Age, Gender, and Liver Enzyme Impact Hospital Stay in COVID-19 Minority Patient with Cancer in the USA: Does Race Matters in the Pandemic?

Patients with cancer are known to have a poor prognosis when infected with SARS-CoV-2 infection. We aimed in this study to assess health outcomes in COVID-19 patients with different cancers in comparison to non-cancer COVID-19 patients from different centers in the United States (US). We evaluated medical records of 1,943 COVID-19 Cancer patients from 3 hospitals admitted between December 2019 to October 2021 and compared them with non-cancer COVID-19 patients. Among 1,943 hospitalized COVID-19 patients, 18.7% (n=364) have an active or previous history of cancer. Among these 364 cancer patients, 222 were African Americans (61.7%) and 121 were Caucasians (33.2%). Cancer patients had significantly longer hospitalization compared to controls (8.24 vs 6.7 days). Overall, Lung cancer is associated with high mortality. Patients with a previous history of cancer were more prone to death (p=0.04) than active cancer patients. In univariate and multivariate analyses, predictors of death among cancer patients were male sex, older age, presence of dyspnea, elevated troponin, elevated AST (0.001) and ALT (0.05), low albumin (p=0.04) and mechanical ventilation (p=0.001). Patients with a previous history of cancer were more prone to death when compared to active cancer COVID-19 patients. Early recognition of cancer COVID-19 patients' death-associated risk factors can help determine appropriate treatment and management plans for better prognosis and outcome.

A - 133 Self-Reported Loss of Consciousness Predicts Executive Functions in Veterans with a History of Traumatic Brain Injury

OBJECTIVE

The long-term cognitive effects of traumatic brain injury (TBI) in military personnel remain unclear and need to be better understood. We assessed how cognitive performance was related to the remote history of TBI involving loss of consciousness (LOC) and blast injury (regardless of LOC) in veterans.

METHOD

Veterans (N = 101; age 42.8 ± 10.5 years; 10 Females) with a self-reported history of TBI and persistent cognitive symptoms were recruited. Effects of (1) the presence of LOC, (2) total number of TBIs with LOC (0, 1-2, >2), and (3) the presence of blast injury were examined on composite scores from tests of executive function (Trail-Making Test B, Color Word Interference), word retrieval (Boston Naming, Letter and Category Fluency), processing speed (Trail Making-A, Color Word Naming/Reading), and episodic memory (Rey-Auditory Verbal Learning Test-total learning and delayed recall), while controlling for age, sex, years of education, and total number of TBIs.

RESULTS

TBI with LOC was a significant predictor of executive function (p = 0.014) and processing speed (p = 0.014), with more episodes of LOC predicting lower functioning, but not of word retrieval or episodic memory (p > 0.1). Additionally, presence of a blast injury, regardless of LOC, did not predict differences in function on any of the composite measures.

CONCLUSIONS

Self-reported TBI history with LOC was associated with poorer executive function and processing speed. The findings further characterize the relationship between TBI history and long-term cognitive sequelae in veterans, particularly suggesting LOC can affect neural systems underlying executive function and processing speed.

The association of federal Medicaid abortion funding restrictions with adverse obstetric outcomes among United States Medicaid recipients

OBJECTIVE

We examine the association of the Hyde Amendment with obstetrical outcomes in a national Medicaid population.

STUDY DESIGN

We conducted a national study of Medicaid-funded abortions to determine the association of restrictions on adolescent, preterm, low-birth weight, and short interpregnancy interval births using administrative data.

RESULTS

States that restricted coverage for abortion had a higher median rate of adolescent (10.2%; vs 7.4%; p-value < 0.001), preterm (11.4%; vs 10.1%; p < 0.001), short interpregnancy interval, (13.0% vs 9.6%; p < 0.001), and low birth weight births (10.2% vs 8.7%; p = 0.003) than states where Medicaid provided comprehensive coverage.

CONCLUSIONS

Restricting federal funds for abortion is associated with adverse outcomes.

IMPLICATIONS

When Medicaid does not provide comprehensive coverage for abortion care, few abortions are provided and higher rates of adverse obstetrical outcomes are noted.

P3a amplitude to trauma-related stimuli reduced after successful trauma-focused PTSD treatment

An elevated P3a amplitude to trauma-related stimuli is strongly associated with posttraumatic stress disorder (PTSD), yet little is known about whether this response to trauma-related stimuli is affected by treatment that decreases PTSD symptoms. As an analysis of secondary outcome measures from a randomized controlled trial, we investigated the latency and amplitude changes of the P3a in responses in a three-condition oddball visual task that included trauma-related (combat scenes) and trauma-unrelated (threatening animals) distractors. Fifty-five U.S. veterans diagnosed with combat-related PTSD were randomized to receive either active or sham repetitive transcranial magnetic stimulation (rTMS). All received cognitive processing therapy, CPT+A, which requires a written account of the index trauma. They were tested before and 6 months after protocol completion. P3a amplitude and response time decreases were driven largely by the changes in the responses to the trauma-related stimuli, and this decrease correlated to the decrease in PTSD symptoms. The amplitude changes were greater in those who received rTMS + CPT than in those who received sham rTMS + CPT, suggesting that rTMS plays beneficial role in reducing arousal and threat bias, which may allow for more effective engagement in trauma-focused PTSD treatment.

Geographic Variation In Effective Contraceptive Use Among Medicaid Recipients In 2018

Medicaid is the largest payer for publicly funded contraception, serving millions of women across the United States. However, relatively little is known about the extent to which effective contraceptive services vary geographically for Medicaid recipients. This study used national Medicaid claims to assess county-level variation in rates of provision of the most or moderately effective methods of contraception and provision of long-acting reversible contraception (LARC) across forty states and Washington, D.C., in 2018. County-level rates of most or moderately effective contraceptive use varied almost fourfold across states, from a low of 10.8 percent to a high of 44.4 percent. Rates of LARC provision varied almost tenfold, from a low of 1.0 percent to a high of 9.6 percent. Despite the fact that contraception is a core benefit within Medicaid, access and use vary substantially across and within states. Medicaid agencies have a variety of options to ensure that people have access to a choice of the full range of contraceptive methods, including removing or loosening utilization controls, incorporating quality metrics or value-based payments into contraceptive services, and adjusting reimbursement to remove barriers to the clinical provision of LARC.

Medicaid Reimbursement For Psychiatric Services: Comparisons Across States And With Medicare

Medicaid is characterized by low rates of provider participation, often attributed to reimbursement rates below those of commercial insurance or Medicare. Understanding the extent to which Medicaid reimbursement for mental health services varies across states may help illuminate one lever for increasing Medicaid participation among psychiatrists. We used publicly available Medicaid fee-for-service schedules from state Medicaid agency websites in 2022 to construct two indices for a common set of mental health services provided by psychiatrists: a Medicaid-to-Medicare index to benchmark each state's Medicaid reimbursement with that of Medicare for the same set of services, and a state-to-national Medicaid index comparing each state's Medicaid reimbursement with an enrollment-weighted national average. On average, Medicaid paid psychiatrists at 81.0 percent of Medicare rates, and a majority of states had a Medicaid-to-Medicare index that was less than 1.0 (median, 0.76). State-to-national Medicaid indices for psychiatrists' mental health services ranged from 0.46 (Pennsylvania) to 2.34 (Nebraska) but did not correlate with the supply of Medicaid-participating psychiatrists. As policy makers look to reimbursement rates as one strategy to address ongoing mental health workforce shortages, comparing Medicaid payment across states may help benchmark ongoing state and federal proposals.

Geographical Variations In Emergency Department Visits For Mental Health Conditions For Medicaid Beneficiaries

Despite Medicaid's importance as a payer and source of coverage for mental health care, relatively little is known about how prevalence, access, and quality might vary among Medicaid beneficiaries. This study used national Medicaid data from 2018 to assess regional variations in emergency department (ED) visits for mental health conditions, a measure that may reflect unmet needs for behavioral health care. We found substantial variations, with rates in the region with the highest visit rates eight times higher than those in the region with the lowest rates. Many regions with high rates of ED visits for mental health conditions also had high rates of outpatient mental health use. Regional patterns differed substantially, with some regions exhibiting high rates of ED visits related to anxiety but low rates for schizophrenia and vice versa. The presence of large variations in ED visits for mental health conditions, with substantial differences in the composition across regions, suggests a need for context-specific solutions, including assessments of the ways in which mental health benefits are structured at the state Medicaid agency level and of differences in provider accessibility and an understanding of the types of mental illness underlying high rates of use.

Catholic sole community hospitals are associated with decreased receipt of postpartum permanent contraception among Medicaid recipients

OBJECTIVES

To examine the association of Catholic hospitals with receipt of postpartum tubal ligation and long acting, reversible contraception among Medicaid recipients.

STUDY DESIGN

We conducted a retrospective cohort study of live births from January 1, 2016 to October 31, 2016 to female Medicaid beneficiaries in the United States between ages 21 and 44. Our main exposure was the presence of a Catholic-affiliated sole community hospital, and our primary outcome was highly effective postpartum contraception. We examined rates of postpartum permanent contraception, along with the use of a long acting, reversible form of contraception (LARC) at 3 and 60 days are postpartum. We compared counties that had only a Catholic-affiliated hospital with counties with only a non-Catholic hospital.

RESULTS

Our study population included 14,545 postpartum Medicaid beneficiaries. Study participants came from 88 counties across 10 United States states. Only 7.7% of women in counties with Catholic sole community hospitals received permanent contraception by 3 days postpartum, compared to 11.3% in counties with non-Catholic sole community hospitals (RD: -3.92%; 95% CI: -6.01%, -1.83%). This difference was not mitigated by receipt of outpatient procedures or long-acting, reversible contraception. Importantly, women residing in counties with Catholic sole community hospitals were much less likely to return postpartum for an outpatient visit between 8 and 60 days postpartum than women in counties with non-Catholic sole community hospitals (35.4% vs 45.4%, RD: -9.29%; 95% CI: -16.71%, -1.86%).

CONCLUSIONS

In counties where the only hospital was Catholic, Medicaid recipients giving birth were significantly less likely to receive permanent contraception and to return for postpartum care.

IMPLICATIONS

Catholic hospitals are increasing in the United States, which may restrict access to postpartum contraception, particularly in rural areas. We found that Medicaid recipients giving birth at a Catholic sole community hospital were less likely to receive permanent contraception and to return for care.

WHO informal consultation on revision of guidelines on evaluation of similar biotherapeutic products, virtual meeting, 30 June – 2 July 2021

The WHO informal consultation was held to promote the revision of WHO guidelines on evaluation of similar biotherapeutic products (SBPs) adopted by the Expert Committee on Biological Standardization (ECBS) in 2009. It was agreed in the past consultations that the evaluation principles in the guidelines are still valid, but a review was recommended to provide more clarity and case-by-case flexibility. The opportunity was therefore taken to review the experience and identify areas where the current guidance could be more permissive without compromising its basic principles, and where additional explanation could be provided regarding the possibility of reducing the amount of data needed for regulatory approval. The meeting participants applauded the leading role taken by the WHO in providing a much-needed streamlined approach for development and evaluation of SBPs which will provide efficient and cost-effective product development and increase patient access to treatments. It was recognized that the principles as currently described in the draft WHO guidelines are based on sound science and experience gained over the last fifteen years of biosimilar approvals. However, since these guidelines when finalised will constitute the global standard for biosimilar evaluation and assist national regulatory authorities in establishing revised guidance and regulatory practice in this complex area, it was felt that further revision and clarity on certain perspectives in specific areas was necessary to dispel uncertainties arising in the current revised version. This report describes the principles in the draft guidelines, including topics discussed and consensus reached.

•

WHO guidelines serve as a basis for the development of national regulatory framework for biosimilars.

•

Revision of guidelines is to provide more flexibility and clarification on data required for regulatory approval.

•

Revised guidelines would contribute to improving consistency on regulatory decision and patient access to treatments.

Postpartum Contraceptive Use Among US Medicaid Recipients

This cohort study uses national Medicaid claims data to assess US state variation in effective contraceptive use 60 days post partum.

O-213 Slow day 5 development affects implantation potential of fresh transferred embryos but not birthweight once pregnancy occurs: A multi-center retrospective cohort study

Study question

Does slow development of fresh transferred day 5 embryos lead to decreased implantation potential and birthweight?

Summary answer

Slow day 5 development was associated with reduced implantation potential when transferred fresh but the subsequent birthweight of the resulting baby was not impacted.

What is known already

Slow development of in vitro cultured cleavage stage embryos is associated with reduced blastocyst development and implantation rates. There is no current consensus regarding whether to transfer fresh slow developing day 5 embryos or to extend culture for a subsequent day with potential for cryopreservation. It is therefore important to understand the true prognosis of fresh transferred day 5 embryos at less advanced developmental stages. This would provide evidence based guidelines for the decision making process in regard to embryo transfer.

Study design, size, duration

This is a retrospective multi-center cohort study, including 1213 consecutive patients undergoing autologous oocyte in vitro fertilization (IVF) treatment during 2016-2019,with fresh transfer of a single day 5 embryo (selection based on developmental stage and inner cell mass and trophectoderm morphology if blastocyst was at the ≥expanding stage). Cycle data were collected from 4 associated private clinics, with repeat cycles of same patients excluded to avoid clustering effect at statistical analysis.

Participants/materials, setting, methods

Live birth and birthweight were followed up in all 1213 fresh day 5 SETs. Multiple regression (logistic or linear) was performed to investigate association between slow day 5 development (defined as ≤ early blastocyst) and (a)live birth, (b) birthweight, and (c) gestation-adjusted birthweight (Z score) to account for gestational age, gender and compared to embryos at ≥ expanded stage. Results were expressed as adjusted odds ratio (aOR) with 95% confidence interval (CI)or coefficients (β).

Main results and the role of chance

No implantation was achieved following single fresh transfer of day 5 embryos that failed to reach early blastocyst stage (n = 76) and were transferred as ≤ morula stage. Live birth rate was significantly lower following single day 5 fresh transfer of an early blastocyst (n = 237, 16%), in comparison to expanding (n = 329, 27%, P = 0.001), expanded(n = 392, 41%, P = 0.000), and hatching/hatched blastocysts (n = 169, 44%, P = 0.000). After adjusting for potential confounding factors including; maternal age, hours post insemination at day 5 assessment, number of oocytes collected, number of 2PN embryos, and number of embryos frozen; multiple logistic regression showed significantly reduced likelihood of live birth resulting from early blastocysts in reference to those at the expanding (aOR=0.584, 0.371-0.917, P = 0.020), expanded (aOR=0.322, 0.208-0.501, P = 0.000), or hatching/hatched stages (aOR=0.255, 0.147-0.443, P = 0.000). However, multivariate linear regression indicated that early blastocysts resulting in a live birth (n = 39) did not lead to altered birthweight (β=-9.091, P = 0.904; β=-34.960, P = 0.343; β=-26.074, P = 0.414; respectively) or Z score (β = 0.045, P = 0.706; β=-0.051, P = 0.426; β=-0.028, P = 0.506; respectively) in reference to the expanding (n = 90), expanded (n = 160), or hatching/hatched stages (n = 75).

Limitations, reasons for caution

The retrospective nature of this study does not allow controlling of unknown confounders. The 4 participating clinics are associated within the same network with shared protocols, therefore, results may not be generalized to other clinics with different settings.

Wider implications of the findings

The findings suggest no clinical value of fresh day 5 transfer of embryos ≤morula stage. Although early blastocysts implant at reduced rate, assuring birthweight outcomes suggest clinical value. Future studies intend to investigate slow growing day 5 fresh transfers versus embryos that were slow growing but transferred after day 6.

Trial registration number

NA

P–191 Time-lapse videography reveals morphometric and morphokinetic differences in the pronuclei of male and female human zygotes

Study question

Do morphometric and morphokinetic profiles of pronuclei (PN) following intracytoplasmic sperm injection (ICSI) vary between male and female human zygotes?

Summary answer

Male and female zygotes displayed different PN morphometrics and morphokinetics. Additionally, variations were identified between sperm-originated (SPN) and oocyte-originated (OPN) pronuclei.

What is known already

Previous studies have investigated the use of PN-associated parameters via static observations as indicators of zygote viability, including size equality or juxtaposition. However, recent clinical application of time-lapse videography (TLV) provides a novel opportunity to assess these pronuclear events with greater accuracy and precision of morphometric and morphokinetic measurement. A number of recent TLV studies have also investigated potential live birth prediction by such PN associated measures, however whether or not there are gender associated differences in such measures which could in turn confound live birth prediction is unknown. Study design, size, duration: This retrospective cohort study included 94 consecutive autologous single day 5 transfer cycles (either fresh or frozen) performed between January 2019 and March 2020. Only ICSI cycles (maternal age &lt;40 years) leading to a singleton live birth (43 males and 51 females) were included for analysis. All oocytes were placed in the EmbryoScope incubator for culture immediately post sperm injection with all annotation performed retrospectively by one embryologist (L-SO).

Participants/materials, setting, methods

Timings included 2nd polar body extrusion (tPb2), SPN(tSPNa)/OPN(tOPNa) appearance (differentiated by proximity to Pb2) and PN fading (tPNF). Morphometrics were evaluated at 8 (stage 1), 4 (stage 2) and 0 hour before PNF (stage 3), measuring PN area (um2), PN juxtaposition, and nucleolus precursor body (NPB) arrangement. Means ± standard deviation were compared using student t test or logistic regression as odds ratio (OR) and 95% confidence interval (CI), and proportional data by chi-squared analysis.

Main results and the role of chance

Logistic regression indicated that male zygotes had longer time intervals of tPb2_tSPNa than female zygotes (4.8±1.5 vs 4.2±1.0 h, OR = 1.442, 95% CI 1.009–2.061, p = 0.044), but not tPb2_tOPNa (4.7±1.8 vs 4.5±1.3 h, OR = 1.224, 95% CI 0.868–1.728, p = 0.250) and tPb2_tPNF (19.9±2.8 vs 19.1±2.3 h, OR = 1.136, 95% CI 0.957–1.347, p = 0.144). SPN increased in size from stage 1 through 2 to 3 (435.3±70.2, 506.7±77.3, and 556.3±86.4 um2, p = 0.000) and OPN did similarly (399.0±59.4, 464.3±65.2, and 513.8±63.5 um2, p = 0.000), with SPN being significantly larger than OPN at each stage (p &lt; 0.05 respectively). However, relative size difference between SPN and OPN was similar between male and female zygotes at 3 stages (33.6±61.7 vs 38.6±50.8 um2, p = 0.664; 38.5±53.1 vs 45.7±71.9 um2, p = 0.585; 38.4±77.4 vs 45.8±63.9 um2, p = 0.615; respectively). More male than female zygotes reached central PN juxtaposition at stage 1 (77% vs 51%, p = 0.010), stage 2 (98% vs 86%, p = 0.048) and stage 3 (98% vs 86%, p = 0.048). Furthermore, more OPN showed aligned NPBs than in SPN at stage 1 (45% vs 29%, p = 0.023), but similar proportions at stage 2 (64% vs 50%, p = 0.056) and stage 3 (76% vs 72%, p = 0.618). There were no gender associated differences detected in NPB alignment in either SPN or OPN (p &gt; 0.05 respectively).

Limitations, reasons for caution

The retrospective design does not allow for control of unknown confounders. Sample size is considered relatively small. PN area measurement may not truly represent volume as PN may not be perfectly spherical. Findings were based on women &lt;40 years old so may not apply to older population.

Wider implications of the findings: These findings augment and extend previous studies investigating PN parameters via static observations. The reported variations between male and female embryos may confound live birth prediction when using pronuclei morphometrics and morphokinetics. Larger scaled studies are warranted to verify these findings.

Trial registration number

Not applicable

576 ESTABLISHING VIRTUAL MULTIDISCIPLINARY ROUND IN BELFAST TRUST NURSING HOMES: PHARMACIST, NURSING & HEALTHCARE TEAM COLLABORATION

Introduction

During the first covid surge, 25% of Belfast HSC Trust (BHSCT) care homes were affected, rising to 44% by surge 3, resulting in limited face to face access for healthcare professionals. Nursing home residents required medicine reviews post-covid infection to optimise medicines and reduce pill burden.

Method

The Care Home Nursing Support Team (CHNST), consultant pharmacist for older people and the lead care home pharmacist medicines optimisation older people (MOOP), rapidly established a multidisciplinary virtual round. Four main steps included:

An SOP was established to ensure consistent pathway for nursing home inclusion criteria and team roles. The inclusion group included residents who were furthest from their baseline including weight loss, swallowing difficulties, decreased mobility, altered sitting balance and polypharmacy.

The pharmacist developed a proforma template for completion by the nursing home staff to gather key information ahead of the round to improve efficiency eg swallow, renal function, pain, falls risk.

The care home resident was included on video link by ipad following careful consent processes. Benefits included enhanced assessment of frailty, mobility, dexterity and adherence.

Results

Conclusion

The multidisciplinary care home rounds provided an efficient means to collaborate with other professionals, while providing holistic & patient-focussed care. Plans are underway for development of an NI MOOP care home pathway.

OP0241 SERIOUS INFECTION WITH TOCILIZUMAB COMPARED TO TNF-INHIBITORS AND OTHER BDMARDS IN RHEUMATOID ARTHRITIS PATIENTS: DOES LINE OF THERAPY MATTER?

Background:

In the real-world, tocilizumab is prescribed to a population of patients different from those prescribed TNF-inhibitors, often older with longer disease duration, worse functional status and more previous b- or tsDMARDs.

Objectives:

The aim of this study was to evaluate if and how the risk of serious infection on tocilizumab and other bDMARDs differs when stratifying by line of therapy in a real-world population of rheumatoid arthritis patients.

Methods:

We included patients registered in the BSRBR-RA treated with tocilizumab, etanercept, adalimumab, infliximab, certolizumab, abatacept or rituximab, including biosimilars. Primary outcome was the occurrence of a serious infection (defined as infection requiring hospitalisation, intravenous antibiotics or resulting in death). Primary covariate of interest was line of therapy (from first to fifth line of therapy). Every change to another b- or tsDMARD was considered a new line of therapy, but not a change between a bio-original and a biosimilar.

Hazard ratios (HR) of serious infections were estimated using an inverse probability weighted Cox regression, based on a propensity score including baseline patient and disease characteristics, and adjusting for time in study (see Table). The reference group was etanercept, which included the highest number of patients. Treatment exposure was analysed without and with stratification by line of therapy.

Table.NETNTCZADAIFXCERTRTXABAN33,91610,6552,6327,8394,4301,6165,5561,188Patient-years19,1294,34214,5048,1352,72612,0091,686Infections8071926814817443374Incidence per 100 patient-years (95%CI)4.2 (3.9-4.5)4.4 (3.8-5.1)4.7 (4.4-5.1)5.9 (5.4-6.6)2.7 (2.2-3.4)3.6 (3.3-4.0)4.0 (3.2-5.1)Unadjusted HR (95%CI)Ref.1.0 (0.9-1.2)1.1 (1.0-1.2)1.4 (1.2-1.6)0.6 (0.5-0.8)0.9 (0.8-1.0)0.9 (0.7-1.2)Adjusted HR* (95% CI)All lines of therapy33,916Ref.1.2 (1.0-1.5)1.1 (1.0-1.3)1.3 (1.1-1.6)0.8 (0.6-1.0)1.0 (0.8-1.1)1.2 (0.8-1.7)1stline16,152Ref.0.9 (0.5-1.5)1.1 (1.0-1.3)1.3 (1.1-1.6)0.6 (0.5-0.9)1.6 (1.2-2.2)-2ndline10,378Ref.1.4 (1.0-2.0)1.1 (0.9-1.4)1.1 (0.7-1.6)0.9 (0.4-2.2)1.0 (0.8-1.2)0.9 (0.5-1.9)3rdline4,676Ref.1.4 (0.9-2.3)1.3 (0.8-2.2)0.9 (0.4-1.9)0.9 (0.3-2.9)0.8 (0.5-1.2)1.5 (0.7-2.9)4thline1,947Ref.1.0 (0.5-2.3)1.3 (0.4-3.7)1.4 (0.5-4.4)0.2 (0.0—2.1)1.0 (0.5.-2.2)0.9 (0.4-2.3)5thline763Ref.0.9 (0.2-3.5)2.5 (0.5-12.4)0.7 (0.1-7.1)3.3 (0.6-18.4)0.9 (0.2-3.5)0.8 (0.2-3.5)

ABA, abatacept; ADA, adalimumab; CERT, certolizumab; ETN, etanercept; HR, hazard ratio; IFX, infliximab; RTX, rituximab; TCZ, tocilizumab

*Adjusted using inverse probably weighting (with age, gender, concomitant steroids, concomitant DMARDs, comorbidities, seropositivity, smoking, disease duration, HAQ and DAS28 at baseline in the model) and time since study entry (categorised from 0 to 4, 0 starting just before or at the moment of entering study, 1 starting during the first year, 2 starting during the second year until 4 for the fourth year and more)

Results:

A total of 33,916 treatment courses were included (Table) contributing to 62,532 years of follow-up. Compared to etanercept, participants starting abatacept, tocilizumab and rituximab were older, had more previous bDMARDs, longer disease duration and more comorbidities. The crude HR of serious infections were higher with infliximab and adalimumab, lower with certolizumab and rituximab, and not significantly different for abatacept and tocilizumab compared to etanercept. After adjustment, HR of serious infections were higher with tocilizumab, adalimumab and infliximab. However, when stratified by line of therapy, HR were no longer significantly different compared to etanercept for tocilizumab, adalimumab and infliximab for most lines of therapy.

Conclusion:

Whilst initially there appears to be a difference in rates of serious infection between biologic therapies, line of therapy may be a confounding factor when comparing the risk of serious infections between bDMARDs.

Disclosure of Interests:

Kim Lauper Consultant of: Gilead-galapagos, Grant/research support from: AbbVie, Lianne Kearsley-Fleet: None declared, Rebecca Davies: None declared, Kath Watson: None declared, Mark Lunt: None declared, Kimme Hyrich Consultant of: AbbVie, Grant/research support from: Pfizer, BMS

SAT0103 THE EFFECT OF BODYWEIGHT ON RESPONSE TO INTRAVENOUS OR SUBCUTANEOUS TOCILIZUMAB IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

Tocilizumab is an IL-6 receptor humanised monoclonal antibody treatment option in rheumatoid arthritis (RA) who have not responded or are intolerant of disease modifying anti-rheumatic drugs (DMARDs) or other biologics. Tocilizumab was available initially as an intravenous (IV) preparation, dosed according to weight, and more recently as a subcutaneous (SC) preparation given at 162mg/weekly irrespective of bodyweight.

Obesity is highly prevalent in RA and there has been concern that starting or switching patients to SC tocilizumab could reduce its effectiveness in those patients with a higher body weight when compared to IV tocilizumab.

Objectives:

To investigate the relationship between bodyweight and DAS28 response at 6 months in tocilizumab naïve RA patients starting IV or SC tocilizumab.

Methods:

The study population comprised RA subjects recruited to the BSRBR-RA up to 30/11/2018 commencing IV or SC tocilizumab for the first time. Patients had to be tocilizumab naïve and have at least one six monthly study follow-up recorded after starting tocilizumab. Baseline characteristics at point of starting tocilizumab are described. Linear regression, fully adjusted for relevant confounders, was used to investigate the relationship between change in DAS28 score from baseline to six months and body weight per ten kilograms (kg), and in a separate analysis, as BMI category. Multiple imputation was used to handle missing data.

Results:

1241 patients starting tocilizumab (902 IV, 339 SC) were eligible for analysis. The median age was 59 years, majority were female, and had median disease duration of 11 years at baseline. Over seventy percent had prior biologic exposure. Median weight was 77kg for IV and 76kg for SC starters, and the majority of patients were categorised as normal weight (30% IV, 37% SC) or pre-obesity (31% IV & SC) according to BMI. Median DAS28 score was 5.8 (IV) and 5.5 (SC) at start of treatment with median improvement after 6-months of 1.50 and 2.02 units respectively. The fully adjusted linear regression model showed no association between body weight or BMI and change in DAS28 score at six months for patients starting IV or SC tocilizumab. (Table).

TableBaseline VariableIntravenous TCZ patients (n=902)Subcutaneous TCZ patients (n=339)Age, median (IQR)58 (50-67)60 (51-70)Gender, n (%) female708 (78)233 (74)Disease duration, median (IQR) years11 (4-21)11 (4-21)DAS28 score, median (IQR)5.8 (5.1-6.6)5.5 (4.7-6.5)Change in DAS28 score, median (IQR)-1.50 (-3.10 - -0.23)-2.02 (-3.72- -0.37)Weight in KGs, median (IQR)77 (64-91)76 (64-88)Change in DAS28, coefficient (95% CI)Body weight per 10kgs*0.04 (-0.01-0.09)-0.005 (-0.11-0.10)BMI category*Normal weightrefrefUnderweight-0.41 (-1.27-0.46)0.08 (-1.62-1.77)Pre-obesity-0.26 (-0.57-0.05)0.02 (-0.44-0.48)Obesity class I, II & III-0.03 (-0.35-0.29)0.08 (-0.40-0.55)

*Fully adjusted for age, gender, disease duration, baseline DAS28 score, baseline HAQ score, co-morbidities, and number of previous biologics

Conclusion:

Data from this study show that body weight does not appear to affect initial response to IV or SC tocilizumab. This is reassuring given that patients are likely to be given SC tocilizumab due to ease of administration and reduced hospital costs.

Disclosure of Interests:

Rebecca Davies: None declared, Arani Vivekanantham: None declared, Mark Lunt: None declared, Kath Watson: None declared, Kimme Hyrich Grant/research support from: Pfizer, UCB, BMS, Speakers bureau: Abbvie, James Bluett: None declared

4325Change in left atrial function predicts incident atrial fibrillation: the multi-ethnic study of atherosclerosis

Background

Longitudinal change in left atrial (LA) structure and function could be helpful in predicting risk for incident AF. We used cardiac magnetic resonance (CMR) imaging to explore the relationship between change in LA structure and function and incident AF in a multi-ethnic population free of clinical cardiovascular disease at baseline.

Methods and results

In the Multi-Ethnic Study of Atherosclerosis (MESA), 2338 participants, free at baseline of clinically recognized AF and cardiovascular disease, had LA volume and function assessed with CMR imaging, at baseline (2000–02), and at Exam 4 (2005–07) or 5 (2010–12). Free of AF, 124 participants developed AF over 3.8±0.9 years (to 2015) following the second imaging. In adjusted Cox regression models, an average annualized change in all LA parameters were significantly associated with an increased risk of AF. An annual decrease of 1–SD unit in total LA emptying fractions (LAEF) was most strongly associated with risk of AF after adjusting for AF clinical risk factors, baseline LA parameters and left ventricular mass-to-volume ratio (hazard ratio per SD=1.91,95% confidence interval=1.53–2.38, P<0.001). The addition of change in total LAEF to an AF risk score improved model discrimination and reclassification (net reclassification improvement=0.107, P=0.017; integrative discrimination index=0.049, P<0.001).

Model discrimination, NRI and IDI Model: CHARGE-AF risk factors# + Baseline LA variable + ΔLA variable CHARGE-AF ΔLAVImin (mL/m2/y) ΔTotal LAEF (%/y) ΔPeak LA Strain (%/y) C-statistic (95% CI) 0.757 (0.721–0.794) 0.787 (0.749–0.824) 0.779 (0.737–0.820) 0.770 (0.732–0.808) NRI† (p-value) – 0.000 (0.991) 0.107 (0.017) 0.017 (0.634) IDI (p-value) – 0.049 (<0.001) 0.049 (<0.001) 0.018 (<0.001) Calibration chi2* (p-value) 19.3 (0.02) 11.68 (0.232) 5.751 (0.765) 3.673 (0.932) AF: atrial fibrillation; LA: left atrium; EF: emptying fractions; Δ: annual change; VImin: minimum indexed volume; CI: confidence interval; NRI: net reclassification improvement; IDI: integrative discrimination index #CHARGE-AF risk factors: age, race, height, weight, systolic and diastolic blood pressure, use of antihypertensive medication, smoking status, diabetes, MI and CHF by the second imaging. † Categories for NRI: <2.5%, 2.5%-5% and >5%. *Model calibration: Grønnesby and Borgan's modified Hosmer-Lemeshow chi-square statistic for survival analysis.

Kaplan-Meier curves of ΔTotal LAEF

Conclusion

In this multi-ethnic study population free of clinical cardiovascular disease at baseline, a greater increase in LA volumes and decrease in LA function were associated with incident AF. The addition of change in total LAEF to risk prediction models for AF improved model discrimination and reclassification of AF risk.

Acknowledgement/Funding

This research was supported by contracts HHSN2682015ehz745.01623I,N01-HC-95159-69 from the NHLBI and UL1-TR-ehz745.016240,UL1-TR-001079,R01-HL-127659 from NIH

Young African American women’s participation in an m-Health study in cardiovascular risk reduction: Feasibility, benefits, and barriers

Background:

Young black women have an increased risk of cardiovascular disease, and thus identifying innovative prevention strategies is essential. A potential preventive strategy is mobile health; however, few studies have tested this strategy in young black women.

Aim:

The purpose of this study was to assess the feasibility of a mobile health intervention through a digital application to reduce cardiovascular disease risk factors in young black women, and identify benefits and barriers to participation.

Methods:

Forty black women aged 25–45 years completed four sessions of cardiovascular disease risk reduction education and a six-month smartphone cardiovascular disease risk reduction monitoring and coaching intervention, targeting heart-healthy behavior modifications. At follow-up, women responded to a semi-qualitative online survey assessing the user-friendliness and perceived helpfulness of the intervention.

Results:

Of 40 women, 38 completed the follow-up survey. Sixty per cent of participants reported that the applications were easy or very easy to maintain, 90% reported that the application was easy or very easy to use. Over 60% observed that their family’s nutrition improved “a lot” or “a medium amount,” and many participants noted positive changes in their children’s diets. Only 8% of participants cited time or cost required to prepare healthy foods as barriers to implementing dietary changes.

Conclusions:

The m-Health intervention was feasible as a means of cardiovascular disease risk reduction for young black women. In addition, we found that targeting women provided indirect benefits for other family members, especially children. Most of the participants did not encounter systemic barriers to participation, suggesting that mobile health interventions can be effective tools to improve health behaviors in vulnerable populations.

Cognitive effects of mifepristone in overweight, euthymic adults with depressive disorders

BACKGROUND

Previous studies have shown that individuals with mood disorders have a higher prevalence of both hypercortisolemia and insulin resistance. Insulin resistance is posited to contribute to the cognitive deficits observed in individuals who have depression. However, the mechanistic relationship between cortisol and insulin within the central nervous system remains to be further elucidated. This study aimed to evaluate the effects of the antiglucocorticoid agent, mifepristone, on metabolic function and cognitive performance in individuals receiving treatment for depressive disorders who were euthymic at baseline.

METHODS

Participants were administered a 600 mg/day dose of mifepristone for 28 days. Oral glucose tolerance tests (OGTTs) and cognitive assessments measuring verbal memory and executive functioning were administered at baseline and after 28 days of treatment.

RESULTS

Improvements in attention and verbal learning were associated with reduction of fasting plasma glucose (FPG) in response to mifepristone treatment.

LIMITATIONS

Limitations include the open-label design of this study and a small sample size.

CONCLUSIONS

The findings from this study suggest that improvement in fasting plasma glucose levels, upon administration of mifepristone, is associated with the improvement in early input of verbal information. Further studies are warranted in order to better evaluate the use of mifepristone or other antiglucocorticoid agents in treatment of mood disorders characterized by metabolic dysfunction.

Diabetes UK evidence-based nutrition guidelines for the prevention and management of diabetes

A summary of the latest evidence-based nutrition guidelines for the prevention and management of diabetes is presented. These guidelines are based on existing recommendations last published in 2011, and were formulated by an expert panel of specialist dietitians after a literature review of recent evidence. Recommendations have been made in terms of foods rather than nutrients wherever possible. Guidelines for education and care delivery, prevention of Type 2 diabetes, glycaemic control for Type 1 and Type 2 diabetes, cardiovascular disease risk management, management of diabetes-related complications, other considerations including comorbidities, nutrition support, pregnancy and lactation, eating disorders, micronutrients, food supplements, functional foods, commercial diabetic foods and nutritive and non-nutritive sweeteners are included. The sections on pregnancy and prevention of Type 2 diabetes have been enlarged and the weight management section modified to include considerations of remission of Type 2 diabetes. A section evaluating detailed considerations in ethnic minorities has been included as a new topic. The guidelines were graded using adapted 'GRADE' methodology and, where strong evidence was lacking, grading was not allocated. These 2018 guidelines emphasize a flexible, individualized approach to diabetes management and weight loss and highlight the emerging evidence for remission of Type 2 diabetes. The full guideline document is available at www.diabetes.org.uk/nutrition-guidelines.

Identification of preoperative factors associated with outcomes following surgical management of intra-abdominal recurrent or metastatic GIST following neoadjuvant tyrosine kinase inhibitor therapy

BACKGROUND

The role of surgical resection in the treatment of patients with metastatic/recurrent gastrointestinal stromal tumors (GIST) is unclear. The aim of this study was to identify preoperative factors associated with oncologic outcomes for recurrent/metastatic GIST after tyrosine kinase inhibitor (TKI) therapy.

METHODS

We identified 107 patients with metastatic or recurrent GIST treated with TKIs and surgical resection (2002-2012). Patients that underwent palliative or incomplete resection were excluded. Complete resection was achieved in 87 patients which comprise the analytic cohort. Univariate and multivariate analyses were conducted to identify risk factors for GIST-specific survival (DSS) and time-to-recurrence (TTR).

RESULTS

At a median follow-up of 51 months (91 months for survivors), median DSS was 74 months and TTR was 21 months. By univariate analysis, unifocal disease, duration of TKI < 365 days, and no evidence of radiographic progression were associated with improved TTR and DSS. Multivariate Cox regression demonstrated that evidence of radiographic progression was associated with shorter DSS (HR 2.53, 95%CI = 1.27-5.06, P = 0.008) and increased risk of recurrence (HR 3.33, 95%CI = 1.91-5.82, P < 0.001).

CONCLUSIONS

Patients with unifocal disease and radiographic evidence of response to TKI therapy may achieve improved oncologic outcomes when complete surgical resection is achieved following treatment with TKI.

Comparison of Kaposi Sarcoma Risk in Human Immunodeficiency Virus-Positive Adults Across 5 Continents: A Multiregional Multicohort Study

BACKGROUND

We compared Kaposi sarcoma (KS) risk in adults who started antiretroviral therapy (ART) across the Asia-Pacific, South Africa, Europe, Latin, and North America.

METHODS

We included cohort data of human immunodeficiency virus (HIV)-positive adults who started ART after 1995 within the framework of 2 large collaborations of observational HIV cohorts. We present incidence rates and adjusted hazard ratios (aHRs).

RESULTS

We included 208140 patients from 57 countries. Over a period of 1066572 person-years, 2046 KS cases were diagnosed. KS incidence rates per 100000 person-years were 52 in the Asia-Pacific and ranged between 180 and 280 in the other regions. KS risk was 5 times higher in South African women (aHR, 4.56; 95% confidence intervals [CI], 2.73-7.62) than in their European counterparts, and 2 times higher in South African men (2.21; 1.34-3.63). In Europe, Latin, and North America KS risk was 6 times higher in men who have sex with men (aHR, 5.95; 95% CI, 5.09-6.96) than in women. Comparing patients with current CD4 cell counts ≥700 cells/µL with those whose counts were <50 cells/µL, the KS risk was halved in South Africa (aHR, 0.53; 95% CI, .17-1.63) but reduced by ≥95% in other regions.

CONCLUSIONS

Despite important ART-related declines in KS incidence, men and women in South Africa and men who have sex with men remain at increased KS risk, likely due to high human herpesvirus 8 coinfection rates. Early ART initiation and maintenance of high CD4 cell counts are essential to further reducing KS incidence worldwide, but additional measures might be needed, especially in Southern Africa.

Use of high-density SNP data to identify patterns of diversity and signatures of selection in broiler chickens

The development of broiler chickens over the last 70 years has been accompanied by large phenotypic changes, so that the resulting genomic signatures of selection should be detectable by current statistical techniques with sufficiently dense genetic markers. Using two approaches, this study analysed high-density SNP data from a broiler chicken line to detect low-diversity genomic regions characteristic of past selection. Seven regions with zero diversity were identified across the genome. Most of these were very small and did not contain many genes. In addition, fifteen regions were identified with diversity increasing asymptotically from a low level. These regions were larger and thus generally included more genes. Several candidate genes for broiler traits were found within these 'regression regions', including IGF1, GPD2 and MTNR1AI. The results suggest that the identification of zero-diversity regions is too restrictive for characterizing regions under selection, but that regions showing patterns of diversity along the chromosome that are consistent with selective sweeps contain a number of genes that are functional candidates for involvement in broiler development. Many regions identified in this study overlap or are close to regions identified in layer chicken populations, possibly due to their shared precommercialization history or to shared selection pressures between broilers and layers.

Clinical Observations and Molecular Variables of Primary Vascular Leiomyosarcoma

IMPORTANCE

Vascular leiomyosarcomas are a rare subtype of leiomyosarcomas that most commonly affect the inferior vena cava and account for 5% of all leiomyosarcomas. These tumors are aggressive malignant tumors for which adjuvant modalities have not shown increased efficacy compared with surgery.

OBJECTIVES

To evaluate the outcomes of patients with vascular leiomyosarcoma and the association between vascular leiomyosarcomas and immunohistochemical molecular markers, to determine their potential prognostic and therapeutic utility.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective medical record review of a cohort of 77 patients who presented to the University of Texas MD Anderson Cancer Center in Houston during the period from January 1993 to April 2012. Data were analyzed during the period from November 2012 to May 2015. All of the patients received a confirmed diagnosis of vascular leiomyosarcoma. Immunohistochemical studies for biomarkers were performed on a tissue microarray that included 26 primary specimens of vascular leiomyosarcoma.

MAIN OUTCOMES AND MEASURES

Demographic and clinical factors were evaluated to assess clinical course, patterns of recurrence, and survival outcomes for patients with primary vascular leiomyosarcoma. A univariate Cox proportional hazards model was used to correlate disease-specific survival and time to recurrence with potential prognostic indicators.

RESULTS

Sixty-three patients with localized disease who underwent surgical resection formed the study population, and their data were used for subsequent outcomes analysis. The median age at diagnosis was 58 years (range, 22-78 years). The majority of patients were female (41 patients [65%]) and white (51 patients [81%]). The 5-year disease-specific survival rate after tumor resection was 65%. The median time to local recurrence was 43 months, the median time to distant recurrence was 25 months, and the median time to concurrent local and distant recurrences was 15 months (P = .04). Strong expressions of cytoplasmic β-catenin (hazard ratio, 5.33 [95% CI, 0.97-29.30]; P = .06) and insulinlike growth factor 1 receptor (hazard ratio, 2.74 [95% CI, 1.14-6.56]; P = .02) were associated with inferior disease-specific survival.

CONCLUSIONS AND RELEVANCE

Vascular leiomyosarcomas are aggressive malignant tumors, with high recurrence rates. Expressions of β-catenin and insulinlike growth factor 1 receptor were associated with poor disease-specific survival. Prospective studies should evaluate the clinical and therapeutic utility of these molecular markers.

Reducing Staphylococcus aureus bloodstream infections associated with peripheral intravenous cannulae: successful implementation of a care bundle at a large Australian health service

BACKGROUND

Healthcare-associated Staphylococcus aureus bacteraemia (HA-SAB) results in morbidity, mortality, and increased healthcare costs, and these infections are frequently regarded as preventable.

AIM

To implement a multi-modal prevention programme for improved processes regarding peripheral intravenous cannula (PIVC) insertion and maintenance, in order to reduce PIVC-associated HA-SAB events in a large Australian health service.

METHODS

Baseline clinical practice was evaluated for a 12-month pre-intervention period. Measures to reduce HA-SAB risk were introduced between January and September 2013: staff education, improved documentation (including phlebitis scoring), and availability of standardized equipment. Post-intervention auditing was performed during the 27 months following intervention. Baseline and post-intervention HA-SAB and PIVC-associated infection rates were compared. Interrupted time-series and Bayesian change-point analyses were applied to determine the impact of interventions and timing of change.

FINDINGS

Significantly improved documentation regarding PIVC insertion and management was observed in the post-intervention period, with fewer PIVCs left in situ for ≥4 days (2.6 vs 6.9%, P<0.05). During the baseline period a total of 68 HA-SAB events occurred [1.01/10,000 occupied bed-days (OBDs)] and 24 were PIVC-associated (35% of total, rate 0.39 per 10,000 OBDs). In the post-intervention period, a total of 83 HA-SAB events occurred (0.99 per 10,000 OBDs) and 12 were PIVC-associated (14.4% of total, rate 0.14 per 10,000 OBDs). PIVC-associated SAB rates were 63% lower in the post-intervention period compared to baseline (P=0.018) with a change point observed following full bundle implementation in October 2013.

CONCLUSION

A successful multi-modal hospital-wide campaign was introduced to reduce PIVC-associated SAB rates. Evaluation of cost-effectiveness and sustainability is required.

Past and projected temporal trends in arthroscopic hip surgery in England between 2002 and 2013

Introduction

Hip arthroscopy is increasingly adopted for the treatment of intra-articular and extra-articular pathologies. Studies from USA demonstrate a 365% increase in the number of procedures performed between 2004 and 2009 and 250% increase between 2007 and 2011. There is limited evidence of long-term efficacy for this procedure and hip arthroscopy is not universally funded across England. The aim of this study is to describe temporal trends in the adoption of hip arthroscopy in England between 2002 and 2013 and to forecast trends for the next 10 years.

Methods

A search of the Hospital Episodes Database was performed for all codes describing arthroscopic hip procedures with patient age, sex and area of residence.

Results

11 329 hip arthroscopies were performed in National Health Service hospitals in England between 2002 and 2013. The number of hip arthroscopies performed increased by 727% (p<0.0001) during this period and is forecast to increase by 1388% in 2023. Females represent 60% of all patients undergoing hip arthroscopy (p<0.001). Median age category is 40–44 for females and 35–39 for males and average age decreased during the study period (p<0.0001). There is significant regional variation in procedure incidence. In the final year of this study the highest incidence was in the Southwest (8.63/100 000 population) and lowest in East Midlands (1.29/100 000 population).

Conclusions

The increase in number of hip arthroscopies performed in England reflects trends in USA and continued increases are forecast. Evidence from robust clinical trials is required to justify the increasing number of procedures performed and regional variation suggests potential inequality in the provision of this intervention.

Identification of stable reference genes for quantitative PCR in cells derived from chicken lymphoid organs

Quantitative polymerase chain reaction (qPCR) is a powerful technique for quantification of gene expression, especially genes involved in immune responses. Although qPCR is a very efficient and sensitive tool, variations in the enzymatic efficiency, quality of RNA and the presence of inhibitors can lead to errors. Therefore, qPCR needs to be normalised to obtain reliable results and allow comparison. The most common approach is to use reference genes as internal controls in qPCR analyses. In this study, expression of seven genes, including β-actin (ACTB), β-2-microglobulin (B2M), glyceraldehyde-3-phosphate dehydrogenase (GAPDH), β-glucuronidase (GUSB), TATA box binding protein (TBP), α-tubulin (TUBAT) and 28S ribosomal RNA (r28S), was determined in cells isolated from chicken lymphoid tissues and stimulated with three different mitogens. The stability of the genes was measured using geNorm, NormFinder and BestKeeper software. The results from both geNorm and NormFinder were that the three most stably expressed genes in this panel were TBP, GAPDH and r28S. BestKeeper did not generate clear answers because of the highly heterogeneous sample set. Based on these data we will include TBP in future qPCR normalisation. The study shows the importance of appropriate reference gene normalisation in other tissues before qPCR analysis.

Serum biomarkers of clinical and cytologic response in dogs with idiopathic immune-mediated polyarthropathy

Background

Immune‐mediated polyarthopathy (IMPA) is common in dogs, and is monitored by serial arthrocenteses.

Hypothesis/Objectives

Plasma C‐reactive protein (CRP), interleukin‐6 (IL‐6), and CXCL8 (interleukin‐8) would serve as noninvasive markers of joint inflammation in IMPA.

Animals

Nine client‐owned dogs with idiopathic IMPA; 6 healthy controls.

Methods

Prospective study. Plasma CRP, IL‐6, and CXCL8 were measured by ELISA at baseline, 2, and 4 weeks during treatment with prednisone at 50 mg/m²/day. Arthrocenteses, the canine brief pain inventory (CBPI), and accelerometry collars were used to assess joint inflammation, lameness, and mobility at all 3 time points.

Results

C‐reactive protein concentrations were higher in IMPA dogs (median 91.1 μg/mL, range 76.7–195.0) compared with controls (median <6.3 μg/mL, <6.3–13.7; P = .0035), and were significantly lower at week 2 (10.6 μg/mL, <6.3–48.8) and week 4 (<6.3 μg/mL, <6.3–24.4; P < .001).

C‐reactive protein was correlated with median CBPI scores (r = 0.68; P = .0004), joint cellularity (r = 0.49, P = .011), and mobility by accelerometry (r = −0.42, P = .048). Plasma IL‐6 concentrations were also higher in IMPA dogs (median 45.9 pg/mL), compared with controls (median <15.7 pg/mL; P = .0008). IL‐6 was lower in IMPA dogs by week 4 (<15.7 pg/mL; P = .0099), and was modestly correlated with CBPI scores (r = 0.47, P = .023). CXCL8 did not differ significantly between IMPA and healthy dogs.

Conclusions

Plasma CRP and IL‐6 might be useful surrogate markers of synovial inflammation and disease activity in dogs with IMPA.

Lifestyle and metformin treatment favorably influence lipoprotein subfraction distribution in the Diabetes Prevention Program

CONTEXT

Although intensive lifestyle change (ILS) and metformin reduce diabetes incidence in subjects with impaired glucose tolerance (IGT), their effects on lipoprotein subfractions have not been studied.

OBJECTIVE

The objective of the study was to characterize the effects of ILS and metformin vs placebo interventions on lipoprotein subfractions in the Diabetes Prevention Program.

DESIGN

This was a randomized clinical trial, testing the effects of ILS, metformin, and placebo on diabetes development in subjects with IGT.

PARTICIPANTS

Selected individuals with IGT randomized in the Diabetes Prevention Program participated in the study.

INTERVENTIONS

Interventions included randomization to metformin 850 mg or placebo twice daily or ILS aimed at a 7% weight loss using a low-fat diet with increased physical activity.

MAIN OUTCOME MEASURES

Lipoprotein subfraction size, density, and concentration measured by magnetic resonance and density gradient ultracentrifugation at baseline and 1 year were measured.

RESULTS

ILS decreased large and buoyant very low-density lipoprotein, small and dense low-density lipoprotein (LDL), and small high-density lipoprotein (HDL) and raised large HDL. Metformin modestly reduced small and dense LDL and raised small and large HDL. Change in insulin resistance largely accounted for the intervention-associated decreases in large very low-density lipoprotein, whereas changes in body mass index (BMI) and adiponectin were strongly associated with changes in LDL. Baseline and a change in adiponectin were related to change in large HDL, and BMI change associated with small HDL change. The effect of metformin to increase small HDL was independent of adiponectin, BMI, and insulin resistance.

CONCLUSION

ILS and metformin treatment have favorable effects on lipoprotein subfractions that are primarily mediated by intervention-related changes in insulin resistance, BMI, and adiponectin. Interventions that slow the development of diabetes may also retard the progression of atherosclerosis.

Feasibility of an obesity intervention for paediatric primary care targeting parenting and children: Helping HAND

BACKGROUND

  The primary care setting offers the opportunity to reach children and parents to encourage healthy lifestyle behaviours, and improve weight status among children.

OBJECTIVE

  Test the feasibility of Helping HAND (Healthy Activity and Nutrition Directions), an obesity intervention for 5- to 8-year-old children in primary care clinics.

METHODS

  A randomized controlled pilot study of Helping HAND, a 6-month intervention, targeted children with body mass index 85-99%tile and their parents. Intervention group attended monthly sessions and self-selected child behaviours and parenting practices to change. Control group received regular paediatric care and was wait-listed for Helping HAND. Session completion, participant satisfaction, child anthropometrics, dietary intake, physical activity, TV viewing and behaviour-specific parenting practices were measured pre and post intervention.

RESULTS

  Forty parent-child dyads enrolled: 82.5% were Hispanic, 80% had a girl and 65% reported income ≤ $30, 000/year. There was 20% attrition from Helping HAND (attended <4/6 sessions). Families self-selected 4.35 (SD 1.75) behaviours to target during the 6-month programme and each of the seven behaviours was selected by 45-80% of the families. There were no between group differences in the child's body mass index z-score, dietary intake or physical activity post intervention. Intervention group viewed 14.9 (SE 2.3) h/week of TV post intervention versus control group 23.3 (SE 2.4) h/week (P < 0.05).

CONCLUSION

  Helping HAND is feasible, due to low attrition, good programme attendance, and clinically relevant improvements in some child and parenting behaviours.

Strategies for the removal of halides from drinking water sources, and their applicability in disinfection by-product minimisation: a critical review

The presence of bromide (Br(-)) and iodide (I(-)) in source waters leads to the formation of brominated and iodinated disinfection by-products (DBPs), which are often more toxic than their chlorinated analogues. The increasing scarcity of water resources in Australia is leading to use of impaired and alternative water supplies with high bromide and iodide levels, which may result in the production of more brominated and iodinated DBPs. This review aims to provide a summary of research into bromide and iodide removal from drinking water sources. Bromide and iodide removal techniques have been broadly classified into three categories, namely; membrane, electrochemical and adsorptive techniques. Reverse osmosis, nanofiltration and electrodialysis membrane techniques are reviewed. The electrochemical techniques discussed are electrolysis, capacitive deionization and membrane capacitive deionization. Studies on bromide and iodide removal using adsorptive techniques including; layered double hydroxides, impregnated activated carbons, carbon aerogels, ion exchange resins, aluminium coagulation and soils are also assessed. Halide removal techniques have been compared, and areas for future research have been identified.

Chlorine disinfection by-products in wastewater effluent: Bioassay-based assessment of toxicological impact

The potential ecological impact of disinfection by-products (DBPs) present in chlorinated wastewater effluents is not well understood. In this study, the chlorinated effluent of traditional wastewater treatment plants (WWTPs) and advanced water reclamation plants (AWRPs) supplying highly-treated recycled water were analyzed for nitrosamines and trihalomethanes (THMs), and a battery of bioassays conducted to assess effluent toxicity. An increase in general toxicity from DBPs was revealed for all wastewaters studied using an in vitro bioluminescence assay. Examples of androgenic activity and estrogenic activity arising from DBPs at specific sampling sites were also observed. The in vivo model (Artemia franciscana) was generally not adversely affected by exposure to DBPs from any of the chlorinated wastewaters studied. The observed toxicity could not be related to the concentrations of THMs and nitrosamines present, indicating that DBPs not monitored in this study were responsible for this. This work highlights the complexity of DBPs mixtures formed in chlorinated wastewaters, illustrating that toxicity of wastewater DBPs cannot be predicted by chemical monitoring of THMs and nitrosamines. The results suggest bioassays may be particularly useful monitoring tools in assessing toxicity arising from DBPs of these complex waters. The research concludes that DBPs formed in the chlorinated wastewaters studied can be toxic and may have a deleterious impact on aquatic organisms that are exposed to them, and therefore, that chlorination or chlorination/dechlorination may not be adequate treatment strategies for the protection of receiving waters. Chlorinated wastewater toxicity (from DBPs) is not well-understood in the Australian context, and this study serves to advise regulators on this issue.

Subclinical atherosclerosis, airflow obstruction and emphysema: the MESA Lung Study

Airflow obstruction is an independent risk factor for cardiovascular events in the general population. The affected vascular bed and contribution of emphysema to cardiovascular risk are unclear. We examined whether an obstructive pattern of spirometry and quantitatively defined emphysema were associated with subclinical atherosclerosis in the carotid, peripheral and coronary circulations. The Multi-Ethnic Study of Atherosclerosis recruited participants aged 45-84 yrs without clinical cardiovascular disease. Spirometry, carotid intima-media thickness (IMT), ankle-brachial index (ABI) and coronary artery calcium (CAC) were measured using standard protocols. Percentage of emphysema-like lung was measured in the lung windows of cardiac computed tomography scans among 3,642 participants. Multiple linear regression was used to adjust for cardiac risk factors, including C-reactive protein. Decrements in forced expiratory volume in 1 s (FEV(1)) and FEV(1)/forced vital capacity ratio were associated with greater internal carotid IMT, particularly among smokers (p=0.03 and p<0.001, respectively) whereas percentage emphysema was associated with reduced ABI regardless of smoking history (p=0.004). CAC was associated with neither lung function (prevalence ratio for the presence of CAC in severe airflow obstruction 0.99, 95% CI 0.91-1.07) nor percentage emphysema. An obstructive pattern of spirometry and emphysema were associated distinctly and independently with subclinical atherosclerosis in the carotid arteries and peripheral circulation, respectively, and were not independently related to CAC.