Surgical outcomes of total duct excision in the diagnosis and management of nipple discharge

INTRODUCTION

Total duct excision (TDE) is performed for the diagnosis and management of nipple discharge. The Association of Breast Surgery's recent guidelines recommend considering diagnostic surgery for single-duct, blood-stained or clear nipple discharge, and for symptomatic management.

METHODS

We retrospectively reviewed the diagnostic and surgical outcomes of all cases of TDE between January 2013 and November 2019.

RESULTS

In total, 259 TDEs were carried out: 219 for nipple discharge, 29 for recurrent mastitis, 3 for screening abnormalities and 8 for breast lumps. Of the nipple discharge group, 121 had blood-stained discharge. Mean patient age was 52 years (range 19-81). Median follow-up time was 45 months (interquartile range 24-63). The following cases were identified on histopathology: 236 benign breast changes, 10 atypical ductal hyperplasia, 4 lobular carcinoma in situ, 2 low-grade ductal carcinoma in situ (DCIS), 3 intermediate-grade DCIS, 2 high-grade DCIS and 2 invasive ductal carcinomas. In total, 3.5% of patients who underwent TDE had a diagnosis of DCIS or invasive carcinoma. Blood-stained discharge was associated with a significant increase in risk of DCIS or carcinoma compared with other nipple discharge colours (p = 0.043). The most common complications of TDE were infection, poor wound healing and haematoma. Nipple discharge recurred in 14.2% of cases.

CONCLUSIONS

TDE can be considered for the diagnostics and management of nipple discharge. Blood-stained nipple discharge increases the risk of DCIS or malignancy, but the majority of the time TDE reveals benign breast pathology.

Loneliness and fearfulness are associated with non-fatal drug overdose among people who inject drugs

BACKGROUND

People who inject drugs (PWID) experience high rates of drug overdose death with the risk of mortality increasing after each non-fatal event. Racial differences exist in drug overdose rates, with higher rates among Black people who use drugs. Psychological factors may predict drug overdose.

METHODS

Cross-sectional data from a survey administered to PWID in Baltimore, MD enrolled in a social network-based intervention were analyzed. Linear regression methods with generalized estimating equations were used to analyze data from indexes and network members to assess for psychological factors significantly associated with self-reported number of lifetime drug overdoses. Factors associated with number of overdoses were assessed separately by race.

RESULTS

Among 111 PWID enrolled between January 2018 and January 2019, 25.2% were female, 65.7% were Black, 98.2% reported use of substances in addition to opioids, and the mean age was 49.0 ± 8.3 years. Seventy-five individuals (67.6%) had a history of any overdose with a mean of 5.0 ± 9.7 lifetime overdoses reported. Reports of feeling fearful (β = 9.74, P = 0.001) or feeling lonely all of the time (β = 5.62, P = 0.033) were independently associated with number of drug overdoses. In analyses disaggregated by race, only the most severe degree of fearfulness or loneliness was associated with overdose among Black participants, whereas among White participants, any degree of fearfulness or loneliness was associated with overdose.

CONCLUSIONS

In this study of PWID loneliness and fearfulness were significantly related to the number of reported overdose events. These factors could be targeted in future interventions.

Reporting of paediatric osteoporotic vertebral fractures in Duchenne muscular dystrophy and potential impact on clinical management: the need for standardised and structured reporting

BACKGROUND

In boys with Duchenne muscular dystrophy (DMD), initiation of bisphosphonate is recommended upon identification of moderate or severe vertebral fractures, even if asymptomatic. Clear radiological reporting is important for consistency of clinical interpretation and management.

OBJECTIVES

To audit radiology reports of spine imaging for vertebral fracture assessment in DMD, and assess potential impact on diagnosis and management.

MATERIALS AND METHODS

Lateral thoracolumbar spine imaging (71 lateral spine radiographs and 13 lateral dual energy absorptiometry spine image) in 84 boys with DMD performed across two centres. Anonymised radiology reports by paediatric radiologists were circulated to two neuromuscular clinicians and two endocrinologists. Clinicians determined if there was vertebral fracture, no vertebral fracture, or unclear interpretation. Endocrinologists also determined if bisphosphonate was indicated. A single observer (a clinician with expertise in vertebral fracture assessment) performed vertebral fracture assessment in 37 images and re-reported using a structured format. Structured reports were re-circulated to the four clinicians to re-evaluate the degree of concordance in clinical diagnosis of vertebral fracture and treatment decisions with bisphosphonate.

RESULTS

The term "fracture" was used in 25/84 (30%) radiology reports and only in 8/43 (19%) with description of vertebral body abnormalities. Fracture grading was included in 7/43 (16%) radiology reports. Diagnostic concordance by the clinicians was noted in 36/84 (43%). Unclear interpretation was noted in 22% to 51% based on radiology reports. No unclear interpretation was noted with structured reports. Complete diagnostic (37/37, 100%) and treatment (37/37, 100%) concordance was noted with the structured reports, whereas complete diagnostic and treatment concordance was noted in only 16/37 (43%) and 17/37 (46%) of the radiology reports, respectively.

CONCLUSION

Only a third of radiology reports of spine imaging in DMD explicitly used the terminology "fracture". Grading was only noted in a small percentage. Variability in diagnostic interpretation by clinicians may lead to differing management plans. As identification of vertebral fracture is a trigger for treatment, developing reporting guidelines for paediatric vertebral fracture assessment will improve care. A structured template should be introduced for radiological reporting of paediatric vertebral fracture assessment.

Changes in Inflammatory Cytokines After Chronic Hepatitis C Treatment Among People Living With HIV

We aimed to evaluate the effect of hepatitis C virus cure on serum inflammatory markers among people with HIV. Among 127 people with HIV, serum alanine aminotransferase, soluble tumor necrosis factor receptor 1, and inflammatory index score were significantly lower at the 24-week time point in patients who achieved sustained virologic response as compared with those who did not.

Unpaid caregiving for people following hip fracture: longitudinal analysis from the English Longitudinal Study of Ageing

PURPOSE

To determine the provision and its change over time in unpaid care for people following hip fracture.

METHODS

Data were sought from the English Longitudinal Study of Ageing (ELSA) cohort. We identified participants who self-reported experiencing a hip fracture, who had clinical and caregiving data in the previous and subsequent two data collection waves. Demographic and clinical data were collected in addition to data on provision of unpaid care, who provided care and the frequency of needs being met.

RESULTS

The analysed cohort consisted of 246 participants [150 females (61%), mean age 78.9 years (standard deviation: 8.6)]. There was an increase in the number of participants requiring unpaid care between the Pre-Fracture and Fracture Wave (29% vs. 59%), which plateaued in the subsequent two waves (56%; 51%). Although both spouse and daughters provided the most unpaid care to participants over this study period, there was an increase in support provided during the Fracture Wave by both sons and daughters. This increased support offered by spouses continued until Post-Fracture Wave 2 when this plateaued. Support provided by friends increased from 3 to 8% and brothers and sisters increased from 0 and 1% Pre-Fracture to 8% by Post-Fracture Wave 2.

CONCLUSION

These findings provide insights into who, what and how unpaid carers support people following hip fracture over time. Given the level of support unpaid carers offer, and previously reported carer stress and burden, undertaking clinical trials to assess the effectiveness of carer-patient support interventions would be valuable.

A Population-Based Assessment of Long-Term Sexual Well-Being and Patient Satisfaction after Breast Reconstruction and Post-Mastectomy Radiation

PURPOSE/OBJECTIVE(S)

In 2016, more than 40% of women who underwent mastectomy for breast cancer went on to have breast reconstruction, but there is little data regarding long-term cosmetic outcomes past 5 years after post-mastectomy radiation (PMRT) and reconstruction. This study aims to evaluate the difference in patient breast satisfaction and sexual well-being over time by receipt of reconstruction and PMRT.

MATERIALS/METHODS

The iCanCare study is a population-based, longitudinal study of women diagnosed with breast cancer in 2014-15 identified in the Los Angeles and Georgia SEER registries. Women were surveyed during initial treatment and again approximately 6 years later in survivorship (2021-2022). Participants were asked about their "Sexual well-being after mastectomy" and "Satisfaction with breasts" using the Breast-Q, which was dichotomized into "high" and "low" scores (using the median), with a high score indicating increased satisfaction. We then evaluated whether satisfaction differed by treatment characteristics, using unadjusted odds ratios (OR) for categorical variables, calculated using the Chi-square test, or the Kruskal-Wallis test for continuous variables. Adjusted odds ratios were found using multivariable logistic regression models adjusting for treatment characteristics, diagnosis, age, BMI, education, and breast cancer stage.

RESULTS

In this preliminary sample of 1191 respondents, 445 underwent mastectomy, of which 272 (61.12%) had reconstruction, and 65 (14.61%) had PMRT. Having breast reconstruction was associated with higher long-term sexual well-being (median score 36.30 vs. 22.20, OR 1.69, 95% confidence interval [CI] 1.09 - 2.64) and breast satisfaction scores (OR 1.53, 95% CI 1.01 - 2.33) compared to not having reconstruction. However, this improvement in sexual well-being was attenuated in women who additionally had PMRT (OR 0.83, CI 0.271 - 2.51). In women who did not have reconstruction after mastectomy, there was no statistically significant difference in sexual well-being scores regardless of the use of PMRT (OR 0.68, CI 0.39 - 1.22). Among respondents in adjusted models who did not receive PMRT, those with reconstruction had higher sexual well-being scores than those with without reconstruction (aOR 2.47, CI 1.34 - 4.56), though there was no statistically significant difference in breast satisfaction scores (p = 0.16) among the groups.

CONCLUSION

Sexual well-being and breast satisfaction are improved with reconstruction 6 years after mastectomy for breast cancer. However, these improvements were attenuated for women who received PMRT. To our knowledge, this is the first study to look at long term outcomes of sexual well-being and treatment satisfaction after breast reconstruction for patients who underwent mastectomy for breast cancer. These data suggest that continued work should be done to optimize patient outcomes when combining PMRT and breast reconstruction.

Second-Phase Hepatitis C Plasma Viral Kinetics Directly Reflects Reduced Intrahepatic Burden of Hepatitis C Virus

BACKGROUND

Mathematical models explain how antivirals control viral infections. Hepatitis C virus (HCV) treatment results in at least 2 phases of decline in viremia. The first phase reflects clearance of rapidly produced virions. The second phase is hypothesized to derive from loss of infected cells but has been challenging to prove.

METHODS

Using single-cell methods, we quantified the number of hepatitis C virus (HCV)-infected hepatocytes in liver biopsies taken before and within 7 days of initiating direct-acting antivirals (DAAs) in a double-blinded randomized controlled trial testing 2 (sofosbuvir-velpatasvir) versus 3 (sofosbuvir-velpatasvir-voxilaprevir) DAAs.

RESULTS

We employed thousands of intrahepatic measurements in 10 persons with chronic genotype 1a HCV infection: median proportion of infected hepatocytes declined from 11.3% (range, 1.3%-59%) to 0.6% (range, <0.3%-5.8%), a loss of 75%-95% infected hepatocytes. Plasma viremia correlated with numbers of HCV-infected hepatocytes (r = 0.77; P < .0001). Second-phase plasma dynamics and changes in infected hepatocytes were indistinct (P = .16), demonstrating that second-phase viral dynamics derive from loss of infected cells. DAAs led to a decline in intracellular HCV RNA and interferon-stimulated gene expression (P < .05 for both).

CONCLUSIONS

We proved that second-phase viral dynamics reflect decay of intrahepatic burden of HCV, partly due to clearance of HCV RNA from hepatocytes.

CLINICAL TRIALS REGISTRATION

NCT02938013.

Pediatric Cardiology Fellowship Standards for Training in Exercise Medicine and Curriculum Outline

Over the past 2 decades, fundamentals of exercise medicine, including clinical exercise testing, assessment and promotion of physical activity, exercise prescription, and supervised exercise training/rehabilitation programming have demonstrated considerable clinical value in the management of children and adolescents with congenital and acquired heart disease. Although the principles of exercise medicine have become an integral component in pediatric cardiology, there are no standardized training recommendations for exercise physiology during pediatric cardiology fellowship at this time. Thus, the Pediatric Cardiology Exercise Medicine Curriculum Committee (PCEMCC) was formed to establish core and advanced exercise physiology training recommendations for pediatric cardiology trainees. The PCEMCC includes a diverse group of pediatric cardiologists, exercise physiologists, and fellowship program directors. The expert consensus training recommendations are by no means a mandate and are summarized herein, including suggestions for achieving the minimum knowledge and training needed for general pediatric cardiology practice.

What is Known About Critical Congenital Heart Disease Diagnosis and Management Experiences from the Perspectives of Family and Healthcare Providers? A Systematic Integrative Literature Review

The experience of diagnosis, decision-making and management in critical congenital heart disease is layered with complexity for both families and clinicians. We synthesise the current evidence regarding the family and healthcare provider experience of critical congenital heart disease diagnosis and management. A systematic integrative literature review was conducted by keyword search of online databases, MEDLINE (Ovid), PsycINFO, Cochrane, cumulative index to nursing and allied health literature (CINAHL Plus) and two journals, the Journal of Indigenous Research and Midwifery Journal from 1990. Inclusion and exclusion criteria were applied to search results with citation mining of final included papers to ensure completeness. Two researchers assessed study quality combining three tools. A third researcher reviewed papers where no consensus was reached. Data was coded and analysed in four phases resulting in final refined themes to summarise the findings. Of 1817 unique papers, 22 met the inclusion criteria. The overall quality of the included studies was generally good, apart from three of fair quality. There is little information on the experience of the healthcare provider. Thematic analysis identified three themes relating to the family experience: (1) The diagnosis and treatment of a critical congenital heart disease child significantly impacts parental health and wellbeing. (2) The way that healthcare and information is provided influences parental response and adaptation, and (3) parental responses and adaptation can be influenced by how and when support occurs. The experience of diagnosis and management of a critical congenital heart disease child is stressful and life-changing for families. Further research is needed into the experience of minority and socially deprived families, and of the healthcare provider, to inform potential interventions at the healthcare provider and institutional levels to improve family experience and support.

Predictors of Atrial Fibrillation in Patients With Stroke Attributed to Large- or Small-Vessel Disease: A Prespecified Secondary Analysis of the STROKE AF Randomized Clinical Trial

Importance

The Stroke of Known Cause and Underlying Atrial Fibrillation (STROKE AF) trial found that approximately 1 in 8 patients with recent ischemic stroke attributed to large- or small-vessel disease had poststroke atrial fibrillation (AF) detected by an insertable cardiac monitor (ICM) at 12 months. Identifying predictors of AF could be useful when considering an ICM in routine poststroke clinical care.

Objective

To determine the association between commonly assessed risk factors and poststroke detection of new AF in the STROKE AF cohort monitored by ICM.

Design, Setting, and Participants

This was a prespecified analysis of a randomized (1:1) clinical trial that enrolled patients between April 1, 2016, and July 12, 2019, with primary follow-up through 2020 and mean (SD) duration of 11.0 (3.0) months. Eligible patients were selected from 33 clinical research sites in the US. Patients had an index stroke attributed to large- or small-vessel disease and were 60 years or older or aged 50 to 59 years with at least 1 additional stroke risk factor. A total of 496 patients were enrolled, and 492 were randomly assigned to study groups (3 did not meet inclusion criteria, and 1 withdrew consent). Patients in the ICM group had the index stroke within 10 days before insertion. Data were analyzed from October 8, 2021, to January 28, 2022.

Interventions

ICM monitoring vs site-specific usual care (short-duration external cardiac monitoring).

Main Outcomes and Measures

The ICM device automatically detects AF episodes 2 or more minutes in length; episodes were adjudicated by an expert committee. Cox regression multivariable modeling included all parameters identified in the univariate analysis having P values <.10. AF detection rates were calculated using Kaplan-Meier survival estimates.

Results

The analysis included the 242 participants randomly assigned to the ICM group in the STROKE AF study. Among 242 patients monitored with ICM, 27 developed AF (mean [SD] age, 66.6 [9.3] years; 144 men [60.0%]; 96 [40.0%] women). Two patients had missing baseline data and exited the study early. Univariate predictors of AF detection included age (per 1-year increments: hazard ratio [HR], 1.05; 95% CI, 1.01-1.09; P = .02), CHA2DS2-VASc score (per point: HR, 1.54; 95% CI, 1.15-2.06; P = .004), chronic obstructive pulmonary disease (HR, 2.49; 95% CI, 0.86-7.20; P = .09), congestive heart failure (CHF; with preserved or reduced ejection fraction: HR, 6.64; 95% CI, 2.29-19.24; P < .001), left atrial enlargement (LAE; HR, 3.63; 95% CI, 1.55-8.47; P = .003), QRS duration (HR, 1.02; 95% CI, 1.00-1.04; P = .04), and kidney dysfunction (HR, 3.58; 95% CI, 1.35-9.46; P = .01). In multivariable modeling (n = 197), only CHF (HR, 5.06; 95% CI, 1.45-17.64; P = .05) and LAE (HR, 3.32; 1.34-8.19; P = .009) remained significant predictors of AF. At 12 months, patients with CHF and/or LAE (40 of 142 patients) had an AF detection rate of 23.4% vs 5.0% for patients with neither (HR, 5.1; 95% CI, 2.0-12.8; P < .001).

Conclusions and Relevance

Among patients with ischemic stroke attributed to large- or small-vessel disease, CHF and LAE were associated with a significantly increased risk of poststroke AF detection. These patients may benefit most from the use of ICMs as part of a secondary stroke prevention strategy. However, the study was not powered for clinical predictors of AF, and therefore, other clinical characteristics may not have reached statistical significance.

Trial Registration

ClinicalTrials.gov Identifier: NCT02700945.

807 The Association between Blood Transfusion and Outcome in Hip Fracture Patients

Aim

Hip Fractures are endemic in older adults across Europe, with potential increases in incidence expected as the population ages. Management of blood loss and anaemia is a mainstay of care for these patients, but there is still significant debate regarding balance between benefit and risk of liberal versus restrictive transfusion policies. Understanding the association between providing blood products and adverse healthcare outcomes in hip fracture patients is a key component in the transfusion decision-making process.

Method

This retrospective cohort study uses national audit data from the Scottish Hip Fracture Audit (SHFA) and the Scottish National Blood Transfusion Service (SNBTS) to examine the association between blood transfusion and important hip fracture process of care measures and healthcare outcomes.

Results

A total of 28 461 patient records were included for assessment across 19 acute hospitals. Blood transfusion during admission was associated with a small but statistically significant decrease in survival at both 30 and 60 days. Those receiving blood transfusion during admission were less likely to be mobilised by the end of the 1st post-operative day, less likely to have a length of stay below the average and had far lower probability of discharge.

Conclusion

This study found that blood transfusion is associated with poor healthcare outcomes following hip fracture, even when adjusted for potential confounding factors. This likely reflects the potential harm of perioperative anaemia rather than any direct impact from transfusion. Further work to reduce perioperative blood loss is therefore key to improving important hip fracture outcomes.

738 DETERMINANTS OF MUSCLE DENSITY IN OLDER PEOPLE: FINDINGS FROM THE HERTFORDSHIRE COHORT STUDY (HCS)

Introduction

Lower calf muscle density (CMD) as assessed by peripheral quantitative computed tomography (pQCT) is associated with greater hip fracture risk, independent of FRAX, falls and bone mineral density. To date, muscle density has been little studied, and its determinants are unknown. In this study, we examine the lifestyle and anthropometric determinants of future muscle density (MD) in the HCS.

Methods

197 men and 178 women, aged 59–70 years, were recruited. A lifestyle questionnaire collected information on physical activity, smoking, alcohol consumption and dietary patterns. Height and weight were measured. pQCT of the radius and tibia was performed a median of 11.5 (IQR 10.9, 12.3) years later. MD was measured at calf and forearm using standard methodology. Baseline characteristics in relation to MD at follow-up were examined separately using linear regression with sex, baseline age and follow-up time included as covariates in all models.

Results

Mean (SD) age at baseline was 64.7 (2.7) years; mean (SD) MD values (mg/cm3) were as follows: forearm [men 79.9 (3.1), women 77.2 (3.2)], calf [men 80.7 (2.6), women 78.5 (2.6)]. Baseline correlates (p &lt; 0.05) of both lower forearm and CMD included female sex, lower weight, and lower BMI. SD difference in CMD for women compared to men, and per SD lower weight and BMI were − 0.84 [95%CI: −1.13, −0.54]), −0.37 [−0.46, −0.27] and − 0.31 [−0.40, −0.23] respectively. Additional correlates of lower CMD included older age and shorter stature. Relationships between MD and age were stronger at the calf (p &lt; 0.001) than the forearm (p = 0.08). Lifestyle measures were not associated with MD.

Conclusion

Female sex, older age, and lower BMI were associated with lower MD in older community-dwelling adults, highlighting the need for sustained muscle conditioning in older individuals. Further studies in larger cohorts are required.

Validation of a tool to assess effectiveness of peer-recruitment for hepatitis C testing and linkage to care among people who inject drugs

OBJECTIVE

People who inject drugs (PWID) have high hepatitis C virus (HCV) infection prevalence but low rates of HCV treatment uptake. To better harness the potential of peer-led social network-based interventions to increase HCV treatment uptake among PWID, simple tools that can help identify individuals with the potential to function effectively as peer-mentors who support network members to get HCV tested and linked to care are needed.

METHODS

Data from a survey administered to index PWID enrolled in a social network-based intervention, in which they were invited to recruit drug use network members for HCV testing and linkage to care, was analyzed. Constructs derived from exploratory factor analysis were validated through confirmatory factor analysis (CFA). We used logistic regression analysis to assess the association between scores in identified constructs and subsequent effectiveness in the peer mentor role, defined as recruiting at least one network member for HCV testing and linkage to care in the 12 weeks following survey completion.

RESULTS

Among 100 PWID with median age 53 years, 74% male, and 71% Black, CFA resulted in a multidimensional three-factor survey with 4 questions related to opinion leadership, 3 questions related to perceived HCV-related stigma, and 3 questions related to HCV communication comfort and care support willingness. Only self-designated opinion leadership was associated with effectiveness in the peer mentor role (adjusted odds ratio 3.76 (95% Confidence interval CI 1.01, 14.0)).

CONCLUSION

We developed and validated a simple tool with potential to ease and improve the efficiency of peer-led social network interventions.

New Zealand women's experiences of managing gestational diabetes through diet: a qualitative study

Background

For women with gestational diabetes mellitus (GDM) poor dietary choices can have deleterious consequences for both themselves and their baby. Diet is a well-recognised primary strategy for the management of GDM. Women who develop GDM may receive dietary recommendations from a range of sources that may be inconsistent and are often faced with needing to make several dietary adaptations in a short period of time to achieve glycaemic control. The aim of this study was to explore how women diagnosed with GDM perceive dietary recommendations and how this information influences their dietary decisions during pregnancy and beyond.

Methods

Women diagnosed with GDM before 30 weeks’ gestation were purposively recruited from two GDM clinics in Auckland, New Zealand. Data were generated using semi-structured interviews and thematic analysed to identify themes describing women’s perceptions and experiences of dietary recommendations for the management of GDM.

Results

Eighteen women from a diverse range of sociodemographic backgrounds participated in the study. Three interconnected themes described women’s perceptions of dietary recommendations and experiences in managing their GDM through diet: managing GDM is a balancing act; using the numbers as evidence, and the GDM timeframe. The primary objective of dietary advice was perceived to be to control blood glucose levels and this was central to each theme. Women faced a number of challenges in adhering to dietary recommendations. Their relationships with healthcare professionals played a significant role in their perception of advice and motivation to adhere to recommendations. Many women perceived the need to follow dietary recommendations to be temporary, with few planning to continue dietary adaptations long-term.

Conclusions

The value of empathetic, individually tailored advice was highlighted in this study. A greater emphasis on establishing healthy dietary habits not just during pregnancy but for the long-term health of both mother and baby is needed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-04297-0.

Breast MRI during Neoadjuvant Chemotherapy: Lack of Background Parenchymal Enhancement Suppression and Inferior Treatment Response

Background Suppression of background parenchymal enhancement (BPE) is commonly observed after neoadjuvant chemotherapy (NAC) at contrast-enhanced breast MRI. It was hypothesized that nonsuppressed BPE may be associated with inferior response to NAC. Purpose To investigate the relationship between lack of BPE suppression and pathologic response. Materials and Methods A retrospective review was performed for women with menopausal status data who were treated for breast cancer by one of 10 drug arms (standard NAC with or without experimental agents) between May 2010 and November 2016 in the Investigation of Serial Studies to Predict Your Therapeutic Response with Imaging and Molecular Analysis 2, or I-SPY 2 TRIAL (NCT01042379). Patients underwent MRI at four points: before treatment (T0), early treatment (T1), interregimen (T2), and before surgery (T3). BPE was quantitatively measured by using automated fibroglandular tissue segmentation. To test the hypothesis effectively, a subset of examinations with BPE with high-quality segmentation was selected. BPE change from T0 was defined as suppressed or nonsuppressed for each point. The Fisher exact test and the Z tests of proportions with Yates continuity correction were used to examine the relationship between BPE suppression and pathologic complete response (pCR) in hormone receptor (HR)-positive and HR-negative cohorts. Results A total of 3528 MRI scans from 882 patients (mean age, 48 years ± 10 [standard deviation]) were reviewed and the subset of patients with high-quality BPE segmentation was determined (T1, 433 patients; T2, 396 patients; T3, 380 patients). In the HR-positive cohort, an association between lack of BPE suppression and lower pCR rate was detected at T2 (nonsuppressed vs suppressed, 11.8% [six of 51] vs 28.9% [50 of 173]; difference, 17.1% [95% CI: 4.7, 29.5]; P = .02) and T3 (nonsuppressed vs suppressed, 5.3% [two of 38] vs 27.4% [48 of 175]; difference, 22.2% [95% CI: 10.9, 33.5]; P = .003). In the HR-negative cohort, patients with nonsuppressed BPE had lower estimated pCR rate at all points, but the P values for the association were all greater than .05. Conclusions In hormone receptor-positive breast cancer, lack of background parenchymal enhancement suppression may indicate inferior treatment response. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Philpotts in this issue.

Female Urgency, Trial of Urodynamics as Routine Evaluation (FUTURE study): a superiority randomised clinical trial to evaluate the effectiveness and cost-effectiveness of invasive urodynamic investigations in management of women with refractory overactive bladder symptoms

BACKGROUND

Overactive bladder (OAB) syndrome is a symptom complex affecting 12-14% of the UK adult female population. Symptoms include urinary urgency, with or without urgency incontinence, increased daytime urinary frequency and nocturia. OAB has a negative impact on women's social, physical, and psychological wellbeing. Initial treatment includes lifestyle modifications, bladder retraining, pelvic floor exercises and pharmacological therapy. However, these measures are unsuccessful in 25-40% of women (refractory OAB). Before considering invasive treatments, such as Botulinum toxin injection or sacral neuromodulation, most guidelines recommend urodynamics to confirm diagnosis of detrusor overactivity (DO). However, urodynamics may fail to show evidence of DO in up to 45% of cases, hence the need to evaluate its effectiveness and cost-effectiveness. FUTURE (Female Urgency, Trial of Urodynamics as Routine Evaluation) aims to test the hypothesis that, in women with refractory OAB, urodynamics and comprehensive clinical assessment is associated with superior patient-reported outcomes following treatment and is more cost-effective, compared to comprehensive clinical assessment only.

METHODS

FUTURE is a pragmatic, multi-centre, superiority randomised controlled trial. Women aged ≥ 18 years with refractory OAB or urgency predominant mixed urinary incontinence, and who have failed/not tolerated conservative and medical treatment, are considered for trial entry. We aim to recruit 1096 women from approximately 60 secondary/tertiary care hospitals across the UK. All consenting women will complete questionnaires at baseline, 3 months, 6 months and 15 months post-randomisation. The primary outcome is participant-reported success at 15 months post-randomisation measured using the Patient Global Impression of Improvement. The primary economic outcome is incremental cost per quality-adjusted life year gained at 15 months. The secondary outcomes include adverse events, impact on other urinary symptoms and health-related quality of life. Qualitative interviews with participants and clinicians and a health economic evaluation will also be conducted. The statistical analysis of the primary outcome will be by intention-to-treat. Results will be presented as estimates and 95% CIs.

DISCUSSION

The FUTURE study will inform patients, clinicians and policy makers whether routine urodynamics improves treatment outcomes in women with refractory OAB and whether it is cost-effective.

TRIAL REGISTRATION

ISRCTN63268739 . Registered on 14 September 2017.

Adiposity and bone microarchitecture in the GLOW study

Low body mass index (BMI) is an established risk factor for fractures in postmenopausal women but the interaction of obesity with bone microarchitecture is not fully understood. In this study, obesity was associated with more favourable bone microarchitecture parameters but not after parameters were normalised for body weight.

INTRODUCTION

To examine bone microarchitecture in relation to fat mass and examine both areal bone mineral density (aBMD) and microarchitecture in relation to BMI categories in the UK arm of the Global Longitudinal Study of Osteoporosis in Women.

METHODS

Four hundred and ninety-one women completed questionnaires detailing medical history; underwent anthropometric assessment; high-resolution peripheral quantitative computed tomography (HRpQCT) scans of the radius and tibia and DXA scans of whole body, proximal femur and lumbar spine. Fat mass index (FMI) residuals (independent of lean mass index) were derived. Linear regression was used to examine HRpQCT and DXA aBMD parameters according to BMI category (unadjusted) and HRpQCT parameters in relation to FMI residuals (with and without adjustment for anthropometric, demographic and lifestyle covariates).

RESULTS

Mean (SD) age was 70.9 (5.4) years; 35.0% were overweight, 14.5% class 1 obese and 7.7% class 2/3 obese. There were significant increasing trends according to BMI category in aBMD of whole body, hip, femoral neck and lumbar spine (p ≤ 0.001); cortical area (p < 0.001), thickness (p < 0.001) and volumetric density (p < 0.03), and trabecular number (p < 0.001), volumetric density (p < 0.04) and separation (p < 0.001 for decreasing trend) at the radius and tibia. When normalised for body weight, all HRpQCT and DXA aBMD parameters decreased as BMI increased (p < 0.001). FMI residuals were associated with bone size and trabecular architecture at the radius and tibia, and tibial cortical microarchitecture.

CONCLUSION

Significant trends in HRpQCT parameters suggested favourable bone microarchitecture at the radius and tibia with increasing BMI but these were not proportionate to increased weight.

Predicting breast cancer response to neoadjuvant treatment using multi-feature MRI: results from the I-SPY 2 TRIAL

Dynamic contrast-enhanced (DCE) MRI provides both morphological and functional information regarding breast tumor response to neoadjuvant chemotherapy (NAC). The purpose of this retrospective study is to test if prediction models combining multiple MRI features outperform models with single features. Four features were quantitatively calculated in each MRI exam: functional tumor volume, longest diameter, sphericity, and contralateral background parenchymal enhancement. Logistic regression analysis was used to study the relationship between MRI variables and pathologic complete response (pCR). Predictive performance was estimated using the area under the receiver operating characteristic curve (AUC). The full cohort was stratified by hormone receptor (HR) and human epidermal growth factor receptor 2 (HER2) status (positive or negative). A total of 384 patients (median age: 49 y/o) were included. Results showed analysis with combined features achieved higher AUCs than analysis with any feature alone. AUCs estimated for the combined versus highest AUCs among single features were 0.81 (95% confidence interval [CI]: 0.76, 0.86) versus 0.79 (95% CI: 0.73, 0.85) in the full cohort, 0.83 (95% CI: 0.77, 0.92) versus 0.73 (95% CI: 0.61, 0.84) in HR-positive/HER2-negative, 0.88 (95% CI: 0.79, 0.97) versus 0.78 (95% CI: 0.63, 0.89) in HR-positive/HER2-positive, 0.83 (95% CI not available) versus 0.75 (95% CI: 0.46, 0.81) in HR-negative/HER2-positive, and 0.82 (95% CI: 0.74, 0.91) versus 0.75 (95% CI: 0.64, 0.83) in triple negatives. Multi-feature MRI analysis improved pCR prediction over analysis of any individual feature that we examined. Additionally, the improvements in prediction were more notable when analysis was conducted according to cancer subtype.

Single hepatocytes show persistence and transcriptional inactivity of hepatitis B

There is no cure for the more than 270 million people chronically infected with HBV. Nucleos(t)ide analogs (NUCs), the mainstay of anti-HBV treatment, block HBV reverse transcription. NUCs do not eliminate the intranuclear covalently closed circular DNA (cccDNA), from which viral RNAs, including pregenomic RNA (pgRNA), are transcribed. A key gap in designing a cure is understanding how NUCs affect HBV replication and transcription because serum markers yield an incomplete view of intrahepatic HBV. We applied single-cell laser capture microdissection and droplet digital PCR to paired liver biopsies collected from 5 HBV/HIV-coinfected persons who took NUCs over 2–4 years. From biopsy 1 to 2, proportions of HBV-infected hepatocytes declined with adherence to NUC treatment (P < 0.05); we extrapolated that eradication of HBV will take over 10 decades with NUCs in these participants. In individual hepatocytes, pgRNA levels diminished 28- to 73-fold during NUC treatment, corresponding with decreased tissue HBV core antigen staining (P < 0.01). In 4 out of 5 participants, hepatocytes with cccDNA but undetectable pgRNA (transcriptionally inactive) were present, and these were enriched in 3 participants during NUC treatment. Further work to unravel mechanisms of cccDNA transcriptional inactivation may lead to therapies that can achieve this in all hepatocytes, resulting in a functional cure.

Single-cell laser capture microdissection integrated with droplet digital PCR was used to study hepatocytes from individuals with chronic hepatitis B.

Association of a Targeted Population Health Management Intervention with Hospital Admissions and Bed-Days for Medicaid-Enrolled Children

IMPORTANCE

As the proportion of children with Medicaid coverage increases, many pediatric health systems are searching for effective strategies to improve management of this high-risk population and reduce the need for inpatient resources.

OBJECTIVE

To estimate the association of a targeted population health management intervention for children eligible for Medicaid with changes in monthly hospital admissions and bed-days.

DESIGN, SETTING, AND PARTICIPANTS

This quality improvement study, using difference-in-differences analysis, deployed integrated team interventions in an academic pediatric health system with 31 in-network primary care practices among children enrolled in Medicaid who received care at the health system's hospital and primary care practices. Data were collected from January 2014 to June 2017. Data analysis took place from January 2018 to June 2019.

EXPOSURES

Targeted deployment of integrated team interventions, each including electronic medical record registry development and reporting alongside a common longitudinal quality improvement framework to distribute workflow among interdisciplinary clinicians and community health workers.

MAIN OUTCOMES AND MEASURES

Trends in monthly inpatient admissions and bed-days (per 1000 beneficiaries) during the preimplementation period (ie, January 1, 2014, to June 30, 2015) compared with the postimplementation period (ie, July 1, 2015, to June 30, 2017).

RESULTS

Of 25 460 children admitted to the hospital's health system during the study period, 8418 (33.1%) (3869 [46.0%] girls; 3308 [39.3%] aged ≤1 year; 5694 [67.6%] black) were from in-network practices, and 17 042 (67.9%) (7779 [45.7%] girls; 6031 [35.4%] aged ≤1 year; 7167 [41.2%] black) were from out-of-network practices. Compared with out-of-network patients, in-network patients experienced a decrease of 0.39 (95% CI, 0.10-0.68) monthly admissions per 1000 beneficiaries (P = .009) and 2.20 (95% CI, 0.90-3.49) monthly bed-days per 1000 beneficiaries (P = .001). Accounting for disproportionate growth in the number of children with medical complexity who were in-network to the health system, this group experienced a monthly decrease in admissions of 0.54 (95% CI, 0.13-0.95) per 1000 beneficiaries (P = .01) and in bed-days of 3.25 (95% CI, 1.46-5.04) per 1000 beneficiaries (P = .001) compared with out-of-network patients. Annualized, these differences could translate to a reduction of 3600 bed-days for a population of 93 000 children eligible for Medicaid.

CONCLUSIONS AND RELEVANCE

In this quality improvement study, a population health management approach providing targeted integrated care team interventions for children with medical and social complexity being cared for in a primary care network was associated with a reduction in service utilization compared with an out-of-network comparison group. Standardizing the work of care teams with quality improvement methods and integrated information technology tools may provide a scalable strategy for health systems to mitigate risk from a growing population of children who are eligible for Medicaid.

Abstract PD4-03: MRI detection of residual disease following neoadjuvant chemotherapy (NAC) in the I-SPY 2 TRIAL

Background: Detecting residual disease accurately using MRI after NAC to identify both responders and non-responders is essential for de-escalating therapy or redirecting patients to more effective treatment. The purpose of this study is to determine if the combination of longest diameter (LD) and functional tumor volume (FTV) from dynamic contrast enhanced (DCE-) MRI is superior to FTV alone or LD alone for assessing treatment response after neoadjuvant therapy in breast cancer patients.

Methods: Data from patients in the graduated drug arms of the I-SPY 2 trial were included in the analysis. Both LD and FTV were assessed using DCE-MRI after neoadjuvant therapy. LD was measured by the site radiologist as the longest dimension of the enhanced area on early post-contrast images. Functional tumor volume (FTV) was assessed as the sum of voxels with enhancement above specific thresholds within the pre-defined region-of-interest (ROI). A linearized variable was derived to represent the combination of FTV and LD. The area under the receiver operating characteristic curve (AUC) was used to evaluate the assessment of treatment response, pathologic complete response (pCR), defined as no invasive disease in the breast and lymph nodes, and in-breast pCR, defined as no invasive disease in the breast only. The analysis was performed in the full cohort and in breast cancer subtype defined by hormone receptor status and HER2 status.

Results: Among the patient cohort of N=675 with FTV and LD, 247 (37%) did and 428 (41%) did not achieve pCR after neoadjuvant therapy. pCR rates varied among HR/HER2 subtypes (HR+/HER2-: 19%; HR+/HER2+: 38%; HR-/HER2+: 71%; HR-/HER2- (triple negative, TN): 43%). In-breast pathologic complete response rates were slightly higher in each group (full: 41%; HR+/HER2-: 23%; HR+/HER2+: 43%; HR-/HER2+: 72%; HR-/HER2-: 49%). Table 1 shows AUCs for assessing pCR using FTV alone, LD alone, and the variable combining FTV and LD. Higher AUCs were observed in all patient groups using the combined variable. AUC of 0.79 (95% CI: 0.77, 0.81) was observed for the combined variable to assess pCR in the full cohort. AUCs varied from 0.69 to 0.86 among HR/HER2 subgroups (HR+/HER2-: 0.69; HR+/HER2+: 0.74; HR-/HER2+: 0.86; HR-/HER2-: 0.80), with no difference in assessing pCR or in-breast pCR. The performance is best for the HR- subtypes.

Conclusions: Both FTV and LD can be used in the assessment of invasive disease residual after neoadjuvant therapy. The combined variable of FTV and LD achieved highest AUCs, compared to using individual variable alone. Tools to improve performance in the HR+ subsets are underway.

AUCs of MR measurements for identifying pCR  FTV alone (95% CI)LD alone (95% CI)Combined (95% CI)FullWith subtype adj.0.73 (0.71, 0.75)0.77 (0.74, 0.79)0.79 (0.77, 0.81)FullWithout subtype adj0.69 (0.65, 0.73)0.72 (0.68, 0.76)0.75 (0.71, 0.79)HR+/HER2- 0.68 (0.60, 0.77)0.68 (0.59, 0.77)0.69 (0.61, 0.77)HR+/HER2+ 0.65 (0.56, 0.75)0.72 (0.64, 0.80)0.74 (0.66, 0.82)HR-/HER2+ 0.69 (0.55, 0.83)0.82 (0.71, 0.92)0.86 (0.77, 0.95)HR-/HER2- (TN) 0.72 (0.66, 0.79)0.73 (0.67, 0.80)0.80 (0.74, 0.85)

Citation Format: Li W, Newitt D, Yun BL, Kornak J, Joe B, Yau C, Abe H, Wolverton D, Crane E, Ward K, Nelson M, Niell B, Drukteinis J, Oh K, Brandt K, Bang DH, Ojeda H, Eghtedari M, Sheth P, Bernreuter W, Umphrey H, Rosen M, Dogan B, Yang W, Esserman L, Hylton N. MRI detection of residual disease following neoadjuvant chemotherapy (NAC) in the I-SPY 2 TRIAL [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr PD4-03.

Abstract P2-08-32: Withdrawn

This abstract was withdrawn by the authors.

Citation Format: Perimbeti SP, Shrivastav R, Ward K, Styler M. Withdrawn [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-08-32.

Comparison of hepatitis C virus testing recommendations in high-income countries

AIM

To investigate hepatitis C virus (HCV) testing recommendations from the United States and other high-income countries.

METHODS

A comprehensive search for current HCV testing recommendations from the top quartile of United Nations Human Development Index (HDI) countries (very high HDI) was performed using Google and reviewed from May 1 - October 30, 2014 and re-reviewed April 1 - October 2, 2017.

RESULTS

Of the 51 countries identified, 16 had HCV testing recommendations from a government body or recommendations issued collaboratively between a government and a medical organization. Of these 16 countries, 15 had HCV testing recommendations that were primarily risk-based and highlight behaviors, exposures, and conditions that are associated with HCV transmission in that region. In addition to risk-based testing, the HCV Guidance Panel (United States) incorporates recommendations for a one-time test for individuals born during 1945-1965 (the birth cohort) without prior ascertainment of risk into their guidance. In addition to the United States, six other countries either have an age-based testing recommendation or recommend one-time testing for all adults independent of risk factors typical of the region.

CONCLUSION

This review affirmed the similarities of the HCV Guidance Panel’s guidance with those of recommendations from very high HDI countries.

Essential TNM: A Means to Collect Stage Data in Population-Based Registries in Low- and Middle-Income Countries

Background and context: Cancer control requires knowledge of cancer incidence. Information on anatomic extent of disease (stage) at presentation significantly enhances incidence and mortality data in understanding the cancer burden. The most frequently used staging classification of cancer disease extent is the tumor, node, metastases (TNM). Population-based registries (PBCR) in low- and middle-income countries (LMIC) frequently have insufficient information to derive complete TNM data, either because of inability to perform the necessary evaluations or because of a lack of recorded information. Aim: To develop a simplified system of recording extent of disease to facilitate the collection of stage data by PBCR and enhance the utility of data to facilitate cancer control in LMICs. Strategy/Tactics: A working group with representatives from the UICC (Union for International Cancer Control), the IARC (International Agency for Cancer Research), IACR (International Association of Cancer Registries) and the NCI (National Cancer Institute) was formed and Essential TNM was developed. When the T, N, and M categories have not been recorded in the clinical records or if the complete data to determine the categories is unavailable, the cancer registrar can code extent of disease according to the Essential TNM scheme. Once a cancer registrar had identifies the presence of metastatic disease (M1) this is recorded and additional information is unnecessary to establish that stage of disease. If there is no metastatic disease the extent of nodal disease is recorded. In turn if there is no nodal disease the extent/size of the primary carcinoma is recorded. The extent of disease can be summarized in the following order: M, N and T. Program/Policy process: Diagrams and rules for combining Essential TNM elements into stage groups (I-IV) or to be expressed as “distant”, “regional” or “localized” if only the most limited data were available, were developed for breast, cervix, prostate and colon cancers and will be demonstrated. Once the schema were developed they were verified in Georgia (USA) and field tested in Ecuador, Malawi, Cote d'Ivoire and Zimbabwe. Outcomes: There was good agreement between the stage identified through Essential TNM and that within the Georgia State Registry. The field tests however identified three key issues: the underidentification of distant metastases, inaccurate the collection of lymph node data and improved training needs. In particular there was uncertainty in the identification of when lymph node involvement was considered to be distant metastatic or regional. In view of this, refinements to the schemas have been made to simplify the collection of nodal data. The schema have been updated to ensure compatibility with the 8th edition of TNM. Training programs are being developed and Essential TNM is being expanded. What was learned: Essential TNM can be used by LMIC PBCR to facilitate the collection of stage data. Further refinements and training are needed and are underway.

Feasibility and Results of Cancer Registry and Noncommunicable Disease Cohort Data Linkages in India

Background: Cancer registries worldwide are vital to determine cancer burden, plan cancer control measures, and facilitate research. Population-based cancer registries are a priority for LMICs by the UICC; the National Cancer Registry Program (NCRP) of India oversees 28 such registries. A primary function of registries is to combine data for the same individual from multiple sources. For other disease cohorts where cancer is an outcome of interest, registries can potentially connect information by linking datasets together. Barriers to successful registration and linkages include systems in which cancer is not a notifiable disease, no universal unique individual identifier exists, and lack of trained personnel. This study utilizes technology and infrastructure to develop better linkages, surveillance, and outcomes. Aim: To assess the feasibility of linking large cohorts designed for cardio-metabolic disease research with cancer registries in New Delhi and Chennai; determine additional steps required for linkage accuracy and completeness; and develop detailed protocols for future applications. Methods: A pilot protocol for linkage between a large diabetes cohort and cancer registries in Delhi and Chennai was developed using MatchPro, a probabilistic record linkage program developed for cancer registries. Probabilistic software links datasets together in the presence of uncertainty (eg misspelled or abbreviated names) to identify record pairs with high probability of representing the same individual. For this study, algorithms were developed to address unique aspects of names and demographics in India. The software and algorithms focused on: detecting duplicates in cancer registries; and linking registries with external files from diabetes cohorts. In Delhi, 3 1-year datasets covering 3 years (2010, 2011, 2012) were linked with the diabetes cohort; in Chennai, the linkage included 3 5-year datasets covering 15 years (2000-04, '05-'09, '10-'14). The unique ID (Aadhaar) is not collected or linked systematically between different systems at this point in time. Results: Linkage attempts yielded potential matches ranked according to probabilistic scores; highest scores were reviewed to determine true matches. In Chennai, this process yielded: (2010-2014) 21% self-reported (SR) cases matching perfectly, 36% requiring follow-up, 13 nonreported (NR) cases found; 2005-2009: 33% SR cases matched perfectly, 1 NR case found; 2000-2004: 1 NR case. Also, 2 training workshops on data linkages and software were held. Conclusion: Linkages between cancer registries and other data sources are feasible in LMICs using probabilistic record linkage software augmented by manual matching. Future efforts to use existing epidemiologic resources (cohorts) and cancer research infrastructure (registries and clinical centers) can enhance research including understanding shared risk factors and pathophysiologic mechanisms e.g., between cancer and other NCD.

Abstract P4-10-21: Disparities in the risk of mortality in breast cancer based on health insurance status

In 2007 Foley et al showed that low-income Canadian residents had a survival advantage over low-income US residents, which was attributed to the equal access to medical care in Canada's universal health care system. Niu et al. found that uninsured and Medicaid insured patients with breast, cervical, colorectal, head and neck, lung, prostate or uterine cancer have higher mortality rates compared to patients with private insurance or Medicare. As substantial proportions of the US population are uninsured or enrolled in Medicaid, we examined the association between in-hospital mortality and different primary payers in patients with breast cancer.

Methods

Adult female admissions (adm) with a primary diagnosis of breast cancer between 1999 and 2014 were extracted from the National Inpatient Sample database using the ICD-9 code 174.9 (N=98631, for a weighted N=484859). The sample was weighted to approximate the full inpatient population of the US over the time period. To minimize the effect of changes in mortality rates based on insurance status over the time interval studied, we grouped the adm into three categories: Group 1 for adm from 1999 to 2003, Group 2 2004 to 2008, and Group 3 2009 to 2014. Chi-Square analysis was done to determine the in-hospital mortality rates by payer group and Cox Proportional Hazard regression was used to determine the hazard of death (HR) within 30 days of adm by payer.

Results

In-hospital Mortality (%) by primary payerYear GroupMedicareMedicaidPrivate InsuranceSelfpay/UninsuredP value13.836.773.4310.140.000124.587.554.9590.000132.843.463.0210.260.0001

Hazard ratio of death within the hospitalizationYear GroupMedicaid vs MedicareP valueUninsured vs MedicareP value12.03 (1.49, 2.76)0.00013.2 (2.49, 4.22)0.000121.56 (1.19, 2.46)0.00012.9 (2.20, 3.80)0.000132.55 (1.99, 3.27)0.00017.76 (1.99, 3.27)0.0001

The number of adm with Medicare or Private insurance were higher than those with Medicaid or Selfpay/uninsured. The in-hospital mortality was highest for Selfpay/uninsured, followed by admissions with Medicaid. After controlling for age, race, median income and comorbidities, the HR was significantly higher in the Medicaid and selfpay/uninsured admissions compared to Medicare admissions. In Group 1, compared to Medicare adm the HR was 103% higher for Medicaid and 220% higher for uninsured. In Group 2, the HR was 56% higher for Medicaid and 196% higher for uninsured. In Group 3, it was 155% higher for Medicaid and 676% higher in uninsured.

Conclusion

Even after controlling for other factors which are implicated in the mortality, the HR is significantly higher in Medicaid and uninsured admissions when compared with Medicare enrolled admissions with breast cancer. Equitable distribution of health was one of the “Aims for Improvement” in the Institute of Medicine's 2001 report, but our results suggests that this has not yet been achieved. Insurance status still appears to play a crucial role in patient outcomes and should be considered as a metric of equitable care. More scientific research is needed in the area of differential receipt of standard therapy in cancer patients considering the limitations of our study.

Citation Format: Perimbeti S, Chakunta H, Liu L, Ward K, Jain M, Styler M. Disparities in the risk of mortality in breast cancer based on health insurance status [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-10-21.

Mild cognitive impairment is associated with poor physical function but not bone structure or density in late adulthood: findings from the Hertfordshire cohort study

This study investigated the association between mild cognitive impairment (MCI) and physical function and bone health in older adults. MCI was associated with poor physical performance but not bone mineral density or bone microarchitecture.

PURPOSE

Cross-sectional study to investigate the association between mild cognitive impairment (MCI) and physical performance, and bone health, in a community-dwelling cohort of older adults.

METHODS

Cognitive function of 222 men and 221 women (mean age 75.5 and 75.8 years in men and women, respectively) was assessed by the Strawbridge questionnaire and Mini Mental State Exam (MMSE). Participants underwent dual-energy X-ray absorptiometry (DXA), peripheral-quantitative computed tomography (pQCT) and high-resolution peripheral-quantitative computed tomography (HR-pQCT) scans to assess their bone density, strength and microarchitecture. Their physical function was assessed and a physical performance (PP) score was recorded.

RESULTS

In the study, 11.8% of women and 8.1% of men were cognitively impaired on the MMSE (score < 24). On the Strawbridge questionnaire, 24% of women were deemed cognitively impaired compared to 22.3% of men. Cognitive impairment on the Strawbridge questionnaire was associated with poorer physical performance score in men but not in women in the unadjusted analysis. MMSE < 24 was strongly associated with the risk of low physical performance in men (OR 12.9, 95% CI 1.67, 99.8, p = 0.01). Higher MMSE score was associated with better physical performance in both sexes. Poorer cognitive function, whether assessed by the Strawbridge questionnaire, or by MMSE score, was not associated with bone density, shape or microarchitecture, in either sex.

CONCLUSION

MCI in older adults was associated with poor physical performance, but not bone density, shape or microarchitecture.

Diabetes care improvement in pharmacist- versus nurse-supported patient-centered medical homes

OBJECTIVES

In 2009 and 2010, 17 primary care sites within 1 healthcare system became patient-centered medical homes (PCMHs), but the sites trained different personnel (pharmacists vs nurses) to improve diabetes care using self-management support (SMS). We report the challenges and successes of our efforts to: 1) assemble a new multipayer (Medicare, Medicaid, commercial) claims dataset linked to a clinical registry and 2) use the new dataset to perform comparative effectiveness research on implementation of the 2 SMS models.

STUDY DESIGN

Longitudinal cohort study.

METHODS

We lost permission to use private-payer data. Therefore, we used claims from Medicare fee-for-service and Medicare/Medicaid dual-eligible patients merged with chronic disease registry data. We studied 2008 to 2010, which included 1 year pre- and 1 year post the 2009 implementation time period. Outcomes were outpatient and emergency department visits, hospitalizations, care process (use of statin), and 3 intermediate outcomes (glycemic control, blood pressure [BP], and low-density lipoprotein cholesterol [LDL-C]).

RESULTS

In our sample of 2826 patients, quality of care improved and utilization decreased over the 2.5 years. Both approaches improved lipid control (LDL-C decreased by an average of 4 mg/dL for pharmacy-SMS and 5.6 mg/dL for nurse-SMS) and diastolic BP (-1.5 mm Hg for pharmacy-SMS and -1.3 mm Hg for nurse-SMS), whereas only the pharmacy-led approach decreased primary care visits (by 0.8 visits). The groups differed slightly on 2 measures (glycated hemoglobin, systolic BP) with respect to the trajectory of improvement over time, but performance was similar by 2.5 years.

CONCLUSIONS

Diabetes care improved during PCMH implementation systemwide, supporting both nurse-led and pharmacist-led SMS models.

Hardware image assessment for wireless endoscopy capsules

Wireless capsule endoscopy is a new technology in the realm of telemedicine that has many advantages over the traditional endoscopy systems. Transmitted images should help diagnosis of diseases of the gastrointestinal tract. Two important technical challenges for the manufacturers of these capsules are power consumption and size of the circuitry. Also, the system must be fast enough for real-time processing of image or video data. To solve this problem, many hardware designs have been proposed for implementation of the image processing unit. In this paper we propose an architecture that could be used for the assessment of endoscopy images. The assessment allows avoidance of transmission of medically useless images. Hence, volume of data is reduced for more efficient transmission of images by the endoscopy capsule. This is done by color space conversion and moment calculation of images captured by the capsule. The inputs of the proposed architecture are RGB image frames and the outputs are images with converted colors and calculated image moments. Experimental results indicate that the proposed architecture has low complexity and is appropriate for a real-time application.

Vessel extraction in X-ray angiograms using deep learning

Coronary artery disease (CAD) is the most common type of heart disease which is the leading cause of death all over the world. X-ray angiography is currently the gold standard imaging technique for CAD diagnosis. These images usually suffer from low quality and presence of noise. Therefore, vessel enhancement and vessel segmentation play important roles in CAD diagnosis. In this paper a deep learning approach using convolutional neural networks (CNN) is proposed for detecting vessel regions in angiography images. Initially, an input angiogram is preprocessed to enhance its contrast. Afterward, the image is evaluated using patches of pixels and the network determines the vessel and background regions. A set of 1,040,000 patches is used in order to train the deep CNN. Experimental results on angiography images of a dataset show that our proposed method has a superior performance in extraction of vessel regions.

Maxillofacial prosthodontics practice profile: a survey of non-United States prosthodontists

Background

This study surveyed non-United States maxillofacial prosthodontists (MFP) to determine their practice profile and rationale for pursuing an MFP career.

Methods

Email addresses for the MFP were obtained from the International Society for Maxillofacial Rehabilitation, American Academy of Maxillofacial Prosthetics, and International Academy for Oral Facial Rehabilitation. Emails with a link to the electronic survey program were sent to each participant. Chi-square and Mann–Whitney-U tests were used to investigate the influence of formal MFP training on professional activities and type of treatments provided.

Results

One hundred twelve respondents (response rate 39%) from 33 nationalities returned the survey. The top three reasons for pursuing an MFP career were personal satisfaction, prosthodontics residency exposure, and mentorship. The predominant employment setting was affiliation with a university (77%). There were significant differences between respondents with and without formal MFP training regarding provision of surgical treatments (P = 0.021) and dental oncology (P = 0.017). Most treatments were done together with otolaryngology, oral surgery (68%) and head and neck surgery (61%). Practitioners not affiliated with a university spent significantly more time in clinical practice (P = 0.002), whereas respondents affiliated with universities spent significantly more time in teaching/training (P = 0.008) and funded research (P = 0.015).

Conclusions

Personal satisfaction is the most important factor in a decision to choose an MFP career. Most of the MFPs work at a university and within a multidisciplinary setting. There were differences regarding type of treatments provided by respondents with and without formal MFP training.