The natural history of primary progressive multiple sclerosis: insights from the German NeuroTransData registry

BACKGROUND

Primary progressive multiple sclerosis (PPMS) is characterised by gradual worsening of disability from symptom onset. Knowledge about the natural course of PPMS remains limited.

METHODS

PPMS patients from the German NeuroTransData (NTD) MS registry with data from 56 outpatient practices were employed for retrospective cross-sectional and longitudinal analyses. The cross-sectional analysis included a contemporary PPMS cohort with a documented visit within the last 2 years before index date (1 Jan 2021). The longitudinal analysis included a disease modifying therapy (DMT)-naïve population and focused on the evolution of expanded disability status scale (EDSS) from the first available assessment at or after diagnosis within the NTD registry to index date. Outcome measures were estimated median time from first EDSS assessment to first 24-week confirmed EDSS ≥ 4 and ≥ 7. Besides EDSS change, the proportion of patients on disability pension were described over time.

RESULTS

The cross-sectional analysis included 481 PPMS patients (59.9% female, mean [standard deviation, SD] age 60.5 [11.5] years, mean [SD] EDSS 4.9 [2.1]). Estimated median time from first EDSS assessment after diagnosis to reach 24-week confirmed EDSS ≥ 4 for DMT-naïve patients was 6.9 years. Median time to EDSS ≥ 7 was 9.7 years for 25% of the population. Over a decade mean (SD) EDSS scores increased from 4.6 (2.1) to 5.7 (2.0); the proportion of patients on disability pension increased from 18.9% to 33.3%.

CONCLUSIONS

This study provides first insights into the German NTD real-world cohort of PPMS patients. Findings confirm the steadily deteriorating course of PPMS accompanied by increasingly limited quality of life.

Selenoprotein-P deficiency is associated with higher risk of incident heart failure

Background

Selenium deficiency has been associated with all-cause and cardiovascular mortality, incident cardiovascular disease (coronary artery disease, myocardial infarction and stroke), and with poor prognosis in patients with acute heart failure (HF). Furthermore, high selenium levels were recently shown to be associated with reduced mortality and reduced incidence of HF in non-smokers.

Purpose

To examine if selenoprotein-P (SELENOP), a main carrier protein of selenium, is associated with incident HF.

Methods

SELENOP concentrations were measured in 5060 randomly selected subjects from the population-based prospective cohort study “the Malmö Preventive Project” (n=18240) using a validated ELISA approach. After exclusion of subjects with prevalent HF (n=230), complete data on all co-variates was available in 4803 subjects (1400 women (29.1%), mean age 69.6±6.2 years, 885 (19.7%) current smokers). SELENOP was continously related to risk of incident HF using Cox regression models adjusted for age, sex, body mass index, systolic blood pressure, anti-hypertensive treatment, smoking status, diabetes status, low-density lipoprotein cholesterol levels, and prevalent coronary events. Further, subjects within the lowest SELENOP quintile were compared to subjects in the remaining four quintiles in an adjusted model.

Results

Each 1 SD increment in SELENOP levels was associated with lower risk of incident HF (n=436) during a median follow-up period of 14.7 years (interquartile range 10.9–15.7 years, hazard ratio (HR) 0.92, 95% confidence interval (95% CI) 0.84–0.99; p=0.049 in a model adjusted for cardiovascular risk factors. Multivariate quintile analyses revealed that the subjects in the lowest SELENOP quintile were at the highest risk of incident HF in an adjusted model (HR 1.46; 95% CI: 1.17–1.83 for incident HF; p for trend 0.039) illustrated in a Kaplan-Meier survival analysis (Figure 1). No interaction effect was seen for sex or smoking.

Conclusion

Low SELENOP levels are associated with a higher risk of incident HF supporting recent studies, which further emphasizes the need for randomly controlled trials to examine if supplementation with selenium improves prognosis.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Swedish Medical Research CouncilSwedish Society of Medicine

How do patients with secondary progressive multiple sclerosis enrolled in the EXPAND randomized controlled trial compare with those seen in German clinical practice in the NeuroTransData multiple sclerosis registry?

Background

In EXPAND (NCT01665144), a phase 3 randomized clinical trial, siponimod reduced disability progression versus placebo in patients with secondary progressive multiple sclerosis (SPMS).

Aim

To understand how a real-world population with SPMS relates to that in EXPAND, we conducted a retrospective, observational cohort study using the German NeuroTransData (NTD) multiple sclerosis (MS) registry.

Methods

The NTD MS registry is run by a Germany-wide network of physicians. Two cross-sectional analyses were performed using the NTD MS registry. The first included patients with SPMS, as recorded in the registry, and compared their characteristics between 1 January 2018 and 31 December 2018 with patients in EXPAND. The second described the characteristics of patients in the registry at the time of diagnosis of SPMS between 1 January 2010 and 31 December 2018.

Results

The first analysis included 773 patients: patients were older in the NTD MS registry than in EXPAND (mean age, 57.9 vs 48.0 years) and had a longer duration of SPMS (mean, 6.2 vs 3.8 years). In the NTD MS registry, median Expanded Disability Status Scale (EDSS) scores were comparable to EXPAND (6.0 versus 6.0), although fewer patients had relapses in the previous 24 months (16% vs 36% [siponimod] and 37% [placebo]). Data on gadolinium-enhancing lesions were only available for 5.8% of patients in the NTD MS registry. The second analysis included 916 patients: at the time of SPMS diagnosis, the mean age was 53.2 years and the median EDSS score was 5.0.

Conclusion

The population in the NTD MS registry was older to that in EXPAND, but were similar in terms of disability. Differences likely reflect the inclusion criteria of EXPAND but also highlight that real-world populations encompass a wider range of patient characteristics.

Severity of COVID19 infection among patients with multiple sclerosis treated with interferon-β

BACKGROUND

Interferon-β, a disease-modifying therapy (DMT) for MS, may be associated with less severe COVID-19 in people with MS.

RESULTS

Among 5,568 patients (83.4% confirmed COVID-19), interferon-treated patients had lower risk of severe COVID-19 compared to untreated, but not to glatiramer-acetate, dimethyl-fumarate, or pooled other DMTs.

CONCLUSIONS

In comparison to other DMTs, we did not find evidence of protective effects of interferon-β on the severity of COVID-19, though compared to the untreated, the course of COVID19 was milder among those on interferon-β. This study does not support the use of interferon-β as a treatment to reduce COVID-19 severity in MS.

PHREND®—A Real-World Data-Driven Tool Supporting Clinical Decisions to Optimize Treatment in Relapsing-Remitting Multiple Sclerosis

Background

With increasing availability of disease-modifying therapies (DMTs), treatment decisions in relapsing-remitting multiple sclerosis (RRMS) have become complex. Data-driven algorithms based on real-world outcomes may help clinicians optimize control of disease activity in routine praxis.

Objectives

We previously introduced the PHREND^® (Predictive-Healthcare-with-Real-World-Evidence-for-Neurological-Disorders) algorithm based on data from 2018 and now follow up on its robustness and utility to predict freedom of relapse and 3-months confirmed disability progression (3mCDP) during 1.5 years of clinical practice.

Methods

The impact of quarterly data updates on model robustness was investigated based on the model's C-index and credible intervals for coefficients. Model predictions were compared with results from randomized clinical trials (RCTs). Clinical relevance was evaluated by comparing outcomes of patients for whom model recommendations were followed with those choosing other treatments.

Results

Model robustness improved with the addition of 1.5 years of data. Comparison with RCTs revealed differences <10% of the model-based predictions in almost all trials. Treatment with the highest-ranked (by PHREND^®) or the first-or-second-highest ranked DMT led to significantly fewer relapses (p < 0.001 and p < 0.001, respectively) and 3mCDP events (p = 0.007 and p = 0.035, respectively) compared to non-recommended DMTs.

Conclusion

These results further support usefulness of PHREND® in a shared treatment-decision process between physicians and patients.

Implementation of a data control framework to ensure confidentiality, integrity, and availability of high-quality real-world data (RWD) in the NeuroTransData (NTD) registry

Objective

To implement a dynamic data management and control framework that meets the multiple demands of high data quality, rigorous information technology security, and flexibility to continuously incorporate new methodology for a large disease registry.

Materials and Methods

Guided by relevant sections of the COBIT framework and ISO 27001 standard, we created a data control framework supporting high-quality real-world data (RWD) studies in multiple disease areas. We first mapped and described the entire data journey and identified potential risks for data loss or inconsistencies. Based on this map, we implemented a control framework adhering to best practices and tested its effectiveness through an analysis of random data samples. An internal strategy board was set up to regularly identify and implement potential improvements.

Results

We herein describe the implementation of a data management and control framework for multiple sclerosis, one disease area in the NeuroTransData (NTD) registry that exemplifies the dynamic needs for high-quality RWD analysis. Regular manual and automated analysis of random data samples at multiple checkpoints guided the development and implementation of the framework and continue to ensure timely identification of potential threats to data accuracy.

Discussion and conclusions

High-quality RWD, especially those derived from long-term disease registries, are of increasing importance from regulatory and reimbursement perspectives, requiring owners to provide data of comparable quality to clinical trials. The framework presented herein responds to the call for transparency in real-world analyses and allows doctors and patients to experience an immediate benefit of the collected data for individualized optimal care.

Workflows of doctors treating patients in medical offices have changed dramatically in recent years. Computers have replaced paper files, and physicians rely on sophisticated digital systems to keep track of data from many sources, including laboratory results and patient-reported outcomes collected using tablets and smartphones. Data collected through these efforts are termed “real-world” data, because they reflect actual healthcare encounters in daily practice. Too often, such data constitute an untapped resource for learning, because the results from individual patients are kept decentralized. When kept separately, it is not possible to understand if certain groups of patients may respond better or worse to certain treatments. Physicians in the NeuroTransData network in Germany decided to remove the barriers for learning by connecting their practices. They now all contribute data to a central data collection called a “registry.” Personally identifying information is replaced with codes to protect privacy, and the data are checked automatically for errors to ensure that no mistakes are introduced. We describe the processes to collect, handle, and analyze real-world data in this network to support scientific studies with data of high quality and to allow insights derived from the data to directly benefit the patients in the network.

The Multiple Sclerosis Data Alliance Catalogue: Enabling Web-Based Discovery of Metadata from Real-World Multiple Sclerosis Data Sources

Background

One of the major objectives of the Multiple Sclerosis Data Alliance (MSDA) is to enable better discovery of multiple sclerosis (MS) real-world data (RWD).

Methods

We implemented the MSDA Catalogue, which is available worldwide. The current version of the MSDA Catalogue collects descriptive information on governance, purpose, inclusion criteria, procedures for data quality control, and how and which data are collected, including the use of e-health technologies and data on collection of COVID-19 variables. The current cataloguing procedure is performed in several manual steps, securing an effective catalogue.

Results

Herein we summarize the status of the MSDA Catalogue as of January 6, 2021. To date, 38 data sources across five continents are included in the MSDA Catalogue. These data sources differ in purpose, maturity, and variables collected, but this landscaping effort shows that there is substantial alignment on some domains. The MSDA Catalogue shows that personal data and basic disease data are the most collected categories of variables, whereas data on fatigue measurements and cognition scales are the least collected in MS registries/cohorts.

Conclusions

The Web-based MSDA Catalogue provides strategic overview and allows authorized end users to browse metadata profiles of data cohorts and data sources. There are many existing and arising RWD sources in MS. Detailed cataloguing of MS RWD is a first and useful step toward reducing the time needed to discover MS RWD sets and promoting collaboration.

Development of Registry Data to Create Interactive Doctor-Patient Platforms for Personalized Patient Care, Taking the Example of the DESTINY System

“Real-world evidence (RWE)” is becoming increasingly important in order to integrate the results of randomized studies into everyday clinical practice. The data collection of RWE is usually derived from large-scale national and international registries, often driven by academic centers. We have developed a digitalized doctor–patient platform called DESTINY (DatabasE-assiSted Therapy decIsioN support sYstem) that is utilized by NeuroTransData (NTD), a network of neurologists and psychiatrists throughout Germany. This platform can be integrated into everyday practice and, as well as being used for scientific evaluations in healthcare research, can also serve as an individual, personalized treatment application. Its various modules allow for a timely identification of side-effects or interactions of treatments, can involve patients via the “My NTC Health Guide” portal, and can collect data of individual disease histories that are integrated into innovative algorithms, e.g., for the prediction of treatment response [currently available for multiple sclerosis (MS), with other indications in the pipeline]. Here, we describe the doctor–patient platform DESTINY for outpatient neurological practices and its contribution to improved treatment success as well as reduction of healthcare costs. Platforms like DESTINY may facilitate the goal of personalized healthcare.

Plasma concentration of proneurotensin and prediction of cause-specific mortality in a middle aged cohort during long-term follow-up

Purpose

To examine the prediction of proneurotensin (Pro-NT) on total and cause-specific mortality in a middle-aged cohort.

Methods

In the population-based middle-aged cohort (n=4632 participants, mean age 57 years) of the Malmo Diet and Cancer (MDC) study, Pro-NT was assessed and total- as well as cause-specific mortality were studied. Main cause of death were based on the International Classification of Diseases (ICD). Assessments were done using Cox proportional hazards models adjusted for age and sex.

Results

During a mean follow-up of 20±3 years, 950 men and 956 women died. There was a significantly increased risk of total mortality in subjects belonging to quartile 4 of Pro-NT (Pro-NT ≥149 pmol/L) compared with quartiles 1–3 (Pro-NT &lt;149 pmol/L), hazard ratio (HR) of 1.29 (95% confidence interval [CI] 1.17–1.42; P&lt;0.001) after adjustment for age and sex. No significant interaction was observed between Pro-NT and gender on total mortality. Individuals within quartile 4 vs. quartiles 1–3 had a HR of 1.41 (95% CI 1.18–1.68; P&lt;0.001) for death due to cardiovascular diseases (n=595/4632), 2.53 (95% CI 1.37–4.67; P=0.003) due to digestive tract diseases (n=42/4632), 1.62 (95% CI 1.04–2.52; P=0.032) due to mental and behavioural diseases (n=90/4632), and 1.91 (95% CI 1.15–3.19; P=0.013) due to unspecific causes of death (n=64/4632). No significant relationships between Pro-NT and deaths due to cancer, infections, neurological or other causes were observed. Adjustments for cardiovascular risk factors only marginally changed these results.

Conclusions

Pro-NT is a predictor of total mortality and the increased risk is driven by deaths due to cardiovascular- digestive tract- mental and behavioural diseases, as well as deaths attributed to unspecific causes.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Knut and Alice Wallenberg Foundationthe Swedish Heart and Lung Foundation.

1298Associations of DMT therapies with COVID-19 severity in multiple sclerosis

Background

People with multiple sclerosis (MS) are a vulnerable group for severe COVID-19, particularly those taking immunosuppressive disease-modifying therapies (DMTs). We examined the characteristics of COVID-19 severity in an international sample of people with MS.

Methods

Data from 12 data-sources in 28 countries were aggregated (sources could include patients from 1-12 countries). Demographic (age, sex), clinical (MS phenotype, disability), and DMT (untreated, alemtuzumab, cladribine, dimethyl-fumarate, glatiramer-acetate, interferon, natalizumab, ocrelizumab, rituximab, siponimod, other) covariates were queried, alongside COVID-19 hospitalisation, admission to ICU, requiring artificial ventilation, and death. Characteristics of outcomes were assessed in patients with suspected/confirmed COVID-19 using multilevel mixed-effects logistic regression, adjusted for age, sex, MS phenotype, and EDSS.

Results

657 (28.1%) with suspected and 1,683 (61.9%) with confirmed COVID-19 were analysed. Among suspected+confirmed/confirmed-only COVID-19, 20.9%/26.9% were hospitalised, 5.4%/7.2% were admitted to ICU, 4.1%/5.4% required artificial ventilation, and 3.2%/3.9% died. Older age, progressive MS-phenotype, and higher disability were associated with worse COVID-19 outcomes. Compared to dimethyl-fumarate, ocrelizumab and rituximab were associated with hospitalisation (aOR=1.56,95%CI=1.01-2.41; aOR=2.43,95%CI=1.48-4.02) and ICU admission (aOR=2.30,95%CI=0.98-5.39; aOR=3.93,95%CI=1.56-9.89), though only rituximab was associated with higher risk of artificial ventilation (aOR=4.00,95%CI=1.54-10.39). Importantly, associations persisted on restriction to confirmed COVID-19 cases. No associations were observed between DMTs and death.

Conclusions

Despite the cross-sectional design of this study, the internal and external consistency of these results with prior studies suggests their use may be a risk factor for more severe COVID-19.

Key messages

Anti-CD20 DMTs may be associated with worse COVID-19 severity amongst people with multiple sclerosis.

Impact of drug diversity on treatment effectiveness in relapsing-remitting multiple sclerosis (RRMS) in Germany between 2010 and 2018: real-world data from the German NeuroTransData multiple sclerosis registry

OBJECTIVE

To evaluate the impact of drug diversity on treatment effectiveness in relapsing-remitting multiple sclerosis (RRMS) in Germany.

DESIGN

This study employs real-world data captured in-time during clinical visits in 67 German neurology outpatient offices of the NeuroTransData (NTD) multiple sclerosis (MS) registry between 1 January 2010 and 30 June 2019, including 237 976 visits of 17 553 patients with RRMS. Adherence and clinical effectiveness parameters were analysed by descriptive statistics, time-to-event analysis overall and by disease-modifying therapies (DMTs) stratified by administration modes (injectable, oral and infusion). Three time periods were compared: 2010-2012, 2013-2015 and 2016-2018.

RESULTS

Between 2010 and 2018, an increasing proportion of patients with RRMS were treated with DMTs and treatment was initiated sooner after diagnosis of MS. Introduction of oral DMT temporarily induced higher readiness to switch. Comparing the three index periods, there was a continuous decrease of annualised relapse rates, less frequent Expanded Disability Status Scale (EDSS) progression and increasing periods without relapse, EDSS worsening and with stability of no-evidence-of-disease-activity 2 and 3 criteria, lower conversion rates to secondary progressive MS on oral and on injectable DMTs.

CONCLUSION

Sparked by the availability of new mainly oral DMTs, RRMS treatment effectiveness improved clinically meaningful between 2010 and 2018. As similar effects were seen for injectable and oral DMTs more than for infusions, a better personalised treatment allocation in many patients is likely. These results indicate that there is an overall beneficial effect for the whole patient with MS population as a result of the greater selection of available DMTs, a benefit beyond the head-to-head comparative efficacy, resulting from an increased probability and readiness to individualise MS therapy.

B-Cell Activity Predicts Response to Glatiramer Acetate and Interferon in Relapsing-Remitting Multiple Sclerosis

Objective

We investigated the predictive value of the enzyme-linked immunospot technique (ELISPOT) in identifying patients with relapsing-remitting multiple sclerosis (RRMS) who will respond to treatment with glatiramer acetate (GA) or interferon-β (IFN-β), based on the brain-reactive B-cell activity of peripheral blood cells.

Methods

In this retrospective, cross-sectional, real-world multicenter study, we identified patients with RRMS in the NeuroTransData MS registry and stratified them based on their documented treatment response (relapse-free in the first 12 months of treatment) to GA or IFN-β. The GA group comprised 73 patients who responded to GA and 35 nonresponders. The IFN-β group comprised 62 responders to IFN-β and 37 nonresponders. Patients with previous or current therapy affecting B-cell activity were excluded. We polyclonally stimulated mononuclear cells from peripheral blood samples (collected after participant selection) and investigated brain-reactive B-cell activity after incubation on brain tissue lysate-coated ELISPOT plates. Validity metrics of the ELISPOT testing results were calculated (Python 3.6.8) in relation to the clinical responsiveness in the 2 treatment groups.

Results

The ELISPOT B-cell activity assay showed a sensitivity of 0.74, a specificity of 0.76, a positive predictive value of 0.78, a negative predictive value of 0.28, and a diagnostic OR of 8.99 in predicting clinical response to GA vs IFN-β therapy in patients with RRMS.

Conclusion

Measurement of brain-reactive B-cell activity by ELISPOT provides clinically meaningful predictive probabilities of individual patients' treatment response to GA or IFN-β. The assay has the potential to improve the selection of optimal first-line treatment for individual patients with RRMS.

Classification of Evidence

This study provides Class II evidence that in patients with RRMS, the brain reactivity of their peripheral-blood B cells predicts clinical response to GA and IFN-β.

New effects of caffeine on corticotropin-releasing hormone (CRH)-induced stress along the intrafollicular classical hypothalamic-pituitary-adrenal (HPA) axis (CRH-R1/2, IP3 -R, ACTH, MC-R2) and the neurogenic non-HPA axis (substance P, p75NTR and TrkA) in ex vivo human male androgenetic scalp hair follicles

BACKGROUND

Human hair is highly responsive to stress, and human scalp hair follicles (HFs) contain a peripheral neuroendocrine equivalent of the systemic hypothalamic-pituitary-adrenal (HPA) stress axis. Androgenetic alopecia (AGA) is supposed to be aggravated by stress. We used corticotropin-releasing hormone (CRH), which triggers the HPA axis, to induce a stress response in human ex vivo male AGA HFs. Caffeine is known to reverse testosterone-mediated hair growth inhibition in the same hair organ culture model.

OBJECTIVES

To investigate whether caffeine would antagonize CRH-mediated stress in these HFs.

METHODS

HFs from balding vertex area scalp biopsies of men affected by AGA were incubated with CRH (10-7 mol L-1 ) with or without caffeine (0·001% or 0·005%).

RESULTS

Compared to controls, CRH significantly enhanced the expression of catagen-inducing transforming growth factor-β2 (TGF-β2) (P < 0·001), CRH receptors 1 and 2 (CRH-R1/2) (P < 0·01), adrenocorticotropic hormone (ACTH) (P < 0·001) and melanocortin receptor 2 (MC-R2) (P < 0·001), and additional stress-associated parameters, substance P and p75 neurotrophin receptor (p75NTR ). CRH inhibited matrix keratinocyte proliferation and expression of anagen-promoting insulin-like growth factor-1 (IGF-1) and the pro-proliferative nerve growth factor receptor NGF-tyrosine kinase receptor A (TrkA). Caffeine significantly counteracted all described stress effects and additionally enhanced inositol trisphosphate receptor (IP3 -R), for the first time detected in human HFs.

CONCLUSIONS

These findings provide the first evidence in ex vivo human AGA HFs that the stress mediator CRH induces not only a complex intrafollicular HPA response, but also a non-HPA-related stress response. Moreover, we show that these effects can be effectively antagonized by caffeine. Thus, these data strongly support the hypothesis that stress can impair human hair physiology and induce hair loss, and that caffeine may effectively counteract stress-induced hair damage and possibly prevent stress-induced hair loss.

COVID-19 in people with multiple sclerosis: A global data sharing initiative

Background:

We need high-quality data to assess the determinants for COVID-19 severity in people with MS (PwMS). Several studies have recently emerged but there is great benefit in aligning data collection efforts at a global scale.

Objectives:

Our mission is to scale-up COVID-19 data collection efforts and provide the MS community with data-driven insights as soon as possible.

Methods:

Numerous stakeholders were brought together. Small dedicated interdisciplinary task forces were created to speed-up the formulation of the study design and work plan. First step was to agree upon a COVID-19 MS core data set. Second, we worked on providing a user-friendly and rapid pipeline to share COVID-19 data at a global scale.

Results:

The COVID-19 MS core data set was agreed within 48 hours. To date, 23 data collection partners are involved and the first data imports have been performed successfully. Data processing and analysis is an on-going process.

Conclusions:

We reached a consensus on a core data set and established data sharing processes with multiple partners to address an urgent need for information to guide clinical practice. First results show that partners are motivated to share data to attain the ultimate joint goal: better understand the effect of COVID-19 in PwMS.

Prognostic factors associated with overall survival in patients with oral cavity squamous cell carcinoma

Background

Low socioeconomic status, increasing age, and poor lifestyle behaviors are associated with poor survival in patients with oral cavity squamous cell carcinoma (OCSCC). To determine the overall survival (OS) and the risk of OCSCC death by tumor subsite.

Material and Methods

A retrospective cohort study of OCSCC patients diagnosed from 2007 to 2009 and treated at a single cancer center in Rio de Janeiro, Brazil. Patient information was obtained from the Hospital Cancer Registry (HCR) database and complemented by individual search of physical and electronic medical records. Descriptive statistics of population characteristics were computed. OS was estimated using the Kaplan-Meier method. Univariate and multivariate Cox proportional hazards regression analyses were used to estimate the risk of death by tumor subsite.

Results

Seven hundred and three patients with OCSCC were identified. Most patients were men (77.4%) with low levels of education (67.5%), who drank (73.9%) and smoked (79.7%). The most prevalent tumor site was the tongue (45.4%), 73.4% of patients had advanced (clinical stage III or IV) OCSCC at diagnosis and 74.1% died during follow-up. For the entire cohort, the OS was 39.1% at two years and 27.9% at five years. The median survival time was 1.4 years (95%CI: 1.2‒1.5). Non-operative treatment (HR: 3.11; 95%CI: 2.26‒4.29; p <0.001), advanced stage (HR 2.14; 95%CI 1.68-2.74; p <0.001), and age >60 years at diagnosis (HR: 1.37; 95%CI: 1.15‒1.64; p <0.001) were independently associated with the risk of death. However, these factors varied by tumour subsite.

Conclusions

Analysis of specific subsites of the oral cavity revealed substantial differences in prognostic factors associated with poor survival in OCSCC.

Key words:Squamous cell carcinoma, oral cavity cancer, survival, prognosis.

[Data on multiple sclerosis in Germany and their representation in the ambulatory registry NeuroTransData (NTD) network]

AIMS AND METHODOLOGY

Description of basic data, common symptoms and their medical, non-drug and combined symptomatic treatment in a large sample of MS patients undergoing outpatient treatment of the German NeuroTransData (NTD) physician network.

RESULTS

Currently there are 21,407 patients in the registry. Average age is 49.0 ± 13.0 years, 72,3 % of them female, average disease duration is 14.3 ± 8,9 years. Relapsing-remitting MS (RRMS) was present in 77 %, secondary-progressive MS (SPMS) 15 %, PPMS 5 %. The mean EDSS score of the total sample was 2.8 (range 0,5-8). Fatigue was the most common symptom in all subtypes (96 %), followed by spasticity (all 31 %, SPMS: 47 %; PPMS 36 %). Regarding symptomatic drug treatment, non-drug treatment and combined treatment, there was a wide range of variation. While spasticity was treated in 81 %, only 21 % of patients with fatigue receiving any form of therapy, Also, fecal and urine incontinence often remained untreated in 69 % resp. 56 % of cases.

CONCLUSIONS

Setup, development and maintenance of a registry for a complex and chronic disease like MS represents an instrument to assess and improve patient care in the outpatient setting. Our results are hard to compare with the DMSG-registry, another German, more hospital-based data collection. However, both registries identify fatigue as the most common symptom in MS.

Towards low-cost QEPAS sensors for nitrogen dioxide detection

Increasing awareness of the adverse health effects of air pollution leads to a demand of low-cost sensors for the measurement of pollutants such as NO₂. However, commercially available low-cost sensors lack accuracy and long-term stability, and suffer from cross-sensitivity to other gases. These drawbacks can be overcome by the method of quartz-enhanced photoacoustic spectroscopy (QEPAS). In QEPAS modulated light is absorbed by the NO₂ molecules, which results in the production of a sound wave. The sound wave is detected by resonance of a quartz tuning fork, which results in a measurable electric signal. Due to the small size of the tuning forks, the gas sensing element can be smaller than 1 cm³. We present the first bare fork QEPAS setup for the ppb-level detection of NO₂, which is ideally suited for environmental trace gas detection without the need of using micro-resonators. Micro-resonators are commonly used to amplify photoacoustic signals. However, micro-resonators have different dependencies on environmental conditions than tuning forks, which makes them difficult to operate in changing conditions. In contrast, our bare fork QEPAS setup is more robust and easily adopted by the use of a low-cost temperature and humidity sensor. By using acoustic filters the integration time could be increased to offer higher sensitivity at a continuous flow rate of 200 std cm³ min^-1. The 1σ noise equivalent concentration is determined to 21 ppb NO₂ in synthetic air for 120 s measurement time, allowing detection which satisfies international health and safety standards thresholds.

Quality of life after total laryngectomy: impact of different vocal rehabilitation methods in a middle income country

INTRODUCTION

The impact of advanced laryngeal cancer and its extensive surgical treatments cause significant morbidity for these patients. Total laryngectomy impacts essential functions such as breathing, communication and swallowing, and may influence the quality of life as well as affecting the social life of laryngeal cancer patients.

OBJECTIVE

Describe the quality of life and analyze the factors associated with the reduced quality of life in patients who have undergone total laryngectomy.

METHOD

Observational cross-sectional study was carried out to evaluate the quality of life of patients who had undergone total laryngectomy due to laryngeal cancer. The fourth version of the UW-QOL Quality of Life Assessment Questionnaire from Washington University, validated for Portuguese, was used.

RESULTS

The study population was 95 patients, and the mean composite score of the QOL was 80.4. In the subjective domains the majority of the patients (38.9%) reported they felt much better at present compared to the month before being diagnosed with cancer. When questioned about how they evaluated their health-related quality of life, there was a predominance of those who considered it good (43.2%), and most considered they had a good quality of life (46.3%) considering personal well-being. The overall quality of life was considered good to excellent by 83.2% of the patients. Patients with tracheoesophageal prosthesis reported a better quality of life, compared to patients using an electrolarynx or esophageal voice.

CONCLUSION

The high mean value of the composite score for quality of life revealed that the patients assessed their quality of life positively. The absence of vocal emission was the only variable associated with a lower quality of life within the composite score according to the UW-QOL questionnaire.

Framework for personalized prediction of treatment response in relapsing remitting multiple sclerosis

BACKGROUND

Personalized healthcare promises to successfully advance the treatment of heterogeneous neurological disorders such as relapsing remitting multiple sclerosis by addressing the caveats of traditional healthcare. This study presents a framework for personalized prediction of treatment response based on real-world data from the NeuroTransData network.

METHODS

A framework for personalized prediction of response to various treatments currently available for relapsing remitting multiple sclerosis patients was proposed. Two indicators of therapy effectiveness were used: number of relapses, and confirmed disability progression. The following steps were performed: (1) Data preprocessing and selection of predictors according to quality and inclusion criteria; (2) Implementation of hierarchical Bayesian generalized linear models for estimating treatment response; (3) Validation of the resulting predictive models based on several performance measures and routines, together with additional analyses that focus on evaluating the usability in clinical practice, such as comparing predicted treatment response with the empirically observed course of multiple sclerosis for different adherence profiles.

RESULTS

The results revealed that the predictive models provide robust and accurate predictions and generalize to new patients and clinical sites. Three different out-of-sample validation schemes (10-fold cross-validation, leave-one-site-out cross-validation, and excluding a test set) were employed to assess generalizability based on three different statistical performance measures (mean squared error, Harrell's concordance statistic, and negative log-likelihood). Sensitivity to different choices of the priors, to the characteristics of the underlying patient population, and to the sample size, was assessed. Finally, it was shown that model predictions are clinically meaningful.

CONCLUSIONS

Applying personalized predictive models in relapsing remitting multiple sclerosis patients is still new territory that is rapidly evolving and has many challenges. The proposed framework addresses the following challenges: robustness and accuracy of the predictions, generalizability to new patients and clinical sites and comparability of the predicted effectiveness of different therapies. The methodological and clinical soundness of the results builds the basis for a future support of patients and doctors when the current treatment is not generating the desired effect and they are considering a therapy switch. (A) The framework is developed using quality-proven real-world data of patients with relapsing remitting multiple sclerosis. Patients have heterogeneous individual characteristics and diverse disease profiles, indicated for example by variations in frequency of relapses and degree of disability. Longitudinal characteristics regarding disease history (e.g. number of previous relapses in the last 12 months) are extracted at the time of an intended therapy switch, i.e. at time point "Today" (left). All clinical parameters are captured in a standardized way (right). (B) The model predicts the course of the disease based on the observed data (panel A), and is able to account for the impact of various available therapies on chosen clinical endpoints. The resulting ranking of therapies has a dependency on patient characteristics, illustrated here by a different highest ranked therapy depending on the number of relapse in the previous 12 months. (C) The model is evaluated for various generalization properties. Compared to performance on the training set (gray) it is able to predict for new patients not part of the training set (red).Top: Prediction for new patients. Middle: Prediction for new clinical sites. Bottom: Prediction for different time windows. (D) In order to assess the clinical impact of the model, disease activity is compared between patients treated with the highest ranked therapy and those treated with any of the other therapies. Patients adhering to the highest ranked therapy are associated with a better disease outcome when compared to those who did not.

The association between plasma proneurotensin and glucose regulation is modified by country of birth

The prevalence of type 2 diabetes (T2D) has increased dramatically in Middle Eastern populations that represent the largest non-European immigrant group in Sweden today. As proneurotensin predicts T2D, the aim of this study was to investigate differences in proneurotensin levels across populations of Middle Eastern and Caucasian origin and to study its associations with indices of glucose regulation. Participants in the age 30 to 75 years, living in Malmö, Sweden, and born in Iraq or Sweden, were recruited from the census register. Anthropometrics and fasting samples were collected and oral glucose tolerance tests conducted assessing insulin secretion (DIo) as well as insulin sensitivity (ISI). A total of 2155 individuals participated in the study, 1398 were Iraqi-born and 757 were Swedish-born participants. Higher fasting proneurotensin levels were observed in Iraqi- compared to Swedish-born participants (137.5 vs. 119.8 pmol/L; p < 0.001) data adjusted for age, sex and body mass index. In Iraqi participants only, plasma proneurotensin was associated with impaired glucose regulation assessed as ISI, DIo and HbA1c, and significant interactions between country of birth and proneurotensin were observed (Pinteraction ISI = 0.048; Pinteraction DIo = 0.014; PinteractionHbA1c = 0.029). We report higher levels of proneurotensin in the general Middle Eastern population. The finding that Middle Eastern origin modifies the relationship of proneurotensin with indices of glucose regulation suggests that proneurotensin may be a stronger determinant of T2D in Middle Eastern as compared to Caucasian populations. These findings may explain part of the excess T2D risk in the Middle Eastern population but needs to be explored further.

Are German family practitioners and psychiatrists sufficiently trained to diagnose and treat patients with alcohol problems?

Background

Harmful alcohol consumption in Germany is a serious public health problem: About 7.7 million adults in Germany can be classified as risky alcohol consumers, about 74,000 deaths per year are related to alcohol consumption, and about 1.8 million adults in Germany (18–64 years) are classified as alcohol dependent. A treatment rate of 9% of all alcohol dependent patients in Germany implies a lack of supply and misuse of medical care. The aim of the study was to examine whether family practitioners (FPs) and psychiatrists have sufficient skills to diagnose and treat patients with alcohol problems.

Methods

A total of 6324 FPs and psychiatrists in the states of Saxony and Rhineland-Palatinate in Germany were invited to participate in this survey. Nine hundred seventy-four participants (90.3%/FPs) could be included in the statistical analysis (response rate: 14.3%/FPs, 21.6%/psychiatrists). Data was analysed descriptively and logistical regressions were used to identify predictors for physicians’ ability to feel adequately trained to diagnose and treat patients with alcohol problems.

Results

In comparison to psychiatrists, less FPs reported feeling sufficiently trained to counsel patients with alcohol problems (81.5% vs. 44.8%). Regression analysis revealed that FPs who felt not adequately trained had less experience with patients with alcohol dependence (OR 7.4), had attended fewer hours on alcohol addiction in continuing medical education (OR 4.8), and were more likely to be female (OR 1.9). A minimum of 10 h of training was associated with improved self-assessed competence.

Conclusion

Harmful drinking is a serious public health problem, and patients with alcohol dependence represent a large and demanding patient group in primary health care setting. Our study shows that the lack of training is a severe barrier in the work with this patient group in the primary care setting.

Abstract P4-10-16: Neoadjuvant chemotherapy infusion in the arm ipsilateral to breast cancer increases the risk of lymphedema

Background: Neoadjuvant chemotherapy (NAC) has been administered to clinically axillary positive breast cancer (BC) patients. Current guidelines still recommend axillary lymphadenectomy (AL) in patients with persistent positive axillary lymph node disease. We aimed to evaluate the association of NAC and/or adjuvant chemotherapy (CT) infusion in the ipsilateral upper limb (IA) with AL and the occurrence of lymphedema (LE) secondary to BC treatment. Methods: A prospective cohort study of 683 women subjected to AL and treated with NAC and/or adjuvant CT for BC. The patients were evaluated before treatment, immediate and every 6 months after surgery. Cumulative incidence and population attributable risks of LE were calculated. Results: 8-year cumulative incidence of LE was 33.1%. NAC and CT infusion and infusion of &gt;2 cycles into the IA respectively increased by 1.68, 1.67 and 1.78 times the risk of LE respectively (all P&lt;0.01). LE could be avoided in 9.4% of cases if the CT infusion had not been administered in the IA. Conclusions: 33.1% of women developed LE. The risk of LE was increased among women who received CT in the IA. Avoidance of NAC or adjuvant CT in the IA could prevent 9% of the LE cases observed in this population.

Citation Format: Bergmann A, Bello MA, Thuker LC, Andrade MF, Bevilacqua JI. Neoadjuvant chemotherapy infusion in the arm ipsilateral to breast cancer increases the risk of lymphedema [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-10-16.

Endothelial dysfunction following coronary artery bypass grafting : Influence of patient and procedural factors

BACKGROUND

Angiopoietin-2 (Angpt2) mediates endothelial dysfunction (ED) following coronary artery bypass grafting (CABG). Its triggers are, however, poorly understood.

METHODS

We examined the time course of ED beyond the early phase of postoperative recovery in 75 patients following CABG with a special focus on different cardiopulmonary bypass (CPB) modes as potential triggers of Angpt2 release.

RESULTS

Nine patients (12.0%) underwent off-pump coronary artery bypass (OPCAB), 31 patients (41.3%) received minimized extracorporeal circulation (MECC), and 35 patients (46.6%) were operated on with (conventional) CPB. Angpt2 levels steadily increased across the observation period (1.7 [1.4-2.1] to 3.4 [2.5-6.1] ng/ml, p < 0.001). Angpt2 levels did not differ between the MECC and CPB groups (p = 0.564). There was no difference between MECC and CPB patients regarding net fluid balance (p = 0.821) and other surrogate markers of postoperative ED. The magnitude of Angpt-2 increase correlated more strongly with baseline C‑reactive protein (r = 0.459, p < 0.001) than with any other parameter. Hospital length of stay correlated more strongly with baseline Angpt2 levels (r = 0.512, p = 0.005) than with follow-up Angpt2 levels and appeared not to be influenced by CPB mode (p = 0.428).

CONCLUSION

CABG is associated with prolonged ED, which is determined by the patient's preoperative inflammatory state rather than by CPB modifications.

Clinical Implications of a New TSH-receptor-antibody-assay (DYNOtest® TRAKhuman) in Autoimmune Thyroid Diseases

Aim: Conventional radioreceptor-antibody-assays (RAAs) fail in the detection of TSH-receptor antibodies (TRAKs) in 10–30% of patients with Graves’ disease (GD). The aim of this study was the evaluation of the diagnostic and clinical impact of a new RRA (DYNOtest® TRAKhuman) which uses the human recombinant TSH-Receptor in the diagnosis of autoimmune thyroid disease. Methods: Sera from 142 consecutive patients (GD: n=50, autoimmune thyroiditis/AIT: n=92) and from 55 controls (31 patients without any thyroid disease and 14 with euthyroid goiter) were evaluated both with the DYNOtest® TRAKhuman-assay and a conventional RRA (TRAK-Assay®). Thyroid in vitro parameters and thyroid sonography were performed in all patients. Results: The DYNOtest® TRAK-assay was significantly superior to the conventional RRA in the diagnosis of GD (p < 0,00012), especially in those who were treated by thionamides (p < 0,003) and in the diagnosis of TRAK-positive patients with AIT(p < 0,003). The majority of TRAK-positive AIT-patients suffered from hypothyroidism. One false positive result in patients with euthyroid goiter was found in the TRAK-Assay® as well as in the DYNOtest® TRAKhuman-Assay. Therefore the specifity of the DYNOtest® TRAKhuman was not inferior compared with the conventional assay. Conclusion: The DYNOtest® TRAK-assay is superior in the diagnostic work up of Graves’ disease compared with a conventional TRAK-assay and offeres an equal specifity.

Neurologist adherence to clinical practice guidelines and costs in patients with newly diagnosed and chronic epilepsy in Germany

PURPOSE

The aim of this study was to evaluate physician adherence to the German Neurological Society guidelines of 2008 regarding initial monotherapy and to determine the cost-of-illness in epilepsy.

METHODS

This was an observational cohort study using health data routinely collected at 55 outpatient neurology practices throughout Germany (NeuroTransData network). Data on socioeconomic status, course of epilepsy, anticonvulsive treatment, and direct and indirect costs were recorded using practice software-based questionnaires.

RESULTS

One thousand five hundred eighty-four patients with epilepsy (785 male (49.6%); mean age: 51.3±18.1years) were enrolled, of whom 507 were newly diagnosed. Initial monotherapy was started according to authorization status in 85.9%, with nonenzyme-inducing drugs in 94.3% of all AEDs. Drugs of first choice by guideline recommendations were used in 66.5%. Total annual direct costs in the first year amounted to €2194 (SD: €4273; range: €55-43,896) per patient, with hospitalization (59% of total direct costs) and anticonvulsants (30%) as the main cost factors. Annual total direct costs decreased by 29% to €1572 in the second year, mainly because of a 59% decrease in hospitalization costs. The use of first choice AEDs did not influence costs. Chronic epilepsy was present in 1077 patients, and total annual direct costs amounted to €1847 per patient, with anticonvulsants (51.0%) and hospitalization (41.0%) as the main cost factors. Potential cost-driving factors in these patients were active epilepsy and focal epilepsy syndrome.

CONCLUSION

This study shows excellent physician adherence to guidelines regarding initial monotherapy in adults with epilepsy. Newly diagnosed patients show higher total direct and hospital costs in the first year upon diagnosis, but these are not influenced by adherence to treatment guidelines.