Differential Burden of HIV Among Adolescent Girls and Young Women by Places Associated With Sex Work: An Observational Study in Mombasa, Kenya

BACKGROUND

The design of HIV prevention programs for adolescent girls and young women (AGYW) are informed by data on who is at highest risk and where they can be reached. Places (hotspots) associated with selling sex are an established outreach strategy for sex work (SW) programs but could be used to reach other AGYW at high risk.

SETTING

This study took place in Mombasa, Kenya.

METHODS

We conducted a cross-sectional, bio-behavioural survey among (N = 1193) sexually active AGYW aged 14-24 years recruited at hotspots. We compared HIV prevalence by subgroup (SW; transactional sex, TS; and non-transactional sex), stratified by hotspot type (venues and nonvenues). We examined whether associations between HIV prevalence and hotspot/subgroup remained after adjustment for individual-level risk factors, and estimated HIV prevalence ratio with and without adjustment for these individual-level factors.

RESULTS

Overall HIV prevalence was 5.6%, 5.3% in venues and 7.3% in nonvenues. Overall SW HIV prevalence was 2-fold higher than among participants engaged in nontransactional sex. After adjusting for age and individual-level risk factors, HIV prevalence was 2.72 times higher among venue-based SWs (95% confidence interval: 1.56 to 4.85) and 2.11 times higher among nonvenue AGYW not engaged in SW (95% confidence interval: 0.97 to 4.30) compared with venue-based AGYW not engaged in SW.

CONCLUSION

AGYW who sell sex remain at high risk of HIV across types of hotspots. The residual pattern of elevated HIV burden by AGWY subgroup and hotspot type suggests that unmeasured, network-level factors underscore differential risks. As such, hotspots constitute a "place" to reach AGYW at high risk of HIV.

Assessing awareness and use of HIV self-testing kits after the introduction of a community-based HIV self-testing programme among men who have sex with men in Kenya

Men who have sex with men (MSM) bear a disproportionate burden of new HIV infections in Kenya, while experiencing discrimination, leading to suboptimal levels of HIV care. HIV self-testing (HIVST) is a tool to increase HIV screening and earlier diagnosis; however, questions remain regarding how best to scale-up HIVST to MSM in Kenya. The main objective of this study was to examine changes in knowledge and use of HIVST after implementation of a community-led HIVST project. Participants were MSM recruited from Kisumu, Mombasa, and Kiambu counties. Data were collected from two rounds (Round 1: 2019; Round 2: 2020) of serial cross-sectional integrated biological and behavioural assessments (IBBA), pre-, and post-project implementation. Two main outcomes were measured: 1) whether the respondent had ever heard of HIVST; and 2) whether they had ever used HIVST kits. Changes in outcomes between IBBA rounds were examined using modified multivariable Poisson regression models; adjusted prevalence ratios (aPR) and 95% confidence intervals (95% CI) are reported. A total of 2,328 respondents were included in main analyses. The proportion of respondents who had heard of HIVST increased from 75% in Round 1 to 94% in Round 2 (aPR: 1.2, 95% CI: 1.2-1.3), while those reporting using an HIVST kit increased from 20% to 53% (aPR: 2.3, 95% CI: 2.0-2.6). Higher levels of education and HIV programme awareness were associated with both outcomes. Awareness and use of HIVST kits increased after implementation of a community-led HIVST implementation project, demonstrating the importance of integration with existing community groups.

80 A PILOT POPS SERVICE (PERI-OPERATIVE CARE OF THE OLDER PERSON UNDERGOING SURGERY): A PROMISING START

Background

It is understood that older persons undergoing surgery benefit from Comprehensive Geriatric Assessment (CGA), however these services remain limited in Ireland. Latest guidelines recommend all patients over 65 undergoing surgery should be screened for frailty and receive a CGA if frailty is identified. Our pilot service was to implement this on our acute surgical in-patient ward.

Methods

Baseline data was gathered prior to implementation of our service. Interventions included education, dedicated sessions for geriatrician input on ward, single point of referral and increased signage. Patients identified as living with frailty (Rockwood Clinical Frailty Score (CFS) ≥5) then received CGA. Progress monitored with monthly audit and foundation doctor feedback surveys over a 6-month period.

Results

We have increased the percentage of patients over 65 being screened for frailty from 0% to a peak of 100% over our pilot 6-month period. Foundation doctor surveys showed an improvement in confidence in screening for frailty (19 to 100%) and managing frailty (13 to 80%). They also reported feeling more supported managing these patients (38% to 100%). Focusing on patients with CFS ≥5, we have shown a reduction in length of stay from a mean of 20 days to 11 days, albeit numbers remain small.

Conclusion

By increasing identification of frailty in older patients, we have managed to apply CGA to appropriate patients. Geriatrician input on the surgical ward has also allowed foundation doctors to feel supported and improve confidence in managing patients living with frailty. Furthermore, we have shown a trend towards reduced length of stay. However, our patient numbers remain low and there is a reliance on our team to screen all patients over 65. Our focus moving forward is for the surgical team to screen for frailty allowing us to expand the service to other surgical wards.

1328 A Risk Stratified Post-Nephrectomy Surveillance Protocol – 5-Year Assessment of Performance

Introduction

Recurrence rate of surgically treated localised renal cell carcinoma (RCC) is reported to be approximately 20%. There is lack of consensus on the optimal surveillance regimen. We assess the performance of our surveillance protocol based upon prognostic histological factors. We report the outcome of our first cohort to reach 5 years follow up.

Method

A retrospective analysis was performed of patients who underwent a radical or partial nephrectomy between March 2014 and October 2015. Patients were classified as high, intermediate, or low risk based on pathology; with each group undergoing individualised radiological follow up.

Results

80 patients with pathologically confirmed RCC who underwent partial or radical nephrectomy were identified. Recurrence was noted in 24% (n = 19), and a third of those patients (n = 7) died within the 5-year follow-up period. 79% (n = 15) of patients with recurrence were of intermediate or high-risk group. 90% of recurrences were picked up on surveillance scans, 5% due to symptoms related to the recurrence and 5% incidentally. 70% occurred within the first 2 years post-surgery. 92% (n = 6) of those who died had an ASA of 2 or higher. In the whole cohort, total number of deaths was 13. 38% (n = 5) died of RCC, 54% (n = 7) died of other causes and in 8% (n = 1) cause of death of was unclear.

Conclusions

Our risk stratified surveillance protocol identified 90% of recurrences within the 5-year follow-up. Future refinement of our protocol could include an assessment of performance status which may influence the schedule of radiological surveillance.

218 The Impact on Minimally Invasive Urological Cancer Surgery During the Covid-19 Pandemic

Aim

Learned bodies recommended restricted use of, or extensive precautions when using, laparoscopic/robotic surgery during the Covid-19 pandemic. We aimed to determine whether minimally invasive surgery (MIS) in uro-oncology patients was safe for patients and staff.

Method

From 16 March to 16 June 2020, patients having MIS in a tertiary referral urology centre were identified from a prospectively collected database. Patient characteristics, operative details and 30-day follow-up for adverse events were recorded including Covid-19 tests and results. Any theatre staff Covid-19 event was traced back 14 days to determine any involvement in these cases.

Results

87 patients were eligible for inclusion (33 robotic prostatectomies, 38 laparoscopic prostatectomies, 11 laparoscopic nephrectomies, 5 robotic nephrectomies). All patients were assessed for symptoms of Covid-19 on the day of theatre. 18(21%) patients had pre-operative screening (all swabs, no CT chest). 46(53%) underwent 14 days pre-operative self-isolation. 38(44%) cases were performed with FFP3 protection. No modification to operating procedure was made for any cases. No patients tested positive for Covid-19 in the 30-day postoperative period. No staff member involved tested positive in the postoperative period. 1 patient tested positive pre-operatively, delaying the operation by 7 weeks. No patients tested positive after the introduction of mandatory screening.

Conclusions

Based on our case-series MIS urological surgery appears to be safe for patients and staff, with no increased risk of Covid-19 complications in patients who are asymptomatic pre-operatively. The introduction of mandatory pre-operative swabs for elective patients, and the use of FFP3 protection, did not significantly alter results.

HIV treatment outcomes among newcomers living with HIV in Manitoba, Canada

BACKGROUND

Despite the overrepresentation of immigrants and refugees (newcomers) in the HIV epidemic in Canada, research on their HIV treatment outcomes is limited. This study addressed this knowledge gap by describing treatment outcomes of newcomers in comparison with Canadian-born persons living with HIV in Manitoba.

METHODS

Clinical data from 1986 to 2017 were obtained from a cohort of people living with HIV and receiving care from the Manitoba HIV Program. Retrospective cohort analysis of secondary data was completed using univariate and multivariate statistics to compare differences in socio-demographic and clinical characteristics and treatment outcomes among newcomers, Canadian-born Indigenous persons, and Canadian-born non-Indigenous persons on entry into HIV care.

RESULTS

By end of 2017, 86 newcomers, 259 Canadian-born Indigenous persons, and 356 Canadian-born non-Indigenous persons were enrolled in the cohort. Newcomers were more likely than Canadian-born Indigenous and non- Indigenous cohort participants to be younger and female and have self-reported HIV risk exposure as heterosexual contact. Average CD4 counts at entry into care did not differ significantly between groups. A higher proportion of newcomers was also diagnosed with tuberculosis within 6 months of entry into care (21%), compared with 6% and 0.6% of Canadian-born Indigenous non-Indigenous persons, respectively. Newcomers and Canadian-born non-Indigenous persons had achieved viral load suppression (< 200 copies/mL) at a similar proportion (93%), compared with 82% of Canadian-born Indigenous participants (p < 0.05).

CONCLUSIONS

The distinct demographic and clinical characteristics of newcomers living with HIV requires a focused approach to facilitate earlier diagnosis, engagement, and support in care.

Sexual and reproductive health among adolescent girls and young women in Mombasa, Kenya

This secondary data analysis of a cross-sectional survey conducted in Mombasa, Kenya characterises sexual and reproductive health (SRH) indicators among adolescent girls and young women (AGYW) engaged in casual and transactional sexual relationships as well as sex work. It describes the association between awareness of local HIV programmes and SRH services uptake for AGYW engaged in sex work. Thirty-eight percent of the participants reported a history of pregnancy. Among participants not trying to get pregnant, 27% stated that they were not currently using any form of contraception. Of the participants who had an abortion, 59% were completed under unsafe conditions. For AGYW engaged in sex work, awareness of local HIV prevention programmes was associated with increased STI testing within the last year (29%) as well as at least one HIV test (99%) compared to those who were not aware of local programming (18% and 92%, respectively); however, only 26% of participants engaged in sex work had heard of local HIV prevention programmes. There were no associations between awareness of local HIV programming and rates of dual contraception use, safe abortion, most recent birth attended by a skilled health professional or testing for HIV during pregnancy. Our study found high need for SRH services, particularly, access to contraception and safe abortion. Continued efforts are required to improve access to the full spectrum of SRH interventions, including family planning services and access to safe abortion in addition to HIV prevention to promote health equity.

Comparative responsiveness of the health utilities index and the RAND-12 for multiple sclerosis

BACKGROUND

Outcome measures need to be valid and have good test-retest reliability and responsiveness. We compared the responsiveness of the RAND-12 and the Health Utilities Index-mark III (HUI3) in persons with multiple sclerosis (MS).

METHODS

In Spring 2018 and 2019, North American Research Committee on Multiple Sclerosis (NARCOMS) registry participants completed the HUI3, the RAND-12, and reported disability (Patient Determined Disease Steps (PDDS)) and employment status (full-time, part-time, and no). We used changes in PDDS and employment status as anchors. We assessed responsiveness using effect size, standardized response mean, and the responsiveness index. We used relative efficiency (RE) to compare the responsiveness of the health-related quality of life (HRQOL) scores, adjusting for sociodemographic factors.

RESULTS

We included 4769 participants in the analysis. They had a mean (standard deviation (SD)) age of 60.9 (10.1) years, and 3826 participants (80.2%) were women. RE was highest for the HUI3 for changes in in disability status (HUI3: 1.0, Physical Component Score-12 (PCS-12): 0.80, and Mental Component Score-12 (MCS-12): 0.41) and for changes in employment status (HUI3: 1.0, PCS-12: 0.70, and MCS-12: 0.17).

CONCLUSION

The HUI3 was more responsive to changes in disability and employment status than the PCS-12 or MCS-12. Given the HUI3's other strong psychometric properties, it may be the preferred generic measure of HRQOL in MS.

Effect of 6% hydroxyethyl starch 130/0.4 on kidney and haemostatic function in cardiac surgical patients: a randomised controlled trial

Whether third‐generation hydroxyethyl starch solutions provoke kidney injury or haemostatic abnormalities in patients having cardiac surgery remains unclear. We tested the hypotheses that intra‐operative administration of a third‐generation starch does not worsen postoperative kidney function or haemostasis in cardiac surgical patients compared with human albumin 5%. This triple‐blind, non‐inferiority, clinical trial randomly allocated patients aged 40–85 who underwent elective aortic valve replacement, with or without coronary artery bypass grafting, to plasma volume replacement with 6% starch 130/0.4 vs. 5% human albumin. Our primary outcome was postoperative urinary neutrophil gelatinase‐associated lipocalin concentrations, a sensitive and early marker of postoperative kidney injury. Secondarily, we evaluated urinary interleukin‐18; acute kidney injury using creatinine RIFLE criteria, coagulation measures, platelet count and function. Non‐inferiority (delta 15%) was assessed with correction for multiple comparisons. We enrolled 141 patients (69 starch, 72 albumin) as planned. Results of the primary analysis demonstrated that postoperative urine neutrophil gelatinase‐associated lipocalin (median (IQR [range])) was slightly lower with hydroxyethyl starch (5 (1–68 [0–996]) ng.ml⁻¹) vs. albumin (5 (2–74 [0–1604]) ng.ml⁻¹), although not non‐inferior [ratio of geometric means (95%CI) 0.91 (0.57, 1.44); p = 0.15] due to higher than expected variability. Urine interleukin‐18 concentrations were reduced, but interleukin‐18 and kidney injury were again not non‐inferior. Of 11 individual coagulation measures, platelet count and function, nine were non‐inferior to albumin. Two remaining measures, thromboelastographic R value and arachidonic acid‐induced platelet aggregation, were clinically similar but with wide confidence intervals. Starch administration during cardiac surgery produced similar observed effects on postoperative kidney function, coagulation, platelet count and platelet function compared with albumin, though greater than expected variability and wide confidence intervals precluded the conclusion of non‐inferiority. Long‐term mortality and kidney function appeared similar between starch and albumin.

Trends of Utilization of Tumor Necrosis Factor Antagonists in Children With Inflammatory Bowel Disease: A Canadian Population-Based Study

BACKGROUND

Population-based studies examining the prevalence of anti-tumor necrosis factor (anti-TNF) antagonist utilization in children and young adults with inflammatory bowel disease (IBD) are lacking. We aimed to describe the trend of anti-TNF utilization in pediatric IBD over time.

METHODS

Survival analyses were performed for all patients diagnosed with IBD before age 18 years in the province of Manitoba to determine the time from diagnosis to first anti-TNF prescription in different time eras (2005-2008, 2008-2012, 2012-2016).

RESULTS

There were 291 persons diagnosed with IBD (157 with Crohn's disease [CD] and 134 with ulcerative colitis [UC]) over the study period. The likelihood of being initiated on an anti-TNF by 1, 2, and 5 years postdiagnosis was 18.4%, 30.5%, and 42.6%, respectively. The proportion of persons aged <18 years utilizing anti-TNFs rose over time; in 2010, 13.0% of CD and 4.9% of UC; by 2016, 60.0% of CD and 25.5% of UC. For those diagnosed after 2012, 42.5% of CD and 28.4% of UC patients had been prescribed an anti-TNF antagonist within 12 months of IBD diagnosis. Initiating an anti-TNF without prior exposure to an immunosuppressive agent increased over time (before 2008: 0%; 2008-2012: 18.2%; 2012-2016: 42.8%; P < 0.001). There was a significant reduction in median cumulative dose of corticosteroids (CS) in the year before anti-TNF initiation (2005-2008: 4360 mg; 2008-2012: 2010 mg; 2012-2016: 1395 mg prednisone equivalents; P < 0.001).

CONCLUSIONS

Over a period of 11 years, anti-TNFs are being used earlier in the course of pediatric IBD, with a parallel reduction in the cumulative CS dose.

Detection of Salmonella in Fresh Cheese, Poultry Products, and Dried Egg Products by the ISO 6579 Salmonella Culture Procedure and the AOAC Official Method: Collaborative Study

Three food types were analyzed for the presence of Salmonella by the AOAC culture method and by the International Organization for Standardization (ISO 6579:2002) culture method. Paired test portions of each food type were simultaneously analyzed by both methods. A total of 21 laboratories representing federal government agencies and private industry, in the United States and Europe, participated in this interlaboratory study. Foods were artificially contaminated with Salmonella and competing microflora if naturally contaminated sources were not available. No statistical differences (p &lt; 0.05) were observed between the AOAC and ISO culture methods for fresh cheese and dried egg products. A statistically significant difference was observed for one of the 2 lots of poultry from the first trial. The poultry meat used in this run was radiation sterilized, artificially contaminated with Salmonella and competitive flora, and then lyophilized. A second trial was conducted with 2 separate lots of raw ground chicken that were naturally contaminated. The results from the second trial showed no statistical difference between the 2 culture methods. A third trial involving 4 laboratories was conducted on 2 separate lots of naturally contaminated raw poultry. Again, no statistically significant differences occurred. It is recommended that ISO 6579:2002 culture method for Salmonella be adopted Official First Action for the analysis of fresh cheese, fresh chilled and frozen poultry, and dried egg products.

Equivalence of Assurance® Gold Enzyme Immunoassay for Visual or Instrumental Detection of Motile and Nonmotile Salmonella in All Foods to AOAC Culture Method: Collaborative Study

Six foods representative of a wide variety of processed, dried powder processed, and raw food types were analyzed by the Assurance® Gold Salmonella Enzyme Immunoassay (EIA) and AOAC INTERNATIONAL culture method. Paired samples of each food type were simultaneously analyzed; one sample by the Assurance method and one by the AOAC culture method. The results for Assurance method were read visually and instrumentally with a microplate reader. A total of 24 laboratories representing federal government agencies and private industry, in the United States and Canada, participated in this collaborative study. Food types were inoculated with species of Salmonella with the exception of raw ground chicken, which was naturally contaminated. No statistical differences (p &lt; 0.05) were observed between Assurance Gold Salmonella EIA with either visual or instrumental interpretation and the AOAC culture method for any inoculation level of any food type or naturally contaminated food. The Assurance visual and instrumental options of reading sample reactions produced the same results for 1277 of the 1296 sample and controls analyzed.

Violence and Mental Health Among Gender-Diverse Individuals Enrolled in a Human Immunodeficiency Virus Program in Karnataka, South India

Purpose: Gender-diverse individuals in India face considerable discrimination, stigma, and violence. There is a dearth of published literature describing experiences of violence among this population and potential links to mental health.

Methods: A questionnaire was administered to 282 study participants, 18 years of age and older, who self-identified as hijra, kothi, double decker, or bisexual and were actively enrolled in a local HIV prevention program in Bangalore, India in 2012. Responses were used to calculate a composite depression/anxiety score. Associations between sociodemographic characteristics and experiences of physical and sexual violence in the previous six months were tested and differences in depression/anxiety score based on experiences of violence were explored.

Results: Recent physical violence was common among study participants and was reported among 46% of nirvan (emasculated) hijras (transgender), 42% of akwa (not emasculated) hijras, and 25% of kothis (feminine acting males). Rape in the previous year was particularly common among akwa hijras (39%). Factors associated with being raped included younger age, less education, and employment in basti (blessings), sex work, chela (disciple of hijra guru), or at a community-based organization. Kothis had the highest depression/anxiety score. No significant difference in depression/anxiety score based on recent history of physical violence or rape was found.

Conclusions: Physical violence and poor mental health are common among gender-diverse individuals in Bangalore, Karnataka. There is a need for services that cater to the unique mental health needs of gender-diverse individuals in India, following rights-based approaches that address the underlying roots of oppression they encounter.

Final validation of the ProMisE molecular classifier for endometrial carcinoma in a large population-based case series

Background

We have previously developed and confirmed a pragmatic molecular classifier for endometrial cancers; ProMisE (Proactive Molecular Risk Classifier for Endometrial Cancer). Inspired by the Cancer Genome Atlas, ProMisE identifies four prognostically distinct molecular subtypes and can be applied to diagnostic specimens (biopsy/curettings) enabling earlier informed decision-making. We have strictly adhered to the Institute of Medicine (IOM) guidelines for the development of genomic biomarkers, and herein present the final validation step of a locked-down classifier before clinical application.

Patients and methods

We assessed a retrospective cohort of women from the Tübingen University Women's Hospital treated for endometrial carcinoma between 2003 and 2013. Primary outcomes of overall, disease-specific, and progression-free survival were evaluated for clinical, pathological, and molecular features.

Results

Complete clinical and molecular data were evaluable from 452 women. Patient age ranged from 29 to 93 (median 65) years, and 87.8% cases were endometrioid histotype. Grade distribution included 282 (62.4%) G1, 75 (16.6%) G2, and 95 (21.0%) G3 tumors. 276 (61.1%) patients had stage IA disease, with the remaining stage IB [89 (19.7%)], stage II [26 (5.8%)], and stage III/IV [61 (13.5%)]. ProMisE molecular classification yielded 127 (28.1%) MMR-D, 42 (9.3%) POLE, 55 (12.2%) p53abn, and 228 (50.4%) p53wt. ProMisE was a prognostic marker for progression-free (P = 0.001) and disease-specific (P = 0.03) survival even after adjusting for known risk factors. Concordance between diagnostic and surgical specimens was highly favorable; accuracy 0.91, κ 0.88.

Discussion

We have developed, confirmed, and now validated a pragmatic molecular classification tool (ProMisE) that provides consistent categorization of tumors and identifies four distinct prognostic molecular subtypes. ProMisE can be applied to diagnostic samples and thus could be used to inform surgical procedure(s) and/or need for adjuvant therapy. Based on the IOM guidelines this classifier is now ready for clinical evaluation through prospective clinical trials.

Upfront Combination Therapy, Compared With Monotherapy, for Patients Not Previously Treated With a Biologic Agent Associates With Reduced Risk of Inflammatory Bowel Disease-related Complications in a Population-based Cohort Study

BACKGROUND & AIMS

Although guidelines recommend inclusion of immune modulators in anti-tumor necrosis factor (TNF) initiation therapy for Crohn's disease (CD) or ulcerative colitis (UC), there are limited data on the incremental effectiveness of this treatment strategy from the real world.

METHODS

We collected data from the Manitoba Inflammatory Bowel Disease (IBD) Epidemiology database on persons with CD (n=852) or UC (n=303), from 2001 through 2016, who began treatment with a TNF antagonist. New and/or continuing users of immunomodulators at the time anti-TNF therapy began were considered recipients of combination therapy. The main outcome was treatment ineffectiveness (IBD-related hospitalization, intestinal resection, corticosteroid use, or change of anti-TNF agent) during TNF antagonist-based therapy or within 90 days after the anti-TNF agent was discontinued. We used Cox proportional hazards models to assess the association between concomitant use of immunomodulators and treatment ineffectiveness.

RESULTS

In patients with CD, combination therapy was associated with a significant decrease in likelihood of treatment ineffectiveness (adjusted hazard ratio [aHR] for ineffectiveness, 0.62; 95% CI, 0.49-0.79). However, this association was not significant in patients with UC (aHR, 0.82; 95% CI, 0.56-1.20). In patients with CD, combination therapy was also associated with increased time to first IBD-related hospitalization (aHR 0.53; 95% CI, 0.36-0.80) and switching anti-TNF agents (aHR, 0.63; 95% CI, 0.41-0.97), but not associated with IBD-related surgery (aHR, 0.76; 95% CI, 0.51-1.12) or new or recurrent use of corticosteroids (aHR, 0.75; 95% CI, 0.55-1.04).

CONCLUSION

In an analysis of a database of real-world patients with IBD, we associated initiation therapy with a combination immune modulators and anti-TNF agents with a decreased likelihood of treatment ineffectiveness for patients with CD but not UC.

Functional gastrointestinal disorders negatively affect health-related quality of life in MS

Objective

To determine the prevalence of functional gastrointestinal disorders, the demographic and clinical characteristics associated with the presence of functional gastrointestinal disorders, and the effects of these disorders with health-related quality of life (HRQOL) in a large, diverse population of persons with MS.

Methods

In 2014, we surveyed participants in the North American Research Committee on Multiple Sclerosis registry regarding functional gastrointestinal disorders using the Rome III questionnaire. Participants also reported their sociodemographic characteristics, disability status using Patient Determined Disease Steps, the presence of comorbid depression and anxiety, health behaviors, and HRQOL using the RAND-12. We determined the prevalence of each gastrointestinal disorder using the Rome III criteria. Using multivariable logistic regression models, we assessed the factors associated with the presence of each bowel disorder. Using linear regression, we evaluated the association between functional gastrointestinal disorders and HRQOL.

Results

Of 6,312 eligible respondents, 76.5% were female, with a mean (SD) age of 58.3 (10.2) years. Forty-two percent of respondents (n = 2,647) had a functional gastrointestinal disorder, most often irritable bowel syndrome (IBS), which affected 28.2% of participants. The prevalence of all functional gastrointestinal disorders increased with greater disability, and the prevalence of IBS increased with longer disease duration. After adjusting for sociodemographic and clinical characteristics, functional gastrointestinal disorders were associated with lower physical and mental HRQOL (both p < 0.0001).

Conclusions

Functional gastrointestinal disorders are common in MS and are associated with reduced HRQOL.

Are perioperative therapeutic doses of statins associated with postoperative pain and opioid consumption after hip surgery under spinal anaesthesia?

Background

The anti-inflammatory effects of statins have been suggested to relieve postoperative pain. This retrospective study tested the association between the perioperative routine use of statins in therapeutic doses, and opioid requirements and pain scores, after hip replacement surgery.

Methods

With IRB approval, data was obtained for adult patients who had elective hip replacement surgery under spinal anaesthesia at Cleveland Clinic between 2005 and 2015. Patients were compared using a joint hypothesis framework. We used the inverse probability of treatment weighting method to control for observed confounding factors (a total of 26).

Results

We included 611 statin users and 780 non-statin users. Pain score during the initial 72 h after surgery was 0.07 higher (95% CI: -0.02, 0.17) in statin users (noninferiority test in both directions P<0.001). The estimated ratio of geometric means in the cumulative i.v. morphine equivalent opioid consumption was 1.01 (95% CI: 0.93, 1.10) for statin vs non-statin users (noninferiority test P=0.001 in the hypothesized direction and<0.001 in the other direction) during the initial 72 h after surgery. The statin and non-statin patients were deemed equivalent on postoperative opioid consumption and pain score.

Conclusions

This is the first large retrospective clinical study that investigates the effects of statin use on postoperative pain and opioid consumption. We observed no difference between statin users and non-users during the initial 72 h after hip surgery. Our findings do not support the routine use of statins as part of an analgesic regimen.

Traditional risk factors may not explain increased incidence of myocardial infarction in MS

Objective

To compare the risk of incident acute myocardial infarction (AMI) in the multiple sclerosis (MS) population and a matched population without MS, controlling for traditional vascular risk factors.

Methods

We conducted a retrospective matched cohort study using population-based administrative (health claims) data in 2 Canadian provinces, British Columbia and Manitoba. We identified incident MS cases using a validated case definition. For each case, we identified up to 5 controls without MS matched on age, sex, and region. We compared the incidence of AMI between cohorts using incidence rate ratios (IRR). We used Cox proportional hazards regression to compare the hazard of AMI between cohorts adjusting for sociodemographic factors, diabetes, hypertension, and hyperlipidemia. We pooled the provincial findings using meta-analysis.

Results

We identified 14,565 persons with MS and 72,825 matched controls. The crude incidence of AMI per 100,000 population was 146.2 (95% confidence interval [CI] 129.0–163.5) in the MS population and 128.8 (95% CI 121.8–135.8) in the matched population. After age standardization, the incidence of AMI was higher in the MS population than in the matched population (IRR 1.18; 95% CI 1.03–1.36). After adjustment, the hazard of AMI was 60% higher in the MS population than in the matched population (hazard ratio 1.63; 95% CI 1.43–1.87).

Conclusion

The risk of AMI is elevated in MS, and this risk may not be accounted for by traditional vascular risk factors.

Validation of an algorithm for identifying MS cases in administrative health claims datasets

OBJECTIVE

To develop a valid algorithm for identifying multiple sclerosis (MS) cases in administrative health claims (AHC) datasets.

METHODS

We used 4 AHC datasets from the Veterans Administration (VA), Kaiser Permanente Southern California (KPSC), Manitoba (Canada), and Saskatchewan (Canada). In the VA, KPSC, and Manitoba, we tested the performance of candidate algorithms based on inpatient, outpatient, and disease-modifying therapy (DMT) claims compared to medical records review using sensitivity, specificity, positive and negative predictive values, and interrater reliability (Youden J statistic) both overall and stratified by sex and age. In Saskatchewan, we tested the algorithms in a cohort randomly selected from the general population.

RESULTS

The preferred algorithm required ≥3 MS-related claims from any combination of inpatient, outpatient, or DMT claims within a 1-year time period; a 2-year time period provided little gain in performance. Algorithms including DMT claims performed better than those that did not. Sensitivity (86.6%-96.0%), specificity (66.7%-99.0%), positive predictive value (95.4%-99.0%), and interrater reliability (Youden J = 0.60-0.92) were generally stable across datasets and across strata. Some variation in performance in the stratified analyses was observed but largely reflected changes in the composition of the strata. In Saskatchewan, the preferred algorithm had a sensitivity of 96%, specificity of 99%, positive predictive value of 99%, and negative predictive value of 96%.

CONCLUSIONS

The performance of each algorithm was remarkably consistent across datasets. The preferred algorithm required ≥3 MS-related claims from any combination of inpatient, outpatient, or DMT use within 1 year. We recommend this algorithm as the standard AHC case definition for MS.

LAG-3+ tumor infiltrating lymphocytes in breast cancer: clinical correlates and association with PD-1/PD-L1+ tumors

Background

Novel immune checkpoint blockade strategies are being evaluated in clinical trials and include targeting the lymphocyte activation gene 3 (LAG-3) checkpoint, alone or in combination with PD-1/PD-L1 blockade. We investigated LAG-3 expression and its prognostic value in a large series of breast cancer patients, and correlated LAG-3 expression with key biomarkers including PD-1 and PD-L1.

Experimental design

LAG-3 expression was evaluated by immunohistochemistry on two tissue microarray series incorporating 4322 breast cancer primary excision specimens (N = 330 in the training and N= 3992 in the validation set) linked to detailed clinicopathologic, biomarker and long-term clinical outcome data. PD-1 and PD-L1 expressions were also evaluated by immunohistochemistry. Stromal or intra-epithelial tumor infiltrating lymphocytes (sTILs or iTILs) expressing LAG-3 or PD-1 were assessed by absolute count. PD-L1 expression was evaluated as the percentage of positive carcinoma cells per core. Kaplan-Meier curves and Cox proportional hazard models were used for survival analyses.

Results

After locking down interpretation cut-offs on the training set, LAG-3+ iTILs were found in 11% of cases in the validation set. In both sets, LAG-3+ iTILs were significantly associated with negative prognostic factors: young age, large tumor size, high proliferation, HER2E and basal-like breast cancer subtypes. In multivariate analyses, breast cancer patients with LAG-3+ iTILs had a significantly improved breast cancer-specific survival [hazard ratio (HR): 0.71, 95% CI 0.56-0.90], particularly among estrogen receptor-negative patients (HR: 0.50, 95% CI 0.36-0.69). Furthermore, we found that 53% of PD-L1+ and 61% of PD-1+ cases were also positive for LAG-3+ iTILs. Concurrent infiltration of LAG-3+ and CD8+ iTILs was significantly associated with increased breast cancer-specific survival (HR: 0.49, 95% CI 0.32-0.74).

Conclusion

LAG-3+ iTILs are enriched in estrogen receptor-negative breast cancers and represent an independent favorable prognostic factor. In addition, a high proportion of PD-1/PD-L1+ tumors are co-infiltrated with LAG-3+ TILs, supporting potential immune checkpoint blockade combination strategies as a treatment option for breast cancer patients.

Diagnoses of Depression and Anxiety Versus Current Symptoms and Quality of Life in Multiple Sclerosis

BACKGROUND

Studies assessing the prevalence of depression and anxiety in multiple sclerosis (MS) have used various ascertainment methods that capture different constructs. The relationships between these methods are incompletely understood. Psychiatric comorbidity is associated with lower health-related quality of life (HRQOL) in MS, but the effects of past diagnoses of depression and anxiety on HRQOL are largely unknown. We compared the prevalence of depression and anxiety in persons with MS using administrative data, self-reported physician diagnoses, and symptom-based measures and compared characteristics of persons classified as depressed or anxious by each method. We evaluated whether HRQOL was most affected by previous diagnoses of depression or anxiety or by current symptoms.

METHODS

We linked clinical and administrative data for 859 participants with MS. HRQOL was measured by the Health Utilities Index Mark 3. We classified participants as depressed or anxious using administrative data, self-reported physician diagnoses, and the Hospital Anxiety and Depression Scale. Multivariable linear regression examined whether diagnosed depression or anxiety affected HRQOL after accounting for current symptoms.

RESULTS

Lifetime prevalence estimates for depression were approximately 30% regardless of methods used, but 35.8% with current depressive symptoms were not captured by either administrative data or self-reported diagnoses. Prevalence estimates of anxiety ranged from 11% to 19%, but 65.6% with current anxiety were not captured by either administrative data or self-reported diagnoses. Previous diagnoses did not decrease HRQOL after accounting for current symptoms.

CONCLUSIONS

Depression and, to a greater extent, anxiety remain underdiagnosed and undertreated in MS; both substantially contribute to reduced HRQOL in MS.

Lower prevalence of multiple sclerosis in First Nations Canadians

Background

We compared the incidence and prevalence of multiple sclerosis (MS) between First Nations (FN) and non-FN populations in Manitoba.

Methods

We applied previously validated algorithms to population-based administrative (health claims) data from Manitoba, Canada, to identify all persons with MS from 1984 to 2011. We identified FN individuals using the Municipality of Registration field held at Manitoba Health. We compared the incidence and prevalence of MS between the FN and non-FN populations using negative binomial models.

Results

From 1984 to 2011, 5,738 persons had MS, of whom 64 (1.1%) were of FN ethnicity. The average annual incidence rate per 100,000 population was 8.15 (95% confidence interval [CI] 5.98–11.1) in the FN population and 15.7 (95% CI 15.1–16.3) in the non-FN population (incidence rate ratio 0.52; 95% CI 0.38–0.71). In 1984, the crude prevalence of MS per 100,000 population was 35.8 (95% CI 14.9–86.1) in the FN population and 113.3 (95% CI 106.3–120.8) in the non-FN population. Between 1984 and 2011, the age-standardized prevalence of MS increased by 351% to 188.5 (95% CI 146.6–230.4) in the FN population. In contrast, the prevalence of MS per 100,000 general population increased by 225%–418.4% (95% CI 405.8–431.0).

Conclusions

The incidence and prevalence of MS are twofold lower in the FN population than the non-FN population. Nonetheless, the prevalence of MS in FN Manitobans is higher than in other indigenous populations outside Canada. Given reports of more rapid disability progression among FN Canadians with MS, and the rising prevalence of MS in this population, attention should be directed to the needs of this population.

Temporal Trends in Initiation of Therapy With Tumor Necrosis Factor Antagonists for Patients With Inflammatory Bowel Disease: A Population-based Analysis

BACKGROUND & AIMS

Anti-tumor necrosis factor (anti-TNF) agents are effective treatments for Crohn's disease (CD) and ulcerative colitis (UC). We aimed to determine their patterns of use and changes in these patterns over time, as well as use of immunomodulators and corticosteroids before anti-TNF therapy for persons with inflammatory bowel diseases.

METHODS

We used the University of Manitoba IBD Epidemiology Database to identify all anti-TNF users with CD and UC from 2001 through 2014. We assessed changes in the prevalence and incidence of anti-TNF use during different time periods (April 2001-March 2005, April 2005-March 2009, or April 2009-March 2013). We also characterized patterns of corticosteroid use, corticosteroid dependence, and immunomodulator use before anti-TNF administration and determined how these changed over time. The primary end point was change in time to first receipt of anti-TNF among the different time periods.

RESULTS

We identified 950 persons (761 with CD and 189 with UC) who received anti-TNF agents. The cumulative prevalence of persons with current or prior anti-TNF exposure in 2014 was 20.4% for CD and 6.0% for UC. In 2014 the cumulative incidence values of anti-TNF exposure within 5 years of diagnosis were 23.4% for patients with CD and 7.8% for patients with UC. Most users of anti-TNF agents had evidence of corticosteroid dependence (more than 2 g prednisone within any 12-month period) before initiation of anti-TNF therapy. Cumulative corticosteroid exposure before anti-TNF use decreased over time for patients with UC, but not significantly for patients with CD. There was no increase over time in the use of concomitant immunomodulators with anti-TNF therapy.

CONCLUSIONS

Use of anti-TNF agents increased from 2001 through 2014, with a concomitant significant decrease in cumulative use of corticosteroids before anti-TNF therapy for patients with UC. However, there has been no reduction in cumulative use of corticosteroids before anti-TNF therapy for patients with CD and no change in use of immunomodulators by patients with CD. These findings indicate a continuing need for optimization of anti-TNF therapy for patients with inflammatory bowel disease.

Assessment of DNA Ploidy in the ProMisE molecular subgroups of endometrial cancer

OBJECTIVE

We sought to determine whether DNA ploidy correlates with the four molecular subgroups of endometrial carcinoma (EC) as determined using ProMisE (Proactive Molecular Risk Classifier for Endometrial Cancer).

METHODS

90 cases of EC previously characterized by clinicopathological parameters, outcomes, and ProMisE molecular subgroup (POLE EDM, MMR-D, p53 wt or p53 abn) were assessed for DNA ploidy using image cytometry. Associations of ploidy with traditional clinicopathological parameters were also tested.

RESULTS

Abnormal DNA ploidy status differed amongst the ProMisE groups (p<0.001) and was found in 80.9% (17/21) of p53 abn, 37.0% (10/27) of p53 wt, 28.6% (4/14) of POLE EDM and 14.3% (4/28) of MMR-D. Abnormal DNA content was significantly associated with lower BMI (p=0.034) and grade 3 tumors (p=0.001). In the entire cohort, abnormal DNA content was significantly associated with worse progression free survival (p=0.0094) but not disease specific survival (p=0.249) or overall survival (p=0.187). When examining ploidy within each of the ProMisE groups, abnormal DNA content correlated with worse overall survival (p=0.041) and progression free survival (p=0.011) in the MMR-D group. No statistically significant relationship was seen in the remaining 3 groups.

CONCLUSION

Abnormal DNA ploidy status did correlate with the molecular subgroups of EC; abnormal DNA content was seen in the large majority of p53 abn cases. Abnormal ploidy however was also seen in smaller numbers in the p53 wt, POLE EDM and MMR-D groups; therefore abnormal DNA content was not a specific marker for any one molecular group. The addition of ploidy to the ProMisE molecular categories conferred additional prognostic value within the MMR-D group, which merits further study.

Adherence to disease-modifying therapies for multiple sclerosis and subsequent hospitalizations

PURPOSE

The aim of this study was to examine the association between optimal adherence to first-line disease-modifying therapies (DMT) for multiple sclerosis (MS) and hospitalizations.

METHODS

We used population-based administrative data from three Canadian provinces. All individuals receiving DMT (interferon-B-1b, interferon-B-1a, or glatiramer acetate) between January 1, 1996, and December 31, 2011 (British Columbia); March 31, 2012 (Manitoba); or March 31, 2014, (Saskatchewan) were included. Adherence was estimated for the first year of DMT (year 0), using the medication possession ratio (MPR). The association between optimal adherence (MPR ≥ 80%) and all-cause and MS-specific hospitalizations in the subsequent 1, 2, and 5 years was assessed using Hurdle Poisson and logistic regression. Rate and odds ratios were adjusted (aRR and aOR) for sociodemographic factors and prior health-care utilization.

RESULTS

Overall, 4746 subjects were followed for a mean 7.8 (SD 4.0) years; 3598 (76%) were women. Optimal DMT adherence was achieved in 3564/4746 (75.1%) subjects. Subsequent all-cause and MS-specific hospitalizations were lower for subjects with optimal versus suboptimal adherence, but none reached statistical significance (1-year period, aRR = 0.77, 95%CI: 0.47-1.26; aOR = 0.80, 95%CI: 0.52-1.25). Similar findings were observed in the 2-year and 5-year periods. Prior health-care utilization (hospitalizations and medications) was associated with future hospitalizations; for every additional medication class, the 5-year all-cause hospitalization rate and likelihood of an MS-specific hospitalization increased by 5% and 11%, respectively (aRR = 1.05, 95%CI: 1.02-1.07; and aOR = 1.11, 95%CI: 1.07-1.14).

CONCLUSIONS

Hospitalization rates were lower in subjects with optimal DMT adherence, but findings were not statistically significant. Prior hospitalization and polypharmacy were associated with increased risk for future hospitalizations in MS. Copyright © 2017 John Wiley & Sons, Ltd.

Increased incidence and prevalence of psoriasis in multiple sclerosis

BACKGROUND

Psoriasis and multiple sclerosis (MS) share some risk factors, and fumarates are effective disease-modifying therapies for both psoriasis and MS, suggesting a common pathogenesis. However, findings regarding the occurrence of psoriasis in the MS population are inconsistent.

OBJECTIVES

We aimed to estimate the incidence and prevalence of psoriasis in the MS population versus a matched cohort from the general population.

METHODS

We used population-based administrative data from the Canadian province of Manitoba to identify 4911 persons with MS and 23,274 age-, sex- and geographically-matched controls aged 20 years and older. We developed case definitions for psoriasis using ICD-9/10 codes and prescription claims. These case definitions were compared to self-reported psoriasis diagnoses. The preferred definition was applied to estimate the incidence and prevalence of psoriasis over the period 1998-2008. We used multivariable Cox regression to estimate the risk of psoriasis in the MS population at the individual level, adjusting for sex, age at the index date, socioeconomic status and physician visits.

RESULTS

In 2008, the crude incidence of psoriasis per 100,000 person-years was 466.7 (95%CI: 266.8-758.0) in the MS population, and 221.3 in the matched population (95%CI: 158.1-301.4). The crude prevalence of psoriasis per 100,000 persons was 4666.1 (95%CI: 3985.2-5429.9) in the MS population, and 3313.5 (95%CI: 3057.4-3585.3) in the matched population. The incidence and prevalence of psoriasis rose slightly over time. After adjusting for sex, age at the index date, socioeconomic status and physician visits, the risk of incident psoriasis was 54% higher in the MS population (HR 1.54; 95%CI: 1.07-2.24).

CONCLUSION

Psoriasis incidence and prevalence are higher in the MS population than in the matched population.

Comparison of the population excess fraction of Chlamydia trachomatis infection on pelvic inflammatory disease at 12-months in the presence and absence of chlamydia testing and treatment: Systematic review and retrospective cohort analysis

BACKGROUND

The impact of Chlamydia trachomatis (chlamydia) control on the incidence of pelvic inflammatory disease (PID) is theoretically limited by the proportion of PID caused by chlamydia. We estimate the population excess fraction (PEF) of treated chlamydia infection on PID at 12-months in settings with widespread chlamydia control (testing and treatment) and compare this to the estimated PEF of untreated chlamydia.

METHODS

We used two large retrospective population-based cohorts of women of reproductive age from settings with widespread chlamydia control to calculate the PEF of treated chlamydia on PID at 12-months. We undertook a systematic review to identify further studies that reported the risk of PID in women who were tested for chlamydia (infected and uninfected). We used the same method to calculate the PEF in eligible studies then compared all estimates of PEF.

RESULTS

The systematic review identified a single study, a randomised controlled trial of chlamydia screening (POPI-RCT). In the presence of testing and treatment <10% of PID at 12-months was attributable to treated (baseline) chlamydia infections (Manitoba: 8.86%(95%CI 7.15-10.75); Denmark: 3.84%(3.26-4.45); screened-arm POPI-RCT: 0.99%(0.00-29.06)). In the absence of active chlamydia treatment 26.44%(11.57-46.32) of PID at 12-months was attributable to untreated (baseline) chlamydia infections (deferred-arm POPI-RCT). The PEFs suggest that eradicating baseline chlamydia infections could prevent 484 cases of PID at 12-months per 100,000 women in the untreated setting and 13-184 cases of PID per 100,000 tested women in the presence of testing and treatment.

CONCLUSION

Testing and treating chlamydia reduced the PEF of chlamydia on PID by 65% compared to the untreated setting. But in the presence of testing and treatment over 90% of PID could not be attributed to a baseline chlamydia infection. More information is needed about the aetiology of PID to develop effective strategies for improving the reproductive health of women.

Abstract P1-09-08: Predictive effect of cytotoxic tumor infiltrating lymphocytes in HER2-positive metastatic breast cancer: A correlative study with CCTG MA.31

Background and Objectives: The presence of tumor infiltrating lymphocytes (TILs), particularly CD8+ cytotoxic T-cells, has been associated with improved prognosis in patients with HER2+ breast cancer. Increasing levels of TILs also appear to predict response to adjuvant trastuzumab in early breast cancer, although they did not predict benefit of combined trastuzumab-lapatinib neoadjuvant dual therapy over monotherapy in NeoALLTO. CCTG MA.31 randomized 652 women with HER2+ metastatic breast cancer to treatment with trastuzumab (T) vs. lapatinib (L), in combination with taxane (Tax) chemotherapy for 24 weeks, followed by the same HER2-targeted monotherapy. Final results from MA.31 found trastuzumab was superior to lapatinib for the primary endpoint of progression free survival (PFS): the hazard ratio (HR) for lapatinib to trastuzumab was 1.37 (95% CI, 1.13-1.65). Although both agents block HER2 signaling, trastuzumab has additional mechanisms of action via the immune system. We hypothesized that TIL levels may predict response to HER2-targeted therapy (trastuzumab vs. lapatinib).

Methods: MA.31 included HER2+ metastatic breast cancer patients, median age 55 years, and median follow-up 21.5 months. Overall TILs were counted per published guidelines on the original H&E stained sections used for pathology review at study entry. Immunohistochemistry (IHC) was performed on unstained sections from tissue microarrays or individual formalin-fixed paraffin-embedded blocks to test expression of lymphocyte biomarkers CD8, FOXP3, CD56 and PD-1 on stromal and intra-tumoral TILs (sTILs, iTILs). Statistical analysis was conducted by CCTG for a total of 9 prespecified biomarker tests. Associations of TILs with PFS were evaluated by univariate stratified log-rank test with graphical Kaplan-Meier curves, and by stratified multivariate Cox proportional hazards regression analysis. Predictive effect was examined with a test of interaction between treatment allocation and biomarker classification (high vs. low, using pre-established cutpoints).

Results: Of the 652 cases, 614 had slides for overall TIL assessment and 427 for IHC biomarker assessments. In this correlative study set, superiority of trastuzumab over lapatinib for PFS was confirmed in multivariate analysis (LTax/T vs. TTax/L: HR = 2.55, 95% CI = 1.43-4.55, p = 0.001). TIL counts by H&E were neither prognostic nor predictive in this set of metastatic HER2+ breast cancers. Lymphocyte IHC markers were not prognostic. However, prespecified stratified univariate analysis detected a significantly higher risk for lapatinib over trastuzumab (HR = 2.94, 95% CI = 1.40-6.17, p = 0.003) in patients with low CD8+ sTIL (&lt; 3) than was observed among those with high CD8+ sTIL (HR = 1.36, 95% CI = 1.05-1.75, p = 0.019). This differential effect was confirmed in multivariate analysis (interaction test p = 0.042). The other tested biomarkers did not demonstrate significant predictive effects.

Conclusions: In this correlative study of metastatic HER2+ breast cancer, a low level of pre-existing stromal cytotoxic T cell infiltration predicts women who benefit most from trastuzumab over lapatinib. Overall TIL counts were neither prognostic nor predictive.

Citation Format: Liu S, Chen B, Burugu S, Leung S, Gao D, Virk S, Kos Z, Parulekar WR, Shepherd L, Gelmon K, Nielsen TO. Predictive effect of cytotoxic tumor infiltrating lymphocytes in HER2-positive metastatic breast cancer: A correlative study with CCTG MA.31 [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P1-09-08.

Chronic lung disease and multiple sclerosis: Incidence, prevalence, and temporal trends

OBJECTIVES

We aimed to estimate the incidence and prevalence of chronic lung disease (CLD), including asthma and chronic obstructive pulmonary disease, in the MS population versus a matched cohort from the general population.

METHODS

We used population-based administrative data from four Canadian provinces to identify 44,452 persons with MS and 220,849 age-, sex- and geographically-matched controls aged 20 years and older. We employed a validated case definition to estimate the incidence and prevalence of CLD over the period 1995-2005, and used Poisson regression to assess temporal trends.

RESULTS

In 2005, the crude incidence of CLD per 100,000 persons was 806 (95%CI: 701-911) in the MS population, and 757 in the matched population (95%CI: 712-803). In 2005, the crude prevalence of CLD was 13.5% (95%CI: 13.1-14.0%) in the MS population, and 12.4% (95%CI: 12.3-12.6%) in the matched population. Among persons aged 20-44 years, the average annual incidence of CLD was higher in the MS population than in the matched population (RR 1.15; 95%CI: 1.02-1.30), but did not differ between populations for those aged ≥45 years. The incidence of CLD was stable, but the prevalence of CLD increased 60% over the study period.

CONCLUSION

CLD is relatively common in the MS population. The incidence of CLD has been stable over time, but the prevalence of CLD has increased. Among persons aged 20-44 years, CLD is more common in the MS population than in a matched population. Given the prevalence of CLD in the MS population, further attention to the effects of CLD on outcomes in MS and approaches to mitigating those effects are warranted.