Predicting the Risk of Disease Recurrence and Death Following Curative-intent Radiotherapy for Non-small Cell Lung Cancer: The Development and Validation of Two Scoring Systems From a Large Multicentre UK Cohort

AIMS

There is a paucity of evidence on which to produce recommendations on neither the clinical nor the imaging follow-up of lung cancer patients after curative-intent radiotherapy. In the 2019 National Institute for Health and Care Excellence lung cancer guidelines, further research into risk-stratification models to inform follow-up protocols was recommended.

MATERIALS AND METHODS

A retrospective study of consecutive patients undergoing curative-intent radiotherapy for non-small cell lung cancer from 1 October 2014 to 1 October 2016 across nine UK trusts was carried out. Twenty-two demographic, clinical and treatment-related variables were collected and multivariable logistic regression was used to develop and validate two risk-stratification models to determine the risk of disease recurrence and death.

RESULTS

In total, 898 patients were included in the study. The mean age was 72 years, 63% (562/898) had a good performance status (0-1) and 43% (388/898), 15% (134/898) and 42% (376/898) were clinical stage I, II and III, respectively. Thirty-six per cent (322/898) suffered disease recurrence and 41% (369/898) died in the first 2 years after radiotherapy. The ASSENT score (age, performance status, smoking status, staging endobronchial ultrasound, N-stage, T-stage) was developed, which stratifies the risk for disease recurrence within 2 years, with an area under the receiver operating characteristic curve (AUROC) for the total score of 0.712 (0.671-0.753) and 0.72 (0.65-0.789) in the derivation and validation sets, respectively. The STEPS score (sex, performance status, staging endobronchial ultrasound, T-stage, N-stage) was developed, which stratifies the risk of death within 2 years, with an AUROC for the total score of 0.625 (0.581-0.669) and 0.607 (0.53-0.684) in the derivation and validation sets, respectively.

CONCLUSIONS

These validated risk-stratification models could be used to inform follow-up protocols after curative-intent radiotherapy for lung cancer. The modest performance highlights the need for more advanced risk prediction tools.

An evaluation of a veterinary-specific mental health service

BACKGROUND

Veterinary professionals are at increased risk of suicide and mental health difficulties compared to the general population. Vetlife Health Support (VHS) is a mental health case management service for veterinarians with mental health difficulties.

AIMS

To evaluate the VHS case management service from the service user's perspective.

METHODS

Service users (n = 98) completed questionnaires assessing their experience with VHS and current mental health status using the Kessler-6 Scale. A sub-sample was interviewed and the data qualitatively analysed (n = 14).

RESULTS

The results show that 97% (n = 95) reported a positive experience with VHS and 98% (n = 96) reported VHS staff respected and listened to them. Participants reported significant improvements in relationships with others after VHS (P < 0.001) and were significantly more likely to be in receipt of formal mental health care after VHS than before (P < 0.01). The main emergent themes from the qualitative interviews were (i) positive communication between clinician and service users, (ii) veterinary-specific mental health services were regarded as important to understanding service users' circumstances, (iii) knowing someone is supporting them positively impacted wellbeing and (iv) confusion with discharge status.

CONCLUSIONS

Most participants reported positive experiences with VHS. Quantitatively, data showed that participants reported significant improvements in relationships and access to formal mental health care after contact with VHS. Interviews with service users revealed that they felt speaking to a mental health professional with veterinary-specific knowledge was beneficial for their wellbeing. Further evaluation assessing whether VHS leads to a measurable impact on psychological wellbeing is recommended.

Burden of Uncontrolled Hyperglycemia and Its Association with Patients Characteristics and Socioeconomic Status in Philadelphia, USA

Purpose: To examine the burden of uncontrolled hyperglycemia in patients with diabetes mellitus (DM) and their characteristics in a large urban city.

Methods: A randomized sample of 4993 patients with DM ≥18 years old who received routine health care in a large university teaching hospital in the city of Philadelphia was analyzed. Uncontrolled hyperglycemia was classified as blood hemoglobin A1c >8%. The associations of uncontrolled hyperglycemia with sociodemographic and cardiovascular factors were analyzed using univariate and multivariate analysis methods.

Results: The results show that patients 18–54 years had the highest prevalence of uncontrolled hyperglycemia (36.0%), followed by those at age 55–64 (30.9%), 65–74 (22.9%), and ≥75 (20.6%) years (p<0.0001). Unadjusted hyperglycemia was significantly associated with patients with increased total cholesterol to high-density lipoprotein ratio (odds ratio [OR]=1.59, 95% confidence interval [CI]: 1.33–1.90, p<0.001), and with prevalent coronary heart disease (OR=1.39, 95% CI: 1.16–1.67, p=0.001). Patients living in neighborhoods with lower socioeconomic status (SES) had significantly higher uncontrolled hyperglycemia rates across the city (r=0.52, R²=0.27, p=0.03).

Conclusions: Findings of this study is one of the first studies to address that younger adults had higher rates of uncontrolled hyperglycemia. Further attention should be paid to the challenges of controlling DM in younger adults and patients who live in neighborhoods with lower SES.

Physical Disorders and Poor Self-Rated Health in Adults Living in Four Latin American Cities: A Multilevel Approach

Considering that urban environments may affect self-rated health through behavioral and psychosocial mechanisms, the aim of this study was to investigate the association between self-rated health and perceived urban environment characteristics among adults living in four Latin American cities. Data is from a population-based survey by Development Bank of Latin America, encompassing adults between 20 and 60 years old in Buenos Aires, Lima, Mexico City, and Panama City. Self-rated health was measured using a single question and the response options were categorized as poor and good. The explanatory variables were empirical Bayes estimates of self-reported area physical disorder, social disorder, access to services, and access to leisure spaces derived from the survey. The covariates were: individual age, sex, education, wealth index, and length of residency in the neighborhood; and an area social environment index. Multilevel logistic regressions with two levels (individual and sub-city areas) were fitted. Poor self-rated health was reported by 34.73% (95% CI: 33.17 to 36.29) of the participants and was associated with physical disorder (OR = 1.16 per SD; 95% CI: 1.02 to 1.32). Our findings suggest that public policies to promote population health should consider area urban environment factors, especially those associated with disorder.

Neighborhood context and kidney disease in Philadelphia

Neighborhood context might influence the risk of chronic kidney disease (CKD), a condition that impacts approximately 10% of the United States population and is associated with significant morbidity, mortality, and costs. We included a sample of 23,692 individuals in Philadelphia, Pennsylvania, who were seen in a large academic primary care practice between January 1, 2016 and December 31, 2017. We used generalized linear equations to estimate the associations between indicators of neighborhood context (e.g., proximity to healthy foods stores, neighborhood walkability, social capital, crime rate, socioeconomic status) and CKD, adjusted for age, sex, race/ethnicity, and insurance coverage. Among those with CKD, secondary outcomes were poor glycemic control (hemoglobin A1c ≥ 6.5%) and uncontrolled blood pressure (systolic ≥ 140 mm Hg and/or diastolic ≥ 90 mm Hg). The cohort represented residents from 97% of Philadelphia census tracts. CKD prevalence was 10%. When all neighborhood context metrics were considered collectively, only lower neighborhood socioeconomic index (a composite assessment of neighborhood income, educational attainment, and occupation) was associated with a higher risk of CKD (lowest tertile vs. highest tertile: adjusted relative risk [aRR] 1.46 [1.25, 1.69]; mid-tertile vs. highest-tertile: aRR 1.35 [1.25, 1.52]). Among those with CKD, compared to residence in the most walkable neighborhoods (i.e., where most essential resources are accessible by foot), residence in neighborhoods with mid-level WalkScore® (i.e., where only some essential neighborhood resources are accessible by foot) was independently associated with poor glycemic control (aRR 1.20, 95% CI 1.01-1.42). These findings suggest a potential role for measures of neighborhood socioeconomic status in identifying communities that would benefit from screening and treatment for CKD. Studies are also needed to determine mechanisms to explain why residence in neighborhoods not easily navigated by foot or car might hinder glycemic control among people with CKD.

Ambient daily pollen levels in association with asthma exacerbation among children in Philadelphia, Pennsylvania

Pollen from trees, grasses, and weeds can trigger asthma exacerbation in sensitized individuals. However, there are gaps in knowledge about the effects, such as the relative risks from different plant taxa and threshold levels of effect. We aimed to describe the local association between pollen and asthma exacerbation among children in the City of Philadelphia, and to evaluate whether effects are modified by children's characteristics and clinical factors (e.g., child's age, race/ethnicity, comorbidities). We conducted a time-stratified case-crossover study of pediatric (age <18 years) asthma exacerbation, with cases identified through electronic health records (EHR) of the Children's Hospital of Philadelphia (CHOP) health system from March through October in the years 2011-2016. Daily pollen counts were obtained from the local National Allergy Bureau certified pollen counter. We applied conditional logistic regression to estimate odds ratios (OR) and 95% confidence intervals (CI) for the association between the pollen level (vs. none detected) and odds of asthma exacerbation, adjusting for temperature, relative humidity, and holidays. We estimated same-day exposure effects, as well as effects from exposure lagged by up to 5 days. There were 35,040 asthma exacerbation events during the study period, with the majority occurring among black, non-Hispanic children (81.8%) and boys (60.4%). We found increased odds of asthma exacerbation among Philadelphia children in association with tree pollen, both for total tree pollen and most individual tree types. Increased odds from total tree pollen were observed at the lowest levels studied (≤5 grains/m³, unlagged, OR = 1.06, 95% CI: 1.02, 1.10), and exhibited a positive exposure-response pattern of effect; tree pollen levels above 1000 grains/m³ (unlagged) were associated with 64% increased odds of asthma exacerbation (95% CI: 1.45, 1.84). Grass pollen was associated with asthma exacerbation only at levels above the 99^th percentile (52 grains/m³), which occurred, on average, two days per year during the study period (with 2-day lag, OR = 1.38, 95% CI: 1.19, 1.60). There was an inverse association (reduced asthma exacerbation) with ragweed pollen that was consistent across analyses. Pollen from other weeds was associated with increased odds of asthma exacerbation, without a clear exposure-response pattern (2-day lag, significant increases ranging from 8% to 19%). Increased odds from tree pollen and weeds (other than ragweed) were higher among children with allergic rhinitis. While there are known benefits from urban vegetation for human health, there are risks as well. It is important to note, however, that pollen is released during a limited time frame each year, and advisories informed by local data can enable susceptible individuals to avoid outdoor exposure on high-risk days.

Loss of the laminin subunit alpha-3 induces cell invasion and macrophage infiltration in cutaneous squamous cell carcinoma

BACKGROUND

Cutaneous squamous cell carcinoma (cSCC) is a common cancer that invades the dermis through the basement membrane. The role of the basement membrane in poorly differentiated cSCC is not well understood.

OBJECTIVES

To study the effect that loss of the laminin subunit alpha-3 (α3) chain from the tumour microenvironment has on tumour invasion and inflammatory cell recruitment.

METHODS

We examined the role of the basement membrane proteins laminin subunits α3, β3 and γ2 in SCC invasion and inflammatory cell recruitment using immunohistochemistry, short hairpin RNA knockdown, RNA-Seq, mouse xenograft models and patient tumour samples.

RESULTS

Analysis of SCC tumours and cell lines using antibodies specific to laminin chains α3, β3 and γ2 identified a link between poorly differentiated SCC and reduced expression of laminin α3 but not the other laminin subunits investigated. Knockdown of laminin α3 increased tumour invasion both in vitro and in vivo. Western blot and immunohistochemical staining identified increased phosphorylated myosin light chain with loss of laminin α3. Inhibition of ROCK (rho-associated protein kinase) but not Rac1 significantly reduced the invasive potential of laminin α3 knockdown cells. Knockdown of laminin subunits α3 and γ2 increased monocyte recruitment to the tumour microenvironment. However, only the loss of laminin α3 correlated with increased tumour-associated macrophages both in xenografted tumours and in patient tumour samples.

CONCLUSIONS

These data provide evidence that loss of the laminin α3 chain in cSCC has an effect on both the epithelial and immune components of cSCC, resulting in an aggressive tumour microenvironment.

Association of Adverse Neighborhood Exposures With HIV Viral Load in Pregnant Women at Delivery

IMPORTANCE

Racial disparities in maternal morbidity and mortality are in large part driven by poor control of chronic diseases. The association between adverse neighborhood exposures and HIV virologic control has not been well described for women with HIV during pregnancy.

OBJECTIVE

To evaluate the association between adverse neighborhood exposures and HIV viral load at delivery.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study assessed HIV surveillance data for pregnant women with HIV who had live deliveries in Philadelphia from January 1, 2005, through December 31, 2015. Data analyses were completed in August 2020.

EXPOSURES

Neighborhood exposures included extreme poverty, educational attainment, crime rates (using separate and composite measures), and social capital categorized above or below the median. Each neighborhood exposure was modeled separately to estimate its association with elevated HIV viral load.

MAIN OUTCOMES AND MEASURES

The main outcome was elevated HIV viral load of ≥200 copies/mL at delivery. We hypothesized that adverse neighborhood exposures would be associated with higher odds of having an elevated viral load at delivery. Confounders included birth year, age, race/ethnicity, previous birth while living with HIV, and prenatal HIV diagnosis. Prenatal care and substance use were considered potential mediators. We used logistic mixed effects models to estimate the association between neighborhood exposures and elevated viral load, adjusting for confounders in Model 1 and confounders and mediators in Model 2.

RESULTS

There were 905 births among 684 women with HIV, most of whom were aged 25 to 34 years (n = 463 [51.2%]) and were Black non-Hispanic (n = 743 [82.1%]). The proportion of women with elevated viral load decreased from 58.2% between 2005 and 2009 to 23.1% between 2010 and 2015. After adjusting for confounders in Model 1, higher neighborhood education was associated with lower odds of having an elevated viral load (adjusted odds ratio [AOR], 0.70; 95% CI, 0.50-0.96). More violent crime (AOR, 1.51; 95% CI, 1.10-2.07), prostitution crime (AOR, 1.46; 95% CI, 1.06-2.00), and a composite measure of crime (AOR, 1.44; 95% CI, 1.05-1.98) were positively associated with having a higher HIV viral load. These associations remained after adjusting for mediators in Model 2. In addition, the AOR for intermediate prenatal care varied between 1.93 (95% CI, 1.28-2.91) and 1.97 (95% CI, 1.31-2.96), whereas the AOR for inadequate prenatal care varied between 3.01 (95% CI, 2.05-4.43) and 3.06 (95% CI, 2.08-4.49) across regression models.

CONCLUSIONS AND RELEVANCE

In this cohort study, adverse neighborhood exposures during pregnancy and poor engagement in prenatal care were associated with poor virologic control at delivery. These findings suggest that interventions targeted at improving maternal health need to take the social environment into consideration.

Heavy precipitation and asthma exacerbation risk among children: A case-crossover study using electronic health records linked with geospatial data

Extreme precipitation events may be an important environmental trigger for asthma exacerbations in children. We used a time stratified case-crossover design and data from a large electronic health record database at the Children's Hospital of Philadelphia (CHOP) to estimate associations of daily heavy precipitation (defined as > 95th percentile of the summertime distribution) with asthma exacerbation among children. We defined control days as those falling on the same day of the week within the same month and year as the case. We restricted our primary analyses to the summer months in years 2011-2016 and used conditional logistic regression models to estimate associations between heavy precipitation and acute asthma exacerbations in both outpatient (primary care, specialty care, and emergency department) and inpatient settings. We investigated numerous individual-level (e.g., age, sex, eczema diagnosis) and environmental measures (e.g., greenspace, particulate matter) as potential effect modifiers. The analysis include 13,483 asthma exacerbations in 10,434 children. Odds of asthma exacerbation were 11% higher on heavy precipitation vs. no precipitation days (95% CI: 1.02-1.21). There was little evidence of effect modification by most measures. These results suggest that heavy summertime precipitation events may contribute to asthma exacerbations. Further research using larger datasets from other health systems is needed to confirm these results, and to explore underlying mechanisms.

Discrimination and Hypertension Risk Among African Americans in the Jackson Heart Study

African Americans have a higher risk of hypertension compared with other racial or ethnic groups in the United States. One possible explanation for this disparity is discrimination. Few studies have examined the association between discrimination and incidence of hypertension. We examined whether everyday discrimination, lifetime discrimination, and stress from discrimination were associated with incident hypertension and whether these associations differed by gender, age, discrimination attribution, and coping responses to discrimination among African Americans in the Jackson Heart Study. Discrimination was self-reported by 1845 African Americans aged 21 to 85 years without hypertension at baseline (2000-2004). Participants completed 2 follow-up study visits from 2005 to 2008 and 2009 to 2013. We used Cox proportional hazards regression to estimate associations of discrimination with incident hypertension. Overall, 52% (n=954) of the participants developed hypertension over the follow-up period. After adjustment for age, gender, socioeconomic status and hypertension risk factors, medium versus low levels of lifetime discrimination (hazard ratio, 1.49 [95% CI, 1.18-1.89]), and high versus low levels of lifetime discrimination (hazard ratio, 1.34 [95% CI, 1.07-1.68]) were associated with a higher incidence of hypertension. No statistically significant interactions with gender, age, attribution, or coping were present. Higher stress from lifetime discrimination was associated with higher hypertension risk after adjustment for demographics (hazard ratio for high versus low, 1.19 [95% CI, 1.01-1.40]), but the association was attenuated after adjustment for hypertension risk factors (hazard ratio, 1.14 [95% CI, 0.97-1.35]). Lifetime discrimination may increase the risk of hypertension in African Americans.

Abstract 2354: Multilevel analysis of colorectal cancer screening in southeastern Pennsylvania

Background: Colorectal cancer (CRC) is a leading cause of mortality in the US. There are racial and socioeconomic disparities in CRC incidence and mortality, in part due to underuse of CRC screening. The goal of this cross-sectional study was to examine multilevel factors associated with CRC screening in Southeastern PA.

Methods: We conducted a cross-sectional study using the Public Health Management Corporation's Community Health Database household survey (2010-2015) and American Community Survey data (2010-2014) to examine multilevel factors related to CRC screening via sigmoidoscopy and colonoscopy. We compared adults age 50+ that received CRC screening within 10 years (N=12963) to non-compliant individuals (N=4585), according to American Cancer Society guidelines. We conducted descriptive analyses to compare individual and residential census tract characteristics of the compliant and non-compliant groups. Multilevel regression models including random intercepts for census tracts (CTs) and CT-level socioeconomic status (SES) were used to examine independent associations with CRC screening compliance. P-values &lt;0.05 were considered statistically significant.

Results: In bivariate analysis, we observed that individuals that did not comply with CRC screening recommendations were more likely to be younger, male, non-black, unmarried, less educated, uninsured, and current smokers than those in compliance. Non-compliant individuals were also more likely to live in areas with lower SES, shorter distance to public transportation, lower educational attainment, lower median income, and higher percentages of uninsured, unemployed, poverty and households on public assistance compared to those in compliance. In multilevel regression analysis, being unmarried (OR=1.49, 95% CI=1.34-1.65), uninsured (OR=1.65, 95% CI=1.30-2.10), or living in lower SES census tracts (below the first SES quartile: OR=1.48, 95% CI=1.30-1.69 and between the 2nd and 3rd quartile: OR=1.51, 95% CI=1.29-1.75 vs. above the highest quartile) were associated with non-compliance in CRC screening recommendations. There were no interactions detected between race and census tract SES in these models.

Conclusions: We identified multilevel factors (marital status, health insurance status, and residential SES) significantly associated with non-compliance to CRC screening recommendations. Individuals and CTs with low levels of compliance can be identified and targeted for tailored interventions, such as peer support and community education about CRC in future studies. Future studies might examine how the availability and location of screening facilities may relate to CRC screening recommendation compliance rates in different neighborhoods.

Citation Format: Charnita M. Zeigler-Johnson, Scott Keith, Kari Moore, Russell McIntire, Preethi Selvan, Steven Melly, Ana Diez-Roux. Multilevel analysis of colorectal cancer screening in southeastern Pennsylvania [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 2354.

Primary Care Accessibility Effects on Health Care Utilization Among Urban Children

OBJECTIVE

Evidence suggests that spatial accessibility to primary care is a contributing factor to appropriate health care utilization, with limited primary care access resulting in avoidable hospitalizations and emergency department visits which are burdensome on individuals and our health care system. Limited research, however, has examined the effects on children.

METHODS

We evaluated associations of spatial accessibility to primary care on health care utilization among a sample of 16,709 children aged 0 to 3 years in Philadelphia who were primarily non-White and publicly insured. Log-Poisson models with generalized estimating equations were used to estimate incidence rate ratios (RR) and 95% confidence intervals (CI), while accounting for 3 levels of clustering (within individual, within primary care practice, within neighborhood).

RESULTS

In age-adjusted models, the lowest level of spatial accessibility was associated with 7% fewer primary care visits (RR 0.93, 95% CI 0.91, 0.95), 15% more emergency department visits (RR 1.15, 95% CI 1.09, 1.22), and 18% more avoidable hospitalizations (RR 1.18, 95% CI 1.01, 1.37). After adjustment for individual- (race/ethnicity, sex, number of chronic conditions, insurance status) and neighborhood-level (racial composition and proportion of housing units with no vehicle), spatial accessibility was not significantly associated with rate of health care utilization.

CONCLUSIONS

Individual-level predisposing factors, such as age, race, and need, attenuate the association between accessibility to primary care and use of primary care, emergency department visits, and avoidable hospitalization. Given the possibility of modifying access to primary care unlike immutable individual factors, a focus on spatial accessibility to primary care may promote appropriate health care utilization.

Absence of the Musculocutaneous Nerve and Associated Compensation by the Median Nerve

The musculocutaneous and median nerves frequently show variations from their normal course. The purpose of this paper is to report a rare variation, in which the right musculocutaneous nerve was absent. Consequently, the median nerve supplied motor innervation to the flexor compartment of the arm and sensory innervation to the lateral aspect of the forearm. The primary targets of this paper are orthopedic surgeons, anesthesiologists and radiologists. In cases of injuries to the upper limb, knowledge of these variations can assist them in avoiding misdiagnoses.

The logistical management of tertiary urethral disease in the United Kingdom: Implications from an online audit of male reconstructive urethral surgery

Objective:

To determine those patient groupings, based on volume and risk, whose optimal urethral reconstructive management might be provided by a reorganisation of UK reconstructive surgeons.

Methods:

Between 2010 and 2017, ~689 men/year were enrolled onto an online audit platform collecting data about urethral reconstruction in the UK; this accrual was compared against hospital episode statistics (HES). The available workforce, and where this was based, was collected. Individual and institutional incumbent patient volumes, pathology, surgical complexity and outcomes from treatment were collated to stratify volume/risk groups.

Results:

More than 90% of all HES-recorded data were accrued, being provided by 50 surgeons at 39 operative sites. Most reconstructive surgery was provided at 10 centres performing >20 procedures/year. More than 50% of all interventions were of a high-volume low-risk type. Of activity, 32.3% was intermediate volume or moderate risk, and 12.5% of men presented for lower-volume or higher-risk procedures.

Conclusion:

Correlation of detailed volume/outcome data allows the definition of patient populations presenting for urethral reconstruction. Stratification of each group’s management, to optimise the surgical outcome, may be applied to a hierarchical service delivery model based on the complexity of the patient’s presenting urethral pathology.

Level of evidence:

Level IV

Rapid polarization mapping in ferroelectrics using Fourier masking

Ferroelectric materials, and more specifically ferroelectric domain walls (DWs) have become an area of intense research in recent years. Novel physical phenomena have been discovered at these nanoscale topological polarization discontinuities by mapping out the polarization in each atomic unit cell around the DW in a scanning transmission electron microscope (STEM). However, identifying these features requires an understanding of the polarization in the overall domain structure of the TEM sample, which is often a time-consuming process. Here, a fast method of polarization mapping in the TEM is presented, which can be applied to a range of ferroelectric materials. Due to the coupling of polarization to spontaneous strain, we can isolate different strain states and demonstrate the fast mapping of the domain structure in ferroelectric lead titanate (PTO). The method only requires a high-resolution TEM or STEM image and is less sensitive to zone axis or local strain effects, which may affect other techniques. Thus, it is easily applicable to in-situ experiments. The complimentary benefits of Fourier masking with more advanced mapping strategies and its application to other materials are discussed. These results imply that Fourier masked polarization mapping will be a useful tool for electron microscopists in streamlining their analysis of ferroelectric TEM samples. LAY DESCRIPTION: This paper addresses a problem that often occurs when looking at a ferroelectric material in the Transmission Electron Microscope (TEM). Ferroelectric samples are interesting because they form tiny areas inside themselves with arrow of charge in each one. The thinner the sample, the smaller these regions, called "domains" become. These arrows of charge point in different directions in each domain of the sample. The boundary where these domains meet have interesting properties to study in a TEM but it's important to figure out which way the arrows point in the domains around the boundary. What causes the arrows in the different domains is tiny shifts of different atoms in unit cell away from their neutral position, usually because they're being squeezed by pressure from the domains nearby. The problem is that these tiny atoms moving are difficult to measure and see where the charged arrow is pointing, often it's hard to know how many different domains are even in the sample and where they begin. This paper discusses a method called "Fourier masking" to quickly see what's going on in the overall TEM sample, where the domains are and roughly where the arrows point. It does this by looking at the spacings of the atoms from a magnification where you can just about see the lines of atoms. In lead titanate the unit cell is a rectangle and the arrow always points in line with the long side of the rectangle. The Fourier masking lets you see which direction the long side of the rectangular unit cell is pointing in different parts of your TEM image. The big advantage is that it takes about two minutes to do and uses software that almost every TEM already has. That lets the TEM user quickly know where the domains are in their TEM samples and roughly which way the arrows of charge are pointing. Then they can choose the most interesting features focus on for higher resolution analysis.

Abstract TP294: Can Stroke Systems of Care Improve Measure Compliance and Outcomes Through Statewide Hospital Collaboration?

Background: The Stroke Encounter Quality Improvement Project (SEQIP) launched in 2009 as a statewide voluntary initiative and collaboration between the American Heart Association, the Kentucky Department for Public Health and 16 acute care hospitals interested in improving stroke care in their communities. The mission is to advance acute stroke care and reduce disparities in Kentucky by: establishing a network that encourages and supports collaboration; increases access to stroke care by targeting underserved areas; provides opportunities to share resources related to program development and proficiency across the continuum of care; and promotes quality outcomes and standardization of care through collegiality and use of evidence-based guidelines and research collaboration.

Purpose: The goal of this unfunded initiative (now in its tenth year) has been to increase adherence to evidence-based guidelines for stroke patients by implementing a unified statewide effort.

Methods: Get With The Guidelines-Stroke data were reviewed with the founding 16 SEQIP hospitals and adherence to evidence-based guidelines was measured and analyzed over a 10-year period.

Results: SEQIP has grown to a network of 35 hospitals with 23 submitting data; patient records increased from 4358 (2008) to 10015 (2018); hospitals achieving Gold GWTG award status increased from 4 to 16; certified stroke centers grew from 4 to 32 decreasing geographic barriers to the nearest certified center; and, SEQIP hospitals achieved statistically significant improvement in all stroke measures.

Conclusions: With deployment of strategically targeted action plans and expected accountability, competing hospitals can collaborate on a statewide level. Sharing of best practices across organizations can empower stroke teams to implement effective strategies within the confines of their resources to achieve collective goals.

High Ambient Temperature and Infant Mortality in Philadelphia, Pennsylvania: A Case-Crossover Study

OBJECTIVE

To quantify the association between heat and infant mortality and identify factors that influence infant vulnerability to heat.

METHODS

We conducted a time-stratified case-crossover analysis of associations between ambient temperature and infant mortality in Philadelphia, Pennsylvania, during the warm months of 2000 through 2015. We used conditional logistic regression models to estimate associations of infant mortality with daily temperatures on the day of death (lag 0) and for averaging periods of 0 to 1 to 0 to 3 days before the day of death. We explored modification of associations by individual and census tract-level characteristics and by amounts of green space.

RESULTS

Risk of infant mortality increased by 22.4% (95% confidence interval [CI] = 5.0%, 42.6%) for every 1°C increase in minimum daily temperature over 23.9°C on the day of death. We observed limited evidence of effect modification across strata of the covariates.

CONCLUSIONS

Our results contribute to a growing body of evidence that infants are a subpopulation that is particularly vulnerable to climate change effects. Further research using large data sets is critically needed to elucidate modifiable factors that may protect infants against heat vulnerability.