Rank-Ordered List of Cost-effective Strategies for Preventing Prosthetic Joint Infection in Total Joint Arthroplasty in an Academic US Hospital

Although the overall rate of prosthetic joint infection (PJI) is low, it remains a major complication associated with total joint arthroplasty (TJA). PJI represents a significant economic burden to the health care system that is projected to increase commensurate with increasing joint replacement volumes. This review provides a rank-ordered list of cost-effective strategies that are performable intraoperatively and have data supporting their efficacy at preventing PJI after TJA. This study may be helpful in assisting surgeons, ambulatory surgery center owners, and hospital acquisition committees to make reasonable and cost-conscious decisions in the face of changing reimbursement. [Orthopedics. 2023;46(6):327-332.].

Previous pre-eclampsia, gestational diabetes mellitus and the risk of cardiovascular disease: A nested case-control study in Sweden

OBJECTIVE

Pre-eclampsia and gestational diabetes mellitus (GDM) are two common pregnancy complications that affect birth outcomes and are associated with a long-term risk of cardiovascular disease (CVD). The aims of this study were to investigate if the pre-eclampsia association with CVD is independent of GDM and modified by body mass index (BMI) or GDM.

DESIGN

Case-control study.

SETTING

Sweden.

POPULATION

Cases were women with a first CVD event between 1991 and 2008 and a previous pregnancy who were matched with controls without CVD (1:5) by year of birth, age and region of birth.

METHODS

Conditional logistic regression was used to evaluate the associations of GDM, pre-eclampsia and maternal BMI with CVD adjusted for potential confounders and effect modifications with interaction tests.

MAIN OUTCOME MEASURES

CVD.

RESULTS

There were 2639 cases and 13 310 controls with complete data. Pre-eclampsia and GDM were independent risk factors for CVD (adjusted odds ratio [aOR] 2.59, 95% CI 2.12-3.17 and aOR 1.47, 95% CI 1.04-2.09, respectively). After stratifying by maternal BMI, the adjusted association of pre-eclampsia with CVD did not differ notably between BMI groups: normal weight (aOR 2.65, 95% CI 1.90-3.69), overweight (aOR 2.67, 95% CI 1.52-4.68) and obesity (aOR 3.03, 95% CI 0.74-12.4). Similar findings were seen when stratifying on GDM/non-GDM.

CONCLUSIONS

Pre-eclampsia and GDM are independent risk factors for later CVD and having both during pregnancy is a major risk factor for later CVD. The association between pre-eclampsia and CVD is not modified by BMI. Effective CVD preventive programs for high-risk women are urgently needed in order to improve women's long-term health.

Psychotherapy employed additionally to Psychopharmacotherapy is not related to Better Treatment Outcome in Major Depressive Disorder

Introduction

Although numerous effective antidepressant (AD) strategies are available for the treatment of major depressive disorder (MDD), many patients do not achieve satisfactory treatment response.

Objectives

The aims of the present European, cross-sectional, multicenter, naturalistic study were (1) to determine the proportion of patients suffering from primary MDD who received additional psychotherapy to their ongoing psychopharmacotherapy and (2) to identify the associated socio-demographic and clinical patterns.

Methods

Patients receiving both treatments were compared to those lacking concomitant additional psychotherapy that was manual-driven psychotherapy (MDP) in all cases.

Results

While 68.8% of a total of 1279 MDD patients received exclusively psychopharmacotherapy, 31.2% underwent a psychopharmacotherapy-MDP combination. The latter patient population was rather younger, higher educated, employed, exhibited an earlier mean age of MDD onset, lower severity of current depressive symptoms with lower odds of suicidality and higher rates of melancholic features, and comorbid asthma and migraine, and was generally treated with lower daily doses of their first-line ADs. Whereas agomelatine was more commonly dispensed in these patients, selective serotonin reuptake inhibitors were more often prescribed in MDD patients lacking additional MDP. No significant between-group differences were detected in terms of treatment outcome.

Conclusions

The fact that the employment of additional MDP was not related to better treatment outcome in MDD represents our major and clinically most relevant finding. Generally, MDP was employed in a minority of our patients who experienced rather beneficial socio-demographic and clinical characteristics. This might reflect an inferior accessibility of these psychotherapeutic techniques for patients who are more severely ill and less socio-economically privileged.

Disclosure

References Bartova L, Fugger G, Dold M, Swoboda MMM, Zohar J, Mendlewicz J, Souery D, Montgomery S, Fabbri C, Serretti A, Kasper S. Combining psychopharmacotherapy and psychotherapy is not associated with better treatment outcome in major depressive disor

Stick or twist? Cost-effectiveness of siponimod compared with continuing existing disease-modifying therapies in the treatment of active secondary progressive multiple sclerosis in the UK

OBJECTIVE

Identification of the phenotypic transition from relapsing-remitting multiple sclerosis (RRMS) to secondary progressive multiple sclerosis (SPMS) is often delayed due to disease complexity and an unwillingness to withdraw RRMS disease-modifying therapies (DMTs), driven by limited SPMS treatment options. Despite the paucity of clinical evidence for efficacy in patients with SPMS, DMTs licensed for RRMS are frequently continued into the early stages of SPMS. The cost-effectiveness of oral siponimod, an active SPMS DMT, versus continued oral or infused RRMS DMTs for patients with active SPMS, was evaluated.

METHODS

A cohort Markov model based on disease progression through Expanded Disability Status Scale health states, with annual cycles and lifetime horizon, was employed to determine the cost-effectiveness of siponimod from a UK National Health Service (NHS) perspective for patients with active SPMS. Baseline characteristics, health state utility values, hazard ratios for time to 6-month confirmed disability progression, annualized relapse rate ratios and adverse events for siponimod were obtained from the phase 3 EXPAND clinical trial, supplemented by published literature. Published costs, resource use data and comparator efficacy data were obtained from the literature and, in the absence of data, reasonable assumptions were made.

RESULTS

Quality-adjusted life years (QALYs) were greater for siponimod versus all comparators (3.45 versus 2.69-2.83). Incremental cost-effectiveness ratios (ICERs), calculated as cost per QALY, for siponimod versus natalizumab (dominant), ocrelizumab (£4,760), fingolimod (£10,033) and dimethyl fumarate (£15,837) indicated that siponimod was cost-effective at the commonly accepted willingness-to-pay threshold of £30,000/QALY.

CONCLUSIONS

Recognition of active SPMS and treatment of this phenotype with siponimod offers a cost-effective and clinically beneficial treatment approach compared with the continuation of oral or infused RRMS DMTs.

Cost-effectiveness of dual-mobility components in patients with displaced femoral neck fractures

AIMS

Total hip arthroplasty (THA) with dual-mobility components (DM-THA) has been shown to decrease the risk of dislocation in the setting of a displaced neck of femur fracture compared to conventional single-bearing THA (SB-THA). This study assesses if the clinical benefit of a reduced dislocation rate can justify the incremental cost increase of DM-THA compared to SB-THA.

METHODS

Costs and benefits were established for patients aged 75 to 79 years over a five-year time period in the base case from the Canadian Health Payer's perspective. One-way and probabilistic sensitivity analysis assessed the robustness of the base case model conclusions.

RESULTS

DM-THA was found to be cost-effective, with an estimated incremental cost-effectiveness ratio (ICER) of CAD $46,556 (£27,074) per quality-adjusted life year (QALY). Sensitivity analysis revealed DM-THA was not cost-effective across all age groups in the first two years. DM-THA becomes cost-effective for those aged under 80 years at time periods from five to 15 years, but was not cost-effective for those aged 80 years and over at any timepoint. To be cost-effective at ten years in the base case, DM-THA must reduce the risk of dislocation compared to SB-THA by at least 62%. Probabilistic sensitivity analysis showed DM-THA was 58% likely to be cost-effective in the base case.

CONCLUSION

Treating patients with a displaced femoral neck fracture using DM-THA components may be cost-effective compared to SB-THA in patients aged under 80 years. However, future research will help determine if the modelled rates of adverse events hold true. Surgeons should continue to use clinical judgement and consider individual patients' physiological age and risk factors for dislocation. Cite this article: Bone Joint J 2021;103-B(12):1783-1790.

Safety and Effectiveness of Outpatient Total Ankle Arthroplasty

Background:

Total ankle arthroplasty (TAA) is a surgical procedure commonly reserved for patients suffering from symptomatic end-stage ankle arthritis. As the number of TAAs increases, so does the associated economic burden. Given these economic constraints, there has been interest in the feasibility of outpatient TAA. The purpose of this study is to evaluate the safety, efficacy, and satisfaction of patients undergoing outpatient TAA.

Methods:

This is a retrospective case series of consecutive patients who underwent outpatient TAA from July 2018 to June 2019. Inclusion criteria included any patient undergoing a primary TAA in the outpatient setting. This was defined as discharge on the same day of surgery or within 12 hours of surgery. All surgeries were completed by a single experienced surgeon through an anterior approach using the Cadence Total Ankle System. Prior to surgery, all patients received a popliteal nerve block. Patients were then discharged home with oral analgesic and a popliteal nerve catheter, which they removed after 48 hours. The primary outcome of interest was postoperative pain control, which was measured using a numeric scale. Secondary outcomes included complication rate, readmission rate, and patient satisfaction. A review of the current literature was then completed to supplement our results.

Results:

In total, 41 patients were included in our analysis. In terms of the primary outcome, the average numeric scale score was 1.98, indicating excellent pain control. Additionally, nearly all 41 patients stated they were very satisfied with their postoperative pain control regimen. In terms of secondary outcomes, the majority of patients stated they were satisfied with discharge on the same day as surgery. There were no readmissions or major complications in our outpatient TAA cohort. When asked if they would recommend the care they experienced to a friend with the same condition, 95% of patients said that they would recommend this care pathway. Our literature review included 5 original studies, which were all retrospective level IV studies. These studies uniformly demonstrated the safety and efficacy of outpatient TAA.

Conclusions:

The results of our study demonstrate the outpatient TAA is associated with excellent pain control using a multidisciplinary pain approach. The use of standardized outpatient postoperative pathways was effective in preventing readmissions and complications, while still resulting in high patient satisfaction scores. A review of the literature complemented our results, as there are largely no significant differences between outpatient and inpatient TAA.

Level of Evidence: Level IV, case series.

P–222 Can we optimise the time that we perform the fertilisation check in the lab? Lessons learnt from time-lapse incubation

Study question

Can time-lapse data be used to identify the optimum time to perform the fertilisation check for oocytes cultured in standard incubation?

Summary answer

The optimum time to perform fertilisation checks for oocytes cultured in standard incubation is 16.5hpi+/–0.5h.

What is known already

Time-lapse incubation allows the embryologist to retrospectively review collated images of oocytes and embryos to capture important embryological observations that may have otherwise been missed. This is a luxury not available to embryologists when oocytes or embryos are cultured in standard incubation. Traditionally, the optimum time to perform the fertilisation check is 17 hours post insemination (hpi) +/- 1 hour. It was hypothesised that this could be fine-tuned ensuring the maximum number of fertilised oocytes were observed, thereby increasing the number of usable embryos for the patient.

Study design, size, duration

This was a retrospective, multicentre analysis including data from 27,022 ICSI derived embryos cultured in time-lapse incubation between January 2011 to November 2019.

Participants/materials, setting, methods

The time of pronuclei appearance and disappearance was recorded using the time-lapse incubation software. The number of oocytes exhibiting normal fertilisation (defined as the presence of two pronuclei) during 30 minute intervals from 15hpi to 20hpi was determined.

Main results and the role of chance

Between 15–17.5hpi the average number of oocytes exhibiting normal fertilisation was 98.19% with most oocytes having visible pronuclei at 16–16.5hpi (98.32%). At 18–18.5hpi the number of visible pronuclei falls to 95.53% and continues to fall to 87.02% at 19.5–20hpi meaning that over 3000 (11%) normally fertilised oocytes, within this cohort, would not be identified.

Limitations, reasons for caution

The conclusions of this investigation cannot be effectively extrapolated to IVF embryos as only ICSI embryos were used for the determination of the results.

Wider implications of the findings: The optimum time to perform fertilisation checks for oocytes cultured in standard incubation is 16.5hpi+/–0.5h. However, without the use of time-lapse incubation, the fertilisation of at least 2% of embryos that create a fetal heart will be missed, even if the fertilisation check is performed in the optimum window (16.5hpi+/–0.5h).

Trial registration number

Not applicable

P–282 A time lapse analysis of 36,671 embryos to compare the incidence of early stage abnormal cleavage events in ICSI and IVF derived embryos

Study question

Is this incidence of early stage abnormal cleavage events different between embryos created following ICSI compared with IVF?

Summary answer

Embryos derived from ICSI are more likely to exhibit abnormal cleavage compared with those from IVF. This difference is most marked in women ≥35 years.

What is known already

Time lapse imaging (TLI) has been instrumental in allowing detailed annotation of early embryo development to provide an objective aid for embryo selection in ART cycles. Amongst several abnormal cleavage events reported, rapid cleavage and multichotomous mitosis/direct cleavage, during the first days after fertilisation have been demonstrated to be associated with lower blastulation rates, reduced implantation potential, increased aneuploidy and poor pregnancy outcomes. With ICSI being utilised commonly, and being the insemination method of choice in some clinics, the incidence of abnormal cleavage was investigated in association with insemination method, ICSI or IVF.

Study design, size, duration

The incidence of abnormal cleavage events was evaluated in a large multicentre retrospective analysis of 36,671 embryos from 6689 patients treated in 8 IVF clinics enabled with time lapse imaging, between 2011 - 2019. This constituted 10931 IVF embryos and 25740 ICSI embryos.

Participants/materials, setting, methods

Following ICSI or after IVF fertilisation check, embryos were time-lapse imaged every 10 minutes and annotated using the EmbryoScope. Second cell cycle durations were calculated as follows: time to reach 3-cell (t3) from 2-cell (t2) (t3-t2 = cc2). These were analysed using a welch t-test as three groups of abnormal cleavage: direct cleavage/trichotomous mitosis (DC) - where cc2=0 hours(h), rapid cleavage within 2h (R2) - where 0<cc2<2h and rapid cleavage between 2–5h (R5) where 2h<cc2<5h.

Main results and the role of chance

The incidence of DC, R2 and R5 in the whole cohort of embryos was 5%, 8% and 9% respectively. In the subpopulation of IVF embryos the incidence of DC, R2 and R5 was 4%, 8% and 9% respectively. In the subpopulation of ICSI embryos the incidence of DC, R2 and R5 was 6%, 8% and 9% respectively. The incidence of DC was significantly higher in ICSI embryos compared with IVF (p < 0.001) whilst R2 and R5 were the same. ICSI derived embryos had a mean (± SE) cc2 value of 9.39 ± 0.03h, compared with 9.56 ± 0.05h for IVF embryos (p < 0.0038). Examination of data split by maternal age demonstrated that ICSI oocytes from women of advanced maternal age (≥35) also had significantly more embryos exhibiting rapid cleavages R2 and R5 than IVF oocytes (p < 0.007). There were no significant differences however, in rates of abnormal cleavages between ICSI and IVF in embryos from women aged <30 (p = 0.06).

Male-factor diagnoses showed no significant differences in abnormal cleavage values between ICSI or IVF in all three abnormal cleavage categories.

Limitations, reasons for caution

This analysis could not control for all potential confounders therefore it is possible that the increased abnormal cleavages observed in this investigation are a result of another, or combination of factors. Despite quality assurance programs being in place across all clinics, there is a risk of annotation bias.

Wider implications of the findings: There is a higher incidence of early abnormal cleavage in embryos derived from ICSI, particularly in those from women of increased age and this research may help elucidate the reasons for this and add to the debate regarding the appropriateness of the increasing use of ICSI.

Trial registration number

Not applicable

P–792 The introduction of an embryo morphokinetics annotation quality assurance scheme across ten fertility clinics including 59 participants

Study question

Can a group-wide quality assurance scheme be developed to effectively determine inter-operator agreement for morphokinetic parameters of interest.

Summary answer

Very strong agreement was found between all operators except for one, therefore this scheme effectively identified areas of improvement in inter-operator annotations.

What is known already

Where fertility clinics use embryo morphokinetics to determine viability potential, quality assurance of annotations is essential. Embryo selection algorithms rely on the manual determination of certain morphokinetic parameters. Variations in these parameters can lead to differences in the algorithm score attributed to an embryo thus potentially affecting its fate. It is vital that all embryologists involved in embryo annotation and selection are consistent with their annotation approach through regular quality assurance mechanisms.

Study design, size, duration

Each participant was required to annotate the same three embryos for morphokinetic parameters of interest, including tPB2, tPNf, t2 to t5, t8, tM, tSB, tB. Participants were also required to grade embryos at 68 hours post insemination (hpi), 112hpi and to assess additional parameters used for embryo selection or future investigations, such as the extent of morula compaction. The aim of this scheme is to release new distribution each quarter to ensure regular participation.

Participants/materials, setting, methods

All embryologists responsible for embryo annotation in a single, UK fertility group were enrolled onto the scheme. A total of 59 participants from 10 fertility clinics in the UK were included. Inter-operator agreement was assessed using two-way, mixed intraclass correlation coefficient (ICC) for consistency. Five categories of agreement were determined based on ICC score; very weak (0–0.2), weak (0.21–0.4), moderate (0.41–0.6), strong (0.61–0.8) and very strong (0.81–1.0).

Main results and the role of chance

Very strong agreement (0.81–1.0) was observed between all operators for all parameters assessed except for one operator who showed a weak agreement (0.21–0.4) with all other operators. Descriptive statistics revealed standard deviations (SD) ranging from 0.34 (t3) to 3.43 (t5). For each parameter the SD across the three assessed embryos ranged from 0.34–3.43; tPB2 (0.11–0.98), tPNf (2.06–4.40), t2 (0.22–0.80), t3 (0.16–0.70), t4 (0.39–0.65). t5 (2.40–5.44), t8 (0.33–2.72), tM (1.00–2.72), tSB (1.08–2.67), tB (1.12–1.81). These results indicate a high concordance with less subjective annotations such as the cell stage divisions and more variability with the subjective annotations such as the blastulation parameters. The concordance with less well practiced or understood annotations, such as extent of morula compaction, planar or tetrahedral orientation at the four cell stage as well as angle of extrusion of second polar body in relation to the first polar body, was poorer as indicated using descriptive statistics. This highlighted the need for experience in performing these annotations before drawing conclusions regarding their predictive nature in relation to an embryo’s viability.

Limitations, reasons for caution

The variability between more subjective parameters would be expected to be higher than others. The participation in these schemes can create false environments which do not reflect how an embryologist would usually score; they may spend longer on some decisions given the nature of the scheme.

Wider implications of the findings: Quality assurance of morphokinetic annotations across clinics utilising standardised selection models is crucial. Robust annotation policies and education programmes are essential in achieving consistent results between operators. Quality assurance schemes can identify individuals who lack consistency overall and can identify reliably annotated parameters to inform inclusion in embryo selection algorithms.

Trial registration number

Not applicable

P–164 Mulitcentre derived time lapse algorithms developed using 6228 transferred embryos with known birth outcome incorporating novel morphological and morphokinetic markers

Study question

Can incorporation of novel markers of morphology with known temporal events successfully rank embryos to enable prediction of propensity for live birth?

Summary answer

Incorporation of variables for trophectoderm and morula grading demonstrably enhanced the model to rank embryos in order of potential for live birth.

What is known already

Models built using morphokinetic markers of development are widely used to rank embryos within a cohort. Such models include defined temporal parameters which are closely related to morphological grade. However, morphological grading by an embryologist is subjective and is not strongly correlated to outcome. Combining with defined kinetic events has been suggested to improve prediction of outcome.

Study design, size, duration

Data from 6228 known live birth outcome embryos from 8 UK clinics between 2011 – 2018 were investigated using an exploratory approach to identify novel markers of development.

Participants/materials, setting, methods

Five significant variables were defined, a derivative of time to start of blastulation; a derivative of trophectoderm grade; a kinetic variable utilising t3, t4, t5 and t8; an interval variable of tB-tSB and a variable based on novel morula classification. To maximise the output, a proxy value was derived for missing datapoints. The model was built using logistical regression and validated using fivefold cross validation with the data split as 80% training and 20% test.

Main results and the role of chance

An algorithm was developed including the five significant variables identified with an AUC of 0.685 demonstrating reliable prediction of live birth. Without morphological variables, the AUC was 0.674 demonstrating the improvement in the prediction value by including the derivative of the trophectoderm and morula grade. This resulted in ten classes of algorithm scores, 1–10, giving a live birth rate from 2% to 46%, irrespective of patient variables, for chance of live birth.

Limitations, reasons for caution

Successful application of the algorithm is reliant on stringent quality assurance for maintenance of accurate annotation and grading, and may not be transferable between laboratories with different SOPs.

Wider implications of the findings: The addition of a trophectoderm and morula grade in combination with morphokinetic parameters, increases the predictive value of the algorithm in relation to live birth outcome. Using proxy values allows maximization of data for model generation, and allows the model to be applied when missing values are present.

Trial registration number

Not applicable

P–206 Does oocyte vitrifcation affect morphokinetics of subsequent embryo development?

Study question

Are the morphokinetic profiles, as assessed using time-lapse technology, of human embryos developed from vitrified oocytes different to those from fresh oocytes.

Summary answer

Vitrification of oocytes does have an effect on early developmental morphokinetic profiles, but this is normalized by the time the embryo has reached blastocyst.

What is known already

Vitrification of oocytes is now commonplace, but little is known about the effect this may have on subsequent embryo development.

Study design, size, duration

This was a retrospective data analysis, from 8 fertility clinics in the UK between 2012 and 2019. Embryos from patients in the vitrified group (n = 557) were matched to fresh patient controls (n = 539). The matching was performed based on the following criteria: type of treatment, patient age, cause of infertility and number of embryos.

Participants/materials, setting, methods

The embryos in each group were compared for mean morphokinetics of key developmental stages in hours post insemination (hpi). Parameters compared included early cleavage divisions (t2-t8), time to start of compaction (tSC), time to morula (tM), time to start blastulation (tSB), time to full blastocyst (tB) and duration of compaction (tB-tSC). Treatment outcomes were compared between the two groups, including percentage of blastocyst formation, clinical pregnancy rate, implantation rate and live birth rate.

Main results and the role of chance

The results showed a significant delay across all early cleavage divisions as follows for vitrified and fresh oocytes respectively: 2-cell (28.14 vs 26.10 (p < 0.001)), 3 cell (37.56 vs 35.37 (p < 0.001)), 4 cell (40.58 vs 37.54 (p < 0.001)), 5 cell (50.31 vs 47.14 (p < 0.001)), 6 cell (53.99 vs 50.87 (p < 0.001)), 7 cell (57.08 vs 54.48 (p < 0.001)) and 8 cell (61.26 vs 58.91 (p < 0.01)). In addition, tSC was also significantly delayed in the vitrified group (80.65 vs 76.36 (p < 0.001)). However, the compaction stage was significantly shorter in the vitrified oocytes (19.02 vs 22.45 (p < 0.001)). Therefore, there was no difference in the time that embryos derived from fresh and vitrified oocytes reached the blastocyst stage (108.03 vs 107.78 (p > 0.05)). No difference was found in clinical pregnancy, implantation or live birth rates but significantly fewer blastocyst developed from vitrified oocytes compared to fresh (36.09% vs 42.4% (p < 0.05)).

Limitations, reasons for caution

Although this was a matched analysis, it was a retrospective in nature therefore is subject to confounders. However, it would be problematic to perform a prospective randomized controlled trial to address this study question given the need to randomize patients to elective freezing of oocytes prior to embryo creation.

Wider implications of the findings: Vitrification of oocytes may affect early developmental morphokinetic profiles, but any effect is normalized by the time the embryo has reached blastocyst. However, fewer blastocysts may develop following oocyte vitrification. This may have implications for oocyte donation banks and those patients choosing to cryopreserve oocytes.

Trial registration number

NA

Converting hip and knee arthroplasty cases to same-day surgery due to COVID-19

AIMS

In 2020, the COVID-19 pandemic meant that proceeding with elective surgery was restricted to minimize exposure on wards. In order to maintain throughput of elective cases, our hospital (St Michaels Hospital, Toronto, Canada) was forced to convert as many cases as possible to same-day procedures rather than overnight admission. In this retrospective analysis, we review the cases performed as same-day arthroplasty surgeries compared to the same period in the previous 12 months.

METHODS

We conducted a retrospective analysis of patients undergoing total hip and knee arthroplasties over a three-month period between October and December in 2019, and again in 2020, in the middle of the COVID-19 pandemic. Patient demographics, number of outpatient primary arthroplasty cases, length of stay for admissions, 30-day readmission, and complications were collated.

RESULTS

In total, 428 patient charts were reviewed for October to December of 2019 (n = 195) and 2020 (n = 233). Of those, total hip arthroplasties (THAs) comprised 60% and 58.8% for 2019 and 2020, respectively. Demographic data was comparable with no statistical difference for age, sex, contralateral joint arthroplasty, or BMI. American Society of Anesthesiologists grade I was more highly prevalent in the 2020 cohort (5.1-times increase; n = 13 vs n = 1). Degenerative disc disease and fibromyalgia were less significantly prevalent in the 2020 cohort. There was a significant increase in same day discharges for non-direct anterior approach THAs (two-times increase) and total knee arthroplasty (ten-times increase), with a reciprocal decrease in next day discharges. There were significantly fewer reported superficial wound infections in 2020 (5.6% vs 1.7%) and no significant differences in readmissions or emergency department visits (3.1% vs 3.0%).

CONCLUSION

The COVID-19 pandemic meant that hospitals and patients were hopeful to minimize the exposure to the wards, and minimize strain on the already taxed inpatient beds. With few positives during the COVID-19 crisis, the pandemic was the catalyst to speed up the outpatient arthroplasty programme that has resulted in our institution being more efficient, and with no increase in readmissions or early complications. Cite this article: Bone Jt Open 2021;2(7):545-551.

Physical training for patients with depression and anxiety - a randomized controlled study

Introduction

Pharmaceutical treatment and psychotherapy constitute the most common treatment methods for depression and anxiety. Physical training has been shown to have comparable effect to cognitive behavioral therapy in treatment of mild to moderate depression and anxiety. Physically active individuals also show lower risks to develop depression and relapse in depression.

Objectives

The objectives are to evaluate how physical activity can affect depressive and anxiety symptoms, by examining biomarkers in the blood and from the gut and also by measuring cognitive functions. Hopefully, this can lead to new treatment strategies for patients with depression and anxiety.

Methods

102 patients are randomized to two groups and undergo 12 weeks intervention as add-on to standard outpatient psychiatric treatment. The first group will participate in physical training three times per week and the other group will receive relaxation therapy on a weekly basis. Daily activity intensity will be measured before and at the last week of intervention with an accelerometer. Blood and faeces sample collection, symptom grading by clinician together with self-rating scales and cognitive screening will be performed at baseline, week 12 and one year of follow-up. The cognitive screenings are performed digitally in cooperation with Mindmore.

Results

The RCT is currently recruiting patients at the Department of Psychiatry of Örebro University Hospital.

Conclusions

The project aims to be holistic in its approach, combining the defining clinical psychiatric symptoms in patients who have both depression and anxiety with the finding and evaluation of new biomarkers from blood and gut to improve cognitive functions.

Disclosure

No significant relationships.

Non-psychotic mental disorders in adolescent men and risk of myocardial infarction: a national cohort study

Background/Purpose

Recent studies show that early life stress is associated with later risk of cardiovascular disease (CVD) and stress may also increase the risk of psychiatric disease. We investigated the association between non-psychotic mental disorders in adolescence and subsequent myocardial infarction, and the role of stress resilience and physical fitness in this association.

Method

This is a register-based cohort study with 238 013 males born between 1952 and 1956 followed from 1987 to 2010 using information from Swedish registers. Stress resilience was measured at a compulsory military conscription examination using a semi-structured interview with a psychologist. Physical fitness was measured at conscription examination with a cycle ergometer test. A total of 34 503 men were diagnosed with a non-psychotic mental disorder at conscription. Using Cox regression, we estimated the association of mental disorders with myocardial infarction after adjustment for other established CVD risk factors in adolescence. Stress resilience and physical fitness were included in the adjusted model in a second set of analyses.

Results

A total of 5891 diagnoses of first myocardial infarction were identified. Non-psychotic mental disorders were associated with an increased risk of myocardial infarction, with a hazard ratio (HR) and confidence interval (CI) of 1.51 (1.41–1.62). The association remained statistically significant after adjustment for other important potential confounders in adolescence such as systolic and diastolic blood pressure, body mass index, inflammation, cognitive function, parental socioeconomic index and a summary disease score (HR 1.24 (CI 1.13–1.35)). The association was further explained by stress resilience and lifestyle factors assessed with a cardiovascular fitness test in adolescence, as the association attenuated but remained statistically significant when further adjusting for stress resilience and physical fitness (HR 1.18 (CI 1.08–1.29)).

Conclusion

A non-psychotic mental disorder in adolescences may increase the risk of developing myocardial infarction later in life. This association was partly but not completely explained by poorer stress resilience and physical fitness. Effective prevention might focus on behaviour/lifestyle and psychosocial stress in early life.

Funding Acknowledgement

Type of funding source: None

Mind and body exercises (MBE), prescribed antidepressant medication, physical exercise and depressive symptoms - a longitudinal study

AIMS

Earlier studies show that participation in mind and body exercises (MBE) is cross-sectionally associated with high levels of depressive symptoms and antidepressants. This study investigates the longitudinal interrelationship between depressive symptoms, MBE and antidepressants.

METHODS

3269 men and 4318 women aged 24-74 years participated in the Swedish Longitudinal Occupational Survey of Health (SLOSH). Measures of MBE practice and depressive symptoms were drawn from the SLOSH questionnaire, data on prescription drugs were obtained from the Swedish Prescribed Drug Register. Structural Equation Modeling (SEM) was used to analyze temporal relationships.

RESULTS

Both MBE practice and antidepressants in 2012 was associated with higher levels of depressive symptoms two years later. Depressive symptoms in turn were associated with higher levels of later MBE practice and antidepressants. These relationships seemed to be explained by confounding by indication and were of higher magnitude for antidepressants than for MBE.

CONCLUSION

Overall, SEM analysis shows that MBE and antidepressant treatment were both bi-directionally associated with depressive symptoms over time. Part of the explanation is likely to be confounding by indication: those with symptoms of depression more likely to undertake treatment, and MBE alone may be more common among those with less severe depression. The results clarify some of our findings from earlier studies and give some important, new information on what people are doing to manage depressive symptoms on a societal level, regarding self-care, medication, and the combination of both.

Association of major California freight railyards with asthma-related pediatric emergency department hospital visits

Asthma is a major health threat and leading cause of chronic morbidity among children. Air pollutants have been linked to exacerbations and promotion of initial development of asthma. Extensive research already conducted assessing adverse health impacts associated with exposure to pollutants from vehicular traffic. However, little research conducted assessing exposure to pollutants stemming from goods movement industry, such as freight railyards. This study's purpose to assess potential association between residential proximity to major freight railyards and asthma-related emergency room (ER) visits in children. This study included children ≤14 yrs. old, living within 30-mile radius of one of 18 freight railyards in California, and having utilized emergency room services between 2007 and 2009, identified through California Office of Statewide Health Planning and Development (OSHPD) database. Logistic regression modeling with all 18 railyards, and models with top 5 polluting railyards, conducted to assess for potential association between asthma related ER visit (asthma vs. non-asthma visit) and railyard residential proximity. A total 109,645 asthma related ER visits identified, majority among low income, minority populations. Within 18 railyard model, children closest to railyard (0-5 miles) were at significant increased odds (OR = 1.15, 95%CI: 1.10-1.20) for asthma related ER visit and stronger odds observed for 5 top emitting railyards (OR = 1.40, 95%CI: 1.29-1.52). Our findings indicate a strong link between asthma ER visits for children and residential proximity to railyards, especially among low-income and minority communities. There's a critical need to better understand complex health risks for individuals residing in these communities and mitigation efforts for this vulnerable population.

Clinical factors predicting treatment resistant depression: affirmative results from the European multicenter study

OBJECTIVES

Clinical variables were investigated in the 'treatment resistant depression (TRD)- III' sample to replicate earlier findings by the European research consortium 'Group for the Study of Resistant Depression' (GSRD) and enable cross-sample prediction of treatment outcome in TRD.

EXPERIMENTAL PROCEDURES

TRD was defined by a Montgomery and Åsberg Depression Rating Scale (MADRS) score ≥22 after at least two antidepressive trials. Response was defined by a decline in MADRS score by ≥50% and below a threshold of 22. Logistic regression was applied to replicate predictors for TRD among 16 clinical variables in 916 patients. Elastic net regression was applied for prediction of treatment outcome.

RESULTS

Symptom severity (odds ratio (OR) = 3.31), psychotic symptoms (OR = 2.52), suicidal risk (OR = 1.74), generalized anxiety disorder (OR = 1.68), inpatient status (OR = 1.65), higher number of antidepressants administered previously (OR = 1.23), and lifetime depressive episodes (OR = 1.15) as well as longer duration of the current episode (OR = 1.022) increased the risk of TRD. Prediction of TRD reached an accuracy of 0.86 in the independent validation set, TRD-I.

CONCLUSION

Symptom severity, suicidal risk, higher number of lifetime depressive episodes, and comorbid anxiety disorder were replicated as the most prominent risk factors for TRD. Significant predictors in TRD-III enabled robust prediction of treatment outcome in TRD-I.

Atopic dermatitis, educational attainment and psychological functioning: a national cohort study

BACKGROUND

Atopic dermatitis (AD) might adversely affect academic performance, possibly through influences on psychological functioning such as stress resilience.

OBJECTIVES

To investigate the association of atopic dermatitis with stress resilience, cognitive function and educational attainment.

METHODS

We used data from a national cohort of men who underwent a military conscription examination at ages 17-20 years in Sweden between 1969 and 1976. All potential conscripts met a physician who assessed current or previous history of AD. Stress resilience was measured by a psychologist using a semistructured interview. The conscription assessment included a written cognitive function test. The highest level of education achieved was identified through record linkage.

RESULTS

The study population included 234 715 men, 1673 (0·7%) of whom had a diagnosis of AD. AD was associated with a greater risk of low stress resilience [adjusted relative risk ratio (RRR) 1·60, 95% confidence interval (CI) 1·38-1·86]. AD was associated with higher cognitive function (β-coefficient 0·15, 95% CI 0·05-0·24) and higher educational level (RRR 1·29, 95% CI 1·13-1·47). However, adjustment for socioeconomic characteristics of the family of origin attenuated the magnitude of the associations and eliminated the statistical significance (β-coefficient 0·06, 95% CI -0·03 to 0·15; RRR 1·16, 95% CI 1·00-1·35).

CONCLUSIONS

Swedish men with AD had lower stress resilience in late adolescence but did not have lower cognitive function or poorer educational attainment. The lower stress resilience associated with AD is consistent with an increased risk of possible long-term adverse health outcomes.

Necrotizing Fasciitis Involving Spine: Unusual Medical Emergency for Spine Surgeon

BACKGROUND

Necrotizing fasciitis (NF) is a surgical diagnosis characterized by a rapidly progressive soft tissue infection, widespread tissue necrosis, and associated systemic illness. Friability of the superficial fascia, dishwater-gray exudate, and absence of pus are surgical characteristics of this diagnosis. Due to rapid progression of the infection, early recognition and aggressive surgical debridement are crucial to reduce mortality. Despite being commonly seen by general, plastic, and orthopedic surgeons, NF is an extremely rare spine surgery emergency. Our objective is to report on a case of NF involving the spine and highlight this unusual surgical emergency for the spine surgeon.

CASE DESCRIPTION

We present a rare case of a 61-year-old woman who presented to the emergency department in septic shock. She had a 1-week history of increasing back pain before presenting to us. Computed tomography revealed extensive soft tissue emphysema with involvement of the L3 vertebral body and spina canal. She underwent emergency surgical debridement. Despite maximal medical and surgical therapies, the patient died secondary to multisystem organ failure within 36 hours of initial presentation.

CONCLUSIONS

To the best of our knowledge, the literature presents only 1 previous case reported involving the spine. Necrotizing fasciitis is an unusual surgical spine surgery emergency. Spine surgeons should be aware of this diagnosis in order to provide timely aggressive surgical debridement.

Clinical correlates of augmentation/combination treatment strategies in major depressive disorder

OBJECTIVE

This multicenter, multinational, cross-sectional study aimed to investigate clinical characteristics and treatment outcomes associated with augmentation/combination treatment strategies in major depressive disorder (MDD).

METHOD

Sociodemographic, clinical, and treatment features of 1410 adult MDD patients were compared between MDD patients treated with monotherapy and augmentation/combination medication using descriptive statistics, analyses of covariance (ancova), and Spearman's correlation analyses.

RESULTS

60.64% of all participants received augmentation and/or combination strategies with a mean number of 2.18 ± 1.22 simultaneously prescribed psychiatric drugs. We found male gender, older age, Caucasian descent, higher weight, low educational status, absence of occupation, psychotic symptoms, melancholic and atypical features, suicide risk, in-patient treatment, longer duration of hospitalization, some psychiatric comorbidities (panic disorder, agoraphobia, obsessive-compulsive disorder, and bulimia nervosa), comorbid somatic comorbidity in general and concurrent hypertension, thyroid dysfunction, diabetes, and heart disease in particular, higher current and retrospective Montgomery and Åsberg Depression Rating Scale total scores, treatment resistance, and higher antidepressant dosing to be significantly associated with augmentation/combination treatment. These findings were corroborated when examining the number of concurrently administered psychiatric drugs in the statistical analyses.

CONCLUSION

Our findings suggest a clear association between augmentation/combination strategies and treatment-resistant/difficult-to-treat MDD conditions characterized by severe symptomatology and high amount of psychiatric and somatic comorbidities.

Dietary Patterns and Retinal Vessel Caliber in the Irish Nun Eye Study

BACKGROUND

Retinal vessel abnormalities are associated with cardiovascular disease risk. Widening of retinal venules is associated with increased risk of stroke while narrowing of retinal arterioles independently predicts incident hypertension, coronary heart disease and diabetes. Dietary factors are known to play an important role in cardiovascular health. However, few studies have examined the association between dietary patterns (DPs) and retinal microvascular health.

OBJECTIVE

To examine the association between 'a posteriori'-derived DPs and retinal vascular caliber (RVC) in older women with a restricted lifestyle.

METHODS

This was a cross-sectional study of 1233 participants (mean age: 76.3 years) from the Irish Nun Eye Study (INES). Computer-assisted software was used to measure RVC from digital eye images using standardized protocols. Dietary intake was assessed using a food frequency questionnaire (FFQ). DP analysis was performed using principal component analysis from completed FFQs. Regression models were used to assess associations between DPs and retinal vessel diameters, adjusting for age, body mass index, refraction, hypertension, diabetes mellitus, ischemic heart disease, cerebrovascular accident and fellow eye RVC.

RESULTS

Two DPs were identified: a 'healthy' pattern with high factor loadings for fruit, vegetables, wholegrains and oily fish and an 'unhealthy' pattern with high factor loadings for sugar and sweets, chips, high fat dairy products and French fries. Adjusted linear regression analysis revealed that those who adhered most closely to the unhealthy DP had wider central retinal venular equivalent (CRVE) (p=0.03) and narrower central retinal arteriolar equivalent (CRAE) (p=0.01) compared to the least unhealthy DP. No independent relationship was observed between the healthy DP and RVC.

CONCLUSION

In this cohort of older women with a restricted lifestyle, an unhealthy DP was independently associated with an unfavorable retinal profile, namely a widening of retinal venules and narrowing of retinal arterioles.

Changes in medical management and colectomy rates: a population-based cohort study on the epidemiology and natural history of ulcerative colitis in Örebro, Sweden, 1963-2010

BACKGROUND

Whether the epidemiology of ulcerative colitis (UC) has changed during recent decades is partly unknown.

AIM

To depict temporal trends in the epidemiology and medical treatment of UC as well as the long-term risk of progression in disease extent and colectomy, during 1963-2010.

METHODS

Patients were identified by evaluation of all medical records in the archive of the Colitis Clinic, Örebro University Hospital. Comparisons were made between three time periods, 1963-1975, 1976-1990 and 1991-2005.

RESULTS

The annual age-standardised incidence increased from 3.5 to 18.5 per 100 000 during the study period (P < .01). Correspondingly, the prevalence increased from 44 to 474 per 100 000 between 1965 and 2010. A higher proportion of males than females had extensive colitis at diagnosis (odds ratio: 1.55; 95% CI 1.17-2.05; P < .01). The risk for progression in disease extent was 34.5% and 18.5% at 10 years, for patients with proctitis and left-sided colitis, respectively (P < .01). The use of 5-aminosalicylates, within 10 years, rise from 79% to 92% between 1963-1975 and 1976-1990 (P < .01). Thiopurine use increased from 7% in 1976-1990 to 34% during 1991-2005 (P < .01). The colectomy rate at 10 years was 13.5% (95% CI 11.1%-15.8%), and the risk was lower among patients diagnosed in 1991-2005 compared to 1963-1975 (adjusted hazard ratio: 0.61; 95% CI 0.39-0.94; P = .02).

CONCLUSION

The incidence and prevalence of UC increased over time, and the observed prevalence in 2010 is among the highest reported. In parallel, a decrease in colectomy rates was observed during the most recent decades, potentially reflecting improved medical treatment.

Prescribing patterns of psychiatric drugs in major depressive disorder – Findings from a large European multicenter, cross-sectional study

Introduction

The multicenter, cross-sectional survey summarizes the current prescription patterns of psychopharmacological medications in patients with major depressive disorder (MDD) treated in European university psychiatric centers.

Methods

The study included a total of 1181 MDD patients who were recruited in 9 academic sites across 8 European countries. Socio-demographic, clinical, and psychopharmacological characteristics were collected within a detailed clinical interview and the current depressive symptom severity was measured by the Montgomery and Åsberg Depression Rating Scale (MADRS). Symptom reduction during the present MDD episode was analyzed by calculating retrospective MADRS scores. Descriptive statistics, analyses of variance (ANOVAs), and Spearman correlation analyses were performed to examine the impact of various features on the applied pharmacological strategies.

Results

Regarding first-line antidepressant medication, the most frequently prescribed drug classes were selective serotonin reuptake inhibitors (SSRIs) (53.4%), serotonin-norepinephrine reuptake inhibitors (SNRIs) (23.6%), noradrenergic and specific serotonergic antidepressants (NaSSAs) (8.2%), tricyclic antidepressants (TCA) (5.1%), and the melatonergic antidepressant agomelatine (5.0%). The most commonly used individual antidepressants were escitalopram (18.4%), venlafaxine (15.2%), sertraline (12.9%), paroxetine (9.1%), mirtazapine (8.2%), duloxetine (7.0%), and fluoxetine (6.5%). Among the patients, 59.4% were treated with polypsychopharmaceutical medications (mean: 2 drugs) and for the number of individual drugs, we found a significant correlation with the present MADRS total score and the MADRS total score change during the current depressive episode.

Conclusion

Consistent with surveys investigating primarily municipal psychiatric treatment centers, we could replicate the observation that SSRIs are the most commonly used antidepressants in MDD for the first time for European university centers.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Long-term pattern of opioid prescriptions after femoral shaft fractures

BACKGROUND

The use of opioids in non-cancer-related pain following skeletal trauma is controversial due to the presumed risk of dose escalation and dependence. We therefore examined the pattern of opioid prescriptions, that is, those actually dispensed, in patients with femoral shaft fractures.

METHODS

We analysed data from the Swedish National Hospital Discharge Register and the Swedish Prescribed Drug Register between 2005 and 2008.

RESULTS

We identified 1471 patients with isolated femoral shaft fractures. The median age was 75 (16-102) years and 56% were female. In this cohort, 891 patients (61%) received dispensed opioid prescriptions during a median follow-up of 20 months (interquartile range 11-32). In the age- and sex-matched comparison cohort (7339 individuals) without fracture, 25% had opioid prescriptions dispensed during the same period. The proportions of patients receiving opioid analgesics at 6 and 12 months after the fracture were 45% (95% CI 42-49) and 36% (32-39), respectively. The median daily morphine equivalent dose (MED) was between 15 and 17 mg 1-12 months post-fracture. After 3 months, less than 5% used prescription doses higher than 20 mg MED per day. Older age (≥ 70 compared with < 70 years) was a significant predictor of earlier discontinuation of opioid use (Hazard ratio [HR] 1.9).

CONCLUSION

A notable proportion of patients continued to receive dispensed prescriptions for opioids for over 6 months (45%) and more than a third of them (36%) continued treatment for at least 12 months. However, the risk of dose escalation seems to be small in opioid-naïve patients.

Remarriage after divorce and depression risk

As marriage is associated with lower depression rates compared with being single in men, we aimed to examine if remarriage compared with remaining divorced is also associated with a reduced depression risk. Swedish register data were used to define a cohort of men who were born between 1952 and 1956 and underwent a compulsory military conscription assessment in adolescence. This study population comprised men who were divorced in 1985 (n = 72,246). The risk of pharmaceutically treated depression from 2005 to 2009 was compared for those who remarried or remained divorced between 1986 and 2004. Cox proportional hazards analysis was used to estimate hazard ratios for the risk of depression identified by pharmaceutical treatment, with adjustment for a range of potential confounding factors including childhood and adulthood socioeconomic circumstances, cognitive, physical, psychological and medical characteristics at the conscription assessment. The results showed that, even though divorced men who remarried had markers of lower depression risk in earlier life such as higher cognitive and physical function, higher stress resilience and socioeconomic advantages than men who remained divorced, remarriage was associated with a statistically significant elevated risk of depression with an adjusted hazard ratio (and 95% confidence interval) of 1.27(1.03 1.55), compared with men who remained divorced. Remarriage following divorce is not associated with a reduced risk of depression identified by pharmaceutical treatment, compared with remaining divorced. Interpersonal or financial difficulties resulting from remarriage may outweigh the benefits of marriage in terms of depression risk.

Decreased stress resilience in young men significantly increases the risk of subsequent peptic ulcer disease - a prospective study of 233 093 men in Sweden

BACKGROUND

Psychosocial stress may influence peptic ulcer disease (PUD) risk, but it can be difficult to identify reliably whether stressful exposures pre-dated disease. The association of stress resilience (susceptibility to stress) with subsequent PUD risk has been incompletely investigated.

AIM

To assess if stress resilience in adolescence is associated with subsequent PUD risk.

METHODS

The participants comprised of 233 093 men resident in Sweden, born 1952-1956 and assessed for compulsory military conscription during 1969-1976, with data provided by national Swedish registers. Stress resilience was evaluated through semi-structured interviews by a certified psychologist. Cox regression assessed the association between stress resilience in adolescence and the risk of PUD from 1985 to 2009, between ages 28 and 57 years, with adjustment for parental socioeconomic index, household crowding and number of siblings in childhood, as well as cognitive function and erythrocyte sedimentation rate in adolescence.

RESULTS

In total, 2259 first PUD diagnoses were identified. Lower stress resilience in adolescence is associated with a higher risk of PUD in subsequent adulthood: compared with high resilience, the adjusted hazard ratios (and 95% CI) are 1.84 (1.61-2.10) and 1.23 (1.09-1.38) for low and moderate stress resilience, respectively.

CONCLUSION

Stress may be implicated in the aetiology of PUD and low stress resilience is a marker of risk.

Characteristics in childhood and adolescence associated with future multiple sclerosis risk in men: cohort study

Background and purpose

Associations with multiple sclerosis (MS) of living conditions in childhood and characteristics in adolescence including physical fitness, cognitive function and psychological stress resilience were investigated.

Methods

A cohort of male Swedish residents born 1952–1956 who were included in the Swedish Military Conscription Register was used to create a nested case−control study comprising 628 MS cases and 6187 controls matched on birth year, county of residence and vital status at time of diagnosis. Conscription examination records were linked with other national register data. Conditional logistic regression was used to evaluate associations with MS subsequent to the conscription examination.

Results and conclusions

Men with MS were less likely to be from more crowded households in childhood (>two persons per room) with an adjusted odds ratio of 0.67 (95% confidence interval 0.51–0.86, P = 0.023). They had lower physical working capacity in adolescence with adjusted odds ratio of 0.94 (95% confidence interval 0.89–0.99, P = 0.026). Cognitive function and stress resilience scores displayed no significant differences between cases and controls. Parental occupation in childhood and body mass index in adolescence were not associated with future MS risk. The inverse association of MS risk with higher levels of household crowding may reflect environmental factors such as the pattern of exposure to microorganisms. Lower physical fitness in men at MS risk may indicate a protective effect of exercise or could be due to prodromal disease activity, although there was no association with cognitive function. Poor psychological stress resilience (and thus risk of chronic stress arousal) was not associated with MS.

Neuronal cell adhesion genes and antidepressant response in three independent samples

Drug-effect phenotypes in human lymphoblastoid cell lines recently allowed to identify CHL1 (cell adhesion molecule with homology to L1CAM), GAP43 (growth-associated protein 43) and ITGB3 (integrin beta 3) as new candidates for involvement in the antidepressant effect. CHL1 and ITGB3 code for adhesion molecules, while GAP43 codes for a neuron-specific cytosolic protein expressed in neuronal growth cones; all the three gene products are involved in synaptic plasticity. Sixteen polymorphisms in these genes were genotyped in two samples (n=369 and 90) with diagnosis of major depressive episode who were treated with antidepressants in a naturalistic setting. Phenotypes were response, remission and treatment-resistant depression. Logistic regression including appropriate covariates was performed. Genes associated with outcomes were investigated in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) genome-wide study (n=1861) as both individual genes and through a pathway analysis (Reactome and String databases). Gene-based analysis suggested CHL1 rs4003413, GAP43 rs283393 and rs9860828, ITGB3 rs3809865 as the top candidates due to their replication across the largest original sample and the STAR*D cohort. GAP43 molecular pathway was associated with both response and remission in the STAR*D, with ELAVL4 representing the gene with the highest percentage of single nucleotide polymorphisms (SNPs) associated with outcomes. Other promising genes emerging from the pathway analysis were ITGB1 and NRP1. The present study was the first to analyze cell adhesion genes and their molecular pathways in antidepressant response. Genes and biomarkers involved in neuronal adhesion should be considered by further studies aimed to identify predictors of antidepressant response.

Multiple sclerosis clinical course and cardiovascular disease risk - Swedish cohort study

BACKGROUND AND PURPOSE

Cardiovascular disease (CVD) risk amongst multiple sclerosis (MS) patients appears raised, but few studies have examined CVD risk amongst an unselected MS patient group. MS course may be relevant for CVD risk. Our aim was to assess CVD risk and variation by course in MS patients.

METHODS

The Multiple Sclerosis Register identified 7667 patients who received an MS diagnosis between 1964 and 2005. They were matched by age, period, region and sex with 76 045 members of the general population without MS using Swedish registers. Poisson regression compared the two cohorts to estimate the relative risk for CVD, overall, as well as grouped and individual CVD diagnoses.

RESULTS

MS patients had an increased adjusted relative risk (with 95% confidence intervals; number of MS cohort events) for CVD of 1.31 (1.22-1.41; n = 847), with some variation by course: relapsing-remitting 1.38 (1.17-1.62; n = 168); secondary progressive 1.30 (1.18-1.53; n = 405) and primary progressive 1.15 (0.93-1.41; n = 108). The association for the relapsing-remitting course was not significant after excluding the first year of follow-up. Overall incidence rates per 1000 person-years for CVD are 11.8 (11.06-12.66) for the MS cohort and 8.8 (8.60-9.05) for the non-MS cohort. The most pronounced association was for deep vein thrombosis: relapsing-remitting 2.16 (1.21-3.87; n = 14), secondary progressive 3.41 (2.45-4.75; n = 52) and primary progressive 3.57 (1.95-6.56; n = 15). MS was associated with ischaemic stroke but largely during the first year of follow-up. MS was associated with a decreased relative risk for angina pectoris and atrial fibrillation.

CONCLUSIONS

There is a significantly increased relative risk for CVD in MS, particularly for venous thromboembolic disorders in progressive MS, suggesting immobility as a possible factor. An increased frequency of ischaemic stroke in MS is most probably due to surveillance bias resulting from diagnostic investigations for MS. There is no increased relative risk for ischaemic heart disease in MS and atrial fibrillation appears to be less common than amongst the general population.

Gestational diabetes mellitus and later cardiovascular disease: a Swedish population based case-control study

Objective

To identify if gestational diabetes mellitus (GDM) is a clinically useful marker of future cardiovascular disease (CVD) risk and if GDM combined with other risks (smoking, hypertension or body mass) identifies high-risk groups.

Design

Population-based matched case–control study.

Setting

National Swedish register data from 1991 to 2008.

Population

A total of 2639 women with a cardiovascular event and matched controls.

Methods

Conditional logistic regression examined associations with CVD before and after adjustment for conventional risk factors and confounders. Effect modification for the association of GDM with CVD by body mass index (BMI), smoking and chronic hypertension was assessed by stratification and interaction testing. Adjustment for diabetes post-pregnancy evaluated its mediating role.

Main outcome measures

Inpatient diagnoses or causes of death identifying ischemic heart disease, ischemic stroke, atherosclerosis or peripheral vascular disease.

Results

The adjusted odds ratios (and 95% confidence intervals) for the association of CVD with GDM are 1.51 (1.07–2.14), 2.23 (2.01–2.48) for smoking, 1.98 (1.71–2.29) for obesity and 5.10 (3.18–8.18) for chronic hypertension. In stratified analysis the association of CVD with GDM was only seen among women with BMI ≥25, with an odds ratio of 2.39 (1.39–4.10), but only women with a BMI <30 accounted for this increased risk. Adjustment for post-pregnancy diabetes attenuated it somewhat to 1.99 (1.13–3.52).

Conclusions

In the absence of other recognised cardiovascular risk factors, such as smoking, obesity or chronic hypertension, GDM is a useful marker of raised CVD risk among women with BMI between 25 and 29.

Abstract P2-12-05: Exploring the experience of relatives with whom genetic test results are communicated

There is increasing interest in the psychosocial impact of genetic testing, both on the individual who has been tested and on family members who could benefit from knowing the test results. The responsibility for informing relatives of genetic test results falls on the proband, the first family member being tested. While there is limited data about the reaction of relatives with whom genetic test results are shared, there is some evidence that open, positive family relationships increase the likelihood of disclosure of test results while emotional distance, family conflict, and loss of contact decrease the likelihood of disclosure. We explored the communication process between probands undergoing genetic testing for BRCA1/2 and their first degree relatives with whom they shared results. Four hundred twenty two women were randomized to a communication skills-building intervention or a wellness control session. Overall, probands shared their test result with 80% of eligible relatives. As part of this study, relatives were surveyed by phone regarding factors associated with the communication process, and their ability to understand and cope with the information provided to them by the proband. This study focuses on 438 relatives (of 253 probands) who reported that test results were shared. The percent of relatives with whom genetic test results were shared did not differ by study group. However, there were significant differences across gender and generation. Female relatives were more likely to receive genetic test results (p = 0.0001), and adult children were more likely to receive genetic test results than either parents or siblings (p = 0.0006). Both positive and true negative test results were more likely to be communicated to relatives than indeterminate or inconclusive results. Comparing the actual test result of the proband with that reported by the relative, we found that 26% of relatives cited an incorrect test result, and this number did not differ by study group. Positive test results were the most likely to be correctly understood by the relatives (90%), while inconclusive test results were the least likely to be correctly understood (60%) (p = 0.005). When asked about their reaction to receipt of test results, 32% of relatives reported difficulty in understanding the test result, and 27% were upset with the information they received. Of those relatives whose proband received a positive test result, only 52% reported intention to pursue testing for themselves. Similarly, only 36% of relatives whose proband received true negative test results intended to pursue testing, implying the relatives did not fully understand the significance of these informative results for their own risk These findings indicate that sharing of genetic test results by probands to their adult first degree relatives is variable, that the information shared is often not well understood, and that there is significant distress associated with the sharing of test results on the part of the relatives. These findings suggest that relying on the probands to share their test results with their relatives is fraught with limitations which may compromise the value of the information for the relatives.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-12-05.

Donor-derived Trypanosoma cruzi infection in solid organ recipients in the United States, 2001-2011

Although Trypanosoma cruzi, the parasite that causes Chagas disease, can be transmitted via organ transplantation, liver and kidney transplantation from infected donors may be feasible. We describe the outcomes of 32 transplant recipients who received organs from 14 T. cruzi seropositive donors in the United States from 2001 to 2011. Transmission was confirmed in 9 recipients from 6 donors, including 3 of 4 (75%) heart transplant recipients, 2 of 10 (20%) liver recipients and 2 of 15 (13%) kidney recipients. Recommended monitoring posttransplant consisted of regular testing by PCR, hemoculture, and serology. Thirteen recipients had no or incomplete monitoring; transmission was confirmed in five of these recipients. Four of the five recipients had symptomatic disease and all four died although death was directly related to Chagas disease in only one. Nineteen recipients had partial or complete monitoring for T. cruzi infection with weekly testing by PCR, hemoculture and serology; transmission was confirmed in 4 of 19 recipients with no cases of symptomatic disease. Our results suggest that liver and kidney transplantation from T. cruzi seropositive donors may be feasible when the recommended monitoring schedule for T. cruzi infection is followed and prompt therapy with benznidazole can be administered.