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Over the past decades, anti-cancer treatments have evolved rapidly from cytotoxic chemotherapies to targeted therapies including oral targeted medications and injectable immunooncology and cell therapies. New anti-cancer medications come to markets at increasingly high prices, and health insurance coverage is crucial for patient access to these therapies. State laws are intended to facilitate insurance coverage of anti-cancer therapies.
Using Massachusetts as a case study, we identified five current cancer coverage state laws and interviewed experts on their perceptions of the relevance of the laws and how well they meet the current needs of cancer care given rapid changes in therapies. Interviewees emphasized that cancer therapies, as compared to many other therapeutic areas, are unique because insurance legislation targets their coverage. They identified the oral chemotherapy parity law as contributing to increasing treatment costs in commercial insurance. For commercial insurers, coverage mandates combined with the realities of new cancer medications — including high prices and often limited evidence of efficacy at approval — compound a difficult situation. Respondents recommended policy approaches to address this challenging coverage environment, including the implementation of closed formularies, the use of cost-effectiveness studies to guide coverage decisions, and the application of value-based pricing concepts. Given the evolution of cancer therapeutics, it may be time to evaluate the benefits and challenges of cancer coverage mandates.
OBJECTIVES/GOALS: Specific Aim 1 To examine sex distribution of psoas cross sectional area (CSA) on CT imaging in a cohort of trauma patients age 55 and older. We will use three methods of assessing psoas CSA: psoas CSA averaged between left and right, average psoas CSA adjusted for height, and average psoas CSA adjusted for body surface area (psoas index). Specific Aim 2 Use multivariable logistic regression prediction modeling to compare the 3 methods of CT psoas muscle measurement widely used in the literature in their ability to predict a composite of in-hospital morbidity and mortality in trauma patients ages 55 and older. METHODS/STUDY POPULATION: The Maine Medical Center Trauma Registry is maintained by the Trauma Surgery Service at Maine Medical Center in Portland, Maine, the only Level-1 trauma center in the state. After receiving approval from the Institutional Review Board of Maine Medical Center for this retrospective cohort study, we queried the Maine Medical Center Trauma Registry for all adults 55 years and older who underwent evaluation by the Trauma Service between January 1, 2015 and January 1, 2019. In the case of multiple admissions within the study time period, only a patient’s index admission was used. MaineHealth IMPACS imaging software was used to measure bilateral psoas CSA on each patient CT. The Maine Medical Center electronic medical record was queried for additional clinical information including the ICD codes associated with each patient encounter. Data analysis was performed using R statistical software (R project, Vienna, Austria). Data is reported as median + IQR for CSA measurements. The agreement between the three methods of quantifying psoas CSA was evaluated using Pearson correlation (R package “stats”). Inter-rater reliability of psoas muscle measurements was evaluated using intra-class correlation (R package “irr”). Prediction models for the composite outcome of in-hospital morbidity and mortality were constructed using multivariable logistic regression. Bootstrapping was used for internal validation and shrinkage to avoid overfitting. Models including psoas CSA were compared to a baseline model without psoas CSA to evaluated incremental added predictive ability. RESULTS/ANTICIPATED RESULTS: This cohort provides a basis for examining the population distribution of psoas CSA in adults 55 years and older. IN addition to a high level of agreement between the three methods of measuring psoas CSA (Spearman coefficient > 0.9), there was also high level of inter rater reliability in psoas muscle assessment (intraclass correlation 0.9). We anticipate that psoas CSA adjusted for body surface area will add the most incremental predictive ability to a model predicting in-hospital morbidity and mortality. DISCUSSION/SIGNIFICANCE OF IMPACT: Given the heterogeneity of health status amongst elderly trauma patients, a major challenge lies in the rapid objective identification of those elderly trauma patients who are frail. Due to the limitations in current frailty measures, there has been a surge of interest in surrogate markers of frailty, such as muscle mass, as predictive factors of poor outcomes after trauma.Several studies have found that sarcopenia is associated with post injury morbidity and mortality. Estimates of the prevalence of sarcopenia among trauma patients vary across studies due to differences in definition and sample characteristics. In order to appropriately categorize patients as sarcopenic, the population distribution of psoas CSA on CT must be established. The psoas measurement that best correlates with outcomes has yet to be determined, and it is unclear which measurement should be implemented in usual practice. Our main objective is to improve the outcomes of sarcopenic patients hospitalized with trauma by implementing in the future patient-centered interventions which will account for sarcopenia.
We present results from deep Chandra X-ray observations of the galaxy group NGC 5813. This system shows three pairs of collinear cavities, with each pair associated with an elliptical AGN outburst shock. Due to the relatively regular morphology of this system, and the unique unambiguous detection of three distinct AGN outburst shocks, it is particularly well-suited for the study of AGN feedback and the AGN outburst history. We find that the mean kinetic power is roughly the same for each outburst, and that the total energy associated with the youngest outburst is significantly lower than that of the previous outbursts. This implies that the mean AGN jet power has remained stable for at least 50 Myr, and that the youngest outburst is ongoing. We find that the mean shock heating rate balances the local radiative cooling rate at each shock front, suggesting that AGN outburst shock heating alone is sufficient to offset cooling and establish AGN/ICM feedback within at least the central 30 kpc. Finally, we find non-zero shock front widths that are too large to be explained by particle diffusion, but are instead consistent with arising from broadening of the shock fronts due to propagation through a turbulent ICM with a mean turbulent speed of ~ 70 km s−1.
Environmental influences on the rate of Alzheimer's disease (AD) progression have received little attention. Our objective was to test hypotheses concerning associations between caregiver personality traits and the rate of AD progression.
Care receivers (CR) were 161 persons with AD from a population-based dementia progression study; 55 of their caregivers were spouses and 106 were adult children. Cognitive status of the CR was measured with the Mini-Mental State Examination every six months, over an average of 5.6 (range: 1–14) years. Linear mixed models tested rate of cognitive decline as a function of caregiver personality traits from the NEO Five-Factor Inventory.
Significantly faster cognitive decline was observed with higher caregiver Neuroticism overall; however, in stratified models, effects were significant for adult child but not spouse caregivers. Neuroticism facets of depression, anxiety, and vulnerability to stress were significantly associated with faster decline. Higher caregiver Extraversion was associated with slower decline in the CR when caregivers were adult children but not spouses.
For adult child caregivers, caregiver personality traits are associated with rate of cognitive decline in CRs with AD regardless of co-residency. Results suggest that dementia caregiver interventions promoting positive care management strategies and ways to react to caregiving challenges may eventually become an important complement to pharmacologic and other approaches aimed at slower rate of decline in dementia.
There is evidence to suggest that GPs experience significant difficulties associated with lack of support from, and communication with, hospital and other specialists in palliative care. The establishment of cancer and palliative care facilitator schemes by Macmillan Cancer Relief reflects these current concerns very clearly. This paper presents some of the findings from the first phase of an evaluation of one such GP facilitator scheme in the Welsh county of Powys. It examines the perceptions and expectations of GP facilitator post-holders during the first year of the facilitator scheme, based upon data gathered from qualitive interviews conducted on three separate occasions. The picture that emerges from the first year of this facilitator project is broadly a positive one. Facilitators have tailored their roles to fit in with and augment the practices with which they deal. Attitudes vary, but their goals of facilitation and education appear similar. Themain challenges facing post-holders is that of being aware of the possible existence of professional rivalries whilst developing their role in ways which do not encroach upon the territories of long-established colleagues.
The diagnosis of psychopathy is important for violence risk assessment.
To investigate whether the syndromal structure of psychopathy, as measured by the Psychopathy Checklist – Revised (PCL–R), is the same in the UK and North America, and whether this measure yields scores that are equivalent in these two regions.
Confirmatory factor analytic and item response theory methods were applied to large samples of PCL–R ratings.
The syndromal structure of psychopathy was invariant across cultures, three distinct factors underpinning the superordinate syndrome of psychopathy. However, PCL–R scores were not equivalent across cultures: the same level of psychopathy was associated with lower PCL–R scores in the UK. Items that reflected affective symptoms had the highest cross-cultural stability.
Scores on the PCL–R obtained in the UK are not directly comparable with those obtained in North America. Care must be exercised when the PCL–R is used to make important clinical decisions in the UK.
Obsessive-compulsive disorder (OCD) is one of the major anxiety disorders in the fourth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-IV: American Psychiatric Association, 1994). The disorder is characterized by persistent obsessions and compulsions that are time-consuming or cause marked distress or impairment and are perceived by the patient to be excessive or unreasonable. Obsessions are intrusive, recurrent, and persistent thoughts, images, or impulses that are unacceptable, unwanted, and usually associated with subjective resistance (Rachman and Hodgson, 1980). The content of the obsession is egodystonic in that it deals with themes that are inconsistent or even alien to one's sense of self, values, or usual ways of behaving (Purdon and Clark, 1999). Because of this the occurrence of the obsession is highly distressing for individuals with OCD, even though they may acknowledge that the intrusion is senseless and irrational (Rachman and Hodgson, 1980). The most commonobsessions involve concerns about dirt/disease contamination, accidents, unintended aggression or violence towards others, inappropriate sexual acts, mistakes, doubt, blasphemous thoughts, orderliness and symmetry, and hoarding.
Compulsions are repetitive, stereotypic, and intentional behavioral or mental responses that are subjectively experienced as an urge or pressure to act. The OCD patient may view the compulsion as excessive or exaggerated but the urge to act is not necessarily resisted in all cases. Compulsions are usually triggered by the occurrence of a distressing obsession.