Identifying priority and bright spot areas for improving diabetes care: a geospatial approach.

The objective of this study was to describe a novel geospatial methodology for identifying poor-performing (priority) and well-performing (bright spot) communities with respect to diabetes management at the ZIP Code Tabulation Area (ZCTA) level. This research was the first phase of a mixed-methods approach known as the focused rapid assessment process (fRAP). Using data from the Lehigh Valley Health Network in eastern Pennsylvania, geographical information systems mapping and spatial analyses were performed to identify diabetes prevalence and A1c control spatial clusters and outliers. We used a spatial empirical Bayes approach to adjust diabetes-related measures, mapped outliers and used the Local Moran\u27s I to identify spatial clusters and outliers. Patients with diabetes were identified from the Lehigh Valley Practice and Community-Based Research Network (LVPBRN), which comprised primary care practices that included a hospital-owned practice, a regional practice association, independent small groups, clinics, solo practitioners and federally qualified health centres. Using this novel approach, we identified five priority ZCTAs and three bright spot ZCTAs in LVPBRN. Three of the priority ZCTAs were located in the urban core of Lehigh Valley and have large Hispanic populations. The other two bright spot ZCTAs have fewer patients and were located in rural areas. As the first phase of fRAP, this method of identifying high-performing and low-performing areas offers potential to mitigate health disparities related to diabetes through targeted exploration of local factors contributing to diabetes management. This novel approach to identification of populations with diabetes performing well or poor at the local community level may allow practitioners to target focused qualitative assessments where the most can be learnt to improve diabetic management of the community

Identifying Priority and “Bright-Spot” Counties for Diabetes Preventive Care in Appalachia: An Exploratory Analysis

Introduction: Type 2 diabetes mellitus (T2DM) prevalence and mortality in Appalachian counties is substantially higher when compared to non-Appalachian counties, although there is significant variation within Appalachia. Purpose: The objectives of this research were to identify low-performing (priority) and high-performing (bright spot) counties with respect to improving T2DM preventive care. Methods: Using data from the Centers for Medicare and Medicaid (CMS), the Dartmouth Atlas of Health Care, and the Appalachia Regional Commission, conditional maps were created using county-level estimates for T2DM prevalence, mortality, and annual hemoglobin A1c (HbA1c) testing rates. Priority counties were identified using the following criteria: top 33rd percentile for T2DM mortality; top 33rd percentile for T2DM prevalence; bottom 50th percentile for A1c testing rates. Bright spot counties were identified as counties in the bottom 33rd percentile for T2DM mortality, the top 33rd percentile for T2DM prevalence; and the top 50th percentile for HbA1c testing rates. Results: Forty-one priority counties were identified (those with high T2DM mortality, high T2DM prevalence, and low HbA1c testing rates), which were located primarily in Central and North Central Appalachia; and 17 bright spot counties were identified (high T2DM prevalence, low T2DM mortality, and high HbA1c testing rates), which were scattered throughout Appalachia. Eight of the 17 bright spot counties were adjacent to priority counties. Implications: By employing conditional mapping to T2DM, multiple variables can be summarized into a single, easily interpretable map. This could be valuable for T2DM-prevention programs seeking to prioritize diagnostic and intervention resources for the management of T2DM in Appalachia

Cost-effectiveness of In-Home Cognitive Behavioral Therapy for low-income depressed mothers participating in early childhood prevention programs

To determine the cost-effectiveness of In-Home Cognitive Behavioral Therapy (IH-CBT) for low-income mothers enrolled in a home visiting program

TCT-99 Short- and Long-Term Outcomes of Patients With Chronic Kidney Disease Undergoing Protected High-Risk Percutaneous Coronary Intervention

Background: Patients with chronic kidney disease (CKD) and concomitant multivessel coronary artery disease (CAD) with or without left ventricular dysfunction often have high surgical risk and are declined for coronary artery bypass grafting. There is little data regarding clinical outcomes in these patients undergoing high-risk PCI (HRPCI) using Impella. Methods: We analyzed patients from the PROTECT III Study who underwent Impella-supported HRPCI and stratified them into 3 groups by kidney function status based on history: 1) normal kidney function, 2) CKD without dialysis, and 3) CKD with dialysis. We compared the composite incidence of major adverse cardiac and cerebrovascular events (MACCE) rate, defined as all-cause death, myocardial infarction (MI), stroke/transient ischemic attack (TIA), and repeat revascularization at 30 and 90 days. Results: We included 1,223 patients, aged 71 ± 11 years; 73% (893) were men, 68% (834) had normal kidney function (serum creatinine [Cr] 1.1 mg/dL, IQR 0.9-1.2), 23% (278) had CKD without dialysis (Cr 1.7 mg/dL, IQR 1.3-1.9), and 9% (111) were on dialysis. Patients on dialysis were younger with more comorbidities such as diabetes, heart failure, anemia, PVD and prior stroke. HRPCI status (urgent or elective), proportion of acute MI, and mean SYNTAX scores were similar. No significant differences in MACCE were shown between groups at 30 days or 90 days (Table). Patients with normal kidney function had comparable risks of 30-day and 90-day MACCE compared with CKD patients without dialysis with Cox proportional hazards analysis, and lower risk of 90-day MACCE compared to CKD patients with dialysis. Notably, CKD patients with or without dialysis also had similar 90-day MACCE risk (Table). Conclusion: Patients with CKD and dialysis undergoing HRPCI exhibit higher risk for 90-day MACCE compared to patients with normal kidney function. CKD patients without dialysis also had higher risk of MI at 90 days. Further research is needed. Categories: CORONARY: Complex and Higher Risk Procedures for Indicated Patients (CHIP

TCT-545 Angiographic Features, Lesion, and Procedural Characteristics in Patients With Chronic Kidney Disease Undergoing Protected High-Risk Percutaneous Coronary Intervention

Background: Patients with chronic kidney disease (CKD) are at risk for accelerated atherosclerosis. There is a paucity of data regarding coronary lesion characteristics and procedural details of CKD patients, especially those on dialysis, undergoing high-risk percutaneous coronary intervention (HRPCI) with left ventricular support. Methods: We analyzed patients from the PROTECT III study who underwent Impella-supported HRPCI, stratified into 3 groups according to kidney function status based on history: 1) normal kidney function; 2) CKD not on dialysis; and 3) CKD on dialysis. Baseline characteristics, angiographic features, and procedural details were assessed. Results: The study population included 3,702 treated lesions in 1,223 patients with a mean age of 71 ± 11 years; 73% (893) were male, 68% (834) had normal kidney function (serum creatinine = 1 mg/dL [IQR: 0.9-1.2]), 23% (278) had CKD not on dialysis (serum creatinine = 1.6 mg/dL [IQR: 1.3-1.9]), and 9% (111) were on dialysis. Patients on dialysis were significantly younger and had more comorbidities, as well as a greater incidence of acute myocardial infarction as an indication for HRPCI compared with the other 2 groups (45.0 [dialysis] vs 30.1 [CKD not on dialysis] vs 36.0 [normal kidney function]; P = 0.03). There was no difference between groups in prevalence of 3-vessel disease (P = 0.63). Patients on dialysis had greater prevalence of severely calcified lesions and higher use of rotational and orbital atherectomy with greater number of passes (Table 1). Despite this, no significant differences were observed in post-PCI Thrombolysis In Myocardial Infarction flow, incidence of no-reflow, or dissection/perforation. Conclusion: In contrast to patients with normal kidney function, patients with CKD with or without dialysis treated with Impella had more comorbidities, higher prevalence of severely calcified lesions, and greater use of atherectomy with more passes. Despite the complexity of PCI, no significant differences in complications were observed. Categories: CORONARY: Complex and Higher Risk Procedures for Indicated Patients (CHIP

31st Annual Meeting and Associated Programs of the Society for Immunotherapy of Cancer (SITC 2016) : part two

Background The immunological escape of tumors represents one of the main ob- stacles to the treatment of malignancies. The blockade of PD-1 or CTLA-4 receptors represented a milestone in the history of immunotherapy. However, immune checkpoint inhibitors seem to be effective in specific cohorts of patients. It has been proposed that their efficacy relies on the presence of an immunological response. Thus, we hypothesized that disruption of the PD-L1/PD-1 axis would synergize with our oncolytic vaccine platform PeptiCRAd. Methods We used murine B16OVA in vivo tumor models and flow cytometry analysis to investigate the immunological background. Results First, we found that high-burden B16OVA tumors were refractory to combination immunotherapy. However, with a more aggressive schedule, tumors with a lower burden were more susceptible to the combination of PeptiCRAd and PD-L1 blockade. The therapy signifi- cantly increased the median survival of mice (Fig. 7). Interestingly, the reduced growth of contralaterally injected B16F10 cells sug- gested the presence of a long lasting immunological memory also against non-targeted antigens. Concerning the functional state of tumor infiltrating lymphocytes (TILs), we found that all the immune therapies would enhance the percentage of activated (PD-1pos TIM- 3neg) T lymphocytes and reduce the amount of exhausted (PD-1pos TIM-3pos) cells compared to placebo. As expected, we found that PeptiCRAd monotherapy could increase the number of antigen spe- cific CD8+ T cells compared to other treatments. However, only the combination with PD-L1 blockade could significantly increase the ra- tio between activated and exhausted pentamer positive cells (p= 0.0058), suggesting that by disrupting the PD-1/PD-L1 axis we could decrease the amount of dysfunctional antigen specific T cells. We ob- served that the anatomical location deeply influenced the state of CD4+ and CD8+ T lymphocytes. In fact, TIM-3 expression was in- creased by 2 fold on TILs compared to splenic and lymphoid T cells. In the CD8+ compartment, the expression of PD-1 on the surface seemed to be restricted to the tumor micro-environment, while CD4 + T cells had a high expression of PD-1 also in lymphoid organs. Interestingly, we found that the levels of PD-1 were significantly higher on CD8+ T cells than on CD4+ T cells into the tumor micro- environment (p < 0.0001). Conclusions In conclusion, we demonstrated that the efficacy of immune check- point inhibitors might be strongly enhanced by their combination with cancer vaccines. PeptiCRAd was able to increase the number of antigen-specific T cells and PD-L1 blockade prevented their exhaus- tion, resulting in long-lasting immunological memory and increased median survival