POS1089 ASSOCIATION BETWEEN PAIN SEVERITY AND HEALTHCARE UTILIZATION IN AN OSTEOARTHRITIS POPULATION: AN 18-YEAR RETROSPECTIVE COHORT STUDY

Background:

Osteoarthritis (OA) is a common disease that varies in severity among patients. A standardized definition to classify patients into different severity levels is lacking, however, due to the disease’s complex pathogenesis and presentation. Prior studies have shown associations between pain severity and higher healthcare resource utilization (HRU) and costs. We investigated an association between pain severity and higher healthcare resource utilization by examining the use of specific OA-related treatments across pain intensity levels in a large, integrated health system’s OA population over an 18-year period.

Objectives:

Our aim was to compare use of medications and other treatments among OA patients experiencing mild, moderate, or severe pain.

Methods:

This was a retrospective study of electronic health records from 2001 to 2018 at Geisinger, an integrated health system in Pennsylvania. Patients were included with a diagnosis code for OA (ICD-9: 715.*, ICD-10 M15-19) on a problem list or encounter or an OA-specific procedure (hip or knee replacement, arthroscopy or injection). We examined pain scores (0-10 scale, with 10 being worst pain) taken after the first OA diagnosis date and defined pain episodes starting on the pain score’s date and lasting for 90 days. If a new pain score was measured before 90 days elapsed, the episode was extended for an additional 90 days, with this process repeated as necessary. Each episode was categorized as mild (pain score 0-3), moderate (4-6), or severe (7-10) based on initial score, and patients could contribute multiple episodes to the analysis. Descriptive statistics were used to quantify treatment utilization during each patients’ mild, moderate and severe episodes. Percentages of patients who had any use of 10 medication types (tramadol, non-tramadol opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), injectable corticosteroids, acetaminophen, salicylates, duloxetine, homeopathic medications, other topical medications, and other over-the-counter (OTC) medications were compared across pain episode types. Percentages of patients with knee or hip surgeries, spine or joint imaging procedures (x-ray, computed tomography or magnetic resonance) and consults to OA-related care (pain management, orthopedics or physical medicine and rehabilitation) were also compared. All analyses used logistic regression with p-values <0.05 considered significant.

Results:

We identified 290,897 patients with OA, representing 34% of the health system population in 2018; 58% were female with mean age of 49 years and mean BMI of 30.5 kg/m2. A total of 801,144 pain episodes were defined, with 75% of patients having at least one pain score. The two most frequently occurring pain scores were 0 (17%) and 5 (13%), and pain episodes were classified as 43% mild, 32% moderate and 25% severe. Significantly higher percentages of patients used certain medication types (NSAIDs, injectable corticosteroids, non-tramadol opioid, duloxetine) in both moderate and severe pain episodes as compared to mild episodes, but other medication types were less likely to be used as pain severity increased (acetaminophen, salicylates, homeopathic medications, other OTC medications). Knee or hip surgeries, imaging, and consults to OA-related specialists were all consistently significantly more likely to occur in patients during moderate or severe pain episodes versus mild episodes (relative risk ratios of 1.76, 1.25 and 1.35 for moderate vs mild, respectively, and 2.00, 1.44 and 1.46 for severe vs mild, all p-values <0.05).

Conclusion:

While pain is generally recognized to be a subjective measure that could be influenced by other unmeasured factors and can be confounded with treatment effectiveness, it is nevertheless the primary symptom of OA. It is important to understand the relationship between pain intensity and treatment utilization, and our results support an overall association between pain and utilization but provide new details on the extent to which it depends on specific utilization type.

Acknowledgements:

Pfizer and Eli Lilly and Company for sponsoring this study.

Disclosure of Interests:

Jove Graham Grant/research support from: I am an employee of Geisinger which received financial support from Pfizer and Eli Lilly and Company in connection with the development of this abstract, Tonia Novosat Grant/research support from: I am an employee of Geisinger which received financial support from Pfizer and Eli Lilly and Company in connection with the development of this abstract, Haiyan Sun Grant/research support from: I am an employee of Geisinger which received financial support from Pfizer and Eli Lilly and Company in connection with the development of this abstract, Brian Piper Grant/research support from: I am an employee of Geisinger which received financial support from Pfizer and Eli Lilly and Company in connection with the development of this abstract, Joseph Boscarino Grant/research support from: I am an employee of Geisinger which received financial support from Pfizer and Eli Lilly and Company in connection with the development of this abstract, Vanessa Duboski Grant/research support from: I am an employee of Geisinger which received financial support from Pfizer and Eli Lilly and Company in connection with the development of this abstract, Melissa Kern Grant/research support from: I am an employee of Geisinger which received financial support from Pfizer and Eli Lilly and Company in connection with the development of this abstract, Eric Wright Grant/research support from: I am an employee of Geisinger which received financial support from Pfizer and Eli Lilly and Company in connection with the development of this abstract, Rebecca Robinson Shareholder of: Eli Lilly & Co., Employee of: Eli Lilly & Co., Edward Casey Shareholder of: Pfizer, Inc., Paid instructor for: As an employee of Pfizer, Inc. this is part of my role., Employee of: Pfizer, Inc., Craig Beck Shareholder of: Pfizer, Inc., Employee of: Pfizer, Inc., Jerry Hall Shareholder of: Eli Lilly & Co., Employee of: Eli Lilly & Co., Patricia Schepman Shareholder of: Pfizer, Inc., Employee of: Pfizer, Inc.

Large-scale space use of large juvenile and adult smalltooth sawfish Pristis pectinata: implications for management

The smalltooth sawfish Pristis pectinata is an endangered species endemic to the Atlantic Ocean. The only known viable populations occur in the USA along both coasts of Florida and in the western Bahamas. Little is known about habitat use and movement ecology of large juvenile and adult smalltooth sawfish. Although Critical Habitat—a management designation in the USA—has been identified for small juveniles, it has yet to be identified for these life stages. Between May 2016 and April 2019, we used passive acoustic telemetry and 3 large data sharing networks of receivers to track movements of 43 large juvenile and adult smalltooth sawfish. During this study, 24 females and 19 males were implanted with transmitters with estimated 4 or 10 yr battery lives. These tagged individuals were detected off the southeastern USA on 461 receivers ranging from off the coast of Brunswick, Georgia, to the lower Florida Keys, and along the Gulf coast to Apalachee Bay, Florida. Seasonal migrations were undertaken by 58% (43% mature; 57% immature) of the tagged individuals, with the remainder being apparent residents of their tagging locations. Tagged sawfish from both size classes and of both sexes migrated, which indicates that neither sex nor length is a predictor of whether a sawfish will migrate or not. Although both coasts of Florida were used for migration, most individuals consistently used the same coast when they migrated. The areas surrounding Boca Grande, Cape Canaveral, and the lower Florida Keys were heavily visited sites that could be further evaluated as potential Critical Habitat for these life stages. Understanding the movement patterns of this Critically Endangered species is essential for creating policies to protect areas important for promoting growth of the population.

Assessing Upstream Determinants of Antibiotic Use in Small-Scale Food Animal Production through a Simulated Client Method

Small-scale food animal production has been celebrated as a means of economic mobility and improved food security but the use of veterinary antibiotics among these producers may be contributing to the spread of antibiotic resistance in animals and humans. In order to improve antibiotic stewardship in this sector, it is critical to identify the drivers of producers’ antibiotic use. This study assessed the determinants of antibiotic use in small-scale food animal production through simulated client visits to veterinary supply stores and surveys with households that owned food animals (n = 117) in Ecuador. Eighty percent of households with food animals owned chickens and 78% of those with chickens owned fewer than 10 birds. Among the households with small-scale food animals, 21% reported giving antibiotics to their food animals within the last six months. Simulated client visits indicated that veterinary sales agents frequently recommended inappropriate antibiotic use, as 66% of sales agents recommended growth promoting antibiotics, and 48% of sales agents recommended an antibiotic that was an inappropriate class for disease treatment. In contrast, few sales agents (3%) were willing to sell colistin, an antibiotic banned for veterinary use in Ecuador as of January 2020, which supports the effectiveness of government regulation in antibiotic stewardship. The cumulative evidence provided by this study indicates that veterinary sales agents play an active role in promoting indiscriminate and inappropriate use of antibiotics in small-scale food animal production.

COVID-19 infection in kidney transplant recipients at the epicenter of pandemics

We investigated the prevalence and clinical outcomes of COVID-19 in recipients of kidney transplants in the Bronx, New York, one of the epicenters of the pandemic. Between March 16 and June 2, 2020, 132 kidney transplant recipients tested positive by SARS-CoV-2 RT-PCR. From May 3 to July 29, 2020, 912 kidney transplant recipients were screened for SARS-CoV-2 IgG antibodies during routine clinic visits, of which 16.6% tested positive. Fifty-five of the 152 patients had previously tested positive by RT-PCR, while the remaining 97 did not have significant symptoms and had not been previously tested by RT-PCR. The prevalence of SARS-CoV-2 infection was 23.4% in the 975 patients tested by either RT-PCR or SARS-CoV-2 IgG. Older patients and patients with higher serum creatinine levels were more likely diagnosed by RT-PCR compared to SARS-CoV-2 IgG. Sixty-nine RT-PCR positive patients were screened for SARS-CoV-2 IgG antibodies at a median of 44 days post-diagnosis (Inter Quartile Range 31-58) and 80% were positive. Overall mortality was 20.5% but significantly higher (37.8%) in the patients who required hospitalization. Twenty-three percent of the hospitalized patients required kidney replacement therapy and 6.3% lost their allografts. In multivariable analysis, older age, receipt of deceased-donor transplantation, lack of influenza vaccination in the previous year and higher serum interleukine-6 levels were associated with mortality. Thus, 42% of patients with a kidney transplant and with COVID-19 were diagnosed on antibody testing without significant clinical symptoms; 80% of patients with positive RT-PCR developed SARS-CoV-2 IgG and mortality was high among patients requiring hospitalization.

Community-Acquired Antimicrobial Resistant Enterobacteriaceae in Central America: A One Health Systematic Review

Community-acquired antimicrobial resistant Enterobacteriaceae (CA-ARE) are an increasingly important issue around the world. Characterizing the distribution of regionally specific patterns of resistance is important to contextualize and develop locally relevant interventions. This systematic review adopts a One Health framework considering the health of humans, animals, and the environment to describe CA-ARE in Central America. Twenty studies were identified that focused on antimicrobial resistance (AMR) in Enterobacteriaceae. Studies on CA-ARE in Central America characterized resistance from diverse sources, including humans (n = 12), animals (n = 4), the environment (n = 2), and combinations of these categories (n = 2). A limited number of studies assessed prevalence of clinically important AMR, including carbapenem resistance (n = 3), third generation cephalosporin resistance (n = 7), colistin resistance (n = 2), extended spectrum beta-lactamase (ESBL) production (n = 4), or multidrug resistance (n = 4). This review highlights significant gaps in our current understanding of CA-ARE in Central America, most notably a general dearth of research, which requires increased investment and research on CA-ARE as well as AMR more broadly.

Mandatory immunization: Empirical examination of governance instruments in 28 Global NITAG Network (GNN) countries

Background

In the Global Vaccine Action Plan 2017 Assessment Report, WHO's SAGE noted need to understand ways in which legislation and regulation are used to advance or undermine immunization. The NITAG Environmental Scan Project sought to address this in a pilot study.

Methods

Data was collected via a secure online survey of GNN members (40 countries Sept 2018). Respondents reporting a mandatory element were asked: (1) what vaccinations were required by law; and (2) what population groups were subject to mandates; (3) what grounds, if any, were available for requesting exemptions.

Results

28 (70%) countries responded, representing every WHO region and World Bank income level. While mandatory immunization programs / elements within broader NIPs were relatively common, jurisdictions varied with respect to immunizations required, population groups affected, grounds for exemptions, and penalties for non-compliance. We observed some loose associations with geography and income level. Children were the most common population group subject to mandates at some stage of childhood development (28/28); healthcare workers were second (8/15 (53%)). Sanctions for failure to immunize varied broadly, ranging from no penalty, to loss of access to social services e.g. admission to school, monetary fines, and incarceration. A variance between countries as to how strictly immunization mandates are enforced was noted.

Conclusions

A variety of approaches existed ranging from Narrow/Permissive to Broad/ Inclusive in scope with enforcement mapping loosely to this continuum from Loose/Permissive to Tight/Coercive. Jurisdictions with few/no vaccines mandated, and few/no target groups identified, Loose approach is expected; for those closer to Broad approach, Tighter controls expected. Coercive measures may be 'positive' (vaccination as a gateway to public services, with possible work-arounds), or 'negative' (failure to vaccinate = penalties).

Urgent Peritoneal Dialysis in Patients With COVID-19 and Acute Kidney Injury: A Single-Center Experience in a Time of Crisis in the United States

At Montefiore Medical Center in The Bronx, NY, the first case of coronavirus disease 2019 (COVID-19) was admitted on March 11, 2020. At the height of the pandemic, there were 855 patients with COVID-19 admitted on April 13, 2020. Due to high demand for dialysis and shortages of staff and supplies, we started an urgent peritoneal dialysis (PD) program. From April 1 to April 22, a total of 30 patients were started on PD. Of those 30 patients, 14 died during their hospitalization, 8 were discharged, and 8 were still hospitalized as of May 14, 2020. Although the PD program was successful in its ability to provide much-needed kidney replacement therapy when hemodialysis was not available, challenges to delivering adequate PD dosage included difficulties providing nurse training and availability of supplies. Providing adequate clearance and ultrafiltration for patients in intensive care units was especially difficult due to the high prevalence of a hypercatabolic state, volume overload, and prone positioning. PD was more easily performed in non–critically ill patients outside the intensive care unit. Despite these challenges, we demonstrate that urgent PD is a feasible alternative to hemodialysis in situations with critical resource shortages.

How medical student placements at a psychiatry hospital can be utilised to make psychiatry a popular career choice

It is perceived that negative attitudes towards mental illness in undergraduate medical students can impact student's decision in choosing psychiatry as a medical career. Improvement in psychiatry placements for undergraduate medical students can result in changing student's attitude towards psychiatry as a career choice. We demonstrate how students’ placements from various medical schools at a major psychiatric hospital contributed towards enhancing student's interest towards psychiatry. Medical students who had their placement over the last one year were contacted for an anonymised student perspective survey.

While majority of students did not have psychiatry as their potential career choice before they started their placements more than two third rated psychiatry as a potential career choice based on their experience from the placements. This encouraged us to improve the placement standards based on student's perspective. Students suggested that more use of medical training in psychiatry, improvement in teaching and placement standards and more psychiatry placements before specialised training can contribute towards making psychiatry as one of the popular career choices. Student's preferred interactive teaching sessions including case based discussions and informal teaching sessions during ward rounds and clinics. Overall students found their placements helpful but more so to perform well in their examinations as compared to coverage of full psychiatry curriculum.

It is planned to conduct the survey again after necessary changes based on student's perspective to evaluate whether further improvement in placements can continue in contributing towards increasing medical recruitment in psychiatry.

Enumeration and Confirmation of Bacillus cereus in Foods: Collaborative Study

A collaborative study was conducted in 15 laboratories to evaluate 2 different techniques for enumerating Bacillus cereus in foods. A direct plating technique using mannitol-egg yolk-polymyxin agar and a most probable number (MPN) technique using trypticase-soy-polymyxin broth were compared for the enumeration of high and low populations of B. cereus in mashed potatoes. The collaborative results showed that the overall mean recovery obtained with the low population level was essentially the same by both techniques. However, the overall mean recovery was significantly higher by the direct plating technique at the high population level. A statistical evaluation of the data also showed that the direct plating technique had better repeatability and reproducibility than did the MFN technique at both the high and low population levels. These results suggest that the MPN technique is suitable for examining foods containing low populations of B. cereus, but that the direct plating technique is preferable for foods that contain a high population of this organism. The confirmatory technique used in the proposed method is reliable for presumptive identification of isolates as B. cereus. The method has been adopted as official first action.

42 Vitrification of invitro-produced feline embryos

Preservation of feline embryos is useful in propagating endangered species, preserving valuable genetics, and supporting biomedical research. Although a wide variety of cryoprotectants (CP) and protocols are successfully used for vitrification of invitro-produced (IVP) embryos, there are often species-specific differences in viability of embryos post-warming. The purpose of this study was to evaluate the viability of IVP feline embryos after vitrification using two common CPs, propanediol (PrOH) or ethylene glycol (EG). Embryos were produced with oocytes and frozen-thawed epididymal sperm collected from local spay-neuter clinics using a published IVP protocol developed for producing domestic feline embryos. Day 7 early blastocysts (stage 5), blastocysts (stage 6), and expanded blastocysts (stage 7) were evaluated for quality (grade 1 or 2) and randomly assigned to one of three treatments: vitrification with PrOH (n=32), vitrification with EG (n=31), or control (n=47), which was allowed to continue in culture until Day 8. The vitrification protocol was as follows. The base medium for all vitrification media was a HEPES-buffered feline optimized culture medium (FOCMH). Embryos were placed in 0.5mL of equilibration medium (7.5% dimethyl sulfoxide, 7.5% PrOH or EG, 0.5M sucrose, 10% Ficoll, and 20% fetal calf serum (FCS)) for 5min at room temperature. Individual embryos were then moved to 20-μL drops of vitrification medium (15% dimethyl sulfoxide, 15% PrOH or EG, 0.5M sucrose, 10% Ficoll, and 20% FCS) at room temperature for 30s before being loaded onto Cryolock devices and plunged into liquid nitrogen. Warming was done using a 3-step process for all vitrified embryos. First, embryos were moved from liquid nitrogen directly to 0.5mL of 1M sucrose, 10% Ficoll, and 20% FCS at 37°C for 1min. Next, embryos were moved to 0.5mL of 0.5M sucrose, 10% Ficoll, and 20% FCS at 20°C for 3min. Finally, embryos were transferred to 0.5mL of FOCMH for 5min at 37°C. All warmed embryos were cultured in medium, optimized for feline embryos, with 5% FCS and evaluated for re-expansion of the blastocoele and progression in development at 24 and 48h. Results are from five replicates. Embryos vitrified in EG exhibited higher percentages of viable embryos 24h after warming (84%) than embryos vitrified in PrOH (59%; P&lt;0.05). The continued embryonic growth of viable embryos after culture for 48h showed equivalent developmental rates, at 87, 96, and 100% for control, EG-treated, and PrOH-treated embryos, respectively (P&gt;0.05). Results indicate EG is a more successful CP treatment for vitrification of feline embryos when evaluating viability 24h post-warming. We report a higher viability of embryos post-thaw than previous studies using the same CPs (Pope et al. 2012 Reprod. Domest. Anim. 47, 125). This may be due to the shorter exposure time to the CPs we used during the vitrification process. We conclude that EG and PrOH are effective CPs for Day 7 feline IVP embryos using this protocol. Further research is needed to increase treatment numbers and evaluate pregnancy rates from embryos transferred post-warming.

Longitudinal dynamics of herd-level Mycobacterium bovis MLVA type surveillance in cattle in Northern Ireland 2003-2016

Investigating genetically-structured diversity in pathogen populations over time is important to better understand disease maintenance and spread. Herd-level surveillance of Mycobacterium bovis genotypes (multi-locus VNTR analysis types, MLVA types) from all culture-confirmed bovine tuberculosis (TB) herd cases was undertaken in Northern Ireland (NI), generating an unparalleled, longitudinal, population-level 14-year survey for this pathogen. Across this population, 295 genetically-distinct M. bovis MLVA types were identified in the 19,717 M. bovis isolates surveyed. Of these, the most frequent was MLVA type 002 (23.0%); 151 MLVA types were represented more than once, in groups ranging from 2 to 4438 isolates. Only 23 MLVA types were isolated in all 14 years. Investigating inter-annual frequency of M. bovis MLVA types, examples of statistically-significant expansions (MLVA types 002, 004, 006, 009 and 027), contractions (MLVA types 001, 007 and 011) and maintenance (MLVA types 003 and 005) were disclosed, during a period of fluctuating bovine TB herd-level incidence at the NI scale. The fixed period frequency distribution of MLVA types remained highly right-skewed. Novel VNTR copy number variant MLVA types (N = 242; an average of 17 per annum) were identified throughout the survey. The MLVA type distribution in the landscape was not random; MLVA types showed statistically-significant geographical localization and strong spatial associations with Divisional Veterinary Office (DVO) regions. There was also evidence of differential risk of particular MLVA types across breeds (Holstein/Friesian vs. other), age-class, and sex and some evidence of an association between the number of animals testing positive for bovine TB during the disclosing test and particular MLVA types, although there was substantial variation.

P716Role of EDRFs in aortic and mesenteric arterial function of the UC Davis Type 2 Diabetic Mellitus (UCD-T2DM) male rats

Acknowledgement/Funding

NIHLBI

Variation in Mycobacterium bovis genetic richness suggests that inwards cattle movements are a more important source of infection in beef herds than in dairy herds

Background

We used genetic Multi-Locus VNTR Analysis (MLVA) data gathered from surveillance efforts to better understand the ongoing bovine tuberculosis (bTB) epidemic in Northern Irish cattle herds. We modelled the factors associated with Mycobacterium bovis MLVA genotype richness at three analytical scales; breakdown level, herd level, and patch level, and compared the results between dairy and non-dairy production types.

Results

In 83% of breakdowns and in 63% of herds, a single MLVA genotype was isolated. Five or more MLVA genotypes were found in less than 3 % of herds. Herd size and the total number of reactors were important explanatory variables, suggesting that increasing MLVA genotype richness was positively related to increases in the number of host animals. Despite their smaller relative size, however, the highest MLVA genotype richness values were observed in non-dairy herds. Increasing inwards cattle movements were important positive predictors of MLVA genotype richness, but mainly in non-dairy settings.

Conclusions

The principal finding is that low MLVA genotype richness indicates that small-scale epidemics, e.g. wildlife, contiguous farms, and within-herd recrudescence, are important routes of M. bovis infection in cattle herds. We hypothesise that these mechanisms will maintain, but may not explicitly increase, MLVA genotype richness. The presence of elevated MLVA richness is relatively rare and likely indicates beef fattening enterprises, which purchase cattle from over long distances. Cattle movements were furthermore an important predictor of MLVA genotype richness in non-dairy herds, but not in dairy herds; this may represent reduced cattle purchasing levels in dairy enterprises, compared to beef. These observations allude to the relative contribution of different routes of bTB infection between production types; we posit that infection associated with local factors may be more evident in dairy herds than beef herds, however in beef herds, inwards movements offer additional opportunities for introducing M. bovis into the herd.

Electronic supplementary material

The online version of this article (10.1186/s12866-019-1530-7) contains supplementary material, which is available to authorized users.