ABSTRACT IMPACT: Younger patients receiving biologics for rheumatoid arthritis have higher medical expenditure. OBJECTIVES/GOALS: TNF inhibiting biologic disease modifying antirheumatic drugs are among the most highly regarded treatment options for rheumatoid arthritis (RA). We aimed at evaluating the medical and prescription costs associated with monoclonal antibody use vs. other RA treatment options in subjects diagnosed with RA. METHODS/STUDY POPULATION: Records from the Medical Panels Expenditure Survey (MEPS) database made available by the Agency for Healthcare Research and Quality were used to identify all RA subjects (n=_____). Demographics and MEPS-provided flags for RA were abstracted from the medical condition files for all the subjects surveyed (2008-2018). Prescribed biologics were identified based on generic and brand names following a manual review to detect any misspellings. Total medical expenses and prescription expenses were abstracted for all identified RA subjects. Subject were surveyed for two consecutive years, thus expenses were assessed for each of the two surveyed years. Costs were adjusted for inflation and expressed in 2018 dollars. The relationship between biologics use, cost and age or gender was evaluated by Fisher’s exact test. RESULTS/ANTICIPATED RESULTS: Most RA subjects did not use biologics. RA was more prevalent in women than in men with no significant correlation between sex and the use of biologics in year 1, year 2, or the combined years (p=.44, p=.63, and p=.65, respectively). Biologics users were found to be significantly younger (p<.001), with a mean of 52.8 years compared to 59 years in those who did not use biologics. The 95% confidence interval was 3.7 to 8.6 years younger than non-users. Total medical and prescription costs were higher for biologics users (p<.001) in all analyses. The mean prescription cost difference was $24,038 more per year for biologics users, and $26,296 more total medical expenses, CI $20,502-$27,230 and CI $21,947-$30,646, respectively. There was a trend for biologics users to have higher non-prescription medical expenses (p=.05). DISCUSSION/SIGNIFICANCE OF FINDINGS: Interestingly, biologics non-users had some extreme outliers with expenses far higher than any biologics users, possibly due to poorly controlled RA due to age and/or comorbidities. Yet, our most interesting findings are the higher use of biologics among younger RA subjects and the elevated costs of care being driven mainly by prescriptions cost.

Second language (L2) speakers produce speech more slowly than first language (L1) speakers. This may be due to a delay in lexical retrieval, but it is also possible that the delay is situated at later stages. This study used delayed picture naming to test whether late production stages (leading up to articulation) are slower in L2 than in L1. Dutch–English unbalanced bilinguals performed a regular and a delayed picture naming task in English and Dutch. Monolingual English controls performed these tasks in English. Speakers were slower when naming pictures in L2 during regular picture naming but not in delayed naming. Reaction time costs of using L2 did not vary with phonological complexity, but there was a larger L2 cost in accuracy with more complex words. We conclude that the very last stages prior to articulation are not significantly slower when bilinguals name pictures in their L2.

Background: During a 2017–2019 intervention in Chicago-area vSNFs to control carbapenem-resistant Enterobacteriaceae, healthcare worker adherence to hand hygiene and personal protective equipment was stubbornly inadequate (hand hygiene adherence, ~16% and 56% on entry and exit), despite educational and monitoring efforts. Little is known about vSNF staff understanding of multidrug-resistant organism (MDRO) transmission. We conducted a qualitative analysis of staff members at a vSNF that included assessment of staff perceptions of personal MDRO acquisition risk and associated personal hygiene routines transitioning from work to home. Methods: Between September 2018 and November 2018, a PhD-candidate medical anthropologist conducted semistructured interviews with management (N = 5), nursing staff (N = 6), and certified nursing assistants (N = 6) at a vSNF in the Chicago region (Illinois) who had already received 1 year of MDRO staff education and hand hygiene adherence monitoring. More than 11 hours of semistructured interviews were collected and transcribed. Data collection and analysis included identifying how staff members related to their own risk of MDRO acquisition/infection and what personal hygiene routines they followed. Transcriptions of the data were analyzed using thematic coding aided by MAXQDA qualitative analysis software. Results: Staff members at all levels were able to describe their perceptions related to the risk of acquiring an MDRO and personal hygiene in great detail. The risk of acquiring an MDRO was perceived as a constant threat by staff members, who described germs as bad and everywhere (Table 1). The perceived threat of MDRO acquisition was connected to individual personal hygiene routines (eg, changing shoes before leaving work), which were considered important by staff members (Table 2). Nursing staff and certified nursing assistants noted that personal hygiene was a critical factor keeping their residents, themselves, and their families free from MDROs. Conclusions: In the context of a quality improvement campaign, vSNF healthcare workers are aware of the transmissibility of microscopic MDROs and are highly motivated in preventing transmission of MDROs to themselves. Such perceptions may explain actions such as why workers may be differentially adherent with infection control interventions (eg, more likely to perform hand hygiene leaving a room rather than going into a room, or less likely to change gowns in between residents in multibed rooms if they believe they are already personally protected with a gown). Our findings suggest that interventions to improve staff adherence to infection control measures may need to address other factors related to adherence besides knowledge deficit (eg, understaffing) and may need to acknowledge self-protection as a driving motivator for staff adherence.

Funding: None

Disclosures: None

Background: Carbapenem-resistant Enterobacteriaceae (CRE) are endemic in the Chicago region. We assessed the regional impact of a CRE control intervention targeting high-prevalence facilities; that is, long-term acute-care hospitals (LTACHs) and ventilator-capable skilled nursing facilities (vSNFs). Methods: In July 2017, an academic–public health partnership launched a regional CRE prevention bundle: (1) identifying patient CRE status by querying Illinois’ XDRO registry and periodic point-prevalence surveys reported to public health, (2) cohorting or private rooms with contact precautions for CRE patients, (3) combining hand hygiene adherence, monitoring with general infection control education, and guidance by project coordinators and public health, and (4) daily chlorhexidine gluconate (CHG) bathing. Informed by epidemiology and modeling, we targeted LTACHs and vSNFs in a 13-mile radius from the coordinating center. Illinois mandates CRE reporting to the XDRO registry, which can also be manually queried or generate automated alerts to facilitate interfacility communication. The regional intervention promoted increased automation of alerts to hospitals. The prespecified primary outcome was incident clinical CRE culture reported to the XDRO registry in Cook County by month, analyzed by segmented regression modeling. A secondary outcome was colonization prevalence measured by serial point-prevalence surveys for carbapenemase-producing organism colonization in LTACHs and vSNFs. Results: All eligible LTACHs (n = 6) and vSNFs (n = 9) participated in the intervention. One vSNF declined CHG bathing. vSNFs that implemented CHG bathing typically bathed residents 2–3 times per week instead of daily. Overall, there were significant gaps in infection control practices, especially in vSNFs. Also, 75 Illinois hospitals adopted automated alerts (56 during the intervention period). Mean CRE incidence in Cook County decreased from 59.0 cases per month during baseline to 40.6 cases per month during intervention (P < .001). In a segmented regression model, there was an average reduction of 10.56 cases per month during the 24-month intervention period (P = .02) (Fig. 1), and an estimated 253 incident CRE cases were averted. Mean CRE incidence also decreased among the stratum of vSNF/LTACH intervention facilities (P = .03). However, evidence of ongoing CRE transmission, particularly in vSNFs, persisted, and CRE colonization prevalence remained high at intervention facilities (Table 1). Conclusions: A resource-intensive public health regional CRE intervention was implemented that included enhanced interfacility communication and targeted infection prevention. There was a significant decline in incident CRE clinical cases in Cook County, despite high persistent CRE colonization prevalence in intervention facilities. vSNFs, where understaffing or underresourcing were common and lengths of stay range from months to years, had a major prevalence challenge, underscoring the need for aggressive infection control improvements in these facilities.

Funding: The Centers for Disease Control and Prevention (SHEPheRD Contract No. 200-2011-42037)

Disclosures: M.Y.L. has received research support in the form of contributed product from OpGen and Sage Products (now part of Stryker Corporation), and has received an investigator-initiated grant from CareFusion Foundation (now part of BD).

Background: During 2017–2019 in the Chicago region, several ventilator-capable skilled nursing facilities (vSNFs) participated in a quality improvement project to control the spread of highly prevalent carbapenem-resistant Enterobacteriaceae (CRE). With guidance from regional project coordinators and public health departments that involved education, assistance with implementation, and adherence monitoring, the facilities implemented a CRE prevention bundle that included a hand hygiene campaign that promoted alcohol-based hand rub, contact precautions (personal protective equipment with glove/gown) for care of CRE-colonized residents, and 2% chlorhexidine gluconate (CHG) wipes for routine resident bathing. We conducted a qualitative study to better understand the ways that vSNF employees engage with the implementation of such infection control measures. Methods: A PhD-candidate medical anthropologist conducted semistructured interviews with management (N = 5), nursing staff (N = 6), and certified nursing assistants (N = 6) at a vSNF in the Chicago region (Illinois) between September 2018 and November 2018. More than 11 hours of semistructured interviews were collected and transcribed. Data collection and analysis focused on identifying healthcare worker experiences during an infection control intervention. Transcriptions of the data were analyzed using thematic coding aided by MAXQDA qualitative analysis software. Results: Healthcare workers described the facility using language associated with a family environment (Table 1). Furthermore, healthcare workers demonstrated motivation to implement infection control policies (Table 2). However, healthcare workers expressed cultural and structural challenges encountered during implementation, such as their belief that some infection control measures discouraged maintenance of a home-like environment, lack of time, and understaffing. Some healthcare workers perceived that alcohol-based hand rub was ineffective over time and left unpleasant textures on the skin. Additionally, some workers did not trust the available gown and gloves used to prevent transmission. Lastly, healthcare workers typically did not prefer 2% CHG wipes over soap and water, citing residual resident postbathing smell as one indicator of CHG ineffectiveness. Conclusions: In a vSNF we found both considerable support and challenges implementing a CRE prevention bundle from the healthcare worker perspective. Healthcare workers were dedicated to recreating a home-like environment for their residents, which sometimes felt at odds with infection control interventions. Residual misconceptions (eg, alcohol-based hand rub is not effective) and negative worker perceptions (eg, permeability of contact precaution gowns and/or residue from alcohol-based hand rub) suggest that ongoing education and participation by healthcare workers in evaluating infection control products for interventions is critical.

Funding: None

Disclosures: None

The Arctic is warming faster than anywhere else of comparable size on Earth, impacting global climate feedbacks and the Arctic biota. However, a warm Arctic is not novel. The Late Cretaceous fossil record of the region enables a detailed reconstruction of polar environmental conditions, and a thriving extinct ecosystem, during a previous 'hothouse’ global climate. Using leaf form (physiognomy) and tree ring characteristics we reconstruct Cenomanian to Coniacian polar thermal and hydrological regimes over an average annual cycle at eight locations in NE Russia and northern Alaska. A new high spatial resolution (∼1 km) WorldClim2 calibration of the Climate Leaf Analysis Multivariate Program (CLAMP) yields results similar to, but often slightly warmer than, previous analyses, but also provides more detailed insights into the hydrological regime through the return of annual and seasonal vapour pressure deficit (VPD), potential evapotranspiration (PET) estimates and soil moisture, as well as new thermal overviews through measures of thermicity and growing degree days. The new results confirm the overall warmth of the region, particularly close to the Arctic Ocean, but reveal strong local differences that may be related to palaeoelevation in the Okhotsk–Chukotka Volcanogenic Belt in NE Russia. While rainfall estimates have large uncertainties due to year-round wet soils in most locations, new measures of VPD and PET show persistent high humidity, but with notably drier summers at all the Arctic sites.

Background: Advances in multiple sclerosis (MS) disease modifying therapy (DMT) have increased laboratory monitoring requirements. Our goal was to survey existing practices and perceptions of risk in laboratory monitoring throughout Canada and assess whether opportunities to improve patient care and safety exist. Methods: A web-based survey assessing prescriber demographics, current infrastructure, and concerns for lab monitoring was sent to the Canadian Network of MS Clinics (CNMSC) listserv, inviting MS clinicians across the country to participate. Results: Respondents included 32/65 CNMSC-affiliated neurologists (49%), 6 registered nurses (RN), 2 nurse practitioners (NP), and 2 non-neurologist physicians from 8/10 provinces. For some questions, analysis was limited to 34 DMT-prescribing clinicians only. Despite broad implementation of electronic medical records (25/34, 74%), many prescribers (15/34, 44%) still receive laboratory results in paper form. In terms of lab monitoring infrastructure, we noted regional variability in the employment of nursing to monitor patient compliance with required laboratory monitoring. There is also a gap in laboratory surveillance, as less than 5% of respondents reported regularly reviewing results on weekends. Providers’ length of practice and volume of MS patients were not associated with different perception of DMT laboratory monitoring risk. Conclusions: This nation-wide survey showed variability in infrastructure used in laboratory monitoring and regional variation in nursing involvement. Providers’ level of concern for laboratory monitoring for DMTs did not vary by years of experience or volume of MS patients followed, suggesting that improved systems, rather than education, could ameliorate perceptions of risk.

Astrophysics Telescope for Large Area Spectroscopy Probe is a concept for a National Aeronautics and Space Administration probe-class space mission that will achieve ground-breaking science in the fields of galaxy evolution, cosmology, Milky Way, and the Solar System. It is the follow-up space mission to Wide Field Infrared Survey Telescope (WFIRST), boosting its scientific return by obtaining deep 1–4 μm slit spectroscopy for ∼70% of all galaxies imaged by the ∼2 000 deg2 WFIRST High Latitude Survey at z > 0.5. Astrophysics Telescope for Large Area Spectroscopy will measure accurate and precise redshifts for ∼200 M galaxies out to z < 7, and deliver spectra that enable a wide range of diagnostic studies of the physical properties of galaxies over most of cosmic history. Astrophysics Telescope for Large Area Spectroscopy Probe and WFIRST together will produce a 3D map of the Universe over 2 000 deg2, the definitive data sets for studying galaxy evolution, probing dark matter, dark energy and modifications of General Relativity, and quantifying the 3D structure and stellar content of the Milky Way. Astrophysics Telescope for Large Area Spectroscopy Probe science spans four broad categories: (1) Revolutionising galaxy evolution studies by tracing the relation between galaxies and dark matter from galaxy groups to cosmic voids and filaments, from the epoch of reionisation through the peak era of galaxy assembly; (2) Opening a new window into the dark Universe by weighing the dark matter filaments using 3D weak lensing with spectroscopic redshifts, and obtaining definitive measurements of dark energy and modification of General Relativity using galaxy clustering; (3) Probing the Milky Way’s dust-enshrouded regions, reaching the far side of our Galaxy; and (4) Exploring the formation history of the outer Solar System by characterising Kuiper Belt Objects. Astrophysics Telescope for Large Area Spectroscopy Probe is a 1.5 m telescope with a field of view of 0.4 deg2, and uses digital micro-mirror devices as slit selectors. It has a spectroscopic resolution of R = 1 000, and a wavelength range of 1–4 μm. The lack of slit spectroscopy from space over a wide field of view is the obvious gap in current and planned future space missions; Astrophysics Telescope for Large Area Spectroscopy fills this big gap with an unprecedented spectroscopic capability based on digital micro-mirror devices (with an estimated spectroscopic multiplex factor greater than 5 000). Astrophysics Telescope for Large Area Spectroscopy is designed to fit within the National Aeronautics and Space Administration probe-class space mission cost envelope; it has a single instrument, a telescope aperture that allows for a lighter launch vehicle, and mature technology (we have identified a path for digital micro-mirror devices to reach Technology Readiness Level 6 within 2 yr). Astrophysics Telescope for Large Area Spectroscopy Probe will lead to transformative science over the entire range of astrophysics: from galaxy evolution to the dark Universe, from Solar System objects to the dusty regions of the Milky Way.

Although most global forest economic studies have found that warming is likely to increase forest supply, these studies have examined only the limited warming expected through 2100. This study extends the analysis out to 2250 to test much higher levels of warming to examine very long term effects. Future warming is predicted to steadily increase forest productivity, with global timber supply predicted to increase through 2250, even with warming up to 11 °C warming. However, natural forestland and biomass will shrink. This result suggests far future forests will not be able to hold the same stock of carbon they hold today.

We question whether the increasingly popular, radical idea of turning half the Earth into a network of protected areas is either feasible or just. We argue that this Half-Earth plan would have widespread negative consequences for human populations and would not meet its conservation objectives. It offers no agenda for managing biodiversity within a human half of Earth. We call instead for alternative radical action that is both more effective and more equitable, focused directly on the main drivers of biodiversity loss by shifting the global economy from its current foundation in growth while simultaneously redressing inequality.

Objectives: Cognitive impairment is common in Parkinson’s disease (PD). Three neurocognitive networks support efficient cognition: the salience network, the default mode network, and the central executive network. The salience network is thought to switch between activating and deactivating the default mode and central executive networks. Anti-correlated interactions between the salience and default mode networks in particular are necessary for efficient cognition. Our previous work demonstrated altered functional coupling between the neurocognitive networks in non-demented individuals with PD compared to age-matched control participants. Here, we aim to identify associations between cognition and functional coupling between these neurocognitive networks in the same group of participants. Methods: We investigated the extent to which intrinsic functional coupling among these neurocognitive networks is related to cognitive performance across three neuropsychological domains: executive functioning, psychomotor speed, and verbal memory. Twenty-four non-demented individuals with mild to moderate PD and 20 control participants were scanned at rest and evaluated on three neuropsychological domains. Results: PD participants were impaired on tests from all three domains compared to control participants. Our imaging results demonstrated that successful cognition across healthy aging and Parkinson’s disease participants was related to anti-correlated coupling between the salience and default mode networks. Individuals with poorer performance scores across groups demonstrated more positive salience network/default-mode network coupling. Conclusions: Successful cognition relies on healthy coupling between the salience and default mode networks, which may become dysfunctional in PD. These results can help inform non-pharmacological interventions (repetitive transcranial magnetic stimulation) targeting these specific networks before they become vulnerable in early stages of Parkinson’s disease. (JINS, 2016, 22, 205–215)