The Map of Need: identifying and predicting the spatial distribution of financial hardship in Scotland's veteran community

INTRODUCTION

During military service, many household costs for both married and single service personnel are subsidised, and transition can leave veterans unprepared for the financial demands of civilian life. Armed Forces organisations such as Sailor, Soldier, Air Force Association (SSAFA) play a central role in understanding the financial challenges that UK veterans face and provide an insight into the financial hardship experienced by veterans. The aim of this study was to use SSAFA beneficiary data as a proxy to identify the nature of financial benefit, the spatial distribution of financial hardship in the Scottish SSAFA beneficiary community and explore factors that might predict where those recipients are located.

METHODS

Using an anonymised data set of Scottish SSAFA financial beneficiaries between 2014 and 2019, this study used a geographical methodology to identify the geospatial distribution of SSAFA benefit recipients and exploratory regression analysis to explore factors to explain where SSAFA beneficiaries are located.

RESULTS

Over half of benefit applicants (n=10 735) were concentrated in only 50 postcode districts, showing evidence of a clustered pattern, and modelling demonstrates association with area-level deprivation. The findings highlight strong association between older injured veterans and need for SSAFA beneficiary assistance.

CONCLUSION

The findings demonstrate that beneficiaries were statistically clustered into areas of high deprivation, experiencing similar challenges to that of the wider population in these areas. Military service injury or disability was strongly associated with areas of high SSAFA benefit use and in those areas high unemployment was also a significant factor to consider.

Evaluation of the immunomodulatory activity of thalidomide on tumor-associated macrophages in the 4T1 murine metastatic breast cancer model

ABSTRACT The present work evaluated the immunomodulatory effect of thalidomide (Thal) at different doses on tumor-associated macrophages (TAMs) using a mouse model of human breast cancer. Mice were inoculated with 4T1 cells in the left flank and treated with Thal once a day at concentrations of 50, 100, and 150mg/kg body weight from the 5th day until the 28th day of tumor inoculation. The tumors were sized, proliferation index and TAMs count were evaluated in primary tumors and metastatic lungs. In addition, the metastasis rate was evaluated in the lungs. Thal at 150mg/kg significantly decreased tumor growth, proliferation index, and TAMs infiltration in primary tumors. Conversely, a higher number of TAMs and lower proliferation index were observed in metastatic lungs in mice treated with 150mg/kg of Thal. Furthermore, Thal at 150mg/kg significantly decreased the metastatic nodules in the lungs. Our findings demonstrated that Thal treatment considerably decreased the primary tumor and lung metastasis in mice associated with different TAM infiltration effects in these sites.

Patient-level costs in intensive care: a case report of a standardized and scalable approach

Background

Intensive care units (ICU) costs account to up to 30% of hospital budgets. Nevertheless, determination of their costs is complex and without agreed methodology, specially when considering patient-level costs (Value-Based Healthcare).

Methods

Case report of a costing methodology implementation, in a 15-bed ICU, in a public, teaching hospital at Teresina/Piauí-Brazil (as part of a broader initiative, with 10 hospitals from all Brazilian regions). All costs incurred during ICU stay were measured from the hospital perspective, applying absorption costing method, by using a standardized approach and a specific central IT system. The study was carried out from Oct/19-Sep/20, including 613 patients, and a team of 10 researchers working with 4 teams of the local hospital (costs, IT, ICU and managers).

Results

ICU fixed costs (personnel, overheads, energy/water, depreciation, non-tracked drugs/medical materials), were divided by service capacity (total bed-hours) for calculation of the costs/minute. Costs were then allocated in the patient level multiplying costs/minute by the ICU length of stay. Variable costs (lab/image tests, transfusions, hemodialysis, and traceable medical materials/drugs) were directly allocated, multiplying the unit cost by the volume consumed per patient. A mini-survey applied 1-year after showed that both cost researchers and hospital staff agreed on the main challenges in measuring patient-level costs (fragmented process; fixed costs available only at the hospital level; lack of control on cost-drivers; indirect costs not considered; any reference for lab/image costs) and that the approach was sufficient to overcome them. The local team also reported increased awareness about the importance of patient-level costs after the experience.

Conclusions

The proposed costing approach allowed the assessment of estimated total costs of each ICU admission. We believe this model can be easily and quickly replicated in other similar scenarios.

Key messages

ICU costs account to up to 30% of hospital budgets. Nevertheless, determination of their costs is complex and without agreed methodology, specially when considering patient-level costs. The proposed costing approach allowed the assessment of estimated total costs of each ICU admission. We believe this model can be easily and quickly replicated in other similar scenarios.

Is there a different impact of traditional risk factors on calcium score, in an asymptomatic population?

Background

The coronary calcium score has been increasingly used to stratify and predict cardiovascular risk, particularly in low and intermediate-risk persons. Understanding which determinants have more impact on coronary calcium score level, could lead to the development of new stricter preventive measures for reducing coronary artery calcification (CAC) and, consequently, cardiovascular risk.

Purpose

Our study aimed to investigate the impact of the traditional risk factors (TRFs) on the CAC score level and if there is a different association between this TRFs and CAC score degrees, in an asymptomatic population.

Methods

The study cohort comprised 1,122 consecutive asymptomatic individuals without known coronary artery disease (CAD) belonging to the healthy controls of GENEMACOR study and referred for computed tomography for CAC scoring assessment. The traditional risk factors considered were (1) current cigarette smoking, (2) dyslipidemia, (3) diabetes mellitus, (4) hypertension and (5) family history of coronary artery disease. According to the Hoff's nomogram, 3 categories were created: low CAC (0≤CAC<100 and P<50); moderate CAC (100≤CAC<400 or P50–75) and high or severe CAC (CAC≥400 or P>75). We evaluated the association of the different TRFs with these levels of CAC score (Chi-square test). Finally, we performed a logistic regression model adjusted for all significant TRFs selected in the bivariate analyses.

Results

Smoking was significantly associated with high levels of CAC score, 28.4% vs 21.7%; p=0.038 as well as hypertension, 58.8% vs 45.6%; p=0.001, type 2 diabetes 21.1% vs 9.6%; p<0.0001, dyslipidemia, 73.0% vs 66.1%; p=0.057. Family history did not show a significant association with CAC (p=0.717). Then, we constructed a logistic regression model adjusted the significant risk factors in previous analysis. The final multivariate analysis, selected as independent predictors of high CAC: Type 2 diabetes; OR=2.309; 95% CI 1.533–3.479; p<0.0001, hypertension; OR=1.627; 95% CI 1.185–2.233; p=0.003, and smoking, OR=1.565; 95% CI 1.102–2.222; p=0.012.

Conclusions

In this study, well-known and modifiable cardiovascular risk factors are associated with high calcium score levels. However, hypertension and diabetes seem to be preferentially associated with higher CAC scores, while tobacco, although it has a significant association, seems to be not so strong as diabetes and hypertension. This concept may mean that smoking has its primary role in plaque instability and not so much in the growing and calcification of plaques.

Funding Acknowledgement

Type of funding sources: None.

Is HNF4A gene, a risk factor or protection against coronary artery disease?

Background

Hepatocyte nuclear factor4 A (HNF4A) gene was considered by GWAS associated with atherosclerosis and CAD susceptibility. Loss-of-function mutations in human hepatocyte nuclear factor 4α (HNF4α), a transcriptor factor encoded by the HNF4A gene, are associated with maturity-onset diabetes of the young and lipid disorders. However, the mechanisms underlying the lipid disorders are poorly understood.

Aim

We propose identifying the genetic predisposition to atherosclerosis progression and events occurrence or regression and better prognosis, through a cohort study from GENEMACOR population.

Methods

We investigated a cohort of 1,712 patients who underwent coronary angiography with more than 70% stenosis of at least one main coronary vessel. 33 SNPs associated with the risk of CAD in previous GWAS were genotyped by TaqMan assays methodology. We evaluated the best genetic model associated with CAD prognosis (events) with a 95% CI in bivariate analysis. The hazard function was performed by a Cox survival regression model adjusted for age, sex, type 2 diabetes, hypertension, and hypercholesterolemia, to evaluate their relationship with the event's incidence. Finally, we constructed Kaplan–Meier cumulative-event curves for the significant genetic variants.

Results

Our evaluation revealed a SNP paradoxically associated with protection from atherosclerosis progression and events occurrence: rs1884613 C>G in the HNF4A gene on chromosome 20 dominant model [OR=0.653; 95% CI (0.522–0.817); p=0.0002]. Cox survival regression model showed a CAD protective effect of HNF4A with a Hazard ratio (HR) of 0.771; p=0.007. The Kaplan-Meier cumulative event analysis disclosed that the CG+GG vs CC genotype of rs1884613 HNF4α was associated with a better prognosis (Breslow test, p=0.004) at the end of the follow-up.

Conclusion

We identified, in this study, one SNPs paradoxically associated with a better CAD prognosis rs1884613 in HNF4A. The HNF4A gene variants could induce loss of HNF4α function, modifying and modulating hepatic lipase and lipid metabolism conferring a beneficial effect on atherosclerosis progression and events occurrence.

Funding Acknowledgement

Type of funding sources: None.

Epicardial adipose tissue volume improves cardiovascular risk reclassification: the Framingham Risk Score example

Introduction

Epicardial adipose tissue (EAT) volume can be noninvasively detected by CT and has been suggested to predict major adverse cardiovascular events (MACE). Framingham Risk Score is one of a number of scoring systems used to determine an individual's chances of developing cardiovascular disease, hence identifying who is most likely to benefit from prevention.

Objectives

The purpose of this study was to determine net reclassification improvement (NRI) and improved risk prediction based on EAT volume, in comparison to a traditionally known cardiovascular risk score, such as the Framingham.

Methods

895 asymptomatic volunteers were prospectively enrolled in a single Portuguese center (mean age 51.9±7.7, 78.5% male) and underwent a median follow-up time of 3.7 years (IQR 5.0). EAT volume was measured by Cardiac Computed Tomography (CCT) using a modified simplified method. For NRI assessment, EAT volume as a continuous variable was added to the Framingham Risk Score.

Results

After 3.7 median years of follow-up, 27 patients developed a MACE. Using NRI, the net proportion of events (netNRIe) that assigned a higher risk was 33.3% (better reclassified), and the net ratio of non-events (netNRIne) was 24.7%, resulting in a net reclassification index (netNRI) of 58.0%. When the new marker was included in the model, 58.0% of patients were better reclassified. In our work, a total of 33.3% of patients who suffered events (n=27) were correctly reclassified and assigned a higher risk.

Conclusion

EAT volume results in a high reclassification rate in an asymptomatic, low-risk population, demonstrating the benefit of this marker beyond traditional risk assessment models. Our study supports its application, especially in carefully selected individuals.

Funding Acknowledgement

Type of funding sources: None. Figure 1

The significant role of coronary artery calcification score in asymptomatic patients with metabolic syndrome

Background

Metabolic syndrome (MetS) is a clinical condition composed of metabolic and cardiovascular risk factors, such as abdominal obesity, hyperglycemia, dyslipidemia and hypertension. Many patients with MetS suffer major adverse cardiovascular events (MACE) that are not adequately identified by traditional risk assessment, suggesting the need for early detection of subclinical coronary heart disease to identify those at high-risk. Coronary artery calcification (CAC) screening has added utility in categorizing patients with low, intermediate and high cardiovascular risk.

Purpose

Evaluate the prognostic role of CAC score in asymptomatic population patients with metabolic syndrome in cardiovascular events risk prediction.

Methods

A total of 1,122 asymptomatic individuals without known coronary heart disease, enrolled from GENEMACOR study, were followed for a mean of 5.3±3.4 years for the primary endpoint of all-cause of cardiovascular events. All were referred for computed tomography for the CAC scoring assessment. According to the Hoff's nomogram, 3 categories were created: low CAC (0≤CAC<100 or P<50); moderate CAC (100≤CAC<400 or P50–75) and high or severe CAC (CAC≥400 or P>75). In a subgroup of 507 individuals with MetS and 615 controls, CAC values were compared by T-student and association of CAC severity with events occurrence was evaluated. Finally, a logistic regression model adjusted for CAC severity was performed in patients with MetS.

Results

Among our population, the extent of CAC differs significantly between men and women in the same age group. Patients with Mets (23.2%, n=115) had higher CAC scores than controls (219.0±486.0 vs 115.8±370.8, p<0.0001). In this cohort, with higher CAC scores, 46.7% vs 22.5% had MACEs (p=0.049) during the follow-up. The logistic regression analysis revealed that CAC≥400 is a MACE predictor (OR=4.326, CI 95% 1.241–15.080, p=0.021) in patients with MetS.

Conclusion

Our results point to the importance of the inclusion of CAC screening in patients with MetS to further stratify those patients that, despite tight control of cardiovascular risk factors, may benefit from more intensive therapies. This tool is a useful and straightforward method that could have a significant impact on the prognosis of future cardiovascular disease in patients with MetS.

Funding Acknowledgement

Type of funding sources: None.

Epicardial adipose tissue (EAT) volume is related to subclinical atherosclerosis and major adverse cardiovascular events (MACE) in asymptomatic subjects

Introduction

Epicardial adipose tissue (EAT) is an emerging cardiovascular risk marker. It has been suggested to be an inflammatory mediator with a role in subclinical atherosclerosis and coronary artery disease. However, its prognostic relevance in hard clinical outcomes remains thoroughly unexplored in the literature.

Purpose

Evaluate the prognostic relevance of EAT, regarding the occurrence of major adverse cardiovascular events (MACE) in an asymptomatic population.

Methods

895 asymptomatic volunteers were prospectively enrolled in a single Portuguese center (mean age 51.9±7.7, 78.5% male) and underwent a median follow-up time of 3.7 years (IQR 5.0). EAT volume was measured by Cardiac Computed Tomography (CCT) using a modified simplified method. Participants were distributed into two groups, above and below the EAT-volume median. We compared both groups regarding the occurrence of MACE through univariate analysis, Kaplan-Meier Survival curves and log-rank test. Association to subclinical atherosclerosis was addressed using correlation between EAT volume and calcium score (Agatson).

Results

There is a strong correlation between EAT volume and calcium score (r=0.205, p<0.0001), sustaining that it may play an important role in mediating coronary artery disease and subclinical atherosclerosis. Patients with higher EAT volume, were exposed to higher occurrence of MACE on follow-up [70.4% (19 of 27) vs 49.4% (429 of 868), p=0.032] with a clearer separation of the curves after 5.7 years.

Conclusion

In an asymptomatic population, EAT volume seems to be related to subclinical atherosclerosis and to the occurrence of adverse cardiovascular events on long-term follow-up. Our study addresses some unanswered questions, such as the prognostic relevance of EAT as an emerging cardiovascular risk marker.

Funding Acknowledgement

Type of funding sources: None.

Does coronary calcium score add value to European SCORE in an asymptomatic population?

Background

Despite being a controversial subject, multiple guidelines mention the use of Coronary Artery Calcification (CAC) scoring in the cardiovascular risk prediction in the asymptomatic population. Adding CAC score to European SCORE (Systematic Coronary Risk Evaluation) may improve the prediction of MACE (Major Adverse Cardiovascular Events), providing better cardiovascular risk stratification.

Purpose

Our study aims to evaluate the impact of CAC severity in MACE prediction compared with SCORE and estimate the additional value of CAC score in cardiovascular risk stratification in a low- risk region and asymptomatic population.

Methods and results

The study consisted of a prospective registry of 1110 asymptomatic individuals free of known coronary heart disease, enrolled from the GENEMACOR study and referred for computed tomography for the CAC scoring assessment. The mean age was 51.6±8.2 years, and 74.1% were male. This population was followed for a mean of 5.2±3.3 years for the primary endpoint of all-cause of cardiovascular events. The extent of CAC differs significantly between men and women in the same age group. Therefore, the distribution of CAC score by age and gender was done using Hoff's nomogram (a). According to this nomogram, 3 categories were created: low CAC (0≤CAC<100 and P<50); moderate CAC (100≤CAC<400 or P50–75) and high CAC (CAC≥400 or P>75). Through a Cox regression for MACE occurrence, SCORE does not remain in the equation, and the higher severity level of CAC presented a significant risk of MACE occurrence with an HR of 7.943 (95% CI 2.948 – 21.401; p<0.0001). Using the C-index, CAC was superior to SCORE (0.729 vs 0.615; p<0.0001). Adding CAC score to SCORE increased MACE prediction compared to SCORE alone (AUC 0.77 vs 0.615; p=0.003).

Conclusion

Our results point to the importance of the CAC score inclusion in primary prevention to improve cardiovascular risk stratification. CAC score in clinical practice could have a prognostic impact on MACE prediction. Larger prospective multicenter cohorts with longer follow-up should reproduce and validate these findings.

Funding Acknowledgement

Type of funding sources: None. Table 1

Assessing the clinical utility of a genetic risk score associated with type 2 diabetes in a southern European population

Background

The development of personalized susceptibility profiles based on genetic information to aid prediction, early detection and prevention of type 2 diabetes (T2D) with potential clinical application, begins to awaken interest in the scientific community. However, its clinical translation is controversial.

Objective

Evaluate the clinical utility of a genetic risk score (GRS) created with the GWAS-derived genetic variants associated to T2D to predict and discriminate the susceptibility to Type 2 diabetes, in a Southern European population with and without T2D.

Methods and results

We studied through a case-control with 3,139 subjects (772 with T2D and 2,367 without) the usefulness of implementing a GRS in clinical practice. We constructed a multiplicative GRS (mGRS) calculated using 10 SNPs of genetic loci robustly associated to T2D (HNF4A rs1884613, IGF2BP2 rs4402960, PPARG rs1801282, TCF7L2 rs7903146, SLC30A8 rs1326634, MC4R rs17782313, ADIPOQ rs266729, FTO rs8050136, TAS2R50 rs1376251 and APO E rs7412 and rs429358), to evaluate the prediction and discrimination of T2D. Two logistic regression models were performed the first with age, sex and BMI. The second with these three risk factors plus hypertension, LDL >130mg/dl and physical inactivity. Logistic regression models, receiver operating characteristic analyses (ROC curve) were used. Each model was analysed individually and added with mGRS to calculate the area under the ROC curve (AUC), which may be considered a global estimate of each model's predictive power. The inclusion of GRS in the first model increased the discriminative power of T2D (AUC=0.669 to 0.692; p<0.0001. In the second model, the increase was AUC=0.712 to 0.729; p<0.0001.

Conclusions

Adding genomic information to traditional models improves the ability to predict and discriminate type 2 Diabetes slightly, compared to traditional models alone. Nevertheless, this increase is not sufficiently robust for translation in clinical practice. However, clinicians should be conscious that T2D genetic research is experiencing a dramatic revolution and stay optimistic that these innovative studies translate into improved care for diabetic patients.

Funding Acknowledgement

Type of funding sources: None.

Genomic prediction of cardiovascular events in a coronary Southern European population

Background

Traditional and clinical risk factors are indicators of atherosclerosis over time and strong independent predictors of cardiovascular events, but it is unknown whether other genetic markers could provide information about the evolution of atherosclerotic coronary artery disease (CAD).

Objective

We propose identifying the genetic predisposition to atherosclerotic plaque progression and events occurrence, through a study cohort from GENEMACOR study population.

Methods

We performed a study with a cohort of 1,712 patients who underwent coronary angiography with more than 70% stenosis of at least one main coronary vessel, during a mean follow-up of 5 years (amplitude range 20 years). 33 SNPs associated with risk of CAD in previous GWAS, were genotyped by TaqMan assays methodology. The best model in the bivariate analysis at 95% CI with all genetic variants was generated, to investigate their association with prognostic and events occurrence. The hazard function at a set of confounding-variables was determined to evaluate their relationship with the event's incidence by the Cox survival analysis regression model. Finally, we constructed Kaplan–Meier cumulative-event curves for the significant variants.

Results

The analysis revealed two SNPs associated with the progression of atherosclerosis and events occurrence: rs12190287 G>C in the TCF21 gene on chromosome 10 (dominant model; OR=1.542; 95% CI 1.069 – 2.224; p=0.020) and the rs1333049 G>C in the CDKN2-AS1 gene on chromosome 9 (recessive model; OR=1.228; 95% CI 1.001 – 1.518; p=0.050). The Kaplan-Meier cumulative event curves in the TCF21 variant rs12190287 G> C showed that the GC+CC vs GG genotype was associated with a worse prognosis (log-rank test, p=0.016) and the CDKN2B-AS1 rs1333049 G> C revealed that the CC vs GG+GC genotype also presented severe prognosis and more events at the end of the follow-up period (log-rank test, p=0.046).

Conclusion

We have identified two SNPs associated with the prognosis of CAD, rs12190287 of TCF21 gene and rs1333049 of CDKN2-AS1 gene. Both are in non-coding enhancer regions and regulate transcriptional mechanisms shared among multiple CAD risk loci and could provide new insights into CAD's pathophysiology identifying core mechanisms for therapeutic intervention modulating the disease risk.

Funding Acknowledgement

Type of funding sources: None.

A genetic risk score predicts recurrent events after myocardial infarction in young patients with a low level of traditional risk factors

Introduction

Coronary Heart Disease (CAD) is a multifactorial disease, including environmental and genetic risk factors. Current smoking, dyslipidemia and diabetes have a significant impact in long- term mortality and morbidity. However, several genetic variants associated with CAD but not with traditional risk factors (TRFs) has been reported to improve prediction of events and extended mortality, in younger CAD people.

Aim

To evaluate the clinical utility of a GRS composed by variants from GWAS associated to CAD but not with TRF to predict life-long residual risk in patients under 55 years old and a low level of TRFs.

Methods

We conducted a prospective study with 573 consecutive patients aged <55 years presenting with AMI and a low level of TRFs (without diabetes and with LDL cholesterol >150 mg/ml). We analysed several biochemical markers and performed a GRS with variants not associated with TRFs (TCF21 rs12190287, CDKN2B-AS1 rs1333049, CDKN2B rs4977574, PHACTR1 rs1332844, MIA3 rs17465637, ADAMTS7 rs3825807, ZC3HC1 rs11556924, SMAD3 rs17228212 and GJA4 rs618675). We studied the GRS association with a primary composite endpoint of all-cause vascular morbidity and mortality including recurrent acute coronary syndrome (myocardial infarct and unstable angina), coronary revascularization (coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI), re-hospitalization for heart failure, ischemic stroke and cardiovascular dead.

Results

A total of 573 patients were studied and followed up for a mean of 4.7±4.0 years. There were 169 recurrent cardiovascular events. The GRS was sub-divided into terciles, verifying that patients in the third tercile (high risk) had a higher number of risk alleles. Compared with the low-risk GRS tercile, the multivariate-adjusted HR for recurrences was 1.520 (95% CI 1.011–2.286); p=0.044 for the intermediate-risk group and was 2.051 (95% CI 1.382–3.044); p<0.0001 for the high-risk group. Inclusion of the GRS in the model with TRFs alone (low risk) improved the C-statistic analysis (C-statistic = 0.030; p=0.004), cNRI (continuous net reclassification improvement) (30.8%), and the IDI (integrated discrimination improvement index) (0.022).

Conclusions

A multilocus GRS may identify young coronary disease patients with a low level of TRFs but at significant risk of long-term events recurrence. The genetic information may improve prediction discrimination, and reclassification over the conventional risk factors alone, providing better cost-effective therapeutic strategies.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Comparison between a genetic risk score and the European SCORE in cardiovascular events prediction in a primary prevention population

Background

The risk for Coronary Artery Disease (CAD) can be estimated using different scores, such as the European SCORE (Systematic Coronary Risk Evaluation) scale or genetic risk score (GRS). The addition of GRS to the European SCORE may increase the precision of predicting MACE (Major Adverse Cardiovascular Events).

Purpose

This study aims to compare the European SCORE and the multiplicative genetic risk score (mGRS) in predicting MACE.

Methods and results

The study included 1110 asymptomatic individuals without known CAD from GENEMACOR prospective registry. We defined the primary endpoint of all-cause cardiovascular events.

The study population had mean age of 51.6 years, 74.1% male and had risk factors of diabetes (11.6%), dyslipidemia (67.5%), hypertension (48.1%) and smoking (22.9%). Using C-index methodology, mGRS score was superior to SCORE in predicting MACE (mGRS = 0.832 Vs SCORE = 0.615; p=0.014).

Conclusions

The mGRS score was superior to SCORE in predicting MACE in an asymptomatic and free of CAD population. Genetic information may improve cardiovascular risk stratification in primary prevention.

Funding Acknowledgement

Type of funding sources: None.