POS1412 IDENTIFYING HIGH-COST DRUGS FOR RARE RHEUMATIC DISEASES IN ROUTINELY COLLECTED NHS DATA. RESULTS FROM A PILOT STUDY OF RITUXIMAB USE IN VASCULITIS USING DATA FROM THE NATIONAL DISEASE REGISTRATION SERVICE AND THE REGISTRATION OF COMPLEX RARE DISEASES-EXEMPLARS IN RHEUMATOLOGY (RECORDER) PROJECT

Background:

Understanding real-world usage of high-cost drugs is crucial to support planning, adoption of innovation and reduce unwarranted variation in treatment. Hospital Episode Statistics (HES) contain diagnoses (coded by ICD-10) and procedures/treatments (coded by OPCS) for all daycase or inpatient care in England. However, OPCS codes are not specific for individual drugs, for example X921 (cytokine inhibitors band 1) includes rituximab (RTX) and 15 other drugs.

Objectives:

We aimed to validate the accurate identification of patients treated with RTX for ANCA-associated vasculitis (AAV) using HES data.

Methods:

We used data from the National Congenital Anomaly and Rare Disease Registration Service (NCARDRS) at Public Health England and their legal permissions (CAG 10-02(d)/2015). We extracted records from HES of all patients treated at two hospitals during financial year 2018/19 who ever had a coded diagnosis of granulomatosis with polyangiitis (GPA, M313), eosinophilic granulomatosis with polyangiitis (EGPA, M301), microscopic polyangiitis (MPA, M317), polyarteritis nodosa (PAN, M300) or arteritis unspecified (I776). Where people had multiple diagnoses of vasculitis, the most specific was considered their diagnosis. Enabled by data sharing agreements, we reviewed hospital records of those patients to validate diagnoses and whether X921 reliably identified RTX. We report the positive predictive value and sensitivity of the coding for X921 and GPA/EGPA/MPA for identifying people with AAV who are treated with RTX.

Results:

At Trust 1 records ever coded with GPA/EGPA/MPA identified 74 people, 69 of whom had AAV confirmed in their medical notes. Among these 74 patients there were 59 episodes coded with X921 procedure codes, of which 56 correctly identified a RTX infusion given for AAV. A total of 64 RTX infusions were given to people with AAV – 3 missed infusions were X921 procedures in patients who had coded diagnoses of PAN or I776 but never GPA/EGPA/MPA and 5 infusions were not coded as X921.

The same analysis at Trust 2 identified 46 people, 44 of whom had AAV confirmed in their medical notes. Among patients identified with AAV there were 17 episodes coded as X921, of which 15 correctly identified a RTX infusion. A total of 23 infusions were given to people with AAV: 4 infusions were X921 procedures in patients who had coded diagnoses of PAN or I776 but never GPA/EGPA/MPA, and 4 infusions were not coded as X921.

Table 1.

Summary of Positive Predictive Values (PPV) applying our algorithm to identify AAV diagnoses and RTX use

Trust 1Trust 2CombinedDiagnosis of AAV and coded as AAV6944113AAV coded7446120Diagnosis of AAV under any code7355128PPV AAV ascertainment (95% CI)93.2% (84.9-97.8)95.7% (85.2-99.5)94.2% (88.4-97.6)Sensitivity of AAV ascertainment (95% CI)94.5% (86.8-98.5)80.0% (67.0-89.6)88.3% (81.4-93.3)RTX given in people coded as AAV561571RTX coded in people coded as AAV591776RTX given for AAV under any diagnostic or procedure code642387PPV RTX ascertainment (95% CI)94.9% (85.9-98.9)88.2% (63.6-98.5)93.4% (85.3-97.8)Sensitivity of RTX ascertainment (95% CI)87.5% (76.8-94.4)65.2% (42.7-83.6)81.6% (71.9-89.1)

Conclusion:

HES data identified patients treated with RTX for AAV with a PPV of 93.4% (85.3-97.8) and sensitivity of 81.6% (71.9-89.1). This demonstrates the utility of national data to identify people receiving RTX for AAV. The RECORDER project, within the National Disease Registration Service plans to conduct real-world studies of the high-cost drug RTX, given for AAV, across the whole of England, and assess whether geography, demographics or socioeconomic factors influence frequency of prescription of this, and potentially other, high-cost drugs in line with the NHS long term plan.

References:

[1]Ward-Platt M, Stevens S, Miller N. I18 The national congenital anomaly and rare disease registration service (NCARDRS): The first year

Acknowledgements:

I have no acknowledgements to declare.

Disclosure of Interests:

Cattleya Godsave: None declared, Mithun Chakravorty: None declared, Megan Rutter: None declared, Peter Lanyon Grant/research support from: P.C.L. is a recipients of a grant from Vifor Pharma. Vifor Pharma had no influence on the design, conduct or interpretation of this study., Jeanette Aston: None declared, Mary Bythell: None declared, Sarah Stevens: None declared, Fiona Pearce Grant/research support from: I have received a research grant from Vifor Pharma

A systematic review of the evidence base for the Lightning Process

BACKGROUND

The Lightning Process (LP), a mind-body training programme, has been applied to a range of health problems and disorders. Studies and surveys report a range of outcomes creating a lack of clarity about the efficacy of the intervention.

OBJECTIVE

This systematic review evaluates the methodological quality of existing studies on the LP and collates and reviews its reported efficacy.

DATA SOURCES

Five databases, PsycINFO, PubMed, CINAHL, Embase, ERIC (to September 2018), and Google and Google Scholar were searched for relevant studies.

STUDY SELECTION

Studies of the LP in clinical populations published in peer-reviewed journals or in grey literature were selected. Reviews, editorial articles and studies/surveys with un-reported methodology were excluded.

DATA EXTRACTION

Searches returned 568 records, 21 were retrieved in full text of which 14 fulfilled the inclusion criteria (ten quantitative studies/surveys and four qualitative studies).

DATA SYNTHESIS AND CONCLUSIONS

The review identified variance in the quality of studies across time; earlier studies demonstrated a lack of control groups, a lack of clarity of aspects of the methodology and potential sampling bias. Although it found a variance in reported patient outcomes, the review also identified an emerging body of evidence supporting the efficacy of the LP for many participants with fatigue, physical function, pain, anxiety and depression. It concludes that there is a need for more randomised controlled trials to evaluate if these positive outcomes can be replicated and generalised to larger populations.

Cannabis use and cognitive functions in at-risk mental state and first episode psychosis

BACKGROUND

Meta-analyses suggest that schizophrenia patients with a history of cannabis use have less impaired cognitive functioning compared to patients without cannabis use.

AIMS

The objective of this study was to assess the association between recency and frequency of cannabis use and cognitive functioning in at-risk mental state for psychosis (ARMS) and first episode psychosis (FEP) individuals.

METHODS

One hundred thirty-six participants completed a cognitive test battery and were assessed for current and past cannabis use. Analyses of covariance models were applied to evaluate the main effects of cannabis use and patient group (ARMS vs. FEP) as well as their interactions on cognitive functioning.

RESULTS

No differences were observed in cognitive performance between current, former, and never users, and there were no significant interactions between cannabis use and patient group. Furthermore, within the group of current cannabis users, the frequency of cannabis use was not significantly associated with cognitive functioning.

CONCLUSION

The results of the present study do not support the notion that FEP patients and ARMS individuals with a history of cannabis use have less impaired cognitive functioning compared to those without cannabis use.

[Prediction of psychosis by stepwise multilevel assessment--the Basel FePsy (Early Recognition of Psychosis)-Project]

BACKGROUND

We have conducted various studies in Basel with the aim of improving the methods for the early detection of psychosis (Früherkennung von Psychosen, FePsy).

METHODS

From 1.3.2000 to 29.2.2004 234 individuals were screened using the Basel Screening Instrument for Psychosis (BSIP). 106 patients were identified as at risk for psychosis; out of these 53 remained in follow-up for up to 7 years (mean 5.4 years). The assessments were done with a specifically developed instrument for history taking, various scales for the psychopathology, assessments of neuropsychology and fine motor functioning, clinical and quantitative EEG, MRI of the brain, laboratory etc.

RESULTS

Based on the BSIP alone, a relatively reliable prediction was possible: 21 (39.6%) of the individuals identified as at risk developed psychosis within the follow-up time. Post-hoc prediction could be improved to 81% by weighting psychopathology and including neuropsychology. Including the other domains obviously allows further improvements of prediction.

CONCLUSIONS

The risk for psychosis should be assessed in a stepwise procedure. In a first step, a clinically oriented screening should be conducted. If an at-risk status is found, further assessments in various domains should be done in a specialised centre.

Insular volume abnormalities associated with different transition probabilities to psychosis

BACKGROUND

Although individuals vulnerable to psychosis show brain volumetric abnormalities, structural alterations underlying different probabilities for later transition are unknown. The present study addresses this issue by means of voxel-based morphometry (VBM).

METHOD

We investigated grey matter volume (GMV) abnormalities by comparing four neuroleptic-free groups: individuals with first episode of psychosis (FEP) and with at-risk mental state (ARMS), with either long-term (ARMS-LT) or short-term ARMS (ARMS-ST), compared to the healthy control (HC) group. Using three-dimensional (3D) magnetic resonance imaging (MRI), we examined 16 FEP, 31 ARMS, clinically followed up for on average 3 months (ARMS-ST, n=18) and 4.5 years (ARMS-LT, n=13), and 19 HC.

RESULTS

The ARMS-ST group showed less GMV in the right and left insula compared to the ARMS-LT (Cohen's d 1.67) and FEP groups (Cohen's d 1.81) respectively. These GMV differences were correlated positively with global functioning in the whole ARMS group. Insular alterations were associated with negative symptomatology in the whole ARMS group, and also with hallucinations in the ARMS-ST and ARMS-LT subgroups. We found a significant effect of previous antipsychotic medication use on GMV abnormalities in the FEP group.

CONCLUSIONS

GMV abnormalities in subjects at high clinical risk for psychosis are associated with negative and positive psychotic symptoms, and global functioning. Alterations in the right insula are associated with a higher risk for transition to psychosis, and thus may be related to different transition probabilities.

Occupational transmission of hepatitis C in healthcare workers and factors associated with seroconversion: UK surveillance data

The study aims were to describe a case series of occupationally acquired hepatitis C (HCV) infections in UK healthcare workers and examine factors associated with transmission using exposure data reported to the Health Protection Agency between July 1997 and December 2007. Fifteen reported cases of documented HCV seroconversion occurred after percutaneous exposure, the majority from hollow-bore needles used in the source patient's vein or artery and contaminated with blood or blood-stained fluid. The seroconversion rate was 2.2% (14/626). In multivariable analysis of healthcare workers with percutaneous exposure to blood or blood-stained fluid, we demonstrate that blood sampling procedures (odds ratio [OR], 5.75; 95% CI, 1.33-24.91; P = 0.01) and depth of injury (OR for deep vs superficial injury, 21.99; 95% CI, 2.02-239.61; P = 0.02) are independently associated with a greater risk of HCV seroconversion. This is the first UK study of occupationally acquired HCV in healthcare workers. It has reinforced our knowledge of risk factors for HCV transmission. Most of these exposures and transmissions were preventable. Healthcare employers should provide regular education on the risks of occupational exposure and prevention through standard infection control procedures. They should ensure the availability of effective prevention measures and facilitate prompt reporting and adequate follow-up of exposures.

[The Basel Screening Instrument for Psychosis (BSIP): development, structure, reliability and validity]

BACKGROUND

Early detection of psychosis is of growing clinical importance. So far there is, however, no screening instrument for detecting individuals with beginning psychosis in the atypical early stages of the disease with sufficient validity. We have therefore developed the Basel Screening Instrument for Psychosis (BSIP) and tested its feasibility, interrater-reliability and validity.

AIM

Aim of this paper is to describe the development and structure of the instrument, as well as to report the results of the studies on reliability and validity.

METHOD

The instrument was developed based on a comprehensive search of literature on the most important risk factors and early signs of schizophrenic psychoses. The interraterreliability study was conducted on 24 psychiatric cases. Validity was tested based on 206 individuals referred to our early detection clinic from 3/1/2000 until 2/28/2003.

RESULTS

We identified seven categories of relevance for early detection of psychosis and used them to construct a semistructured interview. Interrater-reliability for high risk individuals was high (Kappa .87). Predictive validity was comparable to other, more comprehensive instruments: 16 (32 %) of 50 individuals classified as being at risk for psychosis by the BSIP have in fact developed frank psychosis within an follow-up period of two to five years.

CONCLUSIONS

The BSIP is the first screening instrument for the early detection of psychosis which has been validated based on transition to psychosis. The BSIP is easy to use by experienced psychiatrists and has a very good interrater-reliability and predictive validity.

The Basel early-detection-of-psychosis (FEPSY)-study--design and preliminary results

Early detection and therapy of schizophrenic psychoses have become broadly accepted aims in psychiatry, recently even in very early stages of the disorder when clear diagnostic criteria are not yet fulfilled. However, reliable and widely applicable methods do not yet exist. This study aims at contributing to the improvement of the early assessment of psychosis.

METHOD

Individuals potentially at risk are identified by a newly developed stepwise screening procedure. Identified subjects are then examined extensively and followed-up for at least 5 years to detect actual transition to psychosis.

RESULTS

Of 50 subjects who have been followed up for 1-5 years by now, 16 have progressed to frank psychosis, 12 of them during the first 12 months of follow-up.

CONCLUSION

At this stage, our approach seems to be promising for the early detection of psychosis. Further results from this ongoing study will hopefully permit us to optimize the assessment procedure.

Radiological findings in individuals at high risk of psychosis

OBJECTIVE

To assess the prevalence of radiological magnetic resonance imaging (MRI) findings in individuals at high risk of schizophrenia.

METHODS

MRI scans from individuals at high risk of schizophrenia (HR; n = 37) were assessed by a radiologist blind to group status and compared with scans from patients with first episode psychosis (FE; n = 30), depressive controls (DC; n = 17), and healthy controls (HC; n = 26).

RESULTS

There was a significantly higher proportion of radiological findings in individuals at high risk of schizophrenia (35%) and patients with first-episode psychosis (40%) than in patients with depression (18%) or healthy controls (12%). These differences were specific to findings regarded as potentially clinically significant as opposed to normal variants; however, there was no indication for medical treatment.

CONCLUSIONS

The results suggest that a large proportion of those at high risk of psychosis have radiological findings on MRI scanning, and that the prevalence of radiological findings in this group is similar to that in patients with first episode psychosis.

Early detection and treatment of schizophrenia: how early?

OBJECTIVE

Whereas early detection and therapy of schizophrenic psychoses until some time ago concentrated on frank schizophrenia, during the last years some centres have also started to treat patients even before a clear diagnosis could be established. This paper attempts to discuss if and when this is justified in the light of recent research.

METHOD

Mini review of literature.

RESULTS

The rationale for early detection and treatment of schizophrenia is based on several observations: diagnosis and treatment of schizophrenia are often seriously delayed. Consequences of the disease are severe already in the early undiagnosed phase of the disorder and early treatment seems to improve the course of the disease. It can therefore be stated quite safely that patients should be treated as early as possible. However, the question of how early has not been sufficiently answered up to now.

CONCLUSION

We are at the moment in an ethical dilemma between either diagnosing and treating this disorder too late or too early. The only way and prerequisite for solving this dilemma is a more reliable identification of individuals at risk and the beginning disease process.

Chronisch subdurales H�matom bei einem Patienten mit Verdacht auf Prodromalstadium einer Schizophrenie

A patient showing "prodromal symptoms" of suspected psychosis was referred to our clinic specialized in early recognition of schizophrenia where an MRI brain scan showed a chronic subdural hemorrhage. Based on this case, it will be shown that organic brain disease, in addition to incipient schizophrenia, needs to be considered in patients with marked personality changes, social withdrawal, aggressiveness, and suspiciousness. Diagnosis of the first episode and prodromal stage of schizophrenia should include-apart from the case history as well as the psychopathological and physiological findings-certain obligatory medical examinations (EEG, cCT, or MRI) in order to identify possible organic causes and avoid misdiagnoses.

Neuropsychological and neurophysiological findings in individuals suspected to be at risk for schizophrenia: preliminary results from the Basel early detection of psychosis study - Früherkennung von Psychosen (FEPSY)

OBJECTIVE

Our study aims to establish a scientific basis for the very early detection of patients at risk for schizophrenia during the nonspecific prodromal phase of the disorder and to predict its outbreak.

METHOD

A multidomain approach is used. After screening, approved psychopathological, neurophysiological, neuropsychological and neuroradiological investigations are used to assess a sample of individuals suspected to be at risk for schizophrenia.

RESULTS

Neuropsychological and fine motor functioning tests as well as eye movement measurements showed statistically significant differences (P<0.01) between individuals suspected to be at risk for schizophrenia and healthy controls.

CONCLUSION

Individuals suspected to be at risk for schizophrenia show specific impairments in various investigations including neuropsychological and fine motor functioning tests as well as eye movement measurements. A set of methods sensitive to even subtle changes in normal functioning may prove useful in predicting the subsequent outbreak of schizophrenia.

A general statistical analysis for fMRI data

We propose a method for the statistical analysis of fMRI data that seeks a compromise between efficiency, generality, validity, simplicity, and execution speed. The main differences between this analysis and previous ones are: a simple bias reduction and regularization for voxel-wise autoregressive model parameters; the combination of effects and their estimated standard deviations across different runs/sessions/subjects via a hierarchical random effects analysis using the EM algorithm; overcoming the problem of a small number of runs/session/subjects using a regularized variance ratio to increase the degrees of freedom.

Pathologic gambling in patients with Parkinson's disease

Patients with Parkinson's disease frequently have depression, anxiety, and obsessive-compulsive disorder. We observed two patients who had episodes of pathologic gambling. At the same time, their Parkinson's disease deteriorated and they initiated self-medication with dopaminergic drugs. In both patients, signs were present of an addiction to dopaminergic medication. Pathologic gambling ceased in these patients after a few months. The significance of an insufficient dopaminergic reward system in patients with stereotypical addictive-like behavior (e.g., pathologic gambling) is discussed in this report. The most likely explanation for this newly recognized behavioral disorder in patients with Parkinson's disease is enhanced novelty seeking as a consequence of overstimulation of mesolimbic dopamine receptors resulting from addiction to dopaminergic drugs.

The health of women in paid employment: effects of quality of work role, social support and cynicism on psychological and physical well-being

The possible benefits of the workplace experience for women were examined in terms of four determinants; rewards and concerns intrinsic to the job, rewards and concerns extrinsic to the job, social support and cynicism as a measure of attitude. Benefits were identified in terms of three psychological well-being measures: self-esteem, depression and quality of life and in terms of one physical well-being measure: symptomatology. Data were obtained from one hundred and twenty Canadian women in managerial or professional occupations and in clerical-type occupations. Analyses consisted of correlations and hierarchical multiple regression. Intrinsic factors were generally related to psychological well-being while extrinsic factors were more closely associated with physical health. Findings with regard to the beneficial effects of social support in the workplace were not specific, however a cynical attitude can influence the value of the work role, with effects being particularly marked in the clerical group. Because of its relationship with health, it is recommended that cynicism is included in future women's studies.