Abandonment Rates Research Articles

Carbon sequestration potential of second-growth forest regeneration in the Latin American tropics.

Regrowth of tropical secondary forests following complete or nearly complete removal of forest vegetation actively stores carbon in aboveground biomass, partially counterbalancing carbon emissions from deforestation, forest degradation, burning of fossil fuels, and other anthropogenic sources. We estimate the age and spatial extent of lowland second-growth forests in the Latin American tropics and model their potential aboveground carbon accumulation over four decades. Our model shows that, in 2008, second-growth forests (1 to 60 years old) covered 2.4 million km(2) of land (28.1% of the total study area). Over 40 years, these lands can potentially accumulate a total aboveground carbon stock of 8.48 Pg C (petagrams of carbon) in aboveground biomass via low-cost natural regeneration or assisted regeneration, corresponding to a total CO2 sequestration of 31.09 Pg CO2. This total is equivalent to carbon emissions from fossil fuel use and industrial processes in all of Latin America and the Caribbean from 1993 to 2014. Ten countries account for 95% of this carbon storage potential, led by Brazil, Colombia, Mexico, and Venezuela. We model future land-use scenarios to guide national carbon mitigation policies. Permitting natural regeneration on 40% of lowland pastures potentially stores an additional 2.0 Pg C over 40 years. Our study provides information and maps to guide national-level forest-based carbon mitigation plans on the basis of estimated rates of natural regeneration and pasture abandonment. Coupled with avoided deforestation and sustainable forest management, natural regeneration of second-growth forests provides a low-cost mechanism that yields a high carbon sequestration potential with multiple benefits for biodiversity and ecosystem services.

Developing Effective Service Policies for Multiclass Queues with Abandonment: Asymptotic Optimality and Approximate Policy Improvement

We study a single server queuing model with multiple classes and impatient customers. The goal is to determine a service policy to maximize the long-run reward rate earned from serving customers net of holding costs and penalties respectively due to customers waiting for and leaving before receiving service. We first show that it is without loss of generality to study a pure-reward model. Since standard methods can usually only compute the optimal policy for problems with up to three customer classes, our focus is to develop a suite of heuristic approaches, with a preference for operationally simple policies with good reward characteristics. One such heuristic is the Rμθ rule—a priority policy that ranks all customer classes based on the product of reward R, service rate μ, and abandonment rate θ. We show that the Rμθ rule is asymptotically optimal as customer abandonment rates approach zero and often performs well in cases where the simpler Rμ rule performs poorly. The paper also develops an approximate policy improvement method that uses simulation and interpolation to estimate the bias function for use in a dynamic programming recursion. For systems with two or three customer classes, our numerical study indicates that the best of our simple priority policies is near optimal in most cases; when it is not, the approximate policy improvement method invariably tightens up the gap substantially. For systems with five customer classes, our heuristics typically achieve within 4% of an upper bound for the optimal value, which is computed via a linear program that relies on a relaxation of the original system. The computational requirement of the approximate policy improvement method grows rapidly when the number of customer classes or the traffic intensity increases.

The ongoing violence against women: Female Genital Mutilation/Cutting.

Female Genital Mutilation/Cutting (FGM/C) comprises different practices involving cutting, pricking, removing and sometimes sewing up external female genitalia for non-medical reasons. The practice of FGM/C is highly concentrated in a band of African countries from the Atlantic coast to the Horn of Africa, in areas of the Middle East such as Iraq and Yemen, and in some countries in Asia like Indonesia. Girls exposed to FGM/C are at risk of immediate physical consequences such as severe pain, bleeding, and shock, difficulty in passing urine and faeces, and sepsis. Long-term consequences can include chronic pain and infections. FGM/C is a deeply entrenched social norm, perpetrated by families for a variety of reasons, but the results are harmful. FGM/C is a human rights issue that affects girls and women worldwide. The practice is decreasing, due to intensive advocacy activities of international, national, and grassroots agencies. An adolescent girl today is about a third less likely to be cut than 30 years ago. However, the rates of abandonment are not high enough, and change is not happening as rapidly as necessary. Multiple interventions have been implemented, but the evidence base on what works is lacking. We in reproductive health must work harder to find strategies to help communities and families abandon these harmful practices.

Wolf-caribou dynamics within the central Canadian Arctic

The severity of recent declines of barren-ground caribou (Rangifer tarandus groenlandicus) across the central Canadian Arctic has led to harvest restrictions and concerns about population recovery. Wolves (Canis lupus) are the main predator of barren-ground caribou; however, the extent that wolves influence the decline and recovery of caribou herds is unknown. Such uncertainty confounds management responses (e.g., reducing harvest, predator control). We investigated wolf–caribou dynamics on the summer range of barren-ground caribou in the Northwest Territories and Nunavut, Canada (i.e., Bathurst caribou herd). Our primary objective was to test for a numerical response of wolves to changes in the abundance and spatial distribution of caribou. Caribou experienced a >90% decline in abundance over the study period (1996–2014). Using long-term data sets (1996–2012), we developed regression models to investigate relationships between abundance indices of wolves and range-use patterns of caribou. We monitored the movements of adult female wolves fitted with global positioning system (GPS) collars representing individual packs throughout the 2013 and 2014 denning periods. We also investigated pup recruitment, an index of population decline, at a time of low caribou abundance. Finally, we developed a series of stochastic population models to understand how pup recruitment influenced wolf densities on the Bathurst range over the period of caribou decline. As caribou abundance decreased, the late-summer distribution of the Bathurst herd contracted toward the calving ground. These movements correlated with low rates of wolf pup recruitment and high den abandonment, suggesting a regulatory mechanism whereby wolf reproductive success was limited by the low availability of caribou within the denning areas. Furthermore, these data suggested a numerical response, where wolf densities decreased as caribou numbers declined. In 2014, wolf density was estimated at <4 wolves/1,000 km2. Our results suggest that these wolves exhibited a relatively strong numerical response to a single, declining prey base. Given the continued decline in the Bathurst caribou herd, the tundra wolf population on the Bathurst range has likely declined below our 2014 estimate. © 2016 The Wildlife Society.

AN EVALUATION OF THE ABANDONMENT OF ELECTRONICALLY TRANSMITTED PRESCRIPTIONS FOR WARFARIN AND NEW ORAL ANTICOAGULANT AGENTS

A recent study of Humana patients found the rate of primary abandonment in electronically transmitted prescriptions was 12.1%. The highest primary abandonment rates were found with Thrombin Inhibitors and Direct Factor Xa Inhibitors at rates of ≥39% and ≥60% respectively (Bruno A, Ellis J et al

Colony Dynamics of Large Gulls Nesting in Labrador, Canada

Abstract. Information on the status, trends and dynamics of large gulls nesting in northern areas is limited. Herring (Larus argentatus) and Great Black-backed (L. marinus) gull breeding colonies were surveyed in coastal Labrador, Canada, from 1998 to 2003 to assess short-term population trends and colony site dynamics. Between 1998 and 2003, 117 islands distributed across three major archipelagos were surveyed on two or more occasions, documenting 1,054 gull clutches. Nesting was noticeably uniform across islands in the archipelagos, with mild aggregations noted in only one region. Incidence (the proportion of islands occupied by Herring and Great Black-backed gulls) declined over the study period, and there were fewer colonization events than abandonment events (also suggesting declines). Abundance declined in one region and overall at 2.9% per year over the 6-year period. Colony abandonment rates did not detectably decline with increasing colony size, and island isolation, indexed by the number of isla...

Nest sites selection by sympatric cavity-nesting birds in miombo woodlands

Deforestation and habitat fragmentation have long been known as drivers of wildlife depletion but information on their specific impacts on cavity-nesting birds in the miombo woodlands has been lacking. A comparative study of disturbed and undisturbed sites was conducted in miombo woodlands of Zambia to assess impacts of environmental stressors on birds. Foot patrols were employed to locate, identify and count host trees and cavities for cavity-nesting birds on twenty 200 m × 200 m sample plots. Undisturbed forests had three times more cavities (the nesting sites for birds), while there were 24.6% fewer abandoned cavities in undisturbed forests than in disturbed forests. The rate of cavity abandonment was about twice as high in human-dominated forests compared to undisturbed forests (61.3% c.f. 31.9%). Cavity-nesting birds preferred larger (&gt; 36.0 cm diameter at breast height) and taller (&gt; 5.0 m) trees for nest placement, especially in human-dominated forests. A number of cavity-nesting birds preferred Brachystegia spiciformis (zebrawood), Julbernadia paniculata (munsa), Parinari curatellifolia (mobola-plum) and Uapaca kirkiana (mahobohobo) as host trees to 14 other miombo tree species. Arnot’s Chat (Myrmecocichla arnoti) had a wider selection of host trees for cavity-nesting than the other 40 cavity-nesting birds in the study areas. Anthropogenic activities such as uncontrolled firewood collection, wild fires, logging, and land clearing for agriculture negatively influenced wood abundance and diversity, with potential implications for persistence of cavity-nesting birds. The negative impacts of anthropogenic activities could be counteracted by conservation strategies such as implementation of sound forest policies, integrative land use practices, sustainable livelihood security and stakeholders’ awareness of the need to safeguard forest-dependent avifauna.Conservation implications: This comparative study unravels specific anthropogenic impacts on the cavity-nesting birds in the miombo woodlands, which would be relevant for designing and implementing targeted biodiversity conservation interventions against negative local environmental values and attitudes that support rural development on the expense of conservation of biodiversity such as birds.

Con: Buttonhole cannulation of arteriovenous fistulae.

Successful cannulation of arteriovenous fistulas (AVFs) using a safe and effective technique that minimizes patient harm is a crucial aspect of haemodialysis treatment. Although the current standard of care for many years has been the rope-ladder technique (using sharp needles to cannulate rotating sites across the entire AVF), a number of enthusiasts have recently advocated for the alternative method of buttonhole cannulation (using blunt needles to repeatedly cannulate the same site via a healed track) on the basis of putative, as yet unproven benefits. In this article, we review all available observational studies, randomized controlled trials, and systematic reviews and meta-analyses that have compared the clinical outcomes of buttonhole and rope-ladder cannulation of AVFs. These studies clearly and consistently demonstrated that buttonhole cannulation causes significant and serious infectious harm to haemodialysis patients, especially in the home setting. No strategies or treatments have been proven to effectively mitigate this hazard of buttonhole cannulation. Moreover, buttonhole cannulation is associated with a higher rate of abandonment and has not been shown to have any proven benefit compared with the rope-ladder method. Specifically, buttonhole cannulation has not been shown to reduce cannulation-related pain, improve vascular access survival, reduce vascular access interventions, reduce haematoma formation, improve haemostasis or reduce aneurysm formation. Consequently, rope-ladder cannulation should remain the standard of care and buttonhole cannulation should only be used in rare circumstances (e.g. short segment AVFs where the only alternative is a haemodialysis catheter).

Maya Healers' Conception of Cancer as Revealed by Comparison With Western Medicine.

PurposeCultural diversity in clinical encounters is common, yet mental constructions regarding cancer that influence expected treatment are poorly studied for indigenous people. We explored Maya healers' conceptions, diagnosis, and treatment of cancer to remedy this problem.MethodsIn-depth structured interviews with 67 traditional Maya healers in Guatemala across Kaqchikel, Kiche', Mam, Mopan, and Q'eqchi' ethnolinguistic groups were conducted by using a transdisciplinary format. Analysis of qualitative data in categorized matrixes allowed for statistical examination of tendencies and the results were complemented by validation workshops with Maya representatives.ResultsMaya classification of diseases has broad categories of malignant diseases including cancer. Specific Maya terms might equate to particular cancer types, which would open new avenues for research. Notions of malignancy and metastasis were expressed by healers as core characteristics of cancer, a disease believed to be both material and spiritual. Resolution of and/or treatment for cancer is based on restoring physical, mental, emotional, and spiritual equilibrium of the patient and extending that equilibrium to his larger social circle.ConclusionMaya conceptions of cancer determine how traditional diagnostic tools are used and dictate treatment options that include the patient's social-spiritual support system. Official health care providers' understanding of these principles can improve implementation of culturally appropriate protocols that increase indigenous patients' compliance and reduce rates of treatment abandonment.

Performance analysis of a two-node computing cluster

This paper proposes a queueing model for the performance evaluation of a computing cluster. Requests arrive to the configurations according to a Poisson process at rate λ. There is a load balancing hardware in front of two servers to route requests to a free server if any. The service is commenced according to the first-come-first-served (FCFS) principle. The system can be either in the normal state or in the working vacation state. The service time of each customer during the normal state is exponentially distributed. We develop the balance equations for the steady-state probabilities and solve the equations by using the generating function and hypergeometric function. We obtain some performance measures for the system, such as the steady-state probabilities of the servers, the mean system sizes, the mean sojourn time of a customer served as well as the proportion of customers served and the rate of abandonment due to impatience. Finally, some numerical results are presented to demonstrate effects of some parameters on these performance measures of the system.

5α-reductase inhibitors and the risk of grade reclassification for men with long-term follow-up on active surveillance for prostate cancer.

92 Background: The role of 5α-reductase inhibitors (5-ARIs) in prostatic diseases remains controversial because of an FDA black box label. We have previously published on the impact of 5-ARIs in men managed with active surveillance (AS), demonstrating their protective effect against progression. However, the long-term safety of 5-ARIs in the setting of AS has never been described, thus we sought to assess this. Methods: This is a single-institution, prospectively maintained, retrospective cohort study comparing men taking a 5-ARI versus no 5-ARI while on AS for PCa. Pathologic progression was evaluated and defined as Gleason score &gt; 6, maximum core involvement &gt; 50%, or more than 3 cores positive on a follow-up prostate biopsy. Time dependent covariate analysis to account for time on AS but not on 5-ARI was conducted to diminish the likelihood of overestimating the benefit. To account for differences in prostate volume at baseline between 5-ARI and non-5-ARI groups sensitivity analyses were performed, restricting men in the non-5-ARI group to those with larger glands (volume &gt; 40 ml). Kaplan-Meier analyses were conducted along with multivariable Cox proportional hazard regression modeling for predictors of pathologic progression. Results: The original cohort of 288 men on AS were analyzed. The median follow-up was 61.2 months (IQR: 29.8-95.24) with 124 men (43%) experiencing pathologic progression and 119 men (41.3%) abandoning AS. Men taking a 5-ARI experienced a lower rate of pathologic progression (24.3% vs 49.1%; p &lt; 0.001) and were less likely to abandon AS (25.7% vs 46.3%; p = 0.002). On multivariable Cox proportional hazards analysis, lack of 5-ARI use was most strongly associated with pathologic progression (HR: 2.56; 95% confidence interval, 1.32-5.02). Sensitivity analyses done to account for gland size demonstrated that lack of 5-ARI use was still predictive of progression (HR: 2.76; CI, 1.45–5.25; p = 0.002). Importantly, 5-ARI use was not associated with increased risk of high-grade prostate cancer. Conclusions: 5-ARIs were associated with a significantly lower rate of pathologic progression and abandonment of AS in men with median follow-up of 5 years.

The When and Why of Abandonment: The Role of Organizational Differences in Medical Technology Lifecycles

Although the adoption of new technology has received significant attention in management research, investigations of abandonment have lagged. In this study, we examine differences in the rates of abandonment of medical technologies based on whether abandonment occurs in response to the emergence of a superior technology, or in light of new information questioning its efficacy. We link differences in responses to underlying differences in the mission and incentives of organizations. Examining coronary stents across three technological regime changes using a census of approximately 2 million patients admitted to Florida hospitals from 1995-2007, we show meaningful differences across three hospital types: for-profit, not-for-profit, and academic medical centers (AMCs), Results show that for-profit hospitals abandon the earlier generation in favor of a superior technology faster than not-for-profit hospitals, but this is not the case if the efficacy of the technology is questioned. Academic medical centers, however, have the highest rates of abandonment under both triggers. Importantly, we find that organizational factors dominate physician differences as explanatory factors for abandonment. Implications of these findings are two-fold. First, we identify the factors likely at play, i.e. the salience of norms of science and the corresponding trade-offs with economic benefits, when organizations make abandonment decisions. Second, our work underscores the importance of organizational mission, which dominates individual preferences in determining rates of abandonment.

Beyond ‘functionality’ of handpump-supplied rural water services in developing countries

Many rural point-water sources in developing countries consist of wells or boreholes equipped with handpumps. Various estimates have been made of the functionality of such water points, and functionality is now routinely monitored in national and local surveys of service performance. We argue, however, that a single binary (functional/non-functional) indicator is crude and insufficient to provide much information about service sustainability. We set out a categorization of functionality which includes three sub-categories of functional water points and five non-functional sub-categories, with well/handpump water points in mind. We use a simple model to demonstrate that reduction of high rates of early post-construction abandonment and reduction of total downtimes would greatly improve service performance. We show that functionality levels for multi-age populations of wells or boreholes equipped with handpumps would not normally be expected to exceed about 85 per cent. We recommend going beyond functionality monitoring via the collection of quantitative data on rates of abandonment, frequency and duration of breakdown, combined with descriptive narratives of actions to manage and repair water points, in order to generate more nuanced understanding of service performance.

Difficulties in access and estimates of public beds in intensive care units in the state of Rio de Janeiro.

ABSTRACTOBJECTIVE To estimate the required number of public beds for adults in intensive care units in the state of Rio de Janeiro to meet the existing demand and compare results with recommendations by the Brazilian Ministry of Health.METHODS The study uses a hybrid model combining time series and queuing theory to predict the demand and estimate the number of required beds. Four patient flow scenarios were considered according to bed requests, percentage of abandonments and average length of stay in intensive care unit beds. The results were plotted against Ministry of Health parameters. Data were obtained from the State Regulation Center from 2010 to 2011.RESULTS There were 33,101 medical requests for 268 regulated intensive care unit beds in Rio de Janeiro. With an average length of stay in regulated ICUs of 11.3 days, there would be a need for 595 active beds to ensure system stability and 628 beds to ensure a maximum waiting time of six hours. Deducting current abandonment rates due to clinical improvement (25.8%), these figures fall to 441 and 417. With an average length of stay of 6.5 days, the number of required beds would be 342 and 366, respectively; deducting abandonment rates, 254 and 275. The Brazilian Ministry of Health establishes a parameter of 118 to 353 beds. Although the number of regulated beds is within the recommended range, an increase in beds of 122.0% is required to guarantee system stability and of 134.0% for a maximum waiting time of six hours.CONCLUSIONS Adequate bed estimation must consider reasons for limited timely access and patient flow management in a scenario that associates prioritization of requests with the lowest average length of stay.

Childhood acute lymphoblastic leukemia: refusal and abandonmentof treatment in the southeast of Iran.

Acute lymphoblastic leukemia (ALL) accounts for 25% of all malignancies in children. ALL treatment has standard protocols, and treatment abandonment is a main cause of treatment failure. Therefore, this study aimed to assess the relationship between socioeconomic status and rate as well as cause of abandoned treatment in children with ALL in the southeast of Iran. This retrospective, descriptive cohort study was conducted with ALL patients at the Ali Asghar Hospital in the city of Zahedan. The study population included 22 children with different subtypes of ALL who had abandoned their treatment. A structural questionnaire was filled out by patients or their parents. Results were assessed using descriptive and analytical tests. The rate of treatment abandonment was 24.4% (22 patients).We had 18 ALL-L1 (78.3%) and four ALL-L2 (17.4%) patients. Reasons for treatment abandonment were low family income, transportation difficulties, the father's education status, conviction about ALL's incurability, and reference to spiritual means, respectively. Low family income, transportation difficulties, the father's education status, belief about ALL's incurability, and reference to spiritual means were the most common associations with ALL treatment abandonment in that order. Financial problems in this part of the country can impose high costs to the healthcare system.

Large-scale log analysis of digital reading

In this paper, we address daily reading practices of the general public in Russia analyzing 10 months of log data from the commercial ebook site Bookmate. We study different reading characteristics with ebooks, i.e. the reading volume and preferences, reading schedule, reading speed and reading style (including parallel reading patterns and book abandonment rates), with respect to reader gender, book length and genre of the book. We find that book genres impact certain reading behaviors, while gender differences or book length seem to play less of a role in ebook reading. Parallel book reading and book abandonment occur very frequently, possibly pointing towards changing reading behaviors in the ebook environment. The obtained insights demonstrate the high potential of log analysis for book reading studies.

Prosthesis Control with an Implantable Multichannel Wireless Electromyography System for High-Level Amputees

Myoelectric prostheses lack a strong human-machine interface, leading to high abandonment rates in upper limb amputees. Implantable wireless electromyography systems improve control by recording signals directly from muscle, compared with surface electromyography. These devices do not exist for high amputation levels. In this article, the authors present an implantable wireless electromyography system for these scenarios tested in Merino sheep for 4 months. In a pilot trial, the electrodes were implanted in the hind limbs of 24 Sprague-Dawley rats. After 8 or 12 weeks, impedance and histocompatibility were assessed. In the main trial, the system was tested in four Merino sheep for 4 months. Impedance of the electrodes was analyzed in two animals. Electromyographic data were analyzed in two freely moving animals repeatedly during forward and backward gait. Device implantation was successful in all 28 animals. Histologic evaluation showed a tight encapsulation after 8 weeks of 78.2 ± 26.5 µm subcutaneously and 92.9 ± 31.3 µm on the muscular side. Electromyographic recordings show a distinct activation pattern of the triceps, brachialis, and latissimus dorsi muscles, with a low signal-to-noise ratio, representing specific patterns of agonist and antagonist activation. Average electrode impedance decreased over the whole frequency range, indicating an improved electrode-tissue interface during the implantation. All measurements taken over the 4 months of observation used identical settings and showed similar recordings despite changing environmental factors. This study shows the implantation of this electromyography device as a promising alternative to surface electromyography, providing a potentially powerful wireless interface for high-level amputees.

Effectiveness of farmland transfer in alleviating farmland abandonment in mountain regions

Farmland abandonment is a type of land use change in the mountain region, and this change is under rapid development. Whether farmland transfer can prevent this process and promote the effective allocation of land resources or not is a question worth studying and discussion. With the help of the previous research findings, the objective of this paper was to find out the role of farmland transfer on preventing farmland abandonment, by using the methods of multiple view with two factors, and single factor correlation analysis. The results showed that: (1) At village level, a significant negative correlation between farmland transfer and farmland abandonment existed in the study site, with R 2 = 0.7584. This correlation of farmland with high grade farming conditions presented more outstandingly. The fitted curve for the farmland at Level I had the largest R 2 at 0.288, while that for the farmland at Level IV had the smallest R 2 at 0.103. Which indicated that farmland transfer could prevent the abandonment of farmland with high grade farming conditions? (2) At plot level, the abandonment rate of farmland with high grade farming conditions was significantly lower than that of farmland with poor grade farming conditions. It was the lowest at 10.49% for the farmland with Level I farming conditions, whereas the farmland with Level I farming conditions was 26.21%. Abandoned farmland was mainly contributed by farmland with Level IV farming conditions in the study site. (3) At village level, the role of farming conditions on farmland abandonment was insignificant. The univariate correlation analysis revealed that the abandonment ratio was negatively correlated with the proportions of farmland at Levels I and II and their accumulated proportion; however, their R 2 were small at 0.194, 0.258, and 0.275, respectively. The abandonment of farmland with high farming conditions still existed. The abandonment ratios of farmland at Levels I and II were high at 9.96% and 10.60%, respectively. This presented that farmland transfer on behalf of the land rental market was still not developed. (4) However, the village possessed the high rate of farmland transfer, and its rate of farmland abandonment with high grade farming conditions was all lower. When the transfer ratios of farmland were over 20%, the abandonment ratios of farmland at Levels I and II were 6.47% and 6.92%, respectively. Farmland abandonment was still controlled by the improvement of land rental market. And the functions of land rental market optimizing the utilization of farmland resources have been presented to a certain degree. (5) To further improve the marketing degree of land rental, the probability of farmland abandonment could be reduced. Especially, their function to farmland with high grade farming conditions was very obvious, and could avoid the waste of farmland resources with high grade farming conditions.

Impact of Out-of-Pocket Costs on Prescription Fills Among New Initiators of Biologic Therapies for Rheumatoid Arthritis.

Biologic disease-modifying antirheumatic drug (DMARD) therapies are a mainstay of treatment for rheumatoid arthritis (RA), yet high member out-of-pocket (OOP) costs for such therapies may limit patient access to these therapies. To understand whether there is a relationship between OOP costs and the initial fill and subsequent refills of biologic DMARD treatments for RA members. Members of a national Medicare Advantage and Prescription Drug (MAPD) plan with an adjudicated (paid or reversed) claim for a biologic DMARD indicated for RA were identified from July 1, 2007, to December 31, 2012, and followed retrospectively. The first adjudicated claim date was the index date. Members were required to have 180 days of continuous enrollment pre- and post-index and ≥ 1 diagnosis for RA (ICD-9-CM: 714.0 or 714.2) during pre-index or ≤ 30 days post-index. Low-income subsidy and Medicaid-Medicare dual-eligible patients were excluded. The analysis used multivariate regression models to examine associations between initial prescription (Rx) abandonment rates and OOP costs and factors influencing the refill of a biologic DMARD therapy based on pharmacy claims. The final sample size included 864 MAPD members with an adjudicated claim for a biologic DMARD. The majority were female (77.4%) and mean age was 63.5 years (SD = 10.9). Most (78%) had conventional nonbiologic DMARD utilization during pre-index. The overall initial abandonment rate was 18.2% for biologic DMARDs, ranging from 1.3% for the lowest OOP cost group ($0-$250) to 32.7% for the highest OOP cost group (> $550; P < 0.0001 for Cochran-Armitage trend test). ORs for abandonment rose from 18.4 to 32.7 to 41.2 for OOP costs of $250.01-$400.00, $400.01-$550.00, and > $550.00 respectively, relative to OOP costs of ≤ $250.00 (all P < 0.0001). Meeting the catastrophic coverage limit and utilization of a specialty pharmacy for the index claim were both associated with a decreased likelihood of abandoning therapy (OR = 0.29 and OR = 0.14, respectively; both P < 0.05). Among the subset of 533 members with a paid claim, 82.4% had at least 1 refill post-index. The negative association between OOP cost and likelihood of refilling an Rx was highly significant (P < 0.0001). This study suggests that the higher the member OOP cost, the less likely an MAPD member is to initiate or refill a biologic DMARD therapy for RA. Further research is needed to understand reasons for initial Rx abandonment and lack of refills, including benefit design and adverse events.

Strict Treatment Regimen and Febrile Neutropenia Guidelines Allow Favorable Outcomes for Pediatric ALL in Southern India

Background: Children with Acute Lymphoblastic Leukemia (ALL) in resource-poor countries face major challenges including treatment abandonment and poor overall survival (OS) and event-free survival (EFS). To address these issues, in 2002 a non-profit pediatric hematology-oncology center was established in a tertiary medical institution in Kerala, India to provide high-quality treatment and supportive care at low cost. A standardized approach to pediatric leukemia care began in 2010. We present evidence that outcomes on par with that seen in resource-rich nations can be achieved with a rigorous treatment and supportive care approach.Methods: Following IRB approval, we reviewed clinical information and outcomes of all patients above 1 year and less than 14 years of age treated for newly diagnosed B- or T-ALL between January 1, 2010 and January 31, 2015. Seventy-six children were consecutively treated and all are included in this analysis. B-ALL patient treatment was stratified according to BFM relapse risk criteria with standard risk (SR) defined by age 1-6 yrs, peripheral WBC < 20 X 106/ul, good prednisolone response, absence of t(9:22) and t(4:11), and a day 33 marrow in remission by morphology. At any age, poor prednisolone response, t(9:22) or t(4:11), or day 33 marrow not in remission defined high risk (HR), and patients not meeting SR or HR criteria were intermediate risk (IR). Minimal residual disease assessment (MRD) was not utilized in risk stratification or treatment decisions. All patients were treated as per BFM 2002 with modifications. All patients received 4-drug (Vincristine/ Daunorubicin/ L Asparaginase/ Prednisolone) induction and Phase 2 induction of cyclophosphamide, cytosine arabinoside, and daily 6-mercaptopurine (6-MP), followed by consolidation with oral 6-MP and IV methotrexate (MTX), 2 gm/m2 x 4 for SR and IR B-ALL and 5 gm/m2 x 4 for HR B-ALL, T-ALL, and CNS disease. Phase 1 reinduction utilized adriamycin and dexamethasone. The Phase 2 reinduction regimen closely mirrored Phase 2 induction. HR B-ALL and T-ALL patients received 12 Gy prophylactic cranial irradiation, and those with CNS disease 18 Gy. Maintenance therapy consisted of daily oral 6-MP, weekly oral MTX, and monthly IV Vincristine and oral Dexamethasone for 104 weeks. Prophylactic intrathecal MTX was given 11 times through reinduction and every 3 months in maintenance. Febrile neutropenia protocols were enforced to ensure less than 30 minutes elapsed from presentation with fever > 38o C to initiation of broad spectrum antibiotics. To minimize sepsis risk, prophylactic GCSF was given between cycles to target ANC > 0.5 x 106/uL. OS and EFS were assessed by Kaplan-Meier method. Patients were censored at last follow-up. Abandonment was treated as an event in calculating EFS. Kuppuswami Socioeconomic Scale (KES) was applied using phone interviews of guardians.Results: Median follow-up time was 30.3 months (range, 1.9-61 months). One patient (1.3%) died during induction, 1 was censored at loss to follow-up upon transfer of treatment to another center, none abandoned treatment, and 6 (7.9%) relapsed, with 1 (1.3%) relapse within 90 days of diagnosis. At median follow-up, the OS was 93.4% and EFS 90.8% (95% CI, 81.1%-99.1%). SR accounted for 28 (36.8%), IR for 36 (47.4%), and HR for 11 (14.5%) patients. OS by risk stratification is shown in Figure 1. KES analysis on the 65 contactable families revealed a median family income between Indian Rs. 14,000-37,000 (US $218-577)/month, and 14 (21.5%) having income less than Rs. 9,300 (US $145)/month. Thirty (46.1%) stratified as lower-middle class or lower. The primary wage earner had less than a high school education in 21 (32.3%), and was at a clerical or lower work level in 46 (70.8%) of families.Conclusion: Our data demonstrate that, for pediatric ALL, results similar to resource-rich countries can be provided in resource-poor areas through a tertiary care center maintaining adherence to globally accepted guidelines for treatment and management of treatment-associated complications. We plan to report minimum 5-year follow-up for all patients in future. Future prospective studies will examine the role of MRD-based stratification and allogeneic transplant options for high-risk patients, as well as seek to extend the low rates of toxic death and abandonment to neighboring centers by implementation of best practices throughout the region. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.