could help doctors to better understand the advantages of HF-WBI and promote the adoption of HF-WBI in the U.S. Influence of physician-level characteristics on HF-WBI utilization merits further study.

Autism and neurodevelopmental disability risks in children with tracheostomies and ventilators.

BACKGROUND/OBJECTIVE: Infants who survive prematurity and other critical illnesses and require continued invasive mechanical ventilation (IMV) postdischarge (at home) are at high risk of developmental delays and disabilities. Studies of extremely preterm cohorts (<28-week gestation) demonstrate rates of 25% for intellectual disability (ID) and 7% for autism spectrum disorder (ASD). Rates of ASD and ID in children with IMV are unknown. This study aimed to determine neurodevelopmental disability risk in a cohort of children with postdischarge IMV. DESIGN/METHODS: A consecutive series of children with IMV were assessed 1 month, 6 months, and 1 year after discharge. Cognitive, social, and communicative domains were assessed by a Developmental and Behavioral Pediatrician using (1) clinical adaptive test/clinical linguistic and auditory milestone scale (CAT/CLAMS) of the capute scales; (2) pediatric evaluation of disability inventory computer adaptive test (PEDI-CAT); and (3) modified checklist for autism in toddlers, revised (MCHAT-R). Red flag signs and symptoms of ASD using DSM-V criteria were noted. Longitudinal testing was reviewed. Expert consensus impressions of evolving ASD and/or ID were determined. RESULTS: Eighteen children were followed for 1 year; at 1 year, the median age (range) was 23 (17-42) months. Children were 44% male, 33% non-Hispanic White, 39% non-Hispanic Black, and 28% Hispanic. Fifteen (83%) children were prematurity survivors. Median (range) developmental quotients (DQs): full-scale DQ 59 (11-86), CAT DQ 66.5 (8-96), and CLAMS DQ 49.5 (13-100). Twelve (67%) children were highly suspicious for ASD and/or evolving ID. CONCLUSIONS/SIGNIFICANCE: This cohort of children with at-home IMV demonstrates a higher risk of ASD and ID than prior premature cohorts. Larger investigations with longer follow-up are needed.

Uterine Fibroid Prevalence in a Predominantly Black, Chicago-Based Cohort.

(1) Objectives: To investigate the effect of individual-level, neighborhood, and environmental variables on uterine fibroid (UF) prevalence in a Chicago-based cohort. (2) Methods: Data from the Chicago Multiethnic Prevention and Surveillance Study (COMPASS) were analyzed. Individual-level variables were obtained from questionnaires, neighborhood variables from the Chicago Health Atlas, and environmental variables from NASA satellite ambient air exposure levels. The Shapiro-Wilk test, logistic regression models, and Spearman's correlations were used to evaluate the association of variables to UF diagnosis. (3) Results: We analyzed 602 participants (mean age: 50.3 ± 12.3) who responded to a question about UF diagnosis. More Black than White participants had a UF diagnosis (OR, 1.32; 95% CI, 0.62-2.79). We observed non-significant trends between individual-level and neighborhood variables and UF diagnosis. Ambient air pollutants, PM2.5, and DSLPM were protective against UF diagnosis (OR 0.20, CI: 0.04-0.97: OR 0.33, CI: 0.13-0.87). (4) Conclusions: Associations observed within a sample in a specific geographic area may not be generalizable and must be interpreted cautiously.

Tumor Size and Watershed Area Correlate with Incomplete Treatment and Tumor Progression after Selective Radioembolization for Hepatocellular Carcinoma.

PURPOSE: To identify factors of incomplete treatment after segmental transarterial radioembolization (TARE) for treatment-naive and solitary hepatocellular carcinoma (HCC). MATERIALS AND METHODS: A total of 75 consecutive patients (age, 68.5 years [SD ± 8.0]; 25/75 [33.3%] women) with treatment-naive, solitary HCC underwent segmental or subsegmental TARE with glass microspheres (tumor size, 3.8 cm [SD ± 2.2]; administered dose, 222.6 Gy [SD ± 123.9]) at a single institution from November 2015 to June 2022. Radiologic response and progression-free survival (PFS) were assessed as per modified Response Evaluation Criteria in Solid Tumors. RESULTS: Complete treatment was achieved in 48 of 75 (64.0%) patients (mean follow-up, 33.2 months [SD ± 27.4]). Patients with incomplete treatment (27/75, 36%) presented with larger tumor size (5.0 [SD ± 2.5] vs 3.1 [SD ± 1.6] cm; P = .0001), with more tumors located in the watershed zone (81.5% vs 41.7%; P = .001). These patients were less likely to be bridged to transplant or resection (22.2% vs 52.1%; P = .015). Watershed tumors demonstrated worse target tumor PFS (median PFS, 19 months vs not reached; P = .0104) and overall PFS (9.1 months vs not reached; P = .0077). Watershed location was associated with worse PFS among tumors >3 cm in size (8.4 months vs not reached; P = .035) but not in tumors ≤3 cm in size (52.2 months vs not reached; P = .915). CONCLUSIONS: Tumor size and watershed location were associated with incomplete treatment after segmental TARE for HCC. Watershed tumors were associated with worse PFS, particularly tumors larger than 3 cm. These tumors may require careful treatment planning and repeated treatments to ensure a durable response.

Racial and Ethnic Disparities in Receipt of General Anesthesia for Cesarean Delivery.

Importance: General anesthesia for cesarean delivery is associated with increased maternal morbidity, and Black and Hispanic pregnant patients have higher rates of general anesthesia use compared with their non-Hispanic White counterparts. It is unknown whether risk factors and indications for general anesthesia differ among patients of differing race and ethnicity. Objective: To evaluate differences in general anesthesia use for cesarean delivery and the indication for the general anesthetic by race and ethnicity. Design, Setting, and Participants: In this retrospective, cross-sectional, single-center study, electronic medical records for all 35 117 patients who underwent cesarean delivery at Northwestern Medicine's Prentice Women's Hospital from January 1, 2007, to March 2, 2018, were queried for maternal demographics, clinical characteristics, obstetric and anesthetic data, the indication for cesarean delivery, and the indication for general anesthesia when used. Data analysis occurred in August 2023. Exposure: Cesarean delivery. Main Outcomes and Measures: The rate of general anesthesia for cesarean delivery by race and ethnicity. Results: Of the 35 117 patients (median age, 33 years [IQR, 30-36 years]) who underwent cesarean delivery, 1147 (3.3%) received general anesthesia; the rates of general anesthesia were 2.5% for Asian patients (61 of 2422), 5.0% for Black patients (194 of 3895), 3.7% for Hispanic patients (197 of 5305), 2.8% for non-Hispanic White patients (542 of 19 479), and 3.8% (153 of 4016) for all other groups (including those who declined to provide race and ethnicity information) (P < .001). A total of 19 933 pregnant patients (56.8%) were in labor at the time of their cesarean delivery. Of those, 16 363 (82.1%) had neuraxial labor analgesia in situ. Among those who had an epidural catheter in situ, there were no racial or ethnic differences in the rates of general anesthesia use vs neuraxial analgesia use (Asian patients, 34 of 503 [6.8%] vs 1289 of 15 860 [8.1%]; Black patients, 78 of 503 [15.5%] vs 1925 of 15 860 [12.1%]; Hispanic patients, 80 of 503 [15.9%] vs 2415 of 15 860 [15.2%]; non-Hispanic White patients, 255 of 503 [50.7%] vs 8285 of 15 860 [52.2%]; and patients of other race or ethnicity, 56 of 503 [11.1%] vs 1946 of 15 860 [12.3%]; P = .16). Indications for cesarean delivery and for general anesthesia were not different when stratified by race and ethnicity. Conclusions and Relevance: Racial disparities in rates of general anesthesia continue to exist; however, this study suggests that, for laboring patients who had labor epidural catheters in situ, no disparity by race or ethnicity existed. Future studies should address whether disparities in care that occur prior to neuraxial catheter placement are associated with higher rates of general anesthesia among patients from ethnic and racial minority groups.

Selective internal radiation therapy using yttrium-90 microspheres for treatment of localized and locally advanced intrahepatic cholangiocarcinoma.

OBJECTIVES: To evaluate safety and effectiveness of selective internal radiation therapy (SIRT) using yttrium-90 for localized and locally advanced intrahepatic cholangiocarcinoma (iCCA). METHODS: A retrospective review was performed of patients with localized iCCA treated with SIRT at a single institution. Overall survival (OS), local tumor response, progression-free survival (PFS), and toxicity were collected. Stratified analysis was performed based on surgical resection. Predictor analysis of OS was performed using the Fine-Grey regression analysis model with patients bridged to surgery regarded as competing events. RESULTS: A total of 28 consecutive patients with localized iCCA were treated with a total of 38 sessions of SIRT (17 segmental, 13 lobar, and 8 combined deliveries) and a mean dominant target dose per session of 238.4 ± 130.0 Gy. The cumulative radiologic response rate was 16/28 (57.1%) with a median PFS of 265 days. Median survival time (MST) was 22.9 months for the entire cohort with 1-year and 3-year survival of 78.4% and 45.1%, respectively. Ten patients (34.5%) were downstaged to surgical intervention (7 resection, 3 transplant) and showed longer OS (p = 0.027). The 1-year and 3-year OS for patients who received surgery were 100% and 62.5% (95% CI: 14.2-89.3%), respectively. Age (p = 0.028), Eastern Cooperative Oncology Group performance status (p = 0.030), and objective radiologic response (p=0.014) are associated with OS. Two ≥grade 3 hyperbilirubinemia, anemia, and one pleuro-biliary fistula occurred post-SIRT. CONCLUSIONS: SIRT for localized iCCA is safe and effective in achieving radiological response, downstaging to surgery and transplant, and resulting in pathologic necrosis. CLINICAL RELEVANCE STATEMENT: Selective internal radiation therapy should be considered for patients with localized and locally advanced intrahepatic cholangiocarcinoma. KEY POINTS: • The effectiveness of radioembolization for intrahepatic cholangiocarcinoma (iCCA) can be underestimated given the inclusion of extrahepatic disease. • Radioembolization is safe and effective for local and locally advanced iCCA. Age, Eastern Cooperative Oncology Group performance status, and radiologic response are associated with survival. • Radioembolization should be considered for patients with localized and locally advanced iCCA.

Risk perception and surveillance uptake in individuals at increased risk for pancreatic ductal adenocarcinoma.

BACKGROUND: Surveillance for pancreatic ductal adenocarcinoma (PDAC) is recommended for high-risk individuals with genetic variants in PDAC-associated genes and/or family history. Surveillance uptake and adherence may depend on the perception of PDAC risk and cancer worry. We aimed to determine PDAC risk perception in at-risk individuals and assess factors associated with PDAC surveillance uptake. METHODS: At-risk individuals identified from a prospective academic registry were sent a survey electronically. PDAC risk perception, cancer worry and surveillance uptake were surveyed. Factors associated with increased risk perception and surveillance were assessed. Five-year PDAC risk was calculated using the PancPRO risk assessment model, and correlation with subjective risk assessment was assessed. RESULTS: The overall survey response rate was 34% (279/816). The median perceived PDAC risk was twofold (IQR 1-4) above respondents' estimates of general population risk. Factors significantly associated with higher perceived PDAC risk included non-Hispanic white race, post-graduate education level, PDAC-affected first-degree relative, genetic variants and lack of personal cancer history. Cancer worry had a very weak correlation across PDAC risk estimates (r=0.16). No correlation between perceived PDAC risk and 5-year calculated PDAC risk was found. Older age, having a first-degree relative with PDAC, meeting with a medical provider about PDAC cancer risk and awareness of surveillance modalities were significant predictors of undergoing PDAC surveillance. CONCLUSIONS: Individuals at risk for PDAC do not report risk perception that correlates with calculated risk. This presents an opportunity for counselling of at-risk patients to individualise management and improve surveillance uptake for eligible individuals.

Long-term effects of pancreatic islet transplantation on polyneuropathy in patients with brittle diabetes: A single-center experience.

INTRODUCTION/AIMS: Pancreatic islet transplantation (ITx) is increasingly used in patients with brittle type 1 diabetes (T1D). If successful, ITx results in insulin-free euglycemia, but its application is limited by a need for lifelong immunosuppression. The aim of this study was to assess the long-term effects of ITx on the occurrence and course of polyneuropathy in a cohort of patients with brittle T1D. METHODS: In this prospective, single-center study, 13 patients (4 males and 9 females) with brittle T1D had a baseline neurological exam with the calculation of Utah Neuropathy Scale (UNS) and a limited nerve conduction study before ITx, and about yearly after in the patients who achieved insulin independence. RESULTS: Patients were followed for a period of 17 to 133 months. There was no significant difference between UNS and nerve conduction study parameters at baseline and at the end of follow-up, except for significant decreases in peroneal (50.34 ± 6.12 vs. 52.42 ± 6.47 ms, P = 0.005) and ulnar (27.5 ± 2.15 vs. 29.45 ± 2.10 ms, P = 0.009) F-wave latencies and an increase in ulnar sensory nerve conduction velocity (49.98 ± 6.27 vs. 47.19 ± 5.36 m/s, P = 0.04). DISCUSSION: If successful, ITx has a good long-term safety profile for peripheral nerve toxicity, and a favorable effect on diabetic neuropathy.

Gender Bias in Judging Frailty and Fitness for Lung Surgery.

BACKGROUND: Disparities in surgical care for lung cancer have been well documented, and unconscious bias may be a source of inequity. We assessed whether gender biases exist when nonclinical decision makers render decisions about major lung surgery. METHODS: Amazon Mechanical Turk workers, remotely located "crowdworkers" readily available for hire to perform discrete on-demand tasks on the Amazon Mechanical Turk platform, were each shown 4 videos of different standardized patients (SPs) in a clinic setting, 1 video in each energy level (vigorous or frail) and race category (White or Black), randomized to male or female. Workers scored video characteristics and whether they would support the SP's decision to undergo a major lung operation. RESULTS: A total of 855 workers were recruited. The frail White male SP was more likely to have support to undergo lung surgery than the frail White female SP, while the frail Black male SP was much less likely to have support to undergo lung surgery than the frail Black female SP. There were no significant differences in support for surgery between the vigorous male and female SPs and ratings by male and female workers in their recommendations. CONCLUSIONS: Biases related to patient gender exist in the general population and affect views on surgery, particularly in the setting of frailty. Understanding such differences may aid in educational efforts directed at reducing gender-based biases in treatment recommendations.

Using Downgaze Palsy Progression Rate to Model Survival in Progressive Supranuclear Palsy-Richardson Syndrome.

BACKGROUND: Rapid development of downgaze palsy, the most specific symptom of progressive supranuclear palsy (PSP), has been associated with shorter survival in small studies. OBJECTIVE: We hypothesized that the progression rate of downgaze palsy and other disease features could predict survival if assessed soon after the onset of downgaze palsy in a large data set. METHODS: We used a longitudinal database of 414 patients with probable PSP-Richardson syndrome from 1994 to 2020. The data set comprised demographics and, for each visit, 28 PSP Rating Scale (PSPRS) items and PSP stage scores. We calculated the rate of progression of each PSPRS item as its item score when the downgaze item first reached 1 or more (on a 0-4 scale) divided by disease duration at that point. Multivariate Cox regression was applied to identify variables independently associated with survival. We also explored the progression pattern of total PSPRS and downgaze palsy scores with disease course. RESULTS: Independently associated with shorter survival were older onset age and faster progression of downgaze palsy, dysphagia for liquids, difficulty in returning to seat, and PSP stage. Patients with survival duration within 1 year of the median survival (6.58 years) showed approximately linear progression of the PSPRS score and downgaze palsy score during years 2 through 6 of the disease course. CONCLUSIONS: Older onset age and faster progression of downgaze palsy and several axial features are associated with shorter survival. The disease typically progresses in approximately linear fashion during years 2 through 6. These results may aid study design and patient counseling. © 2022 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

The association between developmental delay and endophthalmitis after pediatric cataract surgery using an insurance claims database.

PURPOSE: To evaluate risk factors for postoperative endophthalmitis in pediatric cataract surgery based on an analysis of a large insurance claims database. METHODS: We retrospectively analyzed pediatric (0-18 years) cataract surgeries from the IBM MarketScan Research Database from 2004 to 2017. Suspect cases of endophthalmitis were identified by International Classification of Diseases codes; confirmed cases, by Current Procedural Terminology codes within 7 days of diagnosis. Odds ratios (OR) were assessed for age, sex, aphakia, concomitant vitrectomy, open-globe injury, uveitis, lens displacement, developmental delay, trisomy 21, and immunocompromised status. RESULTS: Among 5,304 eyes of 6,835 patients, the following were factors significantly associated with pediatric cataract surgery-related suspect endophthalmitis: open-globe injury (OR = 7.75; 95% CI, 3.32-18.09; P < 0.001), ocular trauma (OR = 3.64; 95% CI, 1.83-7.24; P < 0.001), aphakia (OR = 2.33, CI 1.15-4.69, P = 0.018), and developmental delay (OR = 4.24, 95% CI, 1.00-18.02; P = 0.05). With univariate analysis of confirmed endophthalmitis cases, the following were identified as statistically significant: open-globe injury (OR = 8.1; 95% CI, 2.64-24.87; P < 0.001), ocular trauma (OR = 4.34, CI 1.72-10.97; P = 0.002), subluxated or dislocated lens (OR = 3.62; 95% CI, 1.04-12.57; P = 0.043), aphakia (OR = 2.86; 95% CI, 1.13-7.26; P = 0.027), and developmental delay (OR = 8.24; 95% CI, 1.86-36.44; P = 0.005). Age, sex, concomitant vitrectomy, and uveitis were not associated with increased risk of endophthalmitis. CONCLUSIONS: Developmental delay may be a risk factor for postoperative endophthalmitis in pediatric cataract surgery. Surgeons can assess preoperative risk by performing a detailed medical and social history for challenges particular to this population that may complicate the postoperative course.

Pre-exposure Prophylaxis Persistence Among Greek Sexual Minority Men: Results from PrEP for Greece (P4G) Study.

Nearly half the new HIV infections in Greece occur in sexual minority men, yet pre-exposure prophylaxis is not currently supported in the national HIV program. We examined factors associated with PrEP persistence among Greek SMM in PrEP for Greece, the first PrEP study in Greece. Participants (n = 100) were recruited from 2016 to 2018 through respondent-driven sampling among SMM in Athens, receiving supplies for daily PrEP at interval visits over 12-months. PrEP persistence, operationalized as Total PrEP Time, was high, 74% of participants achieving perfect persistence. Higher alcohol risk scores (OR 1.27, 95% CI 1.08-1.49) and adherence to HIV testing guidelines (OR 1.23, 95% CI 1.00-1.51) were associated with persistence. Housing impermanence (OR 0.14, 95% CI 0.04-0.48) and serostatus disclosure concerns (OR 0.77, 95% CI 0.60-0.97) were associated with limited PrEP persistence. While PrEP persistence among Greek SMM is high, socioeconomic factors and societal attitudes may challenge prevention efforts.

Hypofractionated Radiation Therapy for Breast Cancer: Financial Risk and Expenditures in the United States, 2008 to 2017.

PURPOSE: Rising cancer care expenditures and technological advancement of shorter radiation therapy regimens have drawn significant attention to the use of hypofractionated radiation therapy in clinical care. We examine the costs of hypofractionated whole breast irradiation (HF-WBI) compared with conventional whole breast irradiation (CF-WBI) in the United States and investigate the influences of patient characteristics and commercial insurance on HF-WBI use. METHODS AND MATERIALS: In a retrospective study using private employer-sponsored insurance claims, a pooled cross-sectional evaluation of radiation therapy in patients with commercial insurance was performed from 2008 to 2017. The study population included female patients with early-stage breast cancer treated with lumpectomy and whole breast irradiation. RESULTS: A total of 15,869 women received HF-WBI, and 59,328 received CF-WBI. HF-WBI use increased from 2008 to 2017. Community-level factors such as a higher proportion of college graduates and greater mixed racial composition were associated with increased HF-WBI use. Mean insurer-paid radiation therapy expenditures were significantly lower for HF-WBI versus CF-WBI (adjusted difference, $6375; 95% confidence interval, $6147-$6603). Mean patient out-of-pocket expenditure for HF-WBI was $139 less than that for CF-WBI. Geographic variation existed across the United States in HF-WBI use (range, 9.6%-36.2%), with no consistent relationship between HF-WBI use and corresponding average cost differences between HF-WBI and CF-WBI. CONCLUSIONS: If trends continue, HF-WBI will soon become the dominant form of radiation treatment in the United States. Although HF-WBI represents significant savings to the health care system and individual patients, no evidence indicated that a financial disincentive had slowed adoption of HF-WBI. Therefore, multilevel approaches, including individuals, the community, and health policy, should be used to promote cost-effective cancer care. Innovations to policies on cost-effective radiation therapy treatment might consider non-financial incentives to promote HF-WBI use.

Disparities in diagnosis, treatment and survival between Black and White Parkinson patients.

INTRODUCTION: Racial disparities in diagnosis, treatment and survival in Black patients with Parkinson's disease (PD) compared to White patients have not been well studied, largely due to limited number of studies and information on Black patients in healthcare systems. Studying racial disparities and identifying underlying factors in large populations are important to understand PD and improve care. METHODS: We retrospectively identified PD patients on both races from 1/1/2006 to 10/31/2017 and compared demographics, socioeconomic status (educations, incomes and insurances), comorbidities (all categories, including mood, cognition and psychosis), treatment (medications for parkinsonism and major non-motor symptoms, and frequency and locations of healthcare) and survival, and identified factors associated with medication usage and survival. RESULTS: We retrospectively studied 2033 PD patients, of whom 725 were Black. Black patients lacked male predominance, were 4 years older at first diagnosis here, more likely to smoke and live in a low education and income community, and possessed limited insurances compared to White patients. Black patients also had more comorbidities and were more likely to receive care through emergency or inpatient service, but less likely to be on medications for parkinsonism and mood disorders. Race, age, smoking status, insurance type, frequency and locations of healthcare and comorbidities were associated with medication usage. Black race, older age, inpatient admission and malignancy were associated with increased risk of death. CONCLUSION: We revealed racial disparities in diagnosis, treatment and survival, and factors associated with medication usage and survival in the largest reported Black PD cohort from a single center.

Chemotherapy response score as a prognostic tool in patients with advanced stage endometrial carcinoma treated with neoadjuvant chemotherapy.

BACKGROUND: Chemotherapy response score (CRS) applied to interval debulking specimens quantifies histopathologic response to neoadjuvant chemotherapy in patients with advanced ovarian carcinoma and correlates with progression-free and overall survival. OBJECTIVE: To investigate whether the chemotherapy response score could be applied to interval debulking specimens in patients with advanced endometrial carcinoma and be a prognostic indicator. METHODS: The study included patients with clinical stage III-IV endometrial carcinoma who received neoadjuvant chemotherapy followed by interval debulking surgery. Chemotherapy response scores were assigned to omental and adnexal metastases, and categorized as no/minimal (CRS1), partial (CRS2), and complete/near-complete (CRS3) response to neoadjuvant chemotherapy. Descriptive statistics were used to evaluate baseline characteristics and feasibility of chemotherapy response score assessment. Univariate analyses were used to evaluate associations between the chemotherapy response score, complete cytoreduction, and survival. RESULTS: This study included 40 patients. The median age was 63.5 years, and 31 patients (78%) had stage IV disease. Thirty patients had an omentectomy, 22 patients (73%) had an omental chemotherapy response score assigned. Thirty-nine patients had a bilateral salpingo-oophorectomy, 28 patients (72%) had an adnexal chemotherapy response score assigned. Omental CRS2 and CRS3 were associated with improved progression-free survival (CRS2: HR=0.18, p<0.01; CRS3: HR=0.11, p<0.01) and overall survival (CRS2: HR=0.10, p<0.01; CRS3: HR=0.16, p=0.04). Adnexal CRS2 and CRS3 were associated with improved progression-free survival (CRS2: HR=0.23, p<0.01; CRS3: HR=0.20, p=0.03). Chemotherapy response scores were also associated with an increased likelihood of having a complete cytoreduction. CONCLUSION: Chemotherapy response score can be applied to omental and adnexal metastases in patients with advanced endometrial carcinoma and was associated with survival and complete cytoreduction. The score may be a prognostic indicator and help to guide first-line treatment of patients with endometrial carcinoma.