An emergency-department-initiated outreach program for patients with opioid use disorder is associated with an increase in agonist therapy and engagement in addictions care: a one-year cohort study

BACKGROUND

People with opioid use disorder (OUD) are high-risk for short-term mortality and morbidity. Emergency department (ED) interventions can reduce those risks, but benefits wane without ongoing community follow-up.

OBJECTIVE

To evaluate an ED-based intensive community outreach program.

METHODS

At two urban EDs between October 2019 and March 2020, we enrolled patients with OUD not currently on opioid agonist therapy (OAT) in a prospective cohort study evaluating a one-year intensive community outreach program, which provided ongoing addictions care, housing resources, and community support. We surveyed patients at intake and at scheduled outreach encounters at one, two, six, and twelve months. Follow-up surveys assessed OAT uptake, addictions care engagement, housing status, quality of life scores, illicit opioid use, and outreach helpfulness. We used descriptive statistics for each period and conducted sensitivity and subgroup analyses to account for missing data.

RESULTS

Of 84 baseline participants, 29% were female and 32% were housed, with a median age of 33. Sixty participants (71%) completed at least one follow-up survey. Survey completion rates were 37%, 38%, 39%, and 40% respectively at one, two, six, and twelve months. Participants had a median of three outreach encounters. Among respondents, OAT was 0% at enrolment and ranged from 38% to 56% at follow-up; addictions care engagement was 22% at enrolment and ranged from 65% to 81% during follow-up; and housing was 40% at enrolment and ranged from 48% to 59% during follow-up. Improvements from baseline to follow-up occurred for all time periods. OAT and engagement in care benefits were maintained in sensitivity and subgroup analyses. Respondents rated the outreach program as helpful at all time periods, CONCLUSION: An ED-initiated intensive outreach program for patients with OUD not yet on OAT was associated with a persistent increase in OAT use and engagement in care, as well as housing.

Factors associated with frequent buprenorphine / naloxone initiation in a national survey of Canadian emergency physicians

OBJECTIVE

To identify individual and site-related factors associated with frequent emergency department (ED) buprenorphine/naloxone (BUP) initiation. BUP initiation, an effective opioid use disorder (OUD) intervention, varies widely across Canadian EDs.

METHODS

We surveyed emergency physicians in 6 Canadian provinces from 2018 to 2019 using bilingual paper and web-based questionnaires. Survey domains included BUP-related practice, demographics, attitudes toward BUP, and site characteristics. We defined frequent BUP initiation (the primary outcome) as at least once per month, high OUD prevalence as at least one OUD patient per shift, and high OUD resources as at least 3 out of the following 5 resources: BUP initiation pathways, BUP in ED, peer navigators, accessible addiction specialists, and accessible follow-up clinics. We excluded responses from sites with <50% participation (to minimize non-responder bias) and those missing the primary outcome. We used univariate analysis to identify associations between frequent BUP initiation and factors of interest, stratifying by OUD prevalence.

RESULTS

We excluded 3 responses for missing BUP initiation frequency and 9 for low response rate at one ED. Of the remaining 649 respondents from 34 EDs, 374 (58%) practiced in metropolitan areas, 384 (59%) reported high OUD prevalence, 312 (48%) had high OUD resources, and 161 (25%) initiated BUP frequently. Age, gender, board certification and years in practice were not associated with frequent BUP initiation. Site-specific factors were associated with frequent BUP initiation (high OUD resources [OR 6.91], high OUD prevalence [OR 4.45], and metropolitan location [OR 2.39],) as were individual attitudinal factors (willingness, confidence, and responsibility to initiate BUP.) Similar associations persisted in the high OUD prevalence subgroup.

CONCLUSIONS

Individual attitudinal and site-specific factors were associated with frequent BUP initiation. Training to increase physician confidence and increasing OUD resources could increase BUP initiation and benefit ED patients with OUD.

Risk profiles and incidence of cardiovascular events across different cancer types

BACKGROUND

Cancer survivors are at increased risk for cardiovascular (CV) disease, although additional data are needed to better understand the incidence of CV events across different malignancies. This study sought to characterize the incidence of major adverse CV events [myocardial infarction, stroke, unstable angina (MACE), or heart failure (HF)] across multiple cancer types after cancer diagnosis.

PATIENTS AND METHODS

Patients were identified from a USA-based administrative claims database who had index cancer diagnoses of breast, lung, prostate, melanoma, myeloma, kidney, colorectal, leukemia, or lymphoma between 2011 and 2019, with continuous enrollment for ≥12 months before diagnosis. Baseline CV risk factors and incidence rates of CV events post-index were identified for each cancer. Multivariable Cox hazards models assessed the cumulative incidence of MACE, accounting for baseline risk factors.

RESULTS

Among 839 934 patients across nine cancer types, CV risk factors were prevalent. The cumulative incidence of MACE was highest in lung cancer and myeloma, and lowest in breast cancer, prostate cancer, and melanoma. MACE cumulative incidence for lung cancer was 26% by 4 years (2.7-fold higher relative to breast cancer). The incidence of stroke was especially pronounced in lung cancer, while HF was highest in myeloma and lung cancer.

CONCLUSIONS

CV events were especially increased following certain cancer diagnoses, even after accounting for baseline risk factors. Understanding the variable patient characteristics and associated CV events across different cancers can help target appropriate CV risk factor modification and develop strategies to minimize adverse CV events and improve patient outcomes.

Patient opinion and acceptance of emergency department buprenorphine/naloxone to-go home initiation packs

OBJECTIVES

Many emergency department (ED) patients with opioid use disorder are candidates for home buprenorphine/naloxone initiation with to-go packs. We studied patient opinions and acceptance of buprenorphine/naloxone to-go packs, and factors associated with their acceptance.

METHODS

We identified patients at two urban EDs in British Columbia who met opioid use disorder criteria, were not presently on opioid agonist therapy and not in active withdrawal. We offered patients buprenorphine/naloxone to-go as standard of care and then administered a survey to record buprenorphine/naloxone to-go acceptance, the primary outcome. Survey domains included current substance use, prior experience with opioid agonist therapy, and buprenorphine/naloxone related opinions. Patient factors were examined for association with buprenorphine/naloxone to-go acceptance.

RESULTS

Of the 89 patients enrolled, median age was 33 years, 27% were female, 67.4% had previously taken buprenorphine/naloxone, and 19.1% had never taken opioid agonist therapy. Overall, 78.7% believed that EDs should dispense buprenorphine/naloxone to-go packs. Thirty-eight (42.7%) patients accepted buprenorphine/naloxone to-go. Buprenorphine/naloxone to-go acceptance was associated with lack of prior opioid agonist therapy, less than 10 years of opioid use and no injection drug use. Reasons to accept included initiating treatment while in withdrawal; reasons to reject included prior unsatisfactory buprenorphine/naloxone experience and interest in other treatments.

CONCLUSION

Although less than half of our study population accepted buprenorphine/naloxone to-go when offered, most thought this intervention was beneficial. In isolation, ED buprenorphine/naloxone to-go will not meet the needs of all patients with opioid use disorder. Clinicians and policy makers should consider buprenorphine/naloxone to-go as a low-barrier option for opioid use disorder treatment from the ED when integrated with robust addiction care services.

Development of Low-Magnetic Susceptibility Microcoils via 5-Axis Machining for Analysis of Biological and Environmental Samples

In environmental research, it is critical to understand how toxins impact invertebrate eggs and egg banks, which, due to their tiny size, are very challenging to study by conventional nuclear magnetic resonance (NMR) spectroscopy. Microcoil technology has been extensively utilized to enhance the mass-sensitivity of NMR. In a previous study, 5-axis computer numerical control (CNC) micromilling (shown to be a viable alternative to traditional microcoil production methods) was used to create a prototype copper slotted-tube resonator (STR). Despite the excellent limit of detection (LOD) of the resonator, the quality of the line shape was very poor due to the magnetic susceptibility of the copper resonator itself. This is best solved using magnetic susceptibility-matched materials. In this study, approaches are investigated that improve the susceptibility while retaining the versatility of coil milling. One method involves machining STRs from various copper/aluminum alloys, while the other involves machining ones from an aluminum 2011 alloy and electroplating them with copper. In all cases, combining copper and aluminum to produce resonators resulted in improved line shape and SNR compared to pure copper resonators due to their reduced magnetic susceptibility. However, the copper-plated aluminum resonators showed optimal performance from the devices tested. The enhanced LOD of these STRs allowed for the first 1H-13C heteronuclear multiple quantum coherence (HMQC) of a single intact 13C-labeled Daphnia magna egg (∼4 μg total biomass). This is a key step toward future screening programs that aim to elucidate the toxic processes in aquatic eggs.

Application of 15N-Edited 1H-13C Correlation NMR Spectroscopy─Toward Fragment-Based Metabolite Identification and Screening via HCN Constructs

Many key building blocks of life contain nitrogen moieties. Despite the prevalence of nitrogen-containing metabolites in nature, 15N nuclei are seldom used in NMR-based metabolite assignment due to their low natural abundance and lack of comprehensive chemical shift databases. However, with advancements in isotope labeling strategies, 13C and 15N enriched metabolites are becoming more common in metabolomic studies. Simple multidimensional nuclear magnetic resonance (NMR) experiments that correlate 1H and 15N via single bond 1JNH or multiple bond 2-3JNH couplings using heteronuclear single quantum coherence (HSQC) or heteronuclear multiple bond coherence are well established and routinely applied for structure elucidation. However, a 1H-15N correlation spectrum of a metabolite mixture can be difficult to deconvolute, due to the lack of a 15N specific database. In order to bridge this gap, we present here a broadband 15N-edited 1H-13C HSQC NMR experiment that targets metabolites containing 15N moieties. Through this approach, nitrogen-containing metabolites, such as amino acids, nucleotide bases, and nucleosides, are identified based on their 13C, 1H, and 15N chemical shift information. This approach was tested and validated using a [15N, 13C] enriched Daphnia magna (water flea) metabolite extract, where the number of clearly resolved 15N-containing peaks increased from only 11 in a standard HSQC to 51 in the 15N-edited HSQC, and the number of obscured peaks decreased from 59 to just 7. The approach complements the current repertoire of NMR techniques for mixture deconvolution and holds considerable potential for targeted metabolite NMR in 15N, 13C enriched systems.

Risk factors associated with 1-week revisit among emergency department patients with alcohol withdrawal

BACKGROUND

Approximately one-quarter of emergency department (ED) visits for alcohol withdrawal result in unscheduled 1-week ED return visits, but it is unclear what patient and clinical factors may impact this outcome METHODS: From January 1, 2015, to December 31, 2018, at three urban EDs in Vancouver, Canada, we studied patients who were discharged with a primary or secondary diagnosis of alcohol withdrawal. We performed a structured chart review to ascertain patient characteristics, ED treatments, and the outcome of an ED return within 1 week of discharge. We used univariable and multivariable Bayesian binomial regression to identify characteristics associated with being in the upper quartile of 1-week ED revisits.

RESULTS

We collected 935 ED visits among 593 unique patients. Median age was 45 years (interquartile range 34 to 55 years) and 71% were male. The risk of a 1-week ED revisit was 15.0% (IQR 12.3; 19.5%). After adjustment, factors independently associated with a high risk for return included any prior ED visit within 30 days, no fixed address, initial blood alcohol level > 45 mmol/L, and initial Clinical Institute Withdrawal Assessment-alcohol revised score > 23. These factors explained 41% of the overall variance in revisits.

CONCLUSION

Among discharged ED patients with alcohol withdrawal, we describe high-risk patient characteristics associated with 1-week ED revisits, and these findings may assist clinicians to facilitate appropriate discharge planning with access to integrated follow-up support.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Exploring the Applications of Carbon-Detected NMR in Living and Dead Organisms Using a 13C-Optimized Comprehensive Multiphase NMR Probe

Comprehensive multiphase-nuclear magnetic resonance (CMP-NMR) is a non-invasive approach designed to observe all phases (solutions, gels, and solids) in intact samples using a single NMR probe. Studies of dead and living organisms are important to understand processes ranging from biological growth to environmental stress. Historically, such studies have utilized ¹H-based phase editing for the detection of soluble/swollen components and ¹H-detected 2D NMR for metabolite assignments/screening. However, living organisms require slow spinning rates (∼500 Hz) to increase survivability, but at such low speeds, complications from water sidebands and spectral overlap from the modest chemical shift window (∼0-10 ppm) make ¹H NMR challenging. Here, a novel ¹³C-optimized E-Free magic angle spinning CMP probe is applied to study all phases in ex vivo and in vivo samples. This probe consists of a two-coil design, with an inner single-tuned ¹³C coil providing a 113% increase in ¹³C sensitivity relative to a traditional multichannel single-CMP coil design. For organisms with a large biomass (∼0.1 g) like the Ganges River sprat (ex vivo), ¹³C-detected full spectral editing and ¹³C-detected heteronuclear correlation (HETCOR) can be performed at natural abundance. Unfortunately, for a single living shrimp (∼2 mg), ¹³C enrichment was still required, but ¹³C-detected HETCOR shows superior data relative to heteronuclear single-quantum coherence at low spinning speeds (due to complications from water sidebands in the latter). The probe is equipped with automatic-tuning-matching and is compatible with automated gradient shimming─a key step toward conducting multiphase screening of dead and living organisms under automation in the near future.

Evaluation of double-tuned single-sided planar microcoils for the analysis of small 13 C enriched biological samples using 1 H-13 C 2D heteronuclear correlation NMR spectroscopy

Microcoils provide a cost-effective approach to improve detection limits for mass-limited samples. Single-sided planar microcoils are advantageous in comparison to volume coils, in that the sample can simply be placed on top. However, the considerable drawback is that the RF field that is produced by the coil decreases with distance from the coil surface, which potentially limits more complex multi-pulse NMR pulse sequences. Unfortunately, ¹ H NMR alone is not very informative for intact biological samples due to line broadening caused by magnetic susceptibility distortions, and ¹ H-¹³ C 2D NMR correlations are required to provide the additional spectral dispersion for metabolic assignments in vivo or in situ. To our knowledge, double-tuned single-sided microcoils have not been applied for the 2D ¹ H-¹³ C analysis of intact ¹³ C enriched biological samples. Questions include the following: Can ¹ H-¹³ C 2D NMR be performed on single-sided planar microcoils? If so, do they still hold sensitivity advantages over conventional 5 mm NMR technology for mass limited samples? Here, 2D ¹ H-¹³ C HSQC, HMQC, and HETCOR variants were compared and then applied to ¹³ C enriched broccoli seeds and Daphnia magna (water fleas). Compared to 5 mm NMR probes, the microcoils showed a sixfold improvement in mass sensitivity (albeit only for a small localized region) and allowed for the identification of metabolites in a single intact D. magna for the first time. Single-sided planar microcoils show practical benefit for ¹ H-¹³ C NMR of intact biological samples, if localized information within ~0.7 mm of the 1 mm I.D. planar microcoil surface is of specific interest.

Comprehensive Multiphase NMR Probehead with Reduced Radiofrequency Heating Improves the Analysis of Living Organisms and Heat-Sensitive Samples

Comprehensive multiphase (CMP) NMR, first described in 2012, combines all of the hardware components necessary to analyze all phases (solid, gel, and solution) in samples in their natural state. In combination with spectral editing experiments, it can fully differentiate phases and study the transfer of chemical species across and between phases, providing unprecedented molecular-level information in unaltered natural systems. However, many natural samples, such as swollen soils, plants, and small organisms, contain water, salts, and ionic compounds, making them electrically lossy and susceptible to RF heating, especially when using high-strength RF fields required to select the solid domains. While dedicated reduced-heating probes have been developed for solid-state NMR, to date, all CMP-NMR probes have been based on solenoid designs, which can lead to problematic sample heating. Here, a new prototype CMP probe was developed, incorporating a loop gap resonator (LGR) for decoupling. Temperature increases are monitored in salt solutions analogous to those in small aquatic organisms and then tested in vivo on Hyalella azteca (freshwater shrimp). In the standard CMP probe (solenoid), 80% of organisms died within 4 h under high-power decoupling, while in the LGR design, all organisms survived the entire test period of 12 h. The LGR design reduced heating by a factor of ∼3, which allowed 100 kHz decoupling to be applied to salty samples with generally ≤10 °C sample heating. In addition to expanding the potential for in vivo research, the ability to apply uncompromised high-power decoupling could be beneficial for multiphase samples containing true crystalline solids that require the strongest possible decoupling fields for optimal detection.

Expanding current applications and permitting the analysis of larger intact samples by means of a 7 mm CMP-NMR probe

Comprehensive multiphase NMR combines the ability to study and differentiate all phases (solids, gels, and liquids) using a single NMR probe. The general goal of CMP-NMR is to study intact environmental and biological samples to better understand conformation, organization, association, and transfer between and across phases/interfaces that may be lost with conventional sample preparation such as drying or solubilization. To date, all CMP-NMR studies have used 4 mm probes and rotors. Here, a larger 7 mm probehead is introduced which provides ∼3 times the volume and ∼2.4 times the signal over a 4 mm version. This offers two main advantages: (1) the additional biomass reduces experiment time, making 13C detection at natural abundance more feasible; (2) it allows the analysis of larger samples that cannot fit within a 4 mm rotor. Chicken heart tissue and Hyalella azteca (freshwater shrimp) are used to demonstrate that phase-based spectral editing works with 7 mm rotors and that the additional biomass from the larger volumes allows detection with 13C at natural abundance. Additionally, a whole pomegranate seed berry (aril) and an intact softgel capsule of hydroxyzine hydrochloride are used to demonstrate the analysis of samples too large to fit inside a conventional 4 mm CMP probe. The 7 mm version introduced here extends the range of applications and sample types that can be studied and is recommended when 4 mm CMP probes cannot provide adequate signal-to-noise (S/N), or intact samples are simply too big for 4 mm rotors.

Inpatient and outpatient treatment patterns of cancer-associated thrombosis in the United States

Low molecular weight heparins (LMWHs) and direct oral anticoagulants (DOACs) are among the recommended treatment options for cancer-associated thrombosis (CAT) in the 2019 National Comprehensive Care Network guidelines. Little is known about the current utilization of DOACs in CAT patients, particularly on the inpatient to outpatient therapy transition. This study assessed real-world treatment patterns of CAT in hospital/ED in adult cancer patients (≥ 18 years) diagnosed with CAT during a hospital visit in IQVIA's Hospital Charge Data Master database between July 1, 2015 and April 30, 2018, and followed their outpatient medical and pharmacy claims to evaluate the initial inpatient/ED and outpatient anticoagulants received within 3 months post-discharge. Results showed that LMWH and unfractionated heparin (UFH) were the most common initial inpatient/ED CAT treatments (35.2% and 27.4%, respectively), followed by DOACs (9.6%); 20.8% of patients received no anticoagulants. Most DOAC patients remained on DOACs from inpatient/ED to outpatient settings (71.4%), while 24.1%, 43.5%, and 0.1% of patients treated with LMWH, warfarin, or UFH respectively, remained on the same therapy after discharge. In addition, DOACs were the most common initial post-discharge outpatient therapy. Outpatient treatment persistence and adherence appeared higher in patients using DOACs or warfarin versus LMWH or UFH. This study shows that DOACs are used as an inpatient/ED treatment option for CAT, and are associated with less post-discharge treatment switching and higher persistence and adherence. Further research generating real-world evidence on the role of DOACs to help inform the complex CAT clinical treatment decisions is warranted.

Associations of exercise-based cardiac rehabilitation with all-cause mortality among patients with atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Background

There is limited evidence of long-term impact of exercise-based CR on clinical endpoints for patients with AF. We therefore compared 18-month all-cause mortality, hospitalisation, stroke, and heart failure in patients with AF and an electronic medical record (EMR) of exercise-based CR to matched controls.

Methods and Results

This retrospective cohort study included patient data obtained on 11 December 2020, from a global federated health research network. AF patients undergoing exercise-based CR were propensity score matched to AF patients without exercise-based CR by age, sex, race, medication, and co-morbidities. We ascertained 18-month incidence of all-cause mortality, hospitalisation, stroke, and heart failure.

Of 1,350,886 patients with AF, 10,625 patients had an EMR of exercise-based CR within 6-months of incident AF. The propensity score matched cohort of 21,250 patients with AF demonstrated that exercise-based CR was associated with 64% lower odds of all-cause mortality (odds ratio 0.36, 95% confidence interval (CI) 0.33-0.40), 41% lower odds of hospitalisation (0.59, 95% CI 0.56-0.63), and 17% lower odds of incident stroke (0.83, 95% CI 0.71-0.98) compared to propensity score matched controls. No significant associations were shown for heart failure at 18-months (0.92, 95% CI 0.81-1.02). The beneficial association of exercise-based CR on all-cause mortality was independent of sex, older age, comorbidities, and AF subtype.

CONCLUSIONS

Exercise-based CR among patients with incident AF was associated with lower odds of all-cause mortality, hospitalisation, and stroke at 18-months follow-up. The longitudinal nature of this retrospective follow-up study strongly supports the provision of exercise programmes for patients with incident AF.

Urine Concentration Does Not Affect Biochemical Testing for Non-adherence

Hypertension is one of the most important modifiable risk factor causing cardiovascular disease. Unfortunately, non-adherence to antihypertensive medications is frequently observed in hypertensive patients and can lead to an increase in morbidity and mortality. Until recently, there was no robust clinical method to objectively diagnose non-adherence. Recently, the detection of medications in urine or blood by mass spectrometry techniques such as liquid chromatography-tandem mass spectrometry (LC–MS-MS) has been accepted as the diagnostic method of choice for the detection of non-adherence. Despite this, it is unclear whether the concentration of urine can affect the detection of medications in urine. Therefore, this study aimed to assess the effect of urine concentration on detection of antihypertensive medications by LC–MS-MS in which urine creatinine is used as an independent marker of urine concentration. Biochemical adherence results for 22 different medications (1,709 prescriptions) in 463 different subjects were converted to an adherence score. The adherence score was defined as the ratio of the total number of subjects in which the drug was detected to the total number of subjects to whom the drug was prescribed. The adherence scores for each medication were correlated with urine creatinine concentration for each medication. Non-adherence was observed in 47.1% of samples with a mean urine creatinine concentration of these samples of 9.4 ± 7.1 mmol/L. There was no significant difference between the urine creatinine concentrations in the detected vs non-detected groups for each of the 22 medications. Furthermore, there are no differences in adherence scores across the urine creatinine concentration. This is the first study to demonstrate that urine creatinine concentration does not affect the results of the adherence screening by LC–MS-MS.

5-Axis CNC Micromilling for Rapid, Cheap, and Background-Free NMR Microcoils

The superior mass sensitivity of microcoil technology in nuclear magnetic resonance (NMR) spectroscopy provides potential for the analysis of extremely small-mass-limited samples such as eggs, cells, and tiny organisms. For optimal performance and efficiency, the size of the microcoil should be tailored to the size of the mass-limited sample of interest, which can be costly as mass-limited samples come in many shapes and sizes. Therefore, rapid and economic microcoil production methods are needed. One method with great potential is 5-axis computer numerical control (CNC) micromilling, commonly used in the jewelry industry. Most CNC milling machines are designed to process larger objects and commonly have a precision of >25 μm (making the machining of common spiral microcoils, for example, impossible). Here, a 5-axis MiRA6 CNC milling machine, specifically designed for the jewelry industry, with a 0.3 μm precision was used to produce working planar microcoils, microstrips, and novel microsensor designs, with some tested on the NMR in less than 24 h after the start of the design process. Sample wells could be built into the microsensor and could be machined at the same time as the sensors themselves, in some cases leaving a sheet of Teflon as thin as 10 μm between the sample and the sensor. This provides the freedom to produce a wide array of designs and demonstrates 5-axis CNC micromilling as a versatile tool for the rapid prototyping of NMR microsensors. This approach allowed the experimental optimization of a prototype microstrip for the analysis of two intact adult Daphnia magna organisms. In addition, a 3D volume slotted-tube resonator was produced that allowed for 2D ¹H-¹³C NMR of D. magna neonates and exhibited ¹H sensitivity (nLOD_ω⁶⁰⁰ = 1.49 nmol s^1/2) close to that of double strip lines, which themselves offer the best compromise between concentration and mass sensitivity published to date.

Regular reassessment of bleeding risk using the HAS-BLED score reduces bleeding outcomes in a prospective cohort: a report from the mAFA II clinical trial extension

Background

The HAS-BLED score was introduced to draw attention to modifiable bleeding risk factors and to identify patients with atrial fibrillation (AF) at high-risk of bleeding for early review and follow-up. The mAFA-II randomised trial reported that a holistic management strategy using App-based mobile Health technology support reduced AF-related adverse outcomes, compared to usual care.

Objective

To assess whether regular reassessment of bleeding risk using the HAS-BLED score would improve bleeding outcomes and oral anticoagulation (OAC) uptake.

Methods

Data for this analysis was drawn from the mAF App intervention arm. Bleeding risk (HAS-BLED score) and stroke risk (CHA2DS2-VASc score) were monitored prospectively using mAFA, and calculated during 4 periods: 1–30 days, 31–60 days, 61–180 days, and 181–365 days. Clinical events and OAC changes in relation to the dynamic monitoring and reassessments were analysed.

Results

We studied 1793 patients with AF (mean age 64 years, 32.5% female). The average number of re-assessments of CHA2DS2-VASc and HAS-BLED scores were 6.8 (SD 4.0) and 6.8 (4.1), respectively.

Comparing baseline and 12 months, the proportion of AF patients with HAS-BLED ≥3 decreased (11.8% vs. 8.5%, p=0.008), with changes in use of concomitant NSAIDs/antiplatelets, renal dysfunction, and labile international normalized ratio (INR) contributing to the decreased proportion of patients with HAS-BLED ≥3 temporally (p&lt;0.05). Use of non-vitamin K antagonist oral anticoagulants (NOAC), warfarin, and any antiplatelet drug was 47.1%, 13.8%, and 15.5%, respectively, at baseline.

Incident bleeding events decreased significantly from 1–30 days to 181–365 days (1.2% to 0.2%, respectively; Table 1). Warfarin and NOAC use increased significantly over this period (17.9% to 18.4% and 46.4% to 51.8%, respectively).

Conclusion

In this clinical trial cohort, dynamic risk monitoring and reassessment using the HAS-BLED score, together with holistic App-based management using mAFA II reduced bleeding events, addressed modifiable bleeding risks and increased uptake of OACs.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): National Natural Science Foundation of China (H2501), NIHR Global Health Research Group on Atrial Fibrillation management

Disparities in clinical characteristics and treatment of multiple myeloma in African American patients

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Background: Based upon interesting recent published findings, we characterize disparities in clinical characteristics, treatment patterns, and outcomes for African American (AA) patients with multiple myeloma (MM) using real-world (RW) data. Methods: A random sample of patients diagnosed with MM were selected from the COTA RW database for the retrospective analysis to be stratified by race, AA (n=395) and other (n=396). To adjust for differences in age and gender, case-control matching was performed. Patient characteristics and treatment patterns were summarized. A Cox proportional hazards model was used to evaluate the relationship between patient characteristics and time to stem cell transplant (SCT). Overall Survival (OS) was calculated using the Kaplan-Meier method. Results: Median time from diagnosis of active MM to start of first-line (1L) treatment was longer among AA as compared to the other cohort (23 vs. 17 days respectively, p=0.01); VRD was the most common 1L therapy (17.39% vs. 18.58% respectively). The percent of patients receiving SCT was similar across racial cohorts (64.56% vs. 66.16%), but AA patients had a longer time to first SCT (234 vs. 204.50 days, p=0.01). Among all patients, Charlson Comorbidity index (CCI) score of 0 (HR: 2.85, CI: 1.77-4.58) and CCI score of 1-2 (HR: 2.79, CI: 1.73-4.49) were significantly associated with an increased likelihood of receiving a SCT. MM diagnosis at an older age was associated with a lower likelihood of receiving a SCT (HR: 0.97, CI: 0.96-0.98). AA cohort exhibited a higher incidence of prior history of MGUS (10.63% vs 8.08%). Cytogenetic profile of the AA and other cohorts are shown in the Table below. Median OS was similar between the AA and other cohorts (145.61 vs. 146.50 months, respectively, p=0.88). Conclusions: AA patients had a longer duration of time to 1L therapy and 1st SCT in our RW study. Despite these differences in time to treatment, OS was similar across racial groups. Future studies are needed to explore the significance of our RW findings and other potentially important clinical characteristics. [Table: see text]

Overall survival (OS) in advanced non-small cell lung cancer (aNSCLC) patients treated with frontline chemotherapy or immunotherapy by comorbidity: A real-world data (RWD) collaboration

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Background: Friends of Cancer Research convened 9 data partners to identify data elements and common definitions for real world (rw) endpoints to evaluate populations typically excluded from clinical trials. Here we report on rwOS by frontline treatment and comorbidities. Methods: A retrospective observational analysis of patients with aNSCLC initiating frontline platinum doublet chemotherapy (chemo) or PD-(L)1-based immuno-oncologic (IO) therapy (monotherapy or chemo combination) between 1 Jan 2011 to 31 Mar 2018 was conducted using administrative claims, EHR, and cancer registry RWD. We evaluated rwOS from frontline therapy initiation using Kaplan-Meier methods, stratified by ECOG status, brain metastases (ICD), history of chronic kidney or liver disease (CKD/ CLD, ICD), and evidence of kidney or liver dysfunction (KD/ LD, lab-based). Results: A total of 33,649 patients were included (N 972-17,454) with 10 to 26% of patients receiving IO as frontline therapy. There was a broad range of comorbidity prevalence across datasets and patients with evidence of comorbidity had comparatively shorter 12-month OS (Table). Conclusions: RWD analyses can generate expanded evidence on patient outcomes for populations routinely excluded from clinical trials and may help inform decision making where sparse data exist on appropriate treatment approaches. Additional understanding of data missingness, sensitivity of definitions, and covariate adjustment are needed to make direct comparisons across regimens and data sources. [Table: see text]

Assessing real-world clinical response in patients with multiple myeloma (MM): A survey of the literature

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Background: A recent study (Foster, Tromanhauser et al. 2019) utilizing Electronic Health Record (EHR) data found that patients with MM rarely have both serum protein electrophoresis (SPEP) and 24-hour urine protein electrophoresis (UPEP) documented in routine clinical practice settings. These elements are necessary to classify response using the International Myeloma Working Group (IMWG) consensus criteria. It could be hypothesized that adding the additional requirements for bone marrow biopsy necessary to confirm a complete response would further reduce the rate of strict adherence to the IMWG criteria in the real world (RW). Clinicians are however assessing response and progression in RW settings and often report these assessments in published literature. In this study, we survey the literature to determine how RW response is being captured and reported outside of the clinical trial setting. Methods: A systematic search was performed using Medline 2010-2019. Using a standardized grading system, English language articles were evaluated that utilized EHR data from routine clinical practice to report RW response in patients with active MM. Registry based and/or pragmatic observational studies were excluded as many had mandatory reporting procedures in place. Studies were then categorized based on methods of assessing response, progression and use of IMWG criteria. Results: The majority of studies grade 1 studies identified (21/25) utilized best response achieved based on treating physician-documented assessment and either did not specify the use of IMWG(10/21) criteria or explicitly stated they did not use conventional criteria (11/21). Progression event capture and reporting varied greatly with many using physician-documented progression, change in regimen, addition of additional agents to existing regimen, stem cell transplant, or an individually created algorithm. Conclusions: Our findings suggest that there is a need for further research on objective techniques for the assessment of RW progression and response in patients with MM. Additionally, validation of an approach that utilizes partial adherence to IMWG criteria would help in the ability to compare findings across clinical trial and RW settings. This validation work is under way, and preliminary results will be reported at the meeting.

In vivo comprehensive multiphase NMR

Traditionally, due to different hardware requirements, nuclear magnetic resonance (NMR) has developed as two separate fields: one dealing with solids, and one with solutions. Comprehensive multiphase (CMP) NMR combines all electronics and hardware (magic angle spinning [MAS], gradients, high power Radio Frequency (RF) handling, lock, susceptibility matching) into a universal probe that permits a comprehensive study of all phases (i.e., liquid, gel-like, semisolid, and solid), in intact samples. When applied in vivo, it provides unique insight into the wide array of bonds in a living system from the most mobile liquids (blood, fluids) through gels (muscle, tissues) to the most rigid (exoskeleton, shell). In this tutorial, the practical aspects of in vivo CMP NMR are discussed including: handling the organisms, rotor preparation, sample spinning, water suppression, editing experiments, and finishes with a brief look at the potential of other heteronuclei (² H, ¹⁵ N, ¹⁹ F, ³¹ P) for in vivo research. The tutorial is aimed as a general resource for researchers interested in developing and applying MAS-based approaches to living organisms. Although the focus here is CMP NMR, many of the approaches can be adapted (or directly applied) using conventional high-resolution magic angle spinning, and in some cases, even standard solid-state NMR probes.

1424The diagnosis of non-adherence in hypertension using a urine biochemical screen is unaffected by drug pharmacokinetics

Introduction

Suboptimal drug adherence in hypertension is pandemic and traditional diagnostic tools to detect non-adherence have lacked accuracy and robustness. The inability to identify non-adherence has therefore driven the development of biochemical drug screening by liquid chromatography tandem mass spectrometry (LC- MS/MS) in urine and blood, which are the most accurate metrics presently available. Urinary antihypertensive testing is evidenced to improve non-adherence rates, significantly decrease blood pressure after physician intervention, and be cost effective. The European Society of Cardiology (ESC) and European Society of Hypertension (ESH) 2018 guidelines have recommended the use of biochemical testing for non-adherence diagnosis. However, it has been argued that the variable pharmacokinetic parameters of the medication (such as their half-lives and clearance rates) may affect the detection of medications in urine and hence the determination of adherence. We hypothesized that pharmacokinetic parameters do not affect the detection of antihypertensive medications in urine.

Aim

This study compared the pharmacokinetic parameters of the most commonly prescribed antihypertensive medications against their detection in urine by LC-MS/MS.

Methods

Results of urinary drug screens from 463 hypertensive patients (total prescribed medications N=1709) were collated. An adherence score termed as the C score (number of detected vs. prescribed medication) was generated for each of the 27 common antihypertensive medications. Pharmacokinetic parameters such as bioavailability, plasma concentration, volume of distribution, half-life, plasma clearance and urinary excretion values for each drug were obtained from published literature. Partial linear correlation was conducted between the C score of all the medications and each pharmacokinetic parameter studied.

Results

40% of patients were non-adherent. The average number of prescribed medications was high (N=3.7, SD: 1.5), and the average number of drugs detected was lower (N=2.5, SD: 1.6). Amlodipine was the most prescribed (N=224), and clonidine was the least (N=10). The half-lives ranged from 0.87 to 39 hours for bumetanide and amlodipine respectively. The urinary excretion percentage varied from <1% for nifedipine, and 94% for benfroflumethiazide. No significant correlation was found between any drug C score and their respective pharmacokinetic variables such as the medication half-lives (figure1).

Half-life versus adherence score

Conclusion

This study reports no significant correlation between drug pharmacokinetics and adherence. To the best of our knowledge this is the first study of its kind. Urinary biochemical testing by LC-MS/MS for non-adherence remains a valid tool for diagnosis although further detailed pharmacokinetic studies are needed to confirm this finding.

Acknowledgement/Funding

None

P2753Anticoagulation control and all-cause death in patients with operated valvular heart disease with and without atrial fibrillation receiving vitamin K antagonists

Introduction

Good quality of anticoagulation in patients with valvular heart disease (VHD) is needed to reduce ischaemic complications. There is limited evidence on factors affecting anticoagulation control in patients implanted with mechanical or tissue prosthetic valve(s).

Objective

To examine quality, factors affecting anticoagulation control and all-cause death in VHD patients with and without atrial fibrillation (AF) receiving a vitamin K antagonist (VKA) oral anticoagulant. The relationship between INR control with all-cause death and ≥1 adverse clinical events (ACE) [thromboembolism, bleeding, cardiovascular hospitalisation and all-cause death] were explored.

Methods

Anticoagulation control of 456 VHD patients [164 (36%) with AF and 290 (64%) without AF] referred to a hospital-based anticoagulation clinic were assessed retrospectively by time in therapeutic range (TTR) (Rosendaal) and percentage of INRs in range (PINRR) for a median of (IQR) 6.2 years (3.3–8.5). VHD was defined by the presence of mechanical or tissue prosthetic valve at either the mitral or aortic site or both.

Results

Mean (SD) age 51 (14.7), 64.5% male, mean (SD) CHA2DS2-VASc score 2.0 (1.4), 96.1% mechanical prosthesis and 64% aortic valve replacement. VHD patients with AF had lower mean TTR and PINRR, lower proportion of optimal TTR (i.e.≥70%) despite similar number of INR tests compared to VHD patients without AF [Table 1]. Predictors of poor TTR on multivariate logistic regression analysis were female sex, AF and anaemia/bleeding history. Significantly higher proportions of VHD patients with AF died [Table 1]. More deaths (13.1% vs. 4.1%; p=0.011) and ≥1 ACE (42.7% vs. 27.6%; p=0.006) were seen in VHD patients with TTR <70% vs. TTR≥70%, respectively.

Table 1 N (%) Total (N=456) AF (N=164) No AF (N=290) p-value Mean (SD) TTR 58.5 (14.6) 55.7 (14.2) 60.1 (14.6) 0.002 TTR ≥70% 98 (21.5) 23 (14.0) 75 (25.7) 0.004 Mean (SD) PINRR 50.1 (13.8) 47.4 (13.5) 51.6 (13.7) 0.002 Mean (SD) INR tests 96.2 (55.3) 100.7 (58.8) 93.7 (53.1) 0.19 All-cause death 51 (11.2) 34 (20.7) 17 (5.8) <0.001 AF: Atrial fibrillation; IQR: interquartile range; PINRR: percentage of INRs in range; SD: standard deviation; TTR: Time in therapeutic range.

Conclusion

The quality of anticoagulation in VHD patients with AF was low. The presence of AF, anaemia/bleeding history and female sex independently predicted poor TTR. All-cause death was more common in VHD patients with AF and poor TTR. Closer INR monitoring is needed especially in VHD patients with AF to improve anticoagulation control and prevent adverse clinical outcomes.

Acknowledgement/Funding

Kementerian Pendidikan Malaysia and Universiti Teknologi MARA for PhD study but not directly for work under consideration

Selective Amino Acid-Only in Vivo NMR: A Powerful Tool To Follow Stress Processes

In vivo NMR of small ¹³C-enriched aquatic organisms is developing as a powerful tool to detect and explain toxic stress at the biochemical level. Amino acids are a very important category of metabolites for stress detection as they are involved in the vast majority of stress response pathways. As such, they are a useful proxy for stress detection in general, which could then be a trigger for more in-depth analysis of the metabolome. ¹H-¹³C heteronuclear single quantum coherence (HSQC) is commonly used to provide additional spectral dispersion in vivo and permit metabolite assignment. While some amino acids can be assigned from HSQC, spectral overlap makes monitoring them in vivo challenging. Here, an experiment typically used to study protein structures is adapted for the selective detection of amino acids inside living Daphnia magna (water fleas). All 20 common amino acids can be selectively detected in both extracts and in vivo. By monitoring bisphenol-A exposure, the in vivo amino acid-only approach identified larger fluxes in a greater number of amino acids when compared to published works using extracts from whole organism homogenates. This suggests that amino acid-only NMR of living organisms may be a very sensitive tool in the detection of stress in vivo and is highly complementary to more traditional metabolomics-based methods. The ability of selective NMR experiments to help researchers to "look inside" living organisms and only detect specific molecules of interest is quite profound and paves the way for the future development of additional targeted experiments for in vivo research and monitoring.

Abstract P6-02-10: Early ultrasound evaluation for prediction of treatment response to neoadjuvant chemotherapy in triple negative breast cancer patients

Background: Triple negative breast cancer (TNBC) is molecularly heterogeneous disease. Genomic profiling to identify the distinct TNBC subtypes is costly with long turnaround time. Early ultrasound after two cycles of neoadjuvant chemotherapy (NAC) has the potential to identify patients who are likely to have pathological complete response. Suspected non-responder patients can undergo comprehensive genetic testing and triaged for specific targeted therapeutic trials.

Aim: To determine the value of ultrasound evaluation after two cycles of NAC to predict complete pathologic response in TNBC breast cancer patients.

Methods: 98 patients enrolled in “A randomized triple Negative Breast Cancer Enrolling Trial to Confirm Molecular Profiling Improves Survival” (Artemis) at the University of Texas MD Anderson Cancer Center had ultrasound evaluation before treatment and after two cycles of NAC (Adriamycin and Cyclophosphamide). Three-dimensional measurements of the tumor were obtained at baseline and after 2 cycles of the NAC. Change in the tumor volume after 2 cycles of NAC was calculated. Residual cancer Volume (RCB) was calculated based on the final histopathology at surgery. Linear regression analysis evaluated associations between residual cancer burden (RCB) and change in volume of the index tumor.

Results: Median tumor size at diagnosis was 3 cm, range 0.6-11.9cm. Median size after two cycles was 2 cm, range 0.6-12.8 cm. RCB 0-I was seen in 55% of patients (54/98). Linear regression analysis demonstrated that of 22 patients with volume reduction &gt;75%, 18 patients (82%) had RCB0-I (95%CI, 61%-93%).

Conclusion: Our data suggest that ultrasound exam after 2 cycles of NAC can identify TNBC patients who are unlikely to respond to standard NAC. These non-responder TNBC patients can be triaged for additional genetic testing and subsequent targeted clinical trials. Study on the larger number of patients is currently on the way.

Citation Format: Adrada BE, Candelaria R, Moulder S, Lane D, Santiago L, Arribas E, Hess KR, Valero V, Thompson A, Helgason T, Ravenberg E, Yang W, Rauch GM. Early ultrasound evaluation for prediction of treatment response to neoadjuvant chemotherapy in triple negative breast cancer patients [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-02-10.

Abstract OT3-05-04: Phase II study of atezolizumab, cobimetinib, and eribulin in patients with recurrent or metastatic inflammatory breast cancer (IBC)

Background: IBCs that do not completely respond to chemotherapy often have dysregulated immune pathways, and novel therapies are needed to improve outcomes in recurrent/metastatic disease. One-third of IBCs express the atezolizumab target PD-L1, and cobimetinib increases PD-L1 expression; thus, we hypothesize that atezolizumab and cobimetinib may act synergistically in IBC. The FDA-approved agent eribulin is active in IBC and has anti-stem cell activity and can reverse the IBC phenotype of epithelial-to-mesenchymal transition. Hence the use of eribulin as a chemotherapy backbone in combination with other novel agents is well justified.

Trial Design: This single-arm, open-label trial is enrolling patients with recurrent IBC or de novo metastatic IBC that has progressed on at least 1 line of standard chemotherapy. During a 4-week pharmacodynamic window, patients have an upfront biopsy, receive atezolizumab and cobimetinib treatment for 4 weeks, and have a second biopsy. Triple-combination treatment then commences, with standard eribulin dosing. After 4 cycles of eribulin, patients receive maintenance targeted therapy until disease progression or intolerable toxicity.

Eligibility Criteria: Patients with metastatic IBC of any molecular subtype must have measurable disease (per RECIST 1.1) amenable to biopsy. Patients with HER2+ disease must have received both pertuzumab and T-DM1. Patients with treated stable brain metastases are allowed. Patients must have recovered from the acute effects of any prior therapies and have adequate hematologic, organ, and cardiac function. Patients with autoimmune diseases or a history of pneumonitis are ineligible.

Specific Aims: The primary objective is to determine the overall response rate (ORR) of the combination therapy. Secondary objectives include determining the safety and tolerability, clinical benefit rate, response duration, progression-free survival, 2-year overall survival rate and predictive biomarker analyses.

Statistical Methods: The trial will enroll up to 9 patients in its phase I/safety lead-in portion and up to 33 patients total. A Bayesian optimal interval design is used to efficiently determine the maximum tolerated cobimetinib dose in phase I. Patients start cobimetinib at the FDA-approved dose of 60 mg/day with a target toxicity rate is 0.3. Phase II will enroll 24 patients to determine the efficacy of the triple-combination therapy. The historical ORR in metastatic IBC is 10%; our sample size provides 80% power to detect an ORR improvement to 25%.

Accrual: The trial has enrolled 7 patients since its start in August 2017.

Citation Format: Alexander A, Marx AN, Reddy SM, Reuben JM, Le-Petross HC, Lane D, Huang ML, Krishnamurthy S, Gong Y, Gombos DS, Patel N, Tung CI, Allen RC, Kandl TJ, Wu J, Liu S, Patel AB, Futreal A, Wistuba I, Layman RM, Valero V, Tripathy D, Ueno NT, Lim B. Phase II study of atezolizumab, cobimetinib, and eribulin in patients with recurrent or metastatic inflammatory breast cancer (IBC) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr OT3-05-04.

Assessing the potential of quantitative 2D HSQC NMR in 13C enriched living organisms

In vivo Nuclear Magnetic Resonance (NMR) spectroscopy has great potential to interpret the biochemical response of organisms to their environment, thus making it an essential tool in understanding toxic mechanisms. However, magnetic susceptibility distortions lead to 1D NMR spectra of living organisms with lines that are too broad to identify and quantify metabolites, necessitating the use of 2D ¹H-¹³C Heteronuclear Single Quantum Coherence (HSQC) as a primary tool. While quantitative 2D HSQC is well established, to our knowledge it has yet to be applied in vivo. This study represents a simple pilot study that compares two of the most popular quantitative 2D HSQC approaches to determine if quantitative results can be directly obtained in vivo in isotopically enriched Daphnia magna (water flea). The results show the perfect-HSQC experiment performs very well in vivo, but the decoupling scheme used is critical for accurate quantitation. An improved decoupling approach derived using optimal control theory is presented here that improves the accuracy of metabolite concentrations that can be extracted in vivo down to micromolar concentrations. When combined with 2D Electronic Reference To access In vivo Concentrations (ERETIC) protocols, the protocol allows for the direct extraction of in vivo metabolite concentrations without the use of internal standards that can be detrimental to living organisms. Extracting absolute metabolic concentrations in vivo is an important first step and should, for example, be important for the parameterization as well as the validation of metabolic flux models in the future.

Anaesthetic Implications of Vascular Type Ehlers-Danlos Syndrome

Vascular type Ehlers-Danlos syndrome is an inherited connective tissue disease, which is typified by tissue fragility, joint hypermobility, a tendency to bleed excessively and rupture of the uterus, the bowel and arteries. Two case reports are presented which describe the anaesthetic management of patients with spontaneous bowel perforations due to vascular type Ehlers-Danlos syndrome. Both cases were associated with relatively minor problems. The implications of this condition for anaesthesia include difficulty (and risk of complications) with vascular access, a risk of spontaneous arterial rupture in the perioperative period, possible cervical spine instability and airway trauma on intubation. There is also a risk of excessive bleeding, potentially difficult neuraxial anaesthesia and an increased risk of epidural haematoma. There also may be associated cardiac or pulmonary disease. However, these two cases and the limited previously published literature suggest that such potential complications are actually rare and that anaesthesia may be conducted in a relatively standard manner in most circumstances.

Metabolic Profiling Using In Vivo High Field Flow NMR

In vivo NMR (nuclear magnetic resonance) has the potential to monitor and record metabolic flux in close to real time, which is essential for better understanding the toxic mode of action of a contaminant and deciphering complex interconnected stress-induced pathways impacted inside an organism. Here, we describe how to construct and use a simple flow system to keep small aquatic organisms alive inside the NMR spectrometer. In living organisms, magnetic susceptibility distortions lead to severe broadening in conventional NMR. Two main approaches can be employed to overcome this issue: (1) use a pulse sequence to reduce the distortions, or (2) employ multidimensional NMR in combination with isotopic enrichment to provide the spectral dispersion required to separate peaks from overlapping resonances. Both approaches are discussed, and protocols for both approaches are provided here in the context of small aquatic organisms.

Improvements in lipid suppression for 1 H NMR-based metabolomics: Applications to solution-state and HR-MAS NMR in natural and in vivo samples

Proton nuclear magnetic resonance (NMR) spectra of intact biological samples often show strong contributions from lipids, which overlap with signals of interest from small metabolites. Pioneering work by Diserens et al. demonstrated that the relative differences in diffusivity and relaxation of lipids versus small metabolites could be exploited to suppress lipid signals, in high-resolution magic angle spinning (HR-MAS) NMR spectroscopy. In solution-state NMR, suspended samples can exhibit very broad water signals, which are challenging to suppress. Here, improved water suppression is incorporated into the sequence, and the Carr-Purcell-Meiboom-Gill sequence (CPMG) train is replaced with a low-power adiabatic spinlock that reduces heating and spectral artefacts seen with longer CPMG filters. The result is a robust sequence that works well in both HR-MAS as well as static solution-state samples. Applications are also extended to include in vivo organisms. For solution-state NMR, samples containing significant amount of fats such as milk and hemp hearts seeds are used to demonstrate the technique. For HR-MAS, living earthworms (Eisenia fetida) and freshwater shrimp (Hyalella azteca) are used for in vivo applications. Lipid suppression techniques are essential for non-invasive NMR-based analysis of biological samples with a high-lipid content and adds to the suite of experiments advantageous for in vivo environmental metabolomics.

Abstract GS5-07: Weight change in postmenopausal women and breast cancer risk in the women's health initiative observational study

Purpose

While obesity is an established breast cancer risk factor, information about the influence of weight loss on breast cancer risk in postmenopausal women is mixed precluding generation of a strong public health message regarding potential benefits of weight loss with respect to cancer risk. Therefore, we evaluated associations between weight change and invasive breast cancer risk in postmenopausal women participating in the Women's Health Initiative (WHI) Observational Study.

Patients and Methods

Postmenopausal women (n=61,335) with no prior breast cancer and normal mammogram who were not underweight (body mass index [BMI] ≥ 18.5 kg/m2), ages 50-79 years at WHI enrollment between 1993 and 1998 at 40 US clinical centers, had body weight and height measured and BMI calculated at the clinical centers at baseline and at year 3. Weight change over 3 years was categorized as: stable (no change ≤ 5%), loss (change ≥ 5%), or gain (change ≥ 5%) with weight lost intentionality determined by self-report response to direct query at year 3. Breast cancers were initially ascertained through annual survey and were centrally confirmed by medical record review. Multi-variable Cox proportional hazards regression models incorporating breast cancer risk factors and baseline BMI were used to evaluate relationships between weight change and breast cancer incidence.

Results

During 11.4 years (mean) of follow-up, 3,061 women developed invasive breast cancer. In multi-variable analyses, compared with women with stable weight (n=41,139), women with weight loss (≥ 5%) (n=8,175) had a significantly lower breast cancer risk (hazard ratio [HR] 0.88 95% confidence interval [CI] 0.78-0.98). Adjustment for mammography did not alter findings (HR 0.88 95% CI 0.78-0.99). There was no significant interaction for breast cancer effect by weight loss intentionality. Women with weight loss ≥ 15% had even lower breast cancer risk (HR 0.63 95% CI 0.45-0.90). While weight gain (≥ 5%) (n=12,021) was not associated with higher overall breast cancer risk, women with weight gain had a significantly higher risk of triple negative breast cancer (HR 1.54 95% CI 1.16-2.05). Weight change association with breast cancer incidence was examined in four subgroups: by tumor subtype (hormone receptor and HER2 status based), baseline BMI (normal, overweight, obese), race/ethnicity, and age group (50, -&lt;70 years). Effects in all subgroups was similar with no evidence of heterogeneity as no interaction term test in these analyses was significant.

Conclusion

Weight loss in postmenopausal women is associated with lower breast cancer risk. These findings suggest that postmenopausal women who lose weight may reduce their breast cancer risk.

Citation Format: Chlebowski RT, Luo J, Anderson GL, Simon M, Barrington W, Reding K, Manson JE, Rohan T, Wactawki-Wende J, Lane D, Strickler H, Mossavar-Rahmani Y, Freudenheim J, Saquib ATN, Stefanick M. Weight change in postmenopausal women and breast cancer risk in the women's health initiative observational study [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr GS5-07.

A Comparison of Brand and Biosimilar Granulocyte-Colony Stimulating Factors for Prophylaxis of Chemotherapy-Induced Febrile Neutropenia

BACKGROUND

Filgrastim-sndz, a granulocyte-colony stimulating factor (G-CSF), was introduced as a biosimilar to filgrastim in 2015, but real-world comparative effectiveness for filgrastim versus filgrastim-sndz has not been reported to date.

OBJECTIVES

To (a) compare the incidence of febrile neutropenia for patients taking filgrastim versus those taking filgrastim-sndz and (b) compare the incidence of a potential serious adverse event for filgrastim versus filgrastim-sndz.

METHODS

This retrospective cohort study identified patients receiving a G-CSF following chemotherapy, using administrative claims from the Humana Research Database. Patients enrolled in a Medicare Advantage Prescription Drug plan with a claim for a G-CSF from October 1, 2015, through September 30, 2016, were identified. G-CSF use had to occur within 6 days of exposure to chemotherapy and without any subsequent chemotherapy within 14 days after G-CSF use. Febrile neutropenia requiring hospitalization was defined as hospitalization within 14 days after G-CSF use with (a) diagnosis of infection and/or neutropenia (broad definition) or (b) infection and neutropenia diagnoses (narrow definition). Serious adverse drug events (spleen rupture, acute respiratory syndrome, serious allergic reactions, capillary leak syndrome, thrombocytopenia, leukocytosis, cutaneous vasculitis, or bones and muscle ache) were also identified within 14 days after G-CSF use. An incidence difference of < 1% with 90% CI crossing zero qualified as support for noninferiority. Two-tailed chi-square tests were also used to investigate differences.

RESULTS

A total of 88 filgrastim and 101 filgrastim-sndz patients were identified. Filgrastim and filgrastim-sndz met the criteria for noninferiority based on an incidence difference of -0.6% (90% CI = -5.1%-4.0%; P = 0.84) for the broad definition of febrile neutropenia and a difference of -0.8% (90% CI = -3.8%-2.1%; P = 0.64) for the narrow definition. For the analysis of serious adverse events, an incidence difference of -2.5% (90% CI = -7.5%-2.5%; P = 0.42) for filgrastim compared with filgrastim-sndz was not sufficient to establish noninferiority.

CONCLUSIONS

This study is one of the first analyses of real-world evidence regarding the noninferiority of filgrastim and filgrastim-sndz. The study results support noninferiority of filgrastim and filgrastim-sndz for prevention of febrile neutropenia requiring hospitalization. While noninferiority for serious adverse events was not supported, there was also no statistically significant difference between filgrastim and filgrastim-sndz. The study's small sample size could have limited the analysis of the relatively rare outcomes of febrile neutropenia requiring hospitalization and serious adverse events. A study including a larger numbers of patients taking filgrastim or filgrastim-sndz could provide additional insights.

DISCLOSURES

This study received no outside funding. Douglas, Kennedy, and Slabaugh were employees of Humana Pharmacy Solutions at the time the study was conducted. Bowe, Schwab, and Lane were employees of Comprehensive Health Insights, a wholly owned subsidiary of Humana, at the time the study was conducted. Study concept and design were contributed by Douglas, Kennedy, Schwab, and Lane, along with Slabaugh and Bowe. Bowe took the lead in data collection, assisted by Schwab, and data interpretation was performed by Schwab, along with the other authors. The manuscript was written by Schwab, Lane, and Douglas and revised by Kennedy, Slabaugh, and Bowe, along with Schwab, Lane, and Douglas.

Giving the Underdog a Leg Up: A Counternarrative of Nonviolent Resistance Improves Sustained Third-Party Support of a Disempowered Group

In the current work, we experimentally examined the effect of exposure to a narrative of nonviolent resistance on third-party attitudes toward and support for a disempowered group involved in asymmetric conflict. Across three experiments, we found that Americans exposed to a brief video about Palestinian nonviolent resistance consistently registered more favorable attitudes toward Palestinians than people who watched a film trailer either unrelated to the Israeli-Palestinian conflict or a trailer to a Palestinian-made film about sympathetic Palestinians violently opposing Israelis. Americans' attitudes toward Palestinians and behavior supporting Palestinian collective action persisted weeks after exposure to nonviolent resistance and were mediated by decreased perceptions that Palestinians are inherently violent. Importantly, positive attitudes toward Palestinians did not result in increased negativity toward Israelis. These data show that exposure to nonviolent resistance can have lasting effects on third-party attitudes and behavior toward an underdog/disempowered group, without driving partisanship.

Healthcare resource utilization and costs for patients with pulmonary arterial hypertension: real-world documentation of functional class

BACKGROUND AND AIMS

Pulmonary arterial hypertension (PAH) is a rare medical disease in which patients experience increased pulmonary vascular resistance (PVR) and pulmonary arterial pressure that can result in remodeling of the pulmonary vasculature and heart, and eventually lead to right heart failure and death. As PAH progresses, patients become unable to perform even routine daily tasks without severe shortness of breath (dyspnea), fatigue, dizziness, and fainting (syncope). Treatment strategies largely depend on assessment of an individual patient's WHO Functional Class. The aim of the present study was to determine whether PAH functional decline, as described by the WHO Functional class (FC), is associated with increased healthcare costs for patients.

METHODS

Patients with a prescription for a FDA-approved treatment for PAH and a medical claim indicating chronic pulmonary heart disease or right heart catheterization were identified from an administrative claims database. Provider-reported data from prior authorization forms required for advanced PAH therapies and medical charts were examined for reported FC. Healthcare resource utilization and costs were the primary outcomes of interest. Costs were accounted in 2014 US dollars ($) from a healthcare payer perspective.

RESULTS

Patients with a reported FC-IV were observed to have the worst outcomes; averaging significantly more inpatient admissions, longer average lengths of stay, and more emergency department visits than the other FC sub-groups, resulting in higher medical costs.

CONCLUSIONS

Using administrative data to document disease severity, this study replicates and expands on findings obtained from the registry study; disease severity was associated with higher healthcare resource utilization and costs. Stakeholders' implications for patient management are discussed.

Analysis of DOM phototransformation using a looped NMR system integrated with a sunlight simulator

Photochemical transformation plays an important role in functionalizing and degrading dissolved organic matter (DOM), producing one of the most complex mixtures known. In this study, using a flow-based design, nuclear magnetic resonance (NMR) spectroscopy is directly interfaced with a sunlight simulator enabling the study of DOM photodegradation in situ with high temporal resolution over 5 days. Samples from Suwannee River (Florida), Nordic Reservoir (Norway), and Pony Lake (Antarctic) are studied. Phototransformation of DOM is dominated by the degradation of aromatics and unsaturated structures (many arising from lignin) into carboxylated and hydroxylated products. To assess longer term changes, the samples were continuously irradiated for 17.5 days, followed by the identification a wide range of compounds and assessment of their fate using off-line 2D-NMR. This study demonstrates the applicability of the looped system to follow degradation in a non-targeted fashion (the mixture as a whole) and target analysis (tracing specific metabolites), which holds great potential to study the fate and transformation of contaminants and nutrients in the presence of DOM. It also demonstrates that components that remain unresolved in 1D NMR can be identified using 2D methods.

Defining food literacy: A scoping review

The term "food literacy" describes the idea of proficiency in food related skills and knowledge. This prevalent term is broadly applied, although its core elements vary from initiative to initiative. In light of its ubiquitous use-but varying definitions-this article establishes the scope of food literacy research by identifying all articles that define 'food literacy', analysing its key conceptualizations, and reporting outcomes/measures of this concept.

METHODS

A scoping review was conducted to identify all articles (academic and grey literature) using the term "food literacy". Databases included Medline, Pubmed, Embase, CAB Abstracts, CINAHL, Scopus, JSTOR, and Web of Science, and Google Scholar. Of 1049 abstracts, 67 studies were included. From these, data was extracted on country of origin, study type (methodological approach), primary target population, and the primary outcomes relating to food literacy.

RESULTS

The majority of definitions of food literacy emphasize the acquisition of critical knowledge (information and understanding) (55%) over functional knowledge (skills, abilities and choices) (8%), although some incorporate both (37%). Thematic analysis of 38 novel definitions of food literacy reveals the prevalence of six themes: skills and behaviours, food/health choices, culture, knowledge, emotions, and food systems. Study outcomes largely focus on knowledge generating measures, with very few focusing on health related outcome measures.

CONCLUSIONS

Current definitions of food literacy incorporate components of six key themes or domains and attributes of both critical and functional knowledge. Despite this broad definition of the term, most studies aiming to improve food literacy focus on knowledge related outcomes. Few articles address health outcomes, leaving an important gap (and opportunity) for future research in this field.

Abstract S5-04: Low-fat dietary pattern and breast cancer overall survival in the women's health initiative dietary modification randomized controlled trial

Introduction: Among 48,835 postmenopausal women randomized in the Women's Health Initiative Dietary Modification (WHI DM) primary prevention trial, 1,767 women were diagnosed with breast cancer during the 8.3 years of dietary intervention. While differences were not statistically significant, there were fewer breast cancers diagnosed in the low fat dietary group women (HR 0.92 95% CI 0.84-1.01, P=0.09) with somewhat lower breast cancer mortality (HR 0.77 95% CI 0.48-1.22) than seen in control group women (JAMA 2006; 295:629). These findings were recently updated, and after 10.9 years (mean) post-diagnosis follow-up, breast cancer overall survival among these 1,767 women measured from diagnosis was greater in the dietary group (10 year survival, 82% vs 78%, 168 (2.24%) versus 319 (2.71%) deaths; HR 0.80 95% CI 0.66-0.97, P=0.02) (AACR Annual Meeting 2016, abstract CT0433, Clinical Trials Plenary Session). We now report low-fat dietary pattern influence on breast cancer overall survival in subgroups defined by breast cancer characteristics.

Methods: The WHI DM trial, conducted at 40 US clinical centers, from1993-1998 enrolled 48,835 postmenopausal women, aged 50-79, without prior breast cancer, with normal mammogram and dietary fat intake &gt;32% of total energy. Participants were randomly assigned to a dietary intervention group (40%, n=19,541) with goals of fat intake reduction to 20% of energy and increased fruits, vegetables and grain intake, or a usual diet control group (60%, n=29,294). As previously reported, the dietary modification program reduced fat intake, increased fruit, vegetable and grain intake and was associated with modest weight loss (all P&lt; 0.001). The current secondary analysis outcome is breast cancer overall survival in subgroups defined by breast cancer characteristics for cases diagnosed during the dietary intervention period. Because of possible selection prior to breast cancer diagnosis, these analyses do not compare randomized outcomes. Therefore, careful attention is paid to control of risk factors for breast cancer in the analysis.

Results: The examined subgroups included histology (ductal, lobular, other), estrogen receptor (ER) status (positive vs. negative by local laboratory), progesterone receptor (PR) status, HER2 status, triple negative (yes/no), stage (local, regional or distant), grade (well, moderately, poorly differentiated), tumor size (&lt;1, 1- 2, &gt;=2 cm), and nodal involvement (none, 1-3, 4+). None of the tests of interaction in subgroups were statistically significant. All subgroup hazard ratios (HR) were less than one except for ER negative cancers, triple negative cancers and those with 4+ positive lymph nodes. The results are suggestive of no influence of the low-fat dietary pattern on triple negative cancers (HR 1.64 95% CI 0.73-3.70 for triple negative vs. HR 0.73 95% CI 0.56-0.95 for other breast cancers, interaction P=0.06).

Conclusion: Compared to a usual diet control group, women randomized to a dietary intervention group providing a low-fat dietary pattern had a significantly increased overall survival following a breast cancer diagnosis with the possible exception of those developing triple negative cancers.

Citation Format: Chlebowski RT, Aragaki AK, Thomson CA, Anderson G, Manson JE, Simon MS, Rohan TE, Snetselar LG, Lane D, Barrington WE, Vitolins M, Womack C, Qi L, Hou L, Thomas F, Prentice RL. Low-fat dietary pattern and breast cancer overall survival in the women's health initiative dietary modification randomized controlled trial [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr S5-04.

Towards single egg toxicity screening using microcoil NMR

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