POS0112 CLASSIFYING SELF-REPORTED RHEUMATOID ARTHRITIS FLARES USING DAILY PATIENT-GENERATED DATA

Background

Flares are an inherent part of the rheumatoid arthritis (RA) disease course and may impact clinical and patient outcomes. The ability to predict flares between clinic visits based on real-time longitudinal patient-generated data could potentially allow for timely interventions to avoid disease worsening. For intensively-collected patient-generated data, machine learning methods offer benefits over traditional statistical tools for accurate prediction, but examples in rheumatology are sparse.

Objectives

Investigate the feasibility of using machine learning methods to classify self-reported RA flares based on a small dataset of daily symptom data collected on a smartphone app.

Methods

We used data from the Remote Monitoring of Rheumatoid Arthritis (REMORA) study, which aimed to improve monitoring of disease severity in RA. Patients tracked daily symptoms (pain, fatigue, function, sleep, coping, physical and emotional wellbeing) on a 0-10 numerical rating scale, duration of morning stiffness, and weekly flares on the REMORA smartphone app for three months.

The outcome was the binary yes/no answer to the weekly flare question “Have you experienced a flare in the last week?”. Several summaries of the eight daily symptom scores collected in the week leading up to the flare question (the exposure period) were used as predictors. These included the mean, min, max, standard deviation and slope. Where exposure periods overlapped, the intersecting symptom reports were allowed to correspond to multiple outcomes.

We fitted three binary classifiers: logistic regression +/- elastic net regularization, a random forest and naïve Bayes. The models were benchmarked using the R package mlr3 and 10-fold cross-validation, with two participants comprising the test set and the remaining 18 the training set.

Finally, the performance of the classifiers was evaluated according to the area under the curve (AUC) of the receiver operating characteristic curve. The model with the highest AUC in the test dataset was considered as the best final model.

Results

Twenty patients tracked daily symptoms over three months. 60% were female, all but one were white British, and mean age was 56.9±11.1 years. The median number of days in the study was 81 (interquartile range (IQR) 80, 82). The collected data comprised an average of 60.6 daily reports and 10.5 weekly reports per participant over the study period. Participants reported a median of 2 flares (IQR 0.75-4.25) resulting in 57 flares in total.

Classifier performances are visualized in Figure 1. The best performing model was logistic regression with elastic net with an AUC of 0.82. At a cut-off point requiring specificity to be 0.80, the corresponding sensitivity to detect flares was 0.60 for this model, meaning that the prediction model correctly identified three in every five self-reported flares, and four in every five non-flares. At this cut-off, the positive predictive value, i.e. the probability that those with a predicted flare indeed go on to have a flare was 53%. The negative predictive value, i.e. the probability that those with a predicted non-flare indeed do not experience a flare, was 85%.

Conclusion

Predicting self-reported flares based on daily symptom scorings in the preceding week using machine learning methods was feasible, although regularized logistic regression outperformed the other machine learning methods in this small dataset. The perceived advantage of machine learning may therefore be attributed to overfitting. It is possible that the observed predictive accuracy will improve as we obtain more data.

Our results point to a future where regular analysis of frequently collected patient-generated data may allow us to predict imminent flares before they unfold with decent accuracy, opening up opportunities for just-in-time adaptive interventions (JITAIs). Depending on the nature and implications of a JITAI, different cut-off values should be explored: different interventions will require different levels of predictive certainty before an action is triggered (eg self-management advice vs. a patient contact).

Disclosure of Interests

Julie Gandrup: None declared, David A Selby: None declared, William Dixon Consultant of: Received consultancy fees from Abbvie and Google

OP0051 TRENDS FOR OPIOID PRESCRIPTIONS AMONG PATIENTS WITH RHEUMATIC AND MUSCULOSKELETAL DISEASES BETWEEN 2006-2020

Background

Opioid prescribing has contributed to a North American epidemic with increasing trends in several European countries1. Rheumatic and musculoskeletal diseases (RMDs) are one of the most common indications for prescribed opioids despite there being little evidence on opioid prescribing and the benefit of long-term use in RMDs.

Objectives

To investigate national UK opioid prescribing trends by studying the patterns of opioid prescribing in new users with the following six RMDs: rheumatoid arthritis (RA), psoriatic arthritis (PsA), axial spondyloarthritis (AxSpA), systemic lupus erythematosus (SLE), osteoarthritis (OA) and fibromyalgia.

Methods

Patients aged 18 years and older with a diagnosis of RA, PsA, AxSpA, SLE and OA with a new episode of opioid use without cancer in the Clinical Practice Research Datalink (CPRD) were included between 01/01/2006 and 31/12/2020. CPRD is a database of anonymised UK primary care electronic health records representative of the national population. New opioid users were defined as individuals with RMDs who had a new episode of opioid use in a 2-year time window up to 6 months before or after an RMD diagnosis. Rates of new opioid users were calculated by dividing the number of new opioid users with an RMD per year by the number of eligible patients registered in CPRD per year. Age- and gender-standardised rates for new opioid users were obtained using direct standardisation for each RMD. Rates of opioid prescriptions among new users for each RMD were calculated by dividing the number of opioid prescriptions among new users with an RMD in the year they had new opioid episodes by patient-years of the new users with an RMD. Trends for the rates in the study period were tested using negative binomial regression. Significant change points were identified by looking at the points where the derivative (i.e. rate of change) of the trends for the rates crossed zero. Recurrent opioid users were defined as patients who had at least 3 opioid prescriptions issued within 3 months after a new opioid episode.

Results

This study included 21,505 RA patients, 8,392 PsA patients, 4,491 AxSpA patients, 4,508 SLE patients, 944,078 OA patients, and 33,829 fibromyalgia patients, who had new opioid episodes between 2006-2020. Whilst the overall trend for RA (2.7* vs 3.9*), PsA (1.0* vs 1.8*) and fibromyalgia (3.7* vs 8.3*) has significantly increased over 15 years, from 2018 onwards, trends of new opioid users appeared to stabilise/decrease (Figure 1). The year 2018 was found to be a significant decreasing change point in the trends of new opioid users for RA, AxSpA, and SLE, whilst this was 2013 in OA and 2019 for fibromyalgia. Opioid prescription rates among new opioid users increased in SLE (4.3# vs 5.4#), OA (4.6# vs 4.9#) and fibromyalgia (5.6# vs 6.5#) but decreased in RA (5.7# vs 5.3#) from 2006 to 2020, despite fluctuations in the rates observed in this period. The highest proportions of recurrent opioid users among the 6 RMDs were patients with RA (32.6%) and fibromyalgia (31.9%).

* The number of new opioid users per 10000 persons

# The number of opioid prescriptions in new users per patient years

Figure 1.

Trends of new opioid users by RMD, 2006-2020.

Conclusion

RA, PsA and fibromyalgia had an overall increase in new opioid users since 2006. The slight decrease in the trends of new opioid users among most of the RMDs after 2018 may reflect an increasing awareness of the opioid epidemic. The high proportions of recurrent opioid users in RA and fibromyalgia patients highlight the importance of exploring the safety of long-term opioid use and effective pain interventions for patients with RMDs.

References

[1]Jani M et al (2020) Time trends and prescribing patterns of opioid drugs in UK primary care patients with non-cancer pain: A retrospective cohort study. PLoS Med 17(10): e1003270

Acknowledgements

This work was funded by a FOREUM grant (grant ID: 125059), MJ is funded through an NIHR Advanced Fellowship (NIHR301413). Thanks to the CPRD fob holders in our centre, Ruth Costello and Ramiro Bravo, for downloading the data.

Disclosure of Interests

Joyce (Yun-Ting) Huang: None declared, David Jenkins: None declared, Belay Birlie Yimer: None declared, Jose Benitez-Aurioles: None declared, Niels Peek: None declared, Mark Lunt: None declared, William Dixon Consultant of: WGD has received consultancy fees from Abbvie and Google., Meghna Jani: None declared.

POS1444 ADOPTION OF DIGITAL MANIKINS TO SELF-REPORT PAIN: A SYSTEMATIC REVIEW

Background:

Chronic pain is common in rheumatic and musculoskeletal conditions, and a major driver of disability worldwide. Knowledge gaps exist with respect to correct estimates of chronic pain [1], what causes it and how best to manage it [2]. To address this, researchers need validated methods to measure pain in large, representative populations. Though many authors have recognised the potential benefits of paper-based and digital pain manikins [3]–[5], it is unknown to what extent studies have adopted digital manikins as a data collection tool.

Objectives:

The objective of our review was to identify and characterise published studies that have used digital pain manikins as a data collection tool.

Methods:

We systematically searched six electronic databases, including Medline, CINAHL, Embase, Scopus, IEEE Xplore digital library, ACM Digital Library, on 3-4 of November 2020 by using a pre-defined search strategy. We included a study in our review if it used a digital manikin for self-reporting any pain aspect (e.g., intensity, type) by people suffering from pain, and if its full text was published in English. We conducted this review by following the PRISMA reporting guidelines and conducted a descriptive synthesis of findings, including manikin-derived outcome measures.

Results:

Our search yielded 4,685 unique studies. After full text screening of 705 articles, we included 14 studies in our review. Most articles were excluded because they used either paper-based manikins or didn’t include enough details to determine that the manikin was digital (n=386). The majority of included studies were published in Europe (n=11). Most studies collected data on a manikin once (n=11); from people with pain conditions (n=9); and in clinical settings (n=9). There was only one study that collected digital pain manikin data in a large sized (i.e., ~20,000) population-based survey.

In most studies participants shaded any painful area on manikin (n=9) and did not enable participants to record location-specific pain aspects (n=11). None of the manikins enabled participants to record location-specific pain intensity. Pain distribution (i.e. number or percentage of pre-defined body areas or locations experiencing pain) and pain extent (i.e. number or percentage of shaded pixels) were commonly used manikin-derived outcome measures. In six studies, a heat map was used to summarise the extent of pain across the population.

Conclusion:

Digital pain manikins have been available since the 1990s but their adoption in research has been slow. Few manikins enabled location-specific pain recording suggesting that the digital nature of the manikin is not yet fully utilised. Future development of a validated digital pain manikin supporting self-reporting of the location and intensity of pain, usable across any device and screen size, may increase uptake and value.

References:

[1]S. E. E. Mills, K. P. Nicolson, and B. H. Smith, “Chronic pain: a review of its epidemiology and associated factors in population-based studies,” Br. J. Anaesth., vol. 123, no. 2, pp. e273–e283, Aug. 2019.

[2]D. B. Reuben et al., “National Institutes of Health Pathways to Prevention Workshop: The Role of Opioids in the Treatment of Chronic Pain,” Ann. Intern. Med., vol. 162, no. 4, p. 295, Feb. 2015.

[3]R. Waller, P. Manuel, and L. Williamson, “The Swindon Foot and Ankle Questionnaire: Is a Picture Worth a Thousand Words?,” ISRN Rheumatol., vol. 2012, pp. 1–8, 2012.

[4]M. Barbero et al., “Clinical Significance and Diagnostic Value of Pain Extent Extracted from Pain Drawings: A Scoping Review,” Diagnostics, vol. 10, no. 8, p. 604, Aug. 2020.

[5]S. M. Ali, W. J. Lau, J. McBeth, W. G. Dixon, and S. N. van der Veer, “Digital manikins to self-report pain on a smartphone: A systematic review of mobile apps,” Eur. J. Pain, vol. 25, no. 2, pp. 327–338, Feb. 2021.

Disclosure of Interests:

None declared

OP0076 HOW TO SELF-EXAMINE FOR TENDER AND SWOLLEN JOINTS: CO-DEVELOPMENT OF A TRAINING VIDEO FOR PEOPLE WITH RHEUMATOID ARTHRITIS

Background:

COVID-19 has catalysed the transformation of healthcare services, with outpatient services increasingly dependent upon remote models of care. Healthcare professionals now have to make clinical assessments based on remote patient examinations. The number of tender and swollen joints a patient has drives decision-making in RA, making it particularly important that people with RA and HCPs have a shared understanding of these examinations.

Even before remote consultations became widespread, long gaps between clinic visits create challenges in enabling HCPs to form an accurate picture of disease activity over time. The REMORA (REmote MOnitoring of Rheumatoid Arthritis) app aims to address this issue by asking people with RA to track disease activity, including counting the number of tender or swollen joints, weekly(1). Data are integrated into the electronic patient record for clinicians to access with patients during clinical consultations. As part of the supporting materials for the REMORA app, we planned to develop a video to train people with RA how to examine their own joints. This video may now help meet the need created by the recent expansion in remote consultations.

Objectives:

To describe the co-production, implementation and evaluation of a video to train patients how to examine their own joints.

Methods:

The need for the video to fill a current gap in patient education was identified by the REMORA patient and public involvement and engagement (PPIE) group. A core working group comprising the PPIE lead, a nurse consultant, rheumatology clinicians, project and communications managers was formed. A storyboard was drafted and feedback gained from the PPIE group and wider REMORA team. Images were sourced from licenced suppliers, or co-developed with the PPIE group where necessary. No ethical approval was required as the PPIE group lead was acting as an equal member of the research term. Written informed consent was gained from video participants. Filming took place between two national lockdowns during the COVID-19 pandemic, providing a challenge to ensure social distancing and requiring the use of masks.

Results:

A 15 minute video to train people with RA to self-examine for tender and swollen joints was developed. An introduction outlining the rationale behind self-examination is followed by a nurse consultant coaching an RA patient in individual joint self-examination. Shoulders, elbows, wrists, metacarpophalangeal joints, proximal interphalangeal joints and knees are included, all of which are counted in disease activity scores.

Early feedback from stakeholders has been overwhelmingly positive. The video will be publicly available on YouTube from February 2021. A survey of patients and HCPs aims to obtain more formal feedback on the video, with a view to a further iteration, if required. Leading national organisations in rheumatology will promote the video, as it supports national programmes including the British Society for Rheumatology national early inflammatory arthritis audit and ePROMS (electronic patient report outcome measure) platform, both of which include entry of patient reported tender and swollen joint counts.

Conclusion:

This video was co-designed by people with RA, aiming to support self-examination of tender and swollen joint counts. Hits on YouTube and survey responses will help assess its impact. Evaluation to assess whether the video affects patients’ ability to self-examine for tender and swollen joints before and after watching is planned. We hope the video will support remote consultations and help people with arthritis to better understand and self-manage their arthritis, and to have shared decision making conversations with their clinicians.

References:

[1]Austin L, Sharp CA, van der Veer SN, Machin M, Humphreys J, Mellor P, et al. Providing ‘the bigger picture’: benefits and feasibility of integrating remote monitoring from smartphones into the electronic health record: findings from the Remote Monitoring of Rheumatoid Arthritis (REMORA) study. Rheumatology. 2020;59(2):367-78.

Disclosure of Interests:

Charlotte Sharp: None declared, Karen Staniland: None declared, Trish Cornell Shareholder of: shares in Abbvie, Employee of: Abbvie, working as a Rheumatology Nurse Consultant, Will Dixon Consultant of: Google and Abbvie, unrelated to this work.

POS0980 ANALYSIS OF PRIMARY CARE CONSULTATION PATTERNS TO AID DIAGNOSIS OF AXIAL SPONDYLOARTHRITIS – AN EXPLORATORY CASE SERIES

Background:

Patients with Axial Spondyloarthritis (AxSpA) often suffer a significant delay to diagnosis. This is associated with poorer outcomes in quality of life, functional capabilities and work productivity [1]. These patients are frequent consulters to primary care in the years preceding rheumatology referral [2]. We hypothesise that analysis of primary care consultation patterns may identify as-yet undiagnosed disease, and suggest that implementing an automated diagnostic algorithm may support early action in primary care.

Objectives:

To undertake a preliminary exploration of primary care consultation patterns in patients with a delayed diagnosis of AxSpA and identify themes for further research.

Methods:

The study was run in Salford, UK, where unique linkage exists across electronic health records (EHR) from primary and secondary care. A dataset of patients with AxSpA was obtained from 2018-2020 hospital physiotherapy clinic records. Ten patients with a time to diagnosis ≥ 5 years were randomly selected for this exploratory analysis. Diagnostic delay was calculated based on rheumatology clinic letter documentation. Age, sex, and HLA-B27 status were recorded. All “Problem” codes from the primary care EHR up to the point of diagnosis were manually reviewed.

Results:

Age at diagnosis was 32-49 years with seven males and three females. Seven were HLA-B27 positive. The average delay to diagnosis was 15.8 years (range 5-30).

On average, patients had 15 primary care consultations (range 5-24) between first coded AxSpA-related symptom and rheumatology referral. Around half of these codes were potentially AxSpA-related (for example, see Figure 1).

Six patients had a coded history of back pain. Two patients presented with other axial symptoms, including: rib pain, MSK chest pain and sciatica.

Five patients presented with peripheral joint symptoms, including: ankle pain, shoulder pain, knee problem, pain in arm, medial epicondylitis elbow, hip pain and groin pain. Of these, four had multiple presentations and three had a previous visit with axial pain.

Two patients had uveitis preceding axial symptoms. One patient had peripheral joint symptoms (hip pain) preceding uveitis.

Inconsistent codes were used for the same problem presenting at different times in nine cases, including: back pain, backache, low back pain, lower back pain.

Other relevant codes were used in seven cases, including: stiffness, arthritis, saw physiotherapist and referred to pain clinic.

Figure 1 illustrates the consultation pattern for a male patient who first presented to primary care with back pain at the age of 35. Despite a relatively typical presentation, his diagnosis was made incidentally 10 years later after an ESR was checked for unrelated reasons. He was significantly disabled in function at the point of being referred to rheumatology.

Conclusion:

Our preliminary analysis suggests that patients with a delayed diagnosis of AxSpA have repeated primary care visits with potentially recognisable symptoms of their disease. These findings support the feasibility of future automated detection, with areas of focus including recognition of non-back pain axial symptoms, extra-articular manifestations, and peripheral joint symptoms.

Whilst half of presentations were not directly AxSpA-related, modern machine learning techniques have the ability to explore whether the pattern or frequency of these consultations are relevant to identifying undiagnosed disease. Such methods can also highlight patterns obscured by extensive data sets and inconsistent coding, with opportunity for implementation back into primary care.

References:

[1]Redeker I et al. Determinants of diagnostic delay in axial spondyloarthritis: an analysis based on linked claims and patient-reported survey data. Rheumatology (Oxford) 2019;58:1634–8.

[2]Yi E et al. Clinical, Economic, and Humanistic Burden Associated With Delayed Diagnosis of Axial Spondyloarthritis: A Systematic Review. Rheumatol Ther. 2020;7(1):65–87

Disclosure of Interests:

None declared.

SAT0065 TIMING OF PNEUMOCOCCAL VACCINATIONS IN RELATION TO STARTING DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS IN RHEUMATOID ARTHRITIS

Background:

Pneumococcal vaccinations are recommended for patients with rheumatoid arthritis (RA). There is evidence that pneumococcal vaccinations are less effective when administered after starting conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs). Vaccination guidelines have changed over time, since 1992 UK guidelines recommend pneumococcal vaccination for the immunocompromised, and in 2003 was expanded to all individual’s age ≥65 years. Guidelines from British Society of Rheumatology (2011) and EULAR (2019) advise to vaccinate prior to starting csDMARDs where possible. There is little evidence about whether these guidelines are being followed.

Objectives:

The aims of this study were to explore the timing of pneumococcal vaccination in patients with RA in relation to starting csDMARDs and examine whether this has changed over time.

Methods:

This was a cross-sectional study using UK electronic health records from primary care between 1st January 2000 and 31st December 2018. To be included in the study patients needed to 1) have a diagnosis of RA, 2) be prescribed csDMARDs up to 3 months prior to, or after RA diagnosis date and 3) have received a pneumococcal vaccination. Index date was considered the start of csDMARDs and vaccinations were required to be up to 5 years prior to the index date or after index date until leaving the practice, death or the end of the study period. For each patient it was determined if the first vaccination was prior to starting csDMARDs. For those vaccinated up to 3 years prior to, or up to 3 years after starting csDMARDs, the time between vaccination and starting csDMARDs in months was determined and this distribution was plotted in a bar chart. To explore how timing of vaccination has changed over time the proportion (with 95% confidence intervals (CI)) of people vaccinated prior to starting csDMARDs was plotted by year.

Results:

Of 21461 people with RA identified who were prescribed their first csDMARD on or after 1st January 2000, there were 8205 (38.2%) patients vaccinated and eligible to be included in the study. The cohort had a mean age 62 years, 66.4% were female. There were 2997 (36.5%) patients vaccinated prior to starting csDMARDs. Those vaccinated prior to starting csDMARDs were older, with 72% (n=2168) being aged 65 years or over vs 28% (n=1465) in those vaccinated after starting csDMARDs. 5358 (65.3%) were vaccinated up to 3 years prior to, or up to 3 years after starting csDMARDs. The distribution showed that the most frequent time of vaccination was in the 3 months after starting csDMARDs and the frequency was higher in the months after starting csDMARDs than in the months preceding (Figure 1). Of those vaccinated outside these times, 1000 (12.2%) were vaccinated >3 years prior and 1844 (22.5%) were vaccinated >3 years after starting csDMARDs. The proportion vaccinated prior to starting csDMARDs has increased over time from a minimum of 17.2% in 2001 to a maximum of 55.6% in 2016. The greatest increases were seen between 2003 and 2007 (Figure 2).

Figure 1.

Time between starting csDMARDs and pneumococcal vaccination

Figure 2.

Proportion and 95% confidence interval of those vaccinated prior to starting csDMARDs by year.

Conclusion:

This study shows that timing of pneumococcal vaccination is improving with a trend towards increasing vaccination prior to starting csDMARDs and a high proportion of patients were vaccinated around the time of csDMARD initiation. However, just over a fifth (22.5%) were vaccinated more than 3 years after starting csDMARDs. Rheumatologists need to continue to work to raise awareness of the importance of vaccinations through better communications to patients and primary care physicians, to ensure best practice is being followed.

Disclosure of Interests:

Ruth E Costello: None declared, Jenny Humphreys: None declared, Kevin Winthrop Grant/research support from: Bristol-Myers Squibb, Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, Galapagos, Gilead, GSK, Pfizer Inc, Roche, UCB, William Dixon Consultant of: Bayer and Google

FRI0120 ORAL GLUCOCORTICOID USE IS ASSOCIATED WITH HYPERTENSION IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

Oral glucocorticoids (GC) are frequently prescribed to patients with rheumatoid arthritis (RA), however GC use is associated with a number of potential side effects. Hypertension is cited as a possible side effect, but few studies have specifically investigated GC-associated hypertension in patients with RA with conflicting results.

Objectives:

The aim of this study was to determine whether GCs were associated with an increased risk of incident hypertension in a cohort of patients with RA.

Methods:

A retrospective cohort of patients with incident RA and no hypertension at RA diagnosis were identified from UK primary care electronic health records (Clinical Practice Research Datalink). GC prescriptions were used to determine time-varying GC use and dose, categorised as: no use, >0–4.9 mg/day, 5–7.4 mg/day, 7.5–14.9 mg/day, ≥15mg/day. A 3-month risk attribution model was used where patients continued to remain at risk for 3 months after the end of prescriptions. Hypertension was identified if a patient had either: 1) 2 consecutive systolic blood pressure (BP) measurements >140mmHg within a year, 2) 2 consecutive diastolic BP measurements >90mmHg within a year or 3) antihypertensive prescriptions on at least two occasions and a Read code for hypertension. Unadjusted and adjusted Cox proportional hazards (PH) regression models were fitted to determine if there was an association between GC use and hypertension. Models were adjusted for baseline age, gender, baseline body mass index, baseline ever smoking, time-varying synthetic disease-modifying anti-rheumatic drug use, time-varying non-steroidal anti-inflammatory drug use and baseline Charlson comorbidity index.

Results:

There were 17,760 patients with incident RA and no hypertension. The cohort had a mean age of 56.3 ± 12.7 years and were predominantly female (68%). 7,421 (42%) were prescribed GCs during follow-up. There were 6,243 cases of incident hypertension over 97547 person years (pyrs) of follow-up, giving an incident rate of 64.1 per 1000 pyrs. Of those 1321 cases were in those exposed to GCs and 4922 were in those unexposed, giving incident rates of 87.6 per 1000 pyrs and 59.7 per 1000 pyrs, respectively. The adjusted Cox PH model indicated that recent GC use was associated with a 17% increased hazard of hypertension (hazard ratio: 1.17 (95% CI 1.10 to 1.24)). When categorised by dose, the adjusted model indicated only doses above 7.5mg were significantly associated with hypertension (Table 1).

Table 1.

Unadjusted and adjusted Cox proportional hazards regression model results

UnadjustedHR (95% CI)Age and gender adjustedHR (95% CI)Fully adjusted* HR (95% CI)Recent GC use1.44(1.35 to 1.53)1.23(1.16 to 1.31)1.17(1.10 to 1.24)Recent GC doseNo GC useReferenceReferenceReference>0 – 4.9mg1.35(1.21 to 1.53)1.13(1.01 to 1.28)1.10(0.98 to 1.24)5mg – 7.4mg1.40(1.22 to 1.60)1.11(0.97 to 1.27)1.07(0.93 to 1.23)7.5mg – 14.9mg1.44(1.33 to 1.57)1.26(1.16 to 1.38)1.18(1.08 to 1.29)15mg and over1.60(1.40 to 1.84)1.45(1.27 to 1.66)1.36(1.18 to 1.56)

* Adjusted for: Baseline age, gender, baseline body mass index, baseline ever smoking, synthetic disease-modifying anti-rheumatic drug use (time-varying), non-steroidal anti-inflammatory drug use (time-varying) and baseline Charlson comorbidity index.

Conclusion:

In this large cohort of patients with RA and without hypertension, recent GC use was associated with incident hypertension. In particular doses ≥7.5mg were associated with hypertension while the association with lower doses was inconclusive. Clinicians need to consider cardiovascular risk when prescribing GCs and ensure BP is regularly monitored.

Disclosure of Interests:

Ruth E Costello: None declared, Belay Birlie Yimer: None declared, Meghna Jani Speakers bureau: Grifols, William Dixon Consultant of: Bayer and Google

THU0551 SOCIAL CARE USE IN PEOPLE WITH CHRONIC PAIN IN THE UNITED KINGDOM

Background:

Chronic pain is a common and disabling health problem and those affected may need support with their activities of daily living (ADLs). Currently there are no data quantifying how much social care support people with chronic pain need.

Objectives:

To describe formal and informal social care use in people with chronic pain

Methods:

Between June-July 2019, previous participants of theCloudy with a Chance of Painstudy were invited to take part in an online survey, adapted from a validated Personal Social Services Research Unit interview survey. It collected data on whether participants with chronic pain needed help with ADLs, how frequently help was needed and who provided it (formal and informal social care). Additional data was collected on demographics, employment status, pain diagnosis, and comorbidities. Descriptive statistics described the burden of social care need and multivariable logistic regression identified factors associated with social care need.

Results:

There were 981 respondents; 791 (81%) were female, median age 59 years (table 1). In the last month 527(61%) respondents reported needing help with ADLs. Over three-quarters of help was provided informally by family and friends (408 (77%)). For 309 (59%) respondents, help was needed at least daily. In the multivariable logistic regression model, needing help was lower with older age, (OR (95% CI) 0.96 (0.94-0.98), but higher in female gender (OR (95% CI) 1.96 (1.27-3.01), fibromyalgia (OR(95% CI) 2.75(2.53-5.54)), osteoarthritis (OR (95% CI) 1.56 (1.11-2.19)) and multi-morbidity OR (95% CI) 2.13 (1.51-3.01)). Compared to full-time work, respondents who were retired or unable to work were also significantly more likely to need help with ADLs, respective OR (95% CI) 2.16 (1.21-3.84) and 6.98 (3.72-13.08).

Table 1.All respondentsn=981Need help$n=527No help$n=337MissingAge med (IQR)59 (50-66)57 (47-64)61 (52-68)5Female n (%)791 (81)452 (86)251 (74)11Employment statusn (%)FTPTSelf-employedStudentHomemakerRetiredUnable to workUnemployed134 (14)169 (17)50 (5)7 (0.7)23 (2)360 (37)221 (23)16 (1.6)54 (10)79 (15)26 (5)4 (0.8)12 (2)151 (29)188 (36)12 (2)70 (21)69 (20)19 (6)2 (0.6)10 (3)143 (42)21 (6)3 (0.9)1Diagnosis reportedn (%)*OsteoarthritisFibromyalgiaRheumatoid arthritisArthritis (type not specified)Ankylosing SpondylitisGoutMigraine/chronic headacheNeuropathic painOther (inc Psoriatic arthritis, hypermobility)929 (95)482 (49)265 (27)205 (21)128 (15)56 (6)18 (2)115 (13)155 (18)272 (29)516 (98)269 (51)207 (39)115 (22)73 (14)33 (6)13 (2)82 (16)120 (23)209 (39)313 (93)160 (47)40 (12)73 (22)55 (16)23 (7)5 (1)33 (10)35 (10)63 (19)11Any MSk diagnosisn (%)828 (95)460 (87)279 (83)64Multi-morbidity∞n (%)712 (82)473 (90)54 (36)0

med - median, IQR - interquartile range, MSk – musculoskeletal

$117 respondents did not answer the question about whether they did or did not need help with ADLs

*some participants reported more than one diagnosis for their pain

includes MSK diseases above and the following chronic diseases listed in questionnaire: angina, heart attack, stroke, COPD, diabetes, cancer, parkinson’s, multiple sclerosis, depression, other (participants asked to specify)

Conclusion:

A high proportion of people with chronic pain needed support with ADLs; for more than half, on a daily or more frequent basis. Interestingly, younger patients were more likely to need help which may reflect responder bias (younger patients with severe pain potentially more likely to respond than those with milder pain). The majority of support was provided informally, and this could be for a number of reasons. For example, lack of awareness/not meeting eligibility/unable to afford formal social care, or preference to be cared for by familiar persons. This should be explored in future research. These results demonstrate the burden of social care may be significantly greater than government and social care organisations are aware, with important implications for policy and planning.

Disclosure of Interests:

Jenny Humphreys: None declared, Katy Dempsey: None declared, Ollie Phelan: None declared, Laura Boothman: None declared, Louise Cook: None declared, William Dixon Consultant of: Bayer and Google

OP0087 NATIONAL VARIATION AND FACTORS ASSOCIATED WITH THE TRANSITION FROM FIRST USE TO LONG-TERM OPIOID USE FOR NON-CANCER PAIN

Background:

Prescribing behaviour of physicians has been described as a key driver of rising opioid prescriptions and long-term opioid use. However, the effect of prescribers requires interpretation within context. No studies have investigated the extent to which regions, practices and prescribers, vary in opioid prescribing accounting for case-mix by considering this hierarchy together.

Objectives:

(i) Quantify and identify risk factors for the transition from new-user to long-term opioid user (ii) Quantify variation of long-term use attributed to region, practice and prescriber, accounting for patient mix and chance variation.

Methods:

We conducted a retrospective observational UK study between 2006-2017 using Clinical Practice Research Datalink. Opioids new users, ≥18 years, without cancer were identified. Long-term opioid use was defined as ≥3 opioid prescriptions issued within a 90-day period from index date, or ≥1 opioid prescription lasting at least 90 days in the first year. A multi-level random-effects logistic regression model was used to examine the association of patient characteristics with the odds of becoming a long-term opioid user. To examine variation in opioid use amongst prescribers, GP practices and region after adjusting for patient case-mix, we used a nested random-effect structure. A ‘high-risk’ region, prescriber or practice was defined as those where the entire adjusted 95% CI lay above the population average.

Results:

1,968,742 new opioid users were included; 14.6% patients transitioned to long-term use. In the fully adjusted model, factors associated with higher odds of long-term opioid use included high morphine milligram equivalents (MME)/day at first prescription, older age, deprivation, fibromyalgia, rheumatological conditions, major surgery (Table). After adjustment for case-mix, the North-West, Yorkshire and South-West were found to be high-risk regions for long-term use. 103 practices (25.6%) and 540 prescribers (3.5%) were associated with a significantly higher risk of long-term use. The odds of becoming a long-term user for a patient belonging to these prescribers reached up to >3.5 times than the population average.

Conclusion:

Prescribing factors, age, deprivation and conditions including fibromyalgia and rheumatological conditions were associated with higher odds of long-term opioid use. In the first UK study evaluating long-term opioid prescribing with adjustment for patient-level characteristics, variation in regions and especially practices and prescribers were observed. Our findings support greater calls for action to reduce practice and prescriber variation by promoting safe practice in opioid prescribing.

Table.

Factors associated with long-term opioid use using a multi-level model accounting for clustering of individuals within prescriber, practice and region

Individual factorsAdjusted Odds Ratio (95% CI) *Prescribing factorsIndex daily MME >2007.59 (6.29, 9.16)Index daily MME 100-2001.12 (1.03, 1.21)Index daily MME 50-1001.58 (1.49, 1.68)Index daily MME <50RefGabapentinoid use2.51 (2.43, 2.60)Psychotropic use1.28 (1.17, 1.40)Age>754.35 (4.26, 4.45)65-753.57 (3.50, 3.65)55-653.03 (2.96, 3.09)35-551.91 (1.88, 1.95)Age <35RefDeprivation (Townsend score)Quintile 5 (Most deprived)1.54 (1.51, 1.57)Quintile 41.34 (1.31, 1.36)Quintile 31.20 (1.18, 1.22)Quintile 21.09 (1.07, 1.11)Quintile 1 (Least deprived)RefPre-existing conditions/ prior proceduresFibromyalgia1.81 (1.49, 2.20)Substance use disorder1.76 (1.70, 1.83)Suicide and self-harm1.56 (1.51, 1.61)Rheumatological conditions Ψ1.54 (1.49, 1.59)Alcohol abuse1.50 (1.45, 1.55)Depression1.28 (1.26, 1.30)Major Surgery1.09 (1.06, 1.13)

Abbreviations: MME, Morphine Milligram Equivalent; *p<0.05. Index daily MME/day is the MME/day at first prescription (MME= daily dose in milligrams X opioid conversion ratio). Ψ Defined by Charlson score including rheumatoid arthritis, SLE, myositis.

Disclosure of Interests:

Meghna Jani Speakers bureau: Grifols, Belay Birlie Yimer: None declared, Therese Sheppard: None declared, Mark Lunt: None declared, William Dixon Consultant of: Bayer and Google

AB1154 EHR-INTEGRATED PATIENT-GENERATED HEALTH DATA FOR SYMPTOM MONITORING IN LONG-TERM CONDITIONS: A SYSTEMATIC REVIEW

Background:

Patients with long-term conditions (LTCs), including many RMDs, often require continuous management of care. Patient-generated health data (PGHD) collected between visits could inform ongoing care management and provide important insights into patient health and well-being. There is increasing interest in integrating PGHD in electronic health records (EHRs). However, integration is still largely aspirational with limited evidence of successful systems.

Objectives:

To map the landscape of EHR-integrated remote symptom monitoring systems in the field of LTCs. The objectives were to 1) characterise state of the art systems, 2) describe their clinical use, and 3) outline anticipated and realized benefits for clinical practice.

Methods:

A systematic search was conducted in three electronic databases up until November 2019. Titles and abstracts were independently screened by two reviewers. One reviewer screened full-text articles, identified those relevant for review and extracted data. Inclusion criteria included 1) symptom reporting systems in adult patients suffering a LTC, 2) integration of data into the EHR, 3) symptom data collected remotely, 4) evidence of use in clinical care. We did not exclude studies based on study design, quality, or sample size. Synthesis focused on describing system specifications and their use. For objective three we adopted a list of outcome indicators [1], which each of the studies were assessed against.

Results:

The initial search yielded 2040 articles. Only 12 studies reporting on ten unique systems were identified. Two systems were used in rheumatology, but the majority were used in oncology. Systems were highly heterogeneous in terms of technical and functional specifications. Nine systems were fully integrated (data viewable in the EHR) while the remaining system represented a partial integration (data viewable via link in the EHR). Five systems allowed repeated data collection at pre-defined intervals between visits with frequencies varying from daily to monthly. The remaining five made a single request before a scheduled clinic visit. The number of items requested from patients ranged from 9-48 per session. We identified three different clinical workflows: Simple (data only used during consultation, n=5), moderate (real-time alerts for providers when severe symptoms were reported, n=4) and on-demand (patient-initiated visits, n=1). Benefits of symptom reporting from each of the studies were categorised as anticipated, realized quantitative, and realized qualitative. We present summarised counts of these benefits in Figure 1. The most common anticipated benefits were better communication, changes to patient management and improved health outcomes. Most common realized benefits were detecting unrecognised problems and changes to patient management.

Figure 1.

Summarized counts of benefits from each included study assessed against Chen et al.’s 10 outcome indicators. Categorized in anticipated (orange), realized quantitative (light purple), and realized qualitative benefits (dark purple).

Conclusion:

There is growing interest and urge for integrating symptom data in the EHR and clinical care. Yet, this review has illustrated that there are limited published efforts to learn from. The heterogeneity in approaches underpins the need for a common framework. There is growing evidence from qualitative work in support of remote symptom-reporting in enabling better and patient-centred care in LTCs. The next step will be for robust, quantitative studies to provide evidence of benefits.

References:

[1]Chen J, Ou L, Hollis SJ. A systematic review of the impact of routine collection of patient reported outcome measures on patients, providers and health organisations in an oncologic setting. BMC Health Serv Res. 2013 Jun 11;13:211.

Disclosure of Interests:

Julie de Fonss Gandrup: None declared, Syed Mustafa Ali: None declared, Sabine van der Veer: None declared, John McBeth: None declared, William Dixon Consultant of: Bayer and Google

Laurel Wilt, Caused by Raffaelea lauricola, is Confirmed in Miami-Dade County, Center of Florida's Commercial Avocado Production

Laurel wilt, caused by Raffaelea lauricola, threatens native and nonnative species in the Lauraceae in the southeastern United States, including the important commercial crop, avocado, Persea americana (2,4). Although the pathogen's vector, Xyleborus glabratus, was detected in Miami-Dade County, FL in January 2010, laurel wilt had not been reported (4). In February 2011, symptoms of the disease were observed on native swampbay, P. palustris, in Miami-Dade County (25°72'N, 80°48'W). Externally, foliage was brown, necrotic, and did not abscise; internally, sapwood was streaked with dark gray-to-bluish discoloration; and, in dead trees, holes of natal galleries of the vector from which columns of frass were attached were evident. On a semiselective medium for R. lauricola, a fungus with the pathogen's phenotype was isolated from symptomatic sapwood. Colonies were slow growing, light cream in color, with dendritic, closely appressed mycelium and often a slimy surface. A representative strain of the fungus was further identified with PCR primers for diagnostic small subunit (SSU) rDNA (1) and its SSU sequence (100% match, GenBank Accession No. JN578863). In each of two experiments, plants of 'Simmonds' avocado, the most important cultivar in Florida, were inoculated with three strains of the fungus, as described previously (3). Symptoms of laurel wilt developed in all inoculated plants and the fungus was recovered from each. After aerial and further ground surveys, additional symptomatic swampbay trees, some of which had defoliated, were detected in the vicinity of the original site. Since swampbay defoliates only a year or more after symptoms develop (4), the 2010 detection of X. glabratus may have coincided with an undetected presence of the disease. As of July 2011, a 6-km-diameter disease focus was evident in the area, the southernmost edge of which is 5 km from the nearest commercial avocado orchard. In August 2011, a dooryard avocado tree immediately north of the above focus was affected by laurel wilt, and an SSU sequence confirmed the involvement of R. lauricola (GenBank Accession No. JN613280). The outbreak of laurel wilt in Miami-Dade County represents a 150 km southerly jump in the distribution of this disease in the United States ( http://www.fs.fed.us/r8/foresthealth/laurelwilt/dist_map.shtml ) and is the first time this disease has been found in close proximity to Florida's primary commercial avocado production area. Approximately 98% of the state's commercial avocados, worth nearly $54 million per year, are produced in Miami-Dade County. Since effective fungicidal and insecticidal measures have not been developed for large, fruit-bearing trees, mitigation efforts will focus on the rapid identification and destruction of infected trees (3,4). References: (1) T. J. Dreaden et al. Phytopathology 98:S48, 2008. (2) S. W. Fraedrich et al. Plant Dis. 92:215, 2008. (3) R. C. Ploetz et al. Plant Dis. 95:977, 2011. (4) R. C. Ploetz et al. Recovery Plan for Laurel Wilt of Avocado. National Plant Disease Recovery System, USDA, ARS, 2011.

Regulatory factors of pheo- and eumelanogenesis in melanogenic compartments

Melanogenesis, i.e., synthesis of melanin and melanosomes, is a "cascade" of event which is channelled by internal and external regulatory factors. The recognition and selection of this information and subsequent differentiation of melanogenesis (melanin type and melanosomal development) would be regulated significantly by melanosomal membrane. The melanogenesis type could be switched relatively easily by UV light, hormone, and availability of tyrosinase substrate. The role of sulphydryl compounds as a regulatory factor in melanogenesis type (in particular for pheomelanogenesis) may not be tied to its absolute presence or absence, but rather, to the effective concentration within the melanocyte at a given time. It is, therefore, probable that the morphogenesis of melanosomes may not follow immediately in response to melanogenesis-type changes, hence the melanocyte revealing more often mosaic forms of melanosomes in nature after exposure to non-genetic factors. The switch of melanogenesis would be significantly controlled by structural and functional availability of vesiculoglobular bodies which are encoded or associated with HMSA-5 (69 kDa) glycoprotein. This HMSA-5 protein shares a significant homology with gp75 "b-locus" protein. However, because of our hypothesis that vesiculoglobular bodies carry post- (and pre-) tyrosinase regulatory factors involving in both pheo- and eumelanogenesis, the term "b-protein" which focuses only on eumelanogenesis may not be applied to HMSA-5.

General practitioners' views on the screening for genital Chlamydia trachomatis infection and partner notification

A postal survey of general practitioners (GPs) in the East Riding of Yorkshire was undertaken to find out their views about screening for Chlamydia trachomatis infection, the reasons for their inability to screen the high-risk population, facilities available for screening in the primary care setting, treatment regimen and the views about partner notification. Although all GPs had the facilities for chlamydial testing, their views on chlamydial screening differed widely and very few offered opportunistic screening. Most of the GPs would prefer the sexual health clinics (genitourinary medicine [GUM] clinics) to undertake partner notification. Less than half of the GPs surveyed offered the ideal antimicrobial therapy against chlamydial infection, as recommended by the Central Audit Group in Genito-urinary Medicine. This survey shows the necessity to disseminate proper guidelines for the management of uncomplicated C. trachomatis infection in the community. Sexual health clinics should make adequate provision to deal with additional workload resulting from the increased referrals of partners to the clinics when the opportunistic screening is widely provided by the GPs.

Expression of proteinases and proteinase inhibitors during embryo-uterine contact in the pig

Implantation in pigs is noninvasive and characterized by interdigitation of embryonic and endometrial epithelial cell processes. However, when pig embryos are transferred to ectopic sites, trophoblast becomes invasive. The objective of this study was to evaluate expression of proteinases and proteinase inhibitors in pig embryos and uteri at the time of endometrial attachment. RNA was extracted from Day 15.75 pig embryos and uteri and reverse transcribed, and cDNA was amplified by polymerase chain reactions using primers specific for urokinase-type plasminogen activator (uPA), matrix metalloproteinases-2 and -9 (MMP-2 and -9), and tissue inhibitors of MMP-1, -2, and -3 (TIMP-1, -2, and -3). Localization of transcripts for the genes of interest in embryos and uteri was performed using in situ hybridization with antisense riboprobes. Day 15.75 pig embryos and uteri expressed transcripts for uPA, MMP-2 and -9, and TIMP-1, -2, and -3. In situ hybridization revealed weak expression of uPA in the trophectoderm and moderate expression in the adjacent extraembryonic endoderm. TIMP-1 transcripts were abundant in extraembryonic endoderm and scattered throughout the trophectoderm. TIMP-2 appeared to be expressed in all cells of the embryo. TIMP-3 expression was observed in the trophectoderm and, to a lesser extent, in the extraembryonic endoderm. Specific localization of MMP-2 and -9 transcripts above background was not observed by in situ hybridization in either embryos or uterus. Uterine expression of uPA and TIMP-1, -2 and -3 was localized to the endometrial stroma. Transcripts of these genes were not observed in either the luminal or glandular endometrial epithelium. These results suggest that pig embryos and uteri express a wide array of proteinases and proteinase inhibitors during the period of uterine association. The abundant expression of proteinases and proteinase inhibitors during the period of uterine association. The abundant expression of TIMP in pig embryos may partially explain the absence of invasive implantation in this species in contrast to implantation typified by rodents and primates.

Insulin receptor at the mouse hepatocyte nucleus after a glucose meal induces dephosphorylation of a 30-kDa transcription factor and a concomitant increase in malic enzyme gene expression

Insulin receptor translocation to the nucleus may represent a mechanism for activation of transcription factors controlling lipogenic gene expression in the mouse hepatocyte. Insulin stimulation was achieved in vivo by oral glucose feeding of mice deprived of food for 24 h. Hepatocytes were fractionated after the glucose meal and nuclei were purified. Insulin receptor levels and phosphorylation state in nuclei were assessed by immunoassay. Insulin receptor significantly increased from basal levels in hepatocyte nuclei within 15 min of the glucose meal. Immunoassay using antiphosphotyrosine indicated that phosphorylation of nuclear insulin receptor increased, whereas phosphorylation of a 30-kDa DNA-binding protein significantly decreased within 15 min of the glucose meal. Glucose treatment significantly increased expression of malic enzyme within the time frame of insulin receptor translocation to the nucleus. Nuclear protein binding to an insulin response element (IRE) within the malic enzyme gene promoter significantly increased within 15 min of the glucose meal. When cell nuclei were isolated from mice that had been deprived of food and treated in vitro with purified, activated insulin receptor, changes were observed in DNA-binding protein phosphorylation and IRE-binding in the absence of cytoplasmic insulin signaling. In vitro incubation of nuclei with activated insulin receptor significantly decreased phosphorylation of a 30-kDa DNA-binding protein compared with basal levels. Increased binding of nuclear proteins to malic enzyme IRE was observed upon stimulation of isolated nuclei with activated insulin receptor. These results suggest that nuclear insulin receptors induce malic enzyme gene expression by regulating phosphorylation of IRE transcription factors.

Cognitive impairment in euthymic bipolar patients with and without prior alcohol dependence. A preliminary study

BACKGROUND

Few studies of the neurocognitive performance of patients with bipolar disorder have been performed while patients are in the euthymic state.

METHODS

Twenty-five euthymic bipolar patients (12 with and 13 without a history of alcohol dependence) were compared with 22 normal control subjects on a neuropsychological test battery assessing a range of cognitive domains. The relationship between subjects' neurocognitive performance and the course-of-illness variables (lifetime episodes and duration of mania, depression, or both), as well as current lithium level, was determined.

RESULTS

The results indicated differences across the groups, with the bipolar patients with and without alcohol dependence performing more poorly than controls on tests of verbal memory. Furthermore, bipolar subjects with a history of alcohol dependence had additional decrements in executive (i.e., frontal lobe) functions when compared with controls. For subjects in the bipolar group, lifetime months of mania and depression were negatively correlated with performance in verbal memory and several executive function measures.

CONCLUSIONS

Our findings support the presence of persistent neurocognitive difficulties in patients with long-standing bipolar disorder who are not in the psychiatrically acute state or who are suffering the effects of alcohol abuse and suggest that there may be an aggregate negative effect of lifetime duration of bipolar illness on memory and frontal or executive systems.

Atropine inhibits gastric distension and pharyngeal receptor mediated lower oesophageal sphincter relaxation

BACKGROUND

Atropine decreases the frequency of transient lower oesophageal sphincter relaxation (TLOSR) through an unknown mechanism. Gastric distension and pharyngeal receptor excitation are two possible sources for the afferent stimulus responsible for TLOSR.

AIMS

To determine whether atropine affects gastric distension induced TLOSR and pharyngeal receptor mediated lower oesophageal sphincter (LOS) relaxation.

METHODS

Oesophageal manometry and pH recordings were performed in 10 healthy volunteers on two separate days in the postprandial setting, following either atropine (15 micrograms/kg intravenous bolus and 4 micrograms/kg/h as a maintenance dose) or placebo. Pharyngeal receptor mediated LOS relaxation was studied in nine subjects by rapid injection of minute amounts of water (0.05, 0.1, 0.2, 0.3, and 0.4 ml) in the pharynx before and after atropine. Gastric distension mediated TLOSR was studied in eight subjects by insufflating the stomach with 300, 600 and 900 ml of CO2 before and after atropine.

RESULTS

Atropine reduced the frequency of spontaneous gastro-oesophageal reflux and TLOSR compared with placebo (p < 0.05). Pharyngeal stimulation resulted in bolus volume dependent LOS relaxation. Atropine decreased the frequency and amplitude of pharyngeal receptor mediated LOS relaxation at bolus volumes of 0.05, 0.1, and 0.2 ml. Gastric distension resulted in intermittent episodes of TLOSR. The frequency of gastric distension induced TLOSR was significantly decreased by atropine.

CONCLUSION

(1) Atropine reduces the frequency of spontaneous reflux and TLOSR in normal subjects; and (2) gastric distension induced TLOSR and pharyngeal receptor mediated LOS relaxation is inhibited by atropine.

Effectiveness of an outpatient intervention targeting suicidal young adults: preliminary results

This study evaluated the effectiveness of a time-limited, outpatient intervention targeting suicidal young adults. Participants (N = 264) were randomly assigned to either the experimental treatment or the control condition (i.e., treatment as usual). In addition to intake assessments, participants completed follow-ups at 1, 6, 12, 18, and 24 months. Both treatment and control participants evidenced significant improvement across all outcome measures throughout the follow-up period. Reductions were reported in suicidal ideation and behavior, associated symptomatology, and experienced stress, along with marked improvement in self-appraised problem-solving ability. Results also indicated that the experimental treatment was more effective than treatment as usual at retaining the highest risk participants. Available data demonstrate the efficacy of a time-limited, outpatient intervention for suicidal young adults. Implications of current findings for intervention with and treatment of this population are discussed.

Effectiveness of an outpatient intervention targeting suicidal young adults: preliminary results

This study evaluated the effectiveness of a time-limited, outpatient intervention targeting suicidal young adults. Participants (N = 264) were randomly assigned to either the experimental treatment or the control condition (i.e., treatment as usual). In addition to intake assessments, participants completed follow-ups at 1, 6, 12, 18, and 24 months. Both treatment and control participants evidenced significant improvement across all outcome measures throughout the follow-up period. Reductions were reported in suicidal ideation and behavior, associated symptomatology, and experienced stress, along with marked improvement in self-appraised problem-solving ability. Results also indicated that the experimental treatment was more effective than treatment as usual at retaining the highest risk participants. Available data demonstrate the efficacy of a time-limited, outpatient intervention for suicidal young adults. Implications of current findings for intervention with and treatment of this population are discussed.

Validation of a new measure of diarrhea

Adequate measures of diarrheal disease are important to assess severity for clinical use and outcomes research. We developed a questionnaire to assess diarrhea severity and complications, and administered it to 205 HIV positive patients with diarrhea, fever, or weight loss. Noteworthy variations in stool form were reported by individuals and across subjects. Self-reported diarrhea correlated with the occurrence of any stool pictured without form. However, verbal descriptors "loose" and "semiformed" had little value in assessment of diarrheal disease. Both verbal and pictorial stool descriptors correlated well with diarrhea complications (pain, urgency, tenesmus, incontinence, and nocturnal diarrhea). By factor analysis, discomfort and nondiscomfort diarrhea complications loaded on different factors, consistent with clinical experience that discomfort is a distinct problem in diarrheal disease. In summary we have developed an instrument to precisely characterize diarrhea severity that correlates well with clinically important events such as incontinence and abdominal pain.

Glutathione plays a key role in the depigmenting and melanocytotoxic action of N-acetyl-4-S-cysteaminylphenol in black and yellow hair follicles

This study examined the effect of glutathione on the in vivo depigmenting potency of N-acetyl-4-S-cysteaminylphenol (N-acetyl-4-S-CAP) in black and yellow mice after multiple intraperitoneal injections on 10 consecutive days. In black mice (C57BL/6J, a/a), N-acetyl-4-S-CAP showed dose-dependent depigmenting potency (0.5, 1.0, and 2.0 mmol/kg), which was in parallel to the tissue eumelanin content (98%, 28%, and 3% of controls, respectively) and to the tissue glutathione content (94%, 85%, and 76%, respectively). In lethal yellow mice (C57BL/6J, Ay/a), only a dose of 2.0 mmol/kg showed the color change of hair to dark, not to white as seen in black mice. This was reflected by the decrease of pheomelanin content (56%) and the increase of eumelanin content (28% of black mice). The simultaneous administration of N-acetyl-cysteine, which up-regulated glutathione content, completely abolished the depigmenting potency of N-acetyl-4-S-CAP, whereas administration of buthionine sulfoximine, which depleted the tissue glutathione content, enhanced the depigmenting potency of N-acetyl-4-S-CAP in black hair. In yellow mice, the darkening of hair follicles by 2.0 mmol/kg of N-acetyl-4-S-CAP was completely abolished by the combined administration of N-acetyl-cysteine, with the resulting hair color the same as in controls, whereas combined administration with buthionine sulfoximine caused some whitening of yellow hair follicles. Our data indicate that the tissue content of glutathione regulates melanocytotoxicity and depigmenting potency of N-acetyl-4-S-CAP and that this alteration of glutathione content may switch the melanogenesis type from pheomelanin to eumelanin.

Molecular control of melanogenesis in malignant melanoma: functional assessment of tyrosinase and lamp gene families by UV exposure and gene co-transfection, and cloning of a cDNA encoding calnexin, a possible melanogenesis "chaperone"

Melanogenesis is a cascade of events significantly controlled by regulatory genes which are associated with the melanosomal membrane. This report introduces our current research efforts dealing with (a) the gene and protein expressions of tyrosinase and Lamp (lysosome-associated membrane protein) families by human melanoma cells after repeated exposures to UV light, (b) the coordinated alterations in the expression of the Lamp family gene and its encoding product after transfection of two genes of the tyrosinase family in human melanoma cells and (c) cloning and sequencing of a Ca(2+)-binding phosphoprotein, calnexin, which could be a candidate as a chaperone for sorting and maturation of tyrosinase and Lamp family glycoproteins in melanogenesis cascade. Our UV exposure study, as well as gene transfection and antisense hybridization experiments, has clearly indicated a marked and coordinated interaction of the Lamp-1 gene with the tyrosinase and TRP-1 genes in this process. We propose that melanogenesis is controlled at least by two major gene family products, i.e., (a) the tyrosinase family of tyrosinase, TRP-1 and TRP-2, and the Lamp family of Lamp-1, Lamp-2 and Lamp-3. These two gene families probably derived from primordial melanogenesis-associated genes which are common or closely related to each other.

The relationship between age and cognitive impairment in HIV-1 infection: findings from the Multicenter AIDS Cohort Study and a clinical cohort

Previous studies have identified age as a risk factor for many neurologic disorders, and a "cerebral reserve" factor has been postulated to explain these findings. This study examined whether age represents a risk factor for HIV-1-related neuropsychological dysfunction. Subjects for study 1 were primarily asymptomatic seropositive (n = 1,066) and seronegative (n = 1,004) nonelderly male community volunteers who completed neuropsychological and reaction time measures. Data analyses revealed a significant effect for age on reaction time and timed neuropsychological measures, but no interaction between age and serostatus. Study 2, employing a similar neuropsychological battery, consisted of 76 seropositive men (29 over age 55) recruited from community outpatient clinics and 47 seronegative controls. We found serostatus and age to have main effects on a number of measures, but a trend for an effect of age-serostatus interaction on only one measure.

Identification of a cDNA coding for a Ca(2+)-binding phosphoprotein (p90), calnexin, on melanosomes in normal and malignant human melanocytes

In order to have a proper biosynthesis and secretion of the melanin-pigment granules (melanosomes) the melanocyte may require a melanosome-associated molecule that provides a signal for assembly and organization of melanogenic enzymes and proteins within the compartment of melanosomes. This study reports the presence of a Ca(2+)-binding phosphoprotein, p90, which can be engaged in such melanogenic function, located on the melanosomal membrane of human melanocytes. A human melanoma cDNA expression library in lambda Zap II was screened with a rabbit polyclonal antibody raised against human melanosomes isolated from cultured human melanoma cells, SK MEL 23. A cDNA encoding a melanosomal protein, M(r) 90 kDa, was identified through this immunoscreening. A partial sequencing of nucleotides (822 bp from the N-terminal domain) of this clone (3.8 kb) and predicted amino acids showed more than 90% homology with dog calnexin, a previously reported endoplasmic reticulum (ER) transmembrane protein. A fusion protein of this p90 with beta-galactosidase expressed in Escherichia coli revealed both the immuno-cross-reactivity with anti-dog calnexin and anti-human melanosome antibodies and the Ca(2+)-binding property. Upon immunohistochemistry, the anti-dog calnexin antibody revealed the positive immunoreactivities with both normal and malignant human melanocytes, showing a much higher expression of antigenic epitope than nonmelanocytic human cells. The laser scanning confocal immunofluorescence, using an antibody against a human melanosome-specific antigen (HMSA-5), and immunoelectron microscopy, using immunogold, confirmed the major localization of anti-dog calnexin antibody epitope on the melanosomes and ER.

cDNA-based functional domains of a calnexin-like melanosomal protein, p90

We have recently identified a gene encoding a calnexin-like protein (p90) by the immunoscreening of a human melanoma cDNA library, using a rabbit anti-human melanosomal antibody. This p90 protein was highly expressed by human melanocytes and associated with melanosomal membrane and endoplasmic reticulum. In this study we report the computer analysis of the predicted amino acid sequence of this calnexin-like melanosomal protein. We found that p90 is a membrane-bound protein whose large N-terminal domain is located within the melanosomal compartment; its shorter C-terminal is exposed to the cytosol and separated by a short transmembrane region. This p90 protein was found to have consensus sequences of a Ca(2+)-binding loop and a protein kinase C phosphorylation site at the N-terminal domain. The C-terminal domain, on the other hand, contained sequences of a casein kinase II phosphorylation site and two protein kinase A phosphorylation sites. Such functional motifs could provide signal transduction across the melanosomal membrane, the reception of melanogenic protein via carriers at the melanosomal membrane and the translocation of melanosomes in the melanocyte.

Cerebral metabolic dysfunction in AIDS: findings in a sample with and without dementia

Positron-emission tomography was coupled with neurological and neuropsychological evaluation to study regional cerebral activity and neurologic status in two groups. Seventeen patients with full-blown AIDS and 14 seronegative control subjects were studied using [18F]2-fluoro-2-deoxy-D-glucose in a resting state. The AIDS group had relative regional hypermetabolism in the basal ganglia and thalamus; stepwise multiple-regression analyses revealed a significant relationship for the AIDS group between temporal lobe metabolism and severity of dementia on the AIDS Dementia Complex Rating Scale. These results suggest that the basal ganglia, thalamus, and temporal lobes are differentially affected in AIDS.

Membrane-mediated effects of the steroid 17-alpha-estradiol on adrenal catecholamine release

The effects of 17-alpha-estradiol on the secretion of catecholamines from the perfused bovine and cat adrenal gland and bovine chromaffin cells in culture elicited by dimethylphenylpiperazinium (DMPP), methacholine and high potassium were studied. In perfused cat adrenal glands, secretion of catecholamines evoked by pulses of DMPP (1 microM for 30 sec) was decreased by 17-alpha-estradiol at concentrations of 1 and 10 microM by 50 and 80%, respectively. However, secretion evoked by pulses of methacholine (3 microM for 30 sec) was not affected by 1 microM of 17-alpha-estradiol and was affected to a variable extent by 10 microM 17-alpha-estradiol. Catecholamine secretion evoked by higher concentrations of methacholine (100 microM for 60 sec) was reduced by 50% by 10 microM 17-alpha-estradiol. 17-alpha-Estradiol decreased secretion evoked by pulses of 120 mM K+ for 10 sec to a similar extent in the perfused bovine and cat adrenal gland. The 45Ca++ uptake into bovine chromaffin cells in culture stimulated by DMPP (100 microM for 10 sec) or high K+ (59 mM for 10 sec) was almost inhibited completely by 100 microM 17-alpha-estradiol. The rapid action precludes a classical genomic mechanism and suggests effects at the cell membrane.

A single amino acid change in CUP2 alters its mode of DNA binding

CUP2 is a copper-dependent transcriptional activator of the yeast CUP1 metallothionein gene. In the presence of Cu+ and Ag+) ions its DNA-binding domain is thought to fold as a cysteine-coordinated Cu cluster which recognizes the palindromic CUP1 upstream activation sequence (UASc). Using mobility shift, methylation interference, and DNase I and hydroxyl radical footprinting assays, we examined the interaction of wild-type and variant CUP2 proteins produced in Escherichia coli with the UASc. Our results suggest that CUP2 has a complex Cu-coordinated DNA-binding domain containing different parts that function as DNA-binding elements recognizing distinct sequence motifs embedded within the UASc. A single-amino-acid substitution of cysteine 11 with a tyrosine results in decreased Cu binding, apparent inactivation of one of the DNA-binding elements and a dramatic change in the recognition properties of CUP2. This variant protein interacts with only one part of the wild-type site and prefers to bind to a different half-site from the wild-type protein. Although the variant has about 10% of wild-type DNA-binding activity, it appears to be completely incapable of activating transcription.