What matters most to pediatric rheumatologists in deciding whether to discontinue biologics in a child with juvenile idiopathic arthritis? A best-worst scaling survey

OBJECTIVES

Care for JIA patients has been transformed in the biologics era; however, biologics carry important (although rare) risks and are costly. Flares after biological withdrawal are seen frequently, yet there is little clinical guidance to identify which patients in clinical remission can safely have their biologic discontinued (by stopping or tapering). We examined what characteristics of the child or their context are important to pediatric rheumatologists when making the decision to discuss withdrawal of biologics.

METHODS

We conducted a survey including a best-worst scaling (BWS) exercise in pediatric rheumatologists who are part of the UCAN CAN-DU network to assess the relative importance of 14 previously identified characteristics. A balanced incomplete block design was used to generate choice tasks. Respondents evaluated 14 choice sets of 5 characteristics of a child with JIA and identified for each set which was the most and least important in the decision to offer withdrawal. Results were analyzed using conditional logit regression.

RESULTS

Fifty-one (out of 79) pediatric rheumatologists participated (response rate 65%). The three most important characteristics were how challenging it was to achieve remission, history of established joint damage, and time spent in remission. The three least important characteristics were history of temporomandibular joint involvement, accessibility of biologics, and the patient's age.

CONCLUSIONS

These findings give quantitative insight about factors important to pediatric rheumatologists' decision-making about biologic withdrawal. In addition to high quality clinical evidence, further research is needed to understand the perspective of patients and families to inform shared decision-making about biologic withdrawal for JIA patients with clinically inactive disease. Key Points ● What is already known on this topic-there is limited clinical guidance for pediatric rheumatologists in making decisions about biologic withdrawal for patients with juvenile idiopathic arthritis who are in clinical remission. ● What this study adds-this study quantitatively examined what characteristic of the child in clinical remission, or of their context, are most important to pediatric rheumatologists in deciding whether to offer withdrawal of biologics. ● How this study might affect research, practice or policy-understanding of these characteristics can provide useful information to other pediatric rheumatologists in making their decisions, and may guide areas to focus on for future research.

The prediction of early mortality following hip fracture surgery in patients aged 90 years and older: the Almelo Hip Fracture Score 90 (AHFS90)

The AHFS⁹⁰ was developed for the prediction of early mortality in patients ≥ 90 years undergoing hip fracture surgery. The AHFS⁹⁰ has a good accuracy and in most risk categories a good calibration. In our study population, the AHFS⁹⁰ yielded a maximum prediction of early mortality of 64.5%.

PURPOSE

Identifying hip fracture patients with a high risk of early mortality after surgery could help make treatment decisions and information about the prognosis. This study aims to develop and validate a risk score for predicting early mortality in patients ≥ 90 years undergoing hip fracture surgery (AHFS⁹⁰).

METHODS

Patients ≥ 90 years, surgically treated for a hip fracture, were included. A selection of possible predictors for mortality was made. Missing data were subjected to multiple imputations using chained equations. Logistic regression was performed to develop the AHFS⁹⁰, which was internally and externally validated. Calibration was assessed using a calibration plot and comparing observed and predicted risks.

RESULTS

One hundred and two of the 922 patients (11.1%) died ≤ 30 days following hip fracture surgery. The AHFS⁹⁰ includes age, gender, dementia, living in a nursing home, ASA score, and hemoglobin level as predictors for early mortality. The AHFS⁹⁰ had good accuracy (area under the curve 0.72 for geographic cross validation). Predicted risks correspond with observed risks of early mortality in four risk categories. In two risk categories, the AHFS⁹⁰ overestimates the risk. In one risk category, no mortality was observed; therefore, no analysis was possible. The AHFS⁹⁰ had a maximal prediction of early mortality of 64.5% in this study population.

CONCLUSION

The AHFS⁹⁰ accurately predicts early mortality after hip fracture surgery in patients ≥ 90 years of age. Predicted risks correspond to observed risks in most risk categories. In our study population, the AHFS⁹⁰ yielded a maximum prediction of early mortality of 64.5%.

Diabetes patient preferences for glucose-monitoring technologies: results from a discrete choice experiment in Poland and the Netherlands

INTRODUCTION

New glucose-monitoring technologies have different cost-benefit profiles compared with traditional finger-prick tests, resulting in a preference-sensitive situation for patients. This study aimed to assess the relative value adults with diabetes assign to device attributes in two countries.

RESEARCH DESIGN AND METHODS

Adults with type 1 or 2 diabetes from the Netherlands (n=226) and Poland (n=261) completed an online discrete choice experiment. Respondents choose between hypothetical glucose monitors described using seven attributes: precision, effort to check, number of finger pricks required, risk of skin irritation, information provided, alarm function and out-of-pocket costs. Panel mixed logit models were used to determine attribute relative importance and to calculate expected uptake rates and willingness to pay (WTP).

RESULTS

The most important attribute for both countries was monthly out-of-pocket costs. Polish respondents were more likely than Dutch respondents to choose a glucose-monitoring device over a standard finger prick and had higher WTP for a device. Dutch respondents had higher WTP for device improvements in an effort to check and reduce the number of finger pricks a device requires.

CONCLUSION

Costs are the primary concern of patients in both countries when choosing a glucose monitor and would likely hamper real-world uptake. The costs-benefit profiles of such devices should be critically reviewed.

Comparing three machine learning approaches to design a risk assessment tool for future fractures: predicting a subsequent major osteoporotic fracture in fracture patients with osteopenia and osteoporosis

Four machine learning models were developed and compared to predict the risk of a future major osteoporotic fracture (MOF), defined as hip, wrist, spine and humerus fractures, in patients with a prior fracture. We developed a user-friendly tool for risk calculation of subsequent MOF in osteopenia patients, using the best performing model.

INTRODUCTION

Major osteoporotic fractures (MOFs), defined as hip, wrist, spine and humerus fractures, can have serious consequences regarding morbidity and mortality. Machine learning provides new opportunities for fracture prediction and may aid in targeting preventive interventions to patients at risk of MOF. The primary objective is to develop and compare several models, capable of predicting the risk of MOF as a function of time in patients seen at the fracture and osteoporosis outpatient clinic (FO-clinic) after sustaining a fracture.

METHODS

Patients aged > 50 years visiting an FO-clinic were included in this retrospective study. We compared discriminative ability (concordance index) for predicting the risk on MOF with a Cox regression, random survival forests (RSF) and an artificial neural network (ANN)-DeepSurv model. Missing data was imputed using multiple imputations by chained equations (MICE) or RSF's imputation function. Analyses were performed for the total cohort and a subset of osteopenia patients without vertebral fracture.

RESULTS

A total of 7578 patients were included, 805 (11%) patients sustained a subsequent MOF. The highest concordance-index in the total dataset was 0.697 (0.664-0.730) for Cox regression; no significant difference was determined between the models. In the osteopenia subset, Cox regression outperformed RSF (p = 0.043 and p = 0.023) and ANN-DeepSurv (p = 0.043) with a c-index of 0.625 (0.562-0.689). Cox regression was used to develop a MOF risk calculator on this subset.

CONCLUSION

We show that predicting the risk of MOF in patients who already sustained a fracture can be done with adequate discriminative performance. We developed a user-friendly tool for risk calculation of subsequent MOF in patients with osteopenia.

The effect of breast MRI on disease-free and overall survival in breast cancer patients: a retrospective population-based study

Purpose

To evaluate the effect of breast MRI on overall survival (OS) and disease-free survival (DFS) of patients with invasive breast cancer in the Netherlands.

Methods

We selected all women from the Netherlands Cancer Registry diagnosed with invasive breast cancer (a) between 2011 and 2013 for the OS-cohort and (b) in the first quarter of 2012 for the DFS-cohort. The study population was subdivided into an MRI and non-MRI group. In addition, subgroups were created according to breast cancer subtype: invasive carcinoma of no special type (NST) versus invasive lobular carcinoma (ILC). OS and DFS were compared between the MRI and non-MRI group using the Kaplan–Meier method and the log-rank test. Cox proportional hazard regression analysis was performed to estimate hazard ratios (HR) with a 95% confidence interval (CI). To account for missing data, multiple imputation was performed.

Results

Of the 31,756 patients included in the OS-cohort (70% non-MRI and 30% MRI), 27,752 (87%) were diagnosed with invasive carcinoma NST and 4004 (13%) with ILC. Of the 2464 patients included in the DFS-cohort (72% non-MRI and 28% MRI), 2161 (88%) were diagnosed with invasive carcinoma NST and 303 (12%) with ILC. The distribution of breast MRI use was significantly lower over different age categories, from 49.0% aged < 50 to 16.5% aged > 70. Multivariable Cox regression showed that breast MRI was not significantly associated with OS overall (HR 0.91, 95%-CI 0.74–1.11, p = 0.35), nor in the different histological subtypes. Multivariable Cox regression analysis showed that breast MRI was also not significantly associated with DFS (HR 1.16, 95%-CI 0.81–1.67), nor in the different histological subtypes.

Conclusion

Use of breast MRI was not significantly associated with an improved OS or DFS in patients treated with primary surgery.

Electronic supplementary material

The online version of this article (10.1007/s10549-020-05906-w) contains supplementary material, which is available to authorized users.

The development and validation of a handicap questionnaire for children with a chronic illness

Introduction: This paper describes the development and initial psychometric evaluation of the Handicap Scale for Children (HSC). This questionnaire is based on the London Handicap Scale (LHS), a valid and reliable utility instrument for measuring social participation in adults.

Methods: A multidisciplinary research group was involved in developing the HSC. The questionnaire was tested in 114 children with a chronic disease and 239 healthy children in the 8-18 age range. Relating the Health Utility Index Mark 3 (HUI3) attributes to corresponding HSC scores tested the assumption that a negative health status would lead to participation problems.

Results: Questionnaire development resulted in a five-dimension questionnaire: mobility, physical independence, daily activities, social integration and orientation. Each dimension included one item with a six-point response scale. A higher score indicates greater handicap. Feasibility testing with 10 children showed that none of the children experienced difficulties in filling in the questionnaire. Conceptual validity, measured by correlations between the dimensions of the HSC and HUI3, was satisfactory. As expected, moderate correlation coefficients between predefined pairs of HUI and HSC attributes were found; other correlation coefficients were low. Criterion validity was also satisfactory, as shown by large differences between the healthy and the chronically ill group and by several criteria within the chronically ill group.

Conclusion: Based on this initial evaluation, the questionnaire seems feasible and valid for use with children in the age range 8-18 years.

Abstract P3-07-68: Population-based validation study of Adjuvant! for primary breast cancer patients in the Netherlands

Background Adjuvant! is an online risk prediction tool that can support breast cancer patients and physicians in clinical decision-making regarding adjuvant systemic treatment. The aim of this study was to validate Adjuvant! on a Dutch population-based cohort of women diagnosed in 2003 and assess its calibration and discriminatory accuracy.

Methods All Dutch patients diagnosed with invasive primary breast cancer in 2003 in the Netherlands meeting the criteria of Adjuvant!; unilateral, unicentric invasive breast cancer, no evidence of metastatic or residual disease, pathologically staged I-III and no pT4 features, were included. Local treatment consisted of breast conserving therapy or ablative surgery and axillary staging. Adjuvant systemic treatment was given according to national guidelines. Patient, tumor and treatment characteristics were retrieved from the Netherlands Cancer Registry. Endpoints were ten-year overall survival, breast cancer specific survival and event free survival.

Findings A total of 8,195 patients were included. Out of all patients, 4,389 (53.6%) received some form of adjuvant systemic therapy. Throughout a ten-year follow-up, 2,156 (26.3%) patients died and 1,953 (23.8%) patients developed a recurrent disease (locoregional, distant or contralateral invasive cancer or DCIS). Ten-year observed overall survival was underestimated by -1.4% (95% CI -2.3 to -0.4, p=0.006), breast cancer specific survival was underestimated by -3.3% (95% CI -4.1 to -2.6, p&lt;0.0001) and event free survival was underestimated by -3.5% (95% CI -4.5 to -2.6, p&lt;0.0001). Discrimination was moderate for overall survival and breast cancer specific survival but poor for event free survival.

Interpretation Adjuvant! does not accurately predict breast cancer specific survival and event free survival in this Dutch population-based study. Dutch patients showed better ten-year survival rates than predicted by Adjuvant!. For specific patient groups, the model could be used to estimate overall survival. We conclude that Adjuvant! should be used with caution in clinical practice in the Netherlands but probably also in other countries and the US.

Citation Format: Siesling S, van Kleef JJ, Bretveld R, Groothuis-Oudshoorn CGM, van der Palen J, Jobsen JJ, Struikmans H. Population-based validation study of Adjuvant! for primary breast cancer patients in the Netherlands. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-07-68.

Foot and ankle joint kinematics in rheumatoid arthritis cannot only be explained by alteration in walking speed

Rheumatoid arthritis (RA) manifests itself in the foot and ankle of RA patients. The foot and ankle joint kinematics of these patients differ from that of healthy subjects. However, the factors that lead to these differences are not yet fully understood. The aim of this study was to analyse the effect of walking speed and the disease process on foot and ankle joint kinematics of RA subjects. Gait recordings of 23 RA and 14 age-matched healthy subjects were performed and their foot and ankle joint kinematics were analysed during the stance phase of the gait cycle. Stance phase characteristics of the group of RA subjects and of the group of healthy subjects were compared. The healthy subjects walked at 100% (Vc), 75% (V75) and 50% (V50) of their comfortable walking speed. In a multi-level linear model significant differences between the two groups due to the factors walking speed and the disease process were analysed. The ankle dorsi-flexion, medial arch and hallux abduction motion at single-stance and toe-off were only influenced by the walking speed. The hallux maximum flexion at toe-off and the midfoot supination at single-stance were influenced by both the walking speed and the disease process. The hindfoot eversion motion at single-stance was only influenced by the disease process. In conclusion, the reduction of walking speed of RA subjects compared to healthy subjects does not explain all of the observed foot and ankle kinematics differences.

The effects of walking speed on forefoot, hindfoot and ankle joint motion

BACKGROUND

Foot and ankle joint kinematic differences have been identified between healthy subjects and subjects with various pathologies suffering from foot and ankle impairments. Changes in temporal factors such as walking speed and double stance time are also found in these pathological conditions. As such, in theory, these factors would also influence the kinematics and hence make it difficult to ascertain the effects of the disease on the kinematics. The aim of this study was to analyse foot and ankle kinematics from gait recordings of healthy subjects walking at comfortable and slower speeds.

METHODS

Gait patterns of 14 healthy subjects were recorded. The subjects were first asked to walk at a comfortable speed and then at predefined speeds of 75% and 50% of their comfortable walking speed respectively. Temporal variables were calculated. Foot and ankle joint kinematics were determined from marker-recordings.

FINDINGS

The subjects walked at mean velocities of 1.28 m/s, 0.97 m/s and 0.65 m/s. With decreasing walking speed the minimum tibio-talar plantar-flexion and maximum hallux dorsi-flexion at toe-off decreased significantly between 3 degrees and 9 degrees. The minimum medial arch at toe-off and minimum midfoot supination at mid-stance were significantly affected by the walking speed. The corresponding individual session differences were small (1 degrees -2 degrees), but the reliability was high and hence the differences were considered clinically relevant.

INTERPRETATION

Walking speed significantly affected foot and ankle kinematics. Studies aiming to improve the understanding of the effects of foot and ankle pathologies on foot and ankle kinematics should take the walking speed into account.

The influence of different intermittent myofeedback training schedules on learning relaxation of the trapezius muscle while performing a gross-motor task

The aim of this study was to investigate the influence of different intermittent myofeedback training schedules, as provided by a Cinderella-based myofeedback system, on learning relaxation and resistance to extinction of the trapezius muscle, in subjects performing a unilateral gross-motor task. Eighteen healthy subjects performed the task without and with feedback to study baseline and learning relaxation. Subsequently, resistance to extinction was investigated by performing the task without feedback. The gross-motor task consisted of continuously moving the dominant arm between three target areas at a constant pace. Subjects were randomly assigned into three groups, characterized by the sequence of feedback schedules with which the task was performed on 3 consecutive days. Auditory feedback was provided after a 5-, 10-, or 20-s interval when a pre-set level of 80% rest was not reached. Bipolar surface electromyography recordings performed at the dominant upper trapezius muscle were quantified using relative rest time (RRT) and root mean square (RMS) parameters. Learning relaxation was defined as an increase in RRT and a decrease in RMS values. Results showed the highest RRT levels as well as a decrease in RMS for the 10-s schedule. Additionally, the 10-s schedule was unique in its ability to elevate muscular rest above the 20% level, which may be considered relevant in preventing myalgia. None of the three schedules showed resistance to extinction. It was concluded that the 10-s interval was preferred over the 5- and 20-s schedules in learning trapezius relaxation in subjects performing a unilateral gross-motor task.