The SelfSTarT intervention for low back pain patients presenting to first contact physiotherapists: A mixed methods service evaluation

INTRODUCTION

Globally, back pain is the leading cause of years of disability. In the United Kingdom, over 20 million people live with musculoskeletal (MSK) pain, with low back pain being one of the most common causes. National strategies promote self-management and the use of digital technologies to empower populations.

AIMS

To evaluate the uptake and impact of providing the SelfSTart approach (STarT Back and SelfBACK App) when delivered by a First Contact Physiotherapist (FCP) to people presenting with low back pain in primary care.

METHODS

Patients presenting with a new episode of low back pain underwent routine assessment and completion of a STarT Back questionnaire. Patients with low/medium scores were offered the SelfBACK App. A control population was provided by the MIDAS-GP study. Patient Experience, outcome measures, healthcare utilisation and retention were captured through the app and clinical systems (EMIS). Interviews with five FCPs explored the experiences of using the SelfSTart approach.

RESULTS

SelfSTarT was taken up by almost half (48%) of those to whom it was offered. Compared to MIDAS-GP, users were more likely to be younger, male, in work, and with higher health literacy. SelfSTarT users reported significant improved experiences relating to receiving an agreed care plan and receiving sufficient information. There were no significant differences in treatments offered. FCPs were positive about the app and felt it had value but wanted feedback on patient progress. They recognised that a digital solution would not be suitable for all.

CONCLUSION

This approach offers an opportunity to empower and support self-management, using robustly evaluated digital technology.

Achievement of Target Gain Larger than Unity in an Inertial Fusion Experiment

On December 5, 2022, an indirect drive fusion implosion on the National Ignition Facility (NIF) achieved a target gain G_{target} of 1.5. This is the first laboratory demonstration of exceeding "scientific breakeven" (or G_{target}>1) where 2.05 MJ of 351 nm laser light produced 3.1 MJ of total fusion yield, a result which significantly exceeds the Lawson criterion for fusion ignition as reported in a previous NIF implosion [H. Abu-Shawareb et al. (Indirect Drive ICF Collaboration), Phys. Rev. Lett. 129, 075001 (2022)PRLTAO0031-900710.1103/PhysRevLett.129.075001]. This achievement is the culmination of more than five decades of research and gives proof that laboratory fusion, based on fundamental physics principles, is possible. This Letter reports on the target, laser, design, and experimental advancements that led to this result.

Genome-scale analysis of essential gene knockout mutants to identify an antibiotic target process

We describe a genome-scale approach to identify the essential biological process targeted by a new antibiotic. The procedure is based on the identification of essential genes whose inactivation sensitizes a Gram-negative bacterium (Acinetobacter baylyi) to a drug and employs recently developed transposon mutant screening and single-mutant validation procedures. The approach, based on measuring the rates of loss of newly generated knockout mutants in the presence of antibiotic, provides an alternative to traditional procedures for studying essential functions using conditional expression or activity alleles. As a proof of principle study, we evaluated whether mutations enhancing sensitivity to the β-lactam antibiotic meropenem corresponded to the known essential target process of the antibiotic (septal peptidoglycan synthesis). We found that indeed mutations inactivating most genes needed for peptidoglycan synthesis and cell division strongly sensitized cells to meropenem. Additional classes of sensitizing mutations in essential genes were also identified, including those that inactivated capsule synthesis, DNA replication, or envelope stress response regulation. The essential capsule synthesis mutants appeared to enhance meropenem sensitivity by depleting a precursor needed for both capsule and peptidoglycan synthesis. The replication mutants may sensitize cells by impairing division. Nonessential gene mutations sensitizing cells to meropenem were also identified in the screen and largely corresponded to functions subordinately associated with the essential target process, such as in peptidoglycan recycling. Overall, these results help validate a new approach to identify the essential process targeted by an antibiotic and define the larger functional network determining sensitivity to it.

Food insecurity screening and local food access: Contributions to nutritional outcomes among children and adults with cystic fibrosis in the United States

BACKGROUND

As the nutritional status of people with CF (PwCF) is associated with their socioeconomic status, it is important to understand factors related to food security and food access that play a role in the nutritional outcomes of this population. We assessed the contributions of CF program-level food insecurity screening practices and area-level food access for nutritional outcomes among PwCF.

METHODS

We conducted a cross-sectional analysis of 2019 data from the U.S. CF Patient Registry (CFFPR), linked to survey data on CF program-level food insecurity screening and 2019 patient zip code-level food access. Pediatric and adult populations were analyzed separately. Nutritional outcomes were assessed with annualized BMI percentiles (CDC charts) for children and BMI (kg/m2) for adults, with underweight status defined as BMIp <10% for children and BMI <18.5 kg/m2 for adults, and overweight or obese status defined as BMIp >85% for children and BMI >25 kg/m2 for adults. Analyses were adjusted for patient sociodemographic and clinical characteristics.

RESULTS

The study population included 11,971 pediatric and 14,817 adult PwCF. A total of 137 CF programs responded to the survey, representing 71% of the pediatric sample and 45% of the CFFPR adult sample. The joint models of nutritional status as a function of both program-level food insecurity screening and area-level food access produced the following findings. Among children with CF, screening at every visit vs less frequently was associated with 39% lower odds of being underweight (OR 0.61, p = 0.019), and the effect remained the same and statistically significant after adjusting for all covariates (aOR 0.61, p = 0.047). Residence in a food desert was associated both with higher odds of being underweight (OR 1.66, p = 0.036; aOR 1.58, p = 0.008) and with lower BMIp (-4.81%, p = 0.004; adjusted -3.73%, p = 0.014). Among adults with CF, screening in writing vs verbally was associated with higher odds of being overweight (OR 1.22, p = 0.028; aOR 1.36, p = 0.002) and higher BMI (adjusted 0.43 kg/m2, p = 0.032). Residence in a food desert was associated with higher odds of being underweight (OR 1.48, p = 0.025).

CONCLUSIONS

Food insecurity screening and local food access are independent predictors of nutritional status among PwCF. More frequent screening is associated with less underweight among children with CF, whereas screening in writing (vs verbally) is associated with higher BMI among adults. Limited food access is associated with higher odds of being underweight in both children and adults with CF, and additionally with lower BMI among children with CF. Study results highlight the need for standardized, evidence-based food insecurity screening across CF care programs and for equitable food access to optimize the nutritional outcomes of PwCF.

Nutritional considerations for a new era: A CF foundation position paper

OBJECTIVE

To provide interim advice and considerations to the CF Community around CF nutrition in the current era.

METHODS

The Cystic Fibrosis (CF) Foundation organized a multidisciplinary committee to develop a Nutrition Position Paper based on the rapidly changing nutrition landscape in CF, due in part to widespread use of cystic fibrosis transmembrane regulator highly effective modulator therapy (HEMT). Four workgroups were formed: Weight Management, Eating Behavior/Food Insecurity, Salt Homeostasis and Pancreatic Enzyme use. Each workgroup conducted their own focused review of the literature.

RESULTS

The committee summarized current understanding of issues pertaining to the four workgroup topics and provided 6 key take-aways around CF Nutrition in the new era.

CONCLUSION

People with CF (pwCF) are living longer, particularly with the advent of HEMT. The traditional high fat, high calorie CF diet may have negative nutritional and cardiovascular consequences as pwCF age. Individuals with CF may have poor diet quality, food insecurity, distorted body image, and an higher incidence of eating disorders. An increase in overweight and obesity may lead to new considerations for nutritional management, given potential effects of overnutrition on pulmonary and cardiometabolic parameters.

Establishing a Cystic Fibrosis Learning Network: Interventions to promote collaboration and data-driven improvement at scale

Introduction

A learning health network is a type of learning health system in which stakeholders use network organization to improve health and health care. Building on existing resources in the cystic fibrosis (CF) community, the Cystic Fibrosis Learning Network (CFLN) was designed to improve medical outcomes and quality of life through an intentional focus on achieving reliable evidence-based chronic care delivery and creating a system for data-driven collaborative learning.

Methods

We describe the development and growth of the CFLN considering six domains of a Network Maturity Grid: system leadership; governance and policy management; quality improvement (QI); engagement and community building; data and analytics; and research. We illustrate the impact of the CFLN experience on chronic care processes and indicators of collaborative infrastructure.

Results

The CFLN represents 36 accredited care centers in the CF Foundation Care Center Network caring for over 6300 patients. Of 6779 patient clinical care visits/quarter, 77% are entered into the CF Foundation Patient Registry within 30 days, providing timely means to track outcomes. Collaborative visit planning is occurring in 93% of clinical care visits to share agenda setting with patients and families. Almost all CFLN teams (94%, n = 34) have a patient/family partner (PFP), and 74% of PFPs indicate they are actively participating, taking ownership of, or leading QI initiatives with the interdisciplinary care team. In 2022, 97% of centers reported completing 1-13 improvement cycles per month, and 82% contributed to monthly QI progress reports to share learning.

Conclusion

The CFLN is a maturing, collaborative infrastructure. CFLN centers practice at an advanced level of coproduction. The CFLN fosters interdisciplinary and PFP leadership and the performance of consistent data-driven improvement cycles. CFLN centers are positioned to respond to rapid changes in evidence-based care and advance the practice of QI and implementation science on a broader scale.

Study protocol for The GOAL Trial: comprehensive geriatric assessment for frail older people with chronic kidney disease to increase attainment of patient-identified goals-a cluster randomised controlled trial

BACKGROUND

An increasing number of older people are living with chronic kidney disease (CKD). Many have complex healthcare needs and are at risk of deteriorating health and functional status, which can adversely affect their quality of life. Comprehensive geriatric assessment (CGA) is an effective intervention to improve survival and independence of older people, but its clinical utility and cost-effectiveness in frail older people living with CKD is unknown.

METHODS

The GOAL Trial is a pragmatic, multi-centre, open-label, superiority, cluster randomised controlled trial developed by consumers, clinicians, and researchers. It has a two-arm design, CGA compared with standard care, with 1:1 allocation of a total of 16 clusters. Within each cluster, study participants ≥ 65 years of age (or ≥ 55 years if Aboriginal or Torres Strait Islander (First Nations Australians)) with CKD stage 3-5/5D who are frail, measured by a Frailty Index (FI) of > 0.25, are recruited. Participants in intervention clusters receive a CGA by a geriatrician to identify medical, social, and functional needs, optimise medication prescribing, and arrange multidisciplinary referral if required. Those in standard care clusters receive usual care. The primary outcome is attainment of self-identified goals assessed by standardised Goal Attainment Scaling (GAS) at 3 months. Secondary outcomes include GAS at 6 and 12 months, quality of life (EQ-5D-5L), frailty (Frailty Index - Short Form), transfer to residential aged care facilities, cost-effectiveness, and safety (cause-specific hospitalisations, mortality). A process evaluation will be conducted in parallel with the trial including whether the intervention was delivered as intended, any issue or local barriers to intervention delivery, and perceptions of the intervention by participants. The trial has 90% power to detect a clinically meaningful mean difference in GAS of 10 units.

DISCUSSION

This trial addresses patient-prioritised outcomes. It will be conducted, disseminated and implemented by clinicians and researchers in partnership with consumers. If CGA is found to have clinical and cost-effectiveness for frail older people with CKD, the intervention framework could be embedded into routine clinical practice. The implementation of the trial's findings will be supported by presentations at conferences and forums with clinicians and consumers at specifically convened workshops, to enable rapid adoption into practice and policy for both nephrology and geriatric disciplines. It has potential to materially advance patient-centred care and improve clinical and patient-reported outcomes (including quality of life) for frail older people living with CKD.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04538157. Registered on 3 September 2020.

Military experience in the management of pelvic fractures from OIF/OEF

INTRODUCTION

Pelvic fractures are a common occurrence in combat trauma. However, the fracture pattern and management within the most recent conflicts, i.e. Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF), have yet to be described, especially in the context of dismounted complex blast injury. Our goal was to identify the incidence, patterns of injury and management of pelvic fractures.

METHODS

We conducted a retrospective review on all combat-injured patients who arrived at our military treatment hospital between November 2010 and November 2012. Basic demographics, Young-Burgess fracture pattern classification and treatment strategies were examined.

RESULTS

Of 562 patients identified within the study time period, 14% (81 of 562) were found to have a pelvic fracture. The vast majority (85%) were secondary to an improvised explosive device. The average Injury Severity Score for patients with pelvic fracture was 31±12 and 70% were classified as open. Of the 228 patients with any traumatic lower extremity amputation, 23% had pelvic fractures, while 30% of patients with bilateral above-knee amputations also sustained a pelvic fracture. The most common Young-Burgess injury pattern was anteroposterior compression (APC) (57%), followed by lateral compression (LC) (36%) and vertical shear (VS) (7%). Only 2% (nine of 562) of all patients were recorded as having pelvic binders placed in the prehospital setting. 49% of patients with pelvic fracture required procedural therapy, the most common of which was placement of a pelvic external fixator (34 of 40; 85%), followed by preperitoneal packing (16 of 40; 40%) and angioembolisation (three of 40; 0.75%). 17 (42.5%) patients required combinations of these three treatment modalities, the majority of which were a combination of external fixator and preperitoneal packing. The likelihood to need procedural therapy was impacted by injury pattern, as 72% of patients with an APC injury, 100% of patients with a VS injury and 25% of patients with an LC injury required procedural therapy.

CONCLUSIONS

Pelvic fractures were common concomitant injuries following blast-induced traumatic lower extremity amputations. APC was the most common pelvic fracture pattern identified. While procedural therapy was frequent, the majority of patients underwent conservative therapy. However, placement of an external fixator was the most frequently used modality. Considering angioembolisation was used in less than 1% of cases, in the forward deployed military environment, management should focus on pelvic external fixation±preperitoneal packing. Finally, prehospital pelvic binder application may be an area for further process improvement.

1156 IMPROVING RECOGNITION OF POLYPHARMACY AND ADDRESSING INAPPROPRIATE PRESCRIBING ON A CARE OF THE ELDERLY WARD

Introduction

Polypharmacy is an increasing concern in medicine which will lead to prescribing errors, serious drug interactions and potentially inappropriate prescribing.

Aim

To improve recognition of ‘Polypharmacy’, routine medication reviews during patient admissions and better communication and awareness of ‘Polypharmacy’ to General Practitioners (GP).

Methods

This audit consisted of two cycles both performed over 6 weeks.

Inclusion criteria

Patients aged 65 &lt; and on 6 &lt; medications, admitted to Elderly Care ward at Chelsea and Westminster hospital. Interventions after the first cycle included education such as encouragement of clear documentation in medical record and GP summary, introduction of medication reviews as part of ward round, collaborative work with pharmacists. Potentially Inappropriate Medications (PIMS) were assessed using the STOPP/START criteria approved by NICE guidelines for review of medication regimes and highlighting PIMS.

Results

First cycle - 30 patients were recruited with an average age of 79.2 (13 males and 17 females). An average number of PIMS at the time of admission was 1.3 and 0.5 on discharge. Only 1/30 (3.3%) has ‘Polypharmacy’ documented and medication reviewed; Medications Reconciliation was 29/30 (96.7%). None of the patient has documentation for Polypharmacy.

Second cycle - 29 patients were recruited with and average age of 80.1. (7 males and 22 females). PIMs on admission was 1.4 and 0.3 on discharge. 25/29 (86.2%) patients had ‘Polypharmacy being documented and Medication review for 29/29(100%). Medication Reconciliation was 29/29(100%). Most Common PIMS across both cycles were statins, antihypertensive and Proton Pump Inhibitor.

Conclusion

The interventions complete improved significantly the awareness of Polypharmacy. There is a significant increment in number of medication review of 96.7% and 82.9% on documentation for ‘Polypharmacy’, and 20% reductions in PIMS on discharge.

Does lesion type or severity predict outcome of therapy for horses with equine glandular gastric disease? - A retrospective study

BACKGROUND

Equine glandular gastric disease (EGGD) is a common condition of the horse. Misoprostol is reported to be superior to oral omeprazole and sucralfate for treatment. Long-acting intramuscular injectable omeprazole (LAIOMEP) is a novel treatment shown to be effective in a small population.

OBJECTIVES

This study aimed to determine LAIOMEP efficacy compared to misoprostol and oral omeprazole and identify characteristics that predict treatment outcome.

METHODS

All horses that underwent gastroscopy between 2012 and 2019 were reviewed. Lesions were characterised by 4 blinded observers, all of whom are diplomates in equine internal medicine, using established descriptors from the ECEIM consensus statement and subjective severity. Treatment outcome was ranked as worsened, improved or healed. Consensus lesion type, lesion severity and treatment choice were compared to outcome and data screened using univariate analysis (chi-squared) to determine whether each predicted outcome. Lesion types where univariate analysis predicted a trend (p<0.2) were included in a multiple-regression analysis to identify predictors of outcome irrespective of treatment.

RESULTS

Only severity significantly predicted final outcome (p = 0.025) with severe lesions being more likely to improve. Treatment choice did not significantly predict outcome. Overall healing rate was 29% (24 horses), and 43% (44 horses) improved. Treatment healing rates were 23% (10), 12% (7) and 27% (7) for LAIOMEP, misoprostol and oral omeprazole, respectively, with improvement in 69% (14), 76% (21) and 61% (9). 64% of the latter group received sucralfate. Worsening occurred in 7% (6). Treatment length varied with a median of 4 weeks (range 4-20 weeks).

CONCLUSIONS

This study showed poorer therapy outcome compared to previous studies. The only initial lesion descriptor to predict outcome was severity and treatment choice did not affect outcome.

Lawson Criterion for Ignition Exceeded in an Inertial Fusion Experiment

For more than half a century, researchers around the world have been engaged in attempts to achieve fusion ignition as a proof of principle of various fusion concepts. Following the Lawson criterion, an ignited plasma is one where the fusion heating power is high enough to overcome all the physical processes that cool the fusion plasma, creating a positive thermodynamic feedback loop with rapidly increasing temperature. In inertially confined fusion, ignition is a state where the fusion plasma can begin "burn propagation" into surrounding cold fuel, enabling the possibility of high energy gain. While "scientific breakeven" (i.e., unity target gain) has not yet been achieved (here target gain is 0.72, 1.37 MJ of fusion for 1.92 MJ of laser energy), this Letter reports the first controlled fusion experiment, using laser indirect drive, on the National Ignition Facility to produce capsule gain (here 5.8) and reach ignition by nine different formulations of the Lawson criterion.

Very low event rate and few device implants in drug-induced brugada. A seven-year experience of ajmaline challenge at a district general hospital

Funding Acknowledgements

Type of funding sources: None.

Background

Patients with a drug-induced Brugada electrocardiogram (ECG) are thought to have a lower risk of sudden cardiac death than those with a spontaneous type 1 ECG. Despite having a Brugada ECG, most patients do not need an implantable cardioverter defibrillator (ICD).

Purpose

To report a district general hospital experience on referral and outcomes of ajmaline challenge (AC) with medium term follow up.

Methods

92 consecutive patients (50 males, mean age 41 ±17) had an AC in a single centre from 2014-2021. High ventricular leads were used from 2015. Ajmaline (1m/kg) was administered intravenously over 10-minutes. Data were collected from the electronic health record.

Results

The AC was positive in 18 (20%) patients. The yield from high leads was higher (7% vs 22%) p=0.28) but not statistically significant. There were no deaths or documented ventricular arrhythmias (VA) in AC positive patients during a median follow up of 3.2 years (1.7-4.9).

The resting ECG was normal in 46.7%. A type 1 pattern had been provoked by fever or electrolyte derangements in 3.3%, type 2 pattern in 8.7% and a type 3 pattern in 5.4%. An RSR pattern (not in keeping with a BrS ECG) was seen in 26.4%. The test was stopped prematurely due to QRS widening &gt;150ms in 1 patient. No adverse arrhythmic events occurred (table 1).

In our cohort, positive AC patients were older (48y vs 37y p= 0.05) and more likely to have a type 2 (28% vs 4% p=0.007) or type 3 ECG (17% vs 3% p=0.05). Asymptomatic patients were more likely to have a normal ECG (22% vs 78% p=0.05)

Of those with a positive AC, nine patients had symptoms of palpitations or syncope (table 2). A subcutaneous ICD (S-ICD) was implanted for syncope in two patients. No device therapies have occurred during a follow up of 2.5 years and 3.9 years respectively. Of those with a positive AC but asymptomatic, one S-ICD was initially implanted due to patient preference. A second S-ICD was implanted in a patient who experienced a collapse and brief seizure in the context of modest alcohol consumption.

In seven positive patients (39%) and 18 negative patients (23%) an ILR was implanted. 1 episode of complete heart block was detected in an ajmaline negative patient during a median follow up of 2.7 years (1.7-3.9).

There were no device related complications or adverse events.

Conclusion

AC is safe with a low number of device implants and ICD shocks. The yield from ILR implants was very low. A single patient had a potentially adverse outcome after consuming alcohol, a known trigger for VA in BrS. Our findings are in keeping with contemporary evidence that suggests the risk of adverse cardiac events in drug-induced BrS is low. However, time to first ICD shock may occur after ten years or more from diagnosis so long term follow up is required.

The Changing Landscape of Nutrition in Cystic Fibrosis: The Emergence of Overweight and Obesity

Cystic fibrosis has historically been characterized by malnutrition, and nutrition strategies have placed emphasis on weight gain due to its association with better pulmonary outcomes. As treatment for this disease has significantly improved, longevity has increased and overweight and obesity have emerged issues in this population. The effect of excess weight and adiposity on CF clinical outcomes is unknown but may produce similar health consequences and obesity-related diseases as those observed in the general population. This review examines the prevalence of overweight and obesity in CF, the medical and psychological impact, as well as the existing evidence for treatment in the general population and how this may be applied to people with CF. Clinicians should partner with individuals with CF and their families to provide a personalized, interdisciplinary approach that includes dietary modification, physical activity, and behavioral intervention. Additional research is needed to identify the optimal strategies for preventing and addressing overweight and obesity in CF.

Patient and family experience of telehealth care delivery as part of the CF chronic care model early in the COVID-19 pandemic

Background

During the COVID-19 pandemic, CF centers shifted to a telehealth delivery model. Our study aimed to determine how people with CF (PwCF) and their families experienced telehealth and assessed its quality and acceptability for future CF care.

Methods

The CF Patient and Family State of Care Survey (PFSoC) was fielded from August 31-October 30, 2020. The PFSoC explored themes of overall telehealth quality, ease of use, desirability, and preference for a future mix of in-person and telehealth care. Demographic covariates considered included: gender, age, CFTR modulator status, and region of residence.

Results

424 PwCF and parents of PwCF responded (47% parents). Most (81%) reported a telehealth visit which included a MD/APP and nurse team members. 91% found telehealth easy to use, and 66% reported similar/higher quality than in-person care. One-third (34%) reported the highest desire for future telehealth care, with 45% (n =212) desiring 50% or more of visits conducted via telehealth. Adults were more likely than parents to report highest desire for future telehealth (64% vs. 36%). Respondents who perceived telehealth as similar/higher quality were more likely to desire future telehealth compared to those who perceived telehealth as lower quality (96% vs. 50%). Mixed methods analysis revealed themes affecting perceptions of telehealth.

Conclusions

PwCF desire for future telehealth was influenced by perception of quality and age. Several themes emerged that need to be explored as telehealth is adapted into the CF chronic care model, especially when thinking about integration into pediatric care.

Comparison of risk factors for coronary event in people with unattributed and non-coronary chest pain: an electronic health record cohort study

Background

Patients presenting to primary care with chest pain are often not given a cause. Patients with such unattributed chest pain have an increased risk of future cardiovascular disease (CVD) compared to patients with diagnosed non-coronary chest pain. It is unknown whether risk factors for CVD determined in the general population are the same for the population with unattributed or non-coronary chest pain.

Purpose

To determine if key risk factors for a coronary event in patients with unattributed chest pain are similar to those for patients with non-coronary chest pain and previously identified in the general population.

Methods

The study used primary care information from the Clinical Practice Research Datalink Aurum linked to hospital inpatient and mortality data. Patients aged ≥18 years with an incident record of unattributed or non-coronary chest pain in 2002–2018 and no diagnosis of CVD were included. We included as potential risk factors those established for CVD in the general population and non-coronary explanations for chest pain. Flexible parametric models estimated hazard ratios (95% confidence intervals (CI)) between factors and incident coronary event (defined as myocardial infarction, angina, coronary heart disease, percutaneous intervention, and coronary artery bypass graft surgery).

Results

There were 375,240 patients with unattributed chest pain (53% female: mean age 49; 47% male: mean age 47) and 245,329 patients with non-coronary chest pain (58% female: mean age 47; 42% male: mean age 44). Median duration of follow-up was 5 years. In the unattributed chest pain group, there were 111 (95% CI: 109, 112) and 140 (138, 142) coronary events per 10,000 person-years in females and males, respectively. Lower rates of coronary event were observed in the non-coronary chest pain group (females: 73 (72, 75); males: 96 (94, 98)). Within females (Figure), in both chest pain groups the strongest risk factors were type I and type II diabetes, atrial fibrillation, and hypertension whereas no associations were observed for migraine and chronic kidney disease. Whilst alternative explanations for non-coronary chest pain also increased the risk of coronary events, associations were less strong than for established general population risk factors. Similar findings were found in males although family history of coronary event was a stronger risk factor in the non-coronary chest pain group compared to the unattributed chest pain group.

Conclusions

The pool of factors found to increase the risk of coronary events in patients presenting with recorded unattributed or non-coronary chest pain are similar but not identical to those identified for the general population. Further research is needed to develop prognostic models to identify patients at the most risk of a coronary event as models developed in the general population are unlikely to be applicable given the increased underlying risk of coronary events in these populations.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Study funded by the British Heart Foundation, reference PG/19/46/34307. KJ also supported by matched funding awarded to the NIHR Applied Research Collaboration (West Midlands). Risk factors for coronary event

Academy of Nutrition and Dietetics: 2020 Cystic Fibrosis Evidence Analysis Center Evidence-Based Nutrition Practice Guideline

The Academy of Nutrition and Dietetics Evidence Analysis Center conducted a systematic review of the literature to develop an evidence-based practice guideline for primary nutrition issues in cystic fibrosis (CF). This guideline is designed to complement and build upon existing evidence-based CF nutrition guidelines. The objective of this guideline was to provide recommendations for registered dietitian nutritionists in the United States delivering medical nutrition therapy to individuals with CF and their families that fill gaps in current evidence-based guidelines on topics that are crucial in order to improve health and prevent disease progression. This guideline provides 28 nutrition recommendations to guide medical nutrition therapy, including nutrition screening, nutrition assessment, and dietary intake. For topics outside the scope of this guideline, practitioners are referred to external, evidence-based recommendations. The CF landscape is evolving rapidly with breakthroughs in cystic fibrosis transmembrane regulator modulators changing CF at a cellular level. Medical nutrition therapy for individuals with CF from infancy through advanced age requires novel and individualized approaches. The Academy Evidence Analysis Library CF guidelines provide a framework for expanding upon current knowledge to determine effective nutrition strategies for individuals with CF through long and healthy futures.

A multiplanet system of super-Earths orbiting the brightest red dwarf star GJ 887

The closet exoplanets to the Sun provide opportunities for detailed characterization of planets outside the Solar System. We report the discovery, using radial velocity measurements, of a compact multiplanet system of super-Earth exoplanets orbiting the nearby red dwarf star GJ 887. The two planets have orbital periods of 9.3 and 21.8 days. Assuming an Earth-like albedo, the equilibrium temperature of the 21.8-day planet is ~350 kelvin. The planets are interior to, but close to the inner edge of, the liquid-water habitable zone. We also detect an unconfirmed signal with a period of ~50 days, which could correspond to a third super-Earth in a more temperate orbit. Our observations show that GJ 887 has photometric variability below 500 parts per million, which is unusually quiet for a red dwarf.

Effect of CFTR Modulators on Anthropometric Parameters in Individuals with Cystic Fibrosis: An Evidence Analysis Center Systematic Review

There is a strong positive association between nutrition status and lung function in cystic fibrosis (CF). Improvements in clinical care have increased longevity for individuals with CF, and it is unknown how cystic fibrosis transmembrane regulator (CFTR) modulation therapy affects nutrition status over time. The objective of this systematic review of the literature was to examine anthropometric (height, weight, and body mass index [BMI; calculated as kg/m²]) and body composition outcomes of CFTR modulation therapy. A literature search of Medline (Ovid), Embase, and CINAHL (EBSCO) databases was conducted for randomized controlled trials examining the effect of CFTR modulation therapy on anthropometric and body composition parameters, published in peer-reviewed journals from January 2002 until May 2018. Articles were screened, data were synthesized qualitatively, and evidence quality was graded by a team of content experts and systematic review methodologists. Significant weight gain with ivacaftor was noted in children and adults with at least 1 copy of G551D mutation. In adults with at least 1 copy of R117H the effect of ivacaftor on BMI was not significant. Effects on BMI were mixed in adults with class II mutations taking ivacaftor with lumacaftor. There was no significant change in BMI in children homozygous for F508del who took ivacaftor with tezacaftor. Elexacaftor-tezacaftor-ivacaftor increased BMI and body weight in individuals 12 years of age and older who were hetero- or homozygous for the F508del mutation. The effect of CFTR modulation therapy on anthropometric parameters depends on the genetic mutation and the type of modulation therapy used. More research is needed to understand the long-term clinical impact of these drugs on nutritional status, including body composition and the role of dietary intake.

FRI0511 THE DESCRIPTIVE EPIDEMIOLOGY AND SECULAR TRENDS OF LOWER BACK PAIN PROCEDURES IN ROUTINE UK NHS CARE FROM 2000 TO 2016

Background:

The lifetime prevalence of lower back pain is between 60% and 70%, with surgical treatments spared for those not responding to other options.

Objectives:

To investigate the age, gender and socio-economic status differences in back pain procedures in the UK between 2000, 2008 and 2016.

Methods:

Data was obtained from primary care electronic medical records (CPRD GOLD) linked to English hospital admissions data. Lower back procedures in patients aged 35+ were identified using OPCS-4 codes for Decompression (Dc), Fusion (F), Therapeutic injections (TI) and Denervation (Dn). Standardised incidence rates (IR) of each type of lower back procedures were calculated per 10,000 CPRD registered person years for each age group, gender, region and SES strata in 2000, 2008 and 2016. IR were also calculated for combinations of age and gender. Negative binomial regression calculated incidence rate ratios (IRR) and 95% confidence intervals.

Results:

The IR of lower back procedures was 21.5 [20.7, 22.3] per 10,000 person years in 2000. This doubled by 2008 (45.5 [44.5, 46.5]) and trebled by 2016 (62.5 [60.8, 64.2]). Number of events and incidence rates of each procedure type are shown in table 1 below. The incidence of Dn has increased 6-fold whilst Dc and F have doubled. Female (IR in 2016 of 73.99 [71.43, 76.61] vs 50.08 [47.90, 52.33] in men, IRR 1.50 [1.41, 1.59]) and age are associated with back procedure rates (figure 1). Large socio-economic differences were observed, with higher procedure rates seen in the most deprived areas. These differences did however narrow over time during the study period (figure 2).

Table 1.

Event numbers and incidence rates of different types of lower back procedure.

FusionDecompressionTherapeutic InjectionDenervationEventsIR (95% CI)EventsIR (95% CI)EventsIR (95% CI)EventsIR (95% CI)20001090.86 (0.71, 1.04)4663.69 (3.36, 4.04)203516.11 (15.42, 16.82)910.72 (0.58, 0.88)20083331.77 (1.58, 1.97)11976.35 (6.00, 6.72)628333.35 (32.53, 34.18)5963.16 (2.91, 3.43)20161591.93 (1.65, 2.26)5256.39 (5.85, 6.96)386547.03 (45.56, 48.54)4875.93 (5.41, 6.48)Figure 1.

Age and Gender stratified incidence rate ratios of all back procedures in 2000, 2008 and 2016

Figure 2.

Deprivation status incidence rate ratios by year

Conclusion:

The incidence of lower back procedures has more than trebled since 2000. Women are more likely to have lower back procedures than men, with patients aged 65-74 the most likely to have a procedure. Procedures in those aged 75+ have become more common over time, potentially increasing the risk of post-operative complications. Socio-economic differences in the incidence of low back procedures are probably related to the known higher prevalence of back pain in deprived areas. Whether the observed narrowing in socio-economic variation over time is explained by a reduced need or by lowered provision needs further research.

Disclosure of Interests:

Danielle E Robinson: None declared, Jennifer Lane: None declared, Richard Craig: None declared, Andrew Judge: None declared, James Bailey: None declared, Dahai Yu: None declared, Kelvin Jordan: None declared, George Peat: None declared, Ross Wilkie: None declared, Alan Silman: None declared, Victoria Y Strauss: None declared, Daniel Prieto-Alhambra Grant/research support from: Professor Prieto-Alhambra has received research Grants from AMGEN, UCB Biopharma and Les Laboratoires Servier, Consultant of: DPA’s department has received fees for consultancy services from UCB Biopharma, Speakers bureau: DPA’s department has received fees for speaker and advisory board membership services from Amgen

Global, Regional, and National Levels and Trends in Burden of Oral Conditions from 1990 to 2017: A Systematic Analysis for the Global Burden of Disease 2017 Study

Government and nongovernmental organizations need national and global estimates on the descriptive epidemiology of common oral conditions for policy planning and evaluation. The aim of this component of the Global Burden of Disease study was to produce estimates on prevalence, incidence, and years lived with disability for oral conditions from 1990 to 2017 by sex, age, and countries. In addition, this study reports the global socioeconomic pattern in burden of oral conditions by the standard World Bank classification of economies as well as the Global Burden of Disease Socio-demographic Index. The findings show that oral conditions remain a substantial population health challenge. Globally, there were 3.5 billion cases (95% uncertainty interval [95% UI], 3.2 to 3.7 billion) of oral conditions, of which 2.3 billion (95% UI, 2.1 to 2.5 billion) had untreated caries in permanent teeth, 796 million (95% UI, 671 to 930 million) had severe periodontitis, 532 million (95% UI, 443 to 622 million) had untreated caries in deciduous teeth, 267 million (95% UI, 235 to 300 million) had total tooth loss, and 139 million (95% UI, 133 to 146 million) had other oral conditions in 2017. Several patterns emerged when the World Bank’s classification of economies and the Socio-demographic Index were used as indicators of economic development. In general, more economically developed countries have the lowest burden of untreated dental caries and severe periodontitis and the highest burden of total tooth loss. The findings offer an opportunity for policy makers to identify successful oral health strategies and strengthen them; introduce and monitor different approaches where oral diseases are increasing; plan integration of oral health in the agenda for prevention of noncommunicable diseases; and estimate the cost of providing universal coverage for dental care.

Week 48 Resistance Analyses of the Once-Daily, Single-Tablet Regimen Darunavir/Cobicistat/Emtricitabine/Tenofovir Alafenamide (D/C/F/TAF) in Adults Living with HIV-1 from the Phase III Randomized AMBER and EMERALD Trials

Darunavir/cobicistat/emtricitabine/tenofovir alafenamide (D/C/F/TAF) 800/150/200/10 mg is being investigated in two Phase III trials, AMBER (NCT02431247; treatment-naive adults) and EMERALD (NCT02269917; treatment-experienced, virologically suppressed adults). Week 48 AMBER and EMERALD resistance analyses are presented. Postbaseline samples for genotyping/phenotyping were analyzed from protocol-defined virologic failures (PDVFs) with viral load (VL) ≥400 copies/mL at failure/later time points. Post hoc analyses were deep sequencing in AMBER, and HIV-1 proviral DNA from baseline samples (VL <50 copies/mL) in EMERALD. Through week 48 across both studies, no darunavir, primary PI, or tenofovir resistance-associated mutations (RAMs) were observed in HIV-1 viruses of 1,125 participants receiving D/C/F/TAF or 629 receiving boosted darunavir plus emtricitabine/tenofovir-disoproxil-fumarate. In AMBER, the nucleos(t)ide analog reverse transcriptase inhibitor (N(t)RTI) RAM M184I/V was identified in HIV-1 of one participant during D/C/F/TAF treatment. M184V was detected pretreatment as a minority variant (9%). In EMERALD, in participants with prior VF and genoarchive data (N = 140; 98 D/C/F/TAF and 42 control), 4% had viruses with darunavir RAMs, 38% with emtricitabine RAMs, mainly at position 184 (41% not fully susceptible to emtricitabine), 4% with tenofovir RAMs, and 21% ≥ 3 thymidine analog-associated mutations (24% not fully susceptible to tenofovir) detected at screening. All achieved VL <50 copies/mL at week 48 or prior discontinuation. D/C/F/TAF has a high genetic barrier to resistance; no darunavir, primary PI, or tenofovir RAMs were observed through 48 weeks in AMBER and EMERALD. Only one postbaseline M184I/V RAM was observed in HIV-1 of an AMBER participant. In EMERALD, baseline archived RAMs to darunavir, emtricitabine, and tenofovir in participants with prior VF did not preclude virologic response.

Dietary Macronutrient Distribution and Nutrition-Related Outcomes in Cystic Fibrosis: A Systematic Review (P12-016-19)

Objectives

Conduct a systematic review (SR) to determine the relationship between dietary macronutrient distribution and nutrition-related outcomes in pediatric and adult participants with cystic fibrosis (CF).

Methods

A literature search of Medline, CINAHL and Embase databases was conducted to identify peer-reviewed articles published from January 2002- May 2018 that examined human participants with CF and addressed the research objective. Articles were screened for relevance, data was extracted and summarized, and risk of bias was assessed by a multidisciplinary team of researchers, practitioners, patient advocates and SR methodologists.

Results

A total of 2409 articles were identified in the search and eight cross-sectional studies and one case-control study met inclusion criteria (N = 4 in pediatrics, N = 4 in adults, N = 1 combined). Evidence quality was low due to weak study designs, small samples size and inconsistent outcome reporting. Available studies did not show statistically significant relationships between dietary macronutrient distribution and lung function (FEV1%) (3 studies) when estimated protein intake ranged from 10–23% of energy, fat intake from 20–46% of energy and carbohydrate intake from 32–67% of energy. Macronutrient distribution was not significantly associated with anthropometric measurements/growth (3 studies), gastrointestinal symptoms (2 studies), glucose fluctuations (1 study) or lipid profile (1 study) in this SR. There were no studies identified examining the relationship between macronutrient distribution and mortality or Quality of Life. Meta-analysis was not possible due to the low quality of data reported.

Conclusions

Recent evidence describing the relationship between dietary macronutrient distribution and nutrition-related outcomes in participants with CF is sparse and low in quality. The evidence reviewed does not suggest that dietary macronutrient distribution is related to key clinical CF outcomes. Higher-quality trials and longitudinal studies are needed to confirm these findings. The need for updated dietary studies is particularly important in light of recent therapeutic advances that are changing the clinical course of individuals with CF.

Funding Sources

Academy of Nutrition and Dietetics and the Medical Nutrition Practice Group DPG.

Effect of Cystic Fibrosis Transmembrane Receptor Modulators on Anthropometric and Growth Parameters in Individuals with Cystic Fibrosis: A Systematic Review (OR36-08-19)

Objectives

Individuals with cystic fibrosis (CF) are at high risk for malnutrition and poor growth. New drugs that modulate CF transmembrane receptor (CFTR) function are available, although their effects on anthropometric parameters are not clear. This systematic review aimed to determine if various CFTR modulator therapies affect weight and growth parameters in individuals with CF.

Methods

A literature search was conducted using MEDLINE, CINAHL and Embase databases for peer-reviewed, randomized controlled trials (RCT) published from January 2002 to May 2018 that examined the effect of CFTR modulation therapy on weight and growth parameters in children and adults with CF. Articles were screened for relevance, data was extracted and summarized, and risk of bias was assessed to determine the quality of evidence.

Results

A total of 612 original articles were identified, and 13 articles representing 10 RCTs were included in qualitative synthesis and three were included in quantitative synthesis. All but one RCT demonstrated low risk of bias. The targeted class of CFTR mutation varied by RCT. Studies indicated that, in children and adults with CF with class III mutations, ivacaftor treatment alone increased weight and BMI (4 RCTs), but it did not influence growth in individuals with class II (1 RCT) or class IV mutations (1 RCT). Treatment with ivacaftor + lumacaftor in adults homozygous for the F508del CFTR mutation (class II) increased BMI following 24 weeks of treatment (2 RCTs), but there was no effect in adults heterozygous for the mutation treated for 8 weeks (1 RCT). Treatment with lumacaftor + tezacaftor in individuals ages 12–20 years with class II mutations did not change growth parameters (1 RCT).

Conclusions

Effects of CFTR modulators on increasing weight and growth in individuals with CF are likely dependent on the therapy formulation (single vs combination therapy) and the targeted CFTR mutation. Whereas ivacaftor alone increases weight and growth parameters in individuals with class III mutations, ivacaftor + lumacaftor is more effective at increasing BMI in adults homozygous for the class II F508del CFTR mutation. Additional studies are needed to determine effects of other CFTR modulator drugs on growth parameters in individuals with varying CFTR mutations.

Funding Sources

Academy of Nutrition and Dietetics/Medical Nutrition DPG, National Institutes of Health.

Efficacy and safety of a non-mineral oil adjuvanted injectable vaccine for the protection of Atlantic salmon (Salmo salar L.) against Flavobacterium psychrophilum

Flavobacterium psychrophilum is the causative agent of Rainbow Trout Fry Syndrome which has had a major impact on global salmonid aquaculture. Recent outbreaks in Atlantic salmon in Scotland and Chile have added to the need for a vaccine to protect both salmon and trout. At present no licensed vaccines are available in Europe, leaving antibiotics as the only course of action to contain disease outbreaks. Outbreaks generally occur in fry at temperatures between 10 and 15 °C. Recently outbreaks in larger fish have given added impetus to the development of a vaccine which can provide long term protection from this highly heterogeneous pathogen. Most fish injectable vaccines are formulated with oil emulsion adjuvants to induce strong and long lasting immunity, but which are known to cause side effects. Alternative adjuvants are currently sought to minimise these adverse effects. The current study was performed to assess the efficacy of a polyvalent, whole cell vaccine containing formalin-inactivated F. psychrophilum to induce protective immunity in Atlantic salmon. The vaccine was formulated with an adjuvant containing squalene and aluminium hydroxide, and was compared to a vaccine formulated with a traditional oil adjuvant, Montanide ISA 760VG, and a non-adjuvanted vaccine. Duplicate groups of salmon (23.5 ± 6.8 g) were vaccinated with each of the vaccine formulations or phosphate buffered saline by intraperitoneal injection. Fish were challenged by intramuscular injection with F. psychrophilum six weeks post-vaccination to test the efficacy of the vaccines. Cumulative mortality reached 70% in the control salmon, while the groups of salmon that received vaccine had significantly lower mortality than the controls (p = 0.0001), with no significant difference in survival between vaccinated groups. The squalene/alum adjuvant was safe, more readily metabolised by the fish and induced less histopathological changes than the traditional oil adjuvant.

Epidemiological Study on Factor VII, Factor VIII and Fibrinogen in an Industrial Population - II. Baseline Data on the Relation to Blood Pressure, Blood Glucose, Uric Acid, and Lipid Fractions

In a preceding paper the baseline data in the Munster Arteriosclerosis Study (PROCAM study) of the levels of fibrinogen, factor VIIc and factor VIIIc were described, and their correlation of age, body weight, smoking, alcohol, pill-using and menopause discussed. In this part the relationship of these coagulation factors to blood pressure, blood glucose, uric acid and lipid parameters, which were examined in 4186 apparently healthy individuals, is presented. The correlations are described using two different statistical models, first the Pearson correlation coefficients after allowing each clotting factor for the effects of age, cigarette and alcohol consumption, body weight, menopausal state, pill using and the other clotting factors, and secondly by a multiple regression analysis. The data suggest that there are multiple interrelationships between hemostatic factors and the variables under consideration. The most striking positive correlations were found for factor VII c to blood glucose and triglycerides in men and women and to HDDcholesterol in women.

Does 'hacking' surface type affect equine forelimb foot placement, movement symmetry or hoof impact deceleration during ridden walk and trot exercise?

BACKGROUND

Both pleasure and competition horses regularly exercise on surfaces such as tarmac, gravel and turf during 'hacking'. Despite this, there is limited evidence relating to the effect of these surfaces upon foot-surface interaction.

OBJECTIVES

To investigate forelimb foot placement, hoof vibration and movement symmetry in pleasure horses on three commonly encountered hacking surfaces.

STUDY DESIGN

Quantitative gait study in a convenience sample.

METHODS

Six horses regularly partaking in hacking exercise were ridden in walk and trot on all surfaces. Horses were equipped with one hoof-mounted, accelerometer and four body-mounted inertial measurement units (IMUs) to measure foot impact and movement symmetry. High-speed (400 FPS) video footage of foot-placement was acquired (dorsal, palmar, lateral views). Foot-impact and movement symmetry were analysed with a mixed effects model and Bowker symmetry tests for foot-placement analysis.

RESULTS

Vibration power and frequency parameters increase as perceived surface firmness increases from grass, to gravel, to tarmac (P≤0.001). Vibration power parameters were consistently greater at trot compared with walk (P≤0.001), but the same was not true for vibration frequency (P≥0.2). Greatest movement asymmetry was recorded during grass surface trotting. No significant difference in foot-placement was detected between the three surfaces.

MAIN LIMITATIONS

This was a field study using three commonly encountered hacking surfaces. Surface properties change easily with water content and temperature fluctuations so care must be taken when considering other similar surfaces, especially at different times of the year. Six leisure horses were used so the results may not be representative of horses of all types.

CONCLUSIONS

Vibration parameters generally increase as perceived surface firmness increases. Increasing speed alters vibration power but not frequency. Further investigations are required to determine the role that this may play in the development of musculoskeletal disease in horses.

Nurses' perceptions of personal attributes required when working with people with a learning disability and an offending background: a qualitative study

WHAT IS KNOWN ON THE SUBJECT?: Learning disability nursing in the area of people with a learning disability and an offending background has developed considerably over recent years, particularly since the publication of the Bradley (). There has been limited work into the competencies nurses require to work in this area, and even less about the personal attributes of learning disability nurses. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Learning disability nursing's specific contribution to the care of this population lies in their knowledge of the interaction between the learning disability, an individual's, sometimes abusive, personal history and an understanding of the subsequent offending behaviour. The knowledge base of nurses working with people with learning disabilities and an offending background needs to reflect the changing service user group. This is particularly in relation to substance misuse, borderline personality disorder, and mental health and the way such factors inter-relate with the learning disability. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Further research is required into the relationship among decision making, risk taking or reluctance to do this, and the personal attributes required by nurses to work in secure learning disability care. Learning disability secure services are likely to continue to undergo change as circumstances alter and the offending population demonstrate greater complexity; nursing competencies and personal attributes need similarly to adapt to such changes. Mental health nursing has a great deal to contribute to effective working with this population, specifically with regard to developing strong relationships when concerns around borderline personality disorder or substance misuse are particularly in evidence.

ABSTRACT

Aim To identify and discuss the personal attributes required by learning disability nurses to work effectively with people with an offending background in secure and community settings. Background This study was part of a larger research investigation into the nursing competencies required to work with people with an offending background. There are few existing studies examining the personal attributes necessary for working with this group. Design A qualitative study addressing the perceptions of nurses around the personal attributes required to work with people with learning disabilities and an offending background. Methods A semi-structured interview schedule was devised and constructed, and 39 individual interviews were subsequently undertaken with learning disability nurses working in high, medium, low secure and community settings. Data were collected over 1 year in 2010/11 and analysed using a structured thematic analysis supported by the software package MAXqda. Findings The thematic analysis produced three categories of personal attributes, named as looking deeper, achieving balance and connecting, each of which contained a further three sub-categories. Conclusion Nursing of those with a learning disability and an offending background continues to develop. The interplay among personal history, additional background factors, nurses' personal attributes and learning disability is critical for effective relationship building.

Graphene electrodes for adaptive liquid crystal contact lenses

The superlatives of graphene cover a whole range of properties: electrical, chemical, mechanical, thermal and others. These special properties earn graphene a place in current or future applications. Here we demonstrate one such application - adaptive contact lenses based on liquid crystals, where simultaneously the high electrical conductivity, transparency, flexibility and elasticity of graphene are being utilised. In our devices graphene is used as a transparent conductive coating on curved PMMA substrates. The adaptive lenses provide a + 0.7 D change in optical power with an applied voltage of 7.1 V_rms - perfect to correct presbyopia, the age-related condition that limits the near focus ability of the eye.

Abstract P6-12-08: Healthcare barrier profiles in patients navigated for cancer screening and treatment and the impact of the affordable care act

Background: The underserved community experiences barriers to cancer screening that result in overall greater mortality rates across all cancers. Insurance coverage brought forth by the Affordable Care Act has the potential to significantly impact these barriers through reducing the burden of health care cost on the patient. In this study the authors observe the impact of the Affordable Care Act on the barrier profiles presented by the patients navigated for cancer screening and treatment.

Methods: Patient navigation encounters were recorded for a total of 1146 patients navigated for cancer screening and treatment at the Cleveland Clinic Foundation from the years 2012 through 2015. A total of 3259 encounters were classified into barrier types. Health care billed encounters were retrieved from EPIC for this group of patients from the time they entered patient navigation and classified in terms of insurance coverage. Patients were categorized according to their barrier profile. Appropriate generalized linear regression models were used to test for association of these profiles to number and types of navigation and health care encounters and cost, and to test for change in types of encounters and patient barrier profiles through time.

Results: The insurance barrier is present in 23% of all navigation encounters. Patients presenting with an insurance barrier had a greater mean number of navigation (p&lt;0.001) and health care encounters (p&lt;0.006), had a greater proportion of self-paid health care encounters (p&lt;0.001) and a lower total cost billed for health care encounters after controlling for number of encounters (p&lt;0.001) . The access barrier is present in 53% of navigation encounters while patients that present with only the access barrier account for 42% of the entire sample. Patients that present with only the access barrier have doubled every year (OR 2.2 per year, 95% CI [1.8 2.6]) from 2012 to 2015, while the proportion of self-paid health care encounters (OR 0.26 per year, 95% CI [0.25 0.28]) and the presence of the insurance barrier (OR 0.55 per year, 95% CI [ 0.49 0.62]) have more than halved during this time period.

Conclusion: Although the Affordable Care Act has clearly had an impact by lowering the number of insurance barrier navigation encounters through time, it has uncovered access as the predominant remaining barrier. Understanding and targeting the access barrier will be the most effective way to potentiate the effects of the ACA on patients being navigated for cancer screening and treatment.

Citation Format: Raska P, Ott MA, Steele A, Bailey A, Hickman D, Allen D, Urbanek D, Glass K, Bailey J, Bell K, Montero A, Abraham J. Healthcare barrier profiles in patients navigated for cancer screening and treatment and the impact of the affordable care act. [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 P6-12-08.

Abstract P1-09-03: Socioeconomic characteristics of African American women with breast cancer

Background: Breast cancer is the most common cancer among African American (AA) women. Despite having a lower incidence of breast cancer compared to white women (124.4 compared to 127.9 per 100,000), AAs have a higher death rate (30.2 compared to 21.3 per 100,000). One explanation for this discrepancy is that breast cancer in AAs is often detected at a later stage compared to white women. We conducted this retrospective study to examine socioeconomic characteristics among AA women with breast cancer to see if there were factors associated with stage of diagnosis which may contribute to the known disparities. Methods: We identified all AA women diagnosed with any stage breast cancer from 2006-2014 within the Cleveland Clinic Cancer Data Warehouse and classified them into either early or late stage disease at time of diagnosis. Stages 0-II were classified as early and stages III-IV as late. We examined several variables at diagnosis including age, marital status, tobacco use, alcohol use, Medicaid insurance status, and breast cancer subtype which included HER-2 positive (HER+), hormone receptor positive/HER2 negative (HR+/HER-), and triple negative(TN). AA median income was obtained from US census data according to the zip code at diagnosis. We conducted univariate logistic regression for individual estimates and confidence intervals and multiple logistic regression and model selection to determine significant predictors of stage of diagnosis. Results: Of the 771 AA women identified, 108 (14%) were diagnosed at a late stage of disease with a median age of 59 years. Receptor status distribution was 12.4%, 31%, and 16.6% for HER+, HR+/HER-, and TN respectively for early stage, and 15.7%, 27%, and 25% for late stage. Among early stage 50% were current or previous smokers and 2.6% had Medicaid insurance compared to late stage patients where 63% were current or previous smokers and 9.2% had Medicaid insurance. Multiplicative effect estimates and 95% confidence intervals from univariate logistic regressions identified the following significant factors: tobacco use 1.48 [1.11-1.96] and Medicaid 3.73 [1.56-8.51] (p-values&lt;0.01), and TNBC 1.67 [1.02-2.68] (p-value&lt;0.05). In a stepwise model selection, only tobacco use and Medicaid were retained in the model, as well as age at diagnosis. Conclusions: There are socioeconomic differences among AA women with breast cancer. Only tobacco use, Medicaid insurance, and age at diagnosis were predictive of late stage in this study.

Citation Format: Winter A, Raska P, Ornstein M, Moore H, Montero A, Budd GT, Tullio K, Bailey J, Abraham J. Socioeconomic characteristics of African American women with breast cancer. [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 P1-09-03.