AB0557 ACHIEVING TREATMENT TARGETS IN PSORIATIC ARTHRITIS WITH APREMILAST IN CANADIAN PRACTICE: REAL WORLD RESULTS FROM APPRAISE

Background:

Real-world evidence on achieving treatment targets with apremilast (APR) in patients (pts) with PsA is limited. In the phase 3 PALACE trials, pts reached remission (REM)/low disease activity (LDA) targets at 52 wks most frequently when early APR treatment was initiated and pts were in moderate disease activity, as measured by Clinical Disease Activity Index for PsA (cDAPSA) score. In APPRAISE, we assessed APR effectiveness/tolerability in pts with PsA in routine clinical practice in Canada.

Objectives:

This interim efficacy analysis focused on the available data on APR effectiveness measuring rate of achieving cDAPSA REM or LDA at 12 mos and Pt Acceptable Symptom Status (PASS) results.

Methods:

The prospective, multicenter, observational APPRAISE study assessed APR effectiveness/tolerability in adults with active PsA in routine clinical care enrolled from July 2018-March 2020. Pts were followed from treatment initiation to 12 mos, with visits suggested every 4 mos. The primary effectiveness endpoint was the rate of achieving at least LDA (cDAPSA <14) at 12 mos. Pt-reported outcome measures were assessed. Data reported are as observed in pts continuing APR treatment.

Results:

In total, 101 pts were enrolled in APPRAISE. Mean age was 52 yrs; 56% were women. Mean (SD) PsA duration at baseline (BL) was 6 (8) yrs. Oligoarticular disease (≤4 joint involvement) was most common (41%), followed by polyarticular (35%). Most pts (92%) received prior conventional DMARDs and 17% received prior biologic therapy; concomitant MTX was reported in 41% at BL. By 12 mos, 41/101 enrolled pts discontinued, 35 reached 12 mos follow-up (4 mos: n=92; 8 mos: n=61), and 25 have yet to reach 12 mos. The majority (92%) of discontinuations due to lack/loss of effectiveness or AEs occurred within 4-8 mos. AEs were primarily GI related early in treatment. The proportion of pts with continued APR achieving cDAPSA REM/LDA treatment targets increased significantly over time (Figure 1). Significant reductions were seen over 12 mos in swollen/tender joint counts and plaque psoriasis, with reduced mean (SD) body surface area of −4% (9%) (Table 1). Prevalence of dactylitis/enthesitis at BL, 4, 8, and 12 mos was 17%/33%, 9%/24%, 5%/19%, and 0%/21%, respectively. Pain assessment (VAS) significantly improved over time. The proportion of pts achieving PASS with continued APR increased significantly over 12 mos (BL: 27%; 12 mos: 65%) (Figure 1). COVID restrictions impacted in-office assessment visits, necessitating reliance on virtual visits.

Conclusion:

Pts with PsA receiving APR were assessed at regular intervals in routine clinical care in Canada. This interim analysis revealed a greater number of pts receiving APR (66%) who completed the 12-mo follow-up achieved REM or LDA, as measured by cDAPSA over 12 mos. A majority of pts (65%) reported satisfaction with their disease state, as measured by PASS. No new safety signals were observed.

Table 1.

Change in Clinical Parameters and Pt-Reported Outcomes From BL to 4, 8, and 12 Mos

Outcome Measure*, Mean (SD)BL (n = 101)4 Mos (n = 92)8 Mos (n = 61)12 Mos (n = 35)Disease/Clinical Parameters Tender joint count (0-68)7.5 (6.7)−2.5 (6.3)*−3.9 (5.2)*−2.2 (6.4) Swollen joint count (0-66)5.4 (5.4)−3.0 (4.5)*−3.1 (4.3)*−3.1 (4.4)* PhGA42.9 (18.8)−19.0 (24.6)*−24.2 (24.2)*−21.2 (26.3)* Body surface area, %3.1 (6.1)−2.2 (6.0)*−2.7 (7.5)*−4.2 (9.1)* cDAPSA22.2 (13.3)−7.9 (12.1)*−10.1 (13.5)*−6.9 (12.0)*Pt-Reported Outcomes PtGA, mm50.0 (24.6)−10.2 (27.5)*−9.1 (31.9)*−3.6 (39.7) Pain, mm48.3 (25.3)−9.5 (26.2)*−12.2 (28.7)*−7.3 (26.0) HAQ-DI0.9 (0.7)−0.13 (0.5)*−0.15 (0.6)−0.1 (0.7)

*Denotes significant change from BL (P<0.05) from paired-sample t-tests; note that mean change from BL may be greater than the mean BL value when improvements of large magnitude, for pts with relatively elevated BL values, are observed in samples with lower n’s. HAQ-DI = Health Assessment Questionnaire-Disability Index; PhGA = Physician’s Global Assessment; PtGA = Patient’s Global Assessment.

Acknowledgements:

This study was funded by Celgene and Amgen Inc. Writing support was funded by Amgen Inc. and provided by Kristin Carlin, RPh, MBA, of Peloton Advantage, LLC, an OPEN Health company.

Disclosure of Interests:

Vinod Chandran Consultant of: AbbVie, Amgen, BMS, Celgene Corporation, Eli Lilly, Janssen, Novartis, Pfizer, UCB, Grant/research support from: AbbVie, Amgen, BMS, Celgene Corporation, Eli Lilly, Janssen, Novartis, Pfizer, UCB, Louis Bessette Consultant of: AbbVie, Amgen, BMS, Celgene Corporation, Eli Lilly, Janssen, Merck, Pfizer, Sanofi, Novartis, UCB, Grant/research support from: AbbVie, Amgen, BMS, Celgene Corporation, Eli Lilly, Janssen, Merck, Pfizer, Sanofi, Novartis, UCB, Carter Thorne Speakers bureau: AbbVie, Amgen, Celgene Corporation, Eli Lilly, Medexus/Medac, Merck, Novartis, Pfizer, Sandoz, Sanofi, Consultant of: Centocor, Medexus/Medac, Merck, Grant/research support from: Novartis, Pfizer, Maqbool Sheriff Speakers bureau: AbbVie, Celgene Corporation, Eli Lilly, Janssen, Merck, Pfizer, Sandoz, Proton Rahman Speakers bureau: AbbVie, Amgen, Celgene, Eli Lilly, Janssen, Merck, Novartis, Pfizer, UCB, Dafna D Gladman Consultant of: AbbVie, Amgen, BMS, Celgene Corporation, Eli Lilly, Galapagos, Gilead, Janssen, Novartis, Pfizer, UCB, Grant/research support from: AbbVie, Amgen, BMS, Celgene Corporation, Eli Lilly, Galapagos, Gilead, Janssen, Novartis, Pfizer, UCB, Sabeen Anwar Consultant of: AbbVie, Amgen Inc., BMS, Novartis, and Pfizer, Grant/research support from: AbbVie, Amgen Inc., Eli Lilly, Janssen, and Pfizer, Jennifer Jelley Employee of: Amgen Canada Inc., Anne-Julie Gaudreau Employee of: Amgen Canada Inc., Manprit Chohan Employee of: Amgen Canada Inc., John S. Sampalis Employee of: JSS Medical Research.

Impact of adherence to treatment with tiotropium and fluticasone propionate/salmeterol in chronic obstructive pulmonary diseases patients

OBJECTIVE

Poor adherence to treatment may contribute to the treatment gap in chronic obstructive pulmonary diseases (COPD). The aim of the current study was to describe the association between adherence to treatment and the risk of COPD moderate (ME) and severe (SE) exacerbations, and health care utilization.

RESEARCH DESIGN AND METHODS

Observational single cohort study utilizing the Quebec Provincial Health Insurance databases. All patients older than 40 years with a diagnosis of COPD between 2001 and 2010 were entered in the study cohort at the time of their first prescription for tiotropium (TIO) alone or co-administered with fluticasone propionate/salmeterol (TIO + FSC). Follow-up continued to the last known claim or death. Adherence was measured by the medication possession ratio (MPR) ≥80% and persistence defined as no treatment gap ≥30 days.

MAIN OUTCOME MEASURES

ME was defined as use of an oral corticosteroid or antibiotic, SE as COPD related hospitalization or an emergency room (ER) visit. COPD related health care resource utilization ascertained was prescription of rescue medications, ER visits, hospitalizations, intensive care unit (ICU) admissions, intubations, and general practitioner (GP) and respirologist visits.

RESULTS

There were 23,707 patients included in this study. Compliance and persistence with TIO for monotherapy patients were 61.1% and 47.6% respectively. For patients treated with TIO + FSC, compliance and persistence for TIO were 62.9% and 45.3% respectively, and for FSC they were 35.4% and 33.0%. Multivariate analyses showed a significant (P < 0.001) adjusted odds ratios for ME (OR(ME)) and SE (OR(SE)) for TIO compliant vs. non-compliant patients (TIO: OR(ME) = 0.543, OR(SE) = 0.712; TIO + FSC: OR(ME) = 0.436, OR(SE) = 0.570). Similarly for FSC compliance: OR(ME) = 0.546; OR(SE) = 0.749. Similar results were observed for persistence. Compliance and persistence with TIO and FSC were associated with significantly reduced rates of health care utilization.

CONCLUSIONS

Despite the typical limitations of an administrative database study, the results of this large population-based study have shown that reduced adherence to treatment with TIO and FSC is associated with increased risk for exacerbations and higher health care utilization in COPD patients.

Impact of adherence to treatment with fluticasone propionate/salmeterol in asthma patients

OBJECTIVE

Low adherence with asthma treatment may be associated with suboptimal outcomes and hence create a treatment gap in the real-life setting. The objective of this study was to assess the long-term association between adherence to treatment with fixed-dose fluticasone propionate/salmeterol (FSC) and the risk of exacerbations and health care utilization in patients with asthma.

RESEARCH DESIGN AND METHODS

Observational single cohort study utilizing the Quebec Health Insurance databases. All patients (age >12 years) with a diagnosis of asthma (ICD9-CM 493.xx) between 2001 and 2010 were entered into the study cohort at the time of their first prescription for FSC at any dose. Follow-up continued to the last known claim or death. Adherence to treatment was ascertained as compliance (medication possession ratio ≥80%) and persistence (absence of treatment gap ≥30 days).

MAIN OUTCOME MEASURES

Outcomes assessed were exacerbations defined as one of the following: use of oral corticosteroid (OCS), emergency room (ER) visit for asthma or hospitalization for asthma. Asthma related health care resource utilizations ascertained were number of prescription claims for rescue medications, ER visits, hospitalizations, intensive care unit (ICU) stay, intubations, and general practitioner (GP) and respirologist visits.

RESULTS

A total of 19,126 patients were included in the study. The proportion of compliant and persistent patients were 42.7% and 29.3% respectively. Multivariate logistic regression analyses showed a significantly reduced adjusted odds of exacerbations for compliant (OR = 0.48; 95% CI: 0.44-0.54) and persistent patients (OR = 0.42; 95% CI: 0.38-0.48). Similarly, significantly lower rates of health care utilization were observed for compliant and persistent patients.

CONCLUSIONS

The results of this large population-based study have shown that increased adherence to treatment with FSC is associated with lower risk for exacerbations, lower rescue medication use and lower health care utilization in asthma patients. Despite the typical limitations of an administrative database study including validity of the diagnosis, the fact that compliance and persistence are calculated based on filled claims which does not guarantee that the patients actually took their medications, and the absence of clinical and laboratory data, the findings have implications for physician and patient awareness of the importance of adherence in the management of asthma.

International prospective evaluation of scintimammography with technetium-99m sestamibi: interim results

OBJECTIVE

The purpose of this study is to evaluate the validity and reliability of scintimammography with technetium-99m (99mTc)-labeled sestamibi as an adjunct radiodiagnostic agent in the diagnosis of breast cancer.

METHODS

This is a multicenter prospective cohort clinical trial that was initiated in June 1999 and will terminate May 2001. All patients with a physical or mammographic finding visiting any of the participating clinics are enrolled in the study. Patients who are younger than 18 years, pregnant, not willing to sign the consent form, or who have undergone an invasive procedure on the breast 30 days or less before scintimammography are excluded. At the time of the first interim report, 633 patients had been recruited from six Canadian centers. To date complete data have been collected for 530 patients.

RESULTS

The mean (SD) age of the patients is 56 (12) years with a range between 24 and 85. There were 122 (23%) of the women in the sample who were postmenopausal and 36 (7%) who were perimenopausal. Breast density was graded as dense for 127 (24%), normal for 260 (50%), and fatty for 138 (26%). Of the 530 women in the study 156 (29%) had a palpable mass at physical examination. The mammographic results were classified as 76 (14%) breast imaging reporting and data system (BIRADS) 5, 60 (11%) BIRADS 4, 70 (13%) BIRADS 3 and the remaining BIRADS 2 or 1. The scintimammography results were positive for 118 (23%) of the patients and negative for 412 (78%). The histopathology showed malignant breast disease for 66 (12.5%) of the patients in the sample. Sensitivity and specificity of scintimammography for the detection of breast cancer was estimated 90.9% and 87.5%, respectively. A positive predictive value (PPV) of 50.8% with a negative predictive value of 98.5% and an accuracy of 87.5% were calculated. The PPV is interpreted as the posttest probability of disease given a positive test result. In this sample the pretest probability of disease would be best estimated by the prevalence of disease, which is equal to 12.5%. A positive scintimammography result would change the estimated probability to 51%, which is equivalent to a 400% change from the pretest value. Therefore a positive scintimammography result significantly increases our ability to predict the presence of malignant disease in this population.

CONCLUSION

The interim results of the present study suggest that scintimammography with 99mTc-sestamibi is accurate and potentially useful as an adjunct to mammography for the detection of breast cancer.

Trauma care regionalization: a process-outcome evaluation

BACKGROUND

Regionalization of trauma care services in our region was initiated in 1993 with the designation of four tertiary trauma centers. The process continued in 1995 with the implementation of patient triage and transfer protocols. Since 1995, the network of trauma care has been expanded with the designation of 33 secondary, 30 primary, and 32 stabilization trauma centers. In addition, during this period emergency medical personnel have been trained to assess and triage trauma victims within minimal prehospital time. The objective of the present study was to evaluate the impact of trauma care regionalization on the mortality of major trauma patients.

METHODS

This was a prospective study in which patients were entered at the time of injury and were followed to discharge from the acute-care hospital. The patients were identified from the Quebec Trauma Registry, a review of the records of acute-care hospitals that treat trauma, and records of the emergency medical services in the region. The study sample consisted of all patients fulfilling the criteria of a major trauma, defined as death, or Injury Severity Score (ISS) > 12, or Pre-Hospital Index > 3, or two or more injuries with Abbreviated Injury Scale scores > 2, or hospital stay of more than 3 days. Data collection took place between April 1, 1993, and March 31, 1998. During this period, four distinct phases of trauma care regionalization were defined: pre-regionalization (phase 0), initiation (phase I), intermediate (phase II), and advanced (phase III).

RESULTS

A total of 12,208 patients were entered into the study cohort, and they were approximately evenly distributed over the 6 years of the study. During the study period, there was a decline in the mean age of patients from 54 to 46 years, whereas the male/female ratio remained constant at 2:1. There was also an increase in the mean ISS, from 25.5 to 27.5. The proportion of patients injured in motor vehicle collisions increased from less than 45% to more than 50% (p < 0.001). The mortality rate during the phases of regionalization were: phase 0, 52%; phase I, 32%; phase II, 19%; and phase III, 18%. These differences were clinically important and statistically significant (p < 0.0001). Stratified analysis showed a significant decline in mortality among patients with ISS between 12 and 49. The change in mortality for patients with fatal injuries (ISS > or = 50) was not significant. During the study period, the mean prehospital time decreased significantly, from 62 to 44 minutes. The mean time to admission after arrival at the hospital decreased from 151 to 128 minutes (p < 0.001). The latter decrease was primarily attributable to changes at the tertiary centers. The proportion of patients with ISS between 12 and 24 and between 25 and 49 who were treated at tertiary centers increased from 56 to 82% and from 36 to 84%, respectively (p < 0.001). Compared with the secondary and primary centers, throughout the course of the study the mortality rate in the secondary and tertiary centers showed a consistent decline (p < 0.001). In addition, the mortality rate in the tertiary centers remained consistently lower (p < 0.001). The results of multivariate analyses showed that after adjusting for injury severity and patient age, the primary factors contributing to the reduced mortality were treatment at a tertiary center, reduced prehospital time, and direct transport from the scene to tertiary centers.

CONCLUSION

This study produced empirical evidence that the integration of trauma care services into a regionalized system reduces mortality. The results showed that tertiary trauma centers and reduced prehospital times are the essential components of an efficient trauma care system.

Costs and effectiveness of extracorporeal gallbladder stone shock wave lithotripsy versus laparoscopic cholecystectomy. A randomized clinical trial. McGill Gallstone Treatment Group

Thirty-five patients were randomized to extracorporeal shock-wave lithotripsy (ESWL) and 25 to laparoscopic cholecystectomy (LC). Stone disappearance occurred in only 12 of 32 ESWL patients [38% (95% CI: 21-56%)] during a 15-month follow-up. Greater incremental gains in quality of life after 6 months were observed among LC patients (p < .01). Total duration of disability was 6.8 +/- 8.5 days for ESWL, and 22.7 +/- 16.6 days for LC (p < .01). Nine (28%) patients crossed over electively to the LC group, but only 44% of these underwent LC within the next 3 years. ESWL cost Can $58.9/ day of disability saved. ESWL is limited by its selective applicability and modest stone disappearance rate. Its cost-effectiveness is largely dependent on patient acceptance of recurrent episodes of biliary colic due to the persistence of stone fragments.

Ineffectiveness of on-site intravenous lines: is prehospital time the culprit?

The purpose of the present study was to test the association between on-site intravenous fluid replacement and mortality in patients with severe trauma. The effect of prehospital time on this association was also evaluated. The design was that of an observational quasi-experimental study comparing 217 patients who had on-site intravenous fluid replacement (IV group) with an equal number of matched patients for whom this intervention was not performed (no-IV group). The patients were individually matched on their Prehospital Index obtained at the scene and were included in the study if they had an on-site Prehospital Index score > 3 and were transported alive to the hospital. The outcome measure of interest was mortality because of injury. The patients in the IV group had a significantly lower mean age (37 vs. 45 years; p < 0.001) and higher incidence of injuries to the head or neck (46 vs. 32%; p = 0.004), chest (34 vs. 17%; p < 0.001), and abdomen (28 vs. 12%; p < 0.001). The IV group also had a higher proportion of patients injured by motor vehicle crashes (41 vs. 27%; p = 0.003), firearms (9 vs. 2%; p = 0.001), and stabbing (20 vs. 9%; p = 0.001). The rate of extremity injuries (38 vs. 59%; p < 0.001) and falls (12 vs. 40%; p < 0.001) was lower for the IV group. In addition, the mean Injury Severity Score was significantly higher for the IV group (15 vs. 9; p < 0.001). The mortality rates for the IV and no-IV groups were 23 and 6% (p < 0.001). Logistic regression analysis showed that after adjusting for patient age, gender, Injury Severity Score, mechanism of injury, and prehospital time, the use of on-site intravenous fluid replacement was associated with a significant increase in the risk of mortality (adjusted odds ratio = 2.3; 95% confidence interval = 1.02-5.28; p = 0.04). To further evaluate the effect of prehospital time on the association between on-site IV use and mortality, the analysis was repeated separately for the following time strata: 0 to 30 minutes, 31 to 60 minutes, and >60 minutes. The adjusted odds ratios (95% confidence interval) for these strata were 1.05 (0.08-14.53; p = 0.97), 3.38 (0.84-13.62; p = 0.08), and 8.40 (1.27-54.69; p = 0.03). These results show that for prehospital times of less than 30 minutes, the use of on-site intravenous fluid replacement provides no benefit, and that for longer times, this intervention is associated with significant increases in the risk of mortality. The results of this observational study have shown that the use of on-site intravenous fluid replacement is associated with an increase in mortality risk and that this association is exacerbated by, but is not solely the result of, increased prehospital times. Our findings are consistent with the hypothesis that early intravenous fluid replacement is harmful because it disrupts the normal physiologic response to severe bleeding. Although this evidence is against the implementation of on-site intravenous fluid replacement for severely injured patients, further studies including randomized controlled trials are required to provide a definitive answer to this question.

Direct transport to tertiary trauma centers versus transfer from lower level facilities: impact on mortality and morbidity among patients with major trauma

BACKGROUND

The purpose of the study was to compare the outcome of severely injured patients who were transported directly to a Level I, tertiary trauma center with those who were transferred after being first transported to less specialized hospitals.

METHODS

The data were based on all patients treated at three tertiary trauma centers in Quebec between April 1, 1993, and December 31, 1995. There were 1,608 patients (37%) transferred and 2,756 patients (63%) transported directly.

RESULTS

The mean age of the patients was approximately 45 years, and more than 60% were males. The predominant mechanisms of injury were falls and motor vehicle crashes. The transfer and direct transport groups were similar with respect to age, gender, and mechanism of injury. Body regions injured were also similar with the exception of head or neck injuries (transfer, 56%; direct, 28%; p < 0.0001). The mean Injury Severity Score was 14, the mean Pre-Hospital Index score was 5.5, and the mean Revised Trauma Score was 7.5. The two groups were similar with respect to these injury severity measures. The primary outcome of interest was mortality described as overall death rate, death rate in the emergency room, and death rate after admission. Other outcomes studied were hospital length of stay and duration of treatment in an intensive care unit. When compared with the direct transport group, transferred patients were at increased risk for overall mortality (transfer, 8.9%; direct, 4.8%; odds ratio, 1.96; 95% confidence interval (CI) = 1.53-2.50), emergency room mortality (transfer, 3.4%; direct, 1.2%; odds ratio, 2.96; 95% CI = 1.90-4.6), and mortality after admission (transfer, 5.5%; direct, 3.6%; odds ratio, 1.57; 95% CI = 1.17-2.11). All of these differences were statistically significant (p < 0.003). Stratified and multiple logistic regression analysis did not alter these results and failed to identify a patient subgroup for which transfer was associated with a reduced risk of mortality. After adjusting for patient age, Injury Severity Score, and presence of injuries to the head or neck and extremities, transferred patients stayed significantly longer in the hospital and the intensive care unit as indicated by the mean length of stay (transfer, 16.0 days; direct, 13.2 days; p = 0.02) and the mean intensive care unit stay (transfer, 2.0 days; direct, 0.95 days; p = 0.001).

CONCLUSION

The results of this study have shown that transportation of severely injured patients from the scene directly to Level I trauma centers is associated with a reduction in mortality and morbidity. Further studies are required for the evaluation of transport protocols for rural trauma. Economic and cost-effectiveness considerations of patient triage are also essential.

Povidone-iodine gel vaginal antisepsis for abdominal hysterectomy

OBJECTIVE

Our goal was to assess the safety and effectiveness of vaginal povidone-iodine gel in reducing febrile morbidity after abdominal hysterectomy.

STUDY DESIGN

This cohort study included 158 women treated with gel immediately before hysterectomy, after the usual surgical preparation, and 317 historic control subjects with the usual surgical preparation only, at two teaching hospitals. Febrile morbidity was assessed by a blinded review of temperature records and was analyzed by Fisher's exact test and multiple logistic regression.

RESULTS

Febrile morbidity occurred in 17% of gel-treated patients and 26% of controls (adjusted odds ratio 0.52, 95% confidence interval 0.31 to 0.89). In patients receiving prophylactic antibiotics the adjusted odds ratio for febrile morbidity in gel-treated patients was 0.47 (95% confidence interval 0.27 to 0.83). Prolonged fever occurred in 17% of controls and 10% of gel-treated patients (adjusted odds ratio 0.52, 95% confidence interval 0.28 to 0.97).

CONCLUSION

Preoperative vaginal povidone-iodine gel is a safe and promising technique for reducing febrile morbidity after hysterectomy.

Risk factors for adult Still's disease

OBJECTIVE

To assess risk factors for adult Still's disease (ASD).

METHODS

A matched case-control study of 60 patients with ASD and 60 same sex siblings closest in age was conducted. Subjects were recruited from cohorts in Eastern Canada, Pittsburgh, and the Arthritis, Rheumatism, and Aging, Medical Information Systems (ARAMIS). A questionnaire was used to obtain data on demographic characteristics, education, income, occupation, exposure to toxic substances, stress, and medical history.

RESULTS

116 patients with ASD were identified, of which 104 participated. 86 identified same sex siblings, of which 60 replied. When compared to same sex siblings, ASD patients were similar with respect to education and occupation but had a trend to higher median income. There were no significant associations of ASD with smoking, alcohol consumption, individual toxic substances, vaccination, blood transfusion, minor or major surgery, pregnancy, or diet in the year preceding disease onset. There were no significant associations with tonsillectomy or adenoidectomy, appendectomy, asthma, hay fever, allergy shots, or pregnancy at any time preceding the onset of disease. There was a statistically nonsignificant increase in a history of exposure to coal dust [odds ratio (OR) 3.0; 95% confidence interval (CI) 0.30 to 28.84], in allergy preceding the onset of disease (OR 2.67; 95% CI 0.71 to 10.05), and in oral contraceptive use in the year preceding onset (OR 2.00; 95% CI 0.18 to 22.06). Stressful life events (OR 2.56; 95% CI 1.18 to 5.52) in the year preceding onset was significantly associated with increased risk for ASD. This positive association should be treated with caution unless confirmed by a separate study.

CONCLUSION

This exploratory study of risk factors for ASD draws attention to stress as a potentially important risk factor, while likely excluding a considerable number of others.

Predictive validity and internal consistency of the pre-hospital index measured on-site by physicians

Physiological measures of injury are used as triage tools to identify patients that require treatment in trauma centres. The Pre-Hospital Index (PHI) is based on systolic blood pressure, pulse, respiratory rate, (level of) consciousness, and presence of penetrating injury. The present study evaluated the validity and internal consistency of the PHI. The study was based on 628 patients assessed by physicians at the scene. Mean age was 38.7 years (SD = 24.8), and 65% were male. Motor vehicle collisions caused the injury for 45%. The majority had head/neck (56%) and extremity (45%) injuries. Mean PHI was 4.62 (SD = 5.77), 40% had a PHI of zero, 6% between 1 and 3, 32% between 4 and 7, and 21% greater than 7. The associations between PHI and rates of hospital admission, surgery, ICU treatment, mortality, duration of hospitalization, and length of ICU stay were significant (p < 0.001). A total of 260 (41.4%) patients had major trauma requiring treatment at a trauma centre. A PHI > 3 had 83% sensitivity and 67% specificity for identifying these patients. Internal consistency of the PHI variables was above the acceptable limits. This study has shown that the PHI is a valid and reliable physiological measure of injury severity and field triage tool.

Preventable death evaluation of the appropriateness of the on-site trauma care provided by Urgences-Santé physicians

The study is based on 44 preventable deaths occurring in a cohort of 360 patients with major trauma. These cases were reviewed by a committee of nine experts. The mean Injury Severity Score (ISS) was 28, and most cases had injuries to the head/neck (68%) and chest (64%). The mean (+/- SD) observed prehospital times, and those considered the maximum allowable by the committee, were 40.6 +/- 12.0 minutes for head/neck injuries and 23.9 +/- 12.2 minutes for chest injuries (p < 0.05). Intravenous (i.v.) lines were started in 38 (86%) of the patients. The committee classified this procedure as harmful for 16 (42%) and neutral for 19 (50%). Among the 18 (46%) that were intubated, this intervention was considered harmful for 17% and neutral for 39%. In two of the three patients for whom a pneumatic antishock garment was applied, this procedure was considered harmful. Of the 34 patients that required direct transport at a level I trauma center, 50% were transferred to such a hospital. These results show significant prehospital delays and high rates of inappropriate IV line initiation and intubation in trauma patients receiving on-site care by physicians. We conclude that prehospital care protocols for trauma patients should emphasize prompt transport and specific on-site care algorithms.

Trauma center designation: initial impact on trauma-related mortality

The movement towards trauma care regionalization in Québec was initiated in 1990, with formal designation of three level I trauma centers in 1993. The purpose of this study is to evaluate the impact of trauma center designation on mortality. The study design is that of a two-cohort study, one assembled during 1987 when designation was not in effect, and the other during the first 5 months of designation. The study focuses on patients that fulfilled the following criteria: i) arrived alive at the hospital, and ii) were admitted. The outcome measures are adjusted mortality, and excess mortality as measured by the TRISS methodology. A total of 158 patients treated in 1987, and 288 treated in 1993, were identified. The mean age of the patients treated in 1993 was significantly higher (40.0, +/- 18.1), when compared with the 1987 group (30.9 +/- 18.1; p < 0.001). Patients in the 1987 cohort had a significantly higher proportion of injuries caused by stabbing (p = 0.02), and a significantly lower proportion caused by falls (p = 0.003). The 1987 cohort had a higher rate of abdominal injuries (p = 0.0001), and external injuries (p = 0.0001), and a significantly lower rate of head or neck injuries (p = 0.003), and injuries to the extremities (p = 0.0001). The mean Injury Severity Score (ISS) for the 1987 cohort was 14.96 (+/- 12.36), and 15.49 (+/- 11.61) in 1993 (p = 0.65). The crude mortality rate was 20% for 1987, and 10% for 1993. The crude odds ratio for mortality in 1987 was 2.10 with 95% confidence intervals between 1.22 and 3.62 (p = 0.006).(ABSTRACT TRUNCATED AT 250 WORDS)

Treatment of Vitamin B12 Deficiency after Gastric Surgery for Severe Obesity

BACKGROUND: Vitamin B12 deficiency after gastric surgery for obesity is due to a failure of separation of vitamin B12, from protein foodstuffs and to a failure of absorption of crystalline vitamin B12 in the presence of intrinsic factor. The purpose of this study was to determine which of four oral doses of crystalline vitamin B12 was most effective in treating vitamin B12 deficiency in 102 patients. METHODS AND RESULTS: At time of entry into the study, the patients had a serum vitamin B12, < 100 pmol L(1), were 29.9 +/- 21.7 months post-op, were 37 +/- 8 years old and had a body mass index of 30 +/- 6 kg m (2). Eight (8%) had had a vertical banded gastroplasty and 94 (92%) a gastric bypass. For the first 3 months all patients received 350 µg per day of crystalline vitamin B12, and all increased their serum vitamin B12 levels to over 100 pmol L(1). The patients were then assigned to receive for a further 3 month period one of four oral doses of crystalline vitamin B12-100 µg, 250 µg, 350 µg and 600 µg. Serum vitamin B12 levels were greater than 150 pmol L(1) after 6 months in 83.3% of patients who received 100 µg; 92.3% of patients who received 250, µg; 94.7% after 350 µg and 95.2% after 600 µg (p%0.525). CONCLUSION: At least 350 µg per day is the appropriate oral dose of crystalline vitamin B12 after gastric surgery for obesity to correct low serum vitamin B12 levels in 95% of patients.

A controlled study of the long-term prognosis of adult Still's disease

PURPOSE

To assess the long-term prognosis of patients with adult Still's disease for physical and psychological disability, pain, social functioning, social support, medication use, formal education, occupation, time lost from work, and family income, and to contrast these results with those of same-sex sibling controls.

PATIENTS AND METHODS

Patients were recruited from medical center-based cohorts in Pittsburgh and Eastern Canada and from a national survey of rheumatologists. Patients and same-sex sibling controls completed the Health Assessment Questionnaire for physical disability, the psychological and social function domains of the Arthritis Impact Measurement Scales, and the Interpersonal Skills Evaluation List questionnaire for social support, and replied to questions on medication use, formal education, occupation, time lost from work, and family income.

RESULTS

One hundred four of 111 eligible adult Still's patients (94%) provided data. They identified 86 same-sex sibling controls, of whom 60 (70%) participated. The mean duration of adult Still's disease was 10 years. Approximately half of patients continued to require medication even 10 years after diagnosis. Patients had significantly higher levels of pain, physical disability, and psychological disability when compared with the controls. However, the levels of pain and physical disability were low compared to patients with other rheumatic diseases. Educational achievement, occupational prestige, social functioning and support, time lost from work, and family income were similar for both patients and controls.

CONCLUSIONS

Despite causing disability, pain, and, in many, the need for long-term medication, patients with adult Still's disease are resilient. The disease did not interfere with educational attainment, occupational prestige, social functioning and support, time lost from work, or family income.

Preventable death classification: interrater reliability and comparison with ISS-based survival probability estimates

The purpose of the study was to compare the injury-related threat to survival estimated by the Injury Severity Score (ISS) and a committee of experts. The charts of 116 (73 fatalities and 43 survivors) patients with severe injuries were reviewed. A committee of nine clinicians classified each case as survivable, potentially survivable, and nonsurvivable based on anatomical descriptors, mechanism of injury, and patient's age. Majority was used to determine the final committee classification. Based on the ISS values, cases were classified as survivable (9-24), potentially survivable (25-49), and nonsurvivable (> 49). The results showed poor interrater reliability among the nine clinicians with an overall intraclass correlation coefficient of 0.43. The ISS-based classification had high agreement with the final committee classification (overall weighted kappa = 0.71). Lower agreement was observed for falls and with increasing number of injuries. This study has demonstrated no additional benefit for using a committee to classify injury severity on the basis of anatomical damage over applying ISS-based survival probabilities. The continued use of the ISS is supported.

Determinants of on-scene time in injured patients treated by physicians at the site

INTRODUCTION

The controversy surrounding the use of advanced life support (ALS) for the pre-hospital management of trauma pivots on the fact that these procedures could cause significant and life-threatening delays to definitive in-hospital care. In Montreal, Québec, on-site ALS to injured patients is provided by physicians only. The purpose of this study was to identify parameters associated with the duration of scene time for patients with moderate to severe injuries treated by physicians at the scene.

HYPOTHESIS

The use of on-site ALS by physicians is associated with a significant increase in scene time.

METHODS

A total of 576 patients with moderate to severe injuries are included in the analysis. This group was part of a larger cohort used in the prospective evaluation of trauma care in Montreal. Descriptive statistics, analysis of variance, multiple linear regression, and multiple logistic regression techniques were used to analyze the data.

RESULTS

Use of ALS in general was associated with a statistically significant increase in the mean scene time of 6.5 min. (p = .0001). Significant increases in mean scene time were observed for initiation of an intravenous route (mean = 6.6 min., p = .0001), medication administration (mean = 5.7 min., p = .0001), and pneumatic antishock garment (PASG) application (mean = 9.3 min., p = .03). Similar differences were observed for total prehospital time. A significant increase in the relative odds for having long scene times (> 20 min.) also was associated with the use of ALS. This level of scene time was associated with a significant increase in the odds of dying (OR = 2.6, p = .009).

CONCLUSION

This study shows that physician-provided, on-site ALS causes significant increase in scene time and total prehospital time. These delays are associated with an increase in the risk for death in patients with severe injuries.

Motion of the patella during walking: a video digital-fluoroscopic study in healthy volunteers

OBJECTIVE

The alignment of the quadriceps muscle and patella suggests that the patella should deviate laterally out of the patellar groove as the quadriceps muscle contracts during walking. The surgical treatment of patellar subluxation has been based on this presumption. The purpose of this study was to determine the movements of the patella in relation to the other bones of the knee joint during normal walking. This is the first study we know of that uses radiographs to show these movements.

SUBJECTS AND METHODS

Eight healthy adult volunteers with no previous complaints referable to the knee walked on a slowly moving treadmill while their patellae were imaged fluoroscopically in the anteroposterior plane with a Toshiba C-arm. Images were retrieved, transferred to radiographic film, and randomized to prevent the observers from knowing the order of images. The position of the patella was measured and plotted in relation to fixed points of the knee.

RESULTS

In each of the subjects at every gait cycle, the patella was observed to move vertically first, followed by a sudden shift to the medial side before returning to its original position.

CONCLUSION

Contrary to conventional understanding, our results show that the patella deviates medially rather than laterally during walking. This occurs because of differential contraction of the components of the quadriceps muscle during walking. The management of painful and subluxated patellae must be reevaluated in light of this finding.

Impact of on-site care, prehospital time, and level of in-hospital care on survival in severely injured patients

A sample of 360 severely injured patients was selected from a cohort of 8007 trauma victims followed prospectively from the time of injury to death or discharge. A case referent study was used to test the association between on-site care, total prehospital time, and level of care at the receiving hospital with short-term survival. Multiple logistic regression analyses showed that use of Advanced Life Support (ALS) at the scene was not associated with survival, whereas treatment at a level I compatible hospital was associated with a 38% reduction in the odds of dying, which approached statistical significance. Total prehospital time over 60 minutes was associated with a statistically significant adjusted relative odds of dying (OR = 3.0). The results of this study support the need for regionalization of trauma care and fail to show a benefit associated with ALS.

Randomised controlled trial of laparoscopic versus mini cholecystectomy. The McGill Gallstone Treatment Group

Laparoscopic cholecystectomy (LC) has gained wide acceptance for treatment of cholelithiasis in preference to open cholecystectomy, though it has not been formally compared with mini cholecystectomy (MC). We have compared these two techniques in a randomised trial. 70 patients with ultrasound-proven cholelithiasis were randomly allocated LC (38) or MC (32); 37 and 25, respectively, underwent the assigned procedure. The mean hospital stay (including 1 preoperative day) was significantly shorter in the LC than the MC group (median 3 [interquartile range 2-3] vs 4 [3-5], p = 0.001) as was duration of convalescence (mean 11.9 [SD 9.1] vs 20.2 [16.5] days, p = 0.04). The rate of return to normal activities was 1.77 times greater in the LC group than in the MC group (95% confidence interval 1.01-3.11, p = 0.03). In regression analysis, the type of cholecystectomy done was the only variable significantly associated with the duration of convalescence. Although there was significant postoperative improvement in all of three quality of life scores in both groups, LC patients improved more quickly than did MC patients. This randomised trial shows the superior effectiveness of LC over MC in treating cholelithiasis.

Standardized mortality ratio analysis on a sample of severely injured patients from a large Canadian city without regionalized trauma care

Flora's Z statistic and standardized mortality ratios (SMRs) as indicators of excess mortality were calculated for a sample of 355 patients with major trauma. A statistically significant overall excess mortality was observed in this sample (Z = 6.77, SMR = 1.81, p less than 0.05). Advanced life support provided by physicians at the scene (MD-ALS) was not associated with reduced excess mortality. A significant trend toward lower excess mortality was associated with a higher level of trauma care at the receiving hospital (p less than 0.05). Total prehospital time over 60 minutes was associated with a significant increase in excess mortality (p less than 0.001). These results support regionalization of trauma care and failed to show any benefit associated with MD-ALS.

Adult Still's disease: manifestations, disease course, and outcome in 62 patients

Clinical and laboratory manifestations, disease course, outcome, and HLA associations were studied in an inception cohort of 62 subjects with adult Still's disease (ASD) from 5 Canadian universities. Twenty-eight patients (45%) were female and the median age at disease onset was 24 years. In general, the clinical features observed in our patients were identical to those in other published series. However, significantly higher frequencies of sore throat (92%), weight loss (76%), lymphadenopathy (74%), pleuritis (53%), pneumonitis (27%), and abdominal pain (48%) were noted in our patients compared to those in a recent literature review. Liver involvement with hepatomegaly (44%) or abnormal liver function tests (LFTs) (76%) was common and was responsible for the 2 deaths attributed to Still's disease in our series. Severe liver failure always occurred in conjunction with aspirin or NSAID therapy. Therefore, whether or not aspirin or other NSAIDs are used, we recommend close monitoring of LFTs in patients with ASD, especially early in the disease course. Laboratory manifestations were similar to those already reported. Leukocytosis (greater than or equal to 15,000/mm3) was present in 50 patients (81%), a normochromic, normocytic anemia (hemoglobin less than or equal to 10 g/dl) in 42 (68%), and an elevated ESR in all. The mean follow-up of the 62 patients was 70 months (range, 2-163). Twenty-one patients (34%) had a self-limited disease course, 15 (24%) an intermittent course, and 22 (36%) a chronic disease course. Four patients (6%) died, and 2 of these deaths were attributed to Still's disease. For those patients who experienced a recurrence of ASD, the flares were usually of shorter duration and milder in severity than the initial episode. No initiating factor for disease exacerbation was identified in our patients. Although 22 of 62 patients (36%) had a chronic disease course, 52 (90%) were in ARA Functional Class I, and only 4 and 2 patients were in ARA Functional Class II and III, respectively. Patients with Still's disease had higher scores than the controls on the Pain (P less than 0.01) and Physical Disability (P less than 0.05) subscales of Arthritis Impact Measurement Scales health status questionnaire. Joint radiographs performed at the follow-up evaluation disclosed typical carpometacarpal and intercarpal involvement in 16 of 39 patients. In our series, HLA-B17, B18, B35, and DR2 were significantly associated with ASD. Three significant predictors of an unfavorable outcome, either a chronic disease course or a longer time to clinical remission, were identified.(ABSTRACT TRUNCATED AT 400 WORDS)

Arthritis impact measurement scales: reliability of a French version and validity in adult Still's disease

The Arthritis Impact Measurement Scales (AIMS) questionnaire was administered to 57 patients with adult Still's disease (ASD) and 104 controls. Six of the 9 scales were consistent for both groups (Cronbach's alpha greater than or equal to 0.70). Two scales, Mobility and Dexterity, were consistent for ASD only (alpha greater than or equal to 0.70). The reliability of a French version of the AIMS was similar to the standard AIMS. Of the 13 associations evaluating criterion related validity of the AIMS in ASD, 11 were statistically significant. We conclude that the French and standard AIMS are comparable and that this questionnaire is reliable and valid for assessing outcome in ASD.

Early detection and treatment of hyperlipidemia: physician practices in Canada

We surveyed primary care physicians in Canada to determine their current practices regarding the detection and treatment of hyperlipidemia in asymptomatic adults 20 years of age or more and to determine the role of selected patient characteristics (age, sex and the presence of coronary heart disease [CHD] risk factors) in their management decisions. The self-administered questionnaire was completed by 428 of 804 family physicians and general practitioners. The proportion of physicians who reported having tested at least 50% of their adult patients varied from 29% to 85% and was related to the number of CHD risk factors present and the patient's age. The proportion of respondents who reported starting dietary or drug therapy among patients with a cholesterol level of 6.2 mmol/L or less increased as the number of CHD risk factors increased and was not related to patient age or sex. According to the factors examined our results suggest that primary care physicians in Canada select patients for screening and treatment mainly on the basis of CHD risk factors present and that their approach is more conservative than that recommended by the Canadian and US consensus conferences.

The relationship of socioeconomic status to subsequent health status in systemic lupus erythematosus

We examined the relationship of socioeconomic status to health status, as determined by the Arthritis Impact Measurement Scales, in 78 systemic lupus erythematosus patients who had been entered into a prospective study. After controlling for age, disease duration, and disease severity, a significant relationship between socioeconomic status and outcome was not demonstrated. All study subjects had health insurance for medical services. The results have potential implications for health care policy.