King's Brief Interstitial Lung Disease questionnaire: responsiveness and minimum clinically important difference

Health status is increasingly used in clinical practice to quantify symptom burden and as a clinical trial end-point in patients with interstitial lung disease (ILD). The King's Brief Interstitial Lung Disease (KBILD) questionnaire is a brief, validated 15-item, disease-specific, health-related quality of life questionnaire that is increasingly used in clinical trials, but little data exist regarding the minimum clinically important difference (MCID). Using pulmonary rehabilitation as a model, we aimed to determine the responsiveness of KBILD and provide estimates of the MCID.KBILD scores, Chronic Respiratory Questionnaire (CRQ) scores, Medical Research Council (MRC) Dyspnoea score and incremental shuttle walk test (ISWT) distance were measured in 209 patients with ILD (105 with idiopathic pulmonary fibrosis (IPF)) before and after an outpatient pulmonary rehabilitation programme. Changes with intervention and Cohen's effect size were calculated. Anchor-based (linear regression and receiver operating characteristic plots) or distribution-based approaches (0.5 sd and standard error of measurement) were used to estimate the MCID of KBILD domain and total scores.KBILD, CRQ, MRC Dyspnoea and ISWT improved with intervention, and the effect sizes of KBILD domain and total scores ranged from 0.28 to 0.38. Using anchor-based estimates, the MCID estimates for KBILD-Psychological, KBILD-Breathlessness and activities, and KBILD-Total were 5.4, 4.4 and 3.9 points, respectively. Using distribution-based methods, the MCID estimate for KBILD-Chest symptoms was 9.8 points. The MCID estimates for KBILD in IPF patients were similar.In patients with ILD and IPF, KBILD is responsive to intervention with an estimated MCID of 3.9 points for the total score.

Translating Improvements with Ixekizumab in Clinical Trial Outcomes into Clinical Practice: ASAS40, Pain, Fatigue, and Sleep in Ankylosing Spondylitis

INTRODUCTION

Ixekizumab, a humanized interleukin-17A antibody, has shown efficacy in ankylosing spondylitis (AS), with a greater proportion of ixekizumab-treated patients achieving an ASAS40 (Assessment of Spondyloarthritis International Society 40) endpoint compared to placebo. An ASAS40 response is a high standard that is not routinely used in clinical practice. The goals of this study were (a) to measure improvement in ixekizumab-treated patients in the four ASAS treatment response domains and in other patient-reported outcomes, and (b) to determine how the ASAS response was associated with changes in spinal pain at night, fatigue, sleep, and the Short Form 36-Item Physical Component Summary (SF-36 PCS).

METHODS

The COAST-V and COAST-W trials were randomized, double-blind, controlled trials examining ixekizumab efficacy in patients with AS who were biologic disease-modifying antirheumatic drug (bDMARD)-naïve and tumor necrosis factor inhibitor (TNFi)-experienced, respectively. Data for the ASAS treatment response domains and other outcomes were collected through 16 weeks. Comparisons between treatment groups were made using a mixed-effects model for repeated measures. To determine how the ASAS response was associated with the changes in spinal pain at night, fatigue, sleep, and SF-36 PCS, comparisons were made between patient groups according to their level of treatment response (ASAS40 vs. ASAS20 vs. ASAS20 nonresponse) using analysis of covariance.

RESULTS

Compared with placebo, patients treated with ixekizumab reported significantly greater improvement in the four ASAS treatment response domains and other outcomes (p < 0.05). Results were consistent for bDMARD-naïve and TNFi-experienced patients. Compared to ASAS20 nonresponders, patients who achieved ASAS40 reported significantly greater mean changes in spinal pain at night (1.0 vs. 5.1 for bDMARD-naïve; 0.5 vs. 5.4 for TNFi-experienced), fatigue (0.6 vs. 3.8 for bDMARD-naïve; 0.2 vs. 3.9 for TNFi-experienced), sleep quality (1.1 vs. 4.0 for bDMARD-naïve; 0.8 vs. 4.9 for TNFi-experienced), and SF-36 PCS (2.6 vs. 11.6 for bDMARD-naïve; 1.2 vs. 12.6 for TNFi-experienced) (p < 0.0001).

CONCLUSION

Patients with AS who were treated with ixekizumab reported greater improvements in multiple patient-reported outcomes than patients who received placebo. Importantly, achieving ASAS40 was associated with a 2.6-fold to 5.3-fold greater improvement in pain, fatigue, sleep, and quality of life for bDMARD-naïve patients, and a 5.1-fold to 18.5-fold greater improvement for TNFi-experienced patients, compared to ASAS20 nonresponders.

TRIAL REGISTRATION

ClinicalTrials.gov identifiers: NCT02696785 and NCT02696798.

FUNDING

Eli Lilly and Company.

Home versus outpatient pulmonary rehabilitation in COPD: a propensity-matched cohort study

Home-based exercise has been proposed as an equivalent treatment strategy to supervised outpatient pulmonary rehabilitation (PR), but it is not known whether its implementation into clinical practice produces similar benefits to those observed in trials. We compared the real-world responses of 154 patients with COPD undergoing home-based exercise with a matched group attending supervised PR. We observed smaller improvements in exercise capacity with home-based exercise compared with PR, but similar improvements in quality of life. We propose that supervised PR remains the standard of care, with home-based exercise a less effective alternative for those unable to attend PR.

Application of machine learning in the diagnosis of axial spondyloarthritis

PURPOSE OF REVIEW

In this review article, we describe the development and application of machine-learning models in the field of rheumatology to improve the detection and diagnosis rates of underdiagnosed rheumatologic conditions, such as ankylosing spondylitis and axial spondyloarthritis (axSpA).

RECENT FINDINGS

In an attempt to aid in the earlier diagnosis of axSpA, we developed machine-learning models to predict a diagnosis of ankylosing spondylitis and axSpA using administrative claims and electronic medical record data. Machine-learning algorithms based on medical claims data predicted the diagnosis of ankylosing spondylitis better than a model developed based on clinical characteristics of ankylosing spondylitis. With additional clinical data, machine-learning algorithms developed using electronic medical records identified patients with axSpA with 82.6-91.8% accuracy. These two algorithms have helped us understand potential opportunities and challenges associated with each data set and with different analytic approaches. Efforts to refine and validate these machine-learning models are ongoing.

SUMMARY

We discuss the challenges and benefits of machine-learning models in healthcare, along with potential opportunities for its application in the field of rheumatology, particularly in the early diagnosis of axSpA and ankylosing spondylitis.

Genome-wide DNA methylation analysis in ankylosing spondylitis identifies HLA-B*27 dependent and independent DNA methylation changes in whole blood

BACKGROUND AND OBJECTIVE

Ankylosing spondylitis is a chronic inflammatory disease characterized by inflammation of the sacroiliac joints and the spine that can lead to significant pain, immobility, and disability. The etiology and pathogenesis of ankylosing spondylitis are incompletely understood, though most patients carry the HLA-B*27 allele. The objective of this study was to evaluate DNA methylation changes in ankylosing spondylitis with the goal of revealing novel mechanistic insights into this disease.

METHODS

Genome-wide DNA methylation analysis was performed in whole blood DNA samples using the Infinium MethylationEPIC array in patients with ankylosing spondylitis compared to age, sex, and race matched patients with osteoarthritis as a non-inflammatory disease control. We studied 24 patients with ankylosing spondylitis, including 12 patients who carry HLA-B*27 and 12 patients who are HLA-B*27 negative. DNA methylation analysis was performed with adjustment for blood cell composition in each sample.

RESULTS

We identified a total of 67 differentially methylated sites between ankylosing spondylitis patients and osteoarthritis controls. Hypermethylated genes found included GTPase-related genes, while hypomethylated genes included HCP5, which encodes a lncRNA within the MHC region, previously associated with genetic risk for psoriasis and toxic epidermal necrolysis. Carrying HLA-B*27 was associated with robust hypomethylation of HCP5, tubulin folding cofactor A (TBCA) and phospholipase D Family Member 6 (PLD6) in ankylosing spondylitis patients. Hypomethylation within HCP5 involves a CpG site that contains a single nucleotide polymorphism in linkage disequilibrium with HLA-B*27 and that controls DNA methylation at this locus in an allele-specific manner.

CONCLUSIONS

A genome-wide DNA methylation analysis in ankylosing spondylitis identified DNA methylation patterns that could provide potential novel insights into this disease. Our findings suggest that HLA-B*27 might play a role in ankylosing spondylitis in part through inducing epigenetic dysregulation.

Identification of Axial Spondyloarthritis Patients in a Large Dataset: The Development and Validation of Novel Methods

OBJECTIVE

Observational axial spondyloarthritis (axSpA) research in large datasets has been limited by a lack of adequate methods for identifying patients with axSpA, because there are no billing codes in the United States for most subtypes of axSpA. The objective of this study was to develop methods to accurately identify patients with axSpA in a large dataset.

METHODS

The study population included 600 chart-reviewed veterans, with and without axSpA, in the Veterans Health Administration between January 1, 2005, and June 30, 2015. AxSpA identification algorithms were developed with variables anticipated by clinical experts to be predictive of an axSpA diagnosis [demographics, billing codes, healthcare use, medications, laboratory results, and natural language processing (NLP) for key SpA features]. Random Forest and 5-fold cross validation were used for algorithm development and testing in the training subset (n = 451). The algorithms were additionally tested in an independent testing subset (n = 149).

RESULTS

Three algorithms were developed: Full algorithm, High Feasibility algorithm, and Spond NLP algorithm. In the testing subset, the areas under the curve with the receiver-operating characteristic analysis were 0.96, 0.94, and 0.86, for the Full algorithm, High Feasibility algorithm, and Spond NLP algorithm, respectively. Algorithm sensitivities ranged from 85.0% to 95.0%, specificities from 78.0% to 93.6%, and accuracies from 82.6% to 91.3%.

CONCLUSION

Novel axSpA identification algorithms performed well in classifying patients with axSpA. These algorithms offer a range of performance and feasibility attributes that may be appropriate for a broad array of axSpA studies. Additional research is required to validate the algorithms in other cohorts.

Special Article: 2018 American College of Rheumatology/National Psoriasis Foundation Guideline for the Treatment of Psoriatic Arthritis

OBJECTIVE

To develop an evidence-based guideline for the pharmacologic and nonpharmacologic treatment of psoriatic arthritis (PsA), as a collaboration between the American College of Rheumatology (ACR) and the National Psoriasis Foundation (NPF).

METHODS

We identified critical outcomes in PsA and clinically relevant PICO (population/intervention/comparator/outcomes) questions. A Literature Review Team performed a systematic literature review to summarize evidence supporting the benefits and harms of available pharmacologic and nonpharmacologic therapies for PsA. GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology was used to rate the quality of the evidence. A voting panel, including rheumatologists, dermatologists, other health professionals, and patients, achieved consensus on the direction and the strength of the recommendations.

RESULTS

The guideline covers the management of active PsA in patients who are treatment-naive and those who continue to have active PsA despite treatment, and addresses the use of oral small molecules, tumor necrosis factor inhibitors, interleukin-12/23 inhibitors (IL-12/23i), IL-17 inhibitors, CTLA4-Ig (abatacept), and a JAK inhibitor (tofacitinib). We also developed recommendations for psoriatic spondylitis, predominant enthesitis, and treatment in the presence of concomitant inflammatory bowel disease, diabetes, or serious infections. We formulated recommendations for a treat-to-target strategy, vaccinations, and nonpharmacologic therapies. Six percent of the recommendations were strong and 94% conditional, indicating the importance of active discussion between the health care provider and the patient to choose the optimal treatment.

CONCLUSION

The 2018 ACR/NPF PsA guideline serves as a tool for health care providers and patients in the selection of appropriate therapy in common clinical scenarios. Best treatment decisions consider each individual patient situation. The guideline is not meant to be proscriptive and should not be used to limit treatment options for patients with PsA.

2018 American College of Rheumatology/National Psoriasis Foundation Guideline for the Treatment of Psoriatic Arthritis

Objective:

To develop an evidence-based guideline for the pharmacologic and nonpharmacologic treatment of psoriatic arthritis (PsA), as a collaboration between the American College of Rheumatology (ACR) and the National Psoriasis Foundation (NPF).

Methods:

We identified critical outcomes in PsA and clinically relevant PICO (population/intervention/comparator/outcomes) questions. A Literature Review Team performed a systematic literature review to summarize evidence supporting the benefits and harms of available pharmacologic and nonpharmacologic therapies for PsA. GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology was used to rate the quality of the evidence. A voting panel, including rheumatologists, dermatologists, other health professionals, and patients, achieved consensus on the direction and the strength of the recommendations.

Results:

The guideline covers the management of active PsA in patients who are treatment-naive and those who continue to have active PsA despite treatment, and addresses the use of oral small molecules, tumor necrosis factor inhibitors, interleukin-12/23 inhibitors (IL-12/23i), IL-17 inhibitors, CTLA4-Ig (abatacept), and a JAK inhibitor (tofacitinib). We also developed recommendations for psoriatic spondylitis, predominant enthesitis, and treatment in the presence of concomitant inflammatory bowel disease, diabetes, or serious infections. We formulated recommendations for a treat-to-target strategy, vaccinations, and nonpharmacologic therapies. Six percent of the recommendations were strong and 94% conditional, indicating the importance of active discussion between the health care provider and the patient to choose the optimal treatment.

Conclusion:

The 2018 ACR/NPF PsA guideline serves as a tool for health care providers and patients in the selection of appropriate therapy in common clinical scenarios. Best treatment decisions consider each individual patient situation. The guideline is not meant to be proscriptive and should not be used to limit treatment options for patients with PsA.

Special Article: 2018 American College of Rheumatology/National Psoriasis Foundation Guideline for the Treatment of Psoriatic Arthritis

OBJECTIVE

To develop an evidence-based guideline for the pharmacologic and nonpharmacologic treatment of psoriatic arthritis (PsA), as a collaboration between the American College of Rheumatology (ACR) and the National Psoriasis Foundation (NPF).

METHODS

We identified critical outcomes in PsA and clinically relevant PICO (population/intervention/comparator/outcomes) questions. A Literature Review Team performed a systematic literature review to summarize evidence supporting the benefits and harms of available pharmacologic and nonpharmacologic therapies for PsA. GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology was used to rate the quality of the evidence. A voting panel, including rheumatologists, dermatologists, other health professionals, and patients, achieved consensus on the direction and the strength of the recommendations.

RESULTS

The guideline covers the management of active PsA in patients who are treatment-naive and those who continue to have active PsA despite treatment, and addresses the use of oral small molecules, tumor necrosis factor inhibitors, interleukin-12/23 inhibitors (IL-12/23i), IL-17 inhibitors, CTLA4-Ig (abatacept), and a JAK inhibitor (tofacitinib). We also developed recommendations for psoriatic spondylitis, predominant enthesitis, and treatment in the presence of concomitant inflammatory bowel disease, diabetes, or serious infections. We formulated recommendations for a treat-to-target strategy, vaccinations, and nonpharmacologic therapies. Six percent of the recommendations were strong and 94% conditional, indicating the importance of active discussion between the health care provider and the patient to choose the optimal treatment.

CONCLUSION

The 2018 ACR/NPF PsA guideline serves as a tool for health care providers and patients in the selection of appropriate therapy in common clinical scenarios. Best treatment decisions consider each individual patient situation. The guideline is not meant to be proscriptive and should not be used to limit treatment options for patients with PsA.

Treatment Patterns Among Patients with Psoriatic Arthritis Treated with a Biologic in the United States: Descriptive Analyses from an Administrative Claims Database

BACKGROUND

In patients with psoriatic arthritis (PsA), limited data exist regarding patterns of biologic therapy use.

OBJECTIVE

To examine treatment patterns and therapy modifications in U.S. patients with PsA receiving a tumor necrosis factor inhibitor (TNFi) or an anti-interleukin (IL)-12/23 inhibitor.

METHODS

Adults with PsA who newly initiated a biologic therapy (index biologic) between January 1, 2013, and January 31, 2015, were included from the Optum Research Database. Biologic therapies comprised those that were approved by the FDA for the treatment of PsA at the time of the study initiation (adalimumab, certolizumab pegol, etanercept, golimumab, infliximab, or ustekinumab). Outcomes included adherence, persistence, and discontinuation of the index biologic; initiation of adjunctive medications (nonbiologics, including those commonly used for pain and/or inflammation); and dose escalation of the index biologic during the 12-month follow-up period.

RESULTS

Of the 1,235 patients included, 52.5% were female, and mean (SD) age was 50.3 (12.1) years. The mean (SD) duration of persistence with a newly initiated index biologic (etanercept [48.1%], adalimumab [24.0%], infliximab [10.4%], golimumab [8.3%], ustekinumab [7.2%], or certolizumab pegol [2.0%]) was 246 (128) days; 44.5% of patients persisted with the index biologic for ≥ 12 months. During the 12-month follow-up period, 22.9% of patients switched to a different biologic, 26.8% discontinued without switching or restarting, and 5.8% discontinued and restarted the index biologic. Of the 1,010 patients who persisted with the index biologic for > 90 days, 45.6% received ≥ 1 adjunctive medication during the period from 90 days after the index date to the end of persistence or 12 months. The most commonly initiated adjunctive medications were corticosteroids (22.0%), opioids (17.1%), and nonsteroidal anti-inflammatory drugs (12.9%). Overall, 9.6% of patients had a dose escalation of the index biologic in the immediate 12-month post-index period.

CONCLUSIONS

This real-world study of treatment patterns for PsA, which used a large U.S. claims database, demonstrated that the majority of patients with PsA discontinued their index biologic (TNFi or anti-IL-12/23 inhibitor) before 12 months. Nearly half of patients initiated an adjunctive medication, many of which were pain and conventional anti-inflammatory medications.

DISCLOSURES

This study was sponsored by Novartis Pharmaceuticals. Optum was commissioned by Novartis to conduct this study, but employment was not contingent on results of the study. Walsh is a paid consultant for Novartis. Adejoro was an employee of Optum at the time of the study and writing of the manuscript. Chastek is an employee of Optum. Palmer and Hur are employees of Novartis. Results of this study were presented as an abstract and poster at the Academy of Managed Care Pharmacy Nexus 2017; October 16-19, 2017; Dallas, TX; and the EULAR 2017 Annual European Congress of Rheumatology; June 14-17, 2017; Madrid, Spain.

The Physician Global Assessment and Body Surface Area composite tool is a simple alternative to the Psoriasis Area and Severity Index for assessment of psoriasis: post hoc analysis from PRISTINE and PRESTA

Background

The product of Physician Global Assessment and Body Surface Area (PGA × BSA) is a new outcome measure for psoriasis severity and response to therapy. The objective of this study was to evaluate PGA × BSA as an alternative to Psoriasis Area and Severity Index (PASI) for psoriasis assessments.

Methods

The relationship between PASI and PGA × BSA was assessed in a post hoc analysis of pooled data from the PRISTINE (NCT00663052) and PRESTA (NCT00245960) trials in patients with moderate-to-severe psoriasis who received etanercept 50 mg/week. Data were analyzed using Spearman and intra-class correlation coefficients, effect sizes, scatterplots, Bland–Altman plots, and Kappa statistics.

Results

Spearman correlations at baseline, week 12, and week 24 were strong for PGA × BSA versus PASI (r=0.78, 0.87, and 0.90, respectively; all P<0.0001) as were intra-class correlations (0.76 [95% confidence interval 0.73–0.80], 0.80 [0.76–0.83], and 0.85 [0.82–0.87], respectively). The effect size was −1.53 for PASI and −0.94 for PGA × BSA (baseline to week 24). Scatterplots and Bland–Altman plots detected a trend across the range of measurement. Kappa statistics (at 12 and 24 weeks) between PASI50/75/90 and 50/75/90% improvement in PGA × BSA showed good agreement (0.58–0.69 at week 12 and 0.63–0.67, respectively; all P<0.0001). At baseline, the Spearman correlation coefficients were 0.96, 0.51, 0.19, and 0.17 for PGA × BSA versus BSA, PGA, Patient Global Assessment, and Dermatology Life Quality Index, respectively (all P<0.001).

Conclusion

PGA × BSA has advantages over PASI for measuring moderate-to-severe psoriasis; it is intuitive, sensitive, and easy to use.

Cohort identification of axial spondyloarthritis in a large healthcare dataset: current and future methods

BACKGROUND

Big data research is important for studying uncommon diseases in real-world settings. Most big data studies in axial spondyloarthritis (axSpA) have been limited to populations identified with billing codes for ankylosing spondylitis (AS). axSpA is a more inclusive concept, and reliance on AS codes does not produce a comprehensive axSpA study population. The first objective was to describe our process for establishing an appropriate sample of patients with and without axSpA for developing accurate axSpA identification methods. The second objective was to determine the classification performance of AS billing codes against the chart-reviewed axSpA reference standard.

METHODS

Veteran Health Affairs clinical and administrative data, between January 2005 and June 2015, were used to randomly select patients with clinical phenotypes that represented high, moderate, and low likelihoods of an axSpA diagnosis. With chart review, the sampled patients were classified as Yes axSpA, No axSpA or Uncertain axSpA, and these classification assignments were used as the reference standard for determining the positive predictive value (PPV) and sensitivity of AS ICD-9 codes for axSpA.

RESULTS

Six hundred patients were classified as Yes axSpA (26.8%), No axSpA (68.3%), or Uncertain axSpA (4.8%). The PPV and sensitivity of an AS ICD-9 code for axSpA were 83.3% and 57.3%, respectively.

CONCLUSIONS

Standard methods of identifying axSpA patients in a large dataset lacked sensitivity. An appropriate sample of patients with and without axSpA was established and characterized for developing novel axSpA identification methods that are anticipated to enable previously impractical big data research.

Healthcare Utilization and Direct Costs in Patients with Ankylosing Spondylitis Using a Large US Administrative Claims Database

Introduction

In addition to the considerable patient and societal burdens, the financial burdens of ankylosing spondylitis (AS) are substantial. Understanding both all-cause and AS-specific direct costs in patients with AS is important if we are to understand the financial impact on patients with AS and payers in the United States. This study assessed both all-cause and AS-specific healthcare utilization and direct costs in US patients with AS using administrative claims data.

Methods

Adults aged ≥ 18 years enrolled in the MarketScan^® Commercial and Medicare databases with ≥ 1 inpatient or ≥ 2 non-rule-out outpatient diagnoses of AS between January 1, 2013, and December 31, 2013, were included. Patients had continuous enrollment with medical and pharmacy benefits for ≥ 12 months before and after the index date (first diagnosis). Non-AS controls were matched up to 5:1 to patients with AS on age, geographic region, index calendar year, and sex. All-cause and AS-specific healthcare utilization and direct costs were measured during the follow-up period and reported as per patient per year.

Results

Patients with AS (N = 6679) had significantly higher rates of total all-cause inpatient admission (12% vs 6%), emergency department visits (23% vs 15%), nonhospital-based outpatient visits (100% vs 84%), hospital-based outpatient visits (68% vs 46%), other outpatient services (97% vs 81%), and medication use (97% vs 82%) compared with matched controls (N = 19,951). Patients with AS had approximately tenfold higher median total healthcare costs than matched controls ($24,978 vs $2139 per patient per year), largely driven by increased outpatient and pharmacy costs; P < 0.05 for all comparisons. The median (IQR) total AS-specific healthcare costs were $10,250 ($774, $28,824).

Conclusion

In this analysis of claims data, increased outpatient and pharmacy costs were key contributors to higher all-cause total healthcare costs in US patients with AS.

Funding

Novartis Pharmaceuticals Corporation, East Hanover, NJ.

Electronic supplementary material

The online version of this article (10.1007/s40744-018-0124-4) contains supplementary material, which is available to authorized users.

PGA×BSA: A Measure of Psoriasis Severity Tested in Patients with Active Psoriatic Arthritis and Treated with Certolizumab Pegol

OBJECTIVE

The product of physician's global assessment and body surface area (PGA×BSA) to assess psoriasis severity has previously been investigated in patients with psoriasis, with the aim of assessing PGA×BSA as an alternative to the time-consuming Psoriasis Area and Severity Index (PASI). Here, we investigate PGA×BSA as an alternative to PASI in patients with psoriatic arthritis (PsA).

METHODS

Analyses used data from the double-blind, placebo-controlled, RAPID-PsA trial (NCT01087788) that investigated the efficacy of certolizumab pegol (CZP) in patients with PsA. Outcomes assessed whether the PGA×BSA and PASI results were comparable, and whether these outcomes correlated with one another or with the Dermatology Life Quality Index (DLQI).

RESULTS

For CZP-treated patients, both PGA×BSA and PASI demonstrated similar sensitivities to treatment between baseline and Week 24, with mean improvements of 77.4% and 69.0%, respectively. Similar improvements were also seen with placebo (PGA×BSA: 3.2%, PASI: 6.1%). Achievement of 75% response criterion in PGA×BSA and PASI was attained by similar proportions of patients with CZP (PGA×BSA75: 59.0%, PASI75: 61.4%) and placebo (PGA × BSA75: 15.1%, PASI75: 15.1%). Cross tabulations showed high concordance between achievement of response outcomes in PGA×BSA and PASI (79.6-95.2%). Spearman correlations revealed strong correlations between PGA×BSA and PASI at baseline (r = 0.78; n = 225) and percentage improvement to Week 24 (r = 0.85; n = 186). Both outcomes were only moderately correlated with DLQI (r = 0.41-0.50; n = 179-249).

CONCLUSION

PGA×BSA is sensitive to changes in skin manifestations in patients with PsA treated with CZP. Further, PGA×BSA correlates strongly with PASI, and achievement of 75% improvement was similar for PGA×BSA and PASI.

Evaluation of the comorbidity burden in patients with ankylosing spondylitis using a large US administrative claims data set

Comorbidities among US patients with ankylosing spondylitis (AS) are inadequately understood. This study compared the prevalence and incidence of comorbidities between patients with AS and matched controls using national claims databases. Adults enrolled in the MarketScan Commercial and Medicare databases with ≥ 1 inpatient or ≥ 2 non-rule-out outpatient diagnoses of AS between January 1, 2012 and December 31, 2014 were included. Patients had to have ≥ 1 AS diagnosis in 2013; the first AS diagnosis in 2013 was assigned as the index date. Control patients without AS were matched to AS patients on age, geographic region, index calendar year, and sex. Comorbidities were evaluated in AS patients and matched controls during the baseline and follow-up periods (before and after the index date, respectively). Hazard ratios of developing new comorbidities were estimated using Cox proportional hazard models adjusted for patients’ characteristics. A total of 6679 patients with AS were matched to 19,951 control patients. In addition to extra-articular manifestations of AS (inflammatory bowel disease [IBD], psoriasis, uveitis), a higher proportion of AS patients had asthma, cardiovascular disease, depression, dyslipidemia, gastrointestinal ulcers, malignancies, multiple sclerosis, osteoporosis, sleep apnea, and spinal fractures during the baseline period than matched controls. After AS diagnosis, a higher proportion of patients developed newly diagnosed cases of cardiovascular diseases, depression, osteoporosis, spinal fracture, IBD, psoriasis, and uveitis than matched controls. In this real-world, US claims-based study, patients with AS were shown to have significantly more comorbidities than matched controls.

Treatment Patterns Among Patients with Psoriatic Arthritis Treated with a Biologic in the United States: Descriptive Analyses from an Administrative Claims Database

BACKGROUND

In patients with psoriatic arthritis (PsA), limited data exist regarding patterns of biologic therapy use.

OBJECTIVE

To examine treatment patterns and therapy modifications in U.S. patients with PsA receiving a tumor necrosis factor inhibitor (TNFi) or an anti-interleukin (IL)-12/23 inhibitor.

METHODS

Adults with PsA who newly initiated a biologic therapy (index biologic) between January 1, 2013, and January 31, 2015, were included from the Optum Research Database. Biologic therapies comprised those that were approved by the FDA for the treatment of PsA at the time of the study initiation (adalimumab, certolizumab pegol, etanercept, golimumab, infliximab, or ustekinumab). Outcomes included adherence, persistence, and discontinuation of the index biologic; initiation of adjunctive medications (nonbiologics, including those commonly used for pain and/or inflammation); and dose escalation of the index biologic during the 12-month follow-up period.

RESULTS

Of the 1,235 patients included, 52.5% were female, and mean (SD) age was 50.3 (12.1) years. The mean (SD) duration of persistence with a newly initiated index biologic (etanercept [48.1%], adalimumab [24.0%], infliximab [10.4%], golimumab [8.3%], ustekinumab [7.2%], or certolizumab pegol [2.0%]) was 246 (128) days; 44.5% of patients persisted with the index biologic for ≥ 12 months. During the 12-month follow-up period, 22.9% of patients switched to a different biologic, 26.8% discontinued without switching or restarting, and 5.8% discontinued and restarted the index biologic. Of the 1,010 patients who persisted with the index biologic for > 90 days, 45.6% received ≥ 1 adjunctive medication during the period from 90 days after the index date to the end of persistence or 12 months. The most commonly initiated adjunctive medications were corticosteroids (22.0%), opioids (17.1%), and nonsteroidal anti-inflammatory drugs (12.9%). Overall, 9.6% of patients had a dose escalation of the index biologic in the immediate 12-month post-index period.

CONCLUSIONS

This real-world study of treatment patterns for PsA, which used a large U.S. claims database, demonstrated that the majority of patients with PsA discontinued their index biologic (TNFi or anti-IL-12/23 inhibitor) before 12 months. Nearly half of patients initiated an adjunctive medication, many of which were pain and conventional anti-inflammatory medications. DISCLOSURES This study was sponsored by Novartis Pharmaceuticals. Optum was commissioned by Novartis to conduct this study, but employment was not contingent on results of the study. Walsh is a paid consultant for Novartis. Adejoro was an employee of Optum at the time of the study and writing of the manuscript. Chastek is an employee of Optum. Palmer and Hur are employees of Novartis. Study concept and design were contributed by Walsh, Chastek, Adejoro, Palmer, and Hur. Adejoro, Chastek, Walsh, Palmer, and Hur collected the data. Data interpretation was performed by Walsh, Palmer, Adejoro, Chastek, and Hur. The manuscript was written and revised by Walsh and Hur, along with the other authors. Results of this study were presented as an abstract and poster at the Academy of Managed Care Pharmacy Nexus 2017; October 16-19, 2017; Dallas, Texas; and the EULAR 2017 Annual European Congress of Rheumatology; June 14-17, 2017; Madrid, Spain.

Evaluation of the comorbidity burden in patients with ankylosing spondylitis treated with tumour necrosis factor inhibitors using a large administrative claims data set

Objectives

Comorbidity incidence rates among US patients with ankylosing spondylitis (AS) treated with tumour necrosis factor inhibitors (TNFis) are inadequately understood. This study compared the relative occurrence of comorbidities between patients with AS treated with TNFis and those not treated with TNFis.

Methods

Adults aged ≥18 years enrolled in the MarketScan Commercial and Medicare Supplemental databases with a diagnosis of AS between 1 January 2008 and 30 June 2015 were eligible. Patients were divided into two groups, those treated with TNFis (TNFi users) and those not treated with TNFis (TNFi nonusers) during the 12 months after the index date, defined as the date of first TNFi treatment or a randomly assigned date for TNFi nonusers. Patients had to have continuous enrolment for 24 months with no AS diagnosis or TNFi therapy pre‐index and a follow‐up period of ≥12 months postindex. The incidence of new comorbidities was evaluated in patients and adjusted for baseline characteristics.

Key findings

A total of 3077 TNFi users and 3830 TNFi nonusers were included. A higher proportion of TNFi users had a new diagnosis of inflammatory bowel disease (hazard ratio [HR], 2.00), including Crohn's disease (HR, 2.45) and ulcerative colitis (HR, 1.65), as well as uveitis (HR, 1.68) and sleep apnoea (HR, 1.21) after initiation of TNFi therapy than TNFi nonusers.

Conclusions

Patients with AS treated with TNFis had higher incidence rates of IBD, uveitis and sleep apnoea after initiation of TNFi therapy than patients not treated with TNFi therapy.

Treatment patterns of biologics in US patients with ankylosing spondylitis: descriptive analyses from a claims database

AIM

Examine treatment patterns among patients with active ankylosing spondylitis (AS) treated with a TNF inhibitor (TNFi).

PATIENTS & METHODS

Patients with AS who initiated a TNFi between 1 January 2013, and 31 January 2015, were identified in the Optum Research Database. Outcomes included adherence, persistence, discontinuation and therapy modifications of the index TNFi during 12-month follow-up.

RESULTS

Of the 426 patients included, 40.6% persisted on the index TNFi for ≥12 months, 31.0% discontinued, 21.4% switched to a different TNFi, and 7.0% discontinued and then restarted. Of the 333 patients who persisted on their TNFi for >90 days, 44.7% received ≥1 add-on medication.

CONCLUSION

A high proportion of patients with AS switched, discontinued or modified their TNFi therapy.

Use of Disease-modifying Antirheumatic Drugs for Inflammatory Arthritis in US Veterans: Effect of Specialty Care and Geographic Distance

Objective.

To evaluate the effect of access to and distance from rheumatology care on the use of disease-modifying antirheumatic drugs (DMARD) in US veterans with inflammatory arthritis (IA).

Methods.

Provider encounters and DMARD dispensations for IA (rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis) were evaluated in national Veterans Affairs (VA) datasets between January 1, 2015, and December 31, 2015.

Results.

Among 12,589 veterans with IA, 23.5% saw a rheumatology provider. In the general IA population, 25.3% and 13.6% of veterans were exposed to a synthetic DMARD (sDMARD) and biologic DMARD (bDMARD), respectively. DMARD exposure was 2.6- to 3.4-fold higher in the subpopulation using rheumatology providers, compared to the general IA population. The distance between veterans’ homes and the closest VA rheumatology site was < 40 miles (Near) for 55.9%, 40–99 miles (Intermediate) for 31.7%, and ≥ 100 miles (Far) for 12.4%. Veterans in the Intermediate and Far groups were less likely to see a rheumatology provider than veterans in the Near group (RR = 0.72 and RR = 0.49, respectively). Exposure to bDMARD was 34% less frequent in the Far group than the Near group. In the subpopulation who used rheumatology care, the bDMARD exposure discrepancy did not persist between distance groups.

Conclusion.

Use of rheumatology care and DMARD was low for veterans with IA. DMARD exposure was strongly associated with rheumatology care use. Veterans in the general IA population living far from rheumatology sites accessed rheumatology care and bDMARD less frequently than veterans living close to rheumatology sites.

Identifying Axial Spondyloarthritis in Electronic Medical Records of US Veterans

OBJECTIVE

Large database research in axial spondyloarthritis (SpA) is limited by a lack of methods for identifying most types of axial SpA. Our objective was to develop methods for identifying axial SpA concepts in the free text of documents from electronic medical records.

METHODS

Veterans with documents in the national Veterans Health Administration Corporate Data Warehouse between January 1, 2005 and June 30, 2015 were included. Methods were developed for exploring, selecting, and extracting meaningful terms that were likely to represent axial SpA concepts. With annotation, clinical experts reviewed sections of text containing the meaningful terms (snippets) and classified the snippets according to whether or not they represented the intended axial SpA concept. With natural language processing (NLP) tools, computers were trained to replicate the clinical experts' snippet classifications.

RESULTS

Three axial SpA concepts were selected by clinical experts, including sacroiliitis, terms including the prefix spond*, and HLA-B27 positivity (HLA-B27+). With supervised machine learning on annotated snippets, NLP models were developed with accuracies of 91.1% for sacroiliitis, 93.5% for spond*, and 97.2% for HLA-B27+. With independent validation, the accuracies were 92.0% for sacroiliitis, 91.0% for spond*, and 99.0% for HLA-B27+.

CONCLUSION

We developed feasible and accurate methods for identifying axial SpA concepts in the free text of clinical notes. Additional research is required to determine combinations of concepts that will accurately identify axial SpA phenotypes. These novel methods will facilitate previously impractical observational research in axial SpA and may be applied to research with other diseases.

Treatment patterns and annual biologic costs in US veterans with rheumatic conditions or psoriasis

OBJECTIVE

To determine annual biologic drug and administration costs to the US Veterans Health Administration (VHA) per treated patient with rheumatoid arthritis (RA), psoriasis (PsO), psoriatic arthritis (PsA), or ankylosing spondylitis (AS) who received abatacept, adalimumab, certolizumab pegol, etanercept, golimumab, infliximab, rituximab, tocilizumab, or ustekinumab.

METHODS

Adults with at least one biologic claim between January 1, 2008 and December 31, 2011 were included. Evidence of enrollment in the VHA was required from 365 days before (pre-index) to 360 days after (post-index) the date of the first biologic claim (index date). Included patients had pre-index diagnoses of RA, PsO, PsA, and/or AS. Drug costs were from Federal Supply Schedule or 'Big Four' in November 2014. Administration costs were VHA fixed costs for infused ($169) and subcutaneous ($25) biologics.

RESULTS

Of the 20,465 patients in the analysis, 10,711 received etanercept, 7838 received adalimumab, and 1196 received infliximab as the index biologic. In these patients, across all uses studied, the VHA incurred greater annual cost per treated patient for infliximab ($18,066) compared with adalimumab ($16,523) and etanercept ($16,526). In the first year post-index, ∼80% of patients were either persistent on these index biologics or re-started these index biologics after a ≥45-day treatment gap. Other biologics comprised <5% of the study population, with sample sizes ranging from 3-374 patients each. Cost by indication for biologics used by >20 patients ranged from $15,056 (etanercept) to $17,050 (abatacept) for RA; $16,697 (adalimumab) to $33,163 (ustekinumab) for PsO; $15,035 (etanercept) to $20,465 (infliximab) for PsA; and $14,239 (etanercept) to $18,536 (infliximab) for AS.

LIMITATIONS

The model was limited to the VHA. Results for biologics other than adalimumab, etanercept, and infliximab were difficult to interpret because of small sample sizes.

CONCLUSIONS

Infliximab has higher cost to the VHA than adalimumab or etanercept.

Mortality in American Veterans with the HLA-B27 gene

OBJECTIVE

To compare survival in American veterans with and without the HLA-B27 (B27) gene.

METHODS

Mortality was evaluated in a national cohort of veterans with clinically available B27 test results between October 1, 1999, and December 31, 2011. The primary outcome was the mortality difference between B27-positive and B27-negative veterans, adjusted for age, sex, race, and diagnoses codes for diseases that may have influenced both B27 testing and mortality, including psoriasis, inflammatory bowel disease, spondyloarthritis (SpA), and other types of inflammatory arthritis. The secondary outcomes were the adjusted mortality HR for B27+ and B27- veterans, in subgroups with and without SpA.

RESULTS

Among veterans with available B27 test results, 27,652 (84.7%) were B27- and 4978 (15.3%) were B27+. The mean followup time was 4.6 years. Mortality was higher in the B27+ group than in the B27- group (HR 1.15, 95% CI 1.03-1.27). Mortality was also higher in the B27+ subgroups with SpA (HR 1.35, 95% CI 1.06-1.72) and without SpA (HR 1.11, 95% CI 0.99-1.24), but the difference was significant only in the subgroup with SpA.

CONCLUSION

B27 positivity was associated with an increased mortality rate in a cohort of veterans clinically selected for B27 testing, after adjustment for SpA. In the subgroup with SpA, the mortality rate was associated with B27 positivity, and in the subgroup without SpA, there was a nonsignificant association between B27+ and mortality.

Adalimumab and Non-Arteritic Anterior Ischaemic Optic Neuropathy: A Case Report

Sequential anterior ischaemic optic neuropathy was observed in a patient treated with a tumour necrosis factor α (TNF) inhibitor, adalimumab, for ankylosing spondylitis. He developed decreased visual acuity in the right eye after 17 months of treatment. Findings showed right optic disc oedema with haemorrhages and visual field defect. Adalimumab was discontinued and vision stabilised. After restarting adalimumab, he developed optic neuropathy in the left eye. Findings showed optic disc oedema, with haemorrhages and visual field changes in the left eye. Adalimumab may be associated with optic neuropathy; providers prescribing TNF inhibitors should be aware of optic neuropathy as a potential complication.

Work productivity loss and fatigue in psoriatic arthritis

OBJECTIVE

To explore the relationship between fatigue and work productivity loss (WPL) in people with psoriatic arthritis (PsA).

METHODS

Data were collected from participants in the Utah Psoriasis Initiative Arthritis registry between January 2010 and May 2013. WPL was measured with the 8-item Work Limitations Questionnaire. Fatigue was assessed with question 1 from the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI#1), "How would you describe the overall level of fatigue/tiredness you have experienced?" and with question 1 from the Psoriatic Arthritis Quality of Life Questionnaire (PsAQOL#1) "I feel tired whatever I do." Psoriatic activity was evaluated with tender joint count (TJC), swollen joint count (SJC), dactylitis count, enthesitis count, inflammatory back pain (IBP), physician global assessment, body surface area, and psoriasis pain and itch.

RESULTS

Among 107 participants, work productivity was reduced by 6.7%, compared to benchmark employees without limitations. Fatigue was reported by 54 patients (50.5%) on PsAQOL#1, and 64 (60.0%) were classified as high fatigue by BASDAI#1. TJC, SJC, enthesitis count, IBP, and depressed mood were highest or most frequent in participants reporting fatigue. After adjustments for psoriatic activity and depressed mood, WPL was associated with fatigue, as measured by PsAQOL#1 (p = 0.01) and BASDAI#1 (p = 0.002).

CONCLUSION

WPL was associated with fatigue, and the association was not entirely explained by the evaluated musculoskeletal, cutaneous, or psychiatric manifestations of PsA.

Lower frequency of obstructive sleep apnea in spondyloarthritis patients taking TNF-inhibitors

STUDY OBJECTIVES

Sleep disturbances, including obstructive sleep apnea (OSA), commonly limit function and quality of life in people with spondyloarthritis (SpA). Systemic inflammation has been implicated in the pathophysiology of both OSA and SpA, and suppression of inflammation with tumor necrosis factor α (TNF) inhibitors may decrease OSA severity. In this study, we compared the frequency of OSA in patients receiving and not receiving TNF-inhibitor therapy.

METHODS

Data were collected from 63 consecutively screened veterans with SpA. Participant interviews, examinations, chart reviews, and referrals to the Salt Lake City Veteran Affairs (SLCVA) Sleep Center were used to obtain demographic data, comorbidities, SpA features, therapy data, and sleep study outcomes.

RESULTS

OSA occurred in 76% of SpA patients. OSA was less common in patients receiving TNF-inhibitor therapy (57%), compared to patients not receiving TNF-inhibitor therapy (91%) (p = 0.01).

CONCLUSIONS

OSA is underrecognized in veterans with SpA, and TNF-inhibition was associated with a lower frequency of OSA.

Vaginal microbicides save money: a model of cost-effectiveness in South Africa and the USA

OBJECTIVE

To determine the hypothetical cost-effectiveness of vaginal microbicides preventing male to female HIV transmission.

METHODS

A mathematical epidemiological and cost-effectiveness model using data from South Africa and the USA was used. The prospective 1-year-long intervention targeted a general population of women in a city of 1,000,000 inhabitants in two very different epidemiological settings, South Africa with a male HIV prevalence of 18.80% and the USA with a male HIV prevalence of 0.72%. The base case scenario assumes a microbicide effective at 55%, used in 30% of sexual episodes at a retail price for the public sector in South Africa of US$0.51 per use and in the USA of US$2.23 per use.

RESULTS

In South Africa, over 1 year, the intervention would prevent 1908 infections, save US$6712 per infection averted as compared with antiretroviral treatment. In the USA, it would be more costly: over 1 year, the intervention would prevent 21 infections, amounting to a net cost per infection averted of US$405,077. However, in the setting of Washington DC, with a higher HIV prevalence, the same intervention would prevent 93 infections and save US$91,176 per infection averted. Sensitivity analyses were conducted and even a microbicide with a low effectiveness of 30% would still save healthcare costs in South Africa.

CONCLUSIONS

A microbicide intervention is likely to be very cost-effective in a country undergoing a high-level generalised epidemic such as South Africa, but is unlikely to be cost-effective in a developed country presenting epidemiological features similar to the USA unless the male HIV prevalence exceeds 2.4%.

Identification of new isolates of Turnip mosaic virus that cluster with less common viral strains

Turnip mosaic virus (TuMV) was found infecting cultivated brassicas and wild and cultivated ornamental Brassicaceae plants in different regions of Spain. Five new TuMV isolates, originating from different host plant species (Brassica cretica, Brassica juncea, Brassica napus, Eruca vesicaria subsp. sativa and Sisymbrium orientale), have been identified. The nucleotide sequences of the coat protein (CP) genes of the five isolates were determined. Phylogenetic analysis of the CP sequences showed that the five isolates grouped into two different clusters. The three isolates from the central region of Spain clustered with a previously reported Pisum sativum isolate from southeastern Spain, whereas the other two isolates from the eastern region clustered with two Italian and two Greek isolates. Both clusters were genetically distinct and belonged to the multi-lineage group OBR. The OBR group contains mainly TuMV isolates from hosts other than Brassica spp. and Raphanus sativus and mostly originating from Mediterranean countries. These new sequences provide further phylogenetic resolution of the OBR group. Although new TuMV isolates have been found in Spain, they were not associated with any serious disease outbreaks.

Genetic mapping of the novel Turnip mosaic virus resistance gene TuRB03 in Brassica napus

A new source of resistance to the pathotype 4 isolate of Turnip mosaic virus (TuMV) CDN 1 has been identified in Brassica napus (oilseed rape). Analysis of segregation of resistance to TuMV isolate CDN 1 in a backcross generation following a cross between a resistant and a susceptible B. napus line showed that the resistance was dominant and monogenic. Molecular markers linked to this dominant resistance were identified using amplified fragment length polymorphism (AFLP) and microsatellite bulk segregant analysis. Bulks consisted of individuals from a BC(1) population with the resistant or the susceptible phenotype following challenge with CDN 1. One AFLP and six microsatellite markers were associated with the resistance locus, named TuRB03, and these mapped to the same region on chromosome N6 as a previously mapped TuMV resistance gene TuRB01. Further testing of TuRB03 with other TuMV isolates showed that it was not effective against all pathotype 4 isolates. It was effective against some, but not all pathotype 3 isolates tested. It provided further resolution of TuMV pathotypes by sub-dividing pathotypes 3 and 4. TuRB03 also provides a new source of resistance for combining with other resistances in our attempts to generate durable resistance to this virus.

The phylogeny of Turnip mosaic virus; comparisons of 38 genomic sequences reveal a Eurasian origin and a recent 'emergence' in east Asia

The genomes of a representative world-wide collection of 32 Turnip mosaic virus (TuMV) isolates were sequenced and these, together with six previously reported sequences, were analysed. At least one-fifth of the sequences were recombinant. In phylogenetic analyses, using genomic sequences of Japanese yam mosaic virus as an outgroup, the TuMV sequences that did not show clear recombination formed a monophyletic group with four well-supported lineages. These groupings correlated with differences in pathogenicity and provenance; the sister group to all others was of Eurasian B-strain isolates from nonbrassicas, and probably represents the ancestral TuMV population, and the most recently 'emerged' branch of the population was probably that of the BR-strain isolates found only in east Asia. Eight isolates, all from east Asia, were clear recombinants, probably the progeny of recent recombination events, whereas a similar number, from other parts of the world, were seemingly older recombinants. This difference indicates that the presence of clear recombinants in a subpopulation may be a molecular signature of a recent 'emergence'.

Strains of Turnip mosaic potyvirus as defined by the molecular analysis of the coat protein gene of the virus

Turnip mosaic virus (TuMV) is a member of the potyvirus genus with a wide host range and highly variable in its biological characteristics. Analysis of the CP gene sequences from databases, combined with the experimental analysis of the CP gene of further isolates, using data derived from sequence or restriction analysis, has allowed the genetic classification of 60 TuMV isolates or sequences. Two main genetic clusters MB (mostly Brassica isolates) and MR (mostly Radish isolates) were found, together with several apparently independent lineages. Isolates in the latter could be grouped as Intermediate between Brassica and Radish clusters (IBR) or outside Brassica and Radish clusters (OBR), according to their genetic distance to the main clusters. The genetic diversity of TuMV isolates deposited in the databases was increased with the sequences of the CP gene of seven selected isolates, mainly belonging to IBR or OBR groups. There was a correlation between the MR genetic cluster and JPN 1 serotype.

Involvement of Beet western yellows virus, Cauliflower mosaic virus, and Turnip mosaic virus in Internal Disorders of Stored White Cabbage

ABSTRACT Experiments over two growing seasons clearly showed that Turnip mosaic virus (TuMV) infection was associated with internal necrosis (sunken necrotic spots 5 to 10 mm in diameter) and Beet western yellows virus (BWYV) infection was associated with collapse of leaf tissue at the margins (tipburn) in heads of stored white cabbage (Brassica oleracea var. capitata). Virtually no tipburn was seen in cv. Polinius, whereas cv. Impala was affected severely. Internal necrotic spots were seen in both cultivars. BWYV appeared to interact with TuMV. Plants infected with both viruses showed a lower incidence of external symptoms and had less internal necrosis than plants infected with TuMV alone. Cauliflower mosaic virus (CaMV) did not induce significant amounts of internal necrosis or tipburn, but did, in most cases, exacerbate symptoms caused by TuMV and BWYV. BWYV-induced tipburn worsened significantly during storage. Post-transplanting inoculation with TuMV induced more internal necrosis than pre-transplant inoculation. There was a significant association between detection of TuMV just prior to harvest and subsequent development of internal necrotic spots. Individually, all three viruses significantly reduced the yield of cv. Polinius, whereas only BWYV and CaMV treatments reduced the yield of cv. Impala.

Critical assessment of the outcome of infrainguinal vein bypass

OBJECTIVE

To perform a more critical assessment of infrainguinal vein bypass.

SUMMARY BACKGROUND DATA

Graft patency may give an unrealistic impression of the outcome of bypass surgery.

METHODS

During a 6-year period, 236 patients undergoing primary vein grafts were entered into the study. An ideal outcome required the patient to have survived 12 months with a patent graft on duplex scanning, no perioperative complication, and no further related open or endovascular surgery or admission.

RESULTS

At 12 months, the secondary graft patency rate was 82%; however, only 22% of patients had an ideal outcome. At 1 year, 44 (19%) patients died, 93 (39%) required further ipsilateral and 39 (17%) contralateral intervention, and a total of 108 (46%) were readmitted. An ideal outcome was more likely in patients receiving calcium channel blockers, principally because of improved primary patency, and less likely in those with cardiac failure requiring furosemide, principally because of worse survival in these patients.

CONCLUSIONS

Few patients achieve an ideal result after infrainguinal vein bypass. Outcome may be improved by the use of calcium channel blockers. Careful consideration is required before performing revascularization in patients with cardiac failure.

A confirmatory factor analysis on the DSM-IV ADHD and ODD symptoms: what is the best model for the organization of these symptoms?

Confirmatory factor analysis (CFA) was used to evaluate five different models for the organization of the DSM-IV ADHD and oppositional defiant disorder (ODD) symptoms (Model 1: a single factor model; Model 2: an ADHD and ODD two factor model; Model 3a: an inattention (INA), hyperactivity/impulsivity (HYP/IMP), and ODD three factor model; Model 3b: an INA, HYP/IMP, and ODD three factor model where the three IMP symptoms cross-load on the ODD factor; Model 4: an INA, HYP, IMP, and ODD four factor model). To evaluate these models, maternal ratings of ADHD and ODD symptoms were obtained at outpatient pediatric clinics on 742 children not in treatment and 91 children in treatment for ADHD. Model 3a resulted in a good fit as well as a significantly better fit than Model 2. Model 3a was also equivalent across treatment status, gender, and age groupings for the most part. Though Models 3b and 4 provided a statistically better fit than Model 3a, the improvement in fit was small and other model selection criteria argued against these more complex models.

The cylindrical inclusion gene of Turnip mosaic virus encodes a pathogenic determinant to the Brassica resistance gene TuRB01

The viral component of Turnip mosaic virus (TuMV) determining virulence to the Brassica napus TuRB01 dominant resistance allele has been identified. Sequence comparisons of an infectious cDNA clone of the UK 1 isolate of TuMV (avirulent on TuRB01) and a spontaneous mutant capable of infecting plants possessing TuRB01 suggested that a single nucleotide change in the cylindrical inclusion (CI) protein coding region (gene) of the virus was responsible for the altered phenotype. A second spontaneous mutation involved a different change in the CI gene. The construction of chimeric genomes and subsequent inoculations to plant lines segregating for TuRB01 confirmed the involvement of the CI gene in this interaction. Site-directed mutagenesis of the viral coat protein (CP) gene at the ninth nucleotide was carried out to investigate its interaction with TuRB01. The identity of this nucleotide in the CP gene did not affect the outcome of the viral infection. Both mutations identified in the CI gene caused amino acid changes in the C terminal third of the protein, outside any of the conserved sequences reported to be associated with helicase or cell-to-cell transport activities. This is the first example of a potyvirus CI gene acting as a determinant for a genotype-specific resistance interaction.

Detection of experimentally produced occult microfractures at the bone-cartilage interface in decalcified sections

We compared three histological preparation methods to detect experimentally produced occult microfractures in decalcified human patellae: a paraffin tape-transfer technique, a paraffin slab-cut method, and a paraffin method with methyl salicylate as the clearing agent. Microfractures were observed at the bone-cartilage interface and were oriented either parallel or perpendicular to the tidemark. Both types of microfractures were documented with each preparation method. The slab-cut method was time-consuming, but the section thickness allowed detailed analysis of the architecture of microcracks as they passed into the depth of the section. The methyl salicylate method was efficient and produced thin, serial sections with good morphological detail and minimal cutting artifact. Reliable histological data were also derived from the tape-transfer technique, but this method was inconsistent. The methods summarized here for processing decalcified human joint tissues provide a basis for future orthopaedic studies investigating occult microfractures at the bone-cartilage interface.

Radial artery use in bypass grafting does not change digital blood flow or hand function

BACKGROUND

Patient selection criteria have not been clearly established for use of the radial artery as a bypass conduit. To help establish such criteria, we measured changes in digital blood flow and hand function after radial artery removal.

METHODS

Ninety-eight patients of the first 122 consecutive patients considered for radial artery harvest met predetermined criteria by vascular noninvasive studies to undergo removal of the radial artery. In 42 of these 98 patients, the radial artery was actually used as a bypass conduit; 28 of these 42 patients returned for noninvasive vascular studies, a critical review of hand function, and a hand symptom questionnaire.

RESULTS

There were no significant differences between the operated and nonoperated hands for digital-brachial indices, cold response, grip or pinch strength, digital two-point discrimination, or nine-hole peg tests. The patients had an increased incidence of a small amount of forearm numbness and tingling, but no increase of pain or cold intolerance.

CONCLUSIONS

For properly selected patients, there are minimal changes in hand function after radial artery removal.

Internal validity of attention deficit hyperactivity disorder, oppositional defiant disorder, and overt conduct disorder symptoms in young children: implications from teacher ratings for a dimensional approach to symptom validity

Uses a dimensional approach to evaluate the internal validity of the attention deficit hyperactivity disorder (ADHD) inattention (I) and hyperactivity/impulsivity (H/I), oppositional defiant disorder (ODD), and overt conduct disorder (CD) symptoms (i.e., whether a symptom has a stronger correlation with its own dimension than the other three dimensions). In Study 1, teachers rated 1,445 children on the DSM-III-R I, H/I, ODD, and overt CD symptoms. In Study 2, teachers rated 1,711 children on the DSM-IV I, H/I, ODD, and overt CD symptoms. All the I symptoms showed internal validity in both studies. In contrast, the H/I symptoms and the ODD symptoms, especially the H/I symptoms, showed weaker internal validity. All the overt CD symptoms showed internal validity except the DSM-IV bullies others symptom, with this symptom being more strongly related to the ODD dimension. Confirmatory factor analysis provided support for a 4-factor model consisting of I, H/I, ODD, and overt CD factors. Finally, the importance of internal validity for the construct validation of the disruptive behavior symptoms is discussed.

Internal validity of the disruptive behavior disorder symptoms: implications from parent ratings for a dimensional approach to symptom validity

A dimensional approach was used to evaluate the internal validity of the DSM-III-R ADHD-inattention, ADHD-hyperactivity/impulsivity, oppositional defiant disorder (ODD), and conduct disorder (CD) symptoms (i.e., whether a symptom has a stronger correlation with its own dimension that the other three). Parents rated 4,019 children between the ages of 2 and 19 on these symptoms. The results showed that 5 of the 6 inattention symptoms, 3 of the 4 hyperactivity symptoms, 1 of the 4 impulsivity symptoms, 6 of the 9 oppositional defiant disorder symptoms, and 8 of the 11 CD symptoms had significant internal validity. Confirmatory factor analysis (CFA) found support for inattention, hyperactivity/impulsivity, oppositional defiant, and conduct disorder dimensions. Multiple-group CFA also found support for factor pattern and loading invariance across gender. The implications of these results as well as the merits of the dimensional approach to symptom validity are discussed in the context of the DSM-IV changes in ADHD, ODD, and CD.

Characterization of the growth center of the avian preovulatory follicle

Anatomical studies have suggested that the germinal disc (GD) region (GDR; GD plus overlying granulosa cells) is the growth center of the avian preovulatory follicle. The objective of this study was to characterize the physiology of the GDR by comparing the functions of two morphologically distinct populations of granulosa cells. The three markers of the physiology of individual granulosa cells examined were 1) proliferation, 2) production of plasminogen activator (PA), and 3) production of progesterone. The effect of LH on each of these functions was also evaluated. Sections 8 mm in diameter were obtained from granulosa cells associated with the GD (GD granulosa cells) and from granulosa cells on the layer distal to the GD (nonGD granulosa cells) from the five largest preovulatory follicles (F5-F1, F1 designated the largest) 12-14 h (before the LH surge) or 2 h (after the LH surge) before ovulation. Proliferation was measured using [3H]thymidine incorporation. PA activity was measured using the chromogenic substrate S-2251. Progesterone was measured by RIA. Incorporation of [3H]thymidine was very high in GD and nonGD granulosa cells from F5 and F4 follicles and decreased dramatically as the follicle progressed through the hierarchy, but remained significantly higher in GD granulosa cells compared to nonGD granulosa cells at all stages of development examined (F5-F1). Exposure of follicles to LH in vivo inhibited [3H]thymidine incorporation by GD granulosa cells in all follicles except the F5. In contrast, in vivo exposure to LH had no effect on [3H]thymidine incorporation by nonGD granulosa cells. PA production by GD granulosa cells was high throughout the stages of maturation studied (F5-F1), whereas PA production by nonGD granulosa cells decreased as follicles matured from F5 to F1. Interestingly, LH stimulated PA production by F5 GD granulosa cells, had no effect on PA production by F3 GD granulosa cells, and inhibited PA production by F1 GD granulosa cells. In contrast, LH inhibited PA production by nonGD granulosa cells in F3 and F1 follicles. Progesterone production by GD granulosa cells was low in F3 and F1 follicles. Progesterone production by nonGD granulosa cells increased as the follicle matured from the F3 to F1 stage and was stimulated significantly by LH. These data indicate that physiological differences in granulosa cell function are dependent upon the location of granulosa cells relative to the GD. GD granulosa cells are less mature, proliferate more rapidly, and produce more PA than nonGD granulosa cells, which produce more progesterone and less PA. Differences in granulosa cell function may be due to the influence of the GD, providing physiological evidence that the GDR may be the growth center of the follicle.

Setting priorities for the Children's Vaccine Initiative: a cost-effectiveness approach

To help the Children's Vaccine Initiative (CVI) achieve its goal of new and improved children's vaccines, we developed and applied a cost-effectiveness model to set priorities for vaccine development. The model measures the health benefits in additional Quality-Adjusted Life Years (QALYs) gained by the combined birth cohorts of all developing countries over an assumed useful life of a proposed vaccine (generally 10 years). It measures costs as the net cost of developing, procuring, and administering the vaccine to the same population and time frame compared to the status quo (the current vaccine, if any). It weights each dollar of in-kind allocation of the existing health infrastructure less heavily than a dollar cash outlay to purchase new vaccine to reflect severe constraints on foreign exchange and non-personnel costs. It expresses cost-effectiveness as the net cost per QALY. The model was applied to 13 candidate vaccines selected by the CVI for initial analysis on the basis of their near-term feasibility. The five most cost-effective improvements, each of which could generate a QALY inexpensively (below $25 per QALY), were an early-administration or an early two-dose measles vaccine, slow release tetanus toxoid (for women), improved typhoid vaccine, and hepatitis B combined with diphtheria-tetanus-pertussis vaccine.

Colour duplex ultrasound: a screening modality for femoropopliteal disease in patients with intermittent claudication

In patients presenting with intermittent claudication, Colour Duplex Ultrasound (CDU) examination of the femoro-popliteal segment has been proposed as a screening modality. Those patients with atheromatous lesions suitable for percutaneous transluminal angioplasty (PTA) could proceed to diagnostic angiography. Patients with long segment occlusive disease demonstrated by CDU, who were not considered suitable candidates for surgery, would not require angiographic examination. This prospective study was performed on 46 limbs in 25 consecutive patients who presented for investigation of claudication. There was close correlation between the two methods in the demonstration of high-grade stenoses and occluded segments. Using angiography as the 'gold standard' this study indicated a diagnostic accuracy for CDU of 93% with a sensitivity of 89% and a specificity of 95%. Angiography tended to show longer occluded segments than CDU. Colour Duplex Ultrasound shows promise as a screening investigation in patients with intermittent claudication to detect lesions that may be suitable for PTA.

The impact of maternal health improvement on perinatal survival: cost-effective alternatives

Each year, an estimated half million women die from complications related to child birth either during pregnancy, delivery or within 42 days afterwards. When pregnant women have complications, their infants are at greater risk of becoming ill, permanently disabled or dying. For every maternal death, there are at least 20 infant deaths: stillbirths, neonatal or postneonatal deaths. Altogether, an estimated 7 million infants each year die perinatally (stillborn or deaths within the first week of life). Low cost, feasible, and effective intervention strategies include: a) improved family planning and abortion services; b) obstetric care at delivery; and, c) prenatal services. Two hypothetical populations of one million (a low mortality and a high mortality country) are used to illustrate maternal and perinatal program strategies and priorities. In countries with high fertility, major reductions in maternal and infant deaths result both from reductions in the number of pregnancies through family planning and from improved obstetric care. Where fertility is already low, reductions result almost entirely from improved obstetric and prenatal care. The investments required are relatively low, while the potential gains are great. The cost to avert each death in a high mortality population is estimated between $800 and $1,500 or as low as $0.50 per capita per year. The priorities for programs targeting maternal and perinatal health depend on demographic, ecologic and economic factors, and should include the promotion of good health, not merely the avoidance of death. More operational research is required on various aspects of maternal and perinatal health; in particular, on the cost-effectiveness of different service components.

Portal to the community. Dedicating a facility to ambulatory and long-term care completes the continuum for a New Jersey system

In 1989 Cathedral Healthcare System, Orange, NJ, began a strategic planning process that culminated in a decision to create a continuum of care. Converting one of its three hospitals from an acute care to an ambulatory care facility gave Cathedral an opportunity to address fiscal realities and at the same time further develop its continuum of care. The converted hospital (Saint Mary's in Orange) would be a key component of a full continuum of care for area residents. Saint Mary's would also serve as a portal of entry to the system's services. The community's need for affordable, accessible healthcare has been well documented. Converting Saint Mary's to alternative uses was one approach the system could take to better meet the needs of this underserved population. In addition to providing ambulatory care, Cathedral will be transforming the acute care beds into much-needed long-term care beds. The conversion will enable Saint Mary's to meet the needs of a growing aging population.

A retrospective analysis of infra-inguinal arterial reconstruction: three year patency rates

Primary infra-inguinal arterial reconstructions were reviewed for primary patency and outcome of thrombosis in 144 patients. Distal anastomoses in these patients were to the popliteal artery and were above the knee in 63, below the knee in 53 and at the tibial level in 28. The treatment used was: polytetrafluoroethylene (PTFE) in 33 cases, PTFE with an interposition vein cuff in 29 cases, autogenous saphenous vein (ASV) in situ in 47 cases, and reversed technique in 26 cases. Life table analysis showed a 59% overall primary patency at 3 years. Patency rates of above knee anastomoses (65%) and below knee (61%) were statistically different from the tibial anastomoses (42%, P = 0.005). In both above and below knee popliteal anastomoses there was a statistically significant difference in the patency of ASV and the PTFE/vein cuff technique (P = 0.0006) but there was no difference between ASV and PTFE. There was no difference in patency rates for the various types of grafts with tibial anastomoses. Data were analysed at 3 years, taking into account the variables of smoking, diabetes or indications for surgery respectively and no difference was found in patency. The number and calibre of the run-off vessels did not influence patency significantly, hence anastomosis to any good quality vessel regardless of run-off is recommended. The poor results with the interposition vein cuff technique are unexplained but this study suggests that the technique should be reserved for anastomoses below the popliteal artery.