Effect of Two Interventional Strategies on Improving Continuous Positive Airway Pressure Adherence in Existing COPD and Obstructive Sleep Apnea Patients: The O2VERLAP Study

BACKGROUND

Obstructive sleep apnea (OSA) is a sleep disorder prevalent in >10% of individuals diagnosed with chronic obstructive pulmonary disease (COPD). Continuous positive airway pressure (CPAP) is the first-line therapy for OSA, but many do not use it enough during sleep to effectively manage OSA. The O₂VERLAP study compared proactive care (PC)-structured web-based peer-coaching education and support intervention versus reactive care (RC)-education and support based on limited scheduled interactions and patient-initiated contacts.

METHODS

Participants were primarily recruited from patient communities (COPD, OSA, and the National Patient-Centered Outcomes Research Network [PCORnet]) through electronic methods. Inclusion criteria: ≥40 years old, diagnosis of both COPD and OSA, and currently using CPAP. Participants were then randomly assigned to either the PC or RC group, with outcomes assessed at baseline and 6 and 12 weeks. The primary study outcome was CPAP adherence (hours of use/night) and secondary outcomes were daytime functioning, sleep quality, and daytime sleepiness. Changes in outcomes over time were examined using random effects models.

RESULTS

The study enrolled 332 participants of which 294 were randomized. While groups differed significantly in CPAP adherence at baseline (PC: 6.1±3.1, RC: 7.3±2.4 hours/night; P<0.001), there were no significant differences in change of primary and secondary outcomes at either 6 or 12 weeks.

CONCLUSION

In this group of patients with both COPD and OSA on CPAP therapy, no difference was found between the provision of PC and RC. The study did find unexpectedly high baseline CPAP adherence levels, which suggests that any improvement from the intervention would have been very small and difficult to detect.

OP0080 STAT3 DEGRADERS INHIBIT Th17 DEVELOPMENT AND CYTOKINE PRODUCTION RESULTING IN PROFOUND INHIBITION OF COLLAGEN-INDUCED AUTOIMMUNE MURINE ARTHRITIS

Background

Signal transducer and activator of transcription 3 (STAT3) is a transcription factor that belongs to a class of targets devoid of catalytic function, thus deemed “undruggable” by standard modalities such as small molecule inhibitors or biologics. STAT3 can be activated by various receptor- and non-receptor tyrosine kinases, playing a critical role in activation pathways triggered by cytokines, hormones, and growth factors, making it an attractive target for the treatment of inflammatory diseases.

Objectives

Kymera has developed heterobifunctional molecules that selectively target STAT3 for degradation and elimination by the ubiquitin-proteasome pathway. We sought to evaluate the pharmacologic potential of these STAT3 degraders through in vitro and in vivo studies relevant to human autoimmune disease, including murine collagen-induced arthritis.

Methods

We evaluated the impact of STAT3 degraders on the activation of human monocytes, dermal fibroblasts, CD4+ T cells, and PBMC by LPS, IL-6/IL-6R, IL-21, IL-23, as well as anti-CD3/CD28 plus a cocktail of cytokines and antibodies. STAT3 degradation and pSTAT3 inhibition were determined in comparison to a JAK1/2 small molecule inhibitor. Inhibition of cytokines, chemokines, and collagen release, as well as Th17 (CD4+CD25-RORγt+CXCR6+) and Treg (CD4+CD25+CD127lowFOXP3+) expansion were used as in vitro efficacy assays. Finally, STAT3 degraders were tested in vivo, in a mechanistic (IL-6 challenge) as well as a disease model (murine CIA) relevant to rheumatology indications.

Results

STAT3 degraders showed broad and potent activity in-vitro against TLR receptor and cytokine-induced activation of immune and stromal cells, including soluble mediator release such as MCP-1/CCL2 and Collagen1a1. STAT3 degradation in CD4+ T cells robustly inhibited the development of Th17 cells, abrogating IL-17, IL-22, IL-8/CXCL8, and TNFα production, and increased Treg numbers in a manner superior to JAK1/2 inhibition. In mice injected with IL-6, plasma levels of serum amyloid A were dose-dependently suppressed by STAT3 degradation. In the murine collagen-induced arthritis model, STAT3 degradation resulted in robust, dose-dependent delay of disease onset and decreased disease incidence, clinical scores, local cytokine expression (paws) and histopathological scores, including the complete alleviation of periosteal bone growth.

Conclusion

These data demonstrate the broad activity of STAT3 degradation in alleviating autoimmune inflammation in models relevant to human disease. Targeted protein degradation of STAT3 thus represents a novel therapeutic approach to treating autoimmune/autoinflammatory diseases such as rheumatoid arthritis.

Disclosure of Interests

Cedric Hubeau Shareholder of: Kymera Therapeutics, Employee of: Kymera Therapeutics, Jeffrey Sullivan Shareholder of: Kymera Therapeutics, Employee of: Kymera Therapeutics, Crystal Brown Shareholder of: Kymera Therapeutics, Employee of: Kymera Therapeutics, Michele Mayo Shareholder of: Kymera Therapeutics, Employee of: Kymera Therapeutics, Vaishali Dixit Shareholder of: Kymera Therapeutics, Employee of: Kymera Therapeutics, Bradley Enerson Shareholder of: Kymera Therapeutics, Employee of: Kymera Therapeutics, Haojing Rong Shareholder of: Kymera Therapeutics, Employee of: Kymera Therapeutics, Bin Yang Shareholder of: Kymera Therapeutics, Employee of: Kymera Therapeutics, Chris De Savi Shareholder of: Kymera Therapeutics, Employee of: Kymera Therapeutics, Jared Gollob Shareholder of: Kymera Therapeutics, Employee of: Kymera Therapeutics, Nello Mainolfi Shareholder of: Kymera Therapeutics, Employee of: Kymera Therapeutics, Anthony Slavin Shareholder of: Kymera Therapeutics, Employee of: Kymera Therapeutics.

The national economic burden of rare disease in the United States in 2019

BACKGROUND

To provide a comprehensive assessment of the total economic burden of rare diseases (RD) in the United States (U.S.) in 2019. We followed a prevalence-based approach that combined the prevalence of 379 RDs with the per-person direct medical and indirect costs, to derive the national economic burden by patient age and type of RD. To estimate the prevalence and the direct medical cost of RD, we used claims data from three sources: Medicare 5% Standard Analytical File, Transformed Medicaid Statistical Information System, and Optum claims data for the privately insured. To estimate indirect and non-medical cost components, we worked with the rare disease community to design and implement a primary survey.

RESULTS

There were an estimated 15.5 million U.S. children (N = 1,322,886) and adults (N = 14,222,299) with any of the 379 RDs in 2019 with a total economic burden of $997 billion, including a direct medical cost of $449 billion (45%), $437 billion (44%) in indirect costs, $73 billion in non-medical costs (7%), and $38 billion (4%) in healthcare costs not covered by insurance. The top drivers for excess medical costs associated with RD are hospital inpatient care and prescription medication; the top indirect cost categories are labor market productivity losses due to absenteeism, presenteeism, and early retirement.

CONCLUSIONS

Our findings highlight the scale of the RD economic burden and call for immediate attention from the scientific communities, policy leaders, and other key stakeholders such as health care providers and employers, to think innovatively and collectively, to identify new ways to help improve the care, management, and treatment of these often-devastating diseases.

Outcomes Important to Patients Diagnosed with Both COPD and Sleep Apnea: Findings from the O2VERLAP Study Focus Groups

INTRODUCTION

Few studies have asked chronic obstructive pulmonary disease (COPD) -obstructive sleep apnea (OSA) overlap syndrome patients what outcomes of continuous positive airway pressure (CPAP) therapy are important to them, while also considering their self-reported CPAP adherence barriers and facilitators. This study conducted a series of focus groups to learn about those issues with the goal of applying these findings to the design of a larger Patient-Centered Outcomes Research Institute-funded scientific study, the O2VERLAP Study.

METHODS

People previously diagnosed with both COPD and OSA, who were current or recent past users of the standard therapy for each condition (i.e., supplemental oxygen and CPAP, respectively), were included. Three qualitative focus groups were run using different communication modalities: (1) teleconference (audio only), (2) in-person, and (3) web-based.

RESULTS

The focus groups included a total of 17 participants. The telephone and online focus groups resulted in more relevant and content-rich transcripts, while the in-person focus groups had far fewer excerpts able to be coded. Participants were most concerned about mask fit and comfort. Other key factors affecting CPAP use included nasal dryness and issues concerning insurance. The most important outcome to patients was daytime functioning.

DISCUSSION

This work found that telephone and web-based qualitative focus groups resulted in greater topical discussions than in-person focus groups, likely due to the customary socializing that occurs in-person. The study identified: (1) CPAP use barriers and facilitators that helped guide intervention development for the larger study and, (2) daytime functioning as the most important outcome for patients.

V3-Loop genotypes do not predict maraviroc susceptibility of CCR5-tropic virus or clinical response through week 48 in HIV-1-infected, treatment-experienced persons receiving optimized background regimens

Viruses from 15 of 35 maraviroc-treated participants with virologic failure and CCR5-tropic (R5) virus in the MOTIVATE studies at Week 24 had reduced maraviroc susceptibility. On-treatment amino acid changes were observed in the viral envelope glycoprotein 120 third variable (V3)-loop stems and tips and differed between viruses. No amino acid change reliably predicted reduced susceptibility, indicating that resistance was genetic context-dependent. Through Week 24, poor adherence was associated with maraviroc-susceptible virologic failure, whereas reduced maraviroc susceptibility was associated with suboptimal background regimen activity, highlighting the importance of overall regimen activity and good adherence. Predictive values of pretreatment V3-loop sequences containing these Week 24 mutations or other variants present at >3% in pretreatment viruses of participants with virologic failure at Week 48 were retrospectively assessed. Week 48 clinical outcomes were evaluated for correlates with pretreatment V3-loop CCR5-tropic sequences from 704 participants (366 responders; 338 virologic failures [83 with R5 virus with maraviroc susceptibility assessment]). Seventy-five amino acid variants with >3% prevalence were identified among 23 V3-loop residues. Previously identified variants associated with resistance in individual isolates were represented, but none were associated reliably with virologic failure alone or in combination. Univariate analysis showed virologic-failure associations with variants 4L, 11R, and 19S (P < 0.05). However, 11R is a marker for CXCR4 tropism, whereas neither 4L nor 19S was reliably associated with reduced maraviroc susceptibility in R5 failure. These findings from a large study of V3-loop sequences confirm lack of correlation between V3-loop genotype and clinical outcome in participants treated with maraviroc.Clinical trial registration numbers (ClinicalTrials.gov): NCT00098306 and NCT00098722.

Fenfluramine for treatment-resistant epilepsy in Dravet syndrome and other genetically mediated epilepsies

Fenfluramine hydrochloride, initially utilized as a weight loss drug in the 1970s and later removed from the market for adverse cardiopulmonary side effects, has since been repurposed as an antiseizure medicine (ASM). The potential antiseizure effects of fenfluramine were first identified in patients with photosensitive epilepsy in the 1980s but it was not rigorously explored as a treatment option until 30 years later. Compared with other ASMs, fenfluramine offers a novel mechanism by acting on serotonin and σ1 receptors, demonstrated in vitro and in vivo in animal models of Dravet syndrome. Results from a large double-blind, placebo-controlled trial demonstrated robust efficacy for seizure reduction in patients with Dravet syndrome, and met its primary endpoint with the 0.7 mg/kg/day fenfluramine treatment group experiencing a 62.3% or greater reduction in mean monthly convulsive seizure frequency (MCSF) compared with placebo. Here we provide a comprehensive review of the preclinical and clinical activity of fenfluramine, a recently approved drug for treatment of epilepsy in patients with Dravet syndrome.

Post-Traumatic Stress Disorder Is Associated with Neuropsychological Outcome but Not White Matter Integrity after Mild Traumatic Brain Injury

The aim of this study was to examine neuropsychological functioning and white matter integrity, in service members and veterans (SMVs) after mild traumatic brain injury (MTBI), with versus without post-traumatic stress disorder (PTSD). Participants were 116 U.S. military SMVs, prospectively enrolled from the Walter Reed National Military Medical Center (Bethesda, MD), who had sustained an MTBI (n = 86) or an injury without TBI (i.e., Injured Control [IC]; n = 30). Participants completed a battery of neuropsychological measures (neurobehavioral and -cognitive), as well as diffusion tensor imaging (DTI) of the brain, on average 6 years post-injury. Based on diagnostic criteria for PTSD, participants in the MTBI group were classified into two subgroups: MTBI/PTSD-Present (n = 21) and MTBI/PTSD-Absent (n = 65). Participants in the IC group were included only if they were classified as PTSD-Absent. The MTBI/PTSD-Present group had a significantly higher number of self-reported symptoms on all neurobehavioral measures (e.g., depression), and lower scores on more than half of the neurocognitive domains (e.g., processing speed), compared to the MTBI/PTSD-Absent and IC/PTSD-Absent groups. There were no significant group differences for the vast majority of DTI measures, with the exception of a handful of regions (i.e., superior longitudinal fascicle and superior thalamic radiation). These results suggest that there is 1) a strong relationship between PTSD and poor neuropsychological outcome after MTBI and 2) a lack of a relationship between PTSD and white matter integrity, as measured by DTI, after MTBI. Concurrent PTSD and MTBI should be considered a risk factor for poor neuropsychological outcome that requires early intervention.

New Adopters of Telemedicine During the Coronavirus-19 Pandemic in Respondents to an Online Community Survey: The Case for Access to Remote Management Tools for Individuals with Chronic Obstructive Pulmonary Disease

Objectives

To investigate telemedicine adoption, emergency department avoidance, and related characteristics of patients with chronic obstructive pulmonary disease (COPD) with and without exacerbations since the coronavirus 2019 (COVID-19) pandemic began.

Methods

We conducted the second of a series of online surveys via SurveyMonkey.com of people with COPD between May 1, 2020 and May 31, 2020. Frequency, percentage, and Fisher's exact test (2-sided) were calculated using SPSS version 26.

Results

More than half of respondents (157, 64%), indicated that they started using telemedicine in 2020. A total of 47% of respondents reported having had at least 1 exacerbation since January 1, 2020. Respondents who had at least 1 exacerbation in 2020 were more likely to start using telemedicine in 2020 than respondents who did not report any exacerbation in 2020 (75.7% versus 54.3%, p < 0.001). Respondents reporting a 2020 exacerbation indicated having a significantly higher avoidance of emergency health care since the pandemic began (27.8%) as compared to those who did not have an exacerbation in 2020 (10.1%), p < 0.001.

Conclusions

In response to social distancing and other COVID-19 precautions, people with COPD are avoiding traditional, in-person health care environments and turning to telemedicine to prevent and manage exacerbations. Further investigation is needed to identify best practices in and barriers to telemedicine in this population.

Secukinumab shows high and sustained efficacy in nail psoriasis: 2.5-year results from the randomized placebo-controlled TRANSFIGURE study

BACKGROUND

Secukinumab, a fully human monoclonal antibody that selectively neutralizes interleukin-17A, a cornerstone cytokine in psoriasis, has shown long-lasting efficacy and safety in the complete spectrum of psoriasis manifestations.

OBJECTIVES

To report the long-term (2·5-year) efficacy and safety of secukinumab in nail psoriasis.

METHODS

TRANSFIGURE, a double-blind, randomized, placebo-controlled, parallel-group, multicentre phase IIIb study in 198 patients, investigated secukinumab 150 mg and 300 mg in patients with moderate-to-severe nail psoriasis.

RESULTS

At week 16, the primary endpoint Nail Psoriasis Severity Index (NAPSI) was met, demonstrating superiority of secukinumab to placebo. The effect was sustained over 2·5 years with a large benefit for nail clearance, with mean NAPSI improvement of -73·3% and -63·6% with secukinumab 300 mg and 150 mg, respectively. At 2·5 years, secukinumab demonstrated sustained clinically significant reductions in total mean Nail Assessment in Psoriasis and Psoriatic Arthritis (NAPPA) quality-of-life (QoL) scores of -52·4% and -18·1%, and 70% and 71% of patients achieved a weighted NAPPA Patient Benefit Index global score of ≥ 2 with secukinumab 300 mg and 150 mg, respectively. Patients showed considerable improvements in the EuroQol 5-Dimension health status questionnaire at 2·5 years, reporting a decrease in pain and discomfort. No new safety findings were observed.

CONCLUSIONS

Secukinumab demonstrated strong and clinically meaningful efficacy for up to 2·5 years in nail psoriasis, with significant sustained QoL improvements and a favourable safety profile.

0696 The O2VERLAP Study: High Cpap Use Levels Found In Overlap Syndrome (OSA And COPD) Patients

Introduction

CPAP therapy is prescribed to help manage disordered breathing during sleep time periods. Most users, especially those with non-severe obstructive sleep apnea (OSA), use it only for some portion of their sleep period. Patients with Overlap Syndrome have both OSA and chronic obstructive pulmonary disease (COPD). While there has been some research on CPAP use levels in this patient population, there has been little indication that they use CPAP any differently than those with OSA only.

Methods

The O2VERLAP Study was a large comparative effectiveness trial enrolling people with COPD and OSA and using two different methods of providing information and support to current users of CPAP therapy. The study utilized an electronic national recruitment strategy and 332 participants were enrolled. CPAP data from the 12-week study period was analyzed. The Pittsburgh Sleep Quality Index was used to determine both estimated total sleep period (TSP) and total sleep time (TST). Because participants were all current users of CPAP, data from the total sample was combined and used. The percentage of TST and TSP that CPAP was used was calculated as CPAP use divided by either TST or TSP.

Results

The mean TST was 6.8 hours, TSP was 8.1 hours, and CPAP use was 6.7 hours. CPAP was used during 98.5% of the TST and during 82.7% of the TSP. Over 35% of the sample used CPAP at a level that was equal to or greater than their total sleep period.

Conclusion

Most OSA study populations use CPAP for some fraction of their night’s sleep. This COPD/OSA study population used CPAP to a markedly high level, including over one-third of the sample (n=~100) who used CPAP more than their self-reported sleep period. Further research on the extent and reasons for non-sleep period (i.e., daytime) CPAP use in COPD patients is warranted.

Support

PPRND #1507-31666.

National and State Estimates of COPD Morbidity and Mortality - United States, 2014-2015

Background: Chronic obstructive pulmonary disease (COPD) remains a leading cause of disability and death in the United States. The "COPD in the United States" project gathered data about the impact of COPD to highlight variability across states and provide a single point of access to data for state decision makers, the public health community and advocates. This report provides a summary of COPD-related morbidity and mortality in the United States and individual states during 2014-2015 (some metrics contain data from other years). Methods: We used data from multiple sources ( the Behavioral Risk Factor Surveillance System [BRFSS], the Centers for Disease Control and Prevention (CDC) Wide-ranging ONline Data for Epidemiologic Research online database, the CDC's chronic disease indicators data, Centers from Medicare and Medicaid Services Chronic Conditions Data Warehouse, Medical Expenditures Panel Survey and the American Association of Cardiovascular and Pulmonary Rehabilitation Pulmonary Rehabilitation Directory) to estimate 10 national and state-specific COPD metrics (prevalence, hospitalizations and emergency department visits, 30-day hospital readmissions, mortality, vaccinations, smoking prevalence, per capita medical cost, and the number of COPD patients per a pulmonary rehabilitation program) and to calculate average score across the 10 metrics. Additionally, we used BRFSS data to calculate the prevalence of common comorbid diseases among people who also report having a diagnosis of COPD. Results: During 2014-2015, 5.9% of adults (more than 15.9 million) reported having been told by their health care professional that they had COPD. The age-adjusted prevalence ranged from 3.7% for Puerto Rico and Hawaii, to 12% for West Virginia. The average score, 1 being best and 5 being worst, of the overall COPD burden based on the 10 key metrics ranged from 1.5 for Puerto Rico and Utah to 4.6 for West Virginia. Conclusion: The level of COPD morbidity and mortality is severe throughout the United States. There is considerable variability in COPD metrics by state. These differences may be useful in identifying and addressing policy gaps in the public health approach to COPD and in implementing the COPD National Action Plan.

Encompassing new use cases - level 3.0 of the HUPO-PSI format for molecular interactions

BACKGROUND

Systems biologists study interaction data to understand the behaviour of whole cell systems, and their environment, at a molecular level. In order to effectively achieve this goal, it is critical that researchers have high quality interaction datasets available to them, in a standard data format, and also a suite of tools with which to analyse such data and form experimentally testable hypotheses from them. The PSI-MI XML standard interchange format was initially published in 2004, and expanded in 2007 to enable the download and interchange of molecular interaction data. PSI-XML2.5 was designed to describe experimental data and to date has fulfilled this basic requirement. However, new use cases have arisen that the format cannot properly accommodate. These include data abstracted from more than one publication such as allosteric/cooperative interactions and protein complexes, dynamic interactions and the need to link kinetic and affinity data to specific mutational changes.

RESULTS

The Molecular Interaction workgroup of the HUPO-PSI has extended the existing, well-used XML interchange format for molecular interaction data to meet new use cases and enable the capture of new data types, following extensive community consultation. PSI-MI XML3.0 expands the capabilities of the format beyond simple experimental data, with a concomitant update of the tool suite which serves this format. The format has been implemented by key data producers such as the International Molecular Exchange (IMEx) Consortium of protein interaction databases and the Complex Portal.

CONCLUSIONS

PSI-MI XML3.0 has been developed by the data producers, data users, tool developers and database providers who constitute the PSI-MI workgroup. This group now actively supports PSI-MI XML2.5 as the main interchange format for experimental data, PSI-MI XML3.0 which additionally handles more complex data types, and the simpler, tab-delimited MITAB2.5, 2.6 and 2.7 for rapid parsing and download.

JAMI: a Java library for molecular interactions and data interoperability

Background

A number of different molecular interactions data download formats now exist, designed to allow access to these valuable data by diverse user groups. These formats include the PSI-XML and MITAB standard interchange formats developed by Molecular Interaction workgroup of the HUPO-PSI in addition to other, use-specific downloads produced by other resources. The onus is currently on the user to ensure that a piece of software is capable of read/writing all necessary versions of each format. This problem may increase, as data providers strive to meet ever more sophisticated user demands and data types.

Results

A collaboration between EMBL-EBI and the University of Cambridge has produced JAMI, a single library to unify standard molecular interaction data formats such as PSI-MI XML and PSI-MITAB. The JAMI free, open-source library enables the development of molecular interaction computational tools and pipelines without the need to produce different versions of software to read different versions of the data formats.

Conclusion

Software and tools developed on top of the JAMI framework are able to integrate and support both PSI-MI XML and PSI-MITAB. The use of JAMI avoids the requirement to chain conversions between formats in order to reach a desired output format and prevents code and unit test duplication as the code becomes more modular. JAMI’s model interfaces are abstracted from the underlying format, hiding the complexity and requirements of each data format from developers using JAMI as a library.

Taxonomy and biogeography of Hemphillia (Gastropoda: Pulmonata: Arionidae) in North American rainforests, with description of a new species (Skade’s jumping-slug, Hemphillia skadei sp. nov.)

Species diversity of the genus Hemphillia Bland and W.G. Binney, 1872 (jumping-slugs) was studied across its range in western North America’s inland temperate rainforests. The taxonomic relationships among jumping-slug populations were clarified by integrating morphological, molecular, and biogeographic approaches. A new species, Skade’s jumping-slug (Hemphillia skadei sp. nov.), was discovered in this process and is described herein. We base this taxonomic decision on molecular comparison of representatives from other Hemphillia species and four morphological characters that distinguish H. skadei from its sister species, the pale jumping-slug (Hemphillia camelus Pilsbry and Vanatta, 1897). The distribution of H. skadei and H. camelus is described along with the notable lack of detection of the marbled jumping-slug (Hemphillia danielsi Vanatta, 1914) within the primary survey area.

Looking after the mouth - Evaluation of a pilot for a new approach to training care home carers in Kent, Surrey and Sussex

Objective This pilot study aimed to produce and evaluate training resources and training in oral health care, including oral hygiene, for carers in care homes in Surrey and Medway.Methods During two training days, for carers from these homes, short, interactive presentations were given on a range of topics relevant to oral health care and oral hygiene of older people, followed by practical training. Prior to any training all attendees completed a 39 question questionnaire to establish their baseline knowledge of oral health and hygiene. At the end of the training day they completed an evaluation form. Fourteen weeks later, they were visited at their place of work and completed the same questionnaire again. Differences in responses between baseline and after 14 weeks were statistically tested using the chi-squared test.Results Sixty-six carers attended the training sessions and 44 were followed up 14 weeks later. The results showed an improvement in carer knowledge at follow up. The majority of carers (36/44) spoke English as their first language. They had a mean age of 41 years, 37 were female and 7 male. They had worked as carers for a mean of 10.9 years (range 4 months-34 years). Over 90% stated that the training day fully met or exceeded their requirements and expectations.Conclusions The results indicated improvements in carer knowledge. However, the carers were atypical of carers in general, as they were self-selected and well-motivated. Nevertheless the content of the training day and the questionnaire should inform future work in this area.

Measuring Sarcopenia Severity in Older Adults and the Value of Effective Interventions

OBJECTIVES

Little is known about the severity and long-term health and economic consequences of sarcopenia. We developed a sarcopenia index to measure severity in older Americans and estimated the long-term societal benefits generated by effective interventions to mitigate severity.

DESIGN

Using a micro-simulation model, we quantified the potential societal value generated in the US in 2010-2040 by reductions in sarcopenia severity in older adults. All analyses were performed in Stata and SAS.

SETTING AND PARTICIPANTS

Secondary data from the National Health and Nutrition Examination Survey (NHANES) (N = 1634) and Health and Retirement Study (HRS) (N = 952) were used to develop a sarcopenia severity index in older adults.

MEASUREMENTS

Multi-trait multi-method and factor analyses were used to validate and calibrate the sarcopenia severity index, which was modeled as a function of gait speed, walking without an assistive device, and moderate physical activity.

RESULTS

In representative elderly populations, reducing sarcopenia severity by improving gait speed by 0.1 m/s in those with gait speed under 0.8 m/s generated a cumulative benefit of $65B by 2040 (2015 dollars). Improving walking ability in those with walking difficulty generated cumulative social benefit of $787B by 2040.

CONCLUSIONS

Reducing sarcopenia severity would generate significant health and economic benefits to society-almost $800B in the most optimistic scenarios.

Better Respiratory Education and Treatment Help Empower (BREATHE) study: Methodology and baseline characteristics of a randomized controlled trial testing a transitional care program to improve patient-centered care delivery among chronic obstructive pulmonary disease patients

BACKGROUND

Chronic Obstructive Pulmonary Disease (COPD) is a leading cause of hospitalizations. Interventional studies focusing on the hospital-to-home transition for COPD patients are few. In the BREATHE (Better Respiratory Education and Treatment Help Empower) study, we developed and tested a patient and family-centered transitional care program that helps prepare hospitalized COPD patients and their family caregivers to manage COPD at home.

METHODS

In the study's initial phase, we co-developed the BREATHE transitional care program with COPD patients, family-caregivers, and stakeholders. The program offers tailored services to address individual patients' needs and priorities at the hospital and for 3months post discharge. We tested the program in a single-blinded RCT with 240 COPD patients who were randomized to receive the program or 'usual care'. Program participants were offered the opportunity to invite a family caregiver, if available, to enroll with them into the study. The primary outcomes were the combined number of COPD-related hospitalizations and Emergency Department (ED) visits per participant at 6months post discharge, and the change in health-related quality of life over the 6months study period. Other measures include 'all cause' hospitalizations and ED visits; patient activation; self-efficacy; and, self-care behaviors.

DISCUSSION

Unlike 1month transitional care programs that focus on patients' post-acute care needs, the BREATHE program helps hospitalized COPD patients manage the post discharge period as well as prepare them for long term self-management of COPD. If proven effective, this program may offer a timely solution for hospitals in their attempts to reduce COPD rehospitalizations.

Experimental Life-Cycle of Varestrongylus eleguneniensis (Nematoda: Protostrongylidae) in a Captive Reindeer (Rangifer tarandus tarandus) and a Muskox (Ovibos moschatus moschatus)

The life-cycle of a recently described protostrongylid lungworm, Varestrongylus eleguneniensis, which infects caribou, muskoxen, and moose from Arctic and boreal regions of North America, was completed experimentally for the first time. A native North American slug species, Deroceras laeve, was infected with the first-stage larvae (L1) isolated from the feces of wild muskoxen to generate third-stage larvae (L3). These were administered to a captive reindeer calf (250 L3) and an adult captive muskox (380 L3). The prepatent periods for the reindeer and muskox were 56 and 72 days, respectively. Patency lasted for only 19 days in the reindeer, and fecal larval counts were very low (0.09-1.53 larvae per gram of feces). Patency in the muskox was at least 210 days, and likely over 653 days, and the fecal larval counts were higher (0.06-17.8 larvae per gram of feces). This work provides the first experimental completion of the life-cycle of V. eleguneniensis.

Growth, morphometrics, and nutrient content of farmed eastern oysters, Crassostrea virginica (Gmelin), in New Hampshire, USA

When harvested, oysters represent a removal from the ecosystem of nutrients such as nitrogen (N) and carbon (C). A number of factors potentially affect nutrient content, but a quantitative understanding across the geographic range of the eastern oysters is lacking. The present study was designed to quantify the relationships among various metrics of farmed eastern oysters near its northern geographic range focusing on nutrient content. Hatchery-reared oysters were deployed in polyethylene bags at six sites, and were measured on multiple occasions from 2010-2012. A quadratic polynomial fit to the combined datasets for shell height indicated that on average a 'cocktail' size oyster (63 mm shell height) would be reached after 2 yr, and 'regular' size (76 mm) would require 3 yr. There were significant differences in growth rates and oyster nutrient content among the sites; means for %N in soft tissue ranged from 6.9 to 8.6, and 0.07 to 0.18 in shell. Percent N in soft tissue and shell were highest at two sites at the mouths of rivers with elevated dissolved inorganic N concentrations in the water. Grand means (all sites, seasons and years combined) of soft tissue N and C for regular size oysters were 7.3% and 38.5%, respectively; and for shell N and C were 0.13% and 12.0%, respectively. Our study extends the range of data on nutrient content of the eastern oyster to northern New England, and indicates that oyster size, seasonality, and nutrient concentration in ambient water potentially affect %N and %C content of oysters.

Splenorenal Arterial Bypass: Description of Technique and Case Example in an Instance of Renal Revascularization during Adrenalectomy for Adrenocortical Carcinoma

We present a patient with a 16 cm adrenocortical carcinoma that underwent a left adrenalectomy en bloc with resection of the involved segment of the left renal artery. A splenectomy and splenorenal bypass was performed to revascularize the left kidney. To our knowledge, this is the first instance in the literature of a splenorenal arterial bypass being reported for renal revascularization during an extirpative oncologic procedure. A 64-year-old male patient, with history significant for adrenocortical carcinoma, status post prior right adrenalectomy with partial right nephrectomy, presented for an elective left adrenalectomy. Preoperative work-up revealed an 11.4 × 13.2 × 16 cm left adrenal mass, most consistent with an adrenocortical carcinoma. At the time of surgery, the mass was found to be intimately adherent to the aorta at the takeoff of the left renal artery. Moreover, the left renal artery appeared to be coursing directly through the mass. The involved segment of the left renal artery was resected en bloc with the tumor. Because of concerns for a small and likely poorly functioning right renal remnant, a decision was made to attempt to salvage the left kidney. This was accomplished by performing a splenectomy and constructing a splenorenal bypass. Serial Duplex Doppler renal ultrasound studies were obtained over the first three postoperative days and demonstrated improved arterial waveforms. Serum creatinine reached a peak level of 3.76 mg/dL on postoperative day 3, and then began to slowly trend down to 3.37 mg/dL on the day of discharge (postoperative day7).