Multi-domain biopsychosocial postoperative recovery trajectories associate with patient outcomes following lumbar fusion.

PURPOSE: The purpose of this study is to describe and assess the impact of multi-domain biopsychosocial (BPS) recovery on outcomes following lumbar spine fusion. We hypothesized that discrete patterns of BPS recovery (e.g., clusters) would be identified, and then associated with postoperative outcomes and preoperative patient data. METHODS: Patient-reported outcomes for pain, disability, depression, anxiety, fatigue, and social roles were collected at multiple timepoints for patients undergoing lumbar fusion between baseline and one year. Multivariable latent class mixed models assessed composite recovery as a function of (1) pain, (2) pain and disability, and (3) pain, disability, and additional BPS factors. Patients were assigned to clusters based on their composite recovery trajectories over time. RESULTS: Using all BPS outcomes from 510 patients undergoing lumbar fusion, three multi-domain postoperative recovery clusters were identified: Gradual BPS Responders (11%), Rapid BPS Responders (36%), and Rebound Responders (53%). Modeling recovery from pain alone or pain and disability alone failed to generate meaningful or distinct recovery clusters. BPS recovery clusters were associated with number of levels fused and preoperative opioid use. Postoperative opioid use (p < 0.01) and hospital length of stay (p < 0.01) were associated with BPS recovery clusters even after adjusting for confounding factors. CONCLUSION: This study describes distinct clusters of recovery following lumbar spine fusion derived from multiple BPS factors, which are related to patient-specific preoperative factors and postoperative outcomes. Understanding postoperative recovery trajectories across multiple health domains will advance our understanding of how BPS factors interact with surgical outcomes and could inform personalized care plans.

Antibody-receptor interactions mediate antibody-dependent cellular cytotoxicity.

Binding of antibodies to their receptors is a core component of the innate immune system. Understanding the precise interactions between antibodies and their Fc receptors has led to the engineering of novel mAb biotherapeutics with tailored biological activities. One of the most significant findings is that afucosylated monoclonal antibodies demonstrate increased affinity toward the receptor FcγRIIIa, with a commensurate increase in antibody-dependent cellular cytotoxicity. Crystal structure analysis has led to the hypothesis that afucosylation in the Fc region results in reduced steric hindrance between antibody-receptor intermolecular glycan interactions, enhancing receptor affinity; however, solution-phase data have yet to corroborate this hypothesis. In addition, recent work has shown that the fragment antigen-binding (Fab) region may directly interact with Fc receptors; however, the biological consequences of these interactions remain unclear. By probing differences in solvent accessibility between native and afucosylated immunoglobulin G1 (IgG1) using hydroxyl radical footprinting-MS, we provide the first solution-phase evidence that an IgG1 bearing an afucosylated Fc region appears to require fewer conformational changes for FcγRIIIa binding. In addition, we performed extensive molecular dynamics (MD) simulations to understand the molecular mechanism behind the effects of afucosylation. The combination of these techniques provides molecular insight into the steric hindrance from the core Fc fucose in IgG1 and corroborates previously proposed Fab-receptor interactions. Furthermore, MD-guided rational mutagenesis enabled us to demonstrate that Fab-receptor interactions directly contribute to the modulation of antibody-dependent cellular cytotoxicity activity. This work demonstrates that in addition to Fc-polypeptide and glycan-mediated interactions, the Fab provides a third component that influences IgG-Fc receptor biology.

Perioperative Serum 25-Hydroxyvitamin D Levels as a Predictor of Postoperative Opioid Use and Opioid Use Disorder: a Cohort Study.

IMPORTANCE: Vitamin D deficiency is associated with chronic pain syndromes and higher opioid use among cancer patients, but its association with opioid use among opioid-naïve subjects following a major surgical procedure with acute pain has not been explored. OBJECTIVE: To determine the association between serum 25-hydroxyvitamin D (25(OH)D) levels, opioid use, and opioid use disorder. METHODS: We identified commercially insured subjects aged 18-64 years with available perioperative serum 25-hydroxyvitamin D (25D) levels who underwent one of nine major surgical procedures in 2000-2014. Primary outcomes were dose and duration of opioid use measured using pharmacy claims. Secondary outcome was opioid use disorder captured using diagnosis codes. Multivariable negative binomial models with generalized estimating equations were performed examining the association between 25D levels and postoperative opioid use measures, adjusting for age, sex, race/ethnicity, Charlson score, education, income, latitude, and season of blood draw. Adjusted Cox regression was used to examine the association with opioid use disorder. RESULTS: Among 5446 subjects, serum 25(OH)D was sufficient (≥ 20 ng/mL) among 4349 (79.9%) subjects, whereas 837 (15.4%) had insufficient (12 to < 20 ng/mL) and 260 (4.8%) had deficient (< 12 ng/mL) levels. On multivariable analysis, as compared with subjects with sufficient 25(OH)D levels, subjects with deficient 25(OH)D levels had 1.7 more days (95% CI 0.76, 2.58) of opioid use per year and had 98.7 higher morphine milligram equivalent dose (95% CI 55.7, 141.8) per year. Among 11,713 study cohort, subjects with deficient 25(OH)D levels were more likely to be diagnosed with opioid use disorders (HR 2.41; 95% CI 1.05, 5.52). CONCLUSION: Patients undergoing common surgical procedures with deficient 25D levels are more likely to have higher opioid use and an increased risk of opioid use disorder compared to those with sufficient levels. Serum 25D levels may serve as a biomarker to identify subjects at increased risk of opioid misuse.

High-Deductible Insurance and Delay in Care for the Macrovascular Complications of Diabetes.

Background: Little is known about the long-term effects of high-deductible insurance on care for chronic medical conditions. Objective: To determine whether a transition from low-deductible to high-deductible insurance is associated with delayed medical care for macrovascular complications of diabetes. Design: Observational longitudinal comparison of matched groups. Setting: A large national health insurer during 2003 to 2012. Participants: The intervention group comprised 33 957 persons with diabetes who were continuously enrolled in low-deductible (≤$500) insurance plans during a baseline year followed by up to 4 years in high-deductible (≥$1000) plans. The control group included 294 942 persons with diabetes who were enrolled in low-deductible plans contemporaneously with matched intervention group members. Intervention: Employer-mandated transition to a high-deductible plan. Measurements: The number of months it took for persons in each study group to seek care for their first major macrovascular symptom, have their first major diagnostic test for macrovascular disease, and have their first major procedure-based treatment was determined. Between-group differences in time to reach a midpoint event rate were then calculated. Results: No baseline differences were found between groups. During follow-up, the delay for the high-deductible group was 1.5 months (95% CI, 0.8 to 2.3 months) for seeking care for the first major symptom, 1.9 months (CI, 1.4 to 2.3 months) for the first diagnostic test, and 3.1 months (CI, 0.5 to 5.8 months) for the first procedure-based treatment. Limitation: Health outcomes were not examined. Conclusion: Among persons with diabetes, mandated enrollment in a high-deductible insurance plan was associated with delays in seeking care for the first major symptoms of macrovascular disease, the first diagnostic test, and the first procedure-based treatment. Primary Funding Source: National Institute of Diabetes and Digestive and Kidney Diseases.

Impact of high-deductible insurance on adjuvant hormonal therapy use in breast cancer.

OBJECTIVE: High-deductible health plans (HDHPs) have become the predominant commercial health insurance arrangement in the US. HDHPs require substantial out-of-pocket (OOP) costs for most services but often exempt medications from high cost sharing. We examined effects of HDHPs on OOP costs and utilization of adjuvant hormonal therapy (AHT), which are fundamental care for patients with breast cancer. METHODS: This controlled quasi-experimental study used claims data (2003-2012) from a large national health insurer. We included 986 women with incident early-stage breast cancer, age 25-64 years, insured by employers that mandated a transition from low-deductible (≤ $500/year) to high-deductible (≥ $1000/year) coverage, and 3479 propensity score-matched controls whose employers offered only low-deductible plans. We examined AHT utilization and OOP costs per person-year before and after the HDHP switch. RESULTS: At baseline, the OOP costs for AHT were $40.41 and $36.55 per person-year among the HDHP and control groups. After the HDHP switch, the OOP costs for AHT were $91.76 and $72.98 per person-year among the HDHP and control groups, respectively. AHT OOP costs increased among HDHP members relative to controls but the change was not significant (relative change 13.72% [95% CI - 9.25, 36.70%]). AHT use among HDHP members did not change compared to controls (relative change of 2.73% [95% CI - 14.01, 19.48%]); the change in aromatase inhibitor use was - 11.94% (95% CI - 32.76, 8.88%) and the change in tamoxifen use was 20.65% (95% CI - 8.01, 49.32%). CONCLUSION: We did not detect significant changes in AHT use after the HDHP switch. Findings might be related to modest increases in overall AHT OOP costs, the availability of low-cost generic tamoxifen, and patient awareness that AHT can prolong life and health. Minimizing OOP cost increases for essential medications might represent a feasible approach for maintaining medication adherence among HDHP members with incident breast cancer.

The Anesthesia Perioperative "Call for Help"-Experience at a Quaternary Pediatric Medical Center: Analysis of 67,564 Anesthesia Encounters.

BACKGROUND: During the past several decades, anesthesia has become increasingly safe. Truly major adverse events are rare, and anesthesia quality researchers have instituted programs to evaluate "near miss" or less critical adverse events to evaluate the safety of anesthesia delivery. In this study, we aimed to evaluate calls for emergency help in our institution as a surrogate for pending critical events. We hypothesized that calls would be more common in patients with high American Society of Anesthesiologists (ASA) physical status, history of prematurity, and children with recent respiratory illness compared to those without these characteristics. METHODS: We analyzed emergent calls for help initiated by perioperative personnel ("STAT" calls) between August 2011 and September 2015 at Boston Children's Hospital. Our analysis had 2 phases: (1) All 193 STAT calls that occurred during this time period were analyzed for demographic variables (age, ASA physical status, gender) and specific features of the STAT calls (provider who initiated the call, anesthetic phase, presence of recent respiratory illness, location). We further categorized the STAT calls as "complicated" or "uncomplicated" based on an unexpected change in patient disposition, and analyzed how demographic factors and specific features related to the likelihood of a STAT call being complicated. (2) A subset of the total calls (108), captured after introduction of electronic intraoperative medical record in July 2012, were analyzed for the incidence of STAT calls by comparing the number and nature of the STAT calls to the number of surgical/diagnostic procedures performed. RESULTS: Univariable and multivariable analysis of the entire cohort of STAT calls (193 cases) identified several characteristics that were more likely to be associated with a complicated STAT call: higher ASA physical status; history of respiratory illness; cardiac inciting event; occurrence during induction phase of general anesthesia; postanesthesia care unit location; and calls initiated by an attending physician or a pediatric anesthesia fellow. Multivariable analysis of the subset of 108 indicated that age <1 year and a history of prematurity were independent predictors of a higher incidence of STAT calls. Offsite anesthesia services were associated with a lower frequency of STAT calls independent of the other variables. CONCLUSIONS: Our study offers the most comprehensive analysis of emergent perioperative calls for help in pediatric anesthesia to date. We identified several characteristics, independently associated with more complicated and frequent perioperative STAT calls. Further research is required to evaluate the utility of this information in preventing and treating adverse events in children undergoing surgery and anesthesia.

Phosphorylation of tau at a single residue inhibits binding to the E3 ubiquitin ligase, CHIP.

Microtubule-associated protein tau (MAPT/tau) accumulates in a family of neurodegenerative diseases, including Alzheimer's disease (AD). In disease, tau is aberrantly modified by post-translational modifications (PTMs), including hyper-phosphorylation. However, it is often unclear which of these PTMs contribute to tau's accumulation or what mechanisms might be involved. To explore these questions, we focus on a cleaved proteoform of tau (tauC3), which selectively accumulates in AD and was recently shown to be degraded by its direct binding to the E3 ubiquitin ligase, CHIP. Here, we find that phosphorylation of tauC3 at a single residue, pS416, is sufficient to weaken its interaction with CHIP. A co-crystal structure of CHIP bound to the C-terminus of tauC3 reveals the mechanism of this clash, allowing design of a mutation (CHIPD134A) that partially restores binding and turnover of pS416 tauC3. We confirm that, in our models, pS416 is produced by the known AD-associated kinase, MARK2/Par-1b, providing a potential link to disease. In further support of this idea, an antibody against pS416 co-localizes with tauC3 in degenerative neurons within the hippocampus of AD patients. Together, these studies suggest a molecular mechanism for how phosphorylation at a discrete site contributes to accumulation of a tau proteoform.

The E3 Ubiquitin Ligase, CHIP/STUB1, Inhibits Aggregation of Phosphorylated Proteoforms of Microtubule-associated Protein Tau (MAPT).

Hyper-phosphorylated tau accumulates as insoluble fibrils in Alzheimer's disease (AD) and related dementias. The strong correlation between phosphorylated tau and disease has led to an interest in understanding how cellular factors discriminate it from normal tau. Here, we screen a panel of chaperones containing tetratricopeptide repeat (TPR) domains to identify those that might selectively interact with phosphorylated tau. We find that the E3 ubiquitin ligase, CHIP/STUB1, binds 10-fold more strongly to phosphorylated tau than unmodified tau. The presence of even sub-stoichiometric concentrations of CHIP strongly suppresses aggregation and seeding of phosphorylated tau. We also find that CHIP promotes rapid ubiquitination of phosphorylated tau, but not unmodified tau, in vitro. Binding to phosphorylated tau requires CHIP's TPR domain, but the binding mode is partially distinct from the canonical one. In cells, CHIP restricts seeding by phosphorylated tau, suggesting that it could be an important barrier in cell-to-cell spreading. Together, these findings show that CHIP recognizes a phosphorylation-dependent degron on tau, establishing a pathway for regulating the solubility and turnover of this pathological proteoform.

Phosphorylation of a Cleaved Tau Proteoform at a Single Residue Inhibits Binding to the E3 Ubiquitin Ligase, CHIP.

Microtubule-associated protein tau (MAPT/tau) accumulates in a family of neurodegenerative diseases, including Alzheimer's disease (AD). In disease, tau is aberrantly modified by post-translational modifications (PTMs), including hyper-phosphorylation. However, it is often unclear which of these PTMs contribute to tau's accumulation or what mechanisms might be involved. To explore these questions, we focused on a cleaved proteoform of tau (tauC3), which selectively accumulates in AD and was recently shown to be degraded by its direct binding to the E3 ubiquitin ligase, CHIP. Here, we find that phosphorylation of tauC3 at a single residue, pS416, is sufficient to block its interaction with CHIP. A co-crystal structure of CHIP bound to the C-terminus of tauC3 revealed the mechanism of this clash and allowed design of a mutation (CHIPD134A) that partially restores binding and turnover of pS416 tauC3. We find that pS416 is produced by the known AD-associated kinase, MARK2/Par-1b, providing a potential link to disease. In further support of this idea, an antibody against pS416 co-localizes with tauC3 in degenerative neurons within the hippocampus of AD patients. Together, these studies suggest a discrete molecular mechanism for how phosphorylation at a specific site contributes to accumulation of an important tau proteoform.

Lower Neurological Risk with Anterior Operations Compared to Posterior Operations for Thoracic Disc Herniations: Analysis of 697 Patients.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: Compare rates of postoperative neural deficits between surgical approaches for thoracic disc herniations (TDHs). SUMMARY OF BACKGROUND DATA: Anterior and posterior approaches for TDH carry high reported neurological risk, albeit comparative risk is not well defined. METHODS: Health Care Utilization Project (HCUP) state inpatient databases (NY, FL, CA; 2005-2014) were queried for patients who underwent TDH operation. Demographics, operative details, surgical approach, neural injury, length of stay (LOS), and discharge location were assessed. Multivariate linear regression was used to determine relative risk of neural deficit and skilled nursing facility (SNF) discharge. RESULTS: Six hundred ninety-seven patients (mean age 52.0 yrs, 194 institutions) met inclusion. Majority of operations were elective (76.0%) and one to two levels (80.5%). Overall neural injury rate was 9.0%. Anterior operations had significantly lower rates of neural injury compared with posterior operations on univariate analysis (4.6% vs. 11.4%; P < 0.01). All multilevel operations had similarly high rates of neural injury. On multivariate analysis, posterior approaches (RR 1.78; P = 0.12) and combined approaches (RR 2.15; P = 0.17) had higher neural risk compared with anterior approaches after controlling for younger age, higher Charlson Comorbidity Index, and nonelective admissions. Combined approaches had similar neural injury rates (13.8%) to posterior operations (11.4%) and significantly longer LOS and SNF discharges compared with single approaches. Neural deficit was associated with discharge to SNF (With = 87.3%; Without = 23.7%; P < 0.01) and increased LOS (With = 12.5 days; Without = 6.9 days; P < 0.01). CONCLUSION: Overall rate of neural deficit after operation for TDH was 9.0%. While anterior approach was associated with a lower neural injury rate, this association was confounded by age, Charlson Comorbidity Index, and admission type. After correcting for these confounders, a nonsignificant trend remained that favored the anterior approach. Neural deficit was associated with increased LOS and discharge to SNF postoperatively.Level of Evidence: 4.

5-Year Revision Rates After Elective Multilevel Lumbar/Thoracolumbar Instrumented Fusions in Older Patients: An Analysis of State Databases.

OBJECTIVE: The purpose of this study wasto evaluate cause-specific 5-year revision rates and risk factors for revision after elective multilevel lumbar instrumented fusion in older patients. METHODS: Older patients (>60 years) who underwent elective multilevel (3+) lumbar instrumented fusions were identified in Healthcare Cost and Utilization Project state inpatient databases and followed for 5 years for revision operations because of mechanical failure, degenerative disease (DD), infection, postlaminectomy syndrome, and stenosis. Cox proportional hazards multivariate analyses were conducted to determine risk factors associated with revision for each diagnostic cause. RESULTS: The cohort included 5,636 patients (female-3,285; average age-71.6 years). Most of the operations were 3 to 7 levels (97.4%), and the mean length of stay was 5.4 days. The overall 5-year revision rate was 16.5% with predominant etiologies of DD (50.7%), mechanical failure (32.2%), and stenosis (8.0%). The revision procedure at the index operation was associated with an increased revision risk for DD (hazards ratio [HR] = 1.59, 95% confidence interval [CI], 1.29 to 1.98, P < 0.001) and mechanical failure (HR = 1.56, 95% CI, 1.19 to 2.04, P = 0.020). Male sex was associated with a significantly reduced revision risk for DD (HR = 0.75, 95% CI, 0.62 to 0.91, P = 0.04). Age, race, and number of comorbidities had no notable effect on the overall or cause-specific risk of revision. DISCUSSION: In this large database analysis, DD and mechanical failure were the most common etiologies comprising a 5-year revision rate of 16.5% after elective multilevel lumbar instrumented fusion in older patients. Revision operations and female patients carried the strongest risks for revision.

Rates and risk factors associated with 30- and 90-day readmissions and reoperations after spinal fusions for adult lumbar degenerative pathology and spinal deformity.

PURPOSE: Analyze state databases to determine variables associated with of short-term readmissions and reoperations following thoracolumbar spine fusions for degenerative pathology and spinal deformity. METHODS: Retrospective study of State Inpatient Database (2005-13, CA, NE, NY, FL, NC, UT). INCLUSION CRITERIA: age > 45 years, diagnosis of degenerative spinal deformity, ≥ 3 level posterolateral lumbar spine fusion. EXCLUSION CRITERIA: revision surgery, cervical fusions, trauma, and cancer. Univariate and step-wise multivariate logistic regression analyses were performed to identify independent variables associated with of 30- and 90-day readmissions and reoperations. RESULTS: 12,641 patients were included. All-cause 30- and 90-day readmission rates were 14.6% and 21.1%, respectively. 90-day readmissions were associated with: age > 80 (OR: 1.42), 8 + level fusions (OR: 1.19), hospital length of stay (LOS) > 7 days (OR: 1.43), obesity (OR: 1.29), morbid obesity (OR: 1.66), academic hospital (OR: 1.13), cancer history (OR:1.21), drug abuse (OR: 1.31), increased Charlson Comorbidity index (OR: 1.12), and depression (OR: 1.20). Private insurance (OR: 0.64) and lumbar-only fusions (OR: 0.87) were not associated with 90-day readmissions. All-cause 30- and 90-day reoperation rates were 1.8% and 4.2%, respectively. Variables associated with 90-day reoperations were 8 + level fusions (OR: 1.28), LOS > 7 days (OR: 1.43), drug abuse (OR: 1.68), osteoporosis (OR: 1.26), and depression (OR: 1.23). Circumferential fusion (OR: 0.58) and lumbar-only fusions (OR: 0.68) were not associated with 90-day reoperations. CONCLUSIONS: 30- and 90-day readmission and reoperation rates in thoracolumbar fusions for adult degenerative pathology and spinal deformity may have been underreported in previously published smaller studies. Identification of modifiable risk factors is important for improving quality of care through preoperative optimization.

Reoperation and Mortality Rates Following Elective 1 to 2 Level Lumbar Fusion: A Large State Database Analysis.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: Reoperation to lumbar spinal fusion creates significant burden on patient quality of life and healthcare costs. We assessed rates, etiologies, and risk factors for reoperation following elective 1 to 2 level lumbar fusion. METHODS: Patients undergoing elective 1 to 2 level lumbar fusion were identified using the Health Care Utilization Project (HCUP) state inpatient databases from Florida and California. Patients were tracked for 5 years for any subsequent lumbar fusion. Cox proportional hazard analyses for reoperation were assessed using the following covariates: fusion approach type, age, race, Charlson comormidity index, gender, and length of stay. Distribution of etiologies for reoperation was then assessed. RESULTS: 71, 456 patients receiving elective 1 to 2 level lumbar fusion were included. A 5-year reoperation rate of 13.53% and mortality rate of 2.22% was seen. Combined anterior-posterior approaches (HR = 0.904, p < 0.05) and TLIF (HR = 0.867, p < 0.001) were associated with reduced risk of reoperation compared to stand-alone anterior approaches and non-TLIF posterior approaches. Age, gender, and number of comorbidities were not associated with risk of reoperation. From 1 to 5 years, degenerative disease rose from 43.50% to 50.31% of reoperations; mechanical failure decreased from 37.65% to 29.77%. CONCLUSIONS: TLIF and combined anterior-posterior approaches for 1 to 2 level lumbar fusion are associated with the lowest rate of reoperation. Number of comorbidities and age are not predictive of reoperation. Primary etiologies leading to reoperation were degenerative disease and mechanical failure. Mortality rate is not increased from baseline following 1 to 2 level lumbar fusion.

High-Deductible Health Plans Paired With Health Savings Accounts Increased Medication Cost Burden Among Individuals With Bipolar Disorder.

Objective: High-deductible health plans paired with health savings accounts (HSA-HDHPs) require substantial out-of-pocket spending for most services, including medications. We examined effects of HSA-HDHPs on medication out-of-pocket spending and use among people with bipolar disorder.Methods: This quasi-experimental study used claims data for January 2003 through December 2014. We studied a national sample of 348 members with bipolar disorder (defined based on International Classification of Diseases, 9th Revision), aged 12 to 64 years, who were continuously enrolled for 1 year in a low-deductible plan (≤ $500) then 1 year in an HSA-HDHP (≥ $1,000) after an employer-mandated switch. HSA-HDHP members were matched to 4,087 contemporaneous controls who remained in low-deductible plans. Outcome measures included out-of-pocket spending and use of bipolar disorder medications, non-bipolar psychotropics, and all other medications.Results: Mean pre-to-post out-of-pocket spending per person for bipolar disorder medications increased by 149.7% among HSA-HDHP versus control members (95% confidence interval [CI], 109.9% to 189.5%). Specifically, out-of-pocket spending increased for antipsychotics (220.9% [95% CI, 150.0% to 291.8%]) and anticonvulsants (109.6% [95% CI, 67.3% to 152.0%]). Both higher-income and lower-income HSA-HDHP members experienced increases in out-of-pocket spending for bipolar disorder medications (135.2% [95% CI, 86.4% to 184.0%] and 164.5% [95% CI, 100.9% to 228.1%], respectively). We did not detect statistically significant changes in use of bipolar disorder medications, non-bipolar psychotropics, or all other medications in this study population of HSA-HDHP members.Conclusions: HSA-HDHP members with bipolar disorder experienced substantial increases in out-of-pocket burdens for medications essential for their functioning and well-being. Although HSA-HDHPs were not associated with detectable reductions in medication use, high out-of-pocket costs could cause financial strain for lower-income enrollees.

Impact of High-Deductible Health Plans on Medication Use Among Individuals With Bipolar Disorder.

OBJECTIVE: High-deductible health plans (HDHPs) require substantial out-of-pocket spending for most services, although medications may be subject to traditional copayment arrangements. This study examined effects of HDHPs on medication out-of-pocket spending and use and quality of care among individuals with bipolar disorder. METHODS: This quasi-experimental study used claims data (2003-2014) for a national sample of 3,532 members with bipolar disorder, ages 12-64, continuously enrolled for 1 year in a low-deductible plan (≤$500) and then for 1 year in an HDHP (≥$1,000) after an employer-mandated switch. HDHP members were matched to 18,923 contemporaneous individuals in low-deductible plans (control group). Outcome measures were out-of-pocket spending and use of bipolar disorder medications, psychotropics for other disorders, and all other medications and appropriate laboratory monitoring for psychotropics. RESULTS: Relative to the control group, annual out-of-pocket spending per person for bipolar disorder medications increased 20.8% among HDHP members (95% confidence interval [CI]=14.9%-26.7%), and the absolute increase was $36 (95% CI=$25.9-$45.2). Specifically, out-of-pocket spending increased for antipsychotics (27.1%; 95% CI=17.4%-36.7%) and anticonvulsants (19.2%; 95% CI=11.9%-26.6%) but remained stable for lithium (-3.7%; 95% CI=-12.2% to 4.8%). No statistically significant changes were detected in use of bipolar disorder medications, other psychotropics, or all other medications or in appropriate laboratory monitoring for bipolar disorder medications. CONCLUSIONS: HDHP members with bipolar disorder experienced a moderate increase in out-of-pocket spending for medications but preserved bipolar disorder medication use. Findings may reflect individuals' perceptions of the importance of these medications for their functioning and well-being.

Integrating Stakeholder Engagement With Claims-Based Research on Health Insurance Design and Bipolar Disorder.

Researchers increasingly recognize that stakeholder involvement enhances research relevance and validity. However, reports of patient engagement in research that relies on administrative records data are rare. The authors' collaborative project combined quantitative and qualitative studies of costs and access to care among U.S. adults with employer-sponsored insurance. The authors analyzed insurance claims to estimate the impacts on enrollee costs and utilization after patients with bipolar disorder were switched from traditional coverage to high-deductible health plans. In parallel, in-depth interviews explored people's experiences accessing treatment for bipolar disorder. Academic investigators on the research team partnered with the Depression and Bipolar Support Alliance (DBSA), a national advocacy organization for people with mood disorders. Detailed personal stories from DBSA-recruited volunteers informed and complemented the claims analyses. Several DBSA audience forums and a stakeholder advisor panel contributed regular feedback on study issues. These multiple engagement modes drew inputs of varying intensity from diverse community segments. Efforts to include new voices must acknowledge individuals' distinct interests and barriers to research participation. Strong engagement leadership roles ensure productive communication between researchers and stakeholders. The involvement of people with direct experience of care is especially necessary in research that uses secondary data. Longitudinal, adaptable partnerships enable colearning and higher-quality research that captures the manifold dimensions of patient experiences.

The antimicrobial potential of cannabidiol.

Antimicrobial resistance threatens the viability of modern medicine, which is largely dependent on the successful prevention and treatment of bacterial infections. Unfortunately, there are few new therapeutics in the clinical pipeline, particularly for Gram-negative bacteria. We now present a detailed evaluation of the antimicrobial activity of cannabidiol, the main non-psychoactive component of cannabis. We confirm previous reports of Gram-positive activity and expand the breadth of pathogens tested, including highly resistant Staphylococcus aureus, Streptococcus pneumoniae, and Clostridioides difficile. Our results demonstrate that cannabidiol has excellent activity against biofilms, little propensity to induce resistance, and topical in vivo efficacy. Multiple mode-of-action studies point to membrane disruption as cannabidiol's primary mechanism. More importantly, we now report for the first time that cannabidiol can selectively kill a subset of Gram-negative bacteria that includes the 'urgent threat' pathogen Neisseria gonorrhoeae. Structure-activity relationship studies demonstrate the potential to advance cannabidiol analogs as a much-needed new class of antibiotics.

Effect of high-deductible insurance on health care use in bipolar disorder.

OBJECTIVES: To determine the impact of high-deductible health plans (HDHPs) on health care use among individuals with bipolar disorder. STUDY DESIGN: Interrupted time series with propensity score-matched control group design, using a national health insurer's claims data set with medical, pharmacy, and enrollment data. METHODS: The intervention group was composed of 2862 members with bipolar disorder who were enrolled for 1 year in a low-deductible (≤$500) plan and then 1 year in an HDHP (≥$1000) after an employer-mandated switch. HDHP members were propensity score matched 1:3 to contemporaneous controls in low-deductible plans. The main outcomes included out-of-pocket spending per health care service, mental health-related outpatient visits (subclassified as visits to nonpsychiatrist mental health providers and to psychiatrists), emergency department (ED) visits, and hospitalizations. RESULTS: Mean pre- to post-index date out-of-pocket spending per visit on all mental health office visits, nonpsychiatrist mental health provider visits, and psychiatrist visits increased by 21.9% (95% CI, 15.1%-28.6%), 33.8% (95% CI, 2.0%-65.5%), and 17.8% (95% CI, 12.2%-23.4%), respectively, among HDHP vs control members. The HDHP group experienced a -4.6% (95% CI, -11.7% to 2.5%) pre- to post change in mental health outpatient visits relative to controls, a -10.9% (95% CI, -20.6% to -1.3%) reduction in nonpsychiatrist mental health provider visits, and unchanged psychiatrist visits. ED visits and hospitalizations were also unchanged. CONCLUSIONS: After a mandated switch to HDHPs, members with bipolar disorder experienced an 11% decline in visits to nonpsychiatrist mental health providers but unchanged psychiatrist visits, ED visits, and hospitalizations. HDHPs do not appear to have a "blunt instrument" effect on health care use in bipolar disorder; rather, patients might make trade-offs to preserve important care.

Reactions to Transgender Women and Men in Public Restrooms: Correlates and Gender Differences.

This study examined reactions to transgender people in public restrooms. Participants (n = 158) completed measures of essentialism and trait aggression and read scenarios where they imagined sharing a restroom with a transwoman or a transman. Participants indicated which restroom targets should use and rated potential negative reactions. Results indicate that targets were assigned to restrooms corresponding to birth sex rather than chosen identity. Women's reactions to transgender women were more negative than men's; men were more negative in reactions toward transmen. Essentialism predicted some (but not all) reactions for all participants. Among women, trait aggression predicted negative reactions, but only to transmen. Among men, aggression predicted negative reactions, but only toward transwomen. This suggests that despite views that transgender people belong in birth-sex restrooms, men and women's trait aggression predicts negative reactions toward them in such instances.

Characterization of ELISA Antibody-Antigen Interaction using Footprinting-Mass Spectrometry and Negative Staining Transmission Electron Microscopy.

We describe epitope mapping data using multiple covalent labeling footprinting-mass spectrometry (MS) techniques coupled with negative stain transmission electron microscopy (TEM) data to analyze the antibody-antigen interactions in a sandwich enzyme-linked immunosorbant assay (ELISA). Our hydroxyl radical footprinting-MS data using fast photochemical oxidation of proteins (FPOP) indicates suppression of labeling across the antigen upon binding either of the monoclonal antibodies (mAbs) utilized in the ELISA. Combining these data with Western blot analysis enabled the identification of the putative epitopes that appeared to span regions containing N-linked glycans. An additional structural mapping technique, carboxyl group footprinting-mass spectrometry using glycine ethyl ester (GEE) labeling, was used to confirm the epitopes. Deglycosylation of the antigen resulted in loss of potency in the ELISA, supporting the FPOP and GEE labeling data by indicating N-linked glycans are necessary for antigen binding. Finally, mapping of the epitopes onto the antigen crystal structure revealed an approximate 90° relative spatial orientation, optimal for a noncompetitive binding ELISA. TEM data shows both linear and diamond antibody-antigen complexes with a similar binding orientation as predicted from the two footprinting-MS techniques. This study is the first of its kind to utilize multiple bottom-up footprinting-MS techniques and TEM visualization to characterize the monoclonal antibody-antigen binding interactions of critical reagents used in a quality control (QC) lot-release ELISA. Graphical Abstract ᅟ.