Complications preceding early deaths in Black and White children with acute myeloid leukemia.
ABSTRACT: Black patients have a twofold increased risk of induction mortality compared to White patients with acute myeloid leukemia (AML). We reviewed diagnosis and billing data from Pediatric Health Information System for 28 AML Induction I deaths to investigate conditions preceding death in White and Black patients. Half of deaths occurred within 10 days of initial diagnostic admission. Respiratory, cardiac, renal, and infectious complications were common prior to both White and Black deaths. Deaths in White patients were more commonly preceded by intracranial hemorrhage compared to deaths in Black patients. Future studies should assess management approaches of complications by race to identify modifiable processes that reduce mortality.
Project description:Black patients with acute myeloid leukemia (AML) experience higher mortality than White patients. We compared induction mortality, acuity of illness prior to chemotherapy, and insurance type between Black and White patients to assess whether acuity of presentation mediates the disparity. Within a retrospective cohort of 1,122 children with AML treated with two courses of standard induction chemotherapy between 2004 and 2014 in the Pediatric Health Information System (PHIS) database, the association between race (Black versus White) and inpatient mortality during induction was examined. Intensive Care Unit (ICU)-level resource utilization during the first 72 hours following admission for initial AML chemotherapy was evaluated as a potential mediator. The total effect of race on mortality during Induction I revealed a strong association (unadjusted HR 2.75, CI: 1.18, 6.41). Black patients had a significantly higher unadjusted risk of requiring ICU-level resources within the first 72 hours after initial presentation (17% versus 11%; RR 1.52, CI: 1.04, 2.24). Mediation analyses revealed the indirect effect of race through acuity accounted for 61% of the relative excess mortality during Induction I. Publicly insured patients experienced greater induction mortality than privately insured patients regardless of race. Black patients with AML have significantly greater risk of induction mortality and are at increased risk for requiring ICU-level resources soon after presentation. Higher acuity amongst Black patients accounts for a substantial portion of the relative excess mortality during Induction I. Targeting factors affecting acuity of illness at presentation may lessen racial disparities in AML induction mortality.
Project description:BACKGROUND:Black patients with acute myeloid leukemia (AML) are more likely to present with high acuity and consequently experience higher rates of induction mortality than white patients. Given the consistently identified racial disparities in overall survival (OS) among patients with AML, we aimed to evaluate whether there were sustained on-therapy racial differences in inpatient mortality, intensive care unit (ICU) requirements, or supportive care beyond initial induction. PROCEDURE:Within a retrospective cohort of 1239 children diagnosed with AML between 2004 and 2014 in the Pediatric Health Information System (PHIS) database who survived their initial course of induction chemotherapy, we compared on-therapy inpatient mortality, ICU-level care requirements, treatment course duration, cumulative length of hospital stay (LOS), and resource utilization after induction I by race. RESULTS:Over the period from the start of induction II through completion of frontline chemotherapy, there were no significant differences in mortality (adjusted odds ratios [OR], 1.01; 95% confidence intervals [CI], 0.41-2.48), ICU-level care requirements (adjusted OR, 0.93; 95% CI, 0.69-1.26), LOS (adjusted mean difference, 3.2 days; 95% CI, -2.3-9.6), or supportive care resource utilization for black patients relative to white patients. Course-specific analyses also demonstrated no differences by race. CONCLUSION:Although black patients have higher acuity at presentation and higher induction mortality, such disparities do not persist over subsequent frontline chemotherapy treatment. This finding allows interventions aimed at reducing disparities to be directed at presentation and induction.
Project description:<b>Background:</b> Cardiovascular deaths increased during the early phase of the COVID-19 pandemic in the United States. However, it is unclear whether racial/ethnic minorities have experienced a disproportionate rise in heart disease and cerebrovascular disease deaths. <b>Methods:</b> We used the National Center for Health Statistics to identify heart disease and cerebrovascular disease deaths for non-Hispanic White, non-Hispanic Black, non-Hispanic Asian, and Hispanic individuals from March-August 2020 (pandemic period), as well as for the corresponding months in 2019 (historical control). We determined the age- and sex-standardized deaths per million by race/ethnicity for each year. We then fit a modified Poisson model with robust standard errors to compare change in deaths by race/ethnicity for each condition in 2020 vs. 2019. <b>Results:</b> There were a total of 339,076 heart disease and 76,767 cerebrovascular disease deaths from March through August 2020, compared to 321,218 and 72,190 deaths during the same months in 2019. Heart disease deaths increased during the pandemic in 2020, compared with the corresponding period in 2019, for non-Hispanic White (age-sex standardized deaths per million, 1234.2 vs. 1208.7; risk ratio for death [RR] 1.02, 95% CI 1.02-1.03), non-Hispanic Black (1783.7 vs. 1503.8; RR 1.19, 1.17-1.20), non-Hispanic Asian (685.7 vs. 577.4; RR 1.19, 1.15-1.22), and Hispanic (968.5 vs. 820.4, RR 1.18, 1.16-1.20) populations. Cerebrovascular disease deaths also increased for non-Hispanic White (268.7 vs. 258.2; RR 1.04, 95% CI 1.03-1.05), non-Hispanic Black (430.7 vs. 379.7; RR 1.13, 95% CI 1.10-1.17), non-Hispanic Asian (236.5 vs. 207.4; RR 1.15, 1.09-1.21), and Hispanic (264.4 vs. 235.9; RR 1.12, 1.08-1.16) populations. For both heart disease and cerebrovascular disease deaths, each racial and ethnic minority group experienced a larger relative increase in deaths than the non-Hispanic White population (interaction term, p<0.001). <b>Conclusions:</b> During the COVID-19 pandemic in the US, Black, Hispanic, and Asian populations experienced a disproportionate rise in deaths due to heart disease and cerebrovascular disease, suggesting that racial/ethnic minorities have been most impacted by the indirect effects of the pandemic. Public health and policy strategies are needed to mitigate the short- and long-term adverse effects of the pandemic on the cardiovascular health of minority populations.
Project description:Clinical outcome of patients with acute myeloid leukemia (AML) is associated with cytogenetic and molecular factors and patient demographics (e.g., age and race). We compared survival of 25,523 non-Hispanic Black and White adults with AML using Surveillance Epidemiology and End Results (SEER) Program data and performed mutational profiling of 1,339 patients with AML treated on frontline Alliance for Clinical Trials in Oncology (Alliance) protocols. Black patients had shorter survival than White patients, both in SEER and in the setting of Alliance clinical trials. The disparity was especially pronounced in Black patients <60 years, after adjustment for socioeconomic (SEER) and molecular (Alliance) factors. Black race was an independent prognosticator of poor survival. Gene mutation profiles showed fewer <i>NPM1</i> and more <i>IDH2</i> mutations in younger Black patients. Overall survival of younger Black patients was adversely affected by <i>IDH2</i> mutations and <i>FLT3</i>-ITD, but, in contrast to White patients, was not improved by <i>NPM1</i> mutations. SIGNIFICANCE: We show that young Black patients have not benefited as much as White patients from recent progress in AML treatment in the United States. Our data suggest that both socioeconomic factors and differences in disease biology contribute to the survival disparity and need to be urgently addressed.<i>See related commentary by Vyas, p. 540</i>.<i>This article is highlighted in the In This Issue feature, p. 521</i>.
Project description:<h4>Background</h4>The COVID-19 pandemic exacerbated existing racial/ethnic health disparities in the United States. Monitoring nationwide Twitter conversations about COVID-19 and race/ethnicity could shed light on the impact of the pandemic on racial/ethnic minorities and help address health disparities.<h4>Objective</h4>This paper aims to examine the association between COVID-19 tweet volume and COVID-19 cases and deaths, stratified by race/ethnicity, in the early onset of the pandemic.<h4>Methods</h4>This cross-sectional study used geotagged COVID-19 tweets from within the United States posted in April 2020 on Twitter to examine the association between tweet volume, COVID-19 surveillance data (total cases and deaths in April), and population size. The studied time frame was limited to April 2020 because April was the earliest month when COVID-19 surveillance data on racial/ethnic groups were collected. Racially/ethnically stratified tweets were extracted using racial/ethnic group-related keywords (Asian, Black, Latino, and White) from COVID-19 tweets. Racially/ethnically stratified tweets, COVID-19 cases, and COVID-19 deaths were mapped to reveal their spatial distribution patterns. An ordinary least squares (OLS) regression model was applied to each stratified dataset.<h4>Results</h4>The racially/ethnically stratified tweet volume was associated with surveillance data. Specifically, an increase of 1 Asian tweet was correlated with 288 Asian cases (P<.001) and 93.4 Asian deaths (P<.001); an increase of 1 Black tweet was linked to 47.6 Black deaths (P<.001); an increase of 1 Latino tweet was linked to 719 Latino deaths (P<.001); and an increase of 1 White tweet was linked to 60.2 White deaths (P<.001).<h4>Conclusions</h4>Using racially/ethnically stratified Twitter data as a surveillance indicator could inform epidemiologic trends to help estimate future surges of COVID-19 cases and potential future outbreaks of a pandemic among racial/ethnic groups.
Project description:Single cell network profiling (SCNP) is a multi-parameter flow cytometry technique for simultaneous interrogation of intracellular signalling pathways. Diagnostic paediatric acute myeloid leukaemia (AML) bone marrow samples were used to develop a classifier for response to induction therapy in 53 samples and validated in an independent set of 68 samples. The area under the curve of a receiver operating characteristic curve (AUC(ROC)) was calculated to be 0·85 in the training set and after exclusion of induction deaths, the AUC(ROC) of the classifier was 0·70 (P = 0·02) and 0·67 (P = 0·04) in the validation set when induction deaths (intent to treat) were included. The highest predictive accuracy was noted in the cytogenetic intermediate risk patients (AUC(ROC) 0·88, P = 0·002), a subgroup that lacks prognostic/predictive biomarkers for induction response. Only white blood cell count and cytogenetic risk were associated with response to induction therapy in the validation set. After controlling for these variables, the SCNP classifier score was associated with complete remission (P = 0·017), indicating that the classifier provides information independent of other clinical variables that were jointly associated with response. This is the first validation of an SCNP classifier to predict response to induction chemotherapy. Herein we demonstrate the usefulness of quantitative SCNP under modulated conditions to provide independent information on AML disease biology and induction response.
Project description:<h4>Importance</h4>Notable increases in mortality from alcohol-induced causes over the past 2 decades in the United States have been reported. However, comprehensive assessments of trends in alcohol-induced mortality by sex, age, race/ethnicity, and social and geographic factors are lacking.<h4>Objective</h4>To examine trends in alcohol-induced mortality rates from 2000 to 2016, comparing results by demographic characteristics including sex, race/ethnicity, age, county-level socioeconomic status, and geographic location.<h4>Design, setting, and participants</h4>This serial cross-sectional study used US national vital statistics data for years 2000 to 2016 for all US residents older than 15 years. Data analysis was conducted from January to September 2019.<h4>Exposures</h4>Trends in alcohol-induced mortality by sex, race/ethnicity, age, county-level socioeconomic status (ie, median income, percentage of unemployed residents, percentage of residents with a bachelor's degree), rurality level, and US state.<h4>Main outcomes and measures</h4>Alcohol-induced mortality, ie, deaths for which alcohol holds a population-attributable fraction of 1. Deaths were expressed per 100 000 residents as absolute and age-standardized rates. Mortality trends were measured as average annual percentage changes (AAPCs) for the entire period (ie, 2000-2016) and annual percentage changes (APCs) for individual periods of change within the study period.<h4>Results</h4>A total of 425 045 alcohol-induced deaths were identified from 2000 to 2016 (2000: 19 627 deaths; 14 979 [76.3%] men; 2016: 34 857 deaths; 25 213 [73.3%] men). The rate of alcohol-induced deaths increased substantially among men (AAPC, 1.4%; 95% CI, 1.0% to 1.8%) and women (AAPC, 3.1%; 95% CI, 2.6% to 3.6%) and accelerated recently (men, 2012-2016: APC, 4.2%; 95% CI, 3.1% to 5.3%; women, 2013-2016: APC, 7.1%; 95% CI, 5.1% to 9.1%). The largest increases by race/ethnicity were observed among American Indian and Alaska Native men (AAPC, 3.3%; 95% CI, 2.6% to 4.0%), American Indian and Alaska Native women (AAPC, 4.2%; 95% CI, 3.8% to 4.6%), and white women (AAPC, 4.1%; 95% CI, 3.6% to 4.7%). Despite initial declines among black women, black men, and Latino men (eg, Latino men, 2000-2003: APC, -5.1%; 95% CI, -9.8% to -0.1%; 2003-2013: APC, -0.6%; 95% CI, -1.4% to 0.2%), increases occurred later in the study period (eg, Latino men, 2013-2016: APC, 4.1%; 95% CI, 0.3% to 8.1%). The rates of increase varied by age group and in turn by racial/ethnic group. Among white individuals, large absolute increases occurred in midlife (eg, men aged 55-59 years, 2000-2003: 25.5 deaths per 100 000 residents; 2013-2016: 43.3 deaths per 100 000 residents; women aged 50-54 years, 2000-2003: 7.4 deaths per 100 000 residents; 2013-2016: 16.5 deaths per 100 000 residents), although APCs were also large for ages 25 to 34 years, ranging from 4.6% to 6.9% per year among men and from 7.3% to 12.0% among women. Among American Indian and Alaska Native individuals, increases throughout the age range were observed, with the largest absolute increase occurring for ages 45 to 49 years among men (2000-2013: 113.6 deaths per 100 000 residents; 2013-2016: 193.1 deaths per 100 000 residents) and for ages 50 to 54 among women (2000-2013: from 56.1 deaths per 100 000 residents; 2013-2016: 105.1 deaths per 100 000 residents).<h4>Conclusions and relevance</h4>This study found large increases in alcohol-induced death rates across age and racial/ethnic subgroups of the US population, which have accelerated over recent years. Large increases in alcohol-induced deaths among younger age groups may be associated with future increases in alcohol-related disease.
Project description:<h4>Introduction</h4>So-called deaths of despair-those involving drug overdoses, alcohol-related liver disease, and suicide-have been rising in the U.S. among middle-aged white, non-Hispanic adults without a college degree. Premature deaths (ages 25-69) from alcoholic liver disease were examined specifically in this study from 1999 to 2018, by sex, race/Hispanic origin, and age group.<h4>Methods</h4>Data were drawn from the 1999-2018 Multiple Cause of Death database and bridged-race estimates of the U.S. resident population, including 281,243 alcoholic liver disease deaths or an average of 8 deaths per 100,000 population. Analyses examined alcoholic liver disease death rates for sex differences among 3 age groups (25-49, 50-59, and 60-69 years), by race and Hispanic origin, from 1999 to 2018; age-adjusted and age-specific annual percentage changes (accounted for cohorts); years of potential life lost; and age of death for sociodemographic backgrounds, alcoholic liver disease clinical courses, and comortalities.<h4>Results</h4>White non-Hispanics increasingly experienced greater alcoholic liver disease mortality than black non-Hispanics and Hispanics, confirming the racial and ethnic crossover observed in previous studies. Although men consistently had higher rates of mortality, male-to-female ratios decreased in the past 2 decades and were the lowest among ages 25-49 years and especially among ages 25-34 years. Although women generally had longer life expectancies, women died of alcoholic liver disease on average about 2-3 years earlier than men.<h4>Conclusions</h4>Prevention and intervention efforts are imperative to address the narrowing sex gap and widening racial disparities in alcoholic liver disease premature deaths.
Project description:CKD is associated with higher risk of death, but details regarding differences in cause-specific death in CKD are unclear. We examined the leading causes of death among a non-dialysis-dependent CKD population using an electronic medical record-based CKD registry in a large healthcare system and the Ohio Department of Health mortality files. We included 33,478 white and 5042 black patients with CKD who resided in Ohio between January 2005 and September 2009 and had two measurements of eGFR<60 ml/min per 1.73 m(2) obtained 90 days apart. Causes of death (before ESRD) were classified into cardiovascular, malignancy, and non-cardiovascular/non-malignancy diseases and non-disease-related causes. During a median follow-up of 2.3 years, 6661 of 38,520 patients (17%) with CKD died. Cardiovascular diseases (34.7%) and malignant neoplasms (31.8%) were the leading causes of death, with malignancy-related deaths more common among those with earlier stages of kidney disease. After adjusting for covariates, each 5 ml/min per 1.73 m(2) decline in eGFR was associated with higher risk of death due to cardiovascular disease (hazard ratio [HR], 1.10; 95% confidence interval [95% CI], 1.08 to 1.12) and non-cardiovascular/non-malignancy diseases (HR, 1.12; 95% CI, 1.09 to 1.14) but not to malignancy. In the adjusted models, blacks had overall-mortality hazard ratios similar to those of whites but higher hazard ratios for cardiovascular deaths. Further studies to confirm these findings and explain the mechanisms for differences are warranted. In addition to lowering cardiovascular burden in CKD, efforts to target known risk factors for cancer at the population level are needed.
Project description:Nearly 2 million patients visit emergency departments (EDs) because of eye concerns annually in the United States. How hospitals currently assign these patients to treatment is important for designing systems that equitably allocate resources for eye care in urgent settings.To investigate factors associated with ophthalmology consultation for eye-related adult ED encounters to assess possible disparities by sex, race/ethnicity, language preference, or residential distance from the medical center.Retrospective observational study of 13 361 adult ED encounters associated with an eye-related billing diagnosis between January 1, 2010, and September 30, 2015, at the University of Michigan Medical Center in Ann Arbor.Measures available from the University of Michigan clinical data warehouse included age, sex, race/ethnicity, preferred language, home distance from the ED, calendar year of encounter, and Charlson-Deyo Comorbidity Index score.Association of the ED encounter with ophthalmology consultation. An ophthalmology consultation was identified by cross-referencing ophthalmology faculty and clinical instructors from 2010 to 2015 against billing providers for consultations using the Charlson-Deyo Comorbidity Index score and billing codes. Measures included patient age, sex, race/ethnicity, home address, preferred language (English vs non-English), and calendar year of encounter.Among the 13 361 encounters, 6840 (51.2%) involved a female patient. Mean (SD) age at encounter was 50.7 (19.3) years; 10 033 patients (75.1%) were of white and 1969 (14.7%) of black race/ethnicity. English was the preferred language for 13 022 patients (97.5%). The ophthalmology service was consulted in 5289 encounters (39.6%). Black patients had significantly lower odds of an ophthalmology consultation than white patients (odds ratio [OR], 0.85; 95% CI, 0.75-0.96). Patients who preferred a non-English language had significantly lower odds of receiving an ophthalmology consultation (OR, 0.73; 95% CI, 0.55-0.98).Many of the 13 361 eye-related ED encounters were managed by ED clinicians with no ophthalmology consultation. Patients who were black or who preferred a language other than English were less likely to have an ophthalmologist involved in their care. The associations found in this observational study do not imply causation but suggest disparities in care that should be further investigated.