Healthcare utilization disparities among children with high-risk neuroblastoma treated on Children's Oncology Group clinical trials.

INTRODUCTION: Disparities in relapse and survival from high-risk neuroblastoma (HRNBL) persist among children from historically marginalized groups even in highly standardized clinical trial settings. Research in other cancers has identified differential treatment toxicity as one potential underlying mechanism. Whether racial and ethnic disparities in treatment-associated toxicity exist in HRNBL is poorly understood. METHODS: This is a retrospective study utilizing a previously assembled merged cohort of children with HRNBL on Children's Oncology Group (COG) post-consolidation immunotherapy trials ANBL0032 and ANBL0931 at Pediatric Health Information System (PHIS) centers from 2005 to 2014. Race and ethnicity were categorized to reflect historically marginalized populations as Hispanic, non-Hispanic Black (NHB), non-Hispanic other (NHO), and non-Hispanic White (NHW). Associations between race-ethnicity and intensive care unit (ICU)-level care utilization as a proxy for treatment-associated toxicity were examined with log binomial regression and summarized as risk ratio (RR) and corresponding 95% confidence interval (CI). RESULTS: The analytic cohort included 370 children. Overall, 88 (23.8%) patients required ICU-level care for a median of 3.0 days (interquartile range [IQR]: 1.0-6.5 days). Hispanic children had nearly three times the risk of ICU-level care (RR 3.1, 95% CI: 2.1-4.5; fully adjusted RR [aRR] 2.5, 95% CI: 1.6-3.7) compared to NHW children and the highest percentage of children requiring cardiovascular-driven ICU-level care. CONCLUSION: Children of Hispanic ethnicity with HRNBL receiving clinical trial-delivered therapy were more likely to experience ICU-level care compared to NHW children. These data suggest that further investigation of treatment-related toxicity as a modifiable mechanism underlying outcome disparities is warranted.

Disparities in access to hematopoietic cell transplant persist at a transplant center.

Disparities in access to hematopoietic cell transplant (HCT) are well established. Prior studies have identified barriers, such as referral and travel to an HCT center, that occur before consultation. Whether differences in access persist after evaluation at an HCT center remains unknown. The psychosocial assessment for transplant eligibility may impede access to transplant after evaluation. We performed a single-center retrospective review of 1102 patients who underwent HCT consultation. We examined the association between race/ethnicity (defined as Hispanic, non-Hispanic Black, non-Hispanic White, and Other) and socioeconomic status (defined by zip code median household income quartiles and insurance type) with receipt of HCT and Psychosocial Assessment of Candidates for Transplantation (PACT) scores. Race/ethnicity was associated with receipt of HCT (p = 0.02) with non-Hispanic Whites comprising a higher percentage of HCT recipients than non-recipients. Those living in higher income quartiles and non-publicly insured were more likely to receive HCT (p = 0.02 and p < 0.001, respectively). PACT scores were strongly associated with income quartiles (p < 0.001) but not race/ethnicity or insurance type. Race/ethnicity and socioeconomic status impact receipt of HCT among patients evaluated at an HCT center. Further investigation as to whether the psychosocial eligibility evaluation limits access to HCT in vulnerable populations is warranted.

Cardiovascular Risk Factor Disparities in Adult Survivors of Childhood Cancer Compared With the General Population.

Background: It is unknown whether a history of childhood cancer modifies the established disparities in cardiovascular risk factors (CVRFs) observed in the general population. Objectives: We sought to determine if disparities in CVRFs by race/ethnicity are similar among childhood cancer survivors compared with the general population. Methods: The Childhood Cancer Survivor Study (CCSS) is a retrospective cohort with a longitudinal follow-up of 24,084 5-year survivors diagnosed between 1970 and 1999. Multivariable piecewise exponential regression estimated incidence rate ratios (IRRs) for hypertension, hyperlipidemia, diabetes, obesity, and ≥2 CVRFs by race/ethnicity. The CCSS sibling cohort and the National Health and Nutrition Examination Survey cohort were used to compare the sociodemographic-adjusted IRRs for same-race/same-ethnicity disparities. Results: Non-Hispanic Black (NHB) (n = 1,092) and Hispanic (n = 1,405) survivors compared with non-Hispanic White (NHW) (n = 13,960) survivors reported a higher cumulative incidence of diabetes (8.4%, 9.7%, and 5.1%, respectively); obesity (47.2%, 48.9%, and 30.2%, respectively); multiple CVRFs (17.7%, 16.6%, and 12.3%, respectively); and, for NHB survivors, hypertension (19.5%, 13.6%, and 14.3%, respectively) by 40 years of age (P < 0.001). Controlling for sociodemographic and treatment factors compared with NHW survivors, IRRs for NHB were increased for hypertension (IRR: 1.4; 95% CI: 1.1-1.8), obesity (IRR: 1.7; 95% CI: 1.4-2.1), and multiple CVRFs (IRR: 1.6; 95% CI: 1.2-2.1). IRRs for Hispanic survivors were increased for diabetes (IRR: 1.8; 95% CI: 1.2-2.6) and obesity (IRR: 1.4; 95% CI: 1.2-1.7). The pattern of IRRs for CVRF differences was similar among CCSS sibling and National Health and Nutrition Examination Survey cohorts. Conclusions: The higher burden of CVRFs among NHB and Hispanic survivors compared with NHW survivors was similar to the general population. The promotion of cardiovascular health equity is critical in this high-risk population.

Sexual Dysfunction Among Adolescent and Young Adult Men Diagnosed with Cancer.

Purpose: Adolescent and young adult (AYA) cancer patients frequently demonstrate sexual dysfunction; however, there is a lack of data quantifying the severity and frequency. Methods: Males aged 18-39 years, diagnosed with cancer of any kind and who were scheduled to begin, were actively receiving, or had completed cancer treatment within 6 months, were offered validated surveys during their oncology appointment. These surveys included the International Index of Erectile Function (IIEF-6), Masturbation Erection Index (MEI), 36-Item Short Form Survey, and 5-point Likert scales to assess their desire and ability to engage in sex and masturbation. Results: Forty subjects completed the IIEF survey with a mean score of 17.7 ± 11, erectile dysfunction (ED) prevalence accordingly was 58%. Thirty-eight subjects completed the MEI with a mean score of 25.3 ± 5.3, ED prevalence was again 58%. Age and IIEF scores demonstrated a statistically significant (p < 0.05, n = 38) Pearson's correlation coefficient of 0.40, patients younger than 30 years had an ED prevalence of 72% (mean IIEF 13), whereas patients aged 30 years and older had an ED prevalence of 45% (mean IIEF 22). All treatment modalities had ED rates >30%: chemotherapy demonstrated the highest prevalence at 64% (mean IIEF 17), whereas radiation therapy had the lowest prevalence at 33% (mean IIEF 23). Conclusion: This study demonstrates that the prevalence of sexual dysfunction among male AYA patients undergoing treatment for cancer is high. AYA oncologists should discuss potential sexual health concerns when treating this population. The exact cause of ED (non-organic vs. organic) within this group should be explored further.

Clinical Implications of Hematologic and Hemostatic Abnormalities in Children With COVID-19.

Leukopenia, thrombocytopenia, elevated D-dimer, and prolonged prothrombin time are considered poor prognostic factors in adults with acute Coronavirus Disease 2019. The prognostic significance of these abnormalities among pediatric patients remains underreported in the literature. This retrospective cohort study evaluates the prognostic implications of hematologic and hemostatic derangements in patients younger than 22-years-of-age who were admitted to a tertiary-care referral institution for management of acute Coronavirus Disease 2019 infection. Leukopenia and thrombocytopenia were identified as independent prognostic factors of disease severity. Although the majority of children, with available results, had elevated D-dimer or prolonged prothrombin time upon initial presentation, these markers were not found to be associated with the development of severe clinical complications.

Regional Implicit Bias Does Not Account for Racial Disparity in Total Joint Arthroplasty Utilization.

BACKGROUND: Racial disparities surrounding the utilization of total hip and total knee arthroplasty (THA, TKA) are well documented. The Implicit Association Test (IAT) is a validated tool used to measure implicit and explicit bias. The purpose of this study is to evaluate if variations in IAT scores by geographical region in the United States (US) correspond with regional variations in THA and TKA utilization by blacks compared to whites. METHODS: Data from the US Census and National Inpatient Sample from 2012 to 2014 were used to calculate THA and TKA utilization rates among Medicare-aged blacks and whites. Data were aggregated by US Census Bureau Division. Regional implicit bias was assessed by calculating a weighted average of IAT scores for each division. RESULTS: Across all geographic regions and years, the surveyed population demonstrated an implicit bias favoring whites over blacks. The population adjusted ratio of white-to-black utilization of THA and TKA by geographic division varied between 0.86-1.85 and 0.87-2.01, respectively. The difference in utilization between geographic divisions reached statistical significance (P < .001). No correlation was found between the IAT scores and race-specific utilization ratios among geographic divisions. CONCLUSION: Implicit bias as measured by regional IAT did not reflect THA and TKA utilization disparities. The racial disparity in utilization of THA and TKA significantly varied between divisions. The observed disparity was greater in divisions with a relatively higher proportion of blacks. To the authors' knowledge, this is the first study to evaluate the impact of implicit bias on utilization of THA and TKA.

Eye-sparing Treatment of Localized Orbital Medulloepithelioma With Neoadjuvant Chemoradiation.

A 9-year-old girl presented with a 3-day history of progressive proptosis accompanied by transient discomfort and blurry vision in the OD. MRI revealed a heterogeneously enhancing intraconal lesion that partially encased and displaced the optic nerve. There was no intraocular or intracranial involvement, nor were there signs of distant metastasis. Histopathologic evaluation and immunohistochemistry were consistent with orbital medulloepithelioma. The patient received 4 cycles of chemoradiation per a retinoblastoma protocol. Repeat MRI scans showed significant tumor regression, and further surgical debulking was performed. There has been no evidence of recurrence for over 14 months. Herein, the authors describe an eye-sparing, multimodal treatment of a rare case of localized orbital medulloepithelioma.

Disparities in the use of antineoplastic immunotherapy in pediatric malignant adrenal tumors.

Dinutuximab is a costly life-prolonging immunotherapy for high-risk neuroblastoma. We used a large pediatric inpatient database to analyze the use of antineoplastic immunotherapy in patients with malignant adrenal tumors 1 year after Food and Drug Administration approval of dinutuximab for high-risk neuroblastoma. On multivariate modeling, children of Black race (odds ratio [OR] 0.62, P = .04; referent non-Black) and the lowest ZIP code income quartile (OR 0.74, P = .03; referent wealthier 3 quartiles) were significantly less like to receive antineoplastic immunotherapy. These results suggest substantial disparities in the distribution of a vital therapy in children with advanced cancer.

Acute lymphoblastic leukemia mortality in Hispanic Americans.

Higher incidence and poorer outcomes of acute lymphoblastic leukemia (ALL) in Hispanic Americans have been attributed to high-risk molecular markers associated with Native American (NA) ancestry. However, the diverse Hispanic populations in the United States differ substantially in ancestry. Continental Hispanics have a high proportion of NA ancestry while Caribbean Hispanics have a lower proportion of NA ancestry. Here, we analyzed mortality data of 2428 children and adults with ALL. Mortality rates were age-adjusted and compared by race and ethnicity using negative binomial regression with particular attention to distinct Hispanic populations. While both Continental (mortality rate ratio (MRR) 2.09, 95% CI 1.82-2.39) and Caribbean (MRR 1.27, 95% CI 1.05-1.54) Hispanics had higher mortality rates than other racial and ethnic groups, Continental Hispanics had significantly higher mortality rates than Caribbean Hispanics. This is the first study to demonstrate a clear difference in ALL mortality by Hispanic group on a population basis.

Lead poisoning risk assessment of radiology workers using lead shields.

Purpose: Lead containing dust may be present on the exterior surfaces of shields used to prevent radiation exposure. We determined whether use of lead shields poses an exposure risk for radiology personnel.Methods: We collected hand dustwipe and blood samples from 58 Radiology Department employees of an academic hospital. Samples were analyzed for lead content by atomic absorption spectroscopy. Results were compared between lead apron users (46) and nonusers (12).Results: Hand dustwipe lead was undetectable (<3 µg/sample) in all cases. Blood lead levels ranged from 0-3 µg/dL.Conclusions: In this study of Radiology Department workers, we did not find an increased risk of lead contamination on their hands or in their blood. Although our sample size is small, we conclude that lead poisoning is unlikely to occur with high frequency in lead shield users.

Validation of Risk Stratification Criteria to Identify Febrile Neonates at Low Risk of Serious Bacterial Infection.

Our objective was to evaluate the accuracy of risk stratification criteria for febrile neonates in the emergency department. This was a retrospective study of febrile neonates ≤56 days of age. Patients were low risk for serious bacterial infection (SBI) if all test results were within normal ranges. Three hundred thirty-eight patients were enrolled with a mean age of 32 (±14) days, and 78 (23%) had SBI: 26 (8%) with bacteremia, 48 (14%) with urinary tract infection, 3 (1%) with meningitis, and 11 (3%) with pneumonia. Risk stratification criteria identified 47 (14%) as low risk, 2 of whom had SBI (both with Group B Streptococcus bacteremia). The sensitivity was 97.4% (95% confidence interval = 91.0% to 99.7%), and the negative predictive value was 95.7% (95% confidence interval = 84.8% to 98.9%). The risk stratification criteria have high sensitivity and high negative predictive value for identifying infants at low risk for SBI. Care must be taken to assure reliable follow-up.

Lead Aprons Are a Lead Exposure Hazard.

PURPOSE: To determine whether lead-containing shields have lead dust on the external surface. METHODS: Institutional review board approval was obtained for this descriptive study of a convenience sample of 172 shields. Each shield was tested for external lead dust via a qualitative rapid on-site test and a laboratory-based quantitative dust wipe analysis, flame atomic absorption spectrometry (FAAS). The χ2 test was used to test the association with age, type of shield, lead sheet thickness, storage method, and visual and radiographic appearance. RESULTS: Sixty-three percent (95% confidence interval [CI]: 56%-70%) of the shields had detectable surface lead by FAAS and 50% (95% CI: 43%-57%) by the qualitative method. Lead dust by FAAS ranged from undetectable to 998 µg/ft2. The quantitative detection of lead was significantly associated with the following: (1) visual appearance of the shield (1 = best, 3 = worst): 88% of shields that scored 3 had detectable dust lead; (2) type of shield: a greater proportion of the pediatric patient, full-body, and thyroid shields were positive than vests and skirts; (3) use of a hanger for storage: 27% of shields on a hanger were positive versus 67% not on hangers. Radiographic determination of shield intactness, thickness of interior lead sheets, and age of shield were unrelated to presence of surface dust lead. CONCLUSIONS: Sixty-three percent of shields had detectable surface lead that was associated with visual appearance, type of shield, and storage method. Lead-containing shields are a newly identified, potentially widespread source of lead exposure in the health industry.