Change in Pediatric Adenotonsillectomy Postoperative Visit Patterns After Opioid Food and Drug Administration Warning

STUDY OBJECTIVE

This study aimed to determine the association between opioid prescriptions given after tonsillectomy with adenoidectomy (T + A) and pain-related return visit rates in pediatric patients. Determine association between Food and Drug Administration (FDA) black box warning against opioid use in this population and pain-related return visit rates.

METHODS

This was a single-institution retrospective cohort study of pediatric patients who underwent T + A between April 2012 and December 2015 and had return visits to the emergency department or urgent care center. Data were obtained from the hospital electronic warehouse using International Classification of Diseases-9/10 procedure codes. Odds ratios (ORs) with 95% confidence intervals (CIs) for return visits were calculated. Multivariate logistic regression analysis was used to measure association between opioid prescriptions and return visit rates as well as FDA warning and return visit rates adjusting for confounders.

RESULTS

There were 4778 patients who underwent T + A, median age, 5 years. Of these, 752 (15.7%) had return visits. Pain-related return visits were higher in patients who received opioid prescriptions (adjusted OR, 1.31; 95% CI, 1.09-1.57). After FDA warning, opioids were prescribed at a lower rate (47.9%) compared with previous (98.6%) (OR, 0.01; 95% CI, 0.008-0.02). Pain-related return visits were lower after FDA warning (OR, 0.73; 95% CI, 0.61-0.87). Steroid prescription rate increased after FDA warning (OR, 415; 95% CI, 197-874).

CONCLUSIONS

Opioid prescriptions were associated with higher pain-related return visits after T + A, whereas issuance of FDA black box warning against codeine use was associated with lower pain-related return visits. Our data suggest that the black box warning potentially had unintended benefits in pain management and health care usage.

Hypofractionated Radiotherapy for Prostate Cancer (HRT20) Trial: Results

PURPOSE/OBJECTIVE(S)

Radiotherapy is a definitive standard treatment for men with localized prostate cancer. Improvements in technology allow higher doses of radiation delivered to the prostate in less days, with lower doses to surrounding healthy tissues trying to reduce side effects. Several studies demonstrated that hypofractionated radiotherapy of 60 Gy is non-inferior to conventional radiotherapy fractionation. To report the first results in toxicity and biochemical relapse free survival of HRT20 trial after 5 years of recruitment. The HRT20 trial is registered (NCT03851926).

MATERIALS/METHODS

A prospective observational study enrolled 298 men with localized prostate cancer (pT1b-T3aN0M0) started in October 2016. Median age was 75 (53-91). Median PSA was 14.5ng/ml. Using NCCN classification: 12,6% were low risk, 50.5% were intermediate and 36.9 % were high risk patients. The median duration of the treatment was 30 days (23-41) The clinical target volume (CTV) consisted of the prostate and seminal vesicles when affected. The CTV-planning target volume (PTV) margin was 0.8 cm. The primary end point evaluated assessed by CTCAE 4.0 was related later adverse events and the second end point was biochemical relapse free survival by Phoenix definition. WMAT plans calculations were carried out using the Monaco TPS version 5.10 based on a single arc arrangement. Univariate and multivariate logistic analyses were carried out.

RESULTS

After median follow up of 56 months. The 5-year incidence rates of grade 2 and 3 late gastrointestinal toxicities were 6.3% and 3.1%, respectively, and those of grade 2 and 3 late genitourinary toxicities were 7.9% and 1%, respectively. PTV volume was found to be correlated with late rectal bleeding (p = 0.02). Also, urinary tract obstruction was correlated with PTV volume. The proportion of patients who were biochemical failure free at 5 years was 88·3% (95% CI 86·0-90·2) Multivariate analysis indicated that risk stage (p = 0.03) and number of positive needles biopsy cores (p = 0.02) were prognostic factor for biochemical relapse-free survival rates.

CONCLUSION

The findings of this study indicate that hypofractionated is well tolerated and it is associated with good 5-years tumor-control outcomes in patients with localized prostate cancer. Long-term follow-up continues.

An Association Between Comorbidities and Postsurgical Complications in Adults Who Underwent Esophagectomy

Background Esophagectomy is the surgical excision of part or all of the esophagus and is associated with both common and serious complications. Various comorbidities, such as diabetes mellitus, smoking, and congestive heart failure (CHF), have been detected in individuals who have undergone esophagectomy. This study investigates the association of baseline characteristics and comorbidities with postoperative complications. Methods A retrospective cohort study based on data from the National Surgical Quality Improvement Program database was conducted, evaluating 2,544 patients who underwent esophagectomy between January 2016 and December 2018. Data included baseline characteristics, established comorbidities, and postoperative complications within 30 days of the procedure. Risk-adjusted and unadjusted logistic regressions were used to assess the odds of postoperative complications against baseline characteristics. Results The majority of our population were white males (80.8% male; 78.2% white), with a mean age of 63.5 years. More than half of the patients were overweight or obese. A minority of our patients had a smoking history, weight loss, diabetes mellitus, chronic obstructive pulmonary disease (COPD), or CHF. The most frequent postoperative complications were as follows: return to the operating room (15.7%), anastomotic leak (12.9%), pneumonia (12.7%), bleeding/transfusions (11.8%), readmissions (11.4%), and unplanned intubation (10.5%). Adjusted associations for odds of experiencing a postoperative complication were found to be statistically significant for age (odds ratio [OR] 1.02, 95% confidence interval [CI] 1.01-1.03, and P < 0.001), operation time (OR 1.002, 95% CI 1.001-1.003, and P < 0.001), race (not white) (OR 1.76, 95% CI 1.26-2.47, and P = 0.001), BMI (underweight) (OR 2.18, 95% CI 1.36-3.50, and P = 0.001), smoking (OR 1.42, 95% CI 1.14-1.76, and P = 0.001), and chemotherapy and/or radiation (OR 0.82, 95% CI 0.68-0.99, P = 0.038). Conclusions Our study found that age, operation time, nonwhite race, underweight BMI, and smoking were independently associated with an increased risk of developing a postoperative complication following esophagectomy. Additionally, neoadjuvant chemotherapy and/or radiation are associated with a decreased risk. Understanding how baseline characteristics and comorbidities can affect rates of postoperative complications may help to adjust care for patients in both pre- and postoperative settings.

The Effect of Health Insurance Status on School Attendance

Introduction Educational achievement is impacted by a student's ability to be present and motivated in the classroom. Since health and education influence one another, disparities in health insurance status among children may exert educationally relevant consequences. However, the association between health insurance coverage and school absenteeism remains poorly understood. Our study aims to assess the association between not having/having gaps in health insurance coverage and an increased number of missed school days. Methods A historical cohort study was performed via secondary analysis of data collected as part of the 2018 National Survey of Children's Health (NSCH). We included children enrolled in school between the ages of 6-17 years and who provided answers to survey questions involving our two variables of interest: health insurance status and missed school days. Our data analysis included 1) a descriptive analysis of the baseline sample characteristics, 2) a bivariate analysis to determine the association between baseline characteristics/confounding variables and the outcome, and 3) a multivariable regression analysis using logistic regression to determine the association of interest while controlling for potential confounding variables. Results A total of 21,498 respondents were included. The unadjusted odds of chronic absenteeism were found to be 16% (OR=1.16) higher in children without insurance or with gaps in insurance compared to children with consistent insurance throughout the year, but the association was not statistically significant (95% CI 0.74 - 1.82, p=0.051). After adjustment by age, sex, race, Hispanic ethnicity, and confounding variables, the odds of chronic absenteeism in children without insurance or with gaps in insurance remained statistically insignificant (aOR=1.05; 95% CI 0.64 - 1.73, p=0.848) compared to those with consistent insurance coverage. Conclusions According to our analysis, the data do not support our hypothesis of a significant difference in missed school days (greater than or equal to 11 missed days of school) among those children who had health insurance compared to those without health insurance/had gaps in insurance coverage.

IL-37-a putative therapeutic agent in cardiovascular diseases

Although it is a member of the Interleukin (IL)-1 family, IL-37 is unique in that it has wide-ranging anti-inflammatory characteristics. It was originally thought to prevent IL-18-mediated inflammation by binding to the IL-18-binding protein. However, upon discovery that it binds to the orphan receptor, IL-1R8, further studies have revealed an expanded role of IL-37 to include several intracellular and extracellular pathways that affect various aspects of inflammation. Its potential role specifically in cardiovascular diseases (CVD) stemmed initially from the discovery of elevated plasma IL-37 levels in human patients with acute coronary syndrome and atrial fibrillation. Other studies using mouse models of ischemia/reperfusion injury, vascular calcification and myocardial infarction have revealed that IL-37 can have a beneficial role in these conditions. This review will explore recent research on the effects of IL-37 on the pathogenesis of CVD.

Poor Perception and Knowledge of Electronic Cigarettes Among Adolescents and Their Parents

OBJECTIVES

Electronic cigarettes (e-cigs) and vaping are a popular form of substance abuse among adolescents. Studies have shown that adolescents have a poor understanding of e-cigs but little is known about parental understanding. The primary objective was to assess if a discrepancy in perception and knowledge regarding the content and safety profile of e-cigs between adolescents and their parents exists.

METHODS

Single-site prospective questionnaire analysis of adolescents (12-21 years) and their parents between November 2018 and March 2019 was performed. Each participant pair received an anonymous, confidential, electronic questionnaire. Data were collected via Research Electronic Data Capture. χ2 and independent t tests were used for comparative analysis.

RESULTS

A total of 300 adolescent/parent pairs were included for analysis. The mean age of adolescents was 15.1 years (SD, 2.1), and that of parents was 43.9 years (SD, 8.7). Overall knowledge of e-cigs was inadequate in both adolescents and parents: 93.7% and 88.3%, respectively (P < 0.0001). Less adolescents (49.0%) compared with parents (71.0%) perceived any health risks to smoking e-cigs (P < 0.0001). Among adolescents, 17% admitted to smoking e-cigs compared with 5.4% smoking conventional tobacco cigarettes (P < 0.0001), and they reported using e-cigs (17.0%) more often than any other substance except alcohol (27.3%). Only 49.7% of adolescents reported receiving formal education at school regarding e-cigs. Parents reported discussing e-cigs risks/benefits with adolescents less often than other topics (71.3% vs 79.0% to 84.3%; P < 0.0007).

CONCLUSIONS

This analysis suggests that perception and knowledge regarding the content and safety profile of e-cigs are poor among both adolescents and parents. These findings support the need for tighter federal regulation and an increase in public health awareness programs.

Predictors of heart failure hospitalization and cardiovascular mortality in patients with chronic right ventricle pacing

Background

Left ventricle (LV) dysfunction after chronic right ventricle (RV) pacing, also known as pacemaker induced cardiomyopathy (PICM) is a relatively common finding, ranging from 15–20% of patients. It has been associated to a high burden RV pacing, age, male gender and intrinsic and paced QRS duration. However, clinical relevance of LV dysfunction in this population has not been studied.

Purpose

The aim of the study was to identify predictors of heart failure (HF) hospitalization and cardiovascular (CV) mortality in patients with RV pacing.

Methods

Retrospective and unicentric study. We studied 2418 patients undergoing single or dual-chamber pacemaker implantation between 2012–2018. Patients were included if they had an echocardiogram prior to implantation and a repeated echocardiogram &gt;3 months after implantation. Baseline LV ejection fraction (LVEF) had to be &gt;50%. PICM was defined as ≥10% decrease in LVEF, resulting in LVEF &lt;50%. Alternative causes of LV dysfunction were excluded. Primary endpoint was heart failure hospitalization. Secondary endpoint was cardiovascular mortality. Competing-risk regression analysis was performed to identify predictors of HFH and CV mortality.

Results

Of 2418 patients, 495 meeting study criteria and 105 (21.2%) met PICM criteria. Follow-up period was 56.1±28.5months. There were no differences in basal LVEF (60.1±0.5% in non-PICM patients vs 59.5±0.5 in PICM patients, p=0.51). Mean LVEF at follow-up was 37.7±0.9 vs 56.7±0.3, p&lt;0.001. After logistic multivariable analysis, factors associated with PICM were alcohol consumption (OR 3.0, 95% CI 1.1–8.0,p=0.032), right bundle branch block (RBBB) (OR 1.9, 95% CI 1.06–3.51,p=0.031), higher RV pacing burden (OR 1.0, 95% CI 1.0–1.1,p=0.008) and higher basal LV end-diastolic diameter (OR 1.1, 95% CI 1.0–1.1,p=0.016).

HFH occurred in 144 patients (29.1%). Factors associated with HFH after multivariable analysis were any decrease in LVEF (LVEF&gt;55% as reference: LVEF 46–55% (HR 2.1, 95% CI 1.3–3.3,p=0.002); LVEF 36–45% (HR=1.5, 95% CI 0.7–3.0; p=0.306), LVEF≤35% (HR 2.44, 95% CI 1.11–5.37,p=0.027), age (HR 1.0, 95% CI 1.0–1.1,p=0.037), alcohol consumption (HR 3.4, 95% CI 1.9–6.1,p&lt;0.001), presence of atrial fibrillation (HR 1.7, 95% CI 1.06–2.70,p=0.027) and paced QRS duration (HR 1.0, 95% CI 1.0–1.02,p=0.031).

CV mortality occurred in 54 patients (10.9%). Factors associated with CV mortality after multivariable analysis were a decrease in LVEF (LVEF 46–55% (HR 1.6, 95% CI 0.8–3.2,p=0.217); LVEF 36–45% (HR=1.6, 95% CI 0.6–4.2,p=0.33); LVEF≤35% (HR 4.6, 95% CI 2.0–10.7,p&lt;0.001), RBBB (HR 2.1, 95% CI 1.1–3.9,p=0.026) and lower haemoglobin (HR 0.8, 95% CI 0.7–0.99,p=0.033).

Conclusion

In patients with RV pacing, factors associated with PICM were alcohol consumption, RBBB, RV pacing burden and basal LV end-diastolic diameter. HF hospitalization and CV mortality are common (29.1% and 10.9%). Any decrease in LVEF is associated with an increase in CV events.

Funding Acknowledgement

Type of funding sources: None.

Association Between Diabetes Mellitus and Carpal Tunnel Syndrome: Results From the United States National Ambulatory Medical Care Survey

Background

Carpal tunnel syndrome (CTS) is the most common compression neuropathy in the upper limb. While various risk factors have been linked to CTS, the role of diabetes mellitus (DM) in the development of CTS remains unclear. Previous studies have failed to consistently demonstrate a clear association between DM and CTS due to variations based on the geographic setting and differences in the study design. The objective of this study was to assess if there is an association between DM and CTS using population-based data from the United States.

Methodology

We used data from patients ≥18 years old who contributed to the National Ambulatory Medical Care Survey between 2006 and 2015. The outcome was CTS identified by the International Classification of Diseases-9-Clinical Modification codes (354.0 and 354.1), and the main independent variable was physician-reported diabetes status. Multivariable logistic regression was used to adjust for confounding variables. Odds ratios (ORs) and 95% confidence intervals (CIs) were reported. Stata v15 was used for all analyses.

Results

Among the patients included in this study (n = 322,092), 13.5% were reported to have diabetes while 0.55% reported CTS. The unadjusted odds of having CTS among patients with diabetes was 0.92 (95% CI: 0.74-1.14; p = 0.447). After adjusting for confounding variables, the association remained not statistically significant (adjusted odds ratio [aOR]: 0.84; 95% CI: 0.65-1.09; p = 0.203). Other variables independently associated with CTS included age 50-59 (aOR: 1.91; 95% CI: 1.49-2.45; p < 0.001), female gender (aOR: 1.31; 95% CI: 1.09-1.58; p < 0.004), and current tobacco users (aOR: 1.32; 95% CI: 1.07-1.63; p < 0.01).

Conclusions

No association was found between DM and CTS in adult ambulatory patients in the United States, but results should be considered in light of potential outcome misclassification.

Brachial-ankle pulse wave velocity with a custom device

BACKGROUND AND OBJECTIVES

The brachial-ankle pulse wave velocity (baPWV) is one of the most widely used arterial stiffness variables for assessing vascular risk. The abiPWV is a device that calculates various PWVs and the blood pressure ankle-brachial index (ABI). The device can also determine baPWV. The aim of this study was to calculate the baPWV with abiPWV, validate it with a reference device (VaSera) and study its clinical usefulness.

PATIENTS AND METHODS

We studied 113 patients (mean age, 53±12years), 59 (52%) of whom were women, and 10 (8.8%) of whom had a previous cardiovascular event. The participants were classified according to cardiovascular risk factors (CRFs) into groupI (none), groupII (1 or 2 CRFs) and groupIII (3 or more CRFs). The patients with a previous cardiovascular event were included in groupIII. All participants had their baPWV measured with abiPWV and VaSera.

RESULTS

The baPWV correlation between the 2 devices was r=0.93 (P<.001), and the percentage error calculated with the Bland-Altman analysis was 4.5%. The baPWV measured with abiPWV (in m/s) was as follows: groupI, 10.5±1.6; groupII, 13.8±2.9 (P<.001 when compared with groupI); and groupIII, 14.1±2.7 (P<.001 when compared with groupI). There were no differences between groupsII and III. The results with VaSera were comparable to those of abiPWV.

CONCLUSIONS

Measuring baPWV with the abiPWV is safe and has a similar clinical utility to that of VaSera. Incorporating this function into the options of abiPWV makes it a complete device for assessing arterial stiffness.

Prevalence and Risk Factors for Anemia in a Population With Hidradenitis Suppurativa

Background: Hidradenitis suppurativa (HS) is an inflammatory disease presenting as nodules evolving into scarred plaques. HS is associated with many co-morbidities, including anemia of chronic disease, though few studies report on this association.

Objectives: This study evaluated the prevalence of anemia among the HS patient population and potential associations between risk factors for HS and anemia development.

Methods: Records diagnosed HS patients in one private practice (BR) were reviewed by investigators. The 92-patient cohort was evaluated for multiple data-points and responses grouped based on age, gender, ethnicity, body mass index (BMI), smoking status, and comorbidities. Data were analyzed using STATA to perform descriptive analysis and bivariate analysis.

Results: The prevalence of anemia in this cohort was 41.3%. Of anemic patients, the majority were men (65.2%), African American (60.6%), and never/former smokers (48.6%). There was a significant increase in the odds of developing anemia in HS patients that are men (odds ratio (OR) 3.8) and African American (OR 3.5).

Conclusions: We show that the prevalence of anemia in an HS patient population greatly surpasses that of the U.S. population (~5%). It is clear that anemia is a significant complication for HS patients. We hope that physicians can recognize the importance of screening patients with HS for anemia to medically optimize treatment for their patients.

Association Between Marijuana Use and Cardiovascular Disease in US Adults

Introduction

The prevalence of marijuana use has increased by about 16% since 2006, translating to approximately 200 million people worldwide. Being so widely used, long-term effects of marijuana use on cardiovascular health are largely unknown. Previous studies have had conflicting results, either showing marijuana use having a negative impact or no significant impact on cardiovascular health. This study aims to add evidence regarding the impact marijuana use has on the prevalence of cardiovascular disease.

Methods

This retrospective study was conducted using the Behavioral Risk Factor Surveillance System (BRFSS) database. Patients who completed the questionnaire and answered all questions in relation to marijuana use and the diagnosis of cardiovascular disease in 2017 were a part of this study. Subjects were excluded if they were children (<18 years old) or had missing data for marijuana use or cardiovascular disease. Age, gender, race/ethnicity, body mass index (BMI), income, exercise, tobacco use, alcohol use, and depression were all considered as potential confounders. Bivariate analysis was conducted to find an initial association between marijuana use and cardiovascular disease, which was followed by a multivariate regression analysis to adjust for confounders. Odds ratios and 95% confidence intervals were calculated. 

Results

A total of 56,742 subjects were included in the analysis. The unadjusted bivariate analysis showed a reduced prevalence of cardiovascular disease in individuals using marijuana (OR 0.65, 95%CI [0.50-0.84]). After adjustment with all additional variables, an adjusted model showed a similar odds ratio, but statistical significance of the association was lost (OR 0.74, 95%CI [0.54-1.01]).

Discussion

A systematic review by Ravi et al in 2018, which looked at marijuana use, cardiovascular risk factors, and clinical outcomes concluded that there was insufficient data to make conclusions regarding the effect of marijuana use and negative long-term cardiovascular effects. Our study lends support to the notion that marijuana use does not have an association with cardiovascular disease. A limitation in our study was that there was missing data from the BRFSS questionnaire due to participants not fully answering all questions concerning cardiovascular disease and marijuana use. This decreased our sample size from 67,974 to 56,742 subjects. The missing participants led to a decrease in the power of our odds ratio, which may have impacted statistical significance of our results. 

Conclusion

Although previous literature has shown that marijuana use has a negative impact on cardiovascular health, our study suggests that users and non-users of marijuana did not have an association with the prevalence of cardiovascular disease. Varying levels of support within the literature highlights the need for further research of this association. 

Comparison of Five-Year Survival Rate Between Black and White Children With Acute Lymphoblastic Leukemia

Introduction

Despite improvements in the prognosis of acute lymphoblastic leukemia (ALL), it is still the most common childhood cancer. The goal of this study was to investigate if there was a significant difference in the five-year survival between Black and White children with ALL, specifically up to the year 2016 which has not been researched.

Methods

A retrospective cohort study of Black and White children diagnosed with ALL between 1975 and 2016 was carried out using the Surveillance, Epidemiology, and End Results (SEER) Program database. Children aged 0-19 were separated into Black or White, and then survival analysis was used to compare five-year survival. A multivariate cox regression analysis was carried out to determine the association between race and five-year survival with ALL.

Results

Our sample included 17,663 cases consisting of 16,238 White children and 1,425 Black children. White children had a significantly increased five-year mortality survival when compared to Black children. Upon using multivariate cox regression analysis, both unadjusted and adjusted models showed a significantly higher risk of death in Black children when compared to White children.

Conclusions

Our study found that there is a significant difference in the five-year survival between Black and White children diagnosed with ALL. The difference in survival persists even when controlling for sex, age at diagnosis, year of diagnosis, and histology. Future studies should be carried out to control for more confounders that the SEER database is unable to control for.

Impact of Insurance Status on Diagnostic Stage in Hodgkin's Lymphoma in the United States: Implications for Detection and Outcomes

Introduction and objective

Hodgkin’s lymphoma (HL) is a form of cancer originating from white blood cells that presents upon diagnosis with well-characterized symptoms (palpable lymph nodes, fever, night sweats, weight loss). HL is currently one of the most treatable cancers, with a successful treatment rate of 75% worldwide. The objective of this study is to evaluate the association between insurance status and the stage of diagnosis of HL in the United States from the years 2007 to 2016.

Methods

A cross-sectional study using secondary data from the Surveillance, Epidemiology, and End Results (SEER) program database was used. Insurance status of each patient was defined as uninsured (not insured or self-pay), any Medicaid (includes Indian/public health service), insured (private insurance, managed care, Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), or Medicare) and insured not specified. Staging was dictated via the SEER combined/American Joint Committee on Cancer (AJCC) cancer staging guidelines. We divided the stages into early-stage (localized) and late-stage (regional by direct extension, involving distant sites/nodes). We used univariate descriptive analysis to determine baseline characteristics, bivariate analysis to evaluate potential confounding, and binary logistic regression to compute unadjusted and adjusted odd ratios and corresponding 95% confidence intervals. 

Results 

Approximately 77% of insured individuals presented with a late-stage diagnosis, compared with 78.1% for insured not specified, 82% for any Medicaid, and 84.9% for uninsured. After adjusting for age, sex, race and marital status, insurance status had a significant impact on the stage of diagnosis of Hodgkin's lymphoma. The odds ratio (OR) for advanced stage diagnosis of HL in uninsured patients compared to insured patients was 1.72 (95% CI 1.03-2.86, p=0.037); for any Medicaid, the OR was 1.37 (95% CI 1.02-1.83, p=0.036), and for insured not specified, 1.09 (95% CI 0.83-1.44, p=0.522).

Conclusions

Uninsured patients are significantly more likely to have a later stage diagnosis of HL compared to those that are insured. The findings of this study coincide with the associations found in previous studies involving other cancers such as breast, cervical, prostate, colorectal, hepatocellular, bladder and kidney cancers outcomes and insurance status. 

Resource utilization and costs associated with achieved LDL-C levels in patients following a myocardial infarction treated with lipid-lowering therapies in Spain

Background/Introduction

Reduction in low-density lipoprotein cholesterol (LDL-C) significantly reduces cardiovascular (CV) risk, especially in patients with atherosclerotic CV disease. There is, however, a lack of evidence on the association between achieved LDL-C and resource utilization and costs.

Purpose

Assess the association of achieved LDL-C levels and resource use and costs in patients treated with lipid-lowering therapies (LLT) following a myocardial infarction (MI).

Methods

Retrospective observational study using the BIG-PAC® database, with anonymized electronic medical records from 1.9 million inhabitants from 7 regions in Spain.

Eligible patients were adults (≥18 years), hospitalized for an MI (index date) between January 2015 and December 2017, treated with LLTs (statins and/or ezetimibe) during follow-up (up to 18 months), and with recorded LDL-C values at baseline and follow-up.

Direct (related to health care interventions) and indirect (related to loss of productivity) costs were estimated in 2018€.

Costs incurred during follow-up were computed by achieved LDL-C. Achieved LDL-C was obtained in the year following the MI and at least 2 months after the index date. LDL-C categories were defined as per the 2016 and 2019 ESC/EAS guidelines for dyslipidaemias management: &lt;55 mg/dL, 55–69 mg/dL, 70–99 mg/dL, 100–129 mg/dL and ≥130 mg/dL. Results were adjusted for age, gender, CV disease history and comorbidities.

Results

6025 patients were included. Mean age (SD) was 69.7 (12.2) and 77% were male.

Resource use (not reported in this abstract) and costs monotonically increased with achieved LDL-C. Mean total costs ranged from 5044€ for patients with LDL-C &lt;55 mg/dL to 7567€ for patients with LDL-C ≥130 mg/dL (Table 1).

Only 11% (641/6025) of patients reached recommended LDL-C levels for very-high-risk patients as per 2016 ESC/EAS guidelines (&lt;70 mg/dL), and 1% (68/6025) the LDL-C levels (&lt;55 mg/dL) proposed in the 2019 guidelines.

Conclusions

Achieving lower LDL-C levels following an MI may be associated to lower resource use and costs. Many patients do not achieve recommended LDL-C levels despite treatment with LLT. These data suggest that use of more intense LLT, with a greater reduction in LDL-C, would be beneficial from a clinical and economic perspective.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Amgen (Europe) GmbH

Brachial-ankle pulse wave velocity with a custom device

BACKGROUND AND OBJECTIVES

The brachial-ankle pulse wave velocity (baPWV) is one of the most widely used arterial stiffness variables for assessing vascular risk. The abiPWV is a device that calculates various PWVs and the blood pressure ankle-brachial index (ABI). The device can also determine baPWV. The aim of this study was to calculate the baPWV with abiPWV, validate it with a reference device (VaSera) and study its clinical usefulness.

PATIENTS AND METHODS

We studied 113 patients (mean age, 53 ± 12 years), 59 (52%) of whom were women, and 10 (8.8%) of whom had a previous cardiovascular event. The participants were classified according to cardiovascular risk factors (CRFs) into group I (none), group II (1 or 2 CRFs) and group III (3 or more CRFs). The patients with a previous cardiovascular event were included in group III. All participants had their baPWV measured with abiPWV and VaSera.

RESULTS

The baPWV correlation between the 2 devices was r = 0.93 (p < .001), and the percentage error calculated with the Bland-Altman analysis was 4.5%. The baPWV measured with abiPWV (in m/s) was as follows: group I, 10.5 ± 1.6; group II, 13.8 ± 2.9 (p < .001 when compared with group I); and group III, 14.1 ± 2.7 (p < .001 when compared with group I). There were no differences between groups II and III. The results with VaSera were comparable to those of abiPWV.

CONCLUSIONS

Measuring baPWV with the abiPWV is safe and has a similar clinical utility to that of VaSera. Incorporating this function into the options of abiPWV makes it a complete device for assessing arterial stiffness.

Use of E-Cigarettes and Self-Reported Lung Disease Among US Adults

OBJECTIVES

Initially marketed for smoking cessation, electronic cigarettes (e-cigarettes) are commonly regarded as safer than combustible cigarettes because they usually contain less nicotine and do not use combustion. However, few studies have examined the health effects of e-cigarettes. The objective of this study was to examine whether e-cigarette use had a differential effect on the prevalence of lung disease among current, former, and never tobacco users.

METHODS

We analyzed data from respondents aged ≥18 (n = 45 908) who responded to questions about e-cigarette use and lung disease in the 2016 Behavioral Risk Factor Surveillance System (BRFSS) survey. We calculated crude odd ratios (ORs) and ORs adjusted by 15 sociodemographic and health behavior factors: age, sex, race/ethnicity, annual household income, health insurance, personal physician, health status, body mass index, education, marital status, exercise, alcohol use, tobacco smoking, tobacco chewing, and metropolitan status.

RESULTS

We found a significant association between e-cigarette use and lung disease, which was significantly modified by tobacco use. Among never tobacco users, the adjusted odds of reporting lung disease were 4.36 (95% CI, 1.76-10.77) times higher among everyday e-cigarette users than among never e-cigarette users. Among current tobacco users, the adjusted odds of reporting lung disease were 1.47 (95% CI, 1.13-1.92) times higher among everyday e-cigarette users than among never e-cigarette users.

CONCLUSIONS

People who have never smoked combustible cigarettes should refrain from starting e-cigarettes, because e-cigarettes carry a significant risk of lung disease independent of tobacco smoking. Additional prospective research into the harmful effects of e-cigarettes would help to further elucidate this link.

A Comparative Case Series of Haitian and non-Haitian Stroke Patients at a Single Center in Miami, Florida

INTRODUCTION

Although Florida is home to the largest number of Haitian immigrants, few studies exist regarding stroke in this population.

METHODS

A comparative case series of Haitian (n=72) and non-Haitian (n=144) stroke patients was conducted. After matching for gender and stroke subtype (78.7% ischemic and 21.3% hemorrhagic), demographics, clinical characteristics, and outcomes were compared.

RESULTS

Compared with non-Haitians, Haitian stroke patients were younger (67 vs 70.5 years; p=.0384), had higher diastolic blood pressures (88.2 vs 80.4 mm Hg; p=.006) and mean arterial pressures (112 vs 104.5 mm Hg; p=.01), and higher mean glycosylated hemoglobin values (7.2 vs 6.5 g/dL; p=.017). There were no significant differences in stroke severity or rates of tissue plasminogen activator (tPA) administration. Haitians were almost 80% less likely to have Medicare or private insurance (OR= 0.23; p&lt;.001).

DISCUSSION

Haitian immigrants need improved access to care and prevention of known stroke risk factors, including hypertension and hyperglycemia.

P581Electronic health records (EHRs) data validation in atherosclerotic/cardiovascular clinical phenotypes

Background

Research efforts to develop strategies to effectively identify patients and reduce the burden of cardiovascular diseases is essential for the future of the health system. Most research studies have used only coded parts of electronic health records (EHRs) for case-detection obtaining missed data cases, reducing study quality and in some case bias findings. Incorporating information from free-text into case-detection through Big Data and Artificial Intelligence techniques improves research quality. Savana has developed EHRead, a powerful technology that applies Natural Language Processing, Machine Learning and Deep Learning, to analyse and automatically extracts highly valuable medical information from unstructured free text contained in the EHR to support research and practice.

Purpose

We aimed to validate the linguistic accuracy performance of Savana, in terms of Precision (P), Recall (R) and overall performance (F-Score) in the cardiovascular domain since this is one of the most prevalent disease in the general population. This means validating the extent to which the Savana system identifies mentions to atherosclerotic/cardiovascular clinical phenotypes in EHRs.

Methods

The project was conducted in 3 Spanish sites and the system was validated using a corpus that consisted of 739 EHRs, including the emergency, medical and discharge records, written in free text. These EHRs were randomly selected from the total number of clinical documents generated during the period of 2012–2017 and were fully anonymized to comply with legal and ethical requirements. Two physicians per site reviewed records (randomly selected) and annotated all direct references to atherosclerotic/cardiovascular clinical phenotypes, following the annotation guidelines previously developed. A third physician adjudicated discordant annotations. Savana's performance was automatically calculated using as validation resource the gold standard created by the experts.

Results

We found good levels of performance achieved by Savana in the identification of mentions to atherosclerotic/cardiovascular clinical phenotypes, yielding an overall P, R, and F-score of 0.97, 0.92, and 0.94, respectively. We also found that going through all the EHRs and identifying the mentions to atherosclerotic/cardiovascular clinical phenotypes, the expert spent ∼ 60h while Savana ∼ 36 min.

Conclusion(s)

Innovative techniques to identify atherosclerotic/cardiovascular clinical phenotypes could be used to support real world data research and clinical practice. Overall Savana showed a high performance, comparable with those obtained by an expert physician annotator doing the same task. Additionally, a significant reduction of time in using automatic information extraction system was achieved.

The association between insurance status and diagnostic imaging for acute abdominal pain among emergency department patients in the United States, 2005-2014

Introduction and objectives: Acute abdominal pain (AAP) is one of the most common complaints in the emergency department (ED). Rapid diagnosis is essential and is often achieved through imaging. Computed tomography (CT) is widely considered an exemplary test in the diagnosis of AAP in adult patients. As previous studies show disparities in healthcare treatment based on insurance status, our objective was to assess the association between insurance status and frequency of CT ordered for adult patients presenting to the ED with AAP from 2005 to 2014. Methods: This study used the National Hospital and Ambulatory Medical Care Survey: Emergency Department Record (NHAMCS) database, which collects data over a randomly assigned 4 week period in the 50 states and DC, to perform an observational retrospective analysis of patients presenting to the ED with AAP. Patients with Medicaid, Medicare or no insurance were compared to patients with private insurance. The association between insurance status and frequency of CT ordered was measured by obtaining odds ratios along with 95% CIs adjusted for age, gender and race/ethnicity. Results: Individuals receiving Medicaid are 20% less likely to receive CT than those with private insurance (OR 0.8, CI 0.6-0.99, p = .046). Those on Medicare or who are uninsured have no difference in odds of obtaining a CT scan compared to patients with private insurance. Additional findings are that black patients are 42% less likely to receive a CT scan than white patients. Conclusions and implications: Patients on Medicaid are significantly less likely to receive a CT when presenting to the ED with AAP. Differences in diagnostic care may correlate to inferior health outcomes in patients without private insurance.

'Real-life' experience in asthmatic children treated with omalizumab up to six-years follow-up

INTRODUCTION AND OBJECTIVES

Omalizumab is present in international guidelines for the control of severe asthma, but data on the long-term effects in children are limited. Our objective was to perform a 'real-life' long-term trial of omalizumab in children with allergic asthma.

MATERIALS AND METHODS

An observational single center 'real-life' study was performed. Data for treatment, lung function, side effect, asthma exacerbations and hospitalizations were recorded at six months and annually.

RESULTS

Forty-eight patients <18 years of age were enrolled. Median treatment period was 2.9 (0.5-6). Fluticasone dose for the maintenance treatment decreases significantly at six months (452mcg/day to 329.89mcg/day, respectively). This difference was maintained throughout the follow-up. Nobody used oral corticosteroid after six months. The rate of hospital admissions and visits to the emergency department for asthma exacerbations decreased significantly in the third years and fourth years follow-up, respectively. There was an improvement in lung function. Mean values of FEV₁ and FEF_25-75% before treatment were 79.88 and 62.94, respectively; after six months of treatment a statistically significant change was seen with a mean FEV₁ of 92.29 and FEF_25-75% of 76.31 (p=0.0001). Lung function values were above normal throughout the six years of treatment. No side effects were reported.

CONCLUSIONS

Overall in 'real life' omalizumab in children reduces asthma exacerbations and hospitalizations, improves lung function, and decreases the maintenance therapy. It is shown to be safe for up to six years of treatment in children.

Stem cell-like transcriptional reprogramming mediates metastatic resistance to mTOR inhibition

Inhibitors of the mechanistic target of rapamycin (mTOR) are currently used to treat advanced metastatic breast cancer. However, whether an aggressive phenotype is sustained through adaptation or resistance to mTOR inhibition remains unknown. Here, complementary studies in human tumors, cancer models and cell lines reveal transcriptional reprogramming that supports metastasis in response to mTOR inhibition. This cancer feature is driven by EVI1 and SOX9. EVI1 functionally cooperates with and positively regulates SOX9, and promotes the transcriptional upregulation of key mTOR pathway components (REHB and RAPTOR) and of lung metastasis mediators (FSCN1 and SPARC). The expression of EVI1 and SOX9 is associated with stem cell-like and metastasis signatures, and their depletion impairs the metastatic potential of breast cancer cells. These results establish the mechanistic link between resistance to mTOR inhibition and cancer metastatic potential, thus enhancing our understanding of mTOR targeting failure.

Asymptomatic LTP sensitisation is common in plant-food allergic children from the Northeast of Spain

BACKGROUND

The sensitisation profile at molecular level in plant-food allergy is complex. Several allergens may be involved, with different potential for severe reactions. lipid transfer proteins (LTP) are considered the most relevant plant-food allergens in adults in Mediterranean countries, but less is known in children.

AIM

To describe the clinical pattern and sensitisation profile of children with plant-food allergy and LTP sensitisation from Northeast Spain.

METHODS

Children with history of immediate reaction to plant-food(s), positive skin-prick-test to the culprit plant-food(s) and specific-IgE to plant-food LTPs were analysed.

RESULTS

130 children were included. 69.2% (90/130) had reacted to ≥2 taxonomically unrelated plant-foods. Peach, walnut, hazelnut and peanut were most frequently involved. Reactions severity ranged from anaphylaxis (45.4%, 59/130) to oral symptoms only. Sensitisation to a particular plant-food LTP not always caused clinical symptoms with that plant-food; 69% (40/58) and 63% (17/27) of peach- and walnut-tolerant subjects had positive rPru p 3 and nJug r 3 specific IgE, respectively. 65.4% (85/130) of children were also sensitised to storage proteins, which was associated to anaphylaxis and nut allergy. However, 60% of patients without nuts/seeds allergy were sensitised to storage proteins. Specific-IgE levels to LTPs and/or storage proteins were not useful to predict allergy (vs. tolerance) to peach, walnut, peanut or hazelnut.

CONCLUSIONS

Sensitisation to LTP and/or storage proteins without clear clinical significance is relatively common. Prospective longitudinal studies are required to evaluate the relevance of these silent sensitisations over time. Caution is required when interpreting the results of molecular-based diagnostic tools in clinical practice.

Population genetic analysis of Anisakis simplex s.l. and Anisakis pegreffii (Nematoda, Anisakidae) from parapatric areas and their contact zone

Genetic markers (ribosomal DNA and mitochondrial DNA) were used for molecular dissection of the Anisakis simplex sensu lato (s.l). complex populations. Host fish were caught off Moroccan coasts, where only Anisakis pegreffii is present, the sympatric area comprising Spanish coasts, and the Little Sole Bank fishing area from Nordeast Atlantic Ocean where the only present species is A. simplex sensu stricto(s.s.). Sequence variations in the amplification products were then assessed indirectly by digestion with restriction endonucleases or directly by sequencing for 623 L3 larvae. The sequences were used to infer the relationships between the two species under study using various methodological approaches. We reveal the high genetic diversity of Anisakis simplex s.s. and A. pegreffii in both mitochondrial and nuclear genes. We detected 10 and 2 fixed differences between A. simplex s.s and A. pegreffii in the Cox2 and ITS1, respectively. We found a proportion of putative hybrids below 20% with similar figures on the Atlantic and Mediterranean coasts. Moroccan hybrids were more similar to A. pegreffii reflecting backcrosses between these mixed genotypes and his ancestor A. pegreffii. We discuss the possible interpretation of these putative hybrids.

Measuring ICTs Adoption in Health Care Facilities in Uruguay

The use of Information and Communication Technologies (ICTs) has gained an important role to enhance healthcare systems by increasing access to services, and improving the quality and equity of care. In order to evaluate the stage of ICTs adoption in the Uruguayan healthcare system, the Governmental Salud.uy Program carried out a national survey to establish the baseline for ICTs adoption, as well as define a set of indicators so as to evaluate the progress on this topic. Data was recorded following the OECD methodology.

Tolerance to egg proteins in egg-sensitized infants without previous consumption

BACKGROUND

Egg-sensitized infants who have never eaten egg may react at first ingestion. We sought to determine the association between skin prick test (SPT) and specific IgE (sIgE) to egg proteins (EP) and oral food challenge (OFC) outcomes to find cut-off points which can diagnose egg allergy.

METHODS

One hundred and fifty-four infants up to 18 months, with cow's milk allergy (CMA) and/or atopic dermatitis (AD) without previous egg consumption, were recruited. SPT to EP were performed. If it was positive, sIgE was performed. If positive SPT and/or sIgE (n = 94), OFC was performed between 12 and 18 months. Receiver operating characteristic (ROC) curves were plotted, and the outcome of the OFC was related to SPT and sIgE. The cut-off points with the best diagnostic accuracy were found.

RESULTS

Ninety-four patients were sensitized to egg (69%) and 60 nonsensitized (31%). Of the sensitized, 27 tolerated cooked (CE) and raw egg (RE) (28.7%). Sixty-seven were allergic (71.3%): 29 reacted to CE, seven to egg yolk (EY) and 22 to egg white (EW) and 38 reacted to RE. 69.2% tolerated CE. EW SPT and ovalbumin (OVA) sIgE have the best area under the curve (AUC). The higher positive predictive values (PPV) were obtained for EW SPT and EW sIgE.

CONCLUSIONS

In egg-sensitized infants with EW SPT ≥8 mm and/or EW sIgE ≥8.36 KU/l, egg diagnostic OFC can be avoided as there is 94% probability of becoming positive. In the other patients, OFC should be performed safely and early to avoid unnecessary diets.