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AbstractBackground and ObjectivesCriminal‐legal (CL) referrals to addiction treatment have historically had low utilization of medications for opioid use disorder (MOUD). While state differences have been reported, an in‐depth longitudinal analysis of state‐by‐state differences is lacking.MethodsThe Substance Abuse and Mental Health Services Administration Treatment Episode Dataset‐Admissions 2000–2020 provided data for individuals entering their initial treatment with an opioid as their primary substance. Outcome was planned use of MOUD, assessing odds ratio (OR) of CL referrals relative to non‐CL referrals cumulatively over the 21‐year period and as incremental change (change in relative disparity) using effect sizes, stratified by each state.Results2,187,447 cases met the criteria. Planned MOUD occurred in 37.7% of non‐CL clients versus 6.5% of CL clients (OR = 0.11, 95% confidence interval = 0.11–0.12). For all clients, planned MOUD increased from 2000 (33.9%) to 2020 (44.8%). This increase was blunted within CL clients, increasing from 2000 (6.4%) to 2020 (13.3%). Rhode Island saw the greatest improvements in equity.Discussion and ConclusionsWhile rates of planned MOUD increased over the 21 years, a significant disparity persisted among CL clients in most states. As opioid use disorders and opioid‐related overdoses are more prevalent among those involved with the CL system, improving this has high impact.Scientific SignificanceProvides the most comprehensive analysis of state‐by‐state inequities in MOUD access for CL relative to non‐CL referrals over a 21‐year period through use of a national data set. Positive outliers are used as case examples for others to follow in pursuit of more equitable care.

AbstractBackgroundImmune thrombocytopenia (ITP) and Evans syndrome (ES) are manifestations of immune dysregulation. Genetic variants in immune‐related genes have been identified in patients with ITP and especially ES. We aimed to explore familial autoimmunity in patients with ITP and ES to understand possible contributions to chronicity.ProcedureWe assessed family history in two ways: via patient report for ITP and ES and by population‐based analysis using the Utah Population Database (UPDB) for ITP. A total of 266 patients with ITP and 21 patients with ES were identified via chart review, and 252 of the 266 patients with ITP were also identified in the UPDB.ResultsChart review showed familial autoimmunity in 29/182 (15.9%) and 25/84 (29.8%) of patients with newly diagnosed+persistent (nd+p) ITP and chronic ITP (cITP), respectively, (p = .009). The UPDB analysis revealed that autoimmunity in relatives of patients with nd+pITP was higher than in relatives of controls (odds ratio [OR]: 1.69 [1.19–2.41], p = .004), but was not significantly increased in relatives of patients with cITP (OR 1.10 [0.63–1.92], p = .734). Incomplete family history in medical records likely contributed to the observed discrepancy.ConclusionsThe findings suggest that familial autoimmunity may have a stronger association with the development of ITP rather than its duration. Twelve (57.1%) patients with ES reported autoimmunity in their relatives. UPDB analysis was omitted due to the small number of patients with ES. The use of population databases offers a unique opportunity to assess familial health and may provide clues about contributors to immune dysregulation features within families.

AbstractBackgroundThe highly variable occurrence of primary liver cancers across the United States emphasize the relevance of location‐based factors. Social determinants such as income, educational attainment, housing, and other factors may contribute to regional variations in outcomes. To evaluate their impact, this study identified and analyzed clusters of high mortality from primary liver cancers and the association of location‐based determinants with mortality across the contiguous United States.MethodsA geospatial analysis of age‐adjusted incidence and standardized mortality rates from primary liver cancers from 2000 to 2020 was performed. Local indicators of spatial association identified hot‐spots, clusters of counties with significantly higher mortality. Temporal analysis of locations with persistent poverty, defined as high (>20%) poverty for at least 30 years, was performed. Social determinants were analyzed individually or globally using composite measures such as the social vulnerability index or social deprivation index. Disparities in county level social determinants between hot‐spots and non‐hot‐spots were analyzed by univariate and multivariate logistic regression.ResultsThere are distinct clusters of liver cancer incidence and mortality, with hotspots in east Texas and Louisiana. The percentage of people living below the poverty line or Hispanics had a significantly higher odds ratio for being in the top quintile for mortality rates in comparison to other quintiles and were highly connected with mortality rates. Current and persistent poverty were both associated with an evolution from non‐hotspots to new hotspots of mortality. Hotspots were predominantly associated with locations with significant levels of socioeconomic vulnerability or deprivation.ConclusionsPoverty at a county level is associated with mortality from primary liver cancer and clusters of higher mortality. These findings emphasize the importance of addressing poverty and related socio‐economic determinants as modifiable factors in public health policies and interventions aimed at reducing mortality from primary liver cancers.

Abstract Background Outcomes in alcohol‐associated liver disease (ALD) are influenced by several race and ethnic factors, yet its natural history across the continuum of patients in different stages of the disease is unknown. Methods We conducted a retrospective cohort study of U.S. adults from 2011 to 2018, using three nationally representative databases to examine potential disparities in relevant outcomes among racial and ethnic groups. Our analysis included logistic and linear regressions, along with competing risk analysis. Results Black individuals had the highest daily alcohol consumption (12.6 g/day) while Hispanic participants had the largest prevalence of heavy episodic drinking (33.5%). In a multivariable‐adjusted model, Hispanic and Asian participants were independently associated with a higher ALD prevalence compared to Non‐Hispanic White interviewees (OR: 1.4, 95% CI: 1.1–1.8 and OR: 1.5 95% CI:1.1–2.0, respectively), while Blacks participants had a lower ALD prevalence (OR: .7 95% CI: .6–.9), and a lower risk of mortality during hospitalization due to ALD (OR: .83 95% CI: .73–.94). Finally, a multivariate competing‐risk analysis showed that Hispanic ethnicity had a decreased probability of liver transplantation if waitlisted for ALD (SHR: .7, 95% CI: .6–.8) along with female Asian population (HR: .40, 95% CI: .26–.62). Conclusions After accounting for key social and biological health determinants, the Hispanic population showed an increased risk of ALD prevalence, even with lower alcohol consumption. Additionally, Hispanic and Asian female patients had reduced access to liver transplantation compared to other enlisted patients.

A clinical trial represents a large commitment from all individuals involved and a huge financial obligation given its high cost; therefore, it is wise to make the most of all collected data by learning as much as possible. A multistate model is a generalized framework to describe longitudinal events; multistate hazards models can treat multiple intermediate/final clinical endpoints as outcomes and estimate the impact of covariates simultaneously. Proportional hazards models are fitted (one per transition), which can be used to calculate the absolute risks, that is, the probability of being in a state at a given time, the expected number of visits to a state, and the expected amount of time spent in a state. Three publicly available clinical trial datasets, colon, myeloid, and rhDNase, in the survival package in R were used to showcase the utility of multistate hazards models. In the colon dataset, a very well-known and well-used dataset, we found that the levamisole+fluorouracil treatment extended time in the recurrence-free state more than it extended overall survival, which resulted in less time in the recurrence state, an example of the classic “compression of morbidity.” In the myeloid dataset, we found that complete response (CR) is durable, patients who received treatment B have longer sojourn time in CR than patients who received treatment A, while the mutation status does not impact the transition rate to CR but is highly influential on the sojourn time in CR. We also found that more patients in treatment A received transplants without CR, and more patients in treatment B received transplants after CR. In addition, the mutation status is highly influential on the CR to transplant transition rate. The observations that we made on these three datasets would not be possible without multistate models. We want to encourage readers to spend more time to look deeper into clinical trial data. It has a lot more to offer than a simple yes/no answer if only we, the statisticians, are willing to look for it.

Background Breast cancer remains a leading cause of cancer morbidity and mortality worldwide. In the United States, Black women face significant disparities in screening mammograms, experience higher rates of breast cancer at advanced stages, and are more likely to die from the disease. Aims This study aimed to develop and beta-test a virtual health navigation program to enhance breast cancer care within the Black community. We identified barriers to utilizing virtual patient navigators and factors impacting the adoption of virtual navigation for breast cancer information among Black women. Methods The vCONET (Virtual Community Oncology Navigation and Engagement) intervention was delivered through the Second Life virtual platform. The informational content was collaboratively developed with community members. Participants engaged in an informational session on risk factors, mammography information, and preventive behaviors. Surveys (n = 18) and focus groups (n = 9) assessed knowledge and insights into perceptions. Results Findings revealed a positive impact of the intervention, with participants expressing increased knowledge and willingness to seek further information about breast cancer prevention, and highlighted the engaging nature of the virtual environment, while acknowledging potential technological challenges. Conclusion Virtual health navigation shows promise in addressing breast cancer disparities by promoting awareness among Black women. Future efforts should optimize virtual navigation approaches through collaborative engagement for lasting impact, enhancing breast cancer care and equity in communities of color.

Abstract Patients with brain metastases (BMETS) frequently emphasize the impact on quality of life (QOL) over prolongation of life at the time of making treatment decisions. Thus, it is critical to evaluate patient-reported health utility scores after treatment of BMETS. Stereotactic surgery (SRS) is becoming the most frequent treatment modality. The objective of this study was to determine the changes in the EuroQol- 5 Dimension (EQ-5D) in patients with BMETS treated with SRS. The NPA SRS Registry is a multi-institutional collaboration prospectively collecting information from patients undergoing SRS since 2017. We queried the registry for the results of the baseline and follow-up EQ-5D questionnaire, with a utility index score given based on the patient’s responses for five domains: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. The cohort included 522 cases treated with SRS between 2017 and 2023; 264 (47.8%), 197 (35.7%), and 91 (16.5%) had 1, 2-4, and 5-14 metastases, respectively. The mean EQ-5D score at the time of SRS was 0.551 (SD=0.443). At the last follow-up after SRS, 107 (34.0%) patients indicated improvement from their EQ-5D baseline while 51 (16.2%) were stable. The score decreased in 113 patients (35.9%) while 44 (13.9%) showed mixed changes (i.e., domain sub-scores both increased and decreased). For mobility, usual activities, pain/discomfort, and anxiety/depression domains patients experienced similar rates of improvement (21.0%-22.5%). In the self-care domain, 32 (10.2%) patients reported improvement, 232 (73.7%) reported no change and 89 (28.3%) had worsening scores. Our study provided the first longitudinal prospective real-world data using the EQ-5D, a health utility tool, in patients with BMETS treated with SRS. In more than half of the cases, the patients reported improved or stable EQ-5D scores over time after treatment. Factors independent of treatment that may prompt worsening QOL following SRS are being identified and will be presented.

PURPOSE Axicabtagene ciloleucel (axi-cel) is an autologous CD19 chimeric antigen receptor (CAR) T-cell therapy that is approved for the treatment of relapsed or refractory large B-cell lymphoma. Little is known about the long-term survivorship after CAR T-cell therapy. METHODS We previously reported the results of 298 patients who were leukapheresed with the intent to receive standard-of-care axi-cel (n = 275 infused) after two or more previous lines of therapy at a median follow-up of 12.9 months. Here, we report extended follow-up of this cohort to a median of 58 months, with a focus on late survivorship events. RESULTS Among axi-cel–infused patients, progression-free survival at 5 years was 29% and overall survival (OS) at 5 years was 40%. The 5-year lymphoma-specific survival was 53% with infrequent late relapses. However, the 5-year nonrelapse mortality (NRM) was 16.2%, with over half of NRM events occurring beyond 2 years. Patients who were 60 years and older had a lower risk of relapse ( P = .02), but a higher risk of NRM compared with patients younger than 60 years (NRM odds ratio, 4.5 [95% CI, 2.1 to 10.8]; P < .001). Late NRM was mainly due to infections and subsequent malignant neoplasms (SMNs). In total, SMNs occurred in 24 patients (9%), including therapy-related myeloid neoplasms (n = 15), solid tumors (n = 7), and unrelated lymphoid malignancies (n = 2). CONCLUSION In the standard-of-care setting, axi-cel exhibits outcomes consistent with those reported in clinical trials, with sustained, durable responses observed at the 5-year time point. However, late infections and the development of SMN are key survivorship issues that reduce long-term survival after CAR T-cell therapy, particularly in the elderly.

Introduction Revision total elbow arthroplasty (TEA) is indicated for component loosening, periprosthetic joint infection, and fractures. Previous investigations into revision TEA complications have small sample sizes and limited exploration of acute complications. This study aims to characterize the 30-day complications and associated demographics of patients undergoing revision TEA using a large national database. Methods The 2015–2020 American College of Surgeons National Surgical Quality Improvement Program database was used to identify all revision TEA patients. Results The analysis included 158 patients (average age 62.6 years). The overall complication rate was 13.9% ( n = 22). The most common 30-day complications were organ/space surgical site infection (3.8%, n = 6), unplanned readmission (3.2%, n = 5), intraoperative or postoperative transfusion (3.2%, n = 5), and unplanned reoperation (1.9%, n = 3). Patients with a history of dyspnea or steroid/immunosuppressant use for a chronic condition had significantly higher rates of bleeding requiring transfusion ( p = .029 and p = .021, respectively). Additionally, patients aged 80 years or older had a significantly higher rate of unplanned readmission ( p = .032). Conclusion Revision TEA has a 13.9% rate of complications within 30-days of surgery, with most involving surgical site infection, unplanned readmission, and blood transfusion. Level of Evidence IV.