Feasibility and Safety of Implementing Volumetric Arc Therapy (VMAT) for Pediatric Craniospinal Irradiation in a Low-Middle-Income Region: The Nigerian Experience.

Purpose: Volumetric modulated arc therapy (VMAT) is a relatively new treatment technique in sub-Saharan Africa. Although craniospinal irradiation (CSI) in the pediatric population has been practiced in Nigeria for many years, the use of VMAT to deliver this treatment is previously undocumented. We reviewed the first set of patients to undergo CSI at a cancer center in Nigeria, detailing the treatment technique, the progress experienced, dose statistics achieved, treatment toxicities, and cancer outcomes to date. Methods and Materials: This was a prospective case series of 5 children with histologically diagnosed cancers requiring CSI whose parents consented to the study. They were recruited at evaluation and followed through the process of their therapy. Toxicity was monitored at weekly review appointments using the Common Terminology Criteria for Adverse Events version 5.0. Follow-up of the children will continue in the long-term effects clinic. Results: Five patients with a median age of 6 were recruited. Diagnoses were intracranial germ cell tumor (n = 2), medulloblastoma (n = 1), pineoblastoma (n = 1), and ependymoma (n = 1). For all patients, a dose of 36.0 Gy in 1.8 Gy daily fractions was prescribed to the entire neuraxis. A subsequent boost of 18 Gy (n = 4) to 19.8 Gy (n = 1) in 10 daily fractions to the primary tumor bed (n = 2) and posterior fossa (n = 2) was delivered. Four patients had chemotherapy before, during, or after radiation therapy. No patient experienced grade 3 or greater toxicity. Conclusions: Our results indicate great progress has been made in the delivery of CSI in Nigeria, demonstrating tolerable acute side effects using VMAT. This series suggests the feasibility of implementing VMAT technology in low- or middle-income countries. Additional follow-up will be needed to determine whether survival rates and chronic toxicity rates are similar to those reported in the literature.

Development of an evidence-based model for predicting patient, provider, and appointment factors that influence no-shows in a rural healthcare system.

BACKGROUND: No-show appointments pose a significant challenge for healthcare providers, particularly in rural areas. In this study, we developed an evidence-based predictive model for patient no-shows at the Marshfield Clinic Health System (MCHS) rural provider network in Wisconsin, with the aim of improving overbooking approaches in outpatient settings and reducing the negative impact of no-shows in our underserved rural patient populations. METHODS: Retrospective data (2021) were obtained from the MCHS scheduling system, which included 1,260,083 total appointments from 263,464 patients, as well as their demographic, appointment, and insurance information. We used descriptive statistics to associate variables with show or no-show status, logistic regression, and random forests utilized, and eXtreme Gradient Boosting (XGBoost) was chosen to develop the final model, determine cut-offs, and evaluate performance. We also used the model to predict future no-shows for appointments from 2022 and onwards. RESULTS: The no-show rate was 6.0% in both the train and test datasets. The train and test datasets both yielded 5.98. Appointments scheduled further in advance (> 60 days of lead time) had a higher (7.7%) no-show rate. Appointments for patients aged 21-30 had the highest no-show rate (11.8%), and those for patients over 60 years of age had the lowest (2.9%). The model predictions yielded an Area Under Curve (AUC) of 0.84 for the train set and 0.83 for the test set. With the cut-off set to 0.4, the sensitivity was 0.71 and the positive predictive value was 0.18. Model results were used to recommend 1 overbook for every 6 at-risk appointments per provider per day. CONCLUSIONS: Our findings demonstrate the feasibility of developing a predictive model based on administrative data from a predominantly rural healthcare system. Our new model distinguished between show and no-show appointments with high performance, and 1 overbook was advised for every 6 at-risk appointments. This data-driven approach to mitigating the impact of no-shows increases treatment availability in rural areas by overbooking appointment slots on days with an elevated risk of no-shows.

Examining Cancer Patients' Perceptions of the Impact of COVID-19 on Teleoncology: Findings From 15 Nigerian Outpatient Cancer Clinics.

PURPOSE: To examine cancer patients' perspectives on the impact of COVID-19 on teleoncology in Nigeria. METHODS: Data from a multicenter survey conducted at 15 outpatient clinics to 1,097 patients with cancer from April and July 2020 were analyzed. The study outcome was telemedicine, defined as patients who reported their routine follow-up visits were converted to virtual visits because of COVID-19 (coded yes/no). Covariates included patient age, ethnicity, marital status, income, cancer treatment, service disruption, and cancer diagnosis/type. Stata/SE.v.17 (StataCorp, College Station, TX) was used to perform chi-square and logistic regression analyses. P values ≤ .05 were considered statistically significant. RESULTS: The majority of the 1,097 patients with cancer were female (65.7%) and age 55 years and older (35.0%). Because of COVID-19, 12.6% of patients' routine follow-ups were converted to virtual visits. More patients who canceled/postponed surgery (17.7% v 7.5%; P ≤ .001), radiotherapy (16.9% v 5.3%; P ≤ .001), and chemotherapy (22.8% v 8.5%; P ≤ .001), injection chemotherapy (20.6% v 8.7%; P ≤ .001) and those who reported being seen less by their doctor/nurse (60.3% v 11.4%; P ≤ .001) reported more follow-up conversions to virtual visits. In multivariate analyses, patients seen less by their doctors/nurses were 14.3 times more likely to have their routine follow-ups converted to virtual visits than those who did not (odds ratio, 14.33; 95% CI, 8.36 to 24.58). CONCLUSION: COVID-19 caused many patients with cancer in Nigeria to convert visits to a virtual format. These conversions were more common in patients whose surgery, radiotherapy, chemotherapy, and injection chemotherapy treatments were canceled or postponed. Our findings suggest how COVID-19 affects cancer treatment services and the importance of collecting teleoncological care data in Nigeria.

Your neighborhood matters: an ecological social determinant study of the relationship between residential racial segregation and the risk of firearm fatalities.

BACKGROUND: Firearm fatalities are a major public health concern, claiming the lives of 40,000 Americans each year. While firearm fatalities have pervasive effects, it is unclear how social determinants of health (SDOH) such as residential racial segregation, income inequality, and community resilience impact firearm fatalities. This study investigates the relationships between these SDOH and the likelihood of firearm fatalities. METHODS: County-level SDOH data from the Agency for Health Care Research and Quality for 2019 were analyzed, covering 72 Wisconsin counties. The dependent variable was the number of firearm fatalities in each county, used as a continuous variable. The independent variable was residential racial segregation (Dissimilarity Index), defined as the degree to which non-White and White residents were distributed across counties, ranging from 0 (complete integration) to 100 (complete segregation), and higher values indicate greater residential segregation (categorized as low, moderate, and high). Covariates were income inequality ranging from zero (perfect equality) to one (perfect inequality) categorized as low, moderate, and high, community resilience risk factors (low, moderate, and high risks), and rural-urban classifications. Descriptive/summary statistics, unadjusted and adjusted negative binomial regression adjusting for population weight, were performed using STATA/MPv.17.0; P-values ≤ 0.05 were considered statistically significant. ArcMap was used for Geographic Information System analysis. RESULTS: In 2019, there were 802 firearm fatalities. The adjusted model demonstrates that the risk of firearm fatalities was higher in areas with high residential racial segregation compared to low-segregated areas (IRR.:1.26, 95% CI:1.04-1.52) and higher in areas with high-income inequality compared to areas with low-income inequality (IRR.:1.18, 95% CI:1.00-1.40). Compared to areas with low-risk community resilience, the risk of firearm fatalities was higher in areas with moderate (IRR.:0.61, 95% CI:0.48-0.78), and in areas with high risk (IRR.:0.53, 95% CI:0.41-0.68). GIS analysis demonstrated that areas with high racial segregation also have high rates of firearm fatalities. CONCLUSION: Areas with high residential racial segregation have a high rate of firearm fatalities. With high income inequality and low community resilience, the likelihood of firearm fatalities increases.

Evaluating the adoption of voice recognition technology for real-time dictation in a rural healthcare system: A retrospective analysis of dragon medical one.

BACKGROUND: In 2013, Marshfield Clinic Health System (MCHS) implemented the Dragon Medical One (DMO) system provided by Nuance Management Center (NMC) for Real-Time Dictation (RTD), embracing the idea of streamlined clinic workflow, reduced dictation hours, and improved documentation legibility. Since then, MCHS has observed a trend of reduced time in documentation, however, the target goal of 100% adoption of voice recognition (VR)-based RTD has not been met. OBJECTIVE: To evaluate the uptake/adoption of VR technology for RTD in MCHS, between 2018-2020. METHODS: DMO data for 1,373 MCHS providers from 2018-2020 were analyzed. The study outcome was VR uptake, defined as the median number of hours each provider used VR technology to dictate patient information, and classified as no/yes. Covariates included sex, age, US-trained/international medical graduates, trend, specialty, and facility. Descriptive statistics and unadjusted and adjusted logistic regression analyses were performed. Stata/SE.version.17 was used for analyses. P-values less than/equal to 0.05 were considered statistically significant. RESULTS: Of the 1,373 MCHS providers, the mean (SD) age was 48.3 (12.4) years. VR uptake was higher than no uptake (72.0% vs. 28.0%). In both unadjusted and adjusted analyses, VR uptake was 4.3 times and 7.7 times higher in 2019-2020 compared to 2018, respectively (OR:4.30,95%CI:2.44-7.46 and AOR:7.74,95%CI:2.51-23.86). VR uptake was 0.5 and 0.6 times lower among US-trained physicians compared to internationally-trained physicians (OR:0.53,95%CI:0.37-0.76 and AOR:0.58,95%CI:0.35-0.97). Uptake was 0.2 times lower among physicians aged 60/above than physicians aged 29/less (OR:0.20,95%CI:0.10-0.59, and AOR:0.17,95%CI:0.27-1.06). CONCLUSION: Since 2018, VR adoption has increased significantly across MCHS. However, it was lower among US-trained physicians than among internationally-trained physicians (although internationally physicians were in minority) and lower among more senior physicians than among younger physicians. These findings provide critical information about VR trends, physician factors, and which providers could benefit from additional training to increase VR adoption in healthcare systems.

Racial and ethnic differences in the relationship between infant loss after prior live birth and hypertensive disorders in pregnancy.

BACKGROUND: Race and ethnicity influence the distribution and severity of hypertensive disorders of pregnancy (HDP) in the U.S. population, although the impact of prior infant loss on this relationship requires further investigation. OBJECTIVES: The aim of this study was to assess the relationship between history of infant loss and the risk of HDP by maternal race and ethnicity. METHODS: For this large cross-sectional study, data were analyzed from the National Center for Health Statistics Vital Statistics Natality Birth Data, 2014-2017. The primary outcome was HDP, and the primary predictor was infant loss after prior live birth. Maternal race/ethnicity was the secondary predictor categorized as Non-Hispanic White (NHW), Non-Hispanic Black (NHB), Hispanic, Asian, or Other. Multiple logistic regression was used to assess the association between history of infant loss and HDP by race and ethnicity. RESULTS: The 9,439,520 women included in this sample were 51% NHW, 15% NHB, 25% Hispanic, 6% Asian, and 3% Other with a mean age of 29.8 ± 5.3 years. In adjusted analyses, infant loss after prior live birth was significantly associated with an 11% odds of HDP (OR 1.11, 95% CI 1.08, 1.13). Stratified by race, NHB (OR 1.28; 95% CI 1.21, 1.36) women had significantly higher odds of HDP, and Hispanic (OR 0.84, 95% CI 0.79, 0.90) and Asian (OR 0.85, 95% CI 0.75, 0.97) women had significantly lower odds compared to NHW women. Within races, all women with infant loss after prior live birth had significantly higher odds of HDP (p < .001), except Other women (p = .632). CONCLUSIONS: Infant loss after prior live birth was significantly associated with higher odds of HDP among NHB women after adjusting for covariates. Further research is warranted to assess underlying mechanisms associated with higher odds of HDP in NHB women.

Context Matters: Assessing the Association Between Area Deprivation and the Severity of Injury and Types of Domestic Violence Victimization Among Women.

OBJECTIVES: To analyze the association between social determinants of health (SDOH), as measured by the Area Deprivation Index (ADI), and the severity of injury and types of domestic violence (DV) victimization among women (≥18 years of age) in Milwaukee, Wisconsin. METHODS: Neighborhood ADI data from the American Community Survey (2014-2018) were merged with Milwaukee Police Department DV data (2013-2017). ADI included multiple SDOH domains (education, employment, income/poverty, and housing quality). Types of DV were classified using an adaptation of the FBI-Uniform Crime Reporting-Hierarchy Rule, including Crimes Against Persons (homicide/negligent manslaughter, sexual assault/rape, and aggravated battery/assault). Chi-square, Anova tests, and logistic regression analyses were performed using Stata v.14.2; p-values ≤ .05 were considered statistically significant. FINDINGS: Except for aggravated battery/assault (OR: 1.003, 95% CI: 1.001-1.010), there was no statistically significant relationship between neighborhood disadvantage and DV victimization in 21,095 DV incidents between 2013 and 2017. Adjusted model results indicate that with each increase in neighborhood disadvantage (by ADI), there was a 1.003 increase in the likelihood for aggravated battery/assault (OR: 1.003, 95% CI: 1.001-1.005). Severity of DV injury was not significantly associated with ADI (OR: 1.002, 95% CI: 0.999-1.004). However, non-Hispanic Black women were 1.3 times more likely than non-Hispanic Whites to be victims of aggravated battery/assault (OR: 1.321, 95% CI: 1.189-1.469). Hispanic women were more likely than non-Hispanic Whites to sustain a more severe injury (OR: 0.841, 95% CI: 0.732-0.970]). CONCLUSION: The likelihood of DV-aggravated battery/assault increased with neighborhood deprivation, and significant associations (and highly lopsided prevalence) were found in types of DV victimization by race/ethnicity, with non-Hispanic Black women experiencing higher prevalence than others. This study adds to the body of knowledge by looking at how macro-level neighborhood-SDOH characteristics influence women's exposure to various forms of DV victimization and demonstrated the feasibility of linking law enforcement DV data to SDOH metrics, providing context for law enforcement DV victimizations.

Adherence to COVID-19 preventive measures and its association with intimate partner violence among women in informal settings of Kampala, Uganda.

Cases of coronavirus disease 2019 (COVID-19) detected, and COVID-19 associated mortality increased since the first case was confirmed in Uganda. While adherence to WHO-recommended measures to disrupt COVID-19 transmission has since been implemented, it has been reported to be sub-optimal. An increase in intimate partner violence (IPV) cases was linked to enforcement of COVID-19 lockdowns and other preventive measures especially in informal settings of Kampala. We determined the association between adherence to COVID-19 preventive measures and intimate partner violence among women dwelling in informal settings in Kampala, Uganda. Between July and October 2020, we conducted a three-month prospective cohort study of 148 women living in informal settlements of Kampala during the COVID-19 lockdown and easing of restrictive measures. Participants were surveyed at baseline, at 3-weeks and 6-weeks (endline). The dependent variable was adherence to COVID-19 preventive measures (remained adherent vs poorly adherent) between baseline and endline surveys. This composite outcome variable was computed from implementing all four variables: social distancing, wearing face masks, frequent hand washing and use of hand sanitizers at baseline and endline surveys. The key independent variable was IPV measured as experiencing at least one form of physical, emotional, or sexual IPV. Covariates were age, education, marital status, household size, occupation, and having problems getting food. Adjusted logistic regression analyses tested the independent association between adherence to COVID-19 preventive measures and intimate partner violence. Among 148 respondents, the mean age (SD) was 32.9 (9.3) years, 58.1% were exposed to at least one form of IPV, and 78.2% had problems getting food. Overall, 10.1% were poorly adherent to COVID-19 preventive measures during the first COVID-19 wave. After controlling for potential confounders, remaining adherent to COVID-19 preventive measures were more likely to experience intimate partner violence when compared to women who were poorly adherent to COVID-19 preventive measures during the first COVID-19 wave in Uganda [OR 3.87 95%CI (1.09, 13.79)]. Proportions of women in informal settlements of Kampala experiencing at least one form of IPV during the first COVID-19 wave is substantial. Remaining adherent to preventive measures for COVID-19 transmission may increase IPV exposure risk among women living in informal settlements in Kampala. Contextualizing COVID-19 interventions to the needs of marginalized and vulnerable women and girls in informal settings of Kampala is warranted. Processes to integrated violence prevention and response strategies into the Uganda COVID-19 prevention strategy are underscored.

Utilization of safe male circumcision among adult men in a fishing community in rural Uganda.

BACKGROUND: In Uganda, most-at-riskpopulations(MARPs) such as fishing communities remain vulnerable to preventable HIV acquisition. Safe Male Circumcision (SMC) has been incorporated into Uganda's HIV prevention strategies. This study aimed at determining SMC utilization and associated factors among adult men in a rural fishing community in Uganda. METHODS: A cross-sectional study was conducted in a rural fishing village in central Uganda. Stratified random sampling of 369 fishermen aged 18-54 yearswas used according to their occupational category; fish monger, boat crew and general merchandise. The dependent variable wasutilization of SMC.A forward fitting multivariable logistic regression model was fitted with variables significant at p≤0.05 controlling for confounding and effect modification. RESULTS: Respondents'mean(SD) age was 30.0(9.3) years. Only8.4%hadSMC and among non-circumcised men, 84.9% had adequate knowledge of SMC benefits while 79.3% did not know were SMC services were offered. Peer support(AOR0.17;95%-CI0.05-0.60) and perceived procedural safety (AOR6.8;95%CI2.16-21.17) were independently associated with SMC utilization. CONCLUSION: In this rural fishing community, SMC utilization was low. These findings underscore the need to inform HIV preventionstrategies inthecontextof peer support and perceptionsheld by rural dwelling men.