Clinical and preclinical pulmonary disease in newly diagnosed rheumatoid arthritis: a two-year follow-up study

OBJECTIVE

Pulmonary disease is a major cause of excess mortality among patients with rheumatoid arthritis (RA). Interstitial lung disease (ILD) is a feared complication, but the benefit of screening is unknown. The aim of this study was to assess the frequency of pulmonary disease, including ILD, in early RA.

METHOD

Patients with newly diagnosed RA were recruited prospectively at a single centre and underwent systematic pulmonary function tests (PFTs) and computed tomography (CT) scans at inclusion and after two years.

RESULTS

The study included 150 patients (mean age 57 years, 63% female; 59% current or former smokers). Of these, 136 underwent baseline PFTs and 137 CT. Mean forced expiratory volume in one second was 99% predicted and forced vital capacity 106%. Mean diffusing capacity of the lungs for carbon monoxide (DLCO) was 84% predicted. Frequently detected CT abnormalities were pulmonary nodules (42%), bronchiectasis (29%), and emphysema (20%). Two patients had clinically significant ILD and six had mild reticulation suggestive of preclinical ILD. No ILD progression was identified at two-year follow-up. Smoking was associated with DLCO<80% (p=0.004), combined hyperinflation and diffusion impairment (residual volume>120% and DLCO<80%) (p=0.004), and visual emphysema on CT (p<0.001).

CONCLUSION

Emphysema and bronchiectasis were common, but most patients had mild disease with preserved lung function. Preclinical or clinical ILD was seen in a minority in this early phase of RA. These findings suggest symptom-based screening and primary intervention focusing on smoking cessation rather than screening for ILD at the time of RA diagnosis.

Fibrinolytic Status and Risk of Death After Acute Pulmonary Embolism

BACKGROUND

Acute pulmonary embolism (PE) is a heterogeneous disease process with variable presentation and outcomes. The endogenous fibrinolytic system is a complex framework of regulatory pathways that maintains homeostasis by dissolving overabundant thrombi. We sought to investigate phenotypic profiles of the endogenous fibrinolytic system among patients presenting with acute PE and their impact on mortality.

METHODS

We enrolled all consecutive patients with acute PE in our institutional Pulmonary Embolism Response Team registry. We collected blood samples at the time of PE diagnosis and analyzed concentrations of plasminogen activator inhibitor 1 (PAI-1), thrombin-activatable fibrinolysis inhibitor (TAFI), and alpha-2-antiplasmin (A2A). We assessed the association of concentration of fibrinolytic inhibitors and 1-year all-cause mortality and various echocardiographic markers of right ventricular (RV) dysfunction.

RESULTS

There is significant variability of PAI-1, A2A, and TAFI concentrations across the spectrum of PE risk profiles with high PAI-1, low TAFI, and low A2A (herein referred to as a high-risk biomarker profile) correlating with worse PE severity. High-risk biomarker profile correlated with high-risk echocardiographic features of RV dysfunction, including increased RV/left ventricular (LV) ratio, low tricuspid annular plane systolic excursion, and low right ventricular outflow tract velocity time integral. Higher-risk biomarker profile was able to discriminate and independently identify patients at high risk of all-cause mortality (Group 2 HR 6 95% CI 1.3-27.8, Group 3 HR 12, 95% CI 1.7-86).

CONCLUSIONS

Further studies are needed to assess the exact pathophysiological link between fibrinolytic status and poor outcome after acute PE and to ascertain the impact of anti-inhibitors of the fibrinolytic system on response to therapy and outcomes after acute PE.

Angiopoietin-2 correlates with pulmonary embolism severity, right ventricular dysfunction, and intensive care unit admission

Risk stratification of acute pulmonary embolism (PE) is important to identify patients at risk for hemodynamic collapse who would benefit from more aggressive therapies. Angiopoietin-2 (Ang-2) is a signaling molecule involved in angiogenesis and is upregulated in response to tissue hypoxia. We aimed to assess the association of Ang-2 with (1) PE severity, (2) echocardiographic and invasive hemodynamic markers of right ventricular (RV) dysfunction, and (3) need for intensive treatment. Patients presenting to our institution with acute PE were included in a prospective database and blood samples were collected and stored for later analysis. A total of 65 patients were included in the study. Ang-2 correlated with PE risk stratification and echocardiographic and invasive hemodynamic markers of RV dysfunction and pulmonary hypertension. An Ang-2 level of > 4101 pg/mL had an odds ratio of 7.4 (95% CI: 1.53-12.5, p < 0.01) for intensive care unit (ICU) admission. In conclusion, Ang-2 correlates with PE severity, RV dysfunction, and need for ICU admission. Ang-2 holds promise as a novel marker that can aid in risk stratification for this patient population.

Four-factor Prothrombin Complex Concentrate for Reversal of Factor Xa Inhibitors versus Warfarin in Life-threatening Bleeding

INTRODUCTION

Factor Xa (fXa) inhibitor reversal for life-threatening bleeding is controversial due to a lack of high-quality evidence. The purpose of this study was to determine the hemostatic efficacy of four-factor prothrombin complex concentrate (4F-PCC) for the reversal of fXa inhibitors compared to warfarin for life-threatening bleeding.

METHODS

This was a multicenter, retrospective cohort study at two academic medical centers between January 1, 2014-December 31, 2019, which included patients who presented to the emergency department with a life-threatening bleed necessitating anticoagulation reversal with 4F-PCC. The primary endpoint was achievement of hemostatic efficacy after 4F-PCC administration.

RESULTS

Of the 525 patients who had an order for 4F-PCC during the study period, 148 patients met the criteria for inclusion (n = 48 fXa inhibitor group; n = 100 warfarin group). Apixaban (52.1%) and rivaroxaban (45.8%) were the most commonly used fXa inhibitors. Effective hemostasis was similar between groups (79.2% fXa inhibitor group vs 85% warfarin group, p = 0.38). This was consistent across all types of bleeding. Thrombotic events were rare in both groups (2% vs 3%).

CONCLUSION

This multicenter, retrospective cohort study demonstrated that using 4F-PCC for treatment of life-threatening bleeding produced effective hemostasis in patients on fXa inhibitors and warfarin.

Impact of Pulmonary Embolism Response Team on Anticoagulation Prescribing Patterns in Patients With Acute Pulmonary Embolism

INTRODUCTION

Anticoagulation remains the mainstay pharmacotherapy for acute pulmonary embolism (PE), but multiple treatment options exist. The Pulmonary Embolism Response Team (PERT) is a multidisciplinary group that evaluates patients, formulates evidence-based treatment plans, and mobilizes resources. The objective of this study was to characterize the anticoagulation prescribing patterns made by PERT and to determine the clinical impact of anticoagulant selection.

MATERIALS AND METHODS

This was a retrospective analysis of patients evaluated by PERT from 2016 to 2018. Multivariable linear regression was conducted to determine predictors of length of stay (LOS).

RESULTS

A total of 209 patients were evaluated by PERT and received anticoagulation on discharge. Of those, 47% received a non-vitamin K oral anticoagulant (NOAC), 29% received warfarin, and 23% received low-molecular-weight heparin. Patient preferences and comorbidities were the most common reasons for NOAC omission. Patients who received NOACs had a shorter median LOS than warfarin (6.1 [4.6-7.6] days vs 10.9 [8.4-13.4] days; P < .05). Selection of NOAC upon discharge was the only factor independently associated with reduced LOS (β coefficient: -0.6; 95% CI: -1.01 to -0.18; P < .01).

CONCLUSION

The most common recommendation made by PERT was to initiate a NOAC upon discharge, resulting in shorter hospital LOS compared to patients who received warfarin.

FRI0069 EFFECTS OF ADALIMUMAB ADDED TO TREAT-TO-TARGET STRATEGY WITH METHOTREXATE AND INTRA-ARTICULAR TRIAMCINOLONE ON LIPIDS IN EARLY- AND TREATMENT NAÏVE RHEUMATOID PATIENTS: SECONDARY ANALYSES FROM THE MULTICENTER DOUBLE-BLIND, RANDOMIZED, PLACEBO-CONTROLLED OPERA TRIAL

Background:

Systemic inflammation in rheumatoid arthritis (RA) is associated with reduced serum lipid levels (LL) and treatment with disease modifying antirheumatic drugs has been associated with increased serum LL [1]. It is unclear whether the changes in serum LL reported in association with adalimumab (ADA) treatment are due to suppressed inflammation or the ADA treatmentper se.

Objectives:

The primary objective was to compare the effect of ADA + methotrexate (MTX) to placebo (PBO) + MTX on changes in low density lipoprotein cholesterol (LDL-C) from baseline to month 12 in patients with early- and treatment naïve RA. Secondary objectives were to compare the treatment groups on changes in total cholesterol (TC), high density lipoprotein cholesterol (HDL-C), triglycerides, very low density lipoprotein cholesterol (VLDL-C) and non-HDL-C (=TC – HDL-C).

Methods:

We present secondary analyses from the OPERA trial, which was an investigator-initiated, multicenter double-blind, placebo-controlled, treat-to-target trial of 180 early and treatment naïve RA patients, who were randomized (1:1) to oral MTX 20 mg once a week in combination with either PBO or ADA 40 mg SC EOW [2]. Any swollen joint was injected with triamcinolone hexacetonide. Lipid profiles of each patient were assessed at baseline and 12 months. All randomized patients with available LDL-C at baseline were included in Intention To Treat (ITT) analysis. Sensitivity analyses were performed on the Per Protocol (PP) and the ITT population with baseline observations carried forward (BOCF). All analyses were based on repeated measurements using mixed linear models.

Results:

In total, 174 patients (97% of the original OPERA trial population) were included in ITT analysis (ADA n=86; PBO n=88) and 156 patients (ADA n=78; PBO n=78) completed the study with LDL-C measurements at both baseline and 12 months (PP). At baseline mean LDL-C was 2.9 mmol/L (SD 0.9) with 63 (36.2%) patients having an LDL-C above 3.0 mmol/L. There was no significant difference in LDL-C change between ADA+MTX and PBO+MTX groups after 12 months. A nearly statistically significant between-group difference in TC change was found. Other changes in LL were comparable across the two groups. Results in ITT, PP and ITT with BOCF populations were similar.

Conclusion:

In early RA patients treated to target with methotrexate and intra-articular triamcinolone, 12 months with the addition of adalimumab did not affect lipid levels.

References:

[1]England BRet al., Bmj2018;361:k1036

[2]Hørslev-Petersen Ket al.,Ann Rheum Dis2014;73:654–61

Disclosure of Interests:

Dzenan Masic: None declared, Kristian Stengaard-Pedersen: None declared, Brian Bridal Løgstrup: None declared, Kim Hørslev-Petersen Grant/research support from: Pfizer (Travel expences), Merete L. Hetland Grant/research support from: BMS, MSD, AbbVie, Roche, Novartis, Biogen and Pfizer, Consultant of: Eli Lilly, Speakers bureau: Orion Pharma, Biogen, Pfizer, CellTrion, Merck and Samsung Bioepis, Peter Junker: None declared, Mikkel Ǿstergaard Grant/research support from: AbbVie, Bristol-Myers Squibb, Celgene, Merck, and Novartis, Consultant of: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Speakers bureau: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Christian Ammitzbøl: None declared, Sören Möller: None declared, Robin Christensen: None declared, Torkell Ellingsen: None declared

Table .

Change in primary and secondary outcomes in the ITT analysis

Right Ventricular Outflow Doppler Predicts Low Cardiac Index in Intermediate Risk Pulmonary Embolism

Intermediate-risk pulmonary embolism (PE) has variable outcomes. Current risk stratification models lack the positive predictive value to identify patients at highest risk of PE-related mortality. We identified intermediate-risk PE patients who underwent catheter-based interventions and right heart catheterization (RHC) and identified those with low cardiac index (CI < 2.2 L/min/m²). We utilized regression models to identify echocardiographic predictors of low CI and Kaplan Meier curve to evaluate PE-related mortality when stratified by the echocardiographic predictor. Of 174 intermediate-risk PE patients, 41 underwent RHC. Within this cohort, 46.3% had low CI. Univariable linear regression identified right ventricular outflow tract velocity time integral (RVOT VTI), right/left ventricular ratio, S prime, inferior vena cava diameter, and pulmonary artery systolic pressure as potential predictors of low CI. Multivariable linear regression identified RVOT VTI as significant predictor of low CI (β coefficient 0.124, 95% confidence interval [CI]: 0.01-0.24, P = .034). Right ventricular outflow tract velocity time integral <9.5 cm was associated with increased PE-related mortality, P = .002. A substantial proportion of intermediate-risk PE patients referred for catheter-based interventions had low CI despite normotension. Right ventricular outflow tract velocity time integral was a significant predictor of low CI. Low RVOT VTI was associated with increased PE-related mortality.

Delayed vasopressor initiation is associated with increased mortality in patients with septic shock

PURPOSE

Mortality rate for septic shock, despite advancements in knowledge and treatment, remains high. Treatment includes administration of broad-spectrum antibiotics and stabilization of the mean arterial pressure (MAP) with intravenous fluid resuscitation. Fluid-refractory shock warrants vasopressor initiation. There is a paucity of evidence regarding the timing of vasopressor initiation and its effect on patient outcomes.

MATERIALS AND METHODS

This retrospective, single-centered, cohort study included patients with septic shock from January 2017 to July 2017. Time from initial hypotension to vasopressor initiation was measured for each patient. The primary outcome was 30-day mortality.

RESULTS

Of 530 patients screened,119 patients were included. There were no differences in baseline patient characteristics. Thirty-day mortality was higher in patients who received vasopressors after 6 h (51.1% vs 25%, p < .01). Patients who received vasopressors within the first 6 h had more vasopressor-free hours at 72 h (34.5 h vs 13.1, p = .03) and shorter time to MAP of 65 mmHg (1.5 h vs 3.0, p < .01).

CONCLUSION

Vasopressor initiation after 6 h from shock recognition is associated with a significant increase in 30-day mortality. Vasopressor administration within 6 h was associated with shorter time to achievement of MAP goals and higher vasopressor-free hours within the first 72 h.

Delayed vasopressor initiation is associated with increased mortality in patients with septic shock

PURPOSE

Mortality rate for septic shock, despite advancements in knowledge and treatment, remains high. Treatment includes administration of broad-spectrum antibiotics and stabilization of the mean arterial pressure (MAP) with intravenous fluid resuscitation. Fluid-refractory shock warrants vasopressor initiation. There is a paucity of evidence regarding the timing of vasopressor initiation and its effect on patient outcomes.

MATERIALS AND METHODS

This retrospective, single-centered, cohort study included patients with septic shock from January 2017 to July 2017. Time from initial hypotension to vasopressor initiation was measured for each patient. The primary outcome was 30-day mortality.

RESULTS

Of 530 patients screened,119 patients were included. There were no differences in baseline patient characteristics. Thirty-day mortality was higher in patients who received vasopressors after 6 h (51.1% vs 25%, p < .01). Patients who received vasopressors within the first 6 h had more vasopressor-free hours at 72 h (34.5 h vs 13.1, p = .03) and shorter time to MAP of 65 mmHg (1.5 h vs 3.0, p < .01).

CONCLUSION

Vasopressor initiation after 6 h from shock recognition is associated with a significant increase in 30-day mortality. Vasopressor administration within 6 h was associated with shorter time to achievement of MAP goals and higher vasopressor-free hours within the first 72 h.

Traditional matriculation vs an early assurance program: Effect on elected student leadership positions and academic performance

INTRODUCTION

The objective of this study was to compare leadership and academic performance among students admitted by traditional pathways vs. a dual acceptance program (DAP).

METHODS

A list of students admitted to the Midwestern University Chicago College of Pharmacy (MWUCCP) DAP was cross-checked with students elected to serve in leadership positions and students on the MWUCCP Dean's List for their first professional year from 2010 to 2015. The proportion of students serving in leadership positions and those on the Dean's List were compared to students that matriculated via the traditional route.

RESULTS

In total, 1069 students were analyzed (n = 937 traditional; n = 132 DAP). DAP students were more likely to have an elected leadership role (n = 61, 46.2% vs. n = 314, 33.5%, p < 0.01) and achieve Dean's List for their first professional year (n = 64, 48.5% vs. n = 292, 31.2%, p < 0.01) compared to traditional students.

DISCUSSION AND CONCLUSIONS

DAP students were more likely to hold an elected leadership position than traditional students. Further study of DAP student motivation is needed to potentially assist in the success of other students.

Implementation of a pharmacy research committee to enhance the pharmacy resident research experience

BACKGROUND AND PURPOSE

Most postgraduate year 1 (PGY1) pharmacy residents complete at least one research project as part of their graduation requirements. The research skills learned prepare residents to address research questions and generate evidence-based recommendations for patient care. However, there are multiple steps involved in a research project, and streamlining this process can be difficult.

EDUCATIONAL ACTIVITY AND SETTING

Northwestern Memorial Hospital (NMH), a large academic center located in Chicago, IL, developed a research committee (RC) to facilitate research within the department of pharmacy for residents and to maintain residency research support materials. These materials included a charter to help guide the organizational structure and operations of the RC, research timelines, and a seminar series.

FINDINGS

The RC works to ensure that the residents overcome any challenges that they may incur during their research projects by setting clear expectations and milestones. Feedback is provided by the residents and incorporated into the research process and support materials.

DISCUSSION

The RC allows for individualized attention and personalization of the research experience for each resident. The program endeavors each year to provide the message that publication should be the final goal of a research project and not presentation at a conference.

SUMMARY

Pharmacy residents receive support from the RC from throughout the year, not only when issues surround their project arise. Institutions may implement or modify existing programs based upon the resources provided.

Analysis of PGY-1 Pharmacy Resident Candidate Letters of Recommendation at an Academically Affiliated Residency Program

Background:

Letters of recommendation (LORs) are a critical component for differentiating among similarly qualified pharmacy residency candidates. These letters contain information that is difficult to ascertain from curricula vitae and pharmacy school transcripts. LOR writers may use any words or phrases appropriate for each candidate as there is no set framework for LORs.

Objective:

The objective of this study was to characterize descriptive themes in postgraduate year 1 (PGY-1) pharmacy residency candidates’ LORs and to examine which themes of PGY-1 pharmacy residency candidates’ LORs are predictive of an interview invitation at an academically affiliated residency program.

Methods:

LORs for candidates from the Pharmacy Online Residency Centralized Application System (PhORCAS) from 2013 and 2014 for the Midwestern University PGY-1 Pharmacy Residency were analyzed. LOR characteristics and descriptive themes were collected. All scores for candidate characteristics and overall PhORCAS recommendation were also recorded.

Results:

A total of 351 LORs for 111 candidates from 2013 (n = 47 candidates) and 2014 (n = 64 candidates) were analyzed; 36 (32.4%) total candidates were offered an interview. Themes that were identified as predictors of an interview included a higher median (interquartile range) number of standout words (3 words [1.3-4] vs 3.8 words [2.5-5.5], P < .01) and teaching references (3.7 words [2.7-6] vs 5.7 words [3.7-7.8], P = .01).

Conclusion:

For this residency program, standout words and teaching references were important when offering interviews.

Left ventricular function at two-year follow-up in treatment-naive rheumatoid arthritis patients is associated with anti-cyclic citrullinated peptide antibody status: a cohort study

OBJECTIVES

In rheumatoid arthritis (RA), the role of autoimmunity, especially anti-cyclic citrullinated peptide antibody (anti-CCP) level, and the time-course of left ventricular (LV) function is unknown. The objective was to assess LV function and the amount of coronary calcium in relation to anti-CCP levels in a cohort of treatment-naive RA patients, and to assess changes in these parameters during a 2 year follow-up period.

METHOD

Sixty-six steroid- and disease-modifying anti-rheumatic drug-naive RA patients were treated with methotrexate according to the Danish national guidelines. We assessed LV function by conventional echocardiography and speckle-tracking echocardiography. We estimated the amount and progression of coronary calcium by coronary computed tomography. Patients were examined at the time of diagnosis and after 2 years.

RESULTS

Patients with elevated anti-CCP at baseline and after 2 years, compared to those with non-persistently elevated anti-CCP, had significantly less improvement in S´ (1 ± 1.4 cm/s vs 0.2 ± 0.9 cm/s; p = 0.04) and a worsening in global longitudinal systolic strain (GLS) (0.6 ± 1.8% vs -1 ± 2.8%; p = 0.04). There was a significant correlation between ΔGLS over 2 years and anti-CCP at 2 year follow-up (r = 0.36; p = 0.006). We observed a small progression of coronary calcium score during the 2 year follow-up period. No differences in progression were found between patients with high anti-CCP titres at baseline and 2 year follow-up (n = 12) and patients with normal/low anti-CCP titres (n = 32) (23.8 ± 40.3 vs 22.6 ± 68.9; p = 0.96).

CONCLUSIONS

Deformation analysis by speckle-tracking echocardiography is a valuable tool to detect early development of myocardial dysfunction despite normal ejection fraction in RA.

c-MYC is a radiosensitive locus in human breast cells

Ionising radiation is a potent human carcinogen. Epidemiological studies have shown that adolescent and young women are at increased risk of developing breast cancer following exposure to ionising radiation compared with older women, and that risk is dose-dependent. Although it is well understood which individuals are at risk of radiation-induced breast carcinogenesis, the molecular genetic mechanisms that underlie cell transformation are less clear. To identify genetic alterations potentially responsible for driving radiogenic breast transformation, we exposed the human breast epithelial cell line MCF-10A to fractionated doses of X-rays and examined the copy number and cytogenetic alterations. We identified numerous alterations of c-MYC that included high-level focal amplification associated with increased protein expression. c-MYC amplification was also observed in primary human mammary epithelial cells following exposure to radiation. We also demonstrate that the frequency and magnitude of c-MYC amplification and c-MYC protein expression is significantly higher in breast cancer with antecedent radiation exposure compared with breast cancer without a radiation aetiology. Our data also demonstrate extensive intratumor heterogeneity with respect to c-MYC copy number in radiogenic breast cancer, suggesting continuous evolution at this locus during disease development and progression. Taken together, these data identify c-MYC as a radiosensitive locus, implicating this oncogenic transcription factor in the aetiology of radiogenic breast cancer.