Cost-effectiveness of out-of-hospital continuous positive airway pressure for acute respiratory failure: decision analytic modelling using data from a feasibility trial

Background

Standard prehospital management for Acute respiratory failure (ARF) involves controlled oxygen therapy. Continuous positive airway pressure (CPAP) is a potentially beneficial alternative treatment, however, it is uncertain whether this could improve outcomes and provide value for money. This study aimed to evaluate the cost-effectiveness of prehospital CPAP in ARF.

Methods

A cost-utility economic evaluation was performed using a probabilistic decision tree model synthesising available evidence. The model consisted of a hypothetical cohort of patients in a representative ambulance service with undifferentiated ARF, receiving standard oxygen therapy or prehospital CPAP. Costs and quality adjusted life years (QALYs) were estimated using methods recommended by NICE.

Results

In the base case analysis, using CPAP effectiveness estimates form the ACUTE trial, the mean expected costs of standard care and prehospital CPAP were £15,201 and £14,850 respectively and the corresponding mean expected QALYs were 1.190 and 1.128, respectively. The mean ICER estimated as standard oxygen therapy compared to prehospital CPAP was £5685 per QALY which indicated that standard oxygen therapy strategy was likely to be cost-effective at a threshold of £20,000 per QALY (67% probability). The scenario analysis, using effectiveness estimates from an updated meta-analysis, suggested that prehospital CPAP was more effective (mean incremental QALYs of 0.157), but also more expensive (mean incremental costs of £1522), than standard care. The mean ICER, estimated as prehospital CPAP compared to standard care, was £9712 per QALY. At the £20,000 per QALY prehospital CPAP was highly likely to be the most cost-effective strategy (94%).

Conclusions

Cost-effectiveness of prehospital CPAP depends upon the estimate of effectiveness. When based on a small pragmatic feasibility trial, standard oxygen therapy is cost-effective. When based on meta-analysis of heterogeneous trials, CPAP is cost-effective. Value of information analyses support commissioning of a large pragmatic effectiveness trial, providing feasibility and plausibility conditions are met.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-021-00404-8.

Vaginal epithelioid angiosarcoma: A literature review of a rare entity in an unusual site

•

Often asymptomatic, hidden location and present late.

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Radiation is a well-recognised cause of any angiosarcoma irrespective of the anatomic site.

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Management can only be generalised from reported angiosarcomas of the uterus, cervix, and ovary.

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Treatment includes external radiation and intracavitary brachytherapy after surgical excision.

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Follow-up is required to assess efficacy as the prognosis remains poor even with early intervention.

We describe an extremely rare case of a 66-year-old woman with a vaginal epithelioid angiosarcoma. She presented with constitutional symptoms, pelvic pain, vaginal bleeding, and a violaceous vaginal lesion. A thorough gynaecological examination, tissue biopsy and imaging were crucial to establish an accurate diagnosis. With only 3 other cases reported in the literature, epithelioid angiosarcoma of the vagina seem to present late due to their nonspecific presentation and secluded location. Once diagnosed, optimal treatment is difficult to determine and together with the overly aggressive behaviour of these tumours, they are associated with a poor prognosis. To our knowledge, our case study and systematic literature review is the first to compare the management outcomes of epithelioid subtype angiosarcomas of the vagina. The rarity of this pathology contributes to diagnostic difficulties and lack of consensus regarding treatment of angiosarcomas of the vagina.

Detecting Miscoded Diabetes Diagnosis Codes in Electronic Health Records for Quality Improvement: Temporal Deep Learning Approach

BACKGROUND

Diabetes affects more than 30 million patients across the United States. With such a large disease burden, even a small error in classification can be significant. Currently billing codes, assigned at the time of a medical encounter, are the "gold standard" reflecting the actual diseases present in an individual, and thus in aggregate reflect disease prevalence in the population. These codes are generated by highly trained coders and by health care providers but are not always accurate.

OBJECTIVE

This work provides a scalable deep learning methodology to more accurately classify individuals with diabetes across multiple health care systems.

METHODS

We leveraged a long short-term memory-dense neural network (LSTM-DNN) model to identify patients with or without diabetes using data from 5 acute care facilities with 187,187 patients and 275,407 encounters, incorporating data elements including laboratory test results, diagnostic/procedure codes, medications, demographic data, and admission information. Furthermore, a blinded physician panel reviewed discordant cases, providing an estimate of the total impact on the population.

RESULTS

When predicting the documented diagnosis of diabetes, our model achieved an 84% F1 score, 96% area under the curve-receiver operating characteristic curve, and 91% average precision on a heterogeneous data set from 5 distinct health facilities. However, in 81% of cases where the model disagreed with the documented phenotype, a blinded physician panel agreed with the model. Taken together, this suggests that 4.3% of our studied population have either missing or improper diabetes diagnosis.

CONCLUSIONS

This study demonstrates that deep learning methods can improve clinical phenotyping even when patient data are noisy, sparse, and heterogeneous.

Assessing personality at risk in personnel selection and development

This paper demonstrates the validity and usefulness of a count technique to screen for potential personality dysfunctioning in NEO‐PI‐R ratings obtained in selection and professional development assessments. The usefulness of this screening technique for Industrial, Work and Organizational (IWO) psychologists is demonstrated in five different samples that were administered the NEO‐PI‐R for selection or development purposes. Three additional samples served as normative data to compute FFM PD count cut‐offs that can be used for selection and career development decisions. Evidence for the construct validity of 6 out of 10 FFM PD counts was provided, and all FFM PD compound scales were significantly related to important criteria, including the final selection decision, the results of a behaviourally oriented selection interview and self‐rated work competencies. The practical utility and limitations of this count technique for personnel selection and development are discussed. Copyright © 2008 John Wiley & Sons, Ltd.

The diagnostic accuracy of pre-hospital assessment of acute respiratory failure

Introduction:

Acute respiratory failure (ARF) is a common medical emergency. Pre-hospital management includes controlled oxygen therapy, supplemented by specific management options directed at the underlying disease. The aim of the current study was to characterise the accuracy of paramedic diagnostic assessment in acute respiratory failure.

Methods:

A nested diagnostic accuracy and agreement study comparing pre-hospital clinical impression to the final hospital discharge diagnosis was conducted as part of the ACUTE (Ambulance CPAP: Use, Treatment effect and Economics) trial. Adults with suspected ARF were recruited from the UK West Midlands Ambulance Service. The pre-hospital clinical impression of the recruiting ambulance service clinician was prospectively recorded and compared to the final hospital diagnosis at 30 days. Agreement between pre-hospital and hospital diagnostic assessments was evaluated using raw agreement and Gwets AC1 coefficient.

Results:

77 participants were included. Chronic obstructive pulmonary disease (32.9%) and lower respiratory tract infection (32.9%) were the most frequently suspected primary pre-hospital diagnoses for ARF, with secondary contributory conditions recorded in 36 patients (46.8%). There was moderate agreement between the primary pre-hospital and hospital diagnoses, with raw agreement of 58.5% and a Gwets AC1 coefficient of 0.56 (95% CI 0.43 to 0.69). In five cases, a non-respiratory final diagnosis was present, including: myocardial infarction, ruptured abdominal aortic aneurysm, liver failure and sepsis.

Conclusions:

Pre-hospital assessment of ARF is challenging, with limited accuracy compared to the final hospital diagnosis. A syndromic approach, providing general supportive care, rather than a specifically disease-orientated treatment strategy, is likely to be most appropriate for the pre-hospital environment.

PP30 The ambulance service and the child and young person’s advance care plan: listening to families and professionals

Background

The Child and Young Person’s Advance Care Plan (CYPACP) is a set of resources to help families and professionals agree a plan of care to be followed when a child/young person with a life-limiting condition develops potentially (i) reversible intercurrent illnesses or (ii) life-threatening complications of their condition. It covers clinical, psychosocial and spiritual issues, is designed for use in all environments that the child encounters, and can be used as a resuscitation and/or end-of-life plan. Little is known about the experiences of Ambulance Service staff who receive copies of these plans and may be called upon to follow the recommendations for treatment and resuscitation.

Methods

As part of a regional qualitative research study, families who have a CYPACP and members of the ambulance service were invited to share their views and experiences of the CYPACP via an online survey, in focus groups or individual interviews. Underpinned by an interpretative framework, thematic and linguistic analyses are being used to understand the implementation in ‘real-world’ settings, and how the CYPACP shapes the experience, delivery and quality of care.

Results

To date 20 families with a CYPACP and 25 members of the ambulance service have taken part. Analysis is on-going. Preliminary findings show that despite families with CYPACPs having multiple experiences of interactions with the ambulance service, it is rare for ambulance crews to attend a call where a child has a CYPACP in place. Findings also suggest that there are critical points within the process of conveying the information contained within the CYPACP document that could be improved.

Conclusion

Following full analysis, it is anticipated that the ambulance services involvement with the CYPACP planning process will be better understood and that improvement strategies, including revision to existing documentation and identification of specific support needs can be made.

Geospatial Distribution and Predictors of Mortality in Hospitalized Patients With COVID-19: A Cohort Study

BACKGROUND

The global coronavirus disease 2019 (COVID-19) pandemic offers the opportunity to assess how hospitals manage the care of hospitalized patients with varying demographics and clinical presentations. The goal of this study was to demonstrate the impact of densely populated residential areas on hospitalization and to identify predictors of length of stay and mortality in hospitalized patients with COVID-19 in one of the hardest hit counties internationally.

METHODS

This was a single-center cohort study of 1325 sequentially hospitalized patients with COVID-19 in New York between March 2, 2020, to May 11, 2020. Geospatial distribution of study patients' residences relative to population density in the region were mapped, and data analysis included hospital length of stay, need and duration of invasive mechanical ventilation (IMV), and mortality. Logistic regression models were constructed to predict discharge dispositions in the remaining active study patients.

RESULTS

The median age of the study cohort (interquartile range [IQR]) was 62 (49-75) years, and more than half were male (57%) with history of hypertension (60%), obesity (41%), and diabetes (42%). Geographic residence of the study patients was disproportionately associated with areas of higher population density (r s = 0.235; P = .004), with noted "hot spots" in the region. Study patients were predominantly hypertensive (MAP > 90 mmHg; 670, 51%) on presentation with lymphopenia (590, 55%), hyponatremia (411, 31%), and kidney dysfunction (estimated glomerular filtration rate < 60 mL/min/1.73 m2; 381, 29%). Of the patients with a disposition (1188/1325), 15% (182/1188) required IMV and 21% (250/1188) developed acute kidney injury. In patients on IMV, the median (IQR) hospital length of stay in survivors (22 [16.5-29.5] days) was significantly longer than that of nonsurvivors (15 [10-23.75] days), but this was not due to prolonged time on the ventilator. The overall mortality in all hospitalized patients was 15%, and in patients receiving IMV it was 48%, which is predicted to minimally rise from 48% to 49% based on logistic regression models constructed to project disposition in the remaining patients on ventilators. Acute kidney injury during hospitalization (odds ratioE, 3.23) was the strongest predictor of mortality in patients requiring IMV.

CONCLUSIONS

This is the first study to collectively utilize the demographics, clinical characteristics, and hospital course of COVID-19 patients to identify predictors of poor outcomes that can be used for resource allocation in future waves of the pandemic.

HIA on affordable housing policies and its effect on health and services of vulnerable populations

Issue

Lack of affordable housing in Utah for vulnerable populations such as immigrants/refugees, low-income families, single parents and individuals with disabilities. A health impact assessment is necessary to identify the negative health impacts that arise and to determine how a policy to provide more funding for affordable housing can benefit the population. This issue is not specific to Utah and is comparable to other housing situations and policies throughout the U.S.

Description

The six steps of an HIA were completed in 4 months to analyze the potential health effects of affordable housing policy changes among low-income families in Utah. The HIA team completed an extensive literature review and communicated with several stakeholders, policy makers, and community leaders. Public state and national data was gathered and analyzed using a logic model and characterization of effects table.

Results

The bill to increase funding will increase affordable housing units throughout Utah. The negative health impacts for the population will decrease such as respiratory illnesses, hospital visits, crime, mental health disorders, and stress. The bill would also help to increase family housing stability, economic development, educational opportunities for children, and access to transportation.

Lessons

The recommendations include the use of funding for new development or the renovation of existing units, the location of developments should be near public transit to allow residents to take advantage of services that previously would not have been accessible. Developments should be an integrated approach that includes social support and case management services to narrow the gap in Utah and other areas in the U.S.

Key messages

Policies to increase affordable housing produce positive health impacts for vulnerable populations. Overall efforts for affordable housing will give these vulnerable populations better access to basic human needs.

Observations of Buried Lake Drainage on the Antarctic Ice Sheet

Between 1992 and 2017, the Antarctic Ice Sheet (AIS) lost ice equivalent to 7.6 ± 3.9 mm of sea level rise. AIS mass loss is mitigated by ice shelves that provide a buttress by regulating ice flow from tributary glaciers. However, ice-shelf stability is threatened by meltwater ponding, which may initiate, or reactivate preexisting, fractures, currently poorly understood processes. Here, through ground penetrating radar (GPR) analysis over a buried lake in the grounding zone of an East Antarctic ice shelf, we present the first field observations of a lake drainage event in Antarctica via vertical fractures. Concurrent with the lake drainage event, we observe a decrease in surface elevation and an increase in Sentinel-1 backscatter. Finally, we suggest that fractures that are initiated or reactivated by lake drainage events in a grounding zone will propagate with ice flow onto the ice shelf itself, where they may have implications for its stability.

Patient safety incidents and medication errors during a clinical trial: experience from a pre-hospital randomized controlled trial of emergency medication administration

AIM

To assess and evaluate patient safety incidents and in particular, medication errors, during a large multi-center pre-hospital trial of emergency therapy (PARAMEDIC2), in order to inform and improve future pre-hospital medicines trials.

METHODS

The PARAMEDIC2 trial was undertaken across five NHS Ambulance Services in England and Wales with randomisation between December 2014 and October 2017. Patients with an out -of-hospital cardiac arrest unresponsive to initial resuscitation were randomly assigned to 1 mg intravenous adrenaline or matching placebo. Records were reviewed to identify trial medication errors involving documentation and/or clinical protocol errors occurring in trial participants. Causes of medication errors, including root cause analysis where available, were reviewed to identify patterns and themes contributing to these errors.

RESULTS

Eight thousand sixteen patients were enrolled, of whom 4902 received trial medication. A total of 331 patient safety incidents was reported, involving 295 patients, representing an overall rate of 3.6% of these, 166 (50.2%) were documentation errors while 165 (49.8%) were clinical protocol/medication errors. An overall rate of 0-4.5% was reported across all five ambulance services, with a mean of 2.0%. These errors had no impact on patient care or the trial and were all resolved CONCLUSION: The overall medication error rate of 1.8% primarily consisted of administration of open-label adrenaline and confusion with trial medication packs. A similar number of patients had documentation errors. This study is the first to provide data on patient safety incidents relating to medication errors encountered during a pre-hospital trial of emergency medication administration and will provide supporting data for planning future trials in this area.

Abstract B102: Factors contributing to precancerous polyp detection in initial screening colonoscopies

Background: The incidence of colorectal cancer is persistently higher in Black/African Americans than other races in the United States. It is less clear whether Black/African Americans are at higher risk for colonic precancerous polyps, which represent an earlier stage in colorectal adenoma-carcinoma progression.

Methods: A retrospective chart review was performed on initial average-risk screening colonoscopies on patients (age 45-75 years) during 2012 at 3 institutions. Multivariable logistic regression models were used to examine the relationship between potential risk factors and the detection of precancerous polyps.

Results: Of the 2,225 initial screening colonoscopies, 1,495 (67.2%) were performed on Black/African Americans and 566 (25.4%) on Caucasian non-Hispanic patients. The mean age of initial colonoscopies was 57.1 y and 56.0 y for Black and Caucasian patients, respectively. Male patients represented 32.0% and 42.8% of the Black and Caucasian patients, respectively. Obese patients represented 41.4% and 31% of Black and Caucasian patients. A higher percentage (30%) of the Black patients were diagnosed with diabetes mellitus compared to Caucasians (11%). Multivariable logistic regression revealed that performance of the colonoscopy by academic gastroenterologists was associated with higher precancerous polyp detection compared to contractual nonacademic gastroenterologists (OR 1.69 95% CI 1.32-2.17, p&lt;0.0001). Because of this observation, a physician feedback program was initiated, and as of 2017 the polyp detection rates at all three institutions reached 25%. In addition, multivariable analysis also identified older age (OR 1.03/year 95% CI 1,01-1,04 p= 0.0006), male sex (OR 1.60 95%CI 1.32-2.00 p&lt;0.0001), current smoking (1.52 95% CI 1.32-2.17 p&lt;0.0001) and diabetes mellitus (OR 1.27 95% CI 0.99-1.63 p = 0.062) as associated with higher precancerous colon polyp detection or adenoma detection rate (ADR). Neither race, ethnicity, BMI, nor insurance was significantly associated with detection rates.

Conclusions: It is imperative that metrics of polyp detection rates be routinely monitored to ensure that all patients have access to high-quality screening colonoscopies. A prospective observational cohort study will help further identify factors associated with precancerous polyp detection, now that variations in operator detection rates have been addressed.

Citation Format: Yakira David, Lorenzo Ottaviano, Jihye Park, Sadat Iqbal, Michelle Likhtshteyn, Samir Kumar, Helen Lyo, Ayanna Lewis, Brandon Lung, Jesse Frye, Li Huang, Ellen Li, Jie Yang, Laura Martello, Shivakumar Vignesh, Joshua Miller, Evan Grossman. Factors contributing to precancerous polyp detection in initial screening colonoscopies [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr B102.

Molecular Cardioprotection and the Role of Exosomes: The Future Is Not Far Away

Heart disease is the leading cause of death in men and women in the United States. During the past several decades, research into the role of specific intracellular mediators, called exosomes, has advanced the understanding of molecular cardioprotection. Exosomes and the micro-RNAs within them may be potential targets for the development of genetically engineered or biosimilar medications for patients in heart failure or with ischemic cardiac disease. This review discusses anesthetic implications of exosome production and the future micro-RNA applications for cardioprotection.

High-Statistics Measurement of Neutrino Quasielasticlike Scattering at 6 GeV on a Hydrocarbon Target

We measure neutrino charged-current quasielasticlike scattering on hydrocarbon at high statistics using the wideband Neutrinos at the Main Injector beam with neutrino energy peaked at 6 GeV. The double-differential cross section is reported in terms of muon longitudinal (p_{∥}) and transverse (p_{⊥}) momentum. Cross section contours versus lepton momentum components are approximately described by a conventional generator-based simulation, however, discrepancies are observed for transverse momenta above 0.5  GeV/c for longitudinal momentum ranges 3-5 and 9-20  GeV/c. The single differential cross section versus momentum transfer squared (dσ/dQ_{QE}^{2}) is measured over a four-decade range of Q^{2} that extends to 10  GeV^{2}. The cross section turnover and falloff in the Q^{2} range 0.3-10  GeV^{2} is not fully reproduced by generator predictions that rely on dipole form factors. Our measurement probes the axial-vector content of the hadronic current and complements the electromagnetic form factor data obtained using electron-nucleon elastic scattering. These results help oscillation experiments because they probe the importance of various correlations and final-state interaction effects within the nucleus, which have different effects on the visible energy in detectors.

A toolbox for the longitudinal assessment of healthspan in aging mice

The number of people aged over 65 is expected to double in the next 30 years. For many, living longer will mean spending more years with the burdens of chronic diseases such as Alzheimer's disease, cardiovascular disease, and diabetes. Although researchers have made rapid progress in developing geroprotective interventions that target mechanisms of aging and delay or prevent the onset of multiple concurrent age-related diseases, a lack of standardized techniques to assess healthspan in preclinical murine studies has resulted in reduced reproducibility and slow progress. To overcome this, major centers in Europe and the United States skilled in healthspan analysis came together to agree on a toolbox of techniques that can be used to consistently assess the healthspan of mice. Here, we describe the agreed toolbox, which contains protocols for echocardiography, novel object recognition, grip strength, rotarod, glucose tolerance test (GTT) and insulin tolerance test (ITT), body composition, and energy expenditure. The protocols can be performed longitudinally in the same mouse over a period of 4-6 weeks to test how candidate geroprotectors affect cardiac, cognitive, neuromuscular, and metabolic health.

ELECTROCARDIOGRAM CHANGES IN ADDISON DISEASE: POTENTIAL CLINICAL MARKER FOR ADRENAL CRISIS

Objective

To present a unique phenomenon of a patient in addisonian crisis with electrocardiogram (ECG) anomalies that resolved following glucocorticoid therapy.

Methods

We present the case report followed by discussion with literature review.

Results

A 25-year-old male with Addison disease (AD) presented with a 1-week history of lightheadedness, shortness of breath, chest pain, abdominal pain, postural hypotension, and tachycardia. The patient was diagnosed with addisonian crisis and started on intravenous, high-dose glucocorticoids. An ECG showed right-heart axis deviation and T-wave inversions. In the context of ongoing chest pain, there was concern for myocardial ischemic attack and the patient underwent an extensive cardiac evaluation. Cardiac workup was negative and an echocardiogram showed an ejection fraction of 50 to 55%. The ECG abnormalities resolved 1 day into his hospital admission and his other symptoms resolved 2 days following treatment with steroids.

Conclusion

AD is a rare, potentially lethal, and commonly misdiagnosed disease often first encountered clinically amidst an incident episode of adrenal crisis. Our AD patient was undergoing an adrenal crisis with ECG changes positive for probable cardiac ischemia. Glucocorticoid deficiency has been previously linked with decreased cardiac function and myocardial ischemia, though the underlying mechanisms are not fully clear. This patient recovered within 2 days after receiving corticosteroid supplementation. There have been similar cases previously reported. In each of these, patients underwent extensive and costly workup to evaluate cardiac function, yet all patients fully recovered with corticosteroids. Understanding the physiology and clinical presentation of adrenal crisis will be useful in establishing an earlier diagnosis, thus preventing mortality and avoiding unnecessary, expensive evaluations.

Triarchic or septarchic?-Uncovering the Triarchic Psychopathy Measure's (TriPM) structure

The Triarchic Psychopathy Measure (TriPM) is based on a 3-dimensional conceptual model, though few studies have directly tested a 3-factor structure. The current study used a large community sample (N = 1,064, 53% males, M_age = 34) to test the structure of the TriPM via exploratory and confirmatory factor analysis, along with 4 community replication samples from North American and Europe (Ns = 511-603, 33-49% males) and 1 European male offender sample (N = 150). Three of these samples were also used to model the correlations between relevant external correlates and the original TriPM factors versus emergent factors to examine the cost of misspecifying TriPM structure. The model analyses did not support a 3-factor model (comparative fit index = .76, root mean square error of approximation = .08), revealing a number of items with limited statistical information, but uncovered a 7-factor structure (comparative fit index = .92, root mean square error of approximation = .04). From the majority of Boldness, Meanness, and Disinhibition scale items, respectively, emerged 3 factors reflecting Positive Self-Image, Leadership, and Stress Immunity; 2 factors tapping Callousness and Enjoy Hurting; and 2 factors involving Trait Impulsivity and Overt Antisociality. Further, the Enjoy Hurting and Overt Antisociality factors were more strongly correlated with one another than with the other scales from their home domains (Callousness and Impulsivity). All 7 emergent factors were differentially associated with the external correlates, suggesting that the 3 original TriPM factors do not optimally represent the conceptual model underlying the TriPM. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Household water insecurity is strongly associated with food insecurity: Evidence from 27 sites in low- and middle-income countries

OBJECTIVES

Food and water insecurity have both been demonstrated as acute and chronic stressors and undermine human health and development. A basic untested proposition is that they chronically coexist, and that household water insecurity is a fundamental driver of household food insecurity.

METHODS

We provide a preliminary assessment of their association using cross-sectional data from 27 sites with highly diverse forms of water insecurity in 21 low- and middle-income countries across Africa, Asia, the Middle East, and the Americas (N = 6691 households). Household food insecurity and its subdomains (food quantity, food quality, and anxiety around food) were estimated using the Household Food Insecurity Access Scale; water insecurity and subdomains (quantity, quality, and opportunity costs) were estimated based on similar self-reported data.

RESULTS

In multilevel generalized linear mixed-effect modeling (GLMM), composite water insecurity scores were associated with higher scores for all subdomains of food insecurity. Rural households were better buffered against water insecurity effects on food quantity and urban ones for food quality. Similarly, higher scores for all subdomains of water insecurity were associated with greater household food insecurity.

CONCLUSIONS

Considering the diversity of sites included in the modeling, the patterning supports a basic theory: household water insecurity chronically coexists with household food insecurity. Water insecurity is a more plausible driver of food insecurity than the converse. These findings directly challenge development practices in which household food security interventions are often enacted discretely from water security ones.

nab-Paclitaxel plus carboplatin or gemcitabine versus gemcitabine plus carboplatin as first-line treatment of patients with triple-negative metastatic breast cancer: results from the tnAcity trial

Background

Metastatic triple-negative breast cancer (mTNBC) has a poor prognosis and aggressive clinical course. tnAcity evaluated the efficacy and safety of first-line nab-paclitaxel plus carboplatin (nab-P/C), nab-paclitaxel plus gemcitabine (nab-P/G), and gemcitabine plus carboplatin (G/C) in patients with mTNBC.

Patients and methods

Patients with pathologically confirmed mTNBC and no prior chemotherapy for metastatic BC received (1 : 1 : 1) nab-P 125 mg/m2 plus C AUC 2, nab-P 125 mg/m2 plus G 1000 mg/m2, or G 1000 mg/m2 plus C AUC 2, all on days 1, 8 q3w. Phase II primary end point: investigator-assessed progression-free survival (PFS); secondary end points included overall response rate (ORR), overall survival (OS), percentage of patients initiating cycle 6 with doublet therapy, and safety.

Results

In total, 191 patients were enrolled (nab-P/C, n = 64; nab-P/G, n = 61; G/C, n = 66). PFS was significantly longer with nab-P/C versus nab-P/G [median, 8.3 versus 5.5 months; hazard ratio (HR), 0.59 [95% CI, 0.38-0.92]; P = 0.02] or G/C (median, 8.3 versus 6.0 months; HR, 0.58 [95% CI, 0.37-0.90]; P = 0.02). OS was numerically longer with nab-P/C versus nab-P/G (median, 16.8 versus 12.1 months; HR, 0.73 [95% CI, 0.47-1.13]; P = 0.16) or G/C (median, 16.8 versus 12.6 months; HR, 0.80 [95% CI, 0.52-1.22]; P = 0.29). ORR was 73%, 39%, and 44%, respectively. In the nab-P/C, nab-P/G, and G/C groups, 64%, 56%, and 50% of patients initiated cycle 6 with a doublet. Grade ≥3 adverse events were mainly hematologic.

Conclusions

First-line nab-P/C was active in mTNBC and resulted in a significantly longer PFS and improved risk/benefit profile versus nab-P/G or G/C.

Quantum-Enhanced Advanced LIGO Detectors in the Era of Gravitational-Wave Astronomy

The Laser Interferometer Gravitational Wave Observatory (LIGO) has been directly detecting gravitational waves from compact binary mergers since 2015. We report on the first use of squeezed vacuum states in the direct measurement of gravitational waves with the Advanced LIGO H1 and L1 detectors. This achievement is the culmination of decades of research to implement squeezed states in gravitational-wave detectors. During the ongoing O3 observation run, squeezed states are improving the sensitivity of the LIGO interferometers to signals above 50 Hz by up to 3 dB, thereby increasing the expected detection rate by 40% (H1) and 50% (L1).

Immunoaffinity Column Cleanup with Liquid Chromatography for Determination of Aflatoxin M1 in Liquid Milk: Collaborative Study

A collaborative study was conducted to evaluate the effectiveness of an immunoaffinity column cleanup liquid chromatographic method for determination of aflatoxin M1 in milk at proposed European regulatory limits. The test portion of liquid milk was centrifuged, filtered, and applied to an immunoaffinity column. The column was washed with water, and aflatoxin was eluted with pure acetonitrile. Aflatoxin M1 was separated by reversed-phase liquid chromatography (LC) with fluorescence detection. Frozen liquid milk samples both naturally contaminated with aflatoxin M1 and blank samples for spiking, were sent to 12 collaborators in 12 different European countries. Test portions of samples were spiked at 0.05 ng aflatoxin M1 per mL. After removal of 2 noncompliant sets of results, the mean recovery of aflatoxin M1 was 74%. Based on results for spiked samples (blind pairs at 1 level) and naturally contaminated samples (blind pairs at 3 levels) the relative standard deviation for repeatability (RSDr) ranged from 8 to 18%. The relative standard deviation for reproducibility (RSDR) ranged from 21 to 31%. The method showed acceptable within- and between-laboratory precision data for liquid milk, as evidenced by HORRAT values at the low level of aflatoxin M1 contamination.

Determination of Fumonisins B1 and B2 in Corn and Corn Flakes by Liquid Chromatography with Immunoaffinity Column Cleanup: Collaborative Study

A liquid chromatographic (LC) method for the determination of fumonisins B1 (FB1) and B2 (FB2) in corn and corn flakes was collaboratively studied by 23 laboratories, which analyzed 5 blind duplicate pairs of each matrix to establish the accuracy, repeatability, and reproducibility characteristics of the method. Fumonisin levels in the corn ranged from &lt;0.05 (blank) to 1.41 μg/g for FB1 and from &lt;0.05 to 0.56 μg/g for FB2, whereas in the corn flakes they ranged from &lt;0.05 to 1.05 μg/g for FB1 and from &lt;0.05 to 0.46 μg/g for FB2. The method involved double extraction with acetonitrile–methanol–water (25 + 25 + 50), cleanup through an immunoaffinity column, and LC determination of the fumonisins after derivatization with o-phthaldialdehyde. Relative standard deviations for the within-laboratory repeatability (RSDr) of the corn analyses ranged from 19 to 24% for FB1 and from 19 to 27% for FB2; for the corn flakes analyses, RSDr ranged from 9 to 21% for FB1 and from 8 to 22% for FB2. Relative standard deviations for the between-laboratories reproducibility (RSDR) of the corn analyses ranged from 22 to 28% for FB1 and from 22 to 30% for the FB2; for corn flakes analyses, RSDR ranged from 27 to 32% for FB1 and from 26 to 35% for FB2. Mean recoveries of FB1 and FB2 from corn spiked with FB1 at 0.80 μg/g and with FB2 at 0.40 μg/g were 76 and 72%, respectively; for corn flakes spiked at the same levels recoveries were 110 and 97% for FB1 and FB2, respectively. HORRAT ratios for the analyses of corn ranged from 1.44 to 1.53 for FB1 and from 0.96 to 1.48 for FB2, whereas for corn flakes they ranged from 1.60 to 1.82 for FB1 and from 1.39 to 1.68 for FB2.