Subclinical thyroid dysfunction, bone mineral density, and osteoporosis in a middle-aged Korean population

Thyroid dysfunction is associated with the loss of bone density (osteoporosis). However, the connection between subclinical thyroid dysfunction and osteoporosis remains controversial. This study found no apparent association between subclinical hypothyroidism or subclinical hyperthyroidism and bone mineral density (BMD) in the lumbar spine and femur.

INTRODUCTION

The present study examined the relationship between subclinical thyroid dysfunction and BMD in healthy middle-aged adults.

METHODS

A total of 25,510 healthy Koreans with normal free thyroxine levels were enrolled from January 2011 to December 2016, and 91% of subjects visited only once. The average age of the 15,761 women was 45, and the average age of the 9749 men was 48. Levels of thyroid-stimulating hormone (TSH) and BMD were recorded in all subjects. BMD was measured using dual-energy X-ray absorptiometry.

RESULTS

No apparent association was found between subclinical thyroid dysfunction and BMD in the lumbar spine, femur-neck, and proximal femur sites compared with a euthyroid group. Age, body mass index (BMI), and postmenopausal status affected BMD in women, and only BMI affected BMD in men. Subclinical hypothyroidism was independently associated with a lower risk of osteoporosis (odds ratio 0.657, 95% confidence interval 0.464-0.930) in 4710 postmenopausal women.

CONCLUSIONS

No apparent association was found between subclinical hypothyroidism or subclinical hyperthyroidism defined on single TSH measurement and BMD at the lumbar spine and femur in a large cohort of middle-aged men and women. Subclinical hypothyroidism was independently associated with a lower risk of osteoporosis in postmenopausal women.

Measurement of Azimuthal Anisotropy of Muons from Charm and Bottom Hadrons in pp Collisions at sqrt[s]=13 TeV with the ATLAS Detector

The elliptic flow of muons from the decay of charm and bottom hadrons is measured in pp collisions at sqrt[s]=13  TeV using a data sample with an integrated luminosity of 150  pb^{-1} recorded by the ATLAS detector at the LHC. The muons from heavy-flavor decay are separated from light-hadron decay muons using momentum imbalance between the tracking and muon spectrometers. The heavy-flavor decay muons are further separated into those from charm decay and those from bottom decay using the distance-of-closest-approach to the collision vertex. The measurement is performed for muons in the transverse momentum range 4-7 GeV and pseudorapidity range |η|<2.4. A significant nonzero elliptic anisotropy coefficient v_{2} is observed for muons from charm decays, while the v_{2} value for muons from bottom decays is consistent with zero within uncertainties.

The Mortality After Release from Incarceration Consortium (MARIC): Protocol for a multi-national, individual participant data meta-analysis

INTRODUCTION

More than 30 million adults are released from incarceration globally each year. Many experience complex physical and mental health problems, and are at markedly increased risk of preventable mortality. Despite this, evidence regarding the global epidemiology of mortality following release from incarceration is insufficient to inform the development of targeted, evidence-based responses. Many previous studies have suffered from inadequate power and poor precision, and even large studies have limited capacity to disaggregate data by specific causes of death, sub-populations or time since release to answer questions of clinical and public health relevance.

OBJECTIVES

To comprehensively document the incidence, timing, causes and risk factors for mortality in adults released from prison.

METHODS

We created the Mortality After Release from Incarceration Consortium (MARIC), a multi-disciplinary collaboration representing 29 cohorts of adults who have experienced incarceration from 11 countries. Findings across cohorts will be analysed using a two-step, individual participant data meta-analysis methodology.

RESULTS

The combined sample includes 1,337,993 individuals (89% male), with 75,795 deaths recorded over 9,191,393 person-years of follow-up.

CONCLUSIONS

The consortium represents an important advancement in the field, bringing international attention to this problem. It will provide internationally relevant evidence to guide policymakers and clinicians in reducing preventable deaths in this marginalized population.

KEY WORDS

Mortality; incarceration; prison; release; individual participant data meta-analysis; consortium; cohort.

Patient preferences for maintenance PARP inhibitor therapy in ovarian cancer treatment

OBJECTIVE

To measure preferences of women with ovarian cancer regarding risks, side effects, costs and benefits afforded by maintenance therapy (MT) with a poly ADP ribose polymerase (PARP) inhibitor.

METHODS

A discrete-choice experiment elicited preferences of women with ovarian cancer regarding 6 attributes (levels in parentheses) relevant to decisions for MT versus treatment break: (1) overall survival (OS; 36, 38, 42 months); (2) progression-free survival (PFS; 15, 17, 21 months); (3) nausea (none, mild, moderate); (4) fatigue (none, mild, moderate); (5) probability of death from myelodysplastic syndrome/acute myelogenous leukemia (MDS/AML; 0% to 10%); (6) monthly out-of-pocket cost ($0 to $1000). Participants chose between 2 variable MT scenarios and a static scenario representing treatment break, with multiple iterations. Random-parameters logit regression was applied to model choices as a function of attribute levels.

RESULTS

95 eligible participants completed the survey; mean age was 62, 48% had recurrence, and 17% were ever-PARP inhibitor users. Participants valued OS (average importance weight 24.5 out of 100) and monthly costs (24.6) most highly, followed by risk of death from MDS/AML (17.9), nausea (14.7), PFS (10.5) and fatigue (7.8). Participants would accept 5% risk of MDS/AML if treatment provided 2.2 months additional OS or 4.8 months PFS. Participants would require gains of 2.6 months PFS to accept mild treatment-related fatigue and 4.4 months to accept mild nausea.

CONCLUSIONS

When considering MT, women with ovarian cancer are most motivated by gains in OS. Women expect at least 3-4 months of PFS benefit to bear mild side effects of treatment.

Strategies to improve continuity maintenance for people with dementia: a rapid realist review

OBJECTIVES

People with life-limiting diseases such as dementia are living longer. How to improve the quality of life of those living with dementia is an important challenge for society. Continuity maintenance in older adulthood is a psychosocial adaptation strategy by searching for preference and familiarity, making a sense of connection, and creating coherence. Continuity maintenance is a useful concept for effective dementia care, which could bring psychosocial benefits. This review investigates effective ways of continuity maintenance for people with dementia (PWD).

STUDY DESIGN

A rapid realist review (RRR) of a comprehensive range of databases was conducted.

METHODS

Realist review methodology provides an explanatory analysis of what works for whom, in what circumstances, and is characterized by its focus on strategies/interventions, contexts, mechanisms, and outcomes. A literature search was conducted using four databases, and articles discussing potential interventions to maintain continuity in PWD were included. Data were extracted on key variables related to contextual factors, mechanisms, and outcomes.

RESULTS

Four key themes emerged: (1) maintaining personal identity, (2) maintaining social identity, (3) keeping a familiar environment, and (4) sustaining daily activities. It is hypothesized that these four factors combine and interact to maintain continuity and ultimately lead to psychosocial benefits.

CONCLUSIONS

Maintenance of identity, environment, and activities is central to continuity for PWD. The resulting model and program theories respond to the need for a coherent approach to continuity maintenance. Using the foundations created by this RRR, nursing homes may psychosocially improve PWD through maintaining continuity.

RRAM-based synapse devices for neuromorphic systems

Hardware artificial neural network (ANN) systems with high density synapse array devices can perform massive parallel computing for pattern recognition with low power consumption. To implement a neuromorphic system with on-chip training capability, we need to develop an ideal synapse device with various device requirements, such as scalability, MLC characteristics, low power operation, data retention, and symmetric/linear conductance changes under potentiation/depression modes. Although various devices have been proposed for synapse applications, they have limitations for application in neuromorphic systems. In this paper, we will cover various RRAM synapse devices, such as filamentary switching RRAM (HfOx, TaOx, Cu-CBRAM) and analog RRAM devices, based on interface resistive switching (Pr0.7Ca0.3MnOx and TiOx) and ferroelectric polarization (HfZrOx). By optimizing potentiation/depression conditions, we could improve the conductance linearity and MLC characteristics of filamentary synapse devices. Interface RRAM has better MLC characteristics with limited retention and conductance linearity. By controlling the reactivity of metal electrodes and the oxygen concentration in oxides, we can modulate the synapse characteristics. Metal-Ferroelectric-Insulator-Semiconductor (MFIS) FET devices exhibit good retention characteristics and analog memory characteristics due to polarization. Based on various synapse device characteristics, we have estimated the pattern recognition accuracy of MNIST handwritten digits and CIFAR-10 datasets. We have confirmed that synapse device characteristics directly affect the pattern recognition accuracy of ANNs. In order to simultaneously satisfy all the requirements of synapse devices, it is necessary to develop new technology capable of controlling the movement of oxygen vacancies and metal ions at the atomic scale. Considering the limited synapse characteristics of current 2-terminal RRAM devices, hardware ANNs capable of only off-chip training can be constructed by optimizing the current RRAM devices by limiting the bit number. A 3-terminal synapse device or a device based on a new operation principle should be developed as an alternative for on-chip training applications.

Comparison of Renal Outcomes in Patients With Left Ventricular Assist Device and Heart Transplantation

BACKGROUND

Renal function is a major consideration for orthotopic heart transplantation (OHT) and left ventricular assist device (LVAD) therapy. We compared serial changes in renal function and outcomes between patients who underwent OHT and LVAD therapy over 12 months.

METHODS

Forty-five and 58 consecutive patients who underwent LVAD implantation (all bridge to transplant or candidacy) and OHT from April 2014 to November 2016 were included. Six of these patients were in both LVAD and OHT cohorts. Survival analysis was calculated using Kaplan Meier and log rank methods. Univariate analysis of data was performed using χ², Mann-Whitney, Kruskal-Wallis, and Wilcoxon signed rank tests where appropriate. Comparisons of the renal function to baseline were conducted using generalized estimating equations.

RESULTS

Renal function had a biphasic course among the LVAD cohort, increasing at 30 days but reducing at 6 and 12 months. Meanwhile, estimated glomerular filtration rate (eGFR) was seen to progressively decline among OHT recipients. Altogether, eGFR was significantly higher at 6 and 12 months among the LVAD cohort compared to OHT (68.3 vs 59.4, P = .046; 68.3 vs 50.4, P = .015). Compared to the baseline average, eGFR had risen among the LVAD patients (P = .031) but had decreased among the OHT group (P < .001) at 12 months. No significant difference in survival was seen at 1 year (84.4% vs 81.0%; P = .540) and 2 years (78.3% vs 78.8%, P = .687) between the cohorts.

CONCLUSION

Despite poorer baseline renal function, LVAD therapy was associated with comparable survival and better renal outcomes compared to OHT at 12 months. Renal impairment may favor the use of LVAD therapy over OHT in the short term.

Prognostic utility of serial 18F-FDG-PET/CT in patients with locally advanced rectal cancer who underwent tri-modality treatment

OBJECTIVE

This study explored the value of serial 18-fludeoxyglucose-positron emission tomography (¹⁸F-FDG-PET/CT) in predicting disease-free survival (DFS) in locally advanced rectal cancer (LARC) treated with neoadjuvant chemoradiation (NCRT) and surgery.

METHODS

We prospectively studied 46 patients with LARC who underwent NCRT and surgery. ¹⁸F-FDG-PET/CT scans were performed at three time-points before surgery (pre-NCRT-PET1, during NCRT-PET2 and following completion of NCRT-PET3). The following semi-quantitative PET parameters were analysed at each time point: maximum standardized uptake value (SUVmax), SUVmean, metabolic tumour volume (MTV) and tumour lesion glycolysis (TLG). Absolute and percentage changes in these parameters were analysed between time points. Statistical analysis consisted of median tests, Cox regression and Kaplan-Meier analysis for DFS.

RESULTS

The median follow-up time was 24 months. A reduction in PET parameters showed statistically significant differences for patients with recurrence compared to those without; percentage changes in MTV between PET1 and PET3 (cut-off: 87%, p = 0.023), percentage changes in TLG between PET1 and PET3 (cut-off: 94%, p = 0.02) and absolute change in MTV PET1 and PET2 (cut-off: 10.25, p = 0.001).An absolute reduction in MTV between PET1 and PET3 (p=0.013), a percentage reduction in TLG between PET1 and PET2 (p=0.021), SUVmax and SUVmean at PET2 (p = 0.01, p = 0.027 respectively)were also prognostic indicators of recurrence.MTV percentage change between PET1 and PET2 and SUVmean percentage change between PET1 and PET3 were also trending towards significance (p = 0.052, p = 0.053 respectively).

CONCLUSION

Serial ¹⁸F-FDG-PET/CT is a potentially reliable non-invasive method to predict recurrence in patients with LARC. Volumetric parameters were the best predictors. This could allow risk-stratification in patients who may benefit from conservative management.

ADVANCES IN KNOWLEDGE

This paper will add to the literature in risk-stratifying patients with LARC based on prognosis, using ¹⁸F-FDG-PET/CT. This may improve patient outcomes by selecting suitable candidates for conservative management.

4291Six-month outcomes from the multicenter, prospective study with the novel PASCAL transcatheter valve repair system for patients with mitral regurgitation in the CLASP study

Background

Severe mitral regurgitation may lead to an impaired prognosis if left untreated. Transcatheter treatment options have emerged as an alternative to surgery and an adjunct to medical therapy. We report the six-month results of the PASCAL transcatheter valve repair system in treating patients with mitral regurgitation enrolled in the multicenter, prospective, single arm CLASP study.

Methods

The PASCAL Transcatheter Valve Repair System is a leaflet repair therapy that uses clasps and paddles to place a woven Nitinol spacer between the native valve leaflets to fill the regurgitant orifice via a transseptal approach. Eligible patients had clinically significant MR despite optimal medical therapy and were deemed candidates for transcatheter mitral repair by the local Heart Team. Safety, performance, and clinical outcomes were prospectively assessed at baseline, discharge, 30 days, and 6 months post-procedure. All major adverse events (MAE) were adjudicated by an independent clinical events committee and echocardiographic images were assessed by a core lab. The MAE rate was the primary safety endpoint, defined as the composite of cardiovascular mortality, stroke, MI, new need for renal replacement therapy, severe bleeding, and re-intervention for study device-related complications.

Results

Between June 2017 and September 2018, 62 patients were enrolled at 14 sites worldwide for transcatheter mitral valve reconstruction using the PASCAL system. The mean age was 76.5 years (62.9% male). All patients had MR grade ≥3+, with 59% functional, 34% degenerative, and 7% mixed etiology, and 51.6% of patients were in NYHA Class III/IV. Successful implantation of the PASCAL device was achieved in 95% of patients. At discharge, 95% of patients had MR grade ≤2+ with 81% grade ≤1+. There was one cardiovascular mortality and the MAE rate was 4.8%. At 30-day follow-up, paired analyses shows that 98% of patients had MR grade ≤2+ with 81% grade ≤1+ and 88% were in NYHA Class I/II (p<0.0001). The 6MWD improved by 38.9 m (p=0.0015) and was accompanied by average improvements in KCCQ and EQ5D scores by 14.1 points (p<0.0001) and 8.3 points (p=0.0028), respectively. The six-month data will be available for presentation.

Conclusions

In this early device experience, the PASCAL transcatheter valve repair system showed an acceptable safety profile and performed as intended in treating patients with mitral regurgitation. The PASCAL device resulted in significant MR grade reduction, which was associated with clinically and statistically significant improvements in functional status, exercise capacity, and quality of life. Continued follow-up is warranted to validate these initial promising results.

Acknowledgement/Funding

Edwards Lifesciences

The future of general surgery training: A Canadian resident nationwide Delphi consensus statement

BACKGROUND

Several models have been introduced to improve and restructure surgical training, but continued barriers exist. Residents are uniquely positioned to offer perspective on practical challenges and needs of reformatting surgical education. This study aimed to establish a nationwide, Delphi consensus statement on the perceptions of Canadian residents regarding the future of general surgery training.

METHODS

Canadian general surgery residents participated in a moderated focus group using the Nominal Group Technique to discuss early subspecialization, competency-based medical education, and transition to practice. Qualitative verbal data were transcribed, categorized into themes, and synthesized into recommendation statements. During an iterative Delphi survey, resident leaders ranked each statement on a 5-point Likert scale of agreement. The survey was terminated once consensus was achieved (≥2 survey rounds and Cronbach's α ≥ 0.80).

RESULTS

A total of 66 statements were synthesized by 16 members of the Canadian Association of General Surgeons Resident Committee. A total of 49 residents participated in the Delphi consensus, which was achieved after 2 voting rounds (Cronbach's α = 0.93). Participants agreed that (1) residency should focus on achieving standardized competencies and milestones based on resident ability to meet specific measurable metrics, (2) early streaming should be offered after "core" milestones and competencies have been achieved, and (3) an explicit period should allow transition-to-independent practice with tailored rotations, greater autonomy, and resident-run clinics. We identified 10 barriers to competency-based medical education implementation.

CONCLUSION

A nationwide consensus regarding the future of surgical training was established among current residents. These findings can inform and help implement guidelines and national curricula that meet the needs of the trainee and address the many challenges they face during their training.

Therapy discontinuation processes in a gynecologic oncology population

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Background: The decision to discontinue anti-cancer therapies in oncology patients is a complex one and may occur in several unique ways. We sought to understand the processes of therapy discontinuation in a gynecologic oncology population and to discern possible changes in the distribution of these processes after implementation of a palliative care (PC) quality improvement project. Methods: Women with incurable gynecologic malignancies seen in the outpatient setting at an academic center were identified with the recommendation for ‘goals of care’ discussion within 3 visits following identification. Processes of discontinuing chemotherapy for this population were assessed and categorized into 1 of 4 categories: definitive outpatient decision, definitive inpatient decision, interruption by hospitalization, treatment holiday, and “no decision.” Retrospective chart review identified a similar cohort of women prior to the implementation of our PC intervention. Univariate analyses were conducted to determine associations between characteristics and binary outcome of definitive outpatient decision versus all other decision processes. Results: 90/102 (88%) pre-intervention subjects and 83/157 (53%) post-intervention subjects had died at time of analysis. Of the total deceased cohort, 59/173 (34%) made a definitive decision to stop therapy in the outpatient setting. After implementation of the PC initiative, there was a trend towards fewer women identified as having made “no decision” (18.1% vs 30%). Those who made a definitive outpatient decision were less likely to die within 30 days of hospitalization than those who did not (OR 0.16 [95% CI 0.07,0.390], p < 0.0001). Conclusions: Discontinuation of therapy is a nuanced concept in gynecologic oncology patients that can be stratified into several processes. While our data demonstrates a possible increase in active decision-making with the PC initiative, a majority of patients near the end of life still did not make definitive therapy cessation decisions. This reveals an urgent need for the development of initiatives to enhance patient engagement and shared decision making for women near the end of life.

Patient preferences for maintenance PARP therapy in ovarian cancer treatment

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Background: Maintenance therapy with PARP inhibitors has become prevalent in treating ovarian cancer. However, the preferences of women with ovarian cancer regarding the risks, side effects and benefits afforded by maintenance therapies are largely unstudied. Methods: A discrete choice experiment was designed to elicit the preferences of women with ovarian cancer regarding 6 attributes (levels presented in parentheses) relevant to the decision for maintenance PARP inhibitor therapy versus surveillance: (1) overall survival (36, 38, 42 months); (2) progression-free survival (15, 17, 21 months); (3) nausea (none, mild, moderate); (4) fatigue (none, mild, moderate); (5) probability of death from myelodysplastic syndrome/acute myelogenous leukemia (MDS/AML) (0%, 1%, 5%, 10%); and (6) monthly out-of-pocket cost ($0, $50, $500, $1,000). Educational material was provided, with embedded questions to test respondents’ understanding. Participants chose between 2 variable clinical scenarios and a constant scenario representing a treatment break, with multiple iterations. Random-parameters logit regression was applied to model participants’ choices as a function of attribute levels. Results: Of 150 women with ovarian cancer recruited, 95 were eligible and completed the survey. The mean age was 62, 48% had recurrent ovarian cancer, and 13% were currently taking a PARP. Participants always significantly preferred better clinical outcomes to worse (except between 0% and 1% risk of MDS/AML), preferred low out-of-pocket cost, and disliked the idea of a treatment break. Participants valued overall survival most (average importance weight 25 out of 100 total), followed by monthly out-of-pocket cost (24), risk of death from MDS/AML (18), nausea (15), PFS (10) and fatigue (8). On average, participants would tolerate a 2% additional risk of MDS/AML in exchange for 2 additional months of PFS and 7% additional risk of MDS/AML in exchange for 6 additional months of PFS. Conclusions: Women with ovarian cancer are willing to accept the side effects of PARP maintenance therapy and a higher than clinically observed risk of MDS/AML in exchange for clinically observed levels of improvement in PFS.

Reduction in opioid use and postoperative pain scores after elective laparotomy with implementation of enhanced recovery after surgery protocol on a gynecologic oncology service

Objective

Enhanced Recovery After Surgery (ERAS) protocols are designed to mitigate the physiologic stress response created by surgery, to decrease the time to resumption of daily activities, and to improve overall recovery. This study aims to investigate postoperative recovery outcomes following gynecologic surgery before and after implementation of an ERAS protocol.

Methods

A retrospective chart review was performed of patients undergoing elective laparotomy at a major academic center following implementation of an ERAS protocol (11/4/2014–7/27/2016) with comparison to a historical cohort (6/23/2013–9/30/2014). The primary outcome was length of hospital stay. Secondary outcomes included surgical variables, time to recovery of baseline function, opioid usage, pain scores, and complication rates. Statistical analyses were performed using Wilcoxon rank sum, Fisher’s exact, and chi squared tests.

Results

One hundred and thirty-three women on the ERAS protocol who underwent elective laparotomy were compared with 121 historical controls. There was no difference in length of stay between cohorts (median 4 days; P = 0.71). ERAS participants had lower intraoperative (45 vs 75 oral morphine equivalents; P < 0.0001) and postoperative (45 vs 154 oral morphine equivalents; P < 0.0001) opioid use. ERAS patients reported lower maximum pain scores in the post-anesthesia care unit (three vs six; P < 0.0001) and on postoperative day 1 (four vs six; P = 0.002). There was no statistically significant difference in complication or readmission rates.

Conclusions

ERAS protocol implementation was associated with decreased intraoperative and postoperative opioid use and improved pain scores without significant changes in length of stay or complication rates.

Patterns of Presentation and Treatment Outcomes of Non-clear-cell Renal Cell Carcinoma and Sarcomatoid Renal Cell Carcinoma Patients in 2 Tertiary Referral Centers in Sydney, Australia

BACKGROUND

Non-clear-cell renal cell carcinoma (nccRCC) and renal cell carcinoma with sarcomatoid features (scRCC) are rare, and represent subtypes with less defined treatment strategies. The aim of this study is to describe the patterns of care and outcomes of these patients in 2 tertiary referral centers in South Western Sydney Local Health District over a 10-year period.

PATIENTS AND METHODS

Patients with RCC seen at South Western Sydney Local Health District from January 1, 2005 to December 31, 2015 were identified from electronic medical records. For each patient, we extracted details regarding demographics, tumor characteristics, treatment, recurrences, and survival, which was analyzed using the Kaplan-Meier method.

RESULTS

Of 178 patients with RCC identified between 2005 and 2015, 23% (n = 41) had nccRCC and 8% (n = 15) had scRCC. Twenty-five patients in total had de novo metastatic disease or disease recurrence. The median follow-up was 46 and 16 months for nccRCC and scRCC, respectively. The median overall survival for nccRCC with metastatic disease was 34 months (range, 14 months to not reached). Seventy percent of these patients received systemic therapy. By contrast, the median overall survival for scRCC with metastatic disease was 10 months (range, 1.6-89 months). Less than one-half of the patients with scRCC received systemic therapy in our cohort, with only 34% receiving no more than 1 line of treatment.

CONCLUSIONS

Our data confirm the rapid and aggressive course of scRCC, highlighting the need for more effective therapeutic strategies in this rare patient population.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

The feasibility of an inpatient intervention to improve end-of-life care in gynecologic oncology patients

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Background: Unscheduled hospitalizations in patients with advanced cancer predicts < 6 month median survival. Patients with cancer hospitalized near the end of life (EOL) often receive aggressive treatments without survival advantages and have poor quality-of-life. EOL discussions and palliative care (PC) services reduce aggressive care. Methods: An intervention was designed to decrease aggressive EOL care in Gynecologic Oncology (GO) inpatients at a high risk for death within 6 months. Inclusion criteria were advanced gynecologic cancer and 1 of the following: bowel obstruction, failure to thrive, dehydration, cancer-related pain, malignant pleural effusion or ascites, or PCN management. Patients were identified by the care team on admission. An independent auditor assessed if patients were appropriately identified. Eligible patients received a 3-part high risk Gynecologic Oncology (HR-GO) bundle: 1) PC consult, 2) goals of care (GOC) conversation ≤ 48 hours of admission, and 3) PC follow-up within 2 weeks of discharge. Data was collected through chart review. Barriers to bundle implementation were identified. Results: 83 eligible patients were admitted between 8/2017-4/2018. 38 patients (46%) had multiple hospital admissions. 41 patients (49%) received the entire bundle during at least one hospital admission. During their 1st hospital admission, 30% of patients received all 3 parts of the HR-GO bundle. Among those who did not receive the entire bundle, 43% had two components missing. PC follow-up was the most commonly missed component, followed by a GOC conversation within 48 hours of admission. As identified by the auditor, twenty percent of eligible patients were not placed into the study cohort during their first hospital admission. Two barriers to bundle implementation were identified:1) the dependence on care team members to identify high-risk patients and 2) the avoidance of needed GOC discussions when patient’s 1° attending was unavailable. Conclusions: The implementation of an inpatient intervention to decrease aggressive EOL care in GO patients is feasible however barriers must be addressed. Currently work on an automated system to identify patients for intervention is ongoing.

Evaluation of a hepatitis C clinical care coordination programme's effect on treatment initiation and cure: A surveillance-based propensity score matching approach

Hepatitis C (HCV) is a viral infection that if left untreated can severely damage the liver. Project INSPIRE was a 3 year HCV care coordination programme in New York City (NYC) that aimed to address barriers to treatment initiation and cure by providing patients with supportive services and health promotion. We examined whether enrolment in Project INSPIRE was associated with differences in HCV treatment and cure compared with a demographically similar group not enrolled in the programme. INSPIRE participants in 2015 were matched with a cohort of HCV-infected persons identified in the NYC surveillance registry, using full optimal matching on propensity scores and stratified by INSPIRE enrolment status. Conditional logistic regression was used to assess group differences in the two treatment outcomes. Two follow-up sensitivity analyses using individual pair-matched sets and the full unadjusted cohort were also conducted. Treatment was initiated by 72% (790/1130) of INSPIRE participants and 36% (11 960/32 819) of study-eligible controls. Among initiators, 65% (514/790) of INSPIRE participants compared with 47% (5641/11 960) of controls achieved cure. In the matched analysis, enrolment in INSPIRE increased the odds of treatment initiation (OR: 5.25, 95% CI: 4.47-6.17) and cure (OR: 2.52, 95% CI: 2.00-3.16). Results from the sensitivity analyses showed agreement with the results from the full optimal match. Participation in the HCV care coordination programme significantly increased the probability of treatment initiation and cure, demonstrating that care coordination for HCV-infected individuals improves treatment outcomes.

An Ecological Study on the Risk of Gastric Cancer With Helicobacter Pylori Prevalence and Other Potential Cofactors in Korea

Background: Korea has a high incidence of gastric cancer and a high prevalence of Helicobacter pylori infection. Observation of prevalence trends and determination of risk factors for gastric cancer are important to establish health policies to prevent and reduce the burden of disease. Currently, there is no evidence of complete correlation between prevalence of H. pylori infection and the occurrence of gastric cancer. Several explanations have been proposed for the paradox of high prevalence of infection and low gastric cancer incidence in certain places, including diet and salt consumption, genetic susceptibility, other infections, aflatoxin-contaminated food, and the interaction of all these factors, but none of them has been clearly established. Aim: To explore the potential effects of prevalence of H. pylori infection and other risk factors on gastric cancer incidence in Korea. Methods: Information on gastric cancer incidence, prevalence of H. pylori infection, and the risk factors for gastric cancer were evaluated from nationally representative data - the Korean National Cancer Registry, nationwide routine health check-up surveillance system, and National Health and Nutrition Survey, respectively. Secular trends of H. pylori infection prevalence and age-standardized incidence rates for gastric cancer by region were examined. Furthermore, trends of income level, education level, marital status, number of family members, smoking status, drinking status, obesity, diabetes, hypertension, dyslipidemia, and age-standardized incidence rates for gastric cancer by region were examined. Results: Gastric cancer incidence showed a decreasing trend from 2011 to 2015; 50.6%–44.4% for men and 22.1%–17.0% for women. The prevalence of H. pylori infection also showed a decreasing trend; from 66.9% in 1998%–54.4% in 2011. In Korea, areas with high prevalence of H. pylori infection also showed high gastric cancer incidence. However, the Chungcheong area showed relatively low prevalence of H. pylori infection, but had the highest gastric cancer incidence in Korea. Other factors which showed similar effects on gastric cancer incidence, like H. pylori infection were large family size (4 or more family members), low income, low education, and obesity. The effect of introduction of 'National Cancer Screening Program' will be evaluated in the final outcome. Conclusion: The results of this study indicated that significant regional differences exist between trends in H. pylori infection prevalence and gastric cancer incidence in Korea. Also, the possibility of lack of association between H. pylori prevalence and the incidence of gastric cancer are suggested. Overall, this study suggests the need for further research to explore potential factors accounting for regional differences in gastric cancer incidence in Korea.

Observation of Complex Time Structures in the Cosmic-Ray Electron and Positron Fluxes with the Alpha Magnetic Spectrometer on the International Space Station

We present high-statistics, precision measurements of the detailed time and energy dependence of the primary cosmic-ray electron flux and positron flux over 79 Bartels rotations from May 2011 to May 2017 in the energy range from 1 to 50 GeV. For the first time, the charge-sign dependent modulation during solar maximum has been investigated in detail by leptons alone. Based on 23.5×10^{6} events, we report the observation of short-term structures on the timescale of months coincident in both the electron flux and the positron flux. These structures are not visible in the e^{+}/e^{-} flux ratio. The precision measurements across the solar polarity reversal show that the ratio exhibits a smooth transition over 830±30 days from one value to another. The midpoint of the transition shows an energy dependent delay relative to the reversal and changes by 260±30 days from 1 to 6 GeV.

Observation of Fine Time Structures in the Cosmic Proton and Helium Fluxes with the Alpha Magnetic Spectrometer on the International Space Station

We present the precision measurement from May 2011 to May 2017 (79 Bartels rotations) of the proton fluxes at rigidities from 1 to 60 GV and the helium fluxes from 1.9 to 60 GV based on a total of 1×10^{9} events collected with the Alpha Magnetic Spectrometer aboard the International Space Station. This measurement is in solar cycle 24, which has the solar maximum in April 2014. We observed that, below 40 GV, the proton flux and the helium flux show nearly identical fine structures in both time and relative amplitude. The amplitudes of the flux structures decrease with increasing rigidity and vanish above 40 GV. The amplitudes of the structures are reduced during the time period, which started one year after solar maximum, when the proton and helium fluxes steadily increase. Above ∼3  GV the p/He flux ratio is time independent. We observed that below ∼3  GV the ratio has a long-term decrease coinciding with the period during which the fluxes start to rise.