Pan cancer analysis of the intra-tumoral microbiome’s correlation with racial disparities.

2021 ◽  
Vol 39 (15_suppl) ◽  
pp. 2519-2519
Author(s):  
Wei Tse Li ◽  
Matthew Uzelac ◽  
Jaideep Chakladar ◽  
Lindsay M. Wong ◽  
Aditi Gnanasekar ◽  
...  
Keyword(s):  
Bladder Cancer ◽  
African Americans ◽  
Racial Disparities ◽  
Racial Differences ◽  
Asian Americans ◽  
Environmental Influence ◽  
Microbial Abundance ◽  
Risk Of Death ◽  
Incidence And Mortality ◽  
Starting Point

2519 Background: Microbiome composition can influence cancer development and is moderated by diet, hygiene, sanitation, and other environmental variables. For example, a Mediterranean diet could increase breast Lactobacillus abundance, while the gut microbiome changes dramatically with fructose intake. Recent studies have revealed correlations between microbial abundance and racial disparities in cancer. Given these reports, it is critical to examine whether environmental influences on the microbiome contribute to racial disparities in cancer incidence and prognosis. Methods: We examined the intra-tumoral microbiome in the lungs, breasts, bladder, colon, rectum, cervix, head and neck, prostate, and pancreas (n = 4,169). Raw tumor RNA sequencing data were downloaded from The Cancer Genome Atlas (TCGA) and aligned to bacterial genomes. Microbial abundance was correlated to race, ethnicity, and prognostic variables (Kruskal-Wallis test or Cox regression, p< 0.05). Results: We identified several microbes correlated with racial disparities for breast and bladder cancer, two microbes for lung squamous cell carcinoma, and one microbe for colon cancer. For breast cancer, African Americans have the highest mortality rate, followed by white Americans and Asian Americans. We found that four microbes, all under the order Burkholderiales, were positively correlated with poor prognosis and were most abundant in African Americans and least abundant in Asian Americans. Therefore, increased abundance of these microbes may contribute to the observed mortality differences between races. For bladder cancer, Asian Americans have the lowest incidence and mortality rates. Seven microbes, including two Geobacillus, two Pseudomonas, and two Burkholderiales, positively correlate with good prognosis and are upregulated in Asian Americans. High Pseudomonas fluorescens abundance is positively correlated with decreased risk of death (HR: 0.57, 95% CI: 0.38-0.85). High abundance of the Burkholderiales R. pickettii (HR: 0.62, 95% CI: 0.42-0.92) and V. paradoxus (HR: 0.59, 95% CI: 0.36-0.98) also exhibit the same trend. Geobacillus and Pseudomonas are both present in food, while Burkholderiales can cause nosocomial infections and are altered by diet. Conclusions: Our study is the most comprehensive to date investigating racial differences in the intra-tumoral microbiome. Our data serve as a starting point for exploring whether environmental influence of microbial abundance contributes to racial disparities in cancer.

Abstract 491: Racial Disparities in the Trends of Acute Myocardial Infarction Outcomes Among Medicaid Patients, 2007-2011

2017 ◽  
Vol 37 (suppl_1) ◽  
Author(s):  
Oluwole M Adegbala ◽  
Akintunde Akinjero ◽  
Samson Alliu ◽  
Adeyinka C Adejumo ◽  
Emmanuel Akintoye ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
African Americans ◽  
Length Of Stay ◽  
Hospital Mortality ◽  
Racial Disparities ◽  
Racial Differences ◽  
Length Of Hospital Stay ◽  
The United States ◽  
Racial Groups

Background: Although, in-hospital mortality from acute myocardial infarction (AMI) have declined in the United States recently, there is a gap in knowledge regarding racial differences in this trend. We sought to evaluate the effect of race on the trends in outcomes after Acute Myocardial Infarction among Medicaid patients in a nationwide cohort from 2007-2011 Methods: We extracted data from the Nationwide Inpatient Sample (NIS) for all hospitalizations between 2007 and 2011 for Medicaid patients aged 45 years or older with principal diagnosis of AMI using ICD-9-CM codes. Primary outcome of this study was all cause in-hospital mortality. We then stratified hospitalizations by racial groups; Whites, African Americans and Hispanics, and assessed the time trends of in-hospital mortality before and after multivariate analysis. Results: The overall mortality from AMI among Medicaid patients declined during the study period (8.80% in 2007 to 7.46% in 2011). In the adjusted models, compared to 2007, in-hospital mortality from AMI for Medicaid patients decreased across the 3 racial groups; Whites (aOR= 0.88, CI=0.70-0.99), African Americans (aOR=0.76, CI=0.57-1.01), Hispanics (aOR=0.87, CI=0.66-1.25). While the length of hospital stay declined significantly among African American and Hispanic with 2 days and 1.76 days decline respectively, the length of stay remained unchanged for Whites. There was non-significant increase in the incidence of stroke across the various racial groups; Whites (aOR= 1.23, CI=0.90 -1.69), African Americans (aOR=1.10, CI=0.73 -1.64), Hispanics (aOR=1.03, CI=0.68-1.55) when compared to 2007. Conclusion: In this study, we found that in-hospital mortality from AMI among Medicaid patients have declined across the racial groups. However, while the length of stay following AMI declined for African Americans and Hispanics with Medicaid insurance, it has remained unchanged for Whites. Future studies are necessary to identify determinants of these significant racial disparities in outcomes for AMI.

Marital Status and Sexually Transmitted Infections Among African Americans

2010 ◽  
Vol 31 (9) ◽  
pp. 1147-1165 ◽  
Author(s):  
Eboni M. Taylor ◽  
Adaora A. Adimora ◽  
Victor J. Schoenbach
Keyword(s):  
African Americans ◽  
Marital Status ◽  
Racial Disparities ◽  
Racial Differences ◽  
Risk Behaviors ◽  
Ethnic Disparities ◽  
Transmitted Infection ◽  
Sexually Transmitted ◽  
Marriage Rates ◽  
Racial Ethnic

This article assesses the relationship between low marriage rates and racial disparities in sexually transmitted infection (STI) rates. Data from the 2002 National Survey of Family Growth was used to examine the prevalence of sexual risk behaviors by marital status. Logistic regression was used to examine whether racial differences in marriage patterns help account for racial disparities in STI rates. Results indicate that the 12-month prevalence of multiple partners and high-risk partnerships was lowest among currently married, intermediate among cohabiting, and highest among formerly and never-married respondents. Of all racial/ethnic groups, African Americans were least likely to be married. In multiple logistic analyses adjustment for marriage attenuated the association between race and STI risk behaviors for African Americans. Low marriage rates may be an important contributing factor to racial/ethnic disparities in STI rates, particularly for African Americans.

Disparities in esophageal cancer care based on race: a National Cancer Database analysis

2021 ◽  
Author(s):  
Ikenna C Okereke ◽  
Jordan Westra ◽  
Douglas Tyler ◽  
Suzanne Klimberg ◽  
Daniel Jupiter ◽  
...  
Keyword(s):  
Overall Survival ◽  
Esophageal Cancer ◽  
African Americans ◽  
Racial Disparities ◽  
Cancer Patients ◽  
Racial Differences ◽  
Tumor Biology ◽  
High Volume ◽  
National Cancer Database ◽  
Survival Difference

Summary Esophageal cancer is one of the most common cancer killers in our country. The effects of racial disparities on care for esophageal cancer patients are incompletely understood. Using the National Cancer Database, we investigated racial disparities in treatment and outcome of esophageal cancer patients. The National Cancer Database was queried from 2004 to 2017. Logistic regression and survival analysis were used to determine racial differences in access, treatment and outcome. A total of 127,098 patients were included. All minority groups were more likely to be diagnosed at advanced stages versus Caucasians after adjusting for covariates (African American OR—1.64 [95% confidence interval 1.53—1.76], Hispanic OR—1.19 [1.08—1.32], Asian OR—1.78 [1.55—2.06]). After adjustment, all minorities were less likely at every stage to receive surgery. Despite these disparities, Hispanics and Asians had improved survival compared with Caucasians. African Americans had worse survival. Racial disparities for receiving surgery were present in both academic and community institutions, and at high-volume and low-volume institutions. Surgery partially mediated the survival difference between African Americans and Caucasians (HR—1.13 [1.10–1.16] and HR—1.04 [1.02–1.07], without and with adjustment of surgery).There are racial disparities in the treatment of esophageal cancer. Despite these disparities, Hispanics and Asians have improved overall survival versus Caucasians. African Americans have the worst overall survival. Racial disparities likely affect outcome in esophageal cancer. But other factors, such as epigenetics and tumor biology, may correlate more strongly with outcome for patients with esophageal cancer.

Racial disparities in lung adenocarcinoma: The contribution of African ancestry.

2021 ◽  
Vol 39 (15_suppl) ◽  
pp. 8516-8516
Author(s):  
Michelle Jeung-Eun Lee ◽  
Eric Chang ◽  
Manan Shah ◽  
Sanjay R. Jain
Keyword(s):  
Lung Cancer ◽  
Native American ◽  
African Americans ◽  
Racial Disparities ◽  
Racial Differences ◽  
African Ancestry ◽  
Genetic Alterations ◽  
Cancer Genome ◽  
Genetic Ancestry ◽  
Genomic Study

8516 Background: Racial disparities in lung cancer are well-known with African Americans disproportionally affected by lung cancer in terms of incidence and survival. Previous comparative analyses of molecular features of lung cancer revealed racial differences in genomic profiles, which supports somatic differences arising from genetic ancestry. Using The Cancer Genome Atlas (TCGA), we investigated the genetic alterations in lung adenocarcinomas (LUAD) on individuals of African (AFR) ancestry. Methods: The genomic and clinical data of TCGA PanCancer Atlas LUAD were downloaded through the GDC Data Portal. Given that substantial proportion of the US population consist of genetically admixed populations, we utilized The Cancer Genome Ancestry Atlas (TCGAA) and LAMP for estimates of genetic ancestry and quantitative ancestral compositions. This dataset contains 518 samples, including 393 self-reported whites and 52 African Americans. For each case the proportion of European, AFR, East Asian, native American ancestry was estimated. The dominant ancestry was defined as ≥50% of admixture from one reference population. Differences in gene mutation frequency were analyzed based on AFR ancestry proportion. The Kaplan-Meier curves were generated, and Cox regression analyses were performed. Results: Global ancestry analysis identified 50 AFR ancestry cases with mean ancestry of 78.3%. The dominant AFR ancestry group matched the self-reported race with 96% accuracy. We identified 9 subjects with ≥90% AFR ancestry, 22 subjects with 80-90% AFR ancestry, 12 subjects with 70-80% AFR ancestry, and 7 subjects with 50-70% AFR ancestry. TP53 was the most frequently mutated gene, and ≥90% AFR ancestry had the highest rate of mutations (77.8%) compared with 80-90% AFR ancestry (68.2%), and 70-80% AFR ancestry (66.8%). We evaluated classic driver gene mutations (EGFR, KRAS, NRAS, PIK3CA, ALK) and found only 33% of ≥90% AFR ancestry subjects carry a known driver mutation, compared to 58-77% in lower proportion of AFR ancestry subjects. Higher AFR ancestry was associated with worse overall survival (OS) and progression free survival (PFS). Median OS was 14.5 months for ≥90% AFR ancestry compared to 71.47 months in 70-80% AFR ancestry (P = 0.048). ≥90% AFR ancestry had median PFS of 12.8 months compared to 33.5 months in 80-90% AFR ancestry, and 47.1 months in 70-80% AFR ancestry (P = 0.002). Conclusions: This study demonstrates the power of genomic study to investigate the etiology of health disparities by analyzing the effect of ancestry on genetic alterations in LUAD. Our results reveal different mutation loads even among AFR ancestry patients. We observed that AFR ancestry is associated with worse OS, suggesting possible influence of germline ancestry in subsequent somatic alterations. Further work is needed to explore how genetic ancestry impacts tumorigenesis and cancer progression to eliminate lung cancer disparities.

scholarly journals Role of Place in Explaining Racial Heterogeneity in Cognitive Outcomes among Older Adults

2015 ◽  
Vol 21 (9) ◽  
pp. 677-687 ◽  
Author(s):  
Sze Yan Liu ◽  
M. Maria Glymour ◽  
Laura B. Zahodne ◽  
Christopher Weiss ◽  
Jennifer J. Manly
Keyword(s):  
Older Adults ◽  
African American ◽  
African Americans ◽  
Racial Disparities ◽  
Racial Differences ◽  
Cognitive Aging ◽  
School Attendance ◽  
Cognitive Outcomes ◽  
Older Americans ◽  
Years Of Schooling

AbstractRacially patterned disadvantage in Southern states, especially during the formative years of primary school, may contribute to enduring disparities in adult cognitive outcomes. Drawing on a lifecourse perspective, we examine whether state of school attendance affects cognitive outcomes in older adults and partially contributes to persistent racial disparities. Using data from older African American and white participants in the national Health and Retirement Study (HRS) and the New York based Washington Heights Inwood Cognitive Aging Project (WHICAP), we estimated age-and gender-adjusted multilevel models with random effects for states predicting years of education and cognitive outcomes (e.g., memory and vocabulary). We summarized the proportion of variation in outcomes attributable to state of school attendance and compared the magnitude of racial disparities across states. Among WHICAP African Americans, state of school attendance accounted for 9% of the variance in years of schooling, 6% of memory, and 12% of language. Among HRS African Americans, state of school attendance accounted for 13% of the variance in years of schooling and also contributed to variance in cognitive function (7%), memory (2%), and vocabulary (12%). Random slope models indicated state-level African American and white disparities in every Census region, with the largest racial differences in the South. State of school attendance may contribute to racial disparities in cognitive outcomes among older Americans. Despite tremendous within-state heterogeneity, state of school attendance also accounted for some variability in cognitive outcomes. Racial disparities in older Americans may reflect historical patterns of segregation and differential access to resources such as education. (JINS, 2015, 21, 677–687)

scholarly journals Racial Disparities in Lung Cancer Diagnosis and Treatment: A Single Center, Retrospective Study in Central Indiana

2020 ◽  
Vol 3 ◽  
Author(s):  
Andrew Killion ◽  
Francesca Duncan ◽  
Nawar Al Nasrallah ◽  
Catherine Sears
Keyword(s):  
Lung Cancer ◽  
African Americans ◽  
Racial Differences ◽  
Cancer Diagnosis ◽  
Private Insurance ◽  
The United States ◽  
Cancer Center ◽  
Stage At Diagnosis ◽  
Lung Cancer Diagnosis ◽  
Incidence And Mortality

Background/Objective:  Lung cancer is the second most common cancer and the leading cause of death from cancer in the United States. However, there is a disparity in incidence and mortality between African Americans and Caucasians. This study aims to analyze factors that could describe this difference, such as treatment, socioeconomic, or behavioral differences using information from an Indiana University Simon Cancer Center (IUSCC) lung cancer registry. We hypothesized that African Americans will have a higher lung cancer stage at diagnosis and mortality, associated with less timely, stage-appropriate treatment.  Methods:  Using data collected from patients diagnosed with lung cancer at IUSCC from 2000-2016, we compared racial differences in diagnoses and subsequent management. Patients were categorized by race and clinical stage at diagnosis. Further categorization by sex, vital status, age at diagnosis, time from diagnosis to treatment and death, tobacco use, surgery, chemotherapy, insurance coverage, and histology was performed. We determined the rates of surgery or chemotherapy by stage at diagnosis. Statistical analyses are by student t-test or 2-way ANOVA.  Results:  African Americans were younger than Caucasians at lung cancer diagnosis (average 63.4 vs. 61.2 years p-value < 0.001). African American race was associated with a longer time from diagnosis to treatment (36.4 vs. 32.1 days, p=0.023) and shorter time from diagnosis to death (475.1 vs. 623.7 days, p=0.001). The data suggests that African Americans have a later stage at diagnosis, are more likely to be uninsured and less likely to be covered by private insurance. The data suggests African Americans have a lower rate of surgery (Stages 1-3) and chemotherapy (Stages 3B and 4).  Conclusion and Potential Impact:  This data suggests racial differences in lung cancer diagnosis, treatment and outcomes. Future analyses will focus on multiple comparisons to determine possible impacts of socioeconomic and environmental factors on these outcomes at IUSCC and other university-affiliated health care systems. 

Racial differences in the perception of lung cancer: Data from the 2005 Health Information National Trends Survey (HINTS)

2007 ◽  
Vol 25 (18_suppl) ◽  
pp. 6556-6556
Author(s):  
C. S. Lathan ◽  
C. Okechukwu ◽  
B. F. Drake ◽  
G. Bennett
Keyword(s):  
Lung Cancer ◽  
African Americans ◽  
Racial Differences ◽  
Lung Cancer Mortality ◽  
Weighting Method ◽  
Cancer Data ◽  
Black And White ◽  
Incidence And Mortality ◽  
Nationally Representative ◽  
White Patients

6556 Background: Black men have the highest rates of lung cancer incidence and mortality in the US, and yet continue to obtain treatment at lower rates than White patients. Racial differences in the perception of lung cancer in the population could contribute to racial disparities in seeking timely treatment. Methods: Data are from the 2005 HINTS survey. Sample design was random digit dialing of listed telephone exchanges in US. Complete interviews were conducted on 5491 adults, of which 1872 respondents were assigned to receive questions pertaining to lung cancer. All analyses were conducted on this subset of respondents. SAS callable SUDAAN was used to calculate χ2 tests and perform logistic regression analyses to model racial differences in perceptions of lung cancer. All estimates were weighted to be nationally representative of US population; jack knife weighting method was used for parameter estimation. Results: Black and White patients shared many of the same beliefs about lung cancer mortality, and etiology. African Americans were more likely than Whites to agree that its hard to follow recommendations about preventing lung cancer (OR 2.05 1.19–3.53 95% CI), to avoid evaluation for lung cancer due to fear of having the disease (OR 3.32 1.84–5.98 95% CI), and to believe that patients with lung cancer would have pain or other symptoms before diagnosis (OR 2.20 1.27–3.79 95% CI). Conclusions: African Americans are more likely to hold beliefs about lung cancer that could interfere with prevention and treatment of lung cancer. No significant financial relationships to disclose. [Table: see text]

scholarly journals Racial Health Disparities in Coronavirus Deaths

2021 ◽  
Author(s):  
Daniel L. Howard
Keyword(s):  
United States ◽  
African American ◽  
Health Disparities ◽  
African Americans ◽  
Racial Disparities ◽  
Racial Differences ◽  
Causes Of Death ◽  
Current Trend ◽  
Racial Groups ◽  
Racial Health Disparities

Preliminary racial data on the coronavirus pandemic indicates that African Americans are much more likely to experience infections, hospitalizations, and death from the virus in comparison to other racial groups. While this appears to be an alarming health outcome regarding African Americans, it is, in fact, not surprising, nor even new information, considering the historical context of racial health disparities and the marginal health of African Americans in the United States. The leading causes of death for African Americans generally and historically reflects the leading causes of death for the entire United States population. More research, and obviously data, is needed to fully understand the factors that cause the overall racial health disparities, in general, and racial disparities in coronavirus cases and deaths, in particular. In the case of the coronavirus pandemic, the racial disparities in deaths reflect racial differences in the way that African Americans live, work, and exist as a result of their ‘second-class citizenship’ with respect to their lower socioeconomic status in comparison to other racial groups. From a health policy perspective, challenges exist to reversing the current trend in coronavirus deaths among African Americans due to a myriad of historic, consistent, and pervasive societally-induced deficits within African American life. The proposed chapter will rely on systematic review of the extant literature on racial health disparities to identify multiple factors that may affect African American deaths due to the current coronavirus pandemic. The chapter will also rely on this framework to inform evidence-based approaches to improve public health for African Americans.

scholarly journals With Equal Access, African Americans with Non-del17p Multiple Myeloma Have Superior Overall Survival, but del17p Still Carries Poor Prognosis across Race: A VA Study

Blood ◽  
2019 ◽  
Vol 134 (Supplement_1) ◽  
pp. 4388-4388 ◽  
Author(s):  
Anusha Munjuluri ◽  
Nathanael Fillmore ◽  
Diana Cirstea ◽  
Hassan Yameen ◽  
Sarvari Venkata Yellapragada ◽  
...  
Keyword(s):  
Multiple Myeloma ◽  
African Americans ◽  
Racial Differences ◽  
Median Survival ◽  
Lower Incidence ◽  
Research Funding ◽  
Cell Transplant ◽  
Risk Of Death ◽  
Disease Biology ◽  
The Difference

BACKGROUND: In multiple myeloma (MM), deletion of TP53/17p (del17p), present in around 10% of patients, is associated with shortened survival. Lower incidence of del17p is reported in African Americans (AA) compared to European Americans (EA), alluding to possible contribution of disease biology to racial differences in outcome among AA and EA patients with MM. Our recent report of a significantly superior age-adjusted risk of death in AA compared to EA patients in the younger (<65) Veteran population also suggests that AA may have a genetic predisposition that renders them to have better therapeutic outcome or have more indolent subtypes of MM. Here we investigated the incidence and impact of del17p on outcome in AA and EA patients with MM at the VA. METHODS: We identified 2677 patients with MM from 1999 to 2017 using the VA's nationwide Corporate Data Warehouse for whom information on del17p was available. We extracted data on patients' age, race, ISS stage, therapy at induction and stem-cell transplant (SCT) utilization. Test results for del17p were extracted from lab panel and pathology reports. Our analysis is focused on patients with this data. RESULTS: Of the 2677 MM patients evaluated for del17p by conventional cytogenetics and/or FISH, self-reported race information was available in 2432 patients, among which AA constituted 35.6% (867) and EA 64.4% (1565). AA had a greater proportion of younger (<65) patients compared to EA (49.48% vs 33.87%, p<0.001). Overall, among those tested, del17p was reported in 7.4% of all patients, but the incidence was significantly lower in AA compared to EA (4.73% vs 8.82%, p<0.001), largely due to the difference in incidence of del17p in younger AA vs EA (3.73% vs 8.30%, p = 0.005). The rates of del17p across different ISS stages were not significantly different, nor did ISS stage differ across race. As expected, del17p was associated with shortened survival. In the full cohort, median survival was 2.26 years for patients with del17p and 4.27 years for those without (p<0.001). These differences were also observed within race (1.74 vs 4.95 in AA, p<0.001, 2.34 vs 4.13 in EA, p<0.001) and age groups (2.67 vs 5.49 in younger, p<0.001; 2.12 vs 3.5 in older, p<0.001). We found no significant racial differences in survival between AA and EA patients with del17p deletion (1.74 vs 2.34, p=0.47) regardless of age category. However, importantly we noted a significant racial difference in the median survival between younger AA and EA without del17p (7.75 vs. 4.87 years, p=0.006). In contrast, in older patients without del17p we observed no significant difference in survival across race. To understand the difference in survival between younger AA and EA without del17p, we compared ISS stage, ECOG status, and novel therapy (bortezomib, lenalidomide, and thalidomide) and SCT utilization between these groups. No significant differences were observed apart from a small difference in utilization of bortezomib in AA patients as compared to EA at induction (63.1% vs 58.3%, p = 0.029). To assess whether bortezomib utilization had any impact on survival, we compared survival among younger AA and EA without del17p after stratifying into three treatment regimens: bortezomib/dex (Vd), lenalidomide/dex (Rd), and RVd. We observed superior survival for AA as compared to EA across all three regimens (Vd: 5.82 vs 3.63 years, p=0.022; Rd: 8.15 vs 5.10, p=0.029; RVd: median not reached vs 6.95, p=0.72), suggesting that the difference in bortezomib utilization was not responsible for the observed difference in survival. Interestingly, among 198 patients with del17p for whom the percentage of cells with deletion was reported, we observed that higher (>55%) clonality was associated with lower median survival compared to those with low clonality (5-55%) (0.97 vs 2.42, p=0.049). The difference was even more significant with a threshold of 35% (p=0.015). CONCLUSIONS: Our large study identified significantly lower incidence of del17p in younger AA compared to EA. We found no racial disparity in survival among AA and EA with del17p regardless of age. In contrast, in the absence of del17p, younger AA demonstrated significantly better survival as compared to younger EA and better response to bortezomib- and lenalidomide-based doublet and triplet induction regimens, suggesting possible differences in disease biology other than del17p that may contribute to a more indolent course and increased sensitivity to therapy. Disclosures Yellapragada: Celgene: Research Funding; Novartis: Employment, Other: Spouse Employment ; BMS: Research Funding; Takeda: Research Funding. Munshi:Takeda: Consultancy; Janssen: Consultancy; Oncopep: Consultancy; Takeda: Consultancy; Oncopep: Consultancy; Celgene: Consultancy; Janssen: Consultancy; Celgene: Consultancy; Amgen: Consultancy; Amgen: Consultancy; Abbvie: Consultancy; Abbvie: Consultancy; Adaptive: Consultancy; Adaptive: Consultancy.

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