Association of cell phone location data and trends in COVID-19 infections during loosening of stay-at-home restrictions

We report that during the loosening of stay-at-home mandates, U.S. counties with more county level workplace cell phone activity had a more rapid increase in incidence of COVID-19. Though these results are not applicable at an individual level, they improve estimation of areas at higher risk of COVID-19 surge.

Maximum Daily Temperature, Precipitation, Ultraviolet Light, and Rates of Transmission of Severe Acute Respiratory Syndrome Coronavirus 2 in the United States

Background

Previous reports have suggested that transmission of SARS-CoV-2 is reduced by higher temperatures and higher humidity. We analyzed case-data from the United States to investigate effects of temperature, precipitation, and UV Light on community transmission of SARS-CoV-2.

Methods

Daily reported cases of SARS-CoV-2 across the United States from 01/22/2020 to 04/03/2020 were analyzed. We used negative binomial regression modelling to investigate whether daily maximum temperature, precipitation, UV Index and the incidence 5 days later were related. We performed sensitivity analyses at 3 days, 7 days and 9 days to assess transmission lags.

Results

A maximum temperature greater than 52°F on a given day was associated with a lower rate of new cases at 5 days[IRR: 0.85(0.76,0.96)p=0.009]. Among observations with daily temperatures below 52°F, there was a significant inverse association between the maximum daily temperature and the rate of cases at 5 days [IRR 0.98(0.97,0.99)p=0.001]. The rate of new cases was predicted to be lower for theoretical states that maintained a stable maximum daily temperature above 52°F with a predicted 23-fewer cases per-million per-day by 25 days of the epidemic. A 1-unit higher UV index was associated with a lower rate at 5 days [IRR 0.97(0.95,0.99)p=0.004]. Precipitation was not associated with a greater rate of cases at 5 days [IRR 0.98(0.89,1.08)p=0.65].

Conclusion

The incidence of disease declines with increasing temperature up until 52°F and is lower at warmer versus cooler temperatures. However, the association between temperature and transmission is small and transmission is likely to remain high at warmer temperatures.

Cell Phone Activity in Categories of Places and Associations With Growth in Cases of COVID-19 in the US

IMPORTANCE

It is unknown how well cell phone location data portray social distancing strategies or if they are associated with the incidence of coronavirus disease 2019 (COVID-19) cases in a particular geographical area.

OBJECTIVE

To determine if cell phone location data are associated with the rate of change in new COVID-19 cases by county across the US.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study incorporated publicly available county-level daily COVID-19 case data from January 22, 2020, to May 11, 2020, and county-level daily cell phone location data made publicly available by Google. It examined the daily cases of COVID-19 per capita and daily estimates of cell phone activity compared with the baseline (where baseline was defined as the median value for that day of the week from a 5-week period between January 3 and February 6, 2020). All days and counties with available data after the initiation of stay-at-home orders for each state were included.

EXPOSURES

The primary exposure was cell phone activity compared with baseline for each day and each county in different categories of place.

MAIN OUTCOMES AND MEASURES

The primary outcome was the percentage change in COVID-19 cases 5 days from the exposure date.

RESULTS

Between 949 and 2740 US counties and between 22 124 and 83 745 daily observations were studied depending on the availability of cell phone data for that county and day. Marked changes in cell phone activity occurred around the time stay-at-home orders were issued by various states. Counties with higher per-capita cases (per 100 000 population) showed greater reductions in cell phone activity at the workplace (β, -0.002; 95% CI, -0.003 to -0.001; P < 0.001), areas classified as retail (β, -0.008; 95% CI, -0.011 to -0.005; P < 0.001) and grocery stores (β, -0.006; 95% CI, -0.007 to -0.004; P < 0.001), and transit stations (β, -0.003, 95% CI, -0.005 to -0.002; P < 0.001), and greater increase in activity at the place of residence (β, 0.002; 95% CI, 0.001-0.002; P < 0.001). Adjusting for county-level and state-level characteristics, counties with the greatest decline in workplace activity, transit stations, and retail activity and the greatest increases in time spent at residential places had lower percentage growth in cases at 5, 10, and 15 days. For example, counties in the lowest quartile of retail activity had a 45.5% lower growth in cases at 15 days compared with the highest quartile (SD, 37.4%-53.5%; P < .001).

CONCLUSIONS AND RELEVANCE

Our findings support the hypothesis that greater reductions in cell phone activity in the workplace and retail locations, and greater increases in activity at the residence, are associated with lesser growth in COVID-19 cases. These data provide support for the value of monitoring cell phone location data to anticipate future trends of the pandemic.

Assessment of Placebo Response in Objective and Subjective Outcome Measures in Rheumatoid Arthritis Clinical Trials

Importance

Large placebo responses in randomized clinical trials may keep effective medication from reaching the market. Primary outcome measures of clinical trials have shifted from patient-reported to objective outcomes, partly because response to randomized placebo treatment is thought to be greater in subjective compared with objective outcomes. However, a direct comparison of placebo response in subjective and objective outcomes in the same patient population is missing.

Objective

To assess whether subjective patient-reported (pain severity) and objective inflammation (C-reactive protein [CRP] level and erythrocyte sedimentation rate [ESR]) outcomes differ in placebo response.

Design, Setting, and Participants

The placebo arms of 5 double-blind, randomized, placebo-controlled clinical trials were included in this cross-sectional study. These trials were conducted internationally for 24 weeks or longer between 2005 and 2009. All patients with rheumatoid arthritis randomized to placebo (N = 788) were included. Analysis of data from these trials was conducted from March 27 to December 31, 2019.

Intervention

Placebo injection.

Main Outcomes and Measures

The difference (with 95% CIs) from baseline at week 12 and week 24 on a 0- to 100-mm visual analog scale to evaluate the severity of pain, CRP level, and ESR.

Results

Of the 788 patients included in the analysis, 644 were women (82%); mean (SD) age was 51 (13) years. There was a statistically significant decrease in patient-reported pain intensity (week 12: -14 mm; 95% CI, -12 to -16 mm and week 24: -20 mm; 95% CI, -16 to -22 mm). Similarly, significant decreases were noted in the CRP level (week 12: -0.51 mg/dL; 95% CI, -0.47 to -0.56 mg/dL and week 24: -1.16 mg/dL; 95% CI, -1.03 to -1.30 mg/dL) and ESR (week 12: -11 mm/h; 95% CI, -10 to 12 mm/h and week 24: -25 mm/h; 95% CI, -12 to -26 mm/h) (all P < .001).

Conclusions and Relevance

The findings of this study suggest that improvements in clinical outcomes among participants randomized to placebo were not limited to subjective outcomes. Even if these findings could largely demonstrate a regression to the mean, they should be considered for future trial design, as unexpected favorable placebo responses may result in a well-designed trial becoming underpowered to detect the treatment difference needed in clinical drug development.

2020 American College of Rheumatology Guideline for the Management of Gout

OBJECTIVE

To provide guidance for the management of gout, including indications for and optimal use of urate-lowering therapy (ULT), treatment of gout flares, and lifestyle and other medication recommendations.

METHODS

Fifty-seven population, intervention, comparator, and outcomes questions were developed, followed by a systematic literature review, including network meta-analyses with ratings of the available evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, and patient input. A group consensus process was used to compose the final recommendations and grade their strength as strong or conditional.

RESULTS

Forty-two recommendations (including 16 strong recommendations) were generated. Strong recommendations included initiation of ULT for all patients with tophaceous gout, radiographic damage due to gout, or frequent gout flares; allopurinol as the preferred first-line ULT, including for those with moderate-to-severe chronic kidney disease (CKD; stage >3); using a low starting dose of allopurinol (≤100 mg/day, and lower in CKD) or febuxostat (<40 mg/day); and a treat-to-target management strategy with ULT dose titration guided by serial serum urate (SU) measurements, with an SU target of <6 mg/dl. When initiating ULT, concomitant antiinflammatory prophylaxis therapy for a duration of at least 3-6 months was strongly recommended. For management of gout flares, colchicine, nonsteroidal antiinflammatory drugs, or glucocorticoids (oral, intraarticular, or intramuscular) were strongly recommended.

CONCLUSION

Using GRADE methodology and informed by a consensus process based on evidence from the current literature and patient preferences, this guideline provides direction for clinicians and patients making decisions on the management of gout.

2020 American College of Rheumatology Guideline for the Management of Gout

OBJECTIVE

To provide guidance for the management of gout, including indications for and optimal use of urate-lowering therapy (ULT), treatment of gout flares, and lifestyle and other medication recommendations.

METHODS

Fifty-seven population, intervention, comparator, and outcomes questions were developed, followed by a systematic literature review, including network meta-analyses with ratings of the available evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, and patient input. A group consensus process was used to compose the final recommendations and grade their strength as strong or conditional.

RESULTS

Forty-two recommendations (including 16 strong recommendations) were generated. Strong recommendations included initiation of ULT for all patients with tophaceous gout, radiographic damage due to gout, or frequent gout flares; allopurinol as the preferred first-line ULT, including for those with moderate-to-severe chronic kidney disease (CKD; stage >3); using a low starting dose of allopurinol (≤100 mg/day, and lower in CKD) or febuxostat (<40 mg/day); and a treat-to-target management strategy with ULT dose titration guided by serial serum urate (SU) measurements, with an SU target of <6 mg/dl. When initiating ULT, concomitant antiinflammatory prophylaxis therapy for a duration of at least 3-6 months was strongly recommended. For management of gout flares, colchicine, nonsteroidal antiinflammatory drugs, or glucocorticoids (oral, intraarticular, or intramuscular) were strongly recommended.

CONCLUSION

Using GRADE methodology and informed by a consensus process based on evidence from the current literature and patient preferences, this guideline provides direction for clinicians and patients making decisions on the management of gout.

Role of Dual Energy Computed Tomography Imaging in the Diagnosis of Gout

Gout is a well-known inflammatory arthritis and affects four percent of the United States population. It results from the deposition of uric acid crystals in joints, tendons, bursae, and other surrounding tissues. Prevalence of gout has increased in the recent decade. Gout is usually seen in conjunction with other chronic comorbid conditions like cardiac disease, metabolic syndrome, and renal disease. The diagnosis of this inflammatory arthritis is confirmed by visualization of monosodium urate (MSU) crystals in the synovial fluid. Though synovial fluid aspiration is the standard of care, it is often deferred because of inaccessibility of small joints, patient assessment during intercritical period, or procedural inexperience in a primary care office. Dual energy computed tomography (DECT) is a relatively new imaging modality which shows great promise in the diagnosis of gout. It is a good noninvasive alternative to synovial fluid aspiration. DECT is increasingly useful in diagnosing cases of gout where synovial fluid fails to demonstrate monosodium urate crystals. In this article, we will review the mechanism, types, advantages, and disadvantages of DECT.

Predictors of inpatient mortality in patients with systemic sclerosis: a case control study

There are few studies on predictors of inpatient mortality in patients with systemic sclerosis (SSc). Knowledge of these predictors is important for the early identification of patients at high risk of inpatient death and for the recognition of modifiable factors. The aim of this study was to define factors associated with greater inpatient mortality in SSc. All admissions coded for SSc (ICD-9-710.1) at the Hospital of University of Pennsylvania, between 2001 and 2011, were reviewed. The diagnosis of SSc was confirmed, and deaths were identified by chart review. For each death, an age, sex, and race matched control with SSc (who did not die during their hospitalization) was identified. We hypothesized group differences in SSc characteristics, non-SSc co-morbidities, and admission labs. Group differences were analyzed using Student's t test as well as Chi(2) tests for dichotomous variables. Exposures associated with death in univariate analyses were used to form a final parsimonious multivariable logistic regression model. After analysis of 658 SSc admissions, 29 cases and 29 matched controls were studied. A significant difference in non-SSc lung disease (p = 0.03), aspiration events (p < 0.01), blood urea nitrogen (BUN) (p < 0.01), and hemoglobin (p = 0.03) was noted between subjects that died compared to matched controls. Odds of death were higher in patients with a higher BUN (OR = 1.06, CI = 1.02-1.11), non-SSc lung disease (OR = 3.87, CI = 1.26-11.88), and aspiration events (OR = 30, CI = 3.58-250.80) and lower in patients with a higher hemoglobin (OR = 0.73, CI = 0.54-0.97). A high BUN, a history of aspiration events, and low Hgb were found to be independently associated with risk of death. A history of lung disease, anemia, renal dysfunction, and aspiration events is associated with higher in-hospital mortality in patients with SSc. The odds of dying in the hospital were 30 times higher among patients with an aspiration event. Stringent measures should be considered to prevent aspiration in at-risk patients.

Utility of immunologic testing in suspected rheumatologic disease

The use of diagnostic testing in the clinical practice of medicine has been a shifting landscape from the time that the first blood test was utilized. This is no different in the field of immunology and in particular rheumatology. As the field of immunology is relatively young, the clinical tests are not well established and therefore guidelines for use are still under debate. In this review, we seek to look at some of the key autoantibodies, as well as other tests that are available to diagnose suspected rheumatologic disease, and examine how to best use these tests in the clinic. In particular, we will focus on the anti-nuclear antibodies, anti-neutrophil cytoplasmic antibodies, complement, cryoglobulins, rheumatoid factor, and anti-citrullinated protein antibodies.