A qualitative exploration of the impacts of COVID-19 in two rural Southwestern Alaska communities

This manuscript presents a qualitative exploration of the experiences of people in two Southwestern Alaska communities during the emergence of COVID-19 and subsequent pandemic response. The project used principles of community based participatory research and honoured Indigenous ways of knowing throughout the study design, data collection, analysis, and dissemination. Data was collected in 2022 through group and individual conversations with community members, exploring impacts of the COVID-19 pandemic. Participants included Elders, community health workers, Tribal council members, government employees, school personnel, and emergency response personnel. Notes and written responses were coded using thematic qualitative analysis. The most frequently identified themes were 1) feeling disconnected from family, friends, and other relationships, 2) death, 3) the Tribal councils did a good job, and 4) loss of celebrations and ceremonies. While the findings highlighted grief and a loss of social cohesion due to the pandemic, they also included indicators of resilience and thriving, such as appropriate and responsive local governance, revitalisation of traditional medicines, and coming together as a community to survive. This case study was conducted as part of an international collaboration to identify community-driven, evidence-based recommendations to inform pan-Arctic collaboration and decision making in public health during global emergencies.

Diverse methodological approaches to a Circumpolar multi-site case study which upholds and responds to local and Indigenous community research processes in the Arctic

This paper outlines the methodological approaches to a multi-site Circumpolar case study exploring the impacts of COVID-19 on Indigenous and remote communities in 7 of 8 Arctic countries. Researchers involved with the project implemented a three-phase multi-site case study to assess the positive and negative societal outcomes associated with the COVID-19 pandemic in Arctic communities from 2020 to 2023. The goal of the multi-site case study was to identify community-driven models and evidence-based promising practices and recommendations that can help inform cohesive and coordinated public health responses and protocols related to future public health emergencies in the Arctic. Research sites included a minimum of 1 one community each from Canada (Nunavut,) United States of America (Alaska), Greenland, Iceland, Norway, Sweden, Finland. The approaches used for our multi-site case study provide a comprehensive, evidence-based account of the complex health challenges facing Arctic communities, offering insights into the effectiveness of interventions, while also privileging Indigenous local knowledge and voices. The mixed method multi-site case study approach enriched the understanding of unique regional health disparities and strengths during the pandemic. These methodological approaches serve as a valuable resource for policymakers, researchers, and healthcare professionals, informing future strategies and interventions.

One leg testing in hip and knee osteoarthritis: A comparison with a two-leg oriented functional outcome measure and self-reported functional measures

OBJECTIVE

To compare the responsiveness of two unilateral lower-limb performance-based tests, the one-leg rise test and the maximal step-up test, with the bilateral 30-second chair-stand test and the self-reported measure of physical function (HOOS/KOOS). Specific aims were to evaluate responsiveness, floor/ceiling effect and association between the instruments.

METHOD

Data was included from 111 participants, mean age 61.3 years (8.3), with clinically verified hip or knee osteoarthritis, who reported less than 150 minutes/week of moderate or vigorous intensity physical activity. Responsiveness, how well the instruments captured improvements, was measured as Cohen's standardised mean difference for effect size, and was assessed from baseline to 12 months following a physical activity intervention. Other assessments were floor and ceiling effects, and correlations between tests.

RESULTS

The maximal step-up test had an effect size of 0.57 (95% CI 0.37, 0.77), the 30-second chair-stand 0.48 (95% CI 0.29, 0.68) and the one-leg rise test 0.12 (95% CI 0.60, 0.31). The one-leg rise test had a floor effect as 72% of the participants scored zero at baseline and 63% at 12 months. The correlation between performance-based tests and questionnaires was considered to be minor (r = 0.188 to 0.226) (p = 0.018 to 0.048).

CONCLUSION

The unilateral maximal step-up test seems more responsive to change in physical function compared to the bilateral 30-second chair-stand test, although the tests did not differ statistically in effect size. The maximal step-up test provides specific information about each leg for the individual and allows for comparison between the legs.

Public health restrictions, directives, and measures in Arctic countries in the first year of the COVID-19 pandemic

Beginning January of 2020, COVID-19 cases detected in Arctic countries triggered government policy responses to stop transmission and limit caseloads beneath levels that would overwhelm existing healthcare systems. This review details the various restrictions, health mandates, and transmission mitigation strategies imposed by governments in eight Arctic countries (the United States, Canada, Greenland, Norway, Finland, Sweden, Iceland, and Russia) during the first year of the COVID-19 pandemic, through 31 January 2021s31 January 2021. We highlight formal protocols and informal initiatives adopted by local communities in each country, beyond what was mandated by regional or national governments. This review documents travel restrictions, communications, testing strategies, and use of health technology to track and monitor COVID-19 cases. We provide geographical and sociocultural background and draw on local media and communications to contextualise the impact of COVID-19 emergence and prevention measures in Indigenous communities in the Arctic. Countries saw varied case rates associated with local protocols, governance, and population. Still, almost all regions maintained low COVID-19 case rates until November of 2020. This review was produced as part of an international collaboration to identify community-driven, evidence-based promising practices and recommendations to inform pan-Arctic collaboration and decision making in public health during global emergencies.

Evidence of secular trends during the COVID-19 pandemic in a stepped wedge cluster randomized trial examining sexual and reproductive health outcomes among Indigenous youth

BACKGROUND

Nen ŨnkUmbi/EdaHiYedo ("We Are Here Now," or NE) is an intervention to prevent STIs, HIV, HCV, and teen pregnancy among Assiniboine and Sioux youth of the Fort Peck Reservation in the state of Montana in the USA. A cluster-randomized stepped-wedge design (SWD) trial is used to evaluate NE, where clusters are schools. The purpose of this study is to evaluate whether there is evidence of a secular trend associated with the COVID-19 pandemic.

METHODS

The original study design is a cluster-randomized stepped-wedge design (SWD), in which five schools that youth from Fort Peck attend are the clusters to be randomized into the intervention one at a time, with all schools eventually being randomized to the intervention across three steps. N/E is a 5-year study involving 456 15- to 18-year-old youth. For this study, we use a mixed quantitative and qualitative methods approach to understand how the COVID-19 pandemic may have been associated with the study's primary outcome variables. Data were drawn from the first cluster exposed to the intervention and one control cluster that did not yet receive the intervention during the period in which COVID-19 mitigation efforts were being implemented. A pre-post COVID questionnaire was added to core measures administered, and semistructured qualitative interviews were conducted with youths regarding their perceptions of how the pandemic altered their sexual behaviors.

RESULTS

One hundred eighteen youth responded to the questionnaire and 31 youth participated in semistructured qualitative interviews. Youth reporting having sex with less people due to COVID-19 reported more sex acts (incident rate ratio (IRR)=3.6, 95% CI 1.6-8.1) in comparison to those who did not report having sex with less people, and youth who reported having sex with the same amount of people due to COVID-19 reported less sex acts (IRR=0.31, 95% CI 0.14-0.7) in comparison to those who did not report having sex with the same amount of people. Youth reporting having sex less times due to COVID-19 experienced a greater number of sex acts in comparison to those who did not report having sex less times (IRR=2.7, 1.2-6.4). Results suggest that more sexually active individuals reported perceiving having sex with less people and less frequent engagement in sex during the pandemic. It is possible that the COVID-19 pandemic period was associated with a truncation in the distribution of sexual activity that would bias an estimate of the intervention's effect.

CONCLUSION

Findings suggest evidence of a secular trend. This trend must be accounted for at trial end, and sensitivity analyses are recommended. Documenting and reporting on these findings encourages transparent reporting during the implementation of a SWD trial during a global pandemic, and informs endline analyses.

TRIAL REGISTRATION

This trial is registered with the Clinical trials registry of the US National Library of Medicine at the National Institutes of Health (NIH). It was registered on October 1, 2018. The study presented in this manuscript is funded by NIH National Institute on Minority Health and Health Disparities (NIMHD), Award # R01MD012761-01, Elizabeth Rink (Principal Investigator). The study's ClinicalTrials.gov number is NCT03694418.

Baseline results from NenŨnkUmbi/EdaHiYedo: A randomized clinical trial to improve sexual and reproductive health among American Indian adolescents

We report on baseline findings from NenUnkUmbi/EdaHiYedo, a community based participatory research randomized controlled trial with American Indian adolescents to reduce sexual and reproductive health disparities. American Indian adolescents aged 13-19 years participated in a baseline survey that was administered in five schools. We used zero-inflated negative binomial regression to evaluate how the count of protected sexual acts was associated with independent variables of interest. We stratified models by self-reported gender of adolescents and tested for a two-way interaction effect between gender and the independent variable of interest. Two hundred twenty-three girls and 222 boys (n = 445) were sampled. The average number of lifetime partners was 1.0 (standard deviation = 1.7). Each additional lifetime partner was associated with a 50% increase in the number of protected sexual acts incident rate ratio (IRR = 1.5, 95% confidence interval [CI] 1.1-1.9) and more than a twofold increase in the likelihood of not having protected sexual acts (adjusted odd ratio [aOR] = 2.6, 95% CI 1.3-5.1). Each additional number of substances used in adolescentss' lifetime was associated with an increased likelihood of not having protected sexual acts (aOR = 1.2, 95% CI 1.0-1.5). In boys, each one standard deviation increase in depression severity was associated with a 50% reduction in the number of times a condom was used adjusted IRR (aIRR = 0.5, 95% CI 0.4-0.6, p < .001). Each 1-unit increase in positive prospections of pregnancy was associated with a pronounced decrease likelihood of not having protected sexual acts (aOR = 0.01, 95% CI 0.0-0.1). Findings support the importance of tribally driven tailoring of sexual and reproducive health interventions and services for American Indian adolescents.

An ecological approach to understanding Women's reproductive health and pregnancy decision making in Greenland

Using a community based participatory research framework and ecological systems theory we explored the experiences of reproductive health among Inuit women living in a remote Northwestern settlement in Greenland to understand the multiple diverse factors that influence their pregnancy outcomes. We conducted 15 in depth interviews with Inuit women between the ages of 19 and 45. Key factors influencing women's pregnancy decision making were: 1) precursors to pregnancy; 2) birth control use; 3) adoption and abortion; and 4) access to reproductive health care. Our results highlight the need to identify pathways through research, policy, health promotion, and health care practice that can support Inuit women in Greenland to be reproductively healthy and make informed decisions about pregnancy that resonate with their cultural beliefs as well as the realities of their everyday lives. We recommend the integration of cultural messaging into interdisciplinary approaches for preventive reproductive health care with women living in remote Arctic communities.

Adaptations Due to the COVID-19 Pandemic in a Community-Based Participatory Research Randomized Control Trial Examining Sexual and Reproductive Health Outcomes among American Indian Youth

In this manuscript, we present changes in study design and analytical strategy due to the COVID-19 pandemic for Nen ŨnkUmbi/EdaHiYedo ("We Are Here Now," or NE). NE is a community-based participatory research multi-level randomized control trial using a stepped wedge design to address sexual and reproductive health disparities among American Indian youth. Adaptations in NE's research design, data collection, and analysis due to the COVID-19 pandemic were made based on meetings with tribally based research team members and outside non-Indigenous researchers involved in NE, as well as the study's Community Advisory Board and the Data Safety Monitoring Board. Based on these iterative discussions, decisions were made to: 1) reorganize the sequence of NE's stepped wedge design clusters, and 2) include additional quantitative and qualitative data collection and analysis in the research design that specifically addressed the impact of COVID-19 on the research participants. These adaptations have the potential to foster greater scientific knowledge in understanding how to address unanticipated 3-way interaction effects in randomized control trials with tribal communities. Findings can also contribute to understanding how public health disasters impact sexual and reproductive health among American Indian youth.

Rationale, Design, and Methods for Nen Unkumbi/Edahiyedo ("We Are Here Now"): A Multi-Level Randomized Controlled Trial to Improve Sexual and Reproductive Health Outcomes in a Northern Plains American Indian Reservation Community

American Indian (AI) youth in the United States experience disproportionate sexual and reproductive health (SRH) disparities relative to their non-Indigenous, white counterparts, including increased rates of sexually transmitted infections (STIs), earlier sexual debut, increased rates of teen birth, and reduced access to SRH services. Past research shows that to improve SRH outcomes for AI youth in reservation communities, interventions must address complex factors and multiple levels of community that influence sexual risk behaviors. Here, we describe development of a multi-level, multi-component randomized controlled trial (RCT) to intervene upon SRH outcomes in a Northern Plains American Indian reservation community. Our intervention is rooted in a community based participatory research framework and is evaluated with a stepped wedge design that integrates 5 reservation high schools into a 5-year, cluster-randomized RCT. Ecological Systems Theory was used to design the intervention that includes (1) an individual level component of culturally specific SRH curriculum in school, (2) a parental component of education to improve parent-child communication about SRH and healthy relationships, (3) a community component of cultural mentorship, and (4) a systems-level component to improve delivery of SRH services from reservation healthcare agencies. In this article we present the rationale and details of our research design, instrumentation, data collection protocol, analytical methods, and community participation in the intervention. Our intervention builds upon existing community strengths and integrates traditional Indigenous knowledge and values with current public health knowledge to reduce SRH disparities.

Early childbearing, family support, and staying in school in a Northern Plains American Indian reservation

American Indian youth experience teen birth and school dropout at higher rates than other racial and ethnic groups in the United States. Early childbearing is associated with adverse health and socioeconomic outcomes, including attenuated education. However, kinship childrearing norms among Northern Plains tribes can support positive experiences of early childbearing. Using a community based participatory research framework, this mixed methods exploratory study engaged high school students from a Northern Plains reservation community to examine youth perceptions of family support and belief in ability to stay in school should they have a child. We elicited youth observations of facilitators and inhibitors to academic achievement for young parents. This research supports the need for strengths-based, gender specific, and family inclusive sexuality education to support young people in their reproductive choices in reservation settings. We highlight the utility of including youth as co-authors and co-researchers in future studies.

POS0023 RACIAL/ETHNIC AND REGIONAL DIFFERENCES IN MULTIMORBIDITY BETWEEN PATIENTS WITH RHEUMATOID ARTHRITIS AND COMPARATORS IN A LARGE NATIONWIDE US STUDY

Background:

Patients with rheumatoid arthritis (RA) have an increased burden of multimorbidity. Racial/ethnic disparities have also been associated with an increased burden of multimorbidity.

Objectives:

We aimed to compare multimorbidity among different racial/ethnic groups and geographic regions of the US in patients with RA and comparators without RA.

Methods:

We used a large longitudinal, real-world data warehouse with de-identified administrative claims for commercial and Medicare Advantage enrollees, to identify cases of RA and matched controls. Cases were defined as patients aged ≥18 years with ≥2 diagnoses of RA in January 1, 2010 - June 30, 2019 and ≥1 prescription fill for methotrexate in the year after the first RA diagnosis. Controls were persons without RA matched 1:1 to RA cases on age, sex, census region, calendar year of index date (corresponding to the date of second diagnosis code for RA), and length of prior medical/pharmacy coverage. Race was classified as non-Hispanic White (White), non-Hispanic Black (Black), Asian, Hispanic, or other/unknown, based on self-report or derived rule sets. Multimorbidity (2 or more comorbidities) was defined using 25 chronic comorbidities from a combination of the Charlson and Elixhauser Comorbidity Indices assessed during the year prior to index date. Rheumatic comorbidities were not included. Logistic regression models were used to estimate odds ratios (OR) with 95% confidence intervals (CI).

Results:

The study included 16,363 cases with RA and 16,363 matched non-RA comparators (mean age 58.2 years, 70.7% female for both cohorts). Geographic regions were the same in both cohorts: 50% South, 26% Midwest, 13% West, and 11% Northeast. Race/ethnicity was not part of the matching criteria and varied slightly between the cohorts: among RA (non-RA) patients, 74% (74%) were White, 11% (9%) Hispanic, 10% (9%) Black, 3% (4%) Asian, and 3% (4%) other/unknown. Patients with RA had more multimorbidity than non-RA subjects (51.3% vs 44.8%). Multimorbidity comparisons across US geographic regions were similar in both cohorts, with comparable multimorbidity levels for patients in the West and Midwest and higher levels for those in the Northeast and South (Figure 1). Among the non-RA patients, 43.5% of Whites experienced multimorbidity, compared to 33.9% of Asians, 46.1% of Hispanics, and 58.4% of Blacks. These associations remained after adjustment for age, sex, and geographic region, with significantly lower multimorbidity among Asians (OR: 0.81; 95%CI: 0.67-0.99) and significantly higher multimorbidity among Hispanics (OR: 1.21; 95%CI: 1.07-1.37) and Blacks (OR: 1.74; 95%CI: 1.54-1.97), compared to Whites in the non-RA cohort. Among the RA patients, racial/ethnic differences were less pronounced; 50.6% of Whites, 42.8% of Asians, 48.8% of Hispanics, and 58.4% of Blacks experienced multimorbidity. Adjusted analyses revealed no significant differences in multimorbidity for Asians (OR: 0.88; 95%CI: 0.70-1.08) and Hispanics (OR: 1.06; 95%CI: 0.95-1.19) and a less pronounced increase in multimorbidity among Blacks (OR: 1.32; 95%CI: 1.17-1.49) compared to Whites in the RA cohort.

Conclusion:

This large nationwide study showed increased occurrence of multimorbidity in RA versus non-RA patients and in both cohorts for residents of the Northeast and South regions of the US. Racial/ethnic disparities in multimorbidity were more pronounced among patients without RA compared to RA patients. This indicates the effects of RA and race/ethnicity on multimorbidity do not aggregate. The underlying mechanisms for these associations require further investigation.

Figure 1.

Logistic regression models comparing multimorbidity levels in RA and non-RA cohorts.

Disclosure of Interests:

Hayley J. Dykhoff: None declared, Elena Myasoedova: None declared, Madeline Peterson: None declared, John M Davis III Grant/research support from: Research grant from Pfizer, Vanessa Kronzer: None declared, Caitrin Coffey: None declared, Tina Gunderson: None declared, Cynthia S. Crowson: None declared.

OP0213 SEX DIFFERENCES IN MULTIMORBIDITY BETWEEN PATIENTS WITH RHEUMATOID ARTHRITIS AND COMPARATORS IN A LARGE NATIONWIDE US STUDY

Background:

Patients with rheumatoid arthritis (RA) have an increased burden of multimorbidity. Although many comorbidities vary by sex, sex differences in multimorbidity among individuals with RA have not been examined.

Objectives:

We aimed to compare multimorbidity between women and men with RA and comparators without RA.

Methods:

We used a large longitudinal, real-world data warehouse with de-identified administrative claims for commercial and Medicare Advantage enrollees, to identify cases of RA and matched controls. Cases were defined as patients aged ≥18 years with ≥2 diagnoses of RA in January 1, 2010 - June 30, 2019 and ≥1 prescription fill for methotrexate in the year after the first RA diagnosis. Controls were persons without RA matched 1:1 to RA cases on age, sex, census region, calendar year of index date (corresponding to the date of second diagnosis code for RA), and length of prior medical/pharmacy coverage. Race was classified as non-Hispanic White (White), non-Hispanic Black (Black), Asian, Hispanic, or other/unknown, based on self-report or derived rule sets. Multimorbidity (2 or more comorbidities) was defined using 25 chronic comorbidities from a combination of the Charlson and Elixhauser Comorbidity Indices assessed during the year prior to index date. Rheumatic comorbidities were not included. Logistic regression models were used to estimate odds ratios (OR) with 95% confidence intervals (CI).

Results:

The study included 16,363 cases with RA and 16,363 matched non-RA comparators (mean age 58.2 years, 70.7% female for both cohorts). In both cohorts, women were slightly younger (mean age 57.5 vs. 59.8 years). Among RA patients, women were more racially/ethnically diverse than men, with 72% of women (78% men) being White, 12% (10%) Hispanic, 11% (7%) Black, 3% (3%) Asian, and 3% (3%) other/unknown. Racial/ethnic diversity was similar among non-RA women and men with 74% women (75% men) being White, 9% (9%) Hispanic, 10% (8%) Black, 4% (4%) Asian, and 3% (4%) other/unknown. Patients with RA had more multimorbidity than non-RA subjects (51.3% vs 44.8%). Observed rates of multimorbidity were similar in women and men with RA (51.6% vs 50.5%, p=0.18), but among non-RA patients, women had lower observed rates of multimorbidity than men (43.7% vs 47.4%, p<0.0001). However, following adjustment for age, race/ethnicity, and geographic region, multimorbidity among RA patients was greater in women versus men (OR: 1.19; 95% CI: 1.11-1.28) and similar among non-RA women and men (OR: 0.97 for females; 95% CI: 0.90-1.05). Examination of individual comorbidities showed that women with RA had more depression, hypothyroidism, diabetes mellitus, and chronic pulmonary disease compared to men with RA and women without RA.

Conclusion:

This large nationwide study showed increased occurrence of multimorbidity in women with RA compared to men with RA, while women and men without RA had similar levels of multimorbidity following adjustment for age, race/ethnicity, and geographic region. The underlying mechanisms for these sex differences require further investigation.

Disclosure of Interests:

Hayley J. Dykhoff: None declared, Elena Myasoedova: None declared, Madeline Peterson: None declared, John M Davis III Grant/research support from: Research grant from Pfizer, Vanessa Kronzer: None declared, Caitrin Coffey: None declared, Tina Gunderson: None declared, Cynthia S. Crowson: None declared

FRI0560 INCREASED RISK OF RHEUMATOID ARTHRITIS DIAGNOSIS IN STATIN USERS IN A LARGE NATIONWIDE US STUDY

Background:

Studies evaluating the effect of statin use on the risk of rheumatoid arthritis (RA) onset have shown conflicting results. Most of these studies evaluated European populations while data from the US are scarce.

Objectives:

We aimed to assess the association between statin use (and intensity) and RA occurrence using claims data from the US population.

Methods:

For this case-control study, we used the OptumLabs Data Warehouse, a large administrative database of commercially insured and Medicare Advantage beneficiaries, to identify cases of RA and matched controls. Cases were defined as patients with 2 or more diagnoses of RA in January 1, 2010 - June 30, 2019 who were ≥18 years old, filled ≥1 prescription for a conventional or biologic disease modifying anti-rheumatic drug, and had no diagnoses of RA during the prior year. Controls were persons without RA matched 1:1 to RA cases on age, sex, census region, calendar year of index date (corresponding to the date of second diagnosis code for RA), and length of prior medical/pharmacy coverage. Statin use was defined as any filled prescription for a statin medication during prior coverage (excluding any new statin prescriptions filled up to 90 days before first RA diagnosis or index date). Logistic regression models were used to estimate odds ratios (OR)with 95% confidence intervals (CI) adjusted for age, sex, race, census region, calendar year and Charlson comorbidity index (excluding RA component).

Results:

The study included 32,465 cases with RA (mean age 57.0, 72.2% female) and 32,465 matched controls (mean age 57.0, 72.2% female). There were 10,759 (33.1%) statin users among RA patients and 4,016 (12.4%) statin users among the matched controls. Statin use was associated with increased risk of RA (adjusted OR 3.34, 95%CI 3.19-3.49). All levels of statin intensity were associated with increased risk of RA (high OR: 3.60, 95% CI 3.28-3.94; medium OR: 3.20, 95% CI 3.04-3.37; low OR: 3.72, 95% CI 3.34-4.15) compared to non-users. Both former and current statin users showed an increased risk of RA (current OR: 3.04, 95% CI 2.80-3.30 and former OR: 3.37, 95% CI 3.20-3.54) compared to non-users.

Conclusion:

This large nationwide study showed increased risk of RA in statin-users vs non-users. The lack of dose dependence may suggest confounding by indication or a common genetic predisposition for cardiovascular disease and RA. The underlying mechanisms for these associations require further investigation.

Disclosure of Interests:

Madeline Peterson: None declared, Hayley J. Dykhoff: None declared, Cynthia S. Crowson Grant/research support from: Pfizer research grant, John M Davis III Grant/research support from: Research grants from Pfizer, Consultant of: Served on advisory boards for Abbvie and Sanofi-Genzyme, Lindsey Sangaralingham: None declared, Elena Myasoedova: None declared

The Burden of Functional Disabilities for Middle-Aged and Older Adults in the United States

OBJECTIVES

Understanding the role of functional capacity on longevity is important as the population in the United States ages. The purpose of this study was to determine the burden of instrumental activities of daily living (IADL) and activities of daily living (ADL) disabilities for a nationally-representative sample of middle-aged and older adults in the United States.

DESIGN

Longitudinal-Panel.

SETTING

Core interviews were often performed in person or over the telephone.

PARTICIPANTS

A sub-sample of 31,055 participants aged at least 50 years from the 1998-2014 waves of the Health and Retirement Study who reported having a functional disability were included.

MEASUREMENTS

Ability to perform IADLs and ADLs were self-reported at each wave. The National Death Index was used to ascertain date of death. The number of years of life that were lost (YLLs) and years lived with a disability (YLDs) were summed for the calculation of disability-adjusted life years (DALYs). Sampling weights were used in the analyses to make the DALYs nationally-representative. The results for YLLs, YLDs, and DALYs are reported in thousands.

RESULTS

Of the participants included, 14,990 had an IADL disability and 13,136 had an ADL disability. Men and women with an IADL disability had 236,037 and 233,772 DALYs, respectively; whereas, there were 178,594 DALYs for males and 253,630 DALYs for females with an ADL disability. Collectively, there were 469,809 years of healthy life lost from IADL impairments, and 432,224 years of healthy life lost from ADL limitations.

CONCLUSIONS

These findings should be used to inform healthcare providers and guide interventions aiming to preserve the functional capacity of aging adults. Prioritizing health-related resources for mitigating the burden of functional disabilities may help aging adults increase their quality of life and life expectancy over time.

Association between HbA1c and peripheral neuropathy in a 10-year follow-up study of people with normal glucose tolerance, impaired glucose tolerance and Type 2 diabetes

AIMS

To explore the association between HbA_1c and sural nerve function in a group of people with normal glucose tolerance, impaired glucose tolerance or Type 2 diabetes.

METHODS

We conducted a 10-year follow-up study in 87 out of an original 119 participants. At study commencement (2004), 64 men and 55 women (mean age 61.1 years) with normal glucose tolerance (n=39), impaired glucose tolerance (n=29), or Type 2 diabetes (n=51) were enrolled. At the 2014 follow-up (men, n=46, women, n=41; mean age 71.1 years), 36, nine and 42 participants in the normal glucose tolerance, impaired glucose tolerance and Type 2 diabetes categories, respectively, were re-tested. Biometric data and blood samples were collected, with an electrophysiological examination performed on both occasions.

RESULTS

At follow-up, we measured the amplitude of the sural nerve in 74 of the 87 participants. The mean amplitude had decreased from 10.9 μV (2004) to 7.0 μV (2014; P<0.001). A 1% increase in HbA_1c was associated with a ~1% average decrease in the amplitude of the sural nerve, irrespective of group classification. Crude and adjusted estimates ranged from -0.84 (95% CI -1.32, -0.37) to -1.25 (95% CI -2.31, -0.18). Although the mean conduction velocity of those measured at both occasions (n=73) decreased from 47.6 m/s to 45.8 m/s (P=0.009), any association with HbA_1c level was weak. Results were robust with regard to potential confounders and missing data.

CONCLUSIONS

Our data suggest an association between sural nerve amplitude and HbA_1c  at all levels of HbA_1c . Decreased amplitude was more pronounced than was diminished conduction velocity, supporting the notion that axonal degeneration is an earlier and more prominent effect of hyperglycaemia than demyelination.

Low first-trimester PAPP-A in IVF (fresh and frozen-thawed) pregnancies, likely due to a biological cause

PURPOSE

The purpose of this study is to confirm a difference in the first-trimester screen maternal biochemistry and false-positive rates (FPR) between pregnancies conceived spontaneously and those conceived via assisted reproductive technologies (ART).

METHODS

Retrospective analysis of the complete population of women (17,889 pregnancies) who had undergone first-trimester screening between January 2004 and September 2009 at three private ultrasound clinics in Queensland, Australia was used in the study. The age, gestation, method of conception, ultrasound markers, biochemistry markers (PAPP-A, fβ-hCG), and type of biochemical analyzer platform (Brahms Kryptor, Immulite 2000) data was collated. Univariate analysis of variance (ANOVA), Spearman's rank nonparametric correlation analysis, and Binary Logistic Regression analysis were used to analyze data. Spontaneous pregnancies were used as controls. Results were considered significant when the p value was less than 0.05.

RESULTS

After exclusions, 16,363 singleton pregnancies, including 1543 conceived via ART, were analyzed. Results from the two biochemistry platforms, Brahms Kryptor and Immulite 2000 were significantly different (p < 0.001); thus, the data was divided for analysis purposes. PAPP-A was universally significantly lower in IVF pregnancies compared to spontaneously conceived pregnancies (p < 0.001). Using the Brahms Kryptor platform, ICSI was associated with significantly decreased PAPP-A (p < 0.046), and a significantly increased FPR (p = 0.012).

CONCLUSIONS

Consistent with previous studies IVF pregnancies had significantly lower PAPP-A levels supporting the need to appropriately adjust the combined first-trimester screening (cFTS) risk algorithm for IVF conceptions. The Brahms Kryptor and Immulite 2000 platforms are significantly different; however, the universally lower PAPP-A findings support the hypothesis that the lower PAPP-A is due to a biological cause.

Application of denitrifying wood chip bioreactors for management of residential non-point sources of nitrogen

Two important and large non-point sources of nitrogen in residential areas that adversely affect water quality are stormwater runoff and effluent from on-site treatment systems. These sources are challenging to control due to their variable flow rates and nitrogen concentrations. Denitrifying bioreactors that employ a lignocellulosic wood chip medium contained within a saturated (anoxic) zone are relatively new technology that can be implemented at the local level to manage residential non-point nitrogen sources. In these systems, wood chips serve as a microbial biofilm support and provide a constant source of organic substrate required for denitrification. Denitrifying wood chip bioreactors for stormwater management include biofilters and bioretention systems modified to include an internal water storage zone; for on-site wastewater, they include upflow packed bed reactors, permeable reactive barriers, and submerged wetlands. Laboratory studies have shown that these bioreactors can achieve nitrate removal efficiencies as high as 80-100% but could provide more fundamental insight into system design and performance. For example, the type and size of the wood chips, hydraulic loading rate, and dormant period between water applications affects the hydrolysis rate of the lignocellulosic substrate, which in turn affects the amount and bioavailability of dissolved organic carbon for denitrification. Additional field studies can provide a better understanding of the effect of varying environmental conditions such as ambient temperature, precipitation rates, household water use rates, and idle periods on nitrogen removal performance. Long-term studies are also essential for understanding operations and maintenance requirements and validating mathematical models that integrate the complex physical, chemical, and biological processes occurring in these systems. Better modeling tools could assist in optimizing denitrifying wood chip bioreactors to meet nutrient reduction goals in urban and suburban watersheds.

Abstract S4-04: Tumor microenvironment of metastasis (TMEM) score is associated with early distant recurrence in hormone receptor (HR) positive, HER2-negative early stage breast cancer (ESBC)

Background: Metastasis is the primary cause of death in ESBC. We have shown in mouse models that a subpopulation of tumor cells expressing invasive Mena isoforms stream, form microanatomic structures (“TMEM”) with endothelial cells and macrophages, intravasate into the circulation at TMEM sites, and metastasize (Harney et al. Cancer Discovery, 2015). Further, TMEM sites (“MetaSites”) are identifiable in human ESBC, and “MetaSite score” [MS] is positively associated with distant recurrence in HR+/HER2- ESBC independent of clinicopathologic features, including IHC4 (Rohan et al. JNCI 2014). Here we determined the association between MS and recurrence in an independent ESBC cohort (E2197; NCT00003519).

Methods: We evaluated primary tumors from 600 patients (median followup 14.8 years) with ESBC (weighted % = 50% T1, 54% N0, 46% N1) treated with surgery and 4 cycles of adjuvant chemotherapy (AC or AT) and endocrine therapy. Grade, ER, PR, and HER2, and Oncotype DX Recurrence Score (RS) were evaluated in central labs (Badve et al. JCO 2008), and MS was determined in a CLIA-certified lab using an analytically validated, fully automated digital pathology/image analysis method that identifies Mena expressing tumor cells in direct contact with CD68+ macrophages and CD31+ endothelial cells (ie, “TMEMs”, or “MetaSites”). The objectives were to determine the association between MS and distant relapse free interval (DRFI) and relapse free interval (RFI). Kaplan-Meier survival curves were used to estimate time-to-event distributions. Cox proportional hazards models were used to assess hazard ratio associated with MS while controlling for covariates, and allowing time-varying association with MS. Both Kaplan-Meier and Cox regression methods addressed stratified sampling by incorporating proper weights. All analyses were performed in R 3.2.3.

Results: MS ranged from 0-199; the weighted mean MS was lower in HR+/HER2- than TN (16.1 vs. 23.8, p=0.001) and HER2+ disease (26.2, p=0.003). MS was not associated with T or N status, and correlated poorly with RS (r=0.29). Proportional hazards models revealed a significant positive association between continuous MS and DRFI (p=0.001) and RFI (p=0.00006) in HR+/HER2- disease in years 0-5 (and by MS tertiles for DRFI [p=0.04] and RFI [p=0.01]), but not after year 5 or in TN or HER2+ disease. Proportional hazards models including clinical covariates (N0 vs. N1; T1 vs. T2; high vs. int. vs. low grade) also revealed significant positive associations for continuous MS with RFI (p=0.04), and borderline association with DRFI (p=0.08). Similar findings for MS (RFI p=0.05;DRFI p=0.10) were noted in a joint model including categorical RS (&lt;18,18-30, &gt;30).

Conclusions: MS, a novel metastasis biomarker reflecting interaction between streaming and metastasizing tumor cells and microenvironment, provides prognostic information complementary to classical clinicopathologic features and RS in HR+/HER2- ESBC. Further evaluation is warranted in order to identify patients at highest risk of recurrence within 5 years most likely to benefit from adjuvant chemotherapy or novel therapies. (Supported by BCRF and NCI CA21115, CA180794, CA23318, CA66636, CA180820).

Citation Format: Sparano JA, Gray R, Oktay MH, Entenberg D, Rohan T, Xue X, Donovan M, Peterson M, Shuber A, Hamilton D, D'Alfonso T, Goldstein LJ, Gerlter F, Davidson N, Condeelis J, Jones J. Tumor microenvironment of metastasis (TMEM) score is associated with early distant recurrence in hormone receptor (HR) positive, HER2-negative early stage breast cancer (ESBC) [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr S4-04.

Population-based cohort study of variation in the use of emergency cholecystectomy for benign gallbladder diseases

Background

The aims of this prospective population-based cohort study were to identify the patient and hospital characteristics associated with emergency cholecystectomy, and the influences of these in determining variations between hospitals.

Methods

Data were collected for consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing the performance of emergency cholecystectomy were analysed by means of multilevel, multivariable logistic regression modelling using a two-level hierarchical structure with patients (level 1) nested within hospitals (level 2).

Results

Data were collected on 4744 cholecystectomies from 165 hospitals. Increasing age, lower ASA fitness grade, biliary colic, the need for further imaging (magnetic retrograde cholangiopancreatography), endoscopic interventions (endoscopic retrograde cholangiopancreatography) and admission to a non-biliary centre significantly reduced the likelihood of an emergency cholecystectomy being performed. The multilevel model was used to calculate the probability of receiving an emergency cholecystectomy for a woman aged 40 years or over with an ASA grade of I or II and a BMI of at least 25·0 kg/m2, who presented with acute cholecystitis with an ultrasound scan showing a thick-walled gallbladder and a normal common bile duct. The mean predicted probability of receiving an emergency cholecystectomy was 0·52 (95 per cent c.i. 0·45 to 0·57). The predicted probabilities ranged from 0·02 to 0·95 across the 165 hospitals, demonstrating significant variation between hospitals.

Conclusion

Patients with similar characteristics presenting to different hospitals with acute gallbladder pathology do not receive comparable care.

Snapshots reflecting the lives of siblings of children with autism spectrum disorders

BACKGROUND

Past research focused on the effects of raising a child with autism spectrum disorder on families. However, most research examined parents' perspectives rather than siblings' perspectives. Therefore, the purpose of this qualitative descriptive design was to use photo elicitation to capture perspectives of siblings living with a child with autism spectrum disorder.

METHODS

Fourteen siblings (nine male) of 13 children with autism spectrum disorder received disposable cameras with 24-27 colour exposures, and were asked to photograph what was important to them within 2 weeks. After developing snapshots, investigators interviewed siblings about their photographs, and used open, axial and selective coding to determine photograph categories and subcategories.

RESULTS

Two major categories were found: people (family members, non-family members) and non-people (personal items/objects, animals, buildings, scenery). Interviews about photographs reflected experiences siblings had with people/non-people in the snapshots and their normal everyday activities. Most photographs revealed family life and activities any sibling would experience whether or not they lived in a family raising a child with autism spectrum disorder.

CONCLUSIONS

Photo elicitation facilitates communication between children and health-care professionals, and provides information about living with a child with autism spectrum disorder from the sibling's perspective. This information contributes to our knowledge base and allows development of specific intervention plans for siblings of these children.