Low barrier medication for opioid use disorder at a federally qualified health center: a retrospective cohort study

Background

Medication for opioid use disorder (MOUD) reduces mortality, but few patients access MOUD. At a Federally Qualified Health Center (FQHC), we implemented a low barrier model of MOUD, including same-day MOUD initiation and a harm reduction philosophy.

Objective

To investigate whether low barrier MOUD improved retention in care compared to traditional treatment.

Design and participants

Retrospective cohort study of patients with at least one visit seeking MOUD at the FQHC during a historical control period (3/1/2018—3/31/2019) and a low barrier intervention period (11/1/2019—7/31/2020).

Main measures

Primary outcomes were any MOUD prescription within 6 months of the index visit and 3- and 6-month retention in treatment without care gap, with care gap defined as 60 consecutive days without a visit or prescription. Secondary outcomes were all-cause hospitalization and emergency department visit within 6 months of the index visit.

Key results

Baseline characteristics were similar between the intervention (n = 113) and control (n = 90) groups, except the intervention group had higher rates of uninsured, public insurance and diabetes. Any MOUD prescription within 6 months of index visit was higher in the intervention group (97.3% vs 70%), with higher adjusted odds of MOUD prescription (OR = 4.01, 95% CI 2.08–7.71). Retention in care was similar between groups at 3 months (61.9% vs 60%, aOR = 1.06, 95% CI 0.78–1.44). At 6 months, a higher proportion of the intervention group was retained in care, but the difference was not statistically significant (53.1% vs 45.6%, aOR 1.27, 95% CI 0.93–1.73). There was no significant difference in adjusted odds of 6-month hospitalization or ED visit between groups.

Conclusions

Low barrier MOUD engaged a higher risk population and did not result in any statistically significant difference in retention in care compared with a historical control. Future research should determine what interventions improve retention of patients engaged through low barrier care. Primary care clinics can implement low barrier treatment to make MOUD accessible to a broader population.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13722-022-00342-1.

Quantum optimization of maximum independent set using Rydberg atom arrays

Realizing quantum speedup for practically relevant, computationally hard problems is a central challenge in quantum information science. Using Rydberg atom arrays with up to 289 qubits in two spatial dimensions, we experimentally investigate quantum algorithms for solving the Maximum Independent Set problem. We use a hardware-efficient encoding associated with Rydberg blockade, realize closed-loop optimization to test several variational algorithms, and subsequently apply them to systematically explore a class of graphs with programmable connectivity. We find the problem hardness is controlled by the solution degeneracy and number of local minima, and experimentally benchmark the quantum algorithm's performance against classical simulated annealing. On the hardest graphs, we observe a superlinear quantum speedup in finding exact solutions in the deep circuit regime and analyze its origins.

Risk factors for dementia onset in older adults with metastatic renal cell carcinoma

Renal dysfunction is a driver of dementia. It is also associated with renal cell carcinoma, possibly the result of the tumor itself or from cancer treatment. This study evaluates metastatic renal cell carcinoma (mRCC) as a risk factor for developing mild cognitive impairment or dementia (MCI/D) as well as the impact of RCC-directed therapies on the development of MCI/D. We identified all patients diagnosed with mRCC in SEER-Medicare from 2007-2015. The main outcome was incident MCI/D within one year of mRCC diagnosis or cohort entry. Exclusion criteria included age <65 at mRCC diagnosis and diagnosis of MCI/D within preceding year of mRCC diagnosis. Patients with mRCC (n=2,533) were matched to non-cancer controls (n=7,027) on age, sex, race, comorbidities and year. Cox proportional hazards regression showed that having mRCC (HR 8.52, 95% MCI/D 6.49-11.18, p<0.001) and being older (HR 1.05 for 1-year age increase, 95% MCI/D 1.03-1.07, p<0.001) were predictive of developing MCI/D. A second Cox proportional hazards regression of only patients with mRCC revealed that neither those initiating treatment with oral anticancer agents (OAAs) nor those who underwent nephrectomy were more likely to develop MCI/D. Black patients had a higher risk of dementia compared to white patients (HR 1.92, 95% MCI/D 1.02-3.59, p=0.047). In conclusion, patients with mRCC were more likely to develop MCI/D than those without mRCC. The medical and surgical therapies evaluated were not associated with increased incidence of MCI/D. The increased incidence of MCI/D in older adults with mRCC may be the result of the pathology itself.

Probing topological spin liquids on a programmable quantum simulator

[Figure: see text].

Analyzing Nonequilibrium Quantum States through Snapshots with Artificial Neural Networks

Current quantum simulation experiments are starting to explore nonequilibrium many-body dynamics in previously inaccessible regimes in terms of system sizes and timescales. Therefore, the question emerges as to which observables are best suited to study the dynamics in such quantum many-body systems. Using machine learning techniques, we investigate the dynamics and, in particular, the thermalization behavior of an interacting quantum system that undergoes a nonequilibrium phase transition from an ergodic to a many-body localized phase. We employ supervised and unsupervised training methods to distinguish nonequilibrium from equilibrium data, using the network performance as a probe for the thermalization behavior of the system. We test our methods with experimental snapshots of ultracold atoms taken with a quantum gas microscope. Our results provide a path to analyze highly entangled large-scale quantum states for system sizes where numerical calculations of conventional observables become challenging.

Controlling quantum many-body dynamics in driven Rydberg atom arrays

The control of nonequilibrium quantum dynamics in many-body systems is challenging because interactions typically lead to thermalization and a chaotic spreading throughout Hilbert space. We investigate nonequilibrium dynamics after rapid quenches in a many-body system composed of 3 to 200 strongly interacting qubits in one and two spatial dimensions. Using a programmable quantum simulator based on Rydberg atom arrays, we show that coherent revivals associated with so-called quantum many-body scars can be stabilized by periodic driving, which generates a robust subharmonic response akin to discrete time-crystalline order. We map Hilbert space dynamics, geometry dependence, phase diagrams, and system-size dependence of this emergent phenomenon, demonstrating new ways to steer complex dynamics in many-body systems and enabling potential applications in quantum information science.

Generation and manipulation of Schrödinger cat states in Rydberg atom arrays

Quantum entanglement involving coherent superpositions of macroscopically distinct states is among the most striking features of quantum theory, but its realization is challenging because such states are extremely fragile. Using a programmable quantum simulator based on neutral atom arrays with interactions mediated by Rydberg states, we demonstrate the creation of "Schrödinger cat" states of the Greenberger-Horne-Zeilinger (GHZ) type with up to 20 qubits. Our approach is based on engineering the energy spectrum and using optimal control of the many-body system. We further demonstrate entanglement manipulation by using GHZ states to distribute entanglement to distant sites in the array, establishing important ingredients for quantum information processing and quantum metrology.

Risk Factors and Outcomes of Opioid Users with and Without Concurrent Benzodiazepine Use in the North Carolina Medicaid Population

BACKGROUND

Concurrent use of opioids and benzodiazepines is associated with increased risk of opioid overdose and death. Clinical guidelines recommend against this practice and quality measures incentivize plans to minimize concurrent use.

OBJECTIVE

To compare comorbidities, risky opioid-related behaviors such as high daily doses or multiple prescribers or pharmacies, and outcomes of users of opioids with and without benzodiazepine in the 2017-2018 North Carolina Medicaid population.

METHODS

This was a retrospective claims analysis that used 2017-2018 North Carolina Medicaid enrollment and administrative claims data to describe 3 populations: (1) opioid users who concurrently used benzodiazepine for at least 30 days, (2) opioid users who used some benzodiazepine for 0 to less than 30 overlapping days, and (3) opioid users who did not use benzodiazepines.

RESULTS

From 2017 to 2018, 6% of opioid users concurrently used opioids and benzodiazepines for at least 30 days, and 14% used some benzodiazepine for less than 30 overlapping days. Persons filling prescriptions for opioids and benzodiazepines were more likely to have mood disorders and more likely to have depression than opioid users who did not use benzodiazepines. Compared with those not using benzodiazepines, opioid users using benzodiazepine were also more likely to have higher daily opioid doses (at least 90 morphine milligram equivalents), at least 3 prescribers, and at least 3 pharmacies for opioid prescriptions. Although enrollees with at least 30 days of overlapping benzodiazepines and opioids had a higher percentage diagnosed with opioid use disorder compared with those with less than 30 days (30% vs. 13%), a similar percentage received medication-assisted treatment continuously for 90 days (2.6% vs. 2.7%) during 2017-2018. Users of opioids and benzodiazepines, whether for at least 30 overlapping days or less, had higher 1-year cumulative incidences of all-cause outpatient emergency department visits (64% and 65% vs. 52%) and all-cause hospitalizations (25% and 21% vs. 14%) compared with opioid users without benzodiazepine use.

CONCLUSIONS

Despite guidelines and quality measures, patients continue to use opioids and benzodiazepines concurrently. Addressing underlying mood disorders and depression, curbing risky opioid-related behaviors, and increasing access to medication-assisted treatment may benefit this population.

DISCLOSURES

This project was supported by Arnold Ventures (formerly Arnold Foundation). Hung reports personal fees from CVS Health and Blue Cross Blue Shield Association, unrelated to this work. Maciejewski reports Amgen stock ownership due to spouse employment, unrelated to this work. McKethan reports personal fees from North Carolina Department of Health and Human Services. All other authors have nothing to disclose. Part of this content was presented as a poster at AMCP Nexus 2019; October 29-November 1, 2019; National Harbor, MD.

Terebratulide brachiopod shell biomineralization by mantle epithelial cells

To understand mineral transport pathways for shell secretion and to assess differences in cellular activity during mineralization, we imaged with TEM and FE-SEM ultrastructural characteristics of outer mantle epithelium (OME) cells. Imaging was carried out on Magellania venosa shells embedded/etched, chemically fixed/decalcified and high-pressure frozen/freeze-substituted samples from the commissure, central shell portions and from puncta. Imaging results are complemented with morphometric evaluations of volume fractions of membrane-bound organelles. At the commissure the OME consists of several layers of cells. These cells form oblique extensions that, in cross-section, are round below the primary layer and flat underneath fibres. At the commissure the OME is multi-cell layered, in central shell regions it is single-cell layered. When actively secreting shell carbonate extrapallial space is lacking, because OME cells are in direct contact with the calcite of the forming fibres. Upon termination of secretion, OME cells attach via apical hemidesmosomes to extracellular matrix membranes that line the proximal surface of fibres. At the commissure volume fractions for vesicles, mitochondria and lysosomes are higher relative to single-cell layered regions, whereas for endoplasmic-reticulum and Golgi apparatus there is no difference. FE-SEM, TEM imaging reveals the lack of extrapallial space between OME cells and developing fibres. In addition, there is no indication for an amorphous precursor within fibres when these are in active secretion mode. Accordingly, our results do not support transport of minerals by vesicles from cells to sites of mineralization, rather by transfer of carbonate ions via transport mechanisms associated with OME cell membranes.

Implementation of a stable, high-power optical lattice for quantum gas microscopy

We describe the design and implementation of a stable high-power 1064 nm laser system to generate optical lattices for experiments with ultracold quantum gases. The system is based on a low-noise laser amplified by an array of four heavily modified, high-power fiber amplifiers. The beam intensity is stabilized and controlled with a nonlinear feedback loop. Using real-time monitoring of the resulting optical lattice, we find the stability of the lattice site positions to be well below the lattice spacing over the course of hours. The position of the harmonic trap produced by the Gaussian envelope of the lattice beams is stable to about one lattice spacing and the long-term (six-month) relative root-mean-square stability of the lattice spacing itself is 0.5%.

Abstract P4-09-08: Shared-patient physician networks and their impact on the uptake of genomic testing in early-stage breast cancer

Background: Oncotype DX (ODX) or 21-gene recurrence score genomic testing is used to stratify risk and determine appropriate treatment in women with early-stage breast cancer (BC). Diffusion of ODX by way of physician networks has not been studied.

Objective: To determine the association between physician network connections, defined by shared patients, and the use of ODX testing.

Methods: SEER-Medicare claims from 2008-2012 were used to identify a cohort of woman with a diagnosis of BC from registry/ICD codes, continuously enrolled in Medicare fee-for-service Part A and B one year prior to and one year following diagnosis. We identify receipt of ODX from the associated CPT code, claim reimbursement, and performing NPI. To look at the influence of network connections on ODX use, we split the study into two time periods: early adoption from 2008-2009, and late from 2010-2012. Medical oncologists with a BC-related claim in the cohort above, and any rendered BC-related service are considered 'connected' if they shared two or more BC patients. Analyses describe these connections and explore the association between connectedness to an early adopting medical oncologist and ODX use in parallel physician and patient-level analyses using generalized linear mixed models with a hospital referral region-specific random effect. Models control for physician and patient-level characteristics where applicable.

Results:24,463 women met study criteria; 12,874 were diagnosed with BC in the early adoption time period (1,790 received ODX) and 11,589 were diagnosed in the late period (2,334 received ODX). 2,073 medical oncologists treated these patients from 2008-2009. The mean number of BC patients treated per medical oncologist was 86.8 during the early adoption period, and medical oncologists had a median number of peer connections of 11 (IQR: 7-18). Early adopting medical oncologists had higher numbers of peer connections and higher average patient counts than non-early adopters. A higher percentage of female medical oncologists were early adopters (39%) then male medical oncologists (33%) (p&lt;0.02). Among non-early adopting oncologists, peer connection to at least two early adopting providers in 2008-2009 is associated with a 3.2 (95% CI: 2.0-4.9) times increase in the odds of ordering ODX in 2010-2012 after adjustment for physician gender and time in practice. In patient-level models with controls for physician and patient characteristics, seeing a medical oncologist with connections to at least two early adopting physicians is associated with a 1.6 times (95% CI: 1.1-2.2) increase in the odds of receiving ODX testing in 2010-2012.

Conclusions: We observe a positive adjusted association between connectedness to an early-adopting physician and ODX prescribing/use in both physician-level and patient-level analyses. These results suggest that provider networks may help diffuse new technologies, and that BC genomic testing is likely to be an area of shared practices between providers. Efforts to increase testing, where appropriate, may benefit from a range of peer-to-peer connection strategies.

Citation Format: Rotter J, Wilson L, Greiner M, Pollack C, Dinan M. Shared-patient physician networks and their impact on the uptake of genomic testing in early-stage breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-09-08.

Nationwide utilization and costs of targeted anti-cancer drugs for elderly patients with solid tumors in the United States, 2004-2015

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Background: Studies of patients age < 65 suggest large increases in utilization and costs of targeted anti-cancer drugs (TADs). However, use and costs of TADs in patients age 65+ have not been examined in a national sample. Methods: We conducted a retrospective analysis of patients ≥ 65 years with invasive lung (LC), breast (BC), or colorectal (CC) cancer using Medicare 5% claims from 2004-2015. We identified the yearly proportion of cancer patients receiving an intravenous TAD and the proportion of Part D enrolled Medicare patients receiving an oral TAD. We examined yearly costs of TADs as a proportion of total Medicare cancer and all-cause spending. Using generalized linear models, we estimated yearly trends in mean cost per beneficiary for TADs, all cancer spending, and total Medicare cost with adjustment for age, sex, region and comorbidities. Costs were adjusted to 2015 dollars using the CPI medical cost index. Results: We observed higher uptake of IV TADs in the 65+ patient population for each of the three cancers compared to oral TADs. IV TAD utilization reached 9.8% in CC patients, 5.0% in lung cancer patients, and 3.7% of BC patients. Use of oral TADs remained lower than use of IV TADs (≤ 1% of patients across all three cancers). From 2005-2015, total and cancer-specific Medicare spending per beneficiary decreased slightly for CC and LC patients and remained stable for BC patients. However, adjusted mean IV TAD spending per beneficiary increased from $139 in 2005 to $897 in 2015 for LC, from $96 to $550 for BC, and from $384 to $455 for CC. For Part D patients, the combined contribution of IV and oral TADs to total yearly cancer spending increased significantly from 2006 to 2015 for LC (2 to 5%), BC (4 to 18%), and CC (6 to 12%) cancers. Conclusions: Use of IV TADs in the US elderly lung, breast, and colorectal cancer populations grew rapidly in the years following FDA approval and stabilized. Use of oral TADs remained low compared to IV agents. Against the backdrop of largely stable Medicare spending, TADs are increasingly responsible for a growing proportion of that spending, particularly in breast cancer patients where TADs accounted for nearly a fifth of all 2015 cancer spending for Part D patients.

Relation of Early Repolarization (J Point Elevation) to Mortality in Blacks (from the Jackson Heart Study)

Conflicting data exist regarding the associations of early repolarization (ER) with electrocardiogram (ECG) and clinical outcomes in blacks. We examined the association of ER defined by J point elevation (JPE) and all-cause mortality, and heart failure (HF) hospitalization in blacks in the Jackson Heart Study (JHS) cohort. We included JHS participants with ECGs from the baseline visit coding JPE and excluded participants with paced rhythms or QRS duration ≥120 ms. We compared the cumulative incidence of 10-year all-cause mortality and 8-year HF hospitalization by presence of JPE ≥0.1 mV in any ECG lead at baseline using Kaplan-Meier estimates and multivariable Cox models. Of the 4,978 participants, 1,410 (28%) had JPE at baseline: anterior leads 97.8%, lateral leads 8.3%, and inferior leads 2.9%. Compared with participants without JPE, those with JPE were younger, more likely to be male and current smokers, and less likely to have hypertension. Over a median follow-up of 8 years, there were no significant differences in the cumulative incidence or multivariable-adjusted hazards of all-cause mortality or HF hospitalization in participants with and without JPE in any lead (adjusted hazard ratio 0.97, 95% confidence interval 0.89 to 1.52, and adjusted hazard ratio 1.18, 95% confidence interval 0.9 to 1.54, respectively). Of the 2,523 participants who completed Exam 3 without JPE at baseline, 246 (10%) developed JPE over follow-up. In conclusion, JPE on ECG was not associated with long-term mortality or HF hospitalization in a large prospective black community cohort, suggesting that ER may represent a benign ECG finding in blacks.

Abstract P6-09-10: Provider characteristics and receipt of oncotype Dx testing in women diagnosed with early stage breast cancer using SEER-Medicare data

Background: Oncotype DX (ODX) genomic testing to evaluate recurrence risk and benefit of adjuvant chemotherapy in patients with ER-positive, node-negative breast cancers was approved for Medicare reimbursement in 2006. We previously examined patient-level factors associated with utilization of ODX testing from 2005-2009 in the SEER-Medicare population; ODX testing occurred most frequently in patients with ER+, node negative disease, with 80% of all tests occurring in patients aged 66-75. In our current study, we examined potential provider factors associated with patient-level ODX testing from 2008 to 2012.

Methods: Using a retrospective cohort design, we identified all individuals who had a SEER diagnosis of breast cancer from 2008-2011 and were enrolled in fee-for-service Medicare parts A and B for one year before and one year after diagnosis. We limited our analysis to individuals who had surgical resection of their breast tumor within 4 months of diagnosis and had a breast tumor which was ER+, invasive, and non-metastatic to capture the eligible patient population. Using Medicare claims data linked with the AMA physician dataset (which includes AMA members and non-members), we identified physician characteristics of the primary breast surgeon and medical oncologist including specialty, gender, years in practice, case volume, utilization of chemotherapy, and whether they serve rural populations. For patients with an ODX test, we used the identification on the claim to link to the performing provider. We examined the associations between provider characteristics and patient receipt of ODX testing using unadjusted and adjusted logistic regression models. Adjusted models included patient demographic and clinical characteristics.

Results: We identified 24,463 eligible breast cancer patients who received their care from 3172 primary surgeons and 2475 medical oncologists. Of 4124 ODX tests ordered for patients in the study, 70% were ordered by the assigned medical oncologist and 16% were ordered by the breast surgeon. In multivariable regression models, multiple physician characteristics were associated with receipt of ODX testing including having an assigned medical oncologist (OR 2.77, 95% CI 2.00-3.82), having a surgeon with a specialty of surgical oncology (OR 1.20, 95% CI 1.09-1.31), having a female medical oncologist (OR 1.10 95% CI 1.02-1.20). Having a medical oncologist with ≥5 years in practice was associated with lower odds of testing (OR 0.83 95% CI 0.76-0.92). Breast surgery performed at an academic hospital was associated with higher odds of ODX testing (OR 1.11 95% CI 1.02-1.20).

Conclusion: The majority of ODX testing for indicated breast cancer patients is ordered by medical oncologists, though surgeons and physicians of other specialties also order the tests in practice. Physician characteristics including gender and time in practice appear to affect a patient's likelihood of receiving ODX testing, creating opportunities for targeting interventions to help women with breast cancer receive optimal care.

Citation Format: Dinan MA, Wilson LE, Greiner M, Pollack CE. Provider characteristics and receipt of oncotype Dx testing in women diagnosed with early stage breast cancer using SEER-Medicare data [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-09-10.

Overtreatment and Deintensification of Diabetic Therapy among Medicare Beneficiaries

BACKGROUND

Deintensification of diabetic therapy is often clinically appropriate for older adults, because the benefit of aggressive diabetes treatment declines with age, while the risks increase.

OBJECTIVE

We examined rates of overtreatment and deintensification of therapy for older adults with diabetes, and whether these rates differed by medical, demographic, and socioeconomic characteristics.

DESIGN, SUBJECTS, AND MAIN MEASURES

We analyzed Medicare claims data from 10 states, linked to outpatient laboratory values to identify patients potentially overtreated for diabetes (HbA1c < 6.5% with fills for any diabetes medications beyond metformin, 1/1/2011-6/30/2011). We examined characteristics associated with deintensification for potentially overtreated diabetic patients. We used multinomial logistic regression to examine whether patient characteristics associated with overtreatment of diabetes differed from those associated with undertreatment (i.e. HbA1c > 9.0%).

KEY RESULTS

Of 78,792 Medicare recipients with diabetes, 8560 (10.9%) were potentially overtreated. Overtreatment of diabetes was more common among those who were over 75 years of age and enrolled in Medicaid (p < 0.001), and was less common among Hispanics (p = 0.009). Therapy was deintensified for 14% of overtreated diabetics. Appropriate deintensification of diabetic therapy was more common for patients with six or more chronic conditions, more outpatient visits, or living in urban areas; deintensification was less common for those over age 75. Only 6.9% of Medicare recipients with diabetes were potentially undertreated. Variables associated with overtreatment of diabetes differed from those associated with undertreatment.

CONCLUSIONS

Medicare recipients are more frequently overtreated than undertreated for diabetes. Medicare recipients who are overtreated for diabetes rarely have their regimens deintensified.

Outcomes Associated With Extraction Versus Capping and Abandoning Pacing and Defibrillator Leads

Background:

Lead management is an increasingly important aspect of care in patients with cardiac implantable electronic devices; however, relatively little is known about long-term outcomes after capping and abandoning leads.

Methods:

Using the 5% Medicare sample, we identified patients with de novo cardiac implantable electronic device implantations between January 1, 2000, and December 31, 2013, and with a subsequent lead addition or extraction ≥12 months after the de novo implantation. Patients who underwent extraction for infection were excluded. Using multivariable Cox proportional hazards models, we compared cumulative incidence of all-cause mortality, device-related infection, device revision, and lead extraction at 1 and 5 years for the extraction versus the cap and abandon group.

Results:

Among 6859 patients, 1113 (16.2%) underwent extraction, whereas 5746 (83.8%) underwent capping and abandonment. Extraction patients tended to be younger (median, 78 versus 79 years; P <0.0001), were less likely to be male (65% versus 68%; P =0.05), and had shorter lead dwell time (median, 3.0 versus 4.0 years; P <0.0001) and fewer comorbidities. Over a median follow-up of 2.4 years (25th, 75th percentiles, 1.0, 4.3 years), the overall 1-year and 5-year cumulative incidence of mortality was 13.5% (95% confidence interval [CI], 12.7–14.4) and 54.3% (95% CI, 52.8–55.8), respectively. Extraction was associated with a lower risk of device infection at 5 years relative to capping (adjusted hazard ratio, 0.78; 95% CI, 0.62–0.97; P =0.027). There was no association between extraction and mortality, lead revision, or lead extraction at 5 years.

Conclusions:

Elective lead extraction for noninfectious indications had similar long-term survival to that for capping and abandoning leads in a Medicare population. However, extraction was associated with lower risk of device infections at 5 years.

Comparison of risk scores for the prediction of stroke in African Americans: Findings from the Jackson Heart Study

BACKGROUND

Evidence from existing cohort studies supports the prediction of incident coronary heart disease and stroke using 10-year cardiovascular disease (CVD) risk scores and the American Heart Association/American Stroke Association's cardiovascular health (CVH) metric.

METHODS

We included all Jackson Heart Study participants with complete scoring information at the baseline study visit (2000-2004) who had no history of stroke (n = 4,140). We used Kaplan-Meier methods to calculate the cumulative incidence of stroke and used Cox models to estimate hazard ratios and 95% CIs for stroke according to CVD risk and CVH score. We compared the discrimination of the 2 models according to the Harrell c index and plotted predicted vs observed stroke risk calibration plots for each of the 2 models.

RESULTS

The median age of the African American participants was 54.5 years, and 65% were female. The cumulative incidence of stroke increased across worsening categories of CVD risk and CVH. A 1-unit increase in CVD risk increased the hazard of stroke (1.07, 1.06-1.08), whereas each 1-unit increase in CVH corresponded to a decreased hazard of stroke (0.76, 0.69-0.83). As evidenced by the c statistics, the CVH model was less discriminating than the CVD risk model (0.59 [0.55-0.64] vs 0.79 [0.76-0.83]).

CONCLUSIONS

Both scores were associated with incident stroke in a dose-response fashion; however, the CVD risk model was more discriminating than the CVH model. The CVH score may still be preferable for its simplicity in application to broad patient populations and public health efforts.

Applicability and feasibility of systematic review for performing evidence-based risk assessment in food and feed safety

Food and feed safety risk assessment uses multi-parameter models to evaluate the likelihood of adverse events associated with exposure to hazards in human health, plant health, animal health, animal welfare, and the environment. Systematic review and meta-analysis are established methods for answering questions in health care, and can be implemented to minimize biases in food and feed safety risk assessment. However, no methodological frameworks exist for refining risk assessment multi-parameter models into questions suitable for systematic review, and use of meta-analysis to estimate all parameters required by a risk model may not be always feasible. This paper describes novel approaches for determining question suitability and for prioritizing questions for systematic review in this area. Risk assessment questions that aim to estimate a parameter are likely to be suitable for systematic review. Such questions can be structured by their "key elements" [e.g., for intervention questions, the population(s), intervention(s), comparator(s), and outcome(s)]. Prioritization of questions to be addressed by systematic review relies on the likely impact and related uncertainty of individual parameters in the risk model. This approach to planning and prioritizing systematic review seems to have useful implications for producing evidence-based food and feed safety risk assessment.

Stringent adherence to a cytomegalovirus-prevention protocol is associated with reduced overall costs in the first 6 months after kidney transplantation

BACKGROUND

We previously documented that a stringent implementation of a preemptive cytomegalovirus (CMV) prevention protocol reduced the number of CMV disease episodes after kidney transplantation, when compared with a routine preemptive protocol. The impact on overall costs was assessed.

METHODS

Cost comparisons were made for inpatient and outpatient costs and overall costs, using costs provided by the financial department. Variables were analyzed using the Wilcoxon rank-sum test. A multivariable global linear model evaluated the effect of all co-variables on cost differences. In Cohort 1 (n = 84), 74% were followed with a standard CMV preemptive protocol, and 26% received prophylaxis. In Cohort 2 (n = 74), an intensified CMV surveillance protocol was applied in 74% of patients, and 26% were given prophylaxis.

RESULTS

Overall, Cohort 1 had significantly higher treatment costs as compared with Cohort 2 (mean Swiss francs [CHF] 104,548 and CHF 76,983, respectively, P = 0.0005). Excluding patients who received prophylaxis reduced these costs to CHF 89,318 in Cohort 1 and CHF 73,652 in Cohort 2. Outcome between Cohort 1 and 2 was comparable.

CONCLUSION

A stringent adherence to the CMV prevention protocol was associated with a significant reduction in overall costs. Whether this benefit is because of the demonstrated reduction in the rate of CMV disease needs to be assessed in a randomized trial.

Single-mode master-oscillator power amplifier at 647 nm with more than 500 mW output power

Using an AlGaInP-based truncated tapered power amplifier, it was possible to boost the output power of a 647-nm distributed Bragg reflector laser from 50 mW to more than 500 mW. The light source has the potential to replace bulky Kr ion lasers still in use at this wavelength.

How Does the Pathophysiology Influence the Treatment of Pelvic Congestion Syndrome and is the Result Long-lasting?

The objectives of this study are to consider the influence of pathophysiology in the treatment of pelvic congestion syndrome (PCS) and to determine the criteria which impact on the long-term results. A classification of venous pathology including three types of pathophysiological conditions, independent of the location of the pelvic venous pathology, is developed and illustrated. These types, diagnosed by cross-sectional imaging and confirmed by phlebography, are associated with a specific therapeutic plan. The long-term results are dependent on the quality of the initial Phlebographic mapping that must be selective and complete, the angiographic findings, in particular the study of collaterals feeding the venous anomalies, the treatment of all venous anomalies, the respect of contraindications, the use of appropriate materials and the occurrence of new pregnancies. In conclusion, the feasibility and satisfactory short-term results of endovascular treatment of PCS are admitted. Questions remain regarding the effectiveness of the different embolic agents and the long-term results of this treatment.

Inducing vortices in a Bose-Einstein condensate using holographically produced light beams

In this paper we demonstrate a technique that can create non-equilibrium vortex configurations with almost arbitrary charge and geometry in a Bose-Einstein condensate. We coherently transfer orbital angular momentum from a holographically generated light beam to a 87Rb condensate using a two-photon stimulated Raman process. Using matter wave interferometry, we verify the phase pattern imprinted onto the atomic wave function for a single vortex and a vortex-antivortex pair. In addition to their phase winding, the vortices created with this technique have an associated hyperfine spin texture.

The REFLECT statement: methods and processes of creating reporting guidelines for randomized controlled trials for livestock and food safety

The conduct of randomized controlled trials in livestock with production, health, and food-safety outcomes presents unique challenges that might not be adequately reported in trial reports. The objective of this project was to modify the CONSORT (Consolidated Standards of Reporting Trials) statement to reflect the unique aspects of reporting these livestock trials. A 2-day consensus meeting was held on November 18-19, 2008 in Chicago, IL, to achieve the objective. Before the meeting, a Web-based survey was conducted to identify issues for discussion. The 24 attendees were biostatisticians, epidemiologists, food-safety researchers, livestock production specialists, journal editors, assistant editors, and associate editors. Before the meeting, the attendees completed a Web-based survey indicating which CONSORT statement items would need to be modified to address unique issues for livestock trials. The consensus meeting resulted in the production of the REFLECT (Reporting Guidelines for Randomized Control Trials) statement for livestock and food safety and 22-item checklist. Fourteen items were modified from the CONSORT checklist, and an additional subitem was proposed to address challenge trials. The REFLECT statement proposes new terminology, more consistent with common usage in livestock production, to describe study subjects. Evidence was not always available to support modification to or inclusion of an item. The use of the REFLECT statement, which addresses issues unique to livestock trials, should improve the quality of reporting and design for trials reporting production, health, and food-safety outcomes.

The REFLECT statement: methods and processes of creating reporting guidelines for randomized controlled trials for livestock and food safety

The conduct of randomized controlled trials in livestock with production, health, and food-safety outcomes presents unique challenges that may not be adequately reported in trial reports. The objective of this project was to modify the CONSORT (Consolidated Standards of Reporting Trials) statement to reflect the unique aspects of reporting these livestock trials. A two-day consensus meeting was held on November 18-19, 2008 in Chicago, Ill, United States of America, to achieve the objective. Prior to the meeting, a Web-based survey was conducted to identify issues for discussion. The 24 attendees were biostatisticians, epidemiologists, food-safety researchers, livestock production specialists, journal editors, assistant editors, and associate editors. Prior to the meeting, the attendees completed a Web-based survey indicating which CONSORT statement items may need to be modified to address unique issues for livestock trials. The consensus meeting resulted in the production of the REFLECT (Reporting Guidelines for Randomized Control Trials) statement for livestock and food safety (LFS) and 22-item checklist. Fourteen items were modified from the CONSORT checklist, and an additional sub-item was proposed to address challenge trials. The REFLECT statement proposes new terminology, more consistent with common usage in livestock production, to describe study subjects. Evidence was not always available to support modification to or inclusion of an item. The use of the REFLECT statement, which addresses issues unique to livestock trials, should improve the quality of reporting and design for trials reporting production, health, and food-safety outcomes.

The REFLECT statement: methods and processes of creating reporting guidelines for randomized controlled trials for livestock and food safety

The conduct of randomized controlled trials in livestock with production, health, and food-safety outcomes presents unique challenges that may not be adequately reported in trial reports. The objective of this project was to modify the CONSORT (Consolidated Standards of Reporting Trials) statement to reflect the unique aspects of reporting these livestock trials. A two-day consensus meeting was held on November 18-19, 2008 in Chicago, IL, United States of America, to achieve the objective. Prior to the meeting, a Web-based survey was conducted to identify issues for discussion. The 24 attendees were biostatisticians, epidemiologists, food-safety researchers, livestock-production specialists, journal editors, assistant editors, and associate editors. Prior to the meeting, the attendees completed a Web-based survey indicating which CONSORT statement items may need to be modified to address unique issues for livestock trials. The consensus meeting resulted in the production of the REFLECT (Reporting Guidelines For Randomized Control Trials) statement for livestock and food safety (LFS) and 22-item checklist. Fourteen items were modified from the CONSORT checklist, and an additional sub-item was proposed to address challenge trials. The REFLECT statement proposes new terminology, more consistent with common usage in livestock production, to describe study subjects. Evidence was not always available to support modification to or inclusion of an item. The use of the REFLECT statement, which addresses issues unique to livestock trials, should improve the quality of reporting and design for trials reporting production, health, and food-safety outcomes.

Statistical evaluation of test accuracy studies for Toxoplasma gondii in food animal intermediate hosts

The availability of accurate diagnostic tests is essential for the detection and control of Toxoplasma gondii infections in both definitive and intermediate hosts. Sensitivity, specificity and the area under the receiver-operating characteristic (ROC) curve are commonly used measures of test accuracy for infectious diseases such as toxoplasmosis. These test performance characteristics are important considerations when selecting from among a group of tests for a specific testing purpose. In this study, we reviewed statistical approaches to evaluation of tests for toxoplasmosis with and without a gold-standard (reference) test, including use of ROC analysis and likelihood ratios which retain the diagnostic information inherent in a quantitative test result. We use previously published data from a comparison of the accuracy of serological tests for swine toxoplasmosis to demonstrate suggested methods of data analysis. We make recommendations for statistical analysis and reporting of test evaluation studies for T. gondii in food animals based on our own experiences and those of others.

A retrospective study of the clinical presentation of 140 dogs and 39 cats with bacteraemia

OBJECTIVES

To evaluate retrospective data from 140 dogs and 39 cats with positive blood cultures that were presented to the Clinic for Small Animal Medicine in Munich from 1995 to 2004.

METHODS

The identity of bacteria isolated from blood cultures of dogs and cats with bacteraemia was determined, and clinical and laboratory findings and outcome of animals with Gram-negative versus Gram-positive bacteraemia were compared.

RESULTS

Sepsis was diagnosed in 81.7 per cent of dogs and 59.5 per cent of cats with bacteraemia. Escherichia coli was isolated in one third of the animals. Dogs with bacteraemia more often showed monocytosis and increased alkaline phosphatase activity, while in cats, hyperglycaemia was found more commonly. Dogs with Gram-negative bacteraemia had hypoalbuminaemia significantly more often than dogs with Gram-positive bacteraemia, while among the remaining parameters, there were no statistically significant differences.

CLINICAL SIGNIFICANCE

Not all dogs and cats with a positive blood culture met the criteria for sepsis. Bacteraemia caused by Gram-positive versus Gram-negative bacteria cannot be distinguished based on clinical or laboratory parameters, and bacterial culture and susceptibility testing have to be performed for the right choice of antibiotic treatment.

Quantitative assessment of the likelihood of the introduction of classical swine fever virus into the Danish swine population

Classical swine fever virus (CSFV) is a major infectious-disease agent of livestock and causes production losses through increased morbidity and mortality, particularly of young pigs. We identified the pathways for introduction of CSFV into Denmark and assessed the annual probability of introduction (based on a US Department of Agriculture model). We developed pathways based on material from scientific articles, reports from veterinary agencies and custom officers, and consultations with experts in the field. Returning livestock trucks and legal meat imports were the most important pathways for CSFV introduction to Denmark from other EU states with predicted overall likelihood of one or more introductions of CSFV within a median of 130 years (46-280) provided mitigating steps, such as cleaning trucks, were maintained to a very high standard. The likelihood would increase dramatically if these activities were abandoned: one or more introductions within a median of 5.2 years (2-14). The predicted risks from live-animal imports and semen were extremely low given the very few imports of these products. The most important countries for Denmark's CSFV risk are Germany and the Netherlands, though this risk is again predicted to be dramatically reduced as long as mitigating activities are maintained. We predicted the risk from illegal movements of pork into Denmark to be low because little pork enters through this route and only a small fraction of this pork would be fed to pigs.

Risk Factors for Changing Test Classification in the Danish Surveillance Program for Salmonella in Dairy Herds

A surveillance program in which all cattle herds in Denmark are classified into Salmonella infection categories has been in place since 2002. Dairy herds were considered test negative and thus most likely free of infection if Salmonella antibody measurements were consistently low in bulk tank milk samples collected every 3 mo. Herds were considered test positive and thus most likely infected if the 4-quarter moving average bulk tank milk antibody concentration was high or if there was a large increase in the most recent measurement compared with the average value from the previous 3 samples. The objective of this study was to evaluate risk factors for changing from test negative to positive, which was indicative of herds becoming infected from one quarter of the year to the next, and risk factors for changing from test positive to negative, which was indicative of herds recovering from infection between 2 consecutive quarters of the year. The Salmonella serotypes in question were Salmonella Dublin or other serotypes that cross-react with the Salmonella Dublin antigen in the ELISA (e.g., some Salmonella Typhimurium types). Two logistic regression models that accounted for repeated measurements at the herd level and controlled for herd size and regional effects were used. Data from 2003 was used for the analyses. A change from test negative to positive occurred in 2.0% of the quarterly observations (n = 21,007) from test negative dairy herds. A change from test positive to negative occurred in 10.0% of quarterly observations (n = 6,168) available from test positive dairy herds. The higher the number of test-positive neighbor herds in the previous year-quarter, the more likely herds were to become test positive for Salmonella. The number of purchased cattle from test-positive herds was also associated with changing from test negative to positive. The bigger the herd, the more likely it was to change from negative to test positive. The effect of herd size on recovery was less clear. Large herds consisting mainly of large breeds or having test-positive neighbors in a 2-km radius were less likely to change from test positive to negative, whereas the breed and neighbor factors were not found to be important for small herds. Organic production was associated with remaining test positive, but not with becoming test positive. The results emphasize the importance of external and internal biosecurity measures to control Salmonella infections.

Recrystallization of tungsten wire for fabrication of sharp and stable nanoprobe and field-emitter tips

Atomically sharp tungsten tips made from single crystal tungsten wire are superior to those made from cold-drawn polycrystalline wire but are rarely used due to their high price. We have devised a method of obtaining highly crystalline tungsten wire by recrystallizing cold-drawn wire. The effect of various heat treatments on the wire microstructure was observed using scanning electron microscopy and x-ray diffraction. A dramatic difference in the shapes of tips etched from cold-drawn and recrystallized wires was observed using transmission electron microscopy. The described annealing process is an inexpensive alternative to using single crystal wires.

Demonstrating freedom from disease using multiple complex data sources 2: case study--classical swine fever in Denmark

A method for quantitative evaluation of surveillance for disease freedom has been presented in the accompanying paper (Martin et al., 2007). This paper presents an application of the methods, using as an example surveillance for classical swine fever (CSF) in Denmark in 2005. A scenario tree model is presented for the abattoir-based serology component of the Danish CSF surveillance system, in which blood samples are collected in an ad hoc abattoir sampling process, from adult pigs originating in breeding herds in Denmark. The model incorporates effects of targeting (differential risk of seropositivity) associated with age and location (county), and disease clustering within herds. A surveillance time period of one month was used in the analysis. Records for the year 2005 were analysed, representing 25,332 samples from 3528 herds; all were negative for CSF-specific antibodies. Design prevalences of 0.1-1% of herds and 5% of animals within an infected herd were used. The estimated mean surveillance system component (SSC) sensitivities (probability that the SSC would give a positive outcome given the animals processed and that the country is infected at the design prevalences) per month were 0.18, 0.63 and 0.86, for among-herd design prevalences of 0.001, 0.005 and 0.01. The probabilities that the population was free from CSF at each of these design prevalences, after a year of accumulated negative surveillance data, were 0.91, 1.00 and 1.00. Targeting adults and herds from South Jutland was estimated to give approximately 1.9, 1.6 and 1.4 times the surveillance sensitivity of a proportionally representative sampling program for these three among-herd design prevalences.