Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

An Electronic Dashboard to Improve Dosing of Hydroxychloroquine Within the Veterans Health Care System: Time Series Analysis

BACKGROUND

Hydroxychloroquine (HCQ) is commonly used for patients with autoimmune conditions. Long-term use of HCQ can cause retinal toxicity, but this risk can be reduced if high doses are avoided.

OBJECTIVE

We developed and piloted an electronic health record-based dashboard to improve the safe prescribing of HCQ within the Veterans Health Administration (VHA). We observed pilot facilities over a 1-year period to determine whether they were able to improve the proportion of patients receiving inappropriate doses of HCQ.

METHODS

Patients receiving HCQ were identified from the VHA corporate data warehouse. Using PowerBI (Microsoft Corp), we constructed a dashboard to display patient identifiers and the most recent HCQ dose and weight (flagged if ≥5.2 mg/kg/day). Six VHA pilot facilities were enlisted to test the dashboard and invited to participate in monthly webinars. We performed an interrupted time series analysis using synthetic controls to assess changes in the proportion of patients receiving HCQ ≥5.2 mg/kg/day between October 2020 and November 2021.

RESULTS

At the start of the study period, we identified 18,525 total users of HCQ nationwide at 128 facilities in the VHA, including 1365 patients at the 6 pilot facilities. Nationwide, at baseline, 19.8% (3671/18,525) of patients were receiving high doses of HCQ. We observed significant improvements in the proportion of HCQ prescribed at doses ≥5.2 mg/kg/day among pilot facilities after the dashboard was deployed (-0.06; 95% CI -0.08 to -0.04). The difference in the postintervention linear trend for pilot versus synthetic controls was also significant (-0.06; 95% CI -0.08 to -0.05).

CONCLUSIONS

The use of an electronic health record-based dashboard reduced the proportion of patients receiving higher than recommended doses of HCQ and significantly improved performance at 6 VHA facilities. National roll-out of the dashboard will enable further improvements in the safe prescribing of HCQ.

Preparing New Nurses During a Pandemic

At the height of the COVID-19 pandemic, faculty, staff, and administrators at a large research university in the mid-Atlantic part of the country pivoted to move many classes, laboratories, and clinical experiences to a virtual environment to mitigate the risks of COVID-19. This article will highlight 2 exemplars of how faculty at this university provided students with options to learn in-person or online and how faculty managed to provide students with valuable online learning experiences. Through innovative teaching strategies, this university was able to graduate competent nurses when they were most needed by society.

Improved screening of fall risk using free-living based accelerometer data

Falls are one of the most costly population health issues. Screening of older adults for fall risks can allow for earlier interventions and ultimately lead to better outcomes and reduced public health spending. This work proposes a solution to limitations in existing fall screening techniques by utilizing a hip-based accelerometer worn in free-living conditions. The work proposes techniques to extract fall risk features from periods of free-living ambulatory activity. Analysis of the proposed techniques is conducted and compared with existing screening methods using Functional Tests and Lab-based Gait Analysis. 1705 Older Adults from Umea (Sweden) were assessed. Data consisted of 1 Week of hip worn accelerometer data, gait measurements and performance metrics for 3 functional tests. Retrospective and Prospective fall data were also recorded based on the incidence of falls occurring 12 months before and after the study commencing respectively. Machine learning based experiments show accelerometer based measures perform best when predicting falls. Prospective falls had a sensitivity and specificity of 0.61 and 0.66 respectively while retrospective falls had a sensitivity and specificity of 0.61 and 0.68 respectively.

POS1422 USE OF DISEASE MODIFYING ANTI-RHEUMATIC DRUGS AND RISK OF MULTIPLE MYELOMA IN PERSONS WITH RHEUMATOID ARTHRITIS

Background

Biologic therapies used in the management of rheumatoid arthritis (RA) target several cytokines that have been implicated in the pathogenesis of multiple myeloma (MM). Yet little is known about the association between use of biologic or targeted synthetic disease modifying anti-rheumatic drugs (b or tsDMARDs) in RA and the incidence of MM.

Objectives

Our objective was to estimate the association between b/tsDMARD use and the risk of MM among persons with RA using Veterans Health Administration (VHA) data. We hypothesized that b-/tsDMARD use is associated with a lower incidence of MM compared with conventional synthetic DMARDs (csDMARDs).

Methods

In this retrospective cohort study, we identified patients >18 years of age diagnosed with RA in any United States VHA facility from 1/1/2002 and 12/31/2018. All patients met the following inclusion criteria: 1) two or more International Classification of Diseases Version 9 or 10 (ICD9 or ICD10) codes for RA at least 7 days apart but no more than 365 days apart 2) a prescription for a csDMARD within 90 days of the first RA diagnosis 3) one inpatient or outpatient visit 30 days to 2 years preceding first RA diagnosis (indicating a regular user of VHA). Medication data was derived from the outpatient prescription fills, bar coded medication administration (BCMA), and intravenous (IV) data domains. The csDMARDs included in these analyses were: methotrexate, sulfasalazine, leflunomide, and hydroxychloroquine. The bDMARDs included were tumor necrosis factor inhibitors (TNFi) and non-TNFi biologics such as tocilizumab, rituximab, abatacept, and biosimilars; tsDMARD was tofacitinib. Patients with MM before the diagnosis of RA were excluded. Incident MM was determined by 1 or more ICD9/10 code or ICD-oncology codes. Multivariable Cox proportional hazards model were performed to estimate the hazard ratio for developing MM among those during and following the use of a b-/tsDMARD relative to b-/tsDMARD-naïve persons adjusting for age, gender, race, and ethnicity.

Results

27,540 veterans with RA met study eligibility criteria, of whom 8,322 (30%) had taken a b-/tsDMARD. Over the study period there were 77 incident MM over a total of 192,000 person years. There were 55 events in users of csDMARDs, an incidence rate (IR) of 0.40 (95% CI 0.30-0.52) per 1000 person-years and 22 in persons currently or formerly using b-/tsDMARDs (IR 0.41, 0.25-0.61 per 1000 person years). The unadjusted hazard ratio for MM following bDMARD use relative to csDMARD only use was 1.04 (0.63, 1.73), which increased to 1.28 (0.76, 2.16) after adjusting for demographic characteristics (Table 1).

Table 1.

Multivariable Cox proportional hazards model for association between use of disease modifying anti-rheumatic drugs and incident multiple myeloma.

Clinical characteristicHazards ratio (95% CI)csDMARDReferenceb-/tsDMARD use1.28 (0.76-2.16)Age*1.04 (1.02-1.07)Female0.58 (0.20-1.62)RaceReferenceWhite2.11 (1.15-3.86)Black0.70 (0.10-5.08)OtherHispanic Ethnicity0.71 (0.17-2.92)

Abbreviations: b-/tsDMARD- biologic or targeted synthetic disease modifying anti-rheumatic drug; CI: confidence interval

*Hazards ratio reflects risk per every 1-year increase in age

Model adjusted for age, gender, race, and ethnicity

Conclusion

In this nationwide VA study, we did not observe an association between bDMARD use and the incidence of MM. Of note, the median interval from initiation of a bDMARD to the end of follow-up was approximately 5.8 years, which does not allow for an examination of a possible longer term influence.

Disclosure of Interests

None declared

POS1434 USE OF BIOLOGIC OR TARGETED SYNTHETIC DISEASE MODIFYING ANTI-RHEUMATIC DRUGS AND THE RISK OF LYMPHOMA IN RHEUMATOID ARTHRITIS

Background

Epidemiologic studies suggest that disease duration and degree of inflammatory activity of rheumatoid arthritis (RA) contribute to lymphoma development (1). Whether the decrease in inflammatory burden seen with use of biologic or targeted synthetic disease modifying anti-rheumatic drugs (bDMARDs or tsDMARDs) translates into a lower risk of lymphoma in RA needs to be studied.

Objectives

The objective of our study was to examine the effect of administration of b/tsDMARDS on the incidence of lymphoma relative to conventional synthetic DMARDs (csDMARDs) in an inception cohort of Veterans with RA.

Methods

We identified patients >18 years of age diagnosed with RA in any US Veterans Affairs (VA) facility from 1/1/2002 and 12/31/2018 using the VA Corporate Data Warehouse (CDW). To be included, each patient was required to meet the following criteria: 2+ RA diagnostic codes at least 7 days apart but no more than 365 days apart; 2) a prescription for a csDMARD within 90 days of the first RA diagnosis; and 3) an inpatient or outpatient visit 30 days to 2 years preceding first RA diagnosis (indicating they are a regular user of the VA). The csDMARDs included in these analyses were: methotrexate, sulfasalazine, leflunomide, and hydroxychloroquine. The bDMARDs included were tumor necrosis factor inhibitors (TNFi) and non-TNFi biologics such as tocilizumab, rituximab, abatacept, and biosimilars; tsDMARD was tofacitinib. Patients with prevalent lymphoma were excluded. Lymphoma diagnoses were identified using International Classification of Diseases Version 9, 10 and Oncology (ICD9, ICD10, ICDO) codes.

We used marginal structural models as described by Hernan et al (2) and time-varying Cox models to control for confounding by indication while evaluating this association. We adjusted for baseline demographics (age, sex, race, ethnicity, year of cohort entry, rheumatology visits), and time-varying CRP and time-varying Rheumatoid Disease Comorbidity Index (RDCI) (3) to control for confounding.

Results

27,421 Veterans with RA met our eligibility criteria. Most of the Veterans (56%) were in the age range 61-80 years old; 89% male, 76% White, 14% African American. 8,225 (30%) patients were treated with a b-/tsDMARD. The crude incidence rates were 1.71 (95% CI 1.5-1.94) per 1000 person-years for those only on csDMARDs and 1.78 (95% CI 1.44-2.18) for patients during or following use of a b/tsDMARDs. After adjustment with both time-fixed and time-varying covariates using marginal structural models, the incidence of lymphoma was not different between patients who did and did not use a b/tsDMARD (hazard ratio=1.06, 95% CI= 0.82-1.37) (Table 1).

Table 1.

Estimates of Effect of bDMARD or tsDMARD use on Lymphoma relative to use of csDMARDs

Marginal Structural Models; adjusted for:@Demographics1.04(0.80, 1.34)#Demographics + CRP1.06(0.82, 1.37)

* per 1000 person-years

@Demographics = age, gender, race, ethnicity, rheumatology visits, and year of cohort entry

#Adjusts for CRP, baseline rheumatology visits (yes/no) and RDCI.

CRP = C-Reactive Protein, RDCI = Rhematic Disease Comorbidity Index, CI = Confidence Interval, b/tsDMARD = biologic or targeted synthetic DMARD, csDMARD = conventional synthetic DMARD

Conclusion

In this large study using the nationwide VA data, we did not observe an association between the use of b/ts DMARDs and an increased risk of lymphoma.

References

[1]Baecklund E, Iliadou A, Askling J, Ekbom A, Backlin C, Granath F, et al. Association of chronic inflammation, not its treatment, with increased lymphoma risk in rheumatoid arthritis. Arthritis Rheum. 2006;54(3):692-701.

[2]Robins JM, Hernan MA, Brumback B. Marginal structural models and causal inference in epidemiology. Epidemiology. 2000;11(5):550-60.

[3]England BR, Sayles H, Mikuls TR, Johnson DS, Michaud K. Validation of the rheumatic disease comorbidity index. Arthritis care & research. 2015;67(6):865-72.

Disclosure of Interests

None declared

Ovarian cancer detection using optical coherence tomography and convolutional neural networks

Ovarian cancer has the sixth-largest fatality rate in the United States among all cancers. A non-surgical assay capable of detecting ovarian cancer with acceptable sensitivity and specificity has yet to be developed. However, such a discovery would profoundly impact the pace of the treatment and improvement to patients’ quality of life. Achieving such a solution requires high-quality imaging, image processing, and machine learning to support an acceptably robust automated diagnosis. In this work, we propose an automated framework that learns to identify ovarian cancer in transgenic mice from optical coherence tomography (OCT) recordings. Classification is accomplished using a neural network that perceives spatially ordered sequences of tomograms. We present three neural network-based approaches, namely a VGG-supported feed-forward network, a 3D convolutional neural network, and a convolutional LSTM (Long Short-Term Memory) network. Our experimental results show that our models achieve a favorable performance with no manual tuning or feature crafting, despite the challenging noise inherent in OCT images. Specifically, our best performing model, the convolutional LSTM-based neural network, achieves a mean AUC (± standard error) of 0.81 ± 0.037. To the best of the authors’ knowledge, no application of machine learning to analyze depth-resolved OCT images of whole ovaries has been documented in the literature. A significant broader impact of this research is the potential transferability of the proposed diagnostic system from transgenic mice to human organs, which would enable medical intervention from early detection of an extremely deadly affliction.

Development of an extension of the OMERACT Summary of Measurement Properties table to capture equity considerations: SOMP-Equity

OBJECTIVE

To develop an equity extension of the OMERACT Summary of Measurement Properties (SOMP) Table, SOMP Equity to describe whether a patient reported outcome measure (PROM) works well among patients of diverse languages and cultures, education levels, and other population characteristics.

METHODS

We used the PROGRESS-Plus framework to categorize equity characteristics assessed in trials of PROM. PROGRESS refers to Place of residence, Race/ethnicity/culture/language, Occupation, Gender/sex, Religion, Education, Socioeconomic status, and Social Capital, while the 'plus' captures additional characteristics, such as age. We pilot tested our SOMP Equity Extension using the Health Assessment Questionnaire (HAQ) as a prototypical PROM.

RESULTS

The SOMP Equity Extension retains the same columns as the original OMERACT SOMP (domain match, feasibility, construct validity, test-retest reliability, longitudinal construct validity, clinical trial discrimination, thresholds of meaning) but uses the PROGRESS-Plus characteristics as rows. We found several examples of studies of the HAQ which had assessed one or more PROGRESS-Plus characteristics.

CONCLUSIONS

The most commonly reported equity considerations were related to language. OMERACT Equity virtual meeting participants were polled and they indicated that the SOMP Equity Extension is useful for highlighting and tracking equity considerations for OMERACT Core Outcome Measurement Instruments.

Effect of dietary supplementation of Bacillus subtilis DSM29784 on hen performance, egg quality indices, and apparent retention of dietary components in laying hens from 19 to 48 weeks of age

The aim of the current study was to evaluate egg production, quality, and apparent retention (AR) of components in response to a multi-dose application of a single strain Bacillus subtilis (SSB; DSM29784) in a corn-soybean meal basal diet fed to hens (19 to 48 wk of age). The treatments consisted of a basal diet with either no probiotic (control, CON), 1.1E+08 (low, LSSB), 2.2E+08 (medium, MSSB) or 1.1E+09 (high, HSSB) CFU/kg of diet. A total of 336, 19-wk old Shaver White layers were used at a stocking density of 7 and 6 hens/replicate-cage in layer I (week-19 to 28) and layer II (week-29 to 48) phases, respectively. Evaluated variables included feed intake (FI), body weight (BW), feed conversion ratio (FCR), egg production, weight, mass, and egg quality (shell thickness, shell breaking strength, albumen height (AH), and Haugh unit (HU)). Excreta was collected at the end of week-28 for AR of components and apparent metabolizable energy (AME). Supplementation of SSB increased (P = 0.008) FI during peak egg-lay (week-24) and BW increased linearly (P = 0.019) in early layer II (week-32). In layer I, LSSB compared with CON increased EM (g/egg) by 3.3% (P = 0.049). In layer II, SSB inclusion tended to improve FCR (linear, P = 0.094; g FI: g EM). Although shell breaking strength was lowest at week-20 with HSSB (4.518 vs. 4.889 kgf for HSSB vs. CON; P = 0.045), AH and HU were improved at higher dose of SSB, in both phases (P ≤ 0.005). Apparent retention of dry matter, AME, and minerals were improved (P < 0.0001) in a dose response. Hence, while the low dose of B. subtilis DSM29784 improved hen performance and maintained egg quality in both phases, a higher dose of SSB improved the interior protein quality of eggs (AH and HU).

Growth performance, apparent retention of components, and excreta dry matter content in Shaver White pullets (5 to 16 week of age) in response to dietary supplementation of graded levels of a single strain Bacillus subtilis probiotic

Administered in adequate amounts, probiotics can be an alternative to antibiotic growth promoters in poultry production. This study evaluated dose response of a single strain of Bacillus subtilis (SSB, DSM29784) on growth performance, apparent retention (AR) of components, and excreta DM content in pullets. A basal corn-soybean meal diet was formulated to meet the specifications for grower (week 5 to 10) and developer (week 11 to 16) phases. In each phase, SSB was added to the basal diet to create 4 test diets: 0 (control, CON), 1.1E+08 (low; LSSB), 2.2E+08 (medium; MSSB), or 1.1E+09 (high; HSSB) CFU of SSB/kg of feed. All diets had TiO2 (0.5%) as a digestibility marker. A total of 720 day-old Shaver White chicks were placed in 48 cages (15 pullets per cage) and reared on a commercial antibiotic free diet for a 4-wk period. At the beginning of week 5, treatments were allocated based on cage BW (n = 12). Birds had free access to feed and water throughout. The BW, BW uniformity, feed intake (FI) and FCR were obtained weekly. Excreta was collected at the end of each phase for AR of DM, organic matter, CP, neutral detergent fiber, minerals, and AME, as well as excreta DM content. In response to SSB inclusion, BW improved in a linear (P < 0.005) and quadratic (P < 0.0001) manner in grower. FI decreased in a linear and quadratic pattern (P < 0.05, week 8 to 10) in grower, and linearly (P < 0.05) across the developer phase. Overall FCR improved in linear and quadratic pattern (P < 0.01) in the grower phase. In both the phases, AME improved in a quadratic pattern (P < 0.05). Inclusion of SSB had a linear reduction (P < 0.0001) in excreta moisture content in the grower phase. In summary, these results demonstrate that B. subtilis probiotic improved performance through enhanced nutrient utilization and reduced excreta moisture content indicating improved pullet gut health.

Growth performance and gastrointestinal responses in heavy Tom turkeys fed antibiotic free corn-soybean meal diets supplemented with multiple doses of a single strain Bacillus subtilis probiotic (DSM29784)1

Growth performance and gastrointestinal (GIT) responses to a single-strain of Bacillus subtilis (SSB) were investigated using 960 Hybrid Converter Toms. A total of 4 iso-caloric and iso-nitrogenous corn-soybean meal-based diets were allocated to 12 replicate cages/pens and fed (ad libitum) in a four-phase feeding program (starter; days 0 to 28, grower-1; days 29 to 56, grower-2; days 57 to 84, and finisher; days 85 to 126). The diets had either 0 (control), 1E+08 (low), 2E+08 (mid) or 1E+09 (high) cfu B. subtilis/kg. Feed intake (FI) and BW were recorded by phase. Excreta samples were collected towards the end of starter and grower-1 phases for apparent retention (AR) of components by marker method and litter moisture, respectively. Selected birds were necropsied on days 28 and 56 for GIT weight and samples for jejunal histomorphology and ceca digesta short chain fatty acids (SCFA). Supplemental SSB had linear and non-linear (P < 0.05) response on BW gain (BWG). Specifically, relative to the control, birds fed low SSB had higher BWG in starter and grower-1 phases whereas bird fed mid and high SSB had lower BWG in grower-2 and birds fed low and mid SSB had higher BWG in finisher phase. Consequently, birds fed low and mid SSB doses were heavier (P < 0.05) than control fed birds at the end of trial. The FCR response to SSB was linear and non-linear (P < 0.05) with birds fed low SSB showing lower FCR than control fed birds in starter, grower-1 and finisher phases. Supplemental SSB had linear and non-linear (P < 0.05) effects on AR of components (DM, ash, crude protein, crude fat, neutral detergent fiber, and gross energy), litter moisture, GIT weight, jejunal histomorphology, and SCFA. Relative to control, birds fed high SSB showed higher AR of components, villi height, day 56 ceca digesta total SCFA concentration, and lower litter moisture. In conclusions, under condition of the current study, growth performance was optimized by low to mid SSB. Improved nutrient retention and indices of gut health suggested higher SSB doses may optimize growth performance under challenging farm conditions.

Impact of hepatitis C treatment on pain intensity, prescription opioid use and arthritis

OBJECTIVE

To assess the impact of direct acting anti-viral (DAA) therapy for hepatitis C virus (HCV) infection on changes in pain intensity and prescription opioid use among Veterans.

METHODS

We conducted a retrospective cohort study of Veterans with HCV who were seen in a rheumatology clinic at least once while receiving DAA therapy between January 1, 2010 and December 31st 2016. Demographic characteristics, HCV status, HCV treatment characteristics, numeric rating scale (NRS) pain scores and opioid prescription data were extracted from the electronic medical record. Pain scores were averaged over 6 months prior to HCV treatment and 6 months after completion of treatment. Prescription opioid dose was converted to a morphine equivalent daily dose (MEDD) and averaged across the two 6-month intervals. Generalized estimating equations were used to model the change in average pain and MEDD from pre- to post-HCV treatment. Effect size was assessed using Cohen's d.

RESULTS

A total of 121 Veterans, 91% male with average age of 59 were included. Average pre-treatment pain was 4.4 (SD 2.4). The average reduction in pain scores was 0.6 points (P = 0.02, Cohen's d = 0.22) after treatment. Among 67 patients prescribed chronic opioid therapy at baseline, average pre-treatment MEDD was 52.4 mg (SD = 62.5 mg) and post-DAA treatment average MEDD was 49.5 mg (SD = 69.3 mg), representing a decrease by 2.9 mg (P < 0.01, Cohen's d = 0.14). Opioid dose reduction was seen in 43/67 patients and 12 patients discontinued opioids entirely.

CONCLUSION

Among US Veterans, subjective pain scores had modest improvement and opioid prescriptions were mildly reduced following treatment with DAA.

Large-area electrode design for vertical electrical impedance scanning of concrete bridge decks

Vertical electrical impedance (VEI) testing is a method that was developed specifically for quantifying the level of protection against chloride ingress in concrete bridge decks. A significant operational difficulty associated with VEI testing has been establishing the required rebar tap as a ground reference. As described in this work, the use of a large-area electrode (LAE) can potentially remove the need for a rebar tap and therefore significantly simplify and accelerate the VEI testing process. The specific objective of the research was to develop both theoretical and practical guidance for the design of an LAE for VEI testing. To investigate several variables that can affect the accuracy of VEI measurements obtained using an LAE connection, including various combinations of deck cover and water resistivity values, electrode separation distance, counter electrode (CE) effective area, and area ratio between the LAE and the CE, an analytical model (AM) and a finite-element model (FEM) were developed and validated with laboratory and field experiments. From the results of the AM and FEM simulations and the results of the laboratory and field experiments, LAE design considerations were developed for each of these variables that should allow proper implementation of a VEI measurement system using an LAE connection.

Toward the Development of a Core Set of Outcome Domains to Assess Shared Decision-making Interventions in Rheumatology: Results from an OMERACT Delphi Survey and Consensus Meeting

OBJECTIVE

The aim of this Outcome Measures in Rheumatology (OMERACT) Working Group was to determine the core set of outcome domains and subdomains for measuring the effectiveness of shared decision-making (SDM) interventions in rheumatology clinical trials.

METHODS

Following the OMERACT Filter 2.0, and based on a previous literature review of SDM outcome domains and a nominal group process at OMERACT 2014, (1) an online Delphi survey was conducted to gather feedback on the draft core set and refine its domains and subdomains, and (2) a workshop was held at the OMERACT 2016 meeting to gain consensus on the draft core set.

RESULTS

A total of 170 participants completed Round 1 of the Delphi survey, and 116 completed Round 2. Respondents came from 29 countries, with 49% being patients/caregivers. Results showed that 14 out of the 17 subdomains within the 7 domains exceeded the 70% criterion (endorsement ranged from 83% to 100% of respondents). At OMERACT 2016, only 8% of the 96 attendees were patients/caregivers. Despite initial votes of support in breakout groups, there was insufficient comfort about the conceptualization of these 7 domains and 17 subdomains for these to be endorsed at OMERACT 2016 (endorsement ranged from 17% to 68% of participants).

CONCLUSION

Differences between the Delphi survey and consensus meeting may be explained by the manner in which the outcomes were presented, variations in participant characteristics, and the context of voting. Further efforts are needed to address the limited understanding of SDM and its outcomes among OMERACT participants.

Poverty, Depression, or Lost in Translation? Ethnic and Language Variation in Patient-Reported Outcomes in Rheumatoid Arthritis

OBJECTIVE

Despite advances in therapies, disparities in outcomes have been documented for rheumatoid arthritis (RA) patients for both ethnicity and English language proficiency. The goals of these analyses were to compare differences in RA patient-reported outcomes, by both self-identification of ethnicity and English language proficiency, and to identify factors that might explain differences among groups.

METHODS

Data were collected through structured telephone interviews of a longitudinal cohort with physician-diagnosed RA (n = 438); only women were included (n = 335). Three groups were defined based on self-reported ethnicity and English proficiency: white/English (n = 219), Hispanic/English (n = 39), and Hispanic/Spanish (n = 77). Outcomes examined were patient-reported physical functioning, pain, and presence of moderate or severe fatigue. Multivariate regression analyses compared outcomes among groups, adjusting for sociodemographic characteristics, health and disease factors, and depression.

RESULTS

Hispanic/Spanish women had worse function, pain, and fatigue than either English-proficient group. Depression was associated with all outcomes (P < 0.0001), and accounted for greater differentials in scores than ethnicity/language proficiency. In interaction analyses, differences between women who were and were not depressed were greater for Hispanic/English than for Hispanic/Spanish. Nondepressed Hispanic/Spanish scores were significantly worse than nondepressed Hispanic/English, i.e., the impact of depression was less for Hispanic/Spanish women because both depressed and nondepressed women in this group reported worse outcomes. After adjustment for sociodemographic factors and depression, language remained significantly associated with outcomes.

CONCLUSION

Disparities in patient-reported outcomes may be driven less by ethnicity than by sociodemographic or psychological factors. Measurement instruments that are not culturally appropriate and equivalent may also hamper meaningful analyses of disparities.

Utilization of Care Outside the Veterans Affairs Health Care System by US Veterans With Rheumatoid Arthritis

OBJECTIVE

Many veterans enrolled in Veterans Affairs (VA) health care systems also receive care through other health care systems. Both VA and non-VA health care use must therefore be considered when conducting research in this population. This study characterized dual-care utilization in veterans with rheumatoid arthritis (RA) and explored associations with RA disease activity.

METHODS

Through a questionnaire mailed to RA patients at 3 VA sites, veterans reported medical services by non-VA primary care and subspecialty providers, comorbidities, non-VA medications, and hospitalizations. Disease Activity Score in 28 joints (DAS28) and Multidimensional Health Assessment Questionnaire (MD-HAQ) scores were recorded during VA clinic visits, and respondent groups were compared.

RESULTS

Of the 510 participants surveyed, 318 (62%) responded. Respondents were older (ages 69 versus 66 years; P = 0.006), more likely nonsmokers (80% versus 67%; P = 0.001), and had lower disease activity (DAS28 3.3 versus 3.8; P < 0.001, MD-HAQ 0.8 versus 0.9; P = 0.01) than nonrespondents (n = 192 [38%]). The respondents with a non-VA provider (n = 130 [41%]) were older (71 versus 68 years; P = 0.001) and had more education (14 versus 13 years; P = 0.021) than nondual-care users. Only 6% of respondents reported having a non-VA rheumatologist, with 2% receiving a non-VA prescribed biologic agent or disease-modifying antirheumatic drug.

CONCLUSION

In this study, VA beneficiaries with RA had lower dual-care utilization than previously reported for the general VA population, with few patients receiving dual rheumatology care or non-VA RA medications. This survey suggests that most US veterans with RA who access VA care use the VA as their primary source of arthritis care.

OMERACT Quality-adjusted Life-years (QALY) Working Group: Do Current QALY Measures Capture What Matters to Patients?

OBJECTIVE

To understand the limitations with current patient-reported outcome measures (PROM) used to generate quality-adjusted life-years (QALY) in rheumatology, and set a research agenda.

METHODS

Two activities were undertaken. The first was a scoping review of published studies that have used PROM to generate QALY in rheumatology between 2011 and 2016. The second was an interactive "eyeball test" exercise at Outcome Measures in Rheumatology 13 that compared subdomains of widely used generic PROM, as identified through the scoping review, to subdomains of the Assessment of SpondyloArthritis Health Index (ASAS-HI) condition-specific PROM for ankylosing spondylitis.

RESULTS

The scoping review included 39 studies. Five different PROM have been used to generate QALY in rheumatology; however, the EQ-5D and Short Form 6 Dimensions (SF-6D) were used most frequently (in 32 and 9 of included studies, respectively). Special interest group participants identified energy/drive and sleep as 2 key subdomains of the ASAS-HI instrument that may be missed by the EQ-5D, and sexual function as potentially missed by the SF-6D. Participants also expressed concerns that aspects of the process of care and non-health outcomes may be missed. Three ways of incorporating additional subdomains were discussed, including using an alternative generic PROM, modifying an existing generic PROM with "bolt-on" subdomain(s), and generating societal weights for a condition-specific PROM.

CONCLUSION

Three priorities for future research were identified: understanding whether the EQ-5D and SF-6D identify what matters to patients with different rheumatic conditions, analyzing how much patients value process or non-health outcomes, and identifying which approaches to incorporating a greater number of subdomains into the QALY are being undertaken in other disease areas.

Muscle Strength and Changes in Physical Function in Women With Systemic Lupus Erythematosus

OBJECTIVE

Cross-sectional studies have observed that muscle weakness is associated with worse physical function among women with systemic lupus erythematosus (SLE). The present study examines whether reduced upper and lower extremity muscle strength predict declines in function over time among adult women with SLE.

METHODS

One hundred forty-six women from a longitudinal SLE cohort participated in the study. All measures were collected during in-person research visits approximately 2 years apart. Upper extremity muscle strength was assessed by grip strength. Lower extremity muscle strength was assessed by peak knee torque of extension and flexion. Physical function was assessed using the Short Physical Performance Battery (SPPB). Regression analyses modeled associations of baseline upper and lower extremity muscle strength with followup SPPB scores controlling for baseline SPPB, age, SLE duration, SLE disease activity (Systemic Lupus Activity Questionnaire), physical activity level, prednisone use, body composition, and depression. Secondary analyses tested whether associations of baseline muscle strength with followup in SPPB scores differed between intervals of varying baseline muscle strength.

RESULTS

Lower extremity muscle strength strongly predicted changes over 2 years in physical function even when controlling for covariates. The association of reduced lower extremity muscle strength with reduced physical function in the future was greatest among the weakest women.

CONCLUSION

Reduced lower extremity muscle strength predicted clinically significant declines in physical function, especially among the weakest women. Future studies should test whether therapies that promote preservation of lower extremity muscle strength may prevent declines in function among women with SLE.

Who receives contraception counseling when starting new lupus medications? The potential roles of race, ethnicity, disease activity, and quality of communication

OBJECTIVE

Family planning discussions are an important aspect of medical care for women with systemic lupus erythematosus (SLE) as active disease is a risk factor for poor pregnancy outcomes, and the medications used for treatment can be harmful to the fetus when used during conception and pregnancy. Our objective was to examine the impact of patient perception of quality and type of communication on receiving contraception counseling.

METHODS

Data were derived from patients enrolled in the University of California, San Francisco Lupus Outcomes Study. Individuals participate in a yearly structured telephone interview that includes assessment of contraception counseling when starting new medications, and measures of communication and decision making. Logistic regression was performed to identify predictors of not receiving contraception counseling.

RESULTS

Of the 68 women included in this analysis, one-third did not receive contraception counseling when starting new medications. Older age, white race, depressive symptoms, and higher SLE disease activity were independently associated with not receiving contraception counseling. Participants who did not receive contraception counseling rated their physicians lower in shared decision-making (SDM) communication.

CONCLUSIONS

This study demonstrates a gap in family planning counseling among women with SLE starting new medications. Future studies to address these potential areas of intervention, including education about the need for contraception through menopause, and mechanisms to engage in SDM surrounding contraception are needed to improve quality of care for women with lupus.

Toward Ensuring Health Equity: Readability and Cultural Equivalence of OMERACT Patient-reported Outcome Measures

OBJECTIVE

The goal of the Outcome Measures in Rheumatology (OMERACT) 12 (2014) equity working group was to determine whether and how comprehensibility of patient-reported outcome measures (PROM) should be assessed, to ensure suitability for people with low literacy and differing cultures.

METHODS

The English, Dutch, French, and Turkish Health Assessment Questionnaires and English and French Osteoarthritis Knee and Hip Quality of Life questionnaires were evaluated by applying 3 readability formulas: Flesch Reading Ease, Flesch-Kincaid grade level, and Simple Measure of Gobbledygook; and a new tool, the Evaluative Linguistic Framework for Questionnaires, developed to assess text quality of questionnaires. We also considered a study assessing cross-cultural adaptation with/without back-translation and/or expert committee. The results of this preconference work were presented to the equity working group participants to gain their perspectives on the importance of comprehensibility and cross-cultural adaptation for PROM.

RESULTS

Thirty-one OMERACT delegates attended the equity session. Twenty-six participants agreed that PROM should be assessed for comprehensibility and for use of suitable methods (4 abstained, 1 no). Twenty-two participants agreed that cultural equivalency of PROM should be assessed and suitable methods used (7 abstained, 2 no). Special interest group participants identified challenges with cross-cultural adaptation including resources required, and suggested patient involvement for improving translation and adaptation.

CONCLUSION

Future work will include consensus exercises on what methods are required to ensure PROM are appropriate for people with low literacy and different cultures.

A population-based study of infection-related hospital mortality in patients with dermatomyositis/polymyositis

OBJECTIVE

Dermatomyositis (DM) and polymyositis (PM) are debilitating inflammatory myopathies associated with significant mortality. We evaluated the relative contribution of infection to hospital mortality in a large population-based study of individuals with PM/DM.

METHODS

Data derive from the 2007 to 2011 Healthcare Cost and Utilization Project National Inpatient Samples and include all hospital discharges that met a validated administrative definition of PM/DM. The primary outcome was hospital mortality. Variables for infections and comorbidities were generated from discharge diagnoses using validated administrative definitions. Logistic regression was used to investigate the relationship between infection and mortality in individuals with PM/DM, adjusting for sociodemographics, utilization variables, and comorbidities. Relative risks (RRs) were calculated to compare the overall prevalence of specific infections and associated mortality in PM/DM hospitalizations with those seen in the general hospitalized population.

RESULTS

A total of 15,407 hospitalizations with PM/DM met inclusion criteria for this study and inpatient mortality was 4.5% (700 deaths). In adjusted logistic regression analyses, infection (odds ratio [OR] 3.4, 95% confidence interval [95% CI] 2.9-4.0) was the strongest predictor of hospital mortality among individuals with PM/DM. Bacterial infection (OR 3.5, 95% CI 3.0-4.1), comprised primarily of pneumonia and bacteremia, and opportunistic fungal infections (OR 2.5, 95% CI 1.5-4.0) were independently associated with hospital mortality. The overall burden of infection in hospitalizations with PM/DM was significantly increased in comparison with the general hospitalized population (RR 1.5, 95% CI 1.4-1.6).

CONCLUSION

Among hospitalized individuals with PM/DM, infection is the leading cause of mortality. Strategies to mitigate infection risk in both the clinic and hospital settings should be evaluated to improve disease outcomes.

Development of a Draft Core Set of Domains for Measuring Shared Decision Making in Osteoarthritis: An OMERACT Working Group on Shared Decision Making

OBJECTIVE

Despite the importance of shared decision making for delivering patient-centered care in rheumatology, there is no consensus on how to measure its process and outcomes. The aim of this Outcome Measures in Rheumatology (OMERACT) working group is to determine the core set of domains for measuring shared decision making in intervention studies in adults with osteoarthritis (OA), from the perspectives of patients, health professionals, and researchers.

METHODS

We followed the OMERACT Filter 2.0 method to develop a draft core domain set by (1) forming an OMERACT working group; (2) conducting a review of domains of shared decision making; and (3) obtaining opinions of all those involved using a modified nominal group process held at a session activity at the OMERACT 12 meeting.

RESULTS

In all, 26 people from Europe, North America, and Australia, including 5 patient research partners, participated in the session activity. Participants identified the following domains for measuring shared decision making to be included as part of the draft core set: (1) identifying the decision, (2) exchanging information, (3) clarifying views, (4) deliberating, (5) making the decision, (6) putting the decision into practice, and (7) assessing the effect of the decision. Contextual factors were also suggested.

CONCLUSION

We proposed a draft core set of shared decision-making domains for OA intervention research studies. Next steps include a workshop at OMERACT 13 to reach consensus on these proposed domains in the wider OMERACT group, as well as to detail subdomains and assess instruments to develop a core outcome measurement set.

Muscle strength, muscle mass, and physical disability in women with systemic lupus erythematosus

OBJECTIVE

Data describing relationships between muscle strength, muscle mass, and physical disability among individuals with systemic lupus erythematosus (SLE) are limited. The present study examines the relationship of muscle strength and muscle mass with physical disability among adult women with SLE.

METHODS

A total of 146 women from a longitudinal SLE cohort participated in the study. All measures were collected during an in-person research visit. Lower extremity muscle strength was assessed by peak knee torque of extension and flexion and by chair-stand time. Total lean body mass, appendicular lean mass, and fat mass (kg/m(2) ) were measured by whole-body dual x-ray absorptiometry. Self-reported physical disability was assessed using the Short Form 36 health survey (SF-36) physical functioning subscale, and the Valued Life Activities (VLA) disability scale. Spearman's rank correlation coefficients tested the correlations between muscle strength, muscle mass, and disability scores. Regression analyses modeled the effect of lower extremity muscle strength and mass on SF-36 and VLA disability scores controlling for age, SLE duration, SLE disease activity measured with the Systemic Lupus Activity Questionnaire, physical activity level, prednisone use, body composition, and depression.

RESULTS

On all measures, reduced lower extremity muscle strength was associated with poorer SF-36 and VLA disability scores. Trends persisted after adjustment for covariates. Muscle mass was moderately correlated with muscle strength, but did not contribute significantly to adjusted regression models.

CONCLUSION

Lower extremity muscle strength, but not muscle mass, was strongly associated with physical disability scores. While further studies are needed, these findings suggest that improving muscle strength may reduce physical disability among women with SLE.

Evaluation of a commercially available organic acid product on body weight loss, carcass yield, and meat quality during preslaughter feed withdrawal in broiler chickens: a poultry welfare and economic perspective

The effect of a commercial organic acid (OA) product on BW loss (BWL) during feed withdrawal and transportation, carcass yield, and meat quality was evaluated in broiler chickens. Two experiments were conducted in Brazil. Commercial houses were paired as control groups receiving regular water and treated groups receiving OA in the water. Treated birds had a reduction in BWL of 37 g in experiment 1 and 32.2 g in experiment 2. In experiment 2, no differences were observed in carcass yield between groups. Estimation of the cost benefit suggested a 1:16 ratio by using the OA. In experiment 3, conducted in Mexico, significant differences on water consumption, BWL, and meat quality characteristics were observed in chickens that were treated with the OA (P < 0.05). These data suggest this OA product may improve animal welfare and economic concerns in the poultry industry by reducing BWL and improving meat quality attributes.

Abstract P4-16-04: Amrubicin as second- or third-line treatment for patients with HER2-negative metastatic breast cancer (MBC): Final results from a phase II trial of the Sarah Cannon Research Institute (SCRI)

Background: Anthracyclines are among the most effective agents in the treatment of breast cancer; however, dose-dependent cumulative cardiotoxicity limits their use. Amrubicin is a synthetic anthracycline topoisomerase II inhibitor demonstrating potent antitumor effects coupled with little potential for cardiotoxicity. We report the final results from a phase I/II trial of amrubicin as second- or third-line therapy for HER2-negative MBC.

Methods: Eligible patients (pts) included women with measurable HER2-negative MBC who had received 1 or 2 prior chemotherapy regimens for MBC. Previous anthracyclines were permitted if ≥ 6 months prior to study entry. Normal LVEF was required. Amrubicin 110 mg/m2 IV (dose established from phase I portion) was administered every 3 weeks until disease progression or intolerable toxicity; growth factor use was permitted. Disease evaluations were performed every 6 weeks and LVEF assessments every 12 weeks. Progression-free survival (PFS) was the primary endpoint; a median PFS ≥ 4.5 months would merit further evaluation of amrubicin in MBC. Toxicity, overall survival, and overall response rate (ORR) were secondary endpoints.

Results: Between 1/2010 and 3/2012, 78 pts were enrolled, and 66 pts are included in this analysis (ph I: 3 pts; ph II 63 pts). Baseline characteristics included: median age 59 years; hepatic metastases in 50%; ≥ 3 sites of metastatic disease in 32%. Triple-negative histology was noted in 27%; prior adjuvant chemotherapy in 50%; prior anthracyclines in 32%; and 2 prior cytotoxic regimens for MBC in 35%. Median treatment duration was 18 weeks (6 cycles), range 1- 24 cycles. The ORR was 21% in evaluable pts (2 CR, 10 PR); 5 of these 12 pts had prior anthracyclines. 14% were not evaluable. The clinical benefit rate (CBR) was 42% (CBR = CR+PR+SD≥ 4 months); 35% of these responders received ≥12 cycles of amrubicin. Median PFS for all pts was 4.0 months (95% CI 2.5- 5.8 months) and did not significantly differ by line of therapy administered (4.0 months as 2nd line vs 4.7 as 3rd line therapy). 36% of pts were free of progression at 6 months. Neutropenia was the most common grade 3/4 toxicity present in 42% and accompanied by fever in 7%. No grade 3/4 non-hematologic toxicity occurred in &gt; 5% pts. One pt previously treated with anthracyclines experienced a transient 20% LVEF decline to 44% at cycle 4. This recovered to baseline within 2 weeks and pt continued to receive 2 additional cycles of amrubicin before experiencing PD. No other grade 3/4 cardiac events were noted. In 3 pts, amrubicin was discontinued due to toxicity (G4 neutropenia, G2 thrombocytopenia, G2 nausea/vomiting/vertigo).

Conclusions: Amrubicin was active and well tolerated in the second- or third-line MBC setting with manageable toxicity. The ORR of 21% and median PFS of 4 months are comparable to other single agents in this setting. The observed CBR of 42%, and the fact that nearly 1/3 of these responders received ≥12 cycles of amrubicin with no cardiotoxicity, suggests that future evaluations of amrubicin in breast cancer are warranted.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-16-04.

Close cooperation between science, management and industry benefits sustainable exploitation of the Falkland Islands squid fisheries

The Falkland Islands fishing industry is unique, as 60-80% of its annual catch consists of two squid species, Illex argentinus and Doryteuthis gahi. Short annual life cycles make both species susceptible to intra-annual environmental changes, resulting in large biomass fluctuations that must be addressed in management of the stocks. In the D. gahi fishery, short chains of communication between science, management and industry allow effective cooperation in the interest of long-term sustainable exploitation. The industry is responsive to short-notice requests for in-season information about the fishery. Management takes into account both scientific advice and industry recommendations, through ongoing consultations before and during the fishing seasons. As a result of this cooperation, D. gahi is one of the best managed squid fisheries in the world with local fishing companies being amongst the largest and most profitable enterprises in the Falklands economy. The I. argentinus fishery has the same potential, but a further level of cooperative management is needed as this squid is a straddling stock between several countries and the high seas. Development of a regional fisheries management organization in the South Atlantic Ocean is required to control multilateral exploitation and ensure long-term sustainability of I. argentinus stocks.

Sex differences in assessment of obesity in rheumatoid arthritis

OBJECTIVE

To determine the prevalence of obesity and how accurately standard anthropometric measures identify obesity among men and women with rheumatoid arthritis (RA).

METHODS

Dual x-ray absorptiometry (DXA) was performed for 141 persons with RA (56 men and 85 women). Two anthropometric proxies of obesity (body mass index [BMI] and waist circumference [WC]) were compared to a DXA-based obesity criterion. Receiver operating characteristic curves determined optimal cut points for each anthropometric measure, relative to DXA. The association of body fat and anthropometric obesity measures with disease status and cardiovascular risk was assessed in multiple regression analyses, controlling for age and glucocorticoid use. All analyses were performed separately for men and women.

RESULTS

A total of 20%, 32%, and 44% of women and 41%, 36%, and 80% of men were classified as obese by BMI, WC, and DXA, respectively. Cut points were identified for anthropometric measures to better approximate DXA estimates of percent body fat (BMI ≥26.1 kg/m(2) for women and ≥24.7 kg/m(2) for men; WC ≥83 cm for women and ≥96 cm for men). For women and men, higher percent fat was associated with poorer RA status. Anthropometric measures were more closely linked to RA status for women, but identified cardiovascular risk for both women and men.

CONCLUSION

A large percentage of this RA sample was overfat; DXA-defined obesity was twice as common in men as in women. Utility of revised BMI and WC cut points compared to traditional cut points remains to be examined in prospective studies, but results suggest that lower, sex-specific cut points may be warranted to better identify individuals at risk for poor RA and/or cardiovascular outcomes.

Choosing wisely: the American College of Rheumatology's Top 5 list of things physicians and patients should question

OBJECTIVE

We sought to develop a list of 5 tests, treatments, or services commonly used in rheumatology practice whose necessity or value should be questioned and discussed by physicians and patients.

METHODS

We used a multistage process combining consensus methodology and literature reviews to arrive at the American College of Rheumatology's (ACR) Top 5 list. Rheumatologists from diverse practice settings generated items using the Delphi method. Items with high content agreement and perceived high prevalence advanced to a survey of ACR members, who comprise >90% of the US rheumatology workforce. To increase the response rate, a nested random sample of 390 rheumatologists received more intensive survey followup. The samples were combined and weighting procedures were applied to ensure generalizability. Items with high ratings underwent literature review. Final items were then selected and formulated by the task force.

RESULTS

One hundred five unique items were proposed and narrowed down to 22 items during the Delphi rounds. A total of 1,052 rheumatologists (17% of those contacted) participated in the member-wide survey, whereas 33% of those in the nested random sample participated; respondent characteristics were similar in both samples. Based on survey results and available scientific evidence, 5 items (relating to antinuclear antibodies, Lyme disease, magnetic resonance imaging, bone absorptiometry, and biologic therapy for rheumatoid arthritis) were selected for inclusion.

CONCLUSION

The ACR Top 5 list is intended to promote discussions between physicians and patients about health care practices in rheumatology whose use should be questioned and to assist rheumatologists in providing high-value care.