Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Evidence-based severity assessment of the forced swim test in the rat

The forced swim test (FST) is a traditional assay, which has been used for more than 40 years to assess antidepressant effects of novel drug candidates. In recent years, a debate about the test has focused on the assumption that the FST is highly aversive and burdening for the animals because of the earlier anthropomorphic interpretation and designation as a "behavioral despair test". The Directive 2010/63/EU and the German Animal Welfare law require a prospective severity classification of the planned experimental procedures. Still, an objective examination of the animals' burden in this test has not been performed yet. To fill this gap, we conducted an evidence-based severity assessment of the forced swim test in rats according to a 'standard protocol' with a water temperature of 25°C. We examined parameters representing the physiological and the affective state, and natural as well as locomotion-associated behaviors in three separate experiments to reflect as many dimensions as possible of the animal's condition in the test. Hypothermia was the only effect observed in all animals exposed to the FST when using this standard protocol. Additional adverse effects on body weight, food consumption, and fecal corticosterone metabolite concentrations occurred in response to administration of the antidepressant imipramine, which is frequently used as positive control when testing for antidepressant effects of new substances. We conclude that this version of the FST itself is less severe for the animals than assumed, and we suggest a severity classification of 'moderate' because of the acute and short-lasting effects of hypothermia. To refine the FST according to the 3Rs, we encourage confirming the predictive validity in warmer water temperatures to allow the rats to maintain physiological body temperature.

A systematic mapping review of the evolution of the rat Forced Swim Test: Protocols and outcome parameters

As depression is projected to become the leading mental disease burden globally by 2030, understanding the underlying pathology, as well as screening potential anti-depressants with a higher efficacy, faster onset of action, and/or fewer side-effects is essential. A commonly used test for screening novel antidepressants and studying depression-linked aspects in rodents is the Porsolt Forced Swim Test. The present systematic mappping review gives a comprehensive overview of the evolution and of the most prevalently used set-ups of this test in rats, including the choice of animals (strain, sex, and age), technical aspects of protocol and environment, as well as reported outcome measures. Additionally, we provide an accessible list of all existing publications, to support informed decision-making for procedural and technical aspects of the test, to thereby enhance reproducibility and comparability. This should further contribute to reducing the number of unnecessarily replicated experiments, and consequently, reduce the number of animals used in future.

Heat-Introduced Formation of Acrylamide in Table Olives: Analysis of Acrylamide, Free Asparagine, and 3-Aminopropionamide

Acrylamide was detected in considerable amounts in black table olives. In this study, besides black, also green and naturally black table olives were investigated for their acrylamide, free asparagine, and 3-aminopropionamide contents before and after heat treatment. Acrylamide amount was 208-773 μg/kg in black table olives and did not change due to heat treatment. In green and naturally black table olives acrylamide was ≤24 μg/kg before heat treatment and rose to 1200 μg/kg afterward. Asparagine content was 0.35-35 mg/kg in all samples before heat treatment and after heat treatment with no considerable change in the range. 3-Aminopropionamide showed amounts of ≤56 μg/kg in the unheated samples and increased up to 131 μg/kg due to heat impact. However, quantified asparagine and 3-aminopropionamide amounts were insufficient in almost all samples to explain the acrylamide quantities formed due to heat treatment based on the formation via the Maillard reaction.

App-basierte Systeme zur Ersthelfer-Alarmierung: Eine Einordnung in Datenschutz und rechtliche Aspekte der Anwendung

Durch unverzüglich eingeleitete Wiederbelebungsmaßnahmen können Überlebensraten im Fall eines Herz-Kreislauf-Stillstands deutlich erhöht werden. Ersthelferalarmierungs-Apps benachrichtigen per Smartphone-Ortung registrierte Personen, sodass sie Erste-Hilfe-Maßnahmen einleiten können, bis der reguläre Rettungsdienst eintrifft. In deutschen Leitstellen will man zwar zunehmend derartige Anwendungen einsetzen, es bestehen aber häufig datenschutzrechtliche und insgesamt juristische Bedenken. Die Notwendigkeit der Berücksichtigung des Datenschutzes ergibt sich aus der EU-Datenschutzgrundverordnung (DSGVO). Bei Gesundheitsdaten gelten zusätzlich zur allgemeinen Rechtfertigungspflicht für Datenverarbeitungen besonders strenge Regeln, die differenziert zu betrachten sind, wenn ein Einverständnis aufgrund des betrachteten speziellen Notfall-Settings nicht möglich ist. Die Rechtfertigung der Verarbeitung kann sich in diesen Fällen aus Art. 6 Abs. 1 lit. c)–e) i. V. m. Art. 9 Abs. 2 lit. c) DSGVO ergeben. In diesem Feld fehlt bisher jedoch eine grundsätzliche Einordnung, wie man herstellerunabhängig und über einen „Datenschutz durch Technikgestaltung“-Ansatz derartige Applikationen umsetzen kann.

Der Beitrag erörtert dazu jeweils mit juristischem Hintergrund, aber auch anhand einer praktischen Lösungsskizze die Aspekte der Ortung der Ersthelfer per App, die Übermittlung der personenbezogenen Daten von Patienten an die Ersthelfer und die Rückübermittlung von Daten hinsichtlich des Einsatzes durch die Ersthelfer an die Leitstelle. Zudem wird auf die rechtliche Stellung und die Haftbarkeit der freiwilligen Ersthelfer eingegangen.

In Summe kommen die Autoren zum Schluss, dass gegen die Ortung der Ersthelfer keine Bedenken bestehen, wenn sie mit deren Einwilligung, unter Beachtung des Grundsatzes der Datenminimierung und dem Aspekt der Vergröberung geschieht und natürlich die technische Lösung professionell umgesetzt wird. Im Punkt der Übermittlung der personenbezogenen Daten von Patienten an die Ersthelfer bestehen in Summe ebenfalls keine Bedenken, sofern auf den Anwendungsfall für besonders zeitkritische Notfälle geachtet wird. Auch die Rückübermittlung von Einsatzdaten durch den Ersthelfer scheint möglich. Eine Strafbarkeit der Beteiligten nach § 203 StGB scheitert spätestens aufgrund des sog. „rechtfertigenden Notstandes“ nach § 34 StGB. Die vorliegende Arbeit ist ein praktischer rechtlicher Leitfaden und kann Grundlage für eine Konzeption und Implementierung einer solchen Lösung sein.

Tolerance of biofilm of a carbapenem-resistant Klebsiella pneumoniae involved in a duodenoscopy-associated outbreak to the disinfectant used in reprocessing

Background

One possible transmission route for nosocomial pathogens is contaminated medical devices. Formation of biofilms can exacerbate the problem. We report on a carbapenemase-producing Klebsiella pneumoniae that had caused an outbreak linked to contaminated duodenoscopes. To determine whether increased tolerance to disinfectants may have contributed to the outbreak, we investigated the susceptibility of the outbreak strain to disinfectants commonly used for duodenoscope reprocessing. Disinfection efficacy was tested on planktonic bacteria and on biofilm.

Methods

Disinfectant efficacy testing was performed for planktonic bacteria according to EN standards 13727 and 14561 and for biofilm using the Bead Assay for Biofilms. Disinfection was defined as ≥ 5log₁₀ reduction in recoverable colony forming units (CFU).

Results

The outbreak strain was an OXA-48 carbapenemase-producing K. pneumoniae of sequence type 101. We found a slightly increased tolerance of the outbreak strain in planktonic form to peracetic acid (PAA), but not to other disinfectants tested. Since PAA was the disinfectant used for duodenoscope reprocessing, we investigated the effect of PAA on biofilm of the outbreak strain. Remarkably, disinfection of biofilm of the outbreak strain could not be achieved by the standard PAA concentration used for duodenoscope reprocessing at the time of outbreak. An increased tolerance to PAA was not observed in a K. pneumoniae type strain tested in parallel.

Conclusions

Biofilm of the K. pneumoniae outbreak strain was tolerant to standard disinfection during duodenoscope reprocessing. This study establishes for the first time a direct link between biofilm formation, increased tolerance to disinfectants, reprocessing failure of duodenoscopes and nosocomial transmission of carbapenem-resistant K. pneumoniae.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13756-022-01112-z.

Dopamine Transporter Knockout Rats Show Impaired Wellbeing in a Multimodal Severity Assessment Approach

In preclinical psychiatry research, animals are central to modeling and understanding biological mechanisms of behavior and psychiatric disorders. We here present the first multimodal severity assessment of a genetically modified rat strain used in psychiatric research, lacking the dopamine transporter (DAT) gene and showing endophenotypes of several dopamine-associated disorders. Absence of the DAT leads to high extracellular dopamine (DA) levels and has been associated with locomotor hyperactivity, compulsive behaviors and stereotypies in the past. The German Animal Welfare Law, which is based on the EU Directive (2010/63/EU), requires a prospective severity assessment for every animal experiment, depending on the extent of the expected degree of pain, suffering, distress or lasting harm that the animals will experience. This should consider all procedures but also the impact of the genotype on the phenotype. Therefore, we examined multiple parameters indicating animal welfare, like burrowing behavior, social interaction, saccharin preference, baseline stress hormone levels and nesting behavior. Additionally, a footprint analysis was performed and home cage activity was analyzed for a more detailed characterization of locomotion. DAT KO rats demonstrated reduced burrowing, social interaction and saccharin preference. We also found pronounced stereotypies and alterations in the gait analysis in DAT KO rats. Moreover, we confirmed the hyperactivity and the impaired sensorimotor gating mechanisms to assure that our rats are exhibiting the correct phenotype. In conclusion, we provide evidence that DAT KO rats show alterations in natural behavior patterns and deduce that the marked stereotypies are a sign for coping difficulties, both indicating a negative influence of the genotype on wellbeing. We suggest to assess further rat models in an objectified severity assessment as previously done in mice to create a relative severity assessment based on scientific evidence. Until then, we propose the classification of homozygous DAT KO rats as “moderate” in accordance with the criteria of the EU directive 2010/63.

MRI biomarker of muscle composition is associated with severity of pelvic organ prolapse

BACKGROUND

The pathophysiology of pelvic organ prolapse is largely unknown. We hypothesized that reduced muscle mass on magnetic resonance defecography (MRD) is associated with increased pelvic floor laxity. The aim of this study was to compare the psoas and puborectalis muscle mass composition and cross-sectional area among patients with or without pelvic laxity.

METHODS

An observational retrospective study was conducted on women > age 18 years old who had undergone MRD for pelvic floor complaints from January 2020 to December 2020 at Stanford Pelvic Health Center. Pelvic floor laxity, pelvic organ descent, and rectal prolapse were characterized by standard measurements on MRD and compared to the psoas (L4 level) and puborectalis muscle index (cross-sectional area adjusted by height) and relative fat fraction, quantified by utilizing a 2-point Dixon technique. Regression analysis was used to quantify the association between muscle characteristics and pelvic organ measurements.

RESULTS

The psoas fat fraction was significantly elevated in patients with abnormally increased resting and strain H and M lines (p < 0.05) and increased with rising grades of Oxford rectal prolapse (p = 0.0001), uterovaginal descent (p = 0.001) and bladder descent (p = 0.0005). In multivariate regression analysis, adjusted for age and body mass index, the psoas fat fraction (not muscle index) was an independent risk factor for abnormal strain H and M line; odds ratio (95% confidence interval) of 17.8 (2-155.4) and 18.5 (1.3-258.3) respectively, and rising Oxford grade of rectal prolapse 153.9 (4.4-5383) and bladder descent 12.4 (1.5-106). Puborectalis fat fraction was increased by rising grades of Oxford rectal prolapse (p = 0.0002).

CONCLUSIONS

Severity of pelvic organ prolapse appears to be associated with increasing psoas muscle fat fraction, a biomarker for reduced skeletal muscle mass. Future prospective research is needed to determine if sarcopenia may predict postsurgical outcomes after pelvic organ prolapse repair.

Impact of Time of Surgery on the Outcome after Surgical Stabilization of Rib Fractures in Severely Injured Patients with Severe Chest Trauma—A Matched-Pairs Analysis of the German Trauma Registry

Purpose

In severely injured patients with multiple rib fractures, the beneficial effect of surgical stabilization is still unknown. The existing literature shows divergent results, and the indication and especially the right timing of an operation are the subject of a broad discussion. The aim of this study was to determine the influence of the time point of surgical stabilization of rib fractures (SSRF) on the outcome in a multicenter database with special regard to the duration of ventilation, intensive care, and overall hospital stay.

Methods

Data from the TraumaRegister DGU collected between 2010 and 2019 were used to evaluate patients above 16 years of age with severe rib fractures [Abbreviated Injury Score (AIS)  ≥ 3] who received an SSRF in a matched-pairs analysis. In this matched-pairs analysis, we compared the effects of an early SSRF within 48 h after initial trauma vs. late SSRF 3–10 days after trauma.

Results

After the selection process, we were able to find 142 matched pairs for further evaluation. Early SSRF was associated with a significantly shorter length of stay in the intensive care unit (16.2 days vs. 12.7 days, p = 0.020), and the overall hospital stay (28.5 days vs. 23.4 days, p = 0.005) was significantly longer in the group with late SSRF. Concerning the days on mechanical ventilation, we were able to demonstrate a trend for an approximately 1.5 day shorter ventilation time for patients after early SSRF, although this difference was not statistically significant (p = 0.226).

Conclusions

We were able to determine the significant beneficial effects of early SSRF resulting in a shorter intensive care unit stay and a shorter length of stay in hospital and additionally a trend to a shorter time on mechanical ventilation.

Expenditures in Young Adults with Hodgkin Lymphoma: NCI-designated Comprehensive Cancer Centers vs. Other Sites

BACKGROUND

Outcomes among Hodgkin Lymphoma (HL) patients diagnosed between 22 and 39 years are worse than among those diagnosed <21 years, and have not seen the same improvement over time. Treatment at an NCI-designated Comprehensive Cancer Center (CCC) mitigates outcome disparities, but may be associated with higher expenditures.

METHODS

We examined cancer-related expenditures among 22-39 year-old HL patients diagnosed between 2001-2016 using de-identified administrative claims data (OptumLabs® Data Warehouse) (CCC: n=1,154; non-CCC: n=643). Adjusting for sociodemographics, clinical characteristics and months enrolled, multivariable general linear models modeled average monthly health-plan paid (HPP) expenditures, and incidence rate ratios compared CCC/non-CCC monthly visit rates.

RESULTS

In the year following diagnosis, CCC patients had higher HPP-expenditures ($12,869 vs. $10,688, p=0.001), driven by higher monthly rates of CCC non-treatment outpatient hospital visits (p=0.001) and per-visit expenditures for outpatient hospital chemotherapy ($632 vs. $259); higher CCC inpatient expenditures ($1,813 vs. $1,091, p=0.001) were driven by 3.1-times higher rates of chemotherapy admissions (p=0.001). Out-of-pocket expenditures were comparable (p=0.3).

CONCLUSIONS

Young adults with Hodgkin lymphoma at CCCs saw higher health plan expenditures, but comparable out-of-pocket expenditures. Drivers of CCC expenditures included outpatient hospital utilization (monthly rates of non-therapy visits and per-visit expenditures for chemotherapy).

IMPACT

Higher HPP-expenditures at CCCs in the year following HL diagnosis likely reflect differences in facility structure and comprehensive care. For young adults, it is plausible to consider incentivizing CCC care to achieve superior outcomes while developing approaches to achieve long-term savings.

Nutrition data use and needs: Findings from an online survey of global nutrition stakeholders

Background

There is growing global demand for country-specific information to track nutritional status and its determinants, including intervention coverage. Periodic population-based surveys form the backbone of most national nutrition information systems. However, data on the coverage of many nutrition specific and sensitive interventions remain sparse.

Methods

An online survey was administered to the international nutrition community in 2018 through relevant listservs and professional networks to characterize their use of nutrition-related indicators and data sources. Respondents were asked about their professional background, access and use of specific indicators and data sources in the previous year, and unmet data needs. Results were tabulated by respondent characteristics and χ² tests used for statistical testing.

Results

Complete survey responses were received from 235 respondents, the majority from non-governmental organizations and research communities, and few from governments. Demographic Health Surveys (DHS) were the most frequently accessed country-specific data source and the Global Nutrition Report (GNR) was the most accessed consolidated data source, each accessed by approximately 75% of respondents. Respondents with a multi-country focus were more likely to have accessed DHS than those with a single-country focus (85% vs 60%, P < 0.001). Similarly, respondents with a multi-country focus were more likely to have accessed the GNR compared to those with a single-country focus (82% vs 66%, P < 0.05). The most commonly accessed indicators overall were the prevalence of exclusive breastfeeding (69%), child minimum dietary diversity (66%), under-5 stunting (65%), and under-5 wasting (65%). Reported data gaps included adult and household diet quality indicators (n = 32), nutrition-sensitive intervention coverage (n = 25), and infant and young child feeding promotion coverage (n = 11). Lack of data availability for the desired geographic level (82%) or demographic group of interest (82%) and out-of-date data (77%) were common data challenges experienced by respondents.

Conclusions

The survey results highlight the continued need for high-quality, actionable nutrition data to help facilitate progress towards national and global nutrition targets.

Patterns and compound specific stable carbon isotope analysis (δ13 C) of capsaicinoids in Cayenne chilli fruits of different ripening stages

INTRODUCTION

Capsaicinoids are alkaloids of high pungency which are exclusively formed by fruits of the genus Capsicum. Capsaicinoid content and composition of Capsicum fruits are influenced by ripening.

OBJECTIVE

Determination of changes in content and pattern of individual capsaicinoids in chilli pods with fruit ripening. Compound specific stable carbon isotope analysis (δ¹³ C values (‰), CSIA) was used for a better understanding of capsaicinoid development during fruit ripening.

METHODOLOGY

Cayenne chillies (Capsicum annuum) were grown in a glasshouse and harvested from different plants at four ripening stages (unripe, semi-ripe, ripe, overripe). Nine capsaicinoids (one verified by synthesis) were quantified by gas chromatography with mass spectrometry (GC-MS). For CSIA, an acetylation method for derivatising capsaicinoids was developed.

RESULTS

Variations in the patterns of the nine capsaicinoids were not relatable to a distinct ripening stage and also total contents varied extensively from plant to plant. However, changes in total capsaicinoid concentrations were systematic. In almost all plants, maximum values were reached in unripe fruits, then decreased to semi-ripe samples and increased again in the following ripening process. Likewise, δ¹³ C values of individual capsaicinoids were always by ~2‰ heavier in unripe than in semi-ripe or ripe fruits. However, direction of changes in sum-δ¹³ C values (‰) (taking contributions of all capsaicinoids together) could not be explained by corresponding variations in capsaicinoid concentrations.

CONCLUSIONS

Both quantification and δ¹³ C values (‰) verified the presence of ripening-related changes in the capsaicinoid content which may be caused by simultaneously proceeding reactions like synthesis, storage and degradation of capsaicinoids.

A randomised trial comparing a brief online delivery of mindfulness-plus-values versus values only for symptoms of depression: Does baseline severity matter?

BACKGROUND

Acceptance/mindfulness-based interventions often focus on (a) developing dispositional mindfulness and (b) pursuing personally meaningful and valued activities. Acceptance/mindfulness-based interventions can reduce depression, but little is known about the combined effects of components or the influence of baseline variables on outcomes. This study tested whether practicing a brief (10-min) mindfulness meditation over a 2-week period followed by a single values session (mindfulness+values) was more effective than values alone (values only) in reducing symptoms of depression. The study was delivered online and modules were fully self-help (i.e., no therapist contact).

METHODS

206 participants (M_age=23.4 years, SD=6.53) with elevated depression scores (DASS-depression ≥ 10) were randomised to: mindfulness+values condition or a 2-week wait period followed by the values session (i.e., values only condition). Symptoms of depression were assessed at baseline, after the 2-week mindfulness practice/wait period, and 1-week following the values session.

RESULTS

Reductions in depression and recovery rates were significantly greater following mindfulness+values than values only. Baseline severity affected outcomes: mindfulness+values was significantly more beneficial than values only for individuals with high baseline levels of depression. Outcomes did not differ for those with low levels of depression. Rates of deterioration were higher than expected for values only participants.

LIMITATIONS

Conclusions are preliminary and tentative due to no follow-up period and a small sample. Drop-out was high (50%) and findings cannot be assumed to generalise to treatment seeking or more diverse samples.

CONCLUSIONS

Tentatively, results suggest mindfulness+values can significantly reduce depression, especially for individuals with higher baseline depression.

Impact of Dependent Coverage Provision of the Affordable Care Act on Insurance Continuity for Adolescents and Young Adults With Cancer

PURPOSE

The 2010 Dependent Coverage Provision (DCP) of the Affordable Care Act (ACA) allowed enrollees to remain on their parents' health insurance until 26 years of age. We compared rates of insurance disenrollment among patients with cancer who were DCP-eligible at age 19 to those who were not eligible at age 19.

METHODS

Using OptumLabs Data Warehouse, which contains longitudinal, real-world, de-identified administrative claims for commercial enrollees, we examined patients born between 1982 and 1993 and diagnosed with cancer between 2000 and 2015. In the recent cohort, patients who turned 19 in 2010-2012 (DCP-eligible to stay on parents' insurance) were matched to patients who turned 19 in 2007-2009 (not DCP-eligible when turning 19). In an earlier control cohort, patients who turned 19 between 2004 and 2006 (not DCP-eligible) were matched to patients who turned 19 between 2001 and 2003 (not DCP-eligible). Patients were matched on cancer type, diagnosis date, demographics, and treatment characteristics. The time to loss of coverage was estimated using Cox models. Difference-in-difference between the recent and earlier cohorts was also evaluated.

RESULTS

A total of 2,829 patients who turned 19 years of age in 2010-2012 were matched to patients who turned 19 in 2007-2009. Median time to disenrollment was 26 months for younger patients versus 22 months for older patients (hazard ratio [HR], 0.85; 95% CI, 0.80 to 0.90; P = .001). In 8,978 patients who turned 19 between 2001 and 2006, median time to disenrollment was 20 months among both younger and older patients (HR, 0.99; 95% CI, 0.94 to 1.03; P = .59). The difference between the recent cohort and the earlier control cohort was a 15% greater reduction in coverage loss (P < .0001), favoring those turning 19 after the DCP went into effect.

CONCLUSION

In the vulnerable population of adolescent and young adult cancer survivors, the ACA may have lowered the insurance dropout rate.

Is Adult Second Language Acquisition Defective?

There is a large literature showing that adult L2 learners, in contrast to children, often fail to acquire native-like competence in the second language. Because of such age effects, adult L2 learning is often viewed as "fundamentally different" from child acquisition and defective in some way. However, adult L2 learners do not always do worse than child learners. Several studies (e.g., Sasaki, 1997; Dąbrowska and Street, 2006; Street, 2017; Dąbrowska, 2019) found considerable overlap between L1 and L2 speakers' performance on tasks tapping morphosyntactic knowledge. Crucially, these studies used grammatical comprehension tasks (e.g., picture selection) to test mastery of "functional" grammar (i.e., grammatical contrasts which correspond to a clear difference in meaning, such as the assignment of agent and patient roles in sentences with noncanonical word order and quantifier scope). In contrast, most ultimate attainment studies (e.g., Johnson and Newport, 1989; Flege et al., 1999; DeKeyser, 2000; DeKeyser et al., 2010) used a grammaticality judgment task (GST) which assessed mastery of "decorative" grammar, i.e., grammatical morphemes such as tense and agreement markers which make relatively little contribution to the meaning conveyed by a sentence. In this study, we directly compared native speakers, late immersion learners, and classroom foreign language learners on tasks assessing both aspects of grammar. As in earlier studies, we found significant differences between native speakers and both non-native groups in performance on "decorative" grammar, particularly when performance was assessed using spoken rather than written stimuli. However, the differences in performance on the "functional" grammar task were much smaller and statistically non-significant. Furthermore, even in the "decorative" grammar task, there was more overlap between native speakers and late L2 learners than reported in earlier research. We argue that this is because earlier studies underestimated the amount of variation found in native speakers.

How are countries planning for costs of nutrition data and information systems?

Background: The first Global Nutrition Report in 2014 called for a "data revolution" in nutrition, so that countries have the latest data to set priorities and monitor progress. Integral to this revolution is understanding how countries are investing in the data, systems and capacity required to support decision-making around nutrition, i.e. their nutrition data and information system (NDIS). Methods: For this reason, our team conducted a desk review of national nutrition plans for 58 Scaling Up Nutrition (SUN) countries to better understand how countries are planning for and estimating the costs of their NDIS. Results: We found that of the SUN national nutrition plans that are publicly accessible, not all are costed and less than half of these have explicit data and monitoring and evaluation (M&E) sections. Of the 19 national plans that had costed data and M&E sections, our initial estimates show costs for data systems ranged from 0.1%-12.8% of total plan costs with limited information on data system components. Conclusions: There is an imminent need for more comprehensive and strategic approaches - including the planning for and financing of - NDIS in countries.

Health plan expenditures young adults with newly-diagnosed Hodgkin lymphoma (HL) by care at NCI-designated comprehensive cancer centers (CCC) vs. other treatment sites (non-CCC)

7081

Background: Patients diagnosed with HL between 22-39y have worse outcomes than younger patients (≤21y); we previously reported that treatment at a CCC mitigates these disparities [Wolfson, Leukemia 2017]. While there is general consensus that CCC care is expensive, expenditures for managing young adults with HL in CCC vs. non-CCC are not known. Methods: Cancer-related expenditures were examined in HL patients diagnosed between 2001-2014 at age 22-39y and treated at CCC and non-CCC sites using commercial insurance claims data (OptumLabs Data Warehouse). Multivariable generalized linear models with log link modeled average monthly health plan paid expenditures, adjusting for sociodemographics, stage, adverse events, pre-existing comorbidities, and diagnostic era. Results: Of the 1501 HL patients, 33% (n = 489) were treated at a CCC. Patients treated at CCC vs. non-CCC did not differ with respect to race, sex, income, diagnostic era or comorbidities (p≥0.3). Mean duration of enrollment was longer in CCC than non-CCC (25 vs. 23 mos; p < 0.001) patients. During the first year after HL diagnosis, total average monthly expenditures were higher in CCC ($9,111) than non-CCC ($7,834, p = 0.001), including those related to inpatient (CCC: $1,790 vs. non-CCC: $1,011; p = 0.001) and outpatient (CCC: $6,971 vs. non-CCC: $6,487; p = 0.001) expenditures. The higher CCC expenditures were associated with higher monthly rates of inpatient admissions (IRR = 1.3, p = 0.001) and outpatient visits (IRR = 1.1, p = 0.02) at CCC. Rates of chemotherapy-related inpatient admissions were higher (IRR = 2.3, p = 0.001) in CCC than non-CCC patients, while outpatient chemotherapy visit rates were lower (IRR = 0.9, p = 0.001) in CCC. During Years 2-3, total average monthly expenditures were higher in CCC ($19,259) than non-CCC ($4,145, p = 0.002) patients. Outpatient expenditures were higher in CCC ($10,164) vs. non-CCC ($2,901, p = 0.001), with higher monthly outpatient visit rates (IRR = 1.7, p = 0.001) at CCC. Conclusions: Inpatient and outpatient cancer-related expenditures in young adults with HL were higher at CCC than non-CCCs. Higher outpatient expenditures at CCC were associated with only higher monthly visit rates. Higher inpatient expenditures were in the setting of higher admission rates, including those related to chemotherapy. Additional work is necessary to understand whether these higher expenditures at CCC are related to supportive care and/or differences in facility structure and billing practices.

Development of the Mitochondrial Intermembrane Space Disulfide Relay Represents a Critical Step in Eukaryotic Evolution

The mitochondrial intermembrane space evolved from the bacterial periplasm. Presumably as a consequence of their common origin, most proteins of these compartments are stabilized by structural disulfide bonds. The molecular machineries that mediate oxidative protein folding in bacteria and mitochondria, however, appear to share no common ancestry. Here we tested whether the enzymes Erv1 and Mia40 of the yeast mitochondrial disulfide relay could be functionally replaced by corresponding components of other compartments. We found that the sulfhydryl oxidase Erv1 could be replaced by the Ero1 oxidase or the protein disulfide isomerase from the endoplasmic reticulum, however at the cost of respiration deficiency. In contrast to Erv1, the mitochondrial oxidoreductase Mia40 proved to be indispensable and could not be replaced by thioredoxin-like enzymes, including the cytoplasmic reductase thioredoxin, the periplasmic dithiol oxidase DsbA, and Pdi1. From our studies we conclude that the profound inertness against glutathione, its slow oxidation kinetics and its high affinity to substrates renders Mia40 a unique and essential component of mitochondrial biogenesis. Evidently, the development of a specific mitochondrial disulfide relay system represented a crucial step in the evolution of the eukaryotic cell.

Nutrition Data Use and Needs: Findings from an Online Survey of Global Nutrition Stakeholders (P22-003-19)

Objectives

There is a growing global demand for information to track nutritional status and its determinants, including intervention coverage. We developed an online survey to identify which nutrition indicators and data sources the global nutrition community uses currently and what information gaps remain.

Methods

We created the survey using Qualtrics software and distributed it through multiple online nutrition-focused listservs and professional networks. Respondents were asked about their professional background, use of nutrition indicators in previous year, sources of accessed data, unfilled data needs, and how they used data in their work. Data were collected from July 16 to August 16 2018. Results were tabulated using Stata Version 14.0.

Results

A total of 264 survey responses were received, 235 with responses beyond identifiers. The majority of stakeholders were from NGO and research communities. Two-thirds reported using data to make monitoring and evaluation decisions (Table 1). Demographic Health Surveys (DHS) were the most accessed national data source in the past year (74%), followed by the Multiple Indicator Cluster Surveys (42%) (Table 2). When data sources were stratified by respondent geographic focus area (single country vs. multi-country), 60% of stakeholders with a single country focus and 85% of stakeholders with a multi-country focus accessed the DHS. Among stakeholders who accessed aggregated data sources, most accessed the Global Nutrition Report (75%).

The majority of respondents accessed or used at least one nutrition coverage or utilization indicator in the last 12 months (97%) including iron and folic acid supplementation for pregnant or lactating women (54%) (Figure 1). Several challenges to accessing and using data were identified such as data sometimes or frequently not being available at the geographical level needed (82%) or being out of out-of-date (77%) (Figure 2).

Conclusions

High-quality, actionable nutrition data are needed to understand progress towards reducing malnutrition and reaching global nutrition targets. Effective monitoring of progress in nutrition requires data that are accessible to decision makers who assess programs and allocate resources.

Funding Sources

Bill & Melinda Gates Foundation.

Supporting Tables, Images and/or Graphs

Impact of the Affordable Care Act on insurance for adolescents and young adults with cancer

e18125

Background: The 2010 Dependent Coverage Provision (DCP) of the Affordable Care Act (ACA) allowed young adults to remain on their parents' health insurance until age 26 years (y), whereas pre-DCP the cut-off varied, but was most often 18 y. Our objective was to compare rates of insurance disenrollment among patients with cancer who were DCP-eligible compared to those who were not. Methods: A retrospective cohort from the OptumLabs Data Warehouse, which includes claims data for privately insured enrollees in a large US health plan, was used. Patients born between 1982-93 diagnosed with cancer between 2000-15 were included. In the Recent Cohort, patients who turned 19 in 2010-12 (who were always eligible to stay on parents’ insurance) were matched to patients who turned 19 in 2007-09 (who were not protected by the DCP when they turned 19). Sensitivity analyses paired patients in an Earlier Cohort, who turned 19 (in 2001-03 and 2004-06), none of whom were eligible for the DCP when they turned 19. Patients were matched on cancer type, diagnosis date, and additional clinical characteristics. Using a time to loss of coverage analysis (defined as > 90 d interruption in insurance enrollment), hazard ratios (HR) were calculated using Cox proportional hazards models. Difference-in-difference between pairs from the Recent and Earlier cohorts was evaluated. Results: Of the 3,013 patients who turned 19 in 2010-12, 2,829 were matched. Median time to disenrollment was 26 months (m) compared to 22 m among patients who turned 19 in 2007-09 (HR 0.88, 95% CI 0.81-0.95, p = 0.0009). In the 4,489 pairs of patients who turned 19 between 2001-06, median time to disenrollment was 20 m among both the younger and older patients in the pair (p = 0.047). In grouped analyses, the difference-in-difference between the Recent and Earlier sets of pairs displayed a 14% reduction in the hazard for losing coverage (p < 0.0001), favoring those who turned 19 after DCP became available. Conclusions: In pediatric cancer patients and survivors, a vulnerable population that needs continuous insurance coverage, these data suggest that the DCP of the ACA lowers the insurance drop-out rate.

HSR19-090: Changes in Adherence to Tyrosine Kinase Inhibitor Treatment Patterns Among Patients With Chronic Myeloid Leukemia and the Impact on Costs: 2001–2017

Background: Chronic myeloid leukemia (CML) treatment improved considerably after introduction of oral tyrosine kinase inhibitors (TKI). As a result, the number of patients living with CML may reach 250,000 by 2040. We track changes in TKI treatment adherence since 2001 and provide an early assessment of treatment costs following the availability of second-generation TKIs and generic imatinib. Methods: A retrospective cohort from the OptumLabs Data Warehouse, which includes claims data for privately insured and Medicare Advantage (MA) enrollees in a large private U.S. health plan with medical and pharmacy benefits, was used. Patients with CML initiated TKI treatment between May 2001 and October 2016 and were continuously enrolled in the health plan 6 months prior through 12 months following TKI start. Adherence was defined by medication possession ratio (MPR1=total days’ supply of imatinib in 1st year divided by 365, 1=perfect adherence). Total health care costs include medical and prescription medication benefits. MPR1 was modeled using ordinary least squares regression. The association between MPR1 and healthcare costs was estimated using a generalized linear model specified with a gamma error distribution and a log link. Results: We identified 1,793 eligible patients. First-line TKI has changed over time (dasatinib and nilotinib represent 45% of all 2016 starts; imatinib 55%). From 2001 to 2016, adherence increased (Table 1). MPR1 was higher in men and increased with age until age ∼62 after which it declined. MPR1 was lower for patients with more comorbid conditions prior to treatment. Overall, MPR1 was inversely associated with total health care costs (medical and pharmacy) among privately insured (P<.001) but not MA enrollees. The net impact of MPR1 on total healthcare costs diminished over time (P<.001) where a 10% point decrease in MPR1 was associated with 12% and 4% lower total costs, prior to and following availability of 2nd generation TKIs, respectively. When examining medical costs only, MPR1 was inversely associated with medical costs for both privately insured (P<.001) and MA enrollees (P=.016). Conclusions: We found that adherence to TKI treatment increased over time. While imatinib is still used more frequently than other TKIs as first-line therapy, second-generation TKIs are becoming increasingly used as first-line agents. Possible cost-offsets are decreasing over time but it may be too early to formally evaluate the impact of generic imatinib.

[Optimization of criteria for activation of trauma teams : Avoidance of overtriage and undertriage]

INTRODUCTION

Severely injured patients are supposed to be admitted to hospital via the trauma room. Appropriate criteria are contained in the S3 guidelines on the treatment of patients with severe/multiple injuries (S3-GL); however, some of these criteria require scarce hospital resources while the patients then often clinically present as uninjured. There are tendencies to streamline the trauma team activation criteria (TTAC); however, additional undertriage must be avoided. A study group of the emergency, intensive care medicine and treatment of the severely injured section (NIS) is in the process of optimizing the TTAC for the German trauma system.

MATERIAL AND METHODS

In order to solve the objective the following multi-step approach is necessary: a) definition of patients who potentially benefit from TTA, b) verification of the definition in the TraumaRegister DGU® (TR-DGU), c) carrying out a prospective, multicenter study in order to determine overtriage and undertriage, thereby validating the activation criteria and d) revision of the current TTAC.

RESULTS

This article summarizes the consensus criteria of the group assumed to be capable of identifying patients who potentially benefit from TTA. These criteria are used to test if TTA was justified in a specific case; however, as the TTCA of the S3-GL are not fully incorporated into the TR-DGU dataset and because cases must also be considered which were not subject to trauma room treatment and therefore were not included in the TR-DGU, it is necessary to perform a prospective full survey of all individuals in order to be able to measure overtriage and undertriage.

CONCLUSION

Currently, the TR-DGU can only provide limited evidence on the quality of the TTAC recommended in Germany. This problem has been recognized and will be solved by conducting a prospective DGU-supported study, the results of which can be used to improve the TR-DGU dataset in order to enable further considerations on the quality of care (e. g. composition and size of the trauma team).

Genome-based analysis of Carbapenemase-producing Klebsiella pneumoniae isolates from German hospital patients, 2008-2014

Background

By using whole genome sequence data we aimed at describing a population snapshot of carbapenemase-producing K. pneumoniae isolated from hospitalized patients in Germany between 2008 and 2014.

Methods

We selected a representative subset of 107 carbapenemase-producing K. pneumoniae clinical isolates possessing the four most prevalent carbapenemase types in Germany (KPC-2, KPC-3, OXA-48, NDM-1). Isolates were processed via illumina NGS. Data were analysed using different SNP-based mapping and de-novo assembly approaches. Relevant information was extracted from NGS data (antibiotic resistance determinants, wzi gene/cps type, virulence genes). NGS data from the present study were also compared with 238 genome data from two previous international studies on K. pneumoniae.

Results

NGS-based analyses revealed a preferred prevalence of KPC-2-producing ST258 and KPC-3-producing ST512 isolates. OXA-48, being the most prevalent carbapenemase type in Germany, was associated with various K. pneumoniae strain types; most of them possessing IncL/M plasmid replicons suggesting a preferred dissemination of blaOXA-48 via this well-known plasmid type. Clusters ST15, ST147, ST258, and ST512 demonstrated an intermingled subset structure consisting of German and other European K. pneumoniae isolates. ST23 being the most frequent MLST type in Asia was found only once in Germany. This latter isolate contained an almost complete set of virulence genes and a K1 capsule suggesting occurrence of a hypervirulent ST23 strain producing OXA-48 in Germany.

Conclusions

Our study results suggest prevalence of "classical" K. pneumonaie strain types associated with widely distributed carbapenemase genes such as ST258/KPC-2 or ST512/KPC-3 also in Germany. The finding of a supposed hypervirulent and OXA-48-producing ST23 K. pneumoniae isolates outside Asia is highly worrisome and requires intense molecular surveillance.

A paternal methyl donor-rich diet altered cognitive and neural functions in offspring mice

Dietary intake of methyl donors, such as folic acid and methionine, shows considerable intra-individual variation in human populations. While it is recognized that maternal departures from the optimum of dietary methyl donor intake can increase the risk for mental health issues and neurological disorders in offspring, it has not been explored whether paternal dietary methyl donor intake influences behavioral and cognitive functions in the next generation. Here, we report that elevated paternal dietary methyl donor intake in a mouse model, transiently applied prior to mating, resulted in offspring animals (methyl donor-rich diet (MD) F1 mice) with deficits in hippocampus-dependent learning and memory, impaired hippocampal synaptic plasticity and reduced hippocampal theta oscillations. Gene expression analyses revealed altered expression of the methionine adenosyltransferase Mat2a and BK channel subunit Kcnmb2, which was associated with changes in Kcnmb2 promoter methylation in MD F1 mice. Hippocampal overexpression of Kcnmb2 in MD F1 mice ameliorated altered spatial learning and memory, supporting a role of this BK channel subunit in the MD F1 behavioral phenotype. Behavioral and gene expression changes did not extend into the F2 offspring generation. Together, our data indicate that paternal dietary factors influence cognitive and neural functions in the offspring generation.

Whole Genome Sequence Analysis of CTX-M-15 Producing Klebsiella Isolates Allowed Dissecting a Polyclonal Outbreak Scenario

Extended-spectrum β-lactamase (ESBL) producing Klebsiella pneumoniae pose an important threat of infection with increased morbidity and mortality, especially for immunocompromised patients. Here, we use the rise of multidrug-resistant K. pneumoniae in a German neurorehabilitation center from April 2015 to April 2016 to dissect the benefit of whole genome sequencing (WGS) for outbreak analyses. In total, 53 isolates were obtained from 52 patients and examined using WGS. Two independent analysis strategies (reference-based and -free) revealed the same distinct clusters of two CTX-M-15 producing K. pneumoniae clones (ST15, n = 31; ST405, n = 7) and one CTX-M-15 producing Klebsiella quasipneumoniae strain (ST414, n = 8). Additionally, we determined sequence variations associated with antimicrobial resistance phenotypes in single isolates expressing carbapenem and colistin resistance, respectively. For rapid detection of the major K. pneumoniae outbreak clone (ST15), a selective triplex PCR was deduced from WGS data of the major outbreak strain and K. pneumoniae genome data deposited in central databases. Moreover, we introduce two novel open-source applications supporting reference genome selection (refRank; https://gitlab.com/s.fuchs/refRank) and alignment-based SNP-filtering (SNPfilter; https://gitlab.com/s.fuchs/snpfilter) in NGS analyses.

Patterns and predictors of lipid-lowering therapy in patients with atherosclerotic cardiovascular disease and/or diabetes mellitus in 2014: Insights from a large US managed-care population

BACKGROUND

Lowering low-density lipoprotein cholesterol with statins reduces risk of cardiovascular events. We examined patterns and predictors of filled prescriptions for lipid-lowering therapy (LLT) in subgroups of patients with atherosclerotic cardiovascular disease (ASCVD) and/or diabetes mellitus (DM).

HYPOTHESIS

Statin treatment remains underutilized across subgroups of high CV risk patients.

METHODS

Patients in the Optum Research Database with these criteria were included: age ≥20 years, 2 years continuous enrollment, and ASCVD and/or DM. Patients were hierarchically classified by the presence of recent acute coronary syndrome, other coronary heart disease, ischemic stroke, peripheral arterial disease (PAD), or only DM. Predictors of filled LLT regimens were examined using multinomial logistic regression.

RESULTS

A total of 1 055 932 individuals met all inclusion criteria. Evidence by point-in-time analysis of filled (not only written) statin prescriptions was 45% for the overall cohort. By subgroups, this was 62%, 52%, 43%, 36%, and 40% for recent acute coronary syndrome, other coronary heart disease, ischemic stroke, PAD, and only DM, respectively. Predictors of higher rates of any statin regimen included age 50 to 69 years, male sex, absence of comorbidities, and filled prescriptions of other standard-of-care therapies.

CONCLUSIONS

In 2014, only 49% of patients with ASCVD and 40% with only DM had evidence for a filled statin prescription. Those with indications of ischemic stroke, PAD, and DM were less likely to receive statins than those with coronary conditions. Other characteristics such as advanced age, female sex, and noncardiac conditions predicted less statin utilization, thereby representing good targets for quality improvement.

External validation of a multivariable claims-based rule for predicting in-hospital mortality and 30-day post-pulmonary embolism complications

BACKGROUND

Low-risk pulmonary embolism (PE) patients may be candidates for outpatient treatment or abbreviated hospital stay. There is a need for a claims-based prediction rule that payers/hospitals can use to risk stratify PE patients. We sought to validate the In-hospital Mortality for PulmonAry embolism using Claims daTa (IMPACT) prediction rule for in-hospital and 30-day outcomes.

METHODS

We used the Optum Research Database from 1/2008-3/2015 and included adults hospitalized for PE (415.1x in the primary position or secondary position when accompanied by a primary code for a PE complication) and having continuous medical and prescription coverage for ≥6-months prior and 3-months post-inclusion or until death. In-hospital and 30-day mortality and 30-day complications (recurrent venous thromboembolism, rehospitalization or death) were assessed and prognostic accuracies of IMPACT with 95 % confidence intervals (CIs) were calculated.

RESULTS

In total, 47,531 PE patients were included. In-hospital and 30-day mortality occurred in 7.9 and 9.4 % of patients and 20.8 % experienced any complication within 30-days. Of the 19.5 % of patients classified as low-risk by IMPACT, 2.0 % died in-hospital, resulting in a sensitivity and specificity of 95.2 % (95 % CI, 94.4-95.8) and 20.7 % (95 % CI, 20.4-21.1). Only 1 additional low-risk patient died within 30-days of admission and 12.2 % experienced a complication, translating into a sensitivity and specificity of 95.9 % (95 % CI, 95.3-96.5) and 21.1 % (95 % CI, 20.7-21.5) for mortality and 88.5 % (95 % CI, 87.9-89.2) and 21.6 % (95 % CI, 21.2-22.0) for any complication.

CONCLUSION

IMPACT had acceptable sensitivity for predicting in-hospital and 30-day mortality or complications and may be valuable for retrospective risk stratification of PE patients.

Evaluation of mortality and readmissions following hospitalization with heart failure

OBJECTIVE

To examine the association of patient/clinical characteristics with mortality and readmission following a heart failure (HF)-related hospitalization.

RESEARCH DESIGN AND METHODS

Claims data, linked to laboratory, race/ethnicity, and mortality data, from a large US health plan were utilized to identify individuals with ≥1 inpatient claim with a diagnosis code for HF (1 January 2008-30 September 2012). Study variables were analyzed using descriptive and multivariable approaches to identify patient/clinical characteristics associated with post-discharge outcomes.

MAIN OUTCOME MEASURES

Primary outcomes included post-discharge mortality and readmission.

RESULTS

A total of 126,214 individuals were identified with a HF-related hospitalization; 19.1% with data to calculate chronic kidney disease (CKD) stage. For the overall sample, mortality probability was 4.9% and 13.4% at 1 and 6 months post-discharge, respectively (4.5% and 12.4% for subset with calculated CKD stage), while readmission (all-cause) probability was 14.8% and 39.6% at 1 and 6 months post-discharge, respectively (18.4% and 44.5% for subset with calculated CKD stage). Within the subset with calculated CKD stage, mortality and readmission probabilities differed by CKD stage (p < 0.001), with decreased renal function corresponding with increased risk of mortality and readmission. After multivariable adjustment, increasing age was associated with increased risk of mortality, while advancing CKD stage, various index hospitalization variables (i.e., pre-admission emergency room visit, intensive care unit during hospitalization), and baseline all-cause hospitalization were associated with both increased risk of mortality and all-cause 1 month readmission.

CONCLUSIONS

Calculated CKD, various index hospitalization variables, and baseline all-cause hospitalization were associated with increased risk of mortality and all-cause 1 month readmission among patients hospitalized with HF. Risk of post-discharge readmission and mortality increased with worse renal function, suggesting that improved management of this subset may reduce the burden and cost of this disease. Key study limitations include those related to retrospective claims-based studies and that renal function data were available for a subset of study patients.

Cost and effectiveness of biologics for rheumatoid arthritis in a commercially insured population

BACKGROUND

Administrative claims contain detailed medication, diagnosis, and procedure data, but the lack of clinical outcomes for rheumatoid arthritis (RA) historically has limited their use in comparative effectiveness research. A claims-based algorithm was developed and validated to estimate effectiveness for RA from data for adherence, dosing, and treatment modifications.

OBJECTIVE

To implement the claims-based algorithm in a U.S. managed care database to estimate biologic cost per effectively treated patient.

METHODS

The cohort included patients with RA aged 18-63 years in the Optum Research Database who initiated biologic treatment between January 2007 and December 2010 and were continuously enrolled 6 months before through 12 months after the first claim for the biologic (the index date). Patients were categorized as effectively treated by the claims-based algorithm if they met all of the following 6 criteria in the 12-month post-index period: (1) a medication possession ratio ≥ 80% for subcutaneous biologics, or at least as many infusions as specified in U.S. labeling for intravenous biologics; (2) no increase in biologic dose; (3) no switch in biologics; (4) no new nonbiologic disease-modifying antirheumatic drug; (5) no new or increased oral glucocorticoid treatment; and (6) no more than 1 glucocorticoid injection. Drug costs (all biologics) and administration costs (intravenous biologics) were obtained from allowed amounts on claims. Biologic cost per effectively treated patient was defined as total 1-year biologic cost divided by the number of patients categorized by the algorithm as effectively treated with that index biologic. Sensitivity analysis was conducted to examine the total health care costs per effectively treated patient during the first year of biologic therapy.

RESULTS

A total of 5,474 individuals were included in the analysis. The index biologic was categorized as effective by the algorithm for 28.9% of patients overall, including 30.6% for subcutaneous biologics and 22.1% for intravenous biologics. The index biologic was categorized as effective in the first year for 32.7% of etanercept (794/2,425), 32.3% of golimumab (40/124), 30.2% of abatacept (89/295), 27.7% of adalimumab (514/1,857), and 19.0% of infliximab (147/773) patients. Mean 1-year biologic cost per effectively treated patient, as defined in the algorithm, was lowest for etanercept ($43,935), followed by golimumab ($49,589), adalimumab ($52,752), abatacept ($62,300), and infliximab ($101,402). The rank order in the sensitivity analysis was the same, except for golimumab and etanercept. 

CONCLUSIONS

Using a claims-based algorithm in a large commercial claims database, etanercept was the most effective and had the lowest biologic cost per effectively treated patient with RA.