Middle Quartiles Research Articles

Early Readmission following NICU Discharges among a National Sample: Associated Factors and Spending.

Infants admitted to the neonatal intensive care unit (NICU) are at increased likelihood of hospital readmission when compared with non-NICU admitted infants, resulting in appreciable financial and emotional burdens. Early readmission, days to weeks, following NICU discharge, may be preventable. Population-based data identifying potentially modifiable factors and spending associated with early readmission are lacking. We conducted a secondary data analysis of privately insured infants in the IBM MarketScan Research Database born from 2011 to 2017 in all 50 states and admitted to the NICU. We examined demographic and clinical characteristics of early readmission within 7 days and between 8 and 30 days following NICU discharge and the payments of NICU and readmission care. Data were analyzed using univariate and multivariable logistic regression. Of the 86,741 NICU survivors analyzed, 3,131 infants (3.6%) were readmitted by 7 days and 2,128 infants (2.5%) between 8 and 30 days. Preterm infants had reduced odds of readmission by 7 days compared with term infants. Infants transferred to a step-down facility (vs. discharge home) and those with congenital anomalies had higher independent odds of readmission by 7 and 8 to 30 days. A higher percentage of NICU infants within the lowest quartile of initial NICU length of stay (LOS) were readmitted by 7 days compared with NICU infants in the middle and highest LOS quartiles (64 vs. 36%, p < 0.01). Median payments of readmissions at 7 and 8 to 30 days was $12,785 and 14,380, respectively. Being term, being transferred to a step-down facility, and having a congenital anomaly were risk factors for early readmission. Shorter initial NICU LOS may be a contributing factor to readmission by 7 days, especially among term infants. These findings identify factors associated with readmission with the hope of preventing early readmission, minimizing spending, and optimizing ideal timing of NICU discharge. · Preterm infants were less likely than term infants to be readmitted within 7 days after discharge.. · Transferred infants had higher odds of readmission versus those who were discharged home.. · Payments for an average single NICU day were $1,000 less than for an average day of readmission..

Listening Effort Measured Using a Dual-task Paradigm in Adults With Different Amounts of Noise Exposure.

Excessive noise levels can result in hearing damage and/or hearing-related symptoms, thereby leading to impaired communication and, eventually a decrease in the quality of life. Moreover, in daily practice, subjects often indicate that listening in noisy situations is a challenging and often exhausting experience, even in the absence of a clinically significant hearing loss. Hence, a person's perceived difficulty of the listening situation will also be important to consider. It has been suggested that beyond the peripheral factors, there are some central cognitive correlates of speech understanding that are essential for communication abilities. The aim of the present study was to evaluate the effect of the amount of noise exposure on hearing as measured by pure-tone audiometry and otoacoustic emissions (OAEs) on the one hand and listening effort measured using a dual-task paradigm on the other hand. The study included 152 adults between 18 and 40 years of age. First, participants completed a self-administered questionnaire regarding the amount of noise exposure. Second, hearing status was evaluated using pure-tone audiometry and transient evoked OAEs (TEOAEs) as well as distortion product OAEs (DPOAEs). Finally, listening effort was evaluated using a dual-task paradigm, which consisted of a primary speech-recognition task in different listening conditions and a secondary visual memory task that were performed both separately and simultaneously. Based on the quartiles of their subjective estimation of noise exposure, the participants were categorized into a group with low noise exposure (lower quartile), moderate noise exposure (two middle quartiles), and high noise exposure (upper quartile). There was no significant difference in hearing thresholds between the participants with low, moderate, and high noise exposure for each frequency of the pure-tone audiometry. In contrast, more absent TEOAEs and DPOAEs were found in the high noise exposed group. Regarding the primary speech-recognition task of the dual-task paradigm, no significant difference in speech recognition was found between the different groups of noise exposure. For the amount of listening effort, it was found that across all listening conditions subjects with high noise exposure expend significantly more listening effort compared with subjects with low and moderate noise exposure. This study is a first exploration of the effects of different amounts of noise exposure on listening effort showing that, listening effort is increased in subjects with high noise exposure compared with subjects with low and medium noise exposure. The most plausible hypothesis pertains to an effect of noise exposure on the peripheral and central auditory system, or a combination of effects on both the auditory system and the high-level cognitive functions necessary for speech understanding in the subjects with high levels of noise exposure. As such, a test for listening effort would be useful as part of a comprehensive test battery within the assessment of subjects exposed to noise.

SEPSIS PREDICTS HIGHER MORTALITY AND CARDIOPULMONARY COMPLICATIONS IN PERIPARTUM CARDIOMYOPATHY-RELATED HOSPITALIZATIONS: A NATIONWIDE ANALYSIS

TOPIC: Critical Care TYPE: Original Investigations PURPOSE: Sepsis-induced cardiomyopathy has been increasingly recognized; however, the prevalence and impact of sepsis in peripartum cardiomyopathy (PPCM) patients need further exploration. We aimed to assess the burden and outcomes of PPCM-related hospitalization with vs. without sepsis in this population-based study in the United States. METHODS: We queried the National Inpatient Sample (2015October-2017) to access PPCM with vs. without sepsis using relevant ICD-10 codes. We compared baseline demographics and comorbidities between the groups (sepsis+ vs. sepsis-). The primary outcomes included all-cause mortality, cardiac arrest including ventricular tachyarrhythmias, cardiogenic shock, respiratory failure, mechanical ventilation/respiratory intubation, and secondary outcomes included patient disposition, length of stay, and hospital charges. A two-tailed p-value<0.05 was considered for statistical significance. RESULTS: Of the 10,275 PPCM admissions, 460 were related to sepsis (0.04%). The PPCM-sepsis+ cohort often consisted of younger (30 [24-36]), white (47.1% vs 39%, p<0.001) patients admitted non-electively (90.2% vs 87.7%, p=0.109) compared to the PPCM-sepsis- cohort. The PPCM-sepsis+ cohort more frequently comprised of Medicaid enrollees (52.2% vs 51.9%, p<0.001), patients in middle income quartile (27.2% vs 26.0%, p=0.007), admissions to large bedsized hospitals (64.1% vs 62%, p=0.588) compared to PPCM-sepsis - cohort. The PPCM-sepsis+ cohort was often associated with congestive heart failure (55.4% vs 48.2%, p=0.003), coagulopathy (10.9% vs 6.4%, p<0.001), chronic kidney disease (15.2% vs 5.9%, p<0.001), anemias (27.2% vs 20.8%, p<0.001), pulmonary circulation disorder (3.3% vs 1.7%, p=0.012), and psychoses (4.3% vs 1.9%, p<0.001) compared to PPCM-sepsis- cohort. PPCM-sepsis+ cohort showed lower frequency of hypertension (40.2% vs 59.9%, p<0.001), obesity (16.3% vs 26.3%, p<0.001), chronic pulmonary disease (8.7% vs 14.9%, p<0.001) and valvular heart disease (7.6% vs 13.0%, p<0.001) compared to sepsis- cohort. The PPCM-sepsis+ cohort had significantly higher frequency and odds of all-cause mortality (7.6% vs 1.2%, aOR 7.59, 95% CI 4.35-13.23; p<0.001) along with higher rates of cardiac arrest (5.4% vs 3.0%, p0.003), cardiogenic shock (8.7% vs 5.2%, p<0.001), respiratory failure (56.5% vs 19.8%, p<0.001), mechanical ventilation/respiratory intubation (28.3% vs 10.9%, p<0.001) compared to the PPCM-sepsis- cohort. The PPCM-sepsis+ cohort were less often discharged routinely (63.0% vs. 81.5%, p<0.001), experienced prolonged hospital stay (5 vs 3 days) and higher hospital charges (60,752$ vs 30,554$) as compared to PPCM-sepsis- cohort (p<0.001). CONCLUSIONS: The frequency of sepsis in PPCM-related admissions remains low. However, concomitant sepsis predicted nearly seven times higher all-cause mortality and alarmingly higher rates of cardiopulmonary complications in PPCM. Preventive screening measures and timely management of sepsis in PPCM could prevent worse outcomes. CLINICAL IMPLICATIONS: Sepsis in PPCM patients leads to significantly higher mortality and morbidity which needs to be further assessed with larger prospective studies. Enforcement of screening protocols in PPCM could help curtail worse outcomes and healthcare expenditure. DISCLOSURES: No relevant relationships by Charu Agarwal, source=Web Response No relevant relationships by Rupak Desai, source=Web Response No relevant relationships by Zainab Gandhi, source=Web Response No relevant relationships by Geethu Jnaneswaran, source=Web Response No relevant relationships by Gaurav Mudgal, source=Web Response No relevant relationships by Athul Raj Raju, source=Web Response No relevant relationships by Bisharah Rizvi, source=Web Response No relevant relationships by Rutul Shah, source=Web Response No relevant relationships by Vivek Joseph Varughese, source=Web Response

Impact of Plasmatic Progesterone on the Day of Frozen Embryo Transfer in Hormone-induced Cycles.

To establish a relationship between serum progesterone values on the day of frozen blastocyst transfer in hormone-replaced cycles with the probability of pregnancy, miscarriage or delivery. This was an ambispective observational study including all frozen-thawed embryo transfer cycles performed at our department following in vitro fecundation from May 2018 to June 2019. The outcomes evaluated were β human chorionic gonadotropin (β-hCG)-positive pregnancy and delivery. Groups were compared according to the level of serum progesterone on the day of embryo transfer: the 1st quartile of progesterone was compared against the other quartiles and then the 2nd and 3rd quartiles against the 4th quartile. A total of 140 transfers were included in the analysis: 87 with β-HCG > 10 IU/L (62%), of which 50 (36%) delivered and 37 had a miscarriage (42%). Women with lower progesterone levels (< 10.7ng/mL) had a trend toward higher β-HCG-positive (72 versus 59%; p > 0.05), lower delivery (26 versus 39%; p > 0.05) and higher miscarriage rates (64 versus 33%; p < 0.01). Comparing the middle quartiles (P25-50) with those above percentiles 75, the rate of pregnancy was similar (60 versus 57%; p > 0.05), although there was a trend toward a higher number of deliveries (43 versus 31%; p > 0.05) and a lower number of miscarriages (28 versus 45%; p > 0.05). These differences were not statistically significant. There were no differences in pregnancy and delivery rates related with the progesterone level when measured in the transfer day. The miscarriage rate was higher in the 1st quartile group.

Impact of Demographic and Socioeconomic Factors on Outcomes Following Allogeneic Hematopoietic Cell Transplantation

BACKGROUNDHousehold demographic and socioeconomic status (SES) variables have been demonstrated to influence treatment decisions and outcomes across a wide range of health disciplines. The relationships between factors such as race, marital status, work status, type of residence, income, insurance payer, and outcomes following allogeneic hematopoietic cell transplantation (alloHCT), however, have not been clearly elucidated. To maximize the likelihood of success, it is essential to determine the impact of these factors so that additional resources can be targeted to at-risk patients. Those who survive the initial alloHCT period remain at risk for long-term complications, thus the ability to align post-transplant support with specific patient needs may influence survival outcomes.METHODSThis retrospective single center study evaluated demographic and outcome data for all consecutive patients who received an alloHCT at the University of California, San Francisco (UCSF) between January 2012 and January 2016. SES data were obtained from social work evaluations conducted prior to and after alloHCT. ZIP codes of primary residence were linked to median household income using 2010 Census data. Using this income data, patients were divided into surrogate income quartiles, with the top quartile earning ≥$89,811 annually and the bottom quartile ≤$50,222 annually. Primary endpoints included relapse free survival (RFS), overall survival (OS), and non-relapse mortality (NRM).RESULTSDuring the period of study, 269 patients underwent alloHCT. Median followup was 2.1 years (yrs). Amongst transplant recipients, 175 (65.1%) were Caucasian, 48 (17.8%) were Hispanic, 37 (13.8%) were Asian or Hawaiian/Pacific Islander, and 9 (3.3%) were African American. Matched related donors were used for 103 (38.3%) patients, unrelated donors for 149 (55.4%), haploidentical donors for 11 (4.1%), and umbilical cord blood for 6 (2.2%). The median age at time of alloHCT was 54 years (range 20-76 yrs). Myeloablative conditioning was used in 143 (53%).In this cohort, RFS was not associated with race, marital status, work status prior to alloHCT, income, caregiver, type of residence after transplant, distance from medical center, or insurance payer. OS was not associated with race, type of residence, distance from medical center, or income. The insurance payer Medicare was associated with decreased OS in comparison with patients whose payer was Medicaid (state payer) or private insurance (p=0.034), but this finding is confounded by age (median age 67, 37, and 53 yrs, respectively). There was no significant survival difference between those with Medicaid or private insurance. Retirement status prior to alloHCT also correlated with decreased OS in comparison with those with full-time, part-time, or no employment (p=0.018). Being divorced was associated with decreased OS in comparison with those who were single or married (p=0.025). The primary designated caregiver was significantly associated with OS, with those having a spouse, parent, or sibling caregiver having prolonged survival in comparison with those whose caregiver was an adult child, other family member, friend, or hired aid (p=0.012). Based on estimated household income, the top income quartile had significantly lower risk of NRM (4.3%), compared to the upper middle (15%), lower middle (11.6%), and bottom (11.9%) quartiles (p= 0.048). NRM was not associated with the other variables assessed. Acute GVHD (overall and grade 2-4) and chronic GVHD incidence rates were not associated with the SES variables assessed.CONCLUSIONSWe found that SES variables do not influence relapse rates, suggesting relapse risk is primarily driven by factors intrinsic to the indication for transplant, as expected. Most of the social variables we assessed also were not associated with OS after alloHCT. Insurance payer and retired status prior to alloHCT were associated with decreased OS, but both of these variables are confounded by age. Importantly, divorced relationship status and caregivers who were adult children, friends, hired aids, or family members other than a spouse, parent, or sibling were significantly correlated with decreased OS. Our findings have the potential to influence recipient risk stratification, housing and caretaker requirements following transplant, and the provision of means-based assistance for at-risk individuals. [Display omitted] DisclosuresMannis:Curis: Honoraria; Juno: Research Funding; Amgen: Honoraria; Agios: Research Funding. Logan:Incyte: Consultancy; Jazz: Consultancy; Kite: Research Funding; Shire: Consultancy; Pharmacyclics: Research Funding; Astellas: Research Funding; Novartis: Consultancy, Research Funding; Amgen: Consultancy.

Level of Neighborhood Deprivation Predicts Fruit &amp; Vegetable and Sugar-Sweetened Beverage Intake in Children Aged 12–24 Months

Abstract Objectives The first USDA Dietary Guidelines for Americans for children under 2 were released in December, 2020, and recommend a diverse diet rich in fruits and vegetables (FV), whole grains and lean protein and avoidance of sugar-sweetened beverages (SSB). We analyzed data for children 12–24 months enrolled in the CDC-funded PREVAIL Cohort in Cincinnati, OH to assess adherence to FV and SSB recommendations by the socioeconomic position (SEP) of their neighborhoods. Methods Diet was assessed using a validated food frequency questionnaire and daily servings of FV and SSB were calculated. Home addresses were geocoded and merged with the Deprivation Index, a validated measure of census tract-level SEP, with residence then classified as being High SEP (least deprived), Low SEP (most deprived) or the middle quartiles of deprivation score. Comparisons of FV and SSB intake were made using logistic or Poisson regression and generalized estimating equations (GEE). Results Dietary data was available for N = 207 children from research visits at 12 (n = 155), 18 (n = 196), and 24 (n = 171) months. Residents in High SEP neighborhoods were 86% white with a median household income of ≥$50,000; residents of Low SEP neighborhoods were 86% Black with a median income of ≤$25,000. Children in High SEP consumed the most and those in Low SEP the least FV per day (mos. 12, 18, 24: High: 3.8, 3.8, 4.5; Low: 2.1, 2.7, 3.2; all P &amp;lt; 0.05). While only 16.8% of children consumed any SSB at month 12, Low SEP children were 13.4 times more likely to consume any SSB than High SEP (37.8% vs 4.4%, P = 0.001). At month 24, 27.4% of High SEP children consumed any SSB and 7.8% consumed SSB at least once daily compared to 58.4% and 27.8%, respectively, in Low SEP children (P &amp;lt; 0.05). In univariate GEE models, children in Low SEP neighborhoods averaged 1/3 fewer FV but 4.6-times more SSB (all P &amp;lt; 0.01) compared to children in High SEP neighborhoods. The middle quartiles of deprivation index were intermediate in their FV and SSB intake. Conclusions In the PREVAIL Cohort, children in more deprived neighborhoods consumed significantly fewer fruits and vegetables and more sugar-sweetened beverages than those in more affluent neighborhoods. Efforts to improve diet quality should focus on promoting and enabling healthy food and beverage consumption in low SEP neighborhoods. Funding Sources Centers for Disease Control and Prevention.

The Predictive Value of Health Anxiety for Cancer Incidence and All-Cause Mortality: A 44-Year Observational Population Study of Women.

Long-term data concerning mortality and serious illness as a function of health anxiety are scarce. We aimed to study health anxiety in relation to long-term mortality and cancer morbidity among women. A Swedish population sample of women (n = 770; ages, 38-54 years) took part in a general medical and psychiatric examination in 1968 to 1969 and were followed up until 2013 in national Swedish registries for all-cause mortality and first diagnosis of cancer. A modified version of the Whiteley Index questionnaire (maximum score, 12) was used to measure health anxiety. Scores were trichotomized based on quartiles as no (score 0, lowest quartile), mild-moderate (score 1-2, middle quartiles), and high (score ≥3, highest quartile) health anxiety. Risks of death and cancer were evaluated with Cox regression models. Compared with women with mild-moderate health anxiety levels, women with no health anxiety had a higher risk of death (age-adjusted hazard ratio [HR] = 1.22, 95% confidence interval [CI] = 1.00-1.49; fully adjusted for baseline sociodemographic, mental, and physical health variables: HR, 1.44, 95% CI = 1.17-1.76). Women with high health anxiety levels had a greater risk of death in age-adjusted analysis (HR = 1.26, 95% CI = 1.04-1.54; fully adjusted HR = 1.21, 95% CI = 0.98-1.49). For both groups, the mortality risk was time dependent and declined during follow-up. We observed no between-group differences in the risk of cancer. In this population-based cohort of midlife women, health anxiety was moderately associated with mortality in a U-shaped fashion. Absence of health anxiety entailed the greatest risk when other factors were taken into account.

The Neuroscience of Organizational Trust and Business Performance: Findings From United States Working Adults and an Intervention at an Online Retailer.

This paper reports findings from a nationally representative sample of working adults to quantify how a culture trust improves business performance. Analysis of the national sample showed that organizational trust and alignment with the company’s purpose are associated with higher employee incomes, longer job tenure, greater job satisfaction, less chronic stress, improved satisfaction with life, and higher productivity. Employees working the highest quartile of organizational trust had average incomes 10.3% higher those working in the middle quartile of trust (p = 0.000) indicating that trust increases productivity. In order to demonstrate the causal effect of trust on business performance, we created an intervention to increase organizational trust in a division facing high job turnover at a large online retailer. The intervention increased organizational trust by 6% and this improved job retention by 1%. These studies show that management practices that increase organizational trust have salubrious effects on business performance.

Change in Cardiac Biomarkers and Risk of Incident Heart Failure and Atrial Fibrillation in CKD: The Chronic Renal Insufficiency Cohort (CRIC) Study

Circulating cardiac biomarkers may signal potential mechanistic pathways involved in heart failure (HF) and atrial fibrillation (AF). Single measures of circulating cardiac biomarkers are strongly associated with incident HF and AF in chronic kidney disease (CKD). We tested the associations of longitudinal changes in the N-terminal fragment of the prohormone brain natriuretic peptide (NT-proBNP), high-sensitivity troponin T (hsTnT), galectin-3, growth differentiation factor 15 (GDF-15), and soluble ST-2 (sST-2) with incident HF and AF in patients with CKD. Observational, case-cohort study design. Adults with CKD enrolled in the Chronic Renal Insufficiency Cohort study. Biomarkers were measured at baseline and 2 years later among those without kidney failure. We created 3 categories of absolute change in each biomarker: the lowest quartile, the middle 2 quartiles, and the top quartile. The primary outcomes were incident HF and AF. Cox proportional hazards regression models were used to test the associations of the change categories of each cardiac biomarker with each outcome (with the middle 2 quartiles of change as the referent group), adjusting for potential confounders and baseline concentrations of each biomarker. The incident HF analysis included 789 participants (which included 138 incident HF cases), and the incident AF analysis included 774 participants (123 incident AF cases). In multivariable models, the top quartile of NT-proBNP change (>232pg/mL over 2years) was associated with increased risk of incident HF (HR, 1.79 [95% CI, 1.06-3.04]) and AF (HR, 2.32 [95% CI, 1.37-3.93]) compared with the referent group. Participants in the top quartile of sST2 change (>3.37ng/mL over 2years) had significantly greater risk of incident HF (HR, 1.89 [95% CI, 1.13-3.16]), whereas those in the bottom quartile (≤-3.78ng/mL over 2years) had greater risk of incident AF (HR, 2.43 [95% CI, 1.39-4.22]) compared with the 2 middle quartiles. There was no association of changes in hsTnT, galectin-3, or GDF-15 with incident HF or AF. Observational study. In CKD, increases in NT-proBNPwere significantly associated with greater risk of incident HF and AF, and increases in sST2 were associated with HF. Further studies should investigate whether these markers of subclinical cardiovascular disease can be modified to reduce the risk of cardiovascular disease in CKD.

The Association of Cesarean Skin Incision Length and Postoperative Wound Complications.

This study was aimed to evaluate the relationship between cesarean skin incision length and wound complications. Planned secondary analysis of a multicenter double-blind randomized trial of adjunctive azithromycin versus placebo (in addition to standard cefazolin) in women ≥24 weeks undergoing cesarean delivery during labor or ≥4 hours after membrane rupture. Skin incision length (cm) was measured just prior to skin closure. The primary outcome was a composite of wound complications (wound infection, separation, seroma, hematoma, or dehiscence) up to 6 weeks of postpartum. Individual components of the composite were examined as secondary outcomes. Outcomes were compared between groups defined by the lowest (≤25th), middle (25-75th) and highest (>75th) incision length quartiles. Logistic regression was used to adjust for potential confounding variables. Of the 2,013 women enrolled in the primary trial, 1,916 had recorded incision lengths and were included in this secondary analysis. The overall rate of composite wound complications was 7.8%. Median incision length was 15.0 cm (interquartile range: 14.0-16.5) with the lowest quartile defined as ≤14, middle as >14 to ≤16.5, and highest as >16.5 cm. Mean BMI, parity, use of staples, and duration of surgery differed significantly between the three incision length groups. In unadjusted analysis, the longest incision lengths were associated with an increased risk of the wound composite and wound infections (odds ratio [OR] = 2.27, 95% confidence interval [CI]: 1.43-3.60 and OR = 2.30, 95% CI: 1.27-4.15, respectively) compared with the shortest incision lengths. However, after multivariable adjustments, these associations were nullified. Additional analyses considering incision length as a continuous variable and using 10th/90th percentile cut-offs still did not suggest any associations with outcomes. Increasing skin incision length is not independently associated with an increased risk of postoperative wound complications. · After multivariable adjustments, skin incision length was not independently associated with an increased risk of postoperative wound complications.. · A reasonable incision length needed to safely perform the procedure should be used..

U-Shaped Relationship of Leukocyte Telomere Length With All-Cause and Cancer-Related Mortality in Older Men.

Telomeres are essential DNA-protein complexes whose attrition results in cellular dysfunction and senescence. Leukocyte telomere length (LTL) correlates with tissue telomere length, representing a biomarker for biological age. However, its predictive value for mortality risk, and for cardiovascular versus cancer deaths, in older adults remains uncertain. We studied 3608 community-dwelling men aged 77.0 ± 3.6 years. Leukocyte telomere length was measured using multiplex quantitative PCR, expressed as amount of telomeric DNA relative to single-copy control gene (T/S ratio). Deaths from any cause, cardiovascular disease (CVD), and cancer were ascertained using data linkage. Curve fitting used restricted cubic splines and Cox regression analyses adjusted for age, cardiometabolic risk factors, and prevalent disease. There was a U-shaped association of LTL with all-cause mortality. Men with T/S ratio in the middle quartiles had lower mortality (quartiles, Q2 vs Q1, hazard ratio [HR] = 0.86, 95% confidence interval [CI] 0.77-0.97, p = .012; Q3 vs Q1 HR = 0.88, CI 0.79-0.99, p = .032). There was no association of LTL with CVD mortality. There was a U-shaped association of LTL with cancer mortality. Men with LTL in the middle quartiles had lower risk of cancer death (Q2 vs Q1, HR = 0.73, CI 0.59-0.90, p = .004; Q3 vs Q1, HR = 0.75, CI 0.61-0.92, p = .007). In older men, both shorter and longer LTL are associated with all-cause mortality. A similar U-shaped association was seen with cancer deaths, with no association found for cardiovascular deaths. Further research is warranted to explore the prognostic utility of LTL in ageing.

Premature Atrial Contractions and Their Association with Stroke Features and Outcome

BackgroundFrequent premature atrial contractions (PACs) are associated with atrial fibrillation, stroke, and mortality. However, the cut-off value for PAC counts that could identify patients with different stroke features is unclear, and the association of PACs to outcome is not determined. MethodsThe study retrospectively included patients with acute ischemic stroke who had underwent both a 24 h Holter recording and a brain MRI in Taipei Veterans General Hospital from January 2015 to May 2016. Patients were categorized into four groups according to their PAC frequencies on 24 h Holter recording. We compared the clinical severity, neuroimage features, stroke subtypes, and functional outcome among the four groups of patients. ResultsAmong the 278 patients, the lower, middle, and upper quartiles of the PAC counts were 23, 74, and 459.5, respectively. In contrast to the 1st quartile of patients, the 3rd (PAC 75-459/24 h) and the 4th (PAC ≥460/24 h) quartiles of patients had higher NIH Stroke Scale (NIHSS) at admission (p = 0.014 and p = 0.002, respectively). The frequencies of cryptogenic stroke were not different among the 4 quartiles of the patients, but cryptogenic stroke patients with ≥ 75PACs/24hours had higher stroke severity compared to those with PACs < 75counts/24 h (NIHSS 9.1 vs. 5.2, p = 0.043). There was an increased trend in infarcts of multiple vascular territories and in mortality at 1 year among the four groups of patients with increased PAC frequency (p = 0.045 and p = 0.002, respectively). The 4th PAC quartile was associated with poor functional outcome (modified Rankin Scale ≥ 4) at 3 months in univariate analysis (OR: 5.66, CI: 2.69–11.91, p < 0.001), but was not an independent predictor after controlling for initial stroke severity. ConclusionsPACs ≥ 75 counts/24 h was associated with higher clinical severity in patients with acute ischemic stroke.

Impact of phase angle on postoperative prognosis in patients with gastrointestinal and hepatobiliary-pancreatic cancer.

Phase angle (PhA), by bioelectrical impedance analysis, has been used in patients with several diseases; however, its prognostic value in patients with gastrointestinal (GI) and hepatobiliary-pancreatic (HBP) cancer is unclear. The aim of the present study was to investigate the effects of PhA on postoperative short- outcomes and long-term survival in these patients. This retrospective study reviewed data from 501 patients with GI and HBP cancers who underwent first resection surgery. The data were divided into the following groups according to the preoperative PhA quartile values by sex: high-PhA group with the highest quartile (Q4), normal-PhA group with middle quartiles (Q3 and Q2), and low-PhA group with the lowest quartile (Q1). Preoperative nutritional statuses, postoperative short-term outcomes during hospitalization, and 5-y survival between three groups were compared. Cox proportional hazard models were used to evaluate the prognostic effect of PhA. PhA positively correlated with body weight, skeletal muscle mass, and handgrip strength, and negatively correlated with age and levels of C-reactive protein. The low-PhA group showed a higher prevalence of malnutrition (48%) than normal-PhA (25%), and high-PhA groups (9%; P < 0.001). The incidence of postoperative severe complications was 10% for all patients (14% in low-PhA, 12% in normal-PhA, and 4% in high-PhA; P=0.018). The incidence of prolonged stays in a postoperative high-care or intensive care unit was 8% in all patients (16% in low-PhA, 8% in normal-PhA, and 2% in high-PhA; P < 0.001). The 5-y survival rate was 74% in all patients (68% in low-PhA, 74% in normal-PhA, and 79% in high-PhA; P < 0.001). The multivariate analysis demonstrated that a low-PhA group was an independent risk factor for mortality (hazard ratio, 1.99; 95% confidence interval, 1.05-3.90; P=0.034). PhA is a useful short-term and long-term postoperative prognostic marker for patients with GI and HBP cancers.

1396-P: The Impact of Neighborhood Factors on Glycemic Control for Women with Type 2 Diabetes during Pregnancy

Objective: To determine whether women living in highly deprived neighborhoods, defined by Area Deprivation Index (ADI), have worse glycemic control than those in less deprived areas. Methods: We performed a retrospective cohort study of low-income, previously uninsured pregnant women with T2DM from 2007-2017. We compared women living in high (≥ top quartile) or middle (middle quartiles) ADI neighborhoods to those living in low (≤bottom quartile) ADI neighborhoods. Demographic characteristics were compared and trends in mean A1c throughout pregnancy were tested with repeated measures analysis. Results: Of 367 women meeting study criteria (ADI range 1-10; IQR 7-10), 81 lived in low, 181 in middle, and 105 in high ADI neighborhoods. Demographics were similar between groups, except the high ADI group had more Black women and more severe diabetes by White Class. All groups achieved significant improvement in HgbA1c; however, the high ADI group was unable to achieve the same level of glycemic control by the third trimester after controlling for race and disease severity. There were no differences in pregnancy outcomes. Conclusion: Intensive prenatal care was insufficient to overcome neighborhood deprivation with regard to glycemic control; thus, additional neighborhood level interventions are likely needed to overcome this inequality. Disclosure L. Zahedi-Spung: None. B.E. Polnaszek: None. H.E. Duckham: None. C.J. Herrick: None. E.B. Carter: None. Funding American Diabetes Association/Pathway to Stop Diabetes (1-19-ACE-02 to E.B.C.); Robert Wood Johnson Foundation (74250); Eunice Kennedy Shriver National Institute of Child Health and Human Development (K23HD095075)

1182-P: Strategies and Factors Associated with Top Performance in Primary Care for Diabetes: Insights from Mixed Methods

Background: Diabetes care quality has changed little over the past 12 years. To learn what strategies and factors seem most important for improvement, we conducted a mixed method analysis of clinic interviews and characteristics of clinics that are in the high, middle, and low quartiles on a composite measure for diabetes. Method: We interviewed 31 leaders from 17 primary care clinics selected from the 416 that agreed to participate in a larger observational study of diabetes performance improvement. Semi-structured interviews on barriers and facilitators of diabetes care were recorded, transcribed, and analyzed for both comparison among clinics at different levels of performance on the outcome measure. We combined interview data with quantitative data about clinic performance on a standardized composite measure of diabetes outcomes and a survey of the presence of care management processes. Results: Interview analysis identified 10 themes that provided unique insights into the factors and strategies that were associated with differences in performance level. The main difference among them was the degree to which top performing clinics used patient data to guide proactive and outreach methods to intensify treatment and monitor impact. Top clinics also reported fewer barriers and more facilitators than lower ranked ones, while all recognized key help from the larger organizations of which most were a part. Conclusions: Top performing clinics’ approach to diabetes care differs from lower performing clinics focusing on proactive care occurring outside of the traditional practice setting. Although confirmatory studies are needed for these preliminary findings, clinical leaders might benefit by considering the value of replicating these differences. Disclosure L. Solberg: None. K.A. Peterson: None. H.N. Fu: None. M. Eder: None. R. Jacobsen: None. Funding National Institute of Diabetes and Digestive and Kidney Diseases (R18DK110732)

0363 Racial/Ethnic Differences in Actigraphy, Questionnaire, and Polysomnography-Measured Indicators of Sleep Health and Sleep Quality: The Multi-Ethnic Study of Atherosclerosis

Abstract Introduction Paradigm shifts in sleep research suggest the importance of considering multi-dimensional sleep health, compared to single metrics, to promote physical and mental well-being and to understand racial/ethnic disparities in sleep. Methods We used data from the Multi-Ethnic Study of Atherosclerosis (MESA; n = 1,740) to create a Sleep Health Score (SHS), including questionnaire (quality, sleepiness); 7-day actigraphy (total sleep time, sleep continuity [sleep maintenance efficiency], timing consistency [midpoint variability], fragmentation, wake after sleep onset, sleep onset latency); and in-home polysomnography (%N3 sleep, %REM sleep, AHI). Sleep parameters were dichotomized based on prior literature or by healthiest quartile(s), with positive values denoting healthier sleep (e.g. Epworth scores &amp;lt; 10). All 11 dichotomized parameters were summed to calculate the SHS (mean=4.9, sd=1.58). We used modified Poisson and linear regression for individual sleep outcomes and the SHS, respectively, adjusting for age and sex. Results The sample was older (mean age=68.28, sd=9.08) and 54% female. SHSs were associated with Black race (β=-0.60 [-0.78, -0.42]) and Hispanic ethnicity (β=-0.40 [-0.59, -0.21]), but not Chinese ethnicity (β=-0.16 [-0.41, 0.08]). Compared to Whites (n=644), Blacks (n=485) showed lower adjusted probability of obtaining favorable levels of: sleep continuity, fragmentation, timing consistency, alertness/sleepiness, and sleep depth (%N3 sleep). Chinese respondents (n=202) had lower probability of obtaining favorable levels of: sleep continuity and timing consistency, but higher probability of quality. Hispanics (n=409) had lower probability of obtaining healthy levels of: sleep continuity, timing consistency, and fragmentation. Neither healthy total sleep time (middle quartiles) nor AHI (&amp;lt;30) differed by race/ethnicity. Conclusion Among MESA-Sleep participants, summary SHSs were lowest in Blacks, followed by Hispanics. Multiple dimensions of sleep - particularly related to continuity and timing consistency - were less favorable across race/ethnic minority groups. A summary SHS may help monitor sleep health across populations, while measurement of specific sleep components may help identify modifiable targets. Support Joon Chung is supported by a T-32 NIH training grant.

Insulin treatment of patients with gestational diabetes: does dosage play a role?

Background and objective In nonpregnant patients high insulin requirements are associated with hypoglycemia and weight gain but not with improvement in glucose control. The effect of insulin requirement on maternal and neonatal outcomes in gestational diabetes mellitus (GDM) is yet unknown. Methods We conducted a retrospective cohort study of maternal and neonatal outcomes of pregnancy according to insulin requirements in women with GDM who were followed and delivered at the Yitzhak Shamir Medical Center between 2006 and 2016. The daily insulin dose in units per body weight was divided into quartiles and analyses were performed to compare the lowest, highest, and two middle quartiles. The primary outcome was a composite of any of the following: cesarean-section (CS), preeclampsia, macrosomia and large for gestational age (LGA) birth weight, neonatal intensive care unit admission, need for phototherapy, and neonatal hypoglycemia. Results Women were divided according to their insulin requirements as follows: 79 (24.8%) women who needed <0.13 IU/kg/day of insulin (insulin-sensitive group), 160 (50%) women who needed 0.14–0.42 IU/kg/day of insulin (comparison-group), and the rest who needed >0.43 IU/kg/day of insulin (insulin resistant group). There were no differences in the composite outcome between the groups (64.6, 61.3, and 69.6% for the insulin sensitive-, comparison- and resistant- groups, respectively, p = .44). Women in the insulin-resistant group had higher fasting glucose levels in the first trimester (91, 98 and 102 mg/dL for women in the insulin sensitive-, comparison- and insulin-resistant groups, respectively; p = .01). Women in the insulin-sensitive group had significantly better glycemic control (fasting glucose levels ≤90 mg/dL and 1-hour and 2-hour postprandial glucose levels ≤140 mg/dL and ≤120 mg/dL for more than 80% of measurements) than those in the insulin-resistant group (70.3 versus 29.9%; p < .001). The rate of CS was significantly higher in the insulin-resistant group (42.3 versus 24.1%; p = .03), but the rate of LGA birth weight was surprisingly higher in the insulin-sensitive group (29.5 versus 16.7%, p = .04). After controlling for confounders, women in the insulin-sensitive group had a decreased risk for CS in relation to the comparison group (OR = 0.46, 95%CI 0.23–0.9, p = .025). Conclusion We found no association between insulin requirements and adverse composite outcome in women with GDM. However, those with higher insulin requirements have poorer glucose control and higher rates of CS than those with lower insulin requirements. Larger studies are needed to inquire short- and long-term outcomes of insulin requirements on fetal and maternal outcomes.

Abstract 73: Sex Hormone Binding Globulin: A Novel Hormonal Biomarker for Ischemic Stroke Risk?

Introduction: Sex hormone binding globulin (SHBG) is a sex-steroid transporter previously linked to cardiometabolic outcomes such as diabetes (DM) and coronary heart disease and their risk factors. It remains uncertain whether SHBG also affects stroke risk, particularly in women. We investigated whether SHBG affects risk of incident ischemic stroke (IS) among women in the Women’s Health Initiative (WHI). Methods: The WHI includes randomized trials and an observational cohort of 161808 postmenopausal women enrolled at 40 sites across the U.S. from 1993 - 1998. We identified 13,192 participants free of prevalent stroke at baseline who were included in one of eleven ancillary studies with serum SHBG. Incident IS events through 2017 were identified via physician adjudication of medical records. We used Cox proportional hazards regression to assess IS risk across quartiles of SHBG levels (Q1 - Q4), first adjusted for demographics, body mass index (BMI), hypertension, alcohol use, and smoking status (Model 1). History of DM was added to remove indirect effects through DM (Model 2), followed by the addition of reproductive risk factors and physical activity (Model 3). Results: Of 13,192 participants (mean age 62.5 years, 67.4% non-Hispanic white, 18.5% black, 5.0% Asian, 7.6% Hispanic), 877 IS events were confirmed during follow-up. Compared to the highest SHBG quartile (referent), women in the lowest quartile had a higher risk of IS in all three models (Model 1: HR 1.51, 95%CI 1.23 - 1.86, Model 2: HR 1.46, 95%CI 1.18 - 1.80, Model 3: HR: 1.38, 95%CI 1.07 - 1.76, trend tests p &lt;0.05 for all). Women in the middle quartiles (Q2, Q3) also had increased IS risk compared with those in the highest SHBG quartile (Table). Conclusions: In this prospective cohort of post-menopausal women, there was a statistically significant inverse association between SHBG levels and IS risk, which supports the notion that SHBG could be used as a risk stratification tool for predicting IS in women.

Body weight sub-populations are associated with significant different welfare, health and egg production status in Australian commercial free-range laying hens in an aviary system

Abstract In order to assess the welfare and health status of commercial free-range laying hens of different body weight quantiles, a total of 7708 Lohmann Brown-classic hens at 74 weeks of age were obtained from 4 commercial free-range flocks housed on the same Australian farm under the same housing conditions. All hens were humanely killed and evaluated for body weight, feather cover, keel bone damage, gastrointestinal parasites, liver appearance, and egg follicle status. Hens were classified according to their body weight distribution percentile as light (bottom quartile, 1.65 ±Â 0.002 kg), medium (middle quartiles, 1.86 ±Â 0.010 kg), and heavy (top quartile, 2.08 ±Â 0.002 kg). All parameters were analysed using nominal regression models with flock, body weight, and their interactions as the predictors. In summary, 55.8% of heavy hens had a single or multiple keel bone damage compared to 48.9% and 50.7% of medium and light hens, respectively (P = 0.0001). Light hens had a significantly (P = 0.001) higher feather cover score on their breast (3.02 ±Â 0.018) than medium (2.96 ±Â 0.013) and heavy hens (2.87 ±Â 0.018) but significantly lower neck feather scores (P = 0.007). Light hens had the highest prevalence of gastrointestinal helminth infection (P = 0.0001), compared to the medium and heavy hens. Heavy hens had the highest incidence of Fatty Liver Syndrome compared to medium and light hens. Heavy and medium hens were significantly (P = 0.0001), more often in full egg follicle production (95.3% and 94.8%, respectively) compared to the lighter hens (90.0%). There was a significant flock effect for all parameters investigated. In conclusion, heavy (2.06 ±Â 0.010 kg) and medium (1.85 ±Â 0.010 kg) hens appeared healthier, more resilient towards infectious diseases and persistent in their egg follicle production. However, heavier hens suffered significantly more often from Fatty Liver Syndrome. Hens in the lowest quartile with mean 1.65 kg were the least economic sub-population.

Serum Klotho, Cardiovascular Events, and Mortality in Nondiabetic Chronic Kidney Disease

Background: Experimental studies indicate that Klotho deficiency is a pathogenic factor for CKD-related complications, including cardiovascular disease (CVD). However, the association between serum Klotho and clinical outcomes in nondiabetic CKD patients needs to be further clarified. We aimed to determine whether serum Klotho levels are associated with CVD events and mortality in predialysis CKD patients without diabetes. Methods: A total of 336 CKD stage 2–5 predialysis patients without diabetes were recruited and followed from the end of 2014 to January 2019 for CVD events and overall mortality. Serum Klotho was detected by ELISA and divided into quartiles (lowest, middle, second highest, and highest quartiles) according to their serum Klotho category. Results: After a median follow-up of 3.52 years (IQR 3.34–3.76), Kaplan-Meier analysis showed that, compared to participants with a Klotho level in the highest quartile (the reference category), those in the lowest Klotho quartile were associated with a higher all-cause mortality risk (HR = 7.05; 95% CI 1.59–31.25) and a higher CVD event risk (HR = 3.02; 95% CI 1.45–6.30). In addition, the middle Klotho quartile was also associated with CVD event risk (HR = 2.56; 95% CI 1.21–5.41). Moreover, in the multivariate-adjusted model, the lowest Klotho quartile remained significantly associated with all-cause mortality (HR = 5.17; 95% CI 1.07–24.96), and the middle Klotho quartile maintained a significant association with CVD event risk (HR = 2.32; 95% CI 1.03–5.21). Conclusion: These results suggest that lower serum Klotho levels are independently associated with overall mortality and CVD events in nondiabetic predialysis CKD patients.