The Time to Inflammatory Bowel Disease Diagnosis for Patients Presenting with Abdominal Symptoms in Primary Care and its Association with Emergency Hospital Admissions and Surgery: A Retrospective Cohort Study

BACKGROUND

Patients with inflammatory bowel disease (IBD) presenting to primary care may experience diagnostic delays. We aimed to evaluate this and assess whether time to diagnosis is associated with clinical outcomes.

METHODS

A retrospective cohort study using English primary care data from January 1, 2010, to December 31, 2019, linked to hospital admission data was undertaken. Patients were followed from the first IBD-related presentation in primary care to IBD diagnosis. Associations of time to diagnosis exceeding a year were assessed using a Robust Poisson regression model. Associations between time to diagnosis and IBD-related emergency hospital admissions and surgery were assessed using Poisson and Cox proportional hazards models, respectively.

RESULTS

Of 28 092 IBD patients, 60% had ulcerative colitis (UC) and 40% had Crohn's disease (CD). The median age was 43 (interquartile range, 30-58) years and 51.9% were female. Median time to diagnosis was 15.6 (interquartile range, 4.3-28.1) months. Factors associated with more than a year to diagnosis included female sex (adjusted risk ratio [aRR], 1.23; 95% CI, 1.21-1.26), older age (aRR, 1.05; 95% CI, 1.01-1.10; comparing >70 years of age with 18-30 years of age), obesity (aRR, 1.03; 95% CI, 1.00-1.06), smoking (aRR, 1.05; 95% CI, 1.02-1.08), CD compared with UC (aRR, 1.13; 95% CI, 1.11-1.16), and a fecal calprotectin over 500 μg/g (aRR, 0.89; 95% CI, 0.82-0.95). The highest quartile of time to diagnosis compared with the lowest was associated with IBD-related emergency admissions (incidence rate ratio, 1.06; 95% CI, 1.01-1.11).

CONCLUSION

Longer times to IBD diagnoses were associated with being female, advanced age, obesity, smoking, and Crohn's disease. More IBD-related emergency admissions were observed in patients with a prolonged time to diagnosis.

The association between inflammatory bowel disease and mental ill health: a retrospective cohort study using data from UK primary care

BACKGROUND

Patients with active inflammatory bowel disease (IBD) and mental illnesses experience worse IBD outcomes.

AIM

To describe the incidence of mental illnesses, including deliberate self-harm, in IBD patients.

METHODS

A population-based retrospective cohort study using IQVIA medical research data of a primary care database covering the whole UK, between January 1995 and January 2021. IBD patients of all ages were matched 4:1 by demographics and primary care practice to unexposed controls. Following exclusion of patients with mental ill health at study entry, adjusted hazard ratios (HR) of developing depression, anxiety, deliberate self-harm, severe mental illness and insomnia were calculated using a Cox proportional hazards model.

RESULTS

We included 48,799 incident IBD patients: 28,352 with ulcerative colitis and 20,447 with Crohn's disease. Incidence rate ratios of mental illness were higher in IBD patients than controls (all p < 0.001): deliberate self-harm 1.31 (95% CI 1.16-1.47), anxiety 1.17 (1.11-1.24), depression 1.36 (1.31-1.42) and insomnia 1.62 (1.54-1.69). Patients with Crohn's disease were more likely to develop deliberate self-harm HR 1.51 (95% CI 1.28-1.78), anxiety 1.38 (1.16-1.65), depression 1.36 (1.26-1.47) and insomnia 1.74 (1.62-1.86). Patients with IBD are at increased risk of deliberate self-harm (HR 1.20 [1.07-1.35]). The incidence rate ratios of mental illnesses were particularly high during the first year following IBD diagnosis: anxiety 1.28 (1.13-1.46), depression 1.62 (1.48-1.77) and insomnia 1.99 (1.78-2.21).

CONCLUSION

Deliberate self-harm, depression, anxiety and insomnia were more frequent among patients with IBD. IBD is independently associated with an increased risk of deliberate self-harm.

OP0030 ASSOCIATION OF TRADITIONAL AND DISEASE-RELATED RISK FACTORS WITH CARDIOVASCULAR EVENTS IN PATIENTS WITH PSORIATIC ARTHRITIS AND PSORIASIS

Background

Patients with psoriatic arthritis and psoriasis, collectively termed psoriatic disease (PsD), have an increased risk for cardiovascular (CV) disease.

Objectives

We aimed to identify traditional CV risk factors and PsD-related risk factors associated with CV events.

Methods

Patients from a longitudinal PsD cohort without a prior history of CV events were included. Detailed information on demographics, comorbidities including traditional cardiovascular risk factors, medications and disease activity is collected according to a standard protocol. The study outcome included any of the following CV events occurring within the first 10 years of patients’ initial clinic visit: angina, myocardial infarction, congestive heart failure, transient ischemic attack, cerebrovascular accident, revascularization procedures and CV death. A total of 10 traditional CV risk factors and 15 PsD-related risk factors were assessed. The association of each risk factor with incident CVEs were analyzed separately using Cox proportional hazards regression models with time-dependent covariates, adjusted for age and sex.

Results

A total of 1,376 patients with PsD, followed between 1978 and 2020, were analyzed (mean age 48.3 ± 12.9 years, 46.8% female). During the follow-up period, 102 (7.4%) patients developed incident CV events. In Cox regression models adjusted for age and sex, age (Hazard Ratio (HR) 1.08, 95% Confidence Interval (CI) 1.06, 1.10), diabetes (HR 1.88, 95% CI 1.17, 3.02), systolic blood pressure (HR 1.02, 95% CI 1.01, 1.03), body mass index (BMI) (HR 1.04, 95% CI 1.01, 1.08), triglycerides (HR 1.24, 95% CI 1.07, 1.43), treatment for hypertension (HR 1.70, 95% CI 1.13, 2.56), and use of lipid-lowering medications (HR 1.70, 95% CI 1.13, 2.56) were among the traditional CV risk factors associated with increased CV risk. Among the PsD-related risk factors, psoriasis area and severity index (PASI) (HR 1.05, 95% CI 1.02, 1.08), erythrocyte sedimentation rate (ESR) (HR 1.02, 95% CI 1.01, 1.02), number of tender joints (HR 1.03, 95% CI 1.01, 1.05), number of swollen joints (HR 1.06, 95% CI 1.01, 1.12), health assessment questionnaire (HAQ) score (HR 1.63, 95% CI 1.23, 2.17), and daily use of non-steroidal anti-inflammatory drugs (NSAIDs) (HR 1.72, 95% CI 1.16, 2.55) were associated with increased CV risk. Use of biologic medications (HR 0.63, 95% CI 0.40, 1.00) was not found to be significantly protective against CV events.

Conclusion

In patients with PsD, we identified six PsD-related risk factors that were significantly associated with incident CV events. These risk factors may be useful for the development of a PsD-specific CV risk prediction score that uses routine clinical assessments in combination with PsD-related biomarkers.

References

[1]Eder L, Wu Y, Chandran V, et al. Incidence and predictors for cardiovascular events in patients with psoriatic arthritis. Ann Rheum Dis 2016;75(9):1680-6.

Acknowledgements

Keith Colaco is supported by the Enid Walker Estate, Women’s College Research Institute, and Arthritis Society (TGP-19-0446). Lihi Eder is supported by a Young Investigator Award from the Arthritis Society (YIA-16-394) and an Early Researcher Award from the Ontario Ministry of Science and Innovation. The Psoriatic Disease Program has been supported by a grant from the Krembil Foundation.

Disclosure of Interests

None declared.

POS1068 Cardiac biomarkers are associated with the development of cardiovascular events in patients with psoriatic arthritis and psoriasis

Background:

N-terminal pro-brain-type natriuretic peptide (NT-proBNP) and troponin I (TnI) are established cardiac biomarkers that predict cardiovascular events (CVEs) in the general population. While patients with psoriatic arthritis and psoriasis, collectively termed psoriatic disease (PsD), have an increased risk of developing CVEs, the use of these cardiac biomarkers to predict CV risk has not been investigated in this population.

Objectives:

We aimed to evaluate the association between these cardiac biomarkers and incident CVEs, and assess their predictive value beyond the Framingham Risk Score (FRS).

Methods:

A longitudinal cohort study was conducted in patients with PsD without prior history of CVEs. NT-proBNP and TnI concentrations were measured using automated clinical assays in the first available serum sample. The study outcome included any of the following CVEs occurring within the first 10 years of biomarker assessment: angina, myocardial infarction, transient ischemic attack, stroke, revascularization and CV death. Associations with incident CVEs were analyzed separately for each biomarker using Cox proportional hazards regression models first adjusted for age and sex, and subsequently for the FRS. The added value of cardiac biomarkers to improve predictive performance beyond the FRS was assessed using the area under the receiver operator characteristic curve (AUC), net reclassification index (NRI) and integrated discrimination index (IDI).

Results:

A total of 1000 patients with PsD were assessed between 2002 and 2019 (mean age 49 ± 12.8 years, 44.6% female) (Table 1). During a mean follow-up of 7.1 years, 64 patients developed incident CVEs. Both TnI (Hazard Ratio (HR) 3.02, 95% Confidence Interval (CI) 1.12, 8.16) and NT-proBNP (HR 2.02; 95% CI 1.28, 3.18) predicted CVEs independently of the FRS (Figure 1). The association was stronger in males than females. Including all cardiac biomarkers and the FRS in a single model, NT-proBNP retained statistical significance (HR 1.91, 95% CI 1.23, 2.97), while TnI did not (HR 2.60, 95% CI 0.98, 6.87). When comparing the predictive performance of the base model (FRS alone, AUC 75.4) to the expanded models, there was no significant improvement in any of the predictive indices with the addition of TnI (AUC 73.5, p = 0.21; NRI 0.08, p = 0.67; IDI 0.005, p = 0.37), NT-proBNP (AUC 71.0, p = 0.35; NRI 0.20, p = 0.06; IDI 0.017, p = 0.10), or both TnI and NT-proBNP (AUC 70.0, p = 0.23; NRI 0.27, p = 0.05; IDI 0.021, p =0.05).

Conclusion:

In patients with PsD, elevated NT-proBNP and TnI predict incident CVEs independent of the FRS. We did not observe a significant improvement in the performance of the predictive model when combining these cardiac biomarkers with the FRS.

References:

[1]Eder L, Wu Y, Chandran V, et al. Incidence and predictors for cardiovascular events in patients with psoriatic arthritis. Ann Rheum Dis 2016;75(9):1680-6.

Table 1.

Baseline characteristics of the study population (n=1000)

VariableMean ± SD / Frequency (%)PsA, no. (%)648 (64.8)PsC, no. (%)352 (35.2)Age (years)49 ± 12.8Male sex, no. (%)554 (55.4)Disease duration (years)20.2 ± 14.1Ethnicity, Caucasian (%)834 (83.4)Current smoker (%)164 (16.4)FRS (%)8.2 ± 8.6Diabetes77 (7.7)Hypertension274 (27.4)BMI (kg/m2)28.7 ± 5.9PASI4.1 ± 6.3Use of lipid-lowering medications (%)100 (10)Current use of DMARDs362 (36.2)Current use of Biologics214 (21.4)Current use of NSAIDs (daily use)265 (26.5)

1 Applicable only to patients with PsA CVE, cardiovascular events; DMARD, disease-modifying antirheumatic drug; FRS, Framingham Risk Score; NSAID, non-steroidal anti-inflammatory drug; PASI, Psoriasis Area Severity Index; PsA, psoriatic arthritis; PsC, psoriasis without arthritis

Figure 1.

Hazard ratios of cardiac biomarker measures for incident cardiovascular events (n = 1000, 64 events). Error bars denote 95% confidence intervals. CI indicates confidence interval; CVEs, cardiovascular events; FRS, Framingham Risk Score; NT-proBNP, N-terminal pro-brain-type natriuretic peptide; TnI, troponin I.

Acknowledgements:

Keith Colaco is supported by the Enid Walker Estate, Women’s College Research Institute, Arthritis Society (TGP-19-0446), National Psoriasis Foundation (Early Career Grant) and the Edward Dunlop Foundation. Lihi Eder is supported by a Young Investigator Award from the Arthritis Society and an Early Researcher Award from the Ontario Ministry of Science and Innovation. The study was supported in part by a discovery grant from the National Psoriasis Foundation and an operating grant from the Arthritis Society (YIO-16-394).

Disclosure of Interests:

None declared.

OP0221 TARGETED METABOLOMIC PROFILING AND PREDICTION OF CARDIOVASCULAR EVENTS: A PROSPECTIVE STUDY OF PATIENTS WITH PSORIATIC ARTHRITIS AND PSORIASIS

Background:

Psoriatic arthritis and psoriasis, collectively termed psoriatic disease (PsD), are associated with increased cardiovascular (CV) risk. Metabolites comprise biomarkers that may add predictive value over traditional CV risk factors.

Objectives:

We aimed to identify metabolites associated with CV events (CVEs) and to determine whether they could improve CV risk prediction beyond traditional CV risk factors.

Methods:

Patients from a longitudinal PsD cohort without a prior history of CVEs were included. In the first available serum sample, a targeted nuclear magnetic resonance (NMR) metabolomics platform was used to quantify 64 metabolite measures comprised of lipoprotein subclasses, fatty acids, glycolysis precursors, ketone bodies and amino acids. The study outcome included any of the following CVEs occurring within the first 10 years of biomarker assessment: angina, myocardial infarction, congestive heart failure, transient ischemic attack, cerebrovascular accident, revascularization procedures and CV death. The association of each metabolite with incident CVEs were analyzed separately using Cox proportional hazards regression models first adjusted for age and sex, and subsequently for traditional CV risk factors. Variable selection was performed using penalization with boosting after adjusting for age and sex. The added predictive value of the selected metabolites to improve risk prediction beyond traditional CV risk factors was assessed using the area under the receiver operator characteristic curve (AUC).

Results:

A total of 977 patients with PsD, followed between 2002 and 2019, were analyzed (mean age 49.1 ± 12.6 years, 45.1% female). During a mean follow-up of 7.1 years, 70 (7.2%) patients developed incident CVEs. In Cox regression models adjusted for CV risk factors, alanine, tyrosine, total high-density lipoprotein (HDL) cholesterol, medium and large HDL particles, and the degree of unsaturation of fatty acids were significantly associated with decreased CV risk. Glycoprotein acetyls, apolipoprotein B, remnant cholesterol, very low-density lipoprotein (VLDL) cholesterol, and very small VLDL particles were associated with an increased CV risk. In proportional sub-distribution hazards regression models adjusted for age and sex, 13 metabolites were selected (Table 1). The age- and sex-adjusted expanded model (base model + 13 metabolites) significantly improved prediction of CVEs beyond the base model (only age and sex) with an AUC of 79.9 vs. 72.6, respectively (p=0.019) (Figure 1).

Table 1.

Regression coefficients of the selected metabolites in a model adjusted for age and sex.

CategoryMetaboliteModel adjusted for Age and SexAmino AcidsAlanine-0.1179Glycine-0.0339Tyrosine-0.1010Fatty acid ratios, relative to total fatty acidsDocosahexaenoic acid-0.0862Unsaturation degree, double bonds per fatty acid-0.1265Fluid BalanceAlbumin+0.0685GlyceridesTriglycerides in IDL cholesterol+0.1546Glycolysis precursorsGlucose+0.1391InflammationGlycoprotein acetyls+0.1478Ketone bodiesAcetoacetate+0.0464Lipoprotein subclassesHDL3 Cholesterol-0.0211Medium HDL-0.0296Large HDL-0.0309Figure 1.

Predictive performance of a model with age and sex alone is compared to a model with age and sex plus selected metabolites.

Conclusion:

Using NMR metabolomics profiling, we identified a variety of metabolites associated with a lower and higher risk of developing CVEs in patients with PsD. Further study of their underlying association with CVEs is needed to clarify the clinical utility of these biomarkers to guide CV risk assessment in this population.

References:

[1]Eder L, Wu Y, Chandran V, et al. Incidence and predictors for cardiovascular events in patients with psoriatic arthritis. Ann Rheum Dis 2016;75(9):1680-6.

[2]Soininen P, Kangas AJ, Wurtz P, et al. Quantitative serum nuclear magnetic resonance metabolomics in cardiovascular epidemiology and genetics. Circ Cardiovasc Genet 2015;8(1):192-206.

Acknowledgements:

Keith Colaco is supported by the Enid Walker Estate, Women’s College Research Institute, Arthritis Society (TGP-19-0446), National Psoriasis Foundation (Early Career Grant) and the Edward Dunlop Foundation. Lihi Eder is supported by a Young Investigator Award from the Arthritis Society and an Early Researcher Award from the Ontario Ministry of Science and Innovation. The study was supported in part by a discovery grant from the National Psoriasis Foundation and an operating grant from the Arthritis Society (YIO-16-394).

Disclosure of Interests:

None declared

SAT0586 PREVALENCE AND RISK FACTORS FOR CARDIO-METABOLIC ABNORMALITIES IN PATIENTS WITH INFLAMMATORY ARTHRITIS ATTENDING CARDIO-RHEUMATOLOGY PRIMARY PREVENTION CLINICS

Background:

Cardio-metabolic abnormalities are common in patients with inflammatory arthritis (IA) but tend to be under-recognized and under-treated.

Objectives:

We aimed to compare the prevalence and risk factors for cardio-metabolic abnormalities between patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA) and ankylosing spondylitis (AS).

Methods:

Consecutive patients enrolled in the University of Toronto Cardio-Rheumatology Network from July 2017 to August 2019 were analyzed. This is a primary prevention program that uses structured clinical, laboratory and multimodal imaging to diagnose and treat cardiovascular disease (CVD). Patients with a rheumatologist-confirmed diagnosis of RA, PsA or AS with no known CVD were evaluated. Information about IA diagnosis, medications and comorbidities was recorded. Each patient was evaluated by a cardiologist focusing on CVD risk assessment. We evaluated the prevalence of previously recorded and newly recognized cardio-metabolic risk factors including hypertension, dyslipidemia, obesity and diabetes. The prevalence of these abnormalities was compared between IA diagnoses. Regression models were used to assess the association between diagnosis and cardio-metabolic abnormalities after adjusting for demographics, smoking, BMI, measures of disease activity and medications.

Results:

A total of 358 patients (201 RA, 124 PsA, 33 AS) were assessed (mean age 59±10.5 years, 68.7% female). Hypertension was reported in 33%, dyslipidemia in 26.8%, diabetes mellitus in 8.9% and overweight/obesity in 69.7% (Figure 1). Newly detected elevations in lipids were frequent for triglycerides (9.3%,), non-HDL-cholesterol (6%,) and LDL-cholesterol (2.7%). Elevated HbA1c occurred in 1.4% and newly diagnosed hypertension occurred in 9.8%. A total of 32.8% patients required a change or initiation of medications for their cardio-metabolic abnormalities (21.7% lipid-lowering therapy, 14.6% aspirin, 11.1% anti-hypertension therapy). Patients with PsA had the highest prevalence of cardio-metabolic abnormalities including dyslipidemia, obesity and hypertension. Having hypertension (prior or new diagnosis), elevated levels of triglycerides, non-HDL cholesterol, total cholesterol and BMI were associated with PsA vs. RA after adjusting for potential confounders (all p<0.05) (Figure 2). No significant association was found between cardio-metabolic abnormalities and AS vs. PsA or RA.

Conclusion:

Dedicated cardio-rheumatology clinics have improved CVD screening and management in an IA population. The burden of cardio-metabolic abnormalities is elevated in PsA and suggests that tailored strategies to reduce adverse CVD events are particularly needed in this subgroup.

Disclosure of Interests:

Lihi Eder Grant/research support from: Abbvie, Lily, Janssen, Amgen, Novartis, Consultant of: Janssen, Speakers bureau: Abbvie, Lily, Janssen, Amgen, Novartis, Shadi Akhtari: None declared, Paula Harvey: None declared, Kuriya Bindee Grant/research support from: Abbvie, Pfizer, Sanofi, BMS, Consultant of: Abbvie, Eli Lily, Pfizer

Severe brady-arrhythmias in systemic lupus erythematosus: prevalence, etiology and associated factors

Background

Severe brady-arrhythmias, requiring a permanent pacemaker (PPM), have been sparsely reported in systemic lupus erythematosus (SLE). The aim of this study was to describe the characteristics of such arrhythmias in a defined lupus cohort.

Patients and methods

The database of the Toronto Lupus Clinic ( n = 1366) was searched for patients who received a PPM. Demographic, clinical, immunological and therapeutic variables along with electrocardiographic (ECG) and echocardiographic findings (based on the last available test prior to PPM) were analyzed. Patients with a PPM (cases) were compared with age-, sex- and disease duration-matched patients without a PPM (controls). Analysis was performed with SAS 9.0; p < 0.05 was considered significant.

Results

Eighteen patients were identified, 13 (0.95%) with complete atrioventricular block and 5 (0.37%) with sick sinus syndrome. Disease duration at PPM implantation was 22 ± 12 years. Compared to controls, cases had more frequently coronary artery disease, hypertension, dyslipidemia and longer antimalarial (AM) treatment duration. The prevalence of first-degree atrioventricular block, right bundle branch block, left anterior fascicular block and septal hypertrophy was also higher. AM treatment was significantly associated with brady-arrhythmias (OR = 1.128, 95% CI = 1.003–1.267, p = 0.044). Nine patients had prior heart disease and one received a PPM two years after renal transplantation. Eight patients did not have any potential risk factors; prolonged AM therapy (mean 22 years) might have been the cause.

Conclusions

Apart from known causes, prolonged AM treatment may be associated with severe brady-arrhythmias in SLE. Certain ECG and echocardiographic characteristics may represent indicators of an ongoing damage in the conduction system.

General Anesthesia with Endotracheal Intubation for Cryotherapy for Retinopathy of Prematurity

We present a technique for treating retinopathy of prematurity (ROP) with cryotherapy under general anesthesia, administered and monitored by a neonatologist, with endotracheal intubation in the neonatal intensive care unit that avoids the serious systemic complications associated with the administration of local anesthetics. Although no significant complications arose in this series, having the intubated infant monitored by trained neonatology staff allows appropriate management should complications arise. We have used this technique to treat 20 eyes with threshold ROP. The mean time to extubation was 40.2 hours. The systemic status and discharge from the neonatal intensive care unit were not influenced by the general anesthesia. This technique allows quick and accurate application of the cryotherapy in a stable and controlled setting. We recommend that physicians consider cryotherapy under general anesthesia with endotracheal intubation for infants with ROP. This technique allows ROP to be treated adequately with minimal risk to the infant.

GAMBLINGLESS: FOR LIFE study protocol: a pragmatic randomised trial of an online cognitive-behavioural programme for disordered gambling

INTRODUCTION

The prevalence of disordered gambling worldwide has been estimated at 2.3%. Only a small minority of disordered gamblers seek specialist face-to-face treatment, and so a need for alternative treatment delivery models that capitalise on advances in communication technology, and use self-directed activity that can complement existing services has been identified. As such, the primary aim of this study is to evaluate an online self-directed cognitive-behavioural programme for disordered gambling (GamblingLess: For Life).

METHODS AND ANALYSIS

The study will be a 2-arm, parallel group, pragmatic randomised trial. Participants will be randomly allocated to a pure self-directed (PSD) or guided self-directed (GSD) intervention. Participants in both groups will be asked to work through the 4 modules of the GamblingLess programme over 8 weeks. Participants in the GSD intervention will also receive weekly emails of guidance and support from a gambling counsellor. A total of 200 participants will be recruited. Participants will be eligible if they reside in Australia, are aged 18 years and over, have access to the internet, have adequate knowledge of the English language, are seeking help for their own gambling problems and are willing to take part in the intervention and associated assessments. Assessments will be conducted at preintervention, and at 2, 3 and 12 months from preintervention. The primary outcome is gambling severity, assessed using the Gambling Symptom Assessment Scale. Secondary outcomes include gambling frequency, gambling expenditure, psychological distress, quality of life and additional help-seeking. Qualitative interviews will also be conducted with a subsample of participants and the Guides (counsellors).

ETHICS AND DISSEMINATION

The study has been approved by the Deakin University Human Research and Eastern Health Human Research Ethics Committees. Findings will be disseminated via report, peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

ACTRN12615000864527; results.

Osteoarthritis-related difficulty walking and risk for diabetes complications

OBJECTIVES

To examine the effect of Osteoarthritis (OA)-related difficulty walking on risk for diabetes complications in persons with diabetes and OA.

DESIGN

A population cohort aged 55+ years with symptomatic hip and knee OA was recruited 1996-98 and followed through provincial administrative data to 2015 (n = 2,225). In those with confirmed OA (examination and radiographs) and self-reported diabetes at baseline (n = 359), multivariate Cox regression modeling was used to examine the relationship between baseline difficulty walking (Health Assessment Questionnaire (HAQ) difficulty walking score; use of walking aid) and time to first diabetes-specific complication (hospitalization for hypo- or hyperglycemia, infection, amputation, retinopathy, or initiation of chronic renal dialysis) and cardiovascular (CV) events.

RESULTS

Participants' mean baseline age was 71.4 years; 66.9% were female, 77.7% had hypertension, 54.0% had pre-existing CV disease, 42.9% were obese and 15.3% were smokers. Median HAQ difficulty walking score was 2/3 indicating moderate to severe walking disability; 54.9% used a walking aid. Over a median 6.1 years, 184 (51.3%) experienced one or more diabetes-specific complications; 191 (53.2%) experienced a CV event over a median 5.7 years. Greater baseline difficulty walking was associated with shorter time to the first diabetes-specific complication (adjusted HR per unit increase in HAQ walking 1.24, 95% CI 1.04-1.47, P = 0.02) and CV event (adjusted HR for those using a walking aid 1.35, 95% CI 1.00-1.83, P = 0.04).

CONCLUSIONS

In a population cohort with OA and diabetes, OA-related difficulty walking was a significant - and potentially modifiable - risk factor for diabetes complications.

Medical abortion: the hidden revolution

While the medical abortion (MA) drugs, mifepristone and misoprostol, have radically altered reproductive health practices around the world, there has been little field research on the sales and use of these drugs, especially in developing countries. This leaves the family planning community with many unanswered questions. While good profiles of contraceptive use are available for many countries and we have good technical data on the MA drugs' efficacy, dosages and regimens such as home dosage of misoprostol versus clinic dosage, we have very little information about the quantities of MA drugs sold, how they are used, where they are used, and, in the case of misoprostol, for what purposes. Sales data are available from one excellent commercial survey and from social marketing sales of mifepristone and misoprostol and these are presented. Acknowledging the sensitivity of the issue, especially in countries where abortion is severely restricted, the author makes a plea for careful additional research to shed light on an important and growing part of the international reproductive health picture.

Proceedings of the Thirteenth International Society of Sports Nutrition (ISSN) Conference and Expo

P1 Impact of antioxidant-enriched nutrient bar supplementation on the serum antioxidant markers and physical fitness components of track and field athletes

Lalitha Ramaswamy, Supriya Velraja

P2 The effects of phosphatidic acid supplementation on fitness levels in resistance trained women

Guillermo Escalante, Phil Harvey, Michelle Alencar, Bryan Haddock

P3 The effects of phosphatidic acid supplementation on cardiovascular risk factors in resistance trained men

Phil Harvey, Guillermo Escalante, Michelle Alencar, Bryan Haddock

P4 The efficacy of sodium bicarbonate supplementation on physical capacity and selected biochemical markers in elite wrestlers

Krzysztof Durkalec-Michalski, Jan Jeszka, Bogna Zawieja, Tomasz Podgórski

P5 Effects of different nutritional strategies in hydration and physical performance in healthy well-trained males

Ana Paula Trussardi Fayh, Alexandre Hideki Okano, Amanda Maria de Jesus Ferreira

P6 Reduction of plasma creatine concentrations as an indicator of improved bioavailability

Ralf Jäger, Martin Purpura, Roger C Harris

P7 Effect of three different breakfast meals on energy intake and nutritional status in college-age women

Molly M. Krause, Kiley A. Lavanger, Nina O. Allen, Allison E. Lieb, Katie A. Mullen, Joan M. Eckerson

P8 Accuracy of the ASA24® Dietary Recall system for assessing actual dietary intake in normal weight college-age women.

Kiley A. Lavanger, Molly M. Krause, Nina O. Allen, Allison E. Lieb, Katie A. Mullen, Joan M. Eckerson

P9 β-aminoisobutyric acid does not regulate exercise induced UCP-3 expression in skeletal muscle

Elisa Morales, Jeffrey Forsse, Thomas Andre, Sarah McKinley, Paul Hwang, Grant Tinsley, Mike Spillane, Peter Grandjean, Darryn Willoughby

P10 The ability of collegiate football athletes to adhere to sport-specific nutritional recommendations

A. Jagim, G. Wright, J. Kisiolek, M. Meinking, J. Ochsenwald, M. Andre, M.T. Jones, J. M. Oliver

P11 A single session of low-volume high intensity interval exercise improves appetite regulation in overweight men

Victor Araújo Ferreira, Daniel Costa de Souza, Victor Oliveira Albuquerque dos Santos, Rodrigo Alberto Vieira Browne, Eduardo Caldas Costa, Ana Paula Trussardi Fayh

P12 Acute effects of oral peppermint oil ingestion on exercise performance in moderately-active college students

Suresh T. Mathews, Haley D. Bishop, Clara R. Bowen, Yishan Liang, Emily A. West, Rebecca R. Rogers, Mallory R. Marshall, John K. Petrella

P13 Associations in body fat and liver triglyceride content with serum health markers in sedentary and exercised rats fed a ketogenic diet, Western diet or standard chow over a 6-week period

A. Maleah Holland, Wesley C. Kephart, Petey W. Mumford, C. Brooks Mobley, Ryan P. Lowery, Jacob M. Wilson, Michael D. Roberts

P14 Physiological changes following competition in male and female physique athletes: A pilot study

Eric T. Trexler, Katie R. Hirsch, Bill I. Campbell, Meredith G. Mock, Abbie E. Smith-Ryan

P15 Relationship between cognition and hydration status in college students at a large Southwestern university

Kate Zemek, Carol Johnston

P16 Whey protein-derived exosomes increase protein synthesis in C2C12 myotubes

C. Brooks Mobley, Petey W. Mumford, David D. Pascoe, Christopher M. Lockwood, Michael E. Miller, Michael D. Roberts

P17 The effect of three different energy drinks on 1.5-mile running performance, oxygen consumption, and perceived exertion

Gabriel J. Sanders, Willard Peveler, Brooke Warning, Corey A. Peacock

P18 The Ketogenic diet improves rotarod performance in young and older rats

Wesley C. Kephart, Petey W. Mumford, Ryan P. Lowery, Michael D. Roberts, Jacob M. Wilson

P19 Absorption of bonded arginine silicate compared to individual arginine and silicon components

David Sandler, Sara Perez Ojalvo, James Komorowski

P20 Effects of a high (2.4 g/kg) vs. low/moderate (1.2 g/kg) protein intake on body composition in aspiring female physique athletes engaging in an 8-week resistance training program

Bill I. Campbell, Danielle Aguilar, Andres Vargas, Laurin Conlin, Amey Sanders, Paola Fink-Irizarry, Layne Norton, Ross Perry, Ryley McCallum, Matthew R. Wynn, Jack Lenton

P21 Effects of a high (2.4 g/kg) vs. low/moderate (1.2 g/kg) protein intake on maximal strength in aspiring female physique athletes engaging in an 8-week resistance training program

Bill I. Campbell, Chris Gai, Seth Donelson, Shiva Best, Daniel Bove, Kaylee Couvillion, Jeff Dolan, Dante Xing, Kyshia Chernesky, Michael Pawela, Andres D. Toledo, Rachel Jimenez

P22 Monitoring of female collegiate athletes over a competitive season reveals changes in nutritional biomarkers

M. Rabideau, A. Walker, J. Pellegrino, M. Hofacker, B. McFadden, S. Conway, C. Ordway, D. Sanders, R. Monaco, M. S. Fragala, S. M. Arent

P23 Comparison of prediction equations to indirect calorimetry in men and women athletes

Jason D. Stone, Andreas Kreutzer, Jonathan M. Oliver, Jacob Kisiolek, Andrew R. Jagim

P24 Regional variations in sweat-based electrolyte loss and changes in plasma electrolyte content in Division I female athletes over the course of a competitive season

M. Hofacker, A. Walker, J. Pellegrino, M. Rabideau, B. McFadden, S. Conway, D. Sanders, C. Ordway, R. Monaco, M. S. Fragala, S. M. Arent

P25 In-season changes in plasma amino acid levels in Division I NCAA female athletes

Ozlem Tok, Joseph K. Pellegrino, Alan J. Walker, David J. Sanders, Bridget A. McFadden, Meaghan M. Rabideau, Sean P. Conway, Chris E. Ordway, Marissa Bello, Morgan L. Hofacker, Nick S. Mackowski, Anthony J. Poyssick, Eddie Capone, Robert M. Monaco, Maren S. Fragala, Shawn M. Arent

P26 Effects of a ketogenic diet with exercise on serum markers of bone metabolism, IGF-1 and femoral bone mass in rats

Petey W. Mumford, A. Maleah Holland, Wesley C. Kephart, Ryan P. Lowery, C. Brooks Mobley, Romil K. Patel, Annie Newton, Darren T. Beck, Michael D. Roberts, Jacob M. Wilson, Kaelin C. Young

P27 Casein supplementation in trained men and women: morning versus evening

Tobin Silver, Anya Ellerbroek, Richard Buehn, Leo Vargas, Armando Tamayo, Corey Peacock, Jose Antonio

P28 A high protein diet has no harmful effects: a one-year crossover study in resistance-trained males

Anya Ellerbroek, Tobin Silver, Richard Buehn, Leo Vargas, Armando Tamayo, Corey Peacock, Jose Antonio

P29 SUP (Stand-up Paddling) athletes: nutritional intake and body composition

Adam Pollock, Anya Ellerbroek, Tobin Silver, Corey Peacock, Jose Antonio

P30 The effects of 8 weeks of colostrum and bio-active peptide supplementation on body composition in recreational male weight lifters

A. Kreutzer, P. Zavala, S. Fleming, M. Jones, J. M. Oliver, A. Jagim

P31 Effects of a Popular Women’s Thermogenic Supplement During an Energy-Restricted High Protein Diet on Changes in Body Composition and Clinical Safety Markers

Cody T. Haun, Petey W. Mumford, Parker N. Hyde, Ciaran M. Fairman, Wesley C. Kephart, Darren T. Beck, Jordan R. Moon, Michael D. Roberts, Kristina L. Kendall, Kaelin C. Young

P32 Three days of caffeine consumption following caffeine withdrawal yields small strength increase in knee flexors

Geoffrey M Hudson, Tara Hannings, Kyle Sprow, Loretta DiPietro

P33 Comparison of cellular nitric oxide production from various sports nutrition ingredients

Doug Kalman, Sara Perez Ojalvo, James Komorowski

P34 The effects of 8 weeks of bio-active peptide supplementation on training adaptations in recreational male weight lifters

P. Zavala, S. Fleming, M. Jones, J. Oliver, A. Jagim

P35 Effects of MusclePharm Assault Black^TM on lower extremity spinal excitability and postactivation potentiation: A pilot study

Brian Wallace, Haley Bergstrom, Kelly Wallace

P36 Effects of four weeks of Ketogenic Diet alone and combined with High intensity Interval Training or Continuous-Moderate intensity on body composition, lipid profile and physical performance on healthy males

Matias Monsalves-Alvarez, Sebastian Oyharçabal, Victoria Espinoza

P37 Effect of branched-chain amino acid supplementation on creatine kinase, muscular performance, and perceived muscle soreness following acute eccentric exercise

Trisha A. VanDusseldorp, Kurt A. Escobar, Kelly E. Johnson, Nathan Cole, Terence Moriarty, Matthew Stratton, Marvin R. Endito, Christine M. Mermier, Chad M. Kerksick

P38 Effects of endurance training on markers of ribosome biogenesis in rodents fed a high fat diet

Matthew A. Romero, C. Brooks Mobley, Melissa Linden, Grace Margaret-Eleanor Meers, R. Scott Rector, Michael D. Roberts

P39 The effects of acute citrulline-malate on lower-body isokinetic performance in recreationally active individuals

Joshua L Gills, Hocheng Lu, Kimberly Parker, Chris Dobbins, Joshua N Guillory, Braden Romer, David Szymanski, Jordan Glenn

P40 The effect pre-ingested L-isoleucine and L-leucine on blood glucose responses and glycemic hormones in healthy inactive adults: Preliminary data.

Daniel E. Newmire, Eric Rivas, Sarah E. Deemer, Robert Wildman, Victor Ben-Ezra

P41 Does protein and source impact substrate oxidation and energy expenditure during and after moderate intensity treadmill exercise?

C Kerksick, B Gieske, R Stecker, C Smith, K Witherbee

P42 Effects of a pre-workout supplement on peak power and power maintenance during lower and upper body testing

Michael T. Lane, M. Travis Byrd, Zachary Bell, Emily Frith, Lauren M.C. Lane

P43 Effects of a pre-workout supplement on peak power production during lower and upper body testing in college-age females

Michael T. Lane, M. Travis Byrd, Zachary Bell, Emily Frith, Lauren M.C. Lane

P44 A comparison of whey versus casein protein supplementation on resting metabolic rate and body composition: a pilot study

Corey A. Peacock, Tobin A. Silver, Megan Colas, Mauricio Mena, Winter Rodriguez, Gabriel J. Sanders, Jose Antonio

P45 A novel mixed-tocotrienol intervention enhances recovery after eccentric exercise: preliminary findings

Andrea Vansickle, Brittany DiFiore, Stephanie Stepp, Grant Slack, Bridget Smith, Kayla Ruffner, Ronald Mendel, Lonnie Lowery

P46 The effects of post-exercise ingestion of a high molecular weight glucose on cycle performance in female cyclists

Katie R. Hirsch, Meredith G. Mock, Malia M.N. Blue, Eric T. Trexler, Erica J. Roelofs, Abbie E. Smith-Ryan

P47 Inclusive vs. exclusive dieting and the effects on body composition in resistance trained individuals

Laurin Conlin, Danielle Aguilar, Bill I. Campbell, Layne Norton, Katie Coles, Eric T. Trexler, Nic Martinez

P48 A whey protein hydrolysate may positively augment resting metabolism compared to intact whey protein

Jordan M. Joy, Roxanne M. Vogel, Thomas H. Hoover, K. Shane Broughton

P49 Seven days of high and low dose creatine nitrate supplementation I: hepatorenal, glucose and muscle enzyme function

R Dalton, R Sowinski, T Grubic, PB Collins, A Colletta, A Reyes, B Sanchez, M Kozehchain, YP Jung, C Rasmussen, P Murano, CP Earnest, M Greenwood, RB Kreider

P50 Seven days of high and low dose creatine nitrate supplementation II: performance

T Grubic, R Dalton, R Sowinski, PB Collins, A Colletta, A Reyes, B Sanchez, M Kozehchain, YP Jung, C Rasmussen, P Murano, CP Earnest, M Greenwood, RB Kreider

P51 Seven days of high and low dose creatine nitrate supplementation III: hemodynamics

R Sowinski, R Dalton, T Grubic, PB Collins, A Colletta, A Reyes, B Sanchez, M Kozehchain, YP Jung, C Rasmussen, P Murano, CP Earnest, M Greenwood, RB Kreider

P52 The efficacy of a β-hydroxy-β-methylbutyrate supplementation on physical capacity, body composition and biochemical markers in highly-trained combat sports athletes

Krzysztof Durkalec-Michalski, Jan Jeszka, Tomasz Podgórski

P53 Does protein and source impact substrate oxidation and energy expenditure during and after moderate intensity treadmill exercise?

C Kerksick, B Gieske, R Stecker, C Smith, K Witherbee

P54 Effects of 30 days of Cleanse™ supplementation on measure of body composition, waist circumference, and markers of gastrointestinal distress in females

Stacie Urbina, Emily Santos, Katelyn Villa, Alyssa Olivencia, Haley Bennett, Marissa Lara, Cliffa Foster, Colin Wilborn, Lem Taylor

P55 The effects of moderate- versus high-load training on body composition, muscle growth, and performance in college aged females

Jason M Cholewa, Amy Hewins, Samantha Gallo, Ashley Micensky, Christian De Angelis, Christopher Carney, Bill Campbell, Laurin Conlin, Layne Norton, Fabricio Rossi

P56 Effect of a multi-ingredient preworkout supplement on cognitive function and perceptions of readiness to perform

MS Koozehchian, PB Collins, R Sowinski, T Grubic, R Dalton, A O’Connor, SY Shin, Y Peter Jung, BK Sanchez, A Coletta, M Cho, A Reyes, C Rasmussen, CP Earnest, PS Murano, M Greenwood, RB Kreider

Blood pressure-lowering effects of nifedipine/candesartan combinations in high-risk individuals: subgroup analysis of the DISTINCT randomised trial

The DISTINCT study (reDefining Intervention with Studies Testing Innovative Nifedipine GITS-Candesartan Therapy) investigated the efficacy and safety of nifedipine GITS/candesartan cilexetil combinations vs respective monotherapies and placebo in patients with hypertension. This descriptive sub-analysis examined blood pressure (BP)-lowering effects in high-risk participants, including those with renal impairment (estimated glomerular filtration rate<90 ml min^-1, n=422), type 2 diabetes mellitus (n=202), hypercholesterolaemia (n=206) and cardiovascular (CV) risk factors (n=971), as well as the impact of gender, age and body mass index (BMI). Participants with grade I/II hypertension were randomised to treatment with nifedipine GITS (N) 20, 30, 60 mg and/or candesartan cilexetil (C) 4, 8, 16, 32 mg or placebo for 8 weeks. Mean systolic BP and diastolic BP reductions after treatment in high-risk participants were greater, overall, with N/C combinations vs respective monotherapies or placebo, with indicators of a dose-response effect. Highest rates of BP control (ESH/ESC 2013 guideline criteria) were also achieved with highest doses of N/C combinations in each high-risk subgroup. The benefits of combination therapy vs monotherapy were additionally observed in patient subgroups categorised by gender, age or BMI. All high-risk participants reported fewer vasodilatory adverse events in the pooled N/C combination therapy than the N monotherapy group. In conclusion, consistent with the DISTINCT main study outcomes, high-risk participants showed greater reductions in BP and higher control rates with N/C combinations compared with respective monotherapies and lesser vasodilatory side-effects compared with N monotherapy.

Social Entrepreneurship: A Case Study From Brazil

Through careful sourcing of commodities, cost-cutting efficiencies, and realistic pricing, 3 large contraceptive social marketing programs evolved into profit-making enterprises while continuing to make low-priced contraceptives available to low-income consumers on a substantial scale.

Liver disease knowledge and acceptability of non-invasive liver fibrosis assessment among people who inject drugs in the drug and alcohol setting: The LiveRLife Study

BACKGROUND

The aim of this study was to assess factors associated with baseline knowledge of HCV and liver disease, acceptability of transient elastography (TE) assessment (FibroScan(®)), and willingness and intent to receive HCV treatment among persons with a history of injection drug use participating in a liver health promotion campaign.

METHODS

The LiveRLife campaign involved three phases: (1) campaign resource development; (2) campaign resource testing; and (3) campaign implementation. Participants were enrolled in an observational cohort study with recruitment at four clinics - one primary health care facility, two OST clinics, and one medically supervised injecting centre - in Australia between May and October 2014. Participants received educational material, nurse clinical assessment, TE assessment, dried blood spot testing, and completed a knowledge survey.

RESULTS

Of 253 participants (mean age 43 years), 68% were male, 71% had injected in the past month, and 75% self-reported as HCV positive. Median knowledge score was 16/23. In adjusted analysis, less than daily injection (AOR 5.01; 95% CI, 2.64-9.51) and no daily injection in the past month (AOR 3.54; 95% CI, 1.80-6.94) were associated with high knowledge (≥16). TE was the most preferred method both pre- (66%) and post-TE (89%) compared to liver biopsy and blood sample. Eighty-eight percent were 'definitely willing' or 'somewhat willing' to receive HCV treatment, and 56% intended to start treatment in the next 12 months. Approximately 68% had no/mild fibrosis (F0/F1, ≥2.5 to ≤7.4kPa), 13% moderate fibrosis (F2, ≥7.5 to ≤9.4kPa), 10% severe fibrosis (F3, ≥9.5 to ≤12.4kPa), and 9% had cirrhosis (F4, ≥12.5kPa).

CONCLUSION

Liver disease and HCV knowledge was moderate. High acceptability of TE by PWID provides strong evidence for the inclusion of TE in HCV-related care, and could help to prioritise HCV treatment for those at greatest risk of liver disease progression.

Problem gambling and family violence: prevalence and patterns in treatment-seekers

The primary aim of this study was to explore the prevalence and patterns of family violence in treatment-seeking problem gamblers. Secondary aims were to identify the prevalence of problem gambling in a family violence victimisation treatment sample and to explore the relationship between problem gambling and family violence in other treatment-seeking samples. Clients from 15 Australian treatment services were systematically screened for problem gambling using the Brief Bio-Social Gambling Screen and for family violence using single victimisation and perpetration items adapted from the Hurt-Insulted-Threatened-Screamed (HITS): gambling services (n=463), family violence services (n=95), alcohol and drug services (n=47), mental health services (n=51), and financial counselling services (n=48). The prevalence of family violence in the gambling sample was 33.9% (11.0% victimisation only, 6.9% perpetration only, and 16.0% both victimisation and perpetration). Female gamblers were significantly more likely to report victimisation only (16.5% cf. 7.8%) and both victimisation and perpetration (21.2% cf. 13.0%) than male gamblers. There were no other demographic differences in family violence prevalence estimates. Gamblers most commonly endorsed their parents as both the perpetrators and victims of family violence, followed by current and former partners. The prevalence of problem gambling in the family violence sample was 2.2%. The alcohol and drug (84.0%) and mental health (61.6%) samples reported significantly higher rates of any family violence than the gambling sample, while the financial counselling sample (10.6%) reported significantly higher rates of problem gambling than the family violence sample. The findings of this study support substantial comorbidity between problem gambling and family violence, although this may be accounted for by a high comorbidity with alcohol and drug use problems and other psychiatric disorders. They highlight the need for routine screening, assessment and management of problem gambling and family violence in a range of services.

Slaughtering sacred cows: six institutional obstacles to advances in family planning

In order to capitalise on new opportunities to advance contraceptive and reproductive health choices globally, organisations working in these fields will need to overcome six institutional obstacles. These are: (i) committee management; (ii) over-medicalisation; (iii) fear of risk and controversy; (iv) conferences, meetings, and symposia; (v) obsession with coordination; and (vi) fear of sex. The reproductive health community will require energy, innovative approaches, and a sharp focus on service delivery to address these hurdles that will otherwise slow down and misdirect programmatic momentum.

Incremental cholesterol reduction with ezetimibe/simvastatin, atorvastatin and rosuvastatin in UK General Practice (IN-PRACTICE): randomised controlled trial of achievement of Joint British Societies (JBS-2) cholesterol targets

AIM

The aim of this study was to compare ezetimibe/simvastatin combination therapy with intensified statin monotherapy as alternative treatment strategies to achieve the Joint British Societies (JBS)-2 and National Institute for Health and Clinical Excellence low-density-lipoprotein cholesterol (LDL-C) target of < 2 mmol/l for secondary prevention or JBS-2 LDL-C target of < 2 mmol/l for primary prevention in high-risk patients who have failed to reach target with simvastatin 40 mg.

METHODS

This is a prospective, double-blind study conducted in 34 UK primary care centres; 1748 patients with established cardiovascular disease (CVD), diabetes or high risk of CVD who had been taking simvastatin 40 mg for > or = 6 weeks were screened and 786 (45%) with fasting LDL-C > or = 2.0 mmol/l (and < 4.2 mmol/l) at screening and after a further 6-week run-in period on simvastatin 40 mg were randomised to ezetimibe/simvastatin 10/40 mg (as a combination tablet; n = 261), atorvastatin 40 mg (n = 263) or rosuvastatin 5 mg (n = 73) or 10 mg (n = 189) once daily for 6 weeks. Rosuvastatin dose was based on UK prescribing instructions. The primary outcome measure was the proportion of patients achieving LDL-C < 2 mmol/l at the end of the study.

RESULTS

The percentage of patients (adjusted for baseline differences) achieving LDL-C < 2 mmol/l was 69.4% with ezetimibe/simvastatin 10/40 mg, compared with 33.5% for atorvastatin 40 mg [odds ratio 4.5 (95% CI: 3.0-6.8); p < 0.001] and 14.3% for rosuvastatin 5 or 10 mg [odds ratio 13.6 (95% CI: 8.6-21.6); p < 0.001]. Similar results were observed for achievement of total cholesterol < 4.0 mmol/l. All study treatments were well tolerated.

CONCLUSION

Approximately 45% of patients screened had not achieved LDL-C < 2 mmol/l after > or = 12 weeks of treatment with simvastatin 40 mg. In this group, treatment with ezetimibe/simvastatin 10/40 mg achieved target LDL-C levels in a significantly higher proportion of patients during a 6-week period than switching to either atorvastatin 40 mg or rosuvastatin 5-10 mg.

Soliton interaction in a complex plasma

The interaction of two counterpropagating solitons of equal amplitudes has been studied experimentally and numerically in a monolayer strongly coupled complex plasma. Complex plasmas are microparticle suspensions in ion-electron plasmas. It was found that the solitons are delayed after the collision. Solitons with higher amplitude experience longer delays. The amplitude of the overlapping solitons during the collision was less than the sum of the initial soliton amplitudes.

[Conclusions and recommendations of a WHO expert consultation meeting on iron supplementation for infants and young children in malaria endemic areas]

This article presents the results of an expert consultation meeting aimed at evaluating the safety and public health implications of administering supplemental iron to infants and young children in malaria-endemic areas. Participants at this meeting that took place in Lyon, France on June 12-14, 2006 reached consensus on several important issues related to iron supplementation for infants and young children in malaria-endemic areas. The conclusions in this report apply specifically to regions where malaria is endemic.

Automated home-based symptom monitoring coupled with centralized telecare management in a statewide trial involving rural and urban community-based oncology practices

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Background: Pain and depression are two of the most prevalent and treatable cancer-related symptoms, each present in at least 20–30% of oncology patients. Therefore, we are conducting the NCI-funded Indiana Cancer Pain and Depression (INCPAD) study, a randomized clinical trial conducted in a statewide network of 13 community-based cancer clinics located in both rural and urban oncology practices. Methods: Patients are screened at the local clinics followed by telephone-based enrollment and informed consent, depression and pain care management, and serial research outcome assessments over a 12-month period. Patients randomized to the intervention complete automated home-based symptom monitoring by interactive voice-recorded phone calls or by internet on a tapering schedule (twice a week tapering to monthly), allowing a single nurse care manager to centrally monitor treatment of patients asynchronously and efficiently. Results: Of the first 1,612 patients screened for the trial, 820 (51%) screened positive for depression and/or pain. Of these screen-positive patients, 760 (93%) were successfully contacted by telephone, of whom 203 were ineligible (most often because of symptoms that did not reach severity thresholds), 299 refused, and 163 were enrolled. Reasons that patients refused included lack of interest in trial participation (n=176), the belief their symptoms were not cancer-related (n=35), too sick (n = 30), too busy (n = 21), or other reasons (n = 36). Conclusions: INCPAD demonstrates the feasibility of enrolling cancer patients from multiple geographically-dispersed practices and providing centralized symptom care management. The fact that two-thirds of eligible patients still refuse to participate in a relatively “low burden” trial focused on alleviating bothersome symptoms and conducted almost exclusively by telephone highlights the need for additional strategies to facilitate enrollment in cancer trials. In particular, specific approaches to overcome low enthusiasm for trial participation need to be developed.

No significant financial relationships to disclose.