Measuring the digital divide among people with severe mental ill health using the essential digital skills framework

AIMS

Amid the vast digitalisation of health and other services during the pandemic, people with no digital skills are at risk of digital exclusion. This risk might not abate by the end of the pandemic. This article seeks to understand whether people with severe mental ill health (SMI) have the necessary digital skills to adapt to these changes and avoid digital exclusion.

METHODS

Two hundred and forty-nine adults with SMI across England completed a survey online or offline. They provided information on their digital skills based on the Essential Digital Skills (EDS) framework, sociodemographic information, and digital access. This is the first time that the EDS is benchmarked in people with SMI.

RESULTS

42.2% had no Foundation Skills, and 46.2% lacked skills for daily life (lacking Foundation or Life Skills). 23.0% of those working lacked skills for professional life (lacking Foundation or Work Skills). The most commonly missing skills were handling passwords and using the device settings (Foundation Skills) and online problem solving (Skills for Life). People were interested in learning more about approximately half of the skills they did not have. People were more likely to lack Foundation Skills if they were older, not in employment, had a psychosis-spectrum disorder, or had no Internet access at home.

CONCLUSION

A significant portion of people with SMI lacked Foundation Skills in this objective and benchmarked survey. This points to a high risk for digital exclusion and the need for focused policy and tailored health sector support to ensure people retain access to key services and develop digital skills and confidence. To our knowledge, this is the first time this has been described using the EDS framework. Services, including the National Health Service (NHS), need to be aware of and mitigate the risks.

Implementation of L4 Automation for Patient-Specific Quality Assurance Using the AUTOFRAME Platform and a Robotic Mechanism

PURPOSE/OBJECTIVE(S)

The AUTOFRAME platform has been previously developed for automating clinical workflows and has achieved L3 automation for patient-specific quality assurance (PSQA). The aim of this study is to further develop the platform to achieve L4 automation, which extends AUTOFRAME to operate Varian's control console (VCC) for the linear accelerator. The goal is to automate all PSQA operations outside of the treatment room.

MATERIALS/METHODS

The automated stages, listed in Table 1, are ranging from L0 to L5. The current study focuses on L4 automation of PSQA, which uses a 6-axis robot arm to control buttons on the VCC. The robotic arm is mounted on a custom frame that is attached onto the VCC to maintain its relative position. The arm is controlled through python scripts, which is run on a raspberry pi and communicates with the AUTOFRAME platform via the PyFlow and AutoFlow subsystems. This integration allows the robotic arm to receive commands from AutoFlow and execute them through PyFlow, activating real-time button-pressing actions.

RESULTS

The integrated L4 system was tested using real PSQA verification plans, which involved a minimum of 4 actions and a maximum of 9 actions on the VCC, including a couch kick that required overriding the couch position. The results showed that the 6-axis arm was able to correctly execute the action groups and guide the robotic arm to consistently press and hold each button with sufficient force and accuracy. All buttons on the VCC, including the Motion-enable, Preparing, Readying, and Delivering buttons, were correctly pushed and held according to the PSQA steps. The system successfully delivered all beams without interruption, and all beam delivery data was collected by the detector for PSQA analysis.

CONCLUSION

The study has further developed the AUTOFRAME platform for L4 automation of PSQA procedures can be achieved. The robotic arm is capable of pushing all required buttons, eliminating all human interactions on the VCC. When combined with previous L0-L3 automations, this will move towards full automation of PSQA procedures. Future work will focus on improving the system's flexibility, stability, and extending its operations to other QA tasks.

Auto Assistant VMAT Planning with HID Automation

PURPOSE/OBJECTIVE(S)

To develop a complete, robust, adaptable and fully customizable software interface for assisting treatment planning procedures on FDA approved commercial system. This will standardize treatment planning process and provide opening interface to other third-party clinical software packages, and introduce AI inference to optimize plan without breaking current clinical planning workflow.

MATERIALS/METHODS

Based on our clinical planning workflow, Varian Eclipse TPS were used. The general HID interface AUTOFLOW was developed with scripting language AutoIt and includes optical character reorganization (OCR) ability. The AUTOFLOW is fully customizable and adaptable for different VMAT planning process. The planning workflow and objective constraints template defined by Northwell health, CFAM are applied. AUTOFLOW operates automatically 3 standard planning interfaces (contouring, external beam planning and optimization) of Eclipse based on information in action tables. The information in the tables, such as auxiliary structures, field set up and initial optimization parameters, can be preset according to the plan template or from other 3rd party packages. Based on Northwell CFAM clinical planning protocol, the planning starts from post-contour approval. AUTOFLOW operates Eclipse to create auxiliary structures, set up planning fields then initiate plan optimization. During the optimization, the AUTOFLOW fills the constraint parameters and monitor the objective goals achievement by OCR. The updated parameters are introduced with our developing machine learning package. The whole planning process were assisted by AUTOFLOW automatically, while the planner can intercept the planning process as need.

RESULTS

The general interface, AUTOFLOW was developed and applied to automatically assist the VMAT procedure in prostate cases. For each prostate case, more than 213 human HID operations on computers were removed from the plan procedure in our CFAM planning protocol. 12 prostate cases without manual interception were tested. The interface succeeds to reducing the VMAT planning time and planner still own the planning control.

CONCLUSION

The AUTOFLOW software interface can be used to perform VMAT planning in current commercial clinical planning system. It can automatically assist planner operation and provide standard interface to 3rd party software packages. The future works will focus on building a cohesive UI, reducing the time further by improving the prediction of optimization parameters and other treatment sites.

A framework for precision "dosing" of mental healthcare services: algorithm development and clinical pilot

BACKGROUND

One in five adults in the US experience mental illness and over half of these adults do not receive treatment. In addition to the access gap, few innovations have been reported for ensuring the right level of mental healthcare service is available at the right time for individual patients.

METHODS

Historical observational clinical data was leveraged from a virtual healthcare system. We conceptualize mental healthcare services themselves as therapeutic interventions and develop a prototype computational framework to estimate their potential longitudinal impacts on depressive symptom severity, which is then used to assess new treatment schedules and delivered to clinicians via a dashboard. We operationally define this process as "session dosing": 497 patients who started treatment with severe symptoms of depression between November 2020 and October 2021 were used for modeling. Subsequently, 22 mental health providers participated in a 5-week clinical quality improvement (QI) pilot, where they utilized the prototype dashboard in treatment planning with 126 patients.

RESULTS

The developed framework was able to resolve patient symptom fluctuations from their treatment schedules: 77% of the modeling dataset fit criteria for using the individual fits for subsequent clinical planning where five anecdotal profile types were identified that presented different clinical opportunities. Based on initial quality thresholds for model fits, 88% of those individuals were identified as adequate for session optimization planning using the developed dashboard, while 12% supported more thorough treatment planning (e.g. different treatment modalities). In the clinical pilot, 90% of clinicians reported using the dashboard a few times or more per member. Although most clinicians (67.5%) either rarely or never used the dashboard to change session types, numerous other discussions were enabled, and opportunities for automating session recommendations were identified.

CONCLUSIONS

It is possible to model and identify the extent to which mental healthcare services can resolve depressive symptom severity fluctuations. Implementation of one such prototype framework in a real-world clinic represents an advancement in mental healthcare treatment planning; however, investigations to assess which clinical endpoints are impacted by this technology, and the best way to incorporate such frameworks into clinical workflows, are needed and are actively being pursued.

Measurement of the N170 during facial neuromuscular electrical stimulation (fNMES)

BACKGROUND

Studies on facial feedback effects typically employ props or posed facial expressions, which often lack temporal precision and muscle specificity.

NEW METHOD

Facial Neuromuscular Electrical Stimulation (fNMES) allows for a controlled influence of contractions of facial muscles, and may be used to advance our understanding of facial feedback effects, especially when combined with Electroencephalography (EEG). However, electrical stimulation introduces significant interference that can mask underlying brain dynamics. Whether established signal processing methods can allow for a reduction of said interference whilst retaining effects of interest, remains unexplored.

RESULTS

We addressed these questions focusing on the classic N170 visual evoked potential, a face-sensitive brain component: 20 participants viewed images of houses, and of sad, happy, and neutral faces. On half of the trials, fNMES was delivered to bilateral lower-face muscles during the presentation of visual stimuli. A larger N170 amplitude was found for faces relative to houses. Interestingly, this was the case both without and during fNMES, regardless of whether the fNMES artefact was removed or not. Moreover, sad facial expressions elicited a larger N170 amplitude relative to neutral facial expressions, both with and without fNMES.

COMPARISON WITH EXISTING METHODS

fNMES offers a more precise way of manipulating proprioceptive feedback from facial muscles, which affords greater diversity in experimental design for studies on facial feedback effects.

CONCLUSIONS

We show that the combining of fNMES and EEG can be achieved and may serve as a powerful means of exploring the impact of controlled proprioceptive inputs on various types of cognitive processing.

Regional blocks for pain control at the end of life in pediatric oncology

Background

Pain management at the end of life is a fundamental aspect of care and can improve patients' quality of life. Interventional approaches may be underutilized for pediatric cancer patients.

Objective

To describe a single institution's 10 years of experience with regional pain management at the end of life in pediatric oncology.

Methods

A retrospective cohort study of 27 patients with pediatric cancer who died between April 2011 and December 2021 and received continuous nerve block (CNB) catheters or single-shot nerve blocks (SSBs) during their last three months of life. The type of blocks, analgesic efficacy, and palliative care involvement were evaluated.

Results

Twenty-two patients (81.5%) had solid tumor diagnoses, including carcinomas, sarcomas, and neuroblastoma. Most (59%) patients received CNB catheters, and 12 patients (44%) received SSBs for pain control. The mean pain score decreases for CNB catheters and SSBs after interventions were -2.5 and -2.8, respectively, on an 11-point scale. Decreases in opioid patient-controlled analgesia dosing requirements were noted in 56% of patients with CNB catheters; likewise, in 25% of patients with SSBs at 24 h and in 8% at 5 days after interventions. Nearly all patients had PC involvement and received care from pain specialists (96% and 93%, respectively). Twenty-three (85%) had physician orders for scope of treatment orders completed before death.

Conclusion

Regional pain control interventions can be effective and safe for relieving regional pain and suffering in dying children and young adults. The collaboration between palliative care and pain management specialists at the end of life can help alleviate suffering and improve quality of life.

Aberrant Right Subclavian Artery: Cadaver Case Report

While examining the anatomy of a cadaver in a medical school gross anatomy course, an aortic arch anomaly was discovered. This variant is consistent with an aberrant right subclavian artery (ARSA). In this variant the right subclavian artery branches from the most distal part of the aortic arch and runs both retrotracheal and retroesophageal as it courses to the right shoulder. This variant is a result of aberrant development of the aortic arch and may include presenting symptoms such as dysphagia and shortness of breath, if any at all. Additional to the ARSA exists a common bicarotid trunk and a direct branching of the left vertebral artery from the aortic arch, both of which are rare anomalies. The cadaver’s medical history includes dysphagia and stretched esophagus, although the severity is unknown. This case report draws attention to these rare anatomical anomalies and includes a discussion of the most common clinical presentation, and surgical implications of an aberrant right subclavian artery anomaly.

Reverse Engineering of Digital Measures: Inviting Patients to the Conversation

Background

Digital measures offer an unparalleled opportunity to create a more holistic picture of how people who are patients behave in their real-world environments, thereby establishing a better connection between patients, caregivers, and the clinical evidence used to drive drug development and disease management. Reaching this vision will require achieving a new level of co-creation between the stakeholders who design, develop, use, and make decisions using evidence from digital measures.

Summary

In September 2022, the second in a series of meetings hosted by the Swiss Federal Institute of Technology in Zürich, the Foundation for the National Institutes of Health Biomarkers Consortium, and sponsored by Wellcome Trust, entitled "Reverse Engineering of Digital Measures," was held in Zurich, Switzerland, with a broad range of stakeholders sharing their experience across four case studies to examine how patient centricity is essential in shaping development and validation of digital evidence generation tools.

Key Messages

In this paper, we discuss progress and the remaining barriers to widespread use of digital measures for evidence generation in clinical development and care delivery. We also present key discussion points and takeaways in order to continue discourse and provide a basis for dissemination and outreach to the wider community and other stakeholders. The work presented here shows us a blueprint for how and why the patient voice can be thoughtfully integrated into digital measure development and that continued multistakeholder engagement is critical for further progress.

Wilson's disease - a tricky diagnosis on the acute take

Wilson's disease is a rare genetic disorder that affects copper metabolism in the body, leading to excess copper accumulation in various organs, including the liver and brain. It often presents to both primary and secondary care, with a combination of liver disease and neurological or psychiatric symptoms, but the presentation can be highly variable. Early recognition and treatment of Wilson's disease is important to prevent critical hepatic and neurological complications. In this case report, we describe the presentation of an 18-year-old male university student with a combination of dysphagia, tremors, and slurred speech, which progressed over several months. Through a series of investigations, the patient was diagnosed with Wilson's disease and received appropriate treatment. This report highlights the importance of considering Wilson's disease in patients with a wide range of symptoms and the need for a pragmatic approach to diagnosis, including routine and additional testing as necessary.

[18F]Sodium fluoride PET-MRI detects increased metabolic bone response to whole-joint loading stress in osteoarthritic knees

OBJECTIVE

Altered joint function is a hallmark of osteoarthritis (OA). Imaging techniques for joint function are limited, but [18F]sodium fluoride (NaF) PET-MRI may assess the acute joint response to loading stresses. [18F]NaF PET-MRI was used to study the acute joint response to exercise in OA knees, and compare relationships between regions of increased uptake after loading and structural OA progression two years later.

METHODS

In this prospective study, 10 participants with knee OA (59 ± 8 years; 8 female) were scanned twice consecutively using a PET-MR system and performed a one-legged squat exercise between scans. Changes in tracer uptake measures in 9 bone regions were compared between knees that did and did not exercise with a mixed-effects model. Areas of focally large changes in uptake between scans (ROIfocal, ΔSUVmax > 3) were identified and the presence of structural MRI features was noted. Five participants returned two years later to assess structural change on MRI.

RESULTS

There was a significant increase in [18F]NaF uptake in OA exercised knees (SUV P < 0.001, KiP = 0.002, K1P < 0.001) that differed by bone region.

CONCLUSION

There were regional differences in the acute bone metabolic response to exercise and areas of focally large changes in the metabolic bone response that might be representative of whole-joint dysfunction.

Systematic review and meta‐analysis of sleep quality in inactive inflammatory bowel disease

Poor sleep in people with inflammatory bowel disease (IBD) has been demonstrated to be prevalent and has been associated with disease activity. This meta‐analysis aimed to assess the prevalence of poor sleep in inactive IBD and in controls by considering cohort and cross‐sectional studies. Electronic databases were searched for publications from inception to 1 November 2021. Poor sleep and IBD activity were defined according to self‐reported subjective sleep measures. A random effects model was used to determine the standardized mean difference between poor sleep in inactive IBD and healthy controls. Publication bias was assessed by funnel plot and Egger's test. Five hundred and nineteen studies were screened with 9 studies included in the meta‐analysis incorporating a total of 729 people with IBD and 508 controls. A random effects model showed a standardized mean difference with poor sleep being more frequent in those with inactive IBD than controls with moderate effect size (Hedge's g 0.41, CI [0.22–0.59]) and no significant heterogeneity. There was no publication bias evident. Poor sleep is more common in individuals with inactive IBD than healthy controls. Further studies should consider potential mechanisms to explain this result, including the role of subclinical inflammation and psychosocial factors that may influence sleep quality in people with IBD.

A systematic review and meta-analysis of the prevalence of poor sleep in inflammatory bowel disease

Study Objectives

Poor sleep-in people with inflammatory bowel disease (IBD) has been associated with worse quality of life, along with anxiety, depression, and fatigue. This meta-analysis aimed to determine the pooled prevalence of poor sleep-in IBD.

Methods

Electronic databases were searched for publications from inception to November 1st 2021. Poor sleep was defined according to subjective sleep measures. A random effects model was used to determine the pooled prevalence of poor sleep-in people with IBD. Heterogeneity was investigated through subgroup analysis and meta-regression. Publication bias was assessed by funnel plot and Egger's test.

Results

519 Studies were screened with 36 studies included in the meta-analysis incorporating a total of 24 209 people with IBD. Pooled prevalence of poor sleep-in IBD was 56%, 95% CI (51-61%) with significant heterogeneity. The prevalence did not differ based on the definition of poor sleep. Meta-regression was significant for increased prevalence of poor sleep with increase in age and increased of prevalence of poor sleep with objective IBD activity but not subjective IBD activity, depression, or disease duration.

Conclusions

Poor sleep is common in people with IBD. Further research is warranted to investigate if improving sleep quality in people with IBD will improve IBD activity and quality of life.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

POS0535 OUTCOMES IN PATIENTS WITH RHEUMATOID ARTHRITIS INITIATING THERAPY WITH ETANERCEPT, ADALIMUMAB, OR JANUS KINASE INHIBITORS

Background

Ongoing debate exists regarding the optimal sequence of tumor necrosis factor inhibitors and Janus kinase inhibitors (JAKis) in patients with rheumatoid arthritis (RA) as first-line biologic or targeted synthetic disease-modifying antirheumatic drug (b/tsDMARD) therapy following conventional therapies.

Objectives

To describe baseline characteristics, effectiveness, persistency, and treatment patterns among first-line b/tsDMARD-naive initiators of etanercept (ETN), adalimumab (ADA), or JAKis (tofacitinib, baricitinib, and upadacitinib).

Methods

Data on patients who initiated b/tsDMARD from 11/2012 to 6/2021 were obtained from the CorEvitas RA Registry, a prospective, multicenter, observational, disease-based registry. Patients ≥18 years with rheumatologist-diagnosed RA and 6- and/or 12-months’ (M) follow-up were included. We report descriptive statistics at baseline, persistency on therapy, escalation/de-escalation of therapy, details on patterns of drug switching, and effectiveness outcomes using regression models adjusted for baseline covariates (demographic/socioeconomic/lifestyle characteristics, comorbidities, medication history, disease activity, and patient-reported outcomes). Outcomes were evaluated at 6M and 12M follow-up.

Results

First-line initiators of ETN, ADA, and JAKis with baseline and follow-up visits were identified: 803, 984, and 361 patients at 6M, respectively; 589, 749, and 264 patients at 12M, respectively. Baseline characteristics were similar among ETN, ADA, and JAKi initiators with the exception of disease duration, which was longer among first-line JAKi initiators (mean, 8.6 y) versus ETN (5.9 y) and ADA (5.8 y) initiators. Unadjusted mean improvement in Clinical Disease Activity Index (CDAI) was generally similar between groups at 6M and 12M (Table 1). Adjusted effectiveness results were similar at 6M and 12M (Figure 1). At 6M, 68% of ETN, 69% of ADA, and 67% of JAKi initiators remained on the same therapy; at 12M, 53% of ETN, 57% of ADA, and 57% of JAKi initiators remained on the same therapy. The frequency of switching to another b/tsDMARD was similar across initiators.

Table 1.

Patient Description at Time of Initiation and Unadjusted Disease Activity Results

ETNADAJAKisAge, years54.4 (12.8)55.5 (12.1)60.9 (12.5)Female, n (%)666 (77)843 (76)303 (77)BMI, kg/m230.4 (7.6)31.3 (7.9)30.8 (7.6)Duration of RA, years5.9 (7.6)5.8 (7.3)8.6 (10.0)BL disease activitya CDAI19.9 (14.3)18.9 (12.7)18.8 (13.2) mHAQ0.5 (0.5)0.5 (0.5)0.5 (0.5) Patient painb48.0 (28.8)49.2 (28.5)45.2 (29.2)Disease activity decrease from BL at 6M CDAI6.9 (13.6)6.4 (12.1)4.7 (12.3) mHAQ0.1 (0.4)0.1 (0.4)0.1 (0.4) Patient painb9.7 (30.2)10.6 (28.4)8.9 (29.5)Disease activity decrease from BL at 12M CDAI7.4 (13.5)6.1 (13.0)5.1 (13.0) mHAQ0.1 (0.4)0.1 (0.4)0.1 (0.4) Patient painb8.8 (29.7)8.7 (30.1)7.5 (28.6)Achievement of LDAc, % 6M43.441.932.5 12M41.039.638.3

aBaseline for combined population with 6M and 12M follow-up. b(range: 0–100). cCDAI ≤10 among those with moderate or high disease activity at baseline.

Data are mean (SD) unless otherwise specified.

ADA, adalimumab; BL, baseline; CDAI, Clinical Disease Activity Index; ETN, etanercept; JAKis, Janus kinase inhibitors; LDA, low disease activity; M, months; mHAQ, modified Health Assessment Questionnaire; RA, rheumatoid arthritis; SD, standard deviation.

Conclusion

In this real-world study in patients initiating first-line b/tsDMARD therapy with ETN, ADA, or JAKis, we did not observe differences in clinical effectiveness/patient-reported outcomes and treatment persistency at 6M and12M after treatment initiation.

Acknowledgements

This study is sponsored by CorEvitas, LLC. CorEvitas has been supported through contracted subscriptions in the last two years by AbbVie, Amgen Inc., Arena, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Chugai, Eli Lilly and Company, Genentech, Gilead, GSK, Janssen, LEO, Novartis, Ortho Dermatologics, Pfizer Inc., Regeneron, Sanofi, Sun, and UCB. Writing support was funded by Amgen Inc. and provided by Su Cappello, PharmD, of Peloton Advantage, LLC, an OPEN Health company, and Julie Wang, DPM, of Amgen Inc.

Disclosure of Interests

Dimitrios A Pappas Shareholder of: Officer or Board Member for Corrona Research Foundation, Speakers bureau: Speaker/Honoraria for AbbVie, Novartis, Roche Hellas, Sanofi, Consultant of: Consultant for AbbVie, Roche Hellas; Advisor for Sanofi, Employee of: Employment by, ownership interest, and stock options in CorEvitas, LLC, Jacqueline O’Brien Employee of: Employment by CorEvitas, LLC., Lin Guo Employee of: Employment by CorEvitas, LLC., Ying Shan Employee of: Employment by CorEvitas, LLC., Joshua Baker Consultant of: Received consulting fees from Bristol Myers Squibb, Pfizer, CorEvitas LLC, and Burns-White, LLC., Greg Kricorian Shareholder of: Employment by and stock ownership in Amgen Inc., Employee of: Employment by and stock ownership in Amgen Inc., Scott Stryker Shareholder of: Employment by and stock ownership in Amgen Inc., Employee of: Employment by and stock ownership in Amgen Inc., David Collier Shareholder of: Employment by and stock ownership in Amgen Inc., Employee of: Employment by and stock ownership in Amgen Inc.

POS0656 FRAILTY AND RISK OF ADVERSE OUTCOMES IN BIOLOGIC OR TARGETED-SYNTHETIC DMARD TREATED PATIENTS WITH RHEUMATOID ARTHRITIS

Background

Recently, it has been recognized that frailty and pre-frailty are common in patients with rheumatoid arthritis (RA) [1]. Whether frailty status portends an increased risk of adverse outcomes in patients with RA on biologic or targeted synthetic disease modifying anti-rheumatic drugs (b- or tsDMARDs) remains unknown.

Objectives

To evaluate the association between frailty and adverse outcomes in patients with RA exposed to b- or tsDMARDs.

Methods

Using the IBM/Watson MarketScan Commercial Claims and Encounters Databases, we identified all patients with RA who filled new prescriptions (or received infusions) for TNFα antagonists (TNFi), non-TNFi biologics (rituximab, abatacept, tocilizumab) or Janus Kinase inhibitors (JAKi) between 2008-2019. We used a 1-year lookback period without the use of these drugs to identify new users. The date of the first prescription within these three drug categories was the index date. Patients’ frailty risk score was calculated using the Claims-Based Frailty Index (CFI) [2], which estimates a deficit-accumulation frailty index using International Classification of Diseases codes, Current Procedural Terminology codes, and Healthcare Common Procedure Coding System codes in administrative claims data in the 1-year baseline period. The index ranges from 0 (not at all frail) to 1 (severely frail). The primary outcome was time to serious infections (those requiring hospitalization); secondary outcomes: any infection (outpatient or inpatient encounters) and all-cause hospitalizations.

Patients were followed until 1) outcome occurrence; 2) disenrollment; 3) >90 days elapsed (or >180 days for rituximab) without further fills of the first drug categories; 4) they filled/received infusions of b-/tsDMARDs from a different drug category; or 5) 2 years after index. Cox proportional hazards adjusting for demographics, calendar year, serious and/or opportunistic infections in the 12-months prior to index were used to estimate the adjusted hazard ratios (aHR) and 95% confidence intervals (CIs) for each outcome. In separate model, we additionally adjusted for comorbidity burden, and health care utilization (HCU).

Results

A total of 62,246 patients with RA met our inclusion criteria of whom 50,910 (82%) started TNFi as their first biologic, 9525 (15%) non-TNFi biologics, and 1811 (3%) JAKi. Among these, 3928 (6%) were considered frail. In multivariable analyses, frail patients had higher risk of serious infections compared to non-frail patients (aHR 2.37, 95% CI 2.05-2.74) which decreased to aHR 1.34, 95% CI 1.13-1.58 (Table 1) after adjusting for comorbidity burden and the HCU. Similarly, frailty was associated with increased risk of any infection (aHR 1.18, 95% CI 1.11-1.25), and all-cause hospitalizations (aHR 1.34, 95% CI 1.21-1.49) relative to non-frail individuals.

Table 1.

Multivariable models evaluating the association between frailty status and inpatient infections as the outcome

Variable#Hazard Ratio (95% Confidence Interval)@Hazard Ratio (95% Confidence Interval)Frail2.37 (2.05, 2.74)1.34 (1.13, 1.58)

#Model adjusts for age, sex, major infection requiring inpatient admission in 12 months prior, concomitant baseline drugs such as csDMARDs, glucocorticoids, NSAIDs and opioids

@Model additionally adjusts for Chalrson comorbidy score and healthcare utilization

Conclusion

Frailty is an important predictor for the risk of adverse outcomes among patients with RA treated with b- or tsDMARDs. Our findings underscore the need for considering this parameter in patient evaluations (even among younger patients) in the clinic.

References

[1]Salaffi F et al: Prevalence of frailty and its associated factors in patients with rheumatoid arthritis: a cross-sectional analysis. Clin Rheumatol 2019

[2]Kim DH et al. Validation of a Claims-Based Frailty Index Against Physical Performance and Adverse Health Outcomes in the Health and Retirement Study. J Gerontol A Biol Sci Med Sci 2019

Acknowledgements

I have no acknowledgements to declare.

Disclosure of Interests

None declared

Cracked Tooth Syndrome: Assessment, Prognosis and Predictable Management Strategies

Cracked tooth syndrome (CTS) is a common presentation in general practice. The diagnosis and management of teeth with CTS may be difficult due to the unknown extent of the crack. This article reviews the aetiology, diagnosis, management and prognosis of teeth with CTS. A thorough examination is required to effectively assess CTS. Intervention should aim to relieve symptoms and brace the remaining tooth structure effectively against further flexion. Restored teeth with CTS have a guarded prognosis due to the risk of further crack propagation, but the chances of survival at 5-years is acceptable (74.1-96.8%).

Addressing Opportunities & Misunderstandings of ASCP International Certification in the Philippines

Introduction/Objective

The objective of this study is to identify the positive viewpoints and misunderstandings Filipino applicants have about the BOC’s international credential and credential maintenance programs. With a total of 10,836 MLS(ASCPi) certificants, the Philippines is the BOC’s largest and most successful international certification market. However, despite the Philippines being the BOC’s largest international certification market, the BOC only certifies about a third of eligible Filipino graduates each year.

Therefore, to encourage additional interest in achieving BOC credentials and to eliminate misunderstanding surrounding the BOC’s Credential Maintenance Program (CMP), the ASCP BOC International Credentialing Committee created and deployed a survey.

The purpose of the survey was to learn as much as possible about the medical laboratory scientist certification market in the Philippines, as well as determine what opportunities Filipino‘s were afforded after they earned their credential. The resulting report based on analysis of the survey results showed there are a number of issues affecting Filipino participation in the BOC’s credential and CMP offerings.

Methods/Case Report

422 individuals from 44 countries of education participated in the survey. This study is a summary of results from the 265 Filipino respondents.

Results (if a Case Study enter NA)

This study confirmed a number of assertions the BOC had about the Filipino credential market. The most important of these assertions is MLS(ASCPi) certification is appealing to Philippine- educated individuals due to its portability (i.e., work eligibility, emigration, etc.).

Conclusion

The BOC should continue leaning into the portability of MLS(ASCPi) certification, but also needs to do a better job of promoting our other international certifications for which Filipinos may be eligible. The BOC needs to place greater emphasis on educating Filipinos on the importance of CMP and on what can be used for CE towards CMP. For example, the BOC needs to create an outreach campaign that helps Filipino credential holders understand CE earned for their PRC (i.e., Philippines-licensure requirements) can also be used for their CMP. Finally, considering the popularity of BOC certification in the Philippines, the BOC should work on creating more content that focuses on promoting the usefulness of pursing an advanced credential, the portability of certification, and the overall demystification of CMP.

Hard to Swallow Results

The American Neurogastroenterology and Motility Society (ANMS) proposed quality measures (QMs) for performance and interpretation of esophageal manometry (EM). We implemented a quality improvement (QI) study at a large community hospital to assess and improve procedural adherence and interpretation of EM studies based on the ANMS QMs using the Chicago Classification 3.0 (CC) Guidelines. For pre-intervention, three motility independent reviewers reinterpreted 60 EM studies conducted by community gastroenterologists without Tier II-III motility training from October to December 2018 for compliance with pre-procedural, procedural, and data interpretation ANMS QMs. In December 2018, we developed a pre-procedural form, educated nurses on EM procedural compliance, and provided preliminary pre-intervention results to gastroenterologists along with literature utilizing the CC 3.0 Guidelines. For post-intervention, we reinterpreted 54 EM studies from January to August 2019 and investigated whether they met QMs for data interpretation with respect to the CC Guidelines and resulted in appropriate treatment. We found a statistically significant improvement in procedural compliance among nursing staff for 30 s of swallows (76% post-intervention versus 12% pre-intervention, p < 0.001) and 7 evaluable swallows (94% post-intervention versus 53% pre-intervention, p < 0.001). However, quality metrics within data interpretation by physicians post-intervention showed mixed results. An incorrect diagnosis was made in 50% (n = 27)) of studies with 72% (n = 39) having at least one missing item based on the CC. The most missed diagnosis was fragmented peristalsis (30%, n = 29). Among the 39% (n = 21) of surgery referrals, 24% (n = 5) were incorrectly referred. Our study shows poor data interpretation by community gastroenterologists without formal motility training despite adequate performance by nursing staff. This further supports the need for a national ANMS certification process for formal HRM education.

Challenges and stresses experienced by athletes and coaches leading up to the Paralympic Games

The demands of high-performance sport are exacerbated during the lead up to the Major Games (i.e., Paralympics). The purpose of this study was to better understand the challenges experienced and strategies utilized by Australian athletes (n = 7) and coaches (n = 5) preparing for the Tokyo Paralympic Games using semi-structured interviews. The thematic analysis highlighted challenges specific to participants’ sport (e.g., budgetary constraints, decentralized experiences, athletes with various impairments), personal life (e.g., moving cities to access coaching, postponing vocational/educational developments, isolation from social circles), and associated uncertainties (e.g., COVID-19, qualifications, accreditations). Participants managed these challenges by utilizing strategies to ‘anticipate and prepare’ (e.g., detailed planning, effective communication, contingency plans) and ‘manage expectations’ (e.g., understanding specific roles and boundaries, focusing on the process [i.e., effort over results]). Trust and communication between athletes and coaches was key in coaches’ better understanding of how athletes’ impairments interact with their training and competition environments and tailor support to each athlete’s unique needs. Last, participants reflected on the ‘pressure’ of the Games due to their performance having an impact on their career trajectory ‘post-Tokyo’ with some athletes contemplating retirement and others realizing the consequences of their performance on sport-related vocation and sponsorship. Coaches also accepted the success of their programs and job security will depend on outcomes at the Games. The findings from this study shed light on factors to consider to reduce challenges for teams preparing for major competitions but also highlight key practical implications to support athletes and coaches leading up, during, and post-major Games.

Determining sample size and length of follow-up for smartphone-based digital phenotyping studies

OBJECTIVE

Studies that use patient smartphones to collect ecological momentary assessment and sensor data, an approach frequently referred to as digital phenotyping, have increased in popularity in recent years. There is a lack of formal guidelines for the design of new digital phenotyping studies so that they are powered to detect both population-level longitudinal associations as well as individual-level change points in multivariate time series. In particular, determining the appropriate balance of sample size relative to the targeted duration of follow-up is a challenge.

MATERIALS AND METHODS

We used data from 2 prior smartphone-based digital phenotyping studies to provide reasonable ranges of effect size and parameters. We considered likelihood ratio tests for generalized linear mixed models as well as for change point detection of individual-level multivariate time series.

RESULTS

We propose a joint procedure for sequentially calculating first an appropriate length of follow-up and then a necessary minimum sample size required to provide adequate power. In addition, we developed an accompanying accessible sample size and power calculator.

DISCUSSION

The 2-parameter problem of identifying both an appropriate sample size and duration of follow-up for a longitudinal study requires the simultaneous consideration of 2 analysis methods during study design.

CONCLUSION

The temporally dense longitudinal data collected by digital phenotyping studies may warrant a variety of applicable analysis choices. Our use of generalized linear mixed models as well as change point detection to guide sample size and study duration calculations provide a tool to effectively power new digital phenotyping studies.

Cracked Tooth Syndrome: Assessment, Prognosis and Predictable Management Strategies

Cracked tooth syndrome (CTS) is a common presentation in general practice. The diagnosis and management of teeth with CTS may be difficult due to the unknown extent of the crack. This article reviews the aetiology, diagnosis, management and prognosis of teeth with CTS. A thorough examination is required to effectively assess CTS. Intervention should aim to relieve symptoms and brace the remaining tooth structure effectively against further flexion. Restored teeth with CTS have a guarded prognosis due to the risk of further crack propagation, but the chances of survival at 5-years is acceptable (74.1-96.8%).

Quantitative systems pharmacology in neuroscience: Novel methodologies and technologies

The development and application of quantitative systems pharmacology models in neuroscience have been modest relative to other fields, such as oncology and immunology, which may reflect the complexity of the brain. Technological and methodological advancements have enhanced the quantitative understanding of brain physiology and pathophysiology and the effects of pharmacological interventions. To maximize the knowledge gained from these novel data types, pharmacometrics modelers may need to expand their toolbox to include additional mathematical and statistical frameworks. A session was held at the 10th annual American Conference on Pharmacometrics (ACoP10) to highlight several recent advancements in quantitative and systems neuroscience. In this mini‐review, we provide a brief overview of technological and methodological advancements in the neuroscience therapeutic area that were discussed during the session and how these can be leveraged with quantitative systems pharmacology modeling to enhance our understanding of neurological diseases. Microphysiological systems using human induced pluripotent stem cells (IPSCs), digital biomarkers, and large‐scale imaging offer more clinically relevant experimental datasets, enhanced granularity, and a plethora of data to potentially improve the preclinical‐to‐clinical translation of therapeutics. Network neuroscience methodologies combined with quantitative systems models of neurodegenerative disease could help bridge the gap between cellular and molecular alterations and clinical end points through the integration of information on neural connectomics. Additional topics, such as the neuroimmune system, microbiome, single‐cell transcriptomic technologies, and digital device biomarkers, are discussed in brief.

RNAi inhibition of angiopoietin-like protein 3 (ANGPTL3) with ARO-ANG3 mimics the lipid and lipoprotein profile of familial combined hypolipidemia

Background

Elevated LDL-C and triglyceride rich lipoproteins (TRLs) are independent risk factors for cardiovascular disease (CVD). Genetic deficiency of angiopoietin-like protein 3 (ANGPTL3) is associated with reduced circulating levels of LDL-C, triglycerides (TGs), VLDL-C, HDL-C and reduced CVD risk, with no described adverse phenotype. ARO-ANG3 is a RNA interference drug designed to silence expression of ANGPTL3. Single doses of ARO-ANG3 have been shown to reduce ANGPTL3, TGs, VLDL-C and LDL-C in healthy volunteers (HVs, AHA 2019). We report the effects of multiple doses of ARO-ANG3 in HVs with a focus on the duration of action.

Methods

ARO-ANG3 was administered subcutaneously to HVs on days 1 and 29 at doses of 100, 200 or 300 mg (n=4 per group). Measured parameters included ANGPTL3, LDL-C, TGs, VLDL-C and HDL-C. Follow up is ongoing.

Results

All HVs have received both doses and follow-up is currently through week 16 (12 weeks after second dose). Mean nadir for ANGPTL3 levels occurred 2 weeks after the second dose (−83–93%) with minimal change for 200 and 300 mg but 16% recovery for 100 mg at week 16. Mean TGs and VLDL-C reached nadir earlier (3 wks, −61–65%) without apparent dose response and minimal change for any dose at wk 16. LDL-C nadir occurred 4–6 wks after the second dose (−45–54%), again with minimal evidence for dose response or change through wk 16. HDL-C was reduced 14–37% at wk 16. ARO-ANG3 was well tolerated without serious or severe adverse events or dropouts related to drug. The most common adverse events have been headache and upper respiratory infections.

Conclusions

Genetic deficiency of ANGPTL3 is a cause of familial combined hypolipemia and is associated with a decreased risk of CVD. Using RNAi to selectively suppress ANGPTL3 production reproduces these genetic effects with a duration of at least 12 weeks following a second dose and with good tolerability over 16 wks. ANGPTL3 inhibition results in lowering of LDL-C and TRLs which may confer protection against CVD in patients with atherogenic mixed dyslipidemia.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Arrowhead Pharmaceuticals

RNA interference targeting apolipoprotein C-III with ARO-APOC3 in healthy volunteers mimics lipid and lipoprotein findings seen in subjects with inherited apolipoprotein C-III deficiency

Background

Individuals with triglycerides (TGs) ≥1,000 mg/dL (11.1 mmol/L) are at increased risk of acute pancreatitis. Genetic studies indicate that individuals with apolipoprotein C-3 (APOC3) loss-of-function mutations have low TGs, reduced cardiovascular risk and no observed adverse phenotype. RNA interference (RNAi) with ARO-APOC3 has shown deep and durable knockdown (KD) of APOC3 after single doses in healthy volunteers (HVs, presented at AHA 2019) with good tolerability. We report here initial results using multiple doses of ARO-APOC3 to silence APOC3 expression in HVs.

Methods

ARO-APOC3 was administered subcutaneously to HVs on days 1 and 29 at doses of 10, 25 or 50 mg (n=4 per group). Measured parameters included plasma concentrations of APOC3, LDL-C, TGs, VLDL-C and HDL-C.

Results

All HVs have received both doses and follow-up for most parameters is available through week (wk) 14 (10 wks after second dose) for the 10 and 25 mg doses and through wk 10 for 50 mg. Mean nadir for APOC3 levels occurred at wk 3 for 10 mg (−73%) and remained similar at wk 10 (−66%), at wk 6 for 25 mg (−90%) with no change at wk 10 and at wk 2 for 50 mg (−94%) unchanged at wk 8. TGs fell faster in the 50 mg group (wk 1: 10 mg −41%; 25 mg −47%; 50 mg −72%). By wk 6 the 25 and 50 mg results were similar (−68% and −74%, respectively) and remained similar through wk 14. 10 mg was less active with a nadir of −56% and mean reductions between 42% and 56% post-nadir. VLDL-C values mirrored TGs. LDL-C reductions were more modest and did not manifest a dose response. Mean nadirs (−23–26%) occurred 4–6 wks after the first dose, again with minimal change through 10–14 wks of follow-up. Consistent with genetic studies, HDL-C increased to a maximum at approximately wk 8 (10 mg +42%, 25 mg +48%, 50 mg +84%). ARO-APOC3 was well tolerated without serious or severe adverse events or dropouts related to drug. The most common adverse events were mild injection site AEs and headache.

Conclusions

Genetic deficiency of APOC3 is associated with substantial reductions in TGs, VLDL-C and increases in HDL-C without an adverse phenotype. Using RNAi to selectively suppress APOC3 production mimics these lipid and lipoprotein effects, with a duration of at least 10 weeks following a second dose and with good tolerability over 16 wks using doses ranging from 10 to 50 mg. Investigation of optimal dosing regimen is ongoing, especially with respect to dosing interval. This therapeutic approach has potential for treating patients with chylomicronemia at risk of pancreatitis.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Arrowhead Pharmaceuticals

Continuous Versus 1-Year Fixed-Duration Nivolumab in Previously Treated Advanced Non-Small-Cell Lung Cancer: CheckMate 153

Limited data exist on the optimal duration of immunotherapy, including for non–small-cell lung cancer (NSCLC). We present an exploratory analysis of CheckMate 153, a largely community-based phase IIIb/IV study, to evaluate the impact of 1-year fixed-duration versus continuous therapy on the efficacy and safety of nivolumab.

The Few Who Made It: Commercially and Clinically Successful Innovative Bone Grafts

Bone reconstruction techniques are mainly based on the use of tissue grafts and artificial scaffolds. The former presents well-known limitations, such as restricted graft availability and donor site morbidity, while the latter commonly results in poor graft integration and fixation in the bone, which leads to the unbalanced distribution of loads, impaired bone formation, increased pain perception, and risk of fracture, ultimately leading to recurrent surgeries. In the past decade, research efforts have been focused on the development of innovative bone substitutes that not only provide immediate mechanical support, but also ensure appropriate graft anchoring by, for example, promoting de novo bone tissue formation. From the countless studies that aimed in this direction, only few have made the big jump from the benchtop to the bedside, whilst most have perished along the challenging path of clinical translation. Herein, we describe some clinically successful cases of bone device development, including biological glues, stem cell-seeded scaffolds, and gene-functionalized bone substitutes. We also discuss the ventures that these technologies went through, the hindrances they faced and the common grounds among them, which might have been key for their success. The ultimate objective of this perspective article is to highlight the important aspects of the clinical translation of an innovative idea in the field of bone grafting, with the aim of commercially and clinically informing new research approaches in the sector.

Global hunger and climate change adaptation through international trade

International trade enables us to exploit regional differences in climate change impacts and is increasingly regarded as a potential adaptation mechanism. Here, we focus on hunger reduction through international trade under alternative trade scenarios for a wide range of climate futures. Under the current level of trade integration, climate change would lead to up to 55 million people who are undernourished in 2050. Without adaptation through trade, the impacts of global climate change would increase to 73 million people who are undernourished (+33%). Reduction in tariffs as well as institutional and infrastructural barriers would decrease the negative impact to 20 million (-64%) people. We assess the adaptation effect of trade and climate-induced specialization patterns. The adaptation effect is strongest for hunger-affected import-dependent regions. However, in hunger-affected export-oriented regions, partial trade integration can lead to increased exports at the expense of domestic food availability. Although trade integration is a key component of adaptation, it needs sensitive implementation to benefit all regions.

An evaluation of continuous subcutaneous infusions across seven NHS acute hospitals: is there potential for 48-hour infusions?

BACKGROUND

Continuous subcutaneous infusions (CSCIs) are commonly used in the United Kingdom as a way of administering medication to patients requiring symptom control when the oral route is compromised. These infusions are typically administered over 24 h due to currently available safety data. The ability to deliver prescribed medication by CSCI over 48 h may have numerous benefits in both patient care and health service resource utilisation. This service evaluation aims to identify the frequency at which CSCI prescriptions are altered at NHS Acute Hospitals.

METHODS

Pharmacists or members of palliative care teams at seven acute NHS hospitals recorded anonymised prescription data relating to the drug combination(s), doses, diluent and compatibility of CSCIs containing two or more drugs on a daily basis for a minimum of 2 days, to a maximum of 7 days.

RESULTS

A total of 1301 prescriptions from 288 patients were recorded across the seven sites, yielding 584 discrete drug combinations. Of the 584 combinations, 91% (n = 533) included an opioid. The 10 most-common CSCI drug combinations represented 37% of the combinations recorded. Median duration of an unchanged CSCI prescription across all sites was 2 days.

CONCLUSION

Data suggests medication delivered by CSCI over 48 h may be a viable option. Before a clinical feasibility study can be undertaken, a pharmacoeconomic assessment and robust chemical and microbiological stability data will be required, as will the assessment of the perceptions from clinical staff, patients and their families on the acceptability of such a change in practice.

AB0354 STEPPING UP FOR INFLAMMATORY ARTHRITIS: A PILOT TRIAL TO TEST BEHAVIORAL ECONOMICS STRATEGY TO INCREASE PHYSICAL ACTIVITY IN INFLAMMATORY ARTHRITIS

Background:

Regular physical activity may have benefits for patients with rheumatoid arthritis (RA) and psoriatic arthritis (PsA), but patients with active disease are often reluctant to increase activity. Principles from behavioral economics (BE), a field combining psychology and economics, have been applied to motivate increased physical activity in non-arthritis patients.1No published studies have examined the application of BE concepts in rheumatology to promote exercise.

Objectives:

To assess the feasibiility and efficacy of a loss aversion financial incentive for increasing step counts and improving disease symptoms in RA and PsA patients with active disease.

Methods:

A randomized controlled pilot trial was performed among patients with RA and PsA. Participants were required to have active disease defined by having at least one swollen joint and a Routine Assessment of Patient Index Data-3 (RAPID3) score>3 (range 0-30 with <3 indicating remission). The trial included two visits (baseline and 14-week) and weekly check-ins via virtual trial platforms, Way to Health and the ArthritisPower app. Patients were given a Fitbit Alta at baseline and completed a two-week run-in period to assess average step count. Patients were then prompted to select a step count goal and complete a commitment contract. After selection of a goal, participants randomized to the intervention arm received a financial loss aversion incentive (each month, patients started with $75 in their account and lost $2.50 for each day they did not reach their goal). Patients were blinded to the other study arm and investigators were blinded to assignment. All patients received weekly text message prompts providing feedback about their performance over the previous week, completed weekly PROs, and had the opportunity to report adverse events including flares of joint pain. After 12 weeks of the intervention (at week 14), the incentive was removed and patients were followed to 26 weeks to determine how long the effect persisted.

Results:

In the pilot trial, 71 patients were verbally consented for screening, 34 underwent screening (of these, two were ineligible), 27 were randomized, and 22 patients completed the 14-week study visit. Mean age of participants was 50 (SD 13), 85% were female, 17(63%) had PsA, mean BMI was 30.6 and mean swollen (0-66) and tender (0-68) joint counts were 6.2 (5.6) and 8.1 (9.1), respectively. Baseline RAPID3 was 10.5 (SD 4.6) and the mean step count at baseline was 5,962. By 28 days, 65% of patients increased their step count. Participants receiving the incentive had an average of 714 more steps per day over the first 14 weeks and a greater probability of reaching 10,000 steps per day during follow-up (30% v. 21%, p=0.41). Among patients who achieved their step count goals more than 50% of days, we observed more improvement in sleep quality, fatigue, and overall well-being (p<0.05) (Figure 1). After adjusting for baseline RAPID3, the 14-week RAPID3 scores were lower in the group that achieved their step goals 50% of the time [B: -3.91 (-11.8, 3.99); a difference that approximates the minimal clinically important difference (MCID) for the RAPID3 (3.6).

Figure 1.

Change in fatigue severity among those with greater adherence to step count goals.

Conclusion:

While financial incentives have worked well in patients without arthritis, the estimated effect of the financial incentive in this small study was more modest in patients with RA and PsA. Those that were able to increase their physical activity and meet their step goals had greater improvements in symptoms over the course of the study. These data support further study in this area to promote physical activity by leveraging concepts from behavioral economics.

References:

[1]Ogdie & Asch. Nat Rev Rheumatol. 2019

Disclosure of Interests:

Alexis Ogdie Grant/research support from: Pfizer, Novartis, Consultant of: Abbvie, Amgen, BMS, Celgene, Corrona, Janssen, Lilly, Pfizer, Novartis, Mitesh Patel Shareholder of: Owner, Catalyst Health LLC, Consultant of: Advisory Board Member for Healthmine Services, Life.io, Holistic Industries, Jeffrey Curtis Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Corrona, Janssen, Lilly, Myriad, Pfizer, Regeneron, Roche, UCB, Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Corrona, Janssen, Lilly, Myriad, Pfizer, Regeneron, Roche, UCB, Kelly Gavigan: None declared, W. Benjamin Nowell: None declared, Joshua Baker: None declared

FRI0572 LEPTIN-ADJUSTMENT OF THE MULTI-BIOMARKER DISEASE ACTIVITY (MBDA) SCORE REDUCES THE INFLUENCE OF ADIPOSITY

Background:

Obesity and excess adiposity influence inflammatory markers and bias disease activity assessment, especially among women. A multi-biomarker disease activity (aMBDA) score has been developed to account for the effects of age, sex and adiposity (leptin) and improves prediction of radiographic damage progression.1

Objectives:

1) Determine if the adjusted measure demonstrates a reduced association with adiposity.

2) Assess the impact of the leptin-adjustment on the score over the range of adiposity.

3) Assess relationships between MBDA scores and clinical disease activity.

Methods:

Patients with rheumatoid arthritis (RA), ages 18-75 years, completed whole-body dual-energy x-ray absorptiometry to quantify fat mass indices (FMI, kg/m2). Age-, sex-, and race-specific Z-Scores were calculated based on the distributions in a healthy reference population. Disease activity was assessed with the CDAI and swollen joint count (SJC). Baseline van der Heijde-Sharpe (vdHS) scores were determined by a radiologist. MBDA assays were performed on stored serum samples. Descriptive statistics described relationships between the FMI Z-Score and the MBDA and the aMBDA. Clinical disease activity, SJC, and radiographic damage were also compared across MBDA score categories.

Results:

Of 104 participants (50% female), the mean (SD) age was 56.1 (12.5) and mean BMI was 28.8 (6.9) (Table 1). The unadjusted MBDA score was strongly associated with BMI among women (Women: Rho=0.46 [p< 0.001]; Men: Rho=-0.12), while the aMBDA was not associated with BMI in women and was inversely correlated in men (Women: Rho=0.17; Men: Rho=-0.32 [p=0.02]). The unadjusted MBDA score was also strongly associated with FMI Z-Score among women (Figure; Women: Rho=0.42 [p=0.002]; Men: Rho=-0.10; p=0.01). The aMBDA was not significantly associated with FMI Z-Score (Female: Rho= 0.17; Male: Rho=-0.26). Leptin-adjustment reduced the MBDA score in the highest quartile of FMI in women but not men, and increased the MBDA score in the lowest FMI quartiles in both women and men; these patients in the lowest FMI quartile had the highest median SJC (p=0.05 for men, p=0.78 for women; Figure). The aMBDA reclassified 4 women (8%) and 9 men (17%) into higher disease activity categories and 2 women (4%) and 2 men (4%) into lower categories. CDAI, SJC, and radiographic scores were similar across activity categories for the unadjusted MBDA score and aMBDA (Table 2).

Table 1.

Baseline Characteristics.

MenWomenN5252Age (yrs)59.1 (11.5)53.0 (12.8)Black, N (%)13 (25%)19 (36%)BMI27.3 (5.4)30.3 (8.0)FMI Z-Score-0.28 (1.3)0.05 (1.1)DAS28(CRP)3.09 (1.13)3.21 (1.24)Disease Duration11.4 (10.9)11.6 (11.9)CRP, mg/dL0.8 (0.5, 1.2)0.8 (0.5, 1.4)CCP Positive, N (%)45 (87%)40 (78%)vdHS (N=93)13 (4, 73)10.5 (2, 47)HAQ0.71 (0.59)0.83, (0.67)MBDA40.0 (13.8)42.1 (16.6)aMBDA43.6 (13.4)42.1 (15.3)Leptin, ng/mL15.1 (21.5)48.9 (41.5)Table 2.

Clinical assessments across MBDA score categories.

CDAISJCvdHSMBDAaMBDAMBDAaMBDAMBDAaMBDAMBDA CategoryLow14.6 (10.9)13.9 (9.9)2 (1, 5)2 (1, 5)9 (1, 33.5)9 (3, 32)Moderate13.2 (10.0)14.4 (11.4)2 (0, 5)3 (0, 6)10 (4, 49)10 (2, 53)High18.4 (12.3)17.7 (11.8)4 (1, 8)5 (2, 7)20.5 (5, 70.5)18 (4, 73)

Conclusion:

Leptin-adjustment of the MBDA score reduced bias related to excess adiposity in women with RA. Adjustment results in lower MBDA scores in women with greater adiposity, and higher MBDA scores in women and men with lesser adiposity. The aMBDA may reduce misclassification due to excess adiposity and improve identification of active disease among patients with lower adiposity. High aMBDA scores among men with low adiposity may reflect severe disease or excess comorbidity in this group.

References:

[1] Curtis et al.Rheumatology (Oxford) 2018. PMID: 30590790

Figure.

Impact of Adjustment on MBDA Score by FMI Z-Score Quartile.

Disclosure of Interests:

Joshua Baker Grant/research support from: Myriad RBM, Consultant of: Bristol-Myers Squib, Burns-White LLC, Jeffrey Curtis Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Corrona, Janssen, Lilly, Myriad, Pfizer, Regeneron, Roche, UCB, Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Corrona, Janssen, Lilly, Myriad, Pfizer, Regeneron, Roche, UCB, David Chernoff Employee of: Myriad, Michael George Grant/research support from: Bristol Myers Squibb, Consultant of: AbbVie

Potential Opioid-Related Adverse Drug Events Are Associated With Decreased Revenue in Hip Replacement Surgery in the Older Population

Introduction

Opioid-related adverse drug events (ORADEs) are an increasingly recognized complication associated with the common prescription of opioids after orthopedic surgery. In this study, we attempted to understand how potential ORADEs following hip replacement surgery in older patients affected hospital length of stay, hospital revenue, and their association with specific risk factors and clinically relevant diseases occurring during hospitalization.

Methods

We conducted a retrospective study using the Centers for Medicare and Medicaid Services Administrative Database to analyze Medicare discharges after hip replacement surgery to identify potential ORADEs. The impact of potential ORADEs on mean hospital length of stay (LOS) and hospital revenue was analyzed.

Results

The potential ORADE rate in patients who underwent hip replacement surgery was 8.6%. The mean LOS for discharges with a potential ORADE was 1.41 days longer than that for discharges without an ORADE. The mean hospital revenue per day with a potential ORADE was US$1708 less than without an ORADE. Potential ORADEs were also found to be strongly associated with poor patient outcomes such as pneumonia, septicemia, and shock.

Discussion

Potential ORADEs in hip replacement surgery in older patients are associated with longer hospitalizations, decreased hospital revenue per day, certain patient risk factors, and clinically relevant diseases occurring during hospitalizations. Our finding of an association between potential ORADEs and decreased hospital revenue per day may be attributed to the management of these adverse events, as a patient may need to undergo additional testing, may need additional treatment regimens, and may need a higher level of care.

Conclusion

By reducing the use of opioids and employing a multimodal analgesic approach, we may improve patient care, decrease hospital lengths of stay, and increase hospital revenue.

The design of a line velocity interferometer for any reflector for inertial confinement experiments on the Z-machine

A line VISAR (Velocity Interferometer System for Any Reflector) has been designed and commissioned at the Sandia National Laboratory's Z-machine. The instrument consists of an F/2 collection system, beam transport, and an interferometer table that contains two Mach-Zehnder type interferometers and an eight channel Gated Optical Imaging (GOI) system. The VISAR probe laser operates at the 532 nm wavelength, and the GOI bandpass is 540-600 nm. The output of each interferometer is passed to an optical streak camera with four selectable sweep speeds. The system is designed with three interchangeable optics modules to select a full field of view of 1 mm, 2 mm, or 4 mm. The optical beam transport system connects the target image plane to the interferometers and the gated optical imagers. The target is integrated into a sacrificial final optics assembly that is integral to the transport beamline.

A243 FACTORS ASSOCIATED WITH POOR QUALITY OF LIFE IN PATIENTS WITH INFLAMMATORY BOWEL DISEASE IN CLINICAL REMISSION: A CROSS-SECTIONAL STUDY

Background

Inflammatory bowel disease (IBD) is associated with a substantial burden on quality of life (QoL). Functional gastrointestinal disorders such as irritable bowel syndrome (IBS) as well as depression and anxiety are more common in patients with IBD as compared with the general population. Although poorer QoL is correlated with IBS, depression and anxiety in individuals with IBD at times of IBD diagnosis and disease activity, it is unclear what, if any, impact these may have on overall quality of life at times of disease remission.

Aims

We aimed to identify factors associated with poor QoL among Canadian patients with IBD in clinical remission.

Methods

We conducted a prospective, cross-sectional study to determine whether fatigue, depression, anxiety and IBS were associated with lower QoL in patients with IBD in clinical remission. We enrolled patients at a single academic tertiary care center with inactive IBD. All eligible patients completed a series of questionnaires that included questions on demographics, disease activity, anxiety, depression, and the presence of irritable bowel syndrome (IBS) symptoms. Stool samples for fecal calprotectin (FC) were also collected to assess for subclinical inflammation. The primary outcome measure was QoL assessed by the short inflammatory bowel disease questionnaire (SIBDQ), with planned subgroup comparisons for fatigue, anxiety, depression and IBS symptoms.

Results

Ninety-three patients were eligible for inclusion in this study. The median SIBDQ scores were lower in patients with anxiety (P&lt;0.001), depression (P=0.004), IBS symptoms (P&lt;0.001), and fatigue (P=0.018).

Conclusions

In this cross-sectional study, we found that anxiety, depression, fatigue, and IBS-like symptoms were all independently associated with lower QoL among patients with inactive IBD. Importantly, subclinical inflammation as defined by a positive fecal calprotectin in the absence of clinical symptoms did not have an adverse effect on QoL. The findings of this study suggest that patients with IBD would likely benefit from screening for depression, anxiety, fatigue and IBS. Further research is warranted to determine if targeted treatment of these conditions, specifically in patients with quiescent IBD would lead to improved outcomes.

Funding Agencies

None