Microhardness Measurements on Tooth and Alveolar Bone in Rodent Oral Disease Models

The mechanical property, microhardness, is evaluated in dental enamel, dentin, and bone in oral disease models, including dental fluorosis and periodontitis. Micro-CT (µCT) provides 3D imaging information (volume and mineral density) and scanning electron microscopy (SEM) produces microstructure images (enamel prism and bone lacuna-canalicular). Complementarily to structural analysis by µCT and SEM, microhardness is one of the informative parameters to evaluate how structural changes alter mechanical properties. Despite being a useful parameter, studies on microhardness of alveolar bone in oral diseases are limited. To date, divergent microhardness measurement methods have been reported. Since microhardness values vary depending on the sample preparation (polishing and flat surface) and indentation sites, diverse protocols can cause discrepancies among studies. Standardization of the microhardness protocol is essential for consistent and accurate evaluation in oral disease models. In the present study, we demonstrate a standardized protocol for microhardness analysis in tooth and alveolar bone. Specimens used are as follows: for the dental fluorosis model, incisors were collected from mice treated with/without fluoride-containing water for 6 weeks; for ligature-induced periodontal bone resorption (L-PBR) model, alveolar bones with periodontal bone resorption were collected from mice ligated on the maxillary 2nd molar. At 2 weeks after the ligation, the maxilla was collected. Vickers hardness was analyzed in these specimens according to the standardized protocol. The protocol provides detailed materials and methods for resin embedding, serial polishing, and indentation sites for incisors and alveolar. To the best of our knowledge, this is the first standardized microhardness protocol to evaluate the mechanical properties of tooth and alveolar bone in rodent oral disease models.

Managing the risks associated with technological disruption in the road transport system: a control structure modelling approach

Road transport is experiencing disruptive change from new first-of-a-kind technologies. While such technologies offer safety and operational benefits, they also pose new risks. It is critical to proactively identify risks during the design, development and testing of new technologies. The Systems Theoretic Accident Model and Processes (STAMP) method analyses the dynamic structure in place to manage safety risks. This study applied STAMP to develop a control structure model for emerging technologies in the Australian road transport system and identified control gaps. The control structure shows the actors responsible for managing risks associated with first-of-a-kind technologies and the existing control and feedback mechanisms. Gaps identified related to controls (e.g. legislation) and feedback mechanisms (e.g. monitoring for behavioural adaptation). The study provides an example of how STAMP can be used to identify control structure gaps requiring attention to support the safe introduction of new technologies.

Real-world treatment satisfaction with erenumab in migraine: analysis of the US National Health and Wellness Survey

OBJECTIVE

The treatment landscape for the prevention of migraine has rapidly evolved in recent years with the advent of calcitonin gene-related peptide therapy, including erenumab. The objective of this study was to assess patient-reported treatment satisfaction among erenumab users.

METHODS

This retrospective, cross-sectional study used data from the 2019 US National Health and Wellness Survey collected during March-July 2019. Respondents self-reporting physician-diagnosed migraine and currently using erenumab were analyzed. Treatment satisfaction was measured on a seven-point Likert scale. Data were further reported by the duration of erenumab treatment. Data on respondents' socio-demographic characteristics and treatment patterns were also collected.

RESULTS

Overall, 67 respondents using erenumab with or without other migraine preventives for up to 1 year were included in the analysis. The mean (standard deviation) age was 46.7 (12.9) years. Most of the respondents were women (86.6%), White (74.6%), and commercially-insured (67.2%). Notably, 40.3% had ≥1 comorbidity per the Charlson Comorbidity Index. Approximately half of the respondents were college graduates and employed (49.3% each). Among the 67 respondents, 46 received erenumab exclusively. Across both cohorts, the percentage of respondents who were satisfied with erenumab treatment was slightly higher among those with a longer treatment duration (overall erenumab cohort: 63.6%, 69.6%, and 75.8% for 0-<3, 3-<6, and 6-12 months, respectively; erenumab monotherapy cohort: 62.5%, 71.4%, and 87.5% for 0-<3, 3-<6, and 6-12 months, respectively). Treatment patterns before switching to erenumab revealed that most respondents had used ≥1 preventive treatment for migraine (80.6%; 54/67), over two-thirds (33/54) of whom had ≥2 treatment failures owing to nonresponse.

CONCLUSION

Satisfaction was high among long-term erenumab users, indicating that those using erenumab for a longer duration are more satisfied. Furthermore, this study provided insights on the basic socio-demographics, disease characteristics, and health behaviors of erenumab users as well as their treatment patterns before switching to erenumab.

Healthcare costs and resource utilization in patients with migraine treated with erenumab: A retrospective, non-interventional study using claims data from the United States

OBJECTIVE

To assess healthcare costs and healthcare resource utilization (HCRU) among adult patients who newly initiated erenumab in the United States.

METHODS

This retrospective, non-interventional analysis included adult patients (aged ≥18 years) newly initiating erenumab and who had three consecutive monthly claims for erenumab (11/1/2017-9/1/2019) from the Komodo Health database. Outcomes included migraine-related and all-cause costs, use of other preventive/acute migraine medications, and HCRU. All outcomes were compared during the 180-day pre- versus the 180-day post-index periods. Cost outcomes were also assessed for longer periods including post-index Days 91-270 and monthly mean post-index costs for the longest time of continuous insurance enrollment.

RESULTS

Overall, 1839 patients with migraine were included for analysis. Compared to the 180-day pre-index period, an increase in total migraine-related costs (+$2639; p < 0.0001), migraine-related prescription costs (+$3435, p < 0.0001), all-cause total costs (+$2977; p < 0.001), and all-cause prescription costs (+$4102; p < 0.0001) were observed during the 180-day post-index period after adjusting for covariates. Conversely, reduction in migraine-related medical costs (-$896; p < 0.0001), and significantly lower odds of migraine-related emergency room visits (odds ratio [OR] 0.60, 95% confidence interval [CI] 0.44-0.82; p = 0.001), migraine-related office visits (OR 0.58, 95% CI 0.53-0.64; p < 0.0001), and migraine-related neurologist visits (OR 0.69, 95% CI 0.63-0.75; p < 0.0001) were observed during the 180-days post-index period. There were significant decreases in the odds of having overall preventive migraine medications (OR 0.81, 95% CI 0.75-0.87; p < 0.0001), acute-migraine medications (OR 0.92, 95% CI 0.85-1.00; p = 0.038), and triptan (OR 0.79, 95% CI 0.73-0.85; p < 0.0001) during the 180-day post-index period. Sensitivity analyses on cost outcomes found no statistically significant differences in pre-index migraine-related costs compared to post-index migraine-related costs when assessing longer post-index follow-up periods.

CONCLUSION

Initiation of therapy with a novel treatment is often associated with an increase in overall healthcare costs due to the entrance costs associated with novel therapy. For a chronic condition such as migraine, cost versus health benefits should be evaluated over a long period (e.g., ≥2 years) to better understand the true benefits of therapy. Data from this study suggest that the entrance cost for erenumab, the primary driver of the high post-index prescription costs gets mitigated by reduced medical costs over long-term follow-up. The results indicate better disease management in adult patients with migraine, which should be an important consideration for both patients and payors, as these findings have shown an offset between migraine-related prescription and medical costs.

Forecasting emergent risks in advanced AI systems: an analysis of a future road transport management system

Artificial Intelligence (AI) is being increasingly implemented within road transport systems worldwide. Next generation of AI, Artificial General Intelligence (AGI) is imminent, and is anticipated to be more powerful than current AI. AGI systems will have a broad range of abilities and be able to perform multiple cognitive tasks akin to humans that will likely produce many expected benefits, but also potential risks. This study applied the EAST Broken Links approach to forecast the functioning of an AGI system tasked with managing a road transport system and identify potential risks. In total, 363 risks were identified that could have adverse impacts on the stated goals of safety, efficiency, environmental sustainability, and economic performance of the road system. Further, risks beyond the stated goals were identified; removal from human control, mismanaging public relations, and self-preservation. A diverse set of systemic controls will be required when designing, implementing, and operating future advanced technologies.Practitioner summary: This study demonstrated the utility of HFE methods for formally considering risks associated with the design, implementation, and operation of future technologies. This study has implications for AGI research, design, and development to ensure safe and ethical AGI implementation.

Evaluation of sarcopenia in patients receiving intravesical Bacillus Calmette-Guérin for non-muscle invasive bladder cancer

BACKGROUND

Sarcopenia is associated with adverse outcomes for patients with muscle invasive bladder cancer (MIBC), but less is known about its impact in the setting of non-muscle invasive bladder cancer (NMIBC). Sarcopenia, skeletal muscle density, and adipose tissue area have been studied as markers of malnutrition and can be determined radiographically. The purpose of this study is to characterize the prevalence of sarcopenia in patients with NMIBC receiving intravesical Bacillus Calmette-Guérin (BCG).

METHODS

Following institutional review board approval, patients with NMIBC having received intravesical BCG were identified using institutional pharmacy records. Patients having undergone computed tomography (CT) of the abdomen and pelvis within 90 days of treatment were included in the analysis. Using sliceOmatic 5.0 software, skeletal muscle area (cm2) was measured at the L3 level to calculate skeletal muscle index (SMI), a marker of sarcopenia. Subcutaneous, visceral, and intramuscular adipose tissue areas in addition to skeletal muscle density were also measured. Frailty was evaluated as a secondary aim using the 5-Item Modified Frailty Index (mFI-5). Using predefined cutoffs, the prevalence of sarcopenia was determined. Descriptive statistics were used to characterize frailty and secondary body composition characteristics. Statistical analysis was performed to evaluate the impact of sarcopenia on recurrence rate and progression.

RESULTS

A total of 308 patients having received BCG between 2015 and 2020 were identified, of which 90 met criteria for analysis. Nearly all (94%) patients completed at least 5 out of 6 BCG induction instillations. Median body mass index (kg/m2) was 27.64 (IQR 24.9, 30.5) for females and 27.7 (IQR 24.9, 30.66) for males. Median SMI (cm2/m2) was 49.44 (IQR 39.39, 55.17) for females and 49.58 (IQR 40.25, 55.58) for males. A majority (61%) of patients were found to be sarcopenic. High-risk frailty was identified 36% of patients. There was no association between sarcopenia and recurrence rate or progression.

CONCLUSIONS

Sarcopenia and frailty are highly prevalent amongst patients with NMIBC. A diagnosis of NMIBC represents a window of opportunity to identify and intervene on modifiable risk factors such as sarcopenia and frailty, which are associated with adverse outcomes in more advanced disease states.

Clinical, Economic, and Humanistic Outcomes Associated with Obesity Among People with Bipolar I Disorder in the United States: Analysis of National Health and Wellness Survey Data

Introduction

People living with bipolar I disorder (BD-I) have an increased risk for obesity compared with the general population that may be related to genetic, lifestyle, and treatment factors. Few studies have examined possible effects of obesity on those living with BD-I. This study examined relationships between obesity and clinical, humanistic, and economic outcomes among adults with BD-I.

Methods

This retrospective, cross-sectional study analyzed survey responses from a nationally representative sample of US adults participating in the 2016 or 2020 National Health and Wellness Survey. Respondents (18-64 years) with a self-reported physician diagnosis of BD-I were included and categorized by body mass index: underweight/normal weight (<25 kg/m2), overweight (25 to <30 kg/m2), or obese (≥30 kg/m2). Adjusted analyses assessed comorbidities, health-related quality of life (HRQoL), work productivity, health care resource utilization (HCRU), and economic outcomes.

Results

In total, responses from 1,853 participants were analyzed; most were female (65%) and white (62%). Respondents with obesity had the highest prevalence of medical comorbidities, including high blood pressure (52%), sleep apnea (37%), hypercholesterolemia (34%), and type 2 diabetes (12%). Obesity was generally associated with the lowest scores of physical health and HRQoL. Activity impairment scores were highest among respondents with obesity, as were numbers of hospitalizations and emergency department visits in the previous 6 months. Respondents with obesity incurred higher annual indirect and direct medical costs ($28,178 and $37,771, respectively) when compared with the underweight/normal weight ($23,823 and $32,227, respectively) and overweight ($24,312 and $35,231, respectively) groups.

Conclusion

In this nationally representative sample, obesity was associated with several outcomes that may negatively affect people living with BD-I, including medical comorbidities, higher HCRU, HRQoL impairments, and greater indirect and direct medical costs. These findings highlight the importance of considering the presence of or risk for obesity and associated medical comorbidities when treating BD-I.

Evaluating Financial Toxicity in Urologic Practice

OBJECTIVE

To evaluate financial toxicity in Urologic surgery using the Comprehensive Score for financial Toxicity (COST) as well as validate a single item measure of toxicity.

METHODS

A cross-sectional study of 182 patients undergoing oncologic and benign urologic procedures at a single academic medical center. Oncologic procedures included robotic assisted laparoscopic prostatectomy, transurethral resection of bladder tumor, and radical cystectomy. Benign procedures included holmium laser enucleation of the prostate, intravesical chemodenervation, ureteroscopy laser lithotripsy, and ureteral stent exchange. Retrospective review, patient interviews, and the previously validated COST survey, as well as a novel single item measure of toxicity were used pre and post-op. Descriptive statistics and logistic regression models compared COST scores by type of urologic procedure.

RESULTS

Eighty (44%) patients underwent oncologic procedures and 102 (56%) benign procedures. Benign patients were most likely to have lower income and be younger than oncologic patients, with a median age of 56.7 vs 64.9. One in 4 patients undergoing urologic procedures experienced moderate to severe financial toxicity, without a statistically significant difference between the benign and the oncology groups pre- or post-operatively. Single item measure strongly correlated with COST (r = -0.80) pre- and post-operative.

CONCLUSION

The COST survey and a single-item financial toxicity measure are both valid tools that can be used to measure financial toxicity in urology. Further research is needed to elicit the exact cause of financial toxicity in the heterogenous urologic patient population.

Protocolized screening and detection of occult alcohol use before and after liver transplant: Lessons learned from a quality improvement initiative

INTRODUCTION

Detection of alcohol (ETOH) use with biomarkers provides an opportunity to intervene and treat patients with alcohol use disorder before and after liver transplant (LT). We describe our center's experience using urine ethyl glucuronide (EtG) and serum phosphatidylethanol (PEth) in alcohol screening protocols.

METHODS

Single-center, retrospective review of patients presenting for LT evaluation, patients waitlisted for LT for alcohol-associated liver disease (ALD), and patients who received a LT for ALD over a 12-month period, from October 1, 2019 through September 30, 2020. Patients were followed from waitlisting to LT, or for up to 12 months post-LT. We monitored protocol adherence to screening for ETOH use- defined as completion of all possible tests over the follow-up period- at the initial LT visit, while on the LT waitlist and after LT.

RESULTS

During the study period, 227 patients were evaluated for LT (median age 57 years, 58% male, 78% white, 54.2% ALD). Thirty-one patients with ALD were placed on the waitlist, and 38 patients underwent LT for ALD during this time period. Protocolized adherence to screening for alcohol use was higher for PEth for all LT evaluation patients (191 [84.1%] vs. 146 [67%] eligible patients, p < .001), in patients with ALD waitlisted for LT (22 [71%] vs. 14 (48%] eligible patients, p = .04) and after LT for ALD, 20 (33 [86.8%] vs. 20 [52.6%] eligible patients, p < .01). Few patients with a positive test in any group completed chemical dependency treatment.

CONCLUSIONS

When screening for ETOH use in pre- and post-LT patients, protocol adherence is higher using PEth compared to EtG. While protocolized biomarker screening can detect recurrent ETOH use in this population, engagement of patients into chemical dependency treatment remains challenging.

Association between bisphosphonate use and COVID-19 related outcomes

Background

Although there are several efficacious vaccines against COVID-19, vaccination rates in many regions around the world remain insufficient to prevent continued high disease burden and emergence of viral variants. Repurposing of existing therapeutics that prevent or mitigate severe COVID-19 could help to address these challenges. The objective of this study was to determine whether prior use of bisphosphonates is associated with reduced incidence and/or severity of COVID-19.

Methods

A retrospective cohort study utilizing payer-complete health insurance claims data from 8,239,790 patients with continuous medical and prescription insurance January 1, 2019 to June 30, 2020 was performed. The primary exposure of interest was use of any bisphosphonate from January 1, 2019 to February 29, 2020. Bisphosphonate users were identified as patients having at least one bisphosphonate claim during this period, who were then 1:1 propensity score-matched to bisphosphonate non-users by age, gender, insurance type, primary-care-provider visit in 2019, and comorbidity burden. Main outcomes of interest included: (a) any testing for SARS-CoV-2 infection; (b) COVID-19 diagnosis; and (c) hospitalization with a COVID-19 diagnosis between March 1, 2020 and June 30, 2020. Multiple sensitivity analyses were also performed to assess core study outcomes amongst more restrictive matches between BP users/non-users, as well as assessing the relationship between BP-use and other respiratory infections (pneumonia, acute bronchitis) both during the same study period as well as before the COVID outbreak.

Results

A total of 7,906,603 patients for whom continuous medical and prescription insurance information was available were selected. A total of 450,366 bisphosphonate users were identified and 1:1 propensity score-matched to bisphosphonate non-users. Bisphosphonate users had lower odds ratios (OR) of testing for SARS-CoV-2 infection (OR = 0.22; 95%CI:0.21-0.23; p<0.001), COVID-19 diagnosis (OR = 0.23; 95%CI:0.22-0.24; p<0.001), and COVID-19-related hospitalization (OR = 0.26; 95%CI:0.24-0.29; p<0.001). Sensitivity analyses yielded results consistent with the primary analysis. Bisphosphonate-use was also associated with decreased odds of acute bronchitis (OR = 0.23; 95%CI:0.22-0.23; p<0.001) or pneumonia (OR = 0.32; 95%CI:0.31-0.34; p<0.001) in 2019, suggesting that bisphosphonates may protect against respiratory infections by a variety of pathogens, including but not limited to SARS-CoV-2.

Conclusions

Prior bisphosphonate-use was associated with dramatically reduced odds of SARS-CoV-2 testing, COVID-19 diagnosis, and COVID-19-related hospitalizations. Prospective clinical trials will be required to establish a causal role for bisphosphonate-use in COVID-19-related outcomes.

Funding

This study was supported by NIH grants, AR068383 and AI155865, a grant from MassCPR (to UHvA) and a CRI Irvington postdoctoral fellowship, CRI2453 (to PH).

Examining factors for the adoption of silvopastoral agroforestry in the Colombian Amazon

Current land use systems in the Amazon largely consist of extensive conventional productivist livestock operations that drive deforestation. Silvopastoral systems (SPS) support a transition to low carbon production if they intensify in sympathy with the needs of biophysical and socio-economic contexts. SPS have been promoted for decades as an alternative livestock production system but widespread uptake has yet to be seen. We provide a schema of associating factors for adoption of SPS based on past literature in tropical agriculture and apply this to a bespoke survey of 172 farms in the Caquetá region of the Colombian Amazon. We find a number of factors which do not apply to this region and argue for a context specific approach. The impact of managing increased market access and opportunities for SPS producers are crucial to avoiding additional deforestation. Further understanding of the underlying antecedents of common factors, such as perceptions of silvopastoral systems, would reduce the risk of perverse policy outcomes.

Haemostatic resuscitation in practice: a descriptive analysis of blood products administered during Operation HERRICK, Afghanistan

INTRODUCTION

Life-threatening haemorrhage is the leading cause of potentially survivable injury in battlefield casualties. During Operation HERRICK (Afghanistan), mortality rates improved year on year due to a number of advances in trauma care, including haemostatic resuscitation. Blood transfusion practice has not previously been reported in detail during this period.

METHODS

A retrospective analysis of blood transfusion at the UK role 3 medical treatment facility (MTF) at Camp Bastion between March 2006 and September 2014 was performed. Data were extracted from two sources: the UK Joint Theatre Trauma Registry (JTTR) and the newly established Deployed Blood Transfusion Database (DBTD).

RESULTS

3840 casualties were transfused 72 138 units of blood and blood products. 2709 adult casualties (71%) were fully linked with JTTR data and were transfused a total of 59 842 units. Casualties received between 1 unit and 264 units of blood product with a median of 13 units per patient. Casualties wounded by explosion required almost twice the volume of blood product transfusion as those wounded by small arms fire or in a motor vehicle collision (18 units, 9 units, and 10 units, respectively). More than half of blood products were transfused within the first 2 hours following arrival at the MTF. There was a trend towards balanced resuscitation with more equal ratios of blood and blood products being used over time.

CONCLUSION

This study has defined the epidemiology of blood transfusion practice during Operation HERRICK. The DBTD is the largest combined trauma database of its kind. It will ensure that lessons learnt during this period are defined and not forgotten; it should also allow further research questions to be answered in this important area of resuscitation practice.

A comparison of perceived image quality between computer display monitors and augmented reality smart glasses

INTRODUCTION

Augmented-reality (AR) smart glasses provide an alternative to standard computer display monitors (CDM). AR smart glasses may provide an opportunity to improve visualisation during fluoroscopy and interventional radiology (IR) procedures when there can be difficulty in viewing intra-procedural images on a CDM. The aim of this study was to evaluate radiographer perception of image quality (IQ) when comparing CDM and AR smart glasses.

METHODS

38 radiographers attending an international congress evaluated ten fluoroscopic-guided surgery and IR images on both a CDM (1920 × 1200 pixels) and a set of Epson Moverio BT-40 AR smart glasses (1920 × 1080 pixels). Participants provided oral responses to pre-defined IQ questions generated by study researchers. Summative IQ scores for each participant/image were compared between CDM and AR smart glasses.

RESULTS

Of the 38 participants, the mean age was 39 ± 1 years. 23 (60.5%) participants required corrective glasses. In terms of generalisability, participants were from 12 different countries, the majority (n = 9, 23.7%) from the United Kingdom. For eight out of ten images, the AR smart glasses demonstrated a statistically significant increase in perceived IQ (median [IQR] 2.0 [-1.0 to 7.0] points) when compared to the CDM.

CONCLUSION

AR smart glasses appear to show improvements in perceived IQ when compared to a CDM. AR smart glasses could provide an option for improving the experiences of radiographers involved in image-guided procedures and should be subject to further clinical evaluations.

IMPLICATIONS FOR PRACTICE

Opportunities exist to improve perceived IQ for radiographers when reviewing fluoroscopy and IR images. AR smart glasses should be further evaluated as a potential opportunity to improve practice when visual attention is split between positioning equipment and image review.

Blood-brain barrier disruption measured by albumin index correlates with inflammatory fluid biomarkers

Blood-brain barrier (BBB) permeability can be measured by the ratio of albumin in cerebrospinal fluid (CSF) and blood and by dynamic contrast-enhanced MRI (DCEMRI). Albumin is a large molecule measured in CSF and blood to form the albumin index (Qalb), which is a global measure of BBB permeability, while the smaller Gadolinium molecule measures regional transfer (Ktrans); few studies have directly compared them in the same patients. We used both methods as part of a study of mechanisms of white matter injury in patients with different forms of dementia. In addition, we also measured biomarkers for inflammation, including proteases, angiogenic growth factors, and cytokines, and correlated them with the BBB results. We found that there was no correlation between Qalb and Ktrans. The Qalb was associated with the matrix metalloproteinases (MMP-2, MMP-3, and MMP-10), the angiogenic factors (VEGF-C and PlGF), and the cytokines (IL-6, IL-8 and TNF-α). On the other hand, Ktrans was associated with the diffusion measures, mean free water and PSMD, which indicate white matter injury. Our results show that the Qalb and Ktrans measure different aspects of BBB permeability, with albumin being a measure of inflammatory BBB opening and Ktrans indicating white matter injury.

The Impact of Special Operations Medics and Corpsmen on Military Medical Student Training: A Qualitative Study

Operation Gunpowder is a high-fidelity military medical field practicum conducted by the Uniformed Services University of Health Sciences, Bethesda, MD. During this multi-day combat simulation, Special Operations Medics and Corpsmen teach military medical students how to treat patients in an austere, resource-limited environment. To investigate the effectiveness of this teaching model, our research team used a qualitative phenomenological design to explore medical students' experiences being taught by Special Operations Medics and Corpsmen during Operation Gunpowder. We found two themes regarding the medical students' personal and professional development: an increased understanding of medics' skills and capabilities and the realization of their future roles as educators and leaders. Our study suggests that the use of Special Operations Corpsmen and Medics in medical student training is a valuable model for both military and civilian medical education and training.

The Associations between Insomnia Severity and Health Outcomes in the United States

Little is known about the associations between insomnia severity, insomnia symptoms, and key health outcomes. Using 2020 United States National Health and Wellness Survey (NHWS) data, we conducted a retrospective, cross-sectional analysis to determine the associations between insomnia severity and a number of health outcomes germane to patients (health-related quality of life (HRQoL), employers and government (workplace productivity), and healthcare payers (healthcare resource utilization (HCRU)). The Insomnia Severity Index (ISI) questionnaire was used to evaluate overall insomnia severity. HRQoL was assessed using the physical and mental component summary scores of the Short Form-36v2 (SF-36v2) questionnaire, and health utility status was measured using the Short Form-6D (SF-6D) and EuroQoL-5D (EQ-5D) questionnaires. Workplace productivity was measured using the Work Productivity and Activity Impairment (WPAI) questionnaire. After adjusting for confounders, greater insomnia severity was significantly associated with worsened quality of life, decreased productivity, and increased HCRU in an apparent linear fashion. These findings have important implications for future research, including the need for specific assessment of insomnia symptoms and their impact on key health outcomes.

Incidence of breakthrough fungal infections on isavuconazole prophylaxis compared to posaconazole and voriconazole

BACKGROUND

Invasive fungal infections (IFIs) are a common infectious complication during the treatment of acute myeloid leukemia (AML), high-risk myelodysplastic syndrome (MDS) or post hematopoietic cell transplantation (HCT). For these patients, the National Comprehensive Cancer Network recommends posaconazole or voriconazole for IFI prophylaxis. In clinical practice, however, there has been increased use of isavuconazole due to favorable pharmacokinetic and pharmacodynamic parameters despite limited data for this indication. The comparative prophylactic efficacy of antifungals in this patient population has not been reported, and an analysis is warranted.

METHODS

This retrospective, matched cohort, single-center study, included AML, MDS, or HCT patients who began treatment or underwent transplant between January 1, 2015 and July 31, 2021. Isavuconazole patients were matched 1:2 with patients receiving posaconazole or voriconazole prophylaxis.

RESULTS

A total of 126 patients were included, 42 received isavuconazole, 81 received posaconazole, and three received voriconazole. The majority of patients were male receiving secondary IFI prophylaxis while receiving steroids for treatment of GVHD. The incidence of possible, probable or proven IFI was 16.7% in the isavuconazole group compared to 10.7% in the posaconazole and voriconazole group (OR 1.28, 95% CI -0.9-1.4; p = .67). Hepatotoxicity occurred in 16 total patients, 14 receiving posaconazole and two receiving isavuconazole.

CONCLUSION

Patients who received isavuconazole prophylaxis during AML induction therapy or post-HCT experienced a similar incidence of breakthrough fungal infections compared to those who received posaconazole or voriconazole. These results suggest no difference in antifungal prophylactic efficacy; however larger prospective comparative studies are needed.

Activity impairment, health-related quality of life, productivity, and self-reported resource use and associated costs of uncomplicated urinary tract infection among women in the United States

BACKGROUND

Uncomplicated urinary tract infections (uUTIs) are among the most common infections in the US. Only a few studies, however, describe the impact of uUTIs from the patient perspective.

METHODS

A cross-sectional online survey of US women aged ≥18 years was performed assessing uUTI burden regarding activity impairment, health-related quality of life (HRQoL), workplace productivity, healthcare resource use (HRU), and costs. Participants who self-reported a uUTI in the prior 60 days treated with ≥1 oral antibiotic were included. Activity impairment was assessed with the Activity Impairment Assessment scale. HRQoL was assessed using a modified Short Form 36 (SF-36). Direct costs were sum of out-of-pocket expenditures and monetized HRU; indirect costs were calculated using Work Productivity and Activity Impairment (WPAI). Participants were stratified by uUTI recurrence, number of prescribed antibiotics for recent uUTI and therapy appropriateness (1 first-line/1 second-line/multiple antibiotics). Multivariable regression analysis assessed the relationship between stratifications and outcomes while controlling for demographic/clinical characteristics. Propensity score matching was used to compare participants to a matched population from the 2020 National Health and Wellness Survey (NHWS), to control for any impact of COVID-19 on responses.

RESULTS

Among 375 participants, impaired activities included sexual intercourse (66.9%), sleep (60.8%) and exercise (52.3%). HRQoL was worse (p<0.0001) than the NHWS population (46.4 vs. 51.3 [physical component score]; 40.0 vs. 46.9 [mental component score]; 0.63 vs. 0.72 [health utility index]). All included WPAI assessments were worse for uUTI cohort vs. NHWS (p<0.0001). Adjusted direct costs were higher for participants receiving 2 vs. 1 antibiotic ($2090 vs. $776; p<0.0001) and receiving multiple antibiotics vs. 1 first-line ($1642 vs. $875; p = 0.002). Recurrent uUTI was associated with increased activity impairment, worse HRQoL, and costs vs. non-recurrent.

CONCLUSIONS

uUTIs were associated with increased activity impairment, worse productivity, and reduced HRQoL. Higher costs were found vs. a matched population.

Mapping the Insomnia Severity Index Instrument to EQ-5D Health State Utilities: A United Kingdom Perspective

OBJECTIVE

This study aimed to map the Insomnia Severity Index (ISI) to the EQ-5D-3L utility values from a UK perspective.

METHODS

Source data were derived from the 2020 National Health and Wellness Survey (NHWS) for France, Germany, Italy, Spain, the UK and the US. Ordinary least squares regression, generalised linear model (GLM), censored least absolute deviation, and adjusted limited dependent variable mixture model (ALDVMM) were employed to explore the relationship between ISI total summary score and EQ-5D utility while accounting for adjustment covariates derived from the NHWS. Fitting performance was assessed using standard metrics, including mean-squared error (MSE) and coefficient of determination (R²).

RESULTS

A total of 17,955 respondent observations were included, with a mean ISI score of 12.12 ± 5.32 and a mean EQ-5D-3L utility (UK tariff) of 0.71 ± 0.23. GLM gamma-log and ALDVMM were the two best performing models. The ALDVMM had better fitting performance (R² = 0.320, MSE 0.0347) than the GLM gamma-log (R² = 0.303, MSE 0.0353); in train-test split-sample validation, ALDVMM also slightly outperformed the GLM gamma-log model, with an MSE of 0.0351 versus 0.0355. Based on fitting performance, ALDVMM and GLM gamma-log were the preferred models.

CONCLUSIONS

In the absence of preference-based measures, this study provides an updated mapping algorithm for estimating EQ-5D-3L utilities from the ISI summary total score. This new mapping not only draws its strengths from the use of a large international dataset but also the incorporation of adjustment variables (including sociodemographic and general health characteristics) to reduce the effects of confounders.

Bolstering the complex study start-up process at NCI cancer centers using technology

Background

The study startup process for interventional clinical trials is a complex process that involves the efforts of many different teams. Each team is responsible for their startup checklist in which they verify that the necessary tasks are done before a study can move on to the next team. This regulatory process provides quality assurance and is vital for ensuring patient safety [10]. However, without having this startup process centralized and optimized, study approval can take longer than necessary as time is lost when it passes through many different hands.

Objective

This manuscript highlights the process and the systems that were developed at The University of Kansas Comprehensive Cancer Center regarding the study startup process. To facilitate this process the regulatory management, site development, cancer center administration, and the Biostatistics & Informatics Shared Resources (BISR) teams came together to build a platform aimed at streamlining the startup process and providing a transparent view of where a study is in the startup process.

Process

Ensuring the guidelines are clearly articulated for the review criteria of each of the three review boards, i.e., Disease Working Group (DWG), Executive Resourcing Committee (ERC), and Protocol Review and Monitoring Committee (PRMC) along with a system that can track every step and its history throughout the review process.

Results

Well-defined processes and tracking methodologies have allowed the operations teams to track each study closely and ensure the 90-day and 120-day deadlines are met, this allows the operational team to dynamically prioritize their work daily. It also provides Principal investigators a transparent view of where their study stands within the study startup process and allows them to prepare for the next steps accordingly.

Conclusion/future work

The current process and technology deployment has been a significant improvement to expedite the review process and minimize study startup delays. There are still a few opportunities to fine-tune the study startup process; an example of which includes automatically informing the operational managers or the study teams to act upon deadlines regarding study review rather than the current manual communication process which involves them looking it up in the system which can add delays.

Diet and irritable bowel syndrome: an update from a UK consensus meeting

There has been a renewed interest in the role of dietary therapies to manage irritable bowel syndrome (IBS), with diet high on the agenda for patients. Currently, interest has focussed on the use of traditional dietary advice (TDA), a gluten-free diet (GFD) and the low FODMAP diet (LFD). A consensus meeting was held to assess the role of these dietary therapies in IBS, in Sheffield, United Kingdom.Evidence for TDA is from case control studies and clinical experience. Randomised controlled trials (RCT) have demonstrated the benefit of soluble fibre in IBS. No studies have assessed TDA in comparison to a habitual or sham diet. There have been a number of RCTs demonstrating the efficacy of a GFD at short-term follow-up, with a lack of long-term outcomes. Whilst gluten may lead to symptom generation in IBS, other components of wheat may also play an important role, with recent interest in the role of fructans, wheat germ agglutinins, as well as alpha amylase trypsin inhibitors. There is good evidence for the use of a LFD at short-term follow-up, with emerging evidence demonstrating its efficacy at long-term follow-up. There is overlap between the LFD and GFD with IBS patients self-initiating gluten or wheat reduction as part of their LFD. Currently, there is a lack of evidence to suggest superiority of one diet over another, although TDA is more acceptable to patients.In view of this evidence, our consensus group recommends that dietary therapies for IBS should be offered by dietitians who first assess dietary triggers and then tailor the intervention according to patient choice. Given the lack of dietetic services, novel approaches such as employing group clinics and online webinars may maximise capacity and accessibility for patients. Further research is also required to assess the comparative efficacy of dietary therapies to other management strategies available to manage IBS.

Patient Preferences Regarding Chaperone Use for Sensitive Examinations

INTRODUCTION

Chaperones are often employed during sensitive patient encounters and have been assumed to be mutually beneficial to the patient and provider. The aim of this study is to characterize patient preferences regarding the use of chaperones.

METHODS

Following Institutional Review Board Approval, a questionnaire designed to evaluate preferences regarding chaperone use from a patient perspective was distributed electronically through the ResearchMatch platform as well as to patients in an outpatient urology clinic. Descriptive statistics were used to assess responder demographics, clinical experiences and preferences. Multiple regression analysis was used to determine factors associated with a preference for having a chaperone present during health care visits.

RESULTS

A total of 913 individuals completed the survey. Over half (52.9%) reported they would not want a chaperone for any part of a health care visit. Although rectal and genital/pelvic examinations were considered sensitive by 76.3% and 85% of responders, respectively, only 25.4% and 15.7% preferred a chaperone during these encounters. Reasons for not wanting a chaperone included trust in the provider (80%) and comfort with examinations (70.4%). Male responders were less likely to report a preference for a chaperone (OR 0.28, 95% CI 0.19-0.39) or consider provider gender as a significant factor in preferring a chaperone (OR 0.28, 95% CI 0.09-0.66).

CONCLUSIONS

Preference regarding the use of a chaperone is primarily influenced by gender of both the patient and the provider. For sensitive examinations commonly performed in the field of urology, most individuals would not prefer a chaperone be present.

Frictional wear of stud implant overdenture abutments after 2 years of in vitro simulated function

Progressive wear of the components of an implant-supported overdenture can lead to loss of denture retention, which affects masticatory function and the patient's quality of life. The primary objective of this in vitro study was to investigate frictional wear in a type of commonly used abutment and thereby estimate the general clinical lifespan of a typical stud abutment and establish a protocol for replacement. Therefore, simulated overdenture insertions and removals equivalent to 2 years of overdenture use were performed to evaluate surface changes in the metal stud abutment component. A digital caliper, scanning electron micrographs taken at ×500 magnification, and profilometer data were used to determine the wear rate and surface roughness. A universal testing machine was used to measure retention load force with 4 clear male nylon inserts (5.0-lb retention) during 2160 insertion and removal cycles. The results showed that with a 6-month replacement program for clear male nylon inserts, the frictional wear on the titanium nitride coating of abutments placed at a 0° position resulted in a decrease of up to 50% in removal forces of the inserts after a simulated 2 years of wear. The combination of wear of the titanium nitride coating and the decrease in retention load values suggests that stud abutments should be replaced after 2 years of use for optimal retention.

Understanding treatment patterns and patient-reported outcomes associated with the use of authorized generics and corresponding independent generics across multiple therapeutic areas

OBJECTIVES

To assess patient characteristics, treatment patterns, and patient-reported outcomes (PROs) associated with authorized generics (AGs) and independent generics (IGs) use.

METHODS

Prescription claims and National Health and Wellness Survey (NHWS) data were linked. Adults with billable national drug code (AG or IG), NHWS completion from June 2015 to July 2019, AG or IG on-hand at NHWS completion, and continuous insurance eligibility in 12 months pre- and post-NHWS completion were included. To be included, all unique medication formulations had to have at least one AG and one IG observation. PRO index date was NHWS completion; claims index date was defined as the first prescription claim identified during the 180-day period prior to NHWS completion for the same active ingredient and formulation type that was on-hand at NHWS completion.

RESULTS

Patients (N = 20,229; 17.2% AG users) in six therapeutic areas (attention deficit-hyperactivity disorder [ADHD], antidepressants, beta blockers [BBs], calcium channel blockers [CCBs], statins, and thyroid) were included. Generally, AG (vs. IG) users were younger and differed in regional access and insurance type (all, p < .05). In multivariable analysis, significant differences were observed for presenteeism and overall work impairment (BBs), healthcare provider visits (BBs), and indirect costs (thyroid) (all, p < .05). AG and IG users differed in persistence (ADHD and statins; both, p < .05) and switch (BBs and CCBs; both, p < .01) rates.

CONCLUSIONS

PRO differences were often small in magnitude and varied by therapeutic area. The impact of switching should consider observed PRO differences, patient preferences, and market availability of AG and IG alternatives.

OP0223 DISTINGUISHING OSTEOARTHRITIS AND RHEUMATOID ARTHRITIS SYNOVIUM WITH MACHINE LEARNING USING AUTOMATED CELL DENSITY AND PATHOLOGIST SCORES

Background

Joint damage in the knee can be severe in both rheumatoid arthritis (RA) and osteoarthritis (OA) such that total knee replacement (TKR) is often the only management option. Pathological assessment of the extent or type of synovial tissue inflammation from joint explants or biopsies can be useful. However, an ongoing challenge in using semi-quantitative assessments of synovitis is the disagreement between human pathologist scores of the same sample. We previously developed and validated a computer vision algorithm to automatically count each cell nucleus in an H&E-stained synovial whole slide image and yield a value of cell density, defined as mean nuclei count per mm2 of tissue1.

Objectives

We sought to develop methods to distinguish OA from RA based on machine learning analysis of histologic features on H&E-stained synovial tissue samples.

Methods

We measured 14 pathologist-scored histology features (137 RA and 152 OA patients) and computer vision quantified cell density (60 RA and 147 OA patients) in H&E stained synovial tissue samples from total knee replacement arthroplasty explants. A random forest model was trained using disease state (OA vs RA) as classifier and histology features and/or cell density as inputs, and feature importance scores for the model were calculated.

Results

Synovium from patients with RA exhibited increased lymphocytic inflammation, lining hyperplasia, neutrophils, detritus, plasma cells, Russell bodies, binucleate plasma cells, sub-lining giant cells, synovial lining giant cells, and fibrin (all p<0.001), while synovium from patients with OA had increased mast cells and fibrosis (both p<0.001). Fourteen pathologist-scored features allowed for discrimination between RA and OA samples, producing a macro-averaged area under the receiver operating curve (AUC) of 0.85. This discriminatory ability was comparable to that of the computer vision score of cell density alone (AUC = 0.88). Combining the pathologist scores with the cell density metric improved the discriminatory power of the model (AUC = 0.91). The three most important features in this combined model were mast cells followed by cell density and fibrosis (Figure 1). AUC values for each individual feature are provided in Table 1. The optimal cell density threshold to distinguish RA from OA synovium was 3,400 cells per mm2, which yielded a sensitivity of 0.82 and specificity of 0.82.

Table 1.

Area under receiver operating characteristic curves (AUC) of the synovial features in distinguishing RA and OA patients

FeatureAUCAutomated Cell Density0.88Fibrosis0.84Mast cells0.80Lining hyperplasia0.78Lymphocytic inflammation0.69Fibrin0.68Plasma cells0.66Detritus0.64Binucleate plasma cells0.60Neutrophils0.60Synovial giant cells0.58Sub-lining giant cells0.57Russell bodies0.56Germinal centers0.51Mucoid change0.50Figure 1.

Importance of synovial features in distinguishing RA and OA synovium

Feature importance scores for supervised machine learning model including all 14 pathology scores and the computer vision-generated cell density.

Conclusion

H&E-stained images of RA and OA TKR explant synovium are distinct. We identified cell density, mast cells and fibrosis as the three most important features for making this distinction, with RA being characterized by increased cell density, low mast cells, and low fibrosis. Cell density greater than 3400 per mm2 of tissue yields a sensitivity of 0.82 and a specificity of 0.82 for distinguishing RA from OA. In the future, this can have clinical and research applications as this technique removes the requirement for subjective selection of a certain field of interest, is reproducible, and is scalable as it does not require technical expertise of a pathologist.

References

[1]Guan S, Mehta B…Orange DE. Rheumatoid Arthritis Synovial Inflammation Quantification Using Computer Vision. ACR Open Rheumatology. 2022 Jan 10;acr2.11381.

Acknowledgements

This work was supported by the C. Ronald MacKenzie Young Scientist Endowment Award, the Leon Lowenstein Foundation, and the Kellen Scholar Award supported by the Anna Marie and Stephen Kellen Foundation Total Knee Improvement Program.

Disclosure of Interests

Bella Mehta Paid instructor for: Novartis, Susan Goodman Consultant of: UCB, Grant/research support from: Novartis, Edward DiCarlo: None declared, Deanna Jannat-Khah Shareholder of: AstraZeneca, Cytodyn, and Walgreens, J. Alex Gibbons: None declared, Miguel Otero Consultant of: Regeneron Pharmaceuticals, Grant/research support from: Tissue Genesis, Laura Donlin Speakers bureau: Stryker, Consultant of: Stryker, Grant/research support from: Karius, Inc, Tania Pannellini: None declared, William Robinson: None declared, Peter Sculco Consultant of: Intellijoint Surgical, DePuy Synthes, Lima Corporate, Zimmer Biomet, and EOS Imaging, Grant/research support from: Intellijoint Surgical and Zimmer Biomet, Mark Figgie Shareholder of: HS2, Mekanika, and Wishbone, Consultant of: Lima and Wishbone, Jose Rodriguez Consultant of: ConforMIS, Medacta, Exactech, Inc, and Smith & Nephew, Grant/research support from: DePuy, Exactech, Inc, and Smith & Nephew, Jessica Kirschmann: None declared, James Thompson: None declared, David Slater: None declared, Damon Frezza: None declared, Zhenxing Xu: None declared, Fei Wang: None declared, Dana Orange: None declared

An audit of acute respiratory antibiotic prescribing in COPD patients during the COVID-19 pandemic

Introduction

Coronavirus-2 is the virus responsible for the COVID-19 pandemic. People with certain risk factors, such as having chronic obstructive pulmonary disease (COPD) may be more likely to develop complications. Research has identified that ~7% of patients with COVID-19 have a bacterial infection, however antibiotic prescribing rates have been found to vary from 38% to 72% (1,2). Primary care is estimated to make up 75% of antibiotic prescribing and was therefore a key target to evaluate whether antimicrobial stewardship principles were being followed during the COVID-19 pandemic.

Aim

To audit the adherence of antibiotic prescribing in people with COPD during the COVID-19 pandemic across a primary care network (PCN) in England against national and local guidelines.

Methods

The management of patients with COPD should follow NICE Guideline (NG) 114, NG168 and the local formulary. Three audit standards were created: 1) 100% of COPD patients should not be started on prophylactic antibiotics to reduce risk from COVID-19; 2) 100% of COPD patients should not be prescribed antibiotics for COVID-19 symptoms; 3) 90% of antibiotic prescription regimens should adhere to local and national guidelines. Prescribing data was collected from 12 practices linked to the PCN. Data of patients who had COPD, were prescribed an antibiotic, and had an indication for the antibiotic between 01/03/20 and the 30/06/20 were extracted and transferred into an anonymised spreadsheet. A total of 1088 data points were extracted. Random stratified sampling provided 300 data points for analysis, ensuring each GP surgery was represented proportionally; the required sample size to determine significance was 291. For each practice, the total number of antibiotics prescribed to COPD patients between March-June 2019 and March-June 2020 was extracted. Descriptive statistics were used to determine antibiotic prescribing adherence and overall rates of prescribing. Inferential statistics were used to compare rates of prescribing pre-vs-during the pandemic.

Results

Antibiotics were not prescribed for any patient for prophylaxis against COVID-19 (100% adherence to criteria 1). Two patients were prescribed antibiotics for ‘suspected disease caused by COVID-19’ (99.4% adherence to criteria 2). In only 28.7% of cases, the antibiotic was prescribed in line with the national and local guidelines (criteria 3). In most cases, treatment duration was the main reason for poor adherence, with longer courses of antibiotics being prescribed (7 rather than 5 days). Prescribing rates did not change significantly in 2020 compared to 2019 (1134 antibiotic prescriptions vs 1029 antibiotic prescriptions; p&gt;0.05).

Conclusion

The audit was successful in determining that the COVID-19 pandemic did not significantly affect antibiotic prescribing rates across the PCN for people with COPD. Adherence to NICE and local guidelines was low, specifically concerning the duration of antibiotic treatment. This highlights an area for improvement; to ensure healthcare professionals across the PCN prescribe in-line with antimicrobial stewardship principles. Extracted data was limited to antibiotic prescribing and could have been expanded to include steroids to provide a fuller audit of prescribing in COPD exacerbations. A re-audit may be beneficial since the publication of NG191.

References

(1) Lansbury L, Lim B, Baskaran V, Lim WS. Co-infections in people with COVID-19: a systematic review and meta-analysis. J Infect. 2020 Aug;81(2):266-275.

(2) Seaton RA, Gibbons CL, Cooper L, Malcolm W, McKinney R, Dundas S, Griffith D, Jeffreys D, Hamilton K, Choo-Kang B, Brittain S, Guthrie D, Sneddon J. Survey of antibiotic and antifungal prescribing in patients with suspected and confirmed COVID-19 in Scottish hospitals. J Infect. 2020 Dec;81(6):952-960.

Real-world usage of bevacizumab-bvzr biosimilar in US oncology practice

OBJECTIVES

Bevacizumab is commonly used to treat solid tumors. However, little is known about the manner and the extent to which bevacizumab biosimilars are utilized in real-world oncology practice in the United States. The objective of this study was to describe patient and provider characteristics and treatment patterns associated with the recently introduced bevacizumab-bvzr biosimilar.

STUDY DESIGN

Retrospective cohort study.

METHODS

A retrospective analysis of medical and pharmacy claims between January 24, 2019, and July 31, 2020, was performed. Adult patients with at least 1 claim indicating usage of bevacizumab-bvzr were included. Patients who could not be assigned to an applicable diagnosis group were excluded. Index treatment date was defined as the date of the first claim for bevacizumab-bvzr. Descriptive analysis was conducted for all study variables.

RESULTS

A total of 206 patients were included; patients most often were 65 years or older (49.5%), were female (62.6%), and resided in the West (45.1%). The most common indications observed for bevacizumab-bvzr were metastatic colorectal cancer (mCRC; 51.0%), cancer of the female genital organs (CFGO; 27.2%), glioblastoma (11.2%), and non-small cell lung cancer (8.7%). Overall, 72.4% and 48.2% of patients with mCRC and CFGO, respectively, had switched to bevacizumab-bvzr from the reference drug or another bevacizumab biosimilar. Bevacizumab-bvzr was used in chemotherapy combination regimens for patients with mCRC and CFGO.

CONCLUSIONS

Utilization was observed in extrapolated indications. Findings suggest that both switching between reference product and bevacizumab biosimilars and using bevacizumab-bvzr as part of chemotherapy combination regimens have been adopted in US oncology practice.

The effect of an augmented reality educational tool on the motivation towards learning in pharmacy students: an evaluative survey

Introduction

Within the context of education, motivation relates to the desire students possess to engage in their learning environment. This quality is vital in determining the effort an individual expresses towards their learning and the desire they have to achieve higher academic performances (1). Educational technologies, particularly digital technologies, have long been used in post-secondary education to increase collaboration, critical thinking and motivation among students (2). The advancements in technology have led to the creation of novel augmented reality (AR) educational tools, however they have not been widely implemented or researched with the education of pharmacy students in the United Kingdom.

Aim

To identify changes of pharmacy students’ self-reported intrinsic motivation towards learning after using the ‘Pharma Compounds AR’ (PCAR) educational tool.

Methods

The PCAR tool was an image-based educational AR mobile application – it displayed 3-D models and animations of complex molecules when unique target images were scanned with the mobile’s camera. 118 stage two undergraduate Pharmacy students from a University in England were approached through cohort emails that contained a link to an online consent form and pre-intervention questionnaire. Participants were required to complete the pre-questionnaire before they received the PCAR tool for at least two months. Students were informed that they could use the tool to accommodate their learning in any way they felt appropriate. Once the intervention period ended, participants completed an online post-questionnaire. Changes in self-reported intrinsic motivation were determined with the use of adapted Intrinsic Motivation Inventory (IMI) Likert scale questions. The pre-questionnaire focused on motivation towards learning using conventional methods and their perceived usefulness, whereas the post-questionnaire focused on motivation towards learning with the PCAR tool and its perceived usefulness. Descriptive and inferential statistical analyses were conducted on the IMI adapted Likert scales.

Results

A total of 68 (57.6% rr) undergraduate Pharmacy students completed the pre-questionnaire. The majority were aged 18-21(82.4%), female (70.6%) and domestic (94.1%). The post-questionnaire was completed by 30 students (44.1% rr), mainly aged 18-21 (83.3%), female (70%), and domestic (86.7%). Participants ranked their agreement to each Likert statement from 1 (not true at all) to 7 (very true). Mean agreement motivation scores were increased after the use of the PCAR tool (pre-3.88 vs post-5.15), as were the mean agreement scores of the learning tools’ perceived usefulness (pre-4.69 vs post-5.29). Dependant T-tests performed on responses of students who completed both questionnaires revealed a significant increase in students’ mean pre- and post-intervention motivation towards learning scores (p=0.000). No significance was calculated between the mean pre-and post-agreement usefulness scores (p&gt;0.05).

Conclusion

Incorporating the PCAR tool into the education of stage two Pharmacy students significantly increased their reported motivation towards learning when compared to conventional methods, it was also reported as being a more useful learning tool. The drop in post-questionnaire responses has to be acknowledge as a limitation as well as not explicitly knowing how students used the PCAR tool in their studies. Nevertheless, the incorporation of AR into schools of Pharmacy could provide students and tutors more engaging teaching and learning experiences.

References

(1) Budiman R. Developing Learning Media Based on Augmented Reality (AR) to Improve Learning Motivation. J Educ Teach Learn. 2016 Sep;1(2):89–94. Available from: https://www.learntechlib.org/p/209026

(2) Martin F, Polly D, Coles S, Wang C. Examining higher education faculty use of current digital technologies: Importance, competence, and motivation. Int J Teach Learn High Educ. 2020;32(1):73–86.

Patient perceptions of clinical pharmacists in general practice

Introduction

As a result of changes in the demands and pressures on the NHS, the role of the pharmacist has advanced from purely dispensing and compounding medicines to a more clinical and patient-centred approach to care (1). Since 2015, NHS England set a target of recruiting practice-based pharmacists into 20% of practices by 2020-2021 as a way of reducing these pressures (2). Conducting evaluations of clinical pharmacists in individual practices is essential for role integration and evolution.

Aim

To explore patient perceptions of clinical pharmacists across three general practices.

Methods

A paper-based questionnaire consisting of open and closed questions was used to gather patient perceptions on the role of a clinical pharmacist and their consultation experiences. Participants included patients over the age of 18 who had attended a face-to-face appointment with a clinical pharmacist from one of three general practice surgeries in England between November and December 2019. The clinical pharmacists were used as a gateway to recruit participants; post-consultation, the pharmacist asked patients if they would complete a questionnaire. Patients were provided with an information sheet and consent form prior to completion of the questionnaire. The questionnaire was anonymous. Data were analysed using descriptive statistics and content analysis.

Results

A total of 39 participants completed the questionnaire. Most participants were elderly (28%) and female (64%). The primary reason for the consultations was due to an acute illness (79%), and the most common outcome was the supply of a prescription (83%). Patients were predominantly unfamiliar with the role of a clinical pharmacist (56%) and 31% of patients reportedly thought their appointment had been with a doctor. All patients were positive about their experience and reported they would “be more than happy to see a pharmacist in the future” and that the role was “a very necessary addition to the practice”. All patients reported that their consultation was the same (51%) or better than they have had with a doctor (49%). Patients commented on the pharmacists’ consultation skills, making statements such as [they] “listened to me”, “asked me questions”, “were really good at explaining” and “spoke in a way I understood”. Clinical pharmacists were reported as being “very professional” and knowledgeable as “[they] knew more about my medication [than the doctor] and prescribed me something to help”. Patients reported that they would recommend the clinical pharmacist to their family and friends when seeking an appointment.

Conclusion

This research highlights patient acceptance towards consultations with a clinical pharmacist and reinforces the competence of pharmacists to undertake this role. A key finding related to the effective consultation skills of the pharmacists and involving the patients in their care. The number of patients who participated limits the generalisability of the findings, and the patient responses may have been a reaction to the individual clinical pharmacists rather than their thoughts on the role overall. Increased publicity and patient education of the role of a clinical pharmacist may promote a greater integration into the multidisciplinary team.

References

(1) Robertson R, Wenzel L, Thompson J, Charles A. Understanding NHS financial pressures. How are they affecting patient care. 2017. The Kings Fund. https://www.kingsfund.org.uk/sites/default/files/field/field_publication_file/Understanding%20NHS%20financial%20pressures%20-%20full%20report.pdf

(2) NHS England 2016. General Practice Forward View. https://www.england.nhs.uk/wp-content/uploads/2016/04/gpfv.pdf

Intensive rehabilitation for functional motor disorders (FMD) in the United States: A review

BACKGROUND: Higher levels of care in the form of intensive rehabilitation may be appropriate for select patients with a diagnosis of functional motor disorder (FMD). Intensive rehabilitation, as delivered through an outpatient day program or through admission to an inpatient rehabilitation facility, can offer a greater frequency and variety of integrated clinical services than most lower levels of care. OBJECTIVE: Higher levels of rehabilitation for FMD have not yet been well characterized in the literature. In this article, we will focus on the population of FMD patients who begin receiving care in the outpatient setting. METHOD: In this review, we describe a range of options for higher levels of FMD care, evaluate the supporting literature, and weigh the pros and cons of each approach. Several specific examples of intensive rehabilitation programs in the United States will be described. Finally, we will consider existing health systems barriers to each of these outpatient and inpatient higher levels of care. RESULTS: Within a stepped model of care, intensive outpatient day-programs and inpatient rehabilitation may be considered for individuals who present with complex, refractory motor deficits from FMD. For appropriately selected patients, a growing body of literature suggests that time-limited, goal-oriented intensive rehabilitation may provide an effective treatment avenue. CONCLUSION: It remains to be determined whether treatment in intensive care settings, while more costly in the short term, could lead to greater cost savings in the long term. The prospect of telemedicine rehabilitation for FND in terms of efficacy and cost also remains to be determined.

712 EVALUATING AN ‘ACUTE FRAILTY TEAM’ MODEL OF CARE IN IMPROVING OUTCOMES FOR PATIENTS WITH FRAILTY ACUTELY ADMITTED TO HOSPITAL

Introduction

In frailty, Comprehensive geriatric assessment (CGA) has benefit in improving patient outcomes, including hospital readmissions and institutionalisation. We looked to evaluate the effectiveness of our newly initiated multi-disciplinary, acute frailty team (AFT) in improving acute care. This team works on the Acute Medical Unit (AMU), delivering early CGA alongside the existing acute medical care.

Methods

The AFT initially targeted identification of frailty using the Rockwood clinical frailty score (CFS) through local quality improvement work. A standard operating procedure, encompassing CGA for all patients with frailty (define as a CFS 5 to 8 or, 4 with a frailty syndrome) was introduced. This assessment was additional to usual acute medical care. The impact was measured by retrospective case note review of 100 AMU admissions with frailty prior to the team being in post (Jan-March 2020) with a subsequent 100 patients seen by the AFT (March–April 2021). The 2 groups were matched for age, gender, frailty scores and pre-admission residence. These 2 cohorts were compared against key performance indices.

Results

The mean age of patients in the Pre and post AFT cohorts were 85 years and 84 years respectively with an average CFS of 6. The identification and documentation of frailty improved in the AFT intervention cohort from 31% to 100% and screening for delirium with 4AT improved from 27% to 91%. The number of patients in the AFT cohort discharged directly from AMU increased from 5% to 14% with the average length of in-patient stay reducing from 10.2 days to 7.8 days. Thirty day remission fell from 23% to 16% in the AFT cohort, and the number of patients discharge to new 24 hour care declined from 21% to 9%.

Conclusion

Our AFT alongside existing acute medical care improved outcomes including, frailty identification, delirium screening, length of stay, re-admissions and institutionalisation.

Abstract P5-01-03: Mouse-intraductal (MIND): An in vivo model for studying the underlying mechanisms of DCIS malignancy

Background: Due to widespread adoption of screening mammography, there has been a significant increase in new diagnoses of ductal carcinoma in situ (DCIS). However, DCIS prognosis remains unclear. Methods: To address this gap, we developed an in vivo model, Mouse-INtraDuctal (MIND), by which patient-derived DCIS epithelial cells are injected intraductally and allowed to progress naturally in mice. The source of DCIS samples reflected clinical practice as predominantly high grade (70%), but also included intermediate grade (27%) and low grade (3%). Thirty-seven patient samples were injected into 202 mouse mammary glands and evaluated for invasive progression at a median duration of 9 months. The expression of clinically relevant biomarkers (ER, PR, Ki-67, HER2 and p53) on patient DCIS FFPE sections and xenografts’ extent of in vivo growth were evaluated for their utility in predicting DCIS invasive progression in the xenografts. Targeted DNA sequencing using Tempus XT oncology assay was used on patient DCIS in order to find a unique pattern of cancer related gene mutations that predicted DCIS invasiveness in the xenografts. Results: Similar to human DCIS, the cancer cells formed in situ lesions inside the mouse mammary ducts and mimicked all histologic subtypes including micropapillary, papillary, cribriform, solid, and comedo. Among 37 patient samples injected into 202 xenografts, at median duration of 9 months, 20 samples (54%) injected into 95 xenografts showed in vivo invasive progression while 17 (46%) samples injected into 107 xenografts remained noninvasive. Among the 20 samples that showed invasive progression in the MIND model, 9 patient samples injected into 54 xenografts exhibited a mixed pattern in which some xenografts showed invasive progression while others remained noninvasive. The mean duration of follow-up was not significantly different among the progressed, non-progressed or mixed groups (ANOVA; p-value=0.44). Among the clinically relevant biomarkers, only elevated progesterone receptor expression in patient DCIS and extent of in vivo growth in xenografts predicted an invasive outcome in the xenografts. Tempus XT oncology assay was used on 16 patient DCIS FFPE sections including eight patient DCIS that showed invasive progression (P), five patient DCIS that remained non-invasive (NP) and three patient DCIS that showed a mixed pattern (M) in the xenografts. Variant severity was called using SnpSift which is a program for identifying phenotype-relevant variants and predicts the severity of SNPs based on their effect on gene expression and function. COSMIC database was also used to identify mutations with pathogenic scores &gt;0.5. Analysis of the frequency of cancer related pathogenic mutations showed no significant differences (P=27, NP=79, M=43, Kruskal-Wallis: P value=&gt;0.05). There were also no differences in the frequency of low, moderate or high severity mutations (P= 25 highly severe, 120 moderately severe and 50 low-severity; NP=9 highly severe, 58 moderately severe and 28 low severity; M=3 highly severe, 33 moderately severe and 14 low severity; Kruskal-Wallis; P value &gt;0.05). Conclusions: Highly severe and pathogenic variants in the patient’s DCIS were not associated with whether the DCIS developed into invasive lesions or remained non-invasive in the MIND models. These results are in agreement with previous studies that showed no significant differences in frequency of non-synonymous mutations and CNAs when comparing pure DCIS with synchronous IDC-DCIS. The MIND models are in immunocompromised mice, so the contribution of the immune system to DCIS progression may not recapitulate cancer progression in an immunocompetent state. However, the MIND model suggests that genetic changes in the DCIS are not the primary driver for the development of invasive disease.

Citation Format: Aditi Rastogi, Jerome Lin, Yan Hong, Darlene Limback, Hanan S. Elsarraj, Haleigh Harper, Haley Haines, Hayley Hansford, Michael Ricci, Carolyn Kaufman, Emily Wedlock, Mingchu Xu, Jianhua Zhang, Lisa May, Terri Cusick, Marc Inciardi, Mark Redick, Jason Gatewood, Onalisa Winblad, Allison Aripoli, Ashley Huppe, Christa Balanoff, Jamie Wagner, Amanda Amin, Kelsey E. Larson, Lawrence Ricci, Ossama Tawfik, Hana Razek, Ruby O Meierotto, Rashna Madan, Andrew K. Godwin, Jeffrey Thompson, Susan G. Hilsenbeck, Andy Futreal, Alastair Thompson, E. Shelley Hwang, Fang Fan, Nicholas Navin, Fariba Behbod, Grand Challenge PRECISION Consortium. Mouse-intraductal (MIND): An in vivo model for studying the underlying mechanisms of DCIS malignancy [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P5-01-03.

Mouse-INtraDuctal (MIND): an in vivo model for studying the underlying mechanisms of DCIS malignancy

Due to widespread adoption of screening mammography, there has been a significant increase in new diagnoses of ductal carcinoma in situ (DCIS). However, DCIS prognosis remains unclear. To address this gap, we developed an in vivo model, Mouse-INtraDuctal (MIND), in which patient-derived DCIS epithelial cells are injected intraductally and allowed to progress naturally in mice. Similar to human DCIS, the cancer cells formed in situ lesions inside the mouse mammary ducts and mimicked all histologic subtypes including micropapillary, papillary, cribriform, solid, and comedo. Among 37 patient samples injected into 202 xenografts, at median duration of 9 months, 20 samples (54%) injected into 95 xenografts showed in vivo invasive progression, while 17 (46%) samples injected into 107 xenografts remained non-invasive. Among the 20 samples that showed invasive progression, nine samples injected into 54 xenografts exhibited a mixed pattern in which some xenografts showed invasive progression while others remained non-invasive. Among the clinically relevant biomarkers, only elevated progesterone receptor expression in patient DCIS and the extent of in vivo growth in xenografts predicted an invasive outcome. The Tempus XT assay was used on 16 patient DCIS formalin-fixed, paraffin-embedded sections including eight DCISs that showed invasive progression, five DCISs that remained non-invasive, and three DCISs that showed a mixed pattern in the xenografts. Analysis of the frequency of cancer-related pathogenic mutations among the groups showed no significant differences (KW: p > 0.05). There were also no differences in the frequency of high, moderate, or low severity mutations (KW; p > 0.05). These results suggest that genetic changes in the DCIS are not the primary driver for the development of invasive disease. © 2021 The Authors. The Journal of Pathology published by John Wiley & Sons Ltd on behalf of The Pathological Society of Great Britain and Ireland.

Accelerating Cancer Patient Recruitment Through a Mobile Application (Clinical Trial Finder)

OBJECTIVE

Participant recruitment is a challenge for any clinical trial but is especially complex in cancer specifically due to the need to initiate treatment urgently. Most participants enrolled in oncology clinical trials are identified as potential participants by the oncologist or other referring provider. Optimal clinical care for patients with cancer includes consideration of participation in a clinical trial. However, the process of finding a clinical trial that is appropriate the patient can be cumbersome and time consuming.

MATERIAL AND METHODS

The University of Kansas Cancer Center has developed a mobile application (app) which streamlines the clinical trial search process for physicians, patients, and caregivers by cohesively integrating all clinical trials currently recruiting in the center and making them easy to browse.

RESULTS

Key aspects of the app include simple filtering options, the ability to search for trials by name, easily accessible assistance, and in-app referral by phone or email. Initial feedback on the app has been very positive, with several suggestions already being implemented in future development. The app was designed to be used both by physicians to find trials, as well as patients in collaboration with their physicians.

CONCLUSION

While long-term results will be crucial to understanding how the app can best serve our patient population, our initial results suggest that health system specific clinical trial apps can address a currently unmet need in the clinical trial recruitment process.

Temporal trends of perfluoroalkyl substances in an Australian wastewater treatment plant: A ten-year retrospective investigation

Per- and poly-fluoroalkyl substances (PFAS) are a problematic group of chemicals used in various industrial and household products. They have been extensively detected in wastewater as a result of day-to-day product usage. Due to concerns about their safety, voluntary and regulatory action to limit the manufacture and use of some individual PFAS has occurred since the year 2000. The impact that this intervention has had on the use and potential exposure of Australians has not been measured. Wastewater serves as a powerful tool to assess the chemical use or consumption patterns of a population over time. We accessed a ten-year wastewater archiving program to conduct a temporal analysis of PFAS trends in an urban Australian population between the years 2010 and 2020. Results showed a decline in the concentrations for most PFAS, and a change in the PFAS profile from perfluorosulfonic acids and long-chain perfluorocarboxylic acids, to the short-chain perfluorocarboxylic acids and PFOS-replacement degradation products such as 5:3 FTCA. Intermittent pulses of PFAS that were significantly higher than 'background' levels (i.e., representing the PFAS input from primarily households) were observed, suggesting continuing industrial PFAS input within the wastewater catchment. This study highlights the long-term consequences of the diffuse use of persistent chemicals in products, and their ability to continue to enter the wastewater stream for decades.

Site Readiness Framework to Improve Health System Preparedness for a Potential New Alzheimer’s Disease Treatment Paradigm

New therapies that address the underlying pathophysiology of Alzheimer’s Disease (AD), coupled with the growth of the AD population, will transform the AD care pathway and present significant challenges to health systems. We explored real-world challenges health systems may face in delivering potential new AD therapies with diverse stakeholders. Key challenges in care included integrating primary care providers into assessment and management, availability of memory care specialists, understanding payment and coverage issues and training mid-level providers to help coordinate care and serve as a shared resource across the system. This input informed a novel Site Readiness Framework for AD, comprising self-assessment exercises to identify health system capabilities and gaps and a framework of core strategies and responsive tools to help prepare to integrate new AD therapies. These resources may help health systems improve readiness to modify care pathways to integrate new therapies for AD.