Prediction Model Development and Validation of 12-Year Incident Edentulism of Older Adults in the United States

INTRODUCTION

Edentulism affects health and quality of life.

OBJECTIVES

Identify factors that predict older adults becoming edentulous over 12 y in the US Health and Retirement Study (HRS) by developing and validating a prediction model.

METHODS

The HRS includes data on a representative sample of US adults aged >50 y. Selection criteria included participants in 2006 and 2018 who answered, "Have you lost all of your upper and lower natural permanent teeth?" Persons who answered "no" in 2006 and "yes" in 2018 experienced incident edentulism. Excluding 2006 edentulous, the data set (n = 4,288) was split into selection (70%, n = 3,002) and test data (30%, n = 1,286), and Monte Carlo cross-validation was applied to 500 random partitions of the selection data into training (n = 1,716) and validation (n = 1,286) data sets. Fitted logistic models from the training data sets were applied to the validation data sets to obtain area under the curve (AUC) for 32 candidate models. Six variables were included in all models (age, race/ethnicity, gender, education, smoking, last dental visit) while all combinations of 5 variables (income, alcohol use, self-rated health, loneliness, cognitive status) were considered for inclusion. The best parsimonious model based on highest mean AUC was fitted to the selection data set to obtain a final prediction equation. It was applied to the test data to estimate AUC and 95% confidence interval using 1,000 bootstrap samples.

RESULTS

From 2006 to 2018, 9.7% of older adults became edentulous. The 2006 mean (SD) age was 66.7 (8.7) for newly edentulous and 66.3 (8.4) for dentate (P = 0.31). The baseline 6-variable model mean AUC was 0.740. The 7-variable model with cognition had AUC = 0.749 and test data AUC = 0.748 (95% confidence interval, 0.715-0.781), modestly improving prediction. Negligible improvement was gained from adding more variables.

CONCLUSION

Cognition information improved the 12-y prediction of becoming edentulous beyond the modifiable risk factors of smoking and dental care use, as well as nonmodifiable demographic factors.

KNOWLEDGE TRANSFER STATEMENT

This prediction modeling and validation study identifies cognition as well as modifiable (dental care use, smoking) and nonmodifiable factors (race, ethnicity, gender, age, education) associated with incident complete tooth loss in the United States. This information is useful for the public, dental care providers, and health policy makers in improving approaches to preventive care, oral and general health, and quality of life for older adults.

Edentulism Predicts Cognitive Decline in the US Health and Retirement Cohort Study

This longitudinal cohort study examines if 1) cognitive decline varies by birth cohort, adjusting for covariates, and 2) edentulism and nonuse of dental care predict 10-y cognitive decline (2008-2018). The Health and Retirement Study (HRS) features a representative sample of US adults over age 50. Eligibility criteria included having cognitive interview data available and responding to the question, "Have you lost all of your upper and lower natural permanent teeth?" at 2+ time points between 2006 and 2018. Use of dental care in the past 2 y was assessed. Linear mixed models for repeated measures estimated the trajectories of mean cognition over time for the birth cohorts, adjusted for baseline cognition, dentition status, dental care use, and covariates (demographic characteristics, health behaviors, and medical conditions). Cohort-by-time interaction terms were included to assess if cognitive decline varied by birth cohort. Ten-year change in cognition status (measured by HRS Cogtot27)-categorized as dementia (<7); cognitive impairment, not demented (7-11) 7≤Cogtot27<12; and normal (≥12)-was also investigated according to birth cohort, dentition status, and dental care use. Mean (SD) baseline age was 63.4 (10.1) y (n = 22,728). Older birth cohorts had greater cognitive decline than younger cohorts. Linear mixed-model estimates and 95% confidence intervals for protective factors for cognitive decline included higher baseline cognition (HRS Cogtot27) (0.49; 0.48-0.50), use of dental care in the past 2 y (0.17; 0.10-0.23), and covariates such as greater household wealth and being married. Risk increased with being edentulous (-0.42; -0.56 to -0.28), history of stroke or diabetes, less education, Medicaid recipient, current smoker, loneliness, and poor/fair self-rated health. Edentulism and irregular dental care are among important predictors of cognitive decline. Tooth retention and regular dental care throughout life appear to be important for maintaining oral and cognitive health.

Periodontal Treatment Reduces Circulating Pro-Inflammatory Cytokine and Chemokine Levels in African American HIV+ Individuals with Virological Suppression

Introduction

Periodontal Disease (PD), a chronic inflammatory disease, is highly prevalent among Persons Living With HIV (PLWH) and is characterized by microbial symbiosis and oxidative stress. Our hypothesis stipulates that periodontal therapy attenuates systemic inflammatory and bacterial burden while improving periodontal status in PLWH.

Methods

Sixteen African Americans (AA) with suppressed HIV viremia on long-term Antiretroviral Therapy (ART) were recruited to this study. Participants were placed into two groups, based on their dental care status: group 1 (In-Care, IC) and group 2 (Out of Care, OC). Periodontal health was investigated at baseline, 3 months, 6 months, and 12 months. Cytokine/chemokines, microbial phyla, and Asymmetric Dimethylarginine (ADMA, a marker for endothelial cell dysfunction) levels were assessed in the serum. Statistical comparisons between groups and at different visits were performed using multiple comparison tests.

Results

Across longitudinal visits, periodontal treatment significantly reduced the levels of several cytokines and chemokines. At baseline, the out of care group had significantly higher blood levels of ADMA and actinobacteria than the IC group. Periodontal treatment significantly altered the abundance of circulating genomic bacterial DNA for various phyla in out of care group.

Conclusions

Periodontal treatment interventions effectively attenuated circulating pro-inflammatory cytokines and altered microbial translocation, both critical drivers of systemic inflammation in PLWH.

Exploring dimensions of quality-of-life in survivors of stroke with communication disabilities - a brief report

BACKGROUND

People with communication disabilities post-stroke have poor quality-of-life.

OBJECTIVES

We aimed to explore the association of self-reported communication disabilities with different dimensions of quality-of-life between 90 and 180 days post-stroke.

METHODS

Cross-sectional survey data were obtained between 90 and 180 days post-stroke from registrants in the Australian Stroke Clinical Registry recruited from three hospitals in Queensland. The usual follow-up survey included the EQ5D-3L. Responses to the Hospital Anxiety and Depression Scale, and extra questions (e.g. communication disabilities) were also collected. We used χ² statistics to determine differences.

RESULTS

Overall, 244/647 survivors completed the survey. Respondents with communication disabilities (n = 72) more often reported moderate to extreme problems in all EQ5D-3L dimensions, than those without communication disabilities (n = 172): anxiety or depression (74% vs 40%, p < .001), pain or discomfort (58% vs 39%, p = .006), self-care (46% vs 18%, p < .001), usual activities (77% vs 49%, p < .001), and mobility (68% vs 35%, p < .001). Respondents with communication disabilities reported less fatigue (66% vs 89%, p < .001), poorer cognitive skills (thinking) (16% vs 1%, p < .001) and lower social participation (31% vs 6%, p < .001) than those without communication disabilities.

CONCLUSIONS

Survivors of stroke with communication disabilities are more negatively impacted across different dimensions of quality-of-life (as reported between 90 and 180 days post-stroke) compared to those without communication disabilities. This highlights the need for timely and on-going comprehensive multidisciplinary person-centered support.

A194 THE ADDITION OF DEAMIDATED GLIADIN PEPTIDE TO TISSUE TRANSGLUTAMINASE ANTIBODIES DOES NOT INCREASE THE ODDS OF CELIAC DISEASE DIAGNOSIS IN AN IGA SUFFICIENT POPULATION

Background

Previous studies proposed that the combination of IgA anti-tissue transglutaminase 2 IgA (TTG) and IgG deamidated gliadin peptide IgG (DGP) antibodies increases celiac disease (CeD) detection rates. However, this remains controversial.

Aims

To evaluate the performance of adding DGP to TTG antibodies, for the diagnosis of celiac disease (CeD) in the immunoglobulin A (IgA)-sufficient population.

Methods

We included consecutive patients with suspected CeD who had both TTG and DGP serology performed simultaneously from 2017–2020 in Hamilton, Canada. Chart review was performed by 3 reviewers to extract data on biopsies, diagnosis of CeD and genetic HLA-DQ2/DQ8. CeD was defined as positive serology (either TTG and/or DGP) and villous atrophy in duodenal biopsies (≥Marsh-3a). A case was defined as an instance of TTG and DGP performed at a single timepoint. A single patient could have represented multiple cases if TTG and DGP were measured at multiple time points. Sensitivity, specificity, negative and positive predictive values were calculated, and ROC curves were generated. Diagnostic odds ratios (DOR) assessed the performance of each serological strategy compared to duodenal biopsies.

Results

There were 580 patients constituting 823 cases that met inclusion criteria, of whom 441 had CeD. IgA-deficient patients (n=100) were excluded. Of the 723 cases remaining, 337 (214 adult;123 pediatric) had serology performed at the time of CeD diagnosis. TTG increased the odds of CeD diagnosis compared with DGP, Diagnostic Odds Ratio (DOR)=53.22 (95% CI 22.63–119.80) vs DOR=21.28 (95% CI 10.67–42.46). The addition of DGP to TTG did not increase the odds of CeD diagnosis [DGP+TTG DOR=51.39 (95% CI 19.36–135.61) vs TTG alone DOR=53.22 (95% CI 22.63–119.80)]. There were 37 discordant cases where only one of either TTG or DGP was positive. HLA-DQ2/DQ8 were absent in 2/9 cases with isolated increased DGP. Among the discordant cases, TTG outperformed DGP (DOR TTG= 4.29; 95% CI 1.09–16.83 vs DOR DGP=0.23; 95% CI 0.06–0.92).

Conclusions

In the IgA-sufficient population, the addition of DGP to TTG testing does not increase the diagnostic accuracy of CeD serologic screening. This has implications in health-care costs as false positive results prompt further investigations. Given these findings, larger prospective studies should be completed prior to adding DGP antibodies to routine TTG serology.

Funding Agencies

None

Distinct Microbial Signatures between Periodontal Profile Classes

Precise classification of periodontal disease has been the objective of concerted efforts and has led to the introduction of new consensus-based and data-driven classifications. The purpose of this study was to characterize the microbiological signatures of a latent class analysis (LCA)-derived periodontal stratification system, the Periodontal Profile Class (PPC) taxonomy. We used demographic, microbial (subgingival biofilm composition), and immunological data (serum IgG antibody levels, obtained with checkerboard immunoblotting technique) for 1,450 adult participants of the Dental Atherosclerosis Risk in Communities (ARIC) study, with already generated PPC classifications. Analyses relied on t tests and generalized linear models with Bonferroni correction. Men and African Americans had higher systemic antibody levels against most microorganisms compared to women and Caucasians (P < 0.05). Healthy individuals (PPC-I) had low levels of biofilm bacteria and serum IgG levels against most periodontal pathogens (P < 0.05). Subjects with mild to moderate disease (PPC-II to PPC-III) showed mild/moderate colonization of multiple biofilm pathogens. Individuals with severe disease (PPC-IV) had moderate/high levels of biofilm pathogens and antibody levels for orange/red complexes. High gingival index individuals (PPC-V) showed moderate/high levels of biofilm Campylobacter rectus and Aggregatibacter actinomycetemcomitans. Biofilm composition in individuals with reduced periodontium (PPC-VI) was similar to health but showed moderate to high antibody responses. Those with severe tooth loss (PPC-VII) had significantly high levels of multiple biofilm pathogens, while the systemic antibody response to these microorganisms was comparable to health. The results support a biologic basis for elevated risk for periodontal disease in men and African Americans. Periodontally healthy individuals showed a low biofilm pathogen and low systemic antibody burden. In the presence of PPC disease, a microbial-host imbalance characterized by higher microbial biofilm colonization and/or systemic IgG responses was identified. These results support the notion that subgroups identified by the PPC system present distinct microbial profiles and may be useful in designing future precise biological treatment interventions.

A143 ACUTE ESOPHAGEAL NECROSIS: A COMPLICATION OF DIABETIC KETOACIDOSIS

Background

Acute esophageal necrosis (AEN) is a rare entity associated with diabetic ketoacidosis (DKA). The pathogenesis is thought to be linked to low volume state, microvascular disease, impaired gastric and esophageal motility increasing acid reflex, all rendering the esophagus prone to injury.

Aims

We report a case of AEN as a complication of DKA in a patient without any overt gastrointestinal bleeding (GIB), along with a literature review.

Methods

Keywords “esophageal necrosis” and “diabetic ketoacidosis” were used in MEDLINE and BASE to retrieve English articles reporting cases of AEN in DKA.

Results

A 63 year old male with history of hypertension, dyslipidemia and non-insulin dependent diabetes mellitus presented to Emergency with 5 day history of severe epigastric pain, dysphagia to solids and liquids, nausea and vomiting (without any overt GIB). Most recent HbA1c was 8.4%. His diabetes was managed with metformin and semaglutide. Bloodwork revealed a hemoglobin of 165g/L and leukocytes of 17.9x109/L. Chemistries showed an anion gap of 25 with bicarbonate of 5mmol/L. Venous blood gas showed acidemia (pH=7.02). B-hydroxybutyrate level was 10.2mmol/L. Urinalysis was negative for leukocytes or nitrites. An abdominal CT ruled out bowel obstruction or intra-abdominal infection/abscess as the source of his discomfort but demonstrated circumferential wall thickening of the distal esophagus. No other triggers were found for this patient’s DKA except perhaps a recently started ketogenic diet. After resolution of DKA, he continued to experience severe epigastric pain, reflux symptoms, and dysphagia. An esophagogastroduodenoscopy (EGD) was performed, which showed AEN with circumferential black, necrotic inflammatory changes in the mid to distal esophagus. Erosions were seen in the body and antrum of the stomach, and multiple clean based ulcers were seen in the duodenum. Patient was started on an insulin regimen prior to discharge. Review of literature shows a total of 13 cases of AEN in DKA, with only one case where the patient did not present with any clinical bleeding. Risk factors for AEN include, hypertension, diabetes mellitus, malignancy, male gender, older age, chronic kidney disease, alcohol abuse and cardiovascular disease. While no medications have been linked to AEN, our patient was recently started on semiglutide, which has been implicated in impaired gastric emptying and increased GERD symptoms. This may further explain why the patient developed AEN.

Conclusions

AEN is a rare entity, especially in the context of DKA. Usually patients present with overt GIB; however, on occasion dysphagia, nausea, and vomiting can be the predominant symptoms. Hence, the threshold to perform EGD in patients with DKA should be low, given their low volume state and potentially impaired gastrointestinal motility due to microvascular disease or medications, putting them at higher risk for AEN.

Funding Agencies

None

Individuals with high bone mass have increased progression of radiographic and clinical features of knee osteoarthritis

OBJECTIVE

High bone mass (HBM) is associated with an increased prevalence of radiographic knee OA (kOA), characterized by osteophytosis. We aimed to determine if progression of radiographic kOA, and its sub-phenotypes, is increased in HBM and whether observed changes are clinically relevant.

DESIGN

A cohort with and without HBM (L1 and/or total hip bone mineral density Z-score≥+3.2) had knee radiographs collected at baseline and 8-year follow-up. Sub-phenotypes were graded using the OARSI atlas. Medial/lateral tibial/femoral osteophyte and medial/lateral joint space narrowing (JSN) grades were summed and Δosteophytes, ΔJSN derived. Pain, function and stiffness were quantified using the WOMAC questionnaire. Associations between HBM status and sub-phenotype progression were determined using multivariable linear/poisson regression, adjusting for age, sex, height, baseline sub-phenotype grade, menopause, education and total body fat mass (TBFM). Generalized estimating equations accounted for individual-level clustering.

RESULTS

169 individuals had repeated radiographs, providing 330 knee images; 63% had HBM, 73% were female, mean (SD) age was 58 (12) years. Whilst HBM was not clearly associated with overall Kellgren-Lawrence measured progression (RR = 1.55 [0.56.4.32]), HBM was positively associated with both Δosteophytes and ΔJSN individually (adjusted mean differences between individuals with and without HBM 0.45 [0.01.0.89] and 0.15 [0.01.0.29], respectively). HBM individuals had higher WOMAC knee pain scores (β = 7.42 [1.17.13.66]), largely explained by adjustment for osteophyte score (58% attenuated) rather than JSN (30% attenuated) or TBFM (16% attenuated). The same pattern was observed for symptomatic stiffness and functional limitation.

CONCLUSIONS

HBM is associated with osteophyte progression, which appears to contribute to increased reported pain, stiffness and functional loss.

FRI0448 FOUR CASES OF SYPHILIS MIMICKING RHEUMATOLOGICAL CONDITIONS PRESENTING TO THE GENERAL RHEUMATOLOGY SERVICE AT ST GEORGES HOSPITAL, LONDON, UK IN 2018-2019

Background:

Sir William Osler once wrote: “He, who knows syphilis, knows medicine”.

Whilst the Tuskegee Syphilis trials live in infamy, the advent of succesful penicillin treatment and sexual health education resulted in the lowest recorded incidence ever in 20011.

Unfortunately, cases of syphilis have nearly tripled in the past decade (from 2,847 in 2009 to 7,541 in 2018 in the UK)1. WHO now estimates the global median prevalence of Syphilis, among men who have sex with men, is 6%2

The current cohort of clinicians will therefore have limited clinical experience of Syphilis, which can often mimic rheumatic conditions. We present the clinical experience of a tertiary teaching centre hospital.

Objectives:

To identify the scope of clinical cases, with a diagnosis of Syphilis, during 2018-2019 at St Georges University Hospital, London, UK.

Methods:

Clinical cases were identified by health professionals and a retrospective review of medical records was undertaken.

Results:

There were 4 cases identified during 2018-19.

PatientAgeSexPast Medical HistorySymptomatologyRisk FactorsPresumed DiagnosisSerology169MaleHypertensionGCABilateral visual loss, rashMSMPrednisoloneTocilizumabGCA-related visual lossRPR 1:64TPPA 1: 10248246FemaleNilJoint pain and swelling, rashHepatitis B Core Antibody positiveUndifferentiatedInflammatory ArthritisRPR 1: 16340MaleNilJoint pain, alopecia, uveitis and rash, weight lossMSMPrimary SyphilisRPR 1: 16TPPA 1: 10248486FemalePulmonary Sarcoidosis, Squamous cell carcinoma of left maxillary sinusLower motor neuron facial nerve palsyPrednisoloneSarcoidosisRPR 1:4TPPA 1:80

GCA: Giant cell arteritis, MSM: Men who have sex with men, RPR: rapid plasma regain, TPPA: Treponema pallidum particle agglutination assay

Case 1:The patient was diagnosed with bilateral uveitis secondary to primary syphilis, and immunosuppression may have contributed to this.

Case 2:The rash developed after the initial presentation and an extended infection screen was performed.

Case 3:The patient had a 6 month duration of symptoms and had had a negative sexual health screen 1 year prior to presentation.

Case 4:The patient had no features of extra pulmonary sarcoidosis and an infectious screen was undertaken.

All 4 cases were referred to the Infectious Disease Unit for treatment. 3 patients received standard treatment with Penicillin, and 1 patient received an oral course of Doxycycline, due to a penicillin allergy.

2 of the 4 cases had complete resolution of symptoms, and 2 of the cases had only partial resolution of symptoms at the time of publication.

Conclusion:

Syphilis can present with an inflammatory arthritis, PMR and GCA –type symptoms, ocular inflammation, neurological disturbance and rashes that can mimic autoimmune conditions.

Our cases highlight the increasing incidence, as well as the risk of reactivation following immunosuppression. Current practice does not advise routine testing for syphilis prior to initiation of immunosuppressive therapy. However the rising incidence should prompt careful evaluation, and detailed sexual history, particularly in high risk groups. The diagnostic test interpretation and treatment requires close collaboration with Infectious Diseases Specialists.

References:

[1]https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/805903/2018_Table_1_STI_diagnoses_and_rates_in_England_by_gender.ods

[2]Report on global sexually transmitted infection surveillance 2018, WHO, ISBN: 978-92-4-156569-1

Disclosure of Interests:

None declared

0203 To and From the Night Shift: Risky On-the-Road Driving in Night Shift Workers

Introduction

Drowsy driving is a common occupational hazard for night shift workers (NSWs). While sleep loss is commonly identified as the primary culprit of drowsy driving, another critical factor to consider is circadian phase. However, the role of circadian phase in driving safety has not been well characterized in NSWs. This study examined if dim light melatonin offset (DLMOff, i.e. the cessation of melatonin secretion) is also a relevant phase marker of susceptibility to four different subtypes of risky on-the-road driving behaviors.

Methods

On-the-road driving was monitored over 8 weeks via a mobile application that tracked risky driving behaviors using accelerometer and GPS data from cell phones (N=15; 3052 total driving events recorded). Risky driving behaviors included: 1) frequency of hard-braking events, 2) frequency of aggressive-acceleration events, 3) duration of excessive-speeding, and 4) duration of phone-usage. At week 2, participants spent 24 hours in-lab where hourly saliva samples were collected and assayed for melatonin, and DLMOff was calculated. Phase angle of driving events relative to DLMOff was used as the predictor in nested mixed-effects regressions, with risky driving behaviors as the outcome variables.

Results

The most common occurrences of risky driving were phone-usage and hard-braking. On average, NSWs had 46.7% and 42.0% of driving events with at least one occurrence of phone-usage and hard-braking, respectively. Rates of aggressive-acceleration and speeding were 24.4% and 20.4%. Positive phase angles (i.e. driving after DLMOff) were associated with reduced rates of hard-braking and aggressive-acceleration, but not of phone-usage and excessive-speeding. Specifically, rates of hard-braking and aggressive-acceleration decreased by 4.5% (p&lt;.01) and 3.4% (p=.05) every two hours following DLMOff, respectively.

Conclusion

The study suggests DLMOff appears to be an important variable for predicting accident risk in NSWs. If replicated, circadian phase should be considered in recommendations to increase occupational health and safety of NSWs.

Support

Support for this study was provided to PC by NHLBI (K23HL138166).

Flossing Is Associated with Improved Oral Health in Older Adults

The effect of preventive oral habits is largely unexplored in older individuals. The purpose of this study was to evaluate the associations between home use of flossing and prevalence of periodontal disease and caries in older adults. Five-year incident tooth loss was also evaluated. Data on 686 individuals ≥65 y-old from the Piedmont 65+ Dental Study were examined including: 1) interproximal clinical attachment level (iCAL), 2) interproximal probing depth (iPD), 3) numbers of caries, and 4) missing teeth. Flossing behavior was evaluated according to the Periodontal Profile Class (PPC) system. Five-year follow-up data (n = 375) was evaluated for incident tooth loss. Dichotomous and categorical variables were analyzed using Pearson chi-square tests as well as covariate-adjusted Cochran-Mantel-Haenszel tests. Multiple linear regression compared clinical parameters based on flossing behavior. Elderly flossers had lower (mean, SE) %iCAL≥3 mm (38.2, 2.38 vs. 48.8, 1.56) and %iPD≥4 mm (8.70, 1.41 vs. 14.4, 0.93) compared to nonflossers (P ≤ 0.005). Flossers showed less coronal caries compared to nonflossers (P = 0.02). Baseline number of missing teeth (mean, SE) was 11.5 (0.35) in nonflossers compared to 8.6 (0.53) in flossers (P < 0.0001). Regular dental visitors had lower oral disease levels compared to episodic dental users. The majority of flossers classified into PPC-Stage I (health) whereas nonflossers classified as PPC-Stages V, VI, and VII (disease). At the 5-y follow-up visit, the average tooth loss for flossers was ~1 tooth compared to ~4 teeth lost for nonflossers (P < 0.0001). Among all teeth, molars showed the highest benefit (>40%) for flossing behavior (P = 0.0005). In conclusion, the extent of oral disease for older individuals was significantly less in flossers than in nonflossers. Flossers showed less periodontal disease, fewer dental caries, and loss of fewer teeth over a 5-y period. These findings further support flossing as an important oral hygiene behavior to prevent oral disease progression in older adults.

Family History of MI, Smoking, and Risk of Periodontal Disease

Periodontal disease (PD) shares common risk factors with cardiovascular disease. Our hypothesis was that having a family history of myocardial infarction (FamHxMI) may be a novel risk factor for PD. Risk assessment based on FamHxMI, conditional on smoking status, was examined given the strong influence of smoking on PD. Exploratory analysis with inflammatory biomarkers and genetic determinants was conducted to understand potential mechanistic links. The Women's Genome Health Study (WGHS) is a prospective cohort of US female health care professionals who provided blood samples at baseline in the Women's Health Study, a 2 × 2 factorial clinical trial investigating vitamin E and aspirin in the prevention of cardiovascular disease and cancer. PD was ascertained via self-report over 12 y of follow-up. Prevalence (3,442 cases), incidence (1,365 cases), and survival analysis of PD were investigated for associations of FamHxMI as well as in strata of FamHxMI by smoking. Kruskal-Wallis, chi-square tests, multivariate regression, and Cox proportional hazard models were used for the analyses. In the WGHS, women with FamHxMI showed higher risk of ever having PD. A particularly high-risk group of having both FamHxMI and smoking at baseline was highlighted in the prevalence and risk of developing PD. PD risk increased according to the following strata: no FamHxMI and nonsmokers (reference), FamHxMI and nonsmokers (hazard ratio [HR] = 1.2, 95% CI = 1.0 to 1.5), smokers without FamHxMI (HR = 1.3, 95% CI = 1.2 to 1.5), and smokers with FamHxMI (HR = 1.5, 95% CI = 1.2 to 1.8). An independent analysis by the dental Atherosclerosis Risk in Communities study ( N = 5,552) identified more severe periodontitis cases among participants in the high-risk group (smokers with FamHxMI). Further examination of interactions among inflammatory biomarkers or genetic exploration with FamHxMI did not explain the risk increase of PD associated with FamHxMI in the WGHS. Future efforts based on an integrative-omics approach may facilitate validation of these findings and suggest a mechanistic link between PD and FamHxMI.

Interdental Cleaning Is Associated with Decreased Oral Disease Prevalence

The purpose of this study was to evaluate the associations between interdental cleaning behavior and the prevalence of caries and periodontal disease and numbers of missing teeth, with data from the National Health and Nutrition Examination Survey (2011 to 2012 and 2013 to 2014). Analysis included the following parameters: interproximal clinical attachment level (iCAL) ≥3 mm, interproximal probing depth (iPD) ≥4 mm, number of coronal and interproximal caries, number of missing teeth, ≥1 surfaces with coronal caries, and periodontal profile classes (PPCs). Chi-square was used for bivariate associations. Associations of interdental cleaning with outcomes were assessed with multiple linear regression and generalized logit regression, adjusting for age, race, sex, diabetes, smoking, education, dental visits, and sugar consumption. Nonusers had a significantly higher percentage of sites with iCAL ≥3 mm and iPD ≥4 mm as compared with individuals who used interdental cleaning devices ( P < 0.0001). Individuals with a higher frequency of cleaning (4 to 7×/wk) had a significantly lower extent of sites with iCAL ≥3 mm as compared with lower-frequency cleaning (1 to 3×/wk; P ≤ 0.05). Interdental cleaning users showed lower numbers of coronal caries, interproximal coronal caries, and missing teeth as compared with nonusers ( P < 0.0001). Nonusers had 1.73-times (95% confidence interval, 1.53 to 1.94) higher odds for having ≥1 surfaces of coronal caries as compared with interdental cleaning users, regardless of the weekly frequency. Individuals were less likely to be in diseased PPCs if they were interdental cleaning users. Low-frequency cleaners (1 to 3×/wk) had significantly greater odds (1.43; 95% confidence interval, 1.08 to 1.88) to have severe disease (PPC-G) versus health (PPC-A) than were high-frequency cleaners (4 to 7×/wk). Interdental cleaning users showed lower levels of periodontal disease and caries and lower numbers of missing teeth. Higher frequency of interdental cleaning was correlated with increased periodontal health. Individuals with severe periodontal disease could show additional oral health benefits by increasing cleaning frequency. The data support the use of interdental cleaning devices as an oral hygiene behavior for promoting health.

Infliximab vs. adalimumab in Crohn's disease: results from 327 patients in an Australian and New Zealand observational cohort study

BACKGROUND

Maintenance anti-tumour necrosis factor-α (anti-TNFα) treatment for Crohn's disease is the standard of care for patients with an inadequate response to corticosteroids and immunomodulators.

AIM

To compare the efficacy and safety of infliximab and adalimumab in clinical practice and assess the value of concomitant immunomodulator therapy.

METHODS

We performed an observational cohort study in consecutive patients with Crohn's disease qualifying for anti-TNFα treatment in Australia and New Zealand between 2007 and 2011. Demographic and clinical data were prospectively recorded to identify independent factors associated with induction and maintenance of response to infliximab or adalimumab, or to either anti-TNFα therapy.

RESULTS

Three hundred and twenty-seven patients (183 infliximab, 144 adalimumab) successfully applied for treatment. Eighty-nine percent responded in all groups and median maintenance of response was similar for the two agents. Concomitant immunomodulator with infliximab, but not adalimumab, demonstrated a significantly longer response overall (P = 0.002), and significantly fewer disease and treatment-related complications (P = 0.017). Corticosteroids at baseline, and/or in the preceding 12 months, were associated with a 9-13 times greater risk of disease flare during maintenance treatment as compared to no corticosteroids (P < 0.0001). Maintenance of response was similar in the anti-TNF naïve and anti-TNF experienced subgroups.

CONCLUSIONS

In this large, real-life study, we demonstrate infliximab and adalimumab to have similar response characteristics. However, infliximab requires concomitant immunomodulator to achieve optimal maintenance of response comparable to adalimumab monotherapy. The results of this study will assist clinicians in further optimising patient care in their day-to-day clinical practice.

The Salivary Microbiome and Oral Cancer Risk: a Pilot Study in Fanconi Anemia

Fanconi anemia (FA) is a rare genetic disease characterized by chromosomal instability and impaired DNA damage repair. FA patients develop oral squamous cell carcinoma (OSCC) earlier and more frequently than the general population, especially after hematopoietic stem cell transplantation (HSCT). Although evidence of an etiological role of the local microbiome and carcinogenesis has been mounting, no information exists regarding the oral microbiome of FA patients. The aim of this study was to explore the salivary microbiome of 61 FA patients regarding their oral health status and OSCC risk factors. After answering a questionnaire and receiving clinical examination, saliva samples were collected and analyzed using 16S rRNA sequencing of the V3-V4 hypervariable region. The microbial profiles associated with medical and clinical parameters were analyzed using general linear models. Patients were young (mean age, 22 y) and most had received HSCT ( n = 53). The most abundant phyla were Firmicutes [mean relative abundance (SD), 42.1% (10.1%)] and Bacteroidetes [(25.4% (11.4%)]. A history of graft-versus-host disease (GVHD) ( n = 27) was associated with higher proportions of Firmicutes (43.8% × 38.5%, P = 0.05). High levels of gingival bleeding were associated with the genera Prevotella (22.25% × 20%), Streptococcus (19.83% × 17.61%), Porphyromonas (3.63% × 1.42%, P = 0.03), Treponema (1.02% × 0.28%, P = 0.009), Parvimonas (0.28% × 0.07%, P = 0.02) and Dialister (0.27% × 0.10%, P = 0.04). Finally, participants transplanted over 11 y ago showed the highest levels of Streptococcus (18.4%), Haemophilus (12.7%) and Neisseria (6.8%). In conclusion, FA patients that showed poor oral hygiene harbored higher proportions of the genera of bacteria compatible with gingival disease. Specific microbial differences were associated with a history of oral GVHD and a history of oral mucositis.

Oxidative Stress and IgG Antibody Modify Periodontitis-CRP Association

In a previous report, we demonstrated the inverse association of high serum 8-isoprostane levels, a marker for oxidative stress, with decreased serum IgG antibodies to oral bacteria. The association between increased serum IgG with increased plaque and periodontitis (increased probing depths) was attenuated by high systemic oxidative stress. Other investigations have reported a role for systemic oxidative stress as a stimulus of hepatic C-reactive protein (CRP) response. These observations led us to hypothesize that the reported relationship of periodontitis to elevated serum CRP, a systemic inflammatory marker, may be modified by oxidative stress and that the levels of serum antibodies to oral bacteria might be an intermediary explanatory variable linking the association of systemic oxidative stress, periodontal disease, and levels of CRP. This hypothesis was explored as a secondary analysis of the Dental ARIC (Atherosclerosis Risk in Communities) study using serum levels of CRP, serum IgG levels to 16 oral organisms, serum levels of 8-isoprostane, and periodontal status. The findings indicate periodontitis is associated with high CRP in the presence of elevated oxidative stress that serves to suppress the IgG response. Only within the highest 8-isoprostane quartile was periodontitis (pocket depth) associated with increased serum CRP levels (P = 0.0003). Increased serum IgG antibody levels to oral bacteria were associated with lowered serum CRP levels. Thus, systemic oxidative stress, which has been demonstrated to be associated with increased levels of CRP in other studies, appears to be associated with the suppression of bacterial-specific IgG levels, which in the presence of periodontal disease can result in an enhanced systemic CRP response. Conversely, individuals with increased serum IgG antibodies to plaque bacteria exhibit lowered serum CRP levels. These 2 factors, oxidative stress and the serum IgG response, appear to function in opposing directions to modify serum levels of CRP and the association with periodontitis.

Association of Synergistetes and Cyclodipeptides with Periodontitis

The purpose of this study was to evaluate the microbial community (MC) composition as it relates to salivary metabolites and periodontal clinical parameters in a 21-d biofilm-overgrowth model. Subjects ( N = 168) were enrolled equally into 5 categories of periodontal status per the biofilm-gingival interface classification. Microbial species within subgingival plaque samples were identified by human microbiome identification microarray. Whole saliva was analyzed by liquid chromatography–mass spectrometry and gas chromatography–mass spectrometry for metabolite identification. Phylum was grouped into MCs according to principal component analysis. Generalized linear and regression models were used to examine the association among MC, species, periodontal clinical parameters, and salivary metabolome. Multiple comparisons were adjusted with the false discovery rate. The study population was distributed into 8 distinct MC profiles, designated MC-1 to MC-8. MC-2 explained 14% of the variance and was dominated by Synergistetes and Spirochaetes. It was the only community structure significantly associated with high probing depth ( P = 0.02) and high bleeding on probing ( P = 0.008). MC-2 was correlated with traditional periodontal pathogens and several newly identified putative periodontal pathogens: Fretibacterium fastidiosum, Fretibacterium sp. OT360/OT362, Filifactor alocis, Treponema lecithinolyticum, Eubacterium saphenum, Desulfobulbus sp. /OT041, and Mogibacterium timidum. Synergistetes phylum was strongly associated with 2 novel metabolites—cyclo (-leu-pro) and cyclo (-phe-pro)—at 21 d of biofilm overgrowth ( P = 0.02). In subjects with severe periodontitis (P2 and P3), cyclo (-leu-pro) and cyclo (-phe-pro) were significantly associated with increased changes in probing depth at 21 d of biofilm overgrowth ( P ≤ 0.05). The analysis identified a MC dominated by Synergistetes, with classic and putative newly identified pathogens/pathobionts associated with clinical disease. The metabolomic discovery of 2 novel cyclodipeptides that have been reported to serve as quorum-sensing and/or bacteriocidal/bacteriostatic molecules, in association with Synergistetes, suggests a potential role in periodontal biofilm dysbiosis and periodontal disease that warrants further investigation.

Chronic periodontitis genome-wide association studies: gene-centric and gene set enrichment analyses

Recent genome-wide association studies (GWAS) of chronic periodontitis (CP) offer rich data sources for the investigation of candidate genes, functional elements, and pathways. We used GWAS data of CP (n = 4,504) and periodontal pathogen colonization (n = 1,020) from a cohort of adult Americans of European descent participating in the Atherosclerosis Risk in Communities study and employed a MAGENTA approach (i.e., meta-analysis gene set enrichment of variant associations) to obtain gene-centric and gene set association results corrected for gene size, number of single-nucleotide polymorphisms, and local linkage disequilibrium characteristics based on the human genome build 18 (National Center for Biotechnology Information build 36). We used the Gene Ontology, Ingenuity, KEGG, Panther, Reactome, and Biocarta databases for gene set enrichment analyses. Six genes showed evidence of statistically significant association: 4 with severe CP (NIN, p = 1.6 × 10(-7); ABHD12B, p = 3.6 × 10(-7); WHAMM, p = 1.7 × 10(-6); AP3B2, p = 2.2 × 10(-6)) and 2 with high periodontal pathogen colonization (red complex-KCNK1, p = 3.4 × 10(-7); Porphyromonas gingivalis-DAB2IP, p = 1.0 × 10(-6)). Top-ranked genes for moderate CP were HGD (p = 1.4 × 10(-5)), ZNF675 (p = 1.5 × 10(-5)), TNFRSF10C (p = 2.0 × 10(-5)), and EMR1 (p = 2.0 × 10(-5)). Loci containing NIN, EMR1, KCNK1, and DAB2IP had showed suggestive evidence of association in the earlier single-nucleotide polymorphism-based analyses, whereas WHAMM and AP2B2 emerged as novel candidates. The top gene sets included severe CP ("endoplasmic reticulum membrane," "cytochrome P450," "microsome," and "oxidation reduction") and moderate CP ("regulation of gene expression," "zinc ion binding," "BMP signaling pathway," and "ruffle"). Gene-centric analyses offer a promising avenue for efficient interrogation of large-scale GWAS data. These results highlight genes in previously identified loci and new candidate genes and pathways possibly associated with CP, which will need to be validated via replication and mechanistic studies.

Neonatologists' perspectives of palliative and end-of-life care in neonatal intensive care units

OBJECTIVE

Determine palliative and end-of-life care practices, barriers and beliefs among US neonatologists, and relationships between practice characteristics and palliative care delivery.

STUDY DESIGN

A descriptive cross-sectional survey with ordinal measurements. The survey was sent to 1885 neonatologists.

RESULTS

There were 725 responses (38.5%) with 653 (34.6%) completing the survey. Of those, 58.0% (n=379) have palliative care teams and 72.0% (n=470) have staff support groups or bereavement services. Palliative care education was deemed important (n=623) and needed. Barriers include emotional difficulties, staff disagreements and difficulty forming palliative care teams. Palliative care teams or staff bereavement groups were significantly predictive of willingness to initiate palliative care and more positive views or experiences.

CONCLUSION

Neonatologists believe that palliative care is important. Education and palliative care teams help provide quality care. Exploration of differing views of palliative care among team members is needed.