Impact of weighting on the association between sociodemographic characteristics, health behaviours and cancer, cardiovascular and all-cause mortality in the Australian 45 and Up Study

BACKGROUND

Weighting can improve study estimate representativeness. We examined the impact of weighting on associations between participants' characteristics and cancer, cardiovascular and all-cause mortality in the Australian 45 and Up Study cohort.

METHODS

Raking weighted cohort data to the 2006 Australian population for seven sociodemographic characteristics. Deaths were ascertained via linkage to routinely collected data. Cox's proportional hazards regression quantified associations between 11 sociodemographic and health characteristics and cancer, cardiovascular and all-cause mortality. The ratios of hazard ratios (RHRs) compared unweighted and weighted estimates.

RESULTS

Among 195,052 included participants (median follow-up 11.4 years), there were 7200 cancer, 5912 cardiovascular and 21,840 all-cause deaths. Overall, 102/111 (91.9%) weighted HRs did not differ significantly from unweighted HRs (100%, 86.5% and 89.2% of 37 HRs for cancer, cardiovascular and all-cause mortality, respectively). Significant differences included a somewhat stronger association between single/widowed/divorced (versus married/de-facto) and cardiovascular mortality (unweighted HR=1.25 (95%CI:1.18-1.32), weighted HR=1.33 (95%CI:1.24-1.42), RHR=1.06 (95%CI:1.02-1.11)); and between no school certificate/qualification (versus university degree) and all-cause mortality (unweighted HR=1.21 (95%CI:1.15-1.27), weighted HR=1.28 (95%CI:1.19-1.38), RHR=1.06 (95%CI:1.03-1.10)).

CONCLUSION

Our results support the generalisability of most estimates of associations in the 45 and Up Study, particularly in relation to cancer mortality. Slight distortion of a few associations with cardiovascular or all-cause mortality were observed.

Development and Validation of txSim: A Model of Advanced Lung Cancer Treatment in Australia

BACKGROUND AND OBJECTIVE

Since 2016, new therapies have transformed the standard of care for lung cancer, creating a need for up-to-date evidence for health economic modelling. We developed a discrete event simulation of advanced lung cancer treatment to provide estimates of survival outcomes and healthcare costs in the Australian setting that can be updated as new therapies are introduced.

METHODS

Treatment for advanced lung cancer was modelled under a clinician-specified treatment algorithm for Australia in 2022. Prevalence of lung cancer subpopulations was extracted from cBioPortal and the Sax Institute's 45 and Up Study, a large prospective cohort linked to cancer registrations. All costs were from the health system perspective for the year 2020. Pharmaceutical and molecular diagnostic costs were obtained from public reimbursement fees, while other healthcare costs were obtained from health system costs in the 45 and Up Study. Treatment efficacy was obtained from clinical trials and observational study data. Costs and survival were modelled over a 10-year horizon. Uncertainty intervals were generated with probabilistic sensitivity analyses. Overall survival predictions were validated against real-world studies.

RESULTS

Under the 2022 treatment algorithm, estimated mean survival and costs for advanced lung cancer 10 years post-diagnosis were 16.4 months (95% uncertainty interval [UI]: 14.7-18.1) and AU$116,069 (95% UI: $107,378-$124,933). Survival and costs were higher assuming optimal treatment utilisation rates (20.5 months, 95% UI: 19.1-22.5; $154,299, 95% UI: $146,499-$161,591). The model performed well in validation, with good agreement between predicted and observed survival in real-world studies.

CONCLUSIONS

Survival improvements for advanced lung cancer have been accompanied by growing treatment costs. The estimates reported here can be used for budget planning and economic evaluations of interventions across the spectrum of cancer control.

A pharmacist-led penicillin allergy de-labelling project within a preoperative assessment clinic: the low-hanging fruit is within reach

BACKGROUND

Having a false penicillin-allergy label is linked to longer hospital stays and to an increased risk of Clostridioides difficile and meticillin-resistant Staphylococcus aureus infection.

AIM

To assess a penicillin-allergy de-labelling tool designed for use by the non-allergist.

METHODS

Patients attending the surgical preoperative assessment clinic (POAC) at a large UK teaching hospital, who reported a penicillin allergy, were directly de-labelled by nursing or pharmacy staff, where appropriate. A penicillin-allergy de-labelling tool designed for use by the non-allergist was adapted and applied; nursing staff were provided with supporting information and education to enable removal of spurious labels. Antimicrobial pharmacists (AMPs) provided follow-up, cross-checked prophylactic antibiotics administered, interrogated clinical notes, and telephoned patients following their surgery, for details of any adverse reactions suffered.

FINDINGS

A total of 163 patients reporting a penicillin allergy were identified for intervention. Twenty-nine (17.8%) patients reported a penicillin-allergy history appropriate for direct de-labelling, of whom eight (27.6%) declined to consent. The remaining 21 patients (12.8%) were directly de-labelled, with 12 (7.4%) patients consenting during their POAC appointment; the remaining nine (5.5%) patients were consented and de-labelled after their surgery by an AMP.

CONCLUSION

The POAC was identified as an appropriate location and time-point in the patient pathway to enable the direct removal of spurious penicillin-allergy labels prior to surgery. Results suggest that this could be undertaken by nursing staff, although support from AMPs enabled a greater number of patients to be de-labelled.

Fifty-year forecasts of daily smoking prevalence: can Australia reach 5% by 2030?

OBJECTIVE

To compare 50-year forecasts of Australian tobacco smoking rates in relation to trends in smoking initiation and cessation and in relation to a national target of ≤5% adult daily prevalence by 2030.

METHODS

A compartmental model of Australian population daily smoking, calibrated to the observed smoking status of 229 523 participants aged 20-99 years in 26 surveys (1962-2016) by age, sex and birth year (1910-1996), estimated smoking prevalence to 2066 using Australian Bureau of Statistics 50-year population predictions. Prevalence forecasts were compared across scenarios in which smoking initiation and cessation trends from 2017 were continued, kept constant or reversed.

RESULTS

At the end of the observation period in 2016, model-estimated daily smoking prevalence was 13.7% (90% equal-tailed interval (EI) 13.4%-14.0%). When smoking initiation and cessation rates were held constant, daily smoking prevalence reached 5.2% (90% EI 4.9%-5.5%) after 50 years, in 2066. When initiation and cessation rates continued their trajectory downwards and upwards, respectively, daily smoking prevalence reached 5% by 2039 (90% EI 2037-2041). The greatest progress towards the 5% goal came from eliminating initiation among younger cohorts, with the target met by 2037 (90% EI 2036-2038) in the most optimistic scenario. Conversely, if initiation and cessation rates reversed to 2007 levels, estimated prevalence was 9.1% (90% EI 8.8%-9.4%) in 2066.

CONCLUSION

A 5% adult daily smoking prevalence target cannot be achieved by the year 2030 based on current trends. Urgent investment in concerted strategies that prevent smoking initiation and facilitate cessation is necessary to achieve 5% prevalence by 2030.

Bayesian cluster analysis

Bayesian cluster analysis offers substantial benefits over algorithmic approaches by providing not only point estimates but also uncertainty in the clustering structure and patterns within each cluster. An overview of Bayesian cluster analysis is provided, including both model-based and loss-based approaches, along with a discussion on the importance of the kernel or loss selected and prior specification. Advantages are demonstrated in an application to cluster cells and discover latent cell types in single-cell RNA sequencing data to study embryonic cellular development. Lastly, we focus on the ongoing debate between finite and infinite mixtures in a model-based approach and robustness to model misspecification. While much of the debate and asymptotic theory focuses on the marginal posterior of the number of clusters, we empirically show that quite a different behaviour is obtained when estimating the full clustering structure. This article is part of the theme issue 'Bayesian inference: challenges, perspectives, and prospects'.

Economic impact of using risk models for eligibility selection to the International lung screening Trial

OBJECTIVES

Using risk models as eligibility criteria for lung screening can reduce race and sex-based disparities. We used data from the International Lung Screening Trial(ILST; NCT02871856) to compare the economic impact of using the PLCOm2012 risk model or the US Preventative Services' categorical age-smoking history-based criteria (USPSTF-2013).

MATERIALS AND METHODS

The cost-effectiveness of using PLCOm2012 versus USPSTF-2013 was evaluated with a decision analytic model based on the ILST and other screening trials. The primary outcomes were costs in 2020 International Dollars ($), quality-adjusted life-years (QALY) and incremental net benefit (INB, in $ per QALY). Secondary outcomes were selection characteristics and cancer detection rates (CDR).

RESULTS

Compared with the USPSTF-2013 criteria, the PLCOm2012 risk model resulted in $355 of cost savings per 0.2 QALYs gained (INB=$4294 at a willingness-to-pay threshold of $20 000/QALY (95 %CI: $4205-$4383). Using the risk model was more cost-effective in females at both a 1.5 % and 1.7 % 6-year risk threshold (INB=$6616 and $6112, respectively), compared with males ($5221 and $695). The PLCOm2012 model selected more females, more individuals with fewer years of formal education, and more people with other respiratory illnesses in the ILST. The CDR with the risk model was higher in females compared with the USPSTF-2013 criteria (Risk Ratio = 7.67, 95 % CI: 1.87-31.38).

CONCLUSION

The PLCOm2012 model saved costs, increased QALYs and mitigated socioeconomic and sex-based disparities in access to screening.

Updated cost-effectiveness analysis of lung cancer screening for Australia, capturing differences in the health economic impact of NELSON and NLST outcomes

BACKGROUND

A national, lung cancer screening programme is under consideration in Australia, and we assessed cost-effectiveness using updated data and assumptions.

METHODS

We estimated the cost-effectiveness of lung screening by applying screening parameters and outcomes from either the National Lung Screening Trial (NLST) or the NEderlands-Leuvens Longkanker Screenings ONderzoek (NELSON) to Australian data on lung cancer risk, mortality, health-system costs, and smoking trends using a deterministic, multi-cohort model. Incremental cost-effectiveness ratios (ICERs) were calculated for a lifetime horizon.

RESULTS

The ICER for lung screening compared to usual care in the NELSON-based scenario was AU$39,250 (95% CI $18,150-108,300) per quality-adjusted life year (QALY); lower than the NLST-based estimate (ICER = $76,300, 95% CI $41,750-236,500). In probabilistic sensitivity analyses, lung screening was cost-effective in 15%/60% of NELSON-like simulations, assuming a willingness-to-pay threshold of $30,000/$50,000 per QALY, respectively, compared to 0.5%/6.7% for the NLST. ICERs were most sensitive to assumptions regarding the screening-related lung cancer mortality benefit and duration of benefit over time. The cost of screening had a larger impact on ICERs than the cost of treatment, even after quadrupling the 2006-2016 healthcare costs of stage IV lung cancer.

DISCUSSION

Lung screening could be cost-effective in Australia, contingent on translating trial-like lung cancer mortality benefits to the clinic.

Large-Scale Population-Based Surveys Linked to Administrative Health Databases as a Source of Data on Health Utilities in Australia

OBJECTIVES

Large-scale health surveys that contain quality-of-life instruments are a rich source of health utility data for health economic evaluations, especially when linked to routinely collected, administrative health databases. We derived health utility values for a wide range of health conditions using a large Australian cohort study linked to population-wide health databases.

METHODS

Short-Form 6-Dimension utility values were calculated for 56 094 adults, aged 47+ years, in the New South Wales 45 and Up Study who completed the Social, Economic, and Environmental Factors survey (2010-2011). Mean utilities were summarized for major health conditions identified through self-report, hospital records, primary cancer notifications, and claims for government-subsidized prescription medicines and medical services. To identify unique associations between health conditions and utilities, beta regression was performed. Utility values were analyzed by time to death using linked death records.

RESULTS

Mean Short-Form 6-Dimension utility was 0.810 (95% confidence interval [CI] 0.809-0.811), was age dependent, and was higher in men than women. Utilities for serious health conditions ranged from 0.685 (95% CI 0.652-0.718) for lung cancer to 0.800 (95% CI 0.787-0.812) for melanoma whereas disease-free respondents had a mean of 0.859 (95% CI 0.858-0.861). Most health conditions were independently associated with poorer quality of life. Utility values also declined by proximity to death where participants sampled 6 months before death had a mean score of 0.637 (95% CI 0.613-0.662).

CONCLUSIONS

Our data offer a snapshot of the health status of an older Australian population and show that record linkage can enable comprehensive ascertainment of utility values for use in health economic modeling.

OP0068 DISTINCT STROMAL AND IMMUNE CELL INTERACTIONS SHAPE THE PATHOGENESIS OF RHEUMATOID AND PSORIATIC ARTHRITIS

Background

Rheumatoid (RA) and psoriatic arthritis (PsA) are common autoimmune and autoinflammatory diseases of unknown aetiology characterised by complex synovial pathology with a detrimental effect on the patient’s quality of life. Significant differences in pathophysiology may explain distinct clinical manifestations and account for differential responses to specific therapeutics. Recent implementation of single cell transcriptomic analysis of sorted synovial cells has revealed the diverse cellular landscape of the RA synovial stromal and immune cell compartments, however, a complete analysis of immune and stromal cells in tandem, for RA and PsA patient synovial tissue has not been performed.

Objectives

To combine novel scRNA transcriptomic approaches and ex vivo assays in order to: identify differences in the cellular landscape of RA and PsA synovial tissue inflammation and immune – stromal cell interactions that drive pathology in RA and PsA.

Methods

Single cell transcriptomic profiling of 178,000 synovial tissue cells from 5 PsA and 4 RA patients, importantly, without prior sorting of immune and stromal cells. This approach enabled the generation of a unique cell atlas of intact synovial tissue identifying immune and stromal cell interactions. State of the art data integration and annotation techniques identified and characterised 18 stromal and 14 immune cell clusters. Bioinformatic examination of cell-cell communication via construction of receptor-ligand interaction networks with further in vitro validation of stromal and immune cell crosstalk through flow cytometric analysis, multiplex ELISA and mitochondrial and single cell metabolic profiling by multiphoton and florescent lifetime imaging microscopy, seahorse.

Results

Following quality control and data integration the PsA and RA cellular landscape was generated and nine mega clusters indicative of fibroblasts, endothelial cells, pericytes, macrophages, dendritic cells (DC), B cells, plasma cells, T cells and NKT consisting of several sub clusters were identified. Distinct points of transcriptomic deviation and convergence between RA and PsA were identified for each of the major cell types of the joint. Specifically, cell cycle and trajectory analysis revealed that only a fraction of synovial T cells are actively proliferating. Additionally, the differential usage of immunoglobulin light chains by memory and plasma cells indicates that plasma cells are potentially not derived from the local memory B cell pool of the synovial tissue. Importantly, we report distinct fibroblast and endothelial cell transcriptomes indicating differentially abundant subpopulations in RA and PsA characterised by distinct transcription factor usage and signalling pathway enrichment. Specifically transcriptomic imputation analysis revealed abundance of invasive FAPα+THY1+ regulated by transcription factor TEAD1 in RA compared to PsA synovial tissue. In order to identify potential cell-cell communication driving inflammation in RA and PsA, novel receptor–ligand interaction networks were generated and downstream of the receptor, target characterisation was performed. Herein we identify RA-specific synovial T cell-derived TGF-β and macrophage IL-1β synergy in driving the transcriptional profile of FAPα+THY1+ invasive synovial-fibroblasts, expanded in RA compared to PsA synovial tissue biopsies (Figure 1). Ex vivo treatment of RA patient synovial fibroblasts identified TGF-b and IL-1b synergy are a major driver of IL-6 production, fibroblast activation and adhesion molecule expression. Interestingly, the aforementioned proinflammatory changes of RA patient synovial fibroblasts were coupled with significant alterations in mitochondrial eccentricity and size and a marked metabolic adaptation towards a strongly glycolytic profile (Figure 1).

Figure 1.

Conclusion

Disrupting specific immune and stromal cell interactions offers novel opportunities for targeted therapeutic intervention in RA and PsA.

Disclosure of Interests

Achilleas Floudas: None declared, Conor Smith: None declared, Orla Tynan: None declared, Nuno Neto: None declared, Vinod Krishna Employee of: Janssen Pharmaceuticals, Sarah Wade: None declared, Megan Hanlon: None declared, Clare Cunningham: None declared, Viviana Marzaioli: None declared, Mary Canavan: None declared, Jean Fletcher: None declared, Suzanne Cole Employee of: Janssen Pharmaceuticals, Ling-Yang Hao Employee of: Janssen Pharmaceuticals, Sunil Nagpal Employee of: Janssen Pharmaceuticals, GSK, Michael Monaghan: None declared, Douglas Veale Consultant of: Janssen, Eli Lilly, Pfizer, Ursula Fearon Consultant of: Janssen, Eli Lilly, Pfizer.

POS0495 CYTOKINE SYNERGY ENHANCES SYNOVIAL FIBROBLAST ACTIVATION IN CHILDREN WITH DOWN’S SYNDROME-ASSOCIATED ARTHRITIS

Background

We have previously shown that children with Down’s syndrome-associated arthritis (DA) display a more aggressive form of inflammatory arthritis compared to that of Juvenile Idiopathic Arthritis (Shih et al., 2019). DA is associated with an increase in polyfunctional T-cells coexpressing TNF-α DA is associated with an increase in polyfunctional T-cells coexpressing TNF-fibroblasts (FLS) (Foley et al., 2019).

Objectives

In this study we examine the effect of cytokine synergy on primary DA FLS function.

Methods

Primary DA FLS were cultured and stimulated with TNF-α (0.1 and 1ng/ml), IL-17A (20 and 50ng/ml), IFN-ɣ (10 and 50ng/ml) and GM-CSF (20 and 100ng/ml) or a combination of these cytokines and the following functional experiments performed. Chemokine and adhesion molecule cell surface expression were quantified by flow cytometry, in addition to quantification of leukocyte-DA-FLS adhesion assays. Gene and protein expression of proinflammatory and metabolic mediators were quantified by ELISA and RT-PCR. Furthermore, real-time metabolic activity in response to cytokine stimulation was assessed by measuring the two major energy pathways: glycolysis (ECAR) and oxidative phosphorylation (OCR), by the Seahorse XFe96 Analyser.

Results

We examined the effects of T cell derived cytokines, TNF-α, IL-17A, IFN-γ and GM-CSF, alone and in combination on DA FLS function. TNF-α, IL-17A and IFN-γ induced IL-6, RANTES and MCP-1 production, with no effect observed for GM-CSF. Furthermore, TNF-α, IFN-ɣ and IL-17A increased leukocyte adhesion to DA FLS. TNF-α and IFN-ɣ induced cell surface expression of CXCR3, CXCR4, ICAM-1 and VCAM-1 on DA FLS. Next, we investigated the potential synergistic relationship that these cytokines could have on proinflammatory mediators. IL-17A and IFN-ɣ potentiated the effects TNF-α on IL-6 and MCP-1 secretion compared to stimulation alone. Furthermore, cytokine synergy significantly induced IL-6, IL-8, RANTES and LDHA mRNA expression compared to basal. IL-17A and IFN-αL-17A and IFN- eeased ts TNF-α on IL-6 and MCP-1 secretion compared to stimulation alone. Additionally, IFN the ECAR:OCR ratio demonstrating a shift in the metabolic profile of DA FLS to glycolysis. Overall DA FLS are transformed from a quiescent metabolic state to an energetic phenotype.

Conclusion

TNF-αNF-lusion:OCR ratio demonstrating a shift in the metabolhe aggressive phenotype of DA FLS through increased cytokine, adhesion molecule and chemokine expression, which is pathways for the treatment of DA.

References

[1]Foley, C. et al. (2019) ‘Increased T cell plasticity with dysregulation of T follicular helper, T peripheral helper and T regulatory cell responses in children with JIA and Down syndrome-associated arthritis’, Arthritis & Rheumatology, pp. 0–1. doi: 10.1002/art.41150.

[2]Shih, Y. J. et al. (2019) ‘Enthesitis-related arthritis is the most common category of juvenile idiopathic arthritis in Taiwan and presents persistent active disease’, Pediatric Rheumatology. Pediatric Rheumatology. doi: 10.1186/s12969-019-0363-0.

Disclosure of Interests

None declared.

AB0074 RAPAMYCIN INHIBITS IL-1β INDUCED RA SYNOVIAL FIBROBLAST ACTIVATION, AN EFFECT ASSOCIATED WITH ALTERATION IN THEIR METABOLIC PROFILE

Background

Rheumatoid Arthritis (RA) is a common autoimmune disease characterized by systemic polyarthritis affecting the joints, most notably of the hands and feet. A fundamental feature of RA is inflammation within the synovial joint due to neo-angiogenesis which facilitates an influx of immune cells and release of pro-inflammatory mediators.

Objectives

In this study we investigate the effect of metabolic reprogramming on IL-1β regulation of stromal cell activation and invasiveness in RA.

Methods

Primary RA synovial fibroblasts (RAFLS) and human umbilical vein endothelial cells (HUVEC) were cultured with IL-1 β (2 ng/mL) alone or in combination with the metabolic inhibitor rapamycin (100nM). Pro-inflammatory cytokines IL-6, MCP-1 and Rantes were quantified by real-time PCR and ELISA. Cellular adhesion and network formation were quantified by adhesion binding assays and Matrigel invasion assays. pS6 (a surrogate marker of the mTOR pathway) was quantified by flow cytometry. Cellular bioenergetics was assessed using the Seahorse-XFe-technology and key glycolytic genes (HK2, PKM2, G6DP) were quantified by real-time PCR. YAP was measured by Western-Blot.

Results

IL-1β significantly induced secretion of IL-6 (p<0.05), MCP-1 (p<0.01) and Rantes (p<0.01) from RAFLS. IL-1β induced leukocyte adhesion to RAFLS (p=0.062) and HUVEC (p=0.051), in addition to an increase RAFLS and HUVEC network formation. This was accompanied by a change in the cellular bioenergetic profile of cells, where IL-1β increased the ECAR/OCR ratio in favour of glycolysis for RAFLS (p<0.05) and HUVEC, and induced the % frequency in the cell surface expression of pS6 on RAFLS. Rapamycin inhibited IL-1β -induced leukocyte adhesion and network formation in RAFLS (p<0.05; p<0.05 respectively) and HUVEC (p<0.05). Rapamycin inhibited IL-1β -induced Rantes secretion (p<0.05), no effect observed for IL-6 and MCP-1. Rapamycin also inhibited IL-1b-induce YAP protein expression which is involved in FLS invasive capacity through cytoskeletal rearrangement. This was accompanied by a shift in the metabolic profile from a glycolytic/energetic state back towards a more quiescent state.

Conclusion

Rapamycin inhibits IL-1β -induced pro-inflammatory mechanisms in key stromal cells involved in the pathogenesis of RA. Targeting metabolism may lead to new potential therapeutic or adjuvant strategies, particularly for those patients who have sub-optimal responses to current treatments.

References

[1]Kim EK, Min HK, Lee SY, Kim DS, Ryu JG, Na HS, Jung KA, Choi JW, Park SH, Cho ML. Metformin rescues rapamycin-induced mitochondrial dysfunction and attenuates rheumatoid arthritis with metabolic syndrome. Arthritis Res Ther. 2020 Apr 10;22(1):77. doi: 10.1186/s13075-020-02174-3. PMID: 32276645; PMCID: PMC7149912.

Disclosure of Interests

None declared

Raking of data from a large Australian cohort study improves generalisability of estimates of prevalence of health and behaviour characteristics and cancer incidence

Background

Health surveys are commonly somewhat non-representative of their target population, potentially limiting the generalisability of prevalence estimates for health/behaviour characteristics and disease to the population. To reduce bias, weighting methods have been developed, though few studies have validated weighted survey estimates against generally accepted high-quality independent population benchmark estimates.

Methods

We applied post-stratification and raking methods to the Australian 45 and Up Study using Census data and compared the resulting prevalence of characteristics to accepted population benchmark estimates and separately, the incidence rates of lung, colorectal, breast and prostate cancer to whole-of-population estimates using Standardised Incidence Ratios (SIRs).

Results

The differences between 45 and Up Study and population benchmark estimates narrowed following sufficiently-informed raking, e.g. 13.6% unweighted prevalence of self-reported fair/poor overall health, compared to 17.0% after raking and 17.9% from a population benchmark estimate. Raking also improved generalisability of cancer incidence estimates. For example, unweighted 45 and Up Study versus whole-of-population SIRs were 0.700 (95%CI:0.574–0.848) for male lung cancer and 1.098 (95%CI:1.002–1.204) for prostate cancer, while estimated SIRs after sufficiently-informed raking were 0.828 (95%CI:0.684–0.998) and 1.019 (95%CI:0.926–1.121), respectively.

Conclusion

Raking may be a useful tool for improving the generalisability of exposure prevalence and disease incidence from surveys to the population.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-022-01626-5.

778Risk of 27 cancer types in relation to tobacco smoking: cohort study involving 229,028 Australians

Background

Tobacco smoke is a known carcinogen and the magnitude of smoking-related cancer risk varies according to time and population. Local, contemporary evidence can drive appropriate tobacco control. We provide comprehensive cancer risk estimates related to smoking in the population-based, New South Wales (NSW) 45 and Up Study.

Methods

We estimated smoking-related hazard ratios (HR) for cancer using Cox proportional hazards regression using linked questionnaire (2006-2009) and incident cancer data (n ≥ 50 cases per cancer type), from the NSW Cancer Registry (to December 2013) (via CHeReL).

Results

Of 18,475 cancers among 229,028 participants aged ≥45 years, current smokers had significantly increased risks of cancers of the lung, larynx, head and neck, oesophagus, liver, bladder, pancreas, stomach, colorectum, and cancers with unknown primary site, compared to never-smokers; lung cancer risk was markedly elevated, including for current-smokers of 1-5 cigarettes/day (HR = 9.25, 95%CI=5.2-16.6), increasing to 38.39 (26.2-56.2) for current-smokers of &gt; 30 cigarettes/day. Quitting substantively decreased cancer risk compared to continued smoking, with lung cancer risk decreasing with decreasing age at quitting (p(trend)&lt;0.05), however risks remained elevated for those quitting aged &gt;25 compared to never-smokers (1.73, 1.1-2.6 for age 26-30 years). An estimated 20% of current-smokers in Australia will get lung cancer during their lifetime versus 1.6% of never-smokers.

Conclusions

Smoking-attributable cancer risks in Australia are significant, comparable to contemporary risks from other developed nations.

Key messages

Smokers – including “light” smokers – are at high cancer risk, with ∼one-fifth of Australian lifetime smokers developing lung cancer. Quitting is beneficial. Continued investment in tobacco control is essential.

AB0916-PARE KNOWLEDGE OF DISEASE, DIAGNOSIS, ADHERENCE AND IMPACT OF RESEARCH IN PATIENTS WITH INFLAMMATORY ARTHRITIS

Background:

The diagnosis and treatment of inflammatory arthritis has been transformed largely by the development of drugs that target specific molecules of the immune system. However, these changes have increased the complexity of the mechanisms of disease, its treatment and patients understanding. Patient education is needed in this area to facilitate decision making and to facilitate strong patient-partnerships in research.

Objectives:

The aim of this study was to examine the level of understanding of inflammatory arthritis patients and the need for strong patient-partnership in research.

Methods:

An online anonymous survey addressed questions about diagnosis, routine tests, medications and how they work, medication adherence, disease flare, heredity, pregnancy, and patient involvement in research.

Results:

There were 1,873 respondents, 1416 of which had inflammatory arthritis (IA)-RA (65.8%) and PsA (34.2%). They were predominantly female (RA 86%, PsA 85 %), aged 55±13 and 50±12. Less than 35% of patients had an understanding of diagnostic tests, what was measured and the implication for disease, with 75.5% also concerned about heredity. There was a high level of understanding of how specific medications treat inflammatory arthritis (72.9%). Adherence was also very high (>87%), with the main reasons for stopping medication without the advice of their clinician, ‘feeling better’ and ‘side effects’ however a significant proportion of patients (69.9%) reported a disease-flare following cessation of medication. Patients of childbearing age (69%) were also concerned that inflammatory arthritis reduced their chances of getting pregnant, with only 8% believing arthritis medications were safe to take during pregnancy. Finally, only 9% of patients had ever been asked to participate in a research study.

Conclusion:

This study demonstrates a need for the development of stronger patient-partnerships with clinicians and researchers in relation to patient education and engagement with research, to create a platform where patients can have meaningful input and involvement in future research studies.

Acknowledgements:

We wish to thank all the patients who contributed to this study

Disclosure of Interests:

Mary Canavan: None declared, Viviana Marzaioli: None declared, Alex Donnelly: None declared, Siobhan Wade: None declared, Alexander Fraser: None declared, Tim O’Sullivan: None declared, Sinead Harney: None declared, Arthritis Ireland: None declared, Douglas Veale Speakers bureau: Abbvie, Janssen, Novartis, MSD, Pfizer, UCB, Consultant of: Abbvie, Janssen, Novartis, MSD, Pfizer, UCB, Grant/research support from: Janssen, Abbvie, Pfizer, UCB, Ursula Fearon Speakers bureau: Abbvie, Grant/research support from: Janssen, Abbvie, Pfizer, UCB

POS0411 TARGETING JAK-STAT SIGNALLING ALTERS THE PHENOTYPIC CHARACTERISTICS OF PsA SYNOVIAL FIBROBLASTS IN RESPONSE TO THE JAK/STAT ACTIVATOR ONCOSTATIN M

Background:

Psoriatic arthritis (PsA) is a chronic inflammatory arthritis associated with psoriasis. The JAK/STAT pathway has been linked to the pathogenesis of PsA. Recently, JAK/STAT inhibitors (JAKi) have emerged as an encouraging class of drugs for the treatment of PsA. Only a few of these inhibitors have been approved for use in PsA patients with others currently in clinical trials.

Objectives:

The aim of this study was to examine the effect of JAKi on primary PsA synovial fibroblasts (FLS) function.

Methods:

Primary PsA FLS were isolated and cultured with JAKi (Peficitinib, Filgotinib, Baricitinib and Upadacitinib) in the presence of the pro-inflammatory JAK/STAT activator - Oncostatin M (OSM). The effect of JAKi on these cells was determined by Migration and Invasion Assays, ELISA and rtPCR. PsA FLS bioenergetics was assessed using an XF24 analyser, which simultaneously quantifies two energetic pathways- glycolysis (ECAR) and Oxidative phosphorylation (OCR).

Results:

OSM-induced Migration and Invasion was supressed by all JAKi with Peficitinib, Filgotinib and Baracitinib showing the greatest effect. Analysis by ELISA and rtPCR showed reduction in MCP-1 and IL-6 expression in response to JAKi, in contrast, an increase in IL-8 was observed. These functional effects were accompanied by a change in the cellular bioenergetic profile of PsA FLS, where OSM significantly increased the ECAR:OCR ratio in favour of glycolysis where PsA FLS displayed a hypermetabolic phenotype. This effect was reversed in the presence of JAKi, which specifically targeted the glycolytic pathway with PsA FLS returning to a more quiescent phenotype.

Conclusion:

This study demonstrates that JAK/STAT signalling mediates the complex interplay between inflammation and cellular metabolism in PsA pathogenesis, inhibition of which shows effective suppression of the pathogenic phenotype of PsA FLS that drives joint destruction.

References:

[1]Chen M, Dai SM. A novel treatment for psoriatic arthritis: Janus kinase inhibitors. Chin Med J (Engl). 2020;133(8):959-967.

Disclosure of Interests:

Aisling O’ Brien: None declared, Megan Hanlon: None declared, Viviana Marzaioli: None declared, Keelin Flynn: None declared, Siobhan Wade: None declared, Douglas Veale Speakers bureau: Abbvie, Janssen, Novartis, MSD, Pfizer, UCB, Consultant of: Abbvie, Janssen, Novartis, MSD, Pfizer, UCB, Grant/research support from: Janssen, Abbvie, Pfizer, UCB, Ursula Fearon Speakers bureau: Abbvie, Grant/research support from: Janssen, Abbvie, Pfizer, UCB

OP0025 CD209+/CD14+ DENDRITIC CELLS ARE ENRICHED AND ACTIVATED AT THE SITE OF INFLAMMATION AND ARE MODULATED BY JAK/STAT SIGNALLING

Background:

Dendritic cells (DCs) are a heterogeneous population of professional antigen-presenting cells which are at the interface between innate and adaptive immunity. A specific subset of DCs is known to derive from monocyte and has a key role in inflammation and infection.

Objectives:

This study aimed to characterize the phenotype and function of a distinct CD209+/CD14+ DC subset in the periphery and at the site of inflammation in patients with rheumatoid (RA) and psoriatic arthritic (PsA), in addition to examining the effect Tofacitinib and TNF inhibitor on their development.

Methods:

Peripheral blood and synovial fluid mononuclear cells (PBMC and SFMC) were isolated by Ficoll density gradient from healthy subject (HC), and patients with RA and PsA. Single cell synovial tissue suspension (ST) from RA and PsA patients were also established using enzymatic/mechanical digestion. PBMC, SFMC and ST were analysed by flow cytometry to identify the CD209+/CD14+ DC subset, its frequency and the cell surface expression of chemokines receptors (CCR6, CCR7, CXCR3, CXCR4 and CXCR5) and activation markers (CD40 and CD80). In addition, PBMC were stimulated with different TLR (LPS, CPG, R848, Poly I:C) and intracellular staining for IL12, TNFα, IL1β and IL6 was performed by flow cytometry. Lineage negative cells (CD3/CD19/CD56-) were stimulate with GMCSF/IL4 in the presence or absence of the JAK/STAT inhibitor Tofacitinib or the TNF inhibitor Humira, and the CD209+/CD14+ DC development was evaluated by flow cytometry.

Results:

We identified, for the first time, a distinct CD209+/CD14+ DC population in PBMC of patients with RA and PsA, with similar frequency across the groups. However, when PBMC were stimulated with TLRs, an increase of IL12 and TNFα was observed in RA and PsA PBMC when compared to HC. Interestingly, this distinct DC population was significantly enriched at the site of inflammation, in both SFMC and ST, displaying a more mature phenotype, evident by the observed significant increase in CD40 and CD80 expression. SPICE analysis further identified differential expression and co-expression of chemokine receptors at the periphery of RA and PsA patients, when compared to the HC. Furthermore synovial tissue single cell analysis from RA/PsA demonstrated a unique chemokines receptors profile demonstrating increased single expression and co-expression of CXCR3 and CXCR5 compared to periphery. Finally, we have previously observed that JAK/STAT is involved in monocyte-derived dendritic cells population development (1,2), therefore we performed CD3, CD19 and CD56 depletion of RA/PsA PBMC followed by stimulation with GMCSF/IL4, to spike the Mo-DC population, in the presence of Tofacitinib or Humira. Interestingly, we observed that JAK/STAT inhibition, but not TNF inhibitor, reduced the generation and development of CD209+/CD14+ DC.

Conclusion:

We identify for the first time a distinct monocyte-derived DC population characterized as CD209+/CD14+ in the periphery of RA and PsA patients. This population was enriched at the site of inflammation and displayed a unique chemokine receptor profile and activation markers, suggesting that these cells are already activated in the periphery of IA patients, and are recruited and further activated in the inflamed joint. In addition, we showed that the CD209+/CD14+ DC development is regulated by JAK/STAT signalling, but not TNF inhibition.

References:

[1]Marzaioli V, Canavan M, Floudas A, et al. Monocyte-Derived Dendritic Cell Differentiation in Inflammatory Arthritis Is Regulated by the JAK/STAT Axis via NADPH Oxidase Regulation. Front. Immunol. 2020;11:1406.

[2]Marzaioli V, Hurtado-Nedelec M, Pintard C, et al. NOX5 and p22phox are 2 novel regulators of human monocytic differentiation into dendritic cells. Blood. 2017;130(15):1734–1745.

Acknowledgements:

The authors also wish to thank all the patients who volunteered to participate into this study and the funding

Disclosure of Interests:

Viviana Marzaioli: None declared, Achilleas Floudas: None declared, Mary Canavan: None declared, Siobhan Wade: None declared, Kieran Murray: None declared, Ronan Mullan: None declared, Douglas Veale Speakers bureau: Abbvie, Janssen, Novartis, MSD, Pfizer, UCB, Consultant of: Abbvie, Janssen, Novartis, MSD, Pfizer, UCB, Grant/research support from: Janssen, Abbvie, Pfizer, UCB, Ursula Fearon Speakers bureau: Abbvie, Grant/research support from: Janssen, Abbvie, Pfizer, UCB

POS0069 INCREASED T CELL RESPONSES, METABOLIC ACTIVITY AND FIBROBLAST INVASIVE CAPACITY IN CHILDREN WITH DOWN’S SYNDROME-ASSOCIATED ARTHRITIS COMPARED TO JUVENILE IDIOPATHIC ARTHRITIS

Background:

Juvenile idiopathic arthritis (JIA) was thought to be the most common inflammatory arthritis in children (Shih et al., 2019). However an aggressive, erosive arthritis of little-known immunologic mechanism occurs 20 times more frequently in children with Down’s syndrome (Foley et al., 2019).

Objectives:

This study was undertaken to characterize immune cell responses and synovial fibroblast invasiveness in children with Down’s syndrome-associated arthritis (DA).

Methods:

Multiparametric flow cytometric analysis was used to examine peripheral blood T cell, B cell and monocyte populations. In addition, T cell cytokine responses and their metabolic profile in children with DA, JIA, Down’s Syndrome (trisomy 21 [T21]), and in healthy controls were assessed. The function of DA primary synovial fibroblasts (FLS) was assessed in response to stimulation with pro-inflammatory mediators alone and in combination (TNF-α, IL-17a, IFN-γ, GM-CSF). The two major energy pathways glycolysis (ECAR) and oxidative phosphorylation (OCR) were quantified by the Seahorse XFe96 Analyser. Migration, adhesion, invasion and cytokine/chemokine secretion were quantified by wound repair scratch assays, Transwell collagen invasion chambers, adhesion binding assays, and ELISAs.

Results:

T cell frequencies were higher in DA compared to JIA and T21 in contrast to B cell frequencies which were decreased. T cell responses in DA were characterized by increased frequencies of CD4+ and CD8+ TNF- α, IFN- γ and GM-CSF producing T cells. The frequency of T peripheral helper (Tph) cells were elevated in children with DA compared to all other groups. In parallel, an increase in their metabolic profile evident by higher phosphorylation of mTOR pathway components AKT, mTOR and S6. Comparison of DA and JIA FLS demonstrated that DA FLS display a more invasive/migratory capacity and are more metabolically active. Based on the increased cytokine responses in DA T cells, we next examined the effect T cell derived cytokines TNF-α, IL-17A, IFN-γ and GM-CSF alone and in combination on DA FLS function. TNF-α, IL-17a and IFN-γ induced IL-6, RANTES and MCP-1 secretion, with no effect observed for GM-CSF. Furthermore, TNF-α and IL-17A induced DA FLS migration and PBMC adhesion to DA FLS. Finally IL17A and IFN-γ potentiated the effect of TNF-α on IL-6 and MCP-1 secretion compared to stimulations alone.

Conclusion:

DA is a more common and aggressive form of arthritis compared to JIA. It is characterized by increased T cell responses and a more invasive FLS phenotype compared to that of JIA, with T cell derived cytokine alone and in combination further inducing DA FLS pathogenic mechanisms. These effects mirror the increased erosive disease observed clinically.

References:

[1]Foley, C. et al. (2019) ‘Increased T cell plasticity with dysregulation of T follicular helper, T peripheral helper and T regulatory cell responses in children with JIA and Down syndrome-associated arthritis’, Arthritis & Rheumatology, pp. 0–1. doi: 10.1002/art.41150.

[2]Shih, Y. J. et al. (2019) ‘Enthesitis-related arthritis is the most common category of juvenile idiopathic arthritis in Taiwan and presents persistent active disease’, Pediatric Rheumatology. Pediatric Rheumatology. doi: 10.1186/s12969-019-0363-0.

Disclosure of Interests:

None declared.

Cancer incidence and cancer death in relation to tobacco smoking in a population-based Australian cohort study

Tobacco smoke is a known carcinogen, but the magnitude of smoking-related cancer risk depends on country-specific, generational smoking patterns. We quantified cancer risk in relation to smoking in a population-based cohort, the 45 and Up Study (2006-2009) in New South Wales, Australia. Cox proportional hazards regressions estimated adjusted hazard ratios (HR) by self-reported smoking history at baseline (2006-2009) for incident, primary cancers via linkage to cancer registry data to 2013 and cancer death data to 2015. Among 229 028 participants aged ≥45 years, 18 475 cancers and 5382 cancer deaths occurred. Current-smokers had increased risks of all cancers combined (HR = 1.42, 95% confidence interval [CI], 1.34-1.51), cancers of the lung (HR = 17.66, 95%CI, 14.65-21.29), larynx (HR = 11.29, 95%CI, 5.49-23.20), head-and-neck (HR = 2.53, 95%CI, 1.87-3.41), oesophagus (HR = 3.84, 95%CI, 2.33-6.35), liver (HR = 4.07, 95%CI, 2.55-6.51), bladder (HR = 3.08, 95%CI, 2.00-4.73), pancreas (HR = 2.68, 95%CI, 1.93-3.71), colorectum (HR = 1.31, 95%CI, 1.09-1.57) and unknown primary site (HR = 3.26, 95%CI, 2.19-4.84) versus never-smokers. Hazards increased with increasing smoking intensity; compared to never-smokers, lung cancer HR = 9.22 (95%CI, 5.14-16.55) for 1-5 cigarettes/day and 38.61 (95%CI, 25.65-58.13) for >35 cigarettes/day. Lung cancer risk was lower with quitting at any age but remained higher than never-smokers for quitters aged >25y. By age 80y, an estimated 48.3% of current-smokers (41.1% never-smokers) will develop cancer, and 14% will develop lung cancer, including 7.7% currently smoking 1-5 cigarettes/day and 26.4% for >35 cigarettes/day (1.0% never-smokers). Cancer risk for Australian smokers is significant, even for 'light' smokers. These contemporary estimates underpin the need for continued investment in strategies to prevent smoking uptake and facilitate cessation, which remain key to reducing cancer morbidity and mortality worldwide.

Birth-cohort estimates of smoking initiation and prevalence in 20th century Australia: Synthesis of data from 33 surveys and 385,810 participants

The aim of our study was to quantify sex-specific patterns of smoking prevalence and initiation in 10-year birth cohorts from 1910 to 1989 in Australia. We combined individual data of 385,810 participants from 33 cross-sectional surveys conducted between 1962 and 2018. We found that age-specific smoking prevalence varied considerably between men and women within birth cohorts born before 1960. The largest difference was observed in the earliest cohort (1910-1919), with up to 37.7% point greater proportion of current smokers in men than in women. In subsequent cohorts, the proportion decreased among men, but increased among women, until there was no more than 7.4% point difference in the 1960-69 birth cohort. In the 1970-79 and 1980-89 cohorts, smoking among men marginally increased, but the proportion was at most ~11.0% points higher than women. Our analysis of initiation indicated that many women born before the 1930s who smoked commenced smoking after age 25 years (e.g., ~27% born in 1910-19); compared to at most 8% of men in any birth cohort. The earliest birth cohort (1910-1919) had the greatest difference in age at initiation between sexes; 26.6 years in women versus 19.0 in men. In later cohorts, male and female smokers initiated increasingly earlier, converging in the 1960-69 cohort (17.6 and 17.8 years, respectively). While 22.9% of men and 8.4% of women initiated smoking aged < = 15 in the 1910-1919 cohort, in the latest cohort (1980-89) the reverse was true (21.4% and 28.8% for men and women, respectively). Marked differences in smoking prevalence and age at initiation existed between birth cohorts of Australian men and women born before 1960; after this, sex-specific trends in prevalence and initiation were similar. Understanding these patterns may inform the evaluation of tobacco control policies and the targeting of potential interventions for exposed populations such as lung cancer screening.

Awake tracheal intubation in a suspected COVID-19 patient with critical airway obstruction

We report the airway management of a patient with suspected COVID-19 with impending airway obstruction requiring urgent surgical tracheostomy. To our knowledge, this is the first reported case of an awake tracheal intubation in a suspected COVID-19-positive patient. Various modifications were put in place during the awake tracheal intubation and surgical tracheostomy procedures to minimise aerosol generation from the patient, such as avoiding high-flow nasal oxygen, establishing conscious sedation with remifentanil before commencing airway topicalisation and avoiding transtracheal local anaesthetic infiltration. A multidisciplinary team discussion before performing the case highlighted aspects of both the airway management and the surgical procedure where particular care and modifications are required. There is a lack of national and international guidance for awake tracheal intubation and tracheostomy in COVID-19 cases. This report nevertheless addresses the key procedural modifications required.

Statistical projection methods for lung cancer incidence and mortality: a systematic review

OBJECTIVES

To identify and summarise all studies using statistical methods to project lung cancer incidence or mortality rates more than 5 years into the future.

STUDY TYPE

Systematic review.

METHODS

We performed a systematic literature search in multiple electronic databases to identify studies published from 1 January 1988 to 14 August 2018, which used statistical methods to project lung cancer incidence and/or mortality rates. Reference lists of relevant articles were checked for additional potentially relevant articles. We developed an organisational framework to classify methods into groups according to the type of data and the statistical models used. Included studies were critically appraised using prespecified criteria.

RESULTS

One hundred and one studies met the inclusion criteria; six studies used more than one statistical method. The number of studies reporting statistical projections for lung cancer increased substantially over time. Eighty-eight studies used projection methods, which did not incorporate data on smoking in the population, and 16 studies used a method which did incorporate data on smoking. Age-period-cohort models (44 studies) were the most commonly used methods, followed by other generalised linear models (35 studies). The majority of models were developed using observed rates for more than 10 years and used data that were considered to be good quality. A quarter of studies provided comparisons of fitted and observed rates. While validation by withholding the most recent observed data from the model and then comparing the projected and observed rates for the most recent period provides important information on the model's performance, only 12 studies reported doing this.

CONCLUSION

This systematic review provides an up-to-date summary of the statistical methods used in published lung cancer incidence or mortality projections. The assessment of the strengths of existing methods will help researchers to better apply and develop statistical methods for projecting lung cancer rates. Some of the common methods described in this review can be applied to the projection of rates for other cancer types or other non-infectious diseases.

Benefits, harms and cost-effectiveness of cancer screening in Australia: an overview of modelling estimates

INTRODUCTION

There are three government-funded population-based screening programs in Australia - the national breast cancer screening program (BreastScreen Australia), the National Cervical Screening Program (NCSP), and the National Bowel Cancer Screening Program (NBCSP). Options for early detection of other cancers (e.g. hepatocellular carcinoma and melanoma) are under investigation. This study provides an overview of the health benefits, harms and cost-effectiveness of population-level breast, cervical and colorectal cancer screening, targeted-risk screening for lung cancer and Lynch syndrome, and prostate specific antigen (PSA) testing in Australia.

METHODS

The study reviewed and, where possible, updated the estimated health benefits, harms and cost-effectiveness of screening approaches from modelling studies for four cancer types, PSA testing and Lynch syndrome testing in Australia. Costs are presented in 2018 Australian dollars.

RESULTS

The renewed NCSP (for women not HPV-vaccinated) and the NBCSP were estimated to be cost-effective versus no screening; the cost-effectiveness ratio (CER) was $16 632 per life-year saved (LYS) for the NCSP, and $3380/LYS for the NBCSP. BreastScreen Australia was predicted to have a CER of $40 279/LYS-$65 065/LYS. In 2017, the NCSP transitioned to 5-yearly primary HPV testing with partial genotyping for HPV types 16 and 18 for women aged 25-74 years. Alongside vaccination, this change is predicted to prevent a further 587 cervical cancer deaths in 2018-2035, and have a favourable benefit-to-harm balance versus prior practice (biennial cytology testing for women aged 18-69 years). On average, the NBCSP (biennial screening using an immunochemical faecal occult blood test for people aged 50-74 years) is estimated to prevent 2519 colorectal cancer deaths and result in 350 colonoscopy-related adverse events annually. The inaccuracy of PSA testing as a screening tool impedes the capacity to conduct meaningful cost-effectiveness analyses at a population level, based on current evidence. Three annual low-dose computed tomography screens for lung cancer using the US National Lung Screening Trial selection criteria would not be cost-effective in Australia. A comprehensive cost-effectiveness evaluation of systematic proband testing, cascade testing and subsequent surveillance for Lynch syndrome in Australia is currently underway.

CONCLUSIONS

Current evidence supports a favourable cost-effectiveness and benefit-to-harm balance for the NCSP and NBCSP. An updated cost-effectiveness and benefits-to-harms analysis for BreastScreen Australia is required. Carefully founded quantitative estimates of health benefits, harms and cost-effectiveness provide an important aid to policy decision making, and form the basis for developing decision aids to guide individual screening decisions. Opportunities exist for lung cancer screening, systematic Lynch syndrome testing and informed decision making about PSA testing. However, more evidence is required on risk assessment, targeting of screening tests, optimal referral pathways, managing potential harms and delivering services in a cost-effective framework.

Lung cancer mortality in Australia in the twenty-first century: How many lives can be saved with effective tobacco control?

OBJECTIVES

To estimate the number of past and future lung cancer deaths that have already been averted by tobacco control initiatives in Australia, and to estimate the number of additional deaths averted under various smoking scenarios.

METHODS

We predicted lung cancer mortality rates and case numbers to 2100 using a previously validated generalized linear model based on age, birth cohort and population cigarette smoking exposure. We estimated the impact of various tobacco control scenarios: 'actual tobacco control' (incorporating the aggregate effect of past and current taxation, plain packaging, mass media campaigns and other initiatives) and scenarios where 10%, 5% and 0% smoking prevalence was achieved by 2025, all of which were compared to a counterfactual scenario with the highest historical smoking consumption level continuing into the future as if no tobacco control initiatives had been implemented.

RESULTS

Without tobacco control, there would have been an estimated 392,116 lung cancer deaths over the period 1956-2015; of these 20% (78,925 deaths; 75,839 males, 3086 females) have been averted due to tobacco control. However, if past and current measures continue to have the expected effect, an estimated 1.9 million deaths (1,579,515 males, 320,856 females; 67% of future lung cancer deaths) will be averted in 2016-2100. If smoking prevalence is reduced to 10%, 5% or 0% by 2025, an additional 97,432, 208,714 or 360,557 deaths could be averted from 2016 to 2100, respectively.

CONCLUSION

Tobacco control in Australia has had a dramatic impact on the number of people dying from lung cancer. Several hundred thousand more lung cancer deaths could be averted over the course of the century if close-to-zero smoking prevalence could be achieved in the next decade.

Lung cancer mortality in Australia: Projected outcomes to 2040

OBJECTIVES

The aim was to develop and validate a statistical model which uses past trends for lung cancer mortality and historical and current data on tobacco consumption to project lung cancer mortality rates into the future for Australia.

METHODS

We used generalized linear models (GLMs) with Poisson distribution including either age, birth cohort or period, and/or various measures of population tobacco exposure (considering cross-sectional smoking prevalence, cigarettes smoked and tar exposure per capita). Sex-specific models were fitted to data for 1956-2015 and age-standardized lung cancer mortality rates were projected forward to 2040. Possible lags of 20-30 years between tobacco exposure and lung cancer mortality were examined. The best model was selected using analysis of deviance. To validate the selected model, we temporarily re-fitted it to data for 1956-1990 and compared the projected rates to 2015 with the observed rates for 1991-2015.

RESULTS

The best fitting model used information on age, birth cohort and tar exposure per capita; close concordance with the observed data was achieved in the validation. The forward projections for lung cancer mortality using this model indicate that male and female age-standardized rates will decline over the period 2011-2015 to 2036-2040 from 27.2 to 15.1 per 100,000, and 15.8 to 11.8 per 100,000, respectively. However, due to population growth and ageing the number of deaths will increase by 7.9% for males and 57.9% for females; from 41,040 (24,831 males, 16,209 females) in 2011-2015 to 52,403 (26,805 males, 25,598 females) in 2036-2040.

CONCLUSION

In the context of the mature tobacco epidemic with past peaks in tobacco consumption for both males and females, lung cancer mortality rates are expected to continually decline over the next 25 years. However, the number of lung cancer deaths will continue to be substantial, and to increase, in Australia's ageing population.

Estimating the Cost-Effectiveness of Lung Cancer Screening with Low-Dose Computed Tomography for High-Risk Smokers in Australia

INTRODUCTION

Health economic evaluations of lung cancer screening with low-dose computed tomography (LDCT) that are underpinned by clinical outcomes are relatively few.

METHODS

We assessed the cost-effectiveness of LDCT lung screening in Australia by applying Australian cost and survival data to the outcomes observed in the U.S. National Lung Screening Trial (NLST), in which a 20% lung cancer mortality benefit was demonstrated for three rounds of annual screening among high-risk smokers age 55 to 74 years. Screening-related costs were estimated from Medicare Benefits Schedule reimbursement rates (2015), lung cancer diagnosis and treatment costs from a 2012 Australian hospital-based study, lung cancer survival rates from the New South Wales Cancer Registry (2005-2009), and other-cause mortality from Australian life tables weighted by smoking status. The health utility outcomes, screening participation rates, and lung cancer rates were those observed in the NLST. Incremental cost effectiveness ratios (ICER) were calculated for a 10-year time horizon.

RESULTS

The cost-effectiveness of LDCT lung screening was estimated at AU$138,000 (80% confidence interval: AU$84,700-AU$353,000)/life-year gained and AU$233,000 (80% confidence interval: AU$128,000-AU$1,110,000)/quality-adjusted life year (QALY) gained. The ICER was more favorable when LDCT screening impact on all-cause mortality was considered, even when the costs of incidental findings were also estimated in sensitivity analyses: AU$157,000/QALY gained. This can be compared to an indicative willingness-to-pay threshold in Australia of AU$30,000 to AU$50,000/QALY.

CONCLUSIONS

LDCT lung screening using NLST selection and implementation criteria is unlikely to be cost-effective in Australia. Future economic evaluations should consider alternative screening eligibility criteria, intervals, nodule management, the impact and cost of new therapies, investigations of incidental findings, and incorporation of smoking cessation interventions.

A simple guide to regional anaesthesia

Regional anaesthesia is widely used in modern anaesthetic practice for perioperative and postoperative analgesia. In the operating theatre, regional anaesthesia is used both on its own and in combination with other techniques (general anaesthesia and sedation). Regional anaesthesia is now a core skill set in anaesthetic training. This article provides a basic outline of regional anaesthesia for surgeons and other non-anaesthetic staff working with anaesthetists, reviewing preparation, consent, basic and specialist equipment, central neuraxial blocks (spinal, epidural and caudal), trunk blocks, upper limb blocks (interscalene, supraclavicular, infraclavicular and axillary) and lower limb blocks (femoral, fascia iliaca, sciatic, popliteal and ankle). It also discusses the pharmacology of the agents used and common complications.

Dental student self-assessment of a medical history competency developed by Oral and Maxillofacial Surgery Faculty

PURPOSE

To develop a standardized competency exam to evaluate dental student knowledge of patients with complex medical histories. Analysis was performed to determine if there is a difference between dental student self-assessment of the exam compared to oral surgery faculty. The overall goal is to enhance student comprehension of advanced medical patients in the pre-doctoral oral and maxillofacial surgery clinic and make changes based on student responses.

METHODS

The exam took place in a simulation laboratory containing two-way mirrors where the student could not see the evaluator. Three standardized patients (trained actors) were given different medical history scenarios to learn prior to the exam. Students were randomly assigned to interview one patient. The graders consisted of senior and junior level faculty. In real time (live) randomized manner, faculty assessed each student using a standardized rubric to assign a score of 1 to 4. Immediately afterwards, students assessed their own performance using the same scale.

RESULTS

Students gave themselves significantly higher grades (P < 0.001) on the exam (10.7 ± 0.12) compared to the faculty (9.2 ± 0.17). There was no significant difference in student (P = 0.16) or faculty assessment (P = 0.29) between the three different medical scenarios. There was no significant difference between faculty in assessment of student performances (P = 0.16).

CONCLUSION

These results suggested that students overestimated their performance compared to the faculty assessment. This could be due to that students assessed their performance based on memory and self-confidence; that exceeds their expectations. Internal calibration of student performances and faculty grading using standardized criteria may produce more accurate and reliable outcomes in student scoring.

Fear of falling, fracture history, and comorbidities are associated with health-related quality of life among European and US women with osteoporosis in a large international study

We studied 7,897 women with postmenopausal osteoporosis to assess factors that influence health-related quality of life (HRQoL). An increased number of comorbidities, fear of falling, and previous vertebral fracture were associated with significant reductions in HRQoL. Understanding the factors that affect HRQoL may improve management of these patients.

INTRODUCTION

HRQoL is impaired in women treated for postmenopausal osteoporosis (PMO). The objective of this study was to examine the relationship between clinical characteristics, comorbidities, medical history, patient demographics, and HRQoL in women with PMO.

METHODS

Baseline data were obtained and combined from two large and similar multinational observational studies: Prospective Observational Scientific Study Investigating Bone Loss Experience in Europe (POSSIBLE EU®) and in the US (POSSIBLE US™) including postmenopausal women in primary care settings initiating or switching bone loss treatment, or who had been on bone loss treatment for some time. HRQoL measured by health utility scores (EQ-5D™) were available for 7,897 women (94 % of study participants). The relationship between HRQoL and baseline clinical characteristics, medical history and patient demographics was assessed using parsimonious, multivariable, mixed-model analyses.

RESULTS

Median health utility score was 0.80 (interquartile range 0.69-1.00). In multivariable analyses, young age, low body mass index, previous vertebral fracture, increased number of comorbidities, high fear of falling, and depression were associated with reduced HRQoL. Regression-based model estimates showed that previous vertebral fracture was associated with lower health utility scores by 0.08 (10.3 %) and demonstrated the impact of multiple comorbidities and of fear of falling on HRQoL.

CONCLUSIONS

In this large observational study of women with PMO, there was substantial interindividual variability in HRQoL. An increased number of comorbidities, fear of falling, and previous vertebral fracture were associated with significant reductions in HRQoL.

[Seasonal variations in the nutritional status of nomad and sedentary children less than 5 years of age living in the Sahel in Chad]

Malnutrition is widespread among rural and nomad populations in the Sahel. It is linked to socio-economic factors and exhibits significant seasonal variations. The aim of this study was to assess the prevalence of malnutrition and associated risk factors among children less than 5 years of age. A repeated cross-sectional study design based on interviews and anthropometric measurements was used. A total of 653 nomad children and 579 sedentary children ranging in age from 0 to 59 months were randomly selected in households/camps on the south-eastern shore of Lake Chad. Data were collected from the same number of children at the end of the dry season (May/June, 2007) and at the end of rainy season (October 2007). Findings showed significant interseasonal variation in the prevalence of global acute malnutrition (GAM) between the end of the dry season and end of the rainy season. The respective variations were 17.9% to 13.7% (p = 0.03) in nomad children and 16.5% to 10.6% (p = 0.004) in sedentary children. Backward stepwise multivariate analysis by logistic regression showed that GAM among children under 5 years of age was significantly correlated with the following risk factors: seasonal variation, child's age, mother's nutritional status, ethnic group, and place of residence (LRT=172 and p < 0.001 for the logistic regression model). These findings demonstrate the critical state of the nutritional situation in the Sahel and rural areas.

Design of the POSSIBLE UStrade mark Study: postmenopausal women's compliance and persistence with osteoporosis medications

Failure to take prescribed medication is common. The POSSIBLE US study is evaluating the impact of physician and patient characteristics on patient-reported compliance and persistence with osteoporosis medications. We report our study design and the baseline characteristics of 4,994 postmenopausal women recruited from primary care physician offices in 33 states.

INTRODUCTION

The Prospective Observational Scientific Study Investigating Bone Loss Experience (POSSIBLE US) is a longitudinal cohort study of osteoporosis therapy in primary care.

METHODS

Between 2004 and 2007, 134 physicians (in 33 states) enrolled postmenopausal women initiating, changing, or continuing osteoporosis medications. After completing a baseline questionnaire, participants will provide data semi-annually for up to 3 years through 2008. Physicians provide patient data at baseline and routine follow-up visits. Participants from 23 sites also signed a release regarding administrative claims data for economic analyses and validation of self-reported data.

BASELINE RESULTS

Four thousand nine hundred and ninety-four evaluable women were recruited from internal medicine (n = 1,784), family practice (n = 1,556), obstetrics/gynecology (n = 1,556), and from one rheumatology practice (n = 98). Mean participant age was 64.3 years (SD = 9.97); 89% were Caucasian; 59% had some college education. Sixty-three percent used a single osteoporosis agent, usually a bisphosphonate. For monotherapy patients, concordance between clinic- and patient-reported medication use was lowest for patients prescribed estrogen therapy (70%) or calcium/vitamin D (72%). Obstetrician/gynecologists enrolled younger women, who were more likely to use estrogen therapy than patients enrolled by other physicians. The 934 women (19%) prescribed only calcium/vitamin D were younger than women prescribed pharmacologic therapy.

CONCLUSIONS

POSSIBLE US provides a unique foundation for evaluating longitudinal use of osteoporosis medications and related outcomes.

The rheology of collapsing zeolites amorphized by temperature and pressure

Low-density zeolites collapse to the rigid amorphous state at temperatures that are well below the melting points of crystals of the same composition but of conventional density. Here we show, by using a range of experimental techniques, how the phenomenon of amorphization is time dependent, and how the dynamics of order-disorder transitions in zeolites under temperature and pressure are equivalent. As a result, thermobaric regions of instability can be charted, which are indicative of polyamorphism. Moreover, the boundaries of these zones depend on the rate at which temperature or pressure is ramped. By directly comparing the rheology of collapse with structural relaxation in equivalent melts, we conclude that zeolites amorphize like very strong liquids and, if compression occurs slowly, this is likely to lead to the synthesis of perfect glasses.

The importance of high-level training for nutrition scientists in Sub-Saharan Africa

Can the African people investigate and critically analyse nutrition needs in their context, identify national or community nutrition problems, plan and evaluate nutrition programs, educate, and communicate scientific knowledge in nutrition without high-level trained staffs with a strong scientific base in human nutrition? Will they be able to tackle their nutrition problems without a sustainable organisation for long-term training and research? In this paper, an attempt is made to analyse factors that will contribute to improving human nutrition in Sub-Saharan Africa. The paper also highlights an experience of institutional capacity building in Senegal, West Africa.