OBJECTIVE:
To measure racial inequities in drug testing among pregnant people during the first prenatal visit based on their drug use disclosure pattern.
METHODS:
We used data from a cohort study of ...patient–clinician communication patterns regarding substance use in first prenatal visits from February 2011 to August 2014. We assessed racial differences (Black–White) in the receipt of urine toxicology testing, stratifying on patients' drug use disclosure to the clinician.
RESULTS:
Among 341 study participants (205 Black 60.1% and 136 White 39.9% participants), 70 participants (33 Black 47.1% and 37 White 52.9% participants) disclosed drug use, and 271 participants (172 Black 63.5% and 99 White 36.5% participants) did not disclose drug use during their first obstetric visit. Of 70 participants who disclosed drug use, 50 (28 Black 56.0% and 22 White 44.0% White) had urine drug testing conducted. Black pregnant patients who disclosed drug use were more likely to be tested for drugs than their White counterparts in the adjusted regression analysis (adjusted odds ratio aOR 8.9, 95% CI 1.3–58.6). Among the 271 participants who did not disclose drug use, 38 (18 Black 47.4% and 20 White 52.6% participants) had urine drug testing conducted. For those who did not disclose drug use, the adjusted model showed no statistically significant differences in urine drug testing by patients’ race (aOR 0.7, 95% CI 0.3–1.6).
CONCLUSION:
When pregnant people disclosed drug use, clinicians were more likely to order urine drug testing for Black pregnant people compared with their White counterparts, suggesting clinician racial bias. Current practice patterns and protocols such as urine drug testing in pregnancy care deserve review to identify and mitigate areas of potential clinician discrimination.
Living Slow and Being Moral Zhu, Nan; Hawk, Skyler T.; Chang, Lei
Human nature (Hawthorne, N.Y.),
06/2018, Letnik:
29, Številka:
2
Journal Article
Recenzirano
Drawing from the dual process model of morality and life history theory, the present research examined the role of cognitive and emotional processes as bridges between basic environmental challenges ...(i.e., unpredictability and competition) and other-centered moral orientation (i.e., prioritizing the welfare of others). In two survey studies, cognitive and emotional processes represented by future-oriented planning and emotional attachment, respectively (Study 1,
N
= 405), or by perspective taking and empathic concern, respectively (Study 2,
N
= 424), positively predicted other-centeredness in prosocial moral reasoning (Study 1) and moral judgment dilemmas based on rationality or intuition (Study 2). Cognitive processes were more closely related to rational aspects of other-centeredness, whereas the emotional processes were more closely related to the intuitive aspects of other-centeredness (Study 2). Finally, the cognitive and emotional processes also mediated negative effects of unpredictability (i.e., negative life events and childhood financial insecurity), as well as positive effects of individual-level, contest competition (i.e., educational and occupational competition) on other-centeredness. Overall, these findings support the view that cognitive and emotional processes do not necessarily contradict each other. Rather, they might work in concert to promote other-centeredness in various circumstances and might be attributed to humans’ developmental flexibility in the face of environmental challenges.
Summary Background The vascular and gastrointestinal effects of non-steroidal anti-inflammatory drugs (NSAIDs), including selective COX-2 inhibitors (coxibs) and traditional non-steroidal ...anti-inflammatory drugs (tNSAIDs), are not well characterised, particularly in patients at increased risk of vascular disease. We aimed to provide such information through meta-analyses of randomised trials. Methods We undertook meta-analyses of 280 trials of NSAIDs versus placebo (124 513 participants, 68 342 person-years) and 474 trials of one NSAID versus another NSAID (229 296 participants, 165 456 person-years). The main outcomes were major vascular events (non-fatal myocardial infarction, non-fatal stroke, or vascular death); major coronary events (non-fatal myocardial infarction or coronary death); stroke; mortality; heart failure; and upper gastrointestinal complications (perforation, obstruction, or bleed). Findings Major vascular events were increased by about a third by a coxib (rate ratio RR 1·37, 95% CI 1·14–1·66; p=0·0009) or diclofenac (1·41, 1·12–1·78; p=0·0036), chiefly due to an increase in major coronary events (coxibs 1·76, 1·31–2·37; p=0·0001; diclofenac 1·70, 1·19–2·41; p=0·0032). Ibuprofen also significantly increased major coronary events (2·22, 1·10–4·48; p=0·0253), but not major vascular events (1·44, 0·89–2·33). Compared with placebo, of 1000 patients allocated to a coxib or diclofenac for a year, three more had major vascular events, one of which was fatal. Naproxen did not significantly increase major vascular events (0·93, 0·69–1·27). Vascular death was increased significantly by coxibs (1·58, 99% CI 1·00–2·49; p=0·0103) and diclofenac (1·65, 0·95–2·85, p=0·0187), non-significantly by ibuprofen (1·90, 0·56–6·41; p=0·17), but not by naproxen (1·08, 0·48–2·47, p=0·80). The proportional effects on major vascular events were independent of baseline characteristics, including vascular risk. Heart failure risk was roughly doubled by all NSAIDs. All NSAID regimens increased upper gastrointestinal complications (coxibs 1·81, 1·17–2·81, p=0·0070; diclofenac 1·89, 1·16–3·09, p=0·0106; ibuprofen 3·97, 2·22–7·10, p<0·0001; and naproxen 4·22, 2·71–6·56, p<0·0001). Interpretation The vascular risks of high-dose diclofenac, and possibly ibuprofen, are comparable to coxibs, whereas high-dose naproxen is associated with less vascular risk than other NSAIDs. Although NSAIDs increase vascular and gastrointestinal risks, the size of these risks can be predicted, which could help guide clinical decision making. Funding UK Medical Research Council and British Heart Foundation.
OBJECTIVE:To examine the cost and clinical outcomes of noninvasive RhD typing with cell-free fetal DNA to selectively deliver antenatal and postnatal prophylaxis with anti-D immune globulin for ...prevention of alloimmunization in RhD-negative women.
METHODS:We developed a decision tree to compare the costs and clinical outcomes of three strategies in an RhD-negative nonalloimmunized population as follows1) routine antenatal anti-D immune globulin prophylaxis and postpartum prophylaxis guided by cord blood typing (the current approach in most of the United States); 2) noninvasive fetal RhD typing with prophylaxis guided by test results; and 3) no screening or prophylaxis. Costs were estimated for testing and treatment algorithms using hospital billing records and information from the manufacturer of the fetal RhD genotyping test. Probability estimates were derived from published literature. The decision tree and sensitivity analyses were constructed and performed with Microsoft Excel.
RESULTS:We estimated the cost of the current approach to prevention of alloimmunization to be $351 per pregnancy, and we estimated the cost of noninvasive determination of fetal RhD status to be $682. Assuming essentially perfect test performance, threshold analysis found the cost must decrease to $119 to break even. The gap widened in favor of routine prophylaxis in most other circumstances (increased false-negative test rate and decreasing prevalence of RhD negativity).
CONCLUSION:Unless the cost of noninvasive fetal RhD typing is reduced substantially, routine antenatal anti-D immune globulin prophylaxis with postpartum prophylaxis guided by cord blood typing is less costly than noninvasive determination of fetal RhD status.
Objective We sought to compare fundal height and handheld ultrasound–measured fetal abdominal circumference (HHAC) for the prediction of fetal growth restriction (FGR) or large for gestational age. ...Study Design This was a diagnostic accuracy study in nonanomalous singleton pregnancies between 24 and 40 weeks’ gestation. Patients underwent HHAC and fundal height measurement prior to formal growth ultrasound. FGR was defined as estimated fetal weight less than 10%, whereas large for gestational age was defined as estimated fetal weight greater than 90%. Sensitivity and specificity were calculated and compared using methods described elsewhere. Results There were 251 patients included in this study. HHAC had superior sensitivity and specificity for the detection of FGR (sensitivity, 100% vs 42.86%) and (specificity, 92.62% vs 85.24%). HHAC had higher specificity but lower sensitivity when screening for LGA (specificity, 85.66% vs 66.39%) and (sensitivity, 57.14% vs 71.43%). Conclusion HHAC could prove to be a valuable screening tool in the detection of FGR. Further studies are needed in a larger population.
INTRODUCTION:
A recent study found that the incidence of invasive squamous cell carcinoma of the vulva (VSCC) is increasing among U.S. women, but rates of VSCC in situ (VIS) have not been reported ...since 2000. In 2008, indications for the human papillomavirus (HPV) vaccine were extended to include prevention of vulvar cancers. To examine its impact, we compared 2001–2018 incidence trends of VIS and VSCC among different populations of U.S. women.
METHODS:
This study was a secondary analysis of 88,942 vulvar cancer cases among adults aged 20 years and older reported in the U.S. Cancer Statistics 2001-2018 databases. We stratified data by tumor behavior (in situ/invasive) and age (20-44, 45-64, 65+ years old), race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic), and U.S. census region (Northeast, South, Midwest, West). Incidence rates and annual percentage changes (APC) were calculated by group.
RESULTS:
VIS incidence significantly decreased from 2001 to 2018 (APC –4.3, 95% CI –4.7 to −3.8) among all groups. Invasive VSCC decreased among 20- to 44-year old women (APC –0.8, 95% CI –1.3 to −0.3), but increased among older women. Regardless of tumor behavior, incidence was highest among non-Hispanic White women and those living in the Midwest.
CONCLUSION:
Rates of VIS are decreasing in women of all ages over 20 years old as well as in invasive VSCC among vaccine-eligible 20- to 44-year-old women. Since the trend began before the vaccine was available, this is probably due to multiple factors. Additional time is needed to fully realize the benefit of HPV vaccination on this cancer.
The human papillomavirus (HPV) vaccine was indicated for the prevention of vulvovaginal cancers in 2008, but its impact on the incidence of vulvar cancers within the US is unknown. To determine this, ...we conducted a secondary analysis of 88,942 vulvar cancer cases among women 20+ years old using the US Cancer Statistics 2001-2018 databases. Data were stratified by tumor behavior (in situ or invasive), age (20-44, 45-64, 65+ years old), race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic), and US census region (Northeast, South, Midwest, West), and incidence rates and average annual percentage changes (AAPC) were calculated by group. Reversing previous trends, the incidence of vulvar carcinoma in situ significantly decreased between 2001 and 2018 among women from all age groups, races/ethnicities, and regions (combined AAPC, -4.3; 95% confidence interval (CI), -4.7 to -3.8). The incidence of invasive vulvar squamous cell carcinoma decreased significantly among 20- to 44-year-old women (AAPC, -0.8; 95% CI, -1.3 to -0.3), but significantly increased among those 45 to 64 (AAPC, 2.3; 95% CI, 1.8-2.8) and 65+ years old (AAPC, 1.2; 95% CI, 1.1-1.4). Regardless of tumor behavior, incidence was highest among non-Hispanic Whites and the Midwest region. Overall, the significant declines in vulvar carcinoma in situ among all ages, as well as invasive vulvar cancer among younger women, are encouraging and complement other recent data suggesting HPV vaccinations are already reducing anal and cervical cancer incidence. Over time, further declines in vulvar carcinoma incidence are likely as uptake and completion rates of the HPV vaccine increase in the US.
We found evidence that HPV vaccinations likely contributed to a decrease in the incidences of vulvar carcinoma in situ and invasive vulvar carcinoma among 20- to 44-year-old women between 2001 and 2018. Our data add to the growing evidence that HPV vaccinations are reducing the incidence of HPV-related anogenital cancers.
Barrett's esophagus is the precursor lesion of esophageal adenocarcinoma, whose progression follows sequential stages. However, the low progression rate and the inadequacy and subjective ...interpretation of histologic grading in predicting Barrett's esophagus progression call for more objective biomarkers that can improve risk prediction. We conducted a genome-wide profiling of 754 human microRNAs (miRNA) in 35 normal epithelium, 34 Barrett's esophagus, and 36 esophageal adenocarcinoma tissues using TaqMan real-time PCR-based profiling. Unsupervised hierarchical clustering using 294 modestly to highly expressed miRNAs showed clear clustering of two groups: normal epithelium versus Barrett's esophagus/esophageal adenocarcinoma tissues. Moreover, there was an excellent clustering of Barrett's metaplasia (without dysplasia) tissues from normal epithelium tissues. However, Barrett's esophagus tissues of different stages and esophageal adenocarcinoma tissues were interspersed. There were differentially expressed miRNAs at different stages. The majority of miRNA aberrations involved upregulation of expression in Barrett's esophagus and esophageal adenocarcinoma tissues, with the most dramatic alterations occurring at the Barrett's metaplasia stage. Known oncomiRs, such as miR-21, miR-25, and miR-223, and tumor suppressor miRNAs, including miR-205, miR-203, let-7c, and miR-133a, showed progressively altered expression from Barrett's esophagus to esophageal adenocarcinoma. We also identified a number of novel miRNAs that showed progressively altered expression, including miR-301b, miR-618, and miR-23b. The significant miRNA alterations that were exclusive to esophageal adenocarcinoma but not Barrett's esophagus included miR-375 downregulation and upregulation of five members of the miR-17-92 and its homologue clusters, which may become promising biomarkers for esophageal adenocarcinoma development.
It is estimated that 6-20% of all cholangiocarcinoma (CCA) diagnoses are explained by primary sclerosing cholangitis (PSC), but the underlying risk factors in the absence of PSC are unclear. We ...examined associations of different risk factors with intrahepatic cholangiocarcinoma (ICC) and extrahepatic cholangiocarcinoma (ECC) in the US.
We conducted a case-control study of 121 ECC patients and 308 ICC patients treated at MD Anderson Cancer Center between May 2014 and March 2020, compared to 1061 healthy controls. Multivariable logistic regression analysis was applied to estimate the adjusted odds ratio (AOR) and 95% confidence interval for each risk factor.
Being Asian, diabetes mellitus, family history of cancer, and gallbladder stones were associated with higher odds of developing ICC and ECC. Each 1-unit increase in body mass index in early adulthood (ages 20-40 years) was associated with a decrease in age at diagnosis of CCA (6.7 months, P<0.001; 6.1 months for ICC, P=0.001; 8.2 months for ECC, P=0.007). A family history of cancer was significantly associated with the risk of ICC and ECC development; the AORs (95%CI) were 1.11 (1.06-1.48) and 1.32 (1.01-2.00) for ICC and ECC, respectively.
In this study, early adulthood onset of obesity was significantly associated with CCA and may predict early diagnosis at younger age than normal weight individuals.
The study highlights the association between obesity and CCA, independent of PSC. There is a need to consider the mechanistic pathways of obesity in the absence of fatty liver and cirrhosis.
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