Design and Statistical Innovations in a Platform Trial for Amyotrophic Lateral Sclerosis

Platform trials allow efficient evaluation of multiple interventions for a specific disease. The HEALEY ALS Platform Trial is testing multiple investigational products in parallel and sequentially in persons with amyotrophic lateral sclerosis (ALS) with the goal of rapidly identifying novel treatments to slow disease progression. Platform trials have considerable operational and statistical efficiencies compared with typical randomized controlled trials due to their use of shared infrastructure and shared control data. We describe the statistical approaches required to achieve the objectives of a platform trial in the context of ALS. This includes following regulatory guidance for the disease area of interest and accounting for potential differences in outcomes of participants within the shared control (potentially due to differences in time of randomization, mode of administration, and eligibility criteria). Within the HEALEY ALS Platform Trial, the complex statistical objectives are met using a Bayesian shared parameter analysis of function and survival. This analysis serves to provide a common integrated estimate of treatment benefit, overall slowing in disease progression, as measured by function and survival while accounting for potential differences in the shared control group using Bayesian hierarchical modeling. Clinical trial simulation is used to provide a better understanding of this novel analysis method and complex design. ANN NEUROL 2023;94:547-560.

Multiple types of distress are prospectively associated with increased risk of ovarian cancer

BACKGROUND

Few modifiable risk factors for epithelial ovarian cancer have been identified. We and other investigators have found that individual psychosocial factors related to distress are associated with higher risk of ovarian cancer. The present study examined whether co-occurring distress-related factors are associated with ovarian cancer risk.

METHODS

Five distress-related factors were measured repeatedly over 21 years of follow-up: depression, anxiety, social isolation, widowhood, and, in a subset or women, posttraumatic stress disorder (PTSD). Cox proportional hazards models estimate relative risks (RR) and 95% confidence intervals (CI) of ovarian cancer for a time-updated count of distress-related factors, in age-adjusted models, then further adjusted for ovarian cancer risk factors and behavior-related health risk factors.

RESULTS

Across 1,193,927 person-years of follow-up, 526 incident ovarian cancers occurred. Women with ≥3 versus no distress-related psychosocial factors demonstrated increased ovarian cancer risk (HRage-adjusted  = 1.71; 95% CI = 1.16, 2.52). No significant difference in ovarian cancer risk was observed in women with one or two versus no distress-related psychosocial factors. In the subsample with PTSD assessed, ≥3 versus no distress-related psychosocial factors was associated with twofold greater ovarian cancer risk (HRage-adjusted  = 2.08, 95% CI = 1.01, 4.29). Further analysis suggested that women at highest ovarian cancer risk had PTSD co-occurring with any other distress-related factor (HR = 2.19, 95% CI = 1.20, 4.01). Adjusting for cancer risk factors and health behaviors minimally impacted risk estimates.

CONCLUSIONS

Presence of multiple indicators of distress was associated with risk of ovarian cancer. When including PTSD as an indicator of distress, the association was strengthened.

Examining the Association Between Childhood Trauma, Brain Injury, and Neurobehavioral Symptoms Among Survivors of Intimate Partner Violence: A Cross-Sectional Analysis

OBJECTIVE

Understanding factors contributing to neurobehavioral symptom burden among intimate partner violence (IPV) survivors has important implications for prevention, screening, and intervention in this vulnerable population. This study aimed to (1) identify the relationship between childhood trauma and neurobehavioral symptoms among a shelter- and community-based sample of IPV survivors, including investigating the mediating role of posttraumatic stress symptoms and alexithymia in this relationship; (2) assess the association between IPV-related brain injury (BI) severity and neurobehavioral symptoms; and (3) assesses whether physical, emotional, or cognitive domains of neurobehavioral symptom burden show differential associations with childhood trauma or IPV-related BI.

SETTING

Community sites serving women who had experienced IPV such as domestic violence shelters and transitional housing sites.

PARTICIPANTS

Women survivors of IPV with and without BI (n = 99), aged 18 to 54 years.

DESIGN

Retrospective, cross-sectional study design.

MEASURES

The following self-reported questionnaires were used: Rivermead Post Concussion Questionnaire (RPQ); Childhood Trauma Questionnaire (CTQ); a modified version of the Conflict Tactics Scale; Brain Injury Severity Assessment (BISA); Clinician-Administered PTSD Scale for DSM IV; and Toronto Alexithymia Scale. The final multivariate regression model assessed the association between childhood abuse, BI severity, and neurobehavioral symptoms (as measured by the RPQ) adjusting for age, educational attainment, and abuse in the past year. We created separate models with total neurobehavioral symptom score as an outcome, as well as somatic, emotional, and cognitive symptom scores. We used structural equation modeling to assess whether posttraumatic stress and alexithymia mediated the effect of childhood trauma and neurobehavioral symptoms.

RESULTS

Childhood trauma was associated with higher levels (P < .01) of overall neurobehavioral symptom burden in women independent of BI and specifically associated with RPQ Emotional and Somatic subscale symptoms (P ≤ .05). BI was positively associated with somatic symptoms in the full sample and cognitive neurobehavioral symptoms in the sample of women with IPV-related BI (P < .05) independent of childhood trauma. Posttraumatic stress symptoms, but not alexithymia, partially mediated the effect of childhood trauma effect on neurobehavioral symptoms.

CONCLUSION

Childhood trauma and BI should not be overlooked as part of efforts to meet the needs of IPV survivors who may experience a range of emotional, somatic, and cognitive symptoms.

Adaptive Platform Trials to Transform ALS Therapy Development

Current therapeutic development in ALS relies on individual randomized clinical trials to test a specific investigational product in a single patient population. This approach has intrinsic limitations including cost, time, and lack of flexibility. Adaptive platform trials represent a novel approach to investigate several interventions for a single disease in a continuous manner. Already in use in oncology, this approach is now being employed more often in neurology. Here, we describe a newly launched, platform trial for amyotrophic lateral sclerosis (ALS). The HEALEY ALS Platform Trial is testing multiple investigational products concurrently in people with ALS, with the goal of rapidly identifying novel treatments, biomarkers, and trial endpoints. This article is protected by copyright. All rights reserved.

Sex-Specific Association of the X Chromosome With Cognitive Change and Tau Pathology in Aging and Alzheimer Disease

Importance

The X chromosome represents 5% of the human genome in women and men, and its influence on cognitive aging and Alzheimer disease (AD) is largely unknown.

Objective

To determine whether the X chromosome is associated with sex-specific cognitive change and tau pathology in aging and AD.

Design, Setting, Participants

This study examined differential gene expression profiling of the X chromosome from an RNA sequencing data set of the dorsolateral prefrontal cortex obtained from autopsied, elderly individuals enrolled in the Religious Orders Study and Rush Memory and Aging Project joint cohorts. Samples were collected from the cohort study with enrollment from 1994 to 2017. Data were last analyzed in May 2021.

Main Outcomes and Measures

The main analysis examined whether X chromosome gene expression measured by RNA sequencing of the dorsolateral prefrontal cortex was associated with cognitive change during aging and AD, independent of AD pathology and at the transcriptome-wide level in women and men. Whether X chromosome gene expression was associated with neurofibrillary tangle burden, a measure of tau pathology that influences cognition, in women and men was also explored.

Results

Samples for RNA sequencing of the dorsolateral prefrontal cortex were obtained from 508 individuals (mean [SD] age at death, 88.4 [6.6] years; 315 [62.0%] were female; 197 [38.8%] had clinical diagnosis of AD at death; 293 [58.2%] had pathological diagnosis of AD at death) enrolled in the Religious Orders Study and Rush Memory and Aging Project joint cohorts and were followed up annually for a mean (SD) of 6.3 (3.9) years. X chromosome gene expression (29 genes), adjusted for age at death, education, and AD pathology, was significantly associated with cognitive change at the genome-wide level in women but not men. In the majority of identified X genes (19 genes), increased expression was associated with slower cognitive decline in women. In contrast with cognition, X chromosome gene expression (3 genes), adjusted for age at death and education, was associated with neuropathological tau burden at the genome-wide level in men but not women.

Conclusions and Relevance

In this study, the X chromosome was associated with cognitive trajectories and neuropathological tau burden in aging and AD in a sex-specific manner. This is important because specific X chromosome factors could contribute risk or resilience to biological pathways of aging and AD in women, men, or both.

Association between psychological resilience and cognitive function in older adults: effect modification by inflammatory status

To examine the association between psychological resilience and cognitive function and investigate the role of acute inflammation as an effect modifier. Total 7535 people from the Cardiovascular and Metabolic Disease Etiology Research Center (CMERC), aged ≥ 50 years and residing in areas near Seoul, South Korea, were included in this cross-sectional analysis. Stressful life events in the past 6 months were gauged by the Life Experience Survey, and current depression symptoms were analyzed with the Beck Depression Inventory-II. Participants were categorized into the following four groups according to their past experience and depression status: reference, resilient, reactive depression, and vulnerable depression. Cognitive function was evaluated using the mini-mental state examination (MMSE). The level of high-sensitivity C-reactive protein (hsCRP) was measured from blood samples. A generalized linear model was used. Upon adjusting for socio-demographic factors, comorbidity, and lifestyle factors, the final model was stratified with the highest quartile of the hsCRP level by sex. Compared to the reference group, the resilient group showed higher MMSE, which was also significant in women (adj-β = 0.280, p-value < 0.001). Vulnerable depression group showed a significantly lower MMSE (adj-β =  − -0.997, p-value 0.002), especially in men. This pattern seemed to be limited to the low hsCRP subgroup. We provided evidence from the largest Korean population used to evaluate the association between psychological resilience and cognition, which was more prominent in low inflammatory status. Psychological resilience was associated with a lower likelihood of cognitive deficit in women. This pattern was modulated by inflammatory status.

Genome-wide association study of rate of cognitive decline in Alzheimer's disease patients identifies novel genes and pathways

INTRODUCTION

Variability exists in the disease trajectories of Alzheimer's disease (AD) patients. We performed a genome-wide association study to examine rate of cognitive decline (ROD) in patients with AD.

METHODS

We tested for interactions between genetic variants and time since diagnosis to predict the ROD of a composite cognitive score in 3946 AD cases and performed pathway analysis on the top genes.

RESULTS

Suggestive associations (P < 1.0 × 10^-6 ) were observed on chromosome 15 in DNA polymerase-γ (rs3176205, P = 1.11 × 10^-7 ), chromosome 7 (rs60465337,P = 4.06 × 10^-7 ) in contactin-associated protein-2, in RP11-384F7.1 on chromosome 3 (rs28853947, P = 5.93 × 10^-7 ), family with sequence similarity 214 member-A on chromosome 15 (rs2899492, P = 5.94 × 10^-7 ), and intergenic regions on chromosomes 16 (rs4949142, P = 4.02 × 10^-7 ) and 4 (rs1304013, P = 7.73 × 10^-7 ). Significant pathways involving neuronal development and function, apoptosis, memory, and inflammation were identified.

DISCUSSION

Pathways related to AD, intelligence, and neurological function determine AD progression, while previously identified AD risk variants, including the apolipoprotein (APOE) ε4 and ε2 variants, do not have a major impact.

Association between maternal psychological adversity and lung function in South African infants: A birth cohort study

OBJECTIVE

The association of perinatal psychological adversity (ie, stressors and distress) with infant lung function (ILF) and development is not well studied in Africa and elsewhere. We determined the association between maternal perinatal psychological adversity and ILF in African infants.

DESIGN

Prospective longitudinal follow up of the Drakenstein Child Health Study birth cohort.

PARTICIPANTS

Seven hundred and sixty-two infants aged 6 to 10 weeks and 485 infants who had data for both maternal perinatal psychological adversity and ILF (measured at 6 to 10 weeks and 12 months).

METHODS

The main analyses were based on cross-sectional measures of ILF at each assessment (6 to 10 weeks or 12 months), using generalized linear models, and then on the panel-data of both longitudinal ILF assessments, using generalised estimating equations, that allowed specification of the within-group correlation structure.

RESULTS

Prenatal intimate partner violence (IPV) exposure was associated with reduced respiratory resistance at 6 to 10 weeks (beta coefficient [β] = -.131, P = .023); postnatal IPV with reduced ratio of time to peak tidal expiratory flow over total expiratory time (tPTEF /tE ) at 12 months (β = -.206, P = .016); and prenatal depression with lower respiratory rate at 6 to 10 weeks (β = -.044, P = .032) and at 12 months (β = -.053, P = .021). Longitudinal analysis found an association of prenatal IPV with reduced tPTEF /tE (β = -.052, P < .0001); postnatal IPV with decreased functional residual capacity (FRC; β = -.086, P < .0001); prenatal posttraumatic stress disorder with increased FRC (β = .017, P < .0001); prenatal depression with increased FRC (β = .026, P < .0001) and postnatal depression with increased FRC (β = .021, P < .0001).

CONCLUSION

Screening for psychological adversity and understanding the mechanisms involved may help identify children at risk of altered lung development and inform approaches to treatment.

Variance components genetic association test for zero-inflated count outcomes

Commonly in biomedical research, studies collect data in which an outcome measure contains informative excess zeros; for example, when observing the burden of neuritic plaques (NPs) in brain pathology studies, those who show none contribute to our understanding of neurodegenerative disease. The outcome may be characterized by a mixture distribution with one component being the "structural zero" and the other component being a Poisson distribution. We propose a novel variance components score test of genetic association between a set of genetic markers and a zero-inflated count outcome from a mixture distribution. This test shares advantageous properties with single-nucleotide polymorphism (SNP)-set tests which have been previously devised for standard continuous or binary outcomes, such as the sequence kernel association test. In particular, our method has superior statistical power compared to competing methods, especially when there is correlation within the group of markers, and when the SNPs are associated with both the mixing proportion and the rate of the Poisson distribution. We apply the method to Alzheimer's data from the Rush University Religious Orders Study and Memory and Aging Project, where as proof of principle we find highly significant associations with the APOE gene, in both the "structural zero" and "count" parameters, when applied to a zero-inflated NPs count outcome.

Elevated DNA methylation across a 48-kb region spanning the HOXA gene cluster is associated with Alzheimer's disease neuropathology

Introduction:

Alzheimer’s disease is a neurodegenerative disorder that is hypothesized to involve epigenetic dysregulation of gene expression in the brain.

Methods:

We performed an epigenome-wide association study to identify differential DNA methylation associated with neuropathology in prefrontal cortex and superior temporal gyrus samples from 147 individuals, replicating our findings in two independent data sets (N = 117 and 740).

Results:

We identify elevated DNA methylation associated with neuropathology across a 48-kb region spanning 208 CpG sites within the HOXA gene cluster. A meta-analysis of the top-ranked probe within the HOXA3 gene (cg22962123) highlighted significant hypermethylation across all three cohorts (P = 3.11 × 10⁻¹⁸).

Discussion:

We present robust evidence for elevated DNA methylation associated with Alzheimer’s disease neuropathology spanning the HOXA gene cluster on chromosome 7. These data add to the growing evidence highlighting a role for epigenetic variation in Alzheimer’s disease, implicating the HOX gene family as a target for future investigation.

Hormone therapy use and physical quality of life in postmenopausal women with multiple sclerosis

OBJECTIVE

To determine the association between hormone therapy (HT) and physical quality of life (QOL) in postmenopausal women with multiple sclerosis (MS).

METHODS

We included female participants from the prospective Nurses' Health Study, with a diagnosis of definite or probable MS, who had completed a physical functioning assessment (PF10; subscale of the 36-Item Short-Form Health Survey QOL survey) at a time point between 3 and 10 years after their final menstrual period (early postmenopause). We assessed the association between HT use at this time point (never vs at least 12 months of systemic estrogen with/without progestin) and both PF10 and the 36-Item Short-Form Health Survey Physical Component Scale. We used a linear regression model adjusting for age, MS duration, menopause type and duration, and further for additional covariates (only ancestry was significant).

RESULTS

Among 95 participants meeting all inclusion criteria at their first postmenopausal assessment, 61 reported HT use and 34 reported none. HT users differed from non-HT users in MS duration (p = 0.02) and menopause type (p = 0.01) but no other clinical or demographic characteristics. HT users had average PF10 scores that were 23 points higher than non-HT users (adjusted p = 0.004) and average Physical Component Scale scores that were 9.1 points higher in the 59 women with these available (adjusted p = 0.02). Longer duration of HT use was also associated with higher PF10 scores (p = 0.02, adjusted p = 0.06).

CONCLUSIONS

Systemic HT use was associated with better physical QOL in postmenopausal women with MS in this observational study. Further studies are necessary to investigate causality.

Complex relation of HLA-DRB1*1501, age at menarche, and age at multiple sclerosis onset

OBJECTIVE

To examine the relationship between 2 markers of early multiple sclerosis (MS) onset, 1 genetic (HLA-DRB1*1501) and 1 experiential (early menarche), in 2 cohorts.

METHODS

We included 540 white women with MS or clinically isolated syndrome (N = 156 with genetic data available) and 1,390 white women without MS but with a first-degree relative with MS (Genes and Environment in Multiple Sclerosis [GEMS]). Age at menarche, HLA-DRB1*1501 status, and age at MS onset were analyzed.

RESULTS

In both cohorts, participants with at least 1 HLA-DRB1*1501 allele had a later age at menarche than did participants with no risk alleles (MS: mean difference = 0.49, 95% confidence interval [CI] = [0.03-0.95], p = 0.036; GEMS: mean difference = 0.159, 95% CI = [0.012-0.305], p = 0.034). This association remained after we adjusted for body mass index at age 18 (available in GEMS) and for other MS risk alleles, as well as a single nucleotide polymorphism near the HLA-A region previously associated with age of menarche (available in MS cohort). Confirming previously reported associations, in our MS cohort, every year decrease in age at menarche was associated with a 0.65-year earlier MS onset (95% CI = [0.07-1.22], p = 0.027, N = 540). Earlier MS onset was also found in individuals with at least 1 HLA-DRB1*1501 risk allele (mean difference = -3.40 years, 95% CI = [-6.42 to -0.37], p = 0.028, N = 156).

CONCLUSIONS

In 2 cohorts, a genetic marker for earlier MS onset (HLA-DRB1*1501) was inversely related to earlier menarche, an experiential marker for earlier symptom onset. This finding warrants broader investigations into the association between the HLA region and hormonal regulation in determining the onset of autoimmune disease.

Rheumatoid arthritis-associated RBPJ polymorphism alters memory CD4+ T cells

Notch signaling has recently emerged as an important regulator of immune responses in autoimmune diseases. The recombination signal-binding protein for immunoglobulin kappa J region (RBPJ) is a transcriptional repressor, but converts into a transcriptional activator upon activation of the canonical Notch pathway. Genome-wide association studies of rheumatoid arthritis (RA) identified a susceptibility locus, rs874040(CC), which implicated the RBPJ gene. Here, chromatin state mapping generated using the chromHMM algorithm reveals strong enhancer regions containing DNase I hypersensitive sites overlapping the rs874040 linkage disequilibrium block in human memory, but not in naïve CD4(+) T cells. The rs874040 overlapping this chromatin state was associated with increased RBPJ expression in stimulated memory CD4(+) T cells from healthy subjects homozygous for the risk allele (CC) compared with memory CD4(+) T cells bearing the protective allele (GG). Transcriptomic analysis of rs874040(CC) memory T cells showed a repression of canonical Notch target genes IL (interleukin)-9, IL-17 and interferon (IFN)γ in the basal state. Interestingly, activation of the Notch pathway using soluble Notch ligand, Jagged2-Fc, induced IL-9 and IL-17A while delta-like 4Fc, another Notch ligand, induced higher IFNγ expression in the rs874040(CC) memory CD4(+) T cells compared with their rs874040(GG) counterparts. In RA, RBPJ expression is elevated in memory T cells from RA patients compared with control subjects, and this was associated with induced inflammatory cytokines IL-9, IL-17A and IFNγ in response to Notch ligation in vitro. These findings demonstrate that the rs874040(CC) allele skews memory T cells toward a pro-inflammatory phenotype involving Notch signaling, thus increasing the susceptibility to develop RA.

GSK3β Interactions with Amyloid Genes: An Autopsy Verification and Extension

Glyocogen synthase kinase 3 (GSK3) plays an important role in the pathophysiology of Alzheimer's disease (AD) through the phosphorylation of tau. Recent work has suggested that GSK3β also plays a role in the amyloid pathway of AD through genetic interactions with APP and APBB2 on in vivo measures of amyloid. This project extends the previously identified genotype interactions to an autopsy measure of amyloid, while also testing the same interactions leveraging gene expression data quantified in the prefrontal cortex. 797 participants (251 cognitively normal, 196 mild cognitive impairment, and 350 Alzheimer's disease) were drawn from the Religious Orders Study and Rush Memory and Aging Project. A mean score of amyloid load was calculated across eight brain regions, gene expression levels from frozen sections of the dorsolateral prefrontal cortex were quantified using RNA amplification, and expression signals were generated using Beadstudio. Three SNPs previously identified in genetic interactions were genotyped using the Illumina 1M genotyping chip. Covariates included age, sex, education, and diagnosis. We were able to evaluate 2 of the 3 previously identified interactions, of which the interaction between GSK3β (rs334543) and APBB2 (rs2585590) was found in this autopsy sample (p = 0.04). We observed a comparable interaction between GSK3β and APBB2 when comparing the highest tertile of gene expression to the lowest tertile, t(1) = -2.03, p = 0.043. These results provide additional evidence of a genetic interaction between GSK3β and APBB2 and further suggest that GSK3β is involved in the pathophysiology of both of the primary neuropathologies of Alzheimer's disease.

The PSEN1, p.E318G variant increases the risk of Alzheimer's disease in APOE-ε4 carriers

The primary constituents of plaques (Aβ42/Aβ40) and neurofibrillary tangles (tau and phosphorylated forms of tau [ptau]) are the current leading diagnostic and prognostic cerebrospinal fluid (CSF) biomarkers for AD. In this study, we performed deep sequencing of APP, PSEN1, PSEN2, GRN, APOE and MAPT genes in individuals with extreme CSF Aβ42, tau, or ptau levels. One known pathogenic mutation (PSEN1 p.A426P), four high-risk variants for AD (APOE p.L46P, MAPT p.A152T, PSEN2 p.R62H and p.R71W) and nine novel variants were identified. Surprisingly, a coding variant in PSEN1, p.E318G (rs17125721-G) exhibited a significant association with high CSF tau (p = 9.2 × 10(-4)) and ptau (p = 1.8 × 10(-3)) levels. The association of the p.E318G variant with Aβ deposition was observed in APOE-ε4 allele carriers. Furthermore, we found that in a large case-control series (n = 5,161) individuals who are APOE-ε4 carriers and carry the p.E318G variant are at a risk of developing AD (OR = 10.7, 95% CI = 4.7-24.6) that is similar to APOE-ε4 homozygous (OR = 9.9, 95% CI = 7.2.9-13.6), and double the risk for APOE-ε4 carriers that do not carry p.E318G (OR = 3.9, 95% CI = 3.4-4.4). The p.E318G variant is present in 5.3% (n = 30) of the families from a large clinical series of LOAD families (n = 565) and exhibited a higher frequency in familial LOAD (MAF = 2.5%) than in sporadic LOAD (MAF = 1.6%) (p = 0.02). Additionally, we found that in the presence of at least one APOE-ε4 allele, p.E318G is associated with more Aβ plaques and faster cognitive decline. We demonstrate that the effect of PSEN1, p.E318G on AD susceptibility is largely dependent on an interaction with APOE-ε4 and mediated by an increased burden of Aβ deposition.

GWAS of cerebrospinal fluid tau levels identifies risk variants for Alzheimer's disease

Cerebrospinal fluid (CSF) tau, tau phosphorylated at threonine 181 (ptau), and Aβ₄₂ are established biomarkers for Alzheimer's disease (AD) and have been used as quantitative traits for genetic analyses. We performed the largest genome-wide association study for cerebrospinal fluid (CSF) tau/ptau levels published to date (n = 1,269), identifying three genome-wide significant loci for CSF tau and ptau: rs9877502 (p = 4.89 × 10⁻⁹ for tau) located at 3q28 between GEMC1 and OSTN, rs514716 (p = 1.07 × 10⁻⁸ and p = 3.22 × 10⁻⁹ for tau and ptau, respectively), located at 9p24.2 within GLIS3 and rs6922617 (p = 3.58 × 10⁻⁸ for CSF ptau) at 6p21.1 within the TREM gene cluster, a region recently reported to harbor rare variants that increase AD risk. In independent data sets, rs9877502 showed a strong association with risk for AD, tangle pathology, and global cognitive decline (p = 2.67 × 10⁻⁴, 0.039, 4.86 × 10⁻⁵, respectively) illustrating how this endophenotype-based approach can be used to identify new AD risk loci.

The CETP I405V polymorphism is associated with an increased risk of Alzheimer's disease

The cholesteryl ester transfer protein (CETP) gene plays an essential role in regulating cholesterol homeostasis and is a candidate susceptibility gene for late-onset Alzheimer's disease (AD). Recent finding suggests that the CETP I405V polymorphism (rs5882) is associated with a slower rate of memory decline and a lower risk of incident dementia. Using data from two ongoing epidemiologic clinical-pathologic cohort studies of aging and dementia in the United States, the Religious Order Study and the Memory and Aging Project, we evaluated the association of the CETP I405V polymorphism (rs5882) with cognitive decline and risk of incident AD in more than 1300 participants of European ancestry. Our results suggest that the CETP I405V polymorphism was associated with a faster rather than a slower rate of decline in cognition over time, and an increased risk of incident AD. This finding is consistent with data showing that the CETP I405V is associated with increased neuritic plaque density at autopsy.

Craving of prescription opioids in patients with chronic pain: a longitudinal outcomes trial

Little is known about whether patients with chronic pain treated with opioids experience craving for their medications, whether contextual cues may influence craving, or if there is a relationship between craving and medication compliance. We hypothesized that craving for prescription opioids would be significantly correlated with the urge for more medication, preoccupation with the next dose, and current mood symptoms. We studied craving in 62 patients with chronic pain who were at low or high risk for opioid misuse, while they were enrolled in an RCT to improve prescription opioid medication compliance. Using electronic diaries, patients completed ratings of craving at monthly clinic visits and daily during a 14-day take-home period. Both groups consistently endorsed craving, whose levels were highly correlated (P < .001) with urge, preoccupation, and mood. The intervention to improve opioid compliance in the high-risk group was significantly associated with a rate of decrease in craving over time in comparison to a high-risk control group (P < .05). These findings indicate that craving is a potentially important psychological construct in pain patients prescribed opioids, regardless of their level of risk to misuse opioids. Targeting craving may be an important intervention to decrease misuse and improve prescription opioid compliance.

PERSPECTIVE

Patients with noncancer pain can crave their prescription opioids, regardless of their risk for opioid misuse. We found craving to be highly correlated with the urge to take more medication, fluctuations in mood, and preoccupation with the next dose, and to diminish with a behavioral intervention to improve opioid compliance.

Anti-cyclic citrullinated peptide revised criteria for the classification of rheumatoid arthritis

OBJECTIVE

The classification of rheumatoid arthritis (RA) is increasingly important as new therapies can halt the disease in its early stages. Antibodies to cyclic citrullinated peptides (anti-CCP) are widely used for RA diagnosis, but are not in the 1987 American College of Rheumatology (ACR) Criteria for RA Classification. We developed and tested the performance characteristics of new criteria for RA classification, incorporating anti-CCP.

METHODS

We identified all subjects seen in our arthritis centre with rheumatoid factor (RF) and anti-CCP tested simultaneously between 1 January and 30 June 2004 and reviewed their medical records for the ACR criteria, rheumatologists' diagnoses, RF and anti-CCP. We revised the ACR criteria in two ways: (a) adding anti-CCP, and (b) replacing rheumatoid nodules and erosions with anti-CCP (CCP 6 criteria). We compared sensitivity and specificity of all criteria, in all subjects and in subjects with arthritis symptoms </=6 months.

RESULTS

Medical records of 292 subjects were analysed: mean age was 54 years, 82% were women, and mean symptom duration was 4.1 years. 17% were RF positive and 14% were anti-CCP positive at initial testing. 78 (27%) had definite RA per treating rheumatologist at latest follow-up. The CCP 6 criteria increased sensitivity for RA classification for all subjects regardless of symptom duration: 74% vs 51% for ACR criteria with a loss in specificity (81% vs 91%). Sensitivity was greatly improved in subjects with symptoms < or =6 months: 25% vs 63% for ACR criteria with a decrease in specificity.

CONCLUSIONS

The CCP 6 criteria improved upon the sensitivity of the ACR criteria, most remarkably for subjects with symptoms < or =6 months and could be used for the classification of subjects for RA in clinical studies.