Anatomical tilt lateral wrist X-ray - Not always 22°

INTRODUCTION

Open Reduction and Internal Fixation (ORIF) with volar locking plates are commonly used to manage distal radial fractures. The anatomical tilt lateral (ATL) wrist X-ray is often required for evaluation of intra-articular screw penetration due to the screw position. This study aims to evaluate the correlation between the tube angulation given by performing radiographers for the ATL projection and the post-examination measurement of radial inclination (RI) on the Posterior Anterior (PA) wrist image.

METHODS

A retrospective review was performed for 36 patients. A standardised method developed by Kreder et al. (1996) was used to measure the RI on the PA wrist image. All ATL images sent into Picture Archiving and Communications System (PACS) have the tube angulation applied annotated on the image. Pearson's correlation was used to analyse the co-relationship between the RI and the tube angle applied for ATL projection.

RESULTS

The average angle of RI measured by the four observers was 19. Normality of 0.385 was established. A positive correlation (p = 0.792) between the RI and the tube angle applied for ATL was found.

CONCLUSION

Our study found a strong positive correlation between the tube angulation applied by performing radiographers for the ATL projection and the post-examination RI measured on the PA wrist image by the independent reviewers. This suggests that radiographers can use the measured RI to apply the tube angulation when performing the ATL wrist X-ray, instead of estimating the tube angulation to be applied.

IMPLICATIONS FOR PRACTICE

Using the measured RI to apply the tube angulation when performing the ATL wrist X-ray will ensure a more reliable and reproducible way that could reduce the number of repeated images and, thus, unnecessary radiation dose to patients.

POS0671 IMPACT OF RACE ON THE EFFICACY AND SAFETY OF TOFACITINIB IN PATIENTS WITH RHEUMATOID ARTHRITIS: A POST HOC ANALYSIS OF PHASE 2, 3 AND 3B/4 CLINICAL TRIALS

Background

While racial disparities in clinical outcomes for rheumatoid arthritis (RA) patients (pts) have been described,1 there is a paucity of data on racial differences in response to advanced therapies.

Objectives

To evaluate impact of self-reported race on tofacitinib efficacy/safety in RA pts.

Methods

This post hoc analysis used pooled data from 8 Phase (P)2, 6 P3 and 1 P3b/4 randomised controlled trials (RCTs) of RA pts treated with tofacitinib 5 or 10 mg twice daily (BID), adalimumab (ADA; 40 mg once every 2 weeks) or placebo (PBO), stratified by self-reported pt race (White, Black, Asian, Other) at baseline (BL). Efficacy outcomes (Month [M]3): ACR20/50/70 and CDAI/DAS28-4(ESR) low disease activity (LDA; scores ≤10 and ≤3.2, respectively) rates, and least squares (LS) mean change from BL (Δ) in DAS28-4(ESR) and HAQ-DI. Incidence rates (IRs; unique pts with events/100 pt-yrs) were estimated for adverse events (AEs) and serious AEs.

Results

6355 pts were included (White, n=4145; Black, n=213; Asian, n=1348; Other, n=649). BL characteristics were generally similar across treatment/racial groups, excepting higher prior bDMARD exposure rates in White/Black vs Asian/Other pts. Across treatments, White, Black, Asian and Other pts most commonly enrolled from Europe (40.9%), North America (68.1%), East/South Asia (97.9%) and Latin America (80.6%), respectively; most Other pts self-reported as Hispanic and/or Latino (52.4%), followed by mixed race (36.8%) and unspecified (4.6%). At M3, ACR50 rates were higher in Other vs White pts with tofacitinib, similar across racial groups with ADA, and numerically higher in Black vs White/Asian/Other pts with PBO (Figure 1); broadly similar trends were seen with ACR20/70 and CDAI LDA rates (data not shown [DNS]). DAS28-4(ESR) LDA rates, and LS mean ΔDAS28-4(ESR) and ΔHAQ-DI were generally comparable across racial groups with active treatment, and numerically higher in Black vs White/Asian/Other pts with PBO (DNS). Across efficacy outcomes, PBO-adjusted response rates and improvements generally supported the trends observed with active treatments (Figure 1; DNS). Safety outcomes were broadly similar across treatment arms, with some higher IRs for AEs observed with Black/Other vs White/Asian pts (Table 1). Results should be interpreted with caution due to low pt numbers in some groups and the heterogenous nature of the Other pts group.

Table 1.

AEs and SAEs, stratified by race

WhiteBlackAsianOthernIR (95% CI)nIR (95% CI)nIR (95% CI)nIR (95% CI)Tofacitinib 5 mg BIDN=1699; PY=1588.3N=93; PY=81.8N=560; PY=548.8N=257; PY=245.9AE1150141.976244.1382150.0205227.1(133.8, 150.3)(192.4, 305.6)(135.4, 165.9)(197.1, 260.4)SAE1469.11519.16111.3176.7(7.7, 10.7)(10.7, 31.4)(8.6, 14.5)(3.9, 10.8)Tofacitinib 10 mg BIDN=1264; PY=1175.4N=60; PY=49.8N=462; PY=487.2N=238; PY=239.8AE919188.548434.3338178.4190234.3(176.5, 201.1)(320.2, 575.8)(159.9, 198.5)(202.2, 270.1)SAE1038.923.9479.7156.2(7.3, 10.8)(0.5, 14.3)(7.1, 12.9)(3.5, 10.2)ADAN=484; PY=390.4N=22; PY=18.6N=73; PY=60.1N=64; PY=49.5AE318140.416162.251157.044161.6(125.4, 156.7)(92.7, 263.4)(116.9, 206.5)(117.4, 216.9)SAE317.6210.3914.511.9(5.2, 10.8)(1.3, 37.4)(6.6, 27.5)(0.1, 10.4)PBON=698; PY=177.3N=38; PY=10.0N=253; PY=72.3N=90; PY=24.5AE369311.623424.9122251.548271.4(280.6, 345.1)(269.4, 637.6)(208.9, 300.3)(200.1, 359.8)SAE2312.519.4810.9311.5(7.9, 18.7)(0.2, 52.2)(4.7, 21.4)(2.4, 33.6)

n, number of pts with events; PY, pt-yrs; SAE, serious AE

Conclusion

Across racial groups, tofacitinib efficacy/safety was consistent with previous tofacitinib RA clinical programme findings. Some racial differences in clinical outcomes were observed, which may reflect regional practice norms or demographic differences. Future analyses should focus on the impact of socioeconomic, cultural, genetic or practice-based differences that may underpin these results.

References

[1]Greenberg et al. Am J Med 2013; 126: 1089-1098.

Acknowledgements

Study sponsored by Pfizer Inc. Medical writing support was provided by Kirsten Woollcott, CMC Connect, and funded by Pfizer Inc.

Disclosure of Interests

Grace C. Wright Speakers bureau: AbbVie, Amgen, Bristol-Myers Squibb, Eli Lilly, Myriad Autoimmune, Novartis and UCB, Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Eli Lilly, Janssen, Myriad Autoimmune, Novartis, Pfizer Inc and UCB, Employee of: Association of Women in Rheumatology, United Rheumatology, Eduardo Mysler Speakers bureau: AbbVie, Bristol-Myers Squibb, Eli Lilly, Janssen, Pfizer Inc, Roche and Sanofi, Grant/research support from: Eli Lilly, Pfizer Inc and Roche, Yi-Hsing Chen Grant/research support from: Bristol-Myers Squibb, GSK and Pfizer Inc, Cassandra Kinch Shareholder of: Pfizer Inc, Employee of: Pfizer Canada ULC, Arne Yndestad Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Kenneth Kwok Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Mary Jane Cadatal Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Rebecca Germino Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Alexis Ogdie Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, CorEvitas, Eli Lilly, Gilead Sciences, GSK, Janssen, Novartis, Pfizer Inc and UCB, Grant/research support from: AbbVie, Amgen, Novartis and Pfizer Inc

OP0264 IMPACT OF BASELINE CARDIOVASCULAR RISK ON THE INCIDENCE OF MAJOR ADVERSE CARDIOVASCULAR EVENTS IN THE TOFACITINIB RHEUMATOID ARTHRITIS CLINICAL PROGRAMME

Background

Results from ORAL Surveillance, a post-authorisation safety study, indicated that patients (pts) with rheumatoid arthritis (RA) aged ≥50 yrs with ≥1 additional cardiovascular (CV) risk factor have an increased risk of major adverse CV events (MACE) with tofacitinib vs tumour necrosis factor inhibitors.1

Objectives

To evaluate the impact of baseline (BL) CV risk on MACE in the wider tofacitinib RA clinical programme.

Methods

Data for pts who received ≥1 tofacitinib dose in 21 Phase 1–3b/4 (excluding ORAL Surveillance) and 2 long-term extension tofacitinib RA studies were pooled and analysed post hoc as two cohorts: (1) overall cohort and (2) CV risk-enriched cohort (pts aged ≥50 yrs with ≥1 additional CV risk factor [current smoker, hypertension, HDL-cholesterol <40 mg/dL, diabetes mellitus, history of myocardial infarction (MI) or coronary heart disease (CHD)]). Data were summarised by average tofacitinib 5 or 10 mg twice daily (BID; average total daily dose of <15 or ≥15 mg, respectively). Incidence rates (IRs; pts with first events/100 pt-yrs) for adjudicated MACE were calculated. MACE IRs were stratified by pts’ BL CV risk profile: pts were first categorised by history of coronary artery disease (HxCAD), then pts without a HxCAD were categorised by 10-yr risk of MACE, per the ASCVD-PCE risk calculator2 with a 1.5 multiplier applied.3

Results

The overall cohort included 7964 pts (average tofacitinib 5 mg BID, n=3969; average tofacitinib 10 mg BID, n=3995); of these, 3125 (39.2%) pts were included in the CV risk-enriched cohort (average tofacitinib 5 mg BID, n=1614; average tofacitinib 10 mg BID, n=1511). In both treatment arms, as expected, higher proportions of pts in the CV risk-enriched cohort had a HxCAD or a high or intermediate 10-yr predicted risk of MACE at BL vs the overall cohort (Table 1). MACE IRs (95% CIs) were lower in the overall cohort (0.38 [0.26, 0.54] and 0.37 [0.27, 0.48] for average tofacitinib 5 and 10 mg BID, respectively) vs the CV risk-enriched cohort (0.72 [0.46, 1.09] and 0.67 [0.46, 0.93], respectively), and were similar between treatment arms. MACE IRs were lower than reported in ORAL Surveillance.1 In the overall cohort, adjudicated MACE most commonly occurred in pts with a HxCAD (IR [95% CI] 0.98 [0.02, 5.47] and 1.05 [0.13, 3.78] for average tofacitinib 5 and 10 mg BID, respectively), or in pts with a high 10-yr risk of MACE at BL (Figure 1). A lower predicted 10-yr MACE risk was associated with lower MACE IRs (Figure 1); trends were similar for the CV risk-enriched cohort (data not shown).

Table 1.

Proportions of pts with a HxCAD and pts without a HxCAD categorised by 10-yr risk of MACE, per ASCVD-PCE risk calculator2 with a 1.5 multiplier applied3

Average tofacitinib 5 mg BIDAverage tofacitinib 10 mg BIDOverall cohort(N=3969)CV risk-enriched cohort(N=1614)Overall cohort(N=3995)CV risk-enriched cohort(N=1511)HxCAD, n (%)61 (1.5)61 (3.8)65 (1.6)60 (4.0)No HxCAD: 10-yr risk of MACE, n (%)High (≥20%)440 (11.1)365 (22.6)337 (8.4)276 (18.3)Intermediate (≥7.5–<20%)853 (21.5)593 (36.7)788 (19.7)530 (35.1)Borderline (≥5–<7.5%)435 (11.0)234 (14.5)404 (10.1)195 (12.9)Low (<5%)2133 (53.7)342 (21.2)2058 (51.5)307 (20.3)Missing data47 (1.2)19 (1.2)343 (8.6)143 (9.5)

CAD is defined as any of MI or CHD.

n, number of pts with specified characteristic; N, number of evaluable pts

Conclusion

In the tofacitinib RA clinical programme, MACE were largely associated with BL CV risk in the overall cohort, consistent with results of ORAL Surveillance, although results should be interpreted with caution due to low pt-yrs of exposure in some pt groups. Noting this limitation, these findings emphasise the importance of assessing and addressing BL CV risk when treating pts with RA.

References

[1]Ytterberg et al. New Engl J Med 2022; 386: 316-326.

[2]American College of Cardiology, American Heart Association. ASCVD risk estimator. https://tools.acc.org/ldl/ascvd_risk_estimator/index.html#!/calulate/estimator/.

[3]Agca et al. Ann Rheum Dis 2017; 76: 17-28.

Acknowledgements

Study sponsored by Pfizer Inc. Medical writing support was provided by Kirsten Woollcott, CMC Connect, and funded by Pfizer Inc.

Disclosure of Interests

Maxime Dougados Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, Merck, Novartis, Pfizer Inc, Roche and UCB, Grant/research support from: AbbVie, Bristol-Myers Squibb, Eli Lilly, Merck, Novartis, Pfizer Inc, Roche and UCB, Christina Charles-Schoeman Consultant of: AbbVie, Gilead Sciences, Pfizer Inc and Sanofi-Regeneron, Grant/research support from: AbbVie, Bristol-Myers Squibb and Pfizer Inc, Zoltán Szekanecz Speakers bureau: AbbVie, Eli Lilly, Novartis, Pfizer Inc, Roche and Sanofi, Paid instructor for: AbbVie, Eli Lilly, Gedeon Richter, Novartis, Pfizer Inc and Roche, Consultant of: AbbVie, Eli Lilly, Novartis, Pfizer Inc, Roche and Sanofi, Grant/research support from: Pfizer Inc, Jon T Giles Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, Genentech, Gilead Sciences and UCB, Grant/research support from: Pfizer Inc, Steven R. Ytterberg Consultant of: Corbus Pharmaceuticals, Kezar Life Sciences and Pfizer Inc, Deepak L Bhatt Grant/research support from: Abbott, Afimmune, Amarin, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Cardax, Chiesi, CSL Behring, Eisai, Eli Lilly, Ethicon, Ferring Pharmaceuticals, Forest Laboratories, Fractyl, HLS Therapeutics, Idorsia, Ironwood, Ischemix, Janssen, Lexicon, Medtronic, MyoKardia, Novo Nordisk, Owkin, Pfizer Inc, PhaseBio, PLx Pharma, Regeneron, Roche, Sanofi, Synaptic and The Medicines Company, Gary G Koch Grant/research support from: AbbVie, Acceleron, Amgen, Arena, AstraZeneca, Cytokinetics, Eli Lilly, Gilead Sciences, GSK, Huya Bioscience International, Johnson & Johnson, Landos Biopharma, Merck, Momentum, Novartis, Otsuka, Pfizer Inc, Sanofi and vTv Therapeutics, Employee of: University of North Carolina at Chapel Hill, Ivana Vranic Shareholder of: Pfizer Inc, Employee of: Pfizer Ltd, Joseph Wu Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Cunshan Wang Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Kenneth Kwok Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Sujatha Menon Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Carol A. Connell Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Arne Yndestad Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Jose L. Rivas Shareholder of: Pfizer Inc, Employee of: Pfizer SLU, Maya H Buch Speakers bureau: AbbVie, Consultant of: AbbVie, Eli Lilly, Gilead Sciences, MSD, Pfizer Inc and Roche, Grant/research support from: Pfizer Inc, Roche and UCB

POS0520 ASSOCIATION BETWEEN BASELINE STATIN TREATMENT AND MAJOR ADVERSE CARDIOVASCULAR EVENTS IN PATIENTS WITH RHEUMATOID ARTHRITIS: A POST HOC ANALYSIS OF ORAL SURVEILLANCE

Background

ORAL Surveillance (NCT02092467) was a post-authorisation safety study of tofacitinib vs tumour necrosis factor inhibitors (TNFi) in patients (pts) with rheumatoid arthritis (RA) aged ≥50 years (yrs) with ≥1 additional cardiovascular (CV) risk factor and an inadequate response to methotrexate (MTX). Statins are used to treat coronary artery disease (CAD) and are recommended by the American College of Cardiology/American Heart Association (ACC/AHA) for the management of pts at risk of atherosclerotic CV disease (ASCVD),1 such as those with ≥7.5% 10-yr risk of major adverse CV events (MACE) or diabetes mellitus.

Objectives

To examine the association between baseline (BL) statin use and MACE in ORAL Surveillance.

Methods

Pts with RA on stable MTX were randomised 1:1:1 to receive tofacitinib 5 or 10 mg twice daily (BID) or TNFi (adalimumab 40 mg every 2 weeks or etanercept 50 mg once weekly). Pts were stratified post hoc by BL statin use (yes/no). Pts were further categorised by history of CAD (HxCAD), BL CV risk score per ACC/AHA guidelines1 (for pts without HxCAD; 10-yr risk of MACE per the ASCVD-pooled cohort equations risk calculator2 with a 1.5 multiplier applied3), and separately by BL diabetes status. CV risk score/BL diabetes status categories were: high (≥20%)/HxCAD (yes), intermediate (≥7.5–<20%) or low-borderline (<7.5%), and diabetes status (yes). For the overall population and each treatment group, risk of MACE was compared between BL statin use (yes vs no) via Cox analyses for each CV risk category and diabetes status (yes). Incidence rates (IRs; pts with first events/100 pt-yrs) and hazard ratios (HRs; BL statin use: yes vs no) were evaluated for adjudicated MACE.

Results

Of 4362 pts (tofacitinib 5 mg BID, n=1455; tofacitinib 10 mg BID, n=1456; TNFi, n=1451), 497 had a HxCAD, and 3813 without a HxCAD had CV risk scores determined; 789 had BL diabetes. Overall, 1020 (23.4%) pts reported BL statin use. Across CV risk score categories for all treatment groups, <50% of pts received statins at BL, with statin use highest in the high/HxCAD category pts (35.7–40.6%) and pts with diabetes (35.7–44.2%) (Table 1). Across categories, no interpretable associations between BL statin use and MACE were found. However, in the overall population, MACE IRs were lower in pts with vs without BL statin use in the high/HxCAD category, and in pts with diabetes (Figure 1). In pts receiving tofacitinib 5 mg BID and TNFi, MACE IRs were lower in pts with vs without BL statin use across all categories (Figure 1).

Table 1.

Proportion of pts receiving statins at BL, by CV risk category and presence of diabetes

n/N (%)OverallTofacitinibTofacitinibTNFi5 mg BID10 mg BIDHigh (≥20%)/HxCAD525/1370 (38.3)168/435 (38.6)193/475 (40.6)164/460 (35.7)Intermediate (≥7.5–<20%)302/1511 (20.0)110/490 (22.4)94/516 (18.2)98/505 (19.4)Low-borderline (<7.5%)178/1429 (12.5)66/513 (12.9)57/446 (12.8)55/470 (11.7)Diabetes (yes)320/789 (40.6)111/251 (44.2)114/272 (41.9)95/266 (35.7)

N, number of pts in each category; n, number of pts receiving BL statins

Conclusion

In this post hoc analysis of data from ORAL Surveillance, most pts did not receive BL statin treatment. This suggests suboptimal CV risk management, particularly in pts at high risk of CV events. There was no interpretable association between BL statin use and MACE. However, pts in the higher risk categories, particularly those receiving tofacitinib 5 mg BID, had lower MACE IRs with vs without BL statin use. This analysis did not take into account initiation or dose adjustment of statin treatment during the study, and had low yrs of exposure in some categories.

References

[1]Arnett et al. J Am Coll Cardiol 2019; 74: e177-232.

[2]American College of Cardiology, American Heart Association. ASCVD risk estimator. https://tools.acc.org/ldl/ascvd_risk_estimator/index.html#!/calulate/estimator/.

[3]Agca et al. Ann Rheum Dis 2017; 76: 17-28.

Acknowledgements

Study sponsored by Pfizer Inc. Medical writing support was provided by Lauren Hogarth, CMC Connect, and funded by Pfizer Inc.

Disclosure of Interests

Jon T Giles Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, Genentech, Gilead Sciences and UCB, Grant/research support from: Pfizer Inc, Christina Charles-Schoeman Consultant of: AbbVie, Gilead Sciences, Pfizer Inc and Sanofi-Regeneron, Grant/research support from: AbbVie, Bristol-Myers Squibb and Pfizer Inc, Maya H Buch Speakers bureau: AbbVie, Consultant of: AbbVie, Eli Lilly, Gilead Sciences, MSD, Pfizer Inc and Roche, Grant/research support from: Pfizer Inc, Roche and UCB, Maxime Dougados Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, Merck, Novartis, Pfizer Inc, Roche and UCB, Grant/research support from: AbbVie, Bristol-Myers Squibb, Eli Lilly, Merck, Novartis, Pfizer Inc, Roche and UCB, Zoltán Szekanecz Speakers bureau: AbbVie, Eli Lilly, Novartis, Pfizer Inc, Roche and Sanofi, Paid instructor for: AbbVie, Eli Lilly, Gedeon Richter, Novartis, Pfizer Inc and Roche, Consultant of: AbbVie, Eli Lily, Novartis, Pfizer Inc, Roche and Sanofi, Steven R. Ytterberg Consultant of: Corbus Pharmaceuticals, Kezar Life Sciences and Pfizer Inc, Gary G Koch Shareholder of: IQVIA, Grant/research support from: AbbVie, Acceleron, Amgen, Arena, AstraZeneca, Cytokinetics, Eli Lilly, Gilead Scienes, GlaxoSmithKline, Huya Bioscience International, Johnson & Johnson, Landos Biopharma, Merck, Momentum, Novartis, Otsuka, Pfizer Inc, Sanofi and vTv Therapeutics, Employee of: University of North Carolina at Chapel Hill, Joseph Wu Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Cunshan Wang Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Kenneth Kwok Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Sujatha Menon Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Yan Chen Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Teoman Yusuf Cesur Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Jose L. Rivas Shareholder of: Pfizer Inc, Employee of: Pfizer SLU, Arne Yndestad Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Annette Diehl Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Deepak L Bhatt Grant/research support from: Abbott, Afimmune, Amarin, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Cardax, Chiesi, CSL Behring, Eisai, Ethicon, Ferring Pharmaceuticals, Forest Laboratories, Fractyl, HLS Therapeutics, Idorsia, Ironwood, Ischemix, Janssen, Lexicon, Lilly, Medtronic, MyoKardia, Novo Nordisk, Owkin, Pfizer Inc, PhaseBio, PLx Pharma, Regeneron, Roche, Sanofi, Synaptic and The Medicines Company.

OP0027 ASSOCIATION BETWEEN BASELINE CARDIOVASCULAR RISK AND INCIDENCE RATES OF MAJOR ADVERSE CARDIOVASCULAR EVENTS AND MALIGNANCIES IN PATIENTS WITH PSORIATIC ARTHRITIS AND PSORIASIS RECEIVING TOFACITINIB

Background

Common comorbidities of psoriatic arthritis (PsA) and psoriasis (PsO) are cardiovascular (CV) disease and metabolic syndrome (MetS).1,2 Risk of CV disease may be associated with increased risk of future malignancies.3 Tofacitinib is a JAK inhibitor for treatment of PsA and has been investigated for treatment of PsO.

Objectives

To examine baseline (BL) CV risk and its association with incidence rates (IRs) of major adverse CV events (MACE) and malignancies in tofacitinib-treated patients (pts) with PsA and PsO.

Methods

Analysis included data from 3 (Phase [P]3/long-term extension [LTE]) trials of pts with PsA and 7 (P2/3/LTE) trials of pts with PsO receiving ≥1 dose of tofacitinib (5 or 10 mg twice daily). IRs (pts with events/100 pt-yrs) for MACE and malignancies (excluding non-melanoma skin cancer) were stratified by: history of coronary artery disease (HxCAD [≥1 of myocardial infarction, coronary heart disease, coronary artery procedure or stable angina pectoris]); BL 10-yr atherosclerotic CV disease (ASCVD) risk (ASCVD-pooled cohort equations calculator [only in pts without HxCAD]); and BL MetS (≥3 of hypertension, raised triglycerides, reduced high-density lipoprotein cholesterol, high waist circumference or high fasting glucose levels).

Results

Of 783 and 3663 pts with PsA and PsO, total tofacitinib exposure was 2038 and 8950 pt-yrs, and median duration of exposure was 3.0 and 2.4 yrs, respectively. In pts with PsA and PsO, 5.0% and 2.5% had HxCAD, respectively; in those without HxCAD, >20% had intermediate/high BL 10-yr ASCVD risk (Figure 1). At BL, 40.9% and 32.7% of pts with PsA and PsO had MetS, respectively. IRs of MACE were greatest in pts with PsA and PsO who had HxCAD/high BL 10-yr ASCVD risk (Table 1). In the PsA cohort, 5/6 pts with MACE had BL MetS. IRs of malignancies in pts with PsA were greatest in those with intermediate/high BL 10-yr ASCVD risk; 8/9 pts with malignancies in these risk categories had BL MetS (Table 1). In the PsO cohort, IR of malignancies was notably greater in those with high vs low/intermediate BL 10-yr ASCVD risk (Table 1).

Table 1.

IRs of MACE and malignancies in pts with PsA and PsO receiving tofacitinib, stratified by HxCAD, BL 10-yr ASCVD risk and BL MetS

MACEMalignanciesPsAPsOPsAPsOn/N[n1]IR (95% CI)n/N[n1]IR (95% CI)n/N[n1]IR (95% CI)n/N[n1]IR (95% CI)HxCADYes1/39[0]0.97 (0.02, 5.38)3/93[0]1.49 (0.31, 4.36)0/39[0]0.00 (0.00, 3.52)0/93[0]0.00 (0.00, 1.83)No5/744[5]0.25 (0.08, 0.59)20/3570[10]0.22 (0.13, 0.34)15/744[10]0.75 (0.42, 1.24)60/3570[26]0.66 (0.51, 0.85)BL 10-yr ASCVD risk categoryHigh risk (≥20%)1/35[1]1.26 (0.03, 7.01)7/179[4]1.67 (0.67, 3.43)1/35[1]1.26 (0.03, 7.03)15/179[10]3.57 (2.00, 5.89)Intermediate risk(≥7.5–<20%)2/121[2]0.62 (0.07, 2.23)9/716[6]0.50 (0.23, 0.95)8/121[7]2.46 (1.06, 4.86)23/716[9]1.28 (0.81, 1.92)Borderline risk(≥5–<7.5%)1/91[1]0.42 (0.01, 2.32)2/400[0]0.19 (0.02, 0.67)2/91[1]0.83 (0.10, 3.01)5/400[1]0.47 (0.15, 1.09)Low risk (<5%)1/487[1]0.08 (0.00, 0.42)2/2241[0]0.03 (0.00, 0.13)4/487[1]0.30 (0.08, 0.77)17/2241[6]0.30 (0.17, 0.47)BL MetSYes5/3200.60 (0.20, 1.40)10/11970.34 (0.16, 0.63)10/3201.20 (0.58, 2.21)26/11970.89 (0.58, 1.31)No1/4630.08 (0.00, 0.44)13/24660.20 (0.11, 0.35)5/4630.40 (0.13, 0.92)34/24660.54 (0.37, 0.75)

Follow-up time calculated up to the day of the first event and subject to risk period of 28 days beyond the last dose of study drug.

CI, confidence interval; N, total pts; n, pts with MACE/malignancies; n1, pts with MACE/malignancies and BL MetS.

Conclusion

In tofacitinib-treated pts with PsA and PsO, raised CV risk and MetS at BL were potentially associated with higher IRs of MACE and malignancies. Our findings support assessing CV risk in pts with PsA and PsO and enhanced monitoring for malignancies in those with raised CV risk.

References

[1]Karmacharya et al. Ther Adv Musculoskel Dis 2021; 13: 1-15.

[2]Garshick et al. J Am Coll Cardiol 2021; 77: 1670-1680.

[3]Lau et al. JACC CardioOncol 2021; 3: 48-58.

Acknowledgements

Study sponsored by Pfizer Inc. Medical writing support was provided by Emma Mitchell, CMC Connect, and funded by Pfizer Inc.

Disclosure of Interests

Lars Erik Kristensen Speakers bureau: AbbVie, Amgen, Biogen, Bristol-Myers Squibb, Eli Lilly, Janssen, MSD, Novartis, Pfizer Inc and UCB, Grant/research support from: Biogen, Janssen, Novartis and UCB, Bruce Strober Speakers bureau: AbbVie, Amgen, Eli Lilly, Janssen and Ortho Dermatologics, Consultant of: AbbVie, Almirall, Amgen, Arcutis, Arena, Aristea, Boehringer Ingelheim, Bristol-Myers Squibb, Cara, Celgene, Dermavant, Dermira, Eli Lilly, GlaxoSmithKline, Janssen, Leo, Meiji Seika Pharma, Novartis, Ortho Dermatologics, Pfizer Inc, Regeneron, Sanofi-Genzyme, Sun Pharma and UCB, Denis Poddubnyy Speakers bureau: AbbVie, Bristol-Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer Inc and UCB, Consultant of: AbbVie, BIOCAD, Gilead Sciences, GlaxoSmithKline, Eli Lilly, MSD, Novartis, Pfizer Inc, Samsung Bioepis and UCB, Grant/research support from: AbbVie, MSD, Novartis and Pfizer, Ying Ying Leung Consultant of: AbbVie, Eli Lilly, Janssen and Novartis, Hyejin Jo Consultant of: Pfizer Inc, Employee of: Syneos Health, Kenneth Kwok Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Ivana Vranic Shareholder of: Pfizer Inc, Employee of: Pfizer Ltd, Dona Fleishaker Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Lara Fallon Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Arne Yndestad Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Dafna D Gladman Consultant of: AbbVie, Amgen, Celgene, Eli Lilly, Galapagos, Gilead Sciences, Janssen, Novartis, Pfizer Inc and UCB.

OP0241 BONE MICROARCHITECTURE ASSESSED BY HIGH-RESOLUTION PERIPHERAL QUANTITATIVE COMPUTED TOMOGRAPHY (HR-pQCT) PREDICTS FRACTURE RISK IN PATIENTS WITH RHEUMATIC DISEASES ON GLUCOCORTICOIDS

Background

Peripheral bone micro-architectural parameters assessed by high-resolution peripheral quantitative computer tomography (HR-pQCT) were able to discriminate vertebral fracture in patients with rheumatic diseases on glucocorticoid (GC) independent of areal bone mineral density aBMD. Whether these parameters could predict future fracture remained to be determined.

Objectives

The aim of this study was to compare the differences in baseline vBMD, bone microarchitecture and estimated bone strength in these patients with and without incident fragility fracture over a period of 5 years.

Methods

This was a multi-centered, retrospective, case-controlled study. Patients with rheumatic diseases on long term GC from 7 regional hospitals who had dual-energy X-ray absorptiometry (DXA) and HR-pQCT done were invited to have a 5th year follow-up assessment. X-rays were repeated. The occurrence of new fragility fracture after 5 years was documented. The baseline clinical characteristics, aBMD, FRAX and HR-pQCT parameters in patients who experienced a new fragility fracture during the 5-year follow-up period (incident fracture group) were compared with patients who did not experience a fragility fracture (control group).

Results

A total of 140 patients were recruited. The mean age of the patients, who were mostly female (80.7%), was 58.7 ± 12.5 years at baseline. SLE and RA were the commonest diagnoses. At baseline, 45.0% and 28.6% of the patients had osteopenia or osteoporosis respectively. The baseline 10-year major osteoporotic and hip fracture risks by FRAX were 13.3% and 6.0% respectively. After 5 years, 47 (33.6%) of the patients developed new fractures. The baseline clinical characteristics of incident facture group and the control group are shown in Table 1. Patients with incident fracture were older. They also had more prevalent fracture and worse mobility. The aBMD and FRAX scores were significantly higher in the incident fracture group. When comparing the HR-pQCT parameters, the incident fracture group had significantly worse vBMD, microarchitecture and bone strength particularly over the tibia at baseline. However, the changes in these parameters were not different between the 2 groups. Multivariate regression confirmed that the baseline vBMD, microarchitectural parameters and estimated bone strength over distal tibia were independent predictors of new fractures after adjusting for age, gender as well as baseline fracture, mobility and osteoporosis status.

Table 1.

Demographic and clinical characteristics at baseline

Control groupn=93Incident fracture groupn=47pAge (years)57 ± 1262 ± 120.015Gender, n (%)Female74 (79.6%)39 (83%)0.629Disease typeSLE40 (43.5%)21 (44.7%)0.711RA19 (20.7%)12 (25.5%)Others33 (35.9%)14 (29.8%)Mobility class, n (%)Ambulatory82 (88.2%)34 (72.3%)0.046Stick-walking9 (9.7%)12 (25.5%)Chair-bound2 (2.2%)1 (2.1%)Previous fracture, n (%)10 (10.8%)12 (25.5%)0.023MedicationsCumulative prednisolone dose (g)20.4 ± 18.722.0 ± 15.50.604Ever or current anti-osteoporotic treatment, n (%)15 (16.1%)11 (23.4%)0.310aBMD (g/cm2) atFemoral neck0.66 ± 0.120.60 ± 0.120.009Lumbar spine0.86 ± 0.150.80 ± 0.160.025FRAX score (%)Major osteoporotic fracture9.9 ± 9.420.6 ± 17.3<0.001Hip fracture3.7 ± 5.610.8 ± 13.20.001HR-pQCT parameters*Distal radius:mTb.vBMD82.0 ± 45.262.6 ± 42.40.016Distal tibia:Average vBMD258 ± 70225 ± 700.010Tb. vBMD144 ± 42122 ± 400.003pTb. vBMD221 ± 52197 ± 460.010mTb.vBMD91.3 ± 37.770.0 ± 40.00.002Tb. number1.50 ± 0.281.36 ± 0.340.010Stiffness162139 ± 42623142054 ± 353750.004Est. failure load-8173 ± 2083-7200 ± 17440.004

*Only statististically significant parameters are shown

Conclusion

A significant proportion (33.6%) of patients with rheumatic diseases on long-term GC developed new fragility fracture in 5 years, which could be predicted by the worse vBMD, microarchitecture and bone strength over tibia at baseline on HR-pQCT independent of aBMD.

Disclosure of Interests

None declared

Automated Cerebral Hemorrhage Detection Using RAPID

BACKGROUND AND PURPOSE

Intracranial hemorrhage (ICH) is an important event that is diagnosed on head NCCT. Increased NCCT utilization in busy hospitals may limit timely identification of ICH. RAPID ICH is an automated hybrid 2D-3D convolutional neural network application designed to detect ICH that may allow for expedited ICH diagnosis. We determined the accuracy of RAPID ICH for ICH detection and ICH volumetric quantification on NCCT.

MATERIALS AND METHODS

NCCT scans were evaluated for ICH by RAPID ICH. Consensus detection of ICH by 3 neuroradiology experts was used as the criterion standard for RAPID ICH comparison. ICH volume was also automatically determined by RAPID ICH in patients with intraparenchymal or intraventricular hemorrhage and compared with manually segmented ICH volumes by a single neuroradiology expert. ICH detection accuracy, sensitivity, specificity, positive predictive value, negative predictive value, and positive and negative likelihood ratios by RAPID ICH were determined.

RESULTS

We included 308 studies. RAPID ICH correctly identified 151/158 ICH cases and 143/150 ICH-negative cases, which resulted in high sensitivity (0.956, CI: 0.911-0.978), specificity (0.953, CI: 0.907-0.977), positive predictive value (0.956, CI: 0.911-0.978), and negative predictive value (0.953, CI: 0.907-0.977) for ICH detection. The positive likelihood ratio (20.479, CI 9.928-42.245) and negative likelihood ratio (0.046, CI 0.023-0.096) for ICH detection were similarly favorable. RAPID ICH volumetric quantification for intraparenchymal and intraventricular hemorrhages strongly correlated with expert manual segmentation (correlation coefficient r = 0.983); the median absolute error was 3 mL.

CONCLUSIONS

RAPID ICH is highly accurate in the detection of ICH and in the volumetric quantification of intraparenchymal and intraventricular hemorrhages.

0113 Evaluating Closed-Loop Auditory Stimulation During Sleep as an Intervention to Improve Memory Consolidation Deficits in Schizophrenia

Introduction

Converging evidence supports the hypothesis that reduced sleep spindles and spindle-slow oscillation (SO) coordination contribute to cognitive deficits in schizophrenia. Closed-loop auditory stimulation in healthy adults increases sleep spindles and improves declarative memory consolidation. Here we investigated whether closed-loop auditory stimulation also improves sleep-dependent procedural memory consolidation as a first step towards an intervention in schizophrenia.

Methods

Thirteen healthy adults participated in two nap sessions (stimulation or detection only) with polysomnography in a counterbalanced order. Participants were trained on the finger tapping Motor Sequence Task (MST), which measures sleep-dependent motor procedural memory consolidation, prior to napping and were tested after awakening. We detected the negative peak of SOs during non-REM sleep and, in the stimulation condition, delivered 50ms of pink noise during the SO up-state.

Results

Auditory stimulation increased SOs and spindles during the SO up-state in a frontocentral cluster of electrodes 800-1200ms after stimulation compared to detection only (p&lt;0.05). Stimulation also showed promise for improving memory consolidation (33% increase in MST overnap improvement from detection-only) but this did not reach significance in this small sample and data collection is ongoing.

Conclusion

Auditory stimulation evoked coordinated spindle-SO events that mediate memory consolidation, but more subjects are needed to evaluate whether it also improves memory. If it does, we will test the effects of stimulation on sleep-dependent memory deficits in patients with schizophrenia. Closed-loop auditory stimulation shows promise as a safe, scalable intervention for cognitive deficits that can be implemented at home with commercially available devices.

Support

R01 MH67720 (DSM & RS), NIH-NHLBI 5T32HL007901-17 (BB), K24MH099421 (DSM), and Simons Foundation (DSM).

Severe Trauma Presenting to the Resuscitation Room of a Hong Kong Emergency Department

Background

Little is known about the epidemiology or mortality associated with trauma in Hong Kong or of its demands on the service of emergency departments. This study describes both the quantity and quality of trauma presenting to an emergency department in Hong Kong.

Methods

In a retrospective study conducted from January to June 1997 there were 100,000 new patient attendances at the emergency department of the Prince of Wales Hospital of which 227 trauma patients (0.002%) were triaged to the Resuscitation Room. Patient records were scrutinised for types and mechanisms of injury, times of injury and arrival at the emergency department, role of alcohol, and scored using an injury severity score. Important outcomes were mortality and duration of hospital stay.

Results

Data was available on 221 (97%) subjects (male to female ratio 3.7:1) of which there were 203 adults and 18 children. Blunt injury accounted for 199/215 (92.6%) cases and penetrating for 16/215 (7.4%) cases. Motor vehicle crashes accounted for 113/205 (55%) cases, falls for 47/205 (23%) cases and assault for 18/205 (9%) cases. 51/224 (23%) cases presented between the hours of midnight and 8 am. The median injury severity score (ISS) was 9 (mean 11; range 1–59). 32/227 (14%) patients died, the majority resulting from road traffic accidents or falls.

Conclusion

Patterns of ‘severe’ trauma in Hong Kong primarily affect male adults, include a preponderance of motor vehicle crashes and falls, and significant mortality.

Tuberculosis and other opportunistic infections in tofacitinib-treated patients with rheumatoid arthritis

OBJECTIVES

To evaluate the risk of opportunistic infections (OIs) in patients with rheumatoid arthritis (RA) treated with tofacitinib.

METHODS

Phase II, III and long-term extension clinical trial data (April 2013 data-cut) from the tofacitinib RA programme were reviewed. OIs defined a priori included mycobacterial and fungal infections, multidermatomal herpes zoster and other viral infections associated with immunosuppression. For OIs, we calculated crude incidence rates (IRs; per 100 patient-years (95% CI)); for tuberculosis (TB) specifically, we calculated rates stratified by patient enrolment region according to background TB IR (per 100 patient-years): low (≤0.01), medium (>0.01 to ≤0.05) and high (>0.05).

RESULTS

We identified 60 OIs among 5671 subjects; all occurred among tofacitinib-treated patients. TB (crude IR 0.21, 95% CI of (0.14 to 0.30)) was the most common OI (n=26); median time between drug start and diagnosis was 64 weeks (range 15-161 weeks). Twenty-one cases (81%) occurred in countries with high background TB IR, and the rate varied with regional background TB IR: low 0.02 (0.003 to 0.15), medium 0.08 (0.03 to 0.21) and high 0.75 (0.49 to 1.15). In Phase III studies, 263 patients diagnosed with latent TB infection were treated with isoniazid and tofacitinib concurrently; none developed TB. For OIs other than TB, 34 events were reported (crude IR 0.25 (95% CI 0.18 to 0.36)).

CONCLUSIONS

Within the global tofacitinib RA development programme, TB was the most common OI reported but was rare in regions of low and medium TB incidence. Patients who screen positive for latent TB can be treated with isoniazid during tofacitinib therapy.

A tensorial approach to access cognitive workload related to mental arithmetic from EEG functional connectivity estimates

The association of functional connectivity patterns with particular cognitive tasks has long been a topic of interest in neuroscience, e.g., studies of functional connectivity have demonstrated its potential use for decoding various brain states. However, the high-dimensionality of the pairwise functional connectivity limits its usefulness in some real-time applications. In the present study, the methodology of tensor subspace analysis (TSA) is used to reduce the initial high-dimensionality of the pairwise coupling in the original functional connectivity network to a space of condensed descriptive power, which would significantly decrease the computational cost and facilitate the differentiation of brain states. We assess the feasibility of the proposed method on EEG recordings when the subject was performing mental arithmetic task which differ only in the difficulty level (easy: 1-digit addition v.s. 3-digit additions). Two different cortical connective networks were detected, and by comparing the functional connectivity networks in different work states, it was found that the task-difficulty is best reflected in the connectivity structure of sub-graphs extending over parietooccipital sites. Incorporating this data-driven information within original TSA methodology, we succeeded in predicting the difficulty level from connectivity patterns in an efficient way that can be implemented so as to work in real-time.

PubMed-supported clinical term weighting approach for improving inter-patient similarity measure in diagnosis prediction

BACKGROUND

Similarity-based retrieval of Electronic Health Records (EHRs) from large clinical information systems provides physicians the evidence support in making diagnoses or referring examinations for the suspected cases. Clinical Terms in EHRs represent high-level conceptual information and the similarity measure established based on these terms reflects the chance of inter-patient disease co-occurrence. The assumption that clinical terms are equally relevant to a disease is unrealistic, reducing the prediction accuracy. Here we propose a term weighting approach supported by PubMed search engine to address this issue.

METHODS

We collected and studied 112 abdominal computed tomography imaging examination reports from four hospitals in Hong Kong. Clinical terms, which are the image findings related to hepatocellular carcinoma (HCC), were extracted from the reports. Through two systematic PubMed search methods, the generic and specific term weightings were established by estimating the conditional probabilities of clinical terms given HCC. Each report was characterized by an ontological feature vector and there were totally 6216 vector pairs. We optimized the modified direction cosine (mDC) with respect to a regularization constant embedded into the feature vector. Equal, generic and specific term weighting approaches were applied to measure the similarity of each pair and their performances for predicting inter-patient co-occurrence of HCC diagnoses were compared by using Receiver Operating Characteristics (ROC) analysis.

RESULTS

The Areas under the curves (AUROCs) of similarity scores based on equal, generic and specific term weighting approaches were 0.735, 0.728 and 0.743 respectively (p < 0.01). In comparison with equal term weighting, the performance was significantly improved by specific term weighting (p < 0.01) but not by generic term weighting. The clinical terms "Dysplastic nodule", "nodule of liver" and "equal density (isodense) lesion" were found the top three image findings associated with HCC in PubMed.

CONCLUSIONS

Our findings suggest that the optimized similarity measure with specific term weighting to EHRs can improve significantly the accuracy for predicting the inter-patient co-occurrence of diagnosis when compared with equal and generic term weighting approaches.

Evaluating joint destruction in rheumatoid arthritis: is it necessary to radiograph both hands and feet?

BACKGROUND

Radiological damage is an important outcome measure in rheumatoid arthritis (RA), both for research and clinical purposes. Depending on the setting, both hands and feet are radiographed, or only a part of these. It is unknown whether radiographing part of the four extremities gives comparable information to radiographing both hands and feet. This study therefore aimed to compare the radiological information obtained both when evaluating single time point radiographs and progression over time, in early and advanced RA.

METHODS

6261 sets of hands and feet x-rays of 2193 RA patients from Leiden, Groningen (both from The Netherlands) and North America were studied. Correlations between joint damage at different regions were compared (unilateral vs bilateral and hands vs feet). Analyses were done at single time points (cross-sectional) and for progression over time (longitudinal), both for continuous severity measures (Sharp/van der Heijde score; SHS) and binomial measures of erosiveness.

RESULTS

When studying single time points, the severity of joint damage (SHS) is highly correlated between left and right, but weakly correlated between hands and feet. Correlation coefficients were higher in advanced than early RA. These findings were comparable in the three datasets. When evaluating erosiveness using only unilateral x-rays or hands without feet, 19.3% and 24.0-40.4% are incorrectly classified as non-erosiveness. Similarly, when evaluating disease progression by imaging only unilateral x-rays or only hand x-rays, progression would have been missed in 11.6-16.2% and 21.2-31.0% of patients.

CONCLUSION

Performing x-rays of both hands and feet yields additive information compared with imaging only a part of these.

Childhood sleep-disordered breathing and its implications for cardiac and vascular diseases

OBJECTIVE

To systematically evaluate the recent literature regarding the relationship between childhood sleep-disordered breathing (SDB)/obstructive sleep apnoea (OSA) and cardiovascular diseases in children.

METHODS

The literature about SDB/OSA and blood pressure, sympathetic activation, arterial distensibility, ventricular hypertrophy and insulin resistance were studied. Meta-analysis of risk of hypertension and high apnoea-hyponoea index were performed to calculate the combined odds ratio and it is equal to 2.93 (95% CI = 1.18-7.29).

RESULTS

The results suggest a significant association between SDB/OSA and hypertension. However, the data are not adequate to draw firm conclusion although evidences were emerging to suggest that SDB/OSA affects blood pressure in either directions in children. Limited evidences also suggest that SDB/OSA is associated with increased sympathetic activation, decreased arterial distensibility and ventricular hypertrophy.

CONCLUSIONS

There is now increasing but not adequate evidence that childhood SDB/OSA is associated with detectable cardiovascular abnormalities.

The Hound of the Baskervilles effect: natural experiment on the influence of psychological stress on timing of death

OBJECTIVE

To determine whether cardiac mortality is abnormally high on days considered unlucky: Chinese and Japanese people consider the number 4 unlucky, white Americans do not.

DESIGN

Examination of cardiac and non-cardiac mortality on and around the fourth of each month in Chinese and Japanese subjects and white controls.

SETTING

United States.

SUBJECTS

All Chinese and Japanese (n=209 908) and white (n=47 328 762) Americans whose computerised death certificates were recorded between the beginning of January 1973 and the end of December 1998.

MAIN OUTCOME MEASURES

Ratio of observed to expected numbers of deaths on the fourth day of the month (expected number was estimated from mortality on other days of the month).

RESULTS

Cardiac mortality in Chinese and Japanese people peaked on the fourth of the month. The peak was particularly large for deaths from chronic heart disease (ratio of observed to expected deaths = 1.13, 95% confidence interval 1.06 to 1.21) and still larger for deaths from chronic heart disease in California (1.27, 1.15 to 1.39). Within this group, inpatients showed a particularly large peak on the fourth day(1.45, 1.19 to 1.81). The peak was not followed by a compensatory drop in number of deaths. White controls, matched on age, sex, marital status, hospital status, location, and cause of death, showed no similar peak in cardiac mortality.

CONCLUSIONS

Our findings of excess cardiac mortality on "unlucky" days are consistent with the hypothesis that cardiac mortality increases on psychologically stressful occasions. The results are inconsistent with nine other possible explanations for the findings-for example, the fourth day peak does not seem to occur because of changes in the patient's diet, alcohol intake, exercise, or drug regimens.

Dopamine production in the caudate putamen restores feeding in dopamine-deficient mice

Dopamine-deficient (DD) mice cannot synthesize dopamine (DA) in dopaminergic neurons due to selective inactivation of the tyrosine hydroxylase gene in those neurons. These mice become hypoactive and hypophagic and die of starvation by 4 weeks of age. We used gene therapy to ascertain where DA replacement in the brain restores feeding and other behaviors in DD mice. Restoration of DA production within the caudate putamen restores feeding on regular chow and nest-building behavior, whereas restoration of DA production in the nucleus accumbens restores exploratory behavior. Replacement of DA to either region restores preference for sucrose or a palatable diet without fully rescuing coordination or initiation of movement. These data suggest that a fundamental difference exists between feeding for sustenance and the ability to prefer rewarding substances.