Randal Paniello
Washington University in St. Louis, Otolaryngology, Faculty Member
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Multivariable analyses are complex statistical methods to evaluate the impact of multiple variables on outcomes of interest. Books have been written on each of these methods detailing the mathematical and statistical objectives and... more
Multivariable analyses are complex statistical methods to evaluate the impact of multiple variables on outcomes of interest. Books have been written on each of these methods detailing the mathematical and statistical objectives and processes. However, we have found very little in the way of brief reports that help the nonstatistically trained physician obtain a basic understanding of multivariable analyses in order to have some understanding of the increasing literature using these methods. This work is organized in 2 parts. This article, Part A, addresses the "big 4" algebraic methods of multivariable analysis. The primary focus of Part A is to present a brief "primer" to help the reader understand the methods and uses; it expressly avoids the many details of statistical assumptions, calculations, and myriad branching alternatives. Part B will concentrate on conjunctive consolidation and will focus on enough information to allow the interested reader to actually perform the analysis. For the statistical scholar, we have included references to several voluminous serious works.
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ObjectivesTo compare taste changes after transoral robotic surgery (TORS) to taste changes in healthy controls.MethodsOropharyngeal cancer patients receiving TORS and healthy controls were recruited. Participants underwent posterolateral... more
ObjectivesTo compare taste changes after transoral robotic surgery (TORS) to taste changes in healthy controls.MethodsOropharyngeal cancer patients receiving TORS and healthy controls were recruited. Participants underwent posterolateral and whole‐mouth psychophysical taste testing (identification, intensity, and hedonics) at baseline and at 2 weeks postoperatively (patients) or follow‐up (controls). Surgeons reported suspension time and glossopharyngeal nerve injury (GNI) based on the identification and sacrifice of the nerve. A Clinical Global Impression (CGI) of taste symptoms was completed at each session (“My sense of taste bothers me” on a 5‐point scale from Never [1] to Always [5]). A taste disorder (TD) was a CGI of 3 (Sometimes) or worse. Within‐subject changes in CGI and psychophysical scores were computed. “Worsened taste” was a CGI increase by ≥1 point at follow‐up.ResultsOf 69 participants, most (33/37 tumor, 31/32 controls) had normal baseline taste (CGI < 3). 14/33...
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Purpose:Pembrolizumab improved survival in patients with recurrent or metastatic head and neck squamous-cell carcinoma (HNSCC). The aims of this study were to determine if pembrolizumab would be safe, result in pathologic tumor response... more
Purpose:Pembrolizumab improved survival in patients with recurrent or metastatic head and neck squamous-cell carcinoma (HNSCC). The aims of this study were to determine if pembrolizumab would be safe, result in pathologic tumor response (pTR), and lower the relapse rate in patients with resectable human papillomavirus (HPV)–unrelated HNSCC.Patients and Methods:Neoadjuvant pembrolizumab (200 mg) was administered and followed 2 to 3 weeks later by surgical tumor ablation. Postoperative (chemo)radiation was planned. Patients with high-risk pathology (positive margins and/or extranodal extension) received adjuvant pembrolizumab. pTR was quantified as the proportion of the resection bed with tumor necrosis, keratinous debris, and giant cells/histiocytes: pTR-0 (<10%), pTR-1 (10%–49%), and pTR-2 (≥50%). Coprimary endpoints were pTR-2 among all patients and 1-year relapse rate in patients with high-risk pathology (historical: 35%). Correlations of baseline PD-L1 and T-cell infiltration ...
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ObjectivesEvaluate factors associated with adherence to ototoxicity monitoring among patients with head and neck cancer treated with cisplatin and radiation therapy at a tertiary care center.MethodsWe performed a single‐institution... more
ObjectivesEvaluate factors associated with adherence to ototoxicity monitoring among patients with head and neck cancer treated with cisplatin and radiation therapy at a tertiary care center.MethodsWe performed a single‐institution retrospective cohort study on adults with head and neck cancer treated with cisplatin and radiation therapy who participated in an ototoxicity monitoring program. The primary outcomes were rates of post‐treatment audiograms at the following time points: one, three, six, 12, and greater than 12 months. Multivariable logistic regression was performed to identify risk factors associated with complete loss of follow‐up after pre‐treatment evaluation.ResultsTwo hundred ninety‐four head and neck cancer patients were analyzed. Overall, 220 (74.8%) patients had at least one post‐treatment audiogram; 58 (20.0%) patients had more than one audiogram. The time point with the highest follow‐up rate was at 3 months (n = 170, 57.8%); rates at the remaining times ranged ...
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For human papilloma virus positive (HPV+) oropharyngeal squamous cell carcinoma (OPSCC), management recommendations for patients with a single metastatic lymph node <6 cm in diameter remain nebulous, leading to treatment heterogeneity... more
For human papilloma virus positive (HPV+) oropharyngeal squamous cell carcinoma (OPSCC), management recommendations for patients with a single metastatic lymph node <6 cm in diameter remain nebulous, leading to treatment heterogeneity in this common subgroup of patients.
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The primary aims of this single-arm, phase 2 trial were to determine the objective response rate (ORR) of human papillomavirus (HPV)-unrelated, locally advanced head and neck squamous-cell carcinoma (LA-HNSCC) to palbociclib monotherapy,... more
The primary aims of this single-arm, phase 2 trial were to determine the objective response rate (ORR) of human papillomavirus (HPV)-unrelated, locally advanced head and neck squamous-cell carcinoma (LA-HNSCC) to palbociclib monotherapy, and to correlate responses to somatic genomic alterations in CDKN2A. HPV-unrelated disease was defined as 1) SCC of the larynx, hypopharynx or oral cavity, or 2) SCC of the oropharynx with <70% of tumor cells expressing p16 by immunohistochemistry and/or absence of high-risk HPV-RNA by in situ hybridization. Genome sequencing (FoundationOne CDx or Tempus xT) was performed on tumor tissue obtained before treatment. Patients received palbociclib 125 mg/d orally on days 1-21 of each 28-day cycle. Tumor response was assessed using RECIST 1.1 on CT scans performed before and after two cycles of palbociclib. After palbociclib, patients received chemoradiation therapy. A sample size of 24 patients yielded an 80% power if the ORR was >38% (alternative...
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Introduction: Unilateral vocal fold paralysis (UVFP) without an identifiable cause is termed idiopathic unilateral vocal fold paralysis (IUVFP). Some authors have postulated that select cases of IUVFP have a viral etiology, but the... more
Introduction: Unilateral vocal fold paralysis (UVFP) without an identifiable cause is termed idiopathic unilateral vocal fold paralysis (IUVFP). Some authors have postulated that select cases of IUVFP have a viral etiology, but the causality has not been established. We set out to review institutional cases of IUVFP and determine if there is a correlation between upper respiratory infection symptoms and presentation of IUVFP. Methods: Cases of IUVFP were reviewed over a 10-year period (2002-2012). The history was investigated to review presenting symptoms. We specifically reviewed for symptoms of upper respiratory infection at the onset of UVFP and tallied the frequency. Symptoms included sore throat, laryngitis, cough, influenza, bronchitis, pneumonia, otalgia, and sinusitis. The seasonal onset (if possible) was determined based on the history provided from the initial consultation. Study Design: Case series. Results: Overall, 107 patients presented with IUVFP; 35.5% of patients re...
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5585 Background: The optimal method of follow-up for patients with upper aerodigestive tract carcinoma (UADT) after curative-intent primary treatment is unknown. There is evidence that the intensity of surveillance varies substantially... more
5585 Background: The optimal method of follow-up for patients with upper aerodigestive tract carcinoma (UADT) after curative-intent primary treatment is unknown. There is evidence that the intensity of surveillance varies substantially among clinicians. Analysis of geographic variation in utilization of medical resources is often used to identify regions of over- or under-utilization. METHODS We surveyed the membership of the American Head and Neck Society regarding their recommended frequency of office visits and 13 surveillance tests (chest x-ray, head-neck CT, chest CT, head-neck MRI, head-neck sonogram, bone scan, CBC, liver function tests, thyroid function tests, serum electrolyte levels, tumor markers, esophagoscopy, and bronchoscopy) for their patients after potentially curative therapy for UADT cancers. RESULTS Of the 1,322 members surveyed, 610 (46%) responded, of which 420 (32%) were evaluable. Pooled responses from nine U.S. census regions, 12 metropolitan statistical areas (MSAs), and overseas members (16% of evaluable responses) were compared. There were statistically significant variations in practice patterns among census regions for office visits, CBC, head-neck CT, sonography, and esophagoscopy (p<0.05, ANOVA). The mean frequency of office visits also differed significantly (p<0.05) among MSAs, ranging from six in Houston to nine elsewhere during year 1 for patients with stage I lesions. Non-U.S. members use significantly more blood tests, imaging studies, and endoscopy for routine cancer surveillance than U.S. members (p<0.05). Surprisingly, the penetration rate of managed care organizations had no significant effect on post-treatment surveillance intensity. CONCLUSIONS This analysis indicates that only a small portion of the wide variation in observed follow-up practice patterns can be explained by geographic determinants. No significant financial relationships to disclose.
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A simple, safe and effective surgical alternative for treating adductor spasmodic dysphonia (ADSD) would appeal to many patients. This study evaluates a new option, using radiofrequency-induced thermotherapy (RFITT) of the thyroarytenoid... more
A simple, safe and effective surgical alternative for treating adductor spasmodic dysphonia (ADSD) would appeal to many patients. This study evaluates a new option, using radiofrequency-induced thermotherapy (RFITT) of the thyroarytenoid muscle (TA) via the minithyrotomy approach to reduce the force of adduction. Fifteen dogs were used. In part 1, the optimal RFITT power settings, exposure time, probe location, and number of passes were determined. Part 2 compared laryngeal adductor pressures (LAPs) at baseline; immediately postintervention; and at 1, 3, or 6 months postintervention. Interventions included RFITT via the transcervical minithyrotomy approach (n = 15), transoral RFITT (n = 3), botulinum toxin (Botox) injection (n = 3), or no-intervention controls (n = 3). Postintervention induced phonation and histologic analyses were performed as well. In the minithyrotomy RFITT group, the mean LAP was 30.3% of baseline immediately posttreatment. At 1, 3, and 6 months postoperatively,...
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The hypoglossal nerve is a logical donor nerve for hemilaryngeal reinnervation because 1) its activity coincides with normal laryngeal adduction during speech and deglutition; 2) it is a large nerve with many axons; and 3) donor site... more
The hypoglossal nerve is a logical donor nerve for hemilaryngeal reinnervation because 1) its activity coincides with normal laryngeal adduction during speech and deglutition; 2) it is a large nerve with many axons; and 3) donor site morbidity is low. This method of laryngeal reinnervation has not been previously reported. Previous studies using the ansa cervicalis for reinnervation have failed to show spontaneous activity. Hypoglossal-to—recurrent laryngeal nerve anastomosis was performed on a series of 5 dogs. The vocal folds were viewed monthly, with the animals awake, by infraglottic examination through a permanent tracheostomy. One dog failed due to technical error. The remaining 4 dogs began to exhibit spontaneous vocal fold adduction within 2 to 4 months. Vocal fold motion was synchronous with spontaneous tongue motion. Complete glottic closure was seen during swallowing at 3 to 5 months. Intraglottic pressure measurements following reinnervation were normal. Hypoglossal nerv...
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Laryngeal adductory pressure (LAP) is the pressure induced as the vocal folds squeeze on a balloon while the recurrent laryngeal nerve (RLN) is stimulated. The LAP has been shown to vary with the frequency of stimulation, with a... more
Laryngeal adductory pressure (LAP) is the pressure induced as the vocal folds squeeze on a balloon while the recurrent laryngeal nerve (RLN) is stimulated. The LAP has been shown to vary with the frequency of stimulation, with a characteristic slope. The RLN was divided and reanastomosed 4 different ways in 12 canine hemilaryngeal preparations; the 4 subgroups represented a range of expected post-reinnervation synkinesis recovery patterns. The LAP frequency-response curve was measured before surgery and at monthly intervals for 6 months after surgery. In the “best-case” group (RLN adductor and abductor trunks each divided and reanastomosed), the slope was found to return to normal. The 2 whole RLN division-reanastomosis groups (precise realignment or 180° rotation) both gave results similar to those of the “worst-case” group (RLN adductor and abductor trunks divided and transposed); these 3 subgroups were all significantly different from baseline. The slope of the LAP frequency-resp...
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Medialization laryngoplasty has become a routine procedure for cases of unilateral vocal fold paralysis. In certain clinical situations, it may become desirable to reverse the procedure and remove the implant. This process was studied... more
Medialization laryngoplasty has become a routine procedure for cases of unilateral vocal fold paralysis. In certain clinical situations, it may become desirable to reverse the procedure and remove the implant. This process was studied experimentally in eight dogs in a chronic model of induced canine phonation. A silicone polymer implant was inserted to medialize one normal vocal fold for a period of 1 month, after which it was removed. Motion of the cricoarytenoid (CA) joint and induced phonation were studied weekly while the implant was in place, and for another month following implant removal. Significant abnormalities were found even with this relatively short period of implantation. With the implant in place, impairment of CA joint mobility was found in seven of the eight dogs, precluding phonation. A dense fibrous capsule rapidly developed around the implant, making its removal technically difficult. Following implant removal, a gradual return to normal function was found in on...
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&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quo... more
&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;Comparative effectiveness research&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; (CER) is not a new concept; however, recently it has been popularized as a method to develop scientifically sound actionable data by which patients, physicians, payers, and policymakers may make informed health care decisions. Fundamental to CER is that the comparative data are derived from large diverse populations of patients assembled from point-of-care general primary care practices and that measured outcomes include patient value judgments. The challenge is to obtain scientifically valid data to be acted upon by decision-making stakeholders with potentially quite diversely different agenda. The process requires very thoughtful research designs modulated by complex statistical and analytic methods. This article is composed of a guiding narrative with an extensive set of tables outlining many of the details required in performing and understanding CER. It ends with short discussions of three example papers, limitations of the method, and how a practicing physician may view such reports.
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Hyperbaric oxygen (HBO) therapy is sometimes used to assist in wound healing after major head and neck cancer surgery. However, there is concern that HBO treatments might enhance the growth of any residual microscopic disease. This was... more
Hyperbaric oxygen (HBO) therapy is sometimes used to assist in wound healing after major head and neck cancer surgery. However, there is concern that HBO treatments might enhance the growth of any residual microscopic disease. This was studied in a mouse model of squamous cell carcinoma (SCC). SCC-VII/SF tumor cells were cultured, and then injected (3 × 10(3) cells) into C3H/HeJ mice in 5 groups: subcutaneous (SQ) control (n = 13), SQ-immediate (n = 12), SQ-delayed (n = 13), tail vein control (n = 8), and tail vein immediate (n = 9). The 3 experimental groups were subjected to HBO therapy, 2.4 atm for 90 minutes, 5 days per week for 4 weeks, starting on postinjection day 3 (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;immediate&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;) or 10 (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;delayed&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;). Tumors in the SQ mice were measured 3 times per week. Lung metastases in the tail vein mice were counted at necropsy. At postimplantation day 28, when the immediate group completed its HBO therapy, the tumor volume in the SQ-immediate group was 49.1% higher than the control group, and the SQ-delayed group was 105.1% higher than controls (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .05). Two weeks later, the SQ-immediate group and SQ-delayed group tumor volumes were still significantly higher than controls, but the difference was smaller (18.4% and 43.8%, respectively; p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .05 only for the delayed group). The tail vein groups had similar numbers of lung metastases, with a mean of 8.7 metastases in the control group and 9.0 metastases in the HBO group (not significant [NS]). This study suggests that HBO therapy does accelerate the growth of microscopic foci of SCCs. This finding differs from some earlier studies and warrants further study.
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Objectives/Hypothesis: To demonstrate the significance of apoptosis in ischemia‐reperfusion injury in revascularized fasciocutaneous flaps and test the hypothesis that pharmacologic inhibition of caspases prolongs the allowable primary... more
Objectives/Hypothesis: To demonstrate the significance of apoptosis in ischemia‐reperfusion injury in revascularized fasciocutaneous flaps and test the hypothesis that pharmacologic inhibition of caspases prolongs the allowable primary ischemia time of these flaps.Study Design: Animal study using the epigastric flap in adult male Sprague‐Dawley rats.Methods: Fifty‐nine rats were treated with the caspase inhibitor (Q‐VD‐OPH) reconstituted in dimethylsulfoxide (DMSO) (n = 20, 8 mg/kg:0.8 mL/kg), DMSO alone (n = 19, 0.8 mL/kg), or saline (n = 20, 0.8 mL/kg). Treatment was given as a single intraperitoneal injection 30 minutes before starting primary ischemia. Epigastric flaps were subjected to increasing ischemia times followed by reperfusion. The flaps were harvested and analyzed 7 days later, and viability was assessed. Probit statistical analysis was used to determine the critical ischemia time. This was defined as the time point when 50% of the flaps in each group were expected to survive.Results: The calculated critical ischemia times were 8.92 hours (95% confidence interval 7.19–10.47 h) for the saline group, 16.35 hours (95% confidence interval 11.82–19.89 h) for the DMSO group, and 21.73 hours (95% confidence interval 19.39–25.37 h) for the DMSO with Q‐VD‐OPH group. These differences were significantly different from each other.Conclusions: Pretreatment of fasciocutaneous flaps with a free radical scavenger alone or in combination with a caspase inhibitor significantly increases the flap's tolerance of primary ischemia. The added benefit of the caspase inhibitor suggests that apoptosis plays an important role in ischemia‐reperfusion injury in soft tissue flaps.
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Research Interests: Medicine, General Surgery, Head and Neck, Humans, Health Services, and 15 moreHead and Neck Cancer, Physicians, Clinical Sciences, Aged, Middle Aged, Adult, Analysis of Variance, Postgraduate Education, Cancer Patient, Age Factors, Age Groups, Neoplasm staging, Bone scan, Head and neck neoplasms, and Population surveillance
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Research Interests: Control, Medicine, General Surgery, Clinical Practice, Head and Neck, and 15 moreHumans, Liver Function, Check, Clinical Sciences, Aged, Middle Aged, Adult, Physical examination, Long Term, Continuity of Patient Care, Liver function tests, Postoperative Period, Guideline Adherence, Health Care Surveys, and Head and neck neoplasms
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Objectives/HypothesisIn‐office recurrent laryngeal nerve conduction studies (NCSs) are a technique that can potentially provide information about laryngeal innervation. NCS is essential in the management of other neuropathies including... more
Objectives/HypothesisIn‐office recurrent laryngeal nerve conduction studies (NCSs) are a technique that can potentially provide information about laryngeal innervation. NCS is essential in the management of other neuropathies including carpal tunnel syndrome and spinal cord injury. We hypothesize that laryngeal NCS may have similar utility in managing patients with vocal fold paralysis, atrophy, and neurodegenerative disease. NCSs are technically challenging because they require transcervical stimulation of the recurrent laryngeal nerve (RLN). This study combines radiographic data with cadaveric dissection to describe the anatomic parameters for optimal RLN stimulation.Study DesignRadiographic and Cadaveric Study.MethodsFifty computed tomography scans were reviewed to determine the dimensions for ideal needle electrode placement. These values were compared to measurements from 12 fresh human cadaveric neck dissections. Ultrasound imaging was utilized in select cases. The neck was dissected to assess the accuracy of electrode placement.ResultsRadiographically, the mean transcervical depth to the RLN was 33.2 mm ± 8.3 mm in males versus 29.4 mm ± 9.4 mm in females. The working space between the lateral trachea and carotid artery was 15.3 mm ± 3.6 mm on the right and 14.1 mm ± 2.9 mm on the left. After placement of stimulating electrodes into the cadaveric neck, the electrode tips were consistently within 8 mm of the RLN. Ultrasound guidance improved placement accuracy of the stimulating electrode.ConclusionsLaryngeal NCSs can provide detailed and objective information about laryngeal innervation that could dramatically improve the management of various neuropathies. In‐office NCSs require technical precision, and this study describes anatomic factors that may affect the feasibility of performing this technique.Level of EvidenceNA Laryngoscope, 131:1566–1569, 2021
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BACKGROUND:The number of elderly patients with oral squamous cell carcinoma (OCSCC) is increasing as the elderly population increases. Unfortunately, evidence to guide the management of these patients is lacking.METHODS:Patients with... more
BACKGROUND:The number of elderly patients with oral squamous cell carcinoma (OCSCC) is increasing as the elderly population increases. Unfortunately, evidence to guide the management of these patients is lacking.METHODS:Patients with OCSCC identified from the National Cancer Database (NCDB) were stratified into age-based cohorts. Demographics, comorbidities, and treatment patterns were analyzed. Patients were stratified into early stage (Stage I/II) and advanced stage (Stage III/IV) disease. The likelihood of receiving multimodality therapy by age was calculated using multinomial logistic regression for each stratum while controlling for potential confounders. Cox proportional hazard regression was used to calculate 5-year mortality risk while controlling for potential confounders.RESULTS:Surgery alone or palliative options were offered to older patients more frequently. After controlling for confounders, older patients were less likely to receive multimodality therapy for both early stage and advanced stage disease. Patients across all age cohorts had improved 5-year survival with surgery and adjuvant therapy.CONCLUSION:Our analyses suggest that elderly patients have unique demographic and pathologic features. They frequently receive less treatment than similarly staged younger patients, yet they benefit from multimodality therapy when feasible. These data suggest an urgent need to critically appraise the care of elderly OCSCC patients within the broader context of their individual comorbidity burden, functional status, and treatment goals.
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Page 1. 24 Unilateral Vocal Cord Paralysis Unilateral vocal cord paralysis: Introductory overview Randall C. Paniello METHODS OVERVIEW For initial inquiries into this topic, a computerized PubMed search of Medline listings ...
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BackgroundHPV‐related oropharyngeal squamous cell carcinoma (OPSCC) is associated with a favorable prognosis, yet patients of color and low socioeconomic status (SES) continue to experience inferior outcomes. We aim to understand how the... more
BackgroundHPV‐related oropharyngeal squamous cell carcinoma (OPSCC) is associated with a favorable prognosis, yet patients of color and low socioeconomic status (SES) continue to experience inferior outcomes. We aim to understand how the emergence of HPV has impacted race and SES survival disparities in OPSCC.MethodsA retrospective cohort of 18,362 OPSCC cases from 2010 to 2017 was assembled using the SEER (Surveillance, Epidemiology, and End Results) database. Cox proportional regression and Fine and Gray regression models were used to calculate hazard ratios (HRs) adjusting for race, SES, age, subsite, stage, and treatment.ResultsBlack patients had lower overall survival than patients of other races in HPV‐positive and HPV‐negative OPSCC (HR 1.31, 95% CI 1.13–1.53 and HR 1.23, 95% CI 1.09–1.39, respectively). Higher SES was associated with improved survival in all patients. Race had a diminished association with survival among high SES patients. Low SES Black patients had consider...