Recent Calendar Research Articles

Incidence of Neuroleptic Malignant Syndrome During Antipsychotic Treatment in Children and Youth: A National Cohort Study.

Objective: The incidence of neuroleptic malignant syndrome (NMS), a rare, potentially fatal adverse effect of antipsychotics, among children and youth is unknown. This cohort study estimated NMS incidence in antipsychotic users age 5-24 years and described its variation according to patient and antipsychotic characteristics. Methods: We used national Medicaid data (2004-2013) to identify patients beginning antipsychotic treatment and calculated the incidence of NMS during antipsychotic current use. Adjusted hazard ratios (HRs) assessed the independent contribution of patient and antipsychotic characteristics to NMS risk. Results: The 1,032,084 patients had 131 NMS cases during 1,472,558 person-years of antipsychotic current use, or 8.9 per 100,000 person-years. The following five factors independently predicted increased incidence: age 18-24 years (HR [95% CI] = 2.45 [1.65-3.63]), schizophrenia spectrum and other psychotic disorders (HR = 5.86 [3.16-10.88]), neurodevelopmental disorders (HR = 7.11 [4.02-12.56]), antipsychotic dose >200mg chlorpromazine-equivalents (HR = 1.71 [1.15-2.54]), and first-generation antipsychotics (HR = 4.32 [2.74-6.82]). NMS incidence per 100,000 person-years increased from 1.8 (1.1-3.0) for those with none of these factors to 198.1 (132.8-295.6) for those with 4 or 5 factors. Findings were essentially unchanged in sensitivity analyses that restricted the study data to second-generation antipsychotics, children age 5-17 years, and the 5 most recent calendar years. Conclusion: In children and youth treated with antipsychotics, five factors independently identified patients with increased NMS incidence: age 18-24 years, schizophrenia spectrum and other psychotic disorders, neurodevelopmental disorders, first-generation drugs, and antipsychotic doses greater than 200 mg chlorpromazine-equivalents. Patients with 4 or 5 of these factors had more than 100 times the incidence of those with none. These findings could improve early identification of children and youth with elevated NMS risk, potentially leading to earlier detection and improved outcomes.

Liver Transplantation Profile Among Teenagers in the United States

PurposeIndications for liver transplantation (LT) vary across age groups. We identified predictors of outcomes for teenage LT waitlisted candidates and recipients in the United States from 2008 to 2022. MethodsThe Scientific Registry of Transplant Recipients 2008–2022 provided data (clinical, sociodemographic, indications for LT, outcomes) for all teenagers (13–19 years) waitlisted for LT in the United States. Sociodemographic and clinical characteristics, including primary listing diagnoses, were evaluated and compared by age group (13–16 vs. 17–19 years) among waitlisted teenage candidates. ResultsThere were 2,813 teenage LT candidates listed between 2008 and 2022. The most common LT indication was acute liver disease (23.5%), followed by biliary atresia or hypoplasia (11.9%), autoimmune hepatitis (11.1%), and primary sclerosing cholangitis (9.7%). In contrast, chronic viral hepatitis, metabolic dysfunction-associated steatotic liver disease, and alcohol-related liver disease (the most common indications in adults) did not exceed 1% each; 2.8% had hepatocellular carcinoma. Excluding the two most recent years, 67.2% of candidates received a transplant; mean time to transplant was 217.0 days (standard deviation 371.6). Independent predictors of receiving a transplant were a more recent calendar year, younger age, higher model for end-stage liver disease score, and an acute liver disease diagnosis (all p < .05). Among the LT group, 3-year survival was 90%, with an improving survival trend. Higher post-transplant mortality was associated with earlier years of transplantation, older age, having Medicaid, being retransplanted, and having hepatocellular carcinoma (adjusted hazard ratios >1, all p < .05). DiscussionIndications for LT among US teenagers are different from adults or younger children. There is a trend toward improved post-transplant outcomes.

Feasibility and safety of the discontinuation of systemic immunosuppressive treatment after single-unit cord blood transplantation in adults

We retrospectively evaluated the incidence, factors, and clinical outcomes of the discontinuation of immunosuppressive treatment (IST) after single-unit unrelated cord blood transplantation (CBT) in adults receiving cyclosporine-based graft-versus-host disease (GVHD) prophylaxis at our institute. Among the 309 patients who achieved engraftment, 247 were able to discontinue IST with a median follow-up of 121 months for survivors. The cumulative incidence of the discontinuation of IST was 46.2% at 180 days, 72.8% at 2 years, and 79.3% at 5 years post-CBT. In the multivariate analysis, discontinuation of IST after CBT was significantly associated with the requirement for steroid therapy (hazard ratio [HR]: 0.46; P < 0.001) and the recent calendar year of CBT (HR: 1.79; P < 0.001). In the conditional landmark analysis at 180 days, discontinuation of IST was not associated with the development of extensive chronic GVHD (HR: 1.00; P = 0.989), non-relapse mortality (HR: 0.49; P = 0.122), relapse (HR: 1.46; P = 0.388), or overall survival (HR: 1.91; P = 0.065). Our data showed that successful discontinuation of IST is common after single-unit CBT in adults. Discontinuation of IST did not affect subsequent outcomes, suggesting that discontinuation of IST is both feasible and safe in adults undergoing single-unit CBT.

Quantifying effects of blood pressure control on neuroimaging utilization in a large multi-institutional healthcare population.

Essential hypertension is a common chronic condition that can exacerbate or complicate various neurological diseases that may necessitate neuroimaging. Given growing medical imaging costs and the need to understand relationships between population blood pressure control and neuroimaging utilization, we seek to quantify the relationship between maximum blood pressure recorded in a given year and same-year utilization of neuroimaging CT or MR in a large healthcare population. A retrospective population-based cohort study was performed by extracting aggregate data from a multi-institutional dataset of patient encounters from 2016, 2018, and 2020 using an informatics platform (Cosmos) consisting of de-duplicated data from over 140 academic and non-academic health systems, comprising over 137 million unique patients. A population-based sample of all patients with recorded blood pressures of at least 50 mmHg DBP or 90 mmHg SBP were included. Cohorts were identified based on maximum annual SBP and DBP meeting or exceeding pre-defined thresholds. For each cohort, we assessed neuroimaging CT and MR utilization, defined as the percentage of patients undergoing ≥1 neuroimaging exam of interest in the same calendar year. The multi-institutional population consisted of >38 million patients for the most recent calendar year analyzed, with overall utilization of 3.8-5.1% for CT and 1.5-2.0% for MR across the study period. Neuroimaging utilization increased substantially with increasing annual maximum BP. Even a modest BP increase to 140 mmHg systolic or 90 mmHg diastolic is associated with 3-4-fold increases in MR and 5-7-fold increases in CT same-year imaging compared to BP values below 120 mmHg / 80 mmHg. Higher annual maximum recorded blood pressure is associated with higher same-year neuroimaging CT and MR utilization rates. These observations are relevant to public health efforts on hypertension management to mitigate costs associated with growing imaging utilization.

Prevalence and Predictors of Follow-up Endoscopic Biopsy in Patients With Celiac Disease in the United States.

To characterize the frequency and predictors of follow-up endoscopic biopsy in patients with celiac disease. The utility of routine follow-up biopsy in patients after a diagnosis of celiac disease is uncertain, especially in patients whose symptoms resolve on the gluten-free diet. Using the Merative MarketScan U.S. commercial insurance and Medicare databases, we identified 30,737 patients with biopsy-diagnosed celiac disease. We followed them until they had a second duodenal biopsy (our primary outcome) or insurance coverage ended. Among the patients with celiac disease we identified, 5976 (19.4%) underwent a follow-up biopsy. The median time between initial and follow-up biopsies was 16.8 months. Compared with younger patients, those aged 20 years or older had an increased likelihood of undergoing a follow-up biopsy (cumulative incidence rate at 5y for patients age ≥20y was 36.0%, 95% CI: 35.0%-37.1% vs 21.9%, 95% CI: 20.5%-23.4% in patients age ≤19y). Follow-up biopsies occurred less frequently in more recent calendar years. Follow-up biopsy was more common among patients with an Elixhauser Comorbidity Index of 1 (hazard ratio: 1.09; 95% CI: 1.01-1.17) or ≥2 (hazard ratio: 1.28; 95% CI: 1.20-1.37) compared with patients with an index of zero. Among patients who had a follow-up biopsy, 57% had a celiac disease-related symptom recorded in the 30 days before the procedure. Follow-up duodenal biopsy is performed in a substantial minority of U.S. patients with celiac disease. Adult age and increased comorbidity burden were associated with a greater likelihood of follow-up biopsy. Just under half of follow-up biopsies are performed for routine surveillance, in the absence of persistent symptoms.

Temporal changes in stroke and heart failure following first-time atrial fibrillation/flutter in patients under 65 years of age: A Danish nationwide study

Abstract Background The incidence of atrial fibrillation/flutter (AF) has increased throughout the past two decades - also for patients under 65 years of age. Whether this increment in patients with AF under 65 years of age also influences the subsequent incidence of ischaemic stroke (stroke) and heart failure (HF) is yet to be elucidated. This patient group are of special interest as this population often is considered at low risk of stroke. Methods Using Danish nationwide registries, we identified all patients from 18–65 years with a first-time AF-diagnosis in 2000-2018. The cohort was categorised according to calendar periods into five groups: 2000-200, 2003-2006, 2007-2010, 2011-2014, and 2015-2018. Crude incidence rate (IR) of stroke and HF per 1,000 person years (PY) were calculated. The cumulative incidence (CI) of stroke and HF during one year of follow-up was computed accounting for death as a competing risk. The reverse Kaplan-Meier estimator was used to examine mortality during one year follow-up. Multivariable Cox proportional hazard analysis was used to compare outcomes between calendar periods with 2000-2002 as comparative reference. Hazard ratios (HR) were reported with 95% confidence intervals (95% CI). Results In this study 51,137 patients were included; 6,911 (median age 56, 64.5% males, 22.0% on OAC) in 2000-2002, 9,964 (median age 58, 65.5% males, 26.4% on OAC) in 2003-2006, 11,538 (median age 58, 64.7% males, 23.9% on OAC) in 2007-2010, 11,764 (median age 58, 63.6% males, in 29.2% on OAC) in 2011-2014, and 10,960 (median age 56, 65.9% males, 39.5% on OAC) in 2015-2018. For stroke, crude IR/1,000 PY [95% CI] declined through calendar time as seen in the Figure. The crude IR were 10.4 [8.0;13.5] in 2000-2002 and 6.3 [4.9;8.0] in 2015-2018 with corresponding CIs of 1.0%, 0.9%, 0.9%, 0.8%, and 0.6%, respectively (p-value for difference=0.08). The corresponding adjusted HRs [95% CI] were 0.94 [0.66;1.35] for calendar period 2003-2006, 0.87 [0.61;1.24] for 2007-2010, 0.86 [0.61;1.23] for 2011-2014, and 0.61 [0.41;0.91] for 2015-2018 as compared with 2000-2002. As seen in the Figure crude IR [95% CI] for HF were stagnant over time with 37.2 [32.4;42.8] in 2000-2002 and 38.3 [34.7;42.3] in 2015-2018 with corresponding CIs of 3.4%, 3.3%, 3.5%, 3.4%, and 3.3%, respectively (p-value for difference=0.89). The corresponding adjusted HRs [95% CI] were 0.93 [0.79;1.10] for calendar period 2003-2006, 0.99 [0.84;1.17] for 2007-2010, 0.99 [0.84;1.16] for 2011-2014, and 1.02 [0.86;1.20] for 2015-2018 as compared with 2000-2002. Mortality with one year of follow-up was 3.8%, 4.4%, 4.4%, 4.5%, and 3.7% in calendar period 1-5 respectively (p-value for difference=0.38). Conclusion From nationwide registries in patients with atrial fibrillation/flutter under 65 years of age, we found a stepwise decline in one-year rates of ischaemic stroke with more recent calendar periods. Heart failure and mortality incidence were stable across calendar time.Incidence rates of ischemic stroke

Spontaneous and induced abortions in women with a diagnosis of gestational related neoplasm: a population-based linkage study in Lombardy, 2010–2020

BackgroundA diagnosis of cancer during pregnancy or within one year after the end of pregnancy is a major clinical and public health issue. The current study aimed at estimating the incidence of pregnancy-associated cancer (PAC) and assessing whether the risk of abortion is increased in women diagnosed with cancer.MethodsThis population-based cohort study used the regional healthcare utilization (HCU) databases of Lombardy, the largest region in Italy, to identify the women who delivered between 2010 and 2020. PAC were identified by oncological ICD-9-CM codes reported in the hospital discharge forms. We computed the ratio of PAC cases to the total number of pregnancies. Following a diagnosis of PAC, the prevalence ratio (PR) of abortion and the corresponding 95% confidence interval (CI), was estimated using a log-binomial model adjusted for maternal age.ResultsDuring the study period, 926 women who gave birth (1.29 cases per 1000 births) and 341 women who had an abortion (1.52 cases per 1000 abortions) were diagnosed with PAC. Regardless of the outcome of pregnancy, the risk of PAC increased with increasing age. The rate of PAC was initially lower among births, but it came very close to the rate of PAC among abortions in the last two calendar years. The proportion of abortions among women with PAC gradually decreased from 27.7% in 2010–2012 to 18.5% in 2019–2020 (p-value < 0.001). Overall, a diagnosis of PAC was related to an approximately 10% increased risk of abortion (PR = 1.11, 95%CI:1.01–1.22). However, no association was observed in 2019–2020 (PR = 0.87, 95%CI:0.65–1.17). Considering only diagnoses made during the first trimester of pregnancy, the risk of abortion was about 2.5 times higher (PR = 2.53, 95%CI:2.05–3.11) and the risk of induced abortion was almost 4 times higher (PR = 3.71, 95%CI:2.82–4.90).ConclusionIn this population the risk of abortion was about 10% higher in women with PAC than in women without PAC. However, this association tended to decrease in more recent calendar periods. This trend seemed to be influenced more by spontaneous than by induced abortions.

Trend over time of HIV-1 drug resistance to nonnucleoside reverse transcriptase inhibitors (NNRTIs) and their drivers: A cohort study from Antiviral Response Cohort Analysis (ARCA).

The rise of HIV-1 drug resistance to nonnucleoside reverse transcriptase inhibitors (NNRTIs) threatens the long-term success of NNRTI-based therapies. Our study aims to describe the circulation of major resistance-associated mutations (RAMs) for NNRTIs in people living with HIV (PLWH) in Italy from 2000 to 2020. We included 5982 naïves and 28 505 genotypes from 9387 treatment-experienced PLWH from the Antiviral Response Cohort Analysis (ARCA) cohort. Transmitted drug resistance (TDR) was found in 12.5% and declined from 17.3% in 2000-2003 to 10.9% in 2016-2020 (p = 0.003). Predictors of TDR were viral subtype B [vs. non-B, adjusted odds ratio (aOR) = 1.94, p < 0.001], zenith viral load (VL) (per 1 log10 higher, aOR = 0.86, p = 0.013), nadir CD4 cell count (per 100 cells/μL increase aOR = 0.95, p = 0.013). At least one RAM for NNRTIs among treatment experienced PLWH was detected in 33.2% and pre-treatment drug resistance (PDR) declined from 43.4% in 2000-2003 to 20.9% in 2016-2020 (p < 0.001). Predictors of PDR were sexual transmission route (vs. others, aOR = 0.78, p < 0.001), time since HIV diagnosis (per 1 month longer, aOR = 1.002, p < 0.001), viral subtype B (vs. non B, aOR = 1.37, p < 0.001), VL (per 1 log10 higher, aOR = 1.12, p < 0.001), nadir CD4 count (per 100 cells/μL increase, aOR = 0.91, p < 0.001), previous exposure to any NNRTI (aOR = 2.31, p < 0.001) and a more recent calendar year sequence (any time span > 2008 vs. 2000-2003, any aOR <1, p < 0.001). Circulation of RAMs to NNRTIs declined during the last 20 years in Italy. NNRTIs remain pivotal drugs for the management of HIV-1 due to safety concerns and long-acting options.

Transgender Identity and Suicide Attempts and Mortality in Denmark

ImportancePrior studies have suggested that transgender individuals may be a high-risk group with respect to suicide attempt and mortality, but large-scale, population-based investigations are lacking.ObjectiveTo examine in a national setting whether transgender individuals have higher rates of suicide attempt and mortality than nontransgender individuals.Design, Setting, and ParticipantsNationwide, register-based, retrospective cohort study on all 6 657 456 Danish-born individuals aged 15 years or older who lived in Denmark between January 1, 1980, and December 31, 2021.ExposureTransgender identity was determined through national hospital records and administrative records of legal change of gender.Main Outcomes and MeasuresSuicide attempts, suicide deaths, nonsuicidal deaths, and deaths by any cause during 1980 through 2021 were identified in national hospitalization and causes of death registers. Adjusted incidence rate ratios (aIRRs) with 95% CIs controlling for calendar period, sex assigned at birth, and age were calculated.ResultsThe 6 657 456 study participants (50.0% assigned male sex at birth) were followed up during 171 023 873 person-years. Overall, 3759 individuals (0.06%; 52.5% assigned male sex at birth) were identified as transgender at a median age of 22 years (IQR, 18-31 years) and followed up during 21 404 person-years, during which 92 suicide attempts, 12 suicides, and 245 suicide-unrelated deaths occurred. Standardized suicide attempt rates per 100 000 person-years were 498 for transgender vs 71 for nontransgender individuals (aIRR, 7.7; 95% CI, 5.9-10.2). Standardized suicide mortality rates per 100 000 person-years were 75 for transgender vs 21 for nontransgender individuals (aIRR, 3.5; 95% CI, 2.0-6.3). Standardized suicide-unrelated mortality rates per 100 000 person-years were 2380 for transgender vs 1310 for nontransgender individuals (aIRR, 1.9; 95% CI, 1.6-2.2), and standardized all-cause mortality rates per 100 000 person-years were 2559 for transgender vs 1331 for nontransgender individuals (aIRR, 2.0; 95% CI, 1.7-2.4). Despite declining rates of suicide attempts and mortality during the 42 years covered, aIRRs remained significantly elevated in recent calendar periods up to and including 2021 for suicide attempts (aIRR, 6.6; 95% CI, 4.5-9.5), suicide mortality (aIRR, 2.8; 95% CI, 1.3-5.9), suicide-unrelated mortality (aIRR, 1.7; 95% CI, 1.5-2.1), and all-cause mortality (aIRR, 1.7; 95% CI, 1.4-2.1).Conclusions and RelevanceIn this Danish population-based, retrospective cohort study, results suggest that transgender individuals had significantly higher rates of suicide attempt, suicide mortality, suicide-unrelated mortality, and all-cause mortality compared with the nontransgender population.

Abstract P448: Trends and Predictors of Statin Initiation Among Veterans With Familial Hypercholesterolemia

Introduction: Familial hypercholesterolemia (FH), defined as LDL-C ≥190mg/dL, is a strong cardiovascular disease (CVD) risk factor. The AHA/ACC guidelines recommend high intensity statins for primary prevention irrespective of global risk assessment. We sought to characterize trends and predictors of statin initiation among Veterans with FH in the Veterans Health Administration (VHA). Methods: Inclusion criteria consisted of care at the VHA (2002-2014), age ≥21 years, baseline LDL-C ≥190 mg/dL, no prevalent CVD, no prior statin use, and statin initiation within 90 days of LDL-C measurement. We defined baseline LDL-C in quartiles: Q1=190-195, Q2=196-202, Q3=203-215, and Q4 &gt;215 (mg/dL). Statin intensity was defined as average intensity over one year following baseline LDL-C measurement. Multivariable logistic regression models were constructed to determine the odds of any statin initiation and high intensity statin initiation. Results: Over 12 years, 165,110 Veterans (age=52.9±11.9, men=91%; white race=74%) were included. Statins were initiated in 88,878 patients (overall 54%, 62% in 2014). Overall, 29,533 Veterans were on high intensity statins (overall 33%, 20% in 2002, 50% in 2014). In multivariable-adjusted logistic regression models, significant predictors of statin initiation were age, white race, diabetes hypertension, smoking, baseline LDL-C, and recent calendar year. Among those initiated on high intensity statins, the same predictors were significant; however, African Americans were more likely to be started on a high intensity statin (Table). Conclusions: Among Veterans with FH, the odds of statin initiation are higher among older, Caucasian, hypertensive, diabetic, and smoking veterans. The odds of statin prescription have increased over time with a higher proportion receiving high intensity statins more recently. These data reflect the VHA changes in clinical practice concordant with ACC/AHA guidelines.

Sex and Race Disparities in Mortality and Years of Potential Life Lost Among People With HIV: A 21-Year Observational Cohort Study.

Since the availability of antiretroviral therapy, mortality rates among people with HIV (PWH) have decreased; however, this does not quantify premature deaths among PWH, and disparities persist. We examined all-cause and premature mortality among PWH receiving care at the Vanderbilt Comprehensive Care Clinic from January 1998 to December 2018. Mortality rates were compared by demographic and clinical factors, and adjusted incidence rate ratios (aIRRs) were calculated using multivariable Poisson regression. For individuals who died, age-adjusted years of potential life lost (aYPLL) per total person-years living with HIV were calculated from US sex-specific life tables, and sex and race differences were examined using multivariable linear regression. Among 6531 individuals (51% non-Hispanic [NH] White race, 40% NH Black race, 21% cis-gender women, 78% cis-gender men) included, 956 (14.6%) died. In adjusted analysis, PWH alive in the most recent calendar era (2014-2018) had decreased risk of mortality compared with those in the earliest calendar era (1998-2003; aIRR, 0.22; 95% CI, 0.17-0.29), and women had increased risk of death compared with men (aIRR, 1.31; 95% CI, 1.12-1.54). Of those who died, Black women had the highest aYPLL (aIRR, 592.5; 95% CI, 588.4-596.6), followed by Black men (aIRR, 470.7; 95% CI, 468.4-472.9), White women (aIRR, 411.5; 95% CI, 405.6-417.4), then White men (aIRR, 308.6; 95% CI, 308.0-309.2). In adjusted models, higher YPLL remained associated with NH Black race and cis-gender women, regardless of HIV risk factor. Despite marked improvement over time, sex disparities in mortality as well as sex and race disparities in YPLL remained among PWH in this cohort.

Antidepressant utilization patterns and predictors of treatment continuation in pregnant women: A 16-year population-based cohort.

Existing data on prenatal antidepressant prescribing patterns are mostly derived from Western countries, with limited research assessing antidepressant continuation and reinitiation during pregnancy. This study aimed to examine antidepressant prescribing practice among Chinese pregnant women in Hong Kong. This population-based study identified women aged 15-50 years who delivered their first and singleton child, and had redeemed at least one antidepressant prescription within 3 months pre-pregnancy and/or during pregnancy between 2003 and 2018, using data from the health-record database of Hong Kong public healthcare services. Antidepressant utilization patterns before and during pregnancy, and factors associated with antidepressant continuation and reinitiation following medication discontinuation were evaluated. Of 466,358 pregnancies, 3019 (0.67%) received antidepressants within 3 months of pre-pregnancy and/or during pregnancy, and 2700 (0.58%) had prenatal antidepressant use. There was a significant rising trend of prenatal antidepressant use over time (0.6% in 2003 to 1.3% in 2018; odds ratio: 1.09, 95% confidence interval = [1.08, 1.10], p < 0.001). A consistent pattern of decreasing overall antidepressant use from 3 months pre-pregnancy to the second trimester was observed, followed by a slight increase in the third trimester. Almost half (n = 949, 49.5%) of 1918 women on antidepressants in 3 months pre-pregnancy continued treatment beyond the first trimester. A total of 8.2% that discontinued antidepressants in 3 months pre-pregnancy or in the first trimester reinitiated treatment in the later stage of pregnancy. Older age at conception (⩾35 years), recent calendar year of delivery (2015-2018), pre-existing depression/anxiety disorders, longer-term pre-pregnancy antidepressant treatment and pre-pregnancy prescription of other psychotropics were significantly associated with antidepressant continuation. Antidepressant reinitiation was predicted by pre-existing depression/anxiety disorders. Our results that prenatal antidepressant use is increasingly prevalent and half of pregnant women discontinued antidepressants 3 months before or after conception underscore the need for future research to clarify the risk and benefit of antidepressant continuation versus discontinuation to facilitate development of evidence-based guidelines, so as to optimize maternal and fetal outcomes.

Characteristics of recent HIV infection among individuals newly diagnosed as HIV-positive in South Korea (2008–2015)

Most HIV-positive individuals diagnosed in Korea are infected through sexual contact, with the time of HIV infection therefore often being unknown. The aim of this study was to investigate the characteristics of diagnosed patients near the time of HIV seroconversion to establish useful HIV intervention strategies. Cross-sectional study. Newly diagnosed HIV cases based on the national HIV surveillance system in South Korea, 2008–2015. To distinguish recent from long-standing HIV infection among 5898 nationwide HIV-positive specimens, limiting antigen avidity assays (Sedia HIV-1 LAg-Avidity EIA, cut-off = 1.5) were performed. Data on CD4+ T cell count at HIV diagnosis and death from AIDS within one year after first HIV diagnosis were used to distinguish recent HIV infections. Acute HIV infection is characterized by detectable HIV RNA or HIV p24 antigen levels, along with a negative or indeterminate antibody western blot result, but with the subject subsequently testing positive after a predetermined period. We analyzed the characteristics of recent and acute HIV infections by sex, age, nationality, HIV testing site, region, and reason for HIV testing. Recent and acute HIV infections were described as the proportion of recent and acute HIV infections among newly-diagnosed cases in a given year. Recent and acute HIV infections over the 8-year study period were 20.5% (1210/5898) and 9.5% (562/5898), respectively. Both infections were generally higher in the following groups: males, younger age, Koreans, individuals who were tested due to disease, residents of smaller city or rural area, and individuals diagnosed in recent calendar years. Acute infections were significantly higher among individuals tested in hospitals and due to suspected HIV infection. The recent and acute HIV infection in younger age groups (< 30 years) has been increasing in a given year. There was an increase in the proportion of young individuals with recent HIV infection, and we identified risk groups more at risk of HIV infection recently in Korea. Therefore, our results could prove useful for the development and assessment of national HIV prevention strategies in Korea and provide valuable data for further HIV research.

Association of Chiropractic Care With Receiving an Opioid Prescription for Noncancer Spinal Pain Within a Canadian Community Health Center: A Mixed Methods Analysis

ObjectiveThe purpose of this study was to examine the association between receipt of chiropractic services and initiating a prescription for opioids among adult patients with noncancer spinal pain in a Canadian community health center. MethodsIn this sequential explanatory mixed methods analysis, we conducted a retrospective study of 945 patient records (January 2014 to December 2020) and completed interviews with 14 patients and 9 general practitioners. We used Cox proportional hazards regression analyses, adjusted for patient demographics, comorbidities, visit frequency, and calendar year to evaluate the association between receipt of chiropractic care and time to first opioid prescription up to 1 year after presentation. Qualitative data were analyzed thematically and integrated with our quantitative findings. ResultsThere were 24% of patients (227 of 945) with noncancer spinal pain who received a prescription for opioids. The risk of initiating a prescription for opioids at 1 year after presentation was 52% lower in chiropractic recipients vs nonrecipients (hazard ratio [HR], 0.48; 99% confidence interval [CI], 0.29-0.77) and 71% lower in patients who received chiropractic services within 30 days of their index visit (HR, 0.29; 99% CI, 0.13-0.68). Patients whose index visit date was in a more recent calendar year were also less likely to receive opioids (HR, 0.86; 99% CI, 0.76-0.97). Interviews suggested that self-efficacy, access to chiropractic services, opioid stigma, and treatment impact were influencing factors. ConclusionPatients with noncancer spinal pain who received chiropractic care were less likely to obtain a prescription for opioids than patients who did not receive chiropractic care.

MP26-01 COMPLETENESS OF 24-HOUR URINE TESTING AMONG US VETERANS WITH URINARY STONE DISEASE

You have accessJournal of UrologyCME1 May 2022MP26-01 COMPLETENESS OF 24-HOUR URINE TESTING AMONG US VETERANS WITH URINARY STONE DISEASE Ryan Hsi, Autumn Valicevic, Sanjeevkumar Patel, John Hollingsworth, and Vahakn Shahinian Ryan HsiRyan Hsi More articles by this author , Autumn ValicevicAutumn Valicevic More articles by this author , Sanjeevkumar PatelSanjeevkumar Patel More articles by this author , John HollingsworthJohn Hollingsworth More articles by this author , and Vahakn ShahinianVahakn Shahinian More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002569.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Contemporary guidelines for the prevention of urinary stone disease (USD) recommend that a 24-hour urine collection be analyzed with a minimum set of urinary analytes. However, unlike a comprehensive metabolic panel, there is no approved set of measurements that a provider can easily order, potentially leading to incomplete testing. To examine this possibility, we analyzed data from the Veterans Health Administration (VHA). METHODS: Using files from the VHA Corporate Data Warehouse (2012 to 2019), we identified a cohort of patients, who primarily use the VHA for their healthcare needs, with at least two outpatient or one surgical encounter for USD. Next, we determined the subset who performed a 24-hour urine collection within 12 months of their index USD encounter. Through Logical Observation Identifiers Names and Codes, we evaluated each collection’s completeness, defined as including all of urine volume, calcium, oxalate, citrate, uric acid, and creatinine. We then fit a multilevel logistic regression model with random effects for facility to evaluate factors associated with testing completeness. RESULTS: In total, 15,660 patients performed a 24-hour urine collection, but nearly half of tests (46.1%) were incomplete. The percentage of complete collections increased over time (43.1% in 2012 to 63.2% in 2019). The facility where a patient was seen mattered. The Figure shows wide variation in unadjusted rates of 24-urine completeness among facilities, ranging from as low as 0% to as high as 98.1%. In the adjusted analysis, there was considerable between-facility variation in 24-hour urine completeness (Median Odds Ratio, 4.98; 95% CI, 3.50-5.50). Collectively, individual facilities contributed almost 46% (ICC, 0.46; 95% CI, 0.35-0.49) to the observed variation in 24-hour urine completeness. Older age, Hispanic ethnicity, and presence of conditions associated with high risk of USD recurrence were significantly associated with a lower odds, whereas female sex and more recent calendar year were associated with a higher odds, of complete testing. CONCLUSIONS: Nearly half of 24-hour urine tests obtained for prevention of USD do not have the minimum set of urinary analytes. These data suggest that addressing the facility level variation in testing completeness may improve the quality of USD care within VHA facilities. Source of Funding: NIDDK R01 DK121709 © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e438 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ryan Hsi More articles by this author Autumn Valicevic More articles by this author Sanjeevkumar Patel More articles by this author John Hollingsworth More articles by this author Vahakn Shahinian More articles by this author Expand All Advertisement PDF DownloadLoading ...

Differential patterns of postmigration HIV-1 infection acquisition among Portuguese immigrants of different geographical origins.

To investigate the dynamics of phylogenetic transmission clusters involving immigrants of Portuguese Speaking Countries living in Portugal. We included genomic sequences, sociodemographic and clinical data from 772 HIV migrants followed in Portugal between 2001 and 2017. To reconstruct HIV-1 transmission clusters, we applied phylogenetic inference from 16 454 patients: 772 migrants, 2973 Portuguese and 12 709 global controls linked to demographic and clinical data. Transmission clusters were defined using: clusters with SH greater than 90% (phylogenetic support), genetic distance less than 3.5% and clusters that included greater than 66% of patients from one specific geographic origin compared with the total of sequences within the cluster. Logistic regression was performed to assess factors associated with clustering. Three hundred and six (39.6%) of migrants were included in transmission clusters. This proportion differed substantially by region of origin [Brazil 54% vs. Portuguese Speaking African Countries (PALOPs) 36%, P < 0.0001] and HIV-1 infecting subtype (B 52%, 43% subtype G and 32% CRF02_AG, P < 0.001). Belonging to a transmission cluster was independently associated with treatment-naive patients, CD4+ greater than 500, with recent calendar years of sampling, origin from PALOPs and with seroconversion. Among Brazilian migrants - mainly infected with subtype B - 40.6% were infected by Portuguese. Among migrants from PALOPs - mainly infected with subtypes G and CFR02_AG - the transmission occurred predominantly within the migrants' community (53 and 80%, respectively). The acquisition of infection among immigrants living in Portugal differs according to the country of origin. These results can contribute to monitor the HIV epidemic and prevent new HIV infections among migrants.

WIGGLE MATCHING WITH CORRELATIONS

AbstractWiggle matching is an important and powerful technique in radiocarbon dating that can be used to improve the precision of calendar age estimates. All radiocarbon determinations require calibration to provide calendar age estimates. This calibration is achieved by comparing the determinations against a calibration curve $\mu ( \cdot )$ to calculate the probability the sample arises from any particular calendar age t. Wiggle matching involves the calibration of a set of radiocarbon determinations taken from samples with known separations between their calendar ages. Since the calendar age separations between samples are known, all the calendar ages are known functions of one particular age, ${T_1}$ — commonly the most recent calendar age. Dating the sequence then reduces to considering $p({T_1} = {t_1}|data)$, the probability of the calendar age ${t_1}$ given the set of radiocarbon determinations. In previous work, a Bayesian approach has been used to derive a nice formula for this quantity under the assumption we have independent pointwise estimates of the calibration curve $\mu (t)$. In this paper, we derive a generalization of this formula showing how to incorporate covariance information from the calibration curve under an assumption of multivariate normality.

Large-Scale Postmarketing Surveillance of Biological Drugs for Immune-Mediated Inflammatory Diseases Through an Italian Distributed Multi-Database Healthcare Network: The VALORE Project.

BackgroundBiological drugs have improved the management of immune-mediated inflammatory diseases (IMIDs) despite being associated with important safety issues such as immunogenicity, infections, and malignancies in real-world settings.ObjectiveThe aim of this study was to explore the potential of a large Italian multi-database distributed network for use in the postmarketing surveillance of biological drugs, including biosimilars, in patients with IMID.MethodsA retrospective cohort study was conducted using 13 Italian regional claims databases during 2010–2019. A tailor-made R-based tool developed for distributed analysis of claims data using a study-specific common data model was customized for this study. We measured the yearly prevalence of biological drug users and the frequency of switches between originator and biosimilars for infliximab, etanercept, and adalimumab separately and stratified them by calendar year and region. We then calculated the cumulative number of users and person-years (PYs) of exposure to individual biological drugs approved for IMIDs. For a number of safety outcomes (e.g., severe acute respiratory syndrome coronavirus 2 [SARS-COV-2] infection), we conducted a sample power calculation to estimate the PYs of exposure required to investigate their association with individual biological drugs approved for IMIDs, considering different strengths of association.ResultsFrom a total underlying population of almost 50 million inhabitants from 13 Italian regions, we identified 143,602 (0.3%) biological drug users, with a cumulative exposure of 507,745 PYs during the entire follow-up. The mean age ± standard deviation of biological drug users was 49.3 ± 16.3, with a female-to-male ratio of 1.2. The age-adjusted yearly prevalence of biological drug users increased threefold from 0.7 per 1000 in 2010 to 2.1 per 1000 in 2019. Overall, we identified 40,996 users of biosimilars of tumor necrosis factor (TNF)-α inhibitors (i.e., etanercept, adalimumab, and infliximab) in the years 2015–2019. Of these, 46% (N = 18,845) switched at any time between originator and biosimilars or vice versa. To investigate a moderate association (incidence rate ratio 2) between biological drugs approved for IMIDs and safety events of interest, such as optic neuritis (lowest background incidence rate 10.4/100,000 PYs) or severe infection (highest background incidence rate 4312/100,000 PYs), a total of 43,311 PYs and 104 PYs of exposure to individual biological drugs, respectively, would be required. As such, using this network, of 15 individual biological drugs approved for IMIDs, the association with those adverse events could be investigated for four (27%) and 14 (93%), respectively.ConclusionThe VALORE project multi-database network has access to data on more than 140,000 biological drug users (and > 0.5 million PYs) from 13 Italian regions during the years 2010–2019, which will be further expanded with the inclusion of data from other regions and more recent calendar years. Overall, the cumulated amount of person-time of exposure to biological drugs approved for IMIDs provides enough statistical power to investigate weak/moderate associations of almost all individual compounds and the most relevant safety outcomes. Moreover, this network may offer the opportunity to investigate the interchangeability of originator and biosimilars of several TNFα inhibitors in different therapeutic areas in real-world settings.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40259-021-00498-3.

Outcomes after mastectomy with immediate breast reconstruction for breast cancer in a multiethnic, middle-income Asian setting

BackgroundAlthough immediate breast reconstruction is increasingly becoming popular worldwide, evidence from resource-limited settings is scarce. We investigated factors associated with immediate breast reconstruction in a multiethnic, middle-income Asian setting. Short-term surgical complications, timing of initiation of chemotherapy, and survival outcomes were compared between women undergoing mastectomy alone and their counterparts receiving immediate breast reconstruction. MethodsThis historical cohort study included women who underwent mastectomy after diagnosis with stage 0 to stage IIIa breast cancer from 2011 to 2015 in a tertiary hospital. Multivariable regression analyses were used to assess factors associated with immediate breast reconstruction and to measure clinical outcomes. ResultOut of 790 patients with early breast cancer who had undergone mastectomy, only 68 (8.6%) received immediate breast reconstruction. Immediate breast reconstruction was independently associated with younger age at diagnosis, recent calendar years, Chinese ethnicity, higher education level, and invasive ductal carcinomas. Although immediate breast reconstruction was associated with a higher risk of short-term local surgical complications (adjusted odds ratio: 3.58 [95% confidence interval 1.75–7.30]), there were no significant differences in terms of delay in initiation of chemotherapy, 5-year disease-free survival, and 5-year overall survival between both groups in the multivariable analyses. ConclusionAlthough associated with short-term surgical complications, immediate breast reconstruction after mastectomy does not appear to be associated with delays in initiation of chemotherapy, recurrence, or mortality after breast cancer. These findings are valuable in facilitating shared surgical decision-making, improving access to immediate breast reconstruction, and setting priorities for surgical trainings in middle-income settings.

Variation in Pediatric Anesthesiologist Sedation Practices for Pediatric Gastrointestinal Endoscopy.

Background: Despite a worldwide shift toward anesthesiologist-administered sedation for gastrointestinal endoscopy in children, ideal sedation regimens remain unclear and best practices undefined.Aim: The aim of our study was to document variation in anesthesiologist-administered sedation for pediatric endoscopy. Outcomes of interest included coefficients of variation, procedural efficiency, as well as adverse events.Methods: IRB approval was obtained to review electronic health records of children undergoing routine endoscopy at our medical center during a recent calendar year. Descriptive and multivariate analyses were used to examine predictors of sedation practices.Results: 258 healthy children [2–21 years (median 15, (Q1–Q3 = 10–17)] underwent either upper and/or lower endoscopies with sedation administered by anesthesiologists (n = 21), using different sedation regimens (29) that ranged from a single drug administered to 6 sedatives in combination. Most patients did not undergo endotracheal tube intubation for the procedure (208, 81%), and received propofol (255, 89%) either alone or in combination with other sedatives. A total of 10 (3.8%) adverse events (9 sedation related) were documented to occur. The coefficient of variation (CV) for sedation times was high at 64.2%, with regression analysis suggesting 8% was unexplained by procedure time. Multivariable model suggested that longer procedure time (p < 0.0001), younger age (p < 0.0001), and use of endotracheal tube intubation (p = 0.02) were associated with longer sedation time.Discussion: We found great variation in anesthesiologist administered regimens for pediatric endoscopy at our institution that may be unwarranted, presenting may opportunities for minimizing patient risk, as well as for optimizing procedural efficiency.