Concurrent Visits Research Articles

Impact of High Deductible Health Plans on Continuous Buprenorphine Treatment for Opioid Use Disorder.

Long-term, continuous treatment with medication like buprenorphine is the gold standard for opioid use disorder (OUD). As high deductible health plans (HDHPs) become more prevalent in the commercial insurance market, they may pose financial barriers to people with OUD. To estimate the impact of HDHPs on continuity of buprenorphine treatment, concurrent visits for counseling/psychotherapy and OUD-related evaluation and management, and out-of-pocket spending. Difference-in-differences analysis comparing trends in outcomes among enrollees whose employers offer an HDHP (treatment group) to enrollees whose employers never offer an HDHP (comparison group). Enrollees with OUD from a national sample of commercial health insurance plans during 2007-2017 who initiate buprenorphine treatment. Number of days of continuous buprenorphine treatment; probabilities of continuous buprenorphine treatment ≥30, ≥90, ≥180, and ≥365 days; probability of concurrent (i.e., within the same month) behavioral therapy (i.e., counseling or psychotherapy); probability of concurrent OUD-related evaluation and management visits; proportions of buprenorphine treatment episodes with counseling/psychotherapy and evaluation and management visits; and out-of-pocket (OOP) spending on buprenorphine, behavioral therapy, and evaluation and management visits. HDHPs were associated with an average increase of $98 (95% CI: $48, $150) on OOP spending on buprenorphine per treatment episode but no change in the number of days of continuous buprenorphine treatment or concurrent use of related services. HDHPs do not reduce continuity of buprenorphine treatment among commercially insured enrollees with OUD but may increase financial burden for this population.

Graph Reachability on Parallel Many-Core Architectures

Many modern applications are modeled using graphs of some kind. Given a graph, reachability, that is, discovering whether there is a path between two given nodes, is a fundamental problem as well as one of the most important steps of many other algorithms. The rapid accumulation of very large graphs (up to tens of millions of vertices and edges) from a diversity of disciplines demand efficient and scalable solutions to the reachability problem. General-purpose computing has been successfully used on Graphics Processing Units (GPUs) to parallelize algorithms that present a high degree of regularity. In this paper, we extend the applicability of GPU processing to graph-based manipulation, by re-designing a simple but efficient state-of-the-art graph-labeling method, namely the GRAIL (Graph Reachability Indexing via RAndomized Interval) algorithm, to many-core CUDA-based GPUs. This algorithm firstly generates a label for each vertex of the graph, then it exploits these labels to answer reachability queries. Unfortunately, the original algorithm executes a sequence of depth-first visits which are intrinsically recursive and cannot be efficiently implemented on parallel systems. For that reason, we design an alternative approach in which a sequence of breadth-first visits substitute the original depth-first traversal to generate the labeling, and in which a high number of concurrent visits is exploited during query evaluation. The paper describes our strategy to re-design these steps, the difficulties we encountered to implement them, and the solutions adopted to overcome the main inefficiencies. To prove the validity of our approach, we compare (in terms of time and memory requirements) our GPU-based approach with the original sequential CPU-based tool. Finally, we report some hints on how to conduct further research in the area.

Development of Deep Learning Models to Predict Best-Corrected Visual Acuity from Optical Coherence Tomography.

PurposeTo develop deep learning (DL) models to predict best-corrected visual acuity (BCVA) from optical coherence tomography (OCT) images from patients with neovascular age-related macular degeneration (nAMD).MethodsRetrospective analysis of OCT images and associated BCVA measurements from the phase 3 HARBOR trial (NCT00891735). DL regression models were developed to predict BCVA at the concurrent visit and 12 months from baseline using OCT images. Binary classification models were developed to predict BCVA of Snellen equivalent of <20/40, <20/60, and ≤20/200 at the concurrent visit and 12 months from baseline.ResultsThe regression model to predict BCVA at the concurrent visit had R2 = 0.67 (root-mean-square error [RMSE] = 8.60) in study eyes and R2 = 0.84 (RMSE = 9.01) in fellow eyes. The best classification model to predict BCVA at the concurrent visit had an area under the receiver operating characteristic curve (AUC) of 0.92 in study eyes and 0.98 in fellow eyes. The regression model to predict BCVA at month 12 using baseline OCT had R2 = 0.33 (RMSE = 14.16) in study eyes and R2 = 0.75 (RMSE = 11.27) in fellow eyes. The best classification model to predict BCVA at month 12 had AUC = 0.84 in study eyes and AUC = 0.96 in fellow eyes.ConclusionsDL shows promise in predicting BCVA from OCTs in nAMD. Further research should elucidate the utility of models in clinical settings.Translational RelevanceDL models predicting BCVA could be used to enhance understanding of structure–function relationships and develop more efficient clinical trials.

Research on Performance Optimization of Web Application System based on JAVA EE

With the development of informatization, the Web application system is being used by more and more enterprises and institutions. With the increase of the user group, the concurrent visits are increasing, which leads to the poor service quality of Web system. Several high-concurrency solutions existed, but they address only one aspect of the performance problem, and small and medium enterprises need to consider the cost. This paper will analyze the performance factors affecting the Web application system through multiple levels, aiming to build a Web application system with high availability, high concurrency, high expansion and less cost. Based on the factors affecting the performance of the Web application system, the project of the online mall system was optimized, and the service support of the Web application system was adjusted to make it more suitable for the system requirements. Besides, related SQL statements were optimized, Java code layer was optimized, user experience layer was optimized, and performance testing and analysis were completed.

Behavior, Diet, and Habitat Use by Blonde Capuchin Monkeys (Sapajus flavius) in a Coastal Area Prone to Flooding: Direct Observations and Camera Trapping

Coastal areas prone to flooding are relatively neglected in primate studies. Eight out of 29 known populations of Critically Endangered Sapajus flavius occur in areas very close to, or containing, mangrove and varzea (i.e., tidal forests) forests, suggesting that these habitats are important for the species. We monitored Sapajus flavius in a mosaic of mangrove forest, estuarine varzea forest, and terra firme forest (i.e., nonfloodable forest) in northeastern Brazil. We carried out the study through direct observations of the animals, tracking their signs and baited camera trapping, between January and December 2016. Direct observations and signs provided 292 records of Sapajus flavius: 61% in terra firme, 36% in varzea, and 3% in mangrove. We recorded 26 food items consumed: 17 plants and 9 animals. Camera trapping provided 396 records of the animals: 21% in terra firme, 73% in varzea, and 6% in mangrove. Concurrent visits to more than one camera trap station suggested fission–fusion behavior in Sapajus flavius. We recorded carried infants throughout 2016, suggesting the absence of reproductive seasonality in the species. Adult females carried infants on 68% of occasions, suggesting that they play a key role in infant care. Sapajus flavius was largely diurnal but showed some crepuscular activity. Agonistic behaviors, although rare, were positively related to the quantity of food available in the baited camera trap stations, while play behaviors were negatively related to food availability. Coastal areas prone to flood are used by Sapajus flavius, especially varzea, and thus they should receive wide attention from researchers and protection from the government to avoid local extinctions of Sapajus flavius and other primates inhabiting such areas in Brazil.

Abstract P192: Improving LDL Documentation and Control in Coronary Artery Disease Patients

Background: Obtaining a fasting lipid profile prior to a scheduled clinic visit can facilitate decision making at the time of the visit. However, this places extra burden on patients and can decrease compliance. Purpose: To assess the frequency of lipid measurement in patients asked to have blood draw a week before clinic visit versus on the same day of clinic visit, and assess how this will affect achieving lipid targets. Methods: A University-based cardiology clinic notes were examined. Patients were scheduled for a fasting lipid profile a week prior to the clinic visit in year 1. Poor compliance was noted and prompted a same day as clinic visit measurement of lipids if a patient could not comply with laboratory appointment (fasting or non-fasting) in year 2, with further lipid management conducted by phone. Patients with documented coronary artery disease were included. A total of 200 encounters (100 in each year) were analyzed. Results: Only 64 (64%) of patients in year 1 had lipid measurements, compared to 84 (84%) of patients in year 2. LDL level in year 1 was 116 ± 36 mg/dL compared with 97 ± 32 mg/dL in year 2 (P &lt; 0.01). Only 34% (22/64) of the patients in year 1 achieved LDL of &lt; 100 mg/dL, compared with 56% (47/84) in year 2. No differences were observed in HDL, triglycerides or blood pressures during the concurrent visits. Conclusion: Improving documentation and control of LDL is achievable if lipid levels are done on clinic visit day, with less burden on patients who cannot comply with a separate laboratory appointment. Although there were many non-fasting levels as a result, the triglyceride levels where not significantly different among the two groups, probably reflecting an overall more intensive lipid management in year 2. Therefore, as has been shown by others, a lipid profile in most cases does not necessarily have to be fasting, especially in patients being treated for stricter targets such as our cohort, which may decrease the burden on patients unable to comply with a fasting state or added clinic visits.

P.464 - The 100-meter timed test: ability to detect change over time in Duchenne muscular dystrophy

The 100-meter timed test (100m) has been proposed as an outcome measure for use in Duchenne muscular dystrophy (DMD) that has the potential to expand the recruitment pool to include both younger and more able boys as it is a concrete concept of running 2 laps around a set of cones. Many of the current assessments used in DMD have a ceiling effect as the most able boys can achieve a perfect score. The 100m eliminates the ceiling effect by allowing the boys to run if able. Although the most able boys may walk as fast as age matched peers, their running speeds are significantly slower. This study documents the sensitivity of the 100m to measure decline in boys with DMD over time. To this end, 40 boys with DMD (age range: 4–13 years) performed the 100m at baseline and then repeated testing at subsequent regularly scheduled clinic visits with time points at 6 months (N = 30), 12 months (N = 17), 18 months (N = 10), and 24 months (N = 2). Longitudinal change in time to complete the 100m was consistent with natural history studies in other functional measures as it improved until the age of 7 and then declined over time. Spearman's rho showed excellent correlations between the 100m and other functional tests performed at concurrent visits including the Six Minute Walk Test (n = 51; r=-0.744, p < 0.001), North Star Ambulatory Assessment (n = 88; r=-0.877, p < 0.001), Time to Rise (n = 82; r = 0.768, p < 0.001), and Ten Meter Walk/Run Test (n = 97; r = 0.926, p < 0.001). Change in percent predicted 100m time over a 6 month (mean = -2.9 ± 7.8) and 12 month (mean = -6.0 ± 9.5) time period suggest it would be an optimal outcome measure in upcoming clinical trials. Sample size calculations using the change in 6 months and 12 months will be presented to demonstrate the utility of the 100m for future clinical trial planning as it could expand the recruitment pool and shorten trial duration.

Application of Conjoint Analysis to Improve Reliability of Dietician Consultation in Pediatric Celiac Disease.

Celiac disease (CD) management involves lifelong adherence to a gluten-free diet, making the dietician a key member in CD care. However, our institution lacked a standardized process for dietary consultation in newly diagnosed CD. To understand provider CD care preferences, a 24-1 fractional factorial conjoint analysis was performed. Attributes studied (2 levels each) included type of initial follow-up gastroenterology (GI) provider, interval from diagnosis to follow-up, concurrence of initial dietary consultation with gastroenterology visit, and on-going follow-up GI provider. CD care was standardized in July 2014 to facilitate concurrent visits with the clinician and dietician during the same clinical session. Changes to mean time of dietary consultation and reliability of dietary consultation were monitored using an individual-control and G-control chart, respectively. Standard control chart rules were followed. Conjoint analysis identified shorter time to initial follow-up visit and concurrent GI/dietician visits as more important attributes in newly diagnosed CD subjects' care. Types of follow-up provider during first or subsequent visits were identified as less important attributes. After initiation of a standardized follow-up process, a special cause was identified in December 2015 with a decrease in the mean time to dietary consultation from 30 to 20 days. In addition, standardized follow-up resulted in a more reliable process as evident by a special cause on the G-control chart in February 2015. Conjoint analysis identified attributes thought to be important in CD follow-up care. After redesign of our care process, a decrease in time to dietary consultation with improved reliability was observed.

Effect of Maternal Responsiveness on Young Infants' Social Bidding‐Like Behavior during the Still Face Task

The effect of maternal responsiveness on infants' emergence of social bidding‐like behavior during the Still Face Task was examined longitudinally at the infant ages of one week, one month, two months, and three months. Infants' social behaviors of smiling or making non‐distress vocalizations while looking at the mother during the still face phase significantly increased when infants were two months of age. These social bidding‐like behaviors at two and three months correlated with maternal responsiveness in the initial interactive phase of the Still Face Task on the concurrent and previous visits and with infants' positive social behaviors in the initial interactive phase at two and three months. Regression analyses indicate that maternal vocal responsiveness on the concurrent visit was the sole predictor of infants' social bidding‐like behavior at two months and was the major predictor of such infant behavior at three months. Maternal responsiveness enhances infants' awareness that they are effective agents in instigating social interaction, as suggested by infants' social behaviors toward their mothers when the mothers are unresponsive. This awareness is present by the infant age of two months. Copyright © 2016 John Wiley &amp; Sons, Ltd.

Abstract P273: Enhancing Documentation and Control of Lipids in a University-Based Cardiology Clinic

Background: Non-compliance with laboratory appointments, separate from clinic visit appointments, for measuring fasting cholesterol may hinder documentation and control of patients’ lipids. Methods: A university-based cardiologist’s clinic notes, from a single year (yr 1), when patients were asked to have a fasting cholesterol a week prior to the clinic visit, were analyzed (100 patients). The poor compliance prompted a same day as the clinic visit measurement (fasting or non-fasting) of lipids, for patients who could not comply with their laboratory appointment, during the following year (yr 2; 130 patients). Lipid values were managed by a subsequent call to the patient. All patients had coronary artery disease or risk equivalent mandating LDL levels &lt; 100 mg/dL. Results: In yr 1, 62% (62/100) of patients had documented lipid profiles compared to 83% (108/130) of patients in yr 2. The average LDL in yr 1 was 115 +/- 36 mg/dL compared with 96 +/- 31 mg/dL in yr 2 (P &lt; 0.01). Only 22% of the patients in yr 1 reached goal of &lt; 100 mg/dL, compared with 65% in yr 2. There were no significant differences in the HDL, TG levels or blood pressures documented during the concurrent visits. Conclusion: Better documentation and control of lipids may be obtained when lipid profiles are done on clinic visit day, with fewer burdens on the patients who cannot comply with a separate laboratory appointment. Although there were many non-fasting levels as a result, the triglyceride levels where not significantly different among the two groups, probably reflecting an overall more intensive lipid management in yr 2, commensurate with the better documentation. Therefore, as has been shown by others, a lipid profile does not necessarily have to be fasting, especially in patients being treated for stricter targets such as our cohort, which may decrease the burden on patients unable to comply with a fasting state or added clinic visits.

Temporal and spatial patterns of serologic responses to Plasmodium falciparum antigens in a region of declining malaria transmission in southern Zambia

BackgroundCritical to sustaining progress in malaria control is comprehensive surveillance to identify outbreaks and prevent resurgence. Serologic responses to Plasmodium falciparum antigens can serve as a marker of recent transmission and serosurveillance may be feasible on a large scale.MethodsSatellite images were used to construct a sampling frame for the random selection of households enrolled in prospective longitudinal and cross-sectional surveys in two study areas in Southern Province, Zambia, one in 2007 and the other in 2008 and 2009. Blood was collected and stored as dried spots from participating household members. A malaria rapid diagnostic test (RDT) was used to diagnose malaria. An enzyme immunoassay (EIA) was used to detect IgG antibodies to asexual stage P. falciparum whole parasite lysate using serum eluted from dried blood spots. The expected mean annual increase in optical density (OD) value for individuals with a documented prior history of recent malaria was determined using mixed models. SatScan was used to determine the spatial clustering of households with individuals with serological evidence of recent malaria, and these households were plotted on a malaria risk map.ResultsRDT positivity differed markedly between the study areas and years: 28% of participants for whom serologic data were available were RDT positive in the 2007 study area, compared to 8.1% and 1.4% in the 2008 and 2009 study area, respectively. Baseline antibody levels were measured in 234 participants between April and July 2007, 435 participants between February and December 2008, and 855 participants between January and December 2009. As expected, the proportion of seropositive individuals increased with age in each year. In a subset of participants followed longitudinally, RDT positivity at the prior visit was positively correlated with an increase in EIA OD values after adjusting for age in 2007 (0.261, p = 0.003) and in 2008 (0.116, p = 0.03). RDT positivity at the concurrent visit also was associated with an increase in EIA OD value in 2007 (mean increase 0.177, p = 0.002) but not in 2008 (−0.063, p =0.50). Households comprised of individuals with serologic evidence of recent malaria overlapped areas of high malaria risk for serologic data from 2009, when parasite prevalence was lowest.ConclusionsSerological surveys to whole asexual P. falciparum antigens using blood collected as dried blood spots can be used to detect temporal and spatial patterns of malaria transmission in a region of declining malaria burden, and have the potential to identify focal areas of recent transmission.

Reimbursement for Living Kidney Donor Follow-Up Care

Currently, many transplantation centers do not follow former living kidney donors on a long-term basis. Several potential barriers have been identified to provide this follow-up of former living kidney donors, including concerns that donor insurance will not reimburse transplantation centers or primary care physicians for this care. Here, we report the rates at which different insurance companies reimbursed our transplantation center for follow-up visits of living donors. We collected data on all yearly follow-up visits of living donors billed from January 1, 2007, to December 31, 2010, representing 82 different donors. Concurrent visits of their recipients were available for 47 recipients and were used as a control group. We find that most bills for follow-up visits of living kidney donors were paid by insurance companies, at a rate similar to the reimbursement for recipient follow-up care. Our findings suggest that, for former donors with insurance, inadequate reimbursement should not be a barrier in providing follow-up care.

Change in International Prostate Symptom Score, prostrate‐specific antigen and prostate volume in patients with benign prostatic hyperplasia followed longitudinally

The natural history of benign prostatic hyperplasia (BPH) in Japan resembles Western studies in that symptoms worsen, improve or stabilize in equal proportions of patients. We sought to determine if this pattern persisted in men seeking care at a urology referral center and if worsening of symptoms was due to increase in prostate volume (PV). We reviewed the records of all BPH patients who attended the Urology Clinic of Sapporo Medical University Hospital, during December 2003 and June 2004 with the inclusion criterion that they have at least two PV and lower urinary tract symptoms measurements using the International Prostate Symptom Score (IPSS). Patients who had prostate cancer or who underwent hormone therapy or prostate surgery between the two visits were excluded. Correlation (Spearman's rank) was used to assess interrelationships among variables at baseline and follow up; the strength of association between change in IPSS and change in PV were modeled by multiple linear regression. Sixty-seven patients were eligible. Baseline PV correlated with residual urine volume (r = 0.37, P < 0.05) and prostate-specific antigen (PSA; r = 0.65, P < 0.001) but not IPSS (r =-0.16). PV increased in 46 (70%) men, remained the same in 10 and decreased in 11; in the former group, the mean prostate enlargement generally increased as baseline PV increased. In multiple linear regression models that included baseline IPSS, correlation between change in IPSS and change in PV was 0.47 (P = 0.05) based on 25 patients with measures at concurrent visits. Change in PV was also correlated with change in quality of life score (0.46, P = 0.02) but not with change in PSA (r = 0.38, P = 0.07, maximum flow rate (-0.24) or residual urine volume (-0.06). IPSS were not correlated with any laboratory measure of urinary function at baseline; however, change in IPSS was associated with change in PV. PV was also moderately correlated to PSA levels and residual urine volume at baseline.