Romosozumab in patients who experienced an on-study fracture: post hoc analyses of the FRAME and ARCH phase 3 trials

Post hoc analysis of FRAME and ARCH revealed that on-study nonvertebral and vertebral fractures by Month 12 were less common in women initially treated with romosozumab versus placebo or alendronate. Recurrent fracture risk was also lower in romosozumab‑treated patients, and there were no fracture‑related complications. Results support continuing romosozumab treatment post‑fracture.

PURPOSE

Post hoc analysis evaluating efficacy and safety of romosozumab, administered in the immediate post‑fracture period, in the FRAME and ARCH phase 3 trials.

METHODS

In FRAME (NCT01575834) and ARCH (NCT01631214), postmenopausal women with osteoporosis were randomized 1:1 to romosozumab 210 mg monthly or comparator (FRAME, placebo; ARCH, alendronate 70 mg weekly) for 12 months, followed by antiresorptive therapy (FRAME, denosumab; ARCH, alendronate). In patients who experienced on-study nonvertebral or new/worsening vertebral fracture by Month 12, we report the following: fracture and treatment‑emergent adverse event (TEAE) incidence through 36 months, bone mineral density changes (BMD), and romosozumab timing. Due to the sample sizes employed, meaningful statistical comparisons between treatments were not possible.

RESULTS

Incidence of on-study nonvertebral and vertebral fractures by Month 12 was numerically lower in romosozumab- versus comparator-treated patients (FRAME, 1.6% and 0.5% versus 2.1% and 1.6%; ARCH, 3.4% and 3.3% versus 4.6% and 4.9%, respectively). In those who experienced on-study nonvertebral fracture by Month 12, recurrent nonvertebral and subsequent vertebral fracture incidences were numerically lower in patients initially treated with romosozumab versus comparator (FRAME, 3.6% [2/56] and 1.8% [1/56] versus 9.2% [7/76] and 3.9% [3/76]; ARCH, 10.0% [7/70] and 5.7% [4/70] versus 12.6% [12/95] and 8.4% [8/95], respectively). Among those with on-study vertebral fracture by Month 12, recurrent vertebral and subsequent nonvertebral fracture incidences were numerically lower with romosozumab versus comparator (FRAME, 0.0% [0/17] and 0.0% [0/17] versus 11.9% [7/59] and 8.5% [5/59]; ARCH, 9.0% [6/67] and 7.5% [5/67] versus 15.0% [15/100] and 16.0% [16/100], respectively). In patients with fracture by Month 12, no fracture‑related complications were reported in romosozumab-treated patients. BMD gains were numerically greater with romosozumab than comparators.

CONCLUSION

Data suggest support for the efficacy and safety of continuing romosozumab treatment following fracture.

TRIAL REGISTRATIONS

NCT01575834; NCT01631214.

Implementing a mental health app library in primary care: A feasibility study

Confronted with a wide range of digital health tools (DHT), professionals and patients need guidance to use these tools correctly and optimize health management. In the fall of 2020, a DHT library developed by Quebec-based company TherAppX was implemented in 22 institutions. The library was designed to enable healthcare professionals to use DHT in clinical care. The purpose of the current study was to assess the feasibility of implementing the library, including user experience, changes in DHT recommendation habits, and factors that helped or hindered the implementation process. A multi-methods design focusing on secondary use of quantitative data collected by TherAppX and semi-structured interviews with users was employed. While the quantitative analyses indicated infrequent use of the library, qualitative analyses highlighted several factors that hindered its implementation, including certain library and user characteristics and the unprecedented context of the COVID-19 pandemic. Nevertheless, the quantitative analyses confirmed interest in DHT and their usefulness during follow-ups. The results revealed a marginally significant pre-post changes in the frequency with which DHT were recommended. This study helped identify areas for improvements and indicates that further evaluation is needed. Future implementations would benefit from ensuring optimal conditions for a successful implementation.

Use of an expert elicitation methodology to compare welfare impacts of two approaches for blood sampling European badgers (Meles meles) in the field

In the UK and Republic of Ireland, the European badger (Meles meles) is considered the most significant wildlife reservoir of the bacterium Mycobacterium bovis, the cause of bovine tuberculosis (bTB). To expand options for bTB surveillance and disease control, the Animal and Plant Health Agency developed a bespoke physical restraint cage to facilitate collection of a small blood sample from a restrained, conscious badger in the field. A key step, prior to pursuing operational deployment of the novel restraint cage, was an assessment of the relative welfare impacts of the approach. We used an established welfare assessment model to elicit expert opinion during two workshops to compare the impacts of the restraint cage approach with the only current alternative for obtaining blood samples from badgers in the field, which involves administration of a general anaesthetic. Eleven panellists participated in the workshops, comprising experts in the fields of wildlife biology, animal welfare science, badger capture and sampling, and veterinary science. Both approaches were assessed to have negative welfare impacts, although in neither case were overall welfare scores higher than intermediate, never exceeding 5-6 out of a possible 8. Based on our assessments, the restraint cage approach is no worse for welfare compared to using general anaesthesia and possibly has a lower overall negative impact on badger welfare. Our results can be used to integrate consideration of badger welfare alongside other factors, including financial cost and efficiency, when selecting a field method for blood sampling free-living badgers.

Evaluation of the Effectiveness of Suicide.ca, Quebec's Digital Suicide Prevention Strategy Platform: Cross-Sectional Descriptive Study

BACKGROUND

In 2017, the Quebec government assigned the Association québécoise de prévention du suicide (AQPS) to develop a digital suicide prevention strategy (DSPS). The AQPS responded by creating a centralized website that provides information on suicide and mental health, identifies at-risk individuals on the internet, and offers direct crisis intervention support via chat and text.

OBJECTIVE

This study aims to evaluate the effectiveness of suicide.ca, Quebec's DSPS platform.

METHODS

This study used a cross-sectional descriptive design. The study population comprised internet users from Quebec, Canada, who visited the suicide.ca platform between October 2020 and October 2021. Various data sources, such as Google Analytics, Firebase Console, and Customer Relation Management data, were analyzed to document the use of the platform. To understand the profile of suicide.ca users, frequency analyses were conducted using data from the self-assessment module questionnaires, the intervention service's triage questionnaire, and the counselors' intervention reports. The effectiveness of the platform's promotional activities on social media was assessed by examining traffic peaks. Google Analytics was used to evaluate the effectiveness of AQPS' strategy for identifying at-risk internet users. The impact of the intervention service was evaluated through an analysis of counselors' intervention reports and postintervention survey results.

RESULTS

The platform received traffic from a diverse range of sources, with promotional efforts on social media directly contributing to the increased traffic. The requirement of a user account posed a barrier to the use of the mobile app, and a triage question that involved personal information led to a substantial number of dropouts during the intervention service triage. AdWords campaigns and fact sheets addressing suicide risk factors played a crucial role in driving traffic to the platform. With regard to the profile of suicide.ca users, the findings revealed that the platform engaged individuals with diverse levels of suicidal risk. Notably, users of the chat service displayed a higher suicide risk than those who used the self-assessment module. Crisis chat counselors reported a positive impact on approximately half of the contacts, and overall, intervention service users expressed satisfaction with the support they received.

CONCLUSIONS

A centralized digital platform can be used to implement a DSPS, effectively reaching the general population, individuals with risk factors for suicide, and those facing suicidal issues.

Survival and Success Rates of Endodontically Treated Teeth Restored with Full Veneer Crowns or Full Cuspal Coverage onlays: A Systematic Review

INTRODUCTION

The aim of this paper is to compare the survival and success rates of endodontically treated posterior teeth restored with full veneer crowns or full cuspal coverage onlays in vivo.

METHODS

A literature search using PubMed, Medline and Embase via Ovid, and The Cochrane Library retrieved English and non-English language articles from 1946 to April 2022. Electronic searches were supplemented with the use of forward citation chaining via Google Scholar.

RESULTS

A total of eleven studies met all predetermined search criteria. Data were extracted and tabulated. Survival rates for onlays ranged from 95% to 100% at two years and 90.7% to 100% at three years with success rates ranging from 86.6% - 96.6% at two years and 86.6% to 96% at three years. Survival results for full veneer crowns were reported at 87.8% at over two years, 95.1% at three years, and 84% - 97.73% at five to ten years. Success rates have been reported at 91.11% - 92.64% at five years and 60% at six years.

CONCLUSIONS

The data suggest that the use of onlays instead of full veneer crowns in the restoration of endodontically treated posterior teeth is favourable in the short to midterm.

Production and use of rapid responses during the COVID-19 pandemic in Quebec (Canada): perspectives from evidence synthesis producers and decision makers

BACKGROUND

The COVID-19 pandemic has required evidence to be made available more rapidly than usual, in order to meet the needs of decision makers in a timely manner. These exceptional circumstances have caused significant challenges for organizations and teams responsible for evidence synthesis. They had to adapt to provide rapid responses to support decision-making. This study aimed to document (1) the challenges and adaptations made to produce rapid responses during the pandemic, (2) their perceived usefulness, reported use and factors influencing their use and (3) the methodological adaptations made to produce rapid responses.

METHODS

A qualitative study was conducted in 2021 with eight organizations in the health and social services system in Quebec (Canada), including three institutes with a provincial mandate. Data collection included focus groups (n = 9 groups in 8 organizations with 64 participants), interviews with decision makers (n = 12), and a document analysis of COVID-19 rapid responses (n = 128). A thematic analysis of qualitative data (objectives 1 and 2) and a descriptive analysis of documents (objective 3) were conducted.

RESULTS

The results highlight the teams and organizations' agility to deal with the many challenges encountered during the pandemic (e.g., increased their workloads, adoption of new technological tools or work processes, improved collaboration, development of scientific monitoring, adaptation of evidence synthesis methodologies and products). The challenge of balancing rigor and speed was reported by teams and organizations. When available at the right time, rapid responses have been reported as a useful tool for informing or justifying decisions in a context of uncertainty. Several factors that may influence their use were identified (e.g., clearly identify needs, interactions with producers, perceived rigor and credibility, precise and feasible recommendations). Certain trends in the methodological approaches used to speed up the evidence synthesis process were identified.

CONCLUSIONS

This study documented rapid responses producers' experiences during the COVID-19 pandemic in Quebec, and decision makers who requested, consulted, or used these products. Potential areas of improvements are identified such as reinforce coordination, improve communication loops, clarify guidelines or methodological benchmarks, and enhance utility of rapid response products for decision makers.

A scoping review of theories, models and frameworks used or proposed to evaluate knowledge mobilization strategies

BACKGROUND

Evaluating knowledge mobilization strategies (KMb) presents challenges for organizations seeking to understand their impact to improve KMb effectiveness. Moreover, the large number of theories, models, and frameworks (TMFs) available can be confusing for users. Therefore, the purpose of this scoping review was to identify and describe the characteristics of TMFs that have been used or proposed in the literature to evaluate KMb strategies.

METHODS

A scoping review methodology was used. Articles were identified through searches in electronic databases, previous reviews and reference lists of included articles. Titles, abstracts and full texts were screened in duplicate. Data were charted using a piloted data charting form. Data extracted included study characteristics, KMb characteristics, and TMFs used or proposed for KMb evaluation. An adapted version of Nilsen (Implement Sci 10:53, 2015) taxonomy and the Expert Recommendations for Implementing Change (ERIC) taxonomy (Powell et al. in Implement Sci 10:21, 2015) guided data synthesis.

RESULTS

Of the 4763 search results, 505 were retrieved, and 88 articles were eligible for review. These consisted of 40 theoretical articles (45.5%), 44 empirical studies (50.0%) and four protocols (4.5%). The majority were published after 2010 (n = 70, 79.5%) and were health related (n = 71, 80.7%). Half of the studied KMb strategies were implemented in only four countries: Canada, Australia, the United States and the United Kingdom (n = 42, 47.7%). One-third used existing TMFs (n = 28, 31.8%). According to the adapted Nilsen taxonomy, process models (n = 34, 38.6%) and evaluation frameworks (n = 28, 31.8%) were the two most frequent types of TMFs used or proposed to evaluate KMb. According to the ERIC taxonomy, activities to "train and educate stakeholders" (n = 46, 52.3%) were the most common, followed by activities to "develop stakeholder interrelationships" (n = 23, 26.1%). Analysis of the TMFs identified revealed relevant factors of interest for the evaluation of KMb strategies, classified into four dimensions: context, process, effects and impacts.

CONCLUSIONS

This scoping review provides an overview of the many KMb TMFs used or proposed. The results provide insight into potential dimensions and components to be considered when assessing KMb strategies.

[Déterminants du succès d'une démarche provinciale d'usage optimal des antipsychotiques chez les résidents en soins de longue durée selon les acteurs clés impliqués dans l'implantation]

Le Québec présente le taux de prescriptions d'antipsychotiques le plus élevé chez les personnes âgées de 65 ans et plus au Canada. La démarche « Optimiser les pratiques, les usages, les soins et les services - antipsychotiques » (OPUS-AP) vise à pallier cet enjeu. Étant donné ses premiers résultats prometteurs, notre étude visait à identifier les déterminants de son succès. Elle repose sur un devis d'étude de cas regroupant une analyse documentaire et 21 entrevues auprès d'acteurs clés impliqués dans l'implantation. Les résultats mettent en lumière cinq déterminants centraux : 1) une démarche intégrée, collaborative et probante; 2) des communications et des réseaux au service de la démarche; 3) un climat d'implantation favorable aux changements; 4) un engagement et une implication des parties prenantes; et 5) une stratégie d'application des connaissances intégrée et appuyée. Des défis et recommandations pour assurer la pérennisation et la mise à l'échelle d'OPUS-AP et inspirer des démarches similaires sont identifiés.

Musculoskeletal disorder (MSD) prevention practices by nurses working in health care settings: Facilitators and barriers to implementation

The incidence of musculoskeletal disorders (MSD) in the healthcare professional population is concerning. In particular, the high incidence of back injuries is an issue for nurses. Although many MSD prevention initiatives are being implemented, these practices are not succeeding in reducing MSDs. Why are these efforts struggling to close the gap between knowledge and practice? This article aims to report on individual and organizational factors that may influence nurses' implementation of MSD prevention practices. A survey was sent to nurses in the Quebec health and social services network. A total of 399 questionnaires were completed and analyzed. The results revealed that nurses have the required knowledge on MSD prevention practices, but have difficulty applying them in their professional context. It would appear that successful implementation of MSD prevention practices relies mainly on organizational factors, including management support, organizational culture, feedback mechanisms, and training that is adapted to the work environment.

[An innovative process for sustaining and scaling up a school-based mental health promotion and anxiety prevention programs: The example of the HORS-PISTE program]

Context Anxiety disorders are among the most prevalent psychopathologies for children and adolescents in Quebec. The prevalence of anxiety disorders is very high and has been affecting a growing number of young people for the past 10 years. It is possible to observe an increased number of anxiety prevention programs for young people around the world. However, some authors point out that they are rarely faithfully implemented, sustained, and scaled up in several schools. Based on implementation science, this HORS-PISTE program was developed to address these important issues by preventing anxiety in Quebec high school students. Implemented in more than 100 schools, the program is now part of Action 4.3 (Promote the deployment of the HORS-PISTE program) of the new interdepartmental Action Plan on Mental Health of the Government of Quebec (2022). Purpose This article aims to describe how the Knowledge-to-Action (KTA) framework, derived of implementation science, was used to design, implement, sustain, evaluate, and scale up the HORS-PISTE program. This framework proposes a cyclical process in seven phases. Method A multi-method and multi-stakeholder approach was conducted with a grant from the Public Health Agency of Canada's Mental Health Promotion Innovation Fund, which has been supporting 20 innovative projects across Canada since 2019. It includes a pre-post evaluation protocol consisting of validated questionnaires, surveys (administered to students, parents, and teachers), semi-structured logbooks completed by program facilitators and implementation review meetings in each school. The different cycles of the program development, implementation and evaluation are discussed through the KTA framework phases. Results From 2017 to 2021, this methodology made it possible to evaluate and readjust the program each year to promote its adaptation and prepare its scaling up. This article highlights the data collected and analyzed in relation to the seven phases of the KTA framework. Conclusion This article demonstrates how implementation science can support designers of anxiety prevention programs who are concerned by scaling up and sustaining their programs. Issues in combining the scientific rigor of evaluation with the reality of the field are also raised.

Community pharmacist consultation service: survey insights into impact of learning on practice, and barriers and enablers to service implementation

Introduction

Some patients attend NHS services with ‘clinically divertible’ urgent low acuity conditions. The NHS Community Pharmacist Consultation Service (CPCS) enables the referral of such patients and subsequent consultation with a community pharmacist. The Centre for Pharmacy Postgraduate Education (CPPE) offered a learning programme to prepare pharmacists for a more clinical and person-centred approach when delivering the CPCS.

Aim

To investigate the impact of the CPPE CPCS learning programme on learnt skills and their application in practice, and barriers and enablers to CPCS delivery.

Methods

A survey was designed to explored participants’ knowledge, confidence and application of taught skills/tools, including clinical history-taking, clinical assessment, record-keeping, Calgary-Cambridge, L(ICE)F (lifestyle, ideas, concerns, expectations, feelings) and SBARD (situation, background, assessment, recommendation, decision) communication tools. Statements on barriers and enablers to CPCS delivery were included. In November/December 2021, CPPE emailed an online survey (one reminder) to CPCS learners who had agreed to be contacted (n=2836). The University of Manchester’s Research Ethics Committee decision tool confirmed that ethics committee approval was not required for this study.

Results

One-hundred and fifty-nine pharmacists responded (5.6%). Sixty percent were female, all ages were represented, the most populous groups being 55-64 (33.3%) and 45-54 years (27.7%). Ethnicity was broadly representative of community pharmacists: 49.0% white, 38.9% Asian, 8.2% black, and 1.9% Arab. Sixty-eight (43%) of respondents were working in a large multiple community pharmacy, 33.3% (n=53) in an independent pharmacy, and 17.0% (n=27) in a small to medium pharmacy multiple. Knowledge of, and confidence in, taught skills were high and respondents reported applying skills in CPCS consultations and wider practice. There was strong positive correlation between the perceived levels of competence and confidence when delivering CPCS (r=0.966, p=<0.001). The level of competence (r=0.259, p=0.003) and confidence increased (r=0.264, p=0.002) with an increasing number of NHS111 referrals. With regards to specific skills learnt, the highest levels of knowledge were recorded for ‘taking a clinical history’ (86% agreement), ‘clinically assessing a patient’ (84%), ‘using L(ICE)F’ (84%), and ‘completing an accurate and concise clinical record’ (81%). Seventy-three percent of respondents agreed they knew how to use the Calgary Cambridge, whilst only 49% knew how to use SBARD. Barriers to CPCS included lack of GP referrals, staffing levels, workload, and GP attitudes. Enablers included a clear understanding of what was expected, minimal concerns over indemnity cover and privacy, and positive patient attitudes towards pharmacy. Those working in independent pharmacies were more likely than those in multiple pharmacies to report that they were receiving GP referrals (68.5% vs. 49.0%, X2=5.249, p=0.022), that they had enough staff to provide the CPCS (45.3% vs. 26.3%, X2=5.526, p=0.019), and that the local GP considers community pharmacy to be an integral part of the primary healthcare team (54.7% vs. 37.2%, X2=4.214, p=0.040). Employed pharmacists were more likely than locums to report that they had a good relationship with their local general practice (57.5% vs. 37.5%, X2=5.436, p=0.020).

Discussion/Conclusion

This study demonstrates that CPPE learning contributed to community pharmacists’ extended knowledge and skills in CPCS delivery, which contributes to enhanced provision of urgent care in England. This study identified barriers, both interpersonal and infrastructural, that may hinder service implementation.

Gathering Strength to Combat Access Inequality

Nestled on the northern edge of Lake Ontario, Prince Edward County is home to a six branch public library system that is proud to have created a robust and vibrant relationship with the local school board. Through the lense of access, this article explores the steps taken by the public library to create meaningful connections with administrative staff on the school board level in order to bring practical training and resources to teachers and students in order to enhance and support their learning. 

Feasibility of delivering foot and ankle surgical courses in a partnership in Eastern, Central and Sothern Africa

BACKGROUND

Foot and ankle pathology if not treated appropriately and in a timely manner can adversely affect both disability and quality adjusted life years. More so in the low- and middle-income countries where ambulation is the predominant means of getting around for the majority of the population in order to earn a livelihood. This has necessitated the equipping of the new generation of orthopaedic surgeons with the expertise and skills set to manage these conditions. To address this need, surgeons from the British Orthopaedic Foot & Ankle Society (BOFAS) and College of Surgeons of Eastern, Central and Southern Africa (COSECSA) transferred the "Principles of Foot and Ankle Surgery" course to an African regional setting. The course was offered to surgical trainees from 14-member countries of the COSECSA region and previously in the UK. The faculty was drawn from practicing surgeons experienced in both surgical education and foot and ankle surgery. The course comprises didactic lectures, case-based discussions in small groups, patient evaluations and guided surgical dissections on human cadavers. It was offered free to all participants. The feasibility of the course was evaluated using the model defined by Bowen considering the eight facets of acceptability, demand, implementation, practicality, adaptation, integration, expansion and limited efficacy. At the end of the course participants were expected to give verbal subjective feedback and objective feedback using a cloud based digital feedback questionnaire. The course content was evaluated by the participants as "Poor", "Below average", "Average", "Good" and "Excellent", which was converted into a value from 1-5 for analysis. The non-parametric categorical data was analysed using the Two-sample Wilcoxon rank-sum (Mann-Whitney) test, and significance was considered to be p < 0.05.

RESULTS

Six courses in total were held between 2018 and 2020. Three in the UK and three in the COSECSA region. There were 78 participants in the three UK courses and 96 in the three courses run in the COSECSA region. Hundred percent of the UK participants and 97% of the COSECSA participants completed the feedback. Male to female ratio was 4:1 for the UK courses and 10:1 for the COSECSA Courses. In both regions all the participants responded that they would recommend the course to their colleagues. Among the COSECSA participants 91% reported that the course was pitched at the right level, which is similar to the 89% of the UK participants (p = 0.28).

CONCLUSION

The BOFAS Principles of Foot and Ankle Surgery course design provides core knowledge, with an emphasis on clinical examination techniques of the foot and ankle, while at the same time, caters for the anticipated difference in the local clinical case mix and resources. This study establishes that by attending the course surgical trainees can achieve their learning goals in foot and ankle surgery with the same high quality qualitative and quantitative feedback in both regions. This would improve their clinical practice and confidence. The multifaceted approach adopted in this course blending didactic teaching, small group discussions, interactive sessions, case-based discussions, cadaveric surgical skills training printed educational materials and feedback helped fulfil these educational objectives. Working in partnership with local expert orthopaedic surgeons from a number of Sub-Saharan countries, was key to adapting the course to local pathology and the COSECSA setting.

Teriparatide and pelvic fracture healing: a phase 2 randomized controlled trial

Pelvic fracture patients were randomized to blinded daily subcutaneous teriparatide (TPTD) or placebo to assess healing and functional outcomes over 3 months. With TPTD, there was no evidence of improved healing by CT or pain reduction; however, physical performance improved with TPTD but not placebo (group difference p < 0.03).

INTRODUCTION

To determine if teriparatide (20 μg/day; TPTD) results in improved radiologic healing, reduced pain, and improved functional outcome vs placebo over 3 months in pelvic fracture patients.

METHODS

This randomized, placebo-controlled study enrolled 35 patients (women and men >50 years old) within 4 weeks of pelvic fracture and evaluated the effect of blinded TPTD vs placebo over 3 months on fracture healing. Fracture healing from CT images at 0 and 3 months was assessed as cortical bridging using a 5-point scale. The numeric rating scale (NRS) for pain was administered monthly. Physical performance was assessed monthly by Continuous Summary Physical Performance Score (based on 4 m walk speed, timed repeated chair stands, and balance) and the Timed Up and Go (TUG) test.

RESULTS

The mean age was 82, and >80% were female. The intention to treat analysis showed no group difference in cortical bridging score, and 50% of fractures in TPTD-treated and 53% of fractures in placebo-treated patients were healed at 3 months, unchanged after adjustment for age, sacral fracture, and fracture displacement. Median pain score dropped significantly in both groups with no group differences. Both CSPPS and TUG improved in the teriparatide group, whereas there was no improvement in the placebo group (group difference p < 0.03 for CSPPS at 2 and 3 months).

CONCLUSION

In this small randomized, blinded study, there was no improvement in radiographic healing (CT at 3 months) or pain with TPTD vs placebo; however, there was improved physical performance in TPTD-treated subjects that was not evident in the placebo group.

Genome-wide analysis of mitochondrial DNA copy number reveals loci implicated in nucleotide metabolism, platelet activation, and megakaryocyte proliferation

Mitochondrial DNA copy number (mtDNA-CN) measured from blood specimens is a minimally invasive marker of mitochondrial function that exhibits both inter-individual and intercellular variation. To identify genes involved in regulating mitochondrial function, we performed a genome-wide association study (GWAS) in 465,809 White individuals from the Cohorts for Heart and Aging Research in Genomic Epidemiology (CHARGE) consortium and the UK Biobank (UKB). We identified 133 SNPs with statistically significant, independent effects associated with mtDNA-CN across 100 loci. A combination of fine-mapping, variant annotation, and co-localization analyses was used to prioritize genes within each of the 133 independent sites. Putative causal genes were enriched for known mitochondrial DNA depletion syndromes (p = 3.09 × 10-15) and the gene ontology (GO) terms for mtDNA metabolism (p = 1.43 × 10-8) and mtDNA replication (p = 1.2 × 10-7). A clustering approach leveraged pleiotropy between mtDNA-CN associated SNPs and 41 mtDNA-CN associated phenotypes to identify functional domains, revealing three distinct groups, including platelet activation, megakaryocyte proliferation, and mtDNA metabolism. Finally, using mitochondrial SNPs, we establish causal relationships between mitochondrial function and a variety of blood cell-related traits, kidney function, liver function and overall (p = 0.044) and non-cancer mortality (p = 6.56 × 10-4).

356 An Unfortunate Case of Spinal Injury and Bladder Dysfunction During the Covid-19 Pandemic

There is no doubt that COVID-19 has had a profound impact on every medical and surgical speciality. In the height of the pandemic many non-emergency services were shut down, including dental services, with unexpected consequences. We present a case which highlights the unexpected and indirect consequences of a national lockdown on a Urology patient and discuss learning points.

A 54-year-old male, previously fit and well suffered with a small dental abscess, media outlets were reporting that dental surgeries were closed, and he therefore attempted to drain the abscess himself. The infection spread to his epidural space, causing compression via a collection at L2 and consequently spinal cord injury. This was managed with urgent lumbar decompression and antibiotics.

A specialist functional urology team were involved after his transfer to the tertiary spinal unit 3 months after his first presentation. He was catheterised but suffered with recurrent catheter blockages. Video urodynamics demonstrated a stable bladder with a low-pressure leak point, managed with urethral catheterisation. A repeat video urodynamics demonstrated a loss of compliance and stress incontinence. Unclear as to whether he would regain function rehabilitation techniques are currently being attempted prior for definitive operative management with an artificial sphincter.

This case highlights the indirect impact of COVID-19 on UK urology services, and this has not been widely reported.

Risk factors for multi-joint disease in patients with glucocorticoid-induced osteonecrosis

This study investigated risk factors for osteonecrosis involving multiple joints (MJON) among glucocorticoid-treated patients. The best predictor of MJON was cumulative oral glucocorticoid dose. Risk of MJON was 12-fold higher in patients who had a second risk factor for osteonecrosis. Further research is needed into strategies for prevention of MJON.

INTRODUCTION

Osteonecrosis (ON) is a debilitating musculoskeletal condition in which bone cell death can lead to mechanical failure. When multiple joints are affected, pain and disability are compounded. Glucocorticoid treatment is one of the most common predisposing factors for ON. This study investigated risk factors for ON involving multiple joints (MJON) among glucocorticoid-treated patients.

METHODS

Fifty-five adults with glucocorticoid-induced ON were prospectively enrolled. MJON was defined as ON in ≥ three joints. Route, dose, duration, and timing of glucocorticoid treatment were assessed.

RESULTS

Mean age of enrolled subjects was 44 years, 58% were women. Half had underlying conditions associated with increased ON risk: systemic lupus erythematosus (29%), acute lymphoblastic leukemia (11%), HIV (9%), and alcohol use (4%). Mean daily oral dose of glucocorticoids was 29 mg. Average cumulative oral dose was 30 g over 5 years. The best predictor of MJON was cumulative oral glucocorticoid dose. For each increase of 1,000 mg, risk of MJON increased by 3.2% (95% CI 1.03, 1.67). Glucocorticoid exposure in the first 6 months of therapy, peak dose (oral or IV), and mean daily dose did not independently increase risk of MJON. The risk of MJON was 12-fold in patients who had a second risk factor (95% CI 3.2, 44.4).

CONCLUSIONS

Among patients with glucocorticoid-induced ON, cumulative oral dose was the best predictor of multi-joint disease; initial doses of IV and oral glucocorticoids did not independently increase risk. Further research is needed to better define optimal strategies for prevention and treatment of MJON.

Implementation of an intersectoral outreach and community nursing care intervention with refugees in Quebec: A protocol study

AIM

To establish and assess an intersectoral local network focused on the roles of registered nurses and primary healthcare nurse practitioners to ensure the continuity of care and service pathways for refugees in Quebec.

DESIGN

Developmental evaluation with a mixed methodology.

METHODS

The qualitative component will include: (1) a document review; (2) observations of participants during meetings of different governance structures; (3) semi-structured interviews with key actors (n = 40; 20/neighbourhood interventions); and (4) focus groups with end users of the services (refugees) (n = 4; 6 to 8 participants per group). The quantitative component will be based on: (1) a data sheet on health and social interventions for refugees users filled in by registered nurses, primary healthcare nurse practitioners and physicians and (2) data analysis of the clinical-administrative database since 2012. This study received funding in June 2019 and Research Ethics Committee approval was granted in July 2020.

DISCUSSION

In Quebec, refugee vulnerability is exacerbated by the lack of integration of existing resources and the lack of access to care and continuity of services. To address these issues, an integrated local network for refugees must be developed. Additionally, we will explore the role of registered nurses and their collaboration with primary healthcare nurse practitioners.

IMPACT

This study will provide recommendations on how to optimize the scopes of practice of registered nurses and primary healthcare nurse practitioners, adapt care and services and develop a local intersectoral network to better meet the complex needs of refugees. It will evaluate the use and the appreciation of new services for targeted populations (neighbourhoods and refugees) and aim to improve the accessibility, continuity and user experience of all health services for those populations.

Downstream effects of polypathology on neurodegeneration of medial temporal lobe subregions

The medial temporal lobe (MTL) is a nidus for neurodegenerative pathologies and therefore an important region in which to study polypathology. We investigated associations between neurodegenerative pathologies and the thickness of different MTL subregions measured using high-resolution post-mortem MRI. Tau, TAR DNA-binding protein 43 (TDP-43), amyloid-β and α-synuclein pathology were rated on a scale of 0 (absent)-3 (severe) in the hippocampus and entorhinal cortex (ERC) of 58 individuals with and without neurodegenerative diseases (median age 75.0 years, 60.3% male). Thickness measurements in ERC, Brodmann Area (BA) 35 and 36, parahippocampal cortex, subiculum, cornu ammonis (CA)1 and the stratum radiatum lacunosum moleculare (SRLM) were derived from 0.2 × 0.2 × 0.2 mm3 post-mortem MRI scans of excised MTL specimens from the contralateral hemisphere using a semi-automated approach. Spearman's rank correlations were performed between neurodegenerative pathologies and thickness, correcting for age, sex and hemisphere, including all four proteinopathies in the model. We found significant associations of (1) TDP-43 with thickness in all subregions (r =  - 0.27 to r =  - 0.46), and (2) tau with BA35 (r =  - 0.31) and SRLM thickness (r =  - 0.33). In amyloid-β and TDP-43 negative cases, we found strong significant associations of tau with ERC (r =  - 0.40), BA35 (r =  - 0.55), subiculum (r =  - 0.42) and CA1 thickness (r =  - 0.47). This unique dataset shows widespread MTL atrophy in relation to TDP-43 pathology and atrophy in regions affected early in Braak stageing and tau pathology. Moreover, the strong association of tau with thickness in early Braak regions in the absence of amyloid-β suggests a role of Primary Age-Related Tauopathy in neurodegeneration.

POS1383 THE ASSOCIATION BETWEEN BARIATRIC SURGERY AND DUPUYTREN DISEASE: A COHORT STUDY FROM SWEDISH NATIONWIDE HEALTHCARE REGISTRIES

Background:

Dupuytren disease (DD) is multifactorial, with several genetic and environmental risk factors contributing to disease susceptibility. High body mass index, however, was suggested to be protective of DD.1 The impact of weight loss among obese patients on DD has not been assessed to date.

Objectives:

To assess the association between bariatric surgery and DD in a secondary care setting.

Methods:

We performed a propensity score (PS)-matched cohort study using data from Swedish nationwide healthcare registries (patient registry [secondary care], causes of death registry, prescribed drug registry). Patients aged 30-79 years who underwent bariatric surgery between 2006 and 2019 were matched to up to 2 obese bariatric surgery-free patients (called unexposed patients) based on their PS. PS-matching was carried out in risk set sampling to reduce selection bias, within 4 sequential cohort entry blocks to account for time trend biases. The outcome DD was defined as a diagnosis of DD in secondary care or partial or total fasciotomy of wrist or hand. After a 1-year run-in period, patients were followed in an “as-treated” approach. We applied Cox proportional hazard regression to calculate hazard ratios (HR) with 95% confidence intervals (CIs) of incident DD among bariatric surgery patients when compared to obese unexposed patients overall, and in subgroups of age, sex, bariatric surgery type, and by duration of follow-up.

Results:

A total of 34 959 bariatric surgery patients were PS-matched to 54 769 obese unexposed patients. A total of 71.6% of bariatric surgery patients were women. Bariatric surgery patients had a mean age of 45.5 years and a mean follow-up of 6.9 years. All patient characteristics in obese unexposed patients were highly similar. We observed 126 and 136 severe DD cases among bariatric surgery and obese unexposed patients, respectively. The risk of DD was significantly increased in bariatric surgery patients compared to obese unexposed patients (HR = 1.30, 95% CI 1.02-1.65). The risk of DD was higher in women (HR = 1.36, 95% CI 1.00-1.84) than in men (HR = 1.05, 95% CI 0.70-1.58). Age did not modify the risk of DD among bariatric surgery patients compared to obese unexposed patients. Malabsorptive bariatric surgery yielded an increased risk of DD when compared to obese unexposed patients (HR = 1.33, 95% CI 1.04-1.71), while restrictive bariatric surgery yielded a null result. The risk of DD increased with duration of follow-up (>5 years of follow-up: HR = 1.63, 95% CI 1.14-2.34, null result in earlier follow-up).

Conclusion:

Our results suggest that substantial weight loss is associated with a latent increased risk of severe DD in an obese population. This observation further strengthens current evidence that high body mass index is protective against DD. The latency of risk increase of DD after bariatric surgery may suggest that slowly adapting metabolic changes may be part of the mechanism of DD emergence.

References:

[1]Hacquebord JH, Chiu VY, Harness NG. The Risk of Dupuytren Surgery in Obese Individuals. J Hand Surg Am. 2017, 42: 149–55.

Acknowledgements:

We thank Prof. Dr. Jesper Lagergren (Karolinksa Institutet, Stockholm, Sweden) for hosting Dr. Theresa Burkard for a research stay at the Upper Gastrointestinal Surgery Group and making the data available for use. Furthermore, we thank Dr. Giola Santoni (Karolinksa Institutet, Stockholm, Sweden) for her technical support.

Disclosure of Interests:

None declared

POS0011 THE ASSOCIATION BETWEEN BARIATRIC SURGERY AND CARPAL TUNNEL SYNDROME: A COHORT STUDY FROM SWEDISH NATIONWIDE HEALTHCARE REGISTRIES

Background:

Carpal tunnel syndrome (CTS) is a chronic compression neuropathy caused by entrapment of the median nerve in the wrist causing pain and sensory loss. Prior observational research suggested that obesity increased the risk of CTS. However, the impact of weight loss among obese patients on CTS has not been assessed to date.

Objectives:

To assess the association between bariatric surgery and CTS in a secondary care setting.

Methods:

We performed a propensity score (PS)-matched cohort study using data from Swedish nationwide healthcare registries (patient registry [secondary care], causes of death registry, prescribed drug registry). Patients aged 18-79 years who underwent bariatric surgery between 2006 and 2019 were matched to up to 2 obese bariatric surgery-free patients (called unexposed patients) based on their PS. PS-matching was carried out in risk set sampling to reduce selection bias, within 4 sequential cohort entry blocks to account for time trend biases. The outcome CTS was defined as a diagnosis of CTS in secondary care or carpal tunnel decompression surgery. After a 1-year run-in period, patients were followed in an “as-treated” approach. We applied Cox proportional hazard regression to calculate hazard ratios (HR) with 95% confidence intervals (CIs) of CTS among bariatric surgery patients when compared to obese unexposed patients overall, and in subgroups of age, sex, bariatric surgery type, and by duration of follow-up.

Results:

A total of 40 619 bariatric surgery patients were PS-matched to 63 540 obese unexposed patients. A total of 72.3% of bariatric surgery patients were women. Bariatric surgery patients had a mean age of 41.7 years and a mean follow-up of 6.8 years. All patient characteristics in obese unexposed patients were highly similar. We observed 1 356 and 1 938 severe CTS cases among bariatric surgery and obese unexposed patients, respectively. Bariatric surgery was not associated overall with CTS (HR of 0.98, 95% CI 0.91-1.05). However, the risk of CTS seemed to decrease with age at bariatric surgery – the lowest CTS risk was observed among bariatric surgery patients aged 18-34 years (HR of 0.87, 95% CI 0.74-1.01), when compared to obese unexposed patients. Sex did not modify the risk of CTS among bariatric surgery patients compared to obese unexposed patients. Restrictive bariatric surgery yielded lower risks of CTS (HRs of 0.81, 95% CI 0.69-0.88) than did malabsorptive bariatric surgery (HR of 0.95, 95% CI 0.88-1.02) when compared to obese unexposed patients. The risk of CTS increased with duration of follow-up. The lowest risk was observed 1-3 years after bariatric surgery (HR of 0.77, 95% CI 0.68-0.88) and the highest risk 6-13 years after bariatric surgery (HR of 1.20, 95% CI 1.05-1.36) when compared to obese unexposed patients.

Conclusion:

Our results suggest that substantial weight loss is not overall associated with severe CTS in an obese patient population. However, bariatric surgery was associated with an initial decreased risk of CTS after bariatric surgery followed by an increased risk in later follow-up. Furthermore, restrictive bariatric surgery but not malapsorptive bariatric surgery was associated with a decreased risk of CTS.

Acknowledgements:

We thank Prof. Dr. Jesper Lagergren (Karolinksa Institutet, Stockholm, Sweden) for hosting Dr. Theresa Burkard for a research stay at the Upper Gastrointestinal Surgery Group and making the data available for use. Furthermore, we thank Dr. Giola Santoni (Karolinksa Institutet, Stockholm, Sweden) for her technical support.

Disclosure of Interests:

None declared.

Implementation conditions leading to the scale-up of an innovation involving the optimal use of antipsychotics in long-term care centers: The Optimizing Practices, use, Care and Services-Antipsychotics (OPUS-AP) program

BACKGROUND

Antipsychotics are often used for the first-line management of behavioral and psychological symptoms of dementia despite their limited efficacy and the risk of serious adverse drug events, compounded with disregard for guidelines recommending prioritizing non-pharmacological interventions. Some innovative interventions promote the deprescription of antipsychotics in long term care (LTC) settings.

OBJECTIVE

The objective of this article is to present the conditions leading to the scale-up of an innovative program on the appropriate use of antipsychotics in LTC centers.

METHODS

The Optimizing Practices, Use, Care and Services-Antipsychotics (OPUS-AP) program is a mixed-method project that aims to improve LTC residents' care through increased knowledge and competency among staff, resident-centered approaches, nonpharmacologic interventions, and by deprescribing antipsychotics when appropriate. This article consists of a qualitative study focused on exploring the implementation conditions of the OPUS-AP program. This study was carried out in an integrated health area of Québec. It consisted of 46 semi-structured interviews with staff members and managers involved in the implementation of OPUS-AP. The qualitative data analysis was inspired by a realistic evaluation approach, which shed light on the causal chain between context, mechanisms, and perceived effects.

RESULTS

This study identified certain conditions conducive to scaling up the OPUS-AP program: an integrated, collaborative and evidence-based approach; communications in support of the process; stakeholder engagement at the strategic, tactical and operational levels; an implementation climate conducive to change; and an integrated knowledge translation strategy.

CONCLUSION

Despite evidence of clinical efficacy, deprescribing programs require great deal of scaling up efforts. Hence, this study underscores the need to further examine conditions for scaling up medication usage programs in real life contexts.

Getting to grips with wildlife research by citizen scientists: What role for regulation?

Wildlife research by citizen scientists, involving the capture and handling of animals, provides clear scientific benefits, but also potential risks to animal welfare. We explore debates about how best to regulate such work to ensure that it is undertaken in an ethical manner.We focus on the UK as a case study, drawing on qualitative research and stakeholder engagement events. We show that because trapping and marking of certain species requires minimal licensing, training and justification, some argue for increased formal regulation to minimise risks to animal welfare. However, others have reflected on the already complex regulatory landscape affecting wildlife research, and have expressed concern that introducing additional formal regulations could potentially make citizen science working with wildlife more difficult. Informal regulation could therefore offer a preferable alternative.We set out three steps that could be taken to open up conversations about ethics and regulation of wildlife-focussed citizen science, in the UK and elsewhere: (a) take stock of wildlife-focussed citizen science in terms of numbers and harms to animal welfare; (b) assess the state of formal regulations and consider reforms; and (c) consider informal regulations as alternatives or additions to formal regulations.

Animal Research beyond the Laboratory: Report from a Workshop on Places Other than Licensed Establishments (POLEs) in the UK

Research involving animals that occurs outside the laboratory raises an array of unique challenges. With regard to UK legislation, however, it receives only limited attention in terms of official guidelines, support, and statistics, which are unsurprisingly orientated towards the laboratory environment in which the majority of animal research takes place. In September 2019, four social scientists from the Animal Research Nexus program gathered together a group of 13 experts to discuss nonlaboratory research under the Animals (Scientific Procedures) Act (A(SP)A) of 1986 (mirroring European Union (EU) Directive 2010/63/EU), which is the primary mechanism for regulating animal research in the UK. Such nonlaboratory research under the A(SP)A often occurs at Places Other than Licensed Establishments (POLEs). The primary objective of the workshop was to assemble a diverse group with experience across a variety of POLEs (e.g., wildlife field sites, farms, fisheries, veterinary clinics, zoos) to explore the practical, ethical, and regulatory challenges of conducting research at POLEs. While consensus was not sought, nor reached on every point of discussion, we collectively identified five key areas that we propose require further discussion and attention. These relate to: (1) support and training; (2) ethical review; (3) cultures of care, particularly in nonregulated research outside of the laboratory; (4) the setting of boundaries; and (5) statistics and transparency. The workshop generated robust discussion and thereby highlighted the value of focusing on the unique challenges posed by POLEs, and the need for further opportunities for exchanging experiences and sharing best practice relating to research projects outside of the laboratory in the UK and elsewhere.

Community outreach workers: Perceived practices and impacts on families and young children

Background

Community outreach workers support individuals accessing healthcare and other services that could be useful to respond to their needs. Even though community outreach workers have been working in the province of Quebec (Canada) for the past 40 years, their practice is poorly documented and evaluated, especially with respect to young children aged 0 to 5 years. This study aimed to document the practice of community outreach workers and its perceived impacts among children and families.

Methods

A qualitative methodology with a descriptive research design was used. We performed a content analysis on 55 scientific and grey literature documents, 24 individual interviews, and 3 focus groups with stakeholders including parents, community outreach workers, healthcare employees, and inter-sectoral partners.

Results

Our analysis reveals three main themes: 1) characteristics of the population served, 2) concrete actions performed by community outreach workers, and 3) perceived impacts of community outreach on families and children. Community outreach workers were perceived as essential to reach families with vulnerable circumstances and children with special needs. With respect to concrete actions, community outreach workers were reported to tailor their interventions to respond in different but complementary ways to the healthcare system. Perceived impacts included increased access for children and families to appropriate services, decreased social isolation, increased empowerment (especially with respect to parental abilities), increased social capital of families, and confidence towards the healthcare system. Results showed that community outreach workers helped to reduce inequalities in health

Conclusions

Community outreach work help the healthcare system to fulfill its legal mandate to protect citizen and increase health and well-being. It is crucial that such type of proximity approaches be not only encouraged but also sustained.

Key messages

Community outreach workers adapt their practices to act in a complementary way to the healthcare system. Community outreach workers help to reduce inequalities in health.

FRI0511 THE DESCRIPTIVE EPIDEMIOLOGY AND SECULAR TRENDS OF LOWER BACK PAIN PROCEDURES IN ROUTINE UK NHS CARE FROM 2000 TO 2016

Background:

The lifetime prevalence of lower back pain is between 60% and 70%, with surgical treatments spared for those not responding to other options.

Objectives:

To investigate the age, gender and socio-economic status differences in back pain procedures in the UK between 2000, 2008 and 2016.

Methods:

Data was obtained from primary care electronic medical records (CPRD GOLD) linked to English hospital admissions data. Lower back procedures in patients aged 35+ were identified using OPCS-4 codes for Decompression (Dc), Fusion (F), Therapeutic injections (TI) and Denervation (Dn). Standardised incidence rates (IR) of each type of lower back procedures were calculated per 10,000 CPRD registered person years for each age group, gender, region and SES strata in 2000, 2008 and 2016. IR were also calculated for combinations of age and gender. Negative binomial regression calculated incidence rate ratios (IRR) and 95% confidence intervals.

Results:

The IR of lower back procedures was 21.5 [20.7, 22.3] per 10,000 person years in 2000. This doubled by 2008 (45.5 [44.5, 46.5]) and trebled by 2016 (62.5 [60.8, 64.2]). Number of events and incidence rates of each procedure type are shown in table 1 below. The incidence of Dn has increased 6-fold whilst Dc and F have doubled. Female (IR in 2016 of 73.99 [71.43, 76.61] vs 50.08 [47.90, 52.33] in men, IRR 1.50 [1.41, 1.59]) and age are associated with back procedure rates (figure 1). Large socio-economic differences were observed, with higher procedure rates seen in the most deprived areas. These differences did however narrow over time during the study period (figure 2).

Table 1.

Event numbers and incidence rates of different types of lower back procedure.

FusionDecompressionTherapeutic InjectionDenervationEventsIR (95% CI)EventsIR (95% CI)EventsIR (95% CI)EventsIR (95% CI)20001090.86 (0.71, 1.04)4663.69 (3.36, 4.04)203516.11 (15.42, 16.82)910.72 (0.58, 0.88)20083331.77 (1.58, 1.97)11976.35 (6.00, 6.72)628333.35 (32.53, 34.18)5963.16 (2.91, 3.43)20161591.93 (1.65, 2.26)5256.39 (5.85, 6.96)386547.03 (45.56, 48.54)4875.93 (5.41, 6.48)Figure 1.

Age and Gender stratified incidence rate ratios of all back procedures in 2000, 2008 and 2016

Figure 2.

Deprivation status incidence rate ratios by year

Conclusion:

The incidence of lower back procedures has more than trebled since 2000. Women are more likely to have lower back procedures than men, with patients aged 65-74 the most likely to have a procedure. Procedures in those aged 75+ have become more common over time, potentially increasing the risk of post-operative complications. Socio-economic differences in the incidence of low back procedures are probably related to the known higher prevalence of back pain in deprived areas. Whether the observed narrowing in socio-economic variation over time is explained by a reduced need or by lowered provision needs further research.

Disclosure of Interests:

Danielle E Robinson: None declared, Jennifer Lane: None declared, Richard Craig: None declared, Andrew Judge: None declared, James Bailey: None declared, Dahai Yu: None declared, Kelvin Jordan: None declared, George Peat: None declared, Ross Wilkie: None declared, Alan Silman: None declared, Victoria Y Strauss: None declared, Daniel Prieto-Alhambra Grant/research support from: Professor Prieto-Alhambra has received research Grants from AMGEN, UCB Biopharma and Les Laboratoires Servier, Consultant of: DPA’s department has received fees for consultancy services from UCB Biopharma, Speakers bureau: DPA’s department has received fees for speaker and advisory board membership services from Amgen

THU0212 FIRST LINE TREATMENT WITH CONVENTIONAL SYNTHETIC DISEASE MODIFYING ANTIRHEUMATIC DRUGS IN RHEUMATOID ARTHRITIS: A MULTINATIONAL POPULATION-BASED COHORT FROM 14 REAL WORLD HEALTHCARE DATABASES AND 9 COUNTRIES - REALITY VERSUS GUIDELINES

Background:

Treatment guidelines recommend early initiation of csDMARDs following diagnosis of rheumatoid arthritis (RA), with methotrexate (MTX) as first-line therapy. Scarce evidence exists on adherence to this guidance

Objectives:

To characterize first-line csDMARD treatment during the first year following an RA diagnosis.

Methods:

14 real world databases (3 Primary care, 6 primary/secondary care records, 5 claims) from 9 countries were included, all mapped to the OMOP common data model.

Patients were included on the earliest event of: 1st diagnosis of RA or 1st DMARD prescription with an RA diagnosis within 30 days. Patients were >18 years-old, required 1+ year pre-index data, and at least 1-year follow-up. Study period covered 2000-2018. Previous users of DMARDs or non-RA inflammatory arthritis history were excluded. Only MTX, Hydroxychloroquine (HCQ), Sulfasalazine (SSZ) and Leflunomide (LEF) were available in all databases.

Results:

We identified 323,547 eligible participants. Large variation was observed internationally (Figure 1). MTX as first-line monotherapy ranged from 33.3% to 74.5%, and in combination with HCQ from 2.1% to 6.7%. Three additional csDMARDs were used as first-line: HCQ in 10.1% to 30.2%, SSZ in 0.9% to 28.7%, and LEF in 1.8% to 15.2%.

Figure 1.

First line csDMARD treatment during 1yr from first observed RA diagnosis

Conclusion:

We report wide heterogeneity of first-line csDMARDs regimens internationally. Despite recommendations for MTX to be first line therapy, data suggest that a large proportion of patients receive alternative csDMARD.

Disclosure of Interests: :

Anthony G Sena Shareholder of: J&J shares, Grant/research support from: Full-time employment salary from Janssen, Consultant of: Full-time employment salary from Janssen, Employee of: Janssen employee, Paid instructor for: Janssen employee, Speakers bureau: Janssen employee, Denis Granados: None declared, Nigel Hughes Shareholder of: J&J shares, Grant/research support from: Full-time employment salary from Janssen, Consultant of: Janssen employee, Employee of: Janssen employee, Paid instructor for: Janssen employee, Speakers bureau: Janssen employee, WALID FAKHOURI Shareholder of: E Lilly Shares, Employee of: Eli Lilly and Company, Antje Hottgenroth Shareholder of: Eli Lilly shares, Employee of: Lilly Deutschland GmbH, Raivo Kolde: None declared, Sulev Reisberg: None declared, Carmen Olga Torre: None declared, Talita Duarte-Salles: None declared, Yesika Díaz: None declared, Jose Felipe Golib-Dzib Grant/research support from: Full-time employment salary from Janssen, Employee of: Yes, Janssen employee, Paid instructor for: Janssen Employee, Speakers bureau: Janssen Employee, Emily S. Brouwer Shareholder of: J&J shares, Takeda shares, Grant/research support from: Full-time employment salary from Janssen, Consultant of: Janssen employee, Employee of: Janssen employee, Paid instructor for: Janssen Employee, Speakers bureau: Janssen Employee, Edward Burn: None declared, Jennifer Lane: None declared, David Vizcaya Employee of: Bayer, Sara Bruce Wirta Employee of: Janssen-Cilag Sweden AB, Marcel de Wilde: None declared, Katia Verhamme: None declared, Peter Rijnbeek: None declared, Elke Theander Employee of: Janssen-Cilag Sweden AB, Katerina Chatzidionysiou Consultant of: AbbVie, Pfizer, Lilly., Daniel Prieto-Alhambra Grant/research support from: Professor Prieto-Alhambra has received research Grants from AMGEN, UCB Biopharma and Les Laboratoires Servier, Consultant of: DPA’s department has received fees for consultancy services from UCB Biopharma, Speakers bureau: DPA’s department has received fees for speaker and advisory board membership services from Amgen, Patrick Ryan: None declared

Effect of increased serum 25(OH)D and calcium on structure and function of post-menopausal women: a pilot study

The purpose was to determine if increasing serum 25(OH)D and calcium in postmenopausal women increased skeletal muscle size, strength, balance, and functional task performance while decreasing muscle fatigue. PCSA of the vastus lateralis increased and ascent of stairs time decreased after 6 months of increased serum 25(OH)D.

PURPOSE

The Institute of Medicine recommends ≥ 20 ng/ml of serum 25-hydroxyvitamin D [25(OH)D] for bone and overall health. Serum 25(OH)D levels have been associated with physical performance, postural sway, and falls. The purpose of this study was to determine if increasing postmenopausal women's serum 25(OH)D levels from 20-30 ng/ml to 40-50 ng/ml improved skeletal muscle size, strength, balance, and functional performance while decreasing skeletal muscle fatigue.

METHODS

Twenty-six post-menopausal women (60-85 years old) with baseline serum 25(OH)D levels between 20 and 30 ng/ml were recruited. Oral over-the-counter (OTC) vitamin D3 and calcium citrate were prescribed to increase subjects' serum 25(OH)D to levels between 40 and 50 ng/ml, serum calcium levels above 9.2 mg/dl, and PTH levels below 60 pg/ml, which were confirmed at 6 and 12 weeks. Outcome measures assessed at baseline and 6 months included muscle physiological cross-sectional area (PCSA), muscle strength, postural balance, time to perform functional tasks, and muscle fatigue. Repeated measures comparisons between baseline and follow-up were performed.

RESULTS

Nineteen subjects completed the study. One individual could not afford the time commitment for the repeated measures. Three individuals did not take their vitamin D as recommended. Two subjects were lost to follow-up (lack of interest), and one did not achieve targeted serum 25(OH)D. Vastus lateralis PCSA increased (p = 0.007) and ascent of stair time decreased (p = 0.042) after 6 months of increasing serum 25(OH)D levels from 20-30 ng/ml to 40-50 ng/ml. Isometric strength was unchanged. Anterior-posterior center of pressure (COP) excursion and COP path length decreased (p < 0.1) albeit non-significantly, suggesting balance may improve from increased serum 25(OH)D and calcium citrate levels.

CONCLUSIONS

Several measures of muscle structure and function were sensitive to elevated serum 25(OH)D and calcium levels indicating that further investigation of this phenomenon in post-menopausal women is warranted.

The Forgotten Second Window: A Pictorial Review of Round Window Pathologies

The round window serves to decompress acoustic energy that enters the cochlea via stapes movement against the oval window. Any inward motion of the oval window via stapes vibration leads to outward motion of the round window. Occlusion of the round window is a cause of conductive hearing loss because it increases the resistance to sound energy and consequently dampens energy propagation. Because the round window niche is not adequately evaluated by otoscopy and may be incompletely exposed during an operation, otologic surgeons may not always correctly identify associated pathology. Thus, radiologists play an essential role in the identification and classification of diseases affecting the round window. The purpose of this review is to highlight the developmental, acquired, neoplastic, and iatrogenic range of pathologies that can be encountered in round window dysfunction.

Prevalence of Asymptomatic Middle Cranial Fossa Floor Pits and Encephaloceles on MR Imaging

BACKGROUND AND PURPOSE

Temporal lobe encephaloceles are increasingly identified and treated as epileptogenic foci. However, there is relatively scant research on the prevalence of asymptomatic encephaloceles. This study set out to describe the frequency of incidental temporal lobe encephaloceles and middle cranial fossa pits.

MATERIALS AND METHODS

A retrospective review was completed of high-resolution (≤0.5-mm section thickness) axial T2WI for internal auditory canal protocol imaging. The presence and laterality of middle cranial fossa pits (small bony defects containing CSF) and encephaloceles (brain parenchyma protrusion through osseous defects with or without bony remodeling) were recorded. Electronic medical records of patients with encephaloceles were searched for a history of seizure.

RESULTS

A total of 203 patients were included in the final cohort; 106 (52.2%) women. Forty-five (22.2%) patients had middle cranial fossa pits: 14 (31.1%) unilateral on the right, 17 (37.8%) unilateral on the left, and 14 (31.1%) bilateral. Ten (5.0%) patients had ≥1 encephalocele, none of whom had a documented history of seizure in the electronic medical record. No significant difference was noted in the frequency of pits or encephaloceles based on sex (P = .332 and P = .383, respectively) or age (P = .497 and P = .914, respectively).

CONCLUSIONS

Incidental middle cranial fossa pits are common findings, and their prevalence is not related to age or sex. Temporal lobe encephaloceles, though rarer, also exist occasionally among asymptomatic patients. Such findings have diagnostic implications for encephaloceles identified during imaging work-up for epilepsy.

Changing Trends in Life Expectancy in Intellectual Disability over Time

Decreased life expectancy (LE) has historically been found among people with intellectual disability (ID) compared to the general population. Several recent studies have looked into ageing and cause of death in ID. Results of many of these studies suggest that, although LE in ID remains lower than the general population, it has increased across many Western societies in recent decades. Increases in LE in the general and ID populations appear to follow similar trends. Some major causes of mortality in ID are similar to the general population, and therefore may be amenable to similar preventative healthcare interventions. In this article, we have outlined possible reasons for improved LE in ID, and potential areas that may require further intervention. However, more detailed studies on mortality in ID may provide more accurate insight into areas requiring intervention in ID populations.

Development and validation of a gene expression test to identify hard-to-heal chronic venous leg ulcers

Background

Chronic venous leg ulcers pose a significant burden to healthcare systems, and predicting wound healing is challenging. The aim of this study was to develop a genetic test to evaluate the propensity of a chronic ulcer to heal.

Methods

Sequential refinement and testing of a gene expression signature was conducted using three distinct cohorts of human wound tissue. The expression of candidate genes was screened using a cohort of acute and chronic wound tissue and normal skin with quantitative transcript analysis. Genes showing significant expression differences were combined and examined, using receiver operating characteristic (ROC) curve analysis, in a controlled prospective study of patients with venous leg ulcers. A refined gene signature was evaluated using a prospective, blinded study of consecutive patients with venous ulcers.

Results

The initial gene signature, comprising 25 genes, could identify the outcome (healing versus non-healing) of chronic venous leg ulcers (area under the curve (AUC) 0·84, 95 per cent c.i. 0·73 to 0·94). Subsequent refinement resulted in a final 14-gene signature (WD14), which performed equally well (AUC 0·88, 0·80 to 0·97). When examined in a prospective blinded study, the WD14 signature could also identify wounds likely to demonstrate signs of healing (AUC 0·73, 0·62 to 0·84).

Conclusion

A gene signature can identify people with chronic venous leg ulcers that are unlikely to heal.

Detecting fluoxetine and norfluoxetine in wild bird tissues and feathers

The contamination of the environment with human pharmaceuticals is widespread and demand for such products is mounting globally. Wild vertebrates may be at particular risk from any effects from pharmaceuticals, because of the evolutionary conservation of drug targets. However, exposure of wildlife to pharmaceuticals is poorly characterised, partly due to challenges associated with detecting rapidly metabolised compounds. As part of a wider study on the behavioural effects of fluoxetine (Prozac) on Eurasian starlings (Sturnus vulgaris), we investigated which avian samples are best suited for detecting exposure to fluoxetine in free-living birds. We analysed plasma, various tissues and tail feathers (grown both in the wild and in captivity during the dosing period) from fluoxetine-treated birds (dosed daily with 0.035 mg kg^-1 bodyweight for 28 weeks), and liver tissue and tail feathers from sham-dosed birds. We detected fluoxetine in only two of twelve plasma samples from dosed birds. In dosed birds, median concentrations of free fluoxetine/norfluoxetine in tissues (two hour post-final dose) were: 111.2/67.6 ng g^-1 in liver, 29.6/5.7 ng g^-1 in kidney, 14.2/4.0 ng g^-1 in lung, 15.1/1.6 ng g^-1 in brain. We estimated that fluoxetine would remain detectable in liver and kidney approximately 4.5 times longer (90 h) than in brain (20h). In dosed birds, fluoxetine was detected in feathers regrown during the dosing period (median concentration = 11.4 ng g^-1) at concentrations significantly higher than in regrown feathers from control birds. Fluoxetine residues were detected in wild-grown feathers (grown before the birds were brought into captivity) at concentrations up to 27.0 ng g^-1, providing some evidence of likely exposure in the wild. Our results show liver and kidney can be used for detecting fluoxetine in avian carcasses and provide a first indication that feathers may be useful for assessing exposure to fluoxetine, and possibly other pharmaceuticals.

Environmentally relevant exposure to an antidepressant alters courtship behaviours in a songbird

Pharmaceuticals in the environment are a recently identified global threat to wildlife, including birds. Like other human pharmaceuticals, the antidepressant fluoxetine (Prozac) enters the environment via sewage and has been detected at wastewater treatment plants. Birds foraging on invertebrates at these sites can be exposed to pharmaceuticals, although the implications of exposure are poorly understood. We conducted experiments to test whether chronic exposure to a maximally environmentally relevant concentration of fluoxetine (2.7 μg day^-1) altered courtship behaviour and female reproductive physiology in wild-caught starlings (Sturnus vulgaris), a species commonly found foraging on invertebrates at wastewater treatment plants. When paired with a female over two days, males sang less and were more aggressive towards fluoxetine-treated females than controls. Fluoxetine-treated females were initially aggressive towards males, becoming significantly less aggressive by the second day. In contrast, control females expressed intermediate levels of aggression throughout. We found no effect of female treatment on female courtship behaviour. Female body condition, circulating testosterone and circulating oestradiol were unaffected by treatment and did not account for male preference. Our findings suggest that exposure to an antidepressant reduced female attractiveness, adding to growing evidence that environmental concentrations of pharmaceuticals can alter important traits related to individual fitness and population dynamics.

The U(n) Gelfand-Zeitlin system as a tropical limit of Ginzburg-Weinstein diffeomorphisms

In this paper, we show that the Ginzburg-Weinstein diffeomorphism [Formula: see text] of Alekseev & Meinrenken (Alekseev, Meinrenken 2007 J. Differential Geom.76, 1-34. (10.4310/jdg/1180135664)) admits a scaling tropical limit on an open dense subset of [Formula: see text] The target of the limit map is a product [Formula: see text], where [Formula: see text] is the interior of a cone, T is a torus, and [Formula: see text] carries an integrable system with natural action-angle coordinates. The pull-back of these coordinates to [Formula: see text] recovers the Gelfand-Zeitlin integrable system of Guillemin & Sternberg (Guillemin, Sternberg 1983 J. Funct. Anal.52, 106-128. (10.1016/0022-1236(83)90092-7)). As a by-product of our proof, we show that the Lagrangian tori of the Flaschka-Ratiu integrable system on the set of upper triangular matrices meet the set of totally positive matrices for sufficiently large action coordinates.This article is part of the theme issue 'Finite dimensional integrable systems: new trends and methods'.

Lack of allergy to timothy grass pollen is not a passive phenomenon but associated with the allergen-specific modulation of immune reactivity

BACKGROUND

Timothy grass (TG) pollen is a common seasonal airborne allergen associated with symptoms ranging from mild rhinitis to severe asthma.

OBJECTIVE

The aim of this study was to characterize changes in TG-specific T cell responses as a function of seasonality.

METHODS

Peripheral blood mononuclear cells (PBMCs) obtained from allergic individuals and non-allergic controls, either during the pollen season or out of season, were stimulated with either TG extract or a pool of previously identified immunodominant antigenic regions.

RESULTS

PBMCs from allergic subjects exhibit higher IL-5 and IL-10 responses in season than when collected out of season. In the case of non-allergic subjects, as expected we observed lower IL-5 responses and robust production of IFN-γ compared to allergic individuals. Strikingly, non-allergic donors exhibited an opposing pattern, with decreased immune reactivity in season. The broad down-regulation in non-allergic donors indicates that healthy individuals are not oblivious to allergen exposure, but rather react with an active modulation of responses following the antigenic stimulus provided during the pollen season. Transcriptomic analysis of allergen-specific T cells defined genes modulated in concomitance with the allergen exposure and inhibition of responses in non-allergic donors.

CONCLUSION AND CLINICAL RELEVANCE

Magnitude and functionality of T helper cell responses differ substantially in season vs. out of season in allergic and non-allergic subjects. The results indicate the specific and opposing modulation of immune responses following the antigenic stimulation during the pollen season. This seasonal modulation reflects the enactment of specific molecular programmes associated with health and allergic disease.