Tumor Response Predicts Survival Time of Nivolumab Monotherapy for Advanced Gastric Cancer: A Subgroup Analysis of the DELIVER Trial (JACCRO GC-08)

BACKGROUND

This prospective observational study evaluated the real-world effectiveness of nivolumab monotherapy in previously treated advanced gastric cancer (GC). A preplanned 2-year final analysis was performed to confirm survival and tumor behavior with nivolumab monotherapy.

PATIENTS AND METHODS

The primary endpoint was overall survival (OS). The data regarding tumor size were prospectively collected and evaluated using the RECIST criteria. Exploratory analyses were performed for survival according to the tumor response and depth of response (DpR) in patients with measurable lesions who were receiving nivolumab monotherapy as third- or later-line therapy.

RESULTS

In 487 patients, the median OS and progression-free survival (PFS) were 5.8 (95% CI 5.3-6.9) months and 1.8 (95% CI 1.7-2.0) months, respectively. The response rate (RR) was 14.5% in 282 patients with measurable lesions. In 234 patients treated with third- or later-line, the DpR was found to be associated with PFS and OS in the Spearman analysis (r = 0.55 and 0.44, respectively) as well as using a discrete variable. When the DpR was divided into 5 groups (-20%≥DpR; -20%

CONCLUSION

The final analysis confirmed the efficacy of nivolumab monotherapy for patients with advanced GC in routine clinical practice. The exploratory analysis indicated that increasing DpR was associated with longer median PFS and OS in nivolumab treatment at a later-line setting.

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Key Words

• gastric cancer
• nivolumab
• real-world data
• tumor response

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Grants

• Japan Clinical Cancer Research Organization

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Affiliation(s)

Yu Sunakawa Department of Clinical Oncology, St. Marianna University School of Medicine, Kawasaki, Japan
Yasuhiro Sakamoto Department of Medical Oncology, Osaki Citizen Hospital, Osaki, Japan
Ryohei Kawabata Department of Surgery, Sakai City Medical Center, Sakai, Japan
Atsushi Ishiguro Department of Medical Oncology, Teine Keijinkai Hospital, Sapporo, Japan
Yusuke Akamaru Department of Gastrointestinal Surgery, Ikeda City Hospital, Ikeda, Japan
Yosuke Kito Department of Medical Oncology, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
Masazumi Takahashi Division of Gastroenterological Surgery, Yokohama Municipal Citizen's Hospital, Yokohama, Japan
Jin Matsuyama Department of Gastroenterological Surgery, Higashi-Osaka City Medical Center, Higashi-Osaka, Japan
Hiroshi Yabusaki Department of Gastroenterological Surgery, Niigata Cancer Center Hospital, Niigata, Japan
Akitaka Makiyama Cancer Center, Gifu University Hospital, Gifu, Japan
Takahisa Suzuki Department of Surgery, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Kure, Japan
Masahiro Tsuda Department of Gastroenterolgical Oncology, Hyogo Cancer Center, Akashi, Japan
Hisateru Yasui Deparment of Medical Oncology, Kobe City Medical Center General Hospital, Kobe, Japan
Jun Hihara Department of Surgery, Hiroshima City North Medical Center Asa Citizens Hospital, Hiroshima, Japan
Atsushi Takeno Department of Surgery, Kansai Rosai Hospital, Amagasaki, Japan
Eisuke Inoue Showa University Research Administration Center, Showa University, Tokyo, Japan
Wataru Ichikawa Division of Medical Oncology, Showa University Fujigaoka Hospital, Yokohama, Japan
Masashi Fujii Japan Clinical Cancer Research Organization (JACCRO), Tokyo, Japan

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Impact of interstitial lung disease on clinical remission and unfavourable events of rheumatoid arthritis: results from the IORRA cohort

OBJECTIVES

We aimed to examine the impact of concomitant interstitial lung disease (ILD) on achieving clinical remission and the occurrence of unfavourable clinical events in patients with RA.

METHODS

Among the participants in the Institute of Rheumatology, Rheumatoid Arthritis (IORRA) cohort from 2011 to 2012, patients not achieving remission of 28-joint disease activity score (DAS28) at baseline and those with chest CT images were enrolled. Based on the chest CT images, the patients were divided into two groups: the ILD group and non-ILD group. The associations among the presence of ILD with time to achieving DAS28 remission and development of death, hospitalized infection, major adverse cardiac events (MACE), or malignancy within 5 years were evaluated using time-dependent Cox regression models.

RESULTS

We enrolled 287 patients in the ILD group and 1235 in the non-ILD group. DAS28 remission was achieved at least once in 55.7% and 75.0% of the ILD and non-ILD groups within 5 years, respectively. Presence of ILD was significantly associated with failure to achieve DAS28 remission (adjusted hazard ratio [aHR]: 0.71; 95% CI: 0.58, 0.89). ILD was also a significant factor associated with death (aHR: 3.24; 95% CI: 2.08, 5.03), hospitalized infection (aHR 2.60; 95% CI: 1.77, 3.83), MACE (aHR: 3.40; 95% CI: 1.76, 6.58), and lung cancer (aHR: 16.0; 95% CI: 3.22, 79.2), but not with malignant lymphoma (aHR: 2.27; 95% CI: 0.59, 8.81).

CONCLUSION

Concomitant ILD was a significant factor associated with failure to achieve clinical remission and the occurrence of the unfavourable clinical events in patients with RA.

Intravenous immunoglobulin treatment for obstetric antiphospholipid syndrome refractory to conventional therapy: A single-arm, open-labelled multicentre clinical trial

OBJECTIVES

The objective of the study was to compare the efficacy of intravenous immunoglobulin (IVIG) therapy for obstetric antiphospholipid syndrome (APS) refractory to conventional treatment.

METHODS

We conducted a single-arm, open-label multicentre clinical intervention trial. The enrolled criteria were patients with refractory APS who had a history of still or premature birth before 30 weeks of gestational age, even though they had been treated with conventional treatment, i.e. heparin and low-dose aspirin. After confirming the foetal heartbeats, a single course of IVIG (0.4 g/kg body weight daily for 5 days) was added to conventional treatment. The primary outcome was a live birth ratio of >30 weeks of gestational period, and the secondary outcome included improving pregnancy outcomes compared to previous pregnancy.

RESULTS

Twenty-five per cent of patients (2 of 8 cases) achieved a live birth after the 30th week of pregnancy by IVIG-only add-on treatment, which is the same prevalence as the historical control. However, by adding other second-line therapy to IVIG and conventional treatment, further three patients (37.5%) achieved improvements in pregnancy outcome compared to previous treatments. In total, five patients (62.5%) were able to achieve preferable pregnancy outcomes through combination treatment including IVIG.

CONCLUSIONS

This clinical trial could not demonstrate the efficacy of IVIG-only add-on therapy at improving the pregnancy outcomes of patients with obstetric APS refractory to conventional treatment. However, the combination of IVIG with rituximab or statins adding to conventional treatment improved pregnancy outcomes and resulted in more live births. Further studies are needed to investigate the efficacy of multi-targeted therapy to treat obstetric refractory APS.

Effects of the abacus-based mental calculation training application "SoroTouch" on cognitive functions: A randomized controlled trial

This study investigated the effect of a home-based computerized cognitive training program that utilizes a digital application for training abacus-based mental calculations, "SoroTouch," on the cognitive functions of healthy middle-aged and older people using a randomized controlled trial. The participants were 20 adults (aged 42-79 years) who were involved in community-based activities for dementia prevention held by a certain organization. The participants were assigned randomly to the intervention (SoroTouch) group or control group. The SoroTouch group received home-based cognitive training with SoroTouch, being asked to use the software every day for 6 months, while the control group did not receive any intervention. To investigate the effect of SoroTouch, CogEvo, a cognitive functions test battery utilizing a tablet device, was administered to all participants once per month during the 6-month intervention period. In addition, before and after the intervention, all participants were asked to take the CogEvo and the Japanese version of the Montreal Cognitive Assessment (MoCA-J). The analyses showed that the SoroTouch group did not improve total scores of the CogEvo and MoCA-J, but large group differences were observed in the two tasks of the CogEvo as follows: 'Follow the order' (modified Trail Making Test) at 2 months after the beginning of the intervention (group differences; 39.4, 95% confidence interval; 7.6-71.2) and 'Route 99' at 6 months (group differences; 39.6, 95% confidence interval; 4.9-74.4). These results provide evidence that a home-based computerized cognitive training program SoroTouch has the potential to improve working memory, attention and planning in healthy middle-aged and older adults.

Risk of flare and damage accrual after tapering glucocorticoids in modified serologically active clinically quiescent patients with systemic lupus erythematosus: a multinational observational cohort study

OBJECTIVES

To assess the risk of flare and damage accrual after tapering glucocorticoids (GCs) in modified serologically active clinically quiescent (mSACQ) patients with systemic lupus erythematosus (SLE).

METHODS

Data from a 12-country longitudinal SLE cohort, collected prospectively between 2013 and 2020, were analysed. SLE patients with mSACQ defined as the state with serological activity (increased anti-dsDNA and/or hypocomplementemia) but without clinical activity, treated with ≤7.5 mg/day of prednisolone-equivalent GCs and not-considering duration, were studied. The risk of subsequent flare or damage accrual per 1 mg decrease of prednisolone was assessed using Cox proportional hazard models while adjusting for confounders. Observation periods were 2 years and censored if each event occurred.

RESULTS

Data from 1850 mSACQ patients were analysed: 742, 271 and 180 patients experienced overall flare, severe flare and damage accrual, respectively. Tapering GCs by 1 mg/day of prednisolone was not associated with increased risk of overall or severe flare: adjusted HRs 1.02 (95% CI, 0.99 to 1.05) and 0.98 (95% CI, 0.96 to 1.004), respectively. Antimalarial use was associated with decreased flare risk. Tapering GCs was associated with decreased risk of damage accrual (adjusted HR 0.96, 95% CI, 0.93 to 0.99) in the patients whose initial prednisolone dosages were >5 mg/day.

CONCLUSIONS

In mSACQ patients, tapering GCs was not associated with increased flare risk. Antimalarial use was associated with decreased flare risk. Tapering GCs protected mSACQ patients treated with >5 mg/day of prednisolone against damage accrual. These findings suggest that cautious GC tapering is feasible and can reduce GC use in mSACQ patients.

Associations of disease duration and anti-citrullinated peptide antibody status with the effectiveness of abatacept in biologic-naïve patients with rheumatoid arthritis: Post hoc analysis of a multicentre, real-world observational study in Japan (ORIGAMI)

OBJECTIVES

The aim of the article is to investigate the associations of disease duration and anti-cyclic citrullinated peptide antibody (ACPA) status with the effectiveness of abatacept in biologic-naïve patients with rheumatoid arthritis (RA).

METHODS

We performed post hoc analyses of the Orencia® Registry in Geographically Assembled Multicenter Investigation (ORIGAMI) study of biologic-naïve RA patients aged ≥20 years with moderate disease activity who were prescribed abatacept. Changes in the Simplified Disease Activity Index (SDAI) and Japanese Health Assessment Questionnaire (J-HAQ) at 4, 24, and 52 weeks of treatment were analysed in patients divided according to ACPA serostatus (positive/negative), disease duration (<1/≥1 year), or both.

RESULTS

SDAI scores decreased from baseline in all groups. SDAI scores tended to decrease more in the ACPA-positive group and disease duration <1-year group than in the ACPA-negative group and disease duration ≥1-year group, respectively. In the disease duration <1-year group, SDAI tended to decrease more in the ACPA-positive group than in the ACPA-negative group. Disease duration was independently associated with the change in SDAI and SDAI remission at Week 52 in multivariable regression models.

CONCLUSIONS

These results suggest that starting abatacept within 1 year of diagnosis was associated with greater effectiveness of abatacept in biologic-naïve patients with RA and moderate disease activity.

Unincreased mortality of patients with early rheumatoid arthritis compared to the general population in the past 17 years: Analyses from the IORRA cohort

OBJECTIVES

The aim of this article is to investigate the mortality rate of patients with early rheumatoid arthritis (RA) over the past 17 years.

METHODS

Japanese patients with early RA enrolled in the Institute of Rheumatology, Rheumatoid Arthritis cohort from 2001 to 2012 were classified into Groups A (2001-06) and B (2007-12). The standardized mortality ratio (SMR) and 5-year survival rate were calculated.

RESULTS

Groups A and B had 1609 and 1608 patients, of which 167 and 178 patients were lost during follow-up and 47 and 45 deaths were confirmed, respectively. The SMR (95% confidence intervals) for Groups A and B were 0.81 (0.59-1.08) and 0.78 (0.57-1.04), respectively, with the condition that all untraceable patients were alive. Assuming that the mortality rate of untraceable patients was twice as high as that of the general population, the SMR was 0.90 (0.68-1.19) for Group A and 0.92 (0.68-1.23) for Group B. The 5-year survival rates were 96.9% and 97.0% for Groups A and B, respectively.

CONCLUSIONS

The 5-year mortality of patients with early RA has been comparable to that of the general Japanese population. The 5-year survival rate has been stable over the past 17 years.

Factors associated with sarcopenia in Japanese patients with rheumatoid arthritis: results from the IORRA cohort study

To investigate the prevalence of and factors associated with sarcopenia in Japanese patients with rheumatoid arthritis (RA). We analyzed a cross-section of patients with RA participating in the Institute of Rheumatology Rheumatoid Arthritis cohort survey in 2021. Participants completed self-administered questionnaires, including a 5-item sarcopenia screening index (SARC-F). Patients with a SARC-F score of 4 or higher were categorized as having sarcopenia. Among 2416 Japanese patients with RA (2113 women and 303 men; mean age 63.9 years), 341 (14.1%) patients were categorized as having sarcopenia. In a multivariable analysis of patients of all ages, age, body mass index (BMI), disease duration, history of fracture, patient pain on a visual analog scale (VAS), patient or physician global assessments based on VAS, and use of nonsteroidal anti-inflammatory drugs (NSAIDs), biologic disease-modifying antirheumatic drugs (bDMARDs), and corticosteroids were significantly (P < 0.05) associated with sarcopenia. Disease duration, patient global assessments based on VAS, and use of NSAIDs and bDMARDs were significantly associated with sarcopenia among the patients aged < 65 years, whereas age, female sex, BMI, disease duration, history of fracture, patient pain VAS and global assessments based on VAS, and use of bDMARDs and corticosteroids were significantly associated with sarcopenia in patients aged ≥ 65 years. In Japanese patients with RA, age, BMI, disease duration, history of fracture, patient pain VAS and global assessments based on VAS, and use of NSAIDs, bDMARDs, and corticosteroids were associated with sarcopenia. Among older patients with RA, female sex was additionally associated with sarcopenia. Key Points • To our knowledge, this is the first report showing factors associated with sarcopenia in Japanese patients with rheumatoid arthritis using a large cohort database. • Age, BMI, disease duration, history of fracture, patient pain on a visual analog scale, and use of nonsteroidal anti-inflammatory drugs, biologic disease-modifying antirheumatic drugs, and corticosteroids were associated with sarcopenia in Japanese patients with rheumatoid arthritis. Limited to elderly patients, female sex was also associated with sarcopenia.

Evaluation of levator ani muscle elasticity after vaginal delivery and cesarean section using shear wave elastography

PURPOSE

The risk of pelvic floor muscle injury is commonly considered to be higher in vaginal than in cesarean delivery. This study aimed to compare levator ani muscle (LAM) elasticity after vaginal and cesarean delivery using shear wave elastography (SWE).

METHODS

Postpartum women who underwent a single SWE evaluation 1 month after their first delivery were divided into vaginal and cesarean delivery groups. The elastic moduli of both sides of the LAM were measured in a horizontal section and compared between the groups. In addition, a subgroup analysis was performed to compare LAM elasticity according to the delivery method within the vaginal delivery group-normal vaginal delivery, episiotomy, and operative vaginal delivery.

RESULTS

Sixty-two women were included (vaginal delivery, n = 47; elective cesarean section, n = 15). Multiple regression analysis revealed that the LAM elastic modulus was significantly lower in the vaginal delivery group than in the cesarean delivery group (right LAM: 44.2 vs. 72.7 kPa, p = 0.0036; left LAM 40.4 vs. 82.7 kPa, p < 0.0001). In the subgroup analysis, the right LAM elastic modulus was significantly lower in the operative vaginal delivery subgroup than in the normal vaginal delivery subgroup (p = 0.0131). However, there was no significant difference in the left LAM elastic modulus between the three subgroups.

CONCLUSION

LAM elasticity was significantly lower after vaginal delivery than after cesarean delivery. Furthermore, the elasticity of the right LAM was lower after operative vaginal delivery than after normal vaginal delivery. SWE has the potential to provide an objective quantitative assessment of postpartum pelvic floor muscle recovery.

Self-controlled Case Series Study for Acute Kidney Injury after Starting Proton Pump Inhibitors or Potassium-Competitive Acid Blocker in Patients with Cancer Using a Large Claims Database

To investigate the risk of acute kidney injury (AKI) in patients with cancer following the initiation of proton pump inhibitors (PPIs) and potassium-competitive acid blocker (PCAB), considering sex and anti-cancer drug use. We conducted a self-controlled case-series study using the Japan Medical Data Center claims data from 12422 patients with cancer who were prescribed PPIs or PCAB between January 2017 and December 2019. Considering the timing of PPI or PCAB, control period (days -120 to -1), risk period 1 (days 0 to +30), and risk period 2 (days +31 to +365) were defined. To assess the incidence rate ratio (IRR) and 95% confidence interval (CI) as the risk ratio, we adjusted for anti-cancer drugs to assess the risk of AKI. Additionally, we also examined sex differences to identify the risk of AKI. AKI was observed in risk period 1 [2.05 (1.12-3.72), p = 0.0192], but a slight reduction was noted in risk period 2 [0.60 (0.36-1.00), p = 0.0481]. A sex-specific increase in the risk of AKI was observed only in males during risk period 1 [2.18 (1.10-4.32), p = 0.0260], with a reduction in risk period 2 [0.48 (0.26-0.89), p = 0.0200]. We identified an increased risk of AKI in patients with cancer starting PPIs or PCAB particularly in males within 30 d after PPI or PCAB initiation, emphasizing the need for vigilant monitoring and management of AKI in this patient population.

Corrigendum: Soluble PD-L1 changes in advanced non-small cell lung cancer patients treated with PD-1 inhibitors: an individual patient data meta-analysis

[This corrects the article DOI: 10.3389/fimmu.2023.1308381.].

Soluble PD-L1 changes in advanced non-small cell lung cancer patients treated with PD-1 inhibitors: an individual patient data meta-analysis

Introduction

Currently, first-line immune checkpoint inhibitors (ICIs), including programmed cell death protein-1 (PD-1) inhibitors, are utilized as monotherapy in advanced non-small cell lung cancer (NSCLC) patients with high programmed death ligand-1 (PD-L1) expression (≧50%). Pre-treatment or post-treatment serum soluble PD-L1 (sPD-L1) has been identified as a potential biomarker for assessing ICI efficacy through fixed-point observations. However, existing studies on sPD-L1 changes have produced inconsistent results or have had sample sizes too small to detect clinically meaningful effect sizes. To elucidate the role of sPD-L1, we conducted a collaborative individual patient data meta-analysis of PD-1 inhibitor treatments.

Methods

We conducted a thorough search of articles in PubMed via Medline, Embase, Scopus, and Cochrane databases from inception to October 20, 2023. Trials were deemed eligible if they contained individual datasets for advanced NSCLC patients, including data on overall survival (OS)/progression-free survival (PFS), as well as pre- and post-treatment sPD-L1 levels after 3-4 cycles of PD-1 inhibitor treatments. Our analysis focused on patients who completed 3-4 cycles of PD-1 inhibitor treatments. The primary outcome measure was OS/PFS, and we assessed changes in sPD-L1 concentration pre- and post-treatment through ELISA analyses.

Results

From our search, we identified a potential seven trials, encompassing 256 patients. Among these, two trials with 26 patients met the criteria for inclusion in our primary analyses. Over a median follow-up period of 10 months, pooled univariate analysis revealed that increases in sPD-L1 levels during PD-1 inhibitor treatment were not associated with OS (HR = 1.25; CI: 0.52-3.02)/PFS (HR = 1.42; CI: 0.61-3.30) when compared to cases with sPD-L1 decreases. Subgroup analyses indicated that the impact of sPD-L1 changes on overall mortality/progression-related mortality remained consistent regardless of gender, age, or the type of treatment (nivolumab or pembrolizumab).

Conclusion

Our findings suggest that changes in sPD-L1 levels during PD-1 inhibitor treatment do not significantly influence the prognosis of advanced NSCLC patients, regardless of gender, age, or treatment type. Continuous monitoring of sPD-L1 may not offer significant advantages compared to fixed-point observations.

Randomized trial of advice from healthcare professionals to eliminate constriction by maternal clothing on the trunk to prevent preterm birth and improve health status

AIM

Women's clothing during pregnancy may influence perinatal outcomes. A preliminary study suggested that midwives' advice to avoid wearing tight clothing during pregnancy may reduce the risk of preterm delivery. We examined the effects of such advice to pregnant women on the risk of preterm birth and health status during pregnancy.

METHODS

An open-label evaluator-blinded randomized controlled trial was conducted at the National Centre for Child Health and Development in Tokyo, Japan. Normal pregnant women were randomly assigned to receive constrictive clothing elimination care or standard care at 20 weeks gestation. The control group was issued leaflets concerning anemia prevention at entry and skin care at 30 weeks' gestation, along with a brief explanation and answers to questions by midwives as standard care. The intervention group received advice from midwives concerning avoiding constrictive clothing in addition to standard care. The primary outcome was the incidence of preterm birth (<37 weeks). The secondary outcomes were 12 indicators related to preterm delivery or health status.

RESULTS

Among 624 randomly assigned women, 599 (intervention group, n = 306; control group, n = 293) completed the study between February 2015 and August 2016. The incidence of preterm birth in the intervention and control groups was 4.2% (13/306) and 5.1% (15/293), respectively (p = 0.614). There were no significant differences regarding any secondary outcomes, including obstetric outcomes and physical/mental indicators, during pregnancy.

CONCLUSIONS

Advice from midwives to avoid constrictive clothing during pregnancy did not influence the incidence of preterm birth or maternal health status.

TRIAL REGISTRATION

UMIN000016853 (March 30, 2015).

Evaluation of the initial timing of infection control pharmacist-driven audit and monitoring of vancomycin therapy in patients with infectious diseases: A retrospective observational study

BACKGROUND

Early monitoring and feedback on the treatment of infectious diseases are some of the methods for optimising antimicrobial treatment throughout the treatment period. Prospective audits and feedback interventions have also been shown to improve antimicrobial use and reduce antimicrobial resistance. We examined the appropriate use of antimicrobials by focusing on the initial timing for audits and feedback intervention of antimicrobial prescription by Infection Control Team pharmacists.

METHODS

We conducted a retrospective observational study in a university hospital in Tokyo, Japan from 1 January 2019 to 31 May 2021. We retrospectively enrolled patients with infections and those patients suspected of having an infection, who were administered vancomycin and assessed at our hospital. The definition of primary outcome was the maintenance of target vancomycin trough blood concentrations of 10-20 μg/ml during treatment. Multivariable logistic regression and multivariate linear regression analyses were performed to test the effectiveness of the initial timing of the intervention by Infection Control Team pharmacists as the explanatory variable.

RESULTS

A total of 638 patients were included in this study, with a median age of 69 years (interquartile range: 54-78 years). Multivariable logistic regression revealed that the maintenance of target vancomycin trough concentrations was not associated with the timing of the audit and the initiation of monitoring by Infection Control Team pharmacists (adjusted odds ratio: 0.99, 95% confidence interval: 0.99-1.00, p = 0.990). Multivariate linear regression revealed that the duration of vancomycin administration was significantly correlated with the timing of initiation of monitoring by Infection Control Team pharmacists (adjusted estimate: 0.0227, standard error: 0.0051, p = 0.012).

CONCLUSIONS

Our study showed that early initiation of a comprehensive audit and monitoring by Infection Control Team pharmacists did not affect the maintenance of the target vancomycin trough blood concentration. However, it reduced the duration of vancomycin administration.

Association between patient-reported outcomes and impairments in work and activity in patients with rheumatoid arthritis in clinical remission: A retrospective analysis using the IORRA database

OBJECTIVES

To explore the patient-reported outcomes (PROs) associated with work productivity and activity impairment (WPAI) in patients with rheumatoid arthritis (RA) in clinical remission.

METHODS

We enrolled patients with RA ≥18 years and with a simplified disease activity index ≤3.3 from the Institute of Rheumatology, Rheumatoid Arthritis data set collected in October 2017. The pain-visual analogue scale, patients' global assessment visual analogue scale (VAS), Japanese version of the Healthcare Assessment Questionnaire (J-HAQ) Disability Index, and duration of morning joint stiffness were selected as the PROs. To evaluate work productivity and activity, the WPAI for RA instrument (WPAI-RA) was used. To assess the contribution of each PRO to the WPAI-RA score, an analysis of variance model was constructed.

RESULTS

The mean age of the 2614 patients was 62.4 years; 85.1% were female. Median values of the WPAI-RA score were 1.1% for absenteeism, 6.5% for presenteeism, 7.4% for work impairment, and 10.2% for activity impairment. Morning joint stiffness contributed the most to absenteeism (18.0%), while pain-VAS contributed the most to presenteeism (57.4%), work productivity loss (51.1%), and daily activity impairment (53.7%). J-HAQ was the second most contributing factor to presenteeism (17.4%), work productivity loss (16.3%), and daily activity impairment (26.0%).

CONCLUSIONS

The pain-VAS and J-HAQ highly contributed to WPAI in patients with RA in clinical remission.

Contribution of the factors to EuroQol 5 Dimensions in rheumatoid arthritis patients achieving low disease activity/remission with abatacept treatment: post-hoc subgroup analyses of the Japanese real-world observational "ORIGAMI" study

OBJECTIVES

To address improvements in quality of life (QOL), we analysed the relative contributions of factors to EuroQol 5 Dimensions (EQ-5D) in abatacept-treated rheumatoid arthritis (RA) patients in the ORIGAMI study.

METHODS

Patients who were evaluable for disease activity through to Week 52 in the ORIGAMI study were divided into those achieving Simplified Disease Activity Index-remission/low disease activity (remission/LDA; n=178) and patients with moderate/high disease activity (MDA/HDA; n=99). We compared the changes in EQ-5D and other outcomes through to Week 52. Focusing on the remission/LDA group, the contribution of each factor to the variance of EQ-5D at baseline and Week 52 was examined using analysis of variance.

RESULTS

The remission/LDA group showed greater improvements than the MDA/HDA group in EQ-5D, Japanese Health Assessment Questionnaire, visual analogue scale for pain (Pain VAS), and patient global assessment (PtGA). In the remission/LDA group, factors significantly contributing to EQ-5D were sex, C-reactive protein, and Pain VAS at baseline, and PtGA and age at Week 52.

CONCLUSIONS

In RA patients who achieved remission/LDA during abatacept treatment, PtGA and age at Week 52 contribute to the variance of EQ-5D, suggesting that identification of factors associated with PtGA may be important to address improvements of QOL.

Multicenter, 2-dose single-group controlled trial of tacrolimus for the severe infertility patients

INTRODUCTION

Infertility is estimated to affect 8% to 12% of reproductive-aged couples worldwide. While approximately 85% of infertile couples have an identified cause, the remaining 15% suffer physically and emotionally from unexplained intractable infertility. In recent years, maternal-to-fetal immunological abnormalities have attracted attention as mechanisms that differ from the conventional factors contributing to infertility and pregnancy loss. A T-helper 2 (Th2)-dominant immune state has been proposed as a maternal immune alteration to eliminate rejection and induce tolerance to a semi-allogeneic fetus. An imbalance in Th1 responses would not induce adequate maternal immune tolerance to the fetus or early embryos. Tacrolimus, widely used as an immunosuppressant agent in solid organ transplant recipients, is expected to suppress maternal rejection and promote tolerance to early embryos after assisted reproductive technology by modulating the immunological environment of the preimplantation endometrium. We planned an exploratory clinical trial to determine the efficacy, safety, and dosage of tacrolimus in women with intractable infertility.

METHODS AND ANALYSIS

This is a multicenter, 2-dose, single-group controlled trial in infertile women who failed to achieve a chemical pregnancy despite multiple in vitro fertilization (IVF) and embryo transfer (ET) treatment cycles. The following 2 key selection criteria were set: no underlying factors of infertility despite appropriate evaluation and presence of Th1-dominant immune state, defined as a Th1/Th2 cell ratio ≥ 10.3 in the peripheral blood. A total of 26 eligible participants are randomly assigned (in a 2:1 ratio) to receive immunosuppressive therapy with oral tacrolimus at a daily dose of 2 mg or 4 mg. Tacrolimus is administered for 16 days starting from 2 days before ET. The primary endpoint is the presence of clinical pregnancy 3 weeks after IVF/ET treatment, and the secondary endpoint is the presence of biochemical pregnancy 2 weeks after IVF/ET treatment. Safety evaluation and biomarker discovery for tacrolimus treatment in infertile women will be conducted simultaneously.

TRIAL REGISTRATION NUMBER

Japan Registry of Clinical Trials (jRCT; jRCTs031220235).

Evaluation of RABBIT risk score in Japanese patients with rheumatoid arthritis starting first bDMARDs: a validation study using the IORRA cohort data

OBJECTIVE

To examine the ability of the Rheumatoid Arthritis Observation of Biologic Therapy (RABBIT) risk score to predict the occurrence of serious infections in Japanese patients with rheumatoid arthritis (RA), after initiating their first biologic disease-modifying antirheumatic drug (bDMARD).

METHODS

We used data from the Institute of Rheumatology, Rheumatoid Arthritis (IORRA) cohort from 2008 to 2020. Patients with RA who were started on their first bDMARDs were included. Those with missing data required to calculate the score were excluded. A receiver operating characteristic (ROC) curve was used to evaluate the discriminatory ability of the RABBIT score.

RESULTS

A total of 1,081 patients were enrolled. During the one-year observational period, 23 (1.7%) patients had serious infections; the most frequent one was bacterial pneumonia (n=11, 44%). The median RABBIT score in the serious infection group was significantly higher than that in the non-serious infection group (2.3 [1.5-5.4] vs 1.6 [1.2-2.5], p<0.001). The area under the ROC curve for the occurrence of serious infections was 0.67 (95% confidence interval 0.52-0.79), suggesting that the score had low accuracy.

CONCLUSION

Our present study revealed that the RABBIT risk score did not have sufficient discriminatory ability for predicting the development of severe infections in Japanese patients with rheumatoid arthritis after initiating their first bDMARD.

The BEETS (JACCRO CC-18) trial: an observational and translational study of BRAF-mutated metastatic colorectal cancer

For BRAF V600E-mutated metastatic colorectal cancer (mCRC), the BEACON phase 3 trial showed survival benefit of triplet therapy with cetuximab (anti-EGFR antibody), encorafenib (BRAF inhibitor) and binimetinib (MEK inhibitor) as well as doublet therapy with cetuximab and encorafenib over irinotecan-based chemotherapy plus anti-EGFR antibody. Both regimens are standards of care in Japan, but definite biomarkers for predicting efficacy and selecting treatment remain lacking. The mechanisms underlying resistance to these regimens also warrant urgent exploration to further evolve treatment. This prospective observational/translational study evaluated real-word clinical outcomes with cetuximab and encorafenib with or without binimetinib for BRAF-mutated mCRC patients and investigated biomarkers for response and resistance by collecting blood samples before and after treatment. Clinical Trial Registration: UMIN000045530 (https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000051983).

Long-term safety and efficacy of mogamulizumab (anti-CCR4) for treating virus-associated myelopathy

Some carriers of human T-cell leukemia virus type 1 (HTLV-1), a retrovirus that primarily infects CD4+ T cells and causes lifelong infection, develop HTLV-1-associated myelopathy/tropical spastic paraparesis (HAM/TSP). Current treatments for HAM/TSP are insufficient with problematic long-term side effects. This study evaluated the long-term safety and efficacy of the anti-CCR4 antibody mogamulizumab in patients with HAM/TSP over a 4-year period. We conducted an open-label, extended long-term study (UMIN trial number: UMIN000019942) of a Phase 1-2a trial with mogamulizumab for HAM/TSP (UMIN000012655). The study participants were patients with corticosteroid-resistant HAM/TSP who could walk 10 m with or without assistive tools. Mogamulizumab was administered at 0.01, 0.03, 0.1, or 0.3 mg/kg at intervals of ≥8 weeks (0.01 and 0.03 mg/kg) or ≥12 weeks (0.1 and 0.3 mg/kg). HTLV-1 proviral load, cerebrospinal fluid inflammatory markers, and clinical symptoms were summarized by descriptive statistics. Missing observations were imputed using the last-observation-carried-forward method. As a post-hoc analysis, we evaluated the therapeutic effect of mogamulizumab on gait function by comparing it with contemporary control data from a HAM/TSP patient registry. Of the 21 participants in the Phase 1-2a, 18 (86%) enrolled in the long-term study and 15 (71%) continued repeated doses of mogamulizumab for 4 years. The median dose was 0.1 mg/kg after 4 years. Seventeen of 21 participants (81%) experienced grade 1-2 skin-related adverse events. Observed grade 3 drug-related adverse effects included three cases of lymphopenia and one case each of microscopic polyangiitis, elevated levels of aspartate aminotransferase, and neutropenia. Four of 21 participants (19%) developed neutralizing antibodies. After 4 years, the peripheral blood proviral load and the number of infected cells in CSF decreased by 60.7% and 66.3%, respectively. Neopterin and CXCL10 CSF concentrations decreased by 37.0% and 31.0%, respectively. Among the 18 participants, spasticity and Osame Motor Disability Score (OMDS) improved in 17 (94%) and 4 (22%), respectively. However, 10 m walking time worsened by 7.3% on average. Comparison with the contemporary control group demonstrated that mogamulizumab inhibited OMDS progression (p = 0.02). The results of the study suggest that mogamulizumab has long-term safety and inhibitory effect on lower limb motor disability progression in corticosteroid-treated patients with HAM/TSP. This will provide a basis for the application of mogamulizumab in HAM/TSP treatment.

Influence of concomitant methotrexate use on the clinical effectiveness, retention, and safety of abatacept in biologic-naïve patients with rheumatoid arthritis: Post-hoc subgroup analysis of the ORIGAMI study

OBJECTIVES

We performed post-hoc analyses of the ORIGAMI study to investigate whether concomitant methotrexate (MTX) influences the clinical outcomes of abatacept in biologic-naïve patients with rheumatoid arthritis.

METHODS

Enrolled patients (n = 325) were divided into two groups according to whether abatacept was prescribed without (MTX-) or with (MTX+) concomitant MTX. We compared the changes in Simplified Disease Activity Index (SDAI), Disease Activity Score-28 with C-reactive protein (DAS28-CRP), and Japanese Health Assessment Questionnaire (J-HAQ) through to 52 weeks of treatment, the abatacept retention rate, and safety.

RESULTS

At Week 52, the mean SDAI (8.9 vs. 8.8), DAS28-CRP (2.6 vs. 2.6), and J-HAQ (0.92 vs. 0.91) scores were comparable in the MTX- (n = 129) and MTX+ (n = 150) groups. Multivariable logistic regression revealed no significant association between MTX use and SDAI (low disease activity) or J-HAQ (minimum clinically important difference). The abatacept retention rates, estimated using the Kaplan-Meier method, were 73.2% and 66.7% in the MTX- and MTX+ groups, respectively. Adverse events occurred in 47.5% (of 139) and 52.2% (of 159) of patients in the MTX- and MTX+ groups, respectively.

CONCLUSION

The effectiveness and safety of abatacept appeared comparable with or without concomitant MTX in this real-world clinical setting.

Genetic effects of demographic bottleneck and recovery in Kinkazan Island and mainland populations of Japanese macaques (Macaca fuscata)

Populations of Japanese macaques were significantly reduced in most areas from the 1900s to the 1960s and then recovered mainly in the northeastern part of Honshu. A drastic reduction in population size reduces genetic variability through a bottleneck effect. Demographic expansion after the reduction that accumulates new mutations can reduce the bottleneck effects or drive the recovery of genetic variability. We examined the genetic status of a small island population (Kinkazan Island) and a larger mainland population (southern Tohoku) of Japanese macaques that experienced recent demographic bottlenecks and recovery using eight microsatellite loci. The two populations were significantly genetically different from each other. The Kinkazan population exhibited lower genetic variability, remarkable evidence of bottleneck (i.e., significant heterozygosity excess and lower frequency of rare alleles), and a considerably smaller effective population size based on genetic data than based on the current census size. These results indicate that the genetic status has not completely recovered from the demographic bottleneck despite a full recovery in census size on Kinkazan Island. New mutations might rarely have accumulated because of the small carrying capacity of the island. Therefore, the genetic variability of the population would have been restrained by the severe bottleneck size, small carrying capacity, and long-term isolation. On the other hand, the bottleneck effect seems to be limited in the southern Tohoku population considering higher genetic variability, non-significant heterozygosity excess in many mutation conditions, and the highest frequency of rare alleles.

Recombinase polymerase amplification using novel thermostable strand-displacing DNA polymerases from Aeribacillus pallidus and Geobacillus zalihae

Recombinase polymerase amplification (RPA) is an isothermal DNA amplification reaction at around 41 °C using recombinase (Rec), single-stranded DNA-binding protein (SSB), and strand-displacing DNA polymerase (Pol). Component instability and the need to store commercial kits in a deep freezer until use are some limitations of RPA. In a previous study, Bacillus stearothermophilus Pol (Bst-Pol) was used as a thermostable strand-displacing DNA polymerase in RPA. Here, we attempted to optimize the lyophilization conditions for RPA with newly isolated thermostable DNA polymerases for storage at room temperature. We isolated novel two thermostable strand-displacing DNA polymerases, one from a thermophilic bacterium Aeribacillus pallidus (H1) and the other from Geobacillus zalihae (C1), and evaluated their performances in RPA reaction. Urease subunit β (UreB) DNA from Ureaplasma parvum serovar 3 was used as a model target for evaluation. The RPA reaction with H1-Pol or C1-Pol was performed at 41 °C with the in vitro synthesized standard UreB DNA. The minimal initial copy numbers of standard DNA from which the amplified products were observed were 600, 600, and 6000 copies for RPA with H1-Pol, C1-Pol, and Bst-Pol, respectively. Optimization was carried out using RPA components, showing that the lyophilized RPA reagents containing H1-Pol exhibited the same performance as the corresponding liquid RPA reagents. In addition, lyophilized RPA reagents with H1-Pol showed almost the same activity after two weeks of storage at room temperature as the freshly prepared liquid RPA reagents. These results suggest that lyophilized RPA reagents with H1-Pol are preferable to liquid RPA reagents for onsite use.

Soluble programmed cell death ligand 1 predicts prognosis for gastric cancer patients treated with nivolumab: Blood-based biomarker analysis for the DELIVER trial

BACKGROUND

The clinical value of soluble forms of programmed cell death-1 (sPD-1), PD ligand 1 (sPD-L1) and cytotoxic T lymphocyte-associated protein-4 (sCTLA-4) for gastric cancer (GC) patients treated with nivolumab monotherapy has remained unknown.

METHODS

Blood samples collected before nivolumab treatment from 439 GC patients enrolled in the DELIVER (Japan Clinical Cancer Research Organisation GC-08) trial were analysed for sPD-1, sPD-L1 and sCTLA-4. Corresponding baseline clinical data were also retrieved.

RESULTS

Higher plasma levels of sPD-1 (hazard ratio [HR] = 1.27, p = 0.020), sPD-L1 (HR = 1.86, p < 0.001) and sCTLA-4 (HR = 1.33, p = 0.008) were significantly associated with shorter overall survival (OS), whereas only higher sPD-L1 levels was significantly associated with shorter progression-free survival (HR = 1.30, p = 0.008). The sPD-L1 concentration was significantly associated with the Glasgow prognostic score (GPS) (p < 0.001), but both sPD-L1 (HR = 1.67, p < 0.001) and GPS (HR = 1.39, p = 0.009 for GPS 0 versus 1; HR = 1.95, p < 0.001 for GPS 0 versus 2) were independently associated with OS. Patients with a GPS of 0 and low sPD-L1 thus showed the longest OS (median, 12.0 months) and those with a GPS of 2 and high sPD-L1 showed the shortest OS (median, 3.1 months), yielding a HR of 3.69 (p < 0.001).

CONCLUSION

Baseline sPD-L1 levels have the potential to predict survival for advanced GC patients treated with nivolumab, with the prognostic accuracy of sPD-L1 being improved by its combination with GPS.

Effects of beta-hydroxy beta-methyl butyrate calcium combined with exercise therapy in patients with cardiac disease: a study protocol for clinical trial

INTRODUCTION

The current treatment for heart disease consists of exercise therapy in addition to pharmacotherapy, nutritional support and lifestyle guidance. In general, nutritional support focuses on protein, salt and energy restrictions, with no active protein or amino acid intake in cases involving moderate or higher renal failure. From this perspective, patients with cardiac disease are at high risk of frailty.Beta-hydroxy beta-methyl butyrate (HMB) is a metabolite of leucine. HMB is widely used for muscle strengthening and can be safely ingested even by patients with renal failure. The proposed study protocol will investigate the effects of HMB-calcium (HMB-Ca) administered in combination with comprehensive cardiac rehabilitation for muscle strength, muscle mass and cardiac function in patients with cardiac disease during the convalescent period. The primary outcome will be knee extensor strength. Secondary outcomes will be gross isometric limb strength and skeletal muscle mass.

METHODS AND ANALYSIS

This study will be a single-blinded, randomised, controlled trial with parallel comparisons between two groups. The study period will be 60 days from the start of outpatient cardiac rehabilitation. Participants will be randomly divided into two groups: an HMB group consuming HMB-Ca one time per day for 60 days; and a Placebo group consuming reduced maltose once one time per day for 60 days. Exercise therapy will be performed by both groups.

ETHICS AND DISSEMINATION

The study protocol will be published in a peer-reviewed journal. Ethics approval was provided by the Showa University Clinical Research Review Board.

TRIAL REGISTRATION NUMBER

jRCTs031220139; Japan Registry of Clinical Trails.

Survival analysis among pediatric patients receiving kidney replacement therapy: a Japanese nationwide cohort study

BACKGROUND

Limited data are available on the survival and causes of death in pediatric patients with chronic kidney disease (CKD) stage 5 receiving kidney replacement therapy (KRT) in Asia.

METHODS

Data were obtained from the Japanese nationwide cross-sectional CKD stage 5 survey on pediatric patients (<20 years of age) who started KRT from 2006 to 2013. The cohort was divided into three groups according to age at the start of KRT: <1, 1-5, and 6-19 years.

RESULTS

Among the 701 children who were included, 59.3% were boys. Peritoneal dialysis was the most common initial modality of KRT (60.3%). Median age at KRT initiation was 10.2 years. Infants (<1 year old) accounted for 16.0% of the total cohort. Overall survival at 1 and 5 years was 97.2% and 92.5%, respectively. Infants had significantly lower survival rates than the other groups (hazard ratio, 5.35; 95% CI, 2.60-11.03; P < 0.001). In contrast, after the age of 1 year, the survival rate improved and did not differ from that of other age groups. The most common causes of death were infection (35.9%) and sudden death (15.4%).

CONCLUSIONS

The overall survival rate of pediatric patients with CKD stage 5 in Japan is like that in other high-income countries. Age at initiation of KRT is an important factor affecting survival since the poorest survival rate was observed in infants. Further improvement in infant dialysis therapy is still needed to improve survival of the youngest children. A higher resolution version of the Graphical abstract is available as Supplementary information.

Cost-consequence of abatacept as first-line therapy in Japanese rheumatoid arthritis patients using IORRA real-world data

OBJECTIVES

To investigate the cost-effectiveness of abatacept (ABA) as first-line (1L) therapy in Japanese rheumatoid arthritis (RA) patients using data from the Institute of Rheumatology, Rheumatoid Arthritis database.

METHODS

A decision-analytic model was used to estimate the cost per American College of Rheumatology response of at least 50% improvement (ACR50) responder and per patient in Clinical Disease Activity Index (CDAI) and Simplified Disease Activity Index (SDAI) remission from a Japanese healthcare payers' perspective over a 2-year time horizon. Clinical characteristics of patients on ABA-1L were matched with those of patients on ABA second or later line (2L+) or tumour necrosis factor inhibitor (TNFi)-1L directly or using propensity scores. Resource utilisation and medical costs were calculated from the Japan Medical Data Center claims database. Parameter uncertainty was addressed by sensitivity and subgroup analyses (age, treatment duration, Japanese version of Health Assessment Questionnaire [J-HAQ] score).

RESULTS

Incremental costs per member per month (ΔPMPM) for ABA-1L versus TNFi-1L and ABA-2L+ were -1,571 Japanese Yen (JPY) and 81 JPY, respectively. For ABA-1L versus TNFi-1L, ΔPMPM by ACR50 response was -11,715 JPY and by CDAI and SDAI remission 11,602 JPY and 47,003 JPY, respectively. Corresponding costs for ABA-1L were lower for all outcome parameters versus those for ABA-2L+. Scenario analyses showed that ABA-1L was cost-effective over TNFi-1L in patients <65 years for any outcome. Furthermore, ABA-1L was cost-effective over ABA-2L+ for all outcomes in patients with age <65 years, disease duration <5 years and J-HAQ ≥1.5.

CONCLUSIONS

ABA-1L demonstrated a favourable cost-effectiveness profile in RA patients, accruing savings for the Japanese healthcare payers.

High incidence of serious infections requiring hospitalisation in human T-cell leukaemia virus type 1-positive rheumatoid arthritis: A case-controlled observational study

OBJECTIVES

We aimed to assess the clinical features of human T-cell leukaemia virus type 1 (HTLV-1)-positive rheumatoid arthritis (RA) patients. Furthermore, we investigated the impact of HTLV-1 infection on incidences of serious infections requiring hospitalisation (SIH) and malignancies.

METHODS

A total of 150 sex- and age-matched HTLV-1-negative and 50 HTLV-1-positive RA patients were enrolled from the HTLV-1 RA Miyazaki Cohort Study. Clinical and laboratory data were collected from this cohort database. The incidence rate (IR) for SIH and malignancies from 2015 to 2020 was analysed.

RESULTS

The median age and female ratio in the study population were 70 years old and 80%, respectively. Although no differences were found in inflammatory marker values between the two groups, the patient global assessment and Health Assessment Questionnaire scores were higher in HTLV-1-positive RA patients. In HTLV-1-negative RA patients, the IR for SIH was 6.37/100 person-years (PY) and 1.32/100 PY for malignancies. In HTLV-1-positive RA patients, SIH occurred in 11.1/100 PY and malignancies in 2.46/100 PY. The crude IR ratio comparing SIH between two groups was 1.74 (95% confidence interval, 1.04-2.84), which was a significant increase.

CONCLUSIONS

HTLV-1-positive RA patients may worsen RA symptoms. HTLV-1 may be a risk factor for SIH.

Trends in Risks of Malignancies in Japanese Patients with Rheumatoid Arthritis: Analyses from a 14-year Observation of the IORRA Cohort

OBJECTIVES

To investigate the trends in risks of overall and site-specific malignancies in patients with rheumatoid arthritis (RA).

METHODS

Among Japanese patients with RA enrolled in the Institute of Rheumatology, Rheumatoid Arthritis (IORRA) cohort, all malignancies that occurred from 2000 to 2013 were extracted. The standardized incidence ratios (SIRs) and 95% confidence intervals (CIs) for overall and site-specific malignancies were calculated during three periods: pre-biologics, 2000-2004; early biologics, 2005-2009; and recent biologics, 2010-2013. Risk factors for overall and specific malignancies were analyzed using time-dependent Cox regression models.

RESULTS

Among 11,299 patients with RA (68,483 person-years), 507 malignancies were confirmed. Similar risks were observed versus the general Japanese population for overall malignancies throughout the three periods, with SIRs (95% CIs) of 0.96 (0.80-1.14) in the pre-biologics period, 0.95 (0.82-1.09) in the early biologics period, and 0.87 (0.75-1.01) in the recent biologics period. Significant increased risk for malignant lymphoma was observed throughout the observation period (SIR 4.61, 95% CI 3.58-5.85). The disease activity was a significant risk factor for overall malignancies and lung cancer.

CONCLUSION

Despite the expanding use of methotrexate and biologics, there were no increases in malignancy risk in Japanese patients with RA.

Association of low-dose glucocorticoid use and infection occurrence in systemic lupus erythematosus patients: a prospective cohort study

BACKGROUND

Infection is a major cause of mortality in patients with systemic lupus erythematosus (SLE). Therefore, minimizing the risk of infection is an important clinical goal to improve the long-term prognosis of SLE patients. Treatment with ≥7.5 mg prednisolone (PSL) or equivalent has been reported to increase the risk of infections. However, it remains unclear whether <7.5 mg PSL or equivalent dose affects the risk of infection in SLE patients. This study evaluated the association between the occurrence of infection in patients with SLE and low-dose glucocorticoid (GC) usage, especially <7.5 mg PSL or equivalent, to explore the GC dose that could reduce infection occurrence.

METHODS

This prospective cohort study included patients from the Japanese multicenter registry of patients with SLE (defined as ≥4 American College of Rheumatology 1997 revised criteria) over 20 years of age. The PSL dose was categorized as PSL 0-2.5, 2.6-5.0, 5.1-7.5, and 7.6-15.0 mg. The primary outcome was infection requiring hospitalization. We conducted a multivariable analysis using time-dependent Cox regression analysis to assess the hazard ratio of infection occurrence compared with a dose of 0-2.5 mg PSL or equivalent in the other three PSL dose groups. Based on previous reports and clinical importance, the covariates selected were age, sex, and concurrent use of immunosuppressants with GC. In addition, two sensitivity analyses were conducted.

RESULTS

The mean age of the 509 SLE patients was 46.7 years; 89.0% were female, and 77.2% used multiple immunosuppressants concomitantly. During the observation period, 52 infections requiring hospitalization occurred. The incidence of infection with a PSL dose of 5.0-7.5 mg was significantly higher than that in the PSL 0-2.5 mg group (adjusted hazard ratio: 6.80, 95% confidence interval: 2.17-21.27). The results of the two sensitivity analyses were similar.

CONCLUSIONS

Our results suggested that the use of 5.0-7.5 mg PSL or equivalent could pose an infection risk in SLE patients. This finding indicates that PSL dose should be reduced to as low as possible in SLE patients to avoid infection.

Association of Disease Activity Using SDAI and DAS-28, but not JADAS-27, with Subsequent Changes in Physical Function in Adult Patients with Juvenile Idiopathic Arthritis

OBJECTIVES

To investigate an optimal composite score for disease activity in adult juvenile idiopathic arthritis (JIA) from the viewpoint of the subsequent changes in physical function.

METHODS

Patients with JIA under the following conditions were enrolled: 1) disease onset < 18 years; 2) registered in the Institute of Rheumatology, Rheumatoid Arthritis database by Tokyo Women's Medical University for the first time between 2000 and 2020; and 3) ≥18 years old at the time of registration. The baseline of each patient was their initial entry into the database. The Simplified Disease Activity Index (SDAI), Disease Activity Score using 28 joints (DAS28), and Juvenile Arthritis Disease Activity Score (JADAS)-27 were compared. Patients were stratified according to mean disease activity scores in each index during the first year from baseline. Trends of estimated mean change in Japanese-HAQ score (ΔJ-HAQ) from baseline to 2 years later was examined across the stratified groups of each index.

RESULTS

We included 294 eligible individuals (median age at onset, 14.0 years; rheumatoid factor positive in 64.7%). A significant increasing trend of the estimated mean ΔJ-HAQ at 2 years after baseline was observed along with an increase in the mean disease activity during the first year measured using DAS28 (p = 0.01) and SDAI (p = 0.018), but not using JADAS-27.

CONCLUSIONS

Disease activity measured using SDAI and DAS28, but not using JADAS27, was significantly associated with subsequent changes in physical function in transitional and adult patients with JIA.

Subjective Symptoms Contributing to the Quality of Life of Rheumatoid Arthritis Patients with Clinical Remission from the IORRA Database

OBJECTIVES

To explore patient-reported outcomes (PROs) related to quality of life (QOL) in patients with rheumatoid arthritis (RA) who achieved clinical remission.

METHODS

In the Institute of Rheumatology, Rheumatoid Arthritis (IORRA) dataset, RA patients over 18 years old who met the simplified disease activity index (SDAI) remission criteria in April 2017 were enrolled in this analysis. Pain-visual analogue scale (pain-VAS) (0-100 mm), Patient's Global Assessment of Disease Activity (0-100 mm), Japanese version of Health Assessment Questionnaire, duration of morning joint stiffness, and fatigue (Checklist Individual Strength 8R [CIS]) were the tools used to evaluate PROs. To assess the contribution of each PRO to the European QOL-5 Dimensions-5 Level (EQ-5D-5L) score, analysis of variance was conducted.

RESULTS

Among the 2,443 patients with remission, the mean EQ-5D-5L was 0.9. The mean pain VAS and patients' global assessment of disease activity (Pt-GA) were 7.2 and 7.4, respectively. Factors that significantly contributed to the EQ-5D-5L were pain-VAS (48.8%), CIS score (18.1%), and Pt-GA (15.6%). Around 82.5% of the variance in EQ-5D-5L were explained by the three PROs.

CONCLUSION

This study demonstrated that pain-VAS, CIS, and Pt-GA were significant contributors to the EQ-5D-5L score in patients with RA who achieved SDAI remission.

POS1298 RELATIONSHIP BETWEEN DISEASE ACTIVITY BY JADAS-27, SDAI, AND DAS-28 AND SUBSEQUENT CHANGES IN PHYSICAL FUNCTION IN ADULT PATIENTS WITH JUVENILE IDIOPATHIC ARTHRITIS

Background

Juvenile Arthritis Disease Activity Score (JADAS) has been developed as a composite disease activity score specific to Juvenile idiopathic arthritis (JIA). Evaluation of disease activity with a composite measure associated with subsequent changes in structural damage of joints and physical function is necessary for the proper management of Rheumatoid Arthritis (RA) with treat-to-target strategy, and this concept should be considered for patients with JIA in transition and adulthood as well. However, the usefulness of JADAS-27 and other composite measures for RA in these patients has been scarecely investigated. Additionally, JADAS-27 is unfamiliar to non-pediatric rheumatologists.

Objectives

We aimed to investigate an optimal composite score for disease activity in adult JIA from the viewpoint of the subsequent changes in physical function.

Methods

Patients diagnosed with JIA with the following conditions were enrolled: 1) disease onset at age < 18 years; 2) registered in the IORRA database for the first time between 2000 and 2020; and 3) ≥18 years old at the time of IORRA registration. The baseline of each patient was their initial entry into the IORRA database. The Simplified Disease Activity Index (SDAI), Disease Activity Score using 28 joints (DAS28), and JADAS-27 were compared. The patients were stratified into four disease activity categories: remission/inactive disease, low disease activity, moderate disease activity, and high disease activity according to mean disease activity scores in each index during the first year from baseline, and mean changes in J-HAQ (mean ΔJ-HAQ) during 2 years from baseline in each disease activity group were estimated using the linear mixed effect model to account for correlations of repeated measures without filling in the missing data after adjusting for sex, age, and disease duration.

Results

We included 294 eligible individuals (median age at onset, 14.0 years; rheumatoid factor positive in 64.7%). The median age at baseline and disease duration was 33.8 (24.1–47.7) years and 21.0 (11.0–34.0) years, respectively. The J-HAQ was completed in all 294 patients, and 171 (58.1%) had a score of less than 0.5 at baseline, which is defined as functional remission. During the 2-year observation period, the median J-HAQ of all patients remained unchanged. There was a trend toward improvement in disease activity over time in all three composite scores. Some differeces were obsered across the three indeces: a higher proportion of patients with high disease activity and a lower proportion of patients in remission/inactive disease were observed with JADAS-27 versus SDAI and DAS28. A significant increasing trend of the estimated mean ΔJ-HAQ at 2 years after baseline was observed along with an increase in the mean disease activity during the first year measured using DAS28 (p = 0.01) and SDAI (p = 0.018), but not using JADAS-27 as shown in Table 1.

Table 1.

Association of the mean disease activity categories during the first year after baseline and mean changes in J-HAQ during the two years after baseline

(n = 294)SDAIDAS28JADAS-27Remission/inactive disease0.019 [−0.190, 0.228]0.053 [0.024, 0.130]0.081 [−0.072, 0.234]LDA0.091 [−0.150, 0.332]0.102 [−0.013, 0.217]0.054 [−0.102, 0.210]MDA or HDA0.155 [−0.286, 0.596]0.136 [0.030, 0.242]0.087 [0.022, 0.152]p-value for trend0.0190.0100.115

(Data are expressed as J-HAQ [95% confidence interval]. P-value less than 0.05 indicate a significant trend of the mean ΔJ-HAQ during the two years after baseline. LDA low disease activity; MDA moderate disease activity; HDA high disease activity)

Conclusion

Disease activity measured using SDAI and DAS28, but not using JADAS27, was significantly associated with subsequent changes in physical function in transitional and adult patients with JIA. This study support the use of SDAI and DAS28, but not JADAS27, in assessing disease activity in these patients to adjust treatments for preventing future deterioration of physical function.

Disclosure of Interests

Takako Miyamae: None declared, Eisuke Inoue Speakers bureau: EI has received lecture fees or consulting fees from Bristol Myers Squibb Co., Ltd., Pfizer Japan Inc., and Nippontect systems Co. Ltd., Eiichi Tanaka Speakers bureau: ET has received lecture fees or consulting fees from AbbVie Japan GK, Asahi Kasei Corp., Astellas Pharma Inc., Ayumi Pharmaceutical Co., Bristol Myers Squibb Co., Ltd., Celltrion Healthcare Japan CO, LTD., Chugai Pharmaceutical Co., Ltd., Daiichi-Sankyo, Inc., Eisai Co., Ltd., Eli Lilly Japan K.K., GlaxoSmithKline K.K., Kyowa Pharma Chemical CO., Ltd., Janssen Pharmaceutical K.K., Mitsubishi Tanabe Pharma Co., Mochida Pharmaceutical CO., Ltd., Nippon Kayaku Co., Ltd., Pfizer Japan Inc., Takeda Pharmaceutical Co., Ltd., Teijin Pharma Ltd, and UCB Japan Co. Ltd., Tomohiro Kawabe: None declared, Katsunori Ikari: None declared, Masayoshi Harigai Speakers bureau: MH has received speaker’s fee from AbbVie Japan GK, Astra Zeneca K. K., Ayumi Pharmaceutical Co., Boehringer Ingelheim Japan, Inc., Bristol Myers Squibb Co., Ltd., Chugai Pharmaceutical Co., Ltd., Eisai Co., Ltd., Eli Lilly Japan K.K., GlaxoSmithKline K.K., Gilead Sciences Inc., Janssen Pharmaceutical K.K., Kissei Pharmaceutical Co., Ltd., Nippon Kayaku Co., Ltd., Nippon Shinyaku Co., Ltd., Novartis Japan, Pfizer Japan Inc., CIMIC Holdings Co., Ltd., Mitsubishi Tanabe Pharma Co., Teijin Pharma Ltd and UCB Japan., Consultant of: MH is a consultant for AbbVie, Boehringer Ingelheim, Bristol Myers Squibb Co., Kissei Pharmaceutical Co., Ltd., and Teijin Pharma., Grant/research support from: MH has received research grants from AbbVie Japan GK, Asahi Kasei Corp., Astellas Pharma Inc., Ayumi Pharmaceutical Co., Boehringer Ingelheim Japan, Inc., Bristol Myers Squibb Co., Ltd., Chugai Pharmaceutical Co., Daiichi-Sankyo, Inc., Eisai Co., Ltd., Kaken Pharmaceutical Co., Ltd., Kissei Pharmaceutical Co., Ltd., Mitsubishi Tanabe Pharma Co., Nippon Kayaku Co., Ltd., Sekisui Medical, Taisho Pharmaceutical Co., Ltd., and Teijin Pharma Ltd.

AB0332 EVALUATION OF THE RABBIT RISK SCORE IN JAPANESE PATIENTS WITH RHEUMATOID ARTHRITIS NEWLY TREATED WITH BIOLOGIC DMARDS: DATA FROM THE IORRA COHORT

Background

Serious infection is one of the most critical adverse events in patients with rheumatoid arthritis (RA) using biologic disease-modifying antirheumatic drugs (bDMARDs). During the first year, infections occur more frequently. Therefore, estimating the risk of developing a serious infection is important for the safe use of bDMARDs. The Rheumatoid Arthritis Observation of Biologic Therapy (RABBIT) risk score predicted the incidence rate of serious infection during 1 year in patients with RA taking DMARDs. Moreover, it has been validated using data from various observational cohort studies and nationwide registries with favorable results, with a reported area under the receiver operating characteristic curve (AUROC) of 0.68–0.871–5. However, the RABBIT risk score has not been validated in RA patients starting a first bDMARD.

Objectives

To investigate the discriminatory ability of the RABBIT risk score for predicting the development of serious infection during 1 year after starting first bDMARDs in Japanese patients with RA using data from the Institute of Rheumatology, Rheumatoid Arthritis (IORRA) cohort.

Methods

The IORRA cohort is a large observational cohort at the Institute of Rheumatology, Tokyo Women’s Medical University. Japanese patients with RA visiting our institute were registered and clinical parameters were assessed biannually. This study enrolled patients with RA who were registered in the IORRA cohort and treated with a first bDMARD. Patients who were missing data needed to calculate the RABBIT risk score were excluded. The RABBIT risk score was calculated using the patient’s age, comorbidities, Japanese-Health Assessment Questionnaire score, history of previous infections, and types of DMARDs used. Serious infections were defined as those requiring hospitalization or treatment with intravenous antibiotics. The occurrence of serious infection during 1 year after starting the first bDMARDs was identified using data from the biannual IORRA cohort and confirmed using medical records. The discriminatory ability of the RABBIT risk score was analyzed by the AUROC.

Results

A total of 1,081 patients with RA and a median age of 55.3 years, in which females were the majority (88.2%), were included. Serious infection occurred in eight patients during 1 year before starting their first bDMARDs. The number of patients starting a TNF inhibitor, IL-6 inhibitor, and abatacept were 830 (76.8%), 170 (15.7%), and 81 (7.5%), respectively. A total of 23 patients (1.7%) had serious infections during 1 year after starting the first bDMARD; the most frequent infection was pneumonia (n=16, 69.6%). The median RABBIT score was 2.3 (IQR 1.6–5.4) in patients with serious infections during the follow-up period, and 1.6 (IQR 1.2–2.5) in patients without serious infections. The discriminatory ability of the RABBIT risk score was slightly poor, with an AUROC of 0.67 (95% CI, 0.52– 0.79).

Conclusion

The RABBIT risk score is highly practical; however, our present study suggested that some adjustments may be required to predict the risk of serious infection in Japanese patients with RA starting a first bDMARD.

Figure 1.

ROC curve of serious infection and RABBIT score with an AUROC of 0.67 (95% CI, 0.52– 0.79).

Disclosure of Interests

Tomoaki Higuchi: None declared, Eiichi Tanaka Speakers bureau: Abbvie, Asahi Kasei pharma co., Bristol Myers Squibb, Chugai Pharmaceutical, Daiichi Sankyo Co., Eisai Pharmaceutical, Janssen Pharmaceutical K.K., Nippon Kayaku, Pfizer, Takeda Pharmaceutical, Taisho Toyama Pharmaceutical Co., and UCB Pharma., Paid instructor for: Abbvie, Asahi Kasei pharma co., Bristol Myers Squibb, Chugai Pharmaceutical, Daiichi Sankyo Co., Eisai Pharmaceutical, Janssen Pharmaceutical K.K., Nippon Kayaku, Pfizer, Takeda Pharmaceutical, Taisho Toyama Pharmaceutical Co., and UCB Pharma., Eisuke Inoue Speakers bureau: Bristol-Meyers and Pfizer, Consultant of: Nippontect systems, Mai Abe: None declared, Kumiko Saka: None declared, Eri Sugano: None declared, Naohiro Sugitani: None declared, Yoko Shimizu: None declared, Moeko Ochiai: None declared, Rei Yamaguchi: None declared, Katsunori Ikari Speakers bureau: Asahi Kasei Pharma Corp., Astellas Pharma Inc., AbbVie Japan GK, Ayumi Pharmaceutical Co., Bristol Myers Squibb Co., Ltd., Chugai Pharmaceutical Co., Ltd., Eisai Co., Ltd., Eli Lilly Japan K.K., Janssen Pharmaceutical K.K., Kaken Pharmaceutical Co. Ltd., Mitsubishi Tanabe Pharma Corp. Pfizer Japan Inc., Takeda Pharmaceutical Co. Ltd., Teijin Pharma Ltd and UCB Japan Co. Ltd., Yamanaka Hisashi: None declared, Masayoshi Harigai Speakers bureau: AbbVie Japan, Ayumi, Boehringer Ingelheim Japan, Bristol-Myers Squibb, Chugai, Eisai, Eli Lilly Japan, GlaxoSmithKline, Kissei, Pfizer Japan Inc, Takeda, Teijin, Consultant of: AbbVie Japan, Boehringer Ingelheim Japan, Bristol-Myers Squibb, Kissei, Teijin, Grant/research support from: AbbVie Japan, Asahi Kasei, Astellas, Ayumi, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Kissei, Mitsubishi Tanabe, Nippon Kayaku, Sekiui Medical, Shionogi, Taisho, Takeda, Teijin.

Regular weighing to prevent excessive gestational weight gain: a study protocol for a systematic review and meta-analysis

BACKGROUND

Excessive weight gain during pregnancy results in maternal and fetal complications and could further impact offspring. The evidence regarding the association between regular weighing during the antenatal period and excessive weight gain is limited.

METHODS

We will systematically review individual and cluster randomized controlled trials that evaluated regular weighing as an intervention compared to weighing only at the first booking of the antenatal visit. Trials that assessed the effectiveness of exercise, diet, or other behavioral interventions will be excluded. Pregnant women with a singleton pregnancy and no preexisting health complications are eligible for the review. The primary outcome will be the proportion of women at term who exceed the upper limit of the target range of weight as defined by the guidelines or recommendations for the population. We will search MEDLINE (via PubMed), Embase (via EMBASE.com ), Scopus, the Cumulative Index to Nursing and Allied Health Literature (CINAHL via EBSCO), The Cochrane Central Register of Controlled Trials (CENTRAL) and the trial protocol registers, ClinicalTrials.gov , and the International Clinical Trials Registry Platform (ICTRP) search portal. Full-text articles, unpublished studies, and ongoing trials reported in any language will be included. Two review authors will independently examine and screen for eligible studies and extract data for synthesis.

DISCUSSION

We will discuss the effectiveness of regular weighing as a single intervention on reducing the proportion of women who have excessive gestational weight gain. This study will provide key information for countries to develop guidelines on antenatal care and strategies to tackle excessive gestational weight gain. We will create a "Summary of findings" table (Summary of findings table 1) according to the methods described in the Cochrane Handbook for Systematic Reviews of Interventions.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020212581.

Growth differentiation factor 15 as a novel diagnostic and therapeutic marker for autoimmune hepatitis

Growth differentiation factor 15 (GDF15) has been reported to be associated with fibrosis and cancer in liver disease. Diagnosis of autoimmune hepatitis (AIH) is often difficult because of the lack of specific markers. We investigated whether GDF15 is useful for diagnosing AIH and determined its therapeutic effects. We enrolled 171 Japanese patients as follows: AIH (n = 45), hepatitis B (HB) (n = 17), hepatitis C (HC) (n = 15), primary biliary cholangitis (PBC) (n = 20), and 74 healthy controls. Serum GDF15 levels were measured, and immunohistological analyses of GDF15 were performed using liver tissue of AIH patients. (1) GDF15 levels (pg/ml) were higher in AIH (1994.3 ± 1258.0) and HC (1568.0 ± 822.3) than in HB (953.2 ± 871.4), PBC (643.9 ± 247.0), and controls (475.3 ± 145.3) (p < 0.0001), as well as in cirrhosis patients (n = 31) than in non-cirrhosis patients (n = 66) (1926.6 ± 1026.0 vs. 1249.1 ± 1124.1, p < 0.0001). In non-cirrhosis patients, GDF15 levels were higher in AIH (1914.0 ± 1327.2) than in HC (955.7 ± 502.7), HB (519.3 ± 197.5), and PBC (643.9 ± 247.0) (p < 0.0001). (2) GDF15 was positively correlated with M2BPGi (r = 0.7728), total bilirubin (r = 0.6231), and PT-INR (r = 0.6332). (3) GDF15 levels could be used to distinguish AIH from other liver diseases in non-cirrhosis patients, with an area under the curve of 0.9373 (sensitivity 93.6%, specificity 79.3%, cut-off value 931.3). (4) GDF15 in AIH decreased after treatment. (5) Immunohistological analyses in AIH liver tissues revealed that GDF15 was strongly expressed in inflammatory cells, hepatic cytoplasm, and sinusoidal endothelial cells, but decreased after treatment. GDF15 is a novel diagnostic marker for AIH and is also expected to be a therapeutic marker for AIH.Clinical Trials Registration: The study protocol was approved by the institutional review board of Kurume University (Approval No.: 19049).

Surgical Intervention for Patients With Rheumatoid Arthritis is Declining Except for Foot and Ankle Surgery: A Single-Center, 20-Year Observational Cohort Study

OBJECTIVE

A global downward trend in the number of rheumatoid arthritis (RA)-related surgeries has been reported. The purpose of our study was to investigate the latest trends in RA-related surgeries in a single-center Japanese RA cohort.

METHODS

This study was a retrospective analysis of RA-related surgeries between 2001 and 2020 in the Institute of Rheumatology Rheumatoid Arthritis cohort. An average of 4,944 patients per semiannual survey was included in the study. The primary goal was to analyze the half-year period prevalence proportion (HPP) of RA-related surgeries in a 20-year period, and the secondary goal was to analyze the HPP of surgeries by site or by categories of disease activity.

RESULTS

There has been a downward trend in the HPP of RA-related surgeries in the 20-year study period. The total HPP of RA-related surgeries decreased by 50.3% during the 20-year study period. There was a significant decrease in knee, hip, shoulder/elbow, and hand procedures. Only foot/ankle joint surgeries significantly increased in volume during this period (p=0.001). The HPP of RA-related surgeries remained unchanged in patients with remission or low disease activity.

CONCLUSION

The number of RA-related surgeries decreased over a 20-year period, but foot/ankle joint surgeries increased in the site-specific evaluation.

Host-related biomarkers including gut microbiome to predict toxicities of nivolumab in advanced gastric cancer: DELIVER trial (JACCRO GC-08)

245

Background: Nivolumab monotherapy demonstrated survival benefit in previously treated gastric cancer (GC) patients (pts) (Kang YK, et al. Lancet 2017) and was involved into standard of care in advanced GC. Immune-related adverse events (irAEs) were observed in about 10% of pts treated with immune-check point inhibitor. Several studies revealed that the toxicities of anti-PD-1-based immunotherapy was associated with composition of gut microbiome, but little is known about GC. We therefore investigated whether host-related factors including genomic information in gut microbiome will serve as predictors for nivolumab-induced toxicities in advanced GC. Methods: The observational/translational study (DELIVER trial: UMIN000030850) has enrolled 501 pts with advanced GC treated with nivolumab alone from March 2018 to August 2019 to evaluate real-world data and discover host-related biomarkers using fecal and blood samples which were collected before treatment with nivolumab [Takahashi Y, et al. Gastric Cancer 2021]. In the biomarker part, the relationship between markers of microbiome/genetic polymorphisms and AEs was evaluated as previously planned for the secondary endpoint. Genomic data in fecal samples and single nucleotide polymorphisms (SNPs) in blood samples were measured by genome shotgun sequence and microarray, respectively, at central lab. Genera and pathway with a median difference of ≥0.01 of normalized value and P-value < 0.05 of t-test were picked up from the first 200 pts (training cohort) and then confirmed in the last 301 pts (validation cohort). Comparison analysis between pts with and without each AE was performed for SNPs in all pts. Results: In the safety population with 487 pts, at the time of 1 year after last patient enrollment, each AE was 87 for diarrhea, 44 for skin eruptions, 29 for hypothyroidism, and 11 for adrenal disorders. In the analysis of gut microbiome, 180 of 200 pts and 257 of 301 pts were available for massive metagenomic in the training cohort and validation cohort, respectively. Four hundred-forty pts were available for analyzing SNPs. Arthrobacter and fatty acid metabolism pathway were identified for candidate markers to predict skin AEs in the training cohort ( p= 0.021 and p= 0.024, respectively) and then confirmed in the validation cohort ( p= 0.011 and p= 0.011, respectively). Patient with high level of the genus or pathway experienced skin AEs more frequently. The SNPs analysis indicated the significant association of genetic polymorphisms of NLRC5 and IL6R with skin toxicities and NOTCH1 and SEMA4D with diarrhea. Conclusions: Genus of Arthrobacter and fatty acid metabolism pathway in gut microbiome predict skin toxicities in advanced GC treated with nivolumab. In addition, some SNPs may potentially become markers for skin toxicities and diarrhea of nivolumab. Clinical trial information: UMIN000030850.

Geographic variations in rheumatoid arthritis treatment in Japan: A nationwide retrospective study using the national database of health insurance claims and specific health checkups of Japan

OBJECTIVES

To characterize the treatments for rheumatoid arthritis (RA) among institution types and prefectures in Japan.

METHODS

Using the National Database of Health Insurance Claims and Specific Health Checkups of Japan in the 2017 fiscal year, we investigated disease-modifying antirheumatic drug (DMARD) and oral corticosteroid prescription trends across 825 thousand RA patients. These data were compared between specialized and non-specialized institutions and by prefecture. RA specialized institutions (SIs) were defined as either institutions registered in the rheumatology training program at the Japan College of Rheumatology or institutions where board-certified rheumatologists were employed.

RESULTS

The overall percentage of patients who never visited an SI was 31.8% and increased with age (16-29 years old = 15.6%; ≥80 years = 42.8%). In twelve prefectures (25.5%), the proportions of patients who never visited an SI were at least 10% higher than the overall average. The proportions of patients who only visited SIs and were prescribed methotrexate and biological DMARDs were ranged from 51.9-72.9% and 19.5-33.2%, respectively. However, those of patients who had never visited an SI and were prescribed those medications were 44.0-71.6% and 7.2-28.0%, respectively.

CONCLUSIONS

This is the first study evaluating the trends in RA treatments by prefecture and institution specialty by using the NDB Japan. Opportunities of patients with RA for visiting SI was unevenly distributed in Japan, affecting some aspects of treatment provided.

Real-world effectiveness of nivolumab in advanced gastric cancer: the DELIVER trial (JACCRO GC-08)

BACKGROUND

There is no large real-world data regarding efficacy and safety of immunotherapy in gastric cancer (GC). Although some tumors can grow rapidly after immunotherapy, the patient proportions and survival outcomes are unclear in GC.

METHODS

A multicenter, prospective observational study was performed to evaluate clinical outcomes including survival time, safety, and tumor behavior of nivolumab treatment for patients with advanced GC. Primary endpoint was overall survival (OS), and secondary endpoints included response rate (RR), disease control rate (DCR), progression-free survival (PFS), tumor growth rate (TGR) at first evaluation, and safety.

RESULTS

Of 501 enrolled patients, 487 were evaluable (median age 70 years, 71% male, performance status 0/1/2 [42%/44%/14%], 21% HER2-pos, 42% patients with ascites). Median OS was 5.82 months (95% CI 5.29-7.00) with a 1-year survival rate of 30% and median PFS of 1.84 months (95% CI 1.71-1.97). The DCR was 39.4% and the RR was 14.2% (95% CI 10.3-18.8) in 282 patients with measurable lesions. In 219 patients evaluable for TGR, 20.5% were identified as hyperprogressive disease (HPD). OS from the first evaluation of patients with HPD was shorter compared with non-HPD (HR 1.77, 95% CI 1.25-2.51, P = 0.001), but it was not worse than that of patients with progression and non-HPD (HR 1.05, 95% CI 0.72-1.53, P = 0.8). A multivariate analysis revealed the presence of peritoneal metastasis was a prognostic factor for OS and PFS.

CONCLUSIONS

Our real-world data demonstrated the comparable survival time to a previous clinical trial and revealed the frequency and prognosis of patients with HPD in advanced GC treated with nivolumab.

Validation of the predictive accuracy of health-state utility values based on the Lloyd model for metastatic or recurrent breast cancer in Japan

INTRODUCTION

Although there is a lack of data on health-state utility values (HSUVs) for calculating quality-adjusted life-years in Japan, cost-utility analysis has been introduced by the Japanese government to inform decision making in the medical field since 2016.

OBJECTIVES

This study aimed to determine whether the Lloyd model which was a predictive model of HSUVs for metastatic breast cancer (MBC) patients in the UK can accurately predict actual HSUVs for Japanese patients with MBC.

DESIGN

The prospective observational study followed by the validation study of the clinical predictive model.

SETTING AND PARTICIPANTS

Forty-four Japanese patients with MBC were studied at 336 survey points.

METHODS

This study consisted of two phases. In the first phase, we constructed a database of clinical data prospectively and HSUVs for Japanese patients with MBC to evaluate the predictive accuracy of HSUVs calculated using the Lloyd model. In the second phase, Bland-Altman analysis was used to determine how accurately predicted HSUVs (based on the Lloyd model) correlated with actual HSUVs obtained using the EuroQol 5-Dimension 5-Level questionnaire, a preference-based measure of HSUVs in patients with MBC.

RESULTS

In the Bland-Altman analysis, the mean difference between HSUVs estimated by the Lloyd model and actual HSUVs, or systematic error, was -0.106. The precision was 0.165. The 95% limits of agreement ranged from -0.436 to 0.225. The t value was 4.6972, which was greater than the t value with 2 degrees of freedom at the 5% significance level (p=0.425).

CONCLUSIONS

There were acceptable degrees of fixed and proportional errors associated with the prediction of HSUVs based on the Lloyd model for Japanese patients with MBC. We recommend that sensitivity analysis be performed when conducting cost-effectiveness analyses with HSUVs calculated using the Lloyd model.

Impact of Concomitant Chronic Kidney Disease on Hospitalized Infections and Remission in Patients with Rheumatoid Arthritis: Results from the IORRA Cohort

OBJECTIVE

To investigate the impact of concomitant chronic kidney disease (CKD) on unfavourable clinical events and remission in Japanese patients with rheumatoid arthritis (RA).

METHODS

We included 5,103 patients with RA with CKD from the Institute of Rheumatology Rheumatoid Arthritis (IORRA) cohort in 2012. CKD stages were classified into four groups: CKD with normal eGFR ≥60 ml/min/1.73 m2 and proteinuria; mild CKD, eGFR ≥45-<60; moderate CKD, eGFR ≥30-<45; and severe CKD, eGFR <30. We assessed the association between concomitant CKD and the occurrence of unfavourable clinical events or achieving remission during a 5-year observational period.

RESULTS

Of the 5,103 patients with RA, 686 (86.6%) had CKD. Concomitant CKD was associated with hospitalized infections (adjusted hazard ratio [aHR] 1.52, 95% confidence interval [CI] 1.07-2.13, p=0.02), especially in the moderate to severe CKD group (aHR 1.93, 95% CI 1.12-3.13, p=0.02). Of all subjects, 2,407 (47.2%) had active RA at baseline and 401 (16.7%) had CKD. Concomitant CKD was also associated with failure of achieving remission (aHR 0.82, 95% CI 0.68-0.99, p=0.04).

CONCLUSION

Concomitant CKD was a risk factor for hospitalized infections in Japanese patients with RA and failure of achieving remission in patients with active RA.