0715 Long-term CPAP Adherence In A Public Sleep Clinic

Introduction

CPAP adherence may drop substantially over a long time frame. Since minorities including Hispanics and low socioeconomic groups have lower short-term acceptance and adherence, long-term adherence may also be reduced. We adapted a brief motivational enhancement education program (BMEEP) (Lai, CHEST 2014) in a Los Angeles County safety-net sleep clinic and found improved CPAP adherence at 3 months. We now report longitudinal long-term adherence over >=2 years. Our hypothesis: Many patients would meet CMS adherence criteria over >= 2 years.

Methods

During 3/1/2016 - 4/1/17, 118 patients completed BMEEP during CPAP initiation and were scheduled for a reinforcement session and routine clinic visits at 1 and 3 months and every 6 months thereafter. Electronic adherence and efficacy data were accessed each visit. Multivariate regression analyses explored association of adherence variables with demographic, clinical and workflow features.

Results

Baseline characteristics (mean (SD) or percent): Age 57.2 (17.8); Women 44.9%; Hispanic 69.5%, Non-Hispanic-White 22.9%, Other 5%, Black 3%; BMI 37; Epworth score 10.4 (6.05). Home sleep testing (69 patients) respiratory event indices were >=15/hr in 67% and >=30/hr in 57%. Polysomnography (81 patients) apnea hypopnea indices were (AHI) >= 15 in 78% and >=30/hr in 43%. By 7/1/2019, 23 (19%) patients were lost with unknown CPAP use status, while 76 (70.5%) of remaining patients continued to use CPAP. At 2 years, CPAP adherence parameters included: Average nightly use, 75% (27.7); Average hours/night, 4.74 (2.5); Average nightly use >=4 hours, 65.2% (31.6); >=70% nightly use >= 4 hours, 35 (51.5%). Average residual AHI was 2.05 (1.69). Adherence parameters in individual patients remained similar throughout 2 years. Long-term adherence was not associated with the demographic, clinical or workflow variables tested.

Conclusion

Programs that educate, motivate and provide regular follow-up for predominantly Hispanic low income populations can achieve acceptable long-term CPAP adherence rates.

Support

None

The role of smartphone applications in clinical practice: a review

OBJECTIVE

The number of medical mobile phone applications continues to grow. Although otorhinolaryngology-specific applications represent a small proportion, there are exciting innovations emerging for the specialty. This article will assess the number of applications available and review how they may be used in clinical practice.

METHOD

The application stores of the two most popular mobile phone platforms, Apple and android, were searched using multiple search terms.

RESULTS

A total of 107 ENT applications were identified and categorised according to intended use. Eight applications were reviewed in more detail and assessed on whether a doctor or allied health professional was involved in their design and if they were evidence-based.

CONCLUSION

There are a number of ENT-specific smartphone applications currently available. As the technology progresses, their scope has extended beyond being purely for reference. Nevertheless, it remains difficult to assess the validity and security of these applications.

An Evaluation of the Hybrid Model for Predicting Surgery Duration

The degree of accuracy in surgery duration estimation directly impacts on the quality of planned surgical lists. Model selection for the prediction of surgery duration requires technical expertise and significant time and effort. The result is often a collection of viable models, the performance of which varies across different strata of the surgical population. This paper proposes a prediction framework to be used after a comprehensive model selection process has been completed for surgery duration prediction. The framework produces a partition of the surgical cases and a "hybrid model" that allocates different predictors from the collection of viable models to different parts of the surgical population. The intention is a flexible prediction process that can reassign models and adapt as surgical processes change. The framework is tested via a simulation study, and its utility is demonstrated by predicting surgery durations for Ear, Nose and Throat surgeries in a New Zealand hospital. The results indicate that the hybrid model is effective, performing better than standard model selection in two of the three simulation studies, and marginally worse when the selected model was the true underlying process.

Addition of docetaxel to hormonal therapy in low- and high-burden metastatic hormone sensitive prostate cancer: long-term survival results from the STAMPEDE trial

BACKGROUND

STAMPEDE has previously reported that the use of upfront docetaxel improved overall survival (OS) for metastatic hormone naïve prostate cancer patients starting long-term androgen deprivation therapy. We report on long-term outcomes stratified by metastatic burden for M1 patients.

METHODS

We randomly allocated patients in 2 : 1 ratio to standard-of-care (SOC; control group) or SOC + docetaxel. Metastatic disease burden was categorised using retrospectively-collected baseline staging scans where available. Analysis used Cox regression models, adjusted for stratification factors, with emphasis on restricted mean survival time where hazards were non-proportional.

RESULTS

Between 05 October 2005 and 31 March 2013, 1086 M1 patients were randomised to receive SOC (n = 724) or SOC + docetaxel (n = 362). Metastatic burden was assessable for 830/1086 (76%) patients; 362 (44%) had low and 468 (56%) high metastatic burden. Median follow-up was 78.2 months. There were 494 deaths on SOC (41% more than the previous report). There was good evidence of benefit of docetaxel over SOC on OS (HR = 0.81, 95% CI 0.69-0.95, P = 0.009) with no evidence of heterogeneity of docetaxel effect between metastatic burden sub-groups (interaction P = 0.827). Analysis of other outcomes found evidence of benefit for docetaxel over SOC in failure-free survival (HR = 0.66, 95% CI 0.57-0.76, P < 0.001) and progression-free survival (HR = 0.69, 95% CI 0.59-0.81, P < 0.001) with no evidence of heterogeneity of docetaxel effect between metastatic burden sub-groups (interaction P > 0.5 in each case). There was no evidence that docetaxel resulted in late toxicity compared with SOC: after 1 year, G3-5 toxicity was reported for 28% SOC and 27% docetaxel (in patients still on follow-up at 1 year without prior progression).

CONCLUSIONS

The clinically significant benefit in survival for upfront docetaxel persists at longer follow-up, with no evidence that benefit differed by metastatic burden. We advocate that upfront docetaxel is considered for metastatic hormone naïve prostate cancer patients regardless of metastatic burden.

The meaningfulness of open data in Public Health and Healthcare

Background

The growing challenges and opportunities of Big Data for Public Health have revealed the potential to improve the efficiency and cost-effectiveness of public policy, for example through better targeting of resources with regard to General Practice (GP) prescribing. Open data has an important role due to its easy access and potential to complement proprietary data sources from, e.g., regional hospitals, and also itself be complemented with social data acquired by specialized approaches.

Methods

MIDAS pipeline of open source tools aiming integrating, analysing and visualising Open Data enabling health professionals and decision-makers to: (i) improve the usability of open data in combination with proprietary data through combining multiple visualisation tools in an integrated dashboard (ii) to explore the meaning of data in a global/local context based on new information using tone analysis and natural language techniques; and (iii) to have better informed decision-making based on evidence from trusted knowledge-bases. Specific data sources used have included information extracted from the biomedical database MEDLINE, worldwide news and government open data. Social media sources have also been used to gather information from the general public.

Results

Results include a strong correlation between antidepressant prescribing and economic deprivation, and a wide variation in how individual GP practices respond to demographic conditions. Automated anomaly detection based on the Local Outlier Probability has also been shown to be an easily understood and controllable approach to identifying prescribing outliers.

Conclusions

MIDAS demonstrates the significant value of open data from heterogeneous sources as basis decision-making in public health and healthcare, particularly when it is combined with proprietary or closed datasets. A key challenge in this regard is the ability to integrate and utilize data from diverse sources in a variety of formats and standards.

Key messages

MIDAS is exemplar on tackling the need for improved standards of open data, and new software architectures, tools and platforms addressing a complex ecosystem of heterogenous data sources and formats. MIDAS demonstrates the significant value of open data from heterogeneous sources as basis decision-making in public health and healthcare, particularly when combined with proprietary datasets.

Evaluating the Prevalence of Low Factor Scores on the ImPACT™ Quick Test in Adolescents and Adults using Multivariate Base Rates

Purpose

The ImPACT™ Quick Test (QT) is a brief iPad-based battery of neurocognitive tests that has been standardized on a sample of children, adolescents, and adults (ages 12-70). We sought to provide information regarding the prevalence of low ImPACT™ QT scores in the normative sample to improve clinical interpretation and reduce the risk of over-interpreting, or misinterpreting, a single low score.

Methods

Participants included 616 individuals ranging in age from 12 to 70, who were assessed individually. The ImPACT QT includes five subtests, contributing to three factor scores: Motor Speed, Memory, and Attention Tracker. The prevalence of low factor scores, stratified by age and gender, were calculated using multivariate base rates.

Results

In the total sample, obtaining 1 score below the 25th percentile was common (base rate, BR=31.8%), but obtaining 2 or more scores in this range was uncommon (BR=13.3%). Similarly, obtaining 1 score below the 16th percentile was common (BR=22.3%), but obtaining two or more scores in this range was very uncommon (BR=5.4%). There were small differences in base rate between genders and the number of low scores were fairly similar across the age groups.

Conclusion

Results from this study parallel previous work illustrating that a substantial percentage of healthy individuals will obtain one or more low test score when administered a battery of multiple cognitive test measures. Given that some healthy, non-concussed individuals will obtain a single score below expected cut-offs, clinicians should caution against overinterpreting a single low test score.

Influence of Pre-Morbid Migraine History on Baseline Vestibular/Ocular Motor Screening and King-Devick Test Performance

Purpose

To examine the effects of premorbid migraine history on baseline Vestibular/Ocular Motor Screening (VOMS) and King-Devick (KD) test performance in youth athletes.

Methods

This study implemented a cross-sectional design and was conducted at a series of youth sport venues in a designated research area. Youth athletes between the ages of 8 and 14 years with a diagnosed history of migraine headaches (n=28) and match controls (n=28) were administered a baseline VOMS and KD test. Between-group comparisons for provocation scores on the VOMS (smooth pursuit, saccades, convergence, vestibular-ocular reflex [VOR], and visual motion sensitivity [VMS]), Near-point of convergence [NPC] average distance (cm), and KD time (seconds) were conducted.

Results

Individuals diagnosed with migraine headaches reported greater VOMS scores compared to match controls on smooth pursuit (0.43±1.1 vs. 0.00±0.0; p=.02), convergence (0.46±1.2 vs. 0.04±0.1; p=.04), horizontal VOR (0.89±1.4 vs. 0.07±0.2; p<.001), vertical VOR (0.61±1.1 vs. 0.11±0.3; p=.04), and VMS (0.86±1.5 vs. 0.04±0.1; p=.01). Differences were also observed on the KD test with worse times in the diagnosed migraine group (54.33±11.8s) compared to match controls (47.17±8.9s; p=.02). No differences were reported on NPC distance between the migraine (2.22±3.1cm) and control group (0.83±1.2; p=.06).

Conclusion

Youth athletes with diagnosed migraine history reported higher baseline VOMS scores and worse KD time compared to match controls, further illustrating the influence of premorbid migraine headaches as a risk factor for elevated baseline concussion assessment. Special consideration may be warranted for post-concussion assessment in athletes with diagnosed migraine headaches.

Simulation, design, and first test of a multi-energy soft x-ray (SXR) pinhole camera in the Madison Symmetric Torus (MST)

A multi-energy soft x-ray pinhole camera has been designed and built for the Madison Symmetric Torus reversed field pinch to aid the study of particle and thermal-transport, as well as MHD stability physics. This novel imaging diagnostic technique combines the best features from both pulse-height-analysis and multi-foil methods employing a PILATUS3 x-ray detector in which the lower energy threshold for photon detection can be adjusted independently on each pixel. Further improvements implemented on the new cooled systems allow a maximum count rate of 10 MHz per pixel and sensitivity to the strong Al and Ar emission between 1.5 and 4 keV. The local x-ray emissivity will be measured in multiple energy ranges simultaneously, from which it is possible to infer 1D and 2D simultaneous profile measurements of core electron temperature and impurity density profiles with no a priori assumptions of plasma profiles, magnetic field reconstruction constraints, high-density limitations, or need of shot-to-shot reproducibility. The expected time and space resolutions will be 2 ms and <1 cm, respectively.

A model for locating fodder shrub plantations sites in the Jordanian badiyah

We developed a GIS desktop model to accurately locate and map prospective areas for sustainable establishment and production of Atriplex plantations and other fodder shrubs in the desert in the north-eastern Jordanian Badiyah. The aim is to provide a tool to assist managers, local communities and development projects in Mediterranean arid and semi-arid rangelands. The model uses freely available data and GIS layers of current land use, land cover, settlement location, soil information, and derivatives from a digital elevation model to provide critical locations of drainage lines and to calculate Areas of Accumulated Water from concentrated runoff. The model identified, accurately located and mapped ~4500 ha (1.44% of the test zone) as technically appropriate for potential shrub plantations sites. The final site map must be field-checked and validated with the local communities and authorities. Our model has potential for wide application over arid and semi-arid Mediterranean rangelands from Morocco to Pakistan, with local adjustment of our parameters and rules. The model considerably reduces the risk and costs of fodder plantation establishment operations, thus increasing the feasibility of efforts to maximise fodder shrub establishment, survival and production.

Description of a multi-university education and collaborative care child psychiatry access program: New York State's CAP PC

OBJECTIVE

Although, child mental health problems are widespread, few get adequate treatment, and there is a severe shortage of child psychiatrists. To address this public health need many states have adopted collaborative care programs to assist primary care to better assess and manage pediatric mental health concerns. This report adds to the small literature on collaborative care programs and describes one large program that covers most of New York state.

PROGRAM DESCRIPTION

CAP PC, a component program of New York State's Office of Mental Health (OMH) Project TEACH, has provided education and consultation support to primary care providers covering most of New York state since 2010. The program is uniquely a five medical school collaboration with hubs at each that share one toll free number and work together to provide education and consultation support services to PCPs.

METHODS

The program developed a clinical communications record to track information about all consultations which forms the basis of much of this report. 2-week surveys following consultations, annual surveys, and pre- and post-educational program evaluations have also been used to measure the success of the program.

RESULTS

CAP PC has grown over the 6years of the program and has provided 8013 phone consultations to over 1500 PCPs. The program synergistically provided 17,523 CME credits of educational programming to 1200 PCPs. PCP users of the program report very high levels of satisfaction and self reported growth in confidence.

CONCLUSIONS

CAP PC demonstrates that large-scale collaborative consultation models for primary care are feasible to implement, popular with PCPs, and can be sustained. The program supports increased access to child mental health services in primary care and provides child psychiatric expertise for patients who would otherwise have none.

More than a virus: a qualitative study of the social implications of hepatitis B infection in China

Background

China has the largest absolute number of people living with hepatitis B with up to 300,000 people estimated to die each year from hepatitis B related diseases. Despite advances in immunisation, clinical management, and health policy, there is still a lack of accessible and affordable health care for people with hepatitis B. Through in-depth interviews, this study identifies the personal, social and economic impact of living with hepatitis B and considers the role of stigma and discrimination as barriers to effective clinical management of the disease.

Methods

Semi-structured qualitative interviews were held with 41 people living with hepatitis B in five Chinese cities. Participants were recruited through clinical and non-government organisations providing services to people with hepatitis B, with most (n = 32) being under the age of 35 years.

Results

People living with hepatitis B experience the disease as a transformative intergenerational chronic infection with multiple personal and social impacts. These include education and employment choices, economic opportunities, and the development of intimate relationships. While regulations reducing access to employment and education for people with hepatitis B have been repealed, stigma and discrimination continue to marginalise people with hepatitis B.

Conclusions

Effective public policy to reduce morbidity and mortality associated with hepatitis B needs to address the lived impact of hepatitis B on families, employment and educational choices, finances, and social marginalisation.

Influence of blanketing and season on vitamin D and parathyroid hormone, calcium, phosphorus, and magnesium concentrations in horses in New Zealand

The aims of the study were to determine the effect of season and blanketing on vitamin D synthesis in horses and examine the interaction between vitamin D and other analytes involved in calcium homeostasis. Twenty-one healthy horses at pasture were included; 5 were covered with standard horse blankets including neck rugs. Blood samples were collected for 13 mo and analyzed for 25-hydroxyvitamin D2 (25OHD2) and 25-hydroxyvitamin D3 (25OHD3), 1,25-dihydroxyvitamin D (1,25[OH]2D), ionized calcium (iCa), total calcium (tCa), phosphorus (P), total magnesium (tMg), and parathyroid hormone (PTH). Grass and hay samples were collected and analyzed for vitamin D, calcium, phosphorus, and magnesium. Climate data were also collected. The serum concentration of 25OHD3 in horses was either undetectable or below the detection limit of the assay, and the main form of 25OHD was 25OHD2. No differences in serum 25OHD2, 1,25(OH)2D, iCa, tCa, P, tMg, and PTH (P ≥ 0.05) concentrations were seen between the 2 groups. Associations were seen between iCa and PTH (P < 0.05), iCa and tMg (P < 0.05), and dietary vitamin D and 25OHD2 (P < 0.05). A strong seasonal trend was seen in serum 25OHD2 (P < 0.0001), which was higher during spring and summer when the amount of sunshine and UV radiation was higher. Parathyroid hormone and 1,25(OH)2D showed opposing trends with PTH higher in winter whereas 1,25(OH)2D was higher in summer. The results suggest that dietary vitamin D may be necessary for horses to fulfill their vitamin D requirements; however, further research is required to determine the contribution of vitamin D3 synthesis in the skin to the vitamin D status of the horse.

Experimental Demonstration of the Collisionless Plasmoid Instability below the Ion Kinetic Scale during Magnetic Reconnection

The spontaneous formation of magnetic islands is observed in driven, antiparallel magnetic reconnection on the Terrestrial Reconnection Experiment. We here provide direct experimental evidence that the plasmoid instability is active at the electron scale inside the ion diffusion region in a low collisional regime. The experiments show the island formation occurs at a smaller system size than predicted by extended magnetohydrodynamics or fully collisionless simulations. This more effective seeding of magnetic islands emphasizes their importance to reconnection in naturally occurring 3D plasmas.

Genetic variation among 82 pharmacogenes: The PGRNseq data from the eMERGE network

Genetic variation can affect drug response in multiple ways, although it remains unclear how rare genetic variants affect drug response. The electronic Medical Records and Genomics (eMERGE) Network, collaborating with the Pharmacogenomics Research Network, began eMERGE‐PGx, a targeted sequencing study to assess genetic variation in 82 pharmacogenes critical for implementation of “precision medicine.” The February 2015 eMERGE‐PGx data release includes sequence‐derived data from ∼5,000 clinical subjects. We present the variant frequency spectrum categorized by variant type, ancestry, and predicted function. We found 95.12% of genes have variants with a scaled Combined Annotation‐Dependent Depletion score above 20, and 96.19% of all samples had one or more Clinical Pharmacogenetics Implementation Consortium Level A actionable variants. These data highlight the distribution and scope of genetic variation in relevant pharmacogenes, identifying challenges associated with implementing clinical sequencing for drug treatment at a broader level, underscoring the importance for multifaceted research in the execution of precision medicine.

Establishing a NORM based radiation calibration facility

An environmental radiation calibration facility has been constructed by the Radiation and Nuclear Sciences unit of Queensland Health at the Forensic and Scientific Services Coopers Plains campus in Brisbane. This facility consists of five low density concrete pads, spiked with a NORM source, to simulate soil and effectively provide a number of semi-infinite uniformly distributed sources for improved energy response calibrations of radiation equipment used in NORM measurements. The pads have been sealed with an environmental epoxy compound to restrict radon loss and so enhance the quality of secular equilibrium achieved. Monte Carlo models (MCNP),used to establish suitable design parameters and identify appropriate geometric correction factors linking the air kerma measured above these calibration pads to that predicted for an infinite plane using adjusted ICRU53 data, are discussed. Use of these correction factors as well as adjustments for cosmic radiation and the impact of surrounding low levels of NORM in the soil, allows for good agreement between the radiation fields predicted and measured above the pads at both 0.15 m and 1 m.