Measuring the digital divide among people with severe mental ill health using the essential digital skills framework

AIMS

Amid the vast digitalisation of health and other services during the pandemic, people with no digital skills are at risk of digital exclusion. This risk might not abate by the end of the pandemic. This article seeks to understand whether people with severe mental ill health (SMI) have the necessary digital skills to adapt to these changes and avoid digital exclusion.

METHODS

Two hundred and forty-nine adults with SMI across England completed a survey online or offline. They provided information on their digital skills based on the Essential Digital Skills (EDS) framework, sociodemographic information, and digital access. This is the first time that the EDS is benchmarked in people with SMI.

RESULTS

42.2% had no Foundation Skills, and 46.2% lacked skills for daily life (lacking Foundation or Life Skills). 23.0% of those working lacked skills for professional life (lacking Foundation or Work Skills). The most commonly missing skills were handling passwords and using the device settings (Foundation Skills) and online problem solving (Skills for Life). People were interested in learning more about approximately half of the skills they did not have. People were more likely to lack Foundation Skills if they were older, not in employment, had a psychosis-spectrum disorder, or had no Internet access at home.

CONCLUSION

A significant portion of people with SMI lacked Foundation Skills in this objective and benchmarked survey. This points to a high risk for digital exclusion and the need for focused policy and tailored health sector support to ensure people retain access to key services and develop digital skills and confidence. To our knowledge, this is the first time this has been described using the EDS framework. Services, including the National Health Service (NHS), need to be aware of and mitigate the risks.

Implementation of L4 Automation for Patient-Specific Quality Assurance Using the AUTOFRAME Platform and a Robotic Mechanism

PURPOSE/OBJECTIVE(S)

The AUTOFRAME platform has been previously developed for automating clinical workflows and has achieved L3 automation for patient-specific quality assurance (PSQA). The aim of this study is to further develop the platform to achieve L4 automation, which extends AUTOFRAME to operate Varian's control console (VCC) for the linear accelerator. The goal is to automate all PSQA operations outside of the treatment room.

MATERIALS/METHODS

The automated stages, listed in Table 1, are ranging from L0 to L5. The current study focuses on L4 automation of PSQA, which uses a 6-axis robot arm to control buttons on the VCC. The robotic arm is mounted on a custom frame that is attached onto the VCC to maintain its relative position. The arm is controlled through python scripts, which is run on a raspberry pi and communicates with the AUTOFRAME platform via the PyFlow and AutoFlow subsystems. This integration allows the robotic arm to receive commands from AutoFlow and execute them through PyFlow, activating real-time button-pressing actions.

RESULTS

The integrated L4 system was tested using real PSQA verification plans, which involved a minimum of 4 actions and a maximum of 9 actions on the VCC, including a couch kick that required overriding the couch position. The results showed that the 6-axis arm was able to correctly execute the action groups and guide the robotic arm to consistently press and hold each button with sufficient force and accuracy. All buttons on the VCC, including the Motion-enable, Preparing, Readying, and Delivering buttons, were correctly pushed and held according to the PSQA steps. The system successfully delivered all beams without interruption, and all beam delivery data was collected by the detector for PSQA analysis.

CONCLUSION

The study has further developed the AUTOFRAME platform for L4 automation of PSQA procedures can be achieved. The robotic arm is capable of pushing all required buttons, eliminating all human interactions on the VCC. When combined with previous L0-L3 automations, this will move towards full automation of PSQA procedures. Future work will focus on improving the system's flexibility, stability, and extending its operations to other QA tasks.

Auto Assistant VMAT Planning with HID Automation

PURPOSE/OBJECTIVE(S)

To develop a complete, robust, adaptable and fully customizable software interface for assisting treatment planning procedures on FDA approved commercial system. This will standardize treatment planning process and provide opening interface to other third-party clinical software packages, and introduce AI inference to optimize plan without breaking current clinical planning workflow.

MATERIALS/METHODS

Based on our clinical planning workflow, Varian Eclipse TPS were used. The general HID interface AUTOFLOW was developed with scripting language AutoIt and includes optical character reorganization (OCR) ability. The AUTOFLOW is fully customizable and adaptable for different VMAT planning process. The planning workflow and objective constraints template defined by Northwell health, CFAM are applied. AUTOFLOW operates automatically 3 standard planning interfaces (contouring, external beam planning and optimization) of Eclipse based on information in action tables. The information in the tables, such as auxiliary structures, field set up and initial optimization parameters, can be preset according to the plan template or from other 3rd party packages. Based on Northwell CFAM clinical planning protocol, the planning starts from post-contour approval. AUTOFLOW operates Eclipse to create auxiliary structures, set up planning fields then initiate plan optimization. During the optimization, the AUTOFLOW fills the constraint parameters and monitor the objective goals achievement by OCR. The updated parameters are introduced with our developing machine learning package. The whole planning process were assisted by AUTOFLOW automatically, while the planner can intercept the planning process as need.

RESULTS

The general interface, AUTOFLOW was developed and applied to automatically assist the VMAT procedure in prostate cases. For each prostate case, more than 213 human HID operations on computers were removed from the plan procedure in our CFAM planning protocol. 12 prostate cases without manual interception were tested. The interface succeeds to reducing the VMAT planning time and planner still own the planning control.

CONCLUSION

The AUTOFLOW software interface can be used to perform VMAT planning in current commercial clinical planning system. It can automatically assist planner operation and provide standard interface to 3rd party software packages. The future works will focus on building a cohesive UI, reducing the time further by improving the prediction of optimization parameters and other treatment sites.

Measurement of the N170 during facial neuromuscular electrical stimulation (fNMES)

BACKGROUND

Studies on facial feedback effects typically employ props or posed facial expressions, which often lack temporal precision and muscle specificity.

NEW METHOD

Facial Neuromuscular Electrical Stimulation (fNMES) allows for a controlled influence of contractions of facial muscles, and may be used to advance our understanding of facial feedback effects, especially when combined with Electroencephalography (EEG). However, electrical stimulation introduces significant interference that can mask underlying brain dynamics. Whether established signal processing methods can allow for a reduction of said interference whilst retaining effects of interest, remains unexplored.

RESULTS

We addressed these questions focusing on the classic N170 visual evoked potential, a face-sensitive brain component: 20 participants viewed images of houses, and of sad, happy, and neutral faces. On half of the trials, fNMES was delivered to bilateral lower-face muscles during the presentation of visual stimuli. A larger N170 amplitude was found for faces relative to houses. Interestingly, this was the case both without and during fNMES, regardless of whether the fNMES artefact was removed or not. Moreover, sad facial expressions elicited a larger N170 amplitude relative to neutral facial expressions, both with and without fNMES.

COMPARISON WITH EXISTING METHODS

fNMES offers a more precise way of manipulating proprioceptive feedback from facial muscles, which affords greater diversity in experimental design for studies on facial feedback effects.

CONCLUSIONS

We show that the combining of fNMES and EEG can be achieved and may serve as a powerful means of exploring the impact of controlled proprioceptive inputs on various types of cognitive processing.

Wilson's disease - a tricky diagnosis on the acute take

Wilson's disease is a rare genetic disorder that affects copper metabolism in the body, leading to excess copper accumulation in various organs, including the liver and brain. It often presents to both primary and secondary care, with a combination of liver disease and neurological or psychiatric symptoms, but the presentation can be highly variable. Early recognition and treatment of Wilson's disease is important to prevent critical hepatic and neurological complications. In this case report, we describe the presentation of an 18-year-old male university student with a combination of dysphagia, tremors, and slurred speech, which progressed over several months. Through a series of investigations, the patient was diagnosed with Wilson's disease and received appropriate treatment. This report highlights the importance of considering Wilson's disease in patients with a wide range of symptoms and the need for a pragmatic approach to diagnosis, including routine and additional testing as necessary.

[18F]Sodium fluoride PET-MRI detects increased metabolic bone response to whole-joint loading stress in osteoarthritic knees

OBJECTIVE

Altered joint function is a hallmark of osteoarthritis (OA). Imaging techniques for joint function are limited, but [18F]sodium fluoride (NaF) PET-MRI may assess the acute joint response to loading stresses. [18F]NaF PET-MRI was used to study the acute joint response to exercise in OA knees, and compare relationships between regions of increased uptake after loading and structural OA progression two years later.

METHODS

In this prospective study, 10 participants with knee OA (59 ± 8 years; 8 female) were scanned twice consecutively using a PET-MR system and performed a one-legged squat exercise between scans. Changes in tracer uptake measures in 9 bone regions were compared between knees that did and did not exercise with a mixed-effects model. Areas of focally large changes in uptake between scans (ROIfocal, ΔSUVmax > 3) were identified and the presence of structural MRI features was noted. Five participants returned two years later to assess structural change on MRI.

RESULTS

There was a significant increase in [18F]NaF uptake in OA exercised knees (SUV P < 0.001, KiP = 0.002, K1P < 0.001) that differed by bone region.

CONCLUSION

There were regional differences in the acute bone metabolic response to exercise and areas of focally large changes in the metabolic bone response that might be representative of whole-joint dysfunction.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

POS0535 OUTCOMES IN PATIENTS WITH RHEUMATOID ARTHRITIS INITIATING THERAPY WITH ETANERCEPT, ADALIMUMAB, OR JANUS KINASE INHIBITORS

Background

Ongoing debate exists regarding the optimal sequence of tumor necrosis factor inhibitors and Janus kinase inhibitors (JAKis) in patients with rheumatoid arthritis (RA) as first-line biologic or targeted synthetic disease-modifying antirheumatic drug (b/tsDMARD) therapy following conventional therapies.

Objectives

To describe baseline characteristics, effectiveness, persistency, and treatment patterns among first-line b/tsDMARD-naive initiators of etanercept (ETN), adalimumab (ADA), or JAKis (tofacitinib, baricitinib, and upadacitinib).

Methods

Data on patients who initiated b/tsDMARD from 11/2012 to 6/2021 were obtained from the CorEvitas RA Registry, a prospective, multicenter, observational, disease-based registry. Patients ≥18 years with rheumatologist-diagnosed RA and 6- and/or 12-months’ (M) follow-up were included. We report descriptive statistics at baseline, persistency on therapy, escalation/de-escalation of therapy, details on patterns of drug switching, and effectiveness outcomes using regression models adjusted for baseline covariates (demographic/socioeconomic/lifestyle characteristics, comorbidities, medication history, disease activity, and patient-reported outcomes). Outcomes were evaluated at 6M and 12M follow-up.

Results

First-line initiators of ETN, ADA, and JAKis with baseline and follow-up visits were identified: 803, 984, and 361 patients at 6M, respectively; 589, 749, and 264 patients at 12M, respectively. Baseline characteristics were similar among ETN, ADA, and JAKi initiators with the exception of disease duration, which was longer among first-line JAKi initiators (mean, 8.6 y) versus ETN (5.9 y) and ADA (5.8 y) initiators. Unadjusted mean improvement in Clinical Disease Activity Index (CDAI) was generally similar between groups at 6M and 12M (Table 1). Adjusted effectiveness results were similar at 6M and 12M (Figure 1). At 6M, 68% of ETN, 69% of ADA, and 67% of JAKi initiators remained on the same therapy; at 12M, 53% of ETN, 57% of ADA, and 57% of JAKi initiators remained on the same therapy. The frequency of switching to another b/tsDMARD was similar across initiators.

Table 1.

Patient Description at Time of Initiation and Unadjusted Disease Activity Results

ETNADAJAKisAge, years54.4 (12.8)55.5 (12.1)60.9 (12.5)Female, n (%)666 (77)843 (76)303 (77)BMI, kg/m230.4 (7.6)31.3 (7.9)30.8 (7.6)Duration of RA, years5.9 (7.6)5.8 (7.3)8.6 (10.0)BL disease activitya CDAI19.9 (14.3)18.9 (12.7)18.8 (13.2) mHAQ0.5 (0.5)0.5 (0.5)0.5 (0.5) Patient painb48.0 (28.8)49.2 (28.5)45.2 (29.2)Disease activity decrease from BL at 6M CDAI6.9 (13.6)6.4 (12.1)4.7 (12.3) mHAQ0.1 (0.4)0.1 (0.4)0.1 (0.4) Patient painb9.7 (30.2)10.6 (28.4)8.9 (29.5)Disease activity decrease from BL at 12M CDAI7.4 (13.5)6.1 (13.0)5.1 (13.0) mHAQ0.1 (0.4)0.1 (0.4)0.1 (0.4) Patient painb8.8 (29.7)8.7 (30.1)7.5 (28.6)Achievement of LDAc, % 6M43.441.932.5 12M41.039.638.3

aBaseline for combined population with 6M and 12M follow-up. b(range: 0–100). cCDAI ≤10 among those with moderate or high disease activity at baseline.

Data are mean (SD) unless otherwise specified.

ADA, adalimumab; BL, baseline; CDAI, Clinical Disease Activity Index; ETN, etanercept; JAKis, Janus kinase inhibitors; LDA, low disease activity; M, months; mHAQ, modified Health Assessment Questionnaire; RA, rheumatoid arthritis; SD, standard deviation.

Conclusion

In this real-world study in patients initiating first-line b/tsDMARD therapy with ETN, ADA, or JAKis, we did not observe differences in clinical effectiveness/patient-reported outcomes and treatment persistency at 6M and12M after treatment initiation.

Acknowledgements

This study is sponsored by CorEvitas, LLC. CorEvitas has been supported through contracted subscriptions in the last two years by AbbVie, Amgen Inc., Arena, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Chugai, Eli Lilly and Company, Genentech, Gilead, GSK, Janssen, LEO, Novartis, Ortho Dermatologics, Pfizer Inc., Regeneron, Sanofi, Sun, and UCB. Writing support was funded by Amgen Inc. and provided by Su Cappello, PharmD, of Peloton Advantage, LLC, an OPEN Health company, and Julie Wang, DPM, of Amgen Inc.

Disclosure of Interests

Dimitrios A Pappas Shareholder of: Officer or Board Member for Corrona Research Foundation, Speakers bureau: Speaker/Honoraria for AbbVie, Novartis, Roche Hellas, Sanofi, Consultant of: Consultant for AbbVie, Roche Hellas; Advisor for Sanofi, Employee of: Employment by, ownership interest, and stock options in CorEvitas, LLC, Jacqueline O’Brien Employee of: Employment by CorEvitas, LLC., Lin Guo Employee of: Employment by CorEvitas, LLC., Ying Shan Employee of: Employment by CorEvitas, LLC., Joshua Baker Consultant of: Received consulting fees from Bristol Myers Squibb, Pfizer, CorEvitas LLC, and Burns-White, LLC., Greg Kricorian Shareholder of: Employment by and stock ownership in Amgen Inc., Employee of: Employment by and stock ownership in Amgen Inc., Scott Stryker Shareholder of: Employment by and stock ownership in Amgen Inc., Employee of: Employment by and stock ownership in Amgen Inc., David Collier Shareholder of: Employment by and stock ownership in Amgen Inc., Employee of: Employment by and stock ownership in Amgen Inc.

POS0656 FRAILTY AND RISK OF ADVERSE OUTCOMES IN BIOLOGIC OR TARGETED-SYNTHETIC DMARD TREATED PATIENTS WITH RHEUMATOID ARTHRITIS

Background

Recently, it has been recognized that frailty and pre-frailty are common in patients with rheumatoid arthritis (RA) [1]. Whether frailty status portends an increased risk of adverse outcomes in patients with RA on biologic or targeted synthetic disease modifying anti-rheumatic drugs (b- or tsDMARDs) remains unknown.

Objectives

To evaluate the association between frailty and adverse outcomes in patients with RA exposed to b- or tsDMARDs.

Methods

Using the IBM/Watson MarketScan Commercial Claims and Encounters Databases, we identified all patients with RA who filled new prescriptions (or received infusions) for TNFα antagonists (TNFi), non-TNFi biologics (rituximab, abatacept, tocilizumab) or Janus Kinase inhibitors (JAKi) between 2008-2019. We used a 1-year lookback period without the use of these drugs to identify new users. The date of the first prescription within these three drug categories was the index date. Patients’ frailty risk score was calculated using the Claims-Based Frailty Index (CFI) [2], which estimates a deficit-accumulation frailty index using International Classification of Diseases codes, Current Procedural Terminology codes, and Healthcare Common Procedure Coding System codes in administrative claims data in the 1-year baseline period. The index ranges from 0 (not at all frail) to 1 (severely frail). The primary outcome was time to serious infections (those requiring hospitalization); secondary outcomes: any infection (outpatient or inpatient encounters) and all-cause hospitalizations.

Patients were followed until 1) outcome occurrence; 2) disenrollment; 3) >90 days elapsed (or >180 days for rituximab) without further fills of the first drug categories; 4) they filled/received infusions of b-/tsDMARDs from a different drug category; or 5) 2 years after index. Cox proportional hazards adjusting for demographics, calendar year, serious and/or opportunistic infections in the 12-months prior to index were used to estimate the adjusted hazard ratios (aHR) and 95% confidence intervals (CIs) for each outcome. In separate model, we additionally adjusted for comorbidity burden, and health care utilization (HCU).

Results

A total of 62,246 patients with RA met our inclusion criteria of whom 50,910 (82%) started TNFi as their first biologic, 9525 (15%) non-TNFi biologics, and 1811 (3%) JAKi. Among these, 3928 (6%) were considered frail. In multivariable analyses, frail patients had higher risk of serious infections compared to non-frail patients (aHR 2.37, 95% CI 2.05-2.74) which decreased to aHR 1.34, 95% CI 1.13-1.58 (Table 1) after adjusting for comorbidity burden and the HCU. Similarly, frailty was associated with increased risk of any infection (aHR 1.18, 95% CI 1.11-1.25), and all-cause hospitalizations (aHR 1.34, 95% CI 1.21-1.49) relative to non-frail individuals.

Table 1.

Multivariable models evaluating the association between frailty status and inpatient infections as the outcome

Variable#Hazard Ratio (95% Confidence Interval)@Hazard Ratio (95% Confidence Interval)Frail2.37 (2.05, 2.74)1.34 (1.13, 1.58)

#Model adjusts for age, sex, major infection requiring inpatient admission in 12 months prior, concomitant baseline drugs such as csDMARDs, glucocorticoids, NSAIDs and opioids

@Model additionally adjusts for Chalrson comorbidy score and healthcare utilization

Conclusion

Frailty is an important predictor for the risk of adverse outcomes among patients with RA treated with b- or tsDMARDs. Our findings underscore the need for considering this parameter in patient evaluations (even among younger patients) in the clinic.

References

[1]Salaffi F et al: Prevalence of frailty and its associated factors in patients with rheumatoid arthritis: a cross-sectional analysis. Clin Rheumatol 2019

[2]Kim DH et al. Validation of a Claims-Based Frailty Index Against Physical Performance and Adverse Health Outcomes in the Health and Retirement Study. J Gerontol A Biol Sci Med Sci 2019

Acknowledgements

I have no acknowledgements to declare.

Disclosure of Interests

None declared

Cracked Tooth Syndrome: Assessment, Prognosis and Predictable Management Strategies

Cracked tooth syndrome (CTS) is a common presentation in general practice. The diagnosis and management of teeth with CTS may be difficult due to the unknown extent of the crack. This article reviews the aetiology, diagnosis, management and prognosis of teeth with CTS. A thorough examination is required to effectively assess CTS. Intervention should aim to relieve symptoms and brace the remaining tooth structure effectively against further flexion. Restored teeth with CTS have a guarded prognosis due to the risk of further crack propagation, but the chances of survival at 5-years is acceptable (74.1-96.8%).

Addressing Opportunities & Misunderstandings of ASCP International Certification in the Philippines

Introduction/Objective

The objective of this study is to identify the positive viewpoints and misunderstandings Filipino applicants have about the BOC’s international credential and credential maintenance programs. With a total of 10,836 MLS(ASCPi) certificants, the Philippines is the BOC’s largest and most successful international certification market. However, despite the Philippines being the BOC’s largest international certification market, the BOC only certifies about a third of eligible Filipino graduates each year.

Therefore, to encourage additional interest in achieving BOC credentials and to eliminate misunderstanding surrounding the BOC’s Credential Maintenance Program (CMP), the ASCP BOC International Credentialing Committee created and deployed a survey.

The purpose of the survey was to learn as much as possible about the medical laboratory scientist certification market in the Philippines, as well as determine what opportunities Filipino‘s were afforded after they earned their credential. The resulting report based on analysis of the survey results showed there are a number of issues affecting Filipino participation in the BOC’s credential and CMP offerings.

Methods/Case Report

422 individuals from 44 countries of education participated in the survey. This study is a summary of results from the 265 Filipino respondents.

Results (if a Case Study enter NA)

This study confirmed a number of assertions the BOC had about the Filipino credential market. The most important of these assertions is MLS(ASCPi) certification is appealing to Philippine- educated individuals due to its portability (i.e., work eligibility, emigration, etc.).

Conclusion

The BOC should continue leaning into the portability of MLS(ASCPi) certification, but also needs to do a better job of promoting our other international certifications for which Filipinos may be eligible. The BOC needs to place greater emphasis on educating Filipinos on the importance of CMP and on what can be used for CE towards CMP. For example, the BOC needs to create an outreach campaign that helps Filipino credential holders understand CE earned for their PRC (i.e., Philippines-licensure requirements) can also be used for their CMP. Finally, considering the popularity of BOC certification in the Philippines, the BOC should work on creating more content that focuses on promoting the usefulness of pursing an advanced credential, the portability of certification, and the overall demystification of CMP.

Hard to Swallow Results

The American Neurogastroenterology and Motility Society (ANMS) proposed quality measures (QMs) for performance and interpretation of esophageal manometry (EM). We implemented a quality improvement (QI) study at a large community hospital to assess and improve procedural adherence and interpretation of EM studies based on the ANMS QMs using the Chicago Classification 3.0 (CC) Guidelines. For pre-intervention, three motility independent reviewers reinterpreted 60 EM studies conducted by community gastroenterologists without Tier II-III motility training from October to December 2018 for compliance with pre-procedural, procedural, and data interpretation ANMS QMs. In December 2018, we developed a pre-procedural form, educated nurses on EM procedural compliance, and provided preliminary pre-intervention results to gastroenterologists along with literature utilizing the CC 3.0 Guidelines. For post-intervention, we reinterpreted 54 EM studies from January to August 2019 and investigated whether they met QMs for data interpretation with respect to the CC Guidelines and resulted in appropriate treatment. We found a statistically significant improvement in procedural compliance among nursing staff for 30 s of swallows (76% post-intervention versus 12% pre-intervention, p < 0.001) and 7 evaluable swallows (94% post-intervention versus 53% pre-intervention, p < 0.001). However, quality metrics within data interpretation by physicians post-intervention showed mixed results. An incorrect diagnosis was made in 50% (n = 27)) of studies with 72% (n = 39) having at least one missing item based on the CC. The most missed diagnosis was fragmented peristalsis (30%, n = 29). Among the 39% (n = 21) of surgery referrals, 24% (n = 5) were incorrectly referred. Our study shows poor data interpretation by community gastroenterologists without formal motility training despite adequate performance by nursing staff. This further supports the need for a national ANMS certification process for formal HRM education.

Challenges and stresses experienced by athletes and coaches leading up to the Paralympic Games

The demands of high-performance sport are exacerbated during the lead up to the Major Games (i.e., Paralympics). The purpose of this study was to better understand the challenges experienced and strategies utilized by Australian athletes (n = 7) and coaches (n = 5) preparing for the Tokyo Paralympic Games using semi-structured interviews. The thematic analysis highlighted challenges specific to participants’ sport (e.g., budgetary constraints, decentralized experiences, athletes with various impairments), personal life (e.g., moving cities to access coaching, postponing vocational/educational developments, isolation from social circles), and associated uncertainties (e.g., COVID-19, qualifications, accreditations). Participants managed these challenges by utilizing strategies to ‘anticipate and prepare’ (e.g., detailed planning, effective communication, contingency plans) and ‘manage expectations’ (e.g., understanding specific roles and boundaries, focusing on the process [i.e., effort over results]). Trust and communication between athletes and coaches was key in coaches’ better understanding of how athletes’ impairments interact with their training and competition environments and tailor support to each athlete’s unique needs. Last, participants reflected on the ‘pressure’ of the Games due to their performance having an impact on their career trajectory ‘post-Tokyo’ with some athletes contemplating retirement and others realizing the consequences of their performance on sport-related vocation and sponsorship. Coaches also accepted the success of their programs and job security will depend on outcomes at the Games. The findings from this study shed light on factors to consider to reduce challenges for teams preparing for major competitions but also highlight key practical implications to support athletes and coaches leading up, during, and post-major Games.

Cracked Tooth Syndrome: Assessment, Prognosis and Predictable Management Strategies

Cracked tooth syndrome (CTS) is a common presentation in general practice. The diagnosis and management of teeth with CTS may be difficult due to the unknown extent of the crack. This article reviews the aetiology, diagnosis, management and prognosis of teeth with CTS. A thorough examination is required to effectively assess CTS. Intervention should aim to relieve symptoms and brace the remaining tooth structure effectively against further flexion. Restored teeth with CTS have a guarded prognosis due to the risk of further crack propagation, but the chances of survival at 5-years is acceptable (74.1-96.8%).

RNAi inhibition of angiopoietin-like protein 3 (ANGPTL3) with ARO-ANG3 mimics the lipid and lipoprotein profile of familial combined hypolipidemia

Background

Elevated LDL-C and triglyceride rich lipoproteins (TRLs) are independent risk factors for cardiovascular disease (CVD). Genetic deficiency of angiopoietin-like protein 3 (ANGPTL3) is associated with reduced circulating levels of LDL-C, triglycerides (TGs), VLDL-C, HDL-C and reduced CVD risk, with no described adverse phenotype. ARO-ANG3 is a RNA interference drug designed to silence expression of ANGPTL3. Single doses of ARO-ANG3 have been shown to reduce ANGPTL3, TGs, VLDL-C and LDL-C in healthy volunteers (HVs, AHA 2019). We report the effects of multiple doses of ARO-ANG3 in HVs with a focus on the duration of action.

Methods

ARO-ANG3 was administered subcutaneously to HVs on days 1 and 29 at doses of 100, 200 or 300 mg (n=4 per group). Measured parameters included ANGPTL3, LDL-C, TGs, VLDL-C and HDL-C. Follow up is ongoing.

Results

All HVs have received both doses and follow-up is currently through week 16 (12 weeks after second dose). Mean nadir for ANGPTL3 levels occurred 2 weeks after the second dose (−83–93%) with minimal change for 200 and 300 mg but 16% recovery for 100 mg at week 16. Mean TGs and VLDL-C reached nadir earlier (3 wks, −61–65%) without apparent dose response and minimal change for any dose at wk 16. LDL-C nadir occurred 4–6 wks after the second dose (−45–54%), again with minimal evidence for dose response or change through wk 16. HDL-C was reduced 14–37% at wk 16. ARO-ANG3 was well tolerated without serious or severe adverse events or dropouts related to drug. The most common adverse events have been headache and upper respiratory infections.

Conclusions

Genetic deficiency of ANGPTL3 is a cause of familial combined hypolipemia and is associated with a decreased risk of CVD. Using RNAi to selectively suppress ANGPTL3 production reproduces these genetic effects with a duration of at least 12 weeks following a second dose and with good tolerability over 16 wks. ANGPTL3 inhibition results in lowering of LDL-C and TRLs which may confer protection against CVD in patients with atherogenic mixed dyslipidemia.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Arrowhead Pharmaceuticals

RNA interference targeting apolipoprotein C-III with ARO-APOC3 in healthy volunteers mimics lipid and lipoprotein findings seen in subjects with inherited apolipoprotein C-III deficiency

Background

Individuals with triglycerides (TGs) ≥1,000 mg/dL (11.1 mmol/L) are at increased risk of acute pancreatitis. Genetic studies indicate that individuals with apolipoprotein C-3 (APOC3) loss-of-function mutations have low TGs, reduced cardiovascular risk and no observed adverse phenotype. RNA interference (RNAi) with ARO-APOC3 has shown deep and durable knockdown (KD) of APOC3 after single doses in healthy volunteers (HVs, presented at AHA 2019) with good tolerability. We report here initial results using multiple doses of ARO-APOC3 to silence APOC3 expression in HVs.

Methods

ARO-APOC3 was administered subcutaneously to HVs on days 1 and 29 at doses of 10, 25 or 50 mg (n=4 per group). Measured parameters included plasma concentrations of APOC3, LDL-C, TGs, VLDL-C and HDL-C.

Results

All HVs have received both doses and follow-up for most parameters is available through week (wk) 14 (10 wks after second dose) for the 10 and 25 mg doses and through wk 10 for 50 mg. Mean nadir for APOC3 levels occurred at wk 3 for 10 mg (−73%) and remained similar at wk 10 (−66%), at wk 6 for 25 mg (−90%) with no change at wk 10 and at wk 2 for 50 mg (−94%) unchanged at wk 8. TGs fell faster in the 50 mg group (wk 1: 10 mg −41%; 25 mg −47%; 50 mg −72%). By wk 6 the 25 and 50 mg results were similar (−68% and −74%, respectively) and remained similar through wk 14. 10 mg was less active with a nadir of −56% and mean reductions between 42% and 56% post-nadir. VLDL-C values mirrored TGs. LDL-C reductions were more modest and did not manifest a dose response. Mean nadirs (−23–26%) occurred 4–6 wks after the first dose, again with minimal change through 10–14 wks of follow-up. Consistent with genetic studies, HDL-C increased to a maximum at approximately wk 8 (10 mg +42%, 25 mg +48%, 50 mg +84%). ARO-APOC3 was well tolerated without serious or severe adverse events or dropouts related to drug. The most common adverse events were mild injection site AEs and headache.

Conclusions

Genetic deficiency of APOC3 is associated with substantial reductions in TGs, VLDL-C and increases in HDL-C without an adverse phenotype. Using RNAi to selectively suppress APOC3 production mimics these lipid and lipoprotein effects, with a duration of at least 10 weeks following a second dose and with good tolerability over 16 wks using doses ranging from 10 to 50 mg. Investigation of optimal dosing regimen is ongoing, especially with respect to dosing interval. This therapeutic approach has potential for treating patients with chylomicronemia at risk of pancreatitis.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Arrowhead Pharmaceuticals

An evaluation of continuous subcutaneous infusions across seven NHS acute hospitals: is there potential for 48-hour infusions?

BACKGROUND

Continuous subcutaneous infusions (CSCIs) are commonly used in the United Kingdom as a way of administering medication to patients requiring symptom control when the oral route is compromised. These infusions are typically administered over 24 h due to currently available safety data. The ability to deliver prescribed medication by CSCI over 48 h may have numerous benefits in both patient care and health service resource utilisation. This service evaluation aims to identify the frequency at which CSCI prescriptions are altered at NHS Acute Hospitals.

METHODS

Pharmacists or members of palliative care teams at seven acute NHS hospitals recorded anonymised prescription data relating to the drug combination(s), doses, diluent and compatibility of CSCIs containing two or more drugs on a daily basis for a minimum of 2 days, to a maximum of 7 days.

RESULTS

A total of 1301 prescriptions from 288 patients were recorded across the seven sites, yielding 584 discrete drug combinations. Of the 584 combinations, 91% (n = 533) included an opioid. The 10 most-common CSCI drug combinations represented 37% of the combinations recorded. Median duration of an unchanged CSCI prescription across all sites was 2 days.

CONCLUSION

Data suggests medication delivered by CSCI over 48 h may be a viable option. Before a clinical feasibility study can be undertaken, a pharmacoeconomic assessment and robust chemical and microbiological stability data will be required, as will the assessment of the perceptions from clinical staff, patients and their families on the acceptability of such a change in practice.

AB0354 STEPPING UP FOR INFLAMMATORY ARTHRITIS: A PILOT TRIAL TO TEST BEHAVIORAL ECONOMICS STRATEGY TO INCREASE PHYSICAL ACTIVITY IN INFLAMMATORY ARTHRITIS

Background:

Regular physical activity may have benefits for patients with rheumatoid arthritis (RA) and psoriatic arthritis (PsA), but patients with active disease are often reluctant to increase activity. Principles from behavioral economics (BE), a field combining psychology and economics, have been applied to motivate increased physical activity in non-arthritis patients.1No published studies have examined the application of BE concepts in rheumatology to promote exercise.

Objectives:

To assess the feasibiility and efficacy of a loss aversion financial incentive for increasing step counts and improving disease symptoms in RA and PsA patients with active disease.

Methods:

A randomized controlled pilot trial was performed among patients with RA and PsA. Participants were required to have active disease defined by having at least one swollen joint and a Routine Assessment of Patient Index Data-3 (RAPID3) score>3 (range 0-30 with <3 indicating remission). The trial included two visits (baseline and 14-week) and weekly check-ins via virtual trial platforms, Way to Health and the ArthritisPower app. Patients were given a Fitbit Alta at baseline and completed a two-week run-in period to assess average step count. Patients were then prompted to select a step count goal and complete a commitment contract. After selection of a goal, participants randomized to the intervention arm received a financial loss aversion incentive (each month, patients started with $75 in their account and lost $2.50 for each day they did not reach their goal). Patients were blinded to the other study arm and investigators were blinded to assignment. All patients received weekly text message prompts providing feedback about their performance over the previous week, completed weekly PROs, and had the opportunity to report adverse events including flares of joint pain. After 12 weeks of the intervention (at week 14), the incentive was removed and patients were followed to 26 weeks to determine how long the effect persisted.

Results:

In the pilot trial, 71 patients were verbally consented for screening, 34 underwent screening (of these, two were ineligible), 27 were randomized, and 22 patients completed the 14-week study visit. Mean age of participants was 50 (SD 13), 85% were female, 17(63%) had PsA, mean BMI was 30.6 and mean swollen (0-66) and tender (0-68) joint counts were 6.2 (5.6) and 8.1 (9.1), respectively. Baseline RAPID3 was 10.5 (SD 4.6) and the mean step count at baseline was 5,962. By 28 days, 65% of patients increased their step count. Participants receiving the incentive had an average of 714 more steps per day over the first 14 weeks and a greater probability of reaching 10,000 steps per day during follow-up (30% v. 21%, p=0.41). Among patients who achieved their step count goals more than 50% of days, we observed more improvement in sleep quality, fatigue, and overall well-being (p<0.05) (Figure 1). After adjusting for baseline RAPID3, the 14-week RAPID3 scores were lower in the group that achieved their step goals 50% of the time [B: -3.91 (-11.8, 3.99); a difference that approximates the minimal clinically important difference (MCID) for the RAPID3 (3.6).

Figure 1.

Change in fatigue severity among those with greater adherence to step count goals.

Conclusion:

While financial incentives have worked well in patients without arthritis, the estimated effect of the financial incentive in this small study was more modest in patients with RA and PsA. Those that were able to increase their physical activity and meet their step goals had greater improvements in symptoms over the course of the study. These data support further study in this area to promote physical activity by leveraging concepts from behavioral economics.

References:

[1]Ogdie & Asch. Nat Rev Rheumatol. 2019

Disclosure of Interests:

Alexis Ogdie Grant/research support from: Pfizer, Novartis, Consultant of: Abbvie, Amgen, BMS, Celgene, Corrona, Janssen, Lilly, Pfizer, Novartis, Mitesh Patel Shareholder of: Owner, Catalyst Health LLC, Consultant of: Advisory Board Member for Healthmine Services, Life.io, Holistic Industries, Jeffrey Curtis Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Corrona, Janssen, Lilly, Myriad, Pfizer, Regeneron, Roche, UCB, Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Corrona, Janssen, Lilly, Myriad, Pfizer, Regeneron, Roche, UCB, Kelly Gavigan: None declared, W. Benjamin Nowell: None declared, Joshua Baker: None declared

FRI0572 LEPTIN-ADJUSTMENT OF THE MULTI-BIOMARKER DISEASE ACTIVITY (MBDA) SCORE REDUCES THE INFLUENCE OF ADIPOSITY

Background:

Obesity and excess adiposity influence inflammatory markers and bias disease activity assessment, especially among women. A multi-biomarker disease activity (aMBDA) score has been developed to account for the effects of age, sex and adiposity (leptin) and improves prediction of radiographic damage progression.1

Objectives:

1) Determine if the adjusted measure demonstrates a reduced association with adiposity.

2) Assess the impact of the leptin-adjustment on the score over the range of adiposity.

3) Assess relationships between MBDA scores and clinical disease activity.

Methods:

Patients with rheumatoid arthritis (RA), ages 18-75 years, completed whole-body dual-energy x-ray absorptiometry to quantify fat mass indices (FMI, kg/m2). Age-, sex-, and race-specific Z-Scores were calculated based on the distributions in a healthy reference population. Disease activity was assessed with the CDAI and swollen joint count (SJC). Baseline van der Heijde-Sharpe (vdHS) scores were determined by a radiologist. MBDA assays were performed on stored serum samples. Descriptive statistics described relationships between the FMI Z-Score and the MBDA and the aMBDA. Clinical disease activity, SJC, and radiographic damage were also compared across MBDA score categories.

Results:

Of 104 participants (50% female), the mean (SD) age was 56.1 (12.5) and mean BMI was 28.8 (6.9) (Table 1). The unadjusted MBDA score was strongly associated with BMI among women (Women: Rho=0.46 [p< 0.001]; Men: Rho=-0.12), while the aMBDA was not associated with BMI in women and was inversely correlated in men (Women: Rho=0.17; Men: Rho=-0.32 [p=0.02]). The unadjusted MBDA score was also strongly associated with FMI Z-Score among women (Figure; Women: Rho=0.42 [p=0.002]; Men: Rho=-0.10; p=0.01). The aMBDA was not significantly associated with FMI Z-Score (Female: Rho= 0.17; Male: Rho=-0.26). Leptin-adjustment reduced the MBDA score in the highest quartile of FMI in women but not men, and increased the MBDA score in the lowest FMI quartiles in both women and men; these patients in the lowest FMI quartile had the highest median SJC (p=0.05 for men, p=0.78 for women; Figure). The aMBDA reclassified 4 women (8%) and 9 men (17%) into higher disease activity categories and 2 women (4%) and 2 men (4%) into lower categories. CDAI, SJC, and radiographic scores were similar across activity categories for the unadjusted MBDA score and aMBDA (Table 2).

Table 1.

Baseline Characteristics.

MenWomenN5252Age (yrs)59.1 (11.5)53.0 (12.8)Black, N (%)13 (25%)19 (36%)BMI27.3 (5.4)30.3 (8.0)FMI Z-Score-0.28 (1.3)0.05 (1.1)DAS28(CRP)3.09 (1.13)3.21 (1.24)Disease Duration11.4 (10.9)11.6 (11.9)CRP, mg/dL0.8 (0.5, 1.2)0.8 (0.5, 1.4)CCP Positive, N (%)45 (87%)40 (78%)vdHS (N=93)13 (4, 73)10.5 (2, 47)HAQ0.71 (0.59)0.83, (0.67)MBDA40.0 (13.8)42.1 (16.6)aMBDA43.6 (13.4)42.1 (15.3)Leptin, ng/mL15.1 (21.5)48.9 (41.5)Table 2.

Clinical assessments across MBDA score categories.

CDAISJCvdHSMBDAaMBDAMBDAaMBDAMBDAaMBDAMBDA CategoryLow14.6 (10.9)13.9 (9.9)2 (1, 5)2 (1, 5)9 (1, 33.5)9 (3, 32)Moderate13.2 (10.0)14.4 (11.4)2 (0, 5)3 (0, 6)10 (4, 49)10 (2, 53)High18.4 (12.3)17.7 (11.8)4 (1, 8)5 (2, 7)20.5 (5, 70.5)18 (4, 73)

Conclusion:

Leptin-adjustment of the MBDA score reduced bias related to excess adiposity in women with RA. Adjustment results in lower MBDA scores in women with greater adiposity, and higher MBDA scores in women and men with lesser adiposity. The aMBDA may reduce misclassification due to excess adiposity and improve identification of active disease among patients with lower adiposity. High aMBDA scores among men with low adiposity may reflect severe disease or excess comorbidity in this group.

References:

[1] Curtis et al.Rheumatology (Oxford) 2018. PMID: 30590790

Figure.

Impact of Adjustment on MBDA Score by FMI Z-Score Quartile.

Disclosure of Interests:

Joshua Baker Grant/research support from: Myriad RBM, Consultant of: Bristol-Myers Squib, Burns-White LLC, Jeffrey Curtis Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Corrona, Janssen, Lilly, Myriad, Pfizer, Regeneron, Roche, UCB, Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Corrona, Janssen, Lilly, Myriad, Pfizer, Regeneron, Roche, UCB, David Chernoff Employee of: Myriad, Michael George Grant/research support from: Bristol Myers Squibb, Consultant of: AbbVie

The design of a line velocity interferometer for any reflector for inertial confinement experiments on the Z-machine

A line VISAR (Velocity Interferometer System for Any Reflector) has been designed and commissioned at the Sandia National Laboratory's Z-machine. The instrument consists of an F/2 collection system, beam transport, and an interferometer table that contains two Mach-Zehnder type interferometers and an eight channel Gated Optical Imaging (GOI) system. The VISAR probe laser operates at the 532 nm wavelength, and the GOI bandpass is 540-600 nm. The output of each interferometer is passed to an optical streak camera with four selectable sweep speeds. The system is designed with three interchangeable optics modules to select a full field of view of 1 mm, 2 mm, or 4 mm. The optical beam transport system connects the target image plane to the interferometers and the gated optical imagers. The target is integrated into a sacrificial final optics assembly that is integral to the transport beamline.

A243 FACTORS ASSOCIATED WITH POOR QUALITY OF LIFE IN PATIENTS WITH INFLAMMATORY BOWEL DISEASE IN CLINICAL REMISSION: A CROSS-SECTIONAL STUDY

Background

Inflammatory bowel disease (IBD) is associated with a substantial burden on quality of life (QoL). Functional gastrointestinal disorders such as irritable bowel syndrome (IBS) as well as depression and anxiety are more common in patients with IBD as compared with the general population. Although poorer QoL is correlated with IBS, depression and anxiety in individuals with IBD at times of IBD diagnosis and disease activity, it is unclear what, if any, impact these may have on overall quality of life at times of disease remission.

Aims

We aimed to identify factors associated with poor QoL among Canadian patients with IBD in clinical remission.

Methods

We conducted a prospective, cross-sectional study to determine whether fatigue, depression, anxiety and IBS were associated with lower QoL in patients with IBD in clinical remission. We enrolled patients at a single academic tertiary care center with inactive IBD. All eligible patients completed a series of questionnaires that included questions on demographics, disease activity, anxiety, depression, and the presence of irritable bowel syndrome (IBS) symptoms. Stool samples for fecal calprotectin (FC) were also collected to assess for subclinical inflammation. The primary outcome measure was QoL assessed by the short inflammatory bowel disease questionnaire (SIBDQ), with planned subgroup comparisons for fatigue, anxiety, depression and IBS symptoms.

Results

Ninety-three patients were eligible for inclusion in this study. The median SIBDQ scores were lower in patients with anxiety (P&lt;0.001), depression (P=0.004), IBS symptoms (P&lt;0.001), and fatigue (P=0.018).

Conclusions

In this cross-sectional study, we found that anxiety, depression, fatigue, and IBS-like symptoms were all independently associated with lower QoL among patients with inactive IBD. Importantly, subclinical inflammation as defined by a positive fecal calprotectin in the absence of clinical symptoms did not have an adverse effect on QoL. The findings of this study suggest that patients with IBD would likely benefit from screening for depression, anxiety, fatigue and IBS. Further research is warranted to determine if targeted treatment of these conditions, specifically in patients with quiescent IBD would lead to improved outcomes.

Funding Agencies

None

Albuminuria in People At Least 40 Years Old: Effect of Obesity, Hypertension, and Hyperlipidemia

Concentrations of urinary albumin and the albumin:creatinine ratio were measured in early-morning urine specimens from 5670 people older than 40 years who participated in a health screening survey of a local workforce. Sex-specific reference intervals were determined in a subgroup of 3597 people after excluding 2073 individuals with Albustix-positive proteinuria; diabetes mellitus; bacteriuria; current hypertension; body mass index greater than or equal to 30 kg/m2; or serum triglyceride greater than or equal to 2.5 mmol/L. The 97.5 percentile concentration for urinary albumin was 28 mg/L in men and 29 mg/L in women; for the albumin:creatinine ratio this was 2.3 g/mol in men and 2.8 g/mol in women. In the study population, the degree of albuminuria showed piecewise log-linear relationships with diastolic blood pressure (P = 0.0001) and body mass index (P = 0.0001), log-linear relationships with hypertriglyceridemia (P = 0.0001) and hypercholesterolemia (P = 0.0001), and a negative piecewise linear relationship with high-density lipoprotein (HDL) cholesterol (P = 0.0461).

Evaluation of avoralstat, an oral kallikrein inhibitor, in a Phase 3 hereditary angioedema prophylaxis trial: The OPuS-2 study

Background

Effective inhibition of plasma kallikrein may have significant benefits for patients with hereditary angioedema due to deficiency of C1 inhibitor (C1‐INH‐HAE) by reducing the frequency of angioedema attacks. Avoralstat is a small molecule inhibitor of plasma kallikrein. This study (OPuS‐2) evaluated the efficacy and safety of prophylactic avoralstat 300 or 500 mg compared with placebo.

Methods

OPuS‐2 was a Phase 3, multicenter, randomized, double‐blind, placebo‐controlled, parallel‐group study. Subjects were administered avoralstat 300 mg, avoralstat 500 mg, or placebo orally 3 times per day for 12 weeks. The primary efficacy endpoint was the angioedema attack rate based on adjudicator‐confirmed attacks.

Results

A total of 110 subjects were randomized and dosed. The least squares (LS) mean attack rates per week were 0.589, 0.675, and 0.593 for subjects receiving avoralstat 500 mg, avoralstat 300 mg, and placebo, respectively. Overall, 1 subject in each of the avoralstat groups and no subjects in the placebo group were attack‐free during the 84‐day treatment period. The LS mean duration of all confirmed attacks was 25.4, 29.4, and 31.4 hours for the avoralstat 500 mg, avoralstat 300 mg, and placebo groups, respectively. Using the Angioedema Quality of Life Questionnaire (AE‐QoL), improved QoL was observed for the avoralstat 500 mg group compared with placebo. Avoralstat was generally safe and well tolerated.

Conclusions

Although this study did not demonstrate efficacy of avoralstat in preventing angioedema attacks in C1‐INH‐HAE, it provided evidence of shortened angioedema episodes and improved QoL in the avoralstat 500 mg treatment group compared with placebo.

The end game: Mortality outcomes in North American professional athletes

Comprehensive investigations into the mortality outcomes of elite athletes can assist in decoding risk factors for premature mortality and provide avenues for exploring human health through engagement in sport. As such, the purpose of this study was to comprehensively examine lifespan trends of athletes from the 4 major sports in North America: Major League Baseball (MLB), National Basketball Association (NBA), National Football League (NFL), and National Hockey League (NHL). We hypothesized that proportional death rates would be similar across the 4 sports, when standardizing the data by debut years. Overall, 17 523 of 50 515 (34.7%) athletes were deceased as of the respective data collection cutoff date for their sport, with MLB players having the highest risk of imminent mortality. Professional basketball players generally had the highest relative proportion of death when standardizing data by debut year, although NHL and NFL players who debuted after 2005 had the highest proportion of death. In addition, a 1-year increase in career length significantly decreased the risk of death (HR: 0.982, 95% CI: 0.978-0.985), even after adjusting for sport type (HR: 0.977, 95% CI: 0.974-0.980). Meaningful significance should be considered given the historical and unique nature of the sample. Nevertheless, investigating risk of death differences through different occupational and biological variables can help highlight aversive trends to lifespan that permeate throughout high-performance athlete populations.