Better translation via collaboration: The MRC National Mouse Genetics Network

The MRC National Mouse Genetics Network (NMGN) has been established in the UK to bring together researchers from academia and industry across the country from a wide range of disease areas and research backgrounds to rapidly facilitate clinical translation of mouse research findings and foster an environment of interdisciplinary learning.

Comparative Effectiveness of Fidaxomicin vs Vancomycin in Populations With Immunocompromising Conditions for the Treatment of Clostridioides difficile Infection: A Single-Center Study

Background

Clostridioides difficile infection (CDI) is a leading cause of morbidity in immunocompromised hosts with increased risk of complications and recurrences. In this study, we examined the clinical effectiveness of fidaxomicin vs vancomycin in treating CDI in this patient population.

Methods

This single-center retrospective study evaluated patients with CDI between 2011 and 2021. The primary outcome was a composite of clinical failure, relapse at 30 days, or CDI-related death. A multivariable cause-specific Cox proportional hazards model was used to test the relationship between treatment and the composite outcome, adjusting for confounders and treating death from other causes as a competing risk.

Results

This study analyzed 238 patients who were immunocompromised and treated for CDI with oral fidaxomicin (n = 38) or vancomycin (n = 200). There were 42 composite outcomes: 4 (10.5%) in the fidaxomicin arm and 38 (19.0%) in the vancomycin arm. After adjustment for sex, number of antecedent antibiotics, CDI severity and type of immunosuppression, fidaxomicin use significantly decreased the risk of the composite outcome as compared with vancomycin (10.5% vs 19.0%; hazard ratio, 0.28; 95% CI, .08-.93). Furthermore, fidaxomicin was associated with 70% reduction in the combined risk of 30- and 90-day relapse following adjustment (hazard ratio, 0.27; 95% CI, .08-.91).

Conclusions

The findings of this study suggest that the use of fidaxomicin for treatment of CDI reduces poor outcomes in patients who are immunocompromised.

Comparison of clinical pathways for hypoglossal nerve stimulation management: in-laboratory titration polysomnography vs home-based efficacy sleep testing

STUDY OBJECTIVES

We conducted this study to evaluate whether laboratory or home-based hypoglossal nerve stimulation (HNS) management would have equivalent objective and subjective obstructive sleep apnea outcomes 6 months after activation.

METHODS

Patients undergoing standard-of-care HNS implantation were randomly assigned in a prospective, multicenter clinical trial to either a 3-month postactivation in-laboratory titration polysomnography (tPSG) or an efficacy home sleep study (eHST) with tPSG by exception for eHST nonresponders at 5 months. Both groups underwent an eHST 6 months postactivation.

RESULTS

Sixty patients were randomly assigned. Patients experienced equivalent decreases in the apnea-hypopnea index (mean difference: -0.01 events/h [-8.75, 8.74]) across both groups with HNS; the selection of tPSG or eHST did not associate with therapy response rates (tPSG vs eHST: 63.2% vs 59.1%). The Epworth Sleepiness Scale (median of differences: 1 [-1, 3]) and device usage (median of differences: 0.0 hours [-1.3, 1.3]) outcomes were similar but did not meet a priori statistical equivalence criteria.

CONCLUSIONS

This prospective, multicenter, randomized clinical trial demonstrated that patients undergoing HNS implantation experienced statistically equivalent improvements in objective obstructive sleep apnea outcomes and similar improvements in daytime sleepiness regardless of whether they underwent tPSG. HNS titration with tPSG may not be required for all postoperative patients.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Inspire Home Study: Utilization of Home Monitoring During Therapy Optimization in Patients With an Inspire Upper Airway Stimulation System (Comparison of Home Sleep Testing vs. In-lab Polysomnography Testing) (HOME); URL: https://clinicaltrials.gov/ct2/show/NCT04416542; Identifier: NCT04416542.

CITATION

Kent D, Huyett P, Yu P, et al. Comparison of clinical pathways for hypoglossal nerve stimulation management: in-laboratory titration polysomnography vs home-based efficacy sleep testing. J Clin Sleep Med. 2023;19(11):1905-1912.

The CKS1/CKS2 Proteostasis Axis Is Crucial to Maintain Hematopoietic Stem Cell Function

Long-term hematopoietic stem cells are rare, highly quiescent stem cells of the hematopoietic system with life-long self-renewal potential and the ability to transplant and reconstitute the entire hematopoietic system of conditioned recipients. Most of our understanding of these rare cells has relied on cell surface identification, epigenetic, and transcriptomic analyses. Our knowledge of protein synthesis, folding, modification, and degradation-broadly termed protein homeostasis or "proteostasis"-in these cells is still in its infancy, with very little known about how the functional state of the proteome is maintained in hematopoietic stem cells. We investigated the requirement of the small phospho-binding adaptor proteins, the cyclin-dependent kinase subunits (CKS1 and CKS2), for maintaining ordered hematopoiesis and long-term hematopoietic stem cell reconstitution. CKS1 and CKS2 are best known for their roles in p27 degradation and cell cycle regulation, and by studying the transcriptome and proteome of Cks1 -/- and Cks2 -/- mice, we demonstrate regulation of key signaling pathways that govern hematopoietic stem cell biology including AKT, FOXO1, and NFκB, together balancing protein homeostasis and restraining reactive oxygen species to ensure healthy hematopoietic stem cell function.

Diagnostic accuracy of the "4 A's Test" delirium screening tool for the postoperative cardiac surgery ward

BACKGROUND

Delirium is prevalent and underdetected among cardiac surgery patients on the postoperative ward. This study aimed to validate the 4 A's Test delirium screening tool and evaluate its accuracy both when used by research assistants and when subsequently implemented by nursing staff on the ward.

METHODS

This single-center, prospective observational study evaluated the performance of the 4 A's Test administered by research assistants (phase 1) and nursing staff (phase 2). Assessments were undertaken during the patients' first 3 postoperative days on the postcardiac surgery ward along with previous routine nurse-led Confusion Assessment Method assessments. These index tests were compared with a reference standard diagnosis of delirium based on Diagnostic and Statistical Manual of Mental Disorders 5th Edition criteria. Surveys regarding delirium screening were administered to nurses pre- and postimplementation of the 4 A's Test in phase 2 of the study.

RESULTS

In phase 1, a total of 137 patients were enrolled, of whom 24.8% experienced delirium on the postoperative cardiac ward. The 4 A's Test had a sensitivity of 85% (95% confidence interval, 73-93) and a specificity of 90% (95% confidence interval, 85-93) compared with the reference standard. The nurse-assessed Confusion Assessment Method had a sensitivity of 23% (95% confidence interval, 13-37) and specificity of 100% (95% confidence interval, 99-100). In phase 2, nurses (n = 51) screened 179 patients for delirium using the 4 A's Test. Compared with the reference rater, the 4 A's Test had a sensitivity of 58% (95% confidence interval, 28-85) and specificity of 94% (95% confidence interval, 85-98). Postimplementation, 64% of nurses thought that the 4 A's Test improved their confidence in delirium detection, and 76% of nurses would consider routine 4 A's Test use.

CONCLUSIONS

The 4 A's Test demonstrated moderate sensitivity and high specificity to detect delirium in a real-world setting after cardiac surgery on the postoperative ward. A modified model of use with less frequent administration, along with increased engagement of the postoperative team, is recommended to improve early delirium detection on the cardiac surgery postoperative ward.

Use of intraoperative haemostatic checklists on blood management in patients undergoing cardiac surgery: a scoping review protocol

INTRODUCTION

A major complication of cardiac surgery is bleeding which can require surgical re-exploration and the transfusion of allogeneic blood products. Re-operative procedures for bleeding have been associated with higher rates of mortality and morbidity, therefore an intervention to reduce this complication would be important. Previous investigation has demonstrated that low-cost solutions, such as the use of an intraoperative haemostatic checklist may result in the reduction of bleeding and subsequent transfusion. The goals of this scoping review aim to assess the efficacy of the use of intraoperative haemostatic checklists on blood management in patients undergoing cardiac surgery. Specifically, the objective is to understand if the use of intraoperative haemostatic checklists has been associated with a reduction in bleeding and blood product utilisation in patients undergoing non-emergent cardiac surgery.

METHODS AND ANALYSIS

A scoping review of literature identifying randomised control and observational trials, reporting on haemostatic checklists in cardiac surgery, will be undertaken. The proposed review will be guided by the methodological framework proposed by Arksey and O'Malley. A search will be conducted for published and unpublished (grey) literature. Published literature will be searched in the following electronic databases: Scopus, MEDLINE, EMBASE and the Cochrane Library. Relevant grey literature will be identified through conference abstracts. Outcomes chosen are patient centred to ensure reduced bleeding and overall positive experience that reduces complications intraoperatively.

ETHICS AND DISSEMINATION

This study does not require ethical approval as the data used are from available publications. Our dissemination strategy includes peer-review publication, presentation at conferences and relevant stakeholders.

Neurological Manifestations of SARS-CoV-2 Infection: Protocol for a Sub-analysis of the COVID-19 Critical Care Consortium Observational Study

Introduction

Neurological manifestations and complications in coronavirus disease-2019 (COVID-19) patients are frequent. Prior studies suggested a possible association between neurological complications and fatal outcome, as well as the existence of potential modifiable risk factors associated to their occurrence. Therefore, more information is needed regarding the incidence and type of neurological complications, risk factors, and associated outcomes in COVID-19.

Methods

This is a pre-planned secondary analysis of the international multicenter observational study of the COVID-19 Critical Care Consortium (which collected data both retrospectively and prospectively from the beginning of COVID-19 pandemic) with the aim to describe neurological complications in critically ill COVID-19 patients and to assess the associated risk factors, and outcomes. Adult patients with confirmed COVID-19, admitted to Intensive Care Unit (ICU) will be considered for this analysis. Data collected in the COVID-19 Critical Care Consortium study includes patients' pre-admission characteristics, comorbidities, severity status, and type and severity of neurological complications. In-hospital mortality and neurological outcome were collected at discharge from ICU, and at 28-days.

Ethics and Dissemination

The COVID-19 Critical Care Consortium main study and its amendments have been approved by the Regional Ethics Committee of participating sites. No further approval is required for this secondary analysis.

Trial Registration Number

ACTRN12620000421932.

Barriers to Successful Discharge After Cardiac Surgery: A Focus Group Study and Cross-Sectional Survey

At present, there is a lack of information on patient and caregiver values, and perceived priorities and barriers, to guide successful post-discharge recovery. This was a single center, multiple methods study that investigated patient, caregiver, and health care provider perceptions of the discharge process after cardiac surgery. Themes emerging from focus group discussions with patients and caregivers were used to develop surveys relating to values, barriers, and challenges relating to the discharge process. Thirty-two patients (n = 16) and caregivers (n = 16) participated in four separate focus groups. Four themes emerged from these discussions: (1) a lack of understanding about what the discharge process entails and when discharge is appropriate, (2) issues relating to the information provided to patients at the time of discharge, (3) participant experiences with the health care system, and (4) the experiences of caregivers. Seventy-eight patients, 34 caregivers, 53 nurses and/or other allied health professionals, and 8 surgeons completed the cross-sectional surveys. The most important component of the discharge process for patients and caregivers was "knowing what to do in an emergency." Health care providers less accurately identified what caregivers perceived as the most important aspects of the discharge process.Statements relating to informational barriers to discharge were the most discordant among patient and caregiver respondents. After discharge, patients and caregivers identified the need for longer-term follow up with the surgeon and more support in the community. Incorporation of patient and caregiver values to guide the post-cardiac surgery discharge process is essential to promote successful recovery.

POS0784 LOW COMPLEMENT LEVELS ARE ASSOCIATED WITH HIGHER MORTALITY IN HOSPITALIZED PATIENTS WITH POSITIVE ANTIPHOSPHOLIPID ANTIBODIES

Background

Antiphospholipid Syndrome is an autoimmune disease characterized by increased risk for vascular thrombosis (arterial and/or venous) thrombosis and/or pregnancy morbidity in the presence of antiphospholipid antibodies. The mechanisms by which aPLs induce thrombosis are unclear; several have been suggested, among them complement activation.(1-2) The complement system is a system of enzymes and regulatory proteins of the innate immune system that play a crucial role in the inflammatory response to various pathogenic stimuli. The complement and coagulation pathways are interconnected, and expanding evidence indicates that complement may be activated in patients with antiphospholipid syndrome (3-5).

Objectives

Our study was intended to better characterize the complicated relations between antiphospholipid antibodies and complement activation among hospitalized patients with antiphospholipid syndrome and its impact on short- and long-term prognosis

Methods

A retrospective cohort studies. Clinical and prognostic data of hospitalized patients with antiphospholipid syndrome and a measurement of complement levels (C3 or C4) were obtained. Rates of long-term mortality, one-year mortality, deep vein thrombosis (DVT), and pulmonary emboli (PE) were compared between patients with low complement levels and patients with normal complement levels. Low complement was defined as C3 < 90 mg/dl or C4 < 10 mg/dl. A multivariate analysis was performed to control for Anticardiolipin levels, β₂ macroglobulin levels and RVVT ratio.

Results

Complete data was available for 6,599 patients, of which 712 (11%) had low complement levels. The median age of the cohort was 47.7, and most of the patients were females (56%). Patients with low complement levels had significantly higher mortality rates 30% vs. 18%, p < 0.001 for long-term mortality (Figure 1) and 15% vs. 5%, p < 0.001 for 1 year mortality when compared to patients with normal complement levels. DVT and PE rates were similar (4% vs 3.8%, P = 0.78 and 4% vs 2.4%, P = 0.13 respectively). Results of the multivariate analysis (Table 1) were consistent and showed that patients with low complement levels had 111% higher mortality rates (CI 1.52-2.90, P < 0.001).

Table 1.

Multivariate Analysis for long term mortality

Multivariate AnalysisOR (CI)pLow Complement2.11 [1.52, 2.90]<0.001Anticardiolipin IGG1.00 [1.00, 1.01]0.243Anticardiolipin IGM0.99 [0.98, 1.00]0.084β₂ IGM1.01 [1.00, 1.01]0.017β₂ IGG1.00 [0.99, 1.00]0.663RVVT Ratio0.99 [0.63, 1.52]0.954Figure 1.

Cumulative 10-Year survival

Conclusion

In hospitalized patients with high aPLs, low complement levels are associated with significantly higher mortality rates. This finding is in correlation with recent literature, suggesting an important role for complement activation in APS.

References

[1]Chaturvedi S, Brodsky RA, McCrae KR. Complement in the pathophysiology of the antiphospholipid syndrome. Front Immunol. 2019 Mar 14;10:449.

[2]Bu C, Gao L, Xie W, Zhang J, He Y, Cai G, et al. beta2-glycoprotein i is a cofactor for tissue plasminogen activator-mediated plasminogen activation. Arthritis Rheum. 2009 Feb;60(2):559–568.

[3]Tedesco F, Borghi MO, Gerosa M, Chighizola CB, Macor P, Lonati PA, et al. Pathogenic role of complement in antiphospholipid syndrome and therapeutic implications. Front Immunol. 2018 Jun 19;9:1388.

[4]Oku K, Nakamura H, Kono M, Ohmura K, Kato M, Bohgaki T, et al. Complement and thrombosis in the antiphospholipid syndrome. Autoimmun Rev. 2016 Oct;15(10):1001–1004.

[5]Salmon JE, Girardi G, Holers VM. Complement activation as a mediator of antiphospholipid antibody induced pregnancy loss and thrombosis. Ann Rheum Dis. 2002 Nov;61 Suppl 2:ii46–50.

Disclosure of Interests

None declared

0755 Comparison of clinical pathways for upper airway stimulation management: in-laboratory titration polysomnography versus home-based efficacy sleep testing

Introduction

Upper airway stimulation (UAS) therapy is an alternative treatment option for select CPAP-intolerant patients with obstructive sleep apnea. Current standard-of-care management uses in-laboratory polysomnography for titration of UAS stimulation amplitude (tPSG) after 3 months of patient self-titration at home. This home monitoring study was designed to evaluate whether tPSG or efficacy home sleep test (eHST) with tPSG by exception for eHST non-responders would have non-inferior apnea-hypopnea index (AHI) outcomes.

Methods

Enrolled patients underwent UAS implantation as part of regular clinical care and were randomized at the activation visit 1:1 between tPSG or eHST for the 3-month post-activation visit. If eHST results were suboptimal (AHI &gt; 15 events/h or &lt; 50% reduction from baseline AHI) patients underwent tPSG titration at 5 months. Both groups had 2-night eHSTs at 6 months post-activation. The primary endpoint was 6-month AHI equivalence between arms (defined as ± 15 events/h). Secondary endpoints were equivalence of Epworth Sleepiness Score (ESS; ± 2), oxygen desaturation index (ODI; ± 15 events/h), and nightly UAS device usage (± 0.5 h).

Results

The study randomized 60 patients from August 2020 through September 2021, who were primarily middle aged (57 ± 10 years), male (67%), Caucasian (98%), and overweight (BMI 29 ± 3 kg/m2), with severe OSA (AHI 35 ± 16). Eleven patients withdrew from the study early. As of December 2021, 41 and 36 patients have completed 3- and 6-month follow-up visits, respectively. Six-month visit AHI, ESS, ODI, and device usage data between arms is currently blinded and is expected to be complete by Q2 2021 prior to SLEEP 2022.

Conclusion

If the study demonstrates equivalent 6-month AHI, ESS, ODI, and usage outcomes, the use of eHST to ascertain therapy efficacy prior to tPSG could be a non-inferior alternative management option to tPSG.

Support (If Any)

Sponsored by Inspire Medical Systems, Inc.

0764 Evaluation of cloud-connected home sensors of apnea-hypopnea index versus polysomnography and home sleep test during upper airway stimulation home titration

Introduction

A growing number of cloud-connected sensors can longitudinally record apnea hypopnea index (AHI) at home. The Ectosense NightOwl is an FDA-approved peripheral arterial tomography device; the Withings Sleep Analyzer mat is an under-mattress sensor with AHI data for retrospective research use (CE marked, not FDA approved). We used these sensors to monitor patients with upper airway stimulation (UAS) therapy during therapy acclimatization and post-titration follow-up and compared sensor AHI to polysomnography (PSG) and home sleep test (HST) AHIs.

Methods

Enrolled patients underwent UAS implantation as part of regular clinical care and were required to have a smartphone. The Ectosense and Withings sensors were distributed at UAS device activation. Patients were asked to use NightOwl weekly, and Withings provided nightly AHI. Sleep studies (PSG & HST) occurred at 3 and 6-mo post implant. Ectosense & Withings AHI were averaged and correlated against the nearest 3- and 6-month sleep study AHIs.

Results

Patients were 67% male, aged 57 ± 10 years. Smartphone platforms were 59% Apple iOS, 24% Google Android, and 17% Unknown. As of October 2021, 45 patients have had near-simultaneous Withings and PSG/HST AHI, 35 have had near-simultaneous NightOwl and PSG/HST AHI. The Withings AHI was fairly linear against PSG/HST AHI, adjusted R2 = 0.47, p &lt; 0.0001, (y=10 + 0.82x). Withings AHI &lt; 15 (n=18) had a 90% positive predictive value for a PSG/HST AHI less than 15 (n=20). Ectosense data was less linear and more scattered, adjusted R2 = 0.15, p=0.01, (y=14 + 0.47x). Ectosense AHI &lt; 15 (n=12) had an 80% positive predictive value of a PSG/HST AHI less than 15 (n=15).

Conclusion

Home-based sensors provide longitudinal SDB data in a home setting and may adequately classify patients with mild sleep apnea, and may have utility for home-based management of UAS patients in the post-implantation period.

Support (If Any)

Inspire Medical Systems

All-cause mortality as the primary endpoint for the GRAIL/National Health Service England multi-cancer screening trial

A randomized trial of the GRAIL Galleri^TM multi-cancer screening test is being planned for the National Health Service in England, and will have 140,000 healthy participants aged 50-79: 70,000 exposed to screening and 70,000 unexposed. The test reportedly detects 50 different cancers and is expected to reduce all-cancer mortality by approximately 25%. Given this effect size-and that cancer deaths constitute a large fraction of all deaths-the trial is sufficiently large to test the effect on all-cause mortality. Because most patients believe cancer screening "saves lives", the GRAIL/National Health Service collaboration could set the evaluation standard for multi-cancer screening.

Patient Engagement in the Design of a Mobile Health App That Supports Enhanced Recovery Protocols for Cardiac Surgery: Development Study

Background

Despite the importance of their perspectives, end users (eg, patients, caregivers) are not typically engaged by academic researchers in the development of mobile health (mHealth) apps for perioperative cardiac surgery settings.

Objective

The aim of this study was to describe a process for and the impact of patient engagement in the development of an mHealth app that supports patient and caregiver involvement with enhanced recovery protocols during the perioperative period of cardiac surgery.

Methods

Engagement occurred at the level of consultation and took the form of an advisory panel. Patients who underwent cardiac surgery (2017-2018) at St. Boniface Hospital (Winnipeg, Manitoba) and their caregivers were approached for participation. A qualitative exploration determined the impact of patient engagement on the development (ie, design and content) of the mHealth app. This included a description of (1) the key messages generated by the advisory panel, (2) how key messages were incorporated into the development of the mHealth app, and (3) feedback from the developers of the mHealth app about the key messages generated by the advisory panel.

Results

The advisory panel (N=10) generated 23 key messages to guide the development of the mHealth app. Key design-specific messages (n=7) centered around access, tracking, synchronization, and reminders. Key content-specific messages (n=16) centered around medical terms, professional roles, cardiac surgery procedures and recovery, educational videos, travel, nutrition, medications, resources, and physical activity. This information was directly incorporated into the design of the mHealth app as long as it was supported by the existing functionalities of the underlying platform. For example, the platform did not support the scheduling of reminders by users, identifying drug interactions, or synchronizing with other devices. The developers of the mHealth app noted that key messages resulted in the integration of a vast range and volume of information and resources instead of ones primarily focused on surgical information, content geared toward expectations management, and an expanded focus to include caregivers and other family members, so that these stakeholders may be directly included in the provision of information, allowing them to be better informed, prepare along with the patient, and be involved in recovery planning.

Conclusions

Patient engagement may facilitate the development of a detail-oriented and patient-centered mHealth app whose design and content are driven by the lived experiences of end users.

Long-term prediction of mortality and comparative treatment benefit following percutaneous or surgical revascularization

Background

The SYNTAX score II 2020 (SSII-2020), which was derived and externally validated from randomized trials, was designed to predict death following percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in patients with three-vessel disease and/or left main disease. We aimed to investigate its value in identifying the safest modality of revascularization in a non-randomized setting.

Methods

Five-year mortality was assessed in 7362 patients with three-vessel disease and/or left main disease enrolled in a Japanese PCI/CABG registry. New-generation drug eluting stents and imaging guidance became the default PCI strategy during enrolment of the last cohort. The discriminative ability of the SSII-2020 for 5-year mortality was assessed using Harrell's C statistic (C-index). Agreement between observed and predicted rates of all-cause mortality following either PCI or CABG and treatment benefit (absolute risk difference) for this outcome were assessed by calibration plots.

Results

The SSII-2020 had helpful discrimination (C-index = 0.72) and good calibration (intercept = −0.11, slope = 0.92) for 5-year mortality. The absolute risk difference in mortality between CABG and PCI (treatment benefit) was well calibrated when the whole population was grouped into quarters according to the predicted absolute risk difference of 5-year mortality. The observed differences in survival in favor of CABG were 4.2% (0.1 to 8.2%, log-rank p=0.05) and 8.5% (3.8 to 13.2%, log-rank p&lt;0.01) in the respective third and fourth quarters. In contrast, the observed differences in survival were not significantly different in either the first (3.0% [−0.8 to 6.8%, log-rank p=0.12]) or the second quarter (1.3% [−2.4 to 5.1%, log-rank p=0.39]).

Conclusions

The SSII-2020 is well able to predict death at 5 years – and the mortality difference between PCI and CABG, and therefore has the potential to support decision making on revascularization in patients with three-vessel disease and/or left main coronary artery disease.

Funding Acknowledgement

Type of funding sources: None.

Impact of Body Mass Index and Discomfort on Upper Airway Stimulation: ADHERE Registry 2020 Update

OBJECTIVES/HYPOTHESIS

To provide the ADHERE registry Upper Airway Stimulation (UAS) outcomes update, including analyses grouped by body mass index (BMI) and therapy discomfort.

STUDY DESIGN

Prospective observational study.

METHODS

ADHERE captures UAS outcomes including apnea-hypopnea index (AHI), Epworth sleepiness scale (ESS), therapy usage, patient satisfaction, clinician assessment, and safety over a 1-year period. BMI ≤32 kg/m² (BMI₃₂ ) and 32 < BMI ≤35 kg/m² (BMI₃₅ ) group outcomes were examined.

RESULTS

One thousand eight hundred forty-nine patients enrolled in ADHERE, 1,019 reached final visit, 843 completed the visit. Significant changes in AHI (-20.9, P < .0001) and ESS (- 4.4, P < .0001) were demonstrated. Mean therapy usage was 5.6 ± 2.2 hr/day. Significant therapy use difference was present in patients with reported discomfort versus no discomfort (4.9 ± 2.5 vs. 5.7 ± 2.1 hr/day, P = .01). Patients with discomfort had higher final visit mean AHI versus without discomfort (18.9 ± 18.5 vs. 13.5 ± 13.7 events/hr, P = .01). Changes in AHI and ESS were not significantly different. Serious adverse events reported in 2.3% of patients. Device revision rate was 1.9%. Surgical success was less likely in BMI₃₅ versus BMI₃₂ patients (59.8% vs. 72.2%, P = .02). There was a significant therapy use difference: 5.8 ± 2.0 hr/day in BMI₃₂ versus 5.2 ± 2.2 hr/day in BMI₃₅ (P = .028).

CONCLUSIONS

Data from ADHERE demonstrate high efficacy rates for UAS. Although surgical response rate differs between BMI₃₂ and BMI₃₅ patient groups, the AHI and ESS reduction is similar. Discomfort affects therapy adherence and efficacy. Thus, proper therapy settings adjustment to ensure comfort is imperative to improve outcomes.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:2616-2624, 2021.

Chitosan-Coated PLGA Nanoparticles Encapsulating Triamcinolone Acetonide as a Potential Candidate for Sustained Ocular Drug Delivery

The current treatment for the acquired retinal vasculopathies involves lifelong repeated intravitreal injections of either anti-vascular endothelial growth factor (VEGF) therapy or modulation of inflammation with steroids. Consequently, any treatment modification that decreases this treatment burden for patients and doctors alike would be a welcome intervention. To that end, this research aims to develop a topically applied nanoparticulate system encapsulating a corticosteroid for extended drug release. Poly (lactic-co-glycolic acid) (PLGA) nanoparticles (NPs) supports the controlled release of the encapsulated drug, while surface modification of these NPs with chitosan might prolong the mucoadhesion ability leading to improved bioavailability of the drug. Triamcinolone acetonide (TA)-loaded chitosan-coated PLGA NPs were fabricated using the oil-in-water emulsion technique. The optimized surface-modified NPs obtained using Box-Behnken response surface statistical design were reproducible with a particle diameter of 334 ± 67.95 to 386 ± 15.14 nm and PDI between 0.09 and 0.15. These NPs encapsulated 55-57% of TA and displayed a controlled release of the drug reaching a plateau in 27 h. Fourier-transform infrared spectroscopic (FTIR) analysis demonstrated characteristic peaks for chitosan (C-H, CONH2 and C-O at 2935, 1631 and 1087 cm-1, respectively) in chitosan-coated PLGA NPs. This result data, coupled with positive zeta potential values (ranged between +26 and +33 mV), suggests the successful coating of chitosan onto PLGA NPs. Upon coating of the NPs, the thermal stability of the drug, polymer, surfactant and PLGA NPs have been enhanced. The characteristics of the surface-modified NPs supports their use as potential candidates for topical ocular drug delivery for acquired retinal vasculopathies.

Referral of adults with obstructive sleep apnea for surgical consultation: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment

INTRODUCTION

This systematic review provides supporting evidence for the accompanying clinical practice guideline on the referral of adults with obstructive sleep apnea (OSA) for surgical consultation.

METHODS

The American Academy of Sleep Medicine commissioned a task force of experts in sleep medicine. A systematic review was conducted to identify studies that compared the use of upper airway sleep apnea surgery or bariatric surgery to no treatment as well as studies that reported on patient-important and physiologic outcomes pre- and postoperatively. Statistical analyses were performed to determine the clinical significance of using surgery to treat obstructive sleep apnea in adults. Finally, the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) process was used to assess the evidence for making recommendations.

RESULTS

The literature search resulted in 274 studies that provided data suitable for statistical analyses. The analyses demonstrated that surgery as a rescue therapy results in a clinically significant reduction in excessive sleepiness, snoring, blood pressure (BP), apnea-hypopnea index (AHI), respiratory disturbance index (RDI), oxygen desaturation index (ODI), increase in lowest oxygen saturation (LSAT), sleep quality, and improvement in quality of life in adults with OSA who are intolerant or unaccepting of positive airway pressure (PAP) therapy. The analyses demonstrated that surgery as an adjunctive therapy results in a clinically significant reduction in optimal PAP pressure and improvement in PAP adherence in adults with OSA who are intolerant or unaccepting of PAP due to side effects associated with high pressure requirements. The analyses also demonstrated that surgery as an initial treatment results in a clinically significant reduction in AHI/RDI, sleepiness, snoring, BP, and ODI, and increase in LSAT in adults with OSA and major anatomical obstruction. Analysis of bariatric surgery data showed a clinically significant reduction in BP, AHI/RDI, sleepiness, snoring, optimal PAP level, BMI, ODI, and an increase in LSAT in adults with OSA and obesity. Analyses of very limited evidence suggest that upper airway surgery does not result in a clinically significant increase in risk of serious persistent adverse events and suggested that bariatric surgery may result in a clinically significant risk of iron malabsorption that may be managed with iron supplements. The task force provided a detailed summary of the evidence along with the quality of evidence, the balance of benefits and harms, patient values and preferences, and resource use considerations.

Referral of adults with obstructive sleep apnea for surgical consultation: an American Academy of Sleep Medicine clinical practice guideline

Introduction

This guideline establishes clinical practice recommendations for referring adults with obstructive sleep apnea (OSA) for surgical consultation.

Methods

The American Academy of Sleep Medicine (AASM) commissioned a task force of experts in sleep medicine, otolaryngology, and bariatric surgery to develop recommendations and assign strengths based on a systematic review of the literature and an assessment of the evidence using the GRADE process. The task force evaluated the relevant literature and the quality of evidence, the balance of benefits and harms, patient values and preferences, and resource use considerations that support the recommendations. The AASM Board of Directors approved the final recommendations.

Recommendations

The following recommendations are intended as a guide for clinicians who treat adults with OSA. Each recommendations statement is assigned a strength ("Strong" or "Conditional"). A "Strong" recommendation (i.e., "We recommend…") is one that clinicians should follow under most circumstances. A "Conditional" recommendation is one that requires that the clinician use clinical knowledge and experience, and strongly consider the patient's values and preferences to determine the best course of action. 1. We recommend that clinicians discuss referral to a sleep surgeon with adults with OSA and BMI<40 who are intolerant or unaccepting of PAP as part of a patient-oriented discussion of alternative treatment options. (STRONG) 2. We recommend that clinicians discuss referral to a bariatric surgeon with adults with OSA and obesity (class II/III, BMI ≥35) who are intolerant or unaccepting of PAP as part of a patient-oriented discussion of alternative treatment options. (STRONG) 3. We suggest that clinicians discuss referral to a sleep surgeon with adults with OSA, BMI<40, and persistent inadequate PAP adherence due to pressure-related side effects as part of a patient-oriented discussion of adjunctive or alternative treatment options. (CONDITIONAL) 4. We suggest clinicians recommend PAP as initial therapy for adults with OSA and a major upper airway anatomic abnormality prior to consideration of referral for upper airway surgery. (CONDITIONAL).

Improving outcomes of hypoglossal nerve stimulation therapy: current practice, future directions and research gaps. Proceedings of the 2019 International Sleep Surgery Society Research Forum

Hypoglossal nerve stimulation (HGNS) has evolved as a novel and effective therapy for patients with moderate-to-severe obstructive sleep apnea (OSA). Despite positive published outcomes of HGNS, there exist uncertainties regarding proper patient selection, surgical technique, and the reporting of outcomes and individual factors that impact therapy effectiveness. According to current guidelines, this therapy is indicated for select patients, and recommendations are based on the Stimulation Therapy for Apnea Reduction (STAR) trial. Ongoing research and physician experiences continuously improve methods to optimize the therapy. An understanding of the way in which airway anatomy, OSA phenotypes, individual health status, psychological conditions and comorbid sleep disorders influence the effectiveness of HGNS is essential to improve outcomes and expand therapy indications. This manuscript presents discussions on current evidence, future directions, and research gaps for HGNS therapy from the 10th International Surgical Sleep Society expert research panel.

Dexamethasone-Loaded Nanostructured Lipid Carriers for the Treatment of Dry Eye Disease

Dry eye disease (DED) or keratoconjunctivitis sicca is a chronic multifactorial disorder of the ocular surface caused by tear film dysfunction. Symptoms include dryness, irritation, discomfort and visual disturbance, and standard treatment includes the use of lubricants and topical steroids. Secondary inflammation plays a prominent role in the development and propagation of this debilitating condition. To address this we have investigated the pilot scale development of an innovative drug delivery system using a dexamethasone-encapsulated cholesterol-Labrafac™ lipophile nanostructured lipid carrier (NLC)-based ophthalmic formulation, which could be developed as an eye drop to treat DED and any associated acute exacerbations. After rapid screening of a range of laboratory scale pre-formulations, the chosen formulation was prepared at pilot scale with a particle size of 19.51 ± 0.5 nm, an encapsulation efficiency of 99.6 ± 0.5%, a PDI of 0.08, and an extended stability of 6 months at 4 °C. This potential ophthalmic formulation was observed to have high tolerability and internalization capacity for human corneal epithelial cells, with similar behavior demonstrated on ex vivo porcine cornea studies, suggesting suitable distribution on the ocular surface. Further, ELISA was used to study the impact of the pilot scale formulation on a range of inflammatory biomarkers. The most successful dexamethasone-loaded NLC showed a 5-fold reduction of TNF-α production over dexamethasone solution alone, with comparable results for MMP-9 and IL-6. The ease of formulation, scalability, performance and biomarker assays suggest that this NLC formulation could be a viable option for the topical treatment of DED.

Real-world efficacy of deep TMS for obsessive-compulsive disorder: Post-marketing data collected from twenty-two clinical sites

BACKGROUND

Deep transcranial magnetic stimulation (dTMS) with the H7-coil was FDA cleared for obsessive-compulsive disorder (OCD) in August 2018 based on multicenter sham-controlled studies. Here we look at the efficacy of dTMS for OCD in real world practices.

METHODS

All dTMS clinics were asked to supply their data on treatment details and outcome measures. The primary outcome measure was response, defined by at least a 30% reduction in the Yale Brown Obsessive Compulsive Scale (YBOCS) score from baseline to endpoint. Secondary outcome measures included first response, defined as the first time the YBOCS score has met response criteria, and at least one-month sustained response. Analyses included response rate at the endpoint (after 29 dTMS sessions), number of sessions and days required to reach first response and sustained response.

RESULTS

Twenty-two clinical sites with H7-coils provided data on details of treatment and outcome (YBOCS) measures from a total of 219 patients. One-hundred-sixty-seven patients who had at least one post-baseline YBOCS measure were included in the main analyses. Overall first and sustained response rates were 72.6% and 52.4%, respectively. The response rate was 57.9% in patients who had YBOCS scores after 29 dTMS sessions. First response was achieved in average after 18.5 sessions (SD = 9.4) or 31.6 days (SD = 25.2). Onset of sustained one-month response was achieved in average after 20 sessions (SD = 9.8) or 32.1 days (SD = 20.5). Average YBOCS scores demonstrated continuous reduction with increasing numbers of dTMS sessions.

CONCLUSIONS

In real-world clinical practice, the majority of OCD patients benefitted from dTMS, and the onset of improvement usually occurs within 20 sessions. Extending the treatment course beyond 29 sessions results in continued reduction of OCD symptoms, raising the prospect of value for extended treatment protocols in non-responders.

Nature versus Nurture: Assessing the Impact of Strain Diversity and Pregrowth Conditions on Salmonella enterica, Escherichia coli, and Listeria Species Growth and Survival on Selected Produce Items

Inoculation studies are important when assessing microbial survival and growth in food products. These studies typically involve the pregrowth of multiple strains of a target pathogen under a single condition; this emphasizes strain diversity. To gain a better understanding of the impacts of strain diversity ("nature") and pregrowth conditions ("nurture") on subsequent bacterial growth in foods, we assessed the growth and survival of Salmonella enterica (n = 5), Escherichia coli (n = 6), and Listeria (n = 5) inoculated onto tomatoes, precut lettuce, and cantaloupe rind, respectively. Pregrowth conditions included (i) 37°C to stationary phase (baseline), (ii) low pH, (iii) high salt, (iv) reduced water activity, (v) log phase, (vi) minimal medium, and (vii) 21°C. Inoculated tomatoes were incubated at 21°C; lettuce and cantaloupe were incubated at 7°C. Bacterial counts were assessed over three phases, including initial reduction (phase 1), change in bacterial numbers over the first 24 h of incubation (phase 2), and change over the 7-day incubation (phase 3). E. coli showed overall decline in counts (<1 log) over the 7-day period, except for a <1-log increase after pregrowth in high salt and to mid-log phase. In contrast, S. enterica and Listeria showed regrowth after an initial reduction. Pregrowth conditions had a substantial and significant effect on all three phases of S. enterica and E. coli population dynamics on inoculated produce, whereas strain did not show a significant effect. For Listeria, both pregrowth conditions and strain affected changes in phase 2 but not phases 1 and 3.IMPORTANCE Our findings suggest that inclusion of multiple pregrowth conditions in inoculation studies can best capture the range of growth and survival patterns expected for Salmonella enterica and Escherichia coli present on produce. This is particularly important for fresh and fresh-cut produce, where stress conditions encountered by pathogens prior to contamination can vary widely, making selection of a typical pregrowth condition virtually impossible. Pathogen growth and survival data generated using multiple pregrowth conditions will allow for more robust microbial risk assessments that account more accurately for uncertainty.

Understanding Longitudinal Changes in Pulmonary Vascular Resistance After Left Ventricular Assist Device Implantation

BACKGROUND

Elevated pulmonary vascular resistance (PVR) is common in patients with advanced heart failure. PVR generally improves after left ventricular assist device (LVAD) implantation, but the rate of decrease has not been quantified and the patient characteristics most strongly associated with this improvement are unknown.

METHODS AND RESULTS

We analyzed 1581 patients from the Interagency Registry for Mechanically Assisted Circulatory Support registry who received a primary continuous-flow LVAD, had a baseline PVR of ≥3 Wood units (WU), and had PVR measured at least once postoperatively. Multivariable linear mixed effects modeling was used to evaluate independent associations between postoperative PVR and patient characteristics. PVR decreased by 1.53 WU (95% confidence interval [CI] 1.27-1.79 WU) per month in the first 3 months postoperatively, and by 0.066 WU (95% CI 0.060-0.070 WU) per month thereafter. Severe mitral regurgitation at any time during follow-up was associated with a 1.29 WU (95% CI 1.05-1.52 WU) higher PVR relative to absence of mitral regurgitation at that time. In a cross-sectional analysis, 15%-25% of patients had persistently elevated PVR of ≥3 WU at any given time within 36 months after LVAD implantation.

CONCLUSION

The PVR tends to decrease rapidly early after implantation, and only more gradually thereafter. Residual mitral regurgitation may be an important contributor to elevated postoperative PVR. Future research is needed to understand the implications of elevated PVR after LVAD implantation and the optimal strategies for prevention and treatment.

A standard set of testing methods reliably enumerates spores across commercial milk powders

Contamination of dairy powders with sporeforming bacteria is a concern for dairy processors who wish to penetrate markets with stringent spore count specifications (e.g., infant powders). Despite instituted specifications, no standard methodology is used for spore testing across the dairy industry. Instead, a variety of spore enumeration methods are in use, varying primarily by heat-shock treatments, plating method, recovery medium, and incubation temperature. Importantly, testing the same product using different methodologies leads to differences in spore count outcomes, which is a major issue for those required to meet specifications. As such, we set out to identify method(s) to recommend for standardized milk powder spore testing. To this end, 10 commercial milk powders were evaluated using methods varying by (1) heat treatment (e.g., 80°C/12 min), (2) plating method (e.g., spread plating), (3) medium type (e.g., plate count milk agar), and (4) incubation time and temperature combinations (e.g., 32°C for 48 h). The resulting data set included a total of 48 methods. With this data set, we used a stepwise process to identify optimal method(s) that would explain a high proportion of variance in spore count outcomes and would be practical to implement across the dairy industry. Ultimately, spore pasteurized mesophilic spore count (80°C/12 min, incubated at 32°C for 48 h), highly heat resistant thermophilic spore count (100°C/30 min, incubated at 55°C for 48 h), and specially thermoresistant spore enumeration (106°C/30 min, incubated at 55°C for 48 h) spread plating on plate count milk agar were identified as the optimal method set for reliable enumeration of spores in milk powders. Subsequently, we assessed different powder sampling strategies as a way to reduce variation in powder spore testing outcomes using our recommended method set. Results indicated that 33-g composite sampling may reduce variation in spore testing outcomes for highly heat resistant thermophilic spore count over 11-g and 33-g discrete sampling, whereas there was no significant difference across sampling strategies for specially thermoresistant spore enumeration or spore pasteurized mesophilic spore count. Finally, an interlaboratory study using our recommended method set and a modified method set (using tryptic soy agar with 1% starch) among both university and industry laboratories showed increased variation in spore count outcomes within milk powders, which not only was due to natural variation in powders but also was hypothesized to be due to technical errors, highlighting the need for specialized training for technicians who perform spore testing on milk powders. Overall, this study addresses challenges to milk powder spore testing and recommends a method set for standardized spore testing for implementation across the dairy industry.

Facing the Ethical Challenges: Consumer Involvement in COVID-19 Pandemic Research

Consumer involvement in clinical research is an essential component of a comprehensive response during emergent health challenges. During the COVID-19 pandemic, the moderation of research policies and regulation to facilitate research may raise ethical issues. Meaningful, diverse consumer involvement can help to identify practical approaches to prioritize, design, and conduct rapidly developed clinical research amid current events. Consumer involvement might also elucidate the acceptability of flexible ethics review approaches that aim to protect participants whilst being sensitive to the challenging context in which research is taking place. This article describes the main ethical challenges arising from pandemic research and how involving consumers and the community could enable resolution of such issues.

Slowed Progression of Age-Related Geographic Atrophy Following Subthreshold Laser

Purpose

To determine the effect of panmacular low-intensity/high-density subthreshold diode micropulse laser (SDM) on age-related geographic atrophy (ARGA) progression.

Methods

The retinal images of all eyes with ARGA in a previously reported database, consisting of all eyes with dry age-related macular degeneration (AMD) active in a vitreoretinal practice electronic medical record (EMR), were identified and analyzed to determine the velocity of radial linear ARGA progression during observation and after panmacular SDM.

Results

Sixty-seven eyes of 49 patients with ARGA, mean age of 86 years were identified as having follow-up both before and after initiation of SDM treatment. All were included in the study. These eyes were followed a mean 910 days (2.5 years) prior to SDM treatment and a mean 805 days (2.2 years) after. Measurement masked to treatment vs observation found the radius of ARGA lesions progressed 1 to 540 µm per year (mean 137µm, SD 107) prior to treatment (controls); and −44 to 303 µm per year (mean 73µm, SD 59) after initiation of periodic panmacular SDM laser. Thus, the velocity of radial linear progression decreased 47% per year following panmacular SDM (p<0.0001). There were no adverse treatment effects.

Conclusion

In cohort of eyes with high-risk dry AMD, panmacular SDM slowed linear radial ARGA progression velocity 47% per year (p<0.0001) without adverse treatment effects. Validated, these findings would constitute an important advance in the prevention of age-related visual loss and a benchmark for future therapies.

Shackled Imagination: Literary Illusions about Blindness

This article reviews the ways blind characters have been depicted by writers from Sophocles ( c 429 BC) to James Dickey (AD 1987). Blindness as usually tragic metaphor predominates in literature through the ages, except for certain popular romances and novels by blind writers. Well-known blind characters throughout the literature and fictional creations of writers of the past two decades are discussed in detail, and discussed in relation to stereotypes of blind people.

0681 Comparison Of Upper Airway Stimulation Outcomes Between Regions And Bmi Groups From The Adhere Registry

Introduction

As factors influencing Upper Airway Stimulation (UAS) effectiveness in obstructive sleep apnea (OSA) patients are of interest, we compared changes in apnea hypopnea index (AHI) and Epworth Sleepiness Scale (ESS) based on region and baseline body mass index (BMI).

Methods

Patients (15≥AHI≤65) of the ADHERE registry with AHI at one-year were grouped by region (Europe (EU) vs United States (US)), and BMI (≤32kg/m2 vs 32-35kg/m2). T-tests and equivalence testing (if the former non-significant) was performed using two-one-sided t-tests. Equivalence margin for AHI was set between -5 and 5 and -2 and 2 for ESS.

Results

By December 2019, 553 of 1600 patients completed 1-year follow-up. Average age was 60±11, 75% male, BMI 29±4 kg/m2, ESS=11±6. Median AHI decreased from 33 to 10, median ESS decreased from 11 to 6. Response defined by 50% AHI reduction and &lt;20 was 70%. Both regions had similar improvements in median AHI (EU: 33 to 10, US: 34 to 10, p &lt; 0.001 vs baseline), median ESS (EU: 12 to 7; US: 11 to 6, p&lt;0.001 vs baseline), and treatment response (EU: 71%, US: 68%). The mean AHI and ESS difference between regions met the equivalence margin. (AHI: mean difference: 0.34, CI:-1.78, 2.46, ESS: mean difference: 0.57, CI:-0.04, 1.19). Mean change in AHI at 1-year was equivalent in BMI groups (≤32 kg/m2 vs 32-35 kg/m2 respectively) median difference: -19.6 vs. -18.8; mean difference: -0.48, (CI:-3.95, 2.97) However, treatment response ratio was different; 73% vs. 60%, p=0.02, i.e. higher BMI patients were less likely to achieve AHI &lt; 20. ESS scores were equivalent; median: 6 vs. 7; mean difference: -0.33, CI: [-1.16, 0.47].

Conclusion

UAS influence on OSA severity defined by AHI and sleepiness was similar irrespective of region and BMI category, however, treatment response defined by 50% AHI reduction and &lt;20 was greater in those with lower BMI.

Support

The statistical support was provided by Inspire Medical System.

Automated sleep stage scoring of the Sleep Heart Health Study using deep neural networks

STUDY OBJECTIVES

Polysomnography (PSG) scoring is labor intensive and suffers from variability in inter- and intra-rater reliability. Automated PSG scoring has the potential to reduce the human labor costs and the variability inherent to this task. Deep learning is a form of machine learning that uses neural networks to recognize data patterns by inspecting many examples rather than by following explicit programming.

METHODS

A sleep staging classifier trained using deep learning methods scored PSG data from the Sleep Heart Health Study (SHHS). The training set was composed of 42 560 hours of PSG data from 5213 patients. To capture higher-order data, spectrograms were generated from electroencephalography, electrooculography, and electromyography data and then passed to the neural network. A holdout set of 580 PSGs not included in the training set was used to assess model accuracy and discrimination via weighted F1-score, per-stage accuracy, and Cohen's kappa (K).

RESULTS

The optimal neural network model was composed of spectrograms in the input layer feeding into convolutional neural network layers and a long short-term memory layer to achieve a weighted F1-score of 0.87 and K = 0.82.

CONCLUSIONS

The deep learning sleep stage classifier demonstrates excellent accuracy and agreement with expert sleep stage scoring, outperforming human agreement on sleep staging. It achieves comparable or better F1-scores, accuracy, and Cohen's kappa compared to literature for automated sleep stage scoring of PSG epochs. Accurate automated scoring of other PSG events may eventually allow for fully automated PSG scoring.

Association between cancer-specific adverse event triggers and mortality: A validation study

Background

As there are few validated measures of patient safety in clinical oncology, creating an efficient measurement instrument would create significant value. Accordingly, we sought to assess the validity of a novel patient safety measure by examining the association of oncology‐specific triggers and mortality using administrative claims data.

Methods

We examined a retrospective cohort of 322 887 adult cancer patients enrolled in commercial or Medicare Advantage products for one year after an initial diagnosis of breast, colorectal, lung, or prostate cancer in 2008‐2014. We used diagnosis and procedure codes to calculate the prevalence of 16 cancer‐specific "triggers"–events that signify a potential adverse event. We compared one‐year mortality rates among patients with and without triggers by cancer type and metastatic status using logistic regression models.

Results

Trigger events affected 19% of patients and were most common among patients with metastatic colorectal (41%) and lung (50%) cancers. There was increased one‐year mortality among patients with triggers compared to patients without triggers across all cancer types in unadjusted and multivariate analyses. The increased mortality rate among patients with trigger events was particularly striking for nonmetastatic prostate cancer (1.3% vs 7.5%, adjusted odds ratio 1.96 [95% CI 1.49‐2.57]) and nonmetastatic colorectal cancer (4.1% vs 11.7%, 1.44 [1.19‐1.75]).

Conclusions

The association between adverse event triggers and poor survival among a cohort of cancer patients supports the validity of a cancer‐specific, administrative claims‐based trigger tool.