Acupuncture Intervention Protocol: Consensus Process for a Pragmatic Randomized Controlled Trial of Acupuncture for Management of Chronic Low Back Pain in Older Adults: An NIH HEAL Initiative Funded Project

Objective

The aim of this article is to describe the consensus process used to develop an acupuncture intervention protocol for an NIH-funded pragmatic randomized controlled trial (PRCT) of acupuncture for the management of chronic low back (cLBP) in older adults (BackInAction).

Background

CLBP is among leading causes of disability worldwide: almost 33% of US adults 65 and older experience LBP. Acupuncture is effective for cLBP but there is no specific data on older adults. The National Institutes for Health (NIH) funded a PRCT of acupuncture needling for this population. An essential trial milestone was development of a consensus intervention protocol.

Methods

An Acupuncture Advisory Panel (AAP) was formed with nine members: two physician-acupuncturists, six licensed acupuncturists representing diverse work backgrounds, and an acupuncture researcher. We used a modified Delphi process that included provision of acupuncture trial data, survey data describing how each expert treats cLBP, three conference calls, and between-call email discussion.

Results

Lively and professional discussions led to a consensus intervention protocol for the BackInAction trial that included steps/staging of care, recommendations for parameters of care session length, number of needle insertion sites, insertion depths, needle retention times, recommended types of needles, both local and distal areas of the body to be treated, acupuncture point options, auricular point options, self-care options, and minimum number of sessions considered ideal.

Conclusion

Using a modified Delphi process, an expert AAP created a consensus intervention protocol for the PRCT of acupuncture needling for cLBP in patients 65 and older.

Risks and Safety of Extended Auricular Therapy: A Review of Reviews and Case Reports of Adverse Events

OBJECTIVE

Auricular acupuncture (AA) and extended auricular therapy (AT) are a part of acupuncture practice shown to benefit patients with pain, anxiety, and other conditions, with cost-effective access enhanced when given in a group setting. Yet there are safety concerns and risks, perhaps unnecessary risks, that attend embedded, indwelling needles applied to the ear as a means of extended AT.

METHODS

Electronic searches were conducted in PubMed, MEDLINE, CINAHL and Cochrane Central Register of Controlled Trials (CENTRAL) for "auriculotherapy," "auricular acupuncture" or "auricular acupressure," "safety," "adverse events," "chondritis," and "perichondritis," with additional manual review of titles, links, and reference lists. Individual auricular therapy adverse event (AE) case reports were included, as well as systematic reviews and or meta-analyses if they evaluated AEs associated with AT.

RESULTS

Nineteen auricular AE case reports and nine safety reviews of or including auriculotherapy were included. Ten systematic reviews of AT with eight specific reviews of auricular acupressure (AP) were also included.

CONCLUSIONS

The primary AE risks is infection, perichondritis, and chondritis stemming from embedded or indwelling needles or potential inadvertent needlesticks from contaminated roaming sharps. Extended AP i.e., application of spheres, preferably seeds (natural, nontoxic botanical Vaccaria seeds) provides clinical benefit without the risks associated with embedded needles. More research is needed to establish if embedded needles at the ear are even necessary or have any advantage over in-session auricular acupuncture for immediate pain relief followed by ear acupressure.

Barriers and Facilitators to Implementing Bundled Acupuncture and Yoga Therapy to Treat Chronic Pain in Community Healthcare Settings: A Feasibility Pilot

Objective: To identify factors associated with implementing bundled group acupuncture and yoga therapy (YT) to treat underserved patients with chronic pain in community health center (CHC) settings. This is not an implementation science study, but rather an organized approach for identification of barriers and facilitators to implementing these therapies as a precursor to a future implementation science study. Design: This study was part of a single-arm feasibility trial, which aimed to test the feasibility of bundling GA and YT for chronic pain in CHCs. Treatment outcomes were measured before and after the 10-week intervention period. Implementation feasibility was assessed through weekly research team meetings, weekly yoga provider meetings, monthly acupuncture provider meetings, and weekly provider surveys. Settings: The study was conducted in New York City at two Montefiore Medical Group (MMG) sites in the Bronx, and one Institute for Family Health (IFH) site in Harlem. Subjects: Participants in the feasibility trial were recruited from IFH and MMG sites, and needed to have had lower back, neck, or osteoarthritis pain for >3 months. Implementation stakeholders included the research team, providers of acupuncture and YT, referring providers, and CHC staff. Results: Implementation of these therapies was assessed using the Consolidated Framework for Implementation Research. We identified issues associated with scheduling, treatment fidelity, communication, the three-way disciplinary interaction of acupuncture, yoga, and biomedicine, space adaptation, site-specific logistical and operational requirements, and patient-provider language barriers. Issues varied as to their frequency and resolution difficulty. Conclusions: This feasibility trial identified implementation issues and resolution strategies that could be further explored in future implementation studies. Clinical Trial Registration No.: NCT04296344.

Left atrial function assessed by speckle tracking echocardiography predicts atrial fibrillation burden after catheter ablation independently of reconduction: a RACE-AF echocardiographic sub-study

Funding Acknowledgements

Type of funding sources: None.

Background

Left atrial (LA) function assessed by 2D speckle tracking echocardiography (STE) has demonstrated to be a useful predictor of recurrence of atrial fibrillation (AF) following catheter ablation (CA). Pulmonary vein reconduction (PVR) is one of the most important causes of recurrent paroxysmal AF (PAF) after ablation. The purpose of this study was to evaluate the association between AF burden (% of time in AF) following CA and LA strain measurements independently of PVR.

Methods

This prospective study included 66 patients with PAF who underwent CA (mean age 60 ± 8 years, 65% male). STE was performed during sinus rhythm prior to CA. AF burden was recorded by continuous rhythm monitoring using implantable loop recorders during a follow-up period of 4-6 months, excluding a blanking period of 3 months. After follow-up, all patients underwent an invasive assessment of pulmonary vein isolation to test for PVR. Multivariable linear regression analysis was used to assess the association between AF burden and peak atrial longitudinal reservoir strain (PALS), peak atrial contraction strain (PACS) and peak atrial conduit strain (PCS).

Results

Prior to CA, median AF burden was 3.8% (IQR: 0.5, 17). During follow-up, 37 patients (56%) were free of AF while median AF burden was 0.7% (IQR: 0.2, 1.6) in patients with an AF burden of more than 0%. A total of 35 patients (54%) were found to have PVR after ablation. Patients with AF recurrence had significantly lower PACS compared to patients with no AF during follow-up (10% ± 6% vs. 14% ± 5%, p = 0.004). No differences in PALS and PCS were observed. Increased PACS remained independently associated with low AF burden following CA after multivariable adjustments for clinical characteristics, comorbidities, and PVR (β=-0.262, p = 0.049) (Figure 1). PALS and PCS did not remain significantly associated with AF burden.

Conclusion

Increased PACS is strongly associated with low AF burden after CA even after adjusting for PVR. This suggests that an analysis of LA function could be useful to stratify patients prior to CA and improve treatment strategies.

Abstract Figure.

Yoga therapy DYADS: A novel approach to chronic pain management in underserved populations

Yoga therapy is an emerging integrative health approach that applies the practices and teachings of yoga for individuals with clinical concerns. It is generally offered as individual sessions between a yoga therapist and client or in a small group setting with several clients who share a clinical concern. Here we describe a third model for consideration- the yoga therapy dyad. A dyad includes two clients working simultaneously with a single yoga therapist and differs from both individual and small group sessions in the potential benefits and challenges. The yoga therapy dyad model that is detailed here was implemented as part of a feasibility trial along with group acupuncture therapy for chronic pain in an underserved population. Underserved populations are at risk for pain and reduced access to care. This pilot may inform future research, policy, education, and clinical practice.

Group Acupuncture Therapy With Yoga Therapy for Chronic Neck, Low Back, and Osteoarthritis Pain in Safety Net Setting for an Underserved Population: Design and Rationale for a Feasibility Pilot

Chronic pain is prevalent in the United States, with impact on physical and psychological functioning as well as lost work productivity. Minority and lower socioeconomic populations have increased prevalence of chronic pain with less access to pain care, poorer outcomes, and higher risk of fatal opioid overdose. Acupuncture therapy is effective in treating chronic pain conditions including chronic low back pain, neck pain, shoulder pain, and knee pain from osteoarthritis. Acupuncture therapy, including group acupuncture, is feasible and effective, and specifically so for underserved and diverse populations at risk for health outcome disparities. Acupuncture therapy also encourages patient engagement and activation. As chronic pain improves, there is a natural progression to want and need to increase activity and movement recovery. Diverse movement approaches are important for improving range of motion, maintaining gains, strengthening, and promoting patient engagement and activation. Yoga therapy is an active therapy with proven benefit in musculoskeletal pain disorders and pain associated disability. The aim of this quasi-experimental pilot feasibility trial is to test the bundling of these 2 effective care options for chronic pain, to inform both the design for a larger randomized pragmatic effectiveness trial as well as implementation strategies across underserved settings.

Young men’s discourses of health service utilization for Chlamydia infection testing in Stockholm

Background

Chlamydia Trachomatis (CT) infection is the most commonly reported sexually transmitted bacterial disease in Sweden, other European countries, as well as globally. CT is often asymptomatic and if it goes untreated it can cause severe reproductive health issues. In Sweden, men test for CT in a much lesser extent than women. The aim of this study is to identify factors influencing Swedish young men to use Health care for CT detection.

Methods

Qualitative study based on 18 semi-structured interviews with young men (18-30 years old) in Stockholm during 2018. A Situational Analysis was conducted (a development of Constructivist Grounded Theory) of the interviews' transcriptions, using Open Code as the software for qualitative analysis in order to code and organize the information obtained. We constructed a situational map to illustrate the positions taken by Swedish young men according to their discourses.

Results

Three ideal types of Swedish young men with different discourses and behaviors towards CT testing were identified: unconcerned men are indifferent about CT and other sexual transmitted infections (STI) and therefore not testing; ambivalent men only test when suspect suffering from an STI and/or are influenced by their social network; Whereas, proactive men test regularly as a way to know they are healthy. The differences between the ideal types are explained by their risk perception, the role of health services, and the positive or negative influence of their social network.

Conclusions

The ideal types of young men identified in this study show a range of discourses linked to their risk perception, the role of health services, and the influence of their social network, which in practice is translated into different behaviours adopted for CT testing. Testing should be encouraged as an important part of CT prevention by educating groups of unconcerned young men about both the consequences of untreated CT and the free testing options available in Sweden.

Key messages

Swedish young men have different discourses towards CT testing depending on their risk perception, the strategies adopted to test and the positive or negative role of their social network. The role of health services and the social support emerged as key factors to promoting testing among Swedish Young men.

AB0209 PREDICTORS OF ACHIEVING STRINGENT REMISSION IN PATIENTS WITH ESTABLISHED RHEUMATOID ARTHRITIS IN CLINICAL REMISSION FOLLOWING A TREAT-TO-TARGET STRATEGY

Background:

Achieving remission according to stringent criteria such as Simplified Disease Activity Index (SDAI) and ACR/EULAR Boolean remission is associated with a better long-term outcome in patients with RA1. Possible predictors of achieving stringent remission in patients in clinical remission, following targeted treatment strategies, have not been investigated.

Objectives:

To investigate the predictive value of clinical, radiographic and MRI variables on achieving more stringent remission in RA patients in clinical remission, following MRI and conventional treat-to-target (T2T) strategies.

Methods:

In this post-hoc study, data were used from 171 RA patients in clinical remission (DAS28-CRP< 3.2 and no swollen joints) on conventional synthetic DMARDs, included in the IMAGINE-RA randomized clinical trial2, where they followed an MRI T2T strategy (targeting absence of osteitis) combined with clinical remission (DAS28-CRP≤3.2 and no swollen joints) or a conventional T2T strategy (targeting clinical remission only). Baseline contrast-enhanced MRIs of the dominant wrist and 2nd-5thMCP joints and radiographs of hands and feet were evaluated according to the OMERACT RAMRIS scoring system and Sharp/van der Heijde method, respectively, by two experienced readers. Potential clinical, radiographic and MRI baseline predictors of remission were first tested in univariate logistic regression analyses with achievement of Clinical Disease Activity Index (CDAI), SDAI, and ACR/EULAR Boolean remission at 24 months as dependent variables. Variables with p<0.25 were subsequently tested in multivariate logistic regression analyses with backward selection, adjusted for age, gender and strategy group. Missing values of covariates were imputed using chained equations.

Results:

Based on the univariate analyses, tender joint count, patient VAS global, VAS pain, VAS fatigue, physician VAS global, HAQ, MRI osteitis, radiographic and MRI erosion and joint space narrowing scores were included in multivariate analyses (Table).

Following the MRI T2T strategy was a positive predictor and high patient VAS global a negative predictor of achieving all definitions of remission. Furthermore, high patient VAS pain was negatively associated with achieving SDAI and ACR/EULAR Boolean remission and high tender joint count negatively associated with achieving CDAI and SDAI remission.

Multivariate logistic regression analyses with backward selection, final modelsDependent variables, remission at 24 monthsCDAISDAIACR/EULAR BooleanOR95% CIp-valueOR95% CIp-valueOR95% CIp-valueCovariatesMRI T2T strategy group2.941.25-7.520.0132.461.03-6.350.0435.472.33-14.11<0.001Female0.900.36-2.250.820.800.31-2.050.640.800.32-1.970.63Age1.020.98-1.070.321.020.98-1.070.331.030.99-1.070.15Tender joint count (0-28)0.330.12-0.860.0230.290.10-0.780.013Patient VAS global0.910.88-0.94<0.0010.930.88-0.97<0.0010.930.88-0.980.003Patient VAS pain0.950.91-1.000.0490.920.87-0.980.004

Conclusion:

In RA patients in clinical remission, poor patient reported outcomes and tender joint count were associated with decreased chance of achieving stringent remission, while following an MRI T2T strategy predicted stringent remission across all definitions thereof.

References:

[1]Smolen et al. Ann Rheum Dis 2017

[2]Møller-Bisgaard et al. JAMA 2019

Disclosure of Interests:

Signe Møller-Bisgaard Grant/research support from: AbbVie, Consultant of: BMS, Speakers bureau: BMS, Celgene, Pfizer, Stylianos Georgiadis Grant/research support from: Novartis, Kim Hørslev-Petersen: None declared, Bo Ejbjerg: None declared, Merete L. Hetland Grant/research support from: BMS, MSD, AbbVie, Roche, Novartis, Biogen and Pfizer, Consultant of: Eli Lilly, Speakers bureau: Orion Pharma, Biogen, Pfizer, CellTrion, Merck and Samsung Bioepis, Lykke Ørnbjerg: None declared, Daniel Glinatsi: None declared, Jakob Møllenbach Møller: None declared, Mikael Boesen Consultant of: AbbVie, AstraZeneca, Eli Lilly, Esaote, Glenmark, Novartis, Pfizer, UCB, Paid instructor for: IAG, Image Analysis Group, AbbVie, Eli Lilly, AstraZeneca, esaote, Glenmark, Novartis, Pfizer, UCB (scientific advisor)., Speakers bureau: Eli Lilly, Esaote, Novartis, Pfizer, UCB, Kristian Stengaard-Pedersen: None declared, Ole Rintek Madsen: None declared, Bente Jensen: None declared, Jan Villadsen: None declared, Ellen Margrethe Hauge: None declared, Philip Bennett: None declared, Oliver Hendricks: None declared, Karsten Asmussen: None declared, Marcin Kowalski: None declared, Hanne Merete Lindegaard: None declared, Henning Bliddal Grant/research support from: received research grant fra NOVO Nordic, Consultant of: consultant fee fra NOVO Nordic, Niels Steen Krogh: None declared, Torkell Ellingsen: None declared, Agnete Nielsen: None declared, Lone Balding: None declared, Anne Grethe Jurik: None declared, Henrik Thomsen: None declared, Mikkel Ǿstergaard Grant/research support from: AbbVie, Bristol-Myers Squibb, Celgene, Merck, and Novartis, Consultant of: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Speakers bureau: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB

FRI0019 MRI INFLAMMATION, DISEASE ACTIVITY AND FUNCTIONAL IMPAIRMENT ARE MORE EFFECTIVELY REDUCED BY ESCALATION TO BIOLOGICS COMPARED TO CSDMARD-ESCALATION IN RHEUMATOID ARTHRITIS PATIENTS IN CLINICAL REMISSION FOLLOWING A TREAT-TO-TARGET STRATEGY: SECONDARY ANALYSES OF THE IMAGINE-RA TRIAL

Background:

The effect of different treatment escalations on MRI inflammation in rheumatoid arthritis (RA) patients following an MRI treat-to-target (T2T) strategy has not previously been investigated.

Objectives:

To compare the effect of different treatment escalations on MRI inflammation, physical function and disease activity in RA patients in clinical remission, following an MRI T2T strategy.

Methods:

One hundred RA patients in clinical remission (DAS28-CRP<3.2 and no swollen joints), on conventional synthetic (cs) DMARDs following an MRI T2T strategy targeting DAS28-CRP≤3.2, no swollen joints plus absence of MRI osteitis, were followed for 2 years with clinical and MRI (wrist and 2nd-5thMCP joints) evaluation every 4 months1. If target was not met, a predefined treatment escalation algorithm dictated: First: increase in csDMARDs (A), second: adding a TNF inhibitor (TNFi) (B), third and onwards: switch between biologics (C). If target was met, no change in baseline csDMARDs was done (D). Outcomes were assessed 4 months after treatment change. MRIs were evaluated with known chronology by one experienced reader. Repeated measures mixed linear models were used to express estimates of group differences on predefined co-primary outcomes (MRI osteitis, HAQ) and key secondary outcomes (MRI combined inflammation, Simplified Disease Activity Index (SDAI)).

Results:

Escalation to first TNFi (B) or to 2ndor later biologic (C) compared to csDMARDs (A) was consistently more effective on all outcomes (e.g. in group B osteitis was reduced with 1.8 units more than A) (Table). Unchanged (D) compared to escalation in csDMARD (A) treatment did not differ, except for HAQ-score. Escalation to a 2ndor later biologics (C) compared to the first TNFi (B) was more effective suppressing MRI inflammation. Escalation to TNFi treatment (B) or to 2ndor later biologic (C) compared to unchanged treatment (D) was more effective on all outcomes except from HAQ-score (no difference between groups).

Comparisons of treatment escalations1A: Increment in csDMARD mono/combination therapy (n=73)); B: Switch from csDMARD combination therapy to TNFi (n=39); C: Switch from TNFi to 2ndbiologic/switch between biologics (n=21); D: No change in csDMARDs from baseline (n=58)A vs BA vs CA vs DB vs CB vs DC vs DOutcomesPrimaryMRIOsteitis1.8 (1.0; 2.6) p<.00013.6 (2.3; 4.8) p<.00010.3 (−0.3; 1.0)p=.321.8 (0.8; 2.9) p=.0006−1.4 (−2.4; −0.5) p=.0045−3.3 (−4.6; −1.9) p<.0001HAQ0.081(0.033; 0.13) p=.00110.091(0.031; 0.15) p=.00320.054(0.014; 0.095) p=.00910.0092(−0.051; 0.070) p=.77−0.027(−0.082; 0.028) p=.33−0.037(−0.10; 0.031) p=.29Key secondaryMRI combined inflammationa2.5 (0.9; 4.1) p=.00185.4 (3.1; 7.7) p<.00010.4 (−0.9; 1.8)p=.522.9 (0.8; 4.9) p=.0064−2.1 (−4.0; −0.2) p=.032−5.0 (−7.5; −2.4) p=.0002SDAI2.7 (1.9; 3.5) p<.00012.4 (1.4; 3.4) p<.00010.5 (−0.2; 1.2)p=.14−0.3 (−1.3; 0.7)p=.60−2.2 (−3.1; −1.3) p<.0001−1.9 (−3.0; 0.8) p=.0006

1Estimates of group differences (least squares means (95% CI)).

aSum score of synovitis, osteitis and tenosynovitis

Conclusion:

T2T-based treatment escalations to biologics compared to csDMARD-escalations more effectively improved MRI inflammation, physical function and disease activity. Further optimization of the treatment in RA patients in clinical remission may improve long-term outcomes.

References:

[1]Møller-Bisgaard et al. JAMA 2019

Disclosure of Interests:

Signe Møller-Bisgaard Grant/research support from: AbbVie, Consultant of: BMS, Speakers bureau: BMS, Celgene, Pfizer, Kim Hørslev-Petersen: None declared, Bo Ejbjerg: None declared, Merete L. Hetland Grant/research support from: BMS, MSD, AbbVie, Roche, Novartis, Biogen and Pfizer, Consultant of: Eli Lilly, Speakers bureau: Orion Pharma, Biogen, Pfizer, CellTrion, Merck and Samsung Bioepis, Robin Christensen: None declared, Lykke Ørnbjerg: None declared, Daniel Glinatsi: None declared, Jakob Møllenbach Møller: None declared, Mikael Boesen Consultant of: AbbVie, AstraZeneca, Eli Lilly, Esaote, Glenmark, Novartis, Pfizer, UCB, Paid instructor for: IAG, Image Analysis Group, AbbVie, Eli Lilly, AstraZeneca, esaote, Glenmark, Novartis, Pfizer, UCB (scientific advisor)., Speakers bureau: Eli Lilly, Esaote, Novartis, Pfizer, UCB, Kristian Stengaard-Pedersen: None declared, Ole Rintek Madsen: None declared, Bente Jensen: None declared, Jan Villadsen: None declared, Ellen Margrethe Hauge: None declared, Philip Bennett: None declared, Oliver Hendricks: None declared, Karsten Asmussen: None declared, Marcin Kowalski: None declared, Hanne Merete Lindegaard: None declared, Henning Bliddal Grant/research support from: received research grant fra NOVO Nordic, Consultant of: consultant fee fra NOVO Nordic, Niels Steen Krogh: None declared, Torkell Ellingsen: None declared, Agnete Nielsen: None declared, Anne Grethe Jurik: None declared, Lone Balding: None declared, Henrik Thomsen: None declared, Mikkel Ǿstergaard Grant/research support from: AbbVie, Bristol-Myers Squibb, Celgene, Merck, and Novartis, Consultant of: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Speakers bureau: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB

Individual vs. Group Delivery of Acupuncture Therapy for Chronic Musculoskeletal Pain in Urban Primary Care-a Randomized Trial

BACKGROUND

Acupuncture has been shown to be effective for the treatment of chronic musculoskeletal back, neck, and osteoarthritis pain. However, access to acupuncture treatment has been limited in medically underserved and low-income populations.

OBJECTIVE

Acupuncture therapy delivered in groups could reduce cost and expand access. We compared the effectiveness of group versus individual acupuncture for pain and function among ethnically diverse, low-income primary care patients with chronic musculoskeletal pain.

DESIGN

This was a randomized comparative effectiveness non-inferiority trial in 6 Bronx primary care community health centers. Participants with chronic (> 3 months) back, neck, or osteoarthritis pain were randomly assigned to individual or group acupuncture therapy for 12 weeks.

PARTICIPANTS

Seven hundred seventy-nine participants were randomized. Mean age was 54.8 years. 35.3% of participants identified as black and 56.9% identified as Latino. Seventy-six percent were Medicaid insured, 60% reported poor/fair health, and 37% were unable to work due to disability.

INTERVENTIONS

Participants received weekly acupuncture treatment in either group or individual setting for 12 weeks.

MAIN MEASURES

Primary outcome was pain interference on the Brief Pain Inventory at 12 weeks; secondary outcomes were pain severity (BPI), physical and mental well-being (PROMIS-10), and opiate use. Outcome measures were collected at baseline, 12 and 24 weeks.

KEY RESULTS

37.5% of individual arm and 30.3% in group had > 30% improvement in pain interference (d = 7.2%, 95% CI - 0.6%, 15.1%). Non-inferiority of group acupuncture was not demonstrated for the primary outcome assuming a margin of 10%. In the responder analysis of physical well-being, 63.1% of individual participants and 59.5% of group had clinically important improvement at 12 weeks (d = 3.6%, 95% CI - 4.2%, 11.4%).

CONCLUSIONS

Both individual and group acupuncture therapy delivered in primary care settings reduced chronic pain and improved physical function at 12 weeks; non-inferiority of group was not shown.

TRIAL REGISTRATION

Clinicaltrials.gov # NCT02456727.

Cochrane reviews on acupuncture therapy for pain: A snapshot of the current evidence

Cochrane is an international non-profit organization established in 1993 to produce and disseminate high quality and unbiased systematic reviews of evidence on health care interventions. At the forefront of systematic review methodology, Cochrane is generally accepted to be among the most carefully prepared and rigorous sources of systematic review evidence. There are numerous Cochrane reviews on nonpharmacologic interventions for pain and multiple Cochrane reviews evaluating acupuncture therapy in pain conditions. But how complete and up to date are those reviews relative to other rigorous systematic reviews with meta-analyses of acupuncture therapy for pain published in the literature? In this 'snapshot' overview, we found 22 relevant Cochrane reviews, some concluding that acupuncture therapy is probably useful for treating specific pain conditions. However, many of the conditions for which acupuncture is most commonly used are either not represented in Cochrane reviews or the existing Cochrane reviews are seriously outdated and do not reflect current evidence. This creates confusion with the risks of adverse effects and addiction liability associated with pain medications, the prevalence of chronic pain, the ongoing opioid epidemic and the need for evidence-based options for pain as part of comprehensive pain care. Clinicians and patients want clarification on safe and effective options to treat pain. Issues involving reviewed trials' inadequate use of sham comparators, of acupuncture as a complex intervention with interactive components and a shift in research focus from efficacy trials to real-world pragmatic trials are discussed in relation to updating Cochrane reviews of acupuncture therapy for pain.

Developing and employing a 'responsive manualization' in the 'Acupuncture Approaches to Decrease Disparities in Outcomes of Pain Treatment' comparative effectiveness study

OBJECTIVE

The aim of this article is to describe the process used to develop an acupuncture therapy manual for a large effectiveness trial comparing individual care against group care for chronic pain in an underserved population. The design needed to not only ensure research consistency and replicability but also be 'responsive' to real world heterogeneous and evolving presentations in challenging physical settings.

BACKGROUND

Chronic pain is prevalent in the United States. While acupuncture is effective for chronic pain, minority, ethnically diverse and lower socioeconomic populations have limited access. Group acupuncture is proposed as a lower cost option to facilitate access in safety net settings, but research on the effectiveness of group versus individual acupuncture is lacking.

METHODS

We engaged a modified Delphi process with expert practitioners from diverse backgrounds who were experienced in individual and group practice. All contributions were recorded and collated for second- and third-round consensus discussions that included contributions by the trial's research acupuncturists.

RESULTS

A 'responsive manual' flow chart was created with suggested sequencing that included interviews concurrent with palpation, Tui na, Gua sha, acupuncture needling, ear treatment, basic recommendations and options for departure with rationale. The manual was implemented by six research acupuncturists in five primary care settings in the Bronx, New York, with weekly team meetings to discuss manual use. There were no serious adverse events (AE) and few minor AE reported in this trial.

CONCLUSION

A 'responsive manual' can be structured and implemented that is not only consistent and replicable but also flexible to accommodate the real-world clinical needs of practitioners and patients in challenging physical settings.

Acupuncture Therapy in a Group Setting for Chronic Pain

Objective

This project was designed to test the feasibility and effectiveness of acupuncture therapy given in a group setting for chronic pain.

Design

Nonrandomized, repeated measures quasi-experimental trial.

Setting

Care was delivered in a primary care clinic waiting area after clinic hours.

Subjects

Included were primary care patients (≥18 years old) with chronic pain of the neck, back, shoulder, or osteoarthritis of any site of at least three months' duration.

Methods

Subjects received eight weekly acupuncture therapy sessions in a group setting. Acupuncture therapy included a combination of palpation, acupuncture needling, Tui na, Gua sha, and auricular treatment. Baseline pain levels were established in a two- to four-week run-in; assessment of the intervention impact on pain intensity, mood, and functional status were made at the end of the treatment period (eight weeks) and 16 weeks after completion of intervention (24 weeks).

Results

Of the total 113 participants recruited for the trial, 96 completed the 24-week protocol. We found a statistically and clinically significant decrease in pain severity, pain interference, and depression in our study population. There were no serious adverse events.

Conclusions

Acupuncture therapy offered in the group setting was effective in reducing pain severity, pain interference, and depression in patients with chronic neck, back, or shoulder pain or osteoarthritis. Benefit persisted through the 24-week measure despite no additional treatment. This finding has potentially important implications for improving access to effective acupuncture treatment for patients with limited financial resources.

Primary Malignant Lymphoma of the Salivary Glands

Five cases of primary malignant lymphomas of the salivary glands are reported. Four lymphomas arose in the parotid gland and one in the submandibular gland. All were non-Hodgkin lymphomas. In 4 cases the lymphomas were of low-grade malignancy, viz. 2 immunocytomas and 2 centroblastic/centrocytic malignant lymphomas, and 1 was a T-immunoblastic malignant lymphoma of high-grade malignancy. Four patients with localized disease were treated with radiotherapy and 1 patient with disseminated disease was treated with chemotherapy. One patient died from a disease unrelated to the malignant lymphoma, and 4 patients were alive at 66-136 months after treatment.

Evidence-Based Nonpharmacologic Strategies for Comprehensive Pain Care: The Consortium Pain Task Force White Paper

Medical pain management is in crisis; from the pervasiveness of pain to inadequate pain treatment, from the escalation of prescription opioids to an epidemic in addiction, diversion and overdose deaths. The rising costs of pain care and managing adverse effects of that care have prompted action from state and federal agencies including the DOD, VHA, NIH, FDA and CDC. There is pressure for pain medicine to shift away from reliance on opioids, ineffective procedures and surgeries toward comprehensive pain management that includes evidence-based nonpharmacologic options. This White Paper details the historical context and magnitude of the current pain problem including individual, social and economic impacts as well as the challenges of pain management for patients and a healthcare workforce engaging prevalent strategies not entirely based in current evidence. Detailed here is the evidence-base for nonpharmacologic therapies effective in postsurgical pain with opioid sparing, acute non-surgical pain, cancer pain and chronic pain. Therapies reviewed include acupuncture therapy, massage therapy, osteopathic and chiropractic manipulation, meditative movement therapies Tai chi and yoga, mind body behavioral interventions, dietary components and self-care/self-efficacy strategies. Transforming the system of pain care to a responsive comprehensive model necessitates that options for treatment and collaborative care must be evidence-based and include effective nonpharmacologic strategies that have the advantage of reduced risks of adverse events and addiction liability. The evidence demands a call to action to increase awareness of effective nonpharmacologic treatments for pain, to train healthcare practitioners and administrators in the evidence base of effective nonpharmacologic practice, to advocate for policy initiatives that remedy system and reimbursement barriers to evidence-informed comprehensive pain care, and to promote ongoing research and dissemination of the role of effective nonpharmacologic treatments in pain, focused on the short- and long-term therapeutic and economic impact of comprehensive care practices.

Abstract 664: Analytical validation and clinical utility of an immunohistochemical PD-L1 diagnostic assay for treatment with durvalumab in urothelial carcinoma patients

Background: A high quality programmed cell death ligand-1 (PD-L1) diagnostic may help to identify patients (pts) most likely to respond to anti-PD-L1/programmed cell death-1 (PD-1) therapy. Here we describe a PD-L1 immunohistochemical (IHC) diagnostic test developed for urothelial carcinoma (UC) pts treated with durvalumab.

Methods: The IHC assay uses an anti-human PD-L1 rabbit mAb optimized for detection of both tumor cell (TC) and tumor-associated immune cell (IC) PD-L1 expression with the OptiView DAB IHC Detection Kit on the automated VENTANA BenchMark ULTRA platform. The assay was validated for intended use in UC formalin-fixed, paraffin-embedded samples in a series of studies that addressed sensitivity, specificity, robustness and precision and implemented in Study CD-ON-MEDI4736-1108 (NCT01693562). Pts were evaluated using the VENTANA PD-L1 (SP263) Assay at a prespecified PD-L1 expression cut-off. Efficacy was analyzed in pts with PD-L1 low/negative (defined as TC &lt;25% and IC &lt;25%) UC and in pts with PD-L1 high (defined as TC ≥25% or IC ≥25%) UC.

Results: The VENTANA PD-L1 (SP263) Assay met all the predefined acceptance criteria (average positive agreement and average negative agreement &gt;85%), showing analytical specificity, sensitivity and precision. It demonstrated ≥97% and ≥85% inter-reader precision agreement for TC and IC respectively. For intra-reader precision, it demonstrated &gt;96% and &gt;87% agreement for TC and IC respectively. For intra-day performance, the assay demonstrated ≥96% agreement for TC and IC and for inter-day performance, it demonstrated ≥98% and 100% agreement for TC and IC respectively. Precision studies for inter-antibody lot, inter-detection kit lot and intra-platform demonstrated &gt;97% agreement for both TC and IC. Inter-laboratory testing was performed at 3 external laboratories and demonstrated an overall agreement rate of 92.3%. The VENTANA PD-L1 (SP263) Assay was implemented in Study CD-ON-MEDI4736-1108 and durvalumab demonstrated clinical activity and durability of response in both PD-L1 high and PD-L1 low/negative subgroups, yet with different response rates. In addition, given the high negative predictive value of the assay, it is especially helpful in evaluating the likelihood of response to durvalumab; pts who were classified as PD-L1 high with the VENTANA PD-L1 (SP263) Assay tended to have a higher objective response rate per RECIST v1.1 than pts who were PD-L1 low/negative.

Conclusions: These data show that determination of PD-L1 expression in TC and IC in UC pts using the VENTANA PD-L1 (SP263) Assay is precise and highly reproducible and highlight the utility of the assay in a clinical setting. The VENTANA SP263 Assay is especially helpful in informing pts and physicians on the likelihood of response to durvalumab, but not for the purpose of restricting treatment to only PD-L1 high pts.

Citation Format: M Zajac, A M. Boothman, Y Ben, A Gupta, J Antal, X Jin, A Nielsen, G Manriquez, C Barker, P Wang, P Patil, N Schechter, M Rebelatto, J Walker. Analytical validation and clinical utility of an immunohistochemical PD-L1 diagnostic assay for treatment with durvalumab in urothelial carcinoma patients [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 664. doi:10.1158/1538-7445.AM2017-664