Treatment rates and healthcare costs of patients with fragility fracture by site of care: a real-world data analysis

In a characterization of treatment rates and healthcare costs among patients with an osteoporotic-related fragility fracture overall and by site of care, costs were high and treatment rates were low.

PURPOSE

Osteoporotic fractures can be debilitating, even fatal, among older adults. The cost of osteoporosis and related fractures is projected to increase to more than $25 billion by 2025. The objective of this analysis is to characterize disease-related treatment rates and healthcare costs of patients with an osteoporotic fragility fracture overall and by site of fracture diagnosis.

METHODS

In this retrospective analysis, individuals with fragility fractures were identified in the Merative MarketScan® Commercial and Medicare Databases among women 50 years of age or older and diagnosed with fragility fracture between 1/1/2013 and 6/30/2018 (earliest fracture diagnosis = index). Cohorts were categorized by clinical site of care where the diagnosis of fragility fracture was made and were continuously followed for 12 months prior to and following index. Sites of care were inpatient admission, outpatient office, outpatient hospital, emergency room hospital, and urgent care.

RESULTS

Of the 108,965 eligible patients with fragility fracture (mean age 68.8), most were diagnosed during an inpatient admission or outpatient office visit (42.7%, 31.9%). The mean annual healthcare costs among patients with fragility fracture were $44,311 (± $67,427) and were highest for those diagnosed in an inpatient setting ($71,561 ± $84,072). Compared with other sites of care at fracture diagnosis, patients diagnosed during an inpatient admission also had highest proportion of subsequent fractures (33.2%), osteoporosis diagnosis (27.7%), and osteoporosis therapy (17.2%) during follow-up.

CONCLUSION

The site of care for diagnosis of fragility fracture affects treatment rates and healthcare costs. Further studies are needed to determine how attitude or knowledge about osteoporosis treatment or healthcare experiences differ at various clinical sites of care in the medical management of osteoporosis.

Protein acetylation protects sperm from spontaneous acrosome reaction

In order to penetrate the egg, spermatozoa must undergo the acrosome reaction in close proximity to the egg. This process can take place only after a series of biochemical changes in the sperm, collectively termed capacitation, occur in the female reproductive tract. Sperm cells can undergo spontaneous-acrosome reaction(sAR) before reaching the vicinity of the egg, preventing successful fertilization. Several mechanisms were shown to protect sperm from undergoing sAR, and all of them are involved in proper capacitation. Here, we describe the involvement of protein acetylation in the mechanism that protects bovine spermatozoa from sAR. Incubation of bovine sperm under non-capacitation conditions revealed a strong increase in sAR that was significantly reduced in the presence of deacetylase inhibitors. Protein kinase A (PKA) is an essential key enzyme in sperm capacitation, and its inhibition results in high sAR. The reduction in sAR by hyperacetylation was independent of PKA activity. We previously demonstrated that calmodulin-kinase II (CaMKII) activity protects sperm from sAR, and here we show that its activity is essential for reduction in sAR by hyperacetylation. We further show that the 'exchange protein directly activated by Camp' (EPAC) mediates both protein lysine acetylation and the reduced rate of sAR caused by hyperacetylation. In conclusion, these results suggest a PKA-independent and EPAC-CaMKII dependent hyperacetylation mechanism that protects sperm from sAR.

Introducing an Ethics Framework for health priority-setting in South Africa on the path to universal health coverage

BACKGROUND

South Africa (SA) has embarked on a process to implement universal health coverage (UHC) funded by National Health Insurance (NHI). The 2019 NHI Bill proposes creation of a health technology assessment (HTA) body to inform decisions about which interventions NHI funds will cover under UHC. In practice, HTA often relies mainly on economic evaluations of cost-effectiveness and budget impact, with less attention to the systematic, specific consideration of important social, organisational and ethical impacts of the health technology in question. In this context, the South African Values and Ethics for Universal Health Coverage (SAVE-UHC) research project recognised an opportunity to help shape the health priority-setting process by providing a way to take account of multiple, ethically relevant considerations that reflect SA values. The SAVE-UHC Research Team developed and tested an SA-specific Ethics Framework for HTA assessment and analysis.

OBJECTIVES

To develop and test an Ethics Framework for use in the SA context for health priority-setting.

METHODS

The Framework was developed iteratively by the authors and a multidisciplinary panel (18 participants) over a period of 18 months, using the principles outlined in the 2015 NHI White Paper as a starting point. The provisional Ethics Framework was then tested with multi-stakeholder simulated appraisal committees (SACs) in three provinces. The membership of each SAC roughly reflected the composition of a potential SA HTA committee. The deliberations and dedicated focus group discussions after each SAC meeting were recorded, analysed and used to refine the Framework, which was presented to the Working Group for review, comment and final approval.

RESULTS

This article describes the 12 domains of the Framework. The first four (Burden of the Health Condition, Expected Health Benefits and Harms, Cost-Effectiveness Analysis, and Budget Impact) are commonly used in HTA assessments, and a further eight cover the other ethical domains. These are Equity, Respect and Dignity, Impacts on Personal Financial Situation, Forming and Maintaining Important Personal Relationships, Ease of Suffering, Impact on Safety and Security, Solidarity and Social Cohesion, and Systems Factors and Constraints. In each domain are questions and prompts to enable use of the Framework by both analysts and assessors. Issues that arose, such as weighting of the domains and the availability of SA evidence, were discussed by the SACs.

CONCLUSIONS

The Ethics Framework is intended for use in priority-setting within an HTA process. The Framework was well accepted by a diverse group of stakeholders. The final version will be a useful tool not only for HTA and other priority-setting processes in SA, but also for future efforts to create HTA methods in SA and elsewhere.

Blood and affective markers of stress in Elite Airmen during a preparatory training course: A pilot study

In highly stressful environments, individuals with diverging stress-reactivity can perform differently. Identification of blood markers of stress-reactivity is of major significance to help human performance during stress. Candidate transcripts were identified between stressed and non-stressed strains of rats’ blood and brain, and overlapping significant differentially expressed genes were selected. Serum levels of human orthologues of these proteins, in lieu of blood RNA, in addition to classic stress and general clinical markers, were measured in 33 Battlefield Airmen undergoing a 52 day long preparatory training course before their course of initial entry (COIE). Blood samples and factors of affective state, negative valence “Threat” and positive valence “Challenge”, were obtained five times across different days of training which included either routine physical exercise or prolonged and intense physical and mental training. During training, levels of chloride (Cl), dehydroepiandrosterone-sulfate (DHEA-S), creatinine kinase (CK), and total carbon dioxide (TCO2) differed between airmen who subsequently graduated from their COIE and those who did not. Time dependent changes of serum TCO2 and neuropeptide Y (NPY), as well as the affective factor Challenge differed by future graduation status throughout the training. Serum levels of parvin beta (PARVB) correlated with the affective factor Threat, while those of NPY, testosterone, coactosin like F-actin binding protein 1 (COTL1) and C-reactive protein (CRP) correlated with factor Challenge during the extended, intensive periods of training, consistently. These pilot data suggest that the identified panel of blood markers can measure stress responsiveness, which has the potential to advance individualized stress-management strategies.

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Levels of novel and classical serum markers signal stress severity in men.

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Biomarker levels reflect stress reactivity of Battlefield Airmen in training.

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Affective measures correlate with serum biomarkers after extended stress.

Associations of hamstring and triceps surae muscle spasticity and stance phase gait kinematics in children with spastic diplegic cerebral palsy

Clinical decisions on interventions to improve function in children with cerebral palsy (CP) are based, in part, on hypothesized interactions amongst physical signs of CP and functional deficits. However, a knowledge gap exists regarding associations between spasticity and gait function. This study quantified associations of hamstring and triceps surae spasticity with hip, knee and ankle CP gait patterns. This is a cohort study of children and adolescents [n = 51; 31 male; 20 female; spastic diplegia; Gross Motor Function Classification System I (n = 23) and II (n = 28)] who participated in a clinical consult including gait (Motion Analysis, USA) and modified Tardieu scale (MTS) testing (hamstrings, triceps surae). Shape-based clustering was performed on stance phase sagittal hip, knee and ankle patterns using z-normalized and non-normalized data. Linear regression (R, v3.5.0, R Core Team, Austria) was conducted to assess associations between MTS measures and data clusters (α = 0.05). Shape-clustering revealed two hip and three knee and ankle clusters for z-normalized and non-normalized data. Significant associations of hamstring spasticity and joint patterns were observed for z-normalized knee clusters (C_{Knee A} p = 0.002; C_{Knee B} p = 0.006) and interactions amongst non-normalized hip and knee clusters (C_HipA:C_{Knee B} p = 0.033). Trends were observed for soleus spasticity and gastrocnemius range of motion angle and non-normalized ankle clusters (C_{Ankle B} p = 0.051; C_{Ankle B} p = 0.053 respectively). Significant associations of early knee extension and hamstring spasticity, observed using shape-clustering of z-normalized data, provide unique information that may inform the identification of individuals most likely to benefit from spasticity management and targets for spasticity management assessment.

Tooth Loss and Nutritional Status in Older Adults: A Systematic Review and Meta-analysis

BACKGROUND/OBJECTIVE

Older adults are at risk for tooth loss and compromised nutritional status. Our objective was to conduct a systematic review and meta-analysis to answer the following question: Among adults aged ≥60 y living in developed countries, what are the associations between tooth loss and nutritional status as assessed by a validated nutrition screening or assessment tool?

METHODS

PRISMA guidelines were followed. PubMed, Scopus, CINAHL, Web of Science, and MEDLINE were searched for studies published in English between 2009 and 2019 that met inclusion criteria. Data extracted included study and participant characteristics, dentition, and nutritional status. Risk of bias was assessed with a modified Newcastle-Ottawa Scale. Random effects meta-analysis was used.

RESULTS

Of the 588 unduplicated articles identified, 78 were reviewed in full text, and 7 met inclusion criteria. Six studies were combined for a meta-analysis, which revealed that individuals who were completely edentulous or who lacked functional dentition had a 21% increased likelihood of being at risk of malnutrition or being malnourished, as compared with those who were dentulous or had functionally adequate dentition (risk ratio, 1.21; 95% CI, 1.11 to 1.32; I² = 70%). Whether the article statistically adjusted for medical history explained most of the heterogeneity in the pooled effect.

CONCLUSIONS AND IMPLICATIONS

Findings suggest that older adults with tooth loss are at greater risk of malnutrition than those with functionally adequate dentition. Use of validated tools to assess risk of malnutrition in older adults with tooth loss is important to promote early intervention and referral to optimize nutrition and oral health status. Findings were limited by heterogeneity, risk of bias, and overall quality of the studies reviewed. Cohort studies that adjust for known confounders and use consistent approaches to assess tooth loss and nutritional status are needed.

KNOWLEDGE TRANSFER STATEMENT

The results of this study suggest that older adults with tooth loss are at greater risk of malnutrition than those with functionally adequate dentition. Screening of this population for malnutrition by health care professionals, including dentists and dietitians, may result in corresponding referrals to optimize nutrition and oral health status. Further research is needed with consistent approaches to assess tooth loss and nutritional status.

Artificial intelligence-guided image acquisition on patients with implanted electrophysiological devices: results from a pivotal prospective multi-center clinical trial

Background

A novel, recently FDA-authorized software uses deep learning (DL) to provide prescriptive transthoracic echocardiography (TTE) guidance, allowing novices to acquire standard TTE views. The DL model was trained by >5,000,000 observations of the impact of probe motion on image orientation/quality. This study evaluated whether novice-acquired TTE images guided by this software were of diagnostic quality in patients with and without implanted electrophysiological (EP) devices, focusing on RV size and function, which were thought to be sensitive to EP devices. Some aspects of the study have previously been presented.

Methods

240 patients (61±16 years old, 58% male, 33% BMI >30 kg/m2, 91% with cardiac pathology) were recruited. 8 nurses without echo experience each acquired 10 view TTEs in 30 patients guided by the software. 235 of the patients were also scanned by a trained sonographer without assistance from the software. 5 Level 3 echocardiographers independently assessed the diagnostic quality of the TTEs acquired by the nurses and sonographers to evaluate the effect of EP devices on DL software performance.

Results

Nurses using the AI-guided acquisition software acquired TTEs of sufficient quality to make qualitative assessments of right ventricular (RV) size and function in greater than 80% of cases for patients with and without implanted EP devices (Table). There was no significant difference between nurse- and sonographer-acquired scans.

Conclusion

These results indicate that new DL software can guide novices to obtain TTEs that enable qualitative assessment of RV size even in the presence of implanted EP devices. The results of the comparison to sonographer-acquired exams indicate the software performance is robust to presence of pacemaker/ICD leads visible in the images (Figure).

Nurse-acquired TTE with visible ICD lead

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Caption Health, Inc.

C-48 Attachment and SES at Newborn, Two, and Four Months Related to Communication Development at Nine and Twelve Months

Objective

Previous literature linked secure infant attachment to subsequent communication competency (Murray & Yingling, 2000). Less is known about that relationship in families of varying SES. This study explores how attachment and income at newborn, two, and four months correspond with communication development at nine and twelve months.

Methods

Longitudinal (n = 30) and cross-sectional (n = 102) reports from PediaTrac□, a parent-report web-based survey to track development (Lajiness-O’Neill, et al., 2018), were collected at newborn (NB; n = 41), two (2m; n = 38), four (4m; n = 37), nine (9m; n = 38), and twelve months (12m; n = 36). The cross-sectional sample had higher income (p = .01). Attachment was measured using PediaTrac□ and the Postpartum Bonding Questionnaire (PBQ; Brockington, Fraser & Wilson, 2006). Communication was measured using PediaTrac□.

Results

A linear regression model predicted communication development at 9m and 12m from attachment and income at NB, 2m, and 4m. PBQ attachment at 2m significantly predicted communication at 9m (b = 0.12, t = 2.28, p = .049). However, income was not significant, and neither attachment nor income at NB, 2m, or 4m predicted communication at 12m.

Conclusions

More secure attachment at two months was related to better communication outcomes at nine months regardless of SES. This finding highlights the importance of parent-infant relationships at two months of age on development, indicating further research on methods to promote secure attachment and positive parent-infant interaction in families of varying SES.

Association between urodynamic parameters and urine neutrophil gelatinase-associated lipocalin concentrations in children with neuropathic bladders

BACKGROUND

Neutrophil gelatinase-associated lipocalin (NGAL) is a marker of acute kidney injury, and has been shown to be a sensitive marker of renal damage in urinary tract obstruction. Children with neurogenic bladders are at risk of renal damage as a result of increased pressure within the urinary system. A marker of upper tract deterioration in this population would be useful to guide management.

OBJECTIVE

The aim of the study is to compare urinary NGAL (uNGAL) concentrations between children who have elevated and normal detrusor pressure and between those with low and normal compliance, on urodynamics.

STUDY DESIGN

This is a cross-sectional study of children with neurogenic bladder who underwent routine urodynamics from August 2015 to March 2016. Patients with positive urine cultures from the time of urodynamics were excluded from analysis. Urine was obtained from the time of urodynamics for uNGAL measurement. Urodynamics were reviewed. High pressure is defined as a detrusor pressure of 40 cm of water or greater at the volume where catheterization is normally performed. Compliance was calculated at the volume where catheterization is performed.

RESULTS

A total of 89 patients were included (low pressure, n = 73; high pressure, n = 16 and low compliance, n = 41; normal compliance, n = 40). Median uNGAL concentrations were not different between patients with low and high pressure, but there was a higher median uNGAL concentration in patients with normal compliance compared with those with low compliance. There was no correlation between maximum detrusor pressure and uNGAL concentration, but there was a moderate relationship between compliance and uNGAL concentration (r_s = 0.43, p < 0.01 for non-normalized uNGAL and r_s = 0.30, p < 0.01 for normalized uNGAL).

DISCUSSION AND CONCLUSION

There is an increase in uNGAL concentrations in patients with normal compliance compared with those with low compliance, but no difference between patients with low or high pressure.

Problems and Complications of Cochlear Implant Surgery

As with any operation, problems and complications may arise with cochlear implant surgery. These may be associated with the scalp flap, mastoid, facial recess, middle ear, or scala tympani. We describe a number of these potential problems and suggest means of avoiding or dealing with them. With careful planning and meticulous attention to detail, complications associated with cochlear implant surgery can be minimized.

Abstract P2-08-05: Association between the neutrophil-to-lymphocyte ratio (NLR) and the 21-gene recurrence score

Introduction: A high neutrophil-to-lymphocyte ratio (NLR) has been reported to be a poor prognostic indicator in several malignancies including breast cancer. It is unknown whether the prognosis associated with high NLR can be explained by other prognostic factors such as proliferation or estrogen receptor signalling. Here we explore the association between NLR and the 21-gene recurrence score (RS).

Methods: The associations between RS, NLR, tumor size, histologic grade, and estrogen receptor (ER) and progesterone receptor (PgR) expression (assessed by immunohistochemistry) were explored in sequential women with early-stage, lymph node-negative (or with lymph node micrometastases), ER-positive and HER2-negative breast cancer treated at Princess Margaret Cancer Centre in Toronto, Canada and in whom results of the RS were available. NLR was measured prior to surgery. Patients with a documented history of pre-existing infectious/inflammatory condition were excluded. Associations were explored using simple linear regression and statistical significance was defined as p&lt;0.05.

Results: A total of 130 women diagnosed between January 2006 and April 2015 were included in the analysis. Median age was 55 (range 32-79), 87% were lymph node negative and 13% had nodal micrometastases. The median NLR was 2.2 (range 0.9-9.1) and was collected at a median of 12 days prior to surgery (range 0-60). The median RS was 18 (range 0-41). There was no association between RS and NLR (R=-0.10, p=0.31), grade (R=0.13, p=0.15), age (R=-0.05, p=0.58) or tumor size (R=0.06, p=0.48). RS was negatively associated with the magnitude of expression of both ER (R=-0.22, p=0.01) and PgR (R=-0.44, p&lt;0.001). There was no association between NLR and grade (R=0.20, p=0.15), age (R=-0.13, p=0.17), tumor size (R=0.14, p=0.93), ER (R=0.01, p=0.94) or PgR (R=0.13, p=0.23)

Conclusion: The poor outcomes associated with high NLR are unlikely explained by proliferation of estrogen receptor signalling.

Citation Format: Srikanthan A, Bedard PL, Goldstein S, Templeton A, Amir E. Association between the neutrophil-to-lymphocyte ratio (NLR) and the 21-gene recurrence score. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-08-05.

Terms, definitions and measurements to describe sonographic features of myometrium and uterine masses: a consensus opinion from the Morphological Uterus Sonographic Assessment (MUSA) group

The MUSA (Morphological Uterus Sonographic Assessment) statement is a consensus statement on terms, definitions and measurements that may be used to describe and report the sonographic features of the myometrium using gray-scale sonography, color/power Doppler and three-dimensional ultrasound imaging. The terms and definitions described may form the basis for prospective studies to predict the risk of different myometrial pathologies, based on their ultrasound appearance, and thus should be relevant for the clinician in daily practice and for clinical research. The sonographic features and use of terminology for describing the two most common myometrial lesions (fibroids and adenomyosis) and uterine smooth muscle tumors are presented.