Cost of Hospitalization Associated with Inpatient Goals-of-Care Program Implementation at a Comprehensive Cancer Center: A Propensity Score Analysis

The impact of goals-of-care programs on acute hospitalization costs is unclear. We compared the hospitalization cost in an 8-month period before implementation of a multimodal interdisciplinary goals-of-care program (1 May 2019 to 31 December 2019) to an 8-month period after program implementation (1 May 2020 to 31 December 2020). Propensity score weighting was used to adjust for differences in potential covariates. The primary outcome was total direct cost during the hospital stay for each index hospitalization. This analysis included 6977 patients in 2019 and 5964 patients in 2020. The total direct cost decreased by 3% in 2020 but was not statistically significant (ratio 0.97, 95% CI 0.92, 1.03). Under individual categories, there was a significant decrease in medical oncology (ratio 0.58, 95% CI 0.50, 0.68) and pharmacy costs (ratio 0.86, 95% CI 0.79, 0.96), and an increase in room and board (ratio 1.06, 95% CI 1.01, 1.10). In subgroup analysis, ICU patients had a significant reduction in total direct cost after program implementation (ratio 0.83, 95% CI 0.72, 0.94). After accounting for the length of ICU admission, we found that the total direct cost per hospital day was no longer different between 2019 and 2020 (ratio 0.986, 95% CI 0.92, 1.05), suggesting that shorter ICU admissions likely explained much of the observed cost savings. This study provides real-world data on how "in-the-moment" GOC conversations may contribute to reduced hospitalization costs among ICU patients.

Enhancing implementation of the I-PASS Handoff Tool Using a Provider Handoff Task Force at a Comprehensive Cancer Center

BACKGROUND

Communication failures are among the most common causes of harmful medical errors. At one Comprehensive Cancer Center, patient handoffs varied among services. The authors describe the implementation and results of an Organization-wide project to improve handoffs and implement an evidence-based handoff tool across all inpatient services.

METHODS

The research team created a task force composed of members from 22 hospital services-advanced practice providers (APPs), trainees, some faculty members, electronic health record (EHR) staff, education and training specialists, and nocturnal providers. Over two years, the task force expanded to include consulting services and Anesthesiology. Factors contributing to ineffective handoffs were identified and organized into categories. The EHR I-PASS tool was used to standardize handoff documentation. Training was provided to staff on its use, and compliance was monitored using a customized dashboard. I-PASS champions in each service were responsible for the rollout of I-PASS in their respective services. The data were reported quarterly to the Quality Assessment and Performance Improvement (QAPI) governing committee. Provider handoff perception was assessed through the biennial Institution-wide safety culture survey.

RESULTS

All fellows, residents, APPs, and physician assistants were trained in the use of I-PASS, either online or in person. Adherence to the I-PASS written tool improved from 41.6% in 2019 to 70.5% in 2022 (p < 0.05), with improvements seen in most services. The frequency of updating I-PASS elements and the action list in the handoff tool also increased over time. The handoff favorability score on the safety culture survey improved from 38% in 2018 to 59% in 2022.

CONCLUSION

The implementation approach developed by the Provider Handoff Task Force led to increased use of the I-PASS EHR tool and improved safety culture survey handoff favorability.

The impact of a multidisciplinary goals-of-care program on unplanned readmission rates at a comprehensive cancer center

PURPOSE

This study examined the 30-day unplanned readmission rate in the medical oncology population before and after the implementation of an institution-wide multicomponent interdisciplinary goals of care (myGOC) program.

METHODS

This retrospective study compared the 30-day unplanned readmission rates in consecutive medical patients during the pre-implementation period (May 1, 2019, to December 31, 2019) and the post-implementation period (May 1, 2020, to December 31, 2020). Secondary outcomes included 7-day unplanned readmission rates, inpatient do-not-resuscitate (DNR) orders, and palliative care consults. We randomly selected a hospitalization encounter for each unique patient during each study period for statistical analysis. A multivariate analysis model was used to examine the association between 30-day unplanned readmission rates and implementation of the myGOC program.

RESULTS

There were 7028 and 5982 unique medical patients during the pre- and post-implementation period, respectively. The overall 30-day unplanned readmission rate decreased from 24.0 to 21.3% after implementation of the myGOC program. After adjusting for covariates, the myGOC program implementation remained significantly associated with a reduction in 30-day unplanned readmission rates (OR [95% CI] 0.85 [0.77, 0.95], p = 0.003). Other factors significantly associated with a decreased likelihood of a 30-day unplanned readmission were an inpatient DNR order, advanced care planning documentation, and an emergent admission type. We also observed a significant decrease in 7-day unplanned readmission rates (OR [95% CI] 0.75 [0.64, 0.89]) after implementation of the myGOC program.

CONCLUSION

The 30-day and 7-day unplanned readmission rates decreased in our hospital after implementation of a system-wide multicomponent GOC intervention.

Healthcare resource use and costs of varicella and its complications: A systematic literature review

Varicella is a highly contagious disease caused by the varicella zoster virus (VZV). While the disease is usually mild, severe complications can occur requiring costly hospitalization. A thorough understanding of the healthcare resource use (HCRU) and costs of varicella is needed to inform health-economic models of preventive strategies. A systematic literature review was carried out to retrieve relevant publications between 1999 and 2021, reporting HCRU and cost outcomes for varicella and its complications. Data were extracted and stratified according to pre-specified age groups and complication categories. Costs were re-based to a $US2020 footing using both purchasing power parity and the medical component of consumer price indexes. Data were summarized descriptively due to high heterogeneity in study design and outcome reporting. Forty-four publications fulfilled the inclusion and exclusion criteria of which 28 were conducted in Europe, 6 in Middle East and Asia, 5 in South America, 3 in North America, and 2 in multiple regions. Primary healthcare visits accounted for 30% to 85% of total direct costs. Hospitalization costs varied between $1,308 and $38,268 per episode depending on country, complication type, and length of stay, contributing between 2% and 60% to total direct costs. Indirect costs, mostly driven by workdays lost, accounted for approximately two-thirds of total costs due to varicella. The management of varicella and related complications can lead to substantial HCRU and costs for patients and the healthcare system. Additional research is needed to further characterize the varicella-associated economic burden and its broader impact from a societal standpoint.

The importance of facilitating goal-concordant care (GCC) in a pandemic: the MD Anderson Experience with hospitalized COVID-19-positive patients

PURPOSE

Provider-patient communication (PPC) about goals of care (GOC) facilitates goal-concordant care (GCC) delivery. Hospital resource limitations imposed during the pandemic made it vital to deliver GCC to a patient cohort with COVID-19 and cancer. We aimed to evaluate the implementation of a real-time goals of care intervention and to make recommendations for future pandemics with similar clinical scenarios.

METHODS

This is a retrospective cohort study, of all COVID-19 positive patients admitted to The University of Texas MD Anderson Cancer Center between March of 2020 and January of 2021. The cohort included the following: (1) patients 18 years of age or older; (2) positive COVID-19 infection; (3) requiring hospitalization. Medical records were reviewed and all patient data including demographics, comorbidities, and outcomes were collected and analyzed in the Syntropy platform, Palantir Foundry, as part of the institutional Data-Driven Determinants of COVID-19 Oncology Discovery Effort (D3CODE) protocol. A multidisciplinary GOC task force developed processes for ease of conducting GOC-PPC and implemented structured documentation. We looked at ACP documentation pre- and post-implementation alongside demographics, length of stay (LOS), 30-day readmission rate and mortality.

RESULTS

There were 494 unique patients identified, 53% male, 61.5% Caucasian, 16.8% African American, and 3.2% Asian. Active cancer was identified in 84.6% patients, of which 65.6% were solid tumors and 34.4% hematologic malignancies. LOS was 9 days with a 30-day readmission rate of 15% and inpatient mortality of 14%. Inpatient ACP note documentation was significantly higher post-implementation as compared to pre-implementation (90% vs 8%, P<0.05). We saw sustained ACP documentation throughout the pandemic suggesting effective processes.

CONCLUSIONS

The implementation of institutional structured processes for GOC-PPC resulted in rapid sustainable adoption of ACP documentation for COVID-19-positive cancer patients. This was highly beneficial for this population during the pandemic, as it demonstrated the role of agile processes in care delivery models, which will be beneficial in the future when rapid implementation is needed.

Improving handoff with the implementation of I-PASS at a tertiary oncology hospital

BACKGROUND

Lack of consistent and standardised handoffs is a leading cause of patient harm. With increased census in our hospital medicine (HM) service, failure to handoff using a standardised method has the potential to cause significant patient harm. We used a quality improvement methodology to standardise an existing and validated handoff tool within our HM team to improve handoff communication among providers and improve patient safety.

METHODS

A quality improvement team was charged with studying handoff communication among HM teams and between day and night shift providers at a tertiary oncology hospital. Multiple plan-do-study-act cycles were conducted, and process flow maps, root cause analysis and an affinity diagram were developed based on feedback from the HM team. The quality improvement team developed a plan to implement I-PASS (Illness severity, Patient summary, Action list, Situation awareness and contingency plan, and Synthesis by receiver) as the standardised handoff tool to be used among the providers in HM at the end of shift and for handoff to the nocturnal covering service. Rates of I-PASS use were collected before and after several educational interventions to encourage use of I-PASS and were displayed in a control chart. After the I-PASS interventions, HM providers were surveyed twice to evaluate the secondary outcomes: the tool's impact on workflow, perceptions of patient safety, ease of use and satisfaction with I-PASS. Survey results were compared using Fisher exact tests.

RESULTS

The HM team's rate of use of I-PASS handoffs increased from 23% to 72%, an improvement of 68%. By the end of the quality improvement project, I-PASS use had increased to 90%. No significant differences were detected in the reported duration of handoffs after I-PASS implementation (on average <5 min per patient, p=0.205). Provider perceptions of handoff quality, efficiency, communication errors and the I-PASS tool's effectiveness were satisfactory.

CONCLUSION

We used a quality improvement methodology to encourage the HM team's adoption of a validated handoff tool. Adherence to the standardised handoff tool significantly improved workflows and facilitated communication between the day and night shift teams.

Combined petrosal approach: a systematic review and meta-analysis of surgical complications

Transpetrosal approaches are known to be associated with a significant risk of complications, including CSF leak, facial palsy, hearing impairment, venous injury, and/or temporal lobe injury. We aimed to evaluate the morbidity of the standard combined petrosal approach (CPA), defined as a combination of the posterior (retrolabyrinthine) and the anterior petrosal approach. We performed a systematic review and meta-analysis of articles reporting on clinical series of patients operated on for petroclival meningiomas through CPA. Studies that used the terminology "combined petrosal approach" without matching the aforementioned definition were excluded as well as clinical series that included less than 5 patients. A total of 8 studies were included involving 160 patients. The pooled complication rates were 3% (95% CI, 0.5-5.6) for CSF leak, 8.6% (95% CI, 4.1-13.2%) for facial palsy, 8.2% (95% CI, 3.9-12.6%) for hearing impairment, 2.8% (95% CI, 0.9-6.5%) for venous complications, and finally 4.8% (95%, 1.2-8.4%) for temporal lobe injury. Contrary to the general belief, CPA is associated with an acceptable rate of complications, especially when compared to alternative approaches to the petroclival area. In view of the major advantages like shorter trajectory, multiple angles of surgical attack, and early tumor devascularization, CPA remains an important tool in the armamentarium of the skull base surgeon.

The Importance of Facilitating Goal-Concordant Care (GCC) in a Pandemic: The MD Anderson Experience with hospitalized COVID-19 positive patients

Purpose

Provider-patient communication (PPC) about goals of care (GOC) facilitates goal-concordant care (GCC) delivery. Hospital resource limitations imposed during the pandemic made it vital to deliver GCC to a patient cohort with COVID-19 and cancer. Our aim was to understand the population and adoption of GOC-PPC along with structured documentation in the form of an Advance Care Planning (ACP) note.

Methods

A multidisciplinary GOC task force developed processes for ease of conducting GOC-PPC and implemented structured documentation. Data were obtained from multiple electronic medical record elements, with each source identified, data integrated and analyzed. We looked at PPC and ACP documentation pre and post implementation alongside demographics, length of stay (LOS), 30-day readmission rate and mortality.

Results

494 unique patients were identified, 52% male, 63% Caucasian, 28% Hispanic, 16% African American and 3% Asian. Active cancer was identified in 81% patients, of which 64% were solid tumors and 36% hematologic malignancies. LOS was 9 days with a 30-day readmission rate of 15% and inpatient mortality of 14%. Inpatient ACP note documentation was significantly higher post-implementation as compared to pre-implementation (90% vs 8%, P < 0.05). We saw sustained ACP documentation throughout the pandemic suggesting effective processes.

Conclusions

The implementation of institutional structured processes for GOC-PPC resulted in rapid sustainable adoption of ACP documentation for COVID-19 positive cancer patients. This was highly beneficial for this population during the pandemic, as it demonstrated the role of agile processes in care delivery models, which will be beneficial in the future when rapid implementation is needed.

Nosocomial COVID-19 at a comprehensive cancer center during the first year of the pandemic: Lessons learned

BACKGROUND

The spread of coronavirus disease 2019 (COVID-19) in health care settings endangers patients with cancer. As knowledge of the transmission of COVID-19 emerged, strategies for preventing nosocomial COVID-19 were updated. We describe our early experience with nosocomial respiratory viral infections (RVIs) at a cancer center in the first year of the pandemic (March 2020-March 2021).

METHODS

Nosocomial RVIs were identified through our infection control prospective surveillance program, which conducted epidemiologic investigations of all microbiologically documented RVIs. Data was presented as frequencies and percentages or medians and ranges.

RESULTS

A total of 35 of 3944 (0.9%) documented RVIs were determined to have been nosocomial acquired. Majority of RVIs were due to SARS CoV-2 (13/35; 37%) or by rhinovirus/enterovirus (12/35; 34%). A cluster investigation of the first 3 patients with nosocomial COVID-19 determined that transmission most likely occurred from employees to patients. Five patients (38%) required mechanical ventilation and 4 (31%) died during the same hospital encounter.

CONCLUSIONS

Our investigation of the cluster led to enhancement of our infection control measures. The implications of COVID-19 vaccination on infection control policies is still unclear and further studies are needed to delineate its impact on the transmission of COVID-19 in a hospital setting.

Reduced reactogenicity of primary vaccination with DT3aP-HBV-IPV/Hib compared with DT2aP-HBV-IPV-Hib among infants: Mathematical projections in six countries

The hexavalent vaccines DT3aP-HBV-IPV/Hib and DT2aP-HBV-IPV-Hib are routinely used for primary immunization of infants against diphtheria, tetanus, pertussis, hepatitis B virus, poliomyelitis, and Haemophilus influenzae type b. A recent publication showed that after primary immunization with these vaccines, the odds ratios of adverse reactions (ARs) were significantly lower for DT3aP-HBV-IPV/Hib than for DT2aP-HBV-IPV-Hib. Our aim is to understand the impact of the various reactogenicity profiles at country level by comparing the ARs induced by one dose of DT3aP-HBV-IPV/Hib versus DT2aP-HBV-IPV-Hib in the primary infant immunization course. A mathematical projection tool was developed to simulate vaccination of infants with both vaccines in six countries: Austria, the Czech Republic, France, Jordan, Spain, and the Netherlands. Proportions of three local and five systemic ARs of interest for both vaccines were based on findings from a previous meta-analysis of ARs in infants. The absolute risk reductions calculated ranged from 3.0% (95% confidence interval [CI]: 2.8%-3.2%) for "Swelling at the injection site, any grade" to 10.0% (95% CI: 9.5%-10.5%) for "Fever, any grade." The difference in occurrence of the AR "Fever, any grade" between vaccines in 2020 ranged from over 7,000 in Austria to over 62,000 in France. Over 5 years, this would amount to a reduction of over 150,000 ARs in Austria and over 1.4 million ARs in France when using DT3aP-HBV-IPV/Hib instead of DT2aP-HBV-IPV-Hib. In conclusion, the estimated numbers of ARs following hexavalent vaccination in six countries showed that vaccination of infants with DT3aP-HBV-IPV/Hib could lead to fewer ARs than vaccination with DT2aP-HBV-IPV-Hib.

Impact of an Interdisciplinary Goals-of-Care Program Among Medical Inpatients at a Comprehensive Cancer Center During the COVID-19 Pandemic: A Propensity Score Analysis

PURPOSE

Many hospitals have established goals-of-care programs in response to the coronavirus disease 2019 pandemic; however, few have reported their outcomes. We examined the impact of a multicomponent interdisciplinary goals-of-care program on intensive care unit (ICU) mortality and hospital outcomes for medical inpatients with cancer.

METHODS

This single-center study with a quasi-experimental design included consecutive adult patients with cancer admitted to medical units at the MD Anderson Cancer Center, TX, during the 8-month preimplementation (May 1, 2019-December 31, 2019) and postimplementation period (May 1, 2020-December 31, 2020). The primary outcome was ICU mortality. Secondary outcomes included ICU length of stay, hospital mortality, and proportion/timing of care plan documentation. Propensity score weighting was used to adjust for differences in potential covariates, including age, sex, cancer diagnosis, race/ethnicity, and Sequential Organ Failure Assessment score.

RESULTS

This study involved 12,941 hospitalized patients with cancer (pre n = 6,977; post n = 5,964) including 1,365 ICU admissions (pre n = 727; post n = 638). After multicomponent goals-of-care program initiation, we observed a significant reduction in ICU mortality (28.2% v 21.9%; change -6.3%, 95% CI, -9.6 to -3.1; P = .0001). We also observed significant decreases in length of ICU stay (mean change -1.4 days, 95% CI, -2.0 to -0.7; P < .0001) and in-hospital mortality (7% v 6.1%, mean change -0.9%, 95% CI, -1.5 to -0.3; P = .004). The proportion of hospitalized patients with an in-hospital do-not-resuscitate order increased significantly from 14.7% to 19.6% after implementation (odds ratio, 1.4; 95% CI, 1.3 to 1.5; P < .0001), and do-not-resuscitate order was established earlier (mean difference -3.0 days, 95% CI, -3.9 to -2.1; P < .0001).

CONCLUSION

This study showed improvement in hospital outcomes and care plan documentation after implementation of a system-wide, multicomponent goals-of-care intervention.

The Impact of Living with INOCA

Background

There is limited literature available on the impact of myocardial ischemia but no obstructive coronary arteries (INOCA) on patients' lives.

Purpose

We sought to determine how INOCA impacts the physical, social, and mental health of persons with this diagnosis.

Methods

A survey was made available to all members of the patient support group from INOCA International over a 3-month time period. Fitness was estimated using the Duke Activity Status Index (DASI), assessing levels of activities performed prior to the onset of INOCA symptoms, and after the diagnosis of INOCA. The formula to estimate fitness in metabolic equivalents (METs) = 0.43 × DASI + 9.6 / 3.5

Results

A total of 297 patients with INOCA responded to the survey; 91.2% were women. The most common diagnosis was coronary microvascular dysfunction (64.3%) and coronary artery spasm (50.5%) (Table 1). 34.4% reported living with symptoms for ≥3 years before their diagnosis of INOCA was made. 77.8% who had been told their symptoms were not cardiac. The symptoms the respondents experienced were numerous, but 92.9% reported symptoms of chest pain, pressure, or discomfort. Fitness levels prior to the onset of INOCA symptoms were significantly higher compared to after diagnosed with INOCA (8.6±1.8 METs vs 5.6±1.8 METs; P&lt;0.0001). Most respondents reported an adverse impact on their home life (80.5%), social life (80.1%), mental health (70.4%), outlook on life (69.7%), sex life (55.9%), and their partner/spouse relationship (53.9%). Work life was also affected once living with INOCA: approximately three-quarters had reduced their work hours or stopping work completely, 47.5% retired early, and 38.4% applied for disability. While living with INOCA, for each 1-MET decrease in fitness, there was a loss of 3.0±0.6 days/months of physical health, 1.8±0.6 days/month of mental health, and 2.9±0.7 days/months of inability to perform recreational activities (p&lt;0.0001) (Figure 1).

Conclusions

Living with INOCA has significant impact on physical, mental and social health. Significant physical fitness declines are seen in those living with INOCA and are lower in those experiencing any adverse impact of living with INOCA. Additionally, the impact of INOCA on the ability to work has important economic consequences to both the patient and society. Increased recognition of the impact of INOCA on these aspects of health need to be recognized and further work is needed to better diagnosis and treat the symptoms of INOCA to improve the quality of life, cardiovascular outcomes, and overall health of this frequently encountered cardiovascular disorder.

Funding Acknowledgement

Type of funding sources: None.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Hospitalization characteristics and outcomes of patients with cancer and COVID-19 at a comprehensive cancer center

PURPOSE

Several studies have confirmed increased mortality among patients with both COVID-19 and cancer. It remains important to continue to report observations of morbidity and mortality from COVID-19 in this vulnerable population. The purpose of this study is to describe the hospitalization characteristics and outcomes of patients with both cancer and COVID-19 admitted to our comprehensive cancer center.

METHODS

This was a descriptive study of the first COVID-19-related hospitalization among adult patients with cancer admitted to our institution. Descriptive statistics were used to summarize patient demographics, clinical as well as hospitalization characteristics. Overall survival (OS) was estimated using the Kaplan-Meier method.

RESULTS

A total of 212 patients were included in our cohort with a mean age of 59 years. Fifty-four percent of patients had history of solid tumor malignancy and 46% had hematologic malignancies. Eighty-five percent of our cohort had active malignancy. The mean length of stay (LOS) for hospitalization was 11.2 days (median LOS of 6 days). Twenty-five percent had severe disease and 10.8% died during their initial hospitalization. Those who had severe disease had worse survival at the end of the observation period.

CONCLUSIONS

COVID-19 among cancer patients causes significant morbidity and mortality as well as repeat hospitalizations. Continued study of COVID-19 in this vulnerable population is essential in order to better inform evolving treatment algorithms, public health policies, and infection control protocols, especially for institutions caring for patients with cancer.

POS0656 FRAILTY AND RISK OF ADVERSE OUTCOMES IN BIOLOGIC OR TARGETED-SYNTHETIC DMARD TREATED PATIENTS WITH RHEUMATOID ARTHRITIS

Background

Recently, it has been recognized that frailty and pre-frailty are common in patients with rheumatoid arthritis (RA) [1]. Whether frailty status portends an increased risk of adverse outcomes in patients with RA on biologic or targeted synthetic disease modifying anti-rheumatic drugs (b- or tsDMARDs) remains unknown.

Objectives

To evaluate the association between frailty and adverse outcomes in patients with RA exposed to b- or tsDMARDs.

Methods

Using the IBM/Watson MarketScan Commercial Claims and Encounters Databases, we identified all patients with RA who filled new prescriptions (or received infusions) for TNFα antagonists (TNFi), non-TNFi biologics (rituximab, abatacept, tocilizumab) or Janus Kinase inhibitors (JAKi) between 2008-2019. We used a 1-year lookback period without the use of these drugs to identify new users. The date of the first prescription within these three drug categories was the index date. Patients’ frailty risk score was calculated using the Claims-Based Frailty Index (CFI) [2], which estimates a deficit-accumulation frailty index using International Classification of Diseases codes, Current Procedural Terminology codes, and Healthcare Common Procedure Coding System codes in administrative claims data in the 1-year baseline period. The index ranges from 0 (not at all frail) to 1 (severely frail). The primary outcome was time to serious infections (those requiring hospitalization); secondary outcomes: any infection (outpatient or inpatient encounters) and all-cause hospitalizations.

Patients were followed until 1) outcome occurrence; 2) disenrollment; 3) >90 days elapsed (or >180 days for rituximab) without further fills of the first drug categories; 4) they filled/received infusions of b-/tsDMARDs from a different drug category; or 5) 2 years after index. Cox proportional hazards adjusting for demographics, calendar year, serious and/or opportunistic infections in the 12-months prior to index were used to estimate the adjusted hazard ratios (aHR) and 95% confidence intervals (CIs) for each outcome. In separate model, we additionally adjusted for comorbidity burden, and health care utilization (HCU).

Results

A total of 62,246 patients with RA met our inclusion criteria of whom 50,910 (82%) started TNFi as their first biologic, 9525 (15%) non-TNFi biologics, and 1811 (3%) JAKi. Among these, 3928 (6%) were considered frail. In multivariable analyses, frail patients had higher risk of serious infections compared to non-frail patients (aHR 2.37, 95% CI 2.05-2.74) which decreased to aHR 1.34, 95% CI 1.13-1.58 (Table 1) after adjusting for comorbidity burden and the HCU. Similarly, frailty was associated with increased risk of any infection (aHR 1.18, 95% CI 1.11-1.25), and all-cause hospitalizations (aHR 1.34, 95% CI 1.21-1.49) relative to non-frail individuals.

Table 1.

Multivariable models evaluating the association between frailty status and inpatient infections as the outcome

Variable#Hazard Ratio (95% Confidence Interval)@Hazard Ratio (95% Confidence Interval)Frail2.37 (2.05, 2.74)1.34 (1.13, 1.58)

#Model adjusts for age, sex, major infection requiring inpatient admission in 12 months prior, concomitant baseline drugs such as csDMARDs, glucocorticoids, NSAIDs and opioids

@Model additionally adjusts for Chalrson comorbidy score and healthcare utilization

Conclusion

Frailty is an important predictor for the risk of adverse outcomes among patients with RA treated with b- or tsDMARDs. Our findings underscore the need for considering this parameter in patient evaluations (even among younger patients) in the clinic.

References

[1]Salaffi F et al: Prevalence of frailty and its associated factors in patients with rheumatoid arthritis: a cross-sectional analysis. Clin Rheumatol 2019

[2]Kim DH et al. Validation of a Claims-Based Frailty Index Against Physical Performance and Adverse Health Outcomes in the Health and Retirement Study. J Gerontol A Biol Sci Med Sci 2019

Acknowledgements

I have no acknowledgements to declare.

Disclosure of Interests

None declared

POS1564-PARE EDUCATION TOPICS AND SMARTPHONE APP FUNCTIONS PRIORITIZED BY PEOPLE WITH RHEUMATIC AND MUSCULOSKELETAL DISEASES

Background

Generating information that people living with a rheumatic and musculoskeletal disease (RMD) find useful while making decisions about their treatment requires identifying and understanding educational needs and interests directly expressed from people living with RMD.

Objectives

To identify what types of information US adults with RMD perceive as important to know about their disease and how they express and prioritize such information.

Methods

Using nominal group technique, focus groups of participants (pts) with RMD generated sets of rank-order educational items which were then aggregated across groups into themes. Based on nominal group results, a survey with the final 28 items was administered online, along with a question about desired functions of a smartphone app for RMD, to members of the ArthritisPower registry in January 2022.

Results

Six nominal groups (n=47) yielded 28 unique items for the online survey of educational priorities. To date, a total of 570 pts completed the survey, of whom 85.4% were female, 89.5% white, mean age of 59.6 (SD 11.2) years. Rheumatoid arthritis (52.5%), osteoarthritis (16.0%), psoriatic arthritis (12.5%), and axial spondyloarthritis (7.5%) were the most common RMDs. Knowing how to tell when a medication is not working, how RMD affects other medical conditions, understanding the results of tests used to monitor their RMD, available treatment options and possible side effects, and how life will change as an RMD progresses were each items that > 75% of pts considered extremely important (Table 1). Top functions pts listed as useful for a smartphone app included being able to participate in research, view lab results, record symptoms or flares, share how they are doing with their provider, and get educational information about their disease (Table 2).

Table 1.

Top Education Topics Adults with Rheumatic and Musculoskeletal Disease Consider Extremely Important (N=570).

Itemn (%)Knowing when the medication is not working505 (88.6)Knowing how a rheumatologic condition can affect your other health conditions or medical issues481 (84.4)Understanding the results of tests used to monitor your condition471 (82.6)Knowing the side effects of available drugs, and how the drugs interact with each other461 (80.9)Finding the right rheumatologist453 (79.5)Having realistic expectations of the effectiveness of the medications445 (78.1)Knowing how the disease will progress, even if the news is bad439 (77.0)Knowing the available medications and treatments for your rheumatologic condition437 (76.7)Knowing how long it takes drugs to work436 (76.5)Understanding how your life will change as your disease progresses434 (76.1)Table 2.

Desired Smartphone App Functions Rated By Adults with Rheumatic and Musculoskeletal Disease (N=570).

App Functionn (%)Participate in patient-centered research299 (52.5)View my lab results283 (49.7)Record my symptoms (e.g. pain, fatigue) or disease flares to track my health over time278 (48.8)Record my symptoms and share how I am doing with my rheumatology provider to know if I am meeting my treatment goals230 (40.4)Get educational information about my disease225 (39.5)Keep track of the medications prescribed by doctor200 (35.1)Schedule and keep track of my medical appointments, rheumatology and other199 (34.9)Track the vaccines I get (i.e. vaccination record)188 (33.0)Help me improve some of my health habits (e.g. sleep, diet, exercise)187 (32.8)Keep track of my use of over-the-counter, complementary or alternative therapies (herbs, tinctures, acupuncture, massage, stretching, etc.)174 (30.5)Get support for my disease from trained patients with my same health condition (i.e. ‘peer coaching’)144 (25.3)

Conclusion

People with RMD prioritized information about medications and prognosis in educational materials, providing guidance for the development of educational tools. A sizeable minority felt educational materials were an important component of a smartphone app, but also identified other important features such as participation in research.

Disclosure of Interests

W. Benjamin Nowell Grant/research support from: Research support from AbbVie, Amgen, Eli Lilly and Scipher, Kelly Gavigan: None declared, Kimberly Garza: None declared, Alexis Ogdie: None declared, Michael George: None declared, Jessica A. Walsh Consultant of: AbbVie, Amgen, Eli Lilly and Company, Janssen, Novartis, Pfizer, and UCB, Grant/research support from: AbbVie, Merck, and Pfizer, Maria Danila: None declared, Shilpa Venkatachalam: None declared, Laura Stradford: None declared, Jeffrey Curtis Consultant of: AbbVie, Amgen, BMS, Corrona, Eli Lilly and Company, Gilead, Janssen, Myriad, Novartis, Pfizer, Regeneron, Roche, and UCB, Grant/research support from: AbbVie, Amgen, BMS, Corrona, Eli Lilly and Company, Janssen, Myriad, Pfizer, Regeneron, Roche, and UCB

P11.03 Sleep analysis of accelerometer data from High Grade Glioma patients in the BrainWear study

BACKGROUND

Sleep disturbance is a common symptom in patients with high grade glioma (HGG). Existing self-reported and uni-dimensional data from questionnaires are of limited value. The observational phase 2 trial, BrainWear (ISRCTN 34351424) provides the first objective analysis of sleep in HGG patients.

MATERIAL AND METHODS

Patients with HGG were asked to wear an AX3 Axivity tri-axial accelerometer throughout treatment. The study employed a wear-as-long-as-possible approach to accelerometry data collection, and we used age-sex matched controls from the UK Biobank as comparators. Baseline was established as a 7 day period of wear prior to surgery or at least 7 days post-surgery. The dataset for this analysis consists of 21 patients with data at baseline and 15 patients during chemo-radiation. Only 16 of the 21 HGG patients at baseline were included for initial comparisons with healthy controls due to age limitations of the UK Biobank cohort for matching. Raw accelerometer data was processed using the GGIR package, with non-imputation of missing data, exclusion of days with &lt;16 hours of wear time and removal of algorithm-identified problematic data. Mann-Whitney U-tests and unpaired T-tests were used to compare 7 sleep-related features between HGG patients and healthy controls at baseline, with choice of statistical test based on shapiro-wilk derived normality. Secondly, to assess changes in sleep in HGG patients across treatment period, K-means clustering of 5 sleep parameters, available longitudinally, was conducted to explore sleep behaviours at baseline (n = 21) and during chemo-radiation.

RESULTS

HGG patients (n = 16) exhibited greater daytime inactivity than healthy controls (n = 32) (p &lt; 0.0001, 2.2 vs 0.5 hrs) and more variation in their 24 hour activity rhythm from day to day (p &lt; 0.0001, 0.12 vs 0.18). We identified 5 sleep features which allowed us to cluster patients’ sleep behaviour, and most (62.5%) of HGG patients have a poor sleep profile. This sleep profile was characterised by an average of 5.4 hours of night-time sleep, 2.1 hours of daytime inactivity and disturbed sleep quality. However, evaluation of HGG patient sleep cluster designation at baseline and during chemoradiation, showed HGG patients with data at both timepoints (n = 9) demonstrate stability or improvement in sleep profile.

CONCLUSION

Patients with HGG have objective evidence of poor sleep compared to healthy matched controls. Further work will explore changes in sleep over time.

Randomized Feasibility Study of Meditative Practices in Hospitalized Cancer Patients

Introduction: There is limited research regarding the benefits of mind-body practices such as meditation in hospitalized patients with an active diagnosis of any cancer type. Methods: We conducted a prospective, randomized, clinical trial (NCT03445572) comparing 2 meditative practices-Isha Kriya (IK) and meditative slow breathing (MSB)-versus wait-list controls in hospitalized cancer patients. Our aim was to determine the feasibility of meditation practice in cancer inpatients. Feasibility was defined as recruitment of more than 50% of the eligible patients approached and at least 60% of the patients having meditated at least 4 days by day 7. Acceptability was assessed on day 7 as a positive response on at least 2 questions on the modified Global Symptom Evaluation (GSE) scale. Results: Forty patients (39% of the eligible patients approached) consented to participate in the study and were randomly assigned to the MSB (n = 13), IK (n = 14), or wait-list (n = 13) groups. Of the 27 patients assigned to receive MSB and IK meditations, day 7 data were available for 18 patients. Fifteen of the 18 patients meditated at least once in the first 7 days, and most (12/15) responded positively on the GSE. Conclusion: Both IK and MSB meditations were acceptable among the hospitalized cancer patients. Feasibility for enrollment and practice was likely not achieved due to limited uninterrupted time for daily meditation, high levels of morbidity in some participants, and limited research staff support. Shorter term outcomes should be explored in future meditation studies involving hospitalized cancer patients.

FRI0572 LEPTIN-ADJUSTMENT OF THE MULTI-BIOMARKER DISEASE ACTIVITY (MBDA) SCORE REDUCES THE INFLUENCE OF ADIPOSITY

Background:

Obesity and excess adiposity influence inflammatory markers and bias disease activity assessment, especially among women. A multi-biomarker disease activity (aMBDA) score has been developed to account for the effects of age, sex and adiposity (leptin) and improves prediction of radiographic damage progression.1

Objectives:

1) Determine if the adjusted measure demonstrates a reduced association with adiposity.

2) Assess the impact of the leptin-adjustment on the score over the range of adiposity.

3) Assess relationships between MBDA scores and clinical disease activity.

Methods:

Patients with rheumatoid arthritis (RA), ages 18-75 years, completed whole-body dual-energy x-ray absorptiometry to quantify fat mass indices (FMI, kg/m2). Age-, sex-, and race-specific Z-Scores were calculated based on the distributions in a healthy reference population. Disease activity was assessed with the CDAI and swollen joint count (SJC). Baseline van der Heijde-Sharpe (vdHS) scores were determined by a radiologist. MBDA assays were performed on stored serum samples. Descriptive statistics described relationships between the FMI Z-Score and the MBDA and the aMBDA. Clinical disease activity, SJC, and radiographic damage were also compared across MBDA score categories.

Results:

Of 104 participants (50% female), the mean (SD) age was 56.1 (12.5) and mean BMI was 28.8 (6.9) (Table 1). The unadjusted MBDA score was strongly associated with BMI among women (Women: Rho=0.46 [p< 0.001]; Men: Rho=-0.12), while the aMBDA was not associated with BMI in women and was inversely correlated in men (Women: Rho=0.17; Men: Rho=-0.32 [p=0.02]). The unadjusted MBDA score was also strongly associated with FMI Z-Score among women (Figure; Women: Rho=0.42 [p=0.002]; Men: Rho=-0.10; p=0.01). The aMBDA was not significantly associated with FMI Z-Score (Female: Rho= 0.17; Male: Rho=-0.26). Leptin-adjustment reduced the MBDA score in the highest quartile of FMI in women but not men, and increased the MBDA score in the lowest FMI quartiles in both women and men; these patients in the lowest FMI quartile had the highest median SJC (p=0.05 for men, p=0.78 for women; Figure). The aMBDA reclassified 4 women (8%) and 9 men (17%) into higher disease activity categories and 2 women (4%) and 2 men (4%) into lower categories. CDAI, SJC, and radiographic scores were similar across activity categories for the unadjusted MBDA score and aMBDA (Table 2).

Table 1.

Baseline Characteristics.

MenWomenN5252Age (yrs)59.1 (11.5)53.0 (12.8)Black, N (%)13 (25%)19 (36%)BMI27.3 (5.4)30.3 (8.0)FMI Z-Score-0.28 (1.3)0.05 (1.1)DAS28(CRP)3.09 (1.13)3.21 (1.24)Disease Duration11.4 (10.9)11.6 (11.9)CRP, mg/dL0.8 (0.5, 1.2)0.8 (0.5, 1.4)CCP Positive, N (%)45 (87%)40 (78%)vdHS (N=93)13 (4, 73)10.5 (2, 47)HAQ0.71 (0.59)0.83, (0.67)MBDA40.0 (13.8)42.1 (16.6)aMBDA43.6 (13.4)42.1 (15.3)Leptin, ng/mL15.1 (21.5)48.9 (41.5)Table 2.

Clinical assessments across MBDA score categories.

CDAISJCvdHSMBDAaMBDAMBDAaMBDAMBDAaMBDAMBDA CategoryLow14.6 (10.9)13.9 (9.9)2 (1, 5)2 (1, 5)9 (1, 33.5)9 (3, 32)Moderate13.2 (10.0)14.4 (11.4)2 (0, 5)3 (0, 6)10 (4, 49)10 (2, 53)High18.4 (12.3)17.7 (11.8)4 (1, 8)5 (2, 7)20.5 (5, 70.5)18 (4, 73)

Conclusion:

Leptin-adjustment of the MBDA score reduced bias related to excess adiposity in women with RA. Adjustment results in lower MBDA scores in women with greater adiposity, and higher MBDA scores in women and men with lesser adiposity. The aMBDA may reduce misclassification due to excess adiposity and improve identification of active disease among patients with lower adiposity. High aMBDA scores among men with low adiposity may reflect severe disease or excess comorbidity in this group.

References:

[1] Curtis et al.Rheumatology (Oxford) 2018. PMID: 30590790

Figure.

Impact of Adjustment on MBDA Score by FMI Z-Score Quartile.

Disclosure of Interests:

Joshua Baker Grant/research support from: Myriad RBM, Consultant of: Bristol-Myers Squib, Burns-White LLC, Jeffrey Curtis Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Corrona, Janssen, Lilly, Myriad, Pfizer, Regeneron, Roche, UCB, Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Corrona, Janssen, Lilly, Myriad, Pfizer, Regeneron, Roche, UCB, David Chernoff Employee of: Myriad, Michael George Grant/research support from: Bristol Myers Squibb, Consultant of: AbbVie

OP0150 WHAT IS THE ROLE OF TEMPORAL ARTERY BIOPSY IN GIANT CELL ARTERITIS FAST-TRACK PATHWAYS WHEN TEMPORAL ARTERY ULTRASOUND IS NEGATIVE?

Background:

A number of centres are now running fast track pathways for diagnosis and management of Giant cell arteritis with ultrasound as the first port of call for diagnosis1. Temporal artery biopsies (TABs) have become the second line of investigation, and it is unclear how useful TAB is in this setting.

Objectives:

This study looked at accuracy of Temporal artery biopsy (TAB) in patients with suspected Giant Cell arteritis (GCA) with negative/inconclusive ultrasound (U/S) and how duration of treatment on steroids prior to these investigations and arterial specimen size affected it.

Methods:

Prospective study of all patients with suspected GCA referred for TAB when U/S was negative or inconclusive, as part of the local fast-track pathway (Coventry). Database included clinical findings, serological work up, U/S and TAB results and treatment. Sensitivity and specificity of U/S and TAB was calculated and compared based on duration of treatment with steroids.

Results:

One hundred and nine patients were referred for TAB via Coventry fast-track-pathway. The sensitivity of U/S in this cohort of patients was 9.08% and specificity was 93.33%. After 3 days of steroid this was 0% and 100% respectively. For TAB when done within 10 days of starting steroids, this was 65% and 87.5% respectively. After 20 days of steroids this was 0 % and 100%. The sensitivity and specificity was 20% and 85% when arterial specimen size was 11-15mm and 47% and 100% when specimen size was 16 mm or more. Sensitivity and specificity of U/S of 644 suspected GCA patients was 48% and 98%.

Conclusion:

Our study demonstrates that TAB plays a relevant role in GCA fast-track-pathways, when U/S is negative/inconclusive. TAB was more sensitive than U/S in this cohort of patients, but overall sensitivity of U/S was higher when calculated for all patients suspected with GCA. Both remain useful tests if performed early. TAB specimen size should ideally be 16mm or more and done within 10 days of starting steroids.

References:

[1]Jonathan Pinnell, Carl Tiivas, Kaushik Chaudhuri, Purnima Mehta, Shirish Dubey, O38 The diagnostic performance of ultrasound Doppler in a fast-track pathway for giant cell arteritis,Rheumatology, Volume 58, Issue Supplement_3, April 2019, kez105.036,https://doi.org/10.1093/rheumatology/kez105.036

Disclosure of Interests:

None declared

Stress transmission in cemented bidisperse granular materials

We analyze stress distributions in a two-dimensional bidisperse cemented granular packing for a broad range of the values of particle-size ratio, the volumes of large and small particles, and the amount of cementing matrix. In such textured porous materials, the stress concentration, which controls the fracture and fragmentation of the material under tensile loading or in grinding processes, reflects not only the porosity but also the contact network of the particle phase and the resulting stress chains. By means of peridynamic simulations under tensile loading, we show how both the texture and stress distribution depend on size ratio, volume ratio, and the amount of the cementing matrix. In particular, the volume fraction of the class of small particles plays a key role in homogenizing stresses across the system by reducing porosity. Interestingly, the texture controls not only the porosity but also the distribution of pores inside the system with its statistical variability, found to be strongly correlated with the homogeneity of stresses inside the large particles. The most homogeneous stress distribution occurs for the largest size ratio and largest volume fraction of small particles, corresponding to the lowest pore size dispersion and the cushioning effect of small particles and its similar role to the binding matrix for stress redistribution across the packing. At higher porosity, the tensile stresses above the mean stress fall off exponentially in all phases with an exponent that strongly depends on the texture. The exponential part broadens with decreasing matrix volume fraction and particle-size ratio. These correlations reveal the strong interplay between size polydispersity and the cohesive action of the binding matrix for stress distribution, which is significant for the behavior of textured materials in grinding operations.

Building an Infrastructure and Standard Methodology for Actively Engaging Patients in Advance Care Planning

PURPOSE

With little to no infrastructure or standardized methodology in place to actively engage patients in advance care planning (ACP), The University of Texas MD Anderson Cancer Center set out to identify needed resources, develop an intervention to improve ACP, and evaluate the intervention's effects.

METHODS

With the support of executive leadership, a multidisciplinary workgroup enlisted the support of ACP champions, performed a root-cause analysis, developed a detailed ACP process flow by provider role, developed patient and family education resources, and developed faculty and staff training materials. The workgroup also implemented two Plan-Do-Study-Act intervention cycles, which identified difficulty using the ACP note function in our electronic health record (EHR) as a barrier to ACP adoption. By educating patients, families, and providers and improving the EHR's functionality, the workgroup aimed to increase the percentage of ambulatory patients with a diagnosis of advanced or metastatic cancer who had a documented ACP conversation with a provider by their third office visit. Our goal was to improve this percentage from 20% at baseline to 50% after the intervention. Data were obtained from our institution's EHRs.

RESULTS

The percentage of patients who had documented ACP conversations increased from 20% at baseline to 34% at the end of fiscal year 2017 and 54% at the end of fiscal year 2018.

CONCLUSION

Owing to the dedicated efforts of many individuals across the institution, the postintervention goal was surpassed. Additional efforts to facilitate ACP conversations are ongoing.

Outcomes of emergency laparotomy in patients on extracorporeal membrane oxygenation for severe respiratory failure: A retrospective, observational cohort study

PURPOSE

There is a paucity of literature to support undertaking emergency laparotomy when indicated in patients supported on ECMO. Our study aims to identify the prevalence, outcomes and complications of this high risk surgery at a large ECMO centre.

MATERIALS AND METHODS

A single centre, retrospective, observational cohort study of 355 patients admitted to a university teaching hospital Severe Respiratory Failure service between December 2011 and January 2017.

RESULTS

The prevalence of emergency laparotomy in patients on ECMO was 3.7%. These patients had significantly higher SOFA and APACHE II scores compared to similar patients not requiring laparotomy. There was no difference in the duration of ECMO or intensive care unit (ICU) stay post decannulation between the two groups. 31% of laparotomy patients survived to hospital discharge. Major haemorrhage was uncommon, however emergency change of ECMO oxygenator was commonly required.

CONCLUSION

Survival to hospital discharge is possible following emergency laparotomy on ECMO, however the mortality is higher than for those patients not requiring laparotomy, this likely reflects the severity of underlying organ failure rather than the surgery itself. Our service's collocation with a general surgical service has made this development in care possible. ECMO service planning should consider general surgical provision.

Protonation of Curcumin Triggers Sequential Double Cyclization in the Gas-Phase: An Electrospray Mass Spectrometry and DFT Study

ESI-protonated natural curcumin (1) undergoes gas-phase cyclization and dissociates via competitive expulsions of 2-methoxy phenol and C₄H₄O₂ (diketene or an isomer). Evidence from mechanistic mass spectrometry and from Density Functional Theory (DFT) reveals that a two-step sequential cyclization occurs for the protonated molecule prior to the unusual loss of the elements of 2-methoxy phenol. Furthermore, the presence of the methoxy group at postion-3 is essential for the second cyclization. The transformation of curcumin upon protonation in the gas phase may be predictive of its solution chemistry and explain how curcumin plays a protective role in biology.

Open path incoherent broadband cavity-enhanced measurements of NO3 radical and aerosol extinction in the North China Plain

We describe the observation of the NO₃ radical using an incoherent broadband cavity-enhanced absorption spectrometer in an open-path configuration (OP-IBBCEAS) in a polluted summer environment in continental China. The instrument was installed 17 m above the ground at the top of a residential complex near the CAREBeijing-NCP 2014 site in Wangdu, Hebei province, about 200 km southwest of Beijing over the period 28 to 30 June 2014. The separation between the transmitter and receiver components of the instrument was 335 cm and the effective pathlength in clean reference air was ~3.4 km. NO₃ was detected above the detection limit on all three nights when the instrument was operational. The maximum mixing ratio measured was ~175 pptv with a detection sensitivity of ~36 pptv for measurements with an average acquisition time of 10 min. While most extractive instruments try to avoid interferences arising from aerosol extinction, the open path configuration has advantages owing to its ability to detect trace gases even in the presence of aerosol loading. Moreover, concurrent retrieval of aerosol optical extinction is possible from analysis of the absorption magnitude of the oxygen B-band at 687 nm. The experimental setup, its calibration, data acquisition, and analysis procedure are discussed, and the results presented here demonstrate the sensitivity and specificity that can be achieved at high spatial and temporal resolution using the novel configuration of IBBCEAS in the open path.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

On the effect of local sample slope during modulus measurements by contact-resonance atomic force microscopy

Contact-resonance atomic force microscopy (CR-AFM) is of great interest and very valuable for a deeper understanding of the mechanics of biological materials with moduli of at least a few GPa. However, sample surfaces can present a high topography range with significant slopes, where the local angle can be as large as  ± 50°. The non-trivial correlation between surface slope and CR-frequency hinders a straight-forward interpretation of CR-AFM indentation modulus measurements on such samples. We aim to demonstrate the significant influence of the surface slope on the CR-frequency that is caused by the local angle between sample surface and the AFM cantilever and present a practical method to correct the measurements. Based on existing analytical models of the effect of the AFM set-up's intrinsic cantilever tilt on CR-frequencies, we compute the non-linear variation of the first two (eigen)modes CR-frequency for a large range of surface angles. The computations are confirmed by CR-AFM experiments performed on a curved surface. Finally, the model is applied to directly correct contact modulus measurements on a durum wheat starch granule as an exemplary sample.

Evidence of niche partitioning among bacteria living on plastics, organic particles and surrounding seawaters

Plastic pollution is widespread in ocean ecosystems worldwide, but it is unknown if plastic offers a unique habitat for bacteria compared to communities in the water column and attached to naturally-occurring organic particles. The large set of samples taken during the Tara-Mediterranean expedition revealed for the first time a clear niche partitioning between free-living (FL), organic particle-attached (PA) and the recently introduced plastic marine debris (PMD). Bacterial counts in PMD presented higher cell enrichment factors than generally observed for PA fraction, when compared to FL bacteria in the surrounding waters. Taxonomic diversity was also higher in the PMD communities, where higher evenness indicated a favorable environment for a very large number of species. Cyanobacteria were particularly overrepresented in PMD, together with essential functions for biofilm formation and maturation. The community distinction between the three habitats was consistent across the large-scale sampling in the Western Mediterranean basin. 'Plastic specific bacteria' recovered only on the PMD represented half of the OTUs, thus forming a distinct habitat that should be further considered for understanding microbial biodiversity in changing marine ecosystems.