Identifying therapeutic candidates for endometriosis through a transcriptomics-based drug repositioning approach

Existing medical treatments for endometriosis-related pain are often ineffective, underscoring the need for new therapeutic strategies. In this study, we applied a computational drug repurposing pipeline to stratified and unstratified disease signatures based on endometrial gene expression data to identify potential therapeutics from existing drugs, based on expression reversal. Of 3,131 unique genes differentially expressed by at least one of six endometriosis signatures, only 308 (9.8%) were in common; however, 221 out of 299 drugs identified, (73.9%) were shared. We selected fenoprofen, an uncommonly prescribed NSAID that was the top therapeutic candidate for further investigation. When testing fenoprofen in an established rat model of endometriosis, fenoprofen successfully alleviated endometriosis-associated vaginal hyperalgesia, a surrogate marker for endometriosis-related pain. These findings validate fenoprofen as a therapeutic that could be utilized more frequently for endometriosis and suggest the utility of the aforementioned computational drug repurposing approach for endometriosis.

Real-world outcomes of mepolizumab for the treatment of severe eosinophilic asthma in Canada: an observational study

BACKGROUND

Mepolizumab, the first widely available anti-interleukin 5 biologic, targets eosinophilic inflammation and has been shown in clinical trials to reduce exacerbations, oral corticosteroid dependence, and healthcare utilization in patients with severe asthma. The impact of mepolizumab in a real-world, publicly funded healthcare setting is unknown. The objective of this study was to describe the demographics and clinical characteristics of real-world patients receiving mepolizumab, and to compare asthma-related outcomes and associated asthma-related costs before and during mepolizumab use.

METHODS

This retrospective, observational study in Ontario, Canada, included patients initiating mepolizumab between February 2016 and March 2019. Patients were identified using the mepolizumab patient support program and linked to the Institute for Clinical Evaluative Sciences database of publicly accessed healthcare. Patient outcomes were obtained for 12 months pre- and post-mepolizumab initiation and compared.

RESULTS

A total of 275 patients were enrolled in the overall patient support program cohort (mean [standard deviation] age 57.6 [13.5] years, mean [standard deviation] of the median per-patient eosinophil count 540.4 [491.9] cells/μL). Mepolizumab was associated with reductions in asthma exacerbations (46.1%, P < 0.001) and in the number of asthma-related visits to general practitioners (40.2%, P < 0.001), specialists (27.2%, P < 0.001), and emergency departments (52.1%, P < 0.001). Associated costs were significantly lower post- versus pre-mepolizumab for asthma-related general practitioner and specialist visits, and for all-cause emergency department visits and hospital admissions.

CONCLUSIONS

In a real-world population of Canadian patients with severe asthma with an eosinophilic phenotype, the use of mepolizumab within a patient support program reduced asthma exacerbations and decreased asthma-related healthcare resource utilization and associated costs.

Adherence to oral antiretroviral therapy in Canada, 2010-2020

OBJECTIVE

To assess antiretroviral therapy (ART) adherence among people with HIV (PWH) in Canada and identify baseline characteristics associated with suboptimal adherence (<95%).

DESIGN

Retrospective observational study using data from the National Prescription Drug Utilization Information System and Régie de l'assurance maladie Quebec (RAMQ) Public Prescription Drug Insurance Plan.

METHODS

This analysis included PWH aged 18 years or older who initiated an ART regimen and were followed for at least 12 months (2010-2020). Patient characteristics were summarized using medical/pharmacy claims data from seven provinces (Alberta, Manitoba, New Brunswick, Newfoundland and Labrador, Ontario, Saskatchewan, and Quebec). ART regimen at index date (first dispensing of a regimen including a core agent) was defined as a single-tablet or multitablet regimen (MTR). Adherence was calculated using a Proportion of Days Covered approach, based on ART dispensing, recorded between April 2010 and the last available date. Multivariate linear regression analysis was used to determine correlations between suboptimal adherence and baseline characteristics.

RESULTS

We identified 19 322 eligible PWH, 44.7% of whom had suboptimal adherence (<95%). Among 12 594 PWH with evaluable baseline data, 10 673 (84.8%) were ART-naive, 74.2% were men, mean age was 42.9 years, and 54.1% received a MTR as their ART. Based on multivariate regression analysis, suboptimal adherence was significantly associated with multitablet ART ( P  < 0.001) and younger age ( P  < 0.001) but not sex.

CONCLUSION

Almost half of adult PWH in Canada had suboptimal adherence to ART. Better understanding of factors influencing adherence may help address gaps in current care practices that may impact adherence.

Patient and Physician Preferences for Regimen Attributes for the Treatment of HIV in the United States and Canada

A long-acting injectable (LAI) antiretroviral therapy (ART) regimen is now available as a treatment option for virologically suppressed adults with HIV-1. This study assessed preference for a LAI regimen using an online survey of virally suppressed people living with HIV (PLWH) and physicians treating HIV in the US and Canada. Preference was elicited in a discrete choice experiment (DCE) with three choice options (switch to a LAI regimen, switch to another daily oral ART regimen, or stay on their current daily oral ART regimen) and four treatment attributes. A total of 553 PLWH and 450 physicians completed the survey. From the DCE results, 59% of PLWH were predicted to prefer a LAI over an alternative oral ART or staying on their current oral treatment, and 55–66% of physicians were predicted to recommend LAI for PLWH, depending on the treatment challenge scenario presented. PLWH indicated LAI would remove daily reminders of HIV (75%) and reduce feelings of being stigmatized (68%). A majority of PLWH and physicians preferred a LAI over oral ART to overcome treatment challenges such as daily pill burden and adherence. These benefits of LAI ART along with preferences of PLWH and physicians can help to inform ART choice.

Building capacity for palliative care delivery in primary care settings: Mixed-methods evaluation of the INTEGRATE Project

OBJECTIVE

To evaluate an intervention aimed at building capacity to deliver palliative care in primary care settings.

DESIGN

The INTEGRATE Project was a 3-year pilot project involving interprofessional palliative care education and an integrated care model to promote early identification and support of patients with palliative care needs. A concurrent mixed-methods evaluation was conducted using descriptive data, provider surveys before and after implementation, and interviews with providers and managers.

SETTING

Four primary care practices in Ontario.

PARTICIPANTS

All providers in each practice were invited to participate. Providers used the "surprise question" as a prompt to determine patient eligibility for inclusion.

MAIN OUTCOME MEASURES

Provider attitudes toward and confidence in providing palliative care, use of palliative care tools, delivery of palliative care, and perceived barriers to delivering palliative care.

RESULTS

A total of 294 patients were identified for early initiation of palliative care, most of whom had multiple comorbid conditions. Results demonstrated improvement in provider confidence to deliver palliative care (30% mean increase, P < .05) and self-reported use of palliative care tools and services (25% mean increase, P < .05). There was substantial variation across practices regarding the percentage of patients identified using the surprise question (0.2% to 1.5%), the number of advance care planning conversations initiated (50% to 90%), and mean time to conversation (13 to 76 days). This variation is attributable, in part, to contextual differences across practices.

CONCLUSION

A standardized model for the early introduction of palliative care to patients can be integrated into the routine practice of primary care practitioners with appropriate training and support. Additional research is needed to understand the practice factors that contribute to the success of palliative care interventions in primary care and to examine patient outcomes.

Cost-effectiveness of the long-acting regimen cabotegravir plus rilpivirine for the treatment of HIV-1 and its potential impact on adherence and viral transmission: A modelling study

Introduction

Combination antiretroviral therapy (cART) improves outcomes for people living with HIV (PLWH) but requires adherence to daily dosing. Suboptimal adherence results in reduced treatment effectiveness, increased costs, and greater risk of resistance and onwards transmission. Treatment with long-acting (LA), injection-based ART administered by healthcare professionals (directly observed therapy (DOT)) eliminates the need for adherence to daily dosing and may improve clinical outcomes. This study reports the cost-effectiveness of the cabotegravir plus rilpivirine LA regimen (CAB+RPV LA) and models the potential impact of LA DOT therapies.

Methods

Parameterisation was performed using pooled data from recent CAB+RPV LA Phase III trials. The analysis was conducted using a cohort-level hybrid decision-tree and state-transition model, with states defined by viral load and CD4 cell count. The efficacy of oral cART was adjusted to reflect adherence to daily regimens from published data. A Canadian health service perspective was adopted.

Results

CAB+RPV LA is predicted to be the dominant intervention when compared to oral cART, generating, per 1,000 patients treated, lifetime cost-savings of $1.5 million, QALY and life-year gains of 107 and 138 respectively with three new HIV cases averted.

Conclusions

Economic evaluations of LA DOTs need to account for the impact of adherence and HIV transmission. This study adds to the existing literature by incorporating transmission and using clinical data from the first LA DOT regimen. Providing PLWH and healthcare providers with novel modes of ART administration, enhancing individualisation of treatment, may facilitate the achievement of UNAIDS 95-95-95 objectives.

1018. Health Technology Assessment of New Long-Acting, Directly-Observed HIV Treatments in Canada: Impact of Real-World Adherence to Daily Oral Therapy on Treatment, Transmission and Cost-Effectiveness

Background

Current antiretroviral therapy (ART) has dramatically improved outcomes for people living with HIV (PLWHIV), however adherence to daily oral dosing remains a challenge for some. New, long-acting (LA) ARTs which are directly administered by physicians eliminate the need to adhere to daily oral dosing and may improve clinical outcomes. The study objective was to evaluate costs and QALYs associated with improved adherence achieved via a novel, directly-observed therapy (DOT) of a monthly LA injectable ART, compared to standard of care (SoC), daily oral therapy.

Methods

A published Markov cohort state-transition model was adapted to model the impact of treatment adherence and subsequent disease transmission. Without the need to adhere to daily dosing, the efficacy of the injectable was modelled independent of adherence whereas virologic suppression in the SoC arm was adjusted to reflect published data on adherence to daily dosing (8.12% below optimal levels observed in clinical trials).

Results

This evidence-based approach of accounting for adherence revealed an increase in lifetime costs for oral SOC of approximately $850, and QALY loss of 0.109 when compared to results without accounting for adherence. Disease transmission results yielded 3 cases averted of HIV per 1,000 patients with LA’s impact on adherence.

Conclusion

In the absence of comparative adherence estimates between a LA, injectable DOT and daily oral therapy in the real world, an evidence-based approach provides a method to address the uncertainty around the true impact on costs and QALYs of a novel mode of administration.

Disclosures

Erin Arthurs, MSc, GlaxoSmithKline (Employee) Ben Parker, MSc, HEOR Ltd. (Employee) Ian Jacob, MSc, HEOR Ltd (Employee) Debbie Becker, MSc, GSK (Consultant) Amy Lee, MSc, PhD, GSK (Consultant) Olivia Hayward, PhD, HEOR ltd. (Employee) Vasiliki Chounta, MSc, GlaxoSmithKline (Shareholder)ViiV Healthcare (Employee) Sarah-Jane Anderson, PhD, GlaxoSmithKline (Employee, Shareholder) Nicolas Van de Velde, PhD, GlaxoSmithKline (Shareholder)ViiV Healthcare (Employee)

2499. Perceptions of and Preferences for Oral or Long-Acting Injectable Antiretroviral Treatment Regimens in the United States and Canada

Background

Antiretroviral treatment (ART) for patients living with HIV (PLHIV) has improved greatly, however, challenges with daily oral dosing remain. New ART options with reduced dosing frequency and innovative delivery methods may help address these challenges. This study assesses patient and physician satisfaction with current treatments and preferences for switching to a monthly or every other month long-acting injectable (LAI) ART.

Methods

This is a cross-sectional online survey of PLHIV and physicians treating PLHIV in United States and Canada. A literature review, clinical expert input, and qualitative and quantitative pilots informed survey design. Eligible PLHIV were on ART for ≥ 6 months and virally suppressed (self-reported). Survey questions for patients evaluate satisfaction and adherence to current ART. Treatment preferences are assessed using a discrete choice experiment (DCE), where respondents choose between staying on current ART, switching to another oral ART or switching to a LAI ART. DCE treatment attributes include dosing frequency, side effects, forgivability, food/mealtime restrictions, and mode of administration. Pilot data for US patients is included here; the main survey will include approximately 550 patients and 450 physicians.

Results

Of 51 PLHIV completing the pilot survey, 80% were male, mean age was 54 years, and 63% were on ART for ≥10 years. Switching ART was common, with 55% reporting changing their ART ≥ 3 times. Just under half of patients (47%) were not totally satisfied with their current ART. Most common reasons for dissatisfaction included daily reminder of having HIV (31%) and having to take medicine every day (28%). Just over a quarter of patients (28%) reported forgetting to take their ART in the prior month. Across all DCE choices, patients preferred to remain on their current treatment 47% of the time, while 45% of the time patients preferred switching to the LAI, and for the remaining 8%, patients chose switching to another oral ART regimen.

Conclusion

Despite advances in ART, treatment challenges remain. Among the treatment-experienced PLHIV in this pilot survey, over half of their choices resulted in switching to an alternative regimen, and when opting to switch, most patients preferred the long-acting injectable treatment regimen.

Disclosures

All authors: No reported disclosures.

Integrating early palliative care into routine practice for patients with cancer: A mixed methods evaluation of the INTEGRATE Project

OBJECTIVE

With increasing evidence from controlled trials on benefits of early palliative care, there is a need for studies examining implementation in real-world settings. The INTEGRATE Project was a 3-year real-world project that promoted early identification and support of patients with cancer who may benefit from palliative care. This study assesses feasibility, stakeholder experiences, and early impact of the INTEGRATE Project METHODS: The INTEGRATE Project was implemented in four cancer centers in Ontario, Canada, and consisted of interdisciplinary provider education and an integrated care model. Providers used the Surprise Question to identify patients for inclusion. A mixed methods evaluation of INTEGRATE was conducted using descriptive data, interviews with providers and managers, and provider surveys.

RESULTS

A total of 760 patients with cancer (lung, glioblastoma, head and neck, gastrointestinal) were included. Results suggest improvement in provider confidence to deliver palliative care and to initiate the Advanced Care Planning (ACP) conversation. The majority of patients (85%) had an ACP or goals of care (GOC) conversation initiated within a mean time to conversation of 5-46 days (SD 20-93) across centers. A primary care report was transmitted to family doctors 48-100% of the time within a mean time to transmission of 7-54 days (SD 9-27) across centers. Enablers and barriers influencing success of the model were also identified.

CONCLUSIONS

A standardized model for the early introduction of palliative care for patients with cancer can be integrated into the routine practice of oncology providers, with appropriate education, integration into existing clinical workflows, and administrative support.

Home Palliative Service Utilization and Care Trajectory Among Ontario Residents Dying on Chronic Dialysis

Background:

Many patients who receive chronic hemodialysis have a limited life expectancy comparable to that of patients with metastatic cancer. However, patterns of home palliative care use among patients receiving hemodialysis are unknown.

Objectives:

We aimed to undertake a current-state analysis to inform measurement and quality improvement in palliative service use in Ontario.

Methods:

We conducted a descriptive study of outcomes and home palliative care use by Ontario residents maintained on chronic dialysis using multiple provincial healthcare datasets. The period of study was the final year of life, for those died between January 2010 and December 2014.

Results:

We identified 9611 patients meeting inclusion criteria. At death, patients were (median [Q1, Q3] or %): 75 (66, 82) years old, on dialysis for 3.0 (1.0-6.0) years, 41% were women, 65% had diabetes, 29.6% had dementia, and 13.9% had high-impact neoplasms, and 19.9% had discontinued dialysis within 30 days of death. During the last year of life, 13.1% received ⩾1 home palliative services. Compared with patients who had no palliative services, those who received home palliative care visits had fewer emergency department and intensive care unit visits in the last 30 days of life, more deaths at home (17.1 vs 1.4%), and a lower frequency of deaths with an associated intensive care unit stay (8.1 vs 37.8%).

Conclusions:

Only a small proportion of patients receiving dialysis in Ontario received support through the home palliative care system. There appears to be an opportunity to improve palliative care support in parallel with dialysis care, which may improve patient, family, and health-system outcomes.

Multidisciplinary cancer conferences as a forum for early identification of patients who can benefit from a palliative approach to care: INTEGRATE quality improvement project

196

Background: Introducing palliative care early in the cancer journey results in a better quality of life, less aggressive care and longer survival compared to patients receiving standard care. The INTEGRATE project goal is to identify and manage patients who may benefit from palliative care earlier in their care. Multidisciplinary cancer conferences (MCCs) are scheduled meetings for oncology teams to prospectively discuss patient diagnostic tests and treatment options. In this study, we tested whether MCCs could be used as a forum to identify patients using the UK Gold Standards Framework Surprise Question (Would you be surprised if this person died within the next year?). Methods: Cancer centres volunteered to participate in a pilot project to test the efficacy of the Surprise Question at MCCs and implement a palliative model of care. Prior to initiation, a survey was completed to identify provider comfort in providing palliative care. All sites received primary level palliative care education by completing Pallium Canada’s LEAP Oncology module. Identified patients received Advance Care Planning, symptom management, referrals and standardized reporting to primary care. Results: A baseline survey showed over 50% of providers had no palliative care training. 157 providers participated in LEAP Oncology. Three MCC disease sites (Lung, GI and CNS) are participating in 3 academic and 1 non-academic cancer centres. Implementation of the Surprise Question began in February 2015 and by August 2016, 300 patients were identified out of 1086 total reviewed patients. At the CNS MCC, 100% of all glioblastoma patients were identified. The Lung and GI sites had lower identification rates (19% and 19%, respectively). Identified patients will have their healthcare utilization (community referrals, billing patterns, etc.) analyzed and final results will be synthesized by project completion in January 2017. Conclusions: MCCs appear to be an excellent forum for identifying patients who may benefit from a palliative approach to care within CNS, Lung and GI site groups. Further analysis will inform broader palliative care recommendations in Ontario.

Stroke After Radiation Therapy for Head and Neck Cancer: What Is the Risk?

PURPOSE

A retrospective population-based cohort study was conducted to determine the risk of ischemic stroke with respect to time, associated with curative radiation therapy in head and neck squamous cell carcinomas (HNSCC).

METHODS AND MATERIALS

On the basis of data from the Ontario Cancer Registry and regional cancer treatment centers, 14,069 patients were identified with diagnoses of squamous cell carcinoma of the oral cavity, larynx, and pharynx who were treated for cure between 1990 and 2010. Hazards of stroke and time to stroke were examined, accounting for the competing risk of death. Stroke risk factors identified through diagnostic and procedural administrative codes were adjusted for in the comparison between treatment regimens, which included surgery alone versus radiation therapy alone and surgery alone versus any exposure to radiation therapy.

RESULTS

Overall, 6% of patients experienced an ischemic stroke after treatment, with 5% experiencing a stroke after surgery, 8% after radiation therapy alone, and 6% after any exposure to radiation therapy. The cause-specific hazard ratios of ischemic stroke after radiation therapy alone and after any exposure to radiation therapy compared with surgery were 1.70 (95% confidence interval [CI]: 1.41-2.05) and 1.46 (95% CI: 1.23-1.73), respectively, after adjustment for stroke risk factors, patient factors, and disease-related factors.

CONCLUSIONS

Radiation therapy was associated with an increased risk of ischemic stroke compared with surgery alone: for both radiation therapy alone and after all treatment modalities that included any radiation treatment were combined. Because of a shift toward a younger HNSCC patient population, our results speak to the need for adequate follow-up and survivorship care among patients who have been treated with radiation therapy. Advances in treatment that minimize chronic morbidity also require further evaluation.

Cost trajectories for cancer patients

BACKGROUND

Health care spending is known to be highly skewed, with a small subset of the population consuming a disproportionate amount of health care resources. Patients with cancer are high-cost users because of high incremental health care costs for treatment and the growing prevalence of cancer. The objectives of the present study included characterizing cancer-patient trajectories by cost, and identifying the patient and health system characteristics associated with high health system costs after cancer treatment.

METHODS

This retrospective cohort study identified Ontario adults newly diagnosed with cancer between 1 April 2009 and 30 September 2010. Costs of health care use before, during, and after cancer episodes were used to develop trajectories of care. Descriptive analyses examined differences between the trajectories in terms of clinical and health system characteristics, and a logistic regression approach identified predictors of being a high-cost user after a cancer episode.

RESULTS

Ten trajectories were developed based on whether patients were high- or low-cost users before and after their cancer episode. The most common trajectory represented patients who were low-cost in the year before cancer, survived treatment, and continued to be low-cost in the year after cancer (31.4%); stage ii cancer of the male genital system was the most common diagnosis within that trajectory. Regression analyses identified increases in age and in multimorbidity and low continuity of care as the strongest predictors of high-cost status after cancer.

CONCLUSIONS

Findings highlight an opportunity to proactively identify patients who might transition to high-cost status after cancer treatment and to remediate that transition.

Multidisciplinary cancer conferences as a forum for early identification of patients who can benefit from palliative care

148

Background: Introducing palliative care early in the cancer journey results in a better quality of life, less aggressive care and longer survival compared to patients receiving standard care. The INTEGRATE Project goal is to identify and manage patients who can benefit from palliative care using the UK Gold Standards Framework Surprise Question (would you be surprised if this person died within the next year?). Multidisciplinary cancer conferences (MCCs) are scheduled meetings for oncology teams to prospectively discuss patient diagnostic tests and treatment options, which were leveraged for the INTEGRATE Project. Methods: A pilot study to test the efficacy of the Surprise Question at MCCs and implementation of a palliative model of care has been implemented in 3 academic and 1 non-academic cancer centres. A survey was completed to identify provider comfort levels in providing palliative care. All sites completed Pallium Canada’s LEAP Onco module, which equips providers with skills to provide primary level palliative care. Patients identified at MCCs received advance care planning, symptom management, referrals and standardized reporting to primary care. Results: Four disease sites (Lung, GI, CNS and Head & Neck) are participating. A baseline survey showed over 50% of providers had no training in palliative care. 161 providers participated in LEAP Onco. Implementation of the Surprise Question at MCCs began in February 2015. Two months of implementation identified 39 patients at the CNS, Lung and GI disease sites out of 108 of patients reviewed. At the CNS MCC, 100% glioblastoma patients were identified. The Lung and GI disease sites had lower identification rates (27% and 10%, respectively). Identified patients will have their healthcare utilization (referrals to community providers, billing patterns, ER visits) analyzed to determine impact of this project. Implementation continues until 2016. Conclusions: MCCs appear to be an excellent forum for identifying patients who can benefit from a palliative approach to care within the CNS, Lung and GI site groups. Further data is being collected to inform provincial recommendations for broader implementation of palliative care in Ontario.

Does evidence support the American Heart Association's recommendation to screen patients for depression in cardiovascular care? An updated systematic review

Objectives

To systematically review evidence on depression screening in coronary heart disease (CHD) by assessing the (1) accuracy of screening tools; (2) effectiveness of treatment; and (3) effect of screening on depression outcomes.

Background

A 2008 American Heart Association (AHA) Science Advisory recommended routine depression screening in CHD.

Methods

CINAHL, Cochrane, EMBASE, ISI, MEDLINE, PsycINFO and SCOPUS databases searched through December 2, 2011; manual journal searches; reference lists; citation tracking; trial registries. Included articles (1) compared a depression screening instrument to a depression diagnosis; (2) compared depression treatment to placebo or usual care in a randomized controlled trial (RCT); or (3) assessed the effect of screening on depression outcomes in a RCT.

Results

There were few examples of screening tools with good sensitivity and specificity using a priori-defined cutoffs in more than one patient sample among 15 screening accuracy studies. Depression treatment with antidepressants or psychotherapy generated modest symptom reductions among post-myocardial infarction (post-MI) and stable CHD patients (N = 6; effect size = 0.20–0.38), but antidepressants did not improve symptoms more than placebo in 2 heart failure (HF) trials. Depression treatment did not improve cardiac outcomes. No RCTs investigated the effects of screening on depression outcomes.

Conclusions

There is evidence that treatment of depression results in modest improvement in depressive symptoms in post-MI and stable CHD patients, although not in HF patients. There is still no evidence that routine screening for depression improves depression or cardiac outcomes. The AHA Science Advisory on depression screening should be revised to reflect this lack of evidence.

Are scores on English and French versions of the PHQ-9 comparable? An assessment of differential item functioning

Background

Medical research increasingly utilizes patient-reported outcome measures administered and scored in different languages. In order to pool or compare outcomes from different language versions, instruments should be measurement equivalent across linguistic groups. The objective of this study was to examine the cross-language measurement equivalence of the Patient Health Questionnaire-9 (PHQ-9) between English- and French-speaking Canadian patients with systemic sclerosis (SSc).

Methods

The sample consisted of 739 English- and 221 French-speaking SSc patients. Multiple-Indicator Multiple-Cause (MIMIC) modeling was used to identify items displaying possible differential item functioning (DIF).

Results

A one-factor model for the PHQ-9 fit the data well in both English- and French-speaking samples. Statistically significant DIF was found for 3 of 9 items on the PHQ-9. However, the overall estimate in depression latent scores between English- and French-speaking respondents was not influenced substantively by DIF.

Conclusions

Although there were several PHQ-9 items with evidence of minor DIF, there was no evidence that these differences influenced overall scores meaningfully. The PHQ-9 can reasonably be used without adjustment in Canadian English- and French-speaking samples. Analyses assessing measurement equivalence should be routinely conducted prior to pooling data from English and French versions of patient-reported outcome measures.

Symptom reporting on the Beck Depression Inventory among post-myocardial infarction patients: in-hospital versus follow-up assessments

OBJECTIVE

Depressive symptoms following myocardial infarction (MI) are often assessed using self-report questionnaires, such as the Beck Depression Inventory (BDI). No studies have examined whether depressive symptom scores assessed by self-report questionnaires during hospitalization post-MI are influenced by factors related to the acute event or hospitalization compared to subsequent outpatient assessments of the same patients. The objective of this study was to compare BDI total scores, somatic scores, and cognitive/affective scores among post-MI patients in-hospital versus at post-discharge follow-up.

METHODS

Secondary analysis of data from two existing cohorts of post-MI patients (Groningen, The Netherlands and Toronto, Canada). In-hospital BDI scores and follow-up scores were compared using paired samples t-tests.

RESULTS

There were 1556 patients from the Groningen sample with BDI data in-hospital and at 3-months post-MI and 229 patients from Toronto with data in-hospital and at 6-months post-MI. BDI total, somatic, and cognitive/affective scores did not differ significantly between in-hospital and follow-up assessments in either sample. Similarly, there were no substantive differences in symptom composition in either sample. Somatic symptoms accounted for 66.3% of total BDI scores in-hospital versus 64.9% at 3-months post-MI for Groningen patients and for 62.1% of total scores in-hospital versus 64.3% at 6-months post-MI for Toronto patients.

CONCLUSION

Overall BDI total scores, somatic scores, and cognitive/affective scores did not differ between in-hospital and subsequent outpatient assessments. The timing of when depressive symptoms are assessed post-MI does not appear to influence the overall level of BDI scores or the composition of symptoms that are reported.

New directions for patient-centred care in scleroderma: the Scleroderma Patient-centred Intervention Network (SPIN)

Systemic sclerosis (SSc), or scleroderma, is a chronic multisystem autoimmune disorder characterised by thickening and fibrosis of the skin and by the involvement of internal organs such as the lungs, kidneys, gastrointestinal tract, and heart. Because there is no cure, feasibly-implemented and easily accessible evidence-based interventions to improve health-related quality of life (HRQoL) are needed. Due to a lack of evidence, however, specific recommendations have not been made regarding non-pharmacological interventions (e.g. behavioural/psychological, educational, physical/occupational therapy) to improve HRQoL in SSc. The Scleroderma Patient-centred Intervention Network (SPIN) was recently organised to address this gap. SPIN is comprised of patient representatives, clinicians, and researchers from Canada, the USA, and Europe. The goal of SPIN, as described in this article, is to develop, test, and disseminate a set of accessible interventions designed to complement standard care in order to improve HRQoL outcomes in SSc.

Prevalence of antidepressant prescription or use in patients with acute coronary syndrome: a systematic review

BACKGROUND AND OBJECTIVES

Depression is common among acute coronary syndrome (ACS) patients and is associated with poor prognosis. Cardiac side effects of older antidepressants were well-known, but newer antidepressants are generally thought of as safe to use in patients with heart disease. The objective was to assess rates of antidepressant use or prescription to patients within a year of an ACS.

METHODS

PubMed, PsycINFO, and CINAHL databases searched through May 29, 2009; manual searching of 33 journals from May 2009 to September 2010. Articles in any language were included if they reported point or period prevalence of antidepressant use or prescription in the 12 months prior or subsequent to an ACS for ≥100 patients. Two investigators independently selected studies for inclusion/exclusion and extracted methodological characteristics and outcomes from included studies (study setting, inclusion/exclusion criteria, sample size, prevalence of antidepressant prescription/use, method of assessing antidepressant prescription/use, time period of assessment).

RESULTS

A total of 24 articles were included. The majority were from North America and Europe, and most utilized chart review or self-report to assess antidepressant use or prescription. Although there was substantial heterogeneity in results, overall, rates of antidepressant use or prescription increased from less than 5% prior to 1995 to 10-15% after 2000. In general, studies from North America reported substantially higher rates than studies from Europe, approximately 5% higher among studies that used chart or self-report data.

CONCLUSIONS

Antidepressant use or prescription has increased considerably, and by 2005 approximately 10% to 15% of ACS patients were prescribed or using one of these drugs.

Depression screening and patient outcomes in cancer: a systematic review

Background

Several practice guidelines recommend screening for depression in cancer care, but no systematic reviews have examined whether there is evidence that depression screening benefits cancer patients. The objective was to evaluate the potential benefits of depression screening in cancer patients by assessing the (1) accuracy of depression screening tools; (2) effectiveness of depression treatment; and (3) effect of depression screening, either alone or in the context of comprehensive depression care, on depression outcomes.

Methods

Data sources were CINAHL, Cochrane, EMBASE, ISI, MEDLINE, PsycINFO and SCOPUS databases through January 24, 2011; manual journal searches; reference lists; citation tracking; trial registry reviews. Articles on cancer patients were included if they (1) compared a depression screening instrument to a valid criterion for major depressive disorder (MDD); (2) compared depression treatment with placebo or usual care in a randomized controlled trial (RCT); (3) assessed the effect of screening on depression outcomes in a RCT.

Results

There were 19 studies of screening accuracy, 1 MDD treatment RCT, but no RCTs that investigated effects of screening on depression outcomes. Screening accuracy studies generally had small sample sizes (median = 17 depression cases) and used exploratory methods to set sample-specific cutoff scores that varied substantially across studies. A nurse-delivered intervention for MDD reduced depressive symptoms moderately (effect size = 0.37).

Conclusions

The one treatment study reviewed reported modest improvement in depressive symptoms, but no evidence was found on whether or not depression screening in cancer patients, either alone or in the context of optimal depression care, improves depression outcomes compared to usual care. Depression screening in cancer should be evaluated in a RCT in which all patients identified as depressed, either through screening or via physician recognition and referral in a control group, have access to comprehensive depression care.

Risk of bias from inclusion of patients who already have diagnosis of or are undergoing treatment for depression in diagnostic accuracy studies of screening tools for depression: systematic review

OBJECTIVES

To investigate the proportion of original studies included in systematic reviews and meta-analyses on the diagnostic accuracy of screening tools for depression that appropriately exclude patients who already have a diagnosis of or are receiving treatment for depression and to determine whether these systematic reviews and meta-analyses evaluate possible bias from the inclusion of such patients.

DESIGN

Systematic review.

DATA SOURCES

Medline, PsycINFO, CINAHL, Embase, ISI, SCOPUS, and Cochrane databases were searched from 1 January 2005 to 29 October 2009.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Systematic reviews and meta-analyses in any language that reported on the diagnostic accuracy of screening tools for depression.

RESULTS

Only eight of 197 (4%) unique publications from 17 systematic reviews and meta-analyses specifically excluded patients who already had a diagnosis of or were receiving treatment for depression. No systematic reviews or meta-analyses commented on possible bias from the inclusion of such patients, even though 10 reviews used quality assessment tools with items to rate risk of bias from composition of the sample of patients.

CONCLUSIONS

Studies of the accuracy of screening tools for depression rarely exclude patients who already have a diagnosis of or are receiving treatment for depression, a potential bias that is not evaluated in systematic reviews and meta-analyses. This could result in inflated estimates of accuracy on which clinical practice and preventive care guidelines are often based, a problem that takes on greater importance as the rate of diagnosed and treated depression in the population increases.

A New Tool for Cellulose Degradation Studies

We describe a new technique for studying thermally-induced chemical transformations in cellulose. The apparatus consists of a carbon dioxide laser for heating, an infrared thermometer, and an optical reflectance spectrometer. To illustrate the technique, we present measurements from a single piece of sample linen along five isotherms in the range 200–290°C. The results are discussed in terms of first-order chemical rate theory and a fourstep model. From the measurements we derive the activation energies, Arrhenius constants, and reflectivities of the chromophoric states.

Reliability of widefield capillary microscopy to measure nailfold capillary density in systemic sclerosis

OBJECTIVES

To determine intra- and inter-observer reliability of widefield microscopy to measure nailfold capillary density in patients with systemic sclerosis (SSc).

METHODS

Five SSc patients were examined with a STEMV-8 Zeiss biomicroscope with 50x magnification. The nailfold of the second, third, fourth and fifth fingers of both hands of each patient were photographed twice by each of two observers, once in the morning and again in the afternoon (total of 32 pictures). Two raters reviewed the photographs to produce capillary density readings. Intra- and inter-rater reliability of the readings were computed using intra-class correlations (ICC). Additional analyses were undertaken to determine the impact of other sources of variability in the data, namely patient, finger, technician and time.

RESULTS

Intra-and inter-rater reliability were substantial (ICC 0.72-0.84) when raters were reading the same photographs or photographs taken at the same time of day. Agreement was only fair between morning and afternoon density readings (ICC 0.30-0.37). Patients, individual fingers and technician accounted for a large part of the variability in the data (combined variance component of 7.69 out of the total 12.23). The coefficient of variation of widefield microscopy was 24%.

CONCLUSIONS

Although intra- and inter-rater reliability of nailfold capillary density measurements using widefield microscopy are good, proper standardisation of the conditions under which capillaroscopy is done and better imaging of nailfold capillary abnormalities should be considered if nailfold capillary density is to be used as an outcome measure in multi-centre clinical trials in SSc.

Infrared laser heating for studies of cellulose degradation

We describe a new technique for studying thermally induced chemical transformations in cellulose. The apparatus consists of a carbon dioxide laser for heating, an IR thermometer, and an optical reflectance spectrometer for tracking the progressive discoloration of the sample. To illustrate the technique, we present measurements from a single piece of sample linen along five isotherms in the 200-290 degrees C range. We derive an algebraic expression for the reflectivity of the sample as a function of the areal concentrations of the chromophoric states produced at temperature. The results are then explained in terms of first-order chemical rate theory and a four-step model. From the measurements we derive the activation energies, Arrhenius constants, and reflectivities of the chromophoric states.

Theoretical performance analysis of sliding window link level flow control for a local area network

A transmitter sends packets over a local area network to a receiver. The receiver has a finite amount of storage capacity for buffering messages. A sliding window protocol is employed to insure all packets are delivered without error in order of arrival. Mean throughput rate and packet delay statistics are studied as a function of model parameters. Simulation data are presented.