SAT0409 BIOLOGIC TREATMENT IN PSORIATIC ARTHRITIS AND AXIAL SPONDYLOPATHY REDUCES SICKNOTES ISSUED BY GPS, DESPITE DELAYS IN DIAGNOSIS: A REAL-LIFE STUDY IN WALES

Background:

Seronegative inflammatory arthritis including psoriatic arthritis (PsA) and axial spondyloarthropathies (AxS) are chronic inflammatory diseases associated with significant morbidities. The National Institute of Health and Clinical Excellence (NICE) has produced several pieces of guidance on disease management including the use of biologic therapies which have been shown to improve patient outcomes and quality of life. However, there are limited real-life data on patient journey from symptom onset to diagnosis and treatment including with biologics in the UK.

Objectives:

The purpose of this study is to examine the real-life patient journey from symptom onset to diagnosis and treatment.

Methods:

Data from the Secure Anonymised Information Linkage (SAIL) databank in Wales, which holds over a billion anonymised records, were used to assess the treatment of patients with PsA or AxS, aged 18 years or over with at least one READ code present for PsA or AxS in their primary care records. We examined the drug use of patients across primary, secondary care and specialist rheumatology clinics to explore the use of NSAIDs, DMARDs and biologics in the real-life setting while exploring demographics, comorbidities and surgical procedures of 1829 PsA and 908 AxS patients.

Results:

The AxS patients were significantly younger at diagnosis and were predominantly male. Typical delays in diagnosis of 8-9 years from symptom onset were observed. The rate of stopping or switching a biologic medication was similar for AxS and PsA patients (Table 1). There was a significant reduction in sicknotes issued following biologic initiation for PsA (Difference: 14.6%, 95% CI: 8.7% to 20.4%) and AxS (Difference 16.9%, 95% CI: 10.5% to 23.3%)

Table 1.

Characteristics of treatment of PsA and AxS patients

PsA (n=1829)AxS (n=908)Difference (95% CI)Female (%, n)55.1% (1007)29.1% (264)26 (22.2 to 29.6)*Mean age at diagnosis (years, SD)46.9 (14)43.5 (14.4)3.4 (2.3 to 4.5)*BMI (Index, SD)30.3 (6.3)28 (5.8)2.3 (1.8 to 2.8)*Time from symptom to diagnosis (years, SD)8.9 (5.5)8.0 (5.6)0.9 (0.5 to 1.3)Hypertension at diagnosis (%, n)24.2% (442/1829)19.4% (176/908)4.8 (1.5 to 8.0)*Time from diagnosis to biologic (years, SD)6.3 (4.7)6.1 (5.0)0.2 (-0.9 to 0.5)Used a Biologic (%, n)23% (420/1829)36.8% (334/908)13.8 (10.2 to 17.5)*NSAIDs used pre-biologic (SD)11.3 (3.2)11.6 (3.2)0.3 (-0.2 to 0.8)Number of DMARDs used pre-biologic (SD)3.1 (1.5)2.5 (1.7)0.6 (0.4 to 0.8)*Biologic treatment change/failure (%, n)21.6% (92/425)22% (74/336)0.4 (-6.4 to 5.5)Sicknotes issued by GPᵻpre-biologic (SD)33.9% (144/425)33.6% (113/336)0.3 (-6.5 to 7.0)Sicknotes issued by GPᵻpost-biologic (SD)(%, n)19.3% (82/425)16.7% (56/336)2.6 (-2.9 to 8.0)Hospitalised for serious infection pre- diagnosis (%, n)7.2% (131/1829)6.3% (57/908)0.9 (-1.2 to 2.8)Hospitalised for serious infection post- diagnosis (%, n)10.4% (190/1829)11.6% (105/908)1.2 (-1.3 to 3.8)Hospitalised for serious infection post- biologic (%, n)5.6% (24/425)6.3% (21/336)0.7 (-2.8 to 4.2)

* Significant at p<0.05

ᵻ General practioner/Primary care physician

Conclusion:

Patients with PsA and AxS were treated with NSAIDs and DMARDs prior to receiving biologic medication in accordance with NICE guidelines. However, there was a long delay from symptom onset to diagnosis. Biologic treatment reduced sicknotes issued by GPs confirming the benefit of biologic treatment on work productivity observed in clinical trials.

Acknowledgments:

The work is funded by a Investigator-led grant from Novartis Pharmaceuticals UK Limited

Disclosure of Interests:

Ernest Choy Grant/research support from: Amgen, Bio-Cancer, Chugai Pharma, Ferring Pharmaceuticals, Novimmune, Pfizer, Roche, UCB, Consultant of: AbbVie, Amgen, AstraZeneca, Biogen, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Chelsea Therapeutics, Chugai Pharma, Daiichi Sankyo, Eli Lilly, Ferring Pharmaceuticals, GlaxoSmithKline, Hospita, Ionis, Janssen, Jazz Pharmaceuticals, MedImmune, Merck Sharp & Dohme, Merrimack Pharmaceutical, Napp, Novartis, Novimmune, ObsEva, Pfizer, R-Pharm, Regeneron Pharmaceuticals, Inc., Roche, SynAct Pharma, Sanofi Genzyme, Tonix, UCB, Speakers bureau: Amgen, Boehringer Ingelheim, Bristol-Myers Squibb, Chugai Pharma, Eli Lilly, Hospira, Merck Sharp & Dohme, Novartis, Pfizer, Regeneron Pharmaceuticals, Inc., Roche, Sanofi-Aventis, UCB, Sinead Brophy: None declared, Roxanne Cooksey: None declared, Lindsey Hanson Employee of: Lindsey Hanson is a permanent employee of Novartis Pharmaceuticals UK Limited, Anna Halliday Shareholder of: Anna Halliday owns Novartis share, Employee of: Anna Halliday is a permanent employee of Novartis Pharmaceuticals UK Ltd.

Outcomes after bloodstream infection in hospitalized pediatric hematology/oncology and stem cell transplant patients

BACKGROUND

Pediatric hematology/oncology (PHO) patients receiving therapy or undergoing hematopoietic stem cell transplantation (HSCT) often require a central line and are at risk for bloodstream infections (BSI). There are limited data describing outcomes of BSI in PHO and HSCT patients.

METHODS

This is a multicenter (n = 17) retrospective analysis of outcomes of patients who developed a BSI. Centers involved participated in a quality improvement collaborative referred to as the Childhood Cancer and Blood Disorder Network within the Children's Hospital Association. The main outcome measures were all-cause mortality at 3, 10, and 30 days after positive culture date; transfer to the intensive care unit (ICU) within 48 hours of positive culture; and central line removal within seven days of the positive blood culture.

RESULTS

Nine hundred fifty-seven BSI were included in the analysis. Three hundred fifty-four BSI (37%) were associated with at least one adverse outcome. All-cause mortality was 1% (n = 9), 3% (n = 26), and 6% (n = 57) at 3, 10, and 30 days after BSI, respectively. In the 165 BSI (17%) associated with admission to the ICU, the median ICU stay was four days (IQR 2-10). Twenty-one percent of all infections (n = 203) were associated with central line removal within seven days of positive blood culture.

CONCLUSIONS

BSI in PHO and HSCT patients are associated with adverse outcomes. These data will assist in defining the impact of BSI in this population and demonstrate the need for quality improvement and research efforts to decrease them.

Metabolic syndrome is a sequela of radiation exposure in hypothalamic obesity among survivors of childhood brain tumors

Survivors of childhood brain tumors may be at risk for early onset of metabolic syndrome, possibly secondary to surgery and/or radiation exposure. This study examines effects of radiation exposure to hypothalamus-pituitary-adrenal axis (HPA) on metabolic risk among survivors of childhood brain tumors. One hundred forty-two met inclusion criteria; 60 had tumor surgery plus radiation exposure (>1 Gray (Gy)) to HPA. The second subgroup of 82 subjects had surgery only and were not exposed to radiation. Both subgroups had survived for approximately 5 years at the time of study. All had clinical evaluation, vital signs, anthropometry, measurement of body composition by dual X-ray absorptiometry and fasting laboratory assays (metabolic panel, insulin, C-peptide, insulin-like growth factor-1, leptin and adiponectin). Body composition data for both subgroups was compared with the National Health and Nutrition Survey (NHANES) subgroup of similar age, gender and body mass index. Cranial surgery was associated with obesity of similar severity in both subgroups. However, survivors exposed to radiation to the HPA also had increased visceral fat mass and high prevalence of growth hormone deficiency and metabolic syndrome. Fat mass alone did not explain the prevalence of the metabolic syndrome in radiation exposure subgroup. Other factors such as growth hormone deficiency may have contributed to metabolic risk. We conclude that prevalence of metabolic syndrome among subjects exposed to hypothalamic radiation was higher than expected from hypothalamic obesity alone. Radiation exposure may exert untoward endocrinopathies due to HPA exposure that worsens metabolic risk. Early screening for metabolic syndrome in this population is indicated.

Effects of insulin on prenylation as a mechanism of potentially detrimental influence of hyperinsulinemia

To investigate the cause and effect relationship between hyperinsulinemia and the increased amounts of farnesylated p21Ras, we performed hyperinsulinemic euglycemic clamps in normal weight volunteers as well as in normal mice and dogs. Insulin infusions significantly raised the amounts of farnesylated p21Ras in the white blood cells of humans, in liver samples of mice and dogs, and in aorta samples of mice. Obese hyperinsulinemic individuals and dogs (made hyperinsulinemic by surgical diversion of the pancreatic outflow from the portal vein into the vena cava) displayed increased amounts of farnesylated p21Ras before the hyperinsulinemic clamps. Infusions of insulin did not alter the already increased levels of farnesylated p21Ras in these experimental models. To further investigate the role of acquired insulin resistance in modulating insulin's effect on p21Ras prenylation, we induced insulin resistance in rats by glucosamine infusion. Insulin-resistant glucosamine-treated animals displayed significantly increased farnesylated p21Ras in response to insulin infusion compared to that in control saline-treated animals. Transgenic models of insulin resistance (heterozygous insulin receptor substrate-1 knockout mice, A-ZIP/F-1 fatless mice, and animals overexpressing glutamine:fructose-6-phosphate amidotransferase) contained increased amounts of farnesylated p21Ras. We conclude that hyperinsulinemia, either endogenous (a prominent feature of insulin resistance) or produced by infusions of insulin, increases the amounts of farnesylated p21Ras in humans, mice, and dogs. This aspect of insulin action may represent one facet of the molecular mechanism of the potentially detrimental influence of hyperinsulinemia.

Risk factors for rifampin mono-resistant tuberculosis

Use of rifampin is required for short-course treatment regimens for tuberculosis. Tuberculosis caused by isolates of M. tuberculosis with resistance to rifampin and susceptibility to isoniazid is unusual, but it has been recognized through surveillance. Patients with tuberculosis (cases) with rifampin mono-resistance were compared with HIV-matched controls with tuberculosis caused by a drug-susceptible isolate. A total of 77 cases of rifampin mono-resistant tuberculosis were identified in this multicenter study. Three were determined to be laboratory contaminants, and 10 cases had an epidemiologic link to a case with rifampin mono-resistant tuberculosis, suggesting primary acquisition of rifampin-resistant isolates. Of the remaining 64 cases and 126 controls, there was no difference between cases and controls with regard to age, sex, race, foreign birth, homelessness, or history of incarceration. Cases were more likely to have a history of prior tuberculosis than were controls. Of the 38 cases and 74 controls with HIV infection, there was no difference between cases and controls with regard to age, sex, race, foreign birth, homelessness, history of incarceration, or prior tuberculosis. Cases were more likely to have histories of diarrhea, rifabutin use, or antifungal therapy. Laboratory analysis of available isolates showed that there was no evidence of spread of a single clone of M. tuberculosis. Further studies are needed to identify the causes of the development of rifampin resistance in HIV-infected persons with tuberculosis and to develop strategies to prevent its emergence.

Patterns and mechanisms of beta-lactam resistance among isolates of Escherichia coli from hospitals in the United States

To study the national distribution of beta-lactam resistance patterns and mechanisms among Escherichia coli organisms isolated in U.S. hospitals, 652 ampicillin-resistant (Am(r)) or ampicillin-intermediate (Ami) isolates were submitted to the Centers for Disease Control from March 1983 through July 1984 by nine hospitals participating in the National Nosocomial Infections Study. Among the isolates (most of which caused urinary tract infections), 78% were Am(r) and 22% were Ami by the interpretative criteria established by the National Committee for Clinical Laboratory Standards. Resistance to carboxypenicillins ranged from 73 to 74%, and that to acylureidopenicillins ranged from 43 to 66%. A total of 26% of the isolates were resistant to cephalothin, and 4% were resistant to cefazolin. Resistance to cefoxitin was 1%, while resistances to cefuroxime and cefamandole were 2 and 7%, respectively. With the exception of cefsulodin (98% resistant) and cefoperazone (1% resistant), there was no resistance to newer cephalosporins or aztreonam. In general, only minor differences in the incidence of resistance to beta-lactam antibiotics were noted in hospital-acquired versus non-hospital-acquired isolates as well as among isolates from various regions of the United States. TEM beta-lactamases were produced by 87% of the 237 Am(r) isolates examined. By our methods, OXA and chromosomal (type I) beta-lactamases were detected in 2 and 28 isolates, respectively, and plasmid-mediated extended-spectrum cephalosporinases were detected in none of the isolates. Disk substrate and clavulanic acid inhibition assays revealed that TEM beta-lactamase conferred Am(r) and resistance to carboxypenicillins, acylureidopenicillins, cephalothin, cefamandole, cefsulodin, and cefoperazone. A total of 391 isolates were screened for plasmids, and 259 isolates were examined by DNA hybridization with a TEM probe. Among 462 plasmids probed, 129 plasmids, ranging from 4 to 140 megadaltons, harbored TEM sequences. Although beta-lactam resistance in clinical isolates of E. coli is predominantly mediated by TEM beta-lactamase, the diverse spectrum of resistance appears to be related to additional strain=dependent factors.

Mechanism of aminoglycoside resistance among beta-lactam-resistant Escherichia coli in the United States

We examined aminoglycoside (AG) resistance in ampicillin-resistant Escherichia coli obtained from nine hospitals participating in the National Nosocomial Infections Study. The isolates were tested to 25 antimicrobials using broth microdilution methods. If the organism was intermediate or resistant to gentamicin, tobramycin, netilmicin, or amikacin, we determined the class of aminoglycoside-modifying enzyme (AME) using the phosphocellulose paper binding assay. Of 423 E. coli, 21 (5%) were intermediate or resistant to one or more of the AGs. All but two of these E. coli isolates had at least one AME. Twelve isolates had phosphotransferase (APH) enzymes; seven had adenyltransferase (ANT) enzymes (all ANT[2"]); and four had acetyltransferase (AAC) enzymes. The seven ANT[2"]-producing isolates were more likely to be acquired in the community than in the hospital (4/7 ANT[2"]-producing E. coli versus one of 14 of the other AG-resistant E. coli, p = 0.03, Fisher's exact test). These findings suggest that for E. coli resistant to both ampicillin and an AG, APH enzymes are the predominant AME class. Additionally, isolates with certain AMEs may be acquired both in the community and in the hospital.

Capillary precipitin typing of Streptococcus pneumoniae

The Neufeld test is presently the method of choice for typing Streptococcus pneumoniae. Although the test is reliable and relatively easy to perform, a simpler test, not requiring microscopic examination, would facilitate large-scale testing. A capillary precipitine test has been designed and tested for its usefulness in typing pneumococci. The type-specific carbohydrate antigens were obtained from broth culture supernatants. The antigens were reacted with type-specific antisera in glass capillary pipettes. Results from 82 reference antigens and 166 antigens from diagnostic pneumococcal strains showed that the reactions ere specific, and the results agreed with Neufeld test results. These results indicate that the precipitin test is as specific as the Neufeld test. The test is easy to perform, requires small amounts of antiserum, and can be completed in a short period of time.