Key Topics on End-of-Life Care for African Americans

Racial classifications of human populations are politically and socially determined. There is no biological or genetic basis for these racial classifications. Health behaviors may be influenced by culture and poverty. Disparities in health outcomes, sometimes resulting in higher mortality rates for African-Americans appear to influence end of life decision-making attitudes and behaviors. To improve the quality of end of life care in African-American communities, health care professionals must better understand and work to eliminate disparities in health care, increase their own skills, knowledge and confidence in palliative and hospice care, and improve awareness of the benefits and values of hospice and palliative care in their patients and families

Phase-specific and lifetime costs of cancer care in Ontario, Canada

BACKGROUND: Cancer is a major public health issue and represents a significant economic burden to health care systems worldwide. The objective of this analysis was to estimate phase-specific, 5-year and lifetime net costs for the 21 most prevalent cancer sites, and remaining tumour sites combined, in Ontario, Canada. METHODS: We selected all adult patients diagnosed with a primary cancer between 1997 and 2007, with valid ICD-O site and histology codes, and who survived 30 days or more after diagnosis, from the Ontario Cancer Registry (N = 394,092). Patients were linked to treatment data from Cancer Care Ontario and administrative health care databases at the Institute for Clinical and Evaluative Sciences. Net costs (i.e., cost difference between patients and matched non-cancer control subjects) were estimated by phase of care and sex, and used to estimate 5-year and lifetime costs. RESULTS: Mean net costs of care (2009 CAD) were highest in the initial (6 months post-diagnosis) and terminal (12 months pre-death) phases, and lowest in the (3 months) pre-diagnosis and continuing phases of care. Phase-specific net costs were generally lowest for melanoma and highest for brain cancer. Mean 5-year net costs varied from less than $25,000 for melanoma, thyroid and testicular cancers to more than$60,000 for multiple myeloma and leukemia. Lifetime costs ranged from less than $55,000 for lung and liver cancers to over$110,000 for leukemia, multiple myeloma, lymphoma and breast cancer. CONCLUSIONS: Costs of cancer care are substantial and vary by cancer site, phase of care and time horizon analyzed. These cost estimates are valuable to decision makers to understand the economic burden of cancer care and may be useful inputs to researchers undertaking cancer-related economic evaluations

Direct association between pharyngeal viral secretion and host cytokine response in severe pandemic influenza

<p>Abstract</p> <p>Background</p> <p>Severe disease caused by 2009 pandemic influenza A/H1N1virus is characterized by the presence of hypercytokinemia. The origin of the exacerbated cytokine response is unclear. As observed previously, uncontrolled influenza virus replication could strongly influence cytokine production. The objective of the present study was to evaluate the relationship between host cytokine responses and viral levels in pandemic influenza critically ill patients.</p> <p>Methods</p> <p>Twenty three patients admitted to the ICU with primary viral pneumonia were included in this study. A quantitative PCR based method targeting the M1 influenza gene was developed to quantify pharyngeal viral load. In addition, by using a multiplex based assay, we systematically evaluated host cytokine responses to the viral infection at admission to the ICU. Correlation studies between cytokine levels and viral load were done by calculating the Spearman correlation coefficient.</p> <p>Results</p> <p>Fifteen patients needed of intubation and ventilation, while eight did not need of mechanical ventilation during ICU hospitalization. Viral load in pharyngeal swabs was 300 fold higher in the group of patients with the worst respiratory condition at admission to the ICU. Pharyngeal viral load directly correlated with plasma levels of the pro-inflammatory cytokines IL-6, IL-12p70, IFN-γ, the chemotactic factors MIP-1β, GM-CSF, the angiogenic mediator VEGF and also of the immuno-modulatory cytokine IL-1ra (p < 0.05). Correlation studies demonstrated also the existence of a significant positive association between the levels of these mediators, evidencing that they are simultaneously regulated in response to the virus.</p> <p>Conclusions</p> <p>Severe respiratory disease caused by the 2009 pandemic influenza virus is characterized by the existence of a direct association between viral replication and host cytokine response, revealing a potential pathogenic link with the severe disease caused by other influenza subtypes such as H5N1.</p

The impact of immediate breast reconstruction on the time to delivery of adjuvant therapy: the iBRA-2 study

Background: Immediate breast reconstruction (IBR) is routinely offered to improve quality-of-life for women requiring mastectomy, but there are concerns that more complex surgery may delay adjuvant oncological treatments and compromise long-term outcomes. High-quality evidence is lacking. The iBRA-2 study aimed to investigate the impact of IBR on time to adjuvant therapy. Methods: Consecutive women undergoing mastectomy ± IBR for breast cancer July–December, 2016 were included. Patient demographics, operative, oncological and complication data were collected. Time from last definitive cancer surgery to first adjuvant treatment for patients undergoing mastectomy ± IBR were compared and risk factors associated with delays explored. Results: A total of 2540 patients were recruited from 76 centres; 1008 (39.7%) underwent IBR (implant-only [n = 675, 26.6%]; pedicled flaps [n = 105,4.1%] and free-flaps [n = 228, 8.9%]). Complications requiring re-admission or re-operation were significantly more common in patients undergoing IBR than those receiving mastectomy. Adjuvant chemotherapy or radiotherapy was required by 1235 (48.6%) patients. No clinically significant differences were seen in time to adjuvant therapy between patient groups but major complications irrespective of surgery received were significantly associated with treatment delays. Conclusions: IBR does not result in clinically significant delays to adjuvant therapy, but post-operative complications are associated with treatment delays. Strategies to minimise complications, including careful patient selection, are required to improve outcomes for patients

Finishing the euchromatic sequence of the human genome

The sequence of the human genome encodes the genetic instructions for human physiology, as well as rich information about human evolution. In 2001, the International Human Genome Sequencing Consortium reported a draft sequence of the euchromatic portion of the human genome. Since then, the international collaboration has worked to convert this draft into a genome sequence with high accuracy and nearly complete coverage. Here, we report the result of this finishing process. The current genome sequence (Build 35) contains 2.85 billion nucleotides interrupted by only 341 gaps. It covers ∼99% of the euchromatic genome and is accurate to an error rate of ∼1 event per 100,000 bases. Many of the remaining euchromatic gaps are associated with segmental duplications and will require focused work with new methods. The near-complete sequence, the first for a vertebrate, greatly improves the precision of biological analyses of the human genome including studies of gene number, birth and death. Notably, the human enome seems to encode only 20,000-25,000 protein-coding genes. The genome sequence reported here should serve as a firm foundation for biomedical research in the decades ahead

Breast cancer management pathways during the COVID-19 pandemic: outcomes from the UK ‘Alert Level 4’ phase of the B-MaP-C study

Abstract: Background: The B-MaP-C study aimed to determine alterations to breast cancer (BC) management during the peak transmission period of the UK COVID-19 pandemic and the potential impact of these treatment decisions. Methods: This was a national cohort study of patients with early BC undergoing multidisciplinary team (MDT)-guided treatment recommendations during the pandemic, designated ‘standard’ or ‘COVID-altered’, in the preoperative, operative and post-operative setting. Findings: Of 3776 patients (from 64 UK units) in the study, 2246 (59%) had ‘COVID-altered’ management. ‘Bridging’ endocrine therapy was used (n = 951) where theatre capacity was reduced. There was increasing access to COVID-19 low-risk theatres during the study period (59%). In line with national guidance, immediate breast reconstruction was avoided (n = 299). Where adjuvant chemotherapy was omitted (n = 81), the median benefit was only 3% (IQR 2–9%) using ‘NHS Predict’. There was the rapid adoption of new evidence-based hypofractionated radiotherapy (n = 781, from 46 units). Only 14 patients (1%) tested positive for SARS-CoV-2 during their treatment journey. Conclusions: The majority of ‘COVID-altered’ management decisions were largely in line with pre-COVID evidence-based guidelines, implying that breast cancer survival outcomes are unlikely to be negatively impacted by the pandemic. However, in this study, the potential impact of delays to BC presentation or diagnosis remains unknown

Molluscan aminostratigraphy of the US Mid-Atlantic Quaternary coastal system: implications for onshore-offshore correlation, paleochannel and barrier island evolution, and local late Quaternary sea-level history

© The Author(s), 2021. This article is distributed under the terms of the Creative Commons Attribution License. The definitive version was published in Wehmiller, J. F., Brothers, L. L., Ramsey, K. W., Foster, D. S., Mattheus, C. R., Hein, C. J., & Shawler, J. L. Molluscan aminostratigraphy of the US Mid-Atlantic Quaternary coastal system: implications for onshore-offshore correlation, paleochannel and barrier island evolution, and local late Quaternary sea-level history. Quaternary Geochronology, 66, (2021): 101177, https://doi.org/10.1016/j.quageo.2021.101177.The Quaternary record of the US Mid-Atlantic coastal system includes onshore emergent late Pleistocene shoreline deposits, offshore inner shelf and barrier island units, and paleovalleys formed during multiple glacial stage sea-level lowstands. The geochronology of this coastal system is based on uranium series, radiocarbon, amino acid racemization (AAR), and optically stimulated luminescence (OSL) methods. We report over 600 mollusk AAR results from 93 sites between northeastern North Carolina and the central New Jersey shelf, representing samples from both onshore cores or outcrops, sub-barrier and offshore cores, and transported shells from barrier island beaches. AAR age estimates are constrained by paired 14C analyses on specific shells and associated U-series coral ages from onshore sites. AAR data from offshore cores are interpreted in the context of detailed seismic stratigraphy. The distribution of Pleistocene-age shells on the island beaches is linked to the distribution of inner shelf or sub-barrier source units. Age mixing over a range of time-scales (~1 ka to ~100 ka) is identified by AAR results from onshore, beach, and shelf collections, often contributing insights into the processes forming individual barrier islands. The regional aminostratigraphic framework identifies a widespread late Pleistocene (Marine Isotope Stage 5) aminozone, with isolated records of middle and early Pleistocene deposition. AAR results provide age estimates for the timing of formation of the three major paleochannels that underlie the Delmarva Peninsula: Persimmon Point paleochannel ≥800 ka; Exmore paleochannel ~400–500 ka (MIS 12); and Eastville paleochannel > 125 ka (MIS 6). The results demonstrate the value of synthesizing abundant AAR chronologic data across various coastal environments, integrating multiple distinct geologic studies. The ages and elevations of the Quaternary units are important for current hypotheses about relative sea-level history and crustal dynamics in the region, which was likely influenced by the Laurentide ice sheet, the margin just ~400 km to the north.This project was funded through a cooperative agreement with the Bureau of Ocean Energy Management of the U.S. Department of the Interior, Offshore Sand Resources for Coastal Resilience and Restoration Planning: M14AC00003 and M16AC00001. We thank J. Waldner (BOEM) for support and encouragement during this project. We also thank S. Howard and K. Luciano, South Carolina Geological Survey, and numerous colleagues in both the Mid-Atlantic and Southeast Atlantic BOEM ASAP projects, active from 2015 through 2019. This paper is contribution #3999 of the Virginia Institute of Marine Science, William & Mary. Partial support was also provided to Hein by the Mid-Atlantic Sea Grant program (NOAA) award numbers R/71856G and R/71856H and a Virginia Sea Grant (NOAA) Fellowship award NA18OAR4170083 supported Shawler. JFW acknowledges support from the University of Delaware Retired Faculty Research Program