A classification system for youth outpatient behavioral health services billed to medicaid

Rates of youth behavioral health concerns have been steadily rising. Administrative data can be used to study behavioral health service utilization among youth, but current methods that rely on identifying an associated behavioral health diagnosis or provider specialty are limited. We reviewed all procedure codes billed to Medicaid for youth in one U.S. county over a 10-year period. We identified 158 outpatient behavioral health procedure codes and classified them according to service type. This classification system can be used by health services researchers to better characterize youth behavioral health service utilization.

Effects of atipamezole on selected physiologic parameters in cynomolgus macaques (Macaca fascicularis)

BACKGROUND

Atipamezole, an α-2 adrenergic receptor antagonist, reverses the α-2 agonist anesthetic effects. There is a dearth of information on the physiological effects of these drugs in cynomolgus macaques (Macaca fascicularis). We assessed atipamezole's physiologic effects. We hypothesized atipamezole administration would alter anesthetic parameters.

METHODS

Five cynomolgus macaques were sedated with ketamine/dexmedetomidine intramuscularly, followed 45 min later with atipamezole (0.5 mg/kg). Anesthetic parameters (heart rate, blood pressure [systolic (SAP), diastolic (DAP), and mean (MAP) blood pressure], body temperature, respiratory rate, and %SpO2) were monitored prior to and every 10 min (through 60 min) post atipamezole injection.

RESULTS

While heart rate was significantly increased for 60 min; SAP, DAP, MAP, and temperature were significantly decreased at 10 min.

CONCLUSIONS

This study indicates subcutaneous atipamezole results in increased heart rate and transient blood pressure decrease. These findings are clinically important to ensure anesthetist awareness to properly support and treat patients as needed.

Associations between outpatient treatment and the use of intensive psychiatric healthcare services

The current manuscript examines concurrent and longitudinal associations between the utilization of outpatient and intensive psychiatric services among Medicaid-enrolled youth. Using an administrative dataset of Medicaid claims from 2007 to 2017, youth were included if they were between the ages of 10-18 (M = 13.4, SD = 2.6) and had a psychiatric Medicaid claim (N = 33,590). Psychiatric services were coded as outpatient, emergency department (ED), inpatient, or residential based on Medicaid codes. Logistic regression analyses indicated that the receipt of even one outpatient visit significantly reduced the odds of having an ED, inpatient, and residential visit within 60-, 90-, and 120-day windows. Survival analyses indicated most youth did not have any ED, inpatient, or residential visit following their first outpatient visit. For remaining youth, having an outpatient visit significantly increased the risk of having an ED, inpatient, and residential visit following their initial appointment, which may suggest these youth are being triaged to a more appropriate level of care. Classification accuracy analyses indicated a cutoff of 2 outpatient visits yielded maximum accuracy in determining youth with ED, inpatient, and residential visits. Findings highlight use of outpatient-level services in reducing risk of more intensive service utilization.

Examining Patterns of Psychotherapy Service Utilization Among Medicaid-Enrolled Adolescents

OBJECTIVE

Adolescents with behavioral health disorders (i.e., mental health disorders and substance use) often experience frequent recurrence of symptoms, suggesting a need for an ongoing behavioral health intervention, rather than a single course of treatment. However, little is known about mental health care service use among adolescents over longer periods. The authors examined longitudinal patterns of outpatient behavioral health service utilization in a large sample of adolescents.

METHODS

Medicaid claims for 8,197 adolescents (ages 10.0-13.9 years, mean±SD=11.5±1.2; 61% male) from one Indiana county between 2006 and 2017 were examined, with a focus on outpatient psychotherapy visits. Latent class analysis (LCA) was used to detect clusters of longitudinal patterns of outpatient psychotherapy visits across 5 years, beginning with an adolescent's first behavioral health visit.

RESULTS

A five-class LCA model emerged with unique classes of service use based on duration and level of engagement (frequency) of monthly outpatient psychotherapy visits. Most adolescents fell in the nonuse class (38.7% of the sample). Additional classes were defined as late-onset low engagement (17.1%), early-onset high engagement (15.5%), early-onset moderate engagement (16.7%), and continuously high engagement (11.9%). Statistically significant differences were found across the classes in average duration and frequency of involvement (p<0.001), as well as in demographic characteristics (race, age, gender, and ethnicity) and behavioral health diagnoses (p<0.001).

CONCLUSIONS

These findings confirm that adolescents with behavioral health diagnoses do not follow a uniform pattern of psychotherapy utilization. The distinct patterns of service use point toward the need to identify appropriate long-term service recommendations for adolescents.

Obstructive and central sleep apnoea in a patient with medically intractable epilepsy

A woman in her 30s with medically intractable epilepsy and Lennox-Gastaut Syndrome on multiple antiseizure medications and with a deep brain stimulator presented to the epilepsy monitoring unit with increased seizure frequency. She was noted to have periods of apparent apnoea time linked to bursts of epileptiform activity on continuous video EEG monitoring. Once the clinical seizures were controlled, she was discharged to the sleep laboratory. She was noted to have obstructive and central sleep apnoea, which improved with the use of positive airway pressure. Central sleep apnoeas were time linked to electrographic seizures. Ictal central apnoea can easily be overlooked and is likely more common than currently recognised in patients with epilepsy. Ictal central apnoea may be a biomarker for sudden unexpected death in epilepsy.

Alliances to disseminate addiction prevention and treatment (ADAPT): A statewide learning health system to reduce substance use among justice-involved youth in rural communities

BACKGROUND

Youth in the justice system (YJS) are more likely than youth who have never been arrested to have mental health and substance use problems. However, a low percentage of YJS receive SUD services during their justice system involvement. The SUD care cascade can identify potential missed opportunities for treatment for YJS. Steps along the continuum of the cascade include identification of treatment need, referral to services, and treatment engagement. To address gaps in care for YJS, we will (1) implement a learning health system (LHS) to develop, or improve upon, alliances between juvenile justice (JJ) agencies and community mental health centers (CMHC) and (2) present local cascade data during continuous quality improvement cycles within the LHS alliances.

METHODS/DESIGN

ADAPT is a hybrid Type II effectiveness implementation trial. We will collaborate with JJ and CMHCs in eight Indiana counties. Application of the EPIS (exploration, preparation, implementation, and sustainment) framework will guide the implementation of the LHS alliances. The study team will review local cascade data quarterly with the alliances to identify gaps along the continuum. The study will collect self-report survey measures longitudinally at each site regarding readiness for change, implementation climate, organizational leadership, and program sustainability. The study will use the Stages of Implementation Completion (SIC) tool to assess the process of implementation across interventions. Additionally, the study team will conduct focus groups and qualitative interviews with JJ and CMHC personnel across the intervention period to assess for impact.

DISCUSSION

Findings have the potential to increase SUD need identification, referral to services, and treatment for YJS.

Caregiving burden among informal caregivers of African American cancer survivors

PURPOSE

Relatively little is known about caregivers of African American cancer survivors. Our goal was to identify the extent of burden among this group of caregivers.

METHODS

Responses from 560 informal caregivers of African American participants of the Research on Cancer Survivors (ROCS) study in Detroit, MI, were analyzed including demographics, assistance provided including activities of daily living (ADLs) and instrumental activities of daily living (IADLs), time spent in caregiving, and caregiver burden (CGB). We assessed relationships between CGB and demographic variables, ADLs/IADLs, and level of care. Multivariable logistic regression determined which ADLs and IADLs were associated with high CGB.

RESULTS

Over 75% of caregivers were female and 97% identified as African American. Mean age was 52.6 years. Fifty-six percent were employed outside the home, and 90% were related to the survivor. Caregivers averaged 35.7 h/week providing care, assisting with on average 2.8 ADLs and 5.0 IADLs. Despite the many hours and activities reported, no caregivers rated CGB as severe; only 4% rated it moderate to severe. ADLs associated with the top quartile of CGB were feeding and toileting; IADLs were finances, telephoning, housework, and medications.

CONCLUSIONS

Caregivers for African American cancer survivors provide many hours of care, yet most describe their CGB as low. Although ADL assistance is often available through the healthcare system, assistance with IADLs presents an opportunity to lessen the burden for these caregivers and their care recipients.

IMPLICATIONS FOR CANCER SURVIVORS

African American cancer survivors receive much care from informal family caregivers, who assist with multiple ADLs and IADLs. Formal IADL assistance programs, similar to those available for ADLs, would benefit both survivors and caregivers.

Behavioral Health Service Utilization Among Detained Adolescents: A Meta-Analysis of Prevalence and Potential Moderators

PURPOSE

Utilization of behavioral health treatment services among adolescents who have been detained or incarcerated within the juvenile justice system is poorly understood, with estimated utilization rates varying widely across studies. This meta-analysis was conducted to review and synthesize the literature on the prevalence of service utilization among this population.

METHODS

Data from 27 studies of 28 distinct samples were abstracted and coded. A meta-analysis was conducted to calculate individual prevalence estimates of behavioral health service utilization, which were combined using random effects models. A moderator analysis was also conducted.

RESULTS

Prevalence effect sizes (pr) for service utilization were low, with effect sizes pr = 33.1% for mental health services, pr = 27.95% for substance use-related services, and pr = 45.32% for unspecified services. The moderator analysis showed significant heterogeneity in prevalence of behavioral health service utilization.

CONCLUSIONS

The findings suggest limited service utilization by adolescents who had been detained or incarcerated, whether assessed before, during, or after confinement. Future research should focus on assessing the quality of, and youth access to, behavioral health services within and outside of juvenile justice facilities. Improved programs to ensure consistent treatment for previously detained or incarcerated adolescents are warranted.

Identification and Characterization of a Phase-Variable Element That Regulates the Autotransporter UpaE in Uropathogenic Escherichia coli

Uropathogenic Escherichia coli (UPEC) is the most common etiologic agent of uncomplicated urinary tract infection (UTI). An important mechanism of gene regulation in UPEC is phase variation that involves inversion of a promoter-containing DNA element via enzymatic activity of tyrosine recombinases, resulting in biphasic, ON or OFF expression of target genes. The UPEC reference strain CFT073 has five tyrosine site-specific recombinases that function at two previously characterized promoter inversion systems, fimS and hyxS Three of the five recombinases are located proximally to their cognate target elements, which is typical of promoter inversion systems. The genes for the other two recombinases, IpuA and IpuB, are located distal from these sites. Here, we identified and characterized a third phase-variable invertible element in CFT073, ipuS, located proximal to ipuA and ipuB The inversion of ipuS is catalyzed by four of the five CFT073 recombinases. Orientation of the element drives transcription of a two-gene operon containing ipuR, a predicted LuxR-type regulator, and upaE, a predicted autotransporter. We show that the predicted autotransporter UpaE is surface located and facilitates biofilm formation as well as adhesion to extracellular matrix proteins in a K-12 recombinant background. Consistent with this phenotype, the ipuS ON condition in CFT073 results in defective swimming motility, increased adherence to human kidney epithelial cells, and a positive competitive kidney colonization advantage in experimental mouse UTIs. Overall, the identification of a third phase switch in UPEC that is regulated by a shared set of recombinases describes a complex phase-variable virulence network in UPEC.IMPORTANCE Uropathogenic Escherichia coli (UPEC) is the most common cause of urinary tract infection (UTI). ON versus OFF phase switching by inversion of small DNA elements at two chromosome sites in UPEC regulates the expression of important virulence factors, including the type 1 fimbria adhesion organelle. In this report, we describe a third invertible element, ipuS, in the UPEC reference strain CFT073. The inversion of ipuS controls the phase-variable expression of upaE, an autotransporter gene that encodes a surface protein involved in adherence to extracellular matrix proteins and colonization of the kidneys in a murine model of UTI.

Porcine Reproductive and Respiratory Syndrome virus reduces feed efficiency, digestibility, and lean tissue accretion in grow-finish pigs

Porcine reproductive and respiratory syndrome (PRRS) virus is a major swine virus that causes reproductive impairment in sows, as well as respiratory disease, reduction in growth rates, and mortalities in all ages of pigs. The objective of this study was to quantify the impact PRRS has on grower-finisher pig feed efficiency and tissue accretion rates. Thirty PRRS naïve, littermate pairs of maternal line Choice Genetics gilts (33.6 ± 0.58 kg BW) were selected and pairs split across 2 barns consisting of 5 pens (n = 6 pigs/pen per barn). Pigs in both barns were fed corn-soybean-DDGS diets ad libitum. All pigs in one barn were inoculated (CHAL) via an i.m. injection of a live PRRS strain isolated from the region (0 d post inoculation, dpi), while pigs in the other barn were given a saline control injection (CONT). Pig performance (ADG, ADFI, G:F) was assessed from 35 kg BW until each group reached market BW (128 kg). Additionally, longitudinal apparent total tract digestibility (ATTD) and body composition was assessed using Dual-energy X-ray absorptiometry (DXA) post inoculation (dpi) to estimate lean, protein, fat and bone accretion rates. Serological data from CHAL pigs showed that PRRS titers peaked 7 dpi and these pigs seroconverted by 35 dpi. According to both genomic and protein PRRS titers, CONT pigs were naïve to CHAL throughout the study. The PRRS infection reduced (P < 0.001) ATTD of dry matter, energy and nitrogen by 3 to 5% at 21 dpi and the reduction in ATTD persisted after 65 dpi. Compared to the CONT, CHAL pigs had decreased ADG (0.89 vs. 0.80 kg/d, P < 0.001), ADFI (2.05 vs. 1.93 kg/d, P < 0.001), and G:F (0.44 vs. 0.41 kg/d, P < 0.001) over the entire test period. The CHAL pigs also had attenuated DXA predicted whole body accretion of lean (547 vs. 633 g/d, P = 0.001), protein (109 vs. 126 g/d, P = 0.001) and fat (169 vs. 205 g/d, P = 0.001) compared to their CONT counterparts from dpi 0 to 80. Based on carcass data at slaughter (and consistent with the DXA data), CHAL pigs had leaner carcasses and reduced yields. These data clearly demonstrate that PRRS infection reduces digestibility, feed efficiency and protein accretion rates in grower-finisher pigs.

Preventive Care Use Among Justice-Involved and Non-Justice-Involved Youth

BACKGROUND AND OBJECTIVES

Youth involved in the juvenile justice system (ie, arrested youth) are at risk for health problems. Although increasing preventive care use by justice-involved youth (JIY) is 1 approach to improving their well-being, little is known about their access to and use of care. The objective of this study was to determine how rates of well-child (WC) and emergency department visits, as well as public insurance enrollment continuity, differed between youth involved in the justice system and youth who have never been in the system. We hypothesized that JIY would exhibit less frequent WC and more frequent emergency service use than non-justice-involved youth (NJIY).

METHODS

This was a retrospective cohort study of administrative medical and criminal records of all youth (ages 12-18) enrolled in Medicaid in Marion County, Indiana, between January 1, 2004, and December 31, 2011.

RESULTS

The sample included 88 647 youth; 20 668 (23%) were involved in the justice system. JIY had lower use rates of WC visits and higher use rates of emergency services in comparison with NJIY. JIY had more and longer gaps in Medicaid coverage compared with NJIY. For all youth sampled, both preventive and emergency services use varied significantly by Medicaid enrollment continuity.

CONCLUSIONS

JIY experience more and longer gaps in Medicaid coverage, and rely more on emergency services than NJIY. Medicaid enrollment continuity was associated with differences in WC and emergency service use among JIY, with policy implications for improving preventive care for these vulnerable youth.

The effect of porcine reproductive and respiratory syndrome virus and porcine epidemic diarrhea virus challenge on growing pigs I: Growth performance and digestibility

Porcine reproductive and respiratory syndrome (PRRS) and porcine epidemic diarrhea (PED) are two diseases costly to the U.S. swine industry. The objective of this study was to determine the impact of PRRS virus and PED virus, alone or in combination, on growth performance, feed efficiency, and digestibility in grower pigs. Forty-two gilts (16 ± 0.98 kg BW) naïve for PRRS and PED were selected and allocated to 1 of 4 treatments. Treatments included 1) a control, 2) PRRS virus infected, 3) PED virus infected, and 4) PRRS+PED coinfection (PRP). Pigs in treatments 2 and 4 were inoculated with a live field strain of PRRS virus via intramuscular and intranasal routes at 0 d after inoculation (dpi). Treatments 3 and 4 were orally inoculated with a cloned PED virus at 15 dpi. Infection with PRRS virus was confirmed by quantitative PCR and seroconversion. Infection with PED virus was confirmed with PCR. Control pigs remained PRRS and PED virus negative throughout the study. All pigs were offered, ad libitum, a standard diet with free access to water. During the test period, PRRS reduced ADG and ADFI by 30 and 26%, respectively (P < 0.05), compared with control pigs, whereas PRP decreased ADG, ADFI, and G:F by 45, 30, and 23%, respectively (P < 0.05). Additional reductions in ADG and G:F were detected in PRP pigs compared with singular PED or PRRS treatments (33 and 16%, respectively). The impact of PED, alone or in combination, on performance (15–21 dpi) reduced ADG (0.66 vs. 0.35 vs. 0.20 kg/d; P < 0.01), ADFI (1.22 vs. 0.88 vs. 0.67 kg/d; P = 0.003), and G:F (0.54 vs. 0.39 vs. 0.31; P = 0.001) compared with control pigs. Compared with control pigs, PRRS infection did not reduce apparent total tract digestibility (ATTD) of nutrients and energy. However, PED infection, alone or in combination, decreased ATTD of DM and energy by 8 and 12%, respectively (P < 0.05). Compared with control pigs, PRP reduced N and OM ATTD by 13 and 3%, respectively (P < 0.05). No significant differences in apparent ileal digestibility (AID) were detected between virus challenges. However, Lys AID tended to be reduced in both PED treatments compared with the control (10 and 12%; P = 0.095). Altogether, PRRS reduced growth but did not alter digestibility. Pigs challenged with PED and, to a greater extent, the coinfection of PED and PRRS viruses had reduced ADG, ADFI, G:F, and ATTD of nutrients and energy.

The effect of porcine reproductive and respiratory syndrome virus and porcine epidemic diarrhea virus challenge on growing pigs II: Intestinal integrity and function

The objective of this study was to determine if intestinal function and integrity is altered due to porcine reproductive and respiratory syndrome (PRRS) virus and porcine epidemic diarrhea (PED) virus infection in growing pigs. Forty-two gilts (16.8 ± 0.6 kg BW), naïve for PRRS and PED, were selected and randomly assigned to 1 of 4 treatments: 1) a control (CON; = 6), 2) PRRS virus challenge only (PRRS; = 12), 3) PED virus challenge only (; = 12), or 4) coinfection of PRRS + PED viruses (PRP; = 12). Treatments 2 and 4 were inoculated with a live field strain of PRRS virus on d 0 after inoculation. Treatments 3 and 4 were inoculated with PED virus on 14 d after inoculation (dpi) and all pigs were euthanized 7 d later (21 dpi). Infection with PRRS virus was determined by viremia and seroconversion. Fecal quantitative PCR was used to confirm PED virus infection. Control pigs remained PRRS and PED virus negative throughout the study. Compared with the CON, intestinal morphology was unaffected by PRRS. As expected, PED and PRP treatments resulted in duodenum, jejunum, and ileum villus atrophy compared with the CON treatment ( < 0.01). Ex vivo transepithelial electrical resistance (TER) did not differ between CON and PRRS pigs (P < 0.05) but was reduced by 40% in PED alone ( < 0.01). Interestingly, TER was increased ( < 0.01) in the PRP pigs. Active transport of glucose was increased in PRRS pigs over CON pigs ( < 0.01), whereas PED had pigs increased ( < 0.01) active glutamine transport over the CON pigs. Jejunum GLUT2 mRNA abundance and sucrase, maltase, and Na+/K+ adenosine triphosphatase activities tended to be increased in PRRS pigs compared with CON pigs ( < 0.06). The jejunum AA transporter, SLC6A14, and mucin 2 mRNA abundance tended to be increased in PED-only pigs ( < 0.10). These data suggest that PRRS infection supports a higher affinity for glucose uptake, whereas PED favors glutamine uptake. Interestingly, digestive machinery during PED challenge remained intact. Altogether, PED but not PRRS challenges alter intestinal morphology and integrity in growing pigs.

Trends in Use and Cost of Second-Generation Antipsychotics Among Children and Teens in Indiana Medicaid, 2004-2012

OBJECTIVE

To replicate and extend a study by the Agency for Healthcare Research and Quality (AHRQ) and Rutgers on antipsychotic use among youths in Medicaid, the authors analyzed Indiana Medicaid claims from 2004 to 2012, extending the earlier study by focusing on second-generation antipsychotics, including both fee-for-service (FFS) and non-FFS patients, and analyzing cost trends.

METHODS

The authors evaluated the impact of several Indiana Medicaid policy changes on medication utilization and cost among children enrolled for at least one month during 2004-2012 (N=683,716-793,637), using an exhaustive antipsychotic list to search the database.

RESULTS

Annual utilization rates for antipsychotics were 2%-3% but were much higher among foster children (10%-15%). Policies implemented in 2007 or later were associated with a significant plateauing of utilization in 2008-2012.

CONCLUSIONS

Growth of second-generation antipsychotic utilization and costs was similar to trends described in the AHRQ-Rutgers study. Several containment strategies appeared effective in addressing these trends.

Mortality of Youth Offenders Along a Continuum of Justice System Involvement

INTRODUCTION

Black male youth are at high risk of homicide and criminal justice involvement. This study aimed to determine how early mortality among youth offenders varies based on race; gender; and the continuum of justice system involvement: arrest, detention, incarceration, and transfer to adult courts.

METHODS

Criminal and death records of 49,479 youth offenders (ages 10-18 years at first arrest) in Marion County, Indiana, from January 1, 1999, to December 31, 2011, were examined. Statistical analyses were completed in November 2014.

RESULTS

From 1999 to 2011 (aggregate exposure, 386,709 person-years), 518 youth offender deaths occurred. The most common cause of death was homicide (48.2%). The mortality rate of youth offenders was nearly 1.5 times greater than that among community youth (standardized mortality ratio, 1.48). The youth offender mortality rate varied depending on the severity of justice system involvement. Arrested youth had the lowest rate of mortality (90/100,000), followed by detained youth (165/100,000); incarcerated youth (216/100,000); and youth transferred to adult court (313/100,000). A proportional hazards model demonstrated that older age, male gender, and more severe justice system involvement 5 years post-arrest predicted shorter time to mortality.

CONCLUSIONS

Youth offenders face greater risk for early death than community youth. Among these, black male youth face higher risk of early mortality than their white male counterparts. However, regardless of race/ethnicity, mortality rates for youth offenders increase as youth involvement in the justice system becomes more protracted and severe. Thus, justice system involvement is a significant factor to target for intervention.

A statewide collaboration to initiate mental health screening and assess services for detained youths in Indiana

OBJECTIVES

We describe a statewide effort to implement detention-based mental health screening and assess follow-up services offered to detained youths in Indiana.

METHODS

A total of 25,265 detention stays (15,461 unique youths) occurred between January 1, 2008, and December 31, 2011, across 16 detention centers participating in the Indiana Juvenile Mental Health Screening Project. We collected screening results and reports of detention-based follow-up mental health services and referrals from justice system records.

RESULTS

Approximately 21% of youths screened positive for mental health issues requiring follow-up. A positive screen significantly predicted that youths would receive a follow-up mental health service or referral while detained or upon detention center discharge, compared with youths who did not screen positive (61% vs 39%). Logistic regression models indicated that a positive screen was associated with (1) contact with a mental health clinician within 24 hours of detention center intake and (2) a mental health referral upon discharge. White youths were more likely than minorities to receive both follow-up services.

CONCLUSIONS

Future statewide efforts to improve the mental health of detained youths should incorporate standards for providing appropriate follow-up services in detention centers.

Abstract P5-12-03: Racial differences in breast cancer survival in a large urban integrated health system

Background: Despite improvements in breast cancer outcomes, there continues to be a large gap in survival between African American (AA) and White women with breast cancer, which may be due at least in part to racial differences in access to care. In order to better understand breast cancer survival disparities, we evaluated factors that predict racial differences in survival among women treated at a large integrated health care system in Southeastern Michigan. Materials and Methods: The study population included 2,387 women (34% AA) with stage I through III breast cancer treated at the Henry Ford Health System (HFHS) from 1996 through 2005. Linked datasets from the HFHS, the Metropolitan Detroit Cancer Surveillance System (MDCSS) and the U.S. Census Bureau were used to obtain socio-demographic and clinical information. Co-morbidity was assessed by the Charlson co-morbidity index (CCI), and economic deprivation was categorized into 5 quintiles of increasingly worse socioeconomic deprivation, using a census tract deprivation index (DI). Results: AA women were significantly more likely than Whites to have larger (41% vs. 32% &gt; 2 cm) and hormone receptor (HR) negative tumors (30% vs 19%), to have a higher CCI (15% vs 9% &gt; 2) and to reside in a more economically deprived area (46% vs. 5% residing in quintile 5). Unadjusted analysis showed that AA had a significantly higher risk of death than White women (hazards ratio [HR], 1.36, 95% confidence interval [CI], 1.16-1.59). After multivariable adjustment for clinical (age, stage, HR and CCI), and societal factors (insurance, DI), race was no longer significantly associated with overall survival, HR, 1.12, 95% CI, 0.94-1.33, p = 0.22, and 1.02, 95% CI 0.83-1.24, p = 0.88, respectively. Stratified analyses by DI showed no racial difference in survival for each of 5 levels of DI. Discussion: In a large urban integrated health care system, racial differences in breast cancer survival appear to be related to clinical and socioeconomic characteristics.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P5-12-03.

Comparison of exposures among Arab American and non-Hispanic White female thyroid cancer cases in metropolitan Detroit

Arab American (ArA) women may be at greater risk for thyroid cancer (TC) than White women. This case-case comparison explored differences in known and proposed risk factors of TC among ArA and non-Hispanic White (NHW) female TC cases in metropolitan Detroit. Cases of invasive TC identified from a population-based registry responded to a telephone survey regarding potential TC risk factors. Thirty ArA women (response rate 52%) and 70 NHW women (67%) participated. NHW women reported significantly more prior thyroid disease (TD), family history of TD, hormone use, cumulative years of hormone use, cigarette and alcohol consumption. In adjusted logistic regression analysis, ArA women had significantly higher odds of exposure to dental x-rays (OR = 3.48, CI 1.01-12.00) and medical radiation (OR = 13.58, CI 1.49-124.04) than NHW women. Risk factors for TC may differ among ArA women and their NHW counterparts.

Generation, selection and preclinical characterization of an Fc-optimized FLT3 antibody for the treatment of myeloid leukemia

The therapeutic efficacy of humanized or chimeric second-generation antitumor antibodies is clearly established, but often limited. In recent years, defined modifications of the glycosylation pattern or the amino-acid sequence of the human immunoglobulin G1 Fc part have resulted in the development of third-generation antibodies with improved capability to recruit Fc receptor-bearing effector cells. The first antibodies of this kind, currently evaluated in early clinical trials, are directed against lymphoma-associated antigens. Fc-engineered antibodies targeting myeloid leukemia are not yet available. We here report on the generation and preclinical characterization of an Fc-optimized antibody directed to the FMS-related tyrosine kinase 3 (FLT3), an antigen expressed on the leukemic blasts of all investigated patients with acute myeloid leukemia (AML). This antibody, termed 4G8SDIEM, mediated markedly enhanced cellular cytotoxicity against FLT3-expressing cell lines as well as blasts of AML patients. FLT3 expression levels on AML cells varied between 300 and 4600 molecules/cell and, in most cases, were substantially higher than those detected on normal hematopoietic precursor cells and dendritic cells (approximately 300 molecules/cell). Antibody-mediated cytotoxicity against these normal cells was not detectable. 4G8SDIEM has been produced in pharmaceutical quality in a university-owned production unit and is currently used for the treatment of leukemia patients.

P2-14-05: Racial Differences in the Use of Adjuvant Chemotherapy for Breast Cancer in a Large Urban Integrated Health System

Background: Despite improvements in breast cancer treatment, there continues to be a gap in survival between African American (AA) and White women with breast cancer, which may be due at least in part to racial differences in the patterns of care. In order to better understand breast cancer survival disparities, we evaluated racial differences in the receipt of adjuvant chemotherapy among women treated at a large integrated health care system in Southeastern Michigan. Materials and Methods: The study population included 2,234 women (33 % AA) with stage I through III breast cancer treated at the Henry Ford Health System (HFHS) from 1996 through 2005. Linked datasets from the HFHS, the Metropolitan Detroit Cancer Surveillance System (MDCSS) and the U.S. Census Bureau were used to obtain sociodemographic and clinical information. Co-morbidity was assessed by the Charlson co-morbidity index (CCI), and economic deprivation was categorized using a neighborhood deprivation index (DI). Results: AA women were significantly more likely than Whites to have larger tumors (40% vs. 31% &gt; 2 cm), as well as more aggressive tumors (29% vs 19% estrogen and progesterone negative). AA women were also significantly more likely than Whites to have other co-morbid conditions (15 % vs. 8% with a CCI of 2+) and to reside in a more economically deprived area (45% vs. 5% reside in the most deprived area). While AA women were more likely to receive adjuvant chemotherapy (47% vs. 43%, p=0.0278), they were also more likely to have a delay in initiation of treatment (57% vs 45% delayed beyond 60 days from diagnosis, p=0.0004). After multivariable adjustment for age, DI, CCI, insurance and surgery, there were no racial differences in treatment delay (Odds Ratio 1.20, 95% confidence interval, 0.82−1.77). Discussion: In a large urban integrated health care system, racial differences in the delay in receipt of adjuvant chemotherapy for breast cancer can be explained by clinical and socioeconomic characteristics.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-14-05.

Risk of renal cell carcinoma in relation to blood telomere length in a population-based case-control study

Background:

There are few known risk factors for renal cell carcinoma (RCC). Two small hospital-based case–control studies suggested an association between short blood telomere length (TL) and increased RCC risk.

Methods:

We conducted a large population-based case–control study in two metropolitan regions of the United States comparing relative TL in DNA derived from peripheral blood samples from 891 RCC cases and 894 controls. Odds ratios and 95% confidence intervals were estimated using unconditional logistic regression in both unadjusted and adjusted models.

Results:

Median TL was 0.85 for both cases and controls (P=0.40), and no differences in RCC risk by quartiles of TL were observed. Results of analyses stratified by age, sex, race, tumour stage, and time from RCC diagnosis to blood collection were similarly null. In multivariate analyses among controls, increasing age and history of hypertension were associated with shorter TL (P<0.001 and P=0.07, respectively), and African Americans had longer TL than Caucasians (P<0.001).

Conclusion:

These data do not support the hypothesis that blood TL is associated with RCC. This population-based case–control study is, to our knowledge, the largest investigation to date of TL and RCC.

Socio-economic aspects of improved sanitation in slums: a review

This socio-economic review provides an overview of the sanitation crisis in slum areas, and re-emphasizes the importance of sanitation. It highlights a lack of recognition of actual drivers for sanitation improvements, and the complexities in the provision of sanitation services in the context of urban slums with a mix of tenants and landlords. It elaborates how the drivers of demand for sanitation outlined in contemporary research are not universal but are rather context specific. The authors point out specific knowledge gaps for future research; for example, the need to establish a scientific basis for context-specific drivers of demand for sanitation improvements in slums, and a better understanding of associated complexities in order to set boundary conditions for achieving desired improvements.

Stroke in relation to use of raloxifene and other drugs against osteoporosis

Prior studies have associated fatal stroke with raloxifene. In a cohort study, we found no excess risk of stroke with raloxifene; whereas, an excess risk of stroke and fatal stroke was seen with alendronate and etidronate. However, the excess risks were small.

PURPOSE

We aim to study the association between use of raloxifene and other drugs against osteoporosis and risk of stroke.

METHODS

This is a nationwide cohort study from Denmark. All users of bisphosphonates and other drugs against osteoporosis between 1996 and 2006 (n = 103,562) as exposed group and three age- and gender-matched controls from the general population (n = 310,683).

RESULTS

Before the drugs were started, patients later initiating alendronate or raloxifene had fewer strokes than the controls. In contrast, patients who later did start clodronate have more strokes. Among the later users of other bisphosphonates, strontium ranelate or parathyroid hormone, no change in the risk of stroke was present. Patients who started raloxifene neither had an excess risk of strokes nor of fatal strokes. No dose-response relationship was present. Among users of alendronate, a decreasing overall risk of stroke was seen with increasing dose. However, for fatal strokes, the risk increased with increasing dose of alendronate. Among users of etidronate, no trend with dose was present for overall stroke risk; whereas for fatal strokes, an increasing risk was seen with increasing dose of etidronate.

CONCLUSIONS

Raloxifene does not seem associated with an excess risk of strokes. The increase seen for alendronate did not seem to be causal as no classical dose-response relationship was present. The dose-response relationship for fatal strokes with alendronate and etidronate needs further examination. However, the excess risks were small and may be due to the underlying disease.

Swelling of SiO2 Quartz Induced by Energetic Heavy Ions

A pronounced swelling effect occurs when irradiating SiO2 quartz with heavy ions (F, S, Cu, Kr, Xe, Ta, and Pb) in the electronic energy loss regime. Using a profilometer, the out-of-plane swelling was measured by scanning over the border line between an irradiated and a virgin area of the sample surface. The step height varied between 20 and 300 nm depending on the fluence, the electronic energy loss and the total range of the ions. From complementary Rutherford backscattering experiments under channelling condition (RBS-C), the damage fraction and corresponding track radii were extracted. Normalising the step height per incoming ion and by the projected range, a critical energy loss of 1.8 ± 0.5 keV/nm was found which is in good agreement with the threshold observed by RBS-C. Swelling can be explained by the amorphisation induced along the ion trajectories. The experimental results in quartz are compared to swelling data obtained under similar irradiation conditions in LiNbO3

Species- and age-dependent changes in the relative amounts of cardiac myosin isoenzymes in mammals

In mice, rabbits, and pigs, two basic types of cardiac myosin isoenzymes were found by electrophoresis of native molecules: a fast-migrating form with high Ca(2+)-dependent ATPase activity and a slow-migrating form with low activity. According to the nomenclature of J. F. Y. Hoh, P. A. McGrath, and P. T. Hale (1978, J. Mol. Cell. Cardiol. 10, 1053-1076) these forms are called, respectively, V1 and V3. In all species, myosin was essentially V3 during fetal life, while V1 appeared around the time of birth. There were species differences in adults: mice remained V1, while rabbits and pigs returned to V3 after 3 weeks of age. Adult dog, beef, and human myosins were also composed of the V3 form only.

Use of bisphosphonates and raloxifene and risk of deep venous thromboembolism and pulmonary embolism

SUMMARY

Prior studies have associated raloxifene and strontium ranelate with deep venous thromboembolism and pulmonary embolism. In a cohort study, we observed an increased risk also with the bisphosphonates. However, the increase was present already before the start of bisphosphonates pointing at an effect of the underlying condition.

INTRODUCTION

We seek to study the association between use of drugs against osteoporosis and risk of deep venous thromboembolism (DVT) and pulmonary embolism (PE).

METHODS

Nationwide register-based cohort study from Denmark with all users of bisphosphonates and other drugs against osteoporosis between 1996 and 2006 (n = 103,562) as cases and three age- and gender-matched controls from the general population (n = 310,683).

RESULTS

Before start of a drug against osteoporosis, an increased risk of DVT/PE was present in the crude analysis for alendronate, etidronate, and risedronate. However, upon adjustment, this increase in risk disappeared. Before start of raloxifene, a decreased risk of DVT/PE was present (odds ratio (OR) = 0.53, 95% confidence interval (CI), 0.39-0.71). After start of a drug, alendronate (HR = 1.20, 95% CI, 1.00-1.43), clodronate (HR = 4.06, 95% CI, 1.47-11.2), and etidronate (HR = 1-37, 95% CI, 1.23-1.51) were all associated with an increased risk of DVT/PE, while raloxifene was only borderline, significantly associated with risk of DVT/PE (HR = 1.64, 95% CI, 0.97-2.77). No dose-response relationship was present except for alendronate, where the risk was inversely associated with dose, i.e., the risk of DVT/PE decreased with increasing average daily dose. The HR for DVT/PE was higher with clodronate and etidronate than with alendronate. Alendronate and raloxifene carried the same risk for DVT/PE.

CONCLUSION

Bisphosphonates seem associated with an increased risk of DVT/PE. However, the association does not seem to be causal.

Spatially resolved nuclear spin relaxation, electron spin relaxation and light absorption in swift heavy ion irradiated LiF crystals

Spatially resolved (19)F and (7)Li spin-lattice relaxation rates are measured for LiF single crystals after irradiation with two kinds of swift heavy ions ((12)C of 133 MeV and (208)Pb of 1.78 GeV incident energy). Like in earlier studies on (130)Xe and (238)U irradiated LiF crystals, we found a strong enhancement of the nuclear spin-lattice relaxation rate within the ion penetration depth and a slight--but still significant--enhancement beyond. By evaluating the nuclear relaxation rate enhancement within the ion range after irradiation with different projectiles, a universal relationship between the spin-lattice relaxation rate and the dose is deduced. The results of accompanying X-band electron paramagnetic resonance relaxation measurements and optical absorption spectroscopy are included in a physical interpretation of this relationship. Also the reason for the enhanced relaxation rate beyond the ion range is further discussed.

Interest, attitudes, and participation in clinical trials among lymphoma patients with online access

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Background: There is an increasing number of investigational agents for lymphomas and a limited patient pool, approximately 5% of available patients. Thus, identifying and addressing obstacles to study enrollment is vital to making progress. Methods: This analysis was made from a non-random population of 251 lymphoma patients with online access to our survey. Results: In this cohort, 43% reported High Interest in clinical trials, 50% have Considered Trials, and 27% Have Participated. Patients who considered studies (126) ranked the following reasons for declining as significant: Randomization (70), Insurance (49), Study Risks / Toxicities (42), Travel and Lodging (30), Eligibility (28), Tests and Procedures (12), and a perception that Regular Treatment is superior (6). See Table 1 for associations with consideration of clinical trials and participation. Conclusions: In this cohort, interest in clinical trials and participation rates were much higher than generally cited. As expected, the discussion of clinical trials with the patient's oncologist was associated with the highest consideration (85%) and participation (53%) rates, suggesting a need to increase awareness of study protocols among treating physicians so that this discussion can become more routine. Patient issues and perceptions regarding randomization, study risk, eligibility, and tests and procedures suggest an opportunity to improve enrollment in clinical trials by focusing on these aspects of study design, specifically, attending to the rationale of the protocol as a treatment decision.

[Table: see text]

No significant financial relationships to disclose.

Spatially resolved characterization of Xe ion irradiated LiF crystals using static field gradient NMR

Spatially resolved (19)F and (7)Li nuclear magnetic resonance (NMR) spin-lattice relaxation rates have been measured in LiF crystals irradiated with 1.44 GeV Xe ions at fluences from 10(10) to 10(12) ions cm(-2). In addition, the F-centre concentration has been measured by optical absorption spectroscopy and the concentration of paramagnetic centres by electron paramagnetic resonance (EPR). Within the ion range, the relaxation rate turns out to increase linearly with the concentration of paramagnetic centres but super-linearly with the F-centre concentration. Beyond the ion range, the relaxation rate is still significantly enhanced compared to non-irradiated LiF.

ADHD and Stroop interference from age 9 to age 41 years: a meta-analysis of developmental effects

BACKGROUND

In this meta-analysis, we investigated whether response inhibition is sensitive to attention deficit hyperactivity disorder (ADHD) status and, if so, what influence maturation has on this attentional symptom of ADHD.

METHOD

We examined 25 studies that reported data on the Stroop color word test in children and adults with ADHD and in age-matched controls; average ages ranged from 9 to 41 years. We utilized a hierarchical approach to analyze the strength of the Stroop effect and whether the effect varies as a function of age. Additionally, we assessed potential differences in maturation rates based on reaction time (RT) of color and color-word conditions.

RESULTS

First, we found that the relationship between color-word and color RT was multiplicative, and the slope of this function (the ratio of color-word RT over color RT) was identical across age groups and ADHD status. Second, we found that although ADHD individuals were on average 1.14 times slower than age-matched controls in both the color and the color-word condition, the maturation rate was identical for both groups.

CONCLUSIONS

The results from this analysis indicate that the Stroop interference effect is not larger in ADHD individuals than in age-matched controls. Further, we did not find evidence for differential maturation rates for persons with ADHD and the control groups. The Stroop interference effect appears to be immune to age, regardless of ADHD status.

Spatially resolved characterization of heavy ion irradiated crystals using static field gradient nuclear magnetic resonance

Static magnetic field gradient NMR has been used for one-dimensional spatial (19)F spin-lattice relaxation profile studies (resolution of the order of 10 µm) in a LiF crystal irradiated with U ions. Technical aspects of the use of large static magnetic field gradients are discussed as well as a special data acquisition mode allowing for effectively measuring spatially resolved spin-lattice relaxation rates as low as 10(-3) s(-1). In addition to the expected enhanced spin-lattice relaxation rate within the ion range, also an enhanced rate beyond the ion range has been found.