How do we measure unmet need within sexual and reproductive health? A systematic review

BACKGROUND

Addressing health inequality with sexual and reproductive health requires an understanding of unmet need within a range of populations. This review examined the methods and definitions that have been used to measure unmet need, and the populations most frequently assessed.

METHODS

Five databases (PubMed, Web of Science, Scopus, The Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Health Management and Policy Database (HMIC)) were searched for studies that described quantitative measurement of unmet need within sexual and/or reproductive health between 2010 and 2021. A narrative synthesis was then undertaken to ascertain themes within the literature.

RESULTS

The database search yielded 19,747 papers; 216 papers were included after screening. 190 studies assessed unmet reproductive health need, of which 137 were analyses of trends among people living in low/lower-middle income countries; 181 used cross-sectional data, with only nine analyses being longitudinal. Eighteen studies analysed unmet sexual health need, of which 12 focused on high and upper-middle income populations. 16 papers used cross-sectional analyses. The remaining 10 studies examined unmet need for a combination of sexual and reproductive health services, eight among populations from upper-middle or high income countries. All were cross-sectional analyses. 165 studies used the Demographic and Health Surveys (DHS) definition of unmet need; no other standardised definition was used among the remaining papers.

DISCUSSION

There is a significant focus on unmet need for contraception among women in low income countries within the published literature, leaving considerable evidence gaps in relation to unmet need within sexual health generally and among men in particular, and unmet reproductive health need in high income settings. In addition, using an increased range of data collection methods, analyses and definitions of unmet need would enable better understanding of health inequality in this area.

Sexual health inequalities among women aged 16-24

Introduction

Gonorrhoea is the second most commonly diagnosed sexually transmitted infection in England, and diagnoses among young women increased 31% between 2018 and 2019. Understanding the patterns of testing and diagnosis among young women is likely to aid prevention among the most vulnerable segments of this population.

Methods

Data on gonorrhoea diagnoses at sexual health services among women aged 16-24 in England were obtained using the GUMCAD STI Surveillance System. We investigated the relationship between two exposure variables (deprivation and ethnicity), and two outcome variables (number of gonorrhoea tests and number of gonorrhoea diagnoses). Poisson regression was used to calculate rate ratios for the relationship between the exposure and outcome variables. The testing analysis was offset for the size of the population, and the diagnosis analysis was offset for the number of tests within the population.

Results

Between 2012 and 2019, gonorrhoea testing and diagnosis rates were highest among women living in the most deprived areas. The rate of testing in the least deprived 10% of neighbourhoods was significantly lower than that seen in the most deprived 10% of neighbourhoods (rate ratio (RR) 0.79; 95% confidence interval 0.79 - 0.80), and the rate of diagnosis in the least deprived 10% of neighbourhoods was around a third of that seen in the most deprived 10% of neighbourhoods (0.35; 0.33 - 0.36). When compared to White British women, the rate of gonorrhoea diagnosis was lower among Bangladeshi (RR 0.89; 0.75 - 1.05), Indian (0.76; 0.68 - 0.84), Pakistani (0.87; 0.77 - 1.00) and Chinese women (0.60; 0.51 - 0.71) and was highest among Black Caribbean (2.26; 2.18 - 2.33) and Black African (1.40; 1.34 - 1.45) women.

Conclusions

This analysis found inequalities in the distribution of gonorrhoea among young women in England that may indicate structural barriers to STI prevention that are affecting Black women and those living within the most deprived populations.

Key messages

• Gonorrhoea testing rates among young women in England are highest among women from deprived areas and Black women.

• Gonorrhoea diagnosis rates among young women in England are highest among women from deprived areas and Black women.

POS1224 RHEUMATOID ARTHRITIS DISEASE ACTIVITY ASSESSED BY PATIENT-REPORTED OUTCOMES AND FLOW CYTOMETRY BEFORE AND AFTER AN ADDITIONAL DOSE OF COVID-19 VACCINE

Background

The Centers for Disease Control and Prevention recommends an additional dose (AddDose) of COVID-19 vaccine for moderately/severely immunosuppressed individuals following an initial vaccine series. The American College of Rheumatology suggests that patients interrupt use (hold) certain DMARDs around the time of COVID-19 vaccination to improve immunogenicity. Whether holding DMARDs around an AddDose of COVID-19 vaccine affects RA disease activity or affects frequencies of lymphocyte populations that may be associated with RA disease activity remains unknown.

Objectives

To test whether RA disease activity and frequencies of lymphocyte populations change pre- vs. post-AddDose of COVID-19 vaccine, overall and stratified by holding vs. continuation of DMARDs around the AddDose.

Methods

Prospective observational cohort study of patients with RA who had completed an initial COVID-19 vaccine series (2 doses of mRNA vaccine or 1 dose of adenovirus vector vaccine). Subjects enrolled July-November 2021, prior to receiving an AddDose. Subjects held or continued DMARDs around the AddDose based on discussion with their rheumatologist and/or personal decision-making. RA disease activity was assessed weekly using the validated patient-reported RA Disease Activity Index-5 (RADAI-5) from enrollment through 4 weeks post-AddDose. We compared mean RADAI-5 pre- vs. post-AddDose using generalized estimating equations to account for correlated data among individual subjects. We aimed to enroll 60 subjects to achieve 91% power to detect a 15% non-inferiority margin in mean RADAI-5 post- vs. pre-AddDose. A subset of subjects with seropositive RA provided blood for flow cytometry at enrollment and week 4 post-AddDose. Frequencies of lymphocyte populations (T peripheral helper [Tph] cells, T follicular helper [Tfh] cells, age-associated B cells [ABC], and plasmablasts) were compared pre- vs. post-AddDose using Wilcoxon paired tests with Bonferroni correction.

Results

Among 71 subjects, mean age was 62 (SD 12) years, 85% were female, and 87% had seropositive RA. Methotrexate (42%) and TNF inhibitors (38%) were the most common DMARDs; 21% were taking prednisone. One subject reported COVID-19 infection prior to the AddDose. The mean RADAI-5 was 3.20 (SD 0.23) pre-AddDose compared to 3.25 (SD 0.23) after (difference of 1.6%, p=0.51). Figure 1 displays mean RADAI-5 in 35 (49%) subjects that held at least 1 DMARD and 36 (51%) subjects that continued all DMARDs around the AddDose. Mean change in RADAI-5 between pre- vs. post-AddDose did not significantly differ based on whether subjects held vs. continued DMARDs (p for interaction = 0.16). Frequencies of Tph, Tfh, ABC, and plasmablast populations did not significantly differ between the pre- and post-AddDose timepoints in subjects that held at least 1 DMARD (n=16) or subjects that continued all DMARD (n=11) (Figure 1).

Conclusion

RA disease activity, measured weekly with a validated patient-reported outcome, is stable around the time of an AddDose of COVID-19 vaccine. Lymphocyte subsets of interest in RA were also similar before and after the AddDose, supporting the observation of stable patient-reported RA disease activity. Holding DMARDs was not associated with greater RA disease activity following the AddDose.

Disclosure of Interests

Sara Tedeschi Consultant of: NGM Biopharmaceuticals: payment to Dr. Tedeschi, Grant/research support from: Moderna: research support to institution, Jacklyn Stratton: None declared, Jack Ellrodt: None declared, Mary Grace Whelan: None declared, Keigo Hayashi: None declared, Kazuki Yoshida Consultant of: OM1, Inc: consulting fees paid to Dr. Yoshida, Lin Chen: None declared, Ifeoluwakiisi Adejoorin: None declared, Kathryne E. Marks: None declared, A. Helena Jonsson Grant/research support from: Moderna: research support to institution

Amgen: payment to institution for unrelated project, Deepak Rao Speakers bureau: Merck: honoraria lecture paid to Dr. Rao, Consultant of: Janssen: consulting fees paid to Dr. Rao

Bristol Myers Squibb: participation on scientific advisory board with compensation paid to Dr. Rao, Grant/research support from: Moderna: research funding paid to institution

Janssen: research funding paid to institution

Merck: research funding paid to institution, Daniel Solomon Grant/research support from: Moderna: payment made to institution

Amgen: payment to institution

Abbvie: payment to institution

CorEvitas: payment to institution

POS0219 EFFECT OF LOW-DOSE METHOTREXATE ON ESTIMATED GLOMERULAR FILTRATION RATE AND KIDNEY ADVERSE EVENTS IN THE CARDIOVASCULAR INFLAMMATION REDUCTION TRIAL

Background:

Low-dose methotrexate (LD-MTX) is a common first-line treatment for systemic rheumatic diseases, and its use is contraindicated in advanced chronic kidney disease (CKD) because it is primarily excreted by the kidneys. Among patients with preserved kidney function, the safety of LD-MTX on estimated glomerular filtration rate (eGFR) and kidney adverse events (AEs) has not been established.

Objectives:

To investigate the effect of LD-MTX on eGFR and kidney AEs using data from a randomized clinical trial.

Methods:

We performed a secondary analysis for eGFR and kidney AEs using the randomized double-blind, placebo-controlled Cardiovascular Inflammation Reduction Trial. Adults with known cardiovascular disease and diabetes and/or metabolic syndrome were randomly allocated to oral LD-MTX (target dose 15-20 mg/week) or placebo. All participants took folic acid 1 mg six days/week. Exclusion criteria included systemic inflammatory disease and creatinine clearance <40 mL/min (by Cockcroft-Gault). eGFR was calculated using the CKD-EPI formula. Clinical kidney AEs were blindly adjudicated. The least-squares mean change of eGFR from baseline was calculated at each study visit; the difference in eGFR slopes between LD-MTX and placebo was compared using a modified intention-to-treat approach. We also compared rates of kidney AEs for LD-MTX versus placebo using Cox proportional hazards models.

Results:

A total of 2,391 subjects were randomized to LD-MTX and 2,395 to placebo. At baseline, mean age was 66 years, 19% were female, mean eGFR was 80.0 mL/min/1.73m2, and 18% had stage 3 CKD or worse. Median follow-up duration was 23 months, and median LD-MTX dose was 16 mg/week. Those randomized to LD-MTX had less decline in eGFR over the entire follow-up compared to placebo (slope difference 1.12, 95%CI 0.59-1.65, p<0.001, Figure 1). Those with CKD stage 3 or worse on LD-MTX saw less eGFR decline than those with CKD stage 2 or better (slope difference among CKD stage 3 or worse: 2.46, 95%CI 1.10-3.82, p<0.001; p for interaction 0.02). The LD-MTX group had higher eGFR than placebo over the first 24 months of study follow-up (p<0.05 at each visit). On safety laboratory monitoring, there were 159 acute kidney injury AEs in the LD-MTX group and 187 in the placebo group (HR 0.83, 95%CI 0.67-1.02, Table 1). There were 37 clinical kidney AEs in the LD-MTX group and 42 in the placebo group (0.87, 95%CI 0.56-1.36). One subject began dialysis in the LD-MTX group compared to 3 in the placebo group.

Table 1.

Rates and hazard ratios for kidney adverse events per random assignment of low-dose methotrexate or placebo in the Cardiovascular Inflammation Reduction Trial (n=4,786).

Low-dose methotrexate (n=2,391)Placebo (n=2,395) (reference)HR (95%CI)EventsRate per 100 person-years (95%CI)EventsRate per 100 person-years (95%CI)SCr collected at safety visitsAny event*1593.42 (2.93, 3.98)1874.06 (3.53, 4.67)0.83 (0.67, 1.02)Mild (SCr 1.5-1.9x baseline)1543.47 (2.97, 4.06)1774.06 (3.51, 4.69)0.85 (0.68, 1.06)Moderate (SCr 2-2.9x baseline)190.41 (0.26, 0.64)240.52 (0.35, 0.78)0.78 (0.43, 1.43)Severe (SCr ≥3x baseline)20.04 (0.01, 0.17)50.11 (0.05, 0.26)0.40 (0.08, 2.04)Adjudicated clinical kidney adverse eventsAny event*370.80 (0.58, 1.11)420.92 (0.68, 1.24)0.87 (0.56, 1.36)Mild240.52 (0.35, 0.77)250.55 (0.37, 0.81)0.95 (0.55, 1.67)Moderate110.24 (0.13, 0.43)110.24 (0.13, 0.43)1.00 (0.43, 2.29)Severe40.09 (0.03, 0.23)80.17 (0.09, 0.35)0.50 (0.15, 1.64)New dialysis10.02 (0.00, 0.15)30.17 (0.09, 0.35)0.34 (0.04, 3.17)

*Acute kidney injury presence and severity was defined by KDIGO (Kidney Disease: Improving Global Outcomes) classification.

CI, confidence interval; HR, hazard ratio; SCr, serum creatinine.

Conclusion:

These results demonstrate the kidney safety of LD-MTX among patients without advanced CKD at baseline. We observed a possible beneficial effect of LD-MTX on preserving kidney function, suggesting that inflammation may be involved in the pathogenesis of CKD in this population.

Disclosure of Interests:

Jeffrey Sparks Consultant of: Dr. J Sparks has performed consultancy for Bristol-Myers Squibb, Gilead, Inova Diagnostics, Optum, and Pfizer unrelated to this work., Grant/research support from: Dr. J Sparks has received research support from Bristol-Myers Squibb., Kathleen Vanni: None declared, Matthew Sparks: None declared, Chang Xu: None declared, Leah Santacroce: None declared, Robert Glynn Grant/research support from: Dr. Glynn has received grant support unrelated to the present research from AstraZeneca, Kowa, Pfizer, and Novartis., Paul Ridker Consultant of: Dr. Ridker has served as a consultant to Corvidia, Inflazome, and CiviBioPharm., Grant/research support from: Dr. Ridker receives research support unrelated to the present study from Kowa, Novartis, and Amarin., Daniel Solomon Grant/research support from: Dr. Solomon receives research support unrelated to the present study from Abbvie, Amgen, Corrona, Genentech, Janssen, and Pfizer.

OP0101 RHEUMATOID ARTHRITIS DISEASE ACTIVITY OVER TIME AND SUBSEQUENT CARDIOVASCULAR RISKS

Background:

Rheumatoid arthritis (RA) patients have an increased risk of cardiovascular (CV) events not fully explained by traditional CV risk factors. The relationship between fluctuating inflammation due to RA disease activity and CV events is of interest.

Objectives:

To examine the influence of time-varying disease activity on the subsequent risks of CV disease.

Methods:

We followed patients from a large US registry of clinically diagnosed RA patients, starting at their first visit with a Clinical Disease Activity Index (CDAI) through the end of follow-up or first CV event. Exposure of interest was disease activity measured by categorical CDAI (high, moderate, low, and remission) averaged within each 6-month window. The outcome of interest was major adverse CV events (MACE) defined as non-fatal myocardial infarction, non-fatal stroke (excluding transient ischemic attacks), and CV death. For baseline confounders we considered age, gender, race, disease duration, Health Assessment Questionnaire, hypertension, diabetes, hyperlipidemia, family history of premature (age<50) CV events, and RF/ACPA seropositivity. For time-varying variables we considered tumor necrosis factor inhibitor (TNFi), non-TNFi biologic, methotrexate, oral glucocorticoid, non-steroidal anti-inflammatory drugs, statin, and aspirin use. We used the marginal structural model (MSM) framework to examine the impact of CDAI at each 6-month interval on MACE. We estimated time-varying hazard ratios (HRs) comparing high CDAI during follow-up to CDAI remission. Several predicted survival curves were constructed under different hypothetical CDAI scenarios, such as early and late transition to CDAI remission.

Results:

40,721 patients were eligible for our analyses. 77% were female and 84% were Caucasian. The mean age was 58 (SD 13) years with mean disease duration of 8.8 (median 5) years. Mean CDAI at their first registry visit was 14 (SD 13; remission 19%, low 31%, moderate 28%, and high 22%). Other baseline characteristics include: 41% current/former smokers, 31.5% with hypertension, 8.6% with diabetes, 18% with hyperlipidemia, and 52% seropositive. The average follow-up duration after baseline was 4.4 (median 3.3; max. 17.6) years. The crude event count of MACE was 1,050 events / 180,402 person-years.

In the MSM analysis, the average HRs, assuming a constant HR, were 1.31 [0.90, 1.90] for low, 1.46 [1.01, 2.10] for moderate, and 1.43 [0.89, 2.31] for high CDAI disease activity categories during each 6-month interval. When approximating time-varying HR with linear trends, the highest estimates during the first 6 months of follow up were 1.61 [0.93, 2.77] for low CDAI, 1.97 [1.13, 3.43] for moderate CDAI, and 2.11 [1.13, 3.96] for high CDAI. These HRs gradually diminished during the follow up (Table). When we constructed hypothetical survival curves with transition to CDAI remission at different time points, earlier transition to CDAI remission was related to better event-free survival (Figure).

Table 1.

Time-varying hazard ratio estimates [95% confidence intervals] by duration in study

Disease activity measured by CDAIYearRemissionLowModerateHigh0.51.00 [ref]1.61 [0.93, 2.77]1.97 [1.13, 3.43]2.11 [1.13, 3.96]11.00 [ref]1.54 [0.97, 2.44]1.85 [1.17, 2.93]1.94 [1.13, 3.31]21.00 [ref]1.42 [1.00, 2.01]1.63 [1.16, 2.29]1.62 [1.04, 2.54]31.00 [ref]1.31 [0.90, 1.90]1.43 [0.97, 2.11]1.36 [0.80, 2.31]41.00 [ref]1.20 [0.72, 2.02]1.26 [0.72, 2.21]1.14 [0.55, 2.36]51.00 [ref]1.11 [0.54, 2.26]1.11 [0.51, 2.42]0.96 [0.36, 2.53]Figure 1.

MACE-free survival curves under hypothetical CDAI scenarios

Conclusion:

High and moderate CDAI were associated with higher hazard of MACE during the earlier period of follow-up, but the increased hazard diminished over time. In hypothetical senarios, earlier transition to CDAI remission would improve MACE free-survival.

Acknowledgements:

This study was sponsored by Corrona, LLC. Corrona is supported through contracted subscriptions with multiple pharmaceutical companies. The analysis was financially supported by Amgen Inc.

Disclosure of Interests:

Kazuki Yoshida Consultant of: OM1, Inc., Grant/research support from: Corrona, LLC., Hongshu Guan: None declared, Scott Stryker Shareholder of: Amgen, Inc., Employee of: Amgen, Inc., Elaine Karis Shareholder of: Amgen, Inc., Employee of: Amgen, Inc., Leslie Harrold Consultant of: AbbVie, Bristol-Myers Squibb, Genentech/Roche, Grant/research support from: Pfizer, Daniel Solomon Grant/research support from: DHS receives salary support from research contracts through Brigham and Women’s Hospital with Abbvie, Amgen, Corrona, Genentech and Janssen.

SAT0453 DELAYED DENOSUMAB INJECTIONS AND FRACTURES RISK AMONG SUBJECTS WITH OSTEOPOROSIS: A POPULATION-BASED COHORT STUDY

Background:

Denosumab is effective for osteoporosis, but discontinuation leads to rapid reversal of its therapeutic effect[1].

Objectives:

To estimate the risk for fracture among users of denosumab who delayed subsequent dosages compared with users who received dosages on time.

Methods:

Population-based cohort study. We included patients aged over 45 years who initiated denosumab for osteoporosis from UK THIN database, 2010 to 2019. Observational data were used to “emulate a hypothetical trial”[2, 3] with three dosing intervals: subsequent denosumab injection 24-28 weeks after prior dose (“on time”), delay by 4-16 weeks (“short delay”), and delay by over 16 weeks (“long delay”). The primary outcome was a composite of all fracture types. Secondary outcomes included major osteoporotic fracture, vertebral fracture, and hip fracture.

Results:

The rate of composite fracture per 1000 person-years was 58.9 for on-time, 61.7 for short delay, and 85.4 for long delay of subsequent denosumab injections. Compared to on-time injections, short delay had a hazard ratio (HR) for composite fracture 1.03 (95% CI 0.63-1.69) and long delay HR 1.44 (95% CI 0.96-2.17; p for trend 0.093). For major osteoporotic fractures, short delay had an HR 0.94 (95% CI 0.57-1.55) and long delay an HR of 1.69 (95% CI 1.01-2.83; p for trend 0.056). For vertebral fractures, short delay had an HR 1.48 (95% CI 0.58-3.79) and long delay 3.91 (95% CI 1.62-9.45; p for trend 0.005).

Conclusion:

While delayed subsequent denosumab dosages over 16 weeks was associated with an increased risk of vertebral and major osteoporotic fracture compared to no delay, composite fracture risk was not increased with longer delays.

References:

[1]Cummings SR, Ferrari S, Eastell R, et al. Vertebral Fractures After Discontinuation of Denosumab: A Post Hoc Analysis of the Randomized Placebo-Controlled FREEDOM Trial and Its Extension. J Bone Miner Res, 2017.

[2]Hernán MA. How to estimate the effect of treatment duration on survival outcomes using observational data. BMJ 2018.

[3]Hernán MA, Robins JM. Using Big Data to Emulate a Target Trial When a Randomized Trial Is Not Available. Am J Epidemiol 2016.

Table.

Rates and Adjusted Hazard Ratios of Fracture

On-timeShort delayLong delayP for linear trendComposite FractureRate (per 1000 person-years)5961.785.4-Unadjusted HR (95 %)Ref1.05 (0.62, 1.76)1.45 (0.95, 2.21)0.097Adjusted HR (95% CI)†Ref1.03 (0.63, 1.69)1.44 (0.96, 2.17)0.093Major Osteoporotic FractureRate (per 1000 person-years)34.831.958-Unadjusted HR (95 %)Ref0.92 (0.55, 1.53)1.67 (0.98, 2.84)0.074Adjusted HR (95% CI)†Ref0.94 (0.57, 1.55)1.69 (1.01, 2.83)0.056Vertebral FractureRate (per 1000 person-years)4.97.319.4-Unadjusted HR (95 %)Ref1.47 (0.58, 3.71)3.93 (1.59, 9.72)0.006Adjusted HR (95% CI)†Ref1.48 (0.58, 3.79)3.91 (1.62, 9.45)0.005Hip FractureRate (per 1000 person-years)10.29.618.3-Unadjusted HR (95 %)Ref0.94 (0.43, 2.04)1.78 (0.80, 3.97)0.18Adjusted HR (95% CI)†Ref0.97 (0.44, 2.12)1.75 (0.81, 3.79)0.173

†Adjusted model: adjusted by age, sex, baseline CCI index, major osteoporotic fracture, oral BP duration (years), 10-year risk of major osteoporotic fracture, prior denosumab doses.

Acknowledgments:

We acknowledge Dr. Dani Prieto-Alhambra for kindly providing Read codes.

Disclosure of Interests:

Houchen Lyu: None declared, Kazuki Yoshida: None declared, Sizheng Steven Zhao: None declared, Xabier García-Albéniz: None declared, Jie Wei: None declared, Chao Zeng: None declared, Sara Tedeschi: None declared, Benjamin Leder Grant/research support from: Research funding from Amgen, Guanghua Lei: None declared, Peifu Tang: None declared, Daniel Solomon Grant/research support from: Funding from Abbvie and Amgen unrelated to this work

OP0111 RHEUMATOID ARTHRITIS SEROLOGIC PHENOTYPE AT DIAGNOSIS AND SUBSEQUENT RISK FOR PNEUMONIA IDENTIFIED USING MACHINE LEARNING APPROACHES

Background:

Patients with rheumatoid arthritis (RA) are at increased risk of serious infections, with considerable excess morbidity and mortality after pneumonia. RA-related autoantibodies such as anti-cyclic citrullinated peptide (CCP) and rheumatoid factor (RF) may be generated at inflamed pulmonary mucosa prior to clinical RA onset. Therefore, patients with seropositive RA may be at increased risk for pneumonia after RA diagnosis due to subclinical pulmonary injury.

Objectives:

We investigated whether seropositive RA was associated with increased pneumonia risk compared to seronegative RA.

Methods:

We performed a retrospective cohort study among RA patients seen at a health care system in Boston, MA. RA patients were identified using a previously validated electronic health record (EHR) algorithm incorporating billing codes, natural language processing (NLP) of notes, medications, and laboratory results at 97% specificity1. We constructed an incident RA cohort using NLP for the index date of initial mention of RA. All patients were required to have both CCP and RF data from clinical care to determine serologic RA phenotype. We used semi-supervised machine learning approaches to identify pneumonia using billing codes and terms extracted using NLP, with the Centers for Disease Control definition of pneumonia from medical record review as a gold standard. The area under the receiver operating curve (AUROC) for this billing code+NLP pneumonia algorithm was 0.94 compared to the standard rule-based pneumonia algorithm (billing code on inpatient discharge) AUROC of 0.86 (p<0.001). Smoking status was extracted using NLP methods. Other covariates, including a previous validated weighted RA multimorbidity score2, were determined using structured EHR data. We used Cox regression to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for pneumonia adjusting for potential confounders.

Results:

We analyzed a total of 4,110 patients with incident RA and both CCP/RF data available. Mean age at index date was 53.0 years (SD 14.8), 77.2% were female, and 79.8% were CCP+ or RF+. During 32,248 patient-years of follow-up (mean 7.8 years/patient), we identified 240 pneumonia cases. Patients with seropositive RA had a HR of 1.99 (95%CI 1.30-3.01, Table) for pneumonia compared to patients with seronegative RA, adjusted for age, sex, smoking, index year, ESR level, glucocorticoid use, DMARD use, and weighted RA multimorbidity score. While CCP+ RA (HR 1.91, 95%CI 1.23-2.97) and RF+ RA (HR 2.07, 95%CI 1.35-3.16) had increased pneumonia risk compared to seronegative RA, the CCP+RF- RA subgroup had no association with pneumonia (HR 0.67, 95%CI 0.23-1.93).

Conclusion:

Patients with incident seropositive RA, particularly RF+ RA, had increased risk for pneumonia throughout the RA disease course that was not explained by measured confounders including smoking status, multimorbidity, medications, and ESR level. Further studies should investigate how RF+ may predispose RA patients to later develop pneumonia after clinical RA diagnosis.

References:

[1]Liao KP, Cai T, Gainer V, et al. Electronic medical records for discovery research in rheumatoid arthritis. Arthritis Care Res. 2010;62(8):1120–1127.

[2]Radner H, Yoshida K, Mjaavatten MD, et al. Development of a multimorbidity index: Impact on quality of life using a rheumatoid arthritis cohort. Semin Arthritis Rheum. 2015;45(2):167–173.

Disclosure of Interests:

Jeffrey Sparks Consultant of: Bristol-Myers Squibb, Optum, Janssen, Gilead, Weixing Huang: None declared, Bing Lu: None declared, Sicong Huang: None declared, Andrew Cagan: None declared, Vivian Gainer: None declared, Sean Finan: None declared, Guergana Savova: None declared, Daniel Solomon Grant/research support from: Funding from Abbvie and Amgen unrelated to this work, Elizabeth Karlson: None declared, Katherine Liao: None declared

FRI0519 IMPROVING RHEUMATOID ARTHRITIS COMPARATIVE EFFECTIVENESS RESEARCH USING THE TARGET TRIAL EMULATION FRAMEWORK: A SYSTEMATIC REVIEW

Background:

Methods used in observational comparative effectiveness research (CER) are highly variable. Target trial emulation is an intuitive design approach that encourages researchers to formulate their question as a hypothetical randomised controlled trial (RCT), or the “target trial”. Using observational data to emulate the target trial helps avoid common biases and has been shown to better align results with actual RCTs.

Objectives:

We systematically reviewed observational CER studies in rheumatoid arthritis to provide examples of design issues that might have been avoided by using target trial emulation.

Methods:

We searched for head-to-head effectiveness comparisons of biologic DMARDs in RA. Study designs were reviewed for components of target trial emulation: 1) eligibility criteria, 2) treatment strategies, 3) assignment procedures, 4) follow-up period, 5) outcome, 6) causal contrasts of interest (i.e., intention-to-treat or per-protocol effect), and 7) analysis plan. Reported methods were taken as the “emulation” of a corresponding target trial, to assess design issues that might introduce bias.

Results:

We found 31 CER studies, the majority of which had one design issue belonging to one of the 7 protocol components (Table 1). The most common issues were: 1) 17 out of 31 studies used post-baseline information to define baseline eligibility (e.g. requiring ≥1 follow-up), which can bias results; 2) 26 out of 31 studies did not declare their causal contrast of interest, which is often made difficult by issue 1 and impacts data analysis and interpretation; and 3) 9 out of 31 studies used statistical selection of confounders rather than pre-defining them, which can also introduce bias (e.g. through adjustment of collider or intermediate variables).

Table 1.

Design issues identified in 31 studies and reasons why they do not correspond to well-defined “target trials”

Design issues identified in study methodsHow these issues can be conceptualized in a RCT protocol1. Eligibility criteriaPost-baseline data requirement (17 out of 31 studies).Impossible to use future data at enrolment.Differential eligibility for each arm (5 studies).Breaks the notion of one group of people randomized to 2+ arms.2. Treatment strategiesMixing prevalent users and new users (1 study)Impossible to assign/randomize to “havingused drug A for X months”Not defining treatment strategies beyond “initiate drug A at baseline” (31 studies)Implied protocol leaves everything up to the treating physician and patient3. Assignment proceduresWeak substantive justification for confounder selection (31 studies)Broken randomization (due to insufficient emulation of randomization)4. Follow-upUnspecified follow-up duration in longitudinal analyses (5 studies)Infeasible to conceive an RCT with unspecified duration. Analysis results may lack interpretability.5. OutcomeJoint outcome of remaining on treatmentandhaving a good response, to avoid missingness (3 studies)Unusual outcome for RCT although technically possible.6. Causal contrasts (i.e., ITT or per-protocol effect)Failure to clarify the estimand (26 studies)Problem also common in RCTs7. Analysis planITT-type analysis among those with follow-upDeviates from the ITT principle (all randomized should be analysed)Per-protocol analyses did not account for post-baseline selection biasProblem also common in RCTs

Conclusion:

The majority of observational CER studies in RA have one or more design issues that may introduce bias. Target trial emulation is a structured approach for designing observational CER studies that helps to avoid common biases.

Disclosure of Interests:

Sizheng Steven Zhao: None declared, Houchen Lyu: None declared, Daniel Solomon Grant/research support from: Funding from Abbvie and Amgen unrelated to this work, Kazuki Yoshida: None declared

OP0071 PREDICTING PERSISTENT HIGH-DOSE OPIOID USE AFTER TOTAL KNEE REPLACEMENT

Background:

Patients undergoing total knee replacement (TKR) are at increased risk of persistent opioid use and dependence

Objectives:

To identify patients with persistent high-dose opioid use after TKR using group-based trajectory models (GBTM) and determine predictors of persistent high-dose opioid users using pre-TKR patient characteristics

Methods:

Using US Medicare claims (2010-2014), we identified patients aged ≥65 years who underwent a TKR and had no history of cancer or high-dose opioid use (>25 mean morphine equivalents (MME)/day) in the year prior. All patients were continuously enrolled in Medicare for ≥360 days prior to and ≥30 days after the TKR. To determine opioid filling patterns after the surgery, patients were followed up to 360 days from the day of TKR. We modeled 12 monthly indicators of opioid prescription fills as a continuous (MME/day) variable using a censored normal GBTM and categorized patients into 4 groups. The primary outcome was persistent high-dose opioid use defined as patients in trajectory Group 3 (38.8 MME/day) or Group 4 (22.4 MME/day). We split the data into training (2010-2013 data) and test (2014 data) sets and used logistic regression to predict high-dose opioid use vs low-dose opioid use (Groups 1 and 2) as a binary outcome utilizing pre-TKR patient characteristics as candidate predictors using the least absolute shrinkage and selection operator (LASSO) regression for variable selection. A reduced model with only 10 pre-specified variables readily available for clinical use was also considered

Results:

The final study cohort included 142,089 patients. The GBTM identified 4 distinct trajectories (Group 1- Short-term, low-dose, Group 2- long-term, low-dose, Group 3- medium-term, high-dose, Group 4-long-term, high-dose) of opioid use in the year after TKR(Figure). Using logistic regression and LASSO, we predicted the probability of persistent high-dose opioid use (N=17,171) (vs. low-dose opioid use) in the training set (N=101,810) for an AUC=0.80. The AUC in the test set (N=40,279) predicting high opioid use (N=5,893) was 0.77. The final model selected 33 variables and identified baseline history of opioid use as the strongest positive predictor of high-dose persistent opioid use. The reduced model with only ten predictors also performed equally well (AUC=0.77)(Table).

Conclusion:

In this cohort of older patients with no history of cancer or high-dose opioid use at baseline, 16.2% became high dose (28.1 MME/day) opioid users during the year after TKR. Our prediction model with 10 readily available clinical factors may help identify patients at high risk of future adverse outcomes from persistent opioid use and dependence after TKR

Figure.

 Trajectories of opioid use patterns after TKR

Table.

Predictors of persistent high-dose opioid use in the reduced mode

VariableMultivariable Odds Ratio (95% CI)Predicting High dose vs.Low dose opioid useP-valueAge (in years)0.94 (0.93-0.94)<0.001Females (Ref=Males)0.99 (0.93-1.06)0.78White race (Ref=Other)1.25 (1.04-1.50)0.02Baseline opioid use (MME/day)1.22 (1.22-1.23)<0.001Substance use (Yes/No)1.10 (1.02-1.20)0.02Benzodiazepine use (Yes/No)1.22 (1.12-1.32)<0.001Anxiolytic use (Yes/No)1.30 (1.19-1.43)<0.001Anticonvulsant use (Yes/No)0.94 (0.87-1.03)0.19Antidepressant use (Yes/No)1.03 (0.96-1.11)0.36NSAID use (Yes/No)1.07 (1.00-1.14)0.04

Disclosure of Interests:

Chandrasekar Gopalakrishnan: None declared, Jessica Franklin: None declared, Yinzhu Jin: None declared, Daniel Solomon Grant/research support from: Funding from Abbvie and Amgen unrelated to this work, Jeffrey Katz Grant/research support from: Dr Katz reported receiving grants from Samumed and Flexion Therapeutics outside the submitted work., Yvonne Lee Shareholder of: Cigna-Express Scripts, Grant/research support from: Pfizer, Consultant of: Highland Instruments, Inc., Patricia Franklin: None declared, Joyce Lii: None declared, Rishi J Desai Grant/research support from: Dr. Desai reported receiving grants from Bayer, Novartis, and Vertex Pharmaceuticals outside the submitted work., Seoyoung Kim Grant/research support from: Seoyoung C Kim has received research grants from AbbVie, Roche, Bristol-Myers Squibb and Pfizer.

OP0019 STABLE VERSUS TAPERED AND WITHDRAWN TREATMENT WITH TUMOR NECROSIS FACTOR INHIBITOR IN RHEUMATOID ARTHRITIS REMISSION (ARCTIC REWIND): A RANDOMISED, OPEN-LABEL, PHASE 4, NON-INFERIORITY TRIAL

Background:

Remission is the preferred treatment target in rheumatoid arthritis (RA), and many patients require biologic DMARDs to reach this state. It is debated whether tapering of tumor necrosis factor inhibitor (TNFi) treatment to discontinuation should be considered in RA patients who sustain remission on treatment (1).

Objectives:

The primary study objective was to assess the effect of tapering and withdrawal of TNFi on the risk of flares in RA patients in clinical remission.

Methods:

In the non-inferiority ARCTIC REWIND trial, RA patients in remission for at least 12 months on stable TNFi therapy were randomly assigned to continued stable TNFi or tapering (half-dose TNFi for 4 months, thereafter withdrawal of TNFi), with visits every four months. csDMARD co-medication was kept stable in both arms. Patients had to be in DAS remission at inclusion with 0/44 swollen joints. The primary endpoint was the proportion of patients with disease flare during the 12-month study period (defined as DAS>1.6, change in DAS>0.6 and 2 or more swollen joints, or the physician and patient agreed that a clinically significant flare had occurred). Full-dose TNFi was reinstated in case of flares in the tapering arm. The non-inferiority margin was 20%, with a predefined superiority test if non-inferiority was not shown. The inferiority null-hypothesis was tested in the per-protocol population by mixed effect logistic regression. Radiographs were scored by van der Heijde modified Sharp score (0 and 12 months, average of two readers, progression: ≥1 unit change). ClinicaltrialsNCT01881308.

Results:

We randomised 99 patients, 92 received the allocated treatment strategy, 84 were included in the per-protocol population. Baseline characteristics, clinical and ultrasound disease activity were balanced (Table). csDMARD co-medication was used by 93% in the stable and 88% in the tapering arm. In the primary analysis, 5% of patients in the stable TNFi arm experienced a flare during 12 months, compared to 63% in the tapering TNFi arm. The risk difference (95% CI) was 58% (42% to 74%, Fig 1), with stable treatment being deemed superior to tapering. 90% in the stable and 81% in the tapering arm did not show progression of radiographic joint damage, difference (95% CI) -9% (-24%, 6%). At 12 months, DAS scores, DAS remission and function were similar between groups (Fig 2). The numbers of adverse events (AE)/serious AE in the stable and tapering arm were 57/2 and 50/3, respectively, with 26 and 15 infections.

Conclusion:

In a randomised clinical trial assessing patients in prolonged and deep RA remission, we observed a large increase in the flare rate in patients who tapered and discontinued TNFi. Patients responded well to reinstated treatment and remission rates in the two study arms were comparable at 12 months.

References:

[1]Smolen et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2019 update. ARD 2020

Table 1.

Baseline values – n (%), mean (SD), or median (IQR)

Stable, n=45Tapering, n=47Age, yrs57 (11)58 (13)Female30 (67%)25 (53%)ACPA+35 (78%)36 (77%)Symptom duration, yrs10 (7)12 (7)DAS0.9 (0.4)0.8 (0.3)CRP mg/L1 (1 – 2)1 (1 – 3)No ulttrasound power Doppler signal in any of 32 joints42 (96%)44 (94%)

Disclosure of Interests:

Siri Lillegraven: None declared, Nina Paulshus Sundlisæter: None declared, Anna-Birgitte Aga: None declared, Joe Sexton: None declared, Inge Olsen: None declared, Åse Lexberg: None declared, Tor Magne Madland: None declared, Hallvard Fremstad: None declared, Christian A. Høili Consultant of: Novartis, Gunnstein Bakland Consultant of: Novartis, UCB, Cristina Spada: None declared, Hilde Haukeland Consultant of: Novartis, Inger M. Hansen: None declared, Ellen Moholt: None declared, Till Uhlig Consultant of: Lilly, Pfizer, Speakers bureau: Grünenthal, Novartis, Daniel Solomon Grant/research support from: Funding from Abbvie and Amgen unrelated to this work, Désirée van der Heijde Consultant of: AbbVie, Amgen, Astellas, AstraZeneca, BMS, Boehringer Ingelheim, Celgene, Cyxone, Daiichi, Eisai, Eli-Lilly, Galapagos, Gilead Sciences, Inc., Glaxo-Smith-Kline, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sanofi, Takeda, UCB Pharma; Director of Imaging Rheumatology BV, Tore K. Kvien Grant/research support from: Received grants from Abbvie, Hospira/Pfizer, MSD and Roche (not relevant for this abstract)., Consultant of: Have received personal fees from Abbvie, Biogen, BMS, Celltrion, Eli Lily, Hospira/Pfizer, MSD, Novartis, Orion Pharma, Roche, Sandoz, UCB, Sanofi and Mylan (not relevant for this abstract)., Paid instructor for: Have received personal fees from Abbvie, Biogen, BMS, Celltrion, Eli Lily, Hospira/Pfizer, MSD, Novartis, Orion Pharma, Roche, Sandoz, UCB, Sanofi and Mylan (not relevant for this abstract)., Speakers bureau: Have received personal fees from Abbvie, Biogen, BMS, Celltrion, Eli Lily, Hospira/Pfizer, MSD, Novartis, Orion Pharma, Roche, Sandoz, UCB, Sanofi and Mylan (not relevant for this abstract)., Espen A Haavardsholm Grant/research support from: AbbVie, UCB Pharma, Pfizer Inc, MSD Norway, Roche Norway, Consultant of: Pfizer, AbbVie, Janssen-Cilag, Gilead, UCB Pharma, Celgene, Lilly, Paid instructor for: UCB Pharma, Speakers bureau: Pfizer, AbbVie, UCB Pharma, Celgene, Lilly, Roche, MSD

SAT0148 TAPERING OF CONVENTIONAL SYNTHETIC DISEASE MODIFYING ANTI-RHEUMATIC DRUGS IN SUSTAINED RHEUMATOID ARTHRITIS REMISSION: RESULTS FROM A RANDOMIZED CONTROLLED TRIAL

Background:

Sustained remission is the goal of rheumatoid arthritis (RA) care, and more patients reach and maintain this state on conventional synthetic disease modifying anti-rheumatic drugs (csDMARDs) with treat-to-target strategies. The knowledge about whether csDMARDs can be tapered in RA remission is limited.

Objectives:

The primary objective of the study was to assess the effect of tapering of csDMARDs on the risk of flares in RA patients in sustained clinical remission.

Methods:

In the open, phase 4, non-inferiority ARCTIC REWIND trial, RA patients in clinical remission for ≥ 12 months on stable csDMARD therapy were randomised to continued stable csDMARD or half dose csDMARD. Patients had to be in DAS remission at inclusion with no swollen joints (of 44). The primary endpoint was the proportion of patients with a disease flare during 12 months (defined as a combination of DAS >1.6, change in DAS >0.6 and ≥2 swollen joints, or the physician and patient agreed that a clinically significant flare had occurred). Patients attended visits every 4 months, with extra visits in case of flares. The non-inferiority margin was 20%, with a predefined superiority test if non-inferiority was not shown. Mixed effect logistic regression was used to test the inferiority null-hypothesis in the per-protocol population. Radiographs at 0 and 12 months were scored by van der Heijde Sharp score (average score of two readers, progression: ≥1 unit change/year). Clinicaltrials.govNCT01881308.

Results:

We enrolled 160 patients, 155 received the allocated treatment strategy. Baseline characteristics were overall well balanced (Table). 78% of patients in the stable csDMARD arm and 84% in the half-dose csDMARD arm used methotrexate monotherapy. In the primary analysis, we observed flares in 6% of patients on stable csDMARD, compared to 25% in the half-dose csDMARD arm, giving a risk difference (95% CI) of 18.3% (7.2% to 29.3%, Fig 1). Non-inferiority could not be claimed, with the results showing superiority of the stable arm over the half-dose arm (Fig 1). Similar results were found in methotrexate monotherapy users. In the stable arm, 2/5 (40%) escalated DMARD medication following the flares, compared to 18/19 (95%) in the tapering arm. No progression of radiographic joint damage was observed in 79.5% of patients on stable DMARDs and 62.7% of those tapering, difference (95% CI) -17.7% (-33.0%, -2.3%, Fig 2E). At 12 months, 92% of patients in the stable and 85% of patients in the tapered arm were in DAS remission (Fig 2C). The frequency of adverse events was 75 in the stable arm and 53 in the tapered arm, with serious adverse events in 2 (2.6%) of patients in the stable and 4 (5.1%, including two serious infections) patients in the tapered arm.

Conclusion:

In RA patients in sustained remission on csDMARDs, continued csDMARD therapy with stable dosage led to significantly fewer disease activity flares and less frequent radiographic joint damage progression than tapered csDMARD treatment.

Table.

Baseline values; mean (SD), n (%) or median (IQR)

Stable, n=78Tapering, n=78Age, yrs55 (12)56 (12)Female50 (64%)54 (69%)ACPA+57 (73%)63 (81%)Symptom dur., yrs3.7 (1.8)3.4 (1.4)DAS0.8 (0.4)0.8 (0.3)CRP mg/L2 (1, 3)2.0 (1,3)MTX monotherapy61 (78%)65 (84%)

Disclosure of Interests:

Siri Lillegraven: None declared, Nina Paulshus Sundlisæter: None declared, Anna-Birgitte Aga: None declared, Joe Sexton: None declared, Inge Olsen: None declared, Hallvard Fremstad: None declared, Cristina Spada: None declared, Tor Magne Madland: None declared, Christian A. Høili Consultant of: Novartis, Gunnstein Bakland Consultant of: Novartis, UCB, Åse Lexberg: None declared, Inger Johanne Widding Hansen: None declared, Inger M. Hansen: None declared, Hilde Haukeland Consultant of: Novartis, Maud-Kristine A Ljosa: None declared, Ellen Moholt: None declared, Till Uhlig Consultant of: Lilly, Pfizer, Speakers bureau: Grünenthal, Novartis, Daniel Solomon Grant/research support from: Funding from Abbvie and Amgen unrelated to this work, Désirée van der Heijde Consultant of: AbbVie, Amgen, Astellas, AstraZeneca, BMS, Boehringer Ingelheim, Celgene, Cyxone, Daiichi, Eisai, Eli-Lilly, Galapagos, Gilead Sciences, Inc., Glaxo-Smith-Kline, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sanofi, Takeda, UCB Pharma; Director of Imaging Rheumatology BV, Tore K. Kvien Grant/research support from: Received grants from Abbvie, Hospira/Pfizer, MSD and Roche (not relevant for this abstract)., Consultant of: Have received personal fees from Abbvie, Biogen, BMS, Celltrion, Eli Lily, Hospira/Pfizer, MSD, Novartis, Orion Pharma, Roche, Sandoz, UCB, Sanofi and Mylan (not relevant for this abstract)., Paid instructor for: Have received personal fees from Abbvie, Biogen, BMS, Celltrion, Eli Lily, Hospira/Pfizer, MSD, Novartis, Orion Pharma, Roche, Sandoz, UCB, Sanofi and Mylan (not relevant for this abstract)., Speakers bureau: Have received personal fees from Abbvie, Biogen, BMS, Celltrion, Eli Lily, Hospira/Pfizer, MSD, Novartis, Orion Pharma, Roche, Sandoz, UCB, Sanofi and Mylan (not relevant for this abstract)., Espen A Haavardsholm Grant/research support from: AbbVie, UCB Pharma, Pfizer Inc, MSD Norway, Roche Norway, Consultant of: Pfizer, AbbVie, Janssen-Cilag, Gilead, UCB Pharma, Celgene, Lilly, Paid instructor for: UCB Pharma, Speakers bureau: Pfizer, AbbVie, UCB Pharma, Celgene, Lilly, Roche, MSD

The Role of Sex Work Pay in Moderating the Effect of Mobile Phone Solicitation on Condom Practices: An Analysis of Female Sex Workers in India

Mobile phones remain a largely untapped resource in the ongoing challenge to address Female Sex Worker (FSW) health, including HIV prevention services, in India. An important step towards designing effective mobile phone-based initiatives for FSWs is clarifying the contextual influences of mobile phone solicitation on sexual risk behavior. In this paper, we extend previously identified associations between mobile phone solicitation and condom practices by examining whether this association is moderated by sex work pay and offer key considerations for future research and implementation. Specifically, we conducted an analysis among 589 Indian FSWs, where FSWs who did not use mobile phones to solicit clients had the lowest mean sex work pay (INR 394/ USD 6.54) compared to FSWs who used both mobile and traditional strategies (INR 563/ USD 9.34). Our analysis indicate low paid FSWs who used mobile phones concurrently with traditional strategies had 2.46 times higher odds of inconsistent condom use compared to low paid FSWs who did not use mobile phones for client solicitation. No such effect was identified among high paid FSWs. These findings also identified group level differences among FSWs reporting different mobile phone solicitation strategies, including violence, client condom use and HIV status. Our results indicate that low pay does moderate the association between mobile phone solicitation and condom practices, but only among a sub-set of low paid FSWs. These findings also demonstrate the utility of classification by different mobile phone solicitation strategies for accurate assessment of sexual risk among mobile phone soliciting FSWs. In turn, this paves the way for novel approaches to utilize mobile phones for FSW HIV prevention. We discuss one such example, a mobile phone-based rapid screening tool for acute HIV infection targeting Indian FSWs.

Examination of the recommended safe and unsafe zone for placement of surgical instruments in thoracentesis and video-assisted thoracic surgery: a cadaveric study

BACKGROUND

Thoracentesis and video-assisted thoracic surgery procedures can result in haemorrhage as a consequence of severing the collateral branches of the posterior intercostal artery. These branches have been shown to be most common in the 5th intercostal space (ICS). Tortuosity has been shown to be especially prevalent nearer to midline. A group of investigators have recommended the 4th and 7th ICS, 120 mm lateral to midline as a safe zone, least likely to hit branches when cutting into the ICS. The present study aimed to investigate that safe zone as a better entry points for procedures. In addition, investigation of the least safe 5th ICS was also performed.

MATERIALS AND METHODS

A total of 56 embalmed human cadavers were selected for the study. With the cadavers laid prone, 2 cm incisions were made at the 4th, 5th and 7th ICS, 120 mm lateral to midline bilaterally. The cadavers were then placed supine and the incisions were dissected. Careful attention was paid to identify if any collateral branches were cut.

RESULTS

After thorough dissection of the 4th, 5th and 7th ICS incision sites, it was shown that damage to the 5th intercostal was seen most frequently.

CONCLUSIONS

Based on this cadaveric study, a 2 cm incision at the 4th, 5th and 7th ICS 120 mm lateral from midline resulted in the most damage at the level of the 5th ICS. The 4th ICS had the least damage seen. Therefore, it is recommended that insertion should be placed at the level of the 4th ICS bilaterally.

Diverticular disease in Scotland: 2000-2010

AIM

Symptomatic diverticular disease (DD) may be increasing in incidence in western society particularly in younger age groups. This study aimed to describe hospital admission rates and management for DD in Scotland between 2000 and 2010.

METHOD

Data were obtained from the Scottish Morbidity Records (SMR01). The study cohort included all patients with a hospital admission and a primary diagnosis of DD of the large intestine (ICD-10 primary code K57).

RESULTS

Scottish NHS hospitals reported 90 990 admissions for DD (in 87 314 patients) from 2000 to 2010. The annual number of admissions increased by 55.2% from 6591 in 2000 to 10,228 in 2010, an average annual increase per year of 4.5%. Most of the increase attributable to DD was due to elective day cases (3618 in 2000; 6925 in 2010) a likely consequence of a greater proportion of the population accessing colonoscopy over that time period. There was an 11% increase in inpatient admissions (2973-3303), 60% of these patients being women. Admissions in younger age groups increased proportionally in the later years of the study, and there was an association between DD admissions and greater deprivation. Despite an increase in complicated DD from 22.9% in 2000 to 27.1% in 2010 and a 16.8% increase in emergency inpatient admissions, the rate of surgery fell during the period of study.

CONCLUSION

This report supports findings of other population-based studies of western countries indicating that DD is an increasing burden on health service resources, particularly in younger age groups.

Mobile phones and sex work in South India: the emerging role of mobile phones in condom use by female sex workers in two Indian states

The aim of this study was to examine female sex workers' solicitation of clients using mobile phones and the association between this and condom use with clients. Cross-sectional data were utilised to address the study's aim, drawing on data collected from female sex workers in Calicut, Kerala, and Chirala, Andhra Pradesh. Use of mobile phone solicitation was reported by 46.3% (n = 255) of Kerala participants and 78.7% (n = 464) of those in Andhra Pradesh. Kerala participants reporting exclusive solicitation using mobile phones demonstrated 1.67 times higher odds (95% CI: 1.01-2.79) of inconsistent condom use than those reporting non-use of mobile phones for solicitation. However, those reporting exclusive solicitation through mobile phones in Andhra Pradesh reported lower odds of inconsistent condom use (OR: 0.03; 95% CI: 0.01-0.26) than those not using mobile phones for solicitation. Findings indicate that solicitation of clients using mobile phones facilitates or hampers consistency in condom use with clients depending on the context, and how mobile phones are incorporated into solicitation practices. Variations in sex work environments, including economic dependence on sex work or lack thereof may partially account for the different effects found.

The impact of MMX mesalazine on disease-specific health-related quality of life in ulcerative colitis patients

BACKGROUND

Past studies with ulcerative colitis (UC) patients indicate that disease activity strongly predicts health-related quality of life (HRQL).

AIM

To examine the degree to which daily treatment with MMX mesalazine predicts improved HRQL for patients with active UC and with stable HRQL for patients with quiescent UC.

METHODS

Data from two phases of a multicentre open-label trial were examined. In the acute phase, 132 patients with mild-to-moderate active UC received MMX mesalazine 2.4-4.8 g/day for 8 weeks, while 206 patients with quiescent UC received MMX mesalazine 2.4 g/day for a 12-month maintenance phase. Disease-specific HRQL was measured at baseline and endpoint of each phase using the Short Inflammatory Bowel Disease Questionnaire (SIBDQ). Repeated-measures anova models examined baseline-endpoint changes in SIBDQ, stool frequency (SF), and rectal bleeding severity (RBS). Correlations assessed the associations between SIBDQ and SF/RBS scores, while ancova techniques tested the sensitivity of SIBDQ to disease recurrence.

RESULTS

SIBDQ scores significantly increased for active mild-to-moderate UC patients following 8 weeks of treatment, while SIBDQ scores remained stable for quiescent UC patients following 12 months of treatment. Changes in SIBDQ scores correlated significantly with changes in SF and RBS scores. Patients with recurrent UC at maintenance phase endpoint had significantly lower SIBDQ scores than nonrecurrent patients.

CONCLUSIONS

Daily MMX mesalazine therapy was associated with significant improvement in disease-specific HRQL for patients with mild-to-moderate active UC and with the maintenance of HRQL for patients with quiescent UC. In both patient groups, HRQL was significantly associated with disease activity.

Evidence needed to manage freshwater ecosystems in a changing climate: turning adaptation principles into practice

It is widely accepted that climate change poses severe threats to freshwater ecosystems. Here we examine the scientific basis for adaptively managing vulnerable habitats and species. Our views are shaped by a literature survey of adaptation in practice, and by expert opinion. We assert that adaptation planning is constrained by uncertainty about evolving climatic and non-climatic pressures, by difficulties in predicting species- and ecosystem-level responses to these forces, and by the plasticity of management goals. This implies that adaptation measures will have greatest acceptance when they deliver multiple benefits, including, but not limited to, the amelioration of climate impacts. We suggest that many principles for biodiversity management under climate change are intuitively correct but hard to apply in practice. This view is tested using two commonly assumed doctrines: "increase shading of vulnerable reaches through tree planting" (to reduce water temperatures); and "set hands off flows" (to halt potentially harmful abstractions during low flow episodes). We show that the value of riparian trees for shading, water cooling and other functions is partially understood, but extension of this knowledge to water temperature management is so far lacking. Likewise, there is a long history of environmental flow assessment for allocating water to competing uses, but more research is needed into the effectiveness of ecological objectives based on target flows. We therefore advocate more multi-disciplinary field and model experimentation to test the cost-effectiveness and efficacy of adaptation measures applied at different scales. In particular, there is a need for a major collaborative programme to: examine natural adaptation to climatic variation in freshwater species; identify where existing environmental practice may be insufficient; review the fitness of monitoring networks to detect change; translate existing knowledge into guidance; and implement best practice within existing regulatory frameworks.

Human airway smooth muscle is structurally and mechanically similar to that of other species

Airway smooth muscle (ASM) plays a vital role in the exaggerated airway narrowing seen in asthma. However, whether asthmatic ASM is mechanically different from nonasthmatic ASM is unclear. Much of our current understanding about ASM mechanics comes from measurements made in other species. Limited data on human ASM mechanics prevents proper comparisons between healthy and asthmatic tissues, as well as human and animal tissues. In the current study, we sought to define the mechanical properties of healthy human ASM using tissue from intact lungs and compare these properties to measurements in other species. The mechanical properties measured included: maximal stress generation, force-length properties, the ability of the muscle to undergo length adaptation, the ability of the muscle to recover from an oscillatory strain, shortening velocity and maximal shortening. The ultrastructure of the cells was also examined. Healthy human ASM was found to be mechanically and ultrastructurally similar to that of other species. It is capable of undergoing length adaptation and responds to mechanical perturbation like ASM from other species. Force generation, shortening capacity and velocity were all similar to other mammalian ASM. These results suggest that human ASM shares similar contractile mechanisms with other animal species and provides an important dataset for comparisons with animal models of disease and asthmatic ASM.

Does major depressive disorder change with age?

BACKGROUND

The authors used results from a 20-year, high-intensity follow-up to measure the influence of ageing, and of age at onset, on the long-term persistence of symptoms in major depressive disorder (MDD).

METHOD

Subjects who completed a 20-year series of semi-annual and then annual assessments with a stable diagnosis of MDD or schizo-affective disorder other than mainly schizophrenic (n=220) were divided according to their ages at intake into youngest (18-29 years), middle (30-44 years) and oldest (>45 years) groups. Depressive morbidity was quantified as the proportion of weeks spent in major depressive or schizo-affective episodes. General linear models then tested for effects of time and time x group interactions on these measures. Regression analyses compared the influence of age of onset and of current age.

RESULTS

Analyses revealed no significant time or group x time effects on the proportions of weeks in major depressive episodes in any of the three age groups. Earlier ages of onset were associated with greater symptom persistence, particularly in the youngest group. The proportions of weeks ill showed intra-individual stability over time that was most evident in the oldest group.

CONCLUSIONS

These results indicate that the persistence of depressive symptoms in MDD does not change as individuals move from their third to their fifth decade, from their fourth to their sixth decade, or from their sixth to their eighth decade. An early age of onset, rather than youth per se, is associated with greater morbidity over two decades.

Age transitions in the course of bipolar I disorder

BACKGROUND

This analysis aimed to show whether symptoms of either pole change in their persistence as individuals move through two decades, whether such changes differ by age grouping, and whether age of onset plays an independent role in symptom persistence.

METHOD

Participants in the National Institute of Mental Health (NIMH) Collaborative Depression Study (CDS) who completed at least 20 years of follow-up and who met study criteria for bipolar I or schizo-affective manic disorder, before intake or during follow-up, were divided by age at intake into youngest (18-29 years, n=56), middle (30-44 years, n=68) and oldest (>44 years, n=24) groups.

RESULTS

The persistence of depressive symptoms increased significantly in the two younger groups. Earlier ages of onset were associated with higher depressive morbidity throughout the 20 years of follow-up but did not predict changes in symptom persistence. The proportions of weeks spent in episodes of either pole correlated across follow-up periods in all age groupings, although correlations were stronger for depressive symptoms and for shorter intervals.

CONCLUSIONS

Regardless of age at onset, the passage of decades in bipolar illness seems to bring an increase in the predominance of depressive symptoms in individuals in their third, fourth and fifth decades and an earlier age of onset portends a persistently greater depressive symptom burden. The degree to which either depression or manic/hypomanic symptoms persist has significant stability over lengthy periods and seems to reflect traits that manifest early in an individual's illness.

The association between course of illness and subsequent morbidity in bipolar I disorder

OBJECTIVE

We examined the relationship between certain bipolar I disorder clinical course variables over 5 years with outcome over the subsequent 5-year period.

METHODS

Prospective observational follow-up data of 123 bipolar I subjects were analyzed. Predictive clinical variables included the frequency and direction of switches, and the quantity, polarity and length of affective periods. Outcome variables were an affective burden index (ABI) accounting for week-by-week severity and weeks hospitalized. Bivariate analyses guided the selection of predictors for multivariable analyses against the outcome variables.

RESULTS

Affective burden index: while the number and direction of switches, the number of polyphasic episodes, weeks in hypomania/mania/mixed state, weeks in minor/major depression, weeks in at least marked affective syndrome, and weeks in any affective syndrome all had bivariate correlation (p<0.01) with the ABI, only weeks in hypomania/mania/mixed state and weeks in minor/major depression made significant contributions in the multivariable analysis (p<0.01) with the ABI. Weeks hospitalized: weeks in at least marked affective syndrome were significantly correlated with weeks hospitalized in bivariate analysis (p<0.01), and maintained a contribution to weeks hospitalized in the multivariable analysis (p<0.01).

CONCLUSIONS

The quantity and severity of weeks in symptomatic affective states are possibly greater predictors of affective burden in bipolar I patients than the quantity and direction of affective switches.

Heterobifunctional multivalent inhibitor-adaptor mediates specific aggregation between Shiga toxin and a pentraxin

[reaction: see text] The first example of a multivalent heterofunctional inhibitor-adaptor, called "BAIT", is described. This multivalent inhibitor-adaptor is able to capture a "target" receptor (Shiga toxin) through its recognition of one ligand of a heterobivalent headgroup while the other ligand binds to an endogenous "trap" protein (serum amyloid P component, SAP). BAIT showed markedly enhanced inhibition of toxin activity. An efficient synthesis of this multivalent cluster containing heterobifunctional ligands was accomplished by chemical and chemoenzymatic approaches.

A study on birth weight in a teaching-referral hospital, Gondar, Ethiopia

OBJECTIVE

To determine the pattern of birth weight of neonates in a teaching-referral hospital and to identify some epidemiological parameters associated with them.

STUDY DESIGN

A prospective descriptive study, using a pre-prepared Questionnaire, on all deliveries in the maternity ward during one year.

SETTING

The Gondar College of Medical Sciences Hospital, Gondar, north western Ethiopia.

RESULTS

810 consecutive hospital births were recorded. The mean birth weight of 373 full term singleton neonates was 3 003g (SD600). The incidence of low birth weight (birth weight < 2 500 g) and very low birth weight (birth weight < 1 500 g) was 15.4% and 2.6% respectively. The mean birth weight and percentage of low birth weight were significantly different in both sexes (p < 0.0001). The birth weight increases as parity and length of gestation increase. As maternal age and maternal height increase, so do the birth weights of their neonates in this study. Total house hold income, maternal education and antenatal care use were not found to influence the mean birth weight in this study.

CONCLUSION

The mean birth weight and prevalence of low birth weight are similar to other reports from Ethiopia. It was observed that as maternal age, maternal height, parity and length of gestation increase, the mean birth weight increase in this study.