Anaemia prevalence and risk factors among children aged 6 to 23 months in rural China

INTRODUCTION

Anaemia is a global public health problem among children. However, few studies have examined anaemia prevalence and risk factors among Chinese children of different ages, particularly in poor rural areas. This study investigated these two aspects among children aged 6 to 23 months in poor rural areas of China.

METHODS

This cross-sectional study included 1132 children aged 6 to 23 months in three prefectures of the Qinba Mountains area. A finger prick blood test for haemoglobin and anaemia was conducted, along with household surveys of socio-demographic characteristics, illness characteristics, and feeding practices. Multiple linear and logistic regression analyses were used to determine predictors of anaemia.

RESULTS

Overall, 42.6% of children in the study displayed anaemia. Children aged 6 to 11 months had the highest anaemia prevalence (53.6%). Anaemia risk factors differed among age-groups and throughout the overall sample. Bivariate and multivariable regression results showed that continued breastfeeding, any history of formula feeding, and consumption of iron-rich or iron-fortified foods were prominent risk factors for anaemia. However, continued breastfeeding and any history of formula feeding had the greatest impact across age-groups (both P<0.05).

CONCLUSION

Anaemia remains a severe public health problem among children aged 6 to 23 months in rural China. Healthy feeding practices, nutritional health knowledge, and nutrition improvement projects are needed to reduce the burden of anaemia among children in rural areas of China.

Unnecessary caesarean section delivery in rural China: exploration of relationships with full-term gestational age and early childhood development

INTRODUCTION

Gestational age at delivery is reportedly associated with cognitive and non-cognitive development in early childhood. Delivery at an earlier full-term gestational age has been associated with an increased rate of caesarean section (C-section) delivery; the high rate of C-section delivery in China implies that the rate of medically unnecessary C-section delivery is also high. This study investigated the relationships of medically unnecessary C-section delivery with full-term gestational age and early childhood development in rural China.

METHODS

We conducted a survey of 2765 children (aged 5-24 months) who resided in 22 national designated poverty counties. Primary caregivers were interviewed to collect information regarding child and household characteristics (including the child's gestational age), each child's delivery method, and reasons for C-section delivery (if applicable). The children were assessed using the Bayley Scales of Infant Development. Developmental outcomes were compared among gestational age-groups; regression analyses were used to assess relationships among medically unnecessary C-section delivery, gestational age, and developmental outcomes.

RESULTS

Overall, 56.2% of children were born at ≤39 weeks of gestation. Among C-section deliveries, 13.1% were medically necessary and >40% could clearly be classified as medically unnecessary. Repeat C-section was the most common reason given for medically unnecessary C-section delivery. For each 1-week increase in full-term gestational age, cognition scale scores increased by 0.62 points (P<0.01), language scale scores increased by 0.84 points (P<0.01), and motor scale scores increased by 0.55 points (P<0.05). Medically unnecessary Csection delivery was significantly associated with lower full-term gestational age.

CONCLUSION

Higher full-term gestational age was significantly associated with better childhood developmental outcomes, indicating that medically unnecessary C-section delivery may negatively influence early childhood development.

Projected impact of oncology biosimilar substitution from the perspective of provider risk in value-based oncology payment models

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Background: Oncology biosimilars may play an important role in managing risk for providers participating in value-based payment (VBP) models. The impact of biosimilar substitution on risk to providers remains unclear, as prior researchers have adopted a generic budget impact approach. Methods: We estimated the impact of biosimilar substitution on financial risk to providers in oncology VBPs by applying simulation approaches to model the quantitative methodology (e.g. episode framing, pricing, risk adjustment) of Medicare’s Oncology Care Model (OCM). Patient demographic and utilization data to fit the models were drawn from the Medicare Limited Data Set (LDS). Risk was defined as total cost of care (TCOC) relative to target price for an episode per the OCM methodology. Target prices were estimated using the most recently available OCM risk adjustment coefficients (2020). Biosimilars for six oncology agents were examined: bevacizumab, rituximab, trastuzumab, epoetin alfa, filgrastim, and pegfilgrastim (hereafter biosimilar investigation agents – BIAs). Episode TCOC was computed under the assumption of the use of reference BIAs and was then recomputed after biosimilar substitution. The study population consisted of 1620 episodes framed per the OCM methodology using the most recently available LDS data (2019-2020) that had use of a BIA. The impact to provider groups was estimated by computing the change in OCM risk bands (incentive payment earned/ neutral/ payment owed back to Medicare) associated with biosimilar substitution in panels of 100 randomly selected episodes from the study population over 10000 simulation runs. In our base model, we assumed that substitution for antineoplastics would occur only in treatment naïve patients and that substitution for supportive therapies would occur for all eligible patients. Treatment naïve status was assessed by examining longitudinal LDS data from 2016-2020 for beneficiaries from the study population. Results: Biosimilar substitution resulted in a mean reduction in cost relative to target of approximately $1,200 per eligible episode and reduced the proportion of practices that were above benchmark for eligible episodes by 33% and increased the number of practices below target for eligible episodes by 42%. Additional scenario analyses suggested that adoption strategy was a major determinant of potential impact. If assumptions of antineoplastic substitution requiring treatment naïve status were relaxed, costs savings relative to target would go from $1200 per eligible episode to $2700. Conclusions: Biosimilar substitution significantly reduces aggregate provider risk in OCM, representing a significant potential intervention for providers to mitigate risk in oncology VBPs both in terms of absolute costs saved relative to target and reduction in risk band relative to payer projections.

Establishing safe, effective ablation in the diseased human ventricle: an analysis of generator impedance and electrogram attenuation

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Biosense Webster Inc

Background

Predictors of effective and safe lesion delivery in the human left ventricle have not been established. Generator impedance (GI) drop and electrogram (EGM) attenuation are indices which can be used as surrogates for ablation lesion parameters. Tissue pops are a complication of myocardial overheating preceded by a rise in GI and can have adverse consequences.

Purpose

To establish the relationships between Ablation Index (AI), Force Time Integral (FTI) and contact force with GI and EGM attenuation. To establish factors early in ablation that are predictive of a GI rise.

Methods

Patients undergoing ventricular tachycardia ablation were recruited. All ablations were performed with contact force sensing surround flow catheters. Electrograms were collected pre and post ablation, with GI, AI, FTI measured during. Ablations were divided into low (LVM, &lt; 0.50mV), intermediate (IVM, 0.51 – 1.50mV) and normal voltage (NVM, &gt; 1.50mV) based upon pre-ablation bipolar EGM amplitude. Ablations with a 5% rise in GI from maximal drop were noted and predictors of this explored.

Results

In 15 patients, 402 ablations were analysed. Filtered percentage GI drop correlated with AI and FTI, (p &lt; 0.0005, Spearman’s ρ = 0.522 and 0.524) and reached a plateau at 763AI and 713gs, a filtered GI drop of 7.5% (Figure 1). Shallower curves occurred progressively from NVM to IVM to LVM, (p &lt; 0.0005), (Figure 2)

The bipolar EGM significantly attenuated with ablation, (median attenuation 0.14mV, [29.3%], p &lt;0.0005), but percentage attenuation did not correlate with AI or FTI.

Parameters associated with a GI rise during ablation were greater mean CF to maximum GI drop, (p = 0.002), greater initial percentage GI drop at 5 seconds, (p &lt; 0.0005), power of 50W (p = 0.005), and perpendicular orientation, (p = 0.006). Percentage GI drop at 5 seconds was the best predictor of ablations with a GI rise, (AUCROC 0.773; 95% CI 0.708 – 0.838; optimal cut-off 2.44%). Mean contact force to maximum GI drop was a poor predictor of a GI rise (AUCROC 0.647; 95% CI 0.577 – 0.718, optimal cut-off 14.7g).

Conclusion

During left ventricular ablation, AI of 763 and FTI of 713gs should be targeted, with a lower impedance drop observed for more scarred myocardium. A GI drop of &lt;2.5% at 5 seconds and contact force &lt; 15g should be used to optimise ablation safety.

UK multi-centre retrospective study of the learning curve and relative performance of the rhythmia high density mapping system for atrial ablation

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): University Hospital Southampton

Background

Rhythmia HDx® is a novel ultra-high density electroanatomical mapping system using an innovative 64 electrode basket catheter. A learning curve is a recognised phenomenon for any new technology and was examined in this study.

Purpose

Comparison of performance, long-term success, and complications using Rhythmia for atrial ablation in the UK.

Methods

Retrospective data collection from three centres across the UK from the introduction of Rhythmia. Patients were matched with controls who had undergone ablation using the well-established Carto3 mapping system. Assessed were: fluoroscopy, radiofrequency ablation and procedure times; acute and long term success, and complications.

Results

253 study patients with 253 controls were included. Significant correlations existed between procedural efficiency metrics and centre experience for de novo atrial fibrillation (AF) ablation (procedure time, Spearman’s ρ = -0.624; ablation time, ρ = -0.795), and de novo atrial flutter (AFlut) ablation (ablation time, ρ = -0.566; fluoroscopy time, ρ = -0.520). No such correlations existed for redo AF, redo AFlut, de novo atrial tachycardia (AT), or redo AT cases. For de novo AF and AFlut, procedural efficiency metrics were significantly improved after 10 procedures in each centre, (procedure time [AF only, p = 0.001], ablation time [AF, p &lt; 0.0005; AFlut p &lt; 0.0005] and fluoroscopy time [AFlut only, p = 0.0022]), and became comparable to controls (Figures 1 and 2). Acute success and long-term success did not see significant improvement with experience but were comparable to the control group. There was no relationship between experience and complications, which were comparable to Carto3 (3.6% in both groups).

Conclusion

A short learning curve exists with the use of Rhythmia HDx for standardised procedures (de novo AF / AFlut). Procedural performance improves and becomes comparable to Carto3 following 10 cases at each centre. Clinical outcomes at 6 and 12 months, and complications are not affected by this learning curve and remain comparable with controls.

Impact of clinical trial enrollment on episode costs in the Oncology Care Model (OCM)

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Background: Clinical trials are critical for improving outcomes for patients with cancer. However, there is some concern from health insurers that clinical trial participation can increase total cost of care for cancer patients. We investigated the impact of clinical trial participation on total costs paid by Medicare during the OCM program in a large community-based practice. Methods: Tennessee Oncology (TO) is a community oncology practice comprising over 90 oncologists across 30 sites of care. We linked TO trial data and electronic medical record data with OCM data for episodes of care from 2016-2018. To assess the impact of trial participation on total cost relative to routine care, we created matched comparator groups for each OCM episode based on cancer type, metastatic status, number of comorbidities, performance status, and age. Patients with breast cancer receiving hormone therapy only were excluded. Absolute and percent cost differences between groups were calculated for episodes that had a comparator group size of five or greater. Differences in total cost for trial episodes were compared to non-trial episodes, and significance was assessed using the Mann–Whitney U test. We also studied the impact of trial participation on receipt of active treatment in the last 14 days of life (TxEOL), hospice use, and hospitalizations. Results: During the study period, 8,026 completed OCM episodes met study criteria. Patients were enrolled in a clinical trial for 459 of these episodes. On average, episodes during which patients were on trial cost $5,973 less than matched non-trial episodes (Table), independent of early versus late-phase trial. Most savings resulted from decreased drug costs. There were no differences in rates of TxEOL (15% vs. 14% p=1.0), rates of hospitalizations (31% vs. 30% p=0.54), or hospice use (52% vs. 62% p=0.08) between trial and non-trial episodes. Median difference from comparator group average cost was significantly lower for clinical trial episodes (-18% vs. -6%, p<0.01). Conclusions: In the community setting, total costs paid by Medicare for patients participating in clinical trials during OCM episodes were lower than costs for similar patients receiving routine care. Clinical trial participation did not adversely impact end-of-life care or likelihood of hospitalization. These findings suggest that patient participation in clinical trials does not increase total cost of care nor enhance financial risk to payers.[Table: see text]

Impact of cancer- and patient-level factors on provider risk in the Oncology Care Model

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Background: Transferring financial risk from payers to providers to align incentives is central to value-based payment (VBP) reform, including Medicare’s Oncology Care Model (OCM). We simulated the impact of selected cancer- and patient-level factors on providers’ risk in OCM for multiple myeloma (MM), due to its clinical complexity. We hypothesize that risk exposure is sensitive to factors extrinsic to the OCM methodology, including clinical phenotype, disease state and progression rate. Methods: Simulation was used to address omitted variable bias in payer data. We developed 9 key clinical MM scenarios to examine provider risk, based on conceptual frameworks that included patient- and cancer-level factors. The model was parameterized using the Medicare limited data set, research literature and domain knowledge. Twenty factors were varied for each model, e.g. age, autologous stem cell transplant (ASCT). Results: Simulations results showed MM risk for providers depended highly on cancer and patient level factors (see table). For example, high-risk patients were on average $21.5K over target while undergoing ASCT (despite risk adjustment for ASCT) and $18-28K under target for follow on maintenance (maint.) episodes. Conclusions: Provider exposure to risk in OCM is highly sensitive to factors at the cancer and patient level. The distribution of clinical phenotypes, state of disease, and rate of disease progression can significantly impact risk exposure for providers in OCM. New methodologies that model risk in more clinically granular ways are needed to improve VBP in oncology. [Table: see text]

New drug approvals and their effect on performance for participants in the Oncology Care Model

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Background: The Oncology Care Model (OCM) is an oncology-specific value-based care model that holds participating practices accountable for all costs of care. Medicare implements quantitative adjustments to model target costs in OCM, including a trend factor to reflect aggregate cost growth and a novel therapy adjustment for new indications. However, it is unclear how well these adjustments account for the emergence of new therapies that are evidence based and influence standard of care for an individual cancer type. We sought to investigate this by studying the impact that FDA approval for brentuximab vedotin (BV) in the first line setting in March 2018 had on OCM practice performance in Hodgkin’s Lymphoma (HL). Methods: We identified all HL OCM episodes attributed to Tennessee Oncology (TO), a large community oncology network of over 90 oncologists, during performance periods (PP) 3 through 6. HL episodes within the lymphoma bundle were identified through the use of individual ICD-10 coded diagnoses on claims for antineoplastic infusions and E&M visits. Using OCM performance data, our electronic health record, and claims data analytics software, we calculated average episode target costs, drug spending by drug type, and hospitalization costs to determine key determinants of OCM performance. Results: During the study period, there were 577 episodes of lymphoma attributed to TO, of which 28 were for patients with HL. TO’s OCM performance in HL was significantly under target in PP4 (under target by $13.5K) and significantly over target in PP5 (over target by $32.1K) after the updated BV FDA approval. Average episode spending on BV increased by over $45K during this timeframe, while OCM target cost increased only by approximately $19K. Despite the change in OCM performance, hospitalization costs and hospice utilization remained relatively stable. Conclusions: In the OCM, despite quantitative payment factors that in principle are intended to adjust target prices to reflect changing cost dynamics, significant gaps exist. These gaps can inappropriately shift risk to providers for the appropriate use of new indications, including those that change standard of care. The example of brentuximab vedotin in HL illustrates the difficulty in reaching performance benchmarks due to dynamics associated with the rising cost of drugs. Further methodological changes are needed in future oncology value-based care models to ensure accurate prediction of rapidly changing treatment costs for appropriate therapies. Hodgkin’s lymphoma OCM payment period cost and utilization comparison data.[Table: see text]

Modeling Medicare’s Oncology Care Model bundles at more clinically granular levels: Evaluating the impact on provider performance

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Background: Aggregating different subtypes of cancers into bundles is an important methodology in oncology payment reform as an alternative to fee for service. However, expected resource utilization can vary significantly across cancer subtypes. We evaluated the impact that modeling Chronic Leukemia into a more clinically granular two part framework of chronic myelogenous leukemia (CML) and chronic lymphocytic leukemia would have on OCM results and the risk that the distribution of clinical subtypes at a practice would influence overall performance in the bundle. Methods: OCM episodes of chronic leukemia initiating between July 2016 and June 2019 were subdivided on the basis of individual ICD-10 coded diagnoses on cancer-related E&M visits. From a total of 4,658 episodes, we randomly sampled with replacement 3,500 episodes from 16 practices using empirical data distributions. Data models and mappings were developed based on clinical knowledge and exploratory data analyses to subdivide the OCM bundle of Chronic Leukemias into CLL and CML. Total cost of care and episode target prices were calculated through implementation of the OCM methodology. The distributional consistencies of episode target, cost, cost above target, and percent above target for the two diseases were evaluated by two-sample Kolmogorov-Smirnov (KS) tests. Results: The CML and CLL subtypes modeled from the aggregate OCM bundle demonstrated significantly different cost distributions relative to each other. As anticipated, treatments used in each subtype varied significantly marking different patterns of expected resource utilization. In our model, CLL episodes were on average 13.7% over target. Average CLL episode costs were $52.2K vs. an average target of $47.6K with 54% of episodes running over target. In contrast, CML episodes were 6.1% under target. Average CML episode costs were $45.2K vs. an average target of $50.3K with 43% of episodes running over target. Conclusions: Value based payment models in oncology such as OCM can be improved by modeling cancer bundles in more clinically granular ways that better reflect expected resource utilization for appropriate, standard of care. Insufficient clinical granularity in bundle construction can lead to provider performance being influenced by the distribution of patient subtypes at the practice. This can lead to inappropriate shifts of risk from payers to providers in value based models. Aggregate vs. subtype episode costs (mean, 5th, and 95th percentiles).[Table: see text]

Evaluating differential cost growth across individual cancers: Insights from Oncology Care Model data

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Background: Analyzing cost growth in oncology often faces significant challenges, including fragmentation of data for infused vs. oral agents and ascertaining the cost of inpatient care. How differential cost growth at the individual cancer level contributes to aggregate cost growth in oncology is often opaque. We leverage the integrated claims data provided by Medicare for its Oncology Care Model (OCM) pilot to analyze variations across individual cancers with respect to cost growth. Methods: OCM’s innovative methodology creates a natural experiment where costs are compared against a counterfactual comprised of Medicare patients seen in non-OCM practices. Leveraging this differential counterfactual provides an opportunity to gain insight into cost growth for individual cancers compared to oncology as a whole. Specifically, cost growth is measured each Performance Period (PP) with respect to the Baseline Period, from 2012 to 2015. We analytically decomposed and remodeled key quantitative factors in OCM associated with cost dynamics in oncology, including the Trend Factor (TF), which represents non-OCM cost growth. From 124,896 episodes, we sampled with replacement 19,191 episodes from 17 practices between PP1 and PP6 using empirical data distributions. We assumed neutral novel therapy and experience adjustments and then compared the overall TF to the remodeled cancer-level TF, reaggregated from the individual episodes. Results: Reallocating the TF reveals that cost growth among cancer types is highly variable in the broader Medicare population. Cost growth at the individual cancer level varied from +99.3% to -14.3%. Of the 21 OCM cancers, 18 have TFs greater than zero, indicating cost growth in the non-OCM Medicare population since the Baseline Period. Four have a TF greater than 50%. Three cancer types show decreasing costs relative to the baseline period: intestinal cancer, MDS, and CNS tumor. Conclusions: Significant variation exists across individual cancer subtypes in terms of cost growth. Aggregate analyses of cancer at large have insufficient specificity to rationalize payment mechanisms. Payment reform efforts within cancer care should directly address dynamics at the individual cancer or cancer subtype level in order to provide more valid considerations for expected resource utilization, including in future payment policies. [Table: see text]

The use of quasi-experimental design methods to evaluate and improve the impact of acute care centers on oncologic emergencies

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Background: Reducing avoidable hospital and emergency department (ED) use are national priorities in cancer care. Acute care centers (ACCs) that expand access for patients with oncologic emergencies are increasingly implemented as alternatives to inpatient and ED care. The impact of these ACCs is uncertain. Additionally, how to rigorously evaluate these interventions and to iteratively improve their effectiveness remains unclear as infrastructure interventions such as ACCs are not amenable to experimental manipulation. Methods: We are developing a novel quasi-experimental framework for evaluating and improving the effectiveness of an ACC intervention at the Simmons Comprehensive Cancer Center (SCCC) of the University of Texas Southwestern. SCCC covers one of the largest geographic regions of any academic medical center in the country, creating challenges addressing access to care. Drawing on the Andersen model for healthcare utilization we hypothesize that ACC effectiveness is mediated through enabling factors, particularly distance. Our initial evaluation framework draws on an untreated control group design with multiple pretest and post-test samples. The control group is comprised of patients living in zip codes farther away from the ACC. Additional analytic work will assess the feasibility of adding a matching cohort group structure based on factors such as onset of illness and matching individual patient episodes based on risk adjustment parameters. If the ACC is later expanded to other sites, the design can be further developed by adding a switching replications methodology to augment the quasi-experiment. Data collection draws on claims data provided through SCCC’s participation in Medicare’s Oncology Care Model (OCM). Results: Over OCM’s initial four performance periods (each six months long), all-cause risk adjusted hospitalization rates for SCCC patients ranged from 25.2% to 27.2%. All-cause risk adjusted OCM ED use ranged from 28.1 to 29.9%. Seeking to improve performance for both, SCCC leadership initially implemented a temporary urgent care clinic in August 2018. This initial prototype clinic was formalized into an operational ACC in August 2020. Evaluation of the impact of this ACC intervention is ongoing. Conclusions: ACCs represent potentially important means to reduce avoidable hospital and ED use. However, complex infrastructure interventions are not amenable to experimental evaluations assessing their impact, and it remains difficult to gain insights into how to tailor services through these interventions to support patients with oncologic urgencies and emergencies. Quasi-experimental approaches when integrated alongside ACC interventions represent promising mechanisms of evaluation and continuous quality improvement.

Practice transformation at scale through a microsystems quality improvement (QI) approach

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Background: How oncology providers should implement practice transformation for value-based care is unclear, particularly at scale. Organizational size enables efficient “top down” approaches, but also presents challenges such as physician engagement. Dis-economies of scale can be acute in oncology due to physician autonomy and coordination costs. We hypothesized that organizational change based in sense-making models that enhance physician engagement and use a decentralized, iterative microsystems approach will enable practice transformation to scale. Methods: Florida Cancer Specialists & Research Institute (FCS) is a physician led 250-oncologist statewide practice, with regional variation in disease state/mix, patient cohort, etc., making a purely top-down approach to organizational change infeasible. FCS prototyped a transformation strategy starting in June 2017 based on sharing interpreted data with physician and executive leadership. Later implementation directly engaged physicians in a microsystems quality QI strategy focused on regional performance. Interventions targeted disease, health service utilization, location, and individual physicians. Performance was evaluated using data from Medicare’s Oncology Care Model (OCM) and assessed using the one-sided risk target (4% below benchmark). We analyzed 70,239 performance period (PP) episodes at FCS across 35,116 patients. Results: In the pre- intervention period (90% of PP1 episodes, completed by June 2017), FCS was 5.8% above target. Performance was 10.9% above target for the remainder of PP1 (10% of PP1 episodes), then improved to 0.3% above target in PP2 and PP3, and below target by 0.9%, 0.8%, and 0.75% in PP4, PP5, and PP6. Early QI efforts focused on performance in lung cancer, which was 2.5% over target in PP1; it improved to 2.1% under target in PP6. Later regional QI sessions targeted cancer, utilization and providers. Pre-intervention, all 18 regions were above target; by PP6, 11 out of 19 regions were below target. Relative to the pre-intervention period, per-episode inpatient costs increased by 12.1% for the remainder of PP1 and increased by 4.3% and 1.3% in PP2 and PP6; inpatient costs decreased in PP3, PP4, and PP5 by 3.8%, 2.4% and 4.8%. Conclusions: Practice transformation in oncology can achieve scale through models of organizational change that foster physician engagement. Data, when clinically contextualized, is a foundational tool in the sense-making process. Scale can develop through an additive microsystems approach in which QI units are de-centralized, accountability is defined, and iteration becomes part of organizational culture. [Table: see text]

Bundling cancer subtypes in value-based care: A pilot analysis of lymphoma episodes in the Oncology Care Model

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Background: Value based models (VBMs) in which cancers are bundled are a growing alternative to fee for service, as in the Oncology Care Model (OCM). However, bundles in OCM may not capture the clinical granularity needed to predict resource utilization for cancer subtypes. One such bundle is lymphoma, which groups highly heterogeneous diseases with distinct treatments and differing intensity of care. Here, we compare OCM predicted episode costs (targets) to actual episode costs by lymphoma subtype. Methods: Our cohort study used OCM data from a large academic medical center (AMC) and large community oncology practice (COP). Six-month episodes of lymphoma beginning between July 2016 and June 2019 were categorized based on ICD-10 diagnoses on antineoplastic infusions and E&M visits, as well as disease and data modeling. Episodes were subdivided into follicular (FL), diffuse large B (DLBCL), small B (SBCL), mantle (MCL), Hodgkin (HL), Waldenstrom macroglobulinemia (WM), mature T/NK (T/NK), and Other. The distributional consistency of episode costs and targets for each subtype relative to the rest of the episodes was evaluated by Kolmogorov-Smirnov tests. We also compared the proportion of subtypes contributing to episodes in the AMC vs. COP. Results: A total of 1801 lymphoma episodes were identified (44% in AMC, 56% in COP). The most common subtypes (DLBCL and FL) contributed a larger proportion of episodes in the COP, while less frequent subtypes (T/NK, WM) were more prevalent at the AMC. Further, episode costs are significantly different across individual subtypes. Target variance was significantly lower than cost variance across subtypes. For example, the average target for WM was $50.4K, average costs were $40.2K, with 26% of episodes over target. In contrast, the average target for T/NK was $55.9K, average costs were $72.7K, with 64% of episodes over target. Conclusions: VBMs such as OCM currently aggregate cancer types and lack clinical granularity. Our evaluation of OCM episodes at an AMC and COP found considerable differences in lymphoma populations and in costs by subtype. Failure to account for clinical features (i.e. lymphoma history) could lead to inappropriate shifts of risk from payers to providers in VBMs.[Table: see text]

664Local catheter impedance drop during pulmonary vein isolation predicts conduction block in patients with paroxysmal atrial fibrillation: initial results of the LOCALIZE clinical trial

Funding Acknowledgements

Boston Scientific

Background

Radiofrequency (RF) catheter ablation for pulmonary vein isolation (PVI) requires resistively heating cardiac tissue to create conduction block. Creation of an RF lesion results in an impedance drop and the magnitude of this drop depends on the temperature and amount of myocardium being heated. Pre-clinical and clinical evaluation of an advanced local impedance (LI) metric found that greater LI drops were indicative of more effective lesion formation.

Purpose

To evaluate whether LI drop is associated with conduction block after first pass encirclement of the PVs in patients with paroxysmal AF.

Methods

LOCALIZE is an ongoing, single-arm, multi-center clinical trial (clinicaltrials.gov NCT03232645). LOCALIZE consists of an index PVI procedure (results presented here) and a 3-month follow-up mapping procedure. In the index procedure, electroanatomical maps of the left atrium were created and ipsilateral PVs were divided into 8 anatomical segments (n = 16 per patient). PVI was performed using point-by-point ablation with blinding of operators to LI. Following initial encirclement and a 20-minute wait period, coronary sinus-paced electroanatomical maps were created to identify gaps within anatomical segments. Gaps were annotated on the map and subsequently ablated. Mean LI drop within each segment was calculated offline as an estimate of regional RF energy delivery (Figure - Left). The diagnostic accuracy of LI drop for predicting segment block was assessed using receiver operating characteristic (ROC) analysis in segments with inter-lesion spacing ≤6mm.

Results

Forty-seven patients with paroxysmal AF underwent PVI at 5 centers (age 62 ± 11 years, male 55.3%). All patients left the index procedure with all PVs isolated. When blinded to LI (n = 3,064 ablations), median baseline LI was 106 (IQR: 97-115) Ω and median LI drop was 18.4 (12.7-24.9) Ω. After first pass encirclement, blocked segments had a significantly larger LI drop (20.2 [14.6-26.0] Ω) than segments with gaps (10.6 [6.9-15.1] Ω, p &lt; 0.01, Figure - Right). The association between LI drop and block was further evaluated along anatomical anterior/posterior wall thickness differences. Anterior block segments were found to have significantly larger LI drops (21.0 [15.9-27.2] Ω) than posterior block segments (16.6 [12.7-23.7] Ω, p &lt; 0.01). ROC analysis of segments with inter-lesion spacing ≤6mm identified optimal LI cut-off values of 16Ω in anterior segments and 11Ω posteriorly, which had positive predictive values for conduction block of 95.6% and 96.7%, respectively.

Conclusions

The magnitude of LI drop is predictive of acute PVI segment conduction block in patients with paroxysmal AF. The thinner posterior wall required smaller LI drops for block compared to the thicker anterior wall. With inter-lesion spacing of ≤6mm, reaching a LI drop of ≥16Ω anteriorly and ≥11Ω posteriorly was highly predictive of acute segment block in de novo PVI.

Abstract Figure. Local impedance drop in de novo PVI

Leukocyte chemotactic factor 2 (LECT2) amyloidosis presenting as pulmonary-renal syndrome: a case report and review of the literature

Leukocyte chemotactic factor-2 (LECT2) amyloidosis has been described as being associated with kidney disease; however, no clinical manifestations outside of the kidney have been previously reported. We describe a patient presenting with pulmonary-renal syndrome found to have deposition of amyloidogenic LECT2 (ALECT2) within both the lung and the kidney. This case is unique in regard to both the patient's clinical presentation of pulmonary-renal syndrome in the setting of amyloidosis and the biopsy finding of ALECT2 deposition within the lung. It also emphasizes the importance of tissue diagnosis in such cases, given that amyloidosis was not initially considered in the differential diagnosis.

Safety and efficacy of multipolar pulmonary vein ablation catheter vs. irrigated radiofrequency ablation for paroxysmal atrial fibrillation: a randomized multicentre trial

Aims

The current challenge in atrial fibrillation (AF) treatment is to develop effective, efficient, and safe ablation strategies. This randomized controlled trial assesses the medium-term efficacy of duty-cycled radiofrequency ablation via the circular pulmonary vein ablation catheter (PVAC) vs. conventional electro-anatomically guided wide-area circumferential ablation (WACA).

Methods and results

One hundred and eighty-eight patients (mean age 62 ± 12 years, 116 M : 72 F) with paroxysmal AF were prospectively randomized to PVAC or WACA strategies and sequentially followed for 12 months. The primary endpoint was freedom from symptomatic or documented >30 s AF off medications for 7 days at 12 months post-procedure. One hundred and eighty-three patients completed 12 m follow-up. Ninety-four patients underwent PVAC PV isolation with 372 of 376 pulmonary veins (PVs) successfully isolated and all PVs isolated in 92 WACA patients. Three WACA and no PVAC patients developed tamponade. Fifty-six percent of WACA and 60% of PVAC patients were free of AF at 12 months post-procedure (P = ns) with a significant attrition rate from 77 to 78%, respectively, at 6 months. The mean procedure (140 ± 43 vs. 167 ± 42 min, P<0.0001), fluoroscopy (35 ± 16 vs. 42 ± 20 min, P<0.05) times were significantly shorter for PVAC than for WACA. Two patients developed strokes within 72 h of the procedure in the PVAC group, one possibly related directly to PVAC ablation in a high-risk patient and none in the WACA group (P = ns). Two of the 47 patients in the PVAC group who underwent repeat ablation had sub-clinical mild PV stenoses of 25–50% and 1 WACA patient developed delayed severe PV stenosis requiring venoplasty.

Conclusion

The pulmonary vein ablation catheter is equivalent in efficacy to WACA with reduced procedural and fluoroscopy times. However, there is a risk of thrombo-embolic and pulmonary stenosis complications which needs to be addressed and prospectively monitored.

ClinicalTrials.gov Identifier

NCT00678340.

Beamline Performance Simulations for the Fundamental Neutron Physics Beamline at the Spallation Neutron Source

Monte Carlo simulations are being performed to design and characterize the neutron optics components for the two fundamental neutron physics beamlines at the Spallation Neutron Source. Optimization of the cold beamline includes characterization of the guides and benders, the neutron transmission through the 0.89 nm monochromator, and the expected performance of the four time-of-flight choppers. The locations and opening angles of the choppers have been studied using a simple spreadsheet-based analysis that was developed for other SNS chopper instruments. The spreadsheet parameters are then optimized using Monte Carlo techniques to obtain the results presented in this paper. Optimization of the 0.89 nm beamline includes characterizing the double crystal monochromator and the downstream guides. The simulations continue to be refined as components are ordered and their exact size and performance specifications are determined.

Comparative efficacy of three 5-HT3 antagonists (granisetron, ondansetron, and tropisetron) plus dexamethasone for the prevention of cisplatin-induced acute emesis: a randomized crossover study

The purpose of this study was to compare the antiemetic efficacy of three 5-HT3 antagonists (granisetron, ondansetron, tropisetron) plus dexamethasone for the prevention of acute emesis induced by high-dose cisplatin chemotherapy. This was a randomized, open label, crossover study. Recruited into the study were 94 chemotherapy-naive patients of whom five were excluded because chemotherapy was not given, noncisplatin regimen was used instead, or presence of anticipatory vomiting. The remaining 89 evaluable patients were mostly (86.5%) male, and were all treated for head and neck cancers. The antiemetic regimens consisted of 1) granisetron 3 mg i.v. and dexamethasone 20 mg i.v. on day 1 (GRADEX); 2) tropisetron 5 mg i.v. and dexamethasone 20 mg i.v. on day 1 (TRODEX); and 3) ondansetron 8 mg i.v. and dexamethasone 20 mg i.v. to be followed by ondansetron 8 mg p.o. x 2 on day 1 (ONDEX). Patients were randomized to receive one of the three regimens in the first cycle, and treatment was crossed over to the other two regimens in subsequent cycles. Antiemetic efficacy was assessed using self-report diaries recording the number of vomiting episodes as well as duration and severity of nausea within the first 24 hours. Complete response was defined as no vomiting with or without mild nausea, and major response was defined as one vomiting episode and/or moderate to severe nausea. Major efficacy refers to either complete or major response. A total of 219 cycles was given to 89 patients: 16 received one cycle only, 16 received two cycles, and 57 received three cycles. No carryover effects were observed between cycles. Using pooled data from all cycles, the complete response rates to GRADEX, TRODEX, and ONDEX were 81%, 68%, and 71%, respectively (p = 0.11); the corresponding major efficacy rates were 91%, 93%, and 86%, respectively (p = 0.36). When only the first cycle was considered, the complete response rates to GRADEX, TRODEX, and ONDEX were 81%, 75%, and 74%, respectively (p = 0.58); the corresponding major efficacy rates were 92%, 94%, and 84%, respectively (p = 0.38). Analysis of the crossover data showed that the majority of patients achieved complete response or major efficacy with the different pairs of regimens, and there were no significant differences between different regimens in terms of complete response or major efficacy. The only exception was GRADEX versus TRODEX, in which 15.5% of patient achieved complete response with GRADEX as compared with 1.7% with TRODEX (p = 0.025). The majority of patients (53%) did not report any preference, whereas 14% preferred GRADEX, 15% preferred TRODEX, and 18% preferred ONDEX. The three 5-HT3 antagonists, when used in combination with steroids, had similar major efficacy for prophylaxis against cisplatin-induced acute emesis. Although GRADEX was superior to TRODEX in terms of complete response, this may not be of clinical significance. The choice of antiemetic regimens should therefore depend on patient preference and drug cost.

Interface: reflections of an ethnic toygirl

This essay interrogates the colonial modernity of Anglo-Australian lesbian hegemony through an experimental text which plays with the aesthetics of cyberspace. Mobilizing the hypertext mark up language (HTML) form of the Internet, it spatializes the creative, the erotic, and the political that landscape the vicissitudes of everyday life for a lesbian of Southeast Asian background living in Australia. "interface" performs as a tryst that drives the queer body politic through the postcolonial in-formations of color, race, gender and identity. This text bears indelible marks from multiple sites and sources: the charges of electronic conversations and etchings on the World Wide Web; the raw pulp of inner-urban graffiti scrawls; passionate voicemails; racist policies in queer venues; fury banner posts; luscious lesbian cinema screenings; sexy fantasy malls; and fleshy style shopping.

BP-1/6C3 expression defines a differentiation stage of transformed pre-B cells and is not related to malignant potential

BP-1 antibody recognizes a cell surface molecule related to the zinc-dependent metallopeptidases that is expressed during a narrow window early in B cell differentiation. Expression of the same molecule, as originally recognized by the mAb 6C3, is widely accepted to be associated with the complete malignant transformation of pre-B lymphoid cells. We have examined BP-1/6C3 expression in a panel of established Abelson virus-transformed cells that includes both cells analogous to pre-B cells and to less differentiated B lineage cells that have not yet completed Ig H chain gene rearrangement. This analysis reveals that many of the less differentiated transformants do not express BP-1/6C3 for an extended culture period. In contrast, virtually all transformants that are analogous to normal pre-B cells express the determinant early in their culture history. The BP-1/6C3 negative transformants are fully tumorigenic in syngeneic mice, demonstrating that BP-1/6C3 expression is not required for complete malignant transformation. Our data thus suggest that the pattern of BP-1/6C3 expression in Abelson virus-transformed cells mimics that observed in normal cells and is indicative of a differentiation event unrelated to the malignant potential of the cells.

Results of treatment for squamous carcinoma of the lower gum

The records of 61 patients with a diagnosis of squamous carcinoma of the lower alveolar ridge were reviewed. The overall two-year survival was 67% with a local or regional failure of 5%. The majority of patients were treated with surgery initially with an excellent local control of 98%, if the patient who died in the postoperative period and the patient lost to follow-up are excluded. Radiation therapy should be used postoperatively for those patients whose cancer exhibits some of the adverse findings such as extensive nodal metastasis, perineural invasion, or inadequate margins of surgical resection.

Giant calcifying epithelioma

Calcifying epithelioma of Malherbe, or benign pilomatrixoma, is described as a skin tumor histologically composed of (1) "shadow" cells, (2) basophilic cells, (3) foreign body cells, and (4) intracellular and stromal calcifications. The dermatologic literature describes this tumor as a small benign lesion that never exhibits a malignant propensity. However, the recent surgical literature associates its enlarged size with its occasional aggressive behavior. In this regard, tumor dimension appears to influence prognosis. The term "giant calcifying epithelioma" appears taxonomically justified as a clinical description of this malignant tumor possessing histologic similarity to benign pilomatrixoma. The surgical literature has not previously stressed the mixed histologic characteristics of this pathologic variant. We report a case that demonstrates the malignant potential of giant calcifying epithelioma. The clinician should be alerted against a false security provided by the benign appearance of preoperative histologic sampling.