A proof-of-concept study applying machine learning methods to putative risk factors for eating disorders: results from the multi-centre European project on healthy eating

BACKGROUND

Despite a wide range of proposed risk factors and theoretical models, prediction of eating disorder (ED) onset remains poor. This study undertook the first comparison of two machine learning (ML) approaches [penalised logistic regression (LASSO), and prediction rule ensembles (PREs)] to conventional logistic regression (LR) models to enhance prediction of ED onset and differential ED diagnoses from a range of putative risk factors.

METHOD

Data were part of a European Project and comprised 1402 participants, 642 ED patients [52% with anorexia nervosa (AN) and 40% with bulimia nervosa (BN)] and 760 controls. The Cross-Cultural Risk Factor Questionnaire, which assesses retrospectively a range of sociocultural and psychological ED risk factors occurring before the age of 12 years (46 predictors in total), was used.

RESULTS

All three statistical approaches had satisfactory model accuracy, with an average area under the curve (AUC) of 86% for predicting ED onset and 70% for predicting AN v. BN. Predictive performance was greatest for the two regression methods (LR and LASSO), although the PRE technique relied on fewer predictors with comparable accuracy. The individual risk factors differed depending on the outcome classification (EDs v. non-EDs and AN v. BN).

CONCLUSIONS

Even though the conventional LR performed comparably to the ML approaches in terms of predictive accuracy, the ML methods produced more parsimonious predictive models. ML approaches offer a viable way to modify screening practices for ED risk that balance accuracy against participant burden.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

POS0535 OUTCOMES IN PATIENTS WITH RHEUMATOID ARTHRITIS INITIATING THERAPY WITH ETANERCEPT, ADALIMUMAB, OR JANUS KINASE INHIBITORS

Background

Ongoing debate exists regarding the optimal sequence of tumor necrosis factor inhibitors and Janus kinase inhibitors (JAKis) in patients with rheumatoid arthritis (RA) as first-line biologic or targeted synthetic disease-modifying antirheumatic drug (b/tsDMARD) therapy following conventional therapies.

Objectives

To describe baseline characteristics, effectiveness, persistency, and treatment patterns among first-line b/tsDMARD-naive initiators of etanercept (ETN), adalimumab (ADA), or JAKis (tofacitinib, baricitinib, and upadacitinib).

Methods

Data on patients who initiated b/tsDMARD from 11/2012 to 6/2021 were obtained from the CorEvitas RA Registry, a prospective, multicenter, observational, disease-based registry. Patients ≥18 years with rheumatologist-diagnosed RA and 6- and/or 12-months’ (M) follow-up were included. We report descriptive statistics at baseline, persistency on therapy, escalation/de-escalation of therapy, details on patterns of drug switching, and effectiveness outcomes using regression models adjusted for baseline covariates (demographic/socioeconomic/lifestyle characteristics, comorbidities, medication history, disease activity, and patient-reported outcomes). Outcomes were evaluated at 6M and 12M follow-up.

Results

First-line initiators of ETN, ADA, and JAKis with baseline and follow-up visits were identified: 803, 984, and 361 patients at 6M, respectively; 589, 749, and 264 patients at 12M, respectively. Baseline characteristics were similar among ETN, ADA, and JAKi initiators with the exception of disease duration, which was longer among first-line JAKi initiators (mean, 8.6 y) versus ETN (5.9 y) and ADA (5.8 y) initiators. Unadjusted mean improvement in Clinical Disease Activity Index (CDAI) was generally similar between groups at 6M and 12M (Table 1). Adjusted effectiveness results were similar at 6M and 12M (Figure 1). At 6M, 68% of ETN, 69% of ADA, and 67% of JAKi initiators remained on the same therapy; at 12M, 53% of ETN, 57% of ADA, and 57% of JAKi initiators remained on the same therapy. The frequency of switching to another b/tsDMARD was similar across initiators.

Table 1.

Patient Description at Time of Initiation and Unadjusted Disease Activity Results

ETNADAJAKisAge, years54.4 (12.8)55.5 (12.1)60.9 (12.5)Female, n (%)666 (77)843 (76)303 (77)BMI, kg/m230.4 (7.6)31.3 (7.9)30.8 (7.6)Duration of RA, years5.9 (7.6)5.8 (7.3)8.6 (10.0)BL disease activitya CDAI19.9 (14.3)18.9 (12.7)18.8 (13.2) mHAQ0.5 (0.5)0.5 (0.5)0.5 (0.5) Patient painb48.0 (28.8)49.2 (28.5)45.2 (29.2)Disease activity decrease from BL at 6M CDAI6.9 (13.6)6.4 (12.1)4.7 (12.3) mHAQ0.1 (0.4)0.1 (0.4)0.1 (0.4) Patient painb9.7 (30.2)10.6 (28.4)8.9 (29.5)Disease activity decrease from BL at 12M CDAI7.4 (13.5)6.1 (13.0)5.1 (13.0) mHAQ0.1 (0.4)0.1 (0.4)0.1 (0.4) Patient painb8.8 (29.7)8.7 (30.1)7.5 (28.6)Achievement of LDAc, % 6M43.441.932.5 12M41.039.638.3

aBaseline for combined population with 6M and 12M follow-up. b(range: 0–100). cCDAI ≤10 among those with moderate or high disease activity at baseline.

Data are mean (SD) unless otherwise specified.

ADA, adalimumab; BL, baseline; CDAI, Clinical Disease Activity Index; ETN, etanercept; JAKis, Janus kinase inhibitors; LDA, low disease activity; M, months; mHAQ, modified Health Assessment Questionnaire; RA, rheumatoid arthritis; SD, standard deviation.

Conclusion

In this real-world study in patients initiating first-line b/tsDMARD therapy with ETN, ADA, or JAKis, we did not observe differences in clinical effectiveness/patient-reported outcomes and treatment persistency at 6M and12M after treatment initiation.

Acknowledgements

This study is sponsored by CorEvitas, LLC. CorEvitas has been supported through contracted subscriptions in the last two years by AbbVie, Amgen Inc., Arena, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Chugai, Eli Lilly and Company, Genentech, Gilead, GSK, Janssen, LEO, Novartis, Ortho Dermatologics, Pfizer Inc., Regeneron, Sanofi, Sun, and UCB. Writing support was funded by Amgen Inc. and provided by Su Cappello, PharmD, of Peloton Advantage, LLC, an OPEN Health company, and Julie Wang, DPM, of Amgen Inc.

Disclosure of Interests

Dimitrios A Pappas Shareholder of: Officer or Board Member for Corrona Research Foundation, Speakers bureau: Speaker/Honoraria for AbbVie, Novartis, Roche Hellas, Sanofi, Consultant of: Consultant for AbbVie, Roche Hellas; Advisor for Sanofi, Employee of: Employment by, ownership interest, and stock options in CorEvitas, LLC, Jacqueline O’Brien Employee of: Employment by CorEvitas, LLC., Lin Guo Employee of: Employment by CorEvitas, LLC., Ying Shan Employee of: Employment by CorEvitas, LLC., Joshua Baker Consultant of: Received consulting fees from Bristol Myers Squibb, Pfizer, CorEvitas LLC, and Burns-White, LLC., Greg Kricorian Shareholder of: Employment by and stock ownership in Amgen Inc., Employee of: Employment by and stock ownership in Amgen Inc., Scott Stryker Shareholder of: Employment by and stock ownership in Amgen Inc., Employee of: Employment by and stock ownership in Amgen Inc., David Collier Shareholder of: Employment by and stock ownership in Amgen Inc., Employee of: Employment by and stock ownership in Amgen Inc.

POS0312 REAL-WORLD EVIDENCE ON ASSESSING PSORIATIC ARTHRITIS BY DISEASE DOMAIN: AN EVALUATION OF THE CorEvitas PSORIATIC ARTHRITIS/SPONDYLOARTHRITIS REGISTRY

Background

Psoriatic arthritis (PsA) is a burdensome, chronic disease that can impact patient functionality and quality of life. Real-world data are limited regarding the most common disease domain combinations in patients with PsA receiving biologic disease-modifying anti-rheumatic drugs.

Objectives

The objective of this study was to describe PsA disease domain frequency, the most common disease domain combinations of PsA manifestations, and pairwise disease domain prevalence in patients initiating treatment with tumor necrosis factor inhibitors (TNFis) or interleukin-17 (IL-17) inhibitors.

Methods

The CorEvitas PsA/Spondyloarthritis (SpA) Registry is a prospective, observational registry for patients with PsA or SpA under the care of a rheumatologist. The current analysis included adults with PsA who initiated treatment with a TNFi (adalimumab, etanercept, certolizumab pegol, infliximab, golimumab), etanercept (ETN; independent exploratory evaluation as a subset of the TNFi group), or an IL-17 inhibitor (ixekizumab, secukinumab) from January 2013 through December 2020. Baseline disease characteristics among the total population and by therapy group were examined for 6 PsA domains, including enthesitis (ET), dactylitis (DA), peripheral arthritis (PA), nail psoriasis (NP), axial PsA (AX), and skin disease (SD). The top 5 most common domain combinations and frequency of other concomitant disease domains within each domain subpopulation are presented.

Results

Among 1005 patients initiating treatment for PsA (mean age, 52.9 years; 57% female, 90% white), the prevalence of disease domains was PA (86%), SD (82%), NP (57%), ET (38%), DA (23%), and AX (20%); these proportions were similar among the therapy groups. The frequency of high skin disease (body surface area [BSA] ≥10%) at baseline was highest in IL-17 initiators (23% vs 16% for TNFi and 9% for ETN). TNFi (40%) and ETN (48%) were more frequently observed as first-line therapy compared with IL-17 inhibitors (14%). The most common disease domain combination overall (14%) was PA, NP, and SD; frequency of the top 3 most common domain combinations were similar among therapy groups (Table 1). Overall, PA and SD were the most common concomitant disease domains observed within each PsA disease domain subpopulation (Figure 1). Results were similar by therapy group (data not shown).

Table 1.

Most common PsA domain combinations overall and by therapy

Domain Combination Ranking by Frequency, n (%)Overall (N=1005)TNFia (n=631)ETN (n=112)IL-17 (n=374)#1PA, NP, SD 138 (14)PA, NP, SD 91 (14)PA, SD 17 (15)PA, NP, SD 47 (13)#2PA, SD 122 (12)PA, SD 84 (13)ET, PA, NP, SD 13 (12)ET, PA, NP, SD 41 (11)#3ET, PA, NP, SD 95 (9)ET, PA, NP, SD 54 (9)PA, NP, SD 12 (11)PA, SD 38 (10)#4ET, PA, SD 64 (6)DA, PA, NP, SD 38 (6)SD 7 (6)ET, PA, SD 33 (9)#5DA, PA, NP, SD 61 (6)ET, PA, SD 31 (5)ET, PA, NP, AX, SD 6 (5)ET, PA, NP, AX, SD 24 (6)

Matching domain combinations are shaded across each therapy group.

ET, enthesitis; DA, dactylitis; PA, peripheral arthritis; NP, nail psoriasis; AX, axial PsA; SD, skin disease; TNFi, tumor necrosis factor inhibitors; ETN, etanercept; IL-17, interleukin-17 inhibitors.

aTNFi includes ETN initiators.

Figure 1.

Conclusion

The most common disease domains and domain combinations were similar among initiators of TNFis, ETN, and IL-17s. IL-17 initiators had high skin disease (BSA ≥10%) more often and initiated as first-line therapy less frequently than TNFi initiators. Assessing all PsA domains is important for optimal disease management.

Acknowledgements

This study is sponsored by CorEvitas, LLC. CorEvitas has been supported through contracted subscriptions in the last two years by AbbVie, Amgen Inc., Arena, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Chugai, Eli Lilly and Company, Genentech, Gilead, GSK, Janssen, LEO, Novartis, Ortho Dermatologics, Pfizer Inc., Regeneron, Sanofi, Sun, and UCB. Writing support was funded by Amgen Inc. and provided by Jacob Huffman, PhD of Peloton Advantage, LLC, an OPEN Health company, and Julie Wang, DPM, of Amgen Inc.

Disclosure of Interests

Philip J Mease Speakers bureau: AbbVie, Amgen Inc., Eli Lilly, Janssen, Novartis, Pfizer, and UCB – speakers bureau, Consultant of: AbbVie, Amgen Inc., Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Eli Lilly, Galapagos, GlaxoSmithKline, Novartis, Pfizer, Sun, and UCB – grant/research support and consultant, Grant/research support from: AbbVie, Amgen Inc., Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Eli Lilly, Galapagos, GlaxoSmithKline, Novartis, Pfizer, Sun, and UCB – grant/research support and consultant, Taylor Blachley Employee of: CorEvitas, LLC – employment, Jacqueline O’Brien Employee of: CorEvitas, LLC – employment, Nicole Middaugh Employee of: CorEvitas, LLC – employment, Greg Kricorian Shareholder of: Amgen Inc. – employment and stock ownership, Employee of: Amgen Inc. – employment and stock ownership, Scott Stryker Shareholder of: Amgen Inc. – employment and stock ownership, Employee of: Amgen Inc. – employment and stock ownership, David Collier Shareholder of: Amgen Inc. – employment and stock ownership, Employee of: Amgen Inc. – employment and stock ownership, Alexis Ogdie Shareholder of: Royalties to husband from Novartis, Consultant of: AbbVie, Amgen Inc., Bristol Myers Squibb, Celgene, CorEvitas’ Psoriatic Arthritis/Spondyloarthritis Registry (formerly Corrona), Eli Lilly, Gilead, Janssen, Novartis, Pfizer, and UCB – consultant, Grant/research support from: AbbVie, Amgen Inc., Novartis, and Pfizer – grant/research support

OP0118 EFFECT OF WITHDRAWING ETANERCEPT OR METHOTREXATE ON PATIENT-REPORTED OUTCOMES IN RHEUMATOID ARTHRITIS PATIENTS IN REMISSION ON COMBINATION THERAPY: RESULTS FROM THE SEAM-RA TRIAL

Background:

Limited studies have assessed the effect of withdrawal of either methotrexate (MTX) or etanercept (ETN) on patient-reported outcomes (PROs) in rheumatoid arthritis (RA).

Objectives:

To evaluate the baseline and change in PROs following withdrawal of MTX or ETN in RA patients with sustained remission receiving combination ETN+MTX.

Methods:

Adult patients with RA on ETN+MTX and in remission (SDAI ≤3.3) for ≥12 months (including a 24-week, open-label, run-in period) were randomized to a 48-week double-blind period to receive ETN 50 mg weekly (N=101), oral MTX 10-25 mg weekly (N=101) or continue ETN+MTX (N=51). The primary endpoint was maintenance of SDAI remission without disease worsening (DW) at week 48 between ETN and MTX groups. Patients who experienced SDAI >11 at any time after randomization, or SDAI >3.3 and ≤11 during 2 consecutive or on 3 non-consecutive visits were considered to have DW and resumed ETN+MTX. PROs assessed were patient global assessment of disease activity (PtGA, 0-100 mm), patient joint pain (PtJP, 0-100 mm), Health Assessment Questionnaire-Disability Index (HAQ-DI), and the 36-item short-form health survey (SF-36) component and domain scores. A 2-sample t-test was used to compare the treatment differences between groups. A subgroup analysis for patients with DW was also performed (DW analysis set) and compared PROs between ETN vs MTX arms (ETN+MTX not shown given the small sample size).

Results:

Of the 253 patients randomized, 121 (47.8%) experienced DW and were included in the DW analysis set. Baseline demographics were generally balanced between the 3 treatment groups. Most patients were women (76.3%), White (87.0%), and with a mean age of 55.6 years. The mean (SD) MTX dose was 16.3 (4.69) mg and the mean (SD) duration of RA was 10.3 (7.8) years. At week 48, a significantly greater proportion of patients on ETN vs MTX monotherapy maintained SDAI remission (49.5% vs 28.7%; P=0.004) after therapy withdrawal. In the overall population, PtGA and PtJP scores were very low at baseline (PtGA–MTX: 4.4, ETN: 4.5, ETN+MTX: 3.5; PtJP–MTX: 4.9, ETN: 5.5, ETN+MTX: 3.5) and showed some worsening over the study period in all treatment groups, with a mean change at week 48 ranging from 5.0 to 10.0 units for PtGA and 3.7 to 8.1 units for PtJP. Patients on ETN had less worsening, with a nominally significant treatment difference observed between ETN and MTX monotherapy groups for PtGA at almost all timepoints, and for PtJP at weeks 12 and 36 (Figure). Mean HAQ-DI (MTX: 0.32; ETN: 0.26; ETN+MTX: 0.28) and SF-36 scores (physical component [PCS]–MTX: 52.1, ETN: 52.7, ETN+MTX: 52.3; mental component [MCS]–MTX: 55.5, ETN: 55.8, ETN+MTX: 57.1) at baseline show that patients had low disability and excellent health-related quality of life compared with normative values for the general non-RA population. HAQ-DI scores were well maintained at weeks 24 and 48 (change from baseline at week 48–MTX: 0.14; ETN: 0.15; ETN+MTX: 0.21). The SF-36 PCS, MCS, and domain scores decreased minimally from baseline with treatment differences that were not nominally significant between groups. Among patients with DW during the study, those on ETN showed less PtGA and PtJP worsening from baseline than those on MTX at weeks 12, 36, and 48 (Figure). Other PROs (HAQ-DI [change from baseline at week 24–ETN: 0.34; MTX: 0.21; at week 48–ETN: 0.15; MTX: 0.15], SF-36 PCS, MCS, and domain scores) showed a similar degree of worsening in both the MTX and ETN arms.

Conclusion:

In patients with sustained SDAI remission on ETN+MTX, mental and physical health as measured by SF-36 was comparable with that of the non-RA population. Withdrawal of ETN (MTX monotherapy) resulted in a greater worsening of PtGA and PtJP than withdrawal of MTX (ETN monotherapy), and patients on ETN monotherapy restored these scores close to baseline towards the end of the treatment period. These findings demonstrate that ETN monotherapy has a greater effect on maintaining overall patient assessment of disease and joint pain compared with MTX monotherapy.

Disclosure of Interests:

Jeffrey Curtis Speakers bureau: AbbVie, BMS, Gilead, Lilly, Novartis, Sanofi, Scipher, Amgen, Corrona, Janssen, Myriad, and Pfizer, Consultant of: AbbVie, BMS, Gilead, Lilly, Novartis, Sanofi, Scipher, Amgen, Corrona, Janssen, Myriad, and Pfizer, Grant/research support from: AbbVie, BMS, Gilead, Lilly, Novartis, Sanofi, Scipher, Amgen, Corrona, Janssen, Myriad, and Pfizer, Elaine Karis Shareholder of: Amgen Inc., Employee of: Amgen Inc., Vivian Bykerk Speakers bureau: Amgen, BMS, Gilead, Pfizer, Sanofi-Genzyme/Regeneron, Scipher Medicine, and UCB., Consultant of: Amgen, BMS, Gilead, Pfizer, Sanofi-Genzyme/Regeneron, Scipher Medicine, and UCB., Grant/research support from: Amgen and Novartis, Greg Kricorian Shareholder of: Amgen Inc., Employee of: Amgen Inc., Priscilla Yen Shareholder of: Amgen Inc., Employee of: Amgen Inc., Paul Emery Speakers bureau: AbbVie, BMS, Celltrion, Gilead, Lilly, MSD, Novartis, Pfizer, Roche, Samsung, Sandoz, and UCB., Consultant of: AbbVie, BMS, Celltrion, Gilead, Lilly, MSD, Novartis, Pfizer, Roche, Samsung, Sandoz, and UCB., Paul Haraoui Speakers bureau: AbbVie, Celgene, Janssen, Pfizer, and UCB., Consultant of: AbbVie, Amgen, BMS, Celgene, Eli Lilly, Janssen, Merck, Pfizer, Roche, Sandoz, Sanofi-Genzyme, and UCB., Grant/research support from: Roche, AbbVie, Amgen, Merck, and Pfizer, David Collier Shareholder of: Amgen Inc., Employee of: Amgen Inc., Brad Stolshek Shareholder of: Amgen Inc., Employee of: Amgen Inc.

The Barts Health NHS Trust COVID-19 cohort: characteristics, outcomes and risk scoring of patients in East London

BACKGROUND: Barts Health National Health Service Trust (BHNHST) serves a diverse population of 2.5 million people in London, UK. We undertook a health services assessment of factors used to evaluate the risk of severe acute respiratory coronavirus 2 (SARS-CoV-2) infection.METHODS: Patients with confirmed polymerase chain reaction (PCR) test results admitted between 1 March and 1 August 2020 were included, alongwith clinician-diagnosed suspected cases. Prognostic factors from the 4C Mortality score and 4C Deterioration scores were extracted from electronic health records and logistic regression was used to quantify the strength of association with 28-day mortality and clinical deterioration using national death registry linkage.RESULTS: Of 2783 patients, 1621 had a confirmed diagnosis, of whom 61% were male and 54% were from Black and Minority Ethnic groups; 26% died within 28 days of admission. Mortality was strongly associated with older age. The 4C mortality score had good stratification of risk with a calibration slope of 1.14 (95% CI 1.01-1.27). It may have under-estimated mortality risk in those with a high respiratory rate or requiring oxygen.CONCLUSION: Patients in this diverse patient cohort had similar mortality associated with prognostic factors to the 4C score derivation sample, but survival might be poorer in those with respiratory failure.

Integrating intravenous frusemide treatment into the community for heart failure patients

Background

A structured pathway was developed to allow patients to safely receive intravenous (i/v) frusemide at home.

This pathway was implemented by an integrated team consisting of primary and tertiary care.

This allowed the traditional acute hospital treatment to be now delivered in the community.

Purpose

This concept has been used on an individual case basis by a minority of acute hospitals.

Previously there was no structured pathway that would allow this treatment to become a standard part of heart failure treatment by acute hospitals.

The pathway would ensure that the treatment would be delivered safely to a cohort of patients who meet certain criteria.

Methods

A pathway was developed by a consultant cardiologist, heart failure (HF) nurses and the Community Intervention Team (CIT)/CareDoc. The Caredoc Community Intervention Team (CIT) is a nurse led professional team that provides acute nursing care to patients in the community setting.

The HF nurse would identify the suitable patient for i/v frusemide as per pathway.

A referral would be sent to the CIT team who would administer the frusemide at the patients home.

The CIT team would take a renal profile daily, check vital signs, check symptoms of HF and check daily weight on the patient while they were receiving i/v frusemide.

The bloods results would be reviewed daily by the HF nurse.

The HF nurse would liaise daily with the CIT team and patient for symptoms, daily weights and vital signs. The patient would then be reviewed in the HF clinic post treatment.

Results

Single centre retrospective analysis was undertaken of the patients who received i/v frusemide at home over a 3 year period.

83 patients meet the inclusion criteria and received the treatment. 70 male and 13 female.

Average age 78 years old.

Average length of treatment 3 days.

Treatment was given twice daily, average daily dose was 137 mg. Majority of treatment was 80mg bd or 60 mg bd.

No failure cannulating any patient as CIT had high cannulation skills due to regular cannulation as part of workload.

3 episodes of hypokalaemia, lowest potassium was 3.1 mmols, all 3 episodes were effectively treated with oral potassium supplements.

No significant acute kidney injury was noted that required change to treatment.

6 patients required heart failure associated admission to hospital, 3 had hypotension, 1 has fast A-flutter and 2 remained resistance to i/v frusemide and required inotropes.

Both patient and carers reported a high satisfaction rate with the service.

Conclusion

National length of stay for a HF patient in Ireland is 11 days.This novel structured pathway successfully selected appropriate patients who can safely receive i/v frusemide at home. 93% avoided hospital admission.This reduces the need for acute hospital admission and significant associated costs. Patients and carers rated 95% satisfaction with service.Sustainability of the project is driven by an integration team approach.

Funding Acknowledgement

Type of funding source: None

FRI0351 DOES SEX OR BODY MASS INDEX IMPACT RESPONSE TO THERAPY IN PSORIATIC ARTHRITIS?: RESULTS FROM A PHASE 3, DOUBLE-BLIND, RANDOMIZED TRIAL EXAMINING METHOTREXATE AND ETANERCEPT AS MONOTHERAPY OR IN COMBINATION FOR TREATING PSORIATIC ARTHRITIS

Background:

In psoriatic arthritis (PsA), contextual factors such as sex and body mass index (BMI) may affect response to therapy.

Objectives:

To examine if sex and BMI influenced 24-week (wk) outcomes in a 48-wk PsA trial of methotrexate (MTX) and etanercept (ETN) as monotherapy (mono) or combined.1

Methods:

MTX- and biologic-naïve adult patients with active PsA were randomized to weekly: MTX 20mg (n=284), ETN 50mg (n=284), or MTX 20mg+ETN 50mg (n=283). Wk-24 outcomes included ACR 20, MDA, VLDA, PASDAS, DAPSA, LDI, SPARCC, BSA, sPGA, and mNAPSI. Descriptive statistics examined outcomes in each treatment arm by sex (male vs female) or BMI (≤30kg/m2vs >30kg/m2). Modeling analyses also examined sex or BMI effect on outcomes when comparing MTX mono to the ETN-containing arms (analyses were adjusted for any prior use of a nonbiologic disease-modifying antirheumatic drug; the model for the influence of sex also adjusted for baseline BMI status). Nominal P-values are provided.

Results:

Baseline disease activity was slightly higher in women, especially with MTX+ETN. Descriptive statistics showed men and women had similar results at wk 24 in the MTX mono and ETN mono arms; with MTX+ETN, men had better outcomes for ACR20, MDA, VLDA, and PASDAS. In treatment-interaction analyses, men had more favorable responses at wk 24 with MTX+ETN vs MTX mono for PASDAS, MDA, and LDI (Table).

Baseline disease activity was similar in both BMI categories. Descriptive statistics in each treatment arm showed no consistent differences in results at wk 24 between BMI categories. In treatment-interaction analyses, BMI ≤30kg/m2had a more favorable response at wk 24 with MTX+ETN vs MTX mono for sPGA (Table).

Conclusion:

Results suggest contextual factors may affect response to therapy in PsA. The treatment-interaction analyses suggest disparate responses to MTX+ETN by sex; BMI only affected skin response.

References:

[1]Mease et al.Arthritis Rheumatol. 2019;71:1112-24

Disclosure of Interests:

Philip J Mease Grant/research support from: Abbott, Amgen, Biogen Idec, BMS, Celgene Corporation, Eli Lilly, Novartis, Pfizer, Sun Pharmaceutical, UCB – grant/research support, Consultant of: Abbott, Amgen, Biogen Idec, BMS, Celgene Corporation, Eli Lilly, Novartis, Pfizer, Sun Pharmaceutical, UCB – consultant, Speakers bureau: Abbott, Amgen, Biogen Idec, BMS, Eli Lilly, Genentech, Janssen, Pfizer, UCB – speakers bureau, Dafna D Gladman Grant/research support from: AbbVie, Amgen Inc., BMS, Celgene Corporation, Janssen, Novartis, Pfizer, UCB – grant/research support, Consultant of: AbbVie, Amgen Inc., BMS, Celgene Corporation, Janssen, Novartis, Pfizer, UCB – consultant, Joseph F. Merola Consultant of: Merck, AbbVie, Dermavant, Eli Lilly, Novartis, Janssen, UCB Pharma, Celgene, Sanofi, Regeneron, Arena, Sun Pharma, Biogen, Pfizer, EMD Sorono, Avotres and LEO Pharma, Atul Deodhar Grant/research support from: AbbVie, Eli Lilly, GSK, Novartis, Pfizer, UCB, Consultant of: AbbVie, Amgen, Boehringer Ingelheim, Bristol Myer Squibb (BMS), Eli Lilly, GSK, Janssen, Novartis, Pfizer, UCB, Speakers bureau: AbbVie, Amgen, Boehringer Ingelheim, Bristol Myer Squibb (BMS), Eli Lilly, GSK, Janssen, Novartis, Pfizer, UCB, Alexis Ogdie Grant/research support from: Novartis, Pfizer – grant/research support, Consultant of: AbbVie, BMS, Eli Lilly, Novartis, Pfizer, Takeda – consultant, David Collier Shareholder of: Amgen Inc., Employee of: Amgen Inc., Elaine Karis Shareholder of: Amgen Inc., Employee of: Amgen Inc., Lyrica Liu Shareholder of: Amgen Inc., Employee of: Amgen Inc., Arthur Kavanaugh Grant/research support from: AbbVie, Amgen, Eli Lilly, Novartis, Janssen, Pfizer, Gilead, UCB, Consultant of: AbbVie, Amgen, Eli Lilly, Novartis, Janssen, Pfizer, Gilead, UCB

Is there an association between the COMT gene and P300 endophenotypes?

P300 wave anomalies correlate with genetic risk for schizophrenia and constitute a plausible endophenotype for the disease. The COMT gene is thought to influence cognitive performance and to be a susceptibility gene for schizophrenia. Unlike two previous studies, we found no significant influence of the COMT gene on P300 amplitude or latency in 189 individuals examined. The well-supported role of the COMT gene both in dopamine catabolism as well as in prefrontal cognition makes a strong theoretical case for the influence of COMT Val158Met polymorphism on P300 endophenotypes. However, the available neurophysiologic evidence suggests that any such association, if present, must be very subtle.

Evidence-informed policy making at country level: lessons learned from the South African Tuberculosis Think Tank

BACKGROUND:

National Tuberculosis Programmes (NTPs) require specialist input to support the development of policy and practice informed by evidence, typically against tight deadlines.

OBJECTIVE:

To describe lessons learned from establishing a dedicated tuberculosis (TB) think tank to advise the South African NTP on TB policy.

INTERVENTION AND EVALUATION METHODS:

A national TB think tank was established to advise the NTP in support of evidence-informed policy. Support was provided for activities, including meetings, modelling and regular telephone calls, with a wider network of unpaid expert advisers under an executive committee and working groups. Intervention evaluation used desktop analysis of documentary evidence, interviews and direct observation.

RESULTS:

The TB Think Tank evolved over time to acquire three key roles: an ‘institution’, a ‘policy dialogue forum’ and an ‘interface’. Although enthusiasm was high, motivating participation among the NTP and external experts proved challenging. Motivation of working groups was most successful when aligned to a specific need for NTP decision making. Despite challenges, the TB Think Tank contributed to South Africa's first ever TB and human immunodeficiency virus (HIV) investment case, and the decision to create South Africa's first ever ring-fenced grant for TB. The TB Think Tank also assisted the NTP in formulating strategy to accelerate progress towards reaching World Health Organization targets.

DISCUSSION:

With partners, the TB Think Tank achieved major successes in supporting evidence-informed decision making, and garnered increased funding for TB in South Africa. Identifying ways to increase the involvement of NTP staff and other experts, and keeping the scope of the Think Tank well defined, could facilitate greater impact. Think tank initiatives could be replicated in other settings to support evidence-informed policy making.

Evidence for three genetic loci involved in both anorexia nervosa risk and variation of body mass index

The maintenance of normal body weight is disrupted in patients with anorexia nervosa (AN) for prolonged periods of time. Prior to the onset of AN, premorbid body mass index (BMI) spans the entire range from underweight to obese. After recovery, patients have reduced rates of overweight and obesity. As such, loci involved in body weight regulation may also be relevant for AN and vice versa. Our primary analysis comprised a cross-trait analysis of the 1000 single-nucleotide polymorphisms (SNPs) with the lowest P-values in a genome-wide association meta-analysis (GWAMA) of AN (GCAN) for evidence of association in the largest published GWAMA for BMI (GIANT). Subsequently we performed sex-stratified analyses for these 1000 SNPs. Functional ex vivo studies on four genes ensued. Lastly, a look-up of GWAMA-derived BMI-related loci was performed in the AN GWAMA. We detected significant associations (P-values <5 × 10-5, Bonferroni-corrected P<0.05) for nine SNP alleles at three independent loci. Interestingly, all AN susceptibility alleles were consistently associated with increased BMI. None of the genes (chr. 10: CTBP2, chr. 19: CCNE1, chr. 2: CARF and NBEAL1; the latter is a region with high linkage disequilibrium) nearest to these SNPs has previously been associated with AN or obesity. Sex-stratified analyses revealed that the strongest BMI signal originated predominantly from females (chr. 10 rs1561589; Poverall: 2.47 × 10-06/Pfemales: 3.45 × 10-07/Pmales: 0.043). Functional ex vivo studies in mice revealed reduced hypothalamic expression of Ctbp2 and Nbeal1 after fasting. Hypothalamic expression of Ctbp2 was increased in diet-induced obese (DIO) mice as compared with age-matched lean controls. We observed no evidence for associations for the look-up of BMI-related loci in the AN GWAMA. A cross-trait analysis of AN and BMI loci revealed variants at three chromosomal loci with potential joint impact. The chromosome 10 locus is particularly promising given that the association with obesity was primarily driven by females. In addition, the detected altered hypothalamic expression patterns of Ctbp2 and Nbeal1 as a result of fasting and DIO implicate these genes in weight regulation.

Characterization of the complications associated with plasma exchange for thrombotic thrombocytopaenic purpura and related thrombotic microangiopathic anaemias: a single institution experience

Background

Plasma exchange (PEX) is a life-saving therapeutic procedure in patients with thrombotic thrombocytopaenic purpura (TTP) and other thrombotic microangiopathic anaemias (TMAs). However, it may be associated with significant complications, exacerbating the morbidity and mortality in this patient group.

Study Design and Methods

We reviewed all PEX procedures over a 72-month period, following the exclusive introduction of solvent–detergent double viral-inactivated plasma in high-volume users, such as TTP, in the United Kingdom (UK). We documented allergic reactions to plasma, citrate reactions, complications relating to central venous access insertion and venous thrombotic events (VTE) in 155 patient episodes and >2000 PEX procedures.

Results

The overall complication rate was low. Allergic plasma reactions occurred in 6·45% of the cohort with only one episode of acute anaphylaxis. Similarly, VTEs were 6·45%, not significantly greater than in medical patients receiving thromboprophylaxis, despite added potential risk factors in TTP. Citrate reactions were the most frequent complication documented, but toxicity was significantly reduced by administration of further calcium infusions during the PEX procedure. There were no serious central line infections and no catheter thrombosis.

Conclusion

Our data confirms that PEX continues to be a life-saving procedure in the acute TTP setting and, the procedure was not associated with an increased mortality and limited morbidity.

Do COMT, BDNF and NRG1 polymorphisms influence P50 sensory gating in psychosis?

BACKGROUND

Auditory P50 sensory gating deficits correlate with genetic risk for schizophrenia and constitute a plausible endophenotype for the disease. The well-supported role of catechol-O-methyltransferase (COMT), brain-derived neurotrophic factor (BDNF) and neuregulin 1 (NRG1) genes in neurodevelopment and cognition make a strong theoretical case for their influence on the P50 endophenotype.

METHOD

The possible role of NRG1, COMT Val158Met and BDNF Val66Met gene polymorphisms on the P50 endophenotype was examined in a large sample consisting of psychotic patients, their unaffected relatives and unrelated healthy controls using linear regression analyses.

RESULTS

Although P50 deficits were present in patients and their unaffected relatives, there was no evidence for an association between NRG1, COMT Val158Met or BDNF Val66Met genotypes and the P50 endophenotype.

CONCLUSIONS

The evidence from our large study suggests that any such association between P50 indices and NRG1, COMT Val158Met or BDNF Val66Met genotypes, if present, must be very subtle.

Copy number variations of chromosome 16p13.1 region associated with schizophrenia

Deletions and reciprocal duplications of the chromosome 16p13.1 region have recently been reported in several cases of autism and mental retardation (MR). As genomic copy number variants found in these two disorders may also associate with schizophrenia, we examined 4345 schizophrenia patients and 35,079 controls from 8 European populations for duplications and deletions at the 16p13.1 locus, using microarray data. We found a threefold excess of duplications and deletions in schizophrenia cases compared with controls, with duplications present in 0.30% of cases versus 0.09% of controls (P=0.007) and deletions in 0.12 % of cases and 0.04% of controls (P>0.05). The region can be divided into three intervals defined by flanking low copy repeats. Duplications spanning intervals I and II showed the most significant (P = 0.00010) association with schizophrenia. The age of onset in duplication and deletion carriers among cases ranged from 12 to 35 years, and the majority were males with a family history of psychiatric disorders. In a single Icelandic family, a duplication spanning intervals I and II was present in two cases of schizophrenia, and individual cases of alcoholism, attention deficit hyperactivity disorder and dyslexia. Candidate genes in the region include NTAN1 and NDE1. We conclude that duplications and perhaps also deletions of chromosome 16p13.1, previously reported to be associated with autism and MR, also confer risk of schizophrenia.

The effect of COMT, BDNF, 5-HTT, NRG1 and DTNBP1 genes on hippocampal and lateral ventricular volume in psychosis

BACKGROUND

Morphometric endophenotypes which have been proposed for psychotic disorders include lateral ventricular enlargement and hippocampal volume reductions. Genetic epidemiological studies support an overlap between schizophrenia and bipolar disorder, and COMT, BDNF, 5-HTT, NRG1 and DTNBP1 genes have been implicated in the aetiology of both these disorders. This study examined associations between these candidate genes and morphometric endophenotypes for psychosis.

METHOD

A total of 383 subjects (128 patients with psychosis, 194 of their unaffected relatives and 61 healthy controls) from the Maudsley Family Psychosis Study underwent structural magnetic resonance imaging and genotyping. The effect of candidate genes on brain morphometry was examined using linear regression models adjusting for clinical group, age, sex and correlations between members of the same family.

RESULTS

The results showed no evidence of association between variation in COMT genotype and lateral ventricular, and left or right hippocampal volumes. Neither was there any effect of the BDNF, 5-HTTLPR, NRG1 and DTNBP1 genotypes on these regional brain volumes.

CONCLUSIONS

Abnormal hippocampal and lateral ventricular volumes are among the most replicated endophenotypes for psychosis; however, the influences of COMT, BDNF, 5-HTT, NRG1 and DTNBP1 genes on these key brain regions must be very subtle if at all present.

Effects of the DAT 3’UTR VNTR Genotype on Brain Function in Healthy Subjects and Patients with Schizophrenia

Aims:

To examine the effect of a polymorphism in the Dopamine Transporter (DAT) gene on brain activation during executive function and, for the first time:

1.

1.

Method:

Functional magnetic resonance imaging was used to measure whole-brain responses during overt verbal fluency in 85 subjects: 44 healthy volunteers and 41 DSM-IV schizophrenia patients. Main effects of genotype and diagnostic group on activation and their interaction were estimated using an ANOVA in SPM5.

Results:

The 10-repeat allele of the 3'UTR VNTR was associated with greater activation than the 9-repeat allele in the left (Z=4.8; FWEp=0.005) and right (Z=4.2; FWEp=0.057) anterior insula and with decreased activation in the rostral anterior cingulate (Z=4.3 FWEp=0.04) during word generation (versus baseline). These effects were irrespective of diagnostic group but generally more marked in patients. There were also strong trends for groupxgenotype interactions in the left middle frontal gyrus and the left nucleus accumbens. Analysis was controlled for task performance, IQ, antipsychotic medication, psychopathology and demographics.

Conclusion:

Cortical function during executive tasks is normally modulated by variation in the DAT gene, effect which is dependent on the brain region. DAT's effect may be altered in schizophrenia patients, which may reflect altered central dopamine function.

Lifetime course of eating disorders: design and validity testing of a new strategy to define the eating disorders phenotype

BACKGROUND

Aetiological studies of eating disorders would benefit from a solution to the problem of instability of eating disorder symptoms. We present an approach to defining an eating disorders phenotype based on the retrospective assessment of lifetime eating disorders symptoms to define a lifetime pattern of illness. We further validate this approach by testing the most common lifetime categories for differences in the prevalence of specific childhood personality traits.

METHOD

Ninety-seven females participated in this study, 35 with a current diagnosis of restricting anorexia nervosa, 32 with binge/purging subtype of anorexia nervosa and 30 with bulimia nervosa. Subjects were interviewed by a newly developed EATATE Lifetime Diagnostic Interview for a retrospective assessment of the lifetime course of eating disorders symptoms and childhood traits reflecting obsessive-compulsive personality.

RESULTS

The data illustrate the extensive instability of the eating disorders diagnosis. Four most common lifetime diagnostic categories were identified that significantly differ in the prevalence of childhood traits. Perfectionism and rigidity were more common in groups with a longer duration of underweight status, longer episodes of severe food restriction, excessive exercising, and shorter duration of binge eating.

CONCLUSIONS

The assessment of lifetime symptoms may produce a more accurate definition of the eating disorders phenotype. Obsessive-compulsive traits in childhood may moderate the course producing longer periods of underweight status. These findings may have important implications for nosology, treatment and future aetiological studies of eating disorders.

Childhood eating and weight in eating disorders: a multi-centre European study of affected women and their unaffected sisters

BACKGROUND

Previous studies have suggested that childhood eating and weight problems may be risk factors for eating disorders. Robust evidence is still lacking.

AIMS

To investigate whether childhood eating and weight problems increase the risk of eating disorders in affected women compared to their unaffected sisters.

METHODS

Women (150) with anorexia (AN) or bulimia nervosa (BN) recruited from clinical and community samples were compared to their unaffected sister closest in age on maternal reports of childhood eating and weight.

RESULTS

Women with BN were significantly more overweight at the ages of 5 and 10 (both OR = 2.8, p < 0.01), ate a lot (OR = 1.3, p < 0.01), were less picky (OR = 0.6, p < 0.05) and ate quickly (OR = 2.3, p < 0.05) between the ages of 6 and 10 compared to their healthy sisters. Significantly more women with AN were described as having a higher weight at 6 months (OR = 0.8, p < 0.01) and 1 year (OR = 0.6, p < 0.01) compared to their healthy sisters. Childhood eating was comparable in the women with AN and their unaffected sisters.

CONCLUSIONS

Traits of childhood overeating were more common in bulimic women compared to their unaffected siblings. Subjects with AN did not differ from their sisters on eating variables. The increased risk of BN due to childhood overweight suggests that prevention strategies for childhood obesity and overweight may therefore be applicable in BN.

Usefulness of scintimammography as an adjunct to mammography and ultrasound in the diagnosis of breast diseases

This study was undertaken to evaluate the diagnostic efficacy of 99mtechnetium methoxyisobutylisonitrile scintimammography (SM) and combined use of mammography and ultrasound in the detection of the breast lesions in the symptomatic breast. Histopathological findings were the gold standard. Eighty patients with symptomatic breasts underwent mammography and/or ultrasound breast followed by SM. In 25 patients there were 27 lesions that were malignant and 55 patients had 65 lesions that were benign. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy of SM were found to be 92, 72, 58, 96 and 78%, respectively, as compared with the combined use of mammography and ultrasound, which showed these parameters to be 89, 94, 86, 95 and 92%, respectively. In this study, SM showed slightly better sensitivity than combined mammography and ultrasound, whereas the specificity was clearly shown as higher in the latter.

Minimally important difference in diffuse systemic sclerosis: results from the D-penicillamine study

OBJECTIVE

To estimate minimally important differences (MIDs) in scores for the modified Rodnan Skin Score (mRSS) and Health Assessment Questionnaire-Disability Index (HAQ-DI) in a clinical trial on diffuse systemic sclerosis (SSc).

PARTICIPANTS AND METHODS

134 people participated in a 2-year, double-blind, randomised clinical trial comparing efficacy of low-dose and high-dose D-penicillamine in diffuse SSc. At 6, 12, 18 and 24 months, the investigator was asked to rate the change in the patient's health since entering the study: markedly worsened, moderately worsened, slightly worsened, unchanged, slightly improved, moderately improved or markedly improved. Patients who were rated as slightly improved were defined as the minimally changed subgroup and compared with patients rated as moderately or markedly improved.

RESULTS

The MID estimates for the mRSS improvement ranged from 3.2 to 5.3 (0.40-0.66 effect size) and for the HAQ-DI from 0.10 to 0.14 (0.15-0.21 effect size). Patients who were rated to improve more than slightly were found to improve by 6.9-14.2 (0.86-1.77 effect size) on the mRSS and 0.21-0.55 (0.32-0.83 effect size) on the HAQ-DI score.

CONCLUSION

MID estimates are provided for improvement in the mRSS and HAQ-DI scores, which can help in interpreting clinical trials on patients with SSc and be used for sample size calculation for future clinical trials on diffuse SSc.

The rationale behind autologous autoimmune hematopoietic stem cell transplant conditioning regimens: concerns over the use of total-body irradiation in systemic sclerosis

Hematopoietic stem cell transplantation (HSCT) is becoming an increasingly recognized indication for treatment of autoimmune diseases and severe immune-mediated disorders. However, multicenter registry data have demonstrated higher than anticipated early toxicity, approximately 10% for autoimmune diseases in general, and 20-27% for diffuse systemic sclerosis (scleroderma). If uncorrected, this high treatment-related mortality will hinder development of stem cell therapy for immune-mediated diseases. In order to develop safer regimens, we address some pitfalls and concepts involved in design and selection of conditioning regimens for autoimmune diseases in general, and because it is associated with the highest regimen-related toxicity, scleroderma in specific.

Comparison of methods to identify individuals at increased risk of coronary disease from the general population

OBJECTIVES

To evaluate the guidelines on measurement of cholesterol in the national service framework for coronary heart disease and to compare alternative strategies for identifying people at high risk of coronary disease in the general population.

DESIGN

Comparison of methods (national service framework criteria, Sheffield tables, age threshold of 50 years, estimated risk assessment using fixed cholesterol values) for identifying people with a 10 year coronary event risk of 15% or greater.

SETTING

Health survey for England 1998.

SUBJECTS

6307 people aged between 30 and 74 years with no history of myocardial infarction, stroke, or angina.

MAIN OUTCOME MEASURES

Proportion of the total population selected for measurement of cholesterol and proportion of people at 15% or greater risk identified.

RESULTS

The national service framework guidelines selected 43.4% (95% confidence interval 42.2% to 44.6%) of the study population for cholesterol measurement and identified 81.2% (80.2% to 82.2%) of those at 15% or greater risk. The Sheffield tables selected 73.1% (72.0% to 74.2%) for cholesterol measurement and identified 99.91% (99.83% to 99.99%) of those at 15% or greater risk. An age threshold of 50 years selected 46.3% (45.1% to 47.5%) for cholesterol measurement and identified 92.8% (92.1% to 93.4%) of those at 15% or greater risk. Estimated risk assessments using fixed cholesterol values selected 17.8% (16.8% to 18.7%) for cholesterol measurement and identified 75.9% (74.8% to 76.9%) of those at 15% or greater risk.

CONCLUSION

Measuring the cholesterol concentration of everyone aged 50 years and over is a simple and efficient method of identifying people at high risk of coronary disease in the general population.