Age, Gender, and Liver Enzyme Impact Hospital Stay in COVID-19 Minority Patient with Cancer in the USA: Does Race Matters in the Pandemic?

Patients with cancer are known to have a poor prognosis when infected with SARS-CoV-2 infection. We aimed in this study to assess health outcomes in COVID-19 patients with different cancers in comparison to non-cancer COVID-19 patients from different centers in the United States (US). We evaluated medical records of 1,943 COVID-19 Cancer patients from 3 hospitals admitted between December 2019 to October 2021 and compared them with non-cancer COVID-19 patients. Among 1,943 hospitalized COVID-19 patients, 18.7% (n=364) have an active or previous history of cancer. Among these 364 cancer patients, 222 were African Americans (61.7%) and 121 were Caucasians (33.2%). Cancer patients had significantly longer hospitalization compared to controls (8.24 vs 6.7 days). Overall, Lung cancer is associated with high mortality. Patients with a previous history of cancer were more prone to death (p=0.04) than active cancer patients. In univariate and multivariate analyses, predictors of death among cancer patients were male sex, older age, presence of dyspnea, elevated troponin, elevated AST (0.001) and ALT (0.05), low albumin (p=0.04) and mechanical ventilation (p=0.001). Patients with a previous history of cancer were more prone to death when compared to active cancer COVID-19 patients. Early recognition of cancer COVID-19 patients' death-associated risk factors can help determine appropriate treatment and management plans for better prognosis and outcome.

Occult tension pneumothorax discovered following imaging for adult trauma patients in the modern major trauma system: a multicentre observational study

BACKGROUND

Tension pneumothorax following trauma is a life-threatening emergency and radiological investigation is normally discouraged prior to treatment in traditional trauma doctrines such as ATLS. Some trauma patients may be physiologically stable enough for diagnostic imaging and occult tension pneumothorax is discovered radiologically. We assessed the outcomes of these patients and compared them with those with clinical diagnosis of tension pneumothorax prior to imaging.

METHODS

A multicentre civilian-military collaborative network of six major trauma centres in the UK collected observational data from adult patients who had a diagnosis of traumatic tension pneumothorax during a 33-month period. Patients were divided into 'radiological' (diagnosis following CT/CXR) or 'clinical' (no prior CT/CXR) groups. The effect of radiological diagnosis on survival was analysed using multivariable logistic regression that included the covariates of age, gender, comorbidities and Injury Severity Score.

RESULTS

There were 133 patients, with a median age of 41 (IQR 24-61); 108 (81%) were male. Survivors included 49 of 59 (83%) in the radiological group and 59 of 74 (80%) in the clinical group (p=0.487). Multivariable logistic regression showed no significant association between radiological diagnosis and survival (OR 2.40, 95% CI 0.80 to 7.95; p=0.130). There was no significant difference in mortality between the groups.

CONCLUSION

Radiological imaging may be appropriate for selected trauma patients at risk of tension pneumothorax if they are considered haemodynamically stable. Trauma patients may be physiologically stable enough for radiological imaging but have occult tension pneumothorax because they did not have the typical clinical presentation. The historical dogma of the 'forbidden scan' no longer applies to such patients.

The empty pelvis syndrome: a core data set from the PelvEx collaborative

BACKGROUND

Empty pelvis syndrome (EPS) is a significant source of morbidity following pelvic exenteration (PE), but is undefined. EPS outcome reporting and descriptors of radicality of PE are inconsistent; therefore, the best approaches for prevention are unknown. To facilitate future research into EPS, the aim of this study is to define a measurable core outcome set, core descriptor set and written definition for EPS. Consensus on strategies to mitigate EPS was also explored.

METHOD

Three-stage consensus methodology was used: longlisting with systematic review, healthcare professional event, patient engagement, and Delphi-piloting; shortlisting with two rounds of modified Delphi; and a confirmatory stage using a modified nominal group technique. This included a selection of measurement instruments, and iterative generation of a written EPS definition.

RESULTS

One hundred and three and 119 participants took part in the modified Delphi and consensus meetings, respectively. This encompassed international patient and healthcare professional representation with multidisciplinary input. Seventy statements were longlisted, seven core outcomes (bowel obstruction, enteroperineal fistula, chronic perineal sinus, infected pelvic collection, bowel obstruction, morbidity from reconstruction, re-intervention, and quality of life), and four core descriptors (magnitude of surgery, radiotherapy-induced damage, methods of reconstruction, and changes in volume of pelvic dead space) reached consensus-where applicable, measurement of these outcomes and descriptors was defined. A written definition for EPS was agreed.

CONCLUSIONS

EPS is an area of unmet research and clinical need. This study provides an agreed definition and core data set for EPS to facilitate further research.

Asymptomatic esophageal perforation discovered after elective cardiac surgery: the importance of clinical awareness

Transesophageal echocardiography (TEE) has become an indispensable part of cardiothoracic surgery at present and is considered to be a safe procedure, rarely associated with complications. However, TEE may cause serious and life threatening complications, as presented in this case report. We describe a patient who developed an empyema after elective cardiac surgery due to an esophageal perforation caused by TEE, without any clinical symptoms. Risk factors for TEE-related complications, identified in recent literature, will be discussed as well as the remarkable absence of clinical symptoms in this particular patient.

Clinical Utility of Dual Phase FDG PET for Distinguishing Tumor Progression from Radionecrosis in the Modern Era

PURPOSE/OBJECTIVE(S)

Dual-phase PET CT, a technique by which two PET/CT scans are taken hours apart, has previously shown utility in differentiating radionecrosis (RN) from tumor progression (TP) after radiation for brain metastases. We sought to validate the utility of this technique in an independent, contemporary patient cohort. Understanding the difficulty of validation without the gold standard of pathologic confirmation in a majority of cases, we hypothesized that a dual-phase PET/CT indicating likely RN would correlate with improved overall survival (OS).

MATERIALS/METHODS

We performed a retrospective cohort study of all patients who received dual-phase FDG-PET between April 2015 and January 2023 at a single center for the purpose of distinguishing RN from TP in brain metastases previously treated with radiation. Scans were classified as indicating likely RN (dpPET-RN), likely TP (dpPET-TP), or unclear (dpPET-Unc) based on final radiology report. A Kaplan Meier (K-M) analysis was performed to evaluate differences in survival among the different dual-phase PET finding categories. An alpha level of 0.05 in the log-rank test was used to determine statistical significance.

RESULTS

We identified 36 patients who met inclusion criteria. All patients had received prior radiation - stereotactic radiosurgery (SRS), whole brain radiotherapy (WBRT) or both- to the lesion, and 21 (58%) had received surgery at some point prior to the dual phase PET CT. One patient received brachytherapy. Median time from the most recent course of radiation until dual-phase PET was 294 days, while median time from most recent surgery to dual-phase PET was 379 days. 14/36 (39%) of scans were called as dpPET-TP,15/36 (42%) were dpPET-RN, and 7/36 (19%) were dpPET-Unc. There were 10 cases where pathology was available after subsequent resection of the lesion. Five of the 10 path reports were concordant with the dual phase PET read, 5 were discordant. On K-M, median survival was 11 months (95% CI: 7.8 to 14.2 months) for dpPET-TP patients, 18 months (95% CI: 7.9 to 33.5 months) for dpPET-RN, and 12 months (95% CI: 0.0 to 51.2 months) for dpPET-Unc. On log rank testing, differences in the survival distribution for the different groups of dual-phase FDG-PET results were not statistically significant, χ2(2) = 4.085, p = .130.

CONCLUSION

Dual-phase PET CT has been proposed as a useful tool for distinguishing TP from RN after prior radiation. In the small subset of cases from our study with pathologic confirmation of outcomes, dual-phase PET failed to show high concordance with pathology. Although the dpPET-RN cohort had numerically superior OS compared to the dpPET-TP and dpPET-unc groups, this result was not statistically significant. Further independent validation of this imaging technique is warranted before it can be relied upon for routine clinical management.

A systematic review and meta-analysis of the effects of community use of oral nutritional supplements on clinical outcomes

The impact of oral nutritional supplements (ONS) on patients with complications (disease related morbidity) requires further exploration. This systematic review included 44 randomised controlled trials (RCT) (29 RCT surgical, 15 RCT medical patients) examining the effect of ONS in community settings on the incidence of complications (n = 716, mean age 67 years, range 35-87). ONS (mean intake 588 kcal/day, range 125-1750; protein 22 g/day, range 0-54; mean energy from protein 22 %, range 0-54) were prescribed for a mean 74 days, range 5-365. Most RCT (77 %) reported fewer complications in the ONS group versus control. Meta-analysis (39 RCT) showed ONS consumption reduced complications including infections, pressure ulcers, wound and fracture healing (OR 0.68, 95 % CI 0.59,0.79; p<0.001). Results showed reductions when ONS were used in hospital and community settings (OR 0.72, 95 % CI 0.59,0.87; p = 0.001) or just in the community (OR 0.65, 95 % CI 0.52, 0.80; p<0.001). Reductions in complications were only seen with high ONS adherence ≥ 80 % (OR 0.63, 95 % CI 0.48,0.83; p = 0.001) and ready-to-drink ONS (OR 0.69, 95 % CI 0.60,0.81; p<0.001). This systematic review and meta-analysis show community-based use of ONS in addition to the diet substantially reduces the incidence of complications. The diversity of ONS, patient populations and complication outcomes within the trials included in this review mean further research is warranted.

1174 THE ROLE OF HIP FRACTURE IN TRAJECTORIES OF DEPRESSIVE SYMPTOMS AMONG OLDER ADULTS: ANALYSIS FROM THE ENGLISH LONGITUDINAL STUDY

Introduction

Older adults experience ‘Late life depression’. Hip fractures may negatively influence trajectories of depressive symptoms in older adults. This study aimed to determine trajectories of depressive symptoms among older adults in England, overall and for those after hip fracture, and identify characteristics defining trajectory membership.

Methods

Analysis of adults aged 60 years or more (n=7,050), including a hip fracture subgroup (n = 384), from the English Longitudinal Study of Ageing. Latent class growth mixture modelling was completed. Depressive symptom prevalence was estimated at baseline. Chi-squared tests were completed to compare baseline characteristics across trajectories.

Results

Three trajectory groups were identified overall and for those with hip fracture: no-, mild-, and moderate-severe- symptoms. The moderate-severe group comprised 13.7% and 7% of participants for overall and hip fracture populations respectively. Overall, the proportion of participants with depressive symptoms were 0.4%, 12.4% and 65.4% for no-, mild-, and moderate-severe- symptom groups, respectively. For the hip fracture subgroup, these proportions were 0.7%, 28.8%, and 85.2%. Depressive symptoms were stable over time, with a weak trend towards increasing severity for the moderate-severe group. Individuals with moderate-severe trajectories were older, more likely to be female, live alone and had worse health outcomes (p &lt; 0.001).

Conclusions

Older adults, and those after hip fracture, follow one of three trajectories of depressive symptoms which are broadly stable over time. The prevalence of depressive symptoms was lower for those with hip fracture however, when present, the symptoms were more severe than the overall population. Results suggest a role of factors including age, gender, and marital status in depressive symptoms trajectories.

Understanding the impact of nuclear-data covariances on various integral responses using adjustment

The EUCLID (Experiments Underpinned by Computational Learning for Improvements in Nuclear Data) project created a library of sensitivities for nine different integral responses with respect to nuclear data. These integral responses were obtained from measurements at LLNL (Lawrence Livermore National Laboratory) pulsed spheres, critical and sub-critical assemblies. At the same time, covariances for ENDF/B-VIII.0 were processed at LANL (Los Alamos National Laboratory). The combination of these data allow us to study the impact of nuclear-data covariances on various integral responses, either by forward-propagating covariances via sensitivities, or by using nuclear data, integral responses, and sensitivities for adjustment. Here, we will present: the impact of 1H, 9Be, 12C, 27Al, 56Fe, 235,238U, and 239,240Pu ENDF/B-VIII.0 covariances on simulated bounds of the following integral responses: LLNL pulsed-spheres neutron-leakage spectra, the effective neutron multiplication factor, reaction rates, and reactivity coefficients of ICSBEP critical assemblies. Also, adjustment results with the same nuclear-data covariances and responses will be discussed.

LA-UR-22-31309

Impact of pre-existing vascular disease on clinical outcomes in patients with non-ST-segment myocardial infarction: a nationwide cohort study

Aims

Little is known about the outcomes and processes of care of patients with non ST-segment myocardial infarction (NSTEMI) who present with “polyvascular” disease.

Methods

We analysed 287,279 NSTEMI patients using the Myocardial Infarction National Audit Project (MINAP) registry. Clinical characteristics and outcomes were analysed according to history of affected vascular bed; coronary artery disease (CAD), cerebrovascular disease (CeVD) and peripheral vascular disease (PVD), with comparison to a historically disease-free control group; comprising 167,947 patients (59%). Further analyses compared cumulative number of affected beds with our control.

Results

After adjusting for demographics and management, vascular bed disease was associated with increased likelihood of MACE (CAD OR: 1.06, 95% CI: 1.01–1.12, P=0.02) (CeVD OR: 1.19, 95% CI: 1.12–1.27, P&lt;0.001) (PVD OR: 1.22, 95% CI: 1.13–1.33, P&lt;0.001) and in-hospital mortality (CeVD OR: 1.24, 95% CI: 1.16–1.32, P&lt;0.001) (PVD OR: 1.33, 95% CI: 1.21–1.46, P&lt;0.001). Patients with no vascular disease were less likely to be discharged on statins (PVD 88%, CeVD 86%, CAD 90% and control 78%), and those with moderate (EF 30–49%) or severe left ventricular systolic dysfunction (LVSD) (EF&lt;30%) were less likely to be discharged on ACE inhibitors (CAD 82%, CeVD 77%, PVD 77%, control 74%). Patients with polyvascular disease were less likely to be discharged on DAPT (PVD 78%, CeVD 77%, CAD 80%, control 87%).

Conclusion

Polyvascular disease patients had a higher adjusted incidence of in-hospital mortality and MACE. Patients with no history of vascular disease were less likely to receive statins or ACE inhibitors/ARBs, but more likely to receive DAPT.

Funding Acknowledgement

Type of funding sources: None.

Single vs multiple cat adoptions: A trade-off between longer adoption times and social bonding in shelter cats

Timely adoption is essential for shelters to prevent unnecessary illness or euthanasia in cats (Felis catus). Many studies have examined the role of individual cat characteristics and environmental factors in facilitating cat adoptions, but none have looked at the role the number of cats being adopted plays. In this study, we examined whether or not adopting cats in pairs influences adoption times, in addition to commonly studied factors. We then collected video data on a small subset of cats to determine whether pairs that were adopted together differed behaviourally from pairs who were not. Our results demonstrate that cats who are adopted as part of a multi-cat outcome spent three days (42%) longer on the adoption floor than those adopted individually, independently of other factors such as age and coat colour. This difference increased to 13 days (185%) longer if the cat had a notification indicating they must be adopted together with another cat. While behavioural data show that these pairs of cats engage in significantly more affiliative behaviour with each other than cats who were adopted singly, there was a large discrepancy between which pairs the shelter classified as multi-outcome and those who would be classified that way based on behaviour alone. We suggest that decisions to place cats together should be made carefully given the potential adverse impacts of keeping cats in the shelter longer. Further, we suggest that guidance should be developed to help shelters accurately and consistently identify which cats merit a multi-outcome adoption.

327 To Fuse or Not to Fuse: The Elderly Patient with Lumbar Stenosis and Low-Grade Spondylolisthesis. Systematic Review and Meta-Analysis of Randomised Controlled Trials

Aim

The optimum surgical intervention for elderly patients with lumbar spinal stenosis(LSS) and low-grade degenerative-spondylolisthesis(LGDS) has been extensively debated. We conducted a systematic review and meta-analysis of randomised-controlled-trials(RCTs) comparing the effectiveness of decompression-alone against gold-standard decompression-with-fusion(D+F) in elderly patients with LSS and LGDS.

Method

A systematic literature search was performed on published databases from inception to October-2021. English-language RCTs of elderly patients (mean age over-65) with LSS and LGDS, who had undergone DA or D+F were included. The quality and weight of evidence was assessed, and a meta-analysis performed.

Results

Seven RCTs (n=581; mean age:65.9 years; 59.9% female) were included. There was no difference in visual-analogue-scale(VAS) scores of back-pain(BP) or leg-pain(LP) at mean follow-up of 28.6 months between both DA and D+F groups (BP: mean-difference (MD)-0.22, 95%CI:-0.76–0.32; LP: MD:-0.26, 95%CI:-0.79–0.27). In addition, subgroup analysis of long-term follow-up (&gt;3 years) showed lower VAS scores for BP and LP in patients who underwent DA (BP MD:-1.70, 95%CI:-2.8-(-0.60); LP MD:-1.00, 95%CI:-1.77-(-0.23)). No difference in disability, measured by Oswestry-Disability-Index(ODI) scores, was found between both groups (MD:0.50, 95%CI: -3.31–4.31). However, patients in DA group had less hospital complications and fewer adverse events (total-surgical-complications OR:0.57, 95%CI:0.36–0.90), despite a higher rate of post-operative DS (OR:8.63, 95%CI:3.35–22.26).

Conclusions

DA is not inferior to D+F in elderly patients with LSS and LGDS. DA has better pain outcomes at three-years follow-up and carries lower risk hospital-complications and fewer adverse-events. Surgeons should weigh these findings with increased risk of DS-progression.

495 Virtual Reality Simulation Training in Hip Surgery Versus Traditional Surgical Education Method: A Systematic Review of Randomised Controlled Trials

Aim

The purpose of this study was to perform a systematic review of the effects of orthopaedic virtual reality simulators on surgical skills across randomised controlled trials.

Method

The authors searched PubMed, CINAHL, MEDLINE, AMED, Eric, Embase, Cochrane Central Register of Controlled Trials, TRIP database and grey literature from 1946 to November 2020. Inclusion criteria were all level one studies, specifically randomised controlled trials with orthopaedic training simulators in hip surgery and clear evaluation of skills attained after virtual reality simulation (VR) training. The primary outcome was the reported quantitative assessment of operative skills acquisition. The Jadad scale was used as a tool in order to appraise the methodological quality of the included trials. The data collected were not amenable for meta-analysis as they were too heterogenous and were analysed and presented using a narrative analysis and the Synthesis Without Meta-analysis (SWiM) reporting guideline.

Results

A total of 1095 articles were identified. Four level I studies, all randomised controlled trials, including 86 participants were eligible for the final analysis. There were significant differences in the types of simulators, training structure, validity types, performance scores and outcome measures described in each study. In three out of four studies (75%) the use of VR training simulators led to improved surgical skills acquisition compared to other traditional teaching methods.

Conclusions

Overall, this review showed that the use of VR simulation training is a potential tool that can enhance surgical skills acquisition in hip surgery procedures compared to traditional education methods.

POS0691 EMULATING A TARGET TRIAL OF ADALIMUMAB VERSUS TOFACITINIB IN PATIENTS WITH RHEUMATOID ARTHRITIS: A COMPARATIVE EFFECTIVENESS ANALYSIS USING THE OPAL REAL-WORLD DATASET

Background

There is increasing recognition of the complementary role for real-world evidence (RWE) in health care and regulatory decision-making (1). However, careful analysis is required when drugs are compared using observational data to account for differences between treatment groups. Electronic medical records (EMR) are an important source of real-world data (RWD), but outcomes are often recorded incompletely.

We emulated a target trial of adalimumab (ADA) versus tofacitinib (TOF) in patients with rheumatoid arthritis (RA) using the OPAL dataset to illustrate the application of methodologies to address the challenges of non-random treatment assignment and incomplete data. The OPAL dataset is derived from EMR of 112 community-based rheumatologists around Australia, where practitioners have discretion to prescribe whichever b/tsDMARD they consider most clinically appropriate.

Objectives

To estimate the average treatment effect (ATE) of TOF compared to ADA at 3 and 9 months, defined as the difference in mean disease activity score (DAS28CRP), in patients with RA who are new users of a b/tsDMARD. This is equivalent to aiming to estimate the intention-to-treat effect in a randomised controlled trial.

Methods

OPAL patients diagnosed with RA were included if they initiated ADA or TOF between 1 October 2015 and 1 April 2021, were new b/tsDMARD users (no prior recorded b/tsDMARD, at least 6 months of prior csDMARD treatment), and had at least 1 component of DAS28CRP recorded at baseline or during follow-up. Data were also extracted on baseline characteristics. Baseline characteristics were DAS28CRP, patient demographics, regional location, disease duration, prescriber characteristics (including gender, experience), prior recorded comorbidities, and prior and concomitant treatment with csDMARDs and oral corticosteroids.

We used random forest multiple imputation to impute missing baseline and follow-up DAS28CRP components (2). Stable balancing weights (SBW) were then used to balance the treatment groups in terms of their baseline characteristics, including DAS28CRP (3). For each imputed dataset, the ATE at 3 months was estimated as the difference between the mean outcome in the two treatment groups after balancing (i.e. weighting) the sample, and then these estimates were averaged across the 10 imputed datasets. The ATE at 9 months was estimated similarly. The whole procedure was subsequently performed in 1000 bootstrap samples to estimate a 95% confidence interval (CI) for the ATEs using the percentile method (4).

Results

842 patients were identified including n=569 treated with ADA and n=273 treated with TOF. After applying the SBW, the maximum difference between the mean of each baseline characteristic in the ADA and TOF groups was less than 0.03% of the corresponding standard deviation in the whole sample, indicating reasonable balance was achieved in this complex dataset. After weighting, mean DAS28CRP reduced from 5.3 at baseline (both ADA and TOF groups) to 2.6 and 2.3 at 3 and 9 months for ADA, and 2.4 and 2.3 at 3 and 9 months for TOF.

The estimated ATE was -0.22 (95% CI -0.36, -0.03; p=0.02) at 3 months, indicating a modest but significant reduction in disease activity for patients on TOF. The estimated ATE was -0.03 (95% CI -0.19, 0.1; p=0.56) at 9 months, indicating no difference between groups.

Conclusion

DAS28CRP was significantly lower at 3 months for patients treated with TOF compared to ADA. However, 3 months of treatment with either drug led to substantive average reductions in mean DAS28CRP, consistent with remission. There was no difference between drugs at 9 months. Future work will estimate a per-protocol effect.

References

[1]Arlett et al. Clin Pharmacol Ther 2022;111(1):21–3.

[2]van Buuren and Groothuis-Oudshoorn J Stat Softw 201145(3):1–67

[3]Zubizarreta J Am Stat Assoc 2015;110(511):910–22

[4]Bartlett and Hughes Stat Methods Med Res 2020;29(12):3533–46

Acknowledgements

The authors acknowledge the members of OPAL Rheumatology Ltd and their patients for providing clinical data for this study, and Software4Specialists Pty Ltd for providing the Audit4 platform.

Disclosure of Interests

Claire Deakin: None declared, Bianca De Stavola: None declared, Geoff Littlejohn Consultant of: Abbvie, Janssen, Bristol Myers Squibb, Gilead, Eli Lilly, and MSD, Hedley Griffiths Consultant of: AbbVie and Eli Lilly, Sabina Ciciriello: None declared, Peter Youssef Speakers bureau: AbbVie, Novartis, Eli Lilly, David Mathers: None declared, Paul Bird Speakers bureau: Abbvie, Janssen, Bristol Myers Squibb, Pfizer, Novartis, Gilead, Eli Lilly, Consultant of: Abbvie, Janssen, Bristol Myers Squibb, Pfizer, Novartis, Gilead, Eli Lilly, Imaging consulting for Synarc and Boston Imaging Core Lab., Tegan Smith: None declared, Catherine OSullivan: None declared, Tim Freeman: None declared, Dana Segelov: None declared, David Hoffman: None declared, Shaun Seaman: None declared

POS1019 REAL-WORLD EVALUATION OF TREATMENT PATTERNS AND PERSISTENCE OF TOFACITINIB IN TREATMENT OF PSORIATIC ARTHRITIS IN AUSTRALIA: AN ANALYSIS OF THE OPAL DATASET

Background

Tofacitinib (TOF), a potent selective inhibitor of Janus kinase (JAK), is an approved treatment of psoriatic arthritis (PsA). In Australia, patients with active PsA despite six months of therapy with a pre-specified combination of csDMARDs are eligible to receive subsidised b/tsDMARDs. The clinician can prescribe the b/tsDMARD they deem to be the most clinically appropriate for the patient. Limited data exist to describe the real-world treatment patterns, characteristics and clinical outcomes of patients with PsA who receive TOF in the real-world setting.

Objectives

To describe real-world treatment patterns and treatment persistence among patients with PsA treated with TOF in the Australian post-approval setting using the OPAL dataset.

Methods

The OPAL dataset is a collection of deidentified clinical data derived from the electronic medical records of 112 rheumatologists at 43 sites around Australia. Adult patients with a diagnosis of PsA who received at least one prescription of TOF, a tumour necrosis factor inhibitor (TNFi) or an interleukin 17 inhibitor (IL-17Ai) between May 2019 and Sept 2020 were eligible, with data up to Sept 2021 included in the analysis. Results were summarised descriptively. Treatment persistence was summarised using Kaplan-Meier methods.

Results

Of 16,692 patients with PsA identified in the OPAL dataset, 1,486 (TOF n=406, IL-17Ai n=416, and TNFi n=664) were eligible for inclusion in this study. At the time of treatment initiation, the mean (SD) age of TOF, IL-17Ai and TNFi treated patients was 55.56 (12.68), 52.65 (12.72) and 50.32 (14.57) years, respectively. 19.2% of patients receiving TOF were first line compared with 41.8% of IL-17Ai and 62.8% of TNFi treated patients. The mean (SD) time from symptom onset to treatment initiation was longest for patients receiving TOF in first line (153.29 (127.50) months) compared to first line IL-17Ai (116.83 (113.97) months) and TNFi treated patients (92.37 (89.01) months). Overall, 34.2% of TOF, 32.9% of IL-17Ai and 26.4% of TNFi treated patients initiated therapy without concomitant cDMARDs being recorded.

Overall median persistence was 16.54 months (95% CI 13.84, 19.53) for TOF treated patients, 17.65 months (95% CI, 15.75, 19.56) for IL-17Ai treated patients and 17.16 months (95% CI 14.86, 20.48) for TNFi treated patients. As expected, persistence was generally longer in patients treated as first line (Figure 1) with patients receiving TOF observed to have slightly higher persistence in the first 15 months of treatment.

Figure 1.

Treatment persistence of patients receiving TOF, IL-17Ai and TNFi as first line therapy. Plot curtailed at 15 months as relatively few patients have information past this point. Where no stop date was recorded, censoring occurs at last recorded visit

Conclusion

In this analysis of a large Australian real-world dataset, TOF was more commonly utilised as a later line therapy for patients with PsA. Patients receiving TOF were observed to have slightly higher persistence within the first 15 months of starting first line therapy in this preliminary analysis.

Acknowledgements

The authors acknowledge the members of OPAL Rheumatology Ltd and their patients for providing clinical data for this study, and Software4Specialists Pty Ltd for providing the Audit4 platform. Financial support was provided by Pfizer Australia

Disclosure of Interests

Geoff Littlejohn Consultant of: Abbvie, Janssen, Bristol Myers Squibb, Gilead, Eli Lilly, and MSD, Jo Leadbetter: None declared, Belinda Butcher: None declared, Marie Feletar: None declared, Catherine OSullivan: None declared, Tegan Smith: None declared, David Witcombe Employee of: Pfizer Australia, Ho Yin Employee of: Pfizer Australia, Peter Youssef Speakers bureau: AbbVie, Novartis, Janssen and Eli Lilly

POS1034 EVOLVING MECHANISM OF ACTION PREFERENCE FOR THE TREATMENT OF PSORIATIC ARTHRITIS IN AUSTRALIA: AN ANALYSIS OF THE OPAL DATASET

Background

There are currently ten biologic and targeted synthetic (b/ts)DMARDs acting via five different modes of action (MOA) available for the treatment of psoriatic arthritis (PsA) in Australia. b/tsDMARDs are government-subsidised, and once the patient reaches the eligibility requirements, the clinician can prescribe the agent deemed most appropriate. Available agents include TNF inhibitors (TNFi, adalimumab, etanercept, infliximab, golimumab, certolizumab pegol), IL-17A inhibitors (IL-17Ai, secukinumab, ixekizumab), and IL-12/23 inhibitor (IL-12/23i, ustekinumab). Two new MOAs were recently added to the rheumatologist’s armamentarium: the first JAK inhibitor (JAKi, tofacitinib) was subsidized from May 2019 followed by upadacitinib from Oct 2021, and an IL-23 inhibitor (IL-23i, guselkumab) was subsidized from July 2021.

Objectives

The aim of this analysis was to describe the changing patterns of b/tsDMARD use for the treatment of PsA in real-world practice in Australia.

Methods

Deidentified clinical data were sourced from the OPAL dataset, which is collected in a custom-built electronic medical record during the routine consultation1. Data from patients >18 years with a physician diagnosis of PsA who were prescribed a b/tsDMARD between Jan-2007 and Sept-2021 were included in the analysis. The software program Tableau was used to display the data.

Results

At Sept 2021, 6,150 (38% of the total) patients with PsA in the OPAL dataset were prescribed b/tsDMARDs. Of these patients, 3741 (61%) were currently prescribed a TNFi, 1503 (24%) an IL-17Ai, 556 (9%) a JAKi, 222 (4%) an IL-12/23i and 134 patients (2%) an IL-23i. Over time, the 1st line TNFi initiations have decreased from 79.5% in 2018 to 65.2% in 2021. Conversely, 1st line IL-17Ai initiations have increased from 14.4% in 2018 to 22.2% in 2021. In 2021, TNFi accounted for 53.4% of 2nd line initiations and 38.2% of 3rd line initiations. IL-17Ai accounted for 30.4% of 2nd and 37.0% of 3rd line initiations and JAKi accounted for 10.5% of 2nd line and 14.2% of 3rd line initiations. In the 3 months that IL-23i has been subsidised, this MOA was the most initiated agent for patients who had been treated with more than two prior b/tsDMARDs. In 2021, 52.1% of patients switching from a 1st line TNFi switched to an alternative TNFi, 33.3% switched to an IL-17Ai and 11.3% switched to a JAKi in 2nd line. Of those switching from a 1st line IL-17Ai, 59.6% initiated a TNFi, 21.2% switched to an alternative IL-17Ai and 11.5% switched to a JAKi.

Conclusion

The patterns of b/tsDMARD utilisation for the treatment of PsA, when the choice of agent is at the discretion of the rheumatologist, remains dynamic and is evolving as new MOAs become available. TNFi remains the most prescribed b/tsDMARD for first line therapy. However an increase in first line use of alternative MOAs has been observed. TNFi cycling remains a commonly utilised real world treatment strategy but appears to be declining as new MOAs become available.

References

[1]Littlejohn GO, Tymms KE, Smith T, Griffiths HT. Using big data from real-world Australian rheumatology encounters to enhance clinical care and research. Clin Exp Rheumatol. Sep-Oct 2020;38(5):874-880.

Figure 1.

Percentage of patients initiating b/tsDMARDs by year and line of therapy.

Acknowledgements

The authors acknowledge the members of OPAL Rheumatology Ltd and their patients for providing clinical data for this study, and Software4Specialists Pty Ltd for providing the Audit4 platform.

Disclosure of Interests

Peter Youssef Speakers bureau: AbbVie, Novartis, Eli Lilly, Sabina Ciciriello: None declared, Gene-Siew Ngian: None declared, Juan Aw: None declared, Barry Kane: None declared, Catherine OSullivan: None declared, Tegan Smith: None declared, Claire Deakin: None declared, Geoff Littlejohn Consultant of: Abbvie, Janssen, Bristol Myers Squibb, Gilead, Eli Lilly, and MSD

Surveillance of RNase P, PMMoV, and CrAssphage in wastewater as indicators of human fecal concentration across urban sewer neighborhoods, Kentucky

Wastewater surveillance has been widely used as a supplemental method to track the community infection levels of severe acute respiratory syndrome coronavirus 2. A gap exists in standardized reporting for fecal indicator concentrations, which can be used to calibrate the primary outcome concentrations from wastewater monitoring for use in epidemiological models. To address this, measurements of fecal indicator concentration among wastewater samples collected from sewers and treatment centers in four counties of Kentucky (N = 650) were examined. Results from the untransformed wastewater data over 4 months of sampling indicated that the fecal indicator concentration of human ribonuclease P (RNase P) ranged from 5.1 × 101 to 1.15 × 106 copies/ml, pepper mild mottle virus (PMMoV) ranged from 7.23 × 103 to 3.53 × 107 copies/ml, and cross-assembly phage (CrAssphage) ranged from 9.69 × 103 to 1.85 × 108 copies/ml. The results showed both regional and temporal variability. If fecal indicators are used as normalization factors, knowing the daily sewer system flow of the sample location may matter more than rainfall. RNase P, while it may be suitable as an internal amplification and sample adequacy control, has less utility than PMMoV and CrAssphage as a fecal indicator in wastewater samples when working at different sizes of catchment area. The choice of fecal indicator will impact the results of surveillance studies using this indicator to represent fecal load. Our results contribute broadly to an applicable standard normalization factor and assist in interpreting wastewater data in epidemiological modeling and monitoring.

93 The Effects of Kinesiophobia on Outcome following Total Knee Replacement: A Systematic Review

Aim

Kinesiophobia, the fear of physical movement and activity related to injury vulnerability, has been linked to sub-optimal outcomes following total knee replacement (TKR). This systematic review has two aims: to define the relationship between kinesiophobia and functional outcomes, pain and range of motion following TKR, and to evaluate published treatments for kinesiophobia following TKR.

Method

A primary search was performed in March 2020. English-language studies recruiting adult primary TKR patients, using the Tampa Scale of Kinesiophobia (TSK) were included. Study quality was assessed using the Newcastle Ottawa Scale for cohort or case control studies, and the Cochrane Collaboration Risk of Bias tool for randomised controlled trials.

Results

All thirteen included papers (82 identified) showed adequately low risk of methodological bias. TSK1 (activity avoidance) correlated with WOMAC functional score at 12 months in three studies (r = 0.20 p &lt; 0.05, R = 0.317 p = 0.001, and correlation coefficient 0.197 p = 0.005). TSK score significantly correlated with mean active range of motion (ROM) at six months (105.33 (SD = 12.34) vs 85.53 (SD = 14.77) p = 0.000) post-operation. Three post-operative interventions improved TSK score vs control following TKR: a home-based functional exercise programme (TSK -14.30 (SD = 0.80) vs -2.10 (SD = 0.80) p &lt; 0.001)), an outpatient CBT programme (TSK 27.76 (SD = 4.56) vs 36.54 (SD = 3.58), and video-based psychological treatment (TSK 24 (SD = 5) vs 29 (SD = 5) p &lt; 0.01).

Conclusions

Kinesiophobia negatively affects functional outcomes up until one year post-operatively, while active ROM is reduced up to six months post procedure. Post-operative functional and psychological interventions can improve kinesiophobia following TKR.

178 Outcomes After Paediatric Extracorporeal Cardiopulmonary Resuscitation (ECPR) In A Tertiary Centre

Objective

To report our outcomes in utilizing extracorporeal membrane oxygenation (ECMO) institution for cardiac arrest.

Method

Retrospective records of all patients that needed ECPR between January 2015 and July 2020 have been reviewed. Primary outcomes were survival to ECMO decannulation, hospital discharge and one year survival. Secondary outcomes were the need for ECMO re-cannulation and neurology outcome using Paediatric Cerebral Performance Category (PCPC).

Results

A total of 44 consecutive patients were identified. 75 % were post cardiac surgery (n = 33), mean time from arrest to initiation of ECMO was 39.5 mins +/- 17.7 mins. Mean highest lactate prior to ECMO was 12.9 +/- 4.4. 79.6 % of patients received central cannulation. 11.4 % of patients (n = 5) needed more than one run of ECMO. Mean hours on ECMO were 175.4 +/- 212.5 hours and mean PCPC score was 2.14 +/- 1.68. Mean ICU stay was 16.2 +/- 16.9 days and total hospital stay was 47 +/- 68.5 days. Overall Survival to ECMO weaning was 68.4 % (n = 13) vs 92 % (n = 23) in neonates and paediatric patients, respectively. Survival to hospital discharge was 47.4 % (n = 9) vs 72 % (n = 18) and one year survival was 42.1 % (n = 8) vs 72 % (n = 18) in the neonatal and paediatric cohort, respectively.

Conclusions

Our survival rates are encouraging and in line with current published literature and comparable favourably to International ELSO (Extracorporeal life support organisation) registry for neonates and paediatric patients of all cause ECPR. Paediatric patients showed a survival advantage over neonates after ECPR.

92 Increased Proportion of Alcohol-Related Trauma in A South London Major Trauma Centre During Lockdown, A Cohort Study

Background

Alcohol has been associated with 10-35% trauma admissions and 40% trauma-related deaths globally. In response to the Covid-19 pandemic, the United Kingdom (UK) entered a state of ‘lockdown’ on 23rd March 2020. Restrictions were most significantly eased on 1st June 2020, when shops and schools re-opened. The purpose of this study was to quantify the effect of lockdown on alcohol-related trauma admissions.

Method

All adult patients admitted as ‘trauma calls’ to a London Major Trauma Centre (MTC) during April 2018 and April 2019 (pre-lockdown; N = 316), and 1st April – 31st May 2020 (lockdown; N = 191) had electronic patient records analysed. Patients’ blood alcohol level and records of intoxication were used to identify alcohol-related trauma. Trauma admissions from pre- and post-lockdown cohorts were compared using multiple regression analyses.

Results

Alcohol-related trauma was present in a significantly higher proportion of adult trauma calls during lockdown (lockdown 60/191 (31.4%), versus pre-lockdown 62/316 (19.6%); (Odds Ratio (OR) 0.83, 95% CI 0.38 to 1.28, p &lt; 0.001). Lockdown was also associated with increased weekend admissions of trauma (lockdown 125/191 weekend (65.5%) vs pre-lockdown 179/316 (56.7%); OR -0.40, 95% CI -0.79 to -0.02, p = 0.041). No significant difference existed in the age, gender, or mechanism between pre-lockdown and lockdown cohorts (p &gt; 0.05).

Conclusions

UK lockdown was independently associated with an increased proportion of alcohol-related trauma. Trauma admissions were increased during the weekend when staffing levels are reduced. With the possibility of subsequent global ‘waves’ of Covid-19, the risk of long-term repercussions of dangerous alcohol-related behaviour to public health must be addressed.

Topography and climate in the upper Indus Basin: Mapping elevation-snow cover relationships

The Upper Indus Basin (UIB), which covers a wide range of climatic and topographic settings, provides an ideal venue to explore the relationship between climate and topography. While the distribution of snow and glaciers is spatially and temporally heterogeneous, there exist regions with similar elevation-snow relationships. In this work, we construct elevation-binned snow-cover statistics to analyze 3415 watersheds and 7357 glaciers in the UIB region. We group both glaciers and watersheds using a hierarchical clustering approach and find that (1) watershed clusters mirror large-scale moisture transport patterns and (2) are highly dependent on median watershed elevation. (3) Glacier clusters are spatially heterogeneous and are less strongly controlled by elevation, but rather by local topographic parameters that modify solar insolation. Our clustering approach allows us to clearly define self-similar snow-topographic regions. Eastern watersheds in the UIB show a steep snow cover-elevation relationship whereas watersheds in the central and western UIB have moderately sloped relationships, but cluster in distinct groups. We highlight this snow-cover-topographic transition zone and argue that these watersheds have different hydrologic responses than other regions. Our hierarchical clustering approach provides a potential new framework to use in defining climatic zones in the cyrosphere based on empirical data.

Experiencing loneliness in parenthood: a scoping review

AIMS

Chronic loneliness is experienced by around a third of parents, but there is no comprehensive review into how, why and which parents experience loneliness. This scoping review aimed to provide insight into what is already known about parental loneliness and give directions for further applied and methodological research.

METHODS

Searches for peer-reviewed articles were undertaken in six databases: PsycINFO, Medline, CINAHL, Embase, Web of Science and Scopus, during May 2019 to February 2020. We searched for English studies which examined loneliness experienced during parenthood, including studies that involved parents with children under 16 years and living at home and excluding studies on pregnancy, childbirth or postbirth hospital care.

RESULTS

From 2566 studies retrieved, 133 were included for analysis. Most studies (n = 80) examined the experience of loneliness in specific groups of parents, for example, teenage parents, parents of a disabled child. Other studies examined theoretical issues (n = 6) or health and wellbeing impacts on parents (n = 16) and their offspring (n = 17). There were 14 intervention studies with parents that measured loneliness as an outcome. Insights indicate that parental loneliness may be different to loneliness experienced in other cohorts. There is evidence that parental loneliness has direct and intergenerational impacts on parent and child mental health. Some parents (e.g. with children with chronic illness or disability, immigrant or ethnic minority parents) also appear to be at increased risk of loneliness although evidence is not conclusive.

CONCLUSION

This work has identified key gaps with further international, comparative and conceptual research needed.

Wastewater Sample Site Selection to Estimate Geographically Resolved Community Prevalence of COVID-19: A Sampling Protocol Perspective

Wastewater monitoring for virus infections within communities can complement conventional clinical surveillance. Currently, most SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) clinical testing is voluntary and inconsistently available, except for a few occupational and educational settings, and therefore likely underrepresents actual population prevalence. Randomized testing on a regular basis to estimate accurate population-level infection rates is prohibitively costly and is hampered by a range of limitations and barriers associated with participation in clinical research. In comparison, community-level fecal monitoring can be performed through wastewater surveillance to effectively surveil communities. However, epidemiologically defined protocols for wastewater sample site selection are lacking. Herein, we describe methods for developing a geographically resolved population-level wastewater sampling approach in Jefferson County, Kentucky, and present preliminary results. Utilizing this site selection protocol, samples (n = 237) were collected from 17 wastewater catchment areas, September 8 to October 30, 2020 from one to four times per week in each area and compared to concurrent clinical data aggregated to wastewater catchment areas and county level. SARS-CoV-2 RNA was consistently present in wastewater during the studied period, and varied by area. Data obtained using the site selection protocol showed variation in geographically resolved wastewater SARS-CoV-2 RNA concentration compared to clinical rates. These findings highlight the importance of neighborhood-equivalent spatial scales and provide a promising approach for viral epidemic surveillance, thus better guiding spatially targeted public health mitigation strategies.

POS0906 PREVALENCE OF SLEEP DISTURBANCE IN PATIENTS WITH ANKYLOSING SPONDYLITIS WITHIN THE AUSTRALIAN CLINICAL SETTING (ASLEEP STUDY): A REAL-WORLD OBSERVATIONAL STUDY USING THE OPAL DATASET

Background:

Sleep disorders are more prevalent in patients with ankylosing spondylitis (AS) compared to the general population. Sleep disturbance in AS, in addition to pain and fatigue, can lead to impaired physical function and reduced quality of life.

Objectives:

The primary objective was to determine the prevalence of sleep disturbance in patients with AS in a real-world Australian cohort using the Insomnia Severity Index (ISI) and Multivariate Apnoea Prediction Index (MAPI). ISI score of ≥ 15 is considered clinical insomnia. MAPI values below 0.05 are suggestive of clinical apnoea.

Methods:

Routinely collected, de-identified clinical data were sourced from the OPAL dataset. Patients aged between 18 and 95 years with a diagnosis of AS and who had completed at least one ISI or MAPI questionnaire between Jan-2019 and Sept-2020 were included. ISI and MAPI questionnaires were emailed to patients using OPAL’s electronic patient reported outcome (ePRO) delivery method or completed in the clinic using a smart device and returned to the patient’s file using a QR code. Disease activity was assessed using BASDAI collected at the same time as the sleep questionnaires. Age, sex and duration of symptoms were used to propensity match patients in the Il-17ai and TNFi group in a 1:2 ratio.

Results:

495 of the 5,323 patients identified with AS completed a questionnaire and were included in the analysis (n=395 TNFi, n=48 Il-17ai (secukinumab), n=52 other therapies). 142 were included in the propensity score matched population (n = 94 TNFi, and n = 48 Il-17ai). In the overall population the mean (SD) age was 48.3 (13.6), 55.4% were males, the mean (SD) BMI was 30.1 (19.6) at the index date and 4.8% reported depression. 51.7% had an optimal disease control (BASDAI <4). The mean (SD) ISI score was 8.6 (6.2). 48.1% reported no clinical significant insomnia, 32.7% reported subthreshold insomnia, 16% reported clinical insomnia (moderate severity) and 3.2% reported clinical insomnia (severe). The mean (SD) MAPI score was 0.4 (0.3). 292 patients (59.0%) had low risk of clinical apnoea, 134 patients (27.1%) had high risk of clinical apnoea and 69 patients 13.9% had not completed the MAPI questionnaire. In the propensity scored matched population, the TNFi and Il-17ai groups had mean (SD) ISI scores of 9.1 (6.6) and 8.9 (5.9) at index, respectively (p = 0.83) and mean (SD) MAPI scores of 0.3 (0.2) and 0.4 (0.3) at index, respectively (p=0.046), however a higher percentage of overweight and obese patients were identified in the Il-17ai treatment group. Ordered logistic regression analysis of the relationship between demographics and ISI in the matched population found that patients with BASDAI ≥4 were seven times more likely to experience greater sleep disturbance (OR 7.29, 95%CI 2.37 to 22.46, p=0.001) than those with BASDAI <4.

Conclusion:

In this real-world AS cohort, poor disease control was associated with sleep disturbance, despite bDMARD therapy. Little difference was observed between TNFi and Il-17ai treatment. Screening for sleep disturbance and fatigue in routine clinical care may provide a more holistic view of the burden of this disease.

Table 1.

Patient characteristics and outcome scores in the propensity score matched population at index.

TNFi (n=94)Il-17ai (n=48)p valueBMI category Underweight2 (2%)1 (2%)0.094 Normal weight33 (35%)8 (17%) Overweight24 (26%)16 (33%) Obese27 (29%)21 (44%) Missing8 (9%)2 (4%)Duration of treatment (months), mean (SD)61.0 (156.7)23.7 (20.1)0.18BASDAI <443 (46%)23 (48%)0.89BASDAI > 416 (17%)8 (17%)Missing35 (37%)17 (35%)ISI score, mean (SD)9.1 (6.6)8.9 (5.9)0.83ISI category (n (%)0.83 No clinically significant insomnia44 (57%)24 (50%) Subthreshold insomnia30 (32%)15 (31%) Clinical insomnia (moderate)15 (16%)8 (17%) Clinical insomnia (severe)5 (5%)1 (2%)MAPI score, mean (SD)0.3 (0.2)0.4 (0.3)0.046MAPI, high apnoea risk Yes17 (18%)16 (33%)0.051 No62 (66%)26 (54%) Missing15 (16%)6 (12%)

Acknowledgements:

The authors acknowledge the members of OPAL Rheumatology Ltd and their patients for providing clinical data for this study, and Software4Specialists Pty Ltd for providing the Audit4 platform. We acknowledge WriteSource Medical Pty Ltd for providing statistical services. Funding for this study was provided by Novartis.

Disclosure of Interests:

Kathleen Tymms: None declared, Belinda Butcher: None declared, Tracey Sletten: None declared, Tegan Smith: None declared, Catherine OSullivan: None declared, Geoff Littlejohn Consultant of: AbbVie, Bristol Myers Squibb, Eli Lilly, Gilead, Novartis, Pfizer, Janssen, Sandoz, Sanofi and Seqirus., Ricky Sadler Employee of: Current employee of Novartis, Rebecca Tronnberg Employee of: Current employee of Novartis, Hedley Griffiths Consultant of: AbbVie, Gilead, Novartis and Lilly.

POS0619 MODELLING OF DISEASE ACTIVITY IN PATIENTS WITH INFLAMMATORY ARTHROPATHIES TREATED WITH ETANERCEPT ORIGINATOR OR BIOSIMILAR AS FIRST-LINE BIOLOGIC IN AN AUSTRALIAN REAL-WORLD DATASET

Background:

The availability of biosimilars as non-proprietary versions of established biologic disease-modifying anti-rheumatic drugs (bDMARDs) is enabling greater access for patients with rheumatic diseases to effective medications at a lower cost. Since April 2017 both the originator and a biosimilar for etanercept (trade names Enbrel and Brenzys, respectively) have been available for use in Australia.

Objectives:

[1]To model effectiveness of etanercept originator or biosimilar in reducing Disease Activity Score 28-joint count C reactive protein (DAS28CRP) in patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA) or ankylosing spondylitis (AS) treated with either drug as first-line bDMARD

[2]To describe persistence on etanercept originator or biosimilar as first-line bDMARD in patients with RA, PsA or AS

Methods:

Clinical data were obtained from the Optimising Patient outcomes in Australian rheumatoLogy (OPAL) dataset, derived from electronic medical records. Eligible patients with RA, PsA or AS who initiated etanercept originator (n=856) or biosimilar (n=477) as first-line bDMARD between 1 April 2017 and 31 December 2020 were identified. Propensity score matching was performed to select patients on originator (n=230) or biosimilar (n=136) with similar characteristics in terms of diagnosis, disease duration, joint count, age, sex and concomitant medications. Data on clinical outcomes were recorded at 3 months after baseline, and then at 6-monthly intervals. Outcomes data that were missing at a recorded visit were imputed.

Effectiveness of the originator, relative to the biosimilar, for reducing DAS28CRP over time was modelled in the matched population using linear mixed models with both random intercepts and slopes to allow for individual heterogeneity, and weighting of individuals by inverse probability of treatment weights to ensure comparability between treatment groups. Time was modelled as a combination of linear, quadratic and cubic continuous variables.

Persistence on the originator or biosimilar was analysed using survival analysis (log-rank test).

Results:

Reduction in DAS28CRP was associated with both time and etanercept originator treatment (Table 1). The conditional R-squared for the model was 0.31. The average predicted DAS28CRP at baseline, 3 months, 6 months, 9 months and 12 months were 4.0 and 4.4, 3.1 and 3.4, 2.6 and 2.8, 2.3 and 2.6, and 2.2 and 2.4 for the originator and biosimilar, respectively, indicating a clinically meaningful effect of time for patients on either drug and an additional modest improvement for patients on the originator.

Median time to 50% of patients stopping treatment was 25.5 months for the originator and 24.1 months for the biosimilar (p=0.53). An adverse event was the reason for discontinuing treatment in 33 patients (14.5%) on the originator and 18 patients (12.9%) on the biosimilar.

Conclusion:

Analysis using a large national real-world dataset showed treatment with either the etanercept originator or the biosimilar was associated with a reduction in DAS28CRP over time, with the originator being associated with a further modest reduction in DAS28CRP that was not clinically significant. Persistence on treatment was not different between the two drugs.

Table 1.

Respondent characteristics.

Fixed EffectEstimate95% Confidence Intervalp-valueTime (linear)0.900.89, 0.911.5e-63Time (quadratic)1.011.00, 1.011.3e-33Time (cubic)1.001.00, 1.007.1e-23Originator0.910.86, 0.960.0013

Acknowledgements:

The authors acknowledge the members of OPAL Rheumatology Ltd and their patients for providing clinical data for this study, and Software4Specialists Pty Ltd for providing the Audit4 platform.

Supported in part by a research grant from Investigator-Initiated Studies Program of Merck & Co Inc, Kenilworth, NJ, USA. The opinions expressed in this paper are those of the authors and do not necessarily represent those of Merck & Co Inc, Kenilworth, NJ, USA.

Disclosure of Interests:

Claire Deakin: None declared, Geoff Littlejohn Consultant of: Over the last 5 years Geoffrey Littlejohn has received educational grants and consulting fees from AbbVie, Bristol Myers Squibb, Eli Lilly, Gilead, Novartis, Pfizer, Janssen, Sandoz, Sanofi and Seqirus., Hedley Griffiths Consultant of: AbbVie, Gilead, Novartis and Lilly., Tegan Smith: None declared, Catherine OSullivan: None declared, Paul Bird Speakers bureau: Eli Lilly, abbvie, pfizer, BMS, UCB, Gilead, Novartis

POS1461-HPR THE DEVELOPMENT OF A NOVEL EPRO DELIVERY SYSTEM TO MEASURE PATIENT QUALITY OF LIFE IN ROUTINE CLINICAL CARE: AN ANALYSIS OF 5 YEARS OF EXPERIENCE

Background:

Registry studies and clinical trials are increasingly incorporating patient reported outcomes (PROs) to measure the full burden of disease and better measure the efficacy and value of medicines; however, the burden of paper-based surveys, time constraints, and privacy concerns impede the widespread use of PROs in routine clinical care.

Objectives:

To develop a simple and secure technological solution to incorporate validated PROs into routine clinical care for patients with rheumatic diseases, and to assess the patient response to functional assessment of chronic illness therapy fatigue (FACIT-F), patient health questionnaire-2 (PHQ-2), and healthcare resource utilization (HCRU) questionnaires delivered using this ePRO method.

Methods:

A novel ePRO questionnaire delivery system was developed by Software4Specialists in partnership with OPAL Rheumatology. Validated PRO questionnaires were sent from the patient’s electronic medical record (Audit4, Software4Specialists) and delivered to the patient’s email address at time intervals specified by the rheumatologist (defaults to quarterly) or completed in the clinic waiting room prior to the consultation using a tablet or the patient’s smart phone (in-practice). Completed questionnaires were encrypted and returned directly to the patient’s Audit4 electronic medical record held on the clinician’s server for review at the next clinical consultation. The link to the PRO questionnaire expired within 28 days if the questionnaire was not completed, and the questionnaires were automatically cancelled if 2 consecutive links expired. This technology was made available to up to 111 rheumatologists located in 42 clinics in 6 states/territories in Australia, and the use of this technology to furnish the clinical consultation was voluntary for clinicians and patients. Deidentified clinical data was extracted from the servers of participating rheumatologists and aggregated across all sites.1 Data collected between April 2016-Dec 2020 was analysed descriptively.

Results:

Between April 2016-Dec 2020, 99,505 FACIT-F, PHQ-2 and HCRU questionnaires have been delivered to 5,784 patients from 39 of 42 contributing clinics (93%). 85% of questionnaires were delivered via email and 15% in-practice. Overall, 85% of patients completed at least one questionnaire, and of all questionnaires sent, 73% were completed. These rates have remained consistent over time. The completion rates were higher when questionnaires were delivered to patients in-practice compared to email (96% vs 69%). Females were more likely to engage with the questionnaires than males (87% vs 81%), and older patients were slightly more likely to complete all questionnaires delivered. 69% of questionnaires sent via email were completed on the day they were delivered and 94% were completed within 7 days. The median (IQR) number of questionnaires completed per patient was 3 (1,7) and the median (IQR) time since the first questionnaire was completed was 13 months (5,26).

Conclusion:

The novel Audit4 ePRO delivery system is an effective tool for incorporating PROs into routine clinical care to capture data directly from the patient on the impact of their condition on their quality of life. The data generated provides a unique opportunity to understand the full burden of disease for patients in the real-world setting and the impact of interventions.

References:

[1]Littlejohn GO, Tymms KE, Smith T, Griffiths HT. Using big data from real-world Australian rheumatology encounters to enhance clinical care and research. Clin Exp Rheum 2020:38(5): 874 -880.

Acknowledgements:

The authors acknowledge the members of OPAL Rheumatology Ltd and their patients for providing clinical data for this study, and Software4Specialists Pty Ltd for providing the Audit4 platform.

Disclosure of Interests:

Kathleen Tymms: None declared, Tegan Smith: None declared, Claire Deakin: None declared, Tim Freeman: None declared, David Hoffman: None declared, Dana Segelov: None declared, Hedley Griffiths Consultant of: AbbVie, Gilead, Novartis and Lilly., Sabina Ciciriello: None declared, Peter Youssef: None declared, David Mathers: None declared, Catherine OSullivan: None declared, Geoff Littlejohn Consultant of: Over the last 5 years Geoffrey Littlejohn has received educational grants and consulting fees from AbbVie, Bristol Myers Squibb, Eli Lilly, Gilead, Novartis, Pfizer, Janssen, Sandoz, Sanofi and Seqirus

POS0223 PATTERNS OF JANUS KINASE INHIBITOR CYCLING FOR THE MANAGEMENT OF RHEUMATOID ARTHRITIS IN REAL-WORLD CLINICAL PRACTICE: AN ANALYSIS OF THE OPAL DATASET

Background:

There are currently eleven biologic and targeted synthetic (b/ts)DMARDs acting via five different modes of action available for the treatment of RA in Australia. The cost of b/tsDMARDs is subsidized by government for patients that have active RA despite six months of combination csDMARD therapy. Once a patient is eligible, the clinician can prescribe the b/tsDMARD they deem to be the most clinically appropriate for the patient. In Oct 2015 the first JAK inhibitor (JAKi) became available in Australia (tofacitinib, TOF), baricitinib (BARI) became available in Sept 2018, and upadacitinib (UPA) in May 2020. Each of these oral tsDMARDs possess different selectivity profiles towards different members of the JAK family (JAK1–3 and Tyk2).

Objectives:

The aim of this analysis was to determine the patterns of JAKi cycling in real-world practice in Australia.

Methods:

Deidentified clinical data were sourced from the OPAL dataset, which is collected in a custom-built electronic medical record during the routine consultation1. Data from patients >18 years with RA who commenced a b/tsDMARD between Jan-2007 and Dec-2020 were included in the analysis. A visual analytics software program was used to display data on medication initiation and cessation dates, and reasons for stopping tsDMARDs, which is recorded in the medical record at the time of the decision.

Results:

At Dec 2020, 28% of the 52,190 patients with RA in the OPAL dataset were prescribed b/tsDMARDs. Of these patients, 3,850 (26.3%) were currently prescribed a JAKi with 51.4% receiving TOF, 29.2% BARI and 19.4% UPA. In 2020, JAKi initiations accounted for 48.8% of all initiations and 30.7% of 1st line initiations; an increase of 6.1% and 3.5% from 2019, respectively. The percentage of patients switching from a first line JAKi to a second line JAKi rather than an agent with another mode of action increased from 33.1% in 2019 to 42.6% in 2020. This is despite 26.2% in 2019 and 45.8% in 2020 of the patients switching to another JAKi citing lack of efficacy as the reason for JAKi discontinuation. In the period between May 2020, when a third JAKi (UPA) become available, and Dec 2020, the majority of patients switching from first line TOF or BARI to another JAKI switched to UPA (69.4% and 83.9%, respectively), whilst 30.6% of first line TOF patients switched to BARI (30.6%), and 16.1% of first line BARI patients switched to TOF in second line. The majority of patients switching from second line TOF or BARI to a third line JAKi switched to UPA (73% and 96%, respectively), with 27% of second line TOF patients switching to BARI and a very low number moving from second line BARI to TOF (4%). JAKi choice after a third line TOF or BARI was almost exclusively UPA (86.2% and 95.5%, respectively).

Conclusion:

There has been significant and sustained uptake of JAKi for the management of RA in Australia and JAKi cycling is increasingly common in routine clinical care. Clinical outcomes and persistence following JAKi cycling requires further investigation.

References:

[1]Littlejohn GO, Tymms KE, Smith T, Griffiths HT. Using big data from real-world Australian rheumatology encounters to enhance clinical care and research. Clin Exp Rheumatol. Sep-Oct 2020;38(5):874-880.

Figure 1.

Patterns of JAKi cycling for the management of rheumatoid arthritis in first, second and third line switching.

Acknowledgements:

The authors acknowledge the members of OPAL Rheumatology Ltd and their patients for providing clinical data for this study, and Software4Specialists Pty Ltd for providing the Audit4 platform

Disclosure of Interests:

Sabina Ciciriello: None declared, Tegan Smith: None declared, Catherine OSullivan: None declared, Kathleen Tymms: None declared, Peter Youssef: None declared, David Mathers: None declared, Claire Deakin: None declared, Hedley Griffiths Consultant of: AbbVie, Gilead, Novartis and Lilly., Geoff Littlejohn Speakers bureau: Over the last 5 years Geoffrey Littlejohn has received educational grants and consulting fees from AbbVie, Bristol Myers Squibb, Eli Lilly, Gilead, Novartis, Pfizer, Janssen, Sandoz, Sanofi and Seqirus.

A rapid assessment of wastewater for genomic surveillance of SARS-CoV-2 variants at sewershed scale in Louisville, KY

In this communication, we report on the genomic surveillance of SARS-CoV-2 using wastewater samples in Jefferson County, KY. In February 2021, we analyzed seven wastewater samples for SARS-CoV-2 genomic surveillance. Variants observed in smaller catchment areas, such as neighborhood manhole locations, were not necessarily consistent when compared to associated variant results in downstream treatment plants, suggesting catchment size or population could impact the ability to detect diversity.

Case for rethinking system leadership and its development in public health

Background

There is growing recognition of the importance of leadership in Public Health (PH) practice, and the need to embed it into the education and training of PH professionals. However the theoretical discourse within leadership research has changed significantly and there is recognition that previous conceptualisations of leadership, and our ways of developing it may be flawed, and need to be changed in practice.

Objectives

This presentation will discuss development of leadership theory, and system leadership. In particular it will highlight how System Leadership differs from previous understandings of leadership and the implications of this for ph practitioners and those charged with developing system leadership capacity within public health.

Body of the session

Leadership in organisations is mostly focused on current/anticipated internal challenges (strategy, performance management, staff engagement, etc.). Leaders are generally developed via individual leader development rather than a focus developing Leadership capacity across organisations/systems. Within PH it is increasingly realised that single organisations can no longer respond effectively to the “wicked” issues they face. They do not possess sufficient know-how to address the complex and multi-dimensional problems faced, so leadership models based on a single hierarchical organisation are not sustainable. There is a need to work collectively in an ecosystem-based approach (not an ego-based system). System Leadership development requires that participants are actively engaged in real attempts to improve PH System. Development requires that underlying values are made explicit, explored and diversity embraced. The emphasis will be on supporting learners in the doing rather than critiquing or talking about it.

Conclusions

There is need to appreciate fully the nature of systems leadership, together with implications for PH practice and the development of system leadership capacity throughout the PH workforce.

SAT0182 THE ASSOCIATION BETWEEN AUTOANTIBODIES AND RITUXIMAB RESPONSE IN SYSTEMIC LUPUS ERYTHEMATOSUS

Background:

Systemic Lupus Erythematosus (SLE) is clinically and immunologically heterogeneous with a variable response to treatment. MASTERPLANS is an MRC-funded consortium that seeks to identify immunophenotypic subgroups of patients that predict response to therapy. Autoantibody profiles can differentiate subgroups of patients and have potential to predict response to treatment.

Objectives:

To determine whether known and novel autoantibodies are associated with response to rituximab (RTX), and analyse the association between these antibodies and disease involvement in various organ systems.

Methods:

Serum was obtained from 224 SLE patients in the BILAG Biologics Registry who received rituximab according to NHS England criteria (2). Patients were recruited if they were starting a first cycle of rituximab for active SLE (BILAG A or 2xBILAG B) despite previous cyclophosphamide or mycophenolate mofetil. Evidence of any single organ system involvement previous or current was taken as having a BILAG score of A-D but not E. Disease activity was measured using BILAG-2004. Clinical response was defined as improvement by >=1 grade in active BILAG-2004 systems with no worsening in other systems. Autoantibodies were measured by immunoprecipitation of proteins by sera from35S-labelled K562 cell lines, followed by SDS-PAGE separation and autoradiography. Autoantibodies not able to be detected by this technique (anti-Ro52, anti-dsDNA and aCL) were measured by ELISA. Autoantibody data was analysed in IBM SPSS and GraphPad Prism v8.2. Association between autoantibodies and RTX response was analysed using binary logistic interaction terms and Pearson’s Chi-Square test.

Results:

Of the 224 patients (201 female, 23 male, median age 40 years) the most common system involvement from the 9 BILAG domains was musculoskeletal (164 patients) and the least ophthalmic (11 patients). Patients with anti-Ro52 and anti-U1RNP/Sm had more frequent involvement of mucocutaneous (p<0.036,p<0.012) and musculoskeletal domains (p<0.015 for U1RNP) respectively.

There were 136 patients with sufficient data to define as either responders (n=67) or non-responders (n=69) to RTX at 6 months. RTX responders had a higher frequency of anti-U1RNP/Sm compared to non-responders (Figure 1). Further Pearson’s Chi-Square analysis showed a significant association between presence of anti-U1RNP/Sm and better response to RTX (p<0.018).

Conclusion:

Our findings suggest that the presence of U1RNP/Sm autoantibodies in a cohort of patients who have received treatment with RTX is associated with more frequent musculoskeletal and mucocutaneous involvement and predicts a more favourable response to treatment.

Acknowledgments :

Funded by a grant from the Medical Research Council, grant number MR/M01665X/1. BILAG BR has been funded by unrestricted educational donations from Roche, GSK and LUPUS UK. Part-funded by a grant from LUPUS UK.

Disclosure of Interests: :

Danyang Li: None declared, Hui Lu: None declared, Juliet Dunphy: None declared, Theresa Smith: None declared, Edward Vital Grant/research support from: AstraZeneca, Roche/Genentech, and Sandoz, Consultant of: AstraZeneca, GSK, Roche/Genentech, and Sandoz, Speakers bureau: Becton Dickinson and GSK, Ian N. Bruce Grant/research support from: Genzyme Sanofi, GSK, and UCB, Consultant of: Eli Lilly, AstraZeneca, UCB, Iltoo, and Merck Serono, Speakers bureau: UCB, Neil McHugh: None declared

THU0209 UPTAKE OF JANUS KINASE INHIBITORS FOR MANAGEMENT OF RHEUMATOID ARTHRITIS IN AUSTRALIA

Background:

JAK inhibitors (JAKi) are oral tsDMARDs with a different mode of action (MOA) to both oral cs- and parenteral bDMARDs. In Australia the cost of b/tsDMARDs for treatment of RA is subsidized if the patient has documented high levels of clinical/laboratory disease activity and has not responded to a pre-specified combination of csDMARDs, including MTX. Once eligible for subsidy the clinician can prescribe the b/tsDMARD deemed most clinically appropriate.

Objectives:

To determine the patterns of use and reasons for initiation and discontinuation of JAKi in real-world rheumatology practice in Australia.

Methods:

Deidentified clinical data were sourced from the OPAL dataset, which is collected in a custom-built electronic medical record at the time of the consultation1by 94 rheumatologists in Australia, representing one third of Australian clinical rheumatologists. Data from patients >18 years with a diagnosis of RA who commenced a b/tsDMARD between Jan-2007 and Sept-2019 were included in the analysis. Tableau®was used to display data on medication initiation and cessation dates, and reasons for starting and stopping b/tsDMARDs, which is recorded at the time of the decision.

Results:

At Sept 2019, there were 45,317 patients with RA in the data set, with 27% prescribed b/tsDMARDs. Of patients currently on treatment at Sept 2019, 53% were receiving a TNFi and 21% a JAKi, with the remainder receiving tocilizumab, abatacept or rituximab. Of patients who commenced their current treatment after JAKi’s become available in Sept 2015, 46% were treated with a TNFi, and 32% were treated with a JAKi. Tofacitinib (TOF) has been the most prescribed b/tsDMARD since Sept 2015 with 22% of all initiations; however, since baricitinib (BARI) became available in Sept 2018, it has taken over as the preferred JAKi with 24% of new initiations compared to 14% for TOF. From Sept 2018-Sept 2019 etanercept and adalimumab were the most commonly prescribed agents in first line, followed by TOF then BARI; however, BARI was the most prescribed agent in lines 2-6+ (figure 1). The main clinician-listed reason for choice of TOF was MOA in 54%, efficacy compared with alternatives in 30%, mode of administration in 7%, efficacy as monotherapy in 7%, and safety in 1%. BARI was chosen for MOA in 35%, efficacy compared with alternatives in 38%, mode of administration in 12%, efficacy as monotherapy in 12%, and safety in 1%. The main reasons for stopping TOF were lack of efficacy (34%), better alternative (25%) and adverse reaction (13%); those for BARI were lack of efficacy (35%) and adverse reaction (25%) which is consistent with the rates observed in the first 12-months of clinical experience with TOF, and better alternative (12%). Patient non-adherence was listed in 1% and 2% of cessations for TOF and BARI, respectively. 45% of patients discontinuing a JAKi in first line switched to a TNFi in second line, and 40% switched to another JAKi, citing lack of efficacy, adverse reaction, and better alternative as the reason for switching.

Figure 1.

Rank of new initiations by line of therapy (Sept 2018-Sept 2019)

Conclusion:

There has been significant and sustained uptake of JAKi for the management of RA in Australia. MOA and perceived efficacy rate much higher than mode of administration for clinicians when selecting a JAKi. Clinical outcomes and persistence following JAKi cycling requires further investigation.

References:

Littlejohn GO, Tymms KE, Smith T, Griffiths HT. Using big data from real-world Australian rheumatology encounters to enhance clinical care and research. Clin Exp Rheum Nov 2019

Disclosure of Interests:

None declared