Longer-term safety of alirocumab with 24,610 patient-years of placebo-controlled observation: further insights from the ODYSSEY OUTCOMES trial

Background

In the ODYSSEY OUTCOMES trial (NCT01663402), alirocumab, a monoclonal antibody to proprotein convertase subtilisin/kexin type 9 (PCSK9), lowered low-density lipoprotein cholesterol from ∼2.3 mmol/L to ∼1.0 mmol/L at 4 months, reduced the risk of major adverse cardiovascular events (MACE: coronary heart disease death, nonfatal myocardial infarction, fatal/nonfatal ischemic stroke, unstable angina requiring hospitalization), and was associated with fewer deaths compared with placebo in 18924 patients (pts) with recent acute coronary syndrome followed for up to 5 years (yrs).

Purpose

In the ODYSSEY OUTCOMES trial, the overall safety of alirocumab and placebo was similar, except for an excess of local injection-site reactions with alirocumab. However, the safety among pts eligible for longer follow-up has not been fully explored.

Methods

The present post hoc analyses describe the efficacy and safety of alirocumab in a pre-specified subgroup (for efficacy) of pts eligible for a minimum of 3 and up to 5 yrs of follow-up.

Results

There were 8242 pts (43.5%) eligible for ≥3 yrs follow-up, of whom 8228 received at least one dose of study medication, comprising 24,610 pt-years of observation with a median follow-up of 3.3 yrs; 6651 pts were eligible for 3 up to 4 yrs, and 1574 patients were eligible for 4–5 yrs, follow-up. As previously reported in a pre-specified analysis of this subgroup, alirocumab significantly reduced death (4.7% vs. 5.9%; p=0.01) compared with placebo. In the present post hoc analysis, alirocumab also significantly reduced MACE vs. placebo (12.0% vs. 14.2%; Hazard Ratio 0.83 [95% CI 0.74 to 0.94]; p=0.003). In a safety analysis, 3217 (78.3%) vs. 3303 (80.2%) pts in the alirocumab vs. placebo group had at least one adverse event (AE) of whom 27.5% vs. 29.4% had a serious AE (Fig. 1). The frequency of permanent discontinuation of study drug due to AEs, incident diabetes, diabetes worsening or complications, neurocognitive events, elevations of ALT>3, AST>3, bilirubin>2, and creatine phosphokinase>10 times the upper limit of normal, were similar with alirocumab vs. placebo (Fig. 1). While pt-reported local injection-site reactions occurred more frequently with alirocumab, the Kaplan-Meier cumulative incidence for time to first local injection site reaction in the longer-term follow-up subgroup was <5% over ∼4 yrs, with most occurring within the first 6 months (Fig. 2).

Conclusions

In an 8228-pt subgroup of the ODYSSEY OUTCOMES trial eligible for at least 3, and up to 5 yrs follow-up, the safety of alirocumab was similar to placebo except for an excess of local injection site reactions. This subgroup also derived significant benefit from reduced MACE and death. Thus, alirocumab appears to be both a safe and effective lipid-modifying treatment when used for up to 5 yrs.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Sanofi and Regeneron

UK reporting radiographers' perceptions of AI in radiographic image interpretation - Current perspectives and future developments

INTRODUCTION

Radiographer reporting is accepted practice in the UK. With a national shortage of radiographers and radiologists, artificial intelligence (AI) support in reporting may help minimise the backlog of unreported images. Modern AI is not well understood by human end-users. This may have ethical implications and impact human trust in these systems, due to over- and under-reliance. This study investigates the perceptions of reporting radiographers about AI, gathers information to explain how they may interact with AI in future and identifies features perceived as necessary for appropriate trust in these systems.

METHODS

A Qualtrics® survey was designed and piloted by a team of UK AI expert radiographers. This paper reports the third part of the survey, open to reporting radiographers only.

RESULTS

86 responses were received. Respondents were confident in how an AI reached its decision (n = 53, 62%). Less than a third of respondents would be confident communicating the AI decision to stakeholders. Affirmation from AI would improve confidence (n = 49, 57%) and disagreement would make respondents seek a second opinion (n = 60, 70%). There is a moderate trust level in AI for image interpretation. System performance data and AI visual explanations would increase trust.

CONCLUSIONS

Responses indicate that AI will have a strong impact on reporting radiographers' decision making in the future. Respondents are confident in how an AI makes decisions but less confident explaining this to others. Trust levels could be improved with explainable AI solutions.

IMPLICATIONS FOR PRACTICE

This survey clarifies UK reporting radiographers' perceptions of AI, used for image interpretation, highlighting key issues with AI integration.

AB1244 TOTAL KNEE ARTHROPLASTY IN PATIENTS UNDER 21 YEARS OF AGE: A U.S. NATIONWIDE ANALYSIS

Background

Total knee arthroplasty (TKA) is a procedure rarely performed in patients under 21 years old. However, the number of patients <21 undergoing TKA in the United States (US) is unknown. In one of the largest US studies of an institutional arthroplasty registry, only 19 TKAs were performed in patients <21 out of ~30,000 primary TKAs over 34 years1. While a few national or multi-national studies have been performed outside the US, these studies have small cohorts (~100), making it difficult to determine the indications for TKA in this age group.

Objectives

We identified the number of patients <21 years of age who underwent TKA in a US nationwide dataset. Additionally, we determined the epidemiological characteristics of patients undergoing TKA, including their age, sex, race, indications for surgery, and in-hospital mortality.

Methods

We analyzed the Kids’ Inpatient Database, which is a national weighted sample of all inpatient hospital admissions in the US in patients <21 years old from ~4,200 hospitals in 46 states. We included all admissions from 2000-2016 with a primary procedural code of TKA determined by ICD-9 and 10 codes. Descriptive statistics such as means and percentages, along with 95% confidence intervals were calculated using appropriate sample weights.

Results

The total number of TKAs performed in patients <21 years old from 2000 to 2016 was 1,331 (Table 1). The majority of TKAs performed (n=936; 70.3%) were for treatment of an oncologic disease. The most common diagnosis was malignant tumor (68.7%), followed by osteoarthritis (7.3%) and inflammatory arthritis or juvenile idiopathic arthritis (JIA) (7.0%) (Figure 1). Osteonecrosis accounted for 3.9% of cases, while mechanical complications accounted for 3.3%. Fewer than 2% of cases had an indication of either benign or uncertain tumor, infection, or trauma. The mean age was 14.8 years, and 48.4% of the cohort was female. A higher proportion of the non-tumor cohort was female (57.1%) than the tumor cohort (44.7%). 57.1% of patients in the overall cohort were White, and this proportion was smaller in the tumor group (53.8%) than the non-tumor group (64.9%). No patients died during the inpatient event. 87.8% of TKAs were performed in urban teaching hospitals.

Table 1.

Characteristics of patients <21 undergoing TKA by diagnosis type

VariableOverallN = 1331Non-tumorN = 395TumorN = 936Age, mean (95% CI)14.8 (14.4, 15.2)15.9 (14.7, 17.1)14.3 (14.1, 14.6)Sex: Female, % (95% CI)48.4 (44.9, 51.9)57.1 (49.1, 64.8)44.7 (41.1, 48.3)Race, % (95% CI) White57.1 (52.3, 61.8)64.9 (55.5, 73.3)53.8 (48.4, 59.2) Black13.1 (10.1, 16.9)16.9 (10.1, 27.2)11.5 (8.7, 14.9) Hispanic19.7 (16.6, 23.3)14.3 (9.9, 20.2)22.0 (18.1, 26.6) Asian or Pacific Islander3.4 (2.1, 5.4)**4.6 (2.9, 7.4) Native American0.9 (0.4, 1.9)**** Other5.8 (4.1, 8.1)2.9 (1.3, 6.4)7.0 (4.8, 10.0)Payor, % (95% CI) Medicare1.4 (0.7, 2.9)4.7 (2.2, 9.7)— Medicaid31.1 (27.5, 35.0)28.0 (21.0, 36.3)32.4 (28.3, 36.7) Private57.8 (53.7, 61.7)60.2 (52.1, 67.8)56.7 (52.2, 61.1) Self-pay3.3 (2.3, 4.9)**4.2 (2.7, 6.2) Other6.1 (4.4, 8.3)5.1 (3.0, 8.6)6.6 (4.5, 9.4)Admission type: elective, % (95% CI)85.9 (81.1, 89.6)81.6 (72.6, 88.2)87.7 (82.2, 91.6)

N represents weighted estimate

CI = Confidence Interval

** Per HCUP guidelines, cell sizes ≤10 have been omitted to protect patient confidentiality

Figure 1.

Most common primary diagnoses for TKA in patients <21 years old

The most common primary diagnosis of 1,331 patients <21 undergoing TKA. Bars represent 95% Confidence Intervals. JIA = juvenile idiopathic arthritis.

Conclusion

TKA is a rarely-performed procedure for patients <21 years old in the US; it is mainly performed in urban teaching centers and has excellent in-hospital survival rates. 70.3% of these procedures are performed for tumors—the vast majority of which are malignant. Also, even with the advent of better treatment options for JIA and inflammatory arthritis, TKA is still performed frequently in this population indicating that better clinical management is needed.

References

[1]Martin JR et al. Adolescent total knee arthroplasty. PMCID: PMC5484984

Acknowledgements

This work was supported by the Kellen Scholar Award supported by the Anna Marie and Stephen Kellen Foundation Total Knee Improvement Program. The authors would like to acknowledge the Healthcare Cost and Utilization Project Data Partners that contribute to Healthcare Cost and Utilization Project: Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, District of Columbia, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin, Wyoming.

Disclosure of Interests

J. Alex Gibbons: None declared, Cynthia Kahlenberg: None declared, Deanna Jannat-Khah Shareholder of: AstraZeneca, Cytodyn, and Walgreens, Susan Goodman Consultant of: UCB, Grant/research support from: Novartis, Peter Sculco Consultant of: Intellijoint Surgical, DePuy Synthes, Lima Corporate, Zimmer Biomet, and EOS Imaging, Grant/research support from: Intellijoint Surgical and Zimmer Biomet, Mark Figgie Shareholder of: HS2, Mekanika, and Wishbone, Consultant of: Lima and Wishbone, Bella Mehta Paid instructor for: Novartis

AB1465 BLACK PATIENTS ARE LESS SATISFIED WITH THE PROCESS OF CARE FOLLOWING PRIMARY HIP AND KNEE ARTHROPLASTY: A RETROSPECTIVE STUDY

Background

Patients’ post-operative satisfaction with their hospital experience is important to patient care, hospital reimbursement, and comparison between hospitals. The Press Ganey (PG) inpatient survey is commonly administered to assess patient satisfaction with the process of care. However, whether patient PG survey scores following primary unilateral hip and knee arthroplasty are associated with a patient’s race and socioeconomic status (SES) is unknown.

Objectives

We aimed to determine whether patient PG survey overall assessment scores differ by race and SES.

Methods

We linked data for patients in large institutional hip and knee arthroplasty registries consisting of surgeries from July 2010–February 2012 to their PG survey responses. Patients undergoing primary unilateral surgery of Black or White race who resided in New York, New Jersey, or Connecticut at the time of surgery were included in the analysis. The primary outcome variable was the PG overall assessment score, calculated as the mean of a patient’s ratings for the three questions in the “Overall Assessment” section of the PG survey and dichotomized as either completely satisfied (score of 100) or not completely satisfied (score <100). Primary payor was used as a proxy for patient SES. Multivariable logistic regression was performed for the hip and knee cohorts separately to determine if patient race and primary payor were associated with not being completely satisfied, adjusting for age, sex, and American Society of Anesthesiology (ASA) score.

Results

There were 2,516 hip patients and 2,113 knee patients with PG overall assessment scores included in the analyses (Table 1). Black patients were more likely to be not completely satisfied compared to White patients in both cohorts [hip (odds ratio (OR)=1.64; 95% confidence interval (CI): 1.03, 2.61; p=0.04)]; [knee (OR=1.83; 95% CI: 1.16, 2.88; p=0.01). In the hip cohort, patients between 70-79 years old (OR=1.71; 95% CI: 1.09, 2.67; p=0.02) and older than 80 years (OR=2.00; 95% CI: 1.20, 3.32; p<0.01) were more likely to be not completely satisfied. In the knee cohort, patients 50-59 years old (OR=0.56; 95% CI: 0.33, 0.97; p=0.04) and 60-69 years old (OR=0.57; 95% CI: 0.33, 0.96; p=0.03) were less likely to be not completely satisfied compared to patients <50 years old.

Table 1.

Likelihood of not being completely satisfied with the process of care (PG score <100)

VariableReferenceCategoryHip Cohort (n = 2,516)Knee Cohort (n = 2,113)Odds Ratio95% CIp-valueOdds Ratio95% CIp-valueAge Group<5050-591.02(0.69, 1.50)0.9390.56(0.32, 0.97)0.039<5060-691.04(0.70, 1.54)0.8580.57(0.33, 0.96)0.034<5070-791.71(1.09, 2.67)0.0190.63(0.36, 1.11)0.113<5080+2.00(1.20, 3.32)0.0080.97(0.53, 1.77)0.912SexFemaleMale0.84(0.69, 1.02)0.0821.03(0.83, 1.26)0.816RaceWhiteBlack1.64(1.03, 2.61)0.0381.83(1.16, 2.88)0.010ASA status121.04(0.70, 1.55)0.8321.23(0.60, 2.51)0.580131.45(0.91, 2.29)0.1161.36(0.64, 2.87)0.41914<0.01(0.00, ***)0.968<0.01(0.00, ***)0.977Primary PayorMedicareMedicaid1.35(0.26, 7.01)0.718<0.01(0.00, ***)0.983MedicareOther/Unknown1.24(0.94, 1.64)0.1260.87(0.65, 1.17)0.362MedicarePrivate1.13(0.61, 2.10)0.6881.01(0.57, 1.78)0.983

ASA = American Society of Anesthesiologist (ASA) physical status classification. PG = Press Ganey. CI = Confidence Interval. *** indicates >999.99. Bold indicates p < 0.05

Conclusion

Black patients were less likely to be completely satisfied compared to White patients following total hip and knee arthroplasty. More research is needed to investigate other factors such as perceived staff courtesy and baseline pain and function to understand why these disparities exist.

Acknowledgements

This work was supported by the Stavros Niarchos Complex Joint Reconstruction Center at Hospital for Special Surgery. The content is solely the responsibility of the authors and does not necessarily represent the official views of the center.

Disclosure of Interests

J. Alex Gibbons: None declared, Orett Burke Jr: None declared, Huong Do: None declared, Emily Ying Lai: None declared, Bella Mehta Paid instructor for: Novartis, Letitia Bradford: None declared, Michael Parks Consultant of: ZimmerBiomet, Linda Russell: None declared, Anne Bass: None declared, Mark Figgie Shareholder of: HS2, Mekanika, and Wishbone, Consultant of: Lima and Wishbone, Susan Goodman Consultant of: UCB, Grant/research support from: Novartis

POS0040-HPR PATIENT PERCEPTIONS OF IMPACT OF GLUCOCORTICOID THERAPY IN THE RHEUMATIC DISEASES: INTERNATIONAL DEVELOPMENT OF A TREATMENT-SPECIFIC PATIENT REPORTED OUTCOME MEASURE

Background

Glucocorticoids (GCs) are a key treatment for inflammatory rheumatic diseases, but they cause a wide range of adverse side-effects which are of concern both to patients and clinicians.

Objectives

The objective of this study was to explore the impact of GC therapy on health-related quality of life (HRQoL) during treatment for rheumatic diseases, as a basis for development of a Patient-Reported Outcome Measure (PROM) to be used in clinical trials and practice.

Methods

Patients from the UK, USA and Australia who were treated with GCs in the last two years for a rheumatic condition were invited to take part in semi-structured qualitative interviews. Purposive sampling was used to include participants with a range of demographic and disease features. A steering committee of patient research partners, clinicians and methodologists devised an initial conceptual framework, which informed interview prompts and cues. Interviews were carried out by experienced qualitative researchers who encouraged participants to tell their stories and talk about the effects, both adverse and beneficial, of their experiences and perceptions of treatment with GCs, to identify salient physical and psychological symptoms and aspects of HRQoL. The interview data were organised using NVivo, and inductive analysis identified initial themes and domains. Candidate questionnaire items were developed and refined using cognitive interviewing, linguistic assessment, and input from patient research partners.

Results

Sixty semi-structured qualitative interviews were conducted (UK n=34, USA n=10, Australia n=16). Mean participant age was 58 years; 39 (66.1%) were female. Purposive sampling of participants provided a broad range of demographic features, GC dosages and inflammatory rheumatic conditions, with 27% having connective tissue disease, 25% inflammatory arthritis, 30% systemic vasculitis and 16% other rheumatic conditions.

Initial domains were developed to identify key themes relating to treatment using GCs and their impact on HRQoL; see Figure 1.

Figure 1.

Steroid PRO Initial Themes

A long-list of 134 initial candidate questionnaire items was developed from the individual themes. These items were reviewed by a qualitative working group of patient research partners, researchers and clinicians to reduce duplication and ambiguity of items. The resulting 62 items were tested and refined by piloting with patient research partners, iterative rounds of cognitive interviews with patients with a range of rheumatic conditions from the UK, USA and Australia, and a linguistic translatability assessment, to define a draft questionnaire of 40 items.

Conclusion

This international qualitative study underpins the development of candidate items for a treatment-specific PROM for patients with rheumatic diseases. The draft questionnaire is currently being tested in an online large-scale survey to determine the final scale structure and measurement properties using Rasch analysis, factor analysis, test-retest, comparison with EQ5D, and known groups analysis.

Disclosure of Interests

Susan Bridgewater Grant/research support from: Vifor Pharma, Michael A Shepherd Grant/research support from: Vifor Pharma, Jill Dawson: None declared, Pamela Richards: None declared, Christine Silverthorne: None declared, Mwidimi Ndosi: None declared, Celia Almeida: None declared, Rachel J Black: None declared, Jonathan T.L. Cheah: None declared, Emma Dures: None declared, Nilasha Ghosh: None declared, Elizabeth A Hoon: None declared, Suellen Lyne: None declared, Iris Navarro-Millan Consultant of: Honorarium on Swedish Orpham Biovitrum (SOBI) advisory board 2021, Diyu Pearce-Fisher: None declared, Carlee Ruediger: None declared, Joanna Tieu: None declared, Kevin Yip: None declared, Sarah Mackie: None declared, Susan Goodman: None declared, Catherine Hill: None declared, Joanna Robson Speakers bureau: EULAR Symposium 2021 for Vifor Pharma, Consultant of: Honorarium for Vifor Pharma advisory board 2021, Grant/research support from: Vifor Pharma 2020-2022

OP0223 DISTINGUISHING OSTEOARTHRITIS AND RHEUMATOID ARTHRITIS SYNOVIUM WITH MACHINE LEARNING USING AUTOMATED CELL DENSITY AND PATHOLOGIST SCORES

Background

Joint damage in the knee can be severe in both rheumatoid arthritis (RA) and osteoarthritis (OA) such that total knee replacement (TKR) is often the only management option. Pathological assessment of the extent or type of synovial tissue inflammation from joint explants or biopsies can be useful. However, an ongoing challenge in using semi-quantitative assessments of synovitis is the disagreement between human pathologist scores of the same sample. We previously developed and validated a computer vision algorithm to automatically count each cell nucleus in an H&E-stained synovial whole slide image and yield a value of cell density, defined as mean nuclei count per mm2 of tissue1.

Objectives

We sought to develop methods to distinguish OA from RA based on machine learning analysis of histologic features on H&E-stained synovial tissue samples.

Methods

We measured 14 pathologist-scored histology features (137 RA and 152 OA patients) and computer vision quantified cell density (60 RA and 147 OA patients) in H&E stained synovial tissue samples from total knee replacement arthroplasty explants. A random forest model was trained using disease state (OA vs RA) as classifier and histology features and/or cell density as inputs, and feature importance scores for the model were calculated.

Results

Synovium from patients with RA exhibited increased lymphocytic inflammation, lining hyperplasia, neutrophils, detritus, plasma cells, Russell bodies, binucleate plasma cells, sub-lining giant cells, synovial lining giant cells, and fibrin (all p<0.001), while synovium from patients with OA had increased mast cells and fibrosis (both p<0.001). Fourteen pathologist-scored features allowed for discrimination between RA and OA samples, producing a macro-averaged area under the receiver operating curve (AUC) of 0.85. This discriminatory ability was comparable to that of the computer vision score of cell density alone (AUC = 0.88). Combining the pathologist scores with the cell density metric improved the discriminatory power of the model (AUC = 0.91). The three most important features in this combined model were mast cells followed by cell density and fibrosis (Figure 1). AUC values for each individual feature are provided in Table 1. The optimal cell density threshold to distinguish RA from OA synovium was 3,400 cells per mm2, which yielded a sensitivity of 0.82 and specificity of 0.82.

Table 1.

Area under receiver operating characteristic curves (AUC) of the synovial features in distinguishing RA and OA patients

FeatureAUCAutomated Cell Density0.88Fibrosis0.84Mast cells0.80Lining hyperplasia0.78Lymphocytic inflammation0.69Fibrin0.68Plasma cells0.66Detritus0.64Binucleate plasma cells0.60Neutrophils0.60Synovial giant cells0.58Sub-lining giant cells0.57Russell bodies0.56Germinal centers0.51Mucoid change0.50Figure 1.

Importance of synovial features in distinguishing RA and OA synovium

Feature importance scores for supervised machine learning model including all 14 pathology scores and the computer vision-generated cell density.

Conclusion

H&E-stained images of RA and OA TKR explant synovium are distinct. We identified cell density, mast cells and fibrosis as the three most important features for making this distinction, with RA being characterized by increased cell density, low mast cells, and low fibrosis. Cell density greater than 3400 per mm2 of tissue yields a sensitivity of 0.82 and a specificity of 0.82 for distinguishing RA from OA. In the future, this can have clinical and research applications as this technique removes the requirement for subjective selection of a certain field of interest, is reproducible, and is scalable as it does not require technical expertise of a pathologist.

References

[1]Guan S, Mehta B…Orange DE. Rheumatoid Arthritis Synovial Inflammation Quantification Using Computer Vision. ACR Open Rheumatology. 2022 Jan 10;acr2.11381.

Acknowledgements

This work was supported by the C. Ronald MacKenzie Young Scientist Endowment Award, the Leon Lowenstein Foundation, and the Kellen Scholar Award supported by the Anna Marie and Stephen Kellen Foundation Total Knee Improvement Program.

Disclosure of Interests

Bella Mehta Paid instructor for: Novartis, Susan Goodman Consultant of: UCB, Grant/research support from: Novartis, Edward DiCarlo: None declared, Deanna Jannat-Khah Shareholder of: AstraZeneca, Cytodyn, and Walgreens, J. Alex Gibbons: None declared, Miguel Otero Consultant of: Regeneron Pharmaceuticals, Grant/research support from: Tissue Genesis, Laura Donlin Speakers bureau: Stryker, Consultant of: Stryker, Grant/research support from: Karius, Inc, Tania Pannellini: None declared, William Robinson: None declared, Peter Sculco Consultant of: Intellijoint Surgical, DePuy Synthes, Lima Corporate, Zimmer Biomet, and EOS Imaging, Grant/research support from: Intellijoint Surgical and Zimmer Biomet, Mark Figgie Shareholder of: HS2, Mekanika, and Wishbone, Consultant of: Lima and Wishbone, Jose Rodriguez Consultant of: ConforMIS, Medacta, Exactech, Inc, and Smith & Nephew, Grant/research support from: DePuy, Exactech, Inc, and Smith & Nephew, Jessica Kirschmann: None declared, James Thompson: None declared, David Slater: None declared, Damon Frezza: None declared, Zhenxing Xu: None declared, Fei Wang: None declared, Dana Orange: None declared

POS0417 LESS ACPA EPITOPE EXPANSION IS FOUND IN ACPA-POSITIVE IMMUNE CHECKPOINT INHIBITOR ARTHRITIS PATIENTS COMPARED TO ACPA-POSITIVE RHEUMATOID ARTHRITIS PATIENTS

Background

Immune checkpoint inhibitors (ICI) have markedly improved the treatment of many advanced cancers; however, they can result in immune-related adverse events (irAE) including ICI arthritis (ICI-A). ICI-A often resembles rheumatoid arthritis (RA) and ~9% of ICI-A patients are anti-citrullinated peptide antibody (ACPA) positive. In RA, ACPA epitope expansion occurs over the years prior to onset of clinical disease. In this study we examined the degree of ACPA epitope expansion in seropositive ICI-A patients in order to determine whether it is similar to early RA, or more suggestive of the pre-clinical phase of disease1.

Objectives

To compare the number of ACPA epitopes targeted in seropositive ICI-A versus RA.

Methods

We used clinical data and serum from 12 ACPA+ ICI-A patients enrolled in a prospective registry and 39 ACPA+ RA patients enrolled in the CATCH-US early RA cohort. ACPA screening was done using a commercial ELISA (positive >20 units/mL). A custom, bead-based antigen array was used to identify antibody reactivities to 16 putative RA associated citrullinated proteins. Synovial fluid (SF) samples from 3 of the ICI-A patients were also tested using the bead-based microarray. Hierarchical clustering software was used to create heatmaps to identify ACPA levels. Z-scores for fluorescence intensity were also calculated separately for each peptide, and a fluorescence level above the mean (Z-score>0) was defined as a positive ACPA. The number of positive epitopes for each patient was determined and compared categorically between the ICI-A and RA patients using Fischer’s exact test.

Results

Characteristics of ICI-A and early RA patients are listed in Table 1. Compared to RA patients, ICI-A patients were older (mean 71 years vs. 48 years), more likely to have ever smoked (67% vs. 36%) and less likely to have positive rheumatoid factor (RF) (8% vs. 69%). Median symptom duration for ICI-A patients was 3.7 months compared to 6.7 months in RA patients. The median ACPA titer was lower in ICI-A patients than RA patients (42 units/mL vs. 250 units/mL). As demonstrated in Figure 1, lower signal intensities (level of ACPA) and a lower number of distinct ACPA epitopes were seen in the serum of ICI-A patients compared to RA patients. Of ICI-A patients, 67% were positive for 0-4 ACPA epitopes, 8% for 5-10 epitopes and 25% for >10 epitopes, as opposed to 23% of RA patients positive for 0-4 epitopes, 36% for 5-10 epitopes, and 41% for >10 epitopes (p=0.02). The one ICI-A patient who was also RF positive had 12 positive ACPA epitopes. There was no significant difference in the number of ACPA epitopes in ICI-A patients who were smokers vs. nonsmokers, RA-like vs. PMR-like, or who received ICI combination vs. ICI monotherapy. In the 3 ICI-A patients with synovial fluid samples, SF ACPA was not demonstrated.

Table 1.

Baseline Characteristics of ACPA+ ICI-A and RA Patients

ICI-A (N=12)Early RA (N=39)Age in years, mean (SD)71.0 (8.3)48.2 (14.6)Female Sex7 (58%)33 (85%)White/Caucasian9 (75%)27 (69%)Symptom Duration in months, median [IQR]3.7 [1.0,11.3]6.7 [4.0,9.7]RF Positive1 (8%)27 (69%)ACPA level (units/mL), median [IQR]42.2 [29.4,70.5]250 [107.5,251.0]Obese (BMI≥30)3 (25%)9 (23%)Current/Past Smoker8 (67%)14 (36%)Cancer Typeǂ Melanoma4 (33%) Renal Cell Carcinoma3 (25%)ICI Regimen PD-1/PD-L17 (58%) CTLA-4+PD-15 (42%)ICI-A Phenotype RA-like9 (75%) PMR-like3 (25%)

ǂOther cancer types in ICI-A patients included urothelial carcinoma (n=2), non-small cell lung cancer (n=2), and head and neck cancer (n=1).

Figure 1.

Heat Map of ACPA repertoire in RA Patients and ICI-A Patients.

Conclusion

ICI-A patients had lower ACPA titers and targeted fewer ACPA epitopes than early RA patients. It remains to be determined if ICI-A represents an accelerated model of RA pathogenesis with ICI triggering an early transition from pre-clinical to clinical disease. This would require sequential sampling and analysis.

References

[1]Sokolove J. et al. PLoS One. 2012;7(5)e35296

Disclosure of Interests

Diviya Rajesh: None declared, Nilasha Ghosh: None declared, Jessica Kirschmann: None declared, Karmela Kim Chan: None declared, Deanna Jannat-Khah Shareholder of: AstraZeneca, Walgreens, and Cytodyn, Susan Goodman Consultant of: UCB Data Monitoring and Safety Board, Grant/research support from: Novartis, Vivian Bykerk Consultant of: Amgen, Bristol Myers Squibb, Genzyme, Gilead, Janssen, Pfizer, Sanofi-Aventis, and UCB, Grant/research support from: Bristol Myers Squibb, Amgen, and The Cedar Hill Foundation, William Robinson: None declared, Anne Bass: None declared.

POS0402 CLONALLY EXPANDED CD38hi CYTOTOXIC CD8 T CELLS DEFINE THE T CELL INFILTRATE IN CHECKPOINT INHIBITOR-ASSOCIATED ARTHRITIS

Background

Immune checkpoint inhibitor (ICI) therapies that promote T cell activation have improved outcomes for advanced malignancies yet can also elicit harmful autoimmune reactions. The T cell mechanisms mediating these iatrogenic autoimmune events remain unclear.

Objectives

To investigate the immunophenotype, transcriptomic feature and clonotypes of T cells from joints of patients affected by ICI-induced inflammatory arthritis (ICI-arthritis).

Methods

Detailed immunophenotyping was performed on mononuclear cells from synovial fluid (SF) using mass cytometry and flow cytometry to identify significantly altered populations in ICI-A compared to seropositive rhrumatoid arthritis (RA) and psoriatic arthritis (PsA) (p<0.05). Bulk RNA-seq was performed on altered SF CD8 T cell subsets from ICI-A, RA and PsA to investigate their transcriptomic features. Cytokine profile and pathways enriched in ICI-A CD8 T cells were examined using differentially expressed genes, intracellular staining, and in vitro culture. TCR clonotypes were examined using single cell RNA-seq of T cells from synovial fluid, tissue and blood of ICI-A.

Results

Compared to the autoimmune arthritides RA and PsA, ICI-arthritis joints contained an expanded CD38hi CD127- CD8+ T cell subset that displays cytotoxic, effector, and interferon (IFN) response signatures. Exposure of synovial T cells to Type I IFN, more so than IFN-γ, induced the CD38hi cytotoxic phenotype. Single cell transcriptomic and T cell repertoire (TCR) analyses indicated that the abundance of CD38hi CD8 T cells in ICI-arthritis resulted from proliferation of a limited number of clones. The CD38hi population appeared distinct from dysfunctional T cells and clonally most related to TCF7+ memory populations. Comparison of synovial tissue from bilateral knees of the same patient demonstrated considerable sharing of TCR clonotypes among CD38hi CD8 T cells between the two joints. Further, TCR clonotypes expanded in synovial fluid of ICI-arthritis patients were detected in circulating T cells, and circulating CD38hi CD8 T cells are also expanded in ICI-arthritis patients.

Conclusion

These results define a distinct CD8 T cell subset in the synovial fluid and in the circulation of patients with ICI-A that may be directly activated by ICI therapy to mediate a tissue-specific autoimmune response.

Disclosure of Interests

None declared.

OP0124 FETAL AND MATERNAL MORBIDITY IN PREGNANT SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) PATIENTS: A 10-YEAR U.S. NATIONAL STUDY

Background

Systemic lupus erythematosus (SLE) is an autoimmune disorder that affects women in their childbearing years. Previously, we demonstrated that fetal and maternal mortality has declined in SLE patients over the years, however little is known about morbidity (1).

Objectives

To determine the proportion of fetal and maternal morbidity in SLE deliveries compared to non-SLE deliveries in a US nationwide study over a decade.

Methods

We used retrospective data from the National Inpatient Sample database to identify all delivery related hospital admissions of patients with and without SLE from 2008 to 2017 using ICD-9 (710.0) and 10 (M32*) codes. Fetal morbidity indicators included preterm delivery and intrauterine growth restriction. 21 indicators of severe maternal morbidity were identified using the standard CDC definition: these are unexpected outcomes of labor and delivery that result in significant short- or long- term consequences to a woman’s health (2). Descriptive statistics and their 95% confidence intervals were calculated using sample weights from the dataset.

Results

Among the 40 million delivery-related admissions, 51,161 patients (10,297 unweighted) were reported to have SLE. SLE patients were more likely to be older and have more comorbidities compared to non-SLE patients (Table 1). Patients with SLE had a higher risk of fetal morbidity, including intrauterine growth restriction (8.0% vs 2.7%) and preterm delivery (14.5% vs 7.3%) than patients without SLE. Amongst the CDC maternal morbidity indicators - SLE patients faced a greater risk of blood transfusion, puerperal cerebrovascular disorders, acute renal failure, eclampsia or DIC, cardiovascular and peripheral vascular disorders, and general medical issues than those without SLE (Figure 1).

Table 1.

Characteristics for deliveries of patients with and without Systemic Lupus Erythematosus

SLE deliveriesNon-SLE deliveriesPercent (%)(95 %CI)Percent (%)(95 %CI)N51,161* (10,297 unweighted)(49,419.14, 52,903.37)40,000,000* (8,055,025 unweighted)(39,200,000; 40,700,000)Age (years)30.05(29.92, 30.18)28.19(28.14, 28.24)RaceWhite46.15(44.83, 47.47)52.43(51.74, 53.11)African American24.68(23.55, 25.85)15.01(14.62, 15.42)Hispanic18.48(17.40, 19.60)21.45(20.81, 22.10)Other10.69(9.93, 11.50)11.11(10.76, 11.47)InsuranceMedicare5.32(4.83, 5.86)0.7(0.66, 0.75)Medicaid38.2(37.00, 39.41)43.79(43.20, 44.39)private insurance51.84(50.55, 53.13)49.8(49.15, 50.45)self-pay1.39(1.13, 1.70)2.74(2.57, 2.92)no charge0.04(0.02, 0.12)0.13(0.09, 0.18)other3.21(2.84, 3.63)2.84(2.73, 2.95)Elixhauser00(*no obs)80.56(80.32, 80.80)1 to 497.84(97.50, 98.12)19.4(19.16, 19.64)5+2.16(1.88, 2.50)0.04(0.03, 0.04)

*Population weighted values are listed.

Figure 1.

Fetal and severe maternal morbidity outcomes in Systemic Lupus Erythematosus (SLE) and non-SLE patients. Cardiovascular and peripheral vascular disorders include acute myocardial infarction, aneurysm, amniotic fluid embolism, cardiac arrest/ventricular fibrillation, heart failure, pulmonary edema/acute heart failure, sickle cell disease with crisis, air and thrombotic embolism, and conversion of cardiac rhythm. General medical issues include hysterectomy, shock, sepsis, adult respiratory distress syndrome, and severe anesthesia complications, temporary tracheostomy, and ventilation.

Conclusion

Our study demonstrates that fetal morbidity and severe maternal morbidity occur at a higher rate in patients with SLE compared to those without, even in this most recent decade. This work can help inform physicians to counsel and manage patients with SLE during pregnancy and its planning.

References

[1]Mehta B, et al. Trends in Maternal and Fetal Outcomes Among Pregnant Women With Systemic Lupus Erythematosus in the United States: A Cross-sectional Analysis. Ann Intern Med.

[2]https://www.cdc.gov/reproductivehealth/maternalinfanthealth/severematernalmorbidity.html

Acknowledgements

This work was supported by the Dean’s Diversity Award at Weill Cornell Medicine.

Disclosure of Interests

Bella Mehta Speakers bureau: Novartis and Jassen, Katharine Kayla J Glaser: None declared, Deanna Jannat-Khah Shareholder of: Cytodyn, AstraZeneca, and Walgreens, Yiming Luo: None declared, Lisa Sammaritano: None declared, Jane E. Salmon: None declared, Susan Goodman Consultant of: UCB, Grant/research support from: Novartis, Employee of: Current Rheumatology Report (section editor), Fei Wang: None declared

Abstract P5-19-01: The impact of streamlined processes and patient-directed messaging to improve enrollment in a remote, pragmatic clinical trial

Background Recent advances in technology have made it possible to conduct remote clinical trials that allow individuals to participate from home with comfort, privacy, and ease. Despite these advances, challenges persist in running remote trials, such as survey question redundancies, lack of patient-initiated data-sharing tools, and unclear patient communication around critical enrollment steps. The Women Informed to Screen Depending on Measures of risk (WISDOM) Study is a pragmatic, preference-tolerant randomized control breast cancer screening trial comparing personalized risk-based screening to traditional, annual screening. The study population includes women ages 40-74 without a history of breast cancer or DCIS. Since 2016, study enrollment has been available to all women in the U.S. who meet study eligibility criteria. Since October 2020, WISDOM has implemented multiple strategies to improve participant experience: participant-initiated data-sharing tools and clear participant messaging. This abstract presents the efficacy of these interventions as they relate to increasing patient enrollment in remote, pragmatic clinical trials. Methods The WISDOM Study online enrollment process includes registration, participant study arm selection or randomization, online consent, and enrollment (submission of multiple study surveys over a secure, online platform). Barriers to online enrollment were uncovered through an internally-conducted needs assessment of participants who enrolled between 2019-2020, and participant feedback obtained through phone interviews conducted by WISDOM’s embedded ethics study. Improvements to our online enrollment procedures were executed in October 2020 and included: improving the clarity of study arm selection options, streamlining data collection surveys, and enacting a secure, patient-initiated online data-sharing tool and an online portal feature with auto-launch of critical information. Study metrics were obtained through Google Analytics and Salesforce. Results Prior to the end of 2020, only 62% of the 30,046 participants who registered for the WISDOM Study completed study enrollment. After improving the enrollment process, of the 5,334 participants registered for the study between Jan-June 2021, 69% completed the enrollment process finishing both the online consent and survey forms. Conversion from consent to enrollment went from 78% in January 2020 to 93% in June 2021. Currently, 56% participants complete enrollment in one day. Streamlining online patient questionnaires led to an increase in completion rates, with 75% of participants completing their yearly surveys, compared to 59% prior to April 2021. A secure patient upload feature for data sharing led to 1,054 participants successfully sharing their mammogram reports with WISDOM between March - June 2021. Previously, mammogram reports were missing for 20% of enrolled participants. This feature has enabled WISDOM to process 300 additional mammogram reports per month. Integration of an auto-launch feature in the participant’s portal in Feb 2021 has led to a 17% increase in participants viewing their screening recommendations in Yr 1. Prior to auto-launch, only 59% (n=6328) of Yr 1 screening recommendations and 61% (n=3681) of genetic testing reports were viewed by participants. Since implementation, the numbers increased to 78% (n=8406) and 85% (n=5160), respectively. Conclusions. Streamlining data to the most essential elements, and minimizing the steps required to share clinical documents, complete questionnaires and open key study notification is essential to improving enrollment rates in virtual, pragmatic trials. Patient-initiated data-sharing tools such as the ability for participants to share documents through secure, online portals is one example of success.

Citation Format: Patricia Choy, Tomiyuri Lewis, Stephanie Flores, Leah Sabacan, Halle Thannickal, Steffanie Goodman, Yiwey Shieh, Lisa Madlensky, Jeffrey A. Tice, Elad Ziv, Martin Eklund, Amie Blanco, Barry Tong, Deborah Goodman, Nancy Anderson, Heather Harvey, Steele Fors, Hannah Lui Park, Antonia Petruse, Skye Stewart, Samrrah Raouf, Janet Wernisch, Barbara Koenig, Celia Kaplan, Robert Hiatt, Neil Wenger, Vivian Lee, Diane Heditsian, Susie Brain, Dolores Moorehead, Barbara A Parker, Alexander Borowsky, Hoda Anton-Culver, Arash Naeim, Andrea Kaster, Laura van 't Veer, Andrea Z LaCroix, Olufunmilayo I. Olopade, Deepa Sheth, Agustin Garcia, Rachel Lancaster, Jennifer James, Galen Joseph, Wisdom Study, Athena Breast Health Network Investigators and Advocates, Allison Stover Fiscallini, Laura Esserman. The impact of streamlined processes and patient-directed messaging to improve enrollment in a remote, pragmatic clinical trial [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P5-19-01.

Racial/ethnic differences in cardiovascular outcomes in a universal healthcare system: insights from the CARTaGENE cohort

Background

While prior studies have shown racial/ethnic differences in cardiovascular (CV) outcomes within private or mixed health care systems, it remains uncertain whether inequalities in cardiovascular outcomes exist between different races and ethnicities in universal health care contexts. We aimed to determine whether there are racial/ethnicity disparities in long-term CV outcomes within a single-payer universal health care system.

Methods

The CARTaGENE study is a population-based prospective cohort study with enrollment of 19,996 individuals between 40–69 years in 2009, in the province of Quebec, Canada. Participants residing in four large metropolitan areas were randomly chosen from the provincial health insurance registry by strata of age, sex, and postal codes. Follow-up was available up to 2016. For this analysis, we retained only participants without prior known CV disease. The primary composite endpoint was time to the first CV event or intervention (CV death, acute coronary syndrome, heart failure, coronary revascularization, ischemic stroke, or peripheral vascular event or revascularization). We used unadjusted and adjusted Cox proportional hazard models to evaluate the association of self-defined race/ethnicity with the primary endpoint.

Results

There were 17,802 eligible participants with a mean age of 51 years (52.5% females) with 111,312 person-years of follow-up (median follow-up of 6.6 years). South Asian (SA) participants had the highest prevalence of diabetes mellitus (29%) and hypertension (32%). After adjustment for age and sex, SA ethnicity was associated with a 95% relative increase in risk for CV events, while East/Southeast Asian (ESA) ethnicity was associated with a 42% relative decrease in risk for CV events compared to White participants. After further adjustment for socioeconomic status and CV risk factors, ESA ethnicity remained associated with a similar decreased CV risk. In contrast, the association of SA ethnicity with increased CV risk was attenuated after full adjustment for baseline characteristics (Table 1).

Conclusions

Racial/ethnic disparities in long-term CV outcomes are present in a single-payer universal healthcare setting. ESA ethnicity was associated with a lower risk of long-term CV outcomes. Future studies are needed to corroborate the reduced risk of long-term major CV events associated with ESA ethnicity. Understanding the reasons related to potential CV protection with ESA ethnicity could facilitate endeavors to reduce long-term CV outcomes in other races/ethnicities.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): McGill Health University Center

COVID-19 PANDEMIC INDUCED DISRUPTIONS IN TROPONIN AND LOW-DENSITY LIPOPROTEIN CHOLESTEROL LABORATORY TEST VOLUMES ACROSS ALBERTA

BACKGROUND

Atherosclerotic cardiovascular disease (ASCVD) is a leading cause of morbidity and mortality in Canada and worldwide. Laboratory tests, including troponin and low-density lipoprotein cholesterol (LDL-C), are important biomarkers of ASCVD risk. The objective of this study was to investigate patterns of testing for troponin and LDL-C test volumes among Alberta residents during the coronavirus disease 2019 (COVID-19) pandemic.

METHODS AND RESULTS

A repeated cross-sectional study design captured population-level laboratory test volumes between March 15, 2019 and December 14, 2020. Three-month cross-sections were derived to report laboratory test volumes by different COVID-19 restriction periods during 2020-2021 and using 2019-2020 as a preceding control period. Percent change for troponin and LDL-C test volumes were calculated for both control and COVID-19 periods among adult (≥18 years of age) Alberta residents, and stratified by age (18-49, 50-65, 66-79, and ≥80 years), sex, and geographic zones (urban, rural). This preliminary data is part of an ongoing study for which further troponin and LDL-C test volumes will be available up until March 14, 2021 (representing one year of data throughout the COVID-19 pandemic). Among the Alberta population, 292,836 troponin and 794,789 LDL-C tests were captured between March 15, 2020 and December 14, 2020 (Figure 1). Testing patterns during the COVID-19 restriction period showed marked reduction in test volumes from the previous year. The initial cross-section of the COVID-19 period (March-June 2020) was characterized by the largest overall reduction with troponin test volumes decreasing 18% and LDL-C test volumes decreasing 63%, compared to the year prior. As restrictions eased in the summer months of 2020, testing volumes rebounded to near pre-pandemic volumes for both tests. However, in the fall of 2020, troponin tests decreased again (-15%). Within these drops in utilization, slightly larger relative declines were observed for troponin test volumes in women (-20%) and patients ≥80 years-old (-25%) and for LDL-C test volumes among urban residents (-64%), women (-67%) and patients aged 18-49 (-66%) and 50-65 (-65%) years (Table 1).

CONCLUSION

This study describes declines in troponin and LDL-C test volumes in the initial and second COVID-19 lockdown periods. Women had overall smaller total troponin and LDL-C test volumes and larger relative declines during the pandemic compared to men. The decrease in these ASCVD-related laboratory test volumes during the pandemic may have been accompanied by other important changes in indicators of healthcare utilization and associated clinical outcomes. Ongoing analyses will further explore the impact of the pandemic.

POS0480 ASSOCIATION OF NEUTROPHIL LYMPHOCYTE AND PLATELET LYMPHOCYTE RATIOS WITH JOINT INFLAMMATION IN RHEUMATOID ARTHRITIS

Background:

Some patients with rheumatoid arthritis (RA) have high disease activity scores (DAS) and low synovial inflammation, and others have high synovial inflammation and low DAS (subclinical synovitis)[1]. It would be clinically useful to identify blood biomarkers of synovial inflammation. Neutrophil-lymphocyte (NLR) and platelet-lymphocyte ratios (PLR) have been reported to distinguish RA patients with moderate/high DAS28 scores from low DAS28 [2]. However, it is not known if these inexpensive, accessible tests are associated with inflammation in synovial tissue at the histological level.

Objectives:

The objective of this study was to evaluate the relationship of pre-operative NLR and PLR with synovial inflammation of the operative joint in RA patients undergoing arthroplasty.

Methods:

230 patients meeting ACR/EULAR 1987 and/or 2010 criteria were recruited prior to elective total hip, knee, shoulder, and elbow replacement. Demographics, RA characteristics, medications, disease activity, and routine tests including complete blood tests (CBC) were collected pre-operatively. Hematoxylin and eosin (H&E) stains were prepared from the synovium of the operative joint and systematically scored by a pathologist as described previously [3]. Synovial lymphocytic inflammation was graded as none, mild, moderate, marked, or band-like. Linear regression was performed to distinguish differences in the NLR, PLR, and CRP in patients with synovial lymphocytic inflammation (SLI).

Results:

As expected, patients on glucocorticoids (GCs) had higher NLR (mean 5.52 (SD 7.68) vs mean 2.82 (SD 1.66) (p<0.001) and higher PLR (mean 233.73 (SD 237.21) vs (mean 162.93 (SD 65.35)) (p-value=0.04)) and those patients (N=92) were therefore excluded from down-stream analyses. On the remaining 138 patients, we tested for associations of PLR, NLR and CRP with SLI using linear regression. In all the models the highest category for synovial lymphocytic inflammation was found to be statistically significantly associated with NLR, PLR and CRP, separately (Table 1).

Conclusion:

NLR, PLR and CRP are associated with high synovial lymphocytic inflammation of the operative joint. This suggests that these inexpensive, routinely performed blood tests may be a useful blood biomarker of synovial inflammation.

References:

[1]Orange, D.E. et al. Histologic and Transcriptional Evidence of Subclinical Synovial Inflammation in Patients With Rheumatoid Arthritis in Clinical Remission. Arthritis Rheumatol. 71(7): 1034-1041 (2019).

[2]Lee, Y.H. Association between the Neutrophil-to-lymphocyte Ratio, and Platelet-to-lymphocyte Ratio and Rheumatoid Arthritis and their Correlations with the Disease Activity: A Meta-analysis. J Rheum Dis. 25(3):169-178 (2018).

[3]Orange, D. E. et al. Identification of Three Rheumatoid Arthritis Disease Subtypes by Machine Learning Integration of Synovial Histologic Features and RNA Sequencing Data. Arthritis Rheumatol. Hoboken NJ 70: 690–701 (2018).

Table 1.

Results from linear regressions evaluating the association of NLR, PLR, and CRP with synovial lymphocytic inflammation.

Linear regression ResultsNLRPLRCRPSynovial Lymphocytic InflammationCoef (95% CI)Coef (95% CI)Coef (95% CI)NoneReferencereferencereferenceMild0.31 (-0.51, 1.13)26.54 (-8.83, 61.90)-1.00 (-2.37, 0.36)Moderate0.73 (-0.18, 1.64)28.66 (-10.22, 67.53)0.46 (-1.09, 2.01)Marked0.21 (-0.80, 1.22)24.62 (-22.80, 72.05)0.81 (-0.87, 2.49)Band-like1.92 (0.81, 3.02)80.42 (31.46, 129.38)2.32 (0.49, 4.16)

OR= Odds ratio, Coef = Coefficient, NLR= neutrophil lymphocyte, PLR= platelet lymphocyte ratio, CRP= C-reactive protein

All significant associations are bolded.

Disclosure of Interests:

Diyu Pearce-Fisher: None declared, Dana Orange Consultant of: Astra Zeneca/MedImmune and Pfizer, Bella Mehta Consultant of: Novartis, Deanna Jannat-Khah: None declared, Susan Goodman Consultant of: UCB, Grant/research support from: Novartis, Horizon Pharmaceuticals

POS0285 ARE RACIAL DISPARITIES IN REVISION TKA OUTCOMES ASSOCIATED WITH HOSPITAL OR SURGEON VOLUME?

Background:

Total knee arthroplasty (TKA) outcomes are linked to surgical volume,1 despite the increase in TKA utilization, racial disparities in TKA outcomes persist. Blacks in the US are at a higher risk of aseptic revision of TKA (R-TKA) when compared to Whites, yet the reasons for this are not understood.

Objectives:

The objective of this study is to examine the relationship between hospital and surgeon annual TKA volume and R-TKA outcomes by race.

Methods:

This is an observational cohort study. New York Statewide Planning and Research Cooperative System data for 2004 – 2013 was used to identify patients who underwent primary TKA. Data through 2015 was used to identify R-TKA within 2 years of the index TKA. Hospital characteristics were obtained from the AHA Annual Survey. Surgeon data was collected from New York State Education Department and New York State Physician Profile. Surgeon annual TKA volume was categorized based on cutoffs established by Wilson et al1 as </=12, 13-59, 60-145 or >/= 146, and hospital TKA volume as </=89, 90-235, 236-644 and >/=645. We calculated the odds of R-TKA in Whites and Blacks separately and generated crude odds ratios (OR) comparing Blacks to Whites to examine trends across volume categories. A multivariable logistic regression model adjusted for known R-TKA risk factors was also performed.

Results:

A total of 163,576 patients were included. Mean (SD) age was 66.4 (10.4) years, 107,233 (65.6%) were female, 124,277 (76.6%) were White and 15,990 (9.8%) were Black. 2925 patients underwent aseptic R-TKA. In logistic regression analysis, Blacks had a higher risk of R-TKA (OR 1.42, 95%CI 1.26-1.6) (Table 1). Risk of R-TKA was also higher when surgeon annual volume was </=12 (OR 1.5, 95%CI 1.25-1.8) or 13-59 (OR 1.16, 95%CI 1.04-1.29) TKA compared to the highest volume surgeons (>/=146). Patients who had surgery at a hospital with annual volume of 236-634 TKA were less likely to undergo R-TKA compared to the highest volume hospitals (>/=645) (OR 0.88, 95%CI 0.79-0.98). Other risk factors for R-TKA were younger age and worker’s compensation, while patients with inflammatory arthritis had a lower risk. Figures 1A and 1B show the odds of R-TKA in Whites and Blacks, respectively, by hospital and surgeon volume. Figure 1C shows the crude OR for Blacks to Whites for each category pair. The OR ranged from 0.9 to 2.5, with the largest disparity found in patients who have TKA performed by surgeons with 60-145 annual TKA volume at the highest volume hospitals (>/=645).

Conclusion:

Patients having TKA by a surgeon performing <60 TKA per year have higher risk of R-TKA. Racial disparities in R-TKA risk are highest for TKA by surgeons performing 60-145 TKA per year at hospitals performing >/=645 TKA per year. Future studies should examine factors, such as whether trainees are involved the surgery, that may vary based on social determines of health, such as patient race and payor.

References:

[1]Wilson S. et al Meaningful thresholds for the volume-outcome relationship in total knee arthroplasty. Journal of bone and joint surgery. 2016;98:1683

Table 1.

Logistic regression of risk for R-TKA

Variable (reference)LevelOdds ratio95% CIp-valueAge--0.950.94-0.95<.001Sex (female)Male1.070.99-1.150.108Race (whiteAsian0.650.42-0.960.031Black1.421.26-1.6<.001Unknown0.810.64-1.020.07Other1.050.92-1.210.446Insurance (Medicare)Medicaid0.890.75-1.060.193Other0.890.7-1.130.331Private0.820.74-0.91<.001Work compensation1.561.35-1.8<.001Surgeon volume (>/=146)</=121.51.25-1.8<.00113-591.161.04-1.290.00660-1451.00.91-1.110.957Hospital volume (>/=645)</= 890.980.84-1.150.84890-2350.990.88-1.120.869236-6440.880.79-0.980.018Hospital bed size (>400 beds)6-1991.131.02-1.250.024200-3991.060.96-1.170.262

Other variables in model: diabetes, obesity, renal disease, COPD, osteoarthritis, osteonecrosis, dislocation, inflammatory arthritis, surgical complication, infection, no college, poverty >20%, years since residency, US/Canada medical school, orthopedic board certified, AHA control, teaching, rural hospital

Disclosure of Interests:

Serene Mirza: None declared, Susan Goodman: None declared, Yi Zhang: None declared, Huong Do: None declared, Bella Mehta: None declared, Stephen Lyman: None declared, Lisa A. Mandl: None declared, Mark Figgie: None declared, Michael Parks Consultant of: Zimmer biomet, Grant/research support from: Zimmer biomet, Linda Russell: None declared, Anne Bass: None declared

POS1097 TREATMENT KNOWLEDGE AND PREFERENCES FOR BLACK PEOPLE WITH HIP AND KNEE OSTEOARTHRITIS: A SYSTEMATIC LITERATURE REVIEW AND META-ANALYSIS

Background:

Black people are less likely to undergo total joint arthroplasties, despite reporting more severe symptoms. (1) While racial disparities exist in treatment utilization for osteoarthritis, comprehensive studies of the treatment preferences of Black people have not been conducted.

Objectives:

The purpose of this manuscript is to systematically review the literature and identify Black osteoarthritis patients’ treatment preferences to understand how they may contribute to racial differences in the utilization of different treatment options.

Methods:

Searches ran on April 8, 2019 and April 7, 2020 in the following databases: Ovid MEDLINE (ALL - 1946 to Present); Ovid EMBASE (1974 to present); and The Cochrane Library (Wiley). Using the Patient/Population-Intervention-Comparison/Comparator-Outcome (PICO) format, our population of interest was Black people with hip and/or knee osteoarthritis, our intervention was preferences and opinions about treatment options for osteoarthritis, our comparator was white people with hip and/or knee osteoarthritis, and our outcome was preferences of osteoarthritis therapies. The protocol was registered under the PROSPERO international register, and the Preferred Reporting Items of Systematic reviews and Meta-Analyses (PRISMA) guidelines were followed.

Results:

Searches across the chosen databases retrieved 10,894 studies after de-duplication, 182 full text, and 31 selected for inclusion in this review. Black people were less likely to use NSAIDs or narcotic analgesics compared to white people. (Figure 1) Black people were more likely than white people to use spirituality and prayer, as well as topical treatments. Utilization of meditation, supplement/vitamin use, and hot/cold treatments was not significantly different between groups. Black people were less willing than white people to consider or undergo joint replacements, even if the procedure was needed and recommended by a physician.

Conclusion:

Racial differences persist in OA care across the spectrum of options. Future interventions should focus on providing accessible information surrounding treatment options and targeting perceptions of the importance of joint health.

References:

[1]Suarez-Almazor ME, Souchek J, Kelly PA, et al. Ethnic Variation in Knee Replacement: Patient Preferences or Uninformed Disparity? Arch Intern Med. 2005;165(10):1117-1124. doi:10.1001/archinte.165.10.1117

Figure 1.

Meta-analysis describing the odds ratios of Black people using NSAIDs and Narcotic Analgesics compared to white people

Disclosure of Interests:

Collin Brantner: None declared, Diyu Pearce-Fisher: None declared, Carine Moezinia: None declared, Haley Tornberg: None declared, John FitzGerald: None declared, Michael Parks Consultant of: Zimmer Biomet, Peter Sculco Consultant of: EOS Imaging, Intellijoint Surgical, DePuy Synthes, Lima Corporate, Cynthia Kahlenberg: None declared, Curtis Mensah: None declared, Ajay Premkuar: None declared, Nicholas Williams: None declared, Michelle Demetres: None declared, Susan Goodman Consultant of: UCB, Grant/research support from: Novartis, Horizon Therapeutics.

AB0834 DEVELOPMENT OF A CONCEPTUAL FRAMEWORK FOR A PATIENT REPORTED OUTCOME MEASURE TO CAPTURE PATIENTS’ PERCEPTIONS OF GLUCOCORTICOID THERAPY DURING TREATMENT FOR RHEUMATIC DISEASES

Background:

Glucocorticoids (GCs) are a key treatment for the autoimmune rheumatic diseases; however, they produce numerous physical and psychological side effects.1 The Outcome Measures in Rheumatology (OMERACT) Glucocorticoid Working Group have identified that there are no Patient Reported Outcome Measures (PROMs) for assessing the impact of systemic GC therapy across multiple rheumatic diseases from the patient’s perspective.2,3

Objectives:

The aim is to explore the impact of GCs on the symptoms and health-related quality of life of adults with rheumatic inflammatory diseases, to inform items for inclusion in a PROM. Key considerations will include patient perceptions of GC therapy at diagnosis and over the course of treatment, for use in future randomised controlled trials or in clinical practice.

Methods:

An international steering committee comprising researchers, rheumatology clinicians, methodologists and patient partners in the UK, Australia and USA developed an initial conceptual framework informed by a review of the literature. Semi-structured interviews were conducted in each country with patients who had an autoimmune rheumatic disease and had received GC therapy. The interviews explored salient aspects of health-related quality of life associated with being treated with GCs.

Results:

Interviews have been completed in three continents with patients who had a range of demographic features, rheumatological conditions and duration and dosage of GC therapy. Figure 1 shows the initial conceptual framework for developing the GC PROM (Steroid PRO).

Figure 1.

Conclusion:

This conceptual framework will act as an evolving guide in the development of a PROM for assessing patients’ perspectives of systemic glucocorticoid therapy. Future work will include inductive analysis of qualitative transcripts to inform candidate questionnaire items, cognitive interviewing, linguistic translatability assessment, and an international validation survey to define the final PROM questionnaire and its measurement properties.

References:

[1]Cheah JTL, Robson JC, Black RJ, et al. The patient’s perspective of the adverse effects of glucocorticoid use: A systematic review of quantitative and qualitative studies. From an OMERACT working group. Semin Arthritis Rheum. 2020 Oct; 50(5):996-1005.

[2]Black RJ, Robson JC, Goodman SM, et al. A Patient-reported Outcome Measure for Effect of Glucocorticoid Therapy in Adults with Inflammatory Diseases Is Needed: Report from the OMERACT 2016 Special Interest Group. J Rheumatol. 2017; 44(11):1754-8.

[3]Cheah JTL, Black RJ, Robson JC, et al. Toward a Core Domain Set for Glucocorticoid Impact in Inflammatory Rheumatic Diseases: The OMERACT 2018 Glucocorticoid Impact Working Group. J Rheumatol. 2019; 46(9):1179-1182.

Disclosure of Interests:

Susan Bridgewater Grant/research support from: Grant from Vifor Pharma for an independent investigator-led study to develop a PRO for steroids, Jill Dawson: None declared, Mwidimi Ndosi: None declared, Rachel J Black: None declared, Jonathan T.L. Cheah: None declared, Emma Dures: None declared, Nilasha Ghosh: None declared, Elizabeth A Hoon: None declared, Iris Navarro-Millan Consultant of: Received consultant fees from SOBI, Diyu Pearce-Fisher: None declared, Pamela Richards: None declared, Carlee Ruediger: None declared, Christine Silverthorne: None declared, Joanna Tieu Grant/research support from: Vifor Pharma, Sarah Mackie Consultant of: Consultancy on behalf of institution for Roche/Chugai, Sanofi, AbbVie and AstraZeneca, Grant/research support from: Educational grant from Roche to attend EULAR2019, Susan Goodman: None declared, Catherine Hill: None declared, Joanna Robson Speakers bureau: Vifor Pharma for educational webinar, Grant/research support from: Grant from Vifor Pharma for an independent investigator-led study to develop a PRO for steroids

FRI0379 VARIATIONS IN THE UTILIZATION OF BILATERAL TOTAL KNEE ARTHROPLASTY IN THE MANAGEMENT OF OSTEOARTHRITIS

Background:

A third of knee osteoarthritis presents with bilateral symptomatic arthritis. In these patients, treatment options include either a staged Unilateral Total knee arthroplasty (UTKA) procedure, or a simultaneous Bilateral TKA (BTKA) procedure. Even though literature regarding outcomes in BTKA procedure has not consistently been favorable, it remains popular in select patients due to use of a single anesthetic, shorter overall surgical time, lower cost and lower overall use of narcotics. African Americans (AAs) have lower utilization and worse outcomes in UTKA literature. It is unclear whether these racial variations extend to BTKA.

Objectives:

We sought to examine BTKA vs UTKA utilization rates and outcomes comparing AA and White patients.

Methods:

National Inpatient Sample (NIS) - Healthcare Cost and Utilization Project (HCUP) database (2007-2016) was used. We identified all patients ≥ 50 years who underwent elective primary TKA using ICD-9-CM code 81.54 for UTKA and BTKA from January 1, 2012 to September 30, 2015, and ICD-10-CM codes 0SRC0x and 0SRD0x thereafter. Patients with inflammatory arthritis, pathologic fractures, metastatic disease and avascular necrosis were excluded. Major in-hospital complications included post-operative myocardial infarction, prosthetic device complication, surgical wound infection, and venous thromboembolism. Differences in temporal trends in utilization and major in-hospital complications of BTKA vs UTKA were compared between AAs and Whites. Multivariable logistic regression models were used to assess differences in both these trends between AAs and Whites after adjusting for individual (age, sex, Elixhauser comorbidity index, and morbid obesity), hospital level (hospital volume, bed size, region and teaching status) and community level (median household income) variables. Discharge weights were used to enable nationwide estimates. Multiple imputation was performed for missing race variable (11.9%).

Results:

From 2007 to 2016, an estimated 276,194 BTKA (unweighted observations 56,675) and 5,528,429 UTKA (unweighted observations 1,131,329) were identified (Table 1). Females had a higher proportion of TKAs performed (62.1% UTKA vs 55.9% BTKA). Patients had fewer comorbidities (measured by the Elixhauser Index) when undergoing BTKA compared to UTKA. The proportion of BTKA amongst all TKAs declined from 5.53% in 2007-08 to 4.03% in 2015-16. AAs continued to have significantly lower proportion of BTKA utilization compared to Whites (4.68% in AAs vs 6.08% in Whites in 2007-08, whereas 3.28% in AAs vs 4.19% in Whites in 2015-16, adjusted p < 0.001) (Figure 1a). In-hospital complication rates for UTKA and BTKA were significantly higher in Whites compared to AAs throughout the study period (0.77% in AAs vs 0.9% in Whites in 2007-08, whereas 0.69% in AAs vs 0.83% in Whites in 2015-16, adjusted p < 0.001) (Figure 1b). The results were similar after imputation of missing race values.

Conclusion:

In this nationwide sample of patients from 2007 to 2016, we found that AAs have lower utilization rate of BKTA compared to Whites, however the in-hospital complication rates were significantly higher in Whites.

References:

N/A

Table 1.

Weighted frequencies and percentages of demographic characteristics among unilateral TKA vs. bilateral TKA (N = 6, 236, 426).

VariableUnilateral TKABilateral TKAPaN = 5,528,429(Unweighted N = 1,131,329)N = 276,194(Unweighted N = 56,675)Patient CharacteristicsAge, mean (SD)67.4 (0.02)65.0 (0.06)<.0001Sex: Female, n(%)3,429,484 (62.1)154,442 (55.9)<.0001Race, n(%): White4,051,648 (50.9)212,468 (76.9)<.0001 African American352,933 (6.4)14,441 (5.2) Other464,407 (8.4)16,443 (6.0) Missing659,439 (11.9)32,842 (11.9)Morbid Obesity, n(%)401,892 (7.3)20,411 (7.4)0.47Elixhauser Indexd, n(%):<.0001 0716,559 (13.0)41,550 (15.0) 1-44,484,941 (81.1)220,638 (80.0) ≥ 5326,928 (5.9)14,007 (5.1)

Disclosure of Interests:

Bella Mehta: None declared, Kaylee Ho: None declared, Jennifer Bido: None declared, Michael Parks Consultant of: Zimmer Biomet, Linda Russell: None declared, Susan Goodman Shareholder of: Reginosine- Investment, Grant/research support from: Novartis, Horizon, Consultant of: Novartis, Celgene, UCB, Said Ibrahim: None declared

FRI0403 CLINICAL FEATURES OF PROSTHETIC JOINT INFECTIONS DIFFER IN PATIENTS WITH INFLAMMATORY ARTHRITIS AND OSTEOARTHRITIS

Background:

Inflammatory arthritis (IA) patients are at increased risk for prosthetic joint infections (PJI). However, because active IA patients without infections can have elevated inflammatory markers that mimic joint infection, PJI diagnosis is challenging in this population.

Objectives:

We used an institutional PJI registry to identify and compare the clinical, microbiologic, and histopathologic features of culture positive (CP) and culture negative (CN) total hip and knee PJI in IA and OA patients. We also evaluated the relationship between culture positivity, IA, and clinical outcomes.

Methods:

A retrospective cohort of THA/TKA PJIs, from 2009 to 2016, were identified by ICD codes, and confirmed by chart review. IA diagnosis was also confirmed by use of IA-specific medications. CN cases were defined as PJIs with no evidence of microbial growth in intraoperative cultures and CP PJI cases were defined by positive microbial growth in intraoperative cultures. Treatment failure was defined as subsequent surgical treatment for infection after the initial infection surgery. H&E slides of OA and IA PJI cases matched by age (+/-5) sex, and culture status were reviewed by a pathologist for evidence of the histopathologic features listed in Table 2. Fisher’s exact test, chi-square test, and Kaplan-Meier estimates were used.

TABLE 1.

Patient characteristics in IA and OA PJIs

IAOAN%/SDN%/SDp-valueTotal36771Age58.511.466.812<.001BMI30.26.7306.70.861Female2877.833243.1<.001CCI2.81.71.72.10.002Smoking411.18611.20.792Glucorticoids1027.8395.1<.001Culture Negative1027.810914.10.024Treatment Success at 2 years1952.8509660.146

IA- inflammatory arthritis; OA – osteoarthritis; PJI -prosthetic joint infection; CCI – Charlson Comorbidity Index

TABLE 2.

Histopathology and clinical presentation in IA and OA PJIs

OA (N=57)IA (N= 31)CP-IA (N=23)CN-IA (N=8)N (%)p-valueN (%)p-valuePathology Review>10 PMN per HPF42 (74)22 (71)0.80620 (87)2 (25)0.003Chronic Inflammation13 (23)23 (74)0.00118 (78)5 (63)0.393Necrosis17 (30)9 (29)18 (35)1 (13)0.38Clinical PresentationMSIS50 (88)26 (84)0.74722 (96)4 (50)0.009Sinus Tract7 (12)7 (23)0.2335 (22)2 (25)1Elevated ESR or CRP41 (72)24 (77)0.62217 (74)7 (88)1Elevated Synovial WBC33 (58)19 (61)0.82313 (57)6 (75)1Elevated Synovial %PMN31 (54)20 (65)0.37714 (61)6 (75)0.333

OA – osteoarthritis; IA – inflammatory arthritis; CP – culture positive; CN – culture negative; MSIS – meets Musculoskeletal Infection Society diagnostic criteria

Results:

807 PJI cases were identified including 36 IA (33 RA and 3 SLE) and 771 OA. A higher proportion of IA PJI were CN (N=10, 27%) vs. OA PJI (N=109, 14%, p=0.02). IA-PJI were younger, female, on glucocorticoids, and with more comorbidities. Type of surgical treatment did not differ significantly between IA and OA groups. Comparing CN-IA vs. CP-IA, no difference was observed in age, smoking, diabetes, surgical treatment, IA-specific meds or Charlson comorbidities. One-year survivorship of CN-IA and CN-OA were 66% and 87% (p>0.05). Across all CP cases, 57% were staphylococcal, with no differences between groups. Treatment failure was more frequent for CP-IA (42%) compared to CP-OA (30%), (p=0.2).

Histopathology of 88 PJIs (31 IA and 57 OA) was reviewed. The IA cohort presented with more chronic inflammation (p=0.001) than the OA cohort. Within the IA cohort, a higher proportion of CP-IA had >10PMN per HPF (p= 0.003) and met MSIS criteria (p=0.009). Comparing CP-OA and CN-OA, there were no significant differences in histopathology findings or number of patients meeting MSIS criteria.

Conclusion:

IA PJIs are more likely to be culture negative than OA PJIs. Although our analysis was limited by our cohort size, our findings including differences in histopathology, and better clinical outcomes suggest the presence of biologic differences between CN and CP PJI that require further study.

Disclosure of Interests:

Milan Kapadia: None declared, Tania Pannellini: None declared, Carine Moezinia: None declared, Andy Miller: None declared, Mark Figgie: None declared, Peter Sculco: None declared, Michael Cross: None declared, Michael Henry: None declared, Linda Russell: None declared, Laura Donlin Consultant of: Consultant – Genentech/Roche, Allina Nocon: None declared, Susan Goodman Shareholder of: Reginosine- Investment, Grant/research support from: Novartis, Horizon, Consultant of: Novartis, Celgene, UCB

0048 The Association Between REM Sleep and Risk of Mortality in Three Independent Cohorts

Introduction

Sleep disorders and sleep characteristics have been linked to higher risk of mortality. Despite the emerging evidence of a sleep-mortality association, the relationship between sleep architecture and mortality aren’t well understood. We hypothesize that reduced REM is associated with increased mortality risk.

Methods

The Osteoporotic Fractures in Men (MrOS) study is a population-based study of 2,675 older men. Cox regression was used to evaluate the association between %REM and mortality rate. Potential covariates were evaluated using 6-fold cross validation. Sensitivity analyses were performed to rule out alternative explanations. Wisconsin Sleep Cohort (WSC) and Sleep Heart Health Study (SHHS) data were used to replicate the findings.

Results

The MrOS sample mean age was 76.3 years (SD=5.51) and the median follow-up time was 12.1 years. There was a 13% higher rate of mortality for every absolute 5% reduction in REM sleep (HR=1.13, 95%CI, 1.08–1.19) after adjusting for multiple demographic, sleep, and health covariates. The association persisted for cardiovascular disease-related mortality (CVD) (HR=1.18, 95%CI, 1.09–1.28), cancer-related mortality (HR=1.14, 95%CI, 1.03–1.26), and other mortality (HR=1.19, 95%CI, 1.10–1.28). The WSC included 45.7% women. The mean age of the 1,388 individuals analyzed was 51.5 (SD=8.5); the median follow-up time was 20.8 years. The effect size for 5% reduction in REM on rate of all-cause mortality was similar in this cohort despite the younger age, inclusion of women, and longer follow-up period (HR=1.17, 95%CI, 1.03–1.34). SHHS data is still being analyzed; however the unadjusted model is consistent with the other cohorts.

Conclusion

We found an association between reduced REM and mortality in two, possibly three independent cohorts, which persisted across different causes of death and multiple sensitivity analyses. Mechanistic studies are needed and strategies to preserve REM may influence clinical therapies and reduce mortality risk.

Support

NHLBI provides funding for the MrOS Sleep ancillary study “Outcomes of Sleep Disorders in Older Men” under grant numbers: R01 HL071194, R01 HL070848, R01 HL070847, R01 HL070842, R01 HL070841, R01 HL070837, R01 HL070838, and R01 HL070839. Wisconsin Sleep Cohort was supported by R01HL62252, RR03186, and R01AG14124 from the NIH. Dr. Redline was partially supported by NHLBI R35 HL135818.

Racial disparities in pre-operative pain, function and disease activity for patients with rheumatoid arthritis undergoing Total knee or Total hip Arthroplasty: a New York based study

Background

Black and Hispanic patients with osteoarthritis have more pain and worse function than Whites at the time of arthroplasty. Whether this is true for patients with rheumatoid arthritis (RA) is unknown.

Methods

This cross-sectional study used data on RA patients acquired between October 2013 and November 2018 prior to elective total knee (TKA) or hip arthroplasty (THA). Pain, function, and disease activity were assessed using the visual analogue scale (VAS), the Multidimensional Health Assessment Questionnaire (MDHAQ), and the Disease Activity Score (DAS28-ESR). We linked the cases to census tracts using geocoding to determine the community poverty level. Race, education, income, insurance and medications were collected via self-report. Using multivariable linear and logistic models we examined whether minority status predicted pain, function and RA disease activity at the time of arthroplasty.

Results

Thirty seven (23%) of the 164 patients were Black or Hispanic (minorities). The MDHAQ and DAS28-ESR were not significantly worse while VAS pain score was significantly worse in minority patients (p = 0.03). There was no significant difference in education between the groups. Insurance varied significantly; 29% of minority patients had Medicaid vs. 0% of Whites (p < 0.0001). In the multivariable analyses minority status was not significantly associated with DAS28-ESR [p = 0.66], MDHAQ [p = 0.26], or VAS pain [p = 0.18].

Conclusions

For Black and/or Hispanic patients with RA undergoing THA or TKA at a high-volume specialty hospital, unlike Black or Hispanic patients with osteoarthritis (OA), there was no association with worse pain, function, or RA disease activity at the time of elective arthroplasty.

Comparative efficacy of epidural clonidine versus epidural fentanyl for treating breakthrough pain during labor: a randomized double-blind clinical trial

BACKGROUND

Breakthrough pain during neuraxial labor analgesia is typically alleviated with additional administration of epidural local anesthetics, with or without adjuvants. Sometimes avoiding neuraxial opioids may be warranted and clonidine is an alternative. In a randomized double-blind trial we compared the efficacy of clonidine versus fentanyl, added to bupivacaine, for the management of breakthrough pain.

METHODS

Term parturients (n=98) receiving bupivacaine 0.0625% with fentanyl 2 μg/mL at 12 mL/h, a patient-administered bolus of 5 mL at lockout 6-10 min and a maximum of four boluses per hour, and experiencing breakthrough pain ≥5/10, were randomized to receive a 10 mL bolus containing 12.5 mg bupivacaine and either clonidine 100 μg or fentanyl 100 μg. The primary outcome was 'success' of study drug treatment, defined as a pain score reduction ≥4/10 within 15 min of administration. Maternal hemodynamics and fetal heart rate were documented for two hours after treatment.

RESULTS

There was no significant difference between groups in success rates (66.0% after clonidine (n=47) vs 74.5% after fentanyl (n=51), P=0.48) or in the incidence of hypotension (systolic blood pressure ≤80% of baseline or <90 mmHg) or sedation at 15 min, with 2/51 and 1/47 subjects in the fentanyl and clonidine groups, respectively, receiving phenylephrine.

CONCLUSION

Epidural clonidine 100 μg was not superior to fentanyl 100 μg for decreasing pain scores within 15 min of co-administration with bupivacaine 0.125% for intrapartum breakthrough pain. The analgesic efficacy and hemodynamic side effects did not significantly differ.

P5471Baseline characteristics, healthcare resource use and clinical outcomes of stable post-myocardial infarction patients with diabetes: insights from the global prospective TIGRIS study

Background

There is a growing prevalence of diabetes worldwide in patients in the general population, including those with prior myocardial infarction (MI).

Purpose

To describe the characteristics, health status, resource utilization and clinical adverse events of stable post-MI patients with diabetes.

Methods

The long-Term rIsk, clinical manaGement and healthcare Resource utilization of stable coronary artery dISease (TIGRIS) prospective observational study (NCT01866904) obtained data from 8985 stable patients 1–3 years post-MI from 369 centres in 25 countries, who provided diabetes status (no, yes, insulin-treated) and follow-up. Diabetes status, other patient characteristics, medications, medical history and healthcare resource utilization were recorded at enrolment. Health status was assessed at enrolment, 1 and 2 years by EQ-5D-3L and converted to an EQ-5D score. Deaths, cardiovascular (CV) events, bleeding events and related hospitalizations were recorded during 2 years of follow-up.

Results

Diabetes mellitus (DM) was prevalent at enrolment in 2966 (33%) patients of whom 872 (29%) were insulin-treated. Compared to patients without DM, those with DM had a higher mean body mass index (28.2 vs 26.6kg/m2) and heart rate (71 vs 67bpm), were more likely to have had ≥2 prior MIs (12% vs 10%), chronic kidney disease (10% vs 6%), peripheral artery disease (10% vs 5%), heart failure (15% vs 10%), anaemia (4% vs 2%), angina (12% vs 9%), stroke (6% vs 4%) and chronic obstructive pulmonary disease (9% vs 7%). Patients with DM reported more problems for each domain of the EQ-5D (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression), which resulted in a lower mean EQ-5D utility score at enrolment (0.83±0.22 for no-diabetes vs 0.86±0.19 for diabetes). Moreover, they also had higher CV hospitalization rates in the 6 months prior to enrolment (6.4% vs 5%). All these measures were more marked in insulin-dependent diabetics. The incidences of all-cause death, CV death and the composite of CV death, MI and stroke were all significantly higher in patients with DM, especially those on insulin (see Figure). For CV death, MI and stroke the 2-year risk ratios, compared to patients without DM, were 2.64 (P<0.001) and 1.48 (P<0.001) respectively for those with insulin-treated DM and non-insulin treated.

Figure 1

Conclusions

Within a global population of stable post-MI patients, those with DM (especially those on insulin) have poorer health status and EQ-5D utility score, higher hospitalization rates and worse clinical outcomes compared with those without DM. Thus, in cardiac clinics worldwide, patients with DM require particularly close attention.

Acknowledgement/Funding

The study was funded by AstraZeneca

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

A strategy for monitoring and evaluating massive open online courses

We argue that the complex, innovative and adaptive nature of Massive Open Online Course (MOOC) initiatives poses particular challenges to monitoring and evaluation, in that any evaluation strategy will need to follow a systems approach. This article aims to guide organizations implementing MOOCs through a series of steps to assist them in developing a strategy to monitor, improve, and judge the merit of their initiatives. We describe how we operationalise our strategy by first defining the different layers of interacting agents in a given MOOC system. We then tailor our approach to these different layers. Specifically, a two-pronged approach was developed, where we suggest that individual projects be assessed through performance monitoring; assessment criteria for which would be defined at the outset to include coverage, participation, quality and student achievement. In contrast, the success of an overall initiative should be considered within a more adaptive, emergent evaluation inquiry framework. We present the inquiry framework we developed for MOOC initiatives, and show how this framework might be used to develop evaluation questions and an assessment methodology. We also define the more fixed indicators and measures for project performance monitoring. Our strategy is described as it was developed to inform the evaluation of a MOOC initiative at the University of Cape Town (UCT), South Africa.

Nanocoating for biomolecule delivery using layer-by-layer self-assembly

Since its introduction in the early 1990s, layer-by-layer (LbL) self-assembly of films has been widely used in the fields of nanoelectronics, optics, sensors, surface coatings, and controlled drug delivery. The growth of this industry is propelled by the ease of film manufacture, low cost, mild assembly conditions, precise control of coating thickness, and versatility of coating materials. Despite the wealth of research on LbL for biomolecule delivery, clinical translation has been limited and slow. This review provides an overview of methods and mechanisms of loading biomolecules within LbL films and achieving controlled release. In particular, this review highlights recent advances in the development of LbL coatings for the delivery of different types of biomolecules including proteins, polypeptides, DNA, particles and viruses. To address the need for co-delivery of multiple types of biomolecules at different timing, we also review recent advances in incorporating compartmentalization into LbL assembly. Existing obstacles to clinical translation of LbL technologies and enabling technologies for future directions are also discussed.

Six-month freedom from treatment failure is an important end point for acute GVHD clinical trials

We studied the ASBMT 6 month (m) freedom from treatment failure (FFTF) as a predictor of survival for patients with acute graft-versus-host disease (aGVHD) requiring treatment. Adult patients undergoing allogeneic hematopoietic cell transplant (HCT) from February 2007 to March 2009 who were enrolled in a prospective biomarker clinical trial and developed aGVHD requiring systemic corticosteroids by day +100 were included (N=44). Six month FFTF was defined per ASBMT guidelines [absence of death, malignancy relapse/progression, or systemic immunosuppression change within 6 months of starting steroids and before chronic GVHD development]. aGVHD was treated with systemic corticosteroids in 44 patients. Day 28 response after steroid initiation (CR+VGPR+PR) occurred in 38 (87%) patients, but only 28 (64%) HCT recipients met the 6 m FFTF endpoint. Day 28 response predicted 6 m FFTF. Achieving 6 m FFTF was associated with improved 2 year (y) overall survival (OS) [81% vs. 48%, P= 0.03)] and decreased 2 y non-relapse mortality [8% vs. 49% (P= 0.01)]. In multivariate analysis, 6 m FFTF continued to predict improved OS (HR, 0.27; P=0.03). The 6 m FFTF endpoint measures fixed outcomes, predicts long-term therapeutic success, and could be less prone to measurement error than aGVHD clinical response at day 28.

Salmonella septic arthritis of the knees in a patient with systemic lupus erythematosus

Hematogenous Salmonella osteomyelitis is uncommon in immunocompetent hosts, but occurs with some regularity in immunosuppressed patients affected by systemic lupus erythematosus (SLE). Surgical debridement with resection of compromised tissue is central to the surgical management of osteomyelitis. Persistence of septic arthropathy may result from inadequate debridement, areas of osteonecrosis (ON), and an abnormal cellular and humoral dysregulation characteristic of SLE. We describe a 53-year-old Hispanic female with SLE on immunosuppressive therapy, who developed acute salmonella-induced septic arthritis and osteomyelitis of both knees associated with ON and recurrent SLE synovitis. She received prolonged antibiotic therapy and an extensive surgical debridement as part of a successful two-stage bilateral total knee replacement. This report illustrates the significance of Salmonella enterica infection in SLE patients, and the role of underlying bone and joint pathology such as bone infarcts, sub-acute osteomyelitis, and SLE synovitis.

Yoga breathing for cancer chemotherapy-associated symptoms and quality of life: results of a pilot randomized controlled trial

BACKGROUND

Many debilitating symptoms arise from cancer and its treatment that are often unrelieved by established methods. Pranayama, a series of yogic breathing techniques, may improve cancer-related symptoms and quality of life, but it has not been studied for this purpose.

OBJECTIVES

A pilot study was performed to evaluate feasibility and to test the effects of pranayama on cancer-associated symptoms and quality of life.

DESIGN

This was a randomized controlled clinical trial comparing pranayama to usual care.

SETTING

The study was conducted at a university medical center.

SUBJECTS

Patients receiving cancer chemotherapy were randomized to receive pranayama immediately or after a waiting period (control group).

INTERVENTIONS

The pranayama intervention consisted of four breathing techniques taught in weekly classes and practiced at home. The treatment group received pranayama during two consecutive cycles of chemotherapy. The control group received usual care during their first cycle, and received pranayama during their second cycle of chemotherapy.

OUTCOME MEASURES

Feasibility, cancer-associated symptoms (fatigue, sleep disturbance, anxiety, depression, stress), and quality of life were the outcomes.

RESULTS

Class attendance was nearly 100% in both groups. Sixteen (16) participants were included in the final intent-to-treat analyses. The repeated-measures analyses demonstrated that any increase in pranayama dose, with dose measured in the number of hours practiced in class or at home, resulted in improved symptom and quality-of-life scores. Several of these associations--sleep disturbance (p=0.04), anxiety (p=0.04), and mental quality of life (p=0.05)--reached or approached statistical significance.

CONCLUSIONS

Yoga breathing was a feasible intervention among patients with cancer receiving chemotherapy. Pranayama may improve sleep disturbance, anxiety, and mental quality of life. A dose-response relationship was found between pranayama use and improvements in chemotherapy-associated symptoms and quality of life. These findings need to be confirmed in a larger study.